Outsmarting Chronic Pain

Transcript for Season 3, Episode 4: Outsmarting Chronic Pain

Dr. Yoni Ashar: Two thirds of people were out of back pain. On average, these people had been in back pain for, for 10 years, a bit over 10 years. And this treatment took course over the span of a month. It was nine sessions over one month and they were out of back pain. 

Judith Warner: Welcome to The World As You'll Know It. I'm your host, Judith Warner.

This season, we're focusing on the brain. And specifically, we're looking at some of the most recent astonishing advancements in brain science — discoveries that have completely altered our understanding of how the brain works, what it's capable of, and how it can be changed.

In this episode, we're focusing on chronic pain, which until a few years ago, might not have been an obvious subject for a podcast about the brain. But new research shows that for many of us, the most effective treatment for chronic pain doesn’t target the back or the neck or whatever hurts the most, but the mind. And to do this topic full justice, we're going to break form today and hear from two experts back-to-back.

Our first guest is Dr. Yoni Ashar. Yoni is a clinical psychologist and an assistant professor at the University of Colorado Anschutz Medical Campus. He'll walk us through what it looks like to fight pain by changing the brain. And he'll share some stories of patients who have done it. 

After that, we'll speak with Dr. Tor Wager, a professor at Dartmouth who's widely regarded as one of the world's top experts in the neuroscience of pain. He'll take us deep inside the brain to understand why seeing a psychologist for your aching back actually works.  

Yoni, thanks so much for joining us. We're so glad to have you. 

Dr. Yoni Ashar: It’s a pleasure. Thank you so much for having me, Judy.

Judith Warner:  Talking about a topic that is near and dear to my heart — or back and hip — and the research that you and others have been doing around the world at this point, which really represents a sea change, in how scientists are understanding and thinking about pain. Can you talk us through that? You know, what was believed before. And what your orientation is now.

Dr. Yoni Ashar: Yeah. The prior paradigm, and would say even the current paradigm, is that chronic pain is primarily due to some kind of problem in the body. If your back hurts, you know, you have a problem in your back. If your knee hurts, maybe it's the cartilage in the knee. And, you could do some psychological thing, like maybe some meditation or mindfulness, or see a therapist. And maybe that would help you feel a little better. Learn how to live better with the pain. Uh, but that was, it's a pretty circumscribed role for, for psychology there. What I see as the incoming paradigm, is that the brain is at the center of many cases of chronic pain. And that retraining the brain, for example, with psychological treatments can lead to the elimination of pain itself.

Judith Warner:  Can you tell us about how you started doing this work? I mean, was there something personal that led you to it?

Dr. Yoni Ashar: My mentor, Dr. Tor Wager, uh, and I, were starting a study on placebo effects and chronic back pain and two clinicians, Howard Schubiner and Allen Gordon approached us and said they have this new treatment that they wanna study for chronic pain. And we said, “Sure, let's do it.” And that led to this whole, um, really exciting area of research and project.

Judith Warner: So for people who don't know who they are, just tell us briefly who Alan Gordon and Howard Schubiner are. And what they do. 

Dr. Yoni Ashar: Howard is a physician and Allen is a therapist. And they have been treating chronic pain for decades now. And what they had been finding in the clinic was that many of their patients were getting out of pain. And that wasn't supposed to be happening. Like in the regular paradigm, people don't get out of pain by, by seeing a therapist or by talking with a physician. Howard, I wanna say, he's a physician. He's not doing injections. He's not giving medications. He's talking to people and changing the way they think, uh, about their pain, working with them on, on an emotional level. And, and they were seeing this pattern of results in their clinic. People just one after another, getting out of pain, not having chronic pain anymore. And they realized they were onto something, that the only way to really bring this to light was by, you know, research. You have to run a study.

Judith Warner:  Were people out in the community very skeptical of this? I mean, did they have to fight for acceptance?

