One of the biggest problems that I see in society in the United States and globally are that people feel invalidated about their painexperience.
They'redismissed. And unfortunately that burden frequently falls on women because in many of these conditions we don't have a clear source ofno-sieception.
We can't put our finger on the thing and say this is what's causingit.
This is why chronic pain is often referred to as the invisibledisease.
And so thesewomen, but it alsomen, are frequently dismissed by their lovedones, theirfamilies, theirfriends, and unfortunately the medicalprofession.
We need to validate people's experiencesfirst.
Understand that what they're experiencing isreal.
So pain is something that so many people livewith.
Sometimes for years without ever really understanding what's goingon.
And how to effectively deal withit.
There's so much misinformation and misunderstanding about everything from chronic pain to migraines and headaches and general aches and pains even acute pain from injury orillness.
What's really happeninghere?
What ispain? Mostimportantly, how do we get out ofit?
Even if it's been there for years and you've been told there's no cure or way out ofit.
We wanted to understand pain and the body on the deepest level and also learn about some cutting edge approaches toit, especially chronic pain that are truly changinglives.
So I asked SeanMackey, one of the country's leading authorities andresearchers, to join me for an eye opening and myth-busting and ultimately profoundly empowering conversation about pain and what we can really do aboutit.
Sean is a renowned expert in pain medicine serving as a professor and chief of the Division of Pain Medicine at StanfordUniversity.
And with a background in bioengineering and a PhD in electrical and computerengineering, as well as anMD, he has been just instrumental in advancing our understanding of pain through his research and leadership in thefield, including serving as the co-chair of the national painstrategy, which aims to transform pain care through an integrative national actionplan.
So in thisconversation, he and I re-really delve into the subjective nature ofpain, the distinction between what he calls no-susception and the actual experience ofpain, and this just multifaceted treatment approach that combines what he calls the six different pillars of paintreatment,medication,procedures,psychology, physicaltherapy, complementaryapproaches, andself-empowerment.
We also discussed some really exciting work that's being done to create scalable digital platforms for delivering quality pain care and brief behavioral interventions to underservedpopulations.
So excited to share this conversation withyou.
I'm JonathanFields, and this is Good LifeProject.
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When we used the phrase or the wordpain, I realized this is broad and complex and I'm sure we'll deconstructit.
But sort of like on a metalevel, what are we actually talkingabout?
Pain is probably one of the most misunderstood conditions outthere.
And it's worth taking a moment to break it down into what it is and what itisn't.
Pain first of all is our harmalarm.
It is there to keep us out ofdanger, out of harm'sway.
It is one of the earliest experiencesknown.
So it goes back all the way to single cell organisms and it was basically either pain orreward.
It was those two things that either drove us towardssomething,food,oxygen,shelter,sex, versuspain, which was to protect us frompredators.
And it's an incredibly conservedexperience.
It's evolved over untold millions ofyears.
And as Imentioned, it is there to protect us fromdanger.
Now in humans and in higher levelorganisms, it has a experiential aspect toit.
What do I mean bythat? One of the most misunderstood aspects of pain is that it is all linked to precisely something going on in thebody.
It is something that is occurring out in yourhand, yourarm, yourback.
And that what is going on out there ispain.
And the thing is that's notpain.
We have another term forthat.
That term isnoceseption.
And I'm sorry it's a technical jargonyterm.
I didn't createit. But it is meant to reflect electrical signals that are generated during harm or injury to thetissues.
So when your tissues getinjured, they generate an electricalsignal.
That electricalsignal, noceseption is sent up into your spinal cord in yourback.
Where there's a little bit of circuitrythere, a lot of circuitry there that's processing thosesignals.
It's stillnoceseption.
And that's sent up to yourbrain.
That's where the real magichappens.
Because that signal you got your big computer up there is taking that input from yourbody.
It's interpretingit. It's shapingit.
And it then becomes your individual unique experience ofpain.
And that's one of the key messages here is that pain is a highly subjectiveexperience.
And you can think of it as many of the other experiences outthere.
You had a Judd Brewer on your show talking aboutanxiety.
That is anxiety is anexperience.
Depression,happiness,love, allexperiences.
The thing that gets complicated with pain is that there is frequently often a signal coming in from your body that is drivingit.
But notalways. Where things went awry in all of this and where there was a lot ofmisperception.
I usually blame it on ReneeDeCarte.
He's not probably fullyresponsible.
But he was a 17th century French philosopher who is responsible for many of the modern aspects ofphilosophy.
He also came up with DeCarte andgeometry, which we still learn inschool.
But when it came topain, he really screwed itup.
Because he represented pain in this dualistic model where there was a direct link from your body to yourmind.
And that was the problem is that there is no direct link that your experience of pain is yours and yoursalone.
And that's one of the key things we learn as pain clinicians is that everybody's experience of pain isdifferent.
And it's going to be different to the samestimulus.
So just to riff off of this abit, I teach the medical school classes that stand for it on pain and noexception.
And so I frequently do a little demonstration inclass.
I have a circulating ice waterbucket.
And I have them come involuntarily.
They dip their arm in thebucket.
And they keep it there for 15seconds.
You all can try this at home if you want and do it with your family andfriends.
It's the samestimulus.
And then they pull their arm out after 15seconds.
And then they whisper their pain score from 0 to10, where 0 is nopain.
10 is the worstimaginable.
And they whispered into the ear of our research coordinator like what theyexperienced.
And then at the end of theclass, I plot out theirscores.
And what it looks like is fascinating because everybody in the class experiences that same stimulusdifferently.
Some peoplesay,no, wasn't painful atall.
It was0.1. Some say it was a3.
Youknow, a little bitpainful.
Some say a6. Somesay,wow, that was the worst pain I have everhad.
I could barely keep my arm inthere.
