Huberman Lab

Dr. Sean Mackey: Tools to Reduce & Manage Pain

Mon Jan 15 2024

painpain managementchronic painbrainsensoryemotionalNSAIDsmechanical interventionsdistraction techniquesmindfulnesspsychological factorsrelationshipsnutritionopioidsalternative treatmentscomplementary approaches

Description

This episode explores the complex nature of pain, including its sensory and emotional components. It delves into the role of the brain in shaping pain perception and the challenges of understanding and empathizing with others' pain. The use of non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief is discussed, along with the importance of finding a balance between managing pain and promoting healing. The episode also explores alternative approaches to pain management, such as mechanical interventions, distraction techniques, and mindfulness interventions. Additionally, it examines the impact of psychological factors, relationships, and nutrition on pain perception. The episode concludes with insights into the opioid crisis, alternative treatments for pain relief, and the importance of comprehensive pain management strategies.

Insights

Pain is a complex and subjective experience shaped by both sensory and emotional factors.

Understanding the multidimensional nature of pain is crucial for effective pain management.

The brain plays a central role in shaping and interpreting pain signals from the body.

Different brain regions work together to create the subjective experience of pain.

Misunderstandings about pain are prevalent in society, leading to challenges in empathizing with others' pain.

Building a foundation of understanding can help improve empathy and support for individuals experiencing pain.

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used for pain relief but do not eliminate pain completely.

Finding a balance between managing pain and promoting healing is important when using NSAIDs.

Mechanical interventions, such as massage and acupuncture, can have chemical consequences in reducing pain.

These interventions work through mechanisms like the gate control theory of pain.

Distraction techniques, mindfulness interventions, and cognitive reframing can be effective in managing pain.

Different approaches engage different neural circuits in the brain to reduce pain perception.

Psychological factors, relationships, and nutrition can impact pain levels and should be considered in comprehensive pain management.

Addressing emotional processing, coping mechanisms, and dietary triggers can help improve pain symptoms.

The opioid crisis involves issues of overprescription, addiction potential, and tragic outcomes.

Opioids should be used as a tool in certain circumstances, with careful consideration of individual risks and benefits.

Alternative treatments like low-dose testosterone and cannabis show promise in relieving pain.

Further research is needed to fully understand their effectiveness and safety.

Complementary approaches, such as acupuncture and physical therapy, play a role in comprehensive pain management.

Collaboration between healthcare professionals is crucial for providing holistic care to individuals with chronic pain.

Chapters

Summary

Transcript

Understanding Pain

00:00 - 14:17

Pain is a complex and subjective experience that includes both sensory and emotional components.
Chronic pain affects about 100 million Americans and costs around half a trillion dollars in medical expenses annually.
Misunderstandings about pain are prevalent in society, so it's important to build a foundation of understanding.
Pain is not the same as the initial stimulus; it is the subjective experience created by the brain.
The brain plays a crucial role in shaping and interpreting pain signals from the body, resulting in individual experiences of pain.
There is no direct one-to-one relationship between the stimulus and the experience of pain.
People tend to project their own experiences of pain onto others, leading to misunderstandings and challenges in empathizing with others' pain.
Conditions like fibromyalgia, which lack visible signs, can be misunderstood or dismissed by others due to our tendency to associate pain with visible injuries or conditions.
The brain does not have a dedicated area solely responsible for processing pain; instead, various regions work together to create the subjective experience of pain.

The Brain and Pain

13:50 - 21:06

There is no single area in the brain that can be identified as the "pain center".
Pain is thought to be represented by a distributed network of different brain systems.
Common brain regions involved in the experience of pain include the insular cortex, cingulate cortex, and amygdala.
Brain-based biomarkers have been developed to identify these regions associated with pain.
Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and acetaminophen are not technically pain killers but rather anti-inflammatory and anti-hyperalgesic drugs.
NSAIDs reduce sensitization in the injured area, but they do not eliminate pain completely.
The threshold for treating or reducing pain should be when it significantly impacts quality of life and daily activities.
The decision to blunt or allow pain depends on individual circumstances and balancing the need for healing with potential risks.