Dr. Yoni Ashar: Yes. They didn't have acceptance, I would say. Maybe now with the study published, there may be more acceptance. I think there's a lot of skepticism. I have a lot of, you know, sympathy for — ‘cause there's a long history of stigmatization. People suggesting that they're making up the pain, it's all in their head. It, it's really a fine line from, from something like that, to an idea that the brain has learned the pain and the pain is real, but the causes are not what we thought. And, and because I think partly because of that fine line, there has been some resistance and skepticism.

Judith Warner:  So, tell me about the study that you were involved in.

Dr. Yoni Ashar: We randomized 151 patients with chronic back pain to one of three conditions: One group got pain reprocessing therapy. One group got a placebo injection, which is a control condition. And the third group was just a, uh, keep doing your usual care, whether it's, you know, stretching or exercise or whatever it is. We asked people how intense their pain was at pre- and post-treatment. And we scanned their brains at pre- and post-treatment and collected many other measures as well. And then we followed people for one year after treatment ended. And what we found was that two thirds of people who were randomized to pain reprocessing therapy, were pain-free or nearly pain-free after treatment. That is reporting a zero or one out of 10 pain.

Judith Warner: That is incredible!

Dr. Yoni Ashar: It's incredible. Two thirds of people were out of back pain. On average, these people had been in back pain for, for 10 years, a bit over 10 years. And this treatment took course over the span of a month. It was nine sessions over one month and they were out of back pain. And in the control groups, it was 20 percent or less of, of people were, were pain-free.

Judith Warner:  So, how did you screen people for the study? I mean, how did you make sure you were getting a range of subjects whose pain might respond to the treatment, and not people who might, I don’t know, really need surgery or something?

Dr. Yoni Ashar: We aimed to be broad in our inclusion criteria. So we were looking for people who were likely to have chronic pain. And to that end, we excluded people whose, uh, leg pain was worse than their back pain, just because that suggests there may be, uh, radiculopathy, which is compression of the nerve root in, in the back. We also excluded people who had a history of metastasizing cancer, because that again, it makes the diagnosis more tricky. So one thing to emphasize that all these criteria don’t tell you what’s causing someone’s pain, but we wanted to just increase the likelihood that, that the people entering were, were likely to have neuroplastic pain.

Judith Warner: And what is neuroplastic pain? Uh, what does it mean?

Dr. Yoni Ashar: So, so this kind of pain we’re talking about has gone by many different names over the, the decades, from nonspecific pain to functional pain, um, idiopathic, uh, primary chronic pain. I like, um, the term neuroplastic because it suggests that, you know, plasticity meaning changes or, you know, modifications in the brain are responsible for the pain.

Judith Warner:  So pain reprocessing therapy, sometimes called PRT, um, was the central treatment that was in the study. Can you tell us exactly what it is and walk us through the journey of doing that therapy?

Dr. Yoni Ashar: So step one: assessment. What is driving someone's pain? So here we're looking for clues, um, that the brain is, or is not playing a role. Uh, if the pain moves around the body. So sometimes, you know, my back hurts on the left. Sometimes it's on the right. Injuries don't move, but the brain can cause sensations to, to move around very easily. When there's, uh, high temporal variability in the pain, right? One day it hurts, one day it doesn't. One day, the pain's eight out of 10, the next day it's like, you know, one out of 10. That is, you know, more consistent with the brain's processing of, of sensory input than with some kind of clear structural problem in the body. Um, other clues are the, uh, history of multiple different pain conditions. When someone has, you know, bellyache starting at age eight, and then headaches starting at age 16, and then back pain starting at age 26, you know, what are the chances they have a problem with their stomach and a problem with their head and a problem with their back, versus one shared kind of vulnerability in terms of how the brain is processing this input from these different body sites? 

Judith Warner: So what comes next?

Dr. Yoni Ashar: So step one A is getting the person on board with that model. For many people, this is a really different way of thinking about their pain. They've been through, you know, literally dozens of doctors and no one's ever told them anything like what we're telling them. And so explaining this idea to them that the brain can learn the pain, that the pain system can be stuck in the “on” state. And, uh, and though the pain is real, it is a false alarm of threat or danger.

Judith Warner:  How do you prove that to them to get them, you know, completely on board with the idea, as you said, and do some people sometimes get insulted? I mean, even though you're not saying this, are they hearing “It's all in your head”?

