In this blog for parents, carers and families of children who have chronic pain, pain researcher Emma Fisher looks at the evidence on the benefits and harms of painkilling drugs for children and teens with chronic pain.
When a child falls over, you feel the thud with every fibre of your body. Their initial scream, then wail, and then the tears start to roll, indicating perhaps shock at what has happened, and then pain. Children experience pain regularly and acute pain is a normal part of development. It teaches avoidance of danger and our bodies typically heal quickly. However, pain can go on for a long period of time, even for children. Chronic pain, or pain that lasts for longer than three months, is reported by around 25% of children and adolescents, and around 10% of children and adolescents will report chronic pain that interferes with their daily life [1; 5]. This means they will miss school, not see their friends, report lower mood and exercise less frequently.
The impact of chronic pain also spreads beyond the child experiencing it. It negatively impacts parents and families, who will have to miss work or even give it up completely to care for their child. Children often attend endless doctors appointments to understand the origin of their pain and seek treatment for it. Childhood chronic pain is poorly understood by medical professionals, who may not have the answers a family seek. Typically the first intervention a child will receive is pharmacological, a drug, to help manage the pain. So, the million-dollar question is – do they actually work at reducing pain in children?
Setting out with a question
We set out to find out the benefits and harms of drugs for children with chronic pain by conducting an overview review. This is a review of all systematic reviews, the highest form of evidence, in this field. We searched the Cochrane library and other journals to understand what trials have been conducted and the quality of reviews that have been conducted. From these systematic reviews, we extracted randomised controlled trials, which are individual trials that test whether a drug works in a group of patients.
Lack of evidence
What we found was quite surprising, considering the number of children with pain who are prescribed drugs. We found 23 systematic reviews in total; 19 of these reviews were Cochrane reviews. The reviews that have investigated this question were typically high quality. Most systematic reviews found no trials in child populations. However, we did find six randomised controlled trials included in the reviews. Just six trials across all drugs and all chronic pain conditions . We did not find any randomised controlled trials for children with cancer-related pain.
The absence of evidence does not mean that drugs do not work, it means that we do not know how they work, who they work for, whether they reduce pain, and if they cause more harm than benefit. We are also not saying that the drugs cause harm, or that children taking drugs prescribed by their doctor should stop taking them. We are highlighting the neglect of research in children and adolescents on this topic.
Children are not mini adults
Children are different to adults in the way they digest drugs. Considering the amount of evidence we have in adults, which includes upwards of 300,000 patients in trials, it is staggering that the review investigating children and adolescents only includes 393 patients. At the current rate, it will take 1000 years to generate a sound evidence base on which to base our medical decisions. Nevertheless, findings in adults provide evidence that these drugs can reduce pain for some people.
Why so little evidence?
The reasons for this are many. First, drug companies were not regulated to trial new drugs in child and adolescent populations until 2003. Second, producing drugs to reduce pain is far more profitable in adults than it is in children. Third, drug companies in America (where most of the drugs are developed) are less incentivised to produce drugs for children due to possible long-term litigation associated with child and adolescent populations.
What else is there out there?
So, we don’t know whether drugs work, but what do we know? Well, psychological therapies have been found to have small effects for reducing pain and disability in children and adolescents with chronic pain [3; 4; 6]. These reviews, which have recently been updated are dominated by trials delivering cognitive behavioural therapy, either face-to-face or remote from the therapist via the internet or an app. However, these trials did not show beneficial effects for reducing symptoms of anxiety or depression in children. Psychological therapies for children with pain aim to deliver skills to manage their pain and get children back to their valued activities, rather than to reduce the pain per se.
As we said at the start, parents are also an important part of this puzzle, and psychological interventions are increasingly including parents and delivering treatment directly to them. These interventions, which include cognitive behavioural therapy or problem-solving therapy, are beneficial at reducing parental distress and protective responses which are linked to higher levels of child disability at both post-treatment and at follow-up .
What do we need to do to help children and adolescents with pain?
We need change in this field through policy, funding, and research to understand more about which drugs are effective, without producing side effects during childhood, so we can better manage child and adolescent chronic pain.
Find out more from our new Special Collection!
This week marks the launch of a Special Collection on the Cochrane Library website, which can be accessed here . On this page, you can learn more about all of the evidence in child and adolescent pain; both acute and chronic pain. We continue to work to disseminate these findings and advocate for children, so we are able to make evidence-based healthcare decisions when treating them.
References may be found here.
Emma Fisher has nothing to disclose.