Dr. Sean Mackey: Tools to Reduce & Manage Pain
02:52:39 Share

Welcome to the huberman lab podcast, where we discuss science and science space tools for everyday life. I'm Andrew huberman and i'm a professor neurobiology and optimal gy at stanford school of medicine. My guess today is doctor sean mckee.

Doctor shaan maki is a medical doctor, that is, he treats patients as well as A P, H, D, meaning he runs a laboratory. He is the chief of the division of pain medicine and a professor of both in ac, sio, logy and ology 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, doctor macy makes clear what the origins of pain are within the nervous system and outside the a system, that is, the interactions between the brain and the body that give rise to the thing that we call pain. Indeed, we discuss the critical link between physical pain and emotional pain, and how altering one's perception of emotional or physical pain can often change the other.

We also discuss some of the changes in the nervous system that occur when we experiences pain and how that can give rise to chronic pain. We also, of course, cover different methods to reduce pain safely. 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 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 oppoi s oppos are substance that your body naturally makes.

But of course, many people are familiar with exogenous oppos, that is, oppos that are available as drugs. And the so called oppoi crisis doctor maxy makes very clear which specific clinical circumstances warrant the use of exogamous opposites, with the is a warning about their potent addicted potential. And we get into a bit of discussion about where the opioid crisis and the use of O, P, O drugs to control pain is and is going.

Before we begin, i'd like emphasize that this podcast is separate from my teaching and research was at stanford. IT is, however, part of my desired effort to bring zero cost to consumer information about science and science related tools to the general public. In keeping with that theme, I like to thank the sponsors of today's podcast.

Our first sponsor is element. Element is an electoral light drink with everything you need and nothing you don't. That means plenty of salt, magnesium in patasse, this so called electorate, and no sugar.

Now, salt magnesium and parasitic are critical to the function of all the cells in your body, in particular to the function of your nerve cells, also called neurons. In fact, in order for your neurons to function properly, all three electro lights need to be present in the proper ratio. And we now know that even slight reductions in electronic concentrations or dehydration of the body can lead to deficits.

And cognitive and physical performance element contains a science back electorate ratio of one thousand milligrams, that one gram of sodium, two hundred milligrams of potassium and sixty milligrams of magnesium. I typically drink element first in the morning when I wake up in order to hydrates my body and make sure I have enough electrical lites. And while I do any kind of physical training, and after physical training as well, especially if i've been sweating a lot, if you'd like to try element, you can go to drink element that's element t dot com slash huberman to claim a free element sample pack with your purchase.

Again, that drink element element dot com slash huberman. Today's epo de is also brought to us by waking up, waking up as a meditation APP that includes hundreds of meditation programs, mindfulness trainings, yoga ea cessions and nsd r non sleep depressed protocols. I started using the waking up up a few years ago because even though i've been doing regular meditation since my teens, and I started doing yoga eja about a decade ago, my dad mentioned to me that he had found an APP turned out to be the waking up APP, which could teach you meditations of different durations.

And IT had allowed of different types of military to place the bringing body into different states, and that he liked IT very much. So I gave the waking up up a try. And I too found IT to be extremely useful, because sometimes I only have few minutes to meditate, other times have longer to meditate.

And indeed, I love the fact that I can explore different types of meditation to bring about different levels of understanding about consciousness, but also to place my brain body into lots of different kinds of states, depending on which meditation I do. I also love that the waking up up has lots of different types of yoga eda sessions. Those you don't know.

Yogananda is a process of lying very still, but keeping an active mind. It's very different than most meditations. And there is excEllent scientific data to show that yoga ea, and something similar to IT called non sleep deep brer N S D R, can greatly restore levels of cognitive and physical energy even, which is to a short ten minute session. If you'd like to try the waking up, you can go to waking up dot com slash huberman and access a free thirty day trial again, that's waking up dot com slash huberman to access a free thirty day trial. And now for my discussion with doctor Shawn maki, doctor mckee, welcome.

Oh, it's a pleasure to be here. Thank you.

This is a long time coming where 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 a emotional component to at.

And IT is incredibly individual. And we'll get more into that hopeful. Ly, as time goes by that you know, your pain is different from my pain and is different from everybody else, is IT takes an incredible toll on society when IT goes chronic, when IT becomes persistent to the tune of about a hundred million americans.

And at last count, about a half a trillion dollars a year in medical expenses are so an astounding problem we're facing in society and one that's only getting worse. And i'm hoping during the course of this discussion that we can kind of break down a little bit of the foundation of pain and kind of build IT back up because unfortunately in society, there's a lot of misunderstanding about what pain is. And I think hopefully we can build a foundation and then lay iron some some useful treatments and usual options for people.

And glad you pointed out this link between the sensory and the emotional experience. Everyone's in a while, i'll pull something. I'll have a like a pink in my neck or my back. And fortunately for me, IT results pretty quickly. But I noticed that when i'm experiencing that kind of pain, that I become slightly more irritable, perhaps much more vital depending on who you ask, and that everything becomes more chAllenging, thinking is harder, sleeping is harder, concentrating on anything besides being it's um IT as if something in's nagging from the inside. And so that raises the next question that I have, which is, is paying something that 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, love, pain. We know that pain, most pain all starts with some stimulus, whether would be that kicking 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 paint. What's going on is that, uh, there are sensors in our sin, or soft tish, or deep tissues called no secretory. And these noses factors are sensing elements, and they sense different types of stimulation, can sense temperature, uh, heat, cold, they sense pressure.

They can sense PH changes due to, for instance, information that may occur from a any something going on in your neck, your shoulder. Those sends signals up their fiber types. And the two that we we refer to, our adult sea fibers, one transmitted very fast.

It's responsible that you know sharp joel to pain that goes to your brain when we, you know, step on attack or put her hand on a hot stove. And there's another fibre called a sea fibre, which is much slower and responsible for that dull ache pain. Now these signals, they go to the spinal court, lie up and down, or a from our head, down to our a, our back, and their their shaped, their 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 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 exception.

Those are electrical signals, electrical chemical impulses being transmitted. And that is to be distinguished from what becomes the subjective experience, the pain you have. And why it's critical is that our brain serves so many functions of emotions, cognition ans a 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 is.

And I think that's important to know, because we are frequently left with this notion of this one to one concordance between the stimulus and the experience of pain you know renae a court that french philosophy in seventeen th century um was the one who first populated this idea of this direct linkage between the body and our actions and the stimulus in the response. It's wrong. And unfortunately, even in medical care, we have this biomedical model that still is perpetuating this idea of a one to one relationship.

And that's a critically important point to get across, in large part because frequently as humans, we tend to project onto others our own experiences of pain. And when we see somebody who's got an injury, something else going on, we immediately put that on them. And that has also been a problem with many people suffering in chronic pain, which is often viewed as the invisible disease.

So when you say we put that on them, you mean when somebody reports being in pain, we have a hard time understanding what they are experiencing because it's going to be very different than the way that we experience pain. Conversely, if somebody dies in pain, they tend to assume that people are experiencing pain the way that they are. Do I have that right?

You have a perfectly ride. And IT, actually, if I can build on that gets worse. Because sometimes you have conditions like fibre biology that maybe will get into where.

Visibly, you don't see anything wrong. We're you used to thinking of pain as a fractured, you know, a bone as a swallow and ankle. We see that. And then we were like, okay, well, you've got pain. You've got legitimate pain. Whereas this invisible disease of chronic pain, frequently, you don't have something awards 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 somewhat mechanistic, but will keep IT accessible anybody, regardless of their background. So you mentioned the noses cept, or are in the body and everywhere in the body and on the surface of the body to be able to detect certain inds of. And then those signals are sent up into the brain.

And the brain creates the subjective experience that we call pain, is very dedicated set of areas in the brain that are something akin to like a pain pathway. And the reason I assess is that for you, for vision, for hearing, for touch, we probably all experiences those somewhat differently. Your perception of red is probably little different than my perception. 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 is supposed to like an area in the brain that 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 the thing that we call pain um like is there in area of the the thalamus structure in middle the brain that takes in coming sensory information that we could say, oh, that's the pain pathway is there a part of our new cortex, the outer shell of the brain more or less beneath the skull but none there's on the outer portion of the human brain that we could say, oh, that's where pain is this or is IT a distributed phenomenon?

Yeah, that's a great question. And you know, because we'd all love that there was a pain center and the brain that we could just go knocked out, but it's not that simple and in part because pain is such a conserve phenomenon IT IT is there IT is so wonderful because IT is so terrible unless IT was wrong. But when you knock out one pathway going to the brain, there's others there that will Carry that system forward and you'll still experience pain, and it's there to keep us all alive.

Now to get to your point now 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 time called at the pain matrix which represented areas such as um the insult core tex, the singular core tex, the amiga la, a number, these brain regions that all subserve different functions were moving away from that because IT seems like every year or so we pick up another region of the brain that contributing to this network that observed some additional functions, some nuances layer to IT. That said, we have been able to identify some common signatures, common brain networks, that seem to represent the experience of pain. And this is where the development of brain based biomarkers has come in. And this is some of the work that i've done starting gash well over a dozen years ago, and others have been building on. And what we're finding is that there does seem to be this this conserved region set of distributed regions that do represent the experience of pain.

So when somebody takes a so called pain killer, let let's take a typical over the counter pain killer, like a ibo proof in, or ceda manifest to a lesson pain of some kind. Where is that drug or drugs acting? Is IT in the body or is IT at the level of the brain or both?

yeah. And this is where some of the chAllenges we get into with language because technically and sets non stroyer anti and flaming drugs like I be proof and like naper son, they're actually not analgesics. They're not technically pain killers. So an .

analgesics is the description for a court pain killer yeah there .

that would be more correct. Like an opioid would be would fit into that category. The end sets are anti flaming drugs. There are also there's another this is a technical term, their anti hyper L G sic drugs. And so one of the things that happens after an injury is that we get sensitization of the area that injured and its a beautiful thing because IT sends a message to us to protect IT. Um what the answer do is they reduce some of that sensitization out in the prophet y in them back in the spinal cord, on in the brain, but they don't actually suffer stance. 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, measured the amount pain i'll go taken and set like i'll be profit if you hit your hand with that same fork theyll be no difference folks .

please .

don't do don't do that at home place. Yes.

or any or anywhere for or anywhere for that matter. But you're describing pain and the local inflation tion response and the hybrid gensia, the increasing 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, any time i've done, you know, surgeries on animals, which I don't do anymore in the laboratory, but we used to, you would give them painkillers post Operation vely. I've had surgeries before had pain killers post Operative ly, although I don't like taking them and like the way they make my brain field. So ah but we of course know that if you increase the dose of any pain medication too much than that a animal or a human can potentially injure themselves worse or not protect that in geria.

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 now allow the pain to be there is an adaptive way of protecting yourself in healing presumable. The information is part of the healing process to and as you mentioned before, paying is so subjective and it's different between all of us. I mean, how do we decide, uh, whether not is a good or bad idea to blunt that pain?

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

I problem that was nonsteady to inflammatory drugs. Indeed, we maybe list off a few though. So I mention i'd be proof in the see to manifest.

So sometimes referred to us in the classic adult, and all we won throw out name brands there. But what are some others? And a proxy.

the proxy is another one toward dollar cute roll. Lac is another one, the two over the counter and sets the prototypical over the counter ones are ibu profit and a percent. Those the ones you can buy over the counter without a prescription.

A thailand all actually has a slightly different mechanism of injury, but you know, still fits in the same general class. IT tends to be more centrally acting. I be a thailand all or sea manifest.

But we say essentially you mean great.

Thank you.

No thank. And and is aspirin considered and and .

said I don't fit into that category of basically a cox psychology's ais and habit or this is one of the the chemical mediators that gets released in injury and that chemical uh substance has attendance to wind up or amplify the non sell tors so that after an injury, you note that you're more sensitive there. After a sun burn, you end up having more sensitive ation that is what we refer to as peripheral sensitization because it's out in the prophet were winding up or amplifying the response uh aspirin and sad in general will reduce that information. Their anti um hypersaline sic and part and again the darg any terms that we use .

come to grow long as we go.

