The New Science of Pain: It's Not Just Physical | Dr. Rachel Zoffness, Being Well

0:00 The first thing to say about pain is that it isn't the thing we've been told it is. Pain comes for all of us one day, if it hasn't already, whether it's back pain or inhabiting an aging body. So, it seems so important to me that we all understand what it is. Not only are you living with terrible chronic pain, but now someone is saying, "It's your fault. You're just mentally ill. It's just stress. You're not managing your anxiety well enough. You have more power over your body than anyone ever has told you before." and that there are all these ingredients in your pain recipe, some of which might be hidden, that you have the power to start to change once you have the science, you have the knowledge, and you have the tools. What I want to offer you is hope and agency. Hello and welcome to Being Well. I'm Forest Hansen. If you're new to the show, thanks for joining us today. And if you've listened before, welcome back. Roughly one in five people are living with some form of chronic pain. And even if you're not one of them, you will probably deal with a significant pain problem at some point in your life. Pain is a topic that's relevant to everyone. But the model that most of us carry around about what pain is and where it comes from has got some real holes in it. We tend to think of pain as physical. Something breaks in the body, you find what's wrong, you fix it, the pain goes away. And that is true sometimes, but the reality is that pain is much more complicated than that.

1:21 Today we talked with Dr. Rachel Zoffnes about what pain actually is, why your thoughts, feelings, and the environment have a bigger role than most people realize, and how we can use that information to create better ways to deal with pain. We focused mostly during this conversation on the psychological and the social, two parts of the biocschosocial model that we spend a good amount of time talking about today. But that doesn't mean that the bio is not really, really important.

1:52 particularly, please do not take this conversation as a reason to change any medication you might be taking without close consultation with your doctor. So, I'm joined today by two guests. First, as usual, by Dr. Rick Hansen. Dad, how are you doing today? >> I'm great. I'm super psyched. And we are also joined by a very special guest, Dr. Rachel Zoffnes. So, Dr. Zoffnes, thanks for joining us. How are you doing? >> I love listening to you guys and thank you so much for having me.

2:20 >> thanks Rachel. I really appreciate that. So, to tell you a little bit more about her, Rachel is a pain psychologist. She is an assistant clinical professor at the UCSF School of Medicine, a UCFS, sorry, UCSF, as an aside, did a phenomenal job on my hip when I got hip surgery. So, hey, love that. And she also lectures on pain science at Stanford. She served on the boards of the US Association for the Study of Pain and the Society of Pediatric Pain Medicine, is a Mayday Fellow, and is the author of a number of books, including her most recent, Tell Me Where It Hurts: The New Science of Pain and How to Heal. Well, I've got a provocative question, sort of a straw man question. So, let's say I throw my back out or let's say I have some kind of chronic pain. ibuprofen works, maybe other drugs, too.

3:08 >> So, you said two different things. If you throw your back out and you have an acute injury, I would treat that differently than if you told me you had had chronic back pain for 5 years. >> So, what we know is that acute pain and chronic pain are two different animals and they work differently in the brain and body. So, just to define our terms, acute pain is pain that's three months or fewer. So that's like you've thrown your back out, you sprained your ankle on a run, even the pain of childbirth or an acute injury, those are all acute pain episodes. Chronic pain is another animal entirely. With chronic pain, what we now know is that chronic pain, believe it or not, is a disease of the central nervous system, our brain, and our spinal cord. So absolutely, medications can and do help. Thank God we no longer need to bite on wooden spoons during surgeries. You know what I mean? Like pain medications are a godsend and a blessing of modern medicine.

4:09 >> I go to the dentist, give me the Novacaane, hit me with that needle, please. >> Yes. Yes. And when you're at the dentist, there are dentists who use things like distraction and foot massage and other strategies that can also help lower pain volume. >> Can I get a referral later? Sounds pretty fun. Bonus benefits, but anyway. Okay. Sorry. Go on. >> But so your question is a good one. Absolutely. For acute pain, medications can and do help and often are enough.

4:39 For chronic pain, what science says is that while medications can be part of the solution, they often and usually are not the entire solution. >> So, you said something there about how chronic pain relates to the central nervous system. This takes me to a question that I was really curious to ask you about after I read your book. What is pain? So, I think the thing that frustrates me the most about pain and the reason I come on podcasts despite being a very nervous public speaker is that none of us are really ever told what pain is or how it works. And you said at the beginning that one in five people live with chronic pain. It's pretty wild. The numbers are incredible.

5:17 1.9 billion people around the globe live with chronic pain. And it's thought that up to a 100 million Americans are living with chronic pain. And to say clearly, none of us is going to escape pain. Pain comes for all of us one day, if it hasn't already, whether it's back pain or inhabiting an aging body. So, it seems so important to me that we all understand what it is. The first thing to say about pain is that it isn't the thing we've been told it is. We have all been told that pain is a purely biomemed phenomenon. And by that I mean something to do just with anatomy and physiology.

5:55 Your knee hurts, you go to the knee doctor, maybe two knee doctors, maybe you have knee surgery. What science says is that pain is about more than just the body part that hurts. In fact, the part of the body that constructs pain isn't our bad back and it isn't our aching knee. Ultimately, the part of our body that constructs pain is our brain. And one of the reasons we know this is because of a condition called phantom limb pain. Phantom limb pain occurs when someone loses a limb, an arm or a leg, and they continue to have terrible pain in the missing body part. Now, if you can have terrible leg pain in a leg that is no longer attached to your body, that tells us pretty definitively that pain must be constructed somewhere else. And that somewhere else is the brain. And the problem arises when we have chronic back pain and we only ever see back doctors and we only ever treat our back and we never talk about our brain. So Rachel, I love your approach and as I was reading through your book, what struck me about it was that it was comprehensive, individualized and kind and as a result super hopeful. And about the comprehensive part I think sometimes and forest will laugh in my 2x2 matrix way about physical problems physical solutions and mental problems and mental solutions. And what's remarkable and many people overlook and you don't is that you can cross over. In other words, if you have a mental problem, let's say like anxious mood around public speaking, you can potentially address that problem with some, I don't know what, beta blocker medication. That's a physical intervention. Or go the other way. If you got a physical problem like chronic back pain, you can address it in part through mental interventions of various kinds like lowering stress and improving a sense of social support and contact and so on. So that's a simplistic way of thinking about comprehensiveness. You work in a even more complicated biocschosocial frame.

8:00 Maybe you could elaborate around that. >> I want to answer your question in a couple of different ways. The number one question I get as a pain psychologist is do you treat physical pain or emotional pain? So I want to knock that out of the park right away. We have established that the part of the body that ultimately constructs the pain experience is the brain. Here is a fun and fundamental fact. The parts of the brain that make emotions also make pain.

8:33 Your listeners will have heard of the lyic system, the amygdala, those are fundamental parts not just of the emotion machinery but also our pain machinery. And what we now know is that 100% of the sensory messages from our body filter through our brain's emotion machinery before they become the thing that we call pain. And that's why our bodies feel worse during times of stress and duress. And it's why depression actually hurts. There is no such thing as pain that isn't emotional. There is no such thing as pain that isn't physical. Pain is always both physical and emotional 100% of the time. And and that's very important for listeners to know because we are not saying pain is all in your head. That is not what is being said here. So there is a word as Rick mentioned that does describe the science of pain very accurately. And that word is biocsychosocial.

9:33 And I want to say what that means because I find it to be so helpful. It's a little different than Rick's 2 by two matrix, but it does involve some equally fun nery. >> How dare you? We just need a third axis. So then it's a Z-axis, but it's coming out from the center of the graph. Absolutely. Okay. Anyways, go ahead, Rachel. We just can't help ourselves. >> So if you imagine a ven diagram with three overlapping circles, >> hey, love it.

9:58 >> And the three overlapping circles are the three domains of pain. So the one domain of pain is the biological domain of pain. And I'll say what all of these are. We have the psychological domain of pain and the sociological domain of pain. And if you imagine those three domains overlapping, pain lives in the messy middle of these three domains of human health. So in the biological domain of pain, we have the things we've all heard the most about. genetics, tissue damage, system dysfunction, inflammation, even diet, exercise, and sleep live here as biological imperatives. But what I want us to notice is that if we're only looking at the bio domain of pain, we are literally missing twothirds of the pain problem, at least according to pain neuroscience. So in the psych domain of pain, we have things like emotions for the reasons I just mentioned. We have predictions and thoughts and beliefs and we even have coping behaviors or how we navigate pain once it starts. And in the sociological domain of pain, it's like the everything else domain. It's socioeconomic status, access to care, race and ethnicity, its social support or loneliness. It is also our environment and and particularly in my mind of import is history of trauma.

11:25 Comorbidity between trauma and chronic pain is 80%. So 80% of people with a history of trauma have chronic pain and vice versa. So so what happens when we treat chronic pain is that we tend to look only at the bio. But pain is much richer and deeper than just that. I want to quickly mention here Rachel that this is not a fringe take that you're advocating for here. The NIH advocates for a biocschosocial approach to pain management. the updated recommendation for chronic pain is to try non-farmacological treatment first before moving to medications that there is the potential for abuse associated with most notably opioids which we will probably talk about at some point today.

12:07 And you give this distinction in the book that was very useful for me personally and it's the distinction between hurt and harm. So hurt is pain, harm is physical damage to the body. These two things typically travel together but they aren't the same thing. And you give these very evocative stories in the book as well. One I think you call it the tale of two nails. To summarize it really quickly, there was this British Medical Journal article where there was a construction worker who like fell off a plank, jumped off a plank, and he landed on this big nail that went all the way through his boot.

12:42 Obviously, he was in excruciating pain. That sounds awful. He was rushed to the hospital. They took his boot off and they found, wait a second, this nail did not penetrate anything. This nail just went clean through the boot, missed his toes, he wasn't stabbed by something. He felt awful. What was going on there? Then there's this other story you tell, different construction worker, clearly construction, dangerous line of business, but okay. He's firing a nail gun. He sees the nail gun misfire. The back of the nail gun hits him in the side of the jaw. He feels awful. He sees a nail like fly off into the air. He's got a toothache. This toothache sticks around for a couple of days. He goes to see a dentist. Wait a second. There's like a 4-in nail embedded in his skull.

