Society for Pediatric Pain Medicine
Better Care for Children in Pain

Correct Answer: D. Person with substance use disorder


The patient’s symptoms fit with a possible diagnosis of substance use disorder. A mental health professional such a psychiatrist would need to formally make the diagnosis and get further history to confirm that the patient meets the criticeria for substance use disorder. The term addict, drug addict or even drug abuser assumes moralistic and judgmental connotation. There is blame, shame and stereotyping, even though increased medical and scientific evidence reveals that addiction is a chronic disease with remission, recurrence and relapse. The public already holds highly stigmatizing views regarding people with SUD; these attitudes as well as those help by the patients themselves can prevent individuals from seeking help, in particular adolescents and young adults ⁴. The DSM V specifically uses the terminology substance (or specific drug such as opioid) use disorder in contrast to previous editions of the DSM.


The DSM V criteria for substance use disorder is as follows^1,2,3 :


1. Taking the substance in larger amounts or for longer than you're meant to.


2. Wanting to cut down or stop using the substance but not managing to.


3. Spending a lot of time getting, using, or recovering from use of the substance.


4. Cravings and urges to use the substance.


5. Not managing to do what you should at work, home, or school because of substance use.


6. Continuing to use, even when it causes problems in relationships.


7. Giving up important social, occupational, or recreational activities because of substance use.


8. Using substances again and again, even when it puts you in danger.


9. Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance.


10. Needing more of the substance to get the effect you want (tolerance).


11. Development of withdrawal symptoms, which can be relieved by taking more of the substance.


We will and do see patients’ with SUD in the operating room, acute pain and chronic pain environments, and avoiding the use of problematic language can make a real difference in patients’ experience and improve compassionate care. The American Academy of Pediatric recently published a paper on the use of the recommended terminology in the care of children, adolescents, young adults and their families ⁵. There is an incredibly helpful table that makes it easy to appreciate which terms are preferred and why those terms should be used. https://doi.org/10.1542/peds.2022-057529


References:


1. McLellan AT. Substance misuse and substance use disorders: Why do they matter in healthcare?. Trans Am Clin Climatol Assoc. 2017;128:112-130.


2. https://www.verywellmind.com/dsm-5-criteria-for-substance-use-disorders-21926


3. American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders 5th ed. Arlington, VA 2013


4. Hadland S et.al. Stigma Associated with Opioid Use Disorder in young Adults: A Case Series. Addict Sci Clin Pract 2018, 13: 15 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5937046/


5. Alinsky RH et.al. Recommended Terminology for Substance Use Disorders in the Care of Children, Adolescents, Young Adults and Families. Pediatrics.2022: 149 (6) https://publications.aap.org/pediatrics/article/149/6/e2022057529/188090/Recommended-Terminology-for-Substance-Use?autologincheck=redirected

Correct Answser: e. All of the above statements are true.


Auriculotherapy is a very common form of acupuncture that is based on the theory that the external ear has a somatotopic microsystem that is connected to the entire body^1,2. Auriculotherapy can be done with traditional acupuncture needles, microneedles on adhesive pads, adhesive pellets, and laser. Auriculotherapy has been shown to have a positive effect on anxiety, insomnia, acute pain, and chronic pain, albeit the quality of studies are limited^2,3,4,5,6. The NADA auriculotherapy protocol was developed to treat detoxification symptoms and reduce drug cravings. In a systematic review of published randomized controlled trials, 64% of studies reported that auriculotherapy was effective in the treatment of substance use disorders⁷. Supplementing existing evidence-based treatment with the NADA protocol may facilitate recovery by increasing treatment retention and decreasing methadone dosage needs⁸. Battlefield acupuncture (BFA) is a specific auriculotherapy treatment used for the treatment of acute pain, commonly used in the military and VA hospitals⁹. The literature regarding its efficacy is inconsistent^2,9,10.


REFERENCES


¹Oleson T. Overview and History of Auriculotherapy. Auriculotherapy Manual: Chinese and Western Systems of Ear Acupuncture, Fourth Edition, Churchill Livingstone, 2014, Pages 1-24. ISBN 9780702035722


²Liebell D. The Science of Auricular Microsystem Acupuncture: Amygdala Function in Psychiatric, Neuromusculoskeletal, and Functional Disorders. Med Acupunct. 2019 Jun 1;31(3):157-163. doi: 10.1089/acu.2019.1339. Epub 2019 Jun 17. PMID: 31297169; PMCID: PMC6604906.


