Healing and hope for chronic pain patients

One in five Canadians live with chronic pain, so for Dr. Vishal Varshney and Dr. May Ong, who spearhead St. Paul’s Hospital’s two pain programs, it’s obvious why pain research, treatment, and care should be a priority for all of us: “If it's not impacting you directly, it's inevitably affecting someone that you know,” says Dr. Varshney.

Dr. Varshney is an anesthesiologist and the inaugural Chair in Pain Management at St. Paul’s Hospital—he’s the first in B.C. to hold this position. He leads a team of experts in the Complex and Interventional Pain Program, which offers advanced interventional pain management therapies and research for the treatment of complex pain.

Dr. Ong is Providence Health Care’s Chair in the Neurobiology and Neuropharmacology of Pain, and heads the Department of Medicine’s Centralized Pain Program at St. Paul’s Hospital. It’s the only program of its kind in Canada. Her team of researchers has published outcomes revealing significant improvements in patients’ pain and function.  After nearly four decades specializing in pain management, Dr. Ong shares that the understanding of pain pathways has evolved tremendously, especially in the past five to 10 years.

While chronic pain is extremely common, it’s an ‘invisible’ problem. “Pain isn’t something that you can see on a blood test, or even on an MRI,” Dr. Varshney explains. “It’s a dynamic process of neuronal adaptation to disease or injury,” Dr. Ong adds. Many patients living with chronic pain bounce from provider to provider without receiving effective treatment—or worse, without being listened to.

Dr. Varshney, Dr. Ong and the entire Pain Clinic team look forward to the expanded capacity at the new St. Paul’s Hospital Clinical Support and Research Centre (CRSC) on the Jim Pattison Medical Campus to continue their breakthrough innovations in centralized pain treatments.

Keith Meldrum is blunt about his near-fatal car accident. “I was just a young, dumb 16-year-old who found out the hard way that if you drink a bunch of alcohol and don't get any sleep, you will roll your car down a bank,” he says. His accident occurred in 1986, but almost 20 years passed before Keith visited St. Paul’s Hospital for his pain.

“We think persistent pain isn't well-understood now? It was terribly misunderstood then,” says Keith, who was left with chronic abdominal wall pain after his accident and the numerous surgeries that followed. Keith got used to doctors brushing him off after hearing his medical history, and every medical intervention he did receive, failed. In fact, one such failure—a paravertebral nerve block injection that gave him a partial lung collapse—was what finally led him to St. Paul’s Hospital in 2004. During his intake, Keith was understandably doubtful. “I fully expected to be told once again, ‘It's not that bad, it’s all in your head’,” he recalls.

Instead, intake doctor David Hunt said, “It’s OK, we believe you.”

Two decades later, Keith still remembers the impact of Dr. Hunt’s words. “It was truly a defining, pivotal change,” he says. Keith was a candidate for neuromodulation, and in 2005, he was given his first spinal cord stimulator (an implanted device that delivers mild electrical signals into the spinal cord to reduce pain). The pain didn’t disappear completely, but the implant provided effective relief, and allowed Keith to channel his energy into other strategies for self-management.

Breathing techniques helped with breakthrough pain, regular exercise built strength and his mental health improved exponentially. He remembers a follow-up visit in 2005: “My wife broke down in tears in that room, thanking them, because it had that much of a profound effect not only on me, but on my family.”

When his spinal cord stimulator reached the end of its life in 2015, Keith returned to St. Paul’s Hospital and became one of the first in Canada to receive a dorsal root ganglion stimulator. “It’s a more specific kind of device: electrodes are placed at specific parts in the spinal cord to deliver electrical signals to turn the volume down on the intensity of nerve pain,” explains Dr. Varshney.

Soon after receiving his first stimulator, Keith started doing advocacy work. Today, he’s lectured at universities, co-authored papers, and given countless others invaluable support and resources for managing their pain. He shares his story of combining medical intervention with psychological and physiological lifestyle changes for significant results.

