Mar 16, 2020
By Kathy Reid
Managing the chronic pain crisis in Canada—the nursing perspective
Take away messages:
- Chronic pain is a significant public health issue in Canada, affecting one in five Canadians.
- The Canadian Pain Task Force is working to improve how chronic pain is managed.
- Nurses can play an integral role in increasing access to evidence-based pain care.
Chronic pain is at the heart of a public health crisis in Canada. One in five Canadians live with chronic pain, and we know it is more common in certain populations, including older adults, females, Indigenous peoples, veterans, and people affected by social inequities and discrimination. It even affects children, with prevalence estimates ranging from 11% to 38% of children who have a chronic pain condition (King et al., 2011).
Chronic pain has a huge economic cost to patients, their families, communities, and society as a whole. The estimated annual cost in Canada is $56–60 billion annually, including direct health care costs and lost productivity (Wilson, Lavis, & Ellen, 2015).
As a nurse, chances are you care for people living with chronic pain, and you may be familiar with the resultant struggles and impacts for patients and their families.
“Having lived with persistent pain for nearly 33 years, it has been, and remains, a focal point of my day-to-day experiences. As much as I never wanted pain to be a defining and controlling part of my life, it has been so. It has taken careers that I dreamed of away from me, and has not allowed me to do many things with my family that others take for granted.”
Canadian Pain Task Force
To help address this crisis, Health Canada created the Canadian Pain Task Force in March 2019 with the mandate of helping the federal government better understand and address the needs of those who live with chronic pain. The Task Force, consisting of eight people, including those who live with pain, is also supported by an External Advisory Panel of researchers, health professionals, and people living with pain from across Canada. This panel provides scientific evidence, information, and advice to the Task Force, and I am one of the three nurses who serve on it.
Early in our mandate, we assessed how chronic pain is being addressed in Canada. We met over two days with representatives from eight different federal government departments, consulted with representatives across the country, reviewed current scientific literature, and heard from 12 people living with chronic pain about their experience and their hopes for the Task Force. This work culminated in the report Chronic Pain in Canada: Laying a Foundation for Action, which was presented to the federal health minister in July 2019. Highlights of the report follow. (For the full report, see Additional Resources, below.)
Nature and definitions of chronic pain
We reviewed the nature of pain, including the definition of chronic pain and the different biological mechanisms that underpin it.
Recently, the World Health Organization has recognized chronic pain as a disease in its own right and has added two classifications: chronic primary pain and chronic secondary pain (Nicholas et al., 2019).
Chronic primary pain diagnoses include chronic widespread pain, complex regional pain syndrome, chronic primary headache, chronic primary visceral pain, and chronic primary musculoskeletal pain.
Chronic secondary pain is diagnosed when the pain emerges as a symptom of another disease (such as cancer), post-surgery, or post-trauma, and persists even after the condition has been treated.
Having this international classification is an important step, as it validates the experience of people living with pain. Yet chronic pain—as a multi-dimensional condition with biological, psychological, and social factors—remains poorly understood by many health care professionals, and because of this is underdiagnosed and undertreated. Health care professionals struggle with completing comprehensive pain histories, providing accurate diagnoses, arranging for medical tests, and developing treatment plans.
Diagnosis and management
While chronic pain is difficult to cure, the evidence supports a biopsychosocial model of care as the most effective approach to treatment and management of pain. This model includes pharmacological, psychological, and physical interventions aimed at reducing the severity of pain and improving function and quality of life. However, accessing health care professionals who can provide these interventions remains a problem for most people living with chronic pain.
Despite being identified as the “gold standard” of care, there are very few multidisciplinary and interprofessional pain clinics in Canada. The few that exist are located in large cities and have long wait lists. And many of the services shown to be effective, such as psychotherapy and physiotherapy, are not provided in the public system, making access difficult for many who do not have private insurance and must pay out of pocket.
The report recognizes the prevalence of chronic pain among people who use drugs, and the stigma associated with problematic substance use. These people also may benefit from appropriate treatments. Access to evidence-based pain management therapies would provide an opportunity to address problematic substance use, but the range of therapies required are not readily available (Dassieu et al., 2019).
Pain awareness and education
The current state of pain education for health professionals is inadequate across disciplines, and there are significant knowledge gaps in both pre- and post-licensure.
A landmark study by Watt-Watson and colleagues (2009) reviewed the curricula across 10 universities in Canada that had health sciences faculties (medicine, nursing, dentistry, pharmacy, physical therapy, occupational therapy, and veterinary medicine) and found that 68% were unable to specify any designated hours for pain education. Veterinary students received two to five times more pain education than health sciences students.
Since that study, there have been some improvements in pain education. The Royal College of Physicians and Surgeons now recognizes pain medicine as a subspecialty and has established training standards. And the Canadian Association of Schools of Nursing (CASN), together with the Association of Faculties of Pharmacy of Canada and the Canadian Association for Social Work Education, recently started a three-year interprofessional education program.
