Rachel Zoffness (on pain)

Welcome, welcome, welcome to Armchair Expert Experts on Expert. I'm Dan Shepherd. I'm joined by Lily Padman. Hi. We have a guest today with the cutest last name, perhaps we've ever had, Rachel Zoffness. Yeah, this was a great episode. I just love that last name. It's a good last name. It's a little misleading because this isn't a Zoff episode. Although it is and also another way. I guess. She is a leading pain psychologist and neuroscientist. This episode is so incredible. I think it's one of the best of the year. It's so many of us know, as you learn in here, there's 1.8 billion people in the world suffering from chronic pain and there's 100 million Americans. And we don't understand how we experience pain truly. And this is an incredible explanation of how it actually works. And it's quite an empowering take on it. Yeah, so her book is called, Tell Me Where It Hurts, the new science of pain and how to heal. I have already sent it to two people who I know who suffer from chronic pain. This is a great one. Please forward it to anyone in your life who's experiencing chronic pain. Please enjoy Rachel Zoffness. We are supported by Quints. I'm pretty picky about what I wear. Not in a fashion way, more in a, if this bugs me even a little, I'm out way. And this time of year always makes me want to reset a bit, clean things up, keep my closet simple. That's why I keep coming back to Quints. The fabrics feel elevated, the fits are thoughtful, and the pricing actually makes sense. Quints makes high quality, everyday essentials using premium materials like 100% European linen and their insanely soft flow knit active fabric. Their linen pieces are lightweight, breathable and comfortable, perfect for spring. And they strike that balance where you look put together without trying too hard. I got their linen pants and honestly I was surprised how good they feel. 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An outlandish battle of the spouses ensues when Les accidentally shrinks Lindy down to six inches tall. Les and Lindy are forced to face their issues in a big way. O.T. Fagbenle and Zoe Lister Jones also star as oddball scientists. Joseph Monvey plays Les's long suffering business partner. Ronnie Chang plays a big shot investor and Sean Clifford plays Lindy's book editor. Underneath the absurdism and screwball comedy is a relationship dramedy about ambition, power struggles, jealousy, and what happens when you feel small for far too long. The Miniature Wife is streaming now only on Peacock. He's an uptown expert. He's an uptown expert. He's an uptown expert. Hi. It's such a pleasure to meet you. Are you a hugger? Yes, let's do it. Monogot, you must know how this started. It's terrifying for me. I'm like a library mouse bookworm. I'm not a public-facing person. You're already so warm feeling. Listen to what happened. I saw Rob by the staircase when I left the house. So by the time I got out and went up the stairs to grab my drink, I saw that he was in the bathroom. And I go, Jesus, what are you taking as shit in there? It was Rachel. I was like, don't you wish I wanted... Oh, no. Is that terrible? It's funny. Oh, my God. Did you get really scared? No. I'm just asking. Good Lord. What a nice word. I know where I am. Come on. Even for me, no matter. Yeah, even for you. You would not do that. We have a friend in common also. Who? Do you see the person who wrote the endorsement on the top of the book? Who did it? Oh, I did see that. Yes. I'm obsessed with her. Oh, yes. She's the reason I teach at Sanford. Well. Because addiction, medicine, and pain are best friends. Yeah, that's right. So you're down, presumably, from San Francisco. Do you live there? Yeah, I'm in the Bay Area. But I'm originally a New Yorker, which is why I have an attitude problem. And I wear too much black. I'm like, curse all the time. I feel like I'm in good company. Those are good attributes. I thought you said you were like a church mouse. Library mouse? Very, very different than church mouse. Yeah, super different. Library people are pervs. Oh, hi. I think. They're like in the nurse category. What's happening? Don't know what's happening. Yeah, no. I was like the kid who was shy and quiet. Shy and quiet. Quiet and shy. And was in the library reading all the time. Books for my friends. Oh, cute. Different than a church mouse. That is different. You're right. How has teaching been for you? Because that requires a ton of get up in front of people and speak. What's funny is that during the pandemic, this thing happened where I was supposed to give all these talks. And I was actually doing that because it was partially a treatment for my own performance anxiety. Yeah, yeah. And public speaking anxiety. The treatment is exposure therapy, right? Yeah. Like if you never do it, you never get through it. So I had all these talks, and then everything got canceled. I was like, okay, what do I do now? So I started planning virtual talks and I started cold pitching podcast hosts. And I pitched a couple of people who actually had really big platforms and I didn't realize it at the time. As I started doing more and more podcasts, I think I did like 42 of them. Wow. And like, as recline came calling. And by the time I did that one, I had done so many that I felt pretty secure in what I wanted to say. And I feel very passionate about the topic and I keep my patience in my mind when I talk about the topic. So I'm sweating through my clothes. Well, that's also because it's for sure. 500. I'm so hot. It's also 90 degrees. Oh my God, I've never had that. But you can also take off your sweater. I'm considering it. It's not going to happen. It's a key outfit. Yeah, it's not going to happen. She would be dying of heat exhaustion when we say, can we remove the sweaters? I don't know. No, it's a cute color. I'll die doing what I love. It's just later. Being this cute sweater. Okay, so you're originally from New York. You really could write a book on universities of America, probably. You mean because I've been to so many? Yeah, you've been to so many. Did I tell you I was a nerd? I think I did, coming in here. You started at Brown, yeah? Yeah, yeah. You were biology? Yeah, I was brain and behavior. I couldn't decide what I wanted to study when I was at Brown. I loved neuroscience. I loved human biology. I thought psychology was so interesting. I couldn't decide if I wanted to research or clinical work or teach kids. So human biology, brain and behavior was sort of an amalgamation of everything. And then when I learned about pain in my first neuroscience class, it lived at the intersection of everything I thought was so rad. Because why? Because why. It just depends on how far down the rabbit hole you want to go. I mean, I've heard you say that you were drawn to it because you were so afraid of pain. Yeah, and that's another reason. Pain scares the shit out of me. And it should, right? Pain is designed to be averse of its design to save your life. If it doesn't grab your attention and get you to stop doing the thing you're doing, there's a chance you could hurt yourself slash die. So that's pain's job. But I always found pain to be very scary. Physical pain. Well. My friend. Well, my friend. Fasten your seat belt. That's the number one question I get, especially because I study pain psychology. So to answer your question very briefly, guess where pain is made? It's not in your bad back and it's not in your aching knee. In the brain. And the parts of your brain that make emotions also make pain. Like your amygdala and your limbic system are a critical part of the pain machinery. And we all know that our bodies feel worse during times of stress and duress. Of course they do. But does anyone ever tell you that at any point in your effing life? Yes. And we're going to march to that granularly. But her question still stands because prior to you understanding that there is no difference between psychological pain and physical pain in one regard. Were you someone that was afraid you were going to get physically hurt or were you afraid you were going to get emotionally hurt? It is a fair and good question. And yes, physical pain is what I was scared of. But of course no one likes emotional pain either. Yeah. I don't know. Some people. Like physical pain too. Like there's a whole BDSM community where pain is pleasurable and there's a reason for that. And maybe we'll even get to that. But it all goes back to pain being made in the brain. Were you sheltered? Were they a very nervous kind of parents? I would say I had very overprotective parents and by nature I was a shy, quiet, Indoor cat. Library mouse. Library mouse. So I was self-protective. Like my sister and brother would be running around playing sports, hitting each other with lacrosstics. I was in the backyard reading books by myself. Self-directed. No one told me to do that. It wasn't because my parents were like, you're going to get hurt. Were you the older? I'm the oldest. Yeah, yeah, yeah. Because they get crazier. We can't have the library mouse at the end. Yeah, no. It's got to be at the beginning. The library mouse is at the beginning. Yeah, yeah. This is a text to party off. Okay, so after Brown you go to, is it San Diego State? Columbia. Columbia next. And we do teaching masters there. I got a masters in psychology. I was interested potentially in education, like teaching psychology or maybe being a professor one day. Like I really couldn't decide what direction to go. I mentioned I was a science teacher at the Bronx Zoo. I was like, I love biology. I love animal behavior. Do I go that route where I'm a science educator? I was a science writer at Natural History Magazine. Oh, cool. Out of the Museum of Natural History in New York City. I was like, that's rad. You're science writing. You're learning so much stuff. You're translating complicated science for the lay public. Do I want to do that? I realized it was just me with my computer and that wasn't satisfying enough. So for me, the education piece, I am also a glutton when it comes to information, especially science. So I was like, what can I do where I consume the most amount of science over the course of my life? So I just went to school for as long as I could. Yeah, where your parents are all getting frustrated. Like we got to figure out what direction or they were just supportive. No, I was working really hard and I'm very self-driven. They were not at any point worried about me. Okay. I think they were probably worried because I was so stressed out. Figuring out your life path is not a casual thing and it can feel scary and intimidating for as long as you're wondering that. And you can be on this journey for forever. Hopefully we'll all have different points in our career where we pivot and do different things. But for me, I've been on this path from the beginning. Like I knew I wanted to help people. I knew I thought neuroscience was amazing. I knew that I wanted to do something with medicine. It really just naturally led me here. I did my honors thesis at Brown on the neuroscience of pain and I studied with a pain neuroscientist there. We studied endogenous neurochemicals that regulate pain. Okay, so those are the ones that are eminent from your body. They're not exogenous, right? It's your body's pharmacy kit. You got it. Yeah. It's the chemicals that are made by your body's pharmacy. And what was the most fascinating aspect of that? I love telling people that. Like when you take a drug, the drug itself isn't the thing that's giving you this sensation. That's right. It's either regulating uptake or down. It's just letting the chemicals in your body go crazy. And it's binding to receptors that your brain has because your brain already makes those chemicals. Yeah. Which is why you adjust. It's in you. It's not whatever you're putting in. Right. So like if you're taking a drug for a very long period of time, your brain does a thing where it down regulates. You probably have heard this term from the other science nerds you've had on where your brain stops producing as much of that thing. So if you're taking chronic opioids, for example, your brain doesn't need to produce as many because you're giving them from an external source. So you down regulate. You don't have as many. Now, neurotransmitters in your brain and the receptors are just picking up what you're giving it instead of like the homemade ones. Take me to San Diego State. Oh, right. Take me there. It's still an education journey. This is hard for me, by the way. I hate talking about myself. I guess what I'm trying to figure out when I ask about your parents and you, I guess there's two versions of this. One is I have anxiety. I'm afraid to pick. I don't really know what my calling is. I'm scared. Another one is I met this salad bar and I just can't stop going up to it and trying something new. It was the latter. Yeah. And also I really wanted to make sure I was going in the right direction because it's a lot of time when you go to school for that long. Like you really want to be sure of shit that this is the right direction. So I just kept honing it and honing it. So San Diego State UCSD was where I went for my PhD and I studied clinical psychology because I decided I wanted to work with patients. And I really was fascinated by the brain body overlap. I still feel this way. I felt like if I had gone to med school, I would have gotten like one slice of the pie. And if I went for my PhD in psychology, I would get another. And I wanted the intersection and I had to kind of go get that on my own, to be perfectly honest. Yeah, we just had Michael Pollan on last week. I just saw him at a diner. He lives in my neighborhood. Oh my god. I almost went up to him and I was like, that's rude. I'm not going to do that. Oh, he probably would have liked it. That must be so annoying. It's only annoying if you go and tell him about your shroom trip. Like how people come up to me and tell me their pain story. Yeah, exactly. I actually don't mind that much because I'm like, oh my god, tell me everything. Right, more data. Yeah. Okay, so at what point do you start seeing patients and specialize in pain psychology? I wanted to hang up a shingle right away. I did the PhD because I wanted to get really good at research. Like if you're a real nerd, you want to make sure that the papers you're reading are high quality. The data is good data. So in my PhD program, I got that. I got what I was looking for, but I really wanted to work with patients and I was obsessed with the science of pain. People think I'm a masochist when I talk about how much I'm interested in pain, but I'm not saying that I enjoy inflicting it or receiving it. Just the science is mind blowing. So I wanted to treat patients right away and, you know, I had been teaching a bit at UCSF and at Stanford. And I just told my colleagues like I'm opening my doors. I want to specialize in chronic pain. I got the hardest patients. I want to say this clearly. Absolutely no one wants to see a psychologist for pain. I am like the used car salesman of pain medicine, right? Of course not. The stigma attached is like you're saying it's all in my head. You're saying it's just emotional. It's not so medic. It's not real. I just want to see a medical doctor. 