Background & Aims
Chronic pain in the pediatric population, which is a risk factor for adult pain, has an estimated prevalence of 5-8%. It is a complex condition with biological, psychological, and social aspects and associated with psychiatric comorbidities.There is good evidence that multidisciplinary rehabilitative treatment leads to return of function and pain reduction. Medications are often used however, little is known about their safety and efficacy as there are currently no FDA-approved options for pediatric population. Despite this, gabapentinoids are often used in pediatric chronic pain patients, largely based on adult literature. In addition to possible limited effectiveness, side effects such as cognitive slowing, negative mood changes and suicidal thoughts require close monitoring of outcomes. As such, we aim at performing a retrospective review of prescription patterns and developing a Quality Initiative for standardizing gabapentin prescribing practices in pediatric chronic patients.
Methods
We conducted a retrospective chart review of all medications prescribed to patients seen by a Pain Specialist and a Psychiatrist at a Pediatric Chronic Pain Service between 2016 and 2022.
A QI Taskforce was then created to characterize gabapentin prescribing patterns by surveying prescribers, and then developing a standardized approach to treatment and monitoring including the following: clear documentation on diagnoses, titration schedule, and follow-plan plan by providers. From a patient perspective, the focus is periodic surveys assessing response and tolerability.
Results
340 patients were seen by Psychiatry at a pediatric pain clinic between 2016-22. The most common classes were antidepressants (93.5%), analgesics (67.9%) and anticonvulsants (66.5%). The most common medication was gabapentin (52.7%). On average, patients were exposed to 3 different medication classes (IQR 2-4) during treatment . For the QI, we reviewed new gabapentin prescriptions over 6 months. We found large variability on starting and target dose, titration duration, and documentation on indications and treatment plan. Provider survey results confirmed the individual variability on dosing, which was not uniformly based on diagnoses or weight, with starting doses ranging from 100 to 500 mg, minimal effective dose 300-900 mg, and maximum of 1200-3600 mg/d). There was variability in patient education about side effects and monitoring of outcomes. Based on results, standardized titration and follow-up schedules, patient education and surveys were developed and are being implemented.
Conclusions
There is limited data on the use of pharmacologic agents in the treatment of chronic pain in pediatrics. Key aspects of safe prescribing practices include assuring a clear indication based on diagnostic assessment, gradually titration of medications to their full therapeutic potential or tolerability, monitoring outcomes, and reassessing the need for medication use with consideration for de-prescribing when no longer necessary. Implementing clinical research and Quality Improvement efforts to clinical practice are ways by which we can continue improve clinical practice and quality of care for pediatric patients with chronic pain.
References
1. American Academy of Pediatrics. Committee on Psychosocial Aspects of Child and Family Health; Task Force on Pain in Infants, Children, and Adolescents. AAP Policy Statement. The assessment and management of acute pain in infants, children, and adolescents. Pediatrics. 2001;108(3):793–797
2. Groenewald CB, Essner BS, Wright D, Fesinmeyer MD, Palermo TM. The economic costs of chronic pain among a cohort of treatment-seeking adolescents in the United States. J Pain. 2014;15(9):925–933
3. Friedrichsdorf SJ, Giordano J, Desai Dakoji K, Warmuth A, Daughtry C, Schulz CA. Chronic pain in children and adolescents: diagnosis and treatment of primary pain disorders in head, abdomen, muscles and joints. Children (Basel). 2016;3(4):42
4. Donado C, Nedeljkovic K, Wangnamthip S, Solodiuk JC, Bourgeois FT, Berde CB. Trends in Gabapentin and Pregabalin Prescribing in a Tertiary Pediatric Medical Center. Hosp Pediatr. 2021 Aug;11(8):909-914
Presenting Author
Monique Ribeiro
Poster Authors
Topics
- Evidence, Clinical Trials, Systematic Review, Guidelines, and Implementation Science