Our limit is pain

A new book describes what to do about it

At the bleeding edge of human performance is pain. We don’t talk about it much, but there’s a reason players go harder in the playoffs than on tanking teams, and it has a lot to do with accepting more risk of pain–of exertion, of collisions, of trying to get out of bed in the morning.

Pain affects little decisions all game long. One of the most important academic papers in NBA history showed that prime Dwight Howard—who looked like a 7-foot He-Man—helped his team win mostly because opponents avoided attempting to score at the rim when he was around. (Meanwhile, there have always been elite shotblockers who were less physically intimidating and had people drive on them constantly, very much including Jay Huff.) Duh! Who throws their body at Goliath?

Years ago I watched every LeBron drive over an entire season, and was blown away at how often defenders clocked him in the head. And the data also showed that after being hit in the head, LeBron tended not to drive as much.

It might seem like a long time ago now, but as a young player in Oklahoma City, Kevin Durant used to attack the rim and dunk over people while getting violently fouled. And while he still draws a lot of fouls, in more recent years they’ve been very much more of the touchy/sneaky variety. Evidently, Durant got hurt and lost his appetite for getting hit. Who can blame him?

It’s deeper and more complex than that, too.

In writing Ballistic, a book about how we move, I was surprised to learn that pain does other funny things. Derrick Rose tore his right ACL, rehabbed like a madman, returned to play, and injured his left knee. It’s incredibly common. When you have the memory of profound pain on one side, the force plate data shows many athletes shift the force of landing to the other side, where that extra force wreaks havoc.

The best teams and athletes need better ways to understand, prevent, and manage pain. At the same time, even most doctors are not on top of the best pain research. Like movement, pain might seem simple, but in fact, both emanate from the brain, which is anything but.

In writing Ballistic, I interviewed Rachel Zoffness, Ph.D. She’s a pain scientist, a clinician who treats the toughest pain patients, an assistant clinical professor at the UCSF School of Medicine, and a lecturer at Stanford. (It’s worth listening to Dr. Zoffness talking to Ezra Klein.) She taught me all kinds of things that apply to all of us every day and that frankly I find life-changing. So when I learned that “Dr. Z” was writing a book, I am pretty sure I got the first review copy.

Tell Me Where It Hurts will be released soon and if it doesn’t change how we see our bodies, we’re doing it wrong. It’s a book with the potential to not just update our thinking about our bodies, but also our doctors’ thinking.

“Those who treat chronic pain would be wise to base their care on this book,” says John D. Loeser, M.D. He’s professor emeritus of neurological surgery and anesthesia and pain medicine at the University of Washington and a past president of the International Association for the Study of Pain. Yale professor Lisa Sanders MD says “As a physician, I was humbled by how much I didn’t know. This book is essential—for anyone living with pain, and for those who care for them.”

Ron Turker, MD, former Director of the Kaiser Permanente Pediatric Pain Clinic, and associate clinical professor of orthopedic surgery at Oregon Health and Sciences University, says “every young physician can benefit from a dose of ‘Zoffness training.’”

So let’s learn. Here’s my lightly edited recent phone conversation with Rachel Zoffness:

Your book is amazing. And honestly, there were fifteen things in there that I would love to explore, starting with the drowning rats. I’m very, very, very sorry for the rats, but I’m also blown away at the difference in how long they will swim, and implications for all of us every day, right? Can you talk me through that a little bit?

That was a study by Curt Richter a long time ago. It was before we had, you know, ethics. But he was a biobehaviorist who was curious about the impact of what I’m going to call psychosocial factors on a lot of things, including motivation and physiology, which of course, overlaps with what you do and write about.

And he hypothesized that hope, and other psychological factors, had a lot to do with motivation and physical ability, which, of course, we all know intuitively. You know, if you feel optimistic and hopeful about, for example, your ability to complete a marathon, chances are higher you’re actually going to be able to complete the marathon, right?

The rats were in these jars full of water, and they were drowning. They were also terrified and scared. And you know, fear does a number on our physiology. I think there were other things he did to the rats too, if I remember correctly, he chopped off their whiskers and other gnarly stuff so the rats that had no hope, those rats did not survive. They did not last very long.

