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Beyond the Prescription
Dr. Rachel Zoffness on Re-Conceptualizing Pain & Pain Management
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Dr. Rachel Zoffness on Re-Conceptualizing Pain & Pain Management

It's not just about body parts

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Pain is an inevitable part of life. But did you know that pain is not just about body parts?

Dr. Rachel Zoffness is an Assistant Clinical Professor at UCSF and leading global pain expert who is revolutionizing the way we conceptualize pain. She explains that hurt (pain) and harm (damage) are not the same—and that pain is never purely biological. Similarly, treating pain is never just about pills. It’s about addressing the social-emotional context around it.

On this episode, Dr. Zoffness sits down with Dr. McBride to discuss how thoughts and feelings inform the experience of pain. And how treating pain must include treating the brain.


Join Dr. McBride every Monday for a new episode of Beyond the Prescription.

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Transcript of the podcast is here!

[00:00:00] Dr. McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor for over 20 years, I've realized that patients are much more than their cholesterol and their weight, that we are the integrated sum of complex parts.

[00:00:33] Our stories live in our bodies. I'm here to help people tell their story to find out are they okay, and for you to imagine and potentially get healthier from the inside out. You can subscribe to my weekly newsletter at

and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts. So let's get into it and go Beyond the Prescription.

[00:01:02] I'm delighted to welcome to the podcast my friend Rachel Zoffness. Dr. Zoffness is a PhD, pain psychologist, assistant clinical professor at UCSF, and an author of a new book called The Pain Management Workbook. She believes like I do, that our bodies and minds are inseparable and that we need to think about pain in a much more nuanced way.

[00:01:25] In other words, when I was trained in medical school, we thought pain was about the body part and that pills were the solution. When actually, as doctors, we describe pain as a biopsychosocial phenomenon. Rachel, I am so happy you're here today. Thank you for joining me.

[00:01:42] Dr. Zoffness: Thank you for inviting me on, Dr. McBride.

[00:01:45] Dr. McBride: What I love about you is that we agree that mental and physical health are inseparable. When I was training in medical school in the 1990s and early 2000s, we were taught that pain was about the body part itself, and that we used medicines to treat pain. We used Tylenol, Advil, opiates, and we were taught to get ahead of the pain and to get people more opiates than we thought they might need because it was cruel to deprive people of pain meds, which of course it is in many ways.

[00:02:16] But we now know just how addicting these medications are, and we also know that pain is about more than the limb that is hurting. So could you describe for me how you talk about pain, this bio psychosocial model? Because it's a big word and I'd love to break it down.

[00:02:34] Dr. Zoffness: Yeah, it's sort of frustrating for people who have been living with pain and also for healthcare providers who treat pain because medicine, as you know, has been rooted in this antiquated, dinosaur era biomedical model, which teaches people that everything to do with pain is just anatomy and physiology.

[00:02:54] But neuroscience has known for many decades that that's not actually true when it comes to pain. And one of the reasons we know this is because of this syndrome called phantom limb pain. And phantom limb pain is when someone loses a limb and arm or a leg, and they continue to have terrible pain in the missing body part.

[00:03:14] Now, 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 does not just live in your leg, and it does not just live in your back. And what science says is that, of course the body is involved in pain production, but ultimately pain is constructed by the brain. 

[00:03:38] And the reason that's so profound, at least for me as someone who treats pain and has lived with pain as many of us have, and all of us will because everybody, everybody is gonna have pain at some point, is that there's lots of parts of the central nervous system that process pain. It's not just there's one pain center, and that's how that goes.

[00:03:56] There's lots of parts of the brain that contribute to the pain experience including the brain's emotion centers contribute to the pain experience, and what that means is how you're feeling emotionally in any given moment, whether you're stressed or anxious or depressed affects intimately the pain that you feel.

[00:04:15] So we know from neuroscience that pain messages are amplified during periods of anxiety or during a global pandemic. That's not gonna surprise anybody, and we all know this. We all know that our bodies feel worse during times of duress. So it's really not that shocking. And we also know that, say if you stub your toe at work on the day you get fired, that exact injury feels completely different than if you stub your toe on a day at the beach when you're hanging out with your friends in the sun. So context matters, emotions matter, thoughts matter. Everything matters to the brain when it's deciding whether or not to make pain and how much, and that's always true.

[00:04:54] Dr. McBride That's a great example and the phantom limb pain is, is, I'd love to talk more about the phantom limb pain because I mean there couldn't be a better example of the construct that pain is—not to say it's not real— it's to say that it's more than just about the limb. So take that example for a second. How do you treat someone who has phantom limb pain? If it's not about the limb?

[00:05:18] Dr. Zoffness: So there is this frustrating thing that happens in medicine where people with chronic pain are often told it's all in their head. Especially if there's no known etiology for the pain. If you've had a lot of scans and tests and you know, people just aren't sure, the doctors are like, we don't know.

[00:05:31] We can't find a thing. So people get told often that pain is all in their head, and that is not what I'm saying. So I want to be very clear. Pain is never all in your head. If you have pain, your pain is real. The important thing to know about pain is that it's the brain in conjunction with the body always working together.

[00:05:47] The interesting thing about phantom limb pain, again, we've said you can have pain in a leg that's no longer attached to your body. And we've said that's because your brain is implicated in the processing of pain in your brain. You have what's called homunculus, and a homunculus is literally a map of your entire body that lives in your brain.