Peripheral Sensitization and Pain Relief

20:40 - 27:49

Peripheral sensitization occurs when a chemical substance amplifies the response of nociceptors after an injury or sunburn.
NSAIDs reduce inflammation and are anti-hyperalgisic, making them effective for pain relief.
Using potent opioids without medical evaluation and treatment for acute injuries can be unsafe.
Professional sports teams often use corticosteroid injections and painkillers to get athletes back on the field quickly, despite limited randomized control trials.
Normal functioning varies depending on the individual's ability to sleep well at night and manage pain.
Blocking inflammation with NSAIDs may delay the healing process, so finding a balance is crucial.
Taking NSAIDs at the lowest effective dose helps improve function while managing pain.
There is individual variability in the effectiveness of different NSAIDs, so rotating them to find what works best is valuable.
Timing and proper administration of NSAIDs are important, including taking them with food and fluids to avoid side effects.
Aspirin can benefit heart health but should be used cautiously and in consultation with a healthcare professional.

Mechanical Interventions and Pain Relief

34:17 - 41:32

Mechanical interventions such as massage, acupuncture, heat, and cold can have chemical consequences in reducing pain through mechanisms like the gate control theory of pain.
The gate control theory of pain involves inhibitory pathways from the brain to the spinal cord and touch fibers that activate with light touch.
Swearing has been shown to reduce pain better than using non-explicative vocalizations.
Rubbing, shaking, and running water on an injured area can activate touch fibers and change the signals in the spinal cord, reducing pain.
Kissing an injured area can activate touch fibers and also provide positive emotional salience, which reduces pain.
The TENS device (Transcutaneous Electrical Neural Stimulation) uses electrical stimulation to activate touch fibers and achieve neuromodulation in the spinal cord.
Pain is modulated in the spinal cord, interpreted in the brain, and can be influenced by factors such as adrenaline levels and individual thresholds for pain.
Pain threshold is defined as the stimulus intensity that results in the onset of the experience of pain.
Different individuals may have different pain thresholds, but it depends on how pain threshold is defined.

Factors Affecting Pain Perception

41:05 - 48:37

Pain is initially transmitted to the brain through fast fibers called A-delta fibers, followed by slower C fibers that convey unpleasantness.
Men generally have higher pain thresholds for heat stimulus compared to women, but individual variability within each gender is greater than the difference between genders.
Pain thresholds can be influenced by factors such as beliefs, expectations, anxiety levels, and early life experiences.
It is unclear whether being told to "suck it up" or expressing emotionality around pain affects the subjective feeling of pain later on.
Parental cues and reactions can influence how children perceive and express pain.
Ignoring a loved one's pain can be maladaptive and may lead to future problems.

Psychological Factors and Pain Management

48:16 - 55:26

Parents' reactions to children's pain have changed over time, with less tolerance for harsh responses.
A father's response of smacking his son after he cut his thumb on a band saw may have been an example of conditioned pain modulation, where engaging a painful stimulus in a different area can inhibit pain.
Conditioned pain modulation is a phenomenon that involves descending pathways from the brain stem to the spinal cord, inhibiting pain.
Chronic painful conditions like fibromyalgia may not respond well to conditioned pain modulation.
Therapeutic heat and cold are debated in terms of their ability to alleviate pain. Heat increases blood flow and relaxes muscles, while cold reduces inflammation and slows nerve firing.
Individual preferences play a role in determining whether heat or cold works best for relieving pain.

Heat, Cold, and Pain Relief

55:02 - 1:02:56

Heat and cold can be used to relax muscles and improve blood flow.
Individual preferences vary when it comes to heat or cold therapy.
Cold packs should not be left on for too long to avoid frostbite.
Regular exposure to pain, such as deliberate cold exposure, can raise one's pain threshold.
The effects of extreme cold exposure on pain thresholds are not well understood.
Cognitive control and cognitive training can potentially change pain thresholds over time.
Movement exercise can also alter pain thresholds by increasing inhibitory tone.
Mindfulness interventions offer different approaches to managing pain, including distraction and meeting the pain head-on.
Distraction techniques can be effective in reducing pain for many individuals.

