President's Letter

D ear Members and Friends,

The Canadian Pain Coalition is pleased to release, during National Pain Awareness Week, November 6-12, 2016, this special newsletter focusing on Adult Immunization.  In this edition we are connecting immunization with benefits to pain prevention and management that will provide information for Canadian adults who live with chronic pain, caregivers, and family members.  CPC anticipates that health professionals may find it helpful as a resource for their patients. 

In this edition, we highlight the immunizations that are available for Canadian adults, explore the fact that 10 percent of adults may not become immunized because of their fear of needle pain, and steps that can be taken to reduce a painful injection experience.  We also connect parents to resources that will help them to reduce negative injection pain experiences for their children as prevention to developing fear of immunization in adulthood.

CPC is pleased to highlight Ontario's recently launched immunization program for herpes zoster (shingles) and to provide information about shingles and postherpetic neuralgia through YouTube video links, government resources, and by re-introducing CPC's updated section on the Pain Resource Centre. 
CPC was most fortunate to have a great deal of assistance in producing this newsletter.  I gratefully acknowledge the support of our contributors who you will meet within the segments, our medical
reviewer for herpes zost er  materials, Dr. Peter Watson, our advisory team members, Dr. Joel Katz and Janice Sumpton, and sponsorship towards this newsletter from Merck Canada.

As always, I remind our readers that the intent of CPC's newsletter is to provide pertinent and helpful information relating to pain and pain issues. The CPC does not endorse, support or recommend any treatment, product, theory or person for our readers.

In my involvement with this project, I realized that the business of adult life can distract a person from remembering to obtain the immunizations that are available to us and can support our continued health and well-being.

I encourage our readers to speak with their health care providers about what immunizations are right for you at what time in your life.
Lynn Cooper,  President
Lynn Cooper receives flu shot from Muhammad Mairaj Naveed, a pharmacist, associate/owner
at Shoppers Drug Mart, Kitchener
Lynn Cooper Says: "Having the flu is not a pleasant experience and the symptoms can make my daily pain much worse. I get my flu shot every year as part of the healthy living part of my pain management plan.
Speak with your Doctor  about if the flu
 shot is right for you.
Reasons for Canadians Living With Daily Pain to Consider Adult Immunization
There are important reasons for the 1 in 5 Canadian adults living with chronic pain, care givers and family members to be aware and consider immunization.
  • Maintaining overall health as an important part of a well-rounded pain management plan that support a healthy, productive lifestyle while living with daily pain
  • Preventing/reducing  other health concerns that add to the burden of chronic pain and may increase the experience of pain
  • Preventing acute pain and chronic pain from diseases like herpes zoster, shingles  (acute) and postherpetic neuralgia (chronic neuropathic pain)
  • Helping to maintain healthy communities by reducing the spread of preventable diseases
  • Other important reasons from Immunize Canada's       Ten Top Reasons to Ask About Adult Immunization
Many Canadian adults are under immunized and are not aware of the vaccinations that are available to them. As part of our mandate to provide educational opportunities towards improved pain management, health , and well-being for Canadians impacted by chronic pain, CPC is providing information that may address common questions about immunization.   These include who should be vaccinated, what vaccines are available, when in adult life to be immunized, where to be vaccinated and why immunize.  

CPC reminds readers to consult with a health care provider and public health unit with health questions about immunization. 

CPC is providing links to government resources below. We gratefully acknowledge the assistance provided by Lucie Marisa Bucci, Senior Manager, Immunize Canada, for links to helpful information on this topic. 

Government Information About Immunization:
Public Health Agency of Canada: Vaccination of Adults: 

Public Health Agency of Canada: Provincial and  T erritorial Immunization Information:

Immunize Canada Information:
Canadian Pain Coalition Disclaimer, 2016
CPC's Newsletter is intended to provide pertinent and helpful information relating to pain and pain issues. The CPC does not endorse, support or recommend any treatment, product, theory or person for our readers.

Anna Taddio PhD, Professor, Leslie Dan Faculty of Pharmacy, University of Toronto, Senior Associate Scientist, The Hospital for Sick Children;  C. Meghan McMurtry, PhD, C.Psych, Assistant Professor, Department of Psychology, University of Guelph, Psychologist, Pediatric Chronic Pain Program, McMaster Children's Hospital;  Susan Bowles, PharmD, MSc, Associate Professor, College of Pharmacy Dalhousie University 

Most vaccinations are delivered via needle and are thus associated with pain. Although onset tends to be in early childhood, fear of needles is a relatively common concern across the lifespan. One survey including approximately 1000 adults and children found that 24% of adults and 63% of children had some degree of fear about needles (Taddio et al., 2012). Critically, approximately 10% of adults are estimated to avoid vaccinations due to concerns about pain and fear. Needle fear exists on a spectrum from low, normative levels to very high levels associated with significant distress or impairment; individuals at the severe end of the spectrum may meet diagnostic criteria for Blood Injection Injury phobia which is found in approximately 3-5% of the population (McMurtry et al., 2015). However, it is clear that even if a phobia is not present, fear of needles can still impact functioning. There are likely multiple factors which interact to create needle fear but a negative experience is commonly reported by those with a high level of needle fear (McMurtry et al., 2015). Experiencing unmanaged pain could be such an experience.

Recently, Help Eliminate Pain in Kids & Adults, HELPinKids&Adults (, a collaborative group of researchers, clinicians, policy makers, and consumers involved in knowledge translation activities related to pain and fear during immunization undertook a review of this topic. From this work, specific recommendations were made for managing pain and fear across the lifespan. The recommendations were organized into domains of pain management, the 4P's, as follows: Procedural, Pharmacological, Physical, and Psychological. Interventions from each of these categories that can be used for vaccine injections in adults are reviewed below [please see the original guideline for recommendations for other age groups]. Some of the interventions can be administered by immunizers, while others can be self-administered.

