The Need for a Canadian Pain Strategy

Pain is poorly managed in Canada. This includes acute pain caused by ongoing tissue damage, trauma or surgery, chronic pain and pain related to terminal illness. Reasons for this include under-recognition of the problem, lack of education regarding pain assessment and treatment in graduating health care professionals, and grossly inadequate funding for research regarding pain. Although we have the knowledge and technology, Canadians cannot be sure they will receive adequate or appropriate treatment for pain along the entire continuum of care from community health professionals to specialists in tertiary health care institutions. The magnitude of the problem is increasing. For example, one in five Canadians experiences chronic pain, children are not spared and the prevalence of chronic pain increases with age (1,2). Many people with diseases such as cancer, HIV and cardiovascular disease are now surviving their acute illness with a resultant increase in quantity of life. However, in many cases, they have poor quality of life due to persistent pain caused either by the ongoing illness or nerve damage caused by the disease even after resolution or cure of the disease. In many cases, pain is also caused by disease treatments such as surgery, chemotherapy or radiotherapy (3,4). Chronic pain is associated with the worst quality of life compared with other chronic diseases such as chronic lung or heart disease (2). There is double the risk of suicide in chronic pain patients compared with people without chronic pain (5). Higher pain severity is associated with higher suicide rates (6) and a sense of hopelessness (7), and suicide rates remain higher even when controlling for mental illness (8). A recent review (9) of opioid (narcotic)-related deaths in Ontario, published in the Canadian Medical Association Journal and reported in papers across the country, identified the tragic fact that pain medicationrelated deaths in Ontario are increasing. Even more tragic was the fact that most of the people who died had been seen by a physician within nine to 11 days before death (emergency room visits and office visits) and that the final encounter with the physician involved a mental health or pain-related diagnosis. In almost one-quarter of the cases, the coroner determined that the manner of death was suicide (9). It is tragic that these patients did not get the help that they needed. It is disturbing that in Ontario, the largest province in the country, there is not a single interdisciplinary pain management program that is fully funded by the Ontario Ministry of Health. At present, wait times for care are greater than one year at more than one-third of publicly funded pain clinics in Canada, with vast areas of the country having no access to appropriate care (10). Patients waiting more than six months from the time of referral to assessment experience deterioration in health-related quality of life, increased pain and increasing depression (11). For this reason, the Canadian Pain Society Task Force on Wait Times determined that wait times for chronic pain conditions beyond six months are medically unacceptable and that, in many cases, six months is far too long to wait for care (12). Understanding Pain The International Association for the Study of Pain taxonomy defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” (13). Pain is divided into two broad categories – acute pain, which is associated with ongoing tissue damage, and chronic pain, which is generally understood to be pain that has persisted for longer periods of time. acUte or Physiological Pain Sources of acute pain include work, vehicular, domestic and sports injuries; childbirth; surgery; fractures; burns; and medical procedures. Acute pain is caused by tissue damage, with triggering of the inflammatory response and activation of ascending neural systems that convey pain-related information. These systems are complex and involve numerous signalling relays and feedback loops, and multiple chemical neurotransmitters. We are also equipped with a sophisticated descending modulatory system or ‘pain defense network’ that enables the body to fight pain. It is this pain defense system that is activated by drugs (eg, opioids) used to treat pain. Acute pain can be controlled using appropriate physical (eg, ice and splinting), pharmacological (eg, anti-inflammatory drugs and opioids) and psychological (eg, reassurance and anxiety management) treatments. Unfortunately, even in the best hospitals in Canada, patients continue to receive inadequate pain control in emergency rooms and after common surgeries. For example, in a study (14) of postoperative pain control after coronary artery bypass grafting, a common procedure to treat or prevent myocardial infarction, less than 30% of the ordered dose of pain medication was given, with approximately 50% of patients continuing to report moderate to severe pain one to five days after surgery. One-quarter of patients rated the pain as ‘extremely unpleasant’, with significant interference in their ability to function even up to the day before discharge. This included interference with breathing and coughing (critical to prevent postoperative lung infection), general activity and walking. Patients continued to deal with these problems at home 12 weeks later. In another study (15) of patients undergoing ambulatory, ‘same-day’ shoulder surgery, patients continued to experience severe levels of pain and poor sleep for at least seven days after surgery. At the end of the seven-day study, pain levels still had not decreased, with implications for healing and function. Given that same-day surgery is an increasing phenomenon, it is