Chronic Pain in Canada - Prevalence, Treatment, Impact and the Role of Opioid Analgesia

OBJECTIVE:To assess the prevalence, treatment and impact of chronic pain in Canada.METHODS:A stratified random sample of 2012 adult Canadians (weighted by sex, age and region according to 1996 census data) was surveyed by telephone in 2001 to determine the prevalence of chronic pain, defined as continuous or intermittent pain for at least six months. A second sample of 340 chronic pain sufferers who were taking prescription medication for their pain was studied in detail to determine current therapeutic approaches and to assess the social and economic impact of chronic pain.RESULTS:Chronic noncancer pain was reported by 29% of the respondents, with increased frequency in women and older age groups. The average duration of pain was 10.7 years and the average intensity was 6.3 (on a scale from 1 to 10), with 80% reporting moderate or severe pain. Anti-inflammatory agents were prescribed for 49% of respondents and opioid analgesics were prescribed for 22% (two-thirds of these were codeine). Almost 70% were worried about addiction potential, and one-third felt that strong analgesics should be reserved for terminal illnesses. Almost one-half were unable to attend social and family events, and the mean number of days absent from work in the past year due to chronic pain was 9.3.INTERPRETATION:Chronic noncancer pain is common in Canadian adults and has a major social and economic impact. Despite growing evidence supporting the efficacy and safety of major opioid analgesics for chronic noncancer pain, less than 10% of chronic pain patients taking prescription medication were treated with a major opioid. Chronic pain is undertreated in Canada, and major opioid analgesics are probably underutilized in the management of moderate to severe pain as part of a multidisciplinary treatment program.

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Racial Differences in Prescription of Opioid Analgesics for Chronic Noncancer Pain in a National Sample of Veterans

Journal of Pain ◽

10.1016/j.jpain.2013.12.010 ◽

2014 ◽

Vol 15 (4) ◽

pp. 447-455 ◽

Cited By ~ 36

Author(s):

Diana J. Burgess ◽

David B. Nelson ◽

Amy A. Gravely ◽

Matthew J. Bair ◽

Robert D. Kerns ◽

...

Keyword(s):

Racial Differences ◽

Opioid Analgesics ◽

National Sample ◽

Chronic Noncancer Pain ◽

Noncancer Pain

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How opioid prescribing policies influence primary care clinicians’ treatment decisions and conversations with patients with chronic pain

Journal of Opioid Management ◽

10.5055/jom.2021.0684 ◽

2021 ◽

Vol 17 (6) ◽

pp. 499-509

Author(s):

Elizabeth C. Danielson, PhD ◽

Christopher A. Harle, PhD ◽

Sarah M. Downs, MPH ◽

Laura Militello, MA ◽

Olena Mazurenko, MD, PhD

Keyword(s):

Primary Care ◽

Chronic Pain ◽

Treatment Decisions ◽

Healthcare Organizations ◽

Chronic Noncancer Pain ◽

Opioid Prescribing ◽

Prevention Guideline ◽

Multistep Process ◽

Primary Care Clinicians ◽

Noncancer Pain

Objective: The 2016 Centers for Disease Control and Prevention guideline for prescribing opioids for chronic pain aimed to assist primary care clinicians in safely and effectively prescribing opioids for chronic noncancer pain. Individual states, payers, and health systems issued similar policies imposing various regulations around opioid prescribing for patients with chronic pain. Experts argued that healthcare organizations and clinicians may be misapplying the federal guideline and subsequent opioid prescribing policies, leading to an inadequate pain management. The objective of this study was to understand how primary care clinicians involve opioid prescribing policies in their treatment decisions and in their conversations with patients with chronic pain.Design: We conducted a secondary qualitative analysis of data from 64 unique primary care visits and 87 post-visit interviews across 20 clinicians from three healthcare systems in the Midwestern United States. Using a multistep process and thematic analysis, we systematically analyzed data excerpts addressing opioid prescribing policies.Results: Opioid prescribing policies influenced clinicians’ treatment decisions to not initiate opioids, prescribe fewer opioids overall (theme #1), and begin tapering and discontinuation of opioids (theme #2) for most patients with chronic pain. Clinical precautions, described in the opioid prescribing policies to monitor use, were directly invoked during visits for patients with chronic pain (theme #3).Conclusions: Opioid prescribing policies have multidimensional influence on clinician treatment decisions for patients with chronic pain. Our findings may inform future studies to explore mechanisms for aligning pressures around opioid prescribing, stemming from various opioid prescribing policies, with the need to deliver individualized pain care.

