The Myth of Normal (4/5): How to hack your brain when you're in pain | Amy Baxter

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2:02Hey, it's Shoshana, and welcome to my September playlist. Fall has a way of resetting our routines, new schedules, new rhythms, and with that reset comes a good chance to revisit our assumptions too. So I've been thinking about a question that comes up constantly in health and medicine, but we don't always stop to examine it. What do we mean when we call something normal? In science, we rely on norms all the time. Normal weight, normal vision, normal behavior, normal ways of coping, functioning, or moving through the world. Those categories can be incredibly useful, but they can also flatten a lot of human complexity.

2:41Because bodies and brains don't always fit neatly into the boxes that we've created for them. And sometimes what we think of as a personal failing, a limitation, or even a disorder looks very different once we understand the biology, the environment, or the assumptions underneath it. So I pulled five conversations from the TED Health Archive that make me rethink some of those assumptions. You'll hear from Mads Tan Christensen on why obesity is far more complicated than willpower. Kate Kale on why autism is so often missed in women and girls. Andrew Leland on why blindness is better understood as a spectrum than a binary.

3:21Amy Baxter on the surprising ways our brains shape the experience of pain. And Casey Davis on why something as ordinary as doing the laundry can become incredibly difficult, and why that has nothing to do with your worth. These episodes cover very different territory, but they all share a common idea. The more closely we look at what we call normal, the more complicated and often more interesting the picture becomes. And I think there's something freeing in that. It invites us to be a little less certain about the judgments we make and about other people and about ourselves. So this playlist is about rethinking normal, where our assumptions come from, who they leave out, and what we might see differently when we start questioning them.

4:14Hey, TED listeners, it's Dr. Shoshana. When I imagine pain, it's usually that ouch moment from smashing my toe on a coffee table or the pounding in my temples after a long day at work. But what if we've gotten it all wrong? In her TED 2023 talk, pain specialist Dr. Amy Baxter throws us a curveball. What if pain isn't just an annoying buzzer to shut off, but more like Survival 101? And what if our pain is actually informed by so much more than a single inciting incident? Take a listen to hear how we may have a bigger say over our aches and twinges than we ever realized.

5:09So if you whack your thumb with a hammer, you think pain is in your thumb. Physicians have a more sophisticated understanding. We know that it's an alarm that goes on nerves to your spine, where it is translated to your brain and pain actually happens. Somewhere. It's a little vague. We actually only get two days of pain education throughout all of medical school. So, in fact, the only pain lecture I remember from the 90s was in a dark room after being awake for 30 hours and hungry and finding out our noon lecture was sponsored by OxyContin. We got pens, we got great lasagna, and they had very cool slides that showed pain stopped by opioids.

6:00And we learned that home opioids aren't addictive. And if you stay ahead of pain, you can keep your patients pain-free. And beyond the obviously egregious marketing, I think it was framing pain-free as the goal that has destroyed countless lives. My friend's son, Christopher, started having severe abdominal pain during this no-pain era. Eventually, he was diagnosed with a colon disease and had surgery his senior year. They sent Christopher home with 90 OxyContin, and then 90 more. And then as the pain started getting faster and faster, uncontrolled pain is terrifying. So when his ran out and his friend's medicine cabinets ran out.

6:49Christopher tried heroin, and Christopher Wolfe lost his battle with substance use at age 32. So did we misunderstand pain? What if pain isn't an alarm to silence, but a learning system for survival? Pain is every organism's primary learning system for survival. I mean, it's like, ouch, don't touch that. Or to paraphrase the princess bride, life is pain, highness. Pain-free was marketing, and it made physicians think that one pill could solve pain. It still makes people feel like you can't be happy if you have some pain. And we now know that if you want to move past pain, it takes work. Setting the bar of pain-free was too high.

7:42Plenty of people could have been more comfortable, but they gave up because pain-free was out of reach. We have really good new information that I'm going to share, and so from now on, I want you to think about pain as a Venn diagram with physiology, fear, and control. I'm going to tell you how each of these can give you power over pain. Right now, I'm translating these in my research into a low back pain device to reduce opioid use. But 20 years ago, I just wanted to have a fast cure for needle pain, for IV access, and my kids' shots. I was driving home one night after a graveyard shift, and my hands were vibrating on the steering wheel because we needed to get the tires balanced.

