Shaping Practice and Policy Advancing the Canadian Pain Research Agenda

1. Shaping Practice and PolicyAdvancing the Canadian Pain Research Agenda Moderators: Jane Mealey, Janet Rennick Presenters: Celeste Johnston, Allen Finley, Patrick McGrath, Bonnie Stevens

2. Canadian Institutes of Health ResearchStrategic Training ProgramPain in Child HealthA 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. Have: Dal, UT, UBC, Usask, CW, HSC, IWK Need: MCH, McGill Other sponsors? www.dal.ca/~pich/

3. Pain in Pediatric Hospitals in Canada: What do we know? Celeste Johnston

4. Under-recognition of pain in children • Swafford & Allen, 1968 • 2/60 post-op children required Rx of pain • “..pediatric patients seldom need medication for the relief of pain. They tolerate discomfort well. The child will say that he does not feel well or that he is uncomfortable, that he wants his parents but often he will not relate his unhappiness to pain.”

5. Reverse Ageism in Pain Management • Eland (1974) > 13/25 post-op children received no analgesia; remaining 12 received a total of 24 doses (half opioid) • 18 post-op adults received 372 opioid and 299 non-opioid analgesics • Beyer et al (1983)> post-cardiac surgery, children received 30% of opioid doses • Schechter et al (1986)> 90 children/90 adults with identical diagnoses: adults received twice the number of opioid doses • Asprey (1991) replicated Eland’s study and found 968 analgesics given instead of 24

6. Pain in Hospitalized Patients in Canada age 4-14 yearsJohnston et al 1992 • 150 children surveyed • 87% had pain in the last 24 hours • 57% reported clinically significant pain • 19% reported usual pain intensity in the severe range • 38% had received analgesics • only half reporting usual or worst pain as severe received analgesic • 63% of surgical patients vs 23% medical patients received medication even though intensity was similar

7. Pain in Hospitalized Pediatric Post-Op Patients Bennett-Branson & Craig, 1993 • 60 Children 7-16 years • Current pain 5.1/10 • Worst 8.8/10

8. Pain in Hospitalized Pediatric Patients Cummings, Reid, Finley, McGrath, 1996 • 200 children • Aged >5, self reported • 21% had clinically significant usual pain • 49% had clinically significant worst pain • Given less medication than Rx: over half reporting clinically significant pain did not receive analgesics

9. Pain in Hospitalized Pediatric Patients: How Are We Doing?Ellis et al 2002 • 237 Children 10 days -17 years • Parents surveyed < 7 yrs • Sampled q2h • 21-30% had clinically significant pain at every assessment • No difference between medical and surgical patients • Difference > over time? Between sites?

10. 2004 Data from same site n=76 charts

11. Emergency Department Study (Johnston et al, under review) • Mean pain score on admission 3.29, 9% severe (8-10) • Mean pain on discharge 2.98, 7% severe (8-10) • 20% improved by 1.5/10 points but • 11% worsened by 1.5/10 • 5% who had no pain on admission, had pain on discharge

12. Pediatric Oncology PatientsMcGrath et al, 1990 • 77 oncology outpatients aged 2-9 • 75% severe pain from bma • 50% mod-severe pain from treatment • 25% pain from disease

13. Consequences of Previous Pain Experience • Less the number than the quality (Bittebier & Vertommen, 1998) • Cancer survivors remember painful procedures, not the disease (Kuttner, 2002) • Chronic pain intensity related to anxiety, depression, self-esteem, and behaviour problems (Varni et al, 1996) • One week after visit to ED, children are reporting higher scores of distress from pain than intensity of pain • Number of invasive procedures predicts negative psychological sequellae (Rennick, 2002)

15. Youngest of the Young • 26-32 weeks: excitatory mechanisms in place but inhibitory mechanisms not • Numerous painful procedures • US (Franck, 1987; Anand,1996) • UK (Barker & Rutter, 1995) • Australia (McLaughlin, 1993) • Canada (Fernandez & Rees,1994; Johnston et al, 1997)

16. Prospective Canadian NICU Survey Johnston et al, 1997 • 14/38 NICU’s participated in 1 week survey of patients with dx other than prematurity: 239 • 2134 invasive procedures performed: 35 procedures had medication orders; 7/35 were non-analgesic sedatives • 1/28 LP’s and 3/5 chest tube insertions given anesthesia

17. Consequences of pain in NICU • Fitzgerald et al (1989). Decreased flexor tension reflex following repeated heelstick- reversed with EMLA • Johnston & Stevens (1996). Increased # procedures related to less robust, i.e. less mature behaviour • Johnston et al (1999). Time between procedures affects response • Grunau et al (2000). Analgesics associated with more robust behaviour

18. Where is the Problem?

19. COOPPPN (2001-2003): • 6 pediatric hospitals in Canada • Charts reviewed for pain assessments and management • Nurses knowledge and attitude about pain (Manwarren, 2001) • Hospitals matched on assessment scores and randomly assigned to bi-weekly one-to-one coaching or control

20. Nurses Knowledge *** p<.06

21. % Patients Documented Assessment *** *

22. % Documented Non-Pharmacological Interventions *** *

23. Pain Practices Cross-Canada Pediatric OncologyEllis et al, 2003 • 26/28 pediatric oncology centres (10/11 pediatric hospitals included) • 48 questions on: • Pain assessment and documentation • Procedural pain • Treatment related pain • Patient education and home care • Staff education • Institutional support for best practice pain management • Complementary therapies • Palliative and end-of-life care • Demographics

24. Centre-reported Results • All used assessment scales, 62% numerical scale, 39% visual analogue scale • 15/26 centres reported pain assessed 80% of the time • 11/26 reported pain adequately treated 80% of the time or better • For BMA’s and LP’s 50% used local anesthetics • Midazolam used 77%, propofol 54% ketamine 35% , lorazapam 23% • 20/26 report 90% patients have venous access device

25. Does self-report reflect practice? • Nurses great overestimate their use of assessment and interventions (Jacob & Puntillo, 1999). • Belief that oncology patients’ pain is better managed: not borne out in data

26. Conclusions • Appear to be improvements over the past decade • Even recent data reveals significant unde-rmanagement of pain in children • How can pain management be improved for children coming to hospital?