Management of Chronic Non-Cancer Pain

Last Updated: July 7, 2020

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This tool is designed to help family physicians and nurse practitioners (primary care providers) develop and implement a management plan for adult patients with chronic non-cancer pain (CNCP) in the primary care setting. CNCP is defined as pain that typically persists or recurs for more than 3 months or past the time of normal tissue healing.^1-4 This tool applies to, but is not limited to pain conditions such as osteoarthritis, low back pain, musculoskeletal pain, fibromyalgia and neuropathic pain.

See Supporting material and resources and References for links to tools and guidelines to assist with diagnosis.

Please note, this tool is not suitable for use in the management of acute pain and is not designed to assist in diagnosing various CNCP conditions. Management of chronic pelvic pain is not within the scope of this tool.

Introduction

This tool focuses on a multi-modal approach to manage CNCP. Primary care providers should use non-pharmacological options, with or without pharmacological options, to build a comprehensive and personalized plan that incorporates the patient’s goals.³

General approach

Work with your patients to identify and understand the complex bio-psycho-social elements involved in their pain and emphasize the value of a multi-modal approach to manage their pain. Management is often a process of repeated trials to determine the effects of specific treatments and can take a few months or years to optimize. Once a treatment plan is identified, initiate, adapt and evaluate how it improves daily function, pain, mood and quality of life, while assessing the risks/benefits for long-term use. It is also important to optimally manage any active underlying health issues related to a patient’s pain (e.g. diabetes, inflammatory arthritis).

Step 1: Assess

Begin to develop a rapport with the patient to encourage trust and information sharing. Start with a thorough baseline assessment, which you may need to be completed over more than one visit.¹

Jump to:
Baseline and ongoing assessment

Step 2: Create a management plan

Based on the assessment, identify the non-pharmacological and/or pharmacological treatments that you and your patient feel comfortable starting.

Jump to:
Management plan
Non-pharmacological therapies
Non-opioid medications
Opioid medications

Step 3: Initiate, adapt and evaluate treatment(s)

Use the patient record and treatment plan to help initiate, adapt and evaluate the non-pharmacological and/or pharmacological treatments on an ongoing basis.

Jump to:
Management plan
Non-pharmacological therapies
Non-opioid medications
Opioid medications

Step 4: Refer, as appropriate

When appropriate, consider referral to a specialist or multidisciplinary clinic.

Jump to:
Intervention management and referral

Expand All

Baseline and ongoing assessment

The Baseline and Ongoing Assessment guides are designed to help develop and monitor a treatment plan for patients with CNCP. They are not designed to diagnose specific CNCP conditions. Consider completing a thorough Baseline Assessment for the following:

Patients with a new diagnosis of CNCP
Patients who are new to your practice with a diagnosis of CNCP
Patients currently in your practice with a diagnosis of CNCP

Guidance on conducting a baseline assessment

Identify pain diagnoses (e.g. osteoarthritis, fibromyalgia, neuropathic pain, etc.)
Document relevant physical examination based on diagnosed pain condition(s)
If suspected Complex Regional Pain Syndrome (CRPS), consider urgent referral
Complete Brief Pain Inventory (BPI): intensity; exacerbating and alleviating factors; character; systemic symptoms; duration, assess functional status and impairment
Past investigations/consultations
Response to current/past treatments (consider whether trial was long enough to evaluate efficacy/side effects)
Past medical history
Current medications (including prescription, non-prescription, and natural products)

Assess functional status and impairment (e.g. BPI)
Psychosocial history: living arrangements; family/social support; family obligations; work status; sleep; relationships

Current and past psychiatric history (e.g. depression PHQ-9, anxiety GAD-7, PTSD)
Family psychiatric history

Review history of substance use, abuse, and addiction (start with family history then personal)
Alcohol, cannabis, prescription medications, illicit drugs Attendance at an addiction treatment program
If on opioids, review for the presence of any opioid use disorder features. May use Opioid Risk Tool, however, it has insufficient accuracy for risk stratification
Use urine drug testing before starting opioid therapy. Consider annual urine drug testing (or more often, as appropriate) for the use of opioid medication and/or illicit drugs

Assess the following to identify patients with CNCP who are at risk for poor outcomes:
- Biomedical: severe pain or increased disability at presentation; previous significant pain episodes; multi-site pain; non-organic signs; iatrogenic factors
- Psychological: belief that pain indicates harm; expectation that passive rather than active treatments are most helpful; fear-avoidance behaviour; catastrophic thinking; poor problem-solving ability; passive coping strategies; atypical health beliefs; psychosomatic perceptions; high levels of distress
- Social: low expectations of return to work; lack of confidence in performing work activities; heavier workload; low levels of control over rate of workload; poor work relationships; social dysfunction/isolation; medico-legal issues

Guidance on conducting an ongoing assessment

Identify new pain, related symptoms or significant change (physical examination as indicated)

Assess the following to identify patients with CNCP who are at risk for poor outcomes:
- Biomedical: severe pain or increased disability at presentation; previous significant pain episodes; multi-site pain; non-organic signs; iatrogenic factors
- Psychological: belief that pain indicates harm; expectation that passive rather than active treatments are most helpful; fear-avoidance behaviour; catastrophic thinking; poor problem-solving ability; passive coping strategies; atypical health beliefs; psychosomatic perceptions; high levels of distress
- Social: Low expectations of return to work; lack of confidence in performing work activities; heavier workload; low levels of control over rate of workload; poor work relationships; social dysfunction/isolation; medico-legal issues

Note: 30% improvement is meaningful for pain and function²

Assess using validated tools (e.g.BPI)
Monitor adherence to pharmacological and pharmacological therapies
Monitor adverse events
Determine effect on pain, function, quality of life, mood and social function
Progress towards patient’s SMART (Specific, Measurable, Agreed-upon, Realistic, Time-based) goals, e.g. taking walks, attending family/social events, returning to part-time work, participating in recreational activities

If on opioids, monitor for aberrant drug-related behaviours, clinical features of Opioid Use Disorder
Use urine drug testing as indicated
In patients with current or past substance use disorder (SUD), monitor for destabilization of disease
Monitor for aberrant use of prescribed medications

* Patients at higher risk of poor outcomes may require closer follow-up and greater emphasis on a diversified non-pharmacological and pharmacological, multi-modal approach to treatment⁶

Management plan

Based on the assessment, identify the non-pharmacological and/or pharmacological treatments that you and your patient feel comfortable starting. To learn more about the non-pharmacological and/or pharmacological options, considerations and guidance on initiating, adapting, and evaluating treatments click on the relevant sections below.

Patient record and treatment plan

cncp-patient-record-treatment-plan.pdf

Download

This patient record and treatment plan is designed to help providers document the ‘agreed-on’ plan that can be filed in a patient’s chart and referred to during subsequent visits to follow up and continue discussion. Download the patient record and treatment plan to help initiate, adapt and evaluate the agreed upon non-pharmacological and/or pharmacological treatments.

Non-pharmacological therapies

Non-pharmacological treatments should be considered for all patients with CNCP.¹ Choose treatments that you and the patient feel comfortable with and then initiate, adapt, and evaluate the treatment plan (use motivational interviewing techniques, as appropriate).

When determining the benefit of a therapy, an improvement of 30% in pain and function scores is considered clinically meaningful;² however, even a smaller improvement may be meaningful to the patient.

Recommendations

Exercise, regardless of form, is recommended for the management of chronic non-cancer pain¹
Cognitive behavioural therapy (CBT) should be considered for the treatment of patients with chronic pain¹

Tips on initating treatment(s)

Recommend general activity and exercise therapies, as appropriate
Recommend combined home and group physical activities to help increase overall activity levels
If the patient is reluctant to try physical activity/exercise therapies try the Elicit-Provide-Elicit technique:^7,8
- Elicit the patient’s thoughts/feelings: “How do you feel about trying some exercise therapy for your pain?”
- Provide information: A common patient concern is that exercise therapy will increase pain: “If I understand correctly, you are concerned that physical activity will increase your pain. Interestingly, it actually tends to do the opposite; physical activity can be an effective way of decreasing pain.”
- Elicit the patient’s opinion: “What do you think about this?”
Pick a low impact physical activity, such as walking, pilates, Tai Chi, yoga or aquatic therapy
Start low and go slow (e.g. 5 min every other day) and aim for a moderate level of intensity of activity^2,9
Consider referral to a physiotherapist if more intensive support is required

Particularly valuable for those with co-morbid depression and/ or anxiety
Start with one of the following psychological therapies: CBT, Mindfulness Based Intervention (MBI), Acceptance Commitment Therapy or Respondent Behavioural Therapy
Consider referral to a psychotherapist, social worker, occupational therapist and/or other mental health professional if more intensive support is required

A self-management program should be considered to complement other therapies patients have initiated¹

Consider any of the following for short-term relief of pain:¹
- Manual therapy
- TENS
- Low level laser therapy
Consider referral to a physiotherapist, chiropractor or osteopath, as appropriate

Tips on adapting treatment(s)

Improve adherence to home physical activity by encouraging graded activity: add 10 min every 3-4 weeks¹⁰
Minimal goal: 30 min of exercise 5 days a week^2,11
Add in other activities as tolerated

Encourage patients to continue to use strategies learned from therapies

Encourage patients to continue to use strategies learned from the program

Encourage patients to participate in 8 therapy sessions over 4-6 weeks¹²

Tips on evaluating treatment(s)