96% of our medical schools have zero dedicated compulsory pain education. I'm going to say that one more time. Wow. 96% of med schools in the United States and Canada have zero dedicated compulsory pain education. The real pain science is out there and it exists. It's just not being taught in med school. And of the 4% that have it, the total is in the four to six hour range or something, right? It's very small. And check this shit out. We're going to talk about this, I'm sure. The current model of understanding and treating pain is the biomedical model. It means when we talk about pain and when we treat pain, we talk about anatomy and physiology and bones and body parts. And yes, that's important. But neuroscience has known for 65 effing years that pain is this word. It's biopsychosocial, which means yes, there's bio components. There's also cognitive and emotional components. There's also social components. But it makes me crazy. I had to study pain on my own for 700 years to really distill down like, what is this and what are we getting wrong? And how has this happened in pain that we've created an opioid epidemic and we're still doing it today? So Michael Pollan was in and his new book is unconsciousness. And similarly, it's riddled with the same challenges in that Rene Descartes broke the mind and the body into two things for us 300 years ago. And we are stuck in that paradigm where there's two different things. There's your thoughts and emotions and then your physiology or your physicality. More and more, we now know there's no such thing as a division in any one of these components. This is one complex system that's talking at all times with itself and it's integrated. And there's no division that can be made. And to put a super fine point on what you're saying, because I'm currently dealing with it with a loved one, to say that it's more than just the physical pain is not to say it's not real. It's 100% real. And the question is what's contributing to it, right? It's very relevant. How are we getting to this pain, which is a 1000% real. And anyone who's listening to preventing the defensiveness, it's real, real, real. No one is suggesting that the pain is not real. So to your point, the patients you're getting have generally gone through years in some cases of exploring every single medical option for their pain. What are some examples of MRIs? That was sort of what triggered when you asked me about opening the private practice. I was getting the patients who weren't getting better. So I have this patient who lives in my brain. And of course I'm changing names and personal details because that's what you're supposed to do. And it's very important for patient privacy. But I have this patient in my mind and I still see him all the time when I talk about pain. One of the chronic pain patients that really sticks in my mind is Sam. It was really Samuel. Sammy. He had been in bed for four years and he had been on 40 medications. He had seen 14 specialists. And I want to describe him to you because I see him in my mind's eye every time I talk about him. He had long on washed hair and his skin was pasty and pale. And he was rocking himself back and forth on my couch with pain. What's funny is I remember thinking to myself, who do I think I am? This kid had been to Stanford. So the punchline is this person who's been bedridden for four years is only 17? Correct. Oh my God. And at 17 when you've missed four years of life, that is really significant. Like those are all the milestones you really only get those once. But I did have imposter syndrome. I absolutely was like, who do I think I am? So we talked about my training and how I'm a nerd and studying pain neuroscience and endogenous brain chemicals that make pain and pain psychology and biology. But I really think of myself as a pain detective. And when someone comes to my office, it's my job to figure out all of the factors that are contributing to the pain that are amplifying the pain and are perpetuating the pain cycle. So when I assessed Sam, I had his records like, yes, family history of migraine, diagnosed with migraine and diffuse amplified body pain of unknown etiology, meaning he was riddled with pain all over his body. No one knew where it was coming from. He had had a million tests. He had been on all the drugs. So when I assess my patients, yes, I want to know your medical history. If you haven't had all the tests and the scans, I'm going to send you. I want to know that your blood and body parts are okay. Then I want to know about the rest of you. We use this word biopsychosocial. That means that there are a lot of factors contributing to pain in any given moment all the time. Sam was depressed and suicidal, shocking. He had been in bed for four years. He had no friends, no life, no hope. He left in seventh grade. He detaches from playing soccer, from having friends. Yes. But what happened? The first thing is he had a migraine. He had crippling migraines. Okay. In his seventh grade, he had crippling migraines and then... Yes. Diffuse amplified body pain. So severe body pain, all the tests, no one knew it was going on. He couldn't go to school. His loving parents were like, what are we supposed to do? He was like, I can't go to school. So he stopped going and that just never ended. Oh my God. I'd be surprised by how common this is in the pain world. So I started getting all those patients. But I want to tell you what happened with Sam. Yeah, yeah. He was depressed and suicidal. He was socially anxious, like crippling social anxiety. He wouldn't talk to kids. His pain was always worse Sunday nights and Monday mornings. So there's a pattern to the pain. Of course, yeah. He was on a white food diet. Oh, like rice and bread. Pasta. He didn't like fruits and vegetables. No, rice, pasta and fries. Pizza, pasta, chips, bread. No. You would pray for rice, I think. For Sam. Rice is white. I mean, like that's not uncommon for a big chunk of the American pediatric population. Like you just don't like fruits and vegetables and so don't eat them. If they're saying they can't eat or they're too sick to eat, then yeah, your parents can be like, fine, just eat these chips, I guess. Eat something. And his only activity at this point. Was reading books. And playing video games. Library. So he's up till four in the morning playing video games to sleep hygiene was all. So in order to help Sam, I knew I needed to help him look at the whole recipe and fix the whole recipe. So we changed his nutrition, how to come to Jesus talk with mom and dad. We were like, how is his body supposed to fight this thing if he's not getting appropriate nutrition, put him on a sleep hygiene protocol. He had to wake up at like 10 instead of like two in the afternoon. Oh, this is appealing it back. Exactly. I like how small you started. You had really tiny steps for him to take. I think the first one was to go outside. It's called a pacing protocol. It's one of the most fundamental parts of a pain plan for people with chronic pain. So week one, he was standing outside in the sun on his porch and texting just one friend week two, he was walking to the corner mailbox and mailing a letter. His mom would actually give him bills she had to pay week three. He was taking his dog to the dog park and having a conversation and we scripted it. Cute dog. Remember paralyzing social anxiety, isolated, stuck at home. By the way, that will amplify pain. All of these ingredients. He got a tutor, started catching up in school, went for his first haircut. When that kid came to my office after his first haircut, he also had gone and bought a backpack. He was a child transformed. That was like one month in, one month in some sunlight, some social exposure. By the way, the more he did, the more he realized he could do mood started going up, stress and anxiety started going down. And oh shit, the brain's connected to the body. When stress and anxiety started going down and mood started going up, all these things started changing. His pain started changing too. The virtuous cycle or the destructive cycle is spinning. So the one he was in was just going to get worse and worse and worse until probably suicide or something else was on the table. And just to notice that one thing's feeding into another and then slowly it's all gaining momentum. And the fact that he was happy when he came to your office with a haircut and a backpack is shining. Yes. And he spoke at his graduation. He returned to school. I love that he had an impact on you. I still think about him. He graduated from high school and he walked across the stage and he said, if you had told me four years ago I'd be graduating high school, I never would have believed you. I maybe cried. That kid got asked a problem by two girls, not by one when he went back to school. And he went with both somehow. He went with both. I would love to talk to him how he juggled that. They were two different schools. Oh, that was the same problem. I'm like, how did Sam? I still hear from his parents. I have to tell you. He saved his life. Very selfishly. You did. It changed my life. I'm not joking. That kid, I was like, I'm never doing anything else. When I met that kid, he was on opioids and Thorazine. I also worked on an inpatient psych unit. If you're a homicidal or suicidal, you will go to an inpatient psych unit where they lock the doors. And if someone's having an acute psychotic episode, they will shoot you full of Thorazine and knock you the F out. This child was on opioids and Thorazine for his pain because we tell people that pain is a purely biomedical problem. That requires a purely biomedical solution. I want to say clearly, I am not a magician, but that kid got out of bed and back to life. He will never again be the kid who's in bed for four years. That will never happen to him again. What are we doing to people in pain? It makes me crazy. Yeah, well, you've seen it. It's not beyond anybody's understanding. Yeah, so let's talk about, first of all, the subjectivity of pain. You've got a lot of different great examples of how we can illustrate that it's not just the broken bone. Although that is definitely part of it. But I think a good place to start is amputee phantom limb pain. I'm obsessed with phantom limb pain. Explain phantom limb pain. Only if I got to hear after my monocles obsessed with phantom pain. I'm kind of obsessed with pain. Well, not pain, but I'm a little bit of what Dax would say a hypochondriac. I don't identify that way, but he identifies me that way. Dax would say. So, you know, I am hyper aware of what will cause distress and pain. I avoid those things pretty much at all costs. So in a psychology class, when we learned about phantom limb, I was like, what? That's horrifying. Okay, so we have all been sold a big fat lie about pain and what it is. So pain is the body's warning system. It's our danger detection system. However, we have been told that pain lives exclusively in our body in the part that hurts. You have back pain, you see 762 backdoctors and you probably get back surgery. And maybe you get a prescription. You have chronic knee pain, you see 40 million knee specialists. Maybe you have surgery. Maybe you take medications. Now, I want to say clearly, surgeries are important and useful. Medications are important and useful. They are not the only treatment for pain and they are not the best treatment for chronic pain, not by a long shot. It's really important because we're going to primarily be talking about chronic pain. And acute pain is pain that lasts three months or under. And that is your stomach hurts you might have gotten food poisoning. So great. Broken bone, acute illness. Yes. So anything that persists for longer than three months, now we're into the chronic pain category. You got it. And this is where we really want to focus. So I am going to be talking about the definition of pain across the board, but you are right. Generally speaking, God, my language is so bad. The fuckery comes when we talk about chronic pain. So sorry for people who are listening, but I know where I am. So hopefully the audience is okay. But the chronic pain world is where we really screw people. But this is true for acute pain too, just the basic signs of pain. So we've all been told pain lives just on our body part that hurts. One of the reasons we know pain isn't constructed just by the body part that hurts is because of this thing called phantom limb pain. Phantom limb pain is when someone loses a limb, an arm or a leg, and they continue to have terrible pain. Monica's knocking on wood. They continue to have terrible pain in the missing body part. Debilitating pain. Yeah. 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 cannot live exclusively in the body part that hurts. I had a patient with phantom hand pain who had lost his hand and his arm in a terrible firework accident. Mateo. Another young boy. Mateo. He felt like his hand was constantly spasming, cramping. The notion of cramping. Sometimes it was picking things up. So if you can have hand pain in a hand that is no longer attached to your body, that tells us pretty definitively that pain is constructed somewhere else and that somewhere else is the brain. And we said before that the parts of the brain that make emotions also make physical pain. Yeah. So the nervous system. Yes. Is kind of mapped in your brain. You have a neural network that knows where all the nerve endings are and it's communicating and it's interesting. This phantom limb pain is an outgrowth of the fact that your brain believes you still have this same nervous system you had before some of it was removed and it takes a while to update it. That's right. I mean, that's mind blowing, isn't it? It has a map of what it's supposed to have and it hangs on to the map long after a piece has been removed. So Mateo, what did you do with Mateo? Yeah. What you're talking about is you have a map of your body that lives in your brain. It's called the homunculus. Actually, when I teach this, I see patients of all ages, adults and kids. But when I teach kids, I ask them what they think a homunculus might look like and they draw me pictures and I used to have a whole wall full of drawings. That's so cute. I see like triceratops with an elephant's trunk. See? Oh yeah, definitely it's a homunculus. That's a pachyderm. Sure. Definitely a pachyderm. Yeah, that's a pachyderm. Yeah, you're good. Yeah, right. And it's a really cool map. So like if I tell you right now without doing anything to sense into your right foot, like what is your right foot doing? Can you feel it? Can you feel it on the table? Is it warm or cold? You can do that. And the reason you can do that is because of your homunculus. It's like a sensory and motor map. With phantom patients, there's a treatment called mirror therapy. And with mirror therapy, there's a lot of books on this. So interesting. So they have a mirror. So they have their functional arm and the damaged arm. And you put a mirror up, they hide the damaged arm, the good arm stays up and there's a mirror reflecting back to the brain. The undamaged arm doing things. So they engage in activities and exercises. And it feeds back to the brain and image of two healthy arms. And it helps update the out of date brain map. It's kind of counterintuitive. Your left arm's hidden. Your damaged left arm's behind you. But your brain sees your left arm and your right arm doing things together. Like Dak said, the map in your brain just hasn't caught up with the damage that has occurred. That arm is gone. Like it's not in danger anymore. But pain is the body's danger system. So your brain is going to continue making. Yeah, yeah, yeah. Yeah, yeah. It's not a trick your brain into thinking. It's like unplugging the association with your left damaged arm. By seeing your right damaged arm in its place. Yes, yes. It's quieting the danger alarm. That's the whole trick with pain is pain is the body's danger system. So credible evidence of danger will amplify the alarm. Credible evidence of safety will lower the alarm. Wow. So like one of my favorite examples of this is if you get slapped and bitten when you're having sex with a hot partner and you want it, it will feel good. If you get slapped and bitten when you're getting mugged, you bet your ass that is going to feel completely different to your danger alarm. Because pain is biopsychosocial, which means it takes into account bio information, but also contextual and social information and also emotions and where you are in the moment and who you're with and what's happening. And intention. And intention. Safety. Yeah. Safety. Yeah. Think of a massage. There's so many great examples. A massage which would otherwise be painful is like euphoric because you have put it in this framing. You're there on purpose. You desire it. You're paying the person to do this to you. You have some notion that it's medicinal. I mean, I always think, oh, they're getting the knot out. No, I don't know. Physiologically, that's even true. But I think we're making progress towards my health. Yes. Some control over it. That is huge. When you think about safety, control is a big part of it, right? Yes. Everything really. Yeah. Enjoying capsaicin, like eating hot, hot foods. Dissidenza. The winner of the hot ones. Yeah. We enjoy that pain. Tattoos. MMA fighting. What are you kidding? There's a million examples of enjoying pain on purpose. It's expectations. It's your context. It's emotions. It's predictions. Stay tuned for more armchair experts if you dare. We are supported by Allstate. Checking Allstate first could save you hundreds on car insurance. That's smart. Not checking your phone's battery before heading out. That'll get you every time. Of course, your phone dies on the way to meet someone, leaving you wandering around, quietly panicking about being in the wrong spot. Yeah. Checking first is smart. So check Allstate first for a quote that could save you hundreds. You're in good hands with Allstate. Potential savings vary, subject to terms, conditions, and availability. Allstate North America Insurance Co and Affiliates Northbrook, Illinois. We are supported by the HBO original show Euphoria. Oh, am I happy that this is back? If you thought HBO's Euphoria was intense in high school, saddle up. Starring Zendaya, Sydney Sweeney, and Jacob Elordi. Season 3 of Euphoria picks up five years later, and life looks