Degree of Knowledge of Health CareProfessionals About Pain Managementand Use of Opioids in Pediatrics

Gabriel R. M. de Freitas, MSc,*Cláudio G. de Castro Jr., MSc,†Stela M. J. Castro, PhD,‡ andIsabela Heineck, PhD*

*Faculty of Pharmacy, Graduated Program ofPharmaceutical Sciences, UFRGS

‡Institute of Mathematics, UFRGS, Porto Alegre, RS

†Program of Hematology and Bone MarrowTransplantation, Hospital Israelita Albert Einstein, SãoPaulo, SP, Brazil

Reprint requests to: Gabriel Rodrigues Martins deFreitas, MSc, Faculty of Pharmacy, UFRGS, Av.Ipiranga, 2752 - Room 203. Porto Alegre, Rio Grandedo Sul 90610-000, Brazil. Tel/Fax: 55-51-33085281;E-mail: grmf.pharma@gmail.com.

Disclosures: Nothing to disclose in relation to thecontents of this article.

Abstract

Objective. To evaluate the degree of knowledgeabout pain management and opioids use by profes-sionals working at three pediatric units.

Design. This is a cross-sectional study.

Setting. This study was carried out at three pediat-ric units (pediatrics, intensive care unit, and oncol-ogy) of Hospital de Clínicas de Porto Alegre, whichis a university hospital located in southern Brazil.

Subject. The subjects of this study include physi-cians, pharmacists, physiotherapists, nurses,nursing technicians, and nursing assistants.

Methods. Cross-sectional study carried out in a uni-versity hospital in southern Brazil. A self-applicable

semi-structured questionnaire was handed out to182 professionals from December 2011 to March2012.

Results. The response rate was 67% (122); theaverage percentage of correct answers was63.2 ± 1.4%. The most frequent errors were: anopioid must not be used if the cause of pain isunknown (47%; 54/115); patients often developrespiratory depression (42.3%; 22/52); and confu-sion about symptoms of withdrawal, tolerance, anddependency syndromes (81.9%; 95/116). Only 8.8%(10/114) reported the use of pain scales to identifypain in children. The most often cited hindrance tocontrol pain was the difficulty to measure and spotpain in pediatric patients. Finally, 50.8% (62/122) ofthem did not have any previous training in painmanagement.

Conclusions. Problems in the processes of painidentification, measurement, and treatment havebeen found. Results suggest that there is a need forboth an investment in continuing education of pro-fessionals and the development of protocols to opti-mize the analgesic therapy, thus preventingincreased child suffering.

Key Words. Pain Management; Opioids; PainAssessment; Pediatrics; Health Care Professionals;Misconceptions About Opioids

Introduction

Pain has economic and social impacts, and has beenregarded as a public health problem. Epidemiologicalstudies have shown that pain accounts for approximately80% of the searches for health services [1,2]. Specificdata on the pediatric population have not been found.According to Fitzgerald [3] and the American MedicalAssociation [4], infants and children may experience apainful stimulus more intensively than adults, due to stron-ger inflammatory response and lack of central inhibitory

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Pain Medicine 2014; 15: 807–819Wiley Periodicals, Inc.

807

influence. The American Academy of Pediatrics [5] hasstated that, despite the vast literature describing how toassess and manage pain in children by using low-cost,widely available, convenient, and safe methods, it has notbeen used. Organizations such as the American PainSociety (APS), Agency for Healthcare Research andQuality (AHRQ), and Joint Commission on Accreditation ofHealthcare Organizations (JCAHO) have proposed guide-lines for pain management [6]. In Brazil, the Ministry ofHealth created the National Program for Education andAssistance to Pain and Palliative Care [7].

Current pain management standards, such as the normsproposed by JCAHO, require pain to be promptlyaddressed and treated. Both credibility and profitability ofhealth care institutions may decrease if pain is not wellmanaged, as patient satisfaction with the health careservice is strongly influenced by the level of pain experi-enced along hospitalization [8].

Treatment choice, including the kind of analgesia anddosage, should be based on pain intensity [8]. Since the1950s, a number of tools to assess pain intensity havebeen developed and validated. The visual analog scale(VAS) and the numerical rating scale (NRS) provide anumerical rating to determine pain intensity, while theverbal rating scale (VRS) rates pain as mild, moderate, orsevere. For patients with limited cognitive ability and chil-dren, scales showing drawings or images are available(Wong-Baker Faces Pain Rating Scale) [8,9].

Children may receive inadequate treatment because ofdifficulties of perception, identification, and verbalization ofpain, or as a result of underutilization of tools to assesspain. Therefore, it is important for professionals not tounderestimate children’s complaints, to try to know theirclinical history as well as the pain characteristics andintensity, to take into consideration the psychological andsocial aspects involved, and to conduct a physical exami-nation to investigate the cause of pain. According to therights of hospitalized children and adolescents, every childhas the right not to feel pain whenever there are means toavoid it [10].

In 1986, the World Health Organization (WHO) launched aguideline presenting the analgesic ladder for physicians todevelop programs aimed at treating cancer pain. Theanalgesic ladder proposes the use of a limited number ofrelatively low-cost medicines, such as morphine, in a step-wise approach. Such guideline has contributed to thelegitimation of the use of opioids to treat oncologic painand triggered a number of campaigns all over the worldintended to teach about the use, benefits, and adverseeffects of those drugs on pain treatment [11,12].

Complementarily, WHO launched the second edition ofCancer Pain Relief: With a Guide to Opioid Availability in1997. These two documents approach physiology andmethods of pain assessment, besides suggesting analge-sic schemes and the use of the WHO ladder. Studies haveshown that the use of the ladder proposed by WHO has

provided a low-cost treatment and adequate pain relief to70–80% of cancer patients [12–14].

Considering the high prevalence of pain patients, primarycare providers have become discontented and concernedwith their training with regards to pain treatment [15].Researches into pain have focused on hindrances to theimplementation of the opioid therapy; although it is gen-erally accepted as the treatment of choice for cancer pain,there is not a consensus on its use with pain arising fromother etiologies [16]. Since the 1990s, several papers havebeen published to foster the use of opioids as a safetreatment of chronic non-cancer pain [9,12,17].

