WEBVTT - The Future of Pain 0:00:00.160 --> 0:00:07.160 Brought to you by Toyota. Let's go places. Welcome to 0:00:07.360 --> 0:00:15.520 Forward Thinking. Hey, and welcome to Forward Thinking, the podcast 0:00:15.560 --> 0:00:17.560 that looks at the future and says, I guess I'm 0:00:17.560 --> 0:00:20.880 always hoping that you'll end this rain. I'm Joe McCormick 0:00:21.000 --> 0:00:24.880 and I'm Lauren Bob and our regular host Jonathan Strickland 0:00:24.960 --> 0:00:26.759 is not with us today. He's I think it a 0:00:26.840 --> 0:00:31.000 castle in Wales playing quidditch or something something to that extent. Yes, 0:00:31.240 --> 0:00:35.560 uh so, you know, go Thunderbucks. And in his absence, 0:00:35.600 --> 0:00:39.519 we are going to to talk about a kind of 0:00:39.560 --> 0:00:43.280 a kind of upsetting subject today. It's great, but it's universal. 0:00:43.520 --> 0:00:47.760 It is. We're talking about pain. Yeah, the future of 0:00:47.760 --> 0:00:51.480 pain and of pain management, of counter pain, you might say, yes, 0:00:51.720 --> 0:00:54.000 more of an emphasis I think on on you know, 0:00:54.040 --> 0:00:56.920 trying to prevent pain. We're not just talking about the 0:00:56.920 --> 0:01:00.960 future of causing causing pain, right because Okay, there's been 0:01:00.960 --> 0:01:04.240 a lot of sad news lately about the increasing rates 0:01:04.240 --> 0:01:08.280 of pain medication over use or abuse and the tragic 0:01:08.360 --> 0:01:11.120 consequences thereof. Yeah, I think a lot of this came 0:01:11.240 --> 0:01:14.440 in the wake of Prince's death recently, which I know 0:01:14.560 --> 0:01:17.280 has been linked in the media to uh to use 0:01:17.319 --> 0:01:20.640 of an opioid drug to treat chronic pain. I believe, yeah, 0:01:20.840 --> 0:01:22.920 I think. I think his official cause of death has 0:01:22.959 --> 0:01:26.679 been listed as an accidental overdose of fentanyl, which is 0:01:26.800 --> 0:01:31.560 this opioid pain relief drug. But but I mean Prince aside, 0:01:31.560 --> 0:01:35.280 and that was certainly tragic. We all miss Prince um. 0:01:35.400 --> 0:01:38.440 But the problem is is very widespread and very serious. 0:01:38.800 --> 0:01:41.120 Some some numbers for you guys. According to the CDC, 0:01:41.520 --> 0:01:46.080 in the United States alone, in over fourteen thousand people 0:01:46.200 --> 0:01:50.960 died from overdoses involving prescription opioids UM. A national survey 0:01:51.000 --> 0:01:53.640 that same year reported that almost two million Americans were 0:01:53.680 --> 0:01:57.960 abusing or physically dependent on prescription opioids, and a thousand 0:01:58.000 --> 0:02:00.720 people go to the emergency room in this country every 0:02:00.800 --> 0:02:06.680 day for misusing prescription opioid drugs. Opioid. I'm sorry, that's 0:02:06.680 --> 0:02:08.799 a funny sounding word to say it is, Isn't it 0:02:09.520 --> 0:02:12.080 like a like the name of a pet, walrus or something. 0:02:12.400 --> 0:02:15.720 It sounds like fiords. It's got that eel in it. 0:02:15.720 --> 0:02:18.800 It reminds me of the of the nerd from Dominoes. 0:02:18.880 --> 0:02:22.360 For some reason, I'm not sure why the nerd the 0:02:22.440 --> 0:02:27.680 noid anyway, at any rate. Yeah, of course, opioids are 0:02:27.760 --> 0:02:30.639 are a class of drugs. They contain drugs like morphine 0:02:30.720 --> 0:02:34.640 and all those opium derived drugs. We'll get into more 0:02:34.639 --> 0:02:37.320 of the specifical thing, Yeah, more of the specifics of 0:02:37.360 --> 0:02:40.440 that lately. But yeah, this is obviously a huge problem. 