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The mindbodygreen Podcast
656: The connection between pain & the brain | Rachel Zoffness, Ph.D.
00:54:36
Zoffness is a pain scientist, pain psychologist, and thought-leader revolutionizing the way we understand and treat pain. She's an assistant clinical professor at UCSF, lectures at Stanford, and consults on the development of pain management programs around the world. Dr. Zoffness’s new book, Tell Me Where It Hurts, is out now, and in the process of being translated into over 25 languages.
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- [00:00]
A
Welcome to the MyBodyGreen podcast. I'm Jason Wakab, founder and co CEO of MyBodyGreen and your host. This episode is sponsored by Rula. Mental health is the foundation for overall health, but finding a therapist who's available, a good fit and takes your insurance is a real barrier. Rula connects you with licensed in network therapists, often with an average copay around $15 per session. Thousands of people are already using RULA to get affordable, high quality therapy that's actually covered by Insurance. Visit rula.commindbodygreen to get started. That's R U L A.com mindbodygreen. You deserve mental healthcare that works with you, not against your budget. This podcast is sponsored by the North Face at the North Face, it's never just a hike. It's a cure for Restless mind Syndrome, the socially acceptable version of running away from home. The argument your feet make with gravity. Out here, it's up to you. Unearth a new kind of trail, wide open and yours to define. The North Face Hike Collection will keep you cool, dry and comfortable every step of the way. Shop the Hike Collection online or find a store@thenorthface.com this podcast is sponsored by Berkeley Life. Low nitric oxide is one of the least talked about reasons people feel tired as they age, and it's fixable. Berkeley Life Nitric Oxide support is clinically proven to raise your levels. Take it for better energy, circulation and performance. Get your first month for only $10 by visiting B E R K E l e y life.com MBG study and play come together on a Windows 11 PC and for a limited time, college students get the best of both worlds. Get the unreal college deal Everything you need to study and play with select Windows 11 PCs. Eligible students get a year of Microsoft 365 Premium and a a year of Xbox game Pass ultimate with a custom color Xbox wireless controller. Learn more@windows.com studentoffer while supplies last ends June 30 terms@ aka mscollegepc what if everything you've been told about pain is wrong? Dr. Rachel Zoffness is a pain psychologist who's been studying the neuroscience of chronic pain for more than 30 years, and her new book, 10 Tell Me Where It Hurts. She argues the way medicine treats pain is missing two thirds of the problem. In today's show, we get into why pain is never purely biochemical. Softness walks me through her pain recipe framework and also talks about the unsettling research and how the words a doctor says can actually amplify pain. I shared my own story of how sciatica almost sent me to back surgery 17 years ago. And she helped me understand something I've thought about for quite some time. Why letting go of the outcome may actually have been the thing that healed me. This is a good one. Let's dive in. So you say everything we've been told about pain is wrong.
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I'm a maker of bold statements. It sometimes works against me, but in this case, I'm going to stand by it.
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A
Well, you're set up for success in the state of social media in 2026. Bold statements and extreme views are the way to go. So have at it.
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B
It's true, I'm a native new and I tend to state bold statements boldly. But this is something I came to believe after studying the neuroscience of pain for more than 30 years and treating chronic pain patients and researching pain. And you know, at this point I feel like I've read every high quality paper there is on it and I stand by it. I mean the thing that we are told about pain that drives me crazy is that pain is a purely biological biomedical problem, meaning that it's just to do with anatomy and physiology and it requires an exclusively or primarily biomedical solution, usually in the form of pills and procedures. Now, it is easy to believe that pain lives exclusively in the body part that hurts, right? I read a little bit about your journey. Chronic back pain is ubiquitous in America and actually around the world. It's easy to believe that if your back hurts, your pain lives exclusively in your back. Here's what science says. While it's easy to believe that pain lives exclusively in the body part that hurts, that's impossible. One of the reasons we know it's impossible is because of a condition called phantom limb pain. Phantom limb pain occurs when someone loses a limb, an arm or a leg, and they continue to have terrible pain in the missing body part. Now, my friends, if you can have terrible leg pain in a leg that is no longer attached to your body, that tells us pretty definitively that pain can't live just in the leg alone or just in the back alone. And what we know is that pain is ultimately constructed by the brain. And when we go to treat chronic pain, how often are we asked about our brain and all of the things that are contributing to the pain experience, which I hope we will talk about here today. Like we we are given prescriptions for medications, we are given recommendations for surgeries, sometimes eight of them. And in fact, when back surgery for back pain, and I am talking about Chronic back pain. When that fails, medicine will give us a new diagnosis called failed back surgery syndrome. True story. As if somehow we failed the surgery, we failed the treatment, instead of the other way around.
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A
So if you were to zoom out, how much is structural in your view versus how much is a nervous system or a brain issue?
