A Scoping Review of Gaps Identified by Primary Care Providers in Caring for Patients with Chronic Noncancer Pain

Figures & data

Figure 1. Flow diagram of methodology process and analysis.

Table

No.	Searches
1	Primary Health Care/
2	Physicians, Primary Care/
3	(primary adj2 care).mp.
4	primary healthcare.mp.
5	exp Physicians, Family/
6	exp Family Practice/
7	exp Community medicine/
8	exp Physician’s Practice Patterns/ and (family or general pract* or primary care or primary health*).mp.
9	exp Regional medical programs/
10	exp homes for the aged/
11	house calls/
12	house call:.mp.
13	housecall:.mp.
14	house visit*.mp.
15	home visit*.mp.
16	Rural Health Services/
17	Hospitals, Rural/
18	Rural Health/
19	(free-standing adj2 clinic?).mp.
20	(free-standing adj2 facilit:).mp.
21	community health centers/
22	child guidance clinics/
23	maternal-child health centers/
24	family doctor?.mp.
25	“family and community medicine.”mp.
26	family medicine.mp.
27	family physician?.mp.
28	family practitioner?.mp.
29	general practice?.mp.
30	general practise?.mp.
31	general practitioner?.mp.
32	(personal adj1 (doctor? or physician? or practitioner?)).mp.
33	primary care provider?.mp.
34	primary health care.mp.
35	primary healthcare.mp.
36	primary health* provider?.mp.
37	pcp staff.mp.
38	community physician?.mp.
39	(resident? adj25 (physician? or doctor? or clinician?)).mp.
40	(intern? adj25 (physician? or doctor? or clinician?)).mp.
41	(trainee? adj50 (physician? or doctor? or clinician?)).mp.
42	or/1-41 [Primary Health Care or General Practice or Family Practice]
43	Chronic Pain/ [MeSH term since 2012]
44	Causalgia/
45	exp Arthralgia/
46	exp Back Pain/
47	exp Central Nervous System/ and exp *”Wounds and Injuries”/
48	exp Central Nervous System/ and exp Pain/
49	exp Chronic Illness/ and exp Pain/ [Historical search for chronic pain]
50	exp Complex Regional Pain Syndromes/
51	exp Diabetic Neuropathies/
52	exp Headache/
53	exp Headache Disorders/
54	exp Herpes Zoster/
55	exp Hyperalgesia/
56	exp Mononeuropathies/
57	exp Nerve Compression Syndromes/
58	exp Neuralgia/
59	exp Neurons, Afferent/
60	exp Nociceptors/
61	exp Palliative Care/
62	exp Pelvic Pain/
63	exp Peripheral Nervous System/ and exp *”Wounds and Injuries”/
64	exp Peripheral Nervous System/ and exp Pain/
65	exp Polyneuropathies/
66	Glossalgia/
67	Mastodynia/
68	Metatarsalgia/
69	Piriformis Muscle Syndrome/
70	Reflex Sympathetic Dystrophy/
71	(afferent adj2 neuron?).mp,kw.
72	(back? adj2 pain*).mp,kw.
73	(cancer* adj3 pain*).mp.
74	(chronic* adj2 headache?).mp,kw.
75	(chronic* adj2 head-ache?).mp,kw.
76	(chronic* adj2 migrain*).mp,kw.
77	(chronic* adj3 pain*).mp,kw.
78	(deafferentation adj2 pain*).mp,kw.
79	(deafferentation adj2 pain*).mp,kw.
80	(dysa?sthetic adj2 pain*).mp,kw.
81	(maladapt* adj2 pain*).mp,kw.
82	(mal-adapt* adj2 pain*).mp,kw.
83	(mononeurit* adj1 multiple*).mp,kw.
84	(mono-neurit* adj1 multiple*).mp,kw.
85	(nerve? adj12 pals???).mp,kw.
86	(nerve? adj2 damag*).mp,kw.
87	(nerve? adj2 injur*).mp,kw.
88	(nerve? adj2 injur*).mp,kw.
89	(nerve? adj2 sensitiv*).mp,kw.
90	(nerve? adj3 entrap*).mp,kw.