0:02:40.520 --> 0:02:43.800 But it's not just a problem that people are overdosing 0:02:43.800 --> 0:02:46.040 on these drugs. I mean, pain is a big enough 0:02:46.080 --> 0:02:52.120 problem on its own to merit some sort of intense solutions. Oh. Absolutely, 0:02:52.400 --> 0:02:55.200 And we're not trying to put out a DARE episode here, 0:02:55.200 --> 0:02:56.239 I don't. I don't know if you were in the 0:02:56.320 --> 0:02:59.080 DARE program when you were in high school. The the 0:02:59.200 --> 0:03:04.720 drugs are are rotten, all y'all. I that's not an acronym, 0:03:04.720 --> 0:03:06.720 but they're rotten, so you should get some fresh ones. 0:03:08.040 --> 0:03:12.320 They've gone off. I'm mostly impressed that I just tried 0:03:12.360 --> 0:03:15.519 to make the E and DARE stand for all y'all um. 0:03:15.680 --> 0:03:18.639 But yeah, we're not. It's right, it's not just a 0:03:18.720 --> 0:03:20.920 drugs are bad problem. And and furthermore, it's not just 0:03:21.080 --> 0:03:24.000 kids that are abusing these drugs. It's a range of 0:03:24.080 --> 0:03:27.679 ages of humans who are doing it. Um. And and 0:03:27.919 --> 0:03:30.600 the problem, of course is that medical science has not 0:03:30.760 --> 0:03:35.320 figured out how to solve pain yet. Yeah. Pain, surprisingly, 0:03:35.400 --> 0:03:37.520 despite the fact that we do know some things about it, 0:03:37.520 --> 0:03:41.040 it is in many ways an open problem in medical science. 0:03:41.080 --> 0:03:43.960 We have some ways of treating it. Obviously, the best 0:03:44.000 --> 0:03:46.120 thing to do to address pain is to go in 0:03:46.200 --> 0:03:49.040 and fix the problem that's causing pain to begin with. 0:03:49.120 --> 0:03:52.360 But then there are lots of issues that will talk about, 0:03:52.560 --> 0:03:55.760 such as chronic pain, where in many cases you've sort 0:03:55.800 --> 0:03:59.040 of lost track of what the original causes and now 0:03:59.120 --> 0:04:03.720 you're just having the subjective experiential problem of distress and 0:04:03.720 --> 0:04:07.320 and unpleasant feelings. Uh and and what can you do 0:04:07.360 --> 0:04:10.440 but treat the feelings themselves at that point? But yeah, 0:04:10.440 --> 0:04:12.480 so pain is a pain is a big problem. Pain 0:04:12.560 --> 0:04:14.400 is a big problem all over the world, in the 0:04:14.480 --> 0:04:18.719 United States alone. In a report in the Journal of Pain, 0:04:20.040 --> 0:04:25.080 good journal name tried to calculate pain, but it tried 0:04:25.080 --> 0:04:28.359 to calculate the cost of chronic pain in the United States. 0:04:28.400 --> 0:04:32.119 And chronic pain has costs, of course, not only because 0:04:32.160 --> 0:04:34.720 you have to pay for the treatment. The drugs cost money, 0:04:34.760 --> 0:04:39.200 the doctor visits cost money, but because it complicates treatments 0:04:39.240 --> 0:04:42.080 for other medical conditions. Say, for example, if if you've 0:04:42.080 --> 0:04:46.560 got chronic pain, Your your your outlook for a different 0:04:46.640 --> 0:04:48.920 kind of condition might be different because you've already got 0:04:48.920 --> 0:04:50.480 this other problem to deal with. You might not be 0:04:50.560 --> 0:04:54.000 able to take the drugs or get the surgeries or 0:04:54.040 --> 0:04:56.719 something like that. Uh two that you would need to 0:04:56.760 --> 0:05:00.200 deal with this other condition. And also because workers tend 0:05:00.240 --> 0:05:03.479 to lose productivity as they experience pain, the more you hurt, 0:05:03.640 --> 0:05:06.160 the less you have to offer. Often. I mean not 0:05:06.240 --> 0:05:08.880 to say you're any worth any less as a person, 0:05:08.920 --> 0:05:11.599 but sure, but it's just different cuts into your ability 0:05:11.640 --> 0:05:14.880 to do things. Yeah, yeah, absolutely So they in this 0:05:15.160 --> 0:05:18.839 study estimated that every year chronic pain costs the United 0:05:18.920 --> 0:05:21.599 States between five hundred and sixty and six hundred and 0:05:21.640 --> 0:05:26.000 thirty five billion dollars, which is actually more than the 0:05:26.120 --> 0:05:31.160 estimated annual costs of cancer, diabetes, or heart disease. So, 0:05:31.520 --> 0:05:33.200 I mean, it's pretty much a no brainer that we 0:05:33.240 --> 0:05:37.159 should be focusing our efforts on finding ways to solve 0:05:37.240 --> 0:05:41.200 the problem of pain. But that's a lot easier said 0:05:41.240 --> 0:05:44.599 than done. Sure, but coming down to the to the 0:05:44.600 --> 0:05:49.360 basic factor that we we don't have a complete concept 0:05:49.480 --> 0:05:53.360 of what pain is. Yeah, it's kind of hard to 0:05:53.400 --> 0:05:56.960 get underneath pain and define it. Isn't it like it's 0:05:57.000 --> 0:06:00.240 such a basic