How the brain interprets pain — and new ways to manage it

0:00This message comes from AT &T. Staying connected matters. That's why AT &T has connectivity you can count on, or they'll proactively make it right. That's the AT &T &T guarantee. Terms and conditions apply. Visit AT &T.com. Guaranteed. for details. This is the TED Radio Hour. Each week, groundbreaking TED Talks. Our job now is to dream big. Delivered at TED conferences. To bring about the future we want to see. Around the world. To understand who we are. From those talks, we bring you speakers and ideas that will surprise you. You just don't know what you're going to find. Challenge you. We truly have to ask ourselves, like, why is it noteworthy?

0:43And even change you. I literally feel like I'm a different person. Yes. Do you feel that way? Ideas worth spreading. From TED and NPR, I'm Manoush Zomorodi. Some kids are obsessed with trains. Others love cooking. And then they're the ones who are really into horses. I was kind of born into it. This is Kat Nod. When I was two years old, I actually learned how to canter on a horse for the first time. By the age of six, Kat knew what she wanted to be when she grew up. I decided I want to go to the Olympics for horseback riding and represent Canada. And my entire life has kind of been centered around that goal of being an Olympic horseback rider.

1:32How much of your life, your daily life, did it take up? Like, what was the whole regimen? Is there a percent higher than 100? in her 20s kat was on track to make it to the 2016 olympics in a sport called three-day eventing so it's got three phases over three days so the dressage is kind of like dancing on horses you have like a routine you do at certain places in a test the second phase is called show jumping that's what you see on tv where they jump the big jumps with the rails that fall down And then the third phase is cross country. It's where you're going over big, solid jumps that if you hit the jumps, you fall down, not the jump.

2:16They'll have like a six foot wide ditch with a wall in the back and you have to jump all of it at the same time or like a seven, eight foot drop into water. And if you make a mistake, the jumps, there's no forgiving. So there she was at the Olympic qualifiers. She and her horse sailed through the first two events. No problem. I was actually in first place heading into cross country, which was my strongest phase. And it was my 25th birthday. And I was super excited. We headed to the start box to do our two-minute countdown. There's nothing that gets me more excited than the last 10 seconds before you get to go.

2:57And we set out on course, my horse Jackson and I. the entire course flew by in perfect jumps there was not even a misstep to a single fence and we headed to home to our very last jump when my horse jackson and i saw a completely different distance from each other to the fence and he's enormous so he's 17 three hands which is just under six feet where his back is and the last fence was a big upright table and he caught the front edge of it with his knees and we had what's called a rotational fall. What I can equivalent is to a somersault in the air and he landed on top of me on the other side and slid 10 feet with him on top of me.

3:47He weighs about 1 ,500 pounds. I lost consciousness for a very brief amount of time. I remember kind of coming back to and he'd jumped off of me and ran off and people rushed over and they're trained to hold you down so you don't get up just in case you have very severe injuries and all I could do was try to flail and figure out where my horse was and that was my main concern is where is he is he okay shock kind of takes over an adrenaline and then I was actually airlifted to the hospital in Seattle and from there it was a definitely whirlwind few days what in the end did they figure out had had happened to you what was damaged in your body so I had broken the transverse processes the wings off both sides of my L2 3 and 4 vertebrae in my back I was told if you're gonna break your back that the way that I broke it was the best way possible.

4:52So that's, I guess, good news. Some comfort. When you were leaving the hospital, what did your doctors tell you to expect? Yeah. So they said that it was going to be about four months till I felt more normalized, like I was going to be able to do more activity, more walking, even think about getting back on a horse. It was tough. The pain level was something I'd never really experienced before. I would hit like an unmanageable level of pain every single day. When I give you the pain scale, like I would hit a 10 out of 10 at some point every day. So what kept you going? Because you thought, okay, well, this is just temporary.

5:34I need to get through this initial period and then I'm going to feel better. Is that what you were thinking? Yeah. So being four months, like four months in hindsight is not that long. Like in the moment, four months in that level of pain feels really long. But four months, I was just trying to grind it out to get back to training. I knew there were still some qualifiers left in the season. So if I could recover and get back quick enough, I could try to still make a run for the, you know, being an Olympic athlete. And I had really just expected my body to bounce back. When did you start to realize that things were not going back to quote unquote normal or before times?

