Dave ARNP

One of the newer treatments that's been extremely successful is Enbrel. I've seen quite a few news segments on it lately, so I would say that's what you're daughter saw. Enbrel is an injection formulation, which was (and I beleive is only) approved for RA. It's useage for psoriasis is still off label (again, to my knowledge). I've seen some great results with it, but it's rather expensive. Another good option is Neoral. Also seen very good results with this. For mild psoriasis, topical Ultravate is decent. -Dave

I think the better idea here would be to use a medication other than Tylenol. Since you've not said what you're treating, it's kinda hard for me to speculate. I will say that the first thing generally done here would be start a COX-2 agent, (I prefer Celebrex) and use Vicodin PRN. Ideally, 400mg of Celebrex to start, then 200mg QD, with Vicodin PRN. If you'll elaborate a little more on the source of pain you're trying to treat, I can make a few more suggestions for you to take to his MD. -Dave

By my figuring, I'm worth $86.76 qhr, at 50hrs a week. I can certainly live with that. :D -Dave

Aww... I feel loved Angelbear -Dave

If the doc had but to walk one day in that poor mans shoes..... The order for pain meds would be enough to kill an elephant. -Dave

Firstly, let me apologise for the poor care you received by those who proclaim to practice pain managment. The care you received is so far below standard that it's not even funny. I don't have the pleasure to dealing with anesthesia residents, although the family practices ones I get can be quite trick. To berate a patient for chosing a method of anestheisa other than the one the provider chose is obsurd. Not enough money in the world to keep me awake during an ortho case. To answer your questions, no you are not a bad patient/person/nurse because you were "hard to put to sleep". Secondly this is NOT the best that we can do at eliminating a patients pain. With todays advances, surgery can be quite painless. People just can't be afraid to make it so. Glad to have you on the board! Hope you decide to make it your home! --Dave

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Personal attacks? Yea... Ok. Beleive that would be your department. I'm not going to explain anything to you. I have patients and people who need and deserve my time. You meet none of that four criteria. -Dave

Don't worry guy... This is just HER opinion. And you know what they say about opinions. -Dave

That sorta of careless disreguard is the reason we have patients who don't bother comming in for their illness. I certainly hope you aren't that dangerous with your real life practice of medicine. -Dave

I know, it's a dark place isn't it. That thread was mentioned to me and I went over and looked at it. Seems that they're so scared of NP's at the moment, they need to come see where we hang out. They're really not worth our time. -Dave

Accuracy of Emergency Nurses in Assessment of Patients' Pain Posted 12/18/2003 Kathleen Puntillo, RN, DNSc; Martha Neighbor, MD; Nel O'Neil, RN, MS; Ramona Nixon, RN, MS Abstract and Introduction Abstract Pain is a common complaint in Emergency Departments. Inpatient studies have shown discrepancies between patients' and nurses' pain assessments. The accuracy of emergency nurse assessments of their patients' pain has not been well investigated. Using a 0 to 10 numeric rating scale (NRS), researchers asked patients to rate their pain intensity in triage. Separately, the triage nurse was asked to rate the patient's pain. This process was repeated with the same patients but different nurses after patients were taken back to a clinical area within the Emergency Department. At triage, patients' average pain intensity score was 7.5 ± 2.2. The triage nurses' ratings were significantly lower at 5.1 ± 2.4 (p http://www.medscape.com/viewarticle/465817

