Pediatricians say colleagues cautious about treating chronic pain in children

Many pediatricians don't think it's their responsibility to treat severe, chronic pain in their patients, according to a new study co-authored by several University of Florida College of Medicine researchers and an investigator from Molloy College.

Writing in the February issue of the Journal of Palliative Medicine, researchers said only 32.3 percent of pediatricians from Florida and California surveyed said treatment of chronic pain was their responsibility.

Physicians don't have as much knowledge of pain treatment as they should, and many pediatricians probably are afraid to manage that part of their patients' treatment, said principal investigator Lindsay A. Thompson, M.D., an assistant professor of pediatrics at UF.

"The side effects for pain medications can be pretty severe," she said. "The opioid medicines are the gold standard for pain treatment, but they have side effects that can decrease your breathing. When you're not in the hospital setting, that's dangerous and primary care providers may worry about the side effects more than the pain."

The researchers received 303 fully completed responses from mail and online questionnaires sent to 800 pediatricians about treatment of severe, chronic pain. Questions also asked about demographics, clinical experience and components related to palliative care.

Pediatricians were allowed to select more than one option when asked who should treat their patients' chronic pain, and most respondents said they thought other providers should oversee pediatric pain treatment.

Pain specialists were the most popular choice, with 58.1 percent of respondents selecting them as the preferred providers for pediatric pain treatment. Other specialists and hospice providers were the second and third most popular options selected, with 39.6 percent and 26.1 percent of respondents selecting them, respectively.

But Thompson emphasized that these aren't realistic ideas, given a lack of pain specialists in the United States, especially ones working in pediatrics.

In the responses, 84.2 percent of pediatricians say they "often" or "always" use patient reports to evaluate pain, and 87.1 percent use parental reports. About 67 percent always or often watch for nonverbal cues, and about 50 percent ask patients to keep "pain diaries."

When it comes to the most commonly used treatments for pain, acetaminophen and nonsteroidal anti-inflammatory drugs, or NSAIDS, topped the list: 61.7 percent of pediatricians said they often or always use acetaminophen, while 66.9 percent often or always use NSAIDS.

Thompson said she thought it was "worrisome" that pediatricians were not more comfortable using acetaminophen and NSAIDS in conjunction with more potent pain medications.

She emphasized that medical schools need to teach students more about pain management, and providers' thinking toward pain needs to evolve.

"Because of the way the population is moving — its long-term illness, its chronic care — I think we have to incorporate these new morbidities, like pain, as something that we have to address," she said. "It needs to become a non-stigmatized, or more readily accepted outcome in and of itself. I think services for kids with chronic illness, life-limiting illnesses need to move to a lifelong model, where pain is one of the first things that physicians and providers address."

Nathaniel Nonoy, M.D., director of the Pediatric Acute Pain Service at the University of North Carolina School of Medicine, said while many children need the services of a pain specialist, pediatricians and other health-care providers not specializing in pain need to learn more about and take more responsibility for treating kids with chronic pain.

"There are a lot of children out there with chronic pain, so many of them that not every one can possibly be treated by a specialist. There simply aren't enough available for every child who needs one," said Nonoy, who did not participate in the research. "Pediatric pain is still a tremendous diagnostic and therapeutic challenge. There's no question about it. We have a lot of work to do in giving the kids the kind of care that they need."

In addition to Thompson, the research was conducted by UF researchers Caprice Knapp, Ph.D., and Elizabeth Shenkman, Ph.D., both of the college's Institute for Child Health Policy; Vanessa L. Madden, B.Sc., a research coordinator at the college; and Veronica Feed, Ph.D., R.N., assistant dean for research and scholarly practice at Molloy College's division of nursing.