But when he pulled the rats out of the water and he gave them some food, and he gave them some water, and I think he pet them, and then he put them back in the water. They had hope, because he did it repeatedly. So he did it the first time that he did it again, and then he did it again. And those rats learned that there was a chance that someone would pull them out of the water. They learned that there was hope of survival, and they just kept treading water, hoping that someone would reach in and save them, because it had happened multiple times already. So their brains learned that there was hope someone was going to rescue them, so they just kept swimming.

We’re used to the idea that maybe you could take a couple of minutes off your marathon time with, say, positive self talk. But the difference here is not a factor of one or two percent. The most hopeless rats drowned after 15 minutes of swimming, while he reported that hopeful rats swam for 81 hours.

I don’t think the study has been replicated. But it’s funny you mention this study. I wrote this book in part because I had read bits and pieces of all these things, and I just wanted an excuse to go back and study. I could have spent twice as much time on this particular phenomenon, because it’s so fascinating. But research does show that hope and optimism has a crazy impact on our physiology, like literally on our brain, on our body and on our pain. And that’s why I picked that study, because I just thought it was so remarkable.

You’ve read my book on movement. And now I’ve read your book on pain. And it seems like so many more things in our world are our brains than we used to think, right? And this rat study, maybe feels like one more example.

Big picture idea! I’m trying to think how far back to go. But big picture, when we have pain, our brains tend to go very negative, which is normal because pain is the body’s danger detection system. And when we feel pain, it’s scary and aversive by definition. Of course it is.

And also, when we feel pain, our mindset tends to go negative. We tend to predict bad things. Like, the brain is a prediction machine. We’ve known that for a long time, and a brain in pain tends to make negative predictions. We know that too. So oftentimes you’ll hear people with pain, and I’m guilty of this too, say things like, what if this never ends? What if this lasts forever? What if I’m a burden to my family? What if I can’t go back to sports or run again or have sex with my partner? Pain steals so many things from you, and the longer you have pain, and the more things it steals from you, the more negative your thoughts become, the more negative your mindset becomes. And that’s, that is standard, that is, that’s just what it does for most people, most of the time.

The problem with that is that we know that our thoughts, our cognitions, our physiological, biological events, like thoughts, aren’t just these like little bubbles that appear above your heads, the way you see in a cartoon. Thoughts are biochemical events in the brain that actually have what I like to call a biological cascade in the body.

So I’m going to, I’m going to give you an example of this, and I promise I’ll connect it all back together. When I first started treating chronic pain, I had people say to me, do you use biofeedback? And I was like, I don’t know what biofeedback is. So no, I don’t.

But I’m interested, so I found a biofeedback expert near me. His name is Dr. Pepper, which, of course, is like the best name for any doctor ever. Dr. Pepper sat me down in a chair, and he said, I’m going to teach you to warm your hands to 90 degrees. And I was like, well, I’m a chronically cold-handed person, A. And B, I’m not sure I believe in voodoo. How are you going to get me to warm my hands to 90 degrees? He was like: basically using your thoughts, but not just your thoughts, because your thoughts are physiological, and they have a biological cascade in your body, and they affect your blood flow and your breathing, your respiration, and they affect your immune functioning. They affect your hormones, and your thoughts also affect your neurotransmitters. You think a thought is just like this small, little event, actually, it has profound effects on your body.

So I sat in the chair and he hooked me up with this biofeedback device. And the biofeedback device was reading my heart rate, it was reading muscle tension, it was also reading galvanic skin response and also skin temperature. So all of these things we think we have no control over, right? Like we don’t necessarily think we can control our heart rate or our skin temperature or our breathing rate.

And then he had me close my eyes, and he said tell me about your to-do list, tell me some things you’re stressed out about. So I started talking about the things I was stressed out about, the patients that weren’t getting better, and taxes that weren’t paid, and the bills that were piled up on my front desk, you know, all the things like, you know, family stuff I had to take care of. And and there was a biofeedback machine that was reading all of the output, my heart rate, my skin temperature, and he had me open my eyes as I was thinking the stressful thoughts and lo and behold, my skin temperature was going down, my heart my heart rate was going up, my muscle tension was spiking.

