The Liz Moody Podcast - The Science Of Pain: Natural Ways To Manage Chronic & Acute Pain + Hidden Causes With Dr. Rachel Zoffness

Episode Date: October 19, 2022

I’m so excited to welcome Dr. Rachel Zoffness to the podcast. Dr. Zoffness is a leading global pain expert who is working to revolutionize the way we understand and treat pain—she’s a pain and health psychologist, lecturer at Stanford University, and assistant clinical professor at the UCSF School of Medicine. She’s the author of The Pain Management Workbook and Chronic Pain and Illness Workbook for Teens, which are treatment guides for people living with pain. On this episode, we talk about:  why a pain recipe revolutionizes how you deal with pain (+ how to figure out yours) the three hidden causes behind all types of pain why, from a neuroscience perspective, literally all pain can be lessened  a guide to developing your own pain plan the three things that universally help reduce pain, regardless of what caused it the best diet to manage pain  what causes chronic pain, and why it impacts some people more than other  what to do today to avoid pain in the future if you aren’t experiencing it right now the relationship between trauma and pain  the surprising way our genes impact how we feel pain the scientific reason why some people like pain in sexual situations how to activate your brain’s natural opioid system  exactly when it makes sense to take pain killers  a genius way to communicate your pain to other people in a way that they understand it  if taking CBD for pain is actually doing anything  and so much more! We would LOVE to hear from you any thoughts, reactions, or takeaways you have as you’re listening, so definitely screenshot and tag me @lizmoody and Rachel @therealdoczoff on Instagram.  To enter the giveaway to be one of the 15 winners of Rachel’s Pain Management Workbook, comment on my most recent post mentioning something you loved or learned from the episode, and follow me @lizmoody and Rachel @therealdoczoff on Instagram.  To join the Healthier Together Podcast Club Facebook group, go to https://www.facebook.com/groups/healthiertogetherpodcast. This episode is sponsored by AG1 by Athletic Greens. Visit athleticgreens.com/healthiertogether and get your FREE year supply of Vitamin D and 5 free travel packs today.  This episode is sponsored by MUD/WTR. Go to mudwtr.com/lizm and use code LIZM for 15% off your order. This episode is sponsored by Cymbiotika. Get 15% off using code LIZ at cymbiotika.com.  This episode is sponsored by Pique. Get 5% off plus a free blooming teas pouch complete with premium Pique samples when you purchase 2 or more cartons from piquetea.com/LIZMOODY and use code LIZMOODY.  Healthier Together cover art by Zack. Healthier Together music by Alex Ruimy. Learn more about your ad choices. Visit megaphone.fm/adchoices

Hello, friends, and welcome back to the Healthier Together podcast. I'm your host, Liz Moody, and I'm a best-selling author and long-time journalist. This podcast is all about helping you live your healthiest, happiest life, whether we're unlocking the secrets for stronger relationships, learning mental health hacks to help with depression and anxiety, or uncovering dermatologist tips to transform our skin. And yes, those are all real episodes, so if any of those topics sound good to you, scroll on back in the archives. Today on the podcast, we're talking about probably one of the most common things.

in the world. Pain. We've all experienced it. We will all continue to experience, whether it's period cramps or headaches or migraines or fibromyalgia or any of the other ways that pain crops up in ways big and small in our lives. But this is a conversation about pain unlike anything you've ever heard before. This conversation completely transformed how I think about and approach pain in my life, and I am so excited to welcome Dr. Rachel Zoffness to the podcast. Dr. Zofman, is a leading global pain expert who is working to revolutionize the way we understand and treat pain. She's a pain and health psychologist, lecture at Stanford University, and assistant clinical professor at the UCSF School of Medicine. She's the author of the Pain Management Workbook and the Chronic Pain

and Illness Workbook for teens, which are treatment guides for people living with pain. In this episode, we talk about why a pain recipe will transform how you deal with pain and exactly how to figure out yours. The three hidden causes behind all types of pain. Why, from a neuroscience perspective, literally all pain can be lessened. A guide to developing your own pain plan. The three things that universally help reduce pain regardless of what caused it. The best diet to manage pain. What causes chronic pain and why it impacts some people more than others? What to do two days to avoid chronic pain in the future if you aren't experiencing it right now? The relationship between trauma and pain, the surprising way that our genes impact how we feel pain, the scientific

reason why some people like pain in sexual situations, how to activate your brain's natural opioid system, exactly when it makes sense to take painkillers and what Dr. Zoffness does in her own life, a genius way to communicate your pain to other people in a way that they will understand it, if taking CBD for pain is actually doing anything and so much more. Dr. Zoffness and I would both love to hear your thoughts as you're listening, and I really want to hear what sticks with you the most from the episode and what you're going to implement into your life to either decrease pain or prevent future pain. So definitely share and tag us both on Instagram. I am at Liz Moody, and she is at The Real Doc Zoff. Zoff has two Fs. We also have an incredible giveaway for this episode. It is so good and so many of you are going to win, so definitely stay tuned to the end to find out how to enter. If you know anyone in your life who's dealing with pain, please. Please send this episode to them. The idea of people continuing to live in pain when this type of knowledge exists makes me literally sick to my stomach. Even things like period cramps, like understanding the three dynamics of what makes them better or worse, it's changed my life already.

And I want to provide relief for as many people as possible. So please be generous with sending the link around to this one. Okay. Are you ready to have your world shifted? Here is Dr. Rachel Zoffness. Rachel, I am so excited to have you here today. You have such a unique and brilliant and world transforming perspective, and I cannot wait to share it with everybody listening.

I was so excited when you reached out to me because I had been watching your stuff for a while and all of a sudden, Liz Moody's in my inbox, so I'm flattered and honored. Well, I would love to just get right into it. Can we kick it off with maybe a few stories of people that you've treated just to reframe the idea of pain treatment and kind of make what we think of as impossible possible. A few quick stories of hope. I would say my life is full of stories of hope. I am the last stop on the train for most people living with chronic pain. I am a pain psychologist and no one has ever heard of that and there's a lot of stigma around this idea that psychology treats pain. And so I spend my entire life

trying to reframe what pain is, which I know we're going to talk about and how to actually treat it and how if you actually are in pain and you're hurting, we have to target the brain in addition to the body. So when people come to me, I am the last stop on the train. They have had all the procedures. They have been on all the medications. They have been to hospitals. They have had surgeries. And the honest truth is I get a lot of people who are very hopeless.

And I know this is going to sound strange, but I sort of love that because I know that I can help them get better. I know that I can help them get well. And I get to say that to them. So one story that sticks out, I have like 40 million. And I try and write down my patient stories sometimes because they're so moving and so overwhelmingly powerful. But one of my earlier chronic pain patients was a 16-year-old who had actually been bedridden for four years. He had chronic migraine and abdominal migraine and diffuse amplified body pain. And no one could figure out what was going on. And he had He had seen 14 different physicians and specialists, and he had been on 40 medications, including opioids and Thorazine. Thorazine is this wild, old school, antipsychotic that just, like, knocks you out. But we still, in 2022, use that as a pain medication for children. It's pretty wild to me. And he was, as anyone would be, very depressed because, again,

He had been in bed for four years. He couldn't go to school. He couldn't play soccer. He couldn't see his friends. He had no life. He couldn't leave his house. And he was very anxious. And it turns out that that's common with chronic pain.

A lot of people deal with low mood and high stress. And I love talking about that not as a mental illness. That's not mental illness. That's a normal response to an abnormal situation. So when I got him, that was one of the first things we talked about, that when your life has been taken away from you and you can't move. and you can't go to school and you can't see your friends, of course, your mood crashes and anxiety and stress spike. But so one of the first things I did with him was teach him about pain and explain how pain works

and explain this connection between brain and body, between physical and emotional and how if you're not targeting the whole person, you're not actually treating their pain. And then we started putting together a pain plan. There's lots of pain plans. They vary depending upon the unique individual. But for him, step one was getting out of bed and standing. on his front porch for a few minutes every day because what had happened and as happens with people with chronic pain, his brain had become very sensitive over time. So small bits of sensory

input to his brain were amplified, were very large and loud. So like if you've ever been in a dark room and you suddenly turn on the lights, you feel blinded by the light. But over time with little bits of light, your brain desensitizes and you're okay. But his brain was hyper, hyper, hyper-sensitive to input. So week one, he just stood on his porch. And week two, he walked to his corner mailbox and then walked home. And week three, he walked around the block. And his goal was to get back to school and to soccer and to have a life again. And I told him, as I would tell any patient who comes to see me, that I could get him back to soccer. And what I've learned over time in this job is that if people don't have hope, they don't have anything. There's no traction unless they believe in you

and they believe in the work. So walking around the block, then walking his dog to the dog park and saying hi to people. And by the way, this was slow and gradual and he had flares. And so it was always this two steps forward, one step back. And then instead of walking around the block, he added a little bit of jogging. And then he did a little bit of running. He went and got a haircut. You know, that was like a game changer.