My gosh. I hope you're joking. Scary to think you might not be. -Dave

clinical validation of flacc: preverbal patient pain scale from pediatric nursing posted 05/06/2003 renee c.b. manworren, linda s. hynan abstract and introduction abstract purpose: to test the validity of the faces, legs, activity, cry and consolability (flacc) pain assessment tool by measuring changes in scores in response to analgesics. method: pediatric nurses used the flacc scale to assess pain in 147 children under 3 years of age who were hospitalized in the pediatric intensive care unit (picu), post-anesthesia care unit (pacu), surgical/trauma unit, hematology/oncology unit, or infant unit. flacc is an observational tool for quantifying pain behaviors. facial expression, leg movement, activity, cry, and consolability are each scored 0-2, for a total flacc score of 0-10. the flacc measurements were done pre-analgesia, at predicted onset of analgesia, and at predicted peak analgesia. findings: pre-analgesia flacc scores were significantly higher than post-analgesic scores and significantly higher for patients who received opioids than patients who received non-opioids. peak analgesia flacc scores across analgesia groups were not significantly different and reflect effective pain relief for patients regardless of analgesic choice. conclusions: the flacc pain assessment tool is appropriate for preverbal children in pain from surgery, trauma, cancer, or other disease processes. the results support pediatric nurses' clinical judgment to determine analgesic choice rather than providing distinct flacc scores to guide analgesic selection. http://www.medscape.com/viewarticle/452694

AGS Clinical Practice Guideline: The Management of Persistent Pain in Older Persons Executive Summary Persistent pain, defined as a painful experience that continues for a prolonged period of time, is prevalent in older adults. The terms persistent and chronic are often used interchangeably in the medical literature. Unfortunately for older persons, chronic pain has become a label that often conjures up negative images and stereotypes associated with longstanding psychiatric problems, futility in treatment, malingering, or drug-seeking behavior. The term persistent pain may foster a more positive attitude for patients and professionals for the many effective treatments that are available to help alleviate suffering. The American Geriatrics Society disseminated a clinical practice guideline for the management of chronic pain in older adults in 1998. Since then, important advances in pharmacology and strategies for the assessment and management of pain in older persons have emerged. The recommendations presented in this updated guideline, The Management of Persistent Pain in Older Persons, are meant to revise, refine and update the previous work. They represent the consensus of a panel of pain experts and were derived from a synthesis of the literature combined with clinical experience in caring for older adults with persistent pain. Important new information provided in this document includes recommendations for pain assessment in cognitively impaired persons, the use of new COX-2 selective nonsteroidal anti-inflammatory medications, the unethical use of placebos, and many other contemporary issues in persistent pain management. In focusing on issues unique to the geriatric population and areas that have been omitted or less well developed in previous work,the new guideline will be helpful to clinicians as well as to researchers and policy makers. Ultimately, we hope the beneficiaries of this work will be those patients who require effective pain management to maintain their dignity, functional capacity and overall quality of life. The recommendations are divided into four sections: Assessment of Persistent Pain, Pharmacologic