I do that because I want to teach these young physicians to be a clear message that pain isindividual.
It is unique to theperson.
And there's another message that's important as a as aclinician.
We should never project our own experiences of pain on the otherpeople.
And simply accept what they tell us when they come in and talk with us about theirpain.
So that's a little bit ofgrounding.
Happy to go into that moredetail.
So part of what I'm hearing you say is that you'relike, let's saysomebody, they wake up in the morning and they'relike,like,my, my knee reallyhurts.
LikeI,like,there's, there's pain quote in myknee.
But what you're sayingis, it's really notaccurate.
There's some stimulus coming from yourknee.
Maybe there's an injurytissue, somethinghappened.
That's traveling its way up through the central nervous system into yourbrain.
And when it hits yourbrain, it's the brain that thensays,oh, thisstimulus.
Now we're going to tell you is the experience ofpain.
Is that sort of like roughlyright?
That is absolutelyperfect.
Okay. This is where Imean, I love this field of pain because it's got so many dimensions and nuance and flavor toit.
Is it those signals that come up to the brain are now shaped by so many otherthings?
They're shapedby, did we get a decent night sleep lastnight?
They're shaped by how much anxiety or depressive symptoms we mayhave.
They're shaped by our early experiences withpain.
And so if you had early traumatic life experiences withpain, it actually sets up in your brain vulnerabilities to amplify things as anadult, which is why we need tobe, youknow, particularly careful about this thing of chronic pain and these injuries in kids because it sets them on a lifelongpath.
It's shaped by ourgenetics.
There are genetic vulnerabilities andsensitivities.
It is shaped by various aspects related tosex.
Women tend to be a bit more sensitive to experimentally evokedpain.
That what I mean by that is if you come into our lab and we cause an experimental stimulus ofpain, a noxiousstimulus, women will report a little bitmore.
I think the press and the media make a little bit too much of that honestly because I think there's more variability within men andwomen.
But we all like to make big deals of smalldifferences.
So there's all these things that shape our attention and distraction topain.
Are we focusing attention onit?
Are we in a state of relaxation when we're experiencing thatpain?
What are our beliefs about that pain in your knee when you wake up in the morning or in your back that you justmentioned?
Let me give you anexample.
One of thequestions, two of the questions that we ask at Stanford when patients comein, it's probably the five most important questions we'll ask about people'spain.
What do you believe is the cause of yourpain?
And what is the meaning of thepain?
First one straightforward.
What do I mean by what is thecause?
What do you think is causing yourpain?
Now when you mentioned your knee or yourback, do you think that I worked out a little bit too hard yesterday and I have a little bit of inflammationthere, I probably overdid it a littlebit, everything's fine and it'll settle down or do you think that you've got some terrible arthritis in your knee with bone on bone grindingaway?
Those are two entirely different belief systems about yourpain.
Building onthat, what is the meaning of yourpain?
Do you believe that your pain is associated with actual tissue damage that'songoing?
So in the firstcase, you were out runningyesterday, you went for a longhike, you're just getting the usual post hike kneepain, it'll goaway.
Or on the otherhand, I have bone on bone arthritis every time Imove, I'm grinding my joint away and it's getting worse and worse andworse.
Why is that important toknow?
Because in the firstsituation, that person will probably take it a little bit easier thatday, but know that everything's going to befine.
In the secondcase, that person is going to protect theirlimb, they are going to guardit, they're not going to want to moveit.
And if that goes on for a long period oftime, that can result indisability, disuse anddysfunction, all for the same amount of pain experienced by theway, but shaped by their beliefs and their understanding of theirpain.
And that's all about thebrain.
The beliefeffect, not only your response toit, so whether yousay,oh, I'll just kind of shake itoff, take it easytoday, I'll be back tomorrow versus something really badhere.
I need to just change my behavior and limit myself and maybe for alife.
I seethat. Does your belief about the source and meaning of the pain also changed the way that we experience the intensity and duration of the pain in themoment?
Absolutely. That greatquestion.
If you believe that yourpain, what is going on out in yourbody, is more related to injurydamage.
And particularly if there's associated anxiety withthat, if you're thinking about itconstantly, your experience of pain is going to be higher than in that other situation I mentioned where you don't think it's injurycausing.
You don't think that this is going to be long lasting and taking over yourlife.
So what is the key message for people inthis?
One, one of the key messages to take home is understand the distinction between hurt andharm.
Meaninglisten,life, life ispain.
We're all going to have aches and pains throughlife.
And we need to understand that that is unfortunately part oflife.
It mayhurt, but those aches and pains are to be distinguished from something that truly is tissuedamaging.
So understand when the pain that you're experiencing is actually associated with real tissue damage and there is a need to protect that bodypart, whether you'reback, your need that youmentioned.
And that's where getting in the hands of a good clinician or starting off with a base of just selfeducation.
Learn yourbody.Yeah, it's fascinating because as you're describingthat, I was immediately reflecting on a number of yearsback, I broke a foot in mybone.
So I was in an air cast and on crutches for the first time I think in my life for sixweeks.
I couldn't put any weight on it atall.
Yeah, after sixweeks, I go back to theortho, they take a new X-rays and the basicallysay, youknow, according to theimaging, you're fullyhealed.
There's literally you can goback, you can do all thestuff.
Hesaid, but because that foot hasn't been weighted for a month and a halfnow, your connective tissue is going to be verydifferent.
Andstructurally, the first time you actually put weight on yourfoot, youknow, we're going to put you into physical therapy and it's going to take awhile.
And what he said to me is that what I want you to know is that you're going to feel pain because remodeling the connective tissue and putting new weight onthis, it's going to beuncomfortable.
But the pain that you're going tofeel, hesaid, there's nothingwrong.
There's nothing when I look at your imagingnow, you're fullyhealed, but you're going to feelpain.