His hair was like long and unwashed. And he was pale and pasty and he was rocking himself back and forth with the pain. So watching this gradual increase in functionality and this gradual decrease in pain was absolutely astonishing. His parents were like, what are you doing with him in your office? And I don't want to pretend that I'm a miracle worker. I did not make up some fancy new treatment for pain. There's not like the Zafnus method. That's not a thing.

I am just doing what I have been trained to do. And neuroscience has known the treatment for chronic pain for many decades. But we live in a universe that is profit-driven. medicine and health care are profit-driven, and when people have pain, they are told that the answer is a pill and a procedure. And anyone with chronic pain will tell you that that is not sufficient most of the time. So we were simultaneously working on his understandable depression and his anxiety and his social isolation and what was going on at home with his family. There was a lot of stuff going on there and his exposure to sunlight and what he was eating. He was on a white food diet.

I see a lot of that, by the way, in chronic pain. A lot of kids, they like pasta and they like bread, but they don't like fruits or vegetables. And guess what that does to pain? So it was this whole person approach. Like, if you really want to treat pain, you cannot just go after the back or the head or the stomach. You have to go after the whole person. Can anyone who has pain have hoped that they can get rid of it? My strong statement is that everybody with chronic pain can change their pain.

100% of people with pain can change their pain. I'm not selling a magic cure. There's no panacea. But the thing that I love to say is that if pain can change, pain can change. And pain is always changing. Anyone with chronic pain will tell you some days are good days, some days are bad days. And there's a reason for that. There's always a recipe for pain, for high pain and for low pain, always.

And it's this complicated recipe of things that are happening inside of us and things that are going on around us. But if pain can change, pain can change. There is hope for 100% of people with chronic pain. So we'll get into the pain recipe because I think that's such a fascinating perspective and way to look at pain. But I would love to talk first about what pain is because you have a very specific definition of it. So can you share how you define pain? So pain is the body's warning system. It's our danger detection system.

And like any system in the human body, the pain system can and does. fail. But one of the most important things about pain is that we have been told and trained to believe that it lives exclusively in the body. So if you have back pain, you understandably will go to the back doctor and you'll have 72 back surgeries and you'll take medications to target your back. But it turns out what science shows, pain does not live exclusively in the body. Pain is actually manufactured by the brain. And one of the reasons we know this is because of this condition called phantom limb pain, where someone loses a body part, like an arm or a leg, and they continue to have terrible pain in the body part that isn't there anymore. And if you can have terrible pain in a leg

that is no longer attached to your body, that's definitive evidence that pain is not manufactured exclusively by your body, but by your brain. And the reason this is critically important for understanding what pain is, is that if you want to actually treat pain, you cannot just target the leg. You cannot just target the back. You have to target the brain. And the funny thing about the brain is that there's lots of parts of the brain working together in any given moment to create pain. And one of the most critical parts of the brain that processes pain, although, of course, they're all important and work together, is your limbic system. And your limbic system is, your brain's emotion center. So I'm going to say this to you differently. 100% of the sensory messages

from your body filter through your brain's emotion center before they become the thing we call pain. So pain is always both physical and emotional, 100% of the time. And people ask me that as a pain psychologist. Do you treat physical pain or emotional pain? And now I just nod my head and I say yes. Does that mean that emotional pain is always going to make physical pain worse and physical pain is always going to make emotional pain worse? Or are they so entangled that you can't even kind of make a statement like that? It's a great question. Can I answer your question by giving you a nerdy metaphor? Yes. So I'm a nerdy scientist. I've been studying pain science for something like 25 years. And metaphors help us make sense of this extremely complicated thing. So I want you to imagine in your central nervous system, which is just your brain and your spinal cord, that you have this thing that I'm going to call the pain dial. And the pain dial operates much like the volume knob on your car stereo. And you can turn pain volume up and you can turn pain volume down. And there's lots of things that do that.

Three things in particular change pain volume. One is stress and anxiety. Always changes pain volume. Two is mood and emotions, like if you're sad or happy, always changes pain volume. And three is attention or what you're focusing on. Now I'm going to say specifically what I mean. When stress and anxiety are high, like during a pandemic, for example, and your body is tense and tight. Your muscles are tense and tight.

And your thoughts are worried. You're worried or you're anxious or you're stressed. Your brain sends a message to your pain dial, amplifying pain volume. So pain feels worse when we're in a state of stress and anxiety. That's just what neuroscience shows. And with mood and emotions, turns out, neuroscience says, when our emotions are negative, we're miserable, we're depressed, we're angry. Our limbic system, the emotion center in our brain,

sends a message to the pain dial amplifying pain volume. So pain feels worse when emotions are negative, when you're having a crap day or you've just been fired at work or you're in a fight with your partner, pain volume is going to be higher. And thing three, we said, is attention, attention meaning, what are we focusing on? What are we thinking about? So if you are home in bed, thinking about your pain, ruminating about your pain, focusing on your pain, research says pain volume is going to be higher. But here's the good news for all of us who want to understand pain. And by the way, that's everybody. None of us, not one of us is going to escape life without pain. So this is important for everyone, whether or not you have chronic pain. The opposite is also true. It turns out

when stress and anxiety are low, your body and your muscles are relaxed and your thoughts are calm, your brain will lower pain volume. Same is true with emotions. When your emotions are positive, You're feeling happy. You're engaged in pleasurable activities. Limbic system, your emotion center will lower pain volume. And thing three, we said, is attention. So when you are distracted, you're so absorbed in some activity. You can briefly forget about your pain.

That is not magic. That is your brain's pain dial. And we all know that's true because over the last couple of years, when we've had to get all of these kids vaccinated, you know that if you stick a screen in front of a child and you sufficiently distract them, they hopefully will not scream when you give them an injection and pain, the experience of pain, feels different all of the time depending on contextual and emotional and cognitive variables. So yes, it's interconnected and that's how. When you think about strength and resilience, like your ability to feel energized, to recover well,

to stay strong as you get older, what do you think that actually comes from? Most people say working out or good nutrition, and yes, of course that matters. But there is a biological foundation underneath all of that that most people are completely overlooking. I have been diving deep into this lately with the team at timeline and what I've learned has genuinely shifted how I think about my own health. Every single movement that your body makes, every step, every workout, every muscle contraction depends on energy produced at the cellular level. And at the center of that is your mitochondria. Here's the thing that nobody tells you, certainly no, Nobody told me, starting around age 30, our mitochondria naturally become less efficient.

More get damaged, more become sluggish, and over time that impacts your energy, your strength, your recovery, and your resilience. Most of us respond by pushing more. We're like noticing these things and we're adding in more protein. We're trying to fix it with more supplements. We're trying to do harder workouts. And those things do help. But timelines research suggests that we also need to be supporting the cellular machinery

underneath. And that is exactly what their supplement, Mitopure does. It contains urolithin A, which helps your body clear out damage mitochondria and support healthier ones so that your cells can produce energy more efficiently. Because this is happening to your cells, it's going to impact your entire body, your immune system, your muscles. One study found that taking mitochondria increased muscle strength by 12% in four months with no change in exercise routine, It's going to impact your energy, your sleep, your skin, your cell health impacts all of this, and urolithin A keeps your cells healthy.

Timeline has done over 15 years of research and testing on this one product, Eurolitha which, by the way, most of us lack the gut bacteria to synthesize naturally. That's why many of us need to supplement it to get the benefits. This has become a staple supplement for me. It is my top way to support how I want to look and feel as I age. Support your cells and how you age with mitochondopure gummies from time. timeline. Visit timeline.com slash Liz and save up to 39% on your mitochondrure gummies. That is timeline.com slash Liz. The number one rule of habits is to make the things that you want

easier and the things that you don't want harder. Yet so many of us want to eat healthier, but so few of us actually take the steps to make eating healthier easier. That's where Marley Spoon comes in. What I love about this company and what's different than all of the other companies out there that are doing like stuff in the same arena is that you can customize your choices based on the effort that you want to put in. So if you want them to send you ingredients, so you can make your own 20 minute meal and like get into your chef energy, they'll send it to you to all be in perfect portions so you eliminate waste. Great. That's sorted. But they also have meals that you can just heat up. They have ready made breakfast, which is always such a tough time of day to get a healthy meal in.