I could not necessarily detect it on my own, but the machine was gathering feedback about my biological processes and was feeding it back to me. So it turns out that stressful thoughts, just your thoughts, increase your muscle tension, increase your heart rate and plummet your skin temperature.

Do you see where I’m going with this? We know, the more tense your muscles, the worse your pain. We know, the more stressed you are, the more cortisol you have in your bloodstream. Stress hormones, the worse your pain. That is proven a million times over. We know, the more stressed you are, also the more, the fewer endorphins you have also, and endorphins are natural, endogenous painkillers, right?

So then Dr. Pepper had me do the opposite. He had me close my eyes. He guided me through a relaxation protocol, some visualization. We know about the role of guided visualization in sports, you know? I mean, that’s not new. And he guided me through all these relaxation protocols, and then had me open my eyes, and lo and behold, my heart rate was lower. My muscle tension was lower. And my hands were warm. My hands were warm, right? So we think that thoughts are just these things that occur between our ears, but actually thoughts are biochemical, physiological events that affect every single thing in our body, from our head to our toes.

And I think you wrote that you learned how to warm your hands.

I did! I think I did three sessions with him, and I could warm my hands to 90 degrees. Still do it. I can do it now, like if you asked me to. Even when I talk about it, my hands start getting red and hot.

The reason I put in that hope study with the rats is because hope is so critical. It’s so critical not just for our mindset or mental health, but it also affects our bodies and our pain, because mindset matters. Mindset matters, and our thoughts matter. We just don’t think about it that way.

I was blown away by this too. Anxiety and depression symptoms are five times more common in people who have chronic pain than in those who don’t.

Chronic pain is a thief. Pain steals from you your ability to work, to hang out with your kids and roll around on the floor, to exercise sometimes, to have sex with your spouse, to engage in pleasurable activities. I mean, pain is a thief. It’s also very scary, it’s also very unpleasant, and the longer you have pain, the more standard and normal it is to feel sad and grief stricken about all the things it has taken from you. The longer you have pain, sometimes the more it takes from you. So it’s normal to feel grief. It’s normal to feel sad. It’s also normal to feel scared. What’s going to happen to my body? Is this going to last forever? What else is it going to take for me? Is this ever going to go away? You know, that is so normal, so I like to talk about it as a normal response to an abnormal situation.

The body is not designed to be in pain all day every day. We’re not designed that way. So your body, your brain, is actually responding to this abnormal situation. The longer you’re in pain, the more scared and anxious you become, the more sad you become. And the fact that that spirals into anxiety and depression, I think, is pretty normal, and research shows it’s pretty normal, actually.

So as a clinician, do you feel like you’re then treating pain, or anxiety and depression, or both?

Oh, how do I answer that question? My first instinct was to say it’s a little bit of a false divide, because we know that when we have pain, chronic pain for really long periods of time, it triggers anxiety and depression. Of course it does. That’s a normal response to an abnormal situation. So I know that my patients who come to me are usually some degree of depressed, even if it doesn’t meet clinical criteria, and some degree of panicked and anxious. And I know that if I’m going to help them manage their pain or make their pain go away. I’m going to have to help them manage their emotions and their mood, because emotions affect pain too, like the emotions we feel change our pain 100 percent of the time, because the parts of the brain that make emotions also make pain.

So I know that someone coming to me for chronic pain is probably experiencing some of those things, and that when I treat them, I have to treat both. You can’t just treat the body, you can’t just treat the brain, you always have to treat both.

If I want your brain to start pumping out opioids, I have to give you messages of hope. We know that’s true. So if I want to change your brain and your body, I have to be careful about the language I use as your treatment provider. I have to be careful not to use inflammatory, terrifying language. I have to be careful not to give you messages of doom and gloom, because you’re going to drown. You’re going to be like the rat that drowns. And if I give you messages of hope and healing, and I tell you, your brain and body are highly malleable, there’s a million things you can do to adjust pain value, you’re going to motherfucking swim for 80-plus hours. But I have to give you the language.

