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Intensive Review of Pediatric Anesthesia 2015

Pediatric Pain Medicine

Stephen Robert Hays, MS, MD, FAAP Associate Professor, Anesthesiology & Pediatrics

Vanderbilt University School of Medicine Pediatric Pain Service / Pediatric Pain Clinic

Monroe Carell Jr. Children’s Hospital at Vanderbilt Nashville, TN

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CME Requirements: Objectives

• Review definitions and neurobiology of pain in children.

• Discuss the multi-modal approach to optimal analgesia.

• Consider doses and indications for selected pharmacologic agents.

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CME Requirements: Disclosures I have no relevant financial relationships with any commercial interests. Vanderbilt is a site for studies as below. Site investigator for industry-sponsored pediatric licensing studies including: IR/ER oxymorphone - Opana®, ENDO ER oxycodone - OxyContin®, Purdue Pharma IV acetaminophen - Orfimev®, Mallinckrodt ER hydromorphone - Exalgo®, Mallinckrodt Tapentadol – Nucynta®, Janssen (IV dexmedetomidine – Precedex®, Hospira)

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CME Requirements: Off-Label

Many anesthetic agents and techniques are

widely used in children; Many such agents and techniques are NOT

approved for such use. Much of current pediatric anesthetic practice,

and most of current pediatric pain practice, is still largely off-label/investigational.

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Definition of Pain • An unpleasant sensory and emotional experience

associated with actual or potential tissue damage or described in terms of such damage. The inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment.

International Association for the Study of Pain

• The behavioral alterations caused by pain are the infantile forms of self-report and should not be discounted as ‘surrogate measures’ of pain

Anand and Craig, Pain 67 (1996)3-6

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The Basic Types of Pain • Somatic – primarily integumentary and/or

musculoskeletal in origin • Visceral – distension, compression or ischemia

in the thorax or abdomen • Neuropathic – direct injury/damage or changes

in the peripheral or central nervous system • Psychogenic – rare and not synonymous with

more common, co-existing psychological overlay • More than one type of pain may be present

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Qualities of Neuropathic Pain • Lancinating, burning, “electrical shock” • Allodynia = pain on light touch • Dysthesia = unpleasant abnormal sensation • Hyperesthesia = increased pain perception • Hyperalgesia = exaggerated pain response • Due to peripheral or central sensitization • And in some cases sympathetic dysfunction

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Referred Visceral Pain 1 1) Somato-visceral Convergence -Visceral pain fibers from the myocardium and somatic pain fibers from left arm converge on the dorsal horn at T4 level à results in classic angina -Right shoulder pain with appendicitis or cholecystitis -Mid-back pain with pancreatitis

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Referred Visceral Pain 2

2) Viscero-visceral Convergence: Visceral pain fibers from the bladder and the colon converge on the dorsal horn at T11, T12 and L1 level à can result in simultaneously perceived symptoms of interstitial cystitis (IC) and irritable bowel syndrome (IBS)

Brain IC

Bladder Colon

+ IBS

Dorsal Horn

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Primary Afferent Fibers

• Three types of sensory fibers • A-β (beta) fibers: transmit touch • A-δ (delta) fibers: myelinated and thus rapidly

transmit sharp, well-localized pain • C fibers: unmyelinated and thus more slowly

transmit dull or aching, diffuse pain • C fibers antidromically release substance P

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Pain Pathways and Projections

Aβ-fiber: touch, pressure Aδ-fiber: first pain, fast, sharp C-fiber: second pain, slow, diffuse

NS = nociceptive specific neuron WDR = wide dynamic range neuron

Rostral projection

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Developmental Neurobiology • Sensory fibers are abundant by 20 weeks • Functional spinal reflex is present by 19 weeks • Connections to the thalamus are present by 20 weeks • Connections to subplate neurons are present by 17 weeks with

intensive differentiation by 25 weeks • Mature thalamocortical projections not present until 29-30 weeks

12 Lee SJ, Ralston H, Drey EA, Partridge J, Rosen MA. Fetal Pain: A Systematic Multidisciplinary Review of the Evidence. JAMA. 2005;294(8):947-954.


