AVOIDANCE OF NEEDLES IN ADULTS
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.
INTERVENTIONS FOR PAIN AND FEAR DURING VACCINATIONS IN ADULTS
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.
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.
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