subjective feeling. Pain almost seems like the 0:06:00.600 --> 0:06:03.279 thing by which you describe other things is not a 0:06:03.360 --> 0:06:05.800 thing that you describe unto itself. Because it's one of 0:06:05.839 --> 0:06:11.320 those baseline experiences of being a human being that it's 0:06:11.360 --> 0:06:13.480 just hard to put your put your mind around it. 0:06:14.080 --> 0:06:17.359 But to give a basic definition, a task force for 0:06:17.400 --> 0:06:21.080 the International Association for the Study of Pain did try 0:06:21.080 --> 0:06:24.200 to give a pretty universal medical definition of pain, and 0:06:24.200 --> 0:06:26.600 it's the one I've seen sided most often, and it 0:06:26.640 --> 0:06:31.480 goes like this quote, pain is an unpleasant, sensory and 0:06:31.760 --> 0:06:36.839 emotional experience that is associated with actual or potential tissue 0:06:36.920 --> 0:06:41.480 damage or described in such terms. Uh So, that's basically 0:06:41.480 --> 0:06:46.760 just saying like pain hurts and is upsetting. Yeah, and 0:06:46.880 --> 0:06:49.479 that emotional part, the upsetting nous is crucial, and I 0:06:49.480 --> 0:06:51.440 want to talk about that more towards the end of 0:06:51.480 --> 0:06:55.360 the episode. But in addition to this really basic definition, 0:06:55.680 --> 0:06:59.400 usually doctors and medical professionals are going to divide pain 0:06:59.440 --> 0:07:04.400 into two, uh basic, very different types, which are acute 0:07:04.480 --> 0:07:08.120 pain and chronic pain. Right, so let's let's start with acute. Yeah, 0:07:08.160 --> 0:07:11.280 Acute pain is the kind of pain that everybody is 0:07:11.280 --> 0:07:16.000 familiar with. It's a temporary result of disease, injury, or inflammation, 0:07:16.120 --> 0:07:18.880 and it's good. It warns you that something is wrong, 0:07:19.320 --> 0:07:21.880 and for this reason it is quite useful, especially in 0:07:21.920 --> 0:07:25.560 today's medicine. So in an evolutionary sense, acute pain is 0:07:25.640 --> 0:07:27.920 useful even you know, if you can't get to a doctor. 0:07:27.920 --> 0:07:31.600 It's useful even in the wild, because you might, for example, 0:07:31.680 --> 0:07:34.960 stop putting weight on that injured leg of yours because 0:07:35.000 --> 0:07:38.080 it hurts when you do, and that gives that leg 0:07:38.240 --> 0:07:41.680 time and ability to heal. Without you continuously putting stress 0:07:41.720 --> 0:07:44.320 on it is just going to make the problem worse. Sure, 0:07:44.440 --> 0:07:46.960 Or if you touch a hot surface, yeah, you remove 0:07:47.000 --> 0:07:51.080 your body apart from it immediately because it hurts, preventing 0:07:51.200 --> 0:07:54.400 further injury, as opposed to just leaning on I don't 0:07:54.400 --> 0:07:57.640 know what's that hot surface. Our our caveman versions of 0:07:57.640 --> 0:08:03.239 ourselves are encountering really hot rocks. I mean fire is bad, 0:08:04.440 --> 0:08:08.080 so yeah, pretty but bad. To stop getting struck by lightning, 0:08:11.000 --> 0:08:13.680 that's the fourth time this week, exactly, I gotta stop 0:08:13.720 --> 0:08:18.200 climbing up this tree. Uh but yeah, So in fact, 0:08:18.280 --> 0:08:21.920 they're there're certain recognized conditions that prevent people from feeling pain, 0:08:22.000 --> 0:08:24.440 and that's not a good thing. Obviously, that sounds great 0:08:24.440 --> 0:08:27.640 because we don't like pain. But you need your pain. 0:08:27.960 --> 0:08:31.680 You need this. It's very important to very useful trait. Exactly, 0:08:31.800 --> 0:08:34.400 people who are born without the ability to feel pain 0:08:34.440 --> 0:08:38.640 have what's known as congenital analgesia, and it is very dangerous. 0:08:38.640 --> 0:08:42.920 People can suffer injuries or illnesses without being aware of them. Uh, 0:08:43.160 --> 0:08:46.720 and then those illness, illnesses, injuries, whatever, the bad state 0:08:46.800 --> 0:08:51.240 can progress without treatment and lead to disability or even death. 