Distraction and Pain Management

1:02:28 - 1:10:26

Distraction and attentional distraction are effective strategies for managing pain.
Engaging in distracting activities such as reading, spending time with friends and family, and participating in community activities can help reduce pain.
Attentional distraction engages specific brain networks involved in distraction, which can significantly reduce pain.
Distraction may not work effectively at night when trying to sleep, making sleep a challenge for people with chronic pain.
Mindfulness-based stress reduction (MBSR) is an effective approach for addressing pain from a nonjudgmental accepting manner.
MBSR has been shown to be effective for anxiety, depression, and pain management.
Cognitive reframing about the meaning of pain is another aspect of pain management that can be helpful.
Different approaches to managing pain engage different neural circuits in the brain.
Understanding the difference between being hurt and being injured is crucial for recognizing when an injury requires rest or when it's just temporary pain.
Recognizing the distinction between hurt versus harm is critical for effective pain management.
Psychological hurt versus psychological injury also plays a role in understanding emotional pain.

The Complexity of Pain

1:09:59 - 1:18:05

Chronic pain conditions can be complicated and require more than a single education session.
The distinction between hurt and harm is important in understanding pain.
Emotional pain is valid and should be acknowledged like any other pain, but it can be harder to define thresholds for psychological pain compared to physical pain.
Pain is a sensory and emotional experience that should be treated holistically.
Anxiety, depression, catastrophizing, anger, fatigue, and sleep are factors that can impact pain levels.
Anger expressed inwardly (anger in) tends to worsen pain.

The Influence of Relationships on Pain

1:17:41 - 1:25:32

Anger and other emotions can be directed inward or outward, impacting the whole person.
Over 200 medications are available for pain, but only a few are FDA approved specifically for pain.
Medications from various fields, such as psychiatry and neurology, can be effective in treating pain.
Nutrition plays a critical role in local and whole-body pain, including anti-inflammatory diets and avoiding trigger foods.
Personal experiences with chronic pain led to the discovery of triggers through experimentation and isolation of certain foods.
Identifying triggers through journaling and gradually reintroducing foods can help improve symptoms.
Quality nutrition is difficult to define, as it varies from person to person.
Experimentation and pattern recognition are important in identifying food-related triggers for pain.

Food Triggers and Pain

1:32:27 - 1:41:03

Elimination diets may be a way to identify food triggers for pain by restricting the number of foods consumed.
Gut infections can change genetic expression and sensitize individuals to certain food antigens.
Sensitivity to different food groups later in life is becoming more common and may be a public health issue.
Funding is being explored to study how foods impact local and systemic pain responses.
The gut microbiome is being studied as part of a biomarker study at Stanford.
Visceral pain, such as irritable bowel syndrome, is more common than previously known.
Visceral pain differs from somatic pain in terms of localization and receptive fields.
Receptive fields for visceral pain are broad and not well localized.
Fibers from the viscera make indirect connections with the spinal cord, leading to convergence with somatic regions and perception of pain in multiple areas.
Viscero-somatic convergence can result in pelvic pain being perceived as lower back pain.

Understanding Pain Perception

1:40:34 - 1:48:08

Pain can be perceived in different areas of the body due to convergence of nerves.
Heart attacks can cause pain that radiates down into the left arm.
After abdominal surgery, some people may experience shoulder pain due to irritation of the diaphragm.
Referred pain occurs when pain is felt in one area but originates from another region.
Damage to nerves anywhere along their pathway can result in neuropathic pain, which is challenging to treat.
Disc bulges in the back often reabsorb over time, but caution should be taken with certain movements.
Psychological stressors can contribute to physical pain, and addressing these stressors may alleviate symptoms.
Early life events and injuries can sensitize individuals to future vulnerability to pain.
Positive emotions and being in positive relationships can change our perception and experience of pain.

The Power of Love in Pain Relief

1:47:51 - 1:56:24

Positive relationships and being in love can change our perception of pain at physiological levels.
A study was conducted to investigate the effects of love on pain perception.
The study recruited couples in the early phase of a romantic relationship, as this phase engages the same neural circuitries as addiction.
Participants were shown pictures of their beloved and an equally attractive acquaintance while experiencing pain.
The study found that thinking about the person they love significantly reduced participants' pain, and the more in love they were, the greater the pain relief.
Attentional distraction also worked well in reducing pain, but it engaged different brain circuits compared to love.
Love activated reward-based circuits such as the nucleus accumbens, amygdala, and substantia nigra, which are associated with addiction pathways.
The strength of a person's relationship a year later was correlated with their brain activity during the study, specifically in the caudate nucleus and insula regions.
High levels of activity in these brain areas during a new romantic partnership predicted a strong relationship over time. However, these findings are unpublished and non-peer reviewed.

