Chronic pain is a complex biopsychosocial ailment, so why do we too-often reduce it to meds, surgery, scans, and injections?
UCSF pain psychologist Dr. Rachel Zoffness, PhD teaches us methods to take better control of our pain. She is the author of The Pain Management Workbook, a world-class educator and columnist for Psychology Today, and a Nerd with a capital N
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Full transcript below!
Dr. Z: Hey guys, Dr. Z. Welcome to the ZDOGGMD Show. Today, I have Rachel Zoffness. She is a PhD pain psychologist, assistant clinical professor at UCSF in the Department of Pediatrics, but really, she’s all about managing pain in a way that isn’t the typical way in this country we manage pain, which is here’s a ton of opioids and bye bye. It’s a much more nuanced, inclusive and holistic way of managing pain that I think is going to help a lot of people. She’s written a book called “The Pain Management Workbook”, which I basically read the entire thing in a morning and it is woke. It will help people. Rachel, welcome to the show.
Dr. Zoffness: Thank you so much. Does anyone refer to you as Z?
Dr. Z: Everybody does, it seems. Yeah.
Dr. Zoffness: Me too, I get that a lot too.
Dr. Z: So they call you Z?
Dr. Zoffness: Yeah.
Dr. Z: So it’s Z and Z?
Dr. Zoffness: Yeah.
Dr. Z: Z and Z Music Factory.
Dr. Zoffness: No.
Dr. Z: No, you push it until it breaks. That’s you. Man, it’s good. We met for the first time this morning basically,
Dr. Zoffness: I know.
Dr. Z: and I feel like I’ve known you forever.
Dr. Zoffness: I know. I think we’re on the same wavelength with a lot of things.
Dr. Z: Something’s happening there. One of the things we’re on a wavelength about is pain.
Dr. Zoffness: Yeah.
Dr. Z: I feel like, ever since I was trained in the standard reductionist western model of pain management, and I started in the 90’s, when I was in training, they would tell me things like, okay, pain is the sixth vital sign or whatever, you need to measure it, and then the best thing for pain is medication, whether it’s starting with Tylenol NSAIDs, Neurontin, escalating to opioids, which they told me, at that time, with pharma’s help, you can’t get addicted if you really have pain because all the receptors absorb the opioid and there’s none left for the addiction magic to happen, and we know how that turned out, and then somehow, we ignored the fact that pain, as you mentioned in your book, is a biopsychosocial phenomenon. What do you mean by that? Help walk us through what you mean by that, because I think that’s the heart of what your teaching is trying to show us.
Dr. Zoffness: Yeah, so I’m a nerd, capital N. I like big words, but I also like breaking down big words, and I think everyone deserves to understand pain. Nothing pisses me off more than the fact that pain is this ubiquitous human experience that we all have, and none of us ever learn about it. So the first question I ask my patients, who come to my office, who’ve had pain for years… By the way, I should say the department I’m currently in is peds, but I treat patients of all ages.
Dr. Z: Got it.
Dr. Zoffness: So I have patients who come to my office who have been in pain for a decade or more, and I’ve had chronic pain pretty much my whole life too, I think a lot of us have had pain, and I always ask them, “So has anyone ever explained pain to you?” Do you want to know how many people have said, “Yes, pain has been explained to me?”
Dr. Z: I’m going to bet a small number, because I don’t know how to explain pain.
Dr. Zoffness: The answer’s zero.
Dr. Z: Oh, wow.
Dr. Zoffness: Yeah, zero, so it occurs to me that both doctors and patients alike deserve to understand pain and to be able to explain it, so biopsychosocial, back to the thing you actually asked me.
Dr. Z: The big nerd word.
Dr. Zoffness: The big nerd word just is a three component word, so if you imagine a Venn diagram, you’ve got the biomedical bubble at the top, so there’s all these biomedical components to pain, like genetics and tissue damage and system dysfunction. We all know about that bubble. It’s the one we teach and talk about the most. Then we’ve got the psychological bubble, which has all the stigma, because when you’re talking about pain, why would you talk about psychology? Psychology is a bad word. We’ll probably get to that.
Dr. Z: Oh, yeah.
Dr. Zoffness: Oh, yeah.
Dr. Z: Yeah, I’m already triggered, Rachel.
Dr. Zoffness: Don’t be triggered. What can I do to soothe you? In the psychology domain, we have emotions and thoughts and past pain memories, like that time you were held down when you got your first injection, those are stored in your hippocampus, and your behaviors are coping behaviors, and everyone has different behaviors when it comes to pain management, which we all know, like some people stay home for many years and some people take medication and some people get 42 surgeries and some people stop going outside and seeing their friends. There’s a whole host of coping behaviors that actually impact the pain you feel, and then there’s the social or the sociological bubble. Am I still okay? Can I keep going? There’s so much information.
Dr. Z: So what’s amazing is, okay, we talked about the bio stuff, yeah, like you said, we all learned that.
Dr. Zoffness: Yeah.
Dr. Z: In the psychological stuff, you said a few things that had me go , because, listen, this idea, when you were held down and got a bunch of injections when you’re a kid, that incorporates into your psychological DNA and it can manifest as fear of needles as an adult,
Dr. Zoffness: 100%.
Dr. Z: it can manifest as anti-vaccine sentiment, because you’re going to cherry pick any information that supports your unconscious belief that these needles are terrifying.
Dr. Zoffness: Totally.
Dr. Z: And it makes me think of my own experience with… I get white coat hypertension. So my blood pressure at home is like 110 over 70. It’s perfect. The minute a doctor or a nurse or any outside person measures it, it’s like 140.
Dr. Zoffness: Through the roof.
Dr. Z: And what I realized, I had this memory that I still carry around of… My parents are both doctors. They took me for a pediatrician visit and it took four people to hold me down to get the injections, but then they had a… I love how this has suddenly become therapy for me. You’re a psychologist. I’m going to use you, all right?
Dr. Zoffness: Yeah, do it.
Dr. Z: With no payment.
Dr. Zoffness: I’m all about it.
Dr. Z: And so I remember the nurse strapping on this really tight blood pressure cuff, and it just squeezing and squeezing, and me, screaming and trying to get up.
Dr. Zoffness: I’m having a visceral response to this by the way.
Dr. Z: Right.
Dr. Zoffness: That’s trauma.
Dr. Z: It’s trauma. So now when someone puts a cuff on me, that isn’t me, my blood pressure goes through the roof.
Dr. Zoffness: Of course it does.
Dr. Z: I feel it right now. So how can we…?
Dr. Zoffness: Do you want to do some belly breathing?
Dr. Z: We’re going to get into that. I love it. No, meditation is part of my life now, but understanding these past, and it seems like a minimal trauma, like, oh, man, people were abused sexually, physically, and here I am complaining about this.
Dr. Zoffness: No, there’s all kinds of trauma and they live in your body. You’ve read “The Body Keeps the Score” probably.
Dr. Z: It’s exactly right, yeah.
Dr. Zoffness: One of my good friends and another pain psychologist researcher, Melanie Noel, actually researches the storage of early pain memories in the hippocampus.
Dr. Z: Oh, wow, so they’re actually really digging into this.
Dr. Zoffness: This is a real thing, so if you get held down as a child, those are your associations with needles and pain, and what research shows is that that then amplifies future pain. So the psychological bubble contains memories of past pain experiences, and those will amplify pain experiences later in life. So if you’re an adult with chronic pain, chances are very high you may have had a traumatic experience at some point in your youth. There’s the ACEs studies, which you mentioned earlier, which show that adverse childhood experiences, including trauma, amplify and make more likely the development of chronic pain later in life.
Dr. Z: Okay.
Dr. Zoffness: It’s a real thing.
Dr. Z: So this all makes perfect sense, because the mind and the body are not two.
Dr. Zoffness: Oh, isn’t that weird?
Dr. Z: Isn’t that strange?
Dr. Zoffness: That the brain is connected to the body 100% of the time.
Dr. Z: 100% of the time.
Dr. Zoffness: What? That’s so weird.
Dr. Z: Yeah, you said that in the book. You just say 100% of the time it’s a body-mind. They’re not two things.
