Editor’s note: The third North American Pain School (NAPS) took place June 24-28, 2018, in Montebello, Quebec, Canada. An educational initiative of the International Association for the Study of Pain (IASP) and Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION), and presented by the Quebec Pain Research Network (QPRN), NAPS brings together leading experts in pain research and management to provide 30 trainees with scientific education, professional development, and networking experiences. This year’s theme was “To Boldly Go…: The Future of Pain Treatment.” Six of the trainees were also selected to serve as PRF-NAPS Correspondents, who provided firsthand reporting from the event, including interviews with NAPS’ six visiting faculty members and summaries of scientific sessions, along with coverage on social media. This is the third installment of interviews from the Correspondents, whose work is featured on PRF and RELIEF, PRF’s companion site for the public. (See interviews with Ian Gilron here, Allan Basbaum here, Michael Salter here, Judy Watt-Watson here, and Irene Tracey here.)
Stefan Friedrichsdorf, MD, is medical director of the Department of Pain Medicine, Palliative Care, and Integrative Medicine at Children’s Hospitals and Clinics of Minnesota, Minneapolis, US. He received his medical degree and completed his pediatric residency in Germany, and subsequently undertook a fellowship in pediatric pain and palliative care at the University of Sydney, Australia. He leads an interdisciplinary pain program and is devoted to preventing and treating acute, procedural, neuropathic, visceral, psycho-social-spiritual, and persistent pain for all pediatric patients. He is also trained in pediatric hypnosis. Friedrichsdorf sat down with PRF-NAPS Correspondent Lauren Heathcote, a postdoctoral fellow and pediatric pain psychologist in the Department of Anesthesiology, Perioperative, and Pain Medicine at Stanford University Medical School, Palo Alto, US, to discuss his journey in the field of pain medicine, his outlook for the future of pediatric pain research, and much more. Below is an edited transcript of their conversation.
How did you become interested in children’s pain?
Before I went into medicine, for quite a few years I was a volunteer camp counselor in charge of up to 70 German kids attending two-week camps in Denmark, Sweden, and Germany. While telling stories at the fireside, I experienced the power of imagination and language; I noticed that I could send them all to sleep by telling a story. I thought, Wow! Hypnotic language is something that might be very exciting.
Then, in Germany, I did an internship at the local children’s hospital prior to starting medical school. Within the first weeks I participated in taking care of a boy who was dying of leukemia. Despite an amazing medical team, I couldn’t help noticing he was suffering from pain and distressing symptoms, and I thought to myself, I want to learn how to reduce pain and suffering during my career.
But when I became a pediatric resident, I noticed that I was the one causing most of the pain. Most of the time a child’s pain is not caused by their disease, but rather by interventions and their treatment. Back in the day, in Germany, there were no phlebotomists. As a young doctor, you had to "practice" on tiny babies to draw their blood every morning, and they were of course screaming bloody murder. Very quickly, I realized that I wanted to help make this go away.
Serendipitously, I learned about and was accepted into a fellowship in pediatric pain medicine and palliative care in Sydney, Australia, mentored by the amazing Dr. John J. Collins. I just loved, loved, loved it! Coming into the room and taking the pain away, well, kids love you, the parents love you, the nurses really like you—nobody likes pain. And taking pain and suffering away was so much more fun than causing it.
Being a children’s palliative care physician probably sounds to many like a distressing, emotionally difficult job. Is that something that comes up for you?
Of course. I have three children in elementary and middle school, and I hope they will graduate from high school, and I hope they do something reasonable and fun in their lives like become a painter or a plumber or go to college. I hope my wife and I will die before our children do. But as we are talking, there are more than 230,000 families in the United States who do not have this privilege, who know that their child is seriously ill and at risk to die the next day, the next week, or the next years. As clinicians, we have to look those parents in the eye and promise that we’re going to be there for them and that we will take care of their children, and decrease pain and suffering as much as possible.
