OUCH Optimism and Understanding Creates Hope ACTION Ontario Patient Advocacy Newsletter Volume 5 Issue 1 ACTION’S Advocacy Pays Off ACTION Ontario has been advocating for the need to better address the diagnosis and management of chronic pain through the implementation of a comprehensive pain strategy. As part of such a strategy, ACTION Ontario’s professional and patient members have been sharing their experience and evidence in order to seek system improvements. On April 8, 2014, with ACTION Ontario in attendance, Ontario Minister of Health and Long-Term Care Deb Matthews, announced a number of steps in order to address chronic pain in the province’s health care system. She specifically thanked Dr. Angela Mailis-Gagnon and ACTION Ontario for their part in making this happen. Spring/Summer 2014 Inside this issue: now there are often long wait times for diagnostic tests due to inappropriate use. Additionally, the government reaffirmed its steps to assist in reducing the inappropriate use of prescription narcotics. As part of the announcement, Janice Frampton spoke on behalf of the millions of Ontarians living with chronic pain. Project ECHO Dr. Ruth Dubin, an ACTION Ontario board member, first heard of the Extensions of Community Healthcare Outcomes (ECHO) project in New Mexico while at an American Academy of Pain Medicine conference in 2012. Minister of Health and Long-Term Care Deb Dr. Dubin connected with Dr. AnMatthews and representatives of ACTION drea Furlan from Toronto Rehab, Ontario, UHN and Project ECHO The first was the announcement of and ACTION Ontario, about bringECHO Ontario demonstration proing this model to address patient and physician needs ject that will connect primary care providers from in Ontario. around the province with experts in managing chronic “I’m really excited that we were able to bring to Onpain. The model uses videoconferencing and casebased learning to connect physicians in the community tario – in relatively short time – a model that has worked so well in New Mexico,” said Dr. Dubin. with the experts to problem solve on how to manage chronic pain through the development of care plans “Patients will benefit from reduced wait times because and the safe use of treatments like opioids. capacity to treat pain will be built at the community level. Currently, patients can wait for months to be able The second announcement was funding for the develto access a clinician with expertise in treating pain,” Dr. opment of provincial referral guidelines for magnetic Dubin said. “The primary care physicians benefit from resonance imaging (MRIs), computerized tomography connecting with experts in pain, mental health and scans (CTs) and other diagnostic imaging in chronic addiction, receiving continuing pain. These guidelines will help ensure appropriate use education and being able to pracof diagnostic imaging equipment so that these tests tice at the highest level of scope.” are available to patients who need them, whereas Dear Readers 2 Physical Therapy the Brain and Chronic Pain 2 3 Profile—Dr. Jackie 4 Gardner-Nix: Mindful Meditation Soars Nutrition for Neuropathic Pain 5 Pain Free Quinoa Recipe 6 Profile—Jim Smith: My Journey After Shingles 6 The Last Word— POT for PAIN: Myths and Truths 7 As part of ACTION Ontario’s dedication to the needs of the pain community, several members of ACTION PNP have completed the Stanford Chronic Pain Self-Management Leader course and are now qualified to facilitate the Stanford Chronic Pain Self-Management program. The Stanford program was developed by Canadian Dr. Sandra LeForte and her colleague Dr. Kate Lorig at Stanford University and is recognized as one of the best and most comprehensive chronic pain self-management programs available. The six-week workshop consisting of 2.5 hours once weekly over a six-week period. If you or anyone in your community would like further information regarding bringing the program to a community group please email: [email protected] or [email protected] . & Leaders Julie Feldman, Alissa Von Bargen, Glen Hutzul, Nikki Vernon, Lisa Hooper, Janice Frampton & Nancy Becker-Halford & 8 Page 2 OUCH Editor’s Message Dear Readers, “Pain nourishes courage. You can’t be brave if you’ve only had wonderful things happen to you.” - Mary Tyler Moore Over the past year I have watched with amazement and a bit of envy as our two beautiful granddaughters have struggled with sheer determination and grit to do what we all did as human beings: sit up, fall over, do it again, stand up, fall down, do it again, walk, fall down, do it again. What happens to us as adults I often wonder? Do we just forget what it is to try? Or are we too afraid to fall down? Or are we just too embarrassed when we do? Thankfully I have always been a child at heart, some may even say childish and extremely determined, even stubborn— I don’t mind. My greatest successes have always come when I’ve put my heart on the line and been fearless. Have I gotten hurt? You bet. Have I been told my dreams and ideas were foolish? Absolutely! Still do. Due to growing up with an undiagnosed Tethered Spinal Cord I was never an “athlete” but prior to my five spinal surgeries I had been fairly fit and active as a flight attendant, wife to Phil and the mother of four girls. After illness, diagnosis and surgeries that all changed, I struggled to find a vehicle that I could do, was safe and inspired me personally to exercise consistently. The treadmill was out because the constant pounding motion is very hard on my back and legs. In the Fall/Winter issue, I shared with you that I was disgusted with myself and could not cope with another sedentary winter. I also mentioned my discovery