Chronic pain in family practice: research and insights

We see patients with chronic pain in the office or hospital almost every day, yet this condition is poorly understood and one of the most difficult to treat.^1,2 This issue of Canadian Family Physician explores the theme of chronic pain through new research, a commentary, and artwork created by those who have lived with the condition.

Since chronic pain often stems from another illness, comorbidities are frequently abundant. This complexity is compounded by the fact that patients may not always be able to describe their symptoms in standard biomedical terms. An Australian study documented how patients used metaphors to describe their pain.³ One patient described a sensation of sharpness as “barbed wire wrapped around [their] feet.” As the authors concluded, “The desire to be understood was evident throughout the data.”

We hope to enhance our understanding of patient experiences through the art included in this issue. Our cover image, Turning to Stone, is a painting by Lili Wilde, who lived with chronic regional pain syndrome until her death in 2019. Her medication options were limited owing to severe allergies. As her husband, Terry, writes, the left side of her face was the only place where pain did not exist, “the one place she could escape to.”⁴

Even when medications are tolerated, the side effects may be severe, even life-threatening. We must recognize the role of the pharmaceutical industry here. In 2020 Purdue Pharma pleaded guilty to criminal charges related to its role in the opioid epidemic in the United States and agreed to pay billions of dollars in penalties.⁵ Yet, while it was pharmaceutical companies that carried out opioid marketing and research falsification, medical journals inadvertently fostered these activities. As outlined in one of this month’s research articles (page 192), medical journals accepted opioid advertisements that did not always mention risks of addiction and death.⁶ Much has been learned over the past decade, and it is now well understood that opioids are not the treatment of choice for chronic noncancer pain.⁷ The importance of nonpharmacologic approaches and team-based care is also evident, as outlined in the program description by Assefa et al (page e52).⁸

Investigations for chronic pain often show limited findings, but in her commentary (page 158), Dr Maureen Allen discusses the utility of noninvasive neuroimaging.⁹ As she outlines in her article, new studies show objective differences in the brains of patients who have chronic pain. This is not to say every patient with chronic pain should undergo functional magnetic resonance imaging, at least not during our current health care crisis with limited resources; rather, new research in the field of noninvasive neuroimaging can help validate the experiences of people living with chronic pain.

Active listening is another way to validate a patient’s symptoms. In his book, The Creative Act: A Way of Being, music producer Rick Rubin discusses the importance of listening in the creative process, an approach that can be applied to medicine.¹⁰ He defines listening as “the suspension of disbelief” and argues that the way you listen to someone influences how (and what) they communicate.

Listening may not be as easy as it seems, however. In our health care system burnout is high, and a hallmark of burnout is cynicism—a mindset not very conducive to listening. We also work in a system that values quantity over quality (eg, through the persistence of the fee-for-service model or the use of shadow-billing targets in a salaried model). In family medicine, the more patients we see in a day, the more valuable we seem. Yet treating patients with chronic pain takes time. The balance between working efficiently and listening empathetically is delicate, and I have yet to master it. It is our hope that the content in this issue provides additional information to help us care for patients and understand them better, too.

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