very different. Now these characters are on their own with the freedom to make choices that can build them or break them. No matter what they're chasing, money, fame, power, love, or redemption, no one can escape their fate. Don't miss the third season of Euphoria, starring two-time Emmy winner Zendaya. Now streaming on HBO and HBO Max with new episodes every Sunday. These guys, specialists come in. They don't just tell you what you should do about your busy work. They actually do it. Start to finish. Case is closed, requests handled, no extra work for you. So you and your team can focus on what matters most. Which for me is, are they obsessed with male bodies on the same level as I am? They never are. To learn how to put AI to work for people, visit servicenow.com. This podcast is brought to you by Squarespace. It's a small in one website platform designed to help you stand out and succeed online. From websites and online stores to marketing tools and analytics, Squarespace gives you everything you need to build and grow your presence in one place. When we first got the armchair expert website up and running, Wobby Wob used Squarespace. And honestly, it made sense right away. It looked polished, it was easy to navigate, and it didn't feel like we had to become web designers just to make something good. What I like about Squarespace is that it gives you a lot of flexibility without making things complicated. You can start with one of their beautiful templates and customize it so it actually feels like you. Whether you're building a portfolio, a business, or just finally making the thing you've been meaning to make. And once it's live, Squarespace also has built-in analytics, which is great because you can actually see what people are engaging with instead of just guessing. So head to squarespace.com slash DAX for a free trial. And when you're ready to launch, use code DAX to save 10% off your first purchase of a website or domain. We want to think it's a subjective thing. It sends a signal. The signal itself is pain. No, the signal's not. It goes into the computer and the computer interprets and comes to a conclusion. If I could give you a grade, you would get A plus plus. Oh, thank you. But that's the thing we don't know. Even now, if you Google what a nocicepter is, a nocicepter are the neurons that live in your body and your tissues and your skin, your organs, and they feed information about potential danger to your brain. Potential danger. But if you look it up, you're going to be told that it's a pain receptor. It makes me crazy. That is sensory data. Sensory data isn't pain until it reaches the brain and the brain uses all available information to decide whether or not to make pain and how much. Yeah. So it isn't a pain receptor. It's like temperature. It's touch. It's reflex. So you touch a flame, a hot burner, nociception, makes your body move before you even think about it or process it. You have an instinctual reaction to that. And I learned all this from Ed Young's book, Amends World. So all these different animals have nociception. Nociception. Yes. But they don't necessarily have pain. Some do, some don't. We're figuring out which ones do. But all animals have this... Nociception. Yes. So what happens is those danger detectors in your skin, organs, send data first to your spinal cord and your spinal cord initiates that automatic instant response. Again, there's a lot of animals that demonstrate constantly they have these survival reflexes. Yes. But they don't have any of the other signatures for pain. So we are somewhat unique in how sophisticated our interpretation is. Yeah, it's true. Okay. I think now is a great time to talk about a tale of two nails. Oh, ho, ho. Sometimes things are so interesting that I'm reading about that they make it to my dinner table. So last night I had to tell my daughters about this. So let's talk about our first construction worker. So I was reading these great papers. There was this one from, I believe it was like 1995 in the British Medical Journal. And they wrote about this construction worker who had been on a job site and he jumped off a plank straight onto a seven inch nail. So he was in terrible pain. They rushed him to the emergency room. They gave him really good drugs. He was in terrible pain. They gave him a bunch of opioids and fentanyl was one of them. He got all the good stuff. And when the good doctors removed his boot, they discovered that a miracle had occurred. The nail had passed between the space between his toes. No. There was no puncture wound. No. There was no tissue damage. Everything was green. No blood. But his pain was real. How is that possible? His brain, aka his danger detector, used all available information to decide whether or not to make pain and how much pain is your body's danger alarm. It exists to save your life. So it used knowledge of his dangerous work environment, memories of past pain experiences and injuries on the job site. It used the horror of the construction workers faces, his friends around him, the visual data of this crazy nail and his brain perceived potential danger and it made pain to protect him. Tale of Nails Number Two. Second construction worker, most dangerous job apparently ever, on a job site using a nail gun. A nail gun misfires. He sees a nail shoot across the room, bury in the wall, cross from him. A nail gun ricochets backwards, clocks him in the jaw. He hits himself in the chin with the nail gun, which hurt. Shoot across the room. And he has mild jaw pain, mild toothache, mild headache, continues on with work and life for six days. At the end of six days, he says to his wife, you know, maybe I'll check out this tooth. Yeah, I can still feel this tooth a little bit. Goes to the dentist, scans his patient's jaw. And Rob, please put up the x-ray of him. Okay, so listen. After both men's surprise, they discover a four-inch nail embedded in his face. I spoke with Dr. Seth Renear on the phone. That's how big of a nerd I am. I was tracking down this photo. I wanted it so bad for the book. He said, this is the luckiest guy ever. And for the listeners, so the nail has entered the top of his jaw and it has passed all the way through his zygomatic, everything all the way up into the frontal lobe. The brain is spanning from his upper jaw into his brain. And the whole story and the picture is also in the book for people who can't see it. Yes, yes. This guy has enormous chunk of metal in his face. And I want to say clearly, very real damage, very little pain. Now, if pain were a reflection of how much damage we have to our body, gentlemen number two with the giant nail in his face should be in crippling, excruciating pain. Gentlemen number one who has a nail in his boot, but not his foot, should actually be fine. We have all had experiences like this. This is a stark example. If you've ever gotten into the shower and you have black and blue marks on your body, you're like, how did those get there? That's evidence of damage to your body without the pain. We know that pain and damage are not the same thing, but we continue to get sold that lie. Okay. So now, and this is the area that I'm constantly saying on here out loud because I heard it from Lane Norton, but I'm relieved to hear. Lane Norton is a buddy of mine. Oh, he's the greatest. I talk about this one often, but you have two examples of it. But now I have the precise numbers, which I'm grateful for, which is there's been two incredibly compelling studies because back pains among the most common pains. Like 80 to 85% of people develop chronic back pain at some point. Chronic back pain. Yeah. So they scanned 3000 healthy individuals, meaning people who have zero back pain, no reported back pain. And nearly all of the individuals scan 90% of subjects ages 60 to 69 and 80% of subjects aged 50 to 59 had bulging discs, disc degeneration and other anatomical abnormalities with no accompanied pain. I want to reiterate that. Yeah. All of us with no back pain are wandering around with slipped and bulging discs and we don't know it. You want to know why we don't know it? We don't have pain. So we've never gotten our backs scanned. However, if you have chronic back pain and you go to get your back scanned and they find a bulging disc, guess what you will be told is causing your pain. They think they have a smoking gun, but you can't have a smoking gun of 90% of us have the same smoking gun. But then that's why when they do those full body scans, what's it called? Pernuvos, the brand of one I got. That's tricky to do because it will tell you, oh, you have a bulging disc here and then you might be like, oh, fuck. And then your brain will probably... Don't ever do that. Have you done that? Please don't do that. Hold on. I did. I don't want her to do it. No, there will be my third argument I have about this. I want to hit the second one, though. Yeah, yeah. So there was another study, too. 1,200 healthy subjects who had no pain, nearly 90% of them had bulging discs. So this is enormous. Less than 5% of back pain is from structural issues. Right. And that is not unique to back pain. Those are similar results when you study the hip, the pelvis, the jaw, the uterus, the wrist, the knee, and neck pain. I went so far down that rabbit hole. There are study after study after study showing that pain and damage, the things we find on scans, that's what we're blaming pain on. But there seems to be very little relationship between the abnormalities found on scans and chronic pain. It's the ultimate correlation, not causation. Yes. But are people listening going to be like, oh, okay, well, when I have chronic back pain, I'm not going to go... That's the thing. Because of this thing we're sold, which is that pain and damage are the same, it's a really, really hard relationship to break. So I'm going to tell you a quick story. 30 years ago, there was a little kid growing up in Jamaica, and he loved to run. He was really fast. And as he grew, something strange was happening to his spine. It started twisting into an S shape. Scoliosis. And he was diagnosed with scoliosis. But it didn't stop him. He didn't get surgery. He was in terrible pain. He kept running. He was faster and faster and faster until he was fast enough to qualify for the Olympics. And by the time he qualified for the Olympics, his body was so twisted, his spine was so abnormal, and his body was so asymmetrical, that his right leg was, I believe, half an inch shorter than his left. And his left leg could only put down 14% as much power as the right leg. He won not one Olympic gold medal, but eight of them. Do you want to guess the name of this gentleman who has extremely severe scoliosis, but has never been treated for it and has very little pain? Usain Bolt. And still holds the world record in the 100, the 200, and the 4x1. Usain Bolt is the fastest man alive. You should see this man's spine. It is absolutely gnolly. And so if the lie was true, that damage and pain are the same. That gentleman should be relegated to a hospital bed. He should not be the fastest man alive. And in fact, we are often told that asymmetry is the cause of our pain. Yeah, yeah. I will say again, he's so asymmetrical that his right leg is half an inch shorter than his left. You would think that would affect a run. Well, check this out. He's running like lightning. The scientists who study his biomechanics have discovered or believe that it is his very asymmetry that helps him go faster. Listeners, do not chop off some of your leg just to be faster. It's not going to make you use Usain Bolt. Now, here's where we get to my own personal story, which is I did the Pranovo scan. And I'm going through the different categories. They do heart, they do lungs, all this stuff. And I get to skeletal system and I have abnormalities. I'm like, oh, what's this? And yeah, I have significant scoliosis at the top of my back. My spine curves to the right pretty dramatically. I went, oh my God, all the times my mom was yelling to me like, you always drop your left shoulder in photos. And we had no explanation other than it was my laziness, I guess, come to find out. Oh yeah, I've had scoliosis significantly. It's visible in photographs now that I have seen the x-ray. But yeah, I have zero issues up there. I've had lower back pain, but nothing where the scoliosis is at all. No issues. Wild. And the same thing, I'm like, oh yeah, if I were in pain and I went and got the x-ray, it would be definitive. I think this is the complexity of it is yes, biological factors matter. Yes, of course, you can have pain with scoliosis. It's just not the only factor that matters. Biosycosocial, it means biological factors matter, cognitive and emotional factors matter, social and environmental factors matter too. And together, those create the pain we feel. Does it work the opposite way though? So often do people go and they're like, oh wow, oh my God, I have scoliosis. Yeah, my back, then does the brain start sending the signal because you're aware now of it? There's a story in the book called How Cancer Cured a Kidney Stone. I should say, should I say that I wrote a book? I wrote a book. It's called Tell Me Where It Hurts. That's why I'm here. It's called Tell Me Where It Hurts. Tell Me Where It Hurts. I took sort of like the most fascinating patient stories and put them in because pain is gnarly and it generates these incredible and counterintuitive stories. So one of the stories I put in the book is called How Cancer Cured a Kidney Stone. So I had a patient who had regular kidney stones and they appeared like clockwork. She would have a six out of 10 pain, abdominal pain, there would be a host of accompanying symptoms and the stone would pass within, I can't remember exactly, I think a max of like a couple of weeks. And then the pain would go away, she would be fine. So she was having the normal constellation of symptoms, her pain was a six out of 10, her father had recently died of cancer, she was having a pain flare and her husband said to her, are you still having pain? It has been like six weeks. Are you sure this is a kidney stone and not something else? And she immediately thought to herself, shit, I have cancer too. Right. I think we all think we have cancer at least once a week. If you're a normal, healthy human being. Thank you. That's validation. And I think her dad had died of maybe abdominal cancer, something like this. So she, yeah, the knocking on the wood, I understand. I didn't want you to see it. Sorry, I won't call it out next time. You're on that old, you do it. You do it. Do it. Do it. I didn't want my handle. I did it small but you still got it. Sorry, I can't help it, I observe behavior all day. So she had the thought, maybe this is cancer pain and she shared that with her husband, she both freaked out. Her pain went to an 11 out of 10. Her report, she fell to the floor screaming. Oh my God. Her husband called 911, she got rushed to the emergency room. They did a scan. They found the kidney stone. Her pain went back down. Oh my God. Don't remember the number, three out of 10. And she went home and the kidney stone passed. Pain is the brain's danger alarm. It's subjective. It thrives on data. Any data we give the brain that amplifies danger will amplify pain. Data we give the brain that makes us feel safe will lower the brain's danger alarm. So that story to me was so revealing. The things we think, the images our brains feed us, the images we get from our doctors, they are going to affect the brain's pain alarm. And of course they should. It is adaptive and evolutionary for our brain to use all available information. Why should we only use data from the body part? We should use all available data, right? Now let's explore these three pillars that attribute to our experience of pain. So the first one's biometric. We understand that one. I think we all understand your bones broken. You have the flu. The biological domain. Yes. Yes. So let's talk about the psychological and how it impacts. Can I add to the bio domain of pain? Yeah, yeah. Okay. So like you said, it's the obvious stuff. It affects you damage, system dysfunction, genetics like Sam's family history of migraine. It's also diet, sleep and exercise. And I like putting them there because those are biological imperatives. The reason I'm going to go into this is because what I want everyone listening to remember is that you have so much more control and agency over pain in your body than anyone has ever told you. If sleep and diet and exercise affect your body, you maybe can't change your genetics. You can change your sleep. You can change your nutrition protocol. You can change your sleep hygiene. I'm always sort of keeping in mind like pain is terrifying. It's overwhelming. It feels unmanageable and uncurable. So if I can help people feel like, oh, there's actually 