They have grab and go snacks. Everything is made from farm fresh produce. with high-quality proteins and you can select by dietary preferences, including Mediterranean diet, which is the top diet that doctors on this podcast recommend. Also, things like gluten-free, dairy-free, low-sodium, anything that you need. The food is so good and it's so gourmet-fe feeling like you feel like you're at a nice restaurant. We're talking like chicken Milanese with a crunchy cucumber arugula salad or everything bagel salmon with truffle chive potatoes. My favorite recent meal was the creamy lemon chicken tray bake. I had one of those moments where I was a lot of those moments where I looked at my plate and I was like, wait, I made this. And so quickly, like so easily,

it's just so little effort for so much reward. Marley Spoon just makes eating well feel easy instead of stressful. And honestly, that is everything. This new year, fast track your way to eating well with Marley Spoon. Head to marlyspoon.com slash offer slash Liz Moody for up to 25 free meals. That is right, up to 25 free meals with Marley Spoon. That is Marley Spoon.com slash offer slash Liz Moody. So remember to get the offer in there. Marley Spoon.com slash offer slash Liz Moody for up to 25 free meals. In one sense, that feels really hopeful because you're just like, oh, if you can affect these other factors, you can have this great impact on your pain.

But on the other hand, it makes it feel in some ways even harder to address pain because you're like, oh, you're in pain. maybe don't feel stress, maybe don't feel anxious, maybe distract yourself. And you're like, how am I supposed to do that? I'm in pain. Totally. I love that you said that because people do hear this and they think that you're saying, oh, just distract yourself and like everything will get better. I think what I'm hoping to communicate is that pain is never a simple thing. It's complex because it involves your brain and your body and environment working together all the time. So what's really critical for us to know is that distraction strategies can help, but it's just one piece of this pain recipe. It's just one piece of the puzzle. Distraction alone is not sufficient. Changing your thoughts and not being anxious alone is not sufficient. It's all the things working in concert all the time. And my whole mission in life is to sort of say, hey, we're actually not honoring how complicated pain really is. We can't just have a back surgery and expect pain to heal. In fact, there's some

crazy statistic. Like, I think back surgery only works something like 19% of the time. I don't actually remember the numbers, but it's pretty low. And there's actually a diagnosis in medicine called failed back surgery syndrome for a reason. So pain is complicated. It's never purely a biomedical thing. And I can explain what I mean by that if I can offer another complicated word. Yeah, give it to us. Do you mind? Great. So it turns out that pain is not a biomedical problem. By that I mean, again, it's never just to do with your leg. It's never just to do with your leg. It's never just to do with your back. Pain is actually biopsychosocial. And I love that word because it explains pain to me in a way that like you said, makes me feel very hopeful because I know that there's three

domains of life I need to be thinking about in every given moment to target my pain. And by the way, I've had chronic pain on and off since I was a child and this information has changed my life. And it's what motivates me to do things like this, even though I'm like a wallflower to make sure that everybody knows that if you actually want to change pain, this is how we do it. So pain, again, is a biopsychosocial problem, not a biological problem, not a purely medical problem. Biosynosocial means that, yes, of course, there's biological components to pain that we need to target. And by that I mean tissue damage and system dysfunction and inflammation and diet and exercise and sleep. Critically important for the treatment of pain. But if you,

If you imagine this biopsychosocial recipe, like there's three bubbles in a Venn diagram. So bio's at the top. Then we've got psych. Then we've got sociological. And pain lives in the middle of those three bubbles. Bio, very important. But if you're missing the psych and you're missing the social, you're missing two-thirds of the pain problem. So in this psychological bubble, which has so much stigma and I spend my whole life fighting

against the stigma, we have things like cognitive factors. and by cognitive, I mean brain-based. So it turns out, neuroscience shows the things we think affect the way our bodies feel, which we all know. When we have a lot of stress and we're thinking stressful thoughts, you can feel that in your body. Your back gets tight, your jaw gets tight. Some of us grind our teeth at night. Our thoughts affect our bodies. So cognitive lives in the psych bubble.

Emotions live in there too. Like we said with the pain dial, if you're depressed or anxious or you have a lot of stress that is going to amplify pain. And the opposite to, positive emotions are going to lower pain volume. And also in this psych bubble, we have trauma. And if we had another like seven hours, we could talk about the relationship between trauma and pain. Because it turns out trauma and chronic pain live together 80% of the time, 80% comorbidity between trauma. Also in this bubble is coping behaviors. What do I mean by that?

When people have chronic pain, there's a lot of things they do and there's a lot of things that we stop doing. coping behaviors is how we cope with our pain. So sometimes we stay in bed for days. We don't see anyone. We don't go outside. We don't move our bodies. We live on potato chips because we just don't have the energy or the strength or the ability to cook a meal. And I say this with great compassion as someone who has had pain on an offer forever. And we go to doctors and we take medications and that's coping. But there's other ways to cope with pain too. And it turns out to heal from pain, we have to get outside. We have to get sunlight in our eyeballs. We have to move our bodies however much we can. We have to connect with other people. So coping changes the pain we feel too. And then we have

the sociological domain of pain. And I like to call that the everything else bubble. So that's our community and our families and our social environment and work and what's going on around us and whether or not we're being abused and whether or not we have access to care and race and ethnicity. and socioeconomic status and whether we have the money to pay for things, including nutritious food. So as you would imagine, again, pain is a complex problem. You cannot reduce it to a back scan or a knee scan. And that's what I'm humbly submitting. So pain is a biopsychosocial phenomenon that necessarily requires a biopsychosocial solution targeting all the things in our bubbles. And there's lots of ways of doing it. So I do want to instill hope. It's complicated, but it is absolutely doable.

And do we want to address different parts of the Venn diagram based on the type of pain that we have? Like, are some types of pain more bio and others more social and others more psycho? No. And I'm going to try and say why. There are bio components to every kind of pain. I see patients with chronic migraine and fibromyalgia and febri disease and cancer. And there's as much bio in each one of those diagnoses as they're in and all the others. You can't pretend that one counts more. And as far as psychological factors, who isn't dealing with a million different emotional factors at any moment in life? Life is very stressful.

You turn on the news right now and your stress system is going to activate. And we're coming off this crazy pandemic where a lot of people were isolated and lost their jobs and profoundly affected their mood. like calls to suicide hotlines went up 8,000% in the last two years. So it's impossible to tease them out. It's just impossible to tease them out. So we all have these factors interacting all the time. And the reason why is because the brain is connected to the body 100% of the time. Everything is always affecting everything. That's just how human beings work. Is there a way then to know when we should be treating the bio versus the social, like if we should be going to a physical therapist and getting PT exercises or addressing inflammation in our body or getting surgery versus working on getting outside,

improving our social relationships, et cetera. We always want to target all parts of the recipe, but we always want the most invasive and dangerous things to be last. I shouldn't be last on the train. I should be first on the train. Least invasive, fewest number of side effects. You save surgery for last unless there's something life-threatening. In chronic pain work, we always want to front load with all the things that we can control first. We want to target mood. We want to target social relationships. We want to target cognitions. We definitely want to go to PT and OT. We definitely want to be moving our bodies. We definitely want to be thinking about nutrition. I am not saying that we don't take pain medications. We do. I am not saying that we don't go to the doctor. We do. But we're always doing all of it. And we want to save for last. the things that are most dangerous and have the most side effects. We always want to try everything

else first. So all the research on chronic pain says it requires a multidisciplinary biopsychosocial approach. Like this isn't just my opinion. I just consume science and spit it back out for people to hear because I believe that science belongs in the hands of the people. So multidisciplinary, biopsychosocial, we always save surgery and dangerous medications for last when nothing else has worked. Should different types of pain be treated differently? Like if I'm getting chronic migraine, should I be taking a different approach than if I have endometriosis and I have debilitating period cramps or I have fibromyalgia? I wonder if this is a good time to talk about the pain recipe because the answer is different ailments and different conditions require a different approach. So everyone who walks into my office, I have the same general gist, but of course I treat everybody differently.

and there's a different recipe that's creating their pain. And by definition, there's going to be a different recipe that's lowering pain volume for each human being that walks into my office asking for help. So, yes, there's a couple of things we want to do differently for every person. So explain the pain recipe to me in the most sort of simplistic and granular sense. The idea of a pain recipe is just this. You love to cook. What's your favorite thing to cook, Liz Moody?

Give me something you like to bake. Let's do that. My best healthy cookies from my cookbook. What's in them just out of curiosity? They have a nut butter base. You can use like almond butter or tahini. And then they have almond or oat flour and then oats and walnuts and chocolate chips and an egg. But you can use a flax egg and then baking soda, I believe.

Oh my God. That sounds so good. My mouth is watering. Mouth is watering. Perfect. So as you know, just as there's a recipe for cookies, turns out there's also a recipe for pain. So with cookies or any recipe you want to bake, it's certain particular ingredients, add in a certain particular order, baked in a particular kind of pan at a particular temperature.

