The Science and Soul of Pain Relief: Insights from a Pain Medicine Specialist
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*A transcription of this episode can be found at the bottom of this page
This podcast is for educational purposes only. The views expressed do not constitute medical advice and are general in nature. You should obtain specific advice from a qualified health professional before acting on any information within this podcast.
Chronic pain affects millions worldwide, but effective pain relief isn’t just about medication. On a recent episode of Pain Coach, Dr. Jonathan Ramachenderan, a former palliative care doctor turned pain medicine specialist, shared profound insights into the complexities of pain management. His holistic approach integrates medicine, psychology, and even spirituality, offering a fresh perspective on achieving long-term relief.
Pain Relief: More Than Just Medicine
Many people view pain relief through a purely biomedical lens—treating symptoms with medication or surgery. However, Dr. Ramachenderan stresses that pain is multidimensional. Emotional distress, past trauma, and even our thought patterns can amplify physical discomfort. He recalls an early experience where a patient’s pain wasn’t responding to morphine, highlighting that sometimes, “there’s pain that no morphine will fix.”
Instead, he advocates for addressing negative pain cognition—the way we interpret and react to pain. Stress, anxiety, and unresolved emotions can heighten our perception of pain. Understanding this connection can be transformative for those seeking lasting relief.
The Pyramid of Pain Care: A Holistic Framework
One of Dr. Ramachenderan’s key contributions is the Pyramid of Pain Care, a structured approach that prioritizes foundational lifestyle changes before resorting to medical interventions. Here’s how it breaks down:
Base of the Pyramid: Lifestyle & Behavioral Foundations
Regular exercise, particularly mobility and strength training
Adequate sleep to allow for recovery and nervous system regulation
Dietary changes to reduce inflammation
Managing stress and emotional well-being
Mid-Level: Targeted Non-Pharmacological & Pharmacological Care
Physiotherapy, cognitive behavioral therapy (CBT), and mindfulness
Medications such as antidepressants and neuropathic pain treatments when necessary
Top of the Pyramid: Advanced Interventions
Injections, spinal cord stimulators, or surgery—but only when foundational steps have been optimized
Dr. Ramachenderan warns that modern medicine often inverts this pyramid, with too many patients relying on opioids and surgeries first before addressing lifestyle factors. The key to sustainable pain relief is reversing this trend.
The Role of Spirituality in Pain Relief
A unique aspect of Dr. Ramachenderan’s philosophy is his belief in spirituality’s role in healing. Whether through faith, connection to nature, or a personal sense of purpose, he finds that those with a deep-rooted sense of meaning often cope better with pain. Chronic pain can lead to a loss of hope, and restoring this hope can be a crucial step in the healing process.
The Future of Pain Management
Dr. Ramachenderan is optimistic about the future of pain medicine. Telehealth, cognitive functional therapy, and a shift away from opioid dependence are all promising developments. He emphasizes the power of self-empowerment, urging patients to actively participate in their recovery rather than waiting for a quick fix.
Final Takeaway: A Message of Hope
For those struggling with chronic pain, Dr. Ramachenderan offers a simple yet powerful message: Pain relief is possible, but it requires a holistic, proactive approach. By combining medical science with emotional, behavioral, and even spiritual strategies, true healing becomes more than just a possibility—it becomes a reality.In 2017, Ray had been working as a physiotherapist for around six or seven years. He began feeling burnt out from his demanding work schedule, which involved six to seven days a week in both private practice and sports. Ray decided to take a solo, three-month trip around Asia for some well-needed rest. However, a month into the trip, he was involved in a serious bike accident in Northern Thailand.
Introducing… PAIN COACH
My new application focused on allowing people with chronic pain to reclaim their life.
Full Episode Transcript:
00:00:00.36
Speaker
um I had this patient that was in the recovery room and she was in so a severe amount of pain. she was She was really struggling with giving her everything for a pain. And one of the nurses said to me, an older nurse, who I'm still friends with, Carol, she said, look, sometimes there's pain that no morphine will fix.
00:00:19.98
Speaker
and And I i always to remember that because what she was saying is that there was other things that were... um were in play here. I really saw at that stage pain has been quite one-dimensional. It was very biomedical.
00:00:33.57
Speaker
And really what Carol was saying is that this this this girl, i I don't know what else was going on, but she was distressed, she was catastrophizing, she was hyperventilating. When i look back at that case objectively now as a pain specialist, I understand um she quite possibly had visceral hyperalgesia. Her organs were sensitized.
00:00:55.66
Speaker
She may have had... um um negative pain cognition is the way that she dealt with pain. She may not have a safe home. She may have been in an abusive relationship. I don't know.
00:01:06.66
Speaker
um She may have a psychiatric diagnosis. She may have have anxiety or depression or like ah are um very rare schizophrenia or bipolar. That's not really a common thing.
00:01:17.69
Speaker
But these other common things inform pain. And personally, from my point of view, i when I get worried and upset and stressed, I get really bad reflux and i my back starts to hurt.
00:01:31.56
Speaker
And that's using my might tell. Everyone has a tell. It's a headache, neck pain, shoulder pain, glute pain, whatever it is. um These are ways that our body informs us that something is happening.
00:01:43.16
Speaker
And I explain it to patients. I say, look, your pain is real. I believe you. There it is. I can see it. And whether we like it or not, whatever happens to us, trauma, memories, experiences, all inform your pain.
00:01:57.19
Speaker
On today's episode of Pain Coach, we're thrilled to have Dr. Jonathan Ramachandran. Jonathan is a former palliative care doctor who has recently transitioned to a pain medicine specialist.
00:02:09.63
Speaker
He's also a TEDx speaker, having shared his insights on the spiritual dimensions of medicine, and he runs the Healthy GP blog, where he explores topics related to the well-being of healthcare professionals.
00:02:24.60
Speaker
This podcast is for educational purposes only. The views expressed in this podcast do not constitute medical advice and are general in nature. You should obtain specific advice from a qualified health professional before acting on any of the information within this podcast.
00:02:44.33
Speaker
I just want to let you know before we get into the conversation that there was some technical glitches throughout this podcast. It doesn't take away from the overall message though.
00:02:54.80
Speaker
Enjoy.
00:02:58.16
Speaker
Tell us a little bit about who you are. That's a good question. It's a wide question. Well, I'm... I think first and foremost, I'd say that ah ah on my line and Instagram, which has changed so many times, but I'd say that I'm Christian.
00:03:17.00
Speaker
i'm a I've been married to my wife, Kylie, for 21 years now. We got married when I was in medical school. So and so I'm forty turning 45 this year. I've got three boys.
00:03:28.60
Speaker
So I'm a dad. And after that, I'd say really I'm a doctor. And I've been a doctor now for 19 years. And, well, we we interacted on a post that you made around talking about um GPs and um about referral to scans. And I commented on your on that post and I wrote that I was a GP, and but I've trained now to become a pain specialist.
00:03:56.52
Speaker
So I'm, yeah, so I, a few days, I finished my pain medicine training three days ago. so I'm waiting for APRA and the college to sign off on my training, which should be fine.
00:04:08.63
Speaker
So I'll probably be starting to see patients in about three weeks. So I call this the second season of my life, my clinical season. My first season lasted about 17 years and this is the next part.
00:04:24.63
Speaker
And I just felt called to train as a pain specialist because the life pivots I've done, was a GP and I did that anesthetics in the country. I calculated I've worked 14 out of the 19 years in the country.
00:04:38.40
Speaker
first in Tamworth in New South Wales and then moved back to Perth and then moved to Albany, which is a beautiful part of the Great Southern. And two of our boys are born there and we have lots of family and, well, lots of friends that we consider family.
