An End to Chronic Pain? Surprising Science is Getting Us Closer. | Dr. Rachel Zoffness

Stop the cycle of chronic pain by fixing the signals in your brain. We’ve been told for decades that pain is purely a physical problem, born of bones and body parts. But the latest neuroscience proves that’s only one piece of the puzzle.

Dr. Rachel Zoffness is a pain scientist, assistant clinical professor at UCSF, and author of the new book Tell Me Where It Hurts. She lectures at Stanford and is revolutionizing how we treat chronic suffering by moving beyond the outdated biomedical model.

The 65-year-old neuroscience secret that proves how pain is generated by your brain. A specific biological “recipe” that allows you to lower the volume of your pain signals in real-time. Why 96% of medical schools are missing the most critical tool for treating chronic conditions. The surprising link between your social life and the actual physical inflammation in your joints. A simple pacing strategy to return to the activities you love without triggering a flare-up.

If you’ve been told you just have to “live with it,” this conversation provides the roadmap to take your power back. Play the episode now to discover the whole-person solution you’ve been searching for.

You can find Rachel at: Website | Instagram | Episode Transcript

Next week, we’re sharing a really meaningful conversation with Dr. Amir Levine about the tiny moments in your relationships that are secretly shaping your confidence, your sense of meaning, and how safe you feel in the world.

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photo credit: DyAnn Chao

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Episode Transcript:

Jonathan Fields: [00:00:00] So you get a feeling when you wake up with that same old ache in your back or your knee, or maybe your head or your neck, and maybe you’ve been told by a string of doctors that it’s just a part of getting older, that you have to learn to deal with it. There’s no clear reason. Or maybe they point to a clear reason, but dealing with that, it’s just not helping at all. It feels like your body is failing you. But what if the real failure is actually in how we’ve been taught to think about pain? Today’s guest is doing something pretty remarkable. Doctor Rachel Zoffness is a pain scientist and clinical professor at UCSF who also lectures at Stanford. She’s the author of the new book, Tell Me Where It Hurts, and she is on a mission to show us that pain is never just about a body part. It’s a whole person problem that requires a whole person’s solution, what she calls a biopsychosocial approach. In this conversation, we explore why a twisted spine doesn’t always lead to a hurting back, how your brain actually manufactures pain through a specific internal recipe, a powerful tool called biofeedback that lets you see your thoughts literally change your physical body in real time, and how even social challenges can lead to physical pain and what to do about it. So excited to share this conversation with you. I’m Jonathan Fields and this is Good Life Project.

Jonathan Fields: [00:01:26] I have been really curious about the mind-body connection. I feel like it’s actually doing a disservice to actually use the phrase mind body anymore because they aren’t separate things. Um, but you know, one thing that is a fairly common experience for so many people as we get older is the experience of pain, either acute or chronic. And oftentimes we’re kind of told it’s just a part of the process of getting older. This is going to ache more. This is going to hurt more like and just kind of deal with it and the understanding of what it is, where it’s coming from. I feel like it’s gotten greater and greater. What in your mind is the the sort of like the most damaging myth that we believe about pain, the one that really keeps people stuck and suffering?

Rachel Zoffness: [00:02:08] Oh, gosh, there’s, there’s.

Jonathan Fields: [00:02:10] And you can name a few.

Rachel Zoffness: [00:02:11] Yeah. That’s easy. But the biggest myth about pain is this myth. We’re all sold that pain is a purely biomedical problem. And by that I mean something to do just with anatomy and physiology, your bones and your body parts. And we have actually known for 65 years of really great neuroscience that pain is never purely biomedical. Like it never just lives in your body. And one of the reasons we know this is because of a condition called phantom limb pain. And have you heard of phantom limb pain before?

Jonathan Fields: [00:02:44] I have, but walk me through it.

Rachel Zoffness: [00:02:46] Yeah. So phantom limb pain occurs when someone loses a limb, an arm or a leg, and they continue to have terrible pain in the missing body part. And if you can have terrible pain in a leg that is no longer attached to your body, that tells us pretty definitively that pain isn’t just manufactured by your leg. Like it just doesn’t just live in your leg. In fact, what we know is that pain is ultimately constructed by your brain. But when you have chronic leg pain and you go to 762 doctors, we don’t usually talk about your brain. We don’t usually talk about all of the factors that are going into maintaining and constructing your pain. You might have leg surgery, you might get medication, you might get referral to PT and OT. And by the way, those things are useful and important. I’m not saying they’re not. But the myth that sustains in medicine is that pain is just biomedical. It’s just about the body part that hurts. But pain, as I’m sure we will discuss, is a whole person problem that requires a whole person solution.

Jonathan Fields: [00:03:56] So if we have known this for, I think you said 65 years or so at least, at least probably known intuitively for a lot longer than that. Right? Right. Why does the myth persist?