Wide-Dynamic Range Neurons • WDR neurons located in lamina V • Receive A-β, A-δ and C fiber input • Respond to both benign and painful stimulus in a

graded (dynamic) fashion • Responsible for referred pain due to organ

convergence from skin/muscle and various visceral organs – such as angina in the left neck and arm

• Crucial role in the development of chronic pain states with “learned” pain pathways

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Peripheral Sensitization

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Wolf and Chong, 1993


Modulators of Peripheral Sensitization

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PNS = peripheral nervous system; CBZ = carbamazepine; OXC = oxcarbazepine; PHT = phenytoin; TPM = topiramate; LTG = lamotrigine; TCA = tricyclic antidepressant.

Beydoun and Backonja, Journal of Pain and Symptom Management Vol. 25 No. 5S May 2003


Central Sensitization

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Wolf and Chong, 1993


Modulators of Central Sensitization

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GBP = gabapentin and [PRG = pregabalin]; LVT = levetiracetam; OXC = oxcarbazepine; LTG = lamotrigine; NMDA = N-methyl-D-aspartate.

Beydoun and Backonja, Journal of Pain and Symptom Management Vol. 25 No. 5S May 2003


Descending Inhibitory System

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PAG = Periaqueductal Grey: Enkephalins and Endorphins LC = Locus Ceruleus: Norepinephrine

NRM = Nucleus Raphe Magnus: Serotonin

Function to inhibit transmission of nociceptive or painful stimuli in the dorsal horn of spinal cord


Modulators of Descending Inhibitory Pathways

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NE = norepinephrine; TCA = tricyclic antidepressant; SSRI = selective serotonin re-uptake inhibitor; SNRI = serotonin and norepinephrine reuptake inhibitor Beydoun and Backonja, Journal of Pain and Symptom Management Vol. 25 No. 5S May 2003


Rational Polypharmacy for Chronic Pain Treatment

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• Acetaminophen: Peripheral/Central • Alpha-2 agonists: Peripheral/Central • Anticonvulsants: Peripheral/Central • Local anesthetics: Peripheral • Non-steroidal anti-inflammatories:

Peripheral/Central • Opioids: Peripheral/Central • Selective norepinephrine reuptake

inhibitors: Central • Selective serotonin reuptake inhibitors:

Central • Tricyclic antidepressants: Central


Pain Assessment Measures

Cognitive/Self-Report

Behavioral Physiologic

Visual Analog Cry: Frequency, quality Heart rate Faces: Bieri, Oucher, Wong-Baker

Facial Expression Blood Pressure

Pain Thermometer Body Position Respiratory Rate Poker Chips Motor Activity Oxygen saturation/level

Color Scales Palmar Sweating Drawings/Maps Catecholamine Levels

Endorphin Levels

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Self-Reported Pain Scales Wong Baker Faces Scale

Bieri Faces Scale R-FPS

Numerical Rating Scale (NRS)

Visual Analogue Scale (VAS)

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Self-Report Pain Tools

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www.usask.ca/nursing/cedn/programs/2010-11_Conferences/Pain2011/Presentations/Pain Scales Master List.pdf


Observational-Behavioral Pain Scales CHEOPS (Children’s Hospital Eastern Ontario Pain Scale)

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Observational Pain Tools

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Pharmacogenetics of Opioids • CYP2D6 critical for analgesic effectiveness • High degree of genetic polymorphism • Ultra-rapid metabolizers and respiratory arrest • CYP2D6 is deficient in ≈ 6-8% of US population • CYP2D6 inhibitors are common and include:

– SSRIs: fluoxetine, paroxetine, fluvoxamine – SNRI: duloxetine (but not venlafaxine) – H1 blockers: hydroxyzine, promethazine – H2 blockers: cimetidine, ranitidine – NSAID: celecoxib

