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For Scientific American Science Quickly, I'm Kendra Peer-Lewis in for Rachel Feldman.
From stubbing your toe to dealing with the occasional headache or sore back.
To experience pain is to be human.
And for minor aches and pains, the occasional over-the-counter medication is usually enough.
But what happens if the pain we're dealing with isn't a one off?
What happens when that pain becomes chronic?
According to 2023 data from the U.S.
Centers for Disease Control and Prevention.
Roughly a quarter of US adults experience chronic pain.
Rachel Zofnitz, a pain scientist and an assistant clinical professor at the University of California, San Francisco, who also teaches pain science at Stanford University, argues that pain is often misunderstood by the general public and by doctors.
The end result, she says in her new book Tell Me Where It Hurts.
The New Science of Pain and How to Heal is that many of us are suffering from more pain than necessary.
I talked with Rachel about her misconceptions around pain and what we can do to reduce how much pain is in our lives.
Here's our conversation.
So what got you into studying pain?
A couple of things.
First of all, I was scared of pain.
You know, pain's an aversive experience, and I think most humans are scared of pain.
But when I took my first neuroscience class as an undergrad nerd at Brown University, I discovered that pain lived at the intersection of all these things.
I wanted to study.
So I couldn't decide what I wanted to be when I grew up.
So I was taking neuroscience and I was taking human biology, brain and behavior.
I was taking psychology courses and pain looked smack in the center of all of those things.
And I really glommed onto it.
So I ended up conducting my honors thesis on anxiety pain, neuroscience and the endogenous neurotransmitters that regulate pain.
And I just really never stopped studying it.
So it's actually funny that we're doing this interview today because I'm actually in pain.
I tweaked my shoulder last week.
I've hit that age where it takes longer to bounce back.
And basically, I think, one of the questions that your book raises and answers, I think, but at a basic level what is pain?
Because so often we're taught that pain is a signal that you tweak your neck or you touch a hot stove.
And so you feel pain.
It's our body's response to injury.
But you say in your book that pain is a lot more nuanced than that.
So in your definition, what is pain?
Yeah.
So simply put, pain is our body's warning system.
It's our danger detection system.
And it's adaptive and evolutionary, right?
Like pain helps us survive.
It tells us Pay attention.
You may need to change your behavior.
Something dangerous and bad might be happening.
The problem is that we've all been fed a lie.
It's a lie that really bothers me.
And the lie we've been sold is that pain lives exclusively in the body part that hurts.
Like if we have chronic back pain, we will see 15 back doctors and maybe have multiple back surgeries and probably get some prescriptions.
And those things can be helpful.
But here's the problem.
Many, many decades of neuroscience tell us that pain is ultimately constructed by the brain, of course, in concert with input from the body and also our environment.
But one of the reasons we know that pain is constructed by the brain is because of a condition called phantom limb pain.
And phantom limb pain is when someone loses a limb, an arm or a leg and they continue to have terrible pain in the missing body part.
Now, If you can have terrible leg pain in a leg that is no longer attached to your body, that tells us pretty definitively that pain can't just live in the body part alone.
And of course we now know pain is ultimately constructed by our brain and our central nervous system.
So what we know about pain is that it's a lot bigger and more complex than we've been led to believe.
But in my mind that's actually good news, not bad news, because if the surgery hasn't worked, there's a million other things we can do to change pain volume.
I think the examples in your book were I think a construction worker put a nail gun through his nail boot and then he got to the ER and he was like in so much pain.
And then he got to the hospital and they realized that the nail hadn't gone through his foot.
So like the pain was completely gone. constructed by the brain in that kind of example.
And then, on the flip side, there was that gentleman who, like put a nail gun through his skull and like didn't even know, until he went to the dentist and they x-rayed him for an unrelated tooth pain.
And that man had no pain.
I guess the question that I have is like, what does that tell us about treating pain?
Because really fundamentally, like if you break your ankle and you're in pain, that's one to one.
You take pain meds and your ankle heals and you're done.
But your book really hones in on like chronic and systemic pain that's a little bit more different.
You've asked good questions and like seven of them.
And that's how it goes with pain, you know.
So I want to try and answer your question which, to me, is at the real heart of what pain is and how we treat it.
So there's this word that describes what pain is.