13:19 And you show this image in the book that blew my mind of this nail like literally up in his head. Obviously, he was uncomfortable, but he was not in the kind of excruciating pain that somebody would imagine if this kind of a thing happened to him. So, there are these real examples that we have out in the world of this very complex relationship between harm and hurt, between actual physical damage to the body and how much pain we feel related to it. And this gets to this distinction that Rick was making when we were talking and doing some prep for this episode where he was thinking in terms of distress versus pain. Are these different things?

13:59 Are they the same thing? Can we feel a lot of distress about a small amount of pain? Like what's the relationship between the more psychological process that a person has and the actual physical symptoms that are going on inside of somebody's body or the level of physical damage to their body? and we were having a tricky time peeling this one apart and this is what you do. So, I'm very curious what your take is on all of this.

14:23 >> First of all, you're the first person to nail the tale of nail stories and you just nailed it. >> Fantastic. >> I'm I'm so deeply impressed. I'm so used to telling the story, but I've never heard it told back so perfectly. And I I I do want to address the thing you said at the beginning of this segment, which is that not only is this not fringe, I have been studying the neuroscience of pain for 30 years because I am a nerd and I was lucky enough at Brown University to have my mentor who was the dean of biology say, "I know you're really interested in pain. I'm going to pair you with a pain neuroscientist so you can write your honors thesis on the neuroscience of pain." I have been watching the science of pain evolve over the past 30 years and this is at the core of pain science. So you're correct.

15:09 It isn't fringe even remotely. This is absolutely basic pain science and and more more people should know it and have access to it. Why is it just in obscure medical journal textbooks? essentially, you know, you could have physical pain or or something that we experience as physical pain as like a two on the harm scale that for whatever reason you're perceiving psychologically as hurt on the 6, seven or eight scale. this construction worker had no harm, but he had a lot of perception of hurt. And there was a big gap between those two things, which then takes us to kind of an obvious question. What are we adding or contributing psychologically in terms of our sense of stress or distress or how scared we are about something that's happened and how does that affect our experience of pain?

15:56 >> So when I say that pain is biocsychosocial, what do I mean by that? I mean that in every given moment, your brain, which is your body's danger detector, is using all available information to decide whether or not to make pain and how much. Things that your brain is using in any given moment include potential damage to the body part, messages from your tissues, knowledge of your dangerous work environment. For example, with these tales of nails, these guys on the job site, the first nail in particular, he used the expression on his co-workers' faces. He jumped off a plank straight onto a 7-in nail and it drove through his boot. And his co-workers faces, they were horrified. His brain also used emotions, including panic. His brain used predictions because the brain is a prediction machine. It used memories of past pain experiences. So, so your brain in any given moment, whether you have an injury or not, isn't just using data from your tissues, it's also using all of this other biocschosocial data to make a decision about how much pain you're in. Because pain is the body's danger alarm. It is not an indicator of damage. It is your danger alarm. It exists to tell you something might be wrong. It's telling you, "Please pay attention. I want you to pay attention just in case there's danger, just in case there's damage. I want you to rest.

17:33 I want you to look at the body part. I want you to scan your surrounding environment. Credible evidence of danger, we now know, will amplify the brain's danger alarm. Credible evidence of safety will lower the brain's danger alarm. So the answer to your question is there's always a recipe of ingredients in any given moment that go into the brain's decision as to whether or not to make pain and how much. There's a metaphor you're probably familiar with from early Buddhism of the two darts, the two arrows, in which there's some kind of primary source of pain, physical or emotional, like for example, a brick falling on your foot or, you know, long-standing grief over a loss of a loved one loosely. And then there's the secondary reactions we add to that primary discomfort. And that second dart is where there are many many opportunities for us. I have a chronic issue in my neck. There's a subtle low low-grade background ache related to it.

18:37 Then I have my reactions to that. They're really separate. And both of those give us opportunities to finish. In other words, we can really practice with the secondary reactions to the particular condition which could be an external condition, could be a physical pain and the actual intensity of that particular condition as it's experienced can probably to some extent be downregulated by mental interventions. It can certainly be upregulated. So that means we can probably reverse that process somewhat. Okay. Okay. So, that's my way of saying back to you kind of sort of what I'm hearing.

19:14 >> Beautifully said. And I want to offer you a metaphor that I often use with patients to describe exactly what you just said. So, I want us to imagine in our central nervous system, which is our brain and our spinal cord, that we have what I'm going to call a pain dial. And the pain dial operates much like the volume knob on your car stereo. Many things can turn pain volume up. Many things turn pain volume down. And among the things that adjust pain volume are emotions, thoughts, predictions, and the behaviors we choose to engage in once the pain starts. For example, we know that negative emotions like stress, anxiety, sad mood, and anger are pain amplifiers. they will absolutely amplify the experience of pain. Conversely, science shows that positive emotions like joy and gratitude and even relaxation will turn that pain volume down. So it does matter a lot. The thoughts we think, the emotions we experience, even the behaviors we choose to engage in because you're exactly right. Those things will adjust pain volume in the brain and they will change our experience of pain. Yeah, you're making me think about you know it better than I do, the study in which was it Matthew Lieberman would have people in an MRI exposed to a mild electric shock and observe circuitry in the brain that literally activated with physical pain distinct from exposing people let's say to social pain like being embarrassed by confederates in the waiting room who are snarking on you before the real experiment supposedly actually begins. So we have this disentangling to some extent and of kind of primary pain circuitry and you know social pain circuitry. But that said if people were having the opportunity to hold the hand to someone while they were getting the electric shock the actual activation of the more ancient pain circuitry was lessened due to that social support. And I thought there was a funny gender distinction as well. Again you know this material better than I do and can correct me please. that women generally were affected by the social support of neutral people, but for men, they needed to be holding the hand of someone they actually cared about. So, I don't know.

21:43 Can you help me here? >> Touch, when it comes to pain, has a massive effect on the brain that lowers pain volume. What we now know is that touch messages reach the spinal cord and the brain faster than danger messages and actually lower pain volume. So, for example, if you bash your head on the kitchen cabinet, the first thing that you do is you reach up and rub it. Why do you do that? >> Oh, I say, Jan, why did you leave that cabinet open?

22:18 >> Great. You default to blame. Perfect. It's also a pull for social supplies. I see what you're doing there, Dad. Very clever. All right. Anyways, go ahead, Rachel. >> You're not the person I would think would default to yelling at someone, I have to say. >> No, I I I really I really don't. I was kidding. >> He's worked on that tendency over the years. That's for sure. >> So, usually like we bash our knee on the dining room table, we rub it. And there's a reason that's our instinct.

22:42 And it's because touch cancels out pain messages to the brain. It actually interrupts the pain signaling process so that pain messages are less intense and we feel them less badly. So touch actually can reduce pain by these physiological pathways because the social, biological, and emotional pathways at this point in the human brain and body are so intimately interconnected. And that's why I think these social factors that affect pain need to be talked about more. We all know that health issues don't follow a 9-to-f5 schedule. With our sponsor, Zachdoc, having no time to book a doctor's appointment is actually not a problem. So, when you suddenly remember that you forgot to schedule that appointment at 1:00 in the morning, or you tweak your back on the dance floor at a family wedding, or maybe you cut your finger making a midnight snack, you can go to Zukdoc anytime and find a doctor you love. ZDOC is a free app and website that helps you find and book highquality in-et network doctors so you can find someone you love. Whether you're looking for dermatology or dentistry, maybe primary care, or one of the over 200 specialties offered on Sockdoc, you can book in-et network appointments with more than 150,000 providers across all 50 states. Want to see your doctor in person? Great. Do you prefer a video visit? you can do that, too. And you can view thousands of verified patient reviews, which is probably my favorite part of the site.

24:18 If I needed to find a doctor, I'd use ZuckDoc. Stop putting off those doctor's appointments and go to zdoc.com/beingwell to find and instantly book a doctor you love today. That's zoodoc.com/beingwell. zdock.com/beingwell. Thanks, Zukdock, for sponsoring this message. You said earlier that all physical pain involves emotional regulation. I think about simpler creatures, crabs, maybe lizards, certainly invertebrates.

24:57 They seem to experience pain. You know, they have withdrawal responses. you know the and the simple basic circuitry and the genetic basis you know which we share with like fish and you know sea slugs is still operative. So it just seems to me that there's some primary pathways whereby very rapidly processed pain signals which then lead to, for example, a withdrawal response like pulling your hand back from the hot stove are not mediated. They're not filtered by the more recently evolved, you know, lyic system so forth, emotional circuitry. So I just want to kind of push on your sort of absolutist statement earlier.

25:37 >> I bring it. I I these are hard conversations. Pain is a complicated topic and I love it. You should. This makes me so happy. So listen to this. >> I hope I'm not creating social pain. >> You're not. You're creating excitement in a nerd brain. What you're talking about is a process called noception. Noception and pain are not the same. No cyception is this fundamental very ancient pathway in creatures whereby they have a withdrawal response to what we're calling a painful stimuli and no cception we have noceptors in our body they live in our tissues in our organs and noceptors are our body's danger detectors so we have noceptors that tell us for example something is too hot or too cold that there are dangerous chemicals that there's too much pressure.

26:34 Noceptors exist to warn us that something might be wrong, that we've reached sort of like a physiological max. And noceptors send that sensory data to the spinal cord. That is where the initiation of the withdrawal response occurs. However, the experience that we call pain is processed by the brain. And the way we make this distinction is that no cception, yes, the withdrawal response, you get away from the thing that's potentially dangerous and you're the the primary cre the jellyfish, the fly, their lives are saved. The experience of pain is a step beyond noception. You bring up an important point, by the way, which is there's absolutely no way to objectively measure pain. Not in any creature and not in humans. The only way we can currently measure pain is by self-report. That's it. So like if you tell me you're in 10 out of 10 pain, I believe you. Is it different than my 10 out of 10 pain? Yes. Is it different than forests? Probably. So you know, we all have our own unique individual experience of pain. it is real and it is valid and no one can tell us that it is any different than what we're reporting it is.

