Chronic Pain - Is it All in Their Head? - Daniel J. Clauw M.D

hello everyone my name is Dan Clough I'm a Rheumatologist here at U of M I lead a large pain research group and I give these talks every couple weeks to chronic pain patients their friends their family members to try to help people that have chronic pain better understand what we now think causes chronic pain what is some of the underlying causes their mechanisms for chronic pain are and even more so to try to give you a sense of the types of things that you can do as a patient to manage your own pain in a lot of other areas of Medicine we have been much more aggressive about trying to involve patients in their own management or in their own care conditions like diabetes would be good examples of for twenty years we've been teaching people about diet and exercise and things like that so that they really are involved in helping manage their illnesses and that really has crept into the management of most chronic medical illnesses except chronic pain we generally don't do a very good job of teaching people with chronic pain some of the things that they can do on their own I mean it's turning out as the pain field is have evolved over the last couple decades a lot of the most effective treatments for chronic pain are not drugs they're not procedures are not surgical interventions but instead they're things that you can do on your own they're things that we used to be somewhat dismissive of with respect to whether they worked or not for paying acupuncture yoga tai chi different things like that and so what I really want to try to do today is give you probably a different view of the chronic pain field and you're coming in thinking of and one of the points of emphasis I'm going to have today is to talk about our understanding of what causes pain and of the fact that a lot of chronic pain is not a problem in the area of the body where the person is experiencing pain it's actually more so a problem with the volume control setting in the brain and when your value control setting in the brain is set too high the nerves throughout your entire body become more sensitive and you feel pain in different areas of your body even though there's nothing wrong in those areas of your body and these conditions of which fibromyalgia would be the poster child but these would include conditions like temporal mandibular joint disorder irritable bowel interstitial cystitis vulvodynia a number of pain conditions that are actually quite highly prevalent pain conditions headache would be another example of this where again what our current thinking is that the problem isn't in any way in the area of the body where the person is experiencing pain it's fundamentally a problem with the volume controller the amplifier setting in the brain and I'll talk about that at great length I'll actually allude to this type of pain being brain pain and contrast that with pain that might be you know coming from your knee and due to a problem in your knee but what I'll really talk a lot about is that same pain in your knee can either be coming from a problem in your knee or it can be coming from a problem with the volume control setting in your brain or some combination of both but what we've learned is that if that pain in your knee is coming from your brain the drug and the non drug treatments that are going to work are entirely different than if that pain in your knee is coming from your knee and most of the drug and non drug treatments that are used in the United States to treat people with chronic pain our treatments that work well if your pain in your knee is coming from your knee but aren't going to work very well at all if your pain in your knee is solely or somewhat coming from this increased volume control setting in your brain I do a lot of consulting with the pharmaceutical industry the University of Michigan mandates that we always show a disclosure side when we're giving a talk of any potential conflicts of interest that we have this slide reminds me to say something that I feel quite strongly about because I am one of the leaders in the field of chronic pain one of the big problems we have in the chronic pain field is simply don't have really effective drugs compared to other diseases or other medical conditions where there really have been fairly dramatic advances in our last 20-30 years you can tell that I'm old I was trained as an internist in the late 70s or they're in the early Simon in the late 80s and so I vividly remembered that the drugs that we had available to treat high blood pressure high cholesterol coronary artery disease and things like that we're actually only marginally effective in the 80s we had a couple classes of drugs a lot of people with those conditions we weren't able to manage very well but in all of those fields there have been fairly dramatic advances in drug therapy lipitor to treat high cholesterol a number of new diabetic drugs that are aimed at different elements of diabetes a whole host of new drugs to treat high blood pressure but but again those advances in those fields in fundamentally better drugs led to fundamental improvements in our ability to treat those illnesses there have not been any comparable advances in the pain field and in fact a lot of the drugs that we're using the pain field are derivatives of drugs that have been around for centuries opioids have been around for centuries okay and and cannabinoids I'll talk a little bit about medical marijuana and cannabis for use in pain has been around for centuries even the non-steroidal anti-inflammatory drugs have been around for a long time and are all derivatives of aspirin which came from willow bark a long time ago so a lot of the drugs that we're using our really old drugs that are only marginally effective and only work in some of the people that we give them to and thus it becomes even more important for people with chronic pain to embrace the use of these non drug therapies because if the drugs alone aren't effective enough to manage the pain then you're going to have to move over to some of these non drug therapies and again I'll talk a lot about how the best management of people with chronic pain is incorporating the right drugs and Percy years for the right kind of pain but all people with chronic pain all patients that have chronic pain should be using these non-drug nonpharmacologic approaches they really should be the foundation or the bedrock of what you're using to treat your chronic pain and then add the drugs and add the procedures where they can be helpful but don't think of the drugs or the procedures as being the do-all or end-all because that will be a pretty frustrating path for you as a chronic pain patient if you're just waiting for that next drug that the next doctor is going to prescribe for you that it's magically going to take your pain away it doesn't happen that I if it did I wouldn't need to be giving lectures every two weeks and we wouldn't have to be doing so much work into the fundamental mechanisms of pain so that we can develop new drugs that are attacking those mechanisms the other thing that I always remember when I show this slide is I'm going to talk about medical marijuana briefly I went to the University of Michigan in the 1970s and and I did smoke recreationally in the 1970s I'll talk a lot about the difference between recreational use of marijuana which is what I was doing in the 1970s because I was trying to get high and medicinal use of marijuana where we're actually trying to not have people get high that the the goal if someone is using marijuana medicinally is to find a dose that controls their pain that doesn't make them high but having said that I actually think it's useful for me to at least acknowledge that on my conflict slide as a theoretically someone that didn't go to the University of Michigan and wasn't this bleeding liberal that I am might have a different view of medical marijuana but I'm really going to be talking about the science and data surrounding cannabis and marijuana and pain not about my experience as a recreational user thirty year or two years ago now I start all of my lectures that I ever give anywhere to big audiences at scientific pain meetings or to these lectures here by showing this slide because I think it's in a very important point you can't see pain on an x-ray or an MRI and there's no chronic pain condition where anything we see on an x-ray or an MRI tells us that person's going to always going to be experiencing pain or that person's not going to be experiencing pain or look at the x-ray and say this person is going to have severe pain versus this person having no pain there is no chronic pain condition where what we see on an MRI or an x-ray accurately predicts who's going to be experiencing pain or how severe the pain is going to be now the disease I'm going to talk about today to use as a metaphor along these lines is the disease called osteoarthritis osteoarthritis is by far the most common cause the chronic pain because it is the type of arthritis that almost all of us will get if we live to be old enough almost all of us will develop osteoarthritis in weight-bearing joints like the knees or the hips if we live to be old enough and because of that osteoarthritis is sort of the 800-pound gorilla in the pain field is it if you look at the entire population including the elderly population that osteoarthritis is usually the most common cause of chronic pain but the way osteoarthritis was conceptualized 30 or 40 years ago when I was first trained as a Rheumatologist is that the more destruction of the joint that someone had this is a knee joint this is an entirely normal knee joint that big black stripe means the person still has cartilage at the end of their femur or at the top of their tibia because cartilage doesn't show up on an x-ray whereas bone shows up his wife so when we see that big black stripe as a Rheumatologist we like that because we know that there's still a lot of cartilage there and again theoretically that knee is not supposed to hurt that's an entirely normal knee x-ray this knee is supposed to always hurt person has totally lost their cartilage they have bone rubbing against bone and this is always done going to lead to pain problem is that's totally false forty percent of people in the United States that have an x-ray that looks like this have no pain whatsoever they have lost all their cartilage they are bone rubbing up on bone but they're not experiencing any pain or any symptoms whatsoever and ten or fifteen percent of people with severe knee Payne will have an x-ray it looks like this there's nothing wrong with them and and by the way one of the reasons that the title of my talk chronic pain is it all in their head is that many of you unfortunately have been told over the course of your lifetime you've come in with pain someone has done an x-ray and they saw an x-ray more like this than an x-ray like this and they said something like there's nothing wrong with you it's all in your head but they've sort of implied that you're making up the pain because they can't see it on an x-ray again I'm one of the leading pain researchers in the world let me tell you there's no chronic pain condition where what you see on an x-ray or what you see on an MRI can tell you whether the person's experiencing pain or not there is always a tremendous disparity between what we see on an x-ray or an MRI and whether people are experiencing pain and the disparity goes in both directions it goes in the direction is that you would expect this person to have pain and they don't and you would expect that person to not have pain and they do so why is that why so one of the analogies that I began using about six or seven years ago by the way I try out most of my new material and my talks on you guys in my patient talks before I go out and give my doctor talks in my science talks but I use all the same slides to talk to patients as I do to use in my scientific talks I mean this is an analogy that I came up with about six or seven years ago that seems to be helpful in allowing people to understand what I'm talking about when I'm talking about the role the brain has in sort of controlling the volume control or the setting of pain and the analogy that I'm going to use now is that the amount of pain that a person is experiencing is akin or analogous to the loudness of an electric guitar and so there's two ways you can get an electric guitar to be louder you can either strum the strings harder and then thus it'll be louder or you can turn up the amplifier and if you turn up the amplifier it's not just a single string that will be louder all the strings that you strum will be louder if you turn up the amplifier on an electric guitar so what's the analogy to human pain well the brain and the spinal cord which we call the central nervous system are analogous to the amplifier setting on an electric guitar whether you're going to feel something that's going on in your knee is partly what's going on in your knee but it's partly what is your amplifier setting in you as a person if you happen to be born with a high amplifier setting such that you're you are more pain sensitive you feel pain with the amount of pressure or the amount of heat or cold that someone else wouldn't necessarily experience as pain and that the fundamental problem in you is that your amplifier is turned up then you'll feel more pain anywhere in your body and because these strings on the guitar are analogous to the nerves that you have going to your muscles and your joints and your bones and things like that if the amplifier is set too high strumming any of these strings will lead the guitar to be louder than it would be if the amplifier was set at a normal level or set at a low level and in fact this really helps explain a lot of this variance between what we see and an x-ray and whether the person's experiencing pain or not so I'm super imposing the knee on the guitar because that's the analogy that I'm using here is that the nerves that are going to the muscles and the bones and the joints of the knee are bringing information