Strong opioids in pediatric palliative medicine

Opioid-Induced Respiratory Depression in Pediatric Palliative Care Patients with Severe Neurological Impairment-A Scoping Literature Review and Case Reports

Pediatric Palliative Care (PPC) addresses children, adolescents, and young adults with a broad spectrum of underlying diseases. A substantial proportion of these patients have irreversible conditions accompanied by Severe Neurological Impairment (SNI). For the treatment of pain and dyspnea, strong opioids are widely used in PPC. Nonetheless, there is considerable uncertainty regarding the opioid-related side effects in pediatric patients with SNI, particularly concerning Opioid-Induced Respiratory Depression (OIRD). Research on pain and OIRD in pediatric patients with SNI is limited. Using scoping review methodology, we performed a systematic literature search for OIRD in pediatric patients with SNI. Out of n = 521 identified articles, n = 6 studies were included in the review. Most studies examined the effects of short-term intravenous opioid therapy. The incidence of OIRD varied between 0.13% and 4.6%; besides SNI, comorbidities, and polypharmacy were the most relevant risk factors. Additionally, three clinical cases of OIRD in PPC patients receiving oral or transdermal opioids are presented and discussed. The case reports indicate that the risk factors identified in the scoping review also apply to adolescents and young adults with SNI receiving low-dose oral or transdermal opioid therapy. However, the risk of OIRD should never be a barrier to adequate symptom relief. We recommend careful consideration and systematic observation of opioid therapy in this population of patients.

From Tramadol to Methadone: Opioids in the Treatment of Pain and Dyspnea in Pediatric Palliative Care

BACKGROUND

More than 15,000 children die annually in the United States due to an underlying life-limiting disease and the majority of those children experience distressing symptoms, which are not adequately relieved, such as pain and dyspnea. Multimodal analgesia, that is multiple agents, interventions, rehabilitation, psychological modalities, and integrative (nonpharmacologic) therapies, act synergistically for more effective pediatric pain and symptom control with fewer side effects than a single analgesic or modality. However, opioids, such as morphine, fentanyl, hydromorphone, oxycodone, and methadone (in the United Kingdom: diamorphine) remain the mainstay medication to effectively treat pain and dyspnea in children with serious illness.

METHODS

This article reviews commonly used opioids in Pediatric Palliative Care, which a special emphasis on 2 potentially particularly effective multimechanistic opioids: tramadol and methadone.

RESULTS

Methadone, due to its multimechanistic action profile, is possibly among the most effective and most underutilized opioid analgesics in children with severe unrelieved pain at end of life. However, methadone should not be prescribed by those unfamiliar with its use: Its effects should be closely monitored for several days, particularly when it is first started and after any dose changes.

CONCLUSIONS

Tramadol appears to play a key role in treating episodes of inconsolability in children with progressive neurologic, metabolic, or chromosomally based condition with impairment of the central nervous system. However, the recent 2017 United States Food and Drug Administration (FDA) warning against pediatric use of tramadol does not seem to be based on clinical evidence, and therefore puts children at risk for unrelieved pain or increased respiratory depression.

[Use of opioids in palliative care of children with advanced cancer]

INTRODUCTION

Despite advances in the treatment of cancer in paediatric patients, 15% of children die from the illness progression in Chile, and pain is the most significant symptom in advanced stages. Although the World Health Organization guidelines demonstrate that opioids are fundamental in pain management, there is still resistance to their use. The main objective of this article was to describe the experience in the use of opioids for pain management in paediatric patients with advanced cancer in palliative care (PC).

PATIENTS AND METHOD

Retrospective study of patients admitted into the PC Program at the Hospital Roberto del Río between 2002 and 2013. Analysis was carried out on demographic data; oncological diagnosis; pain intensity on admission and discharge, according to validated scales; use of non-steroidal anti-inflammatory drugs; weak opioids; strong opioids; adjuvants drugs; the presence of secondary effects resulting from the use of morphine, and the need for palliative sedation.

RESULTS

Of the 99 medical records analysed, the median age was 8 years, 64.6% were male, and there was a similar distribution in three oncological diagnosis groups. Upon admission, 43.4% presented intense to severe pain, and upon discharge there were four patients, but with a maximum VAS score of 7 in only one case. Of the 66 patients taking strong opioids, 89% required less than 0.5mg/kg/hr. Constipation was the most frequently observed secondary effect.

CONCLUSIONS

Two thirds of the patients studied required strong opioids, with which adequate pain management was achieved, with no serious complications observed. The use of opioids in this group of patients, following a protocol, is considered effective and safe.