0:08:51.280 --> 0:08:55.679 And if you have congenital insensitivity to pain, you have 0:08:55.760 --> 0:08:57.640 to be on the lookout all the time. You have 0:08:57.679 --> 0:09:00.439 to be extremely vigilant of what's going on with your 0:09:00.480 --> 0:09:03.120 body because you're it's not going to let you know 0:09:03.280 --> 0:09:06.240 when something is wrong. You have to basically scope. You 0:09:06.240 --> 0:09:08.520 have to observe it right right, You're not a leg 0:09:08.600 --> 0:09:10.760 is bent sideways and you're not going to feel that 0:09:10.840 --> 0:09:14.440 splinter in your foot. You're you have to find it. 0:09:14.559 --> 0:09:17.439 You have to notice it in other ways. So acute 0:09:17.440 --> 0:09:21.440 pain is good and useful, but of course it's not useful. Say, well, 0:09:21.600 --> 0:09:23.640 you know, once you're already aware of the disease, if 0:09:23.640 --> 0:09:26.240 you've got a broken bone or something, you probably will 0:09:26.280 --> 0:09:28.480 need some pain killers to deal with that, and we 0:09:28.559 --> 0:09:31.480 have pretty good remedies for that, right. Yeah, Acute pain 0:09:31.720 --> 0:09:34.920 is a category of pain that we're we're usually pretty 0:09:34.920 --> 0:09:37.400 good at treating these days. You know, like if you've 0:09:37.440 --> 0:09:40.679 got sinus pain due to inflammation because of an infection, 0:09:41.000 --> 0:09:43.160 you could be able to treat the infection, uh, and 0:09:43.200 --> 0:09:46.199 you can definitely take an anti inflammatory to treat the 0:09:46.559 --> 0:09:49.440 cause of that pain. If you've got a knee injury, 0:09:49.480 --> 0:09:52.240 you can help the leg return to normal function faster, 0:09:52.640 --> 0:09:56.040 again treating the cause using you know, a brace or 0:09:56.040 --> 0:09:59.760 physical therapy or again anti inflammatories. And you might also 0:10:00.320 --> 0:10:03.480 you might also be prescribed like muscle relaxers or electrical 0:10:03.480 --> 0:10:07.800 stimulation to lessen the pain while the knee heals. All 0:10:07.800 --> 0:10:11.200 of these are are you know, wonderful modern treatments and 0:10:11.200 --> 0:10:14.360 and has offer all of that. Um uh. But but 0:10:14.440 --> 0:10:16.680 the other type of pain, chronic pain, is a little 0:10:16.720 --> 0:10:20.960 bit more troublesome. Yeah, this is where things get really hairy. 0:10:21.160 --> 0:10:25.040 So long term and for the most part, pointless pain 0:10:25.440 --> 0:10:28.199 is chronic pain. What what does long term mean? Some 0:10:28.280 --> 0:10:31.400 say longer than three months. I've seen longer than six months, 0:10:31.400 --> 0:10:33.160 So I guess we could say longer than three to 0:10:33.280 --> 0:10:37.040 six months might be an approximate general rule. But the 0:10:37.080 --> 0:10:40.760 idea is pain is chronic if it lasts longer than 0:10:40.840 --> 0:10:44.800 the healing time for the problem that's causing it. Ah yeah. 0:10:44.840 --> 0:10:46.920 And and these are again, these are the types of 0:10:46.960 --> 0:10:49.360 issues that we're not so great at treating because often 0:10:49.400 --> 0:10:52.440 we don't have fixes for them. They sometimes involve damage 0:10:52.480 --> 0:10:56.200 to the nervous system itself, or or ongoing tissue damage 0:10:56.240 --> 0:10:58.679 due to some kind of bodily system dysfunction that we 0:10:58.720 --> 0:11:03.600 can mitigate but not necessarily cure, as in a cancer, arthritis, 0:11:03.960 --> 0:11:07.160 And so in these cases we're really just treating the symptoms, 0:11:07.200 --> 0:11:10.360 not the cause. Yeah. So let's look at the cause 0:11:10.400 --> 0:11:15.120 of pain. Uh yeah, because we've are amazing modern medical 0:11:15.760 --> 0:11:19.480 concept of it has not been around forever. Yeah, that's true. 0:11:20.040 --> 0:11:24.480 Perhaps unsurprisingly, ancient people often interpreted pain through a magical 0:11:24.600 --> 0:11:27.360 or spiritual lens. Who would have guessed, uh, it was 0:11:27.400 --> 0:11:30.480 an affliction, you know, it's a punishment, something being done 0:11:30.480 --> 0:11:33.600 to you by another worldly agent. Very common to look 0:11:33.640 --> 0:11:36.840 at pain in these terms, and this type of thinking 0:11:36.920 --> 0:11:39.640 is still somewhat reflected in the origins of the English 0:11:39.640 --> 0:11:43.240 word pain actually, which comes originally through the Old French, 0:11:43.280 --> 0:11:47.480 but originally from the Latin poena, meaning punishment or penalty. 