Priority interventions to improve the management of chronic non-cancer pain in primary care: a participatory research of the ACCORD program

Figures & data

Figure 1 Workshop schedule and descriptions of activities.

Abbreviations: min, minutes; CNCP, chronic non-cancer pain.

Table 1 Order of domains of the Chronic Care Model discussed in each focus group

Focus group	Delivery system design	Decision support	Clinical information systems	Self-management support	Community resources and policies
Physicians	1st	2nd	3rd
Pharmacists	1st	2nd	3rd
Nurses	1st	3rd		2nd
Physiotherapists	1st			3rd	2nd
Psychologists	1st			3rd	2nd
Pain specialists	1st	2nd	3rd
Patients and family members	1st			2nd	3rd

Table 2 Participants’ characteristics

	Physicians	Pharmacists	Nurses	Physiotherapists	Psychologists	Pain specialists	Patients	Family members	Decision makers	Pain researchers
Number (n)	6	6	6	6	6	6	3	3	4	7
Sex, women, n (%)	3(50)	5(83)	6(100)	1(17)	5(83)	5(83)	2(67)	2(67)	1(25)	6(86)
Practice type (n)
Medical clinic	3	–	2	–	–	–	–	–	–	–
GMF/UMF	2	3	2	–	–	–	–	–	–	–
CLSC	–	–	–	–	1	–	–	–	–	–
Hospitals	1	–	–	2	4	6	–	–	–	–
Private clinics	–	–	–	4	1	–	–	–	–	–
Pharmacies	–	2	1	–	–	–	–	–	–	–
Pharmaceutics	–	1	1	–	–	–	–	–	–	–
Ministry of health	–	–	–	–	–	–	–	–	1	–
Health agency	–	–	–	–	–	–	–	–	3	–
Region (n)
03 – Capitale Nationale (Quebec)	–	–	–	1	–	–	–	–	2	–
04 – Mauricie	–	–	1	–	–	–	–	–	–	–
05 – Estrie	1	–	–	–	2	2	–	–	1	1
06 – Montreal	2	2	2	4	1	4	2	1	–	5
08 – Abitibi-Témiscamingue	–	–	–	–	–	–	–	–	–	1
11 – Gaspésie-îles-de-la-Madeleine	–	1	1	–	–	–	–	–	1	–
12 – Chaudière-Appalaches	–	–	–	–	1	–	–	–	–	–
13 – Laval	–	3	2	–	–	–	1	2	–	–
15 – Laurentides	–	–	–	1	1	–	–	–	–	–
16 – Montérégie	3	–	–	–	1	–	–	–	–	–

Abbreviations: CLSC, Centre local de services communautaires (local community services center); GMF/UMF, Groupe de médecine familiale/Unité de médecine familiale (family medicine group/family medicine unit).

Table 3 Challenges in the management of chronic non-cancer pain in primary care, grouped by dimension, with illustrative participants’ quotes for each dimension

