Dr. Sean Mackey: Tools to Reduce & Manage Pain

Welcome to the Huberman Lab podcast where we discuss science and science-based tools for everyday life. I'm Andrew Huberman and I'm a professor of neurobiology and ophthalmology at Stanford School of Medicine. My guest today is Dr. Sean Mackey. Dr. Sean Mackey is a medical doctor, that is, he treats patients, as well as a PhD, meaning he runs a laboratory.

He is the chief of the Division of Pain Medicine and a professor of both anesthesiology and neurology at Stanford University School of Medicine. Today we discuss what is pain. Most of us are familiar with the notion of pain from having a physical injury or some sort of chronic pain or a headache.

Today Dr. Mackey makes clear what the origins of pain are both in the nervous system and outside the nervous system, that is, the interactions between the brain and the body that give rise to the thing that we call pain. Indeed we discuss the critical link between physical pain and emotional pain and how altering one's perception of emotional or physical pain can often change the other.

We also discuss some of the changes in the nervous system that occur when we experience pain and how that can give rise to chronic pain. We also, of course, cover different methods to reduce pain safely, and those methods include behavioral tools, psychological tools, nutrition, supplementation, and, of course, prescription drugs. We discuss the intimate relationship between temperature, that is heat and cold and pain and pain relief.

So if you're interested in the use of heat or cold to modulate pain, that conversation ought to be of interest as well. We also touch on some highly controversial topics such as opioids. Opioids are a substance that your body naturally makes, but, of course, many people are familiar with exogenous opioids, that is opioids that are available as drugs and the so-called opioid crisis.

Dr. Mackey makes very clear which specific clinical circumstances warrant the use of exogenous opioids, with, of course, a warning about their potent, addictive potential, and we get into a bit of discussion about where the opioid crisis and the use of opioids are. And the use of opioid drugs to control pain is and is going. Before we begin, I'd like to emphasize that this podcast is separate from my teaching and research roles at Stanford.

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Again, that's BetterHelp.com slash huberman. And now for my discussion with Dr. Sean Mackie. Dr. Mackie, welcome. Oh, it's a pleasure to be here. Thank you. This is a long time coming. We're colleagues at Stanford, and I'm familiar with your work, but today we're going to take a pretty broad and deep survey of this thing called pain. So I'll just start off very simply and ask, what is pain?

Pain is this complex and subjective experience that serves a crucial role for all of us to keep us away from injury or harm. It is both a sensory and an emotional experience, and I think that gets lost on people that includes this emotional component to it, and it is incredibly individual. And we'll get more into that, hopefully as time goes by, that your pain is different from my pain and is different from everybody else's.

It takes an incredible toll on society when it goes chronic, when it becomes persistent to the tune of about 100 million Americans, and at last count about a half a trillion dollars a year in medical expenses. So an astounding problem we're facing in society, and one that's only getting worse.

And I'm hoping during the course of this discussion that we can kind of break down a little bit of the foundation of pain and kind of build it back up, because unfortunately in society there's a lot of misunderstanding about what pain is. And I think hopefully we can build that foundation and then layer on some useful treatments and usual options for people.

I'm glad you pointed out this link between the sensory and the emotional experience every once in a while I'll pull something or I'll have a kink in my neck or my back. And fortunately for me it resolves pretty quickly. But I notice that when I'm experiencing that kind of pain that I become slightly more irritable, perhaps much more irritable depending on who you ask, and that everything becomes more challenging. Thinking is harder, sleeping is harder, concentrating on anything besides pain.

It's a it's as if something's nagging from the inside. And so that raises the next question that I have, which is. Is pain something that's in our brain in our body or both. It's clearly in our brain. And can I take a moment to kind of lay a little foundation for some of that to help clear up some of the mystery of pain. We know that pain most pain all starts with some stimulus whether it be that kink in your neck or your shoulder from working out or turning the wrong way.

And what's going on there in your body is not pain. What's going on is that there are sensors in our skin or soft tissue or deep tissues called no-susceptors. And these no-susceptors are sensing elements and they sense different types of stimuli. They can sense temperature, heat, cold, they sense pressure. They can sense pH changes due to, for instance, inflammation that may occur from something going on in your neck or your shoulder.

Those send signals up nerve fiber types. And the two that we refer to are adelton C fibers. One transmit's very fast. It's responsible that sharp jolt of pain that goes to your brain when we step on a tack or put our hand on a hot stove. And there's another fiber called a C fiber, which is much slower and responsible for that dull, achy pain. Now, these signals, they go to the spinal cord. Up and down from our head down to our back. And they're shaped, they're changed a little bit.

They then are sent up to the brain. And it's once they hit the brain and they converge with this magical mystery set of nerves in the brain that it becomes the experience of pain. And if there's one key message I'd like to get to the audience is that what goes on out here, what goes on in your shoulder and your neck is not pain. That's no sysception.

Those are electrical signals, electrical chemical impulses being transmitted. And that is to be distinguished from what becomes the subjective experience, a pain that you have. And why it's critical is that our brain serves so many functions of emotions, cognitions, memory, action, all of that, shapes those signals coming in from our body to create your unique experience of pain that's different from everybody else's.

And I think that's important to know because we are frequently left with this notion of this one to one concordance between the stimulus and the experience of pain. You know, Renee DeCarte, that French philosopher, I think 17th century, was the one who first postulated this idea of this direct linkage between the body and our actions and the stimulus and the response and it's wrong.

And unfortunately, even in medical care, we have this biomedical model that still is perpetuating this idea of a one to one relationship. And that's a critically important point to get across. In large part because frequently as humans, we tend to project onto others, our own experiences of pain.

And when we see somebody who's got an injury or something else going on, we immediately put that on them. And that has also been a problem with many people suffering in chronic pain, which is often viewed as the invisible disease. So when you say we put that on them, you mean when somebody reports being in pain, we have a hard time understanding what they are experiencing because it's going to be very different than the way that we experience pain.

Conversely, if somebody's in pain, they tend to assume that people are experiencing pain the way that they are. Do I have that right? You have a perfectly right. And it actually, if I can build on that gets worse because sometimes you have conditions like fibromyalgia that maybe we'll get into where outwardly, visibly, you don't see anything wrong.

We're used to thinking of pain as a fractured bone as a swollen ankle. We see that. And then we're like, okay, well, you've got pain. You've got legitimate pain. Whereas this invisible disease of chronic pain frequently, you don't have something outwardly that you're seeing. But we bring in our own history of pain and we put that on other people. I have a question that's somewhat mechanistic, but we'll keep it accessible to anybody regardless of their background.

So you mentioned the nozzusceptors are in the body and everywhere in the body and on the surface of the body to be able to detect certain kinds of stimuli. And then those signals are sent up into the brain and the brain creates this subjective experience that we call pain. Is there a dedicated set of areas in the brain that are something akin to like a pain pathway? And the reason I asked this is that for vision, for hearing, for touch, we probably all experience those somewhat differently.

Your perception of red is probably a little different than my perception of red. We don't know for sure, but experiment support that idea. But there's a major difference between people experiencing the same thing differently according to a mysterious mechanism in the brain as opposed to an area in the brain that we can look and say, hey, that's where pain is represented.

That's where all these inputs from the body are put together to create this thing that we call pain. Like, is there an area of the thalamus, a structure in the middle of the brain that takes in coming sensory information that we could say, oh, that's the pain pathway.

Is there a part of our neocortex, the outer shell of the brain more or less beneath the skull, but nonetheless on the outer portion of the human brain, that we could say, oh, that's where pain exists. Or is it a distributed phenomenon? Yeah, that's a great question. Because we'd all love that there was a pain center in the brain that we could just go knock out, but it's not that simple.

And in part, because pain is such a conserved phenomenon, it is there. It is so wonderful because it is so terrible unless it goes wrong. But when you knock out one pathway going to the brain, there's others there that will carry that system forward and you'll still experience pain and it's there to keep us all alive. Now, to get to your point, no, there's not one pain brain area. It is thought to be more of a distributed network of different brain systems.

We at one point in time called it the pain matrix, which represented areas such as the insular cortex, the singular cortex, the amygdala, a number of these brain regions that all subserved different functions. We're moving away from that because it seems like every year or so we pick up another region of the brain that's contributing to this network that subserves some additional function, some nuanced layer to it.

That said, we have been able to identify some common signatures, common brain networks that seem to represent the experience of pain. And this is where the development of brain-based biomarkers has come in. And this is some of the work that I've done starting gosh well over a dozen years ago and others have been building on. And what we're finding is that there does seem to be this conserved region set of distributed regions that do represent the experience of pain.

So when somebody takes a so-called pain killer, let's take a typical over-the-counter pain killer, like an ibuprofen or a cedaminophen to lessen pain of some kind. Where is that drug or drugs acting? Is it in the body or is it at the level of the brain or both?

Yeah, and this is where some of the challenges we get into with language because technically NSAIDs, non-steroidal anti-inflammatory drugs like ibuprofen, like NAPRSON, they're actually not analgesics. They're not technically pain killers. So an analgesic is the descriptor for a quote-unquote pain killer. Yeah, that would be more correct, like an opioid would fit into that category.

The NSAIDs are anti-inflammatory drugs. There's another, this is a technical term, they're anti-hyperalgesic drugs. And so one of the things that happens after an injury is that we get sensitization of the area that's injured. And it's a beautiful thing because it sends a message to us to protect it. What the NSAIDs do is they reduce some of that sensitization out in the periphery and then back in the spinal cord and in the brain.

But they don't actually, so for instance, I was going to say try this at home, but probably not. You can, in a normal situation, hit your hand with a fork, measure the amount of pain. I'll go take an NSAID like ibuprofen. If you hit your hand with that same fork, there'll be no difference. Folks, please don't do that at home, please. Or anywhere for that matter.

But you're describing pain and the local inflammation response and the hyperalgesia, the increase in pain in that general area as something very adaptive, very important. So it raises the question, what is the threshold for saying that somebody should treat their pain, reduce their pain? And anytime I've done surgeries on animals, which I don't do anymore in the laboratory, but we used to, you know, you would give them painkillers post-operatively.

I've had surgeries before. I had painkillers post-operatively, although I don't like taking them on. I like the way they make my brain feel. But we of course know that if you increase the dose of any pain medication too much, then that animal or a human can potentially injure themselves worse or not protect that injured area. It raises a whole set of medical ethical, but also just purely biological questions.

How do you set the threshold for yes blunt pain versus no, allow the pain to be there as an adaptive way of protecting yourself in healing, presumably the inflammation is part of the healing process too. And as you mentioned before, pain is so subjective and it's different between all of us. I mean, how do we decide whether or not it's a good or bad idea to blunt that pain?

Yeah, I think the threshold is when it's impacting your quality of life and your ability to take care of the activities that daily, living, engage with family friends, go to work. And that serves kind of a, your threshold for, you know, whether it's reasonable to take a medication or not. So a lot of controversy in the space right now used to be we all recommended just NSAIDs for any type of acute injury.

Could we maybe list off a few of those? So I mentioned ibuprofenacetaminophen. So sometimes referred to as, you know, the classic adbil Tylenol. We won't throw out name brands there, but what are some others in a proxon? The proxon is another one, toward all our keto roll act is another one, the two over the counter NSAIDs, the prototypical over the counter ones are ibuprofen and naperson.

Those are the ones you can buy over the counter without a prescription. Tylenol actually has a slightly different mechanism of injury, but you know, still fits in that same general class. It tends to be more centrally acting, ib Tylenol or acetaminophen. But we say centrally, you mean brain, brain, thank you. And is aspirin considered an NSAID? Yeah, aspirin would fit into that category of basically a Cox cycle oxygenase inhibitor.

This is one of the chemical mediators that gets released during injury. And that chemical substance has a tendency to wind up or amplify the no-susceptors so that after an injury, you note that you're more sensitive there after a sunburn. You end up having more sensitization that is what we refer to as peripheral sensitization because it's out in the periphery. We're winding up or amplifying the response. Aspirin, NSAIDs in general will reduce that inflammation. They're anti-hyperalgesic.

And pardon again, the jargony terms that we use. It's going to be long as we go. But to your point, you don't want to, for instance, let's imagine you have a fractured ankle. You don't want to be reaching for a very potent opioid just so that you can continue walking on a fractured ankle that you haven't gotten evaluated by a clinician and perhaps casted. That wouldn't be safe. Those are rather extreme examples.

We get into those debates in professional sports where they send the person back out on the field with a broken bone, having given them an ejection or something. I'm hoping that doesn't go on anymore. I'm sure it goes on. There's all sorts of other things. I get contacted all the time. Professional teams and athletes asking how they can get back in quicker. Nowadays, the big thing are these peptides that can certainly accelerate healing.

People are traveling out of country, get stem cell injections. All with very few randomized control trials. But I assure you that court side in the locker room, mainly in the locker room, there are corticosterone injections, there are painkiller injections. It's not play at any expense, but it's not far from that.

Yeah. Well, you know, when you're making millions of dollars a year, and I get the being back on the field, but for the rest of us mere mortals, I think that's where we would want to draw a line, get medical attention if you've got an acute injury. Going a little bit deeper into mechanism because I think it's going to serve us well now and going forward, you mentioned the NSAIDs and this COX COX is one of, it's a, it's a, it's a family of prostaglandins. Yeah. Can we talk about prostaglandins?

