We know that there are fundamental factors like sleep and nutrition and movement that make learning easier.

Ditto the core relationships that establish our emotional lives, but as any of the 100 million Americans in chronic pain right now will tell you, nothing is possible when the body aches.

Pain controls lives.

It crushes productivity and creativity.

It strains relationships.

It can lead to addiction and sometimes suicide.

And the way we understand pain affects how we treat pain, which, according to our guest, Dr. Rachel Zoffness, is all wrong.

Rachel Zoffness is a pain psychologist, an assistant clinical professor at UCSF, a lecturer at Stanford, and a scientist on a mission to reset our conception of what pain is so that we can set free the potential of millions of people.

I'm Kelly Corrigan, this is "Tell Me More," and here is my conversation with researcher, educator, psychologist, and butterfly enthusiast Dr. Rachel Zoffness.

[Theme music playing] ♪ Rachel Zoffness.

Hello.

Hi.

So nice to see you.

Nice to see you.

Come on in.

Go on.

All right.

Thank you.

Sure.

We're going to go right up there to the left.

What is the relationship between productivity and pain?

I think that depends on who you ask, and that's one of the hard things about assessing pain, is that pain is just so subjective and variable that it just differs from person to person.

But in general, chronic pain is incredibly disabling for people.

Yeah, I mean, I've had my fair share of migraines, and when it happens, everything stops.

Yeah.

Nothing can happen.

I cannot eat, I can't get out of bed, I can't open a window, I can't talk to anybody, I can't answer a question.

My whole calendar goes dark.

I want to feel unstoppable, and then I'm kind of a person who has to stop.

It, like, crashes into my dream of who I am.

That's awful, and you're not alone.

Can you talk about stigma and shame and pain?

There's a lot of stigma around the chronic pain population for a lot of reasons, chronic pain as distinct from acute pain.

Acute pain is pain that lasts 3 months or fewer, so the pain of childbirth or a broken ankle or, like, an acute illness, and chronic pain is pain that lasts 3 months or longer, or beyond expected healing time.

And there is a lot of stigma around chronic pain, and one of the reasons for that is, for a long time, people have not really known how to treat chronic pain.

In fact, if you look up the treatment or, God forbid, the cure for fibromyalgia, the Internet will tell you that there is none, that it's not treatable, and there is no cure, and that is a lie.

One of the reasons there's a lot of stigma around chronic pain is that it is generally thought to be an incurable condition.

We go into this profession so that we can help people heal.

A lot of providers are taught that chronic pain is not curable or that the treatment for chronic pain is a pill, and that is what a lot of people have been told for many years and, of course, we've seen how that has gone and we know now, unquestioningly, that the true and most effective treatment for chronic pain is not just a pill, because chronic pain is never a purely biological problem.

And now, what have we done to these people who have been on opioids long-term for a lot of years?

A lot of them have been marginalized and stigmatized and called addicts.

And a number of people have, of course, developed very serious addiction and substance-use issues.

What have we done to people living with pain?

It just--it breaks my heart because that's not the true treatment for pain, and the true treatment for pain has been known for a very long time.

That's interesting to me, that it's been known for a long time because I always was reading it as the history of pain was that Big Pharma solved the problem with medication, and to the extent that that wasn't working for you, that's when you became a problem in the system and that this biopsychosocial story that you're telling is new, but you're saying it's not.

No, it's not new.

Of course, there's biological components to health.

There's also cognitive and emotional and behavioral components, the psych.

There's also social and sociological components to health, like socioeconomic status and access to care and race and ethnicity and culture and environment.

All of those things together create health, whether it's diabetes or depression or pain, and we've known that that's true for a very long time.

But you asked specifically about pain, and the biopsychosocial model has been around for a very long time, as has the true nature of pain.

Back in 1965, two of my heroes, Ron Melzack and Patrick Wall, came up with the Gate Control Theory of Pain, and they forever revolutionized pain medicine.

And what they said was that pain was never purely a physical problem, that pain was influenced always by thoughts, by emotions, by context and environment, and they said that, you know, pain is a creation of many things happening at one time, so sensory messages don't just live in a vacuum.

