Lara Pingue is a programming editor at The Globe and Mail.
It was a warm morning in August, 2018, when it happened: I sneezed in my kitchen while making breakfast. Nothing about it was out of the ordinary, except that in the two seconds it took to expel my breath – achoo! – I felt something shift in my lower back. The dull ache that had been nagging me for days had suddenly, violently, erupted into a searing pain. I remember looking around me, stunned, thinking that I had been hit with something.
I wince when I think back on it now. In those moments, I had no idea The Sneeze was just the beginning. I didn’t know that the electric zing I felt was a dislodged soft disc in my lower spine, what doctors would later tell me was a herniated disc.
I didn’t know that the pain would travel down my leg and then bloom into something else entirely, that it would upend every aspect of my life for weeks, then months, and then years.
And I certainly had no way of knowing that on that morning in my kitchen, I was on my way to becoming a statistic. One in five Canadians live with pain that is chronic – that is, lasting more than three months.
Unwittingly, I have become part of a $40-billion problem, according to 2019 estimates on the health care and lost-productivity costs that chronic pain drains from the economy. Statistically, I’m now more likely to kill myself, lose my job, have anxiety, get hooked on opioids and suffer sleep dysfunction than I was before a simple sneeze five years ago.
But here’s the clincher: If you have chronic pain in Canada, well, you’re in for a world of hurt.
In my years ping-ponging through the health care system, I saw doctors who were smart and kind and competent and, importantly, believed me. But it soon became clear that we were operating in a system that isn’t designed for patients like me – people who have pain that doesn’t go away.
In 2019, the Canadian Pain Task Force, a committee of doctors and advocates formed to provide actionable advice to the federal government, issued its first report on the state of pain management in this country. They came out with a 50-page document pointing out long wait times, gaps in public awareness, a raging opioids crisis, barriers to care and a scarcity of health professionals trained in pain. Not surprisingly, they found vulnerable populations – Indigenous people, those living in poverty, women – were even worse off than the general population.
And then there’s what every expert and researcher has told me in hushed, resigned tones: Pain is complicated, mysterious, poorly understood. It’s also almost always invisible. I blend in with any crowd, unremarkable in every way.
What went wrong?
Is there anything more banal and cliché than a middle-aged person with back pain? It’s almost embarrassing to be this predictable. I once walked into the break room in my office where I found a co-worker (middle-aged) lying flat on the floor with his legs propped up on a chair. I knew it before he said it: “Bad back,” he told me.
There’s a conversation that happens in a loop when people find out you have a bad back. Invariably, they tell you they had the same thing once and then ask if you’ve tried a fix that’s blatantly obvious. The answer is always yes.
I’ve tried Tylenol, Advil, muscle relaxants, heating pads, cold packs, acupuncture, physiotherapy, chiropractic. I’ve tried “not thinking about it” and “staying positive.” I’ve tried meditation, prayer, an exercise bike. I’ve read Dr. John Sarno’s world-famous book, Healing Back Pain, which late-night comic Jimmy Kimmel recently hailed for solving his own back woes. I’ve undergone two steroidal epidural procedures, during which a doctor injected corticosteroid into my spine to block the pain (it worked the first time – for about two months).
I’ve tried long walks, short walks, gentle walks, no walks, yoga, Pilates, stretching. I’ve had surgery to remove bits of my ruptured disc with the hope that it would relieve pressure on my nerve. I’ve been on a low dose of antidepressants. At the peak of my pain, I was taking nine capsules a day of pregabalin, a drug that dulls nerve pain but left me feeling foggy and tired.
I’ve wondered endlessly how someone like me – stoic, a non-crier – could be such an utter wimp at tolerating pain.
And then there’s the question that keeps me up at night: What if it’s all in my head?
To answer that, I turn to Dr. Karen Davis, senior scientist at the Krembil Brain Institute and Canada Research Chair in acute and chronic pain research. She’s been studying pain for 40 years and can remember when endorphins were first discovered in the 1970s.
“It was amazing to me to think that we have a system within our brains, within our bodies, to combat pain,” she tells me on a Zoom call.
It turns out the pain really is in my head, or, specifically, in my brain. To understand it, we go back to Pain 101, a lesson most of us learned in high school: Pain is the body’s alarm system, warning us of harm or danger to the body. We touch a hot stove, we recoil. But with chronic pain, the brain continues to get alarm signals even when the danger is no longer there, or when the body has healed.
What still confounds doctors and scientists is why some of us develop chronic pain while others don’t.