Rachel Zoffness: [00:04:11] Oh, there’s a bunch of reasons for that, too. One is that we have a biomedical healthcare system, which is really rooted in this antiquated biomedical model, which sort of separates mind from body, which was the first thing you alluded to. We have this other myth in Western medicine that either your pain is physical, in which case you should see a medical doctor physician, or your pain is emotional, in which case you should see a therapist or a psychologist. But what science says back to this brain thing is that pain is ultimately constructed by the brain. And the parts of your brain that make emotions also make pain. So one of these other myths that persists is that if pain is purely biomedical, what do what do emotions have to do with it? But here’s an important fact. The parts of the brain that make emotions also make pain. Um, the other reason the myth persists. This one I usually suggest people swallow with a glass of bourbon because it’s so upsetting. Um, 96% of medical schools in the United States and Canada have zero dedicated compulsory pain education. I’m going to say that again. 96% of our medical schools have zero dedicated compulsory pain education. And what that means is, you know, our doctors go into healthcare, go into treating pain because they care about people, they care about the human body. They want to help and heal. But we aren’t giving them the tools to do that. And so what’s happening in the world of chronic pain is that doctors are burning out. They don’t know what to do and they aren’t being taught the true science of pain. So what they are recommending is what they’re taught, which is again, the biomedical model. Bones and body parts. And it’s one of the reasons why chronic pain isn’t going down. It’s actually on the rise.

Jonathan Fields: [00:06:11] So if 90%, 96% are not actually given formal education around pain. Um, do you have data or rough data on what percent of the typical population, say by middle years experiences meaningful levels of pain?

Rachel Zoffness: [00:06:29] Listen, 100% of us are going to experience pain one day if we haven’t already. I mean, whether it’s childbirth or back pain or living in an aging body, no one escapes pain. It’s it’s something that I think is so important because we think of pain patients. And I’m putting that in quotes for people who are listening as like on the left and everyone else on the right. But I want to make very clear that we are all pain patients. Like we are all going to have pain. We are chronic pain affects 100 million people in America today and 1.9 billion people around the globe.

Jonathan Fields: [00:07:10] So we are all going to have pain at some point. Should we be blessed to live long enough and experience enough of life? Exactly 100 million people are in chronic pain in one country and 1.9 billion around the world. And yet 96% of the practitioners that we go to to help us resolve them don’t have any meaningful education on how to deal with this effectively.

Rachel Zoffness: [00:07:33] Yeah. So what’s happening in medical school? So I teach currently medical fellows and residents at Stanford and UCSF. And I always conduct an assessment. And I always ask, you know, how much pain education my students have received. And it’s woefully little. Like oftentimes they’ve learned about pain, but it’s been embedded in a course about anatomy or physiology or anesthesiology. It’s not a standalone multidisciplinary course that really teaches what I’m going to call the biopsychosocial model of pain. And I mentioned before that pain is never purely biomedical. What I didn’t do was tell you what pain is pain.

Jonathan Fields: [00:08:12] Let’s go.

Rachel Zoffness: [00:08:12] There is a biopsychosocial problem, and if people remember nothing else from this podcast, I hope you will remember this word. It’s pretty intuitive, but I want to say what it means. Pain, of course, has biological components like tissue damage, system dysfunction. We know diet, sleep, and exercise contribute. However, if you imagine a Venn diagram with three overlapping circles, we’ve got bio, we’ve got psych and we’ve got social pain lives in the middle of those three circles. And if we’re only treating the bio domain of pain. We are missing two thirds of the pain problem, and that’s the major problem that I see in pain medicine today. So in the psych domain of pain, we have emotions. We have thoughts, we have coping behaviors. I mentioned earlier the parts of the brain that make emotions also make pain, like our limbic system we’ve all heard of. This is a critical part of our pain machinery. And then I said the third bubble, the third circle is the social or the sociological domain of pain. And I like to think of that as like the everything else domain. So in there we have socioeconomic status and access to care and race and ethnicity and history of trauma and our social support. Like are we isolated and lonely and alone? We know that affects our health. Are we receiving social support? You know? So all of these factors together are critically important when it comes to producing pain and also reducing pain.

Jonathan Fields: [00:09:52] So bio psychosocial.

Rachel Zoffness: [00:09:57] Got it. Yeah. It’s such a good word. I mean, and we all know that’s true. Like we all know our bodies hurt more during times of stress and duress. And we all have seen from all the books and all the articles what trauma does to the body. Trauma doesn’t just live in our heads. It manifests physically. Of course it does. The brain is connected to the body 100% of the time. But when you go to the doctor for your chronic back pain, do you get asked about your emotional health or your sleep, or do you get asked about your history of trauma? We should be getting referrals for all the parts of the pain recipe instead of just one.

