The Complexity of Pain Management: Part 1

The Complexity of Pain Management: Part 1

Pain. We’ve all experienced it. But what is it, really? Today in Part 1 of The Complexity of Pain Management we welcome back Dr Mark Donohoe, who discusses the intricacies of pain: how it’s defined and perceived, the power of the placebo effect, and how a strong therapeutic relationship can be a game changer for a client experiencing chronic pain.

Covered in this episode

[0:20] Welcoming back Dr Mark Donohoe
[1:00] What is pain?
[9:22] The impact of touch, placebo and the therapeutic relationship on pain
[13:40] The power of placebo on pain
[18:01] Discussing the GAIT trial and theory
[21:32] If the brain doesn’t have pain receptors, how can we have headaches?
[25:19] The prevalence of pain in Australia
[27:21] Differences in perception of pain
[32:56] The practitioner’s role in pain management and how to discuss pain with clients

Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook. Joining us in the studio again today is Dr Mark Donohoe who earned his medical degree from Sydney Uni in 1980. Mark worked around the central coast of New South Wales honing his medical skills, and this is where his interest in integrative medicine sparked, because patients just weren't fitting into the boxes of diagnoses and treatments which were drummed into him in medical school. Mark is considered one of the fathers of integrative medicine in Australia, and he's been a vanguard for patient health throughout his whole career. Welcome back, Mark. How are you?

Mark: Well, 1980 doesn't sound that long ago to me, so I'm guessing I'm doing okay.

Andrew: I know. It was better music, you can rest assured of that. Today we're going to be discussing certain facets, there are so many, of pain, and how it affects our patients. We've got to start off though. What is pain? Anything from Lawrence of Arabia, something to know?

Mark: Yes, yes. There is the famous line, "The trick, William Potter, is not minding that it hurts." So, that's one of those great lines from the movies. Pain is extraordinarily difficult, even after 35 years, oh, or much less than that obviously, but even after 35 years in practice, the concept of pain, the subjective nature of pain, “what is pain?” is one of the hardest questions to answer I think after all that time.

Andrew: Yeah.

Mark: We know it's not a sense. Now, generally, you ask people it's a sense of pain, but the senses, the five senses do not include pain, and that's not an accident. The five senses do not include pain and that's not an accident because going right back to Aristotle and before, the concept of pain is that it's an emotion. It is a sense of feeling. It is an experience of the body.

And so, I think the general agreement now is that pain is the experience of something as a threat to the body, a threat of either injury or a threat of damage. But it's the experience of it. It's not the literal thing. And we separate it from nociception. We have this idea that there are receptors around looking all the time for broken bones, for threats to bites from big cats, you know, all these kind of evolutionary things that we understand. Pain serves a very, very good purpose in that, if you've got receptors, just simple little unmyelinated nerve endings hanging all around the body, when things go wrong, when inflammation occurs, when trauma occurs in an area, there's a nonspecific response where the brain does understand that damage is occurring, or the threat of damage is occurring, and the pain motivates the release of chemicals, which we call endorphins, but something which moderates that, which allows the animal, if they're being chased or bitten or whatever, to escape from injury, to get away. So, I think that the idea that pain is an emotion probably goes a bit far, because that allows us as humans to say, "Well, animals can't experience emotions, therefore they can't have pain, therefore we can experiment on them."

Andrew: Oh, but they can experience emotions.

Mark: I know I've got Digby.

Andrew: The famous dog.

Mark: Yeah, my famous Mr Digby. And Digby definitely does experience pain…

Andrew: Absolutely.

Mark: …and definitely does display the same kind of emotional responses as I would in the same circumstances. However, Digby is different than patients. I learned this just in these last few weeks. He traumatised himself, got an ear infection, managed to tread on an oyster, sliced open his foot. The difference is, dogs don't bring emotional baggage to pain.

Andrew: Ah.

Mark: They don't bring a sense of their past, their fears of future pain. They have not the same sense of the future, and the experience of pain is often described as, yes, it hurts, but if my life is going on like this in the future, I can't stand it. And so, the concept of, you know, the dharma life is suffering and that we have a future that we are going to have to work through, there's something about each individual and their response to this stimulus, this agnostic stimulus of threat, of injury, of damage, of harm. There's something about what baggage we bring from our past. My patients who have severe emotional trauma in their past experience pain at a much higher level 30, 40, 50 years later. The baggage of that kind of post-traumatic experience escalates pain.

And something that I found really useful is, what do the senses do? The senses experience the outside world, but we attenuate it. What does that mean? If the washing machine is going the whole time, the auditory sense dampens it down over time, so it becomes part of the background. So, our five senses work in a way that says, "Yes, the world is out there, but the things that we expect, the normal things going on in life, they dampen down, they attenuate, and they reduce." Pain has the opposite response. Pain tends to escalate and the experience of it grows and becomes higher.

Andrew: Amplifies it.

Mark: So, I have many people with sensory hypersensitivity, what we now call central sensitivities. And that central sensitivities one would say the experience of sound does not attenuate, it becomes more and more prominent in the person's consciousness until they describe it as pain. Touch, light touch on the surface of the skin, generally thought of as quite soothing, a good contact for people with that sensory sensitivity, the lightest touch can be experienced as pain.

