Opioid prescribing within the workers’ compensation system in general has been a cause for concern. The objective of the study was to estimate the prevalence of opioid users among injured workers, referred at a Tertiary Care Pain Clinic, in 2008-2009. A cross-sectional retrospective study of 110 consecutive workers; male/female ratio was 2.3:1; mean age 45.5 years; mean pain ratings were 7.1±1.8. 21% of the workers were diagnosed with a biomedical problem (Group I), 51% with medical/psychological factors (Group II) and 25.5% had identifiable psychological factors but no physical pathology (Group III). Opioids were prescribed in 81.8%; of those 32.2% were on >200mg of daily morphine or equivalent (MED). A higher proportion of opioid users were in Group II and Group III than Group I. The vast majority of referred injured workers in this study were on opioid therapy with 1 in 3 exceeding the “watchful” dose of 200 mg MED

Opioid prescribing within the workers’ compensation system in general has been a cause for concern. The objective of the study was to estimate the prevalence of opioid users among injured workers, referred at a Tertiary Care Pain Clinic, in 2008-2009. A cross-sectional retrospective study of 110 consecutive workers; male/female ratio was 2.3:1; mean age 45.5 years; mean pain ratings were 7.1±1.8. 21% of the workers were diagnosed with a biomedical problem (Group I), 51% with medical/psychological factors (Group II) and 25.5% had identifiable psychological factors but no physical pathology (Group III). Opioids were prescribed in 81.8%; of those 32.2% were on >200mg of daily morphine or equivalent (MED). A higher proportion of opioid users were in Group II and Group III than Group I. The vast majority of referred injured workers in this study were on opioid therapy with 1 in 3 exceeding the “watchful” dose of 200 mg MED

Chronic non-cancer pain (CNCP) affects approximately 25% of Canadians. Opioids are medications frequently prescribed for management of patients with CNCP. Concern about addiction, misuse, and diversion for illicit use led the Canadian medical regulatory bodies to release a national guideline on the safe and effective use of opioids in CNCP. This thesis used an online survey to determine how closely the self-reported practices of Canadian family physicians matched the recommendations of the Canadian Guideline. We received 710 responses suitable for analysis. Thirteen percent of respondents did not prescribe strong opioids for CNCP. Practice gaps indentified were infrequently using a management agreement and monitoring pain with a scale; incorrect choice of second line opioid for mild to moderate pain; incorrect choice of first, second, and third line opioids for severe pain, and starting fentanyl incorrectly. Findings provide baseline information for future follow-up to compare physicians’ adherence to the guideline.

INTRODUCTION: There is uncertainty in the prevalence of chronic non-cancer pain (CNCP) in military veterans. A systematic review and meta-analysis was conducted to elucidate this issue, and examine potential effect modifiers of CNCP prevalence. Additionally, chronic pain is a pervasive and debilitating condition that disproportionately affects military veterans. We recently completed a qualitative study of Canadian veterans living with chronic pain to identify their research priorities; however, the generalizability of our findings was uncertain. METHODS: MEDLINE, EMBASE, PsycINFO, CINAHL, Web of Science were searched from 2013 to January 21, 2021, for observational studies reporting “chronic pain” or pain ≥ 3 months in military veterans. The random-effects meta-analysis was used for pooling data, the Grading of Recommendations, Assessment, Development and Evaluations approach was used for rating quality of evidence, and the Instrument to Assess the Credibility of Effect Modification Analyses was used to rate credibility of the subgroup analyses. Furthermore, from January to March 2021, we emailed a 45-item cross-sectional survey to a list of Canadian veterans that asked about the relative importance of 20 research priorities regarding chronic pain. We explored for statistical significance between male and female responses for any item in which the proportion of endorsement showed a ≥10% difference. RESULTS: 41 observational studies with 5,550,375 military veterans were included. The overall pooled CNCP prevalence is 34% (95% confidence interval (CI) 25% to 45%). However, significant subgroup effect was found for type of prevalence measure (generic or specific) among military veterans (test of interaction p=0.007, moderate subgroup credibility): the pooled generic CNCP prevalence of 43%, 95% CI 29% to 57% (Low-certainty evidence) vs. the pooled specific type of CNCP prevalence of 14%, 95% CI 6.7% to 23% (Moderate-certainty evidence). A multivariable meta-regression model adjusted for proportion lost to follow-up found the type of prevalence measure to be the only significant predictor of CNCP prevalence (p < 0.0001). 313 of 699 Canadian military veterans living with chronic pain completed ≥50% of the survey (45% response rate). Respondents were predominantly male (77%) with a median age of 52 (interquartile range [IQR] 44-58). All 20 research priorities listed in the survey were endorsed as very important by ≥52% of respondents, and three received endorsement by ≥85%: (I) optimizing chronic pain management after release from the military; and (II) identifying and (III) treating mental illness among veterans living with chronic pain. Women were more likely than men to endorse research on post-surgical care for chronic pain prevention or research on holistic care for chronic pain. Men were more likely than women to endorse research on physical activity or exercise for chronic pain. Individuals with higher gross income (≥$80,000) were less likely to endorse research into physiotherapy for chronic pain, or chiropractic for chronic pain compared to those with lower gross income. Individuals with greater age are less likely to endorse research on medical cannabis for chronic pain. CONCLUSIONS: The overall prevalence of CNCP is 34% among military veterans. For generic CNCP, the prevalence is 43%; for a given subtype of CNCP, the prevalence is 11%. Methodologically robust studies are required to more precisely determine CNCP prevalence. The most salient research priorities among our respondents were optimizing chronic pain management during service and after discharge from the military, including co-morbid mental illness. Differences in gender, gross income, and age are implicated in the endorsement of therapy-related priorities, which include surgery, physical activity or exercise, chiropractic, and medical cannabis. Our findings provide insight into the research priorities of Canadian military veterans living with chronic pain. These findings should be considered by granting agencies when formulating calls for proposals, and by researchers who wish to undertake research that will address the needs of military veterans living with chronic pain. / Thesis / Master of Science (MSc)