00:04:52.15
Speaker
And yeah, and that's where my passion for pain grew around actually in palliative care. That I'd say is that the main part of what I do and pain, the just the interest in wanting to help people in pain, different types of cancer pain, non-cancer pain. and oh I think the biggest reason why we moved back to the city was because they there wasn't they weren't adequate chronic persistent pain services in the country.
00:05:21.05
Speaker
And I felt the only way to really do that was to come back and become a pain specialist because then you have a seat at the table. because everything is about qualifications and things like that in Australia. So when you have a seat at the table, you're better able to speak intelligently and have connections really about how you can bring that to pass. So in a nutshell, I'm a pain specialist and a palliative care doctor who works in Perth and hopefully soon in Albany in Western Australia.
00:05:52.90
Speaker
It's a long answer. No, that was a great answer and it was a very broad answer, but it's because I just want people to get to know you and I want to get to know you as well. We have a little bit in common. We're both Christians.
00:06:05.19
Speaker
I actually lived in Albany for a period of time when Dad was over there for work as a pastor and then we moved to Perth. So where you currently are, I lived in Kalamunda up in the hills.
00:06:19.01
Speaker
Yeah. Yeah. Okay. Cool. Cool. Yeah. so We live south of the river. And so one of the things that I'm planning to do is start practice.
00:06:32.00
Speaker
Sorry, for those that are listening, there's a little bit of delay between me and Jonathan. We're not trying to be to be rude, but there's that's what's going on. i what I was saying is that we're looking to, I'm looking to set up practice south of the river um and then as well set up practice in Albany too. So to to work across both of those sites.
00:06:54.30
Speaker
Awesome. Now that sounds sounds cool. so what was, tell me what led you, you touched on your sort of pathway through medicine, but what led you to want to be a pain specialist?
00:07:09.57
Speaker
I think that, Look, there I think they're really formative moments when you start. There are a whole bunch of interns starting their training shortly, well, today and last week across Australia.
00:07:22.86
Speaker
And I think my interest in pain medicine came from when – I was an intern and I was asked to write up some pain relief for a patient post-operative. I think I'm sure it was post-score bladder, post-colycystectomy.
00:07:39.06
Speaker
And he was in pain. I went and I assessed him. i was happy. There wasn't any problem. And I wrote on there exactly what the nurse wanted me to write because at that time you listen like – yeah Just do what the nurses need you to do because you're really just learning how to be a doctor. And I wrote he wrote him up for some intramuscular morphine.
00:07:56.83
Speaker
It was 5 to 10 milligrams. And I came back about half an hour, about an hour later actually, and he was comfortable. and i remember And I just remember thinking the the the satisfaction i had with being able to provide him relief postoperatively.
00:08:11.53
Speaker
Everything turned out fine. He was discharged and it was cool. But I think it was formative moments of being able to write analgesia for people and to help with their pain and in emergency being able to do like ring blocks for people with dislocated fingers, beard blocks, all these interesting cool things, ultrasound guided, very biomedical type things which got me interested in pain.
00:08:35.78
Speaker
But I think often in our lives, we meet people. It's usually people that get us on the pathway to finding a passion. And in 2011, when I was doing my anesthetic training in Joondalup here in WA, I met a professor by the name of Eric Visser and Eric was very passionate about acute pain and there was an acute pain nurse there, Mandy, who's now retired.
00:09:00.79
Speaker
They were very passionate about the way that they treated pain. And that's when it was birthed in me about in 2011. And that just grew over time. And I added to it, you know, in general practice, I acquired a number of patients who were quite complicated, who had medical issues and ma Some of them had been fired from other GPs because of their use of opioids and things like that. And I found it interesting being able to help them get to the root problem in the core.
00:09:30.18
Speaker
and And then i started doing aged care and palliative care. And that became, and there's a lot of pain management that goes with cancer pain, There's a lot of management that goes for people with chronic medical diseases.
00:09:43.13
Speaker
And that's when it was birthed. And I think I realized that think I was I'd i'd turned 40 and I'd realized that I didn't want to get to the end of my clinical career and not have followed this passion.
00:09:56.44
Speaker
If I'd got to the end of my my my working life and loved pain medicine but didn't do anything about it, I knew i'd be i'd regret it. So it took a number of years of talking to my wife and and trying to get things aligned right, but there's no right time. And so we did it.
00:10:15.40
Speaker
And really, it's just walking through open doors. And that was something that was birthed in me and grew. And that's really why I'm here, because I think it's pain medicine is not of all about medicines and injections. And I do think that people are multidimensional and pain is a multidimensional experience.
00:10:37.64
Speaker
And so i think people have a physical experience of pain and whatever happens, the way that they think helps them, well, informs them about what the pain is and the way that their social environment is impacts their pain and what they believe about their pain impacts their pain. And For someone like me who overthinks and thinks about things deeply, overthink is one side, but think about things deeply is the other side.
00:11:03.92
Speaker
I like to think of this and more positively. And so that is what informs me to to be a pain. um led It led me down here, really. Yeah, fascinating journey from, you know, giving that what what you said. what Did you say the nurse pretty much prescribed it? You just signed off on it?
00:11:26.51
Speaker
I find that funny because my my wife's a nurse and she works with junior doctors. And there are times when that obviously is is the case, is that like the the nurse is sort of guiding some of those decisions a little bit um when when people are junior doctors. And I appreciate your hum millet your humility in that.
00:11:45.96
Speaker
And and yeah that one was such a – it's such a simple ah pain relief procedure, giving a medication, and and I'm sure you've learned over the years that not all patients are quite that way. Some of them are a little more complex And and i want I want you to just touch on, you've sort of mentioned how pain is multidimensional.
00:12:07.85
Speaker
I want you to touch on a little bit more about what pain is, what factors contribute to it. um Yeah, I'd like to love to hear your input that.
00:12:19.85
Speaker
if if we If we go on um what what you were werere talking about, nurses informing the way that we practice. When I started doing anaesthetics in Albany, um we I was doing a gynecology list. And if we take, say, two 20-year-old women who are both matched for height and weight and medical issues and physiology and both have the same procedure, say a laparoscopy and a DNC looking for endometriosis or something along the lines of that.
00:12:49.81
Speaker
um I had this patient that was in the recovery room and she was in so a severe amount of pain. Everyone else that day had been very routine and had the same amount of analgesia.
00:13:01.12
Speaker
And I think we were doing four or five laparoscopies, exactly the same procedure. And she was she was really struggling. We'd given her everything for her pain. And one of the nurses said to me, an older nurse who I'm still friends with, Carol, she said, look, sometimes there's pain that no morphine will fix.
00:13:18.93
Speaker
and And I i always to remember that because what she was saying is that there was other things that were... um were in play here. There was, and and for me, I really saw at that stage pain as being quite one-dimensional. It was very biomedical.
00:13:34.38
Speaker
And really what Carol was saying is that this this this girl, i I don't know what else was going on. But she was distressed. She was catastrophizing. She was hyperventilating. It was it was not it's not going well.
00:13:50.16
Speaker
And the more when i look back at that case objectively now as a pain specialist, I understand um she quite possibly had visceral hyperalgesia. Her organs were sensitized.
00:14:00.90
Speaker
She may have had... um um negative pain cognitions, the way that she dealt with pain. She may not have a safe home. She may have been in an abusive relationship. I don't know.
00:14:11.90
Speaker
um She may have a psychiatric diagnosis. She may have of anxiety or depression or but ah or um very rare schizophrenia or bipolar. That's not really a common thing.
00:14:22.93
Speaker
But these other common things inform pain, And then as I learned about the way that pain is processed, especially from our visceral organs, it all comes up through the spinal brachial tract and it runs through our amygdala and our hippocampus.
00:14:38.86
Speaker
And we can't help but attach emotion and sympathetic reflex to our organ pain. Um, And i I think that, um and so the answer is how people experience pain is that pain is multidimensional.
