Shaping Practice and PolicyShaping Practice and PolicyAdvancing the Canadian Pain Advancing the Canadian Pain

Research AgendaResearch Agenda

ModeratorsModerators: Jane Mealey, Janet : Jane Mealey, Janet RennickRennick

Presenters: Presenters: Celeste Johnston, Allen Celeste Johnston, Allen Finley, Patrick McGrath, Bonnie Finley, Patrick McGrath, Bonnie

StevensStevens

Canadian Institutes of Health ResearchCanadian Institutes of Health Research

Strategic Training ProgramStrategic Training Program

Pain in Child HealthPain in Child HealthA Cross-Canada Research Training ConsortiumA Cross-Canada Research Training Consortium

Principal Investigators:

Patrick McGrath, Ken Craig, Allen Finley, Celeste Johnston, Bonnie Stevens, Carl von Baeyer

Research mentors:

Over 30 active researchers in five centers with a shared focus on pediatric pain

Goal:

To develop a community of scholars in pediatric pain

Activities for Trainees in Pain in Child Health:

• Visits to other labs • Web based courses on pain• Annual summer/fall institute • International speakers series

• Supplementary funding for support of trainees • National lab meeting by means of web distance tools

Trainee membership in the consortium is open to people with a commitment to the study of pain in child health in Canada, in any discipline and at any level in their training.

Membership makes trainees eligible for (but does not guarantee) financial assistance. The major training centres are Halifax, Montreal, Toronto, Saskatoon and Vancouver.

www.dal.ca/~pich/

Have: Dal, UT, UBC, Usask, CW, HSC, IWKNeed: MCH, McGillOther sponsors?

Pain in Pediatric Hospitals Pain in Pediatric Hospitals in Canada: What do we in Canada: What do we

know?know?

Celeste JohnstonCeleste Johnston

Under-recognition of pain in Under-recognition of pain in childrenchildren

Swafford & Allen, 1968Swafford & Allen, 1968 2/60 post-op children required Rx of pain2/60 post-op children required Rx of pain ““..pediatric patients seldom need ..pediatric patients seldom need

medication for the relief of pain. medication for the relief of pain. They They tolerate discomfort well.tolerate discomfort well. The child will say The child will say that he does not feel well or that he is that he does not feel well or that he is uncomfortable, that he wants his parents uncomfortable, that he wants his parents but often he will not relate his but often he will not relate his unhappiness to pain.”unhappiness to pain.”

Reverse Ageism in Pain Reverse Ageism in Pain ManagementManagement

Eland (1974) > 13/25 post-op children Eland (1974) > 13/25 post-op children received no analgesia; remaining 12 received no analgesia; remaining 12 received a total of 24 doses (half opioid)received a total of 24 doses (half opioid)

18 post-op adults received 372 opioid and 18 post-op adults received 372 opioid and 299 non-opioid analgesics299 non-opioid analgesics

Beyer et al (1983)> post-cardiac surgery, Beyer et al (1983)> post-cardiac surgery, children received 30% of opioid doseschildren received 30% of opioid doses

Schechter et al (1986)> 90 children/90 Schechter et al (1986)> 90 children/90 adults with identical diagnoses: adults adults with identical diagnoses: adults received twice the number of opioid dosesreceived twice the number of opioid doses

Asprey (1991) replicated Eland’s study and Asprey (1991) replicated Eland’s study and found 968 analgesics given instead of 24 found 968 analgesics given instead of 24

Pain in Hospitalized Patients in Canada Pain in Hospitalized Patients in Canada age age

4-14 years4-14 yearsJohnston et al 1992Johnston et al 1992 150 children surveyed150 children surveyed

87% had pain in the last 24 hours87% had pain in the last 24 hours 57% reported clinically significant pain57% reported clinically significant pain 19% reported usual pain intensity in the 19% reported usual pain intensity in the

severe rangesevere range 38% had received analgesics38% had received analgesics only half reporting usual or worst pain as only half reporting usual or worst pain as

severe received analgesicsevere received analgesic 63% of surgical patients vs 23% medical 63% of surgical patients vs 23% medical

patients received medication even patients received medication even though intensity was similarthough intensity was similar

Pain in Hospitalized Pediatric Post-Op Pain in Hospitalized Pediatric Post-Op Patients Patients