Because I think there are a lot of people nowadays we hear about inflammation. Yeah. You know, inflammation is bad, inflammation is bad, but you know, one of the things that we talk about a lot on this podcast is the fact that, you know, cortisol isn't bad, inflammation isn't bad. These things serve an important biological role. So the prostaglandins seem to be one of the main ways that our immune system responds to a physical or chemical injury and creates inflammation.

And that, as you said, that inflammation sensitizes an area, it makes it literally more sensitive. And then we introduce these drugs that to restore normal functioning and living. Could we establish like what normal functioning is? I mean, for instance, if we make this really concrete, could we say, well, if you can sleep fall, sleep at night and stay asleep, or perhaps go back asleep after you've woken up in the middle of the night, then well, you heal during sleep.

And so, you know, take as little painkiller as possible, but enough that still lets you sleep well at night. Is that sort of normal functioning? Because when I have a kink in my neck, I don't want to do much of anything. I try, but it's really frustrating. So what is, I mean, as a physician, and as a patient, how do we determine normal functioning?

Yeah. And you're getting into the nuance, the complexity of this problem, because we've been talking about NSAIDs, the ibuprofencin naperson, and as I said early on, we used to just give these out all the time. But then the research comes out and shows that by blocking inflammation, by blocking that, we may be blocking the normal healing process. And so we've seen delays in fracture repair. We've been seeing delays in tissue repair.

And so now you've got on one hand a medication that may help with pain, help you improve function. You've got on the other hand something you're taking that may delay the process. Where do you draw the line? As a physician, my approach, is really basically what you said. It's balancing the fact that if you're not sleeping at night, you're not going to heal, and you're not going to be able to do what you need to do the next day.

And if taking an NSAID helps you sleep and helps you engage with what you need to do, take it at the lowest dose that you can get away with. I've heard before that NSAID should be taking no more than once every six hours. People alternate different types of NSAIDs every three hours. That's usually to try and reduce fever. Another situation where an adaptive response fever, people go out of their way to block it, prevent the brain from cooking. But again, it opens up the same set of issues.

And so I'm wondering if somebody has some pain that makes moving about, frustrating, and it's difficult, but they can sleep at night reasonably well, as well as they normally do. Would your suggestion to that person, if their goal is to heal as quickly as possible, to just not take anything? Yeah, so we've got a lot more data on the benefits of NSAIDs, this class of medication reducing pain, than we have data showing the bad consequences of it.

And so we're still needing more data on the whole healing message. I think that a lot of the orthopedic surgeons out there prefer people not to be on NSAIDs after, for instance, a total hip replacement, a total knee replacement, because I think that's pretty clear. But that's not what we're talking about right now. So one of the other interesting things about NSAIDs, like we mentioned ibuprofen and napsin, huge individual variability around those.

So personally, ibuprofen is not very effective for me. Napsin is. For others, it may be just exactly the opposite. So there's value in rotating them and finding out which works best for your particular situation. You mentioned the timing of it. ibuprofen is typically given no more than three times a day. It's got a short half-life. Napsin twice a day.

What's critical, I need to give this message, is in both situations, make sure that you have food in your stomach, make sure you're not taking it on an empty stomach, make sure you're drinking plenty of fluids. And if you've got any GI issues, if you've got any bleeding issues, if you've got kidney issues, if you've got heart issues, talk to your doc, talk to your clinician before you embark on this, because these medications do have side effects and adverse consequences in vulnerable people.

What about aspirin? I've heard that aspirin can benefit heart health, so I take a baby aspirin every day. And if I have a pain that is just too intense for normal functioning, as we're defining it, then I'll increase that dose of aspirin. And I just assume aspirin is the healthiest and sad for me, because, well, it's also good for heart health, and it's killing pain in those instances as opposed to taking anything else. It's my logic flawed. And if it is, feel free to tell me.

Now, for you, your logic is perfect. And that's where it gets to the individual person. And for a lot of people, that model would work as well. So baby aspirin, 81 milligrams a day, acts as an anti-platelet agent. It helps, you know, hear even though we're getting controversy over the role of baby aspirin, if you dive into the current literature. Even baby aspirin is controversial. Even baby aspirin these days.

And now what they're doing with the data is defining age ranges when they say, baby aspirin, yes, baby aspirin, no. And so, you know, we're learning a lot more about that. I still take a baby aspirin. Every day. Yeah, I take a baby aspirin. You get to the higher dose, say four times as much up around 325 milligrams or so. It's now an anti-inflammatory. It's now acting more like the ibuprofen and the noperson. So, different mechanisms of action at different doses.

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Are there any issues with people who drink caffeine who then are taking these drugs? So, what are some of the interactions that these things can have? As far as I know, caffeine actually touches into the prostaglanin pathway, doesn't it? Yes, and that's where caffeine can be used effectively for headaches, for migraines. And it can help potentiate the analgesic response. Some people get stomach irritation, though, with caffeine.

So just, again, mind that you take an NSAID with a lot of coffee, have some food in your stomach. You know, you brought up earlier a seat of menophan or Tylenol. Tylenol doesn't have the same side effect or adverse event profile that the NSAIDs do. So Tylenol is safe on the stomach, where you need to be careful about Tylenol is not to exceed 4,000 milligrams or 4 grams per day in divided doses. So, two extra strength Tylenol done four times a day for many people is safe.

Some say two grams, some say four grams. The key here is around your liver. So, you've got good liver function, if you're not abusing alcohol. That's a general rule of thumb that you can use for Tylenol. But it's not going to upset your stomach. There are versions of the NSAIDs that we refer to as Cox-2 inhibitors. They're very selective, like cello-coxib, that is less irritating on the stomach. That's by prescription only, though.

But you can think of it as working very much the same as the NAPR-SEN and the IV-PROFIN. So, talk with your clinician to try to tease those apart. If you have problems in your stomach with the NSAIDs and they're really effective for you, you can be given other types of medications that help block or reduce the GI issues associated with the NSAIDs. Very useful information. Thank you. Here we're talking about chemical interventions to the pain process. What about mechanical interventions?

I was taught in my basic neuroscience about, I think, it's Melzac and Walls' gate theory of pain. Do I have this right? Where we all have this instinctual response. Animals have it, too, right? If you bump your knee or your toe that you grab and you rub it, and that rubbing response is actually contributing to the activation of a neural pathway that does, indeed, reduce the pain through a legitimate neural inhibition. Tell me if this is still correct and then I'll let you elaborate on it.

I think that is an opportunity for us to talk more generally, or for you to educate us more generally on the mechanistic interventions for pain. Maybe massage above or below the site of pain, maybe acupuncture. Again, there will be chemical consequences of any mechanical intervention, as we know, because that's the language of the nervous system, electricity and chemicals.

But as opposed to taking a drug, you can imagine using manual stimulation or rubbing around it, or perhaps we can also talk about heat and cold. Can we explore that space a bit? Absolutely. And first you're right. So in your first part, Patrick Wall, Ron Melzac, Luminaries in the field of pain back in the 60s, defined the gate control theory of pain.

One of the things to build on the story that we talked about with no susceptors going to the spinal, signals going to the spinal cord, heading up to the brain where the perception of pain occurs. That's not where the story ends. It turns out there are pathways that come down from the brain, down from the brain to the spinal cord that act in an inhibitory role. And we'll build on those also. From the periphery, we've got also fibers called touch fibers.

These are the ones where they get activated with light touch stroking. Their refer to is a beta fibers. They're fast conducting. They head back to the spinal cord, and they make some connections with those no-susceptive fibers. So with that grounding, imagine what you said. You hit your thumb with a hammer. You bang something on an extremity. What is the first thing you do when you hit your thumb with a hammer? Some people rub it.

Yeah. Some people swear, and it turns out there are studies that show that swearing works. Really? Swearing reduces pain. Better than using non-explicative... Yes. Loud vocalizations. I don't know why, but it got some press when that paper came out. I'm not giving carte blanche. We're not saying everybody can go out and swear every time they're in pain. Well, they can, but they'll have to bear the consequences on an individual basis. We're not... We're absolving ourselves of any responsibility.

So rubbing, shaking is another one, which basically is activating those touch fibers. Oh, it is. Putting it... I do that. Everybody does that. Everybody does it. Running it underwater, which doesn't matter whether, in this case, it's hotter, it's cold water. It's the running of the water underneath it. And what is it doing? We all think it's reducing the stimulus out here, and it is not. And the periphery. And the periphery.

What's magical about that, I think, which is so cool, is you're actually changing the signals in your spinal cord. Way back here. In the neck. The deepest free version of what we refer to as neuromodulation that's ever been discovered. You're actually, by doing that, you're changing things, the connections back in your spinal cord. And it's reducing the no-susceptive signals coming in here. That's why we do it. And it works. It works beautifully.

That's why when a kid gets their boo-boo, you know, parents come and rub it. It works. What about the kids? The kids sometimes really want to kiss. Or a romantic partner will sometimes injure themselves. I guess it depends on the nature of the relationship. And they'll say, can you kiss it? Of course. And you kiss it, and then they feel better. Is that purely psychological? Well, okay.

I think an important point to ground here when it comes to the experience of pain is that everything when we say psychological means neuroscience. I know you know that. No, no, forgive me. I have to be careful with the wording that I use. But it's accurate still. It is psychological, but it is neuroscience-based. I mean, they're really becoming one and the same.

But to answer your question, yes, by kissing it, you're activating touch fibers, we can also agree that there's a positive emotional salience that's associated with that. And that positive emotional salience is reducing pain too. What interesting, while in Melzac, sometime later, there was the introduction of a device to take advantage of this, called the Tens Device. And Tens is an acronym Transcutaneous Electrical Neural Stimulation.

And what the Tens Device is doing, and there's many versions of it now, but there are those black electrodes you put over the area, and they're hooked up to wires. And when you turn it on, it causes a buzzing sensation. And that buzzing sensation is activating those touch fibers, the A-beta fibers. And so it's causing that neuromodulation back in the spinal cord. Amazing. It's cool stuff. It's very cool.

And I love that you emphasize that when we're rubbing the periphery or shaking our hand, the periphery again being the body surface away from the brain, that the real mechanism of action is taking place back in the spinal cord, because it really speaks to the body wide and the circuit wide, the nervous system wide, nature of this thing that we call pain. It's happening out, quote, unquote, out here in the periphery, but it's being modulated in the neck level of the spinal cord approximately.

And it's being interpreted at the level of the brain. What explains different pain thresholds? I could imagine it could be any or all of the locations that we've been discussing. And it could be the context as well. I've heard before, and I don't know if this is true, that if you have a lot of adrenaline, epinephrine in your system, that your threshold for pain goes way, way up. There's probably a chemical basis for that, and maybe it's all, you know, anecdote.

But certainly people have different thresholds for pain. I, for instance, do not have a high pain threshold, but I've noticed I have a very quick pain response. So if I stub my toe, it feels like the most painful thing I could possibly experience, but then it's gone very quickly. So it's like a quick inflection and then down. Other people I know, we've never done the experiment.

I think I'd see them stub their toe and they're like, and then, you know, 10 minutes later, they're still feeling the ache. So whose pain threshold is higher? It depends on how you define pain threshold. So how do we define pain threshold? What determines pain threshold? And I guess the $6 million question, are there different pain thresholds between men and women? As it relates to the whole story about childbirth being very painful and that women, quote, unquote, have higher pain thresholds.

I just sent you about 10 questions. So forgive me. Yeah. So what is pain threshold? Yeah, no, it's a great place to start. And maybe, I don't know if you want to circle back around at some point to the heat and cold to finish up the mechanical. Yeah, for you mean, no, no, no, no, no, let me answer your, get to your pain threshold. So the pain threshold is that stimulus intensity that results in the onset of the experience of pain, the first onset of the experience of pain.

So, you know, when you turn up the heat, it's not when it's warm, it's not when it's just hot, it's when the heat becomes the perception of pain. Like when it becomes painfully hot at that point in time, the same works for cold. You mentioned some of the distinction between your experiences of pain to a stimulus and your buddies. And that's normal. That first onset of pain, again, those are those fast fibers, those Adelta fibers, boom, right to your brain.

Those are the protective ones that when we put our hand on a hot stove, we immediately jerk it back. We don't even have a conscious perception yet that we did that. And then it's a moment later when the C fibers are getting up to the brain and the other Adelta fibers are converging into conscious areas of brain that were like, oh, wow, that stove is really hot.

And the C fibers in particular are converging on more emotional regions in the brain that are conveying an unpleasantness to that experience. You don't like it. And you don't want it to happen again, which is why it encodes memories. So you only had to do that once as a child. Now, getting into the pain thresholds, you asked one of the other questions is, do men and women have different pain thresholds? The answer, the short answer is yes. This has been established.

And I want to be careful here. We're saying a couple things. One is, in general, men have higher pain thresholds to things like heat stimulus than women. And what people have to also, though, understand. As scientists, we make a big deal out of small differences. Right? You know, what we do is we take a group of people, in this case men and women. And we apply the same thermal stimulus to them. And we draw averages. The average man has this stimulus. The average woman has this stimulus.