Sensory messages enter a nervous system that has already been informed by context and environment and past experiences and everything you've ever seen and learned, and the brain interprets those sensory messages accordingly, so the true science of pain has been known for a very, very long time, but--and I will piss people off here-- it doesn't make people a lot of money.

As long as you believe that your pain is purely biomedical, purely biological, and it requires a purely biological and biomedical solution, you will take pills and procedures all day long to make sure your pain goes away.

But chronic pain is on the rise.

Our treatments are not working.

We have an opioid epidemic.

The reason chronic pain is on the rise is because we continue, to everyone's detriment, to continue to frame pain as a purely biological, biomedical problem, and it isn't working because it's not true.

♪ One of our guests in a previous season was Lisa Feldman Barrett.

She's so informed on this and she sort of feels like she's screaming into the void, that, like, this is how emotions are made.

Does your point of view totally dovetail with hers?

What I really like about Dr. Feldman Barrett is that she's saying a very similar thing, which is that emotions are not purely biological.

They're also contextual, they're social.

They involve your memory and your history.

Emotions are also biopsychosocial.

I wish we used that word more often to describe more things.

I mean, when it comes to pain, one of the most interesting things to me is it's easy to believe that pain lives just in your ankle or just in your back or just in the part that hurts.

But what we know about pain is that it doesn't just live in your body part that hurts.

It's actually constructed by your brain, and there's lots of parts of your central nervous system that make pain.

One of the reasons we know that pain is not constructed exclusively by your back or by your knee is by this condition called phantom limb pain.

Right.

Phantom limb pain is when someone who has lost a limb--an arm or a leg-- continues to have terrible pain in the missing body part, and we know that if pain lived just in your leg or just in your back, that no leg should mean no pain.

And the fact that you can have terrible leg pain in a leg that's no longer attached to your body tells us pretty definitively, in addition to some other information, that pain is not constructed just by the part that hurts, and neuroscience reveals that pain is constructed by your central nervous system, your brain and your spinal cord.

So there's a condition called failed back surgery syndrome, when you've gone and you've had however many back surgeries and they haven't cured your pain.

Guess which part of the body we've ignored.

Mm-hmm.

We've never targeted the brain, and pain is physical and emotional 100% of the time.

The sensory messages in your body filter through the parts of your brain that construct emotions 100% of the time.

There is no such thing as pain that is just physical.

Never, ever.

Pain is also emotional, so if we're missing or skipping your history of trauma, your depression, your stress, and your stressors, your anxiety, we're not fully treating pain.

But we will send people for 40 knee surgeries and we will put them on 14 medications... Yeah.

without ever targeting the bigger picture.

When I read "The Pain Management Workbook"-- Which I'm honored that you have, by the way.

Oh, it's very valuable.

You know, it talks about your pain voice and your pain dial and pain traps.

Can you talk about where you came to your conclusions?

What is the research you're relying on?

When you dig back into actual pain science, again, this goes back to 1965 with the Gate Control Theory of Pain, where they showed undeniably that cognitive factors, emotional factors, behavioral factors, contextual and environmental factors all actually influence the pain experience.

If you really want to treat pain, you have to treat the whole person and not a body part.

As I learned more and more about pain science, I was wondering about translation of research to practice because something messy and bad happens between what's happening bench-side and what happens bedside, and we know that there's a long delay between research and then what trickles down into practice, and it occurs to me in doing my research that one of the big problems is our education.

There's been a lot of research recently on pain education in medicine, and it turns out that 96% of medical schools in the United States and Canada have zero dedicated compulsory pain education.

That's from a Shipton study from 2018.

I'm like, "How can this possibly be true?"

Pain is the number-one reason people go to the doctor's office.

Right.

Pain is a human problem.

It's going to affect all of us eventually as we age.

It affects the people we love.

Nobody, nobody escapes the experience of pain.

So why is it that there's such poor pain education, and this fund of knowledge we know about pain science isn't making its way through healthcare provider education programs?

The 4% of healthcare providers that do get trained in pain get trained in the biomedical model, which means a focus-- primarily, if not exclusively-- on anatomy and physiology and brain chemistry and pain medications.