Andrew: Is this akin or equivalent, or have some equivalence to what's happening in complex regional pain syndrome, CRPS?

Mark: Yes, I think it does. I think it does, and I think that the pain research area, it's unethical to do experiments on humans…

Andrew: Yeah, yeah, there’s the whole thing, yeah.

Mark: …and so that's one of our problems is, you can do all kinds of experiments. We do do ones with photophobia, you know. So, generally, people attenuate to light. If you go out into bright sunlight, the pupils constrict, the whole body dampens down, the perception of light is not overwhelming. But for a lot of my patients and a lot of people who have these chronic pains and regional pains, that's not the case. The simplest stimulus is enough to escalate and escalate. And so, that getting out of control, there are some mechanisms in the body that we have to control like sensory escalation, and there are some that promote it, and I think that what's happening a lot with the patients that we see with chronic pain these days is that it's not simply that there's threat to injury, or that there is damage, or that there is a knee that's showing osteoarthritis. It's that we bring with it expectations and we bring with it a whole extra layer which provides fabulous opportunities for intervention.

So when I was in medical school, pain was all about analgesia. What can you do to stop it? Local anaesthesia, general anaesthesia, what can you do about pain? We had this normally that when people are under general anaesthetic, they could experience no pain because there's no experience. You've just knocked out experience by taking out higher-level functions, but the body reacted exactly the same way as it would in pain, and those people, where the heart rate escalates, where the trauma responses, adrenaline is released from the body. There are many of those people that wake up in that extraordinary pain, while others wake up in no pain at all. So, it's become much more complicated.

I think it's got also complicated by, you know, these illnesses like fibromyalgia where the problem is, we cannot see why the pain arises. We call it functional pain. It's real experience because the only way that we have of measuring pain is, what does a person tell us about their pain? There is no other measure. There's no objective measure whatsoever for pain, and so we can only take what the person tells us as their experience and believe it to be true.

Andrew: But they don't.

Mark: Yes, I know. And the problem with us as doctors is we're very literal people. We like to know that there's a reason for the trauma. Why do we do so many MRIs of the back? You know, a person with lower back pain, we keep on doing MRIs, CAT scans, we keep on scanning people believing one day that we'll see the origin of the pain. Whereas the pain is a much more nebulous thing, it's not found on the MRIs and the CAT scans, and we know that now. We've got really good studies to show that pain is an experience of around about 10% of the population at any given time, but that for 80%, we cannot determine the cause. So the majority of pain we see as practitioners, the majority of what patients tell us, "I'm in pain, I'm in agony, I have sore back, I have headaches, I have all of these things," the majority of times we are not going to find a cause in a very literal sense, so we need to go back into what is your experience of pain? And rather than doling out drugs, and the typical ones, the oxycodone and the opioids, rather than doling out drugs at the first opportunity, go back into the harder question, the thing that takes a bit of time in a consultation, and that is, “what is the experience?” Why is the pain? Rather than, what is the pain?

Andrew: A few things you said earlier on, one of the things about the problematic issues that you have facing creating pain in a patient. So, it's sort of unethical to cause pain. I remember a very old study, I think it was 1966, where they studied the effect of bromelain on periorbital bruising in boxers having an effect.

Mark: Wow, what a study.

Andrew: Yeah. And I thought, "Can I please go into the placebo arm?" The other one you're talking about massage and things like that.

Mark: Touch.

Andrew: Touch. Very interesting research at the Alfred Hospital. And our listeners can look this up in the Integrative Cardiac Wellness Program. And what they found, and this was research led by Frank Rosenfeldt, also Lesley Braun, there was Lisa Stanguts, Ondine Spitzer, and others, but very important, very good researchers. And what they found was that just...now, they couldn't do body massage, cultural reasons, personal reasons, but also because of drips, drains, and cracked chests. So this was in the heart surgery ward. And so what they decided on was merely a foot massage, and what they found was decreases in post-op pain medications by up to 50%.

Mark: We had that experience in a hospital in the '90s when we had chemically sensitive and chronic fatigue syndrome people in hospital. Pain was one of their commonest problems. We put all of our resources, massive brains into detox, what do we do with sauna, what do we do with psychologist? What do we do with everything? At the end of it, we went back and reviewed. We put the survey out to the people who had been through the hospital. The thing that worked best for managing the symptoms and the sensation of pain and distress, reflexology, foot massage being done by my wife at the time as a kind of additional thing.

Andrew: Yeah.

Mark: But it was never just foot massage. There was also the conversation, while you were touching the foot…

Andrew: Yep.

Mark: …while you were massaging, there's an opportunity for interaction, for unloading. It was fascinating to me that we put up things that cost hundreds of thousands of dollars in infrastructure and costs, and at its simplest level, what do people value most? The touch and the talk had a bigger impact on pain and suffering than all of the technologies that we managed to assemble.

