Appendix 1: Literature review of adult chronic pain

Core Standards for Pain Management Service in the UK (CSPMS) Team

MDT - The multidisciplinary team must include medical consultants trained in chronic or acute pain medicine as appropriate, nurses, physiotherapists, psychologists, pharmacists, and often occupational therapists, and, where available, suitably trained GPs with a special interest (GPwSI) and SAS doctors.

Specialist Pain Management Services in community and secondary care should always involve an MDT; how the MDT is delivered may vary according to local factors, e.g., in remote/rural areas.

Specialised Pain Management Services in a tertiary centre should always involve a multispecialty and multidisciplinary team.

Team function

The multidisciplinary team must communicate regularly and effectively with the patient’s general practitioner.

Pain management services should be staffed and operate to accommodate the local requirements of all patient groups, including children, adolescents, the elderly, and those with complex needs.

Formal MDT meetings are desirable when managing complex pain cases. These meetings should involve representatives from the patient’s medical team, chronic pain specialists, physiotherapists, or psychologists.

The MDT should seek formal arrangements for inclusion of all clinicians involved in the provision of pain management services. This should include speciality doctors, GPs, and locum staff. All GPs should be able to assess pain, triage for serious pathology, assess psychosocial factors that may maintain disability and distress, and instigate simple pain management strategies, evaluate such strategies and triage to specialist pain management services if the patient is not responding or improving within eight weeks.

The multidisciplinary and multispecialty team must have adequate administrative support.

Clinical governance requires ongoing audit and data collection. All MDT and multi-speciality teams should participate in audit and outcome data collection.

Use of technology, triage systems, early intervention & escalation points

Pain Management Best Practices Inter-Agency Task Force Report. Department of Health and Human Services USA

ACI NSW Agency for Clinical Innovation Pain Management Programs – Which Patient for Which Program? A guide for NSW Tier 3 and Tier 2 public health facilities providing pain programs for adults

Individual patient: Practitioners with appropriate skills, working in coordinated way (e.g., clinical psychologist + physiotherapist + GP/Specialist)

Low-medium intensity group: Two or more staff (may include psychologist, physiotherapist, occupational therapist, nurse). Coordinated with medical management

High intensity group: Three or more staff (may include psychologist, physiotherapist, occupational therapist, nurse, psychiatry in paediatrics), with specific medical input (for medication and education). Use of education first. Patient suitability criteria determine what group patient is best

Admission to PMP should follow appropriate multidisciplinary assessment to confirm suitability and identify relevant individual goals.

A PMP may be a part of a series of interventions but should be planned to ensure effective engagement of the person and consistent support of their treatment providers.

PMP typically conducted by an MDT that works in a interdisciplinary way.

Evaluation of outcomes (in terms of achievement of specific goals and common functions, e.g., disability, mood, pain, health care utilisation) is essential (e.g., 1/12, 3/12, 6/12, 12/12 follow up)

PMP require staff with appropriate skills and training (so provision must be made to ensure this is the case for all staff).

To date, the most consistent evidence is that a background understanding and knowledge of cognitive behavioural management therapies, principles and methods is appropriate for all participating staff. 14. Recognition that co-morbid conditions (e.g., spinal cord injuries, diabetes, Post-Traumatic Stress Disorder, Major Depression, Personality Disorders) can complicate participation in a PMP and need to be addressed on an individual basis (e.g., with individual therapy in conjunction with PMP)

Pre assessment education - Enable those referred to a pain service to gain an accurate appreciation of the service and the opportunity to decide if it could meet their needs

STEPS: Self-Training Educative Pain Sessions delivered by members of their multidisciplinary pain team to prospective pain service patients. Followed by a substantial reduction in waiting times for those wishing to still attend their pain service.

‘Individualised, multimodal, multidisciplinary pain management’ - Medications (opioid and non-opioid) - Restorative therapies - Interventional procedures - Behavioural health approaches - Complementary & integrative health

- Found that many gained enough ideas on pain self-management at these sessions not to need more help by the pain service - Davies and colleagues have been careful to emphasise that this level of intervention is unlikely to be enough for the more disabled and depressed patients, especially those who have become more reliant on medication to cope - Those patients who have to make major lifestyle changes in order to live with their chronic pain will still need the help of sorts of programmes outlined further in this document

STEPS approach can provide a useful introduction to a pain service and promote more efficient use of scarce resources. Currently 10/19 NSW pain services offer a pre assessment pain education and orientation programme.

