Managing patients with pain, especially chronic non-cancer pain (CNCP) is challenging given current practice realities. Practice patterns have changed with more patients receiving episodic care from walk-in-clinics, emergency departments, and group or team-based clinics with a variety of participating clinicians. Clinicians can be overwhelmed by guidelines, updates, algorithms, portals, and on-line journals. The British Columbia's Opioid Overdose Crisis has permeated our day-to-day practice and often create prescribing uncertainty. Many have fears (though often misplaced) about potential disciplinary and legal consequences from licensing and legislative bodies. Patients also have access to many sources of information, may come with a history of past trauma and unequal treatment by the health care system, and often struggle with reduced function and ability because of their pain.Team based care# 
The intent of this guideline is to provide practical, accessible, and BC specific guidance. In essence, this is more of a Clinical Guidance Document and not a formal guideline. It's a distillation of many guidelines, expert recommendations, and standards of care. There are few overall pain guidelines for direct comparison. The guideline development working group were made aware of the Appraisal of Guidelines for Research and Evaluation (AGREE) process that helped inform their appraisal of these guidelines.
There is no clear or absolute clinical pathway to managing pain and many controversies persist, especially in the use of opioids and cannabis. The guideline development committee recommends reasonable clinical judgement, clear documentation, and frequent reassessment.

# Scope
This guideline comprises of two parts: 1. Pain Assessment and Management Approaches 2. Pain Management -Pharmacological and Procedural Within scope of this guideline: - Practical recommendations within the primary care setting for a graded, multimodal approach to supporting adult patients ( 19 years) with pain on a continuum from acute, subacute to chronic pain. A multimodal approach is one where patients with pain receive multiple interventions and supports, both concurrently and sequentially. - General approaches to treating patients with pain and links to supportive resources. 

# Key Recommendations
- Patients with moderate to severe acute injury should receive adequate pain control and consideration of early referral to specialized services, where indicated and available. - Consider improving function and reducing disability, rather than elimination of pain, as the goal of pain management strategies, especially when pain progresses into the chronic pain continuum. - A supportive longitudinal therapeutic relationship is a foundation of pain management. Given the changing face of primary care with team-based care, walk-in care, and virtual care, use of databases like Electronic Medical Records (EMRs), PharmaNet, and CareConnect is increasingly important. - Throughout the pain continuum, especially in subacute and chronic phases, assess for biopsychosocial factors (yellow flags) and co-morbid conditions. Be alert to addressing risk factors for developing chronic pain. - Complex Regional Pain Syndrome (CRPS) is often considered a pain emergency and warrants urgent referral or consultation by a pain specialist and consideration of early intervention with steroids. - Consider all forms of interventions, including non-pharmacological and pharmacological, as a 'trial' to be reassessed for effectiveness on a regular basis. - For people with chronic pain not already on opioid therapy, optimize non-pharmacotherapy and non-opioid pharmacotherapy first before considering a trial of opioid therapy. - For all medication, aim for the optimal dose and be aware of the recommended maximal dose with fewest side effects and do regular, recurrent evaluation to assess for meaningful improvement in pain and function. See Managing Pain in Primary Care -Part 2: Pharmacological Management.

# Definition
The International Association for the Study of Pain (IASP) defines pain as "An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage. "
In addition, six key notes are added.
- Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.
- Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.
- Through their life experiences, individuals learn the concept of pain.
- A person's report of an experience as pain should be respected.
- Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being. - Verbal description is only one of several behaviors to express pain; inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain.
While it is convenient to try and categorize pain in terms of mechanism, duration or origin, there can be significant differences in how individuals experience pain and how tissues may heal. The parameters for defining pain as acute or chronic may vary depending on the type of trauma and past history, which suggests that a more nuanced approach to applying a framework for resolution of the pain is often required.
Acute pain is pain generally expected to last less than 4 weeks and occurs within the context of tissue damage and repair, resolving with tissue healing.
Subacute pain (transition zone between acute and chronic) is defined as pain not resolving or diminishing as expected in 4-12 weeks after initial onset. The 'subacute' timeframe should trigger practitioners to pause and reflect on progress of pain management and take steps to reduce the likelihood of transition to chronic pain.
Chronic or persistent pain is pain persisting for greater than 3 months. It can arise from long-term medical conditions not expected to improve such as osteoarthritis, scoliosis, and multiple sclerosis, or it can also be pain that persists beyond expected time of healing.
Pain can be described in terms of mechanisms. Treatment modalities, including adjuvants, may differ significantly depending on the mechanism of pain.
- Nociceptive: arises from actual or threatened damage to underlying tissue (e.g., soft tissue, bone, viscera)
- Inflammatory: perception of noxious stimuli that occur during an inflammatory or immune response.
- Neuropathic: results from damaged or dysfunctional nerves (leads to misfiring pain signals).
- Nociplastic: altered pain perception without clear evidence of actual or threatened tissue damage such as in fibromyalgia.
When considering a patient's experience of pain, it can help to remember:
- Pain is always a personal, learned experience that is influenced to varying degrees by biological, psychological, social, and cultural factors and life experiences. - A person's report of their subjective experience of pain should be respected.
- Although pain usually serves an adaptive role, it may have adverse effects on function, and on social and psychological well-being. - Verbal description is only one of several ways to express pain; inability to communicate does not negate the possibility that a person experiences pain.

