Chronic Non-Cancer Pain


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One in five adults report chronic pain (pain experienced every day for 3 or more months). The Management of Chronic Non-Cancer Pain Tool is designed to help primary care providers manage adult patients with chronic non-cancer pain (CNCP).

Question #1: Which of the following are clinical features of opioid use disorder?

Question #2: Which of the following statements is true with regards to non-pharmacological therapy?

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Management of Chronic Non-Cancer Pain Tool
Management of Chronic Non-Cancer Pain tool

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Through a multidisciplinary and multidimensional approach, the Management of Chronic Non-Cancer Pain Tool is designed to assist family physicians and primary care nurse practitioners develop and implement a management plan for adult patients living with CNCP.

The Management of Chronic Non-Cancer Pain tool applies to pain conditions such as osteoarthritis (OA), low back pain (LBP), musculoskeletal (MSK) pain, fibromyalgia (FM) and neuropathic pain (NP). The management of CNCP is an ongoing process that should be patient centred, collaborative and compassionate. This tool focuses on a multi-modal approach to manage CNCP.

The tool is divided into the following five sections:

  1. Baseline and ongoing assessment
  2. Non-Pharmacological Therapy
  3. Non-Opioid Medications
  4. Opioid Medications
  5. Intervention Management and Referral

Where appropriate, primary care providers (PCPs) should use a combination of non-pharmacological and pharmacological options to build a comprehensive and personalized plan that incorporates the patient’s goals.

LHIN-specific resources


To supplement the tool, we are compiled resources that are specific to each Local Health Integration Network (LHIN). Click on the LHIN to access its resources.

Erie St. Clair
South West
Waterloo Wellington
Hamilton Niagara Haldimand Brant
Central West
Mississauga Halton
Toronto Central
Central
Central East
South East
Champlain
North Simcoe Muskoka
North East
North West

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Project Overview

The Management of Chronic Non-Cancer Pain Tool was developed to help primary care providers apply a multidisciplinary and multidimensional approach to the management of patients who experience chronic non-cancer pain.

Development Process

The Management of Chronic Non-Cancer Pain Tool was developed using the CEP’s integrated knowledge translation approach. This approach ensures that providers are engaged throughout the development processes through the application of user-centered design methodology. Clinical leadership of the resource was provided by Dr. Arun Radhakrishnan. Clinical experts were also engaged to provide feedback on the management of chronic non-cancer pain.

The Management of Chronic Non-Cancer Pain Tool is one of several resources developed as part of the Knowledge Translation in Primary Care Initiative. This multi-year initiative is a collaboration between the Centre for Effective Practice (CEP), Ontario College of Family Physicians (OCFP), and Nurse Practitioners’ Association of Ontario (NPAO). Funded by the Ministry of Health and Long-Term Care, this initiative supports primary care providers with the development of a series of clinical tools and health information resources. Learn more about the Knowledge Translation in Primary Care Initiative.

As part of this initiative, CEP conducted a Primary Care Needs Assessment to determine topics of interest to primary care providers. In this survey, providers identified the need for more effective resources to help identify and manage risks associated with mental health conditions.

Meet the Team

 The need for a more effective approach to managing chronic non-cancer pain was identified by Ontario primary care providers as part of the Knowledge Translation in Primary Care Initiative. The Centre for Effective Practice enlisted the collaboration of clinical leads and a clinical working group.

Clinical Lead

ArunArun Radhakrishnan, MSc, MD, CM CCFP

Dr. Arun Radhakrishnan is a family physician with a focused practice in chronic pain and is the current co-chair of the Collaborative Mental Health Network and the Medical Mentoring for Addictions and Pain Network at the Ontario College of Family Physicians. He is also an adjunct assistant professor with the Department of Family and Community Medicine at the University of Toronto.

In 2013 Arun completed a Master’s degree at the University of Toronto in Health Services Research focusing on the value of information and communication technologies to enable knowledge translation activities in the areas of pain, mental health and addictions to support community physicians. His interests also include teaching and curriculum development around the integration of technology into the clinical encounter.

Acknowledgements

A clinical working group comprised of nurses and physicians oversaw the development of this tool. Members include:

  • Mona Sawhney, nurse practitioner
  • Mireille St-Jean, family physician
  • Jeff Spence, family physician

Thank you to all of our members for their work.

Expert Opinion

In addition to our clinical working group, CEP sought expert input to inform specific aspects of the tool including terminology, physical assessment and the management components. We are grateful to the individuals for their time and expertise.

Supporting Material

Here are some additional resources and sources of information. These supporting materials are hosted by external organizations and we cannot guarantee the accuracy and accessibility of their links. CEP will make every effort to keep these links up to date.