00:14:55.05
Speaker
It's informed over different areas. um We have this beautiful gut-brain connection, for instance, like if we can feel butterflies in our tummy when we get excited and we can go, oh, I'm excited and it's going, oh, something's going to, great, it's going to happen, se the the opposite is possible.
00:15:12.98
Speaker
um You can feel dread and doom and worry and frustration in your belly and in yourself. And personally, from my point of view, i when I get worried and upset and stressed, I get really bad reflux.
00:15:28.77
Speaker
And i my back starts to hurt. And that's reusing my tell. Everyone has a tell. It's a headache, neck pain, shoulder pain, glute pain, whatever it is. um These are ways that our body informs us that something is happening. And the way that we were created is that these things are all attached.
00:15:47.31
Speaker
um Pain, when I explain it to patients, I say, look, your pain is real. I believe you. There it is. I can see it. But it's attached via your brain, via these tracks to your brain.
00:15:59.30
Speaker
And whether we like it or not, whatever happens to us, trauma, memories, experiences, all inform your pain. And so if we're going treat you, I can help you physically, but I need to help you with the other stuff as well. I can't separate. And if you want to separate it, I i don't know if I can help you.
00:16:18.38
Speaker
So that's really the my pitch when I see patients. I try to bring it together. I draw it i'll draw lots of diagrams. Mate, this is ah music to my ears because sometimes I i think that people just think I'm a wacky physio. So to to be able to hear it from someone that's done their you know their fellowship in pain medicine will be really helpful for some of those listeners that are like, ah, it can't be really this mind-body thing.
00:16:46.19
Speaker
um um And, you know, and it's always real. I think you i think you just outlined that very clear and and concise. I want to i want to touch on your experience with low back pain. I was listening to one of your TED Talks, which we' we'll touch on a little bit more, some of the the the content that was in there. But I just want to hear from you, your own experience with low back pain.
00:17:16.05
Speaker
and And what tools you used to help you with that? um are you You were talking about, oh, when I was talking, I think, so was talking about my injury and it was actually my arm.
00:17:32.28
Speaker
um I'd ruptured my biceps tendon and the recovery was less than adequate. And there was a little big worry around developing complex regional pain syndrome in my arm.
00:17:45.03
Speaker
It was numb, was painful, it was swollen and it was not going the right way. And I think and so in my TED Talk, what I was talking about is I was doing all the rehab. I'm a very good patient.
00:18:02.88
Speaker
If someone tells me I listen to my physio ah verbatim, I do everything the doctor tells me to do. Yeah. and because i don't really get sick very much but at the same time there I'm I think it's very good to let someone else take care of you they're the professional and so I was doing everything right but I was still felt like stuck And when I connected to the meaning of what was happening and understood that, yes, I had pain, it was here, but whatever was happening inside of me, the turmoil, i know was affecting the way that my pain was being perceived.
00:18:43.42
Speaker
And so when I... The peace and the joy came when I was able to set a reason behind this, as a purpose behind this. um No matter what, I am going to get through it.
00:18:55.18
Speaker
I'll keep on going. And when I think when we talk about the spiritual dimension, spirituality can be both um horizontal and it can be vertical. Vertical is often connecting to the universe, connecting to a high power.
00:19:10.90
Speaker
And for some people, it's connecting to to God. It's connecting to Creator. The vertical, the horizontal is creating to experiences and people and places and things that allow us to feel joy and peace and bring us hope for the future.
00:19:27.40
Speaker
And so for me, being able to separate, going, oh, my gosh, this is terrible, but to understand what's the purpose behind it? What's the meaning here? What is God trying to teach me? What am I supposed to do here?
00:19:39.74
Speaker
And that allowed a flood of um really ah really joy and to go let's enjoy one of the best summers I ever had. Having this injury, I couldn't work. um And it turned out to be for good, really, why this injury happened.
00:19:54.58
Speaker
Yeah, that's an ni interest. Sorry, i I got it wrong with the the back, but that was the story that I was i was referring to. So thanks for unpacking that. I want to delve, because I think we both agree that probably the biopsychosocial model of pain probably should be extended a little more to include the spiritual.
00:20:15.38
Speaker
Tell me, in what ways do you think that the spiritual realm impacts pain?
00:20:25.89
Speaker
Yeah, so I think so for for my patients, the way I engage with that is I ask them a very open question around what helps you what helps you get through hard time?
00:20:41.63
Speaker
What gives you hope? have And often people will say things, I think I like the question, what gives you hope? what gets you through hard times is a way of people digging down deeper.
00:20:55.08
Speaker
It's like, it's, I'm not asking about the heat pack. I'm not asking about um surgery. I'm asking about how people get through things. And if you asked me, what gives, what helps you get through or ask yourself or ask, um,
00:21:10.83
Speaker
it It might be i pray or I meditate or I i take deep breaths or I spend time with my grandchildren or from my former living in Albany is um is um i I go i i I sit on my porch and i look at the the mountains or ice I look at ah go to my fields or I go look at the ocean and It's this simple question to go, what helps you get through?
00:21:40.20
Speaker
And allowing people then to say, look, that spirituality is not religion, although that sometimes people attach that to it. Being spiritual is understanding the um that you define it as connection.
00:21:55.23
Speaker
So who are you connected to? And you can be connected to God. You can be connected to other people and places and experiences. And so it's a matter of connection.
00:22:05.98
Speaker
And I see it most in palliative care when when people have this source of broken connection that leads to spiritual distress. And spiritual distress is when we despair of life. Why am I here? i want to die. um This ma is meaningless. It's pointless.
00:22:23.96
Speaker
And that's often how there's a, I think there's a lot of spiritual distress in in chronic, in public chronic pain clinics. There's been studies to look at in spiritual distress.
00:22:34.90
Speaker
And, um, I think that a lot of the focus and the thing is that our clinics are doing the best they can. They're seeing patients best they can.
00:22:47.26
Speaker
It's not that that anyone's trying to do the wrong thing, but, um, I think there's a lot of distress. It's like, why is this happening? I want to be better. Where is my hope? It's because the connection to their life has been broken. I wanted to work. I wanted to spend time my grandchildren. I wanted to go.
00:23:04.35
Speaker
ah wanted to retire. I wanted to do that. And that has not happened. And it's not a psychological problem. It's not an opioid problem. it's a It's a loss of hope problem.
00:23:17.06
Speaker
And it's Yeah. And so it's easier to identify, well, how do we help? You know, i it It seems ludicrous to propose to my my colleagues that we should have a chaplain or a, um we have to call them spiritual and wellbeing officers now in the WHO health system.
00:23:37.07
Speaker
But that's what people need, I think. But we're so attached to my opioid, my other stuff, this, you know, it just, it's a tension. You can't come and see the pain specialist and him talk all about hope. It needs to be,
00:23:51.76
Speaker
There needs to be other stuff to get to hope. And that's the, I guess, the biomedical, it's the the movement, it's the psychology, it's the, yes, let's titrate your medicines. You might need an injection, you might need surgery, you know, but then yeah we also have to have, I think giving people a pathway for hope is helpful.
00:24:12.17
Speaker
Yeah, absolutely. that's That's fascinating hearing you unpack that. When I was, um I went and did the Professional Certificate of Pain Science at University of South Australia, which um is run by Laura Mamosley and some of those guys. And when I was listening to them talk about the relationship between fear and pain, it was it was really fascinating to me to see how that connected with for people that are Christian, their their picture of who God is.
00:24:44.16
Speaker
You know, if if God is like a stern and fierce person that's controlling and and, you know, manipulative, then the way that plays out on in their their experiences, including pain, would have a significant impact when we know that that fear amplifies pain.
00:25:04.70
Speaker
and And same when when when when you talk about freedom and whether God is... sort of just moving these puzzle pieces about and there's no real human autonomy in it. I can see how those factors and those ideas of who God is or, you know, what theologians would call theology, which just means the study of God, how those factors could impact someone's pain experience.
