Society for Pediatric Pain Medicine
Better Care for Children in Pain

{“questions”:{“bijfd”:{“id”:”bijfd”,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:” \r\n\r\nA 15-year-boy presents for an urgent revision of a previous ankle dislocation after falling off his skateboard. His past history is significant for ADHD, and anxiety and ankle surgery 6 months ago. He started using marijuana when he was 13, and misused his opioid prescription after his previous surgery. He is very concerned about postoperative pain management and states that he had significant pain after his last surgery. On his way back to the OR he admits to using opioids or \u201cwhatever he can get his hands on\u201d daily since that surgery, and that he seems to need higher and higher doses. He reports having tried to stop without success and is worried about withdrawal. \r\n\r\nWhich of the following terms best describes his probable current diagnosis?\r\n”,”desc”:””,”hint”:””,”answers”:{“9pxb6”:{“id”:”9pxb6″,”image”:””,”imageId”:””,”title”:”A. Drug addict”},”1075s”:{“id”:”1075s”,”image”:””,”imageId”:””,”title”:”B. Substance abuser”},”0l3tw”:{“id”:”0l3tw”,”image”:””,”imageId”:””,”title”:”C. Prescription opioid abuser”},”mfhvh”:{“id”:”mfhvh”,”image”:””,”imageId”:””,”title”:”D. Person with substance use disorder “,”isCorrect”:”1″}}}},”results”:{“ulqx4”:{“id”:”ulqx4″,”title”:””,”image”:””,”imageId”:””,”min”:”0″,”max”:”1″,”desc”:”Correct Answer: D. Person with substance use disorder \r\n\r\nThe patient\u2019s symptoms fit with a possible<\/em> 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<\/sup>. The DSM V specifically uses the terminology substance (or specific drug such as opioid) use disorder in contrast to previous editions of the DSM. \r\n\r\nThe DSM V criteria for substance use disorder is as follows1,2,3<\/sup> : \r\n1.\tTaking the substance in larger amounts or for longer than you’re meant to. \r\n2.\tWanting to cut down or stop using the substance but not managing to. \r\n3.\tSpending a lot of time getting, using, or recovering from use of the substance. \r\n4.\tCravings and urges to use the substance. \r\n5.\tNot managing to do what you should at work, home, or school because of substance use. \r\n6.\tContinuing to use, even when it causes problems in relationships. \r\n7.\tGiving up important social, occupational, or recreational activities because of substance use. \r\n8.\tUsing substances again and again, even when it puts you in danger. \r\n9.\tContinuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance. \r\n10.\tNeeding more of the substance to get the effect you want (tolerance). \r\n11.\tDevelopment of withdrawal symptoms, which can be relieved by taking more of the substance. \r\n\r\nWe will and do see patients\u2019 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\u2019 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<\/sup>. 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 \r\n\r\n\r\nReferences: \r\n1.\tMcLellan AT. Substance misuse and substance use disorders: Why do they matter in healthcare?. Trans Am Clin Climatol Assoc. 2017;128:112-130. \r\n2.\thttps:\/\/www.verywellmind.com\/dsm-5-criteria-for-substance-use-disorders-21926 \r\n3.\tAmerican Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders 5th ed. Arlington, VA 2013 \r\n4.\tHadland 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\/ \r\n5.\tAlinsky 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 \r\n\r\n\r\n”,”redirect_url”:””}}}}