91	(neural adj2 damag*).mp,kw.
92	(neural adj2 injur*).mp,kw.
93	(neural adj3 entrap*).mp,kw.
94	(neural adj3 sensitiv*).mp,kw.
95	(neuro* adj2 pain*).mp,kw.
96	(neuro* adj2 pain*).mp,kw.
97	(neuro* adj2 sensitiv*).mp,kw.
98	(neuropath* adj2 pain*).mp,kw.
99	(pain adj2 low?? adj2 back?).mp,kw.
100	(pain adj5 multiple scleros*).mp,kw.
101	(pain or pains or pained or painful*).mp,kw.
102	(pain* adj3 syndrom*).mp,kw.
103	(pelvic adj5 pain*).mp,kw.
104	(peripheral* adj1 mononeurit*).mp,kw.
105	(peripheral* adj1 mono-neurit*).mp,kw.
106	(peripheral* adj1 neurit*).mp,kw.
107	(peripheral* adj1 polyneurit*).mp,kw.
108	(peripheral* adj1 poly-neurit*).mp,kw.
109	allodynia*.mp,kw.
110	arthralgi*.mp,kw.
111	causalgi*.mp,kw.
112	cephalalgi*.mp,kw.
113	cephalgi*.mp,kw.
114	chronic noncancer* pain?.mp,kw.
115	chronic non-cancer* pain?.mp,kw.
116	chronic nonmalignan* pain?.mp,kw.
117	chronic non-malignan* pain?.mp,kw.
118	colic.mp,kw.
119	dysaesthesi*.mp,kw.
120	dysesthesi*.mp,kw.
121	dysmenorrhea*.mp,kw.
122	dysmenorrhoea*.mp,kw.
123	earache?.mp,kw.
124	ear-ache?.mp,kw.
125	failed back?.mp,kw.
126	glossalgi*.mp,kw.
127	headach???.mp.
128	head-ach???.mp.
129	Herpes Zoster.mp,kw.
130	hyper?esthesi*.mp,kw.
131	hyperalges*.mp,kw.
132	hyperpathi*.mp,kw.
133	hypo?esthesi*.mp,kw.
134	mastodyni*.mp,kw.
135	metatarsalgi*.mp,kw.
136	migrain*.mp,kw.
137	mononeuropath???.mp,kw.
138	mono-neuropath???.mp,kw.
139	neuralgi*.mp,kw.
140	neuropath*.mp,kw.
141	neuropathic.mp,kw.
142	neuropathies.mp,kw.
143	neuropathy.mp,kw.
144	nocicept*.mp,kw.
145	palliat*.mp,kw.
146	paraesthesi*.mp,kw.
147	paresthesi*.mp,kw.
148	phantom limb?.mp,kw.
149	piriformis muscle syndrome?.mp,kw.
150	polyneuropath???.mp,kw.
151	poly-neuropath???.mp,kw.
152	reflex sympathetic dystroph*.mp,kw.
153	sciatic??.mp,kw.
154	shingles.mp,kw.
155	somatosensory.mp,kw.
156	toothache?.mp,kw.
157	tooth-ache?.mp,kw.
158	or/43-157 [Chronic Pain]
159	42 and 158 [PCP + Chronic Pain]
160	*Data Collection/
161	“Surveys and Questionnaires”/
162	Focus Groups/
163	Health Knowledge, Attitudes, Practice/
164	“Health Services Needs and Demand”/
165	Interviews As Topic/
166	Narration/
167	Needs Assessment/
168	Qualitative Research/
169	content analys*.mp.
170	(data adj1 collect*).mp.
171	(discussion or discussions).mp.
172	focus group*.mp,kw.
173	interview*.mp,kw.
174	(need? adj3 assess*).mp.
175	opinion?.mp.
176	poll?.mp,kw.
177	qualitative*.mp.
178	question???.mp.
179	questionnaire?.mp,kw.
180	self-report*.mp.
181	survey*.mp,kw.
182	(theme or themes).mp.
183	or/160-182 [Questionnaires or Surveys and related terms]
184	159 and 183 [PCP + Chronic Pain + Questionnaires]
185	exp Canada/
186	Canada.af.
187	Canada.in.
188	canadian?.af.