6:16Yeah. So about the four month mark, I was really not feeling any better, but they said four months. So four months to the day I got on my horse and the first step he took, like I was instantly 10 out of 10 pain. I was nauseous from pain and I almost fell off just because I couldn't even breathe. And I knew that there was more going on. I knew that something had been missed. I knew that whatever was happening had not healed the way that they were kind of expecting it to. And I had to get instantly off and I was crushed. They actually found out that my pelvis was dislocated and I was having stability issues.

7:02And that's actually why I had so much pain. And I got to the hospital in Vancouver and waited for over four hours in a waiting room on a hard chair with a back that you're thinking any moment, like what if I sneeze and now I'm paralyzed? So it was quite a scary wait, not knowing what level of stability would happen. If I shifted the wrong way, am I going to make it worse? When they finally called me in to do the check with the doctor, I handed him my requisition and he didn't even look at it. He put it down. He didn't examine me. He didn't ask me a single question about my pain, about what I was experiencing, about what my doctor had said.

7:54He looked at me and he said, what drugs do you want? And I was like, no, no, I need help. he said I'm busy so you can take the drugs or you can leave yikes and what did you say I left I wasn't there for narcotics I was there for help and support and I got none of that and it was a really disappointing experience and for me I'd been kind of holding out hope that I was gonna heal physically and to be that dismissed I'd lost hope that day that day was actually the first day of the downward spiral for me mentally. And a couple months after that experience, I kind of hit my rock bottom of where I just couldn't fight through this anymore.

8:41When you say you hit rock bottom, what do you mean? I slid into like depression quite quickly. And I've actually never had experienced anything like depression before. And until you know, you don't know. And the pain was intolerable. I would dislocate my pelvis and fall and be kind of stranded. I limped every single day. Some days my leg almost felt like a peg leg, like I had to drag it behind me. Were you getting treatment at that point? I had stopped. I had kind of given up hope because I had tried so many things previous and nothing had really caused any significant relief or progression of my symptoms.

9:28And I've been told by several doctors that like there's a real chance that this is just physically your life and you'll have to acclimate to it. You won't be able to walk normally. You will limp. You will be in high degrees of pain. You will have instability in your pelvis for life. This is your life now. And yeah, it's like at 25, when you have so much of your life ahead of you, it's really hard to justify spending the rest of your life that way. When you're in that kind of depth of the darkness, you can't see past the darkness. You can't see little light at the end of the tunnel. You're not looking for hope.

10:11You are just alone in the dark. In a single moment, Kat Nod's life was taken over by pain. First acute, then chronic. She felt alone, confused, and hopeless. Like most of us, she'd heard about the dangers of opioids. Roughly 80 ,000 Americans a year are dying from opioid overdoses. And the opioid epidemic has morphed over the years well beyond a pain pill problem. But we don't hear much about other options for coping with pain. So what do we need to know about the next chapter in pain relief? Today on the show, new understandings about how the brain interprets pain and what we can do to manage pain in the short and long term.

11:06Later in the show, we'll hear more from Kat Nod. But first, please meet pain expert Dr. Amy Baxter. When you live with chronic pain, it is really easy for it to take over and define who you are. Amy says that in the 30 years she's been studying and developing methods to treat pain, she has heard all sorts of preconceived notions related to it. talking about pain is so nuanced and loaded in our society because we're supposed to be tough and we're supposed to deal with pain and also because we are a society that fears aging and pain means decrepitude never doing the things that make you you and even a little bit of pain carries extra meaning because it means that both you're weak and you may not get over being weak Amy suggests we put all those judgments aside because pain affects everyone differently.

12:07And as we'll explain later, how the brain processes pain can be confusing. But, she says, we need to remember one key thing about it. Pain is a survival system that serves us. And when it ceases to serve us, then we can choose to ignore it. We don't have to let it rule us. That is the most important paradigm shift for dealing with both acute pain and chronic pain. But the thing about pain is there isn't one answer. It is a giant, different, complex beast to every different person. And so we in the medical profession are use to one right answer and treating it as one thing. It just isn't. In a minute, Amy talks us through the past, present, and future of pain management.

13:04On the show today, rethinking ideas about pain. I'm Manoush Zomorodi, and you're listening to the TED Radio Hour from NPR. We'll be right back.

