GPs' practices when prescribing buprenorphine in primary care: A survey among the Sentinelles network.

INTRODUCTION: France is a leading country for opioid agonist treatment providing, with a predominance of buprenorphine. General practitioners (GPs) are the main prescribers of buprenorphine, but they seem to be less involved over the last 10 years. This work is the second part of a larger study analysing buprenorphine prescribing among French GPs working in primary care, and aims to describe GPs' practices when prescribing buprenorphine. METHODS: This is a cross-sectional study conducted in France from March to July 2021 among a sample of GPs in the Sentinelles network, a national epidemiologic surveillance system. Data about the last situations of initiation and renewal of buprenorphine were collected. RESULTS: Among the 237 participants (34.3% response rate), 156 responded to the questionnaire about the last situation of renewal and 41 about the last situation of initiation. The last initiation occurred more than 12 months earlier for 46.3% of respondents, whereas the last renewal occurred less than 1 month ago for 68.6%. There was an over-representation of the male gender among the patients who were consulting (initiation 70.7%, renewal 68.6%). A majority of patients had an illicit opioid use disorder (initiation 78.0%, renewal 82.7%). Overall, GPs were involved in the general care of patients with opioids use disorder and in opioids harm reduction (initiation 87.8% and 82.9%, renewal 88.5% and 51.9%). CONCLUSION: Among buprenorphine prescribers, initiations were infrequent unlike renewals and involved mainly illicit opioid users.

Barriers and facilitators to the involvement of general practitioners in the prescription of buprenorphine.

INTRODUCTION: France has one of the highest opioid agonist treatment (OAT) coverage rates in the world. French general practitioners (GPs) are providing the majority of prescriptions. However, a fall in the number of GPs initiating buprenorphine has been observed over the last decade. METHODS: The objective of this study was to explore the obstacles and facilitators to the involvement of GPs in the prescription of buprenorphine. A qualitative study comprising 14 individual interviews and a focus group bringing together 5 GPs was conducted among GPs based in France between June 2021 and March 2022. We performed data analysis using a grounded theory methodology. RESULTS: The interviews showed a great diversity in the level of involvement of GPs, depending on their experience, their representations of patients with OUD, their mode of exercise, and their personal preferences. The negative representations of the patients associated with the feeling of physical and ethical endangerment, the feeling of powerlessness, the fear of a disruption of the practice and the feeling of incompetence appeared at the forefront of the difficulties stated. Conversely, the strengthening of initial training and the facilitation of access to self-training tools and multidisciplinarity, the consideration of opioid use disorder (OUD) as a chronic illness with the application of a patient-centered motivational approach, as well as the defining and respecting one's own limits when prescribing buprenorphine seem to be the keys to a balanced and fulfilling practice. CONCLUSION: Raising awareness of the frequency of OUD appeared to be an additional lever to enhance the interest of the GPs concerned. Additional studies focusing on the evolution of professional practices would be necessary to extend these findings.

The Calm after the Storm: A State-of-the-Art Review about Recommendations Put Forward during the COVID-19 Pandemic to Improve Chronic Pain Management.

The COVID-19 pandemic has brought its fair share of consequences. To control the transmission of the virus, several public health restrictions were put in place. While these restrictions had beneficial effects on transmission, they added to the pre-existing physical, psychosocial, and financial burdens associated with chronic pain, and made existing treatment gaps, challenges, and inequities worse. However, it also prompted researchers and clinicians to seek out possible solutions and expedite their implementation. This state-of-the-art review focuses on the concrete recommendations issued during the COVID-19 pandemic to improve the health and maintain the care of people living with chronic pain. The search strategy included a combination of chronic pain and pandemic-related terms. Four databases (Medline, PsycINFO, CINAHL, and PubMed) were searched, and records were assessed for eligibility. Original studies, reviews, editorials, and guidelines published in French or in English in peer-reviewed journals or by recognized pain organizations were considered for inclusion. A total of 119 articles were analyzed, and over 250 recommendations were extracted and classified into 12 subcategories: change in clinical practice, change in policy, continuity of care, research avenues to explore, group virtual care, health communications/education, individual virtual care, infection control, lifestyle, non-pharmacological treatments, pharmacological treatments, and social considerations. Recommendations highlight the importance of involving various healthcare professionals to prevent mental health burden and emergency overload and emphasize the recognition of chronic pain. The pandemic disrupted chronic pain management in an already-fragile ecosystem, presenting a unique opportunity for understanding ongoing challenges and identifying innovative solutions. Numerous recommendations were identified that are relevant well beyond the COVID-19 crisis.

Experiences and Perceptions of Medical Cannabis among People Living with Chronic Pain and Community Pharmacists: A Qualitative Study in Canada.