of the “Gazelle” as the vehicle for my transformation. So, now it is with great pleasure that I share with you the results of consistent exercise. Not only did I lose weight and inches but a funny thing happened during my last physical examination; my bad cholesterol had decreased and the good cholesterol had gone up. Also, my creatinine level, kidney function, had improved – all without the use of medication. Did I hurt myself while exercising? Yup; my own fault, I pushed too hard and paid the price, a month laid up in bed in agony. Was it a quick fix? Nope; slowly but surely the weight came off and my self-esteem increased. As an absolute marvelous consequence and bonus of my new found fitness I am also now in the process of slowly minimizing a couple of my more toxic pain medications, something I didn’t think would ever happen. Nov. 19, 2013 May 15, 2014 Change can happen – when and if you are prepared to do the work. This process was 10 years in the making. Without failure none of us would have success, it’s all part of learning. We’re not all the same, I know that, but maybe this might inspire one person to try and take that first little baby step, fall down and get back up again. It can change your mindset and your life. Thank you to Dr. Angela Mailis-Gagnon, the life blood of this organization. She demands a lot, but gives ten times as much in return. Thank you as well to all our contributors on this journey. Your stories continue to teach, inspire and make a difference. Have a safe and magical summer Best, as always Janice Frampton [email protected] www.actionontario.ca Physical Therapy, the Brain and Chronic Pain By: Judith Hunter, PhD Movement is a basic function of the human body. People in pain move differently. One reason may be the residual effects of the initial injury on a body part itself. However, another reason is the longterm effect of the physiological stress of having a painful condition. Overtime, the nervous system has “learned” that you are in a stressful situation and it mounts a protective response. Although these protective responses were useful in an acute pain situation, they are not useful when the pain is no longer acute. Muscles fatigue, movement patterns change, and movement can be more uncomfortable than it should. These protective responses are not conscious. They include the normal physiological responses to protect you from a threat. For example, blood supply is diverted from core muscles to leg muscles that are used to help a body can run away from a threat. This response is designed to protect you for short periods. However, the persistence of the protective responses is connected to many of the issues that you may be experiencing, including fatigue, appetite changes, sleep disturbance, and posture issues. Even worse, they make exercise difficult. There is very good evidence that exercise can impact pain by improving general health, mood, circulation, and tissue healing. Exercise is a core component of managing your chronic pain. But movement has to be efficient before you can benefit, and not do more harm, from exercise. There is a two-way relationship between movement and pain; each impacts the other. The good news is that there is an explanation for this response and a supervised plan of movement rehabilitation can help the nervous system “unlearn” this protective responses, move more naturally, allowing you to participate in the healthful effects of exercise. Training the brain The brain constantly “learns” and “unlearns” movement patterns. Muscle and joint pain can change how the brain controls movement (motor control strategies). The nervous system is wired so that the muscles will respond to an acute stimulus by moving you away from the stimulus and protecting you from receiving additional painful stimuli from the same source. So we are wired to learn how to avoid pain. The brain learns quickly to avoid (Continued on page 3) Page 3 Volume 5 Issue 1 (Continued from page 2) pain. This can persist after the pain is gone so that even though you may be having a great day, and you may not consciously fear certain movements, the brain may have already re-wired to avoid certain aspects of that movement. The evidence shows people with chronic pain, can lack “movement variability”. Normally, we have a number of ways we can perform even the simplest of movements. For example, you may not realize it, but there are a number of very slight variations in the way you can reach up and pick up a book from a bookshelf. But because of the persisting protective responses, people with chronic pain have much more stereotypical movements. This makes you less adaptable to normal changes in posture and movement that occur as you move across different types of surfaces and through different postures. This lack of variability in movement patterns becomes a limitation to recovery of normal function in people with pain. When your movement patterns are limited, muscles can fatigue more rapidly, and connective tissue can be more easily stressed. This makes movement less rewarding for you and then you will want to move even less. Thus, pain impacts movement and lack of movement impacts pain, and so on. How do physical therapists use movement and exercise therapies to train the brain? Physical therapists, also called physiotherapists, are licensed health care professionals. They are concerned with your physical function and movement to maximize your physical potential and maintain or improve your quality of life. Movement is the fundamental tool for physical therapists. They will help you move better so you can manage your pain and how it affects your day-to-day function including your ability to