Is My Pain All In My Head?

Preston: [00:00:00] My supervisors think it's funny. They're, they're like, yeah, Preston likes to explore with like fantasy and imagination with his patients. And I, I guess I do that a decent amount where like, I'll like literally pull up my computer and be like, okay, this new fantasy life you wanna live, let's build it right now.

Like Minecraft, how to be patient.

Margaret: Preston, how are you doing today? Where are we at? 

Preston: Oh, I, I'm doing fantastic. I had a, a whole day of didactics, just absorbing information and now I get to do the same thing, um, in my dedicated role as Passenger princess, which I honestly, I could get used to this triple PI think 

Margaret: Passenger Princess Preston.

Mm-hmm. Um, that's, I get to be in control, which is my 

Preston: preference. Mm-hmm. Yeah. Every, everybody's happy. 

Margaret: Everybody's in their designated roles. Um, I don't have an icebreaker for us today. I thought we could just like life check in listeners when we film in advance so that we don't miss any weeks, but we just [00:01:00] finished our first week of July and I wonder how you're doing.

I just started a week of fellowship, but how's like life things instead of doing a themed icebreaker? 

Preston: Oh, things are good. So, um. If you aren't aware, uh, and this is the audience as well. I, I start third year, um, this year, and that's more outpatient for my program. So there, there's always one year of entirely outpatient psychiatry residency.

And our program does it third year. And I kind of like it so far, 

Margaret: really say more. 

Preston: Everybody loves to be like, oh, like clinic is so boring. And it's like a lot of procedure, like going through the, the schedule throughout the day. But I own all these patients now, so I'm like, Hey, you know, I feel like they're coach.

I'm like, we're on a team, alright. And I'm gonna see you back in four weeks and we're gonna get to the prob bottom of this. No problemo. It's like, it's fun to feel in charge of people, you know, like, like I have, I've been playing like pseudo responsibility for like five years now. I'm actually feel [00:02:00] somewhat responsible for them now.

'cause before you go into clinic and it's like, okay, do the whole performative like assessment and exam. The attending wants you to present their plan, but they want you to basically just tell them what they want to hear, which is whatever specific plan it is on that day. And then you're like, okay, cool, I'll never see you again.

To, to the patient 

Margaret: that's, yeah, that's real, unfortunately. 

Preston: And then, and then you go out of the rotation, they're like, Aren, didn't you love outpatient? And you're like, I, no, 

Margaret: I just 

Preston: followed people around. I was their note monkey and then I never saw patients again. So 

Margaret: my passion isn't for medicine, it's for shadowing.

Preston: Yeah, dude. Not, not that I love more than watching someone do their job and then write their documentation. 

Margaret: Nothing like it fella. 

Preston: So I think I was, I was like prepared to not like outpatient. Then I was like, oh wait, actually get to be a doctor. So it's kind of nice. 

Margaret: Are you doing like a lot of intakes? So I feel like that's like the positive view of it.

And like the other view of it is like, oh shit, these are my patients. Like these are [00:03:00] mine. Like I'm the person who like talks to them the most. And so I feel like that transition is like exciting and like Yes, finally. Mm-hmm. And then it's like also with that, you know, the dual sidedness of responsibility.

Have you been feeling any of that or do you feel pretty well supported? No, I haven't. Haven't 

Preston: even thought about that yet. I'm like, oh shit, they're my patients. 

Margaret: You're like, no, wait a minute, Preston just getting talk missing. There's the side of this coin your eyes. 

Preston: I think maybe, uh, maybe this is just like my delusional confidence or something, but I, I feel like I've always been wanting to take on more responsibility in, in psychiatry, and I don't mean to devalue our profession, but I think sometimes I'm like, what's the worst that could happen at psych?

You know? 

Margaret: Well, I can think of a few. 

Preston: Yeah. Yeah. And we can always think of like the very glaring, bad things, but I guess mm-hmm. I'm comparing myself to my sister who works in an ICU. Yeah. She is like a CRI care attending, so it's like, okay. You know what I mean? Like I, I feel the pressure differential between like, that's my depression intake and her [00:04:00] patient care every day.

Margaret: That is fair. Her is, hers is immediate. And listeners, I think we've mentioned this before, one of my brothers is also an ICU doctor and my sister is an oncologist, so. I'm not winning any comparison games there either. 

Preston: Don't complain about call. Don't complain about your, don't complain about 

Margaret: call about the emotional impact.

Yeah. Love you guys. Shout out. Um, that's exciting. That's good. I feel like there's like a little, I listened to our burnout episodes that came out recently and we were, we were in the dumps there. I think that was the end of May. 

Preston: Yeah. Yeah. I, I felt that. So what's going on with you? 

Margaret: I started Fellowship last week.

Um, most of it right now is like not patient care issues. It's like. Get duo to have two factor authentication. Authentication, the, the 

Preston: Microsoft Authenticator app, right? 

Margaret: Where you get, like, you [00:05:00] email someone and you're like, Hey, this isn't working. It says this error. And then they're like, are you sure? Like two days later And they email, you're like, I'm, can you just, I'll take care of it if you just give me a phone number for someone.

They're like, let's, we're thinking about this. And I'm like, I needed this yesterday. 

Preston: Oh God. And the ultimate response is like, you need to see this other person. And the other person is like, you need to see a third person. And then the, the third person sends you back to the first one and you're like, I just, I've been going in circles right now.

It's, yeah. 

Margaret: Yeah. It's not great. I will say as someone who is not, is actually in the same system as I was in residency, it hasn't been too bad. Um, I feel for my co-fellows because who are like having to, I don't know for you, but for us, it's like. There's technically three different systems. We're like rotating in, and so I only had to like get acquainted to one of them that I wasn't yet in.

Are coming into the system like just fresh. So there's like many, [00:06:00] many duo authentic authentications. They have to do 

Preston: death by duo. Two factor authentication. Really? 

Margaret: Yeah. Well, and then they'll do the thing, okay, and this is boring, and then we'll get into pain. Guys, sorry, this, I'm gonna cause you pain with bored.

And first this is, I'm gonna induce it. Um, you'll do the thing where you go to orientation, right? Like they'll bring you to the computers, like, we're gonna get you like badges and logins, dah, dah, dah, dah. And when you're at the hospital, you're on their like verified network, whatever. So you can like get into all their website.

And then they're like, yeah. And then when you get home, just like log on through A VPN, you're like, okay, this is great. But then when I tried to do that, it came up with something else that was like, you aren't actually registered in duo, so you actually can't do it on your internet. I was like, and trying to explain this verbally via email to like the person in the like au like the registration office is.

Preston: Yeah. Dude, I feel like I'm, um. Like, I'm at the car, the car shop, and I'm trying to explain the engine noises that my [00:07:00] car's making. And they're like, they're like, well, is it, is it a camp shaft issue or is it a modulator issue? And I'm like, it's going,

can you fix that? 

Margaret: They're like, uh, it's like, you're at the car shop. I'm the box. The thing is not 

Preston: working. 

Margaret: It's like you're at the car shop place, but neither of you are a mechanic. Like, it's like, this is like a third party software that like, this is one of their many hats they wear. Understandably. So they're like, I don't know why the software is glitching on you.

Mm-hmm. Um, but other than that, good. Excited to treat some kids eventually once I get authentic and genuine everywhere. No, you're doing 

Preston: your true passion, which is admin work and then my, then treating the kids will just get in the way. 

Margaret: I'm just trying to be an admin. 

Preston: Dear audience. Yeah. Uh, Margaret's here to click boxes.

Don't get confused about it. I'm 

Margaret: gonna be the arch nemesis of everyone. Just kidding. I love admin. Do it. Well, it sounds like 

Preston: all of this. Onboarding has been a huge pain. 

Margaret: Yeah. You might say it was a pain in the neck. Speaking of, are [00:08:00] you ready for the first part of this, our chronic pain kind of part two episode, um, where I have some myths and truths about pain that I wanted to fast round test you on and judge you on your answers?

