American Journal of Cancer

, Volume 4, Issue 2, pp 77–85 | Cite as

Pain Control Options in Palliative Care

Special Considerations for Children
Therapy in Practice


Although pain management is one of many domains in the care of the dying child, pain is a common symptom which needs to be prioritized and treated meticulously. Pain may be caused by the underlying illness or adverse effects related to medical interventions and treatment, or may be unrelated to either the primary disease or its treatment. Pain assessment should be considered in the light of an overall symptom burden, which can be a matrix of physical, psychologic, social, and spiritual parameters. The assessment and diagnosis of pain is fundamental to the clinical care of dying children since therapies directed at the primary cause may ultimately have a more effective pain management outcome. A dying child’s symptomatology may linger for a long time in the memory of parents and caregivers. Indeed, pain is one of the most feared and distressing symptoms not only to children with cancer receiving palliative care, but also their families.

Pain control options for children with cancer consist of pharmacologic and non-pharmacologic options. The emphasis in this article is on pharmacologic options. Analgesic prescription is based on pain severity assessment: simple analgesics for mild pain and opioids for severe pain. In children, the simplest route of administration for analgesics (oral administration) is recommended and the intramuscular route should be avoided. There are few data on the prescription of adjuvant analgesics in children, with most data from adult studies. Adjuvant analgesic prescription in children tends to be confined to the anticonvulsants and antidepressants. The vast majority of children have satisfactory analgesia using conventional doses of opioids; and only a minority require massive opioid doses or invasive approaches.