Supporting Materials

  1. Complex Regional Pain Syndrome (CRPS)
    Bruehl, S. Complex regional pain syndrome. BMJ. 2015;351.
    http://rsds.org/wp-content/uploads/2014/12/CRPS-bruehl.pdf
  2. Brief Pain Inventory (BPI)
    http://nationalpaincentre.mcmaster.ca/documents/brief_pain_inventory.pdf
  3. PHQ-9
    http://www.ubcmood.ca/sad/PHQ-9.pdf
  4. GAD-7
    http://www.integration.samhsa.gov/clinical-practice/GAD708.19.08Cartwright.pdf
  5. Opioid Risk Tool
    http://nationalpaincentre.mcmaster.ca/opioid/cgop_b_app_b02.html
  6. Medical Mentoring for Addictions and Pain (MMAP)
    http://ocfp.on.ca/cpd/collaborative-networks/mmap
  7. Project ECHO
    http://www.echoontario.ca/Echo-Clinic/Chronic-Pain/Curriculum.aspx
  8. eConsult (OTN Hub)
    https://otnhub.ca/patient-care/
  9. Toronto Academic Pain Medicine Institute (TAPMI)
    http://www.womenscollegehospital.ca/Education-and-Training/tapmi
  10. The Inter-professional Spine Assessment and Education Clinics (ISAEC)
    http://www.isaec.org/refer-to-isaec.html
  11. Additional supporting materials and resources that may be useful for providers and patients:

    Provider Resources
  12. CORE Neck and Headache Tool
    https://thewellhealth.ca/neckheadpain/
  13. CORE Back Pain Tool
    https://thewellhealth.ca/low-back-pain/
  14. RxFiles Opioid Tapering template
    http://www.rxfiles.ca/rxfiles/uploads/documents/opioid-tapertemplate.pdf
  15. CFP Family Physician Summary of Canadian Opioid Guidelines
    http://www.cfp.ca/content/57/11/1257.full.pdf+html
  16. SBIRT (Screening, Brief Intervention, and Referral to Treatment)
    http://www.samhsa.gov/sbirt
  17. McMaster Health Sciences: Practice toolkit
    http://nationalpaincentre.mcmaster.ca/documents/practicetoolkit.pdf
  18. College of Physicians and Surgeons of Ontario (CPSO). Practice Partner: When and how to taper opioids.
    https://www.cpso.on.ca/uploadedFiles/members/resources/Opioid-Tapering-Protocols_Dial-I_2012.pdf
  19. Centres for Disease Control. Pocket Guide: Tapering opioids for
    chronic pain.
    https://www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf
  20. Ontario Pharmacy Evidence Network (OPEN). Evidence-based deprescribing algorithm for benzodiazepine receptor agonists.
    http://www.open-pharmacy-research.ca/evidence-baseddeprescribing-algorithm-for-benzodiazepines/
  21. RxFiles. Urine Drug Screening – Frequently Asked Questions.
    http://www.rxfiles.ca/rxfiles/uploads/documents/Urine-Drug-Screening-UDS-QandA.pdf
  22. Opioid Risk: Urine Drug Testing Guide.
    https://www.nhms.org/sites/default/files/Pdfs/UrineDrugTestingguide.pdf
  23. Patient Resources
  24. Centers for Disease Control and Prevention (CDC) – Prescription opioids: What you need to know
    http://www.cdc.gov/drugoverdose/pdf/aha-patient-opioid-factsheet-a.pdf
  25. McMaster University: Messages for patients taking opioids
    http://nationalpaincentre.mcmaster.ca/opioid/cgop_b_app_b04.html
  26. The Pain Toolkit
    http://www.paintoolkit.org/resources/videos
  27. RNAO Fact sheets: Helping people manage their pain
    http://rnao.ca/bpg/guidelines/fact-sheets/helping-you-manageyour-pain
  28. Mike Evans – Best Advice for People Taking Opioid Medication
    http://www.evanshealthlab.com/opioids/
  29. The Arthritis Society of Canada: Managing Chronic Pain
    https://arthritis.ca/manage-arthritis/living-well-with-arthritis/managing-chronic-pain
  30. My Opioid Manager (Book and App)
    http://prc.canadianpaincoalition.ca/en/my_opioid_manager_book.html
  31. Understanding Pain in less than 5 minutes, and what to do about it!
    https://www.youtube.com/watch?v=C_3phB93rvI
  32. Institute for Safe Medication Practices (ISMP) Canada Opioid Stewardship
    https://www.ismp-canada.org/opioid_stewardship/
  33. Canadian Pain Coalition – Pain Resource Centre
    http://prc.canadianpaincoalition.ca/en/
  34. People in Pain Network
    http://www.pipain.com/
  35. British Columbia Chronic Pain Self-Management Program
    http://www.selfmanagementbc.ca/chronicpainprogram
  36. NeuroNovo Centre for Mindful Solutions (formerly “for Mindfulness-Based Chronic Pain Management”)
    http://neuronovacentre.com
  37. Fact Sheet: Chronic Pain
    http://www.cpa.ca/docs/File/Publications/FactSheets/PsychologyWorksFactSheet_ChronicPain.pdf
  38. The Art of Pain Management
    https://theacpa.org/uploads/Art_and_Music_final.pdf
  39. Self-Management of Chronic Pain
    http://www.cirpd.org/PainManagement/WhatIsChronicPain/Pages/Self-Management.aspx#selfmanage
  40. Webinar – Intro to Mindfulness for Chronic Pain (5 part series)
    http://www.cirpd.org/Webinars/Pages/Webinar.aspx?wbID=24
  41. Webinar – Yoga for people in pain (5 part series)
    http://www.cirpd.org/Webinars/Pages/Webinar.aspx?wbID=16
  42. MoodGym – online CBT program
    https://moodgym.anu.edu.au/welcome
  43. Canadian Mental Health Association (CMHA)
    http://cmha-yr.on.ca/