0:11:48.280 --> 0:11:50.800 And in the earliest uses of pain in English we 0:11:50.840 --> 0:11:52.880 still see this connotation, like if you go back to 0:11:52.920 --> 0:11:55.559 the thirteenth century, say, to look at how pain is 0:11:55.640 --> 0:11:58.400 used in English, you'll see uses like if you hunt 0:11:58.440 --> 0:12:01.640 in the duke's private forest, it is a crime punishable 0:12:01.960 --> 0:12:04.960 on pain of death, meaning you get the death pen 0:12:05.040 --> 0:12:09.280 punishment of death. Yeah. I had never thought about that before. Yeah, 0:12:09.280 --> 0:12:11.960 pretty creepy, hunh. So when you have a pain in 0:12:12.000 --> 0:12:16.840 your in your eyeball, why did I pick eyeball? That's 0:12:16.840 --> 0:12:19.720 a terrible thing. Do you have a stabbing pain in 0:12:19.760 --> 0:12:23.280 your eyeball? It is a punishment from someone. To be fair, 0:12:23.320 --> 0:12:25.640 if I had a stabbing pain in my eyeball, I 0:12:25.679 --> 0:12:29.040 would pretty much assume that anyway, even with science. But 0:12:30.640 --> 0:12:34.640 how fragile science is. But then, of course that you 0:12:34.679 --> 0:12:37.320 get to the ancient Greek physicians, and they sometimes wrote 0:12:37.360 --> 0:12:39.640 about pain as being a result of some form of 0:12:39.760 --> 0:12:43.560 imbalance or disorder or unnatural state. And this is a 0:12:43.679 --> 0:12:45.959 very Greek way of thinking. I think we're going to 0:12:46.040 --> 0:12:49.439 get into the humors again, aren't we, Yes, Yes, so 0:12:49.600 --> 0:12:52.680 health and pleasure were created by order and harmony, things 0:12:52.720 --> 0:12:56.720 being balanced and in their natural state. Pain and displeasure 0:12:56.720 --> 0:13:00.480 were created by chaos and unnatural corruption, or things being 0:13:00.640 --> 0:13:05.680 imbalanced or out of order. And this general philosophical orientation, 0:13:05.720 --> 0:13:09.600 I think informed their literal understanding of the medical causes 0:13:09.640 --> 0:13:11.839 of pain. So I want to read a quote from 0:13:11.960 --> 0:13:14.800 On the Nature of Man, which is an ancient Greek 0:13:14.840 --> 0:13:18.559 medical treatise in the Hippocratic Cannon, not written by Hippocrates, 0:13:18.600 --> 0:13:23.760 but part of his school of thoughts. So it goes 0:13:23.800 --> 0:13:27.960 like this. The body of man has in itself blood, flim, 0:13:28.280 --> 0:13:31.960 yellow bile, and black bile. These make up the nature 0:13:32.000 --> 0:13:35.080 of the body, and through these he feels pain or 0:13:35.240 --> 0:13:38.800 enjoys health. Now he enjoys the most perfect health when 0:13:38.840 --> 0:13:42.280 these elements are duly proportioned to one another in respect 0:13:42.360 --> 0:13:47.120 to compounding, power and bulk, and when they are perfectly mingled. 0:13:47.640 --> 0:13:50.160 Pain is felt when one of these elements is in 0:13:50.320 --> 0:13:54.160 defect or excess, or is isolated in the body without 0:13:54.200 --> 0:13:57.520 being compounded with all the others. Oh yeah, I hate 0:13:57.520 --> 0:13:59.800 it when my flim gets in my toes and causes 0:13:59.840 --> 0:14:02.160 them to ate exactly, So you've got flam in your 0:14:02.160 --> 0:14:04.440 toes and you don't have any you don't have any 0:14:04.480 --> 0:14:07.439 black bile to balance it out. What are you gonna do? 0:14:07.760 --> 0:14:10.680 My toe is gonna hurt, I guess. So that's that's 0:14:10.679 --> 0:14:18.080 why I've got gout. It's not all those I think 0:14:18.080 --> 0:14:21.240 everyone is eating pastries. I think that's a common Yeah, 0:14:21.040 --> 0:14:25.600 we get Tracy and Holly on the line. What did 0:14:25.600 --> 0:14:31.160 they like, ancient ancient cured fish pastries. I'm sure cured 0:14:31.160 --> 0:14:35.600 fish pastries. I would try cured fish pastry. I'll speculate. 0:14:35.600 --> 0:14:39.040 I'll say that's it. But eventually, of course, medical science 0:14:39.080 --> 0:14:42.640 came to understand beyond the idea of the four humors, 0:14:42.680 --> 0:14:44.680 And part of me thinks that that's only got to 0:14:44.720 --> 0:14:48.520 be a partial explanation, right, because they thought, okay, so 0:14:48.560 --> 0:14:51.080 in some sense pain is caused by an imbalance of humors. 