McMaster University

Michael G. DeGroote
National Pain Centre

Scope of Search

Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain

Cluster 3: Monitoring Long-Term Opioid Therapy (LTOT)

R16. Recommendation Statement

No. Recommendation Keyword
R16 When referring patients for consultation, communicate and clarify roles and expectations between primary-care physicians and consultants for continuity of care and for effective and safe use of opioids (Grade C). Collaborative care
  • R16. Discussion
  • R16. Summary of Peer-Reviewed Evidence

R16. Discussion

Options for external assistance include consultation with physicians with expertise in pain management or addiction, referral for treatment intervention, and shared-care models. Once a primary-care physician seeks outside help, successful management of the CNCP patient depends on clear detailed communication and collaboration between all healthcare providers.

1. Referral for Consultation

1.1 Expertise in Pain Management

1. Primary-care physicians seek consultation with physicians experienced in pain management for a variety of reasons, e.g.,

  • co-morbid conditions
  • uncertain diagnosis
  • uncertainty about the need for opioids or the dose
  • problematic adverse effects and/or medical complications
  • significant risk of overdose.

2. Clear communications from the primary-care physician to the consultant include:

  • details describing the patient’s pain condition
  • actions undertaken to manage the pain and results, and
  • specific requested action(s) for the consultant (e.g., confirm diagnosis, screen for risks or misuse, review and advise on need for opioids and dose).

3. Clear communications from the consultant to the primary-care physician include:

  • specific details in response to the request(s) for action
  • clarification of any continuing role in directing care, e.g., if consultant initiates opioids, specification of responsibility for continued prescribing and monitoring the trial.
1.2 Expertise in Addictions

1. Primary-care physicians seek consultation with physicians experienced in addictions when one or more of the following are present:

  • The patient has exhibited aberrant drug-related behaviours.
  • The physician has concerns regarding illicit drug use.
  • There is apparent addiction to opioids.

2. Clear communications from the primary-care physician to the consultant include:

  • details describing the patient’s pain condition
  • concerns regarding opioid misuse and/or addiction, and
  • specific requested action(s) for the consultant (e.g., confirm misuse or addiction and advise on treatment options.)

3. Clear communications from the consultant to the primary-care physician include:

  • recommended treatment
  • clarification of respective continuing roles in directing ongoing care.

2. Referral for Treatment Intervention

The primary-care physician could consider referring the patient for treatment to a multidisciplinary pain program and/or addiction treatment program.

2.1 Multidisciplinary Pain Program

Patients on opioids who continue to have severe pain and pain-related disability appear to have better outcomes when managed by a multidisciplinary pain clinic. There are, however, significant variations in multidisciplinary pain programs: different treatment modalities, diagnostic approaches, healthcare providers, and diverse treatment philosophies regarding the use of opioids for CNCP. In addition, access to multidisciplinary pain programs is very limited in most parts of Canada, and many are not publicly funded.

The referring physician should understand the program’s goals and postdischarge support available. Ideally, these programs would support primary-care physicians through:

  • regular written and telephone communication during the treatment phase
  • ongoing follow-up
  • facilitation of referrals for counseling and addiction treatment as warranted.
2.2 Addiction Treatment Program

Addiction physicians and psychiatrists usually work in formal inpatient or outpatient treatment programs, or in community or hospital-based clinics. In most cases they directly provide detoxification or methadone treatment when appropriate.

3. Shared-Care Models

Examples of shared-care models vary but they do represent another form of information and knowledge sharing. These models could benefit primary-care physicians and their CNCP patients, and also use specialty expertise to the best advantage. Two examples are:

  • Collaboration between primary-care physicians in developing and delivering a care plan for a particular patient seen by both physicians.
  • A mentorship approach where primary-care physicians can access specialty opinion about case management, often with the goal of increasing the primary-care physician’s knowledge, skills, and expertise in managing particular patient groups.

R16. Summary of Peer-Reviewed Evidence

1. Primary-care management of complex-pain patients on opioids is not as effective as ongoing involvement by a multidisciplinary clinic, even when the primary-care physician has been advised by a pain medicine physician.

In one randomized trial, CNCP patients managed by a multidisciplinary pain clinic had reduced pain intensity and decreased short-acting opioid use, whereas patients managed by their primary-care physician with a consultant’s recommendations had no reduced pain intensity and a slight decrease in opioid use. Waiting-list controls actually deteriorated (Becker 2000).

2. Access to multidisciplinary pain programs is very limited.

Pain clinics in Canada vary widely in the types of care providers available, methods, funding, location, and waiting lists (Peng 2007).

Clinics located in academic science centres or publically funded facilities have much longer waiting lists than pain clinics funded by third parties (e.g., workers compensation systems or motor vehicle insurers). The types of patients may vary: hospital-based clinics see more complex patients with significant co-morbidities and more patients with cancer or neuropathic pains (Catchlove 1988), while non-hospital pain clinics and third-party funded clinics may see more musculoskeletal problems (facial pains, headaches, back and neck pain). Access to multidisciplinary pain programs is also variable based on funding, as some of the more intense pain programs are accessible only to those with third-party funding (Peng 2007).