Jonathan Fields: [00:10:35] So I mean, from a practical standpoint then, and that makes sense to me, right? From a practical standpoint, most and tell me if I’m getting this wrong, somebody goes to med school, they do their four years, then they, they probably do a couple of different rotations that kind of figure out what am I going to specialize in. They go into that specialty. They get more training in that specialty, right? Um, but pain exists across all these different specialties. So they’re probably it sounds like what’s happening is they’re getting training in a very sort of like a narrow field where like this is, this is the type of doctor I am. Like, I’m a, I’m a gastroenterologist, I’m an orthopedist and I’m an orthopedist that specializes in this limb and in this joint, right? So there’s a lot of specialization. And of course, within each one of those subdomains, I’m sure they’re going to talk about pain in the context of this particular part of the body. Right? So if I understand what you’re saying, they are talking about pain, but they’re talking about it just as a biological thing related to the part of the body that they’ve specialized in, not more broadly with all the other things you’re talking about.

Rachel Zoffness: [00:11:46] Yes. What we’re learning, I mean. And listen, I am not into the blame game. Blame game like I need.

Jonathan Fields: [00:11:52] Of course.

Rachel Zoffness: [00:11:53] Yeah. And I so I just want to be. I’m always very careful about how I talk. About it. This is a systemic problem. This is not an MD problem. It’s like, you know. The education system is very biomedical biomedically focused. And then the insurance companies will really reimburse biomedical procedures. Like you can get seven back procedures and get prescriptions for pills all day. But when you try and reimburse these other, you know, biopsychosocial treatments for chronic pain insurance companies don’t cover it. So this is a systemic problem. It’s not an MD problem. But to your question, yes, what’s happening in medical school is that there’s a focus on anatomy and physiology. So like you said, you know, if you’re a foot specialist, you will learn about all the bones and the tendons and the joints and the musculoskeletal system. And when something goes wrong, You asked about earlier the myths that persist in medicine. And I want to say one more because it’s related to this question. There is a myth that persists in medicine. Someone recently called me a mythbuster. I really loved that. There’s a myth that persists in medicine that hurt or pain and harm or damage are the same thing. Let me give you an example. Yeah, I’m going to define our terms. So you’re sitting at the kitchen table and you bash your knee.

Rachel Zoffness: [00:13:15] Hurt or pain is the subjective experience of pain that you have when you bash your knee and it’s different for everyone, your pain number will be different than my pain number. Harm is the physical damage that occurs after you bash your knee. So say that your knee turns purple and it starts swelling. That’s harm or damage. And the myth that persists in medicine and that our doctors get taught is that hurt or pain and harm or damage are the same thing. I know this is a challenging concept. Now, when you have back pain and I’m talking about chronic back pain, you will go to the doctor. You will get referred for an MRI or a back scan. And if there’s any abnormality on that scan, your doctor will tell you this is the cause of your pain. Because we are taught, we are trained that pain and damage are the same. So when we have pain, we go looking for damage and we decide that the damage, the abnormality is the cause of our pain. The two things are not the same, especially when it comes to chronic pain. Because chronic pain is considered a disease of the central nervous system, it is our brain and our nervous system that is wonky. It is very rarely something to do with the body.

Jonathan Fields: [00:14:33] Pain and harm. Not the same. That’s right.

Rachel Zoffness: [00:14:37] And hurt and harm are not the same.

Jonathan Fields: [00:14:38] Hurt and harm not the same. And that makes sense to me. Um.

Rachel Zoffness: [00:14:46] And also counterintuitive, right? Also a little confusing, right?

Jonathan Fields: [00:14:49] It’s a little of each. I want to ask you about something that you just mentioned in passing though, before we jump back into that, which is that you and I could be sitting at a table and I could slam my knee at the same force into the table. You could be sitting next to me, slam your knee into the table at the exact same force, and I’d be like, whatever. And you’d be like, double, double, or let’s reverse it. I’m the one who’s like doubled over. And you’re like, oh, I’m totally fine. Right? Um, so it sounds like also the way that we experience pain, like the exact same circumstance, if you take any two people or ten people, they would report probably very and say the same circumstance and even the same level of damage or lack of damage. Right? And they might report one person would tell you it’s a one out of ten or are non-existent, and the other might say it’s a seven out of ten.

Rachel Zoffness: [00:15:43] Exactly.

Jonathan Fields: [00:15:44] So it’s wildly subjective also.

Rachel Zoffness: [00:15:46] Pain is subjective. And I want to tell you what’s happening and why. Because I think it’s so fascinating that you can take ten people with the exact same injury, and they will all give you a different pain number. By the way, I like to talk about things I like. I use a lot of analogies because pain science really is extremely complicated, and I am distilling down these very complex concepts for a reason. Like, I think everyone deserves to understand pain. I said at the beginning, no one will escape. Like, why has no one ever explained pain to us? You have had pain. I have had pain. No one tells us how it works. No one’s even telling our doctors how it works. Why is that okay? So the way I like to talk about pain is just as there’s a recipe for brownies, there is always a recipe for pain. And we used this word biopsychosocial. And in your pain recipe, There are always biological, psychological and social ingredients combining in different combinations in every single minute of your day that are influencing the pain you feel. So yes, of course, tissue damage matters. And also, if you remember we said sleep, diet, movement, emotions, the things you’re thinking, how you’re feeling, who you’re with, your history of trauma, those all go into your pain recipes.