Uh, no. We'll give the answers 

Preston: and then I, you'll judge me anyways, I do that. That's true. I was reading the Run a show and it was like, now after we've reviewed what Preston got wrong, let's move on to the next section. I was like, okay, no faith did I say that? I write that. No faith. 

Margaret: Okay. But whenever I'm writing the all like listeners, I'll be wor we have a document that we share with our producers that is like our run of show.

And half the time when I'm doing it, I just see your little like Google face, like meandering and, and you're like. Your little like mouse will like hop and I'm like, why are you in here when this is the one I'm doing 

Preston: enough onto the myth and truths not 

Margaret: get. Okay. Before I ask you that, what has your experience been with treating chronic pain in med [00:09:00] school?

Like how much do you think like lectures, rotations, um, whether in residency or med school do you feel like you got 

Preston: I've probably had like three or four hour long lectures, um, from either like anesthesiology or palliative care or family medicine. Some, some form about treating like chronic pain in different contexts.

Margaret: Mm-hmm. And what's it been like as a resident? Like do you feel like you've run into it in consults at all when people are like, this is addiction for psychiatry and then you're like, they're actually just being treated. 

Preston: Yeah, so how we run into it in, um. Consults most of the time is like, we have a patient who has chronic pain and they aren't getting along with their treatment team, and there's some kind of like conflict there.

And then they tell somebody somewhere that they're suicidal and then the team is just like, consult psych. And then I go and talk to them and they're just like, well, I'm just seeing so much pain all the time that I'd rather just not live than live with this pain. [00:10:00] Yeah. And you're like, okay, so like your suicide safety plan is like treating your pain then.

Yes. Yeah. And then you end up just being this giant circle where I'm like, okay, back to the team. Treat the pain. You know? But, but I, I don't know, have any other like tools to help out besides my safety assessment, which was coming to the miraculous conclusion that people don't wanna live with pain. 

Margaret: Yeah.

Well I think that's like a really, I mean, great example of. The kind of like interdisciplinary care that these kinds of patients need, both from an evidence-based treatment perspective and just like logistically and on consults, it's kind of the worst setting for that because the ho they come into the hospital, they need to get out of the hospital.

The hospital doesn't want them there for beds, medicine doesn't wanna start a pain med. We aren't gonna start a pain med in a lot of these cases. And the pain meds that we would prescribe aren't gonna help right away. Um, so I think that is a situation that anyone who works in healthcare will [00:11:00] probably relate to.

Like, well, what do we do? Um, and also probably patients who have chronic pain who've experienced this frustration of being shuffled around different care settings. So are you ready for our true or false? 

Preston: Oh, I'm ready. 

Margaret: Okay. Um, it's not in any particular order, and you may surprise me and get all of them right.

I tried to make them a little difficult, so I didn't give you basic ones. If that, you take that as a compliment, you can only say true or false. And I will tell you if you're right or wrong. And then after we take a break from at, from this, we'll come back and talk more in depth about them, okay? Okay. Okay.

Question one, nociceptor. A k, a. The name for receptors for noxious stimuli and pain come from the Latin term, no, C, which means to cut. 

Preston: Um, 

Margaret: false correct fibromyalgia is a type of neuropathic pain of the three types of pain as defined by the Stanford and Association for American Association for Chronic Pain Guide in 2024.

Uh, [00:12:00] 

Preston: true false and 

Margaret: number three, 30% of adults over 65 report suffering from chronic pain, and half of those people per CDC estimates are on pain medication. True? 

Preston: True, correct. 

Margaret: 25% of children suffer from chronic pain. False, 

Preston: true. 

Margaret: The general first line of treatment for chronic pain should be physical therapy followed by medication management when indicated.

True graded motor imagery is one approach in chronic pain. Used to redevelop healthy nerve connections and brain organization to restore movement and diminish pain sensitivity through progressive indication of imagined and enacted physical movement of painful body parts. 

Preston: So sorry, rated neuroimaging Like biofeedback?

Margaret: No, not biofeedback. 

Preston: Okay. True. 

Margaret: If someone has chronic back pain, medication is not indicated for long-term treatment. Uh, 

Preston: pass. 

Margaret: I know you have. That's not an option. [00:13:00] False. Correct. And last question, sleep Difficulty in insomnia is one of the most common complaints in populations with chronic pain. True. Oh, he was on it.

He's like, I work in, I work in the va. I'm sure you deal with a lot of this. Mm-hmm. Okay. Those are all my true false questions. I think you got six right? Of the eight. You passed. 

Preston: All right, we'll take it. I think, yeah. Well, what's passing over five just and 

Margaret: having a good time. 

Preston: Oh my god. I passed. 

Margaret: Okay. So we're gonna take a quick break and we come back, we will talk about these answers and then talk about a overall schematic for thinking about chronic pain as a psychiatrist.

Um, and for people who don't treat pain day to day. So we'll be right back.

Preston: Uh, I have to study for pride and I haven't started yet. I just keep procrastinating it. 

Margaret: Will you accept some wisdom for me as your senior and as a fellow? 

Preston: Oh, happily, [00:14:00] Dr. Duncan. 

Margaret: I've been using now United Psych to get ready for boards this fall and it's a Q Bank, but it's also more than that. There are flashcards, there's different ways to review topics and it's been really helpful for me.

Preston: You know what, it is a great resource. Okay. Study. Preston is coming back. This weekend and now you know psych is leading the charge. 

Margaret: If you, unlike Preston, are ready to take your exam prep to the next level, I'll be ready. You can go to now, you know, psych.com and enter our code for the podcast. Be patient.

That's one word at checkout for 20% off. That's now, you know, psych.com code. Be patient 

Preston: and use the code. It's 20% off and then they'll know that we sent you. That's important. It shows that we do. Good job. Yes. So one podcast that I think all medical providers should be aware of is the sepsis spectrum by sepsis alliance.

It's run by this great critical care provider, Nicole kic. One thing Nicole does really well is she captures the human story within infection. [00:15:00] Anytime a person's involved, there's gonna be a story involved, and she finds a way to bring sepsis outside of the hospital, and she helps experts tell the stories of patients who have sepsis in the community and teaches you how to recognize signs when there's problems to bring them into the hospital.

We know that 87% of sepsis starts in the community, so it's important to make the conversations there. 

Margaret: If we know anything, it's that. As many reps as possible, hearing as many iterations of presentations is how we recognize it better and more quickly. And this podcast can help all of us with that. And you can listen to the sepsis spectrum wherever you get your podcast or watch it on Sepsis Alliance's YouTube channel.

To learn how you can earn free nursing CE credits just by listening, visit sepsis podcast.org.

Okay. Preston, are you ready to learn the two of them that you, I guess you 

Preston: knew most of them. Yeah, I, I think so. To be honest, there were a couple that I was guessing at and I was like, oh, nice. I got it right. I feel like I [00:16:00] answered confidently on like three of those. 

Margaret: And we're doing an aphasia episode next week, and I'm not gonna do any preparation, so that'll be, that'll be me next week.

Yeah. 

Preston: You'll, you won't be, you won't be able to find words for that episode. All 

Margaret: right. Well, that's it. That's it for our episode. That No. Okay. Yeah, no, 

Preston: I, I thought it was hard. I mean, I, I appreciate the Latin, but I think I knew Nociceptor came from something that wasn't cut. So that one I did feel confident about.

Margaret: I knew you would know the root. I was like, he's gonna this. Okay, so, um, you're right that no C is the Latin root and it means to harm. Um, so nociceptors are what Mo So the reference for Almo for all of these, and honestly the reference I go to a lot clinically is Stanford has a chronic pain guide that they put out every year, and it's like 200 pages.

It's free, it's a PD they have online. Um, they are now, as of last year doing it in collaboration with the [00:17:00] Association for Chronic Pain. Um, so they are collabing on that. And so this is, these questions and a lot of my, like clinical based stuff is based on that, um, as the most recent kind of approved resource.