Treatment, Nonpharmacologic Strategies, and Recommendations for Health Systems That Care for Older Persons. For each section, general principles are discussed, followed by the panel's specific recommendations for improving the clinical assessment and management of persistent pain in older persons. This guideline was developed and written under the auspices of the AGS Panel on Persistent Pain in Older Persons, approved by the AGS Board of Directors on April 8, 2002, and published in the June 2002 supplement issue of the Journal of the American Geriatrics Society under the title "The Management of Persistent Pain in Older Persons". The following organizations with special interest and expertise in the management of pain in older persons provided peer review of a preliminary draft of the guideline: American Academy of Family Physicians; American Academy of Home Care Physicians; American Academy of Orthopaedic Surgeons; American Academy of Pain Medicine; American Academy of Physical Therapy; American Academy of Physical Medicine and Rehabilitation; American College of Clinical Pharmacy; American Medical Association; American Occupational Therapy Association; American Society of Anesthesiologists; American Society of Clinical Oncologists; American Society of Consultant Pharmacists; Hospice and Palliative Nurses Association; Oncology Nursing Society. Summary of Key Recommendations The key to effective treatment of persistent pain lies in comprehensive assessment. All older persons should be screened for persistent pain on initial evaluation, on admission to any health care service, and periodically thereafter. Any persistent pain that has an impact on physical function, psychological function, or quality of life should be considered a significant problem The verbally administered zero to ten scale is a good first choice for assessment of pain intensity; however, other scales such as word descriptor scales, faces scales, or pain thermometers may be more appropriate for some patients. For those with moderate to severe cognitive impairment, assessment of behaviors and family or caregiver's observations are essential. The use of placebos in clinical practice is unethical and there is no place for their use in the management of persistent pain. Acetaminophen should be the first drug to consider in the treatment of mild to moderate pain of muskuloskeletal origin. Traditional (i.e., nonselective) nonsteroidal anti-inflammatory drugs (NSAIDS) should be avoided in those who require long-term daily analgesic therapy. The selective NSAIDs, i.e., the COX-2 inhibitors, are preferable. Opioid analgesic drugs are effective, associated with a low potential for addiction, and overall may have fewer long-term risks than other analgesic drug regimens in older persons with persistent pain. As with all medication, careful monitoring for the development of adverse side effects is important. An individualized program of physical activity should be designed to improve flexibility, strength, and endurance, and should be maintained indefinitely. Patient and caregiver education is an essential component in the management of persistent pain. Health care facilities that care for older patients should routinely conduct quality assurance and quality improvement activities to enhance pain management. SOURCE: AGS Panel on Persistent Pain in Older Persons. The Management of Persistent Pain in Older Persons. American Geriatrics Society. J Am Geriatr Soc 2002; 50;6:1-20 The development of this guideline was supported by unrestricted educational grants from Janssen Pharmaceutica, McNeil Consumer & Specialty Pharmaceuticals, a Division of McNeil-PPC, Inc.; Ortho-McNeil Pharmaceutical, Inc.; Pharmacia Corporation; and Purdue Pharma L.P. http://www.americangeriatrics.org/education/executive_summ.shtml