Part of what this work is is over the next month or two through throughrehab, you're going to need to effectively keep using that foot and new ways and putting weight onit.
And it's going to be painful for awhile, but that's the pain ofremodeling.
That's aquote, goodpain.
So he was setting myexpectations, which I thought was reallyfascinating.
It sounds like that's partly what you'redescribing.
Exactly. It sounds like you got in the hand of a goodclinician.
And I can giveyou, that's a beautifulexample.
And I see patients in our clinic all the time where I can giveyou, youknow, here's another one to build onthat.
They're a little bit of an extremeexample, a guy in his40s.
He's an executive master's level tennisplayer.
And he comes in on crutches and he can't put any weight on his foot and the guysdepressed, he'sanxious,why?
Because he can't playtennis.
Youknow, tennis is hisoutlet.
It is his meaning forlife.
And they have told them they can't find what's wrong in hisfoot, butit's, youknow,it's, it's getting worse andworse.
And he's justfrantic. So doing evaluation onhim, find out it's something called a Morton'sneuroma, which is just abig, fibrous growth around the nerves in yourfoot.
And it'spainful. Let me tellyou, it'spainful.
But I told him this and I toldhim,listen, you're not causing your footharm.
You're not injuring yourfoot.
You're not going to become crippled fromthis.
And he just stared at me for about15, 20seconds.
He just looked at me while his mindwas, youknow, turningaway.
And he'slike, you mean I can playtennis.
And I'mlike,yeah, you can play all the tennis youwant.
It's just going tohurt.
And it's like we're donehere.
And he just got up left his crutches and walkedout.
And, youknow,listen, that's an extremeexample.
Okay. And I want to go back to what I saidearlier, which is you can never generalize these stories to otherpeople.
But that is one example of where tremendous fear and uncertainty and confusing hurt for harm caused aproblem.
Yeah. And the anxiety about am I doing further damage by continuing to do thisX, Y and Zactivity.
It sounds like it takes the compounds the experience ofpain.
Youknow, it takes something where you'd belike,okay, so ithurts, but I'm not doing anydamage.
So I want to keep doing the thing that Ilove, as long as it's not like causing any long termthings.
And it sounds like your brain then processes the paindifferently.
The brain processes thosestimulus, saying this is where the problem withpain, we all get intothis.
It requires a degree of precision oflanguage, where we start conflatingterms.
We all doit. I do want to make a pointthough, because there's the flipside.
There are people out there suffering from ongoing tissuedamage.
People suffering from degenerative conditions that are gettingworse, who have tumors due tocancer, who have had traumaticinjuries, who havechronic, painful conditions that we can't figure out what the source of the no-susceptionis.
And I don't want to give people listening in this messagethat,oh, you can just come into my clinic and I'm going to tellyou, you're not hurting yourself and everything's going to befine.
Because that's not themessage.
We're giving examples across this whole continuum ofpain.
And the reason I mention this is one of the biggest problems that I see insociety, in the United States andglobally, are that people feel invalidated about their painexperience.
They'redismissed. Andunfortunately, that burden frequently falls onwomen.
Because in many of theseconditions, we don't have a clear source ofno-susception.
We can't put our finger on the thing andsay, this is what's causingit.
This is why chronic pain is often referred to as the invisibledisease.
And so thesewomen, but it alsomen, are frequently dismissed by their lovedones, theirfamilies, theirfriends, and unfortunately the medicalprofession.
And the medicalprofession, because we don't get much training in medical school and residency aroundpain.
I think that's one of the key messages that I want to giveis, we need to validate people's experiencesfirst.
Understand that what they're experiencing isreal.
Itis. I am not saying this is something all in one's at yourhead.
The experience of pain is something that is in ourbrain,though, that made to some extent be driven by these external signals that we callno-susception.
It brings up a really interesting question in my mindalso, whichis, can we have the experience of pain in our brains without any no-susception beingtriggered?
And what I'm thinking about istrauma,stress,grief, things likethis, where if you asksomebody, my body is riddled inpain, I'm aching all thetime.
My head ispounding. And I guess that's thequestion.
Can you experiencethis?
It not actually be directly related to this process ofno-susception.
Can be based in somethingdifferent?
Yes. Extreme examples of that are things such as post-strokepain.
You've had an injury to a part of yourbrain, typically you're like yourthalamus, and you experience terrible burning whole body or hemibodypain, and the absence of any peripheralno-susception.
But let's take it furtherout.
If you've ever pulled anall-nighter, and those of us who went through medical school or who've pulledall-nighters, we know what it's like to go for long periods of time withoutsleep, I mean you just feel like crap the nextday.
You ache allover.Well, there's probably nothing going on in your body as awhole.
There's probably no increase in no-susceptivesignals.
One of the keythings, and I didn't tell this part of thestory, I mentioned these signals going up to the spinal cord and up to the brain where the experienceoccurs,pain,boom.
But there's something else going ontoo.
And we have signals that come down from ourbrain, and they synapse or they connect in the spinalcord.
And it acts like this big negative feedbackloop.
And what those negative feedback loops do is they turn down the signals coming in from the spinalcord.
And in a healthysituation, we've got this balance of ying andyang, if youwill.
The ascending signals coming up from ourbody, the descending signals comingdown, and in that healthysituation, we experience nopain.
What happens with pain is we either have too much of the signals coming in from ourbody, or we have too littleinhibition, those descendingsignals, too little of those comingdown, and that feedback system is notworking.
And what that means is that you can have pain from normal signals in the absence of injury if your inhibitory system is not workingright.
Does that makesense?Yeah,no,absolutely.
And what wefind, there's a condition called fibromyalgia in which we know that those inhibitory systems are out ofwhack, that people don't have that normal inhibitory tone that theyshould.
