You're listening to Life Kit from NPR. Hey, it's Marielle. I want to talk about rice. Not the grain. The acronym we're given to help us remember what to do after an injury. R. Rest. I. Ice. C. Compression. And E. Elevation. The idea is that you want to let your body recover while minimizing inflammation. Turns out, pain doctors have a new acronym now, featuring very different advice. They would say MEAT. That's M, movement, E, exercise, A, analgesia, and T, treatment, like physical therapy and massage. That, by the way, was Dr. Sanjay Gupta. Maybe you've heard of him. He's a neurosurgeon and a medical reporter for CNN. He says the thinking has changed on this because we've learned that actually inflammation after an injury can be a good thing. It's really interesting to tell people who are injured to get up and walk on it or do whatever because that's not what they're used to hearing. But it's almost like if you allow the body to do its job, if you allow those inflammatory molecules to rush to the scene and do their job, they do a pretty good job. And you're less likely to have chronic pain if you do that early mobilization and don't focus as much on decreasing inflammation. Sanjay has been reporting on pain science for a while now. And he wrote a book called It Doesn't Have to Hurt, Your Smart Guide to a Pain-Free Life. It's estimated that about 20% of people in the U.S. are currently dealing with chronic pain. We hurt. Our world hurts. At the same time, there are researchers studying this topic. And what they've learned might challenge your understandings of pain, where it comes from, and how we can feel better. That was the case for me. Also, researchers have found that simply learning about pain science can help with chronic pain conditions. So on this episode of Life Kit, I talked to Sanjay about some of the surprising developments in pain science, including non-opioid treatments you may not know about. We'll also get into what pain and chronic pain are, and why you might have them even when doctors can't find an obvious source. That's after the break. You say in the book that one of the most significant and surprising developments emerging in pain treatment is the fact that the brain is at the center of any pain experience. Can you tell us more about why that matters? What I think has become clear, and I'm not the first person to say this, the idea that if the brain doesn't decide you have pain, then you don't have pain. And the brain can also create pain where it seems like it wouldn't exist. And I think one of the best examples of that is phantom limb pain, which for a long time has baffled people. Like the limb doesn't even exist anymore. These have been long, you know, sort of regarded as mysteries. But I think what we've concluded is that the brain will decide, hey, that actually doesn't hurt or that does hurt. And it may seem completely out of sorts with what you think the experience should be. And you talk about this in the book. You can see that, too, in two people having a very similar set of circumstances and maybe the same surgery. I think this happened when you perform surgery on two people. and then one is in debilitating pain the day after and the other one is sitting up and talking and everything's fine. The story of the two Joannas, it just so happened that I ended up operating on two women on the same day that basically had the same problem and were very, very similar, not only in terms of what the medical issue was, but in terms of they themselves around the same age, same medical history and everything. And I walk into Joanna number one's room the next day and you can always tell right When you walk into a patient's room, how they're doing, even before you examine them, you know, the window shades are open. She already put on lipstick. Her hair was combed and she was discharged shortly thereafter. Joanna, number two, same operation, same medical history. And she was just miserable. And first thing you think is like, did I miss something here? What's going on? Why such a different outcome? And that's when you realize, I think pain is just, a mysterious thing. And some people respond very differently. And even the same person may respond differently at different times. Like if I had done Joanna Tu's operation a week later, maybe she would have had a totally different outcome. And that would have been because she was less stressed, was better fed. She hadn't had a difficult conversation with her mom. The weather was nicer outside. It's really wild. The things that you don't think matter can matter a whole lot when it comes to something like pain. Yeah And I think that where there a lot of miscommunication around pain and a lot of medical professionals can dismiss people pain Or if they trying to say that there a mental component it ends up sounding to the patient like they saying you making this up or it all in your head or you just need to relax when it not quite as simple as that The point you're hitting on, I think, has been one of the big challenges. The doctors I know, that's not their intent to minimize. But the patient has to be the North Star. I think that's what any good doctor will tell you. You have to listen to the patient and recognize that pain is pretty mysterious. Yeah, and be sort of humble, I think, about what we don't know. Yeah. Takeaway one. Pain can exist even in the absence of injury or tissue damage. It can also linger well after an injury has healed. Even if you no longer have that body part. Of course, there I'm talking about phantom limb syndrome. Also, researchers say that our surroundings and our emotions can affect our pain levels. And we can feel pain when our body perceives danger, even if there isn't any. There was this TEDx talk from a pain researcher in Australia. He talked about how he'd been walking in the bush when he got bitten by a venomous snake. And he ended up having to go to the hospital and it was really serious. And then after that, about six months later, when he had recovered, he was walking in the bush and he felt this excruciating pain. And he assumed he'd been bitten again, but it turned out he'd just been scratched by a twig. So what is going on there? Like, what do pain researchers think is going on there? If you think about why pain exists, it could be physical pain, it could be mental pain, even existential pain. It mainly serves as a warning. It's alerting you to some sort of danger. and