27:53 >> What this goes to and I bet Forest is going to take us there what to do about all this because in a sense because of the comprehensiveness and individualizing of your approach which then goes to the kindness of it. We have so many opportunities for people with chronic pain. Maybe we'll just focus now increasingly on people with chronic pain and how they can apply a lot of the material in your book for that. >> One of the things you talk about, Rachel, is a kind of pain recipe. The different factors that contribute to pain that people might not be as aware of. and these of course exist in these different domains we've already talked about, you know, social, environmental, cognitive factors in addition to the biological layer of it.

28:32 And part of the reason that you spend time talking about the other things is because we tend to overwhelmingly focus on the biological aspect of it when we're given somebody advice in terms of what to do. one of the things you mentioned was already is that trauma and chronic pain are our best friends. they co-occur at a very very high rate. We talk about trauma on the podcast very regularly. I'm wondering if there's anything else that you would like to pull out here as a big part of the pain recipe. maybe particularly things that people wouldn't necessarily expect.

29:01 >> This pain recipe concept, what it means is that just as there's a recipe for brownies, there is always always a recipe for pain. So when my patients come to my office, I ask them, "Do you know some of the ingredients that contribute to a bad pain day?" And they will inevitably say some version of, "Yes, I know I will have a bad pain day if I am sitting and staring at my screen for too many hours. I am not protecting time to move my body or exercise. I am socially isolated. I am eating a crap diet. I am sleeping poorly. Stress is really high. I'm having a lot of family conflict. So, like those are just a few ingredients in what I would call a high pain recipe. And what I love about this approach to treating pain is that once we have our high pain recipe, and I do encourage people to write it down because there's some magic in seeing it on paper in front of your face, it leads us naturally to our low pain recipe, which is typically just the opposite.

30:02 So, for example, one of the ingredients I just mentioned is poor sleep. Science says that poor sleep will actually physiologically amplify pain. And in the pain world, we call this pain insomnia. And it's a known thing. When pain is really bad, we can't sleep. The more we can't sleep, the worse pain feels. The worse pain feels, the worse our sleep. And around and around we go. So I know that I when I have patients who are dealing with pain related sleep issues, one of the most important interventions is called sleep hygiene. And implementing a sleep hygiene protocol will help that person rehabilitate their sleep and it will help pain volume go down. And just to say, you know, just as we have oral hygiene for our teeth, we have sleep hygiene for our sleep. And there is a whole sleep protocol in tell me where it hurts for that reason because sleep is an important ingredient in the pain recipe. So I think what we tend to do when we talk about pain, as you said, is that we tend to focus on the biological ingredients. And that's not bad. That's part of the recipe. It's just not the complete recipe. So things like sleep and nutrition and movement and emotional health and social health are things that we can target also.

31:17 >> So something that you are very careful about in your work is the all in your head stigma particularly for people who are dealing with chronic and more idiopathic forms of pain. Idiopathic pain and again please correct me on this is any kind of pain that doesn't have an obvious physical source associated with it for a person and these are often people who have received a lot of messages from other people already that this is all in their head or they are mentally ill or there is something that is psychologically wrong with them and I'm wondering when you're working with somebody how you balance being very careful about that and that stigma that often accompanies chronic pain with delivering some of the very pragmatic advice that's in the more psycho and social wings of the work that you do.

32:05 >> Yeah. Well, so because I'm a pain psychologist, I think it's easy to wonder if I'm treating physical pain or emotional pain. We've established that, of course, pain is always both. It's never just one or the other because that's the way the brain works. And also, there's this, I guess, myth that has persisted, especially for women and people of color, that pain is all in your head. And a lot of my patients have gotten that message. And I find that the best thing to do is to just lead with neuroscience. And once we know that there's this shared real estate in the brain between physical pain and emotional pain and that all physical pain signals, and I'm putting that in air quotes for listeners, are influenced by emotional data, social data, and emotional data. It sort of takes the stigma away in a way. An aspect of this that's maybe particularly complicated is this idea that you share called central sensitization and to really summarize this very quickly. Basically, as far as I'm aware, the idea is that as we experience pain, we can become more sensitive to pain over time. So, you liken the pain experience to a kind of car alarm for people. Like you were saying earlier, pain is a signal that something's bad, something's wrong, and so we want to change the situation that we're in. So it has a kind of adaptive function associated with it. But over time, if you're exposed to pain chronically, that adaptive function kind of starts to vanish. If you think about it, your brain's still telling you, "I'm in danger. I'm in danger." But your situation is just persisting. So the signaling value of this event, this pain experience is going down and down, but your pain is staying high and high. And that's a really tough spot for a person to be in. So I was hoping that you could say a little bit about central sensitization specifically and then this broader experience of like chronic pain in general.

33:58 >> That was beautifully said. That's right. So acute pain as we mentioned like you go for a run, you twist your ankle. Those pain messages are telling you stop, pay attention, there might be danger, you may need to go to the doctor, something might be wrong. We know with chronic pain, it's a completely different scientific process by which chronic pain arises. So, do either of you I'm going to ask you a question to answer this question.

34:23 >> Yeah, totally. >> is there a skill you were bad at, you practiced it, and over time you got good at it? For me, it was the piano, and only because my mom made me practice. >> Yes, absolutely. I I was not I would not describe myself as a natural mover, and I've got a 15-year dance hobby. So, for sure, for sure. Definitely worked on that one. >> I love that. Rick, do you want to say one, too? not interrupting people.

34:48 >> Deeply true. Deeply true. >> Okay. So, I'm going to say this back to you in neuroscience language. The pathways in our brain are like the muscles in our body. The more we use them, the bigger and stronger they get. So, if Rick, you said to me, you know, Zafnes, I really want big, huge biceps. I would say, Rick, of course you do. Who doesn't want big huge biceps? Go to the gym, lift lots of weights, and over time those bicep muscles will get big and strong. So too is it true of the brain.

35:20 The pathways in the brain that we use get bigger and stronger with time. So for me, the more I practiced the piano, the bigger and stronger the piano pathway in my brain became until, you know, I was like 16 and I could sit down at the piano and my fingers just magically knew what to do. I did not even need to look at the sheet music. And any musician will tell you they have had this experience whether they're playing the guitar, playing the piano where that occurs and you can even hear the song in your head without the music playing.

35:54 That is because of a really cool phenomenon called neuroplasticity. Neuroplasticity means that the brain is always changing with time and input and experience. But here's the downside. Just as the brain can become really good at playing the piano and the piano pathway gets big and strong, the same is true for pain. The longer we practice pain inadvertently, the bigger and stronger the pain pathway in our nervous system becomes and when that occurs, we say that the brain has become sensitive to pain. This process is called central sensitization. The pain system has become highly protective and responsive.

36:40 So small bits of sensory data from the body are now being amplified by a sensitive and protective reactive pain system. So if you've ever been working from home and there's a car out your window and a cyclist has ridden by and the car alarm starts beeping and flashing and you're looking at the car and you're like, "Bro, you're fine. No one's breaking in. the glass isn't broken, you're safe, you're okay, but but the car is alarming anyway. That is like a brain with chronic pain because small bits of sensory data are now activating and amplifying the brain's pain alarm. And it is believed that central sensitization underlies all chronic pain conditions to some degree.

37:24 When I was digging into this stuff, I found that there were a number of both disability and pain patient advocacy groups that were pretty hostile to this whole framework and particularly to the idea of central sensitization. And one of the reasons that they were hostile to it is because as near as I can tell, you can't really test for this. This isn't something where we can tell somebody your pain is centrally sensitized or not. So what happens is it becomes a kind of rule out. we don't have an explanation for why your pain dial is cranked as high as it is. So, we say, "Oh, your systems become sensitized to pain, but this then can closely connect to a kind of it's all in your head diagnosis." And I think that that's part of the reason that there's a lot of push back on this. And so I'm wondering how you think about that including like when you're working with somebody how how do you do this determination of this pain has been become sensitized or actually there is a physiological thing that's going on in you right now that really would create the pain experience that you're having.

38:26 >> Yes. You have touched on one of the many hot button issues in the world of chronic pain, which is it it really goes back to this thing where so many people in pain have been stigmatized and marginalized and told pain is all in their heads. And what a terrible message to give someone who is already suffering. Talk about the double arrow. Like not only are you living with terrible chronic pain, but now someone is saying it's your fault. You're just mentally ill. It's just stress. You're not managing your anxiety well enough.

39:00 You know, it it's maddening. It's just maddening. Look, the only thing I can do is just go back to the neuroscience over and over. Like Clifford Wolf is one of the researchers who's been studying central sensitization for many decades. There is a ton of data that shows that it is actually one of the processes that underlies the development of chronic pain. There are dozens of pain researchers who have shown that this process is at play on a cellular and biochemical level. So you're right in human beings, we cannot prove the moment when central sensitization starts. I cannot like put you in a scanner and say look at that there's central sensitization right there in your brain because there there is no pain center in the brain. There is no one pain chemical. It is impossible to measure pain in in an objective way. All we have is the subjective report. So, so I think it becomes this cyclical and dangerous game where people in pain aren't getting the relief they need. They are getting messages that it is all in their head.

40:01 And I think that's why this word biocschosocial helps us so much because it really honors that of course there's biological components and there are other factors contributing too. >> Totally. The yes and of this came through your work over and over again. And to give like a particular example of this, you talk about fibromyalgia a good bit in the book. and, that's another one where trauma can be a big part of the recipe for that condition. Apparently, they travel together fairly frequently. And for people who might not be familiar, fibromyalgia, it's a long-term condition, widespread body pain, aches and pains, extreme tiredness.