According to WHO standards, opioid drugs orally admin-istered at fixed intervals are the first-choice treatment ofmoderate to severe pain. Drugs used to minimize the mostcommon side effects (e.g., constipation, nausea, seda-tion) should be concomitantly prescribed. The opioiddosage should be continuously adjusted, considering thepatient’s individual reactions in terms of relief and severityof side effects [11,18].

Given the relevance of this theme, this investigation aimsat evaluating the level of knowledge that care providersfrom three pediatric units at a university hospital haveabout pain relief and use of opioids in children.

Methods

This cross-sectional study was carried out at Hospital deClínicas de Porto Alegre (HCPA), which is a 795-beduniversity hospital located in southern Brazil. The presentwork was approved by the Research Ethics Committee ofthe HCPA under the protocol number 11–0488.

Population

The study population consisted of health care profession-als from three pediatric units of the hospital (pediatriconcology—OncoPed, pediatric intensive care unit—ICUPed, and Pediatrics). According to data provided bythe institution, about 300 professionals work at those unitsin three shifts (morning, afternoon, and night), but wecould only interview 182 of these professionals. Changesin shifts and vacation periods, declination to participate,absence due to diseases or retirement, and high turnoverrate of residents made the distribution of questionnaires tothe whole population impossible. Of these, 122 returnedthe questionnaire. The study included 23 physicians, 2pharmacists, 1 physiotherapist, 62 nursing technicians,and 5 nursing assistants. These professionals wereinvolved with patients from different age groups:OncoPed—patients up to 21; ICUPed—patients up to 18;and Pediatrics—patients up to 12.

Data Collection

Firstly, the self-applicable questionnaire (available at http://surveypainmanagement.blogspot.com.br/) was designedbased on tools used in previous studies [19,20,21,22].

808

Freitas et al.

The tool was revised by a physician and a researcher, andthen handed out to 10 professionals from the units abovementioned. Some changes were performed after a pre-liminary analysis of those assessments, resulting in asemi-structured questionnaire with 42 items; 18 of themwere objective questions (15 True statement/False state-ment questions and 3 multiple choice questions), with onlyone correct alternative. The questionnaire was organizedto provide a profile of the participants regarding their levelof knowledge about pain assessment and treatment, atti-tudes toward pain management, technical knowledge ofopioids, perception of barriers to satisfactory pain control,and previous experience with patients in pain. Besidesthat, the tool also collected personal and professional datafrom respondents.

Before the questionnaires were distributed, medical andnursing chiefs from each clinic were contacted to beinformed about the research procedures in order to facili-tate their participation. From December 2011 to March2012, 182 questionnaires were distributed to profession-als from the three different pediatric clinics.

The professionals were asked to fill out the questionnaireat the end of their work shift. A 1-week period was estab-lished for the questionnaires to be returned. Along thatperiod, all the participants were encouraged, by e-mail, tofill out the tool and return it in a sealed envelope to guar-antee they would remain anonymous.

Inclusion Criteria

The study included health care professionals that workedat the three units abovementioned who accepted to par-ticipate in the study by signing a Free Informed ConsentForm. Respondents that neither signed the Consent Formnor returned the questionnaires were not included inthe study.

Statistical Methods

A descriptive analysis was performed with the use ofmeasures of central tendency and sample dispersion. Thechi-square test was applied to verify the statistical signifi-cance of the differences between ratios. P value of 0.05was regarded as statistically significant. For the statisticalanalysis of data, the statistical program SPSS Version18.0 (SPSS Inc., Chicago, IL, USA) was used.

Results

Characteristics of Participants and their Experience inPain Treatment

Between December 2011 and March 2012, 182 healthcare professionals were invited to participate in theresearch and were given a questionnaire; the responsepercentage was 67% (122). Table 1 shows the character-istics of the participants according to workplace andoccupation. Participants’ mean age was 41.8 ± 9.7 years.Out of a total of 122 respondents, 111 (91%) were female,

92 (75.4%) were Christians, 71 (58.2%) worked full time,and 58 (47.5%) had some kind of further training/education. In average, 16.2 years (1–36 years) was thelength of time between their graduation and the day thequestionnaire was applied.

There were significant differences in terms of gender.Among physicians, the ratio of males was higher(P < 0.001), as well as the number of professionals withfurther training/education, which was less usual amongnursing technicians and nursing assistants (P < 0.001).Concerning the workplace, the only significant differencefound was the higher mean age of professionals fromICUPed (P = 0.037) (Table 1).

The average number of patients with pain assisted permonth was 21.5 ± 20.3. More than a half of the healthcare professionals claimed they did not like to work withpain patients (53.3%; 64/120).

Among all participants, 50.8% (62/122) had not beentrained in pain management along their education, whetherin undergraduate course, in residency, or in a technicalcourse. Furthermore, 52.6% (63/119) reported that thehospital had not offered any pain management training tothem in the last 12 months. The professionals that hadsome kind of training in pain treatment during or after theireducation attained higher average of correct answers(67.1 ± 11.3%) than those that did not have any kind oftraining (61.2 ± 5.2%). With regards to personal experiencewith pain patients, 40.2% said they had already had toadminister opioids. These respondents achieved higheraverage of correct answers (66.8 ± 12.4%) than those thatnever had to administer opioids (60.8 ± 7.7%). A significantpiece of data found was that professionals who hadreported they disliked working with patients with pain hadlower average of correct answers (59%) in comparison tothose that had claimed they did not mind dealing with thisproblem (69%) (P = 0.009).

Barriers to Pain Treatment

The barriers to pain management most often cited by theprofessionals were: difficulty of pediatric patients toexpress themselves, lack of prescribed drugs, fear ofadverse drug reaction (ADR), dependency and toleranceresulting from the use of opioids, and professionals’ lackof knowledge or discernment, as Table 2 shows.

