Canadian Pain Strategy
Recommended by the Canadian Pain Society
Brief for the Parliamentary Committee on Palliative and
Compassionate Care
October 2010
1
Executive Summary
Pain is under-treated in Canada and there are major problems with access to
appropriate care for all types of pain. A national pain strategy addressing
educational, clinical and research needs is required. Following the recent
International Pain Summit and the creation of the Declaration of Montreal,
identifying that access to pain management is a fundamental human right, it is
essential that Canada take a leading role in proceeding with a national pain
strategy and demonstrate to Canadians and the rest of the world that it is
possible to treat our citizens with the compassion and dignity that they deserve.
Recommendations:
1. Improve education about pain assessment and management.

Integrate patho-physiology, assessment and treatment of pain into the curriculum of all prelicensure health care schools.

Include pain medicine as a fully accredited program at the Royal College of Physicians and
Surgeons
2. Improve access to appropriate care for pain

Integrate timely and appropriate best practice care for chronic pain into all provincial and
territorial plans for chronic disease at primary to tertiary levels of care

Recognize chronic pain as a chronic disease entity and fully integrate chronic pain into the
chronic disease management primary care redesign initiatives.

Include pain assessment and care in the upcoming 2014 Health Care Accord

All health care institutions in Canada should meet the Canadian Council on Health Services
Accreditations standards on pain

Implement the Long Term Care recommendations concerning pain prepared by the expert
consensus group of leading pain clinicians and public policy experts

3. Provide a continuum of stepped care that ensures the right level of care to the right
person in the right place along with efficient use of resources

Develop a model of care across the continuum that incorporates stepped care that ensures
persons with pain receives the right care at the right time and the right place by level of need

Ensure timely multi-dimensional assessment and management of chronic pain through a
triage system operated by the regional Pain Hubs for complex pain conditions.
4. Develop initiatives to assure appropriate support for research about causes and new
approaches to management of pain.

Direct and dedicated funding for pain research is needed.
5. Ensure that any investment can be measured against expected outcomes to ensure
accountability & sustainability.

