General

Guideline Title

Assessment and management of pain.

Bibliographic Source(s)

Registered Nurses’ Association of Ontario (RNAO). Assessment and management of pain. Toronto (ON): Registered Nurses’ Association of Ontario (RNAO); 2013 Dec. 101 p. [192 references]

Guideline Status

This is the current release of the guideline.

This guideline updates previous versions: Registered Nurses Association of Ontario (RNAO). Assessment and management of pain. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2002 Nov. 142 p.

Registered Nurses Association of Ontario (RNAO). Assessment and management of pain: supplement. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2007 Feb. 27 p.

Regulatory Alert

FDA Warning/Regulatory Alert

Note from the National Guideline Clearinghouse : This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.

August 31, 2016 – Opioid pain and cough medicines combined with benzodiazepines: A U.S. Food and Drug Administration (FDA) review has found that the growing combined used of opioid medicines with benzodiazepines or other drugs that depress the central nervous system (CNS) has resulted in serious side effects, including slowed or difficult breathing and deaths. FDA is adding Boxed Warnings to the drug labeling of prescription opioid pain and prescription opioid cough medicines and benzodiazepines.

Recommendations

Major Recommendations

Definitions for the levels of evidence (Ia, Ib, IIa, IIb, III, IV) are provided at the end of the “Major Recommendations” field.

Practice Recommendations

Assessment

Recommendation 1.1

Screen for the presence, or risk of, any type of pain:

On admission or visit with a health-care professional
After a change in medical status
Prior to, during and after a procedure

(Level of Evidence = Ib)

Recommendation 1.2

Perform a comprehensive pain assessment on persons screened having the presence, or risk of, any type of pain using a systematic approach and appropriate, validated tools.

(Level of Evidence = Ib)

Recommendation 1.3

Perform a comprehensive pain assessment on persons unable to self-report using a validated tool.

(Level of Evidence = III)

Recommendation 1.4

Explore the person’s beliefs, knowledge and level of understanding about pain and pain management.

(Level of Evidence = III)

Recommendation 1.5

Document the person’s pain characteristics.

(Level of Evidence = IIa)

Planning

Recommendation 2.1

Collaborate with the person to identify their goals for pain management and suitable strategies to ensure a comprehensive approach to the plan of care.

(Level of Evidence = Ib)

Recommendation 2.2

Establish a comprehensive plan of care that incorporates the goals of the person and the interprofessional team and addresses:

Assessment findings
The person’s beliefs and knowledge and level of understanding
The person’s attributes and pain characteristics

(Level of Evidence = III)

Implementation

Recommendation 3.1

Implement the pain management plan using principles that maximize efficacy and minimize the adverse effects of pharmacological interventions including:

Multimodal analgesic approach
Changing of opioids (dose or routes) when necessary
Prevention, assessment and management of adverse effects during the administration of opioid analgesics
Prevention, assessment and management of opioid risk

(Level of Evidence = Ib)

Recommendation 3.2

Evaluate any non-pharmacological (physical and psychological) interventions for effectiveness and the potential for interactions with pharmacological interventions.

(Level of Evidence = Ib)

Recommendation 3.3

Teach the person, their family and caregivers about the pain management strategies in their plan of care and address known concerns and misbeliefs.

(Level of Evidence = Ib)

Evaluation

Recommendation 4.1

Reassess the person’s response to the pain management interventions consistently using the same re-evaluation tool. The frequency of reassessments will be determined by:

Presence of pain
Pain intensity
Stability of the person’s medical condition
Type of pain (e.g., acute versus persistent)
Practice setting

(Level of Evidence = IIb)

Recommendation 4.2

Communicate and document the person’s responses to the pain management plan.

(Level of Evidence = IIb)

Education Recommendations

Recommendation 5.1

Educational institutions should incorporate this guideline, Assessment and Management of Pain (3rd ed.), into basic and interprofessional curricula for registered nurses, registered practical nurses and doctor of medicine programs to promote evidence-based practice.

(Level of Evidence = IIb)

Recommendation 5.2

Incorporate content on knowledge translation strategies into education programs for health-care providers to move evidence related to the assessment and management of pain into practice.

(Level of Evidence = IIb)

Recommendation 5.3

Promote interprofessional education and collaboration related to the assessment and management of pain in academic institutions.