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B
Okay, so what we know about pain. I said what pain isn't, but I want to say what pain is. Pain is never purely biomedical. Pain is biopsychosocial. And if your listeners remember nothing else, I hope they remember this word because we all sort of know this intuitively. But I want to say what this word means. If you imagine a Venn diagr with three overlapping circles like did I mention I'm a nerd? And we're going to get nerdy. We're going nerdy. So Venn diagram three overlapping circles. We have the biological factors that contribute to pain, the psychological factors that contribute to pain, which are of course fraught with stigma and misunderstanding. And then we have the sociological ingredients that contribute to pain. And what we now know is that pain lives in the messy middle of all of those contributing factors. So in the bio domain of pain, we have the things we've heard the most about genetics, tissue damage, system dysfunction, like you said, anatomy and physiology. We also have diet, sleep and exercise. And I want to say clearly those things are fundamental to the pain experience. However, if we're only focusing on the biodomain of pain, science says we are missing 2/3 of the pain problem. So in the psych domain of pain, we have things like emotions because check me, we said that ultimately the brain constructs the pain experience. The parts of the brain that make emotions also make pain. Like folks have heard of our limbic system and our amygdala. Those are critical parts not just of the emotion machinery, but of the pain machinery. So like to say this clearly, pain is never all in our heads, but 100% of the sensory messages from our body filter through our brain's emotion machinery before they become the thing we call pain. Why doesn't anyone ever tell us that like emotions are part of the pain experience? And then we have the sociological domain of pain, which is like socioeconomic status, access to care, race and ethnicity, social support, or isolation, which are so important for our health. Turns out, and things like trauma, like we have known the body keeps the score for effing ever. Why is that not part of chronic pain treatment? We know it's part of chronic pain construction. So to answer your question, yes, anatomy and physiology always matter when it comes to pain. They're just not the whole story.
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A
So what would be your ideal protocol? Someone walks into your office, they say, hey, doc, I have lower back pain. Help me out.
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B
Yeah, yeah. It's the reason I wrote Tell me where it Hurts. Like, we have established that I'm a proper nerd and I have been studying pain for such a long time. But why am I the holder of the information? You know, I've been treating pain for a real long time, and I am so tired of patients coming into my office and they've only been given pills and procedures and nothing else. Like, no one has ever told them that pain is more than just body parts. No one has ever told them that emotions can amplify and lower pain volume. So I just, I dumped all this information into a book because I feel like it's so important. Like, in medicine, there's this myth that, you know, there's pain patients over here and there's the rest of us, including providers over here. But to say clearly every single one of us is a pain patient, none of us is going to escape, ever. Pain is coming for all of us one day, if it hasn't already. So who doesn't deserve to understand it? So. So in my mind, the most important part of a pain protocol is crafting what I like to call a pain recipe. So do you like to cook or bake? I do not. My husband does all of that in my house.
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A
I like to eat those things that people cook and bake.
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B
I do, too. Okay, well, so just as there's a recipe for brownies, which I know how to make from a box, there is also a recipe for pain always. So by pain recipe, I mean there's all sorts of ingredients that go into making a high pain day or a bad pain day. I can give you my pain recipe, for example. My high pain recipe is sitting in front of my screen for too many hours. It is not protecting time to walk or exercise. It is poor sleep. When I sleep poorly, my body hurts more. It is eating a crap diet. It is really high stress and not saying no to asks as they come in all day, every day. So there's a lot of ingredients that go into my high pain recipe, and I think a lot of your listeners will resonate with this. I'm wondering if it resonates for you.
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A
Yeah, so it sounds like I walk into your office and I say, doc, I've got lower back pain. Before we get to the structural issue of the back, how are you feeling? How are you eating? How how are you sleeping?
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B
So, order of operations for order of operations. No. The first thing that I do when someone walks into my office is I ask for a release of information to talk to the rest of their medical team. Because I want to know. I want to know medical history. I want to know what's been done. I want to know what medications we're on. I want to know if all the tests have been done. And it's as part of my job. If I'm not collaborating and coordinating care, I'm not helping my patient. So. Or as far as order of operations goes, step number one is coordinating care with the rest of the team and making sure I know that the boxes have been checked. Like, have we checked your blood and bones and body parts? Because if not, that needs to be done. That's the bio domain of pain, right?
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A
It's just looking at the whole system.
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B
Yes.
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A
The central theme of the book, in my view, one of the central themes, like, it's not localized, like, you've got this thing over here. Sure. That's. That's where you've had trauma or an injury, but it's bigger than that.
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B
Exactly. So as far as order of operations goes, I need to know the information that goes in the biodomain of pain. But if I'm looking at your full pain recipe, back to this pain recipe concept, that's just one of the ingredients. Yes. History of injury, your disease, inflammation, that's part of it. But I also want to inquire about the rest of the ingredients in your pain recipe. So we said, just as there's a high pain recipe, like, for me, I mentioned diet, sleep, movement, stress, you know, whether I'm protecting, time to go outside or see friends. That's my high pain recipe. The low pain recipe is just the opposite. So if poor sleep is amplifying my pain or my patient's pain, I know that I need to teach my patient sleep hygiene. Because just as there's a protocol for oral hygiene so our teeth don't fall out and rot, there is also a protocol for good sleep hygiene that will help people in pain sleep better and lower pain volume, just as stress, we now know, is a pain amplifier. And oh my God, is it ever. I. I know that for my patient who's in front of me, I need to assess their stress levels and their emotional health. It's just as important to pain as our physical health and help them reduce stress, whatever that means. So to answer your question, yes, we're always looking at anatomy and physiology, and we're Looking beyond it, both are important
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A
in terms of those buckets for lifestyle. Let's just say you've got exercise, you've got sleep, you've got nutrition, and you've got stress. In your view, which is. Which is paramount. I'm curious. I have a take. But I want to hear your take.
