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- [00:01]
Dr. Sanjay Gupta
We start today with a number, 20%. That's the approximate number of adults in the United States living with chronic pain. That's the kind of pain that can linger for months or even years. And around 8% of adults live with what's called high impact chronic pain. That's the kind of pain that can make everyday tasks like getting out of bed, going to work, connecting with others simply feel like monumental challenges. Chronic pain is not like acute pain. You should think of these as totally different entities. When you touch a hot pan, for example, and you learn to avoid it, that's acute pain. That teaches you a lesson. Chronic pain, that's more complicated. Sometimes it comes out of nowhere. Sometimes it lingers long after the original injury. It can wear you down emotionally. It's difficult to measure, but at the same time, it's very real and very pervasive. 20%. I came across this number when researching my new book on pain, and it immediately jumped out at me. That's 1 in 5 people, 50 million people in the United States alone. That includes people that I know personally. Maybe it includes many of you who are listening. And at one point it included a man named Eric Garland.
- [01:21]
Eric Garland
Did you ever deal with pain yourself?
- [01:25]
I have. I never talked about that in a public forum, but when I would wake up in the morning, I would be unconsciously searching my body for the pain. Is the pain here today? You know, is it here today? And I would look for it now.
- [01:38]
Dr. Sanjay Gupta
That feeling Eric is describing is so relatable. But what makes Eric's story unusual is what he did next. Dr. Garland is a clinical therapist and a psychiatry professor at the University of California, San Diego. He's also the developer of a mind body therapy called more, which stands for Mindfulness Oriented Recovery Enhancement. It's a program that he's used to help thousands of patients reduce their chronic pain by teaching them, paradoxically, to actually lean into their pain. And it eventually ended up helping him as well. So I wanted to have Eric on the show today to explain what MORE actually is, how it works, and what the decades of science behind it can teach us about the brain's role in pain and how we can harness that knowledge to feel better without any of the potential side effects of medication. I'm Dr. Sanjay Gupta, CNN's chief medical correspondent, and this is chasing life.
- [02:46]
Podcast Sponsor
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- [03:21]
Eric Garland
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- [03:27]
Dr. Sanjay Gupta
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- [03:32]
Eric Garland
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- [03:46]
Dr. Sanjay Gupta
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- [03:52]
Eric Garland
Do you think that we have more pain nowadays? I mean, does this seem to be growing in terms of overall numbers?
- [03:59]
It does seem to be an epidemic in the this country and in this world and there's a variety of factors driving it, but I think there's a lot of emotional anguish right now that's really, I think, surfacing and magnifying the pain.
- [04:13]
Well, we'll probably talk about this a lot, but people think of pain as a physical malady. I banged my finger, burned my hand, whatever it might be. But the emotional anguish fueling it, those two things hand in hand.
- [04:28]
Absolutely, absolutely. Because we know that all pain is really in the brain. Whether the pain is coming from arthritis in your knee or a herniated disc in your back, or even a headache, that pain is being generated and signals are being sent up through the body and then getting translated into the conscious experience of pain by the brain itself. And so that's why psychological factors like emotional distress and anguish can really amplify pain in the brain.
- [04:59]
I mean, this is a big idea, right? I mean, if you think about the fact that 20% of this country, from what I've read, 20% of people are in chronic pain. The idea 50 million, 50 million people deal with chronic pain. It's actually the fastest growing condition now in the United States from what I've read. Growing faster than cancer, heart disease or diabetes, it's pretty remarkable.
- [05:21]
That's right.
- [05:22]
But the idea that have we been doing this wrong? I mean, the idea that you want to sort of treat the physical body, obviously that makes sense. But have we been ignoring the brain?
- [05:33]
I think we need to pay more attention to the brain when it comes to pain. If we really want to develop Durable solutions that not only alleviate pain, but also just improve people's lives.
- [05:43]
Some people have said that chronic pain really is a memory that that cannot be extinguished.
- [05:49]
That's right.
- [05:50]
Just playing over and over in your mind, in your brain.
- [05:53]
That's right.
- [05:54]
Does that sort of inform how you approach it?
- [05:56]
Absolutely. Well, that's why, in large part, I've turned to mindfulness as a potential treatment for pain, because mindfulness is all about bringing attention into the present moment.
- [06:08]
So how did that all I know that you were working alongside these primary care docs dealing with emotional anguish and addiction. Tell me about when pain started hitting your radar.
- [06:19]
Patients were coming to me suffering from conditions that really they just couldn't get help with by traditional medicine, like irritable bowel syndrome, for example, or migraine headache or chronic low back pain. And they had received many different treatments, surgeries, physical therapy, medications, and they just weren't really getting the relief that they wanted to get.
