Tools to Reduce & Manage Pain | Dr. Sean Mackey

welcome to the huberman Lab podcast where we discuss science and science-based tools for everyday [Music] life I'm Andrew huberman and I'm a professor of neurobiology and Opthalmology at Stanford School of Medicine my guest today is Dr Shawn Mackey Dr Shawn 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 Macky 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 this thing that we call pain indeed we discussed 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 discussed the intimate relationship between temperature that is heat and cold and pain 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 Mai makes very clear which specific clinical circumstances weren't 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 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 it is however part of my desire and effort to bring zero cost to Consumer information about science and science related tools to the general public in keeping with that theme I'd like to thank the sponsors of today's podcast our first sponsor is Aeropress Aeropress is similar to a French press for making coffee but is in fact a much better way to make coffee the Aero press was developed by Allan Adler who's an engineer at Stanford I knew of Allen because I used to see him in my hometown of paloalto test flying the so-called aobi frisbee so he was sort of famous around my town as This brilliant engineer that would create these unusual products so when I heard about the AO press I got it I tried it and I absolutely loved it 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Professional Therapy with a licensed therapist carried out online I've been going to therapy for well over 30 years initially I didn't have a choice it was a condition of being allowed to stay in school but pretty soon I realize that therapy is extremely valuable in fact I consider doing regular therapy just as important as getting regular exercise including cardiovascular exercise and resistance training which of course I also do every week the reason I know therapy is so valuable is that if you can find a therapist with whom you can develop a really good rapport you not only get terrific support for some of the challenges in your life but you also can derive tremendous insights from that therapy insights that can allow you to better not just your emotional life and your relationship life but of of course also the relationship to yourself and to your professional life to all sorts of career goals in fact IC therapy is one of the key components for meshing together all aspects of one's life and being able to really direct one's focus and attention toward what really matters with better help they make it extremely easy to find a therapist that's ideal for your needs your life circumstances and that can match to to your schedule in a very convenient way if you'd like to try betterhelp go to betterhelp.com huberman to get 10% off your first month again that's betterhelp.com huberman and now for my discussion with Dr Shawn Mackey Dr Mackey 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 you know 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 a 100 million Americans and at last count about a half a trillion dollars a year in medical expenses uh 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 uh in society there's a lot of misunderstanding about what pain is and I think uh hopefully we can build that foundation and then layer on some some useful treatments and useful 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 I'll have like you know like 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 it's a um it's as if something's nagging from the inside and so that raises the 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 uh in your body is not pain what's going on is that uh there are sensors in our skin our soft tissue our deep tissues called noors and these noors are sensing elements and they sense different types of stimuli they can sense temperature uh heat cold they sense pressure they can sense pH changes due to for instance inflammation that may occur from uh any something going on in your neck or your shoulder those sens signals up nerve fiber types and the two that we we refer to are a Delta and C fibers one transmits very fast it's responsible that you know sharp jolt of pain that goes to your brain when we uh you know 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 lie up and down our uh from our head down to our our back and they're 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 in your neck is not pain that's no susception those are electrical signals electrochemical impulses being transmitted and that is to be distinguished from what becomes the subjective experience of pain that you have and why it's critical is that our brain serves so many functions of emotions cognitions uh 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 note because we are frequently left with this notion of this onetoone concordance between the stimulus and the experience of pain you know Renee Dart that French uh philosopher I think 17th century um 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 onetoone 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 uh 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're 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 it 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 you know bone as a swollen ankle we see that and then we like okay well you've got pain you got legitimate pain whereas this invisible disease of chronic pain frequently you don't have something out ly 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 NOS acceptors are in the body and everywhere in the body and on the surface of the body to be able to detect certain kinds of stimula 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 ask this is that for you know 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 experiments support that idea but there's a major difference between people experiencing the same thing differently according to like a mysterious mechanism in the brain as opposed to like an in the brain then we can look and say like hey like like that's where pain is uh represented that's where all these these inputs from the body are put together to create this thing that we call pain um like is there an area of the the thalamus a structure in the middle of the brain that takes incoming sensory information that we could say oh that's the pain pathway is there a part of our neocortex the outer shell of the the brain more or less um 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 and you know cuz we'd all love if 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 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 EXP 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 uh the insular cortex the singulate cortex the amydala a number of these brain regions that all subserve 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 done starting gosh well over a dozen years ago and uh others have been building on and what we're finding is that there does seem to be this this conserved region set of uh distributed regions that do represent the experience of pain so when somebody takes a so-called painkiller let let's take a uh typical over-the-counter painkiller like a ibuprofen or camenen to uh lessen pain of some kind yeah where is 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 nids non-steroidal anti-inflammatory drugs like ibuprofen like Naperson they're actually not analgesics they're not technically pain killers so an analgesic is the descriptor for a quote unquote painkiller yeah there that would be more correct like an opioid would be would fit into that category the N heads are anti-inflammatory drugs they're also 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 um what the ends heads 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 um in a normal situation you know 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 do that at home please yeah or any or anywhere for that matter or anywhere for that matter but you're just describing pain and the local inflammation response and the hyper Alesia 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 I mean you know anytime I've done um you know 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 or had painkillers postoperatively although I don't like taking them I don't like the way they make my brain feel and so uh 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 so it raises a whole set of sort 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 adapt 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 uh whether or not it's a good or bad idea to blunt that pain yeah I think the the the threshold is when it's impacting your quality of life and your ability to take care of activities of daily living engage with family friends go to work and that that serves kind of a your your threshold for you know whether it's reasonable to to take a medication or not it's a lot of controversy in the space right now it used to be we all recommended just Neds for any type of acute injury I is non-steroid anti-inflammatory drugs could could we maybe list off a few of those so I mentioned ibuprofen aceto Menin so sometimes referred to as you know the classic Advil Tylenol we won't throw out name brands there but what are some others nioxin nioxin is another one toor doll or keto rollac is another one the two over-the-counter nids the prototypical over-the-counter ones are ibuprofen and naisin those are the ones you can buy overthe counter without a prescription uh 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 IBU uh Tylenol or acetam menen but taking we say centrally you mean Brain Brain Brain thank you thank you and uh is aspirin considered an insat I don't believe as would fit into that category of basically a Cox cyc oxygenase inhibitor this is one of the the chemical mediators that gets released during injury and that chemical uh substance has a tendency to wind up or amplify the no acceptors 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 sens ization because it's out in the periphery we're winding up or amplifying the response uh aspirin Neds in general will reduce that inflammation they're anti- um hyperalgesic and uh pardon again the jargony terms that we use but hope along as we go but but you know 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 you know we get into those debates right in professional sports where you know they they send the person back out on the field with a broken bone you know having given them an ejection or something I'm I'm hoping that does doesn't go on anymore but uh I'm sure it goes on okay yeah well 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 uh peptides that can certainly accelerate healing people are traveling out of country get stem cell injections all with all with uh very few randomized control trials but I assure you that um Courtside and in the locker room mainly in the locker room their corticosteroid injections their painkiller injections I mean it's it's not play at any expense but it's not far from that okay yeah yeah well you know when you're you're making millions of dollars a year and I I get the being back on the field but for the rest of us mere mortals um 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 IDS and um this uh Cox Cox is one of it's a is it in the family of prostagland can we talk about prostaglandins because I think there are a lot of people nowadays we hear about inflammation yeah you know inflammation's bad inflammation's 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 uh responds to a physical or chemical injury and and creates