Canadian Pain Task Force Report: June 2019

(PDF Version, 1.2MB, 50 pages)

Chronic Pain in Canada: Laying a Foundation for Action

Table of Contents

• Chronic Pain in Canada: Laying a Foundation for Action
  • Preamble
  • Message from the authors
• Section 1: The nature of pain and its impact on Canadians
  • Pain is an unpleasant sensory and emotional experience unique to the individual
  • Chronic pain is a disease in its own right
  • Biological, psychological, and social factors influence our experience of pain
  • Millions of Canadians live with moderate to severe chronic pain
  • Certain populations bear more of the pain burden
  • Pain affects all aspects of one's life
  • There are significant costs to families, communities, and society
  • Data for action to improve the health and well-being of Canadians and our economy
• Section 2: Current approaches to diagnosing and managing chronic pain in Canada
  • Recognition that pain is real and multi-dimensional will support improved diagnosis
  • Physical, psychological, and pharmacological therapies work better together
  • Opioids and cannabis warrant special attention in the current Canadian context
  • Multidisciplinary and interprofessional pain clinics are the gold standard
  • Integrated pain services prevent transition from acute to chronic pain and chronic opioid use
  • Care models that integrate cultural approaches support better outcomes
  • Canadians have inadequate access to pain services and wait times are long
  • Chronic pain care pathways are complex, fragmented, and difficult to navigate
  • Section 2: Summary
• Section 3: Awareness, education, and specialized training for pain
  • There are significant gaps in pain education of health professionals
  • Dedicated pain curricula are needed in pre-licensure education across health professions
  • Team-based education and training enables collaborative and multidisciplinary care
  • Professional development and clinical support opportunities build pain competencies
  • Interprofessional platforms and communities of practice improve access to care
  • Increased public awareness and education are needed to improve prevention and care
  • Innovative knowledge translation activities transform research into practice and build pain awareness
  • Section 3: Summary
• Section 4: Pain research in Canada
  • World-leading research requires national networks, infrastructure, and supports
  • Canada has a solid foundation for a national pain research agenda
  • People living with chronic pain must be equal partners in research
  • Section 4: Summary
• Section 5: Domestic and international action on pain
  • The groundwork exists in Canada for a national pain strategy
  • National leadership and coordination would amplify provincial/territorial efforts
  • Existing pain strategies offer lessons learned
  • Section 5: Summary
• Section 6: Conclusions and next steps
• References

Chronic Pain in Canada: Laying a Foundation for Action

Preamble

The Canadian Pain Task Force was established in March 2019 to help the Government of Canada better understand and address the needs of Canadians who live with pain. Through to December 2021, the Task Force is mandated to provide advice and information to guide government decision-makers towards an improved approach to the prevention and management of chronic pain in this country. The eight Task Force members include people personally impacted by chronic pain, researchers, educators, and health professionals with experience and expertise in preventing and managing chronic pain across major professional disciplines (i.e., medicine, pharmacy, psychology, and physiotherapy). The Task Force is also supported by an External Advisory Panel that provides up-to-date scientific evidence, information, and advice to the Task Force reflecting their wide-ranging areas of expertise and experience.

In the first phase of their mandate ending June 2019, the Task Force assessed how chronic pain is currently addressed in Canada. To inform their assessment, they consulted with Advisory Panel members at a two day workshop in May. They met with representatives from eight federal government departments and agencies. They consulted provincial/territorial government representatives and targeted pain stakeholders, and they reviewed reports and the scientific literature. They also invited twelve people living with chronic pain to provide written responses to questions about their experience with pain and their hopes for the Canadian Pain Task Force. The report herein summarizes their findings from this rapid assessment of the current state of chronic pain in Canada and some of the personal responses from people living with pain. The activities undertaken to inform this report mark only the start of the Task Force's engagement of Canadians in this important work.

Message from the authors

The creation of the Canadian Pain Task Force marks a formal commitment by the Government of Canada to better understand and address the needs of people living with chronic pain. It is an opportunity to build on the incredible work already underway across the country – in peer support groups, clinics, research labs, classrooms, and elsewhere. We see it as a platform to raise the voices of people impacted by pain, to prompt action by all levels of government, and to lay the foundation for a national pain strategy, which will lead to tangible benefits for Canadians living with pain, their families, and society.

One in five Canadians lives with chronic pain. When pain persists, it can affect all aspects of one's life, including work, school, play, caregiving, and community participation. Living with unmanaged pain can lead to sleeplessness, hopelessness, depression and anxiety, diminished quality of life, and isolation. For some Canadians, unmanaged pain has led to poverty, homelessness, and even suicide.

The burden of chronic pain is not shared equally among Canadians. It is more common among older adults, females, Indigenous Peoples^{Footnote 1}, Veterans, and populations affected by social inequities and discrimination. A variety of societal, historical, and occupational factors contribute to these trends. These social determinants can lead to a complex interplay between chronic pain, mental illness, and substance use disorders. Combined with the stigma that accompanies these health issues, this places many at high risk for unmanaged pain.

Anxiety and fear around opioids have also led to unmanaged pain. Some Canadians have been unable to access opioid medications when needed for pain and function. Others have faced undue barriers to obtaining or filling their opioid prescriptions, and some have had their opioid dose abruptly lowered or discontinued. This has resulted in unnecessary pain and suffering, and has led some Canadians to obtain illegal drugs to treat their pain. We must do more to strike the right balance – to promote opioid prescribing practices that balance the benefits and risks of these medications based on the individual needs of each patient.

The consequences of pain extend beyond individuals, affecting families, communities, and society as a whole. Chronic pain is costly for Canadians; not only are there significant direct and indirect costs, but people living with pain often struggle to afford the treatments that can improve their quality of life and ability to participate fully in society. Taking action on pain will improve the lives of seven million Canadians plus their families, and save money.

For too long, chronic pain has been unrecognized and its far-ranging impacts ignored. It has been understood as a symptom of something else, not recognized as a condition in its own right. This is shifting, with the emergence of a global consensus acknowledging chronic pain as a legitimate disease. This consensus is driving nations around the world to take action.

The present report reflects the current state of pain care, education, and research in Canada. It tells us pain is a stigmatized and still invalidated condition, health care professionals still lack the knowledge and skills to treat pain, specialized pain services are largely not accessible, and research findings are not always being used to improve care. Improvement efforts are fragmented and hampered by lack of coordination and funding. We hope this report will ignite a commitment to change.

There are home-grown successes to build on. Many people living with pain, health care professionals, researchers, policy makers, and non-governmental organizations have been contributing to a movement for action on pain in Canada. Innovative clinical models, proven educational approaches, novel support programs, and world-renowned research already exist across the country. What we need is national policy, coordination, and resources to amplify, spread, and accelerate this work, and to address current gaps and inequities.

The next phase of the Task Force's work will involve listening to Canadians who live with and care about pain. There will be many opportunities for engagement, including in-person and online consultations. The input and perspectives shared will then be integrated with existing knowledge and leading practices, to outline an improved and coordinated approach to better understand, prevent, and manage pain in Canada.

The Task Force is grateful to Canadians living with pain who shared their stories and reflections for this first report – powerful testaments to the impact of how we currently approach pain in our country. We also appreciate the vital contributions of the External Advisory Panel members and the wide-ranging expertise they offered to inform this report. We look forward to broadening these discussions as we move into the next phase of our mandate.

Respectfully submitted,

The Canadian Pain Task Force

• Fiona Campbell, Co-Chair
• Maria Hudspith, Co-Chair
• Melissa Anderson
• Manon Choinière
• Hani El-Gabalawy
• Jacques Laliberté
• Jaris Swidrovich
• Linda Wilhelm

Section 1: The nature of pain and its impacts on Canadians

Pain is an unpleasant sensory and emotional experience unique to the individual

Pain is an unpleasant sensory and emotional experience that we all encounter at some point in our lives. It is highly personal and can only be fully appreciated by the individual experiencing the pain.

Biological mechanisms of pain are mediated by the nervous system. Sensory neurons or nociceptors throughout our bodies send signals to the brain through the peripheral nervous system and spinal cord. If the brain interprets these signals as dangerous, we experience pain to warn and protect us. The nervous system can change in response to various factors and these changes can make us more or less sensitive to painful stimuli, or even result in a persistent state of heightened pain sensitivity. We can use this plasticity of our nervous system to manage and diminish the experience of pain. There are three main biological mechanisms that underpin pain:

• Nociceptive pain arises from damage to body tissue, and is the typical pain one experiences as a result of injury, disease, or inflammation. It is usually described as a sharp, aching, or throbbing pain.
• Neuropathic pain arises from direct damage to the nervous system itself. It is typically described as burning or shooting pain, and the skin can be numb, tingling, or extremely sensitive to even light touch.
• Nociplastic pain arises from a change in the way sensory neurons function, rather than from direct damage to the nervous system. The sensory neurons become more responsive (sensitization). It is similar in nature to neuropathic pain.

Pragmatically pain is sub-defined not only by these mechanisms, but also by its duration (acute or chronic). Acute pain is typically nociceptive, but can have a neuropathic component, and chronic pain can also be nociceptive, but typically has a neuropathic or nociplastic component.

Chronic primary pain is pain in one or more anatomical regions that:

1. Persists or recurs for longer than 3 months; and,
2. Is associated with significant emotional distress (e.g., anxiety, anger, frustration, depressed mood) and/or significant functional disability (interference in activities of daily life and participation in social roles); and,
3. The symptoms are not better accounted for by another diagnosis (Nicholas et al., 2019).

Chronic primary pain includes the following sub-diagnoses: chronic widespread pain, complex regional pain syndrome, chronic primary headache or orofacial pain, chronic primary visceral pain, and chronic primary musculoskeletal pain.

Chronic secondary pain is diagnosed when pain originally emerges as a symptom of another underlying health condition. It may persist even after the condition has been treated, in which case it is also considered a disease in its own right. Common examples of chronic secondary pain include chronic cancer pain, chronic post-surgical or post traumatic pain, chronic neuropathic pain, chronic secondary headache, chronic secondary visceral pain, and chronic secondary musculoskeletal pain.

The new ICD-11 classification system also includes a code for pain severity, which accounts for pain intensity, emotional distress, and interference with function.

Biological, psychological, and social factors influence our experience of pain

Biological, psychological, and social factors unique to each individual interact with the nervous system and influence the development and experience of pain. This is the basis of the biopsychosocial model of pain (Gatchel et al., 2007). This model shifts the focus away from the traditional biomedical model and expands our approach to the prevention, assessment, and management of pain to encompass the whole person and their experience of pain. Environmental, emotional, and spiritual factors overlap with some elements of this model and broaden it further (Painaustralia, 2019; Institute of Medicine [IOM], 2011).

Below are some of the factors within each of these dimensions that influence the pain experience, along with some concrete examples:

• "Biological—the extent of an illness or injury and whether the person has other illnesses, is under stress, or has specific genes or predisposing factors that affect pain tolerance or thresholds" (IOM, 2011)
  e.g., sex and stress hormones influence pain sensitivity
• "Psychological—anxiety, fear, guilt, anger, depression, and thinking the pain represents something worse than it does and that the person is helpless to manage it" (IOM, 2011)
  e.g., distraction decreases pain intensity while focus on pain increases pain intensity
• "Social—the response of significant others to the pain—whether support, criticism, enabling behavior, or withdrawal—the demands of the work environment, access to medical care, culture, and family attitudes and beliefs." (IOM, 2011)
  e.g., culture-based coping strategies can reduce pain intensity and the individual's perceived impact of the pain

Pain is complicated and multi-dimensional. The different dimensions of pain (biological, psychological, and social) must be considered to effectively assess, diagnose, and treat pain. They are also helpful to consider when exploring observed patterns of pain within the Canadian population.