72 things I can do maybe starting today. If I can seed some hope, I have done my job. So that's the bio domain. That's the bio domain. And let's talk about psychology now. Yeah. So I want you to imagine that there's a Venn diagram with three overlapping circles. And I should have said this at the very beginning. Of course, the first circle is the bio circle, the one we just talked about. Then we've got the psych circle, psychological factors, and the social or the sociological domain of pain. So pain lives in the middle of these three circles in our Venn diagram. Okay. So you asked about bio covered in the psych domain of pain. This domain of pain is so full of stigma and misunderstanding. So I really front load with just the science. So in the psych domain of pain, we have emotions. We said at the beginning, the limbic system, our amygdala, the parts of our brain that make emotions also make physical pain. So our bodies hurt more during times of stress and duress. We know that's true. Anxiety and depression will amplify the brain's pain alarm. There's like 4,000 papers on that. Our emotional health affects our physical health. And we're in a broken paradigm, which is it's either physical or mental. So if it's physical, go see a doctor. If it's mental, go see a psychologist. That's not a real distinction. I feel so much gratitude. Like this is the line that I go around repeating in Western medicine. We're told either your pain is physical and you need to see a physician or your pain is emotional. You should go see a psychotherapist, but pain is both physical and emotional 100% of the time. You can't separate them out. That's just not how the brain works. Right. When we're treating chronic pain, I actually want us to be thinking about our emotional health. And I am not saying it's all in your head. I am not saying it's all psychological. You just can't deny that the brain is connected to the body. Yeah, it's part of the recipe. I want to talk about some of the specific things within the psychology domain, which would be thoughts, attention, distraction and emotions. So we said emotions. Let's talk about thoughts, attention and distraction. Yes. We tend to think that thoughts are just these air bubbles that appear in our head, you know, in the space between our ears. But thoughts trigger a neurobiological cascade of events in the human body. Right now, I want you to think about your to-do list. All the things you have to do and haven't gotten done, maybe your taxes. That's true for me. How does your body feel? When we think stressful thoughts, our body has a physiological response. Our muscles get tense. We bump cortisol and other stress hormones. Heart rate goes up. Heart rate goes up. Information goes up. Thoughts don't just live in your head. Thoughts affect your body 100% of the time. And then we have in there also, like you said, attention. That's a cognitive factor. So what we know about pain is that when we think about pain and talk about pain and focus on pain, what happens to the brain's danger alarm? It magnifies the pain response. And of course, the opposite is also true. So if you have to give a kid a shot, for example, you shove a screen in front of their face and they will be distracted and laughing and they will not cry and they will not scream. We all know this even as grown-ups. If you've ever been so absorbed in some pleasurable activity that you didn't notice your pain or you briefly forgot about your pain, which happens to everyone, that's not magic. That's just your brain's danger alarm. Right? So attention changes pain too. Yeah, maybe even think about why opiates work. Oh, dude. As I was reading all this, because I have a very well-known issue with opiates at one point. They certainly cure the physical pain, but I think for me, they're only curing the physical pain because they distract me from the mental pain. By the way, that is a known thing. Yeah, it's like it's not sending anything that's making the inflammation go away like NSAID would or something. That's right. It's binding to the opioid receptors and you have a disproportionate amount in your brain's emotion centers. And opioids medicate not just physical pain, but emotional pain, and that's why they're so dangerous and that's why they're so addictive. Yeah, you think they're addressing this physical pain? For me, they're not. They're affecting the angst and discomfort of my emotional life. They're affecting all of it. Yeah, they're muting everything. By the way, what are we doing to people in pain? Especially people with a history of addiction. It's like handing people a loaded gun when they already have a genetic loaded gun. Maybe it feels unfair and unsafe and I hope we'll talk about that. Yeah, I was curious in this psychological pillar. I often think of identity as having a lot to do with this. So my identity is that I'm indomitable. I have reasons why I've made that my identity. I believe if I appear to be indomitable, you will not try to take advantage of me. And so in order to service this identity I have, Monica will tell you that's why I had no business on opioids. My shoulders in four pieces. I got to wait a week to get the surgery because I'm still filming and I go film an episode in a sling racing a rally car with one hand and jumping. And I can do that. I don't know why I can do that. I don't have an explanation. I don't think I was born with that thing where I don't feel pain, but it's not on the table for me to be outwardly vulnerable. And so I do think I've wheeled my way out. I've been yelled at by my wife for carrying things while I just had surgery, right? And I'm like, you know, I can still fucking carry. The notion that I can't carry it is the most painful thing. The pain is not the painful thing. And so I just feel like I have really reformatted my relationship with pain. And my only explanation is that it's this identity thing that I will not threaten my identity by experiencing this pain. Or if I get tattoos, I don't give a fuck. So what do we think about our identity and how can that play a role in there? I feel like every once in a while someone brings an ingredient to me that I haven't thought about before. So the way I frame this is like a pain recipe. Like there's a recipe for brownies. There's always a recipe for pain. And there's biological ingredients in there. There's psychological ingredients. There's sociological ingredients. And I feel like I spend a lot of time with each one of my patients, like mapping out the ingredients. Like what are the things in this recipe of yours that's amplifying your pain? And what can I do to help change those ingredients to help you lower pain volume? And one that I have absolutely till this moment never thought of is identity. Anecdotally, it's so present in my best friend from Childhood Aaron Weekly who also grew up around a lot of violence and being vulnerable was not an option. I see it in my sister and my brother. My mother has it. We don't give a fuck about that. And then somehow some magic happens where I'm not experiencing it. Yeah, yeah. So I'm lying to myself or fighting it. It's like, I don't care. I don't think you're lying to yourself. I think it's adaptive for you in some way. It's like a survival tool for you. I don't know you well enough to know why, but it has been adaptive for you throughout your life. And that's why you've been using it. And that's not a flaw. That's not a character flaw. It has helped you get where you are. I think it's fascinating. It has a tail to the head of that coin. It does go somewhere. It goes into emotional distress that then needs medication. Whatever that medication is, whether it be drugs or whatever it is. Or adrenaline. It's like it's magically, oh, I don't have pain. It's that it gets funneled into somewhere else where people don't see it necessary. Yeah, it has pros and cons. And then that's not good either. Yeah. I hear you. Okay, so let's talk about sociological because I think you probably have a lot of interesting statistics. And I'm sure things differ in these different categories of sex, gender, race, ethnicity, socioeconomic status. How are these factors evident in people's experience with pain? Yeah. So when I was first studying pain as this little library mouse, not church mouse at Brown with this pain neuroscientist, I was like, yeah, pain's biological. It feels pretty intuitive that there's an emotional component. But what is this social shit? Like pain is social. What does that even mean? So I really went down that rabbit hole and I wanted to examine that. So I'm going to give a couple of examples and I hope they're resonant and you can ask me questions about it. So among the worst punishments you can give a human being is solitary confinement. What does it say about human beings that one of the worst things you can do to us is isolate us from others? Being social is biologically adaptive. It helps us survive. It's so fundamental to our very survival that our brains evolved a mechanism to reward us for engaging in it. When we are social, our brains bump out. Serotonin, which bumps our mood. Dopamine, pleasure and reward and motivation. And endorphins, our endogenous homemade pain killers. When we are with other people, pain volume goes down. The opposite is also true. When we are isolated and lonely and alone, especially in solitary confinement, all of those good chemicals crash. And we feel terrible not just physically, not just emotionally, but both because it's connected. This made me think of the weirdest thing while I was reading about this. When I worked for my mom and I worked with all of my friends in my early 20s and we would drink way, way too much on work nights. And we'd stay up till three in the morning and we'd be out in the parking lot at 6 a.m. to fucking wash cars. But because all eight of us were hungover, there was some bizarre joy in sharing that state. And I think people can relate to this on vacation with friends. When you're with a group of people and everyone's hungover versus you're by yourself in your apartment dealing with a hangover, those are totally different experiences, aren't they, Monica? Yeah, that's true. I think so. I never cared about a hangover when I was with my friends. And when I was a solitary drinker, they were insufferable. I mean, there's this old saying that when you share your joy, you double it. When you share your pain, you cut it in half. And that is definitely true for me. Like if I'm suffering, my friends will tell you I will burden them. And for them, they seem to be able to carry it. You can tell me your stuff all day, I'll be fine. You know, like I can carry anyone's stuff. When I share my stuff, it definitely reduces my pain. Yeah. So that's one example of how pain is social. So when people are isolated in their pain, obviously that's going to make it go up exponentially. Yeah. And that's how you feed that. So that was another data point that was so fascinating to me. So former US Surgeon General, Vivek Murthy. Yes, we love Vivek. We have him. Yeah, he's all about ending loneliness. He did that amazing study, like hundreds of thousands of people, where he showed, by the way, he wasn't the first to show this, but he gathered all the scientific data to show that when we are lonely and isolated and alone, it actually is a predictor of a whole host of chronic illnesses and also chronic pain. That are worse outcomes than smoking a pack a day, which is the craziest comp. We all know how bad smoking a pack a day is, but being alone is worse. Not just emotionally, just to make that clear. Loneliness is bad for our physical health. It is a predictor of disease and pain. Yeah, that's so wild. I know. So like all of these data points to me, I was like, oh yeah, pain is social. Social medicine is real, but that's not being prescribed and most of us roll our eyes. Like, yeah, I have chronic pain, blah, blah, blah. Don't tell me it's just hang out with more friends. And I want to say clearly, it's not that simple. It's one of the things. It's one of the ingredients. One of the levers you can pull. It's one of the ingredients in the recipe. Yeah. So we should probably be done with timeouts, right? For kids. There are a lot of psychologists who are anti-timeout. For that reason. Although there is a version of it, which is, it is our baked in learning mechanism. Yeah. Because we're a social primate. And the way it's excluded from the group is insanely powerful. Yeah. So is there a version of it that is... Not too terrible, right? Yeah. Like it's all about degrees of it, I think. But yes, in general, when your kid is dysregulated and you send them away to deal with their dysregulation by themselves, maybe not a great idea, right? Yeah, it's like not going to work really. Yeah. And the goals should be probably to first regulate, then teach the lesson. I think that's also a good order of events. Yeah. I wasn't a big timeout person, but there were a couple of occasions where it felt appropriate. Totally. What do we see with pain? Is it applies to gender? How does it differ with socioeconomics? I have my guesses, but what do we know about that? And redheads. That's physiological, though. What is that? I had to look that up. Someone asked me that on a previous podcast. I was on this podcast called Allergies, which is a science podcast, and she has red hair. And she was like, is that true? So there is some data to suggest that redheads do experience more pain. It's still very new science, and I would not say it's definitive, but there is some research suggesting that it is tied to, like, our sensitivity. This is the most fascinating thing. So all of us, as part of our recipe, have pain thresholds, and some people, and this may be true for you, have higher pain thresholds than other people. And like everything else to do with humans, it is on a spectrum. Some of us are very sensitive. Mm-hmm. And some of us are less sensitive. Oh, look at me like that. I can handle a good amount of pain. Yeah, yeah. Well, it's very, very clear to me. Yeah. If you choose that, you can endure a ton. Yes. So your role as a cheerleader, you endured pain that you wouldn't otherwise be able to endure, because you wanted to be a cheerleader. But you also cut your finger, and it is a very, very big deal. Well, hold on. Both things are true. Indicator. You know. Listen, the finger cutting is not a big deal because it hurts. It's a big deal because I'm alone. That's a huge part of it. Yeah. Then I'm calling people and sending pictures like, is this okay? And as soon as they're like, oh no, whatever they say, the connection with another person is helpful. You're saying that loneliness amplifies the pain alarm, and social support lowers the pain alarm. And it's like, oh, what if I bleed out? It's about that. It hurts. You just proved the point. When we are alone, we feel like this is just biological. We're more at risk of death because we don't have people. We're vulnerable. We're more vulnerable. That's the word. And the second you have social support. I love that example. I wonder if your proximity to us is going to lower or up your pain threshold because you're now across the street. Well, I have a good example. This isn't really pain, although sort of, I guess, but my parents were in town recently, and the alarm went off in the middle of the night. Oh, so scary. Yes. Normal. I was by myself. Oh my God. I would have been so panicked. Cut to a week later, my doorbell rang in the middle of the night. I was by myself, and I was like, oh, I'm dead. I'm dead. I don't know what to do. Do I call? I didn't know. But when I was with my parents, I was just like, it's fine. I had no idea what was going on. Someone could have literally been burgled. A door blew open. Yeah. But she didn't even care. But if you're by yourself, it's definitely a guy with a huge knife entering in a ski mask. It's scream. It was something fine when there were people around, and I assumed it was something bad when I was by myself. I know, but we forget about how that affects our bodies. Yeah. We just forget. This is like one of the many ingredients in these why married people live longer. This is one component of it. You're not having the cortisol dump. It's easier on your body. Yes. Stay tuned for more Armchair Expert, if you dare. We are supported by HP. My mental to do list is already full. Fix something around the house, refill prescriptions. Remember to take someone back. Keep track of a million little life things. The last thing I want on that list is, oh, don't forget printer ink. No, it's horrible. It's the bane of everyone's existence. What if you could just take that off your list for years? The dream. That's the idea behind the HP Smart Tank Printer from America's most trusted printer brand. Instead of those tiny cartridges that always seem to run out at the worst time, the