Background: The use of cannabis to treat chronic pain is under debate despite high expectations from patients. Qualitative data obtained by exploring both patients' and health professionals' perspectives are scarce. Aims: This study aimed to understand the experiences and perceptions of people living with chronic pain and community pharmacists regarding the role of cannabis in chronic pain treatment in the Canadian context where both medical and recreational cannabis are legal. Methods: We conducted 12 online focus groups (July 2020-February 2021) with 26 patients and 19 community pharmacists using semistructured discussion guides. All discussions were audio recorded and transcribed verbatim were analyzed using a reflexive thematic approach. Results: We developed three themes related to patients' perspectives and three themes related to pharmacists' perspectives. Patients' perspectives included (1) cannabis as an alternative to other pain medications, (2) a new treatment with potential health-related risks, and (3) a therapy rather than a recreational drug. Pharmacists' perspectives included (1) challenges in monitoring drug interactions with cannabis in the context of scarce research data, (2) informing and treating patients self-medicating with cannabis amid its growing popularity, and (3) financial costs and legal constraints for patients. Conclusions: This study highlights patients' and pharmacists' urgent need for reliable information regarding the benefits and risks of cannabis. Training tailored to pharmacists' needs and evidence-based information for patients should be developed to support pharmacists' practice, improve patients' experiences, and promote safe cannabis use.

Contexte: L'utilisation du cannabis pour traiter la douleur chronique fait l'objet d'un débat, malgré les fortes attentes des patients. Les données qualitatives issues de l'exploration des perspectives à la fois des patients et des professionnels de la santé, demeurent rares.Objectifs: Cette étude visait à comprendre les expériences et les perceptions des personnes vivant avec une douleur chronique et des pharmaciens communautaires concernant le rôle du cannabis dans le traitement de la douleur chronique dans le contexte canadien, où le cannabis médical et récréatif est légal.Méthodes: Nous avons mené 12 groupes de discussion en ligne entre juillet 2020 et février 2021, réunissant 26 patients et 19 pharmaciens communautaires, à l'aide de guides de discussion semi-structurés. Toutes les discussions ont été enregistrées et transcrites mot à mot, puis analysées à l'aide d'une approche thématique réflexive.Résultats: Nous avons développé trois thèmes liés aux perspectives des patients et trois thèmes liés aux perspectives des pharmaciens. Le point de vue des patients incluait (1) le cannabis comme option de rechange à d'autres médicaments contre la douleur, (2) un nouveau traitement avec des risques potentiels pour la santé, et (3) un traitement plutôt qu'une drogue récréative. Le point de vue des pharmaciens portait sur (1) les défis liés à la surveillance des interactions médicamenteuses avec le cannabis dans le contexte de la rareté des données de recherche, (2) l'information et le traitement des patients qui s'auto-médicamentent avec du cannabis dans un contexte de popularité croissante, et (3) les coûts financiers et les contraintes légales pour les patients.Conclusions: Cette étude met en évidence le besoin urgent des patients et des pharmaciens de disposer d'informations fiables sur les avantages et les risques du cannabis. Une formation adaptée aux besoins des pharmaciens et des informations fondées sur des données probantes pour les patients devraient être développées pour soutenir la pratique des pharmaciens, améliorer l'expérience des patients et promouvoir une utilisation sûre du cannabis.

Pain, mental health and healthcare utilization: Impact of the COVID-19 pandemic on youth with chronic pain, parents and siblings.

BACKGROUND: Paediatric chronic pain was a public health emergency before the novel coronavirus (COVID-19) pandemic, and this problem is predicted to escalate. Pain tends to occur intergenerationally in families, and youth with chronic pain and their parents have high rates of mental health issues, which can further exacerbate pain. Siblings of youth with chronic pain have been largely overlooked in research, as well as the impact of the pandemic on posttraumatic stress disorder (PTSD) symptoms and healthcare utilization. METHODS: This cross-sectional study examined pain, mental health and healthcare utilization in three groups: youth with chronic pain (n = 357), parents of youth with chronic pain (n = 233) and siblings of youth with chronic pain (n = 156) during the COVID-19 pandemic in Canada. RESULTS: More so than with pain symptoms, the results revealed high levels of mental health symptoms (i.e. anxiety, depressive, and PTSD), particularly in individuals more personally impacted by the pandemic. The largest effect was seen on PTSD symptoms for all groups. For parents with chronic pain, greater personal COVID-19 impact was related to worse pain interference. Reported rates of healthcare utilization were strikingly high, with youth with chronic pain, parents (reporting on behalf of their children with chronic pain), and siblings of youth with chronic pain reporting that most consultations were due to pain. CONCLUSIONS: Longitudinal research assessing these outcomes across continued waves of the pandemic is needed to ensure timely, tailored and equitable access to pain and mental health assessment and treatment. SIGNIFICANCE: This study examined pain, mental health, substance use and healthcare utilization in youth with chronic pain, siblings and parents during the COVID-19 pandemic. Greater personal impact of the pandemic was not largely associated with poorer pain outcomes; however, it was associated with mental health, with the largest effect on PTSD symptoms. The high rates and significant association of COVID-19 impact with PTSD symptoms underscore the importance of including PTSD assessment as part of routine screening practices in pain clinics.

Profiles of socially isolated community-dwelling older adults during the COVID-19 pandemic: A latent class analysis.

