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Chronic Pain in Canada: Have We Improved Our Management of Chronic Noncancer Pain?

Chronic Pain in Canada: Have We Improved Our Management of Chronic Noncancer Pain? 10072_boulanger.qxd 21/02/2007 11:51 AM Page 39 ORIGINAL ARTICLE Chronic pain in Canada: Have we improved our management of chronic noncancer pain? 1 2 3 4 4 Aline Boulanger MD , Alexander J Clark MD , Pamela Squire MD , Edward Cui MBA , GLA Horbay PhD A Boulanger, AJ Clark, P Squire, E Cui, GLA Horbay. La douleur chronique au Canada : Avons-nous Chronic pain in Canada: Have we improved our manage- amélioré la prise en charge de la douleur ment of chronic noncancer pain? Pain Res Manage chronique non cancéreuse? 2007;12(1):39-47. HISTORIQUE : La douleur chronique non cancéreuse (DCNC) est un BACKGROUND: Chronic noncancer pain (CNCP) is a global problème global qui n’affecte pas seulement la personne souffrante, mais issue, not only affecting individual suffering, but also impacting the également la prestation des soins de santé et la vigueur des économies delivery of health care and the strength of local economies. locales. OBJECTIVES: The current study (the Canadian Chronic Pain OBJECTIFS : La présente étude (CCPS II [Canadian Chronic Pain Study II [CCPSII]) was designed to assess any changes in the preva- Study II]) a été conçue pour mesurer, le cas échéant, les changements qui lence and treatment of CNCP, as well as in attitudes toward the use ont influé sur la prévalence et le traitement de la DCNC, de même que of strong analgesics, compared with a 2001 study (the CCPSI), and to sur les attitudes vis-à-vis du recours aux analgésiques puissants, compara- provide a snapshot of the current standards of care for pain manage- tivement à une étude réalisée en 2001 (l’étude CCPS I) et dresser un por- ment in Canada. trait des normes actuelles en matière de contrôle de la douleur au Canada. METHODS: Standard, computer-assisted telephone interview sur- MÉTHODE : Méthodologie d’enquête standard par entrevue télé- vey methodology was applied in two segments, ie, a general popula- phonique assistée par ordinateur, appliquée à deux segments de popula- tion survey and a survey targeting randomly selected primary care tion, soit enquête auprès de la population générale et enquête auprès d’omnipraticiens qui soignent la DCNC de modérée à sévère sélectionnés physicians (PCPs) who treat moderate to severe CNCP. au hasard. RESULTS AND DISCUSSION: The patient-reported prevalence RÉSULTATS ET DISCUSSION : La prévalence de la DCNC telle of CNCP within Canada has not markedly changed since 2001 but qu’elle est signalée par les patients au Canada n’a pas sensiblement the duration of suffering has decreased. There have been minor changé depuis 2001, mais la durée de la douleur a diminué. On a noté des changes in regional distribution and generally more patients receive changements mineurs quant à la distribution régionale et en général, un medical treatment, which includes prescription analgesics. Physicians plus grand nombre de patients reçoivent un traitement médical qui inclut continue to demonstrate opiophobia in their prescribing practices; des analgésiques vendus sur ordonnance. Les habitudes de prescription des however, although this is lessened relating to addiction, abuse médecins continuent de témoigner de leur « opiophobie ». Par contre, remains an important concern to PCPs. Canadian PCPs, in general, bien que celle-ci semble moins associée à la peur de la dépendance, les are implementing standard assessments, treatment approaches, evalu- risques d’abus continuent de préoccuper les omnipraticiens. Les ation of treatment success and tools to prevent abuse and diversion, omnipraticiens canadiens appliquent généralement les techniques d’exa- in accordance with guidelines from the Canadian Pain Society and men, les approches thérapeutiques, les évaluations de traitement et les other pain societies globally, although there remains room for outils standard pour prévenir les abus et autres usages illicites, conformé- improvement and standardization. ment aux directives de la Société canadienne pour le traitement de la douleur et d’autres sociétés apparentées à l’échelle globale. Mais il y a tou- Key Words: Assessment; Impact; Prescribing attitudes; Prevalence of jours place pour l’amélioration et la standardisation. chronic pain; Risk of abuse pain lasting for two weeks or longer (2); continuous moder- he current study (the Canadian Chronic Pain Study II T[CCPSII]) was planned to assess changes in chronic pain ate to severe pain, excluding cancer pain (3); pain persisting for three months or longer (4-6); pain not associated with (CP) prevalence and treatment, as well as attitudes toward use of strong analgesics and opiophobia, compared with a malignancy or other terminal diagnosis, persisting for longer similar study conducted in 2001 (CCPSI) (1), and to assess than six months (7); and pain persisting beyond the time the current standards of care for pain management in normally associated with healing for a specific illness or Canada. injury (8,9). The term ‘persistent pain’ has been used inter- CP of noncancer origin has been variably defined, making changeably with CP (10,11). In the current study, CP is it difficult to compare published data. Definitions include defined as ‘pain continuously or intermittently for a period of 1 2 Department of Anaesthesia, University of Montreal, Montreal, Quebec; Chronic Pain Centre, Calgary Health Region and Department of 3 4 Anaesthesia, University of Calgary, Calgary, Alberta; Lions Gate Hospital, Oncology Pain Clinic, Vancouver, British Columbia; Janssen- Ortho Inc, Toronto, Ontario Correspondence and reprints: Dr Aline Boulanger, Pain Clinique, Centre Hospitalier de l'Université de Montréal, 3840 St-Urbain, Montreal, Quebec H2W 1T8. Telephone 514-890-8000 ext 15126, fax 514-412-7132, e-mail [email protected] Pain Res Manage Vol 12 No 1 Spring 2007 ©2007 Pulsus Group Inc. All rights reserved 39 10072_boulanger.qxd 21/02/2007 11:51 AM Page 40 Boulanger et al participants said that moderate to severe CP was not well six months or longer’, to be consistent with the earlier com- parator CCPSI (1) and with the guidelines of the Canadian managed in Canada, and that the consequences included needless suffering, emotional impact (patient and family), Pain Society (9). increased burden to the health care system, economic losses PREVALENCE and drug addiction. General population surveys have reported the prevalence of CP in Canada to be between 15% (2) and 29% (1). BARRIERS TO OPIOID USE Methodological differences contributing to variation may Opiophobia (first coined by Morgan in 1985 [18]) is an irra- include retrospective versus prospective data collection, ran- tional fear of using or prescribing opioids, based on clinical, dom general surveys versus targeted selection, varying patient regulatory and medicolegal potential risk factors that impede recall time periods, different definitions of CP and differing appropriate prescribing in the treatment of pain. Opiophobia age groups surveyed. is an internationally identified factor believed to impede the In other countries, prevalence is variably reported. In a treatment of pain (19). general practice group retrospective analysis in Sweden (12), Physicians globally are concerned by opioid’s cognitive and 30% of patients had some form of defined pain; of these, 37% psychomotor side effects, physical dependency, tolerance, suffered CP (longer than three months). In an Australian gen- legal and regulatory repercussions, the administrative burden eral population survey (5), 19% suffered from CP (longer than associated with prescribing scheduled analgesics, risks of three months). A recent large European survey (13) observed addiction, abuse, misuse, diversion and attracting addicts to CP of moderate to severe pain intensity (PI) in 19% of adults one’s practice (20,21). Similarly, patients may fear a stigma of from 15 countries (range 12% to 30%). ‘terminal disease’ associated with opioids, and social and law enforcement bodies may view legitimate prescribing as putting GU IDELINES society at risk of abuse and/or diversion. Undertreatment of pain is seen as a serious societal problem Opioids, as a class, have well-defined side effects, including globally, and multiple clinical practice guidelines exist for nausea, vomiting, constipation, dizziness and sedation, many the management of chronic noncancer pain (CNCP) (9- of which can be managed with dose adjustments, adjunctive 11,14). Recommended medications for moderate to severe medications and nonpharmacological approaches (22). The CNCP are similar across guidelines; they include nons- safety of the long-term use of opioids in select CNCP patients teroidal anti-inflammatory agents (NSAIDs), and weak and has been studied (23), and, unlike NSAID prostaglandin- strong opioids, and generally follow the World Health related side effects, opioids have no organ toxicity (24). Organization ladder (15). Additional adjuvant therapies fre- Recent reports of hypogonadism associated with long-term quently used include antidepressants and anticonvulsants treatment with oral opioids in male cancer survivors (25) and (16). These clinical practice guidelines emphasize that opi- with long-term methadone treatment of heroin addicts (26), oids can be an essential part of effective pain management, but not with buprenorphine (27), may be significant and war- and discuss ways to minimize abuse, misuse and diversion, rant further study. and how to limit side effects. All note that the treatment The current study provides a snapshot-in-time of the state goal is to achieve improvement in physical, psychological of pain management in Canada. and social functioning. METHODS CCPSI 2001 Survey methodology In 2001, a prevalence study sampled 2012 Canadian adults To assess changes since 2001 in CNCP prevalence, treatment (1). Overall, 29% of respondents reported CP, and prevalence and attitudes to the use of strong analgesics, as well as to capture increased with age. A separate study of 340 CP patients reported current (2004) standards of CNCP care in Canada, a survey was an average pain duration of 10.7 years and an average PI of 6.3 conducted by Ipsos Reid Canada. Approximately 4000 (on a scale of 0 to 10), with 80% reporting moderate to severe Canadian physicians were identified as prescribers of strong pain. The study assessed analgesic treatments used, socioeco- analgesics from the Ipsos Reid national MedSamp Database nomic impact and patient attitudes to opioids. The study con- (based on the 2004 Canadian Medical Directory). From this pool, cluded that CP was undertreated in Canada and that major physicians were randomly selected to reflect physician regional opioid analgesics were underused in the management