40:37 sometimes people also have trouble with like sleeping. That was a big piece of it as well. When I was researching I bumped into work from this guy who had transferred amunoglobin from patients who have fibromyalgia into mice and they replicated the kind of physical experience that fibromyalgia patients have in those mice. So this is things like reduced grip strength, hyper sensitivity. This suggests that there's some kind of bio going on here related to the autoimmune system that could be present in fibro. But then a drug company did the really obvious cool thing. They ran a clinical trial on a drug that blocked about 70% of the antibodies in patients with fibro. So if you've got a immune system issue, if we block those that that issue, that particular receptor amoglobin G I think it was, hey, this your symptoms should go down, right? They tried it for 12 weeks. It did not work. They discontinued the study. So this was really really interesting to me because it's an example where there is some kind of clear biological mechanism that is in the system somewhere that could lead to this experience that a person is having for a chronic condition. But then we create a biological intervention that sounds like it makes sense. It should probably do something in this case and it doesn't. It doesn't seem to help. And there's a part of me that wonders if that just reinforces the message that you're kind of delivering here where it's a complicated spread of stuff. There's a biological thing and there are biological interventions and then there are all these other things that we can do as well. And so I'm wondering what you think about that particular example, but just also I'm kind of setting this up.

42:13 >> I love that example. I want to read those papers. I'm going to ask you to email them to me. But >> sure, totally. >> I think what you're pointing out is this thing that humans have a tendency to do. We want to be reductive because if we're reductive, maybe we can figure out the problem, especially a complex problem. So, in order to be reductive and solve this problem, we we divide it into its component parts. And and you're hearing me do that, too. I'm saying biocschosocial.

42:41 Here's what the reality is. And I'm about to give you an example to illustrate this. They are all interconnected always. You cannot tease them apart. So I I'll give you an example. We know that loneliness, which I am calling a social factor, amplifies pain. And you'll say, Rachel's offness, what are you talking about loneliness? That's just like I'm sitting alone and you know, I don't have any friends and I'm not dating anyone. What could that possibly have to do with my bad back?

43:12 Those things have absolutely nothing to do with each other. And I will say to you, cool. Let's talk about science. Humans are designed to be social animals. In fact, social behavior is so fundamental for our survival that our brains reward us for engaging in it. When we are with other people, our brains bump out all these amazing feelgood brain chemicals like dopamine, which is reward and motivation, serotonin, which bumps our mood, oxytocin, which is connected and bondingness, and And endorphins are homemade endogenous opioids. Pain volume goes down when we are in community. And science shows that the opposite is also true. When we are lonely and isolated and alone, all of those chemicals crash include including our homemade painkillers. When we are lonely and isolated and alone, we feel worse not just emotionally but also physically.

44:16 Piece of data number two. When we are chronically lonely and isolated, our bodies bump out high levels of cortisol. You were talking about the immune system over time. Do you know what high levels of cortisol do to the immune system? They tank it. Which means if you are healthy, you are more likely to get sick. If you are already sick, you are likely to get sicker. And among the elderly, you are more likely to die. Now tell me that all the things are not always interconnected. Social health is emotional health is physical health. You cannot separate them out because ultimately the brain is connected to the body 100% of the time.

44:57 >> I'm also thinking about the distinction I first heard from the psychologist Paul Gilbert. Forest is familiar with this. This the the sense of grief rather than shame. In other words, agency is a double-edged sword. If it's true, as you're arguing, and I'm agreeing that u mental factors and social factors, non-biological factors, certainly influence the experience of pain and actually can directly influence the amount of pain itself, the primary pain itself for sure. that then could lead a person to feel somehow that it's their own fault because those mental and social factors do in fact have influence. That's where I think that grief rather than shame are really relevant here. In other words, there's a kind of reckoning and a facing and a taking of responsibility for the mental and social factors that are in the mix with your distress and with your primary pain. and they're a great opportunity to take a breath and move into one of your wonderful recipes that has to do with I'm drawing a circle here of activity and expanding your window of tolerance if you will for activities and then desensitizing yourself to you know kind of pain syndromes of various kinds and I think that's really important thing to name like yeah yeah yeah you are in the mix yeah your your thoughts and feelings and social behaviors are in the X and big breath time. What a wonderful opportunity to help yourself going forward.

46:40 >> How beautifully said was that and and I thank you for the compassion you're bringing to this conversation and and I think proceeding carefully as I always want to do with this discussion about pain. I think people with pain do understandably sometimes feel like people are saying if you're not better you're just doing it wrong. And I think my message is kind of the opposite which is >> gosh you you have never been given the science and the tools that you've needed maybe beyond medications and you know beyond procedures. And what I want to offer you is hope and agency. Oh my god.

47:22 Hope and agency are such critical ingredients in the pain recipe. And there's so much science that shows that hopefulness, believe it or not, can change the brain to change pain. And and I want to inject listeners and people living with pain with a modicum of hope and a belief that you have more power over your body than anyone ever has told you before. and that there are all these ingredients in your pain recipe, some of which might be hidden, that you have the power to start to change once you have the science, you have the knowledge, and you have the tools. And literally part three of Tell Me Where It Hurts is an entire pain protocol for that reason, including strategies we can use for treating trauma, strategies for improving our social health and our interconnectedness because now we know that that affects our biology, strategies for improving our emotional health in ways that can serve our physical pain. So, so, so thank you for bringing that up. I I think it's deeply important. talking about that protocol a little bit now.

48:25 One of the things that stood out to me the most in the work that you're doing with individuals was for starters how curated it was. you give a number of examples throughout the book of specific things that you were doing with specific people and you're really thinking in terms of their mix. You know what's in their bio and psycho and social. And so it's difficult to generalize here because when somebody is dealing with chronic low back pain, they're going to have a different set of problems and limitations than somebody who's dealing with phantom limb syndrome, than somebody who's dealing with CRPS, which is chronic re complex regional pain syndrome, if I'm saying that correctly there. these are all different problems a person might have. So on the one hand, I'm kind of asking how generalizable is this really? Are there specific things that tend to work for people over and over again? And then a thing that seems to show up over and over in your work is this kind of pacing and what I'll describe as like soft exposure work with people where you're trying to open up what's possible for them given the experiences that they're having dayto-day.

49:30 >> Yes, you're correct that one of the most important things I do with people with pain is something called pacing. If you told me, Forest, you know, Rachel, I'd really like to run a marathon. I would say, that's cool, Forest. I absolutely do not want to run a marathon, but kudos to you. and if you told me that tomorrow you're going to you were going to start by running 26 miles, I would tell you that you were making a big mistake. And if you want to train for a marathon, you are going to pace yourself. What does that mean?

50:01 You're going to start by walking and you'll mix in a little jogging. Then you'll mix in some running. And then over time you'll do some more running and you'll keep hitting a new milestone. And over time your brain and your body will adapt to the amount of stimulation you're giving it. That is also our strategy when it comes to chronic pain. Most patients living with chronic pain have stopped doing a lot of things. Understandably so. Pain is a message that tells us, especially when it's acute pain, to stop, rest, pay attention. But I think that's the complexity of chronic pain, especially when no one has told us that chronic pain is usually not a message that something dangerous is happening with your ankle or your back. Chronic pain is actually a message that your nervous system is in a state of high alarm. It's in a state of overp protection. So, pacing for pain means that I ask my clients, tell me something pain has taken from you that you want to get back. And it can be anything. It can be soccer. One of my patients wanted to go back to Irish dance. One of my patients wanted to go back to fudge making. Like, it doesn't have to be an athletic pursuit. It can literally be anything that pain has taken from you. Then we break that down into tiny achievable goals. Because even with something as simple as fudge making, that involves many things, including getting in your car, driving to the grocery store, walking around the grocery store, coming back to your house, and standing in the kitchen for however long that takes. And that is hard for some people. So we break it down into tiny, tiny, achievable little steps as if you were pacing for a marathon. And we figure out what your baseline is. how much I can do on any given day. And that's going to be different. On a high pain day, you can do very little. And on a low on a low pain day, you can do a lot more. So I I meet my patients where we are. And we create a pacing plan to help them reach their goals. And no matter what that means for you, there are graded gradual steps we can take to help get you back to the goals that you miss and to get you back to the activities pain has taken from you. One of the recurring metaphors for Forest and and me is this notion of an invisible cage in which we function inside of with appreciation for why we built that cage in the first place. It was a necessary set of armor.

52:34 It was a necessary fairly small window of tolerance. We had to do it. Okay, great. But so much of healing and and expanding in this life in various ways is about pushing back millimeter by millimeter the boundaries that we function inside of in all kinds of ways including things like public speaking as well as of course dealing with physical movement when you've got a chronic issue. But then on the other hand, as someone who's grappling with long-term issues like my wife is for example in Forest Mom, you have to be careful about flares and setbacks because then suddenly the the cage, if you will, the bars have come in a little bit further. So you're working on that growing edge very very carefully. One of the things I really appreciated about your approach was getting into the detail very sympathetically, very kindly and compassionately with how people can work that edge and keep you know nudging it out. So point one. point two, I was struck by a research finding that forest found as we prepared for this research shows that for example psychological treatment, you know, mental and social interventions of various kinds distinct from direct physiological interventions like a drug or some surgery, they tend to most reliably reduce what I've called distress or dysfunction, like catastrophizing or fear of movement around the the pain distinct from reducing the intensity of the pain itself. Just now I'm all for reducing intensity of pain itself.

