What a pain in the back: a review of current treatment options with a focus on naproxen sodium.

Non-specific low back pain (LBP) represents a challenging and prevalent condition that is one of the most common symptoms leading to primary care physician visits. While established guidelines recommend prioritizing non-pharmacological approaches as the primary course of action, pharmacological treatments are advised when non-pharmacological approaches are ineffective or based on patient preference. These guidelines recommend non-steroidal anti-inflammatory drugs (NSAIDs) or skeletal muscle relaxers (SMRs) as the first-line pharmacological options for acute or subacute LBP, while NSAIDs are the exclusive first-line pharmacological option for chronic LBP. Although SMRs are generally effective for acute LBP, the available evidence does not support the view that they improve functional recovery, and their comparative efficacy to NSAIDs and other analgesics remains unknown, while studies have shown them to introduce adverse events without significantly reducing LBP. Moreover, opioids continue to be widely prescribed for LBP, despite limited evidence for effectiveness and known risks of addiction and overdose. Broader use of non-opioid pharmacotherapy, including the appropriate use of OTC options, is critical to addressing the opioid crisis. The balance of evidence indicates that NSAIDs have a favorable benefit-risk profile when compared to other available pharmacological treatment options for non-specific LBP, a condition that is primarily acute in nature and well-suited for self-treatment with OTC analgesics. While clinical guidelines do not differentiate between NSAIDs, evidence indicates that OTC naproxen sodium effectively relieves pain across multiple types of pain models, and furthermore, the 14-h half-life of naproxen sodium allows sustained, all day pain relief with reduced patient pill burden as compared to shorter acting options. Choosing the most appropriate approach for managing LBP, including non-pharmacological options, should be based on the patient's condition, severity of pain, potential risks, and individual patient preference and needs.

Perioperative methadone for posterior spinal fusion in adolescents: Results from a double-blind randomized-controlled trial.

BACKGROUND: Posterior spinal fusion is the most common surgical procedure performed for correction of adolescent idiopathic scoliosis in the United States. Intraoperative methadone has been shown to improve pain control in adult patients undergoing complex spine surgery, and current pediatric studies show encouraging results; however, prospective randomized-controlled trials are lacking in the pediatric literature. AIMS: We conducted a single-center double-blind randomized-controlled trial to compare intraoperative use of methadone to morphine in pediatric patients undergoing posterior spinal fusion. METHODS: A total of 47 adolescents undergoing posterior spinal fusion were randomized (stratified by sex) to either a methadone (n = 25) or morphine (n = 22) group. The primary outcome was postoperative opioid consumption. Secondary outcomes included postoperative pain severity, opioid-related side effects, and ratio of patient-controlled analgesia injections: attempts as a behavioral index of uncontrolled pain. RESULTS: Patients in the methadone group consumed less total opioid postoperatively (median [interquartile range], 0.3 mg/kg [0.1, 0.5]) than patients in the morphine group (0.3 mg/kg [0.2, 0.6]), median difference [95% confidence interval] -0.07 [-0.2 to 0.02]; (p = .026). Despite the lower amount of opioid used postoperatively, pain scores for the methadone group (3.5 [3.0, 4.3]) were not significantly different from those in the morphine group (4.0 [3.2, 5.0]; p = .250). Groups did not differ on opioid-related side effects. CONCLUSIONS: A two-dose intraoperative methadone regimen resulted in decreased opioid consumption compared to morphine. Although the clinical significance of these results may be limited, the analgesic equipoise without increased opioid-related side effects and potential for a lower incidence of chronic pain may tip the balance in favor of routine methadone use for adolescents undergoing posterior spinal fusion.

Stress Numerical Rating Scale-11: Validation in Pediatric Inpatient and Outpatient Pain Settings.

Stress is a commonly reported issue in pediatric populations of chronic and acute pain. Both outpatient and inpatient settings impose time constraints, which decreases opportunities to measure and address patient stress. The aim of these studies was to evaluate the validity of the Stress Numeric Rating Scale-11 (SNRS-11) in both inpatient and outpatient settings. The SNRS-11 is a single item stress measure ranging from 0 to 10 with endpoint anchors: 0 = "No stress" and 10 = "Highest stress possible". Results showed discriminative validity in the inpatient sample and convergent and discriminant validity in both outpatient and inpatient samples. Additionally, approximately 40% to 50% of the sample reported moderate-severe stress on all post-operative days. The SNRS-11 shows promise as a quick, easy, and free stress measure to be used in both inpatient and outpatient settings.