And we say, well, women have a little bit more sensitivity to that heat stimulus. And so we then go into the press and we say men are tougher than women. That's a terrible statement. Right, because the tough part is a subjective label. Right? I mean, it gets to a whole bunch of different issues around the adaptive role of pain. I mean, one could argue that if your threshold for pain is lower, that yours serves a more adaptive function.

It's fewer injuries, et cetera. I mean, I guess it gets into the implications of what we mean by, quote unquote, tougher. It does, but it also misses, I think, the big point, which is people are not averages. So what I mean by that is, while the average for a woman may be somewhat less than a man, if you look at the distribution of the curves, they highly overlap. Meaning the individual variability within men and within women is much greater than the difference between men and women.

There's plenty of women on that curve that have much greater heat thresholds than men do. But when you pull things, you end up with that difference. Unfortunately, when things are picked up and you want a quick sound bite out of it, that's what it gets to still down to. So it's not unlike height for that matter. And there are a lot of women that are taller than men. That's exactly it.

But on average, men are taller than women on average. And I would say within this area of pain threshold differences, it's even closer. It's even tighter. You know, it would be I'm making this up the equivalent. I think the average height of a woman is at five three five four the average height of a man five nine five 10. This is imagining the average height being, you know, five six for a woman and five eight for a man.

You know, it's not a huge difference. There's a lot of things that play into changes in pain thresholds. How much and this is where the brain comes in because, you know, much of the no-susception, much of the signals that were transducing were transmitting. And many of us, it's very much the same. It's when it gets to the brain now it's shaped. And it's shaped by things such as your beliefs about that stimulus, your expectations around it. How much anxiety you're having at the moment.

Does increased anxiety increase one's perceived pain? Yes. Yeah, it does. Your early life experiences with this. So if you had traumatic experiences in the past, that alter's brain circuits. Can I interject a question? If one was told just suck it up a lot or if one whimpered or cursed when they hurt themselves, if they were told, you know, don't be a worst, don't be a whim.

Do we know whether or not that increases or decreases the subjective feeling of pain later? I could imagine it going either way. I could imagine the kid that was told, don't be a woose when they cried as a consequence of expressing pain or an experience of pain. Secretly feeling more pain because they aren't able to express the emotionality around the pain. But that if we just look from the outside, we say, wow, that's like pretty tough adult, right? Because they're not crying out in pain.

So do we have any, are there any experiments that have explored that? I don't know. You're getting into, this is a good point, getting into pediatric pain and, you know, if there's been experiments in that space, I stay mainly in the adult area. And my experience with raising a child is an end of one with one son. He's done great. Thank you. I know him very well. He's what you call a great example of highly successful reproduction.

So, you know, say what do they say? It's better to be lucky than good. So I'm sure there was a lot involved. So don't discount it. Don't discard any credit. Thank you. Thank you. You know, my approach with Ian was not to say, you know, necessarily suck it up, but I would, you know, make light of it. I'd have fun with it. And I would kind of laugh and I'm like, wait a go buddy. And I would find he would often laugh, you know. So I think a lot of it is the cues they're taking off the parents.

You know, and again, this is, this is just my one of end parent is if they see you freaking out, the kid's going to freak out too. But does there get to be a point where you're ignoring your child or your loved ones painful issue? Yeah. Now you're getting into some maladaptive, some bad space where I think it's sending that person the wrong message. And they may very well have problems later on.

I will tell you just a very brief anecdote. When I was growing up, I observed a total of zero children and friends who you'll cry out in pain or complained of pain who were told, you know, that was an inappropriate response.

Sometimes I might have heard parents say, you know, I just suck it up or like, or rub it, you'll be okay. That kind of thing. But once and only once we had some friends, I won't tell you what country they were from, but they lived not far from where both Ian and I grew up since we grew up near one another.

And I'll never forget that the younger brother of a friend of mine ran over to the father he had cut his thumb on the band saw. And it wasn't particularly deep, but he was crying in pain. And the father wrapped it, picked up his chin and smacked him across the face.

And said, don't ever do that again. And so what I think he was doing was compounding the lesson about the saw. Yeah. But clearly had no regard for the pain that the that the entry probably caused. Now I haven't followed up with that kid. Yeah. I think we can all agree that by today's standards that would be considered abusive parenting or perhaps, you know, one could say that was, you know, on the far extreme of a response.

But I'll never forget that. And I went home and I told my mom. Yeah. And she said, oh, yeah, when I was growing up, that was actually a more frequent response to kids hurting themselves, especially boys. Yeah. And so things have really changed in terms of how we react to children in pain. But the reason I find this interesting is that ultimately what we're talking about is, how should we interpret our own pain?

Yeah. Can I can I make a commentary about that scenario? And I want to bring in another neuroscience concept that that dad may have been doing inadvertently. And that's something called conditioned pain modulation. So there's another cool phenomenon in pain that pain inhibits pain. So what I mean by that is, when you were, you know, this guy, this kid, but are yourself growing up.

Did you ever walk up to your buddy and say, you know, my arm really hurts. You know, I injured it the other day. And what did what did your buddy do? They'd stomp on your foot. And you'd say, why the heck did you do that? You know, I'm supposed to grown up with the same frozen.

And they say, well, now doesn't doesn't your arm feel better? I mean, like, well, yeah, it does. And yeah, I did grow up with those friends. I tell this story to some people. And I sometimes just get the wide eyes. Like they did what? Yeah, we are not making recommendations here. We're not making recommendations, but it's a real phenomenon. It was described by LaBarrs late 70, 78 or something like that in rodent models initially.

And what happens is that when you engage a no-susceptive stimulus or a painful stimulus in a site distal different from where the primary pain is, it engages a brain stem circuit that has descending pathways to the spinal cord and inhibits pain. It's amazing. Pain inhibits pain. It works. It also has some contributions from higher brain centers. We call this whole phenomenon LaBarrs called this phenomenon diffuse, noxious inhibitory control or Deneck.

The human version of this is called conditioned pain modulation. Why I bring this up not only to help explain that father's actions. Somehow, I don't think that he was thinking, oh, my kids got a pain fly. Hand or finger, he cut himself. I'm going to slap him off the side of the head. He'll feel better. I don't think that's what was going through his head. I wanted to make him feel worse so he didn't go near the bandsaw without being more cautious.

But it probably did reduce the pain a little bit to some extent. Now where it's key is, and maybe we'll get into it later with chronic pain is in some chronic painful conditions, the CPM or the Deneck doesn't work. Like fibromyalgia being one. So pain inhibits pain. Is another neuroscience concept related to pain that's rather cool. Well, and I'm sorry I missed your question. Could you repeat what you're asking?

No, you answered the question and expanded on it in a completely surprising and far more interesting way than I ever anticipated. So thank you. I'm betting that 98% of people listening to this, including myself, have never heard that pain inhibits pain. Incredible.

Let's go back to heat and cold. We briefly touched on heat. But let's talk about the use of quote unquote therapeutic heat or therapeutic cold, a cold pack for a, you know, a, you know, a bruise that really aches or maybe even a break or a sprain or heat. And you know, the, in the world of sport physio cold is now heavily debated, localized cold is heavily debated. You know, you get people saying things.

I don't know if this is true that, you know, it creates a sludging of the, of the fluids trying to head in and out of the injuries. So cold is not as good as heat. Heat allows for the inclusion and removal of waste products. And they, you know, there are all sorts of just so stories that people make up. Some of which might be true.

But what do we know about heat and cold as physiological stimuli in terms of their ability to ameliorate, to help pain? Because of course, if you get things hot enough, you get them cold enough, you can create pain with heater cold. But let's assume we're not getting to that level of heat or cold. And one is in pain.

You know, when I was a kid, we had a hot water bottle that four times when we were sick or something, but sometimes, you know, if I felt an ache on the side, I'd put some hot water in the hot water bottle. Lie on that thing, watch some cartoons. I definitely felt better. Sure. Sure. Well, putting aside the contemporary controversies over the mechanisms you describe, which are, I think, very real and need to be sorted out.

Traditionally, historically, we tend to think of applying cold for the first 48 hours or so after an acute injury and then heat thereafter. Cold has some really cool effects. Cold reduces inflammation. So it reduces some of the release of those inflammatory chemicals. We talked about prostate glandons, cytokines, histamines, other chemokines, all these fancy terms for substances that sensitize the primary no-susceptor. And it reduces the release of those and it reduces inflammation.

Another cool thing, often not appreciated, is nerves don't fire as fast when they're cold. And so if you've got no-susceptors that are firing and you put cold, it's slowing the number of signals coming up and by definition, it's reducing the ultimately the pain you're experiencing. Now, heat has an obvious effect of increasing blood flow. It's going to help relax muscles and get blood into those muscles.

And that's probably why you're putting that hot water bottle on. And it just darn feels good. And so what do I tell people? In part, I tell people use whichever works best for them. I find there's huge individual variability in whether people like heat or like cold. And within reason, they're safe. What do I mean within reason? Don't go putting an ice pack on an extremity for two hours. You know, you'll get a frostbite. So, you know, take care with that.

How cold should one make the point of their body that's in pain? Assuming, of course, that they're not going to give themselves frostbite. Meaning, do you want to numb the area? You'll get past that point where it's a little bit painful and then that, you know, basically you're shutting down some neural pathways and you don't feel anything there. So, you know, if you're not going to get a frostbite, it's numb and then you let the blood flow return when you remove the cold pack.

I mean, that's a reasonable suggestion. Yeah. Well, people, I think we'll appreciate that the specifics of that because, you know, and of course listeners of this podcast often are interested in a whole body, deliberate cold, immersion, you know, cold showers, ice baths, etc.

So, just people experience those as somewhat painful as they get into them and then can experience some numbness when they get out. Is it possible to raise one's pain threshold through the regular exposure to pain in ways that are safe, such as deliberate cold exposure, assuming that one doesn't stay in too long, it's not too cold. And or through, you know, we were talking about sports earlier, but just in general, like, can we raise our pain threshold so that life is less painful?

The short answer to your last question is yes. The answer to your other question about extreme cold and cold exposure, which I know you have a lot of expertise and you can teach me a lot. I'm going to stay in my wheelhouse because I'm not up on the literature in that space, even in its intersection with pain. It's an intriguing concept. I have to imagine that it makes sense you would get some habituation with that repeated exposure.

I think one of the questions that would come up with, for instance, the cold exposure, and I don't know the answer to this, but I'm sure maybe somebody out there does, is their cross modality changes in pain thresholds. I mean, if you expose yourself a lot to cold, does it change your heat thresholds? I would surprise, be surprised if it did. Yeah, I would. Or your pressure. Those are separate parallel pathways.

Yeah, yeah, you know, and, you know, as an aside, I hate the cold, but I do really well with the heat, you know, and so does Ian. I think there's something genetic there. So, you know, I mentioned earlier around men and women and heat thresholds, and I chose that specifically, but each of these are different depending on the stimulus modality. Can you change ultimately your thresholds? Yeah.

Where that involves is a lot of cognitive control. It's a lot of cognitive training around that space. And, you know, there's clearly approaches to that. People have learned that there's different manipulations around that. So, one experiment, this wasn't intended. At least I don't believe so. They were measuring heat thresholds on college students. And we experiment a lot on students, as we all know, we pay them well.

And what they found is that when they're studying guys, studying dudes, when there was an attractive woman who was delivering the stimulus, the thresholds were higher. Because the guys did not want to look like a was in front of this attractive young woman. And that's been pretty well established. So, the experimenter, their gender, plays a big role in that. Has the reverse experiment also been done? I don't know. I don't know. Interesting.

But getting back to your point, yes. I think through a number of, you know, cognitive manipulations, you can ultimately over time change those thresholds. Another one area is exercise, as movement exercise. You know, clearly changes those thresholds over time. You're probably building up some increased inhibitory tone through that process.

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One thing I'm fascinated by in the whole mindfulness space is this idea of whether or not under conditions of stress or in this case pain, whether or not the most adaptive mindset, assuming it's not a tissue damaging level of pain, would be to think about something else, distract oneself from the pain, or conversely whether or not one should go into the pain.

So for people who have chronic pain, maybe it's in a small area of the body that experiences chronic pain, pain quite often, aka chronic pain, or maybe it's whole body pain. I don't think it really matters for the question I'm asking. And people are trying to develop some cognitive ways, or what we call as neuroscientists, you and I top down mechanisms for things like, okay, I'm going to distract myself from the pain.

I'm going to focus on other things I really enjoy, or rather, I'm going to really go into the pain, meet the pain, and realize, I don't know, somehow that it's not as bad, like, somehow there's a... And again, this becomes a very opaque, right? We don't really know what we're talking about when we do these sorts of protocols, but those sorts of things are out there in the mindfulness space, and I think I certainly take mindfulness seriously as an intervention.

But what always bothers me about those sorts of interventions is that they lack the specificity and the granularity, and there's no, kind of, mechanistic logic to explain them. So what are your thoughts on meeting the pain versus distracting oneself from the pain? I'm going to break that down, because there's two concepts there as you alluded to, and they're both effective, and they both work differently.