exercise. You will be actively involved in your physiotherapy. You may learn how to look after your own injuries, illnesses, or disabilities. Physiotherapists assess your pain and movement in detail. They work toward your mutually agreed upon functional goals so you learn to control your pain while maximizing your physical function. Movement activities and exercises may be directed to include stretching or strengthening or endurance activities to help counteract the effects of longstanding protective muscle responses. But, in addition, the important overall approach is to restore normal movement patterns, with functional movement activities. They help you “Retrain the Brain”. A therapist will tailor exercises so they do not cause unwanted protective responses. Strengthening exercises help to desensitize the nervous system so it is less sensitive to the forces of muscle contractions. Motor stability exercises focus on the deep stability muscles. These muscles may be inhibited in people with chronic pain. Motor stability exercises also require you to concentrate. They force the nervous system to focus on the exercise and away from the pain. In the beginning, motor control exercises are gentle. This way, the sensitized nervous system does not interpret the exercises as dangerous for the affected muscles. This type of exercise plan is called “Graded Motor Activity”. Some people have such a sensitive nervous system from these protective responses, that any movement is uncomfortable. The physical therapist will use imagery. Studies show that imagined movements can start to retrain the brain as well as A therapist will tailor exercises so they do not cause unwanted protective responses. the movement itself. This type of exercise plan is called “Graded Motor Imagery”. Physical modalities versus physical therapy There are many physical modalities that help relieve short-term pain: ice or heat, (TENS), acupuncture, manual therapies including mobilization and manipulation, massage. Many professions and patients themselves use these modalities. These modalities in themselves do NOT constitute physical therapy. Just like medications, these modalities are “passive”. They are Judith Hunter PhD meant to be used so that you can actively move and function. The problem is that they can also promote a comforting, “fix-me” belief. In isolation, they are not considered “physical therapy” for chronic pain. Your physical therapist should be working with you to teach you how to manage your pain and movement. Why is regular exercise important when you have chronic pain? General exercise: Movement and exercise can help your brain ‘unlearn’ the protective responses to movement. This will help you move more normally and decrease muscle fatigue and general fatigue. You learn to recognize and distinguish “hurt” vs “harm” and learn the role of pacing. This helps you increase your activity so you can do the physical activities you want to do in day-to-day life. The physical therapist may use a “Quota- system of activity management”, also called “Pacing-up” to help you safely increase movement while retraining the brain to accept that the activity is not threatening. Aerobic exercise: You don’t need to run marathons or climb mountains. Aerobic exercise refers to exercise that aims to get your heart rate up and blood pumping through your body, such as brisk walking, yoga, biking, or swimming. In people with fibromyalgia, researchers have shown that aerobic exercise is beneficial. First, it can flush out the stress chemicals (like cortisol) out of your blood. The effect of this is to calm your sensitive nervous system and improve sleep, concentration, and mood. In addition, the blood circulation helps tired, sore, sensitive and deconditioned muscles get a boost of blood and oxygen. Studies have shown that there is a definite time and intensity needed in aerobic exercise to ease pain. The results are surprising. Stated simply, the average person with fibromyalgia will need to do aerobic exercise for just over 10 minutes and their heart rate up to 95-100 beats per minute to get some benefit. Just think – a 10 minute walk can improve your life, and help you control your pain! In general, the evidence shows that individuals who have decreased function due to pain should learn about the benefits and realistic expectations of exercise, including the potential for slight initial increases in pain. This highlights the importance of professional supervision in retraining movement and determining exercise prescription and as part of a pain management program. There are two excellent books available on Amazon to help patients understand the link between protective responses and pain. One is called “Why do I hurt?” by Adrian Louw; the other is “Explain Pain” (2nd edition) by David Butler and Lorimer Moseley. This is also available as an audio book at http://www.noigroup.com/en/ Product/EPA Dr. Judith Hunter PhD Department of Physical Therapy, University of Toronto Faculty of Rehabilitation Medicine, University of Alberta OUCH Page 4 Profile—Dr. Jackie Gardner-Nix Mindfulness Meditation Soars Shortly after emigrating from the UK to Canada to start a Terry Fox Cancer Research Fellowship in 1982, Dr. Jackie Gardner-Nix came to a realization that eventually led her to create the MindfulnessBased Chronic Pain Management (MBCPM) program in Ontario. As a medical student, she saw many physicians stepping away from patients with chronic pain whose treatment had failed them, and concluded that chronic pain was an undermanaged practice that needed attention. to restore the balance between their mind chronic stress with mindfulness and meditation evaluating the