Outcome indicators for clinical outcomes and health care utilization must be collected.
2
Overview of Pain in Canada
Introduction, the challenge and clinical need
Pain is poorly managed in Canada. This includes acute pain caused by ongoing
tissue damage, trauma or surgery, chronic pain and pain related to terminal
illness. Reasons for this include under-recognition of the problem, lack of
education regarding pain assessment and treatment in graduating health care
professionals and grossly inadequate funding for research regarding pain.
Although we have the knowledge and technology Canadians cannot be sure they
will receive adequate or appropriate treatment for pain along the entire
continuum of care from community health professionals to specialists in tertiary
health care institutions.
The magnitude of the problem is increasing. For example one in five Canadians
suffer with chronic pain, children are not spared and the prevalence of chronic
pain increases with age (Moulin, Clark et al. 2002; Schopflocher, Jovey et al.
2010). Many people with diseases such as cancer, HIV and cardiovascular
disease are now surviving their acute illness with resultant increase in quantity
of life but, in many cases, poor quality of life due to persistent pain caused either
by the ongoing illness or nerve damage caused by the disease even after
resolution or cure of the disease. In many cases the pain is also caused by the
treatments such as surgery, chemotherapy or radiotherapy needed to treat the
disease (McGillion, L'Allier et al. 2009; Phillips, Cherry et al. 2010)1.
Chronic pain is associated with the worst quality of life as compared with other
chronic diseases such as chronic lung or heart disease (Schopflocher, Jovey et
al. 2010). There is double the risk of suicide as compared with people without
chronic pain (Tang and Crane 2006). Higher pain severity is associated with
higher suicide rates (Kikuchi, Obmori-Matsuda et al. 2008), a sense of
hopelessness (Fishbain, Goldberg et al. 1991) and suicide rates remain higher
even when controlling for mental illness (Ratcliffe, Enns et al. 2008).
A recent review of opioid (narcotic) related deaths in Ontario, published in
Canadian Medical Association Journal, and reported in papers across the
country, has identified the tragic fact that pain medication related deaths in
Ontario are increasing. Even more tragic was the fact that most of the people
who died had been seen by a physician within 9-11 days prior to death
(emergency room visits and office visits respectively) and that the final encounter
with the physician involved a mental health or pain related diagnosis. In almost a
quarter of the cases the coroner had determined that the manner of death was
1
This document focuses primarily on non-cancer pain however it is important to note
that there are major gaps in appropriate care for pain in people with cancer with recent
reviews identifying that nearly half of cancer pain is undertreated. Deandrea, S., M.
Montanari, et al. (2008). "Prevalence of undertreatment of cancer pain." Ann Oncology
19: 1985-1991..
3
suicide (Dhalla, Mamdani et al. 2009). It is tragic that these patients did not get
the help that they needed. It is disturbing that in Ontario, the largest province in
the country, there is not a single, interdisciplinary pain management program that
is fully-funded by the Ontario Ministry of Health
At present wait times for care are greater than 1 year at over one third of publicly
funded pain clinics in Canada with vast areas of the country having no access to
appropriate care (Peng, Choiniere et al. 2007). Patients waiting more than 6
months from the time of referral to assessment experience deterioration in health
related quality of life, increased pain and increasing depression (Lynch, Campbell
et al. 2008). For this reason the Canadian Pain Society Task Force on Wait
Times determined that wait times for chronic pain conditions beyond 6 months
are medically unacceptable and that in many cases 6 months is far too long to
wait for care (Lynch, Campbell et al. 2007).
Understanding Pain
The International Association for the Study of Pain taxonomy defines pain as “ an
unpleasant sensory and emotional experience associated with actual or potential
tissue damage or described in terms of such damage” (Merskey 1994). Pain is
divided into two broad categories; acute pain which is associated with ongoing
tissue damage and chronic pain, which is generally taken to be pain that has
persisted for longer periods of time.
Acute or physiological pain
Sources of acute pain include pain caused by sports injuries, childbirth,
postoperative pain, fractures, burns, and medical procedures. Acute pain is
caused by tissue damage with triggering of the inflammatory response and
activation of ascending neural systems that convey pain related information.
These systems are complex, involve numerous signaling relays and feedback
loops and multiple chemical neurotransmitters. We are also equipped with a
sophisticated descending modulatory system or “pain defense network” that
allows the body to fight pain. It is this pain defense system that is activated by the
drugs (eg. opioids) used to treat pain. Acute pain can be controlled using
appropriate physical (eg.ice, splinting), pharmacological (eg. anti-inflammatory,
opioid) and psychological (eg. reassurance, anxiety management) treatments.
Unfortunately even in the best hospitals in Canada patients continue to receive