Measure benefits at 8 or more weeks¹¹
Use BPI to evaluate effect on pain, function and quality of life
If benefits are not identified, try other activity types and continue to counsel about the value of exercise and activity

Use tools like BPI, PHQ-9 to evaluate effect on pain, function and quality of life
Add other types of therapies as appropriate
Rarely, may exacerbate some underlying mental illnesses

After program completion use tools like BPI to evaluate effect on pain, function and quality of life

Follow up after completion of 8 sessions
Use BPI to evaluate effect on pain, function and quality of life

Options

Physical activity/exercises^1,20,21

Scroll (left-right) for details

Aerobic exercise (e.g. walking)
Pain type
- Fibromyalgia
Level of evidence
••
Role in therapy
- Improved global well being and physical function, reduced pain²⁰
Strengthening exercise (e.g. lifting weights)
Pain type
- Fibromyalgia
- Non-specific low back pain
Level of evidence
•
Role in therapy
- Global well being, pain and physical function (fibromyalgia²⁰)
Core stabilising exercises (e.g. pilates)
Pain type
- Fibromyalgia
- Non-specific low back pain
Level of evidence
- Not reported in guideline
Role in therapy
- Reducing pain (non-specific low back pain¹, fibromyalgia²⁰)
Tai Chi
Pain type
- Fibromyalgia
- Chronic arthritis
Level of evidence
- Not reported in guideline
Role in therapy
- Reducing pain, improving disability (arthritis¹), quality of life (fibromyalgia²⁰)
Yoga (any type)
Pain type
- Fibromyalgia
- Headache
- Low back pain
- Rheumatoid arthritis
Level of evidence
- Not reported in guideline
Role in therapy
- Reducing pain and disability (headache, back pain, rheumatoid arthritis²¹)
- Improved quality of life, pain and function (fibromyalgia²⁰)
Therapeutic aquatic exercise
Pain type
- Fibromyalgia
- Headache
- Low back pain
- Rheumatoid arthritis
Level of evidence
••
Role in therapy
- Improved pain, quality of life, physical function, muscle strength (fibromyalgia²⁰, low back pain¹)

Psychological therapies

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Cognitive Behavioural Therapy (CBT)
Pain type
- Orofacial pain
- Low back pain
- Neck pain
- Rheumatoid arthritis
- Fibromyalgia
Level of evidence
••
Role in therapy
- Reduced pain (orofacial, low back pain, fibromyalgia)^1,23; reduced use of analgesics (low back pain); reduced disability (low back pain¹, fibromyalgia²³); improved quality of life (low back pain); improved coping (low back pain, fibromyalgia); reduced depression (low back pain¹, fibromyalgia³); reduced physician visits (low back pain); mproved sleep¹
Harms
- Rarely may include worsening of co-existing mental disorders
Mindfulness based interventions
Pain type
- Fibromyalgia
- Low back pain
- Rheumatoid arthritis
- Musculoskeletal pain
Level of evidence
••
Role in therapy
- Reduced pain, reduced depression and anxiety, improved quality of life
Harms
- Not reported in guideline
Acceptance and Commitment Therapy
Pain type
- Osteoarthritis
- Neuropathic pain
- Low back pain
Level of evidence
•••
Role in therapy
- Improved depression and anxiety
Harms
- Not reported in guideline
Respondent behavioural therapies
Pain type
- Low back pain
Level of evidence
••
Role in therapy
- Short term pain reduction, reduction in disability
- No better than Cognitive Behavioural Therapy
Harms
- Not reported in guideline

Self-management programs¹² and physical therapies

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Self-management programs
Pain type
- Osteoarthritis
- Rheumatoid arthritis
- Fibromyalgia
- Low back pain
- Neck pain
- Shoulder pain
Level of evidence
••
Role in therapy
- Reduced pain and disability (arthritis)²⁰
View Additional Content
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Self-management program characteristics
Primarily educational using interactive and collaborative method often run by patients
Focus on taking an active part in managing their pain
Delivered as: individuals, face-to-face or electronically
Content may include: education around goal setting, self-monitoring, psychological and rehabilitation interventions (e.g. exercise therapies)
Harms
Possible increased pain with exercise, resulting in drop out from programs: if this occurs, explore with the patient how best to help them cope²¹
Manual therapy
Pain type
- Low back pain
- Neck pain
Level of evidence
•••
Role in therapy
- Manual therapy should be considered for short term pain relief of patients with chronic low back pain
- Manual therapy in combination with exercise should be considered for the treatment of patients with chronic neck pain
- Short term: pain relief, functional improvement and cervicogenic headache¹
TENS
Pain type
- Neuropathic pain
- Low back pain
Level of evidence
•••
Role in therapy
- TENS should be considered for the relief of chronic pain; either low or high frequency can be used
- Pain (neuropathic pain)¹, improved function (low back pain)¹
Low level laser therapy
Pain type
- Low back pain
Level of evidence
•••
Role in therapy
- Low level laser therapy should be considered as a treatment option for patients with chronic low back pain
- Reduced pain¹

LEGEND: CATEGORIES FOR LEVELS OF EVIDENCE (according to original guidelines’ taxonomy)
••• Highest level of evidence (meta-analyses; systematic reviews of RCTs; RCTs with varying levels of bias)
•• Mid-level evidence (systematic reviews of case studies; high quality case control or cohort studies; experimental studies w/o randomization; case reports or studies)
• Low-level evidence (expert opinion and/or clinical experiences of respected authorities/guideline development group)

Resources

For providers

For patients

Non-opioid medications New

Non-opioid medications, in combination with non-pharmacological therapies, are the preferred treatment for CNCP.¹Choose a treatment that you and the patient feel comfortable with and then initiate, adapt, and evaluate the treatment plan.

Most patients have either a good response (an improvement of 30% in pain and function scores is considered clinically meaningful) or have no response.²

Recommendations

Start with ONE medication and evaluate

Use a sequential manner (versus parallel) to trial a second medication, if needed

Minimize polypharmacy as much as possible

Click for tips on

Some antidepressants can have a role for neuropathic pain, as well as for nociceptive pain, such as osteoarthritis

Select one medication based on patient’s pain type and professional judgment of risks/benefits
Agree with patient on goals (pain reduction, improved function/mood, other)
Agree on length of initial trial (usually 2 weeks at optimum dose, up to 4 weeks for antidepressants)
Discuss potential side effects/risks
Be aware of concomitant over-the-counter treatments and advise accordingly
Where possible, avoid concomitant sedative and hypnotic medications; be aware of concomitant alcohol use and counsel that there is an increased risk of overdose if alcohol and opioids are used together^1,2
Start at recommended dose

Adjust, as needed, up to an effective dose, unless limited by side effects
Do not exceed the maximum dose

Evaluate effects on pain, function, mood and set goals
Use pain and function assessment scales,¹³e.g. BPI)
Consider trialing two or three drugs in succession from the same class if one is ineffective¹
Avoid co-prescribing two drugs from the same class
Due to safety risks associated with use of oral NSAIDs, use conservative dosing for the shortest possible duration consistent with approved prescribing limits¹⁴
Regularly review ongoing value of each medication
If drug does not produce a meaningful improvement, stop or taper drug¹

Options

General non-opioid medications¹:

Scroll (left-right) for details

Acetaminophen
Pain type
- Osteoarthritis (hip or knee)
Level of evidence
•••

Role in therapy
- Should be considered for hip or knee osteoarthritis (alone or in combination with NSAIDs), in addition to non-pharmacological treatments
View Dosage, Potential Harms & More
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Dosage*
1000-4000 mg/day¹
Dose provided in product labelling (maximum 4000 mg/day) is for short term treatment (5 days)²⁵
There is greater risk (including gastrointestinal adverse events and multi-organ failure) from acetaminophen with extended duration of use, use conservative dosing and treatment duration²⁶
Potential harms
Can be hepatotoxic at doses greater than 3-4 grams/ day and at lower dosages in patients with chronic alcohol use or liver disease²
Consider liver function tests if hepatic risk (history of liver problems or alcohol abuse, long-term use)²⁴
Reduce dose in liver insufficiency or alcohol dependence²
Many medications (e.g. over-the-counter cough and cold and pain relief products) contain acetaminophen; read the label and avoid exceeding maximum dose²⁵
Tapering**
Tapering not required

* Titrate until efficacy or intolerance.^{26, 17} Counsel that side effects often diminish after 1-2 weeks.²⁴
** Tapering recommendations are intended as general guidelines only. Monitor the patient’s response to dosage changes and use clinical judgment to base the pace of the taper on the patient’s response to prior dosage reductions.⁴³
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Celecoxib
Pain type
- Low back pain
- Osteoarthritis
Level of evidence
•••
Role in therapy
- Should be considered for chronic nonspecific low back pain
- May have synergistic, dose-sparing effect when added to opioids¹⁷
View Dosage, Potential Harms & More
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Dosage*
100 mg twice daily or 200 mg once daily (200 mg twice daily for rheumatoid arthritis, 200 mg/day for other type of pain)³⁰
Allow 1-2 weeks for full effect²⁴
Consider lower doses in the elderly²⁹
Swallow whole, take with food^27,28,30,31
Due to serious safety risks associated with oral NSAID use, use conservative dosing and treatment duration consistent with approved prescribing limits²⁶
Potential harms
Risk of gastrointestinal bleeding/perforation, gastritis, and peptic ulcer disease^2,17
Causes fluid retention²³
Avoid in severe renal dysfunction (CrCl < 30 mL/ min) or deteriorating renal disease; use caution if CrCl = 30-59 mL/min^27,28
Avoid in severe hepatic impairment
Avoid during pregnancy (3rd trimester) or breastfeeding, severe uncontrolled heart failure, severe allergy to acetylsalicylic acid or NSAIDs, active peptic ulcer disease, cerebrovascular disease, inflammatory bowel disease, or known hyperkalemia²⁷
Monitor blood pressure and signs of heart failure
Avoid in the elderly (consider topicals instead)¹⁷
Cardiovascular risks (heart attack and stroke)²
Ibuprofen (but not other NSAIDs) interacts with acetylsalicylic acid to make it less effective for cardioprotection and stroke prevention¹²
Tapering**
Tapering not required