Millions of Canadians live with moderate to severe chronic pain

According to several large population-based surveys, an estimated one in five Canadians lives with chronic pain (Schopflocher et al., 2011; Reitsma et al., 2011; Steingrimsdottir et al., 2017). Two thirds of Canadians living with chronic pain report their pain is moderate (52%) to severe (14%), and 50% have lived with chronic pain for over ten years (Schopflocher et al., 2011).

Certain populations bear more of the pain burden

As with many chronic illnesses, chronic pain is not distributed equally among Canadians. Biological, psychological, social, and other factors that influence how we experience pain also influence who will develop chronic pain in the first place. Often the occurrence of disease, as well as the severity of illness, is higher in populations affected by social inequities and discrimination including those living in poverty, Indigenous Peoples, certain ethnic communities, and women (Allan & Smylie, 2015; IOM, 2011).

Older adults

The prevalence of chronic pain increases steadily with age in adults, making this disorder a major health issue for older adults. Approximately one in three Canadians 65 years of age and older lives with chronic pain (Schopflocher et al., 2011; Reitsma et al., 2011). Given the aging population in Canada, we can expect a larger proportion of Canadians to be living with chronic pain in the coming years.

Children and adolescents

Contrary to what many expect, chronic pain is also common among children and adolescents with prevalence estimates ranging from 11% to 38% (King et al., 2011). Common presentations of chronic pain in children include recurrent headaches, abdominal pain, back pain, and musculoskeletal pain (Friedrichsdorf et al., 2016; King et al., 2011). Pain in this age group can impact development and may lead to chronic pain, substance use, and psychological disorders later in life (Groenewald et al., 2019).

Females

Veterans

Veterans report chronic illnesses at a rate two to three times higher than in the general population. Chronic pain affects 41% of Canada's 670,000 Veterans. Almost two thirds (63%) of Veterans with chronic pain also have a diagnosis of a mental health condition, and many say their pain interferes with work, makes it more difficult to adjust to civilian life, and causes stress and activity reductions. The odds of having activity limitations are eleven times greater in those with chronic pain than in those without pain, and 65% of Veterans with past-year suicidal ideation and 76% with past-year suicide attempts also reported chronic pain (Veterans Affairs Canada, 2019).

People who use drugs

The prevalence of chronic pain among people who use drugs is relatively well documented. Prevalence estimates range from 31% to 55% dependent on the specific population surveyed (Heimer et al., 2015; Alford et al., 2016; Voon et al., 2015; Dunn et al., 2015; Peles et al., 2005). This often leads to a cyclical challenge – unmanaged pain may lead to problematic use of substances, which may lead to further declines in health and more pain. In these instances, access to a range of pain management therapies would help to diminish pain and provide a window of opportunity to address the problematic substance use, but the range of therapies required are often not readily available or accessible (Voon et al., 2014; Voon et al., 2015; Dassieu et al., 2019).

Pain affects all aspects of one's life

There is growing awareness of the significant impact of pain on individuals and their families. People living with pain often experience:

• Reduced quality of life and general health;
• Decreased mental and emotional health including increased worrying, stress, anxiety, sadness, depression, anger, and frustration;
• Increased risk of suicide;
• Problems with cognitive function, such as reduced processing speed, selective attention, memory, and executive functioning;
• Increased fatigue, exhaustion, and sleep problems;
• Reduced activities of daily living and physical and social functioning (e.g., sleeping, caregiving, participating in recreation and community life);
• School/work absence and reduced productivity;
• Increased disability and inactivity;
• Decreased social connections and supports; and
• Increased health care utilization.

(IOM, 2011; Duenas et al., 2016; Racine, 2018; Leadley et al., 2012, 2014; Reid et al., 2016)

The magnitude and severity of these impacts are typically higher in populations affected by structural inequities, including those living in poverty, women, Indigenous Peoples, and certain ethnic communities (Allan & Smylie, 2015; IOM, 2011).

There are significant costs to families, communities, and society

Chronic pain carries both human and economic costs for families, communities, and society. In addition to the direct health care costs, pain undermines one's ability to participate fully in relationships, schools, workplaces, and communities.

Data for action to improve the health and well-being of Canadians and our economy

The data indicate chronic pain is a common disease with a significant impact on the health and well-being of Canadians, as well as our economy. It is also clear this disease has a larger impact on subpopulations that routinely face more health and social challenges. These data can be used to inform policy, programming, and investments to reduce the effects of chronic pain in Canada.

There is an international movement to improve data on chronic pain, which will allow countries to better inform action and monitor results. The new standard diagnostic criteria for chronic pain included in the International Classification of Diseases will increase the comparability of data on chronic pain. This will aid the development of national, provincial, territorial, and regional health profiles, and allow stakeholders to monitor changes in trends over time.

Research networks in Canada are also developing registries of people living with pain and standards to collect key information from all patients who seek care at the hospitals and clinics involved in these networks (e.g., demographic data, pain severity and duration, functional limitations, disability). Combined, these efforts will better enable evidence-based action on chronic pain in Canada.

Section 2: Current approaches to diagnosing and managing chronic pain in Canada

Two fundamental ideas covered in the previous section are critical to the effective diagnosis, treatment, and management of chronic pain. First, chronic pain is a disease in its own right, with important perpetuating factors beyond the initiating injury or illness. Second, chronic pain is influenced by a complex interplay of biological, psychological, and social factors unique to each individual experiencing the pain. Gaps in chronic pain care in Canada often reflect gaps in knowledge around these two ideas among both the general population and health care professionals, and failure to adequately address the psychological and social dimensions of pain in an integrated manner along with biological factors.

Recognition that pain is real and multi-dimensional will support improved diagnosis

Frequently, societal norms and beliefs prevent individuals and their caregivers from investigating pain as a legitimate health issue. Attitudes and beliefs reinforcing pain as a normal part of life, have contributed to underdiagnosed and undertreated pain. Gender biases among individuals and health care providers contribute to fewer men seeking health care for pain than women and women's symptoms being overlooked (Samulowitz et al., 2018; Bartley & Fillingim, 2013). Discrimination prevents Indigenous People from receiving the help they need and stigma contributes to the perception that people living with substance use disorder are only seeking treatment for pain so they can obtain more drugs (Voon et al., 2015; Dassieu et al., 2019; Wylie & McConkey, 2019). These issues lead to delays in diagnosis and treatment.

Physical, psychological, and pharmacological therapies work better together

Chronic pain is difficult to cure; there is no evidence that helps us know the overall cure rate for this diagnosis. Sometimes pain can be successfully treated. Commonly, however, treatment is only partially effective, and is geared toward optimizing pain management to improve function and reduce suffering.

Table 1: Examples of interventions for the treatment and management of chronic pain

Table 2: Clinical practice guidelines for chronic pain

Opioids and cannabis warrant special attention in the current Canadian context

Opioids

When prescribed and used as directed by a health professional, opioids play an important role in pain management for many Canadians. In the context of severe acute pain, such as after surgery, injury, or in cases of severe cancer pain or end-of-life care, opioids are a commonly used and effective analgesic. Opioid medications have also been widely used for the management of chronic non-cancer pain (Moulin et al., 2014; National Opioid Use Guideline Group, 2010; Meldrum, 2016; Saïdi et al., 2018).

Recent dramatic increases in opioid-related overdose deaths in North America have heightened awareness around the risks associated with both short- and long-term opioid use. A toxic illegal supply of opioids is currently the main factor driving drug overdose deaths. However, increased availability of prescription opioids has also contributed to opioid-related hospitalizations and deaths since the early 2000s (Fischer et al., 2006; Dhalla et al., 2009; Gomes et al., 2011; Chou et al., 2014; Edlund et al., 2014; Gladstone et al., 2015; Gomes et al., 2018a; Gomes et al., 2018b; Sanger et al., 2018; Ministry of Public Safety and Solicitor General, 2018; Fischer et al., 2018). Opioid medications have been diverted to the illegal market providing a supply for non-medical use (Fischer et al., 2006; Fischer & Rehm, 2009; Gladstone et al., 2015; Health Canada, 2017). In addition, a proportion of individuals prescribed opioids for both acute and chronic pain have experienced significant harms including the development of opioid use disorder, overdose, and death (Sanger et al., 2018; Gomes et al., 2011; Chou et al., 2014; Gomes et al., 2018a; Gomes et al., 2018b). While the relationship between pain, opioids, and opioid-related harms in Canada requires further clarification, available evidence warranted action.

Actions to promote appropriate use of opioids have included the implementation of prescription monitoring programs, informing Canadians about the risks of opioids, and updating evidence-based clinical practice guidelines for opioid prescribing (Busse et al., 2017). Updated guidelines reflect evidence that opioids provide improvement in pain, physical functioning, and health-related quality of life for an appreciable minority of people with chronic pain and that adverse health effects of long-term opioid use can be significant (Busse et al., 2018; Chou et al., 2014; Filiatrault et al., 2016; Mao, 2002; Colvin et al., 2019). These actions have had positive impacts for some people who have avoided unnecessary exposure to opioids and associated harms. However, they have also had unintended consequences for some people living with pain.

Some people who could benefit from opioids in the management of pain now face significant barriers to obtaining a prescription (Dowell et al., 2019; Antoniou et al., 2019; Dassieu et al., 2019; Sinha et al., 2019; Darnall et al., 2019). In addition, many people who have been using opioids for several years and/or who have been taking them at higher doses than currently recommended are being weaned off the medication. Some of these individuals have seen their quality of life and functioning improve when doses were reduced gradually with their consent. Others report being cut off or aggressively weaned without consent, contrary to the updated Canadian guidelines, resulting in debilitating pain, serious withdrawal symptoms, and higher risk of potential overdose for those who turn to illegal sources to manage their pain (Voon et al., 2015; Kahan et al., 2018; Antoniou et al., 2019; Dassieu et al., 2019; Dowell et al., 2019; Darnall et al., 2019). People who use drugs commonly suffer from chronic pain, and some report being denied opioids to manage severe pain (Dassieu et al., 2019; Voon et al., 2015). Ultimately, many people living with pain feel stigmatized, scrutinized, and in some cases dismissed by health care professionals (Antoniou et al., 2019; Dassieu et al., 2019; Sinha et al., 2019).

There is a need to promote shared decision-making between health care professionals and people living with pain. Prescribing decisions must be based on the unique needs of the individual but this is not supported by the current environment. Health care professionals feel pressured to reduce opioid prescribing and often lack the time and knowledge needed to support patient-centred pain care and opioid prescribing (Lynch & Katz, 2017; Dowell et al., 2019). There is an urgent need for stakeholders across the country to reinforce and better support opioid prescribing that balances the benefits and harms of these medications based on the needs of the individual. Efforts are already underway by many – these will be explored and additional opportunities identified in the next phase of our work.

Cannabis

In 2018, there were approximately 340,000 authorized users of medical cannabis in Canada (Health Canada, 2019) and evidence suggests pain is one of the most commonly reported conditions for such use (NASEM, 2017; Nicholas & MacLean, 2019). In addition, the legalization of cannabis is increasing access to cannabis, making it available for self-management of chronic pain, without the need for a conversation between patients and their health professionals to inform shared decision-making. Initial population-based studies indicate such legal reforms have resulted in reductions in pain and better self-assessed health among older adults (Nicholas & MacLean, 2019) as well as some reduction in chronic pain admissions to health care facilities (Delling et al., 2019). There are also suggestions that some individuals may be reducing and replacing certain pain medications, such as opioids, in favour of cannabis (Bachhuber et al., 2019; NASEM, 2017; Nicholas & MacLean, 2019). However, current clinical evidence to support the use of cannabis for pain is limited.