of mod- distribution as per the 2001 Canadian census statistics. In the erate to severe pain. 2001 survey of the management of both cancer- and noncancer- A complementary study of 100 Canadian primary care related pain, 30% of responders were palliative care physicians practitioners (PCPs) and palliative care physicians with a who mostly treated only cancer pain. Because the current survey defined interest in pain (70 PCPs and 30 palliative care focused exclusively on CNCP, only PCPs (general practitioners physicians) assessed attitudes toward CP management, med- and family practitioners) were included, because they are gener- ication use and barriers to the use of opioids in moderate to ally first line in the management of CNCP. A total of 2545 severe CP (17). Most chose NSAIDs or acetaminophen as physicians were contacted by telephone. Of these, 100 were first-line treatment; 32% considered opioids to be the first recruited to participate in the survey. line of treatment. Key barriers to prescribing opioids included To meet the eligibility criteria, physicians were required to addiction potential, abuse or misuse potential, side effects have written 20 or more prescriptions for CNCP in the previous and fear of review by professional bodies. Overall, 68% of four-week period, and at least 51% of their patients being treated 40 Pain Res Manage Vol 12 No 1 Spring 2007 10072_boulanger.qxd 21/02/2007 11:51 AM Page 41 Management of chronic pain in Canada, 2004 TABLE 1 TABLE 2 Methodology: Summary of survey key elements Incidence of chronic pain* by location, age and sex Patient survey Physician survey Incidence, % • Currently experiencing CP • Prevalence and nature of CP 2004 (n=1055) 2001 (n=2012) • Taking medication for pain • Impact of CP on practice Total sample 25 29 • Duration of suffering pain • Elements to consider before Location • Intensity of the pain condition prescribing strong opioids British Columbia 30 31 • Interference with everyday life • Perceived attitudes, obstacles or Alberta 26 34 • Frequency of PCP visits for pain barriers to opioid use Manitoba and Saskatchewan 29 34 • Work days missed due to pain • Patterns of prescribing Ontario 25 33 • Assessing treatment success Quebec 16 18 • Minimizing risk of abuse or misuse Atlantic provinces 36 34 • Impact of poor pain management Age, years CP Chronic pain; PCP Primary care practitioner 18 to 34 17 22 35 to 54 25 29 55+ 33 39 for long-term CP had to suffer from CNCP. CP was defined as Sex pain continuously or intermittently for a period of six months or Male 22 27 longer. Approximately 77% of the 2545 contacted either declined Female 27 31 to participate in or were unavailable for the time of the interview, *Continuous or intermittant pain lasting for six months or longer and 18% contacted did not meet the eligibility criteria. The inter- view lasted approximately 30 min. Physicians were paid an hono- rarium for their participation; the study sponsor was not identified during the research interviews. All interviews were conducted in impact of CP and attitudes surrounding the use of strong anal- June and July 2004. gesics. A complementary general population survey was conducted in February 2004 to benchmark the current prevalence of CP, as Statistical considerations well as its impact on quality of life and on the frequency of visits When conducting a general population survey, the target sample to the PCP. This survey was included as one component of an size is 1000 respondents to give a margin of error within ±3%; for omnibus (multiclient) express survey (Canadian Ipsos Reid a patient or sufferer study, a target of 400 respondents gives a mar- Express). Consumer adults (18 years of age or older), balanced gin of error within 5%. Both are at the 95% level of confidence by region of domicile, sex and age as per 2001 Canadian Census and assume that the sample proportion is at least 50% homoge- statistics, were randomly selected for a general population survey nous. using the random digital dialing method; in the 2001 survey, suf- Descriptive statistics such as frequency distribution, means and ferers were drawn from panels representing specific disease variance were used for the sample analysis. When multiple groups states. All interviews were conducted by experienced staff, using were involved, comparisons of means were conducted using computer-assisted telephone interviews and following standard, ANOVA. For categorical variables, such as attitude statements, computer-assisted telephone interview methodology. Random Pearson χ tests were used. All statistical significance levels were digital dialing calls were placed Tuesday through Thursday set at P<0.05 for the overall sample analysis, and individual P val- evenings (local time) to prevent a bias against those in daytime ues were calculated when deemed necessary. SPSS (version 10.2, employment. This component of the omnibus interview lasted SPSS Inc, USA) was used to perform the analyses. approximately 10 min. A total of 1055 individuals participated, representing a 20% response rate (19.1% in 2001); the response RESULTS rate for omnibus consumer research is generally between 18% Because of the volume of data, to illustrate change over time, and 22% (Ipsos Reid, personal communication). comparisons to the CCPSI are made directly in the presenta- tion of results. Survey questions Patient survey The patient survey included a total of 13 brief questions relating to the origin, duration and intensity of the CP condition(s), treat- Sample: A total of 1055 respondents were included in the sur- vey (the CCPSII), compared with the sample of 2012 respon- ment and quality of life. The key elements of the survey are sum- marized in Table 1. dents in 2001 (the CCPSI general population prevalence survey was conducted in two separate waves with data consis- The physician survey asked a total of 38 questions relating to the population of CNCP patients, focusing on those with moder- tent between waves; both had more than 1000 respondents). The current sample was regionally distributed: British ate to severe pain severity. The key elements of the survey are summarized in Table 1. Columbia, n=132; Alberta, n=100; Saskatchewan and Manitoba, n=100; Ontario, n=385; Quebec, n=238; and the Most of the questions asked were identical to those in the 2001 survey, allowing for comparisons. Some gaps were identi- Atlantic provinces, n=100. There were in total 483 men and 572 women, and age dis- fied and new questions were added, primarily relating to aspects of pain assessment, treatment algorithms, evaluation of therapy, tribution was: 18 to 34 years, n=319; 35 to 54 years, n=444; Pain Res Manage Vol 12 No 1 Spring 2007 41 10072_boulanger.qxd 21/02/2007 11:51 AM Page 42 Boulanger et al Figure 2) Economic impact of chronic pain. Patients reported their annual number of days of work missed as result of pain, and their Figure 1) Degree of pain intensity. Percent of sufferers rating their annual number of visits to a primary care practitioner due to pain, sub- chronic pain intensity on a numerical scale of 1 to 10, where 1 is the categorized by sex and degree of pain intensity least and 10 is the worst: 2004 versus 2001 and 55 years and older, n=259. The sample was stratified region- some extent in 40% of respondents and to a large extent in 28% ally, and balanced by sex, age and region, as per 2001 census (data not collected in 2001). Of those taking prescription statistics. analgesics, 39% said that CP interfered with day-to-day life to Prevalence of CP: CP (continuous or intermittent and lasting some extent, with 37% citing interference to a large extent. In for six months or longer) was experienced by 25% of the sam- those with severe pain, 59% and 29% cited interference to a ple, not significantly different from 29% in 2001 (Table 2). large extent and to some extent, respectively; with moderate The prevalence varied somewhat regionally (minimum in PI, 16% of sufferers cited interference to a large extent and Quebec 16% in 2004 versus 18% in 2001; maximum in the 52% to some extent. Atlantic provinces 36% versus 34% in 2001), with decreases CP patients reporting all pain intensities visited their doc- seen in Alberta (26% versus 34% in 2001), Manitoba and tor specifically because of pain an average of 3.9 times per year. Saskatchewan (29% versus 34% in 2001) and Ontario (25% This increased with increasing PI from 1.9 times per year for versus 33% in 2001). The prevalence increased with age: 18 to mild pain (PI 1 to 3) to 3.1 times per year for moderate pain 34 years, 17%; 35 to 54 years, 25%; and 55 years and older, (PI 4 to 7) to seven times per year in patients with severe CP 33%. It was higher in women (27% versus 22%) but was not (PI 8 to 10). However, 16% of those suffering severe pain had markedly different from 2001. On average, 12% of all individ- not seen a doctor about their pain in the preceding year. The uals surveyed were taking prescription analgesic medications, reported frequency of visits is higher in women (n=4.7) than versus 11% in 2001; this varied regionally from 9% in British in men (n=3.0). In the population reporting CP, of those who Columbia, Saskatchewan and Manitoba, and Quebec to 23% in were gainfully employed (n=197), pain caused an average of the Atlantic provinces (increased from 15% in 2001). As with 3.4 missed work days, with patients suffering severe pain miss- prevalence, medication use increased with age, from 5% in the ing an average of 6.2 days per year (Figure 2). In 2001, a subset youngest group, to 18% in the 55 years and older group, which of CP sufferers assessed for impact of pain reported that the is unchanged from 2001. mean number of days they were unable to work was 9.3; how- Of CP sufferers, 49% were taking a prescription analgesic ever, these data cannot be compared due to methodological medication, compared with 38% in 2001 (P=0.005), again in differences. ratios reflecting the prevalence by age (38% of those aged 18 to 34 years, 44% of those aged 35 to 54 years, 59% of those Physician survey aged 55 years and older) and sex (45% of men, 52% of Sample: A total of 100 PCPs, representative of regional distri- women). Of those with moderate pain (PI 4 to 7), 35% were bution, contributed to the study. In total, 57% of participants taking prescription analgesics; with severe pain (PI 8 to 10), (45% male, 12% female) had been in practice for at least this increased to 72%. Twenty-eight per cent of those with 20 years; 27% (21% male, 6% female) had been practicing for severe PI were not taking any prescription analgesic medica- 10 to 19 years and 10% (11% male, 5% female) had been in tion. Of those suffering any degree of CP, the mean duration of practice for less than 10 years. All analyses and comparisons to CP was 9.8 years, versus 10.7 years in 2001 (P<0.01) (median the CCPSI were