from the knee to the spinal cord in the brain but whether you feel what's going on in your knee as pain or not is just as much due to what your amplifier is set at as what's going on in your knee and that helps explain why a lot of people that have a lot of stuff going on in their knee 40% of people that have a knee x-ray like this don't hurt because these people have a low amplifier setting these people are inherently pain insensitive and thus even though they have a really gnarly looking knee x-ray and there really is something wrong with their knee they don't feel any pain but the people at the other end of the continuum are people that have missions like fibromyalgia irritable bowel vulvodynia temporomandibular joint disorder all of these conditions now that are thought to be much more so a fundamental problem with the volume control in the brain and even though you're at the time that you get those diagnoses like irritable bowel or vulvodynia or interstitial cystitis you have pain in the abdomen or the bladder or whatever that's not where the fundamental problem is in those conditions the fundamental problem when people have those conditions is really now thought to be much more so a volume control setting and in fact the National Institutes of Health in the United States a couple years ago basically came up with this new label called chronic overlapping pain conditions and what they said is conditions like fibromyalgia irritable bowel interstitial cystitis endometriosis they have eight conditions that fall under this label of chronic overlapping pain conditions that what we've learned is that those are all really the same fundamental problem in the brain but people get labeled with the the label that implies that the problem is in the area the body or the persons experiencing pain so they get labeled with irritable bowel syndrome they get labeled with interstitial cystitis because it's in the bladder they get labeled with TMJ syndrome because the pain is in the jaw but that isn't where the problem is that in those conditions the reason the nih came up with this new umbrella term for all of these conditions is the problem in all of those conditions is now really thought to be one fundamental problem in the volume control setting in the brain and so it's very common for people over the course of their lifetime to be given two three four or five of those labels because it's just the first area of the body that your pain showed up in is the first label that you'll get if it turned out that when you were 15 years old the first chronic pain condition that you experienced was painful menstrual periods then the label you would get would be primary dysmenorrhea as if the problem was in your uterus but then two or three years later you had pain in a different area your body a couple years later you had different Erte in a different area buddy and and what we now have come to see is the people with these chronic overlapping pain conditions have one fundamental problem which is in the brain that happens to be manifest in different areas of the body over the course of their lifetime and it's really important to put that together because once you realize that this is one problem in the brain rather than the person has five different problems in different areas of their body that they have to go to different sub specialists they're in charge of that area of the body to control these symptoms once the person realizes that there's a fun one fundamental problem that needs to be dealt with you can dealt with deal with it better and you have a better sort of understanding of where the fundamental problem is and where this problem needs to be attacked rather than thinking it's these are different pain conditions that need fundamentally different treatments because the pain is in different locations in your body so this is just showing a lot of what I have already said verbally is that there's a terrible relationship and askew arthritis between an x-ray and whether people are feeling symptoms or not we've historically blamed psychological factors when we say see that someone has pain that we can't see on an x-ray but what we've learned is that these aren't psychological factors different people just happen to have different volume control settings with respect to how pain sensitive they are and the more pain sensitive you are the more pain you're going to have over the course of your lifetime irregardless of what your x-ray looks like if you have an x-ray like the one on the right you'll have more pain than the one on the left but now in the pain field we understand that we sort of have to add together when we trying to figure out why someone's experiencing pain in their knee or pain in their shoulder or pain in their elbow we have to add together what's going on in that area of the body Plus what is there superimposed volume control setting and if they have a high volume control setting they don't have to have anything wrong in that region of the body in order to have pain and this is why some of you have failed to respond to classes of drugs like non-steroidal anti-inflammatory drugs and narcotics and opioids actually work well for pain that where there is something wrong in your knee you've had you broken your leg you have a certain you had a recent surgical procedure drugs like non-steroidal anti-inflammatory drugs and opioids work really well for that kind of pain but if your pain in your knee is not coming from your knee it's coming from your brain non-steroidal anti-inflammatory drugs won't work opioids won't work injecting your knee won't work and doing surgery to replace your knee won't work because your fundamental problem isn't in your knee and this is why a lot of you have had a lot of these therapies that have been ineffective is that one of the first things that you can tell that someone's pain isn't coming from their knee and by the way I'm using the knee as a metaphor as any random location in the body is that when you're giving drug and non drug therapies that are targeting the knee and these fail to work that's one of the ways that you can say huh maybe the problem isn't in the knee maybe the fundamental problem is a brain volume control problem and we've been using all the wrong drug and non drug therapies because we've really been targeting the wrong area of the body with respect to what the underlying problem it turns out that when I was trained as a Rheumatologist 30 or so years ago our view of osteoarthritis of the knee was it was the classic peripheral pain condition we didn't know anything about the role the brain was having in controlling who has pain and who doesn't have pain and we actually thought that some of these drugs actually worked in almost everyone with osteoarthritis non-steroidal anti-inflammatory drugs NSAIDs drugs like ibuprofen naproxen celebrex would be the drugs that you'd be familiar with or opioids actually don't work any better to treat osteoarthritis then the drugs that have been approved to treat fibromyalgia work in fibromyalgia drugs that you would know as lyrica which is pregabalin or cymbalta which is duloxetine that all of these drugs are only modestly effective and so going back to what I said when I showed you this disclosure slide one of the problems we have in the pain field is all our drugs sort of suck all our drugs none of our drugs are very effective compared to the effectiveness of drugs we have to treat other chronic medical illnesses and therein lies a big problem if you as a patient think that you know because your hypertension can be managed entirely with drugs your pain can be managed entirely with drugs it can't we we simply don't have effective enough drugs most people with chronic pain are not going to get really good improvement of their pain if they rely on drug therapy alone and I wish that weren't the case but it is the case if we didn't know for sure that the knee wasn't the problem 30 percent of people with osteoarthritis of the knees that have their knee replaced don't get any better 30 percent of people with osteoarthritis of the knee that have knee replacement surgery don't have improvements in their pain like many of you probably have had one or more surgical procedures or injections that were thought to relieve your pain but didn't relieve your pain because maybe your pain wasn't coming from the area that they did surgery on or the area that they injected it was in fact coming from your brain and that's not what they were injecting or doing surgery on so the other condition that I'm going to talk about today is a metaphore is about is fibromyalgia because fibromyalgia is the first chronic pain condition that we recognized was a volume control problem and now every pain condition we recognize has a subset of people that have an element of fibromyalgia they have a high volume control setting but fibromyalgia literally was the first condition where we realized in our research group is the leading research group in the world in fibromyalgia we did a lot of those brain imaging studies that legitimize fibromyalgia and turned it from this condition that people thought there's nothing wrong with these people they're just neurotic middle-aged women that are complaining too much to being a legitimate disease that we showed on functional MRI and functional brain imaging that the fundamental problem in fibromyalgia was this increased volume control setting and the people with fibromyalgia are tender all over because their nerves throughout their entire body are more sensitive and we used to diagnose fibromyalgia by Counting how many tender points people had any of you can ever have a tender point count performed okay so the old way of diagnosing fibromyalgia was we counted how many areas of tenderness people had there's 18 tender points and we counted how many areas of tenderness people had tender point counts are totally stupid the whole person's tender it doesn't matter where you push on someone with fibromyalgia if you push on the thumbnail of someone with fibromyalgia they're more tender than someone without fibromyalgia now if to show you how stupid this is now we realize that these areas that we were calling tender points are merely areas where everyone's more tender everyone's more tender in the mid trapezius region I know we're exactly where this tender point is in the mid to previous region I can walk up behind any of you and bring you to your knees by point by pushing with one finger because this is this is but if you push to like an inch over to the right or an inch over to the left it doesn't hurt hardly at all this is just an area because there's a lot of nerves in this area the body that is more tender and everyone in fact all of these eighteen areas of the body literally are just areas that are more tender in every one and it wasn't until about 20 or so years ago that our group and others showed that people with fibromyalgia tender throughout their entire body and that helped show that the fundamental problem is likely to be in the brain if people are tender everywhere in the body no matter where you push whether you push on a thumbnail over muscle over a bone over a joint then it was starting to make sense that the fundamental problem must be that the central nervous system which controls sort of the volume control setting in pain is set to high because that's really one of the only things that could cause someone to be tender anywhere in their body is that if you turn up the amplifier rather than thinking that you're strumming all the strings really hard constantly all the time and that's literally the essence of fibromyalgia now is it's really thought of more as a final common pathway because people with any type of chronic pain whether you start out with neuropathy pain or rheumatoid arthritis or osteoarthritis that even in those pain conditions where there is something wrong out in the periphery rheumatoid arthritis is an autoimmune disease there's inflammation in the joints but about 30 percent of people with rheumatoid arthritis or osteoarthritis in addition to having something wrong in their joints has a high volume control setting so these people with rheumatoid arthritis and osteoarthritis we have to treat them in two different ways we have to give them drug and non drug therapies that are going to reduce the inflammation in their joints but we also have to give them drug and non drug therapies that are going to turn down the volume control because if we don't then it looks like their rheumatoid arthritis is still not really well controlled because even if we get their inflammation under control by giving them these really new good drugs we have for rheumatoid arthritis again another set of diseases that has been revolutionized in the last 20 years are all these new injectable drugs we have to treat all of the autoimmune diseases but about 30 percent of patients with these autoimmune diseases like lupus rheumatoid arthritis psoriatic arthritis don't get much better when we bring their inflammation down to zero with these really powerful drugs because we haven't treated this other component of their pain which is the high volume control component of their pain that wasn't recognized and wasn't addressed and so this is the way that we now think of pain that there are three underlying mechanisms that can cause pain and until about 20 or so years ago we only knew about these two mechanisms and what I'm really going to talk more about is central pain or brain pain that's coming from the central nervous system more so than the nerves or from the knee and the characteristics of that pain are different than the characteristics of pain is coming from the knee or coming from the nerves and the treatments that you have to use are quite different as well because there are treatments that work in the brain not treatments that are working in the knee or working on the nerves so let me go through each of these characters these different types of pain so nociceptive pain is the scientific term we use when pain is coming from your knee there's something wrong in the in the peripheral part of your body in a joint in a bone in