An overview of pain treatment main categories
We sat with Dr Amaury Salavert, an authority in pediatric pain management, for a fascinating talk on pain ranging from assessment to treatments and the contributions Alternative and Complementary medicines can make.
This is part 2 of 6, where we discuss the various types of treatments. For an overview of the various type of pains and how to address them, see part 1.
What are the different families of treatments available for children?
When it comes to treatments, there are both pharmaceutical and non-pharmaceutical options. Let’s look at each category of pain. First, nociceptive pain. There are three levels of pharmaceuticals here. The first level being paracetamol and ibuprofen, which are the most commonly used and generally considered to be the least risky. No painkiller is completely inoffensive though. Paracetamol overdose is a real thing. In the US, acute liver failure due to paracetamol overdose kills nearly 500 people each year. The second level of pharmaceuticals includes medications such as tramadol and codeine. These are not recommended for children under 15 due to potential side effects. As of such they are rarely prescribed. The third level of pharmaceuticals includes opioids such as morphine, fentanyl, oxycodone, and oxycontin. There are many opioids, each varying in strength. For instance fentanyl is 100 times more powerful than morphine.
That's for nociceptive pain, how about neuropathic pain?
Neuropathic treatments are usually long term, complex treatments. Treating neuropathic pain is challenging. Sometimes it requires anxiolytics or antidepressants. Often the best course is a combination of pharmaceutical and non pharmaceutical options.
And finally what about nociplastic pain?
In many cases for nociplastic pain, traditional pharmaceutical treatments may not be effective. This is where specialized advice is necessary. Non-pharmaceutical treatments such as yoga, hypnosis, sophrology, ASMR, and the aid of a psychologist or psychometrician can be very beneficial. Additionally, vitamins and electrical stimulation may be prescribed in some cases. Overall it’s very important to keep in mind this is about treating the patient, not the pain itself. And because every patient is different, so is every pain and every treatment. That’s why it’s always important to see a specialist. Pain is complex and individual.
So you've given us the different types of treatments available in your toolbox. What methods of pain relief do you typically recommend to children?
When it comes to managing pain in children, I typically recommend a combination of pharmaceuticals and non-pharmaceuticals. My two pharmaceuticals go-to are paracetamol and ibuprofen. Additionally, I usually suggest that children take five minutes each day to reflect on their emotions and how they felt throughout the day. This can help to improve their pain management.
What daily strategy do you recommend to manage long term or recurring pain?
For long term or recurring pain, I recommend physical activity such as swimming or muscle strengthening exercises. Exercise can be a great way to reduce pain, even if it may not feel like it at first. It is also important to learn how to manage pain, and this can be done by taking time each day to reflect on how one is feeling so again, the five minutes I mentioned right before. If needed, seeing a psychologist can be beneficial, especially if there has been a recent loss or trauma. Note that this is about managing pain, not alleviating it. Because for chronic pain, the most important thing is to learn how to live with it. And only after learning how to live with it should you focus on slowly reducing it.
How important is it for someone to get better to feel some form of agency over his or her pain?
The importance of feeling a sense of control and agency in the healing process cannot be overstated. It is essential for individuals to feel that they have the power to get better. I have seen repeatedly how positive emotions can help the body to heal itself, even if it is only a placebo effect. I have seen many cases of children and teenagers who have been able to make progress in their recovery when they are given the assurance that they can get better and that they are in control of their own healing. This feeling of being understood and in control of their own body and pain can be incredibly empowering. Non-pharmaceutical therapies and natural products can be very beneficial in this regard.
Are there any age-specific considerations when you're treating a children's pain?
Yes, the type and dosage of pharmaceuticals and non-pharmaceuticals treatments may vary depending on the age of the patient. For example, infants may require different vitamins than teenagers. Furthermore, it is particularly difficult to treat children aged 0-5, as they are unable to communicate their pain levels effectively. It is recommended that the lowest possible treatment be used in these cases. Most of the time that means an emphasis on non-pharmaceuticals. For children aged 5-10, it is also important to note that they may not understand the concept of time, and may not realize that a treatment may take some time to be effective. In this case communication is as important as the treatment. Finally, for children aged 10-12 and beyond, treatments can be administered in a similar way to adults.
Is age the main criteria you use for deciding the strength of a pain relief treatments?
When deciding when to use more aggressive pain relief treatments, age is one of the criteria, but other factors too. Such as the intensity of the pain. I use tools to quantify the pain. If the patient rates his or her pain as 7 or 8 out of 10, we will discuss it before I prescribe a treatment. Also, I always take into consideration the social aspect of pain, as pain is not expressed the same way in all cultures.
Hope you've enjoyed this part of the interview. To continue and learn about the risks and benefits of the various types of treatments available for pediatric pain management, go to part 3.