Supporting Workers with Chronic Pain

Ashley: Hello and welcome to Safe and Sound with CCOHS. According to Health Canada, almost 8 million Canadians live with chronic pain, defined as pain experienced on most days or every day for three months or more. Our guest today is Doctor Andrea Furlan, a physician, scientist and professor in the Department of Medicine at the University of Toronto, whose research focuses on the management of chronic pain. Doctor Furlan also happens to have a popular YouTube channel with many helpful videos on the topic. Doctor Furlan, thanks for joining us today.

Dr. Furlan: Thank you for inviting me to talk to you today.

Ashley: My pleasure. Let's start off with some common misunderstandings workplaces might have about chronic pain. Can you list some of those for us?

Dr. Furlan: Yes. There are many misunderstandings, because chronic pain is not the same thing as acute pain, and a lot of people – including healthcare professionals – don't understand the difference. Acute pain is that pain we all know, like a toothache, an inflamed appendix, an inflamed joint, or a fracture. But chronic pain is different, and you need to understand that chronic pain doesn't show up on an MRI of the knee, even though the knee, the hip, the hand or the neck hurts. There's no imaging, no blood test, no clear diagnosis, because the problem is that the pain has become centralized. It's a problem of the central nervous system – the brain has changed. It's almost like a memory that keeps ringing. I usually explain to patients that it's like the alarm system of a house that's supposed to go off if there's a fire in the kitchen. But imagine that five years later, the fire isn't there anymore, and the alarm keeps going on and on. That means the alarm is broken – it doesn't mean there's still a fire in the kitchen. That's chronic pain. Another misunderstanding is that if someone is using opioids for chronic pain, it's because they're addicted. Also, if a person with chronic pain isn't getting better with treatment, people assume it's because they're weak, mentally incapable, have a low tolerance to pain, or are just lazy. Those are all common misunderstandings I see, not only in workplaces but in healthcare too.

Ashley: Right, so a lot of stigma involved as well, it sounds like.

Dr. Furlan: Yes.

Ashley: What are you hearing most often from your patients about how chronic pain affects their jobs?

Dr. Furlan: First of all, my patients tell me they want to work – very rarely do they say they don't want to work or use chronic pain as an excuse not to go. Most of them love what they do. They've invested time, they have a profession, and that's part of their identity. If you ask someone who they are, the first thing they'll say is their profession. So if they can't work in that profession anymore, they feel like they've lost their identity. They do want to work, but chronic pain is a centralized disease that affects the brain, the central nervous system, and the immune system. The brain is almost in a constant state of hypervigilance. The pain is real, but the brain is generating it – there's no difference to the brain whether the alarm is going off because of a real fire or because it's broken. So pain is pain, whether it comes from an actual injury or from the memory of pain in the brain. My patients tell me they can't sleep at night, they have insomnia, and then fatigue during the day. Because of that, they get brain fog and poor concentration, which makes it hard to think clearly and make decisions at work. They also tell me they lose patience and empathy with coworkers – and if you're working with customers, coworkers, and a team, losing empathy is a real problem. It's also hard for them to commute, drive, or take public transportation. And often they don't even have time during the day for lunch or breaks to exercise, relax, or meditate – activities that actually help reset that brain sensitization. Without those breaks, their only option becomes taking days off or going on disability.

Ashley: That's tough. That's a good segue, I think, into how employers can support workers experiencing chronic pain. What can they do?

Dr. Furlan: This is so important – for managers, coworkers, and supervisors. First, acknowledge that the pain is real. I've heard patients say, thousands of times, that people don't believe them. They say things like, "I wish I had cancer, because people would be more empathetic," or "I wish I'd had an amputation, because then people could see I was suffering" – because pain is an invisible disability. Many of my patients tell me they fake being okay all the time. People ask how they are, and they say they're fine, even though they're hurting. Take fibromyalgia, for example – it affects up to five percent of the general population, more women than men, and causes pain throughout the whole body, all the time. And they have to fake being okay. So the first thing is acknowledging that the pain is real – that they're not inventing it, and it's not simply psychological or emotional. Then, offer accommodations and work modifications, and encourage them to talk to their doctors, nurse practitioners, physiotherapists and psychologists, because sometimes they're even afraid to bring it up with their own doctors. Some doctors will say it's just because they're getting older, or that it's impossible for the whole body to hurt, or that fibromyalgia doesn't exist. Unfortunately, there are still healthcare professionals who don't believe it's real. But the neuroscience of chronic pain has advanced so much in the last twenty to thirty years – even I can barely keep up with how far the science has come.

Ashley: Is that right?

