Dr. Sean Mackey: Tools to Reduce & Manage Pain

Dr. Sean Mackey (00:00:00)

• Dr. Sean Mackey is a medical doctor and a PhD who is the chief of the division of pain medicine and a professor of both anesthesiology and neurology at Stanford University School of Medicine.
• Pain is a complex and subjective experience that serves to keep us away from injury or harm.
• Pain is both a sensory and an emotional experience and is incredibly individual.
• Chronic pain affects about 100 million Americans and costs about half a trillion dollars a year in medical expenses.

Pain, Unique Experiences, Chronic Pain (00:06:13)

• Pain is a complex and subjective experience that serves a crucial role in keeping us away from injury or harm.
• Pain is both a sensory and an emotional experience.
• Pain is incredibly individual and can vary significantly from person to person.
• Chronic pain is a persistent pain that lasts for more than 3 months and can have a significant impact on a person's life.
• Chronic pain affects about 100 million Americans and costs about half a trillion dollars a year in medical expenses.

Pain & the Brain (00:13:05)

• Pain is not simply a physical sensation, but also involves emotional and cognitive components.
• There is no single "pain center" in the brain, but rather a distributed network of brain regions that contribute to the experience of pain.
• Brain-based biomarkers can be used to identify common brain networks that represent the experience of pain.

Treating Pain, Medications: NSAIDs & Analgesics (00:16:15)

• NSAIDs (nonsteroidal anti-inflammatory drugs) like ibuprofen and naproxen are not technically analgesics (painkillers).
• NSAIDs reduce inflammation and sensitization in the injured area and the spinal cord.
• Opioids are analgesics that can potentially cause harm if taken in high doses.
• The threshold for treating pain should be based on its impact on quality of life and daily activities.
• Common over-the-counter NSAIDs include ibuprofen, naproxen, and acetaminophen (Tylenol).
• Aspirin is not considered an NSAID but has anti-inflammatory and anti-hyperalgesic effects.
• It's important to balance pain relief with the potential delay in healing caused by NSAIDs.
• Individual variability exists in the effectiveness of NSAIDs, so rotating them can be beneficial.
• NSAIDs should be taken with food and plenty of fluids to minimize side effects.
• Talk to a doctor before taking NSAIDs if you have any underlying health conditions.

Inflammation, Pain & Recovery; Ibuprofen, Naprosyn & Aspirin (00:22:46)

• Prostaglandins are one of the main ways the immune system responds to injury and creates inflammation.
• Inflammation sensitizes the injured area, making it more sensitive.
• NSAIDs can help with pain and function but may delay the healing process.
• Balancing pain relief with healing is crucial, and the lowest effective dose of NSAIDs should be used.
• NSAIDs should be taken with food and plenty of fluids to minimize side effects.
• Individual variability exists in the effectiveness of NSAIDs, so rotating them can be beneficial.
• Aspirin in low doses (81 mg) acts as an antiplatelet agent and may benefit heart health.
• Higher doses of aspirin (325 mg) have anti-inflammatory effects similar to NSAIDs.

Caffeine, NSAIDs, Tylenol (00:30:19)

• Caffeine can potentiate the analgesic response and be effective for headaches and migraines.
• Caffeine can cause stomach irritation, so it's best to take NSAIDs with food.
• Tylenol (acetaminophen) is safe on the stomach but should not exceed 4,000 milligrams per day.
• COX-2 inhibitors like celecoxib are less irritating to the stomach but require a prescription.

Pain & Touch, Gate Control Theory (00:32:34)

• Gate control theory of pain: rubbing, shaking, or running water on an injured area activates touch fibers that send signals to the spinal cord, inhibiting pain signals.
• Kissing an injured area can reduce pain due to the activation of touch fibers and positive emotional salience.
• Transcutaneous electrical nerve stimulation (TENS) devices use electrical stimulation to activate touch fibers and reduce pain.
• The mechanism of action for mechanical interventions like rubbing or shaking occurs in the spinal cord, not at the site of the injury.

Pain Threshold, Gender (00:38:56)

• Pain threshold is the stimulus intensity that results in the onset of pain.
• Men generally have higher pain thresholds to heat stimuli than women, but there is significant individual variability within both genders.
• The difference in pain thresholds between men and women is often overstated due to the focus on group averages rather than individual variability.

Pain in Children, Pain Modulation (Pain Inhibits Pain) (00:44:53)

• Pain perception is influenced by beliefs, expectations, anxiety, and early life experiences.
• Pain inhibits pain, a phenomenon called conditioned pain modulation (CPM) or diffuse noxious inhibitory control (DNIC).
• CPM involves activating a brainstem circuit that sends descending pathways to the spinal cord, inhibiting pain.
• CPM may explain why some parents' reactions to their children's pain, such as smacking them, might inadvertently reduce the pain.
• However, ignoring a child's pain or sending the wrong message can have negative consequences.