The objectives are to: • explain the ‘whole person’ approach • triage appropriate patients for priority assessment • begin patient engagement, manage expectations, and promote readiness • provide early access to information following referral • provide the opportunity for patients to opt out if the model is not aligned with their expectation • provide exposure to information and resources • to maximise clinic time.

Telehealth consultations with Aboriginal people for pain management

Pain Australia –National Pain Strategy

Optimal to ensure a health or community worker is in attendance, as well as any family members desired. The service can be offered in several ways – directly to a person in their own home, to the GP’s room, to the Aboriginal Medical Service or to the hospital. Pain clinic services can be offered via telehealth to Aboriginal people using Healthdirect Australia’s videocall and other platforms.

Best-practice pain management often requires coordinated interdisciplinary assessment and management involving, at a minimum, physical, psychological, and environmental risk factors in each patient.

- Train and support health practitioners in best practice pain assessment and management - Establish and promote systems and guidelines to ensure adequate management of acute, chronic and cancer pain - Develop and evaluate patient-centred service delivery and funding models for pain management in the community which provide interdisciplinary assessment, care, and support as a part of comprehensive primary health care centres and services - Comprehensive education and training in pain management will give medical, nursing, and allied health professionals in the public and private sectors the knowledge and resources to deliver such care. Education in the biopsychosocial processes underpinning acute and chronic pain will give health professionals an accurate conceptualisation of pain and underpin care. - Participants are referred from primary care and secondary care specialists (orthopaedic surgeons and rheumatologists, in particular). In both cases, referral may be initiated at the request of the individuals. Most individuals will have received specialist care. Ensure meaningful communication about pain management between practitioners and patients, and between practitioners

British Pain Society –Guidelines for Pain Management Programmes for Adults

Many different healthcare professionals including doctors, nurses, psychologists, physiotherapists, and occupational therapists play a part in effective pain management care.

A PMP is delivered by an interdisciplinary team where some competencies are shared, and some are unique to professions. All staff use cognitive behavioural principles to deliver their component(s) of the PMP.

- Medical - Psychologist - Physiotherapist - OT - Nurse - Pharmacist - Clinical support workers - Administration PMPs consist of methods to promote behaviour change and promote well-being. They include education on pain physiology, pain psychology, general health, and pain self-management. PMPs also contain guided practice on exercise and activity management, goal-setting, identifying, and changing unhelpful beliefs and ways of thinking, relaxation and changing habits which contribute to disability. Participants practise these skills in their home and other environments to become expert in their application and in integrating them into their daily routines. Methods to enhance acceptance, mindfulness and psychological flexibility are also recommended.

PMPs are delivered in a group format to normalise pain experience, to maximise the possibilities of learning from other group members and for economy. However, an important addition to this document is the recognition that the content of PMPs may in some circumstances be best provided on an individual basis.

As part of a PMP, education should be provided by all members of the interdisciplinary team, according to their expertise, using an interactive style to enable participants to raise and resolve difficulties in understanding material or in applying it to their situations or problems.

Leadership - Leadership within local management structures and in the daily running of the team and programme is crucial. The discipline or title of the leader(s) is less important than the identification and recognition of these roles. Consideration should be given to professional and clinical support and supervision and necessary resources for the post-holder(s)

- Most NHS staff are accustomed to management hierarchies within their discipline. True interdisciplinary teams require cross-discipline management structures.

The Alberta Pain Strategy 2019-2024

Shifting away from the traditional medical model of pain management and treatment and instead looking at ‘the whole person’ using a modified biopsychosocial model.

While not incorporated within the traditional biopsychosocial model, also recognize that the spiritual aspect of health is important to many, and as such, we will be incorporating this element into our approach for pain Multimodal Pain Strategies, including Appropriate Pharmacologic Interventions The best treatment for acute pain is a multimodal approach involving both pharmacologic and non-pharmacologic treatments (psychological, physical therapy, and a wide variety of other therapeutic options) (Tick et al., 2018; U.S. Department of Health and Human Services, 2019).