So one is attentional distraction, where you are distracting yourself from the thing that is causing pain. It clearly works in a lot of people, and that's why one of the strategies that we recommend for patients, for people living with pain, is to engage in distracting activities. Read a book, go for a walk, spend time with friends and family in particular in the community, and work to get your mind off of pain. What we've learned is that attentional distraction engages specific brain networks.

They tend to be some of the outer layer of brain networks in your prefrontal cortex, some in your singular cortex, and other regions, which are clearly involved with distraction. It's not necessarily that distraction is going to completely eliminate one's pain, but it can reduce it significantly. This is why the biggest problem with distraction from a time of the day is at night. It's when people are trying to sleep.

During the daytime, you can read that book, you can spend time with friends and family, but people with chronic pain that have a 24-7. You can't distract yourself at night when you're trying to get into a relaxed state and fall asleep, and that's why sleep is such a big issue for people with chronic pain. So attentional distraction, it works. Now what you said, I mean the second piece, you said, kind of let's meet the pain, if you will, and there's different approaches to meeting the pain.

One approach that you invoked with mindfulness is addressing the pain from a non-judgmental accepting manner. I'm aware the pain is there. I am not going to judge it. I'm not going to put a value on its bad, it's good, or anything. I'm just going to note its presence. And that has been shown to work as well. In fact, actually when John Kabat-Zinn originally developed mindfulness-based stress reduction, people with low back pain.

Plenty of studies have shown that it works. I've completed just some recent studies in MBSR as well, and we're diving deeply into the data. So it's this non-judgmental acceptance of the will of the pain. Sorry, MBSR is macronin for mindfulness-based stress reduction. MBSR, everybody should do MBSR. I have no financial relationship with any of this, by the way. But mindfulness-based stress reduction has been shown effective for anxiety, for depression, for pain, just about everything.

I think they should put it into all the schools. It's a great skill to learn. No side effects. It takes a little bit of time to learn it. And it can be, in some people, effective and helpful for pain. And that's the key that we're going to keep coming back to, is some of these things work for some of the people some of the time. There's a third aspect of meeting the pain. And that is more of a direct cognitive reframing about the meaning of the pain.

Now, you're coming at the pain, and you have an approach. You're making effort on what you're thinking of the pain. Is that pain damaging, threatening, harmful? Or do you view it as, yeah, it hurts, but it's not harming me. That is a critical, critical aspect of pain management. And that serves as a foundation for something called cognitive behavioral therapy.

The cool thing about a number of these is that there's actually different neural circuits engaged with these different approaches. And I think the key that we have to figure out, and this is where research is going, is which approach works for which person under which circumstance? It's so interesting. It's something you said about understanding the pain, but not over interpreting or catastrophizing the pain seems important.

Knowing the difference between being hurt or feeling hurt versus being injured has been something that's been important to me. I've been involved in sports where clearly pain was involved. It's like I'm hurt, but am I injured? That's the first question. I've rolled an ankle, I'm limping this hurt, am I injured? Meaning, am I going to be back at it in an hour, tomorrow, versus I've broken bones?

It's a great empathy for anybody that does. When you're injured, you feel a snap, and you know you're out for a while, in some cases. Knowing the difference between being hurt and being injured is something that's kind of that key moment. For me, it's always been experienced as a moment of anxiety after feeling pain, especially in a sport where you're like, oh, my going to have to take two weeks off or is this just pain?

I think for people to be able to recognize when pain is reporting an injury versus when pain is just reporting a temporary sensation is really important. Perhaps also for psychological hurt versus psychological injury. That gets to some larger context themes these days of somebody says something, it upsets us, are we hurt or are we injured? I think it gets very murky.

So how does one determine if they are hurt versus injured, and then maybe we could even stretch into the psychological realm, neither of us are psychologists, but it sounds like so much of what you do represents the bridge from the body into the mind. And so be remiss if we didn't talk about emotional pain as well.

Yeah, so what you just said, your spot, your spot on Andrew and that one of the key messages, the key, you know, Mackie's tips for pain management is to understand the distinction between hurt versus harm. Critical, absolutely critical. Let me allow me to illustrate with patient I saw won't name names some time ago guys in his 40s a master's level tennis player, tennis is his life.

He's works as some executive somewhere, but he lives for tennis comes hobbling in on crutches sits down and he's got pain in his foot and he was told not to put pressure on his foot because he's got this injury and it's going to be worse and this has been going on now for months.

And he's now depressed because he can't play tennis tennis is his life this guy's life is tennis. So I examine this guy and it turns out what he has is something called a Morton's neuroma and a Morton's neuroma is a fiber's thickening of tissue around the nerves that go to your toes. And it gets to be like his bundle tissue nerves and it's really painful. It's very painful. But it's not causing harm. There's no harm there it's really painful.

So explain this to the guy and he looks at me with like this light bulb goes off and he's like, you mean I can play tennis. And I'm like, yeah, you can go play all the tennis you want. It's just going to hurt. He got up. He left the crutches in the exam office and he walked away. Now that's an extreme example. I don't want people please to think that that kind of thing occurs all the time. It doesn't chronic pain conditions are often incredibly complicated and need much more than.

You know, a 45 minute or 60 minute education session and you know back to the tennis court. He still had pain in his foot by the way. But he could play. But that gives that example of addressing that fear and the anxiety around that that issue. And I think that's what we first have to learn is does that pain that we're experiencing represent something that is harming us that something that we either need to seek a medical attention now or sometimes soon.

And whether does continued activity worsen the tissue injury or not in my world where I'm carrying mostly for people with chronic pain. We've moved beyond the tissue healing by definition by one of the definitions for chronic pain is that the pain persists beyond the time of tissue healing.

So in many of our sessions our times we're educating people hurt versus harm. It's back pain. We evaluate the spine. We make sure is the spine stable. Is there anything sinister causing damage in most of the cases it's not. And we help people understand that distinction critical critical for people. And yet at the same time you don't want to just ignore something that is a real medical issue that's getting worse and needs medical attention and that's where the complexity of all this comes in.

Did I answer your question? I think this distinction between hurt versus harmed is so important for people to hear. Perhaps you're willing to expand a little bit in terms of the psychological hurt versus harmed. I'm not asking you to comment on societal or generational shifts but you know we'd be avoiding the obvious if we didn't say that in the last really 10 to 15 years has been a pretty dramatic shift in terms of how society at large interprets emotional pain.

So hearing things or seeing things and the idea that emotional pain could be related to physical pain or at least similar enough to it that people's emotional pain is valid.

If anything I'm here to validate the fact that emotional pain is valid like any other pain accepted is different because it becomes very hard to point to a specific kind of threshold reason that word a lot today but I think it's appropriate here threshold between hurt and harmed whereas if I tell you that my left foot hurts which you did a lot in high school.

And then you took an extra of my foot in high school you'd say your foot's broken because it was broken a lot in high school and that's harmed. To continue to do what I was doing to break it in the first place I was harm clearly going to harm myself worse so I had to heal up. But when it comes to psychological pain you know the psychiatry has all these thresholds for normal functioning versus abnormal functioning or you sleeping well normal relationship and on and on.

We don't want to go there because it's not our place but how do you when you see patients how do you take into account the level or the thresholds for their emotional pain because that's part of your job. So I'm asking you this from the perspective of somebody who treats pain.

How do you gauge somebody's psychological pain is it by how intensely they vocalize their pain or does it always go back to how well or poorly their life is being managed at the level of sleep nutrition relationships and so forth. Yeah great great set of questions. There's a lot in there let me first start off with something very simple I don't try to distinguish between this notion of psychological pain physical pain its pain and of end up end up.

I think once I get into or you get into this trying to distinguish is the psychological pain or psychogenic pain which was a terrible term or physical pain you end up putting value judgements on people. And I don't think it serves as well when we're caring for the person in front of us.

If they're in pain I'm addressing the pain the thing to note is at least in people that come into our at Stanford Pain Management Center and other pain centers is that remember pain is a sensory and emotional experience it's all wrapped up. And so we want to treat the whole person.

Sometimes we get we get easy we get easy ones and we just go do a nerve block and pain goes away and that's simple but usually it's much more complex where we're seeing the interaction of an expression of pain that includes a significant amount of anxiety of depression you mentioned this term catastrophizing which we can break down if you'd like and that's probably one of the biggest predictors.

Factors in in amplification of pain and worsening pain and poor treatment response is catastrophizing. I try to treat the whole person and not really parcel out all this I do at Stanford I you I built a digital health system that captures measures a lot of data around a patient's experience across physical psychological and social functioning and we use that data.

To target therapies to understand how much their depressive symptoms are anxiety anger anger big issue in pain huge in pain doesn't make it worse or better invariably it makes it worse yeah and you know you can break anger down in a couple different categories John Burns and others has broken it into like anger in versus anger out I don't know if that term's familiar with you.

Anger out that's my father loud loud angry boysterous banging you know would quickly turn anything into an angry tie rate anger out expressive yelling at the at the news yes yelling at somebody cuts you off in traffic usually yelling at the man because he hated his job anger in. Boiling simmering you know self contained seething that's anger and.

Data seems to support anger in his is worse it's bad so it's not necessarily whether or not directed at someone external in both cases anger in an anger out can be directed someone external it's a question of whether or it's expressed outwardly or contained inside beautifully stated beautifully stated.

So we can't you know anger depression anxiety we capture fatigue sleep and so we try to do is again look at the whole person because they're not just a back if that's where they're having pain or not just a neck or shoulder in your case it's impacting the whole person and we just got done talking earlier about how all of these circuits interact with each other. And so sometimes we can't just eliminate the no-susception and the periphery.

Sometimes we can reduce it but what we have to do is target everything and we have to try to target all these circuits up here and in many cases what we're doing is through education through pain psychology through physical therapy and real rehabilitative approaches on top of it and yes the medications we have now. Now you know we touched based on a few earlier but we have over 200 medications available for pain very few of them FDA approved.

We tend to steal from all the other fields so you're talking about more than 200 medications that can be yes prescribed for pain but as off label treatments perfectly stated yeah there's only a few medications that are actually FDA approved specifically for pain. So what we do is we borrow or steal from the psychiatrist some of their antidepressants which will frequently work very effectively for pain and work on those pain related circuits in the brain.

We take from the neurologist some of the anti seizure medications because those medications while reducing separately seizures for people who don't have seizures they work on eye on channels they work on other neuromodulators that also are involved in pain circuitry.

We can take from the cardiologist medications that work on the heart anti arrhythmia heart rhythm drugs they are potent sodium channel blockers and the sodium channels as you know are responsible for the action potential that generates the nerve impulse signal and so they're like an oral local anesthetic that you take and so we we we take from everybody in our field and the medications.

We're getting back to what you said so just summarizing one I don't really distinguish psychological versus physical pain in my world I I find it better just to treat it as pain and look at the person holistically and go after all the components at once I find that's where we get the best results.

And it is typically bringing a lot of tools to bear speaking of tools to bear what role if any does nutrition play in local horse whole body pain critical and I think we're learning more and more and more about the role of good nutrition of healthy eating anti inflammatory diets avoidance of foods that are triggers. And incredibly under appreciated area. You know I've had my experiences with chronic pain.

I developed an abdominal chronic pain problem shortly after I turned 50 I was throwing a happy hour for our pain psychologists of all people went to a Mexican restaurant I won't name which one got food poisoning that's why I'm not naming it good Mexican food bad food poisoning and ever since that event I can't eat anything in the onion family.

What I'm familiar with onions but what else is in the onion family I'm sure you've researched this now pretty thoroughly considering what you're describing classic and what we refer to as FOD maps you know it's one of the FOD maps and I have now some issues with the others and. Manifested by just severe severe upper abdominal pain and not many other symptoms but you know it put me on this journey where severe abdominal pain didn't know why couldn't sleep.

Couldn't sleep went like I go months without having a restful night sleep I thought I was getting early all timers because I felt like I was getting stupid. And what actually benefited me was of all things the pandemic why because what do we all do we isolated we started eating the same foods and I started noticing I was feeling better when I was eating certain foods my abdominal pain went away and I'd start doing as a scientist experiments.

And I finally was able to isolate and determine what the problem was so now I have complete avoidance on that I'm a little difficult to go out to a restaurant and have dinner but so no onions no onions and what else shallots chives scallions leaks anything in the onion family you know not all I'm fine with garlic.

And you know by healthy eating by identifying something by triggers changed my life and return to a degree of normalcy I think the key for people is you know if you have any kind of similar issues identify those triggers sometimes isolation of you know foods or restrictions and using a journal. And then as you learn from that slowly build foods back into your diet.

I think it's so important for people to hear this and thanks for sharing your personal story around this because I think that nutrition while every physician seems to appreciate that quality of nutrition matters defining what quality nutrition is is really difficult there's still you know.

I have it even we could call them rancorous debates about this you know vegan versus omnivore versus this and you know but it sounds like this is a case where it can become very individualized but I could imagine somebody going to their physician and that position not being you and saying yeah you know I notice that when I eat certain foods I'm in a lot of pain and the physician simply saying well don't eat those foods but unless that person is a trained scientist like not knowing how to go about doing the sorts of experiments that you did with.

It's possible. I'm sorry I know I interrupt you I just want to please build on that if I if I can one of the key things I simplified my story but the key thing is is if I if I eat onions or anything on your family. It's pain for two weeks it is so the thing is is if you get repeated exposures it never stops and it gets very very hard to figure out what it was so it's not like you eat something you get pain it goes away.

