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Faculty of Health Sciences

Michael G. DeGroote National Pain Centre

Guidelines

Expandable List

Several clinical practice guidelines exist to inform the management of chronic jaw pain, however, current clinical practice guidelines are largely consensus-based and provide inconsistent recommendations. This more recent guideline is an evidence-based clinical practice guideline that addresses the limitations of previous guidelines. Rapid recommendations for the guideline can be found here. 

These rapid recommendations are published in BMJ. The increasing legalisation of medical cannabis globally, escalating use by patients, lack of training in the use of medical cannabis or cannabinoids during formal medical education and inconsistent guidance from professional associations and federal agencies have led to confusion regarding the role of medical cannabis in the management of chronic pain.

This guideline seeks to address this confusion by asking what is the optimal, evidence based use of medical cannabis or cannabinoids for chronic pain.

This guideline is published in the Annals of Internal Medicine and recommends use of topical non-steroidal anti-inflammatory drugs (NSAIDs), then oral NSAIDs, then acetaminophen for acute musculoskeletal pain. They recommend against the use of opioids, which were found to be no more effective, but more harmful, than NSAIDs.

This guideline was supported by systematic reviews led by the National Pain Centre on the management of acute pain from non–low back musculoskeletal injuries and predictors of prolonged opioid use after initial prescription for acute musculoskeletal injuries.

Canadians are the second highest users per capita of opioids in the world. The 2017 Canadian Guideline for Opioid for Chronic Non-Cancer Pain was developed to optimize evidence-based prescribing of opioids for chronic non-cancer pain.

The guideline’s recommendations for clinical practice were developed by an international team of clinicians, researchers and patients, led by the Michael G. DeGroote National Pain Centre at McMaster University and funded by Health Canada and the Canadian Institutes of Health Research. The guideline was published by the Canadian Medical Association Journal (CMAJ), the main review of benefits and harms associated with opioids was published in the Journal of the American Medical Association (JAMA) and the synthesis of patients values and preferences was published in Pain Medicine.

The guideline incorporates medical evidence published since the previous national opioid use guideline was made available in 2010. They are recommendations for physicians but are not regulatory requirements.

The guideline does not consider opioid use for acute pain, nor for patients with pain due to cancer or in palliative care or those under treatment for opioid use disorder.

Key Points

  1. Opioid use disorder is often a chronic, relapsing condition associated with increased morbidity and death; however, with appropriate treatment and follow-up, individuals can reach sustained long-term remission.
  2. This guideline strongly recommends opioid agonist treatment with buprenorphine–naloxone as the preferred first-line treatment when possible, because of buprenorphine’s multiple advantages, which include a superior safety profile in terms of overdose risk.
  3. Withdrawal management alone is not recommended, because this approach has been associated with elevated risks (e.g., syringe sharing) and death from overdose in comparison to providing no treatment and high rates of relapse when implemented without immediate transition to long-term evidence-based treatment.
  4. This guideline supports using a stepped and integrated care approach, in which treatment intensity is continually adjusted to accommodate individual patient needs and circumstances over time, and recognizes that many individuals may benefit from the ability to move between treatments.

The target of this guideline is all Canadian healthcare professionals including primary care providers, medical specialists and members of multidisciplinary teams who treat patients with fibromyalgia. It is also relevant to patients with fibromyalgia, who may find this guidance helpful for shared-care decision making.

These guidelines provide evidence-based guidelines for the diagnosis and management of endometriosis.

The Special Interest Group of the Canadian Pain Society produced consensus-based guidelines for the pharmacological management of neuropathic pain. The society aimed to generate an additional guideline for other forms of neuropathic pain treatments.

The criteria used to determine the categorization of the recommendations (Do, Do Not Do and Do Not Know) are defined at the end of the “Major Recommendations” field.

In addition, an explanation of the evidence source (i.e., types of evidence and corresponding “seed” guidelines) is also available. The Guideline Development Group (GDG) considered the balance of benefits and harms for the interventions listed in the Alberta Guideline. Italicized statements relating to harm are included in the recommendations, where appropriate. These statements were sourced from the recommendations or elsewhere in the “seed” guidelines or were created by the GDG.

The purpose of these guidelines is to clinicians make evidence-informed decisions about care of patients with non-specific low back pain.

Recommendations from the Canadian Pain Society consensus statement on the pharmacological management of chronic neuropathic pain.

The Evidence-Based Recommendations for Medical Management of Chronic Non-Malignant Pain below is a guideline facilitated by the College of Physicians and Surgeons of Ontario (CPSO). It is posted on the National Pain Centre website for historical reference. This Guideline was published in November 2000 and functioned as the opioid guideline for that time. The accompanying document Reference Guide for Clinicians for the Medical Management of Chronic Non-Malignant Pain contains information for clinicians extracted from the 2000 guideline. In May 2010, the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain became the current source for information on opioids. The 2010 Guideline will be updated in five years.