Dr. Yoni Ashar: I was quite concerned about that starting out, that people would get insulted. In in, in the course of my clinical work, I've had one person get angry and storm out on me.

Judith Warner: Out of how many? 

Dr. Yoni Ashar: Out of, you know, dozens or, or, or more who have, you know, responded with with some range of like, “Oh my gosh, you nailed it. That's me exactly” to like, “That's interesting, but I don't really think that's me.” But, the getting offended and, and getting insulted is actually pretty rare. What's really touching is when people actually feel like this is the most validating and accurate explanation they've ever received. When people have been kicked around from doctor to doctor and, you know, doctors can't find anything wrong and “I don't know what's causing the pain.” And then you offer this model to them and they're like, “Oh my gosh. Now it all makes sense. This is why I've had all these different pain conditions. This is why the pain moves around my body. This is why, when I'm talking to someone I don't like, I have, you know, spikes in my pain” and it all starts to make sense. And so rather than being insulted, they're so happy to have this kind of framework.

Judith Warner: I would imagine. Especially since I know in the study, the people had been in pain on average for a decade. So you get them on board and then what happens?

Dr. Yoni Ashar: The, the heart of it is thinking and feeling differently about your pain and going from threat to safety. And so there's a few techniques that we will use here. So one of them is simply self-talk, like telling yourself, “I am safe. My back is safe. There's nothing wrong with my back. The pain is a false alarm.” And, and just repeating that, trying to, almost like brainwashing yourself, to, to think differently about, about the pain. Another technique is starting slowly to do the things you have been afraid to do because of the pain. For example, if someone hurt their back playing tennis, then slowly start getting them to play tennis again, ‘cause this is a way to prove to the brain that the back is not injured. You're doing the thing that the brain thought it couldn't do. So the brain is always creating pain to try to protect the body. The, the role of pain is to protect and to defend. To guard against injury. So if there is a, a belief, the back is injured, the brain will create pain so that you don't reinjure the back. But we can come in and say, “Okay, you know, the brain's trying to be helpful, but it's a little confused here. Actually the back is not injured and let's start playing tennis again.” And that will be a way to kind of help update that old belief.

Judith Warner: And the reason it works is because they're rewiring their brains, right? Their brains have gotten wired to, to have certain associations. “If I do this, I'll have pain.” And now you're, you're putting down new wiring? Is that right?

Dr. Yoni Ashar: That is exactly right. From the outside sometimes, it can look a little bit like physical therapy, but the framing could be totally different. We're not doing any exercise to strengthen a muscle or to stretch a muscle. We're doing it to learn new associations.

Judith Warner: Any other techniques that you use as part of this therapy?

Dr. Yoni Ashar: There's another technique here that is really central and perhaps the most central technique in, in PRT, which we call somatic tracking. And it is sort of like a meditative approach to reframing the pain. Usually we have people close their eyes and shift their attention inward. And for most people with chronic pain, the pain is there. And you bring your attention to the pain and remind yourself as you pay attention to the pain that “This is a sensation that's generated by the brain. You know, I'm safe.” And watching the sensations move around. And spending time with these sensations and reminding ourselves that the sensations are not the threat we thought they were.

Judith Warner: And then, how long does it take before people start to feel better when you're doing this therapy with them?

Dr. Yoni Ashar: It is really variable. I have had some people with remarkable, one-session cures.

Judith Warner: Wow. That's incredible. Can you tell us about one of them? 

Dr. Yoni Ashar: Yeah a high school, high school-aged boy had come in with his parents. He had had ongoing headaches for the past two years. A couple years ago, he had been playing basketball, like went up for a dunk, took a hard fall, cracked his head on the cement, had a concussion. And now it's two years later and he's still having headaches. Not only that, they've gotten worse and worse and more frequent. And as he’s, you know, presenting today in the office, every time he talks, his head starts to hurt. And every time he stops talking, the pain goes away. That is a whopping big clue that the, that there's a conditioned association here between speaking and pain, that his brain has made a link between speaking and pain. And talking with him, it became clear that he had a lot of fears around, uh, his head being damaged, his head being fragile, his head having, you know, kind of permanent effects of this hit that he had taken two years ago.