Opioids and Pain Management

1:55:58 - 2:03:51

Endogenous opioids, natural substances in our body, act as painkillers and have varying levels among individuals.
Medicinal chemists have derived opioids like morphine from poppies, which have been used for thousands of years.
Opioids can positively transform lives but also lead to addiction and destruction.
Opioids should be used as a tool in certain circumstances, not as a first-line treatment.
The opioid crisis involves issues of overprescription, addiction potential, cross interactions with other substances, tolerance, and tragic outcomes.
There are use cases where opioids make sense and improve people's lives on an individual basis.
Education around pain management for physicians is lacking compared to veterinarians who receive more training on the subject.
Alternative treatments like low-dose testosterone have shown effectiveness in relieving pain.

Alternative Treatments for Pain

2:03:21 - 2:11:17

The speaker found an alternative treatment for their dog's aches and pains, which was low-dose testosterone.
Despite expecting backlash, the speaker received positive responses from veterinarians about using low-dose testosterone for dogs that were castrated later in life.
There is a discussion to be had about the restrictions that veterinarians face in prescribing certain treatments.
The public perception is that doctors are being paid to prescribe opioids, but the speaker doesn't necessarily believe this to be true.
According to Keith Humphreys at Stanford, there are three types of physicians: those doing the right thing for the right reasons, those doing the wrong thing for the right reasons (overprescribing opioids due to lack of education), and those doing the wrong thing for the wrong reasons (bad docs).
The media blew up the issue of opioid overprescription by focusing on a small group of bad doctors, causing fear among other physicians who then started abandoning patients.
California's experiment targeting doctors prescribing opioids led to a doubling of opioid deaths because doctors cut off patients who then turned to black tar heroin.
The opioid crisis is primarily driven by illicit fentanyl coming from Mexico and China.
Keith Humphreys led a commission on the North American opioid crisis and proposed rational solutions.
The medical board of California revised its prescribing guidelines to put more control back in the hands of physicians and patients.
There is complexity in this space, and it's important to

Exploring Pain Management Options

2:10:48 - 2:19:18

The opioid epidemic is primarily driven by fentanyl, which is cheap and easily brought across borders.
It's important to differentiate between the crisis of opioid addiction and the legitimate use of opioids for pain management.
Some patients who are responsibly using opioids for pain can be successfully weaned off them with compassionate care, leading to improved pain levels.
There are various commonly used opioids, including morphine, oxycodone (which becomes OxyContin when encapsulated in a long-acting version), fentanyl (available in patch form), tramadol, hydromorphone (traded as Dilaudid), and methadone.
Opioids work by binding to opioid receptors in the periphery, spinal cord, and brain.
Benzodiazepines are rarely used for pain relief except in specific cases where there is a generalized anxiety disorder poorly treated with anti-anxiety medication alongside chronic pain.
Kratom is a natural substance with opioidergic properties that has helped some individuals stay off prescription opioids. However, its effects and safety are not fully understood.

Exploring Alternative Pain Relief

2:19:04 - 2:26:05

Methadone and buprenorphine are opioids that can reduce cravings for substances.
There is an increased number of overdose deaths associated with Kratom, a natural substance.
More research is needed to understand the quality, purity, and dose of Kratom.
Cannabis has been shown to reduce neuropathic pain in controlled laboratory situations.
The effectiveness of cannabis for managing pain is still controversial and uncertain.
Unfettered use of cannabis may lead to untoward consequences and population-level experiments are ongoing.
The THC to CBD ratio in cannabis affects its dose and effects on pain management.
Cannabis should not be classified as a Schedule 1 drug due to its potential utility in therapeutic use.
Reclassifying cannabis as a Schedule 2 drug would make it easier to study and provide answers about its benefits.
Different ratios of THC to CBD in cannabis may have varying levels of effectiveness for pain relief.
Certain strains of cannabis, such as Charlotte's web, have shown promise in treating pediatric epilepsy.
Plant-based compounds like Kratom and cannabis have potential therapeutic uses but require further investigation.
Acupuncture, chiropractic care, physical therapy, and other non-traditional medical approaches are considered within the field of pain medicine.

