Opioids and Pain Management
Canada is facing an unprecedented opioid-related public health crisis that is affecting every community across Canada, and people from all walks of life. While the reasons for the crisis are multi-fold, opioids have quickly emerged as one of the primary means for managing acute and chronic non-cancer pain in primary care settings. Canada is the second highest opioid prescribing nation in the world, with 22 million prescriptions for opioids dispensed from Canadian community pharmacies in 2016 (CIHI, 2017). A recent review suggests that 8-12% of people who are initiated into opioid therapy for chronic pain develop an addiction. The potential for long-term opioid use increases after as few as three to five days of prescription therapy. Many illicit opioid users transitioned from prescription painkillers. One of every 550 patients started on opioid therapy has died of opioid-related causes in a median of 2.6 years after their first prescription was written. (CSEPM, 2017).
In response to the crisis, the Government of Canada has made tackling the opioid crisis a priority, by calling on partners to sign a Joint Statement of Action to Address the Opioid Crisis: A Collective Response. CAOT was one of the signatories of the JSA.
The Canadian Association of Occupational Therapists (CAOT) recognizes that while opioids and other non-opioid pharma must remain available to those who need them, non-pharmacological treatment and interventions in pain management are critical to reducing reliance on opioids. To date, solutions to address opioid use have been focused on addictions, treatment, harm reduction (i.e. supervised drug-use sites, overdose prevention sites), and enforcement. There has been little attention paid to prevention through increasing knowledge and raising awareness about non-pharmacological interventions, such as low cost, high-impact occupational therapy services. Integrating equitable access to non-pharmacological pain management interventions within essential health care, is a key response to Canada’s opioid crisis.
By understanding an individual’s pain experience, occupational therapists can implement an appropriate combination of treatment strategies to address the physiological, psychological and social aspects of pain and provide an effective alternative or complement to pain management. Despite the clinical effectiveness of non-pharmacological pain management interventions, there is a gap in accessing alternatives to opioids. While opioids are covered in most public and private health benefit plans, occupational therapy benefit coverage is patchy at best, and many are left with little or no coverage. Other health professionals may not refer individuals to occupational therapy due to the financial implications for their clients/patients. This lack of coverage results in individuals failing to experience the benefits of occupational therapy to address pain management and may result in the use of opioids as the only perceived solution to treat chronic pain.
The inclusion of OTs on all inter-professional primary care teams allows Canadians to receive the care they need through a variety of modalities that includes non-pharmacological solutions.Recent initiatives
The Coalition for Safe and Effective Management released their final report “Reducing the Role of Opioids in Pain Management.” It outlines a series of strategies and recommendation for Canada’s health care system to optimize safe and effective non-pharmacological treatments that could reduce the use of opioids as a first-line treatment for non-cancer pain.
- In response to a call from the Federal Minister of Health, CAOT joined 12 other health professions and research bodies to help to address opioid misuse by identifying potential ways forward that optimize non-pharmacological pain management alternatives in Canada. The Coalition for Safe and Effective Pain Management (CSEPM) was tasked with looking “upstream” to understand why opioids are being prescribed, and to look at the prevention aspect of the opioid crisis. As the basis for its recommendations, the Coalition supports an interprofessional, evidence-informed, patient-centred approach to pain management that is compassionate to those in pain and does not stigmatize current or future opioid users. (CSEPM Interim report, 2017)
- As part of the interim report, CAOT provided three specific non-pharmacological occupational therapy interventions:
- Occupational Therapy Using the Biopsychosocial Approach;
- Occupational Therapy to Support Relapse Prevention; and
- Splinting to Reduce Upper Extremity Pain.
- CAOT developed and shared two occupational therapy policy options for the Canadian health care system that could reduce the impact of opioid use:
- Inclusion of Occupational Therapy Services in Extended Health Benefits Plans; and
- Inclusion of Occupational Therapists on All Inter-Professional Primary Care Teams.
- CAOT attended CSEPM in-person meetings to discuss key messages and strategic directions of CSEPM’s final report, to be released in 2019.
- CSEPM provided a written submission to the Health Canada Pharmacare consultation with the following recommendations:
- Recommendation #1 – Develop and use a strategic approach to increase access to non-pharmacological therapy for pain management in conjunction with a National Pharmacare plan; and
- Recommendation #2 – A National Pharmacare plan should not cover its costs through the taxation of workplace benefits.
- As a member of CSEPM, CAOT hosted workshops on non-opioid interventions for pain management, such as:
- “Best Practice Chronic Pain Management and Assessment for Occupational Therapists”; and
- “Occupation and Trauma: Expanding Occupational Therapy Practice”
- CAOT released related publications:
- Licit, Illicit, Prescribed: Substance Use and Occupational Therapy (Niki Kiepek 2016);
- Coping Strategies for Occupational Engagement and Recovery: A Program Manual for Occupational Therapists and Other Care Providers (Mary McNamara and Theresa Straathof 2017).
- Advocate for occupational therapy as a means of pain management focusing on approaches that include promotion, prevention, and alternatives to opioids, including non-pharmacological solutions by OTs.
- Include occupational therapy services in workplace extended health benefits plans.
- Promote the inclusion of OTs on all inter-professional primary care teams.
Occupational therapy value proposition
- Pain management has been clearly identified as a role for OTs in primary care (McColl & Dickenson, 2009; AOTA, 2014; CAOT, 2013). OTs are able to provide individuals with practical, simple pain management interventions that can be done at home or with intermittent supervision before referral for extended interventions (Muir, 2012) or prescription of opioids, thereby decreasing health care costs and possibly the rate of opioid prescription.
- A primary care team is an environment that is well-suited for OTs to adopt a preventive and forward-thinking approach (Lapointe et al., 2013), which is necessary to effectively manage pain and prevent and/or reduce opioid use for those who are currently using opioids.
- OTs work in a variety of settings, including in hospitals, communities, and rehabilitation settings, homes, local community and workplace which allows them to complete a full, comprehensive assessment that assists in the personalizing and tailoring of interventions related to pain management.
- OTs, within primary care settings, have the ability to work with individuals over an extended period, on an ongoing basis, which can help foster the development of trust between the OT and their clients (Lapointe, James & Craik, 2013). This relationship assists OTs in understanding an individual’s needs related to pain management, including current patterns of opioid use (if applicable), and allows for the implementation of interventions tailored to match the individual’s ever-changing needs.
- Occupational therapy supports relapse prevention; OTs support clients by engaging them in activities that lead to health while serving as a distraction from cravings, alleviation of boredom, and providing a sense of purpose, meaning and well-being. These are factors that contribute to relapse prevention of opioid use for pain management.
- Occupational therapy was the only category of health spending within hospitals where increased spending resulted in reduced re-admission rates (Rogers, Bai, Lavin & Anderson, 2016). Study results link these lower readmission rates to the OT focus on assessing whether a client can be discharged safely and addressing potential barriers. Through focusing on patient factors outside of the hospital, including living situation, and social supports, OTs are well positioned to address risk factors for readmission.
- A study by the Royal College of Occupational Therapists (2016) identified that occupational therapists’ services resulted in avoidance of unnecessary hospital admission and/or reduced hospital stays, saving an average of $15M annually.
- OTs provide several interventions to address pain management that have the potential to minimize existing opioid use, and potentially reduce the number of new opioid users. Involving OTs early in the pain management treatment process has the potential to prevent reliance on opioids and/or development of opioid dependence.