³Vieira A, Reis AM, Matos LC, Machado J, Moreira A. Does auriculotherapy have therapeutic effectiveness? An overview of systematic reviews. Complement Ther Clin Pract. 2018 Nov;33:61-70. doi: 10.1016/j.ctcp.2018.08.005. Epub 2018 Aug 23. PMID: 30396628.


⁴Lan Y, Wu X, Tan HJ, Wu N, Xing JJ, Wu FS, Zhang LX, Liang FR. Auricular acupuncture with seed or pellet attachments for primary insomnia: a systematic review and meta-analysis. BMC Complement Altern Med. 2015 Apr 2;15:103. doi: 10.1186/s12906-015-0606-7. PMID: 25886561; PMCID: PMC4425871.


⁵Dellovo AG, Souza LMA, de Oliveira JS, Amorim KS, Groppo FC. Effects of auriculotherapy and midazolam for anxiety control in patients submitted to third molar extraction. Int J Oral Maxillofac Surg. 2019 May;48(5):669-674. doi: 10.1016/j.ijom.2018.10.014. Epub 2018 Nov 12. PMID: 30442551.


⁶Serritella E, Impellizzeri A, Liguori A, Galluccio G. Auriculotherapy used to manage orthodontic pain: a randomized controlled pilot study. Dental Press J Orthod. 2021 Dec 17;26(6):e2119381. doi: 10.1590/2177-6709.26.6.e2119381.oar. PMID: 34932772; PMCID: PMC8690330.


⁷Lee EJ. Effects of auriculotherapy on addiction: a systematic review. J Addict Dis. 2022 Feb 18:1-13. doi: 10.1080/10550887.2021.2016011. Epub ahead of print. PMID: 35179436.


⁸Baker TE, Chang G. The use of auricular acupuncture in opioid use disorder: A systematic literature review. Am J Addict. 2016 Dec;25(8):592-602. doi: 10.1111/ajad.12453. Epub 2016 Nov 2. PMID: 28051842.


⁹Yang J, Ganesh R, Wu Q, Li L, Ogletree SP, Del Fabro AS, Wahner-Roedler DL, Xiong D, Bauer BA, Chon TY. Battlefield Acupuncture for Adult Pain: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Am J Chin Med. 2021;49(1):25-40. doi: 10.1142/S0192415X21500026. Epub 2020 Dec 29. PMID: 33375924.


¹⁰Taylor SL, Giannitrapani KF, Ackland PE, Thomas ER, Federman DG, Holliday JR, Olson J, Kligler B, Zeliadt SB. The Implementation and Effectiveness of Battlefield Auricular Acupuncture for Pain. Pain Med. 2021 Aug 6;22(8):1721-1726. doi: 10.1093/pm/pnaa474. PMID: 33769534.

Correct Answer: B. From a friend or relative


Examining data from almost 10 million Americans who misused prescription pain relievers in 2017 the Substance Abuse and Mental Health Services Administration reported that over half bought or took the medication from a friend or relative, over one third obtained the medication from a single prescriber, and 6.5% bought the medication from a drug dealer or stranger (1).


These findings point to a strong need not just for responsible opioid prescribing but also the appropriate disposal of leftover opioids remaining in homes when the medication is no longer needed to treat pain. Hospitals can facilitate drug disposal by sponsoring prescription drug take-back days and providing onsite drug lock boxes. In addition, families can be instructed regarding safe home disposal methods. Drug disposal products can be provided when prescription opioids are dispensed to encourage home disposal. Some commercial products act as chemical adsorbents or deterrents while others act by sequestering medicine in a gel matrix (2). However, provision of a disposal product may not significantly increase rates of opioid disposal (3) unless accompanied by active patient and family education (4, 5).


References:


1. https://www.samhsa.gov/data/release/2018-national-survey-drug-use-and-health-nsduh-releases


2. https://sfenvironment.org/sites/default/files/fliers/files/overviewmedicinedisposalproducts_21april2017.pdf


3. Bicket MC, Fu D, Swarthout MD, White E, Nesbit SA, Monitto CL. Effect of Drug Disposal Kits and Fact Sheets on Elimination of Leftover Prescription Opioids: The DISPOSE Multi-Arm Randomized Controlled Trial. Pain Med. 2021 Apr 20;22(4):961-969.


4. Voepel-Lewis T, Farley FA, Grant J, Tait AR, Boyd CJ, McCabe SE, Weber M, Harbagh CM, Zikmund-Fisher BJ. Behavioral Intervention and Disposal of Leftover Opioids: A Randomized Trial. Pediatrics. 2020 Jan;145(1):e20191431.


