CHRONIC PAIN in adolescents final

Running head: Adolescent chronic pain management 1

Management of Chronic Pain in Adolescents

Juliann M. Trumpower

Clemson University

Adolescent chronic pain management 2

Abstract

Purpose: Although frequently under-recognized, chronic pain in adolescents is widespread and

is often the result of a dynamic integration of biological, psychological and sociocultural factors

existing within a unique developmental path. The purpose of this systematic literature review is

to describe the characteristics of adolescents with chronic pain, determine the most efficacious

management of chronic pain in this population and discuss the implications for nursing

education, practice and research.

Methods: A thorough and exhaustive search of multiple electronic databases produced hundreds

of articles but a limited number of research studies published from 2000 to 2016 written in

English. The databases searched were CINAHL, MEDLINE, PubMed, Psych Info and the

Cochrane Central Register of Controlled Trials.

Results: A relatively limited number of studies were found related to the topic despite searches

of multiple databases and expanding years from publication. Ultimately, seventeen studies were

chosen based on relevancy to the topic. There was little to no evidence found for the safe and

effective use of medications, as evidenced by, a lack of high-grade research for this treatment

strategy. In contrast, the vast majority of studies advocated a multidisciplinary approach

consisting of care providers from specialties including medicine, psychology, nursing, and

psychiatry. The strongest evidence base exists for the use of psychological interventions

(relaxation, cognitive-behavioral therapy and acceptance and commitment therapy).

Keywords: Chronic pain, management, pharmaceutical, multidisciplinary, adolescents


Management of Chronic Pain in Adolescents

Chronic pain is defined as persistent and recurrent pain lasting longer than 3

months. (Dobe, Hartman, Kriszi. Hechler, Behlert, & Zernikow, 2013). Chronic pain in children

has been recognized as a major health concern around the world. Conservative estimates are 20-

35% of children and adolescents worldwide suffer from some form of chronic pain (WHO,

2012). In the United States (US), prevalence rates of chronic pain in children are estimated at

15-25% with an annual cost of more than 19.5 billion dollars (Groenewald, Essner, Wright,

Fesinmeyer, & Palermo, 2014). The most common types of chronic pain are musculoskeletal,

headache and abdominal pain. Chronic pain can be further categorized as ongoing and episodic

in children with chronic health conditions, such as arthritis and sickle cell disease, and pain that

is a disorder itself, such as, migraines and complex regional pain syndrome (Suresh, & Shah,

2011). The highest rates of chronic pain occur in females 12-14 years old and 30% of chronic

pain sufferers have had pain lasting over 2 years. Quality of life is impacted by pain that may

make them unable to socialize with peers, participate in sports or hobbies or attend school

(Voerman et al., 2012). In addition, chronic pain may result in sleep disturbances, loss of

appetite and depression (Gupta, 2014). Adolescents with chronic pain and depression are at

increased risk for thinking about and committing suicide (Tilburg, Spence, Whitehead,

Bangdiwala, & Goldston, 2011).

The treatment and management of chronic pain in children and adolescents is a challenge

for health care professionals, especially when the exact cause of pain in not clear (Voerman, et

al., 2012). Children often feel they are not believed and parents grow frustrated and distrustful

of healthcare professionals, as they are sent from one specialist to another for diagnostic testing,

while pain is not adequately managed (Wojtowicz & Banez, 2014). Providers are often


uncomfortable with prescribing effective pain medications, especially opiates, due to fear of drug

addiction and abuse. Negative attitudes and poor knowledge of pain assessment and

management are barriers to pain management in children (Tseng, Weiss, Harrison, Hansen, &

Bruce, 2014). Advanced practice nurses will encounter adolescents with chronic pain and can be

instrumental in guiding treatment. The most effective approach for chronic pain management in

adolescents has been shown to follow a biopsychosocial model utilizing a multi-disciplinary

approach (Wojtowicz & Banez, 2014). This integrative review will examine the characteristics

of youth who suffer from chronic pain, explore the most current and effective treatments for

management and discuss the implications for nursing education, practice and research.

Methods

A systematic review of the literature was performed to locate studies associated

with the management of chronic non-malignant pain in adolescents. The search method was an

in-depth assessment of multiple electronic databases to find related studies published from 2000

to 2016 written in English. The searched databases were CINAHL, MEDLINE, PubMed, Psych

Info and the Cochrane Central Register of Controlled Trials. Keywords used during this

exploration included chronic pain, management, pharmaceutical, multidisciplinary and

adolescents.