[Pediatric perioperative systemic pain therapy: Austrian interdisciplinary recommendations on pediatric perioperative pain management]

BACKGROUND

Many analgesics used in adult medicine are not licensed for pediatric use. Licensing limitations do not, however, justify that children are deprived of a sufficient pain therapy particularly in perioperative pain therapy. The treatment is principally oriented to the strength of the pain. Due to the degree of pain caused, intramuscular and subcutaneous injections should be avoided generally.

NON-OPIOIDS

The basis of systemic pain therapy for children are non-opioids and primarily non-steroidal anti-inflammatory drugs (NSAIDs). They should be used prophylactically. The NSAIDs are clearly more effective than paracetamol for acute posttraumatic and postoperative pain and additionally allow economization of opioids. Severe side effects are rare in children but administration should be carefully considered especially in cases of hepatic and renal dysfunction or coagulation disorders. Paracetamol should only be taken in pregnancy and by children when there are appropriate indications because a possible causal connection with bronchial asthma exists. To ensure a safe dosing the age, body weight, duration of therapy, maximum daily dose and dosing intervals must be taken into account. Dipyrone is used in children for treatment of visceral pain and cholic. According to the current state of knowledge the rare but severe side effect of agranulocytosis does not justify a general rejection for short-term perioperative administration.

OPIOIDS

In cases of insufficient analgesia with non-opioid analgesics, the complementary use of opioids is also appropriate for children of all age groups. They are the medication of choice for episodes of medium to strong pain and are administered in a titrated form oriented to effectiveness. If severe pain is expected to last for more than 24 h, patient-controlled anesthesia should be implemented but requires a comprehensive surveillance by nursing personnel.

KETAMINE

Ketamine is used as an adjuvant in postoperative pain therapy and is recommended for use in pediatric sedation and analgosedation.

Neuropathic pain management in children

There are difficulties in assessing, managing, and evaluating neuropathic pain in dying children, particularly those with neurological impairment. Neuropathic pain in children often presents differently to how it presents in the adult population. Comprehensive assessment as well as pharmacological and non-pharmacological interventions are crucial to its successful management and frequently require input from an interdisciplinary team. Notwithstanding the need for further research, this paper brings together research papers, reviews, and clinical guidelines to present an exploration of existing evidence regarding care for children with neuropathic pain and their families.

Opioids for the management of severe chronic nonmalignant pain in children: a retrospective 1-year practice survey in a children's hospital

OBJECTIVE

This study reviewed opioid prescription for chronic severe nonmalignant pain in a multidisciplinary pediatric pain clinic. We looked at benefits and side effects of therapy, and compared our process of opioid prescription with the practice guidelines defined in adult literature.

DESIGN

Descriptive retrospective practice survey.

SETTING

Multidisciplinary pain clinic in a tertiary pediatric hospital.

PATIENTS

During a 12-month period, 104 patients were seen in the clinic, of which 49 received an opioid as part of their pain management; 11 received an opioid chronically, defined as more than 3 months in this study, and 5 of these were still on opioid at the end of the study period although data on one patient are lacking as she had been transferred to an adult clinic.

METHODS

Information about patients was obtained from chart review.

OUTCOME MEASURES

Benefits and side effects of treatment, as well as the process of prescribing opioids and follow-up.

RESULTS

In the four patients studied, there seem to be better pain control and improved function in these patients while on opioid therapy, despite minor side effects. We identified some areas of improvement in our practice and made recommendations for the use of opioids in pediatric chronic severe nonmalignant pain.

CONCLUSIONS

The evolution of our four patients seems to be in favor of treatment with an opioid for severe chronic nonmalignant pain in certain pediatric patients, in the context of prescribing in a multidisciplinary pain clinic with a multisystem approach to pain management although more data are needed to know if such therapy is safe and beneficial on a longer-term basis.

Pain management in pediatric age group

The management of pain in palliative care of children is somewhat different from that in adults. The use of opioids in pediatric palliative care presents some unique challenges. Confident and rational use of opioids, illustrated by WHO Guidelines is essential for adequate management of pain in children with life limiting conditions.

The DEC-net European register of paediatric drug therapy trials: contents and context

OBJECTIVE

To describe the results and conclusions of DEC-net, an international, publicly available register of paediatric drug therapy clinical trials, and to assess which paediatric health areas are covered by research and by which trial types.

METHODS

The contents of the register, which was set up by four groups (Italy, UK, France, Spain) who searched for paediatric trials and collected data between 2004-2006, were analysed. The disease areas reflected were compared with those covered by published trials and Burden of Disease (BD) data.

RESULTS

In all, 257 trial records were analysed, 86 of which were entered by the Italian partner, 84 by the UK partner, 56 by the French partner and 31 by the Spanish partner. Spain entered the majority of multinational trials, while the UK had the majority of single-centre national trials. Most trials were experimental (79%), and the most commonly represented diseases were neoplasms (14% trials). In all, 28% were double-blind randomised controlled trials (RCTs). The most common disease areas addressed in the 257 trials were similar to the published trials' areas. In contrast, the primary research area was low on the BD list.