National rates of chronic non-cancer pain (CNCP) are rising alongside increasing reports of prescription opioid abuse and mortality. Associations between the rise in CNCP and in opioid abuse seem logical, yet research on CNCP among individuals with opioid dependence is currently limited due to the complicated nature of comorbid conditions in research and treatment. This study aims to expand the CNCP knowledge base by responding to the question: Do individuals with CNCP participating in an opiate treatment program have better or worse treatment outcomes than individuals without CNCP? This study used a secondary dataset including 483 adults from Kentucky’s Opiate Recovery Treatment Outcome Study. Individuals in the sample met DSM-IV-TR criteria for opioid dependence and were in treatment at a licensed opiate treatment program (OTP). Analysis compared cases with and without CNCP on national treatment outcome measures including substance use, recovery support, education, employment, mental health symptoms, and criminal justice system involvement. Results indicated no differences at follow-up between the CNCP (n=163) and non-CNCP (n=320) individuals on substance abstinence, recovery supports, education level, or criminal justice system involvement. At baseline and follow-up there were more unemployed individuals and individuals receiving disability benefits in the CNCP group than the non-CNCP group. Reported anxiety and depression symptoms increased at follow-up, while use of prescription medicine for mental health symptoms declined for both groups (non-significant differences). The only predictors for CNCP cases in this sample were tobacco use and presence of a chronic medical condition. Recommendations include expansion of smoking cessation programs in substance abuse treatment settings. Future research might examine integrated treatment and medical home health models to better address biopsychosocial components of clients with comorbid conditions like opioid dependence and CNCP.

Chronic pain has no cure. It is a lifelong condition presenting a growing concern due to its high occurrence and effects on every facet of life. It cost about $635 billion each year in medical treatment and lost productivity (IOM, 2011). The management of chronic pain using prescription painkiller opioids has increased drastically in the last two decades, leading to a consequential increase in deaths from chronic opioid use. This Plan-Do-Study-Act quality improvement project investigates the problem of the prevalence of opioid prescription using agent-based computational modeling method. The simulation models the interaction of 50 patient-agents with pain self-management messages in an episode of 50 patient iterations (visits) for 10 simulated years. This interaction generates health benefit and risk outcomes represented by wellness data obtained when messages are processed. As the simulation runs, data are dynamically captured and visualized using wellness charts, time series plots, and benefit and risk regression plots. The result of the project provides evidence for research and practice on the process of achieving more impact of programs based on administering pain self-management education to patients with chronic non-cancer pain who are currently on opioid therapy and on the process of customizing interventions that might take advantage of the conditions of behavior change driven by pain self-management messages. The tools and the evidences in this project are highly recommended to nurse practitioners primary care providers involve with providing care to the vulnerable groups of patient with chronic non-cancer pain. These evidences might inform the formation of self-management interventions that might lead to a decline in opioid use and prescription and accelerate the acceptance of self-management practices.

