Pain and Opiates

Anyone following news even occasionally is likely aware of the terrible scourge of opiate addiction sweeping our nation.  Many consider Ocean county to be an epicenter of the problem.  Both the origins and the treating factors are multifactorial–economic, social, educational, legal, technologic, even religious.  And medical–certainly physician prescribing practices contribute.  I think we doctors simply must endeavor to be more cautious and aware when faced with the challenge of treating pain.

There are several studies published currently that look at the use of opiate vs. non-opiates for post-operative pain management for common uncomplicated surgical situations.  Recently the Canadian Medical Journal compared ibuprofen to morphine after simple orthopedic procedures like fracture reduction.  154 children were enrolled from 2013-16 for either medicine.  Pain control was similar for both drugs after the first dose and after multiple treatments.  Not surprisingly, side effects were more common with morphine compared to ibuprofen: nausea (30% vs. 13%), vomiting (12% vs. 3%), drowsiness (31% vs. 15%), dizziness (20% vs. 4%), constipation (9% vs 3%) or “any” (45% vs 26%).

The results of this study were similar to one from 2015 in Pediatrics comparing the same drugs post-tonsillectomy.  There 91 children were observed and the ibuprofen group actually reported better pain relief (68% vs 14%) with fewer incidents of respiratory depression and no difference in post operative bleeding.

So where does that leave us? In each analysis there is very good evidence that the simpler, milder, non-addictive agent is at least as good as the “stronger” opiate painkiller.  Now, while there currently aren’t studies for every clinical situation, I think it is not unreasonable to extrapolate to comparable common surgical/trauma/pain issues like dental procedures and oral surgery, suturing, moderate burns, or outpatient abscess drainage: likely at least as effective to use the milder OTC analgesics like ibuprofen or acetaminophen.  And certainly safer for the child and for the larger community to stay away from the addictive stuff.  Please keep this in mind should your child require such interventions.

For questions about pain management or any other conditions, please don’t hesitate to call, and thanks for following.

Head Lice

1. On vacation recently, Kim and I toured Santa Fe’s “Oldest House,” a >800 year old native American dwelling.  Among the displayed artifacts I noted an ancient lice comb made of bone.  I found it fascinating to contemplate–from such a distant, different time, yet they still struggled with the same annoying, familiar problem.  People are still just people.

Head lice have been with us for eons and probably troubled our pre-human ancestors >1.8 million years ago.  They are now “species specific”–just us folks.  They spend their entire life cycle on the scalp and, unable to fly or jump, die within 2 days of removal.  They primarily infect 3-11 year olds with between 6-11 million cases annually.  A few misconceptions:

1. Head lice infestation is not indicative of poor hygiene.  They are spread by close contact, mostly in schools or camps.  So it no more suggests uncleanliness than picking up a cold or flu–just bad luck.
2. Unlike their skeevy cousin, the body louse, there is no known disease spread by head lice.
3. Sleeping in a bed previously used by an infested person does not spread disease (unless you are sharing the bed simultaneously)
4. <2% of spread is caused by use of inanimate objects like hats or brushes; it’s almost always person-person
5. Most important–nits do not cause spread

Given #5, there is no justification for school “no nit” policies.  Nits are egg husks and can no more spread disease than egg shells make egg salad.(Chemically bonded to the hair,  one can differentiate nits from dandruff by isolating the hair and gently sliding the little flake off with your fingers.  If it slides off its dandruff)  The official AAP position is that involved children need not be removed from class as, once treated, contagiousness is very limited.  So there is more negative impact of social stigma or lost school time for that child and little gained from dismissal.

While drug resistance occurs, AAP guidelines still recommend OTC treatments like Rid or Nix as first line.  Apply a generous amount to the hair and scalp, leave on for >10 minutes, then vigorously shampoo.  Long hair may need 2 bottles.  Be sure to re-treat in a week.  Then vigorously comb out the dead bugs and the nits with a metal fine tooth comb.  The teeth of plastic models will likely break and be ineffective (I suppose if one can scrounge up a bone model, like our long forgotten “Oldest House” friends–that would be ok too!).  If you notice a few straggles hanging on after treatment don’t be discouraged–that’s what the second dose is for.  Personally I recommend everybody in the house be treated together the first time.  Only infected people need the second dose.

These medications are quite safe.  However, repeated application can lead to toxicity, so don’t keep retreating–call me and we can talk about prescriptions.  One last word: dehydration with a heat treatment is often effective.  Other “non-medical” methods–essential or olive oil, petrolatum, mayonnaise(!)  fail often and are not recommended.

Send questions or comments; thanks for following.