HP Smart Tank uses a refillable ink tank and it comes with up to three years of ink included. It's built to be simple. The easiest tank printer you'll ever use with the best print quality. Period. It's the last printer you'll ever need. You know, right before a trip, when you're trying to print out a reservation or itinerary and you realize you haven't touched your printer in months. This is the kind of thing that's just ready when you are. If you want to take one more thing off your mental to do list, search for HP Smart Tank. We are supported by Helix. So a little while back, Helix sent Monica and me mattresses. Neither of us really knew what to expect, but I have to say it's been a few months now and I genuinely notice a difference. What I'm noticing is I run so much cooler on it. I agree. And just the sleep quality is nice. Like when you wake up, you feel like you really are refreshed. Yes. Because otherwise I wake up so sweaty, I'm taking blankets off and then I get cold and then I'm putting them back on. It's a nightmare. And then you're getting no sleep. Here's the thing about Helix. They match you to a mattress based on how you sleep. Side sleeper, back sleeper, you're on hot. Whatever it is, there's a mattress for you. Shipping is free and they have a 120 night sleep trial. So you can actually live with it before you commit. It's funny. Spring is when everyone starts refreshing their space and your mattress is probably the last thing you think to upgrade. Also the thing you spend the most time on. So do yourself a favor and go to helixsleep.com slash armchair for 20% off site wide. That's H-E-L-I-X sleep.com slash armchair for 20% off. Make sure you enter our show name at checkout so they know we sent you helixsleep.com slash armchair. This episode is supported by skims. Monica, I have a question about your skims obsession. Well, I wouldn't really call it an obsession. It's more of a lifestyle choice. Okay. But here's the thing. There are like a thousand underwear brands out there. What makes skims the one you actually recommend to people? Because they fixed all the problems I didn't even realize I was tolerating. Like I used to think it was normal for bras to be just kind of uncomfortable. You just kind of get used to feeling not good or underwear to just not really fit right. And then I tried skims and realized, oh my gosh, it does not have to be this way. So what's this new everyday cotton thing? Okay. It's their newest collection. And honestly, I just love it because it's so comfortable and breathable and it's not moving around your body. It fits properly. And you want that in your underwear. That's actually a really good pitch. Which is why you should check it out. Shop everyday cotton and all of my favorite bras and underwear at skims.com. After you place your order, be sure to let them know we sent you. Select podcast in the survey and be sure to select our show in the dropdown menu that follows. This ad is brought to you by AT&T. You know what makes the master so special? It's not just the legendary shots or the roar of the crowd. It's being connected to every single moment as it happens. Whether you're tracking your favorite golfers round or sharing that unbelievable eagle with your buddies. When the connection matters, it has to be AT&T. AT&T keeps you connected to the game you love because connecting changes everything. Visit AT&T.com slash connect to change to learn more. Did we interrupt your mid-thought? I don't really know. I actually have no idea and I don't care. I keep asking how sex and race and socioeconomic. I'm curious how those, yeah. We've got loneliness covered. So there's a lot of data on socioeconomic status and gender and race and ethnicity. So something that comes to mind is a disproportionate number of people living with chronic pain or women. However, this one really got me. 80% of pain research has been conducted on men and male mice. There's also been a lot of pervasive racism and medicine. Like this is well known. This is not my opinion. This is just what the research says in general over the years. There has been this myth and there's a name for it. I'm forgetting the name of it. It's like the hero myth or something. It's like that black people feel less pain than whites because they have thicker skin. Oh my God. Yeah. It's a holdover from the slave trade. Yes. And so in general, blacks are prescribed something like 50% less pain medications in the emergency room. And the women are believed the least amount about their pain assessment. Black women, if they tell you it's an A, the person immediately cuts that in half. Right. And that leads to this other thing that happens with women in minorities is not being believed or the suggestion that you're histrionic. That word has somehow just found its way into modern medicine or it's psychosomatic. So that's still happening. But let me ask you this. We're going to try to punch from every angle at the risk of offending someone. Is it not conceivable that women in general are more vulnerable physically? You're going to die by the hands of a man more than I'm going to unless I go to war. So it's a subjective threat because of the sexual dimorphism that feeling vulnerable, you get in an elevator with a guy that's 6'2". You have a different experience than when I get in an elevator, right? Yeah. So the feeling of vulnerability, if we're acknowledging that that's part of pain, couldn't that be in the recipe? It sure could, but there isn't data to suggest in general that women are more sensitive to pain than men at a biological genital. Oh, I don't think they are at all. They're giving birth. I would argue they have a higher threshold. Yeah, I would say. That's what makes it so complicated is like because there's all these ingredients and they're always interacting. Is it cultural? Is it sociological? Is it learned? Is it biological? What is the recipe that's creating this thing? And then are poor people experiencing more or less pain? Yeah, also access to care is in this recipe too. When we talk about insurance companies, so many of the treatments we're talking about aren't affordable. So like you can have 42 surgeries and take 72 medications. But like if you want to come see me, it's not reimbursed by insurance companies. It's really crazy. So access to care, being able to afford treatment, access to healthy foods. There's a lot that's stacking up against people who are economically disadvantaged. And so of course that affects their pain too. Okay, so we have a sense of all the things now that are contributing to this, again, phenomenological experience of pain. Yes. But you don't stop there luckily. The last third of the book, Tell Me Where It Hurts, is dedicated to addressing these things. Other than the three you mentioned in the bio under that umbrella, not a lot you're going to do about your genetics or your tendon strength. No. But there's a ton of stuff that you can do in the pain protocol. So how do you identify and track your pain recipe? Yes, part three is a pain protocol. And my mission in life is not only to change the way we talk about pain and the way we understand it, but also the way we treat it. Because we are completely effing people living with chronic pain by telling them that the only solution is a pill or a procedure. So if you came to my office, part three is the pain protocol. And it's exactly what I would do with you. And you'll see in the pain protocol that we walk through like, what are the things in the bio domain of pain that you have the power to change? And what are the strategies and tools that I can offer you to help walk you through that in a very approachable, digestible, not overwhelming way? Because it can feel so overwhelming. A quick part of a lot of people's pain recipe will be like, the pain starts when I've been sitting for a while. Yeah, totally. Right? So what are some common examples? I'll say my pain recipe. My pain recipe is like sitting for too many hours, staring at my screens, not getting up and stretching and moving my body, not drinking water and just like being extremely dehydrated, eating a crap diet. Sure. When I'm hungry, eating chips or something. Poor sleep. Thank you so much. I really appreciate you very much as I talk about my pain recipe. Do you have chronic back pain? I don't, thank God. But I'm aging and so like my body. It hurts. Yeah. So crap diet, sitting too long, not moving my body. Poor sleep. Like I am someone who has insomnia on and off. So like if I have a bad night of sleep, my body will hurt more. Not protecting time to exercise. I don't exercise to lose weight. I exercise because if I don't, my body feels terrible. My mood is shit. Those things for me are sort of like fundamental. Oh, and stress. Stress is so fundamental to my pain recipe. Like if I have too many things to do, which is all the time and I'm not protecting that and I'm not like managing my stress well and I'm doom scrolling at night or watching the news. Yeah. So all those things together will come together for me and create a high pain recipe. Yeah. You got to be aware of what your self-medication is because it's often a part of why you're suffering. Right. You mean like scrolling. We all have a lot of ways to regulate ourselves. Yeah. And many of them make us worse in the same way that drugs do. It's like they temporarily relieve your discomfort, but at a much bigger cost. Like I'm a workaholic. That's one of my. And that's a distraction and distraction is a good tool. But when you overwork, you're overstressed. Yes. You're sitting too long. Your body feels worse. But so just as there's a recipe for high pain, there is always a recipe for low pain and like this high pain recipe. I just outlined the cool thing is that it has an opposite. I know poor sleep is going to mess up my body, make my pain feel worse. So I know I have to put myself on a sleep hygiene protocol. I have been doing this for like 25 years now. My sleep hygiene protocol is like dimming my lights a couple hours before bed, not doom scrolling. Sometimes that means I have to put my phone in another room and I will do it because insomnia messes me up. It means getting out of bed after about 20 minutes if I'm not sleeping so that I'm not lying in bed being like, why aren't I sleeping? This is so annoying. And then stress goes up, anxiety goes up, likelihood of sleeping goes down. So I know what my high pain recipe is. I know what my low pain recipe is. And I know how to get there. That's actually what part three is. So sleep nutrition movement activity, functioning. How about strategies targeting emotional health, including brain based treatments known to adjust pain volume? So can I ask what are things that you guys do for emotional health that's helpful? I have a bonkers. I'm like the most creature of habit. I have such a routine every single day and mine is like exercises number one, meditations. Very important. Journaling is very important. My diet is very important. Sauna is very important. It's embarrassing how much time I put in to prevent me from being in pain. Embarrassing in that I can't believe it takes this much shit, but I don't care because I am not in pain. It's admirable. I've had a bunch of motorcycle accidents. I work out like crazy and I am not in pain and I am generally very stable emotionally and mentally. Good. And these are, I know because I've lived without these routines and I've lived in flaring my arthritis with the foods I'm allergic to. And I've done all the things that were miserable and now I am just very, very regimented about my schedule. Great. So you have figured out your low pain recipe? Other than I can't hack sleep, but whatever. There's going to be some categories that suck. I have forgiveness for myself. Yeah. Good. So you're taking care of your emotional health and by the way also your physical health with that routine. Can I ask you to, you don't have to answer. Yeah, of course. Yeah. I think for me the main thing is being social. I like really make time for that. I try to do that daily. Like hang out after work with people. There was one period of time where two of my friends who I hang out with a ton were both gone and I was like, I'm going to die. I don't know what to do. I need these people. Social medicine is real. Yes. Obviously if I exercise I feel better. I'm not as regimented as dad. That's okay. Is that at it? I'm also 12 years older than dad. If I'm in a good routine, I use exercise all the time. So if I'm in a good routine, yes. But I think the social medicine is a huge one. I want to add, I don't want to pat myself in the back. You do what you have to do. Yeah. You're humming along. Again, you're 12 years younger than me. I do what I have to do to not be miserable. If I got to do less and not be miserable, I would do it. I had to go to AA because I was going to die. I didn't go because I wanted to go. I also think you can look at someone else's routine and feel some kind of shame that you're not executing all this stuff. But you should only be doing what you have to do. This is what I have to do. That's true. There are moments where I'm like, I have to go on a walk. My body and brain know that I just maybe need to do it on the same frequency or whatever. Beautifully done. Phenomenal schedule. Well, no, I didn't say that. I found your low pain recipe and I think it's really amazing. Yeah, it's good. And you guys listed all the things that I would put taking care of emotional health other than when I think of emotional health support, I actually think it's great to talk to someone. And there's so much stigma around that still. It's like 20,000 and here we are and we're still talking about like, it's so shameful to have to see a therapist. So like, I want to see if I can frame this differently. Sorry, I can't believe I didn't say that. I can't believe I didn't start with that. Yeah, therapy. I'm in therapy and it's everything. It's hard to find someone who's available at the times you want, who's qualified, who you like and trust and want to talk to. So I'm not saying it's easy, but research shows it can be extremely, extremely helpful. Just as we go to the gym all the time to exercise our bodies and make our bodies stronger, why would we not engage in some form of brain exercise for our emotional health? When I think of therapy, that's what I think of. We're going to a trained professional who's helping us with our emotional health, with our history of trauma, with our fucked up relationships with our families. Doesn't everybody need that just as much as we need to go on a jog? How much better a place would the world be if we were all engaging in as much brain exercise? Brain exercise as body exercise. So I think about that also. Yeah, I think my reservation there a little bit is I am always conscious, I think, because of where it came from, with how lofty a lot of these are. If you have two jobs and you have two kids and you're a single parent, A, I don't have the money for therapy. And I don't have the free time to exercise like you're saying. These are all real, real pressures. Absolutely. But even to that, I would argue like AA is free. There's a lot of different groups that are free. You can actually engage in group therapy in a lot of ways for free. I would also argue that to prioritize 20 minutes of movement in the day. You could go for five. You'd really be shocked how much time that buys you the rest of it, because you're no longer in that destructive cycle. You're in the virtuous cycle. So you might be shocked with how taking more time for that thing ends up adding time. I think it's a fair and a good point. And the affordability pieces are really huge one. And I think there are a lot of resources out there. There are even workbooks that can help with certain things like depression and anxiety. That's why like your book, someone can get your book and go through this. The purpose of writing the book was sort of like to put the power into hands of anybody who wants to understand it and treat it. You have techniques for modifying negative thoughts. True story. That's great. Social medicine, we just talked about that. Some things that could help that will weirdly downriver affect pain is like better boundaries, creating healthy social connections, healing trauma. These things all impact your experience with pain. Yep. My other curiosity was, again, I brought up AA. AA has abysmal success numbers. Is that true? Oh yeah, it's in the like 30%. But I didn't know. Relative to the other treatments, it's an absolute miracle. You can look at it one or two ways. If you want to go like only 30 some percent of people who go there and getting long term sobriety, sure. But versus the alternative is like single digit. People don't just quit. I mean, very few people just white knuckle it for the rest of their lives. So I'm curious, we