If you leave out ingredients or you bake it at the wrong temperature or you use the wrong receptacle, you are not going to get to the outcome that you want. You are going to have burned, not delicious cookies. And the same is true for pain. There's always a recipe for high pain and there is always a recipe for low pain and there are biopsychosocial ingredients for everyone that go into a high pain recipe, whether it's for fibromyalgia or endometriosis, and there is a collection of ingredients, biopsychosocial ingredients, that go into a low pain recipe. So I love to ask my patients, tell me about a time that you had a bad pain day and tell me about a time that you had a good day, a low pain day. And oftentimes, it's much easier for people to tell me about

the ingredients they believe went into their high pain day. So for me, with my pain, it's not getting out of bed or sitting for too many hours in a row. It's not going outside or exercising or moving my body, even if it's only for five minutes. It's not connecting with other people and being socially isolated. It's not managing my stress and anxiety, which can pile up. I have like 472 emails in my inbox and all these people in pain are relying on me and I'm not taking good care of myself because I want to help everybody else or I just eat really crappy a couple days in a row and my sleep is really off and I'm not taking care of sleep hygiene. So that is my high pain recipe and I know that if I have those ingredients in my high pain recipe, I'm going to have a couple of

bad days. But I also know from doing this work for a long time that my low pain recipe is is just the opposite. So I have to take care of my sleep. And there's this thing in my book. I wrote the pain management workbook and it has a whole protocol for sleep hygiene. Just like teeth hygiene, brushing your teeth. There's also sleep hygiene for improving sleep and minimizing insomnia. There's also things we can do for nutritional health when we have chronic pain. We want to feed our bodies. We all know that we are what we eat and our body is a machine and it requires good fuel. So there's certain foods also in the pain management workbook. We want to be eating for chronic pain and things we do not want to be putting in our bodies. We do not want to be living on potato chips

and ice cream. Also part of the low pain recipe for me and a lot of my clients is figuring out what to do with our normal, natural experience of low mood and stress and anxiety and maybe we have history of trauma. So are we in therapy? Like let's take the stigma out of that. We talk about physical exercise all the time for the body. I firmly believe that everyone deserves to have brain exercise also. If we're moving and we're walking and we're doing yoga every day, let's also make sure we're taking care of our emotional health and all of our family crap. We all have dynamics and things in our past that require attention. So if it's important to exercise the body, I humbly submit. It's important to exercise the brain. What are we doing for our emotional health? That's part

of any pain recipe. I think everyone should get a therapist they like. So we look at the high pain recipe and we figure out what we need to do to stockpile our day with low pain ingredients. And that's the way we start to change pain. Do you have like a few favorite low pain ingredients like things that you kind of universally find work across the board? Yeah, I do. I don't want them to sound too basic because it really is different for every person. But I know for me, my low pain recipe definitely is all the sleep hygiene stuff I'm talking about. Definitely is nutrition. Definitely is getting my body outside, getting sunlight in my pupils, we know that that raises levels of serotonin, raises endorphins. Endorphins, by the way, are endogenous natural opioids and they lower pain volume. So while it feels totally counterintuitive

to move your body and go outside, we know that that's actually going to lower pain volume. So I actually exercise. I build that into my life every day. Every day I exercise outside. It's very important for me for my mental health and my physical health and for my pain recipe. Can you share a few just because everybody should definitely go check out your workbook, but we can't mention food and then not give people a few kind of good for food, good for pain foods, and maybe foods you would avoid if you're experiencing pain. So we want to avoid processed foods and lots of sugar and believe it or not, we don't want to be drinking a lot of alcohol, even though self-medicating with chronic pain is so common and so understandable. We want to be eating whole foods and a lot of green vegetables

and protein. And it doesn't mean, by the way, that you can't have cookies. It doesn't mean that you have to stay off sugar. It's just moderation. And it's just making sure that you're front-loading with all the good stuff. So if somebody's trying to figure out what their own pain recipe is, is the way to do that just to ask that question, like, what did the last day that I experienced low pain look like

and the last day that I experienced high pain look like? Or should you be keeping a diary of symptoms over time? Or what's the best way to get at that for ourselves? It's a little more complicated than that. I do want everybody to be thinking about what biopsychosocial ingredients have gone into good days and bad days. Definitely. There's actually a whole protocol for doing it. That's also in the pain management workbook. And it just walks you through. How do you figure out or even think about what cognitive factors might be in your pain recipe? That's not immediately obvious. And how do you go

about thinking about what the emotional components of pain may have been? Like what's going on this week? Did you get into a huge fight with mom? Are you reading about politics? Like, what are the ingredients that are going into your pain recipe? It's not immediately, overtly obvious. But there is a method to the madness. I promise there is. So people can do exactly what we talked about here today. And for a deeper dive, all of it's in the pain management workbook. And it's pretty self-explanatory. And what if we know our low pain recipe, but our lifestyle doesn't let us get there? Like we don't have time to exercise or we have kids to take care of or we are really anxious about the news on a regular basis. So what you're asking about is in all these environmental

components, which again live in this like sociological, socioeconomic domain of pain. Like, what are the factors we have control over in our pain recipe? What factors do we not have control over? So there are a lot of things we can tweak in our lives, even if it's going outside for five minutes in the morning before the kids get up. One of my chronic pain patients will wake. And I'm not recommending this for everybody. She happens to be a morning person, but she wakes up at 5.30 in the morning, and she goes for a walk outside, and then she meditates. She has 30 minutes to do it before the kids get up and she has to do all the things and make lunches. But she is prioritizing self-care. She's adding low-pain ingredients into her daily recipe to make sure she's going to have a low-pain day.

So there's lots of ways of doing it. We just need to be creative about it. And problem-solving is a huge part of chronic pain management. People will say to me like, no, well, I just don't have time. But if what we were doing was working, wouldn't it be working? Like, we have to change something. If we want a low pain recipe, if we want to have better days, things have to change. So we have to tweak something. We have to do something differently. And what I like, again, about this biopsychosocial visualization is that it tells us there's lots of things we can tweak. There's so, so many things we can tweak to change your pain recipe to change the day you're going to have today. We can go after the bio. We can go after thoughts and emotions and coping behaviors. We can get you extra support. We can go after social stuff.

We can go after our environmental stuff. We can change your diet. We can change your sleep? There's so many things we can tweak. Okay. So we've talked about what to do when you're experiencing pain, how to come up with this pain recipe. But can we talk about what causes chronic pain in the first place? Like, why is some pain acute and then it just goes away and then other people are dealing with pain for years and years and years? So let's define our terms. So acute pain is pain that's three months or fewer. So like a broken ankle or the pain of childbirth, even COVID-related pain. If it's three months or fewer, that's acute pain. Chronic pain is pain that lasts three months or more or beyond expected healing time. That's our current definition of chronic pain.

It's highly imperfect, like everything to do with pain. So a lot more people have had chronic pain than realize it, actually. And here's the interesting science behind chronic pain. People always ask me, well, why hasn't my pain gone away yet? Like, I've had pain for 10 years. What's happening? So here is the science of chronic pain. I want you to tell me an activity that you practiced over time and you got good at.

You were bad at it and you practiced it. And over time, you got bad at it. You got better at it. Mine is piano. My mom made me practice as a kid. What's yours? Writing. Writing.

Awesome. So do you practice every day? Yes. Nice. Very impressive. So I'm going to say this back to you in a neuroscience way. The pathways in your brain are like the muscles in your body. The more you use them, the bigger and stronger they get.

So if you said to me, Rachel Zoffness, I want very big biceps. I would say, that's very cool, is Moody, go to the gym and lift weights lots of times, and over time your bicep muscles will get very big and strong. That's how that works. The same is true with the pathways in your brain. So the more you write, the bigger and stronger the writing pathway in your brain gets. And for me, the more I practiced piano, the bigger and stronger the piano pathway in my brain got. And anyone who plays an instrument knows this.

After a while, I would sit down at the piano. and my fingers would just know what to do. There's no music in front of me, but somehow my brain told my fingers what to do. And even cooler, I could hear the song in my head without any music playing. We've all heard songs in our head before. Your brain is a funny and very cool place.

So the pathways in your brain get bigger and stronger with practice and time. Guess what happens in your brain when you inadvertently accidentally practice pain over and over and over again for weeks and months and years. The pain pathway in your brain and your spinal cord gets really big and strong. And when that happens, we say that your brain has become sensitive to pain. And I'm always thinking about that word sensitive.

What does it mean? When you're sensitive to something, it means small bits of sensory. information to your brain feel really big. So on the 4th of July, if you have a dog, you know dogs are sensitive to sound. And on the 4th of July, every dog in America, poor things, are hiding under the bed because fireworks, which are loud, to a dog with sensitive ears, that sound is massive and intolerable. So what happens with chronic pain is that we've been accidentally practicing pain for months and years. The pain pathway in our central nervous system and our brain and spinal cord has gotten big and strong.

And so our brains are now sensitive to pain. And what that means is small bits of sensory input from the body are being amplified and interpreted by the brain as dangerous when they're not actually dangerous. And your brain, God bless it, is giving you an amplified danger message. Because remember, that's what pain is. Pain is the body's warning system. It's your danger detection system. It exists to protect you and save your life. People who do not feel pain, do not live very long.