Rachel Zoffness: [00:17:09] So like, you know, anyone who likes to cook or bake. I am not one of those people, but I’m sure some of your listeners are. Anyone who likes to cook or bake will tell you that if you want really good brownies, you need to add certain ingredients in a particular order and bake them in a pan of a particular size for a certain amount of time at a certain temperature. If you want good brownies. Like different ingredients will give you a different outcome. The same is true for pain. So all the ingredients going into your pain recipe in that moment that you bash your knee are going to be different than the ingredients in my pain recipe. In that moment that I bash my knee, my emotions are different. My history is different. My body is different. My genetics are different, right? So that’s why when you line up ten people, they will all give you a different pain number, even if the injury is exactly the same.

Jonathan Fields: [00:18:03] I mean, that makes sense to me. And it also probably makes sense that even with the same individual at any given time, they’re going to have very different experience. I’m somebody who’s been told numerous times over the course of my life that I have a very high pain threshold. What’s going on there?

Rachel Zoffness: [00:18:20] Yeah. Right. So, um, you’ll, you’ll hear me continually talking about these different concepts. So, right. So pain recipe, one of the ingredients in the pain recipe that I find so compelling is there, of course is a genetic component. So I mentioned that pain is processed by our brain and our nervous system. And especially when we have chronic pain, it’s a disease of the central nervous system. Like our brain and our nervous system are misfiring. But one of the ingredients in every pain recipe is this sensitivity to pain. And what do I mean by that? Right? Your nervous system, like you said, can either have a very high threshold or low threshold or anywhere in between. And what we know is that there’s been all this research on our sensitivity to sensory stimuli. And some people, like everything else to do with human’s sensitivity exists on a spectrum. So some of us have a highly sensitive nervous system. It’s like a quarter of humans have what’s called a very highly sensitive nervous system. And you know, some of us are low sensitivity. So one of the ingredients in your recipe is that your nervous system is not particularly sensitive to pain. So it doesn’t mean you don’t have pain, although that is a thing. And people who don’t have pain don’t live very long because pain is our body’s warning system. And if you put your hand on a hot stove and the skin melts off and your body doesn’t tell you, you are not going to survive very long. But so your threshold is higher because your sensitivity is a little bit lower. Does that make sense the way I said that?

Jonathan Fields: [00:19:56] Yeah it does. And it’s funny as you’re describing that it makes a lot of sense. And I’m also thinking, um, I seem to have a very high tolerance for physical pain. Um, and I cry at emotional experiences really easily. Sure. And we’ll be right back after a word from our sponsors. All right. So, so if we accept that, right. And let’s kind of drop back into this model that we’re talking about, um, one is biomedical. So there’s something going on that literally we can point to in our bodies. It may or may not be related to harm that we can identify or damage that we can identify. But there’s something, maybe it’s illness, maybe it’s something acute, right? Um, and then there’s the, the psych, the psych part of it, the psychological part of it, um, and the social or the environmental. Um, let’s talk about the psychological part of it because.

Rachel Zoffness: [00:20:50] Yeah.

Jonathan Fields: [00:20:50] That’s, I feel like this is the part also where we all kind of intuitively know this is at play and we all also have that thing, that line that we some, some version of like, oh, it’s all in your head or it’s psychosomatic and it’s always used as a pejorative. Take me deeper into this.

Rachel Zoffness: [00:21:09] Yeah. There’s so many things to say about this, but I want to quickly say this word somatic has become a bad word in medicine. And maybe after this podcast airs, some nice kind doctors can tell us why somatic has become a bad word in medicine. I’m going to tell you what somatic means. Soma literally means of the body and every emotion we have, like emotions don’t just live in our heads. Emotions are physical. When we are anxious, our heart rate goes up, our palms get sweaty. Our mouth gets dry. When we are sad, salt water leaks from our face. Every emotion we have triggers a biological cascade of events in the human body. There are changes in neurotransmitters, in hormones, our endocrine system, our musculoskeletal system. We all know when we’re stressed, our muscles get tense, which, by the way, is bad for pain. Like there’s so many things that emotions do. Emotions are physical. And if emotions are physical, you bet your ass they are related to pain, right? Like we know that stress and anxiety and depression amplify the brain’s pain alarm. We know stress and anxiety tenses. Our muscles and chronic stress can tank our immune system. And what’s happening in medicine is that we’re not addressing emotions as part of the pain recipe, which is so crazy to me. Like it’s been known for a very long time that physical pain and emotional pain share real estate in the brain, but we’re separating it out so profoundly that people with chronic pain are being stigmatized and marginalized, often as mentally ill. So there’s this statistic that I find so compelling, which is that 85%, up to 85% of people living with chronic pain have been diagnosed with clinical depression.