Morphine Neuropathic Pain Cancer Pain Oxycodone Hydromorphone 
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  1. 1.
    Collins JJ, Byrnes ME, Dunkel I, et al. The Memorial Symptom Assessment Scale (MSAS): validation study in children aged 10–18. J Pain Symptom Manage 2000; 19(5): 363–77PubMedCrossRefGoogle Scholar
  2. 2.
    Collins JJ, Devine TB, Dick G, et al. The measurement of symptoms in young children with cancer: the validation of the Memorial Symptom Assessment Scale in children aged 7–12. J Pain Symptom Manage 2002; 23(1): 10–6PubMedCrossRefGoogle Scholar
  3. 3.
    Jay SM, Elliott C, Katz E, et al. Cognitive, behavioral, and pharmacologic interventions for children’s distress during painful medical procedures. J Consult Clin Psychol 1987; 55: 860–5PubMedCrossRefGoogle Scholar
  4. 4.
    Elliott C, Jay SM, Woody P. An observational scale for measuring children’s distress during medical procedures. J Pediatr Psychol 1987; 12: 543–51PubMedCrossRefGoogle Scholar
  5. 5.
    LeBaron S, Zeltzer L. Assessment of acute pain and anxiety in children and adolescents by self-reports, observer reports and a behavior checklist. J Consult Clin Psychol 1984; 52: 729–38PubMedCrossRefGoogle Scholar
  6. 6.
    Kuttner L, Bowman M, Teasdale M. Psychological treatment of distress, pain and anxiety for children with cancer. J Dev Behav Pediatr 1988; 9: 374–81PubMedCrossRefGoogle Scholar
  7. 7.
    Manne SL, Bakeman R, Jacobsen P, et al. Adult and child interaction during invasive medical procedures: sequential analysis. Health Psychol 1992; 11: 241–9PubMedCrossRefGoogle Scholar
  8. 8.
    Jay SM, Elliott C, Ozolins M, et al. Behavioral management of children’s distress during painful medical procedures. Behav Res Ther 1985; 5: 513–20CrossRefGoogle Scholar
  9. 9.
    Jay SM, Ozolins M, Elliott C, et al. Assessment of children’s distress during painful medical procedures. J Health Psychol 1983; 2: 133–47CrossRefGoogle Scholar
  10. 10.
    Gauvain-Piquard A, Rodary C, Rezvani A, et al. Pain in children aged 2–6 years: a new observational rating scale elaborated in a pediatric oncology unit: a preliminary report. Pain 1987; 31: 177–88PubMedCrossRefGoogle Scholar
  11. 11.
    Wolfe J, Grier HE, Klar N, et al. Symptoms and suffering at the end of life in children with cancer. N Engl J Med 2000; 342(5): 326–33PubMedCrossRefGoogle Scholar
  12. 12.
    Drake R, Frost J, Collins JJ. The symptoms of dying children. J Pain Symptom Manage 2003 Jul; 26(1): 594–603PubMedCrossRefGoogle Scholar
  13. 13.
    Collins JJ, Grier HE, Kinney HC, et al. Control of severe pain in terminal pediatric malignancy. J Pediatr 1995; 126(4): 653–7PubMedCrossRefGoogle Scholar
  14. 14.
    Cancer pain relief and palliative care in children. Geneva: WHO, 1998Google Scholar
  15. 15.
    Sandler DP, Smith JC, Weinberg CR, et al. Analgesic use and chronic renal disease. N Engl J Med 1989; 320(19): 1238–43PubMedCrossRefGoogle Scholar
  16. 16.
    Hunt AM, Joel S, Dick G, et al. Population pharmacokinetics of oral morphine and its glucuronides in children receiving morphine as immediate-release liquid or sustained-release tablets. J Pediatr 1999; 135(1): 47–55PubMedCrossRefGoogle Scholar
  17. 17.
    Cherney NI, Chang V, Frager G, et al. Opioid pharmacotherapy in the management of cancer pain. Cancer 1995; 76(7): 1283–92CrossRefGoogle Scholar
  18. 18.
    Stanski DR, Greenblatt DJ, Lowenstein E. Kinetics of intravenous and intramuscular morphine. Clin Pharmacol Ther 1978; 24: 52–9PubMedGoogle Scholar
  19. 19.
    Olkkola KT, Maunuksela EL, Korpela R, et al. Kinetics and dynamics of postoperative intravenous morphine in children. Clin Pharmacol Ther 1988; 44(2): 128–36PubMedCrossRefGoogle Scholar
  20. 20.
    Poyhia R, Seppala T. Lipid solubility and protein binding of oxycodone in vitro. Pharmacol Toxicol 1994; 74: 23–7PubMedCrossRefGoogle Scholar
  21. 21.
    Pelkonen O, Kaltiala EH, Larmi TKL. Comparison of activities of drug metabolizing enzymes in human fetal and adult liver. Clin Pharmacol Ther 1973; 14: 840–6PubMedGoogle Scholar
  22. 22.
    Collins JJ, Geake J, Grier HE, et al. Patient-controlled analgesia for mucositis pain in children: a three-period crossover study comparing morphine and hydromorphone. J Pediatr 1996; 129(5): 722–8PubMedCrossRefGoogle Scholar
