January 15, 2024 • 2hr 52min
Dr. Sean Mackey: Tools to Reduce & Manage Pain
Huberman Lab
Key Takeaways
- Pain is a complex subjective experience that serves a crucial protective role but can become problematic when chronic. It involves both sensory and emotional components.
- Pain originates in the brain, not in the body. Nociceptors in the body detect stimuli, but the experience of pain is created by the brain.
- NSAIDs like ibuprofen work by reducing inflammation, not by directly blocking pain signals. They can delay healing in some cases.
- Mechanical interventions like rubbing or shaking an injured area can provide pain relief by activating touch fibers that inhibit pain signals in the spinal cord.
- Pain thresholds vary between individuals and are influenced by factors like genetics, past experiences, and current mental state. On average, men have slightly higher pain thresholds than women.
- Psychological factors strongly influence pain perception. Techniques like cognitive behavioral therapy, mindfulness, and biofeedback can be very effective for managing chronic pain.
- Opioids can be effective for pain relief but carry significant risks. They should not be a first-line treatment and require careful consideration.
- Complementary approaches like acupuncture may provide benefits for some patients, though the mechanisms are not fully understood.
- Physical therapy and gradual increases in activity are crucial for managing chronic pain and preventing further disability.
- Some supplements like acetyl-L-carnitine and alpha lipoic acid show promise for treating neuropathic pain.
Introduction
In this episode, Dr. Andrew Huberman interviews Dr. Sean Mackey, Chief of the Division of Pain Medicine and Professor at Stanford University School of Medicine. They discuss the complex nature of pain, its origins in the brain and body, various treatment approaches, and the latest research on managing acute and chronic pain.
Dr. Mackey provides insights from his extensive clinical and research experience, covering topics ranging from basic pain mechanisms to cutting-edge therapies. The conversation explores both conventional medical treatments and complementary approaches, emphasizing the importance of individualized, multidisciplinary care for pain management.
Topics Discussed
What is Pain? (5:15)
Dr. Mackey defines pain as a complex and subjective experience that serves a crucial protective role. He emphasizes that pain is both a sensory and emotional experience, varying greatly between individuals. Key points include:
- Pain affects about 100 million Americans and costs around $500 billion annually in medical expenses
- Pain is subjective and unique to each individual
- The experience of pain involves both physical sensations and emotional components
Pain Mechanisms and the Brain (7:36)
Dr. Mackey explains the physiological mechanisms of pain, emphasizing that the experience of pain originates in the brain, not in the body:
- Nociceptors in the body detect stimuli like temperature, pressure, and chemical changes
- Signals travel via nerve fibers to the spinal cord and then to the brain
- The brain interprets these signals and creates the subjective experience of pain
- There is no single "pain center" in the brain; pain involves a distributed network of brain regions
Pain Medications: NSAIDs and Analgesics (15:15)
The discussion covers common pain medications and their mechanisms of action:
- NSAIDs (e.g. ibuprofen, naproxen) work by reducing inflammation, not directly blocking pain
- Acetaminophen (Tylenol) acts more centrally in the brain
- NSAIDs can potentially delay healing in some cases
- Dr. Mackey advises: "If taking an NSAID helps you sleep and helps you engage with what you need to do, take it at the lowest dose that you can get away with."
Mechanical Interventions for Pain (31:54)
Dr. Mackey discusses non-pharmacological approaches to pain relief:
- Rubbing or shaking an injured area activates touch fibers that can inhibit pain signals in the spinal cord
- This is an example of the "gate control theory of pain"
- TENS (transcutaneous electrical nerve stimulation) devices work on a similar principle
Pain Thresholds and Individual Differences (37:04)
The conversation explores factors influencing pain perception:
- Pain threshold is the point at which a stimulus becomes painful
- On average, men have slightly higher pain thresholds than women, but individual variation is significant
- Factors like anxiety, past experiences, and expectations influence pain perception
- Dr. Mackey emphasizes: "People are not averages... The individual variability within men and within women is much greater than the difference between men and women."
Heat, Cold, and Pain Management (51:15)
Dr. Mackey discusses the use of temperature interventions for pain:
- Cold is typically recommended for the first 48 hours after an acute injury to reduce inflammation
- Heat can increase blood flow and help relax muscles
- Individual preferences for heat or cold vary widely
- Caution is needed to avoid tissue damage from extreme temperatures
Psychological Approaches to Pain Management (1:00:13)
The discussion covers various psychological interventions for pain:
- Cognitive behavioral therapy (CBT) can help reframe thoughts about pain
- Mindfulness-based stress reduction (MBSR) teaches non-judgmental awareness of pain
- Biofeedback can help patients learn to control physiological responses
- Dr. Mackey notes: "Different psychological approaches engage different brain circuits to reduce pain."
Opioids and Pain Management (1:46:43)
The conversation addresses the controversial topic of opioid use for pain:
- Opioids can be effective for pain relief but carry significant risks of addiction and side effects
- They should not be used as a first-line treatment for most chronic pain conditions
- The current opioid crisis is largely driven by illicit fentanyl, not prescription opioids
- Dr. Mackey's stance: "I am not pro-opioid, I am not anti-opioid, I am pro-patient."
Complementary Approaches: Acupuncture and Chiropractic (2:17:48)
Dr. Mackey discusses evidence for complementary pain treatments:
- Acupuncture may provide benefits for some patients, though mechanisms are not fully understood
- Chiropractic care shows mixed results in studies, with some evidence of benefit for low back pain
- Caution is advised with high-velocity neck manipulations due to rare but serious risks
Physical Therapy and Activity for Chronic Pain (2:29:27)
The importance of movement and rehabilitation is emphasized:
- Physical therapy is crucial for improving function and quality of life in chronic pain
- Gradual increases in activity through "pacing" can help break cycles of pain and inactivity
- Dr. Mackey explains: "You're training for a marathon, you're training for the long win."
Supplements for Pain Management (2:34:28)
Dr. Mackey discusses evidence for various supplements in pain treatment:
- Acetyl-L-carnitine may have disease-modifying properties for diabetic neuropathy
- Alpha lipoic acid can benefit some types of neuropathic pain
- Omega-3 fatty acids may have anti-inflammatory effects
- Creatine shows promise in small studies for conditions like fibromyalgia
Conclusion
Dr. Mackey emphasizes the need for a multidisciplinary, individualized approach to pain management. He advocates for implementation of the National Pain Strategy to improve pain care across the United States. Key takeaways include:
- Pain is a complex experience involving both physical and psychological factors
- A combination of medical, psychological, and lifestyle interventions is often most effective
- Patients should work with healthcare providers to find the most appropriate treatments for their specific situation
- Continued research and education are needed to advance pain care and reduce the burden of chronic pain
The conversation highlights the complexity of pain and the importance of considering multiple approaches to achieve optimal pain management and improved quality of life for those suffering from acute or chronic pain conditions.
