#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
In this episode of The Peter Attia Drive, Dr. Sean Mackey explores the complex nature of pain, explaining how modern science has moved beyond viewing it as a simple mind-body phenomenon to understanding it as an integrated bio-psycho-social experience. He breaks down three main types of pain—nociceptive, visceral, and neuropathic—and discusses how each type responds to different treatment approaches.
The discussion covers various pain management strategies, from traditional medications to neuromodulation techniques, while examining how psychological factors and sleep influence pain perception. Host Peter Attia shares his personal experience with chronic back pain and subsequent recovery, offering context for the challenges of pain management and the journey toward healing. The episode provides insights into both the evolutionary purpose of pain and current approaches to treating it.
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1-Page Summary
The Definition and Evolutionary Purpose of Pain
Sean Mackey describes pain as both a sensory and emotional experience linked to actual or potential tissue damage. Modern understanding has evolved from Descartes' mind-body dualism to recognize pain as an integrated bio-psycho-social phenomenon. From an evolutionary perspective, Mackey explains that pain serves as a vital survival mechanism, conserved across species dating back to single-cell organisms. The experience of pain varies significantly among individuals, as demonstrated in conditions like fibromyalgia where patients show impaired pain inhibition.
The Different Types of Pain and Their Characteristics
Three main types of pain are discussed. Nociceptive pain, transmitted through A-Delta and C fibers, responds well to traditional analgesics and is typically localized. Visceral pain, originating from internal organs, is more diffuse and can result in referred pain due to signal convergence in the spinal cord. Neuropathic pain, stemming from nervous system damage, presents as burning or shock-like sensations and requires specialized medications like anti-convulsants for treatment.
Pain Management Approaches
The discussion explores various pain management strategies. Mackey notes that while NSAIDs and acetaminophen are effective for nociceptive pain, they have limitations and potential side effects. Neuromodulation techniques like TENS work by activating A-beta fibers to inhibit pain signals. Psychological factors significantly influence pain perception, with depression and anxiety potentially amplifying pain experiences. The experts emphasize that sleep deprivation can increase pain sensitivity and worsen chronic pain conditions.
Personal Experiences With Chronic Pain
Peter Attia shares his journey with severe back pain, including multiple surgeries and chronic neuropathic pain that threatened his medical career. His recovery involved various treatments at a pain clinic, including lidocaine treatments and spinal injections. The experience gave him valuable insight into chronic pain management and fostered empathy for patients dealing with similar challenges, particularly those struggling with opioid addiction.
1-Page Summary
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Clarifications
- Descartes' mind-body dualism is a philosophical concept that suggests the mind and body are separate entities. According to Descartes, the mind is non-physical and distinct from the physical body. This idea contrasts with views that consider the mind and body as interconnected or inseparable. Descartes' dualism has influenced discussions on the relationship between mental experiences and physical processes.
- Signal convergence in the spinal cord occurs when sensory signals from different areas of the body converge onto the same neurons in the spinal cord. This convergence can lead to the brain interpreting signals from one area as originating from another, causing referred pain. In the case of visceral pain, where the pain originates from internal organs, the convergence of signals in the spinal cord can contribute to the experience of pain being felt in a different location than the actual source.
- Anticonvulsants, also known as antiepileptic drugs, are medications used to treat epileptic seizures by suppressing excessive neuron firing. They can also be effective in managing neuropathic pain by targeting various mechanisms in the brain, such as sodium channels and GABA receptors. These drugs work by reducing the release of excitatory neurotransmitters like glutamate while enhancing the function of inhibitory neurotransmitters like GABA. Anticonvulsants have diverse mechanisms of action and are increasingly used beyond epilepsy treatment, including for mood stabilization in conditions like bipolar disorder.
- Neuromodulation techniques like TENS (Transcutaneous Electrical Nerve Stimulation) involve using a device that delivers electrical impulses to nerve fibers through the skin. These electrical signals can help modulate or change how pain signals are perceived by the brain, providing relief from various types of pain. TENS is commonly used as a non-invasive and drug-free method for managing pain, particularly neuropathic pain conditions. The stimulation from TENS devices can help reduce pain perception and promote the release of endorphins, the body's natural painkillers.