  23. 23.
    Collins C, Koren G, Crean P, et al. Fentanyl pharmacokinetics and hemodynamic effects in preterm infants during ligation of patent ductus arteriosus. Anesth Analg 1985; 64: 1078–80PubMedCrossRefGoogle Scholar
  24. 24.
    Koren G, Goresky G, Crean P, et al. Unexpected alterations in fentanyl pharmacokinetics in children undergoing cardiac surgery: age related or disease related? Dev Pharmacol Ther 1986; 9: 183–91PubMedGoogle Scholar
  25. 25.
    Koren G, Goresky G, Crean P, et al. Pediatric fentanyl dosing based on pharmacokinetics during cardiac surgery. Anesth Analg 1984; 63: 577–82PubMedCrossRefGoogle Scholar
  26. 26.
    Johnson K, Erickson J, Holley F, et al. Fentanyl pharmacokinetics in the pediatric population [abstract]. Anesthesiology 1984; 61(3A): A441CrossRefGoogle Scholar
  27. 27.
    Gauntlett IS, Fisher DM, Hertzka RE, et al. Pharmacokinetics of fentanyl in neonatal humans and lambs: effects of age. Anesthesiology 1988; 69: 683–7PubMedCrossRefGoogle Scholar
  28. 28.
    Schechter NL, Weisman SJ, Rosenblum M, et al. The use of oral transmucosal fentanyl citrate for painful procedures in children. Pediatrics 1995; 95: 335–9PubMedGoogle Scholar
  29. 29.
    Collins JJ, Dunkel I, Gupta SK, et al. Transdermal fentanyl in children with cancer: feasibility, tolerability, and pharmacokinetic correlates. J Pediatr 1999; 134: 319–23PubMedCrossRefGoogle Scholar
  30. 30.
    Berde CB, Beyer JE, Bournaki MC, et al. Comparison of morphine and methadone for prevention of postoperative pain in 3- to 7-year-old children. J Pediatr 1991; 1 (Pt 1): 136–41Google Scholar
  31. 31.
    Berde CB, Sethna NF, Holzman RS, et al. Pharmacokinetics of methadone in children and adolescents in the perioperative period [abstract]. Anesthesiology 1987; 67: A519CrossRefGoogle Scholar
  32. 32.
    Miser AW, Davis DM, Hughes CS, et al. Continuous subcutaneous infusion of morphine in children with cancer. Am J Dis Child 1983; 137(4): 383–5PubMedGoogle Scholar
  33. 33.
    Bruera E, Brenneis C, Michaud M, et al. Use of the subcutaneous route for the administration of narcotics in patients with cancer pain. Cancer 1988; 62: 407–11PubMedCrossRefGoogle Scholar
  34. 34.
    Portenoy RK. Adjuvant analgesics. In: Hanks GWC, Doyle D, editors. Oxford textbook of palliative medicine. 2nd ed. New York: University Press, 1993: 187–203Google Scholar
  35. 35.
    Magni G. The use of antidepressants in the treatment of chronic pain. Drugs 1991; 42(5): 730–48PubMedCrossRefGoogle Scholar
  36. 36.
    Heiligenstein E, Garrick S. Psychotropics as adjuvant analgesics. In: Schechter NL, Berde CB, Yaster M, editors. Pain in infants, children, and adolescents. Baltimore (MD): Williams and Wilkins, 1993: 173–7Google Scholar
  37. 37.
    Biederman J, Baldessarini RJ, Wright V, et al. A double-blind placebo controlled study of desipramine in the treatment of ADD: II. Serum drug levels and cardiovascular findings. J Am Acad Child Adolesc Psychiatry 1989; 28: 903–11PubMedCrossRefGoogle Scholar
  38. 38.
    Yee JD, Berde CB. Dextroamphetamine or methylphenidate as adjuvants to opioid analgesia for adolescents with cancer. J Pain Symptom Manage 1994; 9: 122–5PubMedCrossRefGoogle Scholar
  39. 39.
    Forrest WH, Brown BW, Brown CR, et al. Dextroamphetamine with morphine for the treatment of postoperative pain. N Engl J Med 1977; 296(13): 712–5PubMedCrossRefGoogle Scholar
  40. 40.
    Bruera E, Miller MJ, Macmillan K, et al. Neuropsychological effects of methylphenidate in patients receiving a continuous infusion of narcotics for cancer pain. Pain 1992; 48: 163–6PubMedCrossRefGoogle Scholar
  41. 41.
    Bruera E, Faisinger R, MacEachern T, et al. The use of methylphenidate in patients with incident pain receiving regular opiates: a preliminary report. Pain 1992; 50: 75–7PubMedCrossRefGoogle Scholar
  42. 42.
    Tannock I, Gospodarowicz M, Meakin W, et al. Treatment of metastatic prostatic cancer with low-dose prednisone: evaluation of pain and quality of life as pragmatic indices of response. J Clin Oncol 1989; 7(5): 590–7PubMedGoogle Scholar
  43. 43.