(Level of Evidence = Ib)

Recommendation 5.4

Health-care professionals should participate in continuing education opportunities to enhance specific knowledge and skills to competently assess and manage pain, based on this guideline, Assessment and Management of Pain (3rd ed).

(Level of Evidence = IV)

Organization and Policy Recommendations

Recommendation 6.1

Establish pain assessment and management as a strategic clinical priority.

(Level of Evidence = IV)

Recommendation 6.2

Establish a model of care to support interprofessional collaboration for the effective assessment and management of pain.

(Level of Evidence = IIb)

Recommendation 6.3

Use the knowledge translation process and multifaceted strategies within organizations to assist health-care providers to use the best evidence on assessing and managing pain in practice.

(Level of Evidence = III)

Recommendation 6.4

Use a systematic organization-wide approach to implement Assessment and Management of Pain (3rd ed.) best practice guideline and provide resources and organizational and administrative supports to facilitate uptake.

(Level of Evidence = IV)

Definitions:

Levels of Evidence

Ia Evidence obtained from meta-analysis or systematic reviews of randomized controlled trials

Ib Evidence obtained from at least one randomized controlled trial

IIa Evidence obtained from at least one well-designed controlled study without randomization

IIb Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization

III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies

IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities

Adapted from “Annex B: Key to evidence statements and grades of recommendations,” by the Scottish Intercollegiate Guidelines Network (SIGN), 2012, in SIGN 50: A Guideline Developer’s Handbook. Available from http://www.sign.ac.uk/guidelines/fulltext/50/annexoldb.html .

Clinical Algorithm(s)

The following clinical algorithms are provided in the appendices in the original guideline document:

Algorithm for assessing pain in hospitalized children
Algorithm for assessing pain in adults with cancer

Scope

Disease/Condition(s)

Pain (any type)

Guideline Category

Assessment of Therapeutic Effectiveness
Evaluation
Management
Prevention

Clinical Specialty

Family Practice
Nursing

Intended Users

Advanced Practice Nurses
Nurses

Guideline Objective(s)

To provide evidence-based recommendations for nurses and other members of the interprofessional team who are assessing and managing people with the presence, or risk of, any type of pain
To assist nurses and other members of the interprofessional team to focus on evidence-based strategies in the context of the provider-client relationship

Target Population

Patients of all ages and in all care settings with or at risk of acute or persistent pain

Interventions and Practices Considered

Evaluation/Screening

Comprehensive pain assessment
Discussion with patient on knowledge and understanding of pain management
Documentation of person’s pain characteristics

Management

Identification of person’s goals for pain management
Establishing a comprehensive plan of care
Pharmacological pain management plan
Non-pharmacological management of pain
Patient education about pain management strategies
Reassessing pain management

Major Outcomes Considered

Effectiveness of pain relief strategies
Safety and adverse effects of medications used to manage pain
Quality of life

Methodology

Methods Used to Collect/Select the Evidence

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Guideline Search Strategy

Structured Website Search

A member of the Registered Nurses’ Association of Ontario (RNAO) guideline development team (project coordinator) searched an established list of Web sites for guidelines.

Guidelines were selected based on the following criteria:

Focus on topic assessment and management of pain–in general (excluding condition specific entities e.g., musculoskeletal, cardiac or urology disease/disorders) for all types of pain (e.g., acute, persistent [chronic], nociceptive, neuropathic) which includes:
- Assessment
- Prevention & Management
- Education/Training programs
- Organizational Responsibilities
Published between 2007 to 2012
Published in English, national and international in scope
Accessible for retrieval

See the search strategy document (see the “Availability of Companion Documents” field) for a list of websites searched.

Hand Search

RNAO expert panel members were asked to review personal libraries to identify and submit potentially relevant guidelines. Guidelines submitted for consideration by RNAO expert panel members were integrated into the retrieved list of guidelines if they had not been identified by the on-line guideline search and met the inclusion criteria.

Guideline Review

Members of the expert panel critically appraised 16 international guidelines using the Appraisal of Guidelines for Research and Evaluation Instrument II. From this review, the eleven guidelines were selected to inform the review process.