** Tapering recommendations are intended as general guidelines only. Monitor the patient’s response to dosage changes and use clinical judgment to base the pace of the taper on the patient’s response to prior dosage reductions.⁴³
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Diclofenac
Pain type
- Low back pain
- Osteoarthritis
Level of evidence
•••
Role in therapy
- Should be considered for chronic nonspecific low back pain
- May have synergistic, dose-sparing effect when added to opioids²⁰
View Dosage, Potential Harms & More
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Dosage:*
Diclofenac regular-release: 75-100 mg daily (divided into 3 daily doses; max 100 mg/day)²³
Diclofenac sustained release: 75-100 mg once daily (max 100 mg/day)³⁰
Diclofenac + misoprostol: 50 mg (diclofenac) + 200 mg (misoprostol) bid (max dose same as starting dose)³⁴
Allow 1-2 weeks for full effect²⁷
Consider lower doses in the elderly³²
Swallow whole, take with food^30,31,33,34
Due to serious safety risks associated with oral NSAID use, use conservative dosing and treatment duration consistent with approved prescribing limits²⁹
Potential harms
Risk of gastrointestinal bleeding/perforation, gastritis, and peptic ulcer disease^2,20
Causes fluid retention²⁶
Avoid in severe renal dysfunction (CrCl < 30 mL/ min) or deteriorating renal disease; use caution if CrCl = 30-59 mL/min^30,31
Avoid in severe hepatic impairment
Avoid during pregnancy (3rd trimester) or breastfeeding, severe uncontrolled heart failure, severe allergy to acetylsalicylic acid or NSAIDs, active peptic ulcer disease, cerebrovascular disease, inflammatory bowel disease, or known hyperkalemia³⁰
Monitor blood pressure and signs of heart failure
Avoid in the elderly (consider topicals instead)²⁰
Cardiovascular risks (heart attack and stroke)²
Ibuprofen (but not other NSAIDs) interacts with acetylsalicylic acid to make it less effective for cardioprotection and stroke prevention¹⁴
Tapering**
Tapering not required

* Titrate until efficacy or intolerance.^{26, 17} Counsel that side effects often diminish after 1-2 weeks.²⁴
** Tapering recommendations are intended as general guidelines only. Monitor the patient’s response to dosage changes and use clinical judgment to base the pace of the taper on the patient’s response to prior dosage reductions.⁴⁶
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Ibuprofen
Pain type
- Low back pain
- Osteoarthritis
Level of evidence
•••
Role in therapy
- Should be considered for chronic nonspecific low back pain
- May have synergistic, dose-sparing effect when added to opioids¹⁷
View Dosage, Potential Harms & More
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Dosage*
Ibuprofen regular-release formulation: 200-400 mg q6-8h (max 1200 mg/day)^32,33
Ibuprofen 12-hour formulation: 600 mg q12h (max 1200 mg/day)^32,33
Allow 1-2 weeks for full effect²⁴
Consider lower doses in the elderly²⁹
Swallow whole, take with food^27,28,30,31
Due to serious safety risks associated with oral NSAID use, use conservative dosing and treatment duration consistent with approved prescribing limits²⁶
Potential harms
Risk of gastrointestinal bleeding/perforation, gastritis, and peptic ulcer disease^2,17
Causes fluid retention²³
Avoid in severe renal dysfunction (CrCl < 30 mL/ min) or deteriorating renal disease; use caution if CrCl = 30-59 mL/min^27,28
Avoid in severe hepatic impairment
Avoid during pregnancy (3rd trimester) or breastfeeding, severe uncontrolled heart failure, severe allergy to acetylsalicylic acid or NSAIDs, active peptic ulcer disease, cerebrovascular disease, inflammatory bowel disease, or known hyperkalemia²⁷
Monitor blood pressure and signs of heart failure
Avoid in the elderly (consider topicals instead)¹⁷
Cardiovascular risks (heart attack and stroke)²
Ibuprofen (but not other NSAIDs) interacts with acetylsalicylic acid to make it less effective for cardioprotection and stroke prevention¹²
Tapering**
Tapering not required

* Titrate until efficacy or intolerance.^{26, 17} Counsel that side effects often diminish after 1-2 weeks.²⁴
** Tapering recommendations are intended as general guidelines only. Monitor the patient’s response to dosage changes and use clinical judgment to base the pace of the taper on the patient’s response to prior dosage reductions.⁴³
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Meloxicam
Pain type
- Low back pain
- Osteoarthritis
Level of evidence
•••
Role in therapy
- Should be considered for chronic nonspecific low back pain.
- May have synergistic, dose-sparing effect when added to opioids¹⁷
View Dosage, Potential Harms & More
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Dosage*
7.5-15 mg daily (max 15mg/ day)³⁴
Allow 1-2 weeks for full effect²⁴
Consider lower doses in the elderly²⁹
Swallow whole, take with food^27,28,30,31
Due to serious safety risks associated with oral NSAID use, use conservative dosing and treatment duration consistent with approved prescribing limits²⁶
Potential harms
Risk of gastrointestinal bleeding/perforation, gastritis, and peptic ulcer disease^2,17
Causes fluid retention²³
Avoid in severe renal dysfunction (CrCl < 30 mL/ min) or deteriorating renal disease; use caution if CrCl = 30-59 mL/min^27,28
Avoid in severe hepatic impairment
Avoid during pregnancy (3rd trimester) or breastfeeding, severe uncontrolled heart failure, severe allergy to acetylsalicylic acid or NSAIDs, active peptic ulcer disease, cerebrovascular disease, inflammatory bowel disease, or known hyperkalemia²⁷
Monitor blood pressure and signs of heart failure
Avoid in the elderly (consider topicals instead)¹⁷
Cardiovascular risks (heart attack and stroke)²
Ibuprofen (but not other NSAIDs) interacts with acetylsalicylic acid to make it less effective for cardioprotection and stroke prevention¹²
Tapering**
Tapering not required

* Titrate until efficacy or intolerance.^{26, 17} Counsel that side effects often diminish after 1-2 weeks.²⁴
** Tapering recommendations are intended as general guidelines only. Monitor the patient’s response to dosage changes and use clinical judgment to base the pace of the taper on the patient’s response to prior dosage reductions.⁴³
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Naproxen
Pain type
- Low back pain
- Osteoarthritis
Level of evidence
•••
Role in therapy
- Should be considered for chronic nonspecific low back pain.
- May have synergistic, dose-sparing effect when added to opioids¹⁷
View Dosage, Potential Harms & More
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Dosage*
220 mg strength: 220 mg q 8-12h (max 440 mg/day)²⁸
125, 250, 375, and 500 mg strengths: starting dose 250 mg bid may be increased to 375-500 mg bid; usual max = 1000 mg/day (may be increased to 1500 mg/day for limited periods with careful monitoring)³⁵
275 and 550 mg strengths: 275 mg q6-8h (max 1375 mg/day) or 550 mg bid⁶⁶
750 mg sustained-release strength: 750 mg once daily (max 750 mg/day)³⁵
Allow 1-2 weeks for full effect²⁴
Consider lower doses in the elderly²⁹
Swallow whole, take with food^27,28,30,31
Due to serious safety risks associated with oral NSAID use, use conservative dosing and treatment duration consistent with approved prescribing limits²⁶
Potential harms
Risk of gastrointestinal bleeding/perforation, gastritis, and peptic ulcer disease^2,17
Causes fluid retention²³
Avoid in severe renal dysfunction (CrCl < 30 mL/ min) or deteriorating renal disease; use caution if CrCl = 30-59 mL/min^27,28
Avoid in severe hepatic impairment
Avoid during pregnancy (3rd trimester) or breastfeeding, severe uncontrolled heart failure, severe allergy to acetylsalicylic acid or NSAIDs, active peptic ulcer disease, cerebrovascular disease, inflammatory bowel disease, or known hyperkalemia²⁷
Monitor blood pressure and signs of heart failure
Avoid in the elderly (consider topicals instead)¹⁷
Cardiovascular risks (heart attack and stroke)²
Ibuprofen (but not other NSAIDs) interacts with acetylsalicylic acid to make it less effective for cardioprotection and stroke prevention¹²
Tapering**
Tapering not required

* Titrate until efficacy or intolerance.^{26, 17} Counsel that side effects often diminish after 1-2 weeks.²⁴
** Tapering recommendations are intended as general guidelines only. Monitor the patient’s response to dosage changes and use clinical judgment to base the pace of the taper on the patient’s response to prior dosage reductions.⁴³