I have to give you the hope and like that’s the power that health care providers have, and they forget it.

We forget because health care providers aren’t trained in pain, and they aren’t told that language matters. They aren’t told that emotions matter when it comes to pain. And if you’re not told that you’re not going to be careful, you’re not going to be careful with the emotions you inspire in the language you use and the words you deliver. Part of my message is, as healthcare providers or just family members of people who have pain, we want to use our words as weapons in the best possible way. We want to inspire hopeful emotions. We want to empower people. We want to help people swim.

I’ve had similar or analogous conversations with the people at P3 about anxiety which, anecdotally, appears to affect movement. They’re always trying to improve movement, right? Let’s say someone’s had an injury and now they don’t want to meaningfully move their right hip, right?

Well, do you now want to treat the anxiety, or do you want to treat the soft tissue? Their take is like yours: it’s absolutely both–but not a lot of people are really ready for that idea.

I find any mention of anxiety suggests to someone in pain that maybe you’re saying it’s all in their head, or maybe you’re saying they’re mentally ill, and that’s not what you’re saying at all. Of course, pain is scary. That’s by design. Pain is your body’s danger detection system. Yeah, by design, you’re supposed to be scared of pain. If you’re not scared, and you’re not motivated to make change, and you just keep running on the broken ankle, you’re going to permanently damage your body. You’re supposed to be scared. That’s what it’s supposed to do. So yes, you’re supposed to be scared to move your hip.

The problem occurs with chronic pain. Then you stay permanently scared of moving your body. And moving your body is the thing you need to do to get better. So in order to help someone with chronic pain get well, you have to help them navigate the fear and overcome it.

And the only way to do that, literally, the only way is to get them moving again. You have to teach the brain that moving isn’t dangerous, it’s scary, and it might even hurt, but with chronic pain–and I don’t mean acute pain, I don’t mean like a broken hip–I mean with chronic pain, movement isn’t dangerous. You have to move to train your brain that this is just an alarm system that is, you know, screaming without actual danger. And the only way to prove that to someone is to get them slowly and gradually moving again.

So you always have to treat the fear. You always have to treat the panic. Any physical therapist will tell you that if someone is too scared to move, they’ll never get better. So there’s a lot of ways of treating that anxiety, or the fear, you know, or the stress around pain and and I actually think maybe calling it anxiety is part of the problem, because there’s so much stigma around mental health. So maybe we don’t call it anxiety. Maybe we just normalize that you’re stressed and afraid and that pain is supposed to do that to your brain, and this is a normal response. And you know, in order to overcome the pain and the fear, I have to get you to trust that a little bit of movement is safe and okay.

I don’t know when we first talked, but a few years ago now, and your ideas have been in my head that whole time. And I’m not sure how many little events have occurred since then. Bumped a knee or whatever. I don’t know the right way to phrase this but it feels to me like there’s the feeling of the bump. Picture that the size of a golf ball. And then, in the lived experience, there’s another bigger circle around, a basketball, which is the emotional experience of that bump. But the size of that basketball feels malleable–in the sense of how you can make your hands warm. Does that make sense?

You notice that emotions are connected to pain, and you can have some control over the emotions around pain.

I’ll try saying it another way. It feels like pain is X times Y. X might be non-negotiable, some minimal amount of sensation. But the Y, the degree to which we amplify that, feels very plastic and subject to how we process.

Okay, right. So just to back up, I want to say we are told that pain is this purely biological, biomedical phenomenon that has just to do with bones and body parts. That’s what we’re told. That isn’t true.

What we actually know is that pain is ultimately constructed by the brain, and the parts of the brain that make emotions, like our limbic system and our prefrontal cortex, are intimately involved in the pain experience. The parts of the brain that make emotions also make pain. So the reason that’s important is because we think of pain as purely physical, but pain is actually physical and emotional 100 percent of the time.