Systematic Review Search Strategy

Concurrent with the review of existing guidelines, a search for recent literature relevant to the scope of the guideline was conducted with guidance from the RNAO’s chair of the expert panel. The systematic literature search was conducted by a health sciences librarian. The search, limited to English-language articles published between 2006 and 2012, was applied to CINAHL, EMBASE, DARE, Medline, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, ERIC, Joanna Briggs, and PsycINFO databases. The initial search for relevant studies returned 11,768 articles. Due to the volume of research, the inclusion criteria for study methodology was changed and limited to meta-analyses, systematic reviews, integrative reviews, randomized controlled trials and qualitative evidence syntheses. Detailed information about the search strategy for the systematic review, including the inclusion and exclusion criteria as well as search terms, is available online at www.RNAO.ca. Two research associates (master’s prepared nurses) independently assessed the eligibility of studies according to established inclusion and exclusion criteria. The RNAO Best Practice Guideline program manager working with the expert panel, resolved disagreements.

Number of Source Documents

11 guidelines and 88 studies were included.

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Levels of Evidence

Ia Evidence obtained from meta-analysis or systematic reviews of randomized controlled trials

Ib Evidence obtained from at least one randomized controlled trial

IIa Evidence obtained from at least one well-designed controlled study without randomization

IIb Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization

III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies

IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities

Adapted from "Annex B: Key to evidence statements and grades of recommendations," by the Scottish Intercollegiate Guidelines Network (SIGN), 2012, in SIGN 50: A Guideline Developer's Handbook. Available from http://www.sign.ac.uk/guidelines/fulltext/50/annexoldb.html.

Methods Used to Analyze the Evidence

Review of Published Meta-Analyses
Systematic Review with Evidence Tables

Description of the Methods Used to Analyze the Evidence

Guideline Review

Systematic Review

Two research associates (master’s prepared nurses) independently assessed the eligibility of studies according to established inclusion and exclusion criteria. The Registered Nurses’ Association of Ontario (RNAO) Best Practice Guideline program manager working with the expert panel, resolved disagreements.

Quality appraisal scores for 12 papers (a random sample of 14% of articles eligible for data extraction and quality appraisal) were independently assessed by the RNAO Best Practice Guideline research associates. Acceptable inter-rater agreement (kappa statistic, K=0.63) justified proceeding with quality appraisal and data extraction by dividing the remaining studies equally between the two research associates. A final summary of literature findings was completed. The comprehensive data tables and summary were provided to all panel members.

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

For this edition of the guideline, Registered Nurses’ Association of Ontario (RNAO) assembled an expert panel of health-care professionals comprised of members from the previous panel as well as other recommended individuals with particular expertise in this practice area. A systematic review of the evidence took into consideration the scope of the original guideline and subsequent revision supplement (2007). However, the ultimate focus of this review was on core competencies within the scope of nursing practice required for assessing and managing pain, which was supported by four clinical questions. It captured relevant literature and guidelines published between 2007 and 2012. These are the research questions that guided the systematic review:

What are the most effective nursing methods of assessment of pain in persons?
What are the most effective nursing interventions to prevent and manage pain in persons (pharmacological; non-pharmacological, complementary/alternative)?
What education is needed for nursing students on effective pain care?
How do health-care organizations support optimal pain assessment and management practices?

The RNAO expert panel’s mandate was to review the original (2002) and revision supplement (2007) in light of the new evidence, specifically to ensure the validity, appropriateness and safety of the guideline recommendations. This edition is the result of the expert panel’s work to integrate the most current and best evidence to update the guideline recommendations and supporting evidence from the 2007 revision supplement.

The comprehensive data tables and summary were provided to all panel members. In September 2012, the RNAO expert panel convened to revise and achieve consensus on guideline recommendations and discussion of evidence.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

External Peer Review
Internal Peer Review

Description of Method of Guideline Validation

Stakeholders representing diverse perspectives were solicited for their feedback.

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the “Major Recommendations” field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate assessment and management of pain

Potential Harms

Many opioid-naïve patients will develop nausea or vomiting when starting opioids, tolerance usually occurs within 5 to 10 days. Patients commencing an opioid for moderate to severe pain should have access to an antiemetic to be taken if required.
The majority of patients taking opioids for moderate to severe pain will develop constipation. Little or no tolerance develops. The commonest prophylactic treatment for preventing opioid-induced constipation is a combination of stimulant (senna or bisocodyl) and osmotic laxatives (lactulose or PEG 3350).
Sedation can be a common adverse effect when initiating opioids and when increasing opioid doses for pain management. Sedation generally precedes significant respiratory depression. Gradual increase in sedation is an early warning sign and a particularly sensitive indicator of impending respiratory depression in the context of opioid administration.