Anticonvulsants¹ and antidepressants¹:

Anticonvulsants with insufficient evidence to support use in chronic pain:¹ Sodium valproate, lacosamide, lamotrigine, phenytoin, clonazepam, levetiracetam, topiramate

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Carbamazepine
Pain type
- Trigeminal neuralgia (may also be used for general neuropathic pain)
Level of evidence
•••
Role in therapy
- Should be considered for neuropathic pain
View Dosage, Potential Harms & More
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Dosage*
Initiation: 100 mg – 200 mg daily
Titration: increase biweekly by 100-200 mg/ day
Usual maintenance dose: 200- 800 mg per day (in 2 to 4 divided doses)
Doses of up to 1200-1600 mg/ day have been used^1,36
Potential harms
May cause blood dyscrasias and liver toxicity¹⁷
Monitor blood counts and liver function tests²⁷
Enzyme inducer – may interfere with other drugs such as warfarin¹
Tapering**
Every 3 months, consider discontinuing or reducing the dose³⁶
Requires tapering: reduce dose by approximately 20% each week (faster if patient has reduced liver function)³⁷

* Titrate until efficacy or intolerance.^{26, 17} Counsel that side effects often diminish after 1-2 weeks.²⁴
** Tapering recommendations are intended as general guidelines only. Monitor the patient’s response to dosage changes and use clinical judgment to base the pace of the taper on the patient’s response to prior dosage reductions.⁴³
Gabapentin
Pain type
- Neuropathic pain
Level of evidence
•••
Role in therapy
- Should be considered (at doses titrated up to at least 1,200 mg/day) for neuropathic pain
- Generally 1st line gabapentinoid
View Dosage, Potential Harms & More
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Dosage*
Initiation: 300 mg once daily at night
Titration: Increase weekly by 300 mg/day
Usual maintenance dose: 1,200- 3,600 mg/day (divided into 3 doses)¹
Potential harms
May cause dizziness, drowsiness, or confusion^24,17
Potential for abuse could lead to drug misuse or make the patient a target for drug abusers²⁹
Tapering**
Requires tapering: reduce dose gradually over at least 1 week^38,39

* Titrate until efficacy or intolerance.^{26, 17} Counsel that side effects often diminish after 1-2 weeks.²⁴
** Tapering recommendations are intended as general guidelines only. Monitor the patient’s response to dosage changes and use clinical judgment to base the pace of the taper on the patient’s response to prior dosage reductions.⁴³
Pregabalin
Pain type¹
- Neuropathic pain
- Fibromyalgia
Level of evidence
•••
Role in therapy
- Neuropathic pain: should be considered (at doses titrated up to at least 300 mg/day) for neuropathic pain if other 1st and 2nd line pharmacological treatments have failed
- Fibromyalgia: is recommended (at doses titrated up to at least 300 mg/day) for fibromyalgia
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Dosage*
Initiation: 75 mg twice daily
Usual maintenance dose: 300 mg/ day (150 mg bid)
Maximum: 600 mg/day (300 mg bid)²
Potential harms
May cause sedation or dizziness⁸
Tapering**
Reduce dose gradually over at least 1 week²²

* Titrate until efficacy or intolerance.^{26, 17} Counsel that side effects often diminish after 1-2 weeks.²⁴
** Tapering recommendations are intended as general guidelines only. Monitor the patient’s response to dosage changes and use clinical judgment to base the pace of the taper on the patient’s response to prior dosage reductions.⁴³
Tricyclic Antidepressants (TCAs)
Amitriptyline, Nortriptyline, Imipramine
Pain type
- Neuropathic pain
- Fibromyalgia
Level of evidence
•••
Role in therapy
- Should be considered for neuropathic pain, except HIV-related neuropathic pain (imipramine or nortriptyline may be used if amitriptyline is ineffective)
- Should be considered for fibromyalgia
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Dosage*
Amitriptyline: Starting dose 10-25 mg/day; titration: increase weekly by 10 mg/day; usual maintenance dose: 25-125 mg/day¹
Imipramine or nortriptyline: 25-75 mg/day¹
Potential harms
May cause sedation, dry mouth, confusion, constipation, urinary retention, prolonged QT interval, weight gain^24,17
Many side effects may be tolerable with patient education, gradual dose titration and allowance for 1-2 weeks at a steady dose
Caution in elderly (nortriptyline preferred)¹⁷
Tapering**
Taper gradually over 4 weeks to 3 months or more (e.g. reduce dose by 25% every 4 weeks)⁴¹ particularly if patient has been on the drug for 6 weeks or more
Doses should be decreased more slowly towards the end of the Taper^42-53,16

* Titrate until efficacy or intolerance.^{26, 17} Counsel that side effects often diminish after 1-2 weeks.²⁴
** Tapering recommendations are intended as general guidelines only. Monitor the patient’s response to dosage changes and use clinical judgment to base the pace of the taper on the patient’s response to prior dosage reductions.⁴³
Serotonin Norepinephrine Reuptake Inhibitor (SNRI)
Duloxetine
Pain type
- Neuropathic pain due to diabetes
- Fibromyalgia
- Osteoarthritis
Level of evidence
•••
Role in therapy
- Should be considered for diabetic neuropathic pain if other 1st or 2nd line pharmacological therapies have failed
- Should be considered for fibromyalgia
- Should be considered for osteoarthritis
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Dosage*
Starting dose: 60 mg once daily (30 mg starting dose may be used for tolerability reasons in some patients, with a goal of reaching 60 mg once daily within 1-2 weeks)⁴⁵; Usual maintenance dose: 60 mg once daily (doses of up to 120 mg/ day have been used)¹
Potential harms
May cause headache, gastrointestinal upset, insomnia, drowsiness, constipation, fatigue, dizziness¹⁷
Contraindicated in hepatic or severe renal impairment⁴⁵
Tapering**
Requires tapering if patient has been taking for more than 1 week⁴⁵
Taper by switching to 30 mg strength or taking 60 mg on alternate days for at least 2 weeks⁴⁶

* Titrate until efficacy or intolerance.^{26, 17} Counsel that side effects often diminish after 1-2 weeks.²⁴
** Tapering recommendations are intended as general guidelines only. Monitor the patient’s response to dosage changes and use clinical judgment to base the pace of the taper on the patient’s response to prior dosage reductions.⁴³
Serotonin Reuptake Inhibitor (SSRI)
Fluoxetine
Pain type
- Fibromyalgia
Level of evidence
•••
Role in therapy
- Should be considered for fibromyalgia
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Dosage*
20 mg/day (up to 80 mg/day)¹
Potential harms
May cause nausea, dizziness, headache, anxiety, nervousness, drowsiness, weakness, diarrhea, upset stomach, dry mouth, loss of appetite, excessive sweating, sexual dysfunction
May cause aggression or suicidal ideation/ behaviour
May prolong QT⁴⁷
Tapering**
Tapering generally not required (fluoxetine has a low risk of withdrawal symptoms due to its long half-life; active drug substances persist in the body for weeks)^42,47

* Titrate until efficacy or intolerance.^{26, 17} Counsel that side effects often diminish after 1-2 weeks.²⁴
** Tapering recommendations are intended as general guidelines only. Monitor the patient’s response to dosage changes and use clinical judgment to base the pace of the taper on the patient’s response to prior dosage reductions.⁴³

Topicals¹ and medical cannabinoids:

Cannabinoids are not equivalent in effectiveness to anti-depressants or anti-convulsants.¹⁶
Cannabinoid forms can be considered for neuropathic pain.¹⁶

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Nonsteroidal anti-inflammatory drugs (NSAIDs)
Diclofenac solution⁴⁸ or gel⁴⁹
Pain type
- Musculoskeletal pain¹
- Osteoarthritis⁵⁰
Level of evidence
•••
Role in therapy
- Should be considered for musculoskeletal pain¹ or osteoarthritis⁵⁰, in patients who cannot tolerate oral NSAIDs
- Manufactured and compounded NSAID products may vary in potency
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Dosage*
Solution: 50 drops per knee 3 times a day, or 40 drops per knee 4 times a day⁴⁶
Gel: Apply 3-4 times daily (for lower strengths) or twice daily (for higher strengths)⁴⁹
Allow 1 week to reach full effects²⁴
Potential harms
Do not apply to skin with cuts or rashes
May cause skin blistering
Increases sun sensitivity (rare)⁴⁹
Tapering
Tapering is not required for topical medications

* Titrate until efficacy or intolerance.^{26, 17} Counsel that side effects often diminish after 1-2 weeks.²⁴
Salicylate-Containing Rubifacients
Triethanolamine Salicylate
Pain type
- Musculoskeletal pain
Level of evidence
•••
Role in therapy
- Should be considered for musculoskeletal pain if other pharmacological therapies have been ineffective
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Dosage*
1 to 3 plasters (12 hours on, 12 hours off)
Try for up to 4 weeks, then discontinue if no improvement
Potential harms
Skin reddening and irritation at application site
Tapering
Tapering is not required for topical medications

