Optimising Palliative Care for Children using a Multimodal (opioid-sparing) Approach to Pain Management-Lessons from the USA

This report focuses on key lessons learnt from attending a Paediatric Pain Master-class in Minneapolis USA.  A multimodal (opioid-sparing) approach to paediatric pain is the main message brought back to UK nursing and to paediatric palliative care.  This is not an approach which is taught or promoted in UK paediatric hospice care in my experience and consequently needs sharing in order to optimise the care given to this cohort of patients.

Six main categories to an opioid-sparing approach are discussed in greater detail which can together reduce the dose of opioid which might be required by the child or young person, (CYP) thus reducing potential side effects and reducing the burden of pain which they experience;

  1. Non-Opioids and a discussion about the use of COX-2 inhibitors for patients at risk of bleeding
  2. Opioids (specifically use of Methadone and cross tolerance of opioids)
  3. Integrative therapies; aromatherapy and massage; distraction; mindfulness; biofeedback; hypnosis
  4. Psychology and rehabilitation
  5. Adjuvants such as Gabepentinoids and Tricyclic anti-depressants
  6. Invasive approaches such as nerve blocks

It is the combination of using the multimodal approach which targets pain at different receptors to include six approaches to pain management inclusive of pharmacological and non-pharmacological which needs promoting and delivering to CYP.

The appendices contain further information learnt from the travel scholarship which is of equal importance but due to word count restrictions had to placed in the appendix.  This enabled the focus to be kept on the multimodal opioid sparing approach to pain for the core theme.  However, additional lessons learnt are:

  • An alternative drug to use for sialorrhoea in CYP which could be particularly useful for “death rattle” at end of life; Atropine 1% eye drops
  • Neuroirritability in CYP and a proposed neuro pain ladder.
  • Neuropathic pain ladder, (a step-wise approach)
  • Feeding CYP with a neurological impairment
  • Lessons learnt from Canuck Place children’s hospice, Vancouver.

Specific areas of learning and outcomes which will be highlighted and taught to the palliative care team from this travel scholarship:

  • Concurrent use of paracetamol and NSAIDs with opioids and to consider using selective COX-2 inhibitor as NSAID of choice if CYP is at risk of bleeding, Celecoxib.
  • Consider using Methadone when a CYP has escalating pain which is not responding to increasing opioid dose and when a CYP has neuropathic pain. RAHA (Risk Assessment/Hazard Analysis) to be written for the use of Methadone due to its complexity and staff to be taught and empowered to use safely.
  • Opioid switching to be considered if CYP had significant side effects or ineffective pain control and to educate staff when a CYP has significant opioid-induced side effects that we should discuss opioid rotation with their lead clinician and due to the risk of cross tolerance ensure that the dose is always reduced to prevent toxicity.
  • The use of aromatherapy and massage. As a starting point the five essential oils; sweet orange, lemon, lavender, peppermint and spearmint which are used at Minnesota Children’s hospital could be introduced. It has been agreed that a proposal for the use of aromatherapy can be discussed at the next Medicines Management Meeting along side some guidance and consideration to introduce.
  • Recommended apps for distraction to be introduced to CYP who would be able to use independently and source a means to provide iPads for those CYP who don’t have access to one. All hospice iPads now have these useful apps downloaded and ready to use.
  • Mindfulness books and resources to be used for teaching CYP and parents

At beginning of team meetings we have introduced a five-minute mindfulness exercise to get everyone focused, and get our staff familiar with using mindfulness.

  • Referring CYP with chronic pain to the regional palliative paediatrician who has trained in hypnotherapy. Also further training in hypnotherapy for medicine will be suggested to nurses in the team as Dr Kuttner runs a three-day workshop in Minneapolis in Pediatric Clinical Hypnosis.
  • Consider the use of Lidocaine patches for CYP who have a localized area of neuropathic pain.
  • Consider regional anaesthesia if CYP willing to attend hospital and local anaesthetist willing to assess and treat
  • Neuropathic pain ladder (see appendix 8)
  • Management of dysautonomia : Dr Hauer’s suggested neuro pain ladder, ( see appendix 10).
  • Children’s Comfort Promise, (Needleless pain), (see appendix 3). This has been taught to symptom management team and will be disseminated further to the wider nursing team within the hospice.
  • Distraction tools give to Symptom Management team and taught about the importance to use, so all members of team have the equipment ready to use.

 

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