Dr. Zoffness: And in western medicine, we have this really fascinating problem, which drives me nuts, which is either you have physical pain, and you see a physician, or you have emotional pain, and you go to someone like me, but guess what? That’s not how pain works ever, ever. 100% of the sensory signals from the body filter through a part of your brain called the limbic system. The limbic system is your brain’s emotion center. So 100% of the time, pain, which rhymes with brain,
Dr. Z: Very similar words.
Dr. Zoffness: Pain is both physical and emotional, always, ’cause it’s filtering through your limbic system, which is your emotion center. So we separate them out, like you have physical pain, you go to the physician, you have emotional pain, you go to the psychologist, but when you’re living with chronic pain, it’s always both. If you’re not taking care of your emotional health, believe it or not, you’re actually not taking care of your pain.
Dr. Z: And people don’t respect or understand this, because we’re a reductionist materialist society, that believes that everything has a physical biomedical reason for it, and in fact, I think that drives a lot of… You mention it in your book too. It drives a lot of the over-treatment and over-diagnosis and over for chronic pain, like, oh, well, let’s scan every part of your body. “Oh, no, but this can’t be right. “There must be something wrong with my neck, “because I have neck pain. “What are you telling me? “The MRI is negative? “Well then, I want a surgery. “I want something.” And what we’re not addressing is, remember that time, when you were a kid, plus there is a physical thing, so some of you got an injury, plus you’re on a medication that actually has made your pain sensitivity worse, which we can talk about. So I derailed you, but I think it went bio, psychological, so exterior individual, to interior individual, and then what’s the third component?
Dr. Zoffness: The third is social, or sociological, and that’s what I like to call absolutely everything else. So your social context, your relationships, your family, culture and religion, and environment around you, access to good care and quality nutrition, whether or not you have access to doctors, and so it’s literally everything else.
Dr. Z: So why would that affect your pain?
Dr. Zoffness: Yeah, that’s a good question. When I went down this rabbit hole with pain, I was like, why is there a social or sociological bubble? How does that have anything to do with pain? So I have a few responses to that question. Number one, what is the worst punishment you can give a human being? I get a variety of answers to this question. I want to know what you say.
Dr. Z: I would say that the common answer, which I disagree with, is isolation.
Dr. Zoffness: Yes, but you disagree. I want to know everything about it. So if you fuck up, excuse my F bomb, everybody, it’s not just that you go to prison, right? But if you fuck up in prison, you get thrown in the hole, get thrown in solitude. What does it say about human beings that the worst thing you can do to us isn’t prison, it’s isolation? You get cut off from contact with your peers. What does that say about human beings? So what research shows is, in the presence of others, neurochemicals, that live in your brain, that confer feelings of pleasure and reward and happiness, like serotonin and dopamine and oxytocin, go sky high. In the absence of others, those neurochemicals plummet. People literally go insane in solitary confinement. You get depressed, you get anxious, you start hallucinating. You’re not physiologically okay. So one of the worst punishments you can give a human being is solitary confinement. Thing two. They did a whole bunch of research on the elderly who were living in nursing homes. They found some really interesting things. Those who were alone and isolated and lonely were getting sicker more often and dying more frequently than those who lived in community, for a variety of reasons, and I’m fascinated by these, because it ties together the social with the biological. Ready? When you are lonely and isolated and alone, a lovely, lovely hormone called cortisol spikes in your bloodstream. Guess what cortisol does to your immune system? Oh, it tanks it. It tanks it, and it also releases a whole host of other chemicals in your body that physically make you feel worse. So in the presence of others, amazingly, brain chemistry changes, conferring feelings of pleasure and reward and also health, and in the absence of others, you are more likely to get sick, if you’re healthy, get sicker, if you’re already sick, and die, because your immune system is compromised. So that’s just the social component of the sociological bubble, and then you have, well, access to care and access to nutritious food, and of course, that affects your health.
Dr. Z: The built environment.
Dr. Zoffness: And if you’re living in a very stressful, impoverished environment, of course that affects your health and your body, so there’s a ton of things. I also have a fun tale of two nails story that I can tell you, that will very quickly and handily explain how environment affects pain, if you would like me to, or we can save that for later.
Dr. Z: You know what? I want to hear it, but I wanna counter with one thing,
Dr. Zoffness: Please do.
Dr. Z: because remember I said I disagreed about–
Dr. Zoffness: I know, I want to hear.
Dr. Z: Yeah, now, so this is what I think. I think humans are evolved to be social creatures and now, what we’ve done during the pandemic, with lockdowns and closing schools, has been incredibly damaging to our social nature. Zoom is not a substitute for in-person.
Dr. Zoffness: No.
Dr. Z: You sitting in front of me, we create this dyadic thing, it’s ineffable. Language doesn’t point at it, but it’s real. If you were on Zoom right now, the conversation would be 70% less whatever this is.
Dr. Zoffness: Try doing chronic pain therapy over Zoom.
Dr. Z: Exactly, so it doesn’t work. Now, the reason I disagree with isolation being the worst thing you can do to humans, is that I think it is for most humans. We need to learn how to be with ourselves and meditation can help you with this, but this idea that being alone with our actual self should not be unpleasant, and yet, we, as a society, have ingrained that it is unpleasant, because we’re stuck in our head, which we’re going to talk about, those little voices, that constant radio station playing, and we identify with it, and when it’s alone and separate from everything else it is, it’s a source of deep suffering for us, but when we realize we’re not separate, that we are all one thing, you can be alone with this sense of being without suffering. Yes, ma’am?
Dr. Zoffness: I’m so glad you called on me. I have a thought about that, and by the way, I think you’re 100% right, that we have a fear of aloneness, and sometimes that’s born of self-loathing and not liking ourselves very much, and then we are scared of just being with ourselves, ’cause we have to listen to our own thoughts, but I humbly submit that that’s different than forced solitary confinement for long enduring periods of time.
Dr. Z: Fair enough, yes, absolutely.
Dr. Zoffness: Those are different.
Dr. Z: Absolutely.
Dr. Zoffness: And I do think that we are scared of being alone with ourselves and our thoughts, and people don’t know what to do, and we’re clingy and needy and scared of ourselves, and I agree.
Dr. Z: So basically you made the distinction that then allows us both to 100% agree on all of that. Yeah, that’s exactly right.
Dr. Zoffness: That’s good, huh?
Dr. Z: Yeah, you’re pretty woke. I’m a little concerned
Dr. Zoffness: Don’t be.
Dr. Z: that you’re not going to survive well in this society.
Dr. Zoffness: That’s great.
Dr. Z: I’m just saying.
Dr. Zoffness: I hope that’s not a prescription.
Dr. Z: I’m not a doom bait guy, like these guys on Twitter and the pandemic, but I think you’re doomed, I really do.
Dr. Zoffness: Thanks, thanks.
Dr. Z: So tell me this tale of two… Was it tale of two nails?
Dr. Zoffness: Tale of two nails. Yeah, I like it, ’cause it rhymes.
Dr. Z: I like it too.
Dr. Zoffness: Yeah, yeah, yeah.
Dr. Z: Brain and pain,
Dr. Zoffness: I know.
Dr. Z: Male and female.
Dr. Zoffness: There’s lots of rhymes today, okay, so the purpose of the story is multifold, right? So again, I’m going to say this blanket statement, that every human being I’ve ever met has experienced pain at some point, and that there’s 100 million Americans currently, who are living with chronic pain, and probably even more than that, during the pandemic.
Dr. Z: 100 million, so a third?
Dr. Zoffness: Yes, that’s a true story, and I actually think that’s an underestimate.
Dr. Z: I’m with you, and do you think pandemic has made it worse?
Dr. Zoffness: Oh, 100%, and there’s a lot of research that bears that up.
Dr. Z: Got it.
Dr. Zoffness: For a million reasons, like people are cut off from their treatment teams and their support systems and their normal coping strategies, and are turning to really unhealthy coping… Like the spike in alcohol sales and drug… I think drug overdoses have increased by a third since… Yeah, it’s a shit show.
Dr. Z: Double plus on good, though whatever progress there was on opioid crisis
Dr. Zoffness: Oh, it’s gone.
Dr. Z: seems to have reversed.
Dr. Zoffness: Yeah, I think drug overdoses have increased by 30%, and I think 70% of those are opioid-related deaths.
Dr. Z: Wow, I like your use of the term, “shit show.”
Dr. Zoffness: Thank you.
Dr. Z: I think it’s very powerful.
Dr. Zoffness: Thank you.
