Chronic Non-Cancer Pain (CNCP) in the COVID-19 Context
Now more than ever it is important for your patients to look after their health and receive care from you as their healthcare provider. It’s essential that patients continue to seek out care that they need.
This tool has been developed to support primary care providers in navigating and providing patient care in a world where COVID-19 is the ‘new normal’, with considerations and recommendations on what’s ‘new’ and what’s ‘changed’ in the delivery of care for patients living with CNCP. While how care is delivered has changed, efforts should be made to ensure that the quality has not. As always, when treating your patients, continue to use your clinical judgement and follow standards of care, best practices, evidence and guidelines.
Seek support: The following information is for primary care providers who are proficient in CNCP management. If you need support providing the best care possible for your patients, consult specialists via OTN eConsult.
Individuals living with CNCP may be at an increased risk for contracting COVID-19 and experiencing mental health concerns. It is therefore important to put measures in place to ensure continuity of care for pain assessment, management and mental health supports for patients living with CNCP during this time.
Patients living with Chronic Non-Cancer Pain (CNCP) may be at an increased risk for:
- Contracting COVID‐19. CNCP may cause immunosuppression in some individuals, while opioids and steroids used by patients experiencing chronic pain can also suppress the immune response, increasing the risk of infection.
- Experiencing mental health concerns. Social isolation, stigma, loss of personal identity and financial stress, exacerbated during a pandemic, can negatively impact a patient’s quality of life and ongoing experience of pain.
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What's new, what's changed
Ensure continuity of care for those living with chronic pain during the COVID-19 pandemic.
Where feasible, minimize in-person visits to reduce their exposure risk.
- For all non-urgent patient appointments, use remote/virtual care for pain assessment and management, whenever possible.
- For semi-urgent patient appointments, use remote/virtual care approaches to evaluate the patient, triage the urgency and make suitable arrangements for further treatment and/or assessment that can include in-person care.
See the Primary Care Operations in the COVID-19 Context resource for details.
Emphasize biopsychosocial focus and multimodal management. Leverage remote/virtual platforms to support patients to engage with their multidisciplinary pain management team (physical therapist, psychologist, social worker, etc.).
Encourage and help connect patients with online supports:
- Online self‐management programs involving exercise, sleep hygiene, pacing and healthy lifestyle – see the Online Self-Management Program.
- Online cognitive behavioural therapy – see AbilitiCBT and MindBeacon.
- Additional resources and online workshops – see Resources for Canadians living with pain during COVID-19.
- Mental health support – see BounceBack, Wellness Canada and CEP’s Local Services Resource for Community Mental Health Programs.
Educate patients about their treatments and modify ongoing therapies to decrease COVID‐19 risk.
Putting it into practice
Use the following tips for engaging in remote/virtual care for CNCP (Pain, March 20, 2020):
Technology options: When deciding on the best format to provide remote care, consider audio and video quality, background distractions, and lighting. If possible, maintain contact with patients on a regular basis (e.g. once a week or once a month) and avoid switching to PRN contact only. See Primary Care Operations in the COVID-19 Context > Delivering patient care remotely for more information on providing remote care.
Troubleshoot technical issues: If technical issues occur during a session, use this opportunity to model and practice effective problem-solving skills with the patient. Have a backup option agreed upon with the patient in advance.
Scheduling appointments: Ask patients to schedule appointments at a time and place that is free of distractions, so that they will be able to focus on your discussion. In the case of child or adolescent patients, help to structure the session to allow time with both the child and parent. Whenever multiple people are in the room, ask for introductions of all present.
Complementary resources: Identify remote self-help interventions that the patient may use in combination with remote sessions with their healthcare provider. These may include online self‐management programs, books, online materials, smartphone apps, etc.
Positively reinforce patient’s self-management efforts: One of the best ways to do this is to ask for details about strategy use (e.g. what strategies seem to work, where and when did you use the strategy, and what was the outcome). Ask patients about how they motivated themselves to use that strategy and how things went different when they used it. If patients are using self-help online intervention, ask patients specifically what part of the online program or app they have reached and how they have been using the strategies.
Problem solve: Work with the patient to problem solve around difficulties in managing pain. Use a patient-centered approach that encourages them to identify barriers and implement potential solutions. The current context of COVID-19 brings specific challenges to problem solving, and potential anxiety behaviour should be accounted for.
Experiential learning: If possible, include some experiential learning in the session, i.e. work with the patient on a task that may help them in managing pain. This might take the form of helping them develop a daily schedule for their pain management efforts (i.e. taking medication, doing physical exercises, and engaging in physical activities that are meaningful to them). Or it might involve guiding the patient through a brief imagery, meditation, or relaxation exercise. Try to enhance patient mastery of the task by asking the patient what about the task or exercise was easier for them (and why) and what challenges they experienced and how they might address them.