- [06:42]
Did you believe that you could help those patients?
- [06:45]
Yes. Yeah. Because it's not really a belief. Right. It was backed by science. I'm not the first person to come up with this. There were already decades of good science showing that mind, body therapies and psychological experiences could alter pain. And so I felt confident with that backing that I could help.
- [07:06]
Did you ever deal with pain yourself?
- [07:10]
I have. I've never, never talked about that in a public forum. But I developed back pain in 2017. I had a pretty severely herniated disc, large extrusion, L4, L5, bad sciatica shooting down my leg, six months. Couldn't sleep without wrapping an ice pack around my leg. But I didn't pursue surgery because I was already working with lots of patients who had failed back syndrome, having multiple surgeries. And these were folks who were dependent on opioids and many of whom were having real trouble with opioids.
- [07:44]
So at your worst, how bad was this pain?
- [07:48]
So for me, I would say at its worst, the pain was probably a 5 or 6 out of 10. Did it interfere with my life? Absolutely it did. You know, I can recall having to teach or giving long presentations or training and just feeling that burning electric shock down my left leg. And it's incredibly, incredibly distracting. You know, it takes a lot of your mental resources just to cope with that. So the practice of mindfulness meditation, when I would practice intensely, would really alleviate the pain, that my pain would essentially go to zero. But mindfulness did more than that, because mindfulness is also about being aware of the present moment and understanding and noticing what Your mind is doing and the habits that it's falling into. And so I noticed when I would wake up in the morning to go to the bathroom that I would be unconsciously searching my body for the pain. Is the pain here today? Is it here today? And I would look for it and. And of course, this is something that I recognized in my own patients, this tendency. And as you were talking about, about pain being a memory structure in the brain. So being mindful and noticing that my mind was doing this, I had to start training my mind away from that. I started to, for example, I started to train the mind by. Rather than focusing on the left leg and searching for the pain in that leg, I. I focused on the right leg to notice that it felt good and healthy and there was no pain there. And it was sort of a philosophical point, like, why does the painful part of my body deserve the attention? What about the parts of my body that don't hurt or even feel good? Maybe those parts of the body deserve attention. So there was a real element of sort of retraining my mind to not be so hyper vigilant or obsessed about the pain.
- [09:48]
Yeah, that obsession.
- [09:50]
Right.
- [09:50]
And I guess again that idea that it's a memory that can't be extinguished. I remember when I was talking to people about this, it was almost like they were describing it, almost like a post traumatic stress. The way that I would hear people talk about emotional trauma where they would just keep playing the memories over and over again in their head. And it was quite distressing. In some ways. It seems like chronic pain, or at least persistent pain acts the same way. You start to obsess over it.
- [10:18]
That's right. And this isn't something that the person is doing consciously. They don't want to do this. But the mind unconsciously just gets pulled to it. It's like a gravitational pull. And then the mind starts to interpret other sensations from the body as painful.
- [10:36]
Right, right. I want to obviously talk a lot about the more sort of protocol and all of that, but just going back to pain in general, When I decided to explore this topic for a book, I was kind of amazed that there wasn't more that was written about it for the lay public. Why do you think we don't pay as much attention to pain overall?
- [10:58]
Well, I mean, maybe it has to do with part of the ethos in our culture. Just sort of grin and bear it, grit your teeth and just get through the day and tough it out. You know, those are kind of messages that we're told. I think Our treatments for pain aren't very good. There's no easy solution. You know, there's a lot of conditions in medicine where you can resolve it. You can take action, you can do a procedure or give a medication and you can get a cure, right? There's no cure for chronic pain.
- [11:27]
It's also striking to me, like, look, if you have concerns about heart disease, you can measure your cholesterol. If you're worried about diabetes, you can measure your blood sugar. But even you and I, people who know pain, have a hard time sort of defining it, right? Smiley face, frowny face. It's kind of striking to me that out of all the things that we do in a very technologically sophisticated society, that we still look at a chart of smiley faces when it comes to pain. I know that there's not exact answers to these questions, but just like I'm wondering what you think after exploring this for as long as you have, why is that? Why has pain been so sort of difficult for people to pinpoint?
- [12:14]
Well, like you're alluding to, scientists are still actively searching for biomarkers for pain. And there's, there's been progress made in that area, but there's no conclusive marker to date. So that means that understanding a person's pain really has to rely on their subjective self report. At this point, it's just an experience that the person has to communicate. And so that makes pain squishier than other medical conditions.
- [12:46]
Dr. Sanjay Gupta
Okay, after the break, we're going to dig into the details of Garland's approach and how his more program actually rewires the brain's response to pain.
