PEER simplified chronic pain guideline: Management of chronic low back, osteoarthritic, and neuropathic pain in primary care

Christina S Korownyk¹, Lori Montgomery², Jennifer Young³, Simon Moore⁴, Alexander G Singer⁵, Peter MacDougall⁶, Sean Darling⁷, Kira Ellis⁸, Jacqueline Myers⁹, Candice Rochford¹⁰, Marie-Christine Taillefer¹¹, G Michael Allan¹², Danielle Perry¹³, Samantha S Moe¹⁴, Joey Ton¹⁴, Michael R Kolber¹⁵, Jessica Kirkwood¹⁶, Betsy Thomas¹³, Scott Garrison¹⁵, James P McCormack¹⁷, Jamison Falk¹⁸, Nicolas Dugré¹⁹, Logan Sept²⁰, Ricky D Turgeon²¹, Allison Paige²², Jen Potter²², Tony Nickonchuk²³, Anthony D Train²⁴, Justin Weresch²⁵, Karenn Chan²⁶, Adrienne J Lindblad²⁷

Affiliations

¹ Professor in the Department of Family Medicine at the University of Alberta in Edmonton. cpoag@ualberta.ca.
² Family physician with a focused practice in chronic pain in Calgary, Alta.
³ Family physician practising in Collingwood, Ont.
⁴ Clinical Assistant Professor in the Department of Family Practice at the University of British Columbia in Vancouver.
⁵ Associate Professor in the Department of Family Medicine at the University of Manitoba in Winnipeg.
⁶ Professor in the Department of Anesthesia Pain Management and Perioperative Medicine at Dalhousie University in Halifax, NS.
⁷ Adjunct Assistant Professor in the School of Public Administration at the University of Victoria in British Columbia.
⁸ Physiotherapist and Senior Consultant for the Alberta Health Services Rehabilitation Advice Line.
⁹ Clinical pharmacist for the Saskatchewan Health Authority, Regina Area.
¹⁰ Nurse practitioner in Charlottetown, PEI.
¹¹ Clinical psychologist in the pain clinic of the Centre hospitalier de l'Université de Montréal in Quebec.
¹² Director of Programs and Practice Support at the College of Family Physicians of Canada (CFPC).
¹³ Clinical Evidence Expert for the CFPC and Assistant Adjunct Professor in the Department of Family Medicine at the University of Alberta.
¹⁴ Clinical Evidence Experts for the CFPC.
¹⁵ Professor in the Department of Family Medicine at the University of Alberta.
¹⁶ Family physician and Assistant Professor in the Department of Family Medicine at the University of Alberta.
¹⁷ Professor in the Faculty of Pharmaceutical Sciences at the University of British Columbia.
¹⁸ Associate Professor in the College of Pharmacy at the University of Manitoba.
¹⁹ Pharmacist at the CIUSSS du Nord-de-l'Île-de-Montréal and Clinical Associate Professor in the Faculty of Pharmacy at the University of Montreal.
²⁰ Medical student at the University of Alberta.
²¹ Assistant Professor and Clinical Pharmacy Specialist at the University of British Columbia.
²² Assistant Professor in the Department of Family Medicine at the University of Manitoba.
²³ Pharmacist with Alberta Health Services Provincial Drug Utilization and Stewardship.
²⁴ Assistant Professor in the Department of Family Medicine at Queen's University in Kingston, Ont.
²⁵ Assistant Professor in the Department of Family Medicine at McMaster University in Hamilton, Ont.
²⁶ Associate Professor and a care of the elderly physician at the University of Alberta.
²⁷ Clinical Evidence Expert Lead for the CFPC and Associate Clinical Professor in the Department of Family Medicine at the University of Alberta.

PMID: 35292455
PMCID: PMC9833192
DOI: 10.46747/cfp.6803179

PEER simplified chronic pain guideline: Management of chronic low back, osteoarthritic, and neuropathic pain in primary care

Christina S Korownyk et al. Can Fam Physician. 2022 Mar.

. 2022 Mar;68(3):179-190.

doi: 10.46747/cfp.6803179.

