Tools to Reduce & Manage Pain | Dr. Sean Mackey

KEYPOINTS

• 01

  Nociception isn't pain; the brain creates the experience

  Mackey's central message is that signals from an injured shoulder or neck are nociception, electrochemical impulses that the spinal cord modifies and relays upward. Pain only arises when those signals converge with brain systems for emotion, cognition, memory and action. That makes everyone's pain unique, and it's why the biomedical model's assumed one-to-one link between injury and pain is wrong. Chronic pain affects about 100 million Americans and costs roughly half a trillion dollars a year.

• 02

  NSAIDs and acetaminophen: weigh healing against function

  Ibuprofen and naproxen are the over-the-counter NSAIDs. Ketorolac and celecoxib (a COX-2 inhibitor that is gentler on the stomach) require a prescription. Acetaminophen acts more centrally in the brain. Mackey says two extra-strength Tylenol four times a day is safe for many people with good liver function who don't abuse alcohol, though guidance varies between 2 and 4 g a day. On worries that anti-inflammatories slow healing, his approach is pragmatic: if a drug helps you sleep and function, that also aids recovery.

• 03

  Caffeine boosts painkillers

  Caffeine touches the prostaglandin pathway, which is why it helps with headaches and migraines and potentiates analgesics. Because both caffeine and NSAIDs can irritate the stomach, Mackey suggests having food in your stomach when combining them.

• 04

  Gate control and descending pathways change the volume of pain

  Patrick Wall and Ron Melzack's 1960s gate control theory showed that fast touch fibers activated by stroking can damp pain signals in the spinal cord, which is why rubbing a bump helps. Pathways descending from the brain also inhibit spinal pain signals. In conditioned pain modulation ('pain inhibits pain'), a second painful stimulus reduces the first. This system appears impaired in conditions such as fibromyalgia.

• 05

  Cold, heat and pain thresholds

  The traditional rule is cold for about the first 48 hours after an acute injury, then heat. Cold reduces release of inflammatory sensitizers like prostaglandins, cytokines and histamine, and slows nerve firing. Heat increases blood flow and relaxes muscle. Mackey sees huge individual variation and tells people to use whichever works. On average, men have higher heat-pain thresholds than women, but he calls 'men are tougher' a terrible conclusion from small average differences, since a lower threshold may even be protective.

• 06

  Psychological tools measurably reduce pain

  Distraction helps but fails at night, when people with chronic pain most need it. Jon Kabat-Zinn's mindfulness-based stress reduction, which involves non-judgmental acceptance of pain, has evidence for low back pain, anxiety and depression. Mackey says 'everybody should do MBSR,' while stressing that these tools work for some people some of the time. Cognitive reframing of what the pain means is a third approach.

• 07

  Hurt isn't harm, and catastrophizing amplifies pain

  Knowing the difference between hurting and being injured is central. Anger reliably makes pain worse. Mackey cites John Burns's distinction between 'anger out' (expressed yelling) and 'anger in' (contained seething), with data suggesting 'anger in' is worse. His clinic tracks depression, anxiety, anger, fatigue and sleep to treat the whole person.

• 08

  Opioids are a tool, and abrupt cutoffs backfire

  Mackey rejects binary thinking about opioids, which the body also makes endogenously. Some doctors overprescribed after buying marketing claims, but he also describes a well-managed patient cut off from occasional Vicodin who turned to black tar heroin. When California targeted prescribers on death certificates to cut opioid deaths, deaths doubled because doctors abandoned patients. He favors gentle, compassionate tapering and not conflating the overdose crisis with the pain epidemic.

• 09

  Kratom and cannabis remain uncertain

  Mackey worries that kratom's purity and dose are unknown. In controlled lab settings, cannabis has been shown to reduce pain, but products vary widely in THC-to-CBD ratio and dose. He says cannabis 'clearly' should not be a Schedule I drug, which hampers research.