Dr. Z: I use it often. Yeah.
Dr. Zoffness: Yeah, yeah, I think I got off track a little bit.
Dr. Z: Yeah, so the two nails, yeah. Not one nail, but two, but no, this is important.
Dr. Zoffness: Not one nail, but two, right, so again, we have all experienced pain. We all suffer from the same pain education problem, which means that none of us have ever been taught about pain, so as one of those people, I also thought that pain lived exclusively in the body. We usually do, right? If you have back pain, you think that your pain lives exclusively in your back, and you have to go to a million specialists to target your back, because that’s the problem, and it turns out that that’s not actually accurate, and one of the reasons we know that pain does not live exclusively in the body, but is actually constructed by the brain, of course, in conjunction with the body, is because of a condition known as phantom limb pain, which you knew I was going to say.
Dr. Z: ‘Cause I read your book.
Dr. Zoffness: I’m obsessed. I’m obsessed with phantom limb pain. Phantom limb pain is a condition in which an accident survivor or a trauma victim loses a limb, like an arm or leg, and they continue to feel terrible pain in the missing body part, and if pain lived exclusively in the body, no limb should mean no pain, so the conclusion we have drawn, and thank God for neuroscience, the conclusion neuroscience has drawn is that pain is constructed by the brain, of course, with contributions from the body, because again, like you said, this brain, body divide just ain’t a thing.
Dr. Z: Ain’t a thing.
Dr. Zoffness: Right, so Ron Melzack and Patrick Wall are the founding fathers of pain science, as we understand it today, and they elaborated on this phantom limb thing, so I don’t want to pretend that I’m the creator of this, but the tale of two nails, here’s how this goes. This is from two stories from really nerdy science journals that I happen to really love, and I think they outline this phenomenon really well.
Dr. Z: So you’re talking book three of the Harry Potter series or something, right? This is like “Tales of Beedles the Bard”.
Dr. Zoffness: Yes.
Dr. Z: Okay, perfect, good, ’cause now I’m like, tell me more.
Dr. Zoffness: Are there wands?
Dr. Z: Oh, yeah, are there wands?
Dr. Zoffness: Are they dragon heartstring wands?
Dr. Z: I thought that our wands both came from the same dragon part, I could tell.
Dr. Zoffness: It’s griffyn tail, phoenix tail?
Dr. Z: I’m a…
Dr. Zoffness: Griffyn, phoenix?
Dr. Z: Griffyn…
Dr. Zoffness: Gryffindor? I’m getting my magical creatures–
Dr. Z: Hufflepuff?
Dr. Zoffness: I think I actually was sorted into Hufflepuff, because I said I liked animals.
Dr. Z: You strike me as a Hufflepuff.
Dr. Zoffness: I’m not sure that’s a compliment. I really want to be in Gryffindor. I have friends who want to be Slytherin, and I’m like, “Tell me more about that.”
Dr. Z: I was the one, where the sorting hat was like, “You’re totally Slytherin, bro. “I don’t know what you want to be, but you know.” Yeah.
Dr. Zoffness: Right, we can talk about that later.
Dr. Z: Yeah, yeah, yeah, exactly.
Dr. Zoffness: Okay, God, it’s very hard to stay on track.
Dr. Z: It’s difficult.
Dr. Zoffness: But that’s a sign of a good conversation.
Dr. Z: But that’s the joy. That’s the joy of it, yeah.
Dr. Zoffness: Agree, so two construction workers, one gentleman, I believe he was 26, and this was in the early 90’s, he jumped off a platform, this is on a construction site, straight onto a seven inch nail, and it went through straight through his boot, clear through to the other side, and there’s a picture, where you can see this huge nail penetrating through the top of his boot. He was in terrible pain. His colleagues rushed him to the ER. He was sedated, of course, with intravenous opioids, and the good doctors removed his boot and discovered that a miracle had occurred. The nail had passed between the space between his toes. There was no blood, there was no tissue damage, there was no injury, but the man was in terrible pain.
Dr. Z: Oh, wow.
Dr. Zoffness: Right, how is that possible? His brain, which we call your danger detector, used all available information to determine whether or not his body was in danger and how much, because that’s actually what pain is. Pain is your body’s danger detection system. So if your brain believes your body’s in danger, it will make pain to protect you, but like every system in the human body, the pain system can fail. So the brain used all available information, like the visual of the nail sticking through his boot and memories of past pain experiences and knowledge of the dangerous work environment, again, environment, in the social or sociological bubble, and even the expression of his coworkers faces, ’cause he had this seven inch nail, sticking through the top of a shoe, and it created pain to protect him.
Dr. Z: Wow.
Dr. Zoffness: I know, it’s amazing.
Dr. Z: That’s amazing.
Dr. Zoffness: I know, but that’s only story one.
Dr. Z: Oh, no.
Dr. Zoffness: Do you want story two?
Dr. Z: Yes.
Dr. Zoffness: Okay, construction worker, most dangerous job there is apparently, was on a different construction site, don’t remember what year this paper was, so I think also in the 90’s, he was using a nail gun, and the nail gun misfired, but he saw the nail shoot across the room, bury in the wall, but it backfired, so it ricocheted backwards, clocked him in the jaw, so he went home. He had a terrible headache and a toothache for six days, and he said to his wife, after six days… I think he had like a bruise on his jaw, ’cause the thing backfired. He said to his wife, “I’m going to go get this toothache checked out.” He went to the dentist. The dentist did a scan of his jaw and his face and, much to both men’s surprise, they discovered a four inch nail embedded in his face. It was protruding into his cortex.
Dr. Z: Oh my.
Dr. Zoffness: Right, so real damage, real danger, but very little pain. How is that possible? His brain, AKA your danger detector, used all available information, and it saw that nail bury in the wall, and it determined that there was very little danger to his body, so it produced very little pain. So yes, the pain system can fail and always fails, but we always make the mistake of believing that our pain lives exclusively in our body and that we need to go fix that and surgically remove things and cut things up and take pills and blah, blah, blah, blah blah, but what we know is that that doesn’t actually work for chronic pain, and many people living with chronic pain can tell you that, however many procedures later and however many pills later, their pain isn’t fixed, because we’re not focusing on the biopsychosocial problem. We’re focusing exclusively on the biomedical bubble at the top. We’ve got biomedical, we’ve got psychological, we’ve got social, sociological, and we’re focusing on one-third of the pain problem, which actually means we’re missing two thirds of the pain problem, yeah.
Dr. Z: So basically, what I’m gleaning from this, is that this idea that we were taught, that pain is a unequivocal warning signal that something is broken, wrong or dangerous, is not necessarily true. It is your brain’s interpretation of a threat to the body or lack thereof, and therefore, that interpretation can be dysfunctional, based on biologic conditions, psychologic conditions, trauma, et cetera, belief structures, et cetera, and sociological and social conditions, and all of them need to be addressed, if you’re going to have any hope of unwinding chronic pain.
Dr. Zoffness: That’s perfectly said.
Dr. Z: No formal training.
Dr. Zoffness: No, bravo. I really want to… Can I clap?
Dr. Z: Yes. In fact, I deserve it, I earn it, I’m such a great person. No, but the truth is because, as I was reading your book this morning on a StairMaster, I was noting my chronic neck pain, which has gotten worse and worse, and everything you talked about in the book, I started applying in real time, and realizing, wow, this is a psychologically… When I worry that I have a physical process going on, that I’m slipping a disc or pinching a nerve, boy, does the anxiety ratchet up, in which case, the pain ratchets up.
Dr. Zoffness: You’ve got it.
Dr. Z: And I know it’s biopsychosocial, because I have tech neck from staring at this, I sleep funny on the thing, but at the same time, when I worry about the pain, it gets worse, and then it becomes a headache, and then I have trouble interacting with people, ’cause I’m in pain, and then I start falling into the
Dr. Zoffness: I’m screwed.
Dr. Z: cognitive distortions that happen.
Dr. Zoffness: That’s right.
Dr. Z: Overgeneralizing, well, now, that I’m having pain, I might have pain forever.
Dr. Zoffness: Oh, you’ve got it.
Dr. Z: Black and white thinking. Man,
Dr. Zoffness: You just describe it.
Dr. Z: Just every single one, and then, because I actually, a combination of reading about it and meditating and all that, I go, oh, this is what I’m doing. How interesting. And watch, pay attention to the pain, be with the pain. Next thing you know, it’s much more tolerable, if not gone.