OBJECTIVE: To identify different profiles of socially isolated older adults during the first wave of COVID-19 in Quebec, Canada. STUDY DESIGN: Cross-sectional data were obtained through a telehealth socio-geriatric risk assessment tool, ESOGER, administered to adults aged 70 years or more between April and July 2020 in Montreal, Canada. MEASURES: Those living alone with no social contacts in the last few days were considered socially isolated. Latent class analysis was performed to identify profiles of socially isolated older adults based on: age, sex, polypharmacy, use of home care, use of a walking aid, recall of current year/month, anxiety level (scale 0-10), and need for follow-up from a healthcare provider. RESULTS: Three-hundred and eighty (380) older adults identified as socially isolated were analyzed, of whom 75.5 % were female and 56.6 % were over 85. Three classes were identified: Class 1 ("physically frail older females") had the highest proportion of polypharmacy, walking aid, and home care use. Class 2 ("anxious, relatively younger males") were predominantly males who used the least home care but had the highest anxiety levels. Class 3 ("seemingly well older females") had the highest proportion of females, lowest proportion of polypharmacy, lowest anxiety level, and none used a walking aid. Recall of current year/month was similar across the three classes. CONCLUSIONS: This study found heterogeneity among socially isolated older adults during the first wave of the COVID-19 pandemic with varying levels of physical and mental health. Our findings may contribute to the development of targeted interventions to support this vulnerable population during and after the pandemic.

"We survived the pandemic together": The impact of the COVID-19 pandemic on Canadian families living with chronic pain.

Introduction: Pediatric chronic pain is a significant problem in Canada, affecting one in five youth. This study describes the impact of the pandemic on the experiences of Canadian families living with chronic pain through interviews with youth living with chronic pain, parents, and siblings. Methods: Employing a qualitative descriptive design, in-depth semistructured interviews were completed with Canadian youth living with pain, as well as parents and siblings. Participants were not required to be related. Interviews were analyzed using a reflexive thematic analysis approach. Results: Forty-four interviews were completed with 14 parents, 19 youth with chronic pain, and 11 siblings from across the country. Three key themes were developed: (1) absorbing and shifting: the toll of the pandemic on the family system (e.g., loss of coping mechanisms, shifting roles to respond to the pandemic), (2) social ambiguity and abandonment (e.g., social sacrifice and abandonment by the health care system), and (3) building community resilience: familial adaptation to the pandemic (e.g., family cohesion, confidence, and self-management). Discussion/Conclusions: Youth, parents, and siblings reported that the pandemic impacted coping strategies across the family system. These results outline the challenges youth experienced managing their pain and overall health throughout the pandemic and the resilience built within families during this time. Going forward, it would be relevant to examine how racialized and structurally marginalized youth with chronic pain and their families experienced the pandemic. Future research should examine how unexpected benefits of the pandemic (e.g., increased confidence and self-management) may be sustained into the future.

Introduction: La douleur chronique pédiatrique est un problème important au Canada, qui touche un jeune sur cinq. Cette étude décrit les répercussions de la pandémie sur les expériences des familles canadiennes vivant avec la douleur chronique par des entrevues avec des jeunes vivant avec une douleur chronique, des parents et des frères et sœurs.Méthodes: À l'aide d'un devis descriptif qualitatif, des entretiens semi-structurés approfondis ont été réalisés auprès de jeunes Canadiens vivant avec la douleur, leurs parents, et leurs frères et sœurs. Il n'était pas nécessaire que les participants aient un lien familial. Les entretiens ont été analysés à l'aide d'une approche d'analyse thématique réflexive.Résultats: Quarante-quatre entretiens ont été réalisés auprès de 14 parents, 19 jeunes souffrant de douleur chronique et 11 frères et sœurs de tout le pays. Trois thèmes clés ont été abordés : (1) l'absorption et le changement : le coût de la pandémie pour le système familial (p. ex., perte de mécanismes d'adaptation, changement de rôles pour réagir à la pandémie), (2) l'ambiguïté sociale et l'abandon (p. ex., le sacrifice social et l'abandon par le système de soins de santé), et (3) le renforcement de la résilience communautaire : adaptation familiale à la pandémie (p. ex., cohésion familiale, confiance et auto-prise en charge).Discussion/Conclusions: Les jeunes, les parents et les frères et sœurs ont signalé que la pandémie avait eu des répercussions sur les stratégies d'adaptation dans l'ensemble du système familial. Ces résultats décrivent les défis rencontrés par les jeunes pour prendre en charge leur douleur et leur santé globale tout au long de la pandémie, ainsi que la résilience démontrée par les familles pendant cette période. À l'avenir, il serait pertinent d'examiner comment les personnes racialisées et les jeunes structurellement marginalisés souffrant de douleur chronique et leurs familles ont vécu la pandémie.Les recherches futures devraient examiner comment les avantages inattendus de la pandémie (par exemple, une confiance accrue et l'auto-prise en charge) peuvent être maintenus à l'avenir.

Prescribing buprenorphine for opioid use disorder in primary care: A survey of French general practitioners in the Sentinelles network.