inflammation and that as you said that inflammation sensitizes an area makes it literally more sensitive and then we introduce these drugs that um 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 asleep at night and stay asleep or perhaps go back to sleep after you've woken up in the middle of the night then will 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 it's 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 how 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 Neds the IU preference and naisin 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 inset helps you sleep and helps you uh engage with what you need to do take it at the lowest dose that you can get away with I've heard before that NAD should be taken no more than once every six hours people will alternate different types of inss 3 hours that's usually to try and reduce fever another situation where an Adaptive response fever you know people go out of their way to block it right to prevent the brain from cooking but again opens up the same set of issues and so I'm wondering if somebody has some pain that makes you know moving about frustrating and it's and it's difficult but you know they can sleep at night reasonably well maybe not 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 nids this class of medication reducing pain than we have data uh 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 nids 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 n heads like we mentioned ibuprofen and aprin huge individual variability around those so personally ibuprofen is not very effective for me napasin 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 halflife Naperson 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 um 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 and 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 um 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 is my logic flawed and if it is feel free to tell me no for 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 antiplatelet agent it helps you know here 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 with the data is defining age ranges when they say baby aspirin yes baby aspirin no and so 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 doses 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 naason so um different mechanisms of action at different doses I'd like to take a brief moment and thank one of our sponsors and that's ag1 ag1 is a vitamin mineral probiotic drink that also contains adaptogens I started taking ag1 way back in 2012 the reason I started taking it and the reason I still take it every day is that it ensures that I meet all of my quotas for vitamins and minerals and it ensures that I get enough Prebiotic and probiotic to support gut health now gut health is something that over the last 10 years we realized is not just important for the health of our gut but also for our immune system and for the production of neurotransmitters and neurom modulators things like dop and serotonin in other words gut health is critical for proper brain functioning now of course I strive to consume healthy Whole Foods for the majority of my nutritional intake every single day but there are a number of things in ag1 including specific micronutrients that are hard to get from Whole Foods or at least in sufficient quantities so ag1 allows me to get the vitamins and minerals that I need probiotics prebiotics the adaptogens and critical micronutrients so anytime somebody asks me if they were to take Just One supplement what that supplement should be I tell them ag1 because ag1 supports so many different systems within the body that are involved in mental health physical health and performance to try ag1 go to drink a1.com huberman and you'll get a year supply of vitamin D3 K2 and five free travel packs of ag1 again that's drink a1.com huberman I promise we won't go into every medication in such detail but but these are the most commonly used over-the-counter treatments for pain as far as I know um are there any um issues with you know people who drink caffeine who then are taking these drugs are like what are some of the uh the uh interactions that these things can have as far as I know caffeine actually touches into the prostag glandon pathway doesn't it yes and that's where you know caffeine can be used effectively for headaches for migraines and uh it can help potentiate the analgesic response uh some people get uh stomach irritation though with caffeine so just again mind that you take an end said with uh a lot of coffee uh have some food in your stomach you know you brought up earlier acetam menen or Tylenol Tylenol doesn't have the same side effect or adverse event profile that the Nets do so Tylenol is safe on the stomach um where you need to be careful about Tylenol is not to exceed 4,000 milligrams or four gram per day in divided doses so two extra strength Tylenol done four times a day for many people is safe some say 2 gram some say four Gams the key here is around your liver so if 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 um 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 celic coxib that is uh 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 napasin and the ibuprofen so talk with your clinician you know to 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 red the GI issues associated with the insets very useful information thank you here we're talking about chemical interventions to the pain process what about mechanical interventions so I was taught in my basic Neuroscience about I think it's melzack and walls gate theory of pain do I have this right where uh you know we all have this instinctual response animals have it too right if they uh you bump your knee or your toe that you grab it and you rub it and that that rubbing response is actually contributing to the activation of a neural pathway that does indeed reduce the pain through a legitimate neural inhibition and tell me if this is still considered correct and then I'll let you um uh elaborate on it but I think that is an opportunity for us to also talk more generally or for you to educate us more generally on the the mechanistic interventions for pain like um maybe massage above or below the sight of pain maybe acupuncture um so again there will be chemical consequences of any mechanical intervention right as we know because that's the language of the nervous system electricity and chemicals but as opposed to taking a drug you could imagine using manual um stimulation or rubbing around it or or perhaps we can also talk about heat and cold so could we explore that space a bit absolutely and first you're right so uh in your first part uh p uh Patrick Wall Ron mzac luminaries in the field of pain back in the 60s uh defined the gate control theory of pain and one of the things to build on the story that we talked about with no receptors going to the spinal C 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 they 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're you hit your thumb with a hammer you um uh you B bang something on an extremity um what is the first thing you do when you hit your thumb with a hammer uh some people rub it I yell some people swear and it turns out there are studies that show that swearing works really swearing reduces pain better than uh than using non-explicit 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 we're absolving ourselves of any responsibility right so uh rubbing uh shaking is another one which basically is activating those touch fibers oh it is put I do that yeah everybody does that everybody does that running it underwater which you know it doesn't matter whether you know in this case it's hot or it's cold water it's the running of the water underneath it and what is it doing we we all think it's reducing the stimulus out here and it is not at in the periphery in 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 this is the cheapest free version of what we refer to as neuromodulation that's ever been discovered um 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 kiss the kids sometimes they want to kiss you know or a romantic partner will sometimes like injure themselves I guess it depends on the nature of the relationship and they'll say like can you kiss it of course you know then you kiss it and then like they feel better is that purely psychological well okay I think an important point to 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 I I I have to be careful with with the the wording that I use that's my fault but but it's 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 up wall and melac sometime later uh there was the introduction of a device to take advantage of this called the tens device and tens is an acronym transcutaneous electrical neuros stimulation and what the tenens device is doing and there's many versions of it now but there are those black electrodes you put over 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 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 the body wide and the the circuit wide the nervous systemwide nature of this thing that we call pain right it's 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 then it's you know 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 right if you're um you know 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 um anecdote but um 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 uh we've never done the experiment I think I see them stub their toe and they're like ah and then you know 10 minutes later they're still feeling the ache so whose pain threshold is higher that's a 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 I just sent you about 10 questions so forgive me yeah um so what is pain threshold yeah no it it's a 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 but no no no you're let me answer your get to your pain threshold so the pain threshold is uh 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 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 ad Delta 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 consci perception yet that we did that and then it's a moment later when the sea fibers are getting up to the brain and the other a Delta fibers are converging into conscious areas of brain that we're like oh wow that stove is really hot and the ca 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 you 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 the pain thresholds you asked one of the other questions is do men and women have different pain um thresholds uh the answer the short answer is yes this has been established and I want to be careful here with saying a couple things one is in general uh men have uh higher pain thresholds to things like heat stimulus than women and what 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 uh 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 sense sensitivity to that heat stimulus and so we then go into the press and we say uh men are tougher than women that's a terrible statement right because the tough part is a subjective label right I mean it it it gets to a whole bunch of different issues around the Adaptive role of pain right I mean I mean one could argue that if your threshold for pain is lower that your it serves a more adaptive function right fewer injuries Etc 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 um 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 but there's plenty of women on that curve that have much greater heat uh thresholds than men Doh 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 distill down to so so it's not unlike height for that matter there're 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 