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A Review of the Use of Methadone for the Treatment of Chronic Noncancer Pain

Pain Research and Management ◽

10.1155/2005/286713 ◽

2005 ◽

Vol 10 (3) ◽

pp. 133-144 ◽

Cited By ~ 33

Author(s):

Mary E Lynch

Keyword(s):

Chronic Pain ◽

Low Cost ◽

Interindividual Variation ◽

Duration Of Action ◽

Chronic Noncancer Pain ◽

Opioid Dose ◽

Long Duration ◽

Attractive Option ◽

Noncancer Pain ◽

High Bioavailability

Methadone, although having been available for approximately half a century, is now receiving increasing attention in the management of chronic pain. This is due to recent research showing that methadone exhibits at least three different mechanisms of action including potent opioid agonism, N-methyl-D-aspartate antagonism and monoaminergic effects. This, along with methadone's excellent oral and rectal absorption, high bioavailability, long duration of action and low cost, make it a very attractive option for the treatment of chronic pain. The disadvantages of significant interindividual variation in pharmacokinetics, graduated dose equivalency ratios based on prerotation opioid dose when switching from another opioid, and the requirement for special exemption for prescribing methadone make it more complicated to use. The present review is intended to educate physicians interested in adding methadone to their armamentarium for assisting patients with moderate to severe pain.

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The effects of a multiday (10–14 days) subanesthetic dose IV ketamine infusion in the treatment of refractory chronic pain

Pain Management ◽

10.2217/pmt-2021-0064 ◽

2021 ◽

Author(s):

Amokrane Chebini ◽

Sina Marzoughi ◽

Jason Randhawa ◽

Daphne Guh ◽

Stephen Wiseman ◽

...

Keyword(s):

Chronic Pain ◽

Prospective Trial ◽

Pain Syndrome ◽

Chronic Patients ◽

Chronic Neuropathic Pain ◽

Chronic Noncancer Pain ◽

Ketamine Infusion ◽

Pain Syndromes ◽

Clinically Significant ◽

Noncancer Pain

Aim: Ketamine is an anesthetic agent that at lower doses can be a potent analgesic. There has been an interest in the use of low dose ketamine in treatment of chronic pain syndromes. Patients & methods: We report the results of a retrospective observational study for patients diagnosed with a chronic noncancer pain syndrome receiving a 2-week continuous subanesthetic IV ketamine infusion. Results & conclusion: We conclude that a 10–14 days of subanesthetic ketamine infusion in chronic patients results in clinically significant lowering of patients' numerical pain score. Further studies looking at subanesthetic ketamine infusion in a prospective trial of multi-day IV ketamine infusion in chronic refractory chronic neuropathic pain are needed to further assess the efficacy of ketamine.

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Oxymorphone and oxymorphone extended release: A pharmacotherapeutic review

Journal of Opioid Management ◽

10.5055/jom.2008.0018 ◽

2018 ◽

Vol 4 (3) ◽

pp. 131 ◽

Cited By ~ 20

Author(s):

Paul Alexander Sloan, MD ◽

Robert L. Barkin, PharmD, MBA

Keyword(s):