Although there are pockets of excellence in pre-licensure education, such as the University of Toronto Interfaculty Pain Curriculum, we could not identify dedicated pain curricula for pre-licensure students, including nurses. We clearly need standardized, widely available pain-related curricula for all health professions. This education is necessary to improve the understanding of chronic pain as a disease, reduce the stigma of those living with pain, and assist in the navigation of the health care system.
“My interactions with the health care system, in the first 20 years of my pain experience, are best described as ineffective and reductionist. As persistent pain is very complex and affected by several factors, the health care reductionist model does not allow for effective support and management of persistent pain. Because of this ignorance, I have had challenging interactions with health care providers, often being met with opening statements from clinicians such as, ‘So, what do you want me to do for you?’”
Professional development, or post-licensure education to build pain competencies of health professionals, including nurses, is shown to be improving. There are many examples of promising practices that often include patients in the development and delivery of the programs. Examples include intensive workshops, online training modules, and e-resources offered by Pain BC, the SickKids online Pediatric Pain Curriculum, and the University of Alberta and McGill Graduate Certificates in Pain Management.
There are also communities of practice across the country working to improve access to both pain professionals for their expertise as well as access to specialist care. One example is Project ECHO (Extension for Community Healthcare Outcomes) in Ontario, which utilizes technology such as videoconferencing to build local capacity to deliver care.
There is also a great need to increase public awareness to improve prevention and care. This includes innovative knowledge translation activities, which are aimed at transforming research into practice, and can build capacity not only for health professionals, but also for people living with pain. Examples include national networks such as SKIP (Solutions for Kids in Pain) and the Canadian Pain Society. Interactive books, such as the Learning to Live with Chronic Pain eBook, can share the experiences of families dealing with chronic pain.
Role of nurses in improving access to care
The Task Force report outlines the importance of tailoring pain care to the individual person, and identifies that treatment should ideally utilize a model of both self-management and community-based primary care, with specialty pain services available for complex cases. Given this model, nurses are ideally placed to help provide evidence-based pain care to people living with pain.
Nurses are embedded throughout the health care system; they are involved in the care of people living with chronic pain across the spectrum of care settings and across the lifespan. Nurses have multiple opportunities to interact with these people, and to make a difference in their lives. So how can we improve access to needed services?
One possibility is the implementation of self-management programs, which could (and should) be facilitated by nurses. There are areas in the country providing such programs, although these are few, that are often pilot projects, or are limited to urban areas. And it is not clear, from the limited data available, how the nursing role is utilized in many of them.
In a study by Lukewich and colleagues (2015), the authors sought to describe chronic pain self-management from the perspective of people living with pain, within the context of primary care nurses. They surveyed people living with pain, as well as nurses working in primary care, and found that few people living with pain identified nurses as being the “most helpful” facilitators of self-management. Furthermore, few nurses worked in practices that had chronic pain management programs.
Given our nursing scope of practice, and the public health significance of chronic pain, I see a tremendous opportunity for nursing to be more involved in interprofessional care of those who live with pain. This role can include (but is not limited to) increasing access to evidence-based pain care at the primary, secondary, and tertiary care levels; helping people who live with pain navigate the health care system; coordinating care; developing and implementing self-management programs; and collaborating on research teams.
“It took me meeting my chronic pain nurse to realize how I deserved to be treated within the health care system. She taught me that having chronic pain does not mean I deserve to be dismissed or treated as ‘less than.’ If anything, it means that I am a stronger person for it.”
The Task Force is continuing their work, and is now consulting with stakeholders across the country. Regional workshops have been held, and we are preparing for a broader stakeholder consultation. Online public consultation will be open for a period of 60 days from February 27 to April 17 via Health Canada’s Let’s Talk Health consultation portal at https://www.canada.ca/en/health-canada/programs/consultation-understand-prevent-manage-pain.
Survey questions involve barriers to addressing pain; practices to better understand, prevent, and manage pain; and strategies needed for improving approaches to pain in Canada. Questions are guided by four broad themes: access to timely and appropriate pain care; awareness, education, and specialized training; pain research and related infrastructure; and population health surveillance and health system quality improvement.
We invite all Canadians to complete a questionnaire and share their personal experiences with pain, including what is working, what is not working, and what might be done to improve how we understand, prevent, and manage pain in Canada. The survey takes approximately 15 to 30 minutes to complete, depending on how much input people wish to give. (Participants can save their work at any point and submit responses any time before the closing date.)
This will be a wonderful opportunity for nurses to provide input into how chronic pain care can be improved. We hope you will participate.
Dassieu, L., Kaboré, 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. International Journal of Drug Policy, 71, 150–156.
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.
Lukewich, J., Mann, E., VanDenKerhhof, E., & Tranmer, J. (2015). Self-management support for chronic pain in primary care: A cross-sectional study of patient experiences and nursing roles. Journal of Advanced Nursing, 71(11), 2551–2562.
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.
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 sciences faculties in Canadian universities. Pain Research and Management, 14(6), 439–444.
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 and Management, 20(5), 269–279.
Canadian Pain Task Force Report. (June 2019). Chronic Pain in Canada: Laying a Foundation for Action.