Rachel Zoffness: [00:23:13] And, and to me, that’s a real red flag. And I want to be careful and say why? Um, yes, of course, mental illness can co-occur with chronic pain, but what we are telling people with pain is that it’s not normal to experience depression when we live with chronic pain. And I want to clearly say for anyone listening who does have chronic pain, it is absolutely, positively normal and not pathological to experience anxiety and depression when we have pain. Why? Because the human body was not built to be in pain day in and day out for months and years on end. You bet that when you are in pain all day, every day, things have been taken away from you. Like chronic pain is a thief. It steals your ability to work, to go outside, to exercise, to play with your kids on the floor. Sometimes to have sex with your partner. Like if you’re not anxious and stressed about tomorrow or the next procedure, or whether you’ll get better if you’re not feeling grief and sadness about the loss and everything that’s been taken from you, then like, maybe you’re a robot. Of course you feel stressed. Of course you feel sad. So yes, a lot of people are told that pain is all in their head. And that does happen to women and minorities in particular, just to say. But that is not true. Just as pain is never purely physical, it is also never purely emotional. It’s always biopsychosocial. Always, always, always.

Jonathan Fields: [00:24:53] So that that takes us deep into sort of like emotions. What about the other parts? Things like our thoughts, our expectations, our beliefs.

Rachel Zoffness: [00:25:09] Yeah. So, um, I remember when I first started studying pain neuroscience, I was a little undergrad nerd at Brown University, and I was lucky enough to be working with a neuroscientist there. And, you know, it made sense to me intuitively that pain was biological, but this concept, that pain was cognitive was a bit confusing. So let’s talk for a moment about thoughts. So we set about emotions that emotions trigger a biological cascade of events in the body. The same is true for thoughts. Every thought you think changes your physiology. And I’m going to prove that to you with a story. So when I was first treating pain, I had a colleague ask me, do you treat patients using biofeedback? And I was like, what’s biofeedback? If I don’t know what that is, then I’m not going to recommend it to my patients. So I went down the rabbit hole. I read everything I could about biofeedback, and I promise I’ll tell you what this is. And you know, people with chronic pain consider using it as a treatment. It has a lot of evidence. So I went to find me a biofeedback provider. His name was doctor Pepper, which is a great name for any doctor.

Jonathan Fields: [00:26:24] I actually know who he is.

Rachel Zoffness: [00:26:26] Oh my gosh, you don’t really I do.

Jonathan Fields: [00:26:28] Yeah, I’m I’m on his email. I followed his yeah.

Rachel Zoffness: [00:26:33] My head’s exploding. He has become an actually a very dear friend of mine and consulted on the book. Tell Me Where it Hurts, which is one of the reasons I’m here today. And the story is also in the book. So doctor Pepper sat me in a chair and he said, I’m going to teach you to warm your hands to 90 degrees. And I said, listen, doctor Pepper, I studied neuroscience and I don’t really believe in magic, but like, do your best. So he hooked me up to a machine that was providing feedback about my biological processes, these unconscious biological processes. So the machine was reading skin temperature and muscle tension and heart rate. You know, things over which we don’t typically think we have much control. And he sat me in the chair and he said, I want you to think about some stressful things. So very easy for me to do. My brain generated a list of like my to do list and, you know, bills that needed to get paid and some public speaking that I needed to do. I am not a natural public speaker. I get very nervous. And, you know, my some patients that were really struggling. And as I was watching the machine, here’s what was happening. My hand temperature, my finger temperature was plummeting, my heart rate was going up and my muscle tension was spiking.

Rachel Zoffness: [00:27:56] The thoughts in my head were changing my physiology. Now, if I were not hooked up to that biofeedback machine, I would not have been getting feedback in real time about these biological processes. So you could say to me, your thoughts affect your body. And I would be like, yeah, yeah. But when you’re doing biofeedback, you really see it happening in real time. Then he said, close your eyes. And he guided me through a relaxation protocol. So I used diaphragmatic breathing and guided visualization. And we did some autogenic training where I said some things to myself to help my body relax. And when I opened my eyes, here’s what I saw on the biofeedback machine. Muscle tension had gone way down. Heart rate had slowed and my hands were warm. So the moral of the story? We should be paying attention to the thoughts we think. Because the thoughts we think change our pain. And people in pain are often told that there’s no treatment for chronic pain. Like if you Google, you know, treatment for fibromyalgia, you will be told that there is no treatment, there is no cure. Fibromyalgia isn’t curable. That is a load of poop like that is absolutely not true.

Rachel Zoffness: [00:29:20] We actually know the treatment for chronic pain. It’s a biopsychosocial recipe. Like, I want to look at your high pain recipe, and I’m going to help you figure out your low pain recipe. And I mentioned this recipe concept before. So a high pain recipe is all of the ingredients that go into making a bad pain day. So like for me, it’s sitting in my chair for too long staring at my computer. It’s not going outside or exercising. It’s being isolated. It’s having a pile of stressors and not setting boundaries around my time. There are there are all these high paying ingredients that are hijacking my pain system. The cool thing about this pain recipe concept is that just as there’s a recipe for high pain, there is always a recipe for low pain. So for me, I know I can’t sit at my computer all day. I have to go outside and go for a walk. I know that poor sleep increases pain, so I’m going to use sleep hygiene. I know that you asked about thoughts. I know that if I get trapped into these cycles of thinking negative thoughts, predicting terrible things. I know my pain volume will be higher. So all of these ingredients matter, including our thoughts.