Bennett-Branson & Craig, 1993Bennett-Branson & Craig, 1993

60 Children 7-16 years60 Children 7-16 years Current pain 5.1/10Current pain 5.1/10 Worst 8.8/10 Worst 8.8/10

Pain in Hospitalized Pediatric Pain in Hospitalized Pediatric Patients Patients

Cummings, Reid, Finley, McGrath, 1996Cummings, Reid, Finley, McGrath, 1996

200 children 200 children Aged >5, self reportedAged >5, self reported 21% had clinically significant usual 21% had clinically significant usual

painpain 49% had clinically significant 49% had clinically significant

worst painworst pain Given Given less less medication than Rx: medication than Rx:

over half reporting clinically over half reporting clinically significant pain did not receive significant pain did not receive analgesics analgesics

Pain in Hospitalized Pediatric Patients: Pain in Hospitalized Pediatric Patients: How Are We Doing?How Are We Doing?

Ellis et al 2002Ellis et al 2002

237 Children 10 days -17 years237 Children 10 days -17 years Parents surveyed < 7 yrsParents surveyed < 7 yrs Sampled q2hSampled q2h 21-30% had clinically significant 21-30% had clinically significant

pain at every assessmentpain at every assessment No difference between medical No difference between medical

and surgical patientsand surgical patients Difference > over time? Between Difference > over time? Between

sites? sites?

2004 Data from same site 2004 Data from same site n=76 chartsn=76 charts

No Pain Mild Moderate Severe Missing N/A

BPIpainnowgrouped

0

10

20

30

40

Percent

24.36%

2.56%

24.36%

3.85%

35.9%

8.97%

Emergency Department Study Emergency Department Study (Johnston et al, under review)(Johnston et al, under review)

Mean pain score on admission 3.29, Mean pain score on admission 3.29, 9% severe (8-10)9% severe (8-10)

Mean pain on discharge 2.98, 7% Mean pain on discharge 2.98, 7% severe (8-10)severe (8-10)

20% improved by 1.5/10 points but20% improved by 1.5/10 points but 11% worsened by 1.5/1011% worsened by 1.5/10 5% who had no pain on admission, 5% who had no pain on admission,

had pain on dischargehad pain on discharge

Pediatric Oncology PatientsPediatric Oncology PatientsMcGrath et al, 1990McGrath et al, 1990

77 oncology outpatients aged 2-977 oncology outpatients aged 2-9 75% severe pain from bma75% severe pain from bma 50% mod-severe pain from 50% mod-severe pain from

treatmenttreatment 25% pain from disease25% pain from disease

Consequences of Previous Pain Consequences of Previous Pain ExperienceExperience

Less the number than the quality (Bittebier & Less the number than the quality (Bittebier & Vertommen, 1998)Vertommen, 1998)

Cancer survivors remember painful procedures, Cancer survivors remember painful procedures, not the disease (Kuttner, 2002)not the disease (Kuttner, 2002)

Chronic pain intensity related to anxiety, Chronic pain intensity related to anxiety, depression, self-esteem, and behaviour depression, self-esteem, and behaviour problems (Varni et al, 1996) problems (Varni et al, 1996)

One week after visit to ED, children are reporting One week after visit to ED, children are reporting higher scores of distress from pain than intensity higher scores of distress from pain than intensity of pain of pain

Number of invasive procedures predicts negative Number of invasive procedures predicts negative psychological sequellae (Rennick, 2002)psychological sequellae (Rennick, 2002)

Youngest of the YoungYoungest of the Young

26-32 weeks: excitatory mechanisms 26-32 weeks: excitatory mechanisms in place but inhibitory mechanisms notin place but inhibitory mechanisms not

Numerous painful procedures Numerous painful procedures US (Franck, 1987; Anand,1996)US (Franck, 1987; Anand,1996) UK (Barker & Rutter, 1995)UK (Barker & Rutter, 1995) Australia (McLaughlin, 1993)Australia (McLaughlin, 1993) Canada (Fernandez & Rees,1994; Canada (Fernandez & Rees,1994;

Johnston et al, 1997) Johnston et al, 1997)

Prospective Canadian NICU Prospective Canadian NICU Survey Survey

Johnston et al, 1997Johnston et al, 1997

14/38 NICU’s participated in 1 week 14/38 NICU’s participated in 1 week survey of patients with dx other than survey of patients with dx other than prematurity: 239prematurity: 239