INTRODUCTION: Although opioid substitution coverage in France is high and patient care with buprenorphine is mainly managed by general practitioners (GPs), buprenorphine sales have been decreasing since 2011, suggesting that French GPs are prescribing less buprenorphine. Yet this possible change in GP practices has not yet been investigated. This study aimed to examine primary care GPs' opinions about buprenorphine and habits related to prescribing buprenorphine. METHODS: The study team conducted a cross-sectional survey from March 2021 to July 2021 among a sample of GPs in the Sentinelles network, a French epidemiologic surveillance system based on primary care practitioners. The study collected information about substance use disorder (SUD) training, opinions on buprenorphine, and habits related to buprenorphine prescription were collected (initiation and renewal within the past two years). FINDINGS: Among the 237 participants (34 % response rate), 15.2 % reported having had specific training for SUD management. A majority reported a very positive (16 %) or positive (63.7 %) opinion of buprenorphine. Most participants agreed (61.2 %) or strongly agreed (31.2 %) that buprenorphine was efficacious in the treatment of illicit opioid use disorder. Of the 206 GPs who reported having treated patients with opioid use disorder in the past two years, 47 (22.8 %) had initiated a buprenorphine prescription, whereas 177 (85.9 %) had renewed a buprenorphine prescription. Previous SUD training was associated with initiating buprenorphine (OR 4.66; 95 % CI [2.15-10.08]), while female gender was associated with not initiating buprenorphine prescribing (OR 0.46; 95 % CI [0.22-0.98]). CONCLUSION: A sample of French GPs who work in primary care has a positive view of buprenorphine, but the absence of SUD training among this population may be a barrier to their prescribing buprenorphine.

Implementing a Telehealth Support Tool for Community-Dwelling Older Adults During the COVID-19 Pandemic: A Qualitative Investigation of Provider Experiences.

During the COVID-19 pandemic, policymakers had to quickly offer telehealth services to address older adults' needs. This study aimed to understand the experiences of providers who implemented a telephone-based telehealth tool named Socio-Geriatric Evaluation (ESOGER), which assessed health and social isolation risks in community-dwelling older adults in Quebec (Canada). This qualitative study used 20 semi-structured online/phone interviews with health and social service providers coming from publicly-funded healthcare facilities and community organizations. We included adopters and non-adopters of the telehealth tool. Interviews were audio-recorded and transcribed verbatim. We used reflexive thematic analysis to interpret the data. Three dimensions of providers' practice influenced the tool's implementation: service organization, working conditions, and interactions with older adults. Participants reported that the tool fostered continuity of care, provided guidance for their pandemic-related new tasks, and helped identify and support socially isolated older adults. Challenges to implementation included limited appropriateness of the telehealth tool for diverse services, feasibility barriers to adopting a new tool amid the health crisis, and acceptability challenges with some older adults. Despite relevance of the telehealth tool for providers, organizational, professional, and interactional barriers could hinder implementation success. Participatory approaches to telehealth may be promising avenues for future policies in this field.

Frequency and characteristics of patient exclusion criteria in Canadian multidisciplinary pain treatment facilities: a cross-sectional study.

PURPOSE: A multidisciplinary approach is recommended for patients with complex chronic pain (CP). Many multidisciplinary pain treatment facilities (MTPFs) use patient exclusion criteria but little is known about their characteristics. The objective of this study was to describe the frequency and characteristics of exclusion criteria in public Canadian MTPFs. METHODS: We conducted a cross-sectional study in which we defined an MPTF as a clinic staffed with professionals from three disciplines or more (including at least one medical specialty) and whose services were integrated within the facility. We disseminated a web-based questionnaire in 2017-2018 to the administrative leads of MPTFs across the country. They were invited to complete the questionnaire about the characteristics of their facilities. Data were analyzed using descriptive statistics and correlation measures. RESULTS: A total of 87 MTPFs were included in the analyses. Half of them (52%) reported using three exclusion criteria or more. There was no significant association between the number of exclusion criteria and wait time for a first appointment or number of new consultations in the past year. Fibromyalgia and migraine were the most frequently excluded pain syndromes (10% and 7% of MPTFs, respectively). More than one MPTF out of four excluded patients with mental health disorders (30%) and/or substance use disorders (29%), including MPTFs with specialists in their staff. CONCLUSIONS: Multidisciplinary pain treatment facility exclusion criteria are most likely to affect CP patients living with complex pain issues and psychosocial vulnerabilities. Policy efforts are needed to support Canadian MPTFs in contributing to equitable access to pain management.

RéSUMé: OBJECTIF: Une approche multidisciplinaire est recommandée pour les patients souffrant de douleur chronique (DC) complexe. De nombreux centres multidisciplinaires de traitement de la douleur (CMTD) utilisent des critères d'exclusion des patients, mais on ne sait que peu de choses sur leurs caractéristiques. L'objectif de cette étude était de décrire la fréquence et les caractéristiques des critères d'exclusion dans les CMTD publics canadiens. MéTHODE: Nous avons mené une étude transversale dans laquelle nous avons défini un CMTD comme une clinique composée de professionnels de trois disciplines ou plus (y compris au moins une spécialité médicale) et dont les services étaient intégrés à l'établissement. En 2017-2018, nous avons fait parvenir un questionnaire en ligne aux responsables administratifs des CMTD partout au pays. Ils ont été invités à remplir le questionnaire sur les caractéristiques de leurs établissements. Les données ont été analysées à l'aide de statistiques descriptives et de mesures de corrélation. RéSULTATS: Au total, 87 CMTD ont été inclus dans les analyses. La moitié d'entre eux (52 %) ont déclaré utiliser trois critères d'exclusion ou plus. Il n'y avait pas d'association significative entre le nombre de critères d'exclusion et le temps d'attente pour un premier rendez-vous ou le nombre de nouvelles consultations au cours de la dernière année. La fibromyalgie et la migraine étaient les syndromes douloureux les plus fréquemment exclus (10 % et 7 % des CMTD, respectivement). Plus d'un CMTD sur quatre excluait les patients atteints de troubles de santé mentale (30 %) et/ou de troubles liés à l'utilisation de substances (29 %), y compris les CMTD comptant des spécialistes dans leur personnel. CONCLUSION: Les critères d'exclusion des centres multidisciplinaires de traitement de la douleur sont plus susceptibles d'affecter les patients atteints de douleur chronique vivant avec des problèmes de douleur complexes et des vulnérabilités psychosociales. Des efforts au niveau des politiques sont nécessaires pour aider les CMTD canadiens à favoriser un accès équitable à la prise en charge de la douleur.