- Lidocaine treatments involve the use of lidocaine, a local anesthetic, for managing pain. Lidocaine can be administered through various methods like injections or topical applications to numb specific areas. It is commonly used in pain clinics for conditions like neuropathic pain. Lidocaine treatments can provide temporary relief by blocking nerve signals responsible for transmitting pain sensations.
- Opioid addiction is a condition where individuals develop a dependence on opioids, needing the drug to prevent withdrawal symptoms. This addiction can stem from overuse or misuse of prescription painkillers or recreational opioid use. Over time, tolerance to opioids can develop, leading to increased doses and potential health risks. The opioid epidemic in recent years has highlighted the serious consequences of opioid addiction, including overdose deaths and societal impacts.
Counterarguments
- While pain is often linked to tissue damage, some pain syndromes, such as certain types of neuropathic pain, may not have an identifiable source of tissue damage.
- The bio-psycho-social model is comprehensive, but some argue that it may not fully account for the complexity of pain, such as the role of genetics and the immune system.
- The evolutionary purpose of pain is clear, but chronic pain that persists without a clear biological function challenges the idea that all pain serves a survival mechanism.
- The variability in pain experience is recognized, but there may be underappreciated factors such as cultural and societal influences that modulate this variability.
- While fibromyalgia is characterized by impaired pain inhibition, the pathophysiology of the condition is not fully understood, and there may be other mechanisms at play.
- The classification of pain into nociceptive, visceral, and neuropathic is useful, but some pain conditions may involve overlapping mechanisms that do not fit neatly into these categories.
- The effectiveness of NSAIDs and acetaminophen is well-documented, but their role in managing chronic pain is limited, and some argue for more emphasis on non-pharmacological treatments.
- Neuromodulation techniques like TENS are not universally effective and may not provide long-term relief for all patients.
- The impact of psychological factors on pain is significant, but the causal direction (whether psychological distress causes pain or vice versa) can be complex and varies among individuals.
- The relationship between sleep deprivation and pain is bidirectional, and while poor sleep can worsen pain, chronic pain can also lead to sleep disturbances.
- Personal experiences, such as Peter Attia's, are valuable, but they may not be generalizable to all patients with chronic pain, and individual responses to treatment can vary widely.
- The focus on opioid addiction is important, but it is also necessary to consider the challenges of patients who legitimately require opioids for pain management and the risk of under-treatment of pain.
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The Definition and Evolutionary Purpose of Pain
The podcast delves into the complexities of pain, exploring its definition, its place in the evolutive history of species, and how it varies among individuals.
Pain Is an Unpleasant Sensory and Emotional Experience Tied To Actual or Potential Tissue Damage
Descartes' Dualism Replaced by Bio-psycho-Social Pain Model
Sean Mackey describes pain as a dual sensory and emotional experience that signals actual or potential tissue damage. The discussion moves from Rene Descartes' dualistic model, which divides body and mind, to the contemporary understanding that pain is an integrated bio-psycho-social phenomenon. The transformation indicates a broader understanding of how pain involves not only physical sensations but also emotional and psychological facets.
Pain: A Vital Mechanism For Avoidance and Healing
Pain Perception Conserved Across Species and Evolutionarily Selected
Pain is revealed as a motivator essential for the survival of species, including humans. Its fundamental purpose is to act as a harm alarm, leading organisms to avoid danger and seek basic needs, such as food and sex. Dr. Sean Mackey emphasizes that from an evolutionary standpoint, pain has been conserved dating back to single-cell organisms. He also suggests that pain encourages individuals to remain safe until healing occurs, indicating its vital protective mechanism that has been evolutionarily selected.
Furthermore, Mackey elaborates on the conservation of pain responses across species, explaining the relevance of "conditioned pain modulation" (CPM) in humans and "diffuse noxious inhibitory control" (DINEC) in animals. This shared mechanism, where pain in one area can reduce pain in another, highlights the deeply ingrained evolutionary function of pain.