Where you know we can all do that pattern recognition here you have to be able to think back what happened two weeks ago. That may have influenced it so it's not easy. Well this may be a case for elimination diets which are provided and safely where people restrict the number of foods they eat to a very limited number of foods make sure they still get enough calories and macronutrients that they need protein fats and carbohydrates or whatever would have you.

But that by limiting the total number of foods that the eat to like eight or ten basic things then you can build things in and then explore what triggers the pain or what removes the pain. I don't really see any other way I am intrigued by the onion example even though it's a it's a it's your case in particular and we don't want to extrapolate to broadly.

Is there something about onions that's triggering a particular neurochemical or immune pathway or do we have any knowledge of like why onions would create that kind of gut pain. This has been a journey I've been on now for a few years to answer this. One of our GI pain docs that we have come and clean and then when sent me a paper from I know seller nature that showed that after a gut infection. It can change the genetic expression related to sensitizing you to food antigens.

I know I threw out a lot of jargon there basically the short answer is you get an infection and your gut no longer responds properly to a normal food item. And so one explanation maybe I got this infection as it a Mexican restaurant lot of onions and I got sensitized through that infection now subsequently to onions.

You know I saw a Stanford Allergist and a Hanna Watford who's awesome by the way and after I had this I think figured out and I went in and I'm like well you know Dr. Watford or is there anything I can do for this and she laughed and she's like no you're doing everything it's all just avoidance.

And I thinking I was rather unique and special about this thing I said you know do you ever see this and she said oh yeah I see this all the time every day I see this all the time and I thought this isn't unusual I said no I see this thing all the time and I said meaning sensitive. So I said 70 to certain no to certain to different these different food groups and this this thing that occurs later in life something an event that happens to somebody that triggers.

And I said well gosh that sounds like a public health problem and she's like that's what we're debating right now in the allergy community is whether this is representing more of a public health issue and is because I'm seeing I Dr. Watford I'm seeing increasing amounts of this as we go forward.

How interesting well this is not a time to plug the philanthropic arm of our premium podcast but I'm very involved in science philanthropy this sounds like an area to devote some funding to to explore how foods are impacting the local and systemic pain response. I got in you know so I'm running a large biomarker study to characterize people deeply and one of the things that I wanted to put in there is microbiome characterization now to be clear that's out of my wheelhouse.

But the beauty of being at Stanford and other major institutions as you can go make friends. Yeah just in Sonnenberg who's been a guest on this podcast is one of the world experts on the gut microbiome we have a few others to there you go. He's a friendly guy I'm sure he'll collaborate we go we go make friends and people who understand the microbiome we collect the samples and that's where team science is magical and once again the idea looking at the whole person.

As long as we're talking about the gut. Let's talk about pain inside the body because we talked about nozzusceptors on the surface of the body and the pain that most people immediately think of when you have a discussion about pain is that the pain is the most important thing to do. Pain is you know pain on the surface or a broken bone or maybe hit pain or knee pain or back pain but what about pain that resides deeper in the viscera.

You know a gut pain irritable bowel syndrome these things are I'm learning are far more common than that I knew I'm fortunate that if I have a stomach ache or a headache I mean something is wrong I rarely get those I've sometimes been called you know a stomach of steel not because it's hard from the outside.

But because I can eat pretty much anything although I eat pretty cleanly a lot of people write to me and ask questions on social media about irritable bowel syndrome and other forms of gut pain and viscera pain like pain that they feel is really deep within their system typically how is that sort of pain dealt with at a clinical level.

Absolutely visceral pain is a different thing than what we've been describing a lot of which is somatic pain by the way I'll say is an aside I used to have a gut of steel also I could jump down anything anytime anywhere and so you know there was a lot of grief and loss associated with not being able to eat certain foods and that's also something people have to come to grips with.

But getting back to visceral pain so the thing about somatic pain that's another term now somatic meaning the soma the the the extremity that you are alluding to is the no susceptors there very precisely localized where the stimulus the painful stimulus is coming from when you hit your thumb with a hammer you know exactly where that pain is.

Where that pain occurred with the visceral pain what you have are very diffuse what we refer to as receptive fields think about you that last time you had a stomach cake it's not that you put your thumb right here you said it hurts like this whole stomach it's because those receptive fields are very large there broad

there not as well localized and in part the reason for that type of broad receptive field is you're not trying to get away from localized danger so when people get stomach it's often a very broad area when you get pelvic pain it's the same type of thing now there's some fascinating stuff that occurs with visceral pain because those fibers that extend from the visceral pain.

And it's the same thing that we stand from the visceral meaning the lungs the abdomen the pelvis they all head into the spinal cord to. And it just so happens that they make kind of indirect direct connections with the same level that represents the body. So let's think about pelvic pain for instance you frequently will find people that said that have pelvic pain that will describe having lower back pain to.

And it's because of this visceral somatic convergence in the spinal cord it's not that there's something going on in their back it's at these signals that are being driven heavily from the pelvis are coming in and connecting with the same. And the reasons from the back and the convergence of that is now being perceived as pain in both.

And we're seeing that more and more in the research this visceral somatic convergence people have pain in their pelvis and then also over their abdomen classic one that we're aware of we see this in the TV the movies and unfortunately real life or heart attacks.

The visceral fibers that subserve the heart typically the first through the fourth thoracic region well those converge in the spinal cord in similar regions that subserve sensation under the arm and up here that's why people will often say they've got pain with a heart attack radiating down into their arm the left arm to the left arm the heart is on the left side exactly.

After people get abdominal surgery sometimes some blood can leak out and it'll slip underneath the diaphragm the diaphragm is subserved by some of those neck regions three four and five of the cervical which happens to also cover your shoulder and so you'll get people after abdominal surgery they said my shoulders really hurting me doc.

And what we do is we first check to see you know could something have happened during anus you know during placement just make sure there's nothing wrong but frequently it's due to irritation. That's again one of the magical mysteries it's so fascinating about pain.

It seems like a good point to bring up reference pain or is what you're describing an example of reference pain so my understanding of reference pain is that you know like for instance I've got a slight bulge head I think like my lumbar three four disc or something I had a whole body scan recently just a

exploration scan because I had the opportunity not not anything serious fortunately and there's a slightly bulge this there and every once in a while if I do certain movements in the gym I'll get pain down in my right hip and sometimes going down my leg and I used to think it was sciatica because you assume anything on the right backside okay must be wallet induced sciat sciatica back pocket wallet into sciatica

but what I eventually realize is that well it's this dis bulge it just so happens at the nerves that emit from that that region they branch out to a bunch of different areas and so you think the pain is in your leg but the issue is someplace else or

and occasionally indeed I feel the pain elsewhere my body as well it's like a like a matching of regions for pain that seem unrelated is that a way to think about reference pain perfectly the the examples also I referred to of a heart attack causing referred pain

or also the pelvic region associated with back pain as a way of referred pain what you're describing is the fact that pain doesn't have to start with an injury or stimulus in the periphery you could damage the nerves anywhere along the way

and that will be perceived as pain we refer to that as neuropathic pain so that's another distinction you brought up nicely good good segue into there's thought to be several different types or categories of pain we have been talking through much of this time about somatic pain you know injury out here we talked about visceral pain

and when you have damage to a peripheral nerve damage injury to a peripheral nerve or the central nervous system we refer to that as neuropathic pain it frequently has different qualities different characteristics people will refer to it as shooting stabbing shock like burning it can frequently when there's a damage to a nerve or damage to certain regions of the brain being incredibly challenging to treat

by the way the good news is with that light disc bulge is the vast majority of time the discs reabsorb yeah I have to be careful to not do too much spinal flexion like sit ups and stuff I thought that that would help but that actually doesn't strengthen the back it was actually a symmetry between the abdominal muscles and the lower back muscles so it provided I do a lot of back extension type training then that bulge

more or less stays in I just have to be a little cautious not too cautious fortunately as long as we're talking about referenced pain somatic visceral and all the rest what about associative or referenced pain where it's psychological and I don't want to get too abstract here but more and more these days I hear from people who say you know I was in this job and the job sucked

or I was in this relationship in the relationship sucked and I had terrible back pain like really acute localized back pain or chronic headaches or migraines yeah and then they go on vacation or they change their circumstances and lo and behold pain goes away does that surprise you as an expert in pain not at all not at all

which are you know a simplistically referring to as you know there's people are undergoing stress and we have we clearly know that the brain is not a passive recipient of information coming in from the body it's a two way street the brain is causing downstream consequences in the body the brain controls our sympathetic nervous system and parasympathetic nervous system the sympathetic being the fight and flight response it controls the tone of cortisol that's being released

we'll know that in acute situations rapid increases of cortisol and noradrenaline is keeps us away from the lines and tigers in the bears oh my but in a chronic situation and Robert Sapolsky as you know at Stanford has built a career around chronic stress at least in part and very bad for us

and so these chronic stressors impact the end organ the tissue and it's real pain it doesn't mean that we need to go get back surgery it means that probably we need to identify the stressors that are contributing to that and address those and we'll often find that in the scenarios you outline that the pain gets better

some of those targets are interesting there's a lot of memory associated with pain this is where early life events occur and those early life events in injuries can sensitize us to future vulnerability so I was in a car accident when I was 16 fortunate to walk away from it got bad whiplash if I get stressed a lot of my pain manifests in my neck for me as a pain doc it's a signal to me that's like go work out go for a walk in the forest you know and take some time away from the computer

again that's a simplistic message and my experience doesn't translate into everybody else but I'm just validating everything that you you said let's consider the opposite scenario which is positive emotions you've done some very nice studies exploring how being in positive relationships being in love in fact can change our perception that is our experience of pain and probably does so at

real physiological levels as you mentioned earlier psychological is physiological and vice versa it's hard to separate the two but could you share with us what you did in that study and what you found because I find it really interesting and it also points to the incredible power of love in how we experience life yeah I think there's several cool things about that study that I love to share one is how it all came about so

you know us neuroscience geeks often go to the society for neuroscience as an annual meeting and I was hanging out in a sharing room with art Aaron who studies passionate love and he and his wife study passion love and we were having a glass or two of wine and mask and art if you ever you know he ever

studied pain is like no I study love is like if you ever study the night study pain if they never study the intersection another glass of wine no let's do it so we came back to Stanford and there was a young postdoc Jared younger who's now a professor at the University Alabama and I said Jared we're going to fall flat on her face or we're going to this is going to be a cool study and Jared took this on great job so what we did is we advertised on campus for

our couples in an early phase of a romantic relationship because there's a reason for choosing that in an early phase of a romantic relationship you are deeply focused on your beloved they're on your mind all the time you feel great when you're with them you feel terrible when you're not with them doesn't that just sound like an addiction

means that yearning I don't know that's it's a can be a pleasant experience that addictions you know for the people who are using the substance can find it you know in that early phase very pleasant but it turns out that the early phase of a romantic relationship engages the same neural circuitries as addiction interesting same reward circuitry all that so we chose that

and so we said come to us and bring pictures of your beloved and bring pictures of an equally attractive acquaintance clothed this isn't sex that we're studying cloth and we cause them pain in the scanner and we paid them afterwards we needed a control condition for this because thinking about your beloved is very

potentially demanding remember we talked about attentional distraction earlier so we gave people what's called a word generation task very simply can you think about every sport that doesn't involve a ball okay frisbee hockey boxing boxing okay that's intentionally demanding think about every vegetable that's not green and you know so you're running that through your head and we're causing you pain it's an

attentional distraction task so we flash people pictures of their beloved cost paying flash people of their acquaintance cost pain and then distraction okay what do we find love works great it was a wonderful analgesic it's significantly reduced people's pain and it turned out the more in love you were the more pain relief you got when viewing the photo of the person you love

yes when viewing the photo of the person you love now how did we know how much in love they were it turns out the psychologist have got scales for everything and one of them is a passionate love scale which asks how what percentage of the day are you preoccupied thinking about your beloved oh goodness you just sent people now off to give their partners the passionate love

scale that's how much time they're spending thinking about them yeah we we had Stanford students some of them thinking about their beloved 80% of the day I wanted to use this as a screening tool for our resident applicants because I want them focusing on patients not their beloved and that is by the way a joke that bad joke but it's probably is real world we're not just talking about Stanford I mean but when somebody's writing

you a script or a prescription that is or giving you advice yeah you might want to know if they are in a new romantic relationship yeah so the other I thought the other cool thing about this study was attention worked also but attention and love worked on different circuits so attentional distraction they worked equally well attention again worked on some of these

prefrontal regions these outer cortical areas love worked on more of what we classically think of is these reward based circuits the nucleus of the humbans the amygdala one of the descending brainstem regions called the substantiant nigra which is coming down from the brain through that area to the spinal

core to inhibit pain so classic addiction pathway classic and so the key again message for people is different what we would think of is psychological approaches engaging different brain circuits to reduce pain I'll leave you with one last side note that we didn't publish on and that is a Jared went back a year later and we assessed the student strength of their relationship if semi was still ongoing and he found that there was a rather high correlation between the love induced analgesia