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14:57Download the latest episode and subscribe at schwab.com slash podcast or wherever you listen. This message comes from Charles Schwab. When it comes to managing your wealth, Schwab gives you more choices, like full-service wealth management and advice when you need it. You can also invest on your own and trade on Think or Swim. Visit Schwab.com to learn more. Hey, before we get back to the show, I want to tell you about our next bonus episode for TED Radio Hour Plus. We are catching up with Ryan Phelan, head of Revive and Restore. This is a nonprofit that uses the latest technology in gene editing and cloning to try and save species from extinction.

15:40Ryan tells us about their new project, which is working with the U.S. Fish and Wildlife Service to build a genomic library, preserving DNA from all of the country's endangered species. It's pretty wild. That conversation is coming on Thursday. Not a Plus supporter yet? Please join your fellow listeners for bonus content and all our episodes sponsor-free. Go to plus.npr.org slash TED or give it a try right in the Apple Podcasts app. And thanks. It's the TED Radio Hour from NPR. I'm Manoush Zomorodi. On the show today, pain relief, how to rethink and deal with physical pain. And a warning, some of this episode touches on addiction and a drug overdose.

16:31We were just talking to physician and pain expert Amy Baxter. Amy says our ideas about how to treat pain often start at a young age. We start early with children saying, oh, you bumped your this. Oh, you have a fever. Let me give you a pill. We really are telling each other that a pill is the way to solve a problem. And that isn't going to work when that is part of your survival system. You can't shut it down with a pill. Amy believes that we need to teach or be taught to see pain as a messenger and listen closely to what it tells us rather than fear it. But this is not what Amy learned back in medical school 30 years ago.

17:15In medical school, pain was a lot less important than diagnosing and treating whatever was causing it. We didn't actually talk much about what the nature of pain was. It was this amorphous bad thing. But as a doctor, it's kind of like pain happens. Amy did her residency, and she specialized in pediatric medicine. And as a young, budding physician, she found this approach hard to swallow. So one of the hardest things about being a doctor is quelling down your empathy, because it can get in the way of the diagnosis or the management that you need to be responsible for making sure happens. But then the theory of putting aside pain to get a diagnosis faded away.

18:02It was the mid-90s, and a new approach was being offered by pharmaceutical companies. Doctors could be pain advocates for their patients, thanks to a new line of pain relief medications. That was when I first heard the concept of pain-free. At the time, it sounds great. You know, why wouldn't you want that for your patients? We even had buttons that said pain-free on them. And all of us who were pain advocates wore them on our white coats. You know, it's like pain-free. I am going to get you to pain-free. And what's not to love about being pain-free? Amy remembers the first time she got the opioid pitch.

18:42Here she is on the TED stage. The only pain lecture I remember from the 90s was in a dark room like this, 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. And we learned that home opioids aren't addictive. And if you stay ahead of pain, you can keep your patients pain-free. But we've all heard how the story of opioids and addiction has gone.

19:46hurt at all. 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, Christopher tried heroin. And Christopher Wolfe lost his battle with substance use at age 32.

20:35Christopher got 90 OxyContin for a stomach surgery. We would never do that now, but I I was in the generation that if I had taken care of Christopher, I would have written for that. It's just what you did. Doctors trained when I was in the 90s believed that there was no amount of pills you could give someone that would cause a problem if they had, quote, real pain. So it turned out that the promise that OxyContin was less addictive wasn't true. Purdue Pharma pleaded guilty to federal crimes for false marketing. But here we are with researchers saying that more than 2 million Americans now have some degree of opioid addiction.

21:24Can you just explain what these drugs do? What is it that happens in our brain that makes us feel better? Yeah. At least at first. Yeah. What we didn't know is that taking opioids actually increases your sensitivity to pain because you're used to feeling so rewarded that you don't notice it. So dopamine, which is what opioids address, dopamine makes you feel like you're winning and you're so rewarded that you don't care if you're feeling pain because you just feel great. And if it's a really excruciating pain, opioids are the best thing we found to hardcore trigger the dopamine response that makes you feel rewarded.

22:05So it's great for the first couple of days and the first 24 hours after a burn or trauma, the more opioids, the less post-traumatic stress, et cetera. But because your brain is constantly adapting, what ends up happening is after about 72 hours, your mu receptors, your dopamine, I feel great receptors have actually hidden inside cells. And that's about when you go home and you're taking an oral pill that is not nearly as potent as what you were getting through your IV. And now you're just getting the risk and the side effects. What is actually happening that some of us feel awful on Percocet or other narcotic drugs and other people can't get enough of them?