00:25:30.65
Speaker
um and And, yeah, it's it is a fascinating area to me, um obviously, because I'm a Christian. It's it's interesting to me to to think about the connection there. But I really do think we need to move from a biopsychosocial model to to add spiritual.
00:25:48.52
Speaker
um If you started a campaign like that, Jonathan, I'd get on board too. um Just to talk about what you were saying then – is we We have a, I think, if we separate God from this, if we just look at it as ah suffering, because this is what it is, it's suffering.
00:26:10.30
Speaker
Life, if we look at anyone who's ever um done anything great in our life, there's always a degree of suffering that comes from that. Life is attached to suffering, and I think that We've divorced the idea that life just needs to be good.
00:26:28.79
Speaker
It needs to be good, pain-free, painless, absent of any type of disc distraction. And I think that um the fact that it's happened is a massive inconvenience to people.
00:26:40.94
Speaker
It is. think about pain in my own life, whether it's psychological pain or things that happen in your life to your family and friends, it's painful. and But the wisdom of life is that life is is um full of suffering. If we understand and even believe that Jesus was a man um that lived, let's just say that, and his life was example to us that there was suffering.
00:27:08.48
Speaker
There was suffering in what he did and what happened to him. And the gospel is really represents um Jesus' suffering for us.
00:27:19.47
Speaker
and And I think that even if you weren't a Christian, it's just to understand that life is um inconveni um inconvenient that way and because at the end of it is death, which is the ultimate um ah end, really.
00:27:35.51
Speaker
And I think as even thinking about palliative care, bringing in voluntary assisted dying is convenient. If I don't want to suffer, this can end.
00:27:48.56
Speaker
I understand I've written about this quite a lot, but um as a palliative care doctor, I'm a conscientious objector. But it doesn't mean I won't help you with your suffering. I'll help you till the end.
00:28:00.21
Speaker
But suffering in our in our society today has become arbitrary. It's binary, yes or no. I don't want to. So I'll do everything I can to not suffer. But um I think the people who do best are the people who go, it didn't happen to me, it's happened for me.
00:28:20.17
Speaker
I need to do something with my life. um And it's hard. It's extremely draining as a health professional to be able to to have these deep, deep conversations, it's exhausting for you. But I think that there is this expectation that there should be no suffering and um it's hard.
00:28:40.84
Speaker
And think that's actually one of the things I'm really interested in um to be able to understand and unpack that to help people embrace it. Yeah. Interesting. Interesting. It's it's funny because...
00:28:54.62
Speaker
I think there's, you know, there's when they talk about um acceptance in in pain, people that are managing chronic pain, I've talked to another person on on on this show about this sort of balance between acceptance but not helplessness.
00:29:13.58
Speaker
and And I think when you talk about that, what you what you're explaining is that, you know, there is a certain level of acceptance that is required, you know, ah because we are human if you bleed blood you are going to suffer but then i also innately really think that that suffering is the enemy not not the enemy here and now but ultimately the enemy because one day obviously i hope for a world where there is no and pain and suffering anymore um
00:29:46.65
Speaker
And so, yeah, it's this tension of like, okay, what can suffering bring to the here and now? And how can i use that to my advantage and to live a fulfilled life, but but not fully accepting that pain and suffering are a good thing and not the enemy?
00:30:06.33
Speaker
um And look, I think, um just to to go back, I think i've i've done I've written this before, but I'm just going to pull it up here. But um um Romans 5 has a, well, I've used it really, is that suffering this idea between helplessness and acceptance, it's that suffering allows you to persevere. And as you per persevere, um it develops a character.
00:30:33.15
Speaker
And through character development, we have hope. And it's this circle ah that Paul talks about. And I think that's really the the essence of what the cycle is. And then when we when we develop hope,
00:30:46.55
Speaker
we face the next battle and that's this this continuous way you're right it's suffering is um it it is bad could be evil but it there's this cycle that we're learning something in it accepting and not being helpless and being broken by it yeah it's it's it's uh we could talk about suffering the whole podcast yeah ah hundred a hundred percent hundred percent no i enjoy your thoughts on that because You know, of you and I both work with people with complex chronic pain and and obviously suffering is a real thing that we experience day to day through that relationship with with clients but also personally in our own ways.
00:31:28.17
Speaker
um um and And it is something that you really need to grapple with and and wrap your head around. But well we will move on because, you like you said, it will take the whole podcast if stayed there.
00:31:40.75
Speaker
What I wanted you to talk about... yeah is the pyramid of pain care the that you posted on your LinkedIn page and that I commented on and I shared to my my own page um just for listeners because it's hard to... Actually, I'll just ah'll leave it to you and and it's just hard to get a visual for that for for listeners. But if you could spell it out in a in a way that um listeners couldn't also get that visual, that would be helpful.
00:32:16.32
Speaker
Yeah. Look, i um i i like I'd like to think I thought about it myself, but then I saw someone else with a similar pyramid. we must just all be thinking the same, but um I can't remember where I saw it, but um i I think, so after I finished my exam and a lot of stress dissipated, um I started thinking about things and um I was port to they' asked to give a talk.
00:32:43.22
Speaker
And what I realised is that um when we think about high-value pain care, there's because there's a Lancet article that talks about high-value low back pain care, um there's also a guideline that came from the National Clinical Standards around how about um the clinical standards for low back pain.
00:33:04.77
Speaker
And there there's a Medical Journal of Australia article that informs that. And really, when you read that article, you realise that what we're doing in primary care or what even we're doing, even as specialists seeing patients pain, where that what we're going to first is not really the foundation of care.
00:33:24.96
Speaker
And what I found in explaining to my patients is that we've got to get the the foundations right before we start building on top of this um other things. Because, um for instance, um when...
00:33:38.56
Speaker
When I was working in quite an interventional unit, a public unit, patients really just wanted medit. They were coming to the pain clinic really because we were gonna do injections and medications for them.
00:33:51.17
Speaker
But really what we were, were a multidisciplinary service. We really wanted to ah form the bottom of the pyramid. And if you think about the bottom of the pyramid, we all know the food pyramid and the things you do least are at the top and the things that we wanna get right are down the bottom.
00:34:07.28
Speaker
And down the bottom are things, the simple things. It's about getting a diet right. And diet also means probably weight. It's sleep, getting adequate sleep, fixing sleep. Why aren't you sleeping?
00:34:18.78
Speaker
It's getting exercise right. We have to move. We have to do. And moving is, exercise big thing. It's mobility. It's stretching. It's aerobic. It's also strength.
00:34:31.12
Speaker
It's big thing. And it's um drinking, it's ethanol, it's what's so alcohol, it's cannabis. And then it's um that and that's really forms the foundation. Are we getting that right?
00:34:45.14
Speaker
because And I think my my general practice background as well for informs that because that's the thing we need to talk to patients about a lot. And if we can if we're getting the bottom right, we can move up to the next level.
00:34:56.84
Speaker
And if someone has, and and at the next level, there might be medications or more complicated medications, not yet opioids. But at that level, we're doing um more informed care with physios collaborating, saying, look, we need to work out the shoulder, what's going on here, what's going on with our lower back.
00:35:15.34
Speaker
It might be neuropathic pain or it might be post-surgical pain. It might be post-trauma pain. and ah It might be complex regional pain syndrome. might be fibromyalgia.
00:35:26.79
Speaker
We're also involving psychologists. We're also involving education. We're building up the pyramid. So what we can, do the bottom part is what we can manage properly in and primary care and um and we can step up.
00:35:40.15
Speaker
But then as we start going up to the top of the pyramid, we're adding more complicated, more um specific medications, um opioids, for instance, antineopathics and antidepressants and And as you get up to the top of the pyramid in pain management, tip is injections, um surgery, and um I can't remember the last thing that was, and doing things like spinal cord stimulation and things like that.