- [12:58]
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- [14:48]
Eric Garland
When you were in your practice initially and you were seeing these patients who really weren't getting relief with conventional medical therapies, and then somebody in the practice referred them to you and they said, okay, well, now we're going to see, you know, Eric, about this. A therapist, there's always this tension where people say, are you telling me that it's all in my head? How do you deal with that?
- [15:13]
That's a really important point. And, you know, there's a lot of stigma associated with pain. And people with chronic pain have been told oftentimes that their pain is all on their head. So the way that I dealt with that is to help them to understand that all pain is in the head. Because it doesn't matter whether the pain is coming from arthritis in your knee or a herniated disc in your back or a broken bone. All of those conditions send signals up through the spinal cord and into the brain. And that's where the brain creates the conscious experience of pain. So when I explained that to my patients, they started to understand why a mind body therapy could be useful for pain.
- [15:55]
So we're talking about mindfulness oriented recovery enhancement. Okay, that's more three components. Mindfulness, reappraisal and savoring. What's going on here? How does that actually help with pain?
- [16:10]
So mindfulness skills are really useful in helping to alleviate pain because mindfulness changes the way the brain filters and processes pain signals from the body. There are brain structures that really allow more or less signals from the body into the brain. And so mindfulness can really turn the volume of the pain down by changing the way those signals are let into the brain and then relayed into the higher order thinking and feeling parts of it.
- [16:40]
So it's sort of interrupting that then, Is that what you're saying? As the pain signals that are coming up, they're getting processed by the brain, this is sort of interrupting it or down regulating it.
- [16:50]
That's right. And then reappraisal is used to reduce stress and negative emotions. And we know that stress and negative emotions can actually turn up the volume of pain in the brain. It can make pain hurt worse. So by decreasing that negative emotional reaction, we can take the sting out of pain. And then savoring teaches people how to increase natural, healthy pleasure, joy and meaning in life, and potentially also increase activation in the brain's reward system, the release of the brain's own opioids. And if you can produce opioids from within yourself using your own mind, then maybe you don't need to seek opioids outside of yourself in the form of a pill.
- [17:31]
And you have some obviously evidence that it works in terms of people's pain diminishing, but also their reliance on opioids going down as well.
- [17:41]
That's right. We've shown that more reduces opioid misuse by 45%, and that effect is three times as powerful as standard group therapy.
- [17:52]
Is this pretty well accepted science at this point?
- [17:57]
Yes. What I'm describing is new science, but it is well accepted science that's been repeated many times in rigorous studies.
- [18:05]
Excuse if any of these questions sound naive at all, but just what is mindfulness? How do you define it?
- [18:12]
So mindfulness is a form of meditation that involves awareness and acceptance of your thoughts, your emotions, and your body sensations in the present moment, and observing those experiences as if you were a witness.
- [18:28]
And then reappraisal, you're looking at the same event. In this case, we're talking about pain and you're looking at it from a different lens.
- [18:36]
That's right. So instead of viewing pain as this awful, terrible thing that's just ruining your life, we teach patients how to view the pain as pure sensation, not necessarily a signal that they're under threat or that they're under danger.
- [18:55]
And that is often the case with chronic pain. Right? I mean, with acute pain, you might be under threat, there might be an imminent danger, but chronic pain in some ways seems more like a glitch, like it's not supposed to. That signal's not supposed to keep firing over and over again.
- [19:10]
I think that's right. That's how I think about it.
- [19:13]
So if you can convince yourself, look, as painful as this might be, this isn't some toxic force that is somehow destroying your body, you're reappraising in that way.
- [19:23]
That's right. So instead of viewing the pain as a signal that you have something terribly wrong with you, that your health is under threat, viewing the pain as just pure sensation, and we have all sorts of kinds of Sensations in our body and sensations come and go naturally on their own. So learning to view pain in this way, to reappraise pain in this way, and to also notice how it changes over time can be very relieving to people.
- [19:53]
Yeah, I remember talking to this one patient who I interviewed for the book who basically said, I started to look at my pain with curiosity instead of terror, which I thought was really interesting. I'm curious about. This is interesting. It's a little hot now. It's a little tingling associated with this as opposed to, I'm terrified, this is terrible, I'm going to die, or whatever you have.
- [20:15]
That's right. Or I hate this, I can't stand this, I can't take it anymore.
- [20:19]
And then with savoring, as you mentioned, this could help harness your body's own.
- [20:25]
Endogenous opioid production and to increase activity in the brain's reward system, which is crucially important for helping people to reduce their opioid use. Because we know that as the person becomes more and more dependent on the opioid just to feel okay, the brain becomes less able to extract a natural, healthy sense of pleasure, joy and meaning out of everyday life. So they're in a hole, they feel empty inside. And so, so they have to take higher and higher doses of the drug just to kind of preserve a sense of well being.
