Managing Pain in Canada: Prioritizing Clinical Alternatives
Professional Practice Recommendations for Interprofessional Collaboration
Recent clinical guidelines1,2 recommend that non-pharmacologic conservative care options, including chiropractic, are safe and effective for managing musculoskeletal conditions such as low back and neck pain.
However, most non-pharmacological pain management is outside Canada’s public system, creating challenges to ensure it is properly integrated into primary care settings, particularly those where opioids are prescribed for musculoskeletal conditions.
The CCA and the National Advisory Committee are committed to better integration and access to chiropractic care for all Canadians by producing Professional Practice Recommendations, tools, and resources to facilitate triage and referrals to appropriate care.
We believe that by informing the clinical decision-making of providers, we can help Canadians access the right care, at the right time, by the right provider.
Below are some valuable resources to help enhance interprofessional collaboration and facilitate triage and referral to clinical alternatives.
There has been a growing concern about the overuse of opioids and undertreated chronic non-cancer pain.3 While many chronic non-cancer pain treatments exist, opioids are one of the most controversial interventions at a physician’s disposal. Evidence for chronic use of opioids for back pain is meagre and inconclusive. No studies have lasted beyond four months and all had high dropout rates (>20%), mostly because of adverse effects or inefficacy.4
In a study identifying characteristics of chronic non-cancer pain patients who were prescribed opioids, low back pain was the most common complaint (35% of study participants).5 Over 80% of people will experience at least one episode of back pain during their lifetime.6 In addition, back pain is a leading reason for visiting a healthcare provider for musculoskeletal-related complaints.7
In response, the CCA developed an evidence-case for the non-pharmacological management of chronic back and neck pain. The first recommendation in The 2017 Canadian Guideline for Opioids for Chronic non-Cancer Pain states that “when considering therapy for patients with chronic non-cancer pain, we recommend optimization of non-opioid pharmacotherapy and non-pharmacological therapy, rather than a trial of opioids.”6
CCA Professional Practice Recommendations
The CCA’s National Advisory Committee has developed evidence-based Professional Practice Recommendations to inform clinical decision-making in the assessment and management of back and neck pain, as well as best practices in shared-care.
These have been developed to provide first-line health care practitioners better access to pain management alternatives, including chiropractic, by facilitating patient triage, referral, and enhanced communications.
Reporting and Referral Tools
The Reporting Tool is completed by chiropractors following a focused history, examination, diagnosis and/or clinical impressions, along with the proposed plan of management. The Reporting Tool can be submitted (with patient consent) to the patient’s physician and should provide clinically relevant information.
Why use the Reporting Tool?
- Acknowledge a referral
- Report initial evaluation findings
- Re-assess findings
- Issue a discharge summary
- Communicate with a patient’s primary care practitioner when they fail to respond to care and/or there is a deterioration in their overall condition
The Referral Tool is designed to enhance communication between physicians or other primary healthcare practitioners and chiropractors.
The Referral Tool identifies main patient complaints, yellow and red flags, as well as suggested outcome measures. The final component of the Referral Tool allows practitioners to prescribe management strategies (e.g., manual therapy, self-management, or mental health management) and make subsequent referrals.
We are committed to ensuring the tools are responsive and keep pace with evolving understandings of clinical best practice. We’d welcome feedback on the usability, clinical content, and any other suggestions that will improve the effectiveness of these resources.
Question or concerns? Contact Juan Quinonez, CCA manager of policy.
The Professional Practice Recommendations and Resources were developed to reduce the reliance on opioid prescription and emphasize non-pharmacological alternatives to pain management, and are part of the CCA’s commitment to . The Resources are aimed at improving interprofessional communication and coordination of care.
Reporting between healthcare professionals will help ensure that patients are receiving the most appropriate treatment for their condition. Canadians deserve better access to safe and effective pain management. Vulnerable populations are particularly impacted, with a high prevalence of low back pain and barriers to accessing conservative care.
The starting point in reducing the pressure to prescribe opioids is better pain management in primary care settings. Pain is complex, and that is why the most widely-accepted pain strategies strongly promote interprofessional teams with a full range of assessment and treatment skills.
Thank you to the members of the National Advisory Committee who provided guidance and whose expert input was instrumental in the development of the Professional Practice Recommendations and Resources.
- Dr. Gerald Olin, Chair of the Committee
- Dr. Tony Tibbles
- Dr. Richard Brown
- Dr. Diane Grondin
- Dr. John Srbely
- Dr. Gaelan Connell (CCA)
- Dr. Steve Passmore
- Mr. David Crocker
- Dr. Elli Morton
- Dr. Henry Candelaria
- Dr. Frances LeBlanc
References 1 Furlan A. National Opioid Use Guideline Group (NOUGG). Opioids for chronic noncancer pain: a new Canadian practice guideline. CMAJ. 2010; 182(9): 923–30. 2 Qaseem. A., Wilt, T.J., McLean, R. M., Forciea, M.A., & Clinical Guidelines Committee of the American College of Physicians. (2017). Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine. 166(7), 514-530. https://doi.org/10.72326/M16-23672017:166(7):5014-530. 3 Furlan A. National Opioid Use Guideline Group (NOUGG). Opioids for chronic noncancer pain: a new Canadian practice guideline. CMAJ. 2010; 182(9): 923–30. 4 Deyo R, Von Korff M, Duhrkoop D. Opioids for low back pain. BMJ. 2015; 350: g6380. 5 Mailis-Gagnon A, Lakha SF, Ou T, et al. Chronic noncancer pain characteristics of patients prescribed opioids by community physicians and referred to a tertiary pain clinic. Can Fam Physician. 2011; 57(3): e97–105. 6 Walker BF. The prevalence of low back pain: A systematic review of the literature from 1966 to 1998. J Spinal Disord. 2000; 13: 205– 7 Côté P, Cassidy JD, Carroll L. The treatment of neck and low back pain: who seeks care? who goes where? Med Care. 2001; 39(9): 956–