Chronic Pain: Shedding the Second Dark Age | Erik Vance | TEDxJacksonHole


Translator: Tanya Cushman
Reviewer: Silvina Katz Let me give you a quick headache remedy. It comes from Aretaeus of Cappadocia. He was a first century B.C.
philosopher, physician, and kind of a quack. It went like this: you make an incision
right here along the hairline, and then you chisel down through the bone into that spongy layer
between the skull and the brain, and then you let it all heal over, and once it’s healed, no more headache. He wasn’t the only one
who had some interesting ideas about pain relief in olden days. There was, of course, eel innards
that are dried in an oven – you could use those. Or you could take ox bile, mix it with some suet and some urine, rub it all over your body
and then sit next to a fire until you couldn’t handle
the pain anymore, and when you stepped away, the pain in the other part
of the body would be gone. My favorite is if you have a toothache, find a donkey and give it a big kiss. (Laughter) Now you laugh, except
the people back in those times actually believed these things worked. Otherwise why would they
go through it, right? Why, indeed? I would argue that the reason
they went through it is because it actually did work. And by the time I’m done, I hope to convince at least some of you that maybe kissing a donkey
when you have a toothache isn’t such a bad idea. I should start by saying
I am not a scientist; I am a science writer,
which means I’m a storyteller. Like the Brothers Grimm, I use stories to try to find
a more profound and deep truth, the difference being
that my stories are true – are based in fact – because I find that truth
is actually cooler, more interesting and more astounding than anything you could
ever come up with in fiction. I also don’t come to this idly. I was raised in Christian Science, which means I didn’t go
to a doctor until I was 18 years old. If you who don’t know, Christian Science is an American religion
that relies on faith healing, and basically, Christian Scientists
believe that all the matter around us are sort of a mental construct, and that they’re reliant on us – or a higher truth that’s beyond that – that controls it and is also
connected to your mind. It’s kind of like – You ever see the Matrix and how
Neo could see the world around him, but there was also this higher
thing that was beyond it? That’s sort of how it works, and it’s kind of a weird way to grow up – thinking that the entire universe
is a mental construct. I mean, try explaining that
to your third grade show-and-tell; it’s a little complicated. And as I got older, I sort of lost
touch with my religion, and I started experimenting
with drugs a little bit, you know? Tylenol … aspirin … (Laughter) a little Bayer every now and again. But I never lost that curiosity I had for how I had been healed
when I was a little kid. What I came to understand
was that, at least in part, what I’d experienced was related
to something called “the placebo effect.” Now forget everything you think
you know about the placebo effect, the pills and all
that other stuff you hear; it’s a much wider and deeper
thing than you think. So that takes me to my first story, and that will be in Bethesda, Maryland, at the National Institutes of Health where a scientist
by the name of Luana Colloca was nice enough to electrocute
me for half an hour. She hooked me up
to a machine – it was wild – and I saw two lights. I saw green lights and whenever I saw the green light,
I’d get a little sort of zap, a little pinch of a shock. Whenever I saw the red light,
I’d get a big shock. This was one that made
my foot twitch. It was a real, real strong shock. Then she went back and forth:
red light, green light, red light, green light, until every time I saw that red light, I was like, “Dear Lord, what is coming?” And after a while, it felt like maybe she had turned up
the green light just a little bit, like from a one to a two,
but nothing like the red light. And she walked in and said, “Thank you very much. You’re all done. By the way, on that last round
we gave you the big one every single time. And I was floored. I mean, I didn’t feel any pain whenever I saw that green light. And until that point, I sort of thought of the placebo effect
as kind of a form of self-delusion or maybe a story we told ourselves, but what I realized was this was
not me telling myself something; this was something very real. And I came to understand
that the placebo effect is, at least in part, not self-delusion, but it’s actually chemical. Let me tell you what I mean by that. If you could boil down
the brain to one job, if the brain just did one job, if you had to get really specific, what it is, it’s a prediction machine. All day long, it’s making predictions. They could be little predictions like the ground will be hard
when I step on it, or when I drop something, it will fall. Or it could be big ones
about hunting in the plains next year, or whether the Cubs
will win the World Series. But, basically, that’s
what your brain does. It takes the past, applies it to the present and tries to predict the future. And so what a placebo effect is is essentially when reality doesn’t match
the prediction or the expectation. And what’s interesting about your brain
is when those things don’t match, sometimes it’s easier to change reality
than it is to change the expectation. And here’s how your brain does that: Imagine if you burned
your hand on the stove, okay? and you quickly put it
into some cold water. Now imagine that pain relief
going up your arm, into your vertebra, into your thalamus, and then it moves into the ACC