Lack of prescribed drugs, inadequate prescription, andbureaucracy were the most significant barriers identifiedby nurses, pharmacists, and physiotherapist (P = 0.050).The fact that children cannot verbalize pain and fear ofADR (P = 0.014) was pointed out as the most importantbarrier by physicians, technicians, and assistants. Despiteconsiderable fear of ADR, particularly respiratory depres-sion, 63.5% (61/96) of participants never observed suchadverse effect. According to the respondents, the averageof patients with respiratory depression caused by the useof opioids along the last 12 months was 1.3 ± 2.9.

809

Degree of Knowledge About Pain Management

Tab

le1

Cha

ract

eris

tics

of12

2re

spon

dent

s,cl

assi

fied

acco

rdin

gto

thei

roc

cupa

tion

and

wor

kpla

ce

Cha

ract

eris

tics

Gen

eral

(N=

122)

Phy

sici

ans

(N=

23)

Nur

sing

,P

harm

.,an

dP

hysi

o.(N

=32

)Te

ch.

and

Ass

.(N

=67

)P

Val

ueP

edia

tric

s(N

=56

)IC

UP

ed(N

=32

)O

ncoP

ed(N

=34

)P

Val

ue

Age

inye

ars

41.8

±9.

740

.6±

11.1

41.2

±9.

442

.5±

9.4

0.10

440

.3±

9.3

44.3

±9.

841

.9±

9.9

0.03

7(x

±dp

)(2

3–63

)(2

6–63

)(2

3–59

)(2

3–61

)(2

3–63

)(2

7–59

)(2

3–56

)G

ende

rF

emal

e11

1(9

1.0%

)15

(65.

0%)

31(9

7.0%

)65

(97.

0%)

0.00

052

(93.

0%)

28(8

7.2%

)31

(91.

2%)

0.7

Mal

e11

(9.0

%)

8(3

5.0%

)1

(3.0

%)

2(3

.0%

)4

(7.0

%)

4(1

2.5%

)3

(8.8

%)

Year

ssi

nce

grad

uatio

n16

.2±

10.2

17±

11.7

15±

9.5

18±

9.8

0.26

713

±10

.122

±9.

215

±9.

90.

588

(x±

dp)

(1–3

6)(2

–36)

(2–3

6)(1

–35)

(2–3

6)(2

–36)

(1–3

5)F

urth

ered

ucat

ion

Spe

cial

izat

ion

29(2

3.8%

)5

(21.

6%)

24(7

5.0%

)—

12(2

1.4%

)7

(22%

)10

(29.

5%)

Res

iden

cy15

(12.

3%)

9(3

9.2%

)6

(18.

7%)

—7

(12.

5%)

4(1

2.5%

)4

(11.

8%)

Str

icto

sens

u10

(8.1

%)

9(3

9.2%

)1

(3.1

%)

—0.

000

3(5

.4%

)5

(15.

5%)

2(5

.8%

)0.

787

Gra

duat

eco

urse

Cou

rses

4(3

.3%

)—

—4

(6.0

%)

2(3

.6%

)1

(3%

)1

(2.9

%)

No

FE

64(5

2.5%

)—

1(3

.1%

)63

(94.

0%)

32(5

7.1%

)15

(47%

)17

(50%

)W

orki

ngtim

ere

gim

eF

ull-t

ime

71(5

8.2%

)12

(52.

2%)

24(7

5.0%

)35

(52.

2%)

0.08

131

(55.

4%)

19(6

0%)

21(6

1.8%

)0.

826

Par

t-tim

e51

(41.

2%)

11(4

7.8%

)8

(25.

0%)

32(4

7.8%

)25

(44.

6%)

13(4

0%)

13(3

8.2%

)Tr

aini

ngin

pain

man

agem

ent

60(4

9.2%

)10

(43.

5%)

15(4

6.9%

)35

(52.

2%)

0.48

723

(41.

9%)

17(5

3.1%

)20

(58.

8%)

0.50

2S

ourc

eof

upda

ting

abou

tpa

inD

aily

prac

tice

64(5

2.5%

)8

(34.

8%)

13(4

0.6%

)43

(64.

2%)

32(5

7.1%

)15

(46.

9%)

17(5

0.0%

)Tr

aini

ng63

(51.

6%)

1(4

.3%

)17

(53.

1%)

45(6

7.2%

)0.

000

29(5

1.8%

)15

(46.

9%)

19(5

5.9%

)0.

710

Art

icle

read

ing

52(4

2.6%

)19

(82.

6%)

16(5

0.0%

)17

(25.

4%)

22(3

9.3%

)13

(40.

6%)

17(5

0.0%

)

FE

=fu

rthe

red

ucat

ion;

Pha

rm.=

phar

mac

ist;

Phy

sio.

=ph

ysio

ther

apis

t;Te

ch.=

nurs

ing

tech

nici

ans;

Ass

.=nu

rsin

gas

sist

ant.

810

Freitas et al.

ICUPed was the unit in which such situation occurredmost often (3.5 ± 5.2).

Identification, Assessment, and Measurement of Pain

The best-known tools to assess pain intensity pointed outby the respondents were visual analogical scale (39.3%)and numerical scale (36.1%). However, 26.2% of the pro-fessionals did not know any kind of tool to measure pain.

When participants were asked whether they used tools,such as scales to assess pain intensity, 77.9% (95/122)said they performed this procedure in their clinical prac-tice. Moreover, 57.9% (62/107) of the respondentsbelieved that the scales were reliable tools to assess pain,while 28% (30/107) only partially believed in the reliabilityof such scales. Nevertheless, in an open question abouthow to recognize patients’ pain, only 8.8% (10/114)stated they used pain scales. Behavioral evaluations, suchas crying or facial expression, restlessness or moodswings, verbal complaint, and physiological measure-ments, such as changes in vital signs, were the most oftenmentioned ways of identifying pain, as shown in Table 3.