effectiveness of these courses reductions in pain, increased self-esteem, and mood in chronic pain and other patients. and body from practice. Studies found significant improvements in “The psychosocial aspect of pain is very important,” says Dr. Gardner-Nix. “The MBCPM program basically aims to harness the mind’s power to quiet the patient’s pain, see pain as an appropriate message that requires compassionate attention, and put patients in control of their pain.” Dr. Gardner-Nix began her work in pain management in the mid-1980s when she helped set up an at-home palliative team for cancer patients, while The MBCPM program features four levels of doing her cancer research. The team was so succourses, conducted in a similar environment at cessful that her colleagues convinced Dr. Gardner various hospitals and health facilities in Ontario. -Nix to start another at-home palliative program Patients from Toronto can attend MBCPM classes when, after finishing her fellowship, she relocated at a Toronto location including St. Michael’s Hospito Scarborough, Ont., and went into family pracDr. Jackie Gardner-Nix tal. Patients from outside Toronto and within Ontice. Although her experience was with cancer tario can join via telemedicine; although courses pain patients, Dr. Gardner-Nix was referred many are now being run at some of these locations on-site by newly chronic pain patients suffering from pain associated with the back trained MBCPM facilitators. The average number of patients varies and other parts of the body, in addition to cancer patients. In per course (between 10 to 70 people), and classes typically run 1998, after 15 years in cancer pain work, Dr. Gardner-Nix decided for two hours and 50 minutes with a break in between. Small to dedicate her efforts entirely to finding solutions for chronic, nongroup work also makes up a part of class time to help build trust cancer pain patients. and community within each site. “I was already interested in chronic pain while studying medicine The MBCPM program is covered by OHIP if led by an MD, with a in the UK. It was through my work with cancer patients that I realsmall materials and enrollment fee. Facilitators ized more needed to be done to understand are usually certified at a Masters or MD level with and properly treat patients suffering from nonprior experience with mindfulness before training cancer chronic pain,” says Dr. Gardner-Nix. to become a MBCPM facilitator. Many have or From her work with chronic pain sufferers, Dr. had chronic pain themselves. There is a mentorGardner-Nix came across a common pattern. ing and certification process, which facilitators More than 90 per cent had suffered adversity in undertake after their initial training on the curchildhood, including exposure to parent diriculum and auditing of a course. vorce, parent alcoholism, death of a loved one, “Training patients to be mindful of their pain redepression in a parent, and sexual, emotional or quires an attitude of acceptance and collabophysical abuse. This discovery was one of the ration, and is not easy. However, we have seen motivating factors that led Dr. Gardner-Nix to fantastic, life-changing results from the MBCPM program, with a establish the MBCPM program. 70 per cent reporting increase in productivity and an up to 25 per “A lot of chronic pain patients that suffered from childhood ad- cent reporting reduction in medication intake. In addition, a few versity were highly sensitive individuals that responded strongly to patients are able to return to work after years out of the workit. But many do not realize they have been chronically stressed as force. The Mindfulness Solution to Pain course book has been result of these challenging experiences. Chronic stress impairs translated and acquired by publishers in Korea and Germany as healing, especially as we enter middle age when the immune we look into introducing our courses into more countries,” says Dr. system is less robust compared to when young. To really manage Gardner-Nix. chronic pain, it is important to get to its source and go below the Currently, the MBCPM course is offered by trained facilitators in surface in order to heal,” says Dr. Gardner-Nix. several regions of Ontario as well as in Melbourne and Las Vegas. The idea that the mind can affect a person’s health is not new. An additional course is just about to launch in Hong Kong. For Mindfulness meditation began in 1979 when Jon Kabat-Zinn more information on the MBCPM program, visit http:// opened the first Stress Reduction Clinic at the University of Massa- www.neuronovacentre.com/. chusetts. His practice helped heal patients by teaching them how The idea that the mind can affect a person’s health is not new. Volume 5 Issue 1 Page 5 Nutrition for Neuropathic Pain Neuropathic pain is unimaginable. It compares to no other pain. I learned this after a car accident 25 years ago. The collective pain of breaking my back, shattering my wrists, smashing my skull, puncturing my lungs and lacerating my internal organs didn’t rival the agony of the neuropathic pain I experienced from damaging the nerves in my spinal cord. My neuropathic pain is best described as an ice pick being stabbed into my bones every 30-to-60 seconds. In the months following my accident, as my orthopedic and visceral injuries healed, the daily wrath of excruciating neuropathic pain emotionally, mentally and physically consumed, exhausted and debilitated me. Making matters worse, there wasn’t as much knowledge about neuropathic pain then as there is today. So during my four months in acute care hospital I was told that due to my paralysis it was impossible for me to feel anything below my level of spinal