54:14 and I think it's really important to acknowledge that loose distinction between the two and really appreciate that the second darts, the distress around what we're dealing with are where most of our suffering lives. You know, I've had many experiences and others too where I've had a lot of discomfort and it was painful. I didn't like it, but it didn't bother me in that distinction right there. And it didn't constrain my activities of daily living and the way I was dealing with life because that it's in that secondary cascade. I don't mean secondary as it's trivial. I just mean it's kind of the add-on cascade that so much of our suffering is living in. So both and for sure while really appreciating the benefits of improving function and reducing distress around the primary around the primary pain >> and what you just said which is so fundamental is that because pain is biocschosocial treatment must be too I agree with you that we are not just treating pain with psychological approaches that's not what we're doing we are also looking at biological ingredients and sociological ingredients like hopefully we're improving access to care. Hopefully we're talking about your social health and your history of trauma and also medications as needed, sleep, nutrition, movement. We're looking at all of it. So I agree with you. It's not psychological alone. It's not physiological alone.

55:49 It's all of them together because ultimately pain is a whole person problem that requires a whole person solution. So I want to ask you a little bit about that that whole person problem of all of this. So I I looked at all of these treatments. I looked at medications. I looked at psychological interventions. I looked at PT. I tried to dig into the studies. I looked at the big reviews of this. And what I found, and I'm curious what your take is on this as an actual pain scientist, was hm, nothing works that well. So here's what I mean by that. If you look at number needed to treat for all of these different interventions, what you typically find for them is that the N&T is around four or five or six or seven.

56:32 So what that means is that relative to placebo, which is a huge topic here that we haven't dug into yet, but I'm hoping to, each of these interventions, something like Symbalta, which is an SNRI, it's sometimes prescribed for, depression and anxiety disorder, but it's also prescribed for chronic pain. including chronic muscularkeeletal pain, fibromyalgia, all of that. About four in 10 people on this need hit 50% pain relief. But about three in 10 get that from placebo. And this is complicated because placebo isn't just taking a sugar pill. It's everything.

57:07 It's the natural ups and downs that a person experiences. It's whatever else they were they were doing before they started trying this sugar pill. And deluxitine is also worth flagging as an example because it has really rough withdrawal effects associated with it. Once you get on the medication, it is very difficult for people to get off of it. So 44% of the people who take this pill had 50% relief. 29% do that on placebo. So this means that the number needed to treat for it is 1 in six. Big problem. One in six people also stop taking the drug because it gives them stomach distress that is so intense that they don't want to be on it anymore. So this is not great for the medication side of the spectrum. Problem is that for like CBT for chronic pain, as near as I can tell, NT is about 1 in4. So it's better, but it's not great. And a lot of those effects tend to go away over time. But big butt here, and I'm saying a lot, so I'm curious your take on all of this. Big butt is that these are typically biodal distributions. So what that means is that some people are really benefited by something whereas other people are totally not benefited by it at all. Some people do PT totally solves their problem. Some people do CBT for chronic pain totally solves their problem. Some people take a a certain medication wow they get a ton of effect from it with minimal side effects. How great. So this took Rick and me to huh why don't you just do a little bit of everything? And that is maybe a summary of the biocschosocial model. you know, maybe if you just try a little bit of everything, you will find the thing that for you you get that biodal response from, but it's really hard for us to tell which of those things will be the one that really moves the needle for you. and so maybe the real kind of underlying recommendation here behind the whole biocschosocial approach is you just happened to find the the thing that you got a particularly awesome response from. So, I'm wondering what you think about all of that, Rachel.

59:04 >> We live in a quick fix culture that is obsessed with hacking and biomaxing. And unfortunately, that doesn't work for pain. big pharma is now being taken to task to the tune of 54 billion dollars in lawsuits for for feeding us the lie that chronic opioids are a safe and effective treatment for chronic pain, which we now know is not true. But but who doesn't want a quick magic bullet? Pain is miserable. We all want it to just end.

59:45 And most people would do just about anything to make it end right now, including me. I started studying pain because I was scared of it. I mean, pain is an aversive human experience by definition. We all just want it to go away. So, what I am offering is good news mixed in with a little bit of unfortunate news, which is there is no hack for pain. There's no hack. Like yes, PT can be extremely helpful. So can occupational therapy. So can pacing and movement. So can changing nutrition and diet and sleep sometimes is the thing for people. And sometimes it's treating your long and complex history of trauma and and navigating grief, which causes physical symptoms. And sometimes it's getting a back surgery, which is not usually the case. That's usually not the solution for back pain. But but what I'm saying is what I'm presenting to you is yes, it's always in a it's a recipe and there's no quick fix and the best we can do is put together our own unique pain recipe and look at those ingredients and go through them and see which ones we have the agency and power to change until we find the recipe that helps our unique body. And and I promise that if there was a quick fix, I would be out here today stumping for it. And I do get really frustrated because anyone who's on social media will see that there are a lot of influencers in air quotes who are telling us that this supplement is the fix or this new fangled therapy that has this name is the fix or this particular surgery or treatment or medical device is the fix. And and unfortunately, as everyone probably already knows, that is not true.

61:37 >> We spend most of our time on the show talking about the psychological side of being well. But sometimes our low mood, irritability, or foggy thinking has more to do with physiology than psychology. And you can't really figure out what's going on without doing some testing. I wanted to get a better sense of what was going on in my body. So, I worked with our sponsor, Function, to do just that. Function gives you access to over 160 lab tests a year. This is five times more than the typical annual physical.

62:08 Thyroid, hormones, nutrients, inflammation, and more. A licensed clinician reviews every result and translates it all into plain language, so you know what it means and where to focus next. All of your results live in one place so you can spot trends, track changes over time, and get a deeper view of your body year after year. This doesn't replace a doctor or a therapist. It gives you more information that everyone can work from. Check your health with 160 lab tests and access to scans through Function. All for over $365 a year. Learn more at functionhealth.com/beingwell and use codebewell25 for a $25 credit. There's one thing in all of this that might be the fix if the fix exists and that's placebo which you write about quite a bit in the book and I really wanted to ask you about.

63:07 placebo is wild. in part I I didn't actually understand placebo properly before I read your book. I thought that it was, oh, okay, you know, one person takes a pill that that has the medication in it, the other person takes a pill that's like a sugar pill, and we just look at the difference between those two things. That's it. Turns out way more complicated than that. What is the placebo effect? >> I I am I'm so motivated to know that that changed the way you thought about placebo. And it it makes me I'm so it makes me sometimes I feel like I'm shouting into a void and and >> getting feedback from smart people just absolutely makes my day. So >> we do think of a placebo as like a nothing, a sugar pill. And in medicine, if a medication is no better than placebo, it is discarded as useless. But placebo is not nothing. Placebo is the opposite of nothing. A placebo effect occurs when a credible source, say like I'm wearing a stethoscope and a white coat, someone who looks credible, hands you a sugar pill, and says to you, Rick and Forest, this is the most powerful pain medication we have. You are going to feel better right quick. If you believe them and you predict that your pain will go down in response to those predictions and that context and the emotions that it inspires, your brain will bump out high levels of endogenous opioids and your pain will actually go down. So a placebo is not nothing. A placebo is the opposite of nothing. A placebo is a biocschosocial recipe of ingredients that changes your brain and body to change your pain experience. And and there's this word that we hear a lot in I I guess in fringe medicine like self-healing. So I'm almost wary of using it, but I'm going to use it for this purpose. I went over the handlebars of my bike on a on a trip with my husband. We were biking. I was biking downhill. I hit a lot of scree and gravel. I went over my handlebars. I destroyed the crap out of my hands and my knees. I was bloody and bruised. And over the next couple of weeks, I watched as my body self-healed.

65:23 So, like I I'm using this word in like a very real biological sense. Our bodies and brains have a lot of self-healing mechanisms innate inside of us. And when it comes to pain, we can harness that power to change our body's pharmacy to help us feel better. We can engage in all sorts of activities that can boost brain levels of endogenous opioids. And a lot of those things are the things we've been talking about here today. So I do not pretend that placebo is like a magic fix for pain. But I do think it is really compelling evidence that our predictions and our beliefs and the context around us and the emotions we bring to it actually change our brain chemistry and our physiology. I'm going to give a specific example of this which I hope doesn't make my mom who's a licensed acupuncturist mad at me. so they did a huge metaanalysis on acupuncture for back and neck pain, osteoarthritis, headache. It included 18,000 people in all of these studies that they looked at. They did this in 2012 and against no treatment, acupuncture came in way better, about half a standard deviation better in terms of people's experience. This was a wild result, particularly for an acupuncture skeptic like me, right?

66:38 Like, who wa acupuncture was really doing something here. They then tried something that they called sham acupuncture. So, basically, this was a situation where somebody goes in to see a quote unquote acupuncturist. The acupuncturist asks, "What's your problem? Here, I'm going to help you with it." And then they do sham acupuncture. They take these fake needles. Often, they would not even penetrate the skin of the person. They would use them on points that were not magical body meridians as expressed by acupuncture. But what they found was that the differences between real and fake acupuncture were very very small when they tested them against each other. And when people used very convincing fakes, for example, needles that actually penetrated the skin, but in points of the body that were not like acupuncture meridians or points or whatever they're called, the differences got even smaller. So this suggests that most of what is doing the work in that half a standard deviation improvement is all the other stuff ritual, the person's experience, touch, 45 minutes of somebody really paying attention to you and kind of giving a about what your body's experiencing. Wow, how uncommon is that these days for people? And these are all of the things that again you really talk about mattering. and I just thought that was such an interesting example of this.

67:52 >> Isn't it profound? It just blows my mind. I went so far down the rabbit hole when I was writing Tell Me Where It Hurts because I wanted to know everything about what was happening. That is also true when it comes to pain. There are now gosh hundreds of studies showing that what is called sham surgery, which is essentially placebo surgery for very >> This was crazy to read about, by the way, that they will actually like slice people open, do the past medication, all of that, but they won't actually do the procedure. Yeah. Go ahead.

68:24 >> Sham surgery for very real pain conditions like knee osteoarthritis are equally as effective at lowering pain as the surgery itself. And I'll say what that means. Doctors will take patients with very real painful conditions, go through the entire ritual, the operating room, the, you know, the dress, the the cap, wheel them into the operating room, knock them out. Sometimes they will make an incision.