Checking vital signs (P = 0.001) and listening to verbalcomplaints (P = 0.016) were the assessment methodsmore often mentioned by physicians and technicianswhen compared with other professionals; body posture, inturn, was found to be more relevant by nurses, pharma-cists, and physiotherapists (P = 0.009). The comparisonamong the units evidenced a significant difference con-cerning vital signs and physiological alterations, whichseem to be more frequently observed at the Pediatricsand ICUPed than at OncoPed (P = 0.039) (Table 3).

According to 86% (104/121) of the respondents, the pres-ence of a parent facilitates pain assessment.

Only 45% (54/120) of the professionals record pain as avital sign. None of the 23 physicians participating in thestudy records pain together with other physiological mea-surements, such as temperature, heartbeat, blood pres-sure, and respiratory rate. However, 63.3% (19/30) of thenurses and 52.2% (35/67) of the technicians and assis-tants said they record pain (P < 0.001). There was also asignificant difference among units, as 66.7% (36/54) ofprofessionals working at the Pediatrics unit claimed theyrecord pain as a vital sign, whereas only 15.6% (5/32) and38.2% (13/34) do it at ICUPed and OncoPed, respectively(P < 0.001).

Knowledge About Pain Management

As to the use of non-pharmacological practices, allthe professionals reported they adopted such practice;the most often mentioned actions were use of hotwater bottle, cuddling, and reduction of visual andauditory stimuli.

When asked about the existence of a pain treatmentprotocol in the hospital, 69.6% (80/115) said they wereTa

ble

2B

arrie

rsto

adeq

uate

pain

man

agem

ent

mos

tof

ten

cite

dby

part

icip

ants

Topi

csM

entio

ned

%G

ener

al(N

=10

3)%

Phy

sici

ans

(N=

21)

%N

ursi

ng,

Pha

rm.,

and

Phy

sio.

(N=

25)

%Te

ch.

and

Ass

.(N

=57

)P

Val

ue%

Ped

iatr

ics

(N=

50)

%IC

UP

ed(N

=29

)%

Onc

oPed

(N=

24)

PV

alue

Ped

iatr

icpa

tient

,di

fficu

ltyto

eval

uate

and

spot

pain

due

toun

awar

enes

sor

non-

verb

aliz

atio

n

35.9

(37)

47.6

(10)

36.0

(9)

31.6

(18)

0.42

432

.0(1

6)37

.9(1

1)41

.7(1

0)0.

695

Lack

ofpr

escr

ibed

drug

s,in

adeq

uate

pres

crip

tion,

and

bure

aucr

acy

25.2

(26)

9.5

(2)

40.0

(10)

24.6

(14)

0.05

022

.0(1

1)37

.9(1

1)16

.7(4

)0.

158

Lack

ofin

form

atio

nab

out

opio

ids,

fear

ofad

vers

edr

ugre

actio

n(A

DR

),to

lera

nce,

depe

nden

cy,

resp

irato

ryde

pres

sion

20.4

(21)

28.6

(6)

0(0

)26

.5(1

5)0.

014

20.0

(10)

24.1

(7)

16.7

(4)

0.79

4

Lack

ofkn

owle

dge

and

disc

ernm

ent

tom

anag

epa

in15

.5(1

6)14

.3(3

)16

.0(4

)15

.8(9

)0.

984

16.0

(8)

17.2

(5)

12.5

(3)

0.88

6

Rel

ativ

es’p

ress

ure

and

anxi

ety

15.5

(16)

4.8

(1)

20.0

(5)

15.5

(10)

0.29

918

.0(9

)10

.3(3

)16

.7(4

)0.

654

Inad

equa

tepa

inas

sess

men

t(to

ols)

8.7

(9)

9.5

(2)

8.0

(2)

8.8

(5)

0.98

310

.0(5

)10

.3(3

)4.

2(1

)0.

663

Pha

rm.=

phar

mac

ist;

Phy

sio.

=ph

ysio

ther

apis

t;Te

ch.=

nurs

ing

tech

nici

an;A

ss.=

nurs

ing

assi

stan

t.

811

Degree of Knowledge About Pain Management

aware of it. Professionals from the Pediatrics unit showedto be more aware of this protocol (80%; 44/55) than thoseworking at ICUPed (55.2%; 16/29) and OncoPed (64.5;20/31) (P = 0.049). There was also a significant differenceamong professionals, as the number of nursing techni-cians and nursing assistants (80.0%; 48/60) that reportedto know that there was a protocol was larger than thenumber of physicians (43.5%; 10/23) and other profes-sionals with higher education degree (68.8%; 22/32)(P = 0.005).

Only 48.4% (59/122) of the participants agreed that theright dosage of opioids can relieve the patient’s pain.

Finally, Tables 4 and 5 present the results related to knowl-edge of pain management and use of opioids.

The average percentage of correct answers was63.2% ± 1.4. Nursing technicians and assistants achieveda lower percentage of correct answers (55.4% ± 15.2) incomparison to physicians (71.5% ± 11.4) and otherprofessionals with a university degree (73.6% ± 11.1)(P < 0.001). Considering the units, the percentage ofquestions correctly answered by ICUPed (64.4% ± 18.5),Pediatrics (62.3% ± 15.8), and OncoPed (63.7% ± 14.1)did not present statistical difference (P = 0.406).

Two facts were worthy of concern: 26.5% (27/102) of theparticipants said they believed that children under 2 yearsold are less sensitive to pain, and 29% (31/107) of themthought that morphine has a maximum dosage limit. Thepercentage of correct answers to the latter question wassignificantly higher in the Pediatric unit in comparison tothe others (P = 0.005).

Higher rates of correct answers were obtained in ques-tions about via of administration (99.2%; 120/121), aware-ness of the WHO analgesic ladder (94.5%; 52/55), andneed to bear the pain before opioids are used (98.3%;120/122). The errors that drew more attention wererelated to: vital signs are always reliable indicators of painintensity (34.5%; 40/116); patients usually develop respi-ratory depression, even when adequately using opioid for2 months (42.3%; 22/52); and patients that can bedistracted from the pain do not experience severe pain(60%; 73/122).

