Physicians Need to Change Their Approach to Assessing and Treating Complex Chronic Pain in Children: A Q&A with Lonnie Zeltzer, MD

Lonnie Zeltzer, MD, director of the Pediatric Pain Program at Mattel Children’s Hospital at UCLA, and Professor of Pediatrics, Anesthesiology, Psychiatry and Biobehavioral Sciences at the David Geffen School of Medicine at UCLA, discusses barriers to effective pain care in children, explains why primary care physicians and family physicians need additional training in pediatric pain care, and talks about why applying the biopsychosocial model of care equips clinicians to deal with the complexities of pain.

Can you describe the setting in which you practice and the patient population under your care?

I am head of the pediatric pain program, and am also medical director for the pediatric palliative care program, at Mattel Children’s Hospital at UCLA. In my clinic, the primary patients I see are infants to young adults with intractable headache, abdominal pain, muscular pain, CRPS, fibromyalgia, and other kinds of chronic pain. They are often referred to me by primary care physicians, and also by child neurologists, gastroenterologists, rheumatologists, and other subspecialists. I see kids with a wide variety of common and sometimes not-so-common complex chronic pain. In the palliative care program, I see kids with serious illnesses—not necessarily those who are on hospice and imminently dying, although I see some of those—but rather kids who are awaiting a major operation such as a heart or liver transplant, or seriously ill kids who have cancer, liver degenerative diseases, or genetic diseases.

I also have a non-profit clinic, Whole Child LA, where my husband and I spend one day a week providing care to children with chronic pain. We don’t receive any income—the money goes directly into the Whole Child Foundation to help pay for complementary therapies for kids who could benefit but otherwise couldn’t afford it.

Pain Education and Research in the US

Less than 5% of US medical schools offer a separate course in pain management (http://bit.ly/tb0yNO).

The NIH spends less than 1% of its annual budget on pain research (http://bit.ly/tcAyEw).

What attracted you to pediatric pain care?

I was always interested in children and adolescents in particular, and in mind-body medicine even before it was fashionable. Early on, I was interested in why there was such variance and individual difference in chronic diseases—why, for example, one patient with asthma will be in the hospital all of the time, with lots of attacks, and yet another patient with the same condition is fine by comparison. I wanted to know more about how kids’ emotions, thoughts, genetic makeup, and family factors influenced their medical conditions. That led to an interest in pain symptoms, and that became my life’s work.

Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research

Dr. Zeltzer was a member of the Committee on Advancing Pain Research, Care, and Education that researched and authored the Institute of Medicine report on the state of pain care in the US issued earlier this year (http://bit.ly/iQDGyX).

What are some of the challenges associated with assessing pain in children and providing effective pain care to this population?

There are a number of challenges, especially in infants, toddlers, and younger children, and in people who are non-verbal or who have difficulty with verbal communication (including patients who have autism, cerebral palsy, or other conditions that make verbal communication harder). Pain is a very personal experience, and people typically communicate their experience of pain through what they tell others. With patients who have physical or cognitive barriers that make it difficult for them to verbally communicate their personal experience to their clinicians, or with kids who are too young to have the vocabulary to talk about their pain, assessing that pain becomes almost like veterinary medicine, where you’re relying on other modalities like observation, proxy reports from parents, physiologic signs, and response to treatment. You have to use many different modalities to understand the child’s pain experience and determine whether it’s getting better with treatment, worse, or staying the same.

Pediatric Pain Prevalence in the US

• Chronic pain affects up to 38% of US children
• 1.5 million US children have surgery each year. Many receive inadequate pain relief, with one in five developing chronic pain
• 20% of children age 5-17 suffer headaches
• More than one-third of US children complain of abdominal pain lasting two weeks or longer
• 250,000 children age 16 and under have juvenile arthritis

Source: American Pain Foundation (http://bit.ly/rshoQS)

Addressing the family is another key factor in assessing a child’s pain. With children, the unit of care is not the child, it’s actually the family. The child is dependent on the family for bringing him or her in to get medical attention, carrying out treatment plans, and communicating with the physician. If you don’t communicate with the family, you’re not getting a full understanding of the child’s pain. One barrier with this is when there’s a discrepancy between what a child tells you and what a parent tells you about the same set of symptoms or behaviors. There are also issues that go on within the family that affect the child’s pain and function.