What complicates matters is the subjectivity of pain, or how we experience it. The sneeze in my kitchen, for instance, might’ve felt like a 10 out of 10 on a pain scale to me, but register only as a six to someone else.
Pain, and our interpretation of pain, is an opinion – and so it’s easy to see how a doctor might dismiss a patient’s chronic headaches, for instance, if the doctor’s personal experience with headaches has been mild.
Perhaps nothing better illustrates the power of the brain-pain connection than a famous report published by the British Medical Journal in 1995. In it, a 29-year-old construction worker jumped onto a plank and accidentally landed on a seven-inch nail, piercing straight through his boot. In agony, the man was rushed to the hospital and immediately sedated. But when the doctors removed his boot, they discovered the nail had never actually touched his skin; instead, it had passed through the space between his toes, leaving his foot completely unharmed. So how did he feel pain? The perception of harm was so strong, so overwhelming that his brain processed it as pain.
“We like to say, ‘Pain is what you say it is,’” Dr. Davis explains. “Nobody ever questions your perception of smell or taste, or musical preference. All senses are subjective.” The same is true of pain – our brains are different, so we perceive pain differently.
In a landmark study on how the brain reacts to pain, Dr. Davis and her team had people complete a simple task on a computer, interrupting them every so often with a painful jolt to the hand. Dr. Davis assumed the pain would slow them down or cause them to make mistakes, but in fact half of the participants performed the task faster and with fewer mistakes. The results were astonishing, pointing to differences in the way brains are wired to modulate pain.
Her current research uses neuroimaging to find predictive biomarkers of treatment outcomes – or, put more simply: She’s looking for clues in the brain that can predict whether a patient will benefit from a particular treatment over another. Conceivably, one day a patient like me could be tested and assigned a pain profile that would dictate the kind of treatment most likely to work.
Dr. Davis warns there’s no magic bullet – rather, brain research is all about finding “a constellation of magic bullets,” but it’s remarkable how far we’ve come in our understanding of pain. As recently as the 1980s, sick babies who needed surgery were still being operated on without anesthetics because doctors believed they couldn’t feel pain and administering drugs was considered too risky. (That changed, in part, after a high-profile case involving American mother Jill Lawson, who went public after learning her infant son had undergone heart surgery without painkillers and later died. Volumes of research have since concluded that babies do feel pain and, in fact, recover more quickly from medical operations when their pain is managed with drugs.)
What’s fascinating – or maddening, if you’re a pain patient – is how much we’re still discovering. In 2022, researchers at McGill University published a study that suggests blocking inflammation after injury might actually make that pain chronic, a finding that goes against the common practice of taking an anti-inflammatory, such as Advil, to tamp down acute pain. Though the research still needs to go through clinical trials, the findings point to new ways of thinking about pain.
Dr. Davis describes pain research with a baseball analogy: If you’re batting .300, you’re a superstar, even if it means you’re succeeding only 30 per cent of the time. But it also means you’re failing 70 per cent of the time. “You can’t give up,” she says. “Even the greatest batters on the planet have to make adjustments to whatever’s thrown at them.” I just want someone to hit it out of the park.
My stupid bad back
A couple weeks after The Sneeze, I booked an appointment with my family doctor. The Robaxacets I was popping like Tic-Tacs weren’t working and a massage therapist I had seen suggested I might have something more serious than a strained muscle. I was looking for relief, but also for some sort of recognition of my suffering. My doctor listened patiently as I walked her through a litany of my grievances. I couldn’t bend, I couldn’t sit for more than 20 minutes, I couldn’t sleep, everything hurt.
In TV commercials for over-the-counter pain medications and creams, pain is usually depicted in red: We see an actor clutching a sore shoulder or a bad knee, with the offending body part lit up in red. I think about that a lot when trying to describe pain. I use the term “bad back” because it’s easy shorthand, but strictly speaking my back isn’t the problem. While I feel a bit of an ache in my spine, the real pain is in my left leg and it changes like the weather. At first, it was electric – a jolting buzz of pain running up and down my leg, nearly constantly. In the early days after The Sneeze, I would wake up and hobble out of bed at all hours of the night just to change my position. Sometimes the pain pulsed, sometimes it burned, sometimes it ached and throbbed. For a long time, walking hurt and running was out of the question. In the 15-minute jaunt from my office to the train station, my left foot would start to tingle and then become numb.
