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Pharmacological Treatments

Pharmacological Treatments

bottles of pills

This means using pain-relieving medications (e.g. pills, patches, creams/ointments, injections) to help decrease pain. Not all pain needs to be managed with medications and not all medications will be used in the same way. The type and amount of pain medications used will depend on the type of pain and your weight, allergies (if any), and health condition. Sometimes more than one medication will be recommended.  

Some examples of pain medications include acetaminophen, ibuprofen, opioids such as morphine, in addition to other medicines such as amitriptyline, and gabapentin.

Goals of Pharmacological Treatment
In our clinic, we use medications to help children increase their function.  In other words, medications reduce children’s level of pain so that children are able to go to school, be with their friends and do the physical activities they enjoy. Therefore, when we evaluate whether a medication is helping, we not only look at whether a child’s pain is reduced but we want to ensure the medication is also helping the child resume a normal life. Pain-relieving medications will be more effective when they are used together with physical and psychological therapies.

Acetaminophen
Acetaminophen is a safe and effective pain reliever. This drug can be combined with other medications such as a non-steroidal anti-inflammatory drug (NSAID) e.g. ibuprofen, or an opioid e.g. morphine to provide more effective pain relief for moderate to severe pain.

Acetaminophen is known commercially under such names as Tylenol® and Tempra®. Generic acetaminophen, or drug store brands, are just as effective and usually cost less.

Acetaminophen is safe for infants and children when individual and daily dose limits are followed; they come in liquid, suppository, and tablet forms.

Acetaminophen is also available in combined form with different amounts of other pain medicines such as oxycodone and tramadol. Sometimes these are suitable for the relief of moderate pain, but it is more difficult to optimize these combination medications, than when each one is prescribed separately.

Non-steroidal anti-inflammatory drugs (NSAIDs)
NSAIDs, or non-steroidal anti-inflammatory drugs, are a class of drugs that can be very effective in reducing pain. This is especially so when inflammation – usually indicated by redness, swelling, or heat – is playing a part in producing the pain. One of the most commonly used NSAIDs is ibuprofen. It is commonly known in Canada as Advil® or Motrin®. However, generic ibuprofen is just as effective as these brand name medicines and costs less.

NSAIDs are commonly used for headaches, toothache, muscular aches, and menstrual cramps, and may also be used to reduce fever. They may be combined with acetaminophen and opioids to more effectively manage pain due to surgery and to treat some chronic pain conditions.

Ibuprofen is available at the drugstore over the counter without a prescription. However, other NSAIDs, such as naproxen, diclofenac, meloxicam, and celecoxib are available only by prescription.

A note about Aspirin or ASA
Acetylsalicylic acid (ASA) or Aspirin® is also an NSAID but should not be used by children under the age of 16 years because of the risk of developing Reye’s syndrome which can cause liver and brain damage. Reye’s syndrome is rare and is thought to afflict children who have a viral illness, such as flu, and who take aspirin at the same time.

Side effects of NSAIDS
One of the most common side effects of NSAIDs is stomach upset. Usually, this can be avoided by making sure the correct dose is taken and by taking the medicine with food. Eating some crackers or drinking milk just before the medicine is taken is usually enough to avoid a stomach upset. In very rare cases, NSAIDs can cause bleeding problems and their use may need to be stopped. It is important to let your doctor know if your child has a bleeding disorder, asthma, kidney problems, or is undergoing chemotherapy, or has ever had a stomach ulcer before using NSAIDs.

Opioids
Although there are many types, formulations, and strengths of opioids, they are all chemically related to the same poppy plant that produces opium. Opioids are either synthetically produced or natural products and are among the oldest and best-known pain medicines. Morphine is a well-known example of an opioid.

Some people become concerned when their pain needs to be managed with opioids. Mostly they are worried about side effects, addiction and the possibility of an overdose. If opioids are prescribed for your treatment, the amount will be considered based on your weight and how much is needed for effective pain management. Also, anyone prescribed an opioid will need to complete an ‘Agreement for Opioid Therapy’ form to ensure the safety of using opioid therapy. Regular monitoring will also be required. This may include urine testing.