189	british columbia.mp.
190	alberta.mp.
191	saskatchewan.mp.
192	manitoba.mp.
193	ontario.mp.
194	quebec.mp.
195	new Brunswick.mp.
196	prince edward island.mp.
197	nova scotia.mp.
198	newfoundland.mp.
199	northwest territories.mp.
200	yukon.mp.
201	nunavut.mp.
202	or/185-201 [Canada]
203	184 and 202 [PCP + Chronic Pain + Questionnaires + Canada]
204	limit 203 to english language
205	remove duplicates from 204
206	limit 205 to yr = “2020 -Current”

Table 1. A summary of studies on PCPs’ (family physicians, general practitioners, nurse practitioners, and medical learners) perceptions of gaps in treating chronic pain included in the review.

First author, year Study type, Number of participants	Setting/Research theme	Methods	Results
Allen 2011; Pre- and post-intervention survey; 13 physicians, 15 dentists, 26 pharmacists	Interprofessional education (IPE) workshop in Cape Breton, Nova Scotia	Workshop with pre and post surveys evaluating impact of IPE for PCPs to increase self-efficacy in managing patients with CNCP, enhance interprofessional communication, use of local resources, and improve prescribing practices of opioids	Self-efficacy scores were significantly higher after the workshop
			75% of 3-month post workshop respondents reported greater involvement of other health professionals in managing CNCP
			50% of 3-month post-workshop participants reported using local resources with concerns around opioid misuse and 25% reported facilitating contact with addiction services
Allen 2013; Cross-sectional survey; 710 respondents	Canadian FPs’ management of CNCP	Determining FPs’ practices and knowledge in prescribing opioids prior to the release of the 2010 Canadian Guidelines on use of opioids for CNCP	Most FPs practiced in alignment with guidelines in monitoring for adverse events, aberrant behaviour, and advising caution with driving
			FPs did not discontinue opioids even when ineffective
			FPs unaware of ‘watchful dose’ of opioids
			Gaps included access to pharmacy registries in some provinces, and access to pain specialists or addiction services
Baer 2010; Cross-sectional survey; 41 physicians with data on 736 chronic pain patients	Primary care physicians in Southern Ontario	Initial detailed questionnaires were collected to profile usual chronic pain management practices followed by an electronic audit of pain management practices using personal digital assistant technology	Chronic pain patients require considerably more time than patients with other ailments
			PCPs reported needing to make compromises with respect to optimal care of chronic pain
			Barriers included costs, adequate dosing of pain medications, and lack of access to multidisciplinary treatment resources
Baer 2012; Cross-sectional survey; 30 primary care physicians	Canadian primary care physicians	Survey questionnaire of primary care physicians pain management practices compare perceptions of pain patterns versus actual patient results, assess adherence to 2010 recommendations from the Canadian Guideline for Safe and Effective Use of Opioids for CNCP, and document factors influencing physician treatment recommendations	Gaps noted in pain management practices included:
			Non-universal use of validated pain scales despite guideline recommendations
			Underestimation of mixed pain despite common use of multimodal analgesia
			Limited use of non-pharmacological treatments despite patients having private coverage for these treatments
Busse 2020; Cross-sectional survey; 1128 physicians (463 family MDs)	Adherence to/altered practices in response to 2017 Canadian guideline for opioids in CNCP	28-item questionnaire Likert scale question and with opportunity for open-ended responses to some items	Respondents acknowledged resistance by patients, financial barriers to nonpharmacological treatment, lack of availability of nonpharmacological treatment as implementation barriers
			Many respondents noted inadequate time to manage complex cases, lack of access to addiction medicine, and unrealistic to taper some high-opioid dose legacy patients
			Respondents reported increased coverage for chronic pain treatment options by insurers, greater availability to chronic pain treatment services would facilitate guideline implementation
			Suggested CME: managing challenging patients on chronic opioids, instruction on nonopioid options for managing CNCP
			Desired formats for CME were small groups, online courses, or archived videos
Carlin 2017; Qualitative descriptive study; 20 participants	ECHO (Ontario Chronic Pain/Opioid Stewardship) program for managing chronic pain in primary care: aims to increase capacity in managing complex cases in areas with poor access to specialists	Focus group interviews regarding the ECHO model: A tele-mentoring intervention for PCP to enhance pain management skills, combining a didactic presentation by an expert from a “hub” of specialists to PCPs in community and allows a PCP to present a challenging case and receive multidisciplinary guidance on further assessment/management	Participants learned about alternatives to opioid prescribing
