Dr. Sean Mackey: Tools to Reduce & Manage Pain
17 Jan 2024 (8 months ago)
- Dr. Sean Mackey is a medical doctor and a PhD who is the chief of the division of pain medicine and a professor of both anesthesiology and neurology at Stanford University School of Medicine.
- Pain is a complex and subjective experience that serves to keep us away from injury or harm.
- Pain is both a sensory and an emotional experience and is incredibly individual.
- Chronic pain affects about 100 million Americans and costs about half a trillion dollars a year in medical expenses.
- Pain is a complex and subjective experience that serves a crucial role in keeping us away from injury or harm.
- Pain is both a sensory and an emotional experience.
- Pain is incredibly individual and can vary significantly from person to person.
- Chronic pain is a persistent pain that lasts for more than 3 months and can have a significant impact on a person's life.
- Chronic pain affects about 100 million Americans and costs about half a trillion dollars a year in medical expenses.
- Pain is not simply a physical sensation, but also involves emotional and cognitive components.
- There is no single "pain center" in the brain, but rather a distributed network of brain regions that contribute to the experience of pain.
- Brain-based biomarkers can be used to identify common brain networks that represent the experience of pain.
- NSAIDs (nonsteroidal anti-inflammatory drugs) like ibuprofen and naproxen are not technically analgesics (painkillers).
- NSAIDs reduce inflammation and sensitization in the injured area and the spinal cord.
- Opioids are analgesics that can potentially cause harm if taken in high doses.
- The threshold for treating pain should be based on its impact on quality of life and daily activities.
- Common over-the-counter NSAIDs include ibuprofen, naproxen, and acetaminophen (Tylenol).
- Aspirin is not considered an NSAID but has anti-inflammatory and anti-hyperalgesic effects.
- It's important to balance pain relief with the potential delay in healing caused by NSAIDs.
- Individual variability exists in the effectiveness of NSAIDs, so rotating them can be beneficial.
- NSAIDs should be taken with food and plenty of fluids to minimize side effects.
- Talk to a doctor before taking NSAIDs if you have any underlying health conditions.
- Prostaglandins are one of the main ways the immune system responds to injury and creates inflammation.
- Inflammation sensitizes the injured area, making it more sensitive.
- NSAIDs can help with pain and function but may delay the healing process.
- Balancing pain relief with healing is crucial, and the lowest effective dose of NSAIDs should be used.
- NSAIDs should be taken with food and plenty of fluids to minimize side effects.
- Individual variability exists in the effectiveness of NSAIDs, so rotating them can be beneficial.
- Aspirin in low doses (81 mg) acts as an antiplatelet agent and may benefit heart health.
- Higher doses of aspirin (325 mg) have anti-inflammatory effects similar to NSAIDs.
- Caffeine can potentiate the analgesic response and be effective for headaches and migraines.
- Caffeine can cause stomach irritation, so it's best to take NSAIDs with food.
- Tylenol (acetaminophen) is safe on the stomach but should not exceed 4,000 milligrams per day.
- COX-2 inhibitors like celecoxib are less irritating to the stomach but require a prescription.
- Gate control theory of pain: rubbing, shaking, or running water on an injured area activates touch fibers that send signals to the spinal cord, inhibiting pain signals.
- Kissing an injured area can reduce pain due to the activation of touch fibers and positive emotional salience.
- Transcutaneous electrical nerve stimulation (TENS) devices use electrical stimulation to activate touch fibers and reduce pain.
- The mechanism of action for mechanical interventions like rubbing or shaking occurs in the spinal cord, not at the site of the injury.
- Pain threshold is the stimulus intensity that results in the onset of pain.
- Men generally have higher pain thresholds to heat stimuli than women, but there is significant individual variability within both genders.
- The difference in pain thresholds between men and women is often overstated due to the focus on group averages rather than individual variability.
- Pain perception is influenced by beliefs, expectations, anxiety, and early life experiences.
- Pain inhibits pain, a phenomenon called conditioned pain modulation (CPM) or diffuse noxious inhibitory control (DNIC).
- CPM involves activating a brainstem circuit that sends descending pathways to the spinal cord, inhibiting pain.
- CPM may explain why some parents' reactions to their children's pain, such as smacking them, might inadvertently reduce the pain.
- However, ignoring a child's pain or sending the wrong message can have negative consequences.
- Cold reduces inflammation and slows nerve firing, reducing pain.
- Heat increases blood flow, relaxes muscles, and feels good.