Reviews of randomized controlled trials and observational studies indicate cannabis may reduce pain intensity. The evidence is stronger in cases of neuropathic pain, and more moderate for conditions such as musculoskeletal pain, fibromyalgia, headaches, cancer pain, multiple sclerosis, and arthritis (NASEM, 2017; Carr & Schatman, 2019; Whiting et al., 2015; Stockings et al., 2018). However, there are significant side effects and safety concerns noted, and many studies have failed to show benefit for physical and emotional function. This has led several investigators to conclude that cannabis is unlikely to be effective for chronic pain (Stockings et al., 2018; Carr & Schatman, 2019; Mucke et al., 2018). Because of the potential impacts of policy change and the limited number of clinical studies, there are still many unknowns around efficacy and safety of cannabis for chronic pain management. More specifically there are questions related to product selection, dosing, routes of administration, interactions with other medications, substances and treatments, side effects, and potential long-term complications (Carr & Schatman, 2019; NASEM, 2017).

Multidisciplinary and interprofessional pain clinics are the gold standard

There is evidence indicating multidisciplinary pain clinics are clinically and economically effective, making up an important part of the spectrum of pain care (Tunks et al., 2008; Gatchel & Howard, 2018). Treatment might involve a multidisciplinary approach whereby patients work with multiple health professionals separately to establish care plans, or might include interdisciplinary services involving highly integrated teams working together to establish a single patient-centred pain management plan. Research demonstrates these models often achieve decreases in pain intensity and interference, as well as the fear, stress, depression, and anxiety that can often accompany chronic pain. Multidisciplinary clinics have also been associated with decreases in the use of medication, health care utilization, iatrogenic consequences, and disability claims while increasing activity, functioning, coping, and self-efficacy, which can subsequently result in cost savings for the health system (Katz et al., 2019; Campbell et al., 2018; Chao et al., 2019; CADTH, 2018d, 2019c; Waddell et al., 2017b; Gatchel & Howard, 2018).

Integrated pain services prevent transition from acute to chronic pain and chronic opioid use

Transitional pain services (TPS) focus on optimizing the treatment of significant acute pain and use of opioids in order to prevent the development of chronic pain and opioid use disorder. Typically, these services are provided in tertiary care settings and have a particular focus on preventing and treating pain related to major surgery. TPSs include teams of advanced practice nurses, physicians, physiotherapists, and psychologists all specializing in pain. Patients identified as at-risk of transitioning from acute to chronic pain are identified early and provided a range of services to minimize the likelihood of chronic pain and to ensure the transition from hospital to community results in positive outcomes (Katz et al., 2015). These clinics also carefully monitor opioid dosing and support patients to taper their use of opioids. Research has demonstrated such services are effective at reducing opioid consumption and duration of use, achieving reductions in pain intensity and interference, and reducing anxiety among patients participating in the services (Clarke et al., 2018). There are few clinics incorporating transitional services in urban centres in Ontario, British Columbia, Quebec, and Alberta.

Care models that integrate cultural approaches support better outcomes

Chronic pain is often conceptualized by Indigenous Peoples intellectually, spiritually, emotionally, and physically. Many studies looking at the adequacy of available tools for assessing pain indicate Indigenous Peoples prefer more holistic measures or descriptions of pain (Latimer et al., 2018; Harman, 2015). Furthermore, health care institutions, dominated by the biomedical model, impose restrictions on Indigenous People's access to family and traditional rituals, which are seen as central to healing. The inclusion of traditional healing practices in a multidisciplinary pain treatment program would be beneficial, and the use of traditional medicine need not conflict with conventional treatments.

Canadians have inadequate access to pain services and wait times are long

Chronic pain care pathways are complex, fragmented, and difficult to navigate

Similar to other chronic diseases (e.g., diabetes, heart disease), treatment of chronic pain currently takes place across many different care settings. The following is a basic description of the current path a person may take from the onset of symptoms to obtaining the care required to help them manage their pain. This process is not linear, however, and may involve moving back and forth between settings based on symptoms and life circumstances. Self-management underpins each stage and is an important part of relieving pain. It may start with informal efforts but evolves as people are exposed to information, medical advice, and even structured self-management programs that educate people about their condition and build their capacity to take action.

• Onset of Symptoms: People with pain will often try to manage on their own, because of stigma, lack of access to care, or other reasons (e.g., social or cultural norms, familial pressure). They consult with individuals or the internet and other resources, attempting to manage pain based on the knowledge and experience of others. The reliability of information obtained can be questionable and lead to frustration and possibly harmful outcomes. Some may even use substances (prescription or non-prescription) to self-medicate, which furthers potential for harm.
• Primary Care and Complementary/Alternative Care: People may seek treatment in their community (e.g., by chiropractors, naturopathic doctors, osteopaths, acupuncturists, massage therapists). If pain continues, worsens, or starts to interfere with sleep, mood, and function, people might then seek the care of pharmacists, physiotherapists, dentists, family physicians, nurse practitioners, or pediatricians – a challenge considering over 15% of Canadians do not have a regular health care provider (Statistics Canada, 2017).
• Secondary or Specialized Care: If pain continues, people are often referred to a specialist in diagnosing and treating specific diseases (e.g., rheumatologist for arthritis or dentists for orofacial pain, neurologist for chronic headaches). These specialists help to identify and manage "treatable" underlying conditions causing chronic secondary pain, but they may not have the capacity to manage chronic primary pain as a disease in its own right.
• Tertiary Care Involving Multidisciplinary and Interprofessional Teams: When professionals in primary or secondary care are unable to satisfactorily treat chronic pain, they may refer people to specialized chronic pain services in the tertiary sector of care. Treatment might involve working with multiple health professionals to establish care plans, or working with highly integrated teams working together to establish a single patient-centred pain management plan. These services are often inaccessible to most people due to lack of availability or long wait times.

Section 2: Summary

Reviewing the current state of chronic pain treatment and management, it is clear that we need a better way to diagnose, assess, and manage chronic pain and its impacts. The benefits of programs that integrate pharmacological, psychological, and physical treatment options are clear. However, more evidence is needed to clarify the individual and combination therapies that will provide optimal benefits for different people and different types of pain. Research suggests pain care needs to be tailored to the individual and the majority of care and management should ideally take place through self-management and community-based primary care, with specialty services available for complex cases. There is also clearly an issue with limited and variable access to pain services across Canada. Evidence points to the need for increased availability of pain care, from wellness-oriented, community-based care for people with mild functional impairment due to pain, to specialized, multidisciplinary and interdisciplinary care for those experiencing moderate to severe pain and functional impairment. Many services are outside of the publicly funded health system and vary based on insurance coverage and geography. We need to explore how to address these challenges and how the use of technological advances and innovation could help to improve reach and coverage (e.g., telehealth, online platforms, communities of practice). Strategies must also account for populations disproportionately affected and undertreated.

Section 3: Awareness, education, and specialized training for pain

There are significant gaps in pain education of health professionals

Pain education for health professionals is needed for improving and enabling prevention and treatment practices. However, the current state of pain education in Canada remains inadequate across disciplines, with significant knowledge gaps in both pre- and post-licensure contexts (NASEM, 2019; Thompson et al., 2018).

Dedicated pain curricula are needed in pre-licensure education across health professions

Pain-specific pre-licensure curricula can significantly improve knowledge and beliefs about pain among health science students (Watt-Watson et al., 2009). Despite the value, there are major gaps across academic programs. In a review of 10 Canadian universities across 7 provinces, involving the health science faculties of medicine, nursing, dentistry, pharmacy, physical therapy, occupational therapy, and veterinary medicine, 68% of programs were unable to specify any designated hours for pain education and veterinary students were shown to receive 2 to 5 times more pain education than that of health science students (Watt-Watson et al., 2009). Educational content also typically lacks integration of biological aspects with the psychosocial factors that contribute to the experience of pain (Wideman et al., 2019b).

Team-based education and training enables collaborative and multidisciplinary care

Effective pain management can be complex and often involves a range of treatment modalities and approaches that exceed the expertise of any one profession. However, students in health science programs have few collaborative learning experiences. Interprofessional approaches to education have been shown to help balance socialization within one's profession while also learning to understand and work with the strengths of other professionals and reduce the development of misconceptions and stigma (Peter & Watt-Watson, 2008; Watt-Watson et al., 2009; NASEM, 2019).

A survey from across Canada found a need for more opportunities that support interprofessional collaboration, multidisciplinary care, and training in the provision of non-pharmacological options (CADTH, 2018d). Several organizations have developed curricula related to interprofessional education (IASP, 2018a); and there are many excellent models that promote collaborative practice (NASEM, 2019). For example, a learning model in Quebec involves physiotherapists in the training of medical residents (CADTH, 2018d). Of note is the University of Toronto Interfaculty Pain Curriculum – a three-day, globally recognized leading model in pre-licensure education.^{Footnote 4} The program uses a series of teaching modalities to focus on current research and understanding of pain and clinical practice in pain management and has consistently shown positive changes in students' pain knowledge and beliefs (Watt-Watson et al., 2004; Hunter et al., 2008; Watt-Watson et al., 2017; Murphy et al., 2018). The program is currently exploring how best to disseminate the model to other Canadian institutions. Other less intensive models include the North American Pain School (Quebec Pain Research Network)^{Footnote 5} and the Connaught Summer Institute in Pain (University of Toronto)^{Footnote 6}.

Professional development and clinical support opportunities build pain competencies

Professional development allows health professionals to continually develop the competencies they require to successfully provide care. It is often more experiential- and practice-based learning, focused on underlying problems and solutions, and more likely to be patient-centered, collaborative, and team-based. Various models have shown to be successful for improving knowledge and attitudes among different health professions (Peter & Watt-Watson, 2008). Learning is enhanced when patients are involved in the development, delivery, and outcomes and when learning is practice rather than theory-based (Thompson et al., 2018). The current landscape in Canada has many examples of promising practices, involving:

• Intensive multi-day workshops that incorporate interactive sessions, panel discussions, and lectures such as the Practice Support Program for General Practitioners in British Columbia and Clinical Workshops run by Pain BC^{Footnote 7};
• Online training modules and e-resources that build on core curriculum related to pain such as the SickKids Online Pediatric Pain Curriculum^{Footnote 8}, the Pain BC Online Pain Foundations Course, and the Musculoskeletal Clinical Translation Framework (Curtin University, Australia)^{Footnote 9};
• Specialty certification in pain that recognize advanced competency development such as the Canadian Physiotherapy Association Clinical Specialty Program^{Footnote 10}, and the University of Alberta Graduate Certificate in Pain Management^{Footnote 11}; and
• Mentoring programs that match mentee with experienced pain professionals, such as the Canadian Physiotherapy Association Pain Mentorship Programs^{Footnote 12}, the Medical Mentoring for Addictions and Pain Network, and the Pharmacist Mentoring in Addictions and Pain Program^{Footnote 13}.

Interprofessional platforms and communities of practice improve access to care

Recognizing the importance of multidisciplinary approaches and collaboration, particularly for health professionals in rural, remote, and northern communities, innovative online and digital platforms have launched to link different types of providers with needed pain expertise, thereby improving access to specialist care for patients with chronic pain. These models are building on initial successes to slowly scale up to other jurisdictions across Canada.

Increased public awareness and education are needed to improve prevention and care

Awareness building efforts are an increasingly common strategy to help prevent and manage acute and chronic health conditions. They are designed to better align evidence-based clinical guidelines with widely held beliefs and address issues related to stigma and discrimination. The effects of such campaigns involve shifts in knowledge and attitudes about health conditions along with related shifts in behaviours and lifestyles, which can result in positive changes to prevention and health care utilization (Buchbinder et al., 2008; Waddell et al., 2017b).

There are organizations working at the provincial and national level to try to build education, awareness, and support around pain and the experience of living with chronic pain (e.g., Pain BC, l'Association québécoise de la douleur chronique, Chronic Pain Association of Canada) and disease specific organizations advocating for chronic pain related issues (e.g., The Arthritis Society). There are also several nationally based pain-focused networks (e.g., Solutions for Kids in Pain, National ME/FM Action Network, Canadian Pain Society) and tools designed for clinical environments and patient self-management that could be leveraged for public education and awareness. There would therefore be tremendous value in coordinating activities and leveraging lessons from existing efforts to ensure a unified and consistent approach to pain awareness and education in Canada. This approach should include multiple settings, such as schools, workplaces, health care institutions, and homes, and be targeted to multiple populations.