When participants were questioned about withdrawalsymptoms, 81.9% (95/116) confused them with symp-toms of tolerance, dependency, and addiction. A signifi-cant percentage (20.2%; 24/119) of participants believedthat asking for higher doses is related to addiction, and47% (54/115) thought that opioids should be only usedafter the cause of pain has been diagnosed.

Discussion

These research findings are related to experienced pro-fessionals working at a university hospital (more than 16years of work, assisting more than 20 patients with painper month).Ta

ble

3S

igns

and

met

hods

men

tione

dby

prof

essi

onal

sto

asse

sspa

in

Sig

ns/M

etho

dsM

entio

ned

%G

ener

al(N

=11

4)%

Phy

sici

ans

(N=

23)

Nur

sing

,P

harm

.,an

dP

hysi

o.(N

=29

)

%Te

ch.

and

Ass

.(N

=62

)P

Val

ue%

Ped

iatr

ics

(N=

53)

%IC

UP

ed(N

=31

)%

Onc

oPed

(N=

30)

PV

alue

Cry

ing,

faci

alex

pres

sion

and

moa

ning

84.2

(96)

69.6

(16)

89.7

(26)

87.1

(54)

0.09

386

.8(4

6)77

.4(2

4)86

.7(2

6)0.

478

Vita

lsig

nsan

dph

ysio

logi

calc

hang

es46

.5(5

3)60

.9(1

4)17

.2(5

)54

.8(3

8)0.

001

54.7

(29)

51.6

(16)

26.7

(8)

0.03

9R

estle

ssne

ss,

moo

dsw

ings

and

irrita

bilit

y43

.0(4

9)39

.1(9

)51

.7(1

5)40

.3(2

5)0.

543

50.9

(27)

32.3

(10)

40.0

(12)

0.23

1V

erba

lcom

plai

nt37

.7(4

3)34

.8(8

)17

.2(5

)48

.4(3

0)0.

016

30.2

(16)

51.6

(16)

36.7

(11)

0.14

7D

isco

mfo

rt,

body

post

ure

27.2

(31)

13(3

)48

.3(1

4)22

.6(1

4)0.

009

32.1

(17)

25.8

(8)

20(6

)0.

484

Use

ofas

sess

men

tsc

ales

and

tool

s8.

8(1

0)17

.4(4

)13

.2(4

)3.

2(2

)0.

066

5.7

(3)

6.5

(2)

16.7

(5)

0.20

3

Pha

rm.=

phar

mac

ist;

Phy

sio.

=ph

ysio

ther

apis

t;Te

ch.=

nurs

ing

tech

nici

an;A

ss.=

nurs

ing

assi

stan

t.

812

Freitas et al.

Tab

le4

Hig

hest

perc

enta

ges

ofco

rrec

tan

swer

sto

ques

tions

abou

tkn

owle

dge

ofpa

inm

anag

emen

tan

dus

eof

opio

ids

Item

s/(%

)C

orre

ctA

nsw

ers

%G

ener

al(N

=12

2)%

Phy

sici

ans

(N=

23)

%N

ursi

ng,

Pha

rm.,

and

Phy

sio.

(N=

32)

%Te

ch.

and

Ass

.(N

=67

)P

Val

ue%

Ped

iatr

ics

(N=

56)

%IC

UP

ed(N

=32

)%

Onc

oPed

(N=

34)

PV

alue

Q2.

Mix

ing

anal

gesi

csth

atac

tdi

ffere

ntly

may

prov

ide

bette

rpa

inco

ntro

lwith

few

ersi

deef

fect

sth

anus

ing

just

one

anal

gesi

c.(T

)

77.5

91.3

83.9

68.4

0.50

272

.571

.490

.60.

107

Q3.

Due

toth

eir

imm

atur

ene

rvou

ssy

stem

,ch

ildre

nun

der

2ha

vedi

min

ishe

dse

nsiti

vity

topa

inan

dlim

ited

mem

ory

capa

city

tore

call

pain

fule

xper

ienc

es.

(F)

74.1

90.9

87.1

61.0

0.00

476

.976

.766

.70.

554

Q4.

Mor

phin

eha

sa

max

imum

dosa

gelim

it(i.

e.,

abov

eth

islim

it,it

isno

tpo

ssib

leto

obta

ingr

eate

rpa

inre

lief)

.(F

)

71.0

78.3

72.4

67.3

0.61

056

.082

.682

.10.

005

Q7.

Adm

inis

trat

ion

via

ofop

ioid

anal

gesi

csre

com

men

ded

topa

tient

sw

ithsh

ort-

last

ing

and

inte

nse

pain

begi

nnin

gsu

dden

ly,

such

astr

aum

aor

post

-ope

rativ

epr

oced

ure,

isin

trav

enou

s.(T

)

99.2

100.

010

0.0

98.5

0.65

398

.210

0.0

100.

00.

562

Q11

.C

hild

ren

unde

r11

cann

otre

liabl

yre

port

pain

.T

here

fore

,he

alth

care

prof

essi

onal

sde

pend

excl

usiv

ely

onth

eas

sess

men

tby

child

ren’

spa

rent

s.(F

)

88.3

100.

096

.980

.00.

008

92.7

87.1

82.4

0.32

4

Q12

.P

atie

nts’

spiri

tual

belie

fsm

ayca

use

them

toth

ink

that

pain

and

suffe

ring

are

nece

ssar

y.(T

)

84.0

91.3

93.8

76.6

0.05

490

.780

.676

.50.

172

Q13

.P

atie

nts

mus

tbe

enco

urag

edto

bear

the

pain

asm

ust

aspo

ssib

lebe

fore

usin

gan

opio

id.

(F)

98.3

95.7

100.

098

.50.

459

100.

096

.297

.10.

4212

Q14

.M

orph

ine

acce

lera

tes

deat

h.(F

)93

.295

.796

.990

.30.

427

92.2

93.8

94.1

0.92

9Q

16.