know how abysmal the outcome of chronic pain treatment is with doctors. It's in the low, you know, it's under 50%. What kind of success would you say you were experiencing with this marvelous thing? This is gonna sound like a jerk. Okay. Like a brat. Here's why I'm sitting here on your couch despite performance and public speaking anxiety. My patients get better. They get out of bed and they go back to life. I am not saying that their pain disappears completely all of the time. That would make me a liar. Sam continued to have pain flares, but he knew what to do. They didn't paralyze him and they didn't keep him bedridden. He knew what to do. If he needed to rest, he would rest, but he wasn't on the white food diet. He wasn't socially isolating. He wasn't not moving his body. The treatment for chronic pain is known. There is always hope for treating chronic pain. It just isn't told to our doctors. It's not told to us. The treatment for chronic pain is identifying your pain recipe with all of the ingredients and mapping them out hopefully with someone else, but you can also do it on your own. And then figuring out what you need to do to change the ingredients in your pain recipe. There is always hope for treating chronic pain and it makes me crazy because if you Google the treatment for fibromyalgia, it will tell you there is none. I can't tell you how many of my patients were told that there's just no treatment for their pain. They've been through all the medications. In fact, in medicine, if you've had four back surgeries and you still have back pain, you will get diagnosed. Check me with failed back surgery syndrome. As if you failed the treatment instead of the other way around. There is always a treatment for chronic pain. The treatment exists. It's looking at the recipe and figuring out what we can do to lower pain volume and there's a million things we can do. The great challenge to me still seems like asking patients for behavioral modifications versus pills or procedures is a tall order. Getting people to change their behavior is really, really hard. I agree with you. I would say it's a combination of things. I am not telling people to go off their pills. Absolutely not. Pain medications are a godsend. We're no longer biting on wooden spoons. Thank God for good drugs. Think of Ulysses S. Grant dying of throat cancer for months. What was that experience like in the age? I want to say also that opioids are appropriate for post-surgical pain and end-of-life care and cancer pain. I just feel like we are screwing people. Can I ask a question? Yeah, you can ask. Did it start with an injury? Yeah. So I had been eight years sober when I had a motorcycle accident. I was prescribed. I asked my sponsor, am I allowed to take this? I took it. It was completely fine, very misleading. I filed it as a mental note. I'm like, oh, that's weird. That was a drug that I was fine. I didn't take them all. I still did my shit. So that was a very bad data point. And then over the years, I had more injuries. And then what really set it off to the races was, yeah, I had back-to-back hand shoulder surgery and this bullish, arrogant view that this was a drug that didn't seem to affect me in the way that cocaine or alcohol did and that this was kind of a manageable thing. And then, yeah, I was off to the races. But I mean, I want to take 90% of the responsibility for it. I also was open to the idea that there was still something I could do that wasn't the other things I had admitted I couldn't do. I ask a question. Yeah. Would it be fair for me to say, like I don't prescribe, but I observe and I see patients with pain all day. It makes me angry that this is what we're doing to people who have a history of addiction. So my question for you is, do you feel like it's inappropriate for me to say, like, maybe we can recommend different drugs? We can recommend different pain medications for people with a history of addiction than opioids? Do I have a leg to stand on? It's tricky because I'll give you an example. Like, what screened bullshit to me about the James Fry book, which I loved, was he did not have all that dental work without anesthetic. That doesn't happen. No one does that. Yeah. No one should be expected to do that. Addict shouldn't be expected to do that. I don't love putting the responsibility on the doctors, if I'm being honest. I'm in an addict community. The responsibility is mine to say to the doctor, hey, I'm an addict. The pills should go to my wife. This happens in the program all the time. People are responsible for other people's pills. As long as you take it as prescribed and as you're supposed to, you're fine. So that's on me going in to go, like, I should never be holding the pills. If there's some range of how long someone should be on these pills, I should be on the shorter end of these pills. But I don't think it's fair for the surgeon to take on and understand your level of addiction. My dad died 28 years sober. He had many different bouts of being on opiates. It never got him. There wasn't a thing for him. They were in his house. He didn't care. He self-administered. He never abused them. I don't know why. That's what version of addict he was. And then I was this version. So I think it's too much to ask the person that's supposed to be really great at reassembling your bones to also be somehow an addiction specialist who can evaluate. I think that's on us addicts, to be honest. I totally disagree. I want to hear your opinion. Well, for one, we know that the doctors were part of the whole opioid epidemic to begin with. Absolutely. So they do have a responsibility in my opinion. I agree with you that ultimately it's the addict's responsibility. But when you're in your addiction... Yeah, that's a problem. As soon as I had the pills in me, the game plan went out the window. Exactly. When you're sober, you can say, hey, so my wife needs the pills. If you're in your addiction, you're not doing the whole point is to get high. So I do think doctors should have to ask before they prescribe what's your history with addiction. Ask you straight up. They still might lie, but at least it's there. And if the answer is, oh, I have a history, then I think they need to say, well, what's our plan then? That's correct. I agree with you a million percent. We're also in a different era we need to acknowledge because I've had surgeries and all the errors, right? So when the Sacklers were running, I mean, if there is a true villain in it, it is the Sackler family who had a very well-financed count. And they're seeing all this data that was bullshit data that the Sacklers had come up with. So again, I can't expect them to like go specialize in pain medicine if they're a thoracic surgeon. They have to rely on studies and stuff. So they were the victims of a very good campaign by a very well-funded dark ass family. And so there was a period. I talk about this most often. Most of my friends are stuntmen. They all have crazy injuries. Most stuntmen have a kit of opiates at their disposal. That doesn't exist anymore. The damn shot. It's not what it was. So I also don't think we need to overreact to a situation that no longer exists to large degree. You're not walking in with a toothache and walking out with two weeks of percocet anymore. That's not what it was. But I think a lot of that can be a reaction. So that's good. Oh yeah. But they've slammed the door on it. So I don't know that it's the same issue as it was 10 years ago. I respect both of your positions. I find myself landing in the middle because I feel like as a provider, you bet your ass it's my responsibility to assess my patient. And I absolutely need to educate myself about my patient's history. That is my job. My job is to be a patient. I need to educate myself about my patient's history. That is my job. My oath is to do no harm. Every doctor takes that oath. And I, having studied pain for like 35 years, I am doing harm if I am prescribing opioids to someone with a history of addiction. Because what happened to you could happen to anyone. It didn't happen to your dad and bless. But why would I put you in that position? If I'm a good doctor, I am trained to ask that question. You don't have to be trained in addiction medicine to ask. We also might lie to you. That is 100% on you. That's 0% on me. But I did my job. Yes. I asked you, do you have a history of addiction? Am I putting you in harm's way by giving you this particular medication? Because as a doctor, a trained MD knows, there are alternative painkillers out there. It doesn't have to be the most addictive one. So someone could have given you a friendlier, less dangerous drug, and could have saved you the fuckery that you found yourself in. Wouldn't that have been nice for you? Just to say. You're not going to like this answer, but I mean, I had to go through that. You had an important life experience and I'm not, and I am in no way. Discounting it or minimizing it. But had I died, yeah. Had I ODed? You came out on the other end and a lot of people don't. I didn't end up shooting dope downtown. A lot of people end up shooting dope downtown. So like, I think there's definitely the responsibilities on the patient to be honest, to disclose, and even to bring it up. If you feel comfortable for people who don't feel comfortable, the onus is on the doctor. We as healthcare providers have to do our due diligence. We have to get to know our patients just a little bit. Can we do that? If you're a healthcare provider and you're listening, spend three minutes. I literally just did this. I put like a pain assessment on my website because I don't think we assess pain properly. And one of the questions we need to be asking, do you have a history of addiction? It's very simple. You don't have to be trained in addiction medicine. You don't have to do anything. You have to treat the person for addiction. Just ask. I would expect every doctor to ask that. I feel so strongly about that. I haven't seen so many nightmares. I was really honored when you invited me on because I have listened to your episodes where you talk about opioids and pain. And I teach the addiction medicine fellows at Stanford, the next generation of MDs, because they don't learn very much about pain and pain and addiction in America are best friends. Our mutual friend Anna Lemke runs like a pain and addiction center. Well, this is really great. It's in the book. We are, I think 4.5% of the world population in this country consumes 80% of the opioids on planet Earth. Crazy. That is crazy. The number has probably fallen in the last couple of years. But still, there is a point where 4% of the population is consuming 80% of the opioids. I didn't think it was specifically like Oxycontin. Yeah. It's like similar numbers probably to guns. Two things that kill everybody. Yeah. I think we could just do a better job. Yeah. I think we can all agree that we can just do a better job. Well, Rachel, this was awesome. The book is called Tell Me Where It Hurts, the new science of pain and how to heal. It's awesome. It was worthy of a conversation at dinner. I think you'll find that to be the case as well. And the cutest last name ever, Zoffniss. It's almost Zoffniss. It's like Zoffniss with a speech impediment. Well, with the hardest letter. Mixed messages. X might have made it a little harder, but yeah. Zoffniss. What a cute name. Okay. Thanks for coming. I enjoyed this. You're having me. Thanks to you both. I really appreciate it. Yes. Thank you. Stay tuned for the Fat Check. It's Dread the Party's at. So I think I have a fun and ironic update. Okay, let's hear it. About our debate. Oh. About skin marks? No, my arms. Oh, okay. With waving the flag. Okay. If you recall. I think you need to tell people. Yeah, so I was saying I was in a bit of a pickle because I wanted to both work my arms out in case I wave the flag at the MotoGP race. And also my arms don't fit in my suit. Exactly. So I was really, Sophie's choice didn't know what to do. Uh-huh. You were really urging me to skip arm day. Yes, I was. For the safety of the riding. Yes, I was. Big debate. Red carpets came and high heels got invoked. What's that mean? I was pointing out that you're uncomfortable. Oh, during our debate. Yes, yes, yes. Just bringing back all the details. Yes, yes, yes, yes, yes. So I went to Austin with that on the table and the question was what was I going to do? Heed your advice, be responsible or be vain. But you made very clear to me that it wasn't a safety hazard. No, it wasn't. That you could move that I was overreacting. It's uncomfortable. So I chose vanity. Okay. Definitely worked my arms out on Saturday and they did not ask me to wave the flag. Right. So. So that's funny. So that right there is a win for you. That's like a win. No, it's not. What is in a, it is in a funny way, which is like I did this thing, which I shouldn't have done. And then I didn't even get to do the thing. Maybe I won't use the word win. I'll just say that that's a funny mark in your category. And then we'll get to mine, which was, so I did, I got my arms all pumped up and vascularized. Yep. Didn't wave the flag. Didn't even ask me. Yeah. You did. I don't know. I don't know. It's funny. You don't pay as much attention when you're not the one waving. Which then goes to show how many people are paying attention when it's you. I did have someone last year text me and go, Oh my God, you're waving. I mean, another MotoGP fan. Sure. Notice I was waving the flag. Anyways, I did not wave the flag. I was not asked to wave the flag. I was like, well, that was for nothing. But then, and here's the irony, the ironic twist, went to the track on Monday. I don't know. It's because it was so hot and Austin, whatever. I'm tight. You're fine. No issue. I know. So both things happened in reverse. That's right. That's how I feel like it's a win for both of us. It's a win for me if you're safe. That's all I care about. I'm not against you having big arms on a flag wave. Yeah. Only if it comes at the risk of your safety, which you assured me it didn't, but I didn't believe you. And also you. It was just a hilarious outcome. Yeah. Harrison Barnes, wave the flag this year. He's a NBA player for the San Antonio Spurs. Okay. Great. San Antonio Spurs and good because presumably he was very tall. Six, seven, six, seven, get the flag up in the air. Seven. In fact, I might have to go back on my DVR and watch him wave the flag. That's nice. And I want to see how his arm, you know, these NBA players have really nice arms. I'd probably like to check out his arms. Okay. Yeah. Okay. I was just talking side now. Oh, yeah. Great. Really nice arms. Rob just put a picture up. And great delts and he's got some vascularity in his delts. He looks handsome. Yeah. He looks like he's screaming in that photo. Yeah. Yeah. Of happiness. Victory was his. I think it says that's when he found out he was going to wave the flags. Oh, that probably makes sense. Oh, yeah. If I just told him. Okay. Okay. So I was talking to Ricky Glassman yesterday. Oh, great. And it was ostensibly he called for advice, which is always so flattering. I love this role I get to have in Ricky's life. It's very, yeah, I really cherish it. So we're talking about business stuff and everything. And then I don't know how we got on the topic of muscles, but we just went off and he's like, yeah, I don't know how to explain it. I guess because I grew up watching sorts of nigger and Sylvester Son, I'm like, I, that must be it too. And he's like, I just love them so much. And then we were talking about like, to what extent do we love them? And I'm like, you know, I want to squeeze them and stuff. Like, where is this line? This is very weird. Homorotic. Where is that line? You're attracted to it in a. I think there's layers in an aspirational way. Like, oh, I'd like to look like that. Exactly. Yeah. But I also want to feel them. Like I want to squeeze. But you don't want to feel their dick. Do you? No. We went through like, well, how far does it go? I would only want to squeeze sorts of niggers biceps. And I'd like to feel, I'd even like to run my hands across Brad Pitt's abs in fight club. Okay. Right. I'd like to feel that. What do you want to feel? All the definition in the ridges. Uh-huh. Yeah. Can you relate to that? Um, Would you like to run your hand over his abdomen? No, but I'm straight. Yeah. Yeah. So what I want to do is rub my hands over like Kristen's arm muscle. Right. I have zero. I know. This is why it was worth us discussing. That's why you're wondering if you're gay. It's like we're, we're on some trajectory, we're on some spectrum. I think. On the Kinsey scale. I don't think it's that. Where we like want to touch and feel. That's like, that's interesting. Well, because I think it's still like, you want to touch and feel it so you can kind of