inadequate pain control in emergency rooms and after common surgeries. For
example in studies of postoperative pain control after coronary artery bypass
grafting (CABG), a common procedure to treat or prevent heart attacks, less than
30% of the ordered dose of pain medication was given, with approximately 50%
of patients continuing to report moderate to severe pain 1-5 days post surgery.
One quarter of patients rated the pain as “extremely unpleasant” with significant
interference in ability to function even up to the day prior to discharge (WattWatson, Stevens et al. 2004). This included interference with breathing and
coughing (critical to prevent post-operative lung infection), general activity and
4
walking. Patients continued to deal with these problems at home 12 weeks later.
In another study of patients undergoing ambulatory, “same day” shoulder
surgery, patients continued to experience severe levels of pain and poor sleep
for at least 7 days after surgery, at the end of the 7 day study pain levels had still
not decreased, with implications for healing and function (Watt-Watson, Chung et
al. 2004). Given that same day surgery is an increasing phenomenon it is
important to assure that patients receive effective analgesia for management of
the pain at home, this study identifies that this is not occurring. More recent work
has identified the situation has not improved (Watt-Watson, Choiniere et al.
2010).
There is growing evidence that many common surgical procedures are
associated with significant rates of persistent post-operative pain. For example
following cardiac surgery 75% of patients reported moderate to severe pain at 2
days and for 54% at 7 days. At 3 months approximately 40% reported persistent
non-anginal pain that was moderate to severe and interfered with activities and at
6 months this only decreased by 8% leaving 32% suffering chronic pain (WattWatson, Choiniere et al. 2010). Following other common surgical procedures the
rates are 30-50% following amputation, 20-30% following breast surgery
(lumpectomy, mastectomy), 30-40% following thoracotomy, 10% following
inguinal hernia repair, and 10% following caesarian section (Kehlet, Jensen et al.
2006).
Inadequate pain control is the leading cause of post-discharge visits to the
emergency room and early re-admission to hospital. 90 percent of patients could
obtain effective and safe relief of their pain with currently available treatments –
yet only 50% gain access to such treatments (Cousins 2009). It is clear that we
are not meeting the challenge of optimal pain management for a variety of
reasons including lack of knowledge, values and beliefs that affect judgments,
how health care professionals make decisions and use evidence about pain
management, lack of prioritization of pain assessment and management on
individual and institutional levels (Seers, Watt Watson et al. 2006).
It is critical to treat acute pain not only to decrease suffering but also to maximize
healing and minimize the chances of going on to a persistent (chronic) pain
condition.
Chronic pain or patho-physiological pain
Chronic pain can be associated with other chronic diseases, terminal illness, or
may persist after illness or injury. The point at which chronic pain can be
diagnosed may vary with the injury or condition that initiated it; however, for most
conditions pain persisting beyond 3 months is reasonably described as a chronic
pain condition.
Pain research in the past four decades has increased our understanding about
the underlying mechanisms of chronic pain, now understood to involve a neural
5
response to tissue injury. In other words peripheral and central events related to
disease or injury can trigger long lasting changes in peripheral nerves, spinal
cord and brain such that the system becomes sensitized and capable of
spontaneous activity or of responding to non-noxious stimuli which results in
pain. In this case pain persists beyond the point where normal healing takes
place and is often associated with abnormal sensory findings.
Traditionally, clinicians have conceptualized chronic pain as a symptom of
disease or injury. Treatment was focused on addressing the underlying cause
with the expectation that the pain would then resolve. It was thought that the pain
itself could not kill. We now know that the opposite is true. Pain persists beyond
injury and there is mounting evidence that “pain can kill.” In addition to
contributing to ongoing suffering, disability and diminished life quality, it has been
demonstrated that uncontrolled pain compromises immune function, promotes
tumor growth, and can compromise healing with an increase in morbidity and
mortality following surgery (Liebeskind 1991; Page 2005), as well as a decrease
in the quality of recovery (Wu, Rowlingson et al. 2005). Clinical studies suggest
that prolonged, untreated pain suffered early in life may have long lasting effects
which may extend to persistent changes in sensory processing with implications
for pain experienced later in life (Finley, Franck et al. 2005)
Chronic pain has major implications for the individual suffering from pain, but also
family and loved ones who become involved in the suffering person’s challenges,
the work place suffers through loss of productive employees, the community is
deprived of active citizens, and the economic costs of caring for those suffering
from chronic pain are dramatic.
Children
As recently as 20 years ago many people believed that because children did not