a ligament and a muscle and there that pain is occurring because there's something wrong in that area the body there's either damage or inflammation of that area the body if you have that kind of pain the pain you can actually localize the pain very well the location of the pain will be consistent from one day to the next or from one week to the next and there will also be a consistent effect of activity on that pain most types of pain in your knee get worse when you use your knee and get better when you don't use your knee so if you have no susceptible be able to localize it fairly well you'll be able to show with one finger exactly where in your knee it's coming from and you'll be able to say my knee always hurts after I walk more than two blocks or after I climb three flights of stairs because the pain is occurring because you have overused that damaged or inflamed area the body and that area the body is sending a signal to your brain stop doing that you could be hurting yourself now nerve pain has been known for ever nerve pain is when there's either a pinched nerve or a damaged nerve and I didn't I keep forgetting to put this on my electric guitar slide but then the nerves would be comparable to the cord that is going from the electric guitar to the amplifier is it if you cut the cord or you pinch the cord or you damage the cord that that is a theoretical cause of pain and that is essentially nerve pain is that there's something wrong with the nerves throughout our body because we have long-standing diabetes because we develop the herpes zoster because we have a pinched disc in our back or a pinched nerve in our wrist and we develop either sciatica or carpal tunnel syndrome but this is nerve pain and nerve pain has its own unique set of characteristics number one nerve pain will usually follow the the distribution or the pattern of sensory nerves so most types of nerve pain will be primarily in your feet and your hand because that's where nerves end and that's where the pain starts is at the end of the nerves not at the beginning of the nerves so most types of nerve pain will it be in what's called a stocking glove distribution ie will be felt worse in the hands and the feet and then as it progresses maybe people will have nerve pain that moved into other areas of the body but most types of nerve pain is either in a stocking glove distribution or it is in the distribution of the nerve that is being pinched so if you have a pinching of your median nerve as it goes through your wrist that's called carpal tunnel syndrome and you will only have pain and tingling in the fingers that that nerve goes to you won't have to pain and tingling in all five fingers in your hand you'll have pain and tingling in this side of your hand because that's the side of your hand that the median nerve goes to if you have sciatica because you have a nerve pinched as it's coming out of the bottom part of your spine you'll have radiating pain down the back of your leg all the way down into your foot because that's where that nerve goes but but again nerve pain can be distinguished from nociceptive pain both by the location and by the characteristics of nerve pain people will often feel it's burning it's tingling that they feel electrical shocks and things like that those are the characteristics of nerve pain so but this third type of pain has really only been recognized in the last couple decades or so and this would be the type of pain that our research group has been most prominent in teaching the rest of the world about I mean this is central pain or brain pain where the fundamental problem is an increased volume control setting now this pain is different in subtle ways than either nociception so let's go back to the knee again if you have pain in your knee that is occurring because your brain volume control is set to high not because there's something wrong with your knee but your pain in your knee is occurring because your brain volume control is set too high I will tell you a couple characteristics of this pain number one is you won't be able to localize it nearly as well as if it was coming from your knee if I asked you to point with one finger where and you knew you hurt you probably would draw a big circle but you wouldn't just point with one little finger and say that it's in this exact location the location wouldn't be nearly as consistent from our to our day-to-day week-to-week if your knee pain is coming from your brain as if it's coming from your knee if your knee pain is coming from your brain one day it's on this side of your knee a week later it's on this side of your knee and a month later it's in your other knee because the problem isn't in your knee it's in your the brain and in it and so it's not going to be in exactly the same location from our to our day-to-day week-to-week as if you have damage in one area of your body where the pain is always going to be coming from precisely that same location the other thing is that if you have pain that is you're feeling in your knee that is coming from your brain you're not just going to have pain in your brain you're going to have pain in multiple other areas of your body because going back to my guitar analogy if your amplifier is set to high any of the strings if strummed would be louder so the best way to determine that someone has brain pain is we give them a body map and we ask them to mark with X's all the areas of the body you have pain and this includes headaches this includes sore throats this includes any kind of pain or discomfort you have and the more X's you have on your body the more regions of your body that you have pain in intermittently the more likely your pain is coming from your brain because this is the the fundamental characteristic of brain pain is it's going to be much more widespread it's going to involve many more areas of the body than just a single area the body where you're experiencing pain and the best way to determine if someone has brain pain is to give them a body map and say to them to mark this body map with X's all the areas of the body that you have ever had chronic pain ioan in your life or you could ask someone mark this in all the areas of the body that you have ever had to go to a doctor because you had pain or irritation in this area of the body now you're going to hate me when I say this but I'm using this as an exam so I am a incredibly pain insensitive person I've never had a headache in my life I've never had chronic pain in my life I am like that person that could have a knee x-ray that looks like the one on the right and not feel anything whatsoever because I know based on putting myself through all the same research studies that we put research participants through that I have a low volume control setting I'm just fortunate I have a low volume control setting but when I experience acute pain it's it's exists it's like this it's very well localized it's very consistent in location and if you were to give me a sheet of paper that says mark with an X all the different areas of the body that you have ever had chronic pain or that you have ever had to go to a doctor for I'm going to give you back a blank sheet of paper and so our more than half of the people in the population I'm not that odd it's only one out of three people in the population that has any type of chronic pain and a lot of people with chronic pain have brain pain as their fundamental problem so chronic pain occurs trying to paint in different regions of the body very often occurs in the same individual and that is the best marker of the fact that their pain is fundamentally coming from their brain rather than from all those different areas of the body because the the widespread nature of the pain the multifocal nature of the pain Clues us into the fact that the brain or the amplifier is the fundamental problem the other thing about this type of pain is you're going to have other symptoms that come from the central nervous system at the same time as you have pain in multiple areas of the body you're going to have sleep problems fatigue memory problems and mood problems along with your pain because those are all other symptoms that come from the central nervous system and come from the same kind of brain dysfunction that we think causes the increase in the volume control setting causes the fatigue - sleep problems the memory problems the mood problems that go along with brain pain and again these are the poster children for brain pain but people third 40% of people with nerve pain and 20 to 30 percent of people with nociceptive pain also have brain pain so if your primary diagnosis is the you have cancer or the you have osteoarthritis or rheumatoid arthritis it's still you still very well might have brain pain and that may be why your pain has not responded to the drug and non drug treatments that you've been given because your pain was all being treated as though it was all nociceptive pain when in fact some of your pain was coming from this volume control setting and that wasn't being managing we're giving if any drug or non drug therapies aimed at trying to reduce your volume control this is just another way of showing this in the same way is a different people are at different points in this bell-shaped curve of how tender people are how tender you are is one measure we can use of how sensitive you are throughout your entire body with respect to what your brain has done and if you're wondering if you're tender or not and you have never been in any of our research studies where we actually has any one but in any of our studies okay if you come in any of our research studies will smush your thumb and by that I mean we have a little gadget that has a little rubber stopper and that gently puts pressure on someone's thumbnail and with that very light pressure we ask them do you have any pain in your thumbnail and then if you say no we'll give you a little bit more pressure and a little bit more pressure but we'll be able to see where you are in this bell-shaped curve of pain sensitivity and most people with chronic pain will have pain in their thumbnail with about three or four pounds of pressure on their thumbnail they'll start to experience pain in their thumbnail yes and they're over here on this bell-shaped curve I'm over here it takes about 18 pounds of pressure up to my thumbnail for me to experience pain in my thumbnail but that that's important is that if it takes 18 pounds of pressure for me to experience pain in my some nail then it would go without saying that I'd have to have a lot more damage in my thumbnail than you would in order to experience pain because I'm less pain sensitive for the same amount of pressure applied to my thumb and this is really the essence of these brain pain conditions is that people are skewed to the right side of the bell-shaped curve they have a higher volume control setting and the higher their volume control setting the more pain they're going to experience irrespective of what's wrong with your knee that if you're high if your volume control is high you're going to feel stuff as pain that's just day-to-day life that things that happen in day to day life will cause you pain that won't cause me pain because we're at opposite ends of this bell-shaped curve so if you've never had your thumb smushed or you've never had a tender point count and you're wondering if you're tender if it bothers you to wear tight clothing if it bothers you when someone hugs you if it hurts when someone in place of blood-pressure cuff you are at the right side of the bell-shaped curve those are things that don't hurt people that have average pain sensitivity and those are certainly things that don't hurt people like me that are paying in sensitive and again we're realizing that this is really important concept is that where people are on this bell-shaped curve the components of their pain that is due to that problem rather than a problem in their knee needs to be recognized and treated because the drug and the non drug therapies that work for your knee don't work for your brain now Fred wolf is a Rheumatologist that coined this term fibromyalgia Ness like this term because what it's indicating is instead of thinking of fibromyalgia as these people that are really paying sensitive that have pain all over that have widespread pain and and those people have a disease but but people that have pain in like three or four areas of their body and have some fatigue and some sleep problems and don't meet criteria for fibromyalgia don't have anything wrong with them what Fred wolf showed and then our group has done a lot of research in the last five years or so to expand upon this is we shouldn't think of fibromyalgia as yes or no we shouldn't say to a chronic pain patient you know you have fibromyalgia and you don't have fibromyalgia because fibromyalgia is sort of an arbitrary cut point to say that when someone gets to a certain level of tenderness to a certain level of volume control we're going to call a disease if you have a higher than average volume control setting then you have some fibromyalgia that is contributing to your pain and that's a therapeutic target so one of the things that we completely agree with is instead of saying that fibromyalgia is yes or no we should be saying more like this personally has like 80% fibromyalgia or 70% fibromyalgia they don't quite meet criteria for fibromyalgia but but we can tell that a lot of their pain is coming from their brain because they have multifocal pain they have these other symptoms like sleep problems and fatigue that we see along with it and even though they might not quite meet criteria for fibromyalgia we should treat them as we would a fibromyalgia patient because the treatments for fibromyalgia are the treatments that work when the pain is coming from the brain and so this is the new these are the new criteria for fibromyalgia if you're wondering if you have fibromyalgia fill this out and I will tell you if you have fibromyalgia or not but again I am NOT suggesting that we use this rigid criteria of yes or no because because I'll show you data in a couple minutes that show