I also want to say, very carefully, biomedicine is critically important, and God bless chemistry and anatomy and physiology and--and medications, like we have vaccines because of biomedicine and we have pain medications-- which, by the way, I am not opposed to and I think are important-- but when we talk about the biopsychosocial model of pain, which is what pain is, the bio domain is-- is important, critical.

It's tissue damage and system dysfunction and immune response, and it's sleep and diet and exercise, and all of those things are critically important when it comes to pain.

Fix the broken bone, get rid of the rotten tooth, like, the heart is not working properly, we have to fix the heart, but it's just 1/3 of the problem.

If we're only looking at the bio domain of pain, we're missing 2/3 of the pain problem.

My issue is that we tend to exclusively focus on bio medicine when we talk about what pain is and when we talk about how to treat it.

♪ A thing that's come up repeatedly is this balance between personal agency or gumption, circumstance and intervention.

And when you think about how quickly pain will stop a person's ability to have a fulfilling life, and then you think about how each of those elements play out and then the intervention is what?

Pain science is really complicated, so I've learned to talk about pain as a recipe, like just as there's a recipe for brownies, there's also always a recipe for pain, always, and when I think about a pain recipe, I'm always thinking about the biopsychosocial ingredients.

And what I mean by that is what are the biocomponents of my pain?

So, for example, someone with back pain might say, "Sitting for too long "is part of my pain recipe, moving too much "or lifting heavy things is part of my pain recipe.

"Crappy sleep, not eating very well, "having a lot of stress that I'm not managing, being inside and isolated amplifies my pain," so there's many things that will contribute to a pain recipe.

But just as there's a high pain recipe, there is also always a low-pain recipe, so it might be standing up and stretching every 15 minutes instead of sitting at my desk, you know, 9 hours and then realizing, "I forgot to eat lunch."

It might be making sure to go outside and walk for 10 or 15 minutes every day or whatever I can handle.

It will be like making sure I have a robust and healthy social life and I have social support and I'm not isolated because it turns out science says social isolation amplifies pain, too, which is part of the reason, in my opinion, chronic pain exploded during the pandemic.

Stress is a known pain amplifier and exacerbator.

More stress, more pain.

More pain, more stress.

There's all these cycles.

Yeah.

And they're breakable, but first, we have to know what the recipe is.

Well, also, the idea that they're breakable gets at the hopelessness... Oh, yeah.

that sometimes comes with pain.

Yeah.

That can lead to depression, so what do you see in terms of the relationship between pain and depression?

They're intimately connected.

In fact, you were talking before about the stigma around chronic pain.

Mm-hmm.

And people living with chronic pain are often stigmatized, and one of the reasons for that is that there are high rates of depression and anxiety in the chronic-pain population, and I want to do away with that stigma once and for all, right now.

Chronic pain is a thief.

It steals your ability to work, to play, to hang out with your kids and your grandkids, sometimes to have sex with your partner, to engage in sports and your beloved hobbies.

Now, when you've had chronic pain for ten years... Mm.

you bet you're going to feel depressed.

You bet you're going to be anxious about your body and your future.

Of course you're going to feel hopeless, especially as it marches on and on and on, and all you're ever given is a pill.

And maybe it's not helping you, or maybe you've been given a medication, and now it's being taken away from you.

Of course, you're depressed.

Of course, you're anxious, so I want to reframe the way we think about this.

We've already established that, of course, it's normal and natural to feel depressed and anxious when you've lived with pain day in and day out for ten years and it's stolen everything from you.

That is what we call a normal response to an abnormal situation.

You're an educator, and I think about how much common knowledge there is around things like PTSD or ACEs.

Can you talk about something that you wish everybody could understand about your piece of the puzzle, which is pain?

It's critically important for people to know that chronic pain is treatable, and don't believe what you read on the Internet that there's no cure and it's not treatable.

That is wrong.

Pain is a biopsychosocial process, and it requires a biopsychosocial solution, and what's so hopeful for me about this perspective is most people who come to me have tried the bio.

They've tried, like, the procedures and the medications and anti-inflammatories, and that's great.

Like, I am not opposed to those things.

We want that to be part of the low-pain recipe.