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B
Oh, I can't wait to hear your take. I suspect I know the answer to your take. But my answer is the most annoying answer in medicine and science, and it's the one that's given the most. And the answer is. It depends. It depends on the person in front of me. Like, what comes to mind as a patient who was in my office, 17 years old, had been in bed for four years. Four years in bed, was on a white food diet. Yes, that's a thing in America. Like pizza, pasta, bread, cereal, but like hated fruits and vegetables, was not moving his body, had undiagnosed panic attacks and suicidality. Had like history of migraine and diffuse amplified body pain. And you know, when he got better, and he did get better, I don't think it was because we went after any one thing. I think it's we, it's because we went after all the ingredients in his recipe. And by the way, it took some doing, but that kid got out of bed and went back to life, went back to high school, got asked to prom by two girls, not one, which is my favorite part of the story. And, you know, went on to rejoin his soccer team and. And like, it bothers me so much that.
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A
Incredible.
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B
Yeah, I know. And, and so I think, I humbly submit to you that trying to target just one ingredient as the most important actually is part of the problem. Like, humans are complex entities and many factors matter. Brain, when it's deciding whether or not to make pain and how much. It's never just one thing.
- [14:53]
A
Do you think? So my view, and maybe it's more from my personal experience, that emotional wellbeing tends to have a downstream effect where that impacts sleep, nutrition, exercise versus. They all impact each other. But for me, that's the one that we're just kind of like everything goes south and it goes south quickly.
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B
Yeah, that's so funny. That's. I wasn't predicting that one. But, you know, the funny thing about emotions is, you know, we talked about, they always adjust pain volume. And what science knows now is that positive emotions can lower pain volume and negative emotions can amplify pain volume. And it's something we don't pay attention to enough. And the crazy thing about emotions also in My mind that we also don't talk about enough is that every emotion we have has a somatic component. That word has become so stigmatized in medicine, and maybe you can tell me why. Like soma. The word soma in Latin literally means of the body. And emotions aren't something that just lives in the space between our ears. Every emotion we have triggers a neurobiological cascade of events in the human body, which is what you're referring to. So every emotion we have affects things from neurotransmitters to hormones to muscle tension. And it is a down, like you said, it's a downstream neurobiological cascade of events. So it absolutely affects pain. So, for example, when we are sad, salt water leaks from our face. Right. When we are stressed and anxious, we have muscle tension. Our hands sweat, our mouth goes dry. Pain responds to all of these different neurobiological events. Like, think about muscle tension and pain. One of the number one prescribed medications for terrible pain is a muscle relaxant. Like, to your point, when we're stressed and anxious, we are amplifying muscle tension, which amplifies pain, among other things. So, yes, I think emotions are one of the most important hidden ingredients in every pain recipe, for sure.
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A
And what's your view on certain emotions? I think about this two different ways. One is school of thought. Certain emotions show up in certain parts of the body, which is kind of what you're talking about a little bit. And then I also, in my personal experience, whenever I've been under duress or stress, I would find that it would show up in. In whatever part of my body was, like, a little weak.
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B
Totally. Yeah. I really like the way you said that. There is no hard data to explain why pain shows up in what body part. But I do think, like you said, there is some evidence to suggest, like whatever that weakness is, is that genetic? Is that because you damaged a body part or you have a previous injury? There is some data to suggest that that is the part of the body that will experience chronic pain. But. But I do find that fascinating. Like, some people have trigeminal neuralgia, which affects their jaw, their face. Some people have chronic pelvic pain. Some people develop chronic migraine, and in some cases, there's no family history. So why is it that pain shows up where it shows up? It's a really fascinating question. I mean, genetics is certainly part of it, but it's not the whole answer.
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A
How do you think about, for lack of a better word, thinking yourself into and out of pain?
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B
Can you say what you mean better?
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A
I'll give an example. So, like, thinking yourself, you know, how your. Your thoughts or beliefs could potentially cause discomfort or pain or vice versa bring you out of pain. I'll give you a personal example. So about five years ago, it was in my mid-40s. One of my old, closest friends who I was a teammate at Columbia and the basketball team, he had colon cancer. And it was scary. And I had said to him, you know, how did you discover this? And he didn't take the best care of himself, but he said, my iron levels drop precipitously. And the doctor said, no iron pills. You gotta go for a colonoscopy. He goes for a colonoscopy. It's colon cancer. And so about a week or so after that, sure enough, my iron levels dropped. I also had an iron level drop, which I've talked about in the show. But I actually think I had some wonky things post Covid happen to me. That's my theory about why my iron levels dropped. At any rate that happened, my doctor said the same, like, we gotta do a colonoscopy. It was around the time to get it. 45 said, you have to do this. And very unlike me, I became so nervous and so worried that because of my friend, and now I've got the same thing. And I was starting to experience discomfort in my stomach before the colonoscopy. And I remember going into the colonoscopy, I'm on the table, and, like, I've got normal blood pressure. It was like, 170 over, like. And then they put me. Put me under, and I come out, and guess what? I've got nothing. Completely clean. I go to Bubby's in Tribeca and have a huge pancake, and I'm like, fine. After the whole thing, it went away. And I'm saying to myself, wow, I worked myself up in such a way where I had created almost discomfort in my stomach, where I felt like I had something. And my mom was like, this is so unlike you. What's going on? My wife, too. They're like, you're fine, but what is going on? You're not practicing what you preach. But to me, that's an example where, in my view, I almost talked myself into something in my stomach. So I'll pause there.
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B
I think we've all done that in one way or another, and it's really hard not to. So I can go so many directions with this amazing story you just told. Yeah, there's a story just like this in the book. It's called how cancer cured a Kidney stone.
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A
Let's hear it.