			Participants acknowledged challenges in accessing non-pharmacological interventions
			Participants appreciated the support in managing complex patients and they felt less isolated
			Physicians commented they had received little training on pain management and opioid prescribing prior to ECHO
Chow 2017; Needs assessment survey; 162 respondents	Pain management by Canadian FPs for cancer survivors	Determining FPs’ needs in treating chronic pain in cancer-survivors	Most FP reported a lack of knowledge in the management of pain in cancer survivors but were keen to receive medical education on treatment options and clinical practice guidelines Deficits included access to specialists and to non-pharmacology interventions (ex. CBT), cost/coverage of medications, concerns about opioid misuse, knowledge of pharmacotherapy options and stepwise approach to pain management, and lack of time for assessing and treating patients
Clark 2015; Randomized experimental design; 78 PCPs Desveaux 2019; Qualitative study; 22 participants	Telephone consultations with PCPs who referred patients to pain clinics compared to waitlist controls in Calgary, Alberta FPs in Ontario treating CNCP	Patients from a pain clinic waitlist were randomly assigned to usual care or standard telephone consultations, with outcome measures including NRS pain intensity, the Pain Disability Index (PDI), the Short Form (SF)-36 Health Survey, Patient Global Impression of Change scale, Pain Treatment Satisfaction Scale, a PCP satisfaction questionnaire, and a knowledge transfer questionnaire Semi-structured interviews for determining perspectives on opioid prescribing and the barriers/enablers to prescribing opioids for pain	No significant differences were observed between the 2 groups in NRS scores, SF-36, PDI, and Patient Global Perception of Change
			Knowledge transfer related to evidence-based practice of PCPs in the intervention group was between 63.1% and 91.6%
			PCPs reported the telephone consultation was convenient, timely for patient care, an efficient use of time and a useful knowledge transfer strategy
			Beliefs about consequences and capabilities, behavioural regulation and professional role and identity were influential determinants on whether or not a PCP will prescribe opioids
			Most PCPs felt they lacked appropriate answers to assist patients in managing their pain
			Incongruency between usage of opioid guidelines and knowledge of non-pharmacological therapies
			Better communication required among health professionals and with patients about opioids
Desveaux 2019; Qualitative study; 22 participants	FPs in Ontario treating CNCP and prescribing opioids	Semi-structured interviews for determining barriers/challenges in prescribing opioids, surrounding beliefs, and support sources	Discrepancy between PCP training & current practice, tension between PCP & patient expectations
			Influence of length of time in practice and strength of therapeutic relationships on opioid prescribing
			Interventions to address these discrepancies must include changing PCP’s beliefs in their confidence prescribing opioids
			FPs need more support through tailored educational strategies, and shared decision-making with allied healthcare professionals
Furlan 2018; Pre-post intervention study; 170 multidisciplinary participants	ECHO (Ontario Chronic Pain/Opioid Stewardship) program for managing chronic pain in primary care	ECHO model as described above in Carlin 2017	ECHO is a useful template for creating other education programs
			96% of participants were satisfied with ECHO as a learning experience
			Significant increase in self-efficacy
			Significant increase in knowledge
			Enabled best practice dissemination, reduced variations in care, enhanced satisfaction in providing care, improved quality of care, and reduced professional isolation
Furlan 2020; Cross-sectional survey; 265 family physician respondents	Canadian FPs’ management of CNCP and opioid prescribing post-2017 guidelines, update to Allen 2013 survey	Survey assessing self-reported practices of opioid prescribing and knowledge, barriers, and facilitators to adhering to the 2017 opioid prescribing guideline	Wait times to access pain specialist exceeded 1 year in 24% of respondents, and 23% had no access at all
			Knowledge assessment of opioid use revealed physicians averaged 55% correct responses
			Concerns about long-term adverse effects and lack of evidence for use in CNCP major reasons for not prescribing opioids or not using strong opioids
			An average of 66% of respondents adhere to recommended practices while monitoring patients on opioids
			Enablers to opioid prescribing were access to an opioid prescription history from provincial monitoring programs and access to pain/addiction specialists, followed by access to nonpharmacological options