Experiences of Pediatric Pain Professionals Providing Care during the COVID-19 Pandemic: A Qualitative Study.

Chronic pain affects 1 in 5 youth, many of whom manage their pain using a biopsychosocial approach. The COVID-19 pandemic has impacted the way that healthcare is delivered. As part of a larger program of research, this study aimed to understand the impact of the pandemic on pediatric chronic pain care delivery including impact on patients' outcomes, from the perspective of pediatric healthcare providers. A qualitative descriptive study design was used and 21 healthcare providers from various professional roles, clinical settings, and geographic locations across Canada were interviewed. Using a reflexive thematic analysis approach 3 themes were developed: (1) duality of pandemic impact on youth with chronic pain (i.e., how the pandemic influenced self-management while also exacerbating existing socioeconomic inequalities); (2) changes to the healthcare system and clinical practices (i.e., triaging and access to care); (3) shift to virtual care (i.e., role of institutions and hybrid models of care). These findings outline provider perspectives on the positive and negative impacts of the pandemic on youth with chronic pain and highlight the role of socioeconomic status and access to care in relation to chronic pain management during the pandemic in a high-income country with a publicly funded healthcare system.

Perceived risk of opioid use disorder secondary to opioid analgesic medication use by the general population in France.

BACKGROUND: In Europe and France, the use of opioid analgesic drugs has become widespread as an option for pain management. However, their use can lead to nonmedical use and/or opioid use disorder (OUD). This work aimed to assess the perceived risk of OUD secondary to opioid analgesic drugs use by the general population. METHODS: We conducted a cross-sectional observational study using the GrippeNet web-based cohort, comprising about 10,000 French volunteers from the general population, using a self-administered questionnaire. The main outcome was the perceived risk of OUD secondary to opioid analgesic drugs use, assessed by a 4-item scale and modelled using logistic regression (backward procedure). RESULTS: Among 5046 French respondents, after adjustment, 65% believed that the use of analgesic drugs could likely or very likely lead to OUD. Factors associated with the perception of a higher risk were being over 50 and having heard about opioids in the media. Previous opioid use and a high level of education decreased the perception of the risk. Among those having used opioids in the past 2 years (N = 1770), 71.1% reported being not at all concerned by this risk. The majority of the sample perceived the risk of OUD but those having already used opioid analgesics drugs expressed no concern about this risk for themselves. CONCLUSIONS: This finding highlight the need to reinforce warning on the package insert documents, therapeutic education and collaborative care between the prescribing general practitioners and pharmacists to increase awareness of opioid medications users on the risk of OUD. SIGNIFICANCE: This study found that the risk of OUD secondary to opioid analgesics use is well perceived in the general population, but that those having already used opioid analgesics expressed little concern for themselves. This finding could potentially help to raise awareness of healthcare providers and policy makers on the lack of perceived risk regarding these drugs and the need to inform and identify at-risk patients in primary care.

Swallowing the pill of adverse effects: A qualitative study of patients' and pharmacists' experiences and decision-making regarding the adverse effects of chronic pain medications.

INTRODUCTION: Pharmacological treatments of chronic pain can lead to numerous and sometimes serious adverse effects. Drawing on a social science approach to chronic illness, this study aimed to understand the experiences of people living with chronic pain and community pharmacists regarding the definition, prevention and management of analgesic adverse effects. METHODS: This qualitative study proceeded through 12 online focus groups (FGs) with people living with chronic pain (n = 26) and community pharmacists (n = 19), conducted between July 2020 and February 2021 in the province of Quebec, Canada. The semistructured discussion guides covered participants' definitions of adverse effects and decision-making regarding their prevention and management. Discussions were audio-recorded, transcribed verbatim and analysed using grounded theory. RESULTS: Both people with chronic pain and pharmacists provided varying definitions of analgesic adverse effects depending on patients' social and clinical characteristics. Present quality of life and serious long-term risks related to treatment were described as key dimensions influencing adverse effect appraisal. Dilemmas and discrepancies occurred between patients and pharmacists when choosing to prioritize pain relief or adverse effect prevention. Some patients lacked information about their medications and wanted to be more involved in decisions, while many pharmacists were concerned by patients' self-management of adverse effects. Preventing opioid-related overdoses often led pharmacists to policing practices. Despite most pharmacists wishing they could have a key role in the management of pain and adverse effects face organizational and financial barriers. CONCLUSION: Defining, preventing and managing adverse effects in the treatment of chronic pain requires a person-centred approach and shared decision-making. Clinical training improvements and healthcare organization changes are needed to support pharmacists in providing patients with community-based follow-up and reliable information about the adverse effects of chronic pain treatments. PATIENT OR PUBLIC CONTRIBUTION: A person with lived experience of chronic pain was involved as a coinvestigator in the study. He contributed to shaping the study design and objectives, including major methodological decisions such as the choice of pharmacists as the most appropriate professionals to investigate. In addition, 26 individuals with chronic pain shared their experiences extensively during the FGs.