conducted between the 100 respondents in duration in 2004 was 6.0 years) and the mean degree of PI was the current survey and the 70 PCPs responding in the 2001 6.9, versus 6.3 in 2001 (P=0.008). Patients suffering moderate survey (30 palliative care physicians from 2001 were excluded). to severe pain (PI 4 to 10) comprised 88% of the CP patients While the sampling parameters were similar, the randomiza- surveyed in both 2001 and 2004, although the distribution tion process made it unlikely that a significant number of indi- changed, with 37% citing moderate PI in 2004, versus 56% in vidual physicians participated in both the CCPSI and the 2001 (P<0.001) and 51% citing severe PI in 2004, versus 32% CCPSII surveys. in 2001 (P<0.001) (Figure 1). Prevalence and impact on practice: Physicians surveyed esti- Socioeconomic impact of CP: Regardless of medication sta- mated the mean number of patients seen per month for mod- tus, CP was determined to interfere with day-to-day life to erate to severe pain (all types) at 58 (median 50 patients; 42 Pain Res Manage Vol 12 No 1 Spring 2007 Less constipation Rapid onset Easy for patient initiation Low drug interaction Provides peace of mind Less Psychomotor SE's Easy to use Steady rate drug delivery Less nausea/vomiting Duration as claimed Low addiction potential Low diversion/abuse risk Reduces BTP Good for compliance Controls pain 10072_boulanger.qxd 21/02/2007 11:51 AM Page 43 Management of chronic pain in Canada, 2004 100% 90% 80% 15 70% >10 years 60% 5-9 years 50% 1-4 years 40% <1 year 30% 20% 31 30 10% 0% 2004 (n=100) 2001 (n=70) Survey year Figure 4) Body sites of chronic noncancer pain. Percent of patients Figure 3) Duration of suffering in patients having moderate to severe reporting pain at each site (physician survey) chronic noncancer pain (years) reported by primary care practitioners range five to 300 patients) (it is unknown what percentage of 120% their total practice this represents). Eighty-five per cent of patients being treated for long-term CP suffered CNCP, with 100% only 15% suffering cancer pain, unchanged from 2001 (83% 80% CNCP, 17% cancer pain). Of new CNCP patients in 2004, 60% 16% were seen for the first time or were new to the practice, compared with 12% of cancer pain patients. All further data 40% collected referred only to CNCP patients. The average num- 20% ber of prescriptions for CNCP per PCP was 57 per month. 0% Physicians reported that patients suffering moderate to severe CNCP make an average of 10.5 office visits per year (median 10 visits) (in contrast to the three to seven visits per year self- reported by patients). Fully 48% of these patients visited the physician at least 11 times per year, and 19% made 20 or more Figure 5) Important attributes primary care practitioners (PCPs) con- office visits per year. No similar data were collected in the sider when choosing a strong opioid to prescribe for moderate to severe 2001 survey. chronic noncancer pain. BTP Breakthrough pain; SEs Side effects Pain assessment: Of patients seen for CNCP, 67% were cate- gorized as suffering from moderate to severe pain (23% severe, 44% moderate), with 33% suffering mild pain. This was essen- tially unchanged from 2001 (22% severe, 43% moderate and 35% mild). On average, PCPs reported that patients suffered Assessment before prescribing: In assessing a new CNCP patient, most PCPs took a detailed medical history (79% in all from moderate to severe levels of pain for 3.4 years, versus 4.6 years in 2001 (P=0.045); 27% suffered at this PI for more patients and 19% in most patients), history of the pain condi- tion (86% all versus 13% most) and its past treatment (62% than five years, versus 43% in 2001 (P=0.037) (Figure 3). Pain causation and location: Overall, the most frequent causes all versus 33% most), reviewed current treatment (84% all versus 14% most), performed a physical examination (84% all for CNCP were the various arthritis and inflammatory condi- tions (31%), low back or spinal conditions (21%), injury and versus 13% most) and evaluated relatedness to work injury or accident (65% all versus 27% most): 87% of PCPs documented postoperative sequelae (13%), migraine or headache (11%), neuropathic or neurological problems (11%) and soft tissue all these details in the patient chart. Before prescribing any opioid, PCPs checked for potential interactions of analgesics pain (8%). For 19% of CNCP patients, no cause was obvious. Although in 2001, physicians were asked to cite the “most fre- with existing medications (61% all versus 32% most) and excluded risk factors including those of addiction and other quent causes of pain”, compared with 2004, when the question referred to “the cause of pain in the last patient you saw”, the complications (53% all versus 42% most). PCPs also attempted to set appropriate patient expectations (30% all versus 44% key drivers were similar, with low back pain, arthritis, headache and fibromyalgia being most notable, in decreasing most) and set patient-customized treatment goals (27% all versus 46% most). PCPs discussed the treatment options with order of frequency. Physicians reported that patients primarily complained of CP located in the back (95%), significantly 83% of patients. Attributes of opioids that influence prescribing: PCPs were increased from 81% in 2001 (P<0.05). Other sites of pain fre- quently cited (Figure 4) were knees (49% in 2004 versus 39% asked which attributes of a strong opioid influenced their anal- gesic prescribing for moderate to severe CNCP. The most in 2001), neck (37% versus 43%), head (36% versus 46%), hips (34% versus 30%) and shoulders (33% versus 20%) (not important attributes were: pain control (98%); features pro- moting compliance (85%); reduction of breakthrough pain significant). Pain Res Manage Vol 12 No 1 Spring 2007 43 Percent Patients by Duration Suffering Percent PCPs Drowsiness Nausea Diversion Potential Lack of Knowledge Over regulated/Paperwork Abuse/Misuse Potential Constipation Cost/Coverage Addiction Potential 10072_boulanger.qxd 21/02/2007 11:51 AM Page 44 Boulanger et al P<0.01, 2004 vs. 2001 70 # data not collected 2001 PCPs (n=100) 50 2001 * PCPs (n=70) Patient *** barriers Figure 7) Steps primary care practitioners (PCPs) take to minimize the risk of abuse or misuse: Percent reporting, unaided and aided responses. 5 As Abuse, Aberration, Adverse events, Activity, Figure 6) Perceived barriers to prescribing strong opioids: primary care Attitudes; Rx Prescribe practicioners (PCPs), 2004 versus 2001, and patients Standards of care in Canada: How does this translate into TABLE 3 Analgesic therapy in moderate to severe chronic practice? Actual use of the different analgesic classes for mod- noncancer pain erate to severe CNCP did not change between 2001 and 2004. Preferred first-line Actual first-, second- Combining all first-line, second-line and third-line treat- therapy and third-line total ments, opioids of some type are frequently prescribed (83% 2004 2001 2004 2001 Analgesic therapy (n=100), % (n=70), % (n=100), % (n=70), % versus 84%, net 2004 versus 2001), as are NSAIDs (43% ver- sus 41%) (note data were collected before the withdrawal of Net opioids 51* 30 83 84 several selective cyclooxygenase-2 inhibitors for safety con- Codeine (all combinations) 23 19 43 60 cerns in late 2004), acetaminophen (18% versus 20%) and Oxycodones 11 4 33 31 antidepressants (11%; not captured in 2001). However, the Morphines (all) 10 4 41 37 † preference for first-line treatment changed significantly, with Other opioids 7 3 38 19 opioids preferred for (net) 51% of patients in 2004 versus 30% Net NSAIDs 17 29 43 41 in 2001 (P=0.009). Conversely, the preference for NSAIDs Net acetaminophen 13 20 11 NA and acetaminophen decreased, although not significantly *P=0.009 versus 2001; Hydromorphone, fentanyl transdermal reservoir (Table 3). patch. NA Data not collected in 2001; NSAIDs Nonsteroidal anti-inflammatory drugs Strong analgesics (ie, opioids stronger than codeine) were prescribed, on average, to 37% of these patients in 2004 versus 31% in 2001, with codeine combination products the most frequently prescribed medication. Because this question was (81%); low potential for abuse or diversion, defined as ‘selling asked differently between the two surveys, the data (categori- cal in 2001 and continuous in 2004) may not be compared sta- or trafficking’ (80%); and low potential for addiction (76%). Other important attributes included duration of action, tistically. The prescription of these strong opioids was distributed as follows in 2004: first-line treatment, 28%; sec- decreased nausea and vomiting, steady rate of drug delivery and ease of use (Figure 5). This information was not captured ond-line treatment, 39%; and third-line treatment, 34%. In 2001, this distribution was 28%, 30% and 42%, respectively. in the 2001 survey. PCP perception of patient attitudes toward the use of opi- Initial prescriptions were generally for short-acting strong opi- oids in 60% of cases; eventually, 62% of these patients are oids: Of CNCP patients whom PCPs believed would benefit from analgesics more potent than codeine, PCPs estimated switched to long-acting formulations. Assessment of treatment success: A number of strategies that, on average, 27% would be unwilling to receive strong opioids. Physicians believed that patients’ reluctance was pri- were used by PCPs to evaluate the success of therapy. For all or most patients, opioid use patterns (88%) (prescription refills, marily due to concerns about the potential for addiction (79%) and side effects (54%) (Figure 6). compliance, etc), functional improvements (80%) and quality of life improvements (75%) were tracked. To a lesser extent, PCP barriers to prescribing strong opioids: PCPs identified the key barriers to their prescribing of strong opioids, in PCPs set the requirements for reporting of breakthrough pain (59%), prescribe both long-acting and short-acting analgesics descending order of importance, as the potential for addic- tion, costs and formulary or insurance coverage, constipa- to manage breakthrough pain (57%), document the ‘5 As’ (Abuse, Aberration, Adverse events, Activity, Attitudes) in tion, potential for misuse or abuse, as well as the administrative burden of associated paperwork (not included the chart (47%) and contact the patient to assess their status (31%). Essentially, all PCPs (99%) scheduled a follow-up visit in 2001 survey) (Figure 6). 