Rachel Zoffness (on pain)

I'm joined by Lily Padman. >> Hi.

“>> We have a guest today with the cutest last name perhaps we've ever had.”

Rachel's softness. >> Yeah, this was a great episode. >> I just love that last name. >> It's a good last name. It's a little misleading because this isn't a soft episode.

>> Although it is in also another way. >> I guess. >> She is a leading pain psychologist and neuroscientists.

This episode is so incredible.

I think it's one of the best of the year. It's so many of us know as you learn in here. There's 1.8 billion people in the world suffering from chronic pain. And there's 100 million Americans. And we don't understand how we experience pain truly.

>> Yeah. >> And this is an incredible explanation of how it actually works. And it's quite an empowering take on. >> Yes. Yes, so her book is called Tell Me where it hurts the new science of pain and how to heal. I have already sent it to two people who I know who suffered from chronic pain.

This is a great one. Please forward it to anyone in your life who's experiencing chronic pain. Please enjoy Rachel's softness. [ Music ] >> It's such a pleasure to meet you.

>> Are you a huger? >> Yes, let's do it.

“>> Monica, you must know how this started.”

>> This is terrifying for me. I'm like a library. I'm like not a public facing person. >> Okay. >> You're already so warm feeling. >> Well let's do what happened.

I saw Roba the staircase when I left the house. So by the time I got out and went up the stairs, I grabbed my drink. I saw that he was in the bathroom. I don't know what Jesus, what are you taking to shit in there.

It was Rachel. >> I was like, don't you wish I wanted to know. >> That's terrible. >> It's funny. >> Oh my god.

>> Did you get really scared? >> I know where I am. Come on. >> Yeah, even for you, you would not do that. We have a friend in common also.

>> Who? >> Do you see the person who wrote the endorsement on the top of the box? >> Oh, I did see that. >> Yes. >> I'm obsessed with it.

>> Oh yes. >> She's the reason I teach at Stanford. >> Well. >> Because addiction medicine and pain are best friends. >> Yeah, so you're down presumably from San Francisco.

Do you live there? >> Yeah, I'm in the Bay Area. But I'm originally in New Yorker, which is what I have an attitude problem. I wear so much black and I curse all the time. >> I feel like I'm in good company.

>> Those are good at it. >> I thought you said you were like a church mouse. >> Library mouse. >> Very, very different than church mouse. >> Yeah, super different.

>> Yeah, very, people are poor. >> Oh.

“>> I think they're like in the nurse category.”

>> I don't know what's happening. >> Yeah, no, I was like the kid who was shy and quiet and quiet and quiet and shy. And was in the library reading all the time. >> Books for my friends. >> Different than a church mouse.

>> That is different, you're right. >> How is teaching been for you? Because that requires a ton of get up in front of people and speak. >> What's funny is that during the pandemic, this thing happened where I was supposed to give all these talks.

And I was actually doing that because it was partially a treatment for my own performance anxiety and public speaking anxiety. The treatment is exposure therapy, right?

Like if you never do it, you never get through it.

So I had all these talks went and then everything got canceled. It was like, okay, what do I do now? So I started planning virtual talks and I started cold pitching podcast hosts. And I pitched a couple of people who actually had really big platforms

and I didn't realize it at the time. As I started doing more and more podcasts, I think I did like 42 of them. >> Wow. >> And as a client came calling.

And by the time I did that one, I had done so many that I felt pretty secure in what I wanted to say. And I feel very passionate about the topic. And I keep my patience in my mind when I talk about the topic. So I'm sweating through my clothes.

>> Well, that's also because it's for sure. >> 500 times. >> It's also 90 degrees. >> I never, you can also take off your sweater. >> I'm considering it.

>> It's not going to happen. >> It's not going to happen. >> It's not going to happen. She would be dying of heat exhaustion. Can we remove this sweater?

>> No, it's a cute color. >> What do I do when I love this sweater? >> Okay. So you're originally from New York. You really could write a book on universities of America, probably.

>> You mean because I've been to so many? >> Yeah. >> Did I tell you I was a nerd? I think I did. >> You started that brown, yeah?

>> Yeah. >> You were biology? >> Yeah, I was brain and behavior. I couldn't decide what I wanted to study when I was a brown. I loved neuroscience.

I loved human biology. I thought psychology was so interesting. I couldn't decide if I wanted to research or clinical work or teach kids. So human biology, brain, and behavior was sort of an amalgamation of everything.

And then when I learned about pain in my first neuroscience class, it lived at the intersection of everything I thought was so rad.

>> Because why? I just depends on how far down the rabbit hole. >> I mean, I've heard you say that you were drawn to it because you were so afraid of pain. >> Yeah, and that's another reason. Pain scares the shit out of me.

And it should, right? Pain is designed to be a verse of it's designed to save your life. If it doesn't grab your attention and get you to stop doing the thing you're doing, there's a chance you could hurt yourself slash die. >> Yeah. >> So that's pain's job.

But I always found pain to be very scary.

>> Physical pain. >> Well, my friend. >> Well, my friend. >> That's the number one question I get, especially because I study pain psychology.

“So to answer your question very briefly, guess where pain is made?”

It's not in your bad back, and it's not in your aching knee. In the brain. And the parts of your brain that make emotions also make pain. Like your amygdala and your limbic system are a critical part of the pain machinery. And we all know that our bodies feel worse during times of stress and stress.

Of course they do. But does anyone ever tell you that at any point in your effing life? >> Yes, and we're going to march to that granularly. But her question still stands because prior to you understanding that there is no difference between psychological pain and physical pain. In one regard, were you someone that was afraid you were going to get physically hurt?

Or were you afraid you were going to get emotionally hurt? >> It is a fair and good question. And yes, physical pain is what I was scared of, but of course no one likes emotional pain either. >> Yeah. >> I don't know.

Some people like physical pain too.

Like there's a whole BDSM community where pain is pleasurable and there's a reason for that.

And maybe we'll even get to that. But it all goes back to pain being made in the brain. >> Were you sheltered? Were they a very nervous kind of parents? >> I would say I had very over-projective parents.

And by nature, I was shy quiet. >> And/or cat. >> Library, man. >> So I was self-protective. Like my sister and brother would be running around playing sports hitting each other with a cross-dix.

I was in the backyard reading books by myself. Self-directed. No one told me to do that. It wasn't because my parents were like, "You're going to get hurt." >> Were you the older?

>> I'm the oldest. >> Yeah, yeah, yeah. Because they get crazy. We can't have the library mouse at the end. >> Yeah, no.

>> [LAUGH] >> Library mouse is at the beginning. >> Yeah, it takes the party off.

“Okay, so after Brown, you go to is it San Diego state?”

>> Columbia. >> Columbia next. And we do teaching masters there. >> I got a master's in psychology. I was interested potentially in education like teaching psychology.

Or maybe being a professor one day. Like I really couldn't decide what direction to go. I mentioned I was a science teacher at the Bronx Zoo. I was like, I love biology, I love animal behavior. Do I go that route or a science educator?

I was a science writer at Natural History magazine. >> Oh. >> Out of the museum of Natural History in New York City. I was like, that's rad. You're science writing, you're learning so much stuff.

You're translating complicated science for the lay public. Do I want to do that? I realized it was just me with my computer. And that wasn't satisfying enough. So for me, the education piece, I am also a glutton when it comes to information,

especially science. So I was like, what can I do where I consume the most amount of science over the course of my life? So I just went to school for as long as I could. >> Yeah, were your parents that all getting frustrated like we got to figure out what direction

or they were just supportive? >> No, I was working really hard and I'm very self-driven. They were not at any point worried about me. >> Okay.

“>> I think they were probably worried because I was so stressed out.”

Figuring out your life path is not a casual thing. And it can feel scary and intimidating for as long as you're wondering that. And you can be honest journey for forever. Hopefully we'll all have different points in our career where we pivot and do different things. But for me, I've been on this path from the beginning.

Like, I knew I wanted to help people.

I knew I thought neuroscience was amazing.

I knew that I wanted to do something with medicine. It really just naturally led me here. I did my honors thesis at Brown on the neuroscience of pain. And I studied with a pain neuroscientist there. We studied endogenous neurochemicals that regulate pain.

>> Okay, so those are ones that eminent from your body. They're not exogenous, right? That your body's pharmacy kept. >> You got it. >> Yeah.

>> Chemicals that are made by your body's pharmacy. >> And what was the most fascinating aspect of that? I love telling people that like when you take a drug, the drug itself isn't the thing that's giving you this sensation. >> That's right.

>> It's either regulating uptake or down. It's just letting the chemicals in your body go crazy. And it's binding to receptors that your brain has because your brain already makes those chemicals. >> Yeah.

>> Which is why you adjust. >> It's in you. It's not whatever you're bringing. >> Right. >> So like if you're taking a drug for a very long period of time,

your brain does a thing where it down regulates. You probably have heard this term from the other science nerds you've had on, where your brain stops producing as much of that thing. So if you're taking chronic opioids, for example, your brain doesn't need to produce as many because you're giving them

from an external source. So you don't regulate you don't have as many. Now neurotransmitters in your brain and the receptors are just picking up what you're giving it instead of like the homemade ones. >> Take me to San Diego's stay.

>> Right. >> Take me there. >> Take me there. >> Take me there.

>> I guess what I'm trying to figure out when I ask about your parents and you.

I guess there's two versions of this. One is I have anxiety. I'm afraid to pick. I don't really know what my calling is. I'm scared.

Another one is I'm at this salad bar and I just can't stop going. Up to it and trying something new is the latter. >> Yeah, and also I really wanted to make sure I was going in the right direction. Because it's a lot of time when you go to school for that long. Like you really want to be sure shit that this is the right direction.

So I just kept honing it and honing it. So San Diego's stay UCSD was where I went for my PhD. And I studied clinical psychology because I decided I wanted to work with patients. And I really was fascinated by the brain body overlap. I still feel this way.

I felt like if I had gone to med school, I would have gotten like one slice of the pie. And if I went for my PhD in psychology, I would get another. >> Yeah.

>> And I wanted the intersection.

And I had to kind of go get that on my own to be perfectly honest. >> Yeah, we just said Michael Paulan on last week. >> I just saw him at a diner. He lives in my neighborhood. I almost went up to him and I was like, that's rude.

I'm not going to do that. >> He probably would have liked it. >> That must be so annoying. >> Oh, I don't think. >> I'm not annoying if you go and tell him that your shrimp trip.

Like how people come up to me and tell me their pain story. >> Yeah, yeah. >> I actually don't mind that much because I'm like, oh, my God, tell me everything. >> Right, more data. >> Yeah.

“>> Okay, so at what point do you start seeing patients in specialized in pain psychology?”

>> I wanted to hang up a single right away.

I did the PhD because I wanted to get really good at research.

Like if you're a real nerd, you want to make sure that the papers are reading our high quality. The data's good data. So in my PhD program, I got that. I got what I was looking for, but I really wanted to work with patients and I was obsessed with the science of pain. People think I'm a massacist when I talk about, yeah, I'm interested in pain.

But I'm not saying that I'm doing it or receiving it. Just the science is mind blowing. So I wanted to treat patients right away. And, you know, I had been teaching a bit at UCSF and it's Stanford. And I just told my colleagues like I'm opening my doors.

I want to specialize in chronic pain. I got the hardest patients. I want to say this clearly. I absolutely no one wants to see a psychologist for pain. I am like the used car salesman of pain medicine, right?

Of course not. The stigma attached is like you're saying it's all in my head. You're saying it's just emotional. It's so romantic. It's not real.

Yes. I just want to see a medical doctor. 96% of our medical schools have zero dedicated compulsory pain education. I'm going to say that one more time. 96% of med schools in the United States and Canada have zero dedicated compulsory pain education.

The real pain science is out there and it exists. It's just not being taught in med school.

“And of the 4% that have it, the total is in the 4 to 6 hour range or something, right?”

It's very small. And check this shit out. We're going to talk about this. I'm sure. The current model of understanding and treating pain is the biomedical model.