wherever someone is on this continuum of they're on the right side of that bell-shaped curve but they have a higher than average fibromyalgia score or volume control setting then treating them as though they have fibromyalgia as though their brain is causing some of the problem will be helpful therapeutically rather than reserving those treatments for people at the far end of the continuum that meet criteria for fibromyalgia so these are the new fibromyalgia criteria the first thing we ask people to do is mark with an X if they have pain in any of these body regions and you can probably you have this in front of you so you can read it if you can't see it but you literally just put an X in all the areas of the body that you have pain and you get one point for each X you have on this side left side of the screen then you come over to the right side of the screen and we ask you do you have fatigue no a little bit a moderate amount severe do you have trouble with your memory no a little bit a moderate amount severe so you get a zero to three score for how much fatigue you have how much sleep problem you have and how much memory problems you have and then you get one point each for irritable bowel which is pain or cramps in the abdomen depression or headache so you can your fibromyalgia score can go from zero to thirty one thirteen or greater and the score is said to be diagnostic of fibromyalgia so did I just newly diagnosed anyone with fibromyalgia okay that's not what I'm trying to do I'm trying to point out to you that that allowed of your pain is probably coming from your brain because I don't really care if you carry the term fibromyalgia as a diagnostic term what I care is that you and the clinicians who are taking care of you understand that some or much of your pain is coming from your brain and they need to move over to the treatments that are going to work for brain pain where there's a rather than the treatments that are going to work for knee pain so let me show you this example so you can understand what I'm talking about imagine you're an orthopedic surgeon a well-intended orthopedic surgeon someone comes into you with knee pain and they have an x-ray like that person that I showed you at the beginning that really bad looking knee x-ray where the person has bone-on-bone are you going to operate on that person and give them a new artificial joint of course your orthopedic surgeon you want to make people better it's like they have terrible arthritis in their knee and they heard in their knee what's what could possibly go wrong what if that knee was in this person would you think operating on the knee is going to help this person no and this is the problem and I'm showing the two ends of the continuum to make a point because this is a classic fibromyalgia patient with pain in a lot of different areas of the body to make a point to make but I think it makes a point is that you would expect that if someone only had pain in their knee and their body map only had pain in their knee then it's highly likely that there's a problem in their knee if this is their body map what's the likelihood that the knee is so bothersome that that person is going to have major surgery go through all the rehab and things like that and the person is going to come out on the other side like this incredibly well person because there's a whole bunch of other stuff you didn't do anything for that is that you did operating on the knee cannot possibly help so this is what we're talking about here is that the more widespread someone's pain is the more of their pain is coming from the brain and in fact we have just published a whole bunch of studies in people getting knee replacement surgery are people getting a hysterectomy for pain control that show that this fibromyalgia score is an incredibly powerful predictor of who is not going to get better when they have those surgical procedures that are meant to relieve pain is that the higher their fibromyalgia score is the less likely the person is going to get better if we operate on their knee or their uterus because if your problem isn't in your knee or your uterus operating there isn't going to make you better and so this is the reason I show this slide all the time when I talk to physicians is that fibromyalgia sort of the tip of the iceberg people that don't meet criteria for fibromyalgia that have fibromyalgia scores of eight or nine or ten or eleven don't meet criteria for fibromyalgia and maybe their primary diagnostic label isn't anything like fibromyalgia osteoarthritis or rheumatoid arthritis or something else is their primary diagnosis virtually none of these people are being recognized in routine clinical practice as having a problem with the volume control setting in their brain and thus a lot of these people are continuing to be treated with drugs that work in the knee procedures injections that work in the knee because no one picks up on the fact that the fundamental problem is more so in the brain or the central nervous system than it is in knee and this is a big problem that we have in the pain field is to really reach each clinicians that you sort of have to add together what's going on in the knee plus what's going on in the brain volume control setting to figure out why someone's having pain and in many individuals you have to intervene in both places the majority of people have something wrong a little bit wrong in both places so maybe you have a little with something wrong with your knee and a real and a moderately high volume control setting that those two things together can make you have severe knee pain and intervening at your knee would be somewhat helpful if that were the case but if someone only intervenes in the knee and doesn't intervene in the brain in that person that has maybe 60% brain problem and 40% of need problem then that person's pain is only going to get 40% better not the other 60% better so I'm just going to show you these studies really quickly if you want to look through these studies you have the slides in front of you these are studies led by Chad Brahma - who's an anesthesiologist here at the University of Michigan that's doing really great work in the perioperative period to show how important fibromyalgia and this concept of fibromyalgia Ness is and what we were interested in in these studies is does someone's fibromyalgia score predict whether they're going to get better benefit from surgery meant to relieve pain and I already sort of gave you the punchline it's highly predictive of non responsiveness of surgery the other thing that is highly predictive of which is relevant to those of you who have chronic pain it's highly predictive of not responding to opioids with improvement of your pain is it this kind of pain that is coming from your brain is not nearly as responsive to narcotics or opioids as pain that it's in your knee that is coming from your knee so if you have conditions like fibromyalgia irritable bowel headache in those conditions we generally strongly recommend against using opioids not just because they don't work for this kind of pain but because they actually often make people worse and I'm going to talk for a couple minutes about opioids in particular but one of the things that teaching points about brain pain or centralized pain is that it is inherently less responsive to procedures which makes sense but it is also inherently less responsive to narcotics and opioids and these are drugs that are commonly used by people with conditions like fibromyalgia and this sort of gets these individuals into problems because they're using drugs that don't work and may actually make the fundamental problem worse rather than better so in this study before knee replacement surgery or before hysterectomy we gave people this fibromyalgia measure I already showed you how to score this measure that 19 of the points in this measure come from how many X's you have on the body map and 12 points come from a 0 to 3 score for fatigue memory problems and sleep disturbances and 1 point each for these other symptoms see so you can see how you could give someone this measure they would have a score let me just show you how impactful this score is so the score goes from 0 to 31 for each one point increase in someone's fibromyalgia score if they get their knee replaced or if they get their uterus removed they needed 9 milligrams more of oral morphine equivalent that's how we indicate how much opioid someone needed in the pin the perioperative period this is just to control their pain in the first 24 hours after their surgery for each one point increase in the fibromyalgia scale people were 25% less likely to get better with improvement of their pain and these phenomena were linear starting at a score of 0 and going all the way up to 18 or 20 so even people well below the the level of a fibromyalgia score that would have made them qualified for the diagnosis of fibromyalgia this fibromyalgia measure was still highly predictive of surgery non-responsiveness and opioid non-responsive if we compared someone who had a fibromyalgia score of 11 to someone that had a fibromyalgia score of 5 even though neither of those people would be over the 13 level that would give them the diagnosis of fibromyalgia so let me just show this particular slide so these scores here these bars are the number of people that had this fibromyalgia score so on the bottom here which is called the x-axis is the person's fibromyalgia score and these bars just indicate the number of people we had about 600 people in this knee replacement surgery study the number of people out of the 600 or so people that hate each of the score so you can see just a couple people had high scores between 25 and 30 this red line is that on the right side of the red line people would meet criteria for fibromyalgia 13 is the score that gives you the diagnosis of fibromyalgia but what I want to just show you our two people that would not meet criteria for fibromyalgia that are both on the left side of that line at 13 but how impactful different fibromyalgia scores were in predicting surgery responsiveness and opioid responsiveness in someone getting their knee replaced so these are two different people getting their knee replaced neither of them has fibromyalgia they're both on the left side of the line but Kay B has a higher fibromyalgia score than patient a patient be needed 90 milligrams more of oral morphine equivalents in the first 24 hours to control their pain and was five times less likely to get better when we replaced his or her knee compared to patient a these are not subtle findings these are massive differences in to treatment responsiveness that are due to where people are in this bell-shaped curve or where they are on this continuum so this is a big thing that our group and others are out teaching people is you really have to assess where people are on this continuum and even if they don't meet criteria for fibromyalgia per se they still might have the same fundamental problem as fibromyalgia patients have and and still really would benefit from using the drug and the non drug treatments that work for fibromyalgia rather than thinking that all of that person's pain is going to respond to drug and non drug non-drug treatments that work out in the knee it someone's fibromyalgia score doesn't just tell us what isn't going to work and tell us what is going to work the drug duloxetine or cymbalta was shown to be effective in treating osteoarthritis and low back pain and in fact it was approved by the FDA for treating osteoarthritis and low back pain even though we know cymbalta was originally an antidepressant and it's working by increasing levels of serotonin norepinephrine in the brain but levels of serotonin and norepinephrine in the brain control your volume control settings so in the people with knee pain where their knee pain was due to a brain problem those are the people that cymbalta works in and this is a study in low back pain that showed that the people with low back pain that had pain in other locations other than the back we're a lot more likely to respond to cymbalta than people with low back pain that only had low back pain so the more multifocal your pain is the better drugs like cymbalta and lyrica are going to work because those are drugs that work more so in the brain and the less well the drugs like nonsteroidals and opioids are going to work because again it's just really contrasting where is the problem the brain or in the knee and what am I going to target with respect to my drug and non drug therapies same as in rheumatoid arthritis the drug Sibella or mil nasa cran only worked well in the people with rheumatoid arthritis that had all their inflammation well controlled but it was their comorbid fibromyalgia and fibromyalgia Ness that was driving their pain and that's the subset of people that known a sopranos Avella worked in it didn't work in rheumatoid arthritis patients that still had a lot of active inflammation because those people are people that again their pain was due to a problem in their knee and their therapy should have been directed primarily at their knee so every chronic pain condition is it somewhere along this continuum of where 20 or 30% of people with osteoarthritis and rheumatoid arthritis also have brain pain half of people with sickle cell disease or low back pain or air lers Danlos syndrome also have brain pain and most people with conditions like fibromyalgia retention headache or temporomandibular joint disorder or irritable bowel have brain pain but now we're realizing it some people with these conditions have either nerve damage or nociceptive pain so you can't the fundamental problem is we used to think that if we do the diagnostic label that someone had that we would know how to treat them because everyone with that diagnostic label had the same underlying mechanism of pain all people with fibromyalgia have brain pain all people with osteoarthritis have knee pain now though that's all wrong and so we have to look at each person and say I don't really care what your diagnostic label is whether it's osteoarthritis or