uh 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 53 5'4 the average height of a man 5'9 510 this is Imagining the average height being you know 5'6 for a woman and 5'8 for a man you know it's not a huge difference there's a lot of things that play into changes and 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 we're um transducing we're transmitting you know in 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 um 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 okay yeah it does um your early life experiences with this so have you had traumatic experiences in the past that alters brain circuits can I interject a question yeah if one was told just suck it up a lot or if one whimpered or cursed when they uh hurt themselves if they were told um you know don't be a wuss don't be a wimp 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 wuss 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'd say wow they like pretty tough adult right because they're not um crying out in pain so do we have any are there any experiments that have explored that I don't know you're getting in this is a good point getting into um uh 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 N of one with one son um he's done great I happen to know him very well he's a he's he's what you call a great example of Highly successful reproduction so you know it's say what do they say it's better to be lucky than good uh so I'm sure I'm sure there was a lot involved so don't don't discount don't uh don't discard any credit thank you thank you um you know my Approach with Ian was not to say just you know necessarily suck it up but I would uh you know make light of it i' I'd have fun with it and uh I would kind of laugh and I'm like way to go buddy uh and I would find he would often laugh you know so I think a lot of it is the ACC they're taking off the parents you know and again this is this is just my oneof end parent is if they see you freaking out kids going to freak out too um 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 just a very brief anecdote when I was growing up I observed a total of zero children and friends who you know cried out in pain or complained of pain who were told you know um that was an inappropriate response um sometimes I might have heard parents say you know come on 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 what country they were from but they they lived not far from um 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 the lesson about the saw yeah but clearly had no regard for the pain that the that the injury probably caused now I haven't followed up with that kid yeah um I think we can all agree that by today's standards that would be considered um abusive parenting uh or perhaps um 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 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 them 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 and in pain that pain inhibits pain so what I mean by that is when you were you know this guy this kid but or yourself growing up did you ever walk up to your buddy and say you know my 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 and I must have grown up with the same friend oh yeah yeah and and they'd say well now doesn't doesn't your arm feel better and i' be 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 Laars late 70s 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 sight 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 amazing pain inhibits pain it works it also is thought to have some contributions from higher brain centers we call this whole phenomenon lears called this phenomenon diffuse noxious inhibitory control or denck 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 kid's got a painful uh you know 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 he wanted to make him feel worse so he didn't go near the band saw without being more cautious but it probably did reduce the pain a little bit to some extent now where it's key is oh maybe we'll get into it later with chronic pain is in some chronic painful conditions the CPM or the denck doesn't work like fibrom algia being one um so pain inhibits pain uh is another Neuroscience concept related to pain that's rather cool well and I'm sorry I missed your question to could you repeat no you answer the question and and uh expanded on it in a in a completely surprising and far more interesting way than I ever anticipated so thank you I 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 uh 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 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 injury so cold is not as good as heat heat allows for um the uh inclusion and removal of waste products and you know there are all sorts of Just So Stories that people make up some of which might be true I don't know but what do we know about heat and cold as physiological stimula in terms of their ability to ameliorate to help pain because of course if you get things hot enough or you get them cold enough you can create pain with heat or cold but let's assume we're not getting to that level of heat or cold and one is in pain um you know when I was a kid we had a hot water bottle that for times when we were sick with 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 uh reduces inflammation so it reduces some of the release of those inflammatory chemicals we talked about prostaglandins cyto kindes histamines um other chemo kinds all these fancy terms for substances that sensitize the primary Noor 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 receptors that are firing and you put cold it's slowing the number of signals coming up and by definition it's reducing the the the ultimately the pain you're experiencing now Heat heat has an obvious effect of increasing blood flow it's going to help uh relax muscles and get blood into those muscles and that's probably why you were putting that hot water bottle on um and it just darn feels good and so what what do I tell people you know in part I tell people use whichever works best for them um I find there's huge individual variability in whether people like heat or like cold and within reason uh 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 on 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 know 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 it's numb and then you let the blood flow return When you remove the cold pack is that I mean that's a reasonable suggestion okay yeah all right well people I think will appreciate the the um the specifics of that because um you know and of course listeners of this podcast often are interested in whole body deliberate cold immersion you know cold showers ice baths Etc most 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 and it's not too cold um 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 um the answer to your other question about uh 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 at cuz I I'm not up on the literature in that space even in its intersection with pain um it's an intriguing concept uh I have to imagine that it makes sense you would get some habituation uh with that repeated exposure I think one of the the questions that would come up with for instance the cold exposure and I don't know the answer to this but it's I'm sure maybe somebody out there does is is there cross modality um changes in pain thresholds I mean if you expose yourself a lot to cold does it change your heat threshold I don't I would surprise be surprised if it did yeah would or your pressure those are separate parallel Pathways right yeah yeah you know there uh and you know as an aside I hate the cold but I do really well with the heat you know and so does Ian uh you know I think there's something genetic there uh so you know I mentioned earlier around men and women and heat uh 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 uh around that space and you know there's 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 uh heat thresholds uh on college students and and we we experiment a lot on students as as we all know we pay them well um and what they found is that when they're studying guys studying dudes when there was an attractive woman who was delivering the St stimulus the thresholds were higher because the guys did not want to look like a wuss in front of this attractive young woman and that's been pretty well established so the experimenter their gender uh plays a big role in that has the reverse experiment also been done I don't I don't know I don't know interesting um but getting back to your point yes um I think through a number of uh you know cognitive manipulations you can ultimately um over time change those thresholds another one area is ex is movement exercise you know clearly changes uh those thresholds over time you are probably building up um some increased inhibitory tone through that process I'd like to take a quick break and thank our sponsor inside tracker insid tracker is a personalized nutrition platform that analyzes data from your blood and DNA to help you better understand your body and help you reach your health goals now I've long been a believer in getting regular blood work done for the simple reason that many of the factors that impact your immediate and long-term Health can only be analyzed from a quality blood test a major problem with a lot of blood tests out there however is that you get information back about metabolic factors lipids and hormones and so forth but you don't know what to do with that information with inside tracker they make it very easy because they have a personalized platform that allows you to see the levels of all those things metabolic factors lipids hormones Etc but it gives you specific directives that you can follow that relate to nutrition behavioral modifications supplements Etc that can help you bring those numbers into the ranges that are optimal for you if you'd like to try insid tracker you can go to insid tracker.com huberman to get 20% off any of insid tracker plans again that's insid tracker.com huberman one thing I'm fascinated by in the whole mindfulness space yeah uh 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 quote unquote go into the pain so for people who have chronic pain maybe it's in a a small area of the body that experiences chronic pain pain quite often AK 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 so what we call as neuroscientists you and I top down mechanisms for thing 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 some that it's not as bad like somehow there's a and again this becomes very opaque right we don't really know what we're talking about when we when we do these sorts of protocols but those sorts of things are out there in the mindfulness space and I think um I certainly take mindfulness seriously as 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 what are your thoughts on on meeting the pain versus distracting oneself from the pain let's 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 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 um uh go for a walk um 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 singulate cortex um 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 uh significantly and 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 because during the daytime you can read that book you can spend time with friends and family but people with chronic pain that have it 247 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 it works distraction 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 it's 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 Zin 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 uh as well and we're