# Epidemiology of Chronic Pain
According to Statistics Canada, an estimated 7.6 million, or one in five people (across their lifespan) in Canada, live with chronic pain. 1 It is estimated that 1 in 5 adults in BC suffer with chronic pain. 2

# Approach to Care
Pain management is within the scope of practice of all primary care practitioners. Patients seeking management of their pain may at times face social stigma and negative assumptions about their motives, leading to less than adequate care. Successful pain management requires a highly individualized, respectful, evidence-informed treatment approach and benefits from a team-based, biopsychosocial approach. See Appendix A: Overarching Considerations of Pain Management.   - Consider assessment for mood disorder and substance use disorder.
- Assess early for Red Flags. See Table 1: Pain Red Flags below. 

# Constitutional
Unexplained fever (>38C); unexplained weight loss; night sweats

# Complex Regional Pain Syndrome (CRPS)
Previously known as Reflex Sympathetic Dystrophy, an evolving CRPS is usually considered an emergency by pain specialists with a strong suggestion for at least a phone consultation and consideration of an urgent referral. While considered rare, it is occasionally progressive involving the arm, leg, hand, or foot. Symptoms may include excessive pain, swelling, and changes in skin colour, texture, and temperature. A subset of patients may benefit from early steroid therapy so again consider an urgent consultation and referral.

# Functional and Occupational Assessment
Support work rehabilitation, occupational review and return to work or education. Explore work accommodation options (e.g., part-time, modified duties), if appropriate, rather than complete disability.
- For WorkSafeBC and Insurance Corporation of British Columbia (ICBC) injuries, consider early intervention support and consultation. - Many occupational groups, employers and insurance companies have occupational health departments and clinician experts.
Engage early if complex pain or extended disability is anticipated. - If considering prescribing opioids, assess for active and past substance use disorder (SUD) (including nicotine, alcohol, opioids, marijuana) and psychiatric disorders. The presence of these disorders is not a reason to not prescribe but suggests a need to proceed with caution and to have a clear discussion with patient about risks. The presence of any SUD is not an absolute contraindication to prescribe opioids, though it does increase risk of overdose and addiction to opioids. Thus, more safeguards, including enhanced monitoring, need to be put in place and clear documentation of risks and benefits for that particular patient outlined. Certain pain medications may not be safe to prescribe. Patients with pain when on opioid agonist therapy (OAT) need to be referred to an addiction medicine specialist with knowledge of pain treatment. Specific management for individuals in this situation is outside the bounds of this guideline.

# Management
- If opioids are prescribed for acute pain, suggest limiting the duration of the first prescription of opioids to less than 7 days, and use short-acting agents only. 4   - When using the assessment tools, some pain specialists have noted that many patients will label every domain as 10/10. While it may not be an accurate reflection of the actual pain, it may reflect the patient's overall frustration and hopelessness and should not be dismissed as malingering or over-exaggeration. Consider that multiple pain mechanisms may now be involved in the patient's experience of pain. - Re-emphasize that total elimination of pain may not be the goal. Improving function and managing suffering are the priorities. Provide information on pain education and self-management. See Resources: Resources for Patients.
- If recovery is delayed, refer to specialists for expedited assessment or for specialized treatments/ procedures (e.g., epidural or nerve root injections, facet or SI joint injections, joint injections or vertebroplasty). For some conditions such as CRPS and worsening neuropathic pain, referral to specialty services should be as early as possible. This may be especially true in frail older adults as they experience greater functional impairment that can worsen frailty. - As complexity increases, consider combinations of treatments rather than a sequence of treatments. Consider other options, in addition to medications and non-pharmacological interventions. Consider involvement of allied health professionals and/ or teams, where available. See Appendix C: Allied Health Professionals to Support Pain Management. - Explore accommodations for work/school such as the WorkSafeBC Physician's Report.
- For patients involved in motor vehicle accidents who are not recovering as expected or have an unknown diagnosis or complicating factors, consider referral to an ICBC registered care advisor (RCA) within 90 days of the accident for an expedited medical consultation.