But but you know for 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 opposite just so that you can continue walking on a fractured ankle that you haven't gotten evaluated by a clinic in 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 they send the person back out on the field with a broken bone, you know, having given the injection or something, i'm hoping that doesn't go on anymore.

but i'm sure IT goes on. okay. Yeah, there's all sorts of other things. I get contact all the time, professional teams and athlete asking how they can get back in quicker nowaday. The big thing or these peptides that can certainly accelerate healing.

People traveling out of country get stem cell injections with very few render ized control trials. But I assure you that court side in the locker room, mainly in the locker room there corticosterone injections. They are paying killer injection.

I mean, it's not play at any expense ah, but it's not far from that. okay. Now yes.

well, you know when you you're making millions of dollars a year and I get the being back on the field, but for the rest of us, mere models, um I think that's what we would want to draw line, get medical attention if you've got an acute injury going a little .

bit deeper in the mechanism because I think it's going to show as well now and going forward. You mention the end sads and this C O X. Cox is one is, is that in the family of prostate gland? Yes, could we talk about prosthetic? Because I think there are a lot of people now is we hear about inflation tion.

No, inflation tions bad. Inflation tions bad. But you know, one of the things that we talk about, a lot of this dca, is the fact is in the inflation tion is in bad.

These things serve an important biological role. So the prospect lands seem to be one of the main ways that are immune system response to a physical or chemical injury and and creates inflation tion. And that as you said, that inflation tion sensitizers in area makes IT literally more sensitive.

And then we introduced these drugs that um to restore Normal functioning and living, could we establish like what Normal functioning is? I mean, for instance, we make this really concrete. Could we say, well, if you can sleep, fall, sleep at night and stay a sleep, or perhaps go back sleep after you've oke him up in the midnight, then.

Well, you heal during sleep, and so, you know, take as little pain killer as possible, but enough that still lets you sleep well at night. Is that sort of Normal functioning? Because I, when I A kink in my neck, I don't want too 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 new once the complexity of this problem because we've been talking about answer the ibi province and now percent. And as I said early on, ways to just give this out all the time. But then the research comes out and shows that by blocking information, 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 and tissue repair. And so now you've got, on one hand, a medication may help with pain, help you improve function.

You 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 gonna heal and you're not gna be able to do what you need to do the next day. And if taking an answer helps you sleep and helps you a engage with what you need to do, take IT at the lowest dose that you can get away with.

I've heard before that inside should be taken no more than once every six hours. People alternate different types of inside every three hours that usually to try and reduce fever. Another situation where an adaptive response fever, you know, people go out other way to block IT, right, to prevent the brain from coking.

But again, that 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 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 and sets this classic medication reducing pain. We have data of showing the bad consequences of IT. And so we are still needing more data on the whole healing message.

I think that a lot of the orthopaedic surgeons out there prefer people not to be on insets after france since total hyp replacement, a total new replaced 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 and sets like we mentioned, I B proof and appreciate huge individual variability around those. So personally, I B profit is not very effective for me.

No person is for others, that may be just exactly the opposite. So there's value in rotating them and finding out which works best. For your particular situation.

You mention the timing of IT ibuprofen is typically given no more than three times a day. It's got a short half life, no person 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 G I issues, if you've got any bleeding issues, if you've got kidney issues, if you've got hard issues, talk your dock, talk to your clinic before you embark on this because these medications do have side effects and adverse consequences and vulnerable people. And what about aspirin?

I've heard that aspirin in can benefit heart health. So I take a baby aspirin every day. And if I have a pain that is just too intense for Normal functioning as we're defining IT, then i'll increase that dose of aspirin in. 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 now for you, your logic is perfect, and that's where IT gets to the individual person. And for a lot of people, that model would work as well. So baby aspin eighty one milligrams a day, access an anti plate, let age and IT helps.

You know, here, even though we're getting controversy over the role of baby asper, if you dive into the current litter baby after days and now what they're doing with with the data is defining age ranges when they say baby aspern, yes. Baby aspirin, no. And so we're learning a lot more about that.

I still take a baby aspin every day. Yeah, I take a baby aspirin. He get to the higher dose to say four times as much, up around three hundred and twenty five milligrams or so.

It's now in anti flaming. It's now acting more like the ib profit and the eperies. So different mechanism action at different doses.

I'd like to take a quick break and acknowledge one of our sponsors, athletic Greens. Athletic Greens, now called A G one, is a vital mineral probiotic c drink that covers all of your foundational nutritional needs. I've been taking athletic Greens since two thousand and twelve, so i'm delighted they're sponsoring the podcast.

The reason I started taking athletic Greens and the reason I still take athletics Greens once are usually twice a day, is that IT gets to be the probiotics that I need for god. Health, our god is very important, is populated by got microbiome that communicate with the brain, immune system and basically all the biological systems of our body to strongly impact our immediate and long term health. And those probiotics and athletic Greens are optimal and vital for microbiology alth.

In addition, athletic Greens contains a number of adaptations in vitamins and minerals that make sure that all of my foundational nutritional needs are met and IT tastes great. If you'd like to try athletic Greens, you can go to athletic Greens dot com slash huberman, and they'll give you five free travel packs that make IT really easy to mix up athletic Greens while you're on the road, in the car, on the plane, at sea. And they'll give you a year supply of vitamin d three k two.

Again, that's athletic Greenstock comm slash huberman en to get the five three travel packs in the ear supply of vitamin d three k two. I promise we won't go into every medication in such detail, but these are the most commonly used over the counter treatments for pain, as far as I know. Are there any issues with you know, people who drink caffeine who then are taking these drugs? Like what are some of the a, the a interactions that these things can have? As far as I know, caine actually touches into the prostate landing pathway.

yes. And that's where no capping can be effectively for headaches for migrants. And I can help potentiate the analgesic response. Some people get a stomach irrtation that with caffeine are just, again, mind that you take an answer with A A lot of coffee, have some food in your stomach.

You brought up earlier a seat of manifest or thailand all thailand all doesn't have the same side effect or adverse event profile that the assets do. So thailand all is safe on the stomach um where you need to be careful about thailand all is not to exceed four thousand milligrams or four grams per day divided doses. So two extra strength, thailand all done four times a day for many people is safe.

Some say two grams, some say four grams. The key here is around your liver. So you've got good liver function if you're not abusing alcohol.

That's a general rule of them that you can use for thailand all. But it's not going to upset your stomach. There are versions of the assets that we referred to as cox to inhibited. They are very selective like cacos b that is a less irritating on the stomach that's by prescription only though.

But you can think of IT is working very much the same as the napery ent of the ib, proven to talk with your clinic, you know, to try to teeth those apart if you have problems in your stomach with the end sets, and they're really effective for you. You can be given other types of medications that help block or reduce the G. I 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 news science about, I think it's milk and walls, a gate theory of pain.

Do I have this right where know we all have this instinctual response? Animals have IT too, right? If they are, you bump your knee, or your toe that you grab in, you can rub bit.

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 concerned rate. And then i'll let you 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 below the side of pain, maybe active puncture um so again, there will be chemical of any mechanical intervention right as we know, because that's the language of the nervous system, electricity and chemicals but as well as taking a drug give you a using manual stimulation or rubbing around IT or or perhaps we can also talk about hidden cold. So could we explore that space of a bit?

absolutely. And first you're right. So um in your first part pack Patrick wall, ron malec, luminaries in the field of paying back in the sixties, find the gate control theory of pain and one of the things to build on the story that we talked about with no sceptres going to the spinal signals, going to the spinal cord, heading up to the brain where the perception of pain occurs.

That's not where the story ends IT. Turns out there are pathways that come down from the brain, down from the brain to the spinal cord, that act in an inhibitory ory role and will build on those also from the peery. We've got also fibers called touch fibers.

These are the ones who they get activated with, like touch stroking, they referred to as a baa fibers. They're fast conducting. They head back to the spinal cord, and they make some connections with those no suspect fibers.

So without grounding, imagine what you said, you you hit your thong with a hammer. You um uh you bang something on an extremely um what is the first thing you do when you hit your thun with a hammer? Some people rub bit nice yell, some people swear and IT. Turns out there are studies that show that swearing works. Really swearing reduces .

pain Better than then using non explicit uh yes, loud vocalization yes.

swearing works. I don't know why, but there's been IT cuts impressed when that paper came out and. Yeah, I don't i'm not giving car the launch. We're not saying everybody can go out and swear every time .

they're in pain. Well, do they can. But y'll have to bear the consequences on an individual basis. We're not we're solving ourselves in.

So robbing shaking is another one, which basically is activating those touch fibers.

But what did I do that? Everybody does.

Everybody doesn't. Running IT under water, which you know, doesn't matter where the, you know, in this case is hot, is cold water. It's the running of the water underneath IT.

And what is IT doing? We all think it's reducing the stimulus out here. And IT is not at in the prophet and the prophet. What's magical about, I think, which is so cool, is you're actually changing the signals in your spinal cord way back here in the net. This is the cheapest free version, uh, 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 its reducing the no secretive signals coming in here. That's why we do IT and IT works. IT works beautifully. That's why when a kid gets the bubo, you know, our parents come on, rabbit IT works.

What about the kiss? The kids sometimes only want to kiss, know, or romantic partner will sometimes like into themselves. I guess that depends on the nature of the relationship.

And y'll say, like, can you kiss IT? Of course you you kiss IT. And then like, they feel Better that the psychological.

well OK. I think an important point to ground here when IT comes to the experience of pain is that everything, when we say psychological means neuroscience.

Yes, no, no. Forgive me. I have to be careful with with the the wording that I use. That's my fault.

But it's accurate. Still, IT is psychological, that IT is neuroscience based. I mean, the really becoming one in the same. But to answer your question, yes, by kissing IT your activating touch fibers, we can also agree that there's a positive of emotional silence is associated with out and that positive emotional silence is reducing pain too.

What interesting up uh wall in melac sometime later, uh there is the introduction of a device to take advantage of this called the tense device. And tens is an acronym, trans cutaneous electronical neural stimulation and what the tense device is doing. There are many versions of IT now, but there are those black electorates you put over the area and they're hooked up to wires. And when you turn IT on, IT causes a buzz sensation in that buzz sensation is activating those touch fibers, the ebay of fibers. And so it's causing that neuromodulation back in the spinal cord.

amazing. It's cool stuff. It's very cool. And and I love that you emphasize that when they're rubbing the prophet or shaking our hand with the prophet again, being the body surface away from the brain, that the real mechanism of action is taking place back in the spinal court.

Because IT really speaks to the the body wide and the circuit wide, the nervous system wide nature of the thing that we call pain, right, is is happening out to go out here in the preferred, but it's being modulated in the neck level of the spinal cord approximately. And then it's you being interpreted at the level of the brain. What explains different pain of thresh holds.

I could imagine that could be any or all of the locations that we've been discussing yeah and IT could be the context as well, right? If you are um you know i've heard before now know if this is true, that if you have a lot of a drinking epa in your system that your threshold for pain goes way wait up, there's probably a chemical basis for that and maybe it's all you know um anecdote but um certainly people have different threshold for pain. I for instance do not have a high pain but i've know I have a very quick pain response.

So if I stub my toe IT feels like the most painful thing I could possibly experience. But then it's gone very quickly. So it's like a quick inflection.

And then down other people I know we've never kept on the experiment. I think I see them stop their toe and they're and then you ten minutes later, they are still feeling the ache. So whose pain threshold is higher? That depends on how you to find pain threshold.

So how do we define pain thresh hold? What determines pain thresholds? And I guess the six million dollar question, are there different pains rush hold between men and women as IT relates to the whole story about childbirth binger painful, and that women couldn't have higher pay .

thresholds for you.

So what is pain threshold?

Yeah, no. IT. IT is a great place to start in. Maybe I don't know if you want to circle back around at some point to the heat and cold to finish up mechanical.