0:14:51.080 --> 0:14:53.280 But surely they didn't think that was what caused pain 0:14:53.320 --> 0:14:57.000 when you cut yourself, right, or maybe maybe because you're 0:14:57.040 --> 0:15:00.280 like losing blood at that point, and so, well about 0:15:00.440 --> 0:15:03.960 what about a pricking feeling that doesn't quite pierce the skin? 0:15:04.320 --> 0:15:06.160 I don't know, I mean that seems a little off, 0:15:06.520 --> 0:15:09.000 like it doesn't fit their model. Not quite. Yeah, I'm 0:15:09.040 --> 0:15:12.360 not sure that they had entirely thought this through, to 0:15:12.440 --> 0:15:15.520 be fair, they were probably busy with other things. Yes, yeah, 0:15:15.600 --> 0:15:18.760 not to insult those of the Hippocratic school of thought, 0:15:18.880 --> 0:15:21.960 but yeah, no, no. If y'all are time travelers and 0:15:22.000 --> 0:15:25.080 listening to this, we respect you, right. But of course, 0:15:25.160 --> 0:15:27.480 like we were saying, eventually medical science did come to 0:15:27.560 --> 0:15:30.040 understand the crucial role of the nervous system in the 0:15:30.080 --> 0:15:33.120 perception of pain. So, in a standard pain response to 0:15:33.360 --> 0:15:36.280 like a damaging stimulus and knife goes into your skin 0:15:36.440 --> 0:15:39.600 or something, sensory neurons throughout the body or in the 0:15:39.840 --> 0:15:43.560 place where you're getting damaged, called no susceptors set off 0:15:43.600 --> 0:15:46.960 a chain reaction that travels through the nervous system via 0:15:47.040 --> 0:15:51.040 electrical impulses, through the spinal cord and eventually up to 0:15:51.080 --> 0:15:53.920 the brain. And the brain is what processes your pain 0:15:54.040 --> 0:15:57.520 and your reaction to it. Now, this is interesting. It's 0:15:57.560 --> 0:16:00.840 not just like you have one pain center in your brain. 0:16:01.240 --> 0:16:04.280 Multiple regions of the brain are involved in reacting to pain, 0:16:04.360 --> 0:16:08.360 illustrating how pain is sort of a complex phenomenon within 0:16:08.400 --> 0:16:10.920 our bodies. Is not just that one sensation, but a 0:16:10.960 --> 0:16:15.360 state of mind. So it involves direct sensory information, you know, 0:16:15.440 --> 0:16:19.200 like Okay, this pain is thermal and it's intense, and 0:16:19.280 --> 0:16:24.200 it's on my left ankle, and then it involves emotions 0:16:24.240 --> 0:16:29.320 like I don't like that, that's bad, motivation, get away quick, 0:16:30.000 --> 0:16:33.560 and cognition like a plan for escaping this torch being 0:16:33.600 --> 0:16:36.520 held to your ankle or whatever whatever it may be. 0:16:36.800 --> 0:16:39.360 To make it a little bit more complicated, because clearly 0:16:39.520 --> 0:16:41.880 we needed that here. A part of the issue and 0:16:41.960 --> 0:16:45.520 no susceptive pain, that this pain that results from injury 0:16:45.560 --> 0:16:50.040 are chemicals that you're damaged, tissue releases called prostaglandins, which 0:16:50.600 --> 0:16:53.520 a help boost the signal to your spinal cord that 0:16:53.600 --> 0:16:58.200 you know something's up, hey, warning stuff is going down. 0:16:58.560 --> 0:17:01.680 Um and and be they help regulate things like your 0:17:01.720 --> 0:17:05.920 your blood flow and you're clotting principles, So they're they're 0:17:05.960 --> 0:17:10.080 what causes inflammation around an injury. And more on that 0:17:10.160 --> 0:17:12.680 in a minute. Um and I also wanted to mention 0:17:12.760 --> 0:17:16.679 here that there's a second type of pain in contrast 0:17:16.760 --> 0:17:22.320 to no susceptive pain, called called clinical pain or neuropathic pain. 0:17:23.080 --> 0:17:25.960 And neuropathic we can probably guess from that word involves 0:17:25.960 --> 0:17:28.200 the nervous system. Yeah, yeah, this is the pain that 0:17:28.240 --> 0:17:31.800 occurs even though there was no negative stimulation to the 0:17:31.800 --> 0:17:35.880 no susceptors. So either your nerves themselves have received damage 0:17:36.200 --> 0:17:40.840 or something has gone wrong in your pain signaling system somewhere. 