# Chronic Pain (3+ months) Assessment
It may be worthwhile considering a slightly different approach if the patient has long standing and well documented pain, versus the patient who has recently developed chronic pain after an acute event. Many strategies are the same, but a patient with long standing chronic pain may have adapted to achieve some stable level of function and ability, while a patient with new onset of chronic pain may still be uncertain about work options and activities of daily living (ADL) adaptations.
Evaluating and managing patients with chronic pain requires repeat history and physical exams as well as evaluation of disability and psychosocial domains. This can be beneficial even for long-term patients who appear stable. This process can be conducted over multiple office visits and may at various times include:
- Repeat / review history, physical exam - Consider asking yourself:
- What is going on? 2. Could it be something else? 3. Could two things be going on at once? 4. Is the diagnosis still supported by the available evidence? - Review medication history including over the counter (OTC) and "off label" products (including use of cannabis) - Repeat / review pain assessment tools, including functional and occupational assessments - Assess / reassess for mental health conditions (e.g., use screening tools for anxiety, depression, PTSD).
Both chronic pain and depression may frequently co-exist, especially in old age, and may be risk factors for each other. 10 Consider exploring other life changes as possible contributors to depression and/or pain symptoms. 

# Management
- In B.C., many of these modalities are not publicly funded and availability of specialized care may not be equitably available. Access to many specialized pain management services outside of a few large urban centres is often extremely limited. Some of this can be mitigated through "telehealth" type options, which more specialists are using. - However, many patients who qualify for income or disability assistance may receive coverage or partial coverage for noninsured health benefits (NIHB) such as physical therapy, acupuncture, chiropractic care, massage therapy, mental health care, pharmacy coverage, medical supplies, and dental care. For more information see BC Family and social supports. - Federal employees, RCMP members, armed forces personnel, and military veterans may also have additional health benefits coverage. - Best practice treatment plans involve primary care providers working closely with allied health care providers, such as physiotherapists, occupational therapists, psychologists, chiropractors, massage therapists, and social workers, and should be centred around patient education and self-management. Despite many services not being publicly funded, explore coverage through ICBC, WorkSafe BC and patient's work disability services or private insurance, in addition to coverage through income assistance. Refer to Pain BC and PathwaysBC for listings of providers, self-management groups and clinics with experience and training in managing chronic pain. - Match non-pharmacological interventions that are best suited to patient's specific pain mechanism and history, such as physiotherapy or chiropractic therapy for mechanical low back pain (LBP); psychological intervention if there is a possible history of PTSD or Adverse Childhood Experiences (ACEs); Cognitive Behavioural Therapy (CBT) for depression and anxiety; and social work or occupational therapy if housing/financial/job insecurity are present. Using a layered and multimodal approach may be more effective than trying a single intervention at a time. For information on services available in the community, visit Pain BC and HealthLinkBC. - Discuss goals of care. Specifically, improved function, reduced suffering, and patient's other individual goals, and not necessarily removal of all pain. - Review patient expectations for treatment outcomes and address misconceptions or unrealistic expectations.
- Over multiple visits, develop an Individualized Care Plan or chronic pain flow sheet 3 to encourage a better systematic approach to chronic pain. Share and review the plan with the patient. - Provide guidance for practical steps that can be addressed in next visit.
- If a patient has been adherent to therapy for 3-4 months and is not responding, consider an alternative approach.
- Educate patients about chronic pain and the multidimensionality of pain. See Resources: Resources for Patients. It is often assumed that tissue damage will continue to heal, but there may be other interfering factors. - Educate patients that non-opioid treatment gives equal pain control and fewer side effects than opioid treatment for most types of chronic LBP and knee and hip arthritic pain. 11 - Educate patients that opioid use may increase pain sensitivity and add to pain at injury sites during withdrawal. 12,13  These procedures generally don't require imaging, can be performed in an office setting and are not restricted to an accredited facility. It is beyond the scope of this guideline to describe these procedures in detail and their indications, but they tend to be self-explanatory, and several online instruction resources exist.