So first one, nociceptor. I, I like the, the, the nerdy part of me, like knowing what all the receptors are. Yeah. Um, but it will get back to why this matters for one of the other questions, but yeah. So basically it is named after the receptors that pick up on pain or harm or noxious stimuli. Mm-hmm. Um, we'll get into this, that it's kind of complicated to think about pain and whether it always has a relationship with the noxious stimuli.

When I say noxious stimuli, what does that mean to you, Preston? 

Preston: Um, uncomfortable stimuli. 

Margaret: Yeah. To me it brings up the idea of like tissue damage, right? Like something's physically wrong. 

Preston: Mm-hmm. And when we're 

Margaret: talking about [00:18:00] chronic pain, that gets kind of complicated when we can't find a reason or we can't find the stimuli, but someone's Yeah.

Experiencing pain. 

Preston: Makes sense. 

Margaret: Okay. This one was interesting. I actually had forgotten this, but, so number two is fibromyalgia is a type of neuropathic pain of the three types of pain. Um, so you, this was one of the two you got wrong? Um, I thought it was neuropathic as well, but it's actually a third type, which again, we're kind of in the weeds.

We'll get more into the real clinical stuff. So wait, what 

Preston: are the types of neuropathic pain? 

Margaret: Yes, so the three types are three types of pain that they delineate kind of in the Stanford guide. Mm-hmm. Because it can, the treatments kind of delineate in this way, like the three they delineate out is, uh, nociceptive.

So when we're talking pain and noxious stimuli or tissue damage. So pain from like if I cut your arm off Yeah, that would be in their categorization. Nociceptive. So there's damage to the [00:19:00] tissue around it. Neuropathic, which is damage to the nerve. Certainly you can have damage, but I thought you said 

Preston: there's three types of neuropathic pain.

Margaret: No, I said there's three types, types. 

Preston: Okay. Just three types of pain. We'll, we'll find out from our editors. So this, okay. I see Nociceptive, neuropathic, and then one other 

Margaret: neuropathic. And then the one that fibromyalgia and IBS is categorized as no cpl, um, which is pain from an unknown kind of source. So neuropathic is like with type, like complex regional pain syndrome or like if you know about people having pain, um, with like type with diabetes, right.

As the nerve gets damaged, there is pain from like kind of faulty signaling. Nociceptive is from like tissue damage injury, other, other kind of inflammatory, like appropriate 

Preston: somatic response. Yeah. To injuries. Okay. Yeah. 

Margaret: And that, and nociceptive breaks down so the tissue damage one breaks down into somatic and visceral.

So somatic can be kind of. Muscle joint, things like that. And then visceral being [00:20:00] like organ pain. So if someone has, I feel like the one that comes to mind for me is like people with like Crohn's or other inflammatory house. 

Preston: After you eat a ton, 

Margaret: what, 

Preston: like, like, you know, after Thanksgiving when you're just like, oh, too much and then your gall bars going crazy.

Guess that would be one I was 

Margaret: thinking of like illness, like pathology. So like if someone has like Crohn's or ulcerative colitis and they're experiencing pain in the organs. 

Preston: Gotcha. 

Margaret: But also, also you're, 

Preston: or like pregnant, imagine maybe. 

Margaret: I dunno, I'm like very aware of our scope right now, so I'm like, I don't, I, 

Preston: I feel, I feel like provi, like the pain with labor could be like close to visceral pain.

Margaret: I think so. Sorry. You're right. We should, we should be aware of our, it's also somatic though. 'cause then like with labor, it's like actually not, 

Preston: we, we won't touch that. Right. 

Margaret: So I'm gonna get dragged in the comments for this episode in the last episode being like, no, actually Preston. Okay. Um, anyway, I thought that that was interesting because it gets to [00:21:00] the point of like, where's the pain signaling coming from?

That is then coming into like central nerve nervous system awareness and then being felt. Mm-hmm. Um, so that there's kind of these different ways of thinking about the damage and that, I guess the signaling cascade, it ends up being important for how we actually treat it in a lot of ways. Mm. The next question was 30% of adults over 65 report suffering from chronic pain and half of those, or 15% of total adults, over 65 per CDC estimates are on pain medication.

Preston: Yeah, I, I did know that actually that's a statistic that's, it's kind of waved around a lot. And so I think I've just almost come to anticipate like patients of a certain demographic at least it's very likely to have chronic pain. Yeah. Um, in their past. 

Margaret: I think that it, what's interesting is like one in three, like this is over 65, but then it was also true that 25% of children suffer from chronic pain.

I think [00:22:00] that like, I think it was 20 to 25% based on different estimates, but if this, if one in four kids and one in three older adults and probably one in three to four like general adults are struggling with chronic pain, you would think we would get more teaching on it or ways of approaching it throughout medical school.

But I think even more than that in psychiatry training. Like, not that we're gonna be the ones doing like a Botox injection or something, but for how common it is and how interlaced it is with our illnesses, you would think that we would get, it would be more of like a primary focus for us in some ways.

Mm-hmm. Or at least I kind of wish that I'd had that. 

Preston: Yeah. I, I feel the way about a lot of things that like psychiatrists interlaced with. That's fair. 

Margaret: That's very fair. Um, I found that kids won surprising. I would've like not, I would've [00:23:00] guessed like 10% maybe, and I would've thought that would be a high guess.

Preston: Yeah. I, that's why guess I was like, I don't think it's all the way up to 25. 

Margaret: Yeah. But, but 

Preston: yeah. That's, that's incredible. 

Margaret: Yeah. I mean, have you ever worked with treating kids with chronic pain? 

Preston: Yeah, it is really challenging. 

Margaret: Yeah. I feel like there's a whole different set of considerations similar to how like we think about meds differently for.

Psychiatry as kids mm-hmm. Versus like older adults? 

Preston: Well, I, and I've, so personally, like w when I've seen kids dealing with chronic pain, it's a lot of it can be like somatization of psychiatric disorders. Mm-hmm. And so, like, very quickly you're treating this kid who has a lot of chronic pain problems and it comes out like they have a, a pretty toxic situation at home or with their parents or anyone else.

Mm-hmm. And then you start to realize that like, these pain treatments aren't working because this is like this patient's response to their environment and everything else. And so like, it [00:24:00] immediately turns into this jenka pile really fast, is what I found. 

Margaret: Yeah. Yeah. No, I think, I think you're right that there's definitely these other components that can make it be a, like all of these things go into whether someone is sensitized to pain and how the pain is expressed and felt.

Mm-hmm. The next one, which you got correct, was the general first line. Oh wait. No, you didn't. You got this one wrong. The general first line of treatment for chronic pain should be physical therapy followed by medication management when indicated, and this one was a trap. Uh, but I, I think one of the things I learned, so listeners, I, my fourth year in med school, I spent it with, um, an embedded pain psychologist at, in St.

Louis, and we worked on like a primary care guide for treating chronic pain. 

Preston: Mm-hmm. Um, 

Margaret: and one of the things that I found interesting was like the studies on the first step is neurobio education around chronic pain in particular, and that may sound sort of [00:25:00] like 

Preston: wait. And so physical therapy is step two.

Margaret: Well, it depends on the pain problem, but yeah. Yes. Like anything is step two. Wait, so I told you it was a trap. 

Preston: Okay. But that's like a dumb tr the 

Margaret: no, it's not because people, most people get this primary 

Preston: education. 

Margaret: When was the last time you gave a person, when was the last time you taught a patient about central pain sensitization?

Preston: I, I don't think I've ever taught someone about Exactly. 

Margaret: And that's, you're missing the effect of treatment. So, I'm sorry. Yes. I told you, I said I laid a trap and you fell into the trap. However, 

Preston: okay. 

Margaret: Most people are not getting taught. Um, the kind of myths andrus about chronic pain, and we'll come back to that in a second, but the last one was graded motor imagery is one of the many approaches that are kind of psychological.

You said biofeedback, that's also one of them. 

