Pain Management Program - Before You Arrive

We understand how frustrating the wait can be, especially when you are in pain. Our goal is to minimize our wait-times, and ensure access to our services as quickly as possible despite the program demands being very high. Wait times can vary depending on the services you require. If you need to cancel or change your appointment, please provide 72-hours notice so that your appointment time can be given to someone else. 

Managing chronic pain is a complicated and challenging task. Pain medications and medical interventions alone often don’t provide optimal pain relief. Many things affect your pain and reduce the effectiveness of medical treatments, such as stress, emotional distress, activity levels, smoking etc. As a result, you may need a multi-faceted approach from one or more of our team members to address all of the areas of your life that may be impacting your pain. This may include learning new coping strategies and incorporating lifestyle changes into your daily life. 

Often we think of pain as strictly a medical condition. However, many psychological issues increase pain severity and limit the effectiveness of pain medications and other medical treatments. In order for you to regain optimal function and engagement in meaningful activities it is important to understand all of the factors that impact your pain condition including frustration, irritability, grief, anxiety and/or depression. Our social worker and psychologists are available to help our patients who are struggling with mental health and other issues that can accompany living with pain to help improve your self-management and coping strategies and improve quality of life. 

Chronic Pain (pain present for longer than 6 months) cannot be cured, but it can be managed. Self-management is one of the most important treatments for your chronic pain. Self-management in combination with medical management will offer you the best opportunity to manage your pain and regain your quality of life. 

Generally, the family physician/nurse practitioner will be the pain medication prescriber. As you may already know, it is standard practice to ask patients to sign an opioid contract/agreement stating they will only receive opioids from one prescriber. At the St. Joseph’s Hospital Pain Management Program, we want to help you follow any opioid contracts you may have signed with your family physician/nurse practitioner. 

While the pain specialist or the pain clinic pharmacist may make recommendations to start, stop, or change medications, it is the family physician/nurse practitioner who will carry out the prescribing of these medication recommendations. We follow this prescribing strategy because it makes it less likely for communication mix-ups or medication safety issues (e.g., drug-interactions) to be missed if there is just one prescriber looking after your medications. Lastly, many of our pain specialists only work in the pain clinic once a week because they also work in other areas of the hospital (e.g., the operating room or other outpatient clinics). As a result, it is much harder to get prescription requests addressed in a timely fashion through the pain clinic than it would be through a family physician/nurse practitioner’s office.

With that said, there are a few instances where the pain specialist may temporarily prescribe pain medications, such as:

• When the pain specialist provides a prescription for a pain medication at a low dose with instructions to slowly increase the dose and follow-up with the family physician/nurse practitioner within a specific timeframe for re-assessment and the next prescription. In such a situation, the pain specialist will provide advice to the primary care provider about next medication steps when they see you in follow-up. This step-wise prescribing care strategy is undertaken so that everyone’s time can be optimized and the follow-up visit with the primary care provider can be as productive as possible.  
• When an opioid rotation or wean is to be undertaken and it is considered by the pain clinic specialist to be too complex/logistically tedious that it requires more supports than the primary care provider’s office has in place. 
   

Please return all medications that are no longer being used to your local community pharmacy for proper disposal. This is especially true for opioid medications because significant harm can result if someone (such as a child or teenager) or the family pet gets into these medications.

Sometimes the treatment offered will be a nerve block, or an intravenous infusion. These treatments may temporarily impair your ability to drive, either by causing sedation or by blocking sensation to a limb for several hours.

Dr. Bellingham: I believe the work of a pain specialist is to provide patients time and space to allow them to tell their story of pain. I think we are fortunate in the pain clinic to be able to focus on this one problem. By trying to understand a person’s pain, their experiences, and thereby where their pain may be coming from, a pain specialist can apply their specialized knowledge of available pain therapies and resources that may best suit a patient’s condition. While trying these therapies, a pain specialist can provide education about pain management, and work alongside other health care professionals towards improved quality of life and function. In other words, the pain may not be completely relieved, but better managed so that people can achieve their goals.