Innovative knowledge translation activities transform research into practice and build pain awareness

Section 3: Summary

Pre-licensure education and continuing professional development must better integrate sufficient, pain-specific learning into curricula. This would provide health professionals with the knowledge and skills required to prevent and treat pain; furthermore it would enable an essential cultural transformation to better support Canadian actions on pain. Reducing disparities in curricula through common learning resources and outcomes across disciplines, in addition to improved quality assurance of training programs, would help to foster better education. Several examples exist that incorporate people living with pain in the design, delivery, and evaluation of education innovations, shifting from theory- to practice-based education, and emphasizing interprofessional education and collaboration. Similarly, some stakeholders are beginning to implement more general awareness building campaigns in select jurisdictions and for particular populations. As well, knowledge mobilization efforts are underway to accelerate the transformation of research evidence into practice. Currently, most studies look at indicators of practitioner knowledge and satisfaction; few examine whether improvements in knowledge are also leading to better care and improved patient outcomes. There are few studies examining the reach, dissemination, and sustained implementation of awareness building efforts. There is a clear need for better coordination across jurisdictions and health disciplines, and future efforts grounded in anti-oppression approaches that are trauma-informed and sensitive to different social and cultural needs.

Section 4: Pain research in Canada

Globally, pain research focuses on the biopsychosocial mechanisms, epidemiology, clinical features, management principles, and health service delivery models for pain. Canada's pain research landscape is nested in this international research ecosystem, while having its own unique strengths and challenges. For example, Canada is a world leader in biomedical research focused on the basic mechanisms of pain (Council of Canadian Academies, 2012) particularly in areas such as pain genetics and sex differences in the physiology and pathophysiology of pain (Sorge et al., 2015). Yet there remains much work to be done to understand key aspects of pain such as what governs the transition from acute to chronic pain and how early childhood events lead to chronic pain later in life. More work is also needed to translate basic discoveries and mechanistic insights into education and safe and effective therapies that can be delivered cost-effectively to individuals who need them. Considering the breadth and scope of the pain research agenda, it is important to identify research priorities where Canadians can continue to excel and harness the strengths of their existing programs, while ensuring knowledge translation activities facilitate better integration of chronic pain research, education, and clinical practice.

World-leading research requires national networks, infrastructure, and supports

Between 2013-14 and 2017-18, CIHR invested more than $88 million in pain research in areas such as the development of novel analgesics and tools to help health care providers provide more personalized treatments. CIHR also committed $12.5 million (matched by $12.5 million from external partners) to fund a large multidisciplinary pain research network through its Strategy for Patient-Oriented Research (SPOR) from 2016 to 2021. The CIHR SPOR – Chronic Pain Network^{Footnote 22} (CPN) is a national collaboration of patients, researchers, health care professionals, educators, industry, and government who are working to direct new research in chronic pain, train researchers and clinicians, and translate knowledge into guidelines and policy. Patients are engaged as partners, working with researchers and health care professionals to improve health outcomes, identify new treatments, and deliver a more effective health care system to Canadians.

In addition to supporting communication and collaboration among pain stakeholders, the network supports individual research projects on topics related to chronic pediatric pain, pain in older adults, pain in Indigenous populations, the role of mental health and other comorbidities (e.g., obesity, insomnia) in chronic pain, therapeutic targets, pain mechanisms and biomarkers, strategies for pain assessment, and tailored pain interventions. It also supports infrastructure to enable better research including establishing a pain registry, common indicators and outcome measures, and multi-trial coordination.

Canada has a solid foundation for a national pain research agenda

In 2016, CIHR hosted the Canadian Pain Research Summit wherein researchers, clinicians, partners, charities, patients, and policymakers with a common interest in pain came together to reflect on what funding agencies could do to better stimulate pain research. Participants came from across Canada, the United States, and the United Kingdom, to identify opportunities, develop a pain research agenda and encourage new collaborations and initiatives (CIHR, 2016). The discussion resulted in a short list of research areas related to two themes (Table 3): (1) translate basic research into clinical applications; and (2) personalization of pain medicine. Particular emphasis was placed on the importance of partnerships between and among researchers, clinicians, people living with pain, and decision-makers in this research strategy.

Table 3: Research agenda for chronic pain from the 2016 Pain Summit hosted by CIHR

People living with chronic pain must be equal partners in research

Patient engagement provides many valuable outcomes to the research process and improves feasibility, acceptability, rigor, and relevance (Forsythe et al., 2019). As such, Canada is becoming a leader in the engagement of patients in the pain research enterprise, spanning the full spectrum of research prioritization, ethical and peer review, conduct of research, and knowledge translation. For example, since 2017, the Canadian Pain Society has made their Annual Scientific Meetings officially accredited to include people living with pain.^{Footnote 23} In addition to the CIHR SPOR – CPN mentioned above, there have also been several projects in Canada employing a priority setting process that brings together patients, family members, and clinicians as equal partners to identify research priorities^{Footnote 24} (Birnie et al., 2019; Fitzcharles et al., 2017; Poulin et al., 2018). Each of these projects highlights important patient-centred priorities focused on:

• Improving knowledge and competencies in chronic pain;
• Preventing chronic pain and reducing associated symptoms;
• Understanding the impacts of chronic pain;
• Improving patient-centered treatment of chronic pain;
• Improving access to and coordination of chronic pain care; and
• Understanding the interaction of pain with other co-morbidities.

Section 4: Summary

There is a great foundation in Canada for national action on chronic pain research. National research funding agencies, research and advocacy-based organizations and networks, and individual research teams, some collaborating with people living with chronic pain, have worked to define clear directions for a research agenda. However, there is limited research on how to monitor the quality and effectiveness of our health care system for treating chronic pain. Most research investment is concentrated in basic sciences or clinical trials. Research on different treatment options often does not evaluate whether the intended benefits for patients and society are being achieved. Furthermore, there are major gaps in research exploring how to tailor particular treatments to individual patients (personalized medicine). Most research involves data averaged over groups, which may not translate well to all individuals. A paradigm shift is required that enables accounting for inter-individual variability and identifying which patients are most and least likely to benefit from a specific treatment or a combination of treatments.

Section 5: Domestic and international action on pain

The groundwork exists in Canada for a national pain strategy

In 2011, the Canadian Pain Society led calls to governments at the federal, provincial, and territorial levels to develop a coordinated approach to pain in Canada through a national pain strategy. The strategy focused on access to care, awareness and education, research, and ongoing monitoring for pain (Lynch, 2011; Canadian Pain Society [CPS] and the Canadian Pain Coalition [CPC], 2011).

Since that time several initiatives have taken place with the aim of further articulating how to establish a strategy in Canada. In 2017, the McMaster Health Forum convened a stakeholder dialogue with leaders from across Canada on the development and advancement of a national pain strategy. Participants agreed that responses to the drug overdose crisis had resulted in unintended consequences and created uncertainty for those with chronic pain. They also noted the lack of tools available to support effective pain management, the lack of leadership at the policy level, and the need to create a national coordinating body (Waddell et al., 2017a, 2017b).

• Improving knowledge around the causes, physiology, and experience of pain, including mapping of the current realities for people living with and treating pain;
• Developing a more wholesome picture of the socio-economic costs of pain in Canada;
• Enabling better knowledge translation of pain-related research and practices; and
• Mapping the full range of evidence-based treatments and solutions for pain.

(CAHS, 2018)

Over the last few years, the Canadian Pain Care Forum (CPCF) has been working to coordinate and focus the efforts of organizations across Canada with an interest in and desire to improve national and/or provincial pain care public policy. This open forum includes non-profit patient/consumer education and advocacy organizations, health care professional(s) associations, policy organizations, medical services organizations, academic health-science centres, law enforcement, and pharmaceutical and medical products businesses. They meet quarterly and are supported by the Michael G DeGroote Institute for Pain Research and Care and the National Pain Centre, at McMaster University.

In May 2018, the CPCF completed an updated proposal for a Canadian Pain Strategy that has been shared with executives in the organizations of its 80 members across the country including Health Canada. The proposal is a bold but achievable plan to improve the prevention and treatment of chronic pain in Canada and, in so doing, help to address the opioid crisis. The proposal outlines a comprehensive approach involving four elements to address the problem and puts forward milestones by one-, three- and five-year time frames emphasizing quick wins in year one to build momentum (Table 4).

Table 4: The Canadian Pain Care Forum's proposed elements for a Canadian Pain Strategy

National leadership and coordination would amplify provincial/territorial efforts

