Authors:
Christina S. Korownyk, Lori Montgomery, Jennifer Young, Simon Moore, Alexander G. Singer, Peter MacDougall, Sean Darling, Kira Ellis, Jacqueline Myers, , Marie-Christine Taillefer, G. Michael Allan, Danielle Perry, Samantha S. Moe, Joey Ton, Michael R. Kolber, Jessica Kirkwood, Betsy Thomas, Scott Garrison, James P. McCormack, Jamison Falk, Nicolas Dugré, Logan Sept, Ricky D. Turgeon, Allison Paige, Jen Potter, Tony Nickonchuk, Anthony D. Train, Justin Weresch, Karenn Chan and Adrienne J. Lindblad
Canadian Family Physician March 2022, 68 (3) 179-190; DOI: https://doi.org/10.46747/cfp.6803179
Abstract
Objective To develop a clinical practice guideline to support the management of chronic pain, including low back, osteoarthritic, and neuropathic pain in primary care.
Methods The guideline was developed with an emphasis on best available evidence and shared decision-making principles. Ten health professionals (4 generalist family physicians, 1 pain management–focused family physician, 1 anesthesiologist, 1 physical therapist, 1 pharmacist, 1 nurse practitioner, and 1 psychologist), a patient representative, and a nonvoting pharmacist and guideline methodologist comprised the Guideline Committee. Member selection was based on profession, practice setting, and lack of financial conflicts of interest. The guideline process was iterative in identification of key questions, evidence review, and development of guideline recommendations. Three systematic reviews, including a total of 285 randomized controlled trials, were completed. Randomized controlled trials were included only if they reported a responder analysis (eg, how many patients achieved a 30% or greater reduction in pain). The committee directed an Evidence Team (composed of evidence experts) to address an additional 11 complementary questions. Key recommendations were derived through committee consensus. The guideline and shared decision-making tools underwent extensive review by clinicians and patients before publication.
Recommendations Physical activity is recommended as the foundation for managing osteoarthritis and chronic low back pain; evidence of benefit is unclear for neuropathic pain. Cognitive-behavioural therapy or mindfulness-based stress reduction are also suggested as options for managing chronic pain. Treatments for which there is clear, unclear, or no benefit are outlined for each condition. Treatments for which harms likely outweigh benefits for all or most conditions studied include opioids and cannabinoids.
Conclusion This guideline for the management of chronic pain, including osteoarthritis, low back pain, and neuropathic pain, highlights best available evidence including both benefits and harms for a number of treatment interventions. A strong recommendation for exercise as the primary treatment for chronic osteoarthritic and low back pain is made based on demonstrated long-term evidence of benefit. This information is intended to assist with, not dictate, shared decision making with patients.
Chronic pain is one of the most complex and difficult conditions to treat. The Canadian Pain Task Force estimates that in Canada 7.6 million people (1 in 5) live with chronic pain.1 The total direct and indirect cost of chronic pain in 2019 was estimated to be $38.2 billion to $40.3 billion.1 However, even the best available treatments for chronic pain provide, at most, limited improvement for most people. Messages around pain management have been inconsistent and frequently extrapolated from acute pain and palliative care settings.2 While opioids were once heavily promoted for the management of chronic pain, the promised benefits in chronic pain management have not materialized. Additionally, an increase in prescription opioid abuse, overdoses, and death has been observed.2 Despite the prevalence of chronic pain and the subsequent search for effective therapies, an optimal approach in primary care management remains elusive.
Task forces have been assembled to address the growing issue of chronic pain.1,3 The absence of a one-size-fits-all solution is reflected in recommendations for individualized treatment and self-management of pain.4 Decisions may be based on numerous factors including patient experiences with different therapies, acceptability of side effects, accessibility, cost, and coverage. Self-management requires evidence-based education tools to help inform patient decisions.
This guideline will focus on the highest-quality evidence for common conservative therapeutic interventions in low back pain, osteoarthritis, and neuropathic pain. Interventions that are accessible to most urban and rural primary care clinicians were prioritized.
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