Tools to Reduce & Manage Pain | Dr. Sean Mackey
In this episode, Dr. Sean Mackey, Chief of Pain Medicine at Stanford, explains pain's origins in the nervous system and body, its subjective nature, and how it becomes chronic. He details behavioral, psychological, nutritional, and pharmacological tools to manage and reduce pain.
Deep Dive Analysis
21 Topic Outline
Defining Pain: Sensory, Emotional, and Individual Experience
Nociception vs. Pain: Body Signals to Brain Perception
Understanding NSAIDs and Analgesics for Pain Relief
Gate Control Theory and Mechanical Pain Modulation
Defining Pain Thresholds and Influencing Factors
Therapeutic Use of Heat and Cold for Pain Relief
Psychological Approaches: Distraction, Mindfulness, and Cognitive Reframing
Differentiating 'Hurt' from 'Harm' in Pain Management
The Role of Nutrition and Food Triggers in Pain
Understanding Visceral Pain and Viscerosomatic Convergence
Neuropathic Pain and the Impact of Chronic Stress
Romantic Love as an Analgesic and its Neural Basis
Endogenous and Exogenous Opioids: Mechanisms and Clinical Use
The Opioid Crisis: Causes, Physician Roles, and Fentanyl's Impact
Kratom: Properties, Risks, and Research Needs
Cannabis and CBD for Pain: Efficacy and Regulatory Challenges
Pain Management Therapies: Acupuncture and Chiropractic
The Essential Role of Physical Therapy and Pacing for Chronic Pain
Effective Nutraceuticals and Supplements for Pain Management
Advanced Psychological Therapies for Pain Management
The National Pain Strategy and Future of Pain Medicine
10 Key Concepts
Pain
Pain is a complex, subjective experience that is both sensory and emotional, serving a crucial role in protecting us from injury. It is highly individual and distinct from mere nociception, the transmission of electrochemical impulses.
Nociceptors
These are sensory elements located in the skin, soft tissues, and deep tissues that detect various stimuli like temperature, pressure, and pH changes caused by inflammation. They transmit signals to the spinal cord and brain, initiating the process of nociception.
Nociception
Nociception refers to the electrical and electrochemical impulses transmitted from nociceptors in the body to the spinal cord and brain. It is the physiological signaling of potential harm, distinct from the subjective, conscious experience of pain itself, which is generated in the brain.
Gate Control Theory
Proposed by Melzack and Wall, this theory explains how non-painful input (like touch or rubbing, activating A-beta fibers) can 'close the gates' to painful input in the spinal cord. This modulation reduces the perception of pain by interfering with nociceptive signals before they reach the brain.
Conditioned Pain Modulation (CPM)
Also known as Diffuse Noxious Inhibitory Control (DNIC), this is a phenomenon where a painful stimulus applied to one part of the body can reduce pain perception in a different, often distant, area. It engages brainstem circuits that send descending inhibitory pathways to the spinal cord.
Pain Threshold
The pain threshold is defined as the minimum stimulus intensity required for a person to first perceive the sensation of pain. It is influenced by individual factors like genetics, anxiety, beliefs, and past experiences, and can vary between individuals and even within the same person over time.
Catastrophizing
Catastrophizing is a maladaptive thought process characterized by rumination, magnification, and feelings of helplessness regarding pain. It is a significant predictor and amplifier of pain, worsening its perception and leading to poorer treatment responses.
Viscerosomatic Convergence
This phenomenon occurs when nerve fibers from internal organs (viscera) converge and make indirect connections with somatic nerve fibers in the spinal cord at the same level. This convergence can lead to 'referred pain,' where pain originating in an organ is perceived in a distant body region, such as arm pain during a heart attack.
Neuropathic Pain
Neuropathic pain is a type of pain caused by damage or injury to the peripheral nerves or the central nervous system itself, rather than from nociceptor activation. It is often described with distinct qualities such as shooting, stabbing, shock-like, or burning sensations.
Pacing (for chronic pain)
Pacing is a critical strategy for managing chronic pain that involves setting small, achievable activity goals and consistently adhering to them. It aims to break the 'boom-bust' cycle of overactivity followed by withdrawal, helping individuals gradually increase function without exacerbating pain.