Contraindications

Transdermal fentanyl should not be used in opioid-naïve patients.
Meperidine and pentazocine should generally not be used in cancer patients with chronic or acute pain.
Pharmacologic treatment of delirium:
- Avoid benzodiazepines unless alcohol or benzodiazepine withdrawal is suspected.
- Avoid rivastigmine.
- Avoid antipsychotics if increased risk of Torsades de pointes.

Qualifying Statements

These guidelines are not binding on nurses or the organizations that employ them. The use of these guidelines should be flexible, and based on individual needs and local circumstances. They neither constitute a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Registered Nurses’ Association of Ontario (RNAO) give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work.
This nursing best practice guideline is a comprehensive document, providing resources for evidence-based nursing practice and should be considered a tool, or template, intended to enhance decision making for individualized care. The guideline is intended to be reviewed and applied in accordance with both the needs of individual organizations or practice settings and the needs and wishes of the person (throughout this document, the word “person” is used to refer to clients, or patients; that is, the person, their family and caregivers being cared for by the interprofessional team). In addition, the guideline provides an overview of appropriate structures and supports for providing the best possible evidence-based care.
Nurses, other health-care professionals and administrators who lead and facilitate practice changes will find this document invaluable for developing policies, procedures, protocols, educational programs and assessments, interventions and documentation tools. Nurses in direct care will benefit from reviewing the recommendations and the evidence that supports them. But the RNAO particularly recommends practice settings adapt these guidelines in formats that are user-friendly for daily use; some suggested formats for tailoring the guideline to your needs are included.

Implementation of the Guideline

Description of Implementation Strategy

Toolkit: Implementing Clinical Practice Guidelines

Best practice guidelines can only be successfully implemented if planning, resources, organizational and administrative supports are adequate and there is appropriate facilitation. In this light, the Registered Nurses’ Association of Ontario (RNAO), through a panel of nurses, researchers and administrators, has developed the Toolkit: Implementation of Best Practice Guidelines (2012). The Toolkit is based on available evidence, theoretical perspectives and consensus. The RNAO recommends the Toolkit for guiding the implementation of any clinical practice guideline in a health-care organization.

The Toolkit provides step-by-step directions to individuals and groups involved in planning, coordinating and facilitating the guideline implementation. These steps reflect a process that is dynamic and iterative rather than linear. Therefore, at each phase preparation for the next phases and reflection on the previous phase is essential. Specifically, the Toolkit addresses the following key steps, as illustrated in the “Knowledge to Action” framework in implementing a guideline:

Identify problem: identify, review, select knowledge (Best Practice Guideline).
Adapt knowledge to local context: * Assess barriers and facilitators to knowledge use * Identify resources
Select, tailor and implement interventions.
Monitor knowledge use.
Evaluate outcomes.
Sustain knowledge use.

Implementing guidelines in practice that result in successful practice changes and positive clinical impact is a complex undertaking. The Toolkit is one key resource for managing this process. The Toolkit can be downloaded at http://rnao.ca/bpg (see also the “Availability of Companion Documents” field).

Evaluating and Monitoring This Guideline

As you implement the recommendations in this guideline, the RNAO asks you to consider how you will monitor and evaluate its implementation and impact.

Table 7 in the original guideline document is based on a framework outlined in the Toolkit: Implementation of Best Practice Guidelines (2012) and illustrates some specific indicators for monitoring and evaluation of this guideline.

Implementation Strategies

Implementing guidelines at the point of care is multifaceted and challenging; it takes more than awareness and distribution of guidelines to get people to change how they practice. Guidelines must be adapted for each practice setting in a systematic and participatory way, to ensure recommendations fit the local context. Our Toolkit: Implementation of Best Practice Guidelines (2012) provides an evidence-informed process for doing that.