Andrew: Compared to say the 1960s, '70s when you had more time per patient, do you think that part of this issue of pain, of myriad of issues with the doctor-patient relationship, less therapeutic response, shall I say, is because doctors are now restricted by time, so therefore they just don't have that therapeutic conversation?

Mark: Look, I may be a grandfather of integrative medicine, but I'm not a great grandfather of integrative medicine. I had very little experience of the '60s and '70s.

Andrew: Though you would have been a patient.

Mark: No. There's a long story to that, which I won't go into, but I was never a patient. But the problem is, I know from the people who taught us at university, that medicine was more leisurely, and that we brought in a Medicare system and we started putting the clock on consultations, the concept of the honorary, the person who would spend the time, not billing them but they would do good and then charge the rich patients a hell of a lot more money. There was time differences between the 1960s, '70s and before compared to after Medicare's introduction. And Medicare overall is a good system for sickness and disease management, and it became very efficient and you can make an argument that medicine has moved on massively since that time, but the relationship, the time, the ability to spend a therapeutic interaction with somebody has definitely disappeared. And, in fact, I think if you ask most doctors these days, they don't think of a GP consultation or a specialist consultation as a therapeutic interaction. They think of it as an administrative interaction that leads to therapeutics. I will see you for five minutes

Andrew: Yes.

Mark: …and then do a procedure, prescribe a drug, do something, perhaps you want...

Andrew: I will take the placebo out of my therapeutic...

Mark: Yes. And we have been far, far too keen to do that. If any area of medicine is open to beliefs, manipulation, cajoling a person into being pain-free, we call it placebo, but we do know that in pain, placebo management is horrifically important. It's really, really important. When the osteoarthritis studies were done, comparing glucosamine with celecoxib, there was this triumphant "celecoxib is better than glucosamine.” The real story was, pain relief occurred in 60% of the people on the placebo, 66% on the glucosamine, and 69% on celecoxib.

Andrew: Yeah.

Mark: What the big story was was that the 60%, the 90% of all value was being done in the placebo arm, not because of anything else we did. The focus on the last 5% is what randomised controlled trials have done all the way through our last 100 years. And the ability to ignore placebo is, “yes, but that's the rubbish, that's not real science.” Medicine is not real science. Medicine is the art of allowing a person to resume function, to return to life, to believe that they have a future, to do all of the things, and I think the discarding of that has been terrible for pain management. But what the doctor used to be able to do, and I still do today, is give confidence to a person that the future is not going to be like this forever, and that, we call it psychic pain sometimes, it's not psychic, it's real experience of pain. The relief that people have just knowing that there is a future is something that you can't do in those 5, 10, 15-minute consultations. We all get busy with, all the randomised trials show that if I give you this, it will be better than that. And I think that we've forgotten, in our medical training, a lot of what used to be the compassion of medicine, the understanding, the bringing a person into that therapeutic relationship, and I believe, in pain management, that is amazingly important.

Doctors can make all the arguments they like, "Oh, you can't do that with heart disease, you can't do that with cancer." I'm agnostic about even those areas because when people's pain and suffering is relieved, it's amazing what patients and clients can do for themselves. In medicine, we almost like don't even want to believe that. We want to believe that we hold the power, we hold the knowledge, and we will administer it without ever really going through that deeper understanding that my interaction with the suffering person in front of me is the number one reason that they are going to experience or not experience pain in their future. And so, I'm a passionate believer that pain is the unacknowledged area of medicine that we keep on thinking that we have a technical answer for, and none of the technical answers work out well, but the therapeutic relationship works out exceptionally well.

That involves trust between patient and doctor. It involves real commitment from the doctor. You cannot fool a pain patient, they are super sensitive to you putting on an act of, "Oh, I believe that you believe you're in pain, darling." Functional pain is very hard for doctors to grab because we can't see the lesion, but when we believe people and work with them and give them a comfort that the future will be different from the past that they've experienced, we do good. When even psychologists see people and go back over the trauma history of the past and undo the traumas that keep on escalating pain in the present, they do good as well.

So, I think the unexplored areas of pain have been that we have an education that says pain is a literal thing. Here's the nerve endings, here's the nociceptors, here's what the cannabinoids do, here's what the opioids do, that we've already bypassed a lot of what the therapeutic value would be. And I think getting back to that is something that naturopaths and traditional medicine has a deep, deep knowledge of. They have a tradition that goes back thousands of years to what does it take when you've got no trick to take the pain away, what does it take to take the pain and the experience and bring it down…

Andrew: Down.

Mark: …take that down from an escalating experience to a more and more controlled feeling of comfort in the part of the person?

Andrew: Just before we move on, a point, where you're mentioning the glucosamine trial, the GAIT trial, for our listeners, it was improperly done. They used a rubbish form of glucosamine and everybody speaks about it the wrong way. They say “glucosamine plus chondroitin sulfate.” What they don't acknowledge is that it was glucosamine chloride, not glucosamine sulfate…

Mark: Yeah.