rheumatoid arthritis or low back pain what I really care about is does your pain seem to be coming from your back or does it seem to be coming from your brain because the treatments are that are going to work in you I don't care that your label is low back pain some people with low back pain 95% of their pain is coming from their brain and some people with low back pain 95% of their brain is coming from their back and there's everything in between so we can't treat pain based on the label we have to treat pain based on a more nuanced look at the person who has that label and say in that person who has low back mein is it coming from their brain is it coming from their knee or some combination of both and I'm going to treat them accordingly so going this is the diagram I showed you before and all I'm really trying to point out now is that these are all mixed pain states you can't just because the primary mechanism in osteoarthritis is nociception the primary mechanism and diabetic neuropathy pain is nerve pain and the primary mechanism in cybermiles is brain pain is that any individual with any of these conditions can have any of the three mechanisms of pain and so that's how we have to diagnose and treat people with chronic pain is take a more nuanced look at them figure out what the underlying mechanisms are that are driving this entry based on a better understanding of that mechanism and we've learned a lot about the underlying cause of brain pain using brain imaging studies there are a lot of objective abnormalities and people with conditions like fibromyalgia or brain pain the notion that we don't know what is wrong with people with fibromyalgia that there's nothing objective that we can find wrong in fibromyalgia that's all stupid last 20 years different scores of studies that have shown the same thing that we initially showed on the first brain imaging study that was done in fibromyalgia that was published in 2002 so the fundamental problem in fibromyalgia is this increased volume control problem and that that leads to a lot of these downstream consequences but but again a lot of different work that's been done over the last couple decades showing the objective underpinnings of these illnesses which has led to these conditions having increased credibility in the medical and scientific field I mean most people actually can utter the word fibromyalgia now the most people know what it is that isn't what it any of you who have had the label of fibromyalgia for 20 or 30 years you know how far fibromyalgia come in the last couple decades it with respect to acceptance is it where it should be no you still there would be random physicians and health care providers that look at you when you're cross-eyed when you say you have something like fibromyalgia but it's infinitely better than it was 10 years ago or 20 years ago and it's getting a lot better as we train more and more P with a fundamental different understanding of what's causing chronic pain these are again I'm just going to show you very rapidly these are just some of the types of research studies that have been done to show this increased volume control setting these are all studies that were done by our group this is the first functional MRI study done in fibromyalgia and all we really showed is that when fibromyalgia patients say they hurt when we apply a low pressure stimulus to their thumbnail that wouldn't hurt a non fibromyalgia patient we could actually see that their brain was experiencing pain we could see objective evidence that they were experiencing pain even though we were only applying light pressure because we could see that the regions of the brain that are activated when someone is in pain were all activated in the fibromyalgia patients getting that light pressure but not in the controls getting that same amount of pressure so it was a really expensive study that just showed that there was this increased volume control or increased gain setting in people with fibromyalgia since then there's all sorts of different research techniques that show that the different brain regions are too connected to each other or not connected enough to each other this is now a lot of medical conditions that are in the brain couldn't really be objectively diagnosed until the advent of some of these techniques like brain imaging so it's not a surprise that we that were finally able to legitimize conditions like fibromyalgia because it wasn't until the advent of these research techniques that we finally had techniques that we could see how the brain was functioning in a living awake human being I mean we can't biopsy the brain or do things to the brain that we do to other organs or other parts of the body that when your brain is involved in pain it evens changes in size and shape if people who have brain pain most of the brain regions actually shrink than people with brain pain the only brain region that gets bigger in people with brain pain is the brain region called the primary somatosensory cortex which is the brain region that helps tell you where your pain is that paint that region actually gets larger because your brain is trying to be able to tell where all this pain that's coming from different areas your body is coming from so it increases the size of that brain region where as it decreases the size of all the other brain regions because it's trying to reduce the amount of pain that you're experiencing so this isn't just an academic problem because the drugs that work to treat brain pain are entirely different than the drugs that work to treat knee pain here's the drugs that we use to treat knee pain opioids non-steroidal anti-inflammatory drugs cortical steroids can all be used if there's damage or inflammation in the knee these don't work at all if the person's problem is in the brain or is a fundamental amplifier problem now what I'm going to do is I'm going to I'm going to talk very briefly about drugs but I'm not going to talk very long because most of you don't have a background in pharmacology your I am going to highly recommend that if you want to talk to your treating physicians or healthcare providers about trying new drugs for your pain I'm going to strongly recommend it what you do is you tear out this review article on fibromyalgia that I wrote a couple years ago in JAMA and you take this to your physician a couple reasons that I'm recommending you do this number one is that this JAMA is a medical journal that any physician will find to be a credible source of information this will be infinitely better received than if you print something off the internet on fibromyalgia and bring it to your physician but the other reason and it's not just because I wrote the article the other reason that I think this article is really helpful is JAMA actually came to me and asked me to write a review article that was the equivalent to sort of fibromyalgia for dummies but basically so that people that don't understand fibromyalgia can treat fibromyalgia and this table in this article goes through and lists every drug and non drug therapies that is known to be effective in fibromyalgia but if as a result of sitting through this lecture today you have concluded that some of your pain is coming from your brain you need to try these drug and non drug treatments these are the things that are more likely to work in you at least for that component of your pain than the things you have been trying the reason I'm not going to spend a lot of time talking about these things now is that these there's very there's a lot of detail in this table about the dose to start at the side-effect profile how to give these drugs so that they're better tolerated and people can tolerate them and again this would in general be a bit over the head of most lay people that don't have an understanding of the pharmacology of drugs so what I would suggest that you do is take this article and especially this table to one of the health care providers who's been working with you that really is helping manage your pain and just talk to them about trying some of these drug anon drug therapies because these may very well be the types of therapies because they're directed towards the brain that would be more helpful in you than the therapies that you've been getting historically they talked about all of the side effects of the drugs and this is a big problem with all of our drugs as they do have side effects all right really quickly let me just talk about some of the classes the drugs that can be helpful and this also will allow me to talk about two specific classes of drugs opioids and medical marijuana or cannabis so first these drugs here when I point to the drug I will tell you what the brand name is because you're a lot more likely to know the brand name than the generic names that are on the slides this is elavil this is flexural let me stop at flexural if you are not if you have brain pain and you haven't ever tried taking a low nighttime dose of flexural for your brain pain you should it's the it is my favorite drug for conditions like fibromyalgia by low nighttime dose almost all of you have probably been prescribed flexural as a muscle relaxant when it's given as a muscle relaxant it's given 10 milligrams every six hours that is not at all how we recommend people take it when they have brain pain or fibromyalgia they'll take five or ten milligrams two to three hours before bedtime slowly increase the dose the reason I like flexural number one is it's incredibly cheap it's been on the market for about forty years so it's extremely inexpensive number two it doesn't have a lot of drugs or drug interactions with other drugs and number three it actually if it works in you it helps a lot of symptoms other and pain in addition to it helping pain it can help with sleep that's why we give it a couple hours before bedtime may can help with a lot of the other symptoms that people have in the setting of centralized pain or fibromyalgia next class of drugs these drugs are all similar to each other Sibella cymbalta effexor Sabella & cymbalta are approved for use in fibromyalgia the trick with these drugs is a lot of people take these drugs for a couple days and because they're so nauseated or vomiting they stop taking the drug if that happened to you try these drugs again starting at a really low dose going up very slowly and taking them with food and understanding that the nausea and vomiting that occurs with drugs like cymbalta or Sabella typically goes away after about 7 to 10 days so one of the problems with these drugs is there's a tremendous number of people that have chronic pain that were given one of these drugs but we're not told how to start at a low dose take it with food everything that I just said and so when they come in and see us they say I failed cymbalta or I failed Sabella it's like well you didn't really feel that you just weren't prescribed it in the manner in which you would tolerate it the best and so I'm not sure that you really failed it the same thing would be true of this next class of drugs which is lyrica or neurontin we very commonly will have people come in and say I tried lyrica I tried neurontin it didn't work in me and then I'll ask them well what dose did you get up to and they'll say well I got up to 600 milligrams of neurontin and I say well neurontin doesn't ever really work until you get up to 1,800 milligrams 600 milligrams of neurontin is just simply not enough neurontin or lyrica similarly people around 50 milligrams of lyrica and they don't respond so someone declares you know you didn't respond to lyrica the one problem with these drugs that people don't get up to the high enough dose for them to work another problem is people are not told as patients that if you take the entirety of your lyrica dose or your Mountain dose at bedtime or two thirds of the dose at bedtime it'll be way better tolerated than if you take equal amounts three times a day which is how it's often prescribed so any pain specialist that's been taking care of a lot of pain patients will give neurontin or lyric a the majority of the dose at bedtime because we want you to be sedated from the lyrica the sleep that lyrica induces is deep sleep and actually helps to improve your paint part of how it works is by making you sleep deeply so we want you to take a higher percentage of the lyrica or neurontin at bedtime and so that you're sedated and you get that deep sleep whereas if you take that equal amounts of that drug three times a day it's going to cause you to be drowsy during the day rather than at night when we want you to be drowsy and we want you to sleep so these are just subtle things that are in that JAMA article it's not just what drug to give but it's how to start what dose to start out at and gives the physicians and other healthcare providers helpful hints about these drugs and when and where to use them so a couple a couple other drugs tramadol or ultrium is an okay drug I'm not a big fan of ultram just because it doesn't work that well in that many people but it's not a bad as needed drug for a lot of people with brain pain older serotonin reuptake inhibitors like prozac Zoloft axial can be helpful to treat brain pain but you have to go to higher dosages than the antidepressant don't and again that's in that jemma article so if you're on a drug like krola prozac Zoloft or paxil as your anti depressant drug and you are wanting to see if that drug might in fact help your pain you may want to go to your physician and see if he or she would prescribe a higher dose which would be needed to treat pain than the lower dose that's needed to treat depression gamma hydroxybutyrate is a drug that worked really well in clinical trials of fibromyalgia but it is GHB which is the date-rape drug so it was not approved by the FDA for Euston fibromyalgia but GHB is available as a drug to treat certain types of sleep disorders and if you have fibromyalgia you almost always have sleep disorders so you may find a sleep specialist that's willing to prescribe GHB for the sleep problem you have and that might very well help the fibromyalgia and the pain problem you have so it's