It means when we talk about pain and when we treat pain, we talk about anatomy and physiology and bones and body parts. Yes, that's important. But neuroscience has known for 65 effing years that pain is this word. It's biosyco-social, which means yes, there's bio components.

There's also cognitive and emotional components. There's also social components. But it makes me crazy. I had to study pain on my own for 700 years to really distill down. Like, what is this?

And what are we getting wrong? And how has this happened in pain that we've created an opioid epidemic? And we're still doing it today. So Michael Palom was in his new book as unconsciousness. And similarly, it's riddled with the same challenges in that

Renée Descartes broke the mind and the body into two things for us 300 years ago. And we are stuck in that paradigm where there's two different things. There's your thoughts and emotions and your physiology or your physicality. More and more we now know there's no such thing as a division in any one of these components. This is one complex system that's talking at all times with itself.

And it's integrated and there's no division that can be made. And to put a super fine point on what you're saying because I'm currently dealing with it with a loved one. To say that it's more than just the physical pain is not to say it's not real. It's a hundred percent real. And the question is what's contributing to it, right?

It's very relevant. How are we getting to this pain, which is a thousand percent real, and anyone who's listening to Preventing to defensiveness, it's real real. No one is suggesting that the pain is not real. So to you, but the patients you're getting have generally gone through years in some cases of

Exploring every single medical option for their pain. What are some examples of MRIs? That was sort of what triggered when you asked me about opening the private practice. I was getting the patients who weren't getting better. So I have this patient who lives in my brain.

“And of course, I'm changing names and personal details because that's what you're supposed to do.”

And it's very important for patients, privacy.

One of the chronic pain patients that really sticks in my mind to Sam. It was really Samuel. Sammy. He had been in bed for four years, and he had been on 40 medications. He had seen 14 specialists.

And I want to describe him to you because I see him in my mind's eye. Every time I talk about him, he had long-on-washed hair. And his skin was pasty and pale, and he was rocking himself back and forth on my couch with pain. What's funny is, I remember thinking to myself, "Who do I think I am?"

This kid had been to Stanford. So the punchline is this person who's been bedridden for four years is only 17. Correct. Oh my God. And at 17, when you've missed four years of life, that is really significant.

Those are all the milestones you really only get those once. But I did have in Poster syndrome.

“I absolutely was like, "Who do I think I am?"”

So we talked about my training and how I'm a nerd and studying pain neuroscience and endogenous brain chemicals that make pain and pain psychology and biology. But I really think of myself as a pain detective. And when someone comes to my office, it's my job to figure out all of the factors that are contributing to the pain that are amplifying the pain and are perpetuating the pain cycle. So when I assess Sam, I had his records.

Like yes, family history of migraine. Diagnosed with migraine and diffuse amplified body pain of unknown ideology, meaning he was riddled with pain all over his body. No one knew where it was coming from.

He had had a million tests. He had been on all the drugs.

So, when I assess my patients, yes, I want to know your medical history. If you haven't had all the tests and the scans, I'm going to send you. I want to know that your blood and body parts are okay. Then I want to know about the rest of you. We use this word biosychosocial.

That means that there are a lot of factors contributing to pain in any given moment all the time. Sam was depressed and suicidal. Shocking, he had been in bed for four years. He had no friends, no life, no hope. He loved it 7th grade. He detaches from playing soccer, from having friends.

But what happened? The first thing is he had a migraine. He had crippling migraines.

“Okay, in his 7th grade, he had crippling migraines.”

Yes, and then diffuse amplified body pain. So, severe body pain, all the tests, no one knew it was going on. He couldn't go to school. His loving parents were like, "What are we supposed to do?" He was like, "I can't go to school."

So, he stopped going and that just never ended.

Oh, my God. You would be surprised by how common this is in the pain world. So, I started getting all of those patients, but I want to tell you what happened with Sam. Yeah, yeah. He was depressed and suicidal. He was socially anxious, like crippling social anxiety.

What didn't talk to kids, his pain was always worse. Sunday nights and Monday mornings. So, there's a pattern to the pain, of course. He was on a white food diet. Oh, like rice and bread.

He didn't like fruits and vegetables. The fries. I got you. Pizza pasta, chips, bread. Oh, you would pray for rice, I think.

For Sam's wife. I mean, like, that's not uncommon for a big chunk of the American pediatric population. Like, it's just only fruits and vegetables and so don't eat them. If they're saying they can't eat or they're too sick to eat, then yeah, your parents can be like, "Fine, just eat these chips, I guess." Eat something.

And his only activity at this point was reading books. And playing video games. I've played video games. I've played video games. So, it's up to four in the morning playing video games to sleep hygiene was all.

So, in order to help Sam, I knew I needed to help him look at the whole recipe and fix the whole recipe. So, we changed his nutrition. How to come to Jesus talk with mom and dad. We were like, "How is his body supposed to fight this thing?" If he's not getting a perfect nutrition.

Put him on a sleep hygiene protocol. He had to wake up at, like, ten instead of, like, two in the afternoon. Oh, this is a peeling it back. Exactly. I like how small you started.

You had really tiny steps for him to take.

“I think the first one was to go outside.”

It's called a pacing protocol. It's one of the most fundamental parts of a pain plan for people with chronic pain. So, week one, he was standing outside in the sun on his porch and texting just one friend. Week two, he was walking to the corner mailbox and mailing a letter. His mom would actually give him bills.

She had to pay. Week three, he was taking his dog to the dog park and having a conversation and we scripted it. Cute dog. Remember, paralyzing social anxiety. I salated stuck at home.

By the way, that will amplify pain. All of these ingredients.

He got a tutor, started catching up in school, went for his first haircut.

When that kid came to my office after his first haircut. He also had gone and bought a backpack. He was a child transformed. That was like one month in. One month in.

Some sunlight, some social exposure. By the way, the more he did, the more he realized he could do, mood started going up. Stress and anxiety started going down. And oh, shit. The brains connected to the body.

When stress and anxiety started going down and mood started going up. All these things started changing. His pain started changing too. The virtuous cycle or the destructive cycle is spinning. So the one he was in was just going to get worse and worse.

And worse until probably suicide or something else was on the table.

And then slowly, it's all gaining momentum.

“The fact that he was happy when he came to your office with a haircut and a backpack is shining.”

Yes. And he spoke at his graduation. He returned to school. I love it. You had an impact on you.

I don't think about him. He graduated from high school. And he walked across the stage. And he said, if you had told me four years ago, I'd be graduating high school.

I never would have believed you.

I may be cried. That kid got asked to prom by two girls, not by wine when he went back to school. And he went with both. Somehow. I would love that talk to him.

Yeah. They were juggled that. Oh. Oh. The same problem.

I'm like, I didn't see him. I still hear from his parents. Oh. I have to tell you. You saved his life.

Very selfishly. You did. It changed my life. I'm not joking. That kid.

I was like, I'm never doing anything else.

When I met that kid, he was on opioids and Thorzin. I also worked on an inpatient psych unit. If your homicidal or suicidal, you will go to an inpatient psych unit where they lock the doors. And if someone's having an acute psychotic episode, they will shoot you full of Thorzin

and knock you the F out. This child was on opioids and Thorzin for his pain because we tell people that pain is a purely biomedical problem that requires a purely biomedical solution. I want to say clearly. I am not a magician.

But that kid got out of bed and back to life. He will never again be the kid who's in bed for four years that will never happen to him again. What are we doing to people in pain? It makes me crazy. Yeah.

I will not be on anybody's understanding. Yes. So let's talk about first of all, the subjectivity of pain. You've got a lot of different, great examples of how we can illustrate that it's not just the broken bone. Although that is definitely part of it.

“But I think a good place to start is amputee.”

I'm obsessed with phantomly. Explain phantomly. Only if I got to hear after my monogas obsessed with phantom pain. Or I'm kind of obsessed with pain. We'll not pain.

But I'm a little bit of what Dax would say a hypochondriac. I don't identify that way. But he identifies me that way. Excellent. So you know, I am hyper aware of what we'll cause distress and pain.

I avoid those things pretty much at all costs. So in a psychology classroom, we learned about phantomly. I was like, what, that's horrifying. Okay. So we have all been sold a big fat lie about pain and what it is.

So pain is the body's warning system. It's our danger detection system. However, we have been told that pain lives exclusively in our body in the part that hurts. You have back pain. You see 762 back doctors and you probably get back surgery.

And maybe you get a prescription. You have chronic knee pain.

You see 40 million knee specialists.

Maybe you have surgery. Maybe you take medications. Now, I want to say clearly. Surgery is our important and useful. Medications are important and useful.

They are not the only treatment for pain. And they are not the best treatment for chronic pain. Not by a long shot.

“It's really important because we're going to primarily be talking about chronic pain.”

And acute pain is pain that lasts three months or two. And that is your stomach hurts. You might have gotten food poisoning. So great. Broken bone, acute illness.

Yes. So anything that persists for longer than three months. Now we're into the chronic pain. You got it. And this is where we really want to focus.

So I'm going to be talking about the definition of pain across the board. But you are right. Generally speaking, God, my language is so bad. The fuckery comes when we talk about chronic pain. So sorry for people who are listening.

But I know where I am. So hopefully that is okay. But the chronic pain world is where we really screw people. But this is true for acute pain too, just the basic science of pain. So we've all been told pain lives just on our body part that hurts.

One of the reasons we know pain isn't constructed just by the body part that hurts. Is because of this thing called phantom limb pain. Phantom limb pain is when someone loses a limb, an arm or a leg. And they continue to have terrible pain. Monica's knocking on wood.

They continue to have terrible pain in the missing body part. The bill is hating pain. If you can have terrible leg pain. In a leg that is no longer attached to your body, that tells us pretty definitively that pain cannot live exclusively in the body part that hurts.

I had a patient with phantom hand pain who had lost his hand and his arm in a terrible firework accident. Mateo. Another young boy. Mateo. He felt like his hand was constantly spasming.

Cranching. Cranching. Sometimes it was picking things up. So if you can have hand pain in a hand that is no longer attached to your body. That tells us pretty definitively that pain is constructed somewhere else and that somewhere else is the brain.

And we said before that the parts of the brain that make emotions also make physical pain. Yeah, so the nervous system is kind of mapped in your brain. You have a neural network that knows where all the nerve endings are and it's communicating. And it's interesting this phantom limb pain is an outgrowth of the fact that your brain believes you still have.

That's right.

I mean, that's mind-blowing isn't it?

It's like it has a map of what it's supposed to have and it hangs on to the map long after the piece has been removed. So Mateo, what did you do with Mateo? Yeah, what you're talking about is you have a map of your body that lives in your brain. It's called the homonculus. Actually when I teach this I see patients of all ages adults and kids.

But when I teach kids, I ask them what they think a homonculus might look like. And they draw on me pictures and I used to have a whole wall full of drawing. I see like a triceratops with an elephant's trunk. See? Yeah, definitely it's a molecule. It's a pack of her.

That's a pack of her. Yeah, you're good. Yeah, right. And it's a really cool map.

“So like if I tell you right now without doing anything to sense into your right foot, like what is your right foot doing?”

Can you feel it? Can you feel it on the table? Is it warmer cold? You can do that. And the reason you can do that is because of your homonculus. It's like a sensory and motor map with phantom patients. There's a treatment called mirror therapy and with mirror therapy. There's a lot of books on this so interesting.

You erect a mirror. So they have their functional arm and the damaged arm. And you put a mirror up. They hide the damaged arm. And the good arm stays up and there's a mirror reflecting back to the brain. The undamaged arm doing things.

So they engage in activities and exercises. And it feeds back to the brain and image of two healthy arms. And it helps update the out of date brain map. It's kind of counterintuitive. Your left arm's hidden. Your damaged left arm's behind you. But your brain sees your left arm and your right arm doing things together.

Like Doc said, the map in your brain just hasn't caught up with the damage that has occurred. That arm is gone. Like it's not in danger anymore. But pain is the body's danger system. So your brain is going to continue making. Yeah, yeah, yeah, yeah, yeah.

It's not the trick you're brain into thinking. It's like I'm drugging the association with your left damaged arm. I see your right damaged arm in its place. Yes, yes. It's quieting the danger alarm.