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B
Yeah. Well, so I want to first go big picture for everyone because this is such a fundamental, important piece about pain. Pain is our body's warning system. It's our danger detection system. It exists to save our life. Like if you go for a run and you break your leg, you need to stop running, right? Pain gives you the message, stop. Something dangerous has potentially happened. You need to examine your leg. Maybe you need to rest. Maybe you need to get help. Pain saves our lives. When it's acute pain, we said that there's always a recipe of ingredients that create pain. One of the ingredients in the pain recipe are thoughts. Because just like emotions, thoughts do not live exclusively in the space between our ears. Every thought we think triggers a biological cascade in the human body. And I will prove that to you if you start thinking right now about your list of things to do. Your car payments, your rent, you know, like, whatever, you're taking care of, your kids, taxes, like some of us still need to do our taxes. Your body, you. You will feel your heart rate go up, your blood pressure will go up. You will actually feel in your body a change in your physiology. Because every thought you think, just like our emotions, has a neurobiological cascade of events that affects everything from our cardiac functioning to respiration to digestion, to hormones to neurotransmitters. And one story I like to tell that really explains this really well is when I was first starting to treat chronic pain, I had colleagues ask me if I used biofeedback. And I said, quite transparently, I do not prescribe any treatment that I don't understand. So I went down the rabbit hole to read about biofeedback. And I found a local provider named Dr. Pepper, which of course is the best name for any doctor ever. And Dr. Pepper sat me down in a chair and he hooked me up to his biofeedback machine. So there were sensors put on my skin, on my fingertips, and on my chest to measure heart rate. And there was a sensor to measure muscle tension. And he explained that this machine in front of my face was going to read and give me feedback about these underlying biological processes. Heart rate, skin temperature, muscle tension, et cetera. Biofeedback. That's what it is. And he explained to me that the goal for the day was to warm my hands to 90 degrees. And I said, Dr. Pepper, with all due respect, I am into neuroscience and I do not believe in voodoo and I am chronically cold handed and I can't even imagine how you're going to teach me to warm my hands to 90 degrees. And he said, that's really cool. Close your eyes, and I want you to think of all of the stressful things. Like we just said all the things on your to do list. And I did. I went through them in my head. And as I was thinking of them, he had me open my eyes so I could see. And here's what was happening on the screen. My heart rate was going up, my muscle tension was spiking, and my hand temperature was plummeting just from thinking stressful thoughts about my to do list. Then he had me close my eyes, and he guided me through like a guided relaxation. We used something called autogenic training, where you say things to yourself like, my arms and hands are heavy and warm. And we did some visualization. I believe, if I remember, I was imagining my hands over a hot campfire. And some other visualization. And after I think about 5, 10 minutes, he had me open my eyes. And here's what I saw. My heart rate had significantly decreased. My muscle tension had gone back to normal. I was relaxed, and my hands had started getting warm. My finger temperature had increased, and within two sessions, I could warm my hands to 90 degrees using my thoughts. Why? Because your thoughts change your physiology. Your thoughts change your body. We all know that. We experience it every day. But no one makes that pathway clear to us. And if your thoughts can increase muscle tension and change your blood flow, you bet your ass. They also change your pain. Of course they change your pain. It's like, why don't. It makes me crazy that no one's ever been told this before.
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A
I love it.
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B
Yeah. So I tell. I tell a story about this in the book that's called How Cancer Cured a Kidney Stone. And it was so illuminating for me as a provider. I had a patient who had kidney stones, and kidney stones are very painful. And she rated her kidney stones, I believe, like a 6 or 7 out of 10 on the pain scale. And I will say everyone has their own pain rating, so let's not judge her too high, too low. She rated it a six out of about a six or seven out of ten. Let's call it a six.
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A
I had a kidney stone, like, 20 years ago. I thought I was. Someone was stabbing me in the stomach. I would have said it was nine out of ten.
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B
Yeah, right. I know. So different people have different ratings over their pain. She rated it a 6 out of 10 on the pain scale. And I think she was someone who had been in pain before and had had some pretty complex medical issues. So yes, I I have heard also 9 out of 10 or 10 out of 10.
- [26:18]
A
This episode is sponsored by Rula. Mental health is the foundation for overall health, but finding a therapist who's available, a good fit and takes your insurance is a real barrier. Rula connects you with licensed in network therapists, often with an average copay around $15 per session. Thousands of people are already using Rula to get affordable high quality therapy that's actually covered by Insurance. Visit rula.commindbodygreen to get started. That's R U L A.com mindbodygreen you deserve mental healthcare that works with you, not against your budget. This podcast is sponsored by Calocurb. We've all heard the buzz around GLP1s. Calocurb is a clinically studied plant based GLP1 activator. The supplement is designed to help reduce cravings and support healthy weight management by activating the body's natural fullness hormones. Learn more@calocurb.com use code MBG15 for 15% off. That's C A L O C U R B with code MBG15. This podcast is sponsored by Kohler Health. We track our steps, sleep and workouts, but some of the most valuable health signals happen in the bathroom where they get flushed away. Kohler's Dakota fits discreetly onto your toilet and captures biometric signals to provide insights into hydration, gut health and more. That's data that our other wearables can't deliver. The info is securely delivered to the Kohler Health app. Learn more at KohlerHealth.com, use code MBG for a free one year app membership with your Dakota purchase.
- [28:02]
B
Your call has been forwarded to voicemail. Hi, this is Zoe Deutch and Nick Robinson.
- [28:08]
A
Our brand new movie Voicemails for Isabel is all about those little moments that feel like the universe is looking out, feeling homesick.
