Instant Genius - The science of pain, with Dr Monty Lyman

Episode Date: July 18, 2021

Dr Monty Lyman, author of The Painful Truth, tells us what pain really is, how the placebo effect works, and why our emotions have a huge effect on the pain we feel. Once you’ve mastered the basics with Instant Genius, dive deeper with Instant Genius Extra, where you’ll find longer, richer discussions about the most exciting ideas in the world of science and technology. Only available on Apple Podcasts. Produced by the team behind BBC Science Focus Magazine. Visit our website: sciencefocus.com Hosted on Acast. See acast.com/privacy for more information. Learn more about your ad choices. Visit podcastchoices.com/adchoices

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combine handcrafted tradition with cutting-edge innovation and high-end materials, delivering digital precision with analogue warmth. So you can experience exceptional sound at home. Music just as the artist intended. Visit name audio.com to learn more. Hello and welcome to Instant Genius, a bite-sized masterclass in podcast form. I'm Sarah Rigby, online assistant at BBC Science Focus magazine. In this episode, I talk to Dr. Monty Lyman, author of the new book, The Painful Truth.

He tells me all about what pain really is, how the placebo effect works, and why our emotions have a huge effect on the pain we feel. So first of all, could you please just explain what your book, is about? Sure. It's about pain and it's about pain in general, but it has more of a focus on chronic pain, also known as persistent pain, because I believe that's something we really don't understand very well, yet it affects so many, so many people. So just understanding what pain is and the science behind it, looking at why sometimes pain persists, even once a tissue injury is healed and how we can deal with that on the individual level and as a society.

If you'd asked me before I'd read your book to define pain, I probably would have said something like it's a sore, unpleasant feeling that you get when you've injured yourself. But now that I've read your book, I know that's not quite right. So what is pain if it's not just a reaction to an injury? I mean, you've hit on the million-dollar question. You know, we all know pain when we feel it. That's sort of defined. Finding it has been really tricky, and a lot of scientists and clinicians have been in logaheads and in arguments at international conferences for years and years and years as to what pain is. But at its heart, it's very simple. So I'll tell you the official definition of pain, which is by the International Association of the Study of Pain, which was updated last year, which is that pain is an unpleasant, sensory and emotional.

experience associated with actual or potential tissue damage. So that sounds quite dry. My definition of pain is it's a horrible feeling that urges us to protect a body part. And it's really interesting that it's very close to what you said at the beginning. But I think the key thing about pain is that actually most of us and I'm including a lot of doctors and the medical profession misunderstand pain. And I call this the painful untruth, which is that pain is an accurate detector of tissue injury. Actually, the painful truth,

which is one of the main takeaway is probably the main takeaway from my book, is that pain is a protector. So it's a protective mechanism, not an accurate detector of tissue injury. And now you might say, well, you know, well, you know, if I, you know, slam my laptop on my thumb, it hurts. And then if I slam it in a car door, it hurts even more. Surely that, you know, there's a relationship between injury and pain. And of course,

of course it is. But that's fundamentally not what it is. And it's, in many cases, the brain essentially learns pain. Pain can essentially become etched on the brain. So most people living with chronic, otherwise it was a persistent pain, whatever injury it happened at the beginning, has completely healed. But the brain is completely remembered. pain. And I didn't plan to write a book on pain. I think it came to me when I realized the huge issue, the huge problem that we have with pain as a society, and it all comes down to this misunderstanding. I first realized this in my first year as a junior doctor, and I was on an acute medical ward chasing after my consultant, scribbling notes that would record what he said when

he would see all of the new patients that day. So we'd decide whether the patient who'd come in from A&E would go to a ward and stay overnight or whether they'd be discharged home. And at the end of a long day, we came to Paul, not his real name, who was an IT worker in his 40s. And he'd had a lower back pain for about a year. It started, he said it was due to sort of conced out office chair. And then over the months, it began to sort of spread across both sides of his lower back, become more persistent and more intense.

