Ask the Doctor: All Pain is in Your Head

Over the course of the 30 years I practice exclusively in the area of chronic pain, I have spoken to many patients and families trying to explain in simple terms what pain means to a person, how our emotional reactions colour our pain experience and what ways (beyond medicines I prescribe) can change this experience. It is not unusual for me to end my conversation with the statement: “Your pain is truly in your head, …. That means in your brain”. One of the stories I use to back up such a statement is the following, from my own experience as a mother and a scientist.

Many years ago, as I was giving a good night kiss to my two boys, my three year old son Alex, whispered: “Mom, I can’t  get this ring out” and he showed me his swollen right index finger The “ring” was an old washer the little devil had fetched from somewhere and pushed it around his finger. I tried in vain to pull it out using liquid soap but Alex would not stay still, screaming and running around the house and I could not control him. I was alone with my other son Nicholas, a year older, falling asleep. I called a neighbour asking her to watch Nicholas, and took Alex with me to the nearest hospital emergency.

Even at 10:30 p.m., the emergency room was packed with old and young, nervous and resigned, some looking very sick and others calm and patient. Despite his affliction, Alex cruised the room curiously, showing from time to time his swollen finger to other patients. Then he would sit down to play with some spare lego blocks lying on the floor. Strangely, he seemed fairly busy and comfortable while I was freaking out.

His finger looked more and more swollen like a freshly cooked wiener. It was already an hour and I was getting very uncomfortable as I was worried about cutting off the circulation, which meant he could damage the finger permanently. Alex, however, seemed quite absorbed with the blocks and only when I ask he would say “burn, squeeze.” I asked the nurse a couple of times when Alex was going to be seen but the response was sharp– there were other people before him... I called my house to speak to my neighbour and found out that her husband had just returned home. She encouraged me to return home because “maybe all of us can try to take this thing out.”

By midnight, when I parked the car in the driveway, Alex ran to the house to show the neighbours the “big finger”.  Things had progressed and we did not have much time. Steven, good 6 ft 2” tall, headlocked Alex, while I wrapped my whole body around my son’s little legs, and his wife Susan rubbed some vegetable oil around Alex’s finger.  As Alex became totally consumed in his efforts to escape delivering generous kicks to my ribs, Susan within a few seconds pulled the washer off. At the end, I could not tell who was more exhausted, Alex who fought frantically or the three adults who were worried for his finger and what to do about it.

Once the washer was off, it left a deep mark in Alex’s finger, but the colour was getting back to normal. Nevertheless, we now had a new problem. Alex kept howling and squirming, waving his finger in the air and was inconsolable (big difference with his controlled demeanor in the emergency room)! He refused to go to bed and demanded to see Ninja in the middle of the night (those folks whose kids are now late 20s or so, would remember the magical Japanese cartoon warriors who had mesmerized a generation of kids).  I succumbed to the demand and Alex collapsed to sleep within minutes. Next day he never mentioned his finger when we prepared him for the day care. However, I was told later he was displaying his slightly swollen finger to the kids and daycare attendants whenever he would remember (but this finger never stopped him from playing and using his hand freely)!

This is a real life example of what constitutes pain, a complex and multifaceted experience, even when it is acute. Clearly Alex’s tight constriction deprived his finger from blood, and produced chemicals that irritated the nerves of his hand and sent a signal to his little brain: “Finger in trouble”. But if this were the case, why did Alex seem oblivious most of the time in the emergency room, and why did he keep screaming once the constriction was removed?

So, let’s try to understand what pain means for the body and what it means for the mind. Some years ago when I wrote a series of papers for e-CARP Advocacy all related to “blocking pain”, I made the comment that there is a difference between “pain”, the sensory experience that stems from injured tissues (exactly what the finger was telling Alex’s brain), and “suffering”, our emotional reaction to this sensory experience (Alex’s reaction to removing the washer off his finger). These two are intertwined, but they can also be separate. In other words, if you can divide the experience of feeling that something is harmful to the body from the emotional reaction to it, …. you do not feel the pain or you feel a lot less pain.