Now, there's a lot more going on infibromyalgia, but that is in partwhy, andagain, here it's mostly women is alsomen, you can feel pain over your entire body in the absence ofclear, no-susceptive signals comingin.
So it's in partthen, it's theseinhibitory, something's going going awry in that inhibitory system or side of the system that helps balance out or tampdown.
I don't want to call them errant signals because it sounds like what you're also saying is like every signal hasinformation.
Every signal has meaning andinformation.
A lot of thosesignals, a lot of the information going out in our brain at any giventime, is to filter out stuff that's notimportant.
Youknow, filter out extraneous visual stimuli that we're not focusingon, auditorystimuli, we're not focusing on how various parts of our body feel because at the moment intime, because you and I are talking with eachother, that's all going on behind thescenes.
And when that system gets out ofwhack, all of asudden, normal signals become perceived aspainful.
And we have ways of treating that throughmedications, through mind bodyapproaches, through physical therapyapproaches.
Let's go back to yourfoot.
If we could go back to your foot for just asecond, your clinician told you about re-engaging those connectivetissue,right?
And building those up because they weren't used topressure.
But there was actually something else going on in theremodeling.
Your brain and your nervous system needed to be remodeledtoo.
Because your spinal cord and brain had not been used to having those signals coming in on a regularbasis.
And so what you needed to do is retrain those nervous systemcomponents, those systems back to where they were before theinjury.
And that's another reason why you feltpain.
It's not just the peripheral tissues in thefascia.
And I think that's a perfect example once again of where theclinicians, we all tend to look through the lens upon which we'retrained.
Your clinician was probably looked to trainthrough, looked through a lens oftissues,right?
And the thing with pain is it involves so manycomponents.
And it's frequentlylike, what is that old Indian parable of the blind men and theelephant?
Youknow, somebody feels a trunk and thinks it's asnake, somebody feels a leg and thinks it's atree.
That's the thing withpain.
To understand that you really have to put all those pieces together to see it's anelephant.
Yeah, that makes so muchsense.
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I do want to drop back into this the notion of I don't know whether psychogenic or psychosomatic or whatever the proper phrasing is but like I'll give you an example out offriend.
A really troubled relationship with his dad for years he's a little bit further into life and he had migraines my friend had migraines like person tired life his dad passes the migraines goaway.
Sure sure there's greater appreciation for one early life experiences impacting our experience of paying to relationships impactingpain.
And this is a big deal and there are newer newer therapies that are focusing on some of these relationship aspects and treatment and pain these unresolved issues that were they're just unconscious we're not even aware of them until they're brought to the surface was your friend experiencing real pain wellabsolutely.
But this gets to what we were talking about before where these brain circuits can get kind of mocked up they can feed and take over and you can end up with pain where there's no clear evidence of no exception or minimalevidence.
And again that's we're getting in the hands of a good clinician can can go a go a long way to helping unpack some of that there's a therapy these days called EAUT which gets it some of the relationship aspects and some of the challenges and some of the emotional awareness aspects of pain and treating those I think the key thing in all of these and where we're still lacking in the treatment of pain is we don't yet know how to target the right person for the righttreatment.
So frequently somebody like your friend goes through this long laboratory is trial and error process of treatment after treatment after treatment until they find something that works in this case the unfortunate passing of familymember.
The subjectivity of all of this is um fascinating explains a lot and also I would imagine incredibly frustrating in a lot of ways both for the individual experience pain I would imagine for practitioner also where you're really going on a journey of discovery along with someone who walks in because what's obvious or what seems like might be on the surface you know they're just got to keep peeling the onion I mean another thing that comes to mind for me is you know the person who has an injury they experience pain couple let's say to the injury is healed they take me with like the foot thing right I go through physical I go through rehab functionally anatomically physiologically like everything looks like it's good to go what happens with some folks is that the pain never goesaway.
So what's actually happening there when when a pain starts acutely and then in theory everything that needs to be resolved is resolved but the painremains.
Now and this is one of the challenges that we as a medical and scientific community are continuing to face right now when putting a lot of research effort into unlock the mysteries of that that people refer to it as the transition from acute to chronic pain the notion that for a percentage of people their pain doesn't go away after aninjury.
And it's a problem that's only getting worse in society why well one we're living longer and so the very notion of living longer and being exposed to more injury and stuff there's more chronic pain to we're getting better at keeping people alive so you know you look at motor vehicle accidents we can get people to hospitals and treat them pretty quickly we've got great surgeries same thing with war time you know we can get them off the front lines but now you see these men and women coming back whose bodies have been you know repaired if you will to the best extent possible but they're still left with terrible chronicpain.
We have great ways of treating cancer now it's gotten much better but the treatments for cancer frequently it can leave people with persisting pain from the radiation therapy thechemotherapy.
So what is going on here the short answer is we don't have the answer to all these questions we knowthat.
Unfortunately there is a vulnerable population we don't know how much of this is genetics how much of it is what you bring into that injury that sets you up for persistent pain what I mean by that is there are probably some genetic predispositions that we can't control but we can identify there we do know thatwhen.
You come into a surgery or an injury that what you bring into that injury or surgery often has more to do with whether you're going to have persistent pain than the injury of the surgery itself meaning if you have high levels coming in of depression of anxiety history of PTSD big one that's a bigone.
You are set up to be more vulnerable to have persisting pain after that injury and the reason is those brain circuits kind of they're out of whack you know to use a cloak we'll term but they're sensitized and they get woundup.
We know that there are factors that impact those brain circuits and then we also know that there are in some people these molecular triggers and systems in the in the body and the periphery and in the spinal cord that don't go back to normal let me give you kind of an analogy if youwill.
I think you mentioned before the show that you've been dealing with a little bit of acold.