an it's appropriately and the chart but it's not fda-approved in most positions won't prescribe it for use in you have to actually go to special classes to prescribe GHB because of all the concerns about diversion for GHB so I for example don't prescribe GHB I'll talk about medical marijuana or cannabinoids just a second low dose naltrexone is an interesting story anyone know what nell truck zone does so nel trek zone is the oral version of naloxone anyone know what naloxone does you've probably heard this in the press naloxone is the drug that antagonizes opioids so when someone is having an opioid overdose and they stop breathing you inject them with naloxone naltrexone is the oral version of that and oral naltrexone which is blocking the body's own internal opioid receptors has been shown in two different studies to be effective in fibromyalgia let me make sure you understand it this is instead of giving someone an opioid which is what we would think you would do if someone has chronic pain that actually blocking the body's own internal opioid system might be helpful in fibromyalgia and we have done brain imaging studies that show why that might be the case we have shown in a series of brain imaging studies that when people have this kind of pain brain pain and fibromyalgia pain their body's own in opioid system is releasing a lot of endorphins and in kefflin endorphins and Kaplan's are the body own opioids that you release yourself and bind to your opioid receptors they bind to the same opioid receptors that if you gave someone morphine or percocet or oxycontin or heroin that drug would bind to and what we've shown in people with fibromyalgia is that the body is releasing so many of its own opioids that all those opioid receptors in the brain are bound up by the body's own opioids and so when you give that person a opioid drug there's nowhere for it to work there's that those opioid receptors are already being occupied or bound by the person's own opioids they're releasing and this is why blocking the opioid system rather than giving someone opioids might be right thing to do for people with this kind of pain so let me stop for a minute and do two little mini talks one about opioids and one about cannabinoids so I've been do the opioids first so all of you are aware that we have a problem with opioids in the United States it has appropriately been called the opioid epidemic and the reason it's called the opioid epidemic is that opioid overdose has surpassed trauma and a number of other things as one of the leading causes of deaths in the United States last year 55,000 people in the u.s. died of drug overdoses about 40,000 of those were from opioid overdoses way more than guns or motor vehicle accidents or other things that used to be number one as far as the leading cause of death in people under age 45 why do we have this problem well I give hour-long lectures on this I'm not going to give do the entire opioid rant but I will tell you one statistic that points out why we have this problem the u.s. consumes 83 percent of the world's opioids so the reason we have an opioid problem is we think opioids work a lot better to treat pain than any other country which is why we prescribe a way more than any other country there's virtually no other country except Canada in the problem of Canada is it's too close to the US so some of this stuff of opioids is seeped into Canada there's no other countries except the US and Canada that actually use opioids to treat chronic pain that and I in the course of my career because the most of the pain that I have treated over the course of my career is fibromyalgia pain I have never newly prescribed an opioid for someone to treat their chronic pain I've refilled prescriptions occasionally for opioids but I've in a 35 year career of taking care of chronic pain patients I've never ever newly prescribed an opioid saying I want you to use this for chronic pain because up until the 80s or 90s the mantra in the United States was they don't work and we shouldn't be using them to treat chronic pain because there's no evidence they work in chronic pain well then a whole bunch of things happened led by the pharmaceutical companies that have been evil in this regard that that led us positions to start to think that opioids were more effective to treat chronic pain than they really are and then we also started prescribing way more opioids to treat acute pain so we use a lot more opioids after surgical procedures and things like that than any other countries do which and so you add those two things together we use opioids for chronic pain when no other countries do and we use a lot more opioids for acute pain than any other country does we use eighty three percent of the world's opioids even though we have three percent of the world's population so this is the problem and the opioids are everywhere and when they are everywhere they end up getting diverted misused and things like that and then people get addicted to them they start about three-quarters of the people in the u.s. that are addicted to heroin started on a prescription opioid because there's so many prescription opioids that someone takes out of a medicine cabinet from someone that got a big prescription for opioids after their knee replacement surgery and only took two out of their 90 vicodin but when that when if that is sitting in your medicine cabinet in case you don't know that you might as well have a loaded pistol in your medicine cabinet because that is how dangerous those unused opioid prescriptions are because these unused opioid prescriptions end up getting taken by a teenager a friend or a family member they're either given to or sold to someone else who then gets addicted to a prescription opioid and on the street the cheapest opioid is heroin which way cheaper to get heroin per unit high on the street than it is to buy vicodin on the street or act accountant in the street so what happens is someone gets addicted to a prescription opioid they switch over to heroin because it's a cheaper opioid for them to get on the street to fuel their addiction and then one day someone spikes their heroin with fentanyl or or even worse and they don't wake up the next morning because that leads to an overdose that makes them stop breathing so that is the public health problem associated with opioids and that bothers me but what bothers me more so as one of the world's leading pain researchers are the large numbers of patients taking opioids in the it states for chronic pain that think that the opioids are helping their pain but when we look at them as a physician as sort of a neutral third party we actually think the opioids are harming them more than they're helping them but that patient believes because the opioids did help them for the first couple months that they went on the opioid that patient continues to believe that the opioids are helping them even though we don't see any evidence of it so let me do a bit of a cognitive exercise here because this is really important if you are taking an opioid regularly for your chronic pain I am talking to you for the next five minutes and when I say this I don't care if you're using a drug like hydrocodone a couple times a day on a bad day and then the next day you don't have to take it at all if you're using it on an as-needed basis and it really helps during flares of your pain or things like that I don't have any problem with it the problem I have our people that start it out on an intermittent use of an opioid went to a regular dose of an opioid and then slowly gradually increase their opioid dose over time because they thought the opioid was the only of their drugs that was helping them what I want you to if you are in that category if you are taking an opioid regularly for your chronic pain I want you to do a little bit of an exercise with me and I want you to go back and think of what your pain level was when you first started taking an opioid if you just use a 0 to 10 pain scale and even more importantly I want you to think of what was your functional status when you first started taking an opiate by functional status I mean what could you do in a day or what could you not do in a given day when you were first started taking an opioid and so this might have been five years ago three years ago ten years ago when you first started taking opium but I want you all to think of what your pain level was and what your functional status was and then what what I would like you to do is fast-forward to present and compare your pain level now to your pain level then and your functional status now to your functional status then so if I was your treating physician I would do this and if you weren't able to tell me look me in the eye and say my pain is better now than it was when I first started taking the opioid and my functional status is better now I can do more in my day-to-day life than I could when I first started taking opioids if you can do that if you can look at me and say my pain level is better and my functional status is better now that I'm on a regular dose of an opioid and I've gradually increased the dose compared to when I first started taking an opioid I don't care if you take an opioid you might be one of the people that I refer to as unicorns who actually are getting benefit from opioids for their chronic pain but what I don't see that many unicorns the reason I call it unicorns is that when I see people that have chronic pains that are on opioids I see that they're coming in their pain levels are nine eight or nine out of ten they're not their pain isn't in any way well controlled their functional status is crap that they're not able to do anything they basically sit around the house all day because they're not functional they're not able to do anything and this aligns with how opioids work to treat pain the way opioids work to treat pain is they dissociate you from the unpleasantness of your pain but they also dissociate you from life and so when people take enough of an opioid to treat their pain it often does them to other things that give them pleasure in life it often dramatically it decreases their functional status and this is why those of us that are thought leaders in the field look at these patients and say you need to think about tapering off of your opioid because we see that when people slowly gradually taper off of opioids there are usually only one of two things that happen either the pain stays about the same or the pain actually gets a little bit better when your taper off the opioid rather than what you all think would happen is if you slowly taper it off of your opioid is that the pain would get worse or the opioids you're at a high enough dose that you are at risk of not waking up the next morning because if you take the problem with opioids is that they depress breathing the problem is so does alcohol so the drugs like valium or ambien or other drugs like that the what usually happens the cause of fatal opioid overdose if someone takes their their constant dose of opioids and then they take a little bit of alcohol or a little bit more of their valium or their ambien or whatever and that's just enough because those other drugs also depressed breathing that's just enough for them to not wake up the next morning and I'm not trying to be to frighten people here these are that a lot of those 35 or 40 thousand people each year that are dying of opioid overdoses are chronic pain patients here what you're seeing in the newspaper are the people on heroin are the addicts or things like this but this is this happens to chronic pain patients especially if you have slowly gradually gotten up to the fact that you're taking over a hundred oral morphine equivalents of opioids a day this is the line where we've seen that that level can cause death and other really serious complications even amongst people that have chronic pain not people that are abusing heroin so the bottom line here is that people that have chronic pain need to understand that there's been a tremendous sea change in the field of chronic pain is that when we were more permissive and we allowed the opioid manufacturing companies to aggressively market opioids and we sort of went along with it because it's like well you know if these work to treat chronic pain then we'd like our patients with chronic pain to have these drugs as we've seen the consequences of that the pendulum is rapidly swinging the other way but there is a moral here in the story for you as an individual patient in that if you are unmad or to high doses of opioids and you have chronic pain and you can't very clearly tell me yes I'm one of those unicorns that they really have helped me they really make a difference they really have changed my functional status and they make the difference between me being functional and non functional if you're not a unicorn you need to be thinking about lowering europeo it was just to see how you would feel and see the extent to which they either are helping you or maybe they're harming you in ways they're not aware of let me just talk about medical marijuana and cannabis for a minute so a lot of states including Michigan have either signed the medical marijuana law or inactive medical marijuana laws or actually even have legalized marijuana and along with this there has been accumulating evidence that medical marijuana or cannabis can be an effective drug to treat chronic pain and in fact just in the last year there have been a fair number of meta-analysis reviews blue ribbon panels on one that came from the National Academy of Sciences in the United States that concluded that the weight of the evidence now supports the fact that cannabis can be an effective treatment for chronic pain so that's all good all that's theoretically good that it's another treatment for chronic pain that is now available to people in more than half of the states in the United States that either have medical marijuana laws or have legalized marijuana what's the bad part well there's a whole bunch of stuff that's bad about this number one is that most states medical marijuana laws are not really medical