Jonathan Fields: [00:30:36] I’m really curious also about the expectations side of this, which I guess is a subcategory of thoughts. Um, you know, and what pops into my mind is you’re in a scenario where you’re doing something, um, and you have an onset of pain, like back pain slowly starts to build when you’re doing this thing, right. And then you’re doing it again the next week and you notice back pain is starting to build when you’re doing this thing and you do it a third week. Yeah. And then your brain probably starts to expect when I do X, I’m going to experience Y when I do the thing I was doing, when I experience back pain, I’m going to feel pain. Um, how much does that expectation contribute to the actual continued experience of pain, if at all.

Rachel Zoffness: [00:31:22] Oh, absolutely. Expectations, like you said, are a category of thought and thoughts change our bodies. So let’s go sort of high level for a moment and talk about expectations and predictions. So our brain is a prediction machine. Our brain is a prediction machine. Predictions matter a lot when it comes to the experience of pain. So everyone, for example, has heard of the placebo effect. What is the placebo effect? It’s it’s really easy to believe, and we’ve all actually been told that the placebo effect is sort of like a placebo is a nothing. It’s a sugar pill, right? So in medicine, if a medication is no better than placebo, it’s discarded as useless. But a placebo is the opposite of nothing. A placebo is when your expectations and predictions make pain volume go down. So if I’m a credible healthcare provider or I’m a credible source and I hand you a sugar pill and you don’t know it’s a sugar pill, and I say to you, Jonathan, this is the most potent, powerful painkiller ever made. You can expect that in, you know, five hours, your pain will go down. Here’s what happens as a result when the placebo effect kicks in. What’s happening is that your brain is bumping out endogenous homemade opioids and your pain is actually going down. The placebo is not nothing. The placebo is when our thoughts and our expectations and our predictions trigger neurobiological events in the brain and body that actually change pain volume. So, so, you know, we think of these things as completely disconnected, but predictions absolutely change pain.

Jonathan Fields: [00:33:21] I mean, that makes a lot of sense to me. Um, and I guess there’s the placebo and then there’s also the nocebo, which probably fewer people have heard about, but also plays into this.

Rachel Zoffness: [00:33:33] Yeah. So the nocebo effect I actually learned about as I started learning about pain, because the nocebo effect plays such a powerful role here. And I want to say what it is. So we know a placebo effect has, um, a salubrious good effect on our health. A nocebo effect does the opposite. It comes from the word nocere, which means to harm. So a nocebo effect is when we are given, you know, messages from the outside world, sometimes from the internet, sometimes from healthcare providers, sometimes from well-intentioned family members, that bad things are going to happen. We should predict and expect bad outcomes. So like I mentioned before, fibromyalgia. If you go online, you will find the internet will tell you fibromyalgia has no cure. That is a nocebo. If it inspires negative predictions and it makes you feel afraid and pessimistic, it’s absolutely going to hijack pain volume in the brain. That is something that’s been known for a long time. Can I tell you a quick nocebo story that I think will illustrate this point? So, you know, for this book, tell me where it hurts. I did so much research, and one of the papers that I read was about the nocebo effect on a gentleman that they called.

Rachel Zoffness: [00:34:57] And this this was in a medical journal and they called him Mr. A so I’m going to call him Mr. A also. Mr.. A walked into the emergency room with an empty bottle of pills and he said, help me, help me. I’ve taken all my pills. And he fell to the floor and dropped the pill bottle and he was rushed in for an assessment and his blood pressure had bottomed out and his heart rate was spiking, and he was clammy and pasty and pale and they were worried. The doctors were worried they were going to lose him. And so of course, when they did their assessment, they did a bunch of blood tests and other assessments, and everyone was absolutely gobsmacked to discover when the results came back that Mr. A had absolutely no drugs in his bloodstream, what had happened? Mr.. A was part of a study, a clinical trial at a university where they were examining the effects of an antidepressant. And he had been given a bottle of pills and his girlfriend had broken up with him, and he had swallowed the entire bottle of pills, intending to commit suicide. His brain expected and predicted that those sugar pills were poison.

Rachel Zoffness: [00:36:13] And so he had a real physiological response. But when the doctors who were assessing him reached out to the university and the doctors who had prescribed this prescription bottle, they discovered that Mr. A had been randomized into the placebo arm of the trial, meaning that every single pill in that pill bottle was a sugar pill. And as soon as they told Mr. A that he had taken a placebo, within 15 minutes, all of his symptoms were gone, and he got up and he went home. Our expectations and our predictions profoundly change our physiology all of the time. So if you’re someone living with pain and you come to my office, I’m going to ask you your pain story. I want to know what you’re predicting about your body. Are you never going to get better? Have you been given messages that are dangerous for your nervous system and are amplifying your pain alarm because I am going to explode those for you. I want to make sure you know that chronic pain is treatable, that everyone has a recipe and there’s a million ingredients, and there’s a million things we can do to lower your pain volume.