It's a long time listeners will hear in my voice and definitely a little more busy and gravely thannormal.
So what happens in that cold well what happens is the cold viruses activate in part glial cells typically micro glial cells that are non neuronal cells that in our central nervous system and elsewhere and those glial cells release all sorts of chemicalmediators.
Side of kindshistamines,bradykinings,interleukins, blah blah blah and it's an inflammatory soup think of it as a inflammation soup and that inflammation soup during your cold and the same applies during an injury after surgery after an injury puts into play a healing process it brings to bear all of your immune system to come in andfight.
The the offending agent or to repair the damage that was done but part and parcel of that is something called the illness or sickness response whichmeans.
Jonathan I appreciate your here and you invited me on your show but part of you probably wanted to just sit on the couch with a blanket and have somebody bring you the hot cocoa with those little marshmallows onit.
And just kind of rest up because that is hardwired into all of us when we get a cold but also when we get injured if we get an injury that inflammatory soup occurs now the good news is the tissues heal up the inflammation and then inflammatory soup that goes away we go back to businesses normal but in some people it doesn't go back tonormal.
The switches don't turn off the neural inflammation continues and we're left with chronic pain and they still have this urge to kind of isolate from other people and to sit on the couch and you know have somebody bring them the hot cocoa with marshmallows and we're still trying to figure out why those switches don't go back tonormal.
It's a fascinating area of research and there's therapies that are being more and more aimed at those glialtargets.
You use the word switches a number of times there which whenever I hear that word for some reason something me often associates that with epigeneticsnow.
A lot of people have this rough notion of epigenetics as if you know we have a genetic code but that doesn't necessarily determine our lived experience that you know whether certain genes are switched on switched off is much more about how we experience the world how we move through the world I'm wondering whether there's an epigenetic element or component to any ofthis.
Yeah, almost certainly first of all the geneticist out there are going to disagree with me but I think the actual amount of genetic contribution to this is of the development of chronic pain is probably really tiny it's probably really small we've yet to find any direct heritable genetic single nucleotide polymorphisms refer to the SNPs any single genes that are responsible for these chronic pain conditions except inreal.
In addition to that we have a lot of different conditions except in rare rare situations that are kind of cocktail party discussions worth from allows you and can general insensitivity to pain that makes for great movies but in the real world one it's a polygenic meaning it's probably a contribution of multiple genes and even then only small contributions now layering on the environmental influence on yourgenetics.
That's where probably the real action is and so this is getting back to what you you suggested and I think the good news and that is that there's no life sentence per say it's been handed down by our parents and the genes they passed on to us you know we are in control of our destiny for the vast majority of cases there are rareexceptions.
You're one of the other things that pops into my head and I do want to kind of transition into some of the ways that we're treating pain and what the future looks like as well but there's one other thing that is sort of sitting there with me which is I think epigenetics it's became a bit of a buzzword these days that but there's another buzzword that if things have been floating around a lot which is microbiome or the enteric nervous system this notion that you know the nervous system isn't just about your spinal cord in your brain but there's a whole separate system and a lot of it is in some waymanipulable.
Manipulable by all the critters that live in our gut and I'm wondering what your take is on whether that actually has an influence on ourexperience.
Oh absolutely it's a incredibly new untapped area for us to understand research and ultimately treat in pain and the problem I think we have right now is that there's more we don't know than wedo.
So let me just preface by saying yes we know the microbiomes playing a role and I invite people to be careful about the messages out there because in these phases of new research and new understandings sometimes they get oversimplified and sometimes also people enterprising people will try to take advantage of that and sell things snake oil to do that when there's we don't have a lot of datayet.
We do know more and more that the enteric nervous system the nervous system of our gut is directly communicating with our brain it is shaping our experience ofpain.
I've had a personal experience in this space I used to be able to eat anything absolutely anything and I took our group out for a happy hour one night about 10 or more years ago to a Mexican restaurant and I got food poisoning and I had a lot of things to do and that changed my life forever because after that episode I could no longer get near an onion without severe debilitating pain for about a week sometimes two weeks and messed up my sleep and when my sleep was messed up this is again that link between sleep andpain.
This is up your cognition and your overall quality of life and it took me a long time to figure out what was going on and I was able to find answers probably because I'm a pain physician I'm a pain physician scientist and I research the heck out ofit.
There's no treatment for this per se I do avoidance and I I'm fine but clearly something was altered within the gut and my guts response to an onion as an antigen as a substance which is no longer viewed as normal but asabnormal.
Now that's one example I think they're we're going to find that there are plenty of others there's a great interest in these anti inflammatory diets which is a broad and broadterm.
There is undoubtedly something to it the key is once again to figure out the right if you will diet dietary modifications for the right person their painful condition and you know their specificcircumstance.
It's so fast and I feel like we're in this moment where we understand a lot more but it's almost like the more we understand the more we're starting to realize the vastness of what we don't understand and maybe that's new to me maybe you've been living in that world for a long time now yourself but all I can tell you is back in my 20s I used to be a lot smarter than I am namewell.
