It is a few years that I started treating Chronic Pain. It seems I entered in a very challenging time when the difference between chronic pain and the acute pain was not very well known by doctors. In 1986, the World Health Organization (WHO) developed a simple model for the slow introduction and increased the dose of painkillers that became known as the WHO analgesic stepladder. Before this, people were dying in unnecessary pain because drug regulations introduced earlier in the century had increased the stigma and fear associated with both prescribing and taking opioids.
In the start of my practice, we had to fight against ignorance of pain. Doctors tend to ignore what they do not know. As a physician, I remember those days that my nightmare was seeing a patient with chronic back pain. I felt miserable, helpless and a failure to help my patients. That was why I ask questions about depression, which I knew better and treated that symptom. I do not, for a second, judge people who did not want to prescribe narcotics to chronic pain patients, in the fear that they may get addicted.
In 2009, many other up-to-date doctors and I felt obligated to ask for seeing and believing chronic pain and accepting it as a chronic disease that needs treatment. WHO has already given us a very amazing tool, why not using it. I am admitting that I was wrong. WHO was wrong. All Western Medicine got it wrong.
Based on the classical teaching of the medicine of acute pain, every time I saw the patient, I asked him/her about the intensity of pain. According to the response, I increased the dose of narcotics. This is a practical, accurate and acceptable way of finding the right dose of the painkiller for a patient after an operation.
In 2003, an article published in one of the very relevant journals that started waking us up. In this article pointed out that every pain in human, unrelated to the anatomical or etiology, always accompanying with some change in the brain. We all know that some of us have more tolerance for the same pain. In this article, the author suggested that in acute or cancer-related pain, the amount of pain is related and relevant to the tissue injury, the bigger the damage, the more pain. However in Chronic Pain that is long lasting, the amount of pain is not relevant to the size of the damage. In fact, after a while, emotions and psychosocial factors are more relevant to the reported pain by the patient!
Hashmi JA, Baliki MN, Huang L, et al. Shape shifting pain: chronification of back pain
shifts brain representation from nociceptive to emotional circuits. Brain 2013;136:2751-68.
Therefore asking a patient with a chronic long standing pain to score the pain and prescribe narcotics, was an entirely a mistake! I feel I was part of the problem and these days, I am doing my best to destroy the monster that I was involve creating.
We still don't know what the right way is. Honestly, this science is so young that we are learning every day. We just learn how to "see" pain effect on the brain. By using an fMRI, the scientist started seeing some amazing relevance between the increase of the blood flow to some parts of brain and intensity of pain. The issue is, they still could only inflict an acute pain, like a small electric shock. The results and findings would probably have no relevance to chronic pain patients. It is only one more step forward.
In the end, I would like to hear from you, over 5000 patients that I know since 2009. Do you think being on chronic painkillers had increased your quality of life? Could you work? Could you go back to the activities that you have loved to do? What parameter is more relevant to your well being?
Sleep? Appetitle? Walking distance? The amount of time you could stand in one place? How many laugh you had in the last 24 hours? How many times have you cried in the last week? How many meals you enjoyed making in the last week? Last 24 hours? Help us making it right.
We could not be more proud to announce our bringing video conference for patients into our practice! For a long time, distance between patients and their doctors was a big reason for less than acceptable level of care in parts of Ontario for some services.
Over the last 10 years, technology has made it possible to bring people closer, and physicians are no exception. For example, a dialysis patient who needs to see the nephrologist occasionally can now connect virtually with a hospital that owns the dialysis machine, so the patients do not need to physically travel to the hospital for every checkup.
This amazing improvement is still very costly. Some units that enable this type of doctors appointment cost between$10,000 and over $20,000 (based on what is needed for the machine). For private offices like the majority of the pain doctors in Ontario, this price was not affordable. To use this, a doctor like myself who loves to help his brothers and sisters from small cities of Ontario where the farmers and their work would actually "put bread on our tables", the technology was simply out of reach.
A few months ago, we were approached by a group who was founded by the government of Ontario to start a low cost service of consultation that is compatible with TeleMedicine. OTN.ca started by writing a secure program that would let the physician and patient connect together in a secure and realistic environment, face to face. It is true that the patients still have to travel to us for a procedure, the first consultation and all followup sessions after can be done on this TeleMedicineplatform.
If you are interested to be seen by myself or any of the other great specialists I work with, please talk to your doctor to arrange for a referral by TeleMedicine consult. Almost every hospital in Ontario has the unit and many of the Family Health Teams are equipped with TeleMedicine units.
Once we get the referral and medical history from your physician, and we receive your pre-consult questionnaire, we will book your Telemedicine consultation at a location near you and let you know when it is.
Dr. R. Safakish
There have been many questions about different options other than narcotics for severe non-cancer chronic pain. I try to address this question as complete as I can in the following paragraphs:
o You may wonder why you don’t see their advertisement on TV, if they are more effective. One reason is the cost. These medications are old; their price is so low that the manufacturers do not have much of profit and therefore no advertisement!
Dr. Ramin Safakish, anesthesiologist and pain interventionist, is a full time pain interventionist in Allevio Pain Management.