{“questions”:{“znrhm”:{“id”:”znrhm”,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”\r\n\r\nAuriculotherapy is a form of acupuncture that utilizes acupuncture points on the ear. Which of the following statements are true regarding auriculotherapy?\r\n\r\n“,”desc”:””,”hint”:””,”answers”:{“qk36n”:{“id”:”qk36n”,”image”:””,”imageId”:””,”title”:”a.\tIt is a modality of treatment in which the external ear is stimulated to relieve symptoms of the body.”},”tlrrl”:{“id”:”tlrrl”,”image”:””,”imageId”:””,”title”:”b.\tIt can be performed with acupuncture needles, microneedles, adhesive pellets, and laser.”},”e4e6k”:{“id”:”e4e6k”,”image”:””,”imageId”:””,”title”:”c.\tIt has been shown to be effective in the treatment of acute pain, chronic pain, anxiety, and insomnia.”},”45wje”:{“id”:”45wje”,”image”:””,”imageId”:””,”title”:”d.\tAuriculotherapy has been widely used in the form of detoxification treatment and battlefield acupuncture.”},”gixkq”:{“id”:”gixkq”,”image”:””,”imageId”:””,”title”:”e.\tAll of the above statements are true.”,”isCorrect”:”1″}}}},”results”:{“bvy1x”:{“id”:”bvy1x”,”title”:””,”image”:””,”imageId”:””,”min”:”0″,”max”:”1″,”desc”:”Correct Answser: e. All of the above statements are true. \r\n\r\nAuriculotherapy 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<\/sup>. 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 limited2,3,4,5,6<\/sup>. 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<\/sup>. Supplementing existing evidence-based treatment with the NADA protocol may facilitate recovery by increasing treatment retention and decreasing methadone dosage needs8<\/sup>. Battlefield acupuncture (BFA) is a specific auriculotherapy treatment used for the treatment of acute pain, commonly used in the military and VA hospitals9<\/sup>. The literature regarding its efficacy is inconsistent2,9,10<\/sup>. \r\nREFERENCES \r\n1<\/sup>Oleson 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 \r\n2<\/sup>Liebell 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.\r\n3<\/sup>Vieira 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.\r\n4<\/sup>Lan 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.\r\n5<\/sup>Dellovo 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.\r\n6<\/sup>Serritella 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.\r\n7<\/sup>Lee 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.\r\n8<\/sup>Baker 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.\r\n9<\/sup>Yang 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.\r\n10<\/sup>Taylor 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.\r\n”,”redirect_url”:””}}}}

{“questions”:{“c96g2”:{“id”:”c96g2″,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”\r\n\r\n\r\nAmong Americans 12 years of age and older who misuse prescription pain relievers, the most common source of acquired medication is:”,”desc”:””,”hint”:””,”answers”:{“5ykvx”:{“id”:”5ykvx”,”image”:””,”imageId”:””,”title”:”A. From a physician”},”b396e”:{“id”:”b396e”,”image”:””,”imageId”:””,”title”:”B. From a friend or relative”,”isCorrect”:”1″},”eutur”:{“id”:”eutur”,”image”:””,”imageId”:””,”title”:”C. From a drug dealer “}}}},”results”:{“35oih”:{“id”:”35oih”,”title”:””,”image”:””,”imageId”:””,”min”:”0″,”max”:”1″,”desc”:”Correct Answer: B. From a friend or relative\r\n\r\n\r\nExamining 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). \r\nThese 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). \r\nReferences: \r\n1.\thttps:\/\/www.samhsa.gov\/data\/release\/2018-national-survey-drug-use-and-health-nsduh-releases \r\n2.\thttps:\/\/sfenvironment.org\/sites\/default\/files\/fliers\/files\/overviewmedicinedisposalproducts_21april2017.pdf \r\n3.\tBicket 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. \r\n4.\tVoepel-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. \r\n5.\tLawrence 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.”,”redirect_url”:””}}}

