Cover

When The Pain Refuses To Go Away

Even when there is no physical cause, it is rea reaming out for treatment, and may be a lifelong burden

Patricia Chisholm August 16 1999
Cover

When The Pain Refuses To Go Away

Even when there is no physical cause, it is rea reaming out for treatment, and may be a lifelong burden

Patricia Chisholm August 16 1999

When The Pain Refuses To Go Away

Even when there is no physical cause, it is rea reaming out for treatment, and may be a lifelong burden

Patricia Chisholm

From the age of 21, Pat Bauer learned to fear the brainsearing migraines that meant cancelled social engagements, time off work and hours in bed, waiting out the agony. She popped a dizzying array of pills—including powerful doses of morphine—tried natural therapies like herbs, and slept with an ice pack on her head. But there was never any real escape from what became a daily battle with pain. “Some days, I just wished I could drive into a truck and end it all,” the 49-year-old BC Tel supervisor recalls.

Finally, a frustrated family doctor near Bauer’s home in Celista, east of Kamloops, referred her to a multidisciplinary pain centre at St. Paul’s Hospital in Vancouver. First, she was taken off heavy painkillers and put on Nardil, an older generation antidepressant now sometimes used for severe headaches. Her daily regimen for the three weeks in April that she spent at the clinic included physiotherapy, occupational therapy, self-hypnosis and “positive affirmation”—using thoughts to combat the tension and low mood that can make chronic pain worse. Now, Bauer’s headaches are far fewer in number and easier to control. “I need much less sleep and I have a lot more energy,” she says. “It’s so neat to see the world with a clear head. I feel as if I’ve been reborn.”

Aching, stabbing, pounding, throbbing pain: most people

have experienced troubling physical discomfort that drags on for weeks or months. The vast majority recover with little or no medical intervention. But for a significant minority—an estimated five to 15 per cent of the population—chronic pain caused by migraines, low-back pain and nerve damage among other ailments, turns into a lifelong burden. The financial consequences are huge: at least $8 billion a year in Canada, including lost work time, insurance benefits and medical attention. “Treatment is very time consuming and resource intensive,” notes Allan Gordon, a neurologist at Mount Sinai Hospital in Toronto who is helping set up a centre for the study of chronic pain at the University of Toronto. “It’s only now

that society is starting to recognize the extent of the problem.”

There are new reasons for hope, however. Almost every province now has at least one integrated pain clinic, like the one at St. Paul’s, that brings together a wide range of disciplines, from anesthesia, to psychiatry and physiotherapy. Doctors are also gaining fresh insights from a new wave of epidemiological studies revealing who is at risk of chronic pain and which treatments work best. And while many ff doctors remain cautious about opioids—morphine-like drugs with addictive potential—some pain specialists say they should be used when all else fails because addiction is jjj rare among well-supervised patients (page 58).

For patients, though, a big problem still is one of the oldest—convincing others that they really are suffering. Many people with chronic pain that is not life-threatening look healthy. That can make getting treatment, benefits and moral support difficult. Patricia English, who lives in New Westminster, B.C., stopped working as an administrative assistant for the provincial government after experiencing acute headaches in 1993. In 1995, she was diagnosed with fibromyalgia. The disease, which has no known cause or cure, leaves sufferers feeling achy and tired all the time.

English, 42, says that on a “good” day, she might be able to make the bed. On a bad day, she never leaves it. There

are no good therapies for her condition: she takes Tylenol 3 for severe pain, but mostly she simply endures. So it was particularly hard when she was initially denied disability by her employer’s insurer—she had to appeal to get the payments. “People are still more comfortable when it’s something they can see,” she says. “Even doctors.”

Certainly, medical professionals remain divided about the psychological elements of many types of chronic pain. Ian Clarke, a Calgary anesthetist who specializes in chronic pain, says some studies estimate that as few as 10 per cent of patients show signs of a physical disease related to their pain. In Clarke’s view, most chronic-pain sufferers are susceptible

you have to do is accept that the patient has pain.”

And the last thing any physician wants to do is make it worse. Brian Knight, an anesthetist at the University of Alberta Hospital in Edmonton, says he is increasingly reluctant to perform invasive procedures to deal with chronic pain because too often the added discomfort results in no real gain. A surgically severed nerve, for instance, may grow back in a damaged condition that proves to be more painful than the original problem. And amputation produces a “horrible” result, he says—when the patient suffers from so-called phantom-limb pain. A damaged arm may be gone, but the mind still registers pain, leaving the patient doubly disabled.

The only significant improvement in the management of chronic pain, Knight says, is the increasing use of opioids. At least a third of his patients are now on those controversial medications, he says, with some now receiving them in more effective and convenient ways. A nerve block, for instance, can be delivered using a catheter attached to a tiny pump implanted under the skin. The mechanism releases the drug slowly and continuously into the spinal cord. Patients return to a clinic every one to three months to have the medication replenished.

Knight acknowledges that virtually everyone who takes opioids becomes dependent on them, but that is not addiction, he says. While dependent patients experience withdrawal symptoms, they can wean themselves off the drugs within a week or so. Addiction, which occurs in less than one per cent of patients, has more to do with personality traits. Such people, Knight says, may take more of

to their condition because of personality traits and family background. They are not malingerers, he says—they really feel the pain. But he believes the solutions very often lie in psychology, not a prescription.

Others, though, say there is also solid research linking most chronic pain with disease or injury. “When time and time again, reasonable people describe the same symptoms, with the same kind of history, I think something must be there,” says Leslie Bowers, an anesthetist at the Capital Health Region hospitals in Victoria. He accepts that emotional makeup and life stresses have to be considered because they can make suffering worse. “But as a pain physician,” he says, “one of the things

the drug than is prescribed and have to be carefully monitored.

In fact, many physicians are applauding what is widely viewed as a greater commitment by the profession to dealing with chronic pain. Edmonton general practitioner Helen Hays, who limits her practice to managing pain, has a waiting list almost two years long. Most of her patients suffer from some kind of neuropathic pain, which results from nerve damage and is notoriously difficult to treat. Hays, who worked in palliative care for two decades, says that even with the wide array of medications available, she still finds that managing pain with prescription drugs is a complicated process, often requiring several visits and extended

consultations. “Sometimes, it feels as if you are refining forever,” she says, “and in some cases it is just too complex. But the patient needs to know you are still trying—they need to know that you wont abandon them.”

Alan Gaudet knows all about the frustration of trying to find a doctor who will help when dozens of others have given up. Gaudet, 51, a former systems analyst in Brampton, Ont., has severe back pain. He has used a wheelchair since he was 44, when a bad fall exacerbated an industrial injury he suffered as a teenager. A series of operations has done little to repair his bent spine, condemning him to what he describes as “whitehot pain—it feels as if there is a person with knives inside your body, trying to get out.”

His doctors, unable to manage the pain with the usual array of drugs, finally sent him to an oncologist with expertise in alleviating the excruciating pain of cancer patients. He now takes daily doses of hydromorphone, which does not eradicate his suffering but only makes it bearable. “Most doctors wont give you anything stronger than Tylenol 3, but it might as well be candy. Without morphine, Id have lost my mind by now.”

In a few areas, there have been some real gains. Arthritis is synonymous in many peoples minds with crippling, virtually never-ending pain. And when Micheline Barbeau, 61, first began to experience the symptoms of osteo-arthritis around menopause, she was certainly worried. This form of arthritis pro-

Even with an array of drugs

and ice packs, 'some days, I wished I could drive into a truck and end it all’

duces degeneration of cartilage in the joints: the pain, the Calgary resident says, feels as if “someone is grinding your bones.” But regular exercise, Tylenol 3 and daily doses of glucosamine sulphate—a natural remedy derived from shrimp and crab shells that has proven effective in clinical trials—keep her comfortable most of the time. “I have been well served,” she says.

Those at the leading edge of pain research say patients can expect similar improvements for a wider range of conditions in the future. Hamilton psychiatry professor Eldon Tunics helped establish one of the first pain clinics in the country, in 1973. The newest research, he says, is making it easier for physicians to apply the best treatments available, rather than taking a scatter-gun approach to difficult cases. “In the past, doctors mosdy ran when they saw chronic pain and didn’t know what to do with it,” he says. “Now, they are getting the benefit of all this research and experience. There is a much different attitude, so that treating chronic pain is now more legitimate. A much higher proportion of people are getting appropriate treatment.” In the frustrating, often discouraging world of pain control, that is a big step forward. C3

Effective, but also addictive

Even though they are effective, it can be hard to find a physician who will prescribe the morphine-like drugs known as opioids for chronic, non-malignant pain. That is because the medications can also be addictive. Although it is not illegal to use such drugs under a doctor’s care, some physicians worry that prescribing them regularly could get them into trouble with their regulatory bodies. A steady movement is under way, however, to liberalize the use of opioids. Alberta was the first jurisdiction in Canada to do so, publishing new guidelines in 1994. Saskatchewan, British Columbia, Quebec and Nova Scotia have since followed suit. Ontario’s College of Physicians and Surgeons is to decide by the end of the year.

While many physicians still have grave concerns about the possibility of addiction, others, including Dr. Roman Jovey of Mississauga, Ont., believe the benefits of opioids far outweigh their risks.

“I started taking one patient with chronic pain at a time and trying them on opioids,” says Jovey, who has worked in addiction medicine for 18 years. “In the vast majority of cases, people had less pain and a better life.” He says that while opioids are not a panacea, the addiction rate is very low and there are few side-effects. “They’re underused because of fear—in society, and in the profession,” says Jovey. “But they can work for people with long-standing pain when nothing else does.”

Patricia Chisholm