- Individual variability exists in preferences for heat or cold.
- Cold should be used with caution to avoid frostbite.
- Numbing an area with cold can be effective in reducing pain.
- Regular exposure to safe pain, such as deliberate cold exposure, can raise pain thresholds through habituation.
- Cross-modality changes in pain thresholds are possible, but more research is needed.
- Cognitive control, such as avoiding looking like a wuss in front of an attractive person, can temporarily raise pain thresholds.
- Exercise can also increase pain thresholds over time by building inhibitory tone.
- Mindfulness-based interventions lack specificity, granularity, and mechanistic logic.
- Attentional distraction engages specific brain networks and can reduce pain, but it may not be effective at night when people are trying to sleep.
- Non-judgmental acceptance of pain has been shown to be effective in reducing pain.
- Cognitive reframing about the meaning of pain can be helpful in managing pain.
- Catastrophizing pain can worsen the experience of pain.
- The distinction between hurt and harm is critical in pain management.
- Pain that is not causing harm does not need to be avoided.
- Chronic pain conditions are often complex and require more than just education.
- It is important to seek medical attention for pain that is getting worse or may be a sign of a serious medical condition.
- Dr. Mackey does not distinguish between psychological and physical pain, instead treating all pain as pain.
- Pain is a sensory and emotional experience, so treating the whole person is important.
- Anger, especially anger in (simmering, self-contained), is associated with worse pain.
- Medications used for pain include antidepressants, anti-seizure medications, and anti-arrhythmia medications.
- A holistic approach that addresses the whole person, including psychological, physical, and social factors, is most effective in treating pain.
- Nutrition plays a critical role in pain management.
- Identifying and avoiding trigger foods can significantly reduce pain.
- Elimination diets can help identify trigger foods.
- Food sensitization can occur after a gut infection, leading to chronic pain.
- Food sensitivity is a growing public health issue.
- Research is needed to explore how foods impact local and systemic pain responses.
- Visceral pain is different from somatic pain.
- Visceral pain is more diffuse and has larger receptive fields compared to somatic pain.
- Visceral pain can cause referred pain to other areas of the body due to visceral-somatic convergence in the spinal cord.
- Examples of referred pain from visceral organs include:
- Pelvic pain causing lower back pain.
- Heart attack causing pain radiating down the left arm.
- Abdominal surgery causing shoulder pain.
- Referred pain is pain that is felt in a different location from the source of the injury or damage.
- Neuropathic pain is pain caused by damage to a peripheral nerve or the central nervous system.
- Neuropathic pain can have different qualities and characteristics, such as shooting, stabbing, shock-like, or burning pain.
- Stress can contribute to pain by impacting the end organ or tissue.
- Chronic stress can lead to chronic pain.
- Early life events and injuries can sensitize individuals to future pain vulnerability.
- Pain can be associated with memory, and stress can trigger pain in areas previously injured or affected.
- A study explored the intersection of romantic love and pain perception.
- The study found that being in love significantly reduced pain, with a correlation between the intensity of love and the level of pain relief.
- The brain circuits involved in romantic love and addiction were found to be similar, suggesting that the early phase of a romantic relationship engages the same reward circuitry as addiction.
- Attentional distraction was also found to be effective in reducing pain, but it worked on different brain circuits compared to love.
- The strength of a romantic relationship a year later was found to be correlated with the love-induced analgesia and brain activity in the caudate nucleus and insula.
- Endogenous opioids are natural painkillers produced by the body.
- Higher endogenous opioid levels may lead to less emotional reactivity.
- Morphine was the first exogenous opioid derived from the poppy, and medicinal chemists have since created variations of morphine and purely synthetic compounds like oxycodone.
- The use of poppies for pain relief has a long history.
- Opioids can positively transform people's lives by relieving suffering and improving quality of life, but they can also destroy lives due to addiction.
- Opioids should be treated as a tool to be used in certain circumstances and not as a first-line agent.
- The opioid crisis is a complex issue that requires a nuanced approach, considering both the benefits and risks of these drugs.
- Opioid crisis is often attributed to overprescribing of opioids.
- Opioids can be beneficial for pain management when used appropriately.
- Overprescribing occurred due to lack of education among physicians about pain management and alternative treatments.
- Some physicians overprescribed due to marketing messages and lack of alternatives.
- A small group of physicians engaged in illegal activities related to opioid prescribing.
- Fear of legal consequences led many physicians to abruptly stop prescribing opioids, leading patients to seek illicit sources.
