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The Child in Pain, BRAIN, and Neuroethical Issues in Pediatric Pain Research and Care

BY JAMES GIORDANO, PhD

A February 4, 2016 editorial in the Boston Globe addressed the recent Food and Drug Administration (FDA) approval of the opiate analgesic oxycodone (brand named OxyContin) for use in children. This has raised concerns about the relative safety and possible effects of such compounds, as well as the roles of industry and federal government in establishing guidelines and policies for the use of drugs – or any medical intervention. Pediatric pain can incur a host of lifelong neuro-biopsychosocial effects. Moreover, pediatric pain care is complicated by practical and legal issues of long-term and often escalated dosing of opioids, and there is a paucity of safety data and information about potential long-terms risks to the developing brain associated with commonly used analgesics in this fragile population.

Both the dictates of the Brain Research through Advancing Innovative Neurotechnologies (BRAIN) initiative, and invocations of the Presidential Commission for the Study of Bioethical Issues speak to the imperative to translate brain research into viable clinical uses. In light of this, it becomes important to ask if and how novel neurotechnologies can meet the challenges and opportunities of assessing and treating pediatric pain. Research to date has shown promise: For example, neuroimaging studies have sought to identify and establish brain phenotypes for pain. As well, neurogenomics and proteomics may afford an understanding of pediatric pain syndromes and sensitivities to various pharmacotherapeutics. Such studies support the capability and potential clinical utility of neurotechnologically-based assessments. Interventional neuroscientific and neurotechnological techniques, including transcranial and in-dwelling approaches to neuromodulation (such as transcranial magnetic and electrical stimulation, (Moreno-Duarte, et al.; Moisset, et al.; Avery, et al.; Fagerlund, et al.) and forms of deep brain stimulation) (Russo, et al.; Gosset, et al.; Boccard, et al.), and highly specific analgesic ligands and novel pharmaceutical delivery preparations (Tseng, et al.; Healy, et al.; Molet, et al.), may each and all have value in augmenting – or in certain circumstances, perhaps replacing – other methods of pain control.

But any such view to improved approaches to pediatric pain care must also acknowledge a host of neuroethical issues. Thus, while the use of assessment neurotechnologies may be seen as relatively low risk, we must still consider potential burdens and harms of over- or mis-reliance upon perceived objectivity, misdiagnosis, and bias and stigma (of predisposition to pain, and in the subsequent provision of care and social regard). And while interventional neurotechnologies offer great potential to effectively mitigate certain types of pain, we must acknowledge the intersection of unknowns arising from a tentative understanding of the brain, nascent neurotechnology, and the possible longitudinal effects of altering brain structure and function during development.

On one hand the need to address pediatric pain prompts calls for rapid translation of pain research to clinical assessment and care to lessen the burden of the suffering child. On the other, consideration, if not caution must be taken to avoid burdens and harms that may occur as a result of heightened expediency from bench-to-bedside. Tension between these motives could impede the scope and progress of neurotechnologically-based approaches to assessment and treatment of pediatric pain. How then to proceed?

Working in collaboration with Dr. Stefan Friedrichsdorf and his team at the Children’s Hospital and Clinics of Minneapolis, our group has called for a balance, in which we advocate prudent evaluation and use of tools and techniques of brain science that are currently and soon to be available confronting the problem of pediatric pain. Building upon prior work of Liana Buniak, current research scholars Dr. Faisal Akram and Christelle Khadra are addressing the neuroethical issues generated by neurotechnological approaches to assessment and care of pediatric pain.

We posit that priority must be given to:

  • Funding the development and articulation of prospective, longitudinal research in pediatric pain management focusing on the benefits of various types of assessment and intervention, and long-term bio-psychosocial consequences incurred by implementing – or not implementing – particular approaches.
  • Sustained discourse and deliberation focusing on the neuroethical issues associated with pain care in children;
  • Ongoing examination – and possible revision – of guidelines, policies and laws to insure the probity of pediatric pain research and clinical care.

Our group is fond of the adage “measure twice and cut once”, and we unapologetically re-assert this summons here. But it’s important to note that we do not advocate this as an “either/or” proposition, but instead as a “both/and” obligation to meet the neuroethical opportunities and challenges afforded by advancing brain science in the clinical care of those most vulnerable, and to sustain the right and good use of neuroscience and its technologies in society across generations.

James Giordano PhD is Chief of the Neuroethics Studies Program at the Pellegrino Center for Clinical Bioethics, and is Professor in the Department of Neurology at Georgetown University Medical Center. Follow more of Professor Giordano’s work at explore.georgetown.edu, and http://www.neurobioethics.org.

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