#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Apr 21, 2025
auto_awesome
Sean Mackey, a renowned pain medicine professor at Stanford, dives deep into the complex nature of chronic pain. He discusses the evolutionary purpose of pain and how different individuals experience it uniquely. Mackey explores various treatment strategies, from traditional medications to innovative techniques like TENS, emphasizing the intertwined nature of physical and psychological factors. He also shares insights on the impact of sleep on pain sensitivity and the historical evolution of pain management, providing a comprehensive view of this multifaceted challenge.
Pain is a complex sensory and emotional experience essential for survival, challenging the simplistic body-mind distinction.
Understanding pain transmission involves different nerve fibers, highlighting the complexity of pain perception and individual variability.
The shift from a dualistic to a biopsychosocial model emphasizes the need for a holistic approach in addressing chronic pain.
Neuromodulation techniques like TENS can offer non-invasive pain management solutions, enhancing patient autonomy in their treatment plans.
Psychological factors, including anxiety and depression, significantly influence pain perception, necessitating a comprehensive treatment approach that includes mental health.
Innovative research into objective pain measures, such as neuroimaging, aims to develop personalized and effective pain management strategies.
Deep dives
Translating Longevity Science
The podcast emphasizes making the science of longevity more accessible to the general public through comprehensive content in health and wellness. The host, along with a team of analysts, aims to deliver high-quality information without relying on paid advertisements. Instead, the sustainability of this effort is supported through a membership model, which offers exclusive content and benefits to subscribers. This approach underlines the commitment to providing valuable resources aimed at enhancing individual knowledge and health outcomes.
Understanding Pain
Pain is defined as both a sensory and emotional experience, serving as a crucial evolutionary survival mechanism. The discussion highlights the transmission of pain through different nerve fibers, including nociceptive and neuropathic pain, showcasing the complexity of pain perception. Variability in pain experience among individuals is notable, even when exposed to the same stimulus, indicating psychological and emotional influences. This understanding is essential for advancing pain management approaches and improving patient outcomes.
Historical Context of Pain Models
The conversation reviews the historical perspectives on pain, particularly the dualistic model proposed by René Descartes, which suggested a separation between body and mind in pain perception. This model has significantly influenced medical care and policy over centuries, but it is increasingly recognized as inadequate. Modern approaches emphasize the biopsychosocial model, acknowledging that pain perception is a complex interplay of biological, psychological, and social factors. This shift is critical in addressing chronic pain more effectively and humanely.
Nociceptors and Pain Transmission
Nociceptors play a key role in how pain signals are transmitted to the brain, converting various forms of stimuli into electrical impulses. Two primary types of nerve fibers are involved: A-delta fibers transmit sharp, quick pain, while C fibers convey slower, throbbing sensations. Understanding the characteristics and functions of these fibers is crucial for better pain management strategies. This knowledge can help healthcare providers tailor treatments to individual pain experiences.
Role of Neuromodulation
Neuromodulation techniques, such as TENS (Transcutaneous Electrical Nerve Stimulation), are explored as methods for managing pain through the activation of A-beta fibers, which can inhibit nociceptive signals. This highlights a non-invasive approach to pain control that can promote patient autonomy. Sleep deprivation's role in increasing pain sensitivity is also addressed, emphasizing the importance of sleep in pain management. Managing sleep quality and employing neuromodulation techniques can provide significant relief for individuals suffering from chronic pain.
Chronic Pain Management Strategies
A range of approaches for managing chronic pain is discussed, including pharmaceutical options like NSAIDs, opioids, and anti-neuropathic medications. The effectiveness of these treatments can vary based on individual circumstances, with an emphasis on patient-specific needs. The importance of a comprehensive pain management plan, incorporating both medical and non-medical interventions, is stressed for better outcomes. Addressing underlying psychological factors alongside physical symptoms can enhance overall pain relief.
The Impact of Emotional Factors
Psychological factors such as anxiety and depression heavily influence pain perception and management. Understanding these emotional components is crucial for developing effective treatment plans, as they can exacerbate pain experiences. Acknowledging the biopsychosocial model, where biological, psychological, and social elements intertwine, allows for a more holistic approach to pain. This understanding encourages a focus on mental health as a significant aspect of overall well-being in chronic pain patients.