Pediatric Chronic Pain A Position Statement from the American Pain Society Significance of the problem Chronic pain is a significant problem in the pediatric population, conservatively estimated to affect 15% to 20% of children (Goodman & McGrath, 1991). Children* and their families experience significant emotional and social consequences as a result of pain and disability. The financial costs of childhood pain also may be significant in terms of healthcare utilization as well as other indirect costs, such as lost wages due to time off work to care for the child (Li & Balint, in press). In addition, the physical and psychological sequelae associated with chronic pain may have an impact on overall health and may predispose for the development of adult chronic pain (Campo et al., 1999; Walker, Garber, Van Slyke, & Greene, 1995). * This term refers to all individuals in the pediatric age range (i.e., neonates, infants, and adolescents). Definition of chronic pain Acute pain follows injury to the body and generally disappears when the bodily injury heals. It is often, but not always, associated with objective physical signs of autonomic nervous system activity. Chronicpain, in contrast to acute pain, rarely is accompanied by signs of sympathetic nervous system arousal. The lack of objective signs may prompt the inexperienced clinician to say the patient does not "look" like he or she is in pain. (American Pain Society, 1999, p. 4) Chronic pain can be differentiated from acute pain in that acute pain signals a specific nociceptive event and is self-limited. Chronic pain may begin as acute pain, but it continues beyond the normal time expected for resolution of the problem or persists or recurs for other reasons. Chronic pain in children is the result of a dynamic integration of biological processes, psychological factors, and sociocultural context considered within a developmental trajectory. This category of pain includes persistent (ongoing) and recurrent (episodic) pain with possible fluctuations in severity, quality, regularity, and predictability. Chronic pain can occur in single or multiple body regions and can involve single or multiple organ systems. Ongoing nociception can result in a sensitization of the peripheral and central nervous systems to produce neuroanatomical, neurochemical, and neurophysiological changes. It is important that assessment and treatment strategies be based on this definition and related dimensions. To evaluate and treat chronic childhood pain efficiently and effectively, the mind-body dualism must be abandoned. It is meaningless to dichotomize chronic pain as organic versus nonorganic because all pain is associated with, at minimum, neurosensory changes. Maintaining this dichotomy is harmful because such faulty thinking leads to over-medicalization (inappropriate investigations, procedures, and interventions) or insufficient acknowledgment of the child's multidimensional experience and underlying neurophysiology. The International Association for the Study of Pain (IASP) characterized chronic pain as less than 1 month, 1 to 6 months, and greater than 6 months (Task Force on Taxonomy, 1994). Formerly chronic pain was defined as having pain for longer than 6 months. It is now recognized that key elements of chronic pain can be evident much earlier. Definitions also are influenced by developmental factors. For example, recurrent migraine headache that lasts 1 hour in a 4-year-old is typical, whereas headache of this length in adolescents would not likely be classified as a migraine. Chronic pain may include varying amounts of disability, from none to severe, and may be independent of the amount of tissue damage and perceived severity (Melzack & Wall, 1965). Biological, psychological, social, cultural, and developmental factors can impact pain-related functioning. Assessment An evaluation of a child with chronic pain should include consideration of the biological, psychological, and sociocultural factors in the developmental context (Bursch, Walco, & Zeltzer, 1998). The evaluation should begin with a history of the current problem, including a careful description of the pain detailing the sensory characteristics, intensity, quality, location, duration, variability, predictability, exacerbating and alleviating factors, and impact of pain on daily life (e.g., sleeping, eating, school, social and physical activities, family and peer interactions). The history, evaluation, and treatment of the current pain problem in terms of its onset and development should be detailed. Inquiry should include the magnitude of distress for the child and family attributed to the pain and the impact of the pain on cognitive functioning, anxiety, depression, and feelings of hopelessness. Assessment also should include what the child and family members perceive as the cause of the pain and how they respond to it. History of past pain problems in the child and in other family members also should be elicited. A review with the family of current treatments for the pain should include inquiry about home remedies and alternative and complementary therapies (Zeltzer, Bush, Chen, & Riveral, 1997a, 1997b). In addition to the pain history, a typical pediatric history should include medical-surgical history, birth and early childhood history, developmental milestones, social history (i.e., school, friends, interests), and family medical and social history. Particular attention should be paid to recent stressful events, such as deaths, marital disruption, moves, and other changes in life circumstances (e.g., new school). The physical examination will vary depending on the previous assessments the child has undergone and the specific symptoms. However, the physical examination always should include observation of the child's general appearance, posture, gait, and emotional and cognitive state. Muscle spasms, trigger points, and areas of somatic sensitivity to light touch