Aw

aren

ess

ofth

eW

HO

anal

gesi

cla

dder

(mild

pain

:D

ipyr

one;

mod

erat

epa

in:

Tram

adol

;se

vere

pain

:F

enta

nyl).

(T)*

94.5

91.3

96.9

—0.

370

95.7

88.9

100.

00.

372

Q17

.A

nalg

esic

sfo

rpo

st-o

pera

tive

pain

mus

tbe

initi

ally

adm

inis

tere

dev

eryd

ayac

cord

ing

toa

fixed

time

sche

dule

.(T

)*

87.0

82.6

90.3

—0.

640

91.3

94.1

71.4

0.20

4

*Q

uest

ion

answ

ered

only

bypr

ofes

sion

als

with

high

ered

ucat

ion

degr

ee.

(T)

=tr

uest

atem

ent;

(F)

=fa

lse

stat

emen

t;P

harm

.=ph

arm

acis

t;P

hysi

o.=

phys

ioth

erap

ist;

Tech

.=nu

rsin

gte

chni

cian

;Ass

.=nu

rsin

gas

sist

ant.

813

Degree of Knowledge About Pain Management

Tab

le5

Low

est

perc

enta

ges

ofco

rrec

tan

swer

sto

ques

tions

abou

tkn

owle

dge

ofpa

inm

anag

emen

tan

dus

eof

opio

ids

Item

s/(%

)C

orre

ctA

nsw

ers

%G

ener

al(N

=12

2)%

Phy

sici

ans

(N=

23)

%N

ursi

ng,

Pha

rm.,

and

Phy

sio.

(N=

32)

%Te

ch.

and

Ass

.(N

=67

)P

Val

ue%

Ped

iatr

ics

(N=

56)

%IC

UP

ed(N

=32

)%

Onc

oPed

(N=

34)

PV

alue

Q1.

Ana

lges

iain

duce

dby

dose

sof

mor

phin

e1–

2m

gi.v

.us

ually

last

s4–

5ho

urs.

(F)

38.6

33.3

31.3

44.3

0.40

626

.442

.954

.50.

029

Q5.

Ifth

eca

use

ofpa

inis

unkn

own,

opio

ids

mus

tno

tbe

used

durin

gth

eas

sess

men

tbe

caus

eth

eym

aym

ask

the

real

caus

e.(F

)

53.0

69.6

68.8

38.3

0.00

445

.166

.752

.90.

171

Q6.

Vita

lsig

nsar

eal

way

sre

liabl

ein

dica

tors

ofpa

inin

tens

ity.

(F)

65.5

69.6

71.9

60.7

0.50

377

.450

.060

.60.

033

Q8.

The

likel

ihoo

dof

apa

tient

tode

velo

pre

spira

tory

depr

essi

onaf

ter

2m

onth

sof

adeq

uate

trea

tmen

tw

ithop

ioid

anal

gesi

csto

relie

vepe

rsis

tent

canc

er-r

elat

edpa

inis

low

erth

an1%

.(T

)*

57.7

59.1

56.7

—0.

492

43.5

76.5

58.3

0.35

8

Q9.

Pat

ient

sth

atca

nbe

dist

ract

edfr

omth

epa

indo

not

usua

llyha

vese

vere

pain

.(F

)40

.030

.458

.134

.80.

054

40.0

38.7

41.2

0.98

0

Q10

.P

atie

nts

can

slee

p,de

spite

inte

nse

pain

.(T

)25

.647

.831

.315

.20.

006

25.5

28.1

23.5

0.91

8Q

15.

The

mos

tlik

ely

reas

onfo

rpa

tient

sto

ask

for

high

erdo

ses

ofpa

indr

ugs

isth

atth

eyar

eex

perie

ncin

gm

ore

pain

.(T

)

64.7

69.6

96.8

47.7

0.00

067

.356

.368

.80.

886

Q18

.A

fter

sudd

enin

terr

uptio

nof

opio

idus

e,w

ithdr

awal

sym

ptom

sin

clud

esw

eatin

g,ya

wni

ng,

diar

rhea

,an

dre

stle

ssne

ss(T

)

18.1

26.1

22.6

12.9

0.29

916

.732

.36.

50.

145

*Q

uest

ion

answ

ered

only

byhi

gher

educ

atio

npr

ofes

sion

als.

(T)

=tr

uest

atem

ent;

(F)

=fa

lse

stat

emen

t;P

harm

.=ph

arm

acis

t;P

hysi

o.=

phys

ioth

erap

ist;

Tech

.=nu

rsin

gte

chni

cian

;Ass

.=nu

rsin

gas

sist

ant.

814

Freitas et al.

Knowledge About Pain Management

In studies with different approaches to this topic, thepercentage of correct answers has ranged from 31% to71% [20,23,24]. In this study, the percentage of correctanswers achieved by professionals with higher educationdegree was above 70%. As it was expected, nursingtechnicians and nursing assistants obtained a lower rateof correct answers, due to more superficial education.Despite being predictable, these data are worrisome, con-sidering that these professionals are directly involved inassisting children. Offering courses and training couldcomplement education and provide higher quality assis-tance to patients. The source of updating preferred bytechnicians, assistants, and nurses was training, but morethan 50% of those professionals did not have any trainingin pain management. Wells and collaborators [8] haveobserved that only 48% of physicians and nurses partici-pating in their study have been given information aboutpain control in training courses. Kim and collaborators [25]have stated that, although several physicians believe to bevery well trained to manage pain, they evidence negativeattitudes and inadequate level of knowledge aboutthis issue.

The emotional component is also important to health careprofessionals. Participants who dislike assisting patientswith pain made more mistakes upon answering the ques-tionnaire. More than a half of them (53.3%; 64/120) saidthey disliked this experience. The fact that a professionaldislikes dealing with patients in pain may evidence a preju-dice that should be addressed by the health care team.On the other hand, reducing pain intensity causes patientsto complain less, which results in a general improvementin assistance.