Though opioids have a role to play in acute pain, opioid prescribing needs to be done in conjunction with a multimodal strategy, including the use of non-opioid medications, patient education, adequate patient monitoring and follow-up, and with opioid stewardship regarding duration, escalation, and tapering. Strategies for improved management of acute pain and early recognition of patients at risk of Access: Improve access to multimodal resources, a modified biopsychosocial approach, and interdisciplinary teams for people with chronic pain and their support systems to ensure optimal and equitable access to pain care for all Albertans.

- the historically uncoordinated development of pain services across Alberta has resulted in a combination of duplication of services, silos of unrelated services with differing philosophies of care, and large gaps in access.

- Evidence-informed care for chronic pain includes a biopsychosocial, interdisciplinary approach. Not every patient requires team-based care, but for those who do, access to rehabilitation (physiotherapy, kinesiology, occupational therapy), psychological services (including addressing social and financial barriers to treatment), and medical management is essential for high quality care.

Team working - The coexistence of staff with a shared purpose does not make a team. Working together as a team requires frequent and regular times to meet and arrive at shared understandings of participants’ needs and staff provision. Team members also need to appreciate one another’s areas of unique and shared expertise.

- All staff can benefit from discussion with the clinical psychologist or equivalent on the application of cognitive and behavioural principles to their area of work.

Professional development - All staff working as part of an interdisciplinary PMP should have adequate access to continue within-discipline education and development specific to the area of pain, as well as to their own broader areas of professional interest. This should entail attending relevant national meetings and special interest groups and networking with fellow professionals in PMPs outside their geographical area. In depth triage criteria.

Pain management treatment should be offered when indicated by persistent pain causing distress, disability, and a negative impact on quality of life. Treatment is usually offered as a group treatment, but individual therapy is more appropriate for some people.

Screening should be used to identify the factors which are likely to present as obstacles to recovery. These are likely to be, for example: fears about being physically active with pain, the participant’s perceptions about the safety of their job and the attitude of the participant and the employer towards chronic pain and the workplace (Shaw et al., 2009; Nicholas et al., 2011). (2+)

Assessment for inclusion in a PMP should include appropriate medical screening to exclude treatable. disease, to discuss treatment options or the lack of them, and to introduce the concepts of persistent pain and pain management, if this has not already been done. This may be done in primary or specialist settings, according to expertise. Although GPs may be adequately trained in pain management, many more will seek advice and guidance from specialist services. Until GP training is reviewed and improved, issues of participant safety would indicate that specialist advice is recommended (CMO Report: Donaldson L. (2009).

These potential obstacles to return to work should be assessed early and addressed in the treatment process. The level of motivation to work should be routinely highlighted in the assessment process.

It is recommended that obstacles to recovery be assessed in three main domains (Watson et al., 2010): - Psychosocial factors (Yellow Flags), which include fear avoidance beliefs, catastrophizing, attitudes to work and working, psychological distress and pain coping strategies (Nicholas et al., 2011). (2++)

- Perceptions about work (Blue Flags), which include physical job demands, ability to modify work, job stress, workplace social support or dysfunction and job satisfaction (Shaw et al., 2009). (2++)

- Organisational factors (Black Flags), which include the sickness certification process, lack of alternative employment, lack of access to services to assist return to work and lack of interest in rehabilitation from employer (Krause et al., 1998; Young et al., 2005). (2++)

management and referring to it throughout the Strategy as a modified biopsychosocial model.

Understand the complexity of pain and that the approach to pain management will differ based on the type of pain as well as the illness trajectory. As such, recognize an accurate diagnosis is important, in conjunction with a careful explanation of pain, and the need for an interdisciplinary team approach and evidence informed treatments. developing chronic pain offer important preventative options in decreasing the prevalence of chronic pain (Breivik & Stubhaug, 2008; De Kock, 2009; Pain Australia, 2011).