And the word is biopsychosocial.
And if folks listening remember nothing else from this interview, I want you to take home this word with you.
Biopsychosocial, pain is always biopsychosocial.
And I wanna say what that means.
So if you imagine a Venn diagram with three overlapping circles, One of those circles is bio, like biological factors that make pain.
One of those circles is psych, psychological factors that contribute to pain.
And one of those circles is social or sociological factors.
Pain lives smack in the middle of those three domains of pain.
I go into that in the book for a reason because it's not necessarily intuitive.
It's a little more complicated than we realized.
But what's really cool is about telling people that pain is biopsychosocial.
And I'll say a couple of examples of what that means in a moment is that it gives us literally a million ways to adjust pain volume and change the pain we feel.
So in the bio domain of pain we have, like the things we've heard about the most genetics, tissue damage, system dysfunction, which includes disease, and also diet, exercise and sleep.
And I like including those there because it reminds us, of course, pain feels worse when sleep is poor, when nutrition is poor.
And depending on how much or how little we're moving our bodies we all know that changes the pain we feel.
We have a lot of agency over those things.
The psych domain of pain is full of stigma and misunderstanding.
Like if you even talk about that, people assume you're saying it's all in my head.
It's just psychological.
So I'm very careful to always say that.
All pain all the time is biopsychosocial.
Just as pain is never purely physical, it's never purely emotional.
It's always all the things.
So in the psych domain of pain, most importantly in my mind, is emotions.
Emotions change the pain we feel.
And I can tell you why.
Like just basic, straight up neuroscience.
The parts of the brain that make emotions change also make pain.
So, like our limbic system and our amygdala are critical parts not just of the emotion machinery but also the pain machinery.
So negative emotions will amplify pain volume and positive emotions will turn pain volume down.
And also in the psych domain, believe it or not, we have predictions and expectations, like we've all heard of the placebo effect.
That is real right.
We also have coping behaviors.
Like how do we cope with pain once it starts?
Do we isolate, stay home, stay inside, stay in bed, stop moving?
That will amplify pain volume.
And then in the sociological domain of pain, I like to think of that as like the everything else domain, because it's socioeconomic status, it's access to care, it's race and ethnicity.
It's also social support and our social health.
Are we isolated and alone?
Do we have social support?
So all of these things together actually create the pain we feel.
And that's very hopeful for treatment because it gives us a roadmap for treatment.
I have a good friend who had chronic pain for about a decade.
She'd been in a pretty severe car accident.
They ended up, I think, doing like spinal fusion on her back and it didn't work basically.
And so she would be in this state, where she would wake up in the morning and she worked remotely before.
Working remotely was cool.
So she would like work through part midday, and by midday the pain would be so severe she'd have to take pretty strong pain meds.
And that would be like the end of her day.
And she tried hypnosis and it worked.
And what the hypnotist told her, and I don't know if this is made up, but they were like you went through a car accident.
You were in pretty severe pain.
And sometimes that pain signal just gets stuck.
So you've hit past the point where your injury is healed, but your brain is still sending the pain signal.
And what the hypnotist said is that the hypnosis disrupts that pain signal.
Is there any truth at all to that?
Hypnosis really needs major rebranding.
Who wants to be hypnotized?
Are you going to make me buck like a chicken?
The word has such terrible associations, but Clinical hypnosis was established by medical doctors, clinical hypnosis, and it does have evidence of effectiveness for pain.
Of course it's different for different people, but it hits a lot of those things in just the pain science, the pain recipe thing that I just explained that actually can lower pain volume for lots of people.
So obviously I can't speak to your friend, but I can tell you how pain becomes chronic and how it relates to your friend.
Sure.
So you said she had pain for 10 years.
And I get that question a lot from people with chronic pain.
Like, my injury clearly has healed.
It has been 10 years.
What is happening in my body?
And this goes back to that thing we just established, where pain ultimately isn't constructed just by the body part that hurts.
Pain is ultimately constructed by the brain.
And the brain is a fascinating and gnarly place where lots of interesting things happen.
One of the things that happens is neuroplasticity.
Neuroplasticity is the ability of the brain to morph and change with experience, time, and exposure.
So here's one of the ways pain becomes chronic.
I'm going to use science words because we're a science podcast and we love science.