00:36:02.59
Speaker
And so... What we were talking about offline was that sometimes that pyramid is reversed. And in fact, I've got a picture of that. um And where we start at the bottom, we go opioids first, we ejections first, we go we go ah scanning first, we just go and neglect the top of the pyramid.
00:36:23.00
Speaker
And but interestingly, paradoxically, all the evidence is at the bottom of the pyramid. all the Cochrane reviews, there's good, solid evidence, level one evidence for exercise and low back pain, knee osteoarthritis, hip osteoarthritis, exercise um producing um good analgesia, it's psychology helping to inform group programs. it's It's all of these together the most evidence and often they're the most neglected.
00:36:54.13
Speaker
And so I think that the pyramid which I drew, and I've seen it before again, ah is really the the best way to think about pain. And I draw that often for my patients. I say um they think we're coming to see the pain doctor. We're going to look, I'd love to do an injection. Being in theatre is fun.
00:37:14.28
Speaker
It's great. But it's not going to work for you unless we get the bottom right. If you come and see me as a pain doctor, I need to make sure that he's right. That's um the the whole package. Yeah, that's ah it's amazing. Yeah.
00:37:28.67
Speaker
Yeah, to hear that from you, and the importance of lifestyle interventions and behaviour change. I wonder what I have my own ideas around why it's inverted. I think incentive structures, unfortunately, and I'm not saying that all doctors are evil and they want to make money and those kind of things, but there is that bias there. um On top of that, there's, you know, that habit change is hard. It's really hard to change habits and change behaviours.
00:37:56.42
Speaker
Those are probably the two primary reasons why I think the pyramid's often inverted. One is to do with the medical system and the other is to do with patients. And it really just is hard for for people to change habits.
00:38:10.88
Speaker
why Why do you think that pyramid's often inverted? think you're Yeah, um so what you just said then is true. So one of the things that we learn and that we really get a handle on in in pain medicine is understanding a person, because you were saying before about the person patient issues.
00:38:32.30
Speaker
And one of those issues is that you would see as well in physio, ah is his ah is pain cognition. Cognition is how do you think of things? Are you more a warrior? Do you catastrophize?
00:38:46.15
Speaker
um Do you have and this say ah do you have co-orbid a mental, like a psychiatric diagnosis of depression or anxiety? um are you melt or have you And then other things can be like, have you had a history of trauma?
00:39:00.46
Speaker
And so you have quite sensitized trauma um ah nervous system. And so one of the biggest things there is this idea of passive and and active cognitions.
00:39:12.73
Speaker
And often the reason why that pyramid is inverted is because people want things done to them. Give me a tablet. do an injection, give me some massage, put on a heat pack, put on a TENS machine.
00:39:26.20
Speaker
it's Active means that you are actually doing something. You're doing the stretch. You're doing the exercise. You're doing the meditation. You're doing the deep breathing. You're going for the walk. You're breaking that fear avoidance cycle.
00:39:40.53
Speaker
um And so I think that, look, it's really easy. Look, if my natural self is is um it's discipline which breaks that and habits and routine, but we're all naturally, we would just love to sit down and do nothing. When you have pain, it's hard to move. When you have pain, at when I injured my back um a couple of years, about it's,
00:40:04.70
Speaker
a year and a half ago and it's not going. Most of the time, would classify my pain as a 0.5 out of 10. um and sometimes don't even notice it. And when it's really bad, i ah well, every night I stretch, I do weights, I prescribe my physio every three or four times a week.
00:40:24.65
Speaker
I walk and I run and I do things because don't want this to become chronic. I don't want this to overwhelm. and When I say chronic, I don't want it to overwhelm my life and impact my activities. But passive, it will be just a life, do nothing. And I can see it just gets worse and worse and worse and opioids or analgesia and injections aren't going to fix that.
00:40:49.23
Speaker
It's almost a blessing that i hi i I've been inflicted with pain because i i understand, like I can't live without pain.
00:41:01.17
Speaker
these activities. And so when I'm telling my patients stuff, I'm doing the same things I'm saying, but this is balance, you know, we would rather do nothing.
00:41:10.94
Speaker
Yeah, 100%. i um My business is called that i that I started last year is called Physio Pain Coach. And that that word was very intentional, the word coach, because people come to me like as if I've got these magic hands that I'm going to just sort of, I'm going to fix them.
00:41:29.27
Speaker
and And the reality is is that that's not how it works. And people really need to get the power back and feel like they're in control. and to feel empowered with the tools and the skills and the the lifestyle habits. and the And yeah, and you're right, but people often, they just want that really quick fix. And look, we're all guilty of that. We all would choose short-term pleasure over long-term pleasure.
00:42:00.66
Speaker
reward through hard work discipline and those kind of things it's it's not like i'm pointing fingers at people but yeah i was very intentional with that yeah that that we really we really just coach and guide people and they are the ones that heal their body is created and designed to heal to the best of its ability and and they have the tools to be able to create an environment where where that happens um And that's my job is to give them those tools, to give them that environment. You walk alongside them.
00:42:33.00
Speaker
Yeah, 100%. So love hearing that from from you. and and it's a shame that there is that inversion of pain care. And I hope that that you're one of the individuals that that changes that.
00:42:50.21
Speaker
Yeah. Is there, when you think about the future of pain medicine, where do you see it going?
00:43:06.22
Speaker
And what are you what are some really cool new things that are happening in the pain space that provide you with hope that tomorrow's going to be better for people suffering with pain?
00:43:20.72
Speaker
and Okay, so a couple of things. Number one would be that there's there is evidence that the way of prescribing opioids is decreasing.
00:43:37.95
Speaker
We had this, everyone, I think it's been made popular with the Netflix series of, you know, what was it, Pain Hustler, or I can't remember what it was, but the book to read on this is a book called the Empire of Pain.
00:43:52.65
Speaker
excellent it really tells a story about oxycontin and the rise and why it became so popular um there is a trend in australia that the pbs data is showing that we are prescribing less opioids we are seeing that in the clinic we're seeing that patients who are prescribed large large amounts of opioids are not doing that and not having that done anymore ah our specialist GPs are being trained by Akram in the college, Royal College of GPs, are being trained very well to understand this patient's pain. We're going to do lots of multidisciplinary things.
00:44:30.78
Speaker
And going to the opioid, going straight to that is not happening with this new group of, um and i'm and I'm saying as well, the the older group too, like there's a trend away.
00:44:43.24
Speaker
Will it trend back to, don't, The physiology doesn't allow that to happen because if we go back, we're going to have more pain. And because opioids worsen central sensitization, central sensitization worsens pain and lots of other outcomes.
00:45:00.72
Speaker
So that's the thing to be happy about. Like, I think that that's really, that's exciting. I'm happy about it in the future. Does that mean that we'll be out of a job? No, I don't think so. I think that there'll be other things for us to do, of course.
00:45:14.92
Speaker
um the The second thing i think for me as a doctor is very, i'm I'm committed to wanting to have cut um ah provide rural care.
00:45:26.06
Speaker
I think that the use of telehealth, the use of being able to have a hub and spoke model where you have a specialist and a generalist working together in different places, I think is really exciting. There's um just actually published in the pain um journal.
00:45:43.79
Speaker
I was and interviewed, I think, and um I don't think she's a physio, but I think she's a PhD candidate, that Ashley Grant. She's published an article looking, exploring around models of care for rural patients.
00:45:56.90
Speaker
And I think that there's a lot more talk around that. And so i I'm hopeful that the future will be better for rural and regional patients so we can deliver care remote um in their region.