So when your brain is sensitive to pain, it's giving you these amplified danger messages and telling you, stop walking, stop moving, stay at home, stay inside, stay in bed. Turns out that is the opposite of what you need to do to heal from chronic pain. It is the exact opposite. Your brain is giving you false warning messages. false danger messages, and the way we treat chronic pain is by desensitizing a sensitive brain. And I can explain what I mean by that. But I first want to give you an example. So I treat patients with fibromyalgia, which is this chronic pain condition. It's diffuse amplified pain throughout the body. People with fibromyalgia experience pain in different body parts. Sometimes it's six

body parts. Sometimes it's 18 body parts. And I say this with sort of like frustration. If you check the internet, the internet says there's no treatment for fibromyalgia. I want to formally and officially say that is complete and utter BS. There absolutely is a treatment for fibromyalgia. What happens with fibromyalgia is that the brain and the central nervous system have become sensitive, as with all chronic pain conditions over time. So I ask people, is going to a picnic with fibromyalgia dangerous? The answer is no, it's not dangerous to your body to go sit under a tree with your friends

and eat some cheese and crackers. It is not. But your brain is going to give you amplified danger messages. And anyone with fibromyalgia or chronic pain will tell you that they will engage in not dangerous activities, like going outside for five minutes. And their brain will give them these amplified danger messages. And to me, that's just perfect evidence that chronic pain is this glitch in the system where the brain has become hypersensitive over time and needs to be desensitized.

Okay, I have a lot of questions. First of all, why do some people start working that muscle in the first place? Like, why are some people bicep building when other people aren't building those pathways? There's a lot of reasons. So maybe you broke your ankle. I treat patients with this condition called CRPS complex regional pain syndrome. And it often starts with an injury, like some sort of physical damage. And it spirals into this chronic pain condition for a variety of biopsychosocial reasons. So there's a lot of reasons chronic pain can start. It's a lot of things that kick off the cycle, many things. And again, if we go back to trauma, let's just say this now, because I'm so fascinated by the overlap between trauma and chronic pain. And so many of us are living with histories of untreated trauma. So here's what trauma does to the brain. One of the symptoms of PTSD post-traumatic stress disorder is something called hypervigilance.

It's like someone will tap you on the shoulder and you'll have this exaggerated startle response. an exaggerated startle response is one of the hallmarks of trauma. Your body goes into danger and self-protection mode, and I'm going to tell you why. When you have a trauma, your brain learns that the world is dangerous and your body might not be safe. And trauma, it turns out, it changes the brain. And your brain becomes a more sensitive instrument because now it needs to scan the environment, your internal environment and your external environment, looking for possible danger. because something bad and terrible happened to you,

and your brain wants to keep you safe and make sure that doesn't happen again. So in exaggerated startle response is your brain over-protecting you. Someone tapping you on the shoulder again, not dangerous. But if you've had trauma, you know, like guys who have been off at war, if they hear fireworks, they will hit the floor. They'll hit the ground. Their brain is just trying to protect them and keep them safe.

It has become sensitive. So trauma and chronic pain, understandably, live together 80, percent of the time in part because our systems have become more sensitive. And again, pain is your body's danger detection system. So if you have a history of trauma, your brain is going to amplify sensory messages from your body thinking that those might be dangerous. Your brain wants to get your attention and get you to do things to keep you safe just in case something dangerous is happening. So sometimes people with acute pain, if you have an untreated trauma or a complex trauma your brain might go into hyperdrive trying to keep you safe. And it might keep feeding you

danger messages even after the danger has passed. So there's a lot of ways that pain goes from acute to chronic. But those are some of the ways. So if we didn't have chronic pain right now, but we wanted to avoid it in the future, would step one be treating or trying to deal with any unresolved trauma in our life? There are so many steps that we can take. And that, in my mind is a very big one because it's not talked about. So absolutely treating untreated trauma. Yes. Yes. Yes. A hundred percent yes. Making sure that we're dealing with our understandable stress and anxiety. And I'm not saying that everyone has a mental illness, but over the last two years, who wasn't anxious about people they love dying? Who wasn't anxious about getting an illness or

having loved ones fall ill and treating depression? And we want to also make sure that we're moving our bodies, moving our bodies and going outside. We want to make sure that we're eating a healthy diet. We want to make sure we're not socially isolated and we have a social support network. It turns out that neuroscience says social medicine is real. Are there genetic components to pain related diseases or somebody being more likely to develop chronic pain? Like one listener wrote in and she said that both her mom and sister had fibromyalgia and so she was really stressed that she was going to get it, which after our conversation, I'm like, oh no, don't be stressed. But is Is there a genetic component?

The interesting thing about pain is that it comes with so many different conditions. There is a genetic predisposition for a lot of different conditions like breast cancer. So the answer is yes, genes are involved, but they're not the end-all-be-all. So there can be some genetic predisposition for having a more sensitive system, for example, like sensitivity. There's some suggestion that there's some genetic component to how sensitive you are. And again, sensitivity is implicated in pain. And there's, of course, genetic components to different conditions. So I just always go back to zooming out to this big thing.

Like, yes, there's genetics and tissue damage and system dysfunction, all these bio things. And then there's everything else. So even if there's a genetic component in there, that does not mean you are doomed to a life of pain. We have to be very, very careful, actually, to make sure that people don't believe that just because there's some genetic loading that means that they're destined to have pain because that is not true. That's not how that works. I'm genuinely confused how Masterclass gets literally the absolute top.

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Is there a way that we can tell that the messages are false? Because I think in the example you gave, like, is going to a picnic dangerous? That feels very obvious. But sometimes we're like, I'm really low energy, so I shouldn't be working out. or I should just lay in bed all day because that's the caring, nurturing thing to do for myself. And I think it could be hard to suss out what is truly the best, best thing and what you're kind of just telling yourself is the best thing. I think it's very important for people with pain and all of us to just take days off, definitely.

Like if your body wants you to rest, rest. But here's the trap. With chronic pain, your brain is erroneously incorrectly telling you to stay home, stay inside, and rest for weeks and months and years. on end. And there's nothing that makes a brain more sensitive than not having input. Absence of input makes a brain more sensitive. So if we actually want to treat chronic pain, believe it or not, I have something in the book. It's called a pacing plan, a pacing plan in the pain management workbook again, is this plan by which we can figure out how to gradually and slowly and tolerably

increase input for sensitive brain, increase amount of sunlight, increase amount of physical activity, increase social activity, increase beloved hobbies like cooking and baking. It is all possible to do, but you have to start somewhere. So some of my patients start with 30 seconds. On a crap day, and your brain is telling you not to get out of bed, you get out of bed and go outside for 30 seconds, like we did with the kid I told you about at the beginning, and you stand on your porch, and you get some sunlight. And that's your activity for the day and that's okay. There's no shame in this game. But we have to start somewhere. We cannot succumb to a life in bed. That is the recipe for disaster. The people I see have been in bed for months and years. And that's the opposite of what we actually

have to do to treat pain. What about acute pain that's not telling us something? Like a broken ankle, great, don't walk on that ankle. We get it. But what about things like, a headache or period cramps or back pain, what are we supposed to do in those types of moments and what's happening there? So again, pain is the body's danger detection system and the body's warning system. So if you break your ankle and you do not listen to your body and you continue running on a broken ankle, you're screwed. You're going to do really bad damage to your body. So acute pain, in my opinion, is a message that you do need to rest. Like your ankle's not going to heal if you're running on it. If you have period cramps, get a heat.

pad, take some Advil, whatever self-soothing activities make you feel better. Distraction strategies really are helpful for some people and not for everyone. Meditation and mindfulness is super helpful for some people and not for other people. And this is why I love the concept of a pain recipe. Everyone's recipe is going to be different. But I will say for me personally, and I know I keep saying this, but even for acute pain, getting outside and getting sunlight for my personal pain recipe is very important. So I think it's important. I think it's important. for us to think about what are the unique components to our brains that are going to help lower pain volume and turn down that pain dial in any given moment, in any given day, whether it's

acute pain or chronic pain, and every one of us has a recipe. Is there anything that we can do preemptively? Like if we know we are going to have a painful experience in the future, can we prepare ourselves for that in some way that would make it less painful? Yep. I want to introduce a different concept that I want to talk about. We all have something that I'm going to call a pain voice. And everyone hears, we have a conscience that tells us right from wrong. But pain voice is this voice that lives in your head that is often very loud and very catastrophic and very anxious. And it says things like, oh my God, it's going to hurt so much. I'm not going to be able to handle it. It's going to be so terrible. And I'm not going to get better and I'm never going to be able to work again.