and brain activity in the caught a nucleus and in the insular with the strength of the relationship of your later it was so we had a brain scan that was a predictor future strength of a relationship could you tell us the direction of those results so if a new romantic partnership is creating high levels of activity in these two brain areas you just mentioned

then it is a very good predictor that the relationship will yes survive over time well in this limited sample it meant that it it was going to be very strong a year later I understand and you know and we always have to put these caveats unpublished non peer reviewed it was a fun post-hoc data analysis that I'm not sure if anybody's ever you know run with those kind of things

you know but we can explore it in a playful way now and people can do with it what they will it does sort of speak to something important though assuming that result would hold up if the same experiment were done and you know many many hundreds or thousands of people sort of speaks to the idea that the activation of these addiction like circuits in the early phase of a passionate love relationship

in motion a certain number of things that create stability in that relationship which on the face of it makes sense but we've also all heard of the opposite way as well as well which is you know fools Russian or that things that start fast and fast or things like that but here you're talking about the early phase of passion serving this interesting role in terms of

analgesia alleviating pain but also predicting some stability of the relationship over time it's kind of interesting it's fascinating to talk about I you know I feel like I have to put that caveat in that not generalize but a fun thing to talk about and it's where I think cool scientific ideas can come from for future exploration that I think that's also what's pretty neat I find the you know again the different circuits for different approaches to reducing pain

fascinating again that gets to the question you asked me earlier is there one circuit and the answer is no what we have to do is figure out what is the best circuit for a particular person or set of circuits if you're willing I'd like to talk about opioids first if you could educate us on endogenous opioids the opioids that we make inside of our body that we don't that meaning nobody takes as a drug

and then how that informs opioids that people take I mean clearly the so-called opioid crisis is a concern many people addicted to opioids people have died from taking too many opioids but presumably some people have benefited from these opioid drugs as well so I would like to talk about that and then I'd like to also talk about some of the things that are adjacent to the prescription opioids things like

which right now are sort of called into question as to whether or not they will continue to be legally available over the counter so first and foremost what are the endogenous opioids how do they work and that I think will set the stage for the rest yeah so we all have these endogenous and kephalins and endorphins that act as pain killers they are analgesics they are natural substances and all of us that get expressed

there is a certain endogenous tone to these that some have done research on here again Jared did research on this and Stephen Bruehl and others on showing that higher endogenous opioid levels may lead to less emotional reactivity for instance thank god we you know we have endogenous opioids or you know we just couldn't handle it what chemists have figured out is how to you know bring in an exogenous opioids and morphine was the prototypical one from the from the

copy and since then medicinal chemists have built on variations of morphine and created other compounds some variations on morphine some are purely synthetic like the oxycodone could ask a question because I'm fascinated by the history of these things how did you end or when did somebody look at the poppy and then say oh I'm going to start eating poppies or isolating things from poppies and realize that morphine thousands of years ago so poppies have been used for a very long long

time these things have been around so this is this is old school work that's only been refined in more contemporary history and the whole topic of opioids is such an incredibly controversial area and I I feel like I have to

understand the speaker Mike in this case me my you know once position on this my usual mantra is I am not pro opioid I am not anti opioid I am pro patient so I have seen opioids positively transform people's lives help them get back to work spend time with friends and family relieved suffering

particularly in situations end of life but also in people with chronic pain and I have seen opioids destroy lives at a personal level I come from a family background deep deep in addiction I have lost close loved family members to addiction and I'm respectful of that

what I've learned is to not get into this binary mode of thinking it's either this or it's this but to treat opioids as a clinician as a tool to be used in certain circumstances in some people not typically as a front line or first line agent typically much later down if they have failed other therapies

you cannot approach the challenge of opioids without appreciating the deep complexity that we're faced with particularly now in society with all of the litigation ongoing and all the money involved it's a it's a highly nuanced topic so what what what more would you like to talk about opioids well I think that most people hear about the opioid crisis and just assume

that they are quote unquote over prescribed that people are given opioid drugs as a front line treatment perhaps more than they should that the addictive component which I understand is very real the potential for addiction is very real as well as the potential for cross interactions with other things like alcohol and perhaps even other illicit drugs street drugs perhaps if like if people can't fill their prescriptions

and tolerance to the opioids creating issues where people then need more of them there do I have a not close family member but a you know distant family member who had his entire life in arrange beautifully as a practicing lawyer with a beautiful wife and family had a back injury

and then it was prescribed oxycontin it it helped him initially but then it it set off some behavioral psychological pathways that had him seeking more forging prescriptions when you know he understood the law he was a lawyer he eventually went to jail got out the same thing happened again he eventually ended up dead

so and I think there are many examples of that that we hear about in those are very salient and very disturbing very saddening so I think that most people including myself here the opioid crisis and assume that what we really should be doing is seeking a better alternative

but what I'm hearing from you is that there are use cases where opioids make a great deal of sense and that they've really helped improve people's lives and that none of what I just described or anything like it is experienced by those people in fact quite the opposite do I have that right perfectly and and that's again where we we need to treat these at an individual level on a case by case basis and that one size doesn't fit all

yes opioids were over prescribed I think everybody agrees to that in this country and we went through a period of time with massive over prescribing and there's a lot of nuance and reasons why in large part physicians we get terrible education around pain and we don't know how to treat it in general coming out of medical school we get about seven hours of education on pain that narrations get forty it's great if you're taking I think your dog's name is Castello yeah

of course he passed but he took some pain meds for a short while but I found an alternative treatment that worked for better perfect which turned out to be by the way Lodos testosterone he was castrated like he was fixed on his younger and I it's interesting I've gone I've said publicly on very large scale podcasts that I gave my dog Lodos testosterone later in life and it

a lot of his aches and pains at least from what I understood because he started moving better and feeling better and sleeping better and I expected the veterinary community come after me with pitch for not one did that and yet I heard from hundreds of veterinarians it said yes we wish that we could

prescribe those sorts of things to people who castrate their male dogs later in life to emulate their symptoms so that opened up to me a whole world of understanding about some of the restrictions that vet that is in terms of what they prescribe there's a whole discussion to be had about that will do a series on animal and health that health great well the that's hopefully

healthy to you get the point yeah but when it comes to the opioid crisis in this discussion you know I think it's become so laden with the idea that like doctors are on the take like they're getting paid to give opioids to patients and that's why they're doing that and I don't believe that necessarily be the case but I

think that's what the public perception is that it's all financial here's the here's the thing were there bad docs doing bad things yes I'm going to invoke a good friend of mine Keith Humphries at Starrific terrific psychologist who is an addiction medicine psychologist and public policy person and the way he breaks it down and I subscribe to this is you know the there's three types of physicians remember there's about a million physicians in this country about a million

you've got physicians doing the right thing for the right reasons fast majority of docs we need to leave them alone we need to support them we need to help them do their job and not put more obstructions in their way there is a much smaller group of docs doing the wrong thing for the right reasons what I mean by that is these are docs who did over prescribed opioids in this case in this context they did buy into the marketing messages that were put forward they did not have much

education around alternatives in treating pain and they thought by handing out pills just pills in their very brief visits with patients remember primary care docs is my heart goes out to them you know what do they get 14 minutes or so with a patient they gave them something that they thought would help they were doing the the wrong thing for the right reasons but they believe that

they were helping they didn't believe they weren't get catching financial incentives or okay that's right those people we need to educate them we need to train them on proper pain management opioid prescribing deep prescribing and then you've got the tiny little group at the top of this if you will pyramid these are docs doing the wrong thing for the wrong

medicines these are bad docs these are your pill mills these are people breaking the lot they need to go to jail end up the thing is is that that little group at the top in the million or so physicians we have in this country it represents such a small representation but it got blown out by the media and everybody else particularly those docs doing the right

medicines got caught up in it and engendered huge amount of fear huge amount of fear on the physician side and then what happened is the docs just started abandoning patients they cut their patients off I had a young house wife to young kids doc cut her off from a little bit of I could in that she was taken

off for a moment for some back pain that had been well managed on this she was doing all the right things cut her off she turned to black tar heroin you know California great state of California tried an experiment where they monitor death certificates in our state for and the docs prescribing opioids for that and they went after the docs thinking that if they targeted the

docs doing that it would lead to a reduce a reduction in opioid deaths it led to a doubling I know counterintuitive because what happened is the docs abandoned the patients and so we have to be aware of the negative consequences of this now the current I'm not trying to minimize the opioid crisis because it's real but we also now need to put some

context the opioid crisis is being driven by the illicit fentanyls it is more if you just look at the CDC data it's very clear that the fentanyls coming in via Mexico China and others is what driving most of the deaths Keith getting back to Keith led a beautiful Lancet Stanford commission on the North American opioid crisis and put together very rational plan

I just finished serving as a senior advisor to the medical board of California where we revised our prescribing guidelines here they were very draconian before hard limits made people fearful both patients and docs and we've shifted it back over to put the control back in the hands of the physician patient relationship we're hoping it'll make a difference you can see I'm I'm going on a bit here there's there's just

huge complexity in this space I understand you're going to do an episode you know some some time on it in the future and I hope the audience has more opportunity to listen to this other questions I can answer for you that on that way really appreciate the thoroughness of your answer I think that you set a picture in a context that I certainly didn't understand or

appreciate and it sounds like one certainly not the only but one of the major issues is the creation and the propagation of a black market by doctors cutting off patients presumably out of fear those patients then seeking not any but illicit or black market routes to treating their pain which you can understand why they would do that I mean I'm not just

justifying anyone doing anything illegal but somebody's in pain and they had something that worked and now they don't and they're going to go looking for things that are similar to that thing and you're telling us that fentanyl in street drugs basically is what's killing people presumably I doubt it's fentanyl prescribed by physicians or perhaps it is it's not no there used to be a bit of

confusion around that because fentanyl is a prescribed medication in a patch form and in a trosh the trosh use for end of life cancer pain but unfortunately some of the coding used by the CDC in other words got that confused with the listen so it took a while to get a better handle on it but I think we do now yes most of it is being driven by the fentanyl's and we're just seeing this incredible epidemic wave of it it can be made so cheaply

brought across the borders reasonably easily something we definitely need to do to address we want to be careful about not conflating that crisis with the issue of pain which is an epidemic in its own right and for the segment of people who are using opioids responsibly and effectively for their pain and that's where again that nuance comes in are there patients who are also on opioids that have been weaned down you can wean them down gently

and they do better the answer is yes my partner Beth is just finishing up a study on that and you know showing that with compassionate care a number of these patients can be weaned down who voluntarily want to come down and sometimes they find their pain actually improves and part of that improvement may be that opioids have degrees of side effects

and by elimination of those side effects and the the other aspects they're seeing improvement could you list off some of the more commonly used opioids you know morphine and its commercial commercial deliberatives MS content which is a long lasting version of morphine oxycodone which by itself is a short acting medication but when you encapsulated in a long acting version it becomes oxycontin which was the trade name that Purdue put forward fentanyl we mentioned comes in a patch form

there are mixed agents like tram it all which is a kind of a weak opioid but also has what's called serotonin and orapornepern reuptake inhibition we've got delotted which is a version of trading for hydromorphone so there's a slew there's I don't know more than 20 different opioids within that list of 200 medications that we have

methadone is another one people usually think of methadone is a medication used to treat addiction people go to methadone clinics it's a long lasting opioid in the right person in certain circumstances it can be used effectively for chronic pain

by and large they all have the same or similar mechanisms of actions working on opioid receptors this is getting back to your original question to me about where these things work there are opioid receptors in the periphery there are rich sources of opioid receptors in the spinal cord and the dorsal the back part of the spinal cord and then there are many areas in the brain that are rich in opioid receptors it's you know it's all a naturally occurring area when we put in an opioid by mouth

we're binding to those receptors and activating those neural circuits in many cases when I say activating they have an inhibitory role I mean that's one of the major parts is there any role for benzodiazepines in pain relief rarely if to I many of my colleagues would say you know Sean it's just a hard no I'd have to come up with an edge condition of somebody who has a generalized anxiety disorder unportly treated with anti-angsylidics with chronic pain

and the one you find you treat their anxiety with like a benzo it helps with their pain as well but these are edge conditions by and large no what about cratum I had a odd experience with cratum and I've never taken it the experience was the following I started learning about it hearing about it from listeners on the podcast

realized by doing a little bit of a web search that it's available over the counter and that certain people like to take it often like every day at low doses or even higher doses and that there was huge variation in terms of the amount of cratum in the various products and how much people were taking some people talking about cratum as something

it was as if it were innocuous and we can ask whether or not indeed it is innocuous and so I put out a tweet I guess now that Twitter is called X I guess I put out an X anyway doesn't matter and I and I said that my first pass view of the literature on cratum the scientific literature is that you know it had a lot of property similar to opioids although different as well and that it seemed kind of odd and maybe even problematic that it was so widely available and I got bombarded

with I don't want to call them cratum enthusiasts because what I soon discovered was that these people were angry with me for placing even a partial shadow on cratum but what was interesting to me was that they were saying that in their case and I'm assuming they were telling the truth that cratum had helped them get off prescription opioids and that they heavily rely on cratum in various levels of dosage in ways that they felt really help them

and so two things happen one I've been put in the crosshairs of the pro-cratum community not to a severe extent but perhaps the more important thing is and I want to thank that community in part for you know now it's inspired me to do a deep dive search on cratum I'm going to be interviewing one of the laboratories that's done a lot of the research on cratum later in 2024

but also it's made me realize like there are these compounds that are available over the counter that many people feel so passionately about because they really feel like it's helped them not saying it has I'm not saying it hasn't but then again I've never taken it what is cratum or perhaps what receptors does it tickle and what are your thoughts about cratum and people using cratum and maybe I'm pronouncing it wrong I've also heard cratum cratum I'm calling it cratum

yeah cratum is this natural substance that does have as you said opiodurgic properties as well as others that is not fully understood it's been available well naturally for many many years brought in to the United States and I've heard the same stories and I just want you to be prepared that anything I say about cratum there's going to be some angry people after this and it is what it is

