The American Pain Society (2001) has issued a position statement about pediatric chronic pain. The statement represents an important milestone in addressing a neglected area of pediatrics. Children with chronic pain and their families experience significant emotional and social consequences as a result of pain and varying degrees of disability.
According to the American Pain Society (1999), acute pain follows injury to the body and usually disappears when the injury heals. It is often associated with objective physical signs of sympathetic nervous system activity, such as increased vital signs and diaphoresis. Chronic pain is rarely accompanied by signs of sympathetic nervous system arousal. The lack of objective signs may prompt the inexperienced clinician to say the child does not "look" like he or she is in pain. Acute pain is self-limited. Chronic pain may begin as acute pain but it continues beyond the normal time expected. In the past chronic pain was defined as having pain for longer than 6 months. It is now recognized that chronic pain can occur much earlier (American Pain Society, 2001).
Since biological, psychological, social, cultural, and developmental factors can impact pain-related functioning, a thorough evaluation of the child and family is required.
Assessment begins with a history of the current problem, including a description of pain that includes the sensory characteristics, intensity, quality, location, duration, variability, predictability, exacerbating and alleviating factors, and impact on daily life. It is important to determine the current treatments being utilized for the pain, including alternative therapies. A complete physical and neurological examination is essential in the assessment.
A multimodal treatment plan is often the most effective approach with chronic pain. The treatment goal is to reduce or eliminate chronic pain so that the child's functioning is maximized and the quality of life is improved. Treatment techniques include:
Referral to a pediatric pain program should be considered for children with complex or refractory problems not responding to traditional interventions (American Pain Society, 2001).*
Chronic pain in children is a significant problem with emotional, social, and developmental consequences. Nurses need to take an active role in the identification, assessment, and treatment of chronic pain in children. For example, nurses can introduce the use of pain diaries which capture the changing quality and intensity of chronic pain and its influence on activities of daily living.
Helping families comply with drug therapy often includes frank discussions about narcotic addiction to dismiss unrealistic fears of this rare occurrence in patients who take opioids for pain. Physical dependence, tolerance and addiction are discrete and different phenomena that are often confused. The American Society of Addiction Medicine (ASAM), the American Academy of Pain Medicine (AAPM), and the American Pain Society (APS) (2001) recommend that the following definitions be used:
Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following:
Physical dependence is a state of adaptation that often includes tolerance and is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.
Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time.
A key component of nonpharmacologic or "mind-body" techniques is helping children identify which approaches appeal to them and integrating the interventions into the child's and family's life style (Kuttner, 1997). School nurses should be involved in the treatment plan for safe storage of drugs, especially opioids, and in establishing practical solutions for therapies that require a quiet, private place. Family involvement in every aspect of care is essential.
*Information about pain clinics in the United States is available on ampainsoc.org.
A comprehensive pain website with links to numerous other resources is www.pain.com.
March 15, 2002