A key theme that emerges from the literature is that the effective assessment and management of pain requires a continuum of care involving a range of healthcare disciplines working in collaborative partnerships with those in pain (Pain Australia, 2011).

In Alberta, the following are identified as non-pharmacological areas that can be improved through multimodal care: • Pain assessments. • Shared decision making tools, including pain medication tapering strategies upon discharge. • Consideration of all aspects of an individual’s pain experience, described by the biopsychosocial model for pain. • A need to screen patients to determine who is at risk of transitioning to chronic pain

Transitional Pain Service Certain factors increase the risk of developing chronic pain, such as poorly managed acute pain, opioid use, mental health conditions such as anxiety and depression, pain catastrophizing, and trauma symptoms (Hinrichs-Rocker et al., 2009; Theunissen et al., 2012).

A Transitional Pain Service comprehensively addresses the problem of chronic pain preoperatively, postoperatively in hospital, and in the outpatient setting. This service, which may take place in an inpatient or outpatient setting, may improve patients’ pain trajectories, preventing the transition from acute to chronic pain, while reducing suffering, disability, and healthcare utilization and opioid dose escalation.

The goal is to support patients through the stages of surgical recovery. This service works in an interdisciplinary model, focusing on multimodal analgesia with the support of a team including nursing, anaesthesiology, psychology, pharmacy, and with access to addictions specialists. - Innovative models and Virtual Health strategies are necessary to make this possible, regardless of geographic location, e.g., Alberta Telehealth.

Review Article: A Comprehensive Review of Telehealth for Pain Management: Where we are and the way ahead

Sapere – The problem of chronic pain and scope for improvements in patient outcomes

National Strategic Action Plan for Pain Management –Australian Department of Health

Current New Zealand workforce estimated at 11 FTE specialist pain medicine physicians (from 35 Pain Medicine Fellows).

Based on FTE ratio of one per 100,000 patients around 47 FTE is required. This is a deficit of 36.

Situation likely to worsen as pain medicine workforce is aging. 65% of specialists are currently aged 50 years and over.

Specialist pain medicine physicians bring a multi-disciplinary focus – objective of restoring functionality and enabling individuals to live as independently as possible.

Solid evidence of the benefits of multidisciplinary care from experience internationally and in Australia. Controlled trials show that integrated medical, physiotherapy, and psychological interventions using cognitive-behavioural methods can be more effective than usual care in limiting the impact of recent onset back-pain, especially where psychological and social risk factors are present.

Maintaining workforce requires an additional 23 trained specialists in the next 15 years. Assuming there are currently 35 Pain Medicine Fellows and 65 per cent are aged over 50, so would retire within the next 15 years.

At its maximum the existing training allocation would produce four specialists every two years, meaning that the current training system should produce the required amount of pain specialists in 15 years (up to 30 specialists) to maintain the existing workforce available. Three accredited training units – Auckland Regional Pain Service (TARPS), Burwood Hospital Christchurch and Wellington Regional Pain Unit.

4 funded positions for the two-year pain medicine training program. Mainly funded by DHBs. Demand for training positions regularly exceeds supply.

4 currently training in accredited units (2 TARPS, one each in Wellington and Christchurch). 4 Others have completed training time but have outstanding assessments.

MDT likely to include - Physician - Clinical psychologist or psychiatrist - Physiotherapist or other allied health professional such as an OT, pharmacist and may include a dietician and social worker or counsellor - Nurses are an important part of MDT Empowering consumers through - Knowledgeable communities - Skilled health practitioners - Active health professional bodies and colleges - Priority settings and actions led by governments with consumers - Integrated primary health networks - Coordinated research and knowledge base - Supportive workplaces and insurance systems - Active advocacy and influence peak groups - Capable community support groups - Empowered and supported carers and families

Limited ability to increase NZ’s pain medicine workforce by recruiting international medical graduates as there are very few comparable pain medicine training programmes internationally.

Shortage, increased risk of stress and burnout

Interdisciplinary Pain management - Treatment is not ‘one-size-fits-all’ Telehealth is suited to the needs of patients who are unable or unwilling to seek care in-clinic (e.g., disability, stigma, other access issues). There is a paucity of reliable information about the efficacy of telehealth services for these patients.