Morphine and other opioids
The most commonly used opioids are morphine, hydromorphone, oxycodone and fentanyl. These pain medicines act on the tissues of the central nervous system and the brain to provide pain relief. They are usually prescribed for moderate to severe pain associated with surgery and cancer pain, but are also sometimes used for the treatment of chronic pain.

Side effects of opioids
These are some of the more common side effects of opioids:

  • Constipation: all opioids slow down the bowels, and cause constipation and hard stools in about 50% of people. Although laxatives are often prescribed to relieve constipation, this is the only side effect that tends not to improve over time.
  • Drowsiness, nausea and vomiting.
  • Some children develop an urgency to pee, while others have difficulty peeing.
  • Opioids can also alter a child's mood. For example, they might feel euphoric or very giddy, or they might feel a little down or teary.
  • Some children may have vivid dreams or mild hallucinations, and feel disoriented.
  • Uncommonly, and if given in too high a dose, opioids can cause low blood pressure or respiratory depression, which is characterized by shallow breathing and a slow breathing rate. When opioids are started at home the dose is started very low and increased slowly. Children need to be carefully monitored for these effects.
  • With long-term use, children can sometimes become tolerant to opioids, resulting in the need for higher doses to achieve the same pain control
  • Also with long-term use, opioids can result in altered sex hormone production by the body.  This can be monitored by physical exam and discussion with your doctor or nurse practitioner.

    Health care professionals can provide guidance that will help to minimize the impact of these worrying side effects.

A Note about Codeine
Codeine should be used with caution to treat pain in children. Codeine only works because it is converted into morphine by an enzyme in the liver. However, up to 30% of children genetically do not have this enzyme. For them, codeine will have no effect on their pain.  The opposite genetic condition also exists for some people. Called "codeine ultra metabolizers" these children convert codeine into excessive amounts of morphine which can be dangerous. It is possible that a child with this very rare condition could suffer a morphine overdose.  Because of the unpredictable nature of codeine we therefore do not recommend its use.

If codeine is prescribed for you careful monitoring, especially when the medication is first taken, will be required.

Learn more about opioids 

Learn more about the safety and side effects associated with opioids 

Learn more about Morphine for Pain in Children

Learn more about Drug Information

Adjuvant medication
Adjuvant drugs are not true pain relief medications. They are a group of drugs that were developed to treat other conditions, but have been found to be helpful for some pain conditions that are otherwise difficult to treat. Usually, adjuvant drugs are used to enhance the pain relief provided by commonly used pain medicines. However, they may also be prescribed on their own without other pain relievers. Adjuvant drugs are most often used for neuropathic and other chronic pain problems. There are several different types of adjuvant drugs – the ones most commonly used are antidepressants, and anticonvulsants.  

  • Antidepressants

    Tricyclic anti-depressants
    Tricyclic anti-depressants (TCAs), as their name suggests, were first developed to treat depression. However, it has been discovered that they can be helpful in treating neuropathic pain. When used for this purpose, much smaller doses are given than when used for treating depression.

    Side Effects of TCAs
    TCAs can cause side effects. These include dry mouth, dry eyes, constipation, sleepiness and dizziness when standing after lying down. Such effects are usually not troublesome and tend to subside after a few days. Rarely TCAs can make symptoms worse for people who have problems with their heart rhythm. Your doctor may recommend that you have an electrocardiogram (ECG) before starting a TCA to make sure you do not have a problem with your heart rhythm. As with many other medications, TCAs should be taken only at the dose prescribed, as large doses can be dangerous.

      Examples of other antidepressants:

    • Serotonin and norepinephrine reuptake inhibitors (SNRIs). For example: venlafaxine (Effexor) and duloxetine (Cymbalta)
    • Selective serotonin reuptake inhibitors (SSRIs). For example: paroxetine (Paxil) and fluoxetine (Prozac)
  • Anticonvulsants
    Anticonvulsants were first developed to treat seizures. However, they are also used to treat neuropathic pain because they have a calming effect on pain nerves that are overactive.