Jonathan Fields: [00:37:30] So if somebody walks in and let’s say somebody walks into the doctor, their health care provider or therapist, whoever it is, somebody who they view as a person with authority and credibility and they trust what they tell them. And that person says, um, because of this thing, you are going to experience pain. Um, that’s basically setting the person up to experience pain, whether their system was really primed for it or not.

Rachel Zoffness: [00:37:59] It’s true. And I want to say, you know, it’s a really careful dance. I’m a health care provider also. And it’s a, it’s a really careful dance because, you know, we want to be honest and we don’t want to lie to our patients. Like, I’m not going to pretend that this is going to feel good. But you know, we don’t want to set expectations and predictions up for Nocivos. We do not want to be saying things like, you’re going to be in pain forever, or you have the back of an 80 year old or, you know, there’s just there’s so many nocivos out there. I actually, as I was writing this book, I, I went through a lot of my notes from former patients and I wrote down so many nocebo that they had been told like, your pain is just due to damage. If you believe that your back pain is just due to your curved spine or your slipped disc, and that’s not treatable, for example, then you are going to continue to have pain because your pain story is that it’s just biomedical, it’s just physical. And you know, there’s this new not so new diagnosis in medicine that drives me crazy. Like if you have one back surgery and it doesn’t work for your pain, and then you have a second and then you have a third. You will be diagnosed with failed back surgery syndrome. Like as if the as if you failed the treatment instead of the other way around. Like the treatment failed you. You didn’t fail anything. Like you get a label. And of course, the reason that treatments are failing us is because we continue to perpetuate this myth that your pain is just due to spinal spinal cord abnormalities. You know, it’s just due to physical problems. And we know that’s not true.

Jonathan Fields: [00:39:41] Yeah. I mean, it can be contributing to it, but there’s so much.

Rachel Zoffness: [00:39:44] Exactly.

Jonathan Fields: [00:39:45] Exactly.

Rachel Zoffness: [00:39:46] Right. Right. And we heard the story about Usain Bolt with his extremely twisted spine and his extremely abnormal, you know, asymmetrical body and very little pain. The fastest man alive is one of the most asymmetrical, you know, people on the planet with an extremely abnormal spine. You know.

Jonathan Fields: [00:40:06] Imagine if he had been told at a young age because of your spine. It’s definitive. You will be in pain and potentially seriously disabled for the rest of your life. You’ll never be able to walk, let alone run. Um, it’s wild what that messaging can do. But also, I want to acknowledge the dance that you were saying. You know, on the one hand, you don’t want to do that to a patient, but at the same time, you do want to acknowledge the fact that maybe there’s something very real going on. Like maybe some, you know, if somebody is going through, if somebody is diagnosed with cancer and they need to go through some treatments where there’s a very clear like history of it being incredibly unpleasant or painful, um, you also don’t want to just sugarcoat it and say, oh, you’ll sell through, you’ll feel nothing. Don’t worry about it because then they’ll never trust you again.

Rachel Zoffness: [00:41:00] You bring up a very important point. So I want to say this clearly there is always a bio component to pain. Like the bio component of pain is genetics, tissue damage, system dysfunction. Those things matter. But what we know about chronic pain is that the link between hurt and harm is significantly, yes, less strong. So like if you have an acute pain episode, like you go for a run and you have leg pain, I want you to stop running. I want you to go to the doctor. I want you to check it out. If you have chronic pain, I don’t want you resting forever waiting for the pain to go away because this is a central nervous system problem. So yes, I if someone comes to me with pain and they haven’t had all the tests and the scans and the blood tests and assessments, I’m going to send them for those tests because I want to know the biological ingredients that are contributing. So I don’t for a second believe that pain is just emotional. Like that is absolutely not true. Damage matters and it matters a lot.

Jonathan Fields: [00:42:03] So let’s talk about that third part of the big word that we explored earlier in the conversation. Right? And it’s the, the social, the, the connection element to it, the thing that is beyond the physical and beyond the psychological, emotional. Take me into that part.

Rachel Zoffness: [00:42:19] Yeah. Okay. So, um, pain is always social. And, and I think it’s really important for us to think about what that means. So among the worst punishments you can give a human being, it’s not prison. If you mess up in prison, you are thrown in solitary confinement. You are cut off from all communication and connection with others. Like, what does it say about us as human beings that one of the worst things you can do to us is isolate us from others? Human beings were designed evolutionarily to be social. In fact, social behavior is so fundamental to our survival that our brains evolved a mechanism to reward us for engaging in it. When we are social, our brains Produce feel good chemicals like dopamine, which is, you know, reward and pleasure and motivation. Our brains produce serotonin, also a mood booster, and they produce endorphins, which are our brain’s naturally occurring opioids. When we are social, we feel better not just emotionally, but also physically and in the absence of others. All of those chemicals crash. Serotonin, dopamine, endorphins are opioids. They all go down. So social behavior affects our physical body. And Vivek Murthy, he was our, you know, surgeon general a couple of years back, I think it was 2023. And he did this big review, this big report, and it showed that isolation and loneliness were as detrimental to human health as smoking 15 cigarettes a day, like they predicted disease, like actual physical diseases and even premature death, like we forget. We forget that social behavior is a critical part of our pain recipe. So when I have patients, I want to know, do you have social support? Are your relationships healthy or are they toxic because your social relationships are actually impacting pain volume in your brain and they’re affecting your physical body?