That's the whole trick with pain is pain is the body's danger system. So credible evidence of danger will amplify the alarm. Credible evidence of safety will lower the alarm. So like one of my favorite examples of this is if you get slapped and bitten when you're having sex with a hot partner and you want it. But it will feel good.

If you get slapped and bitten when you're getting mugged, you bet your ass that is going to feel completely different to your danger alarm. Because pain is biosychosocial, which means it takes into account bio information, but also contextual and social information and also emotions. And where you are in the moment and who you're with and what's happening.

An intention. An intention? Yeah. Safety. Yeah.

“I think a massage or so many great examples.”

A massage, which would otherwise be painful, is like euphoric because you have put it in this framing. You're there on purpose. Yeah. You desire it. You're paying the person to do this to you.

You have some notion that it's medicinal.

I mean, I always think, oh, they're getting the knot out.

No, I don't know physiologically that's even true. But I think we're making progress towards my health. Yes. Some control over it. That is huge.

When you think about safety, control is a big part of that, right? Yeah. Enjoying capsacin, like eating hot hot food. The winner of the hot ones. Yeah.

We enjoy that pain. Tatoo's MMA fighting. What are you kidding? There's a million examples of enjoying pain on purpose. It's expectations.

It's your context. It's emotions. It's predictions. Stay tuned for our adventure expert. If you dare.

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It's a signal. The signal itself is pain. No, the signal's not. It goes into the computer and the computer interprets and comes to a conclusion. If I could give you a grade, you would get a plus.

Oh, thank you. But that's the thing we don't know. Even now, if you Google what a nosy sector is. A nosy sector are the neurons that live in your body and your tissues and your skin, your organs. And they feed information about potential danger to your brain.

Potential danger. But if you look it up, you're going to be told that it's a pain receptor. It makes me crazy. That is sensory data. Sensory data isn't pain until it reaches the brain.

And the brain uses all available information to decide whether or not to make pain and how much.

It's like temperature. It's touch. It's reflex. So you touch a flame. Yes.

A hot burner. No sea assumption. Make sure body moved before you even think about it or process it. You have an instinctual reaction to that. And I learned all this from Ed Young's book immense world.

So all these different animals have no sea assumption. Yes. But they don't necessarily have pain. Some do some don't. We're figuring out which ones do.

But all animals have this. No sea assumption. Yes. So what happens is those danger detectors in your skin or organs.

Send data first to your spinal cord and your spinal cord initiates that automatic instant response.

Again, there's a lot of animals that demonstrate constantly. They have these survival reflexes. Yes. But they don't have any of the other signatures for pain. So we are somewhat unique in how sophisticated our interpretation is.

Yeah, it's true.

“Okay, I think now's a great time to talk about a tale of two nails.”

Sometimes things are so interesting that I'm reading about that they make it to my dinner table. So last night I had to tell my daughters about this. So let's talk about our first construction worker. So I was reading these great papers. So I was this one from I believe it was like 1995 in the British Medical Journal.

And they wrote about this construction worker who had been on a job site. And he jumped off a plank straight onto a seven inch nail. So he was in terrible pain. They rushed him to the emergency room. They gave him really good drugs.

He was in terrible pain. They gave him a bunch of opioids and fentanyl was one of them.

He got all the good stuff.

And when the good doctors removed his boot, they discovered that a miracle had occurred. The nail had passed between the space between his toe. No, there was no punctual. No, there was no tissue damage.

Everything was green. No blood. But his pain was real. How is that possible? His brain, aka endangered detector, used all available information to decide whether or not to make pain

and how much pain is your body's danger alarm. It exists, save your life.

“So it used knowledge of his dangerous work environment.”

Memories of past pain experiences and injuries on the job site. It used the horror of the construction workers' faces. Yeah. He's friends around the visual data of this crazy nail. And his brain perceived potential danger.

And it made pain to protect him. Tale of nails number two.

Second construction worker.

Most dangerous job apparently ever. On a job site using a nail gun. Nail gun misfires. He sees a nail shoot across the room. And he is mild jaw pain, mild toothache, mild headache.

Continues on with work in life for six days. At the end of six days, he says to his wife, "You know, maybe I'll check out this tooth." Yeah, I can still feel this tooth a little bit. Goes to the dentist. It gets an x-ray.

And Rob, please put up the x-ray of him. Okay, so let's go. Okay, let's check out the tooth. Yeah, I can still feel this tooth a little bit. Goes to the dentist.

It gets an x-ray. Okay, so let's start. March to both men's surprise.

“They discover a four inch nail embedded in his face.”

I spoke with Dr. Seth Rainier on the phone. That's how big of a nerd I am. I was tracking down this photo. I wanted it so bad for the book. He said, "This is the luckiest guy ever."

And for the listener. So the nail has entered the top of his jaw. And in his past all the way through his zygomatic. Everything all the way up into the frontal lobe. The brain is spanning from his upper jaw into his brain.

Yes, and the whole story and the picture is also in the book. Yes, yes, yes. Yes, yes. This guy is the oldest child of metal in his face. And I want to say clearly.

Very real damage. Very little pain. Now, if pain were a reflection of how much damage we have to our body. Gentleman number two, with the giant nail in his face, should be in crippling, excruciating pain.

Gentleman number one, who has a nail in his boot. But not his foot. It should actually be fine. We have all had experiences like this. This is a stark example.

If you've ever gotten into the shower and you have black and blue marks on your body, you're like, how did those get there? That's evidence of damage to your body without the pain. We know that pain and damage are not the same thing, but we continue to get sold that lie.

Okay. So now, and this is the area that I'm constantly saying on here out loud, because I heard it from Lane Norton, but I'm relieved to hear it. It's really Norton is a buddy of mine. Oh, he's the greatest.

I talk about this one often, but you have two examples of it. But now I have the precise numbers, which I'm grateful for, which is there's been two incredibly compelling studies, because vaccines among the most common pains. It's like 80 to 85% of people develop chronic back pain at some point.

Chronic back pain. Yeah. So they scanned 3,000 healthy individuals, meaning people who have zero back pain, no reported back pain.

and 80% of subjects aged 50 to 59 had bulging discs, disc degeneration and other anatomical abnormalities with no accompanied pain. I want to reiterate that. Yeah.

Almost all of us with no back pain are wandering around with slipped and bulging discs. And we don't know it. You want to know why we don't know it?

We don't have pain, so we've never gotten our back scanned.

However, if you have chronic back pain, and you go to get your back scanned, and they find a bulging disc, guess what you will be told is causing your pain. They think they have a smoking gun,

but you can't have a smoking gun of 90% of us have the same smoking gun. Dude, dude, dude, dude, dude, dude.

“But then that's why when they do those full body scans,”

what's it called? Pernevo, it's the brand of one I got. That's tricky to do because it will tell you, oh, you have a bulging disc here, and then you might be like, oh fuck,

and then forever do that. How have you done that, please don't do that? I don't want her to do it. You'll be my third argument I have about this. I want to hit the second one, though.

Yeah, yeah. So there was another state, too. 1200 healthy subjects who had no pain. Nearly 90% of them had bulging disc. So this is enormous.

Less than 5% of back pain is from structural issues. Right. And that is not unique to back pain. Those are similar results when you study the hip, the pelvis, the jaw, the uterus, the wrists, the knee,

and neck pain. I went so far down that rabbit hole. There are study after study after study, showing that pain and damage. The things we find on scans,

that's what we're blaming pain on, but there seems to be very little relationship between the abnormalities found on scans and chronic pain. It's the ultimate correlation, not causation. Yes, but are people listening going to be like,

oh, okay, well, when I have chronic back pain, I'm not going to go, that's the thing. Because of this thing we're sold, which is that pain and damage are the same. It's a really, really hard relationship to break.

So I'm going to tell you a quick story. 30 years ago, there was a little kid growing up in Jamaica and he loved to run. He was really fast. And as he grew, something strange was happening to his spine.

It started twisting into an S shape, and he was diagnosed with scoliosis. But it didn't stop him. He didn't get surgery. He wasn't a terrible pain, he kept running.

He was faster and faster and faster until he was fast enough to qualify for the Olympics. And by the time he qualified for the Olympics, his body was so twisted, his spine was so abnormal,

and his body was so asymmetrical

“that his right leg was, I believe, half an inch shorter”

than his left. And his left leg could only put down 14% as much power as the right leg. He won, not one Olympic gold medal, but eight of them.

Do you want to guess the name of this gentleman who has extremely severe scoliosis,

but has never been treated for it and has very little pain?

You've seen bold and still holds the world record and the one hundred and the two hundred and the four by one. You've seen bold is the fastest man alive. You should see this man's spine. It is absolutely, really, not only.

And so if the lie was true, that damage and pain are the same. That gentleman should be relegated to a hospital bed. He should not be the fastest man alive. And in fact, we are often told that asymmetry

is the cause of our pain. Yeah, I will say again. He's so asymmetrical that his right leg has happened in shorter than his left. You would think that would affect a run.

Well, check this out. He's run like lightning. The scientists who study his biomechanics have discovered or believed that it is his very asymmetry that helps him go faster.

Listeners, do not chop off some of your leg just to be fast. Yeah, it's not going to make you the same role. Now, here's where we get to my own personal story, which is I did the Pranovo scan.

Yeah. And I'm going through the different categories. They do heart, they do lungs, all this stuff. And I get to skeletal system and I have abnormalities. I'm like, oh, what's this?

And yeah, I have significant scoliosis. Yeah. At the top of my back, my spine curves to the right pretty dramatically. I went, oh, my got all the times my mom was yelling at me.

You always drop your left shoulder in photos.

And we had no explanation. Other than it was my laziness, I guess. Come to find out, oh, yeah, I've had scoliosis significantly. Because visible in photographs now that I've seen the X-ray. But yeah, I have zero issues up there.

I've had lower back pain, but nothing where the scoliosis is. And the scoliosis is at all no issues. Wild. And the same thing, I'm like, oh, yeah, if I were in pain, and I went and got the X-ray, it would be definitive.

“I think this is the complexity of it is, yes, biological factors matter.”

Yes, of course, you can have pain with scoliosis. It's just not the only factor that matters. Biosychosocial. It means biological factors matter cognitive and emotional factors matter.

And together, those create the pain we feel. So they work the opposite way, though, so often do people go and they're like, oh, wow. Oh, my god. If scoliosis, yeah, my back then does the brain start sending the signal because you're aware now of it.

There's a story in the book called How Cancer, Cured a kidney stone. I should say, should I say that I wrote a book? I wrote a book. I'll tell you whatever.

I'm here. It's called Tell Me where it's. I took sort of like the most fascinating patient stories and put them in because pain is gnarly.

And it generates these incredible and counterintuitive stories.

So one of the stories I put in the book is called How Cancer, Cured a kidney stone. So I had a patient who had regular kidney stones. And they appeared like clockwork. She would have a six out of ten pain,

abdominal pain. There would be a host of accompanying symptoms. And the stone would pass within. I can't remember exactly.

“I think a max of like a couple of weeks.”

And then the pain would go as she would be fine. So she was having the normal constellation of symptoms. Her pain was a six out of ten. Her father had recently died of cancer. She was having a pain flare.

And her husband's out to her. Are you still having pain? It has been like six weeks. Are you sure this is a kidney stone? And not something else.

And she immediately thought to herself. Shit. I have cancer too. Right.

I think we all think we have cancer.

At least once a week. If you're a normal healthy human being. Yeah. Yeah. I think her dad had died of maybe abdominal cancer.

Something like this. So she, yeah. I understand. I didn't want you to see it. Sorry.

I won't call it on that. You should do it. I didn't know what on your hair. Oh, God. I didn't know that.

Sorry. I can't help it. I observed behavior all day. So she had the thought. Maybe this is cancer pain.

“And she shared that where there has been they both freaked out.”

Her pain went to an 11 out of 10. Her report. She fell to the floor screaming. Oh, my God. Her husband called 911.

She got rushed the emergency room. They did a scan. They found the kidney stone. Her pain went back down. Oh, my God.

Don't remember the number. Yeah. We had a 10. And she went home. And the kidney stone passed.