Dr. B: I had an opportunity to work with a fantastic family doctor in Tobermory when I was in medical school. One day, we visited a patient who was suffering from a chronic pain condition, specifically diabetes related nerve pain. At that time, I had no idea how to manage chronic pain, other than possibly using opioid medications. The family doctor prescribed amitriptyline, a medication used for people who were suffering from depression, not pain. How could this possibly work? He taught me that there are different types of pain and depending on the cause, there are a variety of medications that can be used to treat pain. In this case, I learned that using amitriptyline could be very effective for this person’s nerve pain. I knew a lot of health care providers struggled to help manage painful conditions. I felt I could learn something valuable that could help a lot of people in the future. I was up for the challenge and made my way to become a pain specialist through the specialty of anesthesia.

Dr. H: A pain psychologist helps people understand and manage their chronic pain condition. Our goal is to help people minimize their pain symptoms and achieve the best quality of life possible. We use a number of tools and strategies to help people reach that goal – education, lifestyle changes, coping skills and therapy to help people cope with the emotional impact of living life with a chronic illness.

Dr. H: I developed severe migraines as a child and I have a very distinct memory of a doctor telling my parents “children don’t get migraine headaches.” My headaches went untreated for years. When I began my training, there was still a widespread belief that infants and children don’t experience pain the same way adults do. Adult chronic pain conditions without a clear injury or cause were also often dismissed as, “all in your head.” It was fascinating and infuriating and I wanted to learn more. I joined a large research project focused on assessing and treating pain in premature infants. That was the first of many research projects and clinical placements in paediatric and adult pain management. Treating chronic pain was challenging and complex and I learned that psychological treatments and coping strategies could increase the effectiveness of traditional medical interventions. I thought it would be rewarding and interesting work.

Dr. B: I believe that ideal pain care comes from helping people develop strategies that promote self-management. This can include a daily therapeutic exercise program in someone’s home, psychological ways of managing the stress or negative thoughts that can be associated with pain, or learning different ways of moving or performing tasks with less pain. In other words, learning strategies and lifestyles that can help reduce the negative effects pain can have on a person’s quality of life. Good pain care can also be enhanced using medications as well as procedures such as injections or infusions. These medical components should be used to facilitate the self-management approaches and not replace them. For example, the short to medium term pain relief from a well performed injection may improve someone’s ability to participate in and benefit from psychological counseling and educational programs.
Dr. H: I agree. The severity of chronic pain is influenced by many factors – the injury itself, activity levels, stress, emotional distress, how effective or harmful your coping strategies are etc. You need a full toolbox of pain management strategies to minimize pain severity. No single tool will provide optimal pain relief. I sometimes describe it this way. Would you attempt to do woodworking with only a hammer in your toolbox? Of course not. To me, it seems just as futile to try to manage pain with only injections or pain medications in your toolbox. That is why we developed our Pain101 workshop, and encourage all new patients to attend. Pain 101 describes a wide range of pain management skills and treatments. It helps people to decide which tools they are missing, and develops a treatment plan to add new tools to their toolbox.

Dr. B: Pain specialists try to provide the most up to date and evidence-based care for a person’s pain condition. That said, we need more clinical trials to understand what treatment options should work best for various kinds of pain conditions. We rely on research and clinical guidelines to help formulate a treatment strategy to provide the best possible outcome for a patient. For example, the American College of Rheumatology has recently published a set of best practice recommendations on the optimal medication and injection strategies for the treatment of painful osteoarthritic conditions. By discussing these options, the physician and patient can work together to find the right strategy for their specific pain condition and personal circumstances. The guidelines also provide recommendations for physical, psychosocial, and mind-body approaches. Although physicians may not have expertise in these areas, our colleagues working within our pain clinic do. By asking them for assistance and input, we can work as a team to put forth the best treatment plan for an individual.

Dr. H: There are lots of rewarding moments. I enjoy watching someone master a new coping strategy. It’s even more fun if they thought the skill was “baloney”, and mastering it turned out to be life changing. I love watching someone gain confidence that they can cope with the pain, or find joy and laughter again. Some of my favourite moments at work are watching a strong, connected health care team in action. I might see a patient who has attended Pain 101, start asking for referrals to get the missing tools in their toolbox. I might see a physician or a physiotherapist, who asks the right questions and brings in the right team members to meet that need and help someone who is struggling.