Innovations in Objective Pain Measurement
There is ongoing research aimed at developing objective measures for pain to better assess and manage this complex experience. Studies involving neuroimaging techniques, such as fMRI, have shown promise in identifying brain patterns associated with pain. This evolution in understanding pain may lead to more precise and effective interventions tailored to individual experiences. Innovative approaches could revolutionize pain management by establishing clearer connections between subjective experiences and measurable outcomes.
The Role of Physical Therapy
Rehabilitation and physical therapy are critical components of effective pain management strategies, especially in the recovery from injuries or surgeries. Active rehabilitation promotes muscle strengthening and functional improvement, which can alleviate pain and enhance overall quality of life. Patients must be encouraged to engage in tailored exercise programs to restore mobility and reduce the risk of persistent pain. Integrating both physical and psychological strategies leads to a comprehensive approach to chronic pain management.
Low-Dose Naltrexone in Pain Management
Low-dose naltrexone presents a novel approach for treating various pain-related conditions, including fibromyalgia and chronic pain syndromes. This medication may work by modulating immune responses and reducing neuroinflammation, providing significant improvement in patients' symptoms. Despite limited awareness and availability, low-dose naltrexone has exhibited a good safety profile and potential benefits for managing pain. Ongoing research is required to fully elucidate its mechanisms and establish its role in pain management protocols.
Understanding Fibromyalgia
Fibromyalgia is characterized by widespread bodily pain, fatigue, and cognitive issues, affecting primarily women but increasingly recognized in men. With definitions evolving, awareness and understanding of the syndrome are improving. The condition's management relies on a combination of pharmacological and non-pharmacological approaches to address underlying neuroinflammation and enhance quality of life. Ongoing research is vital to unravel the complexities of fibromyalgia and develop effective treatments.
Sean Mackey is a professor of pain medicine at Stanford University and the director of the Stanford Systems Neuroscience and Pain Lab, where his research explores the neural mechanisms of pain and the development of novel treatments for chronic pain. In this episode, Sean joins Peter for a wide-ranging discussion on the multifaceted nature of pain—as both a sensory and emotional experience—and its evolutionary purpose as a critical survival mechanism. He dives into how pain is transmitted through the nervous system, the different types of pain, and why different individuals perceive pain so differently. Sean shares insights into pain management strategies ranging from medications like NSAIDs and opioids to neuromodulation techniques such as transcutaneous electrical nerve stimulation (TENS). Additionally, this episode explores the interplay between sleep and chronic pain and the psychological and emotional dimensions of pain, and it includes a personal story from Peter about his own experience with pain and how Sean’s expertise helped him more than two decades ago.
We discuss:
The definition of pain, and how our understanding of pain has evolved from a simplistic body-mind separation to a nuanced biopsychosocial model [2:30];
The biological mechanisms behind how we perceive pain [9:30];
The role of consciousness in the perception of pain, and how nociception functions during unconscious states [14:30];
The four types of pain [22:00];
Using fMRI to identify objective biomarkers of pain in the brain [31:30];
The evolutionary role of pain in human behavior and survival [36:00];
How the brain processes and modulates pain signals, Gate Control Theory, the variability in individuals’ pain perception, and effectiveness of neuromodulation techniques like TENS [41:00];
The brain’s influence on pain: the role of emotion, beliefs, sleep, and individual differences in perception and tolerance [53:45];
Peter’s personal journey with chronic back pain, and how the emotional consequences of pain can be more distressing than the pain itself [1:04:30];
The pharmacology of common pain medications—NSAIDs, COX-2 inhibitors, and acetaminophen [1:09:30];
Muscle relaxants: benefits, drawbacks, and personalized strategies [1:20:30];
The definition of chronic pain [1:29:15];
The role of antidepressants in pain management [1:30:15];
Opioids: their controversial and nuanced role in pain management [1:33:45];
Alternative therapies: acupuncture and cannabis [1:54:15];
Fibromyalgia and chronic pain: clinical features, brain mechanisms, and emerging treatments like low-dose naltrexone [2:01:00];
Possible brain benefits of low-dose naltrexone (LDN) for people with mild cognitive impairment [2:15:00];
Peter’s recovery from severe chronic pain—how he went from immobility and high-dose opioids to full functionality [2:20:15];
Breaking the pain cycle: how physical rehabilitation and psychological recovery work together in chronic pain treatment [2:30:45];
Sean’s struggle with cluster headaches, and the value of knowledge, preparation, and empathy in both managing chronic pain and caring for patients [2:39:15]; and