68:56 Sometimes they will not. I think usually they do wheel them back out, give them the posttop drugs, give them the posttop instructions. And the patients don't actually know whether or not they've received the surgery. And what they found is that when someone had a sham surgery, they reported improvement, significantly less pain as if they had actually had surgery. And and this has been done on various different pain conditions, various different body parts, and like the research, the data is so overwhelming that at this point there's no denying that there are all of these other processes that are occurring to stimulate what I call our body's pharmacy and actually physiologically help pain volume go down in the brain.

69:44 And I want to say clearly, these patients weren't faking. They weren't crazy. It's not all in their heads. What was happening is that this combination of biocschosocial ingredients was triggering the release of endogenous opioids and other neurochemicals like endockinabonoids in the brain that was actually changing their experience of pain and and gosh that's so valuable for all of us to know because it means there are so many more things we can do to change pain volume beyond surgeries. I want to ask you about a specific version of this, Rachel, that is completely wild to me, which are open label placeos. And these are fake treatments that the the patient knows is fake. So they remove the deception part of the placebo process. which is totally bizarre to think about. There's even some evidence that people's symptoms for things like IBS or chronic back pain improve even when they know that they're taking a sugar pill. Although I I do want to mention those improvements seem to mostly vanish over time when they do more studies that look back on the that are more retrospective after like a year or two they check in with the person that differences get smaller and smaller. The one long-term follow-up I found with a control group didn't have great lasting effects. But even the temporary improvement of somebody's pain experience from this is like totally wild. If you can tell somebody that a pill is fake and it still works, then what's what's helping them? Like they know that it's not the thing, right?

71:15 Like is something else contributing to this? Do you have any explanation of this? >> Yeah, it's a great question, but I do think Ted Capic at Harvard has found that there are enduring effects for open label placebo, particularly for things like for irritable bowel syndrome, but I I'll I'm not sure. Did you Did you check that? >> Yeah. So, the those studies typically do not control or include a particularly good control arm, at least the ones that I looked at. so they were controlling against nothing at all as opposed to controlling against something or trying to control against treatment as usual or things like that.

71:48 Okay. >> the one I I looked at was Klein Borgman. It's pain 2023. No long-term effects after a 3-we open label placebo treatment for chronic low back pain. Three-year follow-up randomized control trial. So that's the the one that I looked at. But this actually gets us into something that I did want to ask you about. >> The research in this territory is all over the freaking place. >> You can find studies that say one thing. You can find studies that say another thing. There are a ton of methodology concerns and the research. The studies that show the biggest effects are almost always the studies that were like run by the person who created the intervention.

72:23 there's just so much confounding in this space. And so I'm kind of wondering how you navigate thinking about it. How do I say this kindly? We have a profitdriven health care system that cares a lot about profit. And I would humbly submit to you it cares more about profit than it does about you or about me or about our pain. And our profit- driven health care system has a trillion dollar budget to focus on biomemed procedures and medications that you and I have to buy in order to fund the biomedical machine.

73:04 So one of the biggest problems we have in pain research is money and where it's coming from and what it's funding. What is the motivation for pharma or medicine to fund placebo stud? Who makes money off of placeos? Nobody. I mean, what again, the thing that I'm promoting today isn't for sale. No one can bottle it. No one can put it in a syringe and sell it to you. Like, what I am selling everyone here today is the power to change their own pain.

73:37 Like, that is not particularly po popular in a biomed profit-driven healthc care model. So, if you're asking me what I think is at the root of the problem, >> it's money and and and where the money is going and what it's funding. And actually, that's why I appreciate people like you >> who have a platform and have people who believe in their science and because you guys are rigorous scientists and it's very clear even by the prep you did today, which is blowing my mind by the way and and it makes you more credible.

74:10 It makes you more credible. So, you know, I think at the root of this is the fact that not on top of the fact that there's very little money being put into pain research, especially right now, is the fact that 96% of medical schools in the United States have zero dedicated compulsory pain education. And I'm going to say that again. >> 96% of medical schools in the United States have zero dedicated compulsory pain education. That is not because our doctors and healthc care providers don't want to learn about pain. Like providers go into medicine to help and heal. It is their calling. We just aren't giving people the tools and the education that they need to help people living with chronic pain. And that's why healthc care providers are burning out so fast at the rate they're burning out.

74:58 >> Right on. I mean, even in my not a professional, as I often say, I'm just a guy with a podcast, you know, so take it diffidently with this. Even in me going in and looking at the research, and I've read a lot of studies at this point, just prepping for the podcast in general, there were obvious follow-up questions almost always, you know, what happens if you compare sham study or sham surgery with incision to sham surgery without incision? what happens if you go back to the people who we treated with CBT for chronic pain 3 years later and check in on them. How are they doing? Like that kind of stuff.

75:33 There are some follow-up studies in the space, but to your point, they are very limited. And I think the big question is, you're right, a lot of the research that gets funded is research that could be plausibly profitable for somebody. I talked earlier about that attempt to create a drug-based intervention for fibromyalgia focused on like blocking this particular thing. of course they were able to get funding for that because it's a drug company and they would have been able to profit off of the creation of this medication. and so that could I think very plausibly be the root of a lot of what I'm raising here in terms of the fuzziness around these different pieces of research. The lack of clarity that we have about like number needed to treat relative to placebo under different conditions which then just makes it so personal to your point. It is a very individualized process figuring out what's really going to help somebody. And it also kind of takes me back to that shotgun approach.

76:21 You know, maybe part of the encouragement here, and I don't know if somebody with chronic pain wants to hear this or not, is essentially like keep trying, keep believing in yourself, keep thinking that there's something out there that could be helpful. And, even though, you know, certainly just for me, when I'm in a small amount of distress in a given day physically, I don't want to do much of anything. And so I can't imagine that somebody who's dealing with a considerable volume of chronic pain is really interested in that or really, you know, is feels that way about it necessarily, but I do think that's part of the advocacy work that you're doing here that's so important.

76:56 >> And and to your point, rates of suicidality in the chronic pain population are twice as high. And there's a reason for that. If you Google cure for fibromyalgia, Dr. Google will tell you that there is none. And I just want to say that is complete. And I don't know if we're allowed to curse, but I just did that that so there is so much hopelessness and and again like our healthcare providers aren't receiving the pain education they want or need or deserve. And so people living with pain who are downstream of this miseducation and this profit-driven mess are suffering at catastrophic rates. So what can we do to put information into the universe to make people feel more hopeful so that they will hold on so that they will try just one more thing? so that they will look at their comprehensive pain recipe as Rick said and and look at different ingredients which they might not have noticed before or even thought were connected to their pain like their history of abuse and trauma. So I think that's the message here today is is how do we how do we explode that hopelessness? How do we help people feel that they have more agency over their bodies than they ever realized and that they can try just one more thing and that thing might make the difference for them? Rick, I'm really curious what you've been thinking about as we've been talking about this. I'm thinking about the people listening to this who themselves have chronic pain and I'm thinking about the caregivers and friends and loved ones and parents and children and professionals who are helping or with people with chronic pain both and maybe a little later we'll get a little bit from you Rachel about people who are the spouse or a child or a roommate of someone with chronic pain and or a friend and so forth. So, I'm thinking about that and what it's like for them to listen to this. I'm really appreciating what you said a moment ago for us about I call it stones unturned because that's where it's hopeful. What have you not tried yet? So when you think about the recipe of you know the five different kinds of sort of things you could do or the 10 things whatever the biocschosocial package there finding that one pellet in the shotgun approach let's say mixing my metaphors that's the one for you is really helpful A and then B it's helpful to start reflecting on okay what group do I belong to that's going to get a lot of effect size. It's going to get a lot of efficacy from a particular intervention. So finish recognizing that in your book and in your package is a lot of hope is going to reduce your pain per se. that's why I think placebo is quite helpful is because it gives people hope and you know reduces their sense of alarm. So, I want to just kind of put one more plug in here for really realizing that if you take a look at, Dr. Zoffnes's package, it will almost surely reduce your pain and for sure it will reduce your sense of suffering around the pain. One other thing that I wanted to ask you about here, Rachel, was mindfulness-based practices, which makes sense. It's what we talk about a good bit on the podcast in general. Rick has a really strong background in that obviously. you often talk about trying to reduce attention paid to pain in the book because attention will turn the volume up. You know, the more that I'm attending to something, the more that I'm focused on something, the more I'm thinking about my limitation, it's hovering in my mind in the way that we've been talking about throughout this. But you also recommend some mindfulness-based approaches. And those approaches sometimes include a kind of attention paid to pain to some extent. You know, you're holding the pain in your mind. You're holding it loosely, but you're aware of its presence. You're engaging in some kind of practice with it. And in the MBSR community in general, there's some question about the kind of sensory effect of split. You know, is it that I'm decoupling the sensation associated with pain or is it that I'm distracting myself and turning away from it? Like what's actually helping somebody here?

81:12 here. And so I'm wondering how you kind of think about that. >> You are veering into the beautifully complex territory of the intersection between mindfulness, emotional pain, and physical pain. So, so let's do this dance as best we can. So what we know from neuroscience is that our prefrontal cortex when we focus on pain when we talk about pain when we're stuck at home and we're not engaging in activities and we're you know we're really ruminating on our pain our prefrontal cortex is sort of like a magnifying glass and so if I say to you right now think about the body part that hurts and just kind of like hangs you know your your prefrontal cortex will zoom in on that body part and it will amplify the sensory messages. That's just the job of the prefrontal cortex.

81:59 And if I go and ask you to now engage in your favorite activity, whatever that is, gardening or, you know, reading your favorite book or like whatever it is, that that magnifying glass will now zoom out and and everyone I've ever met can tell me about a time they were so engaged in some beloved activity that they briefly forgot about their pain. And that is not magic. That is just, you know, your brain's magnifier zooming in and out.