Pain is the brain's danger alarm. It's subjective. It thrives on data. Any data we give the brain that amplifies danger will amplify pain. Data we give the brain that makes us feel safe will lower the brain's danger alarm.

So that story to me was so revealing. The things we think the images are brains feed us the images we get from our doctors. They are going to affect the brain's pain alarm. And of course they should. It is adaptive and evolutionary for our brain to use all available information.

Why should we only use data from the body part? We should use all available data, right? Now let's explore these three pillars that attribute to our experience of pain. So the first one is biometric. We understand that one.

“I think we understand your bones broken.”

You have biological. Yes. So let's talk about the psychological and how it impacts. Can I add to the bio domain of pain? Yeah.

Okay. So like you said, it's the obvious stuff. It's like tissue damage, system dysfunction, genetics like Sam's family history of migraine. It's also diet, sleep and exercise. And I like putting them there because those are biological imperatives.

The reason I'm going to go into this is because what I want everyone listening to remember is that you have so much more control and agency over pain in your body than anyone has ever told you. If sleep and diet and exercise affect your body, you maybe can't change your genetics. You can change your sleep. You can change your nutrition protocol.

You can change your sleep hygiene.

I'm always sort of keeping in mind.

Like pain is terrifying. It's overwhelming. It feels unmanageable and uncurable. So if I can help people feel like, oh, there's actually 72 things I can do maybe starting today. If I can seed some hope, I have done my job.

So that's the bio domain. That's the bio domain. And let's talk about psychology now. Yeah. So I want you to imagine that there's a venn diagram with three overlapping circles.

And I should have said this at the very beginning. Of course, the first circle is the bio circle. The one we just talked about. Then we've got the psych circle, psychological factors and the social or the sociological domain of pain. So pain lives in the middle of these three circles in our venn diagram.

Okay. So you asked about bio covered in the psych domain of pain. This domain of pain is so full of stigma and misunderstanding. So I really front load with just the science. So in the psych domain of pain, we have emotions. We set at the beginning.

The limbic system, our amygdala, the parts of our brain that make emotions also make physical pain. So our bodies hurt more during times of stress and stress. We know that's true. Anxiety and depression will amplify the brain's pain alarm. There's like 4,000 papers on that.

Our emotional health affects our physical health.

If it's mental, if it's mental, if it's psychological.

Yes. That's not a real distinction. I feel so much gratitude. This is the line that I go around repeating.

“In Western medicine, we're told either your pain is physical and you need to see a physician.”

Or your pain is emotional. You should go see a psychotherapist. But pain is both physical and emotional 100% of the time. You can't separate them out. That's just not how the brain works.

Right. When we're treating chronic pain, I actually want us to be thinking about our emotional health. And I'm not saying it's all in your head. I am not saying it's all psychological. You just can't deny that the brain is connected to the body.

Yeah, it's part of the recipe. I want to talk about some of the specific things within the psychology domain.

Which would be thoughts, attention, distraction, and emotion.

Yes. So we set emotions. But talk about thoughts, attention, and distraction. Yes. We tend to think that thoughts are just these air bubbles that appear in our head.

You know, in the space between our ears. Thoughts trigger a neurobiological cascade of events in the human body. Right now, I want you to think about your to do list.

“All the things you have to do and haven't gotten done.”

Maybe your taxes. That's true for me. How does your body feel? When we think stressful thoughts, our body has a physiological response. Our muscles get tense.

We bump cortisol and other stress hormones. Thought rate goes up. Our information goes up. Thoughts don't just live in your head. Thoughts affect your body a hundred percent of the time.

And then we have in there also, like you said, attention. That's a cognitive factor. So what we know about pain is that when we think about pain and talk about pain and focus on pain, what happens to the brain's danger alarm. It magnifies the pain response.

And of course, the opposite's also true. So if you have to give a kid a shot. For example, you shove a screen in front of their face. And they will be distracted and laughing. And they will not cry.

And they will not scream. We all know this even as grown-ups. If you've ever been so absorbed in some pleasurable activity that you didn't notice your pain or you briefly forgot about your pain. Which happens to everyone. That's not magic.

That's just your brain's danger alarm. Right. So attention changes pain too. Yeah, maybe even think about why opiates work. Oh, dude.

As I was reading all this because I have a very well-known issue with opiates at one point. They certainly cure the physical pain. But I think for me, they're only curing the physical pain because they distract me from the mental pain. By the way, that is a known thing. Yeah, so it's not sending anything that's making the inflammation go away like and said what or something.

That's right. It's binding to the opioid receptors. And you have a disproportionate amount in your brain's emotion centers. And opioids medicate not just physical pain, but emotional pain. And that's why they're so dangerous.

And that's why they're so addictive. Yeah, you think they're addressing this physical pain for me. They're not affecting the angst and discomfort of my emotional life. Yeah, they're muting everything. By the way, what are we doing to people in pain?

Especially people with a history of addiction? It's like handing people a loaded gun when they already have a genetic loaded gun. To me, it feels unfair and unsafe. And I hope we'll talk about that. Yeah, I was curious in this psychological pillar.

I often think of identity as having a lot to do with this. So my identity is that I'm indomitable. I have reasons why I've made that my identity. I believe if I appear to be indomitable, you will not try to take advantage of me. And so in order to service this identity I have,

“Monica will tell you, that's why I had no business on opioids.”

My shoulders in four pieces. I got to wait a week to get the surgery because I'm still filming. And I go film an episode in a sling racing or rally car with one hand and jumping. And I can do that. I don't know why I can do that. I don't have an explanation. I don't think it was born with that thing where I don't feel pain.

But it's not on the table for me to be outwardly vulnerable. And so I do think I've wielded my way out. I've been yelled at by my wife for carrying things while I just said surgery. And I'm like, you know, I can still fucking carry it. The notion that I can't carry it is the most painful thing.

The pain's not the painful thing. And so I just feel like I have really reformatted my relationship with pain. And my only explanation is that it's this identity thing. That I will not threaten my identity by experiencing this pain. Or if I get tattoos, I don't give a fuck.

So what do we think about our identity and how can that play a role in there? I feel like every once in a while someone brings an ingredient to me that I haven't thought about before. So the way I frame this is like a pain recipe.

Like there's a recipe for brownies. There's always a recipe for pain.

And there's biological ingredients in there. There's psychological ingredients. There's sociological ingredients. And I feel like I spend a lot of time with each one of my patients. Like mapping out the ingredients. Like, what are the things in this recipe of yours that's amplifying your pain?

And what can I do to help change those ingredients to help you lower pain volume? And one that I have absolutely tell this moment never thought of is identity. And it go to me. It's so present in my best friend from childhood Aaron Weekly,

I see it in my sister and my brother and my mother has it. We don't give a fuck about that. And then somehow some magic happens where I'm not experiencing it. Yeah, yeah. So then I'm lying to myself for fighting and it's like, I don't care.

I don't think you're lying to yourself.

“I think it's adaptive for you in some way.”

It's like a survival tool for you. I don't know you all enough to know why, but it has been adaptive for you throughout your life. And that's why you've been using it. And that's not a flaw.

That's not a character flaw. It is helped you get where you are. I think it's fascinating. It has a tail to the head of that coin. It does go somewhere goes into emotional distress that then needs medication.

Whatever that medication is, whether it be drugs or whatever it is or adrenaline. It's not just like it's magically, oh, I don't have pain. It's that it gets funneled into somewhere else where people don't see it necessarily. Yeah, it has pros and cons. And then that's not good either.

Yeah. Here you go. Okay, so let's talk about sociological. Because I think you probably have a lot of interesting statistics and I'm sure things differ in these different categories of sex, gender, race, ethnicity, socioeconomic status.

How are these factors evident in people's experience with pain? Yeah.

So when I was first studying pain as this little library mouse,

not church mouse at Brown with this pain neuroscientist, I was like, yeah, pains biological. It feels pretty intuitive that there's an emotional component. But what is this social shit like pain is social? What does that even mean?

So I really went down that rabbit hole and I wanted to examine that. So I'm going to give a couple of examples. And I hope they're resonant and you can ask me questions about it. So among the worst punishments you can give a human being is solitary confinement. What does it say about human beings that one of the worst things you can do to us

is isolate us from others. Being social is biologically adaptive. It helps us survive. It's so fundamental to our very survival. That our brains evolved a mechanism to reward us for engaging in it.

When we are social, our brains bump out. Serotonin, which bumps our mood, dopamine, pleasure and reward and motivation, and endorphins, our endogenous homemade pain killers. When we are with other people, pain volume goes down. The opposite is also true.

When we are isolated and lonely and alone, especially in solitary confinement, all of those good chemicals crash. And we feel terrible not just physically, not just emotionally, but both because it's connected. This may be think of the weirdest thing while I was reading about this. When I worked for my mom and I worked with all of my friends in my early 20s,

and we would drink way, way too much on work nights. And we'd stay up to three in the morning. We'd be out in the parking lot at 6am to fucking wash cars. But because all eight of us were hungover, there was some bizarre joy in sharing that state.

“And I think people can relate to this on vacation with friends.”

When you're with a group of people and everyone's hungover, versus you're by yourself in your apartment dealing with a hangover, those are totally different experiences aren't very monochrome. Yeah, sure, I think so.

I never cared about a hangover when I was with my friends.

And when I was a solitary drinker, they were insufferable. I mean, there's this old saying that when you share your joy, you double it when you share your pain, you cut it in half. And that is definitely true for me, like if I'm suffering, my friends will tell you I will burden them.

And for them, they seem to be able to carry it. You can tell me your stuff all day, I'll be fine. You know, like I can carry anyone's stuff. When I share my stuff, it definitely reduces my pain. Yeah.

So that's one example of how pain is social. So when people are isolated in their pain, obviously that's going to make it go up exponentially. It's going to feed that. So that was another data point that was so fascinating to me.

So former US surgeon general Vivek Murphy. Yes, we love him. And he's all about ending loneliness.

He did that amazing study, like hundreds of thousands of people,

where he showed, by the way, he wasn't the first to show this, but he gathered all the scientific data to show that when we are lonely and isolated and alone, it actually is a predictor of a whole host of chronic illnesses and also chronic pain.

That are worse outcomes than smoking a pack of day, which is the craziest comp. We all know how bad smoking a pack of day is, but being alone is worse. Not just emotionally, just to make that clear.

Loneliness is bad for our physical health. It is a predictor of disease and pain. Yeah, that's so wide. I know. So like all of these data points to me,

I was like, oh yeah, pain is social. Social medicine is real, but that's not being prescribed and most of us roll our eyes. Like, yeah, I have chronic pain, blah, blah, blah. Don't tell me it's just hang out with more friends.

And I want to say clearly, it's not that simple. It's one of the things one of the reasons you can pull. It's one of the ingredients in the recipe. Yeah.

“So you should probably be done with time outs, right?”

For kids. There are a lot of psychologists who are empty time out.

which is it is our baked in learning mechanism because we're a social dynamic.

Being excluded from the group is insanely powerful.

Yeah.

“So is there a version of it that is not too terrible, right?”

Yeah. It's all about degrees of it. Yeah, yeah. But yes, in general, when your kid is dysregulated and you send them away to deal with their dysregulation by themselves,

maybe not a great idea, right? There's a lot of work really. Yeah. And in the goals should be probably to first regulate, then teach the lesson.

I think that's also a good work of events. Yeah. So I wasn't a big time out person, but there were a couple of occasions where it felt appropriate. What do we see with pain is it applies to gender?

How is it differ with socioeconomics? I have my guesses, but what do we know about that? And redheads. That's physiological, though. What is that?

I had a look that up. Someone asked me that on a previous podcast. I was on this podcast called "Olegies," which is a science podcast. And she has red hair.

And she was like, is that true?

So there is some data to suggest that redheads do experience more pain. It's still very new science. And I would not say it's definitive, but there is some research suggesting

that it is tied to like our sensitivity. This is the most fascinating thing. So all of us, as part of our recipe, have pain thresholds and some people. And this may be true for you.

“Have higher pain thresholds than other people.”