cord injury and refused any kind of pain medication. When I was transferred to a rehabilitation hospital my pain was finally addressed with narcotic medication. While the meds certainly didn’t eliminate my pain, it controlled it allowing me to start participating in my rehabilitation program and rebuilding my life. However, I worried about the long-term effects of taking anywhere from two to eight pain killers a day on my stomach lining, liver and overall health. I knew there had to be a healthier way to address my pain and after 10 years of suffering I found it. I changed my diet. Good nutrition can help reduce pain impulses within the nerves, limit the brains perception of pain, and decrease tissue inflammation and damage without the negative side effects associated with pain medications. Here are some recommendations how you can help address your neuropathic pain. 1. Reduce Inflammation Inflammation of tissues can contribute to the onset and intensity of pain. A diet high in processed foods, such as refined sugar (pop, candy, pastries, cakes, cookies etc.), white breads/pasta/rice and dairy will over time lead to chronic inflammation in the body. Eliminating these kinds of food from your diet will help decrease inflammation. Additionally, there are certain foods that actively help reduce inflammation such as turmeric (contains a compound called curcumin, which reduces inflammation) and essential fatty acids (natural oils from plants and fish), so start introducing and/or increasing these in your daily diet. If you don’t like fish or don’t eat it three-four times a week, consider taking daily fish oil supplement (two-four, 1000 mg capsules a day). See side bar for other anti-inflammatory foods. Anti-inflammatory Foods · Turmeric · Omega 3 essential fatty acids –salmon, sardines, mackerel · Olive oil · Green leafy vegetables · Berries · Beets · Almonds/walnuts · Ginger · Garlic *If you are on blood thinning medications – talk to your physician first before taking Omega-3 supplements 2. Avoid Food Allergens and Food Additives It is important to identify and eliminate any food allergies and/or food intolerances from your diet because they can cause inflammation and contribute to pain. Some of the most common food allergens/intolerances are milk, dairy, wheat, gluten, citrus, corn, eggs, sugar, soy, peanuts, pork and yeast. Food additives such as MSG, artificial sweeteners, colours and flavours can also be toxic to your nerve cells and increase sensitivity to pain. Read food labels carefully and avoid these as much as possible. 3. Six-Eight Cups of Fluid a Day Joanne Smith BA, BRT Dip; CNT When the body has a build-up of toxins it can irritate the nerves leading to pain. Certified Nutritional Practitioner Drinking six-eight cups of water, diluted juice and/or herbal tea can help flush out excess toxins from your body. 4. Increase B-vitamins There are eight B-vitamins and many promote healthy nerves and can provide nerve pain relief. For example, biotin can help in the prevention and management of neuropathy and vitamin B6 plays a critical role in pain management by making pain-inhibiting neurotransmitters. Many people are deficient in B-vitamins, so include plenty of vitamin Brich foods in your diet such as avocados, carrots, legumes, lentils, quinoa and whole grains. These foods are also high in fibre so they will assist in removing toxins from your body. If you don’t eat these foods on a regular basis consider taking a B-complex supplement. 5. Eat Tryptophan Rich Foods Eating foods containing the amino acid tryptophan (found in turkey, eggs and salmon) helps to manufacture a natural pain killer called serotonin. Serotonin can help increase a person’s pain threshold. 6. Boost Your Immune System Maintaining a strong immune system is important because bacterial, yeast and viral infections can cause pain and inflammation. For example, fungal and bacterial infections can produce myotoxins that can cause inflammation and irritate the nerves resulting in pain. Consume a diet high in fruits/vegetables and nuts/seeds, which are high in immune boosting nutrients. Daily probiotic supplements (minimum 8 billion micro-organisms) also helps support the immune system. 7. Eat Chili Peppers When tissues become injured they send a pain message to the brain. Nerves use a chemical called substance P to transmit pain signals. Hot chili peppers and cayenne pepper contain a substance called capsaicin, which helps reduce substance P. By following all of the recommendations I’ve made here I was able to reduce my daily debilitating bouts of neuropathic pain to just one-two short episodes a month. I also experienced many other benefits such as weight loss, increased energy and reduced headaches. While my neuropathic pain isn’t completely gone there is no doubt that my quality of life has improved has immensely. www.actionontario.ca (Continued on page 6) Page 6 OUCH (Continued from Nutrition for Neuropathic Pain on page 5) Try this delicious recipe that combines many pain-relieving ingredients! Pain Free Quinoa 2 tbsp olive oil 1 stalk celery, chopped 2 carrots, sliced 1 small onion, minced 1 clove garlic, minced 1 cup vegetable stock ½ cup uncooked quinoa 1 tsp turmeric ¼ cup fresh parsley Sea salt & pepper to taste Instructions Heat the olive oil in a saucepan over medium heat. Stir in the celery, carrots, onion, and garlic. Cook and stir until the onion has softened and turned translucent, about five minutes. Stir in the vegetable stock, quinoa and turmeric. Bring to a simmer, then reduce heat to low, cover, and simmer 25 to 30 minutes until the quinoa is tender and has absorbed the liquid. Once done, fold in parsley and season to