The Toolkit is based on emerging evidence that successful uptake of best practice in health care is more likely when:

Leaders at all levels are committed to supporting guideline implementation
Guidelines are selected for implementation through a systematic, participatory process
Stakeholders for whom the guideline is relevant are identified and engaged in the implementation
Environmental readiness for implementing guidelines is assessed
The guideline is tailored to the local context
Barriers and facilitators to using the guideline are assessed and addressed
Interventions to promote use of the guideline are selected
Use of the guideline is systematically monitored and sustained
Evaluation of the guideline’s impact is embedded in the process
There are adequate resources to complete all aspects of the implementation

The Toolkit uses a knowledge-to-action model that depicts the process of choosing a guideline in the centre triangle, and follows detailed step-by-step directions for implementing recommendations locally.

Implementation Tools

Audit Criteria/Indicators
Clinical Algorithm
Foreign Language Translations
Patient Resources
Resources
Tool Kits

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

Getting Better
Living with Illness
Staying Healthy

IOM Domain

Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)

Registered Nurses’ Association of Ontario (RNAO). Assessment and management of pain. Toronto (ON): Registered Nurses’ Association of Ontario (RNAO); 2013 Dec. 101 p. [192 references]

Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released

2002 Nov (revised 2013 Dec)

Guideline Developer(s)

Registered Nurses’ Association of Ontario - Professional Association

Source(s) of Funding

Funding was provided by the Ontario Ministry of Health and Long-Term Care.

Guideline Committee

Guideline Development Expert Panel

Composition of Group That Authored the Guideline

Development Panel Members

Judy Watt-Watson, RN, MSc, PhD
Panel Co-Chair
Professor Emeritus
The Lawrence S. Bloomberg Faculty of Nursing
University of Toronto
President, Canadian Pain Society
Senior Fellow, Massey College, University of Toronto
Toronto, Ontario

Denise Harrison, RN, PhD
Panel Co-Chair
Chair in Nursing Care of Children, Youth and Families
Children’s Hospital of Eastern Ontario (CHEO) and
University of Ottawa
Murdoch Childrens Research Institute, Australia
Honorary Research Fellow
The University of Melbourne Faculty of Medicine
Dentistry & Health
Sciences, Australia; Honorary Senior Fellow
Ottawa, Ontario

Janette Byrne, RN, BScN, CHPCN(C)
Palliative Pain and Symptom Management
Consultation Program
Nurse Educator
St. Josephs Health Centre
London, Ontario

Marg Cutrara, RN, MSN
PPSM Consultant, Clinical Nurse Consultant
Hospice Palliative Care
Southlake Regional Health Centre
Newmarket, Ontario

Darlene Davis, RN, MN
Health Services Manager, Pain Services
Capital District Health Authority
Halifax, Nova Scotia

Céline Gélinas, RN, PhD
Assistant Professor
Ingram School of Nursing
McGill University
Researcher and Nurse Scientist
Centre for Nursing Research and Lady Davis Institute
Jewish General Hospital
Montreal, Quebec

Nicholas Joachimides, RN, BScN, CRN(c), MCISC
Clinical Educator
Holland Bloorview Kids Rehabilitation Hospital
Toronto, Ontario

Salima S. J. Ladak, RN(EC), MN
Nurse Practitioner, Acute Pain Service – Toronto
General Hospital
Coordinator, UHN Pain APN Network
Toronto, Ontario

Shirley Musclow, RN(EC), MN
Assistant Professor
Lawrence S. Bloomberg Faculty of Nursing
University of Toronto
Toronto, Ontario

Lori Palozzi, RN(EC), MScN, NP
NP - Pediatrics
Anaesthesia Pain Service
The Hospital for Sick Children
Toronto, Ontario

Brenda Poulton, RN, MN, NP
NP Pain Management (Acute Pain Service)
Royal Columbian Hospital Fraser Health
New Westminster, British Columbia

Financial Disclosures/Conflicts of Interest

Declarations of interest and confidentiality were made by all members of the Registered Nurses’ Association of Ontario (RNAO) expert panel. Further details are available from the RNAO.

Guideline Endorser(s)

International Association for the Study of Pain - Medical Specialty Society

Guideline Status

This is the current release of the guideline.

Registered Nurses Association of Ontario (RNAO). Assessment and management of pain: supplement. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2007 Feb. 27 p.