How then can you harness the emotional reaction? There are several ways and one of them is to “alter” the meaning of pain. For example, if you attach a different meaning to this painful sensory experience, the pain may be subdued. For example, turning the thought “pain is damaging my body”, to the thought “pain is honourable” the pain may be blocked. Another way is to draw attention away from the painful stimulus (eg. to distract one’s self from the physical source of pain by devoting brain resources to “something else”). In most cases, tissue damaging stimulation will make us worried and anxious. It is only then that tissue damage will be perceived as pain by our conscious brain. In the example of my son, Alex could not link the constrictive effects of the washer with the very real risk of harming his finger irreversibly; furthermore, he was immensely distracted with the lego blocks in the emergency room and by the environment itself with all these strange people and new experiences.  Alex was only truly hurting when he associated the swollen finger with his feelings for what these three “big people” had done to him, even though the constriction of the finger was gone and his circulation was getting restored.

So, next time you are in pain, attend to it as you should, maybe take a pain killer off the counter or apply a cold dressing, but also turn on your TV to your favorite show or movie and let your brain wander! It will have less opportunity to “feel” pain.

 

Angela Mailis Gagnon, MD, MSc, FRCPC(PhysMed)
Director, Comprehensive Pain Program,
Senior Investigator, Krembil Neuroscience Centre
Toronto Western Hospital,
Chair ACTION Ontario www.actionontario.ca
www.drangelamailis.com

Ask the Doctor: Fixing Broken Back Bones

When a patient of mine visited me recently (a 74 year old lovely woman), she wanted to know if a special procedure that her doctors were prepared to do called vertebroplasty, could fix her pain. She was suffering from severe osteoporosis and her back bones (called vertebrae) were weak. A couple of those had crushed when she got the flu and into serious sneezing spells. So, I had to search the literature to be able to give her an appropriate answer.

This is what I found from a paper published on August 18, 2009 by Andrew Scully in the Medical Post, a Canadian medical newspaper that goes to every physician in the country: Vertebroplasty can be done on an outpatient basis for painful vertebral compression fractures. This procedure has been widely adopted by radiologists based on early clinical data. It involves injection of bone cement into the collapsed vertebra under imaging guidance and local anesthetic, with the patient sedated but conscious. Observational studies (where you look at patients with pain, and check them out before and after the procedure), had shown that the procedure results in immediate and sustained reduction in pain. On the basis of these data vertebroplasty has become readily available with 27 centers in Canada, almost in every province.

But two trials published in the Aug. 6, 2009 New England Journal of Medicine suggest the pain relief may simply be a placebo effect or due to the use of local anesthetic or needles, rather than the injection of bone cement itself. They researchers studied two groups of patients, those who received the true procedure and those who received a “sham” procedure. Both groups of patients received conscious sedation, injection of local anesthetic into their back and the doctors even allowed the distinctive odour of polymethylmethacrylate cement to permeate the room, and provided additional cues such as pressure on the patient’s back or the actual insertion of the vertebroplasty needle, but only one group got injection of bone cement. In one study, researchers led by Dr. David Kallmes, a professor of radiology at the Mayo Clinic in Rochester, Minn., split in two groups 131 patients and followed them for one month, finding no significant differences between vertebroplasty and the sham group in regards to functionality or average pain intensity during the preceding 24 hours. Notably, both groups had improved immediately in disability and pain scores after the intervention. In the other study, Dr. Rachelle Buchbinder, director of clinical epidemiology at Monash University in Melbourne, Australia, gathered six-month follow-up data on 71 patients, finding similar reductions in pain scores in each group (real vertebroplasty and sham group).

Andrew Scully, added: Dr. Andrew Leung, an assistant professor of radiology at the University of Western Ontario and an interventional neuroradiologist at the London Health Sciences Centre, had seen the Mayo study presented at a meeting of the World Federation of Interventional Therapeutic Neuroradiology, and commented: “Everybody at the meeting was just shocked”. Dr. Leung explained that the basic question of whether cement injection was any better than a sham procedure had remained unanswered for years, while radiologists and surgeons debated the merits of vertebroplasty and a more complex and expensive procedure called kyphoplasty. Kyphoplasty uses a balloon to restore the height of the vertebra and create a cavity for injection of cement, and has shown similar reductions in pain to vertebroplasty, but has yet to be subjected to a sham-controlled trial.

“What really is helping people with their pain? I think it’s hard to attribute it all to a placebo effect, but something seems to be working,” Dr. Leung said. “Maybe it’s just putting freezing into the tissues of the back. Or maybe it’s simply putting a needle into somebody’s back, like acupuncture. If that’s all it takes to help people, maybe that’s what we should be doing,” he said, noting the injection of cement carries about a 1% risk of major complication such as infection or damage to the spinal cord. However, Dr. Leung said that while those questions are being sorted out, vertebroplasty, rightly or wrongly, has become the accepted standard of care, as it is simple and can be done on outpatient basis.