{“questions”:{“dk2a5”:{“id”:”dk2a5″,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”\r\n\r\nA 3-month-old, former 28 week gestational age premature male presents for inguinal herna repair. Parents would like to discuss the benefits of spinal anesthesia versus general anesthesia for the procedure. Which of the following is NOT true regarding benefits of spinal or regional anesthesia versus general anesthesia for infants undergoing inguinal hernia repair?”,”desc”:””,”hint”:””,”answers”:{“u03de”:{“id”:”u03de”,”image”:””,”imageId”:””,”title”:”A. Regional anesthesia has been shown to reduce early postoperative apnea events as compared to general anesthesia”},”3dgsr”:{“id”:”3dgsr”,”image”:””,”imageId”:””,”title”:”B. Regional anesthesia reduces late postoperative apnea events as compared to general anesthesia”,”isCorrect”:”1″},”j6zmr”:{“id”:”j6zmr”,”image”:””,”imageId”:””,”title”:”C. Infants with regional anesthesia have greater mean blood pressures intraoperatively as compared to general anesthesia”},”7oxla”:{“id”:”7oxla”,”image”:””,”imageId”:””,”title”:”D. Overall anesthetic and surgical time is reduced with regional anesthesia as compared to general anesthesia”},”sognj”:{“id”:”sognj”,”image”:””,”imageId”:””,”title”:”E. Spinal anesthesia is safe to perform in neonates and infants”}}}},”results”:{“fra55”:{“id”:”fra55″,”title”:””,”image”:””,”imageId”:””,”min”:”0″,”max”:”1″,”desc”:”Correct Answer -\r\nB. Regional anesthesia reduces late postoperative apnea events as compared to general anesthesia\r\n\r\nSpinal 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. \r\n\r\nThe 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. \r\n \r\nThe 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. \r\n\r\nHemodynamically, 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\u00b0C vs 36.0\u00b0C) . 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. \r\n\r\nDiscussion 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. \r\n\r\nReferences: \r\n1.\tJones 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 \r\n\r\n2.\tDohms 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 \r\n\r\n3.\tAndrew 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\u2014Comparing Apnea and Neurodevelopmental Outcomes, a Randomized Controlled Trial. Anesthesiology 2015; 123:38\u201354 \r\n”,”redirect_url”:””}}}

{“questions”:{“o02mn”:{“id”:”o02mn”,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”\r\n\r\nA 14-year-old female softball player presents to your musculoskeletal clinic with 1 week of severe unilateral shoulder pain. She denies any recent trauma to the area. History was unremarkable except for a recent COVID-19 infection approximately 2 weeks ago, during which she was minimally symptomatic. Physical examination includes a positive Hawkins-Kennedy, Neer, Speeds, and Yergason tests. Strength is perceived as 5\/5 in all muscles tested, but limited somewhat by effort and pain. Sensation was normal in C5-T1 dermatomes bilaterally. X-rays did not reveal any underlying pathology. She was subsequently referred to physical therapy. \r\nThe next week, you receive a call from the PT. She reports the patient now has no pain, which makes you feel like you have successfully treated the patient. However, she has developed significant weakness on the affected side. During therapy, she had no active abduction or external rotation of the shoulder (0\/5). She also had significant weakness with elbow flexion (2\/5) and extension (4\/5). She is also reporting some generalized sensory changes of the arm. \r\nWhat is the most likely diagnosis?\r\n”,”desc”:””,”hint”:””,”answers”:{“js4jp”:{“id”:”js4jp”,”image”:””,”imageId”:””,”title”:”A.) Cervical Radiculopathy”},”8vnvz”:{“id”:”8vnvz”,”image”:””,”imageId”:””,”title”:”B.) Rotator Cuff Pathology”},”au1ie”:{“id”:”au1ie”,”image”:””,”imageId”:””,”title”:”C.) Brachial Neuritis”,”isCorrect”:”1″},”doq3q”:{“id”:”doq3q”,”image”:””,”imageId”:””,”title”:”D.) Complex Regional Pain Syndrome”}}}},”results”:{“prriu”:{“id”:”prriu”,”title”:””,”image”:””,”imageId”:””,”min”:”0″,”max”:”1″,”desc”:””,”redirect_url”:”https:\/\/pedspainmedicine.org\/wp-content\/uploads\/2022\/02\/SPPM-Question-of-the-Month-February-22-Answer-Explanation.pdf”}}}