taste with salt to serve. Joanne Smith BA, BRT Dip., CNP Certified Nutritionist Co-author of: Eat Well Live Well With SCI and Other Neurological Conditions For more information on neurological injuries go to www.eatwelllivewellwithsci.com Profile—Jim Smith: My Journey After Shingles As an individual that suffers from chronic pain, I am going to start this piece on a positive note. I was recently very pleased to see the recent commercials on the shingles vaccine. As someone who didn’t originally even know what shingles was, I thought, at last, the info is out. However, I feel the commercial doesn’t go far enough. Up to one in two people will develop shingles sometime in their lifetime and the pain that the commercial demonstrates is absolutely true; however it doesn’t show that a percentage of those people will have long-term chronic pain that can fundamentally change their lives for a very long time. I am one of those percents. It took a lot of documentation on my part and my specialists’ parts to be accepted for disability. I was very clear in describing the pain — deep sharp stabs that would bring tears to one’s eyes and even worse surface pain, which is best described as a bad burn and then rubbing sandpaper on it. Even today, I am on a very high dose of the narcotic fentanyl which does a good job in controlling the deep pain, but not the surface pain which quickly moves from a level four to an eight pain scale with 10 being a level you would wish for death as the day and the clothing wears on. My only hope was a specialist I saw a few years ago, a doctor in his 80’s, that actually hugged me and said I am so so sorry, but I have had patients that have gotten some relief after five years. He was right in that the number of pain hours per day has gone down, but still I am unable to know if I will have a good day or a bad day. And every evening is bad regardless. I first experienced the pain in January 2007 and my family doctor urged me to go to the hospital thinking it was possibly a kidney stone or a heart problem. A day later the rash started on my torso and back and shingles was confirmed. I received the recommended antivirals and then had to wait for the virus to take its course. UnfortuJim Smith nately, it is now 2014 and I am still suffering. The impact The impact on my family was huge. For my wife and was life altering — for the first few years I could not bear the touch of teenage daughter the condition took an enormous toll on our family clothing or even a gentle breeze on my skin. Today I still cannot life, social outings and ability to just enjoy what we used to do on a have bed sheets touch me. day-to-day basis. The financial impact to my family was significant even though I did get disability income. The cost to my employer The lasting pain from shingles has impacted every part of my life. I was very significant given the payment of disability benefits. I did held a senior position in government with a staff of over 300 people find that CPP Disability was supportive and didn’t challenge me the — a career I had worked hard at and was rewarded by a number of way my employer’s disability provider did. Seven years of struggle promotions. That all came to an end as I was no longer able to perwith so many impacts. After seeing the impact on my life, all of my form at work due to the agonizing pain I suffered after contracting friends have run to get the shingles vaccine. Today, I have hope shingles. Fortunately my employer was supportive and I was put on that the impact of neuropathic pain from shingles can be reduced special assignments, including a teaching position at an Ontario through vaccination. I personally would recommend vaccination at university, that would let me better control my hours. Ultimately I had age 50, as I was 52 when my life was changed forever. to go on disability. This resulted in a huge psychological conflict for me, as I want to work and have committed my life to a career. The The Ontario government needs to make this vaccine available for situation was compounded as I was dealing with chronic pain that free to the public and the public needs to be educated about the was invisible to those around me. potential long-term impacts of this illness. From a cost benefit analysis, one month of full CPP disability income is just over $1000. A vacI had gone to a number of pain clinics and had tried a range of cine that costs less than $200 per dose could prevent the payments drugs, all with major psychological impacts and no real pain relief. I of hundreds of thousands if not millions of dollars in also had a neurostimulator implant that would send signals through disability income to individuals that are impacted by my spinal cord to try to out compete the pain signals to the brain. shingles. The process involving neurosurgery was significant and unfortunately The Shingles Virus only provided limited relief. Volume 5 Issue 1 Page 7 The Last Word: POT for PAIN; Myths and Truths By: Dr. Angela Mailis-Gagnon This is a topic I have avoided in past articles for OUCH as I considered it truly too hot and messy. However, the issue has reached a boiling point and cannot be avoided: Is pot useful in the treatment of chronic pain? And if so, how does one get a prescription for medical marijuana? actions of cannabinoids have been conducted in Great Britain, Australia, and the United States, and all have concluded that smoking pot should be permitted under special circumstances, such as when patients are terminally ill, or in other cases for a limited time only. All however, suggest research into alternative methods of administration of the active ingredients in marijuana for rapid action without