44 Pain Res Manage Vol 12 No 1 Spring 2007 Percent citing barriers 10072_boulanger.qxd 21/02/2007 11:51 AM Page 45 Management of chronic pain in Canada, 2004 emerged from a similarly conducted European survey (13), in to assess the success of therapy, with a mean follow-up fre- quency of 21 days. which 52% of CP sufferers were currently taking prescription medicines, but 21% had never taken any prescribed anal- Minimizing the risk of abuse: PCPs were asked about steps taken to minimize the risk of misuse, abuse or drug diversion. gesics. The duration of suffering in Europe was long as well, at a median of 7.0 years (range 4.9 to 9.6 years) (versus the Steps noted included the taking of detailed histories (80% response aided with specific prompts versus 20% unaided or currently reported 6.0 years in Canada). PCPs increasingly are the front line for the management of spontaneous, ‘top-of-mind’ responses), prescriptions for short durations (80% aided versus 16% unaided), mandating regu- CNCP in Canada and elsewhere (28,29). More than two- thirds of CNCP patients seen by PCPs had moderate to severe lar follow-up visits (61% aided versus 34% unaided), limiting the number of prescription repeats (82% aided versus 13% PI, unchanged since 2001, although the duration of patient suffering, estimated by the PCPs, was reduced (3.4 versus unaided) and referring to a specialist (89% aided versus 4% unaided). Patient contracts were used by 23% (aided) versus 4.6 years). This is in contrast to CP patients’ self-reporting pain of a much longer duration (mean 9.8 years); however, it is 17% (unaided) of PCPs, and 28% (aided) versus 2% (unaided) claimed to employ urine drug testing (Figure 7). more congruent with the patient-reported median of 6.0 years. Back pain was the predominant complaint (95%) and was sig- Impact of poor pain management: In 2001, 36% of PCPs considered moderate to severe CNCP to be well managed nificantly increased in frequency in 2004 over 2001 (81%). (only 3% considered CNCP to be very well managed); in The most frequent causes of CP are from arthritis and other 2004, this was similar, at 40%, with only 1% considering inflammatory conditions, similar to in Europe (13). CNCP to be very well managed. Hence, PCPs perceive that Undertreatment of CP remains a concern in many coun- pain is not well managed in 60% of CNCP patients. tries. In parts of the United States, one in five sufferers of CP Physicians cited the consequences of poorly managed CP do not even seek medical care for their pain (30). A difficult to (2004 versus 2001, respectively) as needless patient suffering quantify barrier to care is the subjective and nonverifiable (72% versus 67%), economic costs or loss of productivity nature of pain itself and, occasionally, the lack of obvious (37% versus 13%), poor quality of life (30%; not asked in causative factors (19% in the current study), making assessment 2001), emotional problems or depression (18% versus 22%) difficult for the physician (7). Lack of efficacy of opioids at and frequent visits to the doctor (15% versus 27%). When doses used, side effects and poor compliance also contribute to prompted about the impact of specific aspects, PCPs reported this situation (3). a significant impact of poorly managed CNCP on patient suf- Pharmacotherapy for moderate to severe CNCP remains fering (98%), caregiver burden (85%), health care costs challenging from several perspectives. Because stronger anal- (83%), physician burden (80%), economic productivity gesics, which may be necessary to control this pain, carry the (80%) and aberrant drug-taking behaviours (70%). Four of burden of side effects and concerns of addiction, both patients 10 PCPs suggested that enhanced educational programs and PCPs have fears related to long-term use of strong opioids. would improve their management of CNCP. Additional sug- When asked about prescribing opioids as first-line therapy for gestions for improvement included more pain clinics and moderate to severe CNCP, the PCPs surveyed cited a signifi- enhanced patient or public education. cantly increased preference for strong opioids, from 30% in 2001 to 51% in 2004. However, their actual use of strong opi- oids in the same population increased only modestly from 31% DISCUSSION to 37% over the same time period (not significant). This may The present study confirms that CP remains a major chal- relate to PCPs’ continuing (albeit reduced) concerns relating lenge to the Canadian health care system. The prevalence of to potential for patient addiction, abuse, misuse and diversion; CP in Canada was largely unchanged in 2004 compared with fears of regulatory sanctions; and media reports. These 2001 (25% versus 29%). There were no major changes remained the primary barriers to the prescribing of strong opi- regionally in prevalence, with Quebec retaining the lowest oids in the management of moderate to severe CNCP, despite prevalence and the Atlantic provinces the highest. This pos- some improvements from 2001. Additionally, PCPs perceived sibly reflects a high physician comfort level treating CP in that patients are reluctant to take opioids, mainly because of Quebec, confirmed by higher prescribing patterns the potential for addiction and side effects. Although PCPs (Compuscript MAT 2005, IMS Health Canada). The mean appear to have less concern about addiction and misuse of opi- duration of CP reported was statistically decreased from 10.7 to 9.8 years, perhaps reflecting better or more timely pain oids in 2004 than in 2001, it is clear that opiophobia, concerns about medication costs and the administrative requirements management; however, this remains a substantial timeframe for suffering. Additionally, 88% of individuals suffering for prescribing scheduled medications contribute to subopti- mal use of opioids in managing CNCP. In choosing strong opi- CNCP reported a moderate to severe PI, with a shift showing less moderate pain and more severe pain (P<0.001) com- oids for their patients, PCPs cited pain control, ease of compliance, reduction of breakthrough pain and low potential pared with 2001. In CP sufferers, the reported use of pre- scription analgesics increased from 38% to 49% (P=0.005), for diversion or abuse as the most important attributes to con- yet in those with severe pain, fully 28% did not take any pre- sider. In general, PCPs prefer to initiate opioid therapy with scription pain medication. Pain severity likely contributes to short-acting formulations and later switch to long-acting for- the striking impact of pain with respect to interference with mulations. day-to-day life, the frequency of physician visits and the eco- The use of opioids in CNCP remains controversial (31), nomic impact of missed work days. Comparable data have despite studies showing these medications to be generally safe Pain Res Manage Vol 12 No 1 Spring 2007 45 10072_boulanger.qxd 21/02/2007 11:51 AM Page 46 Boulanger et al revealed that fewer than one-half of these specialists incorpo- and effective when used rationally (32,33) and in accordance the recommendations of multiple guidelines. It is important to rate opioid agreements in their CP practices. PCPs also are clearly aware of urine screening as a management tool educate physicians to be watchful of common pitfalls in pre- scribing opioids, including indicators of inadequate pain con- (although there are limitations depending on the assays used and detection thresholds set) to assess compliance and detect trol, early signs of problematic use of opioids, and outright indicators of misuse and addiction (20,21). Professional associ- diversion. ation guidelines are valuable to teach and to protect both patients and physicians. From both the patient and PCP per- CONCLUSIONS The results of the current study show improvements in the spective, managing opioid side effects is critical to good pain management in CNCP (22). care of CNCP patients, but reveal that the optimal treat- ment of CNCP remains a challenge to Canadian PCPs. While preference for the use of NSAIDs was decreased Although increased prescribing of opioids was seen for the from 2001 to 2004, the actual use was not. It is important to management of CNCP, this remained negatively influenced note that the 2004 survey preceded the withdrawal of several by PCP concerns regarding addiction and abuse. Canadian cyclooxygenase-2 inhibitors due to concerns of mortality risk PCPs, in general, are standardizing pain assessment, treat- in select patients with cardiovascular disease. These products ment approaches and evaluation of treatment success, and have been replaced mainly with older, well-known NSAIDs have begun to use specific tools to prevent abuse and diver- (34). However, significant safety concerns relating to sion. This is in accordance with multiple professional society prostaglandin-related organ toxicity (mainly renal and hepat- guidelines, including those of the Canadian Pain Society. ic) and gastrointestinal bleeding remain with long-term There remains, however, room for improvement and better NSAID use. Future drug development research is needed to fill standardization to further optimize the management of this gap in the analgesic armamentarium. CNCP and its secondary effects on patient quality of life, The survey results show that current Canadian standards of while at the same time minimizing the burden on the health care are congruent with professional society guidelines for care system and the economy. moderate to severe CNCP. This includes screening for opioid management issues, initiating treatment with short-acting opi- ACKNOWLEDGEMENTS: Supported by an unrestricted grant oids before switching to the preferred long-acting opioids and from Janssen-Ortho Inc, Toronto, Ontario. routinely assessing benefits of treatment, including functional improvements. Steps taken to minimize the risk of drug abuse CONFLICT OF INTEREST DISCLOSURE: Drs Boulanger, or misuse may include limiting repeat prescriptions without Clark and Squire have acted as paid speakers on behalf of Janssen- office visits, the use of patient contracts and urine drug screen- Ortho at various continuing health education meetings and profes- sional congresses. Dr Clark has participated as an investigator in ing. The use of contracts was low, but it may be expected that paid clinical research conducted for Janssen-Ortho. Dr Horbay is PCPs concerned about individual patient misuse are referring a paid employee of Janssen-Ortho, directing Clinical Research. these patients to specialists who are more likely to require tri- Mr Cui is a paid employee of Janssen-Ortho, managing Business lateral contracts including the patient and PCP (35). Analytics. However, a recent survey of Canadian anesthesiologists (36) REFERENCES Persons. The management of persistent pain in older persons. J Am 1. Moulin DE, Clark AJ, Speechley M, Morley-Forster MK. Chronic Geriatr Soc 2002;50(6 Suppl):S205-24. Pain in Canada – prevalence, treatment, impact and the role of 11. The Pain Society. Recommendations for the appropriate use of opioid analgesia. Pain Res Manage 2002;7:179-84. opioids for persistent non-cancer pain. A consensus statement 2. 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Chronic Pain in Canada: Have We Improved Our Management of Chronic Noncancer Pain?