diving deeply into the data so it's this non-judgmental acceptance of you will of the pain sorry mbsr is the acronym for mindfulness based stress reduction mbsr everybody should do mbsr let me be CLE 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 uh it's it's a great skill to learn no side effects takes a little bit of time to learn it and uh 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 p 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 um 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 is serves as a foundation for something called cognitive behavioral therapy the the cool thing about a number of these is that there's actually different neural circuits engaged with these different approaches and um I think the key that we have to f figure out and this is where research is going is which approach works for which person under which circumstance so interesting uh something you said about understanding the pain but not um overinterpreting 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 uh where clearly pain was involved it's like I'm hurt but am I injured that's the first question you know like I've rolled an ankle like oh you know like I'm limping this hurts am I injured meaning am I going to be back at it in an hour tomorrow versus I broken bones and it's you know you know great empathy for anybody that does like when you're injured you feel the snap and you know you're out for a while in some cases um so I think knowing the difference between being hurt and being injured is something that's kind of that key moment and for me it's always been experien as a moment of anxiety after feeling pain especially in a sports here like uh oh like am I am I going to have to take two weeks off or is this just pain so 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 and perhaps also for psychological hurt versus psychological injury I mean that gets to some larger context themes these days of somebody says something it upsets us are we hurt or are we injured right you know 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 the bridge from the body into the mind and so it'd 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 macky's tips for pain management is to understand the distinction between hurt versus harm versus harm MH critical absolutely critical let me allow me to illustrate with um patient I saw won't name names some time ago guy's 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 fibrous thickening of tissue around the nerves that go to your toes and it gets to be like this bundle tissue nerves and it's really painful um it's very painful but it's not causing harm there's no harm there it's really painful so I 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 guy 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 um 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 sometime soon and whether does continued activity worsen the tissue injury or not in my world where I'm caring 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 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 person needs medical attention and that's where the complexity of all this comes in did I answer your question yeah beautifully I think this distinction between hurt versus harmed is so important for people to hear um perhaps you're willing to expand a little bit in terms of the psychological hurt versus harmed I mean I'm not asking you to comment on um societal or generational shifts but you know we'd be avoiding the obvious if we didn't say that in the last um really 10 to 15 years there's been a pretty dramatic shift in terms of how Society at large interprets emotional pain right people 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 right and if anything I'm here to validate the fact that emotional pain is valid like any other pain except it is different because it becomes very hard to point to a specific kind of threshold we're using 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 it did a lot in high school and then you took an x-ray 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 I mean 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 had to heal up but when it comes to psychological pain you know psych has all these thresholds for normal functioning versus abnormal functioning are you sleeping well normal relationship and on and on we don't want to go there because that'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 a 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 it's pain end of end of I think once I get into or you get into this trying to distinguish is this psychological pain or psychogenic pain which was a terrible term or physical pain you end up putting value judgments on people and I don't think it serves us 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 uh an expression of pain that includes a significant amount of anxiety y 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 uh in amplification of pain and worsening pain in poor treatment response is catastrophizing um I try to treat the whole person and not really partial out all this I do at Stanford I you I I built a digital health system that captur 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 um how much their depressive symptoms are anxiety anger anger big issue in pain huge in pain does it 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 is familiar with you um anger out that's my father um loud loud angry boisterous banging you know would quickly turn anything into an angry tiate anger out expressive yelling at the at the news yes yelling at somebody who cuts you off in traffic usually yelling at the man uh because he hated his job um anger in boiling simmering you know self-contained seething that's anger in data seems to support anger and is is worse it's bad so it's not necessarily whether or not it's directed at someone external in both cases anger in and anger out can be directed at someone external it's a question of whether or not it's expressed outwardly or contained inside beautifully stated beautifully stated so we C you know anger depression anxiety iety uh we capture fatigue sleep and so what 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 a 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 subception in 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 um through physical therapy and re rehabilitative approaches on top of it and yes the medications we have now you know we touched Bas on a few earlier but we have over 200 medications available for pain um very few of them FDA approved uh 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 what we do is we borrow or steal from the psychiatrists some of their uh their anti-depressants uh which will frequently work very effectively for pain and work on those pain related circuits in the brain we uh take from the neurologist some of the anti-seizure medications because those medications um while reducing separately seizures for people who don't have seizures they work on ION channels um 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- arhythmia or 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 in the medications getting back to to what you said so just summarizing one I I don't really distinguish uh psychological vers 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 or whole body pain I critical and I think we're learning more and more and more about uh the role of good nutrition of healthy eating anti-inflammatory diets uh avoidance of foods that are triggers um and an incredibly underappreciated area um you know I've had my experiences with chronic pain um I developed uh an abdominal chronic pain problem uh 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 um 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 the 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 um manifested by just severe severe up abdominal pain and um not many other symptoms but you know it put me on this journey where uh severe abdominal pain didn't know why couldn't sleep couldn't sleep went like I'd go months without having a restful night's sleep I thought I was getting early Alzheimer's because I felt like I was getting stupid and um what actually benefited me was of all things the pandemic why because what did we all do we isolated and 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 I'm a little difficult to go out to a restaurant and have dinner but you so no onions no onions and what else shallots chives scallions leaks anything in the onion family you know not alium I'm fine with garlic and you know by healthy eating by identifying something by triggers changed my life and returned to degree of normaly I think the key for people is you know if you have any kind of similar issues identify those triggers sometimes uh 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 Avid even we could call them ranous 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 physan 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 would be difficult impossible I'm sorry I know I interrupt you I just want to 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 in onion family it's pain for two weeks wow 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 uh provide they're done 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 uh that they need protein fats and carbohydrates or what what have you but that by limiting the total number of foods that they eat to like eight or 10 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 too 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 um uh one of our GI pain docs that we have come in the CL Lyn newwin 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 throw out a lot of jargon there basically the short answer is you get an infection and you're gut no longer responds properly to a normal food item and so one explanation maybe I got this infection I was at a Mexican restaurant a lot of onions and I got sensitized through that infection now subsequently to onions you know I saw a Stanford uh allergist Hannah Watford who's awesome by the way and uh after I had this I think figured out and I went in and I'm like well you know Dr Watford 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 said like this isn't unusual she like no I see this thing all the time and this thing meaning sensitivity sensitivity 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 uh as we go forward how interesting well um this is not a time to PL the philanthropic arm of our premium podcast but uh I'm very involved in science philanthropy this sounds like an area to De devote some funding to to explore how foods are impacting the local and systemic pain response yeah I 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 is you can go make friends yeah Justin sonenberg who's been a guest on this podcast is one of the world experts on the gut microbiome we have a few others too so 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 um let's talk about pain inside the body because we talked about NOS acceptors on the surface of the body and the pain that most people uh immediately think of when you have a discussion about pain is you know pain on the surface or a broken bone or maybe hip pain or knee pain or back pain but what about pain that resides deeper in the viscera you know a gut pain um irritable bowel syndrome these things are I'm learning are far more uh common than um than I knew I'm fortunate that um if I have a stomach ache or a headache it means something's wrong I rarely get those I sometimes been called that you don't have a stomach of Steel not because it's hard from the outside um 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 uh a lot of which is sematic Pain by the way I'll say