Dr. Zoffness: Magic, but not.
Dr. Z: Yeah, yeah, yeah, so what you said about these stories, anyone who says, “Oh, well, pain’s all in your head.” Well, they’re missing the biological part of it. Anyone who says, “Well, no, pain is a pure physical process,” is wrong. So the only people who are right are people who see the entire holistic picture.
Dr. Zoffness: Who are integrating it.
Dr. Z: Right.
Dr. Zoffness: Yeah, the whole thing, where I got all these patients who are like, “Why am I being sent to a psychologist? “I have a physical problem.” The one I love is, “No, but my pain is organic.” And I’m like, “Yup, that’s right. “All pain is real, all pain is organic “and all pain is biopsychosocial. “All the things are true all the time “and it’s not all in your head.” There are some physicians who do say to their patients and give them this message like, “Well, we can’t find anything on the scans, “so it’s psychological. “Your pain is psychological “and there’s something wrong with you, “maybe you’re mentally ill “and we have to send you to a therapist.” And that makes my job a million times harder, because I am treating, what we’re calling, physical pain, which, of course, I’m submitting to everybody, is both physical and emotional all the time, but I treat physical conditions. I treat people with chronic illness and chronic pain and chronic health. That’s what I do. But it makes my job so much harder when someone says to the patient, “Yeah, it’s just all in your head, “and we can’t find anything on the scans, “and therefore it’s just anxiety or you’re just depressed.” And yes, anxiety and depression feed pain. That’s what neuroscience shows, that pain is amplified when we are anxious and depressed. That’s just a neurological process. It’s a real thing, and we can talk about the mechanism behind that too, if you want. It’s just straight-up neuroscience, the gate control theory of pain, back from ’65. This has been shown that that is true, but that’s not the only cause of your pain, and it does not mean that you’re mentally ill. The other thing that makes me crazy is if you’ve been in pain for a decade, you bet your ass you’re depressed and anxious. Pain is miserable.
Dr. Z: It’s a circle.
Dr. Zoffness: It takes away your life, your hobbies, your ability to have sex with your partner, your ability to engage in work and play. If you’re not depressed and anxious when you’ve had pain for a decade and it’s interfering with your life, I’m worried about you, but we call that situational depression and situational anxiety, and when we treat your pain, miracle of miracles,
Dr. Z: It gets better.
Dr. Zoffness: Yeah, your anxiety and depression. It’s not like your brain is chemically broken, let’s throw you on some drugs, because you’re mentally ill and we just need to fix your anxiety and depression. It makes me crazy.
Dr. Z: It should make you crazy. It makes me crazy and angry. It’s part of the reason I do my show, is I got so disgusted in the practice, the daily practice of hospital medicine, seeing what we’ve done to people, and it’s with good intent. It’s not like these are bad people.
Dr. Zoffness: That’s exactly right.
Dr. Z: Right?
Dr. Zoffness: It’s not malicious.
Dr. Z: But putting a kid with some issues on Thorazine or something, or the kind of things we do to kids, and we’ve reduced them all to one quadrant of experience, which is the organism exterior that we can measure and probe and surgerize and intervene on, and opiatize, if that’s a word,
Dr. Zoffness: It is now.
Dr. Z: Exactly, but we don’t just look at the whole thing. It’s this undulating wave of reality, and this is the thing, like you said, when anybody reduces a person to one of those quadrants, when they say, “Okay, it’s all physical. “I’m a spine surgeon. “I get paid to say that. “I can cut open your back and I will cure you.” And then it doesn’t work, so they go, “You know what? “You’re kind of crazy. “You probably just have mental illness. “I’m going to send you to a psychiatrist “and they can sertraline you and put you on anti-psychotics, “because that’s the problem.” And what does that do to the mind state of the person hearing it? It ruins it.
Dr. Zoffness: Totally.
Dr. Z: Yeah, and in the book, what I like about your book, is you actually give strategies for, okay, well, you can talk about this all day, “Well, it’s terrible that we do this to people “and we reduce it.” So what do we do then? Well, here are, at the minimum, five different things on a list of things that you can start to do. Here are tools, just cognitive behavioral stuff, mindfulness-based stress reduction, there’s simply reframing and listening to your mind and going, hey, remember that? Tell me about the pain voice. This blew my mind.
Dr. Zoffness: Yeah, right. So I like talking about the voice in your head, and I just need to be careful not to suggest that it’s like people hear the voice in your head
Dr. Z: A psychotic voice.
Dr. Zoffness: and they’re like, “Are you saying I’m schizophrenic?”
Dr. Z: No, no.
Dr. Zoffness: No, not that. You have your conscience and you hear the things in your head all day long, so it is normal and natural to have a very loud inner critic. Most of us do. And when we have chronic pain, it’s very common to hear what I have named pain voice, and pain voice is exactly what you think it is. It’s just this jerk, I almost used more curse words, but I think I’m just going to try
Dr. Z: He’s an asshole.
Dr. Zoffness: to calm that down a little bit. You can use the words for me.
Dr. Z: All right.
Dr. Zoffness: 100%.
Dr. Z: I’ll be your anger translator.
Dr. Zoffness: Thank you. And he just predicts bad things all day long, like you’re never going to get better, nothing’s worked so far, so nothing’s going to work, it’s just going to get worse from here, this is going to ruin your job, your sex life, your career, whatever, right? That’s what he does. That’s his job, and he really, really wants you to be in pain, because if you’re not in pain anymore, he’s done.
Dr. Z: His identity’s gone.
Dr. Zoffness: He’s done.
Dr. Z: He’s finished.
Dr. Zoffness: He’s done.
Dr. Z: So I’ll interrupt for a second.
Dr. Zoffness: Please.
Dr. Z: I get so many messages from people with chronic pain, who are suffering, and these messages are all written in pain voice. They’re written in pain voice. This, “I’m never getting better. “Doctors don’t understand me. “This has ruined my life. “Will you please help me? “You’re the only person who seems to understand.” And I’m like, “I’m not a pain doctor, I’m not your doctor, “but I do understand what you’re going through.” And so that pain voice actually manifests sometimes in writing, you can hear it. So this is constantly this chatter in the head of certain people with chronic pain?
Dr. Zoffness: Yes, and just to normalize, we all have some version of a pain voice, everybody, all the time, to varying degrees, depending on what’s going on with your body and your brain. So everyone’s got it, it’s just how loud it is, and the way I like to talk about pain voices, ’cause we all also have the opposite, or the counter, which I’ve called our wise voice, and wise voice is like–
Dr. Z: By the way, I’m a little pissed, because you made wise voice a chick.
Dr. Zoffness: Yeah, yeah, yeah, both of mine are female.
Dr. Z: Oh.
Dr. Zoffness: Yours can be male or whatever sex you want.
Dr. Z: Cis, can they be gender non-binary?
Dr. Zoffness: 100%.
Dr. Z: Okay, good.
Dr. Zoffness: Some of my patients have animals
Dr. Z: Really?
Dr. Zoffness: or emojis.
Dr. Z: So do I have to start listing pronouns for my pain voice and my wise voice?
Dr. Zoffness: Only if you want to.
Dr. Z: Okay, good.
Dr. Zoffness: Yes, so you’re the chooser.
Dr. Z: Freedom, all right, good.
Dr. Zoffness: You’re the decider about your pain voice.
Dr. Z: So back back to your wise voice.
Dr. Zoffness: Yeah, so if you imagine, so there’s a technique in psychology called externalizing, which I find to be very, very powerful with pain. What happens to all of us is, you hear the voice inside your head and it sounds like you, so you believe it, and we all believe the bullshit in our heads all the time. It’s a real problem we all have. And I have a neighbor who has a bumper sticker and it says, “Don’t believe everything you think.” Which I think is brilliant
Dr. Z: That’s brilliant.
Dr. Zoffness: and so hard to do, so when you externalize, you take this voice and you give it a name. My pain voice is Mrs. Beasley. She sounds like an obnoxious school principal.
Dr. Z: Mrs. Beasley, I love it. Mrs. Beasley says you’re gonna suffer until you die.”
