November 20, 2015

Chronic pain seen through a doctor’s eyes

Posted by WARREN PERLEY – Editor, BestStory.ca
Writing from Montreal

Almost one in five Canadians and Europeans has experienced chronic pain in their lifetime. In the U.S., chronic pain afflicts almost one in three people, the figure likely higher due to the large number of wounded American military personnel returning from overseas engagements and the high proportion of people living in poor socioeconomic conditions in that country.

So when Dr. Patricia Lynn Dobkin, a McGill University psychologist, offered to write a first-person account for BestStory.ca about one of her patients whose chronic pain may have delayed diagnosis of a life-threatening condition, I immediately accepted.

Dr. Dobkin, who has extensive experience studying the connection between chronic pain and depression, has changed the identities of the people she writes about in order to protect patient-doctor confidentiality.

But the story Dr. Dobkin tells is true, and her first-person narrative gives us an unusual insight not only into her patient’s feelings but also into her own sentiments as a caregiver struggling to maintain her professional balance, all the while drawing ever closer emotionally to her patient and, ultimately, relating to her like a sister.

In 2015, Dr. Dobkin published a book, Mindful Medical Practice: Clinical Narratives and Therapeutic Insights, showing how mindfulness enables clinicians to be resilient and fully present with their patients in such a way as to promote healing.¹

Prior to moving to Montreal in 1987, Dr. Dobkin trained at a pain clinic at the University of Rochester Medical School in New York state where she obtained her Ph.D. When she arrived in Canada, she was so concerned about the lack of services for patients with chronic pain, particularly those in Quebec, that she took a sabbatical leave from McGill University in 2004, dedicating her time to organizing health care services for such patients. She summarized her findings in a Health Technology Assessment Report that was sent to the Ministry of Health, headed at that time by Dr. Phillip Couillard, now the premier of Quebec. She subsequently published a book chapter and some articles on the topic to increase awareness about this challenging problem.

While speaking recently with Dr. Dobkin about chronic pain, I was reminded of an anecdote related to me by a Crohn’s patient suffering severe chronic pain, caused to a great extent by a fistula near her rectum. During a conversation about her case with her gastroenterologist, the well-meaning doctor said he had just come from a spinning class and asked whether she had ever tried that exercise.

That anecdote is indicative of the fact that most doctors don’t understand the nature of chronic pain or how to treat it. They’re reluctant to prescribe opiates over a protracted period for fear of inducing a chemical dependency in their patients, and most are not conversant with psychotherapeutic approaches to pain management, which can include antidepressants and cognitive behavioral techniques to treat underlying depression which can exacerbate pain. So the symptoms sometimes get ignored by acute-care doctors who are frustrated at not being unable to find a physical source for the chronic pain and who are, at the same time, scared of turning their patients into drug addicts. Some likely conclude that the pain symptoms could be psychosomatic.

And nothing frustrates a doctor more than a patient with an “idiopathic” medical problem, meaning a condition of uncertain or unknown origin. American journalist Meghan O’Rourke wrote an excellent article in The Atlantic issue of November 2014 detailing how it took doctors in the U.S. 15 years to diagnose a medical problem which had left her over those years with persistent anemia, as well as occasional elevated white blood cell counts and inflammation markers.

“To me, my life was slowly dissolving into near-constant discomfort and sometimes frightening pain – terror at losing control,” the 30-something O’Rourke wrote. Her doctors’ response: “You’re fine. We can’t find anything wrong.” Or, as one doctor told her: “You’re probably just tired from having your period.” In spring 2012, a sympathetic doctor, who believed O’Rourke’s pain was real, used new tests to prove she had an autoimmune condition no one else had thought of – Lyme disease, caused by multiple tick bites from her adolescence.

In recent years, a few pain centres have been established to deal with the issue of chronic pain, such as McGill University’s Alan Edwards Centre for Research on Pain, which opened in June 2003 at the Montreal General Hospital. The centre is composed of 39 basic and clinical pain researchers from the Faculties of Medicine, Dentistry and Science. Through their own activities and international collaborations, they focus on new discoveries and their clinical applications to prevent and treat chronic pain.

(The U.S.-based National Institutes of Health defines chronic pain as any pain lasting more than 12 weeks.)

While writing her article for BestStory.ca, Dr. Dobkin told me that the prevalence of chronic pain is a call to action, citing a study led by Professor Donald Schopflocher of the University of Alberta in Edmonton and published in 2011, which showed that 18.9 percent of Canadians report living with persistent pain. This rate varies by region, with the Atlantic provinces the highest (21.9 percent) and Quebec the lowest (15.7 percent). The most common types of pain are low back, arthritis and joint pain.

The President of the Canadian Pain Society, Dr. Mary Lynch, from the Pain Management Unit of the Queen Elizabeth II Health Services Centre in Halifax, Nova Scotia, published a paper, also in 2011, indicating that the wait time to be treated in a Canadian pain clinic was more than one year.

Chronic pain is the single most common cause of disability in working aged adults and it is well documented that chronic pain increases with age. For example, Professor Schopflocher’s study found that 31.5 percent of women 66 years or older reported chronic pain, compared with 22.2 percent of men in the same age group.

A review of the literature led by Dr. Harald Breivik from the Department of Pain Management and Research, University Hospital and University Oslo, in Oslo, Norway indicates that the overall prevalence rate is the same (19 percent) in Europe.

A 2010 American study conducted by Catherine Johannes and her colleagues at RIT Health Solutions in Durham, North Carolina found that 31 percent of American adults are living with chronic pain.

Rates are consistently found to be higher in women in all of these reports. While it is hypothesized that sex hormones (e.g. estrogen and testosterone) play a role in this difference, psychology and culture may account for it as well, Dr. Dobkin told me.

The costs are staggering, reported as both direct and indirect costs. The former includes medical testing, procedures, surgery and medications. The latter includes productivity losses, sick leave, disability payments and use of complementary and alternative therapies not covered by the government (e.g. acupuncture, massage). According to Dr. Lynch, direct costs in Canada are greater than $6 billion per year. Indirect costs are greater than $37 billion annually, which is more than those for cancer, heart disease and HIV combined.

These chronic pain statistics are the backdrop to Dr. Dobkin’s moving account of her very close relationship with a patient whom she considered to be as close as a sister.

^1. You can find Dr. Dobkin’s book, Practice: Clinical Narratives and Therapeutic Insights at amazon.ca:

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