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CYP2D6 Isoenzyme • Cytochrome (CYP) P450 isoenzymes • CYP2D6 responsible for Phase I demethylation • Converts pro-drug into active metabolite: • Metabolizes common opioid analgesics:

Codeine Morphine CYP2D6

Hydromorphone Hydrocodone CYP2D6

Tramadol O-desmethyl tramadol CYP2D6

Oxycodone Oxymorphone CYP2D6

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The Therapeutic Analgesic Window • Maximum serum concentration of opioid still

associated with pain (MCP) versus • Minimal effective analgesic concentration

(MEAC) = the lowest serum analgesic level required for pain control

• Narrow window between MCP and MEAC • Wide inter-patient variability in MEAC • “Goldilocks Phenomenon” – permitting

the patient to find their own “sweet spot” 28


Therapeutic Analgesic Window

29

Patient-Controlled Analgesia. Grass, Jeffrey; MD, MMM Anesthesia & Analgesia. 101(5S) Supplement:S44-S61, November 2005. DOI: 10.1213/01.ANE.0000177102.11682.20


Why PCA Works So Well: MEAC

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Tobias & Ferrante, Problems in Anesthesia, 1998

Patient-Controlled Analgesia. Grass, Jeffrey; MD, MMM Anesthesia & Analgesia. 101(5S) Supplement:S44-S61, November 2005. DOI: 10.1213/01.ANE.0000177102.11682.20


Optimizing PCA • Importance of loading doses to achieve MEAC • Importance of “rescue doses” for breakthrough

pain and sub-therapeutic levels after sleeping • Choice of opioid: consider active metabolites

– Morphine-3-glucoronide and Morphine-6-glucoronide – Hydromorphone excreted unchanged renally

• Multimodal analgesia ≈ balanced analgesia – Routine use of specific adjuvant medications – Dose-dependent side effects thus reduced – More effective analgesia & improved outcomes

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Choice of Opioid for Acute Pain • Morphine versus hydromorphone [versus meperidine] • Morphine superior to meperidine in adults and children

• Comparable analgesia with morphine versus hydromorphone at equipotent doses – more histamine release with morphine

• Morphine is less potent (IV) than hydromorphone: ≈ 5:1

• So if at all possible, use equipotent concentration to reduce effect of inadvertent PCA syringe swap:

–1 mg/ml morphine ≈ 0.2 mg/ml hydromorphone • Meperidine: Infrequently used due to accumulation of

normeperidine which can induce seizures

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Opioids Oral Immediate Release • There is no role for codeine in acute or chronic pain

– This is a prodrug that requires CYP450 conversion into its active metabolite, morphine

• Oxycodone – 5 mg tablets or 5 mg/5 ml liquid – 0.1 mg/kg q 3-6 hrs

• Hydromorphone – 2 mg oral hydromorphone = 2.5 mg of oxycodone

• Morphine – 0.2-0.3 mg/kg q3-6 hrs

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Opioids Long-Acting • Convert to these based upon current opioid use • Oxycodone: SR (OxyContin®) in abuse deterrent formulation

• Morphine: MSContin®, Kadian®, Avinza® • Hydrocodone: Zohydro®

• Hydromorphone: Exalgo®

• Fentanyl: 25 mcg/h = ~90 mg/day PO MS = ~1 mg/h IV MS

• Methadone: 24 h MS mg÷6 = mg po methadone bid – Highly protein bound with sustained clinical effect – go slowly – Prolonged QTc possible at surprisingly low doses

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Other Analgesics • Tramadol • Purportedly good for musculoskeletal pain

– Pediatric RCT data exist for acute and chronic use – SNRI and weak mu-receptor agonist properties – Nausea/vomiting/prururitis with initial use – Avoid using with TCAs, probably the SSRIs (fluoxetine and

paroxetine), and SNRI (duloxetine) to avoid accumulation of tramadol and attendant risk of seizures