Pain Experience Varies Among Individuals
When discussing the individual variation in pain experience, it is noted that the same stimulus may cause substantially different pain responses among different individuals. T ...
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The Definition and Evolutionary Purpose of Pain
Additional Materials
Clarifications
- Descartes' dualism model of pain is based on the idea that the mind and body are separate entities. In this context, pain was seen as a purely physical sensation without emotional or psychological components. This model has been replaced by a more holistic bio-psycho-social approach that recognizes pain as a complex experience involving sensory, emotional, and psychological aspects. The contemporary understanding of pain emphasizes the interconnected nature of physical sensations, emotions, and social factors in shaping an individual's experience of pain.
- The biopsychosocial pain model integrates biological, psychological, and social factors to understand pain. It emphasizes that pain is not solely a physical sensation but also involves emotional and social components. This model provides a comprehensive framework for studying and addressing pain from a holistic perspective. It highlights the interconnected nature of pain experiences, considering not just the physical injury but also the psychological and social influences on pain perception.
- Conditioned pain modulation (CPM) in humans is a phenomenon where the perception of pain in one part of the body can be reduced by the application of a painful stimulus elsewhere. This process involves the body's ability to modulate or regulate pain signals through complex neural pathways. CPM is a form of endogenous pain modulation, meaning it involves the body's internal mechanisms for managing pain. Understanding CPM is crucial in studying individual differences in pain perception and developing strategies for pain man ...
Counterarguments
- The bio-psycho-social model of pain, while comprehensive, may not fully account for all aspects of pain, such as the role of consciousness and the subjective nature of pain.
- The evolutionary purpose of pain, while generally protective, can sometimes be maladaptive, as in the case of chronic pain conditions where pain persists without clear benefit.
- The conservation of pain across species suggests a common mechanism, but the subjective experience of pain may differ significantly between species, and anthropomorphizing animal pain can be misleading.
- The idea that genetic variations related to pain have been weeded out through natural selection oversimplifies the complex interplay between genetics and environment in the development of pain sensitivity.
- The suggestion that hormonal changes during childbirth adjust the pain experience to support procreation may not fully explain the wide variability in pain experiences reported by birthing individuals.
- The mechanisms like CPM and DINEC, while observed in both humans and animals, may operate differently in complex organisms with higher-order brain functions.
- The assertion that pain motivates organisms to seek basic needs like food and sex may not encompass all motivational drives or explain pain experiences unrelate ...
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The Different Types of Pain and Their Characteristics
The discussion with Sean Mackey delves into the complex world of pain, exploring different types of pain, how they are transmitted, and how they respond to treatments.
Nociceptive Pain: Localized, Caused by Primary Nociceptors, Responds To Analgesics
Nociceptive pain originates from tissue damage and is mediated by primary nociceptors. These special sensory receptors act as transducers, converting various forms of energy like heat, pressure, and chemical changes into electrical signals. Sean Mackey explains that these signals are transmitted up the nerves to the brain, although they may not always correlate directly with the experience of pain.
Nociceptive Signals via A-Delta, C Fibers to Spinal Cord, Brain
A-Delta fibers are myelinated, quickly transmitting sharp, acute pain signals to the brain, which evoke immediate withdrawal reflexes. C fibers, conversely, are unmyelinated, contributing to a slower, burning sensation of pain that emerges seconds later. Despite their difference in speed, both fiber types are crucial in conveying pain signals to the brain. These signals are fully impacting the spinal cord and brain even when a patient is unconscious, such as during surgery.
The ability of nociceptive pain to respond to analgesics and its characteristically localizable and time-limited nature make it relatively easier to manage. Analgesic agents like acetaminophen, NSAIDs, COX-2 inhibitors, and opioids are typically used for acute nociceptive pain management. Mackey also notes that TENS (transcutaneous electrical nerve stimulation) might be effective for those with nociceptive musculoskeletal pain, while acupuncture can increase peripheral adenosine, which has an analgesic effect at the nociceptor.