marijuana laws our law in the state of Michigan is a law that was written by pot heads for pot heads and the overwhelming majority of people who have the medical marijuana cards in the state of Michigan are recreational users not legitimate medicinal users now that's not so bad is that one of my favorite sayings in life is it even a blind squirrel gets a nut once in a while so if someone passed a law that was intended for one reason but it actually ended up benefiting legitimate chronic pain patients that's not so bad the thing that I really dislike about the law that was passed in the state of Michigan as well as the laws that were passed in most states is they didn't have any provisions for educating patients and physicians about how to use medical cannabis to treat chronic pain and for that reason a lot of physicians don't see a lot of pain patients that are getting a lot of benefit from cannabis because no one sits down with them and talks to them that is that if you want to try cannabis to treat your pain this is how you should use it these are the principles you should use and you're totally flying blind it would be like me giving you two hundred vicodin in a bottle and you say and not giving you any instructions on how to take it it does it doesn't say how many to take a day what dose to take or whatever I just give you 200 of them and say this might help your pain and you might take 10 at a time you might take zero but you have no guidance whatsoever in what's the right dose what's the right strength what's the right route of administration so I'm going to give a really quick lecture and if you are going to use medical marijuana which if you have pain that is coming from your brain as a result of attending this lecture today it is a very reasonable option which is why it's in the second level of evidence here is cannabinoids are in the second level of evidence if we had a cannabinoid that was a synthetic cannabinoid that was approved for use in pain in the u.s. cannabinoids would be here on the top of the list so they thought this class of drugs works fairly well the problem is in order for you to get this class of drugs you have to ingest or smoke a weed that I don't know the strength of the dose of the strain of the whatever of and for those reasons that's way less optimal and that's weighed lower on the list then something that I do know the dose of the strength of and things like that but having said that I give lectures all over the world saying that I think medical marijuana for treating chronic pain should be below everything else that we use but above opioids and and I've written editorials on the Free Press in in scientific journals and in a lot of other settings making this case and I debate people often making this case and I never lose the debate because if you just look at the data if someone landed from Mars in the year 2017 and looked at what we now know about opioids in chronic pain and looked at what we now know about cannabis and cannabinoids in chronic pain I am quite comfortable the cannabinoids would be approved by the FDA opioids would not be approved by the FDA but that is not how historically we got to the year 2017 so right now because of the historical precedent we have a mismatch is that us physicians and our regulatory agencies are more Pro opioids than they should be and more anti cannabinoids and they should be based on the current evidence and data so let me give you some really simple helpful hints that if you are going to try medical marijuana how you should try it so the first thing is you should somehow take it orally rather than smoke it because any drugs that we're taking or having someone take for a chronic condition we want it to go up slowly stay at a good level and then go down slowly in the system so that people can take it a couple times a day in order to get relief of their pain or their other symptoms if you smoke marijuana your level goes up very rapidly and comes down very rapidly and so you would have to smoke 15 or 20 times a day to keep the marijuana level high enough to for you to continue to have an analgesic effect but that wouldn't be the worst thing about smoking 15 or 20 times a day it's sort of annoying if you have a job you have to go outside and smoke 15 or 20 times a day but the worst thing about smoking 15 times a day is every time you smoke marijuana that level goes up really high in your brain and it makes you high so a lot of what makes you high when you take a drug is the route of administration so all drugs of abuse are smoked or snorted or injected because the more rapidly that drug goes up in your brain the more likely you are to get high the reason we use the drug methadone to keep people off of heroin methadone is an opioid just like heroin just like morphine but all those drugs die into the exact same receptor in the brain the reason we give heroin addicts methadone to stay off of heroin is methadone is an oral form of an opioid that takes a long time to act on and acts for a long time for an entire day and so when people are on methadone once or twice a day they don't crave opioids but they don't ever get high because they're because the oral form of the opioid that goes up slowly and stays at a level and then goes down slowly doesn't make them high and that has also been shown with medical marijuana and cannabis is that if you ingest cannabis as an oil as you know as part of a food as a tea in any number of ways it is way less likely to make you high and when I am giving recommendations about medicinal use of marijuana I don't want you to hi like I wanted to get high in the 70s when I was using recreational marijuana and one of the things that makes my head explode when I do debates about this topic is that people always conflate recreational use of marijuana with medicinal use and I say well why are those two things connected you know why you know in the old days when people when doctors used to be more positive about opioids for treating chronic pain I didn't have to explain you know what was going on with hair the heroin epidemic in the United States in order for me to justify using an opioid clinically and I and I don't necessarily think it's a good idea to legalize marijuana or for recreational use of marijuana I think there's a lot of I have a lot of legitimate concerns as a neuroscientist about recreational use of marijuana especially in younger individuals but that's not what I'm talking about I am my chronic pain physician I'm talking about a field where one by one a lot of our other drugs have had been thrown by the wayside because they have side effects that we didn't know about or because they don't work nearly as well as we thought they did and I'm a pragmatist at the end of the day so if you've tried everything else and you the last two classes of drugs that you have an option to trying are either a cannabinoid or an opioid I would highly recommend you try the cannabinoid start with an oral preparation start with a low THC - high CBD ratio of cannabis because it's a THC that makes you high whereas the CBD doesn't make you high and then start at a really low dose of that and go up very slowly the biggest problem with the edible cannabinoid preparations the cookies the brownies the the oils and things like that is it if you are a cannabis virgin ie you haven't used marijuana recently and you use one of the current strains of marijuana you eat one of those cookies and you are going to be hallucinating for a day at it if you ever read Maureen Dowd the New York Times columnist she wrote a column a couple weeks after Colorado legalized marijuana and she ate a marijuana cookie and sat in her hotel room and hallucinate it for about eight or ten hours is that the these are really like an entire cookie is about ten times more than any of you should be taking if you are a new marijuana user than you've never used it before so this is the really the big thing people have to be careful about is the current marijuana strains are really high in THC and and if you do get access to one of those edibles either an oil cookie or whatever start at a really low dose and go up very slowly and then the last thing I would say is that a lot of people who use medical marijuana are using it as an opioid sparing drug we published a study done at a medical dispensary in Ann Arbor last year that showed that when people started using medical marijuana to treat their pain on average they lower their opioid dose by 2/3 and they felt a lot better when they when their pain was largely being controlled by the cannabinoid than they did when their pain was largely being controlled by the opioid because the cannabinoid has less unpleasant side effects that's why people like to use it recreationally than opioids do but but but the two things that we noted and that it has been shown in other studies that have been done elsewhere is it cannabis is probably a legitimate opioid sparing drug that people can use as a way of lowering their opioid dose and it can be a really helpful really effective drug for people if they start at a low dose they go up very slowly the last thing I would say is start by taking a single nighttime dose of the cannabis because a lot of people that use cannabis and that have integrated it into their regimen find that that dose is really helpful because it helps them sleep in addition to helping improve their pain so that's my cannabis lecture is I'm not as much an advocate of medical marijuana as I am anti opioids I would have to say and if I wasn't practicing in a country that had such an opioid problem I wouldn't probably not be quite as positive about cannabinoids but I really do think there are far safer alternative than opioids and there's a lot of evidence that they actually work in conditions like neuropathic pain and fibromyalgia that opioids actually don't seem to be effective so all of the drugs that we use to treat brain pain match up nicely with neurotransmitters that are known to be too high or too low in people with conditions like fibromyalgia so we are getting to the point now where we are picking our drug and non drug therapies based on a better understanding of what kind of pain someone has if your pain is more nociceptive that far left column from what I was originally showing then you're going to respond better to non-steroidal anti-inflammatory drugs opioid surgery and injection because those drug and non drug therapies are working out in the periphery in the so called knee as I was using as the analogy whereas the drugs that are going to work better if your pain is coming from the nerves are coming from the brain our the tricyclics drugs like flexural or elavil the serotonin norepinephrine reuptake inhibitors like cymbalta the gabapentin always like lyrica or neurontin or the cannabinoids like marijuana so what I want to do now for about 10 minutes is talk about why non drug therapies are so important in treating chronic pain and then give you some guidance about how to use these non drug therapies so a lot of the focus in treating chronic pain is in treating the cause of the pain people can either have a problem in their knee they can have a problem in their brain with respect to their volume control setting by the way I forgot to say this earlier if you have brain pain I'll tell you something about yourself that you didn't know was connected to your pain if you have brain pain you're also more sensitive to the brightness of lights the loudness of noises you have a lot of side effects of drugs because the areas of the brain that set the volume control setting for how sensitive you are to pain set the volume control setting for how sensitive you are to all sensory experiences so again when you look at a light if you are a febrile myalgia patient you couldn't stand up here like I'm standing up here in scary at that bright light without it bothering you because that light you would view that light as being brighter than I view that light how many of you have probably been cringing because my voice is so loud but I can't really stop that it's just the way I talk but any sensory experience in the human body goes through these brain regions like the insula and we've shown that in that one of the fundamental problems in these conditions like fibromyalgia is the insula hyperactive so any sensory information that goes in there comes out to be over interpreted again someone with fibromyalgia will find lights to be brighter noises to be louder odors to be more bad or some and they'll have a lot of side effects of drugs not because they're allergic to the drugs but because they're more sensitive to the drugs the way they're more sensitive to a lot of others types of sensory stimuli so that's why instead of saying disordered pain processing this is disordered sensory processing but going back to this part of the talk I just want to emphasize how and why these non drug therapies are working it doesn't really matter if someone's fundamental problem is in their knee or in their brain if you've had chronic pain for long periods of time you develop more stress because of the chronic pain you've become less active because of the chronic pain you sleep less well because of the chronic pain you gain weight because you're not as active as you used to be or you're taking drugs that cause weight gain or you develop bad habits that you don't know that these habits that you've developed are actually making your pain worse because no one has pointed out to you that this thing that you're doing over and over again is what psychologists would call a maladaptive illness behavior it's a habit that you developed to survive having chronic pain but it's a habit that if you keep doing will actually make your pain worse rather than make your pain better and I'll show you an example of one of these maladaptive illness behaviors or bad habits but as people have had chronic pain for longer and longer this these things down here start to become a bigger problem than what caused the pain in the first place because each of these things down here can go back up to the brain and cause your brain pain to be worse and worse or to cause