should be assessed. Vital signs should include height, weight, blood pressure, heart rate, respiratory rate, and temperature. A complete neurological examination should be conducted. It can be helpful to examine the painful area multiple times during the examination. Somatic pain may be elicited when the child tenses his or her muscles due to fear of the examination. It is common for children with chronic pain to develop secondary myofascial pain because of abnormal body posturing and prolonged inactivity. It is helpful to remember that visceral pain, because of its afferent pathways, may be referred to as somatic dermatomes. If significant findings that have not been previously addressed are identified, referral to the appropriate subspecialist is indicated for more thorough evaluation. Treatment Treatment strategies should be based on the findings of the assessment and should address the inciting and contributing factors. A multimodal approach often is more effective than a single sequential treatment approach. This approach includes specific treatment targeting possible underlying pain mechanisms, as well as symptom-focused management addressing pain, sleep disturbance, anxiety, or depressive feelings. For example, a treatment approach for a child with a recalcitrant myofascial shoulder pain might include amitriptyline for facilitating sleep, transcutaneous electrical nerve stimulation (TENS), biofeedback, and massage for pain. Treatment also should address pain-related disability with the goal of maximizing functioning and improving quality of life. For example, partial or complete return to school should often be an early target of treatment for children with pain-related school absenteeism. Treatment techniques include education about the pain experience and the pain problem, cognitive-behavioral (e.g., self-regulatory behaviors such as hypnosis or biofeedback) strategies, behavioral techniques (e.g., reinforcement), family interventions, physical interventions (e.g., massage, acupuncture, TENS, physical therapy, occupational therapy), and systemic and regional pharmacological interventions (e.g., opioid and non-opioid analgesics, anesthetics, anxiolytics, antidepressants, anticonvulsants, hypnotics, alpha-adrenergic blockers, etc.). Whenever possible, oral routes for medication are preferable. Referral to a pediatric pain program should be considered for children with complex or refractory problems. Evidence-based treatments should be used whenever available. For example, in adolescent migraine headache, cognitive behavioral interventions have better evidence for efficacy than triptans (Hermann, Kim, & Blanchard, 1995) and ibuprofen seems to be more effective than acetaminophen (Hamalainen, Hoppu, Valkeila, & Santavuori, 1997). Most of the currently employed pharmacological strategies are extrapolated from adult trials without evidence of efficacy in children. Controlled trials are needed to address safety and efficacy in this population. Specific pain conditions and treatments Although the previously mentioned treatment strategies apply to all children with chronic pain, more detailed discussion can be found in the references organized by topic at the end of this document. Education Pain management should be part of the educational curriculum of all health professionals who care for children. For example, assessment and management of chronic pain in children should be a mandatory part of pediatric residency. Multidisciplinary pediatric pain programs are a particularly valuable resource for this training. Education of the public will increase community awareness and support of children with chronic pain and shape appropriate public policy. Mass media coverage of chronic pain in children should be promoted (Kuttner, 1996; McGrath, Finley, & Turner, 1992). School staff may benefit from education to facilitate reintegration and support of children with chronic pain in the classroom. Research More research is needed to provide evidence-based treatments in chronic pediatric pain. Targeted government and private funding for research in pediatric chronic pain should be augmented. Such funding would not only benefit children with pain and their families, but also would be relevant, in the long term, for reducing the enormous costs of adult chronic pain (Walco & Harkins, 1999). The treatment of chronic pediatric pain would benefit from the development and support of cooperative pediatric chronic pain research consortia. Examples of key scientific areas that need to be developed include epidemiology, nosology, clinical science (including clinical trials), developmental neurobiology, health services research, sociocultural studies, developmental pharmacology, the developmental psychology of pediatric pain, and the relationship between pediatric and adult chronic pain. Clinical studies should include detailed attention to definition of populations, measurement of pain and distress, documentation of interventions, family factors, culture, gender, and developmental variables such as pubertal status and cognitive function. Outcome variables should be broad and include measures of pain and distress, function, quality of life, and healthcare utilization. Policy Children with chronic pain should have access to appropriate services, and children with complex or refractory chronic pain should be referred directly to pediatric pain programs when possible. Many pain approaches validated on adults that lack a developmental and family focus may be inappropriate or even potentially harmful for children with chronic pain. Reimbursement policies should reflect the multidisciplinary complexity and efforts required to assess and treat children with chronic pain. Comprehensive integrated treatment of medical, psychological, and social factors may be the most cost-effective in the treatment of complex and refractory pediatric pain problems. http://www.ampainsoc.org/advocacy/pediatric.htm