Preston: Mm-hmm. And 

Margaret: behavioral, um, for chronic pain if some, and then seven was if someone has chronic back pain, medication is not indicated for long-term treatment. You got that right? You said false. Um, mm-hmm. I think that gets us into an interesting question, which we'll get into with meds [00:26:00] for chronic pain of.

Using it and then increasing dependence on it versus using it as a PRN. And I think there's an analogous way to think about it as we think about it with like chronic anxiety disorders and benzos, that it's not an mm-hmm. It's not a never thing, it's just a how do we optimize the medications and treatment plan for someone and reduce risks as much as possible.

Preston: Yeah. These are, these are safety nets and parachutes. They aren't our mainstays. 

Margaret: Yeah. And then lastly, sleep difficulty is one of the most common complaints in populations with chronic pain. You have experience with that. I, I mean, I 

Preston: feel like that's half the time is like the initial complaint that comes through and then you start to uncover chronic pain afterwards.

Margaret: Yeah. No, I think, I think you're right. And obviously sleep. Sleep is indicated for us in terms of like who comes to see psychiatrists and then like what makes our illnesses like worse or better. Mm-hmm. Um, yes. So. One of the things I [00:27:00] wanna, I guess, start with talking about is, what is this, like neuro, like common myths that patients will have about chronic pain versus like all other forms of pain.

Which 

Preston: cat was that? 

Margaret: Um, 

Preston: it's lilac. She's on one today. She's been 

Margaret: crazy. She's a crazy girl. Um, so how would you define chronic pain versus acute pain? Like is there a timeline you think of? 

Preston: Um, I would say anything under six weeks is kind of like my general cutoff for acute pain versus chronic pain. 

Margaret: Mm-hmm.

And the, so the way that pain defines it is three months, more than three months is how they def that is their kind of arbitrary cutoff, but 

Preston: Okay. 

Margaret: Yeah. So pain that lasts a long time. I think the other part of that is what caused the pain. So like. If I stub my toe and it still hurts four [00:28:00] weeks later, uh, versus like if I have open heart surgery and I'm still having some twinges, we might consider it different.

So it's, it all, it generally is beyond three months, but also weeks to months beyond what you would expect in the normal healing process for a given injury or disease. 

Preston: And then, and then I think it, it tends to be more vague the way What do you mean by that? So, um, I think people with chronic pain when they, they try to, I try to kind of ask them to pinpoint where it hurts and that they have trouble saying, like, putting, you know, their finger on, on the toe that hurts specifically is just kind of like, my body hurts, this hurts.

You know, I, I've just found, I don't know how, if that's a part of the, the criteria that you've listed, um, outside of like extended. Normal, ordinary, heal, healing processes. But, but 

Margaret: I mean, I think you can think of like, let's say we have a patient who has like [00:29:00] knee pain because he has like knee osteoarthritis, right?

And it's ongoing for years and years and nothing is making it better. Um, we would probably call that chronic pain even if it's super localized. 

Preston: Sure. 

Margaret: Another difference between chronic pain and acute pain, um, is the functionality of it. So one of the things that we think about in pain is like acute pain, is the body signaling, quote unquote correctly, that there is something has happened.

This is outside of things like fibromyalgia or complex regional pain syndrome, but. Basically it's like the body signaling that something is dangerous or the stove is hot and you need to stop or you're going to risk life and limb. Um, I think all of us heard probably during one of those four pain lectures in med school about people born with like a genetic condition that makes them not sense pain and they often die pretty early and have injuries 'cause they can't feel it.[00:30:00] 

Or we've worked with patients who have neuropathies and can't feel their feet and we see their feet and they are not sensing the things that are injuring their feet. So pain has a function in our body that is protective and acute pain is generally thought to be within that the sit the alarm system is working well.

Preston: Mm-hmm. 

Margaret: Whereas chronic pain moves us into this concept of central pain, sensitization, um, and into a sort of broken alarm system that it's not just someone's broken into your house and the alarm is going off. It's like anytime someone sneezes the alarm is going off. And making you very aware that something is amiss, which is not as helpful for chronic pain.

Mm-hmm. Um, the last thing I'll say in terms of differentiating them, that is part of the many things you could say on neurobio education is the differences in how you would encourage a patient to deal with acute pain versus chronic pain. So let's say I [00:31:00] was leaning down to do play therapy with a kid and all of a sudden I had a strain in my back or something and I come and see you and you're my doctor in psychiatry and we're talking about other things, but I'm like, yeah, things just been hard 'cause I've had this back pain for a week since I strained my back.

What would be the difference in what you would tell me to do with that versus if I had had the back pain for a year? 

Preston: Yeah. So I, I think with acute pain, there's almost no discussion about like. Your relationship with the pain, it's really just, here are coping skills or like, what are ways we can get you to survive until the pain subsides.

Mm-hmm. And then you can go back to your normal level of functionality. Right. But when chronic pain, I guess anything that I would counsel you on for acute pain wouldn't really work because the pain's not gonna go away. It's something, it's a roommate at this point. It's not a, a temporary, uh, a roommate couch surfer.

Margaret: Yeah, no, that's exactly right. And I think that's one of the core concepts that is helpful to explain to patients, but [00:32:00] more than explain to kind of work with, um, because there is in the, you know, pain world, you kind of variety of like, let's say injuries. You're exactly right. If someone's been in pain for like a week, you'd probably tell them like, rest is, is probably good.

Like, take it easy, get enough sleep, don't push yourself too much, don't injure yourself further, wait till you feel better and then get back at it or whatever. Mm-hmm. 

Preston: Weight. Weight is at the center of it. 

Margaret: Yeah. Versus chronic pain, mobilization, functioning, kind of behavioral activation and some tolerance of the pain.

And like you said, how you relate to it are all central to getting them back into their life done with compassion and done with like a graded kind of program. But mm-hmm. Wait ice, treat it, wait for it to go away until we start doing the next thing in our life is, does not work and reduces function and worsens pain sensitivity [00:33:00] sometimes.

Mm-hmm. Does that make sense? 

Preston: Yeah, it does. 

Margaret: I think the other thing with, just to touch on pain, uh, central pain, sensitization. The broad idea. We've talked, we talked about this in our pain episode with, uh, lady Spine doc, but it's generally the idea, I'm gonna oversimplify it into a metaphor. The alarm is going off somewhere in your body for long enough without stopping that your central nervous system picks it up and is like, okay, instead of tamping it down, it just makes the central nervous system sort of be on high alert for pain in that area, but also then in other areas of the body.

Mm-hmm. Which is part of why when people have one chronic pain syndrome, they're more likely to get others because there's this centralized process of sensitivity to pain, not just at that nerve site, but now within the central sort of processing and inhibition and disinhibition of pain signaling 

Preston: system.

I see. So, so it, it [00:34:00] changes fundamentally changes the signal to noise ratio that your nervous system is working with. Yeah. Interesting. And so. This is all sympathetically mediated. I, I guess just thinking out loud, um, exercise is a great way to induce norepinephrine modulation of mm-hmm. Muscles and, and joints.

And then also of the medica medicines we use as seno rise or serotonin norepinephrine reuptake as you are, 

Margaret: segwaying us perfectly into our medication approaches. So these, like 

Preston: venlafaxine and duloxetine are quite effective. 

Margaret: Yeah. So do you wanna, so norepinephrine modulation more so than serotonin modulation?

Mm-hmm. 

Preston: Or, or even like opiates or dopamine or anything like that. 

Margaret: Yeah. I wouldn't, I mean, I wouldn't speak to opiates, but dopamine, yes. Mm-hmm. Because there's, there was a discussion on like, Wellbutrin has not been shown to be helpful for pain. Uh, stimulants for sure have not been shown to be helpful for [00:35:00] pain.

Um, but as NRIs have been shown to be helpful in TCAs. As cla as a class have been helpful and it's attributed to the norepinephrine impact compared to just SSRIs alone. 

Preston: Interesting. Uh, what 

Margaret: are the most common ones you think about? Like, do you have any that come to mind that you've seen patients on or that you've thought about starting for people with pain while they were in your psychiatry clinic?