00:46:10.19
Speaker
And I think best care is like the pyramid. We need to do education. We need to do lots of information around how we, I think, because one of the big data set from pain is that patients in the country have less access to physio, less access multidisciplinary care, and therefore have, but not therefore, but concurrently,
00:46:29.59
Speaker
have higher rates of and so i think that that's just a surrogate mark i'm not saying that people are doing the worst doctors are doing not so good things in the country i'm just saying that these are um um data and this is um from a number of years uh probably at 2018 2019 but but um it's good because when we start informing a community, that community starts to change. So I think that this hub and spoke model, telehealth is exciting for other things happening. I think um
00:47:04.76
Speaker
There's lots of, there's always good research happening around the way that we think about pain. I'm very excited around Peter o Sullivan and um JP Canero do some talks for us at the end of last year. So cognitive functional therapy, I'm excited about. I think it's because they're also trying to develop a not-for-profit that helps to put the word out to the world.
00:47:29.00
Speaker
um And so the better ways of being able to deal with pain. um And think about pain as physios and inform people cognitively about how they can move and and think about fear.
00:47:40.22
Speaker
So those would be the things that firstly come to mind for me about things I'm excited about.
00:47:48.30
Speaker
Yeah, it's a good question. Yeah, awesome. No, those are some those are some great things that you've mentioned. I just want to, I probably want to tap into a little bit more around all of those, but when it comes to telehealth, I've been a big proponent of telehealth physio, especially in rural and remote communities.
00:48:10.48
Speaker
And I find there's some certain barriers around that because of the perceptions around what physio is. It's it's very much been a very hands-on dominated, sort of field and there is that true transition away from from that approach to more, you know, these lifestyle factors and and and coaching but also and having a good understanding of the pathoanatomical stuff as well, not just chucking that out but but there's so much we can do when it comes to education and when it comes to lifestyle interventions and habit change and and coaching and guiding.
00:48:49.17
Speaker
But unfortunately, the barrier is that patients don't see how that could be effective. and And often GPs also don't see how that could be effective because they yeah don't see a physio in that light.
00:49:03.62
Speaker
And um I love the work that Peter O'Sullivan's been doing with cognitive functional therapy. I think it's it is important. I guess the most dominant way that I practice is to sort of yeah pick apart and understand how how they understand their pain, um what are the factors that are contributing to taking away some of those fears that may be unfounded or unnecessary and then slowly and gradually exposing people to to movements that they need for day-to-day life.
00:49:37.97
Speaker
um and And you can do all that by telehealth. So I i see a massive role there. So, i yeah, well, it's just awesome hearing you speak like that and and hearing those words because I think, you know, it just means it tells me that some of these barriers will be breaking down over time.
00:49:58.31
Speaker
Yeah. I think as well that... that One of the things I realized when I talk to patients um is sometimes physio can be seen as something that has been done in the past.
00:50:13.35
Speaker
I've done physio. it's a There's a past tense to it. And I often say to people that physiotherapy, there's there's the acute stuff. The hands-on stuff is very should be very acute.
00:50:26.74
Speaker
You need something now, yet there's a muscle that's also there's something happening. Yes, the manipulation happens, but the value of physiotherapy is the the information about your particular vulnerabilities and strengths and how you can particularly, what you can do to improve that and how you can incorporate that to your particular life.
00:50:50.59
Speaker
think that's the value of physio and that's something you do for the rest of your life because If I think about all the exercises that I've done in the gym, it all informed by fit my physio.
00:51:01.19
Speaker
um i don't two I don't do a standard off 5'3", 1", whatever kind of weight program anymore. I do things that have been informed of by physio because as I get older, I have you know shoulder or I have a back or have this or that, they're not so good.
00:51:19.94
Speaker
And I'm pretty much training to to to to live pain-free as I can for the rest of my life. So I think I try to inform patients that physio isn't something you do.
00:51:32.51
Speaker
you do it forever. You do stuff forever. You have to. And it's both a sad truth but also um a wise suggestion, a wise direction because you, I think we have to treat chronic pain as what we would like chronic heart disease or chronic diabetes.
00:51:57.19
Speaker
It is something we need to do. We're not just taking an insulin shot and taking some metformin. um People who have diabetes have to what change the way they eat. They have to exercise. They have to do ah types of exercise, heart disease, aerobic exercise, eat a certain way, not smoke, not drink, not salt.
00:52:17.30
Speaker
It's a lifestyle. And i think when we we need I think chronic pain needs to be in seen as a disease state, for instance, maybe frame it. It's just the framing, really.
00:52:30.50
Speaker
And I think I spend a lot of time with my patients framing. This is what I think, this is how you should think about it. And when it connects, then people can do stuff. you know they They get it. Once they get it, they they're able to go, oh, yeah, maybe that's how I should think about it.
00:52:47.48
Speaker
Yeah, 100%, 100%. hundred percent Because there is ah it is there's a difference between acute pain and acute injuries that, to be honest, you can do pretty much not much in most cases and they'll get better because the body's created to heal. And it is amazing at doing that. and And pain is a protective mechanism that helps people to heal because they, you know, they they lay off certain activities or they change behaviors and they heal.
00:53:17.18
Speaker
um But when it becomes chronic, it's it's a different beast and and lifestyle interventions, just like any chronic disease, are so crucial. So, yeah, that's 100%.
00:53:28.54
Speaker
And, um and and you know, you said physio is something you do, but oftentimes it's even worse Physio, people believe that physio is something that's done to them, um like rather than something that you you have to do for life.
00:53:46.76
Speaker
And it's also physio is a profession. It's not a treatment.
00:53:53.55
Speaker
If a physio failed you, they might they might look very different in the way that they approach you as as me. Or likewise, if I've i've failed someone and and not given the the the recovery that they were hoping for, another approach, and another physio with a different approach may be may be helpful for them. So, yeah, I think that those are some important clarifications.
00:54:18.59
Speaker
I want to touch on a few questions that I personally have.
00:54:24.61
Speaker
about drugs. um The first one is, and and I use this as an a wayit a way into the psychosocial domain for people with chronic pain is that we use these SSRIs are often used in in treatment of pain and as well as in the in the treatment of like psycho psychological issues.
00:54:54.97
Speaker
And and is that what is the pathway there? What's the overlap? Why are antidepressants not only helpful for psychological pain, but also um helpful for pain that we feel in the body? is there some sort of can you Can you sort of dumb down the the physiology that's happening there for us?
00:55:15.62
Speaker
Yeah. Yeah. So I think, so when I think of, when we think about pain, i was just writing about this today. we have to go, what is the pain?
00:55:27.64
Speaker
Where is the pain? hey um Are we talking about headache? Are we talking about a shoulder pain? Are we talking about um um cervical radicular pain, you've got neuropathic pain or lumbar, spine, facet, disc pain, or is it lumbar radicular pain?
00:55:43.90
Speaker
Is it peripheral neuropathy? Is it fibromyalgia? Do have complex regional pain syndrome? What are we talking about? And because that will go what type of pain? Is it neuropathic? Is it nociceptive? Is it nociceptive somatic? Nociceptive visceral?
00:55:59.39
Speaker
Is it not, oh, sorry. ah And then is it nociplastic pain? And nociplastic pain is pain that is experienced without with that visible damage to the somatosensory system.
00:56:12.15
Speaker
So we first need to work out what type of pain it is. And so if we go down, we can break it down pain. So let's say someone has cervical radicular pain.
00:56:22.84
Speaker
They have a disc or an osteophyte that's pressing on their C7. So they have radicular pain down their right arm. um They may, might have had an injection, they may have had surgery, they might, and so now there might be post-surgical pain, it might be post-trauma pain, no one's going to operate anymore and they have this debilitating, ridiculous pain.
00:56:44.55
Speaker
So they might you might see someone on, say, gabapentans and maybe a gabapentanoid or an anti-epileptic. But at the same time, you can use, um you that person might um ah use, actually, let's change that to the lower back.
00:57:01.32
Speaker
So if it was a lower back pain, so it was a L3-4 or L4 radicular pain down the right side. And someone in it, they've had surgery, they've had effusion, they've had so many different things happen.