as an aside I used to have a gut of Steel also I could Chomp 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 uh that's also something people have to come to grips with um but getting back to visceral pain so the thing about somatic pain that's another term now somatic meaning the so the the the extremity that you were alluding to is the no acceptors there uh very precisely localize where the stimulus the painful stimulus is coming from when you hit your thumb with a hammer you know exactly where that pain occurred with the visceral pain what you have are very defuse what we refer to as receptive Fields think about you last time you had a stomach ache it's not that you put your thumb right here what you said is kind of hurts like this your whole stomach whole stomach it's because those receptive fields are very large they're broad they're 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 AIDS 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 viscera meaning the the lungs the abdomen the pelvis they all head into the spinal cord too 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 too 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 that these signals that are being driven heavily from the pelvis are coming in and connecting with the same regions from the back and the convergence of that is now being perceived as pain in both and we we're seeing that more and more in the research this viscerosomatic convergence people have pain in their pelvis and then also over their abdomen um classic one that uh we're aware of we see this in the TV the movies and unfortunately real life are heart attacks so the the visceral fibers that subserve the heart typically the first through the fourth thoracic region well those converge um in the spinal cord in similar regions that subserve sensation under the arm and appear That's why people often say they've got pain with a heart attack radiating down into their arm the left arm typically the left arm the heart is on the left side exactly um 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 man my shoulder's really hurting me Doc and what we do is we first check to see you know could something have happened during an 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 that's so fascinating about pain it seems like a good point to bring up referenced pain um or is what you're describing an example of referenced pain so my understanding of referenced pain is that you know like for instance I I've got a slight bulge at I think like my lumbar 34 disc or something I had a whole body scan recently just a um an exploration scan because I had the opportunity not not anything serious fortunately and there's a slightly bulg disc there and every once in a while if I do certain movements um 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 SC sciatica back pocket wallet induced sciatica um but what I eventually realized is that well it's this dis buul it just so happens that the nerves that emit from that that region um they Branch out to a bunch of different areas and so you think the pain is in your leg but the the issue is someplace else or um and occasionally indeed I feel the pain elsewhere in my body as well it's sort of like a like a matching of regions for pain that seem unrelated is that a way to think about reference pain perfectly the 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 um referred pain um what you're describing is the fact that pain doesn't have to start with an injury or a 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 pain so that's another distinction you brought up uh nicely good good segue into there's thought to be um 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 likee burning it can frequently uh when there's a damage to a nerve or damage to certain regions of the brain be incredibly challenging to treat by the way the good news is with that uh light disc bulge is the vast majority of time the discs reabsorb yeah I have to be careful to not do too much um spinal uh flexion like sit-ups and stuff I thought that that would help but that actually doesn't strengthen the back it was actually a asymmetry between the abdominal muscles and the lower back muscles so 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 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 tooo 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 and 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 the pain goes away does that surprise you as an expert in pain not at all not at all what you're you know simp simplistically referring to is 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 uh controls our sympathetic nervous system and parasympathetic nervous system the sympathetic being the fight andlight response it controls the tone of uh cortisol that's being released and we all know that in acute situations rapid increases of cortisol and um noradrenaline is keeps us away from the Lions and the Tigers and the bears oh my but in a chronic situation and uh Robert spolski as you know it's 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 um some of those targets are interesting um there's a lot of memory associated with pain this is where early life events occur and those early life events and injuries can sensitize us to Future vulnerability so I was in a car act bad car accident when I was 16 uh 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 uh 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 uh 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 uh 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 uh how we experience life yeah yeah I think there's several cool things about that study that I love to share one is how it all came about so um you know us Neuroscience Geeks often go to the society for Neuroscience as an annual meeting and I was hanging out in a sharing a room with art Aaron who studies passionate love and he and his wife study passionate love and we were having a glass or two of wine and I'm asking art have you ever you know have you ever studied pain he's like no I study love and he's like have you ever studied love no I study pain has anybody ever studied the intersection another glass of wine no let's do it so we came back to Stanford and there was a young postto Jared younger who's now a professor at University of Alabama and I said Jared we're either going to fall flat in 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 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 I mean it's that yearning uh I don't know that's it's can be a pleasant experience but addictions you know for the people who are using the substance can find it you know in that early phase very pleasant but it 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 he 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 uh clothed and we caus them pain in the scanner and and and we paid them afterwards um we needed a control condition for this because thinking about your beloved is very uh attentionally demanding remember we talked about attentional distraction earlier so we gave people what's called a word generation task very simply um can you think about every sport that doesn't involve a ball okay uh frisbee hockey boxing boxing okay that's attentionally 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 intentional distraction task so we flash people pick pictures of their beloved cause pain flash people of their acquaintance cause pain and then distraction okay what did we find love works great love works great it was a wonderful analgesic it 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 psychologists 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 to figure out 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 uh I wanted to use this as a screening tool for our resident applicants because uh I I I want them focusing on patience not their beloved and that is by the way a joke that bad joke but but 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 um yeah you might want to know if they are in a new romantic relationship yeah so the the the other I thought the other uh cool thing about this study was attention worked also but attention and love worked on different C 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 as these reward-based circuits the nucleus accumbens uh the amydala um one of the the descending uh brain stem regions called the substantia which is coming down from the brain through that area to the spinal cord to inhibit pain so classic addiction Pathways classic and so the key again message for people is um different what we would think of as psychological approaches engaging different brain circuits to reduce pain I'll leave you with one last uh side note that we didn't publish on and that is uh Jered went back a year later and we assessed the student strength of their relationship if assuming it was still ongoing and he found that there was a rather High correlation between the love induced analgesia and brain activity in the kodate nucleus and in the insular with the strength of their relationship a year later it was so we had a brain scan that was a predictor of future um strength of a relationship could you tell us the direction of those results so if a new romantic partner ship is uh 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 um understand and you know Andrew we always have to put these caveats unpublished non-peer reviewed it was a fun post ha data analysis that I'm not sure if anybody's ever you know run with those kind of things no but we can explore it in a in a playful way now and people can do with it what they will it does sort of speak to something important though um assuming that result would hold up if the same experiment were done and you know 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 set in motion a certain number of things that create cre stability in that relationship which on the face of it um makes sense but we've also all heard it the opposite way of well as well which is you know um Fools Rush In or that uh things that start fast end fast or things like that but here you're talking about um the early phase of passion serving this interesting role in terms of analgesia uh alleviating pain but also predicting some stability of the relationship over time it's kind of interesting it's fascinating to talk about uh you know I feel like I have to put that cavy that not generalized 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 um I find the um 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 would like to talk about that and then I'd like to also talk about some of the um things that are adjacent to the prescription opioids things like katom 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 yeah so we all have these endogenous and keyins and endorphins that um act as painkillers they are uh analgesics they are natural substances in all of us that get expressed uh there is a certain endogenous tone to these that some have uh done research on here again Jared did research on this and Steven Brule and others on showing that higher endogenous opio levels May um you know lead to less emotional reactivity for instance um thank God we you know we have endogenous opioids or you know we just couldn't handle it um what chemists have figured out is how to you know bring in exogenous opioids and morphine was the prototypical one uh from the from the poppy and since then medicinal chemists have built on variations of morphine and created other compounds some again variations on morphine some are purely synthetic like the oxycodone could I ask a question because I'm fascinated by the history of these things how did or when and 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 that morphine