COVID-19 Pandemic Impact and Response in Canadian Pediatric Chronic Pain Care: A National Survey of Medical Directors and Pain Professionals.

Background: The COVID-19 pandemic presents one of the greatest threats to pediatric pain care seen in generations. Due to public health restrictions, many pediatric pain clinics halted in-person appointments, delaying and disrupting access to care. There is no existing research on the impacts of COVID-19 on pediatric chronic pain care in Canada or the challenges experienced by health care professionals and pain clinics. Aims: The aim of this study was to evaluate the impact of COVID-19 on Canadian pediatric chronic pain care by documenting how health care professionals provided care during the first six months of the pandemic. Methods: Two Canadian online cross-sectional surveys were conducted: one among Canadian pediatric pain clinic directors (Study 1) and another among multidisciplinary pediatric pain health care professionals (Study 2). Results: Responses from 13/13 Canadian pediatric pain clinics/rehabilitation programs indicated that all clinics provided virtual care during the pandemic. No significant changes were reported on the frequency of appointment requests. Most clinics reported no perceived change in patient pain levels (n = 9/13, 69%) or occurrence of pain flares (n = 10/13, 77%). Results from 151 individual health care professionals indicated that the majority (90%) of non-emergency department respondents were providing virtual care. The main challenges of virtual care included technological barriers, financial concerns, infrastructure and logistics, privacy, and clinical challenges. Conclusions: This study documented the impact of the COVID-19 pandemic on pediatric chronic pain care in Canada and highlighted the rapid shift to using virtual solutions. Simultaneously, respondents outlined current challenges and potential solutions to consider in the development of virtual care guidelines and policy in Canada.

Contexte: La pandémie de COVID-19 représente l'une des plus grandes menaces pour les soins de la douleur pédiatrique jamais connue depuis des générations. En raison de restrictions de santé publique, de nombreuses cliniques pédiatriques de la douleur ont interrompu les rendez-vous en personne, occasionnant ainsi des retards et des perturbations dans l'accès aux soins. Il n'existe pas de recherche sur les répercussions de la COVID-19 sur les soins pédiatriques de la douleur chronique au Canada ou sur les défis rencontrés par les professionnels des soins de santé et les cliniques de la douleur.Objectifs: L'objectif de cette étude était d'évaluer les répercussions de la COVID-19 sur les soins pédiatriques de la douleur chronique au Canada en documentant la façon dont les professionnels de la santé ont prodigué les soins au cours des six premiers mois de la pandémie.Méthodes: Deux enquêtes transversales canadiennes en ligne ont été menées : l'une auprès des directeurs de cliniques pédiatriques de la douleur canadiennes (Étude 1) et l'autre auprès de professionnels des soins de santé de la douleur pédiatriques multidisciplinaires (étude 2).Résultats: Les réponses obtenues de la part de 13 / 13 cliniques pédiatriques de la douleur / programmes de réadaptation ont indiqué que toutes les cliniques avaient fourni des soins virtuels pendant la pandémie. Aucun changement significatif n'a été rapporté sur la fréquence des demandes de rendez-vous. La plupart des cliniques n'ont signalé aucun changement perçu dans les niveaux de douleur des patients (n = 9/13, 69 %) ou la survenue de poussées douloureuses (n = 10/13, 77 %). Les résultats obtenus de 151 professionnels de la santé ont indiqué que la majorité (90 %) des répondants de département autres que les urgences fournissaient des soins virtuels. Les principaux défis des soins virtuels comprenaient les barrières technologiques, les préoccupations financières, l'infrastructure et la logistique, la confidentialité et les défis cliniques.Conclusions: Cette étude a documenté les répercussions de la pandémie de COVID-19 sur les soins pédiatriques de la douleur chronique au Canada et a mis en lumière le passage rapide à l'utilisation de solutions virtuelles. Simultanément, les répondants ont décrit les défis actuels et les solutions potentielles devant être tenues en compte dans l'élaboration de lignes directrices et de politiques sur les soins virtuels au Canada.

Chronic pain experience and health inequities during the COVID-19 pandemic in Canada: qualitative findings from the chronic pain & COVID-19 pan-Canadian study.