[00:06:06] So if I said to you, Lucy, without doing anything or moving, sense into your foot, can you feel your foot on the ground? Notice if your foot is warm or cold. Can you feel if your foot is moving or… you can do that. And the reason you can do that is because you have a map of your whole body that lives in your brain, your homunculus. 

[00:06:23] So sometimes if you lose a limb, you've lost the limb, but you haven't lost the leg part in your brain map. So with mirror therapy, what we do is. We hold a mirror up to people who have phantom limb pain and they go through a series of activities and structured exercises to help the brain become unconfused and realize that pain, which is your body's danger detection system, doesn't need to send you any more danger or warning systems because the damage has already occurred and there's no warning signals that need to continue. So that's one of the treatments for phantom pain.

[00:06:58] Dr. McBride: It's such a great example and I love the way you described it because I think for a lot of people, doctors included, we have a hard time wrapping our arms around this concept of suffering you can't measure or you can't see it, but everybody who's listening right now can think about their toe or their foot and know that you're directing your attention to it, and there's a reason for it's in our brain. So that is great. That's a beautiful way of opening this conversation about pain being more than just physiological.

[00:07:31] Dr. Zoffness: Exactly right.

[00:07:32] Dr. McBride: Talk to me about—breakdown biopsychosocial, because when someone hears pain is biopsychosocial they may think, oh wow, it's more complicated than I thought, but they don't necessarily know what that means. So what is it?

[00:07:45] Dr. Zoffness: Right. So I happen to really love big words, and this big word in particular has helped me make sense of a lot of different things, not just pain, because it turns out anxiety is biopsychosocial, and depression is biopsychosocial and diabetes. So I'm going say what this word means. So biopsychosocial, what we know now about pain, is that it is never a purely biological thing. It's never just to do with your bad knee or your aching back. Never. It is more complicated than that. Of course it is. And so with this word, biopsychosocial means, and we know that that's what pain is. It means that there, of course, are biological components or triggers for pain contributors 

[00:08:25] So the bio components of pain are genetics and tissue damage and system dysfunction and inflammation, and things like diet and sleep and exercise. Those all are biological contributors to pain. They're very, very, very important. However, what we know about pain is that there's other things that contribute to your experience too, and they're just as important.

[00:08:48] It's not that they're less important. So in the psych, we have bio, we have psych, and we have social or sociological. And the psych domain of pain has so much stigma around that. And I am a pain psychologist, and let me just tell you all day long, all I do is try and explode the stigma around these quote unquote psychological contributors to pain.

[00:09:08] So I want to very clearly say, When you say that pain has psychological components, that's not, again, that it's all in your head. What it means is neuroscience shows that emotions intimately affect the pain we feel, and that negative emotions are going to amplify pain volume and positive emotions and feelings of calm and relaxation are going lower pain volume, turn pain volume down so that lives in that psych bubble.

[00:09:35] Also, in that psych bubble, we know that thoughts and beliefs intimately change the pain we feel. This is supported by many decades of science, for example. We've all heard of the placebo effect. The placebo effect means, Lucy, I'm gonna give you a sugar pill. I'm going to tell you as a pain doctor that this is gonna lower your pain volume, and low and behold, you actually feel better.

[00:09:59] That happens a lot of the time, and the reason that happens is not that the placebo pill is nothing, rather the placebo means you change your beliefs and your brain understands that these danger messages are not needed anymore. So your pain volume is lowered. Beliefs and thoughts change the pain you feel.

[00:10:19] That doesn't mean you can think your way out of pain. It's more complicated than that. But thoughts and beliefs matter. We also have in this bubble coping behaviors. What do I mean by that? People with pain often, understandably believe that they need to stay home, stay inside, not move, not go outside, stop going to work, stop their activities, stop moving.

[00:10:40] Reasonable. However, what science shows is that that ultimately is also going to amplify pain volume and that to treat chronic pain, we have to get out of bed and back to life very slowly and in a structured way, and I'm not telling people to go outside and do things, but behaviors, how we act, how we handle our pain also changes the pain experience.

[00:11:01] Then I said, we have this third domain of pain. It's the social or the sociological domain of pain and what science says is that social factors matter all the time. When it comes to pain and health, humans are social animals. We know that the worst punishment you can give a human being is not Thanksgiving traffic, and it's not your in-laws, it's actually solitary confinement. And what happens when we are lonely and isolated and alone, which happened during the pandemic to a lot of people, our brain amplifies pain volume because a lot of brain chemicals change. So in the presence of others, our brains produce all these chemicals that literally make us feel good.

[00:11:42] Dopamine, serotonin, oxytocin, and endorphins. Endorphins are our brains’ natural painkillers. They are our endogenous opioids. So in the presence of other people, brains produce painkillers. There's other sociological factors that matter also. It's community, it's context, it's environment, it's even race and race and ethnicity, and even racism.

[00:12:07] It's poverty and it's access to care, it's trauma. There's so many, so many things that live in this sociological domain, so, All of it together contributes to the thing, this experience that we call pain. And what's happened in medicine is that we’ve distilled it down to just the biological, the bio bubble. And what that means is that what we've been doing in medicine is missing two thirds of the pain problem. And part of the reason I do things like this and come on podcasts, is to try and change the way we're thinking about pain so that we can change the way we treat pain.