I mean, I know you're let me answer, you get to your pain threshold ld. So the pain threshold ld is, are 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 paying to a stimulus and your bodies. And that's Normal, that first onset of pain. Again, those are those fast fibers as a delta fibers, boom, right to your brain.

Those are the protective ones that when we put our hand on a hot stove, we immediately joke quebec. We don't even have a conscious 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 were converging into consciousness, ies of brain that we're like, oh, wow, that's so was really hot.

And the sea fibers in particular are converging. And more emotional regions in the brain that are conveying and unpleasant ness to that experience. You don't like IT, and you don't want that 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 thresh you asked one of the other questions is, do men and women have different pain thresholds? The answer? The short answers, yes, this has been established.

And I want to be careful here. We're saying a couple things. One is, in general, a men have a higher pain thresh holds to things like heat stimulus than women.

And what what people have to also, though, understand a scientist, 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, a thermal stimulus to them. And we draw averages.

The average man has this stimulus. The average woman has this stimulus. And we say, well, women have a little bit more sensitivity to that heat stimulus. And so we then go into the present, we say, a men are tougher than women at 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 thread hold for paye is lower, that is, IT serves a more adaptive function if you were injuries that I mean, I guess he gets into the implications of what we .

mean by court. 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, thresh holds than men do. But when you pull things, you end up with that difference. Unfortunately, when things are picked up and you want a quick sound bit out of IT, that's what IT gets to still down to.

So not unlike height for that matter, a lot of women that are taller than men, that's exactly IT. But on average, men are taller .

than women on average. And I would say within this area of pain threshold differences, it's even closer. It's even tighter.

You know, I would be on making this up the equivalent, I think the average age of a woman is five, three, five, four. The average child of a man five, nine, five, ten. This is imagining the average height being, you know, five, six for a woman in five, eight for a man.

You know, it's not a huge difference. There's a lot of things that play into changes in pain threshold, how much and this is where the brain comes in because you know much of the no sell tion, much of the signals that were um transducers were transmit. You know in many of us it's very much the same. It's when he gets to the brain now it's shaped and IT shaped by things such as um your belief about that stimulus, your expectations around IT, how much anxiety you're having at the moment .

does increased anxiety increase once perceived pain?

yes. okay. Yeah IT does um your early life experiences with this? So have you had traumatic experiences in the past that altered brain circuits?

Can I trode CT a question if one was told just sucked 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 worse, don't be a whip, do we know whether 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 dubia worse when they cried as a consequence of expressing pain or an experience of pain, secretly feeling more pain because they aren't able to express the emotionality around the pain, but that if we just look from the outside, we say, well, I like pretty tough adult, right? Because they're not crying out in pain. yeah. So do you have any are there any experiments that of .

explorer that I don't know you're getting into? This is a good point getting into a pediatric pain. And you know if there's been experiments in that space, I staying mainly in the adult tera and my experience with raising a child is an end of one with one son. He done great.

Thank you. I know very well he he's what you call a great example of highly successful reproduction.

So say, what do they say? It's Better to be lucky than good. So i'm .

sure there was a lot involved. So count, don't don't discard any credit。

Thank you. Thank you. You know, my approach with in was not to say necessarily suck IT up, but I would you make light of IT to have fun with that. And I would kind of laugh and I like way to go. but.

And I would find he would often laugh, you know so I think a lot of IT is accused of taking off the parents you know and again, this this is just my one of any parent is if they see you freaking out, kids gona freak out to um but does he get to be a point where you're ignoring your child or your loved ones? Painful issue yeah now you're getting into some more adaptive, 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 us a very behanding. When I was growing up, I observed a total of zero children and friends who you cried out in pain or complained of pain, who were told, you know, that was an inappropriate response. Sometimes I might have heard parents say, I I just suck IT up like a rub IT it'll be OK 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 live not far from where both in and I grew up, since we grew 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 thug on the band saw and IT wasn't particularly deep, but he was crying in pain. And the father wrapped IT, picked up his chin and smacked him across the face and said, don't ever do that again and so what I think he was doing was compounding the lesson about the saw yeah but clearly had no regard for the pain that that the injure probably caused no, I haven't followed up with that kid yeah um I think we can all agree that by today's standards that would be consider um abusive parenting 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 he said, ah 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 to ever walk up to your buddy, you know, my ARM really hurts. You know, I entered red at the other day, and what what did your body do? They'd stop on your foot and you say, what the heck did you do that?

You know, grown up with the same from and .

and they table now doesn't doesn't your ARM feel Better? Like, well, yeah does and yeah, I did grow up with those friends. I tell this story to some people, and I sometimes just get the White 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 labarre's late seventy seventy eight or something like that in roaded models initially. And what happens is that when you engage a no perceptive stimulus or a painful stimulus in a site distal different from where the primary pain is, IT engages a brainstem circuit that has descending athletes to the spinal cord and inhibits pain.

Amaze pain, inhibits pain. IT works. IT also thought, have some contributions from higher brain centers. We call this whole phenomenon, the bars call this phenomenon defuse, not inhibitory control or the neck. 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 of my kids got a painful, you know, hand or fingering cut himself, i'm going to a slap mock decided to head, he'll feel Better I don't think that's what was .

going through is if you want to make him feel worse so I 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 maybe will get into that later with chronic pain is in some chronic painful conditions the cpm or the the neck doesn't work like five or my ultra being won. Um so pain inhibits pain um is another neuroscience concept related to pain is rather cool.

Well, and i'm sorry I missed your question. Could you repeat? no.

You answer the question in and expanded on a in in a completely surprising, far more interesting way than I ever anticipated. So thank you. I am bedding that.

Ninety eight percent of people listening to this, including myself, have never heard that pain and habits. Pain incredible. Let's go back to heat and cold.

We briefly touched on he, but the talk about the use of, uh, current quite theraputics at or therapist called that a cold pack for a you know you a Bruce that really eggs or maybe even a breaker, a sprain or heat in the in the world of sport, physio cold is now heavily debated. Localized cold is heavily debated. You get people saying things I don't know.

This is true that IT creates a slugging of the of the fluid trying to head in and out of the injuries. So cold is not as good as heat. Heat allows for um the uh inclusion and removal of waste products. And know there are all sorts of just so people make up some of which you might be true, I don't know.

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

And one is in pain. You know, when I was a kid, we had a hot water bottle that four times when we were sick or something. But sometimes know if I felt in eight on the side, but some hot water and hot water lie on that thing. Watch some cartoons. I definitely fell t Better.

Sure, sure. Well, putting aside the contemporary controversies over the mechanisms you describe, which I think very real and need to be sorted out, traditionally historical, we tend to think of applying hold for the first forty eight hours or so after an acute injury, and then heat there after cold, has some really cool effects called, uh, reduces inflation tion. So reduces some of the release of those inflaming chemicals.

We talk about prostate glands, s side dekanawidah, m means other chemokines. All these fancy terms for substances that sensitize the primary nozette and IT reduces the release of those and IT reduces inflaming. Another cool thing often not appreciated is nerves don't fire is fast when they're cold.

And so if you've got no factors that are firing and you put cold, it's slowing the number of signals coming up. In my definition, it's reducing the the the ultimately the pioneer experiencing now heat. Heat has an obvious effect of increasing blood flow.

It's going to help relax muscles and get blood into those muscles. And that's probably why you're putting that hot water bottles on and IT just don't feels good. And so what what do I tell people? You know, in part, I tell people use whichever works best for them.

I find there's huge individual variability and whether people like heat or like cold, and within reason they're safe. What do I mean? Within reason, don't go putting an ice pack on an extremely for two hours. You know you'll get a frost bite so you take care with that.

How cold should one make the point other body that's in pain, assuming of course, they're not to give themselves frost by meaning do you wanted them? The area you'll get past that point where it's a little bit painful than that. You know basically, you're shutting down some neural pathways and you don't feel anything. There is no and then you let the blood flow return when you remove the cold back.

Is that I mean, it's a reasonable suggestion.

Okay yeah right. Well, people like I think appreciate that the um the specifics of that because of course listeners to this podcast often are interested in whole body deliberate cold emersion you know called towers ice bars that set up most people experience those are somewhat painful as they get into them yeah and then can experience some nominees 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, the exposure, assuming that one doesn't stay in too long is not too cold um and or through you know we're time at sports earlier but just in general like can we raise our pain threshold to that life is less painful?

The short answer to your last question is yes um the answer to your other question about h extreme cold and called exposure, which I know you have a lot of expertise and you can teach me lot. I'm going to stay in my whales because I am not up on the literature in that space even in its intersection with pain. It's an intriguing concept.

I have to imagine that, that 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 instinct, 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 the cross modality um changes in pain thresh hold? I mean, if you exposure yourself up to cold, does IT change your heat threshold?

I know I would surprise, be surprised if he did yeah I your pressure those are separate parallel pathways yeah yeah you know and you know, as an aside, I hate the cold, but I do really well with the heat you know and so die an ah you I think there's something genetic there. So I mentioned earlier around men and women and heat thresh holds, and I chose that specifically. But each of these are different depending on the stimulus modality.

Can you change ultimately, your thresh holds. Yeah, where that involves is a lot of cognitive control. It's a lot of cognitive training around that space. And you there's clearly approaches to that. People have learned that there's different manipulations around that. So one experiment this wasn't intended least I don't believe so they were measuring a heat rush holds um and college students 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 is when there was an attractive woman who is delivering the stimulus, the threshold lds were higher because the guys did not want to a luck like a worse 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 rivers experiment also been in?

I don't I don't know I don't know. Um but getting back to your point, yes, um I think through a number of you cognitive manipulations, you can ultimately over time change those thresholds. Another one area is as movement exercise you know clearly changes those thresholds over time, you are probably building up some increased inhibitory tone through that process.

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

So for people who have chronic pain, maybe it's in a smaller of the body that experience chona pain, pain, quite often A K chronic pain, or maybe it's whole body pain. I don't think that really matters for the question i'm asking. And people are trying to develop some cognitive ways.

So what we call is neuroscientists. And I tapped down mechanisms for, 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 realized, I don't know somehow that it's not as bad like that. Somehow there's a and again, this becomes a very opake, right? We don't really know what we're talking about when we do these sorts of protocols, but those sorts of things are out there in the mindfulness space.

And I think I certainly take mindfulness seriously as as an intervention. But what always bothers me about those sorts of interventions is the lack the specificity in the granularity and there's no of mechanistic logic to explain them. yes. So what what 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 eluted to, and they're both effective and they both worked 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, ts, for people living with pain is to engage and distracting activities.

Read a book um go for a walk. You spend time with friends and family and particular in the community and work to get your mind off of pain. What we've learned is that attention, distraction in ages, specific brain networks, they tend to be some of the outer layer of brain networks and your profondo core tex, some in your singular core tacks in other regions, which are clearly involved with distraction.

It's not necessarily the distraction is going to a completely eliminate once pain, but I can reduce IT, uh, significant. 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 during the daytime.

You can read that book. You can spend time with friends and family, but people with chronic pain that have a twenty four seven, you can't distract yourself at night when you're trying to get into a relax 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'm in the second piece, you said kind of lets 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 onna judit.

I'm not going to put a value on it's bad, it's good or anything. I'm just gonna note its presence and that has been shown to work as well. In fact, actually, when john cabot son originally developed mind from the space stress reduction, people low back pain plane's studies have shown that IT works. I've completed just some recent studies in mbs, r as well, and we're diving deeply into the data. So it's a non judgmental acceptance of the will of the pain.

sorry. Mbs r.

for mindfulness based stress reduction. M B S R, everybody should do. M B S R, let me, because I have no financial relationship with any other, by the way.

But mind on this space, stress reduction has been shown effective for anxiety, for depression, for pain, just about everything. I think they should put IT in to all the schools. It's it's a great skill to learn.

No side effects, takes a little bit of time to learn IT and IT can be in some people, effective and helpful for pain. And that's the key that we're going to keep coming back to his some of these things work for some of the people. Some of the time there's a third aspect of meeting the pain, and that is more of a direct cognitive reframing about the meaning of the pain.