12 Questions Answered
Pain is a complex, subjective experience that is both sensory and emotional, serving a crucial role in protecting us from injury, and is distinct from the mere transmission of electrochemical impulses (nociception).
Pain is clearly in the brain; while sensory signals (nociception) originate in the body, the subjective experience of pain is created and shaped by the brain, integrating emotions, cognitions, and memories.
NSAIDs (e.g., ibuprofen, naproxen) are primarily anti-inflammatory and anti-hyperalgesic, reducing sensitization in the periphery and spinal cord, while acetaminophen (Tylenol) tends to be more centrally acting in the brain.
Yes, rubbing or shaking an injured area activates touch fibers (A-beta fibers) that modulate nociceptive signals in the spinal cord, reducing the perception of pain through a mechanism known as the Gate Control Theory.
Yes, pain thresholds can be changed over time through cognitive control, such as cognitive training, and through regular movement and exercise, which may build up increased inhibitory tone in the nervous system.
Psychological factors significantly shape the experience of pain; increased anxiety, anger (especially 'anger in'), and negative beliefs about pain (catastrophizing) can amplify pain perception and worsen outcomes.
Understanding the distinction between 'hurt' (a sensation of pain) and 'harm' (actual tissue damage or worsening injury) is critical for pain management, as it helps individuals determine when to seek medical attention versus when to continue activity despite discomfort.
Yes, nutrition plays a critical role, with anti-inflammatory diets and the avoidance of specific food triggers (which can be highly individualized, sometimes due to gut infections) potentially leading to significant reductions in pain.
Romantic love can act as a powerful analgesic, significantly reducing pain perception by engaging specific reward-based brain circuits (like the nucleus accumbens and amygdala) and descending pain inhibitory pathways, distinct from attentional distraction.
Endogenous opioids are natural substances like enkephalins and endorphins that our bodies produce, acting as natural painkillers (analgesics) and playing a crucial role in modulating our emotional reactivity and ability to cope with pain.
In controlled laboratory settings, cannabis has shown to reduce neuropathic pain, but its effectiveness in broader populations is less clear due to variability in THC/CBD ratios, dosage, and quality, compounded by regulatory barriers to research.
Finding reliable practitioners often relies on referrals and word-of-mouth recommendations from trusted sources, as online patient ratings can be manipulated, and for complex pain, tertiary referral centers offering comprehensive services are often best.
30 Actionable Insights
1. Distinguish “Hurt” from “Harm”
Understand the critical distinction between ‘hurt’ (a painful sensation) and ‘harm’ (actual tissue damage or worsening injury) to reduce fear and anxiety, and to guide appropriate activity levels.
2. Practice Pacing for Chronic Pain
For chronic pain, set small, incremental activity goals (e.g., adding 50 feet to a walk daily) and adhere to them consistently, even on good days, to avoid overexertion and subsequent setbacks. This prevents a ‘roller coaster’ of activity and inactivity, which can lead to fear of movement and increased disability.
3. Utilize Pain Psychology Techniques
Engage in psychological and behavioral therapies like Cognitive Behavioral Therapy (CBT), Mindfulness-Based Stress Reduction (MBSR), or Acceptance and Commitment Therapy (ACT) to learn skills for managing pain. These therapies teach how to recognize and interrupt unhelpful thought patterns, set goals, pace activities, and use relaxation techniques (e.g., deep breathing, biofeedback) to calm the sympathetic nervous system.
4. Engage Physical/Occupational Therapy
For chronic pain, work with physical and occupational therapists, especially those trained in chronic pain, to improve physical functioning and quality of life. They can help distinguish hurt from harm, set safe activity levels, correct biomechanical issues, and improve endurance and strength.
5. Identify and Avoid Food Triggers
If experiencing chronic pain, particularly gut pain, systematically identify and avoid specific food triggers through careful observation, potentially using an elimination diet and journaling. Certain foods can act as triggers, causing prolonged pain, and avoiding them can significantly improve quality of life.
6. Reframe Pain as “Hurt vs. Harm”
Cognitively reframe the meaning of your pain by actively distinguishing between ‘hurt’ (a temporary sensation) and ‘harm’ (actual injury or damage). This is a critical aspect of pain management and a foundation for cognitive behavioral therapy, helping to reduce fear and anxiety around pain.