[00:12:41] Dr. McBride: It is so important, Rachel, because as you just said, we have reduced the patient to a set of lab tests, a set of complaints, and because doctors don't have time and they aren't trained—we are not trained in pain management like we should be—People who are in chronic pain are often thought to be nuisances, thought to be malingering or thought to be making it up, because we don't have sophisticated ways of treating pain and because it takes time to access the 360 degree version of the person we prescribe pills. Now, I love Advil for a headache. I love Tylenol when I have a fever. But I think what you're saying is that we need to look at the whole person. We need to look at their emotional health, their mental health, their physical health, their story, and address the various complex parts of this person because they're integrated and they show up in pain.

[00:13:40] Dr. Zoffness: That's exactly right.

[00:13:41] Dr. McBride: Can you give me an example, Rachel, of a patient who had intractable pain, who was treated inappropriately by the medical establishment and then got better with this model.

[00:13:52] Dr. Zoffness: It's really interesting. I'm in private practice and I see people with chronic pain and I happen to love working with teenagers in particular. They're sort of forgotten in medicine, especially in the world of pain. We have pediatric pain and we have a lot of adult pain and older adult pain work. It's not being done right in my humble opinion. But we do have a lot of attention and money being thrown at it. And then we have teenagers who are sort of in this messy middle, like they're not quite children, they're not quite adults, but meanwhile, all they want is an adult who will talk to them as if they're an adult.

[00:14:21] They want that sort of respect. They don't wanna be talked down to like a child anymore. And teenage pain is very confusing for a lot of doctors, in part because they fall into this messy middle category and people aren't sure, do we involve parents, do we not? So one of the patients I was thinking of who came through my program was a 16 year old who had been diagnosed with chronic daily migraine that was so debilitating that he couldn't get out of bed. He also had been diagnosed with abdominal migraine, so chronic stomach aches, stomach pain, and he also had diffuse, amplified body pain of no known etiology. So no one really knew where it was coming from or what was going on. 

[00:15:00] And when I met him, He had been in bed for about four years and had missed four years of school. And when he showed up in my office, I want to describe him to you because I will never forget this as long as I live. He came into my office, he had long unwashed hair and he was pasty and pale, and he was heavy because he hadn't been moving his body and hadn't been exercising, had truly been bedridden.

[00:15:25] And he started rocking himself back and forth on my couch with the pain. And I remember thinking like, he's been through Stanford, he's been through UCSF. Who am I to do that? I almost called his neurologist to say I can't do it. Thank God I didn't. But it's just funny. I think as healthcare providers, we all have a little bit of this imposter syndrome—can I do it? And so when I take a history, I don't just ask about the pain and when it started, I want to know everything. Because as we all know now, there's always a pain recipe. There's always bio ingredients and there's always emotional ingredients. There's always contextual and environmental ingredients.

[00:16:03] There's family ingredients, there's trauma. There's coping behaviors—all of that is baked into a pain recipe. So I asked him about his emotional health. He had been paralyzed with social anxiety for most of his life, untreated. He was depressed. He was suicidal, which is not that surprising actually, when you're 16, you have no life, You've been in bed for four years. He had been on 40 medications. He had seen 14 specialists and experts. It's understandable to me that a 16 year old might feel hopeless and helpless and in fact, that's true of a lot of patients who come to me. I am the last stop on the train. Nobody wants to see a psychologist for pain.

[00:16:42] Nobody, and I understand why I also would not want to. So, I realized pretty quickly that there were a lot of parts of his pain recipe that were not being treated. So when we started the program, we did get his parents involved for a number of different reasons, and one of those reasons was that he needed support doing some things to help his social anxiety go down, help his mood improve and help us pain improve, because all of those things are intimately connected all of the time.

[00:17:10] My mantra is that the brain and body are connected 100% of the time. They're never not. Ever. So of course your emotional health affects your physical health. So one of the things we needed him to do in order to help his pain and his mood was start moving his body. And you can't ask someone who's been in intractable pain for four years to go outside and hang out with friends.

[00:17:30] That's not how that goes. So week one, he went out onto his porch and stood in the sun for 10 minutes a day, every day for a week. Week two, he walked the corner mailbox and his mom would give him mail to put in the mailbox. Week three he would walk around the block and he would stop at the corner store and order tea or coffee or whatever, just to have human interaction. And by the way, this was paralyzingly difficult for him and part of our pacing plan, because that's what this was and I'm happy to explain what that is. You go slowly to increase activity, whether it's social activity or physical activity. It was really hard for him. And he would have pain flares. Absolutely.

[00:18:11] And we built that into the treatment strategy. So he would take breaks, as many as he needed. He could take the whole day to get the walk around the block and the stopping for coffee done. Week four, he walked his dog to the dog park and had a conversation with someone. Week five, he mixed in a little bit of jogging and texted a few friends. So as you can see, there was a gradual increase in activity, both social and physical. It was targeting his anxiety, it was targeting his depression. We know that behavioral activation is very critical for depression. We know that social exposure is very critical for treating social anxiety and slowly, slowly, slowly, his mood improved.

[00:18:49] Anxiety started receding, pain volumes started going down. At some point, his neurologist called me and said, “What magic purple pill are you giving this kid?” And I sort of had to say—suppressing my frustration—yeah, that's the whole point. It's not a magic purple pill. And he gradually got back to school and he rejoined his soccer team and he started playing soccer again and his pain went away and he went off to college and became captain of his swim team or whatever. And listen, just to say, this is a kid who's still, he's an adult now who still has migraine, but his migraines do not debilitate him and they will never again dominate his life. And he will never again be in bed for four years because now he knows he has to look at his whole pain recipe. He can't just take medications forever. And I am not. Saying that medications are not helpful, thank God for medications. What I am saying is that it's a bigger picture and humans are more than just a body part.