Now you're coming at the pain and you have an approach, you're making effort on what you're thinking of the pain. Is that pain damaging, threatening, harmful? Or do you view IT is yet 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 I think the key that we have to figure out this is where research is going is which approach works for which person under which circumstance.

So interesting something you said about understanding the pain but not over interpreting or catastrophes. The pain seems important knowing the difference between being hurt or feeling hurt. This is being injured has been something has been important to me been involved in sports um where clearly pain was involved. I can hurt but in my injured that's the first question.

You know, like I was an ankle like a you know like limping this hurt in my injured meaning am I gonna back added in an hour tomorrow verses I broken baLance and it's you know you know great empathy for anybody that does like when you're injured you feel a 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 kind of the key moment for me. It's always been experience as a moment of anxiety after feeling pain, especially in port, like like 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, I gets to some larger context themes these days of somebody says something IT upsets us. Are we hurt or we injured right now?

I think that gets very, marky, so how does one determine if they are hurt versus injured? And then may we could even stretch into the psychological romney rest or psychologist. But that sounds like so much of what you do represents the the bridge from the body into the mind. And so you 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 mappy's tips for pain management is to understand the distinction between hurt versus harm Better verses harm critical, absolutely critical. Let me allow me to illustrate with patient. I saw one name names some time ago.

Guys in his forties, a master's level tennis player. Tennis his life, he works, is some executive somewhere. But he lives for tennis, comes hobbling in on crushes, 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 is gonna worse. And this has been going on now for months, and he's now depressed because he can't blade 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 in Martins and aroma and a Morgan oma is a fibre thickening of tissue around the nerves that go your toes and IT gets to be like his 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 explain this to the guy and he looks at me but like this light bob goes off and he's like, you mean I can play tennis and in my gaga you can go play all the tender suit one, it's just onna hurt. He got up.

He left the clutches in the exam office and he walked away. Now that's an extreme example. I don't want people please to think that that kind of thing occurs all the time.

IT doesn't. Chronic pain conditions are often incredibly complicated and need much more than, you know, a forty five men or sixty minute education session, you know, back to the tennis court. He still had pain in his foot, t 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 worsened the tissue injury or not? In my world, where i'm Carrying mostly for people with chronic pain, we've moved beyond the tissue healing by definition. By one of the definitions for chronic pain is that the pain persists beyond the time of tissue healing.

So in many of our sessions are times were educating people hurt versus harm. It's back pain. We we evaluate the spine, we make sure is the spine stable.

Is there anything sensor 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, that needs medical attention, and that's where the complexity of all this comes in. Did I answer your .

question yet beautifully? I think this distinction between heart versus harmed is so important for people to hear. Perhaps you're willing to expand a little bit in terms of the psychological hurt versus harmed. I mean, i'm not asking you to comment on society or generational shifts, but you know we'd be avoiding the obvious if we didn't say that in the last really ten to fifteen years has 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 validating the fact that emotional pain is valid like any other pain, accept IT is different because IT becomes very hard to point to a specific kind of threshold for using that word a lot today. But I think it's appropriate here, threshold between hurt and harmed where as if I tell you that my left foot hurts, which I did a lot in high school, and then you take an action of my foot in high school, you'd say your foot broken because he was broken a lot in high school.

And that's harmed, I mean, to continue to do what I was doing to break in the first place. I was harmed, clearly going to harm myself worse. So I I hear.

But when IT comes to a psychological pain, you know, psychiatry has all these threshold for Normal functioning versus abNormal functioning. Are you sleeping well? Normal relationship and on and on.

We don't want to go there, so 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 part of your job.

So i'm asking you this, from the perspective of a somebody who treats pain, how do you gauge somebody y'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. A lot in there. Let me first start off with something very simple. I don't try to distinguish between this notion of psychological pain, physical pain, its pain, end of, end of.

I think once I get into or you get into this, trying to distinguish is a 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 as well when we're caring for the person in front of us.

If they're in pain. I'm addressing the pain. The thing to note is at least in people that come into our a standard pain management center in other pain centers is that remember, pain is a sensor in emotional experience, it's all wrapped up.

And so we wanna treat the whole person. Sometimes we get, we get easy, we get easy ones and we just cope, do a nerve block and pain goes away, and that's simple. But usually it's much more complex where we're seeing the interaction of an expression of pain that includes a significant amount of anxiety of depression.

You mention this term catastrophes, which we can break down if you'd like, and that's probably one of the biggest predictive factors. And in amy fiction of pain and worsening pain and poor treatment responses catastrophising, I tried to treat the whole person and not really partial out all this I do. At stanford, I U.

I built a digital health system that captures, measures a lot of data around a patients experience across physical, psychological and social functioning. And we use that data to target therapies to understand how much your depressive symptoms are. Anxiety, anger, anger, big issue in pain, huge in pain, doesn't make IT worse or Better, invariably makes IT worse.

嗯， 啊。 And you you can break anger down in a couple different categories. John burns and others has broken in end, like anger in versus anger out. I enough that terms familiar with you um anger out, that's my father um loud, loud, angry boysterous banging, you would quickly turn anything into an angry tie rate anger out.

expressive yelling at the at the news, yes, yelling at somebody cuts you off in traffic.

usually yelling at the man because he hate to his job. Anger and boiling summering, you know self contain seeing that anger and data seems to support anger in is worse.

It's bad. So it's necessarily whether not directed at someone external. In both cases, anger in and anger out can be directed at someone external is a question of whether it's expressed outward or contained inside.

Beautifully stated, beautifully stated. So we got, you know, anger, depression, anxiety, are we capture a fatigue sleep. And so we try to do is, again, look at the whole person because they're not just back if that's where they're having pain or not just a neck or shoulder, in your case, it's impacting the whole person.

And we just got done talking earlier about how all of these circuits interact with each other. And so sometimes we can't just eliminate the no exception in the profile y, sometimes we can reduce IT. But what we have to do is target everything, and we have to try to target all these circuits up here.

And in many cases, what we're doing is through education, through pain psychology, through physical therapy, an rebilitate approaches on top of that. And yes, the medications we have now and we touched based on a few earlier, but we have over two hundred medications available for pain. Um very few of A F D A approved. We tend to steal from all the other fields.

So you're talking about more than two hundred 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 psychic atrix some of their uh their anti depression of which will frequently work very effectively for pain and work on those pain related circuits in the brain.

We take from the neurologist some of the anti seizure medications because those medications um while reducing separately seizure for people who don't have seizure, they work on iron channels, they work on other neuromodulators that also are involved in pain circuitry. We can take from the cardiologist medications that work on the hard anti rythm hour rythm 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 take from everybody in our field in the and getting back to to what you said. So just summarizing one, I I don't really distinguished psychological versus physical pain in my world.

I I find IT Better just to treated his 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 worth, whole body .

pain critical and I think we're learning more and more and more about the role of good nutrition, of healthy eating, anti flaming diets, avoidance of foods that are triggers and an incredibly under appreciated area. Um you know i've had my experiences with chronic pain. Um I developed an abdominal chronic pain problem.

Shortly after I turned fifty, I was throwing a happy hour for our pain psychologist of all people went to a mexican restaurant. I won't name which one got food poisoning. That's why i'm not naming IT good mexican food, bad food poisoning. And ever since that event, I can't eat anything in the onion family.

what i'm familiar with onions. But what else is in union family? I'm sure you've research is now pretty toughly considering what you're .

describing classic and what we prefer to his fod maps. It's one of the fod maps. And I have now some issues with the others.

And um manifested by just severe severe of abdominal pain and 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 go months without having a restful night sleep.

I thought I was getting early, all timers, because I thought, like, I was getting stupid. And what actually benefited me was, of all things, the pandemic. why? Because what 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 started doing, as a scientist, experiments. And I finally was able to isolate and determine what the problem was. So now I have complete avoidance on that. I'm a little difficult to go out to a restaurant and have dinner.

But so no onions, no on.

And what chalet of scallions leaks anything in the onion family? You know, not allium i'm fine with. And you know, by healthy eating, by identifying something, by triggers, changed my life and return to a degree of Normal thing. I think the key for people is, if you have any kind of similar issues, identify those triggers, sometimes isolation of, you know, foods or restrictions and using a journal. And then, as you learn from that, slowly build foods back into your diet.

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 of that.

Even we could call them rankers debates about this, the vegan versus on, versus no. But that sounds like this is a case where you can become very individual ized. But I could imagine somebody going to their physician and the physician not being new and saying, yeah, you know, I noticed that when I eat certain foods, them in a lot of pain and the physicians simply saying will donate those foods. But unless that person is a trained scientist like not knowing how to go about doing the sort of experiments that you did would be difficult, impossible.

I'm sorry, I know, interpret. I just want to least well on that if I, if I can. One of the key things, I simplified my story, but the key thing is, as a hit, if I eat onions or anything at onion family, it's pain for two weeks.

Well, IT is. So the thing is, is if you get repeated exposures and never stops in IT gets very, very hard to figure out what IT was. So it's not like you eat something, you get pain and 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. So it's not easy.

Well, this may be a case for elimination diets which are provided done safely, where people restrict the number of foods they to a very limited number of foods, make sure they still get enough calories and micro eec, that they need protein products and carbon hydrates or what what have you. But that by limiting the total number foods of the e is like either ten basic things, then you can build things in and then explore what triggers is 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 it's a it's your case in particular, and we don't want to extrapolate to broadly, is there something about onions that triggers a particular no chemicals or immune pathway? Or do we have any knowledge of like why onions would create that kind of got pain?

This has been a journey i've been on now for a few years to answer this, one of our G I pain dogs that we have come to land in the wind, send me a paper from, I know, seller nature that show that after to a good infection, IT can change the genetic expression related to sensitizing you to food antigens. I know I threw out a lot of jargon there.

Basically the short answer is you get an infection and you're got no longer response properly to a Normal food item. And so one explanation, maybe I got this infection, as at a mexican restaurant, lot of onions. And I got sensitized through that infection.

Now, subsequently, the onions, you know, I saw a stanford allergist hand of watford who's awesome, by the way. And after I had this, I think figured out, and I went in and i'm like, well, doctor, what for there's or anything I can do for this and SHE left, ed, 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, you ever see this and he said, oh, yes, I see this all the time, every day. I see this all the time. And I said, this isn't unusual. I like, no, I see this thing all the time and I said.

meaning sensitivity to no.

to certain to different these different food groups and this this thing that occurs later in life, something in a 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 his because i'm seeing I daughter, what for them seeing increasing amounts of this as we go forward?

How interesting. Well, this is not a time to plug the philanthropic ARM of our premium podcast, but i'm very involved in science for anthropic. This sounds like in the area to do devote some funding to do, explore how foods are impacting the local and systemic pain response.

Yes, I got you know so i'm running a large biomarker study to character ze people deeply in one of the things that. Wanted to put in there as microbiome character zia. Now, to be clear, that's out of my whales. But the beauty of being at stanford in other major institutions.

as you can go make friends, justice, one of the world experts, microban. And we have a few others to there is a friendly guy.

i'm sure hill collab. We go make friends and people who understand the microbes and we collect the samples. And that's where team science is magical and want to get the idea looking at the whole person.

as long as we're talking about the gut, let's talk about pain inside the body because we talk about the secretary on the surface of the body. And the pain that most people immediately think of when you have a discussion about pain is pain on the surface or a broken bone, or maybe hit pain, or nee pain or back pain. But what about pain that resides deeper in the VISA? You know good pain, irritable bow syndrome.

These things are i'm learning farm more common than um that I knew I fortunate that um if I have a stomach cake er a headache mean some things wrong. I rarely get those of sometimes your 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 edible balls syndrome and other forms of gut pain and vira 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. Visual pain is a different thing than what we've been describing, a lot of which a thematic pain, by the way, i'll say, is in a side, I used to have a gut of steel. Also, I could jump down anything, anytime, anywhere.