Andrew: …so they're using the wrong type for weight bearing pain. Anyway, moving on. I will put that up on the website for our listeners. Let's go into the theories of pain though. In 1960s, the GAIT theory was developed, but even the developer of the GAIT theory proposes that it may be on shaky ground in certain instances.

Mark: I think, I mean, the GAIT theory still holds, but it's a spinal theory. There was a point where people were focusing on the spine, the kind of sensory nerves, and the ability to interfere with the way those sensory nerves went. So we have one concept of pain is that there are nociceptors or unmyelinated fibres dotted all around the body looking for a particular type of stimulus. The fascinating thing is, the wrong stimulus doesn't cause pain in different areas. The liver has no pain receptors whatsoever. A very important organ, you would imagine that there would be some receptor for injury there, but the only receptor we have is when the capsule stretches there is a nonspecific pain that radiates to the right shoulder. Very, very minimal areas of pain reception in the gut. There's no sensation of burning. You can put very hot things down there. There are stretch receptors which translate to a kind of burning sense of pain or gripping sense of pain.

Andrew: TRPV1?

Mark: Yeah. And so, you have receptors appropriate to what the organ has run into in the past. If you have stabbing, penetrating injuries in the gastrointestinal tract, you were already dead…

Andrew: Right.

Mark: …all the times up until when surgeons came around. So, nature, it's not that it's insensitive to injury, it's just that there are types of injuries that are not survivable and there is no value in having receptors for every possible pain in every possible organ. Nearly everyone is surprised to know that the brain has no pain receptors. I did neurosurgery. You can put your finger into a brain. There is no sense of pain. There is no receptor for the organ that receives all the information about all other pain in the body. So the body is a strange thing. When it comes to what's the threats that are being looked out for, generally speaking, they're the survivable threats that if you get enough information quickly, and you are motivated by pain with the adrenaline, noradrenaline, with the entire cascade of the hormones of the prostaglandins, all being mobilised in a particular way, then the aversion, the withdrawal response, the ability to get away, the mobilisation of the muscles with adrenaline, these are all things that enhance survival. So pain is not there to make us feel pain. Where that becomes a problem is not acute pain, which is a survival reflex, it becomes a problem when the pain is never ending. Chronic pain is a whole different world, and once we know as doctors that there is no damage to the tissue, then we think of our job as simply giving you a drug that will take away the pain, a kind of pain blocker. And that's I think where our difficulties arise, we pay no attention to, and we give no credence to chronic pain that we can't see the cause for, and so we think of our job as simply give a drug that will eventually stop this person from complaining.

Andrew: So headaches, migraines, we feel it.

Mark: I know.

Andrew: We feel the pain in the head. Where are the pain receptors firing here?

Mark: There may not be any. Migraine is a very good example of what we cannot ever provide evidence for. A person experiences the migraine, what do we do? We ask them about…

Andrew: Light.

Mark: …visual aura, we ask them about sensory, or we ask them about what's going on in the brain, not in the head. And so, there is a big difference. If you get a person with aura, that's a brain perception of something that precedes a migraine. What does that mean about pain? Absolutely nothing except that the aura leads on inevitably many people to the migraine, which is excruciatingly bad. What do we do for migraines? We stop people having nausea and then we give a drug to try and counter it. It's not that much better than putting a person in a dark room with no stimulus and music on. So, the studies on what we could do for migraine...

Andrew: Really?

Mark: Yeah. The studies of what you can do for migraine show that we're relatively ineffective, but you and I both know, Andrew.

Andrew: But Sumatriptan and Cafergot...

Mark: Well, they work in different ways, so, even the caffeine is fascinating. People did go for coffees, but there are mutually exclusive ways. Sumatriptan was a triumph of a way to counteract a migraine once it got started, but it didn't tell us anything about the pain perception, it was just a vascular pathway that we were able to interfere with.

Andrew: Right.

Mark: The issue of placebo is something that definitely has to come in here that what is a placebo treatment? Something that the doctor or the naturopath or the treater believes to be true, that inescapably they convey to the patient. So, placebo effect is not the patient's belief in anything. It's the doctor's belief that something will do good. We became so cavalier at the time of the triptans coming out that they worked like magic while we believed them, so did penicillin for viral sore throats, so did a whole range of things that doctors did.

You asked doctors we are furious about evidence-based medicine because once you have all the evidence that something doesn't work, the doctors belief in the things that did work goes away, and then they stop working. And in pain, that's particularly true. We believed in sumatriptan, it was a triumph of advertising as well. I still have people on the triptans. What they do now is, yes, it's a moderate help, it's not the magic that it was 20, 30 years ago, that time it worked well because it had a lot of placebo response going with it, the new magic pills. Everyone anticipating the relief of their pain. Now it's just part of the normal armamentarium and more often than not, it fails. In fact, we're going back a lot more to amitriptyline, to the old tricyclic antidepressants and exploring those as a preferable way to even the magic triptans.

