Strong opioids in pediatric palliative medicine

The management of pain in the palliative care of children is somewhat different from that in adults. It also differs in approach from the management of other types of acute and chronic pain in childhood. Whereas once opioids were thought to be highly dangerous drugs, unsuitable for use in children, they have now taken their place as the mainstay for provision of good analgesia to manage moderate-to-severe pain in both malignant and non-malignant life-limiting conditions. There are relatively little clinical or laboratory data regarding opioids specifically in children. However, much of what has been published regarding the management of pain in palliative medicine in adults can be extrapolated. On saying that, early research in children does suggest some significant differences in opioid pharmacokinetics, particularly with respect to morphine clearance, which seems to be faster in adults. Thus, the use of opioids in pediatric palliative care presents some unique challenges. Confident and rational use of opioids by pediatricians, illustrated by the WHO guidelines, is essential for the adequate management of pain complicating the palliative phase in children with life-limiting conditions. The clinical evidence is accumulating that strong opioids can be used safely and effectively in children with moderate-to-severe pain. They should be used as part of a rational approach to the diagnosis, assessment, and management of pain (table II, figure 2). The WHO pain ladder provides a straightforward structure to such an approach and is recommended to all professionals who deal with pain in children suffering from a life-limiting condition. The evolution of clinical expertise and experience has been paralleled and supported by an expansion of the research evidence base. This seems to show that, where children differ from adults in their handling of morphine, the result is morphine is cleared more rapidly. It is plausible that this may make children more resilient to its effects than adults. More research is needed, as in so many other areas of pediatric clinical pharmacology. Important research areas include the clinical use of methadone in children and the CNS pharmacokinetics of morphine outside adulthood. © 2005 Adis Data Information BV. All rights reserved.