Management of Chronic Non-Cancer Pain

Last Updated: July 7, 2020

No Results Found 0/0

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

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

Stack of papers. Select
Conduct a Baseline Assessment
Pain condition and physical examination
  • 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)
Functional and social history
  • Assess functional status and impairment (e.g. BPI)
  • Psychosocial history: living arrangements; family/social support; family obligations; work status; sleep; relationships
Mental health
  • Current and past psychiatric history (e.g. depression PHQ-9, anxiety GAD-7, PTSD)
  • Family psychiatric history
Substance use history and opioid risk assessment
  • 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
Yellow Flags*
  • 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

* 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 treatment.6

Conduct an Ongoing Assessment
Pain condition and physical examination
  • Identify new pain, related symptoms or significant change (physical examination as indicated)
Monitor Yellow Flags*
  • 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

* 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

Response to treatment

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
Substance use and opioid risk assessment
  • 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 

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.

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

Stack of papers. Click for tips on
Initiating treatment(s)
Physical activity/exercises
  • 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 activity2,9
  • Consider referral to a physiotherapist if more intensive support is required
Psychological therapies
  • 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
Self-management programs
  • A self-management program should be considered to complement other therapies patients have initiated1
Physical therapies
  • 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
Adapting treatment(s)
Physical activity/exercises
  • 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 week2,11
  • Add in other activities as tolerated
Psychological therapies
  • Encourage patients to continue to use strategies learned from therapies
Self-management programs
  • Encourage patients to continue to use strategies learned from the program
Physical therapies
  • Encourage patients to participate in 8 therapy sessions over 4-6 weeks12
Evaluating treatment(s)
Physical activity/exercises
  • 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
Psychological therapies
  • 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
Self-management programs
  • After program completion use tools like BPI to evaluate effect on pain, function and quality of life
Physical therapies
  • Follow up after completion of 8 sessions
  • Use BPI to evaluate effect on pain, function and quality of life
Options
Physical activity/exercises1,20,21
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
Scroll (left-right) for details
  • 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
Scroll (left-right) for details
  • 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
  • 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

Non-opioid medications

Non-opioid medications, in combination with non-pharmacological therapies, are the preferred treatment for CNCP.1 Choose 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

Stack of papers. Click for tips on
Initiating treatment1

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 together1,2
  • Start at recommended dose
Titrating treatment1
  • Adjust, as needed, up to an effective dose, unless limited by side effects
  • Do not exceed the maximum dose
Evaluating treatment13
  • Evaluate effects on pain, function, mood and set goals
  • Use pain and function assessment scales,13 e.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
  • 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
  • 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
  • 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
  • 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
  • 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
Anticonvulsants1 and antidepressants1:

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

Scroll (left-right) for details
  • 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
  • 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
  • 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
    View Dosage, Potential Harms & More
  • 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
    View Dosage, Potential Harms & More
  • 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
    View Dosage, Potential Harms & More
  • Serotonin Reuptake Inhibitor (SSRI)
    Fluoxetine

    Pain type

    • Fibromyalgia

    Level of evidence
    •••

    Role in therapy

    • Should be considered for fibromyalgia
    View Dosage, Potential Harms & More
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

Scroll (left-right) for details
  • 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
    View Dosage, Potential Harms & More
  • 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
    View Dosage, Potential Harms & More
  • 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 studied16,52,53
    View Dosage, Potential Harms & More
  • Buccal Cannabinoids1,52
    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 studied16,52,53
    View Dosage, Potential Harms & More
  • 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 studied16,52,53
    View Dosage, Potential Harms & More

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

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

If the patient wants opioids but they are not clinically appropriate try the Elicit-Provide-Elicit technique
Click for Talking Points
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.

Note: Continuing to prescribe opioids in the face of opioid addiction may put the patient at risk of harm. However, stopping or refusing to prescribe opioids can also cause harm, such as severe withdrawal symptoms or driving the patient to obtain opioids from the street. It is important to mitigate these risks by finding a safe way to reduce and manage opioid use.

Stack of papers. Click for tips on
Initiating opioids1,3
  • 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 opinion2,3
  • 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
Titrating opioids1,3
  • 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).8 Call 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 opinion2,3
  • 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
Evaluating opioids13
  • 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
Tapering opioids
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

Scroll (left-right) for details
  • Codeine

    Pain type1

    • Chronic low back pain
    • Osteoarthritis

    Level of evidence1,3
    •••

    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
    View Dosage, Potential Harms & Clinical Pearls
  • Tramadol

    Pain type1

    • Chronic low back pain
    • Osteoarthritis

    Level of evidence1,3
    •••

    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
    View Dosage & Potential Harms
  • Morphine

    Pain type2

    • Chronic low back pain
    • Osteoarthritis (only continue if there is ongoing pain relief; regular review is required)

    Level of evidence1,3
    ••

    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
  • Oxycodone

    Pain type1

    • Chronic low back pain
    • Osteoarthritis (only continue if there is ongoing pain relief; regular review is required)

    Level of evidence1,3
    ••

    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
  • Hydromorphone

    Pain type1

    • Chronic low back pain
    • Osteoarthritis (only continue if there is ongoing pain relief; regular review is required)

    Level of evidence1,3
    ••

    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
    View Dosage & Potential Harms
  • Fentanyl

    Pain type1

    • Chronic low back pain
    • Osteoarthritis (only continue if there is ongoing pain relief; regular review is required)

    Level of evidence1,3
    ••

    Role in therapy13

    • Use only if patient does not respond to nonopioid therapies
    • Among opioids, this is a 2nd-line opioid for severe pain
    View Dosage & Potential Harms
  • Methadone

    Pain type1

    • Chronic low back pain
    • Osteoarthritis

    Level of evidence1,3
    ••

    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
    View Dosage & Potential Harms
  • Tapentadol

    Pain type1

    • Osteoarthritis (studied mainly in knee osteoarthritis)
    • Low back pain

    Level of evidence1,3
    •••

    Role in therapy13

    • Should be considered as an option for pain relief in patients with chronic low back pain and osteoarthritis
    View Dosage & Potential Harms
  • Buprenorphine (transdermal)

    Pain type1

    • Chronic low back pain
    • Osteoarthritis

    Level of evidence1,3
    ••

    Role in therapy13

    • Useful if problems with oral administration
    View Dosage & Potential Harms
  • Buprenorphine/naloxone

    Pain type1

    • NA

    Level of evidence1,3

    • 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

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

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

Supporting materials and resources

For providers
For patients

*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].

["Fingerprint"]
["Fingerprint"]
['50074653']
['50074653']
["Fingerprint"]
["Fingerprint"]
['50074653']
['50074653']
["Fingerprint"]
["Fingerprint"]
['50074653']
['50074653']