- [20:57]
How do you teach people to savor?
- [20:59]
We start by teaching patients to focus on a positive object, like a rose. We guide them to focus mindfulness, to appreciate the pleasant colors and textures and scent of the flower, as well as the touch of the petals against their skin. And then during this process, we guide the patient to turn their attention inward and to notice positive emotions in the mind or pleasurable sensations in the body. And then to turn their attention inward and to savor the positive inner feeling, really allowing it to expand and breathing into the center of their being. And so they learn this skill in the session with the therapist, and then we ask them to practice it in everyday life with whatever positive objects and events and experiences that come up for them.
- [21:44]
I gotta say, because I've read your work and the savoring part in particular is I found so helpful just in my own life, you know, even aside from pain. And I remember thinking about it, that it's one thing to be grateful in life, it's another thing to savor it. I think it's like turbo boosting your gratitude, which I really appreciated that part of your work. But let's talk about this. Let's say I have a pain problem of some sort, back pain, whatever it might be. It seems like a lot of times you're sort of taught to neglect the pain or to ignore the pain in some ways. It sounds like that's not what you're suggesting.
- [22:24]
No, not at all. So we first start by teaching mindfulness of the breath. So we're turning attention towards the sensation of our breath. And that is really designed to settle the mind and focus the mind. And, you know, if you do that, if you're like most people, after 10 or 20 seconds, your mind's going to start to wander off to other thoughts or feelings or memories. And then what you do is you just notice where the mind has wandered off to, and then you acknowledge it, you accept it, and then you bring your focus of your attention back to the breath. So that's the basic mindfulness practice that we teach. But as the patient gains skill and familiarity with this practice, then we teach them to actually turn attention right towards the pain sensation itself. And that, I think, is a critical piece to healing chronic pain. And it relates to what we discussed earlier about pain being a memory construct in the brain. Because we're guiding patients to actually use mindfulness to zoom into the experience of pain and to break it down into sensations. We also ask them to notice, do the sensations have a center? Do they have edges? Are there spaces inside the sensation where there's no sensation at all? And so really guiding the patient's attention right into the heart of the pain and helping them to break it down in this way. I know it sounds like a paradox, but it can actually alleviate pain in some ways.
- [23:51]
Leaning into it as opposed to avoiding it.
- [23:53]
That's right.
- [23:55]
How effective is this?
- [23:58]
So my colleagues and I have studied more in over 16 randomized clinical trials involving more than 2,000 patients. So we have a really good sense of what this treatment does. And with regard to pain, we have data showing that eight weeks of more can actually result in pain relief that lasts nine months later.
- [24:19]
Later.
- [24:20]
So about 50% of patients achieve a clinically significant reduction in their pain, about a 25% reduction in pain lasting nine months or longer. That's about as much pain relief as you would achieve from 5 milligrams of oxycontin.
- [24:35]
Really?
- [24:37]
Yeah. It's amazing.
- [24:39]
How easy is it to access a program like this? Again, I realize that there's. There's new technologies with telehealth and virtual reality, but you got 50 million people out there. It's a lot of people who are suffering in the United States alone.
- [24:55]
That's right.
- [24:56]
How hard would it be for them to access a program like this?
- [24:59]
We need more providers trained in this evidence based mindfulness oriented recovery enhancement approach. I've trained more than a thousand clinicians from around the US and internationally in this program, which is great, but it's a drop in the bucket. So I'm really working hard to disseminate this therapy across the US to try to make this part of standard of care. That's why I really appreciate having this opportunity to speak with you about this.
- [25:24]
For sure and hopefully people will hear that message. But Eric, a lot of people may be in pain or they know somebody who's in pain and they've been getting pills probably for a long time and now they're going to hear you say, look, at least for a period of time, you could get a lot of relief by just focusing on your mind. What's the message you want to give people?
- [25:46]
The message I want to give people is a message of hope. And this is a safe, immediate and non addictive approach. And one of the beautiful things about learning this approach is that the more you practice it, the better you'll get at it and the more relief you'll achieve.
- [26:06]
Dr. Sanjay Gupta
That was Dr. Eric Garland who reminds us that all pain actually occurs in the brain. If the brain decides you don't have pain, then you don't have pain. And if you want to learn more about other evidence based approaches to pain management like the More program, consider pre ordering my new book. It's called it doesn't have to Hurt your Smart Guide to a Pain Free Life. Thanks for joining us.
- [26:37]
Podcast Sponsor
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