Interaction of chronic pain, obesity and time of day on cortisol in female human adolescents.

Adolescent obesity augments and impedes the treatment of chronic pain. This is associated with increased systemic inflammation and is more prominent in females. In addition, pain and obesity each independently affect the hypothalamic-pituitary-adrenal (HPA) axis. However, the interaction of pain and obesity on the HPA axis and the potential for sexual dimorphism in this phenomenon is not established. We hypothesized that dysregulation of the HPA axis occurs in female human adolescents with chronic pain, obesity, or the combination of the two and is associated with gonadal steroids. We measured serum cortisol, estradiol, and testosterone in 13-17-year-old adolescent females (N = 79) from venous blood drawn during the daytime (0830-1730 h) and analyzed the data in toto and partitioned by morning vs. afternoon sampling time. Subjects were categorized as healthy weight/no pain (controls; BMI = 56th percentile [37-71]), healthy weight with chronic pain, obese without pain (BMI = 97th percentile [95-99]), or the combination of obesity and chronic pain. Serum cortisol was lower with chronic pain and/or obesity compared to healthy controls and was lower with chronic pain and obesity compared to chronic pain alone (healthy weight). The lower serum cortisol in the pain alone group was more prominent in the morning compared to the afternoon. There was no relationship between serum estradiol and testosterone and study group. The decrease in the anti-inflammatory and other pain-ameliorating effects of cortisol may contribute to chronic pain and its resistance to treatment with concurrent obesity in female adolescents.

Lipid signatures of chronic pain in female adolescents with and without obesity.

BACKGROUND: Chronic pain in adolescence is associated with diminished outcomes, lower socioeconomic status in later life, and decreased family well-being. Approximately one third of adolescents with chronic pain have obesity compared to the general population. In obesity, lipid signals regulate insulin sensitivity, satiety, and pain sensation. We determined whether there is a distinct lipid signature associated with chronic pain and its co-occurrence with obesity in adolescents. METHODS: We performed global lipidomics in serum samples from female adolescents (N = 67, 13-17 years old) with no pain/healthy weight (Controls), chronic pain/healthy weight (Pain Non-obese), no pain/obesity (Obese), or chronic pain/obesity (Pain Obese). RESULTS: The Pain Non-obese group had lipid profiles similar to the Obese and Pain Obese groups. The major difference in these lipids included decreased lysophosphatidylinositol (LPI), lysophosphatidylcholine (LPC), and lysophosphatidylethanolamine (LPE) in the three clinical groups compared to the Control group. Furthermore, ceramides and sphingomyelin were higher in the groups with obesity when compared to the groups with healthy weight, while plasmalogens were elevated in the Pain Obese group only. CONCLUSIONS: Serum lipid markers are associated with chronic pain and suggest that specific lipid metabolites may be a signaling mechanism for inflammation associated with co-occurring chronic pain and obesity.

AAAPT Diagnostic Criteria for Acute Neuropathic Pain.

OBJECTIVE: Acute neuropathic pain is a significant diagnostic challenge, and it is closely related to our understanding of both acute pain and neuropathic pain. Diagnostic criteria for acute neuropathic pain should reflect our mechanistic understanding and provide a framework for research on and treatment of these complex pain conditions. METHODS: The Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership with the U.S. Food and Drug Administration (FDA), the American Pain Society (APS), and the American Academy of Pain Medicine (AAPM) collaborated to develop the ACTTION-APS-AAPM Pain Taxonomy (AAAPT) for acute pain. A working group of experts in research and clinical management of neuropathic pain was convened. Group members used literature review and expert opinion to develop diagnostic criteria for acute neuropathic pain, as well as three specific examples of acute neuropathic pain conditions, using the five dimensions of the AAAPT classification of acute pain. RESULTS: AAAPT diagnostic criteria for acute neuropathic pain are presented. Application of these criteria to three specific conditions (pain related to herpes zoster, chemotherapy, and limb amputation) illustrates the spectrum of acute neuropathic pain and highlights unique features of each condition. CONCLUSIONS: The proposed AAAPT diagnostic criteria for acute neuropathic pain can be applied to various acute neuropathic pain conditions. Both the general and condition-specific criteria may guide future research, assessment, and management of acute neuropathic pain.