Tool: Heat, Cold & Pain; Changing Pain Threshold (00:53:20)

• Cold reduces inflammation and slows nerve firing, reducing pain.
• Heat increases blood flow, relaxes muscles, and feels good.
• Individual variability exists in preferences for heat or cold.
• Cold should be used with caution to avoid frostbite.
• Numbing an area with cold can be effective in reducing pain.
• Regular exposure to safe pain, such as deliberate cold exposure, can raise pain thresholds through habituation.
• Cross-modality changes in pain thresholds are possible, but more research is needed.
• Cognitive control, such as avoiding looking like a wuss in front of an attractive person, can temporarily raise pain thresholds.
• Exercise can also increase pain thresholds over time by building inhibitory tone.

Tools: Psychology, Mindfulness-Based Stress Reduction, Catastrophizing (01:00:54)

• Mindfulness-based interventions lack specificity, granularity, and mechanistic logic.
• Attentional distraction engages specific brain networks and can reduce pain, but it may not be effective at night when people are trying to sleep.
• Non-judgmental acceptance of pain has been shown to be effective in reducing pain.
• Cognitive reframing about the meaning of pain can be helpful in managing pain.
• Catastrophizing pain can worsen the experience of pain.

Tool: Hurt vs. Harmed?, Chronic Pain (01:08:29)

• The distinction between hurt and harm is critical in pain management.
• Pain that is not causing harm does not need to be avoided.
• Chronic pain conditions are often complex and require more than just education.
• It is important to seek medical attention for pain that is getting worse or may be a sign of a serious medical condition.

Emotional Pain, Anger, Medication (01:12:38)

• Dr. Mackey does not distinguish between psychological and physical pain, instead treating all pain as pain.
• Pain is a sensory and emotional experience, so treating the whole person is important.
• Anger, especially anger in (simmering, self-contained), is associated with worse pain.
• Medications used for pain include antidepressants, anti-seizure medications, and anti-arrhythmia medications.
• A holistic approach that addresses the whole person, including psychological, physical, and social factors, is most effective in treating pain.

Tool: Nutrition & Pain; Food Sensitization & Elimination Diets (01:20:43)

• Nutrition plays a critical role in pain management.
• Identifying and avoiding trigger foods can significantly reduce pain.
• Elimination diets can help identify trigger foods.
• Food sensitization can occur after a gut infection, leading to chronic pain.
• Food sensitivity is a growing public health issue.
• Research is needed to explore how foods impact local and systemic pain responses.

Visceral Pain; Back, Chest & Abdominal Pain (01:28:45)

• Visceral pain is different from somatic pain.
• Visceral pain is more diffuse and has larger receptive fields compared to somatic pain.
• Visceral pain can cause referred pain to other areas of the body due to visceral-somatic convergence in the spinal cord.
• Examples of referred pain from visceral organs include:
  • Pelvic pain causing lower back pain.
  • Heart attack causing pain radiating down the left arm.
  • Abdominal surgery causing shoulder pain.

Referenced Pain, Neuropathic Pain; Stress, Memory & Psychological Pain (01:34:02)

• Referred pain is pain that is felt in a different location from the source of the injury or damage.
• Neuropathic pain is pain caused by damage to a peripheral nerve or the central nervous system.
• Neuropathic pain can have different qualities and characteristics, such as shooting, stabbing, shock-like, or burning pain.
• Stress can contribute to pain by impacting the end organ or tissue.
• Chronic stress can lead to chronic pain.
• Early life events and injuries can sensitize individuals to future pain vulnerability.
• Pain can be associated with memory, and stress can trigger pain in areas previously injured or affected.

Romantic Love & Pain, Addiction (01:40:23)

• A study explored the intersection of romantic love and pain perception.
• The study found that being in love significantly reduced pain, with a correlation between the intensity of love and the level of pain relief.
• The brain circuits involved in romantic love and addiction were found to be similar, suggesting that the early phase of a romantic relationship engages the same reward circuitry as addiction.
• Attentional distraction was also found to be effective in reducing pain, but it worked on different brain circuits compared to love.
• The strength of a romantic relationship a year later was found to be correlated with the love-induced analgesia and brain activity in the caudate nucleus and insula.

Endogenous & Exogenous Opioids, Morphine (01:48:57)

• Endogenous opioids are natural painkillers produced by the body.
• Higher endogenous opioid levels may lead to less emotional reactivity.
• Morphine was the first exogenous opioid derived from the poppy, and medicinal chemists have since created variations of morphine and purely synthetic compounds like oxycodone.
• The use of poppies for pain relief has a long history.
• Opioids can positively transform people's lives by relieving suffering and improving quality of life, but they can also destroy lives due to addiction.
• Opioids should be treated as a tool to be used in certain circumstances and not as a first-line agent.
• The opioid crisis is a complex issue that requires a nuanced approach, considering both the benefits and risks of these drugs.

Opioid Crisis, Prescribing Physicians (01:53:17)

• Opioid crisis is often attributed to overprescribing of opioids.
• Opioids can be beneficial for pain management when used appropriately.
• Overprescribing occurred due to lack of education among physicians about pain management and alternative treatments.
• Some physicians overprescribed due to marketing messages and lack of alternatives.
• A small group of physicians engaged in illegal activities related to opioid prescribing.
• Fear of legal consequences led many physicians to abruptly stop prescribing opioids, leading patients to seek illicit sources.
• Current opioid crisis is driven by illicit fentanyl.