00:57:14.63
Speaker
um We may, that person obviously has post-trauma arthritic pain in their back, but they also have radicular pain. We may choose to use an antineuropathic and antineuropathics, the first lines are always going to be gabapentinoids. So pregabalin and gabapentin.
00:57:33.50
Speaker
And then now the antidepressants, amitriptyline or duloxetine. Amitriptyline can be other nortriptyline, but these are antidepressants. But these antidepressants have been used to treat neuropathic pain and they have favorable number needed to treat them. the The most favorable number needed to treat is amitriptyline and then duloxetine and then gabapentin and then pregabalin.
00:57:57.76
Speaker
um These are studies in patients with neuropathic pain using an antidepressant for that. So that is, and we know that there's been a couple of studies published recently which show that things like duloxetine is, of all the antidepressants, it is the one with the best, most favourable results, ah low back pain.
00:58:18.88
Speaker
um If you then break that off and go, um okay, someone may have um a different type of pain, like say fibromyalgia, someone has nociplastic pain,
00:58:29.59
Speaker
There's the best evidence in fibromyalgia all come down to exercise and psychology. There's other lesser studies that people also may might use like amitriptyline or metazapine or duloxetine.
00:58:43.05
Speaker
These are often used because the pain of fibromyalgia, someone might describe it as electric-like and burn pins and needles or like just prickly. And so therefore, sometimes antidepressants are used in this case.
00:58:55.99
Speaker
The person might have reasonable mental health, meaning that they have when they do the DAS scoring or they might the pain catastrophizing score or the pain self-efficacy.
00:59:06.93
Speaker
um Or when you talk to them, they don't have clinical or they have major depression. So it really depends what type of pain Can we, what medicines are we using for that?
00:59:18.02
Speaker
And sometimes they have overlap. For instance, if a person has radicular pain, but they have problems sleeping, amitriptyline might be better. so And so amitriptyline is what they call a tricyclic antidepressant.
00:59:32.33
Speaker
Duloxetine is an SNRI. It's a serotonergic and noradrenergic reuptake inhibitor. That can also help with mood. um SSRIs and pain, SSRIs are another group.
00:59:47.44
Speaker
We don't often tend to use them with pain, but sometimes patients might have pain and also be on an SSRI to treat mood. And so that can go together, but antidepressants can be used to treat pain, mostly neuropathic pain and nociplastic pain.
01:00:04.93
Speaker
So that's how I think about it. it's It's not used as part of the, unless you have, so someone with fascinat facet arthritis and has lumbar spine pain, they might've had an injection before and it's helped in an epidural.
01:00:20.27
Speaker
That person who exercises, keeps well, is mentally healthy as they can, doesn't need to have an antidepressant unless they start having radicular pain, neuropathic pain, or they might have concurrent diabetes and they have peripheral neuropathy.
01:00:34.76
Speaker
Then they may need to have some duloxetine. So it really comes down to the... um um the etiology, what's causing it, and the other stuff involved, the other conditions. So it's not um part of the arsenal unless it's part of the they the the picture of pain.
01:00:54.57
Speaker
Does that answer your question? Yeah, absolutely. Fascinating. And, yeah, was I got the SSRIs wrong, but ah to me as a physio, they're antidepressants. But what's fascinating to me, and and I wonder if what your thoughts are on this, is that, like, if those are effective, would that also mean that cycle psychological interventions that – um that are focused around sort of lifestyle and cognitions and, and those kinds of things, would they have that same effect on this nerve type pain that you're talking about? So just for listeners, when, ah when Dr. Jonathan says about neuropathic pain or radicular pain, he's talking about nerve type pain, um which these medicine, saying um which these medicines often are helpful for.
01:01:48.46
Speaker
But my question to you, Jonathan what, what Like why can't we use um psychological interventions or even lifestyle things that improve mood and reduce depression and those kind of things in these pain treatments?
01:02:07.26
Speaker
And if they respond to these nerve medications, does that mean they will also respond to sort of lifestyle interventions that address mood, anxiety, depression?
01:02:21.85
Speaker
Look, I think that, so it comes down to if we break it down to what's happening on the physical level, because it all begins physically.
01:02:33.34
Speaker
If we're looking at say even the neck, we're looking at peripheral neuropathy, just say someone has um um bad peripheral neuropathy post um chemotherapy, or someone has peripheral neuropathy from diabetes, or someone has radicular or nerve pain from a ah disc or an osteophyte in the back, or radicular pain from a disc or osteophyte in their neck.
01:02:59.19
Speaker
and a reticular pain. um It's irritation to the nerve. The nerve root is coming out. There's irritation here. it's um Pain is being generated. There's neuroinflammation.
01:03:11.99
Speaker
um There's the release of neurotransmitters. There's the activate. So it starts peripherally. If it's going on, as you know, persists, persists, persists, is NMDA receptor.
01:03:23.25
Speaker
so I'm going to get technical because um so you have your um your microglial cells, you have neurotransmitters, you have your NMDA receptors that get um activated. That sends a signal to your brain, this pain. It feels like it's my whole arm.
01:03:38.52
Speaker
It's getting out of control. It's worsening. It's worsening. It's worsening. um the tricycl The tricyclic or the SNRI or the gabapentin or the pregabalin or Lyrica, what they're doing on the nerve level is stopping the transmissions from the nerve transmissions from happening across the axon, ah across the action potential. So it's not being transmitted through.
01:04:00.13
Speaker
It's not going through. It's not going through. i'm not going to feel it. So very much on that nerve level, it's working to prevent that from happening. We left it, it would continue. Can we get better non... Well, maybe.
01:04:16.75
Speaker
i'm Look, I think that... um When it's working, say, for peripheral neuropathy after chemo, the the small fibres have been damaged, um the cells have been damaged by the neurotoxic chemotherapy.
01:04:32.93
Speaker
And that's ectopically firing off and causing neuro it's it's great levels of neuroinflammation. There's lots of chemicals going around. So that is desensitizing the nerves coming up to your spine. and You're going, oh, it's painful down there.
01:04:45.94
Speaker
the medicines are stopping the transmission. So the duloxetine and the amitriptyline are working on the descending pathway because we have the ascending going up to the brain, descending coming down.
01:04:58.22
Speaker
And it's stopping that. It's accentuating. So it's accentuating the descending pathway. And the descending pathway is actually the inhibitory pathway. And so that's actually starting to work more. Okay, I feel less pain, it's getting better.
01:05:12.20
Speaker
The descending pathway is really the important part here because the descending pathway is where we do exercise, we release endorphins and dynorphins, exercise-induced hypoalgesia is really the activation of the descending pathway.
01:05:27.82
Speaker
um When we are getting better sleep, when we are reducing the inflammatory load in our body, we're reducing that, we're improving the descending modulation of pain because the central part of of um pain sensitization, when central sensitization, is that dis descending part stops working.
01:05:48.84
Speaker
So what we're really doing with the antidepressants, we're switching that back on. um The gabapentin, the lyricas and stuff are stopping the transmission of the pain going towards the brain.
01:06:00.55
Speaker
So I think the answer to your question is they work handin hand in hand. So often tell patients that exercise, aerobic exercise, very important to being able to produce this, and reduce this inflammatory, neuroinflammation that's happening in your body.
01:06:16.69
Speaker
Keeping yourself mentally well is able to, if if if we're able to... reduce anxiety and worry and catastrophization, we know that these patients have a better pain transmission lessened because they're not.
01:06:31.96
Speaker
um So we know that ah even for IBS or even gut pain, for worried and stressed, they cause intense inflammation of our gut, distension and stress.