Naproxen for Post-Operative Pain.

INTRODUCTION: Post-operative pain is a common type of acute pain that can require therapeutic intervention. Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to manage post-operative pain and help reduce or eliminate the use of opioids. Current pain management guidelines recommend administration of NSAIDs as first line therapy to all post-operative surgical patients, unless contraindicated, as one method to minimize opioid use. METHODS: This article is based on previously conducted studies and does not contain any studies with human participants or animals performed by the author. Literature for controlled trials involving naproxen in a peri-procedural setting was included. Comprehensive meta-analyses and individual clinical trial reports were summarized. RESULTS: Naproxen was shown to have significant efficacy in treating pain following different surgical interventions, eliminating, or reducing the use of rescue opioids in many trials. Importantly, naproxen did not demonstrate an increased rate of bleeding or other adverse events in this elevated-risk population. CONCLUSION: As a generally safe and effective medication, clinical consideration should be given to naproxen when developing any comprehensive, patient-specific, pain management plan.

A Pilot Randomized Controlled Trial of Outcomes Associated with Parent-Nurse Controlled Analgesia vs. Continuous Opioid Infusion in the Neonatal Intensive Care Unit.

PURPOSE: Prospectively compare parent/nurse controlled analgesia (PNCA) to continuous opioid infusion (COI) in the post-operative neonatal intensive care unit (NICU) population. DESIGN/METHODS: A randomized controlled trial compared neonates treated with morphine PNCA to those treated with morphine COI. The primary outcome was average opioid consumption up to 3 post-operative days. Secondary outcomes included 1) pain intensity, 2) adverse events that may be directly related to opioid consumption, and 3) parent and nurse satisfaction. RESULTS: The sample consisted of 25 post-operative neonates and young infants randomized to either morphine PNCA (n = 16) or COI (n = 9). Groups differed significantly on daily opioid consumption, with the PNCA group receiving significantly less opioid (P = .02). Groups did not differ on average pain score or frequency of adverse events (P values > .05). Parents in both groups were satisfied with their infant's pain management and parents in the PNCA group were slightly more satisfied with their level of involvement (P = .03). Groups did not differ in nursing satisfaction. CONCLUSIONS: PNCA may be an effective alternative to COI for pain management in the NICU population. This method may also substantially reduce opioid consumption, provide more individualized care, and improve parent satisfaction with their level of participation. CLINICAL IMPLICATIONS: Patients in the NICU represent one of our most vulnerable patient populations. As nurses strive to provide safe and effective pain management, results of this study suggest PNCA may allow nurses to maintain their patients' comfort while providing less opioid and potentially improving parental perception of involvement. STUDY TYPE: Treatment study. LEVEL OF EVIDENCE: I.

A narrative review of the cardiovascular risks associated with concomitant aspirin and NSAID use.

The concomitant use of low-dose aspirin for cardioprotection and non-steroidal anti-inflammatory agents for pain relief is prevalent, particularly in the elderly for whom cardiovascular disease and pain are common co-morbidities. Non-selective non-steroidal anti-inflammatory drugs (NSAIDs) are known to interfere with the antiplatelet effect of aspirin through competitive binding with COX-1. While the clinical significance of this interference is still unclear, this review sought to assess the body of literature which has evaluated the potential attenuation of the anti-platelet effect of aspirin when dosed concomitantly with an NSAID. This review supports that the pharmacodynamic interaction between aspirin and non-selective NSAIDs occurs, but finds that the interaction varies amongst agents, and is highly dependent on numerous factors including: dose timing, dose of aspirin, and dose of the NSAID in question. Recent findings suggest that patient factors, such as body weight may also be indicators of aspirin's cardiovascular effectiveness. Ultimately, the clinical decision making for concomitant NSAID and low-dose aspirin regimens remains at the patient level.

Persistent subcutaneous CSF leak after removal of epidural catheter.

We report the case of an 11-month-old boy with Wilm's tumor, who underwent nephrectomy. Postoperative pain was managed with a lumbar epidural for 3 days, with the formation of a persistent cerebral spinal fluid cutaneous fistula.

Parent/Nurse-Controlled Analgesia Compared with Intravenous PRN Opioids for Postsurgical Pain Management in Children with Developmental Delay: A Randomized Controlled Trial.