# Procedural
For more complex procedures (e.g., epidural injections, facet joint injections, sympathetic nerve blocks) the BCMQI has described these procedures as Advanced Level I and II, which are required to be done in an approved facility or hospital. Delivery of these procedures in non-hospital settings (e.g., community based GP practices) require facility accreditation and practitioner credentialing. Refer to CPSBC and BCMQI websites for more information.

# Substance Use Reduction
A number of different psychoactive substances have been shown to temporarily supress pain perception in the euphoric phase (the reason the patient with pain may like the feel of the substance). Yet, these same substances can increase pain sensitivity and add to chronic pain in the long run. Alcohol, tobacco, and opioids are all examples.  Patient education on this topic then a trial of tapering down or off of these substances may be needed to help pain perception. In those with CNCP, opioids can produce a dose-dependent pain sensitization that temporarily worsens during tapering. 12,17,18 For those with chronic pain or an opioid use disorder, previous injury sites can hurt again during abrupt withdrawal and add to the risk of opioid re-initiation. Thus, slow tapering along with the use of adjuvant medications like non steroidal anti-inflammatory drugs (NSAIDS) or gabapentinoids may be helpful in adults who do not meet an OUD diagnosis. Previously stable OAT or opioids used for the treatment of OUD should not be routinely tapered.

# Supported Self-Management
- Provide or refer patient to educational resources about science of pain. Pain education has been shown to decrease disability and increase self-efficacy. 19 Refer to Resources: Resources for Patients for helpful resources. - Provide patient with information about self-management (including focused breathing, nutrition, gentle movement, mindfulness meditation, sleep hygiene, etc.) connecting to additional support (e.g., community physical activity programs, dietitians, etc.). - Consider goal setting, including return to work and Brief Action Planning (BAP).

# Allied Health Professionals to Support Non-pharmacological Pain Management
Pain BC has developed an overview of Allied Health Approaches To Chronic Pain Management-A Tool For Primary Care Providers. Many non-pharmacological interventions may be partially or fully covered by third party insurers (e.g., ICBC or WorkSafeBC), or if patient is on disability or income assistance. See Appendix C: Allied Health Professionals to Support Pain Management for more details on allied practitioners.

# Considerations for Referral or Request for Expert Input
When patients DO NOT experience ongoing improvement in function and decrease in suffering then consider: - Consultation with an appropriate specialist.
- Structural cause such as a compression fracture.
- Psychological services if history of PTSD, ACEs, or catastrophizing. - Pain clinic if pain appears to have a nociplastic component.
Guiding principles for referral or request for expert input: - Not seeing appropriate progress and pain looks likely to persist longer than expected.
- Neuropathic features develop, persist, or worsen. - Post-op patients unable to reduce or discontinue opioid use.
- If patient is continuing to show biopsychosocial factors that increase risk of progression to chronic pain.
- Some pain specialists suggest that the emergence of CRPS symptoms warrants at least a phone consultation to assess the need for urgent referral. If WorkSafeBC or ICBC involved, phone the worker's medical advisor and ask for an expedited appointment. - If an interventional or surgical procedure is likely.
- If chronic non-cancer pain and OUD coexist a referral to an addiction specialist is warranted.

# Managing Pain in the Older Adult
Managing pain in the "Older Adult", especially the frail older adult, often requires modifications and adjustments in both approach and dosages. Many experts suggest that age greater than 70 may be an appropriate age to consider age related factors in assessing and managing pain. The definition of frailty is still being fully defined but its current definition is a medical syndrome with multiple causes and contributors, characterized by diminished strength and endurance and reduced physiological function, leading to increased vulnerability for adverse health outcomes such as functional decline and early mortality. While frailty is common with increasing age, it is not an inevitable part of aging. Additional information about Healthy Aging and Preventing Frailty can be found in the updated provincial healthy aging strategy.