Visceral Pain: Diffuse Fields and Referred Pain
Visceral pain arises from the internal organs within the thoracic, abdominal, or pelvic regions and is challenging to pinpoint due to its diffuse nature. Typically expressed with broad gestures over the affected areas, this type of pain does not respond to the same stimuli as nociceptive pain witnessed superficially.
Convergence of Pain and Somatic Signals in the Spinal Cord Leads To Referral Pattern
Referred pain, a phenomenon of visceral pain, is explained by viscerosomatic convergence. The spinal cord conflates sensory signals from both internal organs and other body parts, leading to pain being felt in areas distant to its origin. Classic examples include shoulder pain resulting from diaphragmatic irritation or the arm pain that accompanies a heart attack.
Neuropathic Pain Is Due to Nervous System Injury or Dysfunction
Neuropathic pain stems from damage to the nervous system itself. Mackey discusses various causes like trauma, surgery, or strokes and describes ...
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The Different Types of Pain and Their Characteristics
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Clarifications
- Nociceptors are specialized sensory receptors that detect potentially damaging stimuli, such as heat, pressure, or chemicals. They act as transducers by converting these stimuli into electrical signals that can be transmitted to the brain. Essentially, nociceptors play a crucial role in the initial detection and transmission of pain signals in the body.
- A-Delta and C fibers are types of nerve fibers responsible for transmitting pain signals to the brain. A-Delta fibers are myelinated, fast-conducting fibers that transmit sharp, acute pain signals. In contrast, C fibers are unmyelinated, slower-conducting fibers that transmit dull, burning pain signals. Both types of fibers play essential roles in conveying different aspects of the pain experience to the brain.
- Viscerosomatic convergence is a neurological phenomenon where sensory signals from internal organs and body parts converge in the spinal cord, leading to the brain interpreting pain in areas distant from the actual source. This convergence can cause pain to be felt in regions that are not directly related to the affected internal organ, creating what is known as referred pain. It explains why conditions like a heart attack can manifest as pain in the arm or shoulder due to the overlapping nerve pathways in the spinal cord.
- Gabapentinoids are a class of medications commonly used to treat neuropathic pain. They work by affecting certain neurotransmitters in the brain and spinal cord to help reduce pain signals. Examples of gabapentinoids include [restricted term] and pregabalin. These medications are often prescribed when traditional pain relievers are not effective in managing neuropathic pain.
- Complex regional pain syndrome (CRPS) is a rare neuroinflammatory disorder causing chronic pain and various symptoms. It can start in one limb and spread, with types 1 and 2 distinguished by the presence of nerve injury. CRPS involves inflammation, pain hypersensitivity, vascular dysfunction, and neuroplasticity changes. Symptoms typically appear near the initial injury site.
- Small fiber neuropathy is a type of peripheral neuropathy that affects the small nerve fibers in the body, leading to symptoms like severe pain, tingling, and abnormal skin sensations. These small nerve fibers are responsible for transmitting sensory information and controlling autonomic functions. The condition can cause stabbing or burning pain, often starting in the hands or feet and spreading to other areas of the body. Small fiber neuropathy can be challenging to diagnose and manage due to its diverse sympt ...
Counterarguments
- While nociceptive pain typically responds to analgesics, there are cases where patients may not experience adequate relief, indicating variability in individual responses to pain medication.
- The effectiveness of TENS and acupuncture for nociceptive musculoskeletal pain can vary, and some studies have shown mixed results regarding their efficacy.
- The characterization of visceral pain as not responding to the same stimuli as nociceptive pain might be oversimplified, as there can be overlap in the types of stimuli that affect both nociceptive and visceral pain.
- The concept of referred pain due to viscerosomatic convergence is well-established, but the exact mechanisms and reasons why certain visceral pains refer to specific areas are not fully understood and may involve more complex neural networks.
- While neuropathic pain is often resistant to ordinary analgesics, there are instances where patients with neuropathic pain may still find some degree of relief from these medications, suggesting a need for individualized treatment plans.
