Ask the Doctor: The 5 crises in Pain Management

February 24th 2012: I just could not resist passing on to you a summary of an article that hit my desk. It bears the same title that I used for this paper and was written by Dr. John Loeser, an international pain clinician, Professor of Neurological Surgery, Anesthesiology and Pain Medicine at the University of Washington, Seattle, USA.

Dr. Loeser has an unusually sharp tongue, “calling it exactly as he sees it”. I hope you enjoy reading him as much as I did. The major crises in dealing with pain today according to him are:

(a). Lack of proven efficiency for most treatments providers give patients. How do we find that evidence? Simple: as health providers we have to document what we do for our patients and in turn record how our intervention/ drug/ treatments affect our patients. Do we reduce the amount of drugs they take? Do we decrease doctor’s visits? Do we return patients to work? Do we increase their quality of life? But in order to collect this information many things have to change in our system, as certain countries and even Canadian provinces have done. In Sweden all patients treated in any rehabilitation program are entered in a national registry. In Quebec, all patients attending a university based pain clinic were also entered in a database with 6 months minimum follow up. In Norway all prescriptions are entered in a national database that tracks use of opioids and benzodiazepines (drugs like valium). A somewhat similar system exists in Nova Scotia. None of these exist in Ontario and several other Canadian provinces.

(b).Woeful inadequacies in pain education for medical students and other providers. He states that since all physicians who deal with chronic illnesses will receive chronic pain patients, “no one should receive a medical degree without learning about acute and chronic pain including cancer and non-cancer pain”. He points out that education about pain in other healthcare disciplines is much better (indeed I have written in another paper that a recent Canadian study found that veterinary students get 5 times more pain education during their studies than medical students!). This is confirmed by a CARP poll conducted in the fall of 2010 that stressed how dissatisfied the readers were with their doctor’s understanding of chronic pain.

(c). The unknown value of chronic therapy with opioids. Dr. Loeser stated that the “fundamental question about efficacy of opioids for chronic pain patients has been lost in political, economic and ethical arguments”. He summarized the evolution of opioid treatments in North America from the “opiophobia” of the 50s to “opiophilia” of the 80s-90s, the overprescribing and abuse with deaths and emergency room visits escalating, and then the serious pull back we are seeing now from both providers and authorities. He also pointed out that the “opioid crisis” is more of a North American problem as European countries identified the problem much earlier and took measures to correct it.

(d). Funding for those who provide pain management. Dr. Loeser poignantly stated that “the fundamental principle of capitalism is that money motivates behaviour”. This applies to the USA and Canadian reimbursement systems that have led to “enormous proliferation of surgeries and interventions for pain, while at the same time multidisciplinary pain clinics are closed down”. He stresses that “we need to create public demand” for such multi-disciplinary services that look at the “whole person” (not just a knee or an elbow joint). In Sweden the government body responsible for health care funding, recently put forth a proposal that complex pain cases should have a board to evaluate difficult pain cases and send them to a multidisciplinary team. Already, two Swedish counties have begun the process.

(e). Access to multidisciplinary care. Access is hampered by many factors such as availability of clinics, funding issues, distance, lack of provision of certain treatments, lack of services addressing language and cultural issues etc.

In Ontario, the recently released Drummond report contains 105 recommendations related to health care reform. I happen to believe that coordination, communication and select reform can result in both savings and better care for the patient. So, while the years ahead of us will require we tighten our belts, I believe a national and provincial pain strategies are part of this reform, giving Canadians and Ontarians living with pain the care they deserve.


Angela Mailis Gagnon, MD, MSc, FRCPC(PhysMed)

Director, Comprehensive Pain Program,

Senior Investigator, Krembil Neuroscience Centre

Toronto Western Hospital,

Chair ACTION Ontario