Is your life boxed in with chronic pain?
Dr. Andrea Furlan understands. The staff physician and senior scientist at the Toronto Rehabilitation Institute diagnoses and treats people with a nervous system condition called central sensitization, which helps explain why some people have chronic pain and ultimately turn to dangerous painkillers for relief.
She has also written a book and developed an app called My Opioid Manager, which helps those in pain manage their medications safely. It’s timely information, considering that from January 2016 to June 2018, more than 9,000 Canadians were lost to opioid-related deaths, many of them accidental.
Health writer Diane Peters sat down with Dr. Furlan to talk about medication, chronic pain and the connection between pain and the brain.
Diane Peters: How do you define pain?
Andrea Furlan: The International Association for the Study of Pain has a formal definition I like: “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” When you burn your finger while cooking and experience acute pain, you can see the damage. But with chronic pain, which affects the patients I treat and is driving the opioid crisis, sometimes there’s no actual damage anymore.
D.P. : What about conditions like arthritis and lupus that cause chronic pain?
A.F. : There are conditions that cause ongoing acute pain. But some people have had acute pain in the past, like a car accident in which they broke a lot of bones but they healed, and they continue to experience pain and depression. They don’t have ongoing tissue damage, but they perceive pain.
D.P. : Is this central sensitization, where there’s a dysfunction in the body’s pain system?
A.F. : Yes. The physician says “The pain is in your brain” and the patient thinks the doctor is saying that they’re inventing the pain, but that’s not what she means. Say you had a knee injury, but the injury healed. The pain you experienced caused changes in your spinal cord and brain and now you have this recurrent activity in your central nervous system telling you that you have pain when there’s nothing wrong with you. Pain caused by ongoing damage, such as aches caused by arthritis, is different: It’s localized, and if you remove the cause of the pain, it goes to zero. (Don’t miss these 22 natural home remedies for arthritis pain relief.) For people with central sensitization, the pain occurs outside of the area that was originally damaged because it’s coming from the brain, and it doesn’t just go to zero.
D.P. : Does this happen to everyone who has had pain in the past?
A.F. : No. Some people seem more predisposed to this. It seems to be connected to your overall resilience, personality, culture, family and support system. The mind has a big impact on how the body feels. Because of this connection, some people let pain affect them more. Pain can run in families: If people grow up around chronic pain, they are more likely to develop it because they learn about complaining and suffering.
What happened around the time of the injury is also really important. I have a patient who was in a car accident and her three daughters were in the car; two died and one survived. Both the mother and surviving daughter have chronic pain – it was such a traumatic accident, the pain they felt had a very negative connection. It depends on the treatment you get, too. If a doctor says you need 50 injections in your back and you might not get better, you’re less likely to recover than if a doctor tells you to get some exercise and go back to work and the injury will heal. Athletes are a good example of how attitude affects how you feel. They damage their bodies all the time, but they seldom develop chronic pain because their resilience is so high.
D.P. : What role do opioids play in all of this?
A.F. : When someone takes an opioid for a long period of time, it can suppress their ability to activate their own analgesia. If this happens, every time they try to stop taking the opioid, their natural painkilling system doesn’t kick in quickly or doesn’t kick in at all. It can take weeks or even months. Every time they try to stop, they feel horrible, so they never want to stop.
D.P. : How common is central sensitization?
A.F. : We don’t know. In my population, it’s more than 50 percent, but I see people in chronic pain. We know fibromyalgia is basically central sensitization, and we know that fibromyalgia affects 10 percent of women and a smaller percentage of men, so it’s pretty common. Find out how this fitness blogger recovered from fibromyalgia.
D.P. : How much does this contribute to the opioid crisis?
A.F. : A lot. Family doctors don’t have training in this kind of pain. They only have five minutes to spend with each patient, and these patients want answers. If the doctor gives them a prescription for an opioid, the patient leaves happy and everyone’s happy, but that’s where the problem starts.
D.P. : How do you diagnose central sensitization?
A.F. : The diagnosis is based on a patient’s history and symptoms. The physical exam is very important because I look for what may be causing the pain that we can treat to eliminate those conditions. We also do a thorough neurological exam.
D.P. : What is the treatment?
A.F. : The first step is explaining to patients what they have. For many, that’s enough for them to get better. Once they know it won’t kill them, the pain subsides. They can focus on what’s important to them to feel better. I prescribe exercise. Movement is the best treatment to reverse central sensitization, and they should do whatever they enjoy. I suggest that they start doing exercise in warm water if they’re barely well enough to walk. We tell them about sleep hygiene, and we gradually start to eliminate medications. They join a therapy group so that they can discuss their good days and bad days.
D.P. : How long does it take to start feeling less pain or stop feeling pain altogether?
A.F. : It’s variable. For some, it’s very fast. For others, they still feel pain, but they talk to their pain. They say “Pain, I know you’re here, but I’m not letting you interfere with my life anymore.” They have a different relationship with their pain.
And with lower back pain being the most common type of chronic pain, affecting 63 percent of women and 55 percent of men, make sure to check out the medical reasons behind your aching back.