people's warning systems can have different sensitivities. But basically the brain is like deciding, hey, be really careful here, be really careful. The best way I can tell you to be really careful is to give you pain. You're likely to practice avoidance behavior if I give you pain in this situation. So the brain's trying to make that decision. It doesn't always get it right. Sometimes the pain can be way out of proportion to what it should be. But that same sort of phenomenon likely happened with this particular gentleman. Yeah. And I think that this can show up in chronic pain, right? The doctors can't find, in some cases, an underlying cause or an injury. Or maybe there used to be an injury, but now the tissue has healed and this person still has severe or consistent pain or it just comes back and it goes away and then it comes back again. Yes. Chronic pain is pain that's occurring for at least three months. so they've tried to put a timetable on it but there are people who have pain for decades so you know it can last a really long time why that happens it's still a really interesting and i think mostly unanswered question like we understand why pain exists from an evolutionary standpoint to teach you a lesson touch a hot stove hurts don't do that again those lessons seem obvious after the repair of the tissue, no ongoing tissue injury, and yet the pain persists. This gets into the much more mysterious aspects of pain. Sometimes you can find obvious causes. I mean, I'm a neurosurgeon. I take care of a lot of patients with spine injuries, but sometimes you don't. And I think the question becomes for a lot of pain doctors, so what do you do then? Do you start to probe for the emotional trauma? Do you start to probe for other things that could be potentially worsening this or amplifying the underlying issue. There's nothing off limits in terms of possibly contributing to pain, especially when that pain becomes chronic. Takeaway two, chronic pain is pain that's occurred for at least three months. Sometimes it happens after a known injury or trauma. The tissue heals, but the pain remains. And other times there's no obvious cause. Sanjay says there are still a lot of unanswered questions about why a pain turns from acute to chronic. I'll tell you one of the things that fascinated me just with regard to that chronification of the pain, just the role of inflammation, for example, at the time of injury. Let's say you get a sprained ankle, for example. Your ankle is swollen, it is red, it's painful. You want to do things to minimize inflammation. That's what we had long been told. One of the acronyms, you probably heard RICE, rest ice compression elevate all those things fundamentally decrease inflammation but there was a paper that came out a couple years ago that kind of really upended the thinking on this it was these researchers who are trying to answer the question who is more likely to have chronic pain like what demographic of people what is their medical history what does their blood work look like and the thing that they found that surprised them and i think surprised everybody was the people who had the highest levels of inflammation at the time of injury were the least likely to have chronic pain So more inflammation at the time of injury less likely to have chronic pain which is almost the opposite of what everyone thought. What are we to do with that? I mean, when someone's injured, you know, sprained ankle, whatever, I think what you're hearing now from pain doctors, they'll basically say, hey, look, lean into the pain. mobilize the joint, exercise even, use analgesia, pain medication, if necessary, but don't use anti-inflammatories, and treatment. It's really interesting to tell people who are injured to get up and walk on it or do whatever because that's not what they're used to hearing. But it's almost like if you allow the body to do its job, if you allow those inflammatory molecules to rush to the scene and do their job, they do a pretty good job. And you're less likely to have chronic pain if you do that early mobilization and don't focus as much on decreasing inflammation. We'll hear more from Sanjay Gupta after the break. Let's talk about some of the things that researchers say can help. So I had sciatic pain for a while. Sometimes it would flare up and it would be absolutely like throbbing. and I was speaking to a therapist who had me try this exercise. She said to focus on, I believe it was focus on the area that had pain, like focus intently on it for, I don't know, maybe it was like 20 seconds or something, and then toggle my focus to something else on my body that didn't feel painful at all. So I chose my earlobe because it feels like nothing unless I touch it. And then focus on that for like 20 seconds and then toggle back to the part that hurt. And I swear, it's like it turned the dial down on the pain. It went from throbbing, like maybe at a seven to a two or a three. It felt like magic at the time. Yeah, that's pretty incredible, you know. And for a significant percentage of people who have that sort of chronic pain, again, without an underlying anatomical problem, which sounds like the case for you, it can be really effective. I will say, you know, when I looked at the data and I looked at data around similar protocols, there was one protocol in particular called MORE, which is Mindfulness Oriented Recovery Enhancement. And they would do similar things. They would say, hey, not only lean into the pain, but then also think of a pleasant scene. This sort of idea that, you know, the toxicity of the pain could be somehow remedied by thinking about something that was far more pleasant, you know, whatever it might be, flowers, sunset, time with your kids. And it seemed to be really effective in a percentage of people, not everybody, to be clear. But for the people for whom it was beneficial, it was extremely beneficial. While they were actually undergoing the MORE protocol, for a period of time, they could take their pain scores down. The pain would come back. There is a half-life to these sorts of therapies. But the idea that the type of therapy that you're talking about, Marielle, or this mindfulness-oriented recovery enhancement, which has many components to it, could bring pain scores down that low for a period of time, was proof of concept of just how much of this is occurring in the brain and how much of that is in our control. Takeaway three, brain