So he stopped playing golf and then he stopped seeing his friends. And then he basically never left the house. Alongside that, he had gone through divorce proceedings with his wife as well. And there were lots of other stresses in his life. But on that morning, on that day, he was in so much pain, lower back pain, that he couldn't get out of bed. And he got his son to take him to A&E. He had blood tests and an MRI scan, all of which were normal.

So I went to his bedside and the consultant looked through the notes and said, said I said to Paul, the good news is there's nothing physically wrong with you. To which Paul said, still clutching his lower back, are you saying it's all in my head? And so as Paul was sent home with some painkillers, but he left not knowing what his pain was. Was it caused by some kind of tissue injury that no one could detect with scans or blood tests or anything? Or was it sort of all in his head? Was it a sort of, you know, a thought disorder that he can just think away? was he imagining it?

And I realize that both of those two things are wrong. Pain is not simply a measure of tissue injury, but it's not figment of your imagination, and it's not a thought disorder. And that is what the modern science of pain is revealing. And I think understanding that pain is a protective mechanism, is your brain's unconscious opinion of whether your body is in danger.

I think understanding that is key, and it also helps to break down this divide that we have in Western medicine, that something is either physical, it's in your body, or it's mental, but actually things can be in your brain and affecting your mind and body, and they can be completely real. And I think understanding that, we're a long way to go to understanding that. But understanding that, I believe, is the key to healing as well in terms of chronic pain. So when you talk about the idea of pain being all in your head or, you know, not caused by a physical injury, the word that comes to mind for me is psychosomatic. Is that right? Is that the

word that describes it? Yes. I think definitely that's one way of putting it. I think just understanding that yeah, the mind and body are hugely, hugely interlinked. And it's a false dichotomy saying that you know, something's either in your mind, or in your body. What could cause psychosomatic pain? Well, yeah, that's a really good question. And I think essentially short-term pain is protective. All pain tries to protect us. But say you stub your toe, you get a message. electrical signals that go up from the receptors on the skin of your toe to your spinal cord, they then travel across a microscopic space called a synapse to the next nerve, and then that goes up the spine and then into the brain. But those aren't pain signals. There's no such thing as

a pain signal or a pain receptor. They are danger signals and danger receptors. The sort of medical word for that is no seception, no susceptors. So that signal travels up to the brain, and the brain has to decide, is this a threat to me? And if it thinks it's, if, If the brain thinks that there's something happening in the foot and thinks that it's dangerous, it will create pain. And now this sort of psychosomatic pain in a sense, which I think, I think, yes, definitely one way of putting it, but I like to think that chronic pain or persistent pain is the same thing,

pain that persists longer than the period of tissue injury. So that's usually for three months, but it can vary. But basically, sometimes pain can become wired on the brain. So the brain and the brain learns to create pain. So if you have some, say, pain in your lower back, say, look at lower back pain and you have a twinge in one of your back muscles, you might think, do I have a slip disc? Is my spine damaged?

And the brain wants to protect you, so it really wants to protect your spine. And now even when that muscle injury heals and heals completely, the persistent danger signals, going to the brain, combined with the fear of damage, to yourself, combined with lots of other things, including inflammation, which is a really, really interesting area as well. Essentially, they can make the signals across those little synaps, synapses, those little gaps between the nerves, can essentially amplify the pain. Two ways we see this are in hyperalgesia, which is where something that causes pain causes even more pain.

So, for example, if you stub your toe going into a house, it's a bit painful. And then a few minutes later, if you stub your toe on the same object, leaving the house, even though there's the same amount of force, the pain will be more because there's, the pain has been sort of the, the threshold for pain is increased. And then there's something called allodynia, which is feeling pain in sensations where you don't usually feel pain. The classic example could be sunburn, where, you know, being touched after a sunburn is painful or even a sort of warm shower feels like a sort of torrent of lava. And that's called sensitization. And that process can, in some people and many people, convert this protective short-term pain into long-term pain.