And like everything else to do with humans, it is on a spectrum. Some of us are very sensitive. And some of us are less sensitive. What?

What give you life? I can handle a good amount of pain. What? It's very, very clear to me. If you choose it, you can endure a ton.

So your role as a cheerleader, you endured pain that you wouldn't otherwise be able to endure, because you wanted to be a cheerleader. But you also cut your finger, and it is a very, very big deal.

Well, hold on. Both things are true. I opened the camera. [laughter] The finger cutting is not a big deal

because it hurts. It's a big deal because I'm alone. That's a huge part of it. Then I'm calling people and sending pictures like, "Is this okay?"

And as soon as they're like, "Oh, no." Whatever they say, the connection with another person is helpful. You're saying that loneliness amplifies the pain alarm

and social support lowers the pain alarm. And it's like, "Oh, what if I bleed out?" It's about that. It doesn't hurt. You just moved to the point.

When we are alone, we feel like this is just biological. We're more at risk of death, because we don't have people. We're more vulnerable.

That's the word.

And the second you have social support.

[laughter] I love that example.

“I wonder if your proximity to us is going to lower”

up your pain threshold because you're now across the street. So like, this isn't really pain all those sort of, I guess. But my parents were in town recently

and the alarm went off in the middle of the night. Oh, so scary. Yes. Normal. I was by myself.

Oh, my God. I would have been so panic cut to a week later, but my doorbell rang in the middle of the night. I was by myself. And I was like, "Oh, I'm dead.

I'm dead. I don't know what to do." Do I call it like, "I didn't know." But when I was with my parents, I was just like, "It's fine."

I had no idea what was going on for a month. But I literally burned. A door blue open. But she didn't even care. But if you're by yourself,

it's definitely a guy with a huge nightmare dream in the ski mask. It's true. It was fun. It was fun.

When there were people around, and I assumed it was something bad. And I was by myself. I know, but when you forget about how that affects our bodies.

Yes. We just forget. This is like one of the many ingredients in these wife married people live longer. This is a one component of it.

You're not having the cortisol dump. It's easier on your body. Yes. Stay tuned for more armchair experts. If you dare.

Do we interrupt your midfield? I don't think I have any idea. I have no idea. I don't care. I'm not going to do anything.

I'm not going to do anything. I'm not going to do anything. I'm not going to do anything. I'm not going to do anything. I'm not going to do anything.

I'm not going to do anything. I'm not going to do anything. I'm not going to do anything. I'm not going to do anything. I'm not going to do anything.

I'm not going to do anything. I'm not going to do anything. I'm not going to do anything. I'm not going to do anything. I'm not going to do anything.

I'm not going to do anything. I'm not going to do anything. I'm not going to do anything. I'm not going to do anything. I'm not going to do anything.

I'm not going to do anything. I was with the research says, in general, over the years, there has been this myth. And there's a name for it. I'm forgetting the name of it. It's like the hero myth or something.

It's like that black people feel less pain than whites because they have thicker skin. Yeah. It's a holdover from the sleeve. Yeah. And so it's just to find blacks are prescribed something like 50% less pain medications

in the emergency room. And the women are believed to leave the least amount about their pain and assessment. Black women, if they tell you it's an A, the person immediately cuts that in half.

And that leads to this other thing that happens with women in minorities is not being believed or the suggestion that your histrionic, that word has somehow just found its way into modern medicine or psychosomatic. So that's. But don't ask you this.

We're going to try to punch from every angle that the risk of offending someone. Is it not conceivable that women in general are more vulnerable physically? Or going to die by the hands of a man more than I'm going to unless I go to war. There's an objective threat because of the sexual dimorphism that feeling vulnerable. You get an elevator with a guy that's six to you have a different experience than when

I get an elevator. Right. So the feeling of vulnerability, if we're acknowledging that that's part of pain, couldn't that be in the recipe? It sure could.

But there isn't data to suggest in general that women are more sensitive to pain than men at a biological journey. Oh, I don't think they are at all. They're giving birds. I would argue they have a fire threat.

“That's what makes it so complicated is like because there's all these ingredients and”

they're always interacting.

Is it cultural? Is it sociological? Is it learned? Is it biological? What is the recipe that's creating this thing?

And then are people experiencing more or less? Yeah. Also, access to care is in this recipe, too. We talk about insurance companies, so many of the treatments we're talking about aren't affordable.

Like you can have 42 surgeries and take 72 medications. But if you want to come see me, it's not reimbursed by insurance companies. It's real crazy. So access to care, being able to afford treatment, access to health, he foods. There's a lot that's stacking up against people who are economically disadvantaged.

And so of course that affects their pain, too. Okay. So we have a sense of all the things now that are contributing to this again, phenomenal logical experience of pain. But you don't stop there, luckily.

The last third of the book, Tell Me Where It hurts, is dedicated to addressing these things.

Other than the three you mentioned in the bio under that umbrella, not a lot you're going to do about your genetics or your tendon strength. No. But there's a ton of stuff that you can do in the pain protocol. So how do you identify and track your pain recipe?

“Yes, part three is a pain protocol and my mission in life is not only to change”

the way we talk about pain and the way we understand it, but also the way we treat it. Because we are completely effing people living with chronic pain by telling them that the only solution is a pillar procedure. So if you came to my office, part three is the pain protocol and it's exactly what I would do with you.

And you'll see in the pain protocol that we walk through, like, what are the things in the bio domain of pain that you have the power to change? And what are the strategies and tools that I can offer you to help walk you through that in a very approachable, digestible, not overwhelming way, because it can feel so overwhelming.

A quick part of a lot of people's pain recipe will be the pain starts when I've been sitting for a while. Totally. Right. So what does it make common examples?

I'll say my pain recipe. My pain recipe is like sitting for too many hours staring at my screens, not getting up and stretching and moving my body, not drinking water and just like being extremely dehydrated, eating a crap diet. Sure.

And I'm hungry, eating chips or something, poor sleep. Thank you so much. I really appreciate you very much as I talk about my pain recipe. Do you have chronic back pain? I don't think.

But I'm aging and so like my body hurts. Yeah. So crop diet, sitting too long, not moving my body, poor sleep, like I am someone who has insomnia on and off, so like if I have a bad night of sleep, my body will hurt more, not protecting time to exercise, I don't exercise to lose weight.

I exercise because if I don't, my body feels terrible, my mood is shit. But those things for me are sort of like fundamental, oh, and stress, stress is so fundamental to my pain recipe. Like if I have too many things to do, which is all the time, and I'm not protecting that, and I'm not like managing my stress well, and I'm doom scrolling at night or watching

the news. Yeah. So all those things together will come together for me and create a high pain recipe. Yeah, you gotta be aware of what your self medication is because it's often a part of why you're suffering.

Right. You're mean like scrolling. We all have a lot of ways to regulate ourselves in many of them make us worse. In the same way that drugs do, it's like they temporarily relieve your discomfort, but at a much bigger cost.

“Like I'm a workaholic, that's what am I.”

And that's a distraction, and a distraction is a good tool. But when you overwork, you're overstress, you're sitting too long, your body feels worse.

But so just as there's a recipe for high pain, there is always a recipe for low pain.

And like this high pain recipe I just outlined, the cool thing is that it has an opposite. I know poor sleep is going to mess up my body, make my pain feel worse. So I know I have to put myself on a sleep hygiene protocol. I have been doing this for like 25 years now. My sleep hygiene protocol is like dimming my lights, a couple of hours before bed, not

Sometimes that means I have to put my phone in another room and I will do it because

insomnia messes me up. It means getting out of bed after about 20 minutes if I'm not sleeping.

“So that I'm not lying in bed being like, why are I sleeping this so annoying?”

And then stress goes up, anxiety goes up, like the head of sleeping goes down. So I know what my high pain recipe is, I know what my low pain recipe is, and I know how to get there. That's actually what part three is. So sleep nutrition movement activity functioning, how about strategies targeting emotional

health, including brain-based treatments known to adjust pain volume? So can I ask what are things that you guys do for emotional health, that's helpful? I have a bonkers, I'm like the most creature of habitty. I have such a routine every single day. And mine is like exercise is number one, meditation's very important, journalings very

important. My diet's very important, sauna's very important. It's embarrassing how much time I put into prevent me from being in pain, embarrassing in that I can't believe it takes us much shit. But I don't care because I am not in pain, I've had a bunch of motorcycle accidents,

I work out like crazy, and I am not in pain, and I am generally very stable emotionally and mentally, and these are, I know, because I've lived without these routines, and I've lived in fluttering my arthritis with the foods I'm allergic to, and I've done all the things that were miserable, and now I am just very, very regimented about my schedule. So you have figured out your low pain recipe.

Other than I can't hack sleep, but whatever, there's going to be some categories that suck. I have forgiveness for myself. Yeah. So you're taking care of your emotional health, and by the way, also your physical health

with that routine. Can I ask you to? Yeah, of course.

“I think for me, the main thing is being social.”

I like really make time for that. I try to do that daily, like, hang out after work with people. There was one period of time where two of my friends who I hang out with a ton were both gone, and I was like, I'm going to die. Yeah.

I don't know what to do. I need these people. Social medicine is real. Yes. Obviously, if I exercise, I feel better.

I'm not as regimented as deputy. That's okay. That's what I added. And most of 12 years old there. If I did a good routine, I used to exercise all the time.

So if I'm going to go to routine, yes, but I think the social medicine is a huge one. I want to add, I don't want to pat myself in the back. You do what you have to do. Yeah. You're humming along.

Again, you're 12 years younger than me. But I do what I have to do to not be miserable. If I got to do less, and not be miserable, I would do it. I had to go to A because I was going to die. I didn't go because I wanted to go.

Like, I also think you can look at someone else's routine and feel some kind of shame that you're not executing all this stuff.

“But you should only be doing what you have to do.”

This is what I have to do. That's true. Like, there are moments where I have to go on a walk. My body and brain know that I just want maybe need to do it on the same frequency. I don't know.

Whatever. But you need to please that. It's a nautical schedule. Well, no. I can say that.

I found your low pain recipe.

And I think it's really amazing.

And you guys listed all the things that I would put, like, taking care of emotional health other than when I think of emotional health support. I actually think it's great to talk to someone. And there's so much stigma around that still. It's like 20,000.

And here we are. And we're still talking about, like, it's so shameful to have to see a therapist. So like, I want to see if I can frame this differently. Sorry. I can't believe I didn't say that.

I can live at a Starbucks. I'm in therapy. Yeah. Yeah. And it's everything.

It's hard to find someone who's available at the times you want, who's qualified, who you like, and trust, and want to talk to you. So I'm not saying it's easy. But research shows it can be extremely, extremely helpful. Just as we go to the gym all the time to exercise our bodies and make our bodies stronger.

Why would we not engage in some form of brain exercise for our emotional health when I think of therapy? That's what I think of. A trained professional who's helping us with our emotional health, with our history of trauma, with our fucked up relationships with our families, doesn't everybody need that

just as much as we need to go on a jog? How much better a place with the world be if we were all engaging in as much brain exercise as body exercise. So I think about that also. Yeah.

I think my reservation there a little bit is I am always conscious.

I think because of where it came from, with how lofty a lot of these are. If you have two jobs and you have two kids and you're a single parent, A, I don't have the money for therapy. And I don't have the free time to exercise like you're saying. These are all real real pressures, but even to that I would argue like A is free.

There's a lot of different groups that are free. You can actually engage in group therapy in a lot of ways for free. I would also argue that to prioritize 20 minutes of movement in the day. You could go for five. You'd really be shocked how much time that buys you the rest of, because you're no longer

So you might be shocked with how taking more time for that thing ends up adding time.

I think it's a fair and a good point and the affordability pieces are really huge one. And I think there are a lot of resources out there. There are even workbooks that can help with certain things like depression.

“That's why like your book, someone can get your book and go through this.”

The purpose of writing the book was sort of like to put the power into hands of anybody who wants to understand it and treat it. You have techniques for modifying negative thoughts. True story. That's great.

Social medicine. We just talked about that. Some things that could help that weirdly down river effect pain is like better boundaries, creating healthy social connections, healing, trauma these things all impact your experience with pain.