Boulanger, Aline; Clark, Alexander J; Squire, Pamela; Cui, Edward; Horbay, GLA
Pain Research and Management – Jan 1, 2007
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10072_boulanger.qxd 21/02/2007 11:51 AM Page 39 ORIGINAL ARTICLE Chronic pain in Canada: Have we improved our management of chronic noncancer pain? 1 2 3 4 4 Aline Boulanger MD , Alexander J Clark MD , Pamela Squire MD , Edward Cui MBA , GLA Horbay PhD A Boulanger, AJ Clark, P Squire, E Cui, GLA Horbay. La douleur chronique au Canada : Avons-nous Chronic pain in Canada: Have we improved our manage- amélioré la prise en charge de la douleur ment of chronic noncancer pain? Pain Res Manage chronique non cancéreuse? 2007;12(1):39-47. HISTORIQUE : La douleur chronique non cancéreuse (DCNC) est un BACKGROUND: Chronic noncancer pain (CNCP) is a global problème global qui n’affecte pas seulement la personne souffrante, mais issue, not only affecting individual suffering, but also impacting the également la prestation des soins de santé et la vigueur des économies delivery of health care and the strength of local economies. locales. OBJECTIVES: The current study (the Canadian Chronic Pain OBJECTIFS : La présente étude (CCPS II [Canadian Chronic Pain Study II [CCPSII]) was designed to assess any changes in the preva- Study II]) a été conçue pour mesurer, le cas échéant, les changements qui lence and treatment of CNCP, as well as in attitudes toward the use ont influé sur la prévalence et le traitement de la DCNC, de même que of strong analgesics, compared with a 2001 study (the CCPSI), and to sur les attitudes vis-à-vis du recours aux analgésiques puissants, compara- provide a snapshot of the current standards of care for pain manage- tivement à une étude réalisée en 2001 (l’étude CCPS I) et dresser un por- ment in Canada. trait des normes actuelles en matière de contrôle de la douleur au Canada. METHODS: Standard, computer-assisted telephone interview sur- MÉTHODE : Méthodologie d’enquête standard par entrevue télé- vey methodology was applied in two segments, ie, a general popula- phonique assistée par ordinateur, appliquée à deux segments de popula- tion survey and a survey targeting randomly selected primary care tion, soit enquête auprès de la population générale et enquête auprès d’omnipraticiens qui soignent la DCNC de modérée à sévère sélectionnés physicians (PCPs) who treat moderate to severe CNCP. au hasard. RESULTS AND DISCUSSION: The patient-reported prevalence RÉSULTATS ET DISCUSSION : La prévalence de la DCNC telle of CNCP within Canada has not markedly changed since 2001 but qu’elle est signalée par les patients au Canada n’a pas sensiblement the duration of suffering has decreased. There have been minor changé depuis 2001, mais la durée de la douleur a diminué. On a noté des changes in regional distribution and generally more patients receive changements mineurs quant à la distribution régionale et en général, un medical treatment, which includes prescription analgesics. Physicians plus grand nombre de patients reçoivent un traitement médical qui inclut continue to demonstrate opiophobia in their prescribing practices; des analgésiques vendus sur ordonnance. Les habitudes de prescription des however, although this is lessened relating to addiction, abuse médecins continuent de témoigner de leur « opiophobie ». Par contre, remains an important concern to PCPs. Canadian PCPs, in general, bien que celle-ci semble moins associée à la peur de la dépendance, les are implementing standard assessments, treatment approaches, evalu- risques d’abus continuent de préoccuper les omnipraticiens. Les ation of treatment success and tools to prevent abuse and diversion, omnipraticiens canadiens appliquent généralement les techniques d’exa- in accordance with guidelines from the Canadian Pain Society and men, les approches thérapeutiques, les évaluations de traitement et les other pain societies globally, although there remains room for outils standard pour prévenir les abus et autres usages illicites, conformé- improvement and standardization. ment aux directives de la Société canadienne pour le traitement de la douleur et d’autres sociétés apparentées à l’échelle globale. Mais il y a tou- Key Words: Assessment; Impact; Prescribing attitudes; Prevalence of jours place pour l’amélioration et la standardisation. chronic pain; Risk of abuse pain lasting for two weeks or longer (2); continuous moder- he current study (the Canadian Chronic Pain Study II T[CCPSII]) was planned to assess changes in chronic pain ate to severe pain, excluding cancer pain (3); pain persisting for three months or longer (4-6); pain not associated with (CP) prevalence and treatment, as well as attitudes toward use of strong analgesics and opiophobia, compared with a malignancy or other terminal diagnosis, persisting for longer similar study conducted in 2001 (CCPSI) (1), and to assess than six months (7); and pain persisting beyond the time the current standards of care for pain management in normally associated with healing for a specific illness or Canada. injury (8,9). The term ‘persistent pain’ has been used inter- CP of noncancer origin has been variably defined, making changeably with CP (10,11). In the current study, CP is it difficult to compare published data. Definitions include defined as ‘pain continuously or intermittently for a period of 1 2 Department of Anaesthesia, University of Montreal, Montreal, Quebec; Chronic Pain Centre, Calgary Health Region and Department of 3 4 Anaesthesia, University of Calgary, Calgary, Alberta; Lions Gate Hospital, Oncology Pain Clinic, Vancouver, British Columbia; Janssen- Ortho Inc, Toronto, Ontario Correspondence and reprints: Dr Aline Boulanger, Pain Clinique, Centre Hospitalier de l'Université de Montréal, 3840 St-Urbain, Montreal, Quebec H2W 1T8. Telephone 514-890-8000 ext 15126, fax 514-412-7132, e-mail [email protected] Pain Res Manage Vol 12 No 1 Spring 2007 ©2007 Pulsus Group Inc. All rights reserved 39 10072_boulanger.qxd 21/02/2007 11:51 AM Page 40 Boulanger et al participants said that moderate to severe CP was not well six months or longer’, to be consistent with the earlier com- parator CCPSI (1) and with the guidelines of the Canadian managed in Canada, and that the consequences included needless suffering, emotional impact (patient and family), Pain Society (9). increased burden to the health care system, economic losses PREVALENCE and drug addiction. General population surveys have reported the prevalence of CP in Canada to be between 15% (2) and 29% (1). BARRIERS TO OPIOID USE Methodological differences contributing to variation may Opiophobia (first coined by Morgan in 1985 [18]) is an irra- include retrospective versus prospective data collection, ran- tional fear of using or prescribing opioids, based on clinical, dom general surveys versus targeted selection, varying patient regulatory and medicolegal potential risk factors that impede recall time periods, different definitions of CP and differing appropriate prescribing in the treatment of pain. Opiophobia age groups surveyed. is an internationally identified factor believed to impede the In other countries, prevalence is variably reported. In a treatment of pain (19). general practice group retrospective analysis in Sweden (12), Physicians globally are concerned by opioid’s cognitive and 30% of patients had some form of defined pain; of these, 37% psychomotor side effects, physical dependency, tolerance, suffered CP (longer than three months). In an Australian gen- legal and regulatory repercussions, the administrative burden eral population survey (5), 19% suffered from CP (longer than associated with prescribing scheduled analgesics, risks of three months). A recent large European survey (13) observed addiction, abuse, misuse, diversion and attracting addicts to CP of moderate to severe pain intensity (PI) in 19% of adults one’s practice (20,21). Similarly, patients may fear a stigma of from 15 countries (range 12% to 30%). ‘terminal disease’ associated with opioids, and social and law enforcement bodies may view legitimate prescribing as putting GU IDELINES society at risk of abuse and/or diversion. Undertreatment of pain is seen as a serious societal problem Opioids, as a class, have well-defined side effects, including globally, and multiple clinical practice guidelines exist for nausea, vomiting, constipation, dizziness and sedation, many the management of chronic noncancer pain (CNCP) (9- of which can be managed with dose adjustments, adjunctive 11,14). Recommended medications for moderate to severe medications and nonpharmacological approaches (22). The CNCP are similar across guidelines; they include nons- safety of the long-term use of opioids in select CNCP patients teroidal anti-inflammatory agents (NSAIDs), and weak and has been studied (23), and, unlike NSAID prostaglandin- strong opioids, and generally follow the World Health related side effects, opioids have no organ toxicity (24). Organization ladder (15). Additional adjuvant therapies fre- Recent reports of hypogonadism associated with long-term quently used include antidepressants and anticonvulsants treatment with oral opioids in male cancer survivors (25) and (16). These clinical practice guidelines emphasize that opi- with long-term methadone treatment of heroin addicts (26), oids can be an essential part of effective pain management, but not with buprenorphine (27), may be significant and war- and discuss ways to minimize abuse, misuse and diversion, rant further study. and how to limit side effects. All note that the treatment The current study provides a snapshot-in-time of the state goal is to achieve improvement in physical, psychological of pain management in Canada. and social functioning. METHODS CCPSI 2001 Survey methodology In 2001, a prevalence study sampled 2012 Canadian adults To assess changes since 2001 in CNCP prevalence, treatment (1). Overall, 29% of respondents reported CP, and prevalence and attitudes to the use of strong analgesics, as well as to capture increased with age. A separate study of 340 CP patients reported current (2004) standards of CNCP care in Canada, a survey was an average pain duration of 10.7 years and an average PI of 6.3 conducted by Ipsos Reid Canada. Approximately 4000 (on a scale of 0 to 10), with 80% reporting moderate to severe Canadian physicians were identified as prescribers of strong pain. The study assessed analgesic treatments used, socioeco- analgesics from the Ipsos Reid national MedSamp Database nomic impact and patient attitudes to opioids. The study con- (based on the 2004 Canadian Medical Directory). From this pool, cluded that CP was undertreated in Canada and that major physicians were randomly selected to reflect physician regional opioid analgesics were underused