22:54If you've ever been in a Mexican restaurant and somebody at your table says, I cannot abide cilantro. It tastes like soap. And you're like, Like, are you kidding me? Cilantro is great. That's what's going on with opioids. A percentage of the population get opioids and their taste of it is completely different. So they don't process dopamine in the same way. They don't get as much great taste from the kind of dopamine mastery or novelty or excitement or winning. They're not getting that as much. When they get an opioid, oh yeah, they get it. Huh. And that can be exacerbated by a bad situation. So the right circumstances with the wrong genes is a dangerous combo.

23:38Yes. Even the good circumstance with the wrong genes, three days or more is when the risk starts increasing of being dependent. So it's not necessarily the, no matter how it makes you feel, whether you love it or hate it, regarding pain, it doesn't actually necessarily do the job that we've thought it does? Yeah, I think this really gets to the nature of pain. What is the job that we want opioids to do and what exactly is pain? As I started unpacking the nature of what Purdue Pharma had taught me, I realized I believed, and I think many believed, that pain was a switch on-off and you don't want to have it.

24:22But pain isn't a switch. It's not as magical as if you are in pain and then all of a sudden the pain goes away. Amy now believes that the best definition of pain comes from the International Association of the Study of Pain. They say it's an unpleasant sensory and emotional experience that is associated with actual or potential tissue damage. This idea of pain as a sensory and emotional experience got Amy thinking about where she could begin to try different tactics to mitigate pain. She decided to go back to a place she knew well, a place where many of us first experience acute pain, the pediatrician's office.

25:08I noticed that other doctors weren't addressing needle pain for kids. Like getting a vaccine, like my daughter still screams and she's a teenager. Yeah, well, here's the deal. You and I got six injections and we got them before we were two and we don't remember. And we think we were really cool because we don't mind needles. But yes, starting. So true. I know. Well, so here's the thing. I started looking back at the history of vaccines and I was like, whoa. I had no idea. We have 36 separate shots now. And I realized this when my four-year-old had his vaccines and he had such an awful experience that afterwards he threw up.

25:51And I was like, if he gets old enough to drive himself to the doctor, he won't. A shot punctures the soft tissue of the arm. The sensation goes to the spine, than the brain. And the brain remembers that feeling. So if we anticipate fear feeling that sensation again, that memory can make every future shot seem so much worse. Pain is this contextual response to whether you're safe or not. When you're afraid, your neurotransmitters that say danger are elevated, and your memories of fear are elevated, And that fear increases your perception of pain. And certainly when you're in pain and you're afraid of not being able to get relief, that fear lays down tracks in your brain.

26:47I mean, all of these things happen that increases your perception of pain. So Amy wanted to stop kids from associating shots with extreme pain. How to do that? Lessen the initial sensation. 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. I 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.

27:40Over 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 have decreased pain, and over 80 randomized controlled trials independently all around the world have been published.

28:10So 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. 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. So if you burn your finger and you stick it under cold water, instantly the burn feels better. If you've ever tried putting it just in ice water but not moving it, you will find the cold itself doesn't do it. You have to actually, you know, stir your finger around to make it work.

28:53The movement's the critical part. The cold helps. Well, to manufacture this sensation of movement, I stumbled upon vibration. 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. And 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 plus making a decision cut pain in half. So for example, how many monkeys are actually touching the bed activates the decision switchboard.

29:48I know what you guys are doing. All right, it's five. The biggest hack, though, is understanding why distraction works. And now, through functional MRI, we can actually see pain happen. And 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. So there are so many different things you can try. Cold, vibration, distraction, mind games.

30:40Yeah. You've always got one other thing to try. So it keeps you from being afraid. A big part of my pain re-education came when I was asked to do a talk in Wisconsin for a child life conference. I'd been invited to talk about different medications for sedation because that was my specialty and how to deal with pain. And an amazing woman who invited me, Regina Yoakum, told me afterwards from her wheelchair where she had been since she was young from juvenile arthritis. She said, you know, I appreciate knowing about these medicines, but the thing is there's only a finite number of medicines. There are a much larger number of physical interventions, and there are so many different ways to activate your brain so that you just don't mind pain that really what pain management is for us and for her personally is knowing there's always another option.