see like. What it would feel like if I could run it on. Right. It's still about you guys. No. Yeah. I mean, I mean women have, I have this all the time, like with other women. Do you want to feel any of women's boobs or anything? No. But I do hear that from other women that are straight. Really? Yeah. They're like, oh, I want to squeeze those boobs and they're straight. Okay. Well, I've never, ever wanted to. You've never had a friend of yours ask if they could touch your boobs? Nope. Never. You've been drunk. No. You could want to squeeze them without being sexually attracted. No, I guess, but like, I, whatever. I don't know. I can't speak on behalf of anyone other than me. We've got a sidetrack. Yeah. Okay. I have no desire to squeeze anyone's boobs or touch their genital parts. Touch? Yeah. Like if you saw a big, buoyant butt, you don't want to squeeze it to see what it feels like in your hand. No. Oh, wow. I might want to be, I might want to say like a female. Yeah. Yeah. Yeah. I don't want to squeeze it. I don't want to touch it to know that. I just like, I'm like, oh, they have like great X, Y or Z. I wish I had that. And then, you know, then you hate yourself for a little bit. Okay. And then, um, What are you chomping on over there? Oh, I have some laws and just, I'm still sick. Oh, and I have an, I have a sick spray. I almost brought it since the boats have sprays. No, it's like, no. Okay. So it's pageantry for show. I mean, I'm not better. It's just an activity to do. Oh, yeah. Yeah. Yeah. Okay. So no desire to touch. Okay. I have no desire to touch, but I definitely have admiration, a lot of admiration for a lot of female bodies, but it's still about me. That's, it's still like, I wish I looked like that. It's never outward really towards them. Yeah. It's like, how can I look like that? And I think, I think that's what's happening with you guys too, but maybe the feeling is like, it's still, it's still about that. It's like, okay, what does it feel like to have that? I want to feel the heft of things too. You know, the weight of things and the heft. Right. Yeah. But let me ask you something. Yeah, ask me. So you want to, you want to feel it. Squeeze and prod. Yeah. Touch. I mean, I don't have any physical hands on it with their consent. And, but do you want to do that for females? Like when you see abs on a female, are you like, ooh, I want to, I like, I want to touch that. Not really. No, but I regularly see butts in spandex or something or boobs. And I do want to like, I want to squeeze that. Yes, but that's sexual. That is sexual. Those are the sexual parts. Yeah. And that's different than what you're feeling towards these men and their abs. That's true. And it goes to show if you're not wanting to touch the female abs, it's not about muscles. Exactly. No, it is. It's about actual muscles on the men and how you can get them. Or like how you can relate to them or something. But I think most people out in the world are aware of other people's faces and bodies and their sexuality or not. Yeah, they're probably seeing the ones, whatever one they want. Exactly. That's my whole point. That is your point. Or if, if whatever they feel sexually, their sexual orientation, they might see, you know, like if you're straight, you're going to see the opposite sex a little with more curiosity sexually. But of their erogenous zones. Exactly. Because when you're attracted to someone, it could be really random things you're attracted to on their, on their body. Absolutely. Not just their erogenous zones, you know. Mon's pubis, a shoulder blade. That's the erogenous. That's the clear erogenous zone. But you know, I really like hands. And so I do tend to look at men's hands a lot. This is so fascinating. Again, very anecdotal. I have no idea what the grand data would say, but certainly I'm aware of so many men who have foot fetishes. Right. I don't really know any women that do. I've never heard a woman talk about. This is so interesting. This just came up on Elizabeth and Angel. Oh really? But I know many women who are super into hands. And I don't know a ton of guys who are super into hands. Right. What is going on? Why would one sex? Well, I know why women do. But hands are a huge part of sexual interaction. Because they're going to be all over you. Yeah. They're all over you. They're in you potentially. Sometimes they're in you. They're in you. They're in you. Yeah. They're in charge of all the action. Exactly. Yeah. So that's why I think women can be attracted to these guys. So do you think these guys with foot fetishes want to be manhandled by their feet? Well, that's what I know. Probably. I've seen pornography where guys are getting jerked off with a woman's feet. What? Yes, I have seen that. That seems very hard to do. For her, yeah. Yeah. Yeah, you got to really be coordinated. And how can you do that gracefully? It feels like you'd look so weird. The woman. Yeah. Also, how do you gently bring up like, hey, are you coordinated with your feet? Like, that's a huge thing for you. That's like your ultimate. Like the guy we interviewed for Armchair Anonymous. Yeah, King's. Who liked his toes played with. Mm-hmm. So it's like, this is an important thing to have. Yeah. Is this foot job. We'll call it for sake of time. Okay. How do you suss out whether that partner is going to be able to do that? Because I bet, I imagine there would be a lot of gales that were fully up for it. And they just can't do it. And can't do it. Yeah, I feel like most people can't do that. It's so cordial. If I try to, man, yeah, forget that. I mean, also the amount of leg strength you'd have to have. That's what I'm saying. It's actually a lot more than the foot. You also have to be flexible depending on. Those guys should be, they should be more generous and just be like, can you lay down on your back and I'll hump your feet. Okay. So are they putting the penis. Between their feet. This, like, like this. Yeah. Oh, okay. I imagine it like. That requires a lot of quad and add of the core. I imagined it like that. That could be fine. But that's hard. Yeah, that would work too. Actually, I'm not even sure of the way I said the first one. I think that feels more natural what you just did. Where is the inside your feet. That also is hard on the leg. On the IT band. Yeah, you have to be like out of one of these. Yeah. Okay. I hope nobody asked me to do that because I just, I'm going to look, I'm just going to look bad. What if you say, give me a couple of days to practice on a banana or something to see if I can even do that. Yeah. Being concept, I'm fine with it. And I like there's nothing wrong with that. In theory. Thank you. Uh-huh. Uh-huh. But I think well in this circle, so we got a circle back. No, this like is more evidence to it. Like why the hand and the foot fetish. And like I said, I think the hand makes sense. Sure. I think foot, I think people who have foot fetishes, I think women's feet like remind them of the vagina. I don't understand why. Really? Maybe because the bottom part so soft. What are you basing that on? Have you heard someone say that? I just know it. It's just you're leaping to that. No, I just know it in my heart. Oh, you do? Should we call Eric? Yeah, we can. I mean just to find out if it that's... Remember we've talked to him about this though and his is weirder. His is not like... It doesn't, it's not as conventional. I don't think so. Also we should say Eric's not the kind of person who's buying photos off the internet. Exactly. Yeah, yeah. I think it's like, I think it's a low grade. He just appreciates. He just appreciates the aesthetic a lot and especially because he worked in women's shoes. As a young boy. But he's never said like he wants to like suck any toes or anything. He didn't suck your toes at one point? No, he just cheese-graded them. Oh, okay. He just manicured them. That's his closest. Again, like he wanted aesthetically... Yeah, I guess he wouldn't have sucked your toes. No! Oh my God, that would be a positive. But if anyone would let anyone it be Eric. Yeah, but like I don't think... I don't know, that seems... That is intimate. Well, by the way, toe sucking is a sexual thing. Sure, standard biz. Yeah, and I think it's because it's sense that your feet are very sensitive, just like your vagina. I think there's some similarities. Okay. I think that's what it's about. Having no draw to the feet, I can't begin to figure out what's going on. I think I did it. Can't relate. You think you cracked it? I really do think I cracked it. I just think it's interesting that you think the foot looks like the vagina. Of all the body parts, like if that's the argument, then I think people would be way more into armpits. Not looks. There's just something about it that I think for these people... Is vaginal. Yeah, like the softness, the sensitivity. The forcements. Well, if you have good feet, they're soft. Uh-huh. But if you have bad feet, they're great for you. The toenails. They're like, yeah, they're manicured in a way that like a lot of vaginas are. Okay. Like, camped as we talked about last time. Okay. Like, John camped. Okay. John camped. Yeah, so I just, I think that's what it is. And if you have a foot fetish, please weigh in. Let us know. On whether or not I'm right. Although you might now want to do it in public on the comments. People also, they don't know what it is. Like, I just decided that about hands and I think that's right. Mm-hmm. But that's not what's happening when I'm like at the grocery store and I see someone have nice men with like a strong hand. I'm not like, oh, I want that on me. Uh-huh. It's just like, it's a visceral thing where I'm just like, oh, that's hot. Yeah. Something about that is a PQ. You get a PQ, you get a little bolt of electricity. Yeah. And some people, I think I actually don't get it from a lot of things that a lot of people get it from. Like? Well. Like, what do you hear friends talking about? And you're like, oh, I can't even relate. For me, that's like, I have a friend that's like, talks about ankles and talks about feet. Oh, really? What are you talking about? What the ankles? Because it's skinny. What is that? I don't even want to go into it, but there are guys with things with ankles and I'm just like, how could, of all the things to look at, why is that even where you would be focused on? You've got eyes, lips. The obvious ones. Different body parts. Origenous zones. Well, I know what it is. I'm okay. I'm on fire. Wow. You're really solving a lot of mysteries, age-old mysteries. I think I now understand the ankles. Okay. Because conventionally, you don't really, they're covered up. Okay. Mine are. Yeah. People wearing socks, people wearing pants, shoes, whatever. So it's kind of like, oh, I'm seeing something I'm not really supposed to be seeing. And I have that, like with certain things, if I see that normally are, like, okay, like I really like necks. Okay. Those are always on display. I'm not always, because people have jackets and shirts. You think everyone's wearing turtlenecks? Jackets and shirts and like hats. Okay. That one's a little more. I think necks are pretty. On display. Yeah. Okay. That's probably right. But it still just feels like. You just like necks. No. It's not that they're not on display. You just like them. Well, it feels like, it's not like right in front of me. It's not eyes or lips or something like. But do you mean specifically the back of the neck? Back. Back of the neck. Oh, that's different. Okay. I'm with you. Front of the neck. You're giving as much front of the neck as you are face. I don't care about front of the neck. No, back of the neck. Back of the neck. Yes. And it's like. What are you looking for in the back of the neck? I don't know. It's just like, I just know. You know when you see it. I know when I see it that I like it. And I do think it's like, oh, I'm not really supposed to be looking at that. Oh. Because like they can't see me looking at it maybe. Like there's some stuff. There's some stuff in there. Okay. Now back to the what your friends. You find that you hear your friends talking about specific body parts. Um, In men. That you're like, I don't get it. Well, I'm never like, I don't. Get it. Because no one is saying anything weird. But like, yeah, like. If you're like at a grocery store. There's all the stuff's happening at their. Yeah. You're. You're. You order all your groceries. Yeah. Oh my God. Um, It's like you're doing an improv about it. It's like, we need a location. Grocery, you're always going grocery store. No, because I'm like- Can we get a location that these brother and sister would be in? Grocery store! No, it's just where most like strangers are all together. You see a lot of strangers, yeah. And you're in lines and you're- Exactly, you're behind people. So if someone's at the grocery store, oh, Jess calls this something, okay? So whenever he sees anyone wearing a shirt that's like kind of cropped or like right at the pants, Yeah. He calls that marinara. Oh, interesting. Because when you go to grab, in his, when you go to grab the top of the shelf, you grab the marinara- Which in his mind is always marinara. It's marinara. Okay. It exposes the stuff. Arrows, yeah. And the arrows and like abs. Arrows are really powerful. Arrows are powerful, they are powerful. Yeah, I feel like they're, of the many things a man could have, arrows are like really high up on the list. Now do you like arrows on a woman? Yeah. Well, arrows are literally arrows that are pointing to your genitals. Yeah, yeah. Yeah, it's funny. And it's not that I'm like an ab person. So it's not like I need a six pack, but yeah, even arrows on a gal, you're like- Definitions. I think there's something that we know that we don't know about the arrows. And this goes for a lot of different fitness things, which is like arrows are really hard to get. You're really athletic if you have arrows. Oh. And so somehow your body knows evolutionarily, like that person's very fit. Oh, interesting. And then there's other things where it's like, every guy does bench pressing as a big chest. You're just like, yeah, yeah, yeah, guys have big, it's like, doesn't really say anything. I think it's more that it's pointing to the genitals. I think that's why butts too are really powerful. So I don't have a thing for butts. At all. Really, when you watch like an NFL game, you're not like mesmerized by- I'm not a butt girl. Yeah. Anyway, marinara. Yeah. Okay, so if someone is marinara, I, sometimes it's intriguing to me, but I think most women, that's very intriguing. Okay, there you go. And I'm like- It's a push for you. Hitter miss, not always, even if it's like really nice. Okay. I'm just like, yeah. I like more random things. Uh-huh. Hands, necks, earlobes. Sometimes I just like, I'll see something random on someone's body, like their forearm or something. And I'm like- Oh, and you get a choke. I get PQs. Wow, oh well. Stay tuned for more armchair expert, if you dare. We are supported by a zip recruiter. Oh, get recruited. Did you know the average employer has to sort through roughly 250 resumes per job opening? Which, when you think about it, is kind of insane. There's a lot of people to sift through and a lot of time you probably don't have. 