Pediatric patients need appropriate pain management after surgery [PODCAST]

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“We believe optimal postoperative pain management should provide adequate pain relief, minimize adverse effects, and reduce chances of drug misuse. While we cannot undertreat pain, we also cannot go back to the practice of over-prescribing or unnecessarily prescribing opioids for minor operations. There needs to be a carefully nuanced balance in treating pain, especially for pediatric and adolescent patients.

Going forward there needs to be continued parent and patient education about expectations for recovery post-surgery and proper pain management. This needs to include consistent messaging to families regarding safe use, storage, and disposal of opioids as well as the risks for non-medical use and substance use disorder.

This critically important topic deserves more research and clarification so that the medical community can properly treat pediatric and adolescent pain. Stigmatizing the select use of opioids for children and adolescents after surgery is counterproductive and additional guidance should not emphasize the fear of opioid diversion or misuse over appropriate pain management.”

Rita Agarwal is an anesthesiologist.

She shares her story and discusses the KevinMD article, “Pediatric patients need appropriate pain management after surgery.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Rita Agarwal. She is an anesthesiologist, and she co-wrote the KevinMD article “Pediatric patients need appropriate pain management after surgery.” Rita, welcome to the show.

Rita Agarwal: Thank you. Thank you for inviting me.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and journey to where you are today?

Rita Agarwal: So I’m one of those kids who always wanted to be a doctor, from the time I was quite young. I went to medical school at Baylor in Houston. I did my anesthesiology residency there and my fellowship in peds anesthesia in Denver, at what is now called Children’s Hospital Colorado; at the time, it was Denver Children’s. I had an interest in regional anesthesia and pain management from really as far back as I can remember, in terms of once I started my training.

When I joined the practice at Children’s, again, now Children’s Colorado, then it was just The Children’s Hospital Denver, we were just starting an acute pain service. So I was one of the early, not really a founding member, but one of the early members, and I eventually took over the role of acute pain director. I focused really on inpatient pain management: anyone who went to the OR and had surgery, and anyone who was in the hospital for other reasons who might have acute pain. That was sort of the patient population that I worked with.

I moved to Stanford and to Lucile Packard Children’s Hospital about six years ago and have been a member of the inpatient pediatric pain service here too. I continue very much in the realm of that work and have a real interest in trying to make the perioperative experience, but also the hospital experience, better for kids in pain.

Kevin Pho: So I’ll be honest, I don’t know too much about a pediatric pain service. So can you just share with my audience, what are some typical cases that you see?

Rita Agarwal: Well, I’m glad you asked, because that’s a great question. We typically will follow patients who have more complex surgeries or more painful surgeries. So, for example, posterior spine fusions and pectus excavatum repairs can often be quite painful, as can major orthopedic surgeries, major abdominal general surgery-type cases, occasionally ENT, and occasionally neurosurgical patients with complex pain issues.

We also follow patients who have a history of chronic pain who come back for surgery, because oftentimes, in any patient, adult or pediatric, it’s well proven in the literature that their sensitivity is going to be much greater, and so their needs for pain management are also going to be much greater. So even a surgery that is sometimes a day surgery for those of us who don’t suffer from chronic pain can be a several-day admission for pain management in someone who has a history of chronic pain.

We also see a lot of oncology patients who have acute pain flares related to either the treatment or their disease process. We see patients with sickle cell who have pain flares related to that. At Stanford in particular, we are a big center for immunologic and inflammatory diseases, so we’ll see kids who come in with flares from rheumatologic processes and inflammatory processes. They get periodic flares, come in, and are followed, so we’ll follow those patients. Yeah, that’s pretty typical, I think, of most pediatric pain services. It’s going to vary a little bit from place to place. And any regional anesthetic that’s placed in the operating room that’s going to stay in for a few days, we also follow those patients.

Kevin Pho: So you may be getting into this question a little bit when you talk about your article, but in general, what are the differences in the approach to pain in the pediatric population versus the adult population?

Rita Agarwal: So that varies a little bit depending on the location where that pain is being treated. At a children’s hospital, which is where I’ve spent the majority of my career, we’re much more attuned to appropriate assessment tools and appropriate management strategies. We’re much more educated around using non-pharmacologic techniques like distraction. We have great child life services, who come in and do all kinds of activities with our kids. We have great nurses who, because this is all they do and they work with kids every day, are really good at helping manage some of the pain that can be managed with just things like distraction, touch, massage, that kind of stuff. Until COVID, we had massage services available in the hospital, which was amazing. We never got to use it, but the patients did, and they loved it. Many of them loved it. We have physical therapists and occupational therapists who are really attuned to that.