Assessing pain in children is complicated. It involves a much more varied approach in understanding the pain from the standpoint of the patient, as well as a host of other factors and informants that can influence the experience of pain and function.

Are pediatricians and family physicians adequately trained and prepared to provide effective pain care to children and adolescents? Is more specialized education and training in this area needed?

They absolutely need more training. That was one of the recommendations in the Institute of Medicine report. Physicians want to help their patients, but they face two key barriers: one is insufficient training, not just what to do in terms of medications, but how to really understand the extent of the child’s pain and factors that are influencing it. There is a lot more education that needs to be done, certainly at the primary care level. The other barrier to effective pain care is time. With all of the changes in health care economics, the time available for seeing patients is so limited that it’s a challenge for clinicians to get the kind of full history needed to treat complex chronic pain in children.

With all of the effort put forth to identify this problem and create educational programs, why is there still such a knowledge gap?

I think it’s for the same reason that pain research is underfunded at the National Institutes of Health (NIH). The NIH doesn’t have a specific pain institute. It’s in part because pain is not an organ system—it affects the whole body, so it doesn’t have a sub-specialty organ system “home” like cardiology or endocrinology, for example. The same thing applies with primary care. There are so many things that the primary care physician needs training in, and historically training has often been organized by organ systems. But there’s no whole section on pain. For example, the gastroenterology unit may focus on gastrointestinal disease pathologies, but not pain signaling from the systems perspective. So primary care physicians will learn about gastrointestinal conditions that can cause pain, but they don’t learn about other factors that can produce pain, and therefore pain treatment aimed at a systems level. Pain management requires a more systems-based approach that just isn’t there yet in medical school training or in primary care residency training. There are little bits and pieces beginning, but we’re not quite there.

What is the most important action to take to solve this problem?

Medical schools should require adult pain clinic rotations that follow a biopsychosocial model, and not just a focused interventional pain clinic where people learn how to do interventional procedures for pain. I think people need to learn more about that model. Going to one pain lecture is not going to do it. They have to role model in a rotation working with a clinician who treats patients, whether adults or children, who have chronic functional pain like IBS, fibromyalgia, chronic daily headache, etc.

Whole Child LA

At Whole Child LA, Dr. Zeltzer and the staff provide “integrative mind-body treatment for children suffering pain, stress, and many common disabling conditions.” They work to reduce health care disparities in the community by applying this family-centered model to treat pain in infants, children, adolescents, and young adults. They also train physicians and other clinicians in the treatment of common pain problems presented by children (http://bit.ly/vxNJnE).

What are the defining characteristics of the biopsychosocial model of pain management?

The biopsychosocial model is different from the old Cartesian model, where phenomena are either physical or psychological. We now know that mind, body, and environment are connected and influence each other in multidirectional ways. For example, consider a patient with stomach pain, constipation, bloating, nausea, vomiting, etc. Their gastroenterologist examines them with endoscopy and colonoscopy but doesn’t see anything, yet the patient still has these horrible symptoms that are getting in the way of function. The biopsychosocial model says “Let’s look at pain signaling from a systems perspective, and look at what is influencing pain signaling and why might this person have all of these symptoms that are clearly causing distress.” We now know, for example, that there is a change in neurenteric nerve signaling; we know there are genetic components; we know that the patient’s thoughts/cognitions impact pain; we know that catastrophizing biologically increases pain signaling. These cognitive processes affect not only the extent of the experience of pain, but we know from functional MRI that this thinking changes metabolic activity in pain centers in the brain. We know that our emotions influence pain signaling, and change the neurotransmitters biologically. We know that the patient’s environment can influence both the experience of pain and the patient’s function. The biopsychosocial model of pain management takes into account biologic factors in terms of nerve signaling, (inflammation, metabolic, injury, obstruction, etc) and psychological factors (thoughts, emotions, etc), and environmental factors (what’s said to the child, the context the patient is in, etc). The biopsychosocial model says that a physician should consider all of these factors because they impact one another in fundamental ways to influence the extent of chronic pain experienced, as well as pain-related disability.