And so, you know, there was a lot of grief and loss associated with not being able to eat certain foods, and that's also something people have to come to grips with. Um we're getting back to visual pain. So the thing about thematic pain, that's another terminal thematic, meaning the soma, the the the extremely that you are looting to is the no sell tors there very precisely localize where the stimulus, the painful stimulus, is coming from.

When you hit your thun with a hammer, you know exactly where that pain occurred with a visual pain. What you have are very diverse, what we refer to as receptive fields. Think about you last time you had a stomach cake.

It's not that you put your thun right here. What you said is hurts like this, your whole stomach stomach. It's because those receptive fields are very large, their broad, they're not as well localized in in part, the reason for that type of broad receptive field is you're not trying to get away from localize danger.

So when people get stomach ates is 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 visual pain because those fibers that extend from the visari, meaning the the lungs, the abandon, the pelly's, they all head into the spinal core too.

And I just so happens that they make kind of indirect rect 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 had pelvic pain that will describe having lower back pain, too.

And it's because of this vial thematic convergence in the spinal cord. It's not that they're something going on and they are back. It's at these signals that are being driven heavily from the puvis 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 are seeing that more and more in the research, this VISA samad convergence, people have pain in their pElvis and also over their abdomen. Classic one that we're aware of. We see this in the TV the movies and unfortunately real life for heart attacks. So the visual fibers that subserve the heart, typically the first through the fourth thoracic region well those converge um in the spinal cord in similar regions, observe sensation under the ARM and appear that's why people will often say they've got pain with a heart attack .

radiating down .

into the ARM the left ARM type, the left ARM the heart is on the left side exactly after people get abdominal surgery. Sometimes some blood can leak out and it'll slip underneath the diagram. The diagram m is observed by some of those neck regions, three, four and five.

But the serval, which happens to also cover your shoulder. And so you'll get people after domino surgery. This is man. My shoulders is really hurting me, dog. And what we do is we first check to see, you know could something have happened during you know during placement just make sure there's nothing wrong, but frequently it's due to irrtation. That's again, one of the magical mysteries is so fascinating about .

pain seems like a good point to bring up refections pain or is what you're describing an example of reference pain? So my independent of reference pain is that like for instance, i've got a slight bulge, I think like my lumbar three, four desk or something. I had a whole body recently just a an exploration scan because I had the opportunity, not not anything serious, fortunately.

And there's A A slightly bulge this there. And everyone's in a while. If I do certain movements in the gym, i'll get pain down in my right hip and sometimes going down my leg.

And I used to think that was seattle because you assume anything on the right back side OK must be wallet into eda back pocket and into psychic. But what I eventually realized is that, well, this is bulge. I just so happens that the nerves that admit 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 some place else or and occasionally indeed I feel the pain elsewhere in my body as well. It's like a like a matching of regions for pain that seem unrelated. Is that a way to think about reference pain perfectly?

The the examples also I referred to A 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 stimulus in the you could damage on the nerves anywhere along the way and that will be perceived as pain. We referred to that as neuropathic pain.

So that's another distinction. You brought up a nicely good, good subway and to there is thought to be several different types of categories of pain. We have been talking through much of the time about thematic pain, no injury out here.

We talked about visual pain. And when you have damage to a profile, nerve damage, injury to a purple al nerve or the central nervous system we referred to, that is, neural panthry pain. IT frequently has different qualities, different characteristics. People will refer to IT as shooting, stabbing, shock, like burning IT can frequently, when there's a damage to a nerve or damage to certain regions to the brain, be incredibly chAllenging to treat. By the way, the good news is, with that light disk bulge is the vast majority of time the desk reabsorb.

Yeah, I had to be careful to not do too much spinal flex, like sit ups and stuff. I thought that that would help, but that actually doesn't strength in the back. That was actually A A simec between the abdominal muscles and the lower back muscles.

That was provided A A lot of back extension type training. Then that bull, more less days. And I just have to be a little cautious, not too cautious, fortunately, as long to try about referenced pain. So matic, visual and all the rest, what about associated or reference pain where it's psychological? And I don't want to get two 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 socked, and I had terrible backspin, like really acute localized backpack, or chronic headaches or migraine now. And then they go on vacation, or they change their circumstances, and lone behold, the pain goes away. Does that surprise you as an expert in pain?

Not at all, which are you know a sympathetic cally referred to. As you know, there's people are undergoing stress and we have we clearly know that the brain is not a passive recipient of information coming in from the body. It's a two way street.

The brain is causing downstream consequences in the body. The brain controls are sympathetic nervous system and parasympathetic nervous system. The sympathetic being the fight and flight response. IT controls the tone of a cortisol that's being released.

And we all know that in acute situations rapid increases of cortisol and um north gentle in is keeps us away from the lions and tigers and the bear. Oi, but in a chronic situation and a Robert a poky as you know, its 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 org in 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 this. And we will often find then in the scenarios you outline that the pain gets Better.

Um some of those targets are interesting. There's a lot of memory associated with pain. This is where early life of them occur and those early life events in injuries can sensitize us to future vulnerability.

So I was in a car act, bad car accident, when I was sixteen. Fortunate to walk away from, I got bad way lash if I get stressed. A lot of my pain manifest in my neck. For me, as a pain dog is a signal to me that's like go work out, go for a walk in the forest, you know, and take some time away from the computer again as 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 is positive emotions. You've done some very nice studies, is 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 and physiological advice for so it's hard to separate the two.

Could you share with us what you did in that study and what you found? Because I find IT really interesting. And IT also points to the incredible power of love in how do you experience life?

Yeah, yeah. I think there are several cool things about that study that i'd love to share. One is how IT all came about.

So um you know us neuroscience geeks often go to the society for neuroscience is an annual meeting. And I was hanging out sharing a room with art air and who studies passionate love and. He and his wife study passionate love, and we were having a glaser two of wine and mask and art.

If you ever, you know, we ever study pain, it's like now I study love. Like have you ever studied up? Nice studied painting.

If if you ever studied the intersection of the glass line, no, let's do IT. So we came back to stanford and there was a Young postdoc, jarred Younger, who's now a professor at universal obama. And I said, Jerry, where are gonna fell flat on her face.

Or we're going, this is gonna a cool study, and Jerry took this great job. So what we did is we advertised on campus for couples in an early phase of a romantic relationship because there is 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 means that earning, I don't know that it's can be a pleasant experience that but addictions.

you know, for the people who are using the substance, can find that, you know, in that early phase, very pleasant. But IT IT turns out that the early phase of a romantic relationship engages the same neutral circuitry as addiction interest, 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 cloth this is asn't sex that we're studying cloth. And we caused 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 a attention ally demanding.

Remember, we talked about attentional distraction earlier. So we gave people what's called a word generation task very simply. Can you think about every sport that doesn't involve a ball? Oh, frisbie hockey box boxing.

Okay, that's attention ally demanding. Think about every vegetable. It's not Green so you're bring through and more causing you pain.

It's an attention distraction task. So we flash people pictures of their beloved cos pain, flash people of their acquaintance cosine in and then distraction. Okay, what do 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 and love you are, 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 t love scale, which asks how, what percentage of the day are you preoccupied thinking .

about your beloved good? You just send people now off to give their partners the passionate love scale, go out how much time they're spending. Thinking about them.

Yeah, we had stanford students, some of them thinking about their beloved eighty percent of the day. I wanted to use this as a screening tool for a resident applicants because I want them focusing on patients. Not there are beloved IT. 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 he's writing you a script or prescription that is or giving you advice, yeah you might want to know if they are in a new .

romantic relationship yeah so the other I thought the other cool thing about this study was attention worked also, but attention and love worked on different circuits. So attentional distraction, they worked equally well. Attention, again worked on some of these prefer al regions, these outer cortical areas. Love worked on more of what we classically think of as these reward base circuits, the nuclear accumbens, the girl a um one of the the descending uh brain stem regions called the substantial and nyra, which is coming down from the brain through that area to the spinal cord to inhibit pain.

So classic addiction pathway.

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 side note that we didn't publish on, and that is a jarred went back a year later and we assessed the students strengths of their relationship if swiming was still ongoing.

And he found that there was a rather high correlation between the love and due stanl Julia and brain activity and the coda nucleus. And in the insult with the strength of the relationship. A year later, IT was. So we had a brain scan that was a predict of future strength of a relationship.

Could you tell us the direction of those results? So if a new romantic partnership is, uh, creating high levels of activity in these two brain areas you just mentioned, then IT is a very good predict that the relationship will, yes, survive over time. Well.

in this limited sample, that meant that he was gonna very strong a year later. understand. And and we always have to put these caveats unpublished, non peer reviewed IT was a fun post talk data analysis that i'm not sure if anybody's ever you run with those kind of things.

No, but we can explore IT in in a playful way now. And people can do with that what they will. IT does sort of speak to something important though, assuming that result would hold up if the same experiment we're done.

And many hundreds of thousands of people IT always 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 creates stability in that relationship, which on the face of IT, makes sense. But we've also all heard of the opposite way of well as well, which is, you know, fools, russian or that things that start fast and fast or things like that. But here you're talking about the early phase of passion serving this interesting role in terms of analgesia alleviating, but also predicting some stability of the relationship over time.

It's kind of interesting. It's fascinating to talk about. I feel like I have to put their cavy arding did not generalize but a fun thing the time and it's where I think cool scientific ideas can come from for future exploration.

I think that's also what's pretty IT. Um I find the you know again, the different circuits for different approaches to reducing pain fascinating again. That gets to the question asme earlier are 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 O P O S first. If you get educate us on induction ous O P O S, the O P O S that we make inside of our body that we don't that meaning nobody takes as a drug.

And then how that informs opioid that people take. I mean, clearly the so called O P O ID crisis is a concern. Many people addicted to s people have died from taking too many O P O S.

But present ably, some people have benefit from these O P O drugs as well. So I would like to talk about that. And then i'd like to also talk about some of the things that are adjacent to the prescription.

Obiit seems like cradock, which right now called into question as to whether not they will continue to be legally available over the counter. So first and foremost, what are the endogenous oppos? How do they work? And that I think we'll set the stage for the rest.

Yeah so we all have these indulgences and caffeine and and dorms ins that um act as pain killers. They are analogy sics. They are natural substances in all of us that can expressed there is a certain dodge's tone to these that some have done research on here again, Jerry did research on this and Stephen brule and others on showing that higher indigenous assoiciated levels may you lead to less emotional reactivity, for instance?

Um thank god we we know we have an agent sop OS or know we just couldn't handle IT. Um what chemists have figured out is how to you bring in an exotic and a sop oids. And morphine was the prototypical one from the from the poppy. And since then, medicinal chemists have built on variations of morphine and created other compound, some a, again, variations on morphine summer. Purely sentences like the oxy code down could 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 puppy and then saw me and to start eating puppies or isolation things from poppies, and realized that that more thousands of years ago, so poppies have been used very.

very long, long, long time. These things have been around. So this is, this is old school work that only been refined in more contemporary history. And bull topic of opiates is such an incredibly controversial area.

And I I feel like I have to you, you have to understand the speaker, like in this case, may you know one's position on this? My usual monitors. I am not proof pid.

I am not antioquia, I am pro patient, so I have seen opioid positively transform people's lives, help them get back to work, spend time with friends and family, relieve suffering, particularly in situations end of life, but also in people with chronic pain. And I have seen open its destroy lives at a personal level. I come from a family background deep, deep.

In addition, 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 motive, thinking it's either this or is this, but to treat option ids as a clinic, as a tool to be used in certain circumstances in some people, not typically as a front line or first line agent, typically much later down, if they have failed other therapies.

You cannot approach the chAllenge of opiates without appreciating the deep complexity that were faced with, particularly now in society with all of the the litigation ongoing. And although the money involved, it's a it's a highly nuances topic. So what what more would you like to talk about opioid?

Well, I think that most people hear about the europe crisis in just assume that they are calling overprescribed that people are given oppoa drugs as a front line treatment, perhaps more than they should that the addictive component, which I understand is very real the potential for addiction is very real um as well as the potential for.