So, it's more complicated than it seems. I fall for this all the time, you know, say low-dose naltrexone or cannabinoids, they're the new trendies. Will they hold up over time? We don't know. But we know of mechanisms that they may fiddle with, interfere with, and we know that people who know about them believe in them passionately, and that makes pain research incredibly difficult to do. What I was talking about before with pain research is, it's unethical to go and burn people, and burn people, and burn people, and then find out whether placebos work or not. So pain research is stymied in a way that cardiovascular research is in another area of science. So, it's not that we can't research pain, we do it every day in our practices, but what we do, how we experience it, the time we give to a person has a huge impact on the perception and the experience of pain in each patient or client that we see.

Andrew: How prevalent is pain in Australia then? How big is this issue?

Mark: Yeah. Well, we only have a couple of prevalence studies because pain itself, you know, when you say to a person, are you in pain? Do you mean the pain of bereavement? Do you mean heart pain? What do you…

Andrew: Takotsubo syndrome.

Mark: So, the best pain studies that we have, in fact coming from nearly, I think about 15, 16 years ago, maybe even 2001. The pain prevalence study showed that, if you're looking at how many people are suffering pain at the given time, it goes up as the years go by on average over the entire population, around about 10% to 12% are experiencing pain at any one period of time. That's not trivial. That means, you know, two-and-a-half, three million people…

Andrew. Yeah. Yeah.

Mark: …in pain at any given period, and persistent chronic pain when you get to your 50s, 60s, and 70s is around about 25% to 30%. So, I think it's under 30%, I think 25%. The peak in males tends to be in their 60s to 70s. Because females live a bit longer, they have a slightly higher peak, I think of around about 27%, 28%, and that's in their 80s.

Andrew: Huh.

Mark: So women have more of an issue with pain because things wear out in the body, and joints grind on each other, and, you know, falls happen and hips hurt, and the longer you live it seems the more likely you are to do something or have some kind of chronic pain. So it's not trivial, you could probably make an argument that it's 10% of the population. Compared to fatigue at 20% of the population, they’re similar kinds of numbers, it’s a big percentage, but because it sits in the background, because it is so normalised, fatigue and pain and those kinds of symptoms eventually become part of the landscape. We almost assume them to be there once a person gets to 60. We're all a bit surprised when someone says, "Nope, no pain anywhere. No arthritis anywhere," and you're 75 years of age.

Andrew: Yeah.

Mark: I have a short story, a tiny, tiny one, a farmer in his 70s from way out in the bush. His experience was a fall that caused broken bones that had him have surgery, and he went back to the farm and continued to do his farming and bring the horses in on his 65,000 acres, living alone, living alone.

Andrew: Wow.

Mark: His pain was severe, but it was not as severe as letting the horses be untended, and so he would go back there. They eventually put a cast on him to stop him going out. He fell off a little silo, onto his back, four or five beaters broke the cast, and it put his back into place as he said, and he kept on looking after the horses. He had a pancreatitis, a pain that most people would experience as extreme pain. Did it stop him from going and looking after the horses? Not at all. This was, to me, just a fascinating story because this person's expectations are, "I've got the horses to look after."

Andrew: Yeah.

Mark: Not anything to do with pain. Pain was so far out of his mindset that even what we would regard as experimentally severe pain, fractured vertebras, you know, broken bones by the pace, pancreatitis, which people experience as excruciating pain, nothing stopped him because the world that he lived in was a job he needed to do.

And, to my amazement, I went through the testing and thinking, "Oh boy, this is going to look bad when we get our testing back. Pancreatitis exocrine, can't produce anything, malabsorption." No, this was a person whose life experience was, "I've got a job to do. I'm 75, whatever happens from this point doesn't matter to me, I’ve got to look after the horses." So, when I rang him and I'm saying, "Well, the test results are good," he said, "Yeah, yeah," and he's breathless. And I said, "What are you doing?" He said, "Oh, look, we've got rains coming after a couple of years, I’ve got to get the horses," and I'm thinking, there are differences in the way we perceive the world.

Andrew: Oh, yes.

Mark: If you have no room for pain, if life is so full and there are jobs to be done…

Andrew: Yep.

Mark: …and the distraction and the kind of macro GAIT pain theory...

Andrew: What importance you place on pain as to other things that you have in life.

Mark: How does it compete with other things that I need to do? And I find that all the time in my practice that once people have a purpose, once people find, say, the grandchildren, can be quite healing with pain. But the concept of loneliness and experiencing arthritic pain is terrifying for a person who can only see, "But I'm only going to get older and this pain will get worse." Put grandchildren in who jump on them and do all kinds of terrible things that could exacerbate the pain, it is amazing how analgesic that is.

Andrew: Laughter. I am reminded of a few examples. One was a small child who had broken his leg and there was a side ward, right? So there was I think six beds in this side ward, but a TV up one end had a Pac-Man, and this kid was on 75 milligrams of pethidine. Now, this was the days of pethidine, right?

Mark: Right.

Andrew: So, there's maximum dose, still pain, you know, and his pain was six or seven, so it was uncomfortable for him. All we did was swap him into the far bed, into the nearest bed to the Pac-Man. No pain, happy as Larry. Really interesting. The other one was, a friend's dad had a heart attack and when he went in for an Xray, they found a .22 bullet lodged in his chest and he said, "Oh, I wonder. I remember something about that ricocheted off something." And he just placed no importance on it. Whereas me, I go out with a hurting knee. I mean, I go out, seriously, like I did my finger under the sink, you know, just with the plug.