Complementary Approaches to Pain Management

2:25:38 - 2:33:49

Psychological and behavioral therapies, physical and occupational therapy, complementary alternative medicine approaches, self-empowerment, and learning skills are effective approaches for managing chronic pain.
Acupuncture is a form of complementary alternative medicine that has been practiced for thousands of years and has shown to have benefits in pain management.
The scientific basis of how acupuncture works is not fully understood, but it is believed to activate peripheral adenosine receptors and engage different brain regions.
Finding a reliable acupuncturist can be challenging, but seeking recommendations from trusted sources such as primary care doctors or other clinicians can help.
When it comes to rating systems for healthcare providers, patient ratings can be manipulated through paid services that inflate ratings. Therefore, relying on relationships, word of mouth, and referrals may be more reliable in finding high-quality clinicians.

Finding Quality Healthcare Providers

2:33:19 - 2:41:17

In community settings, reliable sources of quality healthcare are often found through relationships, word of mouth, and referrals.
There is a need for an independent platform or app that can provide information on prior patient experiences to help people find the best healthcare providers.
Acupuncture and chiropractic are two different professions often associated with pain treatments.
Medicare now covers acupuncture for patients over 65 for back pain.
The effectiveness of chiropractic treatment for low back pain is mixed, with some studies showing benefits and others showing no clear results.
High-velocity manipulations in chiropractic care carry a small risk of vertebral artery dissection, which can lead to stroke-like symptoms.
It is important to assess whether acupuncture, chiropractic, or any other treatment provides durable benefits or just temporary relief.
Physical therapists play a crucial role in the treatment of chronic pain by helping patients regain physical functioning and improve their quality of life.
Physical therapists can teach patients about safe movements, body mechanics, pacing, endurance building, and strength training.

Managing Chronic Pain

2:41:01 - 2:49:16

Chronic pain can lead to a cycle of activity and inactivity, causing more disability.
Setting small goals and gradually increasing activity can help manage chronic pain.
Good days and bad days are normal, but it's important to maintain consistency in managing pain.
Collaboration between different healthcare professionals is crucial for comprehensive pain management.
Over-the-counter supplements like acetyl alcarnitine, alpha lipoic acid, vitamin C, fish oil, and creatine have shown potential benefits for pain conditions.
It's important to be aware of the potential side effects, drug interactions, and precautions associated with these supplements.

Supplements and Pain Relief

2:48:47 - 2:56:06

High levels of omega-3s can reduce the viscosity of blood, making it easier to bleed.
Fish oils containing omega-3s have this effect.
The impact of vitamin C on blood viscosity is not well-known.
Over-the-counter agents for pain management are generally harmless and can have positive effects.
Psychological treatments play a critical role in managing pain by addressing emotional processing and coping mechanisms.
Early adverse life events can lead to abnormalities in emotional functioning and impact how individuals experience pain as adults.
Pain psychologists and behavioral therapists help with maladaptive coping and teach skills to manage pain.
Cognitive behavioral therapy, mindfulness-based stress reduction, and acceptance and commitment therapy are effective tools used by pain psychologists.
Empowered Relief is a brief intervention developed for cognitive behavioral therapy that has shown positive results in an NIH-funded study.
A digital health platform has been created to capture high-quality data on physical, psychological, and social functioning for better understanding and treatment of pain.
The goal is to make these tools widely available for free to address the lack of access to quality care outside academic centers.

The National Pain Strategy

2:55:42 - 2:56:37

Dr. Darnell and Dr. Linda Porter co-led the development of the national pain strategy sponsored by NIH and Health and Human Services.
The strategic plan aims to transform the way pain is treated, educate professionals, and communicate with the public.
Full implementation of the National Pain Strategy is desired for significant improvements in the lives of people with pain.
People can support the initiative by contacting their congressmen and congresswomen through phone calls and letters.
PainUSA, a nonprofit organization, was created to advance the implementation of the National Pain Strategy and use high-quality data for better patient care.
Good quality data is needed to influence messages regarding pain treatment.
Dr. Mackey's thoroughness, nuance, and sensitivity in discussing pain-related issues are appreciated.
The podcast provides resources mentioned by Dr. Mackey in the show notes for further exploration.
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