And I'm not going to be able to have sex with my partner. And I'm not going to be able to engage in all my hobbies and it's going to ruin my life, that's pain voice. And I want to introduce everybody to pain voice because even though pain voice is very disruptive and it's easy to hate pain voice, pain voice is just doing its job. It's trying to protect you. It's trying to get your attention and make sure you're safe. So we all have to take care of pain voice. We have to hear her. She's saying things like, it's going to be terrible. But what neuroscience says is that negative and terrified and anxious and catastrophic thoughts are actually going to amplify pain volume. So we want to make sure to know our pain voice. What does she sound like? What are the things she says? How does it

make our bodies feel? What emotions does she inspire? Does she inspire fear and distress and anxiety? If so, guess what's happening to pain volume? And then what do we do about pain voice once we've heard her? How do we soothe her? How do we talk back to her? How do we take care of her? So this pain voice concept is really important to me when I think about when we're preparing for something painful, because pain is an aversive negative experience. By definition, it's built that way. You want to avoid it. Of course you're going to have anxious thoughts about pain. No one wants, well, some people like pain. We can talk about that too. But what do we do to get ahead of that and what are things we can do to soothe our bodies and soothe our pain voice, calm our pain system down, calm our stress system

down to best prepare for a painful procedure? Okay. So how would you talk to her? What are some things we could say to our pain voice. Yeah. Great. So step one when we're dealing with pain voices, knowing what she sounds like and everyone's is different. I like to have people name their pain voice. I named mine Mrs. Beasley. Okay. But the reason we want to name our pain voice is because there's this strategy and psychology called externalizing. And by that, I mean, when you hear this negative voice in your head and it's yelling at you and it's telling you things are going to be terrible and it's going to be terribly painful and your future is going to be dismal. You tend to believe the things you think. We hear this voice in our head and it sounds like us and we believe

ourselves. So there's this useful strategy called externalizing. So when you name pain voice and it's a different name, like Mrs. Beasley is separate from me. Like Rachel, I trust Rachel. I believe Rachel. But Mrs. Beasley is just my pain voice. She's trying to keep me safe. She's not doing a great job. She's overly catastrophic. She's yelling to get my attention and she doesn't need to. So my first step is catching Mrs. Beasley and knowing what she sounds like. That's step one. Step two is checking whether or not the things she's saying are true. So for example, everything's going to be terrible. That's just an example. So I'm going to ask Mrs. Beasley some questions. What are some questions I need to ask Mrs. Beasley? Well, first I need to find out,

is this thought a fact? Or is it BS? It might be true. I have to entertain the possibility that Mrs. Beasley is right. So everything is going to be dismal and awful. Is that thought a fact? Yeah, it's pretty clearly not a fact. So the second I know that it's not a fact, I know that that's just my pain voice. Step three is changing it. How do you change what we call a cognitive distortion? A cognitive distortion is a thought that sounds true, but when you check it out and test it, it turns out it's not actually true. So I made up this strategy. It's called using detective questions. And you go through the detective questions, like, is it a fact? What has happened in the past?

What other things might be happening other than what I'm predicting? So for this particular example, what else might happen? The procedure might go totally fine. And maybe I have pain for a couple days and it's well managed by my lovely doctors. And I set myself up in my environment to have maximal soothing and support. And after a couple of days, I'm totally fine. That's possible too. If the worst possible case scenario is possible, surely some better case scenarios are also possible.

So that's the strategy of navigating our pain voice. That's so interesting because it's definitely the thing I struggle with the most is I'm like, I can deal with this right now, but I can't handle it for a week or for a month or for a year or for a decade. So I have this idea that anything bad in my life will persist forever and that I won't be able to handle that persistence. I'm going to send you the pain management workbook, and I'm going to ask you to do that one thing and tell me how it goes. Because what you end up with after you do the detective questions are a list of statements that you need to read to yourself every single day, every day.

It doesn't matter if it's in front of a mirror or just in your bedroom or on your couch with your cat, but you want to read back to yourself. This is not a fact. This is just a catastrophic, anxious thought. It's just my pain voice. It's trying to protect me. But in the past, I've had procedures and they've been okay. and I've gotten better and my doctor says chances are it's just going to be a few days of discomfort and then I'll be fine. And you read it back to yourself as many times a day. It's like taking medication.

Or even the stuff that we've talked about today, like pain, because I could talk myself, my brain could be like, yes, but there's a chance the procedure wouldn't work or some people have pain forever and that could be you. But then even the stuff we talked about today, which is like everybody has hope, everybody can manage these different factors, et cetera, et cetera. And that would be very calming for me in a way that I think, I think even that part of my brain couldn't talk back to. That's exactly right. And by the way, it's normal to have scared and catastrophic thoughts around pain and procedures and illness. That's so normal. Like, who wants to be sick? Who wants to be in pain? And that's why it's so important to manage the thoughts and the voice because we know that ultimately are scared and scary

negative thoughts are going to just amplify pain volume in the brain and it's not going to serve us well, ultimately. So you mentioned people who like pain in certain contexts. Let's talk about that for a second. Can you talk about why some people enjoy the idea of pain, particularly in a sexual context? Totally. That's not abnormal at all. That's absolutely normal. Here's what I want to say about pain. Context and environment always matter in the production and reduction of pain. So where you are and who you're with and what's happening and how you're feeling, that is going to change your pain experience because the brain takes into account all information when deciding whether or not to make pain and how much. And again, if your brain believes you are safe, it will not make a loud

pain message. It will not try and grab your attention and scare you into doing something like changing your behavior or going to the doctor. So in certain contexts, like if you're someone who enjoys BDSM during sex with a partner that you know and trust and like and you've had conversations about what you like and don't like or say for it. It totally makes sense that pain volume is going to be lower in a context where there's trust and communication. So it turns out research shows that if someone slaps you really hard when you're getting mugged, it's going to feel completely different than that same exact slap when you're having sex with a partner you like and trust. So contact.

and environment matter to the brain 100% of the time always. So pain can feel good. Pain can feel pleasurable. And environment, context, all the information matters to your brain. Is that way, have you heard of the thing of people having orgasms during childbirth? I have heard of that, but I've never researched it. So I don't know a lot about it. I find it to be a really interesting concept. I mean, obviously, there's a lot of stuff happening in that area as well. And maybe I haven't done a lot of research into it either. But I'd be curious if it's like the context of like, oh, I'm having my baby. I'm doing this thing I've always wanted that would make it what is normally painful, pleasurable. Yeah. There is a lot of research around childbirth

pain because it's, you know, we all have been told it's one of the most painful experiences. I'm terrified of it. It's like one of my biggest fears. Yeah. Understandable, but here's a cool bit of information. Turns out that a lot of women forget the pain of childbirth. Like you ask them and they can't remember it. And the reason why is because after a baby is born, your brain gives you this beautiful bath of chemicals like serotonin which raises your mood and dopamine which is like this reward chemical and oxytocin which makes you feel connected and bonded and endorphins which are our natural opioids that lower pain volume and you get this wonderful bath of chemicals after childbirth so you can bond with your baby and it's actually adaptive

if you imagine to sort of forget how painful it was so that you'll do it again because if every woman was like, that was the worst thing I've ever done. I'll never do it again. Like, what happens to human beings? But then I'm like, why not just not have it be painful the first place? Like, why can't we adapt in that way so it doesn't hurt so we don't have to forget it, you know? That seems nicer to me. Agree that it would be nicer. I actually read somewhere that one of the reasons evolution made it painful is that so you will value and take care of the thing that was so expensive to get. What about the dad? Does he not need to? value the baby? It's a great question. Don't ask me. I don't know. I don't know what evolution was doing.

That's so annoying. That annoys me so deeply. Okay. What situations would you take painkillers in and would you do anything different if you were taking painkillers? And by painkillers, do you mean opioids or do you mean any medication that lowers pain volume? I'd actually be curious about either one. I would say over-the-counter medications and then are there situations that you would take opioids in. You're asking me as a pain expert or like my individual preferences? Both. I want to know you as a person and you as an expert. Okay. So me as an expert, I again go back to that thing. Having read all the research, I always want to do the least invasive, least dangerous stuff first. So I want to use my whole host of strategies and I have a lot of them for managing my pain. And the whole

workbook is like these non-pharmacological treatments for chronic pain that science says are effective. So I always want to do those first. So I will do, and everyone can laugh at me. It's okay. I will do belly breathing. I will do biofeedback. I happen to love biofeedback. I can tell you what that is. I will use mindfulness strategies. I will use distraction techniques, all of my self-soothing tools. I will do all of those things first. And also, like if I have an acute injury, I absolutely will take like Advil or Tylenol. I am not a glutton for punishment. I want to say carefully and thoughtfully. that there is a time and place in my very humble opinion for opioids. Like, I am not anti-opioid.