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But you know, I remember we had Hussin on. And he said, and I thought this was interesting, he said like he's really attracted to like, specifically Indian women. The little hairs, that one. He did talk about that. But he talked about in a woman's arm, an Indian woman specifically, like armpit, there's often like extra fat right here. More folds. I have it, I despise it. Oh, you hate it. Oh my God, I hate it. But I remember him specifically talking about that. But he loved it. And that he liked it. And I was like, oh, you know, there really is like, there is a lid for every pot. And I ask for every seat. There really is. Like, you never know what people are attracted to. I know. And you just decide on no one likes this. And then you will confirm that. Exactly. And you're missing out on like, yeah, did you see it all the time? We see people that are paired up and you're like, wow, that person clearly has all the options in the world and that's who they picked. That's interesting. And it should be comforting. Yeah. Yeah. Yeah, it should be. It should be comforting. Someone will like this. But also it's like, I don't know. I go back and forth, I guess, because I don't like that skin fleshy, fatty part of my arm. Arm pit? Arm pit. It's not really the pit. Well, I guess it is the pit sort of, but it's more like on the side. Anyway, I hate it. And I guess I could be like, well, somebody will like this. Like that's, but I don't like it. And I think it's so, it's like, I should probably just care about what I like. I don't like it. So I don't need to find someone who'll like it. It's a better rule of thumb to be making decisions for yourself and know what others will like about you in general. But then you really gotta ask yourself, well, why don't you like it? My hunch is you don't like it because you think other people don't like it. Probably. Cause it's not on the bodies of the women that I look at. And I'm like, oh, I want to look like that. Yeah, but don't want to touch or squeeze. I just don't want to touch. I don't want to touch like their armpit. You don't ever want to poke a big butt to see like what the consistency is. Never. Wow. The thing is, when we talk with this with Nikki, whoever you're attracted to. Yeah, they like it, man. You like all the parts. Yes, totally. Totally. You like it all. Yep. Just gotta have a little bit of confidence. That's why personality is real. Like having a good personality and being someone, somebody wants to be around and hang out with. Like once you're that person, I mean, I say this to someone with no boyfriends. Once you're that person. And I'm pretty strict. God, does that mean I have a bad personality? Why? Because I'm saying if you have a good personality, you can get people. No, I think this is the, what's funny is, I think you're giving yourself this advice. What do you mean? I think you might be a little too, what's the word? Picky's the word, I guess. You gotta go with who's got a good personality and then see if you get attracted to them after that. You don't know anyone with a good personality? The people I know who have good personalities are my friends. Right. And they're all married or they're Jess. Yeah, you're not at the grocery store. I don't go to the grocery store enough. Yeah. I'm not gonna get their personality really from the grocery store. It's funny, you're out a lot. I am out a lot. Yeah. I know you're out a lot. So I'm a little confused. Can I be, I not to be, this, good personalities are few and far between. Are they? Yeah, they really are. Across the board, women and men, good personalities. I'm so misled. That you really wanna, well, I'm misled. That's the problem. My friends, the people in my life have great personalities. Well, I was gonna say, we interview insanely interesting people all week. Yes. And then generally if I hang out with somebody, it's someone in our friendship group. So I probably don't have a great read on the general options personality-wise. Other than when I'm in Nashville, I'm just hanging out with my neighbors and stuff and out at restaurants. Right. I do think that just being my best friend is a hindrance. Yeah, big time. He is the most, he is the most special personality of anyone I've ever met in my entire life. And I spent all my time with him. Uh-huh, I know. Even marinara, like who am I gonna meet? That is, that is, is marinara. Like no one. Yeah. And so this is where I really think sometimes. I'm like, look, I got so lucky. You should send him to conversion camp. No, we're not attracted to each other and that's what's great about us. He has a incredible personality and I get to spend, I get free access to that personality and it's so lucky. That is a problem. If you're deciding, you meet a guy, you've been on a date with him and then you're deciding the next night, do I hang out with Jess or do I hang out with him? That's, yeah, this is interesting. This is a problem kind of. It is, that is what goes through my head. Of course it is. Like, okay, I have two hours to hang out tonight. Am I gonna go on a date? Or am I gonna hang out with this person that's gonna make me laugh for two hours? I'm always gonna pick that. So sometimes I think like, oh, maybe I should just, in fact, most days I think I think this. Like, I'm just so lucky. I have these incredible people in my life. Multiple incredible people. That I think if anyone would be so lucky to have one of these people in their life and I have so many, maybe I should just be lucky and grateful for that and like, that's enough. How about this, if I said there was this new breakthrough, AI figured this out. You and Jess could take this pill. They took your DNA and they engineered it. And after you wake up tomorrow morning, you're gonna be insanely attracted to Jess and he's gonna be insanely attracted to you. Would I do it? Yeah, right? I know, but what if it ruined everything? This is a black mirror episode. This should be a black mirror. It could ruin everything. I think you just gotta be grateful for what you have. All right. Yeah, so let's say you're both attracted to each other, but now he wants to have sex with you more than you wanna have sex with him. Now you have this. Or what if he's selfish in bed or something? Then bad parts of personalities can come out when these things get involved. Jealousy, like there could be a lot of things. Jealousy when he's making other people laugh, all of a sudden it bothers you. 100%. Yeah, because right now you don't care. No, I- But if he was making some girl just laugh uncontrollably and he was your boyfriend. And he was straight? Yeah, you'd be. I know, I'd- You'd tell him to shut up. Well, I know. Just shut up. No. Your comedy's only for me. I know, it is funny, because now when we're out places and he's making people laugh and he's my buddy. I'm like, so I feel so, yeah. I'm like, oh my God, yeah, just my best friend. Like I'm so lucky. And, but yeah, if he was into girls. He's making some hot chick laugh uncontrollably. And you could see she was looking at him like, I wish this guy was my boyfriend. Yeah, and then she's like pulling her shirt down. Pulling her shirt down. And I'm like, fuck you. Get outta here. I break up with you, Jess. Yeah, see who could go badly. I'm leaving it. We wanna take it. Yeah, I'm gonna leave it. All right. Should we do that? One is a fact, yeah. Okay, this is for Rachel Zoffness. What a name. Great name. Yeah, Zoffness. I wish my name was Dax Zoffness. It'd be too many weird letters, but it does soften everything. God, do you wanna hear something embarrassing? Yeah. I can't believe I'm gonna admit this. Oh, good. It's a day of admissions. So when I was young, I would like write a lot of fiction stories. And I would create, I was basically like writing what I wished my life was. Of course. The main character. And I was always thinking about what name, who would I would name the characters and stuff. And I did really like the last name Shepard. Really? Yes, I did. Where did that come from? I don't know. I must've heard it. And I was like, oh, I really wished that was my last name. I like that. Yeah, but it's like, it sounds nice. It sounds really nice. I'm grateful for Shepherd. Don't get me wrong. It's good. Yeah, it's a good name. And then of course I like that it's not spelled the way. So I still have some uniqueness, you know? I love uniqueness. I don't like that. It's annoying. You would want H-E-R-D. Actually, no. I like the way yours is spelled aesthetically better. Yeah, it looks better, right? Yeah, it looks better. Yeah, we don't even have H in there. But it bothers me when people spell it wrong, like when they're like reaching out. No, it's almost exclusively wrong. I get offers or I get these ones that are kind of like they're very flattering letters. Exactly. Begging me to be a part of something. And I'm like, but you didn't even look up how? You don't even... You're acting like a super family. You don't know how to spell my name. But I don't get that but not in the shape of a... Rob McElhaney famously. Oh, well his is so hard. He's let people go over it, yeah. Oh, wow. Yeah, yeah. I get it. It's like just take a second. But I've made them as... I've also made that mistake too. I don't care. Thank God. I mean, I care about so many dumb things, but I don't happen to care too much. I just, it's ironic. I see the irony of like, I'm your biggest fan. I know. It would happen with Kristen too. DACKS, S-H-E-P-H-E-R-A-R-D. Yeah. Yeah, yeah, yeah, yeah. When I was Kristen's assistant and people would reach out asking for things and they would misspell her name, I was like, no. Yeah, yeah, yeah, yeah. They're not getting it. You can't even take the time. So, anyway, so I wanted it to be that. I wanted that as a last name. Monica Shepherd. No, it wasn't Monica. Oh, it was gonna be Gail Shepherd. No, it was like Skye or like Ansley. Ansley Shepherd, that's cool. I know. It is cool. Okay. You never wanted Hollis? Sorry, I didn't know about it. What's your crazy letter slammed in there? I would have written a character. No one's supposed to my name, right? Well, Rob, we've been working together for eight and a half years and honestly, every time I have to write your last name, I get a sharp pang of anxiety. I'm like, I'm never doing this right. Yeah, how dare you complain about yours? I'm gonna try right now in public. I'm gonna try. Okay. I think it's Hollis. H-O-L-Y-C-Z? No, S-Z. Yep. I thought it was C-Z for a second. You can definitely see where there'd be a C in there, right? Hollis, no. I don't normally get a C in the wrong space. You get, do you get H-O-L-L-I-S? Well, phonetically, yes. Yeah. Could you ever thought about changing your name? No, Rob, you be you. I think it was already changed technically from like the real Polish. Oh, probably. Preciationally. Okay, so I blew it in public. Yeah, so it's a tough one for me. I know there's a Y and a Z in there. Having a Y and a Z in your name is tough. It's gonna be tough. Yeah. Yeah. Speaking of names that someone could mispronounce, you say Bolt. It's just some. That's a tough one, yeah. Yeah. So just some stuff about his back. Okay. Scoliosis, yeah. To manage his back issues and protect his spine, Bolt focused heavily on core strength, sometimes doing up to 700 sit-ups per day. Mm-mm-mm. At age 15, he became the youngest male world junior champion ever in the 200 meter, running it under 20 seconds. Wow. During the 2008 Beijing Olympics, he ate roughly 1000 McNuggets over 10 days because he was picky about the food. 1000 McNuggets? That's a scientific experiment. Yeah. Like what would happen if someone ate 1000 nuggets in two weeks? They would set all the world records. That pink sludge video is one of the best mark. I don't know what they were marketing. I mean, Burger King probably was behind that. Like, and I cannot hear the word McNugget and not think of that pink sludge. Oh, thank God I don't. I have no association. It is permanent, it's cemented. I mean, I'll still maybe eat it. They're delicious. Oh yeah. They're delicious. Oh, they're fucking delicious. By the way. I wish I had an excuse to eat 1000 of them in two weeks. Well, you could. I wouldn't look like Usain Bolt. If you do his 700s setups a day, you might. I think I'll also have to be running very fast for, oh, very frequently. Probably. At what margin do women experience chronic pain more than men? Data suggests that approximately 70% of chronic pain cases are women and they suffer from higher pain sensitivity, more severe pain and higher rates of conditions like fibromyalgia and migraines. Fibromyalgia. Remember? Classic. Classic. There used to be so many commercials about fibromyalgia. Yeah, especially on 60 minutes. Yeah. The older person programs. Older demo, yeah. Yeah. Which I am out of officially. You're what? I'm not in the demo anymore. It's 18 to 49. I'm not a valued viewer anymore. Oh no. Yeah. But you're in the fibromyalgia. Yeah. As I said, the older demo, but this is kind of a throwaway demo. It's not what advertisers care about. They care about 18 to 40. That's silly. They should care about the older people because the older people. They have more money, but they spend less. Right. Yeah, they're done buying crap. How much of the world's opioids does the US consume? The US has less than 5% of the world's population, but consumed roughly 30% of the world's opioids in 2009, including more than 99% of the world's hydrocodone and 80% of the world's oxycodone. As of 2017, that was a long time ago, the US and other affluent nations, Canada, Western Europe consume roughly 95% of the global opioid supply, leaving only 5% for the rest of the world. Some Sackler family fun facts. Oh, great. Owners of Purdue Pharma, made approximately $35 billion in revenue from OxyContin sales. In 2025, family agreed to a 7.4 billion settlement as part of a bankruptcy deal, which required them to give up control of Purdue Pharma and ban some from selling opioids in the US of A. Okay, so this is some stats on AA and its success rate. But like- Before you read them, I'm just gonna say that's something very smart and astute that Drew Pinsky said about the success rate AA. AA is a very hard thing to evaluate because you can evaluate a cancer medication because you take the one pill, they took it or they didn't, and then you measure the outcome. Whereas AA is advise, go to meetings, get a sponsor, work the steps, sponsor someone else, do service. So there's a lot of components. So it's hard to measure. I know. If someone has the full dosage, if they do all five of those things consistently, you're gonna get one outcome. Right. And then a person who does one meeting a week and never gets a sponsor doesn't do the steps. I know. That's why I don't really read this. That's the caveat I would say. I don't wanna read this. I don't think that's- What does it say? 10% or something? This is 2014. Well, yeah, this says is 7%. Yeah. And then also how you define it, it's like relapse within the first year. Right. Then, okay. So it says addiction specialist site success rate slightly higher between eight and 12%. But then it says 27% of the participants were sober for less than a year, 24% were sober. From what? Oh, a 2014 study conducted by AA found the following among over 6,000 members. 27% of participants were sober for less than a year, 24% were sober one to five years, 13% were sober five to 10, 14% were sober 10 to 20, 22 were sober for 20 or more years. The eight year follow up showed that 46% of those who chose formal treatment were abstinent. Well, 49% of individuals who attended AA were abstinent. Those are actually- Some more. Yeah, but they're saying these are AA studies. Yeah, what's success? If someone drinks once within a year versus they drank seven days a week. Right. That's pretty successful. Yeah. Over the course of 20 years, they have eight relapses. Does that mean it's not successful? No, to me, that person used eight times in 20 years and they used to use 365 days a year. I know, it's hard. It's really, I don't know. It's hard to- It's almost impossible to evaluate. I agree. Yeah. That's it. Okay, great. Well, I enjoyed Rachel. I've been telling so many people about, the tale of two nails is so fun at a different party. It is, yeah. Especially if you have the X-ray on your phone like I do. Yep. And then the back data is fascinating. The back data is really fascinating. Just pain in general. I mean, it relates to the other episode we had on overdiagnosis where there's phantom seizure. See, people can have seizures- Psychosomatic seizures. That are not caused by epilepsy. You can have, you know, it's similar. Like your body is still reacting. It gets in a high alert survival mode and it doesn't need to be. It just ever, you know, when people will ask like, oh, you've had so many experts on in the past eight years, what have you learned? Like what's your biggest takeaway? I always kind of like trip on that because we, there's so much. But I think the main takeaway is just, the brain is so powerful. It can do anything. It can kill you and it can- It can take you out of this planet to another place. Yes. Yeah. It can save you. It can, I mean, it's like- It can learn to fly. It's all of fucking here. Yeah, yeah, yeah. No, it's the great enigma still. I know. Yeah. We all got one. Some of us didn't get one. That's my disc. Did you even get a brain? Yeah, when God was handing out brains, you must have an option about that. Did you miss that day? There was a thing in Elendor, it was like when God was handing out something, you thought he said something, do you use that ring of bell? Like shirts and you thought he was saying shit. It's not that, but it's like, it's a burn. Yeah, I was like, oh, oh, it's, when God was handing out brains, you thought he said stains and said, no thanks. That's a thing. That's a third grade thing. That's a Christian disc. No, that's a, what's the name of my elementary school? Spring Mills Elementary Diss on third grade. When God was handing out brains, you thought he said stains and said, no thanks. Be honest, did you invent that? Did you come up with it? I could barely remember it. Okay, okay, but I never forget something I create. All right, I love you. All right, love you. I love you. All right, love you. All right, love you. I love you. I love you. I love you. I love you. I love you. I love you. I love you. I love you. I love you.