and the hippocampus and works its way
into the prefrontal cortex, and you think, “Oh, I feel better.” Okay? Placebos work just like that,
except they go backwards; they start in the front and work their way back
into the deeper parts of your brain, and all along the way,
they’re releasing drugs as they go. And your brain has a whole suite
of drugs at its disposal; it’s often called the internal pharmacy. You’ve got serotonin. You’ve got dopamine. You’ve got cannabinoids,
which are found in marijuana, and you’ve also got opioids. And opioids are probably what I felt
when I was getting electrocuted. Now, opioids bring me to my next story,
which deals with chronic pain. And for that, I want to cross
the street from the NIH Labs, to the Walter Reed medical center
and meet Christopher Spevak. Christopher Spevak is a fabulous doctor
who works with veterans who come back from war zones
with terrible injuries – many of them have lost limbs. And with those injuries
come a great deal of chronic pain, and that’s Spevak specializes in. Now, when he meets his patients, he doesn’t ask about their
symptoms or about the injury; he asks about their childhood, specifically about sensory
experiences in their childhood. So, maybe it’s the smell
of eucalyptus trees outside of their house
when they were growing up. Maybe it’s the sound of jazz music
as their mom’s making dinner. Maybe it’s – you know
those little Werther’s caramels that your grandmother always had
for you when you were at her house? It could be that. And he ties those experiences
to the drugs that he’s giving. So every time you take an opioid pill, you take a caramel, or you smell some eucalyptus, or you listen to jazz. And over time, he starts
backing off the drug, and just giving you
the sensory experience. And what’s happened is your brain has created an expectation
that you will feel better, and so it will step into the gap and start self-medicating
the way it normally would. He’s had tremendous success with this: He’s got some older patients
from the Vietnam War who’ve been on opioids for decades, and the more recent patients who he’s been working with this technique have been able to completely
ditch them within months. It’s a phenomenally powerful thing. And this is an important question
because, as you probably know, the opioid crisis in today’s world
has become an epidemic. And I found this really ironic because opioids and morphine were like the quintessential
enlightenment drug. I talked earlier about drilling
into your head and kissing donkeys. That was sort of this dark-ages era
way of treating people, and the enlightenment brought us
into an era of reason and science and, most importantly, mechanisms, okay? And the mechanism
that made opioids so amazing was that they mimic the brain chemicals
that you already have in your head to control pain. Which was phenomenal. Problem is the thing that makes them
so effective at killing pain also makes them very addictive. Over the next 10 years, drug use is predicted
to kill some 500,000 people. That’s more than guns. That’s possibly more than cars. Now you might say, “Why don’t we
just give out pure opioids?” But remember that one in four
Americans suffer from chronic pain. What are we supposed to do with them? The reason why we are losing
the war against opioid addiction is that we are losing the war
against chronic pain. No one knows this better than Sean Mackey, who’s an amazing scientist
and physician at Stanford University. He told me once – he’s a pain doctor – he told me once, “I’ve got a 40% chance
of curing my patients; if I was a baseball player,
I’d be making millions, but as a doctor, that is not good.” And he’s this brilliant guy,
an MD and a PhD, and he hates being at such a disadvantage
against the disease that he’s combating, and he’s become almost desperate for new solutions and new ways
to think about pain, so he started looking
at meditation and mindfulness. He even looks at transcranial
magnetic stimulation, which is this sort of device that electrocutes your head
in very small doses, and it doesn’t really work
much better than a placebo, yet. He’s also got a machine
that you go inside of, and you can see your own pain
while it’s happening, and you can try to bring
your pain levels down – you can watch it
as your brain is processing it. It’s phenomenal. And he’s just hungry
for any solutions he can find. It’s funny because the one
that always pops up in my memory is where he says that if he gets
a lapsed Catholic in his office, one of the things he’ll say is “Why don’t you try going back to church?” And he doesn’t do this because he thinks
God’s going to heal this person; he does it because it’s a way
to start to get control of your disease. It’s a way to create an expectation
that you will have pain relief. This is not about superstition; this is about belief. This is about the same kind
of thing Spevak was tapping into, and the same thing
I was tapping into in that chair. Call it a new sort of enlightenment: tricking the brain to heal itself. See, the old enlightenment
brought us out of superstition and into a world of science and reason. But I think we need
a new sort of enlightenment that brings us into a new way
of looking at pain control. What’s ironic is that it actually
brings us back to the same mechanism that was involved in the Dark Ages, which, you can call it belief, or you can call it expectation, or, if you like, you can call it
placebo or brain chemistry, but you’re tapping into the pain relief
that’s already inside all of us right now. Thank you. (Applause)