- [28:16]
B
Then your sister calls, hearing that perfect
- [28:18]
A
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- [28:41]
B
I've heard that too. Yeah, so. So she had recently lost her dad to cancer. She came into my office and told me this story. She'd recently lost her dad to cancer and I believe it was Pancreatic cancer. And he had been in terrible pain. He had had terrible abdominal pain as he was dying. And so she was having, she was in her office co working with her husband, the way the story goes. And she expressed to her husband she was experiencing pain and she thought it was due to a kidney stone. And her husband said, you've been having this quote unquote kidney stone pain for like a month now. You usually have pain for just a few days and then the kidney stone passes. Are you sure this is a kidney, kidney stone and not something else? And she said to me, her brain was filled with these terrifying thoughts and images of her father's pancreatic cancer. Like she had been with him to the doctor, she had seen the scans and the cancer growing and it had been a traumatic loss for her. She started thinking, oh shoot, this isn't a kidney stone. If this pain has been going on for a month, it is certainly pancreatic cancer. Just like my dad. Had her pain shot to an 11 out of 10. She fell to the floor in crippling pain. She was screaming. Her husband called 911 brought her via ambulance to the hospital. They gave her a ton of pain meds. She was screaming with pain. And as soon as she was brought into a room and the doctor did a scan of her abdomen and found the kidney stone, her pain reduced down to a 2 out of 10. She went home, she passed the kidney stone and her, you know, she, the way she describes the story, she says it was clear to her in that moment that her fear, her thoughts changed pain volume. And of course, of course they did that. That's exactly what they do.
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A
You know, on the flip side, what's your view on outcomes when people maybe don't have that expectation that it's all going to go south, whether it's pancreatic cancer and maybe have a little bit of a laissez faire view, you know, I'll be okay or this isn't so bad or eh, if I get surgery, I get surgery, whatever.
- [31:01]
B
So when I wrote this chapter in Tell Me Where It Hurts on the science of thoughts and pain, I really wanted to get the science right because I want to make sure that people don't think. I'm saying thoughts are the only ingredient. I want to make sure people don't think. I'm saying that pain is all in your head. I want to make sure people don't think. I'm saying you can think pain away, you can't. Pain is more complex than that. Thoughts are just one Ingredient. And they do matter.
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A
It's an input.
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B
Exactly. It's one of the inputs that affects the output. Well said. I really appreciate that. But when I did this research, I came upon a finding that will frustrate many people, people like me who are not optimists and are native New Yorkers and tend to predict the worst case scenario just to be prepared. For example. But the research shows that if you are optimistic about your pain or calm about your pain, your pain will be less intense and it will last less long. So, like, it affects pain intensity and also duration of pain. There's a lot of research on optimism and pain. It sort of makes me crazy because I wish I could be an optimist. I'm just not.
- [32:09]
A
We talked about this before we started. I'll give my brief, you know, founding story of Mind Body Green and my lower back, because it's related to what you just articulated. So I had excruciating sciatica. I had two extruded discs, press semi static nerve L4, L5s. One old basketball injury from college. I was flying too much. I was stressed. I was so worried about money, like, financially. It was the most difficult situation I'd ever been in. And the sciatica was so bad, like, I couldn't walk. It was shooting down my right leg. It was like a lightning rod. Like, I felt it. And walking for me brings me joy. If I don't get my 12,000 steps a day, I am a grumpy dinosaur, as my children would say. So it was brutal. And I went to a doctor and he said, you need back surgery. And at the time, I have nothing against surgery, like your point, but, like, success rates just really aren't where they need to be. And so I sought a second opinion. That doctor said the same thing. He said, I'm looking at the MRI like you need surgery. And it was like an afterthought. He said, you know, maybe some yoga or therapy could help. And I said, okay, I'll give it a try. My wife, My wife, we were dating at the time, she had a yoga practice. So I was like, yeah, I'll try yoga. And I started to practice a little bit of yoga. I started to feel better, started to make changes in my life. All the lifestyle things, nutrition, sleep, et cetera. Over the course of six months, I completely healed. It was my awakening. It was my inspiration for starting. My buddy Green. I said, hey, this is all connected. Mental, physical, spiritual, emotional, environmental, wellbeing. My buddy green. But what I also did, and I've and Like, I. I've thought about this a lot because this happened like 16, 17 years ago. It's the founding story of the company. I think one of the reasons why I healed. I went from, like, in six months, I really let go of the outcome. I said, eh, if I have to get surgery, I'll get surgery. I'll be okay. If I'll try this yoga, if it works, amazing. Like, I'll figure this out. Like, I'm not going to be. Like, I just didn't worry that I would be this guy who literally, I remember being at a baptism for a friend and like, I had to sit down, Like, I couldn't stand it. Was. It just hurt so much. But I just. I don't know why, but I just said, you know what? I'll be okay. Whatever. Surgery, no surgery. Like, I let go of the outcome, which is unlike me. So talk to me about that.