There is no such thing as pain that isn’t influenced by our emotional state, and we all know intuitively that pain feels worse when we’re stressed and miserable. It just always does. And we also know that pain feels less bad when we are engaged in pleasurable activities and out in the world and distracted and feeling good and happy and joyful, like the brain turns down pain volume when our emotions are positive. And of course, this isn’t just like a Pollyanna, go-be-happy message, just think happy thoughts and go and your pain will go away.

That’s not true, and that isn’t what I’m saying. What I am saying is that you can adjust the brain’s pain dial by adjusting emotions, which is exactly what you’re saying. So if you imagine that you have like a volume knob in your central nervous system, which I’m calling a pain dial, and a lot of things can turn pain volume up, and a lot of things can dial pain volume down, so like pain medications turn pain volume down, but emotions also adjust the pain dial.

So we know when we are stressed and anxious and our muscles are tense and tight and our thoughts are worried and pessimistic, the brain is going to amplify pain volume. And we also know the opposite is also true. So when we are relaxed and calm and feeling happy and more engaged in pleasurable activities, the brain’s emotion centers turn pain volume down. So this is exactly what you’re saying. You notice that your emotions change the pain experience, and that’s because you’re neurologically wired for your emotions to adjust pain volume. And that, of course, is adaptive.

Let’s say there’s been a car accident, and you know there’s sirens and you know there is danger, there’s blood everywhere, and you know and there is danger, and your brain is telling you you should be scared. There’s a lot of contextual emotional cues telling you that pain volume should be high. There’s a reason for that. That’s adaptive, because you want to pay attention. You want to feel afraid. You want to go looking for help. You want to check your body to make sure there’s not damage, right? You want to be vigilant in an emergency situation. So all of those negative emotions are actually helping you. They’re helping you to pay attention, they’re helping you to go get help. They’re motivating you.

But that’s not always helpful in situations where there’s not an emergency. So say you’ve had chronic pain for ten years, but your brain is constantly vigilant, and you’re constantly thinking negative thoughts, and you’re in a state of stress, and your muscles are tense and tight. That is not helping you, because chances are high after ten years of chronic pain, there’s not an emergency in your body. Tissues usually heal within three to six months. And if you’ve had pain for 10 years, chances are very high your tissues aren’t telling you that there’s an emergency, right? Your brain is just flipped into emergency mode. And we know that that’s what chronic pain is. Chronic pain is your brain sort of stuck in emergency mode. So you know, having these negative emotions and a lot of fear and terror and panic and you know, sadness around your pain is normal, but it’s actually not helping you. It’s keeping pain volume dial high, but it’s not doing that in an effective way. Does that make sense the way I said it?

It really does. You’re really good at this.

I know you, you mentioned in the book this thing that I feel like I’ve witnessed many times, which is, you know, does it hurt to fall in the playground? And at times, you can literally see a kid will look up to see their parents’ responses, to figure out how worried they should be.

I use this as an example of how we are told that pain is a purely biological, biomedical event, just to do with bones and body parts. And what science says is that pain is actually biopsychosocial. And what does that word mean? It means that, of course, biology matters. It matters a lot. Bones and body parts matter. We have to pay attention to anatomy and physiology. But what neuroscience says, like we’ve talked about, that psychological factors matter to pain also, because the parts of the brain that make emotion also make pain. So emotions matter. We talked about thoughts, cognitions, cognitive events matter. Attention matters. If we’re focusing on pain, it feels worse. And we also know that biopsychosocial pain is also sociological. So social things matter too.

And that sounds crazypants to most people, and it did to me too. I was like, how is pain social? That makes no sense to me. So it turns out that cross-culturally, the way we talk about pain, experience pain, and treat pain differs based on social and cultural norms. So one of the ways I like to think about that is, you know, we all have role models for what we are supposed to do when we are in pain, how we’re supposed to express pain. Like, in some cultures, we’re more emotive, so we might like America, right? Americans will stub our toe and we’ll scream and we’ll hop on one foot and we’ll curse really loudly. And in other cultures, like in some Asian cultures, there’s an emphasis on being more stoic, and you’re, you’re not supposed to scream and hop on one foot and curse really loudly, like that’s not how you express your pain culturally. So you’ll notice there’s a cultural difference in how we experience pain.