Authors

Affiliations

¹ Professor in the Department of Family Medicine at the University of Alberta in Edmonton. cpoag@ualberta.ca.
² Family physician with a focused practice in chronic pain in Calgary, Alta.
³ Family physician practising in Collingwood, Ont.
⁴ Clinical Assistant Professor in the Department of Family Practice at the University of British Columbia in Vancouver.
⁵ Associate Professor in the Department of Family Medicine at the University of Manitoba in Winnipeg.
⁶ Professor in the Department of Anesthesia Pain Management and Perioperative Medicine at Dalhousie University in Halifax, NS.
⁷ Adjunct Assistant Professor in the School of Public Administration at the University of Victoria in British Columbia.
⁸ Physiotherapist and Senior Consultant for the Alberta Health Services Rehabilitation Advice Line.
⁹ Clinical pharmacist for the Saskatchewan Health Authority, Regina Area.
¹⁰ Nurse practitioner in Charlottetown, PEI.
¹¹ Clinical psychologist in the pain clinic of the Centre hospitalier de l'Université de Montréal in Quebec.
¹² Director of Programs and Practice Support at the College of Family Physicians of Canada (CFPC).
¹³ Clinical Evidence Expert for the CFPC and Assistant Adjunct Professor in the Department of Family Medicine at the University of Alberta.
¹⁴ Clinical Evidence Experts for the CFPC.
¹⁵ Professor in the Department of Family Medicine at the University of Alberta.
¹⁶ Family physician and Assistant Professor in the Department of Family Medicine at the University of Alberta.
¹⁷ Professor in the Faculty of Pharmaceutical Sciences at the University of British Columbia.
¹⁸ Associate Professor in the College of Pharmacy at the University of Manitoba.
¹⁹ Pharmacist at the CIUSSS du Nord-de-l'Île-de-Montréal and Clinical Associate Professor in the Faculty of Pharmacy at the University of Montreal.
²⁰ Medical student at the University of Alberta.
²¹ Assistant Professor and Clinical Pharmacy Specialist at the University of British Columbia.
²² Assistant Professor in the Department of Family Medicine at the University of Manitoba.
²³ Pharmacist with Alberta Health Services Provincial Drug Utilization and Stewardship.
²⁴ Assistant Professor in the Department of Family Medicine at Queen's University in Kingston, Ont.
²⁵ Assistant Professor in the Department of Family Medicine at McMaster University in Hamilton, Ont.
²⁶ Associate Professor and a care of the elderly physician at the University of Alberta.
²⁷ Clinical Evidence Expert Lead for the CFPC and Associate Clinical Professor in the Department of Family Medicine at the University of Alberta.

PMID: 35292455
PMCID: PMC9833192
DOI: 10.46747/cfp.6803179

Abstract

Objective: To develop a clinical practice guideline to support the management of chronic pain, including low back, osteoarthritic, and neuropathic pain in primary care.

Methods: The guideline was developed with an emphasis on best available evidence and shared decision-making principles. Ten health professionals (4 generalist family physicians, 1 pain management-focused family physician, 1 anesthesiologist, 1 physical therapist, 1 pharmacist, 1 nurse practitioner, and 1 psychologist), a patient representative, and a nonvoting pharmacist and guideline methodologist comprised the Guideline Committee. Member selection was based on profession, practice setting, and lack of financial conflicts of interest. The guideline process was iterative in identification of key questions, evidence review, and development of guideline recommendations. Three systematic reviews, including a total of 285 randomized controlled trials, were completed. Randomized controlled trials were included only if they reported a responder analysis (eg, how many patients achieved a 30% or greater reduction in pain). The committee directed an Evidence Team (composed of evidence experts) to address an additional 11 complementary questions. Key recommendations were derived through committee consensus. The guideline and shared decision-making tools underwent extensive review by clinicians and patients before publication.

Recommendations: Physical activity is recommended as the foundation for managing osteoarthritis and chronic low back pain; evidence of benefit is unclear for neuropathic pain. Cognitive-behavioural therapy or mindfulness-based stress reduction are also suggested as options for managing chronic pain. Treatments for which there is clear, unclear, or no benefit are outlined for each condition. Treatments for which harms likely outweigh benefits for all or most conditions studied include opioids and cannabinoids.

Conclusion: This guideline for the management of chronic pain, including osteoarthritis, low back pain, and neuropathic pain, highlights best available evidence including both benefits and harms for a number of treatment interventions. A strong recommendation for exercise as the primary treatment for chronic osteoarthritic and low back pain is made based on demonstrated long-term evidence of benefit. This information is intended to assist with, not dictate, shared decision making with patients.

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Figures

**Figure 1.**
PEER simplified chronic pain guideline: *Summary. Treatment interventions for discussion with patients*

See this image and copyright information in PMC

Comment in

Excellent chronic pain guideline.
Suss R. Suss R. Can Fam Physician. 2022 May;68(5):322. doi: 10.46747/cfp.6805322. Can Fam Physician. 2022. PMID: 35552228 Free PMC article. No abstract available.

References

1. The Canadian Pain Task Force . An action plan for pain in Canada. Ottawa, ON: Health Canada; 2021. Available from: https://www.canada.ca/content/dam/hc-sc/documents/corporate/about-health.... Accessed 2021 Sep 13.
1. Ballantyne JC, Sullivan MD. Intensity of chronic pain—the wrong metric? N Engl J Med 2015;373(22):2098-9. - PubMed
1. Pain Management Best Practices Inter-Agency Task Force . Pain management best practices. Inter-Agency Task Force report. Updates, gaps, inconsistencies, and recommendations. Washington, DC: US Department of Health and Human Services; 2019. Available from: https://www.hhs.gov/sites/default/files/pain-mgmt-best-practices-draft-f.... Accessed 2021 Sep 26.
1. Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education . Relieving pain in America: a blueprint for transforming prevention, care, education, and research. Washington, DC: National Academies Press; 2011. - PubMed
1. Allan GM, Ramji J, Perry D, Ton J, Beahm NP, Crisp N, et al. Simplified guideline for prescribing medical cannabinoids in primary care. Can Fam Physician 2018;64:111-20 (Eng), e64-75 (Fr). - PMC - PubMed

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PEER simplified chronic pain guideline: Management of chronic low back, osteoarthritic, and neuropathic pain in primary care

Affiliations

PEER simplified chronic pain guideline: Management of chronic low back, osteoarthritic, and neuropathic pain in primary care

Authors

Affiliations

Abstract

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Full Text Sources

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