Table 5: Provincial and territorial actions on pain

Jurisdiction	Strategies and Actions
British Columbia	In June 2016, the College of Physicians and Surgeons of BC released new standards for opioid prescribing – Practice Standard on Safe Prescribing of Opioids and Stimulants. In 2018, the Ministry of Health, in collaboration with the Ministry of Mental Health and Addictions, Pain BC, and health system partners, worked on identifying gaps and opportunities to improve chronic pain prevention and management, subsequently developing a draft Provincial Chronic Pain Strategy and Action Plan. Options are now being developed for strategy implementation. The BC Guidelines and Protocols Advisory Committee is currently developing a chronic pain clinical practice guideline for primary care. In 2018, the first Transitional Pain Service launched at Vancouver General Hospital with a focus on improving outcomes related to both pain management and opioids for post-surgical patients. Several Divisions of Family Practice are working on pain-related planning and service initiatives. The Shared Care Committee – a Joint Committee of the Doctors of BC and the BC Ministry of Health, have created a "Chronic Pain Spread Network" to bring together communities of primary care physicians working on pain initiatives to share their successes and challenges. A number of new Primary Care Networks are developing with a focus on enhancing community-based pain services. BC Children's Hospital is undertaking a site-wide pediatric pain initiative. Changes to Procedural Pain Management (PPM) standards are being considered to support consistent practice. The College of Physicians and Surgeons of BC developed draft accreditation PPM standards and public feedback concluded May 27, 2019. The next step is for the standards to be approved and then followed by an implementation plan.
Alberta	Strategic Clinic Networks undertook an environmental scan on current state of pain care in the province as well as numerous consultations. The results subsequently informed the development of a provincial pain strategy drafted together with the Pain Society of Alberta. A provincial steering committee is being developed to oversee the priority actions within the 3 streams of the strategy. A pain research strategy is also being developed by the University of Calgary, the University of Alberta, and Campus Alberta Neuroscience, in partnership with the Hotchkiss Brain Institute and Alberta Children's Hospital Research Institute. Several innovative pilot programs underway across the province, e.g., SpineAccess Alberta, is evaluating a multidisciplinary pathway system for individuals with chronic pain. The goal is to increase efficiency within the diagnostic and consultation process for patients. Efforts by a subgroup within the Alberta Health's Opioid Safety Working Group to develop an approach to substance use disorder and pain management. Transitional Pain Service: Focus on the implementation of this service more broadly within Alberta to address challenges, including the development of chronic postsurgical pain and postoperative opioid dose escalation. Primary Healthcare Opioid Response Initiative (Provincial): The Alberta College of Family Physicians, Alberta Medical Association, and Alberta Health Services are working collaboratively with Alberta Health to lead the work of a $9.5 million provincial grant. The grant is for a primary health care response through Primary Care Networks and is intended to provide increased access to services and provide training for primary care providers, who are offering treatment, medication, and care to patients and families affected by the opioid crisis. Provincial Electronic Medical Record: Develop standardized provincial postoperative surgical and discharge analgesia order sets. Alberta is home to the largest multidisciplinary pain program in Canada, partnered with numerous successful primary care based pain projects to keep pain prevention, assessment, and management in the medical home. Work is currently underway to spread this innovation to other primary care networks throughout the province.
Saskatchewan	SaskPain – a provincial network of health professionals dedicated to improving chronic pain has been created. Based on 2014 and 2016 stakeholder dialogues on the state of chronic pain in the province, working groups were created to develop strategies in the areas of pain foundation, education, research and knowledge translation, and practice. Currently undertaking priority setting exercises to inform future provincial strategy. Creation of a multidisciplinary SaskPain Professional Practice Group and on-going work by SaskPain to secure provincial funds to support specialized pain clinics in the province. Workshops, peer support networks, and online courses offered by the Saskatchewan Health Authority such as the LiveWell with Chronic Conditions and LiveWell with Chronic Pain workshops, which assist individuals with attaining support and education on how to manage their pain to improve activities of daily living.
Manitoba	In 2018, a pediatric clinic for complex chronic pain was established at the Winnipeg Health Sciences Centre. Utilizing the biopsychosocial model of chronic pain management and a patient and family centred model, the program is embedded in a larger, region-wide complex pain management program.
Ontario	In 2016 provincial funding announced for the establishment or enhancement of 17 multidisciplinary chronic pain clinics (adult and pediatric). Expansion of Rapid Access Clinics aimed at reducing wait times for services and eliminating unnecessary diagnostic procedures. The Well Initiative provides health care tools and resources, with a dedicated aspect to chronic non-cancer pain that connects individuals to local pain care services through Local Health Integration Networks. Chronic conditions self-management programs delivered through Local Health Integration Networks. Health Quality Ontario has published quality standards on opioid prescribing for acute pain, chronic pain, and low back pain, as well as drafted quality standards for chronic pain care.Footnote 25Footnote 26Footnote 27 The Low Back Pain Strategy administered by the Ministry of Health and Long-Term Care aims to improve pain care to individuals through improvements to access to diagnostic services and self-management tools. The strategy also aims to test two new provincial models of care, including the Inter-professional Spine Assessment and Education Clinics Pilot program and the Primary Care Low Back Pain Pilot program.Footnote 28 Interdisciplinary initiatives such as Health Links and Health TAPESTRY provide support and coordination of care for patients and assist them in navigating the health system and the resources available to them.
Quebec	In 2004, creation of l’Association québécoise de la douleur chronique (AQDC), an association of and for individuals with lived/living experience. Based on the recommendations from AETMISFootnote 29 a national committee on chronic pain management has been in place since 2008, with representation from clinical management, research pain experts, and individuals with lived/living experience. The committee established a continuum of services involving different levels of care. Currently, there are four “Centres d’expertise” in chronic pain management, which are comprised of a Centre Hospitalier Universitaire (tertiary care teaching hospital) with a pain clinic, a rehabilitation center with expertise in the field of pain, and other institutions as necessary. There are also several regional centres located outside of urban centres. A standard referral process has been adopted by each Centre d’expertise and regional centres in the province. Several chronic pain management “algorithme de prise en charge” have been revised and published on the MSSS pain management web siteFootnote 30 for lumbar pain, neuropathic pain, fibromyalgia, and complex regional pain syndrome and additional algorithms on vestibulodynia, shingles, myelopathy, and spinal stenosis are under development. Efforts and consultations are underway to define a "Plan d’action national en douleur chronique 2020-2025" with a focus on the full continuum of care. Several projects have been implemented for coordination and optimization of medical and pharmaceutical practices concerning opioids and the treatment of painFootnote 31. Creation of the Quebec Pain Research Network and a registry of pain patients was established by the Quebec Pain Research Network. Continuing progress to develop an initiative to improve knowledge translation of opioids and pain standards to health care professionals. Creation of a Research Chair in Knowledge Translation in Pain.
New Brunswick	New opioid prescribing guidelines for the management of pain released by the College of Physicians and Surgeons of New Brunswick.
Nova Scotia	Creation of the Nova Scotia Pain Initiative and a related environmental scan of pain services across the province. An Action Plan was developed following the 10 recommendations from a report on pain care in the province (December 2018). A key element of the plan is to leverage IT resources to create a provincially centralized referral and triage system and avoid the duplication of patients on multiple waitlists and refer patients to the right level of care in the right area (geographically). The greatest barrier to success of the Action Plan is the lack of financial resources to support it. Patient Website: The Nova Scotia Health Authority (NSHA) has a live patient and provider website providing education and support to health care professionals in the province. Several education initiatives are underway including creation of standardized/minimum pain education for providers, a dedicated working group is looking at the possibility of incorporating Pain BC’s five-module program, and the NSHA is partnering with Pain BC to conduct a coast-to-coast research project.
Prince Edward Island	Activities of the PEI Action Plan to Prevent and Mitigate Opioid-Related Overdoses and Deaths include education and awareness and guidance on opioid prescribing.Footnote 32
Newfoundland and Labrador	"Improving Health: My Way" six-session program funded by the province to provide self-management support for chronic diseases, including pain.Footnote 33 Mandatory safe prescribing course for all physicians practising medicine in the province. Introduction of "Improving Health Together: A Policy Framework for Chronic Disease Prevention and Management in Newfoundland and Labrador". Chronic pain is included in the framework as one of 4 focus areas.Footnote 34 Provincial Pain Management Advisory Council created to enable a coordinated and standardized pain management service across the province based on best practices. Main focus is to review national and international leading practices, scan current state of pain management services available within the Regional Health Authorities, identify opportunities to develop standards, guidelines, and protocols for system-wide adoption, coordinate efforts across province, and identify and share key performance indicators.
Nunavut	Creation of the Canada-Nunavut Emergency Treatment Fund Bilateral Agreement, which will in part fund enhanced community-based systems offering trauma recovery support, on-the-land healing camps, and other in-community supports.Footnote 35
Northwest Territories	Network of primary care physicians and nurse practitioners are working to improve chronic pain. A single territorial electronic medical record, which provides prescription oversight for controlled substances, has been created. There is a self-management pain program at the tertiary care hospital in Yellowknife and out of Territory chronic pain centres are used for more challenging chronic pain management. The Territory is currently reviewing the data on these referrals to assess if developing a chronic pain program in the NWT would provide patients the benefit of management in-territory when possible.
Yukon	The Opioid Pain Management Working Group includes internal and external to government stakeholders who work to identify opportunities to improve health care. One of their seven priority areas is to improve acute and chronic pain management.

Existing pain strategies offer lessons learned

Table 6: International pain-related actions

Section 5: Summary

There is tremendous momentum for national action on chronic pain. Stakeholders have articulated the main priorities of a national strategy and several provinces are leading efforts to better coordinate and support optimal chronic pain prevention and management within their jurisdictions. Chronic pain appears to be on many provincial agendas. Mapping exercises that outline available services are underway. Evidence is growing around best practices for action based on provincial initiatives in Canada and from international partners working to improve chronic pain management. Defining features for a future national strategy would include awareness building and education, treatment standards and guidelines, self-management strategies, multidisciplinary and specialized pain services, communication and collaboration across jurisdictions, and research. Pain stakeholders across the country have laid the groundwork – national leadership and coordination on the issue of chronic pain could bring this work together for a customized approach that maximizes results for Canadians.

Section 6: Conclusions and next steps

It is clear that chronic pain is a significant public health issue impacting individuals, families, the health system, and society. People living with pain have limited access to the services they require and often face stigma and undue suffering as a result of their condition. This stigma often intersects with other forms of discrimination related to poverty, housing and employment instability, mental illness, race and ethnicity, and other factors further complicating the challenge of living with pain. Canadians living with pain and their loved ones simply deserve better.

There is a range of made-in-Canada approaches and successes that can serve as the foundation for much needed change. A tremendous opportunity exists to leverage and improve existing national data and surveillance in Canada, including deeper explorations of the social context related to chronic pain. Multidisciplinary and interprofessional clinical models and proven education approaches across the health sciences offer promising practices that could be more widely supported. Provincial/territorial policies and efforts could be better coordinated to reduce duplication of effort, maximize efficiency and implementation of best practices, and ensure people living with pain have the same level of care across Canada. A Canadian pain research agenda is required, together with the infrastructure to support future clinical and system-level change. Ultimately, leadership and resources are needed to amplify, spread, and accelerate current activities, coordinate responses, and address current gaps and inequities. International learning tells us this sort of national leadership and investment is likely to yield significant returns in both human and economic terms.

The Canadian Pain Task Force would like to thank all who participated in this initial assessment of the state of chronic pain in Canada. Priority areas for change have been identified but our work is not done. Using this report as a foundation, the Task Force will continue to review evidence and conduct additional consultations with stakeholders across Canada. This next phase of our work will expand on the areas discussed in this report to identify best and leading practices and elements of an improved approach to the prevention and management of chronic pain in Canada. We will continue to increase awareness of chronic pain and to build relationships and networks for change across the country. Together, by igniting a commitment to change, we can improve the health and well-being of Canadians.