I think we all I think I keep getting more more stupid as I go along because the more I know the more I realize oh my god there's there's so much I don't know and we need to learn the good news is our knowledge is growing you know we are learning more more about this condition of chronic pain yes the microbiome my prediction is going to be a key player and in this I think it'll be a key player like much of the rest of what we described earlier in our discussion is meaning when we're talking about treatments it's going to be rare where we find a magic bullet for a chronic pain condition it occurs it can happen I love those times when somebody comes in and I can do a nerve block or you know single medication or a single treatment boom they're cured we all celebrate those usually it is a team based approach where we're applying multiple therapies to go after those pain processing pathways from the periphery or body the spine accord the brain those descending pathways and doing that all together and we'll add on the gut you know that's going to be another approach clearly yeah it's interesting because on the one hand I can see well you're just you're trying to basically attack any any possible contributor from all the different directions because at the end of the day you know especially if you're dealing with a patient in front of you the ultimate outcome is for you as a scientist you want to learn something but for them they just want to stop her yeah so it's like whatever it takes like I would imagine a lot of people they don't entirely care you know the complexity and where it like what are the eight different contributors to this or just like can you help me feel better but on your side it's like but I also need to try and understand like what's happening here because I'm going to see thousands more of you and the more that we can understand and share this knowledge the more we can start to really understand how to help any given person more quickly and more fully well that was beautifully put up you should just run the show that was great you are so right that's what I'm going to say that's what I'm going to say that's what I'm going to say that's what I'm going to say that's what I'm going to say that's what I'm going to say that's what I'm going to say that's what I'm going to say that's what I'm going to say that's what I'm going to say that's what I'm going to say that's what I'm going to say that's what I'm going to say that's what I'm going to say that's what I'm going to say that's why we play these different roles as a physician my job my calling is to help the person in front of me and you're right the thing about pain is that it is being this harm alarm it is incredibly distressing to them they just want to be out of pain they want to stop suffering and particularly with pain that's with you 24 seven it just wears you down it sucks your soul and often you're right they don't care what the treatment is they just want something that'll take that away and I getthat.
And that's what we move towards and you're right the scientist in me where in the other hat wants to understand why they're experiencing it not only to help the person in front of me but hopefully to take that knowledge to help others so that we can come up with safer and more effective treatments for the next person that comes into the clinic that's where we're going with the science is to try to collect high quality data on many of these people to better understand but in the meantime you're right when I'm seeing patients in the clinic it's one at a time and it's helping them with their unique problem and everybody's different I think when people think about how do we treat pain and again we probably need to make a distinction between acute and chronic because I think there may be more obvious ways to treat acute there's the traditional rest ice compression elevation although I guess parts of that are now being debated there you know the OTC the NSA's and then the prescription things that I think we're going to be able to dothat.
And I think the prescription things that I think many people are going to be familiar with and you know to varying degrees of effectiveness and each one with varying degrees of risks also and I feel like increasingly you know chronic pain has become the focus of so many people and as you described earlier oftentimes you show up and there's no clear no prescription process that we can point to which is if mindset and anxiety and fear are part of your experience of pain if somebody tells you I can't tell you where this is coming from that's only going to increase the maybe I'm making an assumption here for for I would imagine for a certain group of people that's going to increase the experience of pain is the lack of knowledge will nobody can tell me where it's from now we had frustration and futility to it and then the concern that I'm not going to be believed to it so everything sort of compounds there and and feel like chronic pain has really become such a pervasive experience and as you described we're living longer you know like where there's more opportunity for it and we're living through some interesting times also which I think creates more opportunity for it when you think about the state of how you're treating things now what are you seeing as being more broadly effective for a lot of people or is that the wrong question the real question there is no broadly effective and we shouldn't be looking for that we really need to take people one by one great question let's it might help to start with the foundation of how we treat somebody with chronic pain and I'll share with you brought up a cupane before what we're finding by the way is a lot of the treatments for chronic pain are making their way into the treatments for a cupane we're finding that they work quite well particularly you know some of the mind body approaches some of the medications that we used in chronic pain also can be effective in a cupane so it is blending or blurring more and more and a lot of that with the idea of trying to reduce those people with a cupane going on to develop chronic pain in addition to trying to get people back to their activities faster focusing on chronic pain I think of six if you will pillars categories of how we approach people with chronic pain and treatments one is the medications two are the procedures interventional procedures are three mind body therapies four physical and occupational therapy approaches what we used to refer to as complementary alternative medicine approaches or integrative health approaches and six is self empowerment so breaking those down in the medications probably have about 200 or so different medications that have shown some benefit in pain that's a lot most of those are not opioids by the way only about 20 of those are opioids but people frequently conflate or think of chronic pain with opioids opioids can't play in a roll the point I'm bringing up is there's a lot of medications out there available to interventions or procedures we have probably over 200 different nerve blocks and other interventional procedures from trigger point injections different nerve blocks all the way up to spinal cord stimulators and implantable drug delivery systems three mind body approaches that run the gamut from classic cognitive behavioral therapy approaches mindfulness based stress reduction approaches acceptance and commitment therapy approaches and there's newer ones like my partner Beth Darnell develops something called empowered relief which is a brief behavioral intervention for physical and occupational therapy approaches we're all familiar with these are building up strength endurance it's teaching people pacing approaches which we can talk about if you want it's helping people learn some of the distinction between hurt and harm and understanding their body five the complementary alternative medicine approaches acupuncture over the counter neutral I'm still using that term I'm not sure if that's even the most contemporary one but it's it's the vitamins the supplements that you you go by off of wherever there are number of those that have been shown to be effective for pain that are over the counter in this country that are actually prescription agents and other countries and number six which is probably the most important one I didn't mention these in a particular priority by the way but