Misconception_in_Pain_Management

There exist among a significant portion of the medical community views that infants and young children do not experience pain in the same way or to the same degree as adults. (Kline, Turnbull, Labruna, Haufler, DeVivio, & Ciminera, 2010).This view dates back many years (Howard, 2003) and is based on a number of misconceptions including a belief that the nervous systems of children are different and they do not experience pain to the same degree as an adult, (Mahay, 2009; “Control of Pain in Children (Paediatric Pain Management),” 2006) and that even if pain is experienced it will be transient and the patient will not remember it (Shepard, 2008; McClain, & Kain, 2005). This is contradicted by recent studies that have identified that neonates may have a greater sensitivity to pain than adults and experience numerous ongoing problems and trauma from pain that is not adequately controlled. Other issues and outdated opinions also impact on the provision of appropriate pain management, with some options for pain relief such as the use of narcotics being considered to be inappropriate for children, based on discredited beliefs that children are more prone to addiction or respiratory depression (Walco, Burns, & Cassidy, 2003; Mahay, 2009) and views that pain will prevent a patient worsening an injury, or that pain relief will make diagnosis more difficult. Frequently the provision of pain relief is dismissed as taking to much time, or is simply not considered because staff views the procedure as routine, and routinely fail to provide pain relief. The situation is exacerbated by the inability of infants and young children to advocate on their own behalf, or even to indicate the presence or level of pain they are experiencing (Mahay; “Control of Pain in Children (Paediatric Pain Management),” 2006; Howard, 2003). Recent studies have indicated that pain experienced by infants and young children has an effect on the development of the nervous system and the immune system, resulting in long lasting physical effects, and in some cases mental and emotional problems (Howard, 2003; Shepard, 2008; Kline et al., 2010). The cumulative result is often a failure to manage pain in infants and young children, to the detriment of the patients’ immediate treatment and recovery, and with possible long term negative health outcomes for the patient and the immediate family (Howard, 2003; Kline et al., 2010; Turner, H.N. 2005). Assessing pain in infants and young children is difficult. Infants are not capable of verbalising their pain, (Mahay, 2009) and even older children often cannot communicate in a way that is comparable to the terms and descriptors used and understood by adults (American Medical Association, 2010). Several methods have been developed to assess pain in infants and young children, “with at least 20 different pain scales in existence for infants alone” (Howard, 2003, p.2465) in common use within medical facilities. These scales are dependant on the attending medical staff having both the skills and the time to perform the necessary evaluation (Ellis, McCleary, Blouin, Dube, & Rowley, 2007). Even where the practitioner is highly skilled, individual variations between paediatric patients may result in less than adequate assessments. Macintyre, Schug, Scott, Visser & Walker, 2010). It has been found that in older children self reporting is more accurate than observation scales (“Control of Pain in Children (Paediatric Pain Management),” 2006). This may demonstrate limitations with the scale that simply cannot be identified without some degree of patient input, which is unavailable from infants. In addition to these pain assessment scales, one commonly used method of pain assessment relies on physiological measurements. This method negates to some degree the need for the patient to describe or detail their pain, and as such is considered a more accurate and reliable method of determining pain levels, however such measurements may not provide a satisfactory level of accuracy in determining the pain being experienced, due to the bodies natural tendency to correct physiological imbalances via homeostatic mechanisms. (Howard, 2003) The view of Gerik (2005) is that “Physiological measures (eg, heart rate and blood pressure) are helpful as adjuncts to self-report and behavioural observations. They are neither sensitive nor specific as indicators of pain.”(p. 297) and further note that “Clinicians frequently use vital signs as an adjunct to pain assessment, although little evidence exists to support the practice” (p. 297). Maccagno (2009) identifies that where infants or young children cannot verbalise their own pain level parents and carers are often better placed to identify pain and distress in their own children due to the closer relationship and extended contact between them. This results in a greater understanding of the patients “normal” state and the ability to detect subtle changes, and to relate these changes to potential causes based on previous experience. Other studies support this assertion (Gerik, 2005). Another area identified as problematic in paediatric pain management is the stratification of medical services in most facilities (Simons, van Dijk, Anand, Roofthooft, van Lingen, &Tibboel, 2003). A number of studies have found differences in how medical practitioners rate the pain of various procedures, with nurses more likely to rate procedures as being more painful than the ratings given by doctors. Simons et al. (2003) postulates that as doctors are responsible for prescribing medication, this variation may in part account for the lack of analgesia provided. Simons et al. also identified that only 59.9% of surveys rating the pain of procedures were returned, and postulates that those not responding