By analyzing Table 4, it is possible to notice that the Pedi-atrics unit had the lowest rate of correct answers to ques-tions about the use of opioids (e.g., Q1, Q4, Q5, and Q8).This could be because OncoPed and ICUPed use opioidsmore often, and their professionals are more used todealing with these drugs.

Barriers to Pain Treatment

Pediatric patients with difficulty to assess pain wereregarded as the main barrier to pain treatment by therespondents in this study. Therefore, there is a need forimplementing the use of tools to more effectively assesspain in children [26]. Other factors seen as hindrances toadequate pain relief were lack of prescribed drugs, andthe bureaucracy involved in opioid prescription. Previousstudies have pointed out that the bureaucracy for obtain-ing, prescribing, and dispensing opioids is an obstacle inthe pain management process [7,27,28].

According to the Brazilian Society for Pain Studies (SBED),the main barriers to pain treatment are: inadequate edu-cation and training of health professionals, whose failurewould be associated with the model of care adopted,which is usually based on the disease; the difficulties on

pain assessment; the lack of knowledge about the phar-macology of opioids, conversion, equianalgesia, and rota-tion; the inappropriate use of adjuvants; diagnosis andinadequate treatment of adverse events; fear of opioid’sadverse events, analgesic tolerance and addiction, thelack of priority for dealing pain, and the establishment ofanalgesic plan based on prognosis and not pain intensity;and finally, the difficulties in reassessment of pain andproposed treatments [29].

Twenty percent of the participants mentioned that fear ofadverse reactions (dependency, tolerance, and respiratorydepression) is one of the primary barriers to the use ofopioids in pain management. This finding is in consonancewith other studies that have also identified such barrier[18,25,30–32].

Peker [32] has found that 82% of physicians and residentsconsider respiratory depression as the most worrisomeadverse reaction to opioids. Even though it is one of themajor fears related to the use of opioids in our study, therespondents reported that this situation is seldom experi-enced (incidence of 0.5%). This result is in consonancewith other studies reporting that respiratory depression isa rare adverse effect, particularly when opioids are titratedfor pain treatment [33,34].

The fact that 81.9% (95/116) of the professionals mistooksymptoms of withdrawal syndrome (sweating, yawning,diarrhea, and restlessness) for symptoms of tolerance(need of higher dosages to achieve analgesia), depen-dency and addiction (compromised control over drug use,compulsive use) indicates lack of knowledge of theseterms and, possibly, a prejudice against the use of opioids.This finding was supported by both the percentage ofprofessionals (20%) who believe that the need to takehigher doses of opioids evidences addiction, and thenumber of participants who think the opioids should beonly used after the cause of pain has been diagnosed,which would result in patient suffering (47%).

We have noticed that lack of formal knowledge about painmanagement, use of opioids, and even methods toassess pain are hindrances to an adequate pain treat-ment. Investments in providing these professionals withcontinuing education are imperative to mitigate the suffer-ing experienced by patients in pain. Besides investmentsin education, the institutions should offer support to thehealth care staff by standardizing and handing out painscales, as well as developing protocols. Investing inknowledge will be of little help if organizational factorsdo not enable professionals to apply this knowledge totheir practice.

Pain Treatment

According to Trescot et al. [35] and Lacy et al. [36], theanalgesic efficacy of opioids does not have a maximumdosage or a conventional limit. The adequate dosagewould be the one that relieves the patient’s pain withoutcausing unmanageable adverse effects. In this study,

815

Degree of Knowledge About Pain Management

approximately 30% of the participants believe there is amaximum morphine dose [36,37].

Not only do health care professionals worry about thepotential of opioid dependency, abuse, inadequate use,and adverse effects, but also about patient-related prob-lems (e.g., drug acceptance, psychiatric comorbidity,reluctance or difficulty to report pain, family history ofaddiction) [19,38–40]. However, opioids, as a pharmaco-logical class, have well-described side effects, whichinclude vomiting, nausea, dizziness, constipation, andsedation. These effects can be minimized by doseadjustment, adjuvant drugs, and non-pharmacologicalapproaches [41]. Opioid analgesics are fundamental topain management in both oncologic and non-oncologicpatients. Effective pain management in these patientsdepends on the administration of the right opioid, with theright dosage and at the right moment [15,16,42–45].

This study has addressed only issues related to opioids,and it is not possible to assess how much the profession-als know about other analgesics used in pain manage-ment. Dos Santos and Heineck has shown that off-labeluse of non-opioid analgesics is significant, and dosageand indication are the parameters in which problems aremore often found in pediatric prescriptions [46].

Pain Identification, Measurement, and Assessment

A review [18] of the barriers to treat cancer pain haspointed out that, besides the lack of knowledge aboutpain management, an important obstacle to pain relief isthe inadequate standard for pain assessment. Our resultshave evidenced that the percentage of use of scales andtools in pain assessment is reduced (only 8.8%), and painis mostly assessed through patients’ reactions and com-plaints. These data suggest that mild and moderate painmay be neglected. Lack of knowledge and training to usesuch tools, non-institutionalization of this practice in somehospital units, and the distrust felt by some professionalsare some of the reasons for non-utilization of those tools.Pain measurement is central to pain treatment becauseadequate therapeutic action will be only possible throughthis procedure [26].

Specifically in children, the right selection of a pain assess-ment tool will depend on the patient’s age and level ofdevelopment, as well as on the involvement of the child’scaregiver to provide information.

Facial expression in reaction to painful stimulus is a sig-nificant indicator of pain in newborns, and the tools rec-ommended in this case are the following: NeonatalFacial Coding System, Premature Infant Pain Profile, andNeonatal Infant Pain Scale. From 2 years on, patientscan provide information about their pain, but cannotunderstand the concepts associated with pain intensityand type. It is recommended to use the Poker Chip Tool,which assesses intensity, without precise quantification[47].

With children over 4 years old, who master language andcommunication skills, self-report measurements are morereliable and can be used. Such tools are ordinal scalesthat inform pain intensity. Some examples are Faces PainScale—Revised, VAS, Oucher Scale, NRS and VNS [47].