La douleur chronique non-cancéreuse (DCNC) est un problème de santé qui touche environ une personne sur cinq au Canada. Elle est associée à une dégradation de la qualité de vie physique et mentale et occasionne des coûts économiques importants. Pour lutter contre la DCNC, les opioïdes ont été largement recommandés et prescrits malgré l’absence de preuves de leur efficacité à long terme, entraînant une augmentation des surdoses. Ces surdoses mais surtout celles causées par le fentanyl illicite ont fait naître une crise sanitaire, la crise des opioïdes. Pour juguler cette crise, des lignes directrices ont été émises pour encadrer de façon plus stricte la prescription d’opioïdes pour la DCNC. Cependant ces mesures peuvent constituer des barrières d’accès aux traitements pour les personnes vivant avec de la DCNC. Il est donc important de garantir un accès sécuritaire aux opioïdes à ceux qui en ont besoin pour fonctionner tout en limitant l’accès inapproprié qui alimente la crise des opioïdes. L’objectif de cette thèse était d’identifier les personnes susceptibles de bénéficier d’une utilisation efficace et sécuritaire des opioïdes à long terme et de mieux comprendre la douleur et les difficultés d’accès au traitement chez les personnes utilisatrices de drogues (PUD). Une première étude, visant à identifier les prédicteurs de l’efficacité des opioïdes à long terme, n’a pas permis de faire ressortir des caractéristiques des personnes susceptibles d’en bénéficier. Deux autres études ont permis d’étudier le nomadisme médical (doctor shopping), un indicateur d’utilisation problématique d’opioïdes, qui consiste à obtenir des ordonnances qui se chevauchent de plusieurs médecins et à les faire dispenser dans différentes pharmacies. Les résultats ont montré que cette pratique est rare chez les personnes vivant avec de la DCNC mais qu’elle peut être associée à la survenue de surdose. Les caractéristiques des personnes à risque de faire du nomadisme médical ont été identifiées permettant ainsi un meilleur suivi. Enfin, une dernière étude a montré que la DCNC est très fréquente chez les PUD et qu’une proportion importante de cette population a recours à des drogues illicites pour soulager leur douleur, courant ainsi le risque de faire une surdose. Ces études montrent la nécessité d’une médecine personnalisée tenant compte des caractéristiques et situations individuelles afin de prescrire le bon médicament à la bonne personne. En somme, ces résultats ont permis d’accroître les connaissances scientifiques sur l’utilisation des opioïdes pour la DCNC. / Chronic non-cancer pain (CNCP) is a health problem that affects about one in five people in Canada. CNCP is associated with a deterioration of physical and mental health-related quality of life and incurs significant economic costs. To better manage CNCP, opioids have been widely recommended and prescribed despite the lack of evidence on their long-term effectiveness, leading to an increase in opioid overdoses. These overdoses but mainly those caused by illicit fentanyl have led to the opioid crisis. To address this crisis, guidelines have been issued to tighten the prescribing of opioids for CNCP. However, these measures can exacerbate barriers of access to treatment for people living with CNCP. Therefore, it is important to ensure safe access to opioids for those who need this medication to improve function while reducing inappropriate access that contributes to the opioid crisis. The aim of this thesis was to identify the characteristics of patients who may benefit from effective and safe long-term opioid therapy and to better understand pain and treatment access difficulties among people who use drugs (PWUD). An initial study, which aimed at examining predictors of long-term opioid efficacy, failed to identify characteristics of those likely to benefit from opioid therapy. Two other studies investigated doctor shopping, an indicator of problematic opioid use, which consists of obtaining overlapping prescriptions from several doctors and pharmacies. The results showed that this practice is rare among people living with CNCP but may be associated with the occurrence of opioid overdose. The characteristics of people at high-risk to engage in opioid doctor shopping were identified, thus allowing better monitoring. Finally, a last study showed that CNCP is very frequent among PWUD and that a significant proportion of this population uses illicit drugs to relieve their pain, which can increase the risk of overdose. These studies show the need for personalized medicine considering individual characteristics and specific situations to prescribe the right drug to the right person. In summary, these results have increased the scientific knowledge about the long-term opioid use in CNCP.

