Thursday, April 1, 2010

Pediatricians Wary of Treating Chronic Pain

Many pediatricians do not consider it their responsibility to treat severe, chronic pain in their young patients, according to a new survey. Meanwhile, children’s pain is often undertreated, so the need for equitable and effective pain management services for this population is a vital concern.

Writing in the Journal of Palliative Medicine, researchers from the University of Florida College of Medicine reported on a survey addressing pediatric chronic pain and palliative care sent to a random sample of 800 U.S. pediatricians. Of the 303 responding, most were non-Hispanic white (56%), and had been in practice 10 or more years (68%). Only about one third of pediatricians (32%) felt it was their responsibility to treat chronic pain; most believed pain specialists (58%), other specialists (40%), and/or hospice providers (26%) should be responsible. Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) were commonly cited medications for “usually” or “always” treating pain in children (62% and 67%, respectively), and 19% reported “rarely” or “never” prescribing opioid analgesics in their pediatric practices. Multivariate analyses showed that there were no consistent pediatrician qualities that predicted the use of opioid prescriptions.

The researchers conclude that a common approach among pediatricians for identifying, assessing, and treating pain is lacking. Only a minority of respondents reported treating chronic, severe pain with opioids, potentially reflecting a fear of side effects and/or the desire for other providers to manage such pain. The findings also may reflect the more frequent, non-serious pain typically seen in pediatricians’ offices and a lack of experience with more serious conditions requiring complex pain management; hence, there is an emphasis on referring such patients to specialists.

COMMENTARY: Pain in children, especially chronic pain, can be a diagnostic and therapeutic challenge. Yet, there are not enough specialists in pediatric pain (or pain overall) to meet the demand, so general practice pediatricians and other healthcare providers need to learn more about and take more responsibility for treating these young patients. Roughly two-thirds of respondents said that they often or always prescribe acetaminophen or NSAIDs; however, NSAIDs might be more hazardous long-term in children (as they are in adults) than potent opioid analgesics [as noted in our prior blogpost here]. A finding in the study that pediatricians with high percentages of patients on Medicaid report even lower opioid prescribing is worrisome, given that this population typically uses more medical services and has lower health status that the general population.

In a news release accompanying the journal article [Mize 2010], principal investigator Lindsay A. Thompson, MD, emphasized that medical schools are not adequately addressing pain management and, consequently, physicians do not have as much knowledge in this area as they should. Many pediatricians appear to be reluctant to manage that part of their patients' treatment, particularly when it comes to prescribing effective opioid analgesics. She concluded that, “With the number of children with chronic and life-limiting illnesses increasing, the demand for equitable and effective pain services will continue to grow.”

> Mize L. Pediatricians say colleagues cautious about treating chronic pain in children. University of Florida Health Center [news release]. 2010(Mar 3) [
available here].
> Thompson LA, Knapp CA, Feeg V, et al. Pediatricians' management practices for chronic pain. J Palliative Med. 2010(Feb);13(2):171-178 [
available here].