in the management of mod- distribution as per the 2001 Canadian census statistics. In the erate to severe pain. 2001 survey of the management of both cancer- and noncancer- A complementary study of 100 Canadian primary care related pain, 30% of responders were palliative care physicians practitioners (PCPs) and palliative care physicians with a who mostly treated only cancer pain. Because the current survey defined interest in pain (70 PCPs and 30 palliative care focused exclusively on CNCP, only PCPs (general practitioners physicians) assessed attitudes toward CP management, med- and family practitioners) were included, because they are gener- ication use and barriers to the use of opioids in moderate to ally first line in the management of CNCP. A total of 2545 severe CP (17). Most chose NSAIDs or acetaminophen as physicians were contacted by telephone. Of these, 100 were first-line treatment; 32% considered opioids to be the first recruited to participate in the survey. line of treatment. Key barriers to prescribing opioids included To meet the eligibility criteria, physicians were required to addiction potential, abuse or misuse potential, side effects have written 20 or more prescriptions for CNCP in the previous and fear of review by professional bodies. Overall, 68% of four-week period, and at least 51% of their patients being treated 40 Pain Res Manage Vol 12 No 1 Spring 2007 10072_boulanger.qxd 21/02/2007 11:51 AM Page 41 Management of chronic pain in Canada, 2004 TABLE 1 TABLE 2 Methodology: Summary of survey key elements Incidence of chronic pain* by location, age and sex Patient survey Physician survey Incidence, % • Currently experiencing CP • Prevalence and nature of CP 2004 (n=1055) 2001 (n=2012) • Taking medication for pain • Impact of CP on practice Total sample 25 29 • Duration of suffering pain • Elements to consider before Location • Intensity of the pain condition prescribing strong opioids British Columbia 30 31 • Interference with everyday life • Perceived attitudes, obstacles or Alberta 26 34 • Frequency of PCP visits for pain barriers to opioid use Manitoba and Saskatchewan 29 34 • Work days missed due to pain • Patterns of prescribing Ontario 25 33 • Assessing treatment success Quebec 16 18 • Minimizing risk of abuse or misuse Atlantic provinces 36 34 • Impact of poor pain management Age, years CP Chronic pain; PCP Primary care practitioner 18 to 34 17 22 35 to 54 25 29 55+ 33 39 for long-term CP had to suffer from CNCP. CP was defined as Sex pain continuously or intermittently for a period of six months or Male 22 27 longer. Approximately 77% of the 2545 contacted either declined Female 27 31 to participate in or were unavailable for the time of the interview, *Continuous or intermittant pain lasting for six months or longer and 18% contacted did not meet the eligibility criteria. The inter- view lasted approximately 30 min. Physicians were paid an hono- rarium for their participation; the study sponsor was not identified during the research interviews. All interviews were conducted in impact of CP and attitudes surrounding the use of strong anal- June and July 2004. gesics. A complementary general population survey was conducted in February 2004 to benchmark the current prevalence of CP, as Statistical considerations well as its impact on quality of life and on the frequency of visits When conducting a general population survey, the target sample to the PCP. This survey was included as one component of an size is 1000 respondents to give a margin of error within ±3%; for omnibus (multiclient) express survey (Canadian Ipsos Reid a patient or sufferer study, a target of 400 respondents gives a mar- Express). Consumer adults (18 years of age or older), balanced gin of error within 5%. Both are at the 95% level of confidence by region of domicile, sex and age as per 2001 Canadian Census and assume that the sample proportion is at least 50% homoge- statistics, were randomly selected for a general population survey nous. using the random digital dialing method; in the 2001 survey, suf- Descriptive statistics such as frequency distribution, means and ferers were drawn from panels representing specific disease variance were used for the sample analysis. When multiple groups states. All interviews were conducted by experienced staff, using were involved, comparisons of means were conducted using computer-assisted telephone interviews and following standard, ANOVA. For categorical variables, such as attitude statements, computer-assisted telephone interview methodology. Random Pearson χ tests were used. All statistical significance levels were digital dialing calls were placed Tuesday through Thursday set at P<0.05 for the overall sample analysis, and individual P val- evenings (local time) to prevent a bias against those in daytime ues were calculated when deemed necessary. SPSS (version 10.2, employment. This component of the omnibus interview lasted SPSS Inc, USA) was used to perform the analyses. approximately 10 min. A total of 1055 individuals participated, representing a 20% response rate (19.1% in 2001); the response RESULTS rate for omnibus consumer research is generally between 18% Because of the volume of data, to illustrate change over time, and 22% (Ipsos Reid, personal communication). comparisons to the CCPSI are made directly in the presenta- tion of results. Survey questions Patient survey The patient survey included a total of 13 brief questions relating to the origin, duration and intensity of the CP condition(s), treat- Sample: A total of 1055 respondents were included in the sur- vey (the CCPSII), compared with the sample of 2012 respon- ment and quality of life. The key elements of the survey are sum- marized in Table 1. dents in 2001 (the CCPSI general population prevalence survey was conducted in two separate waves with data consis- The physician survey asked a total of 38 questions relating to the population of CNCP patients, focusing on those with moder- tent between waves; both had more than 1000 respondents). The current sample was regionally distributed: British ate to severe pain severity. The key elements of the survey are summarized in Table 1. Columbia, n=132; Alberta, n=100; Saskatchewan and Manitoba, n=100; Ontario, n=385; Quebec, n=238; and the Most of the questions asked were identical to those in the 2001 survey, allowing for comparisons. Some gaps were identi- Atlantic provinces, n=100. There were in total 483 men and 572 women, and age dis- fied and new questions were added, primarily relating to aspects of pain assessment, treatment algorithms, evaluation of therapy, tribution was: 18 to 34 years, n=319; 35 to 54 years, n=444; Pain Res Manage Vol 12 No 1 Spring 2007 41 10072_boulanger.qxd 21/02/2007 11:51 AM Page 42 Boulanger et al Figure 2) Economic impact of chronic pain. Patients reported their annual number of days of work missed as result of pain, and their Figure 1) Degree of pain intensity. Percent of sufferers rating their annual number of visits to a primary care practitioner due to pain, sub- chronic pain intensity on a numerical scale of 1 to 10, where 1 is the categorized by sex and degree of pain intensity least and 10 is the worst: 2004 versus 2001 and 55 years and older, n=259. The sample was stratified region- some extent in 40% of respondents and to a large extent in 28% ally, and balanced by sex, age and region, as per 2001 census (data not collected in 2001). Of those taking prescription statistics. analgesics, 39% said that CP interfered with day-to-day life to Prevalence of CP: CP (continuous or intermittent and lasting some extent, with 37% citing interference to a large extent. In for six months or longer) was experienced by 25% of the sam- those with severe pain, 59% and 29% cited interference to a ple, not significantly different from 29% in 2001 (Table 2). large extent and to some extent, respectively; with moderate The prevalence varied somewhat regionally (minimum in PI, 16% of sufferers cited interference to a large extent and Quebec 16% in 2004 versus 18% in 2001; maximum in the 52% to some extent. Atlantic provinces 36% versus 34% in 2001), with decreases CP patients reporting all pain intensities visited their doc- seen in Alberta (26% versus 34% in 2001), Manitoba and tor specifically because of pain an average of 3.9 times per year. Saskatchewan (29% versus 34% in 2001) and Ontario (25% This increased with increasing PI from 1.9 times per year for versus 33% in 2001). The prevalence increased with age: 18 to mild pain (PI 1 to 3) to 3.1 times per year for moderate pain 34 years, 17%; 35 to 54 years, 25%; and 55 years and older, (PI 4 to 7) to seven times per year in patients with severe CP 33%. It was higher in women (27% versus 22%) but was not (PI 8 to 10). However, 16% of those suffering severe pain had markedly different from 2001. On average, 12% of all individ- not seen a doctor about their pain in the preceding year. The uals surveyed were taking prescription analgesic medications, reported frequency of visits is higher in women (n=4.7) than versus 11% in 2001; this varied regionally from 9% in British in men (n=3.0). In the population reporting CP, of those who Columbia, Saskatchewan and Manitoba, and Quebec to 23% in were gainfully employed (n=197), pain caused an average of the Atlantic provinces (increased from 15% in 2001). As with 3.4 missed work days, with patients suffering severe pain miss- prevalence, medication use increased with age, from 5% in the ing an average of 6.2 days per year (Figure 2). In 2001, a subset youngest group, to 18% in the 55 years and older group, which of CP sufferers assessed for impact of pain reported that the is unchanged from 2001. mean number of days they were unable to work was 9.3; how- Of CP sufferers, 49% were taking a prescription analgesic ever, these data cannot be compared due to methodological medication, compared with 38% in 2001 (P=0.005), again in differences. ratios reflecting the prevalence by age (38% of those aged 18 to 34 years, 44% of those aged 35 to 54 years, 59% of those Physician survey aged 55 years and older) and sex (45% of men, 52% of Sample: A total of 100 PCPs, representative of regional distri- women). Of those with moderate pain (PI 4 to 7), 35% were bution, contributed to the study. In total, 57% of participants taking prescription analgesics; with severe pain (PI 8 to 10), (45% male, 12% female) had been in practice for at least this increased to 72%. Twenty-eight per cent of those with 20 years; 27% (21% male, 6% female) had been practicing for severe PI were not taking any prescription analgesic medica- 10 to 19 years and 10% (11% male, 5% female) had been in tion. Of those suffering any degree of CP, the mean duration of practice for less than 10 years. All analyses and comparisons to CP was 9.8 years, versus 10.7 years in 2001 (P<0.01) (median