1. Treatment Options for Treating Pain RECOGNIZE PAIN Pharmacological interventions Non-pharmacological interventions

2. Acute Pain Management Non-pharmacological – Distraction – Music – Holding – Comforting – Positioning – Consoling

3. Acute Pain Management Pharmacological – Consider severity and cause Opioids for post-operative pain – Consider delivery route Enteral IV Bucal or intranasal Topical – Consider side effects Address constipation if using opioids

4. Chronic Pain Management Address the source if known and feasible – Treat pain as source is addressed Use shared decision making to help guide treatment decisions – Realistic goal setting – Prepare family that process of finding the best treatment options may take time Consider both pharmacological and non- pharmacological treatment options

5. Medication Options Gabapentin/Pregabalin – inhibits excitation by binding to alpha-2-delta subunit of Ca ion channels – Neuropathic pain and visceral hyperalgesia Nortriptyline/Amitriptyline – Tricyclic inhibits reuptake of serotonin and norepi – Neuropathic pain and visceral hyperalgesia – Dry mouth, constipation, urinary retention, agitation, risk of prolonged QTc

6. Medication Options Opioids – Opioid receptor agonists – Pain, storming, dyspnea – Risk of sedation, constipation, tolerance Clonidine – Alpha 2 adrenergic receptor agonist – Storming, spasticity, adjust to other pain medications – Hypotension, bradycardia, sedation Cannabinoids – Central pain – Limited studies in children

7. Chronic Problems Associated with Pain Spasticity – Cause of pain – Worsened by pain – Baclofen, benzos, botox, ITB, SDR – Bracing, positioning, stretching Dystonia – Cause of pain – Worsened by pain – Baclofen, trihexylphenidyl, carbidopa/levodopa, DBS Hip subluxation – Often incidental – May be source of pain and may limit care – Botox around the hip – Surgical interventions – Positioning devices