I like to think about this example of when a kid falls on a sidewalk, the first thing he’ll do is look up and look at his parent’s face. And the research has shown that if the parent expresses great distress and alarm, the child will cry. However, if the parent is calm, relaxed and says, oh, honey, you’re okay, and distracts the child, kisses the boo boo, and sends them back off to play, the child will not cry.

So we know that there are social factors that constantly affect pain also. So it’s not just biological and it’s not just emotional, it’s also social.

It’s a pattern that extends into adulthood.

Mini traumas occur all the time in all of our lives. And some people seem to react like their parents are saying, oh my god, are you okay? And some people seem to react like, like, it’ll probably be all right.

The pinnacle of this for me: Kevin Durant tore his Achilles in the NBA Finals. Maybe a lot of us would scream and cry in that moment. But he sat very calmly, took his hand and felt to see if he had an Achilles in place anymore. And then to my eyes he was like, oh, bummer. So mature and pragmatic in the face of trauma. He looked like he was meditating, almost.

I want to be clear what I’m saying. I’m not saying that we shouldn’t scream and cry when we have pain. That’s a fine thing to do. That is normal. It’s a standard cultural thing to express pain and grief. If you are a star athlete and you break a thing in the middle of a game, you break a bone or your tendon tears, it is completely normal to have an emotional response. There’s no judgment here.

But to me, this key piece is not what the person in pain does. It’s not the kid. The key piece to me is what the parent does. How do you respond? And then how does your child respond? Because they’re mirroring you. They’re reacting to you. They’re seeing your face. And you know, the mirror neurons in their brain are responding to what the parent is doing. And you know, we have so much data.

I’m at a pain neuroscience conference right now, and I was listening to the speaker talk, and she was talking about empathic pain, and I am so obsessed with empathic pain, and I’m going to say what that is. It’s so fascinating to me. Empathic pain is when we feel other people’s pain. Yeah, and like some some of us are more sensitive to that, and some of us are less sensitive to that. I happen to be super sensitive to empathic pain, which means I have the worst possible job, because I will physically feel other people’s pain, especially if I love that person. The closer I am to someone, like a family member or my husband or, you know, like the closer I am to someone, the more I feel their pain.

What I mean is I don’t feel it emotionally. I feel it physically. I was working with a child patient, and her jaw bone was deteriorating. She had, if I remember correctly, it was called something like cheerleader syndrome. I don’t know how it got that name, but her jaw bone was deteriorating, and every time that kid would come to my office, I would have jaw pain. I’m not exaggerating, and I know it sounds crazy, but research shows that human beings have mirror neurons in our brain, and they’re called mirror neurons, because we mirror emotional and physical pain of other people.

It’s literally why, if you’re watching a movie and someone gets punched in the face, you flinch. You flinch. It’s not happening to you, but your mirror neurons help you empathize or feel the pain of the person in the movie. We all sometimes, you know, there’s never been a movie where, like, you know, someone didn’t cringe and look away, right? And the reason we do that is because of empathic pain, and that is adaptive, and that is normal because humans are social animals.

We are evolutionarily designed to be tribal, to be social, because when we are social, it confers all these benefits. You know, we have protection against predators, and we have better access to food, because we have people to hunt with us, and more access to people to help us build shelter, right? So being social literally helps us survive. So if you have empathy for other tribe members, it brings you closer together. It is like a social glue. So it’s actually very adaptive to be empathic. So I think about that often when I think about pain, because, because our pain is profoundly influenced by the people around us, and no one tells us that, and we don’t think about it, and we certainly don’t think about it as part of treatment.

I think about Kevin Durant’s reaction, in part, as someone who has experienced chronic pain, where in that pain dial conversation, or my shoddier x times y formulation, I’m trying to use techniques that I’ve learned from reading your work, for instance, like diaphragmatic breathing, which are not so available when I’m hysterical. It does seem like, on some level, there’s a little bit like I’m doing a savvier job of managing my own body if I’m like, Huh? So that happened.