- The use of anti-neuropathic medications like gabapentinoids is common, but these drugs can have side effects and may not be effective for all ...
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Pain Management Approaches: Medications, Procedures, Psychology, Sleep
Peter Attia, Sean Mackey, and others discuss the multifaceted strategies for managing pain, including medications, procedures, psychological factors, and the role of sleep in pain perception.
Oral NSAIDs and Acetaminophen Effective, but Limited, for Nociceptive Pain
Oral NSAIDs like Advil and acetaminophen are well-known medications that Peter Attia and Sean Mackey discuss as part of the pain management repertoire, particularly for nociceptive or inflammatory pain. Mackey notes that NSAIDs vary in efficacy between individuals, hinting at individual variability in responses. They may be more effective for acute and certain chronic forms of pain like back pain, even though they may only slightly reduce pain.
NSAIDs May Delay Healing; Acetaminophen's Action Unclear
Attia and Mackey discuss concerns regarding NSAIDs, including how they may delay the natural healing process, especially for minor injuries. Mackey advises discussing NSAID use with a doctor, especially for older individuals or those with kidney or gastrointestinal issues. For acetaminophen, Attia highlights potential liver damage from overdose, while Mackey adds that its mechanism of action remains somewhat unclear, with suggestions that it may affect the central nervous system and potentially cause some emotional blunting. They agree that a combination of acetaminophen and ibuprofen can be synergistic, providing enhanced pain relief while reducing the need for high doses of either medication.
Neuromodulation: TENS Activates Large Myelinated A-Beta Fibers to Inhibit Pain Signals
Mackey explains Transcutaneous Electrical Nerve Stimulation (TENS) as a method leveraged for its neuromodulatory effect to manage pain via electrical stimulation that activates A-beta fibers. The stimulation of these fibers can inhibit nociceptive signals in the spinal cord, reducing the perception of pain.
Gate Theory: A-Beta Fibers Inhibit Nociceptive Signals
The discussion touches on the gate control theory, which involves descending control systems from the brain and how they converge in the spinal cord to regulate signals. A-beta fibers act in this theory as touch fibers that facilitate gating to modulate pain signals. Mackey explains that activating these fibers by rubbing an injury or using TENS can help reduce pain sensation, suggesting individual variability in pain experience rooted in this mechanism.
Psychological Factors Amplify Pain and Impair Coping Ability
In the context of psychological influences on pain, factors such as preo ...
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Pain Management Approaches: Medications, Procedures, Psychology, Sleep
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Clarifications
- Nociceptive pain is the type of pain that arises from actual or potential tissue damage. It is a protective mechanism that alerts the body to harmful stimuli. Nociceptors, specialized nerve endings, detect noxious stimuli like heat, cold, or pressure, and send signals to the brain to trigger a pain response. This type of pain is distinct from neuropathic pain, which arises from damage to the nervous system itself.
- A-beta fibers are large myelinated nerve fibers that play a role in inhibiting pain signals in the body. They are activated through methods like Transcutaneous Electrical Nerve Stimulation (TENS) to help reduce the perception of pain by interfering with nociceptive signals in the spinal cord. These fibers are part of the gate control theory, which involves regulating pain signals in the spinal cord through touch fibers like A-beta fibers. Activating A-beta fibers can help modulate pain sensation and reduce the perception of pain, showing individual variability in how people experience pain.
- The gate control theory of pain suggests that non-painful input can reduce the perception of pain by closing "gates" in the nervous system. This theory explains how sensations other than pain can influence and modulate the experience of pain. It was proposed in 1965 by Ronald Melzack and Patrick Wall, providing a new understanding of how pain signals are processed in the brain and spinal cord. The theory highlights the complex interplay between different types of sensory input in regulating pain perception.
- Neuromodulation involves using electrical or chemical signals to influence the activity of neurons in the nervous system. It can help regulate pain perception by targeting specific nerve fibers to alter pain signals. Techniques like Transcutaneous Electrical Nerve Stimulation (TENS) leverage neuromodulation to manage pain by activating certain nerve fibers that can inhibit pain signals. Neuromodulation plays a crucial role in pain management by modulating how pain signals are processed in the brain and spinal cord.