    Commonly prescribed anticonvulsants include gabapentin and pregabalin.

Side Effects of Anticonvulsants
These medications are usually well tolerated but can cause some side effects including drowsiness, nausea, dizziness, fatigue, and reduced concentration. These side effects usually subside within a few days and can be minimized by increasing the dose slowly.

Local Anaesthetics
Local anaesthetics block or numb nerves.  They can be used for the management of pain in two ways:

  • Topical preparations; these creams and ointments are used to numb nerves close to the surface of the skin. They can sometimes be applied for prolonged periods to relieve chronic pain, usually in combination with medication such as opioids, NSAIDs, and anticonvulsants.
  • Injections of local anaesthetics. These include trigger point injections and nerve-blocks (e.g. epidural injections). Your pain health care professional will decide, together with you, if one of these treatments is right for you.  

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Psychological Treatments  

pebbles in the sand

Sometimes pain can stay for a long time and can make it difficult to stay in school, be with friends and do things you enjoy. This can make people feel frustrated, angry, sad, or upset, which are normal reactions to pain and the impact of pain on your life. However, stress, worry, sadness, or anger can actually make pain worse. 

Psychological treatments can help people to reduce pain by learning how to manage stress, relax tense muscles, and distract from pain sensations. The goal of psychological treatments in to find strategies that will help you reduce the amount of pain and to control pain and get back to doing what they love to do. When psychological methods of pain management are suggested, it does not mean that the Team thinks your pain is “in your head” or imagined.  Psychological methods are one of the three essential approaches to pain management and are considered for all the patients we assess.

For some patients, an assessment may lead to a diagnosis of psychiatric illnesses such as depression or post-traumatic stress disorder. If so, the psychiatrist will make the appropriate referrals to ensure your child can receive the necessary psychiatric services.

How do Psychologists help manage chronic pain?
By doing careful, individualized assessments, Psychologists help children identify factors in their life that contribute to chronic pain. After specific factors are identified, Psychologists help children reduce these factors by teaching different pain and stress management techniques.

  1. Psychologists help children harness the power of their minds to reduce pain.  Some common pain reduction strategies include physical techniques such as deep breathing and muscle relaxation and mind-based techniques such as reducing distressed thoughts and feelings.  
  2. Psychologists help parents learn strategies to better manage their child’s pain.
  3. Psychologist support children by working with their schools and coaches with the goal of returning children to the activities they enjoy.

Examples of psychological treatments used to treat chronic pain:

Cognitive Behavioral Treatments
When pain sticks around for a  long time, children and their parents can feel angry, frustrated, worried or hopeless.  All of these feelings are triggered by thoughts that pass through our mind.  Examples of such thoughts include:  “my pain will never go away’, “I will never be able to do the things I want” or “nothing helps my pain.”  A closer look reveals that these thoughts are not terribly helpful – they only make us feel worse.  Often, these thoughts are not even accurate.  For example, if kids really think about it, they often can find things that do help their pain, even a bit – like watching TV (it distracts them from their pain), cuddling with a pet, taking medications, or using cold/hot packs.  Cognitive behaviour therapy (CBT) helps kids recognize thoughts about their pain that only make them feel worse and then helps kids to change and reduce the power of these thoughts.  Clinical research shows that CBT is an effective treatment for chronic pain conditions.

Mindfulness Techniques for Pain Management
Mindfulness treatments teaches us to become more aware of our thoughts, emotions and physical sensations at the moment they occur without reacting out of habit or in automatic ways.  Once we master this skill, we can make choices about how to respond to our experience  so we can enjoy life, even in difficult times.  Mindfulness approaches are based on learning to accept our experience and not react to it.  Through acceptance, people can cope with their pain in new and unexpected ways.

Learn more about mindfulness treatments with children.

See more information on the types of psychological treatments that may be used.