Results

Biopsychosocial Characteristics of Adolescents with Chronic Pain

The biopsychosocial model provides a useful theoretical framework for understanding

the relationship between chronic pain and psychiatric symptoms. It accounts for the complex

interplay of biological, psychological, social, environmental and individual factors that

contribute to and maintain chronic pain and subsequent disability (Odell & Logan, 2013).


Skrove, Romundstad and Indredavik (2015) conducted a large cross-sectional population based

study in Norway (Young-Hunt study) of over 7,000 adolescents (50.9% girls, 49.1% boys) which

sought to assess the prevalence of chronic pain with high disability in relation to emotional and

behavioral problems and resilience factors. The prevalence of chronic pain with high disability

increased with increasing scores of anxiety, depression, social anxiety and behavioral problems

(p<0.001). In contrast, both girls and boys with increased scores for resilience factors including

family cohesion, personal competence, social competence, community resources and self-

esteem, had significantly lower prevalence of pain (6.5% vs. 17.6%). A smaller study

(Wojtowicz & Banez, 2015) found the seven pain-associated factors identified in previous

research (Hyman et. al., 2002) were common. These include dependent coping style, chronic

illness in a parent, alexithymic personality, family problems, early pain experiences,

learning/developmental difficulties and perfectionist personality. In a phenomenological,

qualitative study of adolescents with cerebral palsy and severe chronic pain by Castle, Imms and

Howie, (2013), common themes included presence of unrelenting pain, frustration, loneliness,

despair, hopelessness, resentfulness of their dependence and feeling pain consumed their

thoughts, time, and energy. These studies provide further support of the biopsychosocial model

of chronic pain and related functional disability.

Multidisciplinary Management

The primary goal of chronic pain management is to improve all areas of functioning and

quality of life. This is best achieved through a multidisciplinary approach that incorporates

cognitive behavioral therapy (CBT) and other psychological therapies into rehabilitation

programs of functional restoration through physical and occupational treatments along with

standard medical care (i.e. treatment of any underlying conditions) and pharmaceutical


interventions (Odell & Logan, 2013). In addition, school reintegration and addressing significant

sleep disturbances are important aspects of care (Rajapakse, Liossi & Howard, 2014). A study

by Valrie, Bromberg, Palermo and Schanberg (2013) found that not only did pain lead to sleep

disturbances, but poor sleep related to increased pain, poor mood and increased disability.

Members of a multidisciplinary pain team may include physicians (typically

anesthesiologists or physiatrists), nurses, psychologists, physical therapists, occupational

therapists, recreational therapist, pharmacists, social workers, music therapists, and child life

specialists, among others. (Gregoire & Finley, 2013) An exploratory retrospective cohort study

of 70 children treated at an inpatient multidisciplinary pain management program (Blecourt et

al., 2008) showed improved overall level of functioning (including improved motor activities and

ability to assist with activities of daily living), as well as, increased participation in social

activities (p value Chi Square; ADL <0.001). Although it was not a primary outcome, pain

scores were significantly decreased both at discharge and at follow up (p <0.001). These results

mirror a newer retrospective study (Roessler et al., 2016) of consecutive patients admitted to a

functional rehabilitation center between 2010 and 2014 with chronic pain and significant

disability. Utilizing a multidisciplinary approach, 65.5% were treated inpatient and 34.5%

outpatient. Pain improved significantly in 89.7% (95% CI [0.73-0.98]) and pain medication

consumption decreased significantly in 72.4% (95% CI [0.53-0.87]). Patients who had stopped

walking could ambulate again in 91.7% of cases (95% CI [0.73-0.99]) and 86.4% who had

stopped going to school were back full time (95% CI [0.65-0.97]. There were no significant

differences in results between inpatients and outpatients and improvements were maintained at 3-

6 months after discharge in 83.3% of participants. In a larger study by Hechler, Wager &

Zernikow (2014), researchers compared treatment outcomes using three domains (pain intensity,


disability and school absence) between outpatients versus inpatients treated at a multidisciplinary

treatment center and who returned for follow up within a year. Both inpatients and outpatients

reported relatively low levels of pain intensity (NRS 0-10, mean =4 SD =2.7) and disability

(Pediatric Pain Disability Index PPDI: [12-60] mean = 24; SD= 10) at return visit. Compared to

outpatients, more inpatients achieved significant changes in pain intensity (52% vs. 45%) and

disability (46% vs. 31%). Both groups showed significantly reduced school absenteeism with

80% attending school regularly.