Dr. Peter Munk, director of musculoskeletal radiology at Vancouver General Hospital, wrote. “Vertebroplasty is here to stay, but now the time has arrived to determine better which patients benefit the most and in what circumstances.” He and Dr. Mark Baerlocher, a fifth-year resident in the department of medical imaging at the University of Toronto, noted that the conclusions of the studies might have been quite different if more patients had participated, particularly those with more serious pain or those with cancer bone pain.  Dr. Baerlocher, who was part of a study that showed that funding and resource issues were making access to the procedure in Canada problematic, was very worried that governments and insurers might put too much weight on these two studies in their decision-making and “lead to tens of thousands of patients being denied the treatment”.

I searched further and this is what I found. The North American Spine Society (NASS) reviewed the above studies carefully and suggested that the procedure can not be dismissed as ineffective as many patients have been seen at the bedside with dramatic pain relief, often within hours of the intervention with bed-bound elderly person who get the procedure and become nearly pain free and ambulatory. Another study on 1500 patients was presented at the Society of Interventional Radiology's 35th Annual Scientific Meeting in Tampa, Fla. in March 2010, with very positive results, particularly in those with multiple myeloma, a type of bone cancer. John Hopkins Health Alert stated that for now, based on the New England Journal of Medicine studies, the American Academy of Orthopaedic Surgeons has issued guidelines recommending against the use of vertebroplasty. 

In other words, the jury is still out on the value of vertebroplasty. However, since osteoporosis is a common problem in our golden years, painful vertebral fractures are something that some of us may have to face. Talk with your doctor about your particular back problem and weigh all the options before deciding which treatment is best for you better information allows us as consumers and patients to seek proper answers from our doctors regarding what to expect and possible alternatives if vertebroplasty fail.

Angela Mailis Gagnon, MD, MSc, FRCPC(PhysMed)
Director, Comprehensive Pain Program,
Senior Investigator, Krembil Neuroscience Centre
Toronto Western Hospital,
Chair ACTION Ontario www.actionontario.ca
www.drangelamailis.com

Pain, Your Car and Your Wallet: What do They Have in Common?

You must agree this is a very strange title for an article on chronic pain by a pain doc. However, you will soon realize that there is a very strong connection between pain, your wallet and your car.

Symptom fabrication (making up symptoms) has emerged as a serious issue in car accidents (and of course chronic pain is claimed to be a major problem in these cases). I am using excerpts from a chapter (#9, 2003, 2006) in my book BEYOND PAIN”. “In our neighbours to the South, in 1988, the Southeastern Pennsylvania Transportation Authority (SEPTA) initiated a Fraudulent Claims Program, trying to look more closely at the $53 million U.S. the state makes in yearly payments for about 15, 000 personal injury claims.

The FBI got involved in suspicious claims. For example in one serious public transit accident, seven passengers filed claims for injuries sustained in the crash, but only one passenger was found to be in the vehicle at the time of the accident. The other six allegedly injured passengers were indicted for fraud by a grand jury. A 73-year-old doctor was sentenced to 15 months in jail and fined $100,000 US dollars for providing false testimony. Once it became known that SEPTA was after cheaters, injury claims against the authority fell by 60 per cent and lawsuits by 50 per cent, resulting in multimillion dollar savings for the financially strapped transit agency.

In another American story, one small New Jersey bus company was plagued by injury claims for fender bender type accidents. The company asked the New Jersey Insurance Fraud Division to investigate, and in “Operation Bus Roulette”, the fraud division actually staged 10 minor bus accidents throughout New Jersey. They were all videotaped and Connie Chung, then with CBS, with her Eye To Eye team participated in one of the crashes. The Eye To Eye Undercover Report was aired in August 1992 and showed 17 members of the public walking by the crash site, entering the bus after the accident. All 17 later submitted claims for injuries, ranging from $30,000 to $400,000 U.S. per claim. Operation Bus Roulette caught more than 100 people ripping off insurance companies, including 10 doctors and four lawyers”.

If you think we are immune here in Canada from car frauds, dream on! “Project Slip” was launched by the Toronto Police in the summer of 2000, with 35 people charged, including five doctors. This was a multimillion dollar insurance scam for staged car accidents and tumbles in buses and streetcars. In another case, the police launched Canada’s biggest auto insurance fraud investigation ever. This discovered a large Toronto auto insurance fraud ring responsible for 257 suspicious claims worth $10 million Canadian and more than 60 staged car accidents. Fifty four people were involved including physicians and chiropractors (#9, BEYOND PAIN, 2003, 2006).