Dr. Zoffness: Exactly, 100, you got it, and she has these knitted thick eyebrows and lumpy black clothes, and so when I hear her and, of course, I created this for some of my patients, because it’s better to have an example, but now, when I hear pain voice in my head, I’m like, “That’s just Mrs. Beasley and she’s a jerk,” And I know what she sounds like, and I have a list of all the things she commonly says, and sometimes there’s variations, but it’s usually fairly standard. She’s predicting the future, which, by the way, I would love to be able to do, but if I could do that, I’d also be a bazillionaire and we would buy Fiji and it’d be great, but I know I don’t have that super power, so that’s one of my tells, that’s one of my clues. I know it’s Mrs. Beasley, the pain voice, ’cause she’s predicting bad shit about the future, or she’s catastrophizing. “Horrible things are going to happen. “It’s going to be…” That’s Mrs. Beasley, so I have a list of things and that’s my pain voice, and so like you said, once you become clear on what she sounds like, or he, or it, sounds like.
Dr. Z: They.
Dr. Zoffness: They
Dr. Z: I like they, yeah.
Dr. Zoffness: sound like, then you become more aware that it’s not you. It’s not you. It’s just pain voice, and pain voice doesn’t want to be put out of work. Pain voice doesn’t want to be unemployed, so pain voice is going to try very hard to convince you that she’s real and she’s right, and so our job then is to recognize… We call it catch it, check it, change it, so you catch her, then you check her, you test it, to see whether or not it’s true, and then you do something to change it. I’m not pretending that it’s magic, I’m not pretending that it’s easy, but it’s definitely doable.
Dr. Z: So that is the heart of cognitive behavioral therapy,
Dr. Zoffness: Correct, yes.
Dr. Z: as applied to pain. Ah, this is so good, because this whole idea of Descartes, “I think therefore I am,” was a fundamental misapprehension of what we are. We are not our thoughts. Our thoughts appear in us, and if we identify with our thoughts, it’s the cause, inevitably, of suffering, of contraction, of separation, of that inability to be alone voluntarily, and when pain voice is what you identify with and you don’t check it, so you don’t recognize it, so that’s a lack of comprehension or mindfulness, then it becomes you, which then means it becomes your behavior, so all those cognitive distortions you mentioned, like the catastrophizing, oh my God, and by the way, all these same cognitive distortions happen in any news about the pandemic. “Oh, the vaccines work, but not really, “because there are variants,” and now it’s catastrophizing about the variants. So we apply these same things as a collective sometimes, and sometimes it can be protective, so maybe we’re a little more cautious, but in the case of pain, chronic pain, pain voice is not helping you.
Dr. Zoffness: That’s correct.
Dr. Z: Pain voice is harming you.
Dr. Zoffness: That’s correct.
Dr. Z: So how do you, when you check, okay, you recognize it, you catch it, how do you check it when you believe it?
Dr. Zoffness: Right, so I just want to say a quick thing about a thing. I wanna say 40 things, but I’m going to try and just say one. You said, about the collective anxiety and the catastrophizing, that sometimes its purpose is to protect you, and the reason we can’t really hate pain voice is because that’s its goal too. It thinks it’s protecting you, because pain, again, is the body’s warning system, and we know that the system can fail, but ultimately, the reason humans survive is because we have a pain system. If you imagine, I used to think having no pain sounded so amazing. People born without the ability to feel pain die. They do not survive, because pain is protective. If you break your leg on a run and you don’t know it and you keep running, you are screwed.
Dr. Z: Gonna throw a marrow embolism or something. Yeah, a fat embolism.
Dr. Zoffness: There’s like a million examples of that, right? Like if you have food poisoning and you don’t know, and your stomach doesn’t hurt… So pain voice is intending to protect you, but it’s not doing it well, it’s not doing it correctly. I think your point is exactly on target.
Dr. Z: And in your book, you actually reframe it. So for example, anger, as a thing, you reframe, you go, “You can visualize anger as this fluffy dog “that you just need to go take for a walk and love, “instead of…” So that reframing, even of pain voice, Mrs. Beasley’s kind of, but she’s there to help. She actually cares about you. She wants you to be well. It’s just all she knows.
Dr. Zoffness: That’s exactly right. So you asked, “Once you recognize your pain voice, “what do you do about it?” There’s a fun activity called using detective questions. So I just want… Can I back up for a quick second?
Dr. Z: Absolutely.
Dr. Zoffness: Okay, so cognitive behavioral therapy is the strategy or the technique that I use when I treat pain, and I have been doing it for a really long time, and I happen to love it. I think it’s really, really effective and there’s a lot of research. It’s not like this flooffy thing. There’s an abundance of literature out there on cognitive behavioral therapy for anxiety, and for depression, and for family dysfunction, and for sleep and for pain, and guess what? When it comes to pain, all of those things are interconnected. Shocking. Yes, so we can talk about the literature on CBT for forever, but I don’t want to, no.
Dr. Z: Yeah, you could just read “Feeling Good,” the book. I remember that one, or read “The Coddling of the American Mind” by psychologist, Jonathan Haidt.
Dr. Zoffness: I have not read it, but now I will.
Dr. Z: So his whole premise is that CBT, which saved Lukianoff, who was his coauthor, who’s a lawyer, saved him from suicidal depression, can be applied to our current way of how we catastrophize on social media, how we play the world as black and white, good and evil, how we want to cancel people that disagree, because we have distorted thinking, that if I feel bad, if I’m hurt by somebody’s statement, I’m physically hurt. This idea that hurt and harm are not the same, you mentioned in your book. So sorry, so back to cognitive behavioral therapy.
Dr. Zoffness: Yeah, I just want to give a little bit of a… So it’s this evidence-based treatment for all of these different things, including pain. It bridges the gap between medicine and psychology, which is why I like it so much, I always want to live in that space, and it teaches us that our thoughts and our feelings, both our emotions and our physical feelings or sensations, and our behaviors, our daily choices, are connected 100% of the time, and there’s lots of diagrams and all sorts of things that show you how they’re connected. It’s really intuitive once you see it, but it reminds us that the thoughts in our head are connected to the sensations in our body, and like you were saying before, the decisions you make everyday, your behaviors, are connected to your physical sensations and your pain, so all the things are intimately connected all the time. So in CBT, we do focus a lot on the C, which is the cognitive component of pain, which is pain voice and the things you tell yourself, like, “I’m never going to get better, “and nothing’s ever going to help, “and I’m going to die alone with terrible pain,” which, of course, as you imagine, amplifies depression and anxiety, which in turn amplifies pain. So what can you do? There’s a ton of strategies. There’s this one technique called using detective questions. So again, the steps in CBT are catch it, so recognize Mrs. Beasley and pain voice, then check it, just test it out. I think about it as… You know how in movies with pirates, they’re always biting down on gold coins to see if the gold is real.
Dr. Z: Arrgh, this is fake.
Dr. Zoffness: Thank you.
Dr. Z: How do you know? I don’t know, but yes.
Dr. Zoffness: Thank you, and I can’t remember, if you bite down on it, is it supposed to be soft if it’s gold or hard if it’s gold? I can’t remember.
Dr. Z: I don’t know. It makes my fillings tingle when I bite down on a gold doubloon.
Dr. Zoffness: I, personally, have never bitten down on a gold doubloon.
Dr. Z: You know what, then you haven’t lived. You know what? Tell your pirate voice, that’s the one that just goes, “Arrr,” and repeats whatever anyone said, like you just said, “Well, the thing about CBT,” and I just hear, ” CBT.” That’s my pirate parrot voice.
Dr. Zoffness: Parrot, that’s amazing.
Dr. Z: So sorry.
Dr. Zoffness: I wonder if anyone’s pain voice is a pirate.
Dr. Z: You know what? Then it’s worth it. I’d be willing to have chronic pain if I could have a pirate pain voice. “Ye will never be better, you scurvy knave. “Ye back pain is ‘organic’, whatever that means, “and yer chronic Lyme’s shall never be cured.”
Dr. Zoffness: I think we have a business venture in our future. I bet that would really help if you could comedic.
Dr. Z: Humorize it, humorize it.
Dr. Zoffness: Make it comedy. I bet that would actually do a lot. I think you’re onto something.
Dr. Z: It’s like your dog, the fluffy dog, to represent anger.
Dr. Zoffness: Right, that’s right.
Dr. Z: It disarms it a little bit.