5. Lawrence AE, Carsel AJ, Leonhart KL, Richards HW, Harbaugh CM, Waljee JF, McLeod DJ, Walz PC, Minneci PC, Deans KJ, Cooper JN. Effect of Drug Disposal Bag Provision on Proper Disposal of Unused Opioids by Families of Pediatric Surgical Patients: A Randomized Clinical Trial. JAMA Pediatr. 2019 Aug 1;173(8):e191695.

Correct Answer - B. Regional anesthesia reduces late postoperative apnea events as compared to general anesthesia


Spinal anesthesia in neonates and infants has been well studied and shown to be an effective, safe method of anesthesia for procedures <1-2 hours in duration. Multiple studies have demonstrated a low complication rate with spinal anesthesia.


The General Anesthesia compared to Spinal Anesthesia (GAS) study was a multi-nation, multi-institution prospective randomized trial published in 2015. This study randomized 722 infants >26 weeks post menstrual age up to 60 weeks post menstrual age undergoing either unilateral or bilateral inguinal herniorrhaphy into a regional anesthesia (RA) arm and a general anesthesia (GA) arm. The RA arm received one of the following options: spinal alone, spinal with caudal, spinal with ilioinguinal or caudal alone. No sedation or GA was given in the RA arm. The GA arm received sevoflurane for induction and maintenance of general anesthesia supplemented with either caudal block or ilioinguinal block. No opioids or nitrous oxide was allowed intraoperatively. The primary outcome was observed apnea within 12 hours of surgery or until discharge. Apnea was defined as a pause in breathing for more than 15 seconds or more than 10 seconds with an associated desaturation to <80% or bradycardia of a 20% decrease from baseline. Early apnea was defined as apnea occurring within the first 30 minutes postoperatively. Late apnea is defined as occurring between 30 min and 12 hours postoperatively.


The overall rate of at least one postoperative apneic episode in the study was 3%. Ten occurred in the RA arm and 15 in the GA arm. While there was no statistical significance of late apneas between the two study arms, RA did reduce the risk of early postoperative apnea, the degree of post operative desaturation, and the level of needed intervention required for treatment of apnea. This would imply that RA led to less frequent and less clinically significant apneas. Early apneas were also found to be a predictor of late apneas, although more than half of the infants with late apneas had no documented early apnea.


Hemodynamically, patients randomized to the RA arm were also found to have the following advantages: a greater minimum systolic blood pressure (70.7 vs 54.8), less likely to need an intervention for hypotension (7 vs 19%), higher minimum intraoperative heart rate (133.9 vs 127.6 beats per min), and a higher documented temperature (36.1°C vs 36.0°C) . Anesthesia time was shorter in the RA arm (51 vs 66min). In 20% of patients in the RA arm, there was a need for general anesthesia or other sedatives, therefore a backup plan is imperative.


Discussion with the parents regarding risks of a spinal anesthetic versus a general anesthetic should highlight the above advantages: a lower rate of early apneas (but no difference in overall apnea rate), shorter duration of anesthesia, improved blood pressure, and overall low complication rate. This is assuming the anesthesiologist is comfortable with the procedure and possess the knowledge and skill level to perform a spinal anesthetic in this patient population.


References:


1. Jones LJ, Craven PD, Lakkundi A, Foster JP, Badawi N. Regional (spinal, epidural, caudal) versus general anesthesia in preterm infants undergoing inguinal herniorrhaphy in early infancy. Cochrane Database Syst Rev 2015 Jun 9;2015(6): CD003669


2. Dohms K, Hein M, Rossaint R, Coburn M, Stoppe C, Barbara Ehret C, Berger T, Schalte G. Inguinal hernia repair in preterm neonates: evidence that spinal or general anaesthesia is the better option regarding intraoperative and postoperative complications? A systemic review and meta-analysis. BMJ Open 2019 Oct 8;9(10):e028728


3. Andrew J. Davidson, Neil S. Morton, Sarah J. Arnup, Jurgen C. de Graaff, Nicola Disma, Davinia E. Withington, Geoff Frawley, Rodney W. Hunt, Pollyanna Hardy, Magda Khotcholava, Britta S. von Ungern Sternberg, Niall Wilton, Pietro Tuo, Ida Salvo, Gillian Ormond, Robyn Stargatt, Bruno Guido Locatelli, Mary Ellen McCann; Apnea after Awake Regional and General Anesthesia in Infants: The General Anesthesia Compared to Spinal Anesthesia Study—Comparing Apnea and Neurodevelopmental Outcomes, a Randomized Controlled Trial. Anesthesiology 2015; 123:38–54