may believe that pain is not an issue for patients in the neonatal age group. The importance of familiarity and experience in detecting pain in the very young is highlighted by Gerik (2005). This demonstrates the need to consult with and take notice of primary carers in relation to patient care for the very young. In almost all instances the nurse will have considerably greater patient contact, and may develop a greater understanding of each patients baseline, leading to a better recognition of stress and pain while the decisions relating to pain relief are vested in the attending physician or specialist, who will spend negligible time with each patient and therefore may not recognise subtle changes in behaviour (Turner, 2005). In some instances it is postulated that pain relief may be deliberately withheld. A number of reasons for this have been suggested, pain relief is sometimes withheld in the mistaken belief that further diagnostic assessment may be more difficult if pain is masked. Shepard (2008) indicates that painful conditions are not masked by providing even strong pain relief, and diagnostics relying on a pain response can be conducted after administering pain relief. Concerns about respiratory depression persists, although as discussed by Walco et al., (2003) this side effect is not as common as is often supposed, and this unwanted effect can be monitored and corrected in almost all cases. Concerns about addiction continue to influence physicians in the area of pain relief, with a survey by Walco et al indicating 39% of physicians were concerned about addiction in young patients. Walco et al., (2003) identifies a number of justifications used by some to withhold pain relief, including the view that pain is serving some useful purpose, for example discouraging the patient from overusing the damaged area, or even a moral view that pain helps develop character, and as such should be allowed to continue. Walco et al. describes these approaches as “ethically questionable at best” (p165) and indicates that if total pain relief is unachievable or contraindicated, then the goal should be to manage pain at “the lowest possible level.”(p165). The development of chronic pain management services (Howard; Peng, Stinson, Choiniere, Doin, Intrater, LeFort, Lynch, Ong, Rashiq, Tkachuk, & Veillette, 2007) is one method of addressing the issue of pain management in infants and young children. This approach has been developed in a number of paediatric centres around the world (Howard; Peng, et al.) but is not widespread. This approach aims to reduce the problem by the use of multidisciplinary pain management teams as supported by Simons, Logan, Chastain, Cerullo, (2010) and The Department of Human Services (2008). Although Taylor et al. (2008) indicates that even where such a service exists it was only accessed by a small percentage of patients, and that patient who were managed by this Acute Pain Service, although receiving more analgesics, also reported more pain, suggesting that even when those most in need were managed by a multidisciplinary pain team, effective pain management was not being achieved. In some centres non-pharmacological methods are being investigated for pain management. These may include hypnosis, cognitive behavioural therapy, deep breathing and relaxation exercises, distraction, suckling, sucrose, multisensory stimulation of babies, play, and transcutaneous nerve electrical stimulation. (“Control of Pain in Children (Paediatric Pain Management): 2006; Gerik, 2005; Butler, Symons, Henderson, Shortliffe, & Spiegel, 2005). While all these techniques have been shown to assist in pain management, (Howard, 2003) identifies that it is important when implementing a pain management system to recognise the need for pharmacological as well as alternate strategies. A lack of consistency in analgesics use was also found, with medication described as “intermittent”. It was noted that surgical patients and those being managed by dedicated pain management teams were more likely to receive scheduled pain relief, (Taylor, et al. 2008), although it was identified that this higher medication was not necessarily effective in managing individual patient pain (Taylor, et al. 2008). Walco et al. (2003) identifies one reason for the inadequacy of pain management being an “assumption that there is (or should be) a uniform responce to a given pathophysiologic condition or pain stimulus”(p. 158) and says “many care providers continue to ignore the individual child and provide treatment based on their idea of the ‘appropriate’ child”(p. 158) This is also supported by Walco et al. (2003). Taylor, Boyer, & Campbell (2008) found that “surgical patients were more likely than medical patients to have their pain assessed and more likely to receive analgesics”(p.30) and also indicated that children who had undergone surgery were three to four times more likely to have received opioids than non-surgical patients with similar pain intensity. Howard (2003) and Ely (2001) identified a number of difficulties in changing clinical practice. These difficulties included a lack of authority for staff to make changes in their work practices, and a lack of control to affect changes across their department or facility. Many of the reports identified insufficient funding and a lack of resources, combined with a need for additional training and education for staff. While these areas may be a potential source of difficulty in implementing evidence based practice, these same studies frequently indicate that the problems and solutions are known to staff, and the resources are available (Walco et al. 2003; Dowden, McCarthy, & Chalkiadis, 2008). The problem remains, bringing into question the call for additional resources and education. In the article “Achieving