Goodwin 2018; Qualitative survey; Unknown number of participants	Family physicians in Nova Scotia	Semi-structured interviews to determine opioid prescribing patterns, core issues and challenges with respect to opioid prescribing, and what kinds of supports would be helpful	Challenges in prescribing opioids entailed:
			Complexity of CNCP management, physician-patient relationships, concern for diversion, lack of training, and systemic issues (such as wait lists for specialists and cost of pain medications)
			Beneficial supports included:
			Education on CNCP management, prescriber tools such as opioid agreements, and prescriber guidelines
Hassan 2020; Focused group discussion; 20 attendees (5 family MDs, 5 NPs, 1 PA)	Project ECHO workshop participants in Ontario	Focused group discussions on PCPs’ attitudes toward interprofessional care (IPC) and interprofessional education (IPE) on managing patients with CNCP and the impact of ECHO on these attitudes	Physicians viewed IPC/IPE as important for learning aspects of other professionals’ skills
			Negative aspect entailed a difference in communication practices (ex. case presentations) which was felt to slow the progress of time-limited ECHO sessions
			Physicians valued input from non-physician experts in the ECHO hub, with notable learning opportunities
			Participants appreciated belonging to a learning community of practice, even though remote
			Non-physicians realized necessity of IPC/IPE in managing patients with CNCP, found it a good means of acquiring new knowledge around pain management, and for changing interprofessional communication in their practice, while simultaneously providing a venue to have their voices heard
Julien 2015; Cross-sectional survey; 93 FPs	FPs in Northern Quebec	Surveys were sent with an adapted Dillman Total Design Method to assess current and desired knowledge of CNCP and its treatment	Respondents estimated that 25.9% of their patients had CNCP
			Most had taken <10% CME activities involving CNCP in the previous year
			On average, participants perceived a gap between their current knowledge level of CNCP management and desired knowledge level of 28%
Kaasalainen 2007; Cross-sectional survey; 16 NPs	NPs providing primary care in long-term care facilities in Ontario	Survey assessing 33 activities related to pain management, whether they currently performed or should perform said activities, and barriers to fulfilling these roles	81.3% used pain-assessment tools, less than half use clinical practice guidelines
			NPs reported less involvement in prescribing and adjusting pain medications, providing leadership in pain management, or engaging in pain research despite most feeling they should be more involved
			Barriers identified included time constraints, prescribing restrictions, lack of knowledge, difficulties assessing pain (especially in dementia patients), poor collaboration with physicians, and various parties’ reservations about the use of opioids
Lakha 2011; Cross-sectional survey; 148 participants	Tertiary pain clinic referrals made by FPs in Toronto, Ontario	Determining what prompts and limits PCPs from referring their patient with CNCP to a pain clinic	Reasons for referrals included requests for nerve blocks, desire for expertise of the program, concerns about opioid prescriptions, “last resort” for complex patients, medicolegal concerns, or patient request
			Barriers to pain clinic referrals are long wait lists, patient preferences, distance from clinic, language barriers, perceived futility, inability to provide follow-up, or concerns about being prescribed opioids
			Need to promote prompts for PCP to refer to pain clinic
Lalonde 2014; Cross-sectional survey; 137 physicians and 110 pharmacists	PCPs in Laval, Quebec	Participants were sent the KnowPain-50 Questionnaire to assess knowledge attitudes, and beliefs of physicians regarding pain and its treatment, sociodemographic information and previous training, and needs and preferences for a continuing education program	Overall unadjusted mean scores for physicians was 69.3%
			Highest scoring areas included implementation of a treatment plan and general notions of pharmacotherapy and management of analgesic side effects
			Scores were lower in specific patient populations (elderly, those at risk of addiction), specific types of pain (e.g. neuropathic), initial pain assessment, defining goals and expectations, treatment plan development, reassessment and management of longitudinal care, as well as legislative issues
			Physicians acknowledged need for continuing education citing most relevant need for knowledge on differential diagnoses of chronic pain syndromes (71.3%); >40% reported interest in injection-type intervention techniques and indications and referral procedures for pain clinics; 1/3 want training on pain assessment and on physical and psychological follow-up for CNCP patients