82:26 What's interesting to me about mindfulness and by the way I am the hugest fan of MBSR. I did a year of training in MBSR as part of my posttock. I I am really interested in the research around it. I think you know there are a lot of guided audio that I am recommending to patients that they're finding very useful. a lot of workbooks, a lot of strategies, and and I actually think there's something different qualitatively about using harnessing the power of attention as part of a treatment protocol and knowing it's part of a treatment protocol versus staying inside, staying at home, not engaging in work, not engaging in hobbies, and and ruminating about your pain in a way that can I think that I think can be counterproductive and sometimes catastrophic for your body. With mindfulness, when we engage in these attention practices, we're doing a couple of things. I think first of the body scan, for example, where we use our prefrontal cortex as a magnifier to scan through our entire body gradually. And yes, we come across the the place of pain and we do it mindfully and we sit with it and we notice how it's changing and we sit with the different thoughts and emotions that come up as we're having that pain experience. And as Rick said, that can help us tease out the sensation in our body from the thoughts that are accompanying the pain, from the emotions that arise when we have the pain experience. And then in the body scan, as you know, you move on. And what's really cool to me about the body scan is that it helped me come up with a mantra which I'm going to share with you, which is as I'm sitting with the painful body part, what I notice is that the pain is changing. And so I will often afterwards ask my patients to zoom in when they find the painful spot to just when pay attention to the color, the shape, the temperature of the pain, and notice how it's changing over the couple of minutes they're spending with that body part.

84:32 And at the end, they will always report, yep, the pain changed. You know, it was hot red and then it turned a little bit orange and then it extended up a little bit and then it came back down and then it felt like it was swelling and then it sort of shrank back down. And here's the coolest thing about that. If pain is always changing, that means pain can change. If pain is always changing, that means pain can change. Tell me that's not a hopeful message for someone who has lived with pain day in and day out for many years. It's such a great reminder that this is not permanent that it is transient and if it is changing that means it can change. So, so I think there are many things in the world of mindfulness and MBSR that we can harness to to treat pain and change the pain experience in a way that is very productive and helpful. I wanted to ask you, Rachel, from working with so many people, what advice would you give to family members or friends of people dealing with chronic pain?

85:37 >> I think that is a tricky subject. And the reason it's tricky is because we have all experienced, myself included, that oftenimes the people we can help the least are the people we love the most. It's so frustrating. like I can't help my family members with their pain because, you know, I I'm too inside the family system and there's too many dynamics and there's too much going on. So, sometimes the best thing that we can do is offer resources. if you know someone living with pain, you can send them this podcast, for example, if you think the science would be interesting to them. You can share books as resources. You can share websites. The other thing that I think is really helpful is supporting people on their pain journey to engage in some of the activities that might lower their pain volume. So for a lot of my patients, what I encourage them to do as they're engaging in things like pacing is to ask a family member to pace with with them. So if your goal for today is to walk just five minutes, ask a family member to go with you. And the job of that family member is just to sort sort of serve as encouragement and support for the person on the journey. You know, if someone wants to go back to fudgemaking, ask a family member or family member can offer, hey, can I go with you and keep you company? I think having company and support on this journey as we're healing from pain couldn't be more important and family members are in the position of providing exactly that.

87:06 >> Yeah, I wonder if I could build on that. some things I've seen and one is to address the ways in which you are getting worn out by their pain to make sure that you are filling up your own cup and address the ways in which you are maybe feeling helpless. people don't like feeling helpless and or you feel like they should take your advice and they haven't taken your advice or you feel like they're going overboard, whatever that might be that would then lead to an aversive withdrawal response on your part with some maybe irritability and annoyance.

87:41 I'm referring to myself early on in my wife's health issues. you know, that's something to really pay attention to. Can you allow yourself maybe through your own mindfulness practice to be with them to be with their pain? One. Two, obviously compassion for them. Compassion is really important. I think three is knowing in your mind at least what you think would actually be helpful for them. Doesn't mean you communicate it, but at least you know in your mind what that might be. And it might be that they simply keep doing what they're doing to help themselves. or you know that you know there is a particular doctor that would be useful to talk to or a particular book hello that might be helpful to to read or at least have on the bedside table. So I think that's really helpful just to know what it is. And then last given that one of the universals that really does help with pain is social support and people vary in in their subgroups of terms of how social support is delivered and what works for people and so forth.

88:44 But resting in your lovingness, you know, that is what you can influence. You maybe can't change their pain per se. You can't change their behavior per se, but you can change your own rested and lovingness. The degree to which you're lived by love in your relationship with them. >> I loved that so much. And I do think self-compassion for caregivers of people living with pain >> is such a fundamental thing. Burnout is real. We all need respit, you know, when we're caregivers of people living with pain. both physical and emotional and I I think that couldn't be more more fundamental.

89:17 >> So I also have a wild card question I've been thinking about I hope I can ask it which is that in our podcast we deal mainly with psychological issues so forth not so much physical or some ways physically centered issues like like physical pain. I've been thinking about your comment early on that you don't like public speaking. Well for someone who doesn't like public speaking you're freaking good at it. and I just wonder what you've learned from your deep dive into pain science, physical pain predominantly, and the science of it that is relevant for people who are grappling with psychological pain, anxiety, you know, anxiety about speaking in public maybe or just other kinds of psychological issues. What can people learn from physical pain science that could be applied to their own mental health? Broadly, >> I think the answer to that is that the only way out is through. That's my other mantra. The only way out is through.

90:19 With anxiety in particular, when we avoid the things that make us feel anxious, the anxiety grows and the power grows. So too is it true of physical pain. When we stay home and stay inside and avoid physical activity and stop seeing friends, stop moving our bodies, it gives pain power and the power grows. So, so truly the only way out is through. And we do that in small graded doses and hopefully we do that with support and hopefully we do that with a lot of self-love and self-compassion.

90:51 But but truly the only way out is through. >> Beautiful. Rachel, thanks so much for doing this today. This was a long one for us. This is going to clock in at one of the longer episodes we've ever done. I think so. Thanks for thanks for just being here for it and the work you're doing is really fantastic stuff. Would you like to tell people a little bit more about where to find you? What you're doing online? I I don't know if you have a Substack. I feel like everybody has a Substack. You feel like a person who might have a Substack.

91:16 Anyways, >> yeah. so I will say I have done upwards of 60 podcasts at this point and this was one of the smartest ones I've ever done and I'm so grateful to both of you for the the research and the time you put into this. It's it's very clear and it it made for me some some great conversation and very compelling questions. So thank you for that. I have a website. It's just my last name.com. So I have a resources page that I've been putting together for like 20 plus years with zerocost resources.

91:46 It's if you're curious about any of the articles, the research articles we mentioned or if you want guided audio for pain or if you want book recommendations or you know podcast suggestions, I'll put this one up there also. So websitesoftness.com. I am on social media. I dislike social media, but it is where people are learning are learning and getting their science. So out of necessity, I feel like if they're learning from pseudocientists, there should be some real scientists out there. Also, and Tell Me Where It Hurts is in all the bookstores. In fact, friends keep texting me photos from bookstores all over the place, which >> running into your book in the wild is a great experience whenever I bumped into like Resilient at a random bookstore.

92:30 I'm I'm always like, "Oh, oh, nice. They're still selling this sucker." Okay. >> Totally. Yeah. And of course, it's on Amazon, but it's also on bookshop.org for people who want to support independent bookstores. >> Nice. Thank you so much, Rachel. We really appreciate it. This was such an interesting conversation with Dr. Rachel Zoffnness. And I'm going to start the outro here with a couple of disclaimers. The first disclaimer is to reiterate what I said in the introduction to the podcast.

92:57 Please do not take this podcast episode as a reason to cease or change any medication you might be taking for any condition. Any changes to medication should be done in close consultation with your doctor. Rachel talked a lot during this episode about the biocschosocial model. How these are all things that impact a person's pain experience and it is very difficult if not impossible to peel these different aspects apart from each other. Because Rachel is a pain psychologist and because Rick is a psychologist and because we have a mental health focused podcast, we spent most of our time talking about the psycho and the social. This does not mean that the bio does not matter. The bio really matters an awful lot. And particularly when we're dealing with acute pain symptoms, it absolutely makes sense to treat them with medication. And it can make sense in many situations to treat chronic pain with various forms of medication.

94:04 And that's where things start to get really complicated. As I dug into the research on pain and chronic pain, I was struck by, and this is my language, and again, I'm not a scientist. I'm just reading these studies and interpreting them as best as I can, by what I perceived as a fairly poor response rate to most of the interventions that are out there for people. Yes, if you take an opioid, it probably will reduce your pain experience, but there is a lot of complexity that accompanies taking an opioid even just at the level that I did it after I had a hip surgery. It does not feel good. I would not want somebody to have that experience for the rest of their life. And this is before we get into all the challenges with opioid tolerance or physical dependence or addiction. Almost everybody on long-term opioids has either tolerance that is built up around the opioids, so they need to take larger and larger doses of them, or physical dependence that occurs. There's also some evidence, and this is very complicated, but there's some evidence that long-term highdosese opioid use can be associated with a increased sensitivity to pain broadly.

95:21 And this is where the distinction between acute and chronic pain really starts to matter. If you break your wrist tomorrow, the answer is painkillers and a splint, not a breathing exercise. That doesn't mean that the breathing exercise might not help you. It could totally help you. And I completely believe that there are social factors that could support one person with a broken wrist much more than another person with a broken wrist. And so their experience of pain might be quite different even though they both have the same injury. But most of Rachel's work focuses on chronic and mostly on idiopathic pain. So this means not for somebody who is dealing with cancer pain or somebody who is dealing with rheumatoid arthritis. conditions where there is considerable inflammation in the body or an obvious physical source of pain signal. Now, I suspect that Rachel would say that also for those conditions, an individual person's pain dial could be turned higher or lower based on everything we were talking about today, based on social factors, environmental factors, and whether or not their biology was getting enough support through something like sleep and exercise. And this takes us to Rick and Mai's shotgun theory of pain, which again, we are not doctors.