8:27I was ignoring that to think about pain, and when I got home and reached for the door of my house. My hand was numb. Vibration. So I burst in, my Boy Scout husband grabbed some frozen peas, and we had ourselves a genuine eureka moment where cold and vibration blocked pain. Over the next decade, I found the right frequency to block pain. I got a grant, and I created Buzzy, which is vibration plus ice in a B shape. And you put it on your arm when you're getting an injection. And to date, 45 million needle procedures had decreased pain. And over 80 randomized controlled trials independently all around the world have been published.

9:15But...

9:20At about 30 randomized controlled trials in, one of my colleagues came to me and confided that he was in opioid recovery. And he asked whether or not Buzzy could let him get through a total knee replacement drug-free. I'd never thought about it. It's the same pain nerve for knees as for needles. So I said, maybe. And he did it. vibration plus cold replaced OxyContin.

9:52So at that point, I went all in to figure out why. And here is what we know. So the reason that vibration decreases pain is because the physiology of the nerves of light touch, pressure, stretching, and motion all race pain to the spine. Now, people have tried electricity to trigger the light-touch nerves, but we now know that motion is what's most effective at shutting the gate on sharp pain. This is called gate control, and the exact right frequency of vibration triggers the nerves that decrease pain. The physiology of ice is different. So the cold goes up to the brain where the conductor goes obnoxious but not dangerous, I will decrease sensations coming from everywhere.

10:42And it decreases pain everywhere. If a child was so freaked out from previous experiences that even the swab hurt, physiology wasn't as helpful. So we added distraction like a monkey poster, and what we discovered was combining counting counting plus making a decision. Cut paint in half. Here is your paint hack for the day, though. If you do not have monkeys on hand, then find any sentence and count how many of the letters have holes in them. I guarantee you and your family will use this. The biggest hack, though, is understanding why distraction works. And now, through functional MRI, we can actually see pain happen.

11:32And it's not one place. Pain is a symphony of connections from the sensation area to the conductor to the decision switchboard, and then to fear, memory, meaning, control. So if the decision switchboard is occupied sorting monkeys, it can't notify fear and meaning and you feel less pain. What you feel is mostly what you expect to feel. All right, stay with me. If you're a kid, the same punch hurts more from a bully than from your buddy. And if you're an adult and you feel something, the second you think it's cancer, it hurts more and more until you find out it's not. And those same kids who had horrible shot experiences can tolerate all kinds of needle pain to look cool because it is a different context.

12:33These patterns called connectomes are very personal because experiences lay down more of the same sensation. And we now know that people who have certain areas in the brain connected feel more pain than people with different areas connected. And more importantly, untreated pain or intense pain can lay down heavier connections so that even when your body is healed, you will still feel more pain. It's this very plasticity and personalization which makes the physiology, fear, control matrix so useful. Because choosing physiologic options that you can layer that work for you decrease pain. like heat, cold, vibration, deep relaxation, acupuncture, capsaicin, exercise, meditation.

13:27There's more. Christopher probably had 10 of these around his house and just didn't know it. Having control over your options decreases pain. Deep breathing increases control. Choosing what to focus on increases control. Fear and control are the volume knobs for pain. Fear controls so many of our sensations. This shouldn't be unusual, but we don't practice it for pain. So if you're home alone and you hear a clunk, your hearing becomes hypersensitive. But when you remember your kid's home from college, your fear dials down and your brain overrides it and says, don't worry about it. St. Augustine called pain the greatest of evil.

14:19But if it is a survival system, it cannot be all evil. So instead, think of pain as your nagging, safety-obsessed, exaggerating friend who's sometimes wrong. And it's okay to ignore or override your friend if you know that you're safe. This takes practice. On a flight that was turbulent, I had an entire cup of scalding hot coffee dumped straight on my ankle. Electric jolt through my scalp. I ripped off my sock. It was already red. It was going to blister. There was no way I could get my foot into that little sink to get cold water on it. And then I remembered, physiology hack. I had an unopened cold beer.

15:08Medical grade cold beer went on my ankle. Stat! I had a vibrator in my carry-on because I would on my ankle. And then... The pain kind. And then my fear hack. I'm like, there's a barf bag that has holy letters, but I'm going to put it in the pocket pouch and save it because then I have increased control. And pain MacGyver, I was no longer. that concerned.

15:46Although then I realized I'm that guy with my bare foot sticking out in the aisle on a plane with a beer on it.