You’re calmer, right? Your nervous system isn’t in overdrive. You’re right, yeah, that’s right. That’s the connection. That’s exactly the connection. So when your nervous system is in overdrive and you’re in a state of panic and fear the brain’s pain alarm is going to amplify. That pain dial is going to ratchet way up, and you’re going to be less able to manage your pain and deal with your pain, and pain is going to physically feel worse also,

You write about how doctors treat women and minorities differently. Can you talk a bit about how that works?

I mean, this dates back to the slave trade. It’s pretty nasty. Yeah. Just. Historically, there was this racist myth that Blacks, for example, were tougher, were thicker skinned, and therefore felt less pain. I mean, it’s pretty nauseating and disgusting. And you know, there’s been a lot of research on this, and in the literature, in the medical literature, there’s a lot of data to suggest that that myth has pervaded medicine, because when African Americans go to the emergency room with a very painful injury, they receive, on average, significantly less pain medication.

Five times less likely, in one study, to receive opioids for appendicitis.

Are you familiar with this term superhumanization? I learned about it from an academic named Adam Waytz, who describes this phenomenon where white people ascribe superhuman qualities to Black people. But it tends to resolve in Black people being asked to endure more.

Yeah, yeah, wow. That’s very important. That’s a really beautiful way of saying that.

Your book also blew my mind with this talk about the efficacy of sham surgery.

There are all these studies done on placebo. So you are a patient, for example, with knee osteoarthritis, and you sign up for a study where you may or may not get knee surgery, and you don’t know. You’re blinded.

What the researchers do is, let’s say they’ll make an incision in your skin, but they actually won’t go in and do any surgery, they won’t perform any surgery. They’ll just make an incision in your skin. So when you wake up from anesthesia or whatever, you have no idea whether or not you had surgery. And I don’t remember the exact numbers, but something like 70 percent of those people had their pain go away.

The reason that’s powerful is because we think of placebo. If you ask someone what a placebo is, they’ll tell you, it’s a sugar pill. They’ll tell you it’s a nothing. People think that placebo is a nothing.

I’m going to tell you what placebo really is. Placebo is the opposite of nothing. Placebo is when you believe and you expect and you predict that your pain is going to go down as a result of certain circumstances. Like, for example, seeing that your knee has been cut and your doctor has told you there’s a good chance that you had actual surgery. And there’s reason for you to believe that your pain is going to go down. So in response to these biopsychosocial factors, your brain produces endogenous opioids, naturally made opioids, and your pain actually goes down. Placebo is not nothing. Placebo is the opposite of nothing. Placebo is when your brain responds to predictions and situations and other people and messaging around you to actually change your brain and body, like, that’s what placebo is. It’s an example of self healing.

And you know that sounds like voodoo, woo, woo, whatever. But your body self-heals every day. Ask anyone who’s ever had an injury. Anyone who’s ever had an injury will tell you they watch their body self heal. All those lacerations they heal, the bruises fade, and your skin knits back together, and your bones heal. It’s incredible. The body is a self-healing machine. Placebo is just like a self healing mechanism. It’s incredible.

So do you feel like part of your job is getting obstacles out of the way of the self healing machine?

Totally, I feel like a big part of my job is finding out what the nocebos have been. Nocebos are the opposite of placebos. We just talked about how there could be a bunch of biological, emotional, sociological factors that will trigger your brain, your body’s pharmacy to manufacture opioids to help your pain go down, right?

So there’s also the opposite, and the opposite is a nocebo. The opposite is when you know someone tells you chronic pain isn’t treatable, you’re going to be in pain forever, or someone tells you you’ll never run again. I want to say carefully, yes, of course, there are conditions where maybe you’re paralyzed and you really maybe never run, will never run again. Fair.

However, if you Google, is chronic pain treatable? This used to be true. I haven’t googled it in a while, but people with fibromyalgia, for example, are told by the internet and other sources that there is no treatment or cure.

