Chronic Pain

Care for Adults, Adolescents and Children

Resources The Quality Standard In Brief Advisory Committee About

Summary

This quality standard addresses care for people with chronic pain lasting longer than 3 months, and where any signs of serious underlying pathology (i.e., “red flags,” such as cancer, infection, or fracture) or other treatable conditions requiring medical or surgical management have been ruled out. It addresses care for adults, adolescents, and children, but excludes infants. It applies to care for chronic pain delivered in outpatient settings, including primary care, community pain clinics, and interprofessional pain programs.

This quality standard does not specifically address headache, pain from active cancer, or pain experienced during end of life. See Health Quality Ontario’s quality standards Palliative Care and Opioid Prescribing for Chronic Pain for quality statements related to palliative care and the use of opioids for chronic pain.

Scope of This Quality Standard

Terminology Used in This Quality Standard

This quality standard defines “interprofessional care” as care provided by professionals working as a group to provide comprehensive evidence-informed services. Their working environment is participatory, collaborative, and coordinated. The goals for pain management and function are aligned with the goals of the person being treated. Interprofessional collaboration, shared decision-making, coordination of care, and continuity of care (including follow-up care) are hallmarks of this patient-centred approach. Collaborative practice in health care “occurs when multiple health care workers from different professional backgrounds provide comprehensive services by working with patients, their families, carers, and communities to deliver the highest quality of care across settings.”

Why This Quality Standard Is Needed

This quality standard uses the commonly accepted definition of “chronic pain” as pain that typically lasts longer than 3 months or that continues past the time of normal tissue healing. Some common examples of chronic pain include musculoskeletal, neuropathic, and postsurgical pain, but chronic pain is also associated with many other underlying conditions. Chronic pain can also be considered a disease in itself when the underlying cause is unknown but the pain has a significant impact on a person’s physical, emotional, and psychological well-being, with detrimental effects on the person’s functional, social, and economic status, and quality of life. People with chronic pain may also experience mood disorders, sleep disturbances, and impaired social interactions.

Chronic pain is common and can significantly affect quality of life, including the ability to work or attend school. Some estimates suggest that as many as one in five Canadians live with chronic pain. About one-half of people with chronic pain report experiencing the condition for more than 10 years.

Studies show that people with chronic pain have a health-related quality of life similar to individuals with heart disease or chronic obstructive pulmonary disease. In Ontario, the average annual extra cost of chronic pain to the health care system is estimated to be 51% more than for a matched person with similar morbidity and demographic characteristics but without chronic pain.

Chronic pain can be challenging to assess and manage because of the variety of underlying conditions, the relative lack of effective treatments, and the different ways people are affected. A treatment that works well for one person may not work well for another. Effective treatment requires a personalized and equitable approach to care. The challenge is to determine when and where to use different treatments for the best long-term outcomes. Even in cases where pain cannot be eliminated, evidence-based interventions can significantly improve a person’s quality of life, mood, and function.

People with chronic pain achieve the best outcomes when they are treated through a multimodal and interprofessional approach designed to improve function and quality of life. Health care professionals should work together and closely with the person with chronic pain and their family to promote their health and well-being and provide support for their self-management.

While most people with chronic pain are able to receive their care from their primary care provider, some will also require periodic access to an interprofessional pain program or to specialist care. Access to specialized pain care varies across Ontario. In some places, there are no pain specialists, and some pain management interventions might not be available or affordable for everyone.

Principles Underpinning This Quality Standard

This quality standard is underpinned by the principles of respect and equity. People with chronic pain should receive services that are respectful of their rights and dignity and that promote shared decision-making and self-management.

People with chronic pain should be provided services that are respectful of their gender, sexual orientation, socioeconomic status, housing, age, disability, and background (including self-identified cultural, linguistic, ethnic, and religious backgrounds). Equitable access to the health system also includes access to culturally safe care. Language, a basic tool for communication, is an essential part of safe care and needs to be considered throughout a person’s health care journey. For example, services should be actively offered in French and other languages.

Health care providers should be aware of the historical context of the lives of Indigenous Peoples throughout Canada and be sensitive to the impacts of intergenerational trauma and the physical, mental, emotional, and social harms experienced by Indigenous people, families, and communities.

A high-quality health system is one that provides good access, experience, and outcomes for everyone in Ontario, no matter where they live, what they have, or who they are.

How Success Can Be Measured

The Chronic Pain Quality Standard Advisory Committee identified a small number of overarching goals for this quality standard. These have been mapped to indicators that may be used to assess quality of care. No provincially measurable indicators of success were identified because, currently, provincial data sources on chronic pain care are limited, as is the ability to identify people with chronic pain. As data sources or methods are developed to accurately identify people with chronic pain, the provincial measures of success for this standard will be reconsidered.

How Success Can Be Measured Locally

Health care providers may want to monitor their own quality improvement efforts and assess the quality of care they provide to people with chronic pain. It may be possible to do this using their own clinical records, or they might need to collect additional data. We recommend that health care providers consider using the following indicators to measure the quality of care patients are receiving; these indicators cannot be measured provincially using currently available data sources:

Percentage of people with chronic pain who receive non-opioid pharmacotherapy as first-line pharmacological treatment for pain
Percentage of people with chronic pain who experience an improved quality of life
Percentage of people with chronic pain who experience improved functional status

In addition to the overall measures of success, each quality statement within the standard is accompanied by one or more indicators. These statement-specific indicators are intended to guide local measurement of quality improvement efforts related to the implementation of the statement.

To assess the equitable delivery of care, the statement-specific indicators and the overall indicators can be stratified by patient or caregiver socioeconomic and demographic characteristics, such as income, education, language, age, sex, and gender.

What Does It Mean for Patients and Caregivers?

The quality standard allows clinicians to focus on the chronic pain as a disease. It helps them to treat patients’ pain in an organized way, instead of just haphazardly trying to deal with it and potentially missing gentler methods to help the patient. The patient-focused guide helps people with chronic pain understand the process and know what to ask. With these tools, the physician and the patient create a plan, understand the plan, and deal with the plan as a team – it’s a time-saver for physicians and the patient. And there are better outcomes: there are measuring points and timelines to follow to ensure success. If this quality standard can be implemented and bought into, it will be a huge step forward.

- Lutz Plotzke, Lived Experienced Advisor, Chronic Pain Quality Standard Advisory Committee

What Does It Mean for Providers?

There is no magic pill that will take away chronic pain. Helping people with chronic pain is a long-term joint effort between patient and provider, requiring communication and trust in order to set goals and develop a treatment plan. It can be rewarding for clinicians to watch their patients’ quality of life improve—a quality standard helps clinicians and patients work together toward this goal.

How people experience pain does not remain static and how people describe their pain can change over time; as a result, care plans are constantly evolving to include different treatment strategies. The quality standard for chronic pain encourages clinicians to continually do a comprehensive pain assessment and reminds them of the importance of using multiple interventions for the management of pain, in addition to pharmacotherapy.

– Mona Sawhney, Chronic Pain Quality Standard Advisory Committee

Timeline for This Quality Standard

This quality standard was completed in May 2019.

Evidence to Improve Care