References

• Aldington, D., & Eccleston, C. (2019). Evidence-based pain management: Building on the foundations of cochrane systematic reviews. American Journal of Public Health, 109(1), 46-49.
• Alford, D. P., German, J. S., Samet, J. H., Cheng, D. M., Lloyd-Travaglini, C. A., & Saitz, R. (2016). Primary Care Patients with Drug Use Report Chronic Pain and Self-Medicate with Alcohol and Other Drugs. Journal of General Internal Medicine, 31(5), 486–491.
• Allan, B., & Smylie, J. (2015). First Peoples, second class treatment: The role of racism in the health and well-being of Indigenous Peoples in Canada. Toronto: Wellesley Institute. Retrieved from https://www.wellesleyinstitute.com/wp-content/uploads/2015/02/Summary-First-Peoples-Second-Class-Treatment-Final.pdf
• Antoniou, T., Ala-Leppilampi, K., Shearer, D., Parsons, J. A., Tadrous, M., & Gomes, T. (2019). "Like being put on an ice floe and shoved away": A qualitative study of the impacts of opioid-related policy changes on people who take opioids. The International Journal on Drug Policy, 66, 15-22.
• Arthritis Society. (2017). Report on the pain symposium. (Summary). Toronto: Arthritis Society. Retrieved from https://arthritis.ca/getmedia/d3c245a5-a066-4fa3-95f7-9569b835cfd9/Pain-Symposium-Report-FINAL-EN-Screen.pdf
• Bachhuber, M., Arnsten, J. H., & Wurm, G. (2019). Use of cannabis to relieve pain and promote sleep by customers at an adult use dispensary. Journal of Psychoactive Drugs.
• Ballantyne, J. C., & Sullivan, M. D. (2015). Intensity of chronic pain--the wrong metric? The New England Journal of Medicine, 373(22), 2098-2099.
• Bartley, E. J., & Fillingim, R. B. (2013). Sex differences in pain: A brief review of clinical and experimental findings. British Journal of Anaesthesia, 111(1), 52-58.
• Becker, W. J., Findlay, T., Moga, C., Scott, N. A., Harstall, C., & Taenzer, P. (2015). Guideline for primary care management of headache in adults. Canadian Family Physician, 61(8), 670-679.
• Bhandari, R. P., Goddard, J., Campbell, F., Sangster, M., & Stevens, B. (2019). Becoming a pediatric pain specialist: Training opportunities to advance the science and practice of pediatric pain treatment. Pediatric Pain Letter, 21(1).
• Birnie, K., Dib, K., Ouellette, C., Dib, MA., Nelson, K., Pahtayken, D., … Stinson, J. (2019). Partnering for pain: A priority setting partnership to identify patient-oriented research priorities for pediatric chronic pain in Canada. Retrieved from http://www.cihr-irsc.gc.ca/e/51558.html
• Brosseau, L.,  Wells, G.A., Tugwell, P., Egan, M., Dubouloz, C.J., Casimiro, L., . . . Lamb, M. (2005). Ottawa panel evidence-based clinical practice guidelines for therapeutic exercises and manual therapy in the management of osteoarthritis, Physical Therapy, 85(9), 907–971.
• Brosseau, L., Wells, G. A., Pugh, A. G., Smith, C. A., Rahman, P., Àlvarez Gallardo, I. C., … Longchamp, G. (2016). Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercise in the management of hip osteoarthritis. Clinical Rehabilitation, 30(10), 935–946.
• Brosseau, L., Taki, J., Desjardins, B., Thevenot, O., Fransen, M., Wells, G. A., … McLean, L. (2017a). The Ottawa panel clinical practice guidelines for the management of knee osteoarthritis. Part one: introduction, and mind-body exercise programs. Clinical Rehabilitation, 31(5), 582–595.
• Brosseau, L., Taki, J., Desjardins, B., Thevenot, O., Fransen, M., Wells, G. A., … McLean, L. (2017b). The Ottawa panel clinical practice guidelines for the management of knee osteoarthritis. Part two: strengthening exercise programs. Clinical Rehabilitation, 31(5), 596–611.
• Brosseau, L., Taki, J., Desjardins, B., Thevenot, O., Fransen, M., Wells, G. A., … McLean, L. (2017c). The Ottawa panel clinical practice guidelines for the management of knee osteoarthritis. Part three: aerobic exercise programs. Clinical Rehabilitation, 31(5), 612–624.
• Buchbinder, R., Gross, D.P., Werner, E.L. & Hayden, J.A. (2008). Mass media campaigns for the prevention of back pain-related disability. In Rashiq, S., Schopflocher, D., Taenzer, P., & Jonsson, E. Editors (Eds.), Chronic Pain (pp. 233-254). WILEY-VCH Verlag Gmbh & Co. KGaA, Weinheim.
• Busse, J. W., Craigie, S., Juurlink, D. N., Buckley, D. N., Li, W., Couban, R. J., . . . Guyatt, G. H. (2017). Guideline for opioid therapy and chronic non-cancer pain. CMAJ, 189(18), E659-E666.
• Busse, J. W., Wang, L., Kamaleldin, M., Craigie, S., Riva, J. J., Montoya, L., . . . Guyatt, G. H. (2018). Opioids for chronic noncancer pain: A systematic review and meta-analysis. JAMA, 320(23), 2448-2460.
• Bussières, AE, Stewart, G., Al-Zoubi, F., Decina, P., Descarreaux, M., Hayden, J.,. . . Ornelas, J. (2016). The treatment of neck pain-associated disorders and whiplash-associated disorders: A clinical practice guideline.
• Bussières, A. E., Stewart, G., Al-Zoubi, F., Decina, P., Descarreaux, M., Haskett, D., . . . Ornelas, J. (2018). Spinal manipulative therapy and other conservative treatments for low back pain: A guideline from the Canadian chiropractic guideline initiative.
• Canadian Academy of Health Sciences (CAHS). (2018). Summary report arising from forum - November 22, 2018: What will it take to create a national approach to chronic pain? (Summary Report). CAHS Major Forum 2018: Chronic Pain. Retrieved from https://www.cahs-acss.ca/wp-content/uploads/2018/11/Forum-2018-Proceedings-Report.pdf
• Campbell, F., Stinson, J., Ouellette, C., Ostapets, V., & Salisbury, G. (2018). The association between pediatric chronic pain clinic attendance and health care utilization: A retrospective analysis. Canadian Journal of Pain, 2(1), 30-36.
• Canadian Agency for Drugs and Technologies in Health (CADTH). (2018a). Chronic pain management: Pharmacologic treatments (non-opioids). (Report). CADTH. Retrieved from https://www.cadth.ca/sites/default/files/pdf/research_gaps_tool_2_chronic_pain_pharma_EN.pdf
• Canadian Agency for Drugs and Technologies in Health (CADTH). (2018b). Opioids for the treatment of pain. (Report). CADTH. Retrieved from https://www.cadth.ca/sites/default/files/pdf/research_gaps_tool_3_opioids_pain_EN.pdf
• Canadian Agency for Drugs and Technologies in Health (CADTH). (2018c). Chronic pain management: Non-pharmacological treatments. (Report). CADTH. Retrieved from https://www.cadth.ca/sites/default/files/pdf/mindtheresearchgaps_chronic_pain_management_e.pdf
• Canadian Agency for Drugs and Technologies in Health (CADTH). (2018d). Access to and availability of non-pharmacological treatments for chronic non-cancer pain in Canada: An environmental scan. (Report). CADTH. Retrieved from https://www.cadth.ca/sites/default/files/pdf/es0313_access-to-non-pharmacological-treatment-of-pain.pdf
• Canadian Agency for Drugs and Technologies in Health (CADTH). (2019a). Non-opioid options for managing pain. (Summary). CADTH. Retrieved from https://cadth.ca/sites/default/files/pdf/non_opioid_options_for_managing_pain.pdf
• Canadian Agency for Drugs and Technologies in Health (CADTH). (2019b). Tiered care for chronic non-malignant pain: A review of clinical effectiveness, cost-effectiveness, and guidelines. (Summary). CADTH. Retrieved from https://www.cadth.ca/sites/default/files/pdf/htis/2019/RC1074%20Tiered%20Care%20for%20Chronic%20Non-Malignant%20Pain%20Final.pdf
• Canadian Agency for Drugs and Technologies in Health (CADTH). (2019c). Multidisciplinary treatment programs for patients with chronic non-malignant pain: A review of clinical effectiveness, cost-effectiveness, and guidelines – an update. (Summary). CADTH. Retrieved from https://www.cadth.ca/sites/default/files/pdf/htis/2017/RC0894_in_brief_e.pdf
• Canadian Institutes of Health Research (CIHR). (2016). Canadian pain research summit report. (Summit Report). Toronto, Ontario: CIHR. Retrieved from http://www.cihr-irsc.gc.ca/e/50558.html
• Canadian Pain Coalition (CPC) & the Canadian Pain Society (CPS). (2011). Call to action: The need for a national pain strategy for Canada. Retrieved from https://www.cfpc.ca/uploadedFiles/Directories/Committees_List/nat_pain_strategy_for_can_121511_eng.pdf
• Carr, D., & Schatman, M. (2019). Cannabis for chronic pain: Not ready for prime time. American Journal of Public Health, 109(1), 50.
• Cavallo, S., Brosseau, L., Toupin-April, K., Wells, G.A., Smith, C.A., Pugh, A.G., . . . Bigford, S. (2017). Ottawa panel evidence-based clinical practice guidelines for structured physical activity in the management of juvenile idiopathic arthritis. Archives of Physical Medicine Rehabilitation, 98(5), 1018-1041.
• Centre for Effective Practice (CEP), Ontario College of Family Physicians (OCFP), & Nurse Practitioners' Association of Ontario (NPAO). (2018). Management of chronic non-cancer pain tool. Retrieved from https://cep.health/clinical-products/chronic-non-cancer-pain/
• Chao, M. T., Hurstak, E., Leonoudakis-Watts, K., Sidders, F., Pace, J., Hammer, H., & Wismer, B. (2019). Patient-reported outcomes of an integrative pain management program implemented in a primary care safety net clinic: A quasi-experimental study. Journal of General Internal Medicine, 34(7), 1105-1107.
• Children's Healthcare Canada. (2017). Chronic pain toolkit. Retrieved from https://ken.childrenshealthcarecanada.ca/xwiki/bin/view/Paediatric+Pain/Chronic+Pain+Toolkit
• Choinière, M., Peng, P., Gilron, I., Buckley, N., & Hovey, R. (2019). Multidisciplinary pain treatment clinics across Canada in 2017-2018. Unpublished manuscript.
• Choinière, M., Dion, D., Peng, P., Banner, R., Barton, P. M., Boulanger, A., . . . Ware, M. (2010). The Canadian STOP-PAIN project - part 1: Who are the patients on the waitlists of multidisciplinary pain treatment facilities? Canadian Journal of Anaesthesia, 57(6), 539-548.
• Chou, R., Deyo, R., Devine, B., Hansen, R., Sullivan, S., Jarvik, J. G., . . . Turner, J. (2014). The effectiveness and risks of long-term opioid treatment of chronic pain. Evidence report/technology Assessment, Sep(218), 1-219.
• Clarke, H., Azargive, S., Montbriand, J., Nicholls, J., Sutherland, A., Valeeva, L., . . . Katz, J. (2018). Opioid weaning and pain management in postsurgical patients at the Toronto General Hospital transitional pain service. Canadian Journal of Pain 2(1), 236-247.
• Colvin, L. A., Bull, F., & Hales, T. G. (2019). Perioperative opioid analgesia-when is enough too much? A review of opioid-induced tolerance and hyperalgesia. Lancet (London, England), 393(10180), 1558-1568.
• Correctional Service Canada. (2019). Guidance for chronic non-cancer pain management.
• Council of Canadian Academies. (2012). The state of science and technology in Canada, 2012. Retrieved from https://cca-reports.ca/reports/the-state-of-science-and-technology-in-canada-2012/
• Côté, P., Wong, J.J., Sutton, D., Shearer, H. M., Mior, S., Randhawa, K., . . . Stupar, M. (2016). Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration. European Spine Journal, 25(7), 2000-2022.
• Côté, P., Yu, H., Shearer, H. M., Randhawa, K., Wong, J. J., Mior, S., . . . Lacerte, M. (2019). Non‐pharmacological management of persistent headaches associated with neck pain: A clinical practice guideline from the Ontario protocol for traffic injury management (OPTIMa) collaboration. European Spine Journal, 23(6), 1051-1070.
• Darnall, B. D., Juurlink, D., Kerns, R. D., Mackey, S., Van Dorsten, B., Humphreys, K., . . . Lovejoy, T. (2019). International stakeholder community of pain experts and leaders call for an urgent action on forced opioid tapering. Pain Medicine (Malden, Mass.), 20(3), 429-433.