Dr. Zoffness: Totally, disarming is such a powerful technique. Agree 100%. Right, so the detective question trick is you’re basically biting down, as if on a gold coin. You just want to test the thoughts to see, are they true or are they BS? Because, again, we believe the thoughts in our head. They sound real, they sound true to us, so we tend to believe them, whether or not they’re BS. So you want to test them, like biting down on that gold doubloon, just to see, is it real or is it not real? Am I tossing it back or am I putting it in my pocket and keeping it? So there’s a bunch of ways to test the thoughts. So these detective questions that you use, so say I’m thinking the thought, “I’m broken. “I’ll never get better.” That’s a great one. I hear that all… “I’m broken. “I’ll never get better.” So you ask a couple of questions, the detective questions, just to assess. “This might be true. “Maybe this is true. “I should test it out and see.” So the list of questions, I think there’s about 10 of them, one is, is this a fact? And a fact is hard core, 100%, verifiable, cannot be, in any way, rendered untrue. So, “I am broken. “I’ll never get better.” I’m pretty sure if I asked you, “Is this a fact?” You would probably say… What would you say? This is a fact?
Dr. Z: Yeah, of course it’s a fact ’cause Mrs. Beasley says… Actually, it doesn’t. I guess it’s not a fact.
Dr. Zoffness: Right, a fact is like unquestionably, undeniably true.
Dr. Z: It’s an opinion. It’s like “The Big Lebowski.” It’s like your opinion, man.
Dr. Zoffness: It’s like your opinion, dude.
Dr. Z: Yeah, exactly.
Dr. Zoffness: You have to say dude.
Dr. Z: You have to say dude.
Dr. Zoffness: If you’re doing “The Big Lebowski,” yeah, totally. So there’s a bunch of questions you ask those thoughts to test them out and see whether or not they’re actually facts or fiction.
Dr. Z: So that’s the first detective question and that makes sense. What’s another example of a detective question?
Dr. Zoffness: What evidence do you have that this thought might not be true?
Dr. Z: Oh, so you’re playing devil’s advocate with yourself?
Dr. Zoffness: What evidence? I actually really love evidence, because evidence is sort of like the word fact. There’s certain things. I think we all have our logical mind over here and we have our emotion mind over here, and there is a place where they overlap, but emotion mind operates in how you’re feeling, like “Inside Out”, if you’ve seen “Inside Out.”
Dr. Z: It’s a beautiful film.
Dr. Zoffness: And anger is this little red, stumpy, fire-headed guy, and he sees red and he thinks red and he acts red, and that’s emotion mind. And then you have logical mind, which is like, two plus two is four and the sky is blue and there’s no emotion there. So where they intersect is, again, wise mind. We love wise mind, but oftentimes, when we are in pain voice, we’re in our emotion mind. So the detective questions are pure effing logic, just logic, is this a fact? What evidence do I have that this isn’t true? You’re just questioning your emotional thoughts, and you’re just saying, “Is there logic “and science in these beliefs that I’m believing, “and I’m carrying them around like weighted satchels “on my back, and they’re weighing me down, “and they’re making my pain worse, are they true? “Do I need them? “Can I release them? “Do I need them?” So what evidence do I have that this might not be true? I know a lot of people who have had pain, who have tried a couple of different things, and they actually have gotten better, or in the past, when I did X, Y, and Z, my pain, it changed. It didn’t magically disappear, but it changed, so if my pain can change, maybe there’s hope that something in the future will change it, so things like that.
Dr. Z: And the key thing in this is it takes a little bit of diligence, because that logical mind… So we use the analogy on this show, we use Jonathan Haidt’s analogy of elephant and rider. So elephant is our big, limbic, emotional mind, and rider is the little person on top that evolved recently, that has logic and reason and persuasion, and typically, this is the slave to the elephant, because the elephant’s so much bigger and more unconscious and reactive, and we can grow our rider, we can grow the logical component, but it takes mindfulness to actually recognize what the elephant’s doing, so listening to it, catching it, that’s your first step, and then testing it with the detective questions is where the rider goes, “Okay, elephant, “you’re taking me down a crazy path. “Is this path where we really want to go? “Is it true? “Is this the path we need to be on?” And then you’re asking the questions, and then you can actually start to, even as a society, shape the path to help us walk more carefully. That’s another meta abstraction.
Dr. Zoffness: Yeah, right, the question I ask also is, is this thought helping me or is it hurting me? “I’m broken. “I’ll never get better.” That seems helpful. Let’s keep that one.
Dr. Z: Hey, some people are into pain.
Dr. Zoffness: Well, that’s a whole other animal.
Dr. Z: Right, right, right, but not this. Yeah, that’s great. Yeah, exactly, and again, when applied to depression, it’s the same thing, the negative, “I’m never worthy.” The overgeneralization, “Man, I screwed this up, “which means I’ll always screw this up.”
Dr. Zoffness: Screw everything up, that’s right.
Dr. Z: Yeah, “I’ll always screw everything up,” and then you investigate that, and go, okay, look at your past. Has this always been the case?
Dr. Zoffness: Exactly right.
Dr. Z: Is this something that happens?
Dr. Zoffness: That’s right.
Dr. Z: Now, one of the criticisms that CBT gets sometimes from people who’ve tried it as well, you have to be Spock to be able to out-logic some of these very strong emotions. How do you think about that?
Dr. Zoffness: Yeah, I think there is this bad rap, a little bit, that CBT gets, where, I hear people in the pain world say this too, like, “Oh, you want me to out-think my pain or think pain away.” 100% no, totally not, no. The cognitive stuff I find to be useful, I don’t think it’s the core of CBT, and what I like about CBT is, that book is 200 something pages. If you don’t like a strategy, you don’t have to use it. There’s so many that you can use, and I actually find that with some of my… I actually think the cognitive piece is very important, but some people really hate it and that’s okay, so let’s focus on behavior change. There’s so many things you can do to help your body, by changing decisions you’re making every day. So there’s so many behaviors that you can engage in. So CBT, just to your point, is not about becoming some master of your mind, like you have to become a monk and wrangle all of your thoughts. Literally, what I’m asking you to do, is think about your thoughts, just think about them, and then just challenge them every once in a while, Like is this true? Is this a fact? If you can do that, I am satisfied. So that’s thing one. Thing two is like, okay, when people come to my office, I always ask, “Is what you’re doing working?” The answer is no, you wouldn’t be in my office if what you’re doing to manage your pain is working. So what can we do differently to change your pain? That’s my question. What can we do today that will change your pain, that’s different than what we did yesterday or the last year? So CBT is like an amalgamation of a lot of different things. Yes, we’re working on your mind and your thoughts, but we’re not asking you to think your pain away, or become some sort of Master Buddha. That’s not realistic. It’s just not.
Dr. Z: Yeah, it’s really hard. Yeah, but you don’t need to. You don’t need to do that.
Dr. Zoffness: That’s right.
Dr. Z: And I think one of the things that you mentioned is thinking about your thoughts. I would even dig even deeper and say what you’re trying to do is even be aware, without identifying with them, without losing yourself in Mrs. Beasley. You go, “Wait, there’s Mrs. Beasley. “Okay, now, at least I see her “and I know she’s trying to help, “but I know she’s probably wrong, ’cause she’s often wrong, “and it usually appears at a time when I’m suffering a bit.” There was a Shinzen Yen, I think that’s his name? Shinzen Young, a Zen teacher, has the saying that pain is inevitable, but suffering is optional, and so do you think that this sensation of pain, it’s an energetic sensation, is then overlaid with the voices of Mrs. Beasley, the pain voice, and the other things that are happening, that then generate actual suffering, which is an identification with the pain, the loss of hope in the future, the overgeneralization, all the cognitive distortions that arise, and then losing yourself in identifying with those, and it may just be as simple as… The cognitive stuff is important, but just recognizing, oh, look at this, this is how my mind works, and that takes a little practice and instruction, but then it can become quite automatic.
Dr. Zoffness: The saying that pain is optional and suffering is a choice is one I hear a lot. It’s ubiquitous in another CBT offshoot called ACT, which is acceptance and commitment therapy, and I don’t agree that suffering is a choice.
Dr. Z: Ah, tell me, tell me, yeah, tell me.