At work, I hit a low point when it hurt too much to bend over and change out of my winter boots. I briefly considered asking a co-worker to help me, decided it was too humiliating and instead spent the day sweating in my Sorels. Sitting was agony. In meetings, I would bolt up out of my chair and pace the room, desperate to get out of a seated position. Air travel was out of the question, car trips were limited. To this day, I literally can’t sit still.
One day, months after The Sneeze, something shifted again. I felt better, good enough to wander around the city for the weekend with my husband without thinking much about my back. But two days later, the pain came roaring back, a cruel reminder that it wouldn’t be ignored. That night I went to bed angry and depleted, my body aglow in red.
The hunt for relief
In the early weeks after The Sneeze, my doctor told me the facts: Most back pain resolves itself within 12 weeks. If I was still suffering after that, she would order me the MRI I was insisting on – but that came with a warning: Research shows that there’s sometimes very little correlation between the abnormalities found in a back scan and what the patient feels. In other words: My scan could come back completely normal, or it could show any number of structural problems that have nothing to do with my symptoms.
In the meantime, I started massage therapy and physiotherapy, both woefully more costly than my private insurance allotments. Within a couple months I had burned through my coverage limits and was paying hundreds of dollars out of pocket for what I hoped would bring some relief. After a while, I decided it wasn’t working, or at least not fast enough, and I gave up entirely.
I ask Dr. Anuj Bhatia, co-director of the Comprehensive Integrated Pain Program at the University Health Network, why pain is so seemingly impossible to untangle. In a perfect world, he tells me, we could stop pain from becoming chronic by using the “four-Ps” approach: pharmacological, psychological, physical therapy and procedural. With some trial and error, you would find what works for an individual patient.
The problem is that a pain specialist like Dr. Bhatia won’t be the first person you see when you’re hurting – it will be your family doctor, if you’re lucky enough to have one. And even then, many primary-care doctors treat chronic pain as a symptom of an underlying condition, not a condition in its own right – one with complex multiple determinants.
Lack of pain training in medical schools has been documented for years; the fact that veterinarians are better trained than doctors to treat pain is one of the shocking facts experts like to trot out to underscore the disparity. That’s starting to change now, but it’s far from the only challenge.
In a review by Dr. Bhatia and his research group, published in the Canadian Journal of Pain in 2023, primary-care physicians reported feeling professionally isolated, said they had difficulties assessing and managing complex pain cases and were lacking the access to specialists in the pain field, among other challenges. The result is a frustrating experience for doctors and patients alike.
The opioid crisis adds another tragic layer. In 2017, Canada’s new guidelines for prescribing opioids put a chill on prescriptions, and many doctors weaned their patients off the drugs or stopped prescribing them altogether, leaving patients feeling desperate, stigmatized and left to their own devices.
Early this year, U.S.-based pain psychologist Dr. Rachel Zoffness spoke in a now-viral podcast about why chronic pain is so intractable for so many people. I listened to her, rapt, as she called it a “biopsychosocial” problem. Experts use that term a lot to describe the ideal way to assess and treat pain. In simple terms, it means a patient’s entire being is taken into account: Is the patient depressed or experiencing trauma? Is there tissue damage? What is their work and home life like? It’s all connected – but our health care infrastructure isn’t. We pay out of pocket for psychologists and physical therapists and massage therapists in a siloed, disconnected system.
“We’ve all been told this lie that pain is a purely biological, biomedical problem. And so we reasonably believe the only actual treatment for pain is medication or a procedure,” Dr. Zoffness tells me in a phone call from California. She wants to be clear: Yes, sometimes pills and procedures are not only warranted, but necessary. But too often those treatments alone miss other factors. Neuroscience tells us that pain is linked to things such as nutrition, sleep, past injuries, stress – but as long as you believe your problem is only physical, you’ll use only a pill to fix it, she says.
“People with chronic pain know that’s not the solution because 20 years later they’re still in pain.”
But in 2018, I know none of this. I’ve never heard of the word biopsychosocial, and it doesn’t occur to me that my pain could be linked to anything more than a cursed spine. When an MRI of my lower back shows an L4-L5 disc herniation, I feel like I’ve won the lottery. It’s proof that the pain is real. When an orthopedic surgeon tells me I’m an ideal candidate for surgery, I book the earliest date available and start a countdown to getting my life back.
The bad mom
My youngest son, Sam, was just three years old when The Sneeze happened, and so it’s reasonable to assume he has no memory of the version of me who went on long runs and sat at the dinner table without squirming. I spent his older brother’s sixth birthday pacing the aisle instead of sitting in my seat at the movie theatre where he was celebrating with his friends.