So even once an injury, say that lower back pain I was talking about is healed, it can be essentially wired into the brain. And that is still completely real. It's neurological. We think it's, for example, epilepsy, that's all in the brain, but everyone thinks of it as being completely real. chronic pain is often a disease in and of itself. Even when there's no injury, there is severe pain. There can be severe pain. And then dealing with that is very different to dealing with short-term injury. So often short-term pain.

So often short-term pain associated with injuries responds really well to what we call pain killers, I preferable than pain relievers, to things like morphine, if it's severe and paracetam and things like that. But actually, once pain has become written on the brain, and once the brain has learned pain, there are basically no medications that can really, really treat that. And the types of treatments and therapies that people need, once they have chronic pain, are very different.

What sort of treatments can you give? I like to think of it as any treatment that works is one that makes the brain feel safe in its body. And you can think of chronic pain or persistent pain as a sort of an equation in a sense. So anything that increases, is any cues that increase the sense of threat increases and worsens pain. Anything that increases the sense of safety reduces long-term pain.

And I believe the best thing, the first thing that people need to do, or in terms of clinics that need to be available to patients, is pain education. Once people understand that pain is a protector and not just, just a detector of tissue injury, once they know that hurt doesn't equal harm and they are safe to move and that even when they're moving and they're in pain, that they're not damaging themselves, that is huge, that is completely liberating. I think that's the key to living with, reducing and even eliminating chronic pain. And so that's the main one. And then and then from that there are things like movement and physical therapy and things that can reduce inflammation as well,

anything that reduces stress. And also, I think there are, huge social elements to chronic pain as well that need to be dealt with on an individual but also a social social level but when it comes down to it it's it's therapies that make the brain feel safe in its body right i see you mentioned pain relievers there how do pain relievers work how do they stop when i've got um say i've got a headache or i've hurt myself how does a pain reliever stop that from hurting and how does it know where in the body to go that's that's a great question And there are different types of pain relievers. There are anti-inflammatories.

I think of something like I'm ibuprofen or something like that, which essentially when you injure yourself, you have an immune response and inflammatory response, that worsens pain, but also danger receptors. They can increase and create inflammation as well. So inflammation and pain are both protective mechanisms, and they both work to look after our body. Anti-inflammatories work on reducing the inflammation, often at the site of the injury. Then there are some that, so the opioids, the opioid class, which includes, and they come from the opium poppy, which humans have been using and abusing for millennia from which we get heroin, but also morphine and. essentially all other opioids like oxocodone and fentanyl. They work on the danger detector,

or the danger receptors and the nerves that convey the danger signals, and they can dampen it down. But a really interesting thing with opioids is that they are absolutely magical in short-term pain, you know, being in an A&E and on surgical wards and see them be incredibly effective. but the evidence shows that they're really good for short-term pain, but they're actually not very good at all for chronic pain, long-term pain. And actually, in some cases, they can cause something called opioids-intused hyperalgesia,

so they can actually worsen pain. And this is a really interesting area that's only been sort of really explored in the last few years. And it seems that the opioids, as well as acting on receptors that reduce these danger signals, They also activate immune receptors on the cells around our nerves, and so that our body can actually see this molecule as something that's foreign and can become inflamed. And that inflammation can actually make it easier for those danger signals to reach the brain and for people to feel pain.