thousands of years ago okay so poppies have been used for a very long time long long time these things have been around um so this is uh 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 you know you have to understand the speaker my in this case me my you know one's position on this um my usual Mantra is I am not pro- opioid I am not antiopioid 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 relieve suffering particularly in situations um 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 Frontline or first line agent um typically much later down if they have failed other therapies you cannot approach the challenge of opioids uh without appreciating the Deep complexity that we're faced with particularly now in society with all of the the litigation ongoing and all the the money involved um 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 overprescribed that people are given opioid drugs as a Frontline treatment perhaps more than they should that the addictive component which I understand is very real that the potential for addiction is very real um as well as the potential for um cross interactions with other things like alcohol um and perhaps even other illicit drugs you know street drugs perhaps if like if people can't fill their prescriptions um and tolerance to the opioids creating issues where people then need more of them they're doing I have a not close family member but a a you know distant family member who had his entire life arranged beautifully he was a practicing lawyer with a beautiful wife and family had a back injury uh was prescribed Oxycontin it it helped 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 right so and I think there are many examples of that that we hear about and those are very Salient and very disturbing very saddening so I think that most people including myself hear the opioid crisis and assume that 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 we need to treat these at an individual level on a caseby casee basis um and that one one size doesn't fit all um yes opioids were overprescribed I think everybody agrees to that in this country um and we went through a period of time with massive overprescribing and there's a lot of nuance and reasons why in large part um 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 7 hours of Education on pain U veterinarians get 40 it's great if you're taking I think your dog's name is Castello yeah unfortunately he passed but he took some pain meds for a short while but I found an alternative treatment that worked far better perfect which turned out to be by the way lowd dose testosterone he was castrated like he was fixed when he was younger um and I it's interesting i' I've gone i' I've said publicly on very large scale podcasts that I gave my dog low do testosterone later in life and it ameliorated a lot of his aches and pains at least from what I understood cuz he started moving better and feeling better and sleeping better and I expected the veterinary Community to come after me with pitchforks not one wow did that and yet I heard from hundreds of veterinarians that said yes we wish that we could prescribe those sorts of things to people who castrate their male dogs later in life to humiliate their symptoms um so that opened up to me a whole uh world of understanding about some of the restrictions that vet that vets face in terms of what they prescribe there's a whole discussion to be had about that we'll do a series on animal and pet health vet health great well the Vets hopefully are healthy too 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 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 um were there bad docks doing bad things yes um I'm going to invoke uh a good friend of mine Keith humph at St oh yeah terrific terrific um psychologist who an addiction medicine uh psychologist and public policy person and the way he breaks it down and I subscribed 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 um you've got Physicians doing the right thing for the right reasons vast majority dos 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 overprescribe opioids in this case in this context they um 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 uh in their very brief visits with patients remember primary Carex as my heart goes out to them you know what do they get 14 minutes or so with the patient they gave them something that they thought would help they were doing the the wrong thing for the right reasons but they believed that they were helping they didn't have they weren't catching Financial incentives or okay got it that's right those people we need to educate them we need to train them on proper pain management opioid prescribing deprescribing and then you've got the tiny little group at the top of this if you will pyramid these are um docks doing the wrong thing for the wrong reasons these are bad docks these are your pill Mills these are people breaking the law they need to go to jail end of um 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 docks doing the right thing for the right reasons got caught up in it it engendered a 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 um I had a young housewife two young kids uh doc Cut Her Off from a little bit of vicadin that she was taken intermittently for um um 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 um California great state of California tried an experiment where they mon monitor death certificates in our state for and the docs prescribing opioids for that and uh 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 fenel it is more if you just look at the CDC data it's very clear that the fenel coming in Via Mexico China and others uh is what driving most of the deaths um Keith um getting back to Keith led a beautiful uh Lance at Stanford Commission on the North American opioid crisis and put together a very rational plan I just finished serving as a senior adviser 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 uh we're hoping it'll make a difference you can see I'm I'm uh I'm going on a bit here there's there's just huge complexity in this space uh 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 though on that yeah I really appreciate the thoroughness of your answer um I think that you set a picture in a context that I certainly didn't understand or appreciate um 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 um those patients then seeking not any but um illicit or black market routes to treating their pain which you can understand why they would do that I mean I'm not 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 um 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 troch the troch used for end of life cancer pain but unfortunately some of the coding used by the CDC in other words got that confused with the elicit and so it took a while to get a better handle on it but I think you know we do now yes most of it is being driven by the fenel and we're just seeing this incredible epidemic wave of it it can be made so cheaply brought across the borders reasonably easily uh 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 um and that's where again that Nuance comes in um are there patients who are also on opioids that have been weaned down you can wean them down gently compassionately and they do better um the answer is yes uh 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 um the other aspects they're seeing Improvement could you list off some of the more um commonly used opioids um you know morphine and it's uh commercial Del uh commercial derivatives Ms conton which is a long- lasting version of morphine oxycodone which by itself is a short acting medication but when you encapsulate it in a long acting version it becomes Oxycontin which was the trade name that Purdue uh put forward um fentanyl we mentioned comes in a patch form uh there are mixed agents like uh Tramadol which is a kind of a weak opioid but also has some uh what's called serotonin and norrine reuptake inhibition uh we've got diloted which is a version of uh trade name 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 um people usually think of methadone is uh a medication used to uh treat addiction people go to methadone clinics it's a longlasting opioid in the right person and certain circumstances it can be used effectively for chronic pain um 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 um the uh 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 benzodiazapines in pain relief rarely if to I many of my colleagues would say you know Sean it's just a hard no um I Andrew I'd have to come up with an edge condition of somebody who has a generalized anxiety disorder un poorly treated with anti- anxiolytics with chronic pain and when you find you treat their anxiety with like a benzo it helps with their pain as well the but these are Edge conditions by and large no got it and what about katum I had a um a odd experience with katum and I've never taken it uh the experience was the following I started learning about it hearing about it uh 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 katum in the various products and how much people were taking some people talking about as something was as if it were innocuous and we can ask whether or not indeed it is innocuous and so I put out a 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 um first pass view of the literature on katum 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 um I don't want to call them katum enthusiasts because what I soon discovered was that these people um were angry with me for um placing even a partial Shadow on katum 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 katum had helped them get off prescription opioids and that they heavily rely on katum in various do levels of dosage um in ways that they felt really help them and so two things happened one I've been put in the crosshairs of the prrum community not not to a a severe extent but perhaps the more important thing is and I want to thank that Community uh in part for you know now it's inspired me to do a deep dive search on katum I'm going to be interviewing one of the Laboratories that's done a lot of the research on katum later in uh 2024 but also it it's made me realize like there these compounds that are available over the counter that many people feel so passionately about because they really feel like it's helped them I'm not saying it has I'm not saying it hasn't but then again I've never taken it what is katum at or perhaps what receptors does it tickle and what are your thoughts about katum and people using katum and maybe I'm pronouncing it wrong I've also heard Crome I'm calling it katum yeah uh katum is this natural substance that does have as you said opiod deric um 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 katum there's going to be some angry people after this and it is what it is um I have heard the same stories that you have heard about people taking katum and saying it's helping them to stay off of uh prescription opioids or illicit opioids and I get that I think in some way it's binding opioid re ctors and reducing the uh natural craving for these other substances and it makes perfect sense methadone does that buern morphine which I didn't mention before but is a is an interesting opioid that U binds to these receptors and it reduces craving um where I have challenges is in uh just because something is natural doesn't mean that it is safe we are seeing an increased number of Overdose deaths associated with katum um is it poly substance yeah in some cases it is but I think there's a lot we don't know so so poly substance people taking creatum but also alcohol uh benzos getting back