So One of the predominant ways pain becomes chronic is by a process called central sensitization.
What does that mean?
Central because it's central nervous system.
Sensitization, because the nervous system, our pain system in particular, becomes hypersensitive over time.
So here's how this works.
I want you to think of a skill any skill you were bad at, You practiced over time and you got good at it.
For me, it was the piano.
My mom used to make me practice and I was really grouchy about it, but I got good at it.
What about you?
Clarinet.
Clarinet.
Perfect.
So I'm going to use your example.
The more you practice the clarinet in like neuroscience nerd language the bigger and stronger the clarinet pathway in your brain got.
So too for me with piano, like I got to a point after a lot of practice and time where I could sit down at the piano and my fingers just magically knew what to do.
Like I didn't even have to look at the sheet music.
That's because of neuroplasticity.
Now unfortunately, the brain strengthens the pathways we use, whether it's something we want or something we don't want.
So the more we have pain, the bigger and stronger the pain pathway in the brain gets with time.
And when that happens, we say that our brain and our pain system have become sensitive to pain.
And it's taken me a while to sort of explain that word, because there's some like stigma and shame attached to the word sensitive.
So I want to say very clearly, like I live in the Bay Area where we have earthquakes.
You want a sensitive seismograph looking for earthquakes.
Because a sensitive machine is Yes, detects input and magnifies it right.
So you know, if there were a dog in this room and it came into and started sniffing around, it has a sensitive nose, a sensitive sense of smell.
It would detect really faint sense that you and I can't detect.
And to a dog's nose and brain, faint sense are amplified.
So too is it true of a brain that has become sensitive to pain.
When our brain has become sensitive to pain, it picks up and amplifies small bits of sensory data from the body and it exaggerates it.
It amplifies it.
And it tells us there's danger when there isn't.
So, like with my patients who have, for example fibromyalgia, they will tell me they will go to a picnic and their brain will give them this terrible, loud danger alarm.
Because again, that's what pain is.
It's our body's danger system.
And I will ask, Is going to a picnic dangerous when you have fibromyalgia?
The answer is no.
But your sensitive brain is giving you this loud danger alarm anyway.
So when it comes to chronic pain, we know chronic pain is a disease process in its own right.
And the brain has become sensitive.
Central sensitization has occurred.
That's my long way of saying.
I suspect that probably is what was happening with your friend, who was in pain for 10 years post-accident, especially given that clinical hypnosis administered by a care provider was able to lower pain volume, have central sensitization.
Can it be as specific as like a specific pathway?
So like, the ankle that you've injured before might be more sensitive to pain than the ankle that was like never injured
Yeah, that's such a good question.
And I think the answer is yes.
And I don't want to answer definitively, but it would make sense because one of the parts of the brain that makes pain is your hippocampus, which is part of your brain that stores pain memories.
And we learn from past pain experiences.
Those are stored in our hippocampus.
So, like as a kid, if you touch a hot stove you bet your ass.
You will remember that that triggered pain and potentially damage, and you won't do it again.
And I think so too.
You know, the body keeps the score.
We know that's true.
So past injuries are remembered by your brain.
And I think we hold maybe a little more protectively the parts of the body that we've injured in the past.
Your book's central thesis is that because we so fundamentally misunderstand pain, especially chronic pain, we don't have great treatments for it.
I was like shocked in reading your book to learn that the US, even though it's roughly 5 of the world's population, uses around 80 of the world's opioids.
What other ways does mismanaging pain kind of impact us or turn up in sort of American culture, if you will?
Yeah.
So you mentioned before what I call the tale of two nails and you summarized it well.
There was a gentleman who jumped off a plank onto a seven inch nail.
It went through his boot, clear through the other side.
He was in terrible pain.
But when the doctors removed his boot, they discovered that there was no tissue damage and there was no wound and there was no blood.
And his brain.
Of course, our danger detection system used all available data to decide whether or not to make pain and how much.
I think the biggest problem we have in Western medicine is that we sell people and I do use the word sell on purpose this big lie that pain is a purely biomedical problem, something to do just with anatomy and physiology.
That requires a purely biomedical solution, which usually comes in the form of pills and procedures.
We have a profit-driven healthcare system.
