1. Pain is defined by the International Association for Study of Pain as an “unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terns of such damage”. Pain is subjective and multidimensional. Opioid pain relievers saw a 63% increase in use among Americans from 1997 to 2006 (9 years) beginning at age 12. The drug category that Americans aged 12 and older use the most for non medical reasons is opioid analgesics, followed by marijuana. Opioid medications are readily available to the pediatric population. 19% of Americans aged 12 and older get their opioids that are used non-medically from a prescribing physician, and about 50% get them from a family member. Through adolescent years 12-17, the percentage of the population who have used illicit drugs is staggering. 3.9% of 12-13 year olds 9.1% of 14-15 year olds 16% of 16-17 year olds In a recent study by the CDC, 1 in 5 high schoolers have taken a prescription pain killer without a prescription. Pediatrics are at an increased risk for substance abuse. The adolescent brain is developing quickly; however, there is a slow development in the frontal cortical neural systems that lead to adolescents’ natural tendency towards increased risk taking behaviors. Addiction in the pediatric population have steep implications. Introduction of drug abuse during childhood increases the risk of becoming a drug addict later in life. 25% of children who begin to abuse prescription pain killers under the age of 13, will become addicts as an adult. Children who abuse prescription pain killers are 8x more likely to abuse marijuana. Non-Narcotic Perioperative Pain Management in Pediatric Population C. Frederick, SRNA, B. Garrett, SRNA, C. Nearn, SRNA, L. Parker, SRNA, O. Garcia, SRNA, T. Mendelson, SRNA, L. Martin, SRNA Middle Tennessee School of Anesthesia References Continuous pre-emptive analgesia treatments include: regional local anesthetics, NSAIDs, and opiates in conjunction. REGIONAL ANESTHESIA Techniques are increasingly used for both acute and chronic pain management Advantages in ultrasound guidance and tailored dosage regimens Peripheral nerve blocks provide longer lasting analgesia and are associated with a lower rate of complications ACETAMENOPHEN Most common analgesic used Potent post-operative analgesic Safe, potential to be primary analgesic TORADOL A non-steroidal anti-inflammatory drug Relatively low incidence of adverse effects Potent Analgesic Effect IBUPROFEN A non-steroidal anti-inflammatory drug Relatively low incidence of adverse effects Severe pain combination used with opioids CAM (Complementary and Alternative Medicine) Activities Included but not limited to: acupuncture, guided imagery, massage therapy, meditation, movement therapy, relaxation techniques, spinal manipulation, yoga Introduction Results Contact Information chelsea.frederick@mtsa.edu, omar.garcia@mtsa.edu brittony.garrett@mtsa.edu, leia.martin@mtsa.edu, tami.mendelson@mtsa.edu, chelsey.nearn@mtsa.edu lauren.parker@mtsa.edu MedIndia. Retrieved on January 6, 2015. http://www.medindia.net/patients/patientinfo/how-is-cancer-pain-assessed.htm Berde CP, Sethna NP. Analgesics for the treatment of pain in children. N Engl J Med. 2002, 347: 1094-1103 Applications of Regional Anesthesia in Pediatric Patients. (n.d.). Retrieved January 6, 2015, from http://bja.oxfordjournals.org/content/111/suppl_1/i114.full Carney, D., Nicolette, L.A., Ratner, M.H., Minerd, A., & Baesl, T.J. (2001). J Pediatric Surgery, 36. 76-79 Charett, S., Fiola, J.L., Charest, M., Villeneuve, E., Theroux, J., Joncas, J., Parent, S., & May, S.L. (2014). Guided imagery for adolescent post-spinal fusion pain management: a pilot study. American Society for Pain Management Nursing. 