I have heard the same stories that you have heard about people taking cratum and saying it's helping them to stay off of prescription opioids or illicit opioids and I get that I think in some way it's binding opioid receptors and reducing the natural craving for these other substances

and it makes perfect sense a methadone does that buprenorphine which I didn't mention before but is an interesting opioid that binds to these receptors and it reduces craving where I have challenges is in just because something is natural doesn't mean that it is safe

we are seeing an increased number of overdose deaths associated with cratum is it polysubstance yeah in some cases it is but I think there's a lot we don't know so so polysubstance people taking cratum but also alcohol benzo is getting back to the benzo

personally I think we need to put a lot of research into this agent and if it merits it I think it should be a prescribed substance I think part of the challenge that we have is that we don't understand the quality of the purity of the dose that people are taking of this thing

similar type of story with cannabis by the way so I'm hoping that we're going to get the research that we need to really understand what it's doing and whether it is safe and effective I'm left with a lot of unknowns right now you mentioned cannabis is cannabis effective and by extension is CBD effective for managing pain yeah there's another controversial one you'll get a few comments about whatever I say

you know in general listeners of this podcast yes they tell us where they're upset they'll also tell us where they agree our goal here is never to satisfy everybody but just to you know some of this lands in the realm of highly educated opinion some of it is still as you point out speculation because we don't really know what cratum sources people are taking or cannabis etc but I think you'll find and my experience has been that people appreciate that we're having the conversation

and we do read all the comments and those comments often as I mentioned in my earlier anecdote about that tweet often direct us to explore things further and we can always have a second discussion about this down the line so we invite all your comments and criticism cannabis well here's what we know in carefully controlled laboratory situations cannabis has been shown to reduce neuropathic pain that's that nerve related pain from people who have either nerve injury diabetic neuropathy

post-tropetic neurology terrible burning nerve pain condition it has been shown to reduce that in small samples from larger scale epidemiology studies and even larger like clinic based studies that I've done we find it has not been particularly helpful on average compared to people not on cannabis

there's a lot we don't know about the causality of that and the direction of it but all to say that there are many many questions that remain I think the challenge that I personally have is that we're running huge population level experiments as we speak right now

by you know providing unfettered use of cannabis and the bad news is that we're probably going to see some real untoward consequences of it and we're already are the good news is I'm hoping that at a state level we'll be able to use that data to really inform what's going on with cannabis I mean some of the challenges are what I refer to with creatin cannabis is not cannabis is not cannabis you know the t-h-c-e to c-b-d ratios the dose yes all of that we don't know what you're getting

it remains a scheduled one drug by the DEA I in some of my leadership roles and others have called for scheduling of it as a schedule 2 why why not to purposely try to restrict use but by making it a scheduled to drug you've now made it so much easier to research

I don't know if people understand how many barriers there are to scientists studying schedule one drugs could you explain schedule one versus schedule two thank you yeah so schedule the scheduling of drugs is a categorization that describes their abuse liability

and so you have drugs like PCP heroin cannabis which are schedule one which are defined as having high addiction potential and no utility which is just wild because when I think about PCP and cyclody and I certainly don't want people to run out and start taking PCP but chemically and physiologically PCP is ever so similar to ketamine and you know rarely is this discussed but ketamine is now widely used as a therapeutic presumably ketamine is a schedule 2 maybe even schedule 3

yes so some of the the stuff that's thrown into schedule one makes no sense it's historical it's all his it's decades and decades ago of history and clearly cannabis should not be a schedule one hands down no question by scheduling it though you will have the societal benefit of being able to make it more easy to study and then you get the NIH and the FDA into this and we can start really getting answers to the questions

which I do I think it works at the end of the day do I think there is some variation of cannabis THC CBD ratios that will provide some benefit oh absolutely there's too many receptors in our brain that are involved with modulation of pain I just don't know what those are friend of mine Mark Wallace runs pain at UC San Diego has come up with a really nice recipe cocktail of ratios of THC to CBD that he feels very strongly that he can help people using that as an active agent

I know that in Colorado there's a strain of cannabis where they it's pure CBD no THC think they call it Charlotte's web and parents of children with intractable epilepsy will actually move to the state of Colorado in order to get it because it seems to be effective for the treatment of certain forms of pediatric epilepsy that was shared with me with one of our colleagues Nolan Williams when he was a guest on the podcast

so these plant based compounds have have their place whether that's creatum perhaps right we're remaining open about that or cannabis the THC or the CBD or some combination I think it's really interesting I think as long as we're talking about plant compounds how do you view the fields that are what I would call somewhat adjacent to traditional medicine so things like acupuncture chiropractic physical therapy and so forth

as a pain physician within the field of pain medicine or pain management I think about six broad categories of therapies that we provide for people with chronic pain one of these is the medications and there's a whole large group of categories of medications of 200 or so available

two nerve blocks and procedures these range everything from trigger point injections to a nerve blocks with local anesthetic and steroid on up to minimally invasive procedures like spinal cord stimulators implantation of drug delivery pumps three psychological and behavioral therapies pain psychology which has many forms now can be very effective four physical and occupational therapy approaches to chronic pain five this is what we we typically call complimentary alternative medicine approaches

it's a little bit of an outdated term but I think of that as acupuncture neutrosuticals these are the over the counter agents that have actually shown to have benefit in pain that you can get over the counter and last but not least six what I call self empowerment or increasing your agency and here it's about education it's about learning skills it's about being here on the Hooverman you know lab podcasts learning about pain

it's it's that self empowerment and what we find is that those six categories all brought together typically have the best benefit for people living with chronic pain to a lot of people listening to the us right now they go yeah acupuncture I mean this is a you know thousands or tens of thousands of years practice that clearly is grounded in a lot of clinical data and clearly works

and then other people will go oh my goodness they're talking about acupuncture like sticking needles in the body are they just like pain treats pain is that what is about but as you and I both know unless it's being performed incorrectly acupuncture is not painful to receive does acupuncture help treat certain forms of pain is there any scientific basis yes yes there is do I understand what's going on with acupuncture having completed an acupuncture and then I

each funded acupuncture study I just saw that published no you know I'm just being straight we still don't know exactly how acupuncture is working we do know that there's a nice study that showed activation of peripheral adenosine receptors that have a peripheral analgesic effect we know that acupuncture as compared to sham acupuncture engages different brain regions

it's interesting that many of the acupuncture points overlie peripheral nerves and so by needling those nerves are we causing a central change we're turning down the amplifier if you will in the brain maybe where does this fit into my clinical use my usual statement is that if you can afford the wallet biopsy give it a try although find a really good

acupuncturist I've oh yeah yeah I've had acupuncture done I wouldn't say many times but several times and I will say this one of the acupuncturists I went to put needles in my face and I ended up having to go to Stanford Durham to get some of the angiomas that were like blood vessel growth that was the consequence of those needle insertions and so I to the point where I won't if I go to acupuncture

anything don't put any needles in my face because I'll take an angioma my leg or whatever I don't care and I it's not vanity but I didn't like the way that the needles were introducing angiomas to my face now that was probably because this acupuncturist wasn't doing things correctly not saying all acupuncturists do that but here's the problem how do you know which acupuncturists are reliable versus not and for that

matter how do you know what position is reliable versus not I mean I work at an institution like Stanford where I can ask a lot of people and I still might senior administrators won't like this but when I get a recommendation from a docket Stanford I always call somebody at UCSF and cross check

and I don't tell them that I'm cross checking and I'll do the reverse as well when I when I was at UC San Diego I would check up with Stanford so but most people don't have access to that kind of community I mean I can pick up the phone and contact somebody in pretty much any medical

specialty and at multiple institutions but for most people they're waiting into the abyss of acupuncturists of physicians I mean how do our people supposed to navigate this you found a perfect way to do it many of us do the same thing and for those who don't have access to high quality

experts you can use variations of that so you're right with acupuncture most of the ones I've been associated with we use in the clinic or outside are all have been high quality the recommendation would be to try to get a referral or recommendation from somebody who refers to that acupuncturist

docs want to have relationships with people with other clinicians that do a really good job we don't want to be referring to somebody who's bad because it reflects badly on us so it's really doing what in a way what you were doing so try to connect with your

primary care doctor others and get some recommendation for who is high quality with regard to clinicians, pain physicians for instance that's tough there's five to ten thousand of us that are sub specialty trained out there if you're pain is really complicated a complex pain

problem you're probably better off with a tertiary referral center that can provide comprehensive services where possible so is there a centralized website where people can say okay I live in the state of Iowa or I'm you know a lot of our listeners are overseas or you know

where people can find out the like the ratings based on patient experience although that can be complicated I can fast sure the one star out of five star ratings are a little bit more salient there been studies on this people tend to if you know you see a negative review those tend to grab your attention even if they're fewer of them than the many thousands of positive reviews but I mean patients should be able to get the information that they want about previous patients experience right yeah I

got to tell you the the patient ratings it's a highly manipulated situation also well you can pay companies to help jack up your ratings I see that's it's rather easy I see it in the community all the flation of ratings oh my yes inflation of ratings and so then you inflated and it overcomes any of the negative ones we haven't have taken an approach on this and maybe that's naive of us you know we see 25,000 patient visits a year and only a tiny

percentage of them put some rating and it's probably the extremes undoubtedly but we don't manage it I know that in many community settings that they do I didn't answer your question is there a reliable source of quality I still think at the end it's

going to be relationships and word of mouth and referral I do the same thing you do I you know to see Hannah Watford the allergist I asked my primary care docket sanford who's the best who is the person that knows the most about food related issues well some really entrepreneurial guy or gal or group of guy or gals will put together a website or an app or something that really addresses this problem head on well I think of a very few things more useful than a truly independent way of

understanding the prior patient experience and finding the best person for a particular problem and I think AI can help with this yeah but I think AI and you know human interface anyway somebody out there should do it I'm curious about chiropractic for a lot of people again car not chiropractors let's not talk about the people specifically but chiropractic a lot of people put acupuncture and chiropractic adjacent to one another but my

understanding is that insurance often will cover acupuncture but not chiropractic work maybe I got that backwards or maybe I'm just all out wrong but you know with chiropractic work you're talking about often the attempt to relieve compression of nerves certainly nerves are being manipulated if any part of the body is being manipulated I guess manipulates kind of a word that implies something sinister is happening is being adjusted what are your thoughts about

chiropractors assuming the chiropractor is well trained and responsible can it help pain can it help back pain neck pain whole body pain yeah first of all acupuncturists and chiropractic are two entirely different professions just to just to be clear for people and they sometimes get lumped into a similar category of pain treatments and that may be where you know that comes from just closing out on the acupuncture again just to summarize yes

in some patients in some circumstances I found acupuncture to be useful and it's worth a try CMS center Medicare is now paying for acupuncture for people over the ages 65 Medicare for Medicare patients that's something recent and we were happy to see that I believe that was for back pain that should be fact checked but chiropractic mix data well controlled studies some of some have shown that it can be helpful for low back

pain some have shown it isn't it's it's truly not clear the type of chiropractic that involves the doesn't involve kind of you know the fast high velocity manipulation as a physician I have some concerns about that particularly around the neck I've taken care of patients that have had vertebral artery dissections from that rapid wrenching what is a vertebral artery dissection one of the the main arteries that goes from the body to the brain

and the back portion of it is called the vertebral artery and when you do these high velocity manipulations there is a risk albeit small of having a dissection or an embolus thrown off and I've had so it's like a stroke it's like it is a yeah it's like a stroke but there's a lot of approaches that can be done that in some patients have shown some some benefit I think the key with a number of these therapies

and I don't want to single out acupuncture or chiropractic if you go to them ask yourself am I getting durable benefit meaning everybody feels good after a massage right but a couple few hours later it's kind of worn off it's a nice experience in the moment for most people

if you're finding that for acupuncture chiropractic or anything for that matter you know ask yourself is it really providing you durable benefit that is worth the effort or is it just rapid it feels good in the moment we tend to use that in our clinical practices a threshold you know and we like to see things that last for a longer period of time and in many of these treatments whether it be acupuncture chiropractic we use those as an in-road into more of a functional rehabilitative approach

meaning when you get chronic pain you tend to withdraw you tend to stop exercising you stop moving your muscles atrophy you become deconditioned because of the pain and so we want to use these tools that we've been talking about as a way to get people engaged in activity to correct the underlying biomechanical issues that may be present and so they all need to be appropriately staged and that's what working with a good clinician can help with that

yes certainly in my case any time I've had back pain even when it was very severe provided I wasn't harmed and I was just hurt continuing to move and not becoming sedentary was absolutely the fastest route to recovery and in particular doing certain exercises that were particular to my case what if any is the role for physical therapists in the treatment of chronic pain?