# Guiding Principles:
- The frail older adult may require adjustments in medications and dosages, but the use of opioids is not contraindicated. See Part 2: Pharmacological Treatment for more specific guidance. - Persistent pain in frail older adults increases morbidity and poor health outcomes, making treatment a priority.
- Multiple morbidity, cognitive impairment and altered pharmacokinetics and dynamics mandate an individual approach. Some basic bloodwork, including renal function, may be appropriate in the initial assessment phase and intermittently if the use of medication persists. - As cognition worsens, pain is less likely to be reported and may manifest as other distress behaviours (e.g., agitation, resisting care, insomnia, poor appetite). - Older adults are more likely to be taking multiple medications (polypharmacy) and have co-morbidities. Therefore, assess individual patients for drug and disease interactions when prescribing NSAIDs and other medications. - Risk of falls is elevated. However, pain and decreased attention or poor sleep due to chronic pain can also increase the risk of falls. Monitoring the increased risk for managing pain in the elderly is necessary to reduce suffering and increased function. HealthLinkBC offers resources on Pain Control-Learn about pain control. At any time of the day or night, every day of the year, anyone can call 8-1-1 to be connected with a health service navigator. They provide health information, help navigate the health care system and find health services across the province, or connect with a registered nurse, registered dietitian, qualified exercise professional, or pharmacist. Registered nurses at HealthLink BC can help with nonemergency health concerns, to discuss symptoms and procedures, and to recommend whether a health care provider should be seen in person.
- Kelty's Key ("made in BC") also offers an excellent online resource for people with persistent pain.
- Wellness Together Canada basic wellness information, to one-on-one sessions with a counsellor, to participating in a community of support. - Collaboratively support patient with pain's choice in their self-management strategies, while at the same time prescribe safely to minimize adverse events.

# Team Based Care
- Pain management benefits from a multimodal approach (receiving multiple interventions at the same time e.g., yoga, physiotherapy, occupational therapy, counselling, medication). - Get to know pain practitioners in your local community who have training in the management of people with pain and build a network of resources, including low and no cost options and awareness of financial supports. Consider connecting with providers whom the patient has identified as part of their care team or recommend a local practitioner from your network. We acknowledge that access to care may be limited by geography and resources. - Team members may include pharmacists, physiotherapists, massage therapists, acupuncturists, chiropractors, osteopaths, occupational therapists, counsellors, social workers, lifestyle coaches, support for substance use and mental health, psychologists, cognitive behavioural therapists, Indigenous cultural and wellness supports, dietitians and qualified exercise professionals. Team members can also be your own office staff, who may assist with assessment using various tools such as the brief pain inventory and the pain disability index. This can make this complex and sometimes challenging care more manageable. - Refer to HealthLink BC (8-1-1), Pathways, or Pain BC for information on local practitioners and resources. Check the scope of the organization to ensure proper referral. At any time of the day or night, every day of the year, anyone can call 8-1-1 to be connected with a health service navigator. They provide health information, help navigate the health care system and find health services across the province, or connect with a registered nurse, registered dietitian, qualified exercise professional, or pharmacist. Registered nurses at HealthLink BC can help with non-emergency health concerns, to discuss symptoms and procedures, and to recommend whether a health care provider should be seen in person. Pain BC support line can help identify local pain providers including practitioners who can provide guidance and support for self-management. - Involve caregiver/family members as part of the team for frail older adults in pain, particularly if there is cognitive impairment present.

# Safety
- All modalities in a comprehensive plan for managing pain should be assessed from a safety perspective for the patient, practitioner, and the community at large. There may be some uncertainty about how clinicians navigate BCMQI and CPSBC standards, published guidelines, patient demands, family and caregiver concerns, as well as manage their own personal views and bias. As always, document your decisions and rationale well, especially if there is some deviation from College standards or established guidelines, or there are unique patient/family factors that contributed to your course of action. - Communication on the importance of safety is crucial when we have difficult discussions with patients.
- The most obvious safety issue is around medications, especially opioids. Initiating and changing doses, length of prescriptions, tapering doses, and dealing with (for example) unexpected urine drug tests, are all potential conflict points where an initial comment such as "I want this to be safe for you/me/our community", will reset the conversation to one involving safety.

# Patient Safety
Practitioner Safety Community Safety 
The principles of the Guidelines and Protocols Advisory Committee are to:
- encourage appropriate responses to common medical situations - recommend actions that are sufficient and efficient, neither excessive nor deficient - permit exceptions when justified by clinical circumstances

# Contact Information:
Guidelines and Protocols Advisory Committee PO Box 9642 STN PROV GOVT Victoria BC V8W 9P1 Email: hlth.guidelines@gov.bc.ca Website: www.BCGuidelines.ca