There are also the Face, Legs, Activity, Cry, andConsolability Scale and Children’s Hospital of EasternOntario Pain Scale, indicated to post-operative pain in1-year-old children. Most psychometric scales are indi-cated to acute procedural pain or post-operative pain.This is due to the fact that chronic pain requires a morecomplex assessment, including the analysis of functionaladaptive aspects and life quality, besides intensity. In thiscase, the literature recommends questionnaires or moni-toring diaries. Some examples are: Varni/ThompsonPediatric Pain Questionnaire, Pain Diary, and Non-Communicating Children’s Pain Checklist—Revised [47].

Jacob and Puntillo [48] have reported that most nursesbelieve that pain assessment is the first step to relieve painin children. According to their study, less than 25% ofnurses record pain intensity, and only one third of therecords shows some evidence of pain assessment.

Our data have pointed that 94.5% of the professionalswith higher education degrees are aware of the WHOAnalgesic Scale, but most of them rely only on thepatients’ reactions and complaints to check the presenceof pain. The same practice was observed by Saça andcollaborators [49]. A pain assessment tool should not onlyindicate the presence or absence of pain, but also deter-mine its degree of intensity. Therefore, through adequatepain measurement, we can follow the WHO guideline,which considers pain intensity measurement as importantdata for rational prescription, aiming at a more adequateand effective treatment.

Pain Record

Since 2000, the JCAHO, the APS, and the AHRQ havedescribed pain as the fifth vital sign that should always berecorded at the same time and in the same clinical settingin which other vital signs are measured, such as tempera-ture, heartbeat, breathing, and blood pressure, in order tobe available to all and enable the evaluation of actions tobe taken. This would make pain assessment as automaticas the recording of any other vital sign.

A guideline produced in Canada has recommended that,for effective pain control, the health care team should keepthe patient records updated and detailed with informationsuch as: patient’s medical and psychological history, painintensity assessment, treatment scheme, discussionabout the risks and benefits of treatment, list of opioidsprescribed, and outcomes [50].

In the present study, only 45% of the participants recordedpain as a vital sign; no physicians mentioned pain as oneof the vital signs when asked about them. For nurses andtechnicians, such procedure is more usual, but far from

816

Freitas et al.

ideal. Considering the units studied, this routine is moreestablished in the Pediatrics unit, as 66.7% of its profes-sionals record these data. The implementation of painrecording as the fifth vital sign by all professionals requiresteam encouragement and support by the institution.According to Linhares and Doca, the physiological indica-tors might be influenced by pain, but are not specificto it; hence, they should be taken as complementarymeasurements [47].

Eighty percent of the professionals in the Pediatrics unitsaid they were aware of a “protocol” for pain manage-ment, but no pain protocol has been institutionalized atHCPA yet. Actually, several medical services have assis-tance routines that some have called “protocols.” Suchroutines, however, have not undergone an institutionalevaluation to be validated, although they have ended upbeing used by the health care teams on a daily basis.

Poor formal pain management education is reflected inexcessive worrying with the use of opioids, as well as inanswers to questions requiring knowledge about painassessment and drug use. Peker has found that importantpharmacological agents in pain management are not wellknown and that professionals reported poor skills toperform tasks demanding knowledge, education, andexperience in the use of opioids [32]. The Montreal Dec-laration, a document written during the First InternationalPain Summit, in 2010, states that “the access to treatmentof the pain by adequately trained healthcare professionalsis a fundamental human right.” Health care providers havethe ethical responsibility of relieving both the pain and thesuffering it provokes, providing information and favoringimpartial access to drugs and adequate analgesic therapy[51].

Limitations

Health care professionals’ knowledge and attitudestoward pain management were assessed in units of auniversity hospital; therefore, data should not be extendedto services with different characteristics. However, lowerpercentages of correct answers could be expected ininstitutions whose scope does not include professionaleducation. Furthermore, the educational, social, and cul-tural profiles of participants should be taken into consid-eration in data generalization. Another limitation is thestudy focus on opioid analgesics only. This precludes theassessment of knowledge about other analgesics that arealso of major importance in pain management.

Conclusion

This study compared different health care professionalsfrom different clinics as to their knowledge about painmanagement in pediatrics. It has evidenced difficulties inthe processes of pain identification, measurement, andassessment.

The primary barriers that hinder an optimal pain manage-ment are the following: difficulty shown by pediatric

patients to measure and spot the pain, lack of prescribeddrugs, excessive bureaucracy, and fear of adverse reac-tions to opioids.

The level of knowledge of issues related to pain and use ofopioids was found satisfactory for professionals withhigher education degrees. For nursing technicians andnursing assistants, however, the level of knowledge waslower than expected, particularly if we take into accountthat these professionals provide direct assistance to thepatients. No significant differences were found betweenthe units evaluated.

This study has also shown that the professionals studiedhave not adopted the use of tools for pain assessment intheir practices. These tools are useful both to the prescrip-tion of analgesics and to pain reassessment after inter-ventions, whether they are pharmacological or not;besides, they provide better documentation and favorcommunication between the team members.

Prejudice and disinformation surrounding the issuesapproached in this study are important and should beeliminated in the short run through programs of continuingeducation and design of protocols for pain assessmentand treatment in health care institutions. Medium andlong-term actions involve the approach of these issuesalong professionals’ academic/formal education. Further-more, the institutions should provide both organizationalstructure and infrastructure so that the professionals canput into practice the knowledge acquired. Such actionsdo not demand huge investments; simple changes wouldreduce unnecessary suffering in patients in general, andmore specifically in children.

Acknowledgments

We thank Conselho Nacional de DesenvolvimentoCientífico e Tecnológico (CNPq) and Instituto Nacional deCiência, Tecnologia e Inovação Farmacêutica (INCT-IF),the Graduate Course in Pharmacological Sciences ofUFRGS and Hospital de Clínicas de Porto Alegre/RS.

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Degree of Knowledge About Pain Management

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