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https://infirmiere-canadienne.com/blogs/ic-contenu/2020/03/16/douleur-chronique-le-point-de-vue-infirmier-sur-la

Mar 16, 2020, By: Kathy Reid

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.

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.

Pratiques prometteuses

Le perfectionnement professionnel ou la formation après l’entrée en pratique des professionnels de la santé, y compris le personnel infirmier, pour renforcer leurs compétences dans le domaine de la douleur s’améliorent; cela a été démontré. Les exemples de pratiques prometteuses sont nombreux, et dans plusieurs cas, des patients participent à la conception et à la présentation des programmes. Parmi les exemples, citons des ateliers intensifs, des modules de formation en ligne et des ressources électroniques offertes par Pain BC, le curriculum Pediatric Pain en ligne de SickKids et les certificats d’études supérieures en prise en charge de la douleur offerts par l’Université de l’Alberta et l’Université McGill.

Il existe aussi à travers le pays des communautés de pratique qui s’emploient à améliorer l’accès à des professionnels de la douleur, pour leur expertise, et à des soins spécialisés. Le projet ECHO (Extension for Community Healthcare Outcomes, c’est-à-dire Prolongement pour des résultats en soins communautaires), en Ontario, est un exemple. On y utilise des technologies comme la vidéoconférence pour renforcer la capacité locale de prestation de soins.

Si l’on veut améliorer la prévention et les soins, il est également impératif d’augmenter la sensibilisation du public. Cela comprend des activités d’application des connaissances qui visent à faire entrer les résultats des recherches dans la pratique et peuvent renforcer la capacité, non seulement pour les professionnels de la santé, mais aussi pour les personnes atteintes de douleur. Parmi les exemples, on citera des réseaux nationaux comme SKIP (Solutions for Kids in Pain, ou Solutions pour la douleur chez l’enfant) et la Société canadienne de la douleur. Des livres interactifs, comme le livre électronique Learning to Live with Chronic Pain, peuvent faire connaître l’expérience de familles aux prises avec la douleur chronique.

Meilleur accès aux soins : le rôle du personnel infirmier

Dans son rapport, le Groupe de travail explique qu’il est important d’adapter les soins pour la douleur à la personne et que la prise en charge de la douleur devrait idéalement utiliser un modèle d’autogestion et de soins primaires communautaires, des services spécialisés étant offerts pour les cas complexes. Avec un tel modèle, les infirmières et infirmiers sont idéalement placés pour aider à fournir des soins fondés sur des données probantes aux personnes atteintes de douleur.

Le personnel infirmier est intégré dans tout le système de soins de santé; il participe aux soins aux personnes atteintes de douleur chronique dans tous les milieux de soins et à tous les stades de leur vie. Les infirmières et infirmiers ont de multiples occasions d’interagir avec elles et d’améliorer leur vie. Comment pouvons-nous aider ces personnes à accéder aux services dont elles ont besoin?

L’une des possibilités est de mettre en place des programmes d’autogestion qui pourraient (et devraient) être animés par des infirmières et des infirmiers. Des programmes de ce type sont offerts dans certains endroits au Canada, bien qu’ils soient peu nombreux, qu’il s’agisse souvent de projets pilotes et qu’ils se trouvent seulement en milieu urbain. Et le peu de données disponibles ne montre pas, pour beaucoup de ces programmes, le rôle qu’y remplit le personnel infirmier.

Dans une étude, Lukewich et coll. (2015) ont tenté de décrire l’autogestion de la douleur du point de vue de personnes atteintes de douleur chronique dans le contexte du travail du personnel infirmier en soins primaires. Les auteures ont mené une enquête auprès de personnes atteintes de douleur et d’infirmières et infirmiers en soins primaires, et ont établi que les infirmières et infirmiers n’étaient pas perçus par beaucoup de personnes vivant avec la douleur comme les facilitateurs « les plus utiles » de l’autogestion. De plus, peu d’infirmières et d’infirmiers travaillaient dans des pratiques qui offraient un programme de prise en charge de la douleur.

Étant donné le champ de pratique du personnel infirmier et l’importance de la douleur chronique du point de vue de la santé publique, je vois une formidable occasion pour le personnel infirmier de participer davantage aux soins interprofessionnels offerts aux personnes atteintes de douleur. Il pourrait entre autres avoir pour rôle d’augmenter l’accès à une prise en charge de la douleur fondée sur des données probantes au niveau des soins primaires, secondaires et tertiaires; d’aider les personnes atteintes de douleur à s’y retrouver dans le système de santé; de coordonner les soins; de concevoir et de mettre en œuvre des programmes d’autogestion; de collaborer avec des équipes de recherche.

Stakeholder consultation

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.

References

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.

Additional Resources

Canadian Pain Task Force Report. (June 2019). Chronic Pain in Canada: Laying a Foundation for Action.

Learning to Live with Chronic Pain: One Family’s Story

Kathy Reid, RN, MN, is Clinical Nurse Specialist, Policy and Practice, at the Stollery Children’s Hospital, Alberta Health Services, Edmonton, AB. She is also a member of the External Advisory Panel, Canadian Pain Task Force.