			Physicians cited problem-based learning as preferred format, and 1 in 3 would appreciate a day at a pain clinic
Lalonde 2015; Qualitative survey; 6 PCPs (53 multidisciplinary and patient participants)	1-day workshop in Laval, Quebec	Focus and nominal groups to determine challenges and priority interventions in CNCP management and to review current management strategies in primary care, aspects of the chronic care model, and interventions of change	Participants noted knowledge gaps, working in silos, lack of awareness that CNCP is an important clinical problem, difficulties accessing health professionals and services, and lack of patient empowerment
			Suggested interventions include promoting patients’ active participation in their treatment through patient education and log-books/webpages, interdisciplinary approaches, identifying regional experts and training them to disseminate information, defining care paths from primary, secondary, and tertiary care to optimize access to specialized resources, and creating guidelines
Liddy 2016; Cross-sectional study; 93 PCPs (86 family physicians and 7 NPs) Maclean 2017; Qualitative study; 2 primary care physicians Midmer 2006; RCT; 88 participants	Review of all eConsult cases submitted to chronic pain specialists in the Champlain LHIN (Ottawa and surrounding area) Interviews with rural physicians in Newfoundland Online continuing medical education event for FPs on opioid- and benzodiazepine-prescribing for CNCP	Usage data and provider responses to a mandatory closeout survey were analyzed to determine response times, case outcomes, and provider satisfaction Semi-structure interviews focused on barriers to deprescribing opioids and managing CNCP in a rural setting All participants completed a workshop and the intervention group then completed 10 weeks of weekly email case discussion	Median response time to PCP questions by specialists was 1.9 days, and in 74% of cases PCPs received advice suggesting a new /additional course of action
			PCPs were able to avoid referring patients for a face-to-face specialist visit originally planned in 36% of cases and only 44% of eConsult cases resulted in a patient referral
			90% of PCPs rated the service 4 or 5/5 for overall value for patients, and 92% rated it 4 or 5/5 for value to providers
			Study underscores trend in eConsult ability to deliver prompt access to specialist care, possibly reduce pain clinic wait times, and improve patient safety
			Barriers identified include system-related barriers such as addiction treatment and pain clinics, lack of training in pain management and opioid deprescription, lack of interdisciplinary teams
			Web-based learning through email case discussions were helpful, inexpensive and an informal way of continuing medical education albeit most likely helpful in specific and concrete clinical behaviours
Petrella 2006; Pre-post intervention study; 659 participants	Joint Adventures program (1-day workshop) offered in 9 out of 10 Canadian provinces	The combination of script concordance (similar to PBL) + continuing medical education program were used to assist family doctors in acquiring knowledge, skills and tools to improve their management of musculoskeletal disorders	Pre-test found knowledge gaps between level of information participants had before the workshop compared to the level they would like to have
			Specific knowledge items included: differentiation of pain source from inflammation vs. mechanical pain, diagnostic tests, treatment, risk with NSAIDs, exacerbation of pain, and how to utilize community resources
			Qualitative responses identified that changes to clinical practice included more use of complementary therapy, avoidance of NSAIDs, better history and physical exams, and more aggressive pain management
			High degree of satisfaction among participants
Poulin 2018; Quality improvement initiative using a cross-sectional design; 194 PCPs Rice 2018 Qualitative study; 13 medical students and residents	PCPs referring patients to a tertiary pain clinic in Ottawa Interviews with medical students and residents in Toronto, Ontario	Pain consultation requests reviewed for wait-listed patients appropriate for electronic consultation were contacted for consideration of eConsult and a cross-sectional survey was used to analyse outcomes Interviews focused on their experiences treating patients with chronic pain	26% indicated they would use eConsult, 8% indicated their patient could be removed from the clinic waitlist
			Of patients that physicians indication they would use eConsult for 35% subsequently had an eConsult submitted
			Subsequent monthly volumes of eConsult submissions increased
			39% of reviewed PCP referral questions could be at least partially addressed through electronic consulation and may in future reduce wait times for tertiary pain care
			Physicians’ opinion about patients with chronic pain increasingly negative, leading to a decline in empathy