Jonathan Fields: [00:44:35] Mhm. And I think a lot of us know that intuitively, you know, but to basically look and say, okay, so science actually validates this. It’s a part of the quote recipe that you’ve referenced a number of times. So let’s say somebody’s been joining us for this whole conversation. They’re kind of nodding along, saying, this all makes sense. Um, but what do I do with this information? Like I’m in chronic pain. I’ve been in chronic pain for a long time. I’ve seen the 762 people that you referenced Later. Maybe more, maybe less. Um, I’m still in the same shape that I’m in. How do I take all of this new knowledge and feel better?

Rachel Zoffness: [00:45:12] Right? Um, so I think I mentioned that I’m a nerd and I’ve been studying pain science for more than 30 years, and the reason I started studying pain was because I was scared of it. And I believe that knowledge is power. That’s actually why I wrote Tell Me Where It Hurts. I want power in the hands of everyone living with pain and by everyone living with pain, I mean every single person listening because nobody will escape. Pain is coming for all of us in one form or another. So pain education, learning about the science of pain isn’t as complicated as you think. If nothing else, I can help you put together a basic pain recipe. I can help you figure out your high pain ingredients, and once I know your high pain ingredients. I can help you map out your low pain ingredients, like if high. If really poor sleep is hijacking your pain recipe, I can help you put together a sleep hygiene protocol that is in the book. If nutrition is poor, we can look at your nutrition and help fuel your body for less pain and less inflammation. Less inflammation. If you are stuck at home, stuck inside, and stuck in bed, I am going to help you put together a pacing protocol.

Rachel Zoffness: [00:46:33] What is a pacing protocol? You know, just as you would pace for a marathon, I want you to pace for pain. I don’t want you getting out of bed. Like if you want to run a marathon, I am not going to ask you to run 26 miles tomorrow. That would be a bad idea. You know, you’re going to gradually increase your activity. The same is true for pain. So we can put together a pacing protocol for whatever activity it is that you want to do. Like I have patients who want to go back to playing soccer, or they want to go back to Irish dance, or they want to go back to fudge making. Like it doesn’t matter what that activity is. A pacing protocol helps you gradually get back to life. So, you know, I want to say clearly there is so much hope for treating pain. There are so many things we can do beyond pills and procedures. And like, yes, those help. But for a lot of people, it’s just not enough.

Jonathan Fields: [00:47:28] Mm. That feels like it’s a good place for us to come full circle as well. So I always wrap up the same question in this container of Good Life Project.. If I offer up the phrase to live a good life, what comes up?

Rachel Zoffness: [00:47:41] If we think about living a good life, pain is of course, a part of life. And I am not suggesting that we have zero pain. Pain is an important message that tells us that our body is out of balance, or something is wrong and something needs to change. But to live a good life, I want us to be thinking about bio ingredients and psych ingredients and social ingredients. I want us to be thinking about a whole person problem that requires a whole person solution. So we’re going to look at sleep hygiene. We’re going to think about our nutrition. We’re going to go outside and get some sunlight and move our bodies. We’re going to reach out to friends, especially healthy relationships. We’re going to treat our trauma. We’re going to take care of our emotions. Like in my mind, the recipe for treating pain is just helping our bodies get back into balance and helping us feel more healthy and more whole.

Jonathan Fields: [00:48:40] Thank you. Hey, before you leave, be sure to tune in next week for our conversation with Doctor Amir Levine about the tiny moments in your relationships that are secretly shaping your confidence, your sense of meaning, and how safe you feel in the world. Be sure to follow Good Life Project wherever you get your podcasts so you don’t miss any upcoming episodes. This episode of Good Life Project was produced by executive producers Lindsey Fox and me, Jonathan Fields. Editing help by Alejandro Ramirez and Troy Young. Kris Carter crafted our theme music. And of course, if you haven’t already done so, please go ahead and follow Good Life Project. wherever you get your podcasts. If you found this conversation interesting or valuable and inspiring, chances are you did because you’re still here. Do me a personal favor. A seven-second favor and share it with just one person. If you want to share it with more. Hey, that’s awesome. But just one person even then, invite them to talk with you about what you both discovered to reconnect and explore ideas that really matter. Because that’s how we all come alive together. Until next time. I’m Jonathan Fields signing off for Good Life Project.

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