Mark: Yeah. I have one simple parable, which I think is important. In my earliest years, I'd just learned a little bit about homeopathics and Bach flower remedies, these types of things in my practice way back in the distant, you know, the mists of time as you were referring to. And in my practice, up in Erina, a kid came in from the school next door with a broken arm, not a green stick, it was, you know, hanging at quite an angle. I had no analgesics at the time and my naturopath who was working with me there said, "Oh, there's this thing called rescue remedy," and I'm thinking, "Oh, God, rescue remedy."

Andrew: Yeah. Bach!

Mark: The rescue remedy goes to the kid and 15 seconds later he's not crying or screaming anymore. We called the ambulance to take him to the hospital. Ambulance came in, we've got a loose bandage around this arm. They said, "What have you given him?" And I said, "Well, nothing. We just had this rescue remedy," and they said, "Well, he hasn't got a broken arm because, you know, he'd be screaming." They look at the arm, take him to the hospital. A few hours later, a hospital rep came out to get the rescue remedy and took it from our practice, and they were convinced that there was opioids.

Andrew: Right.

Mark: That I had administered a drug without keeping a control. They took it for analysis and in the end what they discovered was that this was 97.5% water and 2.5% alcohol and I got a BT on my hand for giving a person five drops of 2% alcohol. But the thought of my professional colleagues was, this has to have been some drug…

Andrew: Yeah, yeah.

Mark: …because only a drug could do that. The ambulance officers, the same thing. The long and the short of it is one of the ambulance officers came back and started putting rescue remedy in the ambulance just in case it gets a value for the future.

Andrew: Really?

Mark: Yeah. It stayed with this one guy and it was just his little magic trick. But, you know, we still have to come back to what do we do as practitioners about the experience of pain? How do we separate chronic pain from acute pain? How do we separate psychic, you know, bereavement pain from other types of pain? And one of the answers to that is, we just have to accept that the experience of the other person is what we're trying to hook into. It's not an experimental, literal, we cannot do a test to say, "Oh, your pain levels are this." The only test we can do is ask the person, on a visual analog scale, what's your pain levels? And to watch what we do and what we can contribute come into that. There are some good therapeutic options. The big negative one these days is the opioids, the oxycodone and the codeine. They're coming off the list and people are saying, you know, "We've got to get rid of these." They still have their place for acute pain management.

Andrew: Absolutely.

Mark: They’re really, really good, but they're not good for bereavement pain. They're not good for the types of pains which are going to go on for years and years to come. So, that's the area that we find ourselves in now, getting off the drugs and moving onto something that is sustainable and isn't going to escalate and destroy the person's life.

Andrew: What about the practitioner judging the patient? I.e. probably the best example that comes to mind here for me is endometriosis. How many women are poorly managed, misdiagnosed, not diagnosed for years, not believed for years until something happens? Their pain is very poorly managed,

Mark: Yeah.

Andrew: And they try and speak to their doctor about, "I am in pain. I can't function." And there's this total misbelief. I was speaking with Donna Ciccia about this from Endometriosis Australia, and, I mean, you can hear the frustration in her voice. How do we get over that practitioner judging the patient?

Mark: Yeah.

Andrew: What skills can we give our listeners so that they can be better practitioners?

Mark: One of the issues, endometriosis is a good example of misogyny in medicine,

Andrew: Yes.

Mark: You know, the hysterical pain, the hypochondriacal pain. We have these concepts of women somehow experience things that we, real men, who know what literal things are, don't experience.

Andrew: Except for me.

Mark: Yeah. And except for me and except for every other person as well, so that there is a cultural issue with medicine that takes, you know, a couple of generations to get it out before we start to hear people and not prejudge them before they've even said their first words. One of the issues for practitioners is feelings of powerlessness. If you can do nothing, you stop hearing the person's complaints…

Andrew: Yeah.

Mark: …because you don't feel competent to be able to relieve that person's complaints, that leads to isolation in that therapeutic relationship. So one of the very important things is for all practitioners to feel confident and competent in what they are going to do to advise people, all the way from the simplest things. Can this person exercise? Can they move their muscles? Can they do yoga? Can they do simple things of mindfulness that are going to change the perception of pain itself? Because we have no objective measure. The only measure we have is the experience and the expression of the person before us. And it is a thousand-year history, or 5,000-year history of a male-run profession, a masculine type of literal profession denying the experience of especially women and prejudging it, well, what can you do about it? Nothing. Therefore, "Oh, come on, grow up. You know, if you just didn't experience it so much here, are you sure there's anything there?" We make ourselves feel better often at the expense of the person who we belittle. So, the education of practitioners about, there's much more to do for pain than you ever imagined, especially if you have the training that we doctors have, where we think we're dependent upon the dosage, the precise milligram dosage of drug, the morphine-equivalent dosage charts.