Cross interactions with other things like alcohol and perhaps even other illicit drugs, street drugs perhaps if like if people can't fill their prescriptions um and tolerance to the opioids creating issues where people then need more of them. They are do IT I have a not close family member, but I know distant family member who had his entire life arranged beautiful ly as a practicing lawyer with a beautiful wife and family had a back injury, uh, was perscribed boxy content. IT helped him initially, but then IT IT set off some behavioral, psychological pathways that had him seeking more forging prescriptions.

When, you know, he understood the law, he was a lawyer. He eventually went to jail, got out. The same thing happened again. He eventually ended up dead, right? So and I think there are many examples of that, that we hear about, and those are very silent and very disturbing, very saddening. So I think that most people include myself here the opposite crisis in assume that what we really should be doing is seeking a Better alternative. But what i'm hearing from you is that there are use cases where oppos make a great deal sense and that they've really helped improve people's lives, and that none of what I just described, anything like IT as 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 case by case basis. And IT one size doesn't fit all. Yes, oios were overprescribed, I think everybody agrees to in this country. Um and we went through a period of time with massive over prescribing and a lot of nuance and reasons why in large part of physicians, we get terrible education around pain and we don't know how to treat IT in general, coming out of medical school, we get about seven hours of education and pain that narin get forty. It's great if you're taking I think your dog's name is castle.

Yeah unfortunate 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, low dose testosterone. He was caste rated like he was fixed with his Younger and it's interesting.

I i've gone, I have said publicly on very large scale podcast that I gave my dog lotos testosterone later in life and emilian a lot of his cakes and pains, at least from what I understand, because he start moving Better and feeling Better and sleeving Better. And I expect to the veteran community come after me with pitch forks. Not one did that.

And yet I heard from hundreds of veterinary IT said, yes, we wish that we could prescribe those sorts of things to people who castrate their male dogs later in life to imitate their symptoms. So that opened up to me a whole world of understanding about some of the restrictions that, that vets face in terms of what they prescribed. There's a whole discussion to be had about that will do a series on animal and health, that health great.

That's hopefully healthy too. You get the point yeah but when IT comes to the opp o ID crisis in this discussion, I think it's become so later with the idea that like doctors are on the take, like they're getting paid to give opioid 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 here's the thing um where they are bad dogs doing bad things yes um i'm going to invoke A A good friend of mine key .

hampers at yeah rifle .

terrific psychologist who was an addiction medicine psychologist and public policy person and the way he breaks IT down arrives as subscribe to this is you know there are three types of physicians. Remember there's about a million physicians in this country. About a million.

You got physicians doing the right thing for the right reasons, fast majority attacks. 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 ducks doing the wrong thing for the right reasons.

What I mean by that is these are ducks who did over prescribe opiates in this case, in this context, they did buy and to the marketing messages that were put forward. They did not have much education around alternatives in treating pain. And they thought by handing out pills, just pills, in their very brief visits with patients, remember, primary or caradoc is my hecker es out to them.

And what do they get? Fourteen minutes or so the patient, they gave them something that they thought would help. They were doing the the wrong thing for the right reasons.

but they believe that they were helping. They didn't have. They weren't catching financial incentives. Okay.

go those people, we need to educate them. We need to train them on proper pain management, oppoi prescribing, d prescribing. And then you've got a 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 pillow miles.

These are people breaking the lot. They need to go to jail. End up. Um the thing is, is that little group at the top in the millions or so physicians we have in this country IT represent 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 in engendered huge amount of fear, huge amount of fear on the physician side. And then what happened is the dogs just started abandoning patients. They cut their patients off. Um I had a Young housewife to Young kids.

Dog, get off from a little bit of in that SHE was taken intermitted for um some book pain that had been well managed on this he was doing all the right things cut off SHE turned to black tar hair one you know um california great data california try to experiment where they monitor debt certificates in our state for and the dogs prescribing opiates for that. And they went after the docks thinking that if they targeted the dogs doing that IT would lead to a reduce, a reduction and oppoi deaths. I'd LED to a doubling, I know counter intuit, because what happened is the dogs abandoned the patients.

And so we have to be aware of the negative consequences of this. Now the current not trying to minimize the opioid crisis because it's real, but we also now need to put some contacts. The opiate crisis is being driven by the illicit fenton's.

That is more if you can just look at the cdc data, it's very clear that the fentons coming in via mexico, china and others is what driving most of the deaths. Um keth getting back to Keith LED, a beautiful Lancet stanford commission on the north american opioid crisis and put together very rational plan. I just finished serving as a senior advisor to the medical board, california, where we revised our prescribe bing guidelines here.

They were very draconian before hard limits made people fearful, both patients and docks. And we've shifted back over to put the control back in the hands of the physician patient relationship. Um we're hoping it'll make a difference.

You can see I am i'm going on a bit here. There's there's just huge complexity in this space. Um I understand you're going to do an episode some time on IT in the future, and I hope the audience has more opportunity to listen to this other questions I can answer for you that .

on that so we really appreciate the theron's of your answer. I think you set a picture in a context that I certainly didn't understand or appreciate and IT sounds like one certainly not the only, but one of the major issues is the creation and the propagation of a black market by doctors cutting off patients personably out of fear.

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 he's in pain and they had something that worked and now they don't they're going to go looking for things that are similar to that thing. And you're telling us that fatal in street drugs basically is what's killing people personably. I doubt its fence and all prescribed by physicians or perhaps .

IT is it's not no, there used to be a bit of confusion around that because fatal is a prescribed medication in a patch form and in a true the true use for end of life cancer pain. But unfortunately, some of the coding used by the cdc and others, ds got that confused with the illicit. So IT took a while to get a Better handle on IT.

But I think now we do. Now yes, most of IT is being driven by the fantine's, and we're just seeing this incredible epidemic wave of IT. IT can be made so cheaply, brought across the borders reasonably easily, something we definitely need to do to address.

We want to be careful about not conflicting that crisis with the issue of pain, which is an epidemic in its own right, and for the segment of people who are using option ids responsibly and effectively for their pain. And that's where again, that new ones comes in. And other patients who are also on opioid that have been wind down, you can win them down gently, compassionately and they do Better.

Um the answer is yes. Ah my partner death is just finishing up a study on that 这样 you showing that with compassionate care， a number of these patients can be weed down who voluntarily wanna come down and sometimes they find their pain actually improves. And part of that improvement may be that opens have degrees the side effects and by elimination of those side effects and the the other aspects, they're seeing improvement.

Could you list off some of the more um commonly used opiates um you know morphine.

and it's a commercial version commercial deliberative ves M S content which is a long lasting version of more oxy code down which by itself is a short acting medication. But when you capsule ted on a long acting version, IT becomes oxy, which was the trade name that purdue put forward. Fanton we mentioned comes in a patch form.

Uh, there are mixed agents like a tram at all, which is a kind of a weak oppoi but also has um was called serotonin europe appan reuptake inhibition. We've got deleted which is a vignal uh trading for hydrox Moore phone. So there's a su, there's anna.

More than twenty different opioid within that list of two hundred medications that we have. Method is another one um people usually think of is uh medication used to uh treat addiction. People go to method one clinics.

It's a long lasting opposite in the right person in certain circumstances that 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 opiate receptors in the primary there are rich sources of opiate receptors in the spinal cord, in the dorsal um the are back part of the spinal cord and then there are many areas in the brain that are rich in oppoi receptors. You know, it's all a naturally occurring area. When we put in an opposite by mouth, we're binding to those receptors in activating those neural circuits. In many cases, when I say activating, they have an inhibitory ory role. I mean, that's one of the major parts.

Is there any role for a bena as appears in pain relief?

Rarely if to I many of my colleagues would say, you know, shaan, it's just a hard no. I and i'd have to come up with an edge condition of somebody who has a generalized anxiety disorder on poorly treated with anti angiology s with chronic pain. And wouldn't you find you treat their anxiety with like a benzo o IT helps with their pain as well.

But these are edgy conditions. Fine, large, no. Got IT.

What about car? Dom, I had a od experience with cradock and i've never taken IT. The experience was the following. I started learning about IT, hearing about IT um from listeners on the podcast realized by doing a little bit of a web search that is available over the counter and that certain people like to take IT often like every day low doses or even higher doses and that there was huge variation in terms of the amount of cradock in the various product, how much people were taking some people talking about cryo m as something that was as if they were innocuous. And we can ask whether not indeed IT is innocuous. And so I put out of a tweet, I guess now that twitter is called X, I guess I put out an x anyway doesn't matter and and I said that my um first pass view of the literature on cradle, the scientific c literature, is that you know IT had a lot of property similar to opioid, although different as well and that IT seemed of odd and maybe even problematic that IT was so widely available and I got bomb boarded with I don't want to call them cradock enthusiast because what I soon discovered was that these people um were angry with me for um placing even a partial shadow on cradock. 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 cradock had helped them get off prescription opinions and that they heavily rely on cradock in various levels of dosage in ways that they felt really help them.

And so two things happen one i've been put in the crosses of the proclaim community not to in a severe extent but perhaps the more important thing is and I want to thank that community um in part for you know now it's inspired me to do a deep dive search on cradock i'm going to be interviewing one of the laboratories that done a lot of the research on cryder m later in twenty twenty four but also IT it's made me realized that there these compounds are available over the counter that many people feel so passionate about because they really feel like IT helped them not saying IT hadn't, not saying IT han, but then again, i've never taken IT. What is cradock and or perhaps what receptors does IT tickle and what are your thoughts about cryo m and people using call dom? And maybe i'm pronouncing IT wrong. I've also heard crat home create i'm calling .

IT cradock yeah uh craig is is natural substance that does have, as he said, opioid gic 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 cryo m, there's gonna be some angry people after this. And that is what IT is. I have heard the same stories that you have heard about people taking cram and saying it's helping them to stay off of a prescription opioid or illicit opioids.

And I get that I think in some way it's binding opiate receptors and reducing the a natural craving for these other substances. And that makes perfect sense. A method one does that, a duper northin which I didn't mention before. IT is a is an interesting opposite ID that binds to these receptors and IT reduces craving .

um where .

I have chAllenges is in just because something is natural doesn't mean that IT is safe. We are seeing an increased number of overdo ths deaths associated with cradock is IT police substance. In some cases, IT is. But I think there's a lot we don't know.

So so police substance people taking.

creating, but benzo s getting back to the personally, I think we need to put a lot of researching into this agent. And if IT merits that, I think this should be A 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.

You know, similar type of story with cannabis, by the way. So i'm hoping that we're gonna get the research that we need to really understand what it's doing at whether IT is safe and effective. I'm left with a lot of unknowns right now.

Imagine cannabis, cannabis effective and by extension, is C, B, D, 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 all also tells where they agree. Our goal here is never to satisfy everybody. But just to you know some of these lands in in the realm of highly educated opinion, some of IT is still, as you point out, speculation because we don't really know what craig sources people are taking or cannabis a but um I think he will 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 a mentioning my earlier and ic out about that tweet um often direct us to explore things further and we can always have you a second discussion about this down the line. So we invite all your comments and .

criticism can as well. Here's what we know in carefully controlled labat's situations, cannabis has been shown to reduce neuropathic pain. That's that nerve related pain from people who have you.

The nerve injury, a diabetic neuropathy, post stroke, tic neurology, a terrible burning nerve pain condition. IT has been shown to reduce that in small samples from larger scale epidemiology studies and even larger like clinic based studies that i've done. We find IT has not been particularly helpful on average compared to people not on canvas.

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 a 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 in a providing unfathered use of cannabis. And the bad news is, is that we're probably going to see some real untold consequences of IT where already are.

The good news is i'm hoping that at a state level will 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 equate dom cannabis, not cannabis, not cannabis in the T H C to C B D rate shows that s yes, all of that we don't know what you're getting. IT remains a scheduled one drug by the dea.

Um I in some of my leadership roles and others have called for scheduling of IT as a schedule two. Why why not to purposely try to restrict use but by making IT a schedule LED to drug, you've now made this so much easier to research. I don't know if people understand how many barriers there are to scientists studying schedule one drugs.