BACKGROUND: Chronic pain affects about 20 % of the Canadian population and can lead to physical, psychological and social vulnerabilities. However, this condition remains poorly recognized and undertreated. During 2020, as the COVID-19 pandemic disrupted daily living and health care systems, the situation of people with chronic pain has drawn little public attention. METHODS: This qualitative study was part of a pan-Canadian mixed-methods project and aimed to understand the experiences and challenges of people living with chronic pain during the COVID-19 pandemic in Canada. Between May and August 2020, we conducted in-depth semi-structured interviews with 22 individuals living with chronic pain across the country. We used reflexive thematic analysis to interpret data. RESULTS: Our findings underscored four dimensions of the chronic pain experience during the pandemic: (1) Reinforced vulnerability due to uncertainties regarding pain and its management; (2) Social network as a determinant of pain and psychological condition; (3) Increasing systemic inequities intermingling with the chronic pain experience; (4) More viable living conditions due to confinement measures. Though several participants reported improvements in their quality of life and reduced social pressure in the context of stay-at-home orders, participants from socio-economically deprived groups and minorities reported more challenges in accessing pain relief, health care services, and psychosocial support. CONCLUSIONS: The COVID-19 pandemic has revealed and intensified pre-existing disparities and challenges among people living with chronic pain in terms of material resources, psychosocial condition, social support, and access to care. In post-pandemic times, it will be essential to address flaws in health and welfare policies to foster equity and social inclusiveness of people with chronic pain.

Opioid Doctor Shopping: A Rare Phenomenon Among Patients with Chronic Non-Cancer Pain Followed in Tertiary Care Settings.

BACKGROUND: Opioid doctor shopping has not yet been investigated in patients followed in tertiary care settings. This study aimed at assessing the prevalence of opioid doctor shopping among patients with chronic non-cancer pain (CNCP) (ie, pain lasting ≥3 months) attending multidisciplinary pain clinics in Quebec, Canada. PATIENTS AND METHODS: This was a retrospective cohort study of patients with CNCP enrolled in the Quebec Pain Registry (QPR) between 2008 and 2014. QPR data were linked to the Quebec health insurance databases. The index date was the date of the first visit at the pain clinic. Prevalence of doctor shopping was assessed within the 12 months following the index date. Doctor shopping was defined as at least 1 day of overlapping opioid prescriptions from ≥2 prescribers and filled in ≥3 pharmacies. RESULTS: A total of 2191 patients with CNCP with at least one opioid dispensation within the 12 months following the index date were included. The mean age was 58.6±14.9 years and 41.3% were men. The median pain duration was 4 years, and 13.3% of patients were diagnosed with neuropathic pain. Regarding past year comorbidities, 15.0% presented anxiety, 16.8% depression and 6.4% substance use disorder. Among the included patients, 15 (0.7%) presented at least one episode of doctor shopping. Among these doctor-shoppers, 9 (60.0%) exhibited only 1 episode. CONCLUSION: Opioid doctor shopping is a rare phenomenon among patients with CNCP treated in tertiary care settings. Opioids should remain a drug option for patients without substance use disorder, and who have persistent pain despite optimized nonopioid therapy.

"They think you're trying to get the drug": Qualitative investigation of chronic pain patients' health care experiences during the opioid overdose epidemic in Canada.

Background: The opioid overdose epidemic has led health care providers to increased vigilance for opioid-related risks in the treatment of chronic non-cancer pain (CNCP). Media have conveyed stigmatizing representations of opioid analgesics. Aims: This study aimed to understand how the opioid overdose epidemic has impacted health care experiences among people living with CNCP in two Canadian provinces (British Columbia, Quebec). Methods: This qualitative study proceeded through 22 semi-structured interviews conducted in 2019. Participants were recruited from a cross-sectional survey examining the effects of the opioid overdose epidemic on individuals with CNCP. We collected in-depth narratives that we analyzed using a thematic framework. The sample included 12 women and 10 men aged 20 to 70 years, with 11 from each province. Results: Several participants described increased difficulty in accessing medical services for pain since the onset of the opioid overdose epidemic. They reported that some physicians urged them to taper opioids regardless of their pain severity and functional limitations. Some participants reported facing discrimination and care denials as they were labeled "drug-seeking," especially in hospital. Depending on their educational resources, they were unequally able to counter providers' stigmatizing behaviors. However, participants described empathetic relationships with providers with whom they had a long-term relationship. Some participants drew distinctions between themselves and the stigmatized status of "addict" in ways that reinforced stigma toward people who are dependent on opioids. Conclusions: Health policies and provider education programs aimed at reducing opioid-related stigma are needed to counter detrimental consequences of the opioid overdose epidemic for people living with CNCP.