to the benzos um personally uh I think we need to put a lot of research into this agent and if it merits it I think it should be a uh a prescribed substance I think part of the challenge that we have is that we don't understand the quality the Purity the dose that people are taking of this thing uh you know similar type of story with cannabis by the way uh 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 um are our goal here is never to um satisfy everybody but just to you know some of this lands in the in the of Highly Educated opinion um some of it is still as you pointed out speculation because we don't really know what Crum sources people are taking or cannabis Etc but um I think you'll find and my experience has been that um 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 um often direct us to explore things further and we can always have a you know 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 uh diabetic neuropathy uh post-rape neuralgia terrible burning nerve pain condition it has been shown to reduce that in small samples from large 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 uh 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 um many many questions that remain um 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 is that we're probably going to see some real UNT consequences of it and we're already are um the good news is I'm hoping that at a state level we'll be able to use that data to really inform um what's going on with cannabis I mean some of the challenges are what I referred to with uh cannabis is not cannabis is not cannabis you to CBD ratios the dose yes all of that we don't know what you're getting it remains a scheduled One Drug by the DEA um I uh in some of my leadership roles and others have called for scheduling of it as a schedule to why why not to purposely try to restrict use but by making it a schedule to drug you've now made it so much easier to research uh 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 um cannabis which are schedule one which are defined as having high addiction potential and no uh utility which is just wild because when I think about PCP Fen cycline 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 uh widely used as a therapeutic presumably ketamine isn't scheduled to uh maybe even schedule three yes and so some of the 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 uh 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 um a friend of mine uh Mark Wallace uh runs pain at UC San Diego go 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 um using that as an active agent yeah I know that in uh Colorado there's a strain of cannabis where they it's pure CBD no THC I think they call it Charlotte's Web and parents of children with intractable epilepsy will actually move to the state of Colorado in 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 or not it's katum perhaps right we're remaining open about that or cannabis the T 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 uh 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 uh is the medications and there's a whole large group of categories of medications of 200 or so uh available two nerve blocks uh and procedures these range everything from trigger point injections to nerve blocks with local anesthetic and steroid on up to minimally invasive procedures like spinal cord stimulators uh 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 comp implen alternative medicine approaches it's a little bit of an outdated term but I think of that as acupuncture neutraceuticals 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 uh or increasing your agency and here it's about education it's about uh learning skills it's about being here on the hubman you know Lab podcast learning about pay pain um 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 us right now think oh yeah acupuncture I mean this is a you know thousands or tens of thousands of years old 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 it is about but um as you and I both know unless it's being performed um incorrectly acupuncture is not painful to receive does acupuncture help treat certain forms of pain is there any scientific basis yes yes there is um do I understand what's going on with acupuncture having completed an act an NIH funded acupuncture study I just saw that uh published no uh you know I'm I'm just being straight um we still don't know exactly how acupuncture is working uh 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 acue points overly 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 um 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 uh I wouldn't say many times but several times and I will say this um one of the acupuncturists I went to put needles in my face and I ended up having to go to Stanford Derm to get some of the angomas 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 I'm like don't put anything don't put any needles in my face because I'll take an angom on 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 angomas to my face now that was probably because this acupuncturist wasn't doing things correctly not saying all acupuncturist do that but here's the problem how do you know know which acupuncturists are reliable versus not and for that matter how do you know which physician is reliable versus not I mean I work at an institution like Stanford where I can ask a lot of people and I still my uh senior administrators won't like this but when I get a recommendation from a doc at Stanford I always call somebody at UCSF and cross check yeah 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 are people supposed to navigate this you found a perfect way to do it and many of us do the same thing and for those who don't have access to highquality 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 uh 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 so try to connect with your primary care doctor others and get some recommendation um for who is high quality um with regard to clinicians pain Physicians for instance that's tough there's 5 to 10,000 of us that are Subs specialty trained out there if your pain is really complicated a complex pain problem you're probably better off with a ter a referral center that can provide comprehensive Services where possible so is there a is there a centralized website where people can say okay I live in the state of Iowa or I'm um you know a lot of our listeners are overseas or you know where people can find out the like the uh the ratings based on patient experience although that can be complicated I confess sure the one star out of five star ratings are 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 there 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 uh the patient ratings um it's a highly manipulated situation um how so 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 inflation of ratings oh my yes inflation of ratings and so then you inflate it and it overcomes any of the negative ones um we haven't taken an approach uh on this and maybe that's naive of us um 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 uh 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 doc at 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 uh addresses this problem head on because I can think of of very few things more useful than a truly independent way of understanding 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 um I'm curious about Chiropractic for a lot of people again not chiropractors let's not talk about the people specifically but Chiropractic a lot of people put acupuncture and Chiropractic um adjacent to one another but my understanding is that insurance often will cover acupuncture but not Chiropractic work um 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 um compression of nerves certainly nerves are being manipulated if any part of the body is being manipulated I guess manipulate is kind of a word that implies something sinister is happening it's being um adjusted um 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 uh acupuncturist 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 uh you know that comes from uh just closing out on the acupuncture again um just to summarize yes in some patients in some circumstances I found acupuncture to be useful and it's worth a try CMS uh Center uh Medicare uh is now paying for acupuncture for people over the age of 65 uh Medicare for Medicare patients that's something recent and uh we were happy to see that I believe that was for back pain that should be fact checked um but Chiropractic mixed data uh um well controlled studies some of some have shown that it can be helpful for low back pain uh some have shown it isn't it's it's truly not clear uh the type of Chiropractic that involves uh that doesn't involve kind of you know the the fast High Velocity manipulation as a physician I have some concerns about that particularly around the neck uh I've taken care of patients that have had vertebral artery dissections from um that rapid wrenching what is a a vertebral Artery Dissection one of the the the main arteries that goes um from the body to the brain and the back portion of it is called the vertebral artery and uh when you do these high velocity manipulations um there is a risk albeit small of having a dissection or an emis thrown off and I've had so it's like a stroke it's like it is a yeah it's like a stroke um but there's a lot of approaches that can be done that uh in some patients have shown some shown some benefit I think the key with a number of these therapies and I don't want to single out AC acupuncture or Chiropractic if you go to them ask yourself am I getting durable benefit meaning everybody feels good after a massage right but 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 um or is it just rapid it feels good in the moment we tend to use that in our clinical practice is 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 inroad into more of a functional rehabilitative approach uh meaning when you get chronic pain you tend to uh withdraw you tend to stop ex exercising you stop moving your muscle 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 where working with a good clinician can help with that yes certainly in my case anytime I've had back pain even when it was very severe provided I wasn't harmed and I was just hurt uh continuing to move and not becoming sedentary was absolutely the fastest route to recovery and um and in particular doing certain exercises that uh that were particular to my my case um what if any is the role for physical therapists in the treatment of chronic pain absolutely crucial absolutely crucial uh despite being a physician not a physical therapist I have great appreciation and respect for what the physical rehabilitative approaches do because at the end of the day we're trying to get people back to an improved quality of life and physical functioning I mean that and is often what people are most looking for control over their pain control over their life yes reduction and pain but more being able to do more things and there tying in with good physical therapist occupational therapists people who can do uh goal setting uh absolutely critical all of the treatments that I provide typically are meant to help support an increase in physical rehabilitative approaches and so when I do nerve blocks or procedures or give them medication and if we end up reducing some pain we want to tie that in with more activity and what the physical therapists are great particularly those trained in chronic pain is knowing that 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 uh more about body mechanics and help improve endurance and