Could you explain schedule one verse scheduled to?

Thank you. Yeah so schedule the scheduling of drugs is a categorization that describes their abuse liability. And so you have drugs like P C P heroin um cannabis which are scheduled one which are defined as having high addiction potential and no utility.

Just a wild because when I think about pcp and cycling, and I certainly don't want people to run out and to start taking pcp chemically and physiologically, pcp is ever so similar to academy and know rarely is a discussed by kedem is now widely used as a therapeutic c presumable kadee is scheduled to maybe even schedule three?

Yes.

so so some of that the stuff that thrown in the schedule one .

makes no sense. It's historical all its decades and decades ago of history. And clearly, canada canopy schedule one, hands down, no question.

Um 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 in 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 T H C C B D ray shows that will provide some benefit? absolutely.

There's too many recept tors in our brain that are involved with modulation of pain. I just don't know what those are. Um friend of mine uh mark wallace uh runs pain that you see. Sandy ago has come up with a really nice recipe cocktail of ratio of T H C to C B D that he feels very strongly that he can help people using that as an active agent.

Yeah, I know that in colorado there's a string of cannabis where they is pure C B D, no t hc. Think they call IT charleys web. And parents of children with intractable epilepsy will actually move to the state, colorado, in order to get IT, because IT seems to be effective for the treatment of certain forms of pediatric aleph.

Y, that was shared with me with one of our colleagues and knowing Williams when he was a guest on the park, cast. So these plant based compounds have have their place with cry dom perhaps right remaining open about that or cannabis, the the T H C or the C B D or some combination. 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 someone adjacent to traditional medicine? So things like architecture, caro pro, tic physical therapy and so forth.

As a pain physician within the field of pain medicine or pain management, I think about six broad categories of therapies that we provide for people with chronic pain. One of these is the medications and there's a whole large group of categories of medications of two hundred or so available to nerve blocks and procedures.

These range everything from trigger point injections to a nerve blocks with local anesthetic and on up to minimally invasive cede res 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 for physical and occupational theory. P, approaches to chronic pain five, this is what we we typically a complimental alternative medicine approaches.

It's a little bit of an outdated term, but I think that is a nutritional ticals. 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, are increasing your agency and hear it's about education.

It's about learning skills. It's about being here on the human man, you know, a lab podcast learning about pain um it's it's at self empowerment. And what we find is that those six categories all road together typically have the best benefit for people living with chronic .

pain to a lot of people listening to us right now, then go, yeah, I chipsets tuum. This is a thousands or tens of thousands of years or practice that clearly is grounded in a lot of clinical data and clearly works. And the other people will go on like the us.

They're trying to archibong ch like sticking needles in the body. They just like pain, treats pain. Is that what is about? But as you and I both know, unless it's being performed incorrectly, archibong cure is not painful to receive. Does active punctures e help treat certain forms of pain as there are any scientific basis? Yes.

yes, there is. Um do I understand what's going on with archival cher having completed an actual and then I used fund an archipelago study.

I just saw that published .

no you know I really i'm just been in straight um we still don't know exactly how archibong CER is working. We do know that there's a nice study that showed activation of pure feral identic receptors that have a purfled al analgesic effect. We know that archibong cure is compared to sham archipelago, engages different brain regions.

It's interesting that many of the acu points overly powful nerves. And so by middling 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 actually punches. I, oh yeah, yeah. I've had a punch. I wouldn't say many times, but several times. And I will say this. One of the accused science, I went to put needles in my face, and I ended up having to go to stanford dim to get some of the enemas that were like blood vessel growth that was the consequence of those needle in.

And so to the point where I won't, if I go to active punch, I don't put on putting news in my face because i'll take an ng on on my leg or when I I don't care and it's not a vanity, but I didn't like the way that the needles were introducing and gomes to my face. Now that was probably because this active, punctual wasn't doing things correctly. Not saying all archibong ctia do that, but here's the problem.

How do you know which actual tires 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 might senior ministers is won't like this.

But when I get a recommendation from a docket, stanford, I always call somebody at ucsf and cross check yeah and I don't tell them that i'm crossed checking and i'll do the reverse as well. When I when I was at uc and ago, 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 active puncture of physicians. I mean, how do are people sport to navigate this?

You found a perfect way to do IT. Many of us do the same thing. And for those who don't have access to high quality, experts can use variations of that.

So you're right with archibong cher, most of the ones i've been associated with, we using the clinic or outside of all have been high quality. The recommendation would be to try to get A A referral recommendation from somebody who refers to that architecture. Ducks want to have relationships with people with other clinic that do a really good job.

We don't want to be referring to somebody who's bad because IT reflects badly on us. So it's really doing what, in a way, what you were doing. So try to connect with your primary care doctor, others and get some recommendation um for who is high quality um with regard to clinical pain physicians, for instance.

That's tough. There is five to ten thousand of us there, a subspecialties trained out there. If you're pain is really complicated, a complex pain problem, you're probably Better off with a toucher referral center that can provide comprehensive services where possible. So is there is .

there is centralized website where people can say OK live in the state of war, you know a lot of our listeners are overseas or you know where people can find out the like the um the ratings based on patient experience. Although that I can be complicated, I confess sure the one star out of five star ratings are little bit more sAiling. There have been studies on these people tended, if you know you see a negative review, those ten to grab your attention, even if they're fewer of them, then the many thousands of positive reviews. But I mean, patients should be able to get the information that they want about previous patients experience.

right? Yeah I got to tell you the the patient ratings um is a highly manipulated situation. How so well you can pay companies to help jack up your rating.

I that it's otherways I see IT in the community inflation oh my yes, inflation of ratings. And so then you inflated and IT overcomes any of the negative ones. Um we haven't have taken an approach on this and maybe that's not even of us.

We see twenty five thousand patients visits a year and only a tiny percentage of them puts some rating. And it's probably the extremes douteless, but we don't manage IT. I know that in many community settings that they do.

I didn't answer your question is there were reliable source of quality. I still think at the end it's gonna be a relationships and word of mouth and referred. I do the same thing you do.

I, you know, to see hana, what for the allergist. I asked my primary care doctor, sanford, who is the best? Who is the person that knows the most about food related issues?

Well, some really entrepreneurial guy gala group of guy galls will put together a web sider and APP or something that really addresses this problem head on. Because I could think of a very few things more useful than a truly independent way of understanding prior patients experience and finding the best person for a particular problem. And I think A I can help with this, but I think A I and human interface.

Anyway, somebody out there should do IT. Um i'm curious about current active for a lot of people get not car practice. Let's not talk about the people specifically, but car practical. Lot of people put active puncture in car a jay cent to one another. But my understanding is that insurance often will cover archibong cher but not car practical.

Um maybe I got that backwards and maybe i'm just all out wrong, but you know, with crack work you're talking about, often the attempt to relieve compression of nerves, certainly nervous, are being manipulated. If any part of the body is being manipulated, guess manipulates kind of a word that implies something a sinister is happening is being adjusted um what are your thoughts about car praca summer? The car practice is well trained and responsible, can to help pain, can to help back pain, neck pain, whole body pain.

Yeah first, uh architectures and co praca to entirely different professional, right? Just just to be clear for people and they sometimes get lumped into a similar category of pain treatments and that may be where you know that comes from. Just closing out on the archibong cure again um just to summarize, yes, in some patients in some circumstances, I found archibong cure to be useful and it's worth to try cm S H center.

Uh medicare uh is now paying for archival cra for people over the age sixty five, medicare of for medicare patients. That's something recent and we were happy to see that. I believe that was for back pain that should be fact checked but Carry active mix data.

Well controlled studies. Some of some have shown that IT can be helpful for low back pain. Some have shown IT isn't.

It's it's truly not clear the type co practical involves that doesn't involve kind of the fast high city manipulation. As a physician, I have some concerns about that, particularly around the neck. I've taken care of patients that have had vertigo artery dissections from that rapid watching.

What is a vertebral artery .

dissection? One of the the main arteries that goes from the body to the brain and the back portion of IT is called the party bal artery. And when you do these high velocity manipulations, there is a risk, i'll be at small of having a dissection or an ambuLance thrown.

Often i've had to like a stroke. It's IT is a yeah like a stroke. But there's a lot of approaches that can be done that are in some patients have shown some on some benefit. I think the key with a number of these therapies, and I don't want to single oud archipelago or cover.

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 warn off a nice experience in the moment for most people if you're finding that for architecture are practical or anything for that matter, you know ask yourself, is really providing you durable benefit that is worth the effort um or is that just wrap ID IT feels good in the moment. We tend to use that in our clinical practices, a threshold, you know and we like to see things that last for a longer period of time.

And in many of these treatments, whether IT be archibong, CER, co practical, use those as an inroad enter more of a functional lability of approach are meaning, when you get chronic pain, you tend to a withdraw, you tend to stop exercising, you stop moving, your muscles atrophy, you become d conditioned because of the pain. And so we want to use these tools that we've been talking about as a wait to get people engaged in activity to correct the underlying biomechanical issues that may be present. And so they all need to be appropriately stage. And that's what working with a good clinic can help with that.

Yeah certainly my case, any time i've had backpack, even when I was very severe, provided I wasn't harmed and I was just hurt, continuing to move and not becoming sedentary was absolutely the fastest route recovery and and in particular doing certain exercises that that were particular my my case um what, if any, is the role for physical therapies in the treatment .

cronic pain? Absolutely crucial, absolutely crucial. Uh, despite being a physician, not a physical therapy, i've great appreciation respect for what the physical reabsorb approaches do because at the end of the day, we're trying to get people back to and improve quality of life and physical functioning.

I mean that and is often what people are most looking for, control over their pain, control over their life, yes, reduction in pain, but more being able to do more things. And they are tying in with good physical therapy, occupational therapies, people who can do a goal setting, a absolutely critical. All of the treatments that I provide typically are meant to help support an increase in physical rebilitate approaches.

And so when I do, nerve blocks or procedures are give a medication. And if we end up reducing some pain, we want to tie that in with more activity. And what the physical therapy, a great, particularly those trained in chronic pain, is knowing that difference between hurt and harm.

They can work with people to know what's safe for them to do to rehabilitate. They can teach them, uh, more about body mechanics and help improve endurance and strength. They can work around pacing.

Facing is so critical for people with chronic pain. Now this isn't just exclusive to the physical therapies. The psychologists do pacing. I do passing.

What is pacing? Here's the problem with chronic pain. One of the many problems IT waxes in wines.

And so what happens is you go and to have a good day, you go out like ganging busters, and you go do everything that you haven't been able to do for the last week because you've in pain, and then you pay the Price. And when you pay the Price, you're back in bed, you're on the couch, you're not moving. And what happens is you go into this roller coasters of activity and no activity at all.

And what happens is IT in trains in our brain is a classic negative enforcement model. This is classic psychology. And so then people become fearful of more movement.

And as a consequence, they get more and more um this is a 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 black right now, great walk that block out tomorrow, maybe walk a block plus an extra fifty feet, and then the next day, another fifty feet. No more, no more. If you having a great day, don't go to five blocks.

You're training for a marathon. You're training for the long win. Now what's gona happen along the way is that you're gonna have good days and you're gonna bad days on the good days don't go out and exceeded IT set a threshold ld time and on your watch at a distance on the bad days.

Recognize we all have bad days. Everybody has bad days. And you know, you may need some rest during those bad days, but then the next day get up and restart. You know where you were. And that's a type of thing of physical therapist, good paint psychologists, good physician, can help you with entering 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.

And it's something that hopefully all these therapeutic c modalities keep in mind. I mean, I don't know whether not the eugenicists are talking to the physical therapies, are talking to the physician, but I guess this is the reason for referrals, right? Why somebody has a primary care dog and radiates down to the rest.

Is that why? In an ideal, you topia in world? That's exactly, I mean, outside of comprehensive pain centers that have all of the stuff go located, you are dependent on a dock to play a quarterback and bring all those referrals together.