			Subjective nature of chronic pain makes it difficult to evaluate and doctors feel frustrated because of their inability to cure chronic pain (doctors feel defeated by these patients)
			Chronic pain patients lack educational value (preceptors shielded their students from exposure to these kinds of patients during training)
			Medical students need the opportunity to reflect on the skills that are required to provide patient-centred care for this population
Roy 2017; Cross-sectional online survey; 1092 physicians (653 FPs)	An online survey of physicians in Quebec in 2015	Insight on FPs’ concerns, practices, and needs with respect to the management of CNCP	FPs rated their academic training on pain as poor and expressed a desire to have a continuing education program to feel more confident treating CNCP
			Training needs identified included patient evaluation and differential diagnoses of chronic pain syndromes, alternatives to opioid management, monitoring pain, and evaluating and managing risks of abuse, misuse, tolerance, dependence, and diversion
			Access to free telephone or online consultation service with a medical expect was considered useful as reinforcement and as a supportive measure
			Prescription monitoring programs were deemed important for patients who use opioids
Squire 2009; Cross-sectional survey; 20 PCPs	PCPs in BC surveyed by questionnaire	Physicians participated in a 3-month pilot project in chronic pain management involving a one-day symposium, online learning, discussion/case presentation, blog and optional mentorship	Physicians rated the symposium most effective and the online learning least effective program component due to time constraints
			Top-ranked topics included assessment tools and sensory evaluation of neuropathic pain
			Time-sensitive pain assessment and outcome measurement tools affected most practice change
Webster 2019; Qualitative study; 19 primary care clinicians and 8 nurses	PCPs in urban, rural, and Northern settings in Ontario	Interviews with physicians focused on the question “How do PCPs describe the work they do in caring for patients with complex chronic conditions?” for 30-90 minutes for a total of 61 formal, semi-structured interviews, along with 40 hours of observational data in clinical settings by shadowing PCPs daily work in caring for complex patients	Themes identified include:
			dealing with substantial socioeconomic status disadvantages
			disjuncture between patients’ hopes and expectations for pain management and the reality of what physicians can provide (especially in current pressures to restrict opioid prescriptions)
			saying no to patients
			difficulties testing, measuring or accurately evaluating pain in absence of clear biomarkers
			limited access to non-pharmacological health services/supports
			difficulties engaging patients in lifestyle modification
Webster 2019; Qualitative study; 51 PCPs	PCPs in urban rural, and Northern settings in Ontario	Interviews examined patient complexity from PCPs viewpoint and asks about the utility of defining patient complexity as multimorbidity	Findings included: poverty, mental health issues, and history of trauma rendered patients more complex interventions needed by such patients exceeds the scope of medical expertise and social issues complicate otherwise potentially straightforward medical problems, especially in chronic pain patients
Weinberg 2010; Cross-sectional survey; 190 PCPs Wingert 2020; Cross-sectional survey; unknown number of participants	Surveys completed at CME events in Canada Surveys sent by email to practicing physicians, NPs, and residents in Saskatchewan	Multiple choice questions regarding prevalence of chronic pain, screening for opioid misuse risk, acetaminophen dosing, risk factors for NSAID-induced GI events, and codeine metabolism Survey with questions to evaluated burden of CNCP to providers, identify competencies/deficiencies, barriers to care, and resources needed to improve CNCP in Saskatchewan	Majority of respondents not aware of chronic pain prevalence
			Lack of awareness on adverse effects of various medications commonly used in primary care
			Only 18.3% use validated opioid misuse risk tools to screen and 20.3% do not screen patients at all for opioid risk
			Confidence with managing opioid rotation and tapering was 51.7% and 65.3% respectively
			Confidence with managing primary and secondary pain conditions were 60.5% and 75.5%
			Barriers identified include financial barriers, lack of time for patient education, and lack of access to a pain specialist or interdisciplinary pain specialists

CNCP: Chronic Non-Cancer Pain; ECHO: Extension for Community Healthcare Outcomes; NSAIDs: Non-steroidal Anti-inflammatory Drugs; FPs: Family Physicians; LHIN: Local Health Integration Network; PCP: Primary Care Physicians; PBL: Problem-based Learning; RCT: Randomized Controlled Trials; WSIB: Workplace Safety and Insurance Board.