In locations where they don’t do as much pediatrics, or they’re not as used to or as comfortable with pediatrics, I think just starting with basic assessment tools, what’s the appropriate tool to use to assess a younger child versus an older child, can sometimes be challenging. So that would be the first place. In adults, it’s always, you know, zero to 10, zero being no pain, 10 being the worst pain: “What is your pain?” Whereas that may work for a 14-year-old, it’s not going to work for a four-year-old. So just starting at the very basic aspects, that can be an issue.

Kevin Pho: Now, how do you assess pain in someone who really can’t express it on a scale?

Rita Agarwal: So there’s the FLACC score, which was developed by my wonderful friends and colleagues at Michigan, and the modified FLACC score, which is faces, legs, activity, consolability, and cry. It basically looks objectively, or tries to look objectively, at a child: looking at grimacing versus a face that’s either happy or relaxed, looking at the legs and how they’re moving their legs, and looking at how they’re moving around in the bed. So it uses a variety of observable metrics to try to come up with a score, and it’s based on a zero-to-10 score as well, zero being they probably have no pain, 10 being they have pain. It’s been very well validated in postoperative patients, and it’s been well validated in children who are unable to express pain, whether it’s because of developmental or neurologic issues or whether it’s just age-related. So that’s one score.

There are multiple different scales; obviously, there’s not a perfect scale. There’s the Wong-Baker FACES scale, in which you show faces to a child and they pick out which one they think most closely resembles where they are. There’s the Oucher, which actually shows photographs of children’s faces. It’s the same basic concept, with the child looking calm or happy versus, really, with their face scrunched up in pain and crying. The Oucher is really nice because it’s validated for different ethnicities. There is a Caucasian Oucher and an African American Oucher. I know there’s a Hispanic and an Asian one, and I think they were at least working on a Native American one as well. There may be one out now; I can’t remember.

But yeah, there are multiple different scales that can be used in different institutions to try to get the best estimate of what the pain is in the child as possible. We let parents help with that, because they often know their children the best and can really say, especially for children who are developmentally delayed or who have other neurologic issues that might make it more difficult for them to let somebody know how much pain they’re having. Parents are the best judge of that 100 percent of the time.

Kevin Pho: So let’s transition now into the KevinMD article that you co-wrote. It’s titled “Pediatric patients need appropriate pain management after surgery.” Now, for those who didn’t get a chance to read that article, can you just walk my audience through it and share the story of why you decided to co-write it?

Rita Agarwal: Sure. So we wrote it in response to an article that came out in JAMA Surgery, which was an excellent article. Just to be clear, it was an excellent article, by Dr. Kelley-Quon and colleagues. It was a multidisciplinary, multi-institutional set of guidelines that were produced in general surgery to help guide clinicians regarding pediatric pain management. Our concern was that the first five of their recommendations really emphasize addiction and abuse issues much more so than they emphasize appropriate pain management.

And our concern with that article was that they also talk about opioid-free, which is kind of the new, exciting buzzword: Let’s do all of these surgeries without using opioids. That is a laudable goal, but we’re not quite there yet. We’re not quite ready for prime time yet. We can often get kids, and adults, through a big surgery without using opioids by using regional, by using dexmedetomidine, and by using other medications. But oftentimes, once they hit recovery, they do end up needing opioids.

And so we felt like this article was a little bit misleading in that, particularly because recommendations number one through five, which I’d have to go back now and reread, are basically really focusing on the abuse potential of opioids. Our concern was that clinicians, particularly those who are not primarily in the pediatric world, who do some pediatrics or who do minimal pediatrics, might be really dissuaded from using opioids, even when they are appropriate.

We agree with the article itself. It really focuses on, the article by Kelley-Quon in JAMA Surgery, it talks about multimodal. And what we really wanted to do in our KevinMD article is to kind of alert people that yes, opioids can be abused; and yes, adolescents are among the population that is the most experimental in terms of just trying things; and yes, the majority of adolescents who do experiment with opioids get them either from their own leftover prescriptions or from family members’, friends’, or neighbors’ prescriptions. But it’s a small minority of patients. And there were some things that they quoted in their article that, when we went back and read the source materials, weren’t quite as posted in that article.

