What you don’t know about pain will hurt you [PODCAST]

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“If you treat chronic pain, or are someone living with it, remember this: Changing the brain can change pain. Addressing emotional health directly impacts physical health, because brain and body are always connected. Pain psychologists can serve as pain coaches – it doesn’t mean you’re crazy, and it’s not ‘all in your head’ (it’s in your brain!). Try biobehavioral interventions like CBT, biofeedback, and mindfulness, and demand that your insurance company reimburse these treatments. If you’re a health care provider, spread the word about biopsychosocial pain management. Teach patients how pain works, connect brain with body, and offer hope. Knowledge is power. Let’s empower our patients – and each other – to find integrative solutions that work.”

Rachel Zoffness is a pain psychologist.

She shares her story and discusses her KevinMD article, “What you don’t know about pain will hurt you.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Rachel Zoffness. She is a pain psychologist, and she wrote the KevinMD article “What you don’t know about pain will hurt you.” Rachel, welcome to the show.

Rachel Zoffness: Thank you for having me on.

Kevin Pho: We’ll get into your article in a little bit, but first off, can you share your story and journey to where you are today?

Rachel Zoffness: Yeah, that could go in a million different directions. So, I’m a pain psychologist, which no one has ever heard of before. Most physicians tell me they’ve never heard of that. And the reason for that, as you probably know, is that Western medicine is broken. We have this idea that either pain is physical and you see a physician, or pain is emotional and you see a therapist. But what we know about pain is that it’s processed by the brain’s limbic system 100 percent of the time. So, pain is always physical and emotional.

When I was an undergrad at Brown, because I’m a nerd, I started taking neuroscience. I was a brain and behavior major. In my neuro one class, they talked about pain. I had always wanted to live at the intersection of medicine and psychology and neuroscience and science writing and education. I just couldn’t figure out what direction to go in. When I took this neuro class and they started talking about pain, I realized that pain actually lives at the intersection of all of those things. So, I did my honors thesis on pain, in particular the gate control theory of pain, which was created in ’65 and forever revolutionized pain science. I really went down that rabbit hole, and I did my postdoc in non-pharmacological treatments for pain.

I’m super passionate about it in part because I am someone who has lived with chronic pain. I’m really hard-pressed to find anyone who has never had an episode of chronic pain, which is just pain that’s three or more months. Most of us have had an episode of chronic pain, and if we haven’t, we almost certainly will. Very few humans are lucky enough to escape without experiencing pain. But pain is really rarely taught in medical school, and it’s almost never taught in psychology programs. So, it really drives me to spread awareness about pain and how it works.

Kevin Pho: Walk me through a typical day and typical cases that you see.

Rachel Zoffness: Oh, I think I’m atypical. I’m like you a little bit, not a lot, but a little bit, in that I wear lots of hats and I do lots of things. I have a private practice where I see patients with pain. I happen to love working with teenagers, so I’ve really made an effort to focus on teens, but I see kids and adults as well. And I see everything, you name it: fibromyalgia, CRPS, cancer pain, you name it.

But again, I’m really passionate about spreading pain education, and I’ve learned that that really only happens in two major ways: by educating health care providers and educating the public. So, I do stuff like this, or I’m starting to more, because it really resonates with people, I find, when they learn about pain. It’s like everyone wants to understand pain, but it’s so rarely taught.

I also teach health care providers, so that’s a big part of my life. I teach pain education at UCSF. I teach their resident program. I teach pain education at Stanford in their addiction medicine program, and I’m teaching a pain addiction series at Dartmouth-Hitchcock, also, which is close to you up in New Hampshire. I also write articles on pain education for health care providers and the public in Psychology Today. I have a column. And I’ve written two books, The Pain Management Workbook and The Chronic Pain and Illness Workbook for Teens. Again, the reason I did that was because when I was looking for resources, I couldn’t really find very much. So, TL;DR, I spend a lot of time writing, teaching, seeing patients, and spreading awareness about pain education.

Kevin Pho: So, when it comes to traditional education on pain, for which there is very, very little, what would you say is the biggest thing that’s missing?

