They identify a number of impediments that prevent patients in pain from receiving adequate pain management and access to opioids.
These impediments are applicable to children as well – regulations, attitudes, lack of knowledge, economic and procurement issues and fear of addiction (INCB, 2015).
Yet few documents address the extra impediments that children* experience. These include:
- impediments due to their age
- inability to describe their pain
- cultural factors that do not allow them to speak for themselves
- lack of healthcare professionals with the skills to assess pain in children
- especially pre-verbal and non-verbal children; lack of paediatric formulations of essential medications for pain management; and
- extra fears around prescribing opioids for children, such as fear of overdosing.
Even in countries where opioids are available for adults, these factors may still hinder access to pain management for children. Infants and young children are at particularly high risk of inadequate pain assessment and management due to their inability to describe their pain.
Mita** was five years old, living with advanced HIV and with a recto-vaginal fistula. Despite her severe pain, the availability of morphine in the hospital she attended in Indonesia and the advocacy of the hospice nurses, her doctor continued to prescribe first-step pain medicines such as paracetamol, as she was unused to prescribing morphine for children with HIV.
This left Mita in severe pain and emotional distress. Living mainly with her grandmother who struggled to earn a basic living, Mita had no family able to advocate for her.
Yet in another hospital in the same city, children with cancer were prescribed oral morphine by an oncologist trained in paediatric palliative care, highlighting another belief that while children with cancer can be expected to have severe pain, children with HIV are not – therefore are not assessed and treated. Training in palliative care leads to better pain management.
Managing children’s pain
While a few children suffer from complex pain, managing pain in most children is not ‘rocket science’.
We need access to suitable pain medicines, in the correct formulations; simple non-pharmacological treatments (such as massage, hypnosis, guided imagery, rocking); knowledge and skills; tools for pain assessment and the ability to communicate effectively with children at all developmental stages.
Assessment of children’s pain
Assessment of pain is the first step to managing pain. We have some well-validated pain assessment scales for children such as the NIPS (Neonatal Infant Pain Scale) for babies under one year; the FLACC (Faces, Legs, Activity, Crying, Consolability) Scale for non-verbal infants over one year; the Faces Pain Scale (revised) and simple Numerical Scales for older children (Wong et al., 2012).
In 2012 the World Health Organization published new WHO Guidelines for the Pharmacological Management of Persisting Pain in Children with Medical Illnesses and distributed copies to all member countries.
This is backed up by an online teaching module based on the WHO guidelines and available on the e-Learning site of the International Children’s Palliative Care Network.
We have the tools; knowledge can be obtained; skills come with practice. Access to the medicines necessary to manage children’s pain is more complex.
Inequalities in availability of opioids are high, but skilled health care professionals working together with parents could – and should – be advocates for better access to pain medicines for children at local, national and global levels.
* ‘Children’ includes neonates, infants, children and young people
** Name changed to protect her identity.