[00:19:50] Dr. McBride: Amen. Hallelujah. I mean, this applies to really any suffering I think that you cannot measure in a blood test whether it's depression, anxiety, PTSD, chronic fatigue. Patients who don't fit in the mold or, or who don't have a diagnosis that we can see on paper get so easily dismissed by the medical establishment and also get, there's self-stigma, right? When people don't have a, when there's nothing you can hang your hat on from a lab abnormality, it can eat away at your sense of self. And then what's worse is when doctors are not counting your story and you don't then have access to your whole interior world, which is of course essential to how we function in the world every single day.

[00:20:44] And you're right—there's no partition between head and body. It's not like there's a neck down kind of version of humankind. What is your advice to people who are listening who have chronic pain, say from hip injury, a herniated disc, migraines who are thinking to themselves, Huh? I have some imitrex for my migraines. I have some Advil for my back pain. I know how to stretch and move. My life is stressful, but I'm managing it. What else should I be doing?

[00:21:17] Dr. Zoffness: So I'm one of these people who believes that appropriate pain care should be affordable and accessible to everybody. So I published a book during the pandemic called the Pain Management Workbook, and in there is everything to do with pain science. Very digestible. It's like neuroscience that anyone can read, and it also has a ton of strategies in there.

[00:21:39] And I think the most important thing, if you're living with pain or if you treat pain and you're not sure what to do next, is to figure out how to put together a pain recipe. And that's in the book, the Pain Management Workbook. And I'm gonna say what that is and what it means. Every single person has a pain recipe, everyone. So for me, my pain recipe, for example, is sitting for too many hours without getting up and moving, not exercising, eating poorly, not taking care of my body, poor sleep, fights with my family or my partner or whatever. A lot of stress at work. I know that if it's a high stress day, I probably will not have a good pain day.

[00:22:22] And also my level, managing my level of stress and anxiety, so whether I'm actually actively incorporating self-care, like am I going for walks? Am I going outside in the sun? Am I making sure that I'm scheduling time to be in nature or go to pleasurable activities? So that's my pain recipe.

[00:22:42] And as you can see in that pain recipe, there are bio components, there are cognitive and emotional and behavioral components, and there's social components always. And so when you put together a pain recipe, the cool thing about it is, there's always a high pain recipe. Like I like to ask people like, you know, do you like to cook or bake?

[00:23:00] Because I do not. But as you know, if you like to cook or bake, there's always a recipe that will get you to the end point that you're seeking. And the same is true for pain. Like just as there's a recipe for brownies, there's a recipe for pain. And so I just gave you my high pain recipe. The cool thing about a high pain recipe is that a low pain recipe is the exact opposite. A little bit more nuanced than that, but there's always this high pain recipe, low pain recipe sort of thing. So for me, sitting for too many hours without taking a break is part of my high pain recipe, and the reason that's great valuable information is because I know that to manage my pain, I need to set my alarm every hour and go for a walk outside, even if it's literally two minutes, five minutes, or my next phone call, I take it on a walk around the block, whatever.

[00:23:49] Whatever I have to do to structure in these things that I need to get to a low paying recipe. That's what I do like scheduling pleasurable activities and walks in nature on the weekend and making sure to see friends and making sure to put boundaries around toxic relationships and not spend time with certain people, because guess what? You're allowed to do that. So whatever ingredients are in your high pain recipe, figuring out that recipe is the way to lower pain volume. So that's one of the strategies in the pain management book. 

[00:24:16] Dr. McBride: I love it. I think at the root there, Rachel is, is a self-awareness. Giving ourselves permission to look inside and to think about, as I say, our stories and how they live in our bodies. To take time to look at the narratives inside, some of which are rooted in fact, and some of which are not rooted in reality.

[00:24:34] For example, the patient who says, I've been in bed for four years. I am a broken person. I'm an identified patient in the family, I'm a problem. You know, if you, if you organize your thoughts, feelings, and behaviors around a narrative isn't fully fact-based, then that's only gonna exacerbate the very problems you have.

[00:24:56] So, making sure, obviously someone who is suffering is entitled to feel like they are a patient or a challenge. But if we can look inside and access our stories and then ideally rewrite some of those narratives like I can and I will and I'm able, I mean the agency there. I think a little bit of what you're talking about is sort of making your own recipe, making your own kit so you don't feel so helpless and a victim of yourself.

[00:25:28] Dr. Zoffness: And I think that goes back to this thing where there's cognitive components to pain and beliefs matter a lot. This particular patient I was talking about believed that there was no hope for him and understandably so. And the first thing I told him when he came to my office was that I was going to help him. And of course, I didn't know that for sure, but I knew for sure that he needed to believe that. So I said, I can help you and, and I knew that he needed to believe in me for any of this to even work.

[00:25:53] Dr. McBride: The other thing is the trust you're describing. I mean, for me to help someone—I'm sure it's the same for you as a clinician—to help someone who has an intractable problem, whether it's obesity or PTSD, heart disease, to feel like they have hope and possibility. They have to really, really trust the messenger and the guide because if you feel hopeless, if you feel like there's nothing out there for me and you've been treated like a bag of organs and not a person, that alone is a barrier to care. And so just aligning with the patient and leading with empathy and curiosity in my mind opens the door to that partnership, which sounds almost corny and hokey, but there's an incredible therapeutic benefit to the patient when you can align… And it's like, believe the patient, they are not making this up.