Rachel Zoffness: Oh, dude. So, in Western medicine, we have a biomedical model of health and a biomedical model of pain. The problem there is that what we know from decades of research is that pain is not purely biomedical. When I say biomedical, I mean having to do just with the body, and something that should be pills and procedures. What we know about pain is that it’s actually a biopsychosocial phenomenon.

What I mean by that is that yes, of course, there are biological components to pain, like tissue damage and system dysfunction and inflammation, and diet, exercise, and sleep, of course, affect pain. No one would argue with that. But the biopsychosocial model of health, which is this evidence-based, well-established thing, tells us that there are also psychological components of pain, and of course, there’s a lot of stigma around that. And there are also sociological components of pain.

Psychological components of pain are things like cognitions. We know from neuroscience that the things you think affect how you feel. Emotions also affect pain. Neuroscience tells us that negative emotions, like stress and anxiety and depression and anger, will actually amplify the pain you feel. And coping behaviors, which are also in the psychology bubble, change pain, too. I know you know this. People with chronic pain often stay home, stay inside, miss out on life, miss out on friends, don’t exercise, don’t move their bodies, don’t get sunlight, you know? Of course, that’s a natural and normal response to pain, but we know that that’s actually really bad for chronic pain, and it makes pain worse. So, the way we behave in response to pain changes the pain we feel.

Then there’s this social, or sociological, domain of pain, and that’s the everything-else bubble. That’s socioeconomic status and access to care and race and ethnicity, and of course your social support network and family relationships and context and environment. There’s a reason that your toe hurts more when you stub it on the day you get fired and you’re in a really bad mood, versus you stub your toe and you’re out with your friends eating ice cream. The subjective experience of pain changes depending on context and environment.

So, pain lives in the middle of those three bubbles, and that’s just not taught. There’s this paper that came out just a couple of years ago that showed 96 percent of medical schools in the United States and Canada have zero dedicated compulsory pain education. It blows my mind. Pain is the number one reason people go to us. And by the way, it’s not just medicine; all the disciplines are bad. In psychology, there’s almost no pain education, and the limbic system, again, the emotion center, is responsible for processing pain. So, therapists are seeing patients with chronic pain, too, and don’t know what to do with them.

Kevin Pho: And you talked more about that in your KevinMD article, “What you don’t know about pain will hurt you.” Now, for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Rachel Zoffness: Yeah. Pain education starts with just sort of explaining that pain does not live exclusively in the body, and I just want to say what I mean by that, and the article goes through this, too. It’s very easy to believe that pain lives exclusively in the body. If your back hurts, you totally normally and naturally believe that that pain lives exclusively in your back. But what science tells us is that that isn’t accurate, and that’s not true. Pain is actually processed by the brain, by the brain.

One of the reasons we know that is because of a condition called phantom limb pain. Phantom limb pain is when someone loses an arm or a leg and they continue to have terrible pain in the missing body part. If you can have pain in a body part that isn’t there anymore, that tells us that pain must be constructed elsewhere, and that elsewhere is the brain.

But when we treat pain in America, and really around the world, we go after the body part. There are surgeries and procedures all day long, and we don’t tell our patients that in order to effectively treat their pain, we actually need to target their brain. And there’s a lot of stigma around treating pain in any other way. If you suggest something like cognitive behavioral therapy, which is what I do, or you send someone to a pain psychologist, or even to a biofeedback provider, what people hear is, “Oh, you’re saying it’s all in my head. You’re saying I’m faking it. You’re saying it’s just emotional or psychological pain.” And that’s not true. Pain is always biopsychosocial. So, how you’re feeling emotionally, what you’re thinking, and how you’re acting are always going to affect pain, because pain is not living in your body. It’s processed by your brain. So, the article just walks through the science of pain, like pain neuroscience, the way pain has been mistreated, and then options for treating pain effectively.

Kevin Pho: So, take us through a case study, for instance, in your office. Let’s say I referred a patient with chronic pain to you. Take us through what you would do, and perhaps how that would change the patient.