Pediatric Chronic Pain A Position Statement from the American Pain Society Significance of the problem Chronic pain is a significant problem in the pediatric population, conservatively estimated to affect 15% to 20% of children (Goodman & McGrath, 1991). Children* and their families experience significant emotional and social consequences as a result of pain and disability. The financial costs of childhood pain also may be significant in terms of healthcare utilization as well as other indirect costs, such as lost wages due to time off work to care for the child (Li & Balint, in press). In addition, the physical and psychological sequelae associated with chronic pain may have an impact on overall health and may predispose for the development of adult chronic pain (Campo et al., 1999; Walker, Garber, Van Slyke, & Greene, 1995). * This term refers to all individuals in the pediatric age range (i.e., neonates, infants, and adolescents). Definition of chronic pain Acute pain follows injury to the body and generally disappears when the bodily injury heals. It is often, but not always, associated with objective physical signs of autonomic nervous system activity. Chronicpain, in contrast to acute pain, rarely is accompanied by signs of sympathetic nervous system arousal. The lack of objective signs may prompt the inexperienced clinician to say the patient does not "look" like he or she is in pain. (American Pain Society, 1999, p. 4) Chronic pain can be differentiated from acute pain in that acute pain signals a specific nociceptive event and is self-limited. Chronic pain may begin as acute pain, but it continues beyond the normal time expected for resolution of the problem or persists or recurs for other reasons. Chronic pain in children is the result of a dynamic integration of biological processes, psychological factors, and sociocultural context considered within a developmental trajectory. This category of pain includes persistent (ongoing) and recurrent (episodic) pain with possible fluctuations in severity, quality, regularity, and predictability. Chronic pain can occur in single or multiple body regions and can involve single or multiple organ systems. Ongoing nociception can result in a sensitization of the peripheral and central nervous systems to produce neuroanatomical, neurochemical, and neurophysiological changes. It is important that assessment and treatment strategies be based on this definition and related dimensions. To evaluate and treat chronic childhood pain efficiently and effectively, the mind-body dualism must be abandoned. It is meaningless to dichotomize chronic pain as organic versus nonorganic because all pain is associated with, at minimum, neurosensory changes. Maintaining this dichotomy is harmful because such faulty thinking leads to over-medicalization (inappropriate investigations, procedures, and interventions) or insufficient acknowledgment of the child's multidimensional experience and underlying neurophysiology. The International Association for the Study of Pain (IASP) characterized chronic pain as less than 1 month, 1 to 6 months, and greater than 6 months (Task Force on Taxonomy, 1994). Formerly chronic pain was defined as having pain for longer than 6 months. It is now recognized that key elements of chronic pain can be evident much earlier. Definitions also are influenced by developmental factors. For example, recurrent migraine headache that lasts 1 hour in a 4-year-old is typical, whereas headache of this length in adolescents would not likely be classified as a migraine. Chronic pain may include varying amounts of disability, from none to severe, and may be independent of the amount of tissue damage and perceived severity (Melzack & Wall, 1965). Biological, psychological, social, cultural, and developmental factors can impact pain-related functioning. Assessment An evaluation of a child with chronic pain should include consideration of the biological, psychological, and sociocultural factors in the developmental context (Bursch, Walco, & Zeltzer, 1998). The evaluation should begin with a history of the current problem, including a careful description of the pain detailing the sensory characteristics, intensity, quality, location, duration, variability, predictability, exacerbating and alleviating factors, and impact of pain on daily life (e.g., sleeping, eating, school, social and physical activities, family and peer interactions). The history, evaluation, and treatment of the current pain problem in terms of its onset and development should be detailed. Inquiry should include the magnitude of distress for the child and family attributed to the pain and the impact of the pain on cognitive functioning, anxiety, depression, and feelings of hopelessness. Assessment also should include what the child and family members perceive as the cause of the pain and how they respond to it. History of past pain problems in the child and in other family members also should be elicited. A review with the family of current treatments for the pain should include inquiry about home remedies and alternative and complementary therapies (Zeltzer, Bush, Chen, & Riveral, 1997a, 1997b). In addition to the pain history, a typical pediatric history should include medical-surgical history, birth and early childhood history, developmental milestones, social history (i.e., school, friends, interests), and family medical and social history. Particular attention should be paid to recent stressful events, such as deaths, marital disruption, moves, and other changes in life circumstances (e.g., new school). The physical examination will vary depending on the previous assessments the child has undergone and the specific symptoms. However, the physical examination always should include observation of the child's general appearance, posture, gait, and emotional and cognitive state. Muscle spasms, trigger points, and areas of somatic sensitivity to light touch