Dr. Furlan: Yes. Chronic pain is mainly a disease of the nervous system. There's now research showing changes in the brain, brainstem, spinal cord, the immune system, and even the gut microbiome as a result of chronic pain. So it's a biological disease, and it's important to acknowledge that there is treatment – and to make sure workers know what benefits are available to them. Do they know they can use psychologist sessions? That they may have ten, twelve, or thirty massage therapy sessions covered per year? That they can get a discount on a gym membership? That they can take sick days? Informing them about what's available in their benefits can go a long way.

Ashley: Those are some great ideas – and even something as simple as making space to take a break, go for a walk, or have some time to meditate.

Dr. Furlan: Yes.

Ashley: What steps can workers experiencing chronic pain take to advocate for themselves?

Dr. Furlan: As I said, most people with chronic pain are afraid of disclosing it and how they'll be seen. I see people try to be stoic and say things like, "I'm resilient, I have a high pain tolerance, it's only pain" – and then they don't talk about it, they don't disclose. So the first step is to talk about it. Chronic pain affects about twenty percent of the adult population in Canada – so that's one in five people. You may have coworkers going through the same thing without knowing it, because everyone's hiding it. You could even form a support group and help each other. Learn more about the modern neuroscience of pain mechanisms. Bring in someone to talk about it. Explore non-traditional treatments like mind-body therapies, self-management, movement, acupuncture, yoga, or aqua therapy. There's also evidence that exposure to nature helps, because it calms the brain out of that hypervigilant, overdrive state. One of my patients told me their doctor examined their knee and said it was strong, with a perfect range of motion, and that they could do anything they wanted – the pain was just a signal remaining in the pain system, not evidence of ongoing damage. So overcoming that fear of pain is key. I also encourage people to become less reliant on medications alone. People tend to equate pain with a structural problem that needs a pill – but that's usually only true for acute pain. If you have acute pain, you likely have a structural issue. But with chronic pain, the structural problem has often already healed, and all that remains is the centralization – so medications, including opioids, aren't as effective for chronic pain as they are for acute pain. That's why I encourage people to rely less on medication long-term, and instead talk to their doctor about other options – never stopping medication abruptly, but working with their doctor to explore other approaches. In the long run, non-drug options tend to be healthier and safer.

Ashley: That's important to know. And when workers are returning from an injury, what makes the difference between an effective return-to-work plan and one that unintentionally makes things worse for someone with chronic pain?

Dr. Furlan: Reaching that balance is really hard. You don't want to return too soon while still in an acute pain phase, because you might be in that transition from acute to chronic. If there's still an acute injury – like tendonitis, or recovery from surgery – you do need to give the body time to heal. But if the original injury or condition is no longer present and what remains is chronic pain, then the sooner you get back into a place where your brain can be distracted by other things, the better. I tell my patients with chronic pain to think of work as therapy for the brain, because we need to occupy it with things other than pain. If you spend the day at home, you have more time to think about the pain – and the more you think about it, the stronger those neural pathways become. That's neuroplasticity: the more you practice something, the better you get at it, whether that's playing piano or dwelling on pain. So work can actually help you unlearn those pain pathways by occupying your brain with something else. Another important part of return to work is addressing mental health, not just physical health – we can't separate mind and body. Any treatment for chronic pain needs to combine mind, body and physical approaches, because chronic pain involves emotions, and if we don't address those emotions, we won't get the best results, even with physical treatments like physiotherapy. When you also work with a mental health provider to address the fear of movement – which is very common with chronic pain – recovery is much faster, because the fear of pain can be more disabling than the pain itself.

Ashley: That's fascinating, and I know we're just scratching the surface on a topic we could talk about for a very long time. What else would you like our audience to know about chronic pain and your work?

Dr. Furlan: There's so much more I wish I had time to cover. If people want to learn more about chronic pain, there are excellent resources available online. I put a lot of videos on YouTube, because I don't always have enough time with my own patients in the clinic here at UHN – I have more than two hundred videos where I talk about exercise, diet, sleep, and other aspects of chronic pain, looking at the whole person. I've also published two books with much of the same material as my YouTube channel, for people who prefer reading to watching. So there's something for everyone – if you like watching, find me on YouTube; if you like reading, I have books on chronic pain.

Ashley: Amazing – clearly the content is resonating with people. You've built quite an audience.

Dr. Furlan: Yes, a lot of people.

Ashley: That's amazing. Well, thank you so much, Doctor Furlan, for taking the time to be here with us today. We appreciate your expertise, and as Doctor Furlan mentioned, you can look for more information on her YouTube channel or check out her books. You can also find a library of information on many health and workplace health and safety topics at our website, ccohs.ca. Thanks for listening, and stay safe out there.