We pay so much attention to that, that we lost sight of the very things that now we understand make a much, much higher difference. The therapeutic relationship is the start, but the finding of the motivation of the person, what brings this person alive? What brings them out of the fearful constriction that pain applies to a person and expands their horizons to pain-free abilities that they can do something about? Yoga is a tricky one because there are some people with pain where the assonance of yoga is still a problem, but yoga is not just the assonance. Yoga is the breath, is the experience and the ability to finally move into a meditative response, for the pain not to carry with it all the emotion that the Aristotleian version of pain is about. If you don't carry the emotion, pain is relieved significantly. Not completely, but you can get significant reduction in pains just by taking what's the emotions that are correlated with this and how do we ease those emotions? You can bomb a person out, you can give drugs, and I have done this a thousand times, and I regret it. Well, every time that I think when the person say, "But give me something for my pain," and they're not willing to hear or care, how about we try mild exercise? How about we try meditation?

Andrew: This was going to be my next question. The converse. The difficult conversation about, can we explore other options?

Mark: Yeah. Well, that's because medicine created a world in which there is a pill for everything, and once you have that as your primary belief system for an entire population in the first world, you know, in Australia, America, Britain, in Europe, we have an expectation that pain is just the thing that should be optional and we have taken away. We have lost the concepts of what's the meaning of the pain? How much do I carry from my past? How much of the pain I experience now is the unexpressed trauma from when I was a kid abused by alcoholic parents? We have to go back into exploring those. What does it take? Time, empathy, touch. Incredibly important in pain that the majority of people that I see no longer have any sensory input. They no longer have touch as a way of relieving pain. When a person touches another person, there can be an initial withdrawal response from people who are in pain all the time, that it's almost like, "Don't touch me, you know. I am unstable here." But eventually, the therapeutic touch is unbelievably important in releasing those endorphins and in mobilising the pain-relieving response. An isolated human experiences pain completely differently to a person who is experiencing touch the whole time. So, those basic things, massage, touch, loving, sex. Sex is one of the best pain relievers we know, but people...

Andrew: Not with your patients.

Mark: No. No. Thank you for that. A clear reminder.

Andrew: A clear reminder.

Mark: Yes, yes. But sex has an ability to mobilise so many different hormones, and sex does not necessarily mean intercourse, but that whole thing of loving touch, of sexual contact with a person, a lover, or a partner, those things make massive differences compared to the strongest of the drugs that we have.

Andrew: And vice versa. The isolation. You know, the isolation can amplify pain and things like that.

Mark: And I think, if there's one thing we can offer today is, that is, if you amplify any sensation, it becomes pain. sensation amplified, a withdrawal even from foods, right? One thing that I've found is, people find restrictive diets, "Oh, they relieve some of my symptoms," but they put people into a sensory kind of dead-end, that if you always have food as a fearful, restrictive thing, then your world restricts chemical sensitivity. You restrict your world. Once your world is restricted, all stimulus starts to become on that verge of painfulness.

Andrew: So this is the mashed potato and peas brigade. The people that have restricted all sorts of foods down to the lowest common denominator, if you like, and now they're sensitive to everything.

Mark: Yes. And so they're sensitive to food. Some are sensitive to sound, some to touch, some to chemicals, petrochemicals and the like. So, the fearful withdrawal after many years of putting people through this, you know I did restrictive diets, we did, you know, chemical-free homes, but the fact is that, as you restrict all sensory input, what's leftover starts to become experienced as an escalating pain, and we don't think of it as pain as in nociceptors out there experiencing shortage of food, it's just that now more and more foods that should be nutritious and good for the person start to become a problem. The anticipation of adverse reaction starts to become a problem. It's important that people be able to re-emerge into their world and be pain-free with the life that they wish to live. Not pain-free on the drugs that put them to bed and prevent them from leaving their room, and leave them with migraines in dark rooms half of their life.

So, this is not a prescription. It's, if you are before a patient or before a client, and that client is describing a constrictive life with the fear of the future, with pain becoming the dominant sensation and escalating with less and less sensory input, then our job is to reverse that. You can use tools like cannabis. People find cannabis does that very, very well. Low dose naltrexone, there are tricks and there are tools that can be used temporarily which switch on the kind of, the endogenous opioids, the met-enkephalins and the like. There are tricks that we can do to start their process, and I think that that's important. In the herbal area, there are lots and lots of good herbs from headaches and they're very, very restricted periods of time of use. Where our problem arises, I believe, is when we think of things that work in the short-term being very useful for the long-term. So if we keep with our patients and our clients saying, "Here's a short term answer that can give you some relief while we move to a longer-term and sustainable answer, can you do yoga? Can you do mild exercise? Do you have the opportunity for touch with, in a relationship with a person?" Or if not, can therapeutic touch be used to relieve the pain, that mobilising the endogenous pain relief is important, but de-escalating so that there is not a fear of every new stimulus setting off ever more pain off into the future.

Andrew: So you've got the people that just have not got time for pain.

Mark: Right.

Andrew: They're the people, you know, you don't seem to have to worry about.

