Giving a Good Needle: Resident Guide to Decreasing Injection Pain

Distraction Techniques

Although patients should be made aware of the injection sites and reasonable expectations should be set, distraction techniques are easy to implement and can be valuable in directing the patient’s focus away from the anticipated injection. A patient’s clothing, jewelry, and body art; reading material; and the weather are examples of topics that can be discussed as “talkesthesia.” For younger patients, various distraction techniques have been developed, ranging from basic distraction with stickers or toys to increasingly sophisticated methods such as virtual reality glasses worn during the procedure.¹⁰ In actual practice, I prefer to use available technology that is inexpensive and already familiar to the child; for instance, allowing children to watch their favorite short Web videos or play a video game during the procedure, as long as the biopsy site allows it, is an ideal adjunct to proper topical anesthesia and good injection technique. For adults, quickly plugging in their favorite musical artist to an Internet radio application also can allevi-
ate anxiety.

Several distraction techniques also can be administered directly at the injection site based on the gate control theory of pain. Tactile stimuli delivered proximal to the injection site creates sensory “noise” at the level of the spinal cord, masking the noxious sensation carried on unmyelinated C fibers.⁷ If you have ever hit your head on an open cabinet, for instance, the instinctual desire to immediately rub the area to reduce the pain functions on this same premise. Various tactics may be employed, including stretching or pinching the skin, rubbing, and tapping; however, I find that the major limitation to many of these methods is performing them safely. An inadvertent stick may be more likely if your fingers are dancing in the path of the needle. Generally, I like to rub the skin about 3- to 5-cm proximal to the injection site with the index finger of the supporting hand as the needle is inserted and continue while the deposit of anesthetic is placed. A potentially safer option is a small handheld massager, though concerns about sterility and durability with autoclaving may limit its use to select patients.¹¹

Special Patient Considerations

Although we do our best to control the operator-dependent aspects of injection pain, patient factors also can complicate the administration of adequate anesthesia and occasionally can lead to unintended surprises. Patients with red hair whose characteristic locks are the result of mutations in the melanocortin 1receptor have been identified as being resistant to the effects of local anesthesia, putatively related to the role of melanocortin 1 receptor in pain modulation.¹² This discovery highlights the fact that there likely are numerous undiscovered mutations that cause resistance to anesthetic agents. It further underscores the need to ensure adequate numbing by testing the patient’s level of sensation prior to beginning any procedure.

Conclusion

By keeping your patient’s comfort in mind, you will not only enhance their confidence in you as their physician but will also encourage good follow-up care and adherence to any prescribed protocols. In the future, needleless injection devices and more rapid topical anesthesia may further decrease pain associated with dermatologic procedures.¹³