Like pharma is finally being taken to task, to the tune of 54 billion, for selling us the lie that chronic opioids are safe for chronic pain.
We, of course, know that that isn't true, but if you have pain, you will go to the doctor or maybe five or maybe 10 doctors, and you will be told that your pain lives in the body part that hurts, like your bad back or your aching knee, and you will be prescribed Solutions that focus again on anatomy and physiology.
Now, why is that a problem?
Neuroscience has known for going on 65 years that pain is a biopsychosocial problem, that there's a whole recipe of ingredients that contribute to the production and reduction of chronic pain.
Yes, body parts are important, but they're not the whole picture.
And there are so many things we can do to reduce pain volume beyond pills and procedures.
And again, I am not anti-medication or anti-surgery.
Those can be life-saving, but they're just not the full picture.
So There's part three of the book is an entire pain protocol for people living with pain to walk people through.
Like there's no point in me holding the information.
I've been studying pain a long, long time but, like me, holding the information and helping the handful of people who can come see me isn't the answer.
You know, I want, power to be in the hands of people living with pain.
I just want to say there's actually a lot of hope for treating pain.
There's many, many things we can do.
But as long as our culture persists with this myth, what are we as patients supposed to do?
And to add to that, one of the reasons this myth persists is that 96 of medical schools in the United States have zero dedicated compulsory pain education.
That is mind blowing.
And, like the 4 of medical schools that do have pain education, really focus on the biomedical model anatomy physiology, biochemistry.
So like.
I say this with great compassion for our healthcare providers.
Like our doctors go into this field to help and heal, and we're not arming them with the information they need to do the job that they signed up to do.
So can we talk a little bit about the pain protocol that you kind of outlined towards the end of your book.
Obviously, it's an entire section, but what are the highlights, if you will?
Let's see.
Okay, so the pain protocol...
I think that pain can feel extremely overwhelming.
And what that means for a lot of us is that treatment can also feel very overwhelming.
Like, great, I threw this big word at you, biopsychosocial.
What am I supposed to do now?
So I divided the protocol up.
You know, we said there's three major pillars of pain.
We said bio, we said psych, we said social.
So I divided each one of those into very discrete parts with very discrete activities that are extremely achievable.
And every person who will approach it will have a different experience of pain And we'll need to start in a different place.
And certain activities will resonate and others won't.
But in the bio domain of pain, for example, we have sleep hygiene, because pain somnia, is a real thing.
Pain somnia is that thing where we have pain and pain makes sleep hard.
But the poorer our sleep, the worse pain feels.
So it has a whole protocol for sleep hygiene.
It has some tips for nutrition.
So in the psych domain, we talked about emotional health.
So just some like low hanging fruit.
We know that stress is one of the biggest pain amplifiers.
And my patients know that.
They will tell me that during periods of intense stress, their bodies feel worse.
By the way, that's just biology.
When our bodies are stressed, our muscles are tense.
Our bodies are cranking out high levels of stress hormones like cortisol, which raise pain volume.
It also changes our brain chemistry in a way that will amplify pain volume.
So low-hanging fruit for the emotional domain of pain is mapping out our stressors and then putting caps around them.
Like what are things we can do?
For example, maybe I won't doom scroll at night or watch the news before bed.
And in the sociological domain of pain, there's also In part three, some other low-hanging fruit.
For example, we know that social isolation is a pain amplifier.
So what can I do to increase my social support and set boundaries around toxic relationships?
Because we know that those make us feel worse.
That is awesome.
And obviously, if people want to know the full sweep, they can check out your book.
Can you remind everyone what the title of your book is?
Yes.
The book is called Tell Me Where It Hurts.
And I believe you can find it on bookshop.org as well as Amazon.
Thank you so much for taking the time to speak with us today.
Thank you for your great questions.
You can watch the video version of this conversation on the Scientific American YouTube channel.
That's it for today.
See you on Monday for our weekly science news roundup.
Science Quickly is produced by me, Kendra Peer-Lewis, along with Fonda Mwangi, Shishmita Patek and Jeff DelVecchio.
This episode was edited by Alex Saguiera and Naeem Amarsi.
Shana Poses and Aaron Shattuck fact-check our show.
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For Scientific American, this is Kendra Peer-Lewis.
Have a great weekend.