So step one is, you know, assessment and then getting him on board with the model. And I told him that the concussion had long-ago healed. You know, there was very unlikely that there's any sustained damage. It was not a severe concussion by, by any means.

Judith Warner: And I imagine you had, I don't know, imaging or something to back that up? 

Dr. Yoni Ashar: Yeah, he had done, previously, all the medical rule-outs. He had seen a number of doctors et cetera. And the head is designed to withstand impacts. That's why we have thick skulls and we have cerebral spinal fluid. It's designed for that. And, uh, I got him on board with this idea that his brain had made an association between speaking and pain and between bright lights and pain and all these other things and pain. And our job in treatment was to learn a new belief that his head was not damaged. There was nothing fragile, he did not need to protect his head. And the way we did that was by head banging. We just, like, pretended we were in a rock concert and just started shaking our heads around left and right. And up and down. And at first he was like, “This is crazy, no way.” I mean, this, this, he had been, like, figuratively walking around with his head in bubble wrap, uh, ‘cause he was so protective of it. And it was like, we have to stop protecting cuz that protecting is what's reinforcing the belief that there was some kind of injury. I think at first we probably just did some turning from left to right. Then as you saw that nothing was happening, then you start a little more vigorously. And by the end we were, we were totally head banging.

Judith Warner: That's so funny. But you weren't like banging on the wall. That's what I imagine when you first said it. 

Dr. Yoni Ashar: No, we were not banging our heads on the walls. There's no need to do that. We were just swinging our heads in the air around and around. And that was enough for him to basically get this idea like, oh, he doesn't need to protect his head. His head is safe and strong and healthy. And he had a, a dramatic reduction in symptoms. 

Judith Warner: It really was just one visit to recovery? 

Dr. Yoni Ashar: So we had, I would say like 80 percent improvement in one session. And maybe another 10 percent in the second session. And he was, you know, 90 percent better in, in two sessions. But, those are nice stories to share. That's not the typical progression.

Judith Warner: Can you tell me the story of a patient who is more typical?

Dr. Yoni Ashar: Yeah. So thinking about uh, a more recent client, she is um, a woman in her fifties and approached with, uh, facial pain. In the past two to three years, there had been a lot of relentless, excruciating pain on one side of, of, of the face and a series of literally dozens of specialists, from dentistry to neurosurgery, you name it, all kinds of procedures, including an exploratory brain surgery. I, um, shared the model with her and there was, I would say interest, openness, skepticism, doubt, and over the course of multiple sessions her thinking started to shift from, “That's an interesting idea that there's something wrong with my brain here” to “Gosh, that seems really likely” to “I'm, you know, pretty confident that's what it is.” And we started doing things that were avoided. So in this case, the person was afraid to, to brush their teeth when they didn't have pain, because that might cause the pain. Well, we are brushing our teeth every morning, no matter what. And over time, the days with jaw pain became less and less frequent, the pain became less and less intense and now it's been gone for months.

Judith Warner: So how long did you work with her before the pain was gone?

Dr. Yoni Ashar: Four or five months. It was a process. But there was slow improvement throughout the way. And throughout the way, was also noticing how like stress when there was uh, tension in their relationship, a fight with, with a spouse, um, then the pain starts to spike. So starting to understand that relationship and see like, “Okay, this is the stress that's driving the pain.”

Judith Warner: And um, did she have other pain conditions at the time or was it all just the facial pain at that point?

Dr. Yoni Ashar: Funny you should ask. As soon as the facial pain went down, the other pain condition started flaring up. Which is another piece of evidence that it’s neuroplastic. When you see that kind of symptom substitution, “Oh gosh. Now my knee feels fine, but now my shoulder is hurting.” It's like the brain has a pain habit and it's gonna look for some place in the body to put it. And so, you know, from this perspective, when that happens, ironically, it's, it's good news in a way that it reaffirms our understanding, our belief in what's driving the pain.

Judith Warner: Do you have any, um, stories of patients who, no matter what you did, just didn't improve?