Dr. Zoffness: I actually think if you say to someone living with pain, pain is inevitable, but suffering is a choice, they’re like, “Oh, yeah, FU,” because I don’t think suffering is a choice. I think suffering is part of human experience. I think we can make choices that can amplify suffering and amplify pain, and I think we can make choices that reduce suffering and reduce pain, but I do not think that suffering is a choice, and I think saying that to people… This is not a critique of you, obviously, ’cause you did not make up the saying, and I know that it’s a very popular one and I hear it a lot. I do think it’s very dismissive of people living with pain, because you are suggesting that they aren’t doing it right, or that they’re doing something that’s choosing to suffer as much as they’re suffering.
Dr. Z: Right, right, right, right, right, right.
Dr. Zoffness: So I take umbrage, which is another word I really enjoy.
Dr. Z: Yes, another Dolores Umbridge from…
Dr. Zoffness: Another Harry Potter reference by accident.
Dr. Z: Yeah, I think the intentionality of that statement is that you have tools within your power when taught to reduce your suffering.
Dr. Zoffness: Correct, and I embrace that.
Dr. Z: Right, right, so I think we agree. The interesting thing about that suffering piece, that you said, is I actually think a degree of suffering is crucial to the human experience. I don’t think it would exist, if it wasn’t. If we were all Buddhas and have liberated ourselves from suffering because we don’t cling to anything and we don’t grasp, we don’t identify with thoughts. We are just open, ever present, this moment awareness, not a very interesting life. So we can strive towards some asymptote of that to make ourselves feel a little better and have a journey, but, in the end, I think our suffering makes us, first of all, it gives us compassion for others. Without absolutely feeling the worst you’ve ever felt, how will you be able to really understand another person’s pain? It’s very hard to do. So it’s very nuanced and complicated, but I like what you said, that it is dismissive a little bit of people with chronic pain, you’re saying, “It’s just optional, just turn it off.” Yeah, yeah, yeah, yeah.
Dr. Zoffness: “Yeah, you’re suffering. “Well, that’s your problem.”
Dr. Z: You sure don’t have the ability to bootstrap yourself up.
Dr. Zoffness: Yeah, totally.
Dr. Z: Right, exactly.
Dr. Zoffness: Yeah, I think, as you’ve been saying throughout, there is this relationship between anxiety and depression and pain all the time, and there are tools that we can use to manage, so can I give you a metaphor that I like to teach all the time?
Dr. Z: Please.
Dr. Zoffness: And it ties together the relationship between all these things and it explains pain neuroscience, which I’m deeply obsessed with, ’cause neuroscience is rad.
Dr. Z: It’s pretty rad.
Dr. Zoffness: It’s just rad. So here’s what we know about pain. If this gets too nerdy…
Dr. Z: Oh, come on, you’re talking about this show.
Dr. Zoffness: Yeah, fair, okay, all right, so I want you to imagine, in your central nervous system, that you have, what I’m going to call, a pain dial. So it’s like the volume knob on your car stereo. You can turn it up and turn it down to change pain volume.
Dr. Z: Mine goes to 11.
Dr. Zoffness: I’ll keep that in mind.
Dr. Z: All right.
Dr. Zoffness: Okay, and there is no one single pain center in your brain. With certain things, there’s just one center in your brain for that thing, but pain is what we call a diffuse neurological experience, or diffuse neurological process, so there’s lots of parts of your brain that process pain, and there’s three in particular that I’m going to tell you about, because they’re relevant to this pain dial analogy that I want to give you. So one is your prefrontal cortex, responsible for executive functioning and attentional processes, so like what you’re focusing on. Keep that in mind. That affects the pain you feel. The second is your cerebral cortex, the part of your brain, shockingly, responsible for thoughts, back to the cognitive, thoughts affect pain, and the third that I want to tell you about, even though there are like 25, is your limbic system, and as we mentioned at the beginning of the show, your limbic system is your brain’s emotion center. So again, what that tells us, is that pain, this thing we call physical pain, is both physical and emotional 100% of the time. So here’s how this works. Ready? There’s a lot of things that can change pain volumes. This is my five minute pitch. There’s a lot of things that can change pain volume and change your pain dial. So three things in particular, stress and anxiety is one, mood and emotions is two and attention is three. Stress, anxiety, mood or emotions and attention. Here’s how this works. When stress and anxiety are high and your body is tense and tight, say, during a pandemic, and your thoughts are negative, which often happens when we have pain, our brain sends a message to our pain dial, turning it way up, so whatever pain you had before, when you’re stressed or anxious, your pain now feels worse. Thing two is mood. So when mood is low and you’re miserable and depressed, or your emotions are negative, you’re angry, you’re frustrated, your limbic system sends a message to your pain dial, amplifying pain volume. Thing three is attention. So when you are home and in bed and missing work and isolated, like during a pandemic, your prefrontal cortex sends a message to your pain dial, turning it way up. Pain feels worse when you’re focusing on it, which we all know is true. You’re thinking about it, you’re focusing on it, suddenly it feels worse, right? But the opposite is also true. So when stress and anxiety are low and your body is relaxed, your muscles are relaxed and your thoughts are calm, which is why meditation and mindfulness, as you have said, are so helpful for pain, your brain sends a message to your pain dial, turning pain volume down, pain feels less bad. When your mood is high, you’re happy, your emotions are positive, you’re having experiences that are joyful, your limbic system turns down pain volume, amazingly, and three is attention. So when you are distracted and you’re focused on other things, I always ask my patients, tell me about a time you briefly forgot about your pain ’cause you were so absorbed in some activity, and most of us have had that experience, where you’re just so absorbed in something, you just briefly forget about everything else, right?
Dr. Z: The flow state, yeah.
Dr. Zoffness: Right, and that’s not magic actually. This is your pain dial in action. So when you are really distracted away from your pain, your prefrontal cortex turns down your pain dial, so that’s why distraction strategies work, even with kids getting vaccines, which is such an important thing that’s going to be happening very soon, you distract kids with screens. It’s like the one time in my life that I’m like, “Use screens all you want.”
Dr. Z: Use screens, yeah.
Dr. Zoffness: When you’re distracted, your pain dial is turned down, so pain feels less bad. So back to your point, there are so many things we can do to turn down pain volume, but what happens in our culture is that we throw pills and procedures at pain, and we lose this whole other two thirds of our biopsychosocial pain problem, and we’re not paying attention to all these other things that we have agency over, that we have power over. Pain is in our body. We have control over our brains and bodies. We just forget that. We have this external locus of control, where all there is are pills and procedures, and that’s what we do for pain.
Dr. Z: Nailed it.
Dr. Zoffness: Thank you.
Dr. Z: That’s it. That’s the summary of your whole book.
Dr. Zoffness: Oh, thank you.
Dr. Z: What it is, your book says, “Okay, here’s the pain dial. “Here are the different levels.” Like you said, prefrontal cortex, attention, cortex, thought, limbic, emotion, all influence pain dial, so here are several different strategies, and you don’t have to just pick one, you don’t have to use this one if you don’t like it, but you can mix and match to turn your pain dial down, and whether it’s diaphragmatic breathing, which triggers a parasympathetic relaxation response, which lowers cortisol and stress, lowers the pain volume, or whether it’s biofeedback, which was an amazing piece of the book, where you’re talking about making your hands heat up. It’s a Wim Hof cold method kind of thing, and it works. It works.
Dr. Zoffness: It’s amazing.
Dr. Z: Whether it’s EEG feedback, using one of the devices where you’re measuring brainwaves and chilling them out, there are so many non-pharmacologic options, and then you have the pharmacologic options too. Okay, now, here’s where we’re going to… We should dive into this a little bit, and it will piss people off, but you know what? That’s the whole idea of everything we do, is to make people angry, so that they think, and they wake up a little bit. Opioids, so in the US, we use, what? 80% of the world’s opioids? We don’t have 80% of the world’s pain. We just respond to it in a reductionist one quadrant way, which is, well, everything’s biomedical, so here’s a pill. Now, what is the downside of opioids for…? We know that they can work for acute pain, what is the downside of opioids for chronic pain, when it comes to this pain dial?
Dr. Zoffness: Right, so I think I mentioned, I’m a nerd with a capital N and I believe in science. It’s how I make sense of the world. What we know about opioids from research, just research, is that actually what they do over time is sensitize the brain to pain. So over time, actually, opioids are turning up your pain dial and you need more to have the same effect. Everyone has experienced that. Anyone who’s been on opioids knows you develop a tolerance. Yes, what that means is your brain is getting more sensitive to pain over time, so opioids are making you worse. I am not anti-opioid. Thank God for opioids seriously.