    Greenberg HS, Kim J, Posner JB. Epidural spinal cord compression from metastatic tumor: results with a new treatment protocol. Ann Neurol 1980; 8: 361–6PubMedCrossRefGoogle Scholar
  44. 44.
    Weinstein JD, Toy FJ, Jaffe ME, et al. The effect of dexamethasone on brain edema in patients with metastatic brain tumors. Neurology 1973; 23: 121–9PubMedCrossRefGoogle Scholar
  45. 45.
    Watanabe S, Bruera E. Corticosteroids as adjuvant analgesics. J Pain Symptom Manage 1994; 9: 442–5PubMedCrossRefGoogle Scholar
  46. 46.
    Khurana DS, Riviello J, Helmers S, et al. Efficacy of gabapentin therapy in children with refractory partial seizures. J Pediatr 1996; 128: 829–33PubMedCrossRefGoogle Scholar
  47. 47.
    Mellick GA, Mellicy LB, Mellick LB. Gabapentin in the management of reflex sympathetic dystrophy [letter]. J Pain Symptom Manage 1995; 10(4): 265–6PubMedCrossRefGoogle Scholar
  48. 48.
    Westlin JE, Letocha H, Jakobson S, et al. Rapid, reproducible pain relief with [131]iodine-meta-iodobenzylguanidine in a boy with disseminated neuroblastoma. Pain 1995; 60: 111–4PubMedCrossRefGoogle Scholar
  49. 49.
    Cherny NI, Foley KM. Nonopioid and opioid analgesic pharmacotherapy of cancer pain. Hematol Oncol Clin North Am 1996; 10: 79–102PubMedCrossRefGoogle Scholar
  50. 50.
    Berde CB, Lehn BM, Yee JD, et al. Patient controlled analgesia in children and adolescents: a randomized, prospective comparison with intramuscular morphine for postoperative analgesia. J Pediatr 1991; 118: 460–6PubMedCrossRefGoogle Scholar
  51. 51.
    Galer BS, Coyle N, Pasternak GW, et al. Individual variability in the response to different opioids: report of five cases. Pain 1992; 49: 87–91PubMedCrossRefGoogle Scholar
  52. 52.
    Portenoy RK. Opioid analgesics. In: Portenoy RK, Kanner RM, editors. Pain management: theory and practice. Philadelphia (PA): FA Davis Co.; 1996Google Scholar
  53. 53.
    Drake R, Longworth J, Collins JJ. Opioid rotation in children with cancer. J Palliat Med 2004; 7(3): 419–22PubMedCrossRefGoogle Scholar
  54. 54.
    Inturrisi CE, Portenoy RK, Max M, et al. Pharmacokinetic-pharmacodynamic relationships of methadone infusions in patients with cancer pain. Clin Pharmacol Ther 1990; 47: 565–77PubMedCrossRefGoogle Scholar
  55. 55.
    Eide PK, Jorum E, Stubhaug A, et al. Relief of post-herpetic neuralgia with the N-methyl-D-aspartic acid receptor antagonist ketamine: a double-blind cross-over comparison with morphine and placebo. Pain 1994; 58: 347–54PubMedCrossRefGoogle Scholar
  56. 56.
    Persson J, Axelsson G, Hallin RG, et al. Beneficial effects of ketamine in a chronic pain state with allodynia. Pain 1995; 60: 217–22PubMedCrossRefGoogle Scholar
  57. 57.
    Nelson KA, Park KM, Robinovitz E, et al. High dose dextromethorphan versus placebo in painful diabetic neuropathy and postherpetic neuralgia. Neurology 1997; 48: 1212–8PubMedCrossRefGoogle Scholar
  58. 58.
    Eisenberg E, Pud D. Can patients with chronic neuropathic pain be cured by acute administration of the NMDA-receptor antagonist amantadine? Pain 1994; 74: 37–9Google Scholar
  59. 59.
    Collins JJ, Grier HE, Sethna NF, et al. Regional anesthesia for pain associated with terminal malignancy. Pain 1996; 65: 63–9PubMedCrossRefGoogle Scholar
  60. 60.
    Matson DD. Neurosurgery of infancy and childhood. Springfield (IL): Charles C. Thomas, 1969: 847Google Scholar
  61. 61.
    Truog RD, Berde CB, Mitchell C, et al. Barbiturates in the care of the terminally ill. N Engl J Med 1992; 327: 1678–82PubMedCrossRefGoogle Scholar
  62. 62.
    Kenny NP, Frager G. Refractory symptoms and terminal sedation in children: ethical issues and practical management. J Palliat Care 1996; 12: 40–5PubMedGoogle Scholar
  63. 63.
    Truog RD, Burns JP, Shurin SB, et al. Principles and practice of pediatric oncology. 4th ed. In: Pizzo PA, Poplack DG, editors. Ethical considerations in pediatric oncology. Philadelphia (PA): Lippincott Williams & Wilkins, 2002: 1411–30Google Scholar

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© Adis Data Information BV 2005

Authors and Affiliations

  1. 1.Head, Pain and Palliative Care ServiceThe Children’s Hospital at WestmeadSydneyAustralia

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