“Golden Half Hour in Chronic Pain”

A recent editorial (NL Schecter et al. JAMA Pediatr. 2021;175(1):7–8. doi:10.1001/jamapediatrics.2020.1798. Full text: The Golden Half Hour in Chronic Pediatric Pain—Feedback as the First Intervention -thanks to Ben Gold for this reference) notes that with pain we need to take a more holistic approach: ” Commonly, patients with chronic pain are evaluated by multiple clinicians, including pediatricians and specialists, each of whom may have addressed only one of the child’s persistent symptoms (ie, headache, abdominal pain, dizziness, nausea, or fatigue). When each symptom is addressed in isolation, it seldom provides comprehensive relief. Moreover, this process can foster a family’s belief that each symptom represents a distinct illness.”

Key points:

  • Brief feedback discussion following an assessment for pediatric chronic pain may be akin to the “golden hour” in trauma or neonatal care.  During this critical time, there is an opportunity to connect with a family, clarify misconceptions, move toward a shared biopsychosocial understanding of pain, and engage families in a comprehensive plan for recovery.”
  • Tips for mastering the golden hour:
    • Elicit Parent and Child Expectations at the Outset “This facilitates a thorough understanding of a family’s main concerns, reduces anxiety, and improves satisfaction. For example, if a parent reports that they expect their child to undergo additional diagnostic testing, this needs to be appreciated and addressed during the feedback.”
    • Validate Symptoms  “Explicitly stating that you do not believe the child is “faking” or that the problem is merely due to psychological stress is critical”
    • Offer a Positive Diagnosis “Although you are special, your symptoms are not unique or mysterious…. If the focus is on what has been ruled out, there are always additional diagnoses that you, the patient, or the internet can introduce.”
    • Provide Education “it can be helpful to explain that chronic pain is like a fire alarm that keeps ringing although there is no fire. “
    • Emphasize a Multidisciplinary Intervention Plan plan for medical intervention, psychological support, and physical activity
    • Stay Connected “Plan follow-up visits (every 4-6 weeks)”
    • Offer an Optimistic Appraisal  “optimistic appraisals are most effective when a clinician has first validated a child’s pain, provided a positive diagnosis and education, and outlined an evidence-based, multidisciplinary approach to care”

My take: This article offers helpful advice. However, whether there is a “golden hour” of opportunity is not clear. Having better outcomes with early intervention could easily be related, at least in part, to selection bias.

Related blog posts:

From Ashish Jha Twitter Feed 2/1/21:

CDC Guideline for Prescribing Opioids for Chronic Pain

Full Text: CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016

D Dowell et al. JAMA. Published online March 15, 2016. doi:10.1001/jama.2016.1464 .

Excerpts:

  • No evidence shows a long-term benefit of opioids in pain and function vs no opioids for chronic pain with outcomes examined at least 1 year later (with most placebo-controlled randomized clinical trials ≤6 weeks in duration).

  • Extensive evidence shows the possible harms of opioids (including opioid use disorder, overdose, and motor vehicle injury).

  • Extensive evidence suggests some benefits of nonpharmacologic and nonopioid pharmacologic therapy, with less harm.

CDC: “We know of no other medication routinely used for a nonfatal condition that kills patients so frequently,”

1st Six Recommendations (12 total)

1. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. (Recommendation category: A; evidence type: 3)

2. Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and consider how opioid therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. (Recommendation category: A; evidence type: 4)

3. Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy. (Recommendation category: A; evidence type: 3)

4. When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. (Recommendation category: A; evidence type: 4)

5. When opioids are started, clinicians should prescribe the lowest effective dosage.  (Recommendation category: A; evidence type: 3)

6. Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than 7 days will rarely be needed. (Recommendation category: A; evidence type: 4)

Other points:

  • Avoid concurrent benzodiazepines
  • Review state prescription drug monitoring program to look for dangerous combination therapies and prior opiod dosing
  • Consider risk mitigation strategies (eg. naloxone)
  • Suggests urine screening at start to screen for illicit substance abuse which increases risk

USAToday’s review of these guidelines: CDC issues new guideline on opiods

Bottomline: This report is very important for those who prescribe opiods for chronic pain.