– Follow liver function tests for reversible elevation – 50 mg tablet at a dose of 0.5-1 mg/kg (25 mg, 50 mg, 75

mg or 100 mg) q 6 hrs PRN – 100, 200, 300 mg ER tablets

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Non-Steroidal Anti-inflammatory Drugs • Parenteral:

– Ketorolac (Toradol®): 0.25-0.5 mg/kg q6h from infancy – Ibuprofen (Caldolor®): Adults 400-800 mg q6h – [Indomethacin (Indocin®]

• Oral: – Ibuprofen: 10 mg/kg q6h – Naproxen: 10 mg/kg q8-12 h – Diclofenac: 1 mg/kg q8h – Meloxicam: 0.125 mg/kg qday – Celecoxib: 50-100 mg bid (10-25 kg->25 kg)

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Role of Benzodiazepines in Pediatric Acute Pain Management

• Very common and significant co-morbid anxiety occurs in hospitalized children & adolescents

–Pain viewed by many younger children as punishment –Anxiety increases perceived pain intensity in all ages

• A benzodiazepine is often synergistic in reducing opioid use and self-reported pain intensity

• Low-dose diazepam is safe and effective: –30 mg/kg IV or 70 mg/kg PO q 4 hrs on prn basis –Avoid tendency to schedule the benzodiazepine dose –Avoid lorazepam: common paradoxical effect, esp. adolescents

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Types of Pediatric Chronic Pain

Most Common Pain Locations or Diagnoses

21%

16%

16%14%

13%

13%7%

Abdominal Pain

Low Back Pain

Fibromyalgia

Headache

CRPS I and II

Musculoskeletal Pain

Chest and Rib Pain

Vetter, 2008

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Significance: The Personal Health Impact of Pediatric Chronic Pain

• Two large-scale epidemiologic studies have observed a 25% to 46% point prevalence of chronic pain of at least three months duration in the pediatric age group – Headache, abdominal pain, limb pain, and back pain being the most

frequent locations

• Common chronic pain-related functional issues: – Sleep problems (54%) – Inability to pursue hobbies (53%) – Eating problems (51%) – School absence (49%) – Inability to interact with friends (47%)

Perquin et al., 2000; Roth-Isigkeit et al., 2004; Roth-Isigkeit et al., 2005

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Significance: The Public Health Impact of Pediatric Chronic Pain

• Chronic “benign” pediatric pain persists for at least 1 to 2 years in 30%-45% of cases

• In a cohort of 8, 11 and 14 year olds, with chronic headache or chronic back pain

– 59% of females and 39% of males reported similar pain at 21, 24 and 27 years of age

• Children and adolescents with chronic pain: 1. Utilize various healthcare services 2. Require prescription analgesic medications 3. Both at a significantly greater rate than their healthy peers à

Greater healthcare costs

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Perquin et al., 2003; Brattberg, 2004; Perquin et al., 2000, 2001


The Bio-Psycho-Social Approach To Pediatric Chronic Pain

• Cornerstone of integrative pediatric pain medicine – Holistic clinical care that is aimed at assessing and treating

the “whole person” whether child, adolescent, adult, or elder

• Bio à apply one’s biomedical knowledge and skills

• Psycho à attend to common mental health issues

• Social à address family, peer group, school factors

• All three need to be addressed for the greatest chance for successful chronic pain treatment

• Requires a multidisciplinary healthcare team 41


Specific Tangible Goals of a Pediatric Chronic Pain Medicine Program

• Reduce pain intensity and frequency • Maximize patient function (¯ disability) • Improve health-related quality of life • Mitigate adverse parental & family impact • Optimize patient and parental satisfaction • All of these goals can/should be measured

longitudinally - patient-reported outcomes (PRO)

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The Family Stress Model vis-à-vis Pediatric Chronic Pain Management

• Family and situational factors play a major role in the natural history of pediatric chronic pain

