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.

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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.

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  • Maybe this is not obvious to you, but anesthesiologists treat pain of many types in many different patients. Rather than go into details of protocols for various causes of pain, here, I strongly suggest you consult an anesthesiologist colleague. Despite the common belief to the contrary, we do a lot more than put patients to sleep. I should know, I practiced anesthesia for 40 years.

  • A child in excruciating pain such as with severe burns and daily dressing changes deserves pain control. Give it what it needs, including opioids. When healing and treatment progresses to less painful stages, the switch to non-opioids must be made. I understand the dilemma of MDs in the ER, but there is no room for torture – thanks to the Hippocratic oath. Adhering firmly to what is best for a patient has to prevail over lay-people opinions (parents, politicians). This medically warranted use of opioid pain control does require thoughtful and addiction-preventing follow-up, and this does not lie with the ER doctor but the (burn) specialists / treating doctors / family doctors.

  • Thanks for your detailed reply. As a parent, as a retired LISW, unless there was let’s say skin breakthrough with a fracture- an ugly sight and if I remember correctly my brother’s face looked ashen as he held his arm with the bone jutting out then I would feel comfortable in giving a short term limited dose prior to surgery. There are other issues as well but the ER experience is a moral and ethical quandary . There is NO continuity of care, it’s a heightened stress event with long waits and no way of coping for the children. One also must as a physician think child abuse as in the spiral fracture so well documented by C. Henry Kemp’s, himself a refugee and WWII survivor. The ER is fraught with unknowns. You as a physician are seeing folks in trauma whether physical or emotional and usually both. As a family we have tried to avoid the ER experience. Sometimes there is no other option. And bread far as ER breaks most times I have seen an PA and a general wrap is done with a visit to the Orthopod in the next day. So how is it you are dealing with opioids as an administrator? And going directly to an orthopod is difficult insurance wise. Go figure. I tried that route. Back in the day my father would just do the entire casting himself since had time as a Chief Resident on Ortho after returning from the front lines of the Korean War like before the MASH Unit. But those days are long long gone. Could you possible do a narration of a typical day in the ER for you or one of the residents. Aren’t you all on call in a PRN basis? And what about ethics? How can you prescribe an opioid if you don’t know the family, the environment, and have an inkling on the child him or herself?

    • So true, the ER has a lot of unknowns at the time and you have to work with what you have at the time.
      Trying to make a patient and parent comfortable while providing your best care. With busy ERs too and long wait times, i totally agree with the heightened stress levels.
      I think every ER is different and no day is the same, Different cases every day and different family and patient encounters.
      Most ERs have a set schedule of when you have to work and while not sure i will call it PRN basis. You come in when you are scheduled to work and while there is no continuity of care we try to make sure to encourage families to follow up with their usual providers or any of our urgent cares in scenarios where there is no current provider and we want these kids to be seen sooner.

      Like i mentioned we face the dilemma of giving sometimes getting consent to give a single dose in scenarios when absolutely needed and when families refuse, we cant give it.
      While we dont know these families, our aim is still to provide emergent care to stabilize patients and make them comfortable before further care by inpatient or outpatient providers.

  • kids are more resilient than you think. a lot depends on how you phrase the question. I’d give a kid with a burn one dose of an opiate them immediately get anesthesiology to devise some long term pain control and try behavioral techniques like guided imagery and hypnosis so they can be in control. a kid with a bad burn is terrified from the experience. we want to avoid letting them confuse the relief they feel when the pain has abated with the rush from the opiate. what about cbd? wouldn’t that be better than exposing kids to opiates.

    • Thanks for your comment.
      I liked that you mentioned a dose during the immediate need and then devising a pain protocol. That is the same thing we aim for. But that single dose has become a dilemma too, understandably due to the opioid crisis.

      CBD has continued to emerge over recent years for multiple medical interventions, with a lot of controversies in benefit and risks
      However, i am not experienced enough or well versed in its use to comment on it. I am also not certain if it is used in emergency pain control.

    • This is what I was trying to suggest in my initial comment, without being dogmatic. A single dose of narcotic or better still, incremental doses of an intravenous narcotic titrated to pain relief with movement (not just at rest) to be administered under observation in the ER. Then this is followed by REGULAR NOT PRN doses of acetaminophen alternating with ibuprofen. Then , if necessary, short term oral narcotics for breakthrough pain. Discuss this general pain management problem with a pediatric (or adult) anesthesiologist colleague to develop a general protocol, not an individual consult for this individual patient.

  • Dr. Orajiaka,
    Twenty five to thirty years ago and prior opioids of any kind were never prescribed for ordinary ortho and other pediatric cases. My daughter had three re settings of her arm without any type of pain treatment. It was only after the third manipulation that I called the doc’s office and demanded his office staff get him in the OR and get a script written. I would have gladly okayed a surgical reset but the doc looked down at my daughter prior to the first reset and said you don’t want to go to surgery do you? He botched the whole treatment big time.
    Other than that one incident any falls or retinal tears, broken ankles or arms were treated without opiates.
    Tufts University has a department that was founded by the Sackler Family and came up with the pain face code. At the time, I thought great having seen Sickle Cell Aniema patients in great pain along with elderly patients who dealt with compressed and fractured vertebrae.
    Unfortunately, this was only a tool for selling pain medication rather than coming from a true sense of compassion.
    I would suggest you go up to your local burn unit since they have both pediatric and adult patients and ask the staff and patients how they deal with the pain with the daily treatment.
    I have never heard of a burn unit patient becoming addicted to opiotes. I wonder why?

    • Dear Mary,

      I appreciate your comments.
      So many treatment regimens have evolved over the past years with of course some being positive and others negative.

      Most patients with acute injuries are in worse pain during the initial hours it occured and during intake managments.

      My article was intended for initial pain control when we anticipate our patients to be in worse pain and after the benign medications such as ibuprofen and tylenol have been tried with little to no benefits. In most reduced and casted fractures (with some exceptions of course), patients rarely continue to require aggressive pain control

      In admitted patients such as in burn, who require repeat daily dressings, different pain protocols are used with opioids being an option but which providers also thread with caution.

      So again, I was focusing more on initial pain control in ER
      I hope this answers your question

      Thanks