Figure 2. Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram of study selection process.

Table 2. Scoping review inductive coding and emerging themes.

Categories	Subthemes	Themes
Inconsistency/limited experience in applying validated instruments for assessing pain	Improving pain assessment and appropriate pharmacological management	Pain medicine competencies and practices
Difficulty in assigning differential diagnoses for etiology of pain
Uncertainty about choosing first-/second-/third-line analgesics
Transition from pro-opioid CNCP management to deprescribing with new opioid guidelines	Advancing opioid prescribing and deprescribing strategies
Opioid prescribing skills, screening, and attitudes toward prescribing
Limited use of allied health such as physio- and psychotherapies in managing pain	Nonpharmacological interventions to manage pain
Absence of multidisciplinary care leading to professional isolation in managing pain	Challenges in building interprofessional collaborations	Interprofessional collaboration
Impact of exposure to interprofessional education on improving multidisciplinary care
Lack of clearly defined referral and care paths	Deficits in local and regional resources
Long wait times to access resources for care
Physicians find it difficult to trust patients’ pain reports when opioids are prescribed	Therapeutic relations between PCPs and patients with CNCP	Attitudes and therapeutic relationships
Stress on PCPs in managing mental health and complex social needs of patients with CNCP
Difficulties with time management when treating patients with CNCP
Lack of exposure to CNCP treatment options in medical and nursing school curricula	Deficits in training PCP trainees in managing CNCP
Absence of comprehensive training programs for managing CNCP
Continuing education via tele-mentoring (ECHO), online modules, workshops/conferences		Strategies to reduce gaps in care
Benefits of telephone/virtual consultation services for care of patients with complex CNCP
Systemic improvements to streamline access to tertiary pain care centers

Table 3. Deductive coding for the scoping review using the CANMeds framework.

		Medical expert	Communicator	Collaborator	Leader	Health advocate	Scholar	Professional
Themes	Subthemes
Pain medicine competencies and practices	Improving pain assessment	Pain assessment, use of validated tools	Creating reliable virtual platforms for discussing challenging scenarios				Further research into effective continuing education delivery models
	Advancing opioid prescribing and deprescribing strategies	Supporting the transition of practice guidelines, opioid deprescribing
	Nonpharmacological interventions to manage pain	Increased use of allied health supports
Interprofessional collaboration	Challenges in building interprofessional collaboration			Tele-mentoring (e.g., ECHO), optimizing use of physio- and psychotherapy
	Deficits in local and regional resources			Virtual consultation	Developing local/regional resources for care with primary, secondary, and tertiary pain centers of expertise	Streamlining referral pathways	Availability of in-person or virtual training for updates in pain medicine
Attitudes and therapeutic relationships	Therapeutic relations between PCPs and patients with CNCP		Knowledge transfer and communication between tertiary pain centers and PCPs			Enhancing access to resources for improving mental and social health		Early exposure to CNCP in medical training to shift negative attitudes toward CNCP
	Deficits in training PCP trainees in managing CNCP	Integrating pain medicine in medical and nursing schools’ curricula
Strategies to reduce gaps in care		Enhancing pain curriculum in both undergraduate and postgraduate programs	Increasing means by which PCPs can obtain supports in addition to traditional consults via e-consult and telephone consultations	Knowledge transfer through effective use of various technology mediums and shared care models	Sharing expertise between pain centers and primary care	Streamlining referral pathways	Continuous reevaluation of strategies trialed moving forward to foster lifelong learning in the profession	Initiatives such as Project ECHO to increase empathy and confidence in caring for patients with CNCP