So actually, in the long run, opioids don't really work for long-term pain. And then there are other types of painkillers, things like, gabapentin and pre-gabalin. And it also affects the sort of the dampening down those, those danger signals. And they're usually used for something called neuropathic pain, which is when there's usually damage to a nerve. And there are sort of lots and lots of danger signals being sent up to the brain. So there are lots of different types of, of pain relievers. But actually, in terms of long-term pain, they're not very effective at all. When I have a headache or a migraine, I always take ibuprofen because I want to

notice that paracetamol didn't work as well. And then eventually I decided that it didn't do, paracetamol didn't do anything at all when I had a migraine. Do you think that I may be causing a sort of the opposite of a placebo effect in there when I expect paracetamol not to work? And so it doesn't work. Definitely. I think the word expect is brilliant. I think the placebo effect should be called the expectation effect. And with that is something called the nocebo effect, the opposite of the placebo effect where you believe that something's not going to work or something's going to damage you and then it does. I think one of the most fascinating studies that gives you an insight into the placebo effect was one done in 2011 by Irene Tracy's team in Oxford, where they had people

hooked up to a drip and they had experimental heat exposed on their hands, so causing pain. And they started an infusion of fentanyl, which is a powerful opioid. And initially they start the infusion without telling them, and then they reported their pain to improve a bit, which isn't surprising because opioids reduce pain. But then the experimenter said, okay, we're about to start the infusion now, even though the infusion had already started, and the pain relief doubled. Then what was really interesting is that the experimenter said, okay, we're going to stop the infusion now, but they didn't actually stop the infusion. But when they said we'll stop the infusion, the pain relief completely disappeared and they were back in pain,

right, so as though they were having no fentanyl at all. And that's absolutely fascinating because it's essentially a huge amount of pain is essentially what our brain is trying to predict what's going on and our expectations play a huge part in that. And I think that's, it's not just a sort of an interesting quirk. I think that plays a huge part in the sort of, say, the doctor-patient interaction. I think confident doctors who instill confidence and have a good rapport with their patients, that is medicine in and of itself. Because recent research has shown that the placebo effect is blocked. It doesn't work if you block, if you give someone an opioid blocker.

So our brain creates its own opioids. Endorphins, probably the most famous. And that's actually how the placebo effect work. And so the brain opens its own drug cabinet. So, you know, the placebo effect is powerful and it does work and it is useful. And when you were talking about taking this pills, I've heard of someone who takes a painkiller every morning. And he actually talks to his painkillers.

He says, are you guys going to do great today? That kind of positivity that he has with them, that kind of ritual that he's created. All of that's doing is improving the creating, it sounds crazy. It's sort of, it's creating the cues that, okay, this is going to work. And then this opens up a fast,

you can go down a fascinating rabbit hole of, recent studies that have shown that placebo's work even though when you know that you're taking a placebo called the open label placebo. Because we thought, it makes sense that we assumed that deception was key for the placebo effect. But actually, that's not true at all.

I think that was, I've lived with really bad irritable bowel syndrome for as long as I can remember until, I mean, this is another story, until I was essentially cured of it via hypnosis. But years before that happened, I was sort of lying, sort of hunched over on the couch.

I couldn't get out. I couldn't stand up. The IBS was that bad. And I was staying over with some family members. And one of my family members, who I won't mention or give away their identity. They love homeopathy, which, you know, homeopathy, it only works fine with the placebo effect.

There's no, there's no mechanism that there's been proven at all to show that it works in any other way. So she said, okay, do you want to just try one of these tablets? And I was like, okay, fine. So I looked at the container with some kind of faux Latin name on it, and you knew it was I was just taking a sugar pill. But I took it anyway. And actually my IVS completely went away that day,

which completely terrified me. But then I started to look into some work that's been going on. And actually, there have been a number of studies that show that giving people prescivos, even when they're told that it's a placebo, it's inert, it doesn't do anything, can actually help a lot of different pain conditions. So it's a really fascinating and complex area. So should I be talking up my painkillers instead? This is definitely going to work.

I completely agree. What is the link between pain and emotions? So that's really interesting. I think when I was writing the book, people would say, are you going to write about emotional pain as well as physical pain? But actually, pain is not physical and it's not emotional. It's both of those things. They're hugely, hugely intertwined.

mind. There have been some fascinating cases where some people who have had damaged to certain areas of the emotional brain, who've experienced pain before, but when those areas are knocked out because of a stroke, they know that they're experiencing, they know that they're experiencing pain, but it's not painful. It's not unpleasant. And a lot of these people actually end up, have been found sort of driving, you know, needles into their eyes and damaging themselves, because there's just no aversion to, there's no sort of movement to wail or disgust or, or aversion to pain.