Law Library, Univ of Michigan

Law Library, Univ of Michigan

Ketamine for chronic pain –is this a good idea?

A recent phase 1 study explored the use of oral ketamine for chronic pain (J Pediatr 2013; 163: 194-200).

Ketamine has several mechanisms of actions in improving pain.  It is frequently used in emergency room settings because of its analgesic and dissociative amnestic qualities.  In addition, it has relatively little cardiorespiratory impact, a short half-life, and is better tolerated in children than adults.

Given the frequency of chronic pain in children and the relative paucity of treatment options, the authors aimed to determine whether ketamine in a short-term study (2 weeks) would be safe and effective.  This prospective study enrolled 12 patients who received ketamine 3 times per day at dosages of 0.25-1.5 mg/kg/dose .**

Pain diagnoses included chronic pancreatitis, Crohn’s disease, esophageal spasm, headache, joint pains, and other causes.  Median age was 16 years (range 11-19).

Results:

  • Two participants, both treated with 1.5 mg/kg/dose, experienced dose-limiting toxicities: sedation and anorexia.
  • Of the 12 patients, 5 had improvement in pain scores; 2 of these patients had complete resolution of pain which lasted >4 weeks off ketamine treatment.
  • There was evidence of norketamine accumulation in many patients.  Norketamine is the major metabolite of ketamine.

**Note: All medication dosages should be checked in standard references for individual patients.  This blog may have transcription errors with regard to dosages.

Related blog posts:

Pain changes brain

For several years, there has been research showing changes in PET scans and functional MRI in association with functional abdominal pain.  A recent article goes a step further showing microstructure  brain changes in patients with chronic pancreatitis (Gut 2011; 60: 1554-62).

This study examined 23 patients with pain due to chronic pancreatitis and 14 controls.  Using a 3T MR scanner, apparent diffusion coefficients (ADC) and ‘fractional anistotropy’ (FA) values were assessed in numerous parts throughout the brain.  This new technology, uses an MRI for diffusion tensor imaging which assesses changes in white and grey matter microstructure not evident with more conventional imaging.  Chronic pancreatitis patients had increased ADC in the amygdala, cingulate cortex, and prefrontal cortex.  In addition, FA values were reduced in the cingulate cortex and secondary sensory cortex.  These areas of the brain with these changes are known to be involved in the processing of visceral pain.  Microstructural changes were correlated to patients’ clinical pain scores.  Some of the changes can be influenced by other factors including alcohol usage, depression, Alzheimer’s or diabetes.

This study echoes findings from others that demonstrate structural reorganization of the brain in association with chronic pain.

Additional references:

  • -Gastroenterology 2010; 139: 1310. n=15 IBS women, 12 controls.  IBS pts have emotional modulation of neural responses to visceral stimuli (eg rectal stimulation) –based on functional MRI studies.
  • -Gastroenterology 2006; 130: 26 & 34. Functional MRI measured in response to barostat show increased sensitivity in pts c IBS. Also, altered 5-HT signaling in IBS-D & IBS-C.
  • -J Pediatr 2001; 139: 838-843. Pts c IBS, RAP more sensitive to visceral perception in rectum and stomach respectively.
  • -Gastroenterology 2005; 128: 1819. Brain response to visceral aversive conditioning –>similar cortical responses between actual and anticipated stimuli.
  • -Cereb Cortex 2010; 20: 1409-19.  Changes in brain anatomy associated with neuropathic pain following spinal cord injury.
  • -J Am Acad Child Adolesc Psychiatry 2010; 49: 173-83.  White matter microstructure changes in adolescents with major depression.