15:57Power over pain isn't always pretty, but it is possible, and it is absolutely critical, because there's one more misconception we have not talked about. I honestly thought that opioids turned off some pain switch. They turn on our reward system. So some people feel amazing, but most people just still feel pain but don't care. Now, this is a godsend for people with chronic pain diseases. We should not take them away. And in the trauma bay, the more morphine the first 24 hours after a burn or a wound, the less post-traumatic stress, the less chronic pain later. But studies show that recovery after surgery is just as well accomplished with coaching and physiologic options.

16:49And if you're one of the people who feel amazing with opioids, it's too risky. A study in 2019 found that one in 15 young adults who got opioids for their wisdom tooth removal had substance use disorder within a year. Ibuprofen works better. So what do we do? Well, in my dream world, we have healthcare systems pay for options and coaching for Christopher's everywhere. And we quit giving double-digit prescriptions for opioids for home recovery. In the real world, 80 ,000 people died in the U.S. last year from opioid overdoses, and 80 % of substance use disorder starts with a pill prescribed for pain, usually taken from your friend's medicine cabinet.

17:41People can't afford options. Doctors 20 years later still don't know them. But you do. You all now know to throw away the opioids in your medicine cabinet. You now know that there are options you can use to decrease pain and you know that pain-free should be ditched for more comfortable. And whether you dump spout in coffee, or pain wakes you and exhausts you every day, options that are in your control can allow you to reframe pain. Thank you. Thank you.

18:33Wow, Amy, thank you. Like, really, thank you. It's amazing. So how do you think that pain scales have set us back from this work that you're doing, and how is the NIH treating pain and addiction differently now? So one of the 120 versions of this talk, I talked about how the thing is, in the 90s, if we wanted to disease-ify pain, it meant that we had to be able to measure it. And so that was where the FACES scales come from. And they're actually very useful in the emergency department to tell whether or not a medicine is working. In fact, we were one of the first ones that showed with sickle cell that the patient's report based on the scales was what was most indicative of whether they needed to be admitted rather than any biologic marker.

19:17But what we're doing now is we're using something called the PROMA scales. So it's how intense pain is on five-point scales, how much it interferes. So there's pain interference, pain intensity. And the way we're looking at pain is much more on the impact for the person rather than trying to pretend there's any kind of objective pain measurement. Okay. And you mentioned that you're working on some new applications for Buzzy, specifically like for back pain. What are some of the possibilities that we have here for what this could do for us in the future? Yeah, on my tombstone is going to be a vibrating bee.

19:57It's actually called duotherm, not bussy. But what we've learned is that there are harmonics of interaction between the specific frequencies that cancel out the pain. So there's one particular nerve called the patinium that has a very specific frequency range. And by causing them to interact, we're starting to explore more about the pain that's coming from the fascia between the skin and between the muscles. But that area is where we're unexplored. And so by interacting with different frequencies and then layering heat or cold pressure options, giving people the choice of so many different ways to do it, it's really engaging all the different areas of the brain from which pain comes.

20:38Wow. Okay. Well, thank you so much, Amy. You're welcome. Thank you all.

20:55That's it for today's episode. Thank you so much for listening. This episode was produced by Dan O'Donnell and fact-checked by Vanessa Garcia-Woodworth. Special thanks to Maria Lages, Grace Rubenstein, Farrah Degrange, Jimmy Gutierrez, Anna Phelan, Michelle Quint, and Colin Helms. I'm Dr. Shoshana Ungerleiter. I'll talk to you again next week.

21:22Today's episode is sponsored by Kashi. Say hi to new Kashi Gut Health Granola, a straightforward, delicious way to fuel your gut, made with prebiotics, fiber, and cultures. My favorite flavor, blueberry almond, has perfectly crispy clusters, delicious almonds, and bursts of whole blueberries. It's an easy fit for a daily routine, whether that's for breakfast or a snack. In a world of overwhelm, it's a straightforward, delicious choice. Try new Kashi Gut Health Granola.

21:54With no fees or minimums on checking accounts, it's no wonder the Capital One Bank guy is so passionate about banking with Capital One. If he were here, he wouldn't just tell you about no fees or minimums. He'd also talk about how most Capital One cafes are open seven days a week to assist with your banking needs. Yep, even on weekends, it's pretty much all he talks about. In a good way. What's in your wallet? Terms apply. See CapitalOne.com slash bank. Capital One N.A. member FDIC.

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