DSEN Abstract
A Rapid Review of Best Practice Guidance of the Management of Chronic Pain and Concurrent Mental Illness and/or Substance Use Disorders
This research was funded by CIHR- Drug Safety and Effectiveness Network
Summary
- High quality evidence is lacking for the best practice guidance for managing chronic pain and concurrent mental illness and/or substance use conditions.
- For managing chronic pain and concurrent mental illness or substance use conditions, a better understanding of the specific interventions to deliver versus what not to deliver is needed. Given the presence of broad recommendations and interventions that are not recommended for individuals with chronic pain and concurrent conditions, additional guidance for interventions that are effective within this complex population is necessary.
- For individuals with chronic pain and comorbid mental health conditions, CPGs included recommendations of providing psychological care multidisciplinary care, and the tailoring of interventions based on the mental health condition. Recommendations against the use of ziconotide, and implantation and use of a dorsal root ganglion stimulator were also noted. The importance of considering the eligibility of people with chronic pain for intrathecal drug delivery was also highlighted.
- Future systematic reviews may provide a greater breadth of available evidence through focused searching for studies related to the treatment of mental illness or substance use conditions in the context of chronic pain.
Authors: Danielle Rice, Dianna Wolfe, Mona Hersi, Leila Esmaeilisaraji, Claire Butler, Pauline Barbeau, Becky Skidmore, Brian Hutton
For more information, please contact Brian Hutton at bhutton@ohri.ca.
What is the issue?
In 2018, the WHO and an international working group developed a definition and classification system for chronic pain, thereby advancing the recognition of chronic pain as a health condition, in its own right. People living with chronic pain are at an increased risk of mental health conditions such as depression and anxiety, decreased cognitive function, reduced health (e.g., fatigue, disability), and impairments in social functioning. These impairments can further perpetuate the presence of mental health symptoms. Stigma associated with chronic pain and reluctance from healthcare providers to deliver specific interventions, such as opioids, can further complicate treatment efforts, potentially resulting in the development of problematic substance use and an undertreatment of chronic pain. We conducted a rapid review to determine best practices for managing chronic pain in the context of mental health or substance use conditions.
What was the aim of the study?
The following review questions were addressed:
- What do best practice guidelines and knowledge synthesis articles recommend for the management of chronic pain and concurrent mental health conditions and/or substance use disorders?
- What agreement and divergence exists between recommendations for the management of chronic pain in the context of concurrent mental health conditions and/or substance use disorders?
How was the study conducted?
Ovid MEDLINE, including Epub Ahead of Print and In-Process & Other Non-Indexed Citations, Embase Classic + Embase, and PsycINFO were searched in 2020 for clinical practice guidelines (CPGs), overviews of reviews/umbrella reviews, overviews of guidelines, and network meta-analyses that focused on individuals with chronic pain, including individuals with comorbid mental illness or substance use conditions. Studies were included if they: (1) met criteria of a high-quality CPG or systematic review; (2) were conducted or published in Canada, the USA, the UK, or Australia, or were international or European clinical practice guidelines; and (3) were available in full text in either English or French. Interventions of interest included pharmacologic, psychological, physical, self-management, and multidisciplinary interventions to manage chronic pain among patients with concurrent mental illness or substance use conditions. We extracted recommendations from CPGs and conclusions from overviews and network meta-analyses regarding the interventions of interest. Extracted data were collated and synthesized, with similar recommendations and messages grouped to demonstrate where agreement existed.
What did the study find?
- Nine high-quality CPGs and two high-quality overviews were included.
- CPGs more commonly presented recommendations for mental health conditions rather than SUD; however, recommendations were generally high level (e.g., “provide psychological care”) and not specific (e.g., provide psychotherapy, such as cognitive behavioural therapy).
- Recommendations were provided related to timing of intervention delivery, interventions that were and were not recommended, types of care, and risk/benefit considerations.
- Recommended interventions included pharmacotherapy (e.g., opioid agonist treatment), psychological care (e.g., psychological support), physical interventions (e.g., transcranial direct current stimulation), and approaches to care delivery (e.g., multidisciplinary care).
- There was a notable presence of recommendations for what NOT to do, with less guidance of the best practice management for individuals with chronic pain and concurrent conditions.
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