96:32 Take it with a grain of salt. When I was looking at the research, what I found is that most of the response rates to treatment were biodal in nature. What this means is that there weren't a lot of people who were helped a little, although sometimes that did happen, but rather typically in studies, there would be groups that responded really positively to one treatment or another. And then also another group inside of that study that really did not respond to that same treatment. And this seemed to be the case across a lot of different treatments. CBT for chronic pain, different kinds of medication, responsiveness to physiootherapy in the case where you're dealing with like chronic lower back pain or something like that. And what this suggests is that some people are helped a lot. We don't really know who those people are going to be. And so it makes sense to try a lot of things. Now, does it make sense to try a lot of things because you're going to find the the one magic treatment for you where you're really biodally distributed into the good group and that thing just really helps you out? Maybe it could also mean that Rachel's biocschosocial model is really in play for that person. They're trying a lot of different stuff. They're playing with all of these different interventions and the combination of those things. Looking at each of those different verticals that we have for dealing with pain is really helping them kind of work the whole problem.

97:48 This relates closely to the nature of pain as a signaling event for us. Pain is multiffactorial. It includes all of these different aspects to it. It's also a guesstimation. It's the brain's interpretation of what's happening right now and what is likely to happen in the future based on the information it has. This takes us to the two nail stories that I told early on in the podcast. The construction worker who thought that a nail had stabbed his foot when it really hadn't and he felt extreme pl pain pain.

98:19 another construction worker who was stabbed by a nail, didn't realize it, and felt relatively little pain compared to what you'd think this person would be feeling based on what happened to them. And this brings us to a distinction between hurt and harm. Hurt is pain. Harm is physical damage. They commonly co-occur, but they don't always co-occur. And we have many many many examples of situations like a phantom limb syndrome where somebody is experiencing a lot of pain without an obvious physical explanation for it.

98:50 Rachel's frame is that while acute pain has an adaptive purpose, chronic pain mostly doesn't. Most of chronic pain and again her framework is the signaling system that has gone ary. It is an alarm that is sounding away when there is no real danger. Now, I think that this covers idiopathic pain fairly well, but plenty of chronic pain has an ongoing physical source of some kind. Rheumatoid arthritis, again, cancer, ongoing inflammation, real tissue damage, all of that. even examples with back pain, it gets really complicated. There are people who have on an MRI obvious structural abnormalities or problems in their lower back and they don't feel much pain at all. Then there are plenty of people who have those same problems who experience a lot of pain. So there's this complex mix of physical, environmental, social, all of this stuff that's contributing to somebody's experience. And part of the reason that I'm spending so much time talking about this is because arguments about what pain is and what contributes to pain and about whether or not somebody is experiencing a physical issue or not and how much of a physical issue exists for that person.

100:03 These conversations are immensely contentious and they're even argued about in the research literature right now. We don't have perfect answers to a lot of the questions that we were asking today. But what we want to do is sit with somebody's real experience, particularly the experience of somebody who feels like they have absorbed a lot of messages that they are just exaggerating or they're just making things up or it's all in their head. And I want to say again in the recap here that that is not at all what we're saying. you are having a pain experience and more often than not there is some kind of physiological basis for what's going on. I gave the example of fibromyalgia. For a long time a lot of people, not everybody but a lot of people thought that fibromyalgia was basically not quite constructed by the people who were experiencing it but they were very dismissive of it. There was a lot of medical establishment that had a lot of questions about people with fibromyalgia experiences because we didn't have an obvious physical source for it. Well, we looked into it more and more and we found something that looks an awful lot like a physical source. And that's why during the podcast I told I told the story of Dr. Andreas Goel. I hope I'm saying that correctly. This was in 2021. He and his colleagues transferred immunoglobin G. This is the most common type of antibbody in your blood from fibromyalgia patients into mice and they reproduced a bunch of the physical symptoms associated with fibromyalgia in those mice. There was a clear physiological mechanism here. But even there it's incredibly complicated because then these drug companies went and tried to create a pill that would block this particular antibbody and you know hopefully improve the experience of people with fibromyalgia and they were not able to do it. The drug they were testing that blocked this antibbody did not seem to improve the patients experience that much. So what's going on with that? We have this plausible physical mechanism for why people are feeling this way. But when we block that physical mechanism, it doesn't seem to help so much. Does this mean we have the wrong physical mechanism? Does this mean we don't understand what's going on well enough yet? Or does this mean that this stuff is really complicated and it's made up of a wide variety of factors here? As a non-expert in this space, I don't know what the answer to that question is. I'm not sure if anybody knows what the answer to that question is. Frankly, the more that I that I dig into this stuff, the more complicated it gets. What I can say with some confidence is that placebo is a huge part of this whole thing.

102:41 There are so many examples, whether it's open label placebo or sham surgeries or more traditional forms of placebo, of people improving considerably when being given a treatment that based on the physiological mechanism that is explanatory for why that treatment works should not work. And yet they're getting some benefit out of it. And again, that just hammers how at least some of the equation here is psychological and emotional and supportd driven, feeling that somebody else cares about you. The the sense that there is something that you can do to maybe help yourself feel a little better here. And I hope I am not being profoundly redundant here cuz I feel like I've said this 18 times, but it's just one of those things I want to be really careful about. I hope that none of this is taken as a suggestion that the biological part of this whole thing doesn't matter or that you're not having a physiological experience that would lead to you experiencing a lot of pain. Of course, it could. I have chronic low back pain. Then if I I look at an MRI, there is a actual bulging disc in my back. It goes up, it goes down. it has gotten a lot better over time. I've done a lot of PT for it. I had a hip surgery. I had a real issue in my hip and it was not because there was some lack of support that I was getting at the time that I experienced pain in my hip for years because there was a physical issue. I got surgery on that hip. We went in, we solved the problem.

104:13 Guess what? The pain went away. Particularly the pain that was associated with exercise and dancing and things like that. So this stuff, to say it again, is complicated. And I appreciate Rachel's interdisciplinary approach because she is shining a light on the parts of the equation, the psychological and the social, that frequently get missed. We then talked a bit during the conversation about practical things that somebody with chronic pain can do. For starters, we talked about pacing, which is essentially a form of exposure work.

104:41 Rachel's idea is that a body that is in motion stays in motion. A body that is at rest stays at rest. It is very understandable for a whole bunch of different reasons why somebody with chronic pain would not want to go and try stuff or somebody would not want to try to push out the the bars of the invisible cage that we were talking about during the podcast episode. And again, I hope that this comes across as supportive and understanding. But one of Rachel's key ideas with pacing and with pain management in general is that people with chronic pain tend to have days where they feel better and days where they feel worse. They do more on the days when they feel better because of course they do and they do less on the days that they feel worse because of course they do. But what we actually want to do is smooth things out between those two extremes and be thoughtful and take a graded approach to what we're doing. So her actual protocol is that you pick a meaningful activity that you miss. she used fudge making as the example during the conversation. You then break it into small measured steps.

105:45 You're going to specify where, when, how, and with whom you are doing this thing. Then you're going to log how much time you can comfortably do this activity for on both a low pain day and a high pain day. You add those numbers together and you divide by two. You then subtract a couple of minutes as a kind of cushion and then that's your baseline. The goal is to add a few minutes each week. The hardest part of this protocol is doing the same amount that time that you've established whether it is a good day or a bad day.

106:20 That is really hard. And throughout the book, Rachel talks about movement, diet, rest, sleep, exercise, all of these aspects of the bio that are not just medication. Rachel and Rick talked a bit throughout the conversation really about these distinctions between pain versus distress and all of the feelings that could surround the pain experience. across the trials that I looked at looking at all of these different treatments where again response rates were often a number needed to treat of 1 in 4 1 in 5 1 and six so even for the interventions that we have that are really quite good they're still treating a minority of the people who are trying the intervention which again is kind of an argument for a little bit of everything here anyways what I saw was that different forms of psychological treatment move catastrophizing and fear of movement more than they move pain intensity. That was a really interesting finding for me. Another thing that I appreciate about Rachel's work is how individual she is with the people that she works with. In her book, there are a number of case studies of her taking a really well-rounded approach to the end of one person that she's interacting with in front of her. And what this implies is that any person is going to have a very different pain recipe from any other person. We can generalize here. We can say that on average there are a wide variety of things that might help or hurt a person, but we can't say what's going to help or hurt you. And if you have found something that really works for you, amazing. Keep doing it.

108:03 And if you're still looking for that thing that really works for you, I have confidence that you can find it. I have confidence that it is out there somewhere for you. I really wish that for you. I'm very very grateful that I do not have a chronic pain problem in a significant way. And not to get like a little sackcharine at the end here, but my heart really goes out to anybody who is dealing with this on a day-to-day basis. And it's part of the reason that we're interested in talking to people like Rachel who have ideas for when medication is not enough or for when medication is an inadequate solution to your problem for whatever reason. I think Rick and I are both pretty pro medication in general. I love painkillers. you know, I I try to avoid using them too much, but man, Advil, ibuprofen is a beautiful thing. if you take it, of course, you know, reasonably and responsibly and all of that, but this is a really complicated field for people and it's a field where people are often pushed into a pretty specific set of interventions and man, there's just a big broad world out there. So, we want to be a little bit more inclusive, a little bit more interdisciplinary, and hopefully just give people a bigger menu of options here. I hope you enjoyed today's episode. This was a really long one. It might be the longest one we've ever done on the podcast. If you have questions, thoughts, comments about it. I'm sure people will. You can reach us at contactbwellpodcast.com.

109:38 You can leave a comment on YouTube, on Spotify. I am very curious what people's takes are on this one. And you know, I hope that we were really able to walk the middle path here in terms of how we approached this topic. If you made it this far and you somehow haven't subscribed to the podcast, that seems almost unlikely to me. But hey, if it's the case, you can subscribe now on Spotify, Apple, YouTube, wherever you get your podcasts. You can also find us on Patreon, patreon.com/beingwellodcast.

110:07 So until next time, thanks so much for listening and I'll talk to you soon. >>