Dr. Yoni Ashar: Oh, definitely. There there's some of those and there's some, that's more of a, like a slow burn.

Judith Warner: With the ones who didn't improve, is there any pattern that you can identify as to why? 

Dr. Yoni Ashar: This is my, uh, you know, hypothesis, my kind of clinical sense here. I don't have data for this. But it is kinda holding onto fear, just holding onto this fear that, “But what if?” Uh, “But what if there is something medically going on with me?”

Judith Warner: So the cycle of doubt.

Dr. Yoni Ashar: Cycle of doubt. The cycle of fear. That's one factor. And the other factor, I would guess, is people who just have, um a lot of really difficult emotions, a lot of stress in their lives, and it can be really hard to make any changes and their system is so dysregulated that it’s, that the pain is kind of flaring all the time. 

Judith Warner: Oh boy, I bet a lot of people can relate to that, maybe a little too much, and it's good to know that progress is being made. I can't wait to hear more about the work you’ll do in the future. But for now, thank you so much for speaking with us. It's really been wonderful.

Dr. Yoni Ashar: Thank you, Judy. It's been a pleasure.

Judith Warner: So as I mentioned at the top of the show, that was the first of two conversations we’re having today about new ways of thinking about chronic pain. 

Next, we’re going to follow up on Dr. Ashar, by getting into some of the neuroscience behind this new thinking. How pain can be “seen” in the brain, thanks to fMRI technology, and what brain imaging can tell us about what’s really going on when something hurts.

I’ll be talking to Dr. Tor Wager, a cognitive neuroscientist and professor at Dartmouth College,  who has spent decades studying what different experiences look like inside the brain. As he puts it: 

Dr. Tor Wager: Everything that we think and feel, every emotion that we have, has some physiological basis in the brain.  

Judith Warner: He also happens to be one of Yoni Ashar’s mentors and they worked together on the study looking at pain reprocessing therapy. Dr. Wager, welcome! 

Dr. Tor Wager: Thank you. It's really a pleasure to be here.

Judith Warner: It’s so nice to have you. Part of your specialty, one of the things you're most known for, is mapping. In the brain. Mapping of emotion or feeling, but also of pain, you know, using scans to locate and find it, show it. Does acute pain, does it look different in the brain from chronic pain that lives on after the initial injury has healed, but people are still suffering?

Dr. Tor Wager: Absolutely. So, um, when we look at chronic pain, an emerging story is that it looks different, is that there's a shift from those sensory circuits that lead to immediate pain experience and immediate action, to circuits that you could characterize as related to emotion and avoidance. And so that's been one of the really interesting themes in the literature. And what that means is, is that chronic pain may be different than the kinds of pain that you get from pinching and poking and so forth. And to me, what this means is that the way in which it's different is that it's not just about the sensations coming in and the immediate pain, it's about the long term avoidance that you attach to it. It's about the, the suffering that you attach to it. And that's the result of a learning process. So we can, you know, learn something that something hurts right now, right? So that's an immediate experience. But then if, if something predicts that, then we can start to respond to that thing. So maybe it's a certain movement first and that predicts. And so then the movement starts to elicit this avoidance signal, this bad suffering kind of signal. 

Judith Warner:  So to put this in concrete physical terms, if say, I injure my back playing tennis and I'm in agony for a week or two, and then I gradually recover, are you saying that my brain could re-activate the pain again the next time I’m on the court in anticipation of an injury, even if I was fine?  

Dr. Tor Wager: Yeah. Our brains generalize and predict. And so it's the things that predict the pain that become painful in this way, right? That, that we're, in it's essentially our brains are anticipating and avoiding in advance because it's trying to protect the organism. And the problem, I think, happens with chronic pain when people get stuck in that phase and they don't then bounce back to the other side.

Judith Warner: So Yoni Ashar just told us that this way of thinking about pain is pretty new. In part, it’s come about thanks to new ways of using brain scans to see how different parts of the brain work together under different circumstances, and I think in part, it’s come about along with the emergence of your specialty, cognitive neuroscience. I’m going to admit that I had to do a bit of research to start to understand your specialty in relation to the other brain sciences. Can you help out our listeners so they don’t have to start Googling?

