Many approaches needed to alleviate chronic pain
By Dr. Ryan Amadeo
Winnipeg Regional Health Authority
Published Monday, November 2, 2020
At some point in our lives each of us will experience pain. Usually, it's a temporary inconvenience that stems from garden-variety sources such as a headache or muscle strain. Yet there are many people – half of all Canadians in fact – for whom pain is not simply inconvenient, but chronic and debilitating.
Chronic pain can present itself at any time, sometimes as the result of an underlying condition like multiple sclerosis or cancer, and sometimes related to surgery or other treatments for an illness. For some, there is no specific injury or illness to point to.
Take, for example, chronic back and neck pain: together, those conditions make up roughly half of the patients seen in the Winnipeg Regional Health Authority's Pain Clinic. The vast majority of these patients do not have a specific injury or illness that triggered the start of their suffering, but just because we can't pinpoint a trigger does not diminish the symptoms, the pain they feel, or the negative impact that pain and discomfort has on their daily lives and activities.
Thankfully, as my colleague, Dr. Renée El-Gabalawy, a Clinical Health Psychologist who is the director of the Clinical Research Network for the Chronic Pain Network at the University of Manitoba, is fond of saying, "Life can be better and we have treatments that work."
There will be some of you who, after reading that last sentence, might be asking, "What has psychology got to do with the management of chronic pain?"
Plenty. We know that mental and physical health are intricately connected and can mutually maintain one another. For example, living with a chronic condition can exacerbate existing mental health conditions or cause depression or anxiety. Moreover, most chronic pain conditions cannot be ‘cured' or resolved, so the focus is on managing pain and improving daily functioning and quality of life – something that requires a multi-disciplinary, multi-modal approach.
The Pain Clinic is a referral-based service that generally sees an even split of patients from primary care practitioners (family doctors) and specialists (like surgeons, cardiologists or oncologists) and treats patients who have not been able to successfully manage their chronic pain through other methods. Clinical Health Psychologists such as Dr. El-Gabalawy and her colleagues work specifically with clients to support physical treatments and therapies with psychology that helps provide coping techniques and mechanisms for patients living with chronic pain.
The psychology team applies Cognitive Behavioural Therapies including a newer therapeutic approach called Acceptance and Commitment-based Therapy (or ACT) which is focused not on moving beyond or "beating" chronic pain, but on helping patients lead a meaningful life with pain. This is accomplished by using a number of strategies such as reducing their preoccupation with emotions (e.g., fears, anger or hopelessness) through acceptance and focusing on valued actions. For example, addressing a fear and subsequent avoidance of engaging in physical activity because it may result in exacerbating back pain helps patients adopt a mindset where they can work to reduce their risks while still practicing physical activities that deliver proven health and psychological benefits. It allows them to live their valued life with pain, and ultimately can reduce suffering.
Evidence consistently supports the fact that applying an interdisciplinary approach to pain management offers the best outcomes for patients. This includes disciplines like clinical psychology, as described, as well as experts such as physiotherapists, occupational therapists, specialists in particular conditions, chiropractors and others as needed in order to provide an all-encompassing, holistic care plan.
A patient seeking support for back pain, for example, will likely work with a physiotherapist to develop an activity plan that is safe, appropriate and that builds strength to support areas of pain. If their pain has altered their level of function or mobility, they may see an occupational therapist to adapt their daily activities to minimize pain. They may also see a chiropractor or massage therapist for acute pain management if pain is exacerbated by a certain activity or event such as a long car ride or shoveling. They may see our clinical psychologists to help them address fears related to their mobility. And they may see me or a physician colleague for medication therapy or steroid injections, if and where appropriate.
Though there is, understandably, a degree of concern among the general public around the use of pain medication (especially opioids, which people sometimes associate with addiction and negative outcomes), you should know that regulatory bodies across North America, and in Manitoba in particular, have worked hard to identify and create protocols, guidelines and expectations that support physicians and patients who require those medications as a part of their overall treatment plan.
It is imperative that anyone who uses or prescribes these medications be fully aware of the risks associated with them and monitors their use, and their effects, carefully. Rest assured that balancing those risks is an important part of the work that we do in the Pain Clinic.
The fact remains, however, that medication remains a necessary and effective therapy for the pain management of some clients – one that cannot be replaced by other methods. We respect the strength of those medications, and prescribe them in in the smallest doses possible.
We're dedicated to using all the tools in our tool kit – including medications and psychological approaches – in order to mitigate risk while providing necessary relief for patients who experience significant, chronic pain.
For more information about chronic pain and its treatment, visit wrha.mb.ca/psychology/services/chronic-pain/.
Dr. Ryan Amadeo is the Medical Director of the Winnipeg Pain Clinic. This column was published in the Winnipeg Free Press on Monday, November 2, 2020.