Chronic Pain ◽

Extended Release ◽

Analgesic Efficacy ◽

Opioid Analgesics ◽

Immediate Release ◽

The United States ◽

Efficacy And Safety ◽

Open Label ◽

Opioid Agonist ◽

Noncancer Pain

The treatment of chronic pain remains an enormous challenge in the United States. Opioid analgesics are an important component of pharmacotherapy for chronic pain and have proven efficacy in the management of cancer and noncancer chronic pain. The newest addition to oral opioid pharmacotherapy is oral oxymorphone, a semisynthetic opioid agonist that is now available in oral immediate-release (IR) and extended-release (ER) formulations. This review discusses the pharmacology, pharmacokinetics, pharmacodynamics, pharmacotherapeutics, and clinical use of oral oxymorphone IR and ER formulations for the management of moderate to severe pain for different types of patients in a variety of settings. Two published studies evaluated the efficacy and safety of oxymorphone IR in patients with moderate to severe postoperative pain and demonstrated that it provides rapid and effective analgesia and is generally well tolerated. Six published randomized controlled trials and three published open-label studies evaluated the efficacy and safety of oxymorphone ER for chronic cancer or noncancer pain. These trials found analgesic efficacy and tolerability comparable to that provided by morphine controlled release (CR) or oxycodone CR; treatment effects with oxymorphone ER were durable for treatment periods of 12 weeks at the same dose or up to 1 year with little dose escalation. Titrated doses of oxymorphone ER were effective and generally well tolerated in both opioid-experienced and opioid-naïve patients. Aspects of oxymorphone metabolism and limited protein binding may simplify treatment in certain populations.

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Effectiveness of Opioid Analgesics in Chronic Noncancer Pain

Pain Practice ◽

10.1111/papr.12176 ◽

2014 ◽

Vol 15 (3) ◽

pp. 272-278 ◽

Cited By ~ 4

Author(s):

Renata Ferrari ◽

Maria E. Zanolin ◽

Genni Duse ◽

Marco Visentin

Keyword(s):

Opioid Analgesics ◽

Chronic Noncancer Pain ◽

Noncancer Pain

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The Role of Testosterone Supplemental Therapy in Opioid-Induced Hypogonadism: A Retrospective Pilot Analysis

American Journal of Men s Health ◽

10.1177/1557988316672396 ◽

2016 ◽

Vol 11 (4) ◽

pp. 1208-1213 ◽

Cited By ~ 15

Author(s):

Omer A. Raheem ◽

Sunil H. Patel ◽

David Sisul ◽

Tim J. Furnish ◽

Tung-Chin Hsieh

Keyword(s):

Chronic Pain ◽

Rating Scale ◽

Numerical Rating Scale ◽

Opioid Therapy ◽

Total Testosterone ◽

Chronic Noncancer Pain ◽

Numerical Rating ◽

Noncancer Pain ◽

Supplemental Therapy

Chronic opioid therapy for pain management is known to induce several endocrine changes. The authors examined the effect of testosterone supplemental therapy (TST) in patients with chronic, noncancer pain undergoing opioid therapy. It was hypothesized that treatment of opioid-induced hypogonadism (OIH) can reduce opioid requirements in patients suffering from chronic pain and approve their quality of life. Over 18 months period, patients with OIH were identified in a tertiary referral pain center, Numerical Rating Scale (NRS) pain scores and daily morphine equivalent dose (MED) were the primary outcomes measured. Data were collected and comparative analysis performed between men undergoing TST versus nontreatment group. Twenty-seven OIH patients (total testosterone <300 ng/dL) were identified during the study period. TST group consists of 11 patients, while non-TST group consists of 16 patients as control cohort. Mean patient age (55 and 54.4, p = .4) and basic metabolic index (28.5 and 31.9, p = .07) in TST and non-TST groups, respectively. Mean follow-up total testosterone (ng/dL) was significantly higher after TST compared with the non-TST group (497.5 vs. 242.4 ng/dL, p = .03). Median follow-up NRS was 0 and 2 in the TST and non-TST groups ( p = .02). Mean MED (mg) decreased by 21 mg in TST group and increased by 2.5 mg in non-TST group ( p < .05). This study reports that treatment of OIH with TST can reduce opioid requirements in men with chronic pain as quantified by MED. It also confirms previous reports on the potential effects of OIH and that TST is effective in correcting opioid-induced endocrine abnormalities.