Dr. Tor Wager: Well, the idea is that everything that we think and feel, every emotion that we have, has some physiological basis in the brain. And mostly, we can't see those yet. So the neurology underlying these processes is really complicated. So we can just see the tip of the iceberg, but the idea is to develop measures of the brain that are sensitive and specific to particular kinds of mental events, pain being one of them and what cognitive neuroscientists do, broadly speaking, is try to understand how those psychological processes map onto brain processes, and that can give us a handle on how we can treat them. How we can intervene and affect the brain and thereby affect the mind.

Judith Warner: It seems like with pain, there really have been big leaps forward over the past 10 or maybe 20 years in terms of what you can see with imaging. Is that right?

Dr. Tor Wager: That's true. I think, when I started studying cognitive neuroscience, it was unclear how reliable brain signals could be. And, the studies were small, the technology was early, and the results were frankly all over the place. So when I was a student, that was one of the questions I asked myself, you know, “How, how good can brain imaging be?” And in particular my lab uses functional magnetic resonance imaging — fMRI — which is one of the most widely used brain imaging technologies. And we, we asked ourselves, “How good can this be?” And recently over the past years with the study of pain, we've realized that it can measure processes that correspond to human pain, uh, much more reliably than I had thought possible in those early years.

Judith Warner: In the early years, when you began as a graduate student, doing this work and then, you know, early on as your time as a professor, I don't know how old you are, but was this before the use of fMRI or was it, did it all happen around the same time?

Dr. Tor Wager: I'm 47, I think, and the tool – I was one of the first group of graduate students that came in explicitly using fMRI as a primary research tool. So it had just been developed. The first functional neuro imaging signal with fMRI was, was done in 1991. And so prior to that, it didn't exist. There were other technologies people have used. And, uh, I think for me, at least all these techniques have their strengths and weaknesses, but fMRI has taken it to a new level in terms of being able to image the whole brain. You know, we can get about 300,000 bits of information about local brain activity every half a second. So there's just this river of data coming in about what's happening in a person's brain, as they're experiencing pain, as they're feeling emotions, as they're directing their attention to one spot or another and doing other tasks. 

Judith Warner: How does fMRI make that possible? What's the unique information that it gives you?

Dr. Tor Wager: FMRI is a magical technology, really, I think. It's, um, it, it uses signals that are related to blood flow and blood oxygen and it takes advantage of some properties, uh, in the blood of, of hemoglobin when oxygen is, is pulled out of the blood, into the tissue to support mental processes and brain processes, then, there is an oxygen change and then there's a blood flow change. And what that means is that the, the protons are spinning a little bit differently. There's this magnetic signal and the MRI scanner uses, uh, these principles of nuclear magnetic resonance imaging to pick that signal up and then to reconstruct it into a three-dimensional image, which is a Nobel prize winning, uh, development. Right, that you could, you could create an image of what's happening in somebody's brain at, at every point.

Judith Warner: And so, coming back to pain and what's been learned more recently about pain. How did you, I mean, I think you started with thoughts, emotions, memory, belief I know, was very important in mapping those things. And I believe pain came a little bit later, is that right?

Dr. Tor Wager: That's right. I mean I started off my career studying the control of attention and how people learned to direct their attention. And I think I was interested in that because I've been interested in, in self-control and what are the effects of our thoughts, how we deploy our thinking machinery, and what effects it can have on our brains, on our bodies, on our lives. And I gravitated towards studying emotions and pain. And it's partly because I think those are the things that are so central to what drives our behavior, what drives our lives, you know, what really determines our success or failure. 

Judith Warner: In our previous conversation with Yoni Ashar, one of your former students, we talked about the pretty impressive and surprising results from the study that you were part of looking at Pain Reprocessing Therapy.  You looked at people’s fMRI results before and after treatment. So what did you see on those images? 