* Titrate until efficacy or intolerance.^{26, 17} Counsel that side effects often diminish after 1-2 weeks.²⁴
Synthetic tetrahydrocannabinol
Nabilone-Oral
Pain type
- Neuropathic pain¹⁶
Level of evidence
- Evidence is weaker than for other drug treatments¹⁶
- No research evidence to support use in other types of chronic pain (fibromyalgia, low back pain, osteoarthritis); only for neuropathic pain that has failed to respond to standard treatments¹⁶
Role in therapy
- In general, other pharmacological and nonpharmacological neuropathic pain therapies should be tried first
- Long-term benefits and harms in chronic non-cancer pain not well studied^16,52,53
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Dosage
1 or 2 mg bid; max 6 mg/day⁵³
Potential harms
May cause drowsiness, euphoria, dry mouth, hallucinations
Even low doses of cannabis can cause cognitive impairment lasting up to 24 hours¹⁶
May cause physical or psychological dependence⁵²
Dried cannabis is not appropriate for people:
under 25 years of age
with personal or strong family history of psychosis
with current or past cannabis use disorder
with cardiovascular disease
who are pregnant, planning to become pregnant, or breastfeeding¹⁶
Caution (for oral cannabis) in liver dysfunction⁵³
Tapering
Data not available on tapering¹⁶
If patients using cannabinoids are also on high doses of benzodiazepines or opioids, consider lowering the dose of these medications¹⁶
Buccal Cannabinoids^1,52
Nabiximols
Pain type
- Neuropathic pain¹⁶
Level of evidence
- Evidence is weaker than for other drug treatments¹⁶
- No research evidence to support use in other types of chronic pain (fibromyalgia, low back pain, osteoarthritis); only for neuropathic pain that has failed to respond to standard treatments¹⁶
Role in therapy
- In general, other pharmacological and nonpharmacological neuropathic pain therapies should be tried first
- Nabiximols are indicated as adjunctive treatment for neuropathic pain in patients with multiple sclerosis⁵²
- Long-term benefits and harms in chronic non-cancer pain not well studied^16,52,53
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Dosage
4 to 8 sprays/day (divided bid); max 12 sprays/day⁵²
Potential harms
May cause drowsiness, euphoria, dry mouth, hallucinations
Even low doses of cannabis can cause cognitive impairment lasting up to 24 hours¹⁶
May cause physical or psychological dependence⁵²
Dried cannabis is not appropriate for people:
under 25 years of age
with personal or strong family history of psychosis
with current or past cannabis use disorder
with cardiovascular disease
who are pregnant, planning to become pregnant, or breastfeeding¹⁶
Caution (for oral cannabis) in liver dysfunction⁵³
Tapering
Data not available on tapering¹⁸
If patients using cannabinoids are also on high doses of benzodiazepines or opioids, consider lowering the dose of these medications¹⁸
Vaporizer or edible product
Dried cannabis
Pain type
- Neuropathic pain¹⁶
Level of evidence
- Evidence is weaker than for other drug treatments¹⁶
- No research evidence to support use in other types of chronic pain (fibromyalgia, low back pain, osteoarthritis); only for neuropathic pain that has failed to respond to standard treatments¹⁶
Role in therapy
- In general, other pharmacological and nonpharmacological neuropathic pain therapies should be tried first
- Do not use for neuropathic pain unless other pharmacologic therapies, nonpharmacologic therapies, and oral cannabinoids have failed¹⁶
- Long-term benefits and harms in chronic non-cancer pain not well studied^16,52,53
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Dosage
Dose is difficult to standardize due to limited dosing studies, differences in administration and cannabinoid content of different strains of cannabis, as well as interpatient variability.
One study of vaporized cannabis used 800 mg placed in the vaporizer, with 8 to 12 inhalations taken over 2 hours. Inhale slowly over 5 seconds, hold breath for 10 seconds, then gently exhale.
For smoked cannabis (note: vaporization is generally preferred to smoking for safety reasons), the dose may range from 100-700 mg of no more than 9% THC cannabis daily. The upper safe level is approximately 3.0 g of dried cannabis per day (this upper limit would only be used for experienced cannabis users, not naïve patients, and would be gradually reached).¹⁶
There is some evidence for dry cannabis use with the bulk of the information on vaporized and smoked. Very little evidence exists in edible products. The upper safe limit is 3.0 g (this would only be used for experienced cannabis users).
Potential harms
May cause drowsiness, euphoria, dry mouth, hallucinations
Even low doses of cannabis can cause cognitive impairment lasting up to 24 hours¹⁶
May cause physical or psychological dependence⁵²
Dried cannabis is not appropriate for people:
under 25 years of age
with personal or strong family history of psychosis
with current or past cannabis use disorder
with cardiovascular disease
who are pregnant, planning to become pregnant, or breastfeeding¹⁶
Caution (for oral cannabis) in liver dysfunction⁵³
Tapering
Data not available on tapering¹⁶
If patients using cannabinoids are also on high doses of benzodiazepines or opioids, consider lowering the dose of these medications¹⁶

Resources

For providers

For patients

Opioid medications

Opioid medications are not the preferred treatment for CNCP but may be considered in selected patients. If opioids are used, they should be combined with non-pharmacological treatments and non-opioid medications as appropriate.²

Before trying opioids, it is not necessary to sequentially “fail” non-pharmacological or non-opioid pharmacological therapies, though it is important to weigh expected benefits and risks of therapy.² There is no high quality evidence showing that opioids improve pain or function with long-term use.

Naloxone: Advise patients with an opioid prescription to obtain a take-home naloxone kit. Ontarians with a health card are eligible for a free take-home naloxone kit from pharmacies, community organizations and provincial correctional facilities.²

Recommendations*

Opioids should be reserved for patients that meet the following criteria:

Non-opioid treatments have been trialled or are being trialled concurrently;

Pain is severe enough to interfere with daily function; and

Patient is at a low risk of Opioid Use Disorder.

Use the Opioid Risk Tool to gauge potential risk.^2,5 Supplement with a history identifying high risk factors such as current anxiety, depression, PTSD and/or current or past history of problematic substance use (e.g. alcohol, opioids, cannabis). Patients with a high risk/active Substance Use Disorder may require further consultation with an addictions expert.

Opioid Use Disorder (OUD)⁵

Clinical features of OUD

Altering the route of delivery: injecting, biting or crushing oral formulations
Accessing opioids from other sources: taking the drug from friends or relatives; purchasing the drug from the ‘street’; double-doctoring
Unsanctioned use: multiple unauthorized dose escalations; binge use rather than scheduled use
Drug seeking: recurrent prescription losses; aggressive complaining about the need for higher doses; harassing medical office staff for faxed scripts or ‘fit-in’ appointments; nothing else ‘works’
Repeated withdrawal symptoms: marked dysphoria, myalgia, gastrointestinal symptoms, cravings
Accompanying conditions: Currently addicted to alcohol, cocaine, cannabis, or other drugs; underlying mood or anxiety disorders are not responsive to treatment
Social features: Deteriorating or poor social function; concern expressed by family members
Views on the opioid medication: Sometimes acknowledges being addicted; strong resistance to tapering or switching opioids; may admit to mood-leveling effect; may acknowledge distressing withdrawal symptoms

Strategies to prevent OUD

Identify high risk patients: individuals with current anxiety, depression, PTSD; individuals with current or past history of problematic alcohol or drug use.
Do not prescribe opioids to patients at high risk for OUD unless they have a biomedical pain condition affecting function, and have failed at all first-line non opioid treatments. Do not prescribe for fibromyalgia or simple low back pain.
Take a baseline urine drug sample. Do not prescribe opioids if cocaine or non-authorized drugs are present.
Dispense small amounts frequently – weekly, twice weekly, daily if necessary; especially if patient runs out early.
Set the maintenance dose at the lowest possible dose – in most cases, it should be no more than 50 MME.
Avoid any drug that is commonly misused in the community (e.g. hydromorphone, fentanyl, oxycodone).
If patient shows clinical features of OUD, consider management with buprenorphine or methadone, or specialized addiction clinic referral if appropriate.

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Set goals with patient (pain reduction, improved function/mood)
Discuss the short-term benefits and potential side effects/risks, such as potential loss of efficacy over time
Use the lowest effective dose – aim to keep the dose under 90 MME. If a larger dose is required, consider obtaining a second opinion^2,3
Avoid prescription of sedative and hypnotic medication when possible
Benzodiazepines can considerably lower the lethal opioid dose; consider tapering off of benzodiazepines or starting with a lower dose of opioid
Be aware of concomitant use of alcohol and over the counter medications
Parenteral opioids are not recommended in CNCP (high risk of overdose, addiction, and infection)
Use caution with controlled-release formulations: they can cause overdose if bitten/crushed (this converts them to immediate-release)¹³
Agree on duration of an opioid trial (e.g. typically 2 weeks at optimal dose)
For patients on opioids over 90 morphine milligram equivalents (MME) or patients on opioids with a potential risk for overdose (i.e. past/active/evolving Opioid Use Disorder or concurrent benzodiazepine use), encourage the patient to obtain take home naloxone (kit or intranasal spray) from their pharmacist²
Before starting opioids, discuss an “exit strategy” for how opioids will be discontinued if they do not produce benefits that outweigh risks²