the risks associated with smoke inhalation. Before we begin I will provide a brief, historical overview of marijuana, or hemp plant, from my book BEYOND PAIN, published in 2003 with David Israelson. The cannabis sativa L or hemp plant was one of the first plants to be used by man all over the world to create fibers for the manufacturing of clothes and ropes, food and medicines and, in social and religious rituals. When it comes to pain, the extracts of the cannabis plant called cannabinoids were used by ancient populations thousands of years ago, as well as by Asian populations in the Middle Ages and for different pains in the West during the 1800s, with commercial preparations supplied at the time by the pharmaceutical company Lilly and Squibb. On July 30, 2001, following a highly publicized Supreme Court of Canada case, the federal government hastily established a set of Marijuana Medical Access Regulations. These regulations spelled out three categories of people who can apply to possess marijuana for medical reasons: 1. People who suffer from a terminal illness and are doomed to die within 12 months; 2. Those who suffer from multiple sclerosis, spinal cord diseases, AIDS etc, provided that all other available treatments have been tried or found not to be appropriate; 3. An all-inclusive “non-of-the-above” category, consisting of those suffering from conditions other than those mentioned above, provided again that all Health Canada announced other treatments have failed. Cannabinoids were however discontinued as medical As of March 31, 2014, agents in the 1930s. It was only in 1964 that the sole psybig changes to the country’s medical marijuana Patients once prescribed choactive ingredient of canmedical marijuana by their rules. In a capsule, a) the option for patients to n a bi s , D el ta 9 - TH C , physician via a lengthy proc(tetrahydrocannabinol), was grow their own pot was ess could either grow their isolated in pure form. The disown pot or find someone to covery of morphine receptors grow it for them. Nevertheless, revoked, and they in the brain and the spinal from 2001 to now, about must now acquire their 37,000 patients had been record in the 1970s led to the discovery of endorphins, the ceiving medical marijuana marijuana from a body’s own pain killers. Simiacross the country. larly the discovery of cannabi- designated provider, and b) the requirement that noid receptors in the brain As of March 31, 2014, Health Health Canada approves the use of medical (CB1) made scientists quesCanada announced big tion whether the brain prochanges to the country’s marijuana was lifted duces marijuana-like submedical marijuana rules. In a stances as well. Indeed, two capsule, a) the option for pasuch internally produced compounds, c a l l e d tients to grow their own pot was revoked, and they must now ac“endocannabinoids”, were discovered. quire their marijuana from a designated provider, and b) the requirement that Health Canada approves the use of medical mariAfter that discovery, synthetic cannabinoids were created, some juana was lifted. of which have other than psychoactive functions. Today synthetic cannabinoids are in use to increase the appetite of patients with Two kinds of patients visit me in my clinic asking for marijuana preAIDS and for prevention of vomiting and nausea in cancer pa- scriptions. One of my latest cases happened just a couple of tients who are undergoing chemotherapy. months ago. This 26-year-old man was a labourer, working for a large company and handling heavy equipment. He recently apCannabinoids seem to have protective effects on nervous tissues, peared in his place of employment with a license for medical and may work on inflammation, anxiety and several other condi- marijuana and asked to have a 10-minute break “every 90-120 tions. Numerous animal experiments to date also demonstrate minutes” to smoke a joint. The employer put him on medical leave that cannabinoids can block many different kinds of pains. A very and asked for an assessment regarding the validity of his claim. interesting aspect of cannabinoids is their potential to help other drugs work better. For example, L-DOPA, a drug used in Parkin- While taking a proper history from this healthy looking young man, son’s disease, works much better in people when combined with I discovered that he lived in the GTA, drives to work in Toronto daily apomorphine, a cannabinoid. Some cannabinoids are commer- and had been smoking pot for many years before obtaining a cially available in Canada in the form of pill such as nabilone medical marijuana prescription. Also, for the past three years his (known as Cesamet) as well as an oral spray (Sativex). family physician saw him once a year only when renewing his pot license. When I asked on what medical grounds he was granted a The current major debate in medical and political circles relates to medical marijuana license, I was presented with a single specialist the question of whether smoking marijuana for medical reasons should be permitted. Major reviews of the possible therapeutic (Continued on page 8) Page 8 OUCH The Last Word (Continued from page 7) consultation page from 2005, eight whole years ago, saying “maybe he has fibromyalgia.” My detailed examination failed to find a single spot of tenderness to confirm the diagnosis. Naturally, I concluded that I saw no medical reason for this man to justify his pot smoking, that I did not agree with the physician who granted him the license, and I expressed serious concerns about him driving under the influence of cannabis or operating heavy equipment. On the other hand, this 32-year-old woman, mother of four young kids, has been my