In January 13, 2012, City News reported that a man pleaded guilty in the University Avenue Courthouse in Toronto to fraud of $1.5M. This man in 2007 had a company that cruised salvage yards for wrecked cars that were written off. Then a licensed mechanic would supply false safety certificates and members of the group would crash these cars in city streets “creating accidents”. Project Green Light charged altogether 34 people in this scam.

In February 2012, “Project Whiplash” led to 37 arrests of people primarily from the South Asian/ Tamil community in early morning raids in the Greater Toronto Area (GTA). A total of 130 charges stemmed from 77 staged collisions (The Toronto Star, February 23, 2012). Many of those charged were working as paralegals or operators of rehabilitation or medical clinics and prayed on immigrants of the same community with few English language skills.

The Star provided some more interesting information as follows: The auto insurance fraud costs Ontarians $1.3 billion a year, accounting for 10-15% of the premiums (Auditor General of Ontario). GTA holds the enviable title of the “staged collision capital of Canada (Rick Dubin, VP Investigative Services, Insurance Bureau of Canada). State Farm Insurance alone lost 4 $M in the Project Whiplash scam. False claims have escalated in the last five years, so that auto insurance fraud is “extensive, increasing and having a substantial impact on auto insurance premiums” (Ontario Auto-insurance Anti-fraud Task Force).

Mind you, almost all the “injuries” stemming from such staged accidents are soft tissue injuries associated with “pain”.

So, next time you look at the new increase in your car insurance premiums, connect the dots: pain, wallet and car!

Angela Mailis Gagnon, MD, MSc, FRCPC(PhysMed)
Director, Comprehensive Pain Program,
Senior Investigator, Krembil Neuroscience Centre
Toronto Western Hospital,
Chair ACTION Ontario www.actionontario.ca
www.drangelamailis.com

Ask the Doctor: A Lost Battle in the War on Pain

I borrowed this title from the thoughtful article of journalist André Picard that was published in the Globe and Mail on March 6, 2012. This was one of the most sensible pieces of journalism I have read in quite a while in addressing the inappropriate use of prescription narcotics.

 André Picard commented on the replacement on March 1, 2012, of OxyContin, a powerful pain killer which was replaced by OxyNEO, a chemically identical but tamper-resistant version. OxyContin and other powerful opioids provide addicts with a “high” particularly when their route of administration is altered (such as by crushing, snorting or injecting it instead of just swallowing it). Together with the disappearance of OxyContin in the form we have come to know, a number of provincial and federal drug plans have “de-listed” OxyNEO, meaning it will no longer be paid for by public drug plans. While most patients already taking OxyContin will be able to get OxyNEO for a transitional period of up to a year, it will be very difficult for new patients to get the drug, unless they are being treated for cancer. In some provincial plans, including Ontario; patients will still be able to get OxyNEO after the   transitional period, but only if the physicians fill out lengthy paperwork numerous months before the expiry of the transition period. This is something that in all likelihood won’t occur.

 The change in medications offered, threw a large number of people into chaos: physicians who do not know what to do; legitimate patients who take this drug with good pain control; and addicts who take it to get “high”.

 Governments did this presumably to avoid the soaring cost of OxyContin prescriptions and to curtail abuse. On the surface this looks like a good change in public policy.

 But is it? Let’s see how these events happened:

  • OxyContin withdrawal was initiated by Purdue Pharma, the company that makes the drug, as regulators and academics have regularly asked the pharmaceutical industry to come forward with tamper-resistant versions of medications. The switch to the new OxyContin (called OxyNEO in Canada and re-formulated OxyContin in the United States) had already happened in the US over a year ago. American websites for those addicted to the drug had already gone on advising their “followers” that the “good stuff still existed in Canada”, but this is no longer the case.
  • Clearly consumption of the drug was going to be reduced as OxyNEO is disliked by addicts. The industry was well aware of this and they proceeded to create newer formulations exactly to curtail the problem of abuse, by providing a safer drug.
  • Did the switch happen abruptly? Absolutely not. Governments were warned many months before the switch by the company, who indicated that supplies of old OxyContin were limited and were to be withdrawn from the market at a set date. They were also warned of the potential fall outs and the need for education for physicians and pharmacists.
  • Without adequate preparation of physicians, pharmacists, as well as legitimate patients, chaos ensues. Physicians have not been trained to switch or reduce OxyContin for their patients, addicts are left with the loss of their supplies, pharmacists are worried about robberies, and legitimate patients are looked upon as villains and abusers. Indeed we have seen a couple of deaths in Ontario where patients have been switched to other opioids by physicians not well trained and informed.
  • As for governments and their money saving plans, what is the actual reality? Certainly not the one they thought it would be. Other highly addictive opioids are still covered by government plans such as hydromorph (Dilaudid). Addicts are switching in droves to those drugs, which are still paid for by public money.