Dimension	Quotes
Knowledge gap
Poor knowledge and lack of training on pain Lack of valid assessment tools Lack of clear treatment protocol	“Primary care does not understand what specialists ask, and patient is caught in this mess.” [Pain specialist] “Physicians are not aware of chronic pain because it is unfamiliar to them and because they don’t have the knowledge; they seem uncomfortable and helpless. The question of training is in my opinion a key element that should be further developed in primary care.” [Researcher] “There are very good screening questionnaires, but people don’t know about them.” [Nurse] “There are [treatment protocols], but they are not well known. The college [of physicians] produced three documents on chronic pain in the last 4–5 years. When you look at the appendices, many could definitely be used, and people don’t use them.” [Primary care physician]
“Work in silos”
Lack of time and resources for physicians Lack of communication Difficulties in managing the medical record	“The main obstacle for me is [lack of] time and isolation. I feel alone working in my office and caring for those patients. Lack of connections with everything: tools, community network, professional network, other physicians.” [Primary care physician] “There is no one linking with family physician, like a care manager, informing patient, coordinating patient care.” [Pain specialist] “I find the multidimensional aspect that comes with chronic pain is not addressed. Following-up on chronic pain cases in private practice is, for me all alone, extremely difficult.” [Psychologist] “It takes a shared electronic file, including the list of medications that have been tried, with failures and secondary effects, to prevent repeating errors. It would also help physicians.” [Nurse] “For the pharmacists to really do their job, they need to have access to diagnoses, laboratory results, and intentions to treat.” [Pharmacist] “I think the problem is record management […] Either we don’t do it, or we don’t do it adequately.” [Primary care physician]
Lack of awareness regarding chronic non-cancer pain
Little or no societal and clinical recognition of pain as a disease	“For many people who do not have chronic pain, the concept of chronic pain is something quite cranky. It is not science. I think perceptions of it are blurred, unproven, unaccepted. We feel it is untrue: those people are not truly suffering. And that’s what patients tell us, they are not believed.” [Primary care physician] “We don’t like to spend time assessing pain: it takes long and it is boring hearing someone in your office saying ‘Oh, I don’t sleep well, and I am not able to do this and that […]’, etc.” [Nurse]
Difficulties in access to health professionals and services
Lack of care paths Lack of information on resources	“Getting to see a specialist takes time. And you see your husband suffering – he can’t be sitting for long. And seeing him suffering, he’s chronic, it’s been going on for a long time.” [Family member] “What is difficult for us, when we need expertise, we can’t access. When we want to send the patients to an expert or to a team who can make an assessment – because we have tried many things we thought could help, and they didn’t work, we haven’t access.” [Primary care physician]
Patient empowerment needs
Patient isolation Lack of community resources Lack of awareness of existing community resources	“Last week, I read an article on fibromyalgia. It was such a relief to read about a public people with a context of chronic pain. It was comforting because I was feeling like I am not alone on this planet.” [Patient] “We have just talked about support and isolation. Well, I think it is the case. There is a need to get together, and not to feel all alone.” [Psychologist] “We have to give patients a sense of being in control again.” [Nurse] “I often realize when patients come to the pain clinic that no one has taken time to explain many things, occupational therapy, posture, self-management of medications. And they are waiting for someone to save them.” [Physiotherapist]

Table 4 Priority interventions identified grouped by intervention theme, with total score, votes and illustrative participant’s quote for each priority intervention

Intervention themes	Total score (votes)	Quotes
Interdisciplinary continuing education
Provide multidisciplinary clinical teams with uniform, standardized continuing education program on chronic non-cancer pain (CNCP) (eg, know-how, skills)	991 (37)	“Training must address how we work together, what teamwork is and who will take the lead over the intervention. After that, the role of each individual.” [Primary care physician]
Provide standardized tools for synthesis and follow-up to be filled out by clinicians and patients to consistently transfer information in a shared language	775 (37)	“We need an interdisciplinary electronic record, accessible to diverse clinicians, interfaced.” [Pharmacist] “When patient would forget pain logbook, it would be no problem, it would be computerized.” [Pharmacist]
Enhance clinical expertise by providing a bank of information shared with all clinicians and patients (eg, website)	291 (19)	“We should have an electronic decision-support tool; 1 can’t believe we are starting again to look in the books. We need an e-library, if you’re querying arthritis, you have the latest guidelines, tools for patients etc.” [Nurse]
Interdisciplinary approach
Train care managers in pain management	442 (22)	“There should be pain management nurses in primary care. We should be able to intervene more efficaciously, and we should also involve and educate patients, remind them, and check for secondary effects.” [Nurse]
Develop an accessible and affordable approach to interdisciplinary collaboration	330(18)	“Quite often, when physicians practice in silos, they let go those patients. It goes a lot better when physicians do interdisciplinary practice, we share the follow-up of patients with multiple challenges, and thus it frees up physician time.” [Nurse]
Widen the range of professional responsibility of clinicians (other than the physician) to overcome bottlenecks and increase efficiency	313 (16)	“Shared care, physiotherapist should be able to prescribe radiographies, and certain anti-inflammatory medications. Bill 90 allows nurses to do many things.” [Physiotherapist]
Perform psychosocial assessment at the moment chronic pain is diagnosed	125(6)	“There should be a psychosocial assessment. It would allow orienting […] because psychosocial events often taint patient’s reaction to treatment or to events.” [Psychologist]
Regional expert
Identify regional experts and train them to disseminate information and support clinicians	551 (30)	“Just like we did in palliative care, we appointed a regional physician in charge, who takes on regional leadership. He reaches for expertise. There has to be regional leadership instead of saying ‘the Health Agency will do it’. The Health Agency is no one, it’s a building.” [Primary care physician]
Care path
Define roles and responsibilities of primary, secondary, and tertiary care and establish care paths to improve access to specialized resources in CNCP treatment	599 (25)	“Service corridors must be made between two departments, and be supported by both Health Agencies that have come to sit and listen to each other. One receives, one refers, and one refers back, so there must be agreements between departments.” [Primary care physician]
Self-care support
Promote the active participation of patients in their treatment through education adapted to their needs (eg, aggravating factors, self-management of pain, alternative therapies)	312(16)	“I answer [other patients’] emails. I tell them they must not stay in bed, they must continue exercise, see their doctor, and we don’t speak of curing chronic pain, we speak of soothing. The objectives must not be too high, and we still must have objectives. And you have to go smoothly with exercising so that people don’t opt out.” [Patient]
Establish a paper or web logbook for patients and clinicians	272(17)	“They are given digital instruments. They fill out a logbook of their day and their medication use. I cannot work without the patient.” [Primary care physician]
Specific guideline
Systematically assess pain as the fifth vital sign	30(2)	“People speak a lot of the four vital signs and in my opinion there should be five: pain is the fifth … Then it would be important to formalize it and to have a systematic assessment model.” [Nurse]