Unfortunately, the vast majority of children worldwide are still to this day dying in pain. They die with distressing symptoms like nausea, vomiting, and shortness of breath, and most of them do not have access to anyone who has vaguely been trained in advanced pain and symptom management or palliative care. We must never stop achieving our goal of eradicating suffering and pain.
What project are you working on right now that you’re most excited about?
Children’s Minnesota recently became the very first children’s hospital in the world to implement a Comfort Promise, which means doing everything possible to prevent and treat pain for every child, every time. A survey among our patients showed that what we did least well was prevent needle pain. To quote Joey Tribbiani [a character played by the actor Matthew LeBlanc on the hit TV show Friends], one of the most famous American philosophers of all time, "this is not rocket surgery."
There is strong evidence for four basic modalities we can apply to prevent, or at least significantly decrease, needle pain in children: 1) numbing cream; 2) sucrose or breastfeeding for infants younger than 12 months; 3) letting a child sit upright; and 4) distraction. Importantly, we never, ever hold a child down. By implementing this Comfort Promise we were able to change clinical practice in one of the largest children’s hospitals in the United States. As a result, staff turnover is decreased, patient satisfaction is up, and kids are less likely to become needle phobic. It’s a big deal.
What I’m most excited about right now is that we were just awarded a grant from The MAYDAY Fund to help four other children’s hospitals in Toronto, Montreal, Kansas City, and Atlanta to roll out a similar Comfort Promise process. My hope is that this eventually becomes the standard of care worldwide—that every single children’s hospital, every single pediatric clinic where kids experience elective needle procedures such as blood draws, vaccination, or injection, starts to use these modalities and stops holding kids down.
What do you hope pain research will tell us in the next five to 10 years that we don’t already know?
In the case of chronic pain and children with primary pain disorders, emerging data seem to support the notion that it becomes a self-fulfilling prophecy whether or not a child becomes pain free. If at the end of our interdisciplinary pain clinic intake, after the patients and their families have spent four hours with our team, we have convinced the child that he or she can become pain free, they overwhelmingly become pain free by enrolling into our rehabilitative active treatment program. On the day before we see them in our pain clinic, we ask our patients whether they think they will ever become pain free, and currently it’s only about 12 percent. After we spend about 90 minutes with the whole team of four clinicians together with the family in the same room at the same time, we split up, and the patient sees a physician or nurse practitioner, followed by a physical therapist, followed by a pain psychologist, while the parents spend time with a social worker/family therapist.
After lunch, we then provide what we lovingly call the "dog and pony show": a one-hour exit interview where we explain that their pain is real, that they’re not making this up, and that they’re not crazy. But they have to do the hard work first, including physical therapy, psychological therapy, getting back to school, and sleeping better, in order to make the pain go away; it’s not the other way around.
Currently, when we ask our patients again about their expectations for becoming pain free at the end of the clinic intake, we’re seeing it’s gone up to somewhere between 82 percent and 92 percent. There’s good adult data showing that this is probably a self-fulfilling prophecy. The vast majority of the kids we see do become pain free. I’m fascinated by what’s happening there, and I really want to understand how this real pain, which is so debilitating, actually seems to be eliminated through physical therapy, rehabilitation, group psychology, cognitive behavioral therapy, and the use of integrative non-pharmacological modalities.
You are a very psychologically minded pediatrician. How do you integrate pharmacological and non-pharmacological approaches in your practice?
Thank you—this means a lot coming from a pediatric pain psychologist. I truly believe that the only way to provide excellent pain control is to utilize multimodal analgesia. If there’s tissue injury, this may include basic analgesics such as ibuprofen, and paracetamol/acetaminophen. It may include weak opioids such as tramadol or strong opioids such as morphine or fentanyl. It may include adjuvant analgesics such as gabapentinoids, low-dose ketamine, alpha agonists, tricyclic antidepressants, sodium channel blockers, and so on. We may need nerve blocks or neuraxial analgesia.
