PAIN knock-on effect1, 7 neuropathic pain can co-exist8


. Nociceptive and .


. Human and animal studies have shown that pain has long term effects; painful experiences in early childhood can change the nervous system, increasing the likelihood of having pain later on in life3, 4


Pain Management in Children Chronic pain affects one in five children on a weekly basis or more. This includes headaches, stomach aches and joint pains. Approximately one in twenty children are very disabled by their level of pain; it interferes with school attendance, family life and play. Astonishingly, as little as 3% of children suffering with chronic pain receive adequate analgesia3


.


Prolonged and untreated pain in early life can have an effect on stress hormone responses in vulnerable children, which can lead to altered nociceptive processing and hence future pain experience4


.


in itself; it is not always a symptom of another disease. Guidance on the treatment of children’s pain is at an early stage of development and needs to continue to grow so that the needs of children are being met. There still exists a lack of resources available to clinicians and healthcare professionals for the treatment of pain in children. Inadequate education of healthcare professionals and parents alike means that pain is not being appropriately managed.


ORAL ANALGESICS


People tend to have a poor opinion of paracetamol, perhaps because it is widely available at fuel stations and local newsagents or perhaps because it is inexpensive. However, when taken regularly, paracetamol is a very effective drug for both pain and temperature reduction1


. It . Approximately


two thirds of children with chronic pain will go on to become adults with chronic pain3


The World Health Organisation states that all patients with pain should be treated, irrespective of whether or not a cause can be identified5


.


There are numerous pain scales in existence which assess the level of pain a child experiences. Many self- report tools are available for children from four years old, and specific assessment tools exist for infants and disabled children who are unable to describe their pain4


.


However, a number of obstacles exist in assessing pain and providing the appropriate level of analgesia. One problem is that children’s pain can be difficult to recognise. Many children use coping strategies to help with their pain. These include sleeping or playing, leading caregivers to the false conclusion that the child is not in pain4


. Another is the exaggerated


fears of the side effect profiles of anaesthetics and analgesics4


. . However,


after the neonatal period has passed, there are few developmental concerns with analgesic treatment4


The SIGN guideline on chronic pain does not cover pain in children. There are no NICE guidelines on chronic pain in children, only those for other conditions which draw on the treatment of pain in a minor way. Chronic pain is recognised as an illness


should always be recommended as first line treatment for any type of pain. Despite the drug having been on the market for over 50 years, its mechanism of action is not completely understood1


. Reports suggest that


it inhibits prostaglandin production and in doing so it interferes with the transmission of pain9


.


Another widely available painkiller is ibuprofen. All NSAIDs have antipyretic properties as well as being effective agents against pain and inflammation. One point to note is that individuals show significant differences in both tolerance and response to the various NSAIDs and so they should always be offered an alternative when the first NSAID has been ineffective. All drugs within this class can cause increased risk of stroke and heart attacks;


HOWEVER, A NUMBER OF OBSTACLES EXIST IN


ASSESSING PAIN AND PROVIDING THE APPROPRIATE LEVEL OF ANALGESIA. ONE PROBLEM IS THAT CHILDREN’S PAIN CAN BE DIFFICULT TO RECOGNISE. MANY CHILDREN USE COPING STRATEGIES TO HELP WITH THEIR PAIN.


ibuprofen is considered to be the safest of NSAIDs.


Opioids are either semi-synthetic or synthetic. They should be recommended for moderate to severe pain in accordance with the WHO analgesic ladder. Although many pharmacists and other healthcare professionals are hesitant to advise on the use of opioids due to the potential for addiction, tolerance and dependence, some patients have favourable outcomes over long periods of time when prescribed opioids. According to the SIGN guideline 136, patients must always be advised as to the common side effects of opioids and must be made fully aware of their treatment plan before initiation of an opioid8


. Additionally, any patient


initiating treatment with an opioid or undergoing an increase in dose should be advised to avoid driving


until feeling fit enough to do so safely1. Specialist referral is advised where problem drug use or tolerance develops; pharmacists have a key role in identifying people who have potentially become tolerant to or dependent upon opioid analgesics. Neuropathic pain rarely responds to the treatments within the WHO analgesic ladder. SIGN guidance states that gabapentin should be considered primarily for the treatment of such pain, and pregabalin can be considered if first and second line therapies are ineffective10


come to a quick conclusion that these treatments have been ineffective, but ensure a sufficient amount of time has been allowed when trialling an antiepileptic drug for neuropathy - generally one month is long enough. Amitriptyline can be considered for fibromyalgia and neuropathy in accordance with the SIGN guideline.


Tricyclic antidepressants and anticonvulsants are the mainstay of neuropathic pain and can be used individually or in combination1


.


These medicines are often used off –license for chronic pain and the patient information leaflet can cause confusion in some patients, so pharmacists need to ensure patients are aware of the appropriateness of these drugs in treating pain. The World Health Organisation has developed a two-step treatment for pain. Step one, for mild pain, recommends the use of ibuprofen and paracetamol. Ibuprofen and paracetamol are widely recognised as the mainstay of treatment for minor pain in children. Step two, which aims to alleviate moderate to severe pain, recommends the use of morphine.


SCOTTISH PHARMACIST - 47


. Patients can


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