Opioids & Fentanyl; Morphine, Oxycontin, Methadone (02:02:21)

• Fentanyl in street drugs is the primary cause of opioid-related deaths, not fentanyl prescribed by physicians.
• Compassionate opioid weaning can be successful for patients who want to reduce their opioid use.
• Commonly used opioids include morphine, oxycodone, fentanyl, Tramadol, hydromorphone, 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 anxiety contributes to pain.

Kratom, Cannabis, CBD & Pain; Drug Schedules (02:07:44)

• Kratom has opioid-like properties and is available over the counter.
• Some people find kratom helpful in reducing opioid use, but its safety and efficacy need further research.
• Cannabis has been shown to reduce neuropathic pain in small studies, but large-scale studies show mixed results.
• Cannabis is not a uniform substance, and THC to CBD ratios and doses vary.
• Cannabis remains a Schedule One drug, which hinders research.
• Rescheduling cannabis as a Schedule Two drug could facilitate research and regulation.

Pain Management Therapies, Acupuncture (02:18:12)

• Acupuncture is one of six broad categories of therapies for chronic pain.
• Acupuncture has been shown to activate peripheral adenosine receptors and engage different brain regions compared to sham acupuncture.
• The exact mechanism of acupuncture's pain-relieving effects is still not fully understood.
• Acupuncture can be effective for certain types of pain, but it's important to find a qualified acupuncturist.

Finding Reliable Physicians, Acupuncturist (02:22:19)

• To find reliable physicians or acupuncturists, seek recommendations from trusted sources such as primary care doctors or colleagues.
• Be cautious of inflated patient ratings, as they can be manipulated.
• Consider using an independent platform that provides genuine patient experiences and ratings to find the best healthcare providers.

Chiropractic & Pain Treatment; Chronic Pain & Activity (02:26:36)

• Chiropractic and acupuncture are different professions with distinct approaches to pain management.
• Acupuncture has shown some effectiveness in certain patients and circumstances, and is now covered by Medicare for back pain in patients over 65.
• Chiropractic care has mixed evidence for its effectiveness in treating low back pain.
• High-velocity chiropractic manipulations may pose a risk of vertebral artery dissection, especially in the neck.
• Chronic pain often leads to reduced activity and deconditioning.
• Physical therapy and rehabilitation are crucial in addressing chronic pain by helping patients safely engage in activity and improving biomechanical issues.

Physical Therapy & Chronic Pain; Tool: Pacing (02:31:35)

• Physical therapists play a vital role in chronic pain management by providing rehabilitation, goal setting, and education on body mechanics.
• Pacing is a critical tool in managing chronic pain, involving setting small, incremental goals for physical activity.
• Avoid overdoing activities on good days and recognize that bad days are normal.
• Consistency in pacing helps prevent the negative reinforcement cycle of pain and inactivity.
• Effective pain management involves collaboration between different healthcare providers, including primary care doctors, pain psychologists, and physical therapists.

Supplements: Acetyl-L-Carnitine, Alpha Lipoic Acid, Vitamin C, Creatine (02:36:35)

• Acetyl-L-Carnitine:
  • Improves mitochondrial health.
  • Studied in the Sydney trials for diabetic neuropathy.
  • Shown to improve nerve conduction velocity.
• Alpha Lipoic Acid:
  • Has antioxidant and calcium channel modulating properties.
  • May benefit neuropathic pain.
  • Can cause stomach upset.
• Vitamin C:
  • Prophylactic use may reduce the likelihood of nerve pain after surgery.
• Fish Oil (Omega-3s):
  • Beneficial for chronic pain.
  • May reduce the viscosity of the blood, increasing the risk of bleeding.
• Creatine:
  • Shown some benefit in fibromyalgia and other conditions in small studies.

Pain Management, Cognitive Behavioral Therapy (CBT), Biofeedback (02:42:25)

• Pain psychology and behavioral therapy can help with maladaptive coping and thought processes related to pain.
• CBT involves recognizing unhelpful thoughts and patterns, interrupting them, and teaching goal setting, pacing, and relaxation techniques.
• Biofeedback provides closed-loop feedback to help individuals learn to calm down the sympathetic nervous system.
• Mindfulness-based stress reduction and acceptance and commitment therapy are other tools used by pain psychologists.
• Empowered relief is a brief intervention developed by Dr. Mackey's partner, Beth, that condenses 8 weeks of CBT into 2 hours.
• Digital platforms and online treatments are being developed to make pain management tools more accessible.

National Pain Strategy, National Pain Care Act (02:48:32)

• Dr. Mackey co-led the development of the National Pain Strategy, a strategic plan for transforming pain assessment, care, education, and communication.
• Full implementation of the National Pain Strategy would make a significant difference in the lives of people living with pain.
• Concerned citizens can help advance the implementation of the National Pain Strategy by contacting their representatives and writing letters.
• Dr. Mackey's nonprofit organization, Pain USA, aims to advance the implementation of the National Pain Strategy and use high-quality data to inform pain care and treatments.