McCulloch, R; Berde, C; (2021) Difficult pain: Adjuvants or co-analgesics. In: Hain, R and Goldman, A and Rapoport, A and Meiring, M, (eds.) Oxford Textbook of Palliative Care for Children. Oxford University Press: Oxford, UK.

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Abstract

A common reason that pain is difficult to treat—perhaps the most common—is that its physical components are relatively minor contributors to the patient’s ‘total’ experience of pain. The child’s own existential suffering must always be considered in the evaluation of refractory symptoms. The suffering of families can be expressed through frequent requests of breakthrough medications on behalf of the child, and such distressed behaviour may inappropriately influence clinical decision-making, leading to increases in opioid dose that are not indicated and so risk causing unnecessary toxicity. It is nevertheless possible to describe several clusters of clinical symptoms that can characterize a patient’s pain and indicate that management is likely to need more than general-purpose analgesics such as opioids. Identifying a patient’s pain syndrome by forming a clear understanding of the clinical scenario in combination with careful, detailed assessment, and measurement of pain is important for both diagnosis and treatment. Establishing the aetiology of pain is important. Pain in children with life-limiting conditions (LLC) is often multifactorial, however, involving a combination of nociceptive and neuropathic features as a result of multiple pathologies. Increasing survivorship from conditions that previously would have proved fatal means the management of pain is now influenced by developments in understanding of genomics, plasticity, and the response to painful stimuli in a preexisting damaged nervous system, all of which can be involved in the individual child’s own unique experience of pain. At the same time, concern about rare adverse effects of opioids such as hyperalgesia and central sensitization can contribute to the complexity of pain management in the child. As biomolecular knowledge and evidence grows to support theories regarding complex neuro-immune mediated inflammatory and neuropathic pain processes it highlights the increasing potential for pain modulation. There remains, however, a substantial gap between such theoretical advances and robust evidence of positive clinical outcomes in analgesic interventions for children.

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