2134 invasive procedures performed: 2134 invasive procedures performed: 35 procedures had medication orders; 35 procedures had medication orders; 7/35 were non-analgesic sedatives 7/35 were non-analgesic sedatives

1/28 LP’s and 3/5 chest tube 1/28 LP’s and 3/5 chest tube insertions given anesthesiainsertions given anesthesia

Consequences of pain in Consequences of pain in NICUNICU

Fitzgerald et al (1989)Fitzgerald et al (1989). Decreased flexor . Decreased flexor tension reflex following repeated heelstick- tension reflex following repeated heelstick- reversed with EMLA reversed with EMLA

Johnston & Stevens (1996). Johnston & Stevens (1996). Increased # Increased # procedures related to less robust, i.e. less procedures related to less robust, i.e. less mature behaviourmature behaviour

Johnston et al (1999). Johnston et al (1999). Time between procedures Time between procedures affects responseaffects response

Grunau et al (2000).Grunau et al (2000). Analgesics associated with Analgesics associated with more robust behaviourmore robust behaviour

Where is the Problem? Where is the Problem?

COOPPPN (2001-2003):COOPPPN (2001-2003):

6 pediatric hospitals in Canada6 pediatric hospitals in Canada Charts reviewed for pain assessments Charts reviewed for pain assessments

and managementand management Nurses knowledge and attitude about Nurses knowledge and attitude about

pain (Manwarren, 2001)pain (Manwarren, 2001) Hospitals matched on assessment Hospitals matched on assessment

scores and randomly assigned to bi-scores and randomly assigned to bi-weekly one-to-one coaching or controlweekly one-to-one coaching or control

Nurses KnowledgeNurses Knowledge

60

62

64

66

68

70

72

74

76

Pre-intervention Post-intervention

ExperimentalControl

***

p<.06

% Patients Documented % Patients Documented AssessmentAssessment

0

10

20

30

40

50

60

Pre-intervention Post-intervention

ExperimentalControl*

***

% Documented Non-% Documented Non-Pharmacological InterventionsPharmacological Interventions

0

2

4

6

8

10

12

14

16

18

Pre-intervention Post-intervention

ExperimentalControl

*

***

Pain Practices Cross-Canada Pain Practices Cross-Canada Pediatric OncologyPediatric Oncology

Ellis et al, 2003 Ellis et al, 2003

26/28 pediatric oncology centres (10/11 26/28 pediatric oncology centres (10/11 pediatric hospitals included)pediatric hospitals included)

48 questions on:48 questions on: Pain assessment and documentationPain assessment and documentation Procedural painProcedural pain Treatment related painTreatment related pain Patient education and home carePatient education and home care Staff educationStaff education Institutional support for best practice pain Institutional support for best practice pain

managementmanagement Complementary therapiesComplementary therapies Palliative and end-of-life carePalliative and end-of-life care DemographicsDemographics

Centre-reported ResultsCentre-reported Results

All used assessment scales, 62% numerical All used assessment scales, 62% numerical scale, 39% visual analogue scalescale, 39% visual analogue scale

15/26 centres reported pain assessed 80% of 15/26 centres reported pain assessed 80% of the time the time

11/26 reported pain adequately treated 80% 11/26 reported pain adequately treated 80% of the time or betterof the time or better

For BMA’s and LP’s 50% used local For BMA’s and LP’s 50% used local anestheticsanesthetics

Midazolam used 77%, propofol 54% Midazolam used 77%, propofol 54% ketamine 35% , lorazapam 23% ketamine 35% , lorazapam 23%

20/26 report 90% patients have venous 20/26 report 90% patients have venous access deviceaccess device

Does self-report reflect Does self-report reflect practice? practice?

Nurses great overestimate their use Nurses great overestimate their use of assessment and interventions of assessment and interventions (Jacob & Puntillo, 1999).(Jacob & Puntillo, 1999).

Belief that oncology patients’ pain is Belief that oncology patients’ pain is better managed: not borne out in better managed: not borne out in datadata

ConclusionsConclusions

Appear to be improvements over the Appear to be improvements over the past decadepast decade

Even recent data reveals significant Even recent data reveals significant unde-rmanagement of pain in unde-rmanagement of pain in childrenchildren

How can pain management be How can pain management be improved for children coming to improved for children coming to hospital? hospital?