Rachel Zoffness: I will gladly do that. That’s actually a great question. I was recently treating a patient with CRPS, which is complex regional pain syndrome, a pain syndrome that often affects the extremities, so hands, feet, arms, legs. He was suffering with chronic pain in both feet and both legs. To describe his condition to you, his legs and feet were alternately purple and blue, or red, and his pain was really intense. It was prickly and hot. Sometimes his legs would turn cold, and he had trouble walking. He didn’t have much motor coordination or motor function. He had a lot of swelling, and there were a lot of vascular changes in his legs, too. And he was breaking out in these terrible, bloody, weeping lesions all over both of his legs.

He had a treatment team of 12 physicians. You name it, he had seen everyone in every department: anesthesiology and pain medicine and immunology and dermatology and neurology, and we could just keep going all day. But when I met him, his team had not yet gotten together to talk about his case or coordinate care. His CRPS diagnosis had actually been missed. He was being treated with IVIG infusions, which is not actually a treatment for CRPS. There’s no evidence of effectiveness.

Once I realized what was going on, we put him on what’s called a pacing plan for pain. A pacing plan is a little bit what it sounds like. If you said, “Zoffness, I want to run a marathon,” I would say, “Listen, Dr. Kevin, don’t do that tomorrow if you haven’t been doing some gradual training, because your brain and body need to get used to that amount of activity.” So, pacing for chronic pain when it comes to CRPS is a similar process. It’s exposure to little bits of stimulation and activity a little bit at a time.

Also, with CRPS, we have learned that to desensitize the brain, which is actually what’s regulating pain, not the skin and not the legs, you also need to do touch desensitization. So, you actually have to touch the legs. You have to use temperature desensitization, so we were doing warm and cool baths. And the most important part of this treatment was also, in addition to cognitive behavioral therapy, which he was doing with me, referring him to a PT who was very well schooled in pain, who happened to be a dear friend of mine. So, we tag-teamed this case, and we coordinated care. He got better within about three months, and he went back to life after two years of being in bed with chronic pain.

So, that’s just a small example, and there were a lot of other things we were doing with him, too, to help him manage his pain and figure out how to start moving his body again, and to live with the normal and understandable anxiety and depression that often come with chronic pain. But that was a pretty great example.

Kevin Pho: So, for patients who are on, for instance, long-term chronic opioids, can a biopsychosocial approach lessen their need or take them off of opioids completely? Is there potential for that?

Rachel Zoffness: A biopsychosocial approach to pain is actually the only effective approach to pain. Medications alone are never going to effectively treat a chronic pain condition. We just know that. And by the way, this is not an opinion. This is just a synthesis of decades and decades of research. It’s just not sufficient. Medications can lower pain volume. Of course they can. But over the long term, what research shows, and I always get in trouble for this, so I just want to add that caveat, what research shows is that opioids actually sensitize the brain to pain over time. If you Google that, there’s an actual opioid sensitization process that is well known in the literature. It’s well established. So, over the long term, opioids are not an effective treatment for pain. They will dampen pain volume, of course, that’s true, but it’s not sustainable, and it doesn’t target all these biopsychosocial processes that are maintaining the pain cycle. That’s my controversial answer.

Kevin Pho: So, how does one go about finding a pain psychologist? How many of you are there?

Rachel Zoffness: Yeah, KevinMD, that’s a real problem, and it’s one I’m trying to squash. Again, pain is not taught in most psychology programs, because in Western medicine, again, we have this idea that physicians treat physical pain and psychologists treat emotional pain. Of course, we know that that’s not true, because neuroscience tells us that’s not true. But the answer is, there are people who treat chronic pain who are in therapy and psychology.

You do want to find a cognitive behavioral therapist, and if that cognitive behavioral therapist is not trained in pain, you can hand them a CBT for pain workbook. There are many out there. I mentioned mine, The Pain Management Workbook, and I wrote it because I’m so angry that we aren’t trained in pain. There aren’t available providers for treating people with chronic pain. So, anyone who’s trained in CBT can use the workbook, but there are others besides mine. It doesn’t have to be mine. There are a number of pain management workbooks out there that are CBT-based, and any therapist who’s trained in CBT can do it with any patient.

So, the answer is, it’s a real problem: the lack of health care providers trained in pain across disciplines, but in psychology in particular. But there are a few hacks, and they’re not great, and it’s not ideal, but it’s definitely better than nothing.