7. Use Distraction for Pain Reduction
Engage in distracting activities like reading a book, going for a walk, or spending time with friends and family to shift your focus away from pain. Attentional distraction can significantly reduce pain by engaging specific brain networks.
8. Practice Nonjudgmental Pain Acceptance
Approach pain with a nonjudgmental, accepting mindset, simply noting its presence without assigning positive or negative value to it. Mindfulness-based stress reduction (MBSR) has been shown to be effective for pain, including low back pain.
9. Determine Pain Treatment Threshold
Consider treating pain when it significantly impacts your quality of life, ability to perform daily activities, or engage with family, friends, and work. This impact serves as a reasonable threshold for deciding whether to take medication or seek other interventions.
10. Apply Heat or Cold for Pain Relief
Use either heat or cold therapy for pain relief, based on individual preference and what works best, aiming to numb the area with cold for temporary relief. Avoid prolonged application (e.g., two hours) to prevent frostbite, and note that both can reduce pain (cold reduces inflammation and slows nerve firing; heat increases blood flow and relaxes muscles).
11. Ensure Proper Hydration & Electrolytes
Dissolve one packet of Element (containing sodium, magnesium, potassium) in 16 to 32 ounces of water first thing in the morning and during physical exercise. Proper hydration and adequate electrolytes are critical for optimal brain and body function, as even slight dehydration diminishes cognitive and physical performance.
12. Take NSAIDs with Food and Fluids
When taking NSAIDs like ibuprofen (typically no more than 3x/day) or naproxen (typically no more than 2x/day), always ensure you have food in your stomach and drink plenty of fluids. This helps mitigate side effects and adverse consequences; consult a clinician if you have GI, bleeding, kidney, or heart issues.
13. Use Tylenol Safely for Pain Relief
If using Tylenol (acetaminophen), do not exceed 4,000 milligrams (4 grams) per day in divided doses, and be mindful of liver function, especially if consuming alcohol. Tylenol is safer on the stomach than NSAIDs but can have adverse effects on the liver if the daily dose limit is exceeded.
14. Find Effective NSAIDs Through Rotation
If using NSAIDs like ibuprofen or naproxen, experiment by rotating them to discover which one is most effective for your individual pain. There is significant individual variability in how people respond to different NSAIDs.
15. Use Touch/Movement for Acute Pain Relief
For acute pain, rub or shake the affected area, or run it under water (hot or cold) to activate touch fibers and modulate pain signals in the spinal cord. This ’neuromodulation’ reduces nociceptive signals and provides effective pain relief.
16. Swearing Can Reduce Pain
When experiencing acute pain, swearing can be an effective, albeit socially contextual, method to reduce the pain sensation. Studies have shown that swearing works to reduce pain.
17. Exercise to Increase Pain Threshold
Incorporate regular movement and exercise into your routine. Exercise can change pain thresholds over time by building up increased inhibitory tone in the nervous system.
18. Raise Pain Thresholds Through Cognitive Training
Engage in cognitive control and training to potentially change your pain thresholds over time. Pain thresholds are influenced by cognitive factors and can be manipulated through training.
19. Model Calm Responses to Pain
When others, especially children, experience pain, respond with lightheartedness or humor rather than fear or distress. Individuals often take cues from those around them, and a calm, positive response can influence their perception of pain.
20. Treat All Pain Equally
When addressing pain in yourself or others, avoid distinguishing between ‘psychological’ and ‘physical’ pain, and instead treat all pain as valid and requiring attention. Distinguishing between types of pain can lead to unhelpful value judgments and does not serve the person experiencing pain.
21. Avoid Pain Catastrophizing
Recognize and actively avoid catastrophizing about pain, which involves exaggerating the threat or negative consequences of pain. Catastrophizing is a significant predictor of pain amplification, worsening pain, and poor treatment response.
22. Use Opioids Judiciously
Understand that opioids are a tool for pain management, best used in specific circumstances for some individuals, typically after other therapies have failed, and not as a first-line treatment. This approach acknowledges their potential for both benefit and harm, emphasizing individualized, later-stage use for severe, intractable pain.