Dr. Z: Yeah, they’re a lifesaver.
Dr. Zoffness: Totally, and there’s a time and a place to use them, and because there is so little pain education in the United States… By the way, 96% of medical schools in the United States and Canada have zero dedicated compulsory pain education, 96% of medical schools, so because pain is so poorly taught and so poorly understood, we just throw pills at it, because, again, to your point before, this is not malicious. Of course, everyone who’s a healthcare provider just wants to ease pain and suffering. We all want to do that, and with a lack of education, you just do it the best way you know how. You’ve maybe heard that opioids can help pain, so you throw pills at it. We’re doing that less now, of course, ’cause the epidemic. I’m not trying to throw anyone under the bus here, is what I’m trying to say. Everyone has good intent, except for big pharma. I’ll throw them under the bus all day long.
Dr. Z: Absolutely, yeah.
Dr. Zoffness: Yeah, I can’t even deal with that. We’ll talk about that, but just to say, opioids, we know for a fact, is this a fact? Yes. We know for a fact that opioids are not effective treatments for chronic pain. No one’s debating it. It’s not even a conversation. Everyone knows that that’s true. So do you want opioids for a surgery, post-surgical pain? Yeah, yes, you do, and thank blessings, but do you need them long-term? No, they’re gonna make you worse.
Dr. Z: So I agree. When I’ve said this on the show, I get death threats from people with chronic pain.
Dr. Zoffness: I know, I’m worried about that too, but I’m not anti-opioid. I am all about wellness and health.
Dr. Z: Well, yeah, yeah, so here’s a question, and I think this is important, because many in the chronic pain community are suffering very deeply. The opioid is now part of their lives, for better or for worse. Their pain threshold is up. They have opioid hyperalgesia, whatever you want to call it, and now they’re terrified, because this pendulum swung the other way, and they’re like, “You’re going to take my one thing “that keeps me alive away.” And the truth is, if you did take it away, they would go into horrible withdrawal, their pain would go through the roof. How do you think about this? What do we do?
Dr. Zoffness: I should be really careful to say, just because we know that opioids are not an effective treatment for long-term pain, does not mean that we should rip people off of their opioids, if they have been on them long-term. In fact, because opioids sensitize the brain to pain, what’s going to happen if you rip people off their opioids is suffering and pain, both of them, are gonna be through the roof, so what we actually need to do is provide alternative treatment and support to people who have already been prescribed opioids, and there are a lot of people who are doing work in this space. One of them is Beth Darnall, who’s another pain psychologist. There’s a lot of research being done on ethical tapering and how to have conversations about ethical tapering, if people even want to taper, and the conversation we need to have about whether or not it’s even ethical to rip people off of their opioids, if they’ve been on them for long periods of time, because is that their fault? And the answer is no. Physicians, the people they were trusting.
Dr. Z: Who were acting with good intent,
Dr. Zoffness: Put them on this medication.
Dr. Z: Like you said, I think, when pharma told us back in the day, hey, you can help people without addiction, we wanted to believe them, because we want to help people without addiction. It’s not like we’re bad people. Well, some of us are. Some of us, the pill mill doctors–
Dr. Zoffness: The Slytherins.
Dr. Z: Yeah, the Slytherins.
Dr. Zoffness: No, just kidding.
Dr. Z: But you know what? Snape was a Slytherin.
Dr. Zoffness: Yeah, I know. Bless his soul.
Dr. Z: Yeah, he was a complex guy actually. In the end, he was a little bit creepy around Harry’s mom. I’m very concerned about the whole situation there, but that’s a whole ‘nother conversation. I think the key thing is let’s try to avoid starting opioids for chronic pain.
Dr. Zoffness: Correct.
Dr. Z: Let’s try to be very mindful about when we start them for acute pain, when we have modalities. Again, if the mind, body thing is so important, even telling patients, “Listen, this Tylenol plus NSAID together “seems to help 95% of people feel so much better, “that they don’t even need to escalate to something “like an opioid that has these risks, “so let’s start with this.” And, as we approach an hour here, I want to be mindful of your time, ’cause I think you’ve gotta dart across back to the bay and do what it is you do, which is help people who are suffering with pain, which is a cool… Do you ever feel like, “I get to do this,” how awesome that is?
Dr. Zoffness: Totally, I actually feel like it’s selfish because I feel so good about it, I love it so much. I love it, yeah. I said this before, I really do feel like pain is a ubiquitous human experience, and I wish that I had known what I know about pain now a million years ago. I think it would have changed my own journey. Luckily, I was never hooked on opioids, but I’ve so much compassion for people who that’s their only means of pain control because it’s just such a deeply flawed space in medicine, the way we treat pain and the way we treat pain patients and stigmatize them.
Dr. Z: Yeah, it’s really awful. We’re going to look back and go, “Barbaric.”
Dr. Zoffness: Oh, it totally is barbaric.
Dr. Z: You’re a nerd, right? Are you a Star Trek nerd?
Dr. Zoffness: I’m not, I’m sorry.
Dr. Z: Okay, that’s too bad, because Bones went back to 1980’s San Francisco, he’s the doc, and he saw that they were doing dialysis on a woman, and he was like, “Dialysis, barbarians, “just take one of these and call me in the morning.” And, of course, he’s a reductionist, but I think that’s how we’re going to look back at pain and go, “We were barbaric. “What were we doing? “This amount of suffering.” This is what I propose. Will you come back and dive in more about… Okay, now, I should mention this book, let me get it in focus, “The Pain Management Workbook”, and I’ll put a link to your Amazon. It’s excellent. Will you come back and talk to me about fibromyalgia and talk to me about these chronic pain syndromes, CRPS? Will you talk to me about…? ‘Cause they’re the bane of physicians, ’cause we feel powerless, and so do you promise you’ll come back and talk about those things?
Dr. Zoffness: Sure.
Dr. Z: Do you have stuff to say about ’em?
Dr. Zoffness: I always have stuff. Can you tell that I always have stuff to say? I have strong opinions and I state them strongly, as a true New Yorker.
Dr. Z: I thought there was something about you I liked. The, “I’m going to bite down on the doubloon “and see if what we say is true.”
Dr. Zoffness: We can talk about doubloons.
Dr. Z: Me pirate doubloon voice says, “Aye, Rachel Zoffness, “thank you for coming on me show.”
Dr. Zoffness: This was so interesting and so fun.
Dr. Z: It was such a joy, and the last thing I want to say is I once had a little routine I would do for the interns, when I was in attending.
Dr. Zoffness: I’m scared.
Dr. Z: It was called a pirate MD,
Dr. Zoffness: Oh, dear.
Dr. Z: And the whole idea is if we just trained physicians like they train pirates… We forced them to obey pirate rules, for example. Everyone had to have a little spirit animal on their shoulder, and when you presented a patient, you had to do it in full pirate, so you’d be like, “Aye, Bed 5 Mr. Williams is a 33 year old landlubber,
Dr. Zoffness: That is delightful.
Dr. Z: “status post “keelhauling.” Oh, go ahead.
Dr. Zoffness: If you F up, do you have to walk off the plank?
Dr. Z: Oh, yeah, yeah. “Dispo to the plank.” Every diagnosis is scurvy. It’s like, “Number one, scurvy. “Plan: the plank. “Number two, also scurvy. Plan: keelhauling.”
Dr. Zoffness: Do you prescribe rum? Is that the number one?
Dr. Z: Rum TID PRN, angst. Pirate angst. I love it. Rachel, what a joy. Thank you, thank you for sharing your wisdom with us.
Dr. Zoffness: Thanks for having me on.
Dr. Z: And we’ll have you back. Guys, if you like this sort of thing, please share the show with someone you know, who’s suffering from pain, or yourself. Check out the book. Really, we need to change the paradigm about how we think about this stuff, and if you want to change the paradigm about how we do social media and improve our overall discourse with an Alt-Middle critical way of thinking, then support our show on YouTube, Facebook, Locals, wherever you like. Just go to zdoggmd.com/supporters, or you can support us one-time at paypal.me/zdoggmd, and I will send you a personal thank you email and a pirate emoji, arrr! All right, I love you all. We out. Thank you, professor.
Dr. Zoffness: Thank you, thank you.
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