have fully developed nervous systems they did not experience pain as much as
adults. This thinking led to a situation where infants and children were not
provided with appropriate pain relief when receiving painful procedures.
Research has demonstrated that this is inaccurate. Even premature neonates
experience pain and this pain is associated with physiological changes (eg.
respiratory and heart rate) and specific behavioral changes (eg. specific facial
expression, crying) that can be used in the assessment and treatment of
pediatric pain (Stinson and McGrath 2010) The prevalence of recurring or
persisting pains in children is 15-30% (Stanford, Chambers et al. 2008).
Recurrent and chronic pain leads to significant interference with daily functioning,
is associated with poor school performance (Gauntlett-Gilbert and Eccleston
2007) and may increase the risk of having chronic pain in adulthood (Jones,
Power et al. 2009; Palermo, Koh et al. 2010). Children with pain also experience
more mental health problems. It is a priority to address pain in children, yet there
are only 5 centers with dedicated pain management facilities for children in
Canada (Peng, Stinson et al. 2007) thus most children in Canada do not have
access to best practice care for management of pain.
6
Aging Populations
Pain is also a major concern among older adults because of its high prevalence,
estimated to be as high as 65% for those living in the community and up to 80%
for those living in long term care facilities. By the year 2036 one in four
Canadians will be over 65 years of age, compounding the problem of pain
management in old age (Hadjistavropoulos, Gibson et al. 2010; StatisticsCanada
2010). Well-documented under treatment and under assessment of pain among
older adults reflect systemic failure to adequately address the needs of this
rapidly increasing segment of the population and represent one of the most
pressing ethical concerns of pain clinicians (Ferrell, Novy et al. 2001) .
Cancer and HIV survivors
As medical technology improves many people with previously fatal conditions
such as cancer and HIV are surviving to live longer lives. The introduction of
combination antiretroviral therapy (cART) in the mid 1990s has dramatically
reduced morbidity and mortality associated with HIV among those with access to
treatment. The incidence of HIV sensory neuropathy (HIV-SN) has been rising
(Phillips, Cherry et al. 2010). This pain condition is due to nerve damage caused
by the the HIV virus itself and/or the treatments used to treat the HIV because
many of the treatments are toxic to nerves. Recent estimates of the prevalence
of HIV-SN range from 20-50%. In Canada the most recent figures indicate the
number of people living with HIV (including AIDS) continues to rise from an
estimated 57,000 in 2005 to 65,000 in 2008 (a 14% increase)2 , this means that
there are more than 25,000 people with HIV-SN in Canada now and this will
increase annually. The increase will be due to new infections and the increased
risk of developing HIV-SN as the duration of the disease progresses in those
already infected.
The situation with cancer survivors is very similar (Levy, Chwistek et al. 2008;
Moryl, Coyle et al. 2010). This is a growing, under recognized and undertreated
problem. The most frequent cause is neuropathic pain caused by the surgery,
chemotherapy or radiotherapy. Management of chronic pain must be integrated
into comprehensive cancer care so that cancer survivors can fully enjoy their life
(Levy, Chwistek et al. 2008).
The Treatment Need
The best treatment of acute pain is to assess pain and treat effectively as soon
as pain is apparent. A useful concept is to consider pain the “fifth vital sign”. In
other words as medical staff monitor the patient’s pulse, blood pressure,
respirations and heart rate, they should also assess and treat the pain. If pain
can be anticipated based on the expected procedure (eg. surgery, bone marrow
aspiration, needle stick in the eye for certain opthalmological procedures) then
effective pain treatment and sedation should be offered before the procedure
2
Canada Aids Committee Toronto http://www.actoronto.org/home.nsf/pages/hivaidsstatscan
7
starts. Treatment may include early, effective use of pain relieving medications
from the anti-inflammatory and opioid (narcotic) categories with use of additional
pain relieving medications or sedatives and local or regional anesthetic blocks as
appropriate (MacIntyre, Scott et al. 2010).
Treatment of chronic pain should span the continuum of self-management up to
to and including access to full interdisciplinary pain management teams
depending on the type of pain and the level of complexity. Interdisciplinary teams
are required as chronic pain may lead to significant limitations in the ability to
pursue work in the wage earning work force, one’s roles in relationship and to
care for children or others. This may also lead to an emotional response with
resultant anxiety, depression or self-medication which can lead to substance
dependency and addiction disorders (Lynch 2010).
The Educational Need
A recent survey of pre-licensure pain curricula in health science and veterinary
training programs across Canada has identified inadequate training about pain
among health care practitioners. This survey included medical schools, and
faculties training nurses, dentists, physiotherapists and occupational therapists
as well as veterinary medicine programs. Only one third of the programs could