Preston: Yeah, so I, I mean, classically duloxetine of the SNRIs is probably the most common one we use. Um, venlafaxine, not as often. Uh, from what I've seen, it has less of an effect size than duloxetine. I, I actually like, so I've been kind of proven wrong. I think over the last year I used to have a lot of skepticism about duloxetine, 'cause I, I would read papers about how much it actually helps people with their pain.

Mm-hmm. The average pain rating, you know, on patients that had whole regimens and then like plus or minus [00:36:00] duloxetine, it would be self-reported pain of like 6.5. And then in the treatment group it would be like 5.7. These are scales out of 10. So I was like, what, what is the actual difference of like, you know, rating your pain of five out of 10 versus like a six out of 10 and, and like it was over the course of, you know, a thousand patients, if that's the average change, like how, how many of these patients are like really gonna be noticing that difference?

Mm-hmm. Um, but anecdotally, I've seen a lot of people that, like they find duloxetine does a great job of, um, reducing their pain and, and I think one thing that's unique about a lot of psychiatric treatments is that we get these averages that are spit out in our surveys. The reality is in a lot of patients, they either work or don't work.

Mm-hmm. Mm-hmm. So it's like the average is like, you know, half of a, of a of a point, but that comes from it doing nothing for 10 people's pain and then doing like basically everything for the other five people's pain, and then the average comes out to be somewhere in the middle. Right. 

Margaret: Right. Yeah. Well, [00:37:00] and like the fact that there's any significant difference on these studies compared to 

Preston: mm-hmm.

Margaret: We've tried. Right? Like regular SSRIs, we've tried other things at versus placebo and they have no effect size placebo come out in the wash. Yeah. 

Preston: Notable. 

Margaret: Yeah. Um, so yes, I agree with you. It's definitely not the cure all. It's generally more thought to be helpful for neuropathic pain. Um, and then TCAs, the common ones were nortriptyline amitriptyline, and then.

Mil Milram or Vela is FDA approved for fibromyalgia treatment. Mm-hmm. Um, and possibly more potent, um, than others at blocking norepinephrine, which is an S-N-R-I-I believe I am. I tripping. Is that, I don't think 

Preston: I know the mechanism of that one. 

Margaret: I think it's an SNSI. Yeah. So it's thought to be more, possibly more potent in the norepinephrine field than Tine and Ben Super.

Yeah. But I've never prescribed it [00:38:00] clearly. 'cause I was just like, is it necessarily, yeah, me neither. But I've seen rheumatology prescribe it and had had a couple patients who had good impact from it. So, um, the other thing, thinking about pain meds, not with SNRIs, but like TCAs from our view, a psychiatrist is just thinking about like, um.

For people, two things. One, if we're treating in the Jerry population or for anyone who's just very ill and struggles with balance or other things like that. Thinking about, um, side effect profile in terms of dizziness, like hypertension, um, other kind of cho cholinergic burden. And then thinking about if they actually are on pain meds, um, to make sure we're, uh, thinking about serotonin load if they're on SNRI or TCA.

Mm-hmm. Just because some pain med, other pain meds can also be, uh, serotonergic. Mm-hmm. So those are our kind of like psychiatry's in the right to prescribe these ones, right? 

Preston: [00:39:00] Mm-hmm. Like 

Margaret: those are our, our kids. Those are our meds. 

Preston: Yeah. Tramadol comes to mind. Yes. When you talk about these other like, pain medications and Yeah.

My rant about tramadol is that it's, oh, I know this 

Margaret: rant it. 

Preston: Pharmacologically is actually closer to venlafaxine than it is to codeine. Mm-hmm. So it, it's better to think about it as like an SNRI that has a little bit of opiate action rather than an opiate medication that has some serotonin interactions.

Granted, it does have an active metabolite that is a lot more specific for opiate receptors and, and other things. But as far as like mood benefits and, and anxiety and pain is concerned, that's, that's where tramadol kind of lives. I always find it so funny that like there'll be, uh, people, like family members will say like, oh, I didn't, I didn't need antidepressants.

I just had to get my pain, treat with tramadol. Then my mood got way better. And you're just like, yeah, depress getting venlafaxine. [00:40:00] And then when you stop your tramadol, you're, they're like, they're gonna stop my tramadol. I'm in mood tanked again. You're like, oh yeah, I wonder why. 

Margaret: Um, yeah, I remember I did a rotation with, uh, toxicology.

I feel like you could be a toxicology person. I mean, we can't, as, can we have psychiatry go into talks idea? I don't think so. Um, I love the toxicology people. I did the rotation with them every day, was like them debating and doing a rant and one of them was about tramadol, uh, and then showing us the blog, uh, the talks and the tox in the hound that has an article called Tram Don't.

I'm 

Preston: like, it stuck so hard. Yeah. Tram never. 

Margaret: Um, a couple other things that I think because we see our patients frequently, um, ideally, especially if there are therapy patients as well, we may be the ones kind of like talking with them the most. So I think just to touch on non-opioids that are like over the counter that our patients might be taking, um, [00:41:00] and how their side effects can interact.

So what are you think, do you ever talk with your patients besides the intake of like what overcount the counter medications are you taking? Do you ever talk, get in the weeds with them about this? 

Preston: Um, I mean, I, I guess it, like, it varies by patient, so I, I may ask them if they're taking other over the counter supplements or, or like what they're doing to treat their pain mm-hmm.

If they have any. Mm-hmm. But, um, the one I will get into the weeds on will be Tylenol. Mm-hmm. So I don't, I think this was hammered into me from a lot of my family med rotations. UNC had a great family med department and one of the things that they cared a lot about was like, must be nice getting patients on scheduled Tylenol and like Yeah.

Helping them really, it's almost like selling the benefits of like. Doing like consistent low hanging fruit for pain management before escalating. 'cause I think a lot of patients will say like, I'm, I'm really frustrated. Tylenol doesn't touch my pain at all. So I'm almost like unwilling to try it and I want to try something [00:42:00] more powerful.

But then you almost, you have to reaff, like reappraise Tylenol and say, it's not great at like killing your pain right now. Yeah. But if you take it at the same time every day, it can be pretty effective for at least like reducing the baseline and making it easier for the other interventions that we have.

Margaret: Yeah. Yeah. No, that's, that is the, one of the points I was, I was gonna like make with this is like thinking about scheduling it. The only other parts I had to add was like thinking about, um, options for topicals that people haven't tried. Although those are mostly based for like arthritis, but like we, we see it all the time in inpatient, but outpatient, like, we don't really talk with our patients about this.

Mm-hmm. Like lidocaine patches will tarn gel. Um, thinking about. Whether a different, like whether them getting prescribed from their PCP and this would, this would be outside of our scope, but like, um, different options based on side effects. So like Celecoxib is a selective Cox two [00:43:00] inhibitor, so it can be, have less GI impact if someone's really struggling with that, especially if they're combined with our meds that aren't always, uh, making them feel good GI wise.

And for, from the ulcer perspective for NSAIDs. Um, and then thinking about their kidneys if we are also like treating someone with lithium, uh, always asking about that. But I think exactly what you said of like thinking about with the patient, when are they actually taking it? Have they had time to get guidance for their own personal life?

And if we're seeing them week after week with how they're taking it, if it can be optimized. 

Preston: Yeah. The, the other thing that I could do a better job of, um, but I guess I'm like really in a PCP role is like if you counsel someone on diet and exercise. I think a lot of us are just like, make sure that you eat healthy and exercise.

Preston, you gotta stop 

Margaret: skipping my, you gotta stop skipping. We're not done with meds yet. Oh, sorry. Um, okay. Psychiatric meds. A couple other, just things that are [00:44:00] a little outside. Some want a couple inside scope and then a couple outside our scope, but that we think about sometimes Gabapentin is always one that we can prescribe, like its Swiss 

Preston: army knife.

Margaret: It's um, for neuropathic pain. It can also have some indication for helping people with cravings. With alcohol use disorder. It's not great at that, but like, again, if there's multiple indications, like let's say someone has a history of alcohol use disorder prior and they have nerve like neuropathy post like heavy alcohol use.

