BACKGROUND: Neuropathic pain (NeP), redefined as pain caused by a lesion or a disease of the somatosensory system, is a disabling condition that affects approximately two million Canadians.OBJECTIVE: To review the randomized controlled trials (RCTs) and systematic reviews related to the pharmacological management of NeP to develop a revised evidence‐based consensus statement on its management.METHODS: RCTs, systematic reviews and existing guidelines on the pharmacological management of NeP were evaluated at a consensus meeting in May 2012 and updated until September 2013. Medications were recommended in the consensus statement if their analgesic efficacy was supported by at least one methodologically sound RCT (class I or class II) showing significant benefit relative to placebo or another relevant control group. Recommendations for treatment were based on the degree of evidence of analgesic efficacy, safety and ease of use.RESULTS: Analgesic agents recommended for first‐line treatments are gabapentinoids (gabapentin and pregabalin), tricyclic antidepressants and serotonin noradrenaline reuptake inhibitors. Tramadol and controlled‐release opioid analgesics are recommended as second‐line treatments for moderate to severe pain. Cannabinoids are now recommended as third‐line treatments. Recommended fourth‐line treatments include methadone, anticonvulsants with lesser evidence of efficacy (eg, lamotrigine, lacos‐amide), tapentadol and botulinum toxin. There is support for some analgesic combinations in selected NeP conditions.CONCLUSIONS: These guidelines provide an updated, stepwise approach to the pharmacological management of NeP. Treatment should be individualized for each patient based on efficacy, side‐effect profile and drug accessibility, including cost. Additional studies are required to examine head‐to‐head comparisons among analgesics, combinations of analgesics, long‐term outcomes and treatment of pediatric, geriatric and central NeP.

Neuropathic pain (NeP), generated by disorders of the peripheral and central nervous system, can be particularly severe and disabling. Prevalence estimates indicate that 2% to 3% of the population in the developed world suffer from NeP, which suggests that up to one million Canadians have this disabling condition. Evidence‐based guidelines for the pharmacological management of NeP are therefore urgently needed. Randomized, controlled trials, systematic reviews and existing guidelines focusing on the pharmacological management of NeP were evaluated at a consensus meeting. Medications are recommended in the guidelines if their analgesic efficacy was supported by at least one methodologically sound, randomized, controlled trial showing significant benefit relative to placebo or another relevant control group. Recommendations for treatment are based on degree of evidence of analgesic efficacy, safety, ease of use and cost‐effectiveness. Analgesic agents recommended for first‐line treatments are certain antidepressants (tricyclics) and anticonvulsants (gabapentin and pregabalin). Second‐line treatments recommended are serotonin noradrenaline reuptake inhibitors and topical lidocaine. Tramadol and controlled‐release opioid analgesics are recommended as third‐line treatments for moderate to severe pain. Recommended fourth‐line treatments include cannabinoids, methadone and anticonvulsants with lesser evidence of efficacy, such as lamotrigine, topiramate and valproic acid. Treatment must be individualized for each patient based on efficacy, side‐effect profile and drug accessibility, including cost. Further studies are required to examine head‐to‐head comparisons among analgesics, combinations of analgesics, long‐term outcomes, and treatment of pediatric and central NeP.

Our knowledge of the prevalence and sources of pain within hospital is limited. The present study is an epidemiological investigation of pain in a pediatric hospital. All children who were inpatients in a tertiary care hospital (excluding Neonatal ICU and psychiatry patients) and one parent per child were potential subjects. Interviews were conducted on three weekdays. Parent interviews were used for children less than 5 years of age (n = 102); child interviews were used for children age 5 years and older (n = 98). Subjects reported the intensity and source of the worst, usual and current pain during the past 24 h, and help received for pain. Medical and demographic variables and analgesics prescribed and administered were obtained from the medical record. Forty-nine percent of subjects reported clinically significant levels of worst pain. Twenty-one percent of subjects had clinically significant levels of usual pain. Causes of pain were variable and included disease, surgery, and intravenous lines (I.V.). Pain intensity was not significantly related to age, gender, patient type (medical, surgical), or diagnostic category. Children were given significantly less medication than was prescribed, regardless of their reported pain level. Nurses, mothers, and 'no-one' were frequently reported as helping with pain. Medications and nonpharmacological methods were reported as helpful in managing pain. Many children endure unacceptable levels of pain during hospitalization. Pain prevention and management must be more aggressive. Pain assessment should be approached with the same attention as vital signs. Improvements in analgesic prescription and administration practices and non-pharmacological pain control methods are needed.

Background Children being cared for in hospital undergo multiple painful procedures daily. However, little is known about the frequency of these procedures and associated interventions to manage the pain. We undertook this study to determine, for children in Canadian hospitals, the frequency of painful procedures, the types of pain management interventions associated with painful procedures and the influence of the type of hospital unit on procedural pain management. Methods We reviewed medical charts for infants and children up to 18 years of age who had been admitted to 32 inpatient units at eight Canadian pediatric hospitals between October 2007 and April 2008. We recorded all of the painful procedures performed and the pain management interventions that had been implemented in the 24-hour period preceding data collection. We performed descriptive and comparative (analysis of variance, χ²) analyses. Results Of the 3822 children included in the study, 2987 (78.2%) had undergone at least one painful procedure in the 24-hour period preceding data collection, for a total of 18 929 painful procedures (mean 6.3 per child who had any painful procedure). For 2334 (78.1%) of the 2987 children who had a painful procedure, a pain management intervention in the previous 24 hours was documented in the chart: 1980 (84.8%) had a pharmacologic intervention, 609 (26.1%) a physical intervention, 584 (25.0%) a psychologic intervention and 753 (32.3%) a combination of interventions. However, for only 844 (28.3%) of the 2987 children was one or more pain management interventions administered and documented specifically for a painful procedure. Pediatric intensive care units reported the highest proportion of painful procedures and analgesics administered. Interpretation For less than one-third of painful procedures was there documentation of one or more specific pain management interventions. Strategies for implementing changes in pain management must be tailored to the type of hospital unit.

The non-communicating children's pain checklist (NCCPC) has displayed preliminary validity and reliability for measuring pain in children with severe cognitive impairments (Dev Med Child Neurol 42 (2000) 609). This study provides evidence of the psychometric properties of a revised NCCPC (NCCPC-R) with a larger cohort of children. Caregivers of 71 children with severe cognitive impairments (aged 3-18) conducted observations of their children using the NCCPC-R during a time of pain and a time without pain. Fifty-five caregivers completed a second set of observations. The score results on the NCCPC-R were: internally consistent, significantly related to pain intensity ratings provided by caregivers, consistent over time, sensitive to pain, and specific to pain. Analyses of children's individual scores indicated up to 95% of their scores were consistent. Receiver operating characteristic curves suggest a score of 7 or greater on the NCCPC-R as indicative of pain in children with cognitive impairments, with 84% sensitivity and up to 77% specificity. These results provide evidence of NCCPC-R having excellent psychometric properties.