Kevin Pho: What’s the response from pain management clinicians, anesthesiologists, pain management providers? What’s their response to your approach?

Rachel Zoffness: Yeah, it’s pretty wild. You know, I feel like I am spouting this controversial stuff, and I’m going to get a lot of, and I do, by the way. Sometimes people get very angry, and they still think I’m saying, “Oh, pain’s in your head.” Or they think I’m anti-medication, and I’m not at all. Thank God for opioids and other drugs for short-term acute pain, by the way. Post-surgical pain, bless your soul.

But in general, I’m on the board of the Society of Pediatric Pain Medicine. It was previously all anesthesiologists, and they let me join their board, because I think people who specialize in pain know that the system is broken. They’re seeing their patients suffering, and they know that the biomedical approach is not working, and they’re grateful that there are people out there who are advocating for this more accurate treatment of pain. So, I find in general, physicians are super open to it and so glad to have this collaboration between disciplines, because health is multidisciplinary, because humans are multidisciplinary. There’s just no way around that fact. Our brains are connected to our bodies 100 percent of the time. So, we have to target both brain and body when we’re targeting chronic pain. So, anesthesiologists and pain medicine specialists are usually absolutely wonderful to work with.

Kevin Pho: We’re talking to Rachel Zoffness. She is a pain psychologist, and she wrote the KevinMD article “What you don’t know about pain will hurt you.” Rachel, short of sending a patient with chronic pain to a pain psychologist, are there any things that primary care physicians like myself can do in the exam room that can utilize some of your biopsychosocial techniques?

Rachel Zoffness: Yeah. OK, so the first thing I would say is pain education is critical for patients living with chronic pain. If we don’t relocate pain from the body to the brain, none of our patients are ever going to buy in to a biopsychosocial approach. If you continue to believe that pain lives exclusively in your back, and you need to have 42 surgeries to fix it, why would you ever go see someone like me? Or why would you go to biofeedback? Biofeedback, by the way, is amazing for chronic pain. But no one’s ever going to do that if they continue to believe that pain is exclusively a body-based phenomenon.

So, pain education: You can do a down-and-dirty, five-minute pain education. You can even have a handout. You can use the crap from my book; I don’t care. There’s so much good pain education out there. So, that’s step one, I think: relocating pain to the brain and making sure people understand that that’s what’s happening. There’s a really easy way of explaining pain neuroscience, which I would happily explain if we had more time, and if you tell me to, I will. But there’s a metaphor that we use in pain neuroscience of this pain dial that can be turned up and down, and what raises pain volume is thoughts and emotions and coping behaviors. So, just explaining that basic stuff, I find to be critically important.

Then there are a lot of coping strategies and pain management strategies that come from CBT and biofeedback that primary care physicians absolutely can and should recommend. I would recommend having a list of therapists, CBT therapists that you trust and like, who know about pain. I would recommend having PTs and OTs you can refer to who know about pain. I would suggest always referring to biofeedback, which is this magical treatment for pain. I happen to love it. So, there are a lot of collaborative things that we can do.

Kevin Pho: What are some resources that physicians can look at?

Rachel Zoffness: So, I’ve spent 10 years collecting them, and they’re on my website. I’m struggling to think offhand of the best book and the best websites. I have a really nerdy website. It’s just my last name, zoffness.com, and there’s a resources page with a ton of free resources. I just have been making lists of books and websites and apps. There really is actually a lot of stuff out there, believe it or not. There’s an app called Curable that I happen to really like for chronic pain. Gosh, there really is a lot, but it’s overwhelming actually to think about it. But there’s a ton of stuff on the website, and the resources are free.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Rachel Zoffness: My take-home message is that chronic pain is absolutely treatable. People with chronic pain do not have to be going through this alone. Support is available. Resources are available. Pain is biopsychosocial. It is not biomedical. And what that means is it requires collaboration between all of our disciplines: medicine, psychology, PT, OT. For people to get well, all of us need to be working together. That’s the take-home.

Kevin Pho: Rachel, thank you so much for sharing your time and insight, and thanks again for being on the show.

Rachel Zoffness: Thanks for having me.

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