This could be one that could be helpful for both, um, as well as pregabalin, although I hope you gotta get ready to do your prior auth on that. Unless it's fibromyalgia. But then room probably should just prescribe it 'cause they won't get pushback. That we will get pushback as I've experienced. Uh, and then there's some specialized things we won't get into in terms of like anti epileptics, especially for trigeminal neuralgia and some indication for neuropathic pain.

The last category I have is muscle relaxants, [00:45:00] which we are not pre, I'm not prescribing, you're not prescribing, but that interact with our medication and with mental status. And so I think the basics of those are probably important for us to just be aware of. So recognizing, um, zanaflex or tine is more for spasticity and Ms.

Muscle relaxant. So the biggest common one is Flexeril or cyclobenzaprine. Mm-hmm. Um, which about Robaxin. Yes. That is another, yeah, that's another one. 

Preston: Okay. 

Margaret: Um, my favorite named one that, again, we never prescribed these, but a skelaxin, just someone's like skeleton relax, which is generic, is metaxalone. Um, and then technically Baclofen is actually not a muscle relaxant, but mm-hmm.

In, it's used for neuromuscular spasms. Baclofen and Flexeril are not necessarily really recommended for chronic general chronic pain outside of spasticity. Um, for, and, and especially for [00:46:00] long-term use because they can be, uh, kind of sedating and cognitive can kind of reduce cognition function taken long term.

But I think we should recognize them, especially if we have a patient coming in who's like, yeah, I just haven't been able to focus for the last like year and I've just been really feeling tired during the day. 

Preston: Yeah. I, yeah, I, I don't think I appreciate like, the side effects of muscle relaxers. I almost like, my relationship with like Flexeril right now is almost like diagnostic where like if I see Flexeril on their list and, and in addition to this, um, anthology of other medications or, or you know, kind of giant list of medications, I'm like, oh, you know, this is kinda a chronic pain situation.

And then, but then I don't think about like, Hey, should they, is this Flexeril like helping with, with the rest of their cocktail meds? Or is it like one of many things that's probably contributing to their, their, uh, poor cognition or sleepiness throughout the day? 

Margaret: Right. Well, and as we talk a little bit about the [00:47:00] therapies and one of the therapies for chronic pain is the model that, you know, I know I love and know, which is acceptance and commitment therapy.

Preston: Mm-hmm. 

Margaret: Is when we get granular with our patients about their pain and how they're experiencing it. Maybe one side effect from one of these medications that we're not prescribing, like feeling more lethargic throughout the day. Maybe for one patient it's like, eh, it only really impacts me and I take it mostly at night, so it's fine.

Versus for someone else, it's making it really hard to like get up when their kids get up and help them get ready for school. And it makes them feel all sorts of guilt and a like sense of identity change. Then knowing that detail and knowing like working with pain if they're prescribing. But again, pain is still hard to see regularly.

Mm-hmm. Sometimes PCPs like, how do we engage with care to help them, especially given how intertwined pain and anxiety depression are and insomnia. 

Preston: Mm-hmm. 

Margaret: Can be a tool for us to know and be [00:48:00] like more thoughtful collaborative care clinicians. 

Preston: So what are your pointers as someone who has more experience with acceptance and commitment therapy about how to approach this with someone?

I think I've found, uh, a lot of challenge in, in counseling someone on their chronic pain. 

Margaret: Yeah. So I mean, I think one of the things you'll find this year, I know you've started to do therapy last year. Um, it's definitely not, I got, well, one thing I always say to my patients with pain is, I'm sure you've experienced a lot of frustration in dealing with this and living with this, and I can't imagine that.

And you've probably had many, many treatments that have failed and people who have wanted to, wanted to help you, but then also maybe brushed it away or couldn't get what you're going through. So starting there, the second thing is always the pain. In your, I think I've said this on the podcast before, the pain is in your head [00:49:00] and in your neurons, but so is the pain if I cut your arm off, um mm-hmm.

So 

Preston: it's it's always in your head. 

Margaret: It's always in your head. Yeah. So, mm-hmm. I think start and then saying like, and there meant there are illnesses we're discovering now that we didn't have the tools to see why this kind of, you know, different types of like inflammation or other things were happening.

And just probably told people 10 years, 30 years, a hundred years ago that they were making it up because we just didn't have the science for it yet. So I think starting with that, 'cause some people have understandably, some almost like minor medical 

Preston: PTSD from care. Yeah. Just care, like chronic invalidation from the medical system.

Margaret: Yeah. So kind of being like establishing your identity of like, I am a safe space without being, like, 

Preston: without being pandering or, 

Margaret: yeah. And well, without also being like, and I, you should know I'm not an opioid prescriber. Like, I will say that straight out, like that's frustrating when you talk about your frustration towards that.

But that is not my role or my [00:50:00] recommendation. Um, I think from an ACT perspective, so ACT's kind of core pillars are mindfulness to the present moment, increasing psychological flexibility and diminishing avoidance behaviors in favor of values-oriented behaviors. So when it comes to working with people with pain from an act perspective, CBC is also like the most studied and pain and is evidence-based.

And ACT in some ways is a descendant of CBT. Um, so CBT would work more around like different fixed. Beliefs and that's not like mm-hmm. We're gonna have you think that your pain's not bad. I know you know this Preston, but for the listeners that is not CBT when done well with pain is not like, what if you just knocked it off and thought this is actually good that I have pain, but it is getting more in the weeds.

Like I used to be someone who loved gardening and I did this every Saturday and Sunday all [00:51:00] day with my kids and now I can't because my back hurts so much and I'm never gonna have that part of me back. Um, that might be a fixed belief where when we push at it and kind of say, is there a way we can get a chair out there?

Or like, is there a way we can elevate a table so you can work on things and mm-hmm. Maybe someone will need to help you. But so that is still part of CBT. Some of it, if we went further would've been like, what do you value about gardening that the pain's getting in the way? What is the type of person you are and how do we, instead of totally giving up gardening or avoiding any try at it because it's might induce pain.

Do kind of a graded exposure work where we try little different experiments, um, to live out that value still despite the pain. Um, the other part is kind of mindfulness and compassionate acceptance. So always on one hand, we're trying to, and this is true for all of our mental health concerns, like always, we're trying to optimize what we can from a neurobio medication and intervention [00:52:00] perspective.

And the pain is still here, and for many people will still be here, ideally at a reduced like intensity. But how do we not spend every day fixated on like, is my pain gonna ever go away? Why aren't people treating me correctly? Da da dah. Mm-hmm. And all of this really happens over sessions, many sessions.

It wouldn't all obviously happen in one setting. 

Preston: Gotcha. So, so the, the intervention isn't targeting. Why won't my pain go away? It's, it's targeting these false beliefs like, my life is over unless my pain is at zero. 

Margaret: Yeah. 

Preston: Statements like that where, so then you teach, you, you can reframe and say, okay, um, what if your pain was at a tolerable level or what, what a tolerable level even look like?

Or have you considered that? And then like you can still work on adjusting and, and treating the pain, but also now accepting [00:53:00] how you can move forward with your life in the way you want to. Yeah. 

Margaret: I think that's more of like the CBT and somewhat, and I'll say motivational interviewing is also used a lot in pain.

Um, sometimes motivational interviewing is used before you ever embark on any of these like therapeutic interventions, because if you're like, I don't think therapy can do anything for my pain, and this is bullshit. Mm-hmm. And like, I need whatever, like it's, every therapy session will feel invalidating, understandably.

And there are people who like. I mean, you think of like sickle cell, like you think of like people have being mistreated by the medical system whose pain needed to be treated in a different way and for systemic reasons. And then other cases, scientific reasons it wasn't. So you definitely should be ready, I think, for the therapies in some way to like have them work.

Preston: Mm-hmm. 