Psychological Therapies

Psychological interventions are the most evidence-based treatments and are an integral

component of the multidisciplinary pain treatment model. The primary goal of cognitive-

behavioral therapy (CBT) treatment is to teach the child self-regulation techniques through the

use of such strategies as relaxation, biofeedback, and guided imagery, as well as, cognitive

restructuring to help the patient perceive pain as less debilitating (Odell & Logan, 2013).

Psychological therapies, delivered to children and families, significantly reduce pain and

disability in children (Clinch & Eccleston, 2008). However, many adolescents do not receive

treatments due to lack of providers, expense and geographical distance to treatment centers.

(Palermo et. al, 2009). New and innovative technology has utilized computer-based programs

and smartphone applications to deliver psychological therapies remotely. A Cochrane Database

System Review by Fisher, Law, Palermo and Eccleston (2009), reviewed 8 randomized

controlled trials of adolescents (N=371 participants) with chronic pain who received remotely

delivered psychological therapies and found them to reduce pain severity across pain types but

showed no beneficial effect on improving disability. In addition, a meta-analysis of CBT

treatment (Velleman, Stallard and Richardson, 2010) identified four studies that all reported


significant post-treatment improvements in pain frequency, duration and intensity (50% from

baseline to post-treatment).

Acceptance and Commitment Therapy (ACT) is a new CBT approach that does not focus

on symptom control (reduced pain or depression) but rather aims to help individuals encounter

pain openly and without resistance. This can liberate an individual to focus on living a

personally meaningful and valued life, despite distress. Two studies of ACT therapy (Weiss et

al., 2013 and Gauntlett et al, 2012) found this treatment to significantly increase acceptance and

decrease depression, catastrophizing and functional disability.

Pharmaceutical Management

The World Health Organization (WHO) has the only guidelines on the pharmacological

treatment of persisting pain in children with medical illnesses and advocates a two-step approach

of acetaminophen and NSAIDS initially, followed by morphine or other opiate equivalents as

needed (WHO, 2012). In the United States, the Center for Disease Control (CDC) has issued

guidelines for the pharmacological management of chronic pain in adults but these specifically

exclude use for anyone under eighteen (Dowell, Haegerich & Chou, 2016). While the use of

opiates in chronic pain is rarely recommended in adolescents, they have been shown effective in

certain known disorders such as neurodegenerative diseases, juvenile arthritis and sickle cell

(Gregoire & Finley, 2013). This was demonstrated by a small practice study (Slater et al, 2010)

that found patients had better pain control and improved function while on opioid therapy. Many

of the medications currently used to treat chronic pain in children (i.e. amitriptyline, gabapentin,

and pregablin) are being used without evidence of safety and efficacy in children but rather on

findings extrapolated from adult trials (Walker, 2008).


Ketamine, an N-methyl-D-aspartate receptor antagonist, has been shown to improve pain

and decrease opioid use in the adult population and may be used as an adjunct for refractory pain

(Sheehy, et al, 2015). A longitudinal cohort study of consecutive pediatric patients (Sheehy, et

al, 2015), found that ketamine significantly reduced pain intensity (p<0.001). Pain reduction was

greatest in patients who suffered from trauma, complex regional pain syndrome (CRPS) and

postural orthostatic tachycardia syndrome (POTS) and was smallest in patients with chronic

headache. Similarly, a retrospective review by Mooney, Pagel and Kundu (2014), on the

efficacy of intravenous lidocaine infusions, found them to be well tolerated in adolescents, with

few side effects and significant pain relief. Interestingly, maximum pain reduction occurred in

patients with the highest reported intensity of pain (Mooney, Pagel & Kundu, 2014).

Complementary and Alternative Medicine (CAM) use in adolescents with chronic pain is

on the rise as methods for relief of pain are sought. This may encompass a group of diverse

medical practices and products that are not generally considered to be a part of conventional

medicine. Examples are herbal supplements, essential oils, massage, hypnotherapy, acupuncture

and yoga. In a study on CAM use by Vinson, Yeh, Davis and Deirdre (2014), a multivariable

model found that female gender, parental education, greater pain intensity and higher disability

were independently associated with CAM use. In addition, CAM use was found to have a

significant correlation with accommodative coping skills (B 0.2, p value 0=.003).