If you’re told that, that has a nocebo effect. And what I mean by that is, and this is widely studied, I’m not making this up. There’s so much research your brain will produce chemicals that will make your pain feel worse. So for example, cortisol will spike. Muscle tension will spike, immune functioning will plummet. Your immune system will stop functioning normally. Your brain’s opioid levels will start plummeting. Nocebos affect you physiologically. It’s like this recipe that will make your pain feel worse.

So I do feel like a big part of my job is asking my patients, what messages have you been given? And then I have to think very carefully about how do I undo those messages, and not in like a cheerful, fake, optimistic way, because that doesn’t work. How do I use science to help you believe that science actually shows that chronic pain is treatable, and there’s a million things I can do to help you hijack your brain and body to activate your body’s pharmacy to help you feel better. Because that’s real. Our bodies have an endogenous, natural pharmacy. We know that’s true. We’ve always known that’s true. So how do I help you get these obstacles out of the way and help you start believing that your pain is treatable and you have a lot of agency and power. And there’s many things I can help you do to help your pain go down. Because you can control your pain dial you absolutely can. We’re not told that, and we’re not told how to do it, but there’s a million things I can do to help you change your cognitions and change your emotions and change your social health and change your biology and physiology to help adjust that pain dial.

Are there certain popular nocebos that you encounter again and again?

Totally. Actually, there’s a section in the book where I list out, I think it’s in part three, where I, like, list out all these nocebic messages. People with fibromyalgia are told by the Internet and healthcare providers that there’s no treatment or cure. Like, what are you supposed to do with that? By the way, fibromyalgia is basically amplified full body pain. So you’re someone living with amplified full body pain, and you’ve just been told there’s no treatment or cure. What the F are you supposed to do with that? You know, like, you just, like, basically you’re telling someone to just lay down and die, like you’ve taken away all agency, all hope, all motivation. Like, what does that do to someone’s physiology? I don’t just mean their psychology. What does that do to their physiology? We actually know what that does. It takes your immune system. It takes your brains, opioid levels. It makes your body feel worse. You destroy someone when you tell them there’s no hope, you kind of get this feeling the wheels are coming off the wagon, and then that feeling does, in fact, encourage the wheels to come off the wagon.

So is it good news or bad news that these processes are so deeply managed by the brain?

Oh, it’s the best news ever. Because we know neuroplasticity is real, and neuroplasticity means that the brain is malleable and changeable with time and practice and experience. And any basketball player will tell you that if you want to hit a 3-pointer, you have to effing practice over and over and over and over again, because your brain and body are plastic. Neuroplasticity means brain and body change with experience, time and practice, so the more you stand there and practice your 3-point shot, the better you’re going to get at it over time.

We know that the pathways in the brain are like the muscles in our body. The more we use them, the bigger and stronger we get. So the more we use the 3-point pathway in the brain, the bigger and stronger that pathway is going to get. The more we use like the piano pathway in the brain when we practice the piano, the bigger and stronger the piano pathway in the brain is going to get, like when I was a kid practicing piano after a while, after a couple of months, I could just sit down at the piano and my fingers just knew what to do, like I didn’t even have to look at the sheet music. And that’s because your brain changes with time and experience and practice.

And the same is true with pain. The longer we practice pain, the bigger and stronger the pain pathway in the brain gets. But the reason that’s good news is because if the brain can change, pain can change. If the brain can change, pain can change. So just as we can practice pain, we can also practice all of these healing techniques that will help the pain go down. So like, if you imagine, there’s a pain reduction pathway in the brain, and the more you practice these pain reduction techniques, the easier and more natural it’s going to be for you to reduce pain volume when you need to and when you want to.

So you were talking about diaphragmatic breathing. That’s one strategy. I was talking about biofeedback. That’s another strategy. The more I practice biofeedback, the quicker I could warm my hands, but I want to say what I was actually doing when I was warming my hands. I was redirecting the blood flow in my body. I was changing my heart rate. I was reducing my muscle tension, and those are the very things we need to do if we want pain volume to go down. And we can do those things. Science says we have control over our body much more than we thought, and we have control over our brain’s pain pathways much more than we thought, and it takes time and practice and experience.

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