Objectives: The aim of this study was to conduct a randomized, controlled comparison of outcomes associated with parent/nurse-controlled analgesia (PNCA), with and without a basal (background) opioid infusion, with intravenous (IV) opioids intermittently administered by a nurse on an "as needed" basis (IV PRN) for postoperative pain management in children with developmental delay (DD). Methods: Participants included children with DD expected to require IV opioids for at least 24 postoperative hours. Patients were randomized to one of three groups: PNCA with a basal infusion, PNCA without a basal infusion, or IV PRN opioids. Demographics, pain scores, opioid consumption, and frequency of side effects were collected beginning 12 hours after emerging from anesthesia to decrease the impact of anesthetic agents on outcomes. Results: The 81 participants (median = 12.0, 9.0-15.0 years) were primarily Caucasian (74%) males (58%), with severe DD (69%) having spinal surgery (41%). The proportion of patients in each group with pain scores ≤3 vs ≥ 4 revealed no between-group differences in any epoch (P = 0.09-0.27). Patients in the PNCA with a basal group consumed significantly more opioid (median = 0.03 mg/kg/h morphine equivalents, 0.02-0.03 mg/kg/h) than the PNCA without a basal infusion. No difference was found between the PNCA without a basal (median = 0.01 mg/kg/h morphine equivalents, 0.00-0.02 mg/kg/h) and the PRN groups (median = 0.01 mg/kg/h morphine equivalents, 0.01-0.02 mg/kg/h). There were no statistically significant differences in side effects, with the exception that more children in the PNCA group required supplemental oxygen (P = 0.05). Conclusions: Results suggest there may be no advantage to PNCA over PRN opioids in this patient population after the first 12 postoperative hours with regard to pain scores, opioid consumption, or side effects.

The ACTTION-APS-AAPM Pain Taxonomy (AAAPT) Multidimensional Approach to Classifying Acute Pain Conditions.

Objective: With the increasing societal awareness of the prevalence and impact of acute pain, there is a need to develop an acute pain classification system that both reflects contemporary mechanistic insights and helps guide future research and treatment. Existing classifications of acute pain conditions are limiting, with a predominant focus on the sensory experience (e.g., pain intensity) and pharmacologic consumption. Consequently, there is a need to more broadly characterize and classify the multidimensional experience of acute pain. Setting: Consensus report following expert panel involving the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION), American Pain Society (APS), and American Academy of Pain Medicine (AAPM). Methods: As a complement to a taxonomy recently developed for chronic pain, the ACTTION public-private partnership with the US Food and Drug Administration, the APS, and the AAPM convened a consensus meeting of experts to develop an acute pain taxonomy using prevailing evidence. Key issues pertaining to the distinct nature of acute pain are presented followed by the agreed-upon taxonomy. The ACTTION-APS-AAPM Acute Pain Taxonomy will include the following dimensions: 1) core criteria, 2) common features, 3) modulating factors, 4) impact/functional consequences, and 5) putative pathophysiologic pain mechanisms. Future efforts will consist of working groups utilizing this taxonomy to develop diagnostic criteria for a comprehensive set of acute pain conditions. Perspective: The ACTTION-APS-AAPM Acute Pain Taxonomy (AAAPT) is a multidimensional acute pain classification system designed to classify acute pain along the following dimensions: 1) core criteria, 2) common features, 3) modulating factors, 4) impact/functional consequences, and 5) putative pathophysiologic pain mechanisms. Conclusions: Significant numbers of patients still suffer from significant acute pain, despite the advent of modern multimodal analgesic strategies. Mismanaged acute pain has a broad societal impact as significant numbers of patients may progress to suffer from chronic pain. An acute pain taxonomy provides a much-needed standardization of clinical diagnostic criteria, which benefits clinical care, research, education, and public policy. For the purposes of the present taxonomy, acute pain is considered to last up to seven days, with prolongation to 30 days being common. The current understanding of acute pain mechanisms poorly differentiates between acute and chronic pain and is often insufficient to distinguish among many types of acute pain conditions. Given the usefulness of the AAPT multidimensional framework, the AAAPT undertook a similar approach to organizing various acute pain conditions.