So you need, we need, pain is always, in the sense, always physical, but it's always emotional as well. And what's really interesting actually is someone I interviewed for the book, an Australian man called Evan, who's a remarkable man. He, in 2006, he got into the Australian SAS, which is one of the most highly regarded special forces regiments. And they were about to go to Afghanistan. And most of the army were just there to sort of build bridges,

physically and metaphorically, but he would be part of a team going behind enemy lines. And as part of that, they were given resistance to interrogation training, which is it's not meant to be torture, but it's meant to be very stressful. And he essentially, to cut a very long story short, he was abused and tortured by some of his own men

who for various reasons were they were pretty incompetent and they took a dislikeing to him. So for about 90 hours he was tortured. He was put in stress positions, naked in a cold, dank room. He had blaring music on and he had blacked out ski goals. He was also beaten up so much that he was bleeding from places that he didn't reach,

didn't know where the blood was coming from. But after that, after that episode, Evan left the army. And for a seven-year period, even though he sustained, didn't sustain any serious physical injuries, during the torture. He had terrible whole body pain for six, seven years. He took a lot of painkillers, none of them worked at all. He couldn't put boots on.

He couldn't get into a swimming pool that wasn't sort of bath temperature. He was just very hypersensitive to pain, even though there was no physical damage. And what's really interesting is that his pain only went away. Well, there were two things that reduced his pain. the first is that after six or seven years, or he had taken the Australian government to court, and he won, and they paid all of his extensive legal costs,

and they gave him reinstated his rank. And it was only after that that the pain actually lifted, as well as he did undergo some psychological therapy for post-traumatic stress disorder, called EMDR. And it was those things that reduced his pain. So I think, you know, for people who are living with chronic pain, I'd never say do CBT or something about your pain will go away.

But if we ignore the emotional element of pain at our peril and for anyone to be, to be able to live with chronic pain, being able to express emotions and deal with emotions is is completely, completely necessary. And that's why I think various psychological therapies are really important. As is dealing with social issues, I think, people who are oppressed in society. are more likely to have long-term pain. And all of those things that the torture is used on Evan, so things like fear, isolation, rejection, confusion, those things ramp pain up massively

and can cause and worse in chronic pain. Those are the same things that oppression in society can cause to people. So that's why actually pain is really interesting because it doesn't just look at the biological, it looks at the psychological and the social. And these things are really important. Evan's story is very tragic and very extreme, but most of us would experience a similar sort of ramping up of pain because of anxiety or other emotions. I was thinking about this and I thought, you know, when you see those videos online of a baby who's about to get their first jabs and the doctor's doing something silly and making them laugh so they don't notice, is that actually a way of reducing their pain?

It's not just to sort of take their mind off it. Oh, that's a really, really interesting point, actually, because I think needle phobia is something that, you know, I've had needle phobia for a while. And I think I just think I overthink things. And sometimes maybe I just want, I suspect, well, you know, the person giving me the injection is one of my more sort of incompetent friends

from medical school or something like that. But it's hugely important because if people develop needlephobia at a young age, they're less likely to have vaccinations, they're more likely for their children not to have vaccines, which as we know at the moment with the COVID-19 pandemic, it's hugely important. But also these people are less likely to give blood and various other things like that.