should be assessed. Vital signs should include height, weight, blood pressure, heart rate, respiratory rate, and temperature. A complete neurological examination should be conducted. It can be helpful to examine the painful area multiple times during the examination. Somatic pain may be elicited when the child tenses his or her muscles due to fear of the examination. It is common for children with chronic pain to develop secondary myofascial pain because of abnormal body posturing and prolonged inactivity. It is helpful to remember that visceral pain, because of its afferent pathways, may be referred to as somatic dermatomes. If significant findings that have not been previously addressed are identified, referral to the appropriate subspecialist is indicated for more thorough evaluation. Treatment Treatment strategies should be based on the findings of the assessment and should address the inciting and contributing factors. A multimodal approach often is more effective than a single sequential treatment approach. This approach includes specific treatment targeting possible underlying pain mechanisms, as well as symptom-focused management addressing pain, sleep disturbance, anxiety, or depressive feelings. For example, a treatment approach for a child with a recalcitrant myofascial shoulder pain might include amitriptyline for facilitating sleep, transcutaneous electrical nerve stimulation (TENS), biofeedback, and massage for pain. Treatment also should address pain-related disability with the goal of maximizing functioning and improving quality of life. For example, partial or complete return to school should often be an early target of treatment for children with pain-related school absenteeism. Treatment techniques include education about the pain experience and the pain problem, cognitive-behavioral (e.g., self-regulatory behaviors such as hypnosis or biofeedback) strategies, behavioral techniques (e.g., reinforcement), family interventions, physical interventions (e.g., massage, acupuncture, TENS, physical therapy, occupational therapy), and systemic and regional pharmacological interventions (e.g., opioid and non-opioid analgesics, anesthetics, anxiolytics, antidepressants, anticonvulsants, hypnotics, alpha-adrenergic blockers, etc.). Whenever possible, oral routes for medication are preferable. Referral to a pediatric pain program should be considered for children with complex or refractory problems. Evidence-based treatments should be used whenever available. For example, in adolescent migraine headache, cognitive behavioral interventions have better evidence for efficacy than triptans (Hermann, Kim, & Blanchard, 1995) and ibuprofen seems to be more effective than acetaminophen (Hamalainen, Hoppu, Valkeila, & Santavuori, 1997). Most of the currently employed pharmacological strategies are extrapolated from adult trials without evidence of efficacy in children. Controlled trials are needed to address safety and efficacy in this population. Specific pain conditions and treatments Although the previously mentioned treatment strategies apply to all children with chronic pain, more detailed discussion can be found in the references organized by topic at the end of this document. Education Pain management should be part of the educational curriculum of all health professionals who care for children. For example, assessment and management of chronic pain in children should be a mandatory part of pediatric residency. Multidisciplinary pediatric pain programs are a particularly valuable resource for this training. Education of the public will increase community awareness and support of children with chronic pain and shape appropriate public policy. Mass media coverage of chronic pain in children should be promoted (Kuttner, 1996; McGrath, Finley, & Turner, 1992). School staff may benefit from education to facilitate reintegration and support of children with chronic pain in the classroom. Research More research is needed to provide evidence-based treatments in chronic pediatric pain. Targeted government and private funding for research in pediatric chronic pain should be augmented. Such funding would not only benefit children with pain and their families, but also would be relevant, in the long term, for reducing the enormous costs of adult chronic pain (Walco & Harkins, 1999). The treatment of chronic pediatric pain would benefit from the development and support of cooperative pediatric chronic pain research consortia. Examples of key scientific areas that need to be developed include epidemiology, nosology, clinical science (including clinical trials), developmental neurobiology, health services research, sociocultural studies, developmental pharmacology, the developmental psychology of pediatric pain, and the relationship between pediatric and adult chronic pain. Clinical studies should include detailed attention to definition of populations, measurement of pain and distress, documentation of interventions, family factors, culture, gender, and developmental variables such as pubertal status and cognitive function. Outcome variables should be broad and include measures of pain and distress, function, quality of life, and healthcare utilization. Policy Children with chronic pain should have access to appropriate services, and children with complex or refractory chronic pain should be referred directly to pediatric pain programs when possible. Many pain approaches validated on adults that lack a developmental and family focus may be inappropriate or even potentially harmful for children with chronic pain. Reimbursement policies should reflect the multidisciplinary complexity and efforts required to assess and treat children with chronic pain. Comprehensive integrated treatment of medical, psychological, and social factors may be the most cost-effective in the treatment of complex and refractory pediatric pain problems. http://www.ampainsoc.org/advocacy/pediatric.htm