A Safety Evaluation of a Nature-Identical l-Ergothioneine in Sprague Dawley Rats.

l-(+) Ergothioneine is a naturally occurring thiol amino acid with antioxidant properties and potential benefits as a dietary supplement. Despite its century-old identification and wide distribution in human food, little is known of its mechanism of action and safety. The nature-identical biomimetic of l-(+) ergothioneine, produced by Mironova Labs and supplied as Mironova (EGT+), has been investigated in the present studies for its mutagenic and toxicologic potential. In a plate incorporation and preincubation assay with Salmonella typhimurium strains TA98, 100, 1,535, and 1,537 and Escherichia coli WP2uvrA strain, at dose concentrations of 1.58, 5, 15.8, 50, 158, 500, 1,580, and 5,000 µg/plate with and without metabolic activation, no cytotoxicity or mutagenicity was observed. Following a preliminary 28-day study, a repeated dose 90-day gavage study at dose levels of 0, 400, 800, and 1,600 mg/kg body weight (bw)/d in Sprague Dawley rats, in which dose-proportional systemic absorption was confirmed by plasma analysis, no adverse clinical, body weight/gain, food consumption and efficiency, clinical pathology, or histopathological changes associated with the administration of the nature-identical ergothioneine were observed. In conclusion, EGT+ administered over 90 days was well tolerated with a no adverse effect level at 1,600 mg/kg bw/d, the highest dose tested for male and female rats. In addition, the nature-identical test substance, EGT+ was not mutagenic in a bacterial reverse mutation assay at plate concentrations of up to 5,000 µg/mL in the presence or absence of metabolic activation.

A Randomized Clinical Trial of Jet-Injected Lidocaine to Reduce Venipuncture Pain for Young Children.

STUDY OBJECTIVE: The J-Tip (National Medical Products Inc, Irvine, CA) uses air instead of a needle to push lidocaine into the skin. To our knowledge, no studies have investigated its use for venipuncture in young children. We determine whether the J-Tip decreased venipuncture pain in young children compared with vapocoolant spray. METHODS: Children aged 1 to 6 years were randomized into 3 groups: intervention (J-Tip), control (vapocoolant spray), and sham (vapocoolant spray and pop of an empty J-Tip). The procedure was videotaped and scored with the Face, Legs, Activity, Cry and Consolability (FLACC) tool at 3 points; baseline, before approach; device, at J-Tip deployment; and at venipuncture. The FLACC tool was scored 0 (none) to 10 (severe). Comparisons of pain scores over time were made with the generalized estimating equation. Venipuncture success and adverse effects were assessed and compared with χ(2). RESULTS: Two hundred five children enrolled: intervention 96, control 53, and sham 56. There were no between-group differences in baseline characteristics. There was no mean change in pain scores from device to venipuncture in the intervention group (0.26; 95% confidence interval [CI] -0.31 to 0.82), but there was an increase in pain in the control (2.82; 95% CI 1.91 to 3.74) and sham (1.68; 95% CI 0.83 to 2.52) groups. This change was greater for the control and sham compared to the intervention group. There was no difference in venipuncture success between groups. No severe adverse events occurred. Minor adverse events were the same between groups. CONCLUSION: Use of the J-Tip for children aged 1 to 6 years reduced venipuncture pain compared with vapocoolant spray or sham treatment.

Distinct Influences of Anxiety and Pain Catastrophizing on Functional Outcomes in Children and Adolescents With Chronic Pain.

OBJECTIVES: Examine whether anxiety and pain catastrophizing are distinct constructs in relation to functional outcomes in pediatric chronic pain, and whether they differentially predict functional outcomes based on age. METHODS: In all, 725 youth (191 children, 534 adolescents) with chronic pain completed measures of pain characteristics, anxiety, pain catastrophizing, functional disability, and health-related quality of life (HRQOL). Structural equation modeling was used to examine interrelationships. RESULTS: Anxiety and pain catastrophizing were distinct. For both children and adolescents, pain catastrophizing predicted pain, functional disability, and HRQOL, and was a stronger predictor of pain intensity. For children, anxiety predicted HRQOL, and pain catastrophizing was a stronger predictor of functional disability. For adolescents, anxiety predicted functional disability and HRQOL, and anxiety was a stronger predictor of HRQOL. CONCLUSIONS: There were age-related differences regarding whether anxiety or pain catastrophizing more strongly predicted specific functional outcomes. Assessment and intervention efforts should emphasize both anxiety and pain catastrophizing.

Migration of pediatric epidural catheters.