Yep. My other curiosity was again, I brought up A. A has a bismal success numbers. Is that true? Oh yeah. It's in the like 30%.

And did not am relative to the other treatments, it's an absolute miracle.

You can look at it one of two ways. If you want to go like, only 30, some percent of people who go there and getting long term sobriety, sure. But versus the alternative is like single digit, people don't just quit. I mean, very few people just white knuckle it for the rest of their lives.

So I'm curious. We know all of bismal, the outcome of chronic pain treatment is with doctors. It's in the low, you know, it's under 50%.

“What kind of success would you say you were experiencing with this more of all this?”

Sound like a jerk. Okay. Like a brat. Let's be honest. Here's why I'm sitting here on your couch despite performance and public speaking anxiety.

Yeah. My patients get better. They get out of bed and they go back to life. I am not saying that their pain disappears completely all of the time. That would make me a liar.

Sam continued to have pain flares, but he knew what to do. They didn't paralyze him and they didn't keep him bedridden. He knew what to do. If he needed to rest, he would rest, but he wasn't on the white food diet. He wasn't socially isolating.

He wasn't not moving his body. The treatment for chronic pain is known.

There is always hope for treating chronic pain.

It just isn't told to our doctors. It's not told to us. Your pain recipe, with all of the ingredients and mapping them out, hopefully with someone else,

“but you can also do it on your own and then figuring out what you need to do.”

To change the ingredients in your pain recipe, there is always hope for treating chronic pain. It makes me crazy because if you google the treatment for fibromyalgia, it will tell you there is none. I can't tell you how many of my patients were told that there's just no treatment for

their pain, they've been through all the medications, in fact, in medicine. If you've had four back surgeries and you still have back pain, you will get diagnosed. Check me with failed back surgery syndrome. As if you failed the treatment instead of the other way around, there is always a treatment for chronic pain.

The treatment exists. It's looking at the recipe and figuring out what we can do to lower pain volume and there's a million things we can do. The great challenge to me still seems like asking patients for behavior and modifications. Versus pills or procedures is a tall order.

Getting people to change their behavior is really, really hard. I agree with you. I would say it's a combination of things. I am not telling people to go off their pills. Absolutely not.

Like pain medications are a God send. We're no longer biting on wooden spoons. Thank God for good drugs. I think if you list these escran, dying to throw cancer for months, like what was that experience?

No. And I want to say that opioids are appropriate for post-surgical pain and end of life, care and cancer pain. I just feel like we are screwing people. Can I ask a question?

You don't get what you're going to ask? Did it start with an injury? Yeah. So I had been eight years sober when I had a motorcycle accident. I was prescribed, I asked my sponsor and my allowed to take this.

Oh, boy. I took it. It was completely fine, very misleading. I filed it as a mental note. I'm like, oh, that's weird.

That was a drug that I was fine. I didn't take them all, still did my shit. So that was a very bad data point. And then over the years I had more injuries and then what really set it off to the races was, yeah, I had back to backhand shoulder surgery.

Then this bullish arrogant view that this was a drug that didn't seem to affect me in the way that cocaine or alcohol did, and that this was kind of a manageable thing. And then yeah, I was off to the races. But I mean, I want to take 90% of the responsibility for it. I also was open to the idea that there was still something I could do that wasn't the

other things I had admitted I couldn't do. I ask a question. Yeah. Would it be fair for me to say, like, I don't prescribe, but I observe an IAC patients with pain all day.

So my question for you is, do you feel like it's inappropriate for me to say, like, maybe

“we can recommend different pain medications for people with a history of addiction than”

opioids? Do I have a leg to say that? It's tricky because I'll give you an example, like what screen bullshit to me about the James Fry book, which I love was he did not have all that dental work without an aesthetic. That doesn't happen.

No one does that. No one should be expected to do that, addict shouldn't be expected to do that. I don't love putting the responsibility on the doctors, if I'm being honest, but I'm an addict community. The responsibility is mine to say to the doctor, hey, I'm an addict.

The pills should go to my wife. This happens in the program all the time. People are responsible for other people's pills. As long as you take it as prescribed and as you're supposed to, you're fine. So that's on me going in to go, like I shouldn't ever be holding pills.

If there's some range of how long someone should be on these pills, I should be on the shorter end of these pills.

But I don't think it's fair for the surgeon to take on and understand your level of addiction.

My dad died 20 years sober. He had many different bouts of being on opiates. It never got him. There wasn't a thing for him. They were in his house.

He didn't care. He self administered. He never abused them. That's what version of addict he was. And then I was this version.

So I think it's too much to ask. The person that's supposed to be really great at reassembling your bones to also be somehow an addiction specialist who can evaluate. I think that's on us, addicts to be honest. I totally does.

I want to hear your opinion. Well, for one, we know that the doctors were part of the whole opioid epidemic to get into it. So they do have a responsibility in my opinion. I agree with you that ultimately it's the addict's responsibility. But when you're in your addiction,

yeah, that's the problem. So as I had the pills and the game plan went out the minute. Exactly. When you're sober, you can say, hey, so my wife needs the pills. If you're in your addiction, you're not doing the whole point is to get hot.

So I do think doctors should have to ask before they prescribe what's your history with addiction. Ask you straight up. They sell my lie, but at least it's there.

And if the answer is, oh, I have a history.

“Then I think they need to say, well, what's our plan then?”

That's correct. We're always doing a different error. We need to acknowledge, because I've had surgeries in all the errors, right? So when the slacklers were running, I mean, if there is a true villain in it, it is the sacrifice of a family who had a very well-financed campaign to convince doctors who hadn't

studied pain. Less than a 1%. Yeah. So they don't know. And then they're in there, and they're seen all this data that was bullshit data that

the slacklers were come up with. So again, I can't expect them to go specialize in pain medicine if they're a thoracic surgeon. They have to rely on studies and stuff. So they were the victims of a very good campaign by a very well-funded, dark ass family.

And so there was a period. I talk about this. Most of my friends are stuntmen. They all have crazy injuries. Most stuntmen have a kit of opiates, they're disposal.

That doesn't exist anymore. The damn shot. It's not what it was. So I also don't think we need to overreact to a situation that no longer exists to large degree.

You're not walking in with a toothache and walking out with two weeks of purpose anymore. But I think as a result of it, yes. So that's good. Oh, yeah.

But they've slammed the door on it. So I don't know that it's the same issue as it was 10 years ago. I respect both of your positions. I find myself landing in the middle because I feel like as a provider, you bet your ass it's my responsibility to assess my patient.

And I absolutely need to educate myself about my patient's history. That is my job. My oath is to do no harm. Every doctor takes that oath. And I having studied pain for like 35 years, I am doing harm if I am prescribing opioids

to someone with a history of addiction because what happened to you could happen to anyone. It didn't happen to your dad and bless. But why would I put you in that position? If I'm a good doctor, I am trained to ask that question. You don't have to be trained in addiction medicine to ask.

We also might lie to you. That is 100% on you, that's zero percent on me. But I did my job.

“Yes, I asked you, do you have a history of addiction?”

Am I putting you in harm's way by giving you this particular medication? Because as a doctor, a trained MD knows, there are alternative pain killers out there. It doesn't have to be the most addictive one. So someone could have given you a friendlier, less dangerous drug and could have saved you the fuckery that you found yourself in.

Wouldn't that have been nice for you just to say? You're not going to like this answer, but I mean, I had to go through that. You had an important life experience, I'm not, and I am in no way discounting it or I'm using it. But how did I die?

How did I owe me? You came out on the other side. There are a lot of people died. I didn't end up shooting dope downtown, a lot of people end up shooting dope downtown. So like I think there's definitely the responsibilities on the patient to be honest, to disclose

If you feel comfortable for people who don't feel comfortable, the onus is on the doctor.

We as healthcare providers have to do our due diligence, we have to get to know our patients just a little bit. Can we do that? If you're a healthcare provider and you're listening, spend three minutes. I literally just did this.

I put like a pain assessment on my website because I don't think we assess pain properly. And one of the questions we need to be asking, do you have a history of addiction? It's very simple. You don't have to be trained in addiction medicine. You don't have to do anything.

“You have to treat the person for addiction.”

Just ask. I would expect every doctor to ask that. I feel so strongly about that and I've seen so many nightmares. I was really honored when you invited me on because I have listened to your episodes where you talk about opioids and pain and I teach the addiction medicine fellows at Stanford,

the next generation of MDs because they don't learn very much about pain and pain and addiction in America or best friends. Our mutual friend Analemke runs like a pain and addiction center. Well, this is really great in the book. We are, I think, 4.5% of the world population in this country consumes 80% of the opioids

on-planers. Yeah. Crazy. That is crazy. That is crazy.

The number is probably fallen in the last couple years.

It's still. Yeah. There was a point where 4% of the population was consuming 80% of the opioids. I think you're specifically like oxycontin. Yeah.

Yeah. It's like similar numbers probably to guns. Two things like kill everybody. Yeah. Yeah.

I think we could just do a better job. Yeah. You know? Well, Rachel, this was awesome. The book is called "Tell me where it hurts the new science of pain and how to heal."

It's awesome. It was worthy of a conversation at dinner. I think you'll find that to be the case as well. And the cutest last name ever is softness. It's almost softness.

It's like softness with a speech impediment. What? What? The hardest letter. Yeah.

Mixed messages. Excellent. A little harder. Yeah. Okay.

Thanks for coming. I enjoyed that. Thank you. Thank you.

Stay tuned for Fat Check.

It's Dr. Pardy's out. So I think I have a fun and ironic update. Okay. Let's hear it. About Art debate.

Oh. About Good Marx. No, my arms. Oh, okay. With waving the flag.

Okay.

“If you're a model, I think you need to tell people.”

Yeah. So I was saying I was in a bit of a pickle because I wanted to both work my arms out in case I wave the flag at the MotoGP race and also my arms don't fit in my suit. Exactly. So I was really so if he's choice didn't know what to do, you were really urging me to skip

arm day. Yes, I was. For the safety of the riding. Yes, I was. Big debate.

Red carpets came and the high heels got invoked. What's that mean? I was pointing out that you're uncomfortable. Oh, you're the hardiest. Yes, yes, yes, yes, yes, yes.

Yes, yes, yes, yes, yes, yes, yes. So I went to Austin with that on the table. And the question was, what was I going to do? He drew advice. Be responsible or be vain.

But you made very clear to me that it wasn't a safety hazard. No, what could move. That I was overreacted. Just uncomfortable. So I chose vanity.

Okay. Definitely work my arms out on Saturday. And they did not ask me to wait for the flag. Right. So that's funny.

So that right there is a win for you. That's a good win. No, it's not. It is in a funny way, which is like I did this thing, which I shouldn't have done. And then I didn't even get to do the thing.

Maybe I won't use the work win. I'll just say that that's a funny mark in your category. And then we'll get to the mind, which was. So I did. I got my arms all pumped up.

Yeah. And vascularized. Yep. Didn't wave the flag. Didn't even ask me.

Yeah. I don't know. I don't know. 20. You don't pay as much attention when you're not there.

Which then goes to show how many people are paying attention when it's you. I did have someone last year. Text me and go. Oh my god. You're waving.

I mean, another MotoGP fan. Yeah. Notice how it's waving the flag. Anyways, I did not wave the flag. It was an asked a wave of flag.

I was like, well, that was for nothing. But then. And here's the irony. The ironic twist. Yeah.

Went to the track on Monday. I don't know. Because it was so hot and awesome. Whatever. Arms weren't tight.

You're fine. No issue. I know. So both things happened in reverse. That's right.

“That's how I feel like it's a win for both of us.”

It's a win for me if you're safe. That's all I care about. I'm not against you having big arms on a flag wave. Yeah. Only if it comes at the risk of your safety.

Which you assured me it didn't. But I didn't believe you. And also. It was just an hilarious outcome. Yeah.

Harrison Barnes wave the flag this year. He's an NBA player.

Okay. Okay. So you're going to see an Antonio spurs. And good. Because they have presumably.

He was very tall. 6. 7. 6. 7.