CONCLUSIONS

DEC-net has demonstrated that international research efforts exist, even for paediatrics, although there may be an imbalance between national and multinational studies and a limited approach to double-blind RCTs. Recent initiatives will increase the number of children participating in research, and European legislation will require prospective registration. Paediatric research priorities must be better defined, however, and this can be done by registering research and making the information available to all relevant actors.

Opioid use in palliative care of children and young people with cancer

OBJECTIVE

Identify opioids prescribed, preferred routes, and doses among children with incurable cancer.

STUDY DESIGN

Prospective survey with monthly questionnaires regarding patients 0 to 19 years old from oncology centers. Data were collected by professionals on each patient for 6 months or until death, and analyzed from patients who died. Impact of tumor was analyzed with Kruskal-Wallis and Mann-Whitney tests. Major opioid dosages are expressed as oral morphine equivalents.

RESULTS

Of 185 children recruited, 164 (88 boys, 76 girls) died. Mean palliative care duration was 67 days. One hundred forty-seven (89.6%) received major opioids. Morphine, diamorphine, and fentanyl were prescribed in 75%, 57.9%, and 11.6%, respectively. Seventy-three (44.5%) received >1 major opioid. Median monthly maximum doses prescribed rose from 2.1 mg/kg/24 h (study entry) to 4.4 mg/kg/24 h (death) (P < .001); overall variable (0.09-1500 mg/kg/24 h, median 3.7 mg/kg/24 h). Opioids were given by the oral (117/164, 71.3%), intravenous (68/164, 41.5%), subcutaneous (40, 28%), rectal (20, 12.2%), and transdermal (18, 11%) routes. There was a shift to intravenous use as death approached. Numbers within each tumor group were too small to show significance. Children with solid tumors outside the central nervous system were likely to receive more opioids, be given multiple different opioids, and receive opioids in the last month.

CONCLUSIONS

The study shows the United Kingdom practice of opioid use and provides comparator data for practice in children's palliative medicine.

Deliberate termination of life of newborns with spina bifida, a critical reappraisal

OBJECTS

Deliberate termination of life of newborns (involuntary euthanasia) with meningomyelocele (MMC) is practiced openly only in The Netherlands. 'Unbearable and hopeless suffering' is the single most cited criterion for this termination, together with the notion that 'there are no other proper medical means to alleviate this suffering'. In this paper, both (and other) statements are questioned, also by putting them in a broader perspective.

METHODS

First, a historical overview of the treatment of newborns with MMC is presented, concentrating on the question of selection for treatment. Second, a thorough analysis is made of the criteria used for life termination. Third, a case of a newborn with a very severe MMC is presented as a 'reference case'.

CONCLUSION

'Unbearable and hopeless suffering' cannot be applied to newborns with MMC. They are not 'terminally ill' and do have 'prospects of a future'. In these end-of-life decisions, 'quality of life judgments' should not be applied. When such a newborn is not treated, modern palliative care always will suffice in eliminating possible discomfort. There is no reason whatsoever for active life-termination of these newborns.

Ensuring pain relief for children at the end of life

Pain management in the context of pediatric palliative care can be challenging. The present article reviews, through a case-based presentation, the nonpharmacological and pharmacological methods used to ensure adequate pain control in children facing end of life. Details on the impressive range of opioid dosages required and routes of administration are highlighted from published literature and clinical experience. Where available, evidence-based recommendations are provided. Potential side effects of pain medication and barriers to good pain control are discussed. Novel analgesics and innovative delivery methods are presented as future tools enhancing pain relief at the end of life. Some challenges to ethically grounded research in this important context of care are reviewed.

Restless Legs Syndrome

Restless legs syndrome (RLS) is a common and often disabling sensorimotor disorder. Epidemiologic studies suggest that RLS is an underrecognized and undertreated disorder affecting both children and adults. The diagnosis is based primarily on the following four essential criteria: (1) an urge to move, usually associated with paresthesias, (2) onset or exacerbation of symptoms at rest, (3) relief of symptoms with movement, and (4) symptoms manifesting in a circadian pattern. Supplemental workup including polysomnography, iron profile, and/or neuropathy screen can provide support for the diagnosis and aid in the treatment strategy. Behavioral techniques, dopaminergic agents, opiates, benzodiazepines, and antiepileptics all have potential value in treating this disorder. Dopaminergic agents continue to be the most effective RLS treatment. However, due to their potential long-term side effects, these agents should not be considered the sole treatment of choice. In the end, the therapeutic plan should be individualized to suit each patient's presentation and needs.