number six is self empowerment which is it all starts with getting educated with learning your body with learning your painful condition and using that knowledge to empower you so that's the way that we kind of approach the buckets the pillars if you will of treating chronic pain there are others but those are that's broadly how how we think about it and it is a matter it is the issue of putting the right treatment for that right person in the right circumstance and that's where it gets frustrating for the frequently the patient because unfortunately a lot of the data out there can't direct us and say this treatment will work better than that treatment for this particular condition we have just general guidance that's where a lot of the research is going is to better understand this work better than that I mean the way you lay out the six pillars also it's interesting to me because the the order that you share them in feels like it's also there's a bit of a correlation with the timeline that it takes between intervention and relief and maybe that's wrong or right but sort of like it's it's the more immediate interventions unit they're not full and then like down on the other end we have self empowerment which you say is like maybe the most important one but that's not an overnight thing yeah you know this this is like a you know it's knowledge building it's practice building it's it's skill building I wonder whether we look at that last one we say oh yeah self empowerment sure sure sure sure but give me like give me the shot or give me the procedure or give me the pill because like that's going to help me now and we're doing ourselves a disservice by focusing more intensely on the instant moment I think it would never blame anybody for wanting to be out of pain now of course like I've been in that moment and we all have but oftentimes I think when this stimulus for pain stops creating pain in our brain the motivation to do the work for something like CBT or self empowerment becomes greatly diminished until the experience of pain comes back that's the way we're wired isn't it you know isn't that something is you're right the self empowerment aspects not only can help us in our pain now but they set up skills for the future and I'm sure you've had many guests on your show that have talked about these mind body approaches but they apply to things outside pain depression anxiety stress sleep you know you name it they're basic skills building we should teach the stuff in schools honestly and you know have our kids better prepared for inevitable stressors and pain that occurs in life and you're right it is probably the most important one and the people that I see that come into our clinic because we're up what's referred to as a tertiary referral center we tend to see the really complicated patients who've already been through a lot yeah they want something right now what we try to do is put it all together you know we we don't do just one thing but do it all and integrate in that self empowerment with it yeah and we'll be right back after word from our sponsors hi this is Janice Torres from Yolkieto Dinedo if you own or operate a business whether it's a local operation or a global corporation partnering with Bank of America could be your smartest move by teaming with Bank of America you'll enjoy exclusive digital tools award winning insights and business solutions so powerful you'll make every move matter position your business to capitalize on opportunity in a moment's notice visit Bank of America dot com slash banking for business to learn more 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affiliates national average 12 months savings of $744 by new customer surveyed who saved with progressive between June 2022 and May 2023 potential savings will vary discounts not available in all states and situations imagine the softest sheets you've ever felt now imagine them getting even softer over time that's what you'll feel with bowl and branches organic cotton sheets in a recent customer survey96% replied that bowl and branch sheets get softer with every wash start getting your best night sleep in these sheets that get softer and softer for years to come try their sheets with a 30 night guarantee plus get15% off your first order at bowl and branch dot com code buttery exclusion supply see site for details I'm wondering where you see in the six pillars also for lack of a better word attentional control you know agency over our attention falls and what's coming up for me is I remember for in a past life I was a yoga teacher for seven years I would step onto a floor a couple days a week and for 90 minutes my job was to take 50 human beings and make that 90 minutes worthwhile for them because we were in New York we were moving fast and it was I had an obligation to responsibility and noble responsibility there were plenty of times where before I would step into that room at a pounding headache and I didn't want to go I didn't want to do it but I had this repeated experience of I would get in there literally would hear the latch on the door close behind me into the practice room there you know all these people sitting on their mats waiting for this to begin I would sit down within a matter of three four or five minutes I'm teaching and for the next 90 minutes I don't functionally I don't have a headache the moment I I bring people out of final relaxation chef Austin on the last person leaves I have a headache again and so it got me really curious about the role of attention in pain because my attention was hyper focused on a room full of people like I was there I had a job to do and I was really very very intentionally present with them my attention was with them and it made it all if I was doing quote doing my job it made it hard to focus on what was happening inside of me but the minute that job was over I was back so I'm curious about the role of attention in the experience of pain yeah attentional distraction has been studied extensively in the context of acute and chronic pain and what you describe as a beautiful example of where it works and we often work to get people engaged in activities that will be distracting walking exercising reading books particularly engaging with friends and family because one of the negative aspects that we're more greatly appreciating is that people withdraw from social engagement where that fits within the pillars it actually fits into multiple ones so our pain psychologist behavioral therapist teach skills around attention attentional distraction and also different forms of psychological interventions for instance acceptance and commitment therapy and mindfulness based stress reduction both have some components of how do you interpret when you're experiencing that pain that headache you know do you focus your attention on it do you think about it or do you just kind of accept it and be aware of it in a non-judge mental manner and from a pain standpoint those are skills that can go a long way I'm grossly oversimplifying this by the way for the sake of a story next this is used extensively within physical therapists and they help people with again setting goals getting them active doing things that will be distracting for them next I mentioned compliment alternative medicine which may not be the best term I kind of put yoga into that and actually there's good data by the way on yoga and back pain and yoga and other chronic pain conditions and yoga perfect example of that and then lastly that self empowerment recognizing john then what you just said you recognize that thing you learned from it so those were skills that you could use to take forward I think some of the challenges that we run into in pain is that we can engage those attentional distraction systems well during the day time I think where they start to break down is it night when we're trying to sleep and that's something we still need to work on because you know people are just staring up at the dots on the ceiling it's hard to distract yourself away and then when your sleep gets out of whack as we talked about you feel more pain and gets into a vicious cycle so there's a clear opportunity there for improvement as you look at the worth that you're doing right now because you're involved in the research side of things as well when you look at the next five years the next ten years what's really exciting you in thisdomain?