• Contending with a child with a chronic medical condition, especially one that is associated with chronic pain and disability, is a potent parental and family stressor

• Effective pediatric pain management is one of the cornerstones of a family-centered philosophy and healthcare model

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Family Dynamics and Pediatric Pain • Pediatric chronic pain frequently impacts the

parents, grandparents and siblings • Often lifestyle related issues and changes • Common occurrence of significant pain amplification

by the parent(s) and family (sick role) • Pain has become their reason for being • Sickness model – form of Munchausen’s by Proxy • Delayed adolescent emancipation • “Super Boy/Girl Syndrome”

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Key Players in a Multidisciplinary Pediatric Chronic Pain Program

• Physical Therapist – Graded strength training and aerobics – Stretching exercises, TENS, ultrasound therapy – Chronic pain-oriented: not “no pain no gain”

• Occupational Therapist – Biomechanics and ergonomics, fine motor skills – Increase ability to perform activities of daily living (ADL) – Work closely with school personnel

• Massage Therapist – Myofascial release and deep tissue massage

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Psychotherapy • Address any mood disorder in addition to patient

coping skills, life stressors at home, school, and peers interaction

• Need to treat the mind as well as the body: cognitive, behavioral and supportive psychotherapy often all have a place

• Frequent patient resistance – “Are you saying it’s all in my head?!”

• Key role of the primary care physician in supporting its use

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Breaking the Chronic Pain Cycle • Often very well-ingrained pain behaviors • Dietary, sleep, lifestyle and social factors • Secondary gain is a real issue in pediatrics • Pain amplification and/or increased somatization

are also frequently present • Sickness model à avoid promoting it • Critical to return to school (“job”) ASAP • Tough love approach in many cases • Be prepared for anger and resistance

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Shared Decision Making • The path to wellness for a pediatric chronic

pain patient is seldom clear • Often a process of trial and error • Empowering the patient and his/her

parents critical to success • Shared decision making is one way to

empower the patient and parent(s) • It works for many but not all families

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Role of Chronic Analgesics • Mechanistic approach targets the various

analgesic receptors • Single drug therapy often falls short • Multimodal drug therapy can be essential • Apply prudent “rational polypharmacy” • Adjuvant medications allow for lower doses and

thus usually fewer side effects • Results in improved patient function • Side effects are dose-dependent • “Start low and go slow” with Rx dosing

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Classes of Chronic Pain Medications Therapeutic Class Drugs

Antidepressants Tricyclic antidepressants, selective serotonin re-uptake inhibitors, serotonin and norepineprine re-uptake inhibitors

Antiepileptics/Anticonvulsants Carbamazepine, divalproex, gabapentin, , lamotrigine, levetiracetam, oxcarbazepine, pregabalin, and topiramate

Anti-dysrhythmics Lidocaine, mexiletine

Topical formulations Lidocaine, capsaicin, diclofenac, many others

Analgesics Acetaminophen, NASIDs, tramadol, opioids

NMDA antagonists Ketamine, dextromethorphan, methadone

GABA antagonists Clonazepam and baclofen

Alpha-2 agonists Clonidine, tizanidine

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Multimodal Pain Therapy

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• Acetaminophen • Alpha-2 agonists • Anticonvulsants • Local anesthetics • Non-steroidal anti-inflammatories • Opioids • Selective norepinephrine

reuptake inhibitors • Selective serotonin reuptake

inhibitors • Tricyclic antidepressants


Pediatric Analgesics and Psychotropics

• Only fluoxetine and escitalopram are FDA-approved for use in patients < 16 years of age

• Most others are not FDA-approved for use in pediatrics and thus require off-label use

• Start low and go slow to assess dose-response and allow accommodation to side effects

• Multimodal drug therapy, aka rational poly-pharmacy is commonly required, though data to support such use are very sparse, even in the adult population

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Non-Opioid Analgesics in the Treatment of Pediatric Pain