We have still an opioid epidemic. It got worse during the pandemic. Opioid overdoses were higher during the pandemic than ever before in human history. There's a reason for that. However, for acute pain, in my humble opinion, like you have some terrible surgery, thank God for opioids. And by the way, opioids only work because they bind to a receptor that we already have in our brains. We have endorphins. We have a number of endogenous naturally made opioids in our

brain. Our brains already make opioids. So I think opioids are appropriate for very short-term use. However, what has happened in our culture, as you know, is that Big Pharma has billions of dollars, literally billions of dollars to market to you and to me, this concept, this idea that pain is a purely biomedical problem that requires a purely biomedical solution and you need a pill to fix your pain. That is a lie. We have literally decades of science that say that that story that you've been sold, that I've been sold, that we've all been sold is a complete lie. Opioids are not an appropriate treatment for chronic pain. That's what science says. This is not my opinion. I have no skin in this game. Science says that over time, opioids sensitize the brain. We've talked about sensitivity a lot

on this show today. Opioids over time make your brain more sensitive to danger messages, not less. It's opioid-induced hyperalgesia. That's the name. If you go and look in the scientific literature, it exists in abundance. Science says we do not want people taking opioids forever for their pain. Now, that does not mean that we rip opioids out of the hands of people who have been on them for decades, because that leaves people without hope. It leaves them with extra sensitive brains and without appropriate tools to manage their pain, and I think that's unethical. So what we want to do is actually teach everyone how pain actually works, give them all the tools to effectively manage their pain, and then you can gradually wean off. But that's a story for another time, and that's an individual

patient thing. So for me, you asked, when do I take them and when do I not? I do not take opioids for pain. And I've been lucky. I had one surgery and I took them for two days and then stopped. But I try and stay away from them personally. I think the thing that makes us want to veer towards the bio part of the solution is that it justifies the idea that pain is real.

Because I think that there's this idea that if pain can be treated by going, outside or belly breathing, that it must be somehow your fault. Like if it's in your brain, that you should be able to fix your brain, you should be able to control your brain. That's not real. Can you speak to that stigma? I'm so glad you said that. Yeah. And I want to be clear that I am not suggesting that you can cure pain by going for a walk or doing belly breathing. That is not true. That's not how that goes. It's a complex recipe and everyone has to deal with the bio and the psych and the social in their own way and find their own recipe. But it's all the things working together. And there is a lot of stigma around that and I spend my whole life sort of fighting it because

you're right. I do think that's exactly why people focus on the bio because it makes you feel like my pain is real. Now, what I want to go back to is pain does not live exclusively in the body. You can have as many knee surgeries as you want. And yes, sometimes it will fix a thing. But it will fix a mechanical and atomical thing, but that's not where pain lives. You may have a mechanical and anatomical problem and a surgery will fix that. But pain lives in your brain. Pain is manufactured in part by your brain's limbic system, which is your emotion center. So if we are not targeting, the body and the brain, end your emotions, end your environment, and all of the things happening inside of you and around you, we're not actually treating your pain. We can treat your

knee, but we're not treating your pain. So in my mind, it's like, I know how to calm my own stress system because my stress system is very active and I know it's going to amplify my pain. So I know some strategies for calming my stress system. So that's why I'm talking about the going outside and the belly breathing. It's not a magic cure for pain, but I know that I can lower pain volume if I'm taking control of my stress system. So to me, the real place that we want to start for anyone with pain is understanding what pain is and how it works. Because if you don't understand what pain is, you are just going to endlessly get surgeries and pills and procedures. Now, I have a statistic for you. Ninety-six percent of medical schools in the United States and

Canada have zero dedicated compulsory pain education. Our providers are not learning about pain. And I give grand rounds at hospitals around the country and I speak at conferences around the world. I love my physician colleagues and they will confirm there is insufficient pain education in med school. It's insufficient. I'm not saying that nobody learns about pain. But when people do learn about pain, it's usually the biomedical model. So we talk again about anatomical problems and we talk about medications. Most of our providers, and that includes therapists and PTs and OTs and nurses.

most of us do not learn that pain is a biopsychosocial problem. And so what we feed patients are biomedical solutions because there's not sufficient pain education. And what I'm trying to do is make sure that everyone understands how pain works. Because the only way any of us are ever going to escape and be okay is by knowing our pain recipes and knowing how to lower pain volume. And imagine how different the world would be if every doctor said what I'm saying today to every patient.

Everyone would have more hope. Everyone would have more tools. So it's time to change pain medicine. We're going to do it. Is there a simple way, like a sentence you could give us that we could use to communicate to somebody who's like, oh, see, if you're trying these things and they work, it was all in your head. And it's your fault you suffered from pain all this time.

Or just like a way to communicate this more nuanced, more complex, more science-backed way of thinking about pain. Yeah. The pain dial metaphor is my ascent. the whole. I always go back to the pain dial metaphor. The pain dial metaphor is just straight up neuroscience and it explains this overlap between the parts of the brain that process cognitive factors like thoughts and attention and the parts of the brain that process emotion and also, of course, physical components of pain. So in my mind, the pain dial really handily does that where you

explain to people, of course pain is real. If you have pain, it's real and it's not all in your head, but your brain plays a very big role. And if we're not targeting the brain and we're not targeting the whole person, we're just not targeting pain. So that's sort of my hack. And then you mentioned that our brains have endogenous opioids. Are there ways that we can activate that as kind of like a getting rid of pain hack? Yes. Your brain's natural opioid system, you've heard of them. They're endorphins. And people talk about endorphins a lot when they talk about a runner's high. A runner's high, people will get this huge endorphin rush and they feel really good like they're floaty. But you can hack your endorphin system all day every day. Sunlight raises

your brain's level of endorphins. Humans, by the by, we are diurnal animals. What does that mean? It means we are most active during times when the sun is up, when it's sunny, and we are least active at night when the sun is down and all the nocturnal animals come out and go through our garbage. It's important for us to get sunlight. And endorphins is one of the consequences of getting sunlight in your pupils. Do not go and stare at the sun. Just being outside and getting sunlight in your eyeballs is enough to stimulate production of endorphins. Also, the other huge thing is exercise and movement. And with chronic pain, it's very hard to exercise. So I try to use the word movement more often. But if you can exercise, exercise raises your natural levels of opioids in your brain. Any exercise,

swimming, walking, biking, hiking, sex, raises levels of endorphins in the brain. So there's many kinds of movement and activity that we can do to raise endorphins. And foods, I believe, if I'm not lying, that chocolate also raises endorphins in the brain. I'm a huge advocate of chocolate. So there's lots of ways of raising your endorphins. Are there minimum viable doses for those, like for movement? If we go walk for a minute or two, will that raise endorphins but just like, less than if we walked for 20 or 30 minutes? I think it's a unique individual to individual thing,

but yes, generally speaking, the more you move, the more endorphins will be released. And the more chocolate we eat, the more. Yeah, I don't know about that one. I haven't done my chocolate research sufficiently to speak to that. I'm going to say that that science. And then you mentioned biofeedback. Can you explain what that is? Yeah. A lot of people haven't heard of biofeedback and it's one of my favorite treatments for chronic pain and I folded into my work all the time. So biofeedback is this really cool technique whereby you get hooked up to a machine and it gives you feedback in real time about unconscious biological processes like skin temperature and heart rate and galvanic skin response. And that's like the lie detector test. So here's my biofeedback story.

I had a long bout of chronic leg pain for about 10 years. And someone said, you should go to a biofeedback provider. And I went to this biofeedback provider and he sat me down on a chair. And by the way, I have a very nerdy website, just my last name, Zafniz.com. I have a resources page and you can find a biofeedback provider near you if this is something that you want to look into. Also on that website, there's like more books and articles and links to websites and guided audio than you've ever wanted in your life. Okay, so he sat me down in a chair and he hooked me up to this machine that was reading skin temperature and galvanic skin response. Again, the lie detector test stuff and my heart rate and muscle tension.

And he said, I am going to teach you to warm your hands to 90 degrees. And I said, I am a scientist and I do not believe in voodoo. And I have had cold hands my whole life. Turns out, Liz Moody, that cold hands are a sign of being stressed and potentially anxious. Did not know that. I know. Cold hands, cold feet, sign of stress. Yes. Have you heard of like cold feet before you get married? Oh my God. Yes, I have. But I've literally never put that together with the fact that my husband all the time is like get your cold feet off my body. Totally. It's a sign of stress. Right. Because emotions don't just live in your head. Emotions come out in your body. So, physiologically, when we're in a state of stress and anxiety, one of the things that happens is that

our blood gets pulled to our core and our extremities get cold because our body is preparing to fight or flight. And when you need to fight or flight, your body pulls all of your resources, your blood to your core. Because you can live without an arm, you can live without feet, but you can't live without your core. So your blood gets pulled to your core and hands and feet get cold. I know. So did he teach you? So he said, close your eyes. I want you to use some guided imagery. And he had me, I know how ridiculous this sounds. I am a scientist. He had me imagine or envision hot soup flowing down my arms from my shoulders into my hands. He had me imagining, God, I've been doing this so long that now when I talk about it, my hands get red and hot because my brain is trained now. Yes. He had me imagine holding my hands over a hot campfire. He had me. He had me, imagine holding my hands over a hot campfire. He had me. use belly breathing and autogenic training. Autogenic training is when you say things, phrases to yourself, like my hands are heavy and warm. And as I was staring at this biofeedback machine, my hands were getting hotter and hotter. I could see, like there's no denying that it's working because biofeedback

means you're getting feedback about your biology. So I'm staring at this machine and my hands are going up to 92 degrees just because I'm thinking about it. because your thoughts affect your physiology 100% of the time. It's crazy. And it turns out biofeedback is one of the number one treatments for chronic migraine. The American Migraine Foundation has on their website. Biofeedback has been found to be equally as effective as all of these crazy migraine medications without the side effects. Mind blown. So now I teach biofeedback to everyone who comes in my office. So how would you use that for something like a migraine instead of, picturing your hands getting warm? Are you picturing your head pain going away, kind of?