About three months after The Sneeze, I took Sam out to ride in his battery-powered Jeep, a monstrously loud toy car that he loved to ride in. I watched as he discovered the Jeep’s faster second gear and peeled off the sidewalk and onto the street, gleefully swerving around parked cars and kids on bikes. Running after him wasn’t an option – the brisk walk I was managing already hurt enough – and so I screamed for him to get off the road, waving my arms uselessly, but he couldn’t hear me over the noisy engine.
When he finally stopped the Jeep and I hobbled over to him, my panic melted into a white-hot rage. I stood there on the street yelling at him, watching his face change from glee to confusion and then to fear. I was furious not with him, but with my own body, how it betrayed me. It had already sucked so much joy out of parenthood and now it was coming for what was left. I couldn’t keep them safe any more.
What’s more, my chronic pain actually puts my kids at an increased risk of developing their own problems with pain, says Dr. Christine Chambers, professor of psychology & neuroscience and pediatrics at Dalhousie University. Research shows that children of parents with chronic pain are more at risk of “poorer outcomes” than those of healthy adults, which includes reporting higher levels of pain and increased levels of anxiety and depression.
Part of the reason is biological and psychological, but it’s also social – a learned behaviour. Dr. Chambers tells me about a time years ago when she applied ice to her back after an injury and watched in awe as her young child mimicked her actions, wobbling around with an imaginary ice pack on his back. “I thought, my God, he’s picked that up from me.”
Of course I know that not every child of a parent with pain will suffer the same fate, but there’s no denying that my own kids have lost something. The Jeep incident haunts me. And in my bedroom there’s a red velvet box stuffed to the brim with homemade cards. “Dear Mommy,” they say. “I hope your back feels better soon.”
In March, 2020, the world changed. As scores of office workers sat hunched over their laptops in makeshift home offices, I took to my bedroom floor, where I would sprawl for hours in various ergonomically disastrous positions to do my work. I couldn’t get comfortable and I wasn’t alone. Thousands of Canadians reported worsening pain during the pandemic as we all adjusted to a new and scary reality. It had been nearly a year since I had back surgery, the results of which left me virtually unchanged: not much better, but no worse.
But in 2022, something shifted again. Slowly, and without even noticing at first, I started to get better. I could sit for longer periods of time. I stopped waking up in the middle of the night with pulsing pain. That’s not to say things are perfect – I think I’ve given up running for good – but I recognize myself again. There was a long time when I didn’t.
That’s maybe the most frustrating part of this story, how seemingly random it all is. There was no breakthrough moment or miracle cure, no routine or treatment I could point to as the holy grail that saved me. It just happened.
I imagine telling myself in 2018 that if I just waited four years, everything would eventually be better. Most of us don’t have four years to wait. I had, and continue to have, the best possible circumstances: I have a job, a home, a supportive husband and family, private insurance, and I live in the biggest city in the country, a hub of the medical field. But what about all the people who don’t share my same luck?
In 2021, the Canadian Pain Task Force issued its final report, a list of all the things we should do right now to address pain. There’s some good news buried among this 20-page document, but this line struck me: “Innovative treatments and clinical models, proven educational models … and world-renowned research ready for implementation already exist across the country.” In other words, it’s all right here in front of us – we’ve got the tools and brainpower to solve a multibillion-dollar problem and save countless people from misery. We’ve just got to do it.
Dr. Fiona Campbell is the last person I call for this story. She’s the former co-chair of the task force, so she’s intimately acquainted with all the things we’ve got to do to change the system – and in fact, she tells me, some of them are already happening. Pain education in medical schools is ramping up, awareness is slowly trickling in, new online portals for pain management are popping up. None of it is fast or perfect, but it’s happening.
Then I ask Dr. Campbell what I ask everyone else: Is she hopeful?
She’s careful about her answer. We’ll always have chronic pain because it’s not a completely preventable condition, she tells me. But earlier, better treatment and less stigma will go a long way to making sure people like me aren’t wasting years of their life looking for an answer. “In my opinion, things will be better,” she says.
I can’t tell if she’s right. But I know how much can change in an instant. Or in the two seconds it takes to sneeze.
Chronic pain and wellness: More from The Globe and Mail
Want to ease pain in your lower back? From Kitsilano Beach in Vancouver, yoga instructor Amber Brown walks us through a move to help with that: A two-knee twist, or Supta Matyendrasana.
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