But medications alone are never enough—they oversimplify the approach to a complex problem. Many kids with persistent pain display mental health issues such as anxiety or depression, either as a result of the pain or as part of an underlying condition, which requires cognitive behavioral therapy or a similar treatment. And of course, I’m highly excited about the use of mind-body techniques. I’m trained in self-hypnosis and use it basically every day with my patients; I use magic tricks for distraction, and it really helps. And there’s enough data supporting why this may work. Since I also use pharmacology, it helps to give me more credibility among my colleagues to at the same time also use deep breathing, biofeedback, bubble blowing, and self-hypnosis. This is better than me being the medication prescriber and telling the kids that for deep breathing they have to see someone else.
The problem is that some hospitals and pain services still feel that it’s all about numbing the pain, by just giving enough medication. This simply doesn’t work for many of our pediatric patients, even if they have post-operative pain, where this is the most common model of using medication only.
You also established and run the Pediatric Pain Master Class. What inspired you to do this, and what impact has it had so far?
When I came to the United States in 2005, I really wanted to go to an excellent pediatric pain crash course. But at the time, there wasn’t one. About two years later, a few colleagues asked me whether they could swing by and shadow me to learn from my approach to managing acute or chronic pain. So, to teach, I decided to have a course and invite the best people on the planet to come to Minneapolis. I thought maybe 10 people would come—our first year we had 36.
Over the years, it has developed from a five- to now a seven-day course. To the best of my knowledge, it’s the only course of its kind where people from all specialties come from all over the world—this year we had people from 10 different countries from five different continents—to get a crash course in pediatric pain management. And after seven days, you get a pretty good idea of what to do with 90 percent of the children inside a children’s hospital. The other 10 percent are difficult; there you arguably need a pain fellowship or specialist training.
We just finished our 11th Pediatric Pain Master Class this year. We have trained more than 650 clinicians from all six continents from more than 40 countries. It’s very cool and groovy to watch people getting excited to implement these changes when they go back home, and to truly change the world.
You aren’t afraid to engage with the media and talk about the problem of pain in children. But some scientists, especially at an early-career stage, worry about being misrepresented by the media. What’s your advice for young scientists?
Connect with somebody who has media training, or, even better, get some media training. Think about your take-home message and gently change the topic: If you ask me in this interview about a certain pain medication, and the one thing I want to hammer home is that you should never hold children down for needle pokes, I will make sure that I talk about that in the second sentence. You’ll hear politicians doing this all the time. Also, never tweet after 8 p.m. at a conference after you’ve had your first glass of wine!
Is there anything about you that people might be surprised to know?
Other than the fact that I’m happily married to a much smarter pediatrician than I am and that we have three amazing kids, most people may not know that I’m a Star Trek fan. Deep Space Nine is my favorite show. I’m happy anytime to have an hour-long conversation about any plots from Star Trek.
If you no longer did clinical work as part of your job and had more time for other things, what would you do instead?
I love to teach, and I love to teach how to teach. If we give a Grand Rounds presentation, if we actually teach something, how do we actually change behavior so it improves our patients’ healing? How do we not make it boring? I received, together with my co-investigators, a $1.6 million grant from the NIH to teach how to teach pediatric pain and palliative care; it’s called EPEC-Pediatrics. So other than going half-time and traveling much more with my kids and my family, I could see myself teaching how to teach in order to change behavior. I could also see myself doing much more on quality improvement projects such as the Comfort Promise to change hospital systems.
At the end of the day, I’d like to leave a footprint in the sand, as we all do, hoping that I can inspire the next generation of young interdisciplinary colleagues to do the right things and to do well in their careers. When I am eventually sitting in Costa Rica, on the beach with a nice drink in my hand, I hope once in a while to get a postcard from somebody for whom I have made a real difference.
