“For patients with chronic pain, including chronic migraine, there is hope. Don’t give up; you can conquer your chronic pain. Try to find a healthcare professional who understands these concepts and work with them. Don’t feel abandoned, and don’t try to do it by yourself. Sometimes it’s a lonely journey; try to join a group.” – Andrea Furlan
Editor’s note: Andrea Furlan, MD, PhD, is an associate professor of medicine in the Department of Medicine at the University of Toronto, Canada. She is also a scientist at the Institute for Work & Health in Toronto, and a senior scientist at KITE, Toronto Rehabilitation Institute, University Health Network. She also sees patients with chronic pain at the Toronto Academic Pain Medicine Institute (TAPMI).
Furlan recently wrote a book about chronic pain for patients, and her new work will also be relevant to people with headache disorders and even to healthcare providers. She recently spoke via Zoom with Neil Andrews, a science journalist and executive editor of Migraine Science Collaborative, to talk about her career path, why she wrote the book, and much more. This interview has been edited for clarity and length.
What was your path to medicine, and particularly to pain medicine?
I became interested in medicine when I was in my teenage years because I had debilitating menstrual cramps, every month. I realized that pain is so dehumanizing and debilitating, so I decided to do medicine. When I was in medical school, there was no pain specialty. I thought about going into neurology, rheumatology, orthopedics – and then I found physiatry. Physiatrists see the person as a whole, and we treat disabilities. And I found that chronic pain is an invisible disability.
When I was a physiatry resident in Brazil, I focused on chronic low-back pain. When I moved to Canada, I started working and my first job was with the Cochrane Collaboration [now known simply as Cochrane], doing Cochrane Reviews for the Back Review Group. When you do a Cochrane Review, you have to read thousands of articles. Then, I was the lead author of the first Canadian opioid guideline, telling doctors how to prescribe opioids for chronic pain. That put me in a position where I was knowledgeable about when to prescribe and how to de-prescribe. So that’s my journey to pain medicine.
What types of chronic pain do you encounter most in your clinical work?
As a physiatrist, I mainly see musculoskeletal pain. That includes neck pain, shoulder pain, hip pain, back pain, knee pain, and fibromyalgia. Because I know a lot about opioids, I also get referrals of people who are struggling with their opioids, either because they are taking opioids and they still have pain, are on high doses of opioids, are getting into trouble with opioids, or want to stop and are having difficulty stopping.
Do you see a lot of headache patients?
I do see people who have headaches or migraine. I’m not a migraine specialist, so if they only have migraine, then I tell them to see a migraine specialist. But because migraine is co-morbid with many other pain conditions – for instance, many people who have neck pain start having headaches or migraines – I see the person as a whole; I cannot ignore their migraines or headaches because these are co-morbid in many of my patients.
Let’s talk about the book. Why did you decide to write a book about chronic pain for people with pain?
The idea of writing something about pain started around 2017/2018 because I had written the opioid guideline for doctors. I noticed that the doctors wanted to explain things to patients, but the patients were not on the same page with them. For instance, if you tell patients they need to exercise because it’s good for their chronic pain, the patients were saying, “When I exercise, it hurts more, so why do you want me to exercise?” So patients needed to understand the science behind exercise, that it initially hurts, but then you need to trust the process and keep doing it.
In 2019, I asked myself if I should write a book. My son, who was a teenager at the time, told me not to write a book but open a YouTube channel instead. So that’s what I did. I started recording myself with my cell phone, explaining things to my own patients that I didn’t have the time to explain during the medical encounter, especially the reasons why I was asking them to do certain things for their pain. I put the recordings on YouTube, but initially I didn’t tell anyone else; I didn’t even tell my family. I didn’t want people to see me as a “YouTuber,” but my patients loved the videos, saying that now they could understand what I wanted them to do.
In 2020, when the COVID-19 pandemic started, and a lot of people were locked down, my channel exploded. By 2021, I had 100,000 subscribers, and then I approached a publisher, saying that I had all these videos and scripts, but that these didn’t follow a sequence. So we agreed that a book made sense; the book has QR codes that link to my videos and explain the steps that I want patients to follow. We published the book this year, and now my YouTube channel has more than half a million subscribers.
You mentioned talking with patients about the science of why exercise is effective for pain. When I was reading your book, I was struck by the in-depth yet very readable explanation of pain neuroscience at the start. Why is it important for people with pain to know about pain neuroscience? Is it mainly so that they will accept the various treatments, whether it’s exercise or something else?
Yes, and that’s why it’s right in the beginning of the book. There have been clinical trials where people deliver pain neuroscience education as part of an intervention, and many physiotherapists now use pain neuroscience education as part of a physiotherapy session, sending messages to the patient about how the pain system works.
This is extremely important. If you don’t understand the disease that you have, how can you understand and accept the treatments for it? If you don’t understand that chronic pain is a disease of the pain system, if you don’t even know that you have a pain system in your body, why in the world are you going to do what I’m asking you to do? The adherence would be super low. So the first step is to understand the neuroscience of pain that we now know. Thirty years ago, when I graduated from medical school, we knew very little about the science of chronic pain, but now we have so much knowledge. And that’s what I tried to address at the beginning of the book: What is chronic pain?
In the book, you write that conquering chronic pain is like climbing a mountain, and patients are tasked with doing a lot of the work to ensure that they can complete the climb; the doctor is really just the guide. As a physician, do your patients ever say that their pain is already hard enough to deal with and now you’re putting an extra burden on me to climb the mountain? And if you do hear that, how should doctors navigate that conversation with their patients?