yeah I'm jazzed about the future right now and the opportunity to improve the lives of large numbers of people so my research wears a couple hats one is I'm a neuroscientist who studies a human pain condition using a number of techniques like functional magnetic resonance imaging sensory testing and published a number of papers to understand mechanisms of pain individual differences in pain the impact of brain circuits on pain and translate that into therapies and that's one hat and right now where we're moving into is the development of objective biomarkers for pain now what I mean by that is as we talked about pain is a subjective experience but what we need are biomarkers that we can develop to predict what treatment will work for which person I don't mean biomarkers to determine if somebody's in pain or not in pain I can always just ask somebody but we want to know are there markers physiologic or otherwise that will help us predict are you going to respond to yoga or an NSA or a nerve block that's where the field needs to go and that's where a lot of our research is right now second hat for the last 20 years I have been working to collect high quality data on real world people with chronic pain because we need to learn from each and every person so we built an informatics platform it's called choir which we put in a multiple clinics pain clinics and it captures high quality data on people with chronic pain we're using that data to pattern classify and to understand the person in front of us so that it can help us guide treatments and where things are exciting for me is one blending that learning health system that I've developed with the biomarker work that we're doing and then there's one last component to it and that is my partner Beth Darnell who's also a professor in pain she is a pain psychologist scientist and what Beth has developed are these brief behavioral interventions brief meaning in cognitive behavioral therapy which I know you're very familiar with it's typically eight weeks eight weeks people he to say it they frequently don't want to go to it they're working they're busy it's hard to get them there she's distilled down the components into a single session that's about 90 minutes oh wow yeah we've studied this with NIH grants she's got a large national grant right now to spread this throughout the country what we've shown with the NIH grants is it works as well as cognitive behavioral therapy it's we're not looking to replace CBT but we want to develop systems that can translate scale and make them more available to others the problem we have in society is that most of the major pain centers are concentrated in small clusters in the country I live in California in the Bay Area you just go 30 40 miles inland that's farmland it's just a huge swathe that's in it is a health care desert out there and people can't get good quality care and so we're extending we're taking this work this digital health platform we're putting it out into a national cloud based model under a nonprofit and the idea is to collect high quality data on people with pain lived experiences with pain and be able to deliver effective brief behavioral treatments and other treatments and what motivates this is in part I co led the development for our country the national pain strategy this was for the US health and human services and we put this out in 2016 and one of the strategic goals was to develop such a platform and you'd be surprised nothing exists like this so that's what's exciting it's bringing together 20 years of my research that's decades of research bringing all this together into something that our goal is to really help large large numbers of people out there and asking you ask a scientist what they're excited about no ramble ramble on forever now it's fascinating because you know what you're describing is effectively you know working to democratize not just education but modality is that would potentially help millions of people who don't necessarily have access to these major pain centers or leading researchers or you know you're basically saying like we've done a lot of work for decades now we figured out some really interesting stuff we don't know at all we've got some insight that you know like I think we really valuable to a lot of people in a lot of places so let's figure out how to share let's distribute that rather than hoarding it perfectly stated we were all striving in research to come up with the next new treatment and we do need new treatments for pain but the thing is we've got a lot of treatments out there a lot of things that actually work and we just need to get them in the hands of people and make those available and cost effective orfree.
So one other thing popped into my head before I let you go which is you were hearing a lot of stories now about AI and medicine especially on the being able to identify potential existing molecules or pharmaceuticals or drugs or supplements ornutrients.
For use cases that maybe we didn't know about or or entirely new things do you have a take on the role of AI in the future of pain research andtreatment.
Oh it is it is going to be a huge part of the future my crystal balls a little bit cloudy as all ours are at thispoint.
Yeah so I think anybody who comes in and tells you they've got the answer I would be questioning that because the field is just moving so fast we are deeply involved in using you know large language models generative AI approaches within our research and building tools within ourclinic.
I do know that I don't think that that these AI tools are going to put pain docs or other docs out of business but I think that the docs that don't use them will be out ofbusiness.
I think from an augmenting our clinical care they're going to be invaluable and allow us to do thingsbetter.
From a research standpoint I see some incredible opportunities and we need to be rather thoughtful about how we applythem.
Let me just give you a simple simple breakdown onthis.
We have these models these AI models that are interpretable and AI models that are black boxes you're familiar with this so as a visit black boxes mean we don't know what the heck is going oninside.
Now as a physician we are probably not going to trust an AI system that just gives us an answer and we don't know where the heck it came from but we will trust something that just gives us a suggestion or anidea.
I think the key for us is to use these AI models where they provide interpretable results we can look under the hood we can see what's going on and understand those factors that are contributing to its decisionmaking.
That's I'm particularly excited about that in finding insights into our research data I've been impressed with some of the AI models on our brain imaging data and some of our biomarkerdevelopment.
So all I can say is it's an exciting time we need to take some care and being cautiously optimistic appropriately skeptical and using these tools as wisely aspossible.
I don't know what Jonathan what do you think you've been you've been probably asking that question to a lot of people if you got any any clear definitive answer pretty much anyone who I trust is said it's fascinating we're using it and we're holding on for dear life and we have to takethat.
Yeah,yeah, it's like you wake up tomorrow it's like oh something new wow but it is I mean I think of any application that I've you know talked to people about are seen involved in the applications in various parts of medicine to me or where I just see you know potential potential for really stunning acceleration of ideas and solutions and interventions and just knowledge happening and like you said you know we also need to be thoughtful and ethical and cautious and keep people in the middle of this whole experience so I'm excited you know for where it's all headed feels a good place for us to come full circle as well so question I always wrap up with everyone in this container of good life project if I offer up the phrase to live a good life what comes up I am living a great life so I have a life Beth and I live on top of a mountain where we work darn near every day and our work is going to be a greatdeal.
Our work is tied in with our life and our mission and we're both committed towards improving the lives of people in pain that's what why we were put on thisplanet.
And at the same time every day she comes down and drags me out into the forest and we go for a forest hike for an hour and a half or so and walk in the trees and it's a creativetime.
Where we can talk about our lives and also about pain and then we come back and do more and so you know I recognize what a blessed life I have I come from a very working background and person only person to go to college I think so I'm appreciative of the gifts that have been given to me and I just want to put those to good useand.
Beth feels very much the same way so I think it's having that meaning and a purpose and a way to it Stanford execute on that purpose to make adifference.
Thankyou. Hey before you leave if you love this episode say that you'll also love the conversation we had with Dr David Segal about the science of longevity you'll find a link to his episode in the shownotes.
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