[00:26:49] No one wants to make up a story of, I'm in so much pain, or I have experienced something that is unique to me, no one's ever experienced and I'm alone. No one wants to feel that way. And so just giving people permission to be human and then by a doctor or PhD, Rachel's Zoffness, that's a meaningful intervention.

[00:27:10] Dr. Zoffness: Yeah. I was also thinking about what you were saying before about how, and it's so true, how chronic pain patients are such a challenging population for doctors to treat, and there's a bunch of papers actually that have come out on this that show that one of the reasons for this is that there's a lack of pain education in medical school, and there's this crazy statistic that sort of blows my mind, which is that 96% of medical schools in the United States and Canada have zero dedicated compulsory pain education. And all these subsequent papers that came out where physicians were interviewed, like, how comfortable do you feel treating pain? And it's what you were saying before, there's this lack of comfort, understandably.

[00:27:47] How are physicians supposed to feel, or any of us as clinicians supposed to feel comfortable treating a thing that we haven't truly been taught about in part because it's not really well understood. It happens to be well understood, but it's not really, the education is so poor. Like as a patient. Do you ever get taught about pain if it's not really being taught in medical school, it's not being taught to, to the lay public. So how do we treat a thing unless we really understand it?

[00:28:14] Dr. McBride: Exactly, and then doctors don't have time. It's not the doctor's fault, it's the system's fault. We don't have time to elicit the whole story and the whole landscape of that person's interior world, and then we have to know what to do with it. And that takes time. And that's just not what modern medicine is designed to do right now.

[00:28:32] Dr. Zoffness: No it's not. It's a profit driven healthcare system.

[00:28:34] Dr. McBride: It's awful. What do you see as the relationship between chronic pain and addiction?

[00:28:41] Dr. Zoffness: So it's interesting. I started teaching at Stanford a couple of years ago and I'm teaching the Addiction Medicine Fellows, and I remember when I first went down this rabbit hole in pain science, realizing that addiction, medicine and chronic pain have started to become synonymous, and I am a nerd, and the way I make sense of the world is by reading everything.

[00:29:05] So I started reading every single paper I could find. Here's a heartbreaking statistic. 80% of people in America who have become addicted to heroin started out as pain patients. There's this disconnect, I think until recently that we, and there's also a lot of blame, like people with addiction are blamed for their addiction. But 80% started out as pain patients. That means they went to their doctor, this person they trusted and they were like, help me. I have pain. And the doctor, totally, understandably because doctors were lied to for forever [and told that this] medicine is the thing you need to give. It's the treatment for pain. They gave this medication that hijacks the brain and hijacks your central nervous system.

[00:29:46] Dr. McBride: You're talking about narcotics and opiates.

[00:29:49] Dr. Zoffness: Correct, oh, did I not say that? Sorry. Yeah.

[00:29:51] Dr. McBride: No, but that's, I just wanted to tell you because I mean, that's what we were taught in medical school.

[00:29:54] Dr. Zoffness:Yeah. Oh, no, no, absolutely.

[00:29:56] Dr. McBride: That's what we were taught. Get ahead of the pain opiates, Oxy five, 10 milligrams Q4 to six hours, more than you think they need.

[00:30:04] Dr. Zoffness: Right, of course. And, and that's because there was great marketing. Everyone who has seen dope sick knows this now. Yeah. And there's a book called Drug Dealer MD by Anna Lemke that all of this has just been really blown open over the last couple of years. And of course now pharma is paying a 26 billion payout in reparations, but in my mind, that is absolutely not enough.

[00:30:28] The number of lives lost and the way that pain medicine has been completely hijacked is pretty gnarly. And I also want to be clear to say I am not anti-opioid. Thank God for opioids post dental surgery. If that's something that your body can tolerate, you don't have a history of addiction, like I am not anti-opioid, But the issue for me is the way we've framed pain as a biomedical problem that requires a purely biomedical solution. And we know that that's not true, and we know that that's actually wrong. And we also have known for a very long time that opioids can be very dangerous for people. So the fact that that's sort of become the de facto treatment, especially for chronic pain, is so heartbreaking.

[00:31:08] Rachel: I treat so many patients who have been in pain for a really long time and now they have two issues. You asked, like with a relationship, there are all these dual diagnosis clinics now around America where the dual diagnoses are chronic pain and opioid addiction. Like what are we doing to people with pain? It's so unacceptable.

[00:31:28] Dr. McBride: It's completely unacceptable. And then when you think about the mental health world and the false dichotomies there—I know you talk about your frustration and anger about the way. People are treated in the current medical industrial complex. My particular cross to bear is the way we talk about mental health, which is as if mental health calmness, serenity, and the ability to be happy when mental health is really the ability to have an appropriate emotional response to the setting and to have agency and tools to manage the inevitable potholes on the road of life. 