So that was why we wanted to write the article: to basically say there are a lot of different ways to treat pain in children. Kids are great in that they’re easily distractible. When you see that kid who’s sitting there playing on the phone, that’s a great distraction tool. That’s a great tool. Don’t discourage them from doing that. Let them use it. If they’re playing on their phone and talking to their friends, or on social media, or whatever it is that they’re doing, they’re focused on something other than their pain. Their attention has moved away, and so consequently, they oftentimes need less pain medication.

There are a lot of other medications that can be used. Acetaminophen, tried-and-true Tylenol, is a great drug. All the non-steroidals, in varying degrees and varying types: Toradol for the IV version, ibuprofen. I mean, all of those drugs are great, and using all of them together. So emphasizing a positive, active approach toward multimodal pain management, versus “Avoid opioids, opioids are bad, opioids can cause addiction,” that was sort of our goal: to try to really bring people around, which is what I’ve been doing for 30 years.

I was early in the opioid epidemic, when people were focused on the adult issues. I actually was part of, and I am still part of, the American Academy of Pediatrics, and I presented a resolution there regarding opioid use, and people at that time were looking at me like, “Opioids aren’t a problem for kids.” So I’m well aware of the literature around this. But the bottom line is it’s a small minority of children, of adolescents, who abuse opioids, and people should not be afraid to give opioids because of that potential. What they should be doing is using appropriate dosing and appropriate amounts.

So when a child gets sent home after a surgery, instead of sending them home with 50 oxycodone, knowing that they’re probably only going to use five or 10, maybe send them home with five or 10 oxycodone. Then, if they need more, they can hopefully call and get a refill if that’s needed, or at least the physician or someone in their office can evaluate what’s going on and decide what they need to do. So we agree with it: Don’t send everybody home with 50 opioids. But we don’t agree with the really strong emphasis on “They’re going to abuse it; kids are going to sell their drugs; kids are going to use their drugs in ways that are inappropriate.”

And we’re also a little concerned about the really strong emphasis on opioid-free, because I just don’t think we have enough adjuvant medications yet, particularly ones that kids can go home with, that can replace opioids safely and effectively. In some patients, it can definitely be done, but not in everyone.

Kevin Pho: So I’m an internal medicine physician, and of course, in the adult population, there’s tremendous emphasis on that connection between habit-forming potential and opioids. I know you alluded to this in your answer in the past, but just so I’m clear and my audience is clear, what is the habit-forming potential of opioids in the pediatric population? And I guess you could stratify the pediatric population into adolescents and non-adolescents as well.

Rita Agarwal: So specifically in adolescents, and I think in the non-adolescent group, part of it is we don’t actually have great literature on any of this. The literature that is quoted is often from all kinds of medications. There’s a group, again out of Michigan, called Monitoring the Future that does these annual surveys of middle school, high school, and now college kids, looking at a whole variety of different things, but among them, looking at habits and behaviors, and among those is opioid use and misuse.

I mean, I don’t know that we know what percentage of children will develop habit forming, what the actual habit-forming potential is. We know that it definitely does occur. Beyond that, is it 1 percent of the population? Is it 10 percent of the population? Is it higher? We don’t really have a good sense of that. The thought is it’s probably around less than 9 to 10 percent, but it’s hard to really come up with a number, because those studies are minimal.

One of the studies that was quoted was a study done, I think, in Detroit, looking at two different high school groups of kids and asking kids. These were all survey-based, and you and I know that surveys can help get a lot of basic information, but there’s a whole host of problems that come along with surveys, especially asking high school kids questions. We never know if they’re going to answer truthfully or not, right? But asking, “If approached to sell a medication, would you do that?” Well, there was a large percentage of kids who said yes, if they were approached to sell their prescription medications, they absolutely would. But when you go back and read the actual article, it was primarily in reference to kids who are on ADHD medications, and not so much opioids, primarily because there are more kids on ADHD medications than on opioids. So we don’t know. The simple answer is we don’t know.

We know that there is a potential. There’s no denying that there is a potential, and there’s also no denying that children who are exposed to opioids as adolescents, whether for appropriate prescription and medical uses versus non-prescribed use, do have a higher incidence of going on to abuse those and going on to use heroin. That’s a study, actually, that Dr. Kelley-Quon also did a few years ago that was published in JAMA. It looked at just high schoolers, again survey data, at one high school in LA. They looked at kids who were given opioids for some surgery, versus kids who never used opioids during high school, versus kids who used them outside of appropriate prescriptions.

Obviously, the kids who used them inappropriately had the highest incidence of going on to persistently use. And then they looked at heroin use as one of their outcomes, and they had by far the highest incidence. But any kid who had gotten an opioid during high school had a higher percentage of use than the kids who didn’t get any opioids. It’s still only 2 to 3 percent, but it’s more than the kids who didn’t get any opioids in high school, in terms of their use.

