Chronic Pain

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Overview

When a child or youth has chronic pain, their care should include a multimodal, biopsychosocial approach employing physical, psychological, occupational, and pharmacologic modalities*. 
_{^{Guidelines on the management of chronic pain in children. Geneva: World Health Organization; 2020. License: CC BY-NC-SA 3.0 IGO.}} 

When opioids are prescribed and administered for chronic pain, there are several considerations to ensure safer therapeutic use:

• Children and youth with chronic pain should receive an individualized and multidisciplinary approach to their care
• Physical (e.g., physical therapy) and psychological (e.g., biofeedback, distraction) treatments should be used for all children and youth with chronic pain
• Non-opioid medications can be considered as part of balanced multimodal pharmacotherapy to treat chronic pain in pediatric patients, simple analgesia (e.g., acetaminophen, NSAIDs), antidepressants, anticonvulsants, and topical treatments such as lidocaine patches
• Opioids are rarely prescribed for chronic pain in the pediatric population, due to the lack of evidence regarding its efficacy in chronic pain as well as their adverse effects profile
• For the rare circumstances when opioids are indicated for chronic pain, they should be trialed at the lowest effective dose, titrated over time, linked to improvements in function (not pain reduction alone), and used for the shortest period of time possible
• Opioids should be prescribed by a single healthcare professional with close monitoring and follow up
• Any healthcare professional overseeing the use of opioids for chronic pain should have the knowledge and skills to assess pain and function; appropriately prescribe, monitor, taper, and discontinue opioids; and recognize and treat opioid use disorder
• Children and their families should always be counselled about the potential side effects of opioid medications
• Potential risk for higher-risk opioid use should be assessed using a validated risk assessment tool before prescribing or administering opioid analgesia
• Children and youth who are prescribed opioids for chronic pain should be educated about the risks of physical and psychological dependence, as well as withdrawal

Opioids should be prescribed and administered in a culturally safe way.

Also consider risks for opioid use disorder, higher-risk opioid use, child age, and preexisting mental health diagnoses. 

However, even when these risks are present, children with severe chronic pain have the right to adequate pain management, which may include the use of opioids. Children and their families should share the decision-making about whether opioid analgesia is appropriate for them with their healthcare provider.

Adverse childhood experiences (abuse, neglect, and household dysfunction occuring before the age of 18) have the potential to impact a youth’s perception and expression of pain, and its association with chronic pain.

If there is a need for long-term opioid use for chronic pain, establish a clear plan that identifies a single prescriber (only one person) and includes regular followup (monitoring symptoms and function), communication and record keeping.

Definition of chronic pain:
Pain that persists or recurs for longer than three months. The World Health Organization’s International Classification of Disease (ICD-11) considers chronic pain as a disease in its own right (i.e., chronic primary pain) or secondary to an underlying disease (i.e., chronic secondary pain). It can include chronic cancer-related pain, chronic neuropathic pain, chronic secondary visceral pain, chronic post-traumatic and post-surgical pain, chronic secondary headache and orofacial pain, and chronic secondary musculoskeletal pain. Children can experience acute and chronic pain concurrently.
^{CAN/HSO 13200:2023 Pediatric Pain Management Standard, 2023}

“Chronic pain is a complex phenomenon which can have a devastating impact on the quality of life for children and youth, and their families. Health professionals can help young people with chronic pain find ways to cope with their symptoms and allow them to lead rich, meaningful lives. A holistic approach is essential to achieve these goals. Although opioids may be considered for some types of chronic pain in children, their role is limited due to their potential for harm, and limited efficacy in the setting of chronic pain. However, in rare situations when opioids are indicated for chronic pain, a trial of opioids should be considered only when a combination of nonopioid pharmacotherapy and physical and psychological strategies have provided inadequate symptom control.”

~ Dr. Marie-Joëlle Doré-Bergeron, Physician

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