Mark: They may still need pain relief, but, yes, you don't have to worry about that escalating off into the future.

Andrew: Amplification of pain. Then you've got the people that already expect...They're in pain, their pain is amplified by some factor, but they expect a pain relief thing and they may not be open yet, he says, to other forms of therapy which might decrease that amplification.

Mark: Yes.

Andrew: Then you've got the people that just say, "Help. I'll do anything. I'll do everything. Help"

Mark: Take away my pain.

Andrew: "Take away my pain." So, the problematic one is the one in the middle here, they just want a pill. They just want it now. They just want to go away. How do you have that difficult conversation to say, "Look, yes, there's a quick fix, but it's a quick fix for now, and you're back next week. Are you interested? Where are you at? Can we investigate? There is evidence for…

Mark: Yeah.

Andrew: …pain-relieving therapies which are not drugs which have effect, which have efficacy." How do you open that conversation in let us say the closed patient.

Mark: You ask easy questions at the end of every podcast. I think that these are the ones that could be explored forever. But, if the initial discussion with the person is, “you don't need a pill in the long-term, you need a sustainable solution” which is going to de-escalate, have that pain diminish not in an hour but in a month, a 6-month and a 12-month period. You need to, in effect, get younger and get less pain as that time goes by and make it clear that most of the short-term fixes are exactly what they are, for short-term fixes. They are a way to get to the other side of pain occupying all of your mind. And people go down that path because...A friend of mine said this, when you're in pain, the only thing you think of is pain. When you're not in pain, everything else is an opportunity to think about. What we have to do is invade that mind with other things to think about, with, not just distractions, this isn't a Sudoku, or play a bit of chess, it is, what's the meaning for you?

Andrew: Right.

Mark: What will motivate you to want to be pain-free and to live a life pain-free, to imagine that life pain-free? Visualisation could do it for some people. I tend to use literal things because I'm a doctor, I tend to use things like low-dose tricyclics, amitriptyline. People get the experience of, "Oh, that's not morphine, and it worked."

Andrew: Do you find, in that state, in their pain-free state, or the lessened state then they're more open?

Mark: They are. They're definitely more open, because one of the things that happens in my practice, which doesn't happen in most is, people are on drugs that they've been on apparently successfully, they come to me to get off them. And the question is, yes, I can take my codeine, my 10 codeine a day, and I feel like I'm out of pain, but I don't like it. I don't like the constipation. I don't like the adverse. I don't like that I am doped up for the whole time. I can't experience any joy in life. I am pain-free but neutral, rather than living a life where the pain is peripheral to anything that I'm experiencing otherwise. So I do have the job of taking people off those drugs, and it's a really tricky thing to do. I think that that's a worthy of an entire podcast. If we go through the literal side of pain, what are the tools? What are the simple things you can do to get people from "My only focus is pain," to, "Okay, pain is manageable, where do we move it now?" And that's where the discussion really does take place. People, males of 70 years of age become open to the idea of meditation. I'm too young for that to have happened to me yet, but, you know, in the future I rather hope that those will be my futures.

But, meditation, mindfulness, yoga, acupuncture. Acupuncture is incredibly valuable as a starting point.

Andrew: Oh yeah.

Mark: And the whole thing of this sham acupuncture versus real acupuncture, the job is not to do trials. The job is to find things for an individual that are effective in allowing them to re-enter the life pain-free. Acupuncture works brilliantly for person after person, and then the next person I think it will work for nothing, just nothing happens whatsoever. What works for that person is, "Oh, but I've taken to walking and I've got a dog," or, "I've got a cat,"

Andrew: They’ve got meaning…

Mark: …or, "I've got a pet cockroach," and provide meaning, provides a way of a person moving from the experience internally that escalates, to a de-escalation of that and a meaning outside.

And so, I am a big fan of even simple things like pets, visiting the grandchildren, family, eating meals at the same time with the family members, love, affection, cuddling, contact. They have a powerful effect on pain, but no drug that I've ever prescribed has ever done. And so, that ability to move from things that are not all that effective and have a lot of side effects, to a life in which pain is still there, but I don't mind. The mind plays the part there, and that idea of T. Lawrence of, "Yes it hurts but only if I pay attention to it." Where is my attention? Somewhere else in life. And if I can provide, as the doctor, that other thing to place the attention on and give the person the confidence that they are not going to be experiencing this for the next 30 years of their life, then the pain goes back to its normal position, de-escalated. Yes, it's there, but it doesn't dominate. It takes the person out of themselves and back into the life they want to live.

Andrew: I love. I'm looking forward to inviting you back for our next podcast where we'll delve into some of the therapies that you employ to relieve pain.

Mark: Yeah. The tricks.

Andrew: The tricks.

Mark: The tricks that get you across the first hurdle or two, and then the long-run is...

Andrew: But of course, I think the foundation in any practitioner relationship should be one of pure, purity for you, for the practitioner. And in your case, it's care, you know, and I thank you for that. Thanks for joining us on FX Medicine today.

Mark: Been a pleasure again.

Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook.

OTHER PODCASTS WITH MARK INCLUDE:

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