Clinical Pain Advisor: What are the benefits of this type of approach?
Dr Peterson: Education is the largest benefit. Many families do not recognize or appreciate the strong role psychology plays in the burden of chronic pain. Depression and anxiety could be preexistent to the development of chronic pain, which will worsen chronic pain states or could be reactive to chronic pain. In both cases, chronic pain reduces the quality of life and could result in pain becoming refractory to treatment if not properly addressed.
If the role of psychology is not integrated into the initial visit, families may not go to a psychology-only visit unless it is made clear to them that the pain psychologist will teach them about tools to decrease pain intensity and improve quality of life. It must be emphasized that the visit to the psychologist is not because they are imagining these symptoms. Unfortunately, many children and families have been told, “The pain is not real — it is in your head.”
Another benefit is that it avoids families having to come for separate visits, with instead, one comprehensive visit during which the patient is evaluated by a team of experts who all have a unique role and input into the care and treatment plan. Many families travel hours to receive any pediatric chronic pain care, as there are not many practices that have familiarity with pediatric chronic pain, so to have a comprehensive visit is a significant convenience.
Dr Muhly: The management of pain is complicated and often challenging, thus providers charged with caring for children with pain must provide an agile and multifaceted approach. We often talk about having multiple tools to deal with pain. While the acute pain process can be improved through the provision of regional anesthesia, opioids, or other traditional nonopioid medications, the recovery can be augmented through the introduction of techniques including acupuncture, art, music, and play therapy. These interventions can help normalize the child’s recovery and provide a level of distraction that can help minimize the pain response and reduce the need for medications and hospitalization.
Additionally, it is increasingly recognized that anxiety and depression can complicate recovery from acute and chronic pain. Thus, the involvement of a psychologist specifically trained in pediatric pain management represents an invaluable member of an acute pain service and is an absolute necessity in the treatment of chronic pain in children.
Clinical Pain Advisor: What would you recommend to clinicians who wish to establish or participate in such an approach?
Dr Peterson: I would encourage the clinician to recognize that this approach will require dedication, time, and convincing.
Dedication, because involvement of multiple disciplines requires coordination and organization. Pain in psychology and in physical therapy involve additional training. Who is interested? Who will pay for the training? And how will time be split with pain and the home department? You would also have to generate a referral base — many specialties need help with their patients with chronic pain. You would need to notify patients of the availability of this resource and be able to meet the demand. Not every patient with chronic pain requires an interdisciplinary evaluation, so it is important to establish the criteria.
Time, because the visits are longer (about 3 hours) and emotionally heavy. Patients and families share significant psychosocial challenges — for example, deaths in the family, divorce, abuse, suicide attempts — that may not have been discussed or identified in previous clinical evaluations. Because the comprehensive visits are just that, we are able to capture these challenges in the visit and provide support and a personalized treatment plan.
You also need to be convincing because you will have to convey to the hospital administration that this is a significant service to families. These comprehensive visits are not revenue generators. The time it takes for one comprehensive visit is equivalent to each member of the interdisciplinary team seeing 3 patients. The large fiscal benefit comes from its prevention of an emergency department visit or inpatient admission of a child with chronic pain. The annual healthcare utilization for children with chronic pain is $19.5 billion in the United States (more than the annual cost of pediatric asthma and obesity combined) when factoring in the direct and indirect medical costs and productivity losses.8