Procedural interventions
Do Not Aspirate for Intramuscular Vaccine Injections
■   Aspiration during injections involves pulling back on the needle prior to injecting the vaccine into the muscle.  This increases pain due to longer dwelling time of the needle in the tissue and wiggling of the needle during the aspiration process. Aspiration is not necessary for vaccine injections because of the lack of major blood vessels in sites used for injection.

Administer the most painful vaccine last when multiple injections are being given sequentially
■   Some vaccines are more painful than others (e.g., pneumococcal conju gate). As pain intensifies with each injection, administering the most painful vaccine first sets a higher pain level to start, causing the overall immunization experience to be more painful. So it is best to administer the most painful injection last. 

Apply Topical Anesthetics
■   Topical anesthetics block transmission of pain signals from the skin and reduce the pain associated with needle-procedures. These agents require some planning in that they need to be applied 30 to 60 minutes (depending on the product) ahead of time to the site of injection. Importantly, while these products reduce immunization-associated pain, they do not prevent the sense of pressure when a vaccine is administered. Patients should be advised of this prior to the injection

Use Upright Positioning
■   Positioning is an important aspect of reducing distress related to vaccination.  Sitting upright promotes a sense of control, resulting in a reduction in fear and distress.
Use Muscle Tension
■  For individuals with a history of fainting or feeling dizzy during needle procedures, a simple technique called muscle tension can be used (Öst & Sterner, 1987). Large muscle groups (e.g., abdomen, legs, arm contralateral to injection site) are tensed for 15-20 seconds until a flush is felt in the face and then released (i.e., not relaxed, just back to baseline). This is repeated before, during, and after the procedure until no longer feeling dizzy. The proposed mechanism behind this technique is elevation in blood pressure to avoid the precipitous drop in blood pressure that leads to a dizzy feeling or actual faint (vasovagal syncope). 



Language and Interactions

■   Words that are used by immunizers may affect distress levels during vaccination. Explain what is going to happen using neutral language (e.g., 'Here I go') rather than threatening language (e.g., 'Here comes the bee sting'). Minimize reassurance as this tends to focus attention on the procedure, and do not tell people it will not hurt as this is ineffective and promotes distrust.  
■   Breathing interventions (e.g., asking patients to cough or breath-hold) can reduce pain during vaccine injections. 
For individuals with a high level of needle fear, a separate approach is needed which starts long before an actual procedure as individuals who are this fearful may never even attend a medical appointment where a needle is to be given. In a separate document specifically for individuals with high levels of needle fear, we make recommendations focused on exposure-based treatments. These treatments require the involvement of professionals with an expertise in these techniques (e.g., psychologists).  

Using a Lifespan Approach
Minimizing pain and fear during vaccinations and other injections during childhood may reduce the likelihood that individuals develop fears of needles and future health care avoidance behaviours, including vaccination non-compliance. To this end, we recommend that immunizers and parents employ strategies consistently throughout childhood to mitigate pain and fear and that when able, children themselves take on an active role in determining what interventions they prefer. Interventions that have been demonstrated to be effective for mitigating pain and fear in children specifically are reviewed in the HELPinKids&Adults guideline.

CPC Provides Other Helpful Links:

Shingles is a painful rash, consisting of red patches of skin with small blisters (vesicles) that look very similar to early chickenpox.
Source: Medline
For several years, the Canadian Pain Coalition has actively raised awareness among the general public and CPC membership about the existence of the herpes zoster vaccine as an important option for older Canadians in the prevention of herpes zoster (shingles).   The acute pain of herpes zoster can be excruciating and for many who develop nerve damage from having shingles, the long-term, chronic pain of postherpetic neuralgia is devastating. 

In 2014, the CPC created an update, written by Dr. Peter Watson, to the section on herpes zoster within the Pain Resource Centre.

The same year, CPC participated with the Canadian Pain Society in creating a herpes zoster position statement, Safety and Effectiveness of the herpes zoster vaccine to prevent postherpetic neuralgia (published in Pain Research and Management).

More information about shingles and the herpes zoster vaccine can be viewed on the following links:

The only program of its kind in Canada!
Ontario Making Shingles Vaccine Free for Seniors First-in-Canada Program Will Save Seniors Money and Support Healthy Aging

Ontario is the first jurisdiction in Canada to provide the shingles vaccine free of charge, saving eligible seniors approximately $170 and helping them stay healthy.

Starting today, the shingles vaccine will be available across the province for people 65 to 70 years of age. The government is investing $68 million over three years in order to publicly fund the vaccine, which will reduce the likelihood of Ontario seniors developing the painful infection, and reduce visits to emergency rooms and hospitals.

Shingles, also known as herpes zoster, affects more than 42,000 people every year in Ontario and can cause complications such as loss of vision and debilitating nerve pain. Studies show that the vaccine is highly effective when seniors are vaccinated between the ages of 65 - 70, and this new program aligns with scientific and expert recommendations from Canada's National Advisory Committee on Immunization and Ontario's Provincial Infectious Diseases Advisory Committee on Immunization. 

Those who are eligible for the shingles vaccine should contact their primary care doctor or nurse practitioner to receive the vaccination. 

Expanding Ontario's publicly funded immunization program to help seniors stay healthy is part of the government's plan to build a better Ontario through its Patients First: Action Plan for Health Care, which is providing patients with faster access to the right care, better home and community care, the information they need to stay healthy and a health care system that's sustainable for generations to come.

Here are some links to further releases and information on the Ontario Program: