Prevention & Recovery
How to deal with chronic pain
Prevention & Recovery
How to deal with chronic pain
Kelly Corry, 47, has had another bad night. "I woke up crying, and ended up on the toilet at 2 a.m. writhing in pain," she says. "Last night I thought, I can't do this anymore."
With a medical history checkered with numerous bouts of inflammation-related illnesses, Kelly could be chronic pain's unwitting poster child. The resident of Hillsdale, Ont., is among the estimated one in three Canadians who endure chronic pain, typically described as noncancer pain lasting longer than six months, or beyond the usual time for recovery. Kelly's pain has lasted more than 20 years.
Unlike a decade ago, now sufferers like Kelly have more treatment options to relieve constant, unremitting pain – from acupuncture and yoga to meditation and tai chi, as well as an ever-widening array of traditional pain management techniques.
Welcome to the new mind-body paradigm of chronic pain management.
How it started
Kelly's medical problems began when she was in her early 20s, shortly after the birth of a second healthy daughter. A third pregnancy ended in miscarriage, and then she developed vulvodynia, a pain caused by inflammation of the vulva, and interstitial cystitis, a bladder inflammation. "Any time there would be urine in there, it would just burn and burn," says Kelly. Next came gallbladder pain, which led to the removal of her gallbladder. Excessive menstrual bleeding and severe abdominal pain drove her to seek a hysterectomy.
Back in the mid-1990s, there wasn't much anyone could do for Kelly's intense bladder pain. Her doctors gave her narcotics and suggested that she move out west where the drier climate might help. So she and her family moved to Calgary. It was a stressful chapter for Kelly and her husband and their then-teenage daughters. And it wasn't a solution: in Calgary, Kelly had an operation to remove her bladder (she now wears a bag on her stomach that collects urine). The operation didn't completely alleviate the pain; she relies on three doses a day of OxyContin, a powerful narcotic, to do that.
Her marriage survived the pain and strain, though, and she and her husband returned to Ontario. Recently Kelly had another setback: she was diagnosed with multiple sclerosis, a progressive neurological disease, while still battling vulvodynia.
Kelly's story echoes that of other Canadians. An SES Research survey conducted last October found that 16 per cent of respondents reported living in constant pain, while 20 per cent experience pain on a daily basis.
Page 1 of 5The consequence of chronic pain
The root cause of chronic pain often remains a mystery. Another survey carried out last year, by Harris/Decima for Pfizer Canada, found that among those who have been regularly suffering from two or more symptoms of chronic pain for more than six months, almost half (47 per cent) have not been diagnosed.
Chronic pain is also costly, with nine per cent of women and 10 per cent of men with chronic pain reporting that their pain interferes with their ability to work. The price tag is an estimated $12,558 in lost income per person with pain per year, according to SES.
Worse, it can have devastating consequences on self-esteem. When Nicole St-Laurent-Ward, 53, of Moncton, N.B., developed fibromyalgia in 1995, the excruciating pain in her hips began to limit her mobility and led to chronic fatigue. She was forced to quit her job at Radio-Canada and became depressed and anxious. "I felt scattered, disconnected," she says.
Like Kelly, Nicole sought help from traditional pain drugs. But while over-the-counter pain relievers, such as hot packs and analgesic rubs, are readily available in drugstores, they're not likely to do the trick for chronic, unremitting pain. It's often a challenge for chronic pain sufferers to get effective prescription pain medication, partly because doctors are leery of taking on the task. "Are patients undertreated? I think so," says Dr. Zohar Waisman, a psychiatrist with the Wasser Pain Management Centre in Toronto. "Unlike an infection, where we give a person antibiotics," he says, "chronic pain is much more complicated to deal with."
That's not to say there isn't a wide variety of effective prescription pain relievers. First, there are the opioids, such as codeine, morphine, oxycodone and methadone, which can be critical in chronic pain management, says Mary Lynch, president-elect of the Canadian Pain Society and director of pain management at Queen Elizabeth II Health Sciences Centre in Halifax. These drugs, which are most often taken orally but can be infused (administered through intravenous, intraspinal, epidural or subcutaneous routes) or applied through the skin with a patch, can be important in managing pain. However, doctors need to screen for risk of addiction and watch for signs of overdose (recently reported with the use of fentanyl patches) and long-term dependence. "About 10 per cent of the population has the disease of addiction," says Allan Gordon, a neurologist and director at the Wasser Centre.
As well as the opioids, there are analgesic combinations – an antidepressant taken with an anticonvulsant – that act as aneuro-modulators, explains Lynch, meaning they alter the way the brain processes pain. Included in these combinations can be Gabapentin and Carbamazepine, anticonvulsant drugs formerly used solely to treat epileptic seizures.
Also emerging are the cannabinoids, drugs derived from cannabis, such as medical marijuana. "It's a field that is developing," says Lynch.
Before a doctor prescribes any of these drugs, though, he should make an accurate diagnosis. And that can be difficult because of the many different types of pain; for example, there are various forms of arthritis pain, neuropathic pain (stemming from an injury to the nervous system), multiple sclerosis pain, migraine pain and fibromyalgia, to name a few.
Accurately pinpointing the source of pain takes some detective work, but it's important because it can affect treatment, notes Marlene Noble, a physiotherapist at St. Paul's Hospital in Vancouver. "There's a whole different way of treating pain if it's peripheral pain due to a new injury than if it's long-term chronic pain," she says.
Page 2 of 5The waiting game
Unfortunately, given an aging population that demands an increasing level of services, the waiting period for a thorough assessment and treatment plan can be long. Many pain clinics across the country have waiting lists of a year or longer.
But once patients do get assessed at a clinic, they're likely to be greeted with a whole new approach to treatment. They may be seen by a pain specialist and a psychiatrist, as well as a neurologist and a physiotherapist – all under one roof.
It's part of the new mind shift in chronic pain management that's been burgeoning over the last 10 years. The emphasis has changed from a quick fix to patients learning how to self-manage their pain for a lifetime, explains Noble. Today, there is also more of a team approach; members of a treatment team work together on all aspects of the pain problem, including psychological, social and physical. "You really have to look at all areas of that person and not just the pain problem," she says.
Acupuncture is an increasingly important part of this new holistic approach. A mainstay of Chinese medicine, acupuncture balances the body's energy by inserting fine sterile needles under the skin at specific points along energy pathways (meridians). When treating pain, the needles are sometimes placed on the opposite body part to that afflicted with pain (on a right hand, for example, if the left hand is affected), says David A. Bray, a doctor of traditional Chinese medicine in Toronto.
There's mounting evidence that acupuncture reduces pain, especially for people with muscular, nerve and lower-back pain. German researchers recently found that patients who were treated with acupuncture over six weeks experienced a nearly 50 per cent decrease in pain intensity, while those treated with conventional treatments over the same period had a less than 25 per cent decrease in pain.
A growing body of research is uncovering the benefits of other alternative approaches to pain, too. For example, a study released last September found that tai chi, qi gong and yoga in particular improved arthritis pain, joint pain and stiffness; and in other studies, yoga improved hip extension and stride length, and reduced joint tenderness and hand pain.
As well as traditional drugs, Nicole uses the holistic approach, including massage, reflexology and meditation, to keep her pain manageable. "I think it was a wake-up call for my health," she says.
As for Kelly, both meditation and acupuncture helped reduce her pain. Recent personal issues made it difficult for her to continue these practices, but she says she wants to get back to them. "I'm open to anything that works."
Page 3 of 5Embracing the holistic approach
As the pain management community embraces a holistic approach to care, it's also beginning to view pain itself in a whole new light. Increasingly, pain is seen less as a physical affliction and more as the result of an injury that permanently changes the brain and leaves a lingering fear. "When someone hurts you as a kid, you remember it really well," explains Min Zhou, a pain researcher at the University of Toronto. "The idea is that the injury leaves a mark that doesn't go away, which can trigger pain long after the initial symptoms have subsided." Zhou's research focuses on the part of the brain that may be responsible for that – the anterior cingulate cortex, located in the prefrontal cortex. It's an area that "lights up" in diagnostic tests, such as a functional MRI, when a person is exposed to painful stimuli.
Zhou has developed a genetically mutant mouse that feels pain such as a needle prick, but not chronic pain. He's optimistic that this model will lead the way to the development of a drug that reduces chronic pain but preserves other sensations like hot and cold in humans – something that current pain medicines can't do. (Many patients who take drugs like oxycodone lose sensation of hot and cold.) But Zhou acknowledges that such a drug could take at least 10 years to develop.
Kelly certainly hopes that day will come a lot sooner. Dosed up on oxycodone and still suffering from chronic inflammation, she says even short trips to Tim Hortons can be gruelling and are a regular reminder of her reduced quality of life. But she's determined nonetheless. "You've got to keep going," she says.
Dealing with long-term pain can be exhausting and emotionally draining. Here are some tips for coping.
• Chronicle the pain. Day-to-day tracking of pain and paying attention to the variations in intensity can provide clues as to the nature and severity of the condition, while providing a scale on which to grade the pain, says David A. Bray, a doctor of Chinese medicine in Toronto.
• Get a referral to a pain clinic. Such a referral may be key since some family doctors don't feel comfortable managing chronic pain, says Dr. Zohar Waisman, a neurologist in Toronto. Beware: You may have a long wait ahead of you.
• Learn the stages of pain. By doing so, you'll understand the different treatment approaches, including the physical and cognitive techniques such as meditation, says Marlene Noble, a physiotherapist in Vancouver.
• Keep moving. With help from a pain clinic specialist or doctor, develop an exercise routine, such as yoga, that keeps you limber. The worst thing patients can do is not exercise, says Noble.
• Be your own pain advocate. "You can't just sit back and let the doctors do it," says Kelly Corry, a chronic pain sufferer In Hillsdale, Ont. What you can do: search out pain specialists on the Internet, join a support group to share findings, know your treatment options and be vocal about your concerns to doctors, employers, friends and family.
Page 4 of 5Where to go for help
Chronic pain clinics are springing up across the country. Here's a list of just a few from coast to coast.
NEWFOUNDLAND: Centre for Pain and Disability Management, Rehabilitation and Continuing Care Program, L.A. Miller Centre, 100 Forest Rd, St. John’s, Nfld.; (709) 777-7048.
P.E.I.: Island Pain Management Clinic, Boardwalk Medical Centre, 220 Water St. Pky, Charlottetown; (902) 367-3344.
NOVA SCOTIA: Pain Management Unit, Queen Elizabeth II Health Sciences Centre, 5820 University Ave., Halifax; (902) 473-4130.
NEW BRUNSWICK: The Stan Cassidy Centre for Rehabilitation, 180 Woodbridge St., Fredericton; (506) 452-5225.
QUEBEC: CAP Pain Centre (Centre de la Doleur CAP), 710-2015 rue Drummond, Montreal; (514) 842-1117.
ONTARIO: Chronic Pain Management Unit, Hamilton Health Sciences, Chedoke Hospital, 820 Sanatorium Rd, Hamilton; (905) 521-7931.
Wasser Pain Management Centre, Mount Sinai Hospital, 600 University Ave., Toronto; (416) 586-5997.
MANITOBA: Health Sciences Centre Pain Clinic, 820 Sherbrook St., Winnipeg; (204) 787-7199.
SASKATCHEWAN: Functional Rehabilitation Program, Wascana Rehabilitation Centre, 2180-23rd Ave., Regina; (306) 766-5790.
Saskatoon Health Region – Chronic Pain Centre, 204-75 24th St. E., Saskatoon; (306) 655-4000.
ALBERTA: Chronic Pain Centre, Calgary Health Region, 160-2210 2nd St. SW, Calgary; (403) 943-9900.
Multidisciplinary Pain Centre, University of Alberta Hospital, 8440-112 St., Edmonton; (780) 407-8638.
B.C.: The Pain Centre, St. Paul’s Hospital, 1081 Burrard St., Vancouver; (604) 682-2344 ext. 63276.
For more pain clinic listings, go to www.canadianpainsociety.ca/PainClinics_List.pdf.
New drugs deliver
Oral narcotic medicine is no longer the only pain management choice. New treatment and drug delivery systems are now available.
• Botox. Used increasingly to treat migraines, this neurotoxin is injected, often in a halo around the head. Although it may take two to three weeks to kick in, Botox can provide pain relief for up to two to three months.
• Transcutaneous electrical nerve stimulation. A mild electrical current is passed through the nerve pathway to block pain signals to the brain. It's often used to treat lower-back, myofascial, neuropathic and arthritis pain.
• Nerve blocks: A drug that blocks pain, administered through an epidural injected into the lower back, the affected nerve or as an IV.
• Intrathecal pump. Implanted under the skin in the abdomen, this small pump slowly delivers pain medication, such as morphine, through a catheter into the spinal fluid. It's often used for severe, long-term pain that covers a large area of the body.
• Spinal cord stimulator: A small device that is surgically placed under the skin, it sends signals to the spine and blocks pain impulses. It can provide a 50 per cent reduction in pain, and is often used in patients for whom other treatment options have failed.
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