• Dassieu, L., Kabore, J. L., Choinière, M., Arruda, N., & Roy, E. (2019). Chronic pain management among people who use drugs: A health policy challenge in the context of the opioid crisis. The International Journal on Drug Policy, In press.
• Delling, F. N., Vittinghoff, E., Dewland, T. A., Pletcher, M. J., Olgin, J. E., Nah, G., . . . Marcus, G. M. (2019). Does cannabis legalisation change healthcare utilisation? A population-based study using the healthcare cost and utilisation project in Colorado, USA. BMJ Open, 9(5), e027432.
• Dhalla, I. A., Mamdani, M. M., Sivilotti, M. L., Kopp, A., Qureshi, O., & Juurlink, D. N. (2009). Prescribing of opioid analgesics and related mortality before and after the introduction of long-acting oxycodone. CMAJ, 181(12), 891-896.
• Dowell, D., Haegerich, T., & Chou, R. (2019). No shortcuts to safer opioid prescribing. The New England Journal of Medicine, 380(24), 2285-2287.
• Duenas, M., Ojeda, B., Salazar, A., Mico, J. A., & Failde, I. (2016). A review of chronic pain impact on patients, their social environment and the health care system. Journal of Pain Research, 9, 457-467.
• Dunn, K. E., Finan, P. H., Tompkins, D. A., Fingerhood, M., & Strain, E. C. (2015). Characterizing pain and associated coping strategies in methadone and buprenorphine-maintained patients. Drug and alcohol dependence, 157, 143–149.
• Edlund, M. J., Martin, B. C., Russo, J. E., DeVries, A., Braden, J. B., & Sullivan, M. D. (2014). The role of opioid prescription in incident opioid abuse and dependence among individuals with chronic noncancer pain: The role of opioid prescription. The Clinical Journal of Pain, 30(7), 557-564.
• Filiatrault, M. -., Chauny, J. -., Daoust, R., Roy, M. -., Denis, R., & Lavigne, G. (2016). Medium increased risk for central sleep apnea but not obstructive sleep apnea in long-term opioid users: A systematic review and meta-analysis. Journal of Clinical Sleep Medicine, 12(4), 617-625.
• Finley, C. R., Chan, D. S., Garrison, S., Korownyk, C., Kolber, M. R., Campbell, S., (2018). What are the most common conditions in primary care? Systematic review. Canadian Family Physician, 64, 832-840. Retrieved from https://www.cfp.ca/content/cfp/64/11/832.full.pdf
• First Nations Information Governance Centre (FNIGC). (2018). National report of the First Nations Regional Health Survey. Retrieved from https://fnigc.ca/sites/default/files/docs/fnigc_rhs_phase_3_volume_two_en_final_screen.pdf
• Fischer, B., Jones, W., Varatharajan, T., Malta, M., & Kurdyak, P. (2018). Correlations between population-levels of prescription opioid dispensing and related deaths in Ontario (Canada), 2005-2016. Preventative Medicine 116(2018), 112-118.
• Fischer, B., & Rehm, J. (2009). Deaths related to the use of prescription opioids. CMAJ, 181(12), 881-882.
• Fischer, B., Rehm, J., Patra, J., & Cruz, M. F. (2006). Changes in illicit opioid use across Canada.CMAJ, 175(11), 1385.
• Fitzcharles, M., Ste-Marie, P., Goldenburg, D., Pereira, J., Abbey, S., Choinière, M., . . . Shir, Y. (2013). 2012 Canadian guidelines for the diagnosis and management of fibromyalgia syndrome: Executive summary. 18(3).
• Fitzcharles, M., Brachaniec, M., Cooper, L., Dubin, R., Flynn, T., Gerhold, K., . . . El-Gabalawy, H. (2017).  A paradigm change to inform fibromyalgia research priorities by engaging patients and health care professionals. Canadian Journal of Pain, 1(1), 137 - 147.
• Forsythe, L. P., Carman, K. L., Szydlowski, V., Fayish, L., Davidson, L., Hickam, D. H., . . . Anyanwu, C. U. (2019). Patient engagement in research: Early findings from the patient-centered outcomes research institute. Health Affairs (Project Hope), 38(3), 359-367.
• Fredriksen-Goldsen, K. I., Kim, H. J., & Barkan, S. E. (2012). Disability among lesbian, gay, and bisexual adults: Disparities in prevalence and risk. American Journal of Public Health, 102(1), e16-21.
• Friedrichsdorf, S. J., Giordano, J., Desai Dakoji, K., Warmuth, A., Daughtry, C., & Schulz, C. A. (2016). Chronic pain in children and adolescents: Diagnosis and treatment of primary pain disorders in head, abdomen, muscles and joints. Children (Basel, Switzerland), 3(4), 42.
• Gaskin, D. J., & Richard, P. (2012). The economic costs of pain in the United States. The Journal of Pain, 13(8), 715-724.
• Gatchel, R., & Howard, K. (2008). The biopsychosocial approach. Practical Pain Management, 8(4). Retrieved from https://www.practicalpainmanagement.com/treatments/psychological/biopsychosocial-approach
• Gatchel, R. J., Peng, Y. B., Peters, M. L., Fuchs, P. N., & Turk, D. C. (2007). The biopsychosocial approach to chronic pain: Scientific advances and future directions. Psychological Bulletin, 133(4), 581-624.
• Gladstone, E. J., Smolina, K., Weymann, D., Rutherford, K., & Morgan, S. G. (2015). Geographic variations in prescription opioid dispensations and deaths among women and men in British Columbia, Canada. Medical Care, 53(11), 954-959.
• Gomes, T., Khuu, W., Craiovan, D., Martins, D., Hunt, J., Lee, K., . . . Juurlink, D. N. (2018a). Comparing the contribution of prescribed opioids to opioid-related hospitalizations across Canada: A multi-jurisdictional cross-sectional study. Drug and Alcohol Dependence, 191, 86-90.
• Gomes, T., Khuu, W., Martins, D., Tadrous, M., Mamdani, M. M., Paterson, J. M., & Juurlink, D. N. (2018b). Contributions of prescribed and non-prescribed opioids to opioid related deaths: Population based cohort study in Ontario, Canada. BMJ (Clinical Research Ed.), 362, k3207.
• Gomes, T., Mamdani, M. M., Dhalla, I. A., Paterson, J. M., & Juurlink, D. N. (2011). Opioid dose and drug-related mortality in patients with non-malignant pain. Archives of Internal Medicine, 171(7), 686-691.
• Groenewald, C. B., Law, E. F., Fisher, E., Beals-Erickson, S. E., & Palermo, T. M. (2019). Associations between adolescent chronic pain and prescription opioid misuse in adulthood. The Journal of Pain, 20(1), 28-37.
• Guerriere, D. N., Choinière, M., Dion, D., Peng, P., Stafford-Coyte, E., Zagorski, B., . . . Ware, M. (2010). The Canadian STOP-PAIN project - part 2: What is the cost of pain for patients on waitlists of multidisciplinary pain treatment facilities?. Canadian Journal of Anaesthesia, 57(6), 549-558.
• Guy, S. D., Mehta, S., Casalino, A., Côté, I., Kras-Dupuid, A., Moulin, D. E., . . . Loh, E. (2016). The CanPain SCI clinical practice guidelines for rehabilitation management of neuropathic pain after spinal cord: recommendations for treatment. Spinal Cord, 54, S14-S23.
• Harman, K. (2015). Interpretation of the experience of pain: Using a two-eyed approach to address a clinically relevant health issue.  Physiotherapy Practice 15(2), 25-27.
• Health Canada. (2017). Government of Canada. Baseline survey on opioid awareness, knowledge and behaviours for public education research report. Ottawa (ON): Prepared by Earnscliffe Strategy Group for Health Canada. Retrieved from http://epe.lac-bac.gc.ca/100/200/301/pwgsc-tpsgc/por-ef/health/2018/016-17-e/report.pdf
• Health Canada. (2019). Government of Canada. ARCHIVED – market data under the Access to Cannabis for Medical Purposes Regulations. Retrieved from https://www.canada.ca/en/health-canada/services/drugs-medication/cannabis/licensed-producers/market-data.html
• Health Quality Ontario. (2018). Chronic pain. Care for adults, adolescents, and children. Retrieved from https://www.hqontario.ca/Evidence-to-Improve-Care/Quality-Standards/View-all-Quality-Standards/Chronic-Pain
• Heimer, R., Zhan, W., & Grau, L. E. (2015). Prevalence and experience of chronic pain in suburban drug injectors. Drug and alcohol dependence, 151, 92–100.
• Hogan, M. E., Taddio, A., Katz, J., Shah, V., & Krahn, M. (2016). Incremental health care costs for chronic pain in Ontario, Canada: A population-based matched cohort study of adolescents and adults using administrative data. Pain, 157(8), 1626-1633.
• Hunter, J., Watt-Watson, J., McGillion, M., Raman-Wilms, L., Cockburn, L., Lax, L., . . . Salter, M. (2008). An interfaculty pain curriculum: Lessons learned from six years experience. Pain, 140(1), 74-86.
• Institute of Medicine. (2011). Relieving pain in America: A blueprint for transforming prevention, care, education, and research (2011). The National Academies Press.
• International Association for the Study of Pain. (2018a). IASP Curricula - Education. Retrieved from https://www.iasp-pain.org/Education/CurriculaList.aspx?navItemNumber=647
• International Association for the Study of Pain. (2018b). Pain in Women. Retrieved from https://www.iasp-pain.org/GlobalYear/PaininWomen
• Johnston, C. (2014). New residency program for pain specialists. CMAJ, 186(15), 1135-4891.
• Kahan, M., Dubin, R., & Clarke, H. (2018). The 2017 Canadian opioid guideline: Already time for an overhaul. CMAJ, 190(10), E300.
• Katz, J., Weinrib, A., Fashler, S. R., Katznelzon, R., Shah, B. R., Ladak, S. S., . . . Clarke, H. (2015). The Toronto General Hospital transitional pain service: Development and implementation of a multidisciplinary program to prevent chronic postsurgical pain. Journal of Pain Research, 8, 695-702.
• Katz, L., Patterson, L., & Zacharias, R. (2019). Evaluation of an interdisciplinary chronic pain program and predictors of readiness for change. Canadian Journal of Pain, 3(1), 70-78.
• King, S., Chambers, C. T., Huguet, A., MacNevin, R. C., McGrath, P. J., Parker, L., & MacDonald, A. J. (2011). The epidemiology of chronic pain in children and adolescents revisited: A systematic review. Pain, 152(12), 2729-2738.
• Latimer, M., Rudderham, S., Lethbridge, L., MacLeod, E., Harman, K., Sylliboy, J. R., . . . Finley, G. A. (2018). Occurrence of and referral to specialists for pain-related diagnoses in first nations and non-first nations children and youth. CMAJ, 190(49), E1434-E1440.
• Leadley, R. M., Armstrong, N., Lee, Y. C., Allen, A., & Kleijnen, J. (2012). Chronic diseases in the European Union: The prevalence and health cost implications of chronic pain. Journal of Pain & Palliative Care Pharmacotherapy, 26(4), 310-325.
• Leyland, N., Casper, R., Laberge, P., Singh, S. S., & SOGC. (2010). Endometriosis: Diagnosis and management. Journal of Obstetrics and Gynaecology Canada, 32(7) (Suppl 2), S1-32.
• Liddy, C., Moroz, I., Mihan, A., & Keely, E. (2019). Assessment of the generalizability of an eConsult service through implementation in a new health region. Journal of the American Board of Family Medicine, 32(2), 146-157.
• Lussier, D. (2015). Prise de position de la société québécoise de gériatrie sur l'évaluation et la prise en charge de la douleur. Société Québécoise de Gériatrie.
• Lynch, M. E. (2011). The need for a Canadian pain strategy. Pain Research & Management, 16(2), 77-80.
• Lynch, M. & Katz, J. (2017). "One size fits all" doesn't fit when it comes to long-term opioid use for people with chronic pain. Canadian Journal of Pain, 1(1), 2-7.
• Mailis, A., & Taenzer, P. (2012). Evidence-based guideline for neuropathic pain interventional treatments: Spinal cord stimulation, intravenous infusions, epidural injections and nerve blocks. Pain Research & Management, 17(3), 150-158.
• Mao, J. (2002). Opioid-induced abnormal pain sensitivity: Implications in clinical opioid therapy. Pain, 100(3), 213-217.
• Meana, M., Cho, R., & DesMeules, M. (2004). Chronic pain: The extra burden on Canadian women. BMC Women's Health, 4(Suppl 1), S17.
• Meldrum, M. L. (2016). The ongoing opioid prescription epidemic: Historical context. American Journal of Public Health, 106(8), 1365-1366.