Monitor every 2-4 weeks
Do a 3-day “tolerance check” for those at high risk of sedation (elderly, on benzodiazepines, renal or hepatic impairment, COPD, sleep disorders, cognitive impairment).⁸Call the patient 3 days after initiation or dose change to ask about signs of sedation³
Titrate oral opioids until efficacious* (an improvement in function and/or pain of 2 points on a 10-point scale)^3,17
Benzodiazepines can considerably lower the lethal opioid dose; consider tapering off of benzodiazepines or starting with a lower dose of opioid
Parenteral opioids are not recommended in CNCP (high risk of overdose, addiction, and infection)
Use caution with controlled-release formulations: they can cause overdose if bitten/crushed (this converts them to immediate-release)¹³
Most patients respond to doses in the range of 0-50 MME. As the dose increases, the risk of overdose, addiction, falls, motor vehicle accidents and sleep apnea increase as well
Use the lowest effective dose – aim to keep the dose under 90 MME. If a larger dose is required, consider obtaining a second opinion^2,3
Opioids have a medium effect on pain (10-20% reduction) and a small effect on function (<10% change): function can improve even when pain is still present^2,3

For conditions where opioids may be effective, establish realistic expectations:²
- After titration, evaluate benefits and risks of continued therapy at least every 3 months²
- If drug does not produce a meaningful improvement, discontinue/taper
- If opioids are inappropriately used, the risk of overdose, hypogonadism, sleep disorders or respiratory function can worsen

Indications to taper and discontinue opioids

Insufficient analgesia, insufficient effect on function, or a failed opioid trial
Significant side effects (e.g. sedation, fatigue, depression, sleep apnea, falls, motor vehicle accidents, testosterone suppression)
Suspected Opioid Use Disorder
High opioid dose (well above 90 MME), even if no obvious side effects are present

How to taper⁵

Explain to the patient that tapering often improves pain, mood and function
Opioids should never be abruptly stopped, as it may trigger unauthorized use and is an increased risk for overdose
There are many protocols for an opioid taper. For examples of opioid tapers see the Opioid Tapering Template

Tapering pearls

In patients who have been on opioids for years a slower taper is more likely to be successful
Taper more cautiously during pregnancy and/or seek out expert consultation – acute withdrawal increases the risk of premature labour and spontaneous abortion
Avoid sedative-hypnotic medications, especially benzodiazepines, during the taper¹⁹
Optimize non-opioid management of pain and provide psychosocial support for anxiety related to the taper
Some patients may begin to manifest an Opioid Use Disorder during the taper. Arrange for appropriate treatment and consider naloxone use

* Recommendations above have been developed in part from a consensus of expert opinion.

Options

Putting the evidence in perspective: While many opioid therapies have 2 or 3 dots under “Evidence level”, denoting a good quality of evidence, this simply means that the studies were well-designed, not that the effect was large.

Most of the studies were no more than 3 months long, and the overall effect size of opioids is only moderate for pain (corresponding to a 1 or 2 point decrease on a 10-point pain scale) and low for improved function (corresponding to a 10% or smaller improvement in function).

Non-opioid treatments are considered 1st-line in managing chronic non-cancer pain. Opioids should be used only if non-opioid treatments have failed or cannot be used.²²

WATCHFUL DOSE: Guidelines recommend reassessing the benefit/risk of doses ≥50 MME/day and to “avoid or justify increasing dosage” at doses ≥90 MME/day.^2,18

Oral meperidine: has no role in the treatment of chronic non-cancer pain because of its poor oral bioavailability and the accumulation of a toxic metabolite.¹³

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Codeine
Pain type¹
- Chronic low back pain
- Osteoarthritis
Level of evidence^1,3
•••
Role in therapy¹³
- Use only if patient does not respond to non-opioid therapies
- Among opioids, this is a 1st-line opioid for mild to moderate pain
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Dosage¹³
Immediate release formula: start 15-30mg q4h prn; titration q7d, increase by 15-30mg/d; max 600 mg/d or acetaminophen 4g/d
>Controlled release formula: start 50mg q12h; titration q2d, increase by 50mg/d; max 300 mg q12h
Potential harms¹³
Nausea, constipation, drowsiness, dizziness, dry skin/itching, vomiting
Abuse/addiction (risk lower than with stronger opioids)
Clinical Pearls
When used with acetaminophen, limit max acetaminophen dose to 3.2g/day
Maximum duration of therapy for breastfeeding women = 4 days (some women rapidly metabolize codeine to morphine; causing neonatal toxicity)
Tramadol
Pain type¹
- Chronic low back pain
- Osteoarthritis
Level of evidence^1,3
•••
Role in therapy¹³
- Use only if patient does not respond to non-opioid therapies
- Among opioids, this is a 1st-line opioid for mild to moderate pain
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Dosage¹³
Tramadol/acetaminophen (37.5/325 mg): start 1 tab q4-6h (max 4 tabs/d); titration q7d, increase by 1 tab q4-6h; max 8 tabs/d
Tramadol immediate release: starting dose (days 1-3) 25 mg qam; titration (as tolerated), day 4-6: 25 mg bid, Day 7-9: 25 mg tid, Day 10-12: 25 mg qid, Day 13-15: 50 mg tid, Day 16 and thereafter: 50 mg qid
Tramadol controlled release: start 100-150 mg q24h (depends on brand); titrate q2-7d (depends on brand); max 300-400 mg/d (depends on brand)
Potential harms¹³
Seizure risk (in patients at high risk of seizure or patients on medications that increase serotonin, such as selective serotonin reuptake inhibitors [SSRIs])
Nausea, constipation, drowsiness, dizziness, dry skin/itching, vomiting
Abuse/addiction: (risk may be lower than with other opioids)
Morphine
Pain type²
- Chronic low back pain
- Osteoarthritis (only continue if there is ongoing pain relief; regular review is required)
Level of evidence^1,3
••
Role in therapy¹³
- Use only if patient does not respond to non-opioid therapies
- Among opioids, this is a 2nd-line opioid for mild to moderate pain and a 1st-line opioid for severe pain
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Dosage¹³
Immediate release: start 5-10 mg q4-6h (max 40 mg/d); titrate: q7d, increase by 5-10 mg/d; max: reassess benefit/risk of doses ≥ 50 MME/ day, avoid or justify increasing dosage at doses ≥ 90 MME/day
Controlled release: start 10-15 mg q12-24h; titrate q14d, increase by 5-10 mg/d; max: reassess benefit/risk of doses ≥ 50MME/ day, avoid or justify increasing dosage at doses ≥ 90 MME/day
Potential harms¹³
Nausea, constipation, drowsiness, dizziness, dry skin/itching, vomiting
Abuse/addiction: Use with caution in patients with high risk of opioid abuse
Avoid in renal impairment (toxic metabolite can accumulate)
Oxycodone
Pain type¹
- Chronic low back pain
- Osteoarthritis (only continue if there is ongoing pain relief; regular review is required)
Level of evidence^1,3
••
Role in therapy¹³
- Use only if patient does not respond to non-opioid therapies
- Among opioids, this is a 2nd-line opioid for mild to moderate pain and a 1st-line opioid for severe pain
View Dosage & Potential Harms
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Dosage¹³
Immediate release: start 5 mg q6h (max 30 mg/d); titrate q7d, increase by 5 mg/d; max: reassess benefit/risk of doses ≥50 MME/ day, avoid or justify increasing dosage at doses ≥ 90 MME/day
Controlled release: start 10 mg q12h; titrate q14d, increase by 10 mg/d; max: reassess benefit/risk of doses ≥ 50 MME/ day, avoid or justify increasing dosage at doses ≥ 90 MME/day
See Opioid Manager for corresponding oxycodone dose
Potential harms¹³
Nausea, constipation, drowsiness, dizziness, dry skin/itching, vomiting
Abuse/addiction: Use with caution in patients with high risk of opioid abuse
Hydromorphone
Pain type¹
- Chronic low back pain
- Osteoarthritis (only continue if there is ongoing pain relief; regular review is required)
Level of evidence^1,3
••
Role in therapy¹³
- Use only if patient does not respond to nonopioid therapies
- Among opioids, this is a 2nd-line opioid for mild to moderate pain and a 1st-line opioid for severe pain
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Dosage¹³
Immediate release: start 1-2 mg q4-6h (max 8 mg/d); titrate q7d, increase by 1-2 mg/d; max: reassess benefit/risk of doses ≥ 50 MME/ day, avoid or justify increasing dosage at doses ≥ 90 MME/day
Controlled release: start 3 mg q12h (max 9 mg/d); titrate q14d, increase by 3 mg/d; max: reassess benefit/risk of doses ≥50 MME/ day, avoid or justify increasing dosage at doses ≥ 90 MME/day
See Opioid Manager for corresponding hydromorphone dose
Potential harms¹³
Nausea, constipation, drowsiness, dizziness, dry skin/itching, vomiting
Abuse/addiction: Use with caution in patients with high risk of opioid abuse
Fentanyl
Pain type¹
- Chronic low back pain
- Osteoarthritis (only continue if there is ongoing pain relief; regular review is required)
Level of evidence^1,3
••
Role in therapy¹³
- Use only if patient does not respond to nonopioid therapies
- Among opioids, this is a 2nd-line opioid for severe pain
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Dosage¹³
Only use fentanyl in patients who have taken a morphine equivalent dose (MED) of at least 60- 100 mg/day for at least 2 weeks
Use Opioid Manager to convert from other opioids
Do not switch patients directly from codeine to fentanyl (10% of Caucasian patients lack the enzyme that metabolizes codeine to morphine; these patients may not have developed a tolerance to opioids)
In Ontario, fentanyl patches must be prescribed and dispensed in accordance with the Patch For Patch program
The Opioid Patch Exchange Disposal Tool can help assist with patch exchange
Potential harms¹³
Nausea, constipation, drowsiness, dizziness, dry skin/itching, vomiting
Abuse/addiction: Use with caution in patients with high risk of opioid abuse
Avoid placing sources of heat on top of patch (e.g. heating pads)
Methadone
Pain type¹
- Chronic low back pain
- Osteoarthritis
Level of evidence^1,3••
Role in therapy¹³
- Use only if patient does not respond to nonopioid therapies
- Methadone is primarily used for managing addiction but may sometimes be used to manage pain. Health Canada has removed the exemption on prescribing for methadone. For more information on the new requirements visit CPSO – Methadone Program
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Dosage¹³
Methadone is not intended for initial titration in an opioid trial
Consult a specialist with expertise in methadone treatment
Potential harms¹³
Nausea, constipation, drowsiness, dizziness, dry skin/itching, vomiting
Abuse/addiction: Use with caution in patients with high risk of opioid abuse
Avoid in renal impairment (toxic metabolite can accumulate)
Tapentadol
Pain type¹
- Osteoarthritis (studied mainly in knee osteoarthritis)
- Low back pain
Level of evidence^1,3
•••
Role in therapy¹³
- Should be considered as an option for pain relief in patients with chronic low back pain and osteoarthritis
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Dosage¹³
Immediate release: start 50 mg q 4-6 h prn; titrate 50 mg q 4-6 h; max: not recommended daily doses >700 mg on the first day of therapy and 600 mg on subsequent days
Controlled release: start 50 mg bid (approximately every 12 hours); titration increase by 50 mg bid every 3 days; usual dose: 100-250 mg bid
The 50 mg extended-release tablets are intended for short-term use in the initial titration phase only
Patients currently taking other opioids: Tapentadol has a dual mechanism of action – muopioid agonist plus norepinephrine reuptake inhibitor. Therefore caution is advised when switching to tapentadol from pure mu-opioids.^55,56
Potential harms¹³
Nausea, constipation, drowsiness, dizziness, dry skin/itching, vomiting, hypotension^55,56
Abuse/addiction^55,56
Buprenorphine (transdermal)
Pain type¹
- Chronic low back pain
- Osteoarthritis
Level of evidence^1,3
••
Role in therapy¹³
- Useful if problems with oral administration
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Dosage¹³
May be used in opioid-naïve and opioid-experienced patients (in patients taking up to 80 mg oral MME/ day)⁵⁷
May cause opioid withdrawal symptoms in patients taking long-term or higher dose opioids before being switched to buprenorphine⁵⁸
Opioid-naïve patients: starting dose: start with the smallest patch 5 mcg/hr, change patch every 7 days; titration: remove current patch and replace with the next highest strength every 7 days as required
Max dose: 20 mcg/hr patch every 7 days
>Opioid-experienced patients: Start on 5 mcg/hr or 10 mcg/hr patch, provide adequate rescue medication, and titrate by 5 to 10 mcg/hr every 7 days as required (max 20 mcg/ hr)^60,61
Patches available as 5, 10, 15, and 20 mcg/hr
Tip: If pain occurs at the end of the dosing interval it is usually a sign that the dosage needs to be increased, not that the dosage interval needs to be decreased
Potential harms¹³
Nausea, constipation, drowsiness, dizziness, dry skin/itching, vomiting
Abuse/addiction
Allow 3 weeks before reusing the same patch site⁵⁷, and avoid exposing the patch to direct sunlight (increases absorption)⁵⁸
Do not use in people weighing less than 40 kg⁵⁷
May accumulate in severe hepatic impairment⁵⁸
Buprenorphine/naloxone
Pain type¹
- NA
Level of evidence^1,3
- NA
Role in therapy¹³
- Used for substitution treatment for adults with problematic opioid dependence. The naloxone component is to deter injection and intranasal use and abuse⁵⁹
- Do not use in opioid-naïve patients
View Dosage & Potential Harms
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Dosage¹³
Patients dependent on heroin or short-acting opioids: Start when objective signs of withdrawal occur (Clinical Opioid Withdrawal Scale [COWS] score of 13 or greater), but not less than 6 hours after the patient last used opioids
Patients receiving methadone: first, reduce methadone to minimum dose tolerable by patient, then start buprenorphine/naloxone only when objective signs of withdrawal appear (COWS score of 13 or greater) and generally not less than 24 hours after the patient last used methadone
Starting dose: day 1: 4 mg, then an additional 4 mg dose if needed. Usual dose target for Day 1 is 8-12 mg; titration: increase by 2-8 mg to a level that holds the patient in treatment and prevents withdrawal effects; usual maintenance dose: 12 mg to 16 mg once daily, maximum 24 mg daily
Once stable, may give twice the patient’s daily dose every other day (e.g. give 16 mg every other day for a patient stabilized on 8 mg daily) or 3 times a week (with twice the daily dose on Monday and Wednesday and three times the daily dose on Friday); do not exceed 24 mg on any one day⁵⁹
Potential harms¹³
Should only be prescribed by physician who:
Has experience in substitution treatment of opioid dependence
Has completed a recognized education program
Must be dispensed daily under healthcare professional supervision until patient is stable enough to safely store take-home doses
Co-ingestion with alcohol or other CNS depressants could lead to a fatal overdose
Accidental consumption of even one dose by an opioidnaïve person could lead to fatal overdose
Side effects:
After first dose: withdrawal effects (e.g. shaking, sweating, headache, pain, muscle aches, nausea)
Other side effects: constipation, anxiety, tiredness, nausea/vomiting, dizziness, orthostatic hypotension⁵⁹

