DSEN Abstract
A rapid review of best practice guidance of the management of chronic pain and concurrent mental illness and/or substance use disorders

What is the issue?

In 2018, the World Health Organization 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 and/or substance use disorders.

Summary

  • High quality evidence best practice guidance is lacking for the management of chronic pain and concurrent mental illness and/or substance use conditions.
  • 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 disorders, CPGs included recommendations focused on timing of intervention delivery, effective interventions, types of care, and risk/benefit considerations. Recommendations against certain interventions (e.g., ziconotide, opioids) were also noted for certain comorbid mental health and substance use disorders.
  • Review findings suggest that the exclusion of individuals with chronic pain and concurrent mental health and/or substance use disorders from primary studies may be a contributing factor to the lack of systematic review and CPG evidence available.

Authors: Danielle Rice, Dianna Wolfe, Mona Hersi, Leila Esmaeilisaraji, Claire Butler, Candyce Hamel, Nadera Ahmadzai, Becky Skidmore, Pauline Barbeau, Brian Hutton

For more information, please contact Brian Hutton, bhutton@ohri.ca.

What was the aim of the study?

The following review questions were addressed:

  • What do best practice guidelines, overview of reviews, overviews of guidelines, network-meta-analyses, and meta-analyses recommend for the management of chronic pain and concurrent mental health 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 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, network meta-analyses, and meta-analyses of randomized controlled trials, that focused on individuals with chronic pain, including individuals with comorbid mental health and/or substance use disorders. 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 health disorders and/or substance use conditions. We extracted recommendations from CPGs and conclusions from overviews, meta-analyses, 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?

  • Five CPGs, one meta-analysis, and one overview of reviews were included.
  • All included CPGs were developed for medical conditions. No CPGs developed for mental health or substance use disorders met quality criteria and included recommendations for managing chronic pain.
  • There were no eligible network meta-analyses that focused on our population of interest and only one subgroup analysis of a single meta-analysis was eligible for inclusion.
  • Recommendations for mental health diagnoses were generally high level (e.g., “provide medical management”) and not specific (e.g., provide a trial of selective serotonin reuptake inhibitors).
  • Recommendations were related to effective interventions and interventions that pose risks, timing of intervention delivery, types of care, and risk/benefit considerations.
    • Recommended interventions included pharmacotherapy (e.g., opioid agonist treatment), psychological care (e.g., mental health intervention), and approaches to care delivery (e.g., weaker potency opioids and immediate release formulations).
  • There was a notable presence of interventions that were not recommended, with less guidance focused on specific interventions for managing chronic pain and concurrent conditions.
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