As a physician who works in a pediatric emergency department, I see the downsides of trampolines, monkey bars, coffee tables with sharp corners, and even hot soup — all common sources of children’s injuries. No matter what the trauma, many of my patients are in pain. And with all of the publicity around opioids, treating injured children’s pain has become a complicated, and often emotional, issue.
Pain can often be eased with acetaminophen or ibuprofen. But broken bones, burns, and other severe injuries that cause excruciating pain usually require something stronger, like an opioid.
In the era of opioid abuse and the overdose crisis, conversations around using medications such as morphine and fentanyl to control pain can be difficult to have with patients and parents. No one wants to become part of the grim statistics, such the 70,000 Americans dying from drug overdoses in a year or the nearly 9,000 children and adolescents who died from prescription and illicit opioid poisoning in the United States between 1999 and 2016.
Yet untreated or inadequately treated pain can harm children, both immediately and in the long term. It can also affect their development, their reactions to future painful experiences, and may cause post-traumatic stress disorder.
Since pain is a subjective experience, the best way to gauge it is by asking the person experiencing it how he or she feels. That usually works with older children, but doesn’t with infants and young children who can’t verbalize what they are feeling. For them, several behavioral scales can be used to assess and estimate pain.
Opioids work by binding to receptors in the brain that control pain and emotions. Taking opioids many times diminishes the brain’s sensitivity to the drug, making it hard to feel pleasure from anything besides the drug. That can lead to dependence and addiction. Taking a single dose to immediately control severe pain in the emergency room, and then quickly moving on to non-opioid pain control, does not cause dependence. It can temporarily depress breathing, which is why doctors determine the dose based on a child’s weight and carefully monitor his or her breathing.
My colleagues and I must walk a fine line between alleviating a patient’s pain while allaying fears and concerns of parents regarding the side effects and unclear potential for addiction from one or two doses of an opioid.
When I begin treating a child with a severe burn or broken bone, I start gearing up for the conversation about pain control, knowing I might get a response from his or her parents like, “I don’t want my child getting hooked on those drugs,” or, “Are you trying to make my child an addict by giving her those drugs?”
I usually start slowly, and say to parents something like, “It’s great you gave your child ibuprofen or acetaminophen at home, but I think she needs more than that.” Most parents know what opioids are and have opinions about them. I can see worry on their faces the second I mention the word.
Some say, “I trust your judgment.” Others immediately say no. When that happens, I suggest trying more ibuprofen or acetaminophen and seeing if that helps. If it doesn’t, I’ll once again recommend an opioid.
Some parents say, “My child will be fine without opioids. Go ahead and do what you need to do.” But that’s not going to work if I must debride a burn or set a broken bone. Other parents won’t even discuss an opioid for pain control. That’s hard, because I can’t order pain medicine without parental consent, even when I know a child is suffering.
The aim of fulfilling a well-known part of the Hippocratic oath — first, do no harm — still guides the care I deliver. But in the emergency department, determining which harm not to do becomes problematic: Do I withhold an opioid and do no harm by preventing the unlikely but real possibility of addiction or side effect of respiratory depression? Or do I prescribe an opioid and do no harm by eliminating pain and its negative psychological effects, such as anxiety and possible PTSD from future medical care.
There’s no clear answer, which is why my colleagues and I who treat children in pain find ourselves constantly walking this tightrope and trying to ethically and clinically balance which “do no harm” to attend to.
Nkeiruka Orajiaka, M.D., works as an attending emergency medicine physician in Ohio.