identify time designated for mandatory teaching about pain. The mean total
number of hours designated for pain teaching over the entire academic training
program was 15 for dentistry, 16 for medicine, 31 for nursing, 28 for occupational
therapy, 13 for pharmacy, 41 for physical therapy and 87 for veterinarians (WattWatson, McGillion et al. 2008). In other words veterinarians receive 5 times
more education for pain than people doctors. It is not surprising then, that when
people in pain present to their community practitioners for help, these family
physicians or in some cases nurse practitioners (where they are available) are
not well equipped to help them. This is also true about the education of
specialists with implications for pain care following painful medical procedures,
trauma or surgery.
The Research Need
Research for pain is grossly under-funded in Canada as compared to the burden
of illness. The Canadian Pain Society conducted a survey about pain research
funding in Canada. Of 79 active researchers doing pain related studies 65 had
received funding in the past 5 years amounting to a total of $80.9 Million dollars.
This is less than 1% of total funding provided by the Canadian Institutes for
Health Research (CIHR) and only 0.25% of the funding for all health research
(Lynch, Schopflocher et al. 2009). Only 6 randomized controlled trials examining
treatments for pain were funded by CIHR from 1999-2009, and only 2 of these
involved chronic pain.
Statistics Canada reports that total spending on research and development in the
health field amounted to 6.3 billion dollars for 2007 (Statistics Canada, 2008).
Considering the overall burden of pain in Canada, pain research is under-funded.
8
A rough comparison between cancer and chronic pain is instructive. According to
the latest available estimates, (Health Canada 2002), the cost of direct health
care for cancer was about 2.5 billion dollars per year in 1998. The total amount of
research funding for cancer in 2008 was 390 million dollars (Canadian Cancer
Research Alliance, 2008). Using these figures, the ratio of research dollars to
direct health care costs would be about 41 times higher for cancer than for
chronic pain. Pain research is comparatively grossly under-funded.
Pain Costs Canada
Chronic pain is costly not only to the patient but also to society as a whole.
Expenditures on chronic pain include both direct costs related to treatment and
provisions of health care services, and indirect costs such as those associated
with loss of productivity, lost tax revenues and disability payments. Uncontrolled
pain continues to be the single most common cause of disability amongst
working-age adults in Canada (Statistics Canada – Housing, Family and Social
Statistics Division. A Profile of Disability in Canada. Statistics Canada. 89-577XIE, 1-24.2001). Sixty percent of people with chronic pain eventually loose their
job, suffer loss of income or will have a reduction in responsibilities as a result of
their pain For those who are still employed, it is anticipated that they will have a
mean number of 28.5 lost-work days per year.
Chronic pain costs more than cancer, heart disease and HIV combined.
Estimates place direct health care costs for Canada to be more than $6 billion
per year and productivity costs related to job loss and sick days at $37 billion per
year (Phillips and Schopflocher 2008; Schopflocher, Jovey et al. 2010) . Patients
are referred to Pain Clinics when first-line treatments are not available, severe
unremitting pain and/or complex psychosocial situations exist. The economic
burden of patients who wait for access to pain clinics was studied by the
Canadian Stop-Pain Research Group. They reported that patients while waiting
to access Pain Clinics spent a median of $17,544/year, the vast majority of which
were indirect expenditures, e.g., lost labour time and funding of private health
care treatments. This demonstrates the significant financial burden pain has on
the individual as well as our society (Choiniere, Dion et al. 2010; Guerriere,
Choiniere et al. 2010).
The International Initiative
The International Association for the Study of Pain (IASP) hosted the first
International Pain Summit this year on September 3 in Montreal. Over 250
representatives from 84 countries, professional and human rights organizations
endorsed that access to pain management is a fundamental human right and
contributed to the Declaration of Montreal which is in the final phases of editing
and approval. The Declaration recognizes the intrinsic dignity of all persons and
the right of access to pain management without discrimination and the obligation
of governments and health care institutions to establish laws, policies, and
systems that will help to promote, and will certainly not inhibit, the access of
people in pain to fully adequate pain management. It is further acknowledged
that failure to establish such laws, policies, and systems is unethical and a
9
breach of the human rights of people harmed as a result.
It is essential that Canada take a leading role in embracing the Declaration of
Montreal and show the rest of the world that it is possible to treat our citizens with
the compassion and dignity that they deserve.
The Solution and Recommendations
To improve the treatment of pain in Canada will require a national pain strategy.
The national strategy should follow the recommendations below.
Recommendations:
1. Improve education about pain assessment and management.