LEGEND: CATEGORIES FOR LEVELS OF EVIDENCE (according to original guidelines’ taxonomy)
••• Highest level of evidence (meta-analyses; systematic reviews of RCTs; RCTs with varying levels of bias)
•• Mid-level evidence (systematic reviews of case studies; high quality case control or cohort studies; experimental studies w/o randomization; case reports or studies)
• Low-level evidence (expert opinion and/or clinical experiences of respected authorities/guideline development group)

Resources

For providers

For patients

Intervention management and referral

Ensure that all necessary and relevant information, as required by the clinic or specialist, is included when initiating a referral.

Options

Psychological therapy

Consider when¹

Patient has moderate to high levels of distress
Patient has difficulty adjusting to a life with pain
Patient is struggling to change their behaviour and maintain normal activities
Patient is referred to specialist pain service

Pain specialist service  (may include interventional management)

Consider when¹

Treatment failure after trial of 4 drugs for neuropathic pain
Opioid dose is greater than 90 MME²
Inadequate response to non-specialist management

Features

Interventional procedures can provide short-term relief of pain, though some interventions are associated with rare but significant adverse outcomes (e.g. stroke, death)
Consider the following procedures for the specified conditions:
- Lumbar or cervical epidurals in hospital-based centres (e.g. spinal stenosis, discogenic pain +/- radicular pain)
- Facet joint injections, median branch blocks (e.g. facet joint pain)
- Radiofrequency nerve ablation (e.g. facet and sacroiliac joint pain)
- Spinal cord stimulators (e.g. low back and associated limb-based pain in failed back surgery)
- Trigger point injections (e.g. myofascial pain syndromes)

Multidisciplinary pain management program

Consider when¹

Patient has poor functional capacity
Patient has moderate to high levels of distress
Patient has failed to benefit from other, less comprehensive therapies
If referring patient for CRPS, urgent consultation and management required

Features

Rehabilitation and exercise therapy
Patient education
Vocational therapy
Medical management

Resources

For providers

Supporting materials and resources

For providers

Clinical resources

Clinical supports

For patients

Information on pain

Information on non-pharmacological therapies

Information on opioids

Support groups and self-management programs

Download a printable patient handout with all resources and supports

CNCP-PT-resource-for-web-2020.03.30.pdf

Download

*These supporting materials and resources are hosted by external organizations and as such, the accuracy and accessibility of their links are not guaranteed. CEP will make every effort to keep these links up to date.

