Angela is a physician who has been caring for people with pain for three decades and currently is director of an interdisciplinary pain clinic.
Many things, from biology to psychology to the environment, affect our perception and expression of pain. Culture and where we come from is a huge factor and is not well understood. I am Greek. When a kid falls, we kiss the booboo. “Oh, poor kid! Let me rub it.” That’s a lot of attention from a very young age. Things that focus attention to pain, augment pain.
I don’t accept “chronic pain” as a useful term because it tells you nothing about the origin of pain, lumping all chronic pain together. I am a biker. My motorcycle fell onto my knee and for five years I was in a brace and had a hell of a lot of pain. I converted my two-wheeler to a trike so I could continue biking. I have a black belt in Tae Kwon Do. I couldn’t do that after the knee surgery, but I was back in the gym doing other things. I lived within my limitations… I had chronic pain by definition. And then I got my knee replaced, and the pain was gone.
Other people with chronic pain, even if the original source is minimized, get many emotional consequences. They can become de-socialized and demoralized. They can’t work. Families are destroyed. All of this enhances the perception of pain, and it’s this other stuff that is so difficult to treat.
I never treat pain as one entity. You tell me that a person has chronic pain, and I ask where it is coming from. Is it physical? Is it augmented by psychological factors? Is it a combination? If I don’t know all of those elements, I am not prepared to treat.
People are ready to open up when they know you are interested. That you have enough time, and not 10 minutes. Unfortunately, in this system, many people don’t have the time.
For many years, I have spoken about the dual tragedy of opioids. Too much and too little. One size does not fit all. In the '50s, we had opiophobia [opioid phobia]. In the '80s, we got into the hysteria of prescribing opioids for everybody. Now the pendulum has switched to the other side. I have seen extremes of both.
I was asked to do an assessment of a woman who submitted receipts to her insurance company for reimbursement during one year for 31,000 tablets of OxyIR 20 mg ordered by her family doctor.
She didn’t seem to have anything wrong with her other than minor degenerative changes to her joints. I felt that the physician was in cahoots with the patient.
I didn’t believe that this patient was taking 31,000 oxycodone in 12 months. I reported the physician to the College.
And then I see hundreds and hundreds of patients who could benefit from small doses of opioids who are deprived of them.
Twenty-to-25 percent of my patients are over 65. Some of them have spinal stenosis, no joints left, are inoperable. This is where I need opioids; when everything else has failed. I give them small doses. Some of them, when I suggest opioids, say, “No! I am going to get addicted.” I say, “Are you kidding me?”
We have a large Italian population, and daughters bring in their grandparents. I saw a woman who couldn’t get out of the chair. Hips and knees totally gone and inoperable. I said, “Grandma, I am going to put you on liquid morphine.” “Nope!” I gave her the preaching and put her on two or three milligrams of liquid morphine two or three times a day. She comes in a month later. Hugs and kisses! Her family says she is a different person. Two months later I see another Italian woman. Friend of the first one. No hips, no knees. She wanted, in broken English, the same magic drug I had given to her friend.
The providers! Some of them are killing me! Even with modest prescriptions of opioids they drop patients like hot potatoes. I have reached the point where I say, “Okay, you want me to take care of these patients? I will treat them and stabilize them. But you are going to sign an opioid agreement form, that when the patient is done with me and I discharge them back to your care, you will continue to prescribe. You want me to see the patient again, I will do that. But I can’t be the primary prescriber for a thousand patients a year.”
The resistance I find is unreal. A physician was looking after a young guy with severe carpal tunnel. Sole breadwinner of the family. His job was to put up big light fixtures. He had three kids and a wife. I maintained him on a Butrans patch and two Percocets a day until he could get his surgery.
The physician refused to prescribe them and the patient reported her to the College. Then she came back to me and said, “OK, I am signing the opioid agreement form.” The guy will go for surgery, and after his surgery he’ll come off the opioids.
We just saw a man who had 50 years of multiple surgeries. He doesn’t have a joint intact in his body. Never once had he been through multidisciplinary management! He fell into the hands of some crook who told him that the only way he would prescribe opioids was if he were to have injections weekly. And the family doctor wanted nothing to do with him. I said, “Sir, you have a ton of problems. I can’t leave you like this.” I put the patient through a multidisciplinary program for the first time in his life, seeing a psychologist, mindfulness therapy, my exercise therapist. The guy is very grateful for the access that he never had. My therapist gave him a yellow rubber band that he uses to do exercises at home. On his third appointment the patient said to the therapist, “I have a beautiful collection of coins, but if my house was to catch fire today and I could take out only one thing, I would take that little yellow rubber band with me.” I have him on 70 mg of OxyNEO a day and a couple of Percocets when he exercises. And the guy is so grateful. These stories break your heart.
One of the requirements at our clinic is that people have to be within a 50-kilometre radius of the clinic because they have to come two, three times a week, and devote two to three hours each time. We have an informed consent that stipulates all of their obligations. We have homework. They understand that they are going to be discharged if they are not doing what they are supposed to do. So, devotion, commitment, motivation, coming on time, not missing—those are a must.
I had an offer in the '90s to go to Johns Hopkins and I said no, because I wanted to treat all those who needed me, not only those who could afford me. Over the past three years, I am more than grateful that I have been given the opportunity through funding from the Ontario Ministry of Health to treat all those who need us. The beauty of this program is that the government pays for all of the providers who are not doctors. And that is where the magic happens.
The past two or three years have been the best of my professional life because I can practise the best evidence-based kind of social medicine that anyone could dream of. The reward of seeing people getting back to life and seeing that we changed their lives—it’s everything.
WATCH ANGELA'S VIDEO