Integrate patho-physiology, assessment and treatment of pain into the curriculum of
all pre-licensure health care schools.

Include pain medicine as a fully accredited program at the Royal College of
Physicians and Surgeons3
2. Improve access to appropriate care for pain

Integrate timely and appropriate best practice care for chronic pain into all provincial
and territorial plans for chronic disease at primary to tertiary levels of care

Recognize chronic pain as a chronic disease entity and fully integrate chronic pain
into the chronic disease management primary care redesign initiatives.

Include pain assessment and care in the upcoming 2014 Health Care Accord

All health care institutions in Canada should meet the Canadian Council on Health
Services Accreditations standards on pain (figure 1)

Implement the Long Term Care recommendations concerning pain prepared by the
expert consensus group of leading pain clinicians and public policy experts
(Hadjistavropoulos , Marchildon et al. 2009)
3. Provide a continuum of stepped care that ensures the right level of care
to the right person in the right place along with efficient use of resources

Develop a model of care across the continuum that incorporates stepped care that
ensures persons with pain receives the right care at the right time and the right
place by level of need

Ensure timely multi-dimensional assessment and management of chronic pain
through a triage system operated by the regional Pain Hubs for complex pain
conditions.
4. Develop initiatives to assure appropriate support for research about
causes and new approaches to management of pain.
3
The proposal for Pain Medicine as a specialty is currently before the Royal College of
Physicians and Surgeons of Canada, other countries such as Australia and the UK have
approved Pain Medicine as a recognized specialty.
10

Direct and dedicated funding for pain research is needed.
5. Ensure that any investment can be measured against expected
outcomes to ensure accountability & sustainability.

Outcome indicators for clinical outcomes and health care utilization must be
collected.
11
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Watt-Watson, J., M. McGillion, et al. (2008). "A survey of pre-licensure pain
curricula in health science faculties in Canadian universities." Pain Res
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Watt-Watson, J., B. Stevens, et al. (2004). "Impact of preoperative education on
pain outcomes after coronary artery bypass graft surgery." Pain 109: 7385.
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Inclusion of pain management in the AIM standards
CCHSA has enhanced the concept of pain management in its AIM standards:
Pain focused criteria are enhanced in the upcoming version of our Standards Document to be
used in 2005. In the revised standards, a pain-focused criterion contains specific actions to meet
the standard. Actions relate to assessment, management, related monitoring, organizational
responsibility, and includes assessment measures. Criteria that incorporate pain management
are now more evidence-based and have a greater emphasis on the organization’s accountability
to train and update staff, patients and families on pain management options and strategies.
Sections where reference to “pain management” in the standards can be found:
New reference to pain management can be found in Acute Care Standard 13.0, under the subsection Delivering Services, which covers the topics delivering services, medications, and clients’
responsibilities. Criterion 13.11 specifically addresses the team’s processes for assessing and
managing the client’s pain. This criterion is included in all care sections of the standards where
appropriate for the management of pain, from Cancer Care, Maternal/Child, Rehabilitation and
Long-Term Care, to Acquired Brain Injury, Ambulatory Care and Critical Care. Processes
addressed in this criterion are as follows:
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The team knows how to assess pain using standardized clinical measures
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All clients receive a pain assessment on admission and routinely for those with painful
procedures and/or conditions
The team knows how to implement pain management strategies appropriately and
routinely monitors their effectiveness
The organization trains and updates staff on pain relief strategies that are evidencebased and that guide them to minimize risk factors to reduce or prevent adverse
consequences e.g. unrelieved acute pain can have consequences such as persistent
pain.
The team documents findings and communicates with colleagues as appropriate
The team identifies and consults with experts in pain when a complex problem occurs
The team educates patients and families on pain management options and strategies for
appropriate relief
How pain management has been considered in the context of patient safety:
Increasingly, pain management is being discussed in relation to patient safety because of
inadequate pain relief, under-medication and related interference in activities for patients who
have been discharged after surgery. Currently, the safe use of medication practices address the
use of opioids. To reflect this, our medical standards also include reference to opioids when
needed in our guidelines.
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