Opioids for the management of severe chronic nonmalignant pain in children: a retrospective 1-year practice survey in a children's hospital.

OBJECTIVE: This study reviewed opioid prescription for chronic severe nonmalignant pain in a multidisciplinary pediatric pain clinic. We looked at benefits and side effects of therapy, and compared our process of opioid prescription with the practice guidelines defined in adult literature. DESIGN: Descriptive retrospective practice survey. SETTING: Multidisciplinary pain clinic in a tertiary pediatric hospital. PATIENTS: During a 12-month period, 104 patients were seen in the clinic, of which 49 received an opioid as part of their pain management; 11 received an opioid chronically, defined as more than 3 months in this study, and 5 of these were still on opioid at the end of the study period although data on one patient are lacking as she had been transferred to an adult clinic. METHODS: Information about patients was obtained from chart review. OUTCOME MEASURES: Benefits and side effects of treatment, as well as the process of prescribing opioids and follow-up. RESULTS: In the four patients studied, there seem to be better pain control and improved function in these patients while on opioid therapy, despite minor side effects. We identified some areas of improvement in our practice and made recommendations for the use of opioids in pediatric chronic severe nonmalignant pain. CONCLUSIONS: The evolution of our four patients seems to be in favor of treatment with an opioid for severe chronic nonmalignant pain in certain pediatric patients, in the context of prescribing in a multidisciplinary pain clinic with a multisystem approach to pain management although more data are needed to know if such therapy is safe and beneficial on a longer-term basis.

A conceptual model and practice framework for managing chronic pain in children and adolescents.

Pain is a complex phenomenon: a sensory experience originating in traumatized tissues; an emotional (affective) experience that signals danger in the internal (body) or external environment; and a "disposition to act" that results either in "action" that prioritizes escape or in "inhibition of action" to minimize injury or facilitate healing. Recent advances in our understanding of the affective components of pain have significant implications for the treatment of chronic pain in children and adolescents. This article describes a chronic pain clinic for children and adolescents developed by the pain service of a large pediatric teaching hospital. Pain is conceptualized and managed in terms of multiple, interrelating systems (the body level, the psychological level, and the social level). This model of care is illustrated with reference to the management of two cases of children with chronic pain and significant functional impairment. A brief overview of the care utilization of 62 children referred to the Chronic Pain Clinic is also provided, with the clinical characteristics of 40 children with somatoform pain disorder (SPD) being described in more detail. Of 28 children with SPD treated with our systems intervention, 82% reported significant reductions in pain intensity, 71% returned to school full time, and 29% part time. An advantage of this integrated, family-based assessment and treatment approach is the overarching emphasis on identifying the contribution of each system to the child's subjective experience of pain, thereby avoiding the deleterious polarization of the pain as either physical or psychogenic in origin.