Margaret: Um, the other things that I think work when you're like, not formally doing therapy with someone but wanna help them build up skills is like talking about is an activity I always do with people of [00:54:00] like pacing. So for people who have chronic illness or chronic pain, often, like, they'll have bad days and good days.

And on the bad days, the good days, it's almost like they wanna catch up with everything they miss on their bad days. Mm-hmm. But then because they overdo it in some ways, they set off this kind of cycle of doing a ton of a worse, 

Preston: bad day and then a more intense good day and then Okay. 

Margaret: So helping them find patterns and then learn how to pace is a huge part, I think, of the work of pain psychology and then using these like emotion regulation, distress tolerance, mindfulness and like values-based prompts to, to build out from there.

But the first step is always awareness. So I'll send them like a graph that's like, can you fill this out for me for a week? 'cause I wanna, you've been through so much with pain already and you've been through so many confusing med changes that first I just wanna start with us knowing where we're at.

That's where I would start 

Preston: in outpatient, the beginning. Tell me about the first time you were ever in pain [00:55:00] and then silence. 

Margaret: Well, and then they, they, one of the things is also mindfulness is stress reduction, which I know you're so good at, uh, you're so good at mindfulness. And then the thing you had mentioned about lifestyle is the final part of this, well obviously referrals for all the things that are like interventional, um, and pain clinic that are many, many, and we won't get into as well as physical therapy.

Um. But lifestyle. What do you tell people who are dealing with chronic pain? Do you tell them things or do, if they ask about like, what are lifestyle factors, I guess? 

Preston: Mm-hmm. Um, that 

Margaret: you think about if they asked. 

Preston: So, um, I usually start by saying that like, it's gonna be the obvious answers that, uh, we all hear.

And I, I kind of almost like make a joke about it, where it's like we spend all this effort doing all this science and biochemistry and studies to find out that the healthiest thing is what your grandma told you to do, which is eat your [00:56:00] vegetables and go run around outside. And that's in a lot of ways, like the best advice I can get you and I.

And then I'll say like, I know it sounds really simple, but it doesn't make it easy. Mm-hmm. Because I think we often will conflate like simple with easy, but like complicated doesn't mean hard either. Some, sometimes, sometimes doing something and the idea of it are, there's just a huge disconnect. So like, for example.

Running a marathon is just, it's pretty simple, right? You just left foot, right foot, left foot, right foot for a long time. But it's a really hard thing to do and that that's what exercise might be for you. And also it's gonna make a big difference for your pain. Mm-hmm. And, and a lot of people helps get them to a new level of function.

Margaret: I mean, I think the biggest thing is like prescribing, like is helping people actually come up with a plan and not just like a smart goal, but I don't think as many people as we think know how to find the growing edge for themselves of exercise. And similar [00:57:00] back to the pacing thing, right? Like, and same goes with like, let's say you wanted to eat a different kind of diet because it may be better for your like inflammatory or autoimmune illness.

I think you're right that it's like, it is kind of these basic things, but I think the movement from A to B. Isn't like rocket science, but I don't think it's something that most people have a lot of experience doing in a way that doesn't either punish themselves or be extreme and then lead to kind of on off.

Preston: Yeah, 

Margaret: and I think that's where our like background and our understanding of therapy can be particularly helpful with lifestyle change is understanding habit and behavioral change and helping them week after week slowly grow in an area that might be the most helpful for them, especially in pain.

Honestly, it is exercise. 

Preston: Mm-hmm. Yeah. I, I think what I've found I do a lot is out like do open brainstorming with patients about ways [00:58:00] that they can move.

'cause usually the, the initial statement is like, I'll exercise more. And if you just say you're gonna do anything more, like, I'll tell you for free, you're probably not going to, yeah. Unless you've like, identified a specific time that you're gonna execute on that thing. Like, like just the same and like, oh, I, I've been trying to sleep more, like, have you, how like, oh, mm-hmm I'm gonna bed at nine.

Like, there we go. You know, we're making a difference. 

Margaret: So I've been trying to make a better podcast. Yeah, 

Preston: exactly. Any, any measurable goals there? And I giggled 

Margaret: again, any smart goals. 

Preston: We'll pick, you know, anything from soccer, walking groups, run clubs, hiking, and then we'll say, okay, well hiking more is too vague.

Like, like. I'll like, pull up on my computer. Let's pick out a hiking trail that you would like right now. You know, we kind of go, oh, this one looks, oh, no, I don't, I don't like the, you know, this route. Okay. Let's try another one. Okay. So, you know, your homework is to go on, um, like Sunny side, like, [00:59:00] uh, like Devil's Egg Crest four Mile Hiking Trail, and tell me how it is and I'll see you next time.

And if it, and if you don't or are aren't able to, then we'll talk about like, what prevented you from doing that. So like either way it pushes the therapy forward in a helpful di direction, or we get to see some behavioral activation mm-hmm. And benefit there. Mm-hmm. So, I don't know. My, my supervisors think it's funny.

They're like, yeah, Preston likes to explore with like fantasy and imagination with his patients. And I, I guess I do that a decent amount where like, I'll like literally pull up my computer and be like, okay, this new fantasy life you wanna live, let's build it right now, like Minecraft. But, but it ends up kind of helping make these goals in the future more concrete.

Margaret: You, you should get trained and act. 'cause that's what we do. We go through like we have them do, Val, if you actually do ACT sessions, it's like we go through all the values in a certain area and then we say you're at, okay, how would you rate where you're at in this part of your life? And it's like, well, what would it look like if this part you were living what?

Like what [01:00:00] values would you live by? What would it look like if you were living at this at a 10? And okay, how do we go from not, and then like what are the practices or values that you would have to be doing day in and day out to move your life that way? And then how can we, each week we talk about like, are you living at that eight?

And it's like, let's say that person wants to run a marathon or something. Mm-hmm. It wouldn't be that living at an eight means that they're running the pace. They'd be running and they're doing this much mileage. It's like I'm doing the next hard step, which is doing couch to 5K this week, whatever. Um. So, I mean, I, I and other act therapists agree with your methods and also I always end my visits by being like, and I'm g and I'm gonna annoy you.

I'm gonna ask about this next time. So, but I say the same thing. I'm like, and if you don't do it, that's okay. We'll figure out what, what, what made this like the assignment that didn't work. And it gives us data. It's a hypothesis. 

Preston: Mm-hmm. I can't lose when you're collecting data 

Margaret: that was so nerdy. That's a [01:01:00] pod that, the merch,

um, that's most of my things. I think something we're, we didn't really get into just we're at kind of at the end of this episode is, was many, much, many things we didn't get into, but just to talk about, about substance use and the understandable self medication with substance. Um, especially in the history of pain as the sixth or whatever vital sign, um, and the opioid epidemic in medicine.

Preston: I, I found almost. Part more pressing for me these days has been marijuana. Hmm. A lot of people will self-medicate with marijuana, um, and then have mixed results on their pain, but I mm-hmm. But I've noticed it's been a, like a challenging relationship. Yeah. And, and to be honest, like I think I try to move slowly with people that have like a, a pretty strong [01:02:00] relationship with their self-developed and reasonably self-developed coping skills, especially if they involve substances.

But it's, it does make a lot of other, like pain management really tough, I think. Yeah. 

Margaret: Yeah. No, I think similar to our marijuana episode, mixed bag, mixed efficacy, it's not recommended, um, necessarily broadly for pain at this point. And onc can be, and it can be useful for some people, but it's, it's not, I think the kind of only.

Beneficial kind 

Preston: of, 

Margaret: uh, ambrosia. We thought it was going to be a decade ago when it first started becoming legal, remember 

Preston: from our marijuana episode. But I even mentioned that like people have a hard time developing insight into like how their weed isn't helpful for them. Yeah. Again, got a lot of backlash on social media.

I was like raised right now. They really love their weed. 

Margaret: Guys, we're gonna post this on the Instagram. You [01:03:00] got rage baiting right now, fishing for anger. Um, do you have anything else you wanna add in terms of things like you feel like you think about with pain or for your patients? We are going to have an episode with, with, um.