pain via other mechanisms and so what we see is that when people have chronic pain for 10 2030 years even if the volume control setting in the brain is not getting worse over time or the knee x-ray isn't getting worse over time these things just get worse and worse over time and so what people see as they have chronic pain for long periods of time is they slowly gradually worsen not because this is getting worse but because they're accumulating more of these sort of downstream consequences of having chronic pain these downstream consequences of chronic pain are not going to it all be made better by taking any of the drugs that I talked about or by getting surgery or getting injections these consequences of having chronic pain we have to attack in and of themselves using a rehab approach and trying to get people sleeping better trying to get them active again the body's two most potent internal analgesic systems that are as potent as opioids in the human body for turning down your volume control setting our sleep inactivity do we and others have done studies just showing that if you compare people in the population who sleep well to people that don't sleep well the people that don't sleep well are a lot more pain sensitive they have a higher volume control setting and have a lot more pain the people same with activity or exercise the more active people are the high lower their volume control setting and the and this is why we use exercise or activity as a treatment for chronic pain because if we can get people active it doesn't make their pain go away but we really have to slowly gradually chip away at some of these downstream consequences of having chronic pain to manage people that have chronic pain because not all the chronic pain is occurring from these things up here and in fact when I see someone that's had fibromyalgia for twenty years and in my mind I'm trying to say how much of this is going to get better by me giving them a drug like lyrica or cymbalta that's going to lower their volume control and how much of this is going to really be more working on a rehab approach that's going to work on some of these downstream consequences often if someone's had chronic pain for 20 years it's like 70% this and 30% this but that's really I'm more aggressively working down here using this rehab approach and this is where these non pharmacologic therapies can be incredibly helpful I'll talk about a website that our group developed called fibro guide this is a website that Dave Williams and a faculty member in our group developed by 10 years or so ago to teach patients with fibromyalgia self-management strategies we tested this website like you would test a drug and when we tested this website this website worked as well as any of the drugs that are approved in fibromyalgia now we're not suggesting you use it instead of the approved drugs we're suggesting you use it in addition to the approved drug because it's really working in a different way it's working on a different element of fiber mile just working down here and rehab again and trying to correct all of these downstream consequences of having chronic pain whereas liriko is working up here by reducing the volume control setting in the person's brain but you got to use the drug in the non drug therapies together to get good management over all of chronic pain patients and this is where resources like fibro guide can be incredibly helpful because you can go to fibro guide and you can spend months in fibro guide going in the nooks and crannies and the different modules and chapters and fiber guides and all of these are aimed directly at patients so you can try these things see what works see what doesn't work but these non drug therapies can be extremely helpful in controlling pain and should be used in addition to the right drugs and the right procedures I'm not saying to use them instead of I'm but right now in the u.s. very few physicians treating chronic pain appreciate how important this rehab approach is and how important the empowering our patients to manage help manage their own pain of is in overall pain management so let me give you an example of one bad habit that every chronic pain patients that I've ever met develops this is what psychologists would call a maladaptive illness behavior I like chiding my psychologist colleagues it's like that's psychobabble no one can really understand what a maladaptive illness behaviors so this is I've to translate this is a bad habit that you develop to survive having chronic pain that actually makes your pain words so if you go to the website you'll see me doing the same streaming video so you'll see it all over again but what I want to do is give an example of one maladaptive illness behavior I'm going to draw a graph here to explain this to you this is one of the occupational hazards of becoming a scientist you start to grow draw graphs to explain things to people I'm actually pretty fun at a cocktail party I have a good sense of humor but I might pull out a napkin and draw a graph so it I don't know what it is it's probably it's not maladaptive for my career it's adaptive in my career it could be maladaptive if I was a total dweeb and I just drew graphs at cocktail parties luckily I'm not I think it was that recreational marijuana in the 70s so if you have pain that is coming from your brain one of the things that you find most annoying about it is you don't know when you're going to have these players because these flare is often like control your entire life is that after you start having players it's like well if I can't do something on a day when I have a flare then I don't plan to do it at all because it's I've had too many times that I couldn't do this thing that I wanted to do because it coincided with one of these players so you'll all acknowledge that flares are bad and that they're they are probably one of the most bothersome things about having chronic pain because you don't know when these days are going to occur so let me um I'm not going to make you guess too long but I'm going to ask you all to guess what you all do that contributes to these flares of chronic pain and I'm going to give you a hint so that you can all get the answer right simultaneously because it'll be on video and it'll be cool that you all get the right answer right simultaneously is what do you all do after you've had three or four bad days and you finally have a good day you had three or four bad days in a row and you finally have a good day what do you all do you overdo it you try to get everything done that you weren't able to get done those last three or four days this is the reason I love this for the audience-participation part of the program because everyone gets the answer right what is overdoing it cause what do you do again three or four days later when you feel good again okay so this is what psychologists would call a maladaptive illness behavior it's not you know I mean it's something that you developed is it's a habit that you develop because you're you got stuff you got to get done you got to survive you have you have things you want to get done and if you feel good it's sort of intuitive that you might want to actually then do something proactive and and and get stuff done but this unknowingly contributes to the flares and so if you had this maladaptive illness behavior this isn't by any means the only maladaptive illness behavior that people develop it's the one that I use as an example there are two modules in fibro guides that we would have you go to the first module and fibro guide that we have you go to is called pacing and pacing sounds simple but it literally is teaching people that if you do about the same amount of activity every day whether you're having a good day or a bad day you can turn this pattern of players into something more like this and if I gave you a drug that made you go from green to black I declare a success and keep you on the drug because it's making your flares about half as often as they used to be and it's reducing your peak pain by about thirty percent it's not a home run but it's a single or a double and that's all we're hitting a singles or doubles when we're treating pain by the way if you know baseball is there's not a lot of home runs in the pain field in fact if you try to hit home runs you'll strike out in the pain field that's the problem in the pain field but so if people pace they an average over a couple months of doing homework and really trying to change their behaviors they can change their pattern of pain from this to this no side effects no cost no nothing except just a self-realization and an understanding that you were in some way contributing to these flares and that you can at some level you're not going to make the players go away there's going to be some natural variation of flares but you're at least not doing this to contribute to this and thus you have less players and they're not as intense when you have them so this is the first thing we would have people do is do the pacing they'd get better the second thing we would have them do is something that we encourage people to do after any treatment that is effective whether it's a drug whether it's a procedure or whatever and that is start doing things that you now can do because your pain is better that you weren't able to do a month ago or a year ago because when your pain was worse so let's imagine that you really used to like to go to the movies with friends that was like your really thing that you really enjoy doing and it turned out that because too many movie dates that you planned coincided with flares either you stopped planning to go to the movies with your friends or your friends stopped calling you because they didn't want to keep getting just every time but for one reason or another you stopped doing this because there were too many times that it coincided with a flare well that was all very reasonable because at that time you couldn't do this but now that you're like now that you're in the black line rather than the Green Line you can do it you're having the flares are less often the flares are less intense so pick the last thing used you stopped doing or the second from last thing you stopped doing because that was something that you stopped doing just when you went over your pain got a little worse the frequency of flares got a little worse and you then you were that put you over that hill where you couldn't do that thing well that's the first thing you should start doing again and this sounds overly simplistic but the module that does this is called pleasant activity scheduling and it makes people with chronic pain understand and appreciate that their biggest responsibility in the overall management of their chronic pain as a patient is that when your pain gets 20% better or 30% better for whatever reason a new drug a procedure it just happens it does there's no reason your responsibility as a patient is to try to improve your function by 30% is to try to go back up to doing the things you used to be used to do when your pain wasn't as bad and then what happens is you'll actually spiral upward this is really one of the the really cool things about taking care of chronic pain patients when you integrate this rehab approach with the drug and the non drug therapies is that people with chronic pain will almost always slowly gradually get worse because what happens is the pain leads to decrease in sleep increase in stress increase in weight decrease in activity which leads to more pain and people slowly gradually spiral downhill year after year they get 5% worse 20% to 10% worse but in many cases the fundamental cause of the pain hasn't changed at all it's that these downstream consequences of the pain are causing the slow gradual worsening and these are the things that we're taking on so when someone is a pain patient appreciates this and they get a 20% improvement in their pain and and it's like okay I'm going to then I'm going to do what I'm gonna do this is go to this and start going to movies with friends pleasant activity scheduling there's two types of categories the chronic pain patients stop doing when they get chronic pain these are things that are so the things you stopped doing as your pain gets worse and worse are things that are fun and things that keep you active and sometimes they're things that are fun to keep you active but these are the things that are on this list in pleasant activity scheduling we don't know which of those 50 things on the list are the things you want to do it's just a bunch of random things that people like doing but we do make you start doing them and say because you got this improvement if you capitalize on that 20 percent or 30 percent improvement in your pain by starting to do stuff that you had stopped doing you can actually spiral upward because you'll sleep better at night because you're more active your symptoms will get better and this is really the essence of this rehab approach and integrating the non pharmacologic therapies with the pharmacologic therapies is that these really work well together and complement each other and i don't think we're ever going to get to the point that we're going to be able to treat chronic pain without using these non pharmacologic therapies and without at least in part employing this rehab approach even if we get blockbuster drugs that are really a lot more effective at treating chronic pain than we have right now I think we're always going to have to be integrating these non drug therapies with the drug therapies and the problem with these non drug therapies they're not widely recommended by the people that are seeing you they're not they're often not really reimbursed by third party payers or they're not very available this is why fibro guide can be very helpful because this is all something you can do on your own via a website you don't really have to have any specific anyone prescribing it or anyone specifically recommending it you

Channel: Michigan Medicine

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Id: B0EhNajqkdU

Length: 114min 19sec (6859 seconds)

Published: Wed Aug 16 2017