Dr. H: Our patients have the strongest voice on their health care team. We can provide education and advice, but they get to choose how they will manage their pain. The problem is, we all tend to get stuck in familiar habits, even when those habits aren’t healthy (think smoking, emotional eating etc.). We often see patients who rely on a pain treatment, such as a medication or injection. Or it might be pushing through the pain in order to do things the way they used to. These patients are asking us for help. They want things to be different. They are having major pain flare-ups. They are in distress and their quality of life is the pits. We may see that their pain management strategies aren’t working well. We may offer more helpful treatments or coping strategies. However, for lots of different reasons, sometimes people stay stuck and they are on the same pain/emotional distress roller coaster months later. It’s hard to watch someone make choices that hurt them in the long run, especially when it’s your job to help them learn new ways to cope with their pain.

Dr. H: There are many different reasons. Sometimes people are stuck because they don’t know what to do. Once they learn what to do to manage their pain, they take that info and run with it. More often, people are stuck because change is HARD. It can be scary and unfamiliar. Sometimes people are stuck because they know they need to change but they don’t want to change. They are grieving and angry and the emotions keep them stuck in a miserable place. Sometimes people are stuck because that one treatment or coping strategy makes them feel that they have some control over a life (or a body) that feels out of control. This can be true even when that strategy doesn’t help control their pain very well at all.

Dr. H: Well, we know what doesn’t help – telling people they need to change! How many times have we heard that we should eat healthier, exercise more, stop smoking? It doesn’t help. We can help by:

• Listening. Describing what we hear and see: “Your family is your priority, so you push through the pain to cook and clean and care for them. But by the time your family comes home for supper you are in agony and miserable to be around. You go to bed and don’t get to spend any time with the people you love.”
• Exploring what works and what doesn’t. How do they want things to be different? “It feels good to take care of them, but it hurts them too.” “I want to enjoy time with my family.”
• Acknowledging that change is hard, and that you can start with small steps. If we hear: “I can’t change, that’s who I am,” maybe start with, “It is hard to change our habits and routines, isn’t it? I can see lots of opportunities to help you enjoy more quality time with your family. Let’s look at a few. Is there one small change on that list that seems like a step in the right direction?”

Understanding that change is a gradual process, and we can support people in different ways at different stages.

Dr. B: Unfortunately, this is not an uncommon situation. Even at best, we can only expect pain medications to provide approximately 20-30 per cent pain relief. When pain medications or medical treatments don’t seem to be working, this is when I believe we need to  ensure that patients are afforded all resources our pain clinic has to offer. Modern medicine usually is not able to conquer chronic pain. It is the combination of these services that we hope can provide meaningful improvements in quality of life.

Dr. B: As a physician who can help patients reduce their pain intensity by using injections, it has been frustrating to have to delay treatment to facilitate social distancing. When someone relies primarily on regular injections for pain relief, their pain relief depends on external factors they have no control over. In other words, injections rely on a special set of circumstances that may not always be there. For example, injection therapy depends on the availability of things like proper equipment, specific physicians, the clinic schedule and the avoidance of any side effects or complications. What happens if equipment breaks down? Or the physician that provides the injection has an emergency and cancels? Or we get shut down by a pandemic? Pain relief from injection therapy becomes completely ineffective in situations like these. One of the ‘silver linings’ of our inability to provide injections is that it allows us to promote some of the other types of pain therapies that our pain clinic can offer that can have tremendous value, especially in the face of a pandemic. Good pain care promotes self-management. In other words, learning strategies and lifestyle changes to manage pain and improve quality of life. Lately, I’ve been thinking that learning these techniques is like building up your own store of personal protective equipment (PPE) against the negative effects a pain condition can have.
Dr. H: I agree. Pain Management skills can be adapted to fit many different situations or circumstances. In fact, many of our patients report they are using the skills they have learned to help themselves and their loved one’s cope with COVID-19.

Dr. B: In the end, I believe the greatest success that our clinic can provide is if someone who suffers from pain does not have to come back for repeated clinic visits. This would indicate to me that we have been able to provide them with the tools that they can use on their own to continue enjoying a good quality of life.