Get the flag up in the air. 7. In fact, I'm going to have to go back on my DVR and watch him wave the flag. That's nice.

“I think these NBA players have really nice arms.”

I'd probably like to check out his arms. Okay. Yeah. Okay. I was just talking side now.

Oh, yes. Great. Great. Great. Great.

And great delts. And he's got some vascularity in his delts. He was handsome. Yeah. He looks like he's screaming in that photo.

Yeah. Of happiness. Mm. Victory was his idea. I think it says that's when he found out he was going to wave the flag.

Oh, that's probably makes sense. Oh, yeah. Oh, yeah. Okay. So it's not going to Ricky.

Glassman. Oh, great.

And it was ostensibly he called for advice, which is always so flattering.

I love this role I get to have in Ricky's life. It's very, yeah. I really cherish it. So we're talking about business stuff and everything. And then I know how we got on the topic of muscles.

But we just went off. And he's like, yeah. I don't know how to explain it. I guess because I grew up watching Swords and Nigger and the divester son. I'm like, I got must be it, too.

And he's like, I just love them so much.

“And then we were talking about like to what extent do we love them?”

And I'm like, you know, I want to squeeze them and stuff. Mm-hmm. Like, where is this line? This is very weird. Homorotic.

Where is that line? You're attracted to it in a-- Right, there's layers. In an aspirational way. Yeah.

What? Oh, I'd like to look like that. Exactly. Yeah. But I also want to feel them.

Like, I want to squeeze-- But you don't want to feel their dick. Do you? No. We went through like, well, how far does it go?

I would only want to squeeze Swords and Nigger's biceps. And I'd like to feel-- I'd even like to run my hands across Brad Pitt's abs in Fight Club. Okay. Right?

I'd like to feel that. What do you want to feel? All the definition in the ridges. Uh-huh. Yeah.

Can you relate to that? I'm just going to run your hand over his. No, but-- I'm straight. Yeah, yeah.

You know what I don't want to do is rub my hands over like Kristen's arm muscle. Right. I have zero. I know. This is why it was worth us discussing.

Yes, I was discussing. We're on some spectrum. I'm the Kinsey Scale. I don't think it's-- Well, we like want to touch and feel.

That's like that's interesting. Well, because I think it's still like-- You want to touch and feel it. So you can kind of see like-- What would feel like if I could run--

Right. It's still about you guys. You think so? Yeah. I mean, women have-- I have this all the time, like with other women--

Do you want to feel any of women's boobs or anything? No. But I do hear that from other women that are straight. Really? Yeah, they're like, oh, I want to squeeze those boobs.

And they're straight. Okay.

Well, I've never, ever wanted to--

You've never had a friend of yours ask if they could touch your boobs. No. Never. You've been drunk. No.

You don't want to squeeze them without being sexually attracted? No. I guess. But like, whatever. I don't know.

I can't speak on behalf of anyone other than me. Right. Side-track. Yeah. Okay.

I have no desire to touch any of-- Squeeze anyone's boobs or touch their-- How about a bot? Genital parts? Touch?

Yeah. Like if you saw a big, buoyant butt. You don't want to squeeze it to see what it feels like in your hand? No. Oh, wow.

I might want to say, like, a female. Yeah. Yeah. Yeah. Yeah.

I might be like, oh, my god, that person has such a nice body. Like, I wish my body looked like-- Uh-huh. But I don't need to want to-- You don't want to squeeze it.

No. I don't need to touch it to know that. I just like, I'm like, oh, they have like great X, Y, or Z. I wish I had that. And then, you know, then you hate yourself for a little bit.

Okay. And then-- What are you jumping on over there? Oh, I have some laws and just-- Okay.

I'm still sick. Oh, and I have a sick spray. Well, I almost brought it since we both have sprays. No. It's like natural.

Oh. Okay. So it's page 3 for show. I mean, I'm not better. It's just an activity to do.

Oh, yeah. Okay. So no desire to touch-- Okay. I've no desire to touch, but I definitely have admiration.

A lot of admiration for a lot of female bodies. But it's still about me. That's-- it's still like, I wish I looked like that. Mm-hmm.

It's never outward really towards them.

Yeah. But it's like, how can I look like that?

“And I think I think that's what's happening with you guys, too.”

But maybe the feeling is still-- still about that. It's like, okay, what does it feel like to have that? I want to feel like having-- I want to feel like having-- Mm-hmm.

You know, the weight of things and the heft. Right. Mm-hmm. Yeah. But let me ask you something.

Yeah. So you want to-- you want to feel--

Yeah. Touch.

Get your physical hands on it.

Mm-hmm. With their consent. Yeah. And-- but do you want to do that for females? Like, when you see abs on a female--

Are you like, oh, I want to-- I want to touch that. Not really. No. But I regularly see butts in spandex or something. Or boobs.

And I do want to-- I want to-- Yes. But that's sexual. Those are sexual parts. Yeah.

That's different than-- but you're feeling towards these men and their abs. That's true. It goes to show if you're not wanting to touch the female abs. It's not about muscles. Exactly.

No, it is. It's about actual muscles. Okay. On the men and how you can get them. Mm-hmm.

Or like how you can relate to them or something. Yeah.

“I think most people out in the world are aware of other people's”

faces and bodies and whatever, sexually or not. Yeah. They're probably seeing the ones whatever one they want. Exactly. That's my whole point.

That is your point. Or if whatever they feel sexually, there's sexual orientation. They might see, you know, like, if you're straight, you're going to see the opposite sex a little with more curiosity,

sexually. Of their arogenous zones. Exactly. Because when you are attracted to someone, it could be a really random thing that you're attracted to.

On their body. Absolutely. Not just their arogenous zones, you know? Mon's pubis. You're an arogenous.

That's the clear arogenous zone. But, you know, I really like hands. Mm-hmm. And so I do tend to look at men's hands a lot. This is so fascinating.

Again, very anecdotal. I have no idea what the grand data would say. But, certainly I'm aware of so many men who have foot fetishes. Right. I don't really know any women that do.

I've never heard a woman talk about it.

It's so interesting. This just came up on Elizabeth's an angel. Oh, really? Uh-huh. But, I know many women who are super into hands.

Mm-hmm. And I don't know a ton of guys who are super into hands. Right. What is going on? Why would one-

Well, I know a women do. And their hands are a huge part of sexual interaction. Interaction. Because they're going to be all over you. Yeah.

They're all over you. They're in you potentially. They're in you. They're in you. Yeah.

They're in charge of all the action. Exactly. Yeah. So, that's why I think women can be.

“So, do you think these guys with foot fetishes want to be manhandled by their feet?”

Well, that's what I mean. Probably. I've seen pornography where guys are getting jerked off with a woman's feet. Yeah. Yes, I have seen that.

That's just very hard to do.

For her, yeah. Yeah. Yeah. You've got to really be more manhandled. And how can you do that, like, gracefully.

It feels like you'd look so weird, the woman. Yeah. Also, how do you gently bring up? Like, hey, are you coordinated with your feet? Yeah.

Like, if that's a huge thing for you. Mm-hmm. That's like your ultimate. Like, the guy we interviewed for arm-chair anonymous. Yeah.

Kinks. Who, like, his toes played with. Mm-hmm. So, it's like, it's me. Yeah.

He wants, this is an important thing to have. Yeah. Is this foot job? We'll call it for sake of time. Okay.

How do you sus out whether that partner's going to be able to do that? Because I bet I imagine there would be a lot of gals that were fully up for it. And then you just can't do it. Yeah. I feel like most people can't do that.

That's so quarterly. I try to, man. Yeah. Forget that.

“I mean, also, the amount of leg strength you'd have to have.”

That's what I'm saying. It's actually a lot more than the foot. Yeah. So, you know, you're going to be able to do that. You're going to be able to do that.

So, you're going to be able to do that. So, you're going to be able to do that. So, you're going to be able to do that. So, you're going to do that. So, you're going to do that.

So, you're going to do that. So, you're going to do that. So, you're going to do that. So, you're going to do that. So, you're going to do that.

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So, you're going to do that. So, you're going to do that. So, you're going to do that. So, you're going to do that. So, you're going to do that.

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So, you're going to do that. So, you're going to do that. So, you're going to do that. So, you're going to do that. So, you're going to do that.

So, you're going to do that. So, you're going to do that. So, you're going to do that. So, you're going to do that. So, you're going to do that.

So, you're going to do that. So, you're going to do that. I don't even want to go into it.

“But there are guys with things with angles.”

So, I'm just like, how could of all the things to look at. Why is that even where you would be focused on? You've got eyes, lips, y'all have this ones. Different body parts. I know that.

I'm okay. I'm not fired. Wow. You're really solving a lot of mysteries. Age-old mysteries.

I think I now understand the angles. Okay. So, I'm going to do that. I'm going to do that. I'm going to do that.

So, I'm going to do that. So, I'm going to do that. So, I'm going to do that. So, I'm going to do that. So, I'm going to do that.

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So, I'm going to do that. So, I'm going to do that. So, I'm going to do that. So, I'm going to do that. So, I'm going to do that.

So, I'm going to do that. So, that's interesting. And it should be comforting. Yeah. Yeah.

Yeah. It should be comforting. It's like, someone will like this. Yeah. But also, it's like, I don't know.

I go back and forth, I guess. Because, you know, I don't like that skin, flesh, fatty part of my arm. It's like, it's not really the pain. Well, I guess it is the pit sort of. But it's more like on the side.

Anyway, I hate it. I guess I could be like, well, somebody will like this. But I don't like it.

“And I think it's like, I should probably just care about what I like.”

I don't like it. So, yeah. I mean, to find someone who likes it.

And then what others will like about you in general. Yeah.

“But then you really got asked to say, well, why don't you like it?”

My hunch is you don't like it because you think other people don't like it. Probably. Because it's not on the bodies of the women that I look at. I'm like, oh, I want to look like that. Yeah, but don't want to touch.

I just don't want to touch. I don't want to touch like their armpit.

You never want to poke a big butt to see like what the consistency is.

Never. Wow. The thing is we talk with this with Nikki. Whoever you're attracted to. Yeah.

They like it, man. You like you like all the parts. Yes. Totally. Totally.

Yeah. That's right. That's why that's why. Personalities real. Like having a good personality and being someone somebody wants to be.

Around and hang hang out with. Like, once you're that person, I mean, I say this is someone with no boyfriend. Once you're that person. And I'm pretty strict. God, does that mean I have a bad personality?

Why? Because I'm saying if you have a good personality, you can get people. No, I think this is the what's funny is I think you're giving yourself this advice.

“I mean, I think you might be a little too.”

What's the word? I pick these the word, I guess.

You got to go with who's got a personality.

And then see if you get attracted. I don't know. You don't know anyone that goes personally. The people I know of the personalities are my friends. Right.

And they're all married or they're just. Yeah, you're not at the grocery store. I don't go to the grocery store. Yeah. I'm not going to get.

I'm not going to get their personality really from the grocery store. It's funny. You're out a lot. I am out a lot. Yeah.

I know you're out a lot. Some of little confused. Can I be, I'm not to be this good personalities are few and far between. Are they? Yeah.

They really are across the board women and men. Good personalities. I'm so misled. Well, I'm misled. That's the problem.

My friends. The people in my life have great personality. Well, as I say, we interview in St. Lee interesting people all week. Yes. And then generally, if I hang out with somebody, it's one of someone in our friendship group.

So I probably don't have a great read on the general options personality wise. But then when I'm in Nashville, I'm just hanging with my neighbors and stuff and out of restaurants. Right. I do think that just being my best friend is a hindrance. Yeah, big time.

He is the most special personality and anyone I've ever met my entire life. They've been all my time with him. Uh-huh. Even Maranera. Like, who am I going to meet?

That is Maranera. Like no one. Yeah. And so this is where I really think sometimes. I'm like, look.

I got so lucky.

“You should send him the conversion camp.”

No, we're not attracted to each other. And that's what's great about us. He has a incredible personality. And I get to spend, I get free access to that personality. And it's, it's so lucky.