patient for four to five years. She was the victim of a bad accident when her leg was crushed by her car door after a truck drove into her. She ended up with a very painful and twisted foot, which is permanently contracted and deformed as she walks on the outside of the foot. She is a very good mom, a very active woman, has taken every prescribed drug properly and followed every recommendation I’ve made. Unfortunately, the effect from painkillers is moderate and not effective enough for her needs. Lately she started using two-to-three cups of marijuana tea to enhance the effects of the painkillers and sleep. She is a very compliant patient who has not done well with all appropriate drugs I have prescribed for her condition and does not use any illicit drugs (except pot that she told me about). I have tested her with urine drug screens and I know she is indeed clear from other substances, and does not use smoked pot (that means she minimizes the risk to her lungs from other inhaled substances that exist in a pot cigarette). In other words, she is an ideal patient for medical marijuana, and I had no problems signing the appropriate papers. I hope these examples give you an idea of the two types of people that approach me for medical marijuana. The first group is characterized by many or all of the following: young age, previous pot use, possible other illicit drug and/or alcohol abuse, questionable indication for pain with no evidence of substantial physical pathology, unemployed and/or on disability payments, while their complaints are vague at best (diffuse body pain, mechanical back pain, insomnia, anxiety, etc.). This is the group I have no good reason to prescribe pot. The second group includes patients of all ages or social status, with serious pathology who have followed medical recommendations faithfully for long periods, have failed medical management and have serious conditions affecting the nervous system (such as nerve injury, multiple sclerosis, spinal cord injury, neuropathy associated with AIDS, etc). Unfortunately, the vast majority of those who approach me seeking medical marijuana prescriptions belong to the first group and this is exactly the population that frightened family doctors tell me will overwhelm their offices once the floodgates of Medical Marijuana’s new rules open. I have reviewed numerous scientific studies (my reviews are in the e-CARP advocacy newsletter where I write monthly). To summa- rize for the reader, this is what science says so far regarding the effectiveness of pot: · Cannabis products in general and smoked cannabis in particular work for certain kinds of pain specifically due to injury of the nervous system (AIDS neuropathy, Multiple Sclerosis, Spinal Cord Injury, etc); · The effect is no better than that of weak (but not strong) opioids or non-opioid drugs for neuropathic pain; · Very low dose of smoked cannabis three times a day (a single Dr. Angela Mailis-Gagnon puff actually each time) may work for pain and sleep problems in neuropathic pain patients; · Higher doses of cannabis have an adverse effect on memory and attention and can actually increase instead of decreasing pain; · When smoked cannabis is compared to cannabis in the form of a legally prescribed pill on experimental pain, the pill seems to have longer lasting effects. So what do the doctors say? The Canadian Medical Association, the College of Family Physicians of Canada and the Federation of Medical Regulatory Authorities of Canada and other professional medical associations, are against the new regulations of Health Canada, because the effectiveness and safety of smoked cannabis has not been established. While smoked cannabis can offer some reprieve from pain in some specific conditions for neuropathic pain, smoked cannabis is NOT innocuous. A recently published Swedish study on 50,000 Swedish males over a 40-year period showed definite evidence that smoked cannabis is a risk factor for lung cancer. Studies also show that users of medical cannabis are at higher risk than the general pain population for addiction to cannabis and other drugs, because they a) are mostly young and male, and b) they have higher rates of mental illness and opioid and illicit drug misuse. Recreational cannabis use is a well-established risk for psychosis and for the development of schizophrenia. Cannabis use is associated with mood and anxiety disorders, and an increased risk of suicide in both psychotic and non-psychotic samples. Preliminary evidence as well links cannabis use during pregnancy to neuro-developmental abnormalities in infants. Finally, adolescent users in general appear to be at risk for long-term cognitive impairment, social dysfunction, impaired work and school performance, anxiety and depression, and psychotic disorders. Health Canada has created a nightmare for both physicians and patients with these new regulations, so that both physicians and patients are quite unhappy. As I said over 10 years ago in my book BEYOND PAIN, when the first medical marijuana regulations were imposed on doctors by the federal government in 2001, politicians then put “the cart before the horse”. History now repeats itself only this time, unfortunately, it is a much bigger cart. Angela Mailis Gagnon, MD, MSc, FRCPC(PhysMed) Director, Comprehensive Pain Program, Senior Investigator, Krembil Neuroscience Centre Toronto Western Hospital, www.drangelamailis.com Chair ACTION Ontario www.actionontario.ca OUCH is a publication of ACTION Ontario. All materials are the intellectual property of ACTION Ontario and cannot be reproduced without the expressed consent of ACTION Ontario.
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