Clear that scientific rigour of most pain related telehealth studies is less that optimal.

People living in pain can be best supported in primary care with only a small proportion requiring tertiary care

Interdisciplinary pain management - Empowered consumers and carers - Integrated care including electronic health systems - Telehealth to link specialist services - Specialist pain medicine physicians accessible across the sector - Funding models that underpin affordable and coordinated health services - Education, training, and support for health professionals

- Development of overarching education strategy to promote evidence based pain management education - Validated assessment and monitoring tools for chronic pain - Develop national clinical guidelines on pain and support for health providers to provide best practice pain management as outlined in the National Pain Strategy

An Action Plan for Pain in Canada – Health Canada

Models of care for addressing chronic Musculoskeletal pain and health in children and adolescents –Stinson et al

- Interprofessional assessment and management Critical factor in the development of an effective pain management plan is face to face discussion by consumers and team members on the relative importance of factors identified by them in the patient AND ongoing communication between team members and patients on the progress of the pain management strategy. - Review of existing decision plain support systems available - Expand training opportunities for health practitioners in pain management - Develop a 6 month workplace based certificate in clinical pain medicine for GPs - Creation of a public database of health practitioners who have completed pain management training courses - MBS item for pain education - MBS item for GPs with specialist qualification in pain medicine - specific materials and engagement activities to provide prescribers with guidance on the quality use of medications

‘Goal two -people have equitable and consistent access to a continuum of timely, evidence-informed, and person centred pain care and supports across jurisdictions’

‘Goal three – people living with pain and health professionals have the knowledge, skills and educational supports to appropriately assess and manage pain based on population needs. The broader community understands pain as a legitimate, biopsychosocial condition and stigma is reduced’ System reform and innovative person-centred pathways and models of care - Designed to build specialist capacity - How best to develop and implement innovative person-centred care pathways (such as stepped care, hub and spoke models, or transitional pain services) to improve early access to pain assessment, treatment, and management - Enable models that cross provincial boundaries to support seamless care and consistent access to specialty hubs - Ensure adequate connection of rural, remote, and indigenous communities to speciality networks, hubs, and services

National standards and guidance - National mechanism to develop and disseminate pain-related guidance and best practices in the organisation and provision of care - Mechanism needs to include dedicated activities that support knowledge translation and mobilisation as well as ongoing review and evaluation of guidelines over pre-determined intervals

Virtual treatment, self-management, and peer-supports - National pain specific online portal for people to access an interactive repository of services, information, and resources, with appropriate psychosocial supports for navigation of resources as needed - Connect this portal and integrate pain-related content with other online resources (e.g. federally funded platforms like ‘Wellness Together Canada’ and the ‘Knowledge Development and Exchange youth mental health HUB’ - Ensure these online platforms have telephone options and adequate means of access for those without adequate internet services

Health system organisation and delivery of care - Ensure that clinicians understand their obligations to treat or redirect patients regardless of pain condition, complexity of symptoms, and/or history or current use of opioids - Create capacity to spread existing and develop new best practice education/training programs and initiatives across Canada at the community, regional, provincial, and national levels - Enable staff in telehealth and general referral systems to link people to necessary chronic pain resources and supports - Educate clinicians on specific chronic pain diagnostic coding and measurement resources - Encourage health professionals working with Indigenous Peoples to understand Indigenous specific definitions of pain and hurt, how it is expressed, preferences for treatment and management, and concepts of Two-Eyed Seeing

Pre-Licensure education and training - Align with international best practices - Focus on not only profession-specific but also interprofessional competencies that recognise the full range of professions relevant to pain Integrate individuals with lived and living experience into training education and curricula development

MoC = ‘evidence informed policy or framework that outlines the optimal manner in which condition-specific care should be made available and delivered to consumers’

Young people (children and adolescents) should not be viewed as ‘little adults’