References

  1. Scottish Intercollegiate Guideline Network (SIGN). Sign Guideline 136: Management of chronic pain. 2013.
    Centers for Disease Control and Prevention (CDC): CDC Guideline for Prescribing Opioids for Chronic Pain. 2016; 65(1).
    http://www.cdc.gov/drugoverdose/prescribing/guideline.html
  2. Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain. Canada: National Opioid Use Guideline Group (NOUGG). 2010 [cited 2016 June 2]. Available from:
    http://nationalpaincentre.mcmaster.ca/opioid/
  3. Registered Nurses’ Association of Ontario. Assessment and Management of Pain (3rd ed.). Toronto, ON: Registered Nurses’ Association of Ontario. 2013.
  4. Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain: Practice Toolkit. Canada: National Opioid Use Guideline Group (NOUGG). 2010. Available from: http://nationalpaincentre.mcmaster.ca/documents/practicetoolkit.pdf
  5. Centre for Effective Practice, University Health Network, and Toronto Rehab. Opioid Manager: Switching Opioids. 2011 [cited 2016 June 3] Available from:
    https://thewellhealth.ca/wp-content/uploads/2016/04/opioid_switching_form_april_13_final-1.pdf
  6. Nicholas MK, Linton SJ, Watson PJ, Main CJ and ‘Decade of the Flags’ Working Group. Early identification and management of psychological risk factors (“yellow flags”) in patients with low back pain: a reappraisal. Phys Ther 2011; 91(5):737-53.
  7. Centre for Effective Practice (2011). The Opioid Manager. Toronto: Centre for Effective Practice. [cited 2015 November 6] Available from:
    https://thewellhealth.ca/pain
  8. Bruckenthal P. Motivational interviewing in managing pain. [cited 2016 August 12] Available from: http://www.aspmn.org/Documents/Webinars/Handouts%207-24-15%20ASPMN%20Webinar.pdf
  9. Pain Toolkit. Motivational interviewing: a way of talking. [cited 2016 August 12] Available from: http://www.paintoolkit.org/news/article/motivationalinterviewing-a-way-of-talking
  10. Arthritis Canada. Physical activity & arthritis. [cited 2016 August 12] Available from:
    http://arthritis.ca/getmedia/2102ed41-cac6-44c0-ad8e-ac5a2dcbd2a2/PhysicalActivity-ArthritisGuide.pdf
  11. Centers for Disease Control and Prevention (CDC): Physical activity for arthritis. [cited 2016 July 12] Available from:
    http://www.cdc.gov/arthritis/basics/physical-activity-overview.html
  12. Office of Disease Prevention and Health Promotion (ODPHP). Physical activity guidelines advisory committee report. [cited 2016 August 12] Available from:
    https://health.gov/paguidelines/Report/G5_musculo.aspx
  13. American College of Rheumatology (ACR). ACR OA Guidelines: Non-pharmacological – knee and hip. 2009. [cited 2016 September 8] Available from:
    http://www.rheumatology.org/Portals/0/Files/ACR%20OA%20Guidelines%20Non-pharmacological%20-%20Knee%20and%20Hip.pdf
  14. Kahan M, Mailis-Gagnon A, Wilson L, Srivastava A. Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain: Clinical summary for family physicians. Part 1: General population. Can Fam Physician 2011; 57:1257-66.
  15. McAlindon TE, Bannuru RR, Sullivan MC, Arden NK, Berenbaum F, Bierma-Zeinstra SM, Hawker GA, Henrotin Y, Hunter DJ, Kawaguchi H, Kwoh K, Lohmander S, Rannou F, Roos EM, Underwood M. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage. 2014;22(3):363-88.
  16. National Institute for Health and Care Excellence (NICE). Osteoarthritis: Care and management. 2014 [cited 2016 September 8] Available from:
    https://www.nice.org.uk/guidance/cg177
  17. College of Family Physicians of Canada (CFPC). Authorizing Dried Cannabis for Chronic Pain or Anxiety: Preliminary Guidance from the College of Family Physicians of Canada. Mississauga, ON: College of Family Physicians of Canada; 2014. [cited 2016 September 8] Available from:
    http://www.cfpc.ca/uploadedFiles/Resources/_PDFs/Authorizing%20Dried%20Cannabis%20for%20Chronic%20Pain%20or%20Anxiety.pdf
  18. 2017 Draft Recommendations for Use of Opioids in Chronic Non-Cancer Pain. Canada: National Opioid Use Guideline Group (NOUGG). 2017 [cited 2017 February 2]. Available from:
    http://nationalpaincentre.mcmaster.ca/guidelines.html
  19. Department of Family and Community Medicine. University of Toronto. Chronic pain management one-pager. 2013. [cited 2016 August 8] Available from:
    http://dfcmopen.com/wp-content/uploads/2014/11/Chronic-Pain-Management.pdf
  20. Centre for Addiction and Mental Health. Prescription Opioid Policy Framework. Toronto: CAMH. 2016. [cited 2016 October 30] Available from:
    http://www.camh.ca/en/hospital/about_camh/influencing_public_policy/Documents/CAMHopioidpolicyframework.pdf
  21. Pottie K, Thompson W, Davies S, Grenier J, Sadowski C, Welch V, Holbrook A, Boyd C, Swenson JR, Ma A, Farrell B. 2016. Evidence-based clinical practice guideline for deprescribing benzodiazepine receptor agonists. (Unpublished manuscript) [cited 2016 August 1]. Available from:
    http://www.open-pharmacyresearch.ca/evidence-based-deprescribing-algorithm-for-benzodiazepines

