A new prescription for pain
After seeing consequences of powerful painkillers, specialists encourage patients and doctors to find a safer ‘pain plan’
The diagnosis knocked the wind out of her: breast cancer and the prospect of a mastectomy within days.
As an anesthesiologist — a specialist who makes surgical miracles possible by putting patients in a deep sleep and then awakening them to live again — Dr. Rassamee Ling knew what to expect after surgery.
“My big worry was preventing chronic pain. I knew right at the outset that was a possibility,” Ling says eight months after her initial surgery and two months after breast reconstruction.
She turned to her friend and colleague Dr. Brenda Lau, a fellow anesthesiologist who also practises at the Jim Pattison Outpatient Care and Surgery Centre in Surrey, for advice.
Lau also runs the Vancouver clinic Change Pain, and is at the forefront of a new way of treating pain. She is among a small group of specialists who take an all-encompassing approach, encouraging a series of small steps — including improving nutrition and reducing anxiety — that can help manage pain without relying solely on potentially dangerous opioid-based drugs.
“We want to challenge the way we think about pain; to deal with it before it starts,” Lau says. “Getting a head start can stop the train ... For some, the opioid overdose crisis is where the train can lead.”
Over-prescription of oxycodone for chronic pain can lead to drug dependence and overdose, health experts say. In B.C., counterfeit street drugs made to look like these prescription painkillers are now often laced with the powerful, and potentially deadly, opioid fentanyl. Illicit drug overdoses claimed the lives of 914 people in B.C. in 2016.
The Michael G. Degroote National Pain Centre’s guidelines for treating chronic pain, released last week, say the first choice of treatment should be medications that aren’t opioid-based, such as acetaminophen and ibuprofen, or medication to treat the underlying condition causing the pain. That should go along with non-drug therapies: exercise, acupuncture, physiotherapy and massage, to name a few.
Dr. Norm Buckley, director of the National Pain Centre at McMaster University in Hamilton, Ont., puts these non-drug treatments under the heading of good practices — approaches that won’t harm the patient even if there isn’t enough evidence to prove any single one of them will stop pain on its own.
“All those things would definitely fit into an acute pain strategy that avoids any potential risks of starting patients on opioids,” he says in a phone interview, adding most people have no ill effects from a short run of opioid painkillers after surgery.
Lau agrees, but says patients are largely left to their own devices once they’ve been discharged from hospital and would do better with an overall game plan about returning to health.
“We knew what can go wrong and we thought: ‘What can we do about it?’” Lau says.
Because of her training and expertise in pain management, Lau has made personalized pain plans for family and friends during the last year: her husband after an emergency operation to remove his appendix, a friend following gall bladder surgery and Ling as she faced the shock of cancer.
“I had five days from diagnosis to surgery, so that didn’t leave me a lot of time to prepare,” says Ling, 48. “But it was so empowering to be told even the few things that I could do pre-operatively because the diagnosis takes away your sense of control.
“The thing that helped most was the first thing she (Lau) told me, how to deep breathe, box breathing,” Ling says, referring to the slow, even breathing with pauses at each inhalation and exhalation, “because you have these moments of physical, visceral terror where your heart’s racing and you need to find a way to control that.
“I was diagnosed on a Thursday and as I got closer to Tuesday’s surgery, waves of panic would hit. That was the tool that got me through that weekend,” says Ling, whose soft-spoken manner hides a wealth of determination.
Before Ling’s surgery, the doctors took a proactive approach, which they call “prehab.”
Lau consulted with the anesthesiologist scheduled for Ling’s mastectomy, who decided to apply local anesthetic to key nerves in her chest that would block pain for almost 24 hours.
That meant even after Ling came out of the general anesthetic, her chest wall was numb. This is a key concept in preventing chronic pain syndrome: Don’t let it become unbearable in the first place.
Ling says she now encourages anyone having surgery to be open to all the tools available to anesthesiologists, including nerve blockers.
Buckley says using nerve blockers has advantages, but not all anesthesiologists can perform them and they take more operating-room time — a precious resource.
“These kinds of techniques — although it’s challenging to demonstrate this — might lead to less persistent pain. It also may allow people to have better immediate post-operative pain control and not have to take narcotics,” Buckley says.
The goal is to walk the line between over-treating and under-treating pain, both of which carry risks.
Post-surgical pain syndrome — in which patients feel increased discomfort even after their wounds heal — has been associated with under-treated pain around the time of surgery.
“You have these moments of physical, visceral terror where your heart’s racing and you need to find a way to control that.” — DR. RASSAMEE LING
A complication that can result from over-treating pain is opioid-induced hyperalgesia, in which patients feel increased pain even as opioid doses go up.
Pain B.C., a charitable organization that offers education and support, estimates one in five British Columbians experience ongoing pain. Persistent pain troubles 10 to 50 per cent of patients after common surgeries like groin hernia repair, breast and chest surgery, leg amputation and coronary artery bypass surgery, according to a study published in The Lancet, a respected medical journal. This pain becomes debilitating post-surgical pain syndrome in up to 10 per cent of those patients.
Ling decided to take just enough of the narcotic painkillers she was prescribed after surgery to be able to get a decent night’s sleep and start moving normally as soon as possible.
“Any time you have an injury, the body heals by laying down fibrin and that’s the start of inflexible tissue — a scar,” Ling explains. So she set about breaking down tight bands of tissue across her chest by leaning into a plastic massage ball covered in short, blunt spikes.
“There’s good pain and bad pain. Anytime I had a stretch discomfort I knew I was investing in being painfree in a short period of time,” says Ling, who returned to work Feb. 2.
In what seems like a cruel twist, Lau, 43, was diagnosed with thyroid cancer last fall. Her thyroid was surgically removed and she was given a small amount of radioactive iodine to halt the spread of tumours.
She has only recently returned to work with a new, huskier voice and has cut back from her typical 80-hour week. Lau regularly practises yoga and consumes 20-30 servings of vegetables a day, often as cold-pressed juice. She didn’t take any opioid painkillers during her illness.
“I’ve rediscovered medicine as a patient,” Lau says. “Cancer has been my friend. It’s forced me to look at what I can change going forward.
“With this kind of personal experience, we now know this works for us. We have to start thinking about health differently and recovery after injury differently.”