Dr. Tor Wager: Yeah. The fMRI differences that we saw, were reductions in some of the areas that code pain experience, and that are the most important for determining the emotional value of pain. And we, we scan people pre and post-treatment, so that's originally and after a month. And, I also wanna say that, in terms of knowing what it is that works, like with any psychological and behavioral treatment, there's no one specific ingredient that's doing all the work, right. So the way I see it, what works with PRT is, we give them this personalized assessment. So we connect the idea that pain isn’t in their back itself. Um, and we, we try to make it real for them and then give them this alternative narrative and give them hope. You know that “Yeah, you could actually get better. You know? We've seen people like you get all the way better.” And that's something that is pretty rare. I think a lot of care providers, physicians, psychotherapists and so on, are pretty reluctant to say, “You will get better” because they don't know. Don't lie to people, right? You can't do that, but you could give people hope, because it is possible, right, that they got better. 

Judith Warner: How widespread is this kind of treatment right now? And how is the medical profession, the physical therapy profession, you know, all of the related parts of the pain industry, how open are traditional practitioners to this? Do insurance companies reimburse it? You know, is this being welcomed as something useful, helpful, something that will additionally help get us out of the opioid epidemic or are people putting up barriers because it's potentially threatening? 

Dr. Tor Wager: I think it's early days, uh, to, to say. Um, what I've seen from the study is a lot of interest. And I think it can be rolled in under the umbrella of, of CBT because it really is a, you know, a version. There's some changes in sort of what you tell people, what confidence, where you set the upper limits of how, how good they can, you know, become. Um, but, but it really, is, is in fundamentally, it's in that same family, you know, which is insurance reimbursable, you know, already, right. It doesn't have to be a brand new thing. What I, what I hope happens is that people will take the principles of this and take them into their practices, you know, in a way that fits for, for what they're doing.

Judith Warner: So one thing you were curious about, coming out of the chronic back pain study, I think was, can you predict who's going to react well to this kind of therapy? Are you still asking yourself those questions? Have you made any progress in finding any of that out?

Dr. Tor Wager: The biggest predictor, isn't a demographic characteristic. It's not whether you're male or female, or if you had shorter or long duration pain. It’s whether this idea clicks in for you. I've had people in our lab who had chronic pain, uh, you know, low, low level, but real, you know, chronic pain. This clicks in, and they they're actually better. Right. They realize it. And then the unwinding process starts. Um, so maybe that's what some people need. So the best predictor was a change in your pain beliefs. And by pain beliefs, I mean, whether you'd agree that, um, if you were gonna try to control pain, it would just get worse or that if you were to, to move in this way, you'd experience unbearable pain. So these feelings about the causes of pain and about the future consequences of pain.

Judith Warner: And finally, so many people suffer from chronic pain. I think it's something like one in five Americans. Do you have any sense of how many of them might have the kind of pain that could be treated with something like pain reprocessing therapy?

Dr. Tor Wager: I think pain is, is so pervasive because it's a sign of, of many different things that can potentially be wrong, you know? So it occurs in almost every area of medicine and you know, many, many disorders. And so it's, you know, it's humbling. The more we find out about the neuroscience of pain, the more complex we see it is. So I, I don't think it's right to, to simplify things down to, you know, “All, all chronic pain is just fear in your brain” or “all chronic pain is safe, but just pain.” But the message is that a, a lot of it actually is.

Judith Warner: Well Dr. Wager, this has been really great. You’ve covered a lot of ground. Um, I know you said this is early days, and I’m very eager to see where it all goes. In fact, I know a lot of people are going to be really eager to see where it goes. So thank you! 

Dr. Tor Wager: Great. Well, it's, it's been really a lot of fun.

Judith Warner: Thank you so much for listening to my conversation with Dr. Tor Wager and Dr. Yoni Ashar. Join me next week when I speak with Dr. Matthew Johnson of the Johns Hopkins Center for Psychedelic and Consciousness Research. We’ll learn about how psychedelic drugs could soon become FDA-approved treatments for conditions like depression and addiction.

Dr. Matthew Johnson: I just don't know of another drug class where you have examples of people saying that they did this drug one time, sometimes like 30, 40, 50 years ago. And they say it changed their life for the better.

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