That is a problem. If you're, if you're deciding, you mean a guy. You've been on the day with him. And then you're deciding the next night. Do I hang out with Jesse?

Exactly. That's, yeah, this is interesting. This is a problem. It is. Yeah.

That is what goes through my head. Of course it is. Like, okay, I have two hours to hang out tonight. Am I going to go on a date? Or am I going to hang out with this person that's going to make me laugh for two hours?

Yeah.

I'm always going to pick that.

Yeah. So sometimes I think like, oh, maybe I should just, in fact, most days, I think I think this. Like, I'm just so lucky. I have these incredible people in my life. A multiple incredible people.

Uh-huh. That I think if anyone would be so lucky to have one of these people in their life. And I've so many. Yeah. Maybe I should just be lucky and grateful for that.

And like, that's enough. How about this, if, if I said, there was this new breakthrough, AI figured this out. Okay. You and Jess could take this pill.

They took your DNA and they engineered it. And when you, after you wake up, trauma, and you're going to be insanely attracted to Jess. And he's going to be insanely attracted to you. Oh. What I do is.

Yeah. Why? I know, but what if it ruined everything? This is a black mirror. At this, this should be a black mirror.

It could ruin everything. Yeah. I think you're just going to be grateful. But you have. All right.

You know. Yeah. So let's see. You're both attracted to each other. But now I'm saying he wants to have sex with you more than you want to have sex with him.

Now you have. Or what if he's like selfish and bad or something like that. Like, you know, bad parts of personalities can come out when these things get involved. Mm. jealousy.

Like, there could be a lot of C when he's making other people laugh all the sudden. Oh, there you do. Oh, 100%. Yeah. Because right now you don't care.

No. But if he was making some girl just laugh on control. Blin. He was your boyfriend. He was straight.

Yeah. I know. I know. He's shut up. No.

You're your company's only for me.

It is funny.

“Because now when we're out places and he's making people laugh and.”

And he's my, you know, buddy. I'm like, so I feel so yeah. I'm like, Oh, my God. Yeah. Just my best friend.

Yeah. I'm so lucky. Yeah. And. But yeah.

If he was into girls. He's making some hot chick laugh uncontrollably. And you could see she was looking at him. Like, I wish this guy was my boy. Yeah.

And then she's like pulling her down. I'm like, fuck you. Get out of here. I break up with you, Jess. Yeah.

See, you could go badly. I'm leaving it. We wouldn't take it. Yeah. Okay.

All right. I should be doing that. Yeah. Okay. This is for Rachel's offness.

What a name. Great name. Yeah. Softness. Um, which my name was Dax softness.

It'd be too many weird letters. But it does soften everything. God, do you want to hear something embarrassing? Yeah. I can't believe I'm an admit this.

Oh, good. Today of admissions.

“So when I was young, I was like, you know, right.”

A lot of fiction stories on my computer. Uh-huh. And I would, um, create. I was basically like writing. What I wish my life was.

Of course. Yeah. The main character.

And I was always like thinking about what name.

But I wouldn't like name the characters and stuff. Um, and I did really like the last name, Shepherd. Really? Yes. I did.

Where did that come from? I don't know. I must have heard it. And I was like, oh, I really wish that was my last name. I like it.

Yeah. But it's like, it sounds nice. Uh-huh. It sounds really nice. I'm grateful for Shepherd.

Yeah. Don't give me wrong. It's good. Yeah. It's just, it's a good name.

Of course, I like that. It's not spelled the way. So I, I still have some uniqueness. You know, I don't like that. It's annoying.

You would like a GRD. Actually, no. I like the way yours spelled them aesthetically. Yeah. It looks better.

Yeah. It looks better. Yeah. When we have H in there. But it bothers me when people spell it wrong.

Like when they're like reaching out. Oh, it's almost exclusively wrong. I get offers or I get these, these ones that are kind of like they're very flattering Letters. Exactly.

You need to be a part of something. And I'm like, but you didn't even broke up. You don't even. You're like a super family. You don't know how to spell many.

Yeah. But I don't get that button on the ship. Rob McLeanie famously. Oh, he's like people go over it. Oh, wow.

Yeah. Yeah. I get it.

It's like just take a second.

But I've made them. I've also made that mistake. I don't care. I think God. It's one.

I mean, I care about so many dumb things. But I don't, I don't happen to care too much. I just, it's ironic. I see the irony of like. I'm your biggest fan.

I know. It would happen. D.A.C.K.S. S-H-E-P-H-E-R-A-R-D. Yeah.

Yeah. Yeah. Yeah. When I was Chris and assistant and people would reach out, asking for things. And they would misspell her name.

I was like, no. Yeah. You're not getting it. You can't even take the time. So.

Anyway. So I wanted it to be. I wanted that as a last name. Monica Shepherd. No.

It wasn't Monica. Oh. I needed that. No. It was like sky.

Sky Shepherd. I'm like Anzley. Anzley. Yeah. That's cool.

I know. Yeah. It is cool. Um. Okay.

You never wanted Hollis? Sorry. I didn't know about it. I would have written a character. No, it was my name, right?

Well, Rob, we've been working together for eight and a half years.

“Honestly, every time I have to write your lesson, it might get a sharp pang of anxiety.”

Like, never doing this right.

Yeah. How dare you? I'm trying now in public. I'm going to try. Okay.

I think it's Hollis. H-O-L-Y-C-Z. No. S-Z. Yeah.

Okay. Wow. You're in a second. You can definitely see where there'd be a C in there, right? Hollis.

No. I don't normally get a C in the wrongs. You get H-O-L-L-I-S. Well, it's phonetically yes. Yeah.

Could we ever thought about it? No. Rob, you be you. I think it was already changed technically from like the real Polish. Oh, probably.

Preciation really. Okay, so I blew it in public. Yeah. So it's a tough one for me. I think there's a Y in a C in there.

I got it. Oh, having a Y in a Z in your name is tough. It's going to be tough. Yeah. Yeah.

Speaking of names that someone could miss pronounced. You same bolt. That's a tough one, you. Yeah. So just some stuff about his back.

It's going to go this way. To manage his back issues and protect his spine, bolt focus heavily on core strength. Sometimes doing up to 700 setups per day.

the world junior champion ever in the 200 meter running it under 20 seconds.

During the 2008 Beijing Olympics, he ate roughly 1,000 McNuggets over 10 days, because he was picky about the food. What? 1,000 McNuggets. That's a, that's a scientific experiment.

Yeah.

“Like what would happen if someone ate 1,000 nuggets in two weeks?”

They would set all the world records. And that pink sledge video is one of the best mark. I don't know what they were marketing. I mean, a burger king probably was behind that. Like, and I cannot hear the word McNugget and not think of that pink sledge.

Oh, thank God. I don't. I have no association. It is permanent. It cemented.

I mean, I'll still maybe eat it. There are delicious. Oh, yeah. There are delicious.

Oh, they're fucking delicious.

By the way. I wish I had an excuse to eat 1,000 of them in two weeks. Well, you could. I wouldn't look like you same bowl. If you do 700 setups a day, you might.

I think I'll also have to be running. Very fast, very frequently. Probably.

“At what margin do women experience chronic pain more than men?”

Data suggests that approximately 70% of chronic pain cases are women. And they suffer from higher pain sensitivity more severe pain and higher rates of conditions like fibro myalgia and migraines. Fibro myalgia. Number classic classic.

There used to be so many commercials about fibro myalgia. Yeah, especially on 60 minutes. Yeah. The older person programs. Older demo.

Yeah. Which I am out of officially. You're what? I'm not in the demo anymore. It's 18 to 49.

I'm not a valued viewer anymore. Oh, no. Yeah. But you're in the fibro myalgia? Yeah.

That's why I said the older demo. But this kind of a throwaway demo. It's not what advertisers care about. They care about 18 to 49. That's silly.

“They should care about the older people because the older people.”

They have more money, but they spend less. Right. They're done buying crap. How much of the world's opioids is the US consume? The US has less than 5% of the world's population,

but consumed roughly 30% of the world's opioids in 2009. Including more than 99% of the world's hydrocodone. Who? And 80% of the world's oxycodone. Mm.

As of 2017, that was a long time ago. The US and other affluent nations, Canada, Western Europe, consume roughly 95% of the global opioid supply, leaving only 5% for the rest of the world. Mm.

Some sacchar family fun facts. Oh, great. Owners of Purdue Pharma. Made approximately $35 billion in revenue from oxycodone sales. In 2025, the only agreed to a 7.4 billion settlement as a part of a bankruptcy deal,

which required them to give up control of Purdue Pharma and bandsom from selling opioids in the US of A. Okay, this is some stats on A.A. And it's success rate. But like... Before you read 'em, I'm just going to say something very smart

and a student that drew Pinsky said about the success rate A.A. A is a very hard thing to evaluate because you can evaluate a cancer medication because you take the one pill. They took it or they didn't, and then you measure the outcome. Whereas A is advice, go to meetings, get a sponsor, work the steps,

sponsor someone else, do service, right? So there's a lot of components. So it's hard to measure. If someone has the full dosage, if they do all five of those things consistently,

you're going to get one outcome.

And then a person who does one meeting a week and never gets a sponsor doesn't do stats.

That's why it doesn't really mean. I don't want to read this. I don't think that's... What does it say? 10% or something?

This is 2014. Well, yeah, this says 7%. Yeah. And then also how you define it, it's like relapse within the first year. Right?

Then okay. So it says addictions, special sites, success rates, slightly higher between 8 and 12%. But then it says 27% of the participants were sober for less than a year, 24% were sober. So from what? Oh, a 2014 study conducted by AA found the following among over 6,000 members.

27% of participants were sober for less than a year, 24% were sober 1 to 5 years. 13% were sober, 5 to 10, 14% were sober, 10 to 20. 22 were sober for 20 or more years. The eight-year follow-up showed that 46% of those who chose formal treatment were absinit. Well, 49% of individuals who attended AA were absinit.

Those are actually... So more. Yeah, but they're saying... Yeah, the other thing is like...

If someone drinks once within a year versus they drank 7 days a week.

Right. That's pretty successful. Yeah.

“But over the course of 20 years, they have 8 relapses.”

No, to me, that person used 8 times in 20 years. And they used 3 or 6 to 8 days a year? I know. It's really... I don't know.

It's impossible to evaluate it. I agree. Yeah. That's it. Okay, great.

Well, I enjoyed Rachel. I've been telling so many people about the tale of two nails is so fun at a different party. Especially if you have the X-ray on your phone like I do. Yep. And then the back dad is fascinating.

The back dad is really fascinating. Yeah. Just pain and general. I mean, it relates to the other episode we have on over... We had on over Diagnosis where there's phantom...

See, there's... People can have... See, there's a better... Not caused by epilepsy. Yeah.

It's similar. Like, your body is still reacting. Yeah. So now I alert survival mode. And it doesn't need to be...

It just... You know what people will ask?

“Like, are you that so many experts on in the past eight years?”

What have you learned? What's your biggest takeaway?

I always kind of like trip on that because we...

They're so much. Yeah. But I think the main takeaway is just... The brain is so powerful. Yeah.

Can do anything. It can kill you. And it can... It can... Take you to another...

It take you out of this planet to another place. Yes. It can save you. It can... I mean, it's...

It can learn to fly. I'm fucking here. Yeah. Yeah. No, it's...

It's the great enigma still. Right now. Yeah. We all got one. Some of us didn't get one.

That's my dish. Did you even get a brain? Yeah.

“When God was handing out brains, you must have an option for that.”

Did you miss that dad? That was a thing. When God was handing out something. Did you thought he said something? Did you...

Did you just that ring about? Like shirts and you thought he was eating shit. It's not that. But it's like... It's a burn.

Yeah. It was like... Oh, it's... When God was handing out brains, you thought he said... Stains and said...

No thanks. That's a thing. That's a third great thing. That's a Christian dish. No, that's a...

Was it an oil-metry school? Springwheels elementary dish on third grade. When God was handing out brains, you thought he said... Stains and said... No thanks.

Be honest. Did you invent that? No. I could really remember. Okay.

I never forget something I create.

All right. All right. Love you. Thank you.