Guideline Availability

Electronic copies: Available in English, Spanish, French, and Korean from the Registered Nurses’ Association of Ontario (RNAO) Web site.

Print copies: Available from the Registered Nurses Association of Ontario (RNAO), Nursing Best Practice Guidelines Program, 158 Pearl Street, Toronto, Ontario M5H 1L3.

Availability of Companion Documents

The following are available:

Toolkit: implementation of clinical practice guidelines. Toronto (ON): Registered Nurses’ Association of Ontario (RNAO); 2012 Sep. 154 p. Electronic copies: Available in Portable Document Format (PDF) from the Registered Nurses’ Association of Ontario (RNAO) Web site.
Registered Nurses’ Association of Ontario – Nursing Best Practice Guidelines Program assessment and management of pain-third edition-December 2013. Guideline search strategy. Toronto (ON): Registered Nurses’ Association of Ontario (RNAO); 2013 Dec. 6 p. Electronic copies: Available in PDF from the RNAO Web site.
Sustainability of best practice guideline implementation. Toronto (ON): Registered Nurses’ Association of Ontario (RNAO); 24 p. Electronic copies: Available in PDF and as a power point presentation from the RNAO Web site.
Educator’s resource: integration of best practice guidelines. Toronto (ON): Registered Nurses’ Association of Ontario (RNAO); 2005 Jun. 123 p. Electronic copies: Available in PDF from the RNAO Web site.

The appendices in the original guideline document contain various resources, including self-report and other tools for assessing pain in various populations and the Pasero Opioid-Induced Sedation Scale (PASS). Table 7 in the original guideline document contains indicators for evaluation and management.

Print copies: Available from the Registered Nurses’ Association of Ontario (RNAO), Nursing Best Practice Guidelines Project, 158 Pearl Street, Toronto, Ontario M5H 1L3.

Mobile versions of RNAO guidelines are available from the RNAO Web site.

Patient Resources

The following are available:

Health education fact sheet. Helping you manage your pain. Toronto (ON): Registered Nurses’ Association of Ontario (RNAO); 2 p. Electronic copies: Available in Portable Document Format (PDF) from the Registered Nurses’ Association of Ontario (RNAO) Web site.
Health education fact sheet. Helping people manage their pain. Toronto (ON): Registered Nurses’ Association of Ontario (RNAO); 2 p. Electronic copies: Available in PDF from the RNAO Web site.

Print copies: Available from the Registered Nurses’ Association of Ontario (RNAO), Nursing Best Practice Guidelines Project, 158 Pearl Street, Toronto, Ontario M5H 1L3.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline’s content.

NGC Status

This NGC summary was completed by ECRI on December 17, 2003. The information was verified by the guideline developer on January 16, 2004. This summary was updated on May 3, 2005 following the withdrawal of Bextra (valdecoxib) from the market and the release of heightened warnings for Celebrex (celecoxib) and other nonselective nonsteroidal anti-inflammatory drugs (NSAIDs). This summary was updated by ECRI on June 16, 2005, following the U.S. Food and Drug Administration advisory on COX-2 selective and non-selective non-steroidal anti-inflammatory drugs (NSAIDs). This NGC summary was updated by ECRI Institute on January 3, 2008. The updated information was verified by the guideline developer on March 4, 2008. This summary was updated by ECRI Institute on May 1, 2009 following the U.S. Food and Drug Administration advisory on antiepileptic drugs. This NGC summary was updated by ECRI Institute on March 20, 2014. This summary was updated by ECRI Institute on June 2, 2016 following the U.S. Food and Drug Administration advisory on Opioid pain medicines. This summary was updated by ECRI Institute on October 21, 2016 following the U.S. Food and Drug Administration advisory on opioid pain and cough medicines combined with benzodiazepines.

Copyright Statement

With the exception of those portions of this document for which a specific prohibition or limitation against copying appears, the balance of this document may be produced, reproduced, and published in its entirety only, in any form, including in electronic form, for educational or non-commercial purposes, without requiring the consent or permission of the Registered Nurses’ Association of Ontario, provided that an appropriate credit or citation appears in the copied work as follows:

Registered Nurses’ Association of Ontario (2013). Assessment and Management of Pain (3rd ed.). Toronto, ON: Registered Nurses’ Association of Ontario.

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