Dr Muhly: This type of multidisciplinary pain management approach is resource-intensive and is dependent on departmental and institutional support for sustainability. Having a dedicated pain team that is responsible for managing pediatric pain can be a centralizing force in this process, but it requires a commitment to recruit and retain staff with expertise in managing acute and chronic pain. Traditionally, anesthesiologists have filled this role, especially in the acute care setting, as their training allows them to provide acute pain management that can be continued throughout the recovery process. 

However, to successfully build a multidisciplinary pain management program, good communication between surgeons, anesthesiologists, nurses, physical therapists, and other allied healthcare providers is vital. If this does not exist, a practical approach would be to identify a population at risk for severe pain postoperatively — for example, posterior spinal fusion for scoliosis — and develop a multidisciplinary recovery protocol. This allows each member of the team to contribute to and “own” the protocol, which will help with implementation and sustainability. Incorporation of nontraditional approaches such as acupuncture may take time, as identifying practitioners comfortable with this type of inpatient practice can be difficult.

Clinical Pain Advisor: What are remaining needs in this area in terms of research and physician or patient education?

Dr Peterson: The remaining needs are significant. The American Pain Society presented a research agenda for pediatric chronic pain in 2012, which outlines the comprehensive research, education, and policy needs.9  

Research: The development of a pediatric chronic pain research consortia in which studies investigating prevention, assessment, and treatment of chronic pain conditions are refined and developed is important. The identification of risk factors for chronic pain, the development of screening tools, biomarkers, and medications that are mechanism-based, as well as research on placebogenomics, and nonpharmacologic modalities such as virtual reality are essential.

Education: There is a need to improve pain education, so as to integrate it into medical training and to remove the associated stigma. There are schools in which relaxation techniques are taught to children with asthma, but no such support or education is provided to children with chronic pain. There has to be recognition across the board — from parents, schools, medical teams, public health, and insurance companies — about the differences between chronic and acute pain. Resting, waiting for the pain to get better, and pulling a child out of school worsens chronic pain conditions and decreases quality of life.

Policy needs: Policy improvements are needed to advocate for children with chronic pain. Many insurance companies would reject an intensive inpatient pain rehabilitation program but will approve an invasive medical procedure for the same indication. Interdisciplinary visits are often not supported due to a lack of education. Chronic pain often does not respond to monotherapy and requires a multimodal approach for treatment.

The cost of chronic pain is tremendous, both fiscally and more importantly, through its impact on the lives of children and families.

Dr Muhly: For the field of pediatric pain management to progress, we need more pediatric-specific research on the impact of various analgesic interventions. Much of the practice of acute pain management in children is built on evidence obtained from adult studies. Additionally, we must recognize that the child’s ability to cope with and manage acute and chronic pain is influenced by a number of factors, including their inherent anxiety levels, their emotional and intellectual maturity, as well as parental support. More research is needed to understand this complex interplay and to identify children with low coping skills who are at risk for poor recovery to provide preoperative resources to optimize the child’s recovery. 

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References

1. Wren AA, Ross AC, D’Souza G, et al. Multidisciplinary pain management for pediatric patients with acute and chronic pain: a foundational treatment approach when prescribing opioids. Children (Basel). 2019;6(2):33.

2. Palermo TM, Eccleston C, Lewandowski AS, Williams AC, Morley S. Randomized controlled trials of psychological therapies for management of chronic pain in children and adolescents: an updated meta-analytic review. Pain. 2010;148(3):387-397.

3. Chadi N, McMahon A, Vadnais M, et al. Mindfulness-based intervention for female adolescents with chronic pain: a pilot randomized trial. J Can Acad Child Adolesc Psychiatry. 2016;25(3):159-168.