• Ministry of Public Safety and Solicitor General. (2018). Illicit drug overdose deaths in BC findings in coroner's investigations. (Report). British Columbia: Provincial Government. Retrieved from https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/illicitdrugoverdosedeathsinbc-findingsofcoronersinvestigations-final.pdf
• Moulin, D., Boulanger, A., Clark, A. J., Clarke, H., Dao, T., Finley, G. A., . . . Williamson, O. D. (2014). Pharmacological management of chronic neuropathic pain: Revised consensus statement from the Canadian pain society. Pain Research and Management, 19(6), 328-335.
• Mucke, M., Phillips, T., Radbruch, L., Petzke, F., & Hauser, W. (2018). Cannabis-based medicines for chronic neuropathic pain in adults. The Cochrane Database of Systematic Reviews, 3, CD012182.
• Murphy, L., Lax, L., Musa, R., Langlois, S., Kanofsky, S., Hunter, J., … Stevens, B. (2018). Mapping of pain curricula across health professions programs at the University of Toronto. Canadian Journal of Pain, 2(1), 182-190.
• National Academies of Sciences, Engineering, and Medicine (NASEM). (2017). The health effects of cannabis and cannabinoids: The current state of evidence and recommendations for research. The National Academies Press.
• National Academies of Sciences, Engineering, and Medicine (NASEM). (2019). The role of nonpharmacological approaches to pain management: Proceedings of a workshop. The National Academies Press.
• National Opioid Use Guideline Group (NOUGG). (2010). Canadian guideline for safe and effective use of opioids for chronic non-cancer pain. Part A. Retrieved from http://nationalpaincentre.mcmaster.ca/opioid_2010/
• Nicholas, L. H., & Maclean, J. C. (2019). The effect of medical marijuana laws on the health and labor supply of older adults: Evidence from the health and retirement study. Journal of Policy Analysis and Management, 38(2), 455-480.
• Nicholas, M., Vlaeyen, J. W. S., Rief, W., Barke, A., Aziz, Q., Benoliel, R., . . . IASP Taskforce for the Classification of Chronic Pain. (2019). The IASP classification of chronic pain for ICD-11: Chronic primary pain. Pain, 160(1), 28-37.
• Painaustralia. (2019). The cost of pain in Australia. (Report). Deloitte Access Economics. Retrieved from https://www.painaustralia.org.au/static/uploads/files/the-cost-of-pain-in-australia-final-report-12mar-wfxbrfyboams.pdf
• Peles, E., Schreiber, S., Gordon, J., & Adelson, M. (2005). Significantly higher methadone dose for methadone maintenance treatment (MMT) patients with chronic pain. Pain, 113(3), 340-346.
• Peng, P., Choinière, M., Dion, D., Intrater, H., Lefort, S., Lynch, M., . . . STOPPAIN Investigators Group. (2007). Challenges in accessing multidisciplinary pain treatment facilities in Canada. Canadian Journal of Anaesthesia, 54(12), 977-984.
• Peter, E., & Watt-Watson, J. (2008). Improving pain management education. In Rashiq, S., Schopflocher, D., Taenzer, P., & Jonsson, E. Editors (Eds.), Chronic Pain (pp. 255-264). WILEY-VCH Verlag Gmbh & Co. KGaA, Weinheim.
• Poulin, P., Shergill, Y., Romanow, H., Busse, J., Chambers, P. D.,Christine, Cooper, L., . . . Stinson, J. (2018). Researching what matters to improve chronic pain care in Canada: A priority-setting partnership process to support patient-oriented research. Canadian Journal of Pain, 2, 191-204.
• Racine, M. (2018). Chronic pain and suicide risk: A comprehensive review. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 87, 269-280.
• Reddan, M. C., & Wager, T. D. (2019). Brain systems at the intersection of chronic pain and self-regulation. Neuroscience Letters, 702, 24-33.
• Registered Nurses Association of Ontario. (2013). Assessment and management of pain (Third edition). Clinical best practice guidelines. Retrieved from https://rnao.ca/sites/rnao-ca/files/AssessAndManagementOfPain_15_WEB-_FINAL_DEC_2.pdf
• Reid, K., Simmonds, M., Verrier, M., & Dick, B. (2016). Supporting teens with chronic pain to obtain high school credits: Chronic pain 35 in Alberta. Children (Basel, Switzerland), 3(4).
• Reis, F., Nogueira, L., Meziat-Filho, N., Louw, A., Palermo, T., & Ickmans, K. (2018). A journey to learn about pain. Retrieved from https://www.yumpu.com/en/document/read/61002254/a-journey-to-learn-about-pain
• Reitsma, M. L., Tranmer, J. E., Buchanan, D. M., & Vandenkerkhof, E. G. (2011). The prevalence of chronic pain and pain-related interference in the Canadian population from 1994 to 2008. Chronic Diseases and Injuries in Canada, 31(4), 157-164.
• Royal College of Physicians and Surgeons of Canada (RCPSC). (2018). Objectives of training in the subspecialty of pain medicine. (Version 2.0). Royal College of Physicians and Surgeons of Canada.
• Samulowitz, A., Gremyr, I., Eriksson, E., & Hensing, G. (2018). "Brave men" and "emotional women": A theory-guided literature review on gender bias in health care and gendered norms towards patients with chronic pain. Pain Research & Management, 2018, 6358624.
• Sanger, N., Bhatt, M., Shams, I., Shahid, H., Luo, C., Tam, S. L., . . . Samaan, Z. (2018). Association between socio-demographic and health functioning variables among patients with opioid use disorder introduced by prescription: A prospective cohort study. Pain Physician, 21(6), E623-E632.
• Schopflocher, D., Taenzer, P., & Jovey, R. (2011). The prevalence of chronic pain in Canada. Pain Research & Management, 16(6), 445-450.
• Saïdi, H., Pagé, M. G., Boulanger, A., Ware, M. A., & Choinière, M. (2018). Effectiveness of long-term opioid therapy among chronic non-cancer pain patients attending multidisciplinary pain treatment clinics: A Quebec Pain Registry Study. Canadian Journal of Pain, 2(1), 113-124.
• Sinha, C. B., Bakshi, N., Ross, D., & Krishnamurti, L. (2019). Management of chronic pain in adults living with sickle cell disease in the era of the opioid epidemic: A qualitative study. JAMA Network Open, 2(5), e194410.
• Sorge, R. E., Mapplebeck, J. C., Rosen, S., Beggs, S., Taves, S., Alexander, J. K., . . . Mogil, J. S. (2015). Different immune cells mediate mechanical pain hypersensitivity in male and female mice. Nature Neuroscience, 18(8), 1081-1083.
• Statistics Canada. (2017). Primary health care providers, 2016. (Health Fact Sheet). Retrieved from https://www150.statcan.gc.ca/n1/pub/82-625-x/2017001/article/54863-eng.htm
• Steingrimsdottir, O. A., Landmark, T., Macfarlane, G. J., & Nielsen, C. S. (2017). Defining chronic pain in epidemiological studies: A systematic review and meta-analysis. Pain, 158(11), 2092-2107.
• Stockings, E., Campbell, G., Hall, W. D., Nielsen, S., Zagic, D., Rahman, R., . . . Degenhardt, L. (2018). Cannabis and cannabinoids for the treatment of people with chronic non-cancer pain conditions: A systematic review and meta-analysis of controlled and observational studies. Pain, 159(10), 1932-1954.
• The Hospital for Sick Children (SickKids). (2018). Guidelines for pain assessment and management for neonates. Retrieved from https://www.sickkids.ca/clinical-practice-guidelines/clinical-practice-guidelines/export/CLINH143/Main%20Document.pdf
• The Hospital for Sick Children (SickKids). (2017). Pain management. Retrieved from https://www.sickkids.ca/clinical-practice-guidelines/clinical-practice-guidelines/export/CLINH142/Main%20Document.pdf
• Thompson, K., Johnson, M. I., Milligan, J., & Briggs, M. (2018). Twenty-five years of pain education research-what have we learned? Findings from a comprehensive scoping review of research into pre-registration pain education for health professionals. Pain, 159(11), 2146-2158.
• Todd, K. H., Ducharme, J., Choinière, M., Crandall, C. S., Fosnocht, D. E., Homel, P., . . . PEMI Study Group. (2007). Pain in the emergency department: Results of the pain and emergency medicine initiative (PEMI) multicenter study. The Journal of Pain, 8(6), 460-466.
• Toward Optimized Practice (TOP) Low Back Pain Working Group, Institute of Health Economics Alberta. (2017). Evidence-informed primary care management of low back pain: Clinical practice guideline. (Third edition). Edmonton, AB: Toward Optimized Practice. Available from: http://www.topalbertadoctors.org/cpgs/885801
• Traeger, A., Buchbinder, R., Harris, I., & Maher, C. (2017). Diagnosis and management of low-back pain in primary care. CMAJ, 189(45), E1386–E1395.
• Tunks, E. (2008). Multidisciplinary pain clinic treatment. In Rashiq, S., Schopflocher, D., Taenzer, P., & Jonsson, E. Editors (Eds.), Chronic Pain (pp. 141-152). WILEY-VCH Verlag Gmbh & Co. KGaA, Weinheim.
• Veterans Affairs Canada (VAC). (2019). Chronic pain in Veterans. Retrieved from https://www.veterans.gc.ca/eng/about-vac/research/research-directorate/info-briefs/chronic-pain
• Voon, P., Callon, C., Nguyen, P., Dobrer, S., Montaner, J., Wood, E., & Kerr, T. (2014). Self-management of pain among people who inject drugs in Vancouver. Pain Management, 4(1), 27-35.
• Voon, P., Callon, C., Nguyen, P., Dobrer, S., Montaner, J. S., Wood, E., & Kerr, T. (2015). Denial of prescription analgesia among people who inject drugs in a Canadian setting. Drug and Alcohol Review, 34(2), 221-228.
• Waddell, K., Moat, K., & Lavis, J. (2017a). Dialogue summary: Developing a national pain strategy for Canada. (Dialogue Summary). Hamilton, Canada: McMaster Health Forum. Retrieved from https://www.mcmasterforum.org/docs/default-source/product-documents/stakeholder-dialogue-summary/pain-strategy-sds.pdf?sfvrsn=2
• Waddell, K., Moat, K., & Lavis, J. (2017b). Evidence brief: Developing a national pain strategy for Canada. (Evidence Brief). Hamilton, Canada: McMaster Health Forum. Retrieved from https://www.mcmasterforum.org/docs/default-source/product-documents/evidence-briefs/pain-strategy-eb.pdf?sfvrsn=2
• Walton, D. M., & Elliott, J. M. (2017). An integrated model of chronic whiplash-associated disorder. The Journal of Orthopaedic and Sports Physical Therapy, 47(7), 462-471.
• Watt-Watson, J., Hunter, J., Pennefather, P., Librach, L., Raman-Wilms, L., Schreiber, M., . . . Salter, M. (2004). An integrated undergraduate pain curriculum, based on IASP curricula, for six health science faculties. Pain, 110(1-2), 140-148.
• Watt-Watson, J., McGillion, M., Hunter, J., Choinière, M., Clark, A. J., Dewar, A., . . . Webber, K. (2009). A survey of prelicensure pain curricula in health science faculties in Canadian universities. Pain Research and Management, 14(6), 439-444.
• Watt-Watson, J., Lax, L., Davies, R., Langlois, S., Oskarsson, J., & Raman-Wilms, L. (2017). The pain interprofessional curriculum design model. Pain Medicine (Malden, Mass.), 18(6), 1040-1048.
• Whiting, P. F., Wolff, R. F., Deshpande, S., Di Nisio, M., Duffy, S., Hernandez, A. V., . . . Kleijnen, J. (2015). Cannabinoids for medical use: A systematic review and meta-analysis. JAMA, 313(24), 2456-2473.
• Wideman, T. H., Edwards, R. R., Walton, D. M., Martel, M. O., Hudon, A., & Seminowicz, D. A. (2019a). The multimodal assessment model of pain: A novel framework for further integrating the subjective pain experience within research and practice. The Clinical Journal of Pain, 35(3), 212-221.
• Wideman, T. H., Miller, J., Bostick, G., Thomas, A., Bussières, A., & Wickens, R. H. (2019b). The current state of pain education within Canadian physiotherapy programs: A national survey of pain educators. Disability and Rehabilitation.
• Wilson, M. G., Lavis, J. N., & Ellen, M. E. (2015). Supporting chronic pain management across provincial and territorial health systems in Canada: Findings from two stakeholder dialogues. Pain Research & Management, 20(5), 269-279.
• Wylie, L., & McConkey, S. (2019). Insiders' insight: Discrimination against Indigenous Peoples through the eyes of health care professionals. Journal of Racial and Ethnic Health Disparities, 6(1), 37-45.