“Keith educates patients about using a variety of different resources— it's not just going to be one pill or one injection that will address this, it really needs to be addressed from all different angles,” says Dr. Varshney. It’s exactly the kind of holistic, interdisciplinary care that the team at the Complex and Interventional Pain Program champions.

Keith is also an enthusiastic proponent of pain research: he trusts the work, just as his physicians at St. Paul’s Hospital trusted in him. “I have never been treated with such care, concern and empathy,” he says.

In 2016, Angelo Marvuglia spent six weeks in the hospital. After a virus, he developed double pneumonia, a pulmonary embolism, and pericarditis, which was eventually diagnosed as chronic. “After that point, I just never felt better—I kept getting worse and having new and different symptoms,” he says.

His pain, focused mostly on the left side of his body, prevented him from working at his family-owned small business, playing with his children and, on many days, simply getting out of bed. “I was walking with a four-wheeled walker, I would spend easily three-quarters of my day sleeping and I was taking over 100 pills a day,” Angelo shares. Still, there was no relief.

Angelo feels the physicians he was seeing had tunnel vision—once they heard about his cardiac history, his symptoms would be largely dismissed. This went on for years, until one of his cardiologists suggested he may have Multiple Sclerosis (MS). He was sent to the UBC Hospital MS Clinic, and after an official diagnosis, the MS Neurologist referred him to Dr. May Ong at St. Paul’s Hospital. Dr. Ong was determined to find an innovative solution, because the conventional medications just weren’t working. “Every single thing you can name, Angelo had tried,” she remembers.

She explains that his MS lesions caused sensitivity to touch, poor balance and daily debilitating pain. Angelo describes it as a seven-to-nine out of ten, burning, hot, tingling pain.

Chronic pain like Angelo’s doesn’t always have a clear cause—and it doesn’t just go away. In some cases, a past illness or injury rewires how the brain processes pain, sending constant signals even when there’s no physical reason. This is called centralized pain, and it requires a specialized approach. That’s exactly what Angelo needed. Because his pain was central neuropathic, Dr. Ong suggested IV ketamine infusion therapy to block the abnormal nerve signals that caused his symptoms.

Ketamine, originally developed as an anesthetic, works by blocking pain receptors in the nervous system. In this first-of-its-kind treatment, patients are admitted to the hospital to receive continuous IV infusions of ketamine over a period typically ranging from 10 to 14 days.

The ketamine is administered at subanesthetic doses, meaning the amounts are lower than those used for anesthesia, allowing patients to remain alert and functional during treatment. This protocol aims to modulate pain pathways and provide relief from chronic pain; the treatment is carefully supervised to ensure patient safety and monitor for any side effects.

There’s no such thing as a miracle cure, but what Angelo experienced was pretty close. “Within a couple days, I was feeling a lot better,” Angelo recalls, “and by the end of that first infusion, my pain was down to a two or three out of 10.” Angelo’s body had been sending unprompted pain signals to his brain, and the ketamine helped rewire those faulty signals, creating new neural pathways.

In just under two years, Angelo received four infusions at St. Paul’s Hospital. “By the end of my fourth one, which would have been in 2022, I actually was experiencing zero out of ten on the pain scale,” he says.

If you ask Dr. Ong what she’s most proud of, she’ll say helping her patients return to function and work, and that’s especially true for Angelo’s case.

Now, he works part-time as a table dealer at a casino, a job that requires plenty of speed, dexterity, quick thinking, and confidence. “I’m right there, in the public’s eye, dealing with people and the chips and the cards with both my hands,” Angelo says.

“Everything has to be done perfectly; it's a challenge, but I enjoy it. I think some of my coworkers think I'm a bit crazy for loving my work the way I do, but they haven't been through the same experiences as I have.” Playing in the yard with his three children or going for a short hike to a neighbourhood waterfall are things he doesn’t take for granted, and he’s grateful to Dr. Ong for her mindful dedication to ketamine therapy as a neuropathic pain treatment.

“She’s an incredible doctor who makes time for patients and is incredibly knowledgeable, and I'm really appreciative of the fact that she's not afraid to try something new… because it worked.”

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