strength uh they can work around pacing pacing is so critical for people with chronic pain now this isn't just exclusive to the physical therapists 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 waines and so what happens is you go out and have a good day you go out like Gang Busters 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 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 um disuse uh 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 the 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 now have um and it's something that hopefully all these therapeutic modalities keep in mind I mean I don't know whether or not the acupuncturists are talking to the physical therap therapists are talking to the physician but I guess this is the reason for referrals right why somebody has a primary care dock then then it you know radiates down to uh the rest is that why in a in an ideal utopian world that's exactly it I mean outside of uh Comprehensive Pain centers that have all of the stuff collocated you are dependent on a dock to play quarterback uh and bring all those referrals together it's incredibly challenging for uh Primary Care dock to do that with the limited amount of time they're given to see a person um this is where we're trying to use technology to to help better with that integration and I I do think there's hope for the future we'll have better ways of managing that and handling it what is your view on non-prescription compounds so-called supplements or neutraceuticals for the treatment of pain fascinating topic this country is rather unique in having uh you know a wide slew of over-the-counter agents that are actually um 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 acety carnitine is one of them acety carnitine is thought to work on mitochondrial metabolism and improve mitochondrial health and it's been used I believe as a anti-aging and maybe even a cognitive enhancement agent um you need and it's been studied out of an Australian study I think it was called the Sydney trials uh 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 induction velocity changes and that's how we monitor nerve health is in a normal nerve they move nerve pulses move at a certain rate and when they're injured from diabetes they they you know it's much slower and you lose signal this actually improved nerve Health you can buy those at a vitamin shop uh order them online uh alphal lipoic acid is another one alphal lipoic acid uh at least two mechanisms one is it's a free radical scavenger and second uh that's been more recent is it is a ttype calcium channel modulator and calcium channels are in our nerves and it uh turns those down and it can have some benefit for neuropathic pain um people have taken alphalipoic 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 one what I found though is you have ttype calcium channels in your heart and I do hit uh high intensity interval training and I was Finding I couldn't get my heart rate over 150 so I had I stopped it um that's not a adverse event that's just an annoyance but that's useful um vitamin C so if you're going in for surgery and it's a 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 fish oil the Omega-3s have been found to be beneficial uh around chronic pain um more recently the data here is on smaller numbers creatine which I imagine you've probably talked about it at at some length but creatine has shown in small pilot studies some benefit in fi myalgia and some other uh types of conditions so there are a number of these substances that are backed up beyond the uh you know the anic data that we joke about the anecdotal there's actually good randomized control trials and this is uh something that people can uh easily take advantage of um 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 and 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 um you want to be careful of and not taking when you're going into surgery because they can be uh platelet Inhibitors and they can cause you to bleed more isn't vitamin C one such comp uh substance that that causes uh excessive bleeding or or some people report that um high levels of Omega-3s can increase the um can reduce the viscosity of the blood meaning you bleed easier the the Omega-3s of fish oils yes absolutely the vitamin C I'm not familiar honestly with that as a blood thinging agent maybe I'm I'm uh misinformed there or or maybe I'm just for it but that's that's one I don't usually think of as a a blunt thinner someone will put in the show note comments one way or the other I'll get corrected I I but there's a number of these over-the-counter agents that are uh that are available the vast majority are innocuous that I've mentioned that I've mentioned there meaning they they don't uh cause harm at the at reasonable dosage um uh but they can have positive effects well perfectly stated yeah well thank you for sharing that list I think um as you mentioned many compounds that are only available by prescription overseas are are indeed available over the counter in the US in this area of neutral like supplements is um still an area that's actively debated depending on people's stance but it's refreshing to hear somebody who's you know a uh um formerly trained physician and um and scientist who um Embraces so many different approaches in in the treatment of pain along those lines um perhaps you'd be willing to talk about the olical 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 susception these are the signals coming up to the brain once it hits the brain you know we're dealing with everything that person is Liv 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 uh early uh life experiences is a paper that just came out in jamama uh literally in the last few days where they did a metaanalysis of brain Imaging studies on people with early adverse life events and what they found is abnormalities in emotional processing emotional functioning and people who have these um giving strong evidence that what happens to you early in life impacts us as adults and stays with us it changes our wiring now this is where in part pain psychologists behavioral therapists can come in they can help with some of the uh maladaptive coping the 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 um incredibly helpful uh does it eliminate pain um 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 proc some this procedure bit with psychology we're trying to hit all of these Pathways in aggregate U 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 with goal setting and pacing to teach people relaxation techniques through deep breathing um things like biof feedback um in Silicon Valley where I practice the engineers love the biof feedback I'm an engineer by formal training so I get it but it's that closed loop feedback because remember the the brain is controlling the periphery and controlling the sympathetic nervous system and when we're in pain our sympath sythetic nervous system gets revved up when the sympathetic nervous system gets revved up blood vessels constrict uh heart rate goes up our muscles get tense um and we need sometimes ways of learning how to calm down that sympathetic nervous system um cognitive behavioral therapy mindfulness-based stress reduction acceptance and commitment therapy are some of the tools that they use my partner Beth has developed a brief inter ition called empowered relief yes I'm biased um it works we've studied this in an NIH funded study and it's a way of getting eight weeks of cogni behavioral therapy in two hours wow 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 and the beauty of them is they're going to be much easier to disseminate broadly to the public than for instance a pill you know I can't we can't just go put into FedEx or the US Post Office you know start sending out pills to everybody but we can develop treatments online that uh can teach people skills and really help is that the plan for this um abbreviated but equally effective cognitive behavioral therapy yes now you're getting into kind of my beths in my life mission so you know I've spent the last 12 years building a uh digital platform a health platform that we've integrated into clinics and capture high quality data covering all aspects of people's physical psychological and 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 like 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 healthc 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 but you get outside those those catchment 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 um before you answer that um I'll just add an answer that you already gave which is it sounds like the implementation of this um incredible set of tools and database that you've um collaborated with Dr Darnell Beth Darnell to uh to develop is at least one of them so now that that um that answer was given by me then you can it frees up uh the opportunity for you to give another answer what is the if you had one wish for the field of pain medicine uh going forward what what would that wish be yeah so a few years ago um I co-led for the country the development of the national pain strategy and this was uh 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 uh 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 uh 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 uh 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 um and it's if we just actually Implement what we put forward it'll make a huge difference in the lives of people uh 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 so that's how I learned in junior high school and high school uh what little I attended and by the way go to school folks I had to catch up a lot but I do do remember them saying that you know this was a democracy is a democracy and that um those phone calls and letters can often matter for what um gets you know sent up the flag pole and what ultimately gets approved and implemented beautifully stated you're you're absolutely right and in fact the nidus 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 bipar you don't hear that much anymore bipartisan effort um 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 um and one call two calls doesn't make much of a difference but that if people are saying um you know this is important to them that people in power eventually start taking action the the legis they listen and and in part um Again part of this life mission both to develop this platform I've created a nonprofit um 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 highquality data to better inform the care of patients of people with pain and to deliver highquality um treatments because we do know also that people listen to data and we need good quality data to influence uh those messages but please yes make those calls write those letters it does work well Sean Dr Mackey thank you so much for everything that you're doing you took us on quite a tour um 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 um just on behalf of myself and everybody listening I just really want to thank you you've um 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 Dr huberman I appreciate the opportunity to come on and spend some time and uh 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 Absol absolutely amazing and um 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 Dr Shawn Mackey 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 Dr Macky mentioned during today's episode please refer to the show note captions if you're learning from and or enjoying this podcast please subscribe to our YouTube channel that's a terrific zeroc cost way to support us in addition 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