0:17:40.960 --> 0:17:45.560 It's like getting pain spam. Yeah exactly, It's just word 0:17:45.640 --> 0:17:48.439 salads full of pain spam, and and your brain is 0:17:48.560 --> 0:17:52.320 going like, well, crape, I still have to deal with 0:17:52.320 --> 0:17:54.679 this email, I guess. So, yeah, you don't really have 0:17:54.720 --> 0:17:58.080 a choice, do you. We can. We can route spam 0:17:58.080 --> 0:18:00.800 into a into a junk folder. If only we could 0:18:00.800 --> 0:18:03.560 do that with pain spam. Yeah, oh man, let's call 0:18:03.640 --> 0:18:06.639 let's call some science science dudes. Well, that may be 0:18:06.800 --> 0:18:09.600 part of our part of our solution profile later on. 0:18:10.200 --> 0:18:13.000 So today we do have some comprehension of how pain 0:18:13.040 --> 0:18:15.560 works in the body, but we still don't know everything, right, 0:18:15.840 --> 0:18:18.399 But the more we learn, the better we can treat pain. 0:18:18.880 --> 0:18:21.200 One of the things that we're that we're learning about 0:18:21.400 --> 0:18:25.920 is how chronic pain changes the brain. And doesn't sound good. 0:18:26.040 --> 0:18:29.199 It does. It's not good. That's terrible, um for for 0:18:29.280 --> 0:18:31.960 reasons that we really don't understand very well yet. Chronic 0:18:32.000 --> 0:18:36.520 pain creates changes in the brain's connections and chemistry. Yeah, 0:18:36.520 --> 0:18:39.200 so Most of the stories you hear about the plasticity 0:18:39.240 --> 0:18:41.560 of the adult brain are positive, but this one not 0:18:41.640 --> 0:18:44.760 so much. Not so much. Yeah, it leads to abnormal 0:18:44.800 --> 0:18:48.160 functioning that can increase the sensation of pain and the 0:18:48.280 --> 0:18:52.239 likelihood of emotional conditions like anxiety and depression, which is 0:18:52.359 --> 0:18:56.080 just a horrible, no good feedback loop. And and so 0:18:56.119 --> 0:18:58.320 this is one of the really big things that would 0:18:58.359 --> 0:19:02.280 be super rad to figure out, no doubt. So we 0:19:02.280 --> 0:19:04.840 we certainly have these pain problems. Of course, you've got 0:19:04.840 --> 0:19:08.040 the more manageable acute pain pain problems. You know, you've 0:19:08.040 --> 0:19:10.880 got hurt. It hurts, and you've got to figure out 0:19:10.880 --> 0:19:13.200 a way to deal with that. But that's temporary. We've 0:19:13.240 --> 0:19:15.440 got sort of a handle on that. Then we've got 0:19:15.440 --> 0:19:19.680 these bigger problems chronic pain. Uh, the way chronic pain 0:19:19.840 --> 0:19:22.600 changes the way our nervous system works and all that. 0:19:23.000 --> 0:19:27.760 So what are our pain treatment options today? What are 0:19:27.760 --> 0:19:31.000 the things that are most often used by doctors and 0:19:31.160 --> 0:19:35.199 by people dealing with pain to fix the problems. As 0:19:35.240 --> 0:19:38.199 we said earlier, there are some physical therapies, but but 0:19:38.240 --> 0:19:41.280 the drug therapies are what we wanted to concentrate on today. 0:19:41.920 --> 0:19:45.919 So I think the first category to consider is the 0:19:45.960 --> 0:19:49.240 nonsteroidal anti inflammatory drugs, which are like aspirin and like 0:19:49.320 --> 0:19:51.840 the proof and stuff like that. We're pretty familiar with these, 0:19:51.960 --> 0:19:55.480 Oh yeah, yeah, they're They're the most commonly used drugs 0:19:55.560 --> 0:19:59.399 for acute pain because they work by by blocking the 0:19:59.400 --> 0:20:02.480 effects of a couple of particular enzymes that are necessary 0:20:02.520 --> 0:20:07.080 for your body to make those aforementioned prostaglandins UM that 0:20:07.080 --> 0:20:10.760 that caused the inflammation and and stronger pain signals to 0:20:11.040 --> 0:20:14.280 go to the brain. So that is how they work 0:20:14.640 --> 0:20:18.480 pretty simple over the counter. Don't usually need a prescription 0:20:18.520 --> 0:20:21.080 for them, um, unless you get them in very very 0:20:21.160 --> 0:20:24.920 high doses or if they're mixed with something else. But yeah, 0:20:25.200 --> 0:20:29.399 moving over into the prescription category, you've got antidepressants and 0:20:29.480 --> 0:20:33.720 anti epileptics, which are sometimes used in in chronic and 0:20:33.800 --> 0:20:38.760 especially in neuropathic pain. Both are actually really poorly understood 0:20:38.760 --> 0:20:41.399 in their mechanisms, like no one's really entirely sure how 0:20:41.400 --> 0:20:44.480 they work, but researchers think that the chemical actions of 0:20:44.560 --> 0:20:48.840 both might help block pain pathways, might help block those 0:20:48.840 --> 0:20:51.960 signals that are shooting around telling your brain that stuff sucks. 