Table

Clinical vignette 1	Clinical vignette 2
Mrs Collette Comeau, aged 45, is married and has a full-time position as a medical archivist. She has two children, aged 8 and 12. Her husband is a pharmaceutical representative and has to spend many days a week away from home. Mrs Comeau has been suffering from fibromyalgia for 20 years. Pains spread over her whole body; they appeared without any precise causal event. She suffers from pains every day. On a scale from 0 to 10 where 0 represents “no pain” and 10 represents the “worst possible pain”, her average pain level is about 5 and varies from 0 to 7 depending on the time of day; it is weaker in the morning and increases throughout the day. Her pains considerably disturb her sleeping, and wake her up suddenly almost every night. Her pains interfere with her daily activities. She is often irritable, which interferes with her relationships with others. At work, she is not always fully efficacious, and she stays home about 10 days a year. She often refuses to participate in social and entertainment activities because of her pain. Mrs Comeau wants to remain independent. She often hesitates to ask for help. She does not believe she has power over her pain. Still, she believes her medication helps and medicine could perhaps one day completely relieve her pain.	Mr Jacques Levasseur, aged 68, is widowed and retired. He lives alone at home. He has three children and seven grandchildren who occasionally come to visit him. He suffers from arthritis for 10 years already. His pain is in all his joints, in particular in his knees. Although he always feels some pain (about 2 on a scale of 0 to 10), pain is not constant. Many times a week, pain becomes very acute, up to 9. His pain particularly interferes with walking and doing house-keeping tasks. Pain often prevents his sleeping and makes him sullen. His sudden mood swings affect his relationships with others. He often refuses to participate in social activities. Before pain appeared, he loved to play golf. Now, he does not dare play anymore, because he is afraid pain will worsen if he walks much. Mr Levasseur has little hope of one day being totally relieved. He often feels helpless, and useless.
Medical history	Medical history
➢ Pain control strategies  ○ Psychotherapy, several years ago  ○ Distraction techniques a few times a week  ○ Yoga twice a week ➢ Medical follow-up  ○ Family physician  ○ Not followed-up by a specialist physician  ○ No consultations for physiotherapy, ergotherapy, massotherapy, or chiropractic ➢ Medications  ○ Herbal tea for constipation  ○ Antiemetic medication (against nausea)  ○ Anti-acid medication (against heartburn) ○ Fentanyl patches (75 μg every 2 days) and 150 mg of pregabalin every day	➢ Pain control strategies  ○ Relaxation techniques ➢ Medical follow-up  ○ Family physician  ○ Has already consulted physiotherapists, occupational therapists, chiropractors, and osteopaths, without success ➢ Medications  ○ Acetaminophen a few times a week  ○ Muscle relaxant  ○ Anti-inflammatory medication (Celebrex 200 mg)