Implications for Nursing Education, Practice and Research

Pain assessment and management should by an integral part of all healthcare provided by

practitioners who care for children and adolescents. It is widely accepted that healthcare

providers are seeing a significant number of adolescents with chronic pain which is effecting

their development and quality of life. A multidisciplinary approach based on a biopsychosocial


framework has proven to be the most effective treatment strategy for adolescents with chronic

pain, however, most healthcare providers have limited understanding of this and instead refer

patients from specialist to specialist for diagnosis without adequately treating pain.

Unfortunately, there is limited information to guide clinical practice and a significant lack of

scientific data for the safety and efficacy of pharmaceuticals for the treatment of chronic pain.

There are enormous gaps in research on the pharmacological treatment of chronic and complex

pain in children and adolescents. Future research is desperately needed in the pharmacokinetics

and pharmacodynamics of drugs currently used in the treatment of chronic pain in children to

ensure safe and effective drug dosage. In addition, some classes of medications including

anticonvulsants and antidepressants being used in select pediatric pain conditions have not been

studied in this population and can have dramatically different results amongst users.

Conclusion

In the course of this research, a very limited amount of research was found related to the

treatment of chronic pain in children and adolescents. The majority of studies found, were small

in size and many had significant limitations identified. Most advocate a multidisciplinary

approach utilizing a biopsychosocial framework. The gaps in research on pharmacological

interventions are profound and the scientific community should be called upon to invest in

research on the safety and efficacy of pain-relieving medications, specifically in children with

persistent pain related to medical illnesses. Any findings measured in future studies should

include both positive (pain relief, improved quality of life, etc.) and negative (prevalence,

severity of adverse effects, etc.) outcomes. Finally, healthcare professionals, who will most

certainly encounter adolescents with chronic pain, are implored to validate the patient’s


complaints and work with them, their family members and other members of the healthcare team

to bring relief and improved quality of life.


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Tables

Table 1. Domains of clinical evaluation of chronic pain at presentation

Biological Psychological Social

Pain characteristics Mood School attendance

Site/sites Anxiety Social functioning (peer/family)

Time features- onset, frequency, etc.

Depression Parental behaviors (protective responsiveness, overbearing, minimization

Descriptors Cognitions (attitudes, beliefs) pain catastrophizing

Parent characteristics- age, educational level, economic status

Intensity (0-10) NRS Sleep Cognitions (catastrophizing, expectancies

Radiation Behavioral problems Isolation

Precipitating factors Social isolation Inability to participate in sports and hobbies

Relieving factors loneliness Chronic illness in parent-Parent with chronic pain

Physical functioning hopelessness Community resources available

Level of disability Resilience factors Ability to participate in activities- outings, Band, support groups

*Note- areas for Provider assessment


Figures

Figure 1. Proposed Management Algorithm of chronic pain in adolescents

Chronic Pain

Clear Diagnosis

medlDddDiagnosis

Unknown cause

Optimize Disease Specific

TREATMENT

Pain persists

NO YES

MANAGEMENT WITHIN

BIOPSYCHOSOCIAL

FRAMEWORK

Continue disease

specific Management

Pain education

Psychological TxSLEEP Medications

INTERVENTIONS

AS APPROPRIATE

PT/OTCAM- herbs,

hypnosis, yoga, etc.

Pain persists

Pediatric Pain

SpecialistInpatient or

outpatient pain rehab


Figure 2. Experience of 17 year old with chronic pain and disability

SS

Pain

ananand

Family “My

mom/dad worry about me,

dad had change jobs to

stay home with me”

Fitness

“I used to be able to

walk with a walker, now I

only use my wheelchair.

Even swimming makes my

pain worse”

Independence “my

mom has to help me take a

shower and use the bathroom… I

used to be able to dress myself

It’s not fair… I’m 17”

Appetite

“I can’t eat when

the pain is bad, my meds make

my stomach hurt, I’m just not

hungry and sometimes the

pain is so bad I throw up’

Moods

“I get angry and

frustrated. I just go to my

room. I say mean things to my

family. I don’t want to talk to

anyone. I cry at night when I

can’t sleep”

Social Life

“I don’t see my

friends much, Mostly, I lay

in bed and watch TV- I used

to play in the school band”

Education

“I used to love school,

but have missed 85% of school

this year. I can’t concentrate

when my pain is bad”

Sleep

“I go to bed early but

wake up and can’t go back to

sleep, when I don’t sleep my pain

is worse”

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CHRONIC PAIN in adolescents final