6(4) 1-10. Forrest, J.B., Heitlinger, E.L., & Revell, S. (May 1997). Ketorolac for postoperative pain management in children. Drug Safety, 16(5), 309-329 Gehdoo, R. P. (2004). Post operative pain management in paediatric patients. Indian J Anaesth, 48(5), 406-14. Impact of Non-Narcotic Oral Analgesics on Pain Management. (n.d.). Retrieved January 6, 2015, from http://www.amjmed.com/article/0002-9343(88)90471-8/pdf International association for study of pain, Subcommittee on Taxonomy. Pain terms: a list with definitions and notes on usage. Pain 1979; 6: 249-252. Lalloo, C., Stinson, J.N. (2014). Assessment and treatment of pain in children and adolescents. Best Practice and Research Clinical Rheumatology, 28(2), 318. Module 6 Pain Management: Pediatric Pain Management. (2013, January 6). Retrieved January 6, 2015, from http://www.ama-cmeonline.com/pain_mgmt/printversion/ama_painmgmt_m6.pdf National Institute of Health (July 2014). Complementary, alternative, or integrative health: what’s in a name? National Center for Complementary and Alternative Medicine. http://nccam.nih.gov/health/whatiscam Popping Pills: Prescription Drug Abuse in America. (n.d.). Retrieved January 7, 2015, from http://www.drugabuse.gov/related-topics/trends-statistics/infographics/popping-pills-prescription-drug- abuse-in-america Post Operative Pain Management in Pediatric Patients. (n.d.). Retrieved January 6, 2015, from http://medind.nic.in/iad/t04/i5/iadt04i5p406.pdf Preemptive Analgesia-Treating Postoperative Pain by Preventi... : Anesthesia & Analgesia. (n.d.). Retrieved from http://journals.lww.com/anesthesia- analgesia/Citation/1993/08000/Preemptive_Analgesia_Treating_Postoperative_Pain.26.aspx Therapeutic Opioids: A Ten-Year Perspective on the Complexities and Complications of the Escalating Use, Abuse, and Nonmedical Use of Opioids. (n.d.). Retrieved January 6, 2015, from http://www.painphysicianjournal.com/2008/april/2008;11;S63-S88.pdf Woolf, C., & Chong, M. (n.d.). Preemptive Analgesia—Treating Postoperative Pain by Preventing the Establishment of Central Sensitization. Anesthesia & Analgesia, 77(2), 362-379. Retrieved January 6, 2015, from http://journals.lww.com/anesthesia- analgesia/Citation/1993/08000/Preemptive_Analgesia_Treating_Postoperative_Pain.26.aspx Fig 1. Postoperative daily morphine requirements (milligrams per kilogram per day) in 29 pediatric inpatients surgical cases prospec- tively treated with a standard regimen of intravenous ketorolac and supplemented with intravenous morphine sulfate. Contemporary controls received morphine only. Pairs were frequency matched for age (± 6 months) and surgical procedure. Postoperative daily morphine requirements in twenty nine pediatric inpatient surgical cases prospectively treated with a regimen of intravenous ketoralac and supplemented with intravenous morphine sulfate. Fig 1. Postoperative daily morphine requirements (milligrams per kilogram per day) in 29 pediatric inpatients surgical cases prospec- tively treated with a standard regimen of intravenous ketorolac and supplemented with intravenous morphine sulfate. Contemporary controls received morphine only. Pairs were frequency matched for age (± 6 months) and surgical procedure. If preemptive opioids are given, the patient needs lower doses of opioids postoperatively. The patient will also be able to go longer without opioid immediately postoperatively. Continuous preemptive analgesia might enable decreasing doses of opioids or other analgesics over the postoperative period. Risks and side effects of complex combination therapy should be considered on a patient by patient basis. Over-sedation was decreased when nurses administered Paracetamol or a Ketorolac/Paracetamol combination was given in addition to opioids. Decreased ileus, sedation, PONV, decreased respiratory rate/drive, and addiction potential, all adverse side effects of opiate use. Non-narcotic drugs, especially in adjunct with narcotic drugs, are effective, have fewer side effects, typically decrease inflammatory mediators, and are very useful for mild to moderate pain. Non-narcotic drugs can also be used in adjunct with regional anesthesia techniques for decreased pain. Main Points National Institute on Drug Abuse. Retrieved on January 6, 2015. http://www.drugabuse.gov/ Forrest, J.B., Heitlinger, E.L., & Revell, S. (May 1997). Ketorolac for postoperative pain management in children. Drug Safety, 16(5), 309-329