[00:32:15] And then we talk about the mentally ill, which as if there's some kind of distinctive line in the sand where you go from mentally healthy to one click over, oh, mentally ill broken person, totally healthy person over here. So just like you do with your own patients, when I'm talking to my patients about their emotional health because it's relevant to their physical health, surprise, surprise, I don't say, are you anxious or, are you depressed? I say, okay, given that everyone has anxiety, where are you on the continuum of anxiety and what are you using to manage the anxiety? Where are you on the continuum of mood given that you're located somewhere on the mood continuum? What's your depression recipe? What, I don't say that but what is the thing that, what brings your mood down? And then what brings it up? And if it's recreational drugs, then maybe we should think about an alternative plan. If it's nature and being with your loved ones, maybe we need to lean into that avenue. And if your mood is pulled down by a toxic relationship, maybe we need to put a fence around it. I believe in Prozac. I believe in Zoloft. I believe in psycho-pharmacology. I also believe in treating the person and not just the pathology.

[00:33:34] Dr. Zoffness: So you said it exactly the way I would say it. And I do teach about a depression recipe. And of course there is one. During the pandemic, calls to suicide hotlines went up 8000% in some parts of our country. Now, was everyone mentally ill during the pandemic or was there an external situational trigger that made us all anxious and fearful about our loved ones or whatever?

[00:33:59] However you responded to that thing or made you feel depressed because you couldn't do all the things you wanted to do. You couldn't go to work, you couldn't go to the movies, you couldn't go to restaurants. You couldn't see your grandparents in the hospital. Of course there's a depression recipe. And depression again is biopsychosocial also always, all the time for everyone. It's not just a chemical imbalance. And by the way, a paper came out recently by Joanna Moncrieff showing that, we've all known this for a long time also, but there's no such thing as a chemical imbalance. That is an effing lie. That is a lie. If you look at all the brains of people who are depressed and not depressed, there actually is no evidence to support that people who are depressed have less serotonin than people who are not depressed.

[00:34:40] Actually, that has no evidence and no traction in medicine. So the one issue with that is, if you believe the lie you've been sold by big pharma, that depression is a biological problem that requires a biological solution, All you'll ever do is take a pill, and it's the same as true with pain, but depression is just as bio psychosocial as pain is.

[00:35:02] Dr. McBride: That is exactly right. It is not true that depression or anxiety or PTSD is a result of a chemical imbalance. That is a narrative that has been pushed out for whatever reason. And, and as a result, we end up treating patients with pills and pills alone, not uniformly. I wanna make it clear though, that's not to say that Zoloft Prozac, all these SSRIs cannot and do not help people with depression, anxiety, PTSD, and that they are appropriate for some people in the context of the biopsy psychosocial model. In other words, when that paper came out, which illustrated what we've known for a long time, it just needed to be said again, that chemical imbalance is not accurate. Patients of mine were calling and saying, well, does that mean that I shouldn't be on my Zoloft? Does that mean I shouldn't be on my Prozac? 

[00:35:52] Meanwhile, as I say to my patients, Zoloft is one piece of the larger puzzle of your health and wellbeing. If it is helping you tolerate the anxious thoughts and feelings and the cognitive distortions that then allow you to get more out of therapy, that allow you to activate on the recipe for feeling better, then that is an entirely appropriate medication. It doesn't mean you're mentally ill if you take medicines and you're mentally well if you don't take medicines. It's just a piece of the puzzle, just like being in nature and exercising. So I think it's important to be clear that just because it's not true that these phenomena are chemical imbalances, it can still be true that medications can help. This is where the nuance gets lost. Because if you're someone who believes in the middle ground, where biopsychosocial elements intersect, you run the risk of people misunderstanding and thinking that you are anti-medication and that everything in our world is fixable with willpower, thoughts, and behavioral modification when that's not true.

[00:37:04] Dr. Zoffness: Yeah, I think that's why it's so important to say like there's always a bio component to everything. Of course genetics matter and you know, of course neurotransmitters matter. But I think the message, the take home message here is that whether it's depression or anxiety or diabetes or migraine, there's always a recipe of factors that are contributing every single day. And we know that because what I like to say to my patients is like, if you tell me certain times over the course of the day that pain goes up and pain goes down, or if you monitor your pain over the course of the week, you know that there are certain times that pain goes up and pain goes down.

[00:37:37] Rachel: And what that means is that if pain is always changing, Pain can change. If pain can change, then pain can change. And what that means in any given moment or hour of your day or your week, there's different bio psychosocial factors that are contributing to your pain recipe. So times when your pain is low might be you're distracted, you're with friends, you are watching a funny movie and shoving ice cream in your face and during that period of time, those two hours, your pain volume is a little bit lower. Your pain volume might be higher when you're driving to the doctor's office for a procedure that's upcoming and you're feeling really worried and you feel your heart is racing and your body is tight, and of course we know that those are gonna contribute to a higher pain volume. So it's always all the things working together. It's never just one thing.

[00:38:24] Dr. McBride: This morning I was talking to Lisa Damour about anxiety, and I think there's some parallels here with pain. Insofar as some anxiety is helpful and productive. In other words, if we didn't have anxiety, we would walk into traffic. We would not turn in our term paper. We would not veer away from the bus that's coming at us. Anxiety is a problem potentially when it's out of proportion to the actual threat and takes on the life of its own. Pain too has a function. I mean, it's a warning signal. It's telling us that, you know what, you've stepped on a thorn. You have arthritis in your knee, that maybe means it's time for an evaluation of your surrounding muscle structures and maybe you need a new knee. So how do you describe to patients, when pain is okay or enough and when we should tolerate it and when it's not enough? Because a pain-free existence is impossible.