0:20:52.640 --> 0:20:55.560 UM and anidepressants, of course, have a bonus action of 0:20:56.359 --> 0:20:59.600 maybe making a patient feel emotionally better, which helps to 0:20:59.760 --> 0:21:02.680 de stabilized that that feedback loop. Well, yeah, as we've 0:21:02.760 --> 0:21:07.000 established already, emotion clearly is part of the medically recognized 0:21:07.040 --> 0:21:11.560 profile of pain. It's not just sensory information on your ankle, 0:21:11.800 --> 0:21:15.240 it's it's your whole disposition towards it's your feelings about 0:21:15.240 --> 0:21:17.800 it as well, Shure. So antidepressants can help with that. 0:21:18.359 --> 0:21:22.440 The category of drugs that we started this episode off 0:21:22.480 --> 0:21:26.760 talking about opioids, is the category that are that's the 0:21:26.800 --> 0:21:30.160 subjective of the most concern for a number of reasons, 0:21:30.240 --> 0:21:33.760 all basically boiling down to the facts that they're really 0:21:33.880 --> 0:21:37.240 effective at blocking pain and also that they have really 0:21:37.320 --> 0:21:39.399 dangerous side effects. We'll get into the side effects in 0:21:39.400 --> 0:21:43.800 a second. But how opioids work. Okay, so your body 0:21:44.160 --> 0:21:48.680 makes opioids. They are neurotransmitters that plug into particular neuro 0:21:48.760 --> 0:21:53.560 receptors and relief pain. Yeah. Yeah, because your your body 0:21:53.560 --> 0:21:56.760 has a sort of internal dialogue, Gwen, pain is going on. 0:21:57.240 --> 0:22:00.000 There's like there there are pain amplifiers and then pain 0:22:00.000 --> 0:22:04.520 pain dampeners to sort of to regulate what's going on 0:22:04.640 --> 0:22:07.520 back and forth between your nerve cells in your brain. Right, 0:22:07.600 --> 0:22:09.480 and so so this this is one of those pain 0:22:09.520 --> 0:22:13.280 relievers in your body, and opioid drugs work by plugging 0:22:13.320 --> 0:22:16.919 into those same neural receptors and producing similar effects yea, 0:22:17.840 --> 0:22:22.200 or not yea, because they're not quite the same as 0:22:22.200 --> 0:22:26.120 the opioids that your body makes, and those chemical differences 0:22:26.240 --> 0:22:29.160 lead to the unpleasant side effects that we see, right, 0:22:29.440 --> 0:22:31.560 and so there are a lot of side effects. In fact, 0:22:31.600 --> 0:22:34.000 we should try to address as well as we can 0:22:34.359 --> 0:22:37.240 a sort of broad range of the problems with pain 0:22:37.320 --> 0:22:40.960 treatment options that exist in the drugs of today. One 0:22:41.000 --> 0:22:44.000 of the most straightforward ones, though it's probably worth mentioning, 0:22:44.160 --> 0:22:48.080 is simple inadequacy. Yeah, Like, a problem with a lot 0:22:48.119 --> 0:22:50.920 of pain treatments and medications is that they do not work, 0:22:51.040 --> 0:22:53.439 or they do not work enough. This maybe should go 0:22:53.480 --> 0:22:55.679 without saying, but it's something to consider. You know, you 0:22:55.760 --> 0:22:58.119 might be taking a tile and all for your pain 0:22:58.560 --> 0:23:01.840 and find uh i k I already took the pill, 0:23:02.000 --> 0:23:05.000 but it's still really really hurts. It does not reduced 0:23:05.080 --> 0:23:07.879 the pain to a tolerable level, right, sure, or that 0:23:07.920 --> 0:23:11.159 your body develops a tolerance to it over time, in 0:23:11.200 --> 0:23:14.439 the case of opioids in particular. Yeah, And so another 0:23:14.480 --> 0:23:16.960 one of the big things is going to be side effects, 0:23:16.960 --> 0:23:20.040