- [34:38]
B
I read your story and have heard you talk about your story before. And to me, it's such an incredible and profound example of how there's always a recipe for pain. And also there's so much more agency than we've ever been told to change our pain recipe. So I was really struck by how changing those ingredients profoundly changed your pain. And what strikes me the most about the story you just told, actually is the role of thoughts and emotions in pain, which just seems to keep coming up in this conversation, probably because those are such forgotten ingredients. And I'm a person who explains neuroscience by metaphor. So here we go. There's no one single pain center in the brain. Pain is a diffuse neurological process. Like, there's lots of parts of the brain that make pain, including our cerebral cortex, the parts of our brain responsible for thoughts, our limbic system, the parts of the brain responsible for emotions, and our prefrontal cortex, which is the part of our brain that makes predictions and also is responsible for attention and other factors. And I like to think of it as like a pain dial. So sort of like much like the volume knob on your car stereo. And there's many ingredients that turn pain volume up, and there's many things that turn pain volume down. Like pain medication is one of those things, but also thoughts, predictions, and emotions. So like we said before, negative emotions will turn that pain dial up, positive emotions will turn pain volume down, and also stress and anxiety. When we're stressed and anxious, pain volume is dialed high. When we're calm and relaxed, pain volume in the brain is dialed down. So the shift sounds like it was a number of different things, like you were doing yoga, you were moving your body, you were stretching, but also you were thinking about your pain differently, and you were thinking about the outcomes differently. And thinking about it differently changed your emotional state and changed your physical state, because, duh, all the things are connected in the brain. Like, why would the brain only use one bit of data? Our brain is a prediction machine.
- [36:44]
A
Learning.
- [36:45]
B
Our brain uses all available information when deciding whether or not to make pain and how much. And predictions is part of that.
- [36:51]
A
You know, it's so funny. The language or the describing the brain as a prediction machine. We had Joshua Brown on the podcast. I don't know if you're familiar with his work, but essentially he was diagnosed with cancer just after his first child was born. He was very young. And his. His work is around spirituality and how he had an interesting take. How. Because I'm going to touch on faith. He found that people who really believed they were going to heal, they had better outcomes. Like, they expected it versus, like, I really hope I heal, not to like. And I thought that. And he said that. And he used the exact same language. Your brain's a prediction machine.
- [37:39]
B
Yeah. Can I tell you the science of why?
- [37:42]
A
Please.
- [37:42]
B
I am obsessed with this, and I wrote a whole chapter on it. I'm obsessed with this. It's called the body's pharmacy. So check this out. We call this thing the placebo effect. The placebo effect is when we predict and believe that there will be a change in our bodies and that change actually occurs. When people hear the word placebo, they think it's a nothing. Right? Like, you hear a placebo and you think it's a sugar pill and nothing. In medicine, if a medication is no better than a placebo, it is discarded as useless. But I want to say what the placebo effect really is and what that word really means. If I am a legitimate healthcare provider and I hand you a pill and I'm wearing a white coat and a stethoscope, for example, there's credibility. And you believe in me and the treatment I'm giving you. And I say to you, this is the most potent, powerful painkiller we have. You are going to feel better after you take it. If you believe me. If you believe me and you predict that your pain will go down, your brain will start bumping out endogenous homemade opioids and other neurochemicals, and your pain volume will actually go down. A placebo is not nothing. A placebo is the opposite of nothing. A placebo occurs when we believe that our pain will Go down. We believe we'll start feeling better. And our body responds with a neurobiological cascade of events. So, yes, there's a ton of science to support that. If we believe we're going to start feeling better and we have faith that our health is going to improve, pain volume will start going down. We will start feeling better. So, like, this to me just keeps going back to this concept of a pain recipe. Like beliefs and thoughts are an important part of that recipe.
- [39:40]
A
So what's in your daily protocol, if you will? Because as you mentioned, pain's inevitable. It's going to happen, it's going to hit. But we want to be ready. In the same way, if you want muscles, you got to go to the gym. You have to do resistance training. So how do we prep every day? And what are high leverage behaviors?
- [39:55]
B
Totally. You know, I, I always answer this question with some caution because everyone listening is at a different stage of health and strength. So I always like to start with my patients where they are. So there's a couple buckets I want to look at. Like, I want to look at the bio domain of pain and I want to know what's changeable there. What's changeable there is sleep. Like, we can't change genes necessarily, but we can change ingredients like sleep and the quality of our sleep. We can change things like nutrition. What fuel are we giving our bodies to fight pain and disease and illness? We can change things like how much we move. And to me, those are some of the fundamental places to start. So, for example, I always have my patients, and I do this myself, commit to being outside and moving their bodies for however many minutes a day they can do it. If it's 60 seconds, bless you. That's where we start. If you can do five minutes between meetings, great. If you can go for an hour, jog. That's what we're doing. And we're blocking it off in your schedule to make sure it happens. And even better, if I can get you to do it with someone. Like, if you have a partner, a husband, a wife, a kid, a co working buddy, a gym buddy who's willing to do it with you, that makes it a million times more likely you'll actually achieve that goal. So I really like to start with movement, which is counterintuitive to most people because pain tells you to stop moving. It does. And when you have acute pain, like a broken leg, you should stop moving. Absolutely. When you have chronic pain, which is three months or longer, what we now know is that chronic pain is A disease of the central nervous system. It means there have been changes to your brain and spinal cord that are amplifying the brain's pain alarm, often in the absence of tissue damage and actual danger. So movement science shows is one of the most fundamental things we can start doing to lower pain volume. So I like to start there. I also really love giving people sleep hygiene protocols. I feel like that's also low hanging fruit. And by that I mean I might not be able to change your sleep overnight, but I can get you to start engaging in healthy sleep habits starting right now. For example, I am going to ask you, and I know how hard this one is to put your phone in a little bin in a room that you won't be in two hours before bed. We're just going to start there. I know how hard it is. But we're going to make a list of other activities that you might like engaging in. Maybe it's stretching or listening to an audiobook or reading a magazine or hanging out with your kids. But we're not on screens two hours before bed. So there's a bunch of low hanging fruit that target some of those ingredients that we can get going with right away that costs $0.