[00:39:20] Dr. Zoffness: Yeah, so I like to always talk about pain as the body's danger detection system. It's our warning system, right? So as you said, you put your hand on a hot stove. If you don't get those danger messages, you'll leave your hand on the. Dove and your skin will melt off. Or you go for a run and you break your ankle and you don't stop running and seek help and rest so your bones can repair, you're screwed. You're going to further damage your body in bones and tissues. So pain is a very important danger message. And I remember when I was an undergrad at Brown, I had this wonderful professor, Mark Bear, who I talk about all the time now because his neuroscience textbook changed my life. And he would talk about how some people are born without the ability to feel pain like this congenital insensitivity, this high threshold.

[00:40:04] And I remember thinking, gosh, that sounds so. Lovely. And then he went on to say, and they don't live very long because again, if you imagine you, you damage your body, but your brain doesn't give you any of these warning messages or these danger messages. You're not gonna live very long. So pain is important and we have to pay attention to pain.

[00:40:23] So acute pain is pain that's three months or less. And acute pain is like the pain of childbirth or like you get a virus and you have muscle pain and then it goes away. Or the pain of a broken bone or torn ligament—that's acute pain. Chronic pain is pain that lasts three months or longer or beyond expected healing time, which is very nebulous and the definitions are just not that great, but pain that lasts beyond expected healing time.

[00:40:52] And we know that there's a difference between these two things. And one of the ways I like to talk about this, when people come to my office, they say, well, I've been in pain for seven years, 10 years, why is my pain chronic? How did this happen? And there's a number of ways by which pain can become chronic.

[00:41:13] But one of the processes that underlies chronic pain is called central sensitization. And what that means is we talked about the location of pain construction and how that happens in our brain and we know that our brains are like the muscles in our body. The more we use certain pathways in our brain, the bigger and stronger those pathways get.

[00:41:34] So for example, for me, I played the piano growing up. I didn't really like to and I didn't really want to, but my mom would say, Rachel, sit down and practice. It's the only way you're gonna get better at it. And over time, of course, she was right. The more I practiced, the bigger and stronger the piano pathway, which isn't a real thing, but the piano pathway in my brain got bigger and stronger with time until I could sit down at the piano and my fingers would just know what to do. Right? Not magic. That's just your brain changing with time and experience and exposure. And there's a word for that, and it's called neuroplasticity.

[00:42:13] Neuroplasticity literally means your brain over the course of your life is always changing, always, even into adulthood. It's morphing every time you have an experience. It's the reason you can learn a new language, even when you're 62. So just as practicing the piano made the piano pathway in my brain big and strong, the same happens when we have pain all day long, over and over for many months and weeks and years. What happens is the more we accidentally practice pain, the bigger and stronger the pain pathway in your brain gets. And I wanna say that carefully because there's no actual pain pathway. There's a lot of different ways that pain is processed by different parts of the brain, but we know that of course circuits in the brain and neural networks get stronger with use in time.

[00:43:03] So pain pathway for the sake of this metaphor, gets bigger and stronger with use. The more and more we use it. And when that happens, we say that your brain has become sensitive to pain. And I think about that word all the time. What does sensitive mean? So if you have a dog, and it's the 4th of July, we know that of course dogs are much more sensitive to sound than we are. So when all the fireworks are going off on July 4th, all the dogs in America are hiding under our beds. We give them thunder shirts or whatever, thunder jackets so that they'll calm down and it's because their brains are very sensitive to sound. And the same is true with our brains when we become sensitive to pain over time.

[00:43:48] Small bits of sensory input from the body to a sensitive brain sound and feel very big. So for example, an example I'd like to use is for my fibromyalgia patients. You go for a picnic with a bunch of friends and you're sitting under a tree in the sun, and we can all agree that that is not dangerous. But your brain might give you very amplified danger messages anyway. So things that are not dangerous can result in a very loud danger alarm. And when, when, when that happens, we know that the brain has become sensitive. And that's a chronic pain process. That's not true of acute pain.

[00:44:26] Acute pain and chronic pain are different processes, and they're both biopsychosocial. There's bio, cognitive, emotional, behavioral, sociological factors that play into both, but it's really important to think about how to desensitize a sensitive brain once pain has become chronic.

[00:44:44] Dr. McBride: Rachel, I think we need you on every corner of America because as you opened with pain is an inevitable part of life. And when we medicalize it and put it in a box and prescribe a pill, we're really depriving people the opportunity to have access to their internal world and then have agency. And I just wonder, how are you're gonna get this message out there even more than you already are. You were on the Ezra Klein show. You've written this phenomenal book. You're talking to me today. You are making a difference every day with your patients, but like I want you to have a megaphone because this is so important. It's so relevant.

[00:45:31] Dr. Zoffness: It's so relevant. I also think about this distinction between like, like you were saying before, it's like pain patients to the left and like providers and everybody else to the right and like. That's not how pain works. Pain is coming for everybody. There's no one that escapes the human experience of pain, whether you had it in childhood or you have an injury now, or you know, pain later in life. So it seems so critically important to me that we all are the holders of the truth. Like I'm just tired. Like you were talking before about, gosh, why were we all sold this big lie that depression is due to a chemical imbalance. The answer is that was a pharma marketing device. That's why that we all, we all got that message cuz it was literally plastered.

