Abstract
BackgroundChronic pain is common in children and adolescents and is often associated with severe functional disability and mood disorders. The pharmacological treatment of chronic pain in children and adolescents can be challenging, ineffective, and is mostly based on expert opinions and consensus. Ketamine, an N-methyl-D-aspartate receptor antagonist, has been used as an adjuvant for treatment of adult chronic pain and has been shown, in some instances, to improve pain and decrease opioid-requirement. We examined the effects of subanesthetic ketamine infusions on pain intensity and opioid use in children and adolescents with chronic pain syndromes treated in an outpatient setting.MethodsLongitudinal cohort study of consecutive pediatric patients treated with subanesthetic ketamine infusions in a tertiary outpatient center. Outcome measurements included self-reported pain scores (numeric rating scale) and morphine-equivalent intake.ResultsOver a 15-month period, 63 children and adolescents (median age 15, interquartile range 12–17 years) with chronic pain received 277 ketamine infusions. Intravenous administration of subanesthetic doses of ketamine to children and adolescents on an outpatient basis was safe and not associated with psychotropic effects or hemodynamic perturbations. Overall, ketamine significantly reduced pain intensity (p <0.001) and yielded greater pain reduction in patients with complex regional pain syndrome (CRPS) than in patients with other chronic pain syndromes (p = 0.029). Ketamine-associated reductions in pain scores were the largest in postural orthostatic tachycardia syndrome (POTS) and trauma patients and the smallest in patients with chronic headache (p = 0.007). In 37 % of infusions, patients had a greater than 20 % reduction in pain score. Conversely, ketamine infusions did not change overall morphine-equivalent intake (p = 0.3).ConclusionsThese data suggest that subanesthetic ketamine infusion is feasible in an outpatient setting and may benefit children and adolescents with chronic pain. Further, patients with CRPS, POTS, and a history of trauma-related chronic pain are more likely to benefit from this therapeutic modality.
Highlights
Chronic pain is common in children and adolescents and is often associated with severe functional disability and mood disorders
Patients and clinical findings Between January 2013 and April 2014, 63 patients with chronic pain syndromes received a total of 111 treatments delivered over 277 ketamine infusions (Table 1)
Indications for ketamine administration included 1) requirement of escalating doses of opioid associated with non-tolerated side effects or 2) lack of improvement in pain intensity and/ or disabilities with other standard treatment modalities
Summary
Chronic pain is common in children and adolescents and is often associated with severe functional disability and mood disorders. The pharmacological treatment of chronic pain in children and adolescents can be challenging, ineffective, and is mostly based on expert opinions and consensus. Psychological, and social consequences of chronic pain in children and adolescents, its clinical evaluation requires exploration of these various domains and its therapy a multidisciplinary approach [11, 12]. In many children and adolescents, the pharmacologic treatment of chronic pain requires a combination of opioids, anticonvulsants, and antidepressants [13]. The choice of pharmacological agents to treat children and adolescents with chronic pain is predominately based on expert opinions, studies showing efficacy of given therapies in adults, and on practitioner’s consensus [15,16,17]. It is imperative that effective therapies are developed to improve the health outcomes of children and adolescents with chronic pain
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