the CCPSI were conducted between the 100 respondents in duration in 2004 was 6.0 years) and the mean degree of PI was the current survey and the 70 PCPs responding in the 2001 6.9, versus 6.3 in 2001 (P=0.008). Patients suffering moderate survey (30 palliative care physicians from 2001 were excluded). to severe pain (PI 4 to 10) comprised 88% of the CP patients While the sampling parameters were similar, the randomiza- surveyed in both 2001 and 2004, although the distribution tion process made it unlikely that a significant number of indi- changed, with 37% citing moderate PI in 2004, versus 56% in vidual physicians participated in both the CCPSI and the 2001 (P<0.001) and 51% citing severe PI in 2004, versus 32% CCPSII surveys. in 2001 (P<0.001) (Figure 1). Prevalence and impact on practice: Physicians surveyed esti- Socioeconomic impact of CP: Regardless of medication sta- mated the mean number of patients seen per month for mod- tus, CP was determined to interfere with day-to-day life to erate to severe pain (all types) at 58 (median 50 patients; 42 Pain Res Manage Vol 12 No 1 Spring 2007 Less constipation Rapid onset Easy for patient initiation Low drug interaction Provides peace of mind Less Psychomotor SE's Easy to use Steady rate drug delivery Less nausea/vomiting Duration as claimed Low addiction potential Low diversion/abuse risk Reduces BTP Good for compliance Controls pain 10072_boulanger.qxd 21/02/2007 11:51 AM Page 43 Management of chronic pain in Canada, 2004 100% 90% 80% 15 70% >10 years 60% 5-9 years 50% 1-4 years 40% <1 year 30% 20% 31 30 10% 0% 2004 (n=100) 2001 (n=70) Survey year Figure 4) Body sites of chronic noncancer pain. Percent of patients Figure 3) Duration of suffering in patients having moderate to severe reporting pain at each site (physician survey) chronic noncancer pain (years) reported by primary care practitioners range five to 300 patients) (it is unknown what percentage of 120% their total practice this represents). Eighty-five per cent of patients being treated for long-term CP suffered CNCP, with 100% only 15% suffering cancer pain, unchanged from 2001 (83% 80% CNCP, 17% cancer pain). Of new CNCP patients in 2004, 60% 16% were seen for the first time or were new to the practice, compared with 12% of cancer pain patients. All further data 40% collected referred only to CNCP patients. The average num- 20% ber of prescriptions for CNCP per PCP was 57 per month. 0% Physicians reported that patients suffering moderate to severe CNCP make an average of 10.5 office visits per year (median 10 visits) (in contrast to the three to seven visits per year self- reported by patients). Fully 48% of these patients visited the physician at least 11 times per year, and 19% made 20 or more Figure 5) Important attributes primary care practitioners (PCPs) con- office visits per year. No similar data were collected in the sider when choosing a strong opioid to prescribe for moderate to severe 2001 survey. chronic noncancer pain. BTP Breakthrough pain; SEs Side effects Pain assessment: Of patients seen for CNCP, 67% were cate- gorized as suffering from moderate to severe pain (23% severe, 44% moderate), with 33% suffering mild pain. This was essen- tially unchanged from 2001 (22% severe, 43% moderate and 35% mild). On average, PCPs reported that patients suffered Assessment before prescribing: In assessing a new CNCP patient, most PCPs took a detailed medical history (79% in all from moderate to severe levels of pain for 3.4 years, versus 4.6 years in 2001 (P=0.045); 27% suffered at this PI for more patients and 19% in most patients), history of the pain condi- tion (86% all versus 13% most) and its past treatment (62% than five years, versus 43% in 2001 (P=0.037) (Figure 3). Pain causation and location: Overall, the most frequent causes all versus 33% most), reviewed current treatment (84% all versus 14% most), performed a physical examination (84% all for CNCP were the various arthritis and inflammatory condi- tions (31%), low back or spinal conditions (21%), injury and versus 13% most) and evaluated relatedness to work injury or accident (65% all versus 27% most): 87% of PCPs documented postoperative sequelae (13%), migraine or headache (11%), neuropathic or neurological problems (11%) and soft tissue all these details in the patient chart. Before prescribing any opioid, PCPs checked for potential interactions of analgesics pain (8%). For 19% of CNCP patients, no cause was obvious. Although in 2001, physicians were asked to cite the “most fre- with existing medications (61% all versus 32% most) and excluded risk factors including those of addiction and other quent causes of pain”, compared with 2004, when the question referred to “the cause of pain in the last patient you saw”, the complications (53% all versus 42% most). PCPs also attempted to set appropriate patient expectations (30% all versus 44% key drivers were similar, with low back pain, arthritis, headache and fibromyalgia being most notable, in decreasing most) and set patient-customized treatment goals (27% all versus 46% most). PCPs discussed the treatment options with order of frequency. Physicians reported that patients primarily complained of CP located in the back (95%), significantly 83% of patients. Attributes of opioids that influence prescribing: PCPs were increased from 81% in 2001 (P<0.05). Other sites of pain fre- quently cited (Figure 4) were knees (49% in 2004 versus 39% asked which attributes of a strong opioid influenced their anal- gesic prescribing for moderate to severe CNCP. The most in 2001), neck (37% versus 43%), head (36% versus 46%), hips (34% versus 30%) and shoulders (33% versus 20%) (not important attributes were: pain control (98%); features pro- moting compliance (85%); reduction of breakthrough pain significant). Pain Res Manage Vol 12 No 1 Spring 2007 43 Percent Patients by Duration Suffering Percent PCPs Drowsiness Nausea Diversion Potential Lack of Knowledge Over regulated/Paperwork Abuse/Misuse Potential Constipation Cost/Coverage Addiction Potential 10072_boulanger.qxd 21/02/2007 11:51 AM Page 44 Boulanger et al P<0.01, 2004 vs. 2001 70 # data not collected 2001 PCPs (n=100) 50 2001 * PCPs (n=70) Patient *** barriers Figure 7) Steps primary care practitioners (PCPs) take to minimize the risk of abuse or misuse: Percent reporting, unaided and aided responses. 5 As Abuse, Aberration, Adverse events, Activity, Figure 6) Perceived barriers to prescribing strong opioids: primary care Attitudes; Rx Prescribe practicioners (PCPs), 2004 versus 2001, and patients Standards of care in Canada: How does this translate into TABLE 3 Analgesic therapy in moderate to severe chronic practice? Actual use of the different analgesic classes for mod- noncancer pain erate to severe CNCP did not change between 2001 and 2004. Preferred first-line Actual first-, second- Combining all first-line, second-line and third-line treat- therapy and third-line total ments, opioids of some type are frequently prescribed (83% 2004 2001 2004 2001 Analgesic therapy (n=100), % (n=70), % (n=100), % (n=70), % versus 84%, net 2004 versus 2001), as are NSAIDs (43% ver- sus 41%) (note data were collected before the withdrawal of Net opioids 51* 30 83 84 several selective cyclooxygenase-2 inhibitors for safety con- Codeine (all combinations) 23 19 43 60 cerns in late 2004), acetaminophen (18% versus 20%) and Oxycodones 11 4 33 31 antidepressants (11%; not captured in 2001). However, the Morphines (all) 10 4 41 37 † preference for first-line treatment changed significantly, with Other opioids 7 3 38 19 opioids preferred for (net) 51% of patients in 2004 versus 30% Net NSAIDs 17 29 43 41 in 2001 (P=0.009). Conversely, the preference for NSAIDs Net acetaminophen 13 20 11 NA and acetaminophen decreased, although not significantly *P=0.009 versus 2001; Hydromorphone, fentanyl transdermal reservoir (Table 3). patch. NA Data not collected in 2001; NSAIDs Nonsteroidal anti-inflammatory drugs Strong analgesics (ie, opioids stronger than codeine) were prescribed, on average, to 37% of these patients in 2004 versus 31% in 2001, with codeine combination products the most frequently prescribed medication. Because this question was (81%); low potential for abuse or diversion, defined as ‘selling asked differently between the two surveys, the data (categori- cal in 2001 and continuous in 2004) may not be compared sta- or trafficking’ (80%); and low potential for addiction (76%). Other important attributes included duration of action, tistically. The prescription of these strong opioids was distributed as follows in 2004: first-line treatment, 28%; sec- decreased nausea and vomiting, steady rate of drug delivery and ease of use (Figure 5). This information was not captured ond-line treatment, 39%; and third-line treatment, 34%. In 2001, this distribution was 28%, 30% and 42%, respectively. in the 2001 survey. PCP perception of patient attitudes toward the use of opi- Initial prescriptions were generally for short-acting strong opi- oids in 60% of cases; eventually, 62% of these patients are oids: Of CNCP patients whom PCPs believed would benefit from analgesics more potent than codeine, PCPs estimated switched to long-acting formulations. Assessment of treatment success: A number of strategies that, on average, 27% would be unwilling to receive strong opioids. Physicians believed that patients’ reluctance was pri- were used by PCPs to evaluate the success of therapy. For all or most patients, opioid use patterns (88%) (prescription refills, marily due to concerns about the potential for addiction (79%) and side effects (54%) (Figure 6). compliance, etc), functional improvements (80%) and quality of life improvements (75%) were tracked. To a lesser extent, PCP barriers to prescribing strong opioids: PCPs identified the key barriers to their prescribing of strong opioids, in PCPs set the requirements for reporting of breakthrough pain (59%), prescribe both long-acting and short-acting analgesics descending order of importance, as the potential for addic- tion, costs and formulary or insurance coverage, constipa- to manage breakthrough pain (57%), document the ‘5 As’ (Abuse, Aberration, Adverse events, Activity, Attitudes) in tion, potential for misuse or abuse, as well as the administrative burden of associated paperwork (not included the chart (47%) and contact the patient to assess their status (31%). Essentially, all PCPs (99%) scheduled a follow-up visit in 2001 survey) (Figure 6). 