• Central voltage dependent calcium channel (α2δ) blockers – Gabapentin and pregabalin: “global analgesics” – Gabapentin oral solution (250 mg/5 ml; 100, 300, 600 mg) – Behavioral/mood changes in pediatric patients

• Tramadol – Avoid or limit dose with the TCAs, SSRIs – Citalopram and sertraline are weak CYP2D6 inhibitors;

duloxetine is moderate • Baclofen/tizanadine are analgesics & muscle relaxants • Most are either not FDA-approved for use in pediatrics and/or

are an off-label use

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Analgesic Psychotropics in the Treatment of Pediatric Pain

• Tricyclic antidepressants: a mainstay Rx for Headaches, neuropathic pain, MSK pain, sleep – Tertiary amines: amitriptyline and imipramine – Secondary amines: nortriptyline and desipramine – Nortriptyline oral solution (5 mg/5 ml) – Initial low-dose and monitor Ψ∆s closely – 2º amines may have faster onset of action – Initial ECG to r/o WPW and prolonged QTc – Pblood level at 0.5 mg/kg: slow metabolizer

• Other antidepressants based on anxiety, need for sleep: – Mirtazapine à consider Remeron® SolTab – Duloxetine + trazodone (for insomnia)

• Benzodiazepine (anxiety) – Clonazepam à consider Klonopin® wafer

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Tricyclic Antidepressants I • TCAs are most commonly used medication for

virtually all pediatric chronic pain conditions – Low NNT of ≈ 2 in adult diabetic neuropathy

• Tertiary amines converted à secondary amines – amitriptyline à nortriptyline metabolite – imipramine à desipramine metabolite – Additive clinical effect but also side effects/toxicity

• Amitriptyline (Elavil®) – Most sedating of the TCAs: usually qhs dosing

• Nortriptyline (Pamelor®) – Only TCA available as liquid (10 mg/5 ml)

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Tricyclic Antidepressants II • Initial low-dose of 5 mg to 10 mg and titrate slowly

every 5 to 7 days to 1 mg/kg • ECG first to rule out WPW and prolonged QTc

– Be aware of other drugs that prolong the QTc – Increased resting heart rate commonly occurs

• POne-time blood level at 0.5 mg/kg to rule out patient being a “slow metabolizer” – If therapeutic level at a low dose, do not increase

dose but be mindful of competitive metabolism • Weight gain common and can be a concern • If daytime drowsiness occurs with amitriptyline

(hang-over effect), then switch to nortriptyline

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SSRI Antidepressants • Selective serotonin-reuptake inhibitors: sertraline,

citalopram, escitalopram • Effective anti-depressants but very little data to

support their use in treating chronic pain • Only citalopram (Celexa®) and paroxitene (Paxil®)

have limited positive efficacy data for adult diabetic neuropathy

• Serotonin syndrome with the concomitant administration of other serotonin agonists – List of drugs is long and a bit disconcerting

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SNRI Antidepressants • Serotonin-norepinephrine reuptake inhibitors • Enhance descending inhibitory pain pathways • Venlafaxine • Desvenlafaxine • Duloxetine

– FDA-approved for depression, generalized anxiety disorder, fibromyalgia, MSK and diabetic neuropathy

– Initially low dose of 20 mg qhs or qAM – Gradually increase to 20 mg bid and 30 mg bid – Maximum dose of 120 mg per day in adults – Sweating, nausea, tachycardia at rapid higher doses


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Other Antidepressants • Mirtazapine • Very useful for co-existing depression + anxiety

– Improved sleep + increased appetite + weight gain – Functional bowel disorders and headaches – 7.5 mg, 15 mg, 30 mg dose qhs (SolTab available)

• Trazodone • Tetracyclic antidepressant

– Often added to SNRI to improve sleep pattern with less dependency than with other Rx sleep aids