- Typically, usually present to primary care providers - Many primary care providers report lack of confidence in their paediatric MSK clinical skills and thus may unnecessarily report these children who may be difficult to assess to sub-specialists (paediatric rheumatologists or chronic pain programmes) - Evidence subspecialists are overburdened, resources are managed inefficiently, and unnecessary costs are incurred (e.g., children undergoing unnecessary, costly, and sometimes painful investigations) - Highlighted need to adopt a biopsychosocial approach MoC’s implemented through:

Integration of services - Coordinated and integrated health services across sectors are an essential ingredient to the successful implementation of CMP MoCs

Harnessing technology to improve access - Movement towards building consumer capacity to reduce care disparities related to geographical, financial or health literacy barriers through digital health tech - E.g., telehealth, online interventions, and mobile apps - An advantage of these therapies is that they can enable non-specialists and peers to be trained to provide pain management support, thereby improving access particularly to children and adolescents living in rural remote areas

RCT of nurse delivered CBT versus supportive psychotherapy telehealth interventions for chronic back pain – Rutledge et al 2018

Results suggest that telehealth, nurse-delivered CBT, and SC treatments for chronic back pain can offer significant and relatively comparable benefits.

Results that a primary care nurse trained in delivery of a telehealth CBT or SC treatment can produce statistically significant benefits among patients with chronic low back pain, with benefits comparable between the two interventions.

Nurses in primary care settings who were trained with behavioural pain therapies could reduce the number of referrals to speciality mental health or pain clinics where behavioural pain therapies are usually available only in limited supply.

The results from recent, high-quality, clinical trials of telehealth interventions for chronic pain suggest that these treatments can have significant benefits for pain outcomes ad that they be better suited to the future model of medical care in shifting from hospital or clinic based to home-based care.

The Pain Course: 12- and 24- month outcomes from a RCT of an Internet-Delivered Pain Management Program Provided with Different Level of Clinician Support – Dear et al 2018

Findings suggest that the outcomes of internet-delivered programs may be maintained over the long term. Clinically significant decreases were maintained at 12 and 24 month follow up for disability, depression, anxiety, and average pain level measures.

A cost-effectiveness analysis of an internet-delivered pain management program delivered with different levels of clinician support – results from an RCT –Dear et al 2021

Findings suggest that carefully developed and administered internet-delivered PMPs, provided with different levels of clinician support had reduced distress and disability maintained over two years.

Inequity in outcomes from New Zealand Chronic Pain Services – Lewis et al, 2021

At treatment end, there were significantly poorer scores for Pacific people compared to Europeans for several of the DASS-21 and PCS subscales, while there were no differences between European, Māori and Asian ethnicities. At follow-up, almost all outcome measures were poorer for Māori compared to European, and several of the DASS-21 and PCS subscales were poorer for Asian and Pacific people compared to Europeans. - More prominent disparities in the psychosocial variables - Findings suggest Māori responded well during the treatment period but that this was not maintained once treatment ceased

- Ethnic disparities in access to chronic pain management services have been reported in both New Zealand and internationally. - In NZ ACC provides funding for people with, or at risk of developing chronic pain related to an accident or injury to attend private pain management services

** Different cultures have different beliefs and frameworks for experiencing, interpreting, and managing pain, some of which may clash with the biopsychosocial framework currently implemented by pain management clinics. For example, spirituality and the concept of whānau rather than individual health are integral components of health for Māori, Pacific people, and some Asian cultures. Clinicians have previously acknowledged the importance of spiritual beliefs in managing pain and it is known that adherence to treatment improves when patients and clinicians share cultural beliefs.

- Cultural safety of chronic pain clinics should be reviewed in regard to both assessment and management procedures - Would be useful to determine the validity of the current questionnaires in Māori, Pacific, and Asian populations in New Zealand - Clinicians should take the time to explore spiritual components and cultural beliefs relating to pain, as well as the impact of pain on whānau health and cultural and social activities - Traditional cultural beliefs and practices can be meaningfully incorporated into management when they are concordant with evidence-based pain management principles - Emphasis needed on self-management and long-term strategies to maintain the gains obtained during treatment - Need to address communication barriers

Ethnic disparities in attendance at New Zealand’s chronic pain services – Lewis, Upsdell 2018

Across all services that provided data, Europeans were overrepresented by 9% while Pasifika and Asians were under-represented by 58% and 49% respectively. Māori patients scored significantly worse than Europeans in all clinical assessment measures, while Pasifika and Asian patients score worse on the majority of measures.

