Mr. J. an 89 year old gentleman, bright and well educated, saw me 3 years ago, on the desperate plea of his son and daughter. Dad had developed a painful condition in his left lower leg with sharp jabs of knife-like and burning pain and bouts of uncomfortable pins and needles sensation. To make the story short, the moment I saw Mr. J. I noticed very slow movements of his toes in that affected leg. He had become aware of them since the onset of the pain but did not know what to make out of these movements. I thought of a very rare and painful syndrome named “painful legs, moving toes”. The commonest abnormality associated with the syndrome comes from the spine when a nerve root is pinched and compressed usually because of degenerative changes. There was only one problem: Mr. J. had nothing but minor back pain for years to the point he felt it was not worth talking about. I sent Mr. J for a spinal MRI and nerve tests. The MRI was clear: he had an absolutely lousy back and his nerve root was squeezed at the site of the painful leg. A nerve test was able to confirm that Mr. J. had a pinched nerve in his back. The tests made me confident that my original diagnosis of “painful legs, moving toes” was right.
Since there is no cure for this condition, I decided to target different issues that contributed to Mr. J.’s pain. I prescribed a medication to sleep, another one to sooth the nerve pain (which by the way is not covered by the province of Ontario even for those over 65) and a powerful opioid, liquid morphine. Mr. J originally reacted to my last proposal: “My God, doctor, I do not want to get hooked and addicted”! It took me time to convince Mr. J. and his daughter who always comes with him, that he needs the drug, he will not get hooked because he has a good medical reason to take it, and I promised I will start him with baby doses. Three years later, at the remarkable age of 92, though he hardly looks early 70s, Mr. J. continues to use the medications I prescribed, and he is doing very well. His pain is much better controlled and he has a very active life as he is a widow living alone. As a matter of fact he just went to Europe for a long holiday. Leaving my office, ready to pack and go with the family to his trip, he gave me a big hug and a warm kiss. “Without you doctor, I would have been unable to go to this trip”. “By the way” he continued, “did I tell you, you are my #41 doctor”? I certainly did not believe my ears. My good old Mr. J. had seen 40 doctors before me over the course of few years seeking diagnosis and treatment and had kept meticulous notes, so I had to believe him.
Why did Mr. J. made the rounds of 40 physicians and countless non medical practitioners before he got diagnosis and treatment? Why were some of his important medications not covered by the system even if he was over 65? How much money did my patient spend out of pocket throughout the years of his ordeal? Where did Mr. J. get his fear of being hooked on drops of morphine? The answer is simple: because the province of Ontario and several other provinces do not have a comprehensive strategy for pain management, a strategy that will equip professionals, public at large, patients, administrators and policy makers with necessary education and knowledge to tackle the problem, define the gaps of care, coordinate existing resources, reallocate funds from money wasted in the system to processes that are useful and effective, provide smooth flow from one level of care to the other and even provide the public with techniques to prevent and self manage pain.
Another time I will explain how the province of Ontario tries to address the issue of chronic pain.