Copyright & Disclaimer

CEP fully supports the use of the Management of Chronic Non-Cancer Pain Tool by providers, educators, decision-makers and others. Please read the following information prior to use of the tool to ensure appropriate permission is sought and appropriate citation is used.

Creative Commons License

Creative CommonsThe Management of Chronic Non-Cancer Pain Tool is a product of the Centre for Effective Practice.  Permission to use, copy and distribute this material for all non-commercial and research purposes is granted, provided that all copies, modifications, and distributions contain full reproductions of this Creative Commons License and the following Disclaimer along with appropriate citation.  Use of the Management of Chronic Non-Cancer Pain Tool for commercial purposes or any modifications of the tool are subject to charge and use must be negotiated with Centre for Effective Practice (Email: [email protected])

For statistical and bibliographic purposes, please notify the Centre for Effective Practice ([email protected]) of any use or reprinting of the tool.

Please use this citation when referencing the tool: Reprinted with Permission from Centre for Effective Practice (March 2017). Management of Chronic Non-Cancer Pain Tool. Toronto: Centre for Effective Practice.

Disclaimer

The Management of Chronic Non-Cancer Pain Tool (the “tool”) contains links to websites and other external resources (“Third Party Resources”) that are operated by and/or created by third party organizations.  These third party organizations are solely responsible for the information contained in, and the operation of (as applicable), their respective Their Party Resource(s).

This tool was developed for licensed health care professionals in Ontario as a guide only and does not constitute medical or other professional advice.  Primary care providers and other health care professionals are required to exercise their own clinical judgment in using this tool.

Neither the Centre for Effective Practice (“CEP”), Ontario College of Family Physicians, Nurse Practitioners’ Association of Ontario, Government of Ontario, the contributors to this tool, nor any of their respective agents, appointees, directors, officers, employees, contractors, members or volunteers: (i) are providing medical, diagnostic or treatment services through this tool; (ii) to the extent permitted by applicable law, accept any responsibility for the use or misuse of this tool by any individual including, but not limited to, primary care providers, or entity, including for any loss, damage or injury (including death) arising from or in connection with the use of this tool, in whole or in part; or (iii) give or make any representation, warranty or endorsement of any of the Third Party Resources, that are owned or operated by third parties, including any information or advice contained therein.