[00:46:15] I remember I lived in New York City growing up—I mean I'm a New Yorker born and bred—and there was this huge 20 foot ad on the side of a building and it said depression is not a flaw in character, it's just a flaw in chemistry. And I remember thinking, God, that's so brilliant. It's making you feel like, oh, it's not my fault, it's just my chemistry. So like if your chemistry is broken, of course the only fix is a pill. It's brilliant marketing, and we all have been sold this lie for very many decades about pain, about depression, about anxiety. It is a lie. That's not the solution. The solution is never just a pill ever, ever, never.

[00:46:53] Dr. McBride: Which is ironically not anti-pill.

[00:46:56] Dr. Zoffness: No, I'm not at all anti-pill.

[00:47:01] Dr. McBride: We could talk about big pharma all day long… 

[00:47:04] Dr. Zoffness: It's just not the only solution. It's much more complicated. As humans we're just more complicated than that. Right. We're not just chemistry, we're more than that.

[00:47:11] Dr. McBride: To close. I want to ask you about you. You told me a little bit about your pain recipe and what you do to manage discomfort, psychological, biological. What are the sort of biggest insights you've learned from your own patients, who I find my best teachers. What have you learned from your patients about how to care for yourself?

[00:47:34] Dr. Zoffness: Two different answers to that question. The first thing that comes into mind, just what have I learned from my patients has been this, I don't believe necessarily in magic or miracles, but when I see teenagers get out of bed and go back to life, like I told you about this patient that I had who had chronic pain all over his body and chronic migraine and went back to soccer and went back to school. And what I didn't tell you, he got asked to prom when he went back to school, not by one girl, but by two. And watching this kid, he invited me to his graduation and at his high school graduation, he got on stage and said, if you told me four years ago I'd be graduating high school, I never would've believed you.

[00:48:17] And this magic miracle is just science. I don't have a magic wand, it's just disseminating this information about what pain really is and how pain really works. And I see it every day as my patients get out of bed and back to life. And it's it's what galvanizes me to do things like this. I actually am a library mouse and I do not like public speaking, but I can do it here with you because it's just you and me, so it's fine. It galvanizes me to go out into the world and just spread the message. You have to bridge the gap between physical pain and emotional pain if you want to treat pain because it's this lie in Western medicine that either your pain is physical and you see a physician or your pain is emotional and you see a therapist, and that's never how pain works ever. Emotional pain is physical. Anyone with anxiety can tell you how physical. That pain is, you have chest pain and you know there are times your body hurts and your sweat. There's so many physical parts of emotional pain and physical pain is emotional. People with chronic pain have 50% higher rates of depression and suicidality. Physical and emotional pain are connected always. So the biggest message I get from my patients is that this is real and we all need to be practicing it.

[00:49:35] We can't just be talking about it theoretically. We all need to go back into our offices or to our doctors or to our patients and reframe this thing that has been broken and put it back together, and it is doable. It's absolutely positively doable. And the most important message I want to convey is that chronic pain is always treatable. Anyone who tells you that it's not doesn't understand pain. Chronic pain is always treatable. There is always hope for treating pain. Always.

[00:50:04] Dr. McBride: So tell me, Rachel, where can people follow you?

[00:50:06] Dr. Zoffness: I am on Twitter. What is I think actually how we initially connected, I think I commented on one of your posts. I'm @DrZoffness on Twitter. I also do a lot of pain education on Instagram. I'm @therealdoczoff which is very funny cause I picked that initially as a joke. I joined, I think, maybe at the end of 2019 and didn't actually do anything there and just planned on following some of my friends. But now I really am using it to disseminate information about pain. And I also have, uh, websites, just my last name, zoffness.com and there's a ton of free resources. It's super important to me that pain information and treatment is affordable and accessible to everybody. I'm so tired of this lack of insurance reimbursement and it's really, it's unacceptable. There's an entire resources page with books and videos and websites and just a to a ton of free stuff. 

[00:50:59] Dr. McBride: And then there's your, there's your workbook, which is just such a great resource.

[00:51:02] Dr. Zoffness: yeah, the Pain Management workbook is on Amazon and it's on my publisher's website, their new Harbinger. It's just called the Pain management Workbook. I figured go simple!

[00:51:11] Dr. McBride: It's great. It's great. Rachel, I want to say thank you so much for joining me today. You're an inspiration and I wish it wasn't true that you're a rare bird in this medical system, in this country, but I think it's pretty rare. And I think that's why I reached out to you. It's why I connected with you. It's why I've been so excited to have you on the show because it's really a crying shame that this is unusual information when it's basic human 101.

[00:51:40] Dr. Zoffness: I Totally agree.

[00:51:41] Dr. McBride: and you do such a good job of explaining it. So, Rachel, thank you so much for joining me. It's been a pleasure.

[00:51:49] Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you like this episode to rate and review it. And if you have a comment or question, please drop us a line at info@lucymcbride.com

[00:52:11] The views expressed on this show are entirely my own and do not constitute medical advice for individuals that should be obtained from your personal physician.

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Beyond the Prescription
Each week, Dr. Lucy McBride talks with her guests like she does her patients — pulling the curtain back on what it means to be healthy, connecting the dots between mental and physical health. To Dr. McBride, health is about more than the absence of disease. Health is a process, not an outcome. It's about having awareness of our medical facts, acceptance of the things we cannot control, and agency over what we can change. To learn more about Dr. McBride, visit: https://www.lucymcbride.substack.com/about To sign up for her weekly newsletter, visit www.lucymcbride.substack.com/welcome