Pain treatments, their risks and benefits
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 3 of 6, where we discuss the risks and benefits of the various types of treatments. For an overview of the various type of pains and how to address them, see part 1. For an overview of the various treatments available, see part 2.
What are the most effective medications you have found for treating pediatric pain? What are the associated risks?
When it comes to treating pediatric pain, the most effective medications depend on the individual, his/her disease, and his/her family. It’s really as much about the benefits than it is about the risks. One of the main risks associated with using pain medication with children is misuse, which can lead to serious side effects such as vertigo, shortness of breath, and liver damage. When it comes to opioids, I’ve had instances where I was 100% sure the family would misuse my prescription. In such cases, even if it would be the most effective thing for the child, I won't prescribe it because of the family. Paracetamol is another particularly dangerous medication if taken in excess. It can be fatal and is one of the most common causes of suicide with young patients.
Could you give me an example of something a bit stronger than paracetamol and its associated risks?
When it comes to all pain medication, it is important to be aware of the potential risks associated with taking them. For example, taking an overdose of opioids such as codeine or tramadol can cause short-term effects such as sleeplessness and shortness of breath, and can even lead to a breath or cardiac arrest. When it comes to long-term side effects, addiction is the biggest potential risk of using pain medication. Maybe there are some other lesions but we don't know about them since opioid(s) addiction usually leads to death before they appear.
It is evident that pain management is a complex process that requires collaboration with a variety of medical professionals. Could you tell me more about this collaboration?
It is important to have a comprehensive approach to pain management, and I believe that this is especially true in pediatrics. I work with school teachers, school nurses, and other medical professionals to gain a better understanding of the patient's condition. For example, school nurses can provide valuable information about the patient's behavior and how they are coping with their pain. I also provide referrals to psychologists, psychiatrists, and other professionals to ensure that the patient receives the best possible treatment. Additionally, I often prescribe activities such as swimming, as research has shown that patients are more likely to follow through with a doctor's recommendation if it is written on a prescription. I believe that it is important to give patients the power to choose, and to provide them with recommendations that can help guide their decision. From what I understand, this approach is not unique to me, and I believe that many of my colleagues take a similar approach when it comes to pain management.
To close the discussion on collaboration, are there any therapies that you find yourself recommending more frequently?
In terms of the most effective therapies, I am most confident in hypnosis as I have practiced it repeatedly and seen its effectiveness. I often recommend consulting a massage therapist and taking time for self-care too. However, I also recommend other therapies such as yoga even if I am not personally familiar with them. Ultimately, I believe it is important to consider the patient's preferences and to be open to trying different treatments if the first one does not work.
How about alternative treatments?
I always recommend alternative treatments. Like I said, they can help on multiple levels and that includes providing hope and a powerful sense of agency. The key is to make every patient a part of his or her treatment. I was first introduced to this belief through Dr Hunter "Patch" Adams and it was strengthened over the years by my own experience. As for which alternative treatments, there are as many as there are patients.
Based on what you said, it seems that alternative treatments are well suited for long term pain. How do you then measure their effectiveness?
I ask my patients simple things. I ask them if they can do their daily life activities, such as bending over to tie their shoelaces or walking 500 meters to the grocery store. This is a more subjective way of measuring the impact of the treatment, as opposed to using biomarkers. Ultimately, the long-term benefit of alternative treatments is that it puts the patient back in control of their pain and their life and that's what I'm evaluating.
Can we talk about the risk associated with alternative treatments for pain relief?
The biggest risk is patients not taking their prescribed medication because they think alternative treatments are enough. There are other risks too. For example, taking too many vitamins can trigger bladder movement, and if the kidneys are not functioning properly, the vitamins can become stuck in the body and cause side effects. Another example is hypnosis done wrong. It can have short-term side effects, such as feelings of disorientation. Additionally, when taking multiple products, both pharmaceutical and non-pharmaceutical, it is important to be aware of potential interactions. For children, this is less of a concern though as they typically do not take more than 5-10 medications.
How do you ensure that alternative treatments are safe for pain relief in children in the first place?
When it comes to ensuring the safety of alternative treatments for pain relief in children, I always take great care to only prescribe treatments that have been tested and reported to be effective. Occasionally, I may prescribe something new, in which case I will always check the internet on specialized websites such as UpToDate and Cochrane for verification. Even then, it is important to remain critical of the information found on these websites, as they may be biased due to the fact that they are often financed by the project itself. Additionally, it is important to be aware that clinical research on these products is often limited, and that any bias in favor of the treatment may be due to the fact that negative results are simply not published. As an example, I recall a French doctor who claimed to have a cure for COVID, but upon reading the article, it was clear that the data had been manipulated to exclude the 10 worst patients. This bias was very obvious and made it difficult to prescribe the treatment.
So you look at the evidence, but you still use critical thinking because you try to control for bias?
Yes when it comes to medical studies, it is important to always be aware of potential biases. In many countries, medical students are taught how to identify and control for bias in publications. For instance, if a study is funded by a pharmaceutical company, it is likely to be biased in favor of their product. Additionally, it is important to be aware of the age of the participants in a study, as studies conducted on adults may not be applicable to pediatric populations. In fact, many treatments for children are never tested and are instead used empirically. Sometimes we just know they work because they’ve been used for 40 years and have proven to be safe and effective over that time.
Do you control for potential interactions?
Yes, of course. When it comes to controlling for interactions in pediatrics, the main source of information is the patient. The patient is usually aware of any diseases they may have, such as diabetes or thyroid problems. When prescribing medication, it is important to be aware of any potential interactions and to take into account the number of drugs the patient is taking. Generally, in pediatrics, two to three drugs is the maximum, but for elderly patients, this number can be higher. To ensure the best possible pain relief, collaboration with other non-medical professionals, such as psychologists, physiotherapists, and even osteopaths though there aren’t a lot of evidence to support it, can be beneficial. This can help on all levels, including give the patient hope.