BACKGROUND: Postoperative pain control in the pediatric population frequently involves epidural catheters placed intraoperatively. A retrospective review of epidural catheter tip position was conducted by evaluation of routine chest anterior-posterior (A-P) X-rays obtained by the surgical and ICU teams. METHODS: Of the 174 pediatric epidural catheters placed during a 1-year period at Children's Hospital of Wisconsin, 59 pediatric patients with chest X-rays demonstrating epidural catheter tip on at least 2 days were reviewed. The change in epidural catheter position was then calculated. The overall reason for discontinuation of epidural analgesia in the larger population was also compiled. RESULTS: It was determined that epidural catheters migrated more frequently in patients <10 kg and 10-40 kg, when compared to those >40 kg P < 0.001. The average migration seen on X-ray was 1.1 levels inward in those <40 kg and 0.3 levels inward in those >40 kg. The incidence of catheters discontinued secondary to falling out, or migrating in, was also increased in those patients <40 kg when compared to those >40 kg. CONCLUSION: Results suggest that epidural catheters move inward more frequently and fall out more frequently in patients <40 kg.

Costs and benefits of bundled community-based screening for carotid artery stenosis, peripheral artery disease, and abdominal aortic aneurysm.

PURPOSE: Perform an initial formal assessment of the costs and benefits of bundled cardiovascular screening. Primarily, determine the relative importance of data uncertainties to the integrity ofmodeled outcomes associated with bundled screening for carotid artery stenosis (CAS), peripheral artery disease (PAD), and abdominal aortic aneurysm (AAA); secondarily, establish parameters around potential costs and outcomes benefits of this screening bundle. DESIGN: A decision-analysis framework composed of four decision tree submodels with transition probabilities specific to four age- and gender-specific subgroups. Model transition probabilities for each of the four submodels are based on the prevalence of all possible combinations of the presence or absence of moderate CAS, significant CAS, PAD, and AAA, and the likelihood of appropriate or inappropriate medical follow-up. METHODOLOGY: Evaluates a hypothetical self-funded employer with 10,000 beneficiaries and who is considering whether to provide bundled cardiovascular health screenings. Screenings would be performed in addition to any other medical screenings commonly performed by physicians to assess cardiovascular risk. Determine costs and catastrophic events (death, myocardial infarction, stroke, other cardiovascular-related events, amputation events) for these self-funded hypothetical beneficiaries aged ≥ 50 years and < 65 years. RESULTS: The model predicts approximately $54 million in health care costs over 10 years for the control cohort and $51 million for the screening cohort, representing a 5.2% reduction in 10-year health care spending due to screening. CONCLUSION: This initial analysis predicts robust cost and health benefits associated with the decision to provide bundled cardiovascular health screening to a self-funded employer's beneficiaries aged ≥ 50 years and < 65 years. Further analyses are necessary to better quantify the magnitude of the cost and health benefits.

Is there an alternative to continuous opioid infusion for neonatal pain control? A preliminary report of parent/nurse-controlled analgesia in the neonatal intensive care unit.

BACKGROUND: Continuous opioid infusion (COI) remains the mainstay of analgesic therapy in the neonatal intensive care unit (NICU). Parent/nurse-controlled analgesia (PNCA) has been accepted as safe and effective for pediatric patients, but few reports include use in neonates. This study sought to compare outcomes of PNCA and COI in postsurgical neonates and young infants. METHODS: Twenty infants treated with morphine PNCA were retrospectively compared with 13 infants treated with fentanyl COI in a Midwestern pediatric hospital in the United States. Outcome measures included opioid consumption, pain scores, frequency of adverse events, and subsequent methadone use. RESULTS: The PNCA group (median 6.4 µg · kg(-1) · h(-1) morphine equivalents, range 0.0-31.4) received significantly less opioid (P < 0.001) than the COI group (median 40.0 µg · kg(-1) · h(-1) morphine equivalents; range 20.0-153.3), across postoperative days 0-3. Average daily pain scores (based on 0-10 scale) were low for both groups, but median scores differed nonetheless (0.8 PNCA vs 0.3 COI, P < 0.05). There was no significant difference in the frequency of adverse events or methadone use. CONCLUSION: Results suggest PNCA may be a feasible and effective alternative to COI for pain management in postsurgical infants in the NICU. Results also suggest PNCA may provide more individualized care for this vulnerable population and in doing so, may potentially reduce opioid consumption; however, more studies are needed.