C C E E N N L L E E Pediatric Palliative Care Pain Physiology Pain is a complex physiologic process Transduction Transmission Perception of pain Modulation

C C E E N N L L E E Pediatric Palliative Care Types of Pain Nociceptive Pain (normal processing of pain)  Somatic  Bone, joints, connective tissue  Achy, throbbing  Well localized  Visceral  Organs, soft tissue  Aching, cramping  Localized, diffuse Neuropathic Pain (abnormal processing of pain)  Centrally mediated  Deafferentation pain  Sympathetic pain  Peripherally mediated  Polyneuropathies  Mononeuropathies  Sharp, shooting, electric  Usually requires adjuvant medications

C C E E N N L L E E Pediatric Palliative Care Tolerance  effect of a medication over time, requiring  dose to achieve same level of efficacy Should consider differential diagnosis Tolerance ≠ addiction Easily managed by  dose or  interval between dosing Should not withhold opioid

C C E E N N L L E E Pediatric Palliative Care Physiological Dependence Development of withdrawal syndrome after:  Abrupt discontinuation of therapy  Substantial dose reduction  Administration of antagonist medication (naloxone)

C C E E N N L L E E Pediatric Palliative Care Psychological Dependence (Addiction) Pattern of compulsive drug use characterized by continued craving for an opioid and the need to use the opioid for effects other than pain relief Three distinguishing characteristics  Continued cravings with/without pain  Illegal and anti-social behavior in order to obtain the drug  Chronic, relapsing condition APS, 2008

C C E E N N L L E E Pediatric Palliative Care Pain Management Severe pain should be seen as a medical emergency Rapid assessment and treatment of pain is imperative Close collaboration with physicians/APNs, pharmacists, other nurses, and family is essential to optimum use of analgesic treatments.

C C E E N N L L E E Pediatric Palliative Care WHO Analgesic Stepladder

C C E E N N L L E E Pediatric Palliative Care By the Clock Acetaminophen/NSAIDs – PRN or ATC Opioid medications should be given on scheduled basis  Provide adequate PRN doses for breakthrough pain Adjuvant medications – dependent on particular agent

C C E E N N L L E E Pediatric Palliative Care Stay Ahead of Pain Individualize to the child based on their level of pain, prior experience with opioids, and desired activity level Frequently assess pain level and adjust as necessary In pain crisis - rapid titration to comfort is imperative Dosages calculated by weight

C C E E N N L L E E Pediatric Palliative Care Least Traumatic Route of Administration  Oral is not always the least traumatic means, particularly in toddler/early childhood  Avoid rectal  No ‘SHOTS’

C C E E N N L L E E Pediatric Palliative Care Routes Oral/Transmucosal  Long-acting preps  Breakthrough IR preps Transdermal  Limited use in escalating pain

C C E E N N L L E E Pediatric Palliative Care Routes (cont.) Topical Intravenous/Subcutaneous Intraspinal/epidural

C C E E N N L L E E Pediatric Palliative Care Opioids in Neonatal Population Reduce clearance of majority of opioids Prolonged half-life Tachyphylaxis