 To sum it up, what happened is not good public policy unless all aspects of the problem are addressed. Otherwise new problems are created.

 As I have said so many times before, opioid overprescribing, abuse and diversion is a symptom of a disease, not the disease itself. Regulations and impositions alone do not work. You need education of providers and patients, mental health and addiction services, interdisciplinary care, options for treatments (opioids, drugs that are alternative to opioids, but also non pharmacological approaches), access to proper care from the primary level to the specialist, provision of expert help lines for physicians and telemedicine for remote areas, self management approaches and preventative strategies, and the list goes on, all summed up with one sentence —  a Comprehensive Pain Strategy for Canada and its provinces.

Angela Mailis Gagnon, MD, MSc, FRCPC(PhysMed)
Director, Comprehensive Pain Program,
Senior Investigator, Krembil Neuroscience Centre
Toronto Western Hospital,
Chair ACTION Ontario www.actionontario.ca
www.drangelamailis.com

Ask the Doctor: Neuropathic Pain Treatments

As with every kind of chronic pain, the most basic premise of treatment is for the physician to look "at the whole person", not just the part that is injured and hurts ("whole person approach"). There is a long line of diverse treatments for neuropathic pain ranging from medications to physical therapies, psychological treatments, injections and surgery. We will start exploring medications first.

There are two types of drugs that can help. Drugs that specifically work on "injured nervous tissues" and drugs that work as general pain killers.

1.The first class of drugs (often called "neuropathic drugs") are NOT regular pain killers and do not work like regular pain killers (eg. "I take the medication when I hurt and the pain will decrease within an hour or so"). For these drugs to work, they must be taken regularly every day, so that heir level in your blood remains steady. All these drugs have several indications, other than neuropathic pain and work on variable aspects of the pain systems within our bodies.

The older class of these drugs falls under the category of "tricyclic antidepressants" or TCAs, such as amitriptyline, nortriptyline, desipramine etc. Please note that I am using only generic names when I refer to drugs (and not company names known as "brand" names). Your doctor or pharmacist will tell you exactly what the commercial name of these drugs is. While they are good old drugs for depression, they have been also found to work in neuropathic pain and additionally help with sleep and mood. In terms of pain mechanisms, TCAs seem to work in several pain pathways within our nervous system that control neurochemicals called norepinephrine and serotonin.

Another class of neuropathic drugs includes drugs that work against epileptic seizures ("antiepileptics or anticonvulsants"). Examples of these drugs are gabapentin, pregabalin (and the oldest of all, carbamazepine). These drugs seem to work by blocking the activity of irritable nerves, the same way they suppress the explosive activity of an epileptic brain.

Other types of drugs with double and triple properties (for example against neuropathic pain, depression, anxiety etc) include duloxetine, while in some cases pills containing local anesthetic (exactly like the one your dentist gives you when he freezes your tooth), such as mexiletine, may work. All of these drugs work in some way or shape by affecting transmission of nerve impulses within the nervous system.

Very few of these drugs are approved formally by Health Canada for use specifically in neuropathic pain conditions, namely pregabalin and duloxetine. However, "off label use" (use of drugs for other than their approved indications) is widespread and nearly "standard practice".

As with all other drugs, your doctor will have to decide what is best for you based on a number of considerations: What is the effectiveness of the drug? What is the "side effect" profile (eg. what kind of side effects does this drug have and how safe is it for you, particularly if you take other drugs as well)? How expensive is the drug? How easy is it for you to take (eg. do you need to take many pills several time per day or just a few)? The doctor should also have a plan. Every such drug should be given on the basis of a "trial" with a lower dose to start, slow upwards increase based on how well it works and what kind of potential side effects it has, a period of stabilization and then re-assessment. Does it really work? And what happens if it does not work at all? How is the drug going to be reduced and stopped? What is the next alternative? What happens if it only works partially? Will you be given a second drug to increase the effect of the first one? These and other questions should be discussed with your doctor.

Money wise, each province has different regulations regarding neuropathic drugs paid by the provincial health care system for those over 65. Most extended health care plans will cover most or all neuropathic drugs of all classes I reported earlier.