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Abuse-deterrent formulations of prescription opioid analgesics in the management of chronic noncancer pain

Pain Management ◽

10.2217/pmt-2015-0005 ◽

2016 ◽

Vol 6 (5) ◽

pp. 497-508 ◽

Cited By ~ 21

Author(s):

Martin E Hale ◽

Derek Moe ◽

Mary Bond ◽

Maciej Gasior ◽

Richard Malamut

Keyword(s):

Opioid Analgesics ◽

Prescription Opioid ◽

Chronic Noncancer Pain ◽

Prescription Opioid Analgesics ◽

Noncancer Pain

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Opioid Misuse and Addiction Among Patients With Chronic Pain

Pain Care Essentials ◽

10.1093/med/9780199768912.003.0021 ◽

2019 ◽

pp. 339-354

Author(s):

Marc O. Martel ◽

Robert N. Jamison

Keyword(s):

Chronic Pain ◽

Opioid Therapy ◽

Screening Tools ◽

Prescription Opioid ◽

Opioid Misuse ◽

Chronic Noncancer Pain ◽

Medication Misuse ◽

Opioid Medications ◽

Noncancer Pain

Chapter 20 provides an introduction to understanding the prevalence and risk factors as well as screening tools for assessing opioid misuse and addiction in patients with chronic pain. In the era of the opioid epidemic in North America and beyond, the use of prescription opioid medications to help improve function in chronic noncancer pain is frequently debated. Out of fear of iatrogenic addiction, litigation, and/or potential medication misuse, some clinicians are refusing to prescribe opioids for chronic pain. Evidence indicates that rates of opioid misuse and addiction are fairly high among chronic pain patients prescribed long-term opioid therapy, but there is consensus that opioids can be safe and effective for carefully selected and monitored patients.

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A Two-Year Prospective Multicenter Study of Opioid Therapy for Chronic Noncancer Pain: Prescription Trends and Predictors

Pain Medicine ◽

10.1093/pm/pny275 ◽

2018 ◽

Vol 20 (11) ◽

pp. 2166-2178 ◽

Cited By ~ 1

Author(s):

Dalila R Veiga ◽

Liliane Mendonça ◽

Rute Sampaio ◽

José M Castro-Lopes ◽

Luís F Azevedo

Keyword(s):

Chronic Pain ◽

Clinical Outcomes ◽

Opioid Therapy ◽

Opioid Use ◽

Opioid Prescription ◽

Chronic Noncancer Pain ◽

Noncancer Pain ◽

Opioid Users

Abstract Objectives Opioid use in chronic pain has increased worldwide in recent years. The aims of this study were to describe the trends and patterns of opioid therapy over two years of follow-up in a cohort of chronic noncancer pain (CNCP) patients and to assess predictors of long-term opioid use and clinical outcomes. Methods A prospective cohort study with two years of follow-up was undertaken in four multidisciplinary chronic pain clinics. Demographic data, pain characteristics, and opioid prescriptions were recorded at baseline, three, six, 12, and 24 months. Results Six hundred seventy-four CNCP patients were recruited. The prevalence of opioid prescriptions at baseline was 59.6% (N = 402), and 13% (N = 86) were strong opioid prescriptions. At 24 months, opioid prescription prevalence was as high as 74.3% (N = 501), and strong opioid prescription was 31% (N = 207). Most opioid users (71%, N = 479) maintained their prescription during the two years of follow-up. Our opioid discontinuation was very low (1%, N = 5). Opioid users reported higher severity and interference pain scores, both at baseline and after two years of follow-up. Opioid use was independently associated with continuous pain, pain location in the lower limbs, and higher pain interference scores. Conclusions This study describes a pattern of increasing opioid prescription in chronic pain patients. Despite the limited improvement of clinical outcomes, most patients keep their long-term opioid prescriptions. Our results underscore the need for changes in clinical practice and further research into the effectiveness and safety of chronic opioid therapy for CNPC.

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