It's incredibly chAllenging for a primary or care dog to do that with a limit at a time they are given to see a person. This is where we're trying to use technology to to help Better with that immigration. And I do think there's hope for the future will have Better ways of managing .

that in handle IT. What is your view on non prescription compound so called supplements or neta seuthes for the treatment of pain?

Fascinating topic. This country is rather unique in having uh a wide su of over the counter agents that are actually a prescription in europe and other countries. And there are over the counter agents that have been shown to be effective for a number of pain conditions.

So for neuropathy pain, a catala carnatic is one of them. A catala carnet is thought to work on micon real meta lisp and improve metacarpal health. And it's been used to believe as a uh anti aging and maybe even a cognitive enhancement agent um unique.

And it's been studied out of an australian study. I think I was called the sydney trials actually. And what they found is one of the few over the counter agents that actually had disease modifying properties, meaning they studied this in diabetic neuropathy.

The clinical end point was not pain reduction. The clinical end point was nerve conduction velocity changes. And that's how we monitor nerve health, is in a Normal nerve, they move nerve able pulses move at a certain rate.

And when they're injured from diabetes, they say, you know, it's much slower and you lose signal. This actually improving your health. Now you have to take this at higher doses.

It's typically two thousand, three thousand grams. It's a pretty large doses world. You can buy those at a vitam shop, order them online.

Uh, although I poc acid is another one, although I poke acid at least two mechanisms. One is it's a freeload al scavenger and second h that's been more reason is IT is A T type calcium channel. Modulator and calcium channels are in our nerves and turns those down.

And IT can have some benefit for neuropathy pain. People have taken off like poke 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, in just an end of one. What I found though, is you have t type calcium channels in your heart. And I do hit high intense of the nerval training and I was finding I couldn't get my heart rate over one hundred and fifty.

So I had I stopped IT. Um that's not an adverse event. That's just an annoyance, but that's useful.

Y and see, so if you're going in for surgery and it's maybe a nerve related surgery that you're gonna they found by them and see propagator ally can reduce the likelihood of having certain earth pain conditions after surgery. Fish oil of the omega trees have been found to be a beneficial around chronic pain. More recently.

The data here is on smaller numbers, creatine, which I imagine you've probably talked about IT at some length, but creatine has shown in small pilotto studies and benefit in five middle and some other types of conditions. So there are a number of these substances that are backed up and beyond the you know the aneth data that we joke about the anecdotal there's actually good randomize control trials and this ah something that people can easily take advantage of. Just be mindful that just because it's natural, just because it's over the counter doesn't equate with a hundred percent safety, meaning get educated about the side effects in the adverse events, get educated about the drug drug interactions, the age and age and interactions. And for instance, there are these over the counter agent sum of which you want to be careful, love, and not taking when you're going into surgery because they can be a platelet inhibitors and they can cause .

you to bleed more. Isn't vitamin c one such substance .

that that causes a excessive bleeding?

Or or some people report that um high levels of mega es can increase the can reduce the blood, meaning the bleeding here.

the omega three office shoals. Yes, absolutely. The vitamin c i'm not familiar honestly .

with a blood maybe misformed there maybe i'm just forgetting .

but that's that's one I don't usually think of is a blunt dinner someone .

will put in the show of comments one way or the .

other corrected I I but there's a number of these over the counter agents that are a that are available, the vast majority innocuous that i've mentioned, that i've .

mentioned the s meaning to cause harm at the at reasonable doses, but they can have positive effects. Well, I perfectly said.

yeah well.

thank you for sharing that list. I think as you mentioned, many compounds that are only available prescription overseas r deed available over the counter in the U. S. In this area. Neutral udal like supplements is still an area that's actively debated depending on people stance. But it's refreshing to hear somebody who's yeah um formally trained physician and and scientists to um embraces so many different approaches in the treatment of pain along of those lines. Perhaps you be willing to talk about the psychological treatments that can be effective for pain.

again, absolutely critical in the management of people with you wide range of pain problems. And recall, what we talked about is, know, this is no suspect. These are the signals coming up to the brain.

Once IT hits the brain, you know, we're dealing with everything that person has lived through and also is currently experiencing, meaning their levels of anxiety, depression, how they cope with pain in the past, how they cope with IT now, a early a life experiences as a paper that just came out in a jam ma uh little in the last few days where they did the analysis of brain imaging studies on people with early adverse life events and what they found is abNormalities in emotional processing, emotional functioning in people who have these um giving strong evidence that what happens to early in live impact us as adults and stays with us. IT changes are wiring. Now this is where in part pain psychologist behavioral therapies can come in.

They can help with sum of the a more adaptive coping, the the thought processes involved with pain. They can help teach skills. So for the vast majority of paint 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. Um does IT eliminate pain. A few of the things that we do actually eliminate pain. What trying to do is chip away, you know, a little bit with this medication, a little bit with this site, is this procedure that with psychology, we're trying to hit all of these pathways and aggregate um to make a real difference.

The pain psychology just use classically techniques like cogniac behavioural al therapy which involves often recognizing these unhelpful thoughts and patterns that we all get into around pain and even life, to interacting those thoughts, to helping people again with goal setting and passing, to teach people relaxation techniques through deep breathing things like biofeedback. Um in silicon valley where I practice the engineers love the biofeedback. I'm an engineer.

By formal training, I get IT, but it's that close look feedback because remember, the the brain is controlling the periphery and controlling the sympathetic nervous system. And when we're in pain or sympathetic nervous system gets wrapped up, when the sympathetic nervous system gets raped up, blood vessels construct a heart rate goes up, our muscles get tense. And we need sometimes ways of learning how to calm down that sympathetic nervous system.

Um cogan behavioral therapy, mindfulness based stress reduction, acceptance and commitment therapy are some of the tools that they use. My partner, bath, has developed a brief in intervention called empowered relief. Yes, i'm biased. IT works. We've studied this in an nh, a funded study, and it's a way of getting eight weeks of caught on behavioral therapy and two hours not meant to replace C, B, T, but as an additional tool. And you're gonna see as time goes by, more and more of these tools come out in the beauty of them is they're gonna be much easier to disseminate broadly to the public then for in since a pill. And I can't we can't just go put in the fed x for the U S post office you to start sending up pills to everybody, but we can develop treatments online that can teach people skills and really help.

Is that the plan for this um abbreviated but equally effective cognitive having oral therapy?

Yes, now you're getting into kind of my bets in my life mission. So you i've spent the last twelve years building a digital platform, a health platform that we have integrated into clinics and capture high quality data covering all aspects of people's physical, psychological, social functioning. And the reason for that is to address a critical need that we have on Better quality data about people.

The data in, 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 U. A, I in the background for prediction.

And now death 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.

And 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 thirty miles, forty miles outside of the bay area and you're in a health care desert.

And I don't say that disparate ging to any dogs working out there, but it's different. There's only a handful of large academic centers and large practice. In the country, when you get outside those those catchment areas, people struggle with how to get good quality care. You ask that question earlier, how do you find good quality care? And so we're working to make that, that available to everybody.

fantastic. I was going to ask you as a final question, what is your if you had one wish for the future of pain medicine and the treatment of pain, what that would be before you answer that, i'll just add and the answer that you already gave, which is that sounds like the implementation of this incredible set of tools and database that you've collaborated with, doctor or nail, but are nail to to develop as at least one of them.

So now that that that answer was given by me, then you can IT freeze up 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 would that? 为什么？

yeah. So a few years ago, I code for the country the development of the national pain strategy. And this was sponsored by the nih and health human services. And I call at this with doctor Linda porter from the nh. We brought together eighty a national experts in pain research, pain clinical care, pain policy, and people would live 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 our care for people with pain, how we educate professionals, how we communicate with the public. My wish would be for full implementation of the national pain strategy. IT, unfortunately, took back seat when I was released the same time with the cdc opposite guidelines.

And the opposite guidelines sucked all the oxygen of the room. But the this strategic plan IT was well thought out. It's the one that we have for our country. It's noncontroversial non partisan 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 are living with pain.

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

Beautifully stated, your absolutely writing. In fact, the night test for the national pain strategy originally came about through a number of concerned citizens with pain doing that very thing and lobbying what became a bipartisan you don't hear that much anymore bipartisan effort um to put for the national pain care act. They got got put into the affordable care act, they called for the development of an institute medicine report on pain that LED to the national pain strategy, all starting with concern people making those phone calls and writing those letters.

So that means calling your congresswomen and congress woman leaving messages. I hear this works. I mean, I know people are doing this for other initiatives, and one call, two calls doesn't make much of a difference, but that if people are saying you this is important to them, that people in power eventually start taking action.

the legislation, they listen. And in part um again, part of this life mission, both to develop this platform, i've created a nonprofit called pain USA and its main mission is to help advance the implementation of the national paint strategy and backed within that is this platform also to use high quality data to Better inform the care of patients of people with pain and to deliver high quality treatments because we do know also that people listening to data and we need good quality data to influence those messages. But please, yes, make those calls, write those letters. IT does work, Shawn.

Doctor mckey, thank you so much for everything that you're doing. You took us on quite a tour in terms of depth and bread of the thing that we think of and and unfortunately in some cases as experiences as pain, although we also learned its highly adaptive, in some cases can protect us, doesn't deed 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 exist.

We touch into some somewhat controversial areas, but I really appreciate the theron's and the nuance and the sensitivity with which you touch into all of those issues. And just on behalf of myself and everybody listening, I just really want to thank you. You've contributed a great deal today to the public education of what pain is, what IT isn't and how to treat IT. Thank you ever so much.

Thank you. Doctor hover. And I appreciate the opportunity to come on and spend some time and are you giving a platform help educate and inform people out there? I gotto tell you, nobody does IT Better you. You've been absolutely amazing. And thank you again.

Thank you. It's a labor of love, and I appreciate the kind words. Come back again.

Thank you.

Thank you for joining me today for my discussion all about pain and ways to control pain with doctor shaun 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 doctor mackie mentioned during today's episode. Please refer to the show note captions.

If you're learning from and or enjoying this podcast, please subscribe our youtube channel. It's a terrific zero cost way to support us. In addition, police described to the podcast on both spotify and apple, and on both spotify, apple, you can leave us up to a five star review.

Please also check out the sponsors mentioned at the beginning and throughout today's episode. That's the best way to support this podcast. If you have questions or comments for me or guess or topics that you like me to include on the huberman lab podcast, please put those in the comments on youtube.

I do read all the comments during today's episode. And on many previous episodes of the huberman la podcast, we discuss supplements. While supplements are necessary for everybody, many people drive tremendous benefit from them for things like improving sleep, for hormonal support and for focus.

The huberman la podcast has partnered with momentous supplements, and we ve done that for several reasons. First of all, momentous supplements are the very highest quality. Second, momentous ships internationally, which we realize is important because many of you reside outside of the united states.

Third, momentous supplements tend to focus on single ingredient formulations, which is important if you want to develop the most biologically and cost effective supplement regiment. For you to learn more about the supplements discussed on the huberman in that podcast, please go to live momentous dot com slash huberman. Again, that's live momentous spill O U S dot com slash huberman.

If you're not already following me on social media, I am huberman lab on all social media platforms, so that instagram, twitter now called x threats, linton and facebook, and on all of those platforms, I discussed science and science related tools, some of which overlaps the content of the huberman lab podcast, but much of which is distinct from the content on the huberman lab podcast. Again, that's huberman lab on all social media platforms. If you haven't already described to our neural network news letter, IT is a zero coast news letter that includes summaries of podcast episodes as well as protocols in the form of brief one to three page P D F.

For things like how to improve sleep, how to regulate dopamine, deliberate cold exposure, deliberate heat exposure, exercise protocols and much more. To sign up, simply go to huberman lab dot com, go to the menu tabs, scroll down to news's letter, and provide us with your email. And I want to point out that we do not share your email with anybody.

And again, the newsletter is completely zero cost. Thank you once again for joining me for today's discussion all about pain and ways to control pain with doctor Shawn mckee. I and last but certainly not least, thank you for your interest in science.