23. Consider Acetyl-L-Carnitine for Neuropathic Pain
For neuropathic pain, consider supplementing with acetyl-L-carnitine at higher oral doses, typically 2,000-3,000 grams. It has shown disease-modifying properties by improving mitochondrial health and nerve conduction velocity, particularly in diabetic neuropathy.
24. Consider Alpha-Lipoic Acid for Neuropathic Pain
For neuropathic pain, consider supplementing with alpha-lipoic acid. It acts as a free radical scavenger and a T-type calcium channel modulator, which can benefit nerve pain, though it can cause stomach upset and may affect heart rate during high-intensity exercise.
25. Use Vitamin C for Nerve Pain Prevention
If undergoing nerve-related surgery, consider taking vitamin C prophylactically. Vitamin C has been found to reduce the likelihood of developing certain nerve pain conditions post-surgery.
26. Supplement with Omega-3s for Chronic Pain
Consider supplementing with fish oil (omega-3s), as they have been found to be beneficial for chronic pain. Be aware that high levels may reduce blood viscosity.
27. Consider Creatine for Fibromyalgia
For fibromyalgia and similar conditions, consider supplementing with creatine. Small pilot studies have shown some benefit for these conditions.
28. Explore Empowered Relief for Pain Management
Consider exploring ‘Empowered Relief,’ a brief two-hour intervention developed by Dr. Beth Darnell, as an additional tool for pain management. It offers an abbreviated way to access principles of cognitive behavioral therapy.
29. Utilize Meditation & NSDR
Practice yoga nidra or non-sleep deep rest (NSDR) sessions, even short 10-minute ones, using an app like Waking Up. Yoga nidra and NSDR can greatly restore levels of cognitive and physical energy.
30. Advocate for National Pain Strategy
Contact your congressperson and congresswoman by phone or letter to advocate for the full implementation of the National Pain Strategy. Legislative action driven by concerned citizens can lead to significant improvements in pain care, education, and public communication.
7 Key Quotes
What goes on out here, what goes on in your shoulder, in your neck, is not pain. That's nociception. Those are electrical signals, electrochemical impulses being transmitted. And that is to be distinguished from what becomes the subjective experience of pain that you have.
Dr. Sean Mackey
Pain is this complex and subjective experience that serves a crucial role for all of us to keep us away from injury or harm. It is both a sensory and an emotional experience, and I think that gets lost on people that includes this emotional component to it.
Dr. Sean Mackey
Swearing reduces pain.
Dr. Sean Mackey
Pain inhibits pain.
Dr. Sean Mackey
One of the key messages, the key, you know, Mackey's tips for pain management is to understand the distinction between hurt versus harm.
Dr. Sean Mackey
I am not pro-opioid. I am not anti-opioid. I am pro-patient.
Dr. Sean Mackey
The opioid crisis is being driven by the illicit fentanyls.
Dr. Sean Mackey
2 Protocols
Pacing for Chronic Pain
Dr. Sean Mackey- Set small, achievable activity goals, such as walking comfortably for one block.
- Gradually increase activity in small, consistent increments (e.g., add 50 feet each day), avoiding sudden large increases.
- On 'good days,' adhere strictly to the set activity threshold and do not exceed it to prevent overexertion and subsequent pain flare-ups.
- On 'bad days,' allow for necessary rest, but aim to resume activity at the established threshold the following day.
- Maintain consistency in activity levels to train the body and brain for long-term functional improvement, rather than short-term gains followed by setbacks.
Elimination Diet for Identifying Food Triggers
Dr. Sean Mackey- Restrict the diet to a very limited number of basic, non-triggering foods (e.g., 8-10 items) for a period to observe if pain symptoms improve or disappear.
- Ensure that the restricted diet still provides adequate calories and essential macronutrients (protein, fats, carbohydrates).
- Keep a detailed food and symptom journal to track all food intake and corresponding pain responses, noting any delayed reactions that may occur days after consumption.
- Slowly reintroduce individual foods, one at a time, over a period of days or weeks, while meticulously monitoring for the re-emergence of pain or other symptoms.
- Identify specific food triggers by observing consistent pain responses following reintroduction, and then maintain avoidance of those identified triggers.