- Current opioid crisis is driven by illicit fentanyl.
- Fentanyl in street drugs is the primary cause of opioid-related deaths, not fentanyl prescribed by physicians.
- Compassionate opioid weaning can be successful for patients who want to reduce their opioid use.
- Commonly used opioids include morphine, oxycodone, fentanyl, Tramadol, hydromorphone, and methadone.
- Opioids work by binding to opioid receptors in the periphery, spinal cord, and brain.
- Benzodiazepines are rarely used for pain relief, except in specific cases where anxiety contributes to pain.
- Kratom has opioid-like properties and is available over the counter.
- Some people find kratom helpful in reducing opioid use, but its safety and efficacy need further research.
- Cannabis has been shown to reduce neuropathic pain in small studies, but large-scale studies show mixed results.
- Cannabis is not a uniform substance, and THC to CBD ratios and doses vary.
- Cannabis remains a Schedule One drug, which hinders research.
- Rescheduling cannabis as a Schedule Two drug could facilitate research and regulation.
- Acupuncture is one of six broad categories of therapies for chronic pain.
- Acupuncture has been shown to activate peripheral adenosine receptors and engage different brain regions compared to sham acupuncture.
- The exact mechanism of acupuncture's pain-relieving effects is still not fully understood.
- Acupuncture can be effective for certain types of pain, but it's important to find a qualified acupuncturist.
- To find reliable physicians or acupuncturists, seek recommendations from trusted sources such as primary care doctors or colleagues.
- Be cautious of inflated patient ratings, as they can be manipulated.
- Consider using an independent platform that provides genuine patient experiences and ratings to find the best healthcare providers.
- Chiropractic and acupuncture are different professions with distinct approaches to pain management.
- Acupuncture has shown some effectiveness in certain patients and circumstances, and is now covered by Medicare for back pain in patients over 65.
- Chiropractic care has mixed evidence for its effectiveness in treating low back pain.
- High-velocity chiropractic manipulations may pose a risk of vertebral artery dissection, especially in the neck.
- Chronic pain often leads to reduced activity and deconditioning.
- Physical therapy and rehabilitation are crucial in addressing chronic pain by helping patients safely engage in activity and improving biomechanical issues.
- Physical therapists play a vital role in chronic pain management by providing rehabilitation, goal setting, and education on body mechanics.
- Pacing is a critical tool in managing chronic pain, involving setting small, incremental goals for physical activity.
- Avoid overdoing activities on good days and recognize that bad days are normal.
- Consistency in pacing helps prevent the negative reinforcement cycle of pain and inactivity.
- Effective pain management involves collaboration between different healthcare providers, including primary care doctors, pain psychologists, and physical therapists.
- Acetyl-L-Carnitine:
- Improves mitochondrial health.
- Studied in the Sydney trials for diabetic neuropathy.
- Shown to improve nerve conduction velocity.
- Alpha Lipoic Acid:
- Has antioxidant and calcium channel modulating properties.
- May benefit neuropathic pain.
- Can cause stomach upset.
- Vitamin C:
- Prophylactic use may reduce the likelihood of nerve pain after surgery.
- Fish Oil (Omega-3s):
- Beneficial for chronic pain.
- May reduce the viscosity of the blood, increasing the risk of bleeding.
- Creatine:
- Shown some benefit in fibromyalgia and other conditions in small studies.
- Pain psychology and behavioral therapy can help with maladaptive coping and thought processes related to pain.
- CBT involves recognizing unhelpful thoughts and patterns, interrupting them, and teaching goal setting, pacing, and relaxation techniques.
- Biofeedback provides closed-loop feedback to help individuals learn to calm down the sympathetic nervous system.
- Mindfulness-based stress reduction and acceptance and commitment therapy are other tools used by pain psychologists.
- Empowered relief is a brief intervention developed by Dr. Mackey's partner, Beth, that condenses 8 weeks of CBT into 2 hours.
- Digital platforms and online treatments are being developed to make pain management tools more accessible.
- Dr. Mackey co-led the development of the National Pain Strategy, a strategic plan for transforming pain assessment, care, education, and communication.
- Full implementation of the National Pain Strategy would make a significant difference in the lives of people living with pain.
- Concerned citizens can help advance the implementation of the National Pain Strategy by contacting their representatives and writing letters.
- Dr. Mackey's nonprofit organization, Pain USA, aims to advance the implementation of the National Pain Strategy and use high-quality data to inform pain care and treatments.