So actually, I think reducing anxiety in childhood as of vaccinations and injections is really, really crucial. And there are some really easy ways to do that. So if we look at what pain is, pain is to protector. Anything that increases the sense of threat worsens pain, anything that increases a sense of safety reduces pain. So, for example, if a child's having an injection, or if your child's having an injection or you're the caregiver,

have them sit up, give them a sense of that, you know, they're able to move. If they're sort of lying down and pinned down, that's really bad. You don't want to do that. If they can be hugged, depending on their age, if they can be breastfeeding or giving the sugary sweet or distracted, I think that's really key. and I think it's I think that that's just incredibly important I think one one important thing as well is to

is to not say things like oh I'm so sorry oh you know don't worry about it oh it's kind of you know you've got it's all about sort of being confident saying oh you've done really well that's also partly because you know our subconscious doesn't really register the word don't you don't worry if they don't worry like oh you'll worry about something what's wrong so actually um it's it's so if I'm you know, on the ward as a doctor and I'm assessing someone with the sort of an injured left arm, what I could do at the end of it is look at their right arm and say, oh, you know, how's your right arm doing? A fine, good, can you move it for me? Great. Even that kind of stuff is actually just gives them positive cues. And it's not, obviously, it's not, you know, the last thing you want to do is to say,

oh, this isn't going to hurt, we're not hurting. But confidence, I think, is a hugely important. And actually, that brings me to a really, yeah, really interesting, a fascinating study about the confidence of caregivers. So there was a study where they had two, so a wisdom tooth pain killer study where there were two groups of people who've just had their wisdom tooth removed. And both of those groups are split into having one of two treatments. So one half of, so one group, half of them are given fentanyl, given a really powerful opioid, which is great, and half are given a placebo. In the other group, half are given a placebo, but half are given not. And half are given Naloxone, which is a opioid blocker.

So that definitely shouldn't help with any kind of pain, the opposite of anything. So the dentists knew which patient they had. So they knew that the patient in front of them had a 50% either had a 50% chance of having this really good opioid or a placebo or that patient was the person who's not going to get any opioid, but they were going to have a receiver or this opioid blocker and the dentists weren't able to tell the patients what which group they were in. What was absolutely fascinating is for those in the placebo group of the 50% placebo or 50% opioid, their pain was reduced quite significantly.

But in the other group where the dentists knew that they were only going to get a placebo or the opioid blocker, their pain actually got worse. So those kind of subtle clues of a confident, clinician or not completely non-verbal cues of a confident clinician or a non-confident clinician either created pain or reduced it. And so I think I think that's hugely important. And I think you're completely right. I think anxiety and fear are the greatest fuels for the fire of pain. So I think there are some really practical things you can do with things like needlephobia. So what are the three things that you think we all should take away? Three things we all should know about pain.

That's really interesting. I think firstly is to understand that pain is a protector. Pain is trying to protect us, even if it's ruining our life with persistent chronic pain, understanding that pain is trying to protect us is crucial. The second thing I think is understanding that pain is real. So everyone's pain is real and we should take it really seriously and understand that it's, even if pain is completely made by the brain, it's not all in your head. And that's really key.

I think we need to understand that people are in pain. Third thing, I think, and I'm thinking about this more and more, I think, actually, is that pain should drive us to love. And it sounds a bit, you know, it sounds a little bit airy-fairy, but it's actually various strands of science are showing that if we love ourselves, if we are in pain, or we love others and support others who are in chronic pain, giving them our time, our love and our confidence. On the individual level, but also on a societal level,

I think that is hugely revolutionary and something we need to do as individuals and as a society. And it can really relieve pain. So I think the three things are to understand that pain is a protector, not an accurate detector of injury, that all pain is real and pain should drive us to love. Thank you for listening to this episode of Instant Genius. That was Dr. Monty Lyman.

If you want to know more, check out his book, The Painful Truth. Or, to hear him tell me about using hypnosis and virtual reality as pain relief, and the people who don't feel pain at all, head over to the Instant Genius Extra podcast. The summer issue of BBC Science Focus magazine is on sale this week. Pick up a copy in store or visit sciencefocus.com. This podcast is sponsored by name, audio and focal. The texture and emotional depth. of music can be lost through digital sources or poor signal.

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