Opioid-sparing strategies and early intervention can improve pediatric pain care

Chronic pain affects approximately one in five children, yet many families continue to believe that medications—particularly opioids—are the primary solution for persistent pain. Jamie Fleming, MD, says that misconception can delay more effective treatments centered on restoring function and addressing the multiple factors that influence how children experience pain.

Fleming, section chief of Pain Management and director of Interventional Pain Management at Phoenix Children's, said the health system's comprehensive pediatric pain program emphasizes early intervention and multidisciplinary care while limiting opioid use to select circumstances. In 2025, Phoenix Children's expanded its services with a dedicated pediatric interventional pain procedural suite designed specifically for children, allowing many procedures to be performed outside the operating room while supporting coordinated care.

Does opioid-sparing care mean undertreating pain?

Fleming said one of the most common misconceptions is that avoiding opioids means children will receive inadequate pain relief.

"One important thing about emphasizing all of these other therapies before opioids is that opioid sparing does not mean under treating pain," Fleming said. "So it's that that's a very important thing to distinguish, and very rarely are opioids a part of our pain treatment protocol."

She acknowledged that many families arrive hoping for a medication that will eliminate pain immediately.

"Sometimes we have families come in that really say we just want something to take pain away, and that's something we hear frequently because it's such a difficult and frustrating experience for the families," Fleming said.

Instead, she said successful treatment requires addressing the many biologic, psychological, and environmental factors that influence pain.

"I think the thing for families and also practitioners to know is that really that's not going to be the magic bullet for their pain. We can't really take it away with just one modality," Fleming said. "We really need to integrate all these things to best address all the things that influence their nervous system and how it's processing pain."

Why is early intervention important for preventing chronic pain?

According to Fleming, prevention often begins before pain becomes chronic.

"Our philosophy around pain is early prevention and early treatment," she said. "Oftentimes, this goes far before they ever reach our pain clinic."

She described how surgeons at Phoenix Children's identify patients who may be at higher risk for persistent pain and refer them to the pain team before surgery.

"A lot of our surgeons will recognize risk factors when they're assessing patients for surgery, and they'll end up sending those patients to our pain clinic preemptively for us to see them, evaluate them, come up with a pain treatment plan around their surgery, and also educate those patients on what to expect," Fleming said.

The program also incorporates regional anesthesia techniques, including nerve blocks, nerve catheters, and epidurals, to reduce perioperative pain and minimize the need for stronger medications.

"When you combine all of these things, it really matters because severe acute postoperative pain is a big risk factor for persistent chronic pain," Fleming said.

What should pediatricians do when caring for children with chronic pain?

Fleming said one of the most important interventions requires no medication or procedure.

"I think there's several main points, and one of those is believe the child and validate their pain. And I would say that's the single most important thing," she said.

She also encouraged pediatricians to help children remain engaged in daily life whenever possible.

"Trying to encourage the patient to stay connected to school and social activities is really big," Fleming said. "When they start avoiding those things, it often reinforces the pain cycle and makes it worse."

Rather than prolonged rest, she recommended gradual return to activity with support from rehabilitation specialists.

"We want to avoid prolonged rest," Fleming said. "Things like physical therapy are important... chronic pain is a different story. And so we encourage gradual return to activity."

When should pediatricians refer children for specialty pain care?

Fleming encouraged pediatricians to look beyond physical symptoms when evaluating children with persistent pain.

"Very important to screen for sleep problems, mood problems, also other stressors at home or school because that will influence the way that they're experiencing pain," she said.

She also emphasized that referrals should occur before disability becomes entrenched.

"Importantly, refer to physical therapy and psychology early. Refer to your pain program early," Fleming said.

Finally, she encouraged pediatricians to help families establish realistic expectations for treatment.

"Set the expectation to the patient and their family that they won't have zero pain, and that's not the goal," Fleming said. "The goal is getting back to living life."