- [42:42]
A
So I'll share a counterintuitive view on your sleep protocol. So I sleep with my phone next to me and I'm totally fine with it unless something super stressful comes across that's like work related. With that said, with tv, we watch tv. My wife and I love watching tv. I am impacted by what we're watching. So if it's anything that's like a little too stressful or dark programming or too intense. So like we're watching. I think it's Friends and Neighbors on Apple TV right now. It's, it's so good, but it's a little dark and I get amped up from watching that. Like it won't. Like I need to watch like my mindless Netflix and that will relax me and take my mind off of work and I'm good. But if I watch something too intense on tv, I am impacted. That impacts my sleep. But I love TV because it, because it's, it distracts me from everything else.
- [43:35]
B
Right. So. So again, we said before, the answer to everything is it depends on the person in front of you. So for some people, I'm the same way. Like, I can watch really mindless stupid TV for a couple hours and be fine. But there's a couple of scientific reasons why we reduce screen before bed. Like blue light.
- [43:50]
A
Yeah. I wear My glasses.
- [43:51]
B
Yeah, exactly. So like if you're, if you have like a blue light setting or like a night setting on your phone, you're fine as far as blue light goes. But it's not just the blue light, like you said, it's also content. And what are most people doing on their phones? They're doom scrolling. I do not want you doom scrolling. Before bed, you are prohibited from reading the news before bed. That is going to keep you up and activated. And the more activated you are, the less likely you are to sleep. And the worse your sleep gets, the worse your pain gets. So there's usually some relationship between screen behavior and poor sleep and high pain. So that's why it's such low hanging fruit, because that's a behavior we can all modify.
- [44:30]
A
So something else you touch on and I love you say friends are medicine. Strong link between social connection and pain reduction. Tell us more.
- [44:37]
B
It's such a huge connection and it's so profoundly fascinating to me. So one of the worst punishments you can give a human being is solitary confinement. What does it say about human beings that one of the worst things you can do to us is isolate us from others? The science of this is incredible. We are such inherently evolutionarily social animals that our brain rewards us for engaging in social behavior in the presence of others. Our brains produce all of these neurochemicals that make us feel good, like dopamine, which is reward and motivation, and serotonin, which boosts our mood. And oxytocin, which is a chemical of connectedness and bonding. And wait for it, endorphins, which are our endogenous opioids, are homemade painkillers. And when we are in the absence of others, all of those chemicals crash and we feel worse, not just emotionally, but also physically. And Vivek Murthy, our former US Surgeon General, did this incredible multi year study compiling all the research and data he found on how loneliness affects the human body and found that loneliness and social isolation are major predictors of chronic pain and disease later in life. So like again, this goes back to the connectedness of all things and, and that makes sense, like the brain is connected to the body 100% of the time. There is no disconnect. This is like a false divide we have in medicine. The other piece of data I thought that was so fascinating is that among the elderly who are lonely and isolated and alone, they have higher rates of morbidity and mortality, which higher rates of disease and illness and death than those that have robust social support. And I wanted to know the science of why. Among the reasons is that loneliness and isolation is a major stressor on the human body. Like, we are designed to be tribal. We are designed to be in community because community confers support and protection from predators, access to food and water and shelter, like it is fundamental for our survival. So among those who are lonely and isolated and alone, this stressor changes their physiology. It bumps their levels of cortisol in their bloodstream. What is cortisol? Cortisol is a stress hormone that suppresses our immune system over time. So among those who are lonely and isolated and alone, with very high rates of cortisol, high levels of cortisol, it means if they're healthy, they're more likely to get sick. If they are already sick, they are likely to get sicker, and they are also more likely to die. Like social health is fundamental to our physical health that has been known for a very long time.
- [47:41]
A
Yeah, 100%. We did a podcast specifically on the Rosetto Study because of this, how it's counter to everything we talk about as it relates to health and wellness and lifestyle. But these were the most socially healthy people maybe who ever lived. They did all the wrong things, but no heart disease. It's incredible. The book is amazing, and it's filled with so much science. And I'm curious, from the person who spent five years writing this book, what was the most surprising science to you where you just said, wow, I can't believe I'm reading this.
- [48:12]
B
Gosh, I think the most surprising science was around nocebo. And I want to say what that word means. So we. We defined placebo. Placebo is not nothing. It's when predictions and expectations and context change your neurobiology to change your pain. Nocebo is the opposite. Nocebo is when words and context and predictions and emotions actually amplify pain volume in the brain. And there's so much data to show that the things our providers say to us and the things we research on Dr. Google in Air quotes for listeners actually affect our pain. Like, it's called a nocebo effect. It's the opposite of the placebo effect. And. And the nocebo effect can occur. For example, if a doctor says to you, there's no treatment for chronic pain, you're going to have pain for the rest of your life. It does to your brain the opposite of what a placebo effect is like. If I say to you, here's a pill. It's the most powerful painkiller we have, your pain volume is likely to Go down, you're likely to feel better, and your brain bumps out endogenous opioids. In the presence of negative predictions and context that supports those negative predictions, your brain will lower levels of endorphins and the other chemicals that make you feel better. Muscle tension will increase, stress hormones will increase. All of those ingredients that make for a terrible pain day will increase, and you will actually feel worse. Like, you told that story earlier about how when you were predicting that your symptoms were actually due to cancer, you actually felt worse, you started developing pain, your stomach started hurting. And I told you the story of my patient whose pain went through the roof when she predicted that the pain she was experiencing, which was due to a kidney stone, was actually cancer. So, like, the brain is a prediction machine, and our predictions and the messages we receive from the outside world can amplify pain volume. And the reason I went down that rabbit hole so far is because I truly. Every patient who comes to my office has a nocebo story. Every single one. Like, I. So I'm always listening for the messages they've been given. Like, it's just bone on bone in there. You have the back. You have the back of an 80 year old. I mean, like, like, we could be at this all day. So, like, I want every listener to know that any message you receive from anyone that inspires hopelessness or fear is a nocebo. And we have to fight so hard to not believe those nocebic messages.