– 50 mg scored tablet at a sliding dose of 25 mg, 50 mg, 75 mg or 100 mg qhs


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Benzodiazepines • Alprazolam • Excessive use of it for chronic anxiety

– More appropriate for panic disorder • Clonazepam • Some data to support its use in neuropathic pain

– Initially 0.25 mg to 0.5 mg bid scheduled – In select patients consider dissolvable wafer

• Diazepam • Active metabolites with sustained clinical effect

– Anxiolytic and muscle relaxant properties – 1 mg to 5 mg (0.07 mg/kg) PO q 8-12 hours PRN


Anticonvulsant Analgesics I • Central voltage dependent calcium channel (α2δ)

blockers – Considered widely applicable “global analgesics” – Gabapentin: 5mg/kg up to 20 mg/kg per dose

• Initially 100 mg tid increased gradually to 300 mg tid and as needed 600 mg tid (1200 mg po tid in adults)

– Pregabalin • FDA approved for fibromyalgia and select neuropathies • Initially 50 mg bid increased gradually to 150 mg bid and as

needed to maximum of 300 mg bid – Need to be taken on scheduled basis and not PRN – Virtually no toxicity seen with other anticonvulsants but

95% excreted unchanged renaly: Pserum CR 61


Anticonvulsant Analgesics II • Carbamazepine (Tegretol®) • Levetiracetam (Keppra®) • Lamotrigine (Lamictal®) • Oxcarbazepine (Trileptal®)

– Peripheral and central Na channel blocker – Adults: 300 mg bid à target dose of 900 mg bid – Pediatrics: 8-10 mg/kg/day ÷ bid initially à reported

target anti-seizure dose for 20-29 kg = 900 mg/day; 29-39 kg = 1200 mg/day; > 39 kg = 1800 mg/day

– 3% incidence of hyponatremia (< 125) in adults but only 0.4% <17 yrs; sedation common at higher doses 62


Local Anesthetics • Lidocaine

– Amide local anesthetic via Na channel blockade – Systemic analgesic at 3-5 mcg/ml plasma levels – Only local anesthetic with documented and clinically

significant anti-inflammatory properties – Diagnostic and therapeutic intravenous infusion of 1-2

mg/kg over 1 hour for neuropathic pain – Commonly used topically as 5% patch (Lidoderm®)

• Mexilitene – Oral equivalent of lidocaine and thus promising – Initial 150 qd mg increased to 150 mg bid and tid – But high, use limiting, incidence of gastritis and diarrhea

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Muscle Relaxants

• Baclofen as an analgesic and muscle relaxant – GABA-B receptor agonist – 10 mg tid initially, increased to 20 mg tid

• Tizanidine – α2 agonist properties similar to clonidine – Analgesic and muscle relaxant properties – Postural hypotension at higher doses – 2 mg tid with a maximum dose of 8 mg tid – Follow liver function tests for reversible elevation

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The Child in Pain • Acceptance is hard. To accept my pain means holding it in my arms, like a package

handed to me, my proper burden to be carried. The package may be heavy as lead, or burning hot, or stuck through with razors, but I must concede that it is my package, simply because it has arrived in my life. It is not a mistake. It has not been sent by accident to the wrong person. I may not welcome it, but accepting it means I carry it without protest for as long as necessary — and then I lay it down. Jeanne Duprau

• People don't expect government to solve all their problems. But they sense, deep in their bones, that with just a slight change in priorities, we can make sure that every child in America has a decent shot at life, and that the doors of opportunity remain open to all. They know we can do better. Barack Obama

• Right from the moment of our birth, we are under the care and kindness of our parents, and then later on in our life when we are oppressed by sickness and become old, we are again dependent on the kindness of others. Since at the beginning and end of our lives we are so dependent on others’ kindness, how can it be in the middle that we would neglect kindness toward others? The Dalai Lama

• Do not wait for leaders; do it alone, person to person. Mother Teresa

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pediatric pain medicine - secure.societyhq.com · musculoskeletal in origin • visceral –...

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