But if you've tried those and they're not working, it means we need to look at the other 2/3 of the pain problem.

What I mean by that is, in the psych or the psychological domain of pain, we have coping behaviors.

How are we coping with pain?

We have lifestyle.

What are the decisions I'm making every day when I get out of bed?

How is my nutrition?

How is my sleep?

Am I going outside and moving my body?

How is my emotional health?

How is my mental health?

You know, how do I think about my pain?

Am I having thoughts like, "This is going to last forever, nothing has ever helped me, so nothing ever will"?

Mm-hmm.

Because that is going to amplify your brain's danger detector.

It's going to amplify pain volume, and also, we want to be looking at the social and the sociological domain of pain.

There are certain things we can't control, but there are many things we can do in the social and sociological domain of pain to change pain volume.

It is not hopeless.

That's your message.

My message is that it's extremely hopeful because there's a million things we can do to change pain.

♪ Is insurance catching up to this point of view?

Like, are they going to start covering more than just the biomedical solutions?

Insurance is not catching up.

The word has to be spread, and people have to be angry about the way that pain is being mistreated, and it is being grossly mistreated.

And in case this is news to anybody, we have a profit-driven healthcare system, and money is the bottom line.

I am not saying, of course, that healthcare providers don't exist to help people.

We all do.

I am a healthcare provider, but the bottom line for hospitals is profit.

They're all going to go out of business otherwise, and we have a biomedical model, which means they have to sell you the pills, they have to sell you the procedures, they have to prescribe MRIs.

Do you know the degree of prescribing of MRIs and scans in America is higher than, like, any other country by a large margin?

And it brings in dollar bills, but it's critically important for things like pain psychology to not only exist more, but to be reimbursed more, and for all sorts of therapy for trauma, which intimately impacts pain.

We know because trauma and chronic pain are co-morbid, or live together up to 80% of the time.

So all of these things need to A--be part of pain treatment, and B--need to comfortably be reimbursed, because how is anyone supposed to afford appropriate biopsychosocial pain care if there's no hope of getting reimbursement for those services?

Can you give us one behavior that you want us to continue, one behavior that you want us to eliminate, and one behavior that you want us to multiply?

One behavior I want us to continue is to continue this push forward for pain education.

Doctors and healthcare providers and patients are desperate for it and hungry for it, and before, we were talking about this lack of pain education.

It's not because doctors and providers don't want to know, there's just a lack of real estate for some reason and medical schools to teach this biopsychosocial approach to pain.

A behavior I would eliminate is an overreliance on biomedical treatments for pain.

I am not saying I want to get rid of pills and procedures-- they're important, I want to keep them-- and especially for acute pain, research shows they're very helpful and very important, but what we also know, neuroscience says that when pain becomes chronic, it becomes its own disease process.

The brain and nervous system become hypersensitized to pain, so when pain becomes chronic, targeting the body part alone is not going to be enough.

So when it comes to treating chronic pain, I would like to see a vast reduction in purely and exclusively biomedical procedures and interventions.

A behavior we should multiply is I hope everyone in the universe starts going around talking about the word "biopsychosocial" and how having a biopsychosocial lens to health and to pain, in particular, will really galvanize us and drive us to seek out biopsychosocial solutions.

♪ We have a thing at "Tell Me More" called "Plus One," where we give you an opportunity to shout out somebody who's been instrumental to your thinking or your well-being.

Who is your plus one?

I think my plus one has to be Dr. Ron Melzack, and he is no longer with us, and so I never got to meet him, but he was one of the world's first pain psychologists, and no one has ever heard of a pain psychologist.

Like, in Western medicine, we have this erroneous and idiotic divide, like either your pain is physical and you see a doctor, or your pain is emotional and you see a therapist.

But as we all know, all pain is processed by the parts of the brain that construct emotions, so all pain is physical and emotional, and we need more pain psychologists out there, and Ron Melzack was a champion of that call.

He was one of the developers of the Gate Control Theory of Pain, which completely revolutionized pain medicine, and he was a champion of talking about the role of thoughts and beliefs and emotions in pain.