• Median time spent with patients during an office visit: 15.7 minutes
• Median number of topics covered during visit: 6 (Source: http://1.usa.gov/tEMveI)
• The average duration of time spent with a patient during a visit is 15.2 minutes for pediatricians and 17.9 minutes for family practitioners. According to one study, the amount of time spent by family physicians on family history discussions averaged 2.6 minutes for a new patient and 1.8 minutes for a return patient. (Source: http://bit.ly/tePZnF)

Does the current model of pain management lead to an overreliance on medications in pediatric pain management?

No, I don’t think that overmedication is a problem. Inappropriate medication or solely focusing on the use of medication, rather than taking a more multipronged approach, is more of a problem. If a kid is missing school because they have chronic daily headache, just giving them aspirin, ibuprofen, Tylenol, or opioids is not necessarily going to solve the headache problem. The more the kids use those medications, the more they become reliant on that medication. It may be that the child has a learning disability so that school is a stressor in certain areas, or that there are bullies at school, or there are family problems or other stressors. Until you address these, just giving the medication isn’t going to be enough.

“Physicians’ lack of knowledge about the appropriate use of pain medications is tied into their approach to diagnosing different kinds of pain and their lack of understanding of the different factors that influence pain.”

The other problem is use of inappropriate medications because of a lack of pain management training. Physicians’ lack of knowledge about the appropriate use of pain medications is tied into their approach to diagnosing different kinds of pain and their lack of understanding of the different factors that influence pain. Adolescents who are experiencing pain often have opioids prescribed by their physicians, yet still have pain. Their physicians don’t know what else to do, so they give the child more and more opioids. Now the child is dependent on the opioids, and has been trained to be pain medication—seeking for the goal of pain relief, because no other strategies have been available.

It’s complex, but physicians can be trained to provide proper pain management. However, the best way to do this is not with a lecture or two, but by role modeling good biopsychosocial pain evaluation and treatment. We need more support for the biopsychosocial model, and to reimburse physicians for the time they spend with patients. Our health care system right now pushes the rapid visit, which favors medications and interventional procedure. Physicians are paid a lot more for an epidural injection than for spending time teaching cognitive and behavioral pain coping strategies, or getting a better history so they can provide more targeted treatment.

“The time available for seeing patients is so limited that it’s a challenge for clinicians to get the kind of full history needed to treat complex chronic pain in children.”

Yet we also see the opposite extreme, with some physicians forgoing the use of opioids due to the legal scrutiny on this class of medications. Is this a defensible position for physicians to take, to restrict access to some forms of care?

It’s happening! Legal constraints are scaring some physicians who could be trained to prescribe opioids appropriately. They’re prevented from providing full pain care and instead are just referring out. The reality is that there aren’t that many pain specialists relative to the number of people with chronic pain. The IOM report talked about the magnitude of the problem of chronic pain and the cost of chronic pain. If we try to just rely on the specialists, it’s not going to happen. That’s why there’s such a need for primary care physicians to receive better training, and for laws that are fair and supportive of good treatment for chronic pain. We also need more pain specialists, so primary care physicians can have access to them for consultation, perhaps using telemedicine, for the more complex conditions.

Biopsychosocial Treatment of Chronic Pain

• The biopsychosocial model is a conceptual model that proposes that psychological and social factors must also be included along with the biological variables in understanding chronic painn
• Pain is best viewed as an interactive, psychophysiological behavior pattern that cannot be separated into distinct, independent psychosocial and physical components
• Biological, psychological, and social factors must all be simultaneously addressed. Psychological treatment needs to be integrated with other therapeutic components, such as physical therapy and medication management, to address all components comprising the experience of chronic musculoskeletal pain

Source: The International Association for the Study of Pain (http://bit.ly/w0en8y)

What are some of the most promising recent developments in pediatric pain research? What studies or trends should our readers keep an eye on?

Research into modern imaging techniques like functional MRI, and some of the research into what goes on in the brain in relation to pain, the pain experience, and pain vulnerability, has enormous potential, because it shows us how our thoughts and emotions actually biologically impact neuro-signaling and neurotransmitters, and in a sense it gives validity to the biopsychosocial model of pain. Another promising area is research into understanding differences in the way pain may be processed in men and women. Also, research into the inadequacy of pain treatment in children, and what happens across puberty in terms of the pain signaling process. Another important area is research on cultural and racial disparities. We have to look at all of the barriers that may prevent certain subgroups of individuals, underserved populations, from receiving adequate pain treatment, and what the fallout is from that.