Other classes of drugs are regular pain killers you can take over-the-counter, such as aspirin type of drugs (ibuprofen etc) and acetaminophen in different combinations (those found in Tylenol to name one). However, they do not work well for neuropathic pain. Even prescription drugs that are anti-inflammatories are not very good for neuropathic pain. There is a place for strong pain killers (morphine and morphine-like drugs called opioids), which could be quite helpful when combined with neuropathic drugs. However, their administration should be well thought (a subject of thorough discussion between you and your physician) due to several side effects and risks, and certainly they should not be the first ones or the only ones given for neuropathic pain. Remember, the same questions you will be discussing with your doctor for the neuropathic drugs that I cited earlier, should be asked as well when strong pain killers are contemplated.

Remember, drugs can be very valuable for restoration of our health, but they can also have side effects. An informed consumer, who takes responsibility for his /her health and works hand-in-hand with the doctor, makes a better patient.

Angela Mailis Gagnon, MD, MSc, FRCPC(PhysMed)
Director, Comprehensive Pain Program,
Senior Investigator, Krembil Neuroscience Centre
Toronto Western Hospital,
Chair ACTION Ontario www.actionontario.ca
www.drangelamailis.com

Ask the Doctor: A Primer on Neuropathic Pain

dr_angela_mailis-gagnon.jpg

If you twist your foot by accident, you will get what we call a simple "sprain", with swelling of the ankle, some bruising and some deep aching pain for a few days. If you break a bone, you will experience aching, throbbing pain that settles quickly once the arm or the leg is in a cast. If you have arthritis in your joints you know that the pain comes with activity and will respond well to aspirin-like drugs. Food poisoning will give you twisting cramping pain from inflamed guts. All these pains are known to scientists under the umbrella name of "nociceptive pain" and we are all too familiar with them. These are the pains that come from broken bones, pulled muscles, inflammation and even pain from your heart, your gallbladder or the gut.

But there is another kind of pain, a strange one that comes from cut or pinched nerves (like the sciatic nerve at the back of your legs), an injured spinal cord (as in the case of spinal cord injury with paralysis) or a damaged brain (after a stroke or a trauma to the head). This type of pain is called "neuropathic" pain and it's kind of a "short circuit" in the body's sensory apparatus. Neuropathic pain may make you feel that an injured body part is on fire, that "ants are crawling under your skin", that a knife is getting into your flesh and cuts you suddenly, or that you are hit by a lightning bolt or shot with a shotgun. A draft of air can bring a spell of sharp shooting pains, the touch of the clothes becomes intolerant, the warm water of the shower is scorching, or hundreds of pins and needles are pricking your skin. If you feel this kind of pain, you are not alone. About 8% of Canadians suffer from neuropathic pain, which means that 2.5 million in our country (one million in Ontario alone) are victims of this pain, a pain that has "many causes", but only one face, "the face of distress and suffering".

Some conditions are extremely prone to causing neuropathic pain. For example, 75% of people over 75 years of age will continue to experience post-herpetic neuralgia after an attack of shingles; 65% of patients with Multiple Sclerosis, 70% of people with spinal cord injury, 75% of people with amputation and 54% of patients with AIDS will also experience neuropathic pain. What about 20-30% of patients with diabetes and painful diabetic neuropathy, 8% of people after a stroke, 14-15% of patients with mastectomy for cancer, thoracotomy, heart bypass surgery and numerous other operations, who continue to experience relentlessly neuropathic pain? The list is not done: patients with afflictions of the spine like a chronically herniated disc or pinched spinal nerve, those with nerve injuries after accidents or those who received chemotherapy for cancer can suffer as well from lifelong neuropathic pain.

Neuropathic pain is difficult to diagnose and even more difficult to treat. There are many treatments for neuropathic pain but, unfortunately, they do not work for everyone. These therapies range from special medications to painkillers, physical therapies and alternative medicine therapies, psychological and behavioural treatments, certain injections into the path of nerves or even surgery.

To understand this kind of pain log into www.actionontario.ca site, a website that educates and advocates on behalf of neuropathic pain sufferers or their families. In the next newsletter, we’ll cover in detail the different treatments that can help those who suffer from neuropathic pain.

Angela Mailis Gagnon, MD, MSc, FRCPC(PhysMed)
Director, Comprehensive Pain Program,
Senior Investigator, Krembil Neuroscience Centre
Toronto Western Hospital,
Chair ACTION Ontario www.actionontario.ca
www.drangelamailis.com