Skip to content

Welcome to the IME Insider

Timely information and insights into the world of evidence-based medicine as it applies to IMEs and other health-related services across Canada. Your feeback and suggestions are welcome.

Part 2: Chronic Pain


Treating Chronic Pain on the Modern Medical Landscape

Treating chronic pain is an issue that has been made more complex by concerns associated with the long-term use of opioid analgesics, which can include addiction as well as unpleasant side effects. In fact, the number one recommendation made by the 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain is to avoid the use of opioids in initial treatment. In its place, a multi-disciplinary approach to managing chronic pain is preferable1. This can include not just the use of non-opioid analgesic-based pain management plans, but also those incorporating physical exercise, physiotherapy, diet, and psychological intervention.

This is not to say that opioids are to be completely avoided when treating chronic pain. Above all, the goal of any treatment plan is to provide patients with the support required to live their lives as pain-free as possible. In fact, most guidelines for managing chronic pain reflect the World Health Organization analgesic ladder that begins with nonsteroidal anti-inflammatories (NSAIDs), moves up to mild opioids, and plateaus at strong opioids2. Even the Canadian Guidelines cited above do not rule out the use of opioids (except in the case of patients who demonstrate a substance abuse disorder) but point out that NSAIDs can show similar effectiveness to opioids in mitigating pain without being linked to strong side effects1. Overall, the preference is to explore other options prior to committing to opioid-based pain management.

Non-drug treatment alternatives can be as varied as the types and causes of chronic pain experienced by patients and are often linked to the details of an individual's pain triggers, sources, and experience. Physiotherapy, massage therapy, exercise, TENs electric stimulation, acupuncture, yoga, Tai Chi, osteopathic treatment, spinal manipulation, and mindfulness-based stress reduction have all shown benefits in chronic pain management1. Throughout any treatment, it's important for patients to feel involved in the decisions made to manage their pain, with clear communication between themselves and practitioners serving as a cornerstone of that empowerment3. Therapies should also be linked to the severity and impact of chronic pain on the daily lives of each patient.

It is also extremely important to consider the link between chronic pain and psychological dysfunction. Those living with chronic pain are at significantly increased risk of depression and anxiety. Although psychological drugs such as antidepressants and anticonvulsants have been shown to be effective in some cases at mitigating pain in patients, the mental health aspect of managing this condition is at least as critical, particularly given the long-term nature of the symptoms and potential side effects associated with stronger drug-based treatment programs1.

Unlike other conditions, putting together a chronic pain treatment program can sometimes require challenging the bias against opioids as a pain management strategy and fears of their side effects in both patients and medical professionals. Although they should usually be considered only after multi-disciplinary treatment options have been exhausted, they do have an important place in treating some types of chronic pain when prescribed carefully within the context of a program where patient and doctor have a regular and constant open line of communication.

  1. Busse J, Guyatt G, Carrasco A, et al. The 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain. http://www.cmaj.ca/content/suppl/2017/05/03/189.18.E659.DC1/170363-guide-1-at-updated.pdf (accessed April 24, 2018).
  2. Boulanger A, Clark AJ, Squire P, et al. Chronic pain in Canada: Have we improved our management of chronic noncancer pain? Pain Research & Management 207;12(1):39-47.
  3. NIH. Chronic Pain: Symptoms, Diagnosis, & Treatment. NIH Medline Plus 2011;6(1):5-6.