44 Pain Res Manage Vol 12 No 1 Spring 2007 Percent citing barriers 10072_boulanger.qxd 21/02/2007 11:51 AM Page 45 Management of chronic pain in Canada, 2004 emerged from a similarly conducted European survey (13), in to assess the success of therapy, with a mean follow-up fre- quency of 21 days. which 52% of CP sufferers were currently taking prescription medicines, but 21% had never taken any prescribed anal- Minimizing the risk of abuse: PCPs were asked about steps taken to minimize the risk of misuse, abuse or drug diversion. gesics. The duration of suffering in Europe was long as well, at a median of 7.0 years (range 4.9 to 9.6 years) (versus the Steps noted included the taking of detailed histories (80% response aided with specific prompts versus 20% unaided or currently reported 6.0 years in Canada). PCPs increasingly are the front line for the management of spontaneous, ‘top-of-mind’ responses), prescriptions for short durations (80% aided versus 16% unaided), mandating regu- CNCP in Canada and elsewhere (28,29). More than two- thirds of CNCP patients seen by PCPs had moderate to severe lar follow-up visits (61% aided versus 34% unaided), limiting the number of prescription repeats (82% aided versus 13% PI, unchanged since 2001, although the duration of patient suffering, estimated by the PCPs, was reduced (3.4 versus unaided) and referring to a specialist (89% aided versus 4% unaided). Patient contracts were used by 23% (aided) versus 4.6 years). This is in contrast to CP patients’ self-reporting pain of a much longer duration (mean 9.8 years); however, it is 17% (unaided) of PCPs, and 28% (aided) versus 2% (unaided) claimed to employ urine drug testing (Figure 7). more congruent with the patient-reported median of 6.0 years. Back pain was the predominant complaint (95%) and was sig- Impact of poor pain management: In 2001, 36% of PCPs considered moderate to severe CNCP to be well managed nificantly increased in frequency in 2004 over 2001 (81%). (only 3% considered CNCP to be very well managed); in The most frequent causes of CP are from arthritis and other 2004, this was similar, at 40%, with only 1% considering inflammatory conditions, similar to in Europe (13). CNCP to be very well managed. Hence, PCPs perceive that Undertreatment of CP remains a concern in many coun- pain is not well managed in 60% of CNCP patients. tries. In parts of the United States, one in five sufferers of CP Physicians cited the consequences of poorly managed CP do not even seek medical care for their pain (30). A difficult to (2004 versus 2001, respectively) as needless patient suffering quantify barrier to care is the subjective and nonverifiable (72% versus 67%), economic costs or loss of productivity nature of pain itself and, occasionally, the lack of obvious (37% versus 13%), poor quality of life (30%; not asked in causative factors (19% in the current study), making assessment 2001), emotional problems or depression (18% versus 22%) difficult for the physician (7). Lack of efficacy of opioids at and frequent visits to the doctor (15% versus 27%). When doses used, side effects and poor compliance also contribute to prompted about the impact of specific aspects, PCPs reported this situation (3). a significant impact of poorly managed CNCP on patient suf- Pharmacotherapy for moderate to severe CNCP remains fering (98%), caregiver burden (85%), health care costs challenging from several perspectives. Because stronger anal- (83%), physician burden (80%), economic productivity gesics, which may be necessary to control this pain, carry the (80%) and aberrant drug-taking behaviours (70%). Four of burden of side effects and concerns of addiction, both patients 10 PCPs suggested that enhanced educational programs and PCPs have fears related to long-term use of strong opioids. would improve their management of CNCP. Additional sug- When asked about prescribing opioids as first-line therapy for gestions for improvement included more pain clinics and moderate to severe CNCP, the PCPs surveyed cited a signifi- enhanced patient or public education. cantly increased preference for strong opioids, from 30% in 2001 to 51% in 2004. However, their actual use of strong opi- oids in the same population increased only modestly from 31% DISCUSSION to 37% over the same time period (not significant). This may The present study confirms that CP remains a major chal- relate to PCPs’ continuing (albeit reduced) concerns relating lenge to the Canadian health care system. The prevalence of to potential for patient addiction, abuse, misuse and diversion; CP in Canada was largely unchanged in 2004 compared with fears of regulatory sanctions; and media reports. These 2001 (25% versus 29%). There were no major changes remained the primary barriers to the prescribing of strong opi- regionally in prevalence, with Quebec retaining the lowest oids in the management of moderate to severe CNCP, despite prevalence and the Atlantic provinces the highest. This pos- some improvements from 2001. Additionally, PCPs perceived sibly reflects a high physician comfort level treating CP in that patients are reluctant to take opioids, mainly because of Quebec, confirmed by higher prescribing patterns the potential for addiction and side effects. Although PCPs (Compuscript MAT 2005, IMS Health Canada). The mean appear to have less concern about addiction and misuse of opi- duration of CP reported was statistically decreased from 10.7 to 9.8 years, perhaps reflecting better or more timely pain oids in 2004 than in 2001, it is clear that opiophobia, concerns about medication costs and the administrative requirements management; however, this remains a substantial timeframe for suffering. Additionally, 88% of individuals suffering for prescribing scheduled medications contribute to subopti- mal use of opioids in managing CNCP. In choosing strong opi- CNCP reported a moderate to severe PI, with a shift showing less moderate pain and more severe pain (P<0.001) com- oids for their patients, PCPs cited pain control, ease of compliance, reduction of breakthrough pain and low potential pared with 2001. In CP sufferers, the reported use of pre- scription analgesics increased from 38% to 49% (P=0.005), for diversion or abuse as the most important attributes to con- yet in those with severe pain, fully 28% did not take any pre- sider. In general, PCPs prefer to initiate opioid therapy with scription pain medication. Pain severity likely contributes to short-acting formulations and later switch to long-acting for- the striking impact of pain with respect to interference with mulations. day-to-day life, the frequency of physician visits and the eco- The use of opioids in CNCP remains controversial (31), nomic impact of missed work days. Comparable data have despite studies showing these medications to be generally safe Pain Res Manage Vol 12 No 1 Spring 2007 45 10072_boulanger.qxd 21/02/2007 11:51 AM Page 46 Boulanger et al revealed that fewer than one-half of these specialists incorpo- and effective when used rationally (32,33) and in accordance the recommendations of multiple guidelines. It is important to rate opioid agreements in their CP practices. PCPs also are clearly aware of urine screening as a management tool educate physicians to be watchful of common pitfalls in pre- scribing opioids, including indicators of inadequate pain con- (although there are limitations depending on the assays used and detection thresholds set) to assess compliance and detect trol, early signs of problematic use of opioids, and outright indicators of misuse and addiction (20,21). Professional associ- diversion. ation guidelines are valuable to teach and to protect both patients and physicians. From both the patient and PCP per- CONCLUSIONS The results of the current study show improvements in the spective, managing opioid side effects is critical to good pain management in CNCP (22). care of CNCP patients, but reveal that the optimal treat- ment of CNCP remains a challenge to Canadian PCPs. While preference for the use of NSAIDs was decreased Although increased prescribing of opioids was seen for the from 2001 to 2004, the actual use was not. It is important to management of CNCP, this remained negatively influenced note that the 2004 survey preceded the withdrawal of several by PCP concerns regarding addiction and abuse. Canadian cyclooxygenase-2 inhibitors due to concerns of mortality risk PCPs, in general, are standardizing pain assessment, treat- in select patients with cardiovascular disease. These products ment approaches and evaluation of treatment success, and have been replaced mainly with older, well-known NSAIDs have begun to use specific tools to prevent abuse and diver- (34). However, significant safety concerns relating to sion. This is in accordance with multiple professional society prostaglandin-related organ toxicity (mainly renal and hepat- guidelines, including those of the Canadian Pain Society. ic) and gastrointestinal bleeding remain with long-term There remains, however, room for improvement and better NSAID use. Future drug development research is needed to fill standardization to further optimize the management of this gap in the analgesic armamentarium. CNCP and its secondary effects on patient quality of life, The survey results show that current Canadian standards of while at the same time minimizing the burden on the health care are congruent with professional society guidelines for care system and the economy. moderate to severe CNCP. This includes screening for opioid management issues, initiating treatment with short-acting opi- ACKNOWLEDGEMENTS: Supported by an unrestricted grant oids before switching to the preferred long-acting opioids and from Janssen-Ortho Inc, Toronto, Ontario. routinely assessing benefits of treatment, including functional improvements. Steps taken to minimize the risk of drug abuse CONFLICT OF INTEREST DISCLOSURE: Drs Boulanger, or misuse may include limiting repeat prescriptions without Clark and Squire have acted as paid speakers on behalf of Janssen- office visits, the use of patient contracts and urine drug screen- Ortho at various continuing health education meetings and profes- sional congresses. Dr Clark has participated as an investigator in ing. The use of contracts was low, but it may be expected that paid clinical research conducted for Janssen-Ortho. Dr Horbay is PCPs concerned about individual patient misuse are referring a paid employee of Janssen-Ortho, directing Clinical Research. these patients to specialists who are more likely to require tri- Mr Cui is a paid employee of Janssen-Ortho, managing Business lateral contracts including the patient and PCP (35). Analytics. However, a recent survey of Canadian anesthesiologists (36) REFERENCES Persons. The management of persistent pain in older persons. J Am 1. Moulin DE, Clark AJ, Speechley M, Morley-Forster MK. Chronic Geriatr Soc 2002;50(6 Suppl):S205-24. Pain in Canada – prevalence, treatment, impact and the role of 11. The Pain Society. Recommendations for the appropriate use of opioid analgesia. Pain Res Manage 2002;7:179-84. opioids for persistent non-cancer pain. A consensus statement 2. 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