absolutely crucial, absolutely crucial despite being a physician not a physical therapist I've great appreciation respect for what the physical rehabilitative approaches do because at the end of the day we're trying to get people back to and improve quality of life and physical functioning

I mean that is often what people are most looking for control over their pain control over their life yes reduction in pain but more being able to do more things and they are tying in with good physical therapist

occupational therapist people who can do goal setting absolutely critical all of the treatments that I provide typically are meant to help support and increase in physical rehabilitative approaches and so when I do nerve blocks or procedures or give a medication and if we end up reducing some pain

we want to tie that in with more activity and what the physical therapist or great particularly those trained in chronic pain is knowing that difference between hurt and harm they can work with people to know what's safe for them to do to rehabilitate

they can teach them more about body mechanics and help improve endurance and strength they can work around pacing pacing is so critical for people with chronic pain now this isn't just exclusive to the physical therapist the psychologist do pacing I do pacing what is pacing?

here's the problem with chronic pain one of the many problems it waxes and wanes and so what happens is you go out and have a good day you go out like gangbusters and you go do everything that you haven't been able to do for the last week because you've been in pain and then you pay the price and when you pay the price you're back in bed or you're on the couch and you're not moving and what happens is you go into this roller coaster of activity and no activity at all

and what happens is it entrains in our brain it's a classic negative reinforcement model this is classic psychology and so then people become fearful of more movement and as a consequence they get more and more disuse atrophy and then more disability

so the key what do you do about that? the key is you set small goals baby steps if you can walk comfortably for a block right now great walk that block tomorrow maybe walk a block plus an extra 50 feet and maybe the next day another 50 feet no more no more if you're having a great day don't go do five blocks you're training for a marathon you're training for the long win now what's going to happen along the way is that you're going to have good days and you're going to have bad days

on the good days don't go out and exceed it set a threshold time it on your watch set a distance on the bad days recognize we all have bad days everybody has bad days and you know you may need some rest during those bad days but then the next day get up and restart you know where you were and that's a type of thing a physical therapist good pain psychologist good physician can help you with and tying that in by the way with these other therapies

very interesting I've never heard of pacing but it makes total sense and I can see how people could really hinder their own progress without that basic understanding which thanks to you we know have and it's something that hopefully all these therapeutic modalities keep in mind I mean I don't know whether not the acupuncturists are talking to the physical therapists are talking to the physician

but I guess this is the reason for referrals right why somebody has a primary care doc then and it radiates down to the rest is that why in an ideal utopian world that's exactly it I mean outside of a comprehensive pain centers that have all of the stuff co located you are dependent on a doc to play quarterback and bring all those referrals together it's incredibly challenging for a primary care doc to do that with the limited amount of time they're given to see a person

this is where we're trying to use technology to help better with that integration and I do think there's hope for the future we'll have better ways of managing that and handle it what is your view on non prescription compounds so-called supplements or nutraceuticals for the treatment of pain fascinating topic this country's rather unique in having you know a wide slew of over the counter agents that are actually prescription in Europe and in other countries

and there are over the counter agents that have been shown to be effective for a number of pain conditions so for neuropathic pain acetyl alcharnitine is one of them acetyl alcharnitine is thought to work on mitochondrial metabolism and in prove mitochondrial health and it's been used I believe as a anti-aging and maybe even a cognitive enhancement agent you need and it's been studied out of an Australian study I think it was called the Sydney Trials actually

and what they found it's one of the few over the counter agents that actually had disease modifying properties meaning they studied this in diabetic neuropathy the clinical endpoint was not pain reduction the clinical endpoint was nerve conduction velocity changes and that's how we monitor nerve health is

and a normal nerve they move nerve both pulses move at a certain rate and when they're injured from diabetes they you know it's much slower and you lose signal this actually improved nerve health you can buy those at a vitamin shop order them online alpha-lipoc acid is another one alpha-lipoc acid

at least two mechanisms one is it's a free radical scavenger and second that's been more recent is it is a T type calcium channel modulator and calcium channels are in our nerves and it turns those down and it can have some benefit for neuropathic pain people have taken alpha-lipoc acid for a general sense of well-being and it is generally well tolerated it can cause a little bit of stomach upset

I will tell you I took this one myself for a while and this is you know again just an N of 1 what I found though is you have T type calcium channels in your heart and I do hit a high intensity interval training and I was finding I couldn't get my heart rate over 150 so I stopped it

that's not an adverse event that's just an annoyance but that's useful vitamin C so if you're going in for surgery and it's maybe a nerve related surgery that you're going to have they found vitamin C prophylactically can reduce the likelihood of having certain nerve pain conditions after surgery

the omega-3s have been found to be a beneficial around chronic pain more recently the data here is on smaller numbers creatine which I imagine you probably talked about it at some length but creatine has shown in small pilot studies some benefit in fibromyalgia and some other types of conditions

so there are a number of these substances that are backed up beyond the you know the anachdata that we joke about the anachdotal there's actually good randomized control trials and this is something that people can easily take advantage of

just be mindful that just because it's natural just because it's over the counter doesn't equate with 100% safety meaning get educated about the side effects in the adverse events get educated about the drug drug interactions the agent agent interactions and for instance there are these over the counter agents some of which you want to be careful of and not taking when you're going into surgery because they can be a platelet inhibitors and they can cause you to bleed more

isn't vitamin C one such compass substance that causes excessive bleeding or some people report that high levels of omega-3s can increase the can reduce the viscosity of the blood meaning you bleed easier the omega-3s of fish oils yes absolutely the vitamin C I'm not familiar honestly with as a blood thing agent maybe I'm misinformed there

maybe I'm just forgetting it but that's that's one I don't usually think of is a blunt thinner someone will put in the show notes comments one way or the other corrected I but there's a number of these over the counter agents that are that are available the vast majority are innocuous that I've mentioned that I've mentioned the occupies meaning they don't cause harm at the at reasonable doses

but they can have positive effects well perfectly stated yeah well thank you for sharing that list I think as you mentioned many compounds that are only available prescription overseas are indeed available over the counter in the US in this area of nutraceuticals like supplements is still an area that's actively debated depending on people's

stance but it's refreshing to hear somebody who's you know I formally trained physician and scientists who embraces so many different approaches in the treatment of pain along those lines perhaps you be willing to talk about the psychological treatments that can be effective for pain again absolutely critical in the management of people with you know wide range of pain problems and recall what we talked about is you know this is no

exception these are the signals coming up to the brain once it hits the brain you know we're dealing with everything that person is live through and also is currently experiencing meaning there are levels of anxiety depression how they cope with pain in the past how they cope with it now

early life experiences a paper that just came out in a jamma literally in the last few days where they did a meta analysis of brain imaging studies on people with early adverse life events and what they found is abnormalities and emotional processing emotional functioning and people who have these giving strong evidence that what happens to early in life impacts us as adults and stays with us it changes our wiring now

this is where in part pain psychologist behavioral therapist can come in they can help with some of the maladaptive coping the thought processes involved with pain they can help teach skills so for the vast majority of pain psychology this is not your typical psychoanalytic lying on a couch you know talking about you know whatever this is about teaching people skills

incredibly helpful does it eliminate pain few of the things that we do actually eliminate pain what we're trying to do is chip away you know a little bit with this medication a little bit with this proceed sometimes this procedure that with psychology we're trying to hit all of these pathways in aggregate to make a real difference

the pain psychologist use classically techniques like cognitive behavioral therapy which involves often recognizing these unhelpful thoughts and patterns that we all get into around pain and even life

to interrupting those thoughts to helping people again with goal setting and pacing to teach people relaxation techniques through deep breathing things like biofeedback and silicon valley where I practice the engineers love the biofeedback I'm an engineer by formal trainings I get it but it's that closed loop feedback because remember the the brain is controlling the periphery

and control in the sympathetic nervous system and when we're in pain our sympathetic nervous system gets wrapped up when the sympathetic nervous system gets wrapped up blood vessels constrict heart rate goes up our muscles get tense

and we need sometimes ways of learning how to calm down that sympathetic nervous system cognitive behavioral therapy mindfulness based rest reduction acceptance and commitment therapy or some of the tools that they use my partner Beth has developed a brief intervention called empowered relief yes I'm biased

we've studied this in an NIH funded study and it's a way of getting eight weeks of cognitive behavioral therapy in two hours well not meant to replace CBT but as an additional tool and you're going to see as time goes by more and more of these tools come out in the beauty of them is

they're going to be much easier to disseminate broadly to the public then for instance a pill you know I can't we can't just go put into FedEx or the US post office you start sending up pills to everybody but we can develop treatments online that can teach people skills and really help is that the plan for this abbreviated but equally effective cognitive behavioral therapy

yes now you're getting into kind of my best in my life mission so you know I've spent the last 12 years building a digital platform health platform that we've integrated into clinics and capture high quality data covering all aspects of people's physical psychological social functioning and the reason for that is to address a critical need that we have on better quality data about people the data and the information that we have on people with pain and many health conditions is terrible

and so I created this platform to be able to capture high quality data put it to use use AI in the background for prediction and now Beth has created these brief interventions which we're integrating and the notion is to make that widely available for free we're giving it all away I said this is a life mission we both have been blessed to be at Stanford where we have everything

but you know you go just 30 miles 40 miles outside of the Bay Area and you're in a health care desert and I don't say that disparaging to any docs working out there but it's different there's only a handful of large academic centers and large practices in the country when you get outside those and those catchmen areas people struggle with how to get good quality care you asked that question earlier how do you find good quality care

and so we're working to make that that available to everybody fantastic I was going to ask you as a final question what is your if you had one wish for the future of pain medicine and the treatment of pain what that would be before you answer that I'll just add an answer that you already gave which is it sounds like the implementation of this incredible set of tools and database that you've collaborated with

Dr. Darnell but Darnell to develop is at least one of them so now that that that answer was given by me then you can it frees up the opportunity for you to give another answer what is the if you had one wish for the field of pain medicine going forward what would that wish be

yeah so a few years ago I co led for the country the development of the national pain strategy and this was sponsored by the NIH and Health and Human Services and I co led this with Dr. Linda Porter from the NIH we brought together 80 national experts in pain research,

pain clinical care, pain policy and people with lived experience with pain we put together a strategic plan for the country on how to enact a cultural transformation and change the way we assess care for people with pain how we educate professionals how we communicate with the public

my wish would be for full implementation of the national pain strategy it unfortunately took back seat when it was released the same time with the CDC opioid guidelines and the opioid guidelines sucked all the oxygen out of the room

but the the strategic plan it was well thought out it's the one that we have for our country it's non controversial nonpartisan it is motherhood and apple pie and it's if we just actually implement what we put forward it'll make a huge difference in the lives of people living with pain

is there anything that people listening to this podcast can do to try and move the implementation of that initiative up are there congress people to call I mean this is how I learned in junior high school in high school what little I attended and by the way go to school folks I had to catch up a lot but I do remember them saying that you know this was a democracy is a democracy and that those phone calls and letters can often matter for what gets you know sent up the flagpole and what ultimately gets a

proved and implemented beautifully stated you're you're absolutely right and in fact the night is for the national pain strategy originally came about through a number of concerned citizens with pain doing that very thing and lobbying what became a bipartisan you don't hear that much anymore by partisan effort to put forward a national pain care act that got put into the affordable care act that called for the development of an institute of medicine report on pain that led to the national

pain strategy all starting with concerned people making those phone calls and writing those letters so that means calling your congressman and congresswoman leaving messages I hear this works I mean I know people they're doing this for other initiatives and one call to calls doesn't make much of a difference but that if people are saying you know this is important to them that people didn't power eventually start taking action

the the legislators they listen and and in part again part of this life mission both develop this platform I've created a nonprofit called pain USA and its main mission is to help advance the implementation of the national pain strategy and baked within that is this platform also to use high quality data to better inform the care of patients of people with pain and to deliver high quality

treatments because we do know also that people listen to data and we need good quality data to influence those messages but please yes make those calls write those letters it does work well Sean doctor Mackie thank you so much for everything that you're doing you took us on quite a tour in terms of depth and breadth of the thing that we think of and unfortunately in some

cases experience as pain although we also learned it's highly adaptive in some cases can protect us does indeed protect us thank you for taking us on that tour of the biology the psychology the various treatments the context in which all of this exists we touched into some somewhat controversial areas but I really appreciate the thoroughness and the nuance and the sensitivity with which you touch into all of those issues

and just on behalf of myself and everybody listening I just really want to thank you you've contributed a great deal today to the public education of what pain is what it isn't and how to treat it so thank you ever so much thank you doctor here remain I appreciate the opportunity to come on and spend some time and you're giving a platform to help educate and inform people out there I got to tell you nobody does it

better you you've been absolutely amazing and thank you again thank you it's a labor of love and I appreciate the kind words come back again thank you thank you for joining me today for my discussion all about pain and ways to control

pain with doctor Sean Mackie I hope you found the conversation to be as interesting and as informative as I did to learn more about and explore some of the resources that doctor Mackie mentioned during today's episode please refer to the show note captions if you're

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