IV Lidocaine Helpful for Mechanical Allodynia Laurie Barclay, MD Feb. 2, 2004-Intravenous (IV) lidocaine is helpful for mechanical allodynia, according to the results of a randomized trial published in the Jan. 27 issue of Neurology. "We have previously shown, using quantitative sensory tests, that IV lidocaine induced selective and differential analgesic effects in patients with central neuropathic pain," write N. Attal, MD, PhD, from Université Versailles-Saint-Quentin in France, and colleagues. "Thus the treatment alleviated spontaneous pain and mechanical allodynia/hyperalgesia, but had no effect on thermal allodynia/hyperalgesia. This argued against a generalized effect on pain perception, but rather emphasized that lidocaine presented with specific antiallodynic and antihyperalgesic effects in such patients." In this double-blind, crossover design study, 22 patients with pain caused by postherpetic neuralgia or nerve trauma received lidocaine, 5 mg/kg IV, or placebo infusion over 30 minutes and were evaluated using quantitative sensory testing. On an open-label basis, 16 patients subsequently received mexiletine titrated from 400 to 1,000 mg per day (mean, 737 mg/day). Lidocaine significantly decreased ongoing pain for up to six hours, with a peak effect 60 to 120 minutes after injection. It also decreased mechanical dynamic allodynia and static or punctate mechanical allodynia/hyperalgesia, but not thermal allodynia and hyperalgesia, suggesting that the analgesic effects of the drug were modality-specific. Compared with patients without allodynia, those with concomitant mechanical allodynia had significantly greater effects from lidocaine and mexiletine on spontaneous pain intensity. The authors suggest that patients with mechanical allodynia may be good candidates for treatment with local anesthetic-like drugs and possibly with other sodium-channel blockers. "The usual definition of a responder to a certain drug in the context of neuropathic pain, although it has the advantage of simplicity and permits a clinical comparison between different drugs, is probably too broad and may lack sensitivity," they write. "Our study highlights that the response to a drug rather depends on a combination of symptoms that may relate to specific common mechanisms and favors the importance of a mechanism-based classification of neuropathic pains." The Institut UPSA de la Douleur supported this study. Neurology. 2004;62:218-225 Reviewed by Gary D. Vogin, MD http://www.medscape.com/viewarticle/468048

The walk to left field (AKA where you're located) is a bit far. I'm going to stay on 1st base. -Dave

I know Fab! The outspoken, don't tell ME that I can't do that NP has been thinking about medical school. The urge is actually really starting to wane. I adore primary care and practicing pain mgmt in it. Going to medical school for primary care would just teach me another view of the same thigns I already know. If I do go to medical school, it will either be to do a residency in GAS, or PM&R, ofcourse fellowshiping in Pain. -Dave

Thank you! See, it's not so hard. I'm an agreeable person! I'm am not in any way saying that MD's cannot be replaced. I wouldn't want them to, half of my family would be jobless! MD's are 100% needed for speciality fields. Would I let a midwife deliver my child? Maybe. Via a c-section? Absolultely no. Would I let a NP or PA perform a CABG on me? Nope. I want the most highly trained CT Surgeon on the planet. Neurosurgery? Nope. Still need a pro. However... BP through the roof? NP ER presentation with CP and R/O MI? NP Routine GYN? NP Chronic pain? NP Acute pain? NP GERD? NP OA/RA? NP Septic infection in ICU? NP Np's can and DO provide superior care. MD's do as well. DO's do as well. -Dave

You obviously don't know me very well. -Dave