01:06:45.19
Speaker
um intense peristalsis and people experience that and so we're able to control emotions we're able to exercise we're able to they go hand in hand so that's why i think the bottom of the pyramid is really important because um getting adequate sleep we reset our so we're not full gas on our um amygdala we're not full gas to like ah fear and worry and um and um And I think that book, Why We Sleep, is really important. there's lots of good chapters in there about the way that um we're able to um reset our brain. Sleep is a reset to our um the way that our our brain functions. And often patients with pain chronic pain um don't sleep well.
01:07:30.45
Speaker
So it's really getting to the bottom of that. I think sleep is not something we address very well. We often ah try to bomb. Often when I see someone who's taking lots of medicines at night to shut down their brain, often think, why are we not addressing what's truly happening?
01:07:47.67
Speaker
um Why your brain can't quiet down? Is there trauma? Is there worry? Is there rumination? And so the long answer to your question is medicines work together.
01:07:57.99
Speaker
Will it happen on its own? um As a medico, I i ah don't think so. Could it happen? Of course. Look, um I don't want to, um I'm not, i think,
01:08:10.03
Speaker
I can see the line between guru and science here. and And I think my answer is it go works hand in hand because that's the way that I think about it in my brain.
01:08:21.86
Speaker
I don't know whether we could reverse it without. Perhaps you could. I don't know. but I think I would always use medicines. And then we get up to a good amount and you're better. And then what we do is we taper it back down.
01:08:34.00
Speaker
High medicines are not forever, always for a period, a season. And then we always try to bring it back. yeah Yeah, I guess my my my fascination, and I'm sure we could discuss this longer, and um' we probably lost a few listeners, but only just because of the technical side of things. But I ah guess when it comes down to it, I see is that like in the synapse, at the end of the day, they're the same neurochemicals that we're that were that are being altered.
01:09:04.98
Speaker
Whether you're doing positive affirmations to yourself or gratitude or whether there's a and there's a drug that's changing that, I feel like both of those things can alter them.
01:09:18.41
Speaker
So for me, I just use it as a bit of a selling point for for for patients is that, you know, your mind does really play a role on on your pain.
01:09:28.49
Speaker
Yeah. And that doesn't mean that it's... I think we separate the mind and the body as in physiology versus not physiology, but they're all just intertwined.
01:09:39.29
Speaker
Like your brain is physiology. there's There's actual literal things that are happening. And so I just find it interesting and and sometimes ah ah a pivotal shift for people to go, ah that's how psychology works. Because if I can say to them, look, we use...
01:09:58.04
Speaker
in In medicine, they use drugs that help and depressed people that are depressed with antidepressants. These same drugs are used on pain. If there's some lifestyle things where we can change your mood and and and improve your overall psychological well-being, this will have an impact on on your pain.
01:10:19.14
Speaker
So, yeah, I find um that really cool. And and i don't i don't at all I don't at all think that there's not a place um for sure, 100%. I think that there is a time and place.
01:10:30.83
Speaker
um And I send many people to to pain specialists and and sports docs and those kind of things for those well interventions as well.
01:10:43.07
Speaker
i Look, i think I think we need to be... i I agree. I think we need to be, the um the word might be bullish completely on the non-pharmacological. That needs to be the core.
01:10:57.10
Speaker
It needs to be everything I'm doing is really trying to maximize, reduce negative pain cognitions, the way I think about pain. improve my mood, mood um improve my moving, improve my lifestyle and habits, reduce the things that are causing neuroinflammation.
01:11:16.47
Speaker
um That needs to be the core, I think. And that's why I think the bottom part of that pyramid is very important. And so you need to be ultra bullish because... if we're doing that well we can add and then we can taper i think that that's the way that we need to do it because i don't think anyone needs to be on high doses of medicine forever i do think we get better um and if we're really maximizing the bottom we can really enter any suffering look i always say that look we could use this we could try that why don't we chat later
01:11:50.60
Speaker
um If it doesn't work, we'll try this. And then just really maximising those other things. And when I write my letters to the gp GPs, I always break things down. i always write physical, non-pharmacological, physical interventions, physical exercise.
01:12:06.64
Speaker
Then be pharmacological, what we're going to do. Then I write psychological, what we're going to do. And spiritual. i don't Spiritual offer doesn't often make it in unless I've engaged with the patient around the spiritual.
01:12:17.77
Speaker
But that's how I break down my letters and really try to make sure that we're really maximizing the non-pharmacological. um Because ah in the end, if it's reiterated by me, it's in the letter, I think it really very it helps.
01:12:34.73
Speaker
For sure. For sure. i don't want to take too much of your time. We could speak for hours and and I hope that I can continue those conversations on and off throughout the years. But um I often ask guests, what would you, if if someone's in pain right now and they feel like overwhelmed and helpless, what would your words be to them just to end?
01:13:02.06
Speaker
I think, so if I think about When I think about pain, I think we often go to the physical and we go, this is getting worse.
01:13:12.56
Speaker
That's why I'm in pain. It's more inflamed. its It's something's happened. It's broken. It's fractured. There's a God. I'm not saying there's cancer. I'm just saying there's something going wrong. I can't see it. It's back here. It's inside.
01:13:25.63
Speaker
Our mind just spirals. um Our mind's very good at fear. mind's very good at going down the rabbit hole. If you've ever been on the beach, um you see those four-wheel drive tracks.
01:13:38.75
Speaker
Our brains are conditioned that way. We always go to the thought, um the door is open. Someone did, something's happened or there's a, um we're conditioned to these thoughts. If something's happened, oh, that happened.
01:13:50.06
Speaker
So if it's pain, we just go, it's worse. It's fearful. that's I need more medicine. I need this. We always go to fear. I'd say so to when you're in that moment to go, okay, it's it's physical, yes.
01:14:03.16
Speaker
it's um Nothing's changed. To talk to yourself, it's to go, it's probably okay. um And to to break it down the way that we we were talking about it, to go biological.
01:14:14.43
Speaker
What have I done? Have I stretched? Have I done by what I needed to do today? Have I taken my medicine? Have I done this? Great. What's happening in my life? Am I worried? Am I stressed? Is there something happening?
01:14:25.67
Speaker
um What could be causing this? What's happening in my world, outside my world? Is there something that's not quite right? and then going And then going to how am I going to get through this? say And often I think people, there's no hope. It's going to get worse. It's going to get worse. What's going to happen?
01:14:43.70
Speaker
And I think the simple idea of being able to talk to yourself and encourage yourself is giving yourself compassion. Look, if you haven't fallen over, you don't have a fever, you're not bleeding, it's not swollen, you're not losing weight, it's probably not a red flag.
01:14:58.69
Speaker
it Your pain goes up and down. Some days are better than others. But I'd say for someone to talk to themselves, to break it down, to to encourage themselves. What's happening?
01:15:09.81
Speaker
What's happening in here? What's happening out there? What have I done? What can I do? It's coaching yourself. it's It's leading yourself away from this the down. And the more that we do that, we build this self-efficacy and efficacy means that we can get ourselves out of the hole.
01:15:27.85
Speaker
We're more resilient. And so that's that's what I'd say. Talk to yourself and encourage yourself. Break it down. What if I systematically, like how we've brought it and down today
01:15:41.96
Speaker
Yeah, no, that's amazing because, yeah, lots lots of people, they get flare-ups and and when they get flare-ups, I think that they're they're doing more harm to their body or that their body is getting worse and and deteriorating. And um as as you've described, there can be multiple factors that increase pain intensity. And so that's a really pragmatic way of breaking it down. Has anything changed and and and looking at those different dimensions?
01:16:08.20
Speaker
Thanks heaps, Jonathan. I appreciate your time. i appreciate you taking out the time to to speak to speak with me, but speak to people that are struggling with pain that are listening.
01:16:19.70
Speaker
um Thank you so much and thank you for the work that you do. Thanks, Lachlan. Thanks for having me. If you found today's episode helpful, please follow the podcast and leave a review.
01:16:32.12
Speaker
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