- Transcutaneous Electrical Nerve Stimulation (TENS) is a therapy that uses a device to deliver mild electrical currents through electrodes placed on th ...
Counterarguments
- While NSAIDs and acetaminophen are commonly used, their long-term effectiveness and safety profile are not ideal for all patients, and alternative treatments may be necessary.
- The variability in NSAID efficacy suggests that personalized medicine approaches could be more effective in managing pain for different individuals.
- The potential for NSAIDs to delay healing may not be significant in all types of injuries or tissues, and more research is needed to fully understand this relationship.
- The unclear mechanism of action of acetaminophen raises questions about its precise role in pain management and whether there might be more effective alternatives.
- The synergistic effect of combining acetaminophen and ibuprofen may not be experienced by all patients, and there are risks associated with combining medications without medical supervision.
- TENS may not be effective for all types of pain or all patients, and its efficacy can vary widely.
- The gate control theory is a simplified model of pain perception, and actual pain modulation is more complex and involves multiple pathways and factors.
- Psychological factors are indeed important in pain perception, but the relationship is complex, and interventions targeting these factors may not be effective for all patients.
- The link between preoperative psychological states and postoperative opioid use is not deterministic, ...
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Personal Experiences With Chronic Pain and Its Impact
Podcast host Peter Attia shares his intimate journey through severe back pain, surgeries, and chronic neuropathic pain, shedding light on the profound ways in which persistent pain can jeopardize one's career and quality of life.
Podcast Host Recounts Severe Back Pain, Surgeries, and Chronic Neuropathic Pain
During his third year of medical school, Attia recalls a severe back pain episode that started after getting off his bike, leaving him incapable of getting out of bed without assistance. This was due to a significant herniation at the L5 S1 disc, with a fragment pressing on the S1 nerve root, which led to extreme pain. Despite undergoing discectomies and laminotomies, he developed chronic neuropathic pain that didn't initially respond to procedures like a lidocaine treatment.
Severe Pain Jeopardized His Medical School Completion and Career Pursuits
This pain significantly threatened Attia's completion of medical school and his goal of becoming a surgeon. The psychological impact of potential career loss due to chronic pain was a distressing element for Attia. He humorously reflects on how adolescent risk-taking could easily lead to injury and pain, offering a glimpse into his past experiences that may have contributed to his condition.
Pain Clinic Treatments Aid Host's Recovery and Function
Attia sought help at a pain clinic on the recommendation of his then-partner. Procedures such as an IV lidocaine drip, spinal injections, and targeted treatments at the T12 L1 area finally brought temporary relief. These interventions allowed Attia to engage in rehabilitation, which was critical for him to rebuild back strength and improve mobility within nine months to a year of the initial injury. He pursued his rehabilitation with intense determination and ultimately improved his functional capacity.
Acknowledging Challenges in Chronic Pain Management and Value of Interdisciplinary Approach
The podcast features discussions on pain management, implying the necessity of an interdisciplinary approach in addressing chronic pain effectively. Dr. Sean Mackey mentions the usage of [restricted term] and the importance of managing sleep in chronic pain treatment, while also reflecting on the variable success of acupuncture in treating different types of pain.
Host's Journey Informs Empathy In Treat ...
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Personal Experiences With Chronic Pain and Its Impact
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Actionables
- You can create a personal pain management journal to track your symptoms and treatment effectiveness. Start by noting daily pain levels, activities, diet, and sleep patterns. This data can help you identify triggers and patterns in your pain, which you can then discuss with healthcare providers to tailor your treatment plan more effectively.
- Develop a mini routine of gentle back exercises to do throughout the day. Incorporate simple stretches and core-strengthening movements that you can perform at your desk or during breaks. This can help maintain back strength and mobility without requiring a significant time commitment or special equipment.
- Engage in a virtual support group for chronic pain to en ...
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