A patient and a fellow creator later this season. Mm-hmm. Talking about chronic illness and I believe chronic pain. Is that right? Mm-hmm. 

Preston: Yeah. Um, Alex Eson from calling in Sick, so she's a, a, a creator. She has a lot of chronic pain and kind of documents her life and interactions with doctors. And so as she's been really, I've been on her podcast and she's been really kind of fun to pick her brain and talk about like, the experience from the patient perspective.

So I, I think she'll be a, a great addition to this conversation. Yeah. Um, this 

Margaret: chronic pain is very much a team sport and picking up all, again, all these data points of like, what, what does one person find works for their life, their values and [01:04:00] their pain is, they are kind of the core, they're in the pain psychology clinic.

We would call them the quarterback of their team. Mm-hmm. Um, which is a different emphasis than other parts of, you know. You're probably not the corridor back in the OR when you're getting a surgery. 

Preston: Ideally. Yeah, yeah, exactly. Um, yeah, and I think like one thing we can talk more with Alex about is, is where the disconnect happens between patients and doctors.

Um, because I like, one thing that we kind of talked about before was that there is this almost like this

dance, and sometimes it feels like a, like a protected game of Battleship where the patient is trying to convince you that they're in pain and they're like, what codified language can I use to convince you that I'm in pain? And we're going back, we're like, what codified language can I use to convince you that weed isn't helpful for your pain?

And yeah. And then, and and, and at the root of all of it is kind of [01:05:00] just an inability to see the other person's side, the other person's perspective. And then yeah, the antidote sometimes can just be like sitting on and be like, okay, here's cards on the table. This is everything I think, and here's everything I know and why.

And then you can do the same. But a lot of that just comes from like. Starts with having a good relationship with the doctor that is managing your pain. Yeah. And additionally is a really, I think that was the other thing I wanted to get on, which is having that like quarterback in addition to yourself, I guess your backup quarterback being another physician, rather than what happens to a lot of them is they become, um, pinballs in a machine.

Yes. Where they go see their PCP and they say like, oh, you need to see another doctor for that. And then you go see the pain doctor and they're like, okay, you need to see a different doctor to do the injections. And you go see the injection doctor and they're like, we don't accept your insurance. And you go back to the PCP and the PCPs like, oh, we could try this new different medicine.

But like, you should also see a therapist's talking about your pain. You're like, I'm talking to nine different people about my pain. I go through the same spiel every time and then you get acupuncture and they're people lost. I'm not getting anywhere. Person 

Margaret: who listens to you and it [01:06:00] actually makes your pain better and maybe the intervention actually makes your pain better.

And then you tell your primary doctor that and they're like, well, that's fake. And then you're 

Preston: Yeah. Yeah. Exactly. 

Margaret: Um. I think the other, but from the clinician side, it's like, how do we deal with our own impotence? 

Preston: Mm-hmm. 

Margaret: Like, and how do we not take that out on the patient? Like, I think that's like a big thing every day you seem, you just 

Preston: have to call it out.

Like, I, I find myself doing that more. I'm like, look, honestly, as a society, we're bad at treating pain. Like, like you, you lead with that, right? Rather than just kind of trying to dance around the subject of like, oh, you know, I'm just a bureaucrat and Yeah. All these appropriate channels for getting referred to a specialist to have your pain managed.

Margaret: Yes. Yeah. Instead of answering their, like, I feel unheard by being like, well, this is what the science has shown. So it's like, stop gal. Like, it's like, not [01:07:00] gaslighting, but it's like, it's like I am, I'm deep in love island right now. And there was a scene where like this guy started to fight with one of the girls on the island, and then suddenly just like his face went blank and he was like.

They were in the middle of like yelling at each other and his face just went blank. And he goes, he's like, well, if you can't like control how you feel or like, if that's how you feel, I don't wanna talk about this. So like, that's what we do sometimes as clinicians. We like, 

Preston: yeah, 

Margaret: well this is what the stud evidence shows.

Preston: I mean, we put people in a cage, know people each other, they're so pissed. And then, yeah. And then by the time they're like, get emotionally animated about it, we're like, I need you to calm down. You know? 

Margaret: Yeah. And it's like, girl, you did, you made them though. 

Preston: Yes. And, and then we're like, oh, are you agitated?

Here? Here. Fill out this agitated questionnaire. Agitated you are. Have you tried filling out our unheard questionnaire? 

Margaret: Are you mad? The questionnaire.[01:08:00] 

How mad are you? The a mad? 

Preston: Are you mad at me? 

Margaret: You heard it for research, ground break breaking, breaking research here on the podcast. So much paperwork. Oh, all right. Well, we hope that wasn't too painful for you 

Preston: or chronic. We we're keeping, um, our honesty with the timeline. So I, I guess in, in summary, chronic pain is very different from acute pain.

Um, it has to do with dysregulation of the signaling cascade lasting for longer than three months, and it kind of falls under these neuropathic, sematic or no plastic types. We have lots of different medications to treat them, but, um, the ones that come to mind are things like SNRIs, um, some antiepileptic drugs, gabapentin, and then muscle relaxers are the, the ones we went through.

In addition, we don't really talk about treating, um, mood symptoms, but depression can change how you [01:09:00] interpret pain. So even just targeting depression itself can modulate people's pain. And then you have acceptance and commitment therapy to go through and help people cope with and also become willing to, uh, tolerate their pain in addition to the treatments they're getting.

And then we try to counsel people with diet and exercise and giving them not just specific smart goals, but also like events or goalposts that can be reflected on in the next session. And all this is in the backdrop, like we just joked about, of a super complex behemoth of bureaucracy that refers patients inside the jaws of the industrial medical complex that is America.

And it's absolutely a nightmare to handle. And if you're a patient that has to do this, I'm sorry. And if, if you come across my clinic, I'm gonna tell you that I'm sorry, then we'll start working on your pain. All that being said. Perfect. Thank you so much for listening. We always enjoy, um, having you bring us along for, for the ride.

Uh, that [01:10:00] is either your car or your walk with your dog or maybe you're just sitting on the couch. If you like the show, we want to hear about it. If you don't like it, we want to hear about as well. We're always looking for new ideas. You can come chat with us in our fun. Oh, they changed the, they changed the wording in here.

Come chat with us in our fun human contact fun content podcast family on Instagram and TikTok at Human Content Pods. Or contact our team directly at How to be patient pod.com. You can always see more from me and Margaret on my YouTube channel at its prerow or Margaret's at Badar everyday on TikTok and Instagram.

We also have, um, at how to be patient on Instagram. It's like Margaret and I's Little Shared Neo Pet. We're up to 2,300 followers now. So thank you. All of our super fans out there. Yeah. We'll, we'll keep posting for now. Join us while we're 

Margaret: still an underdog story. Yeah, you can say you there at the beginning.

Yeah, we do them 

Preston: before 10 K followers. Full YouTube videos will be available on each, each week on my channel. [01:11:00] And then if you wanna listen to us on audio, we will be anywhere. You can find your podcast on either Apple or Spotify. Um, thanks again for listening. We're your host, Preston Roche and Margaret Duncan.

Our executive producers are me, Preston, Roche, Margaret Duncan, Will Flanary, Kristen Flannery, Aaron Corny, Rob Goldman, and Shahnti Brooke. Our editor and engineer is Jason Portizo. Our music is Bio Benz V. To learn more about our program, disclaimer and ethics policy submission verification and licensing terms and our HIPAA release terms, go to How to be patient pod.com or reach out to us at how to be patient@humancontent.com with any questions or concerns.

How to be patient is a human content production. Bye

how to.

Thank you for watching. If you wanna see more of us or if you wanna see, this is lilac. She's my [01:12:00] cat. She's gonna be waving her hand at one of the floating boxes, which will lead to more episodes. Lilac Point to the other episodes. Lilac doesn't know what the internet is, but I swear they're there. They, they probably exist for real.

But in the meantime, I'm just gonna pet lilac and then I'm gonna go dance in the background.