Contexte: La douleur chronique non cancéreuse (DCNC) génère des retombées économiques et sociétales importantes. L’identification des patients à risque élevé d’être de grands utilisateurs de soins de santé pourrait être d’une grande utilité; en améliorant leur prise en charge, il serait éventuellement possible de réduire leurs coûts de soins de santé. Objectif: Identifier les facteurs prédictifs bio-psycho-sociaux des grands utilisateurs de soins de santé chez les patients souffrant de DCNC et suivis en soins de première ligne. Méthodologie: Des patients souffrant d’une DCNC modérée à sévère depuis au moins six mois et bénéficiant une ordonnance valide d’un analgésique par un médecin de famille ont été recrutés dans des pharmacies communautaires du territoire du Réseau universitaire intégré de santé (RUIS), de l’Université de Montréal entre Mai 2009 et Janvier 2010. Ce dernier est composé des six régions suivantes : Mauricie et centre du Québec, Laval, Montréal, Laurentides, Lanaudière et Montérégie. Les caractéristiques bio-psycho-sociales des participants ont été documentées à l’aide d’un questionnaire écrit et d’une entrevue téléphonique au moment du recrutement. Les coûts directs de santé ont été estimés à partir des soins et des services de santé reçus au cours de l’année précédant et suivant le recrutement et identifiés à partir de la base de données de la Régie d’Assurance maladie du Québec, RAMQ (assureur publique de la province du Québec). Ces coûts incluaient ceux des hospitalisations reliées à la douleur, des visites à l’urgence, des soins ambulatoires et de la médication prescrite pour le traitement de la douleur et la gestion des effets secondaires des analgésiques. Les grands utilisateurs des soins de santé ont été définis comme étant ceux faisant partie du quartile le plus élevé de coûts directs annuels en soins de santé dans l’année suivant le recrutement. Des modèles de régression logistique multivariés et le critère d’information d’Akaike ont permis d’identifier les facteurs prédictifs des coûts directs élevés en soins de santé. Résultats: Le coût direct annuel médian en soins de santé chez les grands utilisateurs de soins de santé (63 patients) était de 7 627 CAD et de 1 554 CAD pour les utilisateurs réguliers (188 patients). Le modèle prédictif final du risque d’être un grand utilisateur de soins de santé incluait la douleur localisée au niveau des membres inférieurs (OR = 3,03; 95% CI: 1,20 - 7,65), la réduction de la capacité fonctionnelle liée à la douleur (OR = 1,24; 95% CI: 1,03 - 1,48) et les coûts directs en soins de santé dans l’année précédente (OR = 17,67; 95% CI: 7,90 - 39,48). Les variables «sexe», «comorbidité», «dépression» et «attitude envers la guérison médicale» étaient également retenues dans le modèle prédictif final. Conclusion: Les patients souffrant d’une DCNC au niveau des membres inférieurs et présentant une détérioration de la capacité fonctionnelle liée à la douleur comptent parmi ceux les plus susceptibles d’être de grands utilisateurs de soins et de services. Le coût direct en soins de santé dans l’année précédente était également un facteur prédictif important. Améliorer la prise en charge chez cette catégorie de patients pourrait influencer favorablement leur état de santé et par conséquent les coûts assumés par le système de santé. / Background: Chronic non-cancer pain (CNCP) has major social and economic impacts. Identifying patients at risk of being heavy health care users could be very useful; therefore, by improving their care direct health care costs could eventually be reduced. Purpose: To identify bio-psycho-social factors predicting the risk of being a heavy health care user among primary care CNCP patients. Methods: Patients reporting moderate to severe CNCP for at least 6 months with an active analgesic prescription from a primary care physician were recruited in community pharmacies on the territory of the Réseau universitaire integré de santé (RUIS), of the Université de Montréal between May 2009 and January 2010. The latter comprises six areas: Mauricie and centre du Quebec, Laval, Montreal, the Laurentians, Lanaudière and Montérégie. Upon recruitment, their bio-psycho-social characteristics were documented through self-administered and telephone questionnaires. The direct health costs were estimated for the health care services provided to patients in the year preceding and following recruitment using the database of the Régie d’Assurance maladie du Québec, RAMQ (Quebec province public health care insurance). These costs took into account the pain-related hospitalizations, emergency room visits, ambulatory care, and medication prescribed for pain treatment and drug side effects Heavy health care users were defined as those in the highest annual direct health care costs quartile in the year following recruitment. Logistic multivariate regression models using the Akaike information criterion were developed in order to identify the predictors of heavy health care use. Results: The median annual direct health care cost incurred by heavy health care users (n = 63) was CAD 7,627, compared to CAD 1,554 for the standard health care users (n = 188). The final predictive model of the risks of being a heavy health care user included pain located in the lower body (Odds ratio (OR) = 3.03; 95% CI: 1.20 - 7.65), pain-related disability (OR = 1.24; 95% CI: 1.03 - 1.48), and health care costs in the previous year (OR = 17.67; 95% CI: 7.90 - 39.48). Other retained variables were sex, comorbidity, depression level, and patients’ attitudes towards medical pain cure. Conclusion: Patients suffering from CNCP in the lower body and having a greater impact of pain on their daily functioning were more likely to be heavy health care and services users. Previous year annual direct cost was also a significant predictor. Improving pain management in this clientele of patients may improve their health and eventually reduce their health care cost to the health care system.

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