- [50:42]
A
I love it. Reminds me of Ellen Langer, too.
- [50:44]
B
Yeah, yeah, Ellen Langer is great.
- [50:46]
A
So I'm curious, my last question. What did you change personally in this process? You write in the book and you say, oh, wow, I could do better here, let's tweak this.
- [50:56]
B
As far as my own health, I can tell you that I developed eye pain while I was writing this book. And I have treated pretty much every pain and every body part there is known to humankind, including, like, toes and ears. But I had never treated eye pain. And I was so confounded when I developed this pain. And I was given very scary diagnoses and nocebic messages. I was told that I was potentially going blind. I had to go to the emergency room. My retina was possibly detached scratching. Because I had all these symptoms that suggested that could be happening. This, the nocebic messages had did a real job on my nervous system. I was petrified. I realizing I haven't told this story before. I was like, told that I needed to reduce significantly, like, screen time. I told my editor I had to Take a break from the book. I was, like, lying in the dark. I was listening to audiobooks. It was gnarly. I was in so much pain. And funny enough, my husband, who is not a healthcare provider, has heard me talking about all of this stuff for so many years. Pain is biopsychosocial. There's always a recipe. And he was like, I wonder what the recipe for your eye pain is. And he said, you know, I've noticed that over the last couple of months, you've been hunched over this tiny screen and you've been reading thousands. And that is not an exaggeration of medical journal articles, you know, and with tiny print. And I'm wondering if maybe eye strain is part of your recipe and also the stress and pressure of writing the book. Because I had an editor who was down my throat constantly about deadlines, and I hold myself to an extremely high standard. And I wanted to write the best possible book I could possibly write with all the data, all the latest science, you know, great stories. And as soon as he said that, I had, like, this epiphany, this moment of, like, oh, my God, like, I'm not paying attention to my own pain recipe. I'm not setting aside enough time to be outside and move my body. And I am really stressed out. I'm not doing enough to take care of my stress levels. And I'm on this tiny screen reading all of these articles that are so intense and trying to translate them. I'm not taking enough breaks. I need to do so many things. So, like, I changed so many things in that moment. Like, I started setting a timer every 20 minutes to get me to get up and get away from my screen and go outside. I got a big monitor so that I wasn't staring at a tiny screen anymore. I got a program. I can't remember what it's called, that would read articles to me. Check this out. They were neuroscience articles, and you could pick any voice. And I picked Snoop Dogg's voice. So I had Snoop Dogg reading neuroscience articles. To me, it was a total game changer. Like, within a couple of months, I wasn't completely better, but I was feeling a.
- [53:46]
A
So, like, you should have had him do the audiobook.
- [53:49]
B
I know. I totally. The introduction. That would have been amazing. And I actually had this story in the book, and I took it out. Actually, I was asked to take it out, but. But the pressure I was experiencing, like, writing a book is no joke. I've wanted to do this my whole life. I've wanted to be a writer since I was 6 years old and like this was my dream to write a book in the style of Oliver Sacks that would go into the world and help people who were living with pain, you know, and, and the pressure I was putting on myself was, was immense. So like you said, you had you experienced a shift in your pain when you started letting stuff go? I realized there was a good chance I wasn't going to make my deadlines. And I was like, oh, well, I guess I'm not going to make my deadlines. And it really, that was one of the ingredients that shifted it for me too. So. So there were a lot of ingredients in that recipe, but thankfully I'm a lot better.
- [54:35]
A
I love it. Let's get Snoop. Let's make Snoop Dogg happen. I think maybe he has a different view on how he treats pain.
- [54:42]
B
I think you're right. And I'm not opposed to medical marijuana. I will say for the record, but maybe you could.
- [54:48]
A
I see an IG collab in your future with Snoop Dogg.
- [54:51]
B
Oh my God.
- [54:52]
A
He's hanging out with Martha Stewart. Who knows what's possible, right?
- [54:55]
B
Yeah, maybe pain scientists are next on his list.
- [54:58]
A
Yeah, there you go. Let's put it out there.
- [55:00]
B
Okay. It's in the universe now. Hey, Snoop Dogg.
- [55:03]
A
Call me Rachel. Thank you so much. The book is amazing. Tell me where it hurts.
- [55:07]
B
I'm so honored that you read it and liked it. It means a lot to me. I appreciate it.
- [55:13]
A
Ryan Reynolds here from Mint Mobile. I don't know if you knew this, but anyone can get the same premium wireless for 15amonth plan that I've been enjoying. It's not just for celebrities. So do like I did and have one of your assistant's assistants switch you to Mint Mobile today. I'm told it's super easy to do@mintmobile.com
- [55:31]
B
Switch upfront payment of $45 for 3 month plan equivalent to $15 per month required intro rate first 3 months only, then full price plan options available, taxes and fees, extra fee, full terms@mintmobile.com.