So it’s clearly there. How to quantify that is difficult to say. We see lots of kids who go home on opioids and come back for other things and are not misusing them. So it’s a fine line. It’s a balance, and we just wanted to try to present what we feel is a more balanced viewpoint: Use them when you need them, don’t use them if you don’t need them, and think about how much you’re using.

Kevin Pho: We’re talking to Rita Agarwal. She’s an anesthesiologist, and she co-wrote the KevinMD article “Pediatric patients need appropriate pain management after surgery.” Rita, give us a sense of how this argument is playing out in the pediatric pain management world. What is the response to Dr. Quon and colleagues’ article in JAMA Surgery, and the response to your article on KevinMD?

Rita Agarwal: So, the response to my article on KevinMD, or our article, because I co-wrote it with two of my fellow board members from the Society for Pediatric Pain Medicine. At the time I wrote the article, I was the president; now I’m the immediate past president of that society. One of the reasons we started this society, and I was one of the co-founders of the society, was really to address these kinds of issues, to try to figure out the best ways to provide appropriate pain medication for children, or pain management for children, with acute pain as well as chronic pain.

The response to our article on KevinMD was overwhelmingly positive. It was really, really excellent in terms of engagement and in terms of the positive comments that I read. There weren’t a ton of comments, but a lot of the ones that were there were grateful, and they included a couple from patients, which I thought was really nice.

The response to the article in JAMA Surgery, at least among the pediatric pain world: We’re lucky enough that we have a pediatric pain listserv, which is just an email-based server, so we have a lot of people, both nationally and internationally and from multiple disciplines, who were appalled. They all responded to it very similarly to the way we did. Again, our letter to the editor of JAMA Surgery was just published on the second of June of this month, with a response from Dr. Kelley-Quon and colleagues. In their response, they say, “Well, we’re really not trying to focus on the abuse potential of opioids,” and arguing some other stuff. And my sense is we all really want what’s best for kids.

But I will tell you, among the pain population that is on this listserv, we were outraged. It wasn’t just myself and my colleagues in the Society for Pediatric Pain Medicine. It was this broader international group, as well as groups that are multidisciplinary, who were outraged, because they really felt like this article was giving the impression that all kids are going to go out there and abuse drugs and that you shouldn’t be doing opioids at all. I know that’s not what the authors intended. I know the first author, and I know a couple of the other authors very well, so I know that is not what they intended. But that is certainly the way it came across, I think, as just someone reading that particular article.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Rita Agarwal: Yes, please treat pain appropriately. Start with the basics. Start with acetaminophen. Acetaminophen around the clock is an excellent analgesic. Add on non-steroidals if there are no contraindications to their use. Again, think about round-the-clock use for very acute pain situations where the pain is likely to be occurring most of the time, and PRN if the pain is intermittent.

And then think about other things that you can do. Absolutely think about things like distraction and biofeedback. There are a ton of apps out there that can help with things like meditation; it’s not strictly biofeedback, but that can really help with calming. Think about non-pharmacologic techniques. Think about the mind-body connection. Kids are very good at a lot of these things. Distraction is huge. TV watching, let the kid play, have as much free time as possible during that acute recovery phase: It’s totally fine during that time, because if it’s helping distract them from their pain, they’re not going to need as much, and they’re not going to feel as much of the discomfort that could be coming from that.

But use opioids if the kid needs it, if it’s a big surgery, a big broken bone, or a big pain flare from something. Use opioids as prescribed by your physicians, as needed or prescribed appropriately. If you have any questions, please call a pediatric pain team. Please go to the SPPM website, which is pedspainmed.org, I think. I should know that off by heart, but I don’t. But if you look up the Society for Pediatric Pain Medicine, we have a section for frequently asked questions. We also have, under one of our tabs, I think it’s under resources, all of the local pediatric pain services that are available throughout the country, and some internationally.

So most of us are always willing. We get calls all the time from people who want advice on how to best treat a pain problem in a child. So please call someone who knows. Go to the website. You’ll see a lot of great information on there, and you may even be able to get some of your questions answered without having to call someone. But contact someone locally, or someone nearby, or someone. And, you know, if you’re calling by phone or virtually, there are a lot of places you can call to get advice.

Kevin Pho: Rita, thank you so much for sharing your time and insight, and thanks again for being on the show.

Rita Agarwal: Thank you so much for inviting me. I really enjoyed this, and I hope this is useful for the audience.

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