Setting goals: At the end of the session, work with the patient to identify specific goals that are meaningful to them and doable that they should complete before your next session. Let them know you will start the next session by going over the goals with them.
Self-help activities: Integrate self-help activities into the overall treatment goals. At the end of the session, assign patients a specific self-help task to complete before their next session (e.g. download app, work through the first exercise).
Remember the context: Always be flexible: this is a stressful time for everyone, but particularly for those with long-term conditions. Each patient will be dealing with extra pressures (e.g. financial, childcare, and health of others) that may influence their pain and ability to cope.
Putting it into practice
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- An in-person evaluation may not be needed for continued management.
- An in-person evaluation is required for any significant, sustained increase in opioid prescribing.
- Ensure patients receive their appropriate prescriptions to avoid withdrawal. Ensure availability of naloxone kits and training on their use.
- Whether in person or remote, assessments should still adhere to recommended opioid safe prescribing procedures (CEP, November 2017).
Non‐steroidal anti‐inflammatory drugs (NSAIDs)
- Patients can continue use. Monitor for adverse effects.
- See Medication cautions: COVID-19 and NSAIDs for more information.
- Consider the risks (immune suppression, altered immune response, adrenal insufficiency, etc.) and benefits of continued use.
- Consider the use of a decreased doses if possible.
- Chronic Non-Cancer Pain Tool (CEP, May 2018).
- Caring for patients with pain during the COVID‐19 pandemic: consensus recommendations from an international expert panel (Shanthanna et al, April 7, 2020).
- Online Self-Management Program (2019).
- Resources for Canadians living with pain during COVID-19 (Government of Canada, 2020).
- Guided sessions for movement and relaxation for pain during COVID-19 (Pain BC, 2020).
These supporting materials and resources are hosted by external organizations. The accuracy and accessibility of their links are not guaranteed. CEP will make every effort to keep these links up to date.
Acknowledgement and legal New
The COVID-19 Resource Centre was developed by the Centre for Effective Practice (CEP) in collaboration with the Department of Family Medicine at McMaster University, the Ontario College of Family Physicians and the Nurse Practitioners’ Association of Ontario using a rapidly modified version of the CEP’s integrated knowledge translation approach. They are some of several clinical resources developed as part of the Knowledge Translation in Primary Care Initiative. 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.
Clinical Working Group
A clinical working group was established and provides significant input and oversight into the development of this resource. Members include:
• Claudia Mariano, MSc, NP-PHC
• Darren Larsen, MD, CCFP, MPLc
• Derelie Mangin, MBChB (Otago), DPH (Otago), FRNZCGP (NZ)
• Dominik Nowak, MD MHSc, CCFP, CH
• Jennifer P. Young, MD, FCFP-EM
• Lee Donohue MD, CCFP, MHSc, MPLc
• Mira Backo-Shannon, MD, BSc, MHSc
• Paul Preston, MD, CCFP, CCPE, CHE
• Rob Annis, MD, CCFP
• Soreya Dhanji, MD, CCFP
In addition to our clinical working group the CEP also obtained feedback from others, including:
• Arun Radhakrishnan, MSC, MD, CM, CCFP
• Central Region Primary Care Leadership
• David Daien, MD, CCFP
• David Makary, MD, CCFP
• David Price, BSC, MD, CCFP, FCFP
• Jose Silveira, BSC, MD, FRCPC, DIP, ABAM
• Michael Chang MD, FRCP(C)
• Payal Agarwal, MD, CCFP
• Robert Sauls MD, CCFP(PC), FCFP
• Tara Walton, MPH
Lastly, for certain sections, the CEP also obtained feedback from others, specifically:
Readiness assessment for delivering in-person care
Operational requirements for in-person care
COVID-19 Provincial Primary Care Advisory Table
• David Price (Chair), MD
• Andrea Sereda, MD
• Annelind Wakegijig, MD
• Beth Sweeney
• Cathy Faulds, MD
• David Daien, MD
• David Kaplan, MD
• Kamila Premji, MD
• Kelly Van Camp
• Kim McIntosh, MD
• Michael Green, MD
• Rebecca Carson
• Sarah Newbery, MD
• Thuy-Nga (Tia) Pham, MD
• Registered Nurses Association of Ontario
• Association of Family Health Teams of Ontario
Thank you to everyone who supported the development of this resource.
Conflict of interest
• Clinical Leads receive compensation for their role
• Clinical Working Group receive an honorarium for their participation
• Focus group and usability participants receive a small token of appreciation (e.g. gift certificate)
The Chronic Non-Cancer Pain (CNCP) in the COVID-19 Context resource 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 the above disclaimer, this paragraph and the following paragraphs, and appropriate citations appear in all copies, modifications, and distributions. Use of the Chronic Non-Cancer Pain (CNCP) in the COVID-19 Context resource for commercial purposes or any modifications of the Tool are subject to charge and use must be negotiated with the Centre for Effective Practice (Email: firstname.lastname@example.org).
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