Ethnic disparities in access to chronic pain services are evident by the marked under-attendance of Pasifika and Asian ethnicities. Māori, in particular, also have a greater need for healthcare related to pain.

‘The Doctor doesn’t need to see you now:’ reduction in general practice appointments following group pain management – Clare et al 2019

Patients living with chronic, non-malignant, musculoskeletal pain are frequent visitors to GP services, placing a large burden on resources. Study showed 43.3% decrease in the number of GP appointments in the yar following a Pain Management Program (PMP).

A systemic Review of Technology-assisted SelfManagement Interventions for Chronic Pain – Heapy et al 2015

Across modality, the existing evidence suggests that technology-assisted psychological interventions are efficacious for improving self-management of chronic pain in adults. All modalities have been shown to provide benefit and no clearly superior modality has emerged.

The pain course: exploring predictors of clinical response to an Internet-delivered pain management program – Dear et al 2016

The current findings suggest that a broad range of patients may benefit from emerging Internet-delivered pain management programs and that it may not be possible to predict who will or will not benefit based on patient’s demographic, clinical and psychological characteristics.

Evaluation of an innovative tele-education intervention in chronic pain management for primary care clinicians practising in underserved areas –Furlan et al, 2019

ECHO – Extension for community healthcare outcomes. Uses case-based learning and videoconferencing to connect specialists with providers in underserved areas. ECHO aims to increase capacity in managing complex cases in areas with poor access to specialists. - Collaborative model of tele-health education and care management that empowers participating clinicians to provide expert level care in their own communities.

ECHO Ontario Chronic Pain/Opioid Stewardship includes an interprofessional group of CP experts, the ‘hub.’ - The Hub connects with multiple primary healthcare providers, the ‘spokes’ in Ontario using video conference once a week - The hub team includes physicians (pain medicine, addiction, family medicine, neurology, physiatry and psychiatry), psychologists, nurse, social worker, PTs, OTs, pharmacists, chiropractor and medical librarian, and a telemedicine technician

59% were prescribers or PAs and NPs who have an indirect influence on the prescriber they work with. 18% were pharmacists and RNs and the other 23% were allied health professionals.

Primary health care providers attended ECHO – participants were physicians, NPs, pharmacists, and allied health professionals

Study shows that ECHO improved providers’ self-efficacy and knowledge. All professions improved self-efficacy, but the groups of physicians, PAs and NPs had the highest gain in self-efficacy compared to the other professions. Evaluated outcomes from a multidisciplinary group practising in Ontario. Suggestion that the project may be used as a template for creating other educational programs on other medical topics.

Results showed that ECHO significantly improved participants’ knowledge regarding CP assessment, treatment, and opioid prescribing.

Systematic evaluation of commercially available pain management apps examining behaviour change therapy (BCTs) – Gamwell et al, 2021

Current pain management apps often use evidence-based pain management BCTs.

Awareness, experiences and perceptions of telehealth in a rural Queensland community –Bradford et al, 2015

For telehealth initiatives to be successful there needs to be greater public awareness and understanding of the potential benefits of telehealth. Empowering patients as partners in the delivery of healthcare may be an important factor in the growth of telehealth services.

Psychological therapies (remotely delivered) for the management of chronic and recurrent pain in children and adolescents (Review) – Fisher et al, 2019

Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC644 5568/

- Psychological therapies delivered remotely (primarily via the Internet) were helpful at reducing pain for children and adolescents with headache when assessed immediately following treatment. However, did not find a beneficial effect for these children at follow‐up. - Found no beneficial effect of therapies for reducing pain intensity for children with other types of pain. Further, did not find beneficial effects of remotely‐delivered therapies on physical functioning, depression, or anxiety post‐treatment for headache and mixed chronic pain conditions. - However, there were limited data for mixed chronic pain conditions to draw conclusions from these outcomes, particularly at follow‐up. Satisfaction with treatment was described in the trials and was generally positive. Six trials described side effects which were not linked to receiving psychological therapies.