I hear this all the time – because people with chronic pain are already tired. Imagine living with pain every day, and the volume of pain is turned up, so it is agonizing pain. People with chronic pain have poor concentration, they can’t sleep at night, and they’re fatigued during the day. So I know it’s a burden on them to ask them to do a little bit more for themselves, but I tell them there is no other way.
In the book, there are a lot of cases, which I collected over 30 years, of people who changed a few things in their life – and that made a big difference. I know it’s an effort, and I’m not asking them to change everything at once. I ask them to choose one thing and change that, because it helps a lot, and then they feel motivated to change other things.
Earlier you said that your YouTube videos are not in a particular order, but that the chapters of the book are. What does that look like?
I chose very carefully the order of the steps that I want patients to take because I want them to first try to retrain the pain system, control the emotions, and then take care of their sleep and nutrition. I also talk in the book about how they can talk to their doctors about pain, how they can talk to their family, and how they can talk to their coworkers, and their managers at work. And then they can exercise and use medications. Finally, when they are then at the top of the mountain, having conquered chronic pain, they can focus on life goals and living a fulfilling life despite having chronic pain.
When I say conquering chronic pain, it means the mountain is still there; the pain will not be eliminated. But you can live really well when you get to the top of the mountain, and you can look back and say that you conquered the mountain. Even if you have a higher mountain to conquer in the future and the next flare-up comes, which some people will have, you’re ready. You’re prepared to conquer the next mountain in your life because you now have tools in your toolbox that you used in the past and that worked for your pain.
I was struck by the emphasis in the book on the psychosocial aspects of pain, especially the role of the mind and emotions, which is certainly relevant to migraine and headache, too.
One of the biggest barriers I have with my patients is when I try to explain that their mind has a lot of power over how they feel pain. I’m not telling them that their pain is imaginary; that’s not what I’m saying. What I’m saying is that emotions and pain come together. Pain is an alert that something is wrong, so everybody who is in pain, by default, biologically, needs to be in fear and be hypervigilant. But in chronic pain, that fear and hypervigilance no longer have any useful function. So when patients understand that by doing something like meditation, their pain can be reduced, just by losing the fear of that pain, it’s one of the major turning points that I see in them. My patients who are doing really well are those who are able to control their emotions – who can relax and reduce their sympathetic drive and activate their parasympathetic nervous system.
Can you say more about the role of the sympathetic and parasympathetic nervous system in pain?
The sympathetic nervous system is responsible for the alert, for the fight-or-flight response. For people who have pain, the sympathetic system is turned on almost all of the time. The parasympathetic nervous system is the one that is activated when you are resting, relaxing, digesting food, or when you are healing. Mental health providers can teach patients how to deactivate the sympathetic nervous system and activate the parasympathetic nervous system. Breathing exercises, meditation, mindfulness, going for a walk, listening to music, taking a bath – those are things that activate the parasympathetic nervous system.
Considering all of this, which healthcare providers are best suited to treat chronic pain?
The best duo to treat people with chronic pain would be a mental health provider and a physical provider like a physiotherapist, occupational therapist, or chiropractor. We now have two-in-one people – there are now physiotherapists who are learning how to do both or psychologists who are learning to do both. So you do the exercise for the mind at the same time that you do the exercise for the body.
Earlier you talked about believing patients when they say they have pain. But there is still a lot of stigma in the pain field and also in the migraine field. When I have the opportunity to speak with people who have migraine, they often talk about all the stigma they have experienced, including from the doctors they have seen. How did we reach a point where there are doctors who stigmatize their own patients?
The stigma comes from chronic pain being an invisible disease. With acute pain, we can see what is wrong, on an X-ray or on an MRI. But MRIs are useless for chronic pain because everybody has abnormalities on an MRI. I talk about this in the book – I have never seen one single patient or one single healthy person who doesn’t have abnormalities on the MRI. The abnormalities usually don’t correlate well with the pain.
Opioids are another layer of complication. Some people with chronic pain do get better with opioids. But with the opioid crisis, so many people are getting opioid use disorders, which is the new name for addiction, or are dying of overdoses, or are using opioids just to get high and are buying illicit forms of opioids. The doctors think the patient is drug seeking and an addict.
When I was reading the book, I concluded that you are very optimistic about the future of pain treatment. Is it because we know about the science of pain, and so we know that there are treatments that are going to help, based on the science? Is that the main source of your optimism?
Yes, that’s true, but it’s also because I’ve seen, with these eyes of mine, with these 30 years of experience that I have, people who came back to the follow-up to tell me that they don’t need me anymore. “I’m discharging you, Dr. Furlan. I know I have chronic pain, but I know how to take care of myself. You can take the next patient. I don’t need to come anymore.”
That must be a good feeling.
Yes, it is.
Is there anything else you’d like to mention that I haven’t asked you? Or maybe there’s something you’d like to reiterate?
I think getting education in the field of pain should be a requirement for any healthcare professional. We need healthcare professionals who understand what chronic pain is, and how to make a good diagnosis. And doing the physical examination is really important. That’s my message.
And for patients with chronic pain, including chronic migraine, there is hope. Don’t give up; you can conquer your chronic pain. Try to find a healthcare professional who understands these concepts and work with them. Don’t feel abandoned, and don’t try to do it by yourself. Sometimes it’s a lonely journey; try to join a group.
8 Steps to Conquer Chronic Pain: A Doctor’s Guide to Lifelong Relief. By Andrea Furlan, MD, PhD. Published in 2023 by Robert Rose Inc.
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
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