1. Pain Management: Pediatric Chronic Illness Gregory Kirkpatrick, MD Pediatric Hematology/Oncology

2. Childhood Chronic Pain Position Statement from the American Pain Society Significance of the problem : Affects 15% to 20% of children (Goodman & McGrath, 1991). Creates significant emotional and social consequences. Financial costs, healthcare utilization and indirect costs are high Impact child’s overall health and may predispose for adult chronic pain (Campo et al., 1999; Walker, Garber, Van Slyke, & Greene, 1995).

3. Defining Pain Pain means an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Acute pain signals a specific nociceptive event and is self-limited Chronic pain has been defined as pain that lasts longer than 3 (6) months and continues beyond the normal time expected for resolution of the problem or persists or recurs for other reasons.

4. Defining Pain Acute Pain Classification Somatic Pain: Result of activation of nociceptors (sensory receptors) sensitive to noxious stimuli in cutaneous or deep tissues. Experienced locally and described as constant, aching and gnawing. The most common type in cancer patients. Visceral Pain: Mediated by nociceptors. Described as deep, aching and colicky. Is poorly localized and often is referred to cutaneous sites, which may be tender. In cancer patients, results from stretching of viscera by tumor growth.

5. Defining Pain Chronic Pain Classification Nociceptive pain: Visceral or somatic. stimulation of pain receptors by tissue inflammation, mechanical deformation, ongoing tissue injury. Responds well to common analgesic medications and nondrug strategies. Neuropathic Pain: Involves the peripheral or central nervous system. Does not respond predictably to conventional analgesics. May respond to adjuvant analgesic drugs. Mixed or undetermined pathophysiology: Treatment is unpredictable; requires various approaches. Psychologically based pain syndromes: Traditional analgesia is not indicated.

6. Assessing Pain

7. Age variations in abilty to identify Location Quality Time element Source

8. Assessing Pain Wong/Baker FACES Pain Rating Scale FLACC Pain Intensity Rating

9. Assessing Pain

13. Managing Pain General Treatment Principles: Ask about pain regularly. Believe the patient's and family's reports of pain and what relieves it. Choose appropriate pain control options. Deliver interventions in a timely, logical, and coordinated fashion. Empower patients and their families.

14. Managing Pain Opioid Medications

15. Managing Pain Opioid Medications

16. Managing Pain Opioid Medications

17. Managing Pain Opioid Medications

18. Managing Pain Non-steroidal Anti-inflammatory

19. Managing Pain Adjuvant Medication for Pain Corticosteroids Decadron Prednisone Most specific indication for brain metastasis and spinal cord compression. May add benefit for pain associated with inflammatory process. Side effects common: hunger and weight gain, stretch marks, muscle weakness

20. Managing Pain Adjuvant Medication for Pain Anticonvulsants Carbamazepime Gabapentin Neuropathic pain: May be helpful as antidepressant

21. Managing Pain Adjuvant Medication for Pain Antidepressants Amytriptyline Doxepin Trazadone Serotonin re-uptake inhibitors May be helpful as antidepressant Neuropathic pain of peripheral nerve injury

22. Managing Pain Adjuvant Medication for Pain Diphenhydramine Transdermal clonidine (0.1 to 0.2 mg/day)

23. Managing Pain Wisconsin Cancer Pain Initiative

24. Managing Pain Physical Pain Management Exercise regimen Cutaneous stimulation techniques: superficial heat and cold, massage, pressure or vibration Physical therapy: active and passive range-of-motion exercises to prevent joint contracture, muscle atrophy, cardiovascular deconditioning

25. Managing Pain Rehabilitation Treatment Modalities Physical Therapy Occupational Therapy Alternative Interventions: Acupuncture, reflexology, aroma therapy, music therapy, dance therapy, yoga, hypnosis, relaxation and imagery, distraction and reframing, psychotherapy, peer support group, spiritual, chiropractic, magnet therapy, bio-feedback, meditation, relaxation techniques

26. Managing Pain Nonpharmacologic Interventions: Invasive Procedures With rare exception, noninvasive treatments should precede invasive palliative approaches Palliative radiation therapy: treatment of symptomatic metastasis where tumor has caused pain, obstruction, or compression. Radiation should be administered in the fewest fractions possible to promote patient comfort during and after treatment. Neurolytic blockade of peripheral nerves should be reserved with rare exception for instances in which other therapies (palliative radiation, TENS, pharmacotherapy) are ineffective, poorly tolerated, or clinically inappropriate. Intraspinal medication (Ommya resevoir)

27. Managing Pain Psychological Intervention

28. Managing Pain Painful Procedures

29. Perceived Pain

30. Specific Disease States Sickle Cell Anemia Bone Infarction Pneumonia Abdominal Crisis

31. Specific Disease States Cancer Bone Pain Primary Bone Tumors Bone Metastasis Bone Marrow Metastasis

32. Specific Disease States Cancer Nerve Pain Spinal Cord Compression Increased Intracranial Pressure Peripheral Nerve Compression/Injury

33. Specific Disease States