Pharmacological Interventions for Chronic Pain in Pediatric Patients: A Review of Guidelines [Internet]

Excerpt

Chronic pain is defined as recurrent or persistent pain that extends longer than the expected healing time (generally three months or more).^, Chronic pain affects the individual, as well as the individual’s family, society and the health care system. Untreated chronic pain in childhood is associated with risk of subsequent pain as well as physical and psychological impairment in adulthood. A higher proportion of chronic pain in adulthood was reported in those who had chronic pain in adolescence compared with those who were pain free in adolescence. Pathophysiological classifications of chronic pain in the pediatric population include nociceptive pain (somatic or visceral), neuropathic pain (from damage to or dysfunction of the peripheral or central nervous system) and idiopathic pain (no known cause).^, The most common chronic pain disorders in the pediatric population include primary headache, centrally mediated abdominal pain syndromes, and chronic/recurrent musculoskeletal and joint pain.

Globally, pain is a common feature among children and adolescents, and in many it is chronic.^, A systematic review of studies on the prevalence rates of chronic pain in children and adolescents reported that there was wide variation in the prevalence rates depending on demographics and psychosocial factors; prevalence rates were 8% to 83% for headache, 4% to 53% for abdominal pain, 4% to 40% for musculoskeletal pain, 14% to 24% for back pain, and 5% to 88% for other pain. According to the 2007/2008 Canadian Community Health Survey of individuals in the age group 12 years to 44 years the prevalence of chronic pain was estimated as 9.1% in males and 11.9% in females; for the pediatric subgroup (12 years to 17 years) the prevalence was 2.4% in males and 5.9% in females.

The development and persistence of chronic pain involve multiple, integral, neural pain networks (i.e., peripheral, spinal, and brain) that interact in a complex way to contribute to an individual’s experience of pain. In children these peripheral, spinal, and brain networks are not mature and change over time as the child matures, which adds further complexity to understanding, evaluating and treating pain in the pediatric population.

Pharmacological agents have been used for treatment of chronic non-cancer pain in children and adolescents. These include acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), anti-depressants, anticonvulsants, and opioids. NSAIDS include agents such as aceclofenac, acetylsalicylic acid, celecoxib, choline magnesium trisalicylates, diclofenac, etodolac, etoricoxib, fenoprofen, ibuprofen, indomethacin, ketoprofen, ketorolac, mefenamic acid, meloxicam, nabumetone, naproxen, parecoxib, phenylbutazone, piroxicam, sulindac, tenoxicam, and tiaprofenic acid. Anti-depressants include agents such as amitriptyline, nortriptyline, imipramine, duloxetine, fluoxetine, and bupropion. Anticonvulsants include agents such as gabapentin and pregabalin. Opioids include agents such as buprenorphine, codeine, fentanyl, hydromorphone, methadone, morphine, oxycodone, and tramadol.

There appears to be limited evidence available with respect to pharmacological treatments for management of chronic pain in pediatric patients. One systematic review reported that there was no evidence from RCTs to support or refute the use of paracetamol (acetaminophen) for treating chronic non-cancer pain (CNCP) in children and adolescents. A second systematic review investigated the clinical efficacy of NSAIDs for treating CNCP in children and adolescents. The authors reported that there were few RCTs identified and they were of low or very low quality, and they had insufficient data for analysis; hence they were unable to comment on the efficacy or harm of NSAIDs for treating CNCP in children and adolescents. A third systematic review investigated the clinical efficacy of antidepressants for treating CNCP in children and adolescents. The authors reported that there were few RCTs identified and they were of small sample size and of very low quality, and they had insufficient data for analysis; hence they were unable to comment on the efficacy or harm of anti-depressants for treating CNCP in children. A fourth systematic review reported that there was no evidence from RCTs to support or refute the use of opioids for treating CNCP in children and adolescents. There appears to be uncertainty regarding clinical effectiveness pharmacological interventions for treating CNCP in children and adolescents. Hence guidelines regarding the use of pharmacological interventions for treatment of chronic pain is pediatric and young people are important.

The aim of this report is to review the evidence-based guidelines regarding pharmacological interventions for pediatric and youth patients with chronic pain.