training and mindfulness exercises are promising treatments for chronic pain where there's no identifiable injury. These exercises are free, you can do them at home, and they have no negative side effects. So why not try, right? They can include guided visualizations, body scans, where you mentally scan from your head to your feet and focus on the sensations without judgment, meditation, and writing exercises, among other things. Also, talk therapy with a clinician who specializes in chronic pain could be helpful. They'll know about these kinds of exercises, and they can help you work through tendencies that some researchers say are more common in people with chronic pain, like perfectionism. There are also apps that can walk you through these exercises and give you prompts. A lot of strategies that people use sort of in the bucket of mindfulness, different types of mindfulness. So like an analytical sort of meditation where you are truly analyzing your pain and treating it as a curious observer rather than having that pain inhabit your body. Like I'm just going to, oh, this is fascinating. Let me see sort of what's happening here. Oh, it's this shape. And it's that analytical versus the type of meditation where you might be thinking about something pleasant. There are all sorts of other therapies. I mean, there's emergency rooms around the country that will hardly use any opioids. They are called opioid-free or opioid-sparing emergency rooms. Besides things like meditation, they're using things like ketamine. You have patients who will get nerve blocks So I saw an 80 guy who came and fell broke his hip Very painful Did not want narcotics and the ER did not want to give him narcotics He got a nerve block. Took about 10 minutes for the nerve block. You have a team that comes down and does it. But he got faster pain relief in terms of how quick the nerve block kicked in than he would have if he had been given opioids. These are not new therapies, but I think opioids sort of just sucked all the oxygen out of the room for a long time. and a lot of existing therapies got minimized or even ignored. You're going to tell me to go be mindful instead of taking a pill? It just wasn't how people were thinking in this country. It's starting to change. But I think part of the reason I wrote the book was I wanted to show people the data behind this, and give them some hope that there were other really, really effective options moving forward. Takeaway four, there are other options for pain relief besides opioids. And in addition to the mental exercises we talked about, and painkillers like NSAIDs and acetaminophen. You might be able to get a nerve block or a trigger point injection, which is when your doctor injects a local anesthetic and sometimes a steroid directly into your muscle to treat painful knots. There are topical treatments like heat packs and lidocaine patches. Some doctors treat their patients with low doses of ketamine, which can provide rapid pain relief and be helpful when chronic pain flares. Also, there are lifestyle habits that might improve your pain levels. Regular movement, better sleep, an anti-inflammatory diet, and even connection. Having friends, having community. It's helpful to know there are actually lots of things to try. You just have to get plugged into the right information or the right clinic. How easy is it to find a pain clinic or a pain doctor? It's challenging. Yeah. I mean, it is really challenging. And, you know, I think I had an audacious sort of thought when I was writing the book that when you work in a hospital, and especially if you're writing a book, you tend to see how things work. And you recognize that a lot of those things are adaptable into people's lifestyles. Pain doctors are remarkable people because, you know, frankly, they're everything. They're like these Swiss army knives. They're doctors. They're psychologists. They understand techniques. They know how to do nerve blocks. Obviously, many of those things you could never possibly do at home. but I think there's a lot of things that you can do and there's lots of reasons why we are hurting more than ever and many of those things are within our control. Sanjay, thank you so much for this. It's been really nice to talk to you. I could talk about this all day, you know. Same. All right, time for a recap. Takeaway one, pain can exist even in the absence of injury or tissue damage. It can also linger well after an injury has healed. And researchers say that our surroundings and our emotions can affect our pain levels too. Takeaway two, chronic pain is pain that's occurred for at least three months. And sometimes this happens after a known injury or trauma. Other times there's no obvious cause. Takeaway three, brain training and mindfulness exercises are promising treatments for chronic pain where there's no identifiable injury. These can include guided visualizations, body scans, writing exercises, meditation, and more. Also, talk therapy with a clinician who specializes in chronic pain could be helpful for you. And takeaway four, there are other options for pain relief besides opioids and alongside those mental exercises and painkillers like NSAIDs and acetaminophen. You might be able to get a nerve block or a trigger point injection. There are also topical treatments like heat packs and lidocaine patches, and some doctors give their patients low doses of ketamine. Also, some lifestyle changes might help with chronic pain levels, including regular movement and sleep, an anti-inflammatory diet, and connecting more often with other people. And that's our show. While you're here, though, what do you think about rating and reviewing Life Kit in your podcast app? Here's a recent review I liked from listener FWalter819. The subject line, admit it, you need this too. Having learned many of these lessons the hard way, I recommend LifeKit instead. And for all the lessons they cover that I never learned, thanks. Better late than never. Thanks for listening, FWalter819. This episode of LifeKit was produced by Margaret Serino. Our digital editor is Malika Garib, and Megan Cain is our senior supervising editor. Beth Donovan is our executive producer. Our production team also includes Andy Tegel, Claire Marie Schneider, Sylvie Douglas, and Mika Ellison. Engineering support comes from Tiffany Vera Castro. Fact-checking by Tyler Jones and Barclay Walsh. I'm Mariel Segarra. Thanks for listening.