organisational change in pediatric pain management” Dowden et al., (2008) clearly identifies poor utilisation of topical anaesthetic creams to manage pain of procedures involving needles, even though they were available and staff were aware of there purpose. Dowden et al. then include in their conclusion a table indicating the use of educational posters to promote this management tool. This is indicative of one of the major impediments to introducing new evidence based methods into clinical practice, for although the method is already available and well known by staff it is not being utilised. This supports the views of Walco et al. (2003), being that education and knowledge is not resulting to changes in behaviour among medical practitioners. In their conclusions Simons et al. (2003) call for “systematic approaches” (p.1058) and recommend “continuous intravenous infusion of opioids”(p.1061) for infants undergoing certain treatments. They state that “clinicians estimated that most neonatal intensive care unit procedures are painful, but only a third of the neonates received appropriate analgesic therapy” (p.1058). Walco et al. (2003) supports this view and the tone of their conclusion suggests frustration, as although the evidence of neonates experiencing pain and with increasing evidence of ongoing problems where such pain is not managed appropriately, clinical practice continues to fail in meeting the needs of pain control in paediatric settings. Ely (2001) found in a trial where postoperative pain assessments were conducted on a regular structured basis there was no significant improvement in pain management, with 25% of patients receiving no analgesia, and a further 25% receiving inadequate analgesia, mirroring the control group. Furthermore, while oral medication was available, intramuscular injection was used for some of the analgesic administration, adding to the pain and distress. The inference from this study is that requiring nurses to carry out mandated pain assessments, while identifying and documenting patient pain, would not improve pain management practices. Ely (2001) found in a study of 260 experienced paediatric nurses that their own institution’s pain assessment tool was only used by less then 33% of the working nurses. Also “developmentally appropriate pain assessment tools” (p, 473) were not being utilised. Similarly Walco et al., (2003) identifies that while there are published guidelines based on recent data and ongoing educations in the field of pain management in children, these strategies are not sufficient to change physicians’ behaviour. Walco et al. calls for regulation, in the form of administrative interventions and set protocols for pain management. Approaches generally promoted for changing clinical practice in accordance with new advances and evidence based methods rely on education and promotion within the workplace. In many of the studies considered here staff appears to be aware of the issues, suggesting education and awareness is not the cause of poor practice. Similarly, in several instances adequate resources appear to be provided, but staff fails to utilise them, although they appear to be familiar with them. While many medical practitioners claim to be aware of and can describe new evidence based methodology, being able to relate this to pre-existing paradigms and outdated practices, best practice is not being achieved, and patients continue to suffer substandard care. One concerning aspect of the study by Dowden et al., (2008) is the way they firstly identify that staff are all aware of the problems, but in the conclusions suggest continued or increased education and awareness will correct the problem. Given that the shortcomings were exposed by staff interviews, and that in some instances staff are well aware of procedures and resources to alleviate pain, but still fail to utilise them, this approach cannot be considered scientific or evidence based. The problem appears to be one of staff attitudes and resistance to change rather than a lack of knowledge or resources. This supports the views of Simons et al. (2003) and Walco et al. (2003) and suggests that staff may not implement new strategies unless forced to do so. In attempting to bring about changes to pain management practices within the paediatric field the commonly used methods of education, promotion, resourcing and awareness campaigns have been shown in multiple studies to be ineffective in changing the practices being employed, although these same studies show that the underlying beliefs responsible for poor pain management are being recognised as obsolete or discredited by many of the medical practitioners involved. Given that the problem has been identified, researched and discussed for over 2 decades without significant changes to practice (Ely, 2001) coercive methods such as those proposed by Walco et al. (2003) may be the most appropriate for effecting the changes needed if paediatric patients and their carers are to receive appropriate treatment for pain within the medical system. Pressure through medical associations and patient advocacy groups may result in legislated standards tied to accreditation. Pressure on individual facilities may result in policies defining minimum standards of patient care in relation to pain management, although Walco et al. identified that this does not necessarily result in improved treatment, even when specific assessments are introduced via policy and procedures. Education of patients and, for this age group, their carers is one approach that could be used, but given the poor standards currently being provided, an educated patient base may come to distrust their medical providers, and conflict may result where patients carers demand unachievable levels of pain management in specific cases.