Contexte: L'épidémie de surdose d'opioïdes a conduit les prestataires de soins de santé à une vigilance accrue des risques liés aux opioïdes dans le traitement de la douleur chronique non cancéreuse (DCNC). Les médias ont véhiculé des représentations stigmatisantes des analgésiques opioïdes.Objectifs: Cette étude visait à comprendre comment l'épidémie de surdose d'opioïdes a eu un impact sur les expériences avec les soins de santé des personnes vivant avec la DCNC dans deux provinces canadiennes (Colombie-Britannique, Québec).Méthodes: Cette étude qualitative a été réalisée au moyen de 22 entretiens semi-structurés menés en 2019. Les participants ont été recrutés à partir d'une enquête transversale examinant les effets de l'épidémie de surdose d'opioïdes sur les personnes atteintes de DCNC. Nous avons recueilli des récits approfondis que nous avons analysés en utilisant un cadre thématique. L'échantillon comprenait 12 femmes et 10 hommes âgés de 20 à 70 ans, parmi lesquels 11 provenaient de chacune des deux provinces.Résultats: Plusieurs participants ont décrit une difficulté accrue à avoir accès aux services médicaux pour la douleur depuis le début de l'épidémie de surdose d'opioïdes. Ils ont déclaré que certains médecins les avaient incités à réduire les opioïdes, quelle que soit la gravité de leur douleur et leurs limitations fonctionnelles. Certains participants ont déclaré être confrontés à de la discrimination et au refus de soins car ils ont été qualifiés de « chercheurs de drogue ¼, en particulier à l'hôpital. En fonction de leurs ressources éducatives, ils ont été inégalement capables de contrer les comportements stigmatisants des prestataires. Cependant, les participants ont décrit des relations d'empathie avec les prestataires avec lesquels ils avaient une relation à long terme. Certains participants ont établi des distinctions entre eux-mêmes et le statut stigmatisé de « toxicomane ¼ d'une manière qui renforce la stigmatisation des personnes dépendantes aux opioïdes.Conclusions: Les politiques de santé et les programmes d'éducation des prestataires visant à réduire la dépendance aux opioïdes et la stigmatisation liée aux opioïdes est nécessaire afin de contrer les conséquences néfastes de l'épidémie de surdose d'opioïdes pour les personnes vivant avec la DCNC.

Impact of the Opioid Epidemic and Associated Prescribing Restrictions on People Who Live With Chronic Noncancer Pain in Canada.

OBJECTIVES: Little is known about the consequences of the opioid epidemic on people living with chronic noncancer pain (CNCP). This study examined this issue in people who lived in the most impacted province by opioid overdoses in Canada (British Columbia [BC]) or one of the least impacted (Quebec [QC]), and examined the factors associated with opioid use. MATERIALS AND METHODS: This cross-sectional study was carried out in adults living in BC (N=304) and QC (N=1071) who reported CNCP (≥3 months) and completed an online questionnaire that was tailored to their opioid status. RESULTS: Almost twice as many participants in BC as in QC were proposed to cease their opioid medication in the past year (P<0.001). The proportion who reported having hoarded opioids in fear of not being able to get more in the future was also significantly higher in BC (P<0.001) compared with QC. In addition, they were significantly more likely to have had their opioid dose decreased than those in QC (P=0.001). No significant association was found between opioid discontinuation and province of residence. Two-thirds of the BC participants felt that the media coverage of the opioid crisis was very to extremely detrimental to CNCP patients in general, this percentage being significantly higher than in QC (P<0.001). DISCUSSION: The opioid epidemic and associated prescribing restrictions have had harmful effects on Canadians with CNCP. The clinical community, the general public, and the media need to be aware of these negative consequences to decrease patients' stigmatization and minimize inadequate treatment of CNCP.

Conversations About Opioids: Impact of the Opioid Overdose Epidemic on Social Interactions for People Who Live With Chronic Pain.

The objective of this study was to understand the impact of the opioid overdose epidemic on the social lives of people suffering from chronic pain, focusing on interactions within their personal and professional circles. The study was based on 22 in-depth interviews with people living with chronic pain in Canada. Using thematic analysis, we documented three main impacts of the opioid overdose epidemic: (a) increased worries of people in pain and their families regarding the dangers of opioids; (b) prejudices, stigma, and discrimination faced during conversations about opioids; and (c) stigma management attempts, which include self-advocacy and concealment of opioid use. This study represents important knowledge advancement on how people manage stigma and communicate about chronic disease during everyday life interactions. By showing negative effects of the epidemic's media coverage on the social experiences of people with chronic pain, we underscore needs for destigmatizing approaches in public communication regarding opioids.

Impact of the COVID-19 pandemic on the pharmacological, physical, and psychological treatments of pain: findings from the Chronic Pain & COVID-19 Pan-Canadian Study.

INTRODUCTION: Multimodal treatment is recognized as the optimal paradigm for the management of chronic pain (CP). Careful balance between pharmacological and physical/psychological approaches is thus desirable but can be easily disrupted. OBJECTIVES: This study aimed at exploring the impact of the COVID-19 pandemic on pharmacological and physical/psychological treatments of CP. METHODS: A Pan-Canadian cross-sectional web-based study was conducted between April 16th and May 31st 2020 among adults living with CP when the country was in the ascending slope of the first COVID-19 pandemic wave. RESULTS: A total of 2864 participants shared their treatment experience (mean age: 49.7 years and women: 83.5%). Among medication users (n = 2533), 38.3% reported changes in their pharmacological pain treatment. The main reasons were as follows: (1) changes in pain symptoms, (2) lack of access to prescribers/cancellation of medical appointments, and (3) increased medication intake in compensation for stopping physical/psychological treatments because of the pandemic. Among participants who used physical/psychological pain management approaches before the pandemic (n = 2467), 68.3% had to modify their treatments or self-management strategies. Common reasons were lack of access to clinics/exercise facilities and the need to compensate for having to stop another type of physical/psychological treatment because of the pandemic-related public health safety measures. CONCLUSIONS: Our study underlines the negative impact of the COVID-19 pandemic on access to pain relief, which is considered a fundamental human right. Results will help to justify resource allocation and inform the development of interventions to be better prepared for waves to come and future health crises.