When you're using guided imagery, what's happening is you're changing circulation and you're changing blood flow. And it turns out that with chronic migraine and chronic headache, as we all know, blood flow is a huge component of what triggers and lowers migraine and headache. Blood flow. There's a lot of signs on us. So a lot of the medications we use for migraine change blood flow and circulation. And it turns out that there's lots of ways of doing that. You can do it with a medication and you can do it with biofeedback too. That's so interesting. Could you reverse engineer it? Like, could you make your hands warm with like mittens or those little hand warmers to signal to your body that you shouldn't be anxious because you're safe because you have the blood flow

to your hands? That's such an interesting idea. I don't think that that is sufficient to turn off your stress alarm. But hopefully it will make your hands warm. But I don't think it's sufficient. Yeah, exactly. But I don't think it's sufficient because your body is trying to prepare you for some sort of emergency or some sort of condition that it thinks is dangerous. So your brain is going to keep changing, like restricting circulates. So people when they have panic attacks, for example, will say sometimes hands and toes get tingly or they'll lose sensation. And that's because of that change in circulation where all of your blood is flowing to your core and away from your extremities. Anxiety is something that I deal with on a pretty regular basis. Would biofeedback be something. that would be useful for me? Yes, 100% yes. Biofeedback is brilliant. And it's the kind of thing you, you like learn it. You don't need to see a practitioner all the time forever. It's like a methodology, you learn and then you can use whenever you need it. Once I was trained in biofeedback, I knew it. Now I can, I literally can warm my hands on command. I've had cold hands my whole life.

It's so cool. But here's the thing. Here's why I love this for chronic pain. When I teach patients, especially kids, I happen to love working with adolescents, but I work with people of all ages. When I teach my kids, this biofeedback technique called handwarming, they literally say, oh my God, I can make fireballs with my hands. What else can I do with my mind? And that's all you want for chronic pain. You want people to believe that they can affect change in their bodies using their brain. It is such a crazy amazing superpower and can affect change in your body using your brain. That's how were built. But if you've had pain for a long time, you might not believe that. You may have lost sense of agency and power. And all of these techniques and tools that I'm talking about,

their primary function is to give you your power back. We all need to get our power back. And that's the whole point of all of this stuff. How do we give people their power back so that they have the tools to manage their pain? How do you feel about non-pharmaceutical bio-altering things for pain? So I'm thinking like I got asked a lot about CBD. I got asked a lot about THC. I got asked a lot about magnesium, which I know is very commonly used for migraine. So how do we feel about supplements in that way? A couple things to say.

Again, I do not believe that the bio domain is not important. Bio is important too. Of course we want to take care of bio. I am also all about whatever helps. Whatever works, let's work it. Like if magnesium is working for you, great. If it's not working for you, let's dial back. I have a rule of thumb in my practice, actually.

Whatever medications and supplements you're on, if you've been on them three months or longer and they're not working, let's taper off of them, of course, with the help of your doctor, not on your own. But if it's working for you, it's working. So I'm all about whatever works. You asked about CBD. There's a lot of recent research that shows that marijuana and CBD are not, believe it or not, actually effective pain management strategies in the long term.

But I want to be very careful about that. Again, everyone's brain is unique and different. If it works for you, God bless. I am all about whatever works, but I'm just repeating the science. There's a lot of science that has come out recently that says the CBD industry has a lot of money to market to you that this is actually truly effective for pain management. But what the science says is that that's not actually true. CBD can help some people some of the time. And it can help people with appetite. Like if you have cancer and you're undergoing chemo and you have no appetite, it can help people with that. So it's not that it's useless. It's just from what I've read, it's not all it's cracked up to be as far as pain management goes. So rule of thumb, if it's working for you, great. If it's been three months or more, consider tapering off of it and trying something else. But what we don't want is anyone only focusing on the bio-domain of pain. So I see patients and their only strategy is smoking weed or CBD gummies.

That is a no-go because that is a band-aid. You are going to continue to have pain. That's not a cure. CBD is not a treatment for pain. It can lower pain volume for some people, but it's not making the actual problem go away. It's not making your brain less sensitive. If you actually want to treat chronic pain, we need to go after the whole biopsychosocial recipe. CBD, that's just a band-aid. It's not actually going to treat your pain. Okay. We've talked about a lot of stuff today. I would love if you could just leave us with one homework assignment, maybe one homework assignment for somebody who is suffering from chronic pain

and one homework assignment for somebody who is not, but just wants to think about pain differently in their life, something that people could finish this podcast today and immediately do to transform their relationship with pain. One homework assignment is I want everyone to rewind to this part of the podcast where we talk about the pain dial and see if you can explain it to someone you love. What I've learned in my life is if you can teach a concept, it means. it has sunk into your brain. So rewind to the pain dial and then teach it to someone. Because again, everyone deserves to understand pain. None of us are going to escape. You will be giving your loved ones,

whether it's your partner or your parents or your kids, a great gift if you explain to them how pain works. So if you can teach it, you understand it, and then you can also manage it and change your own pain. And that to me seems like a really important gift. Is there a message that you'd like to leave people with about pain? Yes, chronic pain is treatable. It's always treatable. There's always hope for changing pain. Anyone who has ever told you that it's all in your head or that your pain is not treatable unless you're taking a pill has lied to you and they don't understand pain. And that's not your fault and it's not their fault. There's just a lack of pain education out there. Chronic pain is always treatable, period. I love that. Can you share a little bit about your work? You've mentioned your website. And resources you have there. You've mentioned your workbook. Where can we find all of that? What can we find? Give us all of the details. Yeah, I want everyone to come find me because I want to change pain medicine and I can't do it alone. We need an army of people to do it. So I am on Instagram. I do a lot

of pain education on there. I'm at the real docs off. I'm also on Twitter. I'm at Dr. Zoffness. I do a lot of pain education on Twitter. I have a website where I've been compiling pain education resources for people with pain and people who know people with pain. For about a decade, it's just my last name at Zafniz.com. There's workshops on there if you want to learn more and do a deeper dive. There's book recommendations. There's websites. There's guided audio. There's how to find providers. There's just like a ton of stuff. But please do come find me on social media. We do need an army to change pain medicine and we want to get the attention of the rest of the world. I think it's just so nice to have a community. And thank you for

inviting me to be part of yours. Thank you so much for agreeing to come here and just share all the amazing knowledge you have and the amazing work that you're doing. You're changing the world. I feel honored that you spent this time with me. Thank you for inviting me, Liz. I hope you're walking away with some tangible tips that you can implement into your life. And if you think that there's anything that could help someone else in this episode, please shoot them a link. I'm personally going to be trying out the biofeedback. So I will report back on that. I am really excited to see how it helps my anxiety. Two things, before I let you go. If you haven't already, go join the Healthier Together Podcast Club Facebook page. The posts are ranging from healthy recipe ideas to product

reviews to people just meeting up for coffee and I love it so much. I will link the group in my show notes or you can just search Healthy Together Podcast Club on Facebook. It should come right up. The in-person clubs have also kicked off so you can get more information for those in the Facebook group as well. And finally, we have an incredible giveaway for this episode. Dr. Zoffness is giving away 15 copies of her pain management workbook to the healthier together community. Yes, 15 copies. So your chances of winning are very high on this one.

To enter, just follow me at Liz Moody and Dr. Zoffness at the real Doc Zoff with two Fs on Instagram and comment on my most recent post mentioning something that you loved or learned from this episode. The post does not need to be about the episode. Just mention Dr. Zoffness so that I know that you're entering. And if you would like a bonus entry, you can take a screenshot of this. episode and share why everyone should listen to your stories. Just make sure that you tag me at Liz Moody and at Dr. Zoffness at the real Doc Zoff so we can both see. If you're new here,

make sure that you're subscribed to you. Do not miss out on any future episodes. We have really exciting ones coming up, including one on figuring out your life's purpose and a gut health episode that will transform how you think about your immune health forever. That one is a must listen as we're heading into cold and flu season. So subscribe, subscribe. Subscribe. subscribe so you do not miss out on anything. Okay, I love you and I will see you next week on the next episode of the Healthier Together podcast. If you have headaches, allergies, brain fog, skin irritation, or you've been dealing with hormone issues, you are especially going to want to listen to this ad. Every single thing that I just listed has been linked to chemicals and household cleaners.

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