Ron Melzack is one of my heroes because he took psychology out of this little realm where it was living, where it was just about emotional pain and said, "Pain is physical and emotional always."

♪ Kelly: Are you ready for the "Tell Me More" speed round?

Um, maybe.

Let's try.

Ha ha ha!

First concert?

My first concert was with my mom, and it was Peter, Paul, and Mary, and they sang "Puff the Magic Dragon" and I was really delighted.

I was, like, 8.

Whoa.

Yeah.

Best live performance you've ever seen?

The best live performance I've ever seen was recently, and it was with my partner, and it was Lady Gaga.

Let me tell you, that woman is a phenom.

She also, by the way, lives with chronic pain.

What was your first job?

Ha!

I had two first jobs.

One was being a science teacher at the Bronx Zoo, which was phenomenal.

It was me and a bunch of, like, very overly educated, like, 8- to 12-year-olds who all wanted to be herpetologists, and we would go around talking about evolution and opposable thumbs.

It was delightful, and I miss it every day.

My other first job was a research assistant and science writer at "Natural History" magazine, which used to be a glossy print magazine, at the Museum of Natural History in New York City, and it was wonderful.

I learned so much.

What is the last book that blew you away?

The last book I read that blew me away was called "Saving Normal," by Allen Frances.

He was one of the authors of "The Diagnostic and Statistical Manual," the DSM, which we use as a Bible... Yep.

in psychiatry, and he talks about how those diagnostic criteria are actually quite arbitrary and random and how they're expanding every year, so more and more people are falling into the category of "depressed" when, you know, perhaps it's a normal response to an abnormal situation.

If your high school did superlatives, what would you have been most likely to become?

I was a shy library mouse in high school, and we probably had superlatives, but I did not get one.

But I had someone write in my yearbook, like, "most likely to become," like, "a neuroscientist" or something like that.

Oh, nice.

So--tsk--yeah.

Who is your favorite celebrity crush?

Oh, he's no with-- he's not alive anymore, but Oliver Sacks is my celebrity crush.

I love Oliver Sacks.

That's perfect.

What do you wish you had more time to do?

My biggest issue actually isn't time.

It's giving myself permission to relax.

What's your go-to mantra for hard times?

Mm, one step at a time.

Is there anyone you would like to apologize to?

Yes, there's a thing happening right now that's making me crazy.

I closed temporarily my private practice to focus on bigger-picture, larger-scale pain education, and--and writing, and so I'm having to say no to all of these people who are writing to me, and for a very long time, I could say yes to everyone, and it's heartbreaking.

The messages I get would make you weep, and I hate saying no.

What's something big you've been wrong about?

So, for a very long time, especially being a woman, a psychologist in medicine, I--I thought I was supposed to be small and in the corner.

And I've had two very powerful men in positions of medicine tell me I needed to know my place, and I've decided that they're wrong and I was also wrong, and that--about being small and that what I actually need to do is be very loud and very big about the problems that I am seeing and the truths that I am seeing in science and do stuff like this, so I think... Great.

I've been wrong about the smallness of women, particularly in medicine.

If you could pass one law or overturn one Supreme Court case?

Free healthcare.

Healthcare, especially effective pain treatment, should not only be for rich people.

If your mother wrote a book about you, what would it be called?

Heh!

I think it would be called "Ferdinand," because as a child, "Ferdinand the Bull" was one of my favorite books and, you know, while all my friends were running around, I was under my favorite cherry blossom tree, reading books.

If you could say 4 words to anyone, who would you address and what would you say?

Everybody living with pain, and the 4 words would be, "There is always hope."

That's great.

Thank you so much.

Thank you so much.

Here are my takeaways from my conversation with Dr. Rachel Zoffness.

Number 1--pain is never solely a biological event.

It is always biopsychosocial.

Number 2-- the bench-to-bedside lag is too great.

We must close the gap between what we learn in the lab and how we treat patients.

Number 3--sometimes, what we call depression is a very normal response to very abnormal circumstances.

Number 4--pain's job is to grab our attention.

Our job is to direct it.

Number 5--to everyone experiencing chronic pain, do not despair.

We have agency, we have hope, We have science.

[Theme music playing] ♪ ♪ ♪