References

[1]
Scottish Intercollegiate Guideline Network (SIGN). Sign Guideline 136: Management of chronic pain. 2013.
[2]
Centers for Disease Control and Prevention (CDC): CDC Guideline for Prescribing Opioids for Chronic Pain. 2016; 65(1).
[3]
2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain. Canada: Michael G. DeGroote National Pain Centre. 2017 [cited 2018 July 2].
[4]
Registered Nurses’ Association of Ontario. Assessment and Management of Pain (3rd ed.). Toronto, ON: Registered Nurses’ Association of Ontario. 2013.
[5]
Centre for Effective Practice and University Health Network (November 2017). Opioid Manager. Toronto. [cited 2018 July 2].
[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]
Bruckenthal P. Motivational interviewing in managing pain. [cited 2016 August 12].
[8]
Pain Toolkit. Motivational interviewing: a way of talking. [cited 2016 August 12].
[9]
Arthritis Canada. Physical activity & arthritis. [cited 2016 August 12].
[10]
Centers for Disease Control and Prevention (CDC): Physical activity for arthritis. [cited 2016 July 12].
[11]
Office of Disease Prevention and Health Promotion (ODPHP). Physical activity guidelines advisory committee report. [cited 2016 August 12].
[12]
American College of Rheumatology (ACR). ACR OA Guidelines: Non-pharmacological – knee and hip. 2009. [cited 2016 September 8].
[13]
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.
[14]
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.
[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]
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].
[17]
Department of Family and Community Medicine. University of Toronto. Chronic pain management one-pager. 2013. [cited 2016 August 8].
[18]
Centre for Addiction and Mental Health. Prescription Opioid Policy Framework. Toronto: CAMH. 2016. [cited 2016 October 30].
[19]
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].
[20]
Busch AJ, Barber KA.R. Overend TJ, Peloso PMJ, Schachter CL. Exercise for treating fibromyalgia syndrome. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD003786. DOI: 10.1002/14651858.CD003786.pub2.
[21]
Bussing A, Osterman T, Ludtke R, Michalsen A. Effects of yoga interventions on pain and pain-associated disability: A meta-analysis. The Journal of Pain 2012;13(1):1-9.
[22]
Du S, Yuan C, Xiao X, Chu J, Qiu Y, Qian H. Self-management programs for chronic musculoskeletal pain conditions: a systematic review and meta-analysis. Patient Educ Couns. 2011;85(3):e299-301.
[23]
Williams ACDC, Eccleston C, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database of Systematic Reviews. 2012;11.
[24]
RxFiles. Chronic non-malignant pain (CNMP). 2005. General pharmacological considerations: Supplement tables.
[25]
Tylenol Extra Strength [product labelling]. McNeil Consumer Healthcare; February 5, 2015.
[26]
Osteoarthritis Research Society International (OARSI). OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis and cartilage 2014;22:363-388.
[27]
Voltaren/Voltaren SR [product monograph]. Dorval, QC: Novartis Pharmaceuticals Canada Inc.; June 21, 2016.
[28]
Aleve [product monograph]. Mississsauga ON; Bayer Inc. Consumer Care; January 8, 2015.
[29]
RxFiles. Pain management in older adults. 2014.
[30]
Celebrex [product monograph]. Kirkland, QC: Pfizer Canada Inc. 2016.
[31]
Arthrotec [product monograph]. Kirkland QC: Pfizer Canada Inc. 2015.
[32]
Advil Arthritis Pain [product monograph]. Mississauga, ON: Pfizer Consumer Healthcare Inc. 2013.
[33]
Advil Tablets, Caplets, Gel Caplets, Extra Strength Caplets, Muscle and Joint, and 12 hour [product monograph]. Mississauga, ON: Pfizer Consumer Healthcare Inc. 2015.
[34]
Mobicox [product monograph]. Burlington ON: Boehringer Ingelheim Canada Ltd. 2014.
[35]
Apo-Naproxen [product monograph]. Toronto, ON: Apotex Inc.; 2015.
[36]
Tegretol [product monograph]. Dorval, QC: Novartis Pharmaceuticals Canada Inc. 2014.
[37]
Garnett WR, St. Louis EK, Henry TR, Bramley T. Transitional polytherapy: Tricks of the trade for monotherapy to monotherapy AED conversions. Current Neuropharmacology. 2009;7:83-95.
[38]
Neurontin [product monograph]. Kirkland, QC: Warner-Lambert Company LLC. 2016.
[39]
Zhang L, Rainka M, Freeman R, et al. A randomized, double-blind, placebo-controlled trial to assess the efficacy and safety of gabapentin enacarbil in subjects with neuropathic pain associated with postherpetic neuralgia (PXN110748). J Pain. 2013;14(6):590-603.
[40]
Lyrica [product monograph]. Kirkland, QC: Pfizer Canada Inc. 2014.
[41]
National Health Service (NHS). Deprescribing: a practical guide. 2015.
[42]
Ramaswamy S, Malik S, Dewan V. Tips to manage and prevent discontinuation symptoms. Current Psychiatry. 2005;4(9):29-44.
[43]
Hogan DB. Strategies for discontinuing antipsychotic medications. CSG Journal of CME 2014;4(2):14-18.
[44]
Shelton RC. Steps following attainment of remission: Discontinuation of antidepressant therapy.
[45]
Cymbalta [product monograph: Canada]. Toronto ON: Eli Lilly Canada Inc. 2016.
[46]
Cymbalta [product monograph: Australia]. Australia: Eli Lilly. 2015.
[47]
Apo-Fluoxetine [product monograph]. Toronto, ON: Apotex Inc. 2013.
[48]
Pennsaid [product monograph]. Montreal, QC: Paladin Labs Inc. 2010.
[49]
Voltaren Emulgel [product monograph]. Mississauga, ON: GlaxoSmithKline Consumer Healthcare Inc. 2016.
[50]
National Institute for Health and Care Excellence (NICE). Osteoarthritis: Care and management. 2014 [cited 2016 September 8].
[51]
Myoflex.ca. Extra Strength.
[52]
Sativex [product monograph]. Toronto, ON: Bayer Inc. 2012.
[53]
Cesamet [product monograph]. Montreal, QC: Valeant Canada Limited. 2009.
[54]
Ontario Ministry of Health and Long-Term Care. Ontario Naloxone Pharmacy Program.
[55]
Nucynta [product monograph]. Toronto, ON: Janssen Inc. August 4, 2014.
[56]
Nucynta Extended-Release [product monograph]. Toronto, ON: Janssen Inc. August 4, 2014.
[57]
BuTrans [product monograph]. Pickering, ON: Purdue Pharma; August 5, 2016.
[58]
RxFiles. Q&A Summary: BuTrans patch. September 2010.
[59]
Suboxone [product monograph]. Scarborough, ON: RBI Specialized Importation Co. Inc. August 24, 2015.
[60]
College of Physicians and Surgeons of Ontario (CPSO). Prescribing drugs.
[61]
Ontario College of Pharmacists (OCP). Prescription regulation summary chart.
[62]
Ontario Ministry of Health and Long-Term Care. Ontario’s Narcotics Strategy.
[63]
Ontario Ministry of Health and Long-Term Care. Important notice regarding changes to the Ontario Drug Benefit (ODB) program funding of opioid medications.
[64]
MedSask (University of Saskatchewan). Switching opioids using equivalence tables.
[65]
Ultram [product monograph].
[66]
Anaprox [product monograph].
[67]
Centre for Effective Practice. (February 2018). Opioid Tapering Template: Ontario. Toronto: Centre for Effective Practice. [cited 2018 July 2].

Legal

This Tool was developed as part of the Knowledge Translation in Primary Care Initiative, led by Centre for Effective Practice with collaboration from the Ontario College of Family Physicians and the Nurse Practitioners’ Association of Ontario. Clinical leadership for the development of the tool was provided by Dr. Arun Radhakrishnan, MSc, MD, CM CCFP and was subject to external review by health care providers and other relevant stakeholders. This Tool was funded by the Government of Ontario as part of the Knowledge Translation in Primary Care Initiative.

This tool was developed for licensed health care professionals in Ontario as a guide only and does not constitute medical or other professional advice. Health care professionals are required to exercisetheir 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, 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 external sources referenced in this Tool (whether specifically named or not) that are owned or operated by third parties, including any information or advice contained therein.

Management of Chronic Non-Cancer Pain 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 Management of Chronic Non-Cancer Pain 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: info@cep.health).

Developed by:

In collaboration with:

Management of Chronic Non-Cancer Pain

Introduction

General approach

Step 1: Assess

Step 2: Create a management plan

Step 3: Initiate, adapt and evaluate treatment(s)

Step 4: Refer, as appropriate

Baseline and ongoing assessment

Guidance on conducting a baseline assessment

Pain condition and physical examination

Functional and social history

Mental health

Substance use history and opioid risk assessment

Yellow Flags*

Guidance on conducting an ongoing assessment

Pain condition and physical examination

Monitor Yellow Flags*

Response to treatment

Substance use and opioid risk assessment

Management plan

Patient record and treatment plan

Non-pharmacological therapies

Recommendations

Tips on initating treatment(s)

Physical activity/exercises

Psychological therapies

Self-management programs

Physical therapies

Tips on adapting treatment(s)

Physical activity/exercises

Psychological therapies

Self-management programs

Physical therapies

Tips on evaluating treatment(s)

Physical activity/exercises

Psychological therapies

Self-management programs

Physical therapies

Options

Physical activity/exercises1,20,21

Scroll (left-right) for details

Aerobic exercise (e.g. walking)

Strengthening exercise (e.g. lifting weights)

Core stabilising exercises (e.g. pilates)

Tai Chi

Yoga (any type)

Therapeutic aquatic exercise

Psychological therapies

Scroll (left-right) for details

Cognitive Behavioural Therapy (CBT)

Mindfulness based interventions

Acceptance and Commitment Therapy

Respondent behavioural therapies

Self-management programs12 and physical therapies

Scroll (left-right) for details

Self-management programs

Manual therapy

TENS

Low level laser therapy

Resources

Non-opioid medications New

Recommendations

Click for tips on

Options

General non-opioid medications1:

Scroll (left-right) for details

Acetaminophen

Celecoxib

Diclofenac

Ibuprofen

Meloxicam

Naproxen

Anticonvulsants1 and antidepressants1:

Scroll (left-right) for details

Carbamazepine

Gabapentin

Pregabalin

Amitriptyline, Nortriptyline, Imipramine

Duloxetine

Fluoxetine

Physical activity/exercises^1,20,21

Self-management programs¹² and physical therapies

General non-opioid medications¹:

Anticonvulsants¹ and antidepressants¹:

Topicals¹ and medical cannabinoids:

Diclofenac solution⁴⁸ or gel⁴⁹

Pain specialist service  (may include interventional management)