#111 - Dr. Sean Mackey - Why Your Brain Keeps You In Pain (And How To Break Free)

Dr. Sean Mackey reframes pain as more than a simple signal from injury by showing how it’s shaped by the brain, perception, and experience. He breaks down why chronic pain can persist even after the body heals, and how our understanding of it has been oversimplified for centuries. This conversation offers a clearer, more empowering way to understand pain and what it actually takes to reclaim your life.

Timestamps: 
00:00 Pains As An Experience, Not A Feeling
01:07 Nociception & Pain
06:20 Seeing The Brain As Separate From The Body
08:53 Dr. Mackey's Background
20:25 The Most Common Types Of Pain 
22:15 The Process For Helping People
28:39 Hurt vs. Harm
40:38 What Makes You More Susceptible To Experiencing Chronic Pain
45:36 Experiencing Pain, But No Physical Issues
54:07 Placebos & Pain
1:03:32 The Importance Of Language When Talking About Pain
1:07:13 The Future Pain Care
1:11:53 Parting Words 

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Transcript

Dr. Sean Mackey reframes pain as more than a simple signal from injury by showing how it’s shaped by the brain, perception, and experience. He breaks down why chronic pain can persist even after the body heals, and how our understanding of it has been oversimplified for centuries. This conversation offers a clearer, more empowering way to understand pain and what it actually takes to reclaim your life.

Tim Doyle (00:06.486)

How does it help to see pain as an experience rather than a feeling?

Sean Mackey (00:14.296)

We open up by saying that pain is probably one of the most misunderstood experiences in medicine. It's real, it's biological, and it's shaped by much more than just tissue injury alone. Sometimes it tracks injury closely, and sometimes the nervous system becomes overprotective. The challenge is to avoid overly simplistic stories.

and understand what's driving pain in a particular person. And hopefully we'll unpack some of that during our discussion here.

Tim Doyle (00:52.32)

Yeah, I feel like we have such an incomplete understanding of what pain truly is. And that's what makes the experience of it that much more unbearable. Like we're unconscious and blind to what's really going on, which makes it that much more fearful. So I want to, within our conversation, really counteract that and give people a better understanding of that. And I think an important place to start with that is this relationship of

no deception and pain because I don't think that's a term that many people know what that is.

Sean Mackey (01:28.482)

Well, you're right. Gosh, I got to tell you in interviews, it's rare that somebody would actually ask me that question and even bring up that term nociception because in the past it was so jargony that it just didn't lend itself to common language. So this is great that it's starting to get into the vocabulary. It's an old term. It's a Greek term. And nociception is the nervous system detecting

possible tissue threat or injury. It is what's going on, for instance, out here in the periphery. If you hit your thumb with a hammer or you step off a curb and you twist your ankle, those nervous system impulses that are transmitted because of tissue damage or maybe the threat of damage, that's nociception. And that's to be distinguished from the conscious experience

that is pain that may result as a consequence of that nociception. So they can overlap, but they're absolutely not the same. And there's a historical reason why we conflate these frequently. I frequently go back to René Descartes, the 17th century French philosopher. Brilliant guy gave us Cartesian geometry that...

we were all probably tortured with in grade school. One of the godfathers of modern philosophy, he came up with the first mechanistic understanding of pain. He was the first, because before that, pain was thought to be due to, you know, something that you were morally deficient in or a punishment from God. So he came up with this model. The model...

was this dualistic model which had a direct linkage between the injury out here in the periphery and the brain and the reflex action of your moving away from it. It's a one-to-one experience. And that model, what he did is he tied nociception to pain directly. He linked them. And unfortunately, that linkage was carried forward.

Sean Mackey (03:52.367)

for hundreds and hundreds of years. And I will share with you, it's even present in medical training and sciences today. And what we're trying to do is break that linkage and help people understand. There can be overlap, but they are still quite different.

Tim Doyle (04:10.293)

So is nociception pretty standard and objective among all people and then the experience of pain is very individualistic or can nociception change person to person?

Sean Mackey (04:23.938)

Wow, that's a great question. We know probably more about what generates now the experience of pain because of the work that our lab and others have done through brain imaging. And we're understanding better the individual differences that shape our experience of pain. The individual differences in human nose deception, I think we're beginning to tease apart, but it's been a little harder and.

you have to get into a measurement of tiny little nerve fibers, C fibers and A delta fibers, something called micro-neurography, in which it's still a relatively new science. So if you're asking the question, for a given stimulus, a given increasing temperature, increasing pressure, do we all transduce the same signal the same exact way?

I don't know. I think there's commonalities. I think there's a lot of shared aspects. We're probably going to find that there are some unique differences as well. Because the thing is, is if you're asking about nociception and the processes, you you want to capture things before they hit the spinal cord because the spinal cord is acting like its own little computer that's shaping those signals, sending it up to the brain.

but then there's all this inhibitory or down regulation that's coming back down into the spinal cord. So it's a really complex closed loop feedback system.

Tim Doyle (06:05.043)

In an anecdotal kind of cultural way, why do you think it is that we see the brain and the mind being separate from the body?

Sean Mackey (06:17.678)

Because it's simple. It's a simple explanation and it aligns with our personal experiences most of the time. Meaning, somebody gets an injury, we immediately equate that with pain. And we can relate on an individual basis. And we're taught that the injury is equivalent to pain.

It's a nice, simple, easy story to digest. It's much, much harder to take the leap and think of pain as this conscious individual subject of experience that can occur in the absence of something that we obviously see. And that's where in society now we need to all take that leap and understand that. And I think that's

Sean Mackey (07:19.414)

A lot of what our research is doing and what other people's research is doing is try to unpack that and help people understand why. Because as maybe we'll get to a little bit later, so many people have been invalidated, stigmatized, because they're claiming, they say that they've got chronic pain, but you can't see it.

Tim Doyle (07:45.726)

Yeah, I I dealt with chronic back pain a long time ago or feels like a long time ago now, but it was only five years ago. And I think a large reason for why I was in pain for such a long time is because

Sean Mackey (07:50.307)

Yeah.

Tim Doyle (08:06.993)

I was blind to what was truly going on. And when I actually got a real education on pain and how the brain plays a role in it, like that knowledge and education truly feels like medicine in a way. And

Tim Doyle (08:27.733)

the vast majority of society don't have that education. And I want to get into your education a little bit and more so on your personal side. So your educational foundation is actually in bioengineering and electrical engineering. And then you shifted into med school and you get into anesthesiology. And then from anesthesiology, you shift into this pain medicine care.

What was it about pain that made you feel like you found the path that you wanted to pursue?

Sean Mackey (09:02.254)

Yeah.

I'm an example of somebody who did not get good mentoring growing up. I come from a deep working class, blue collar background. I was the first person to go to college and I'm just trying to figure it out. Everybody's got an idea of what I should do, but most of those were bad.

Sean Mackey (09:32.119)

I went into bioengineering because I love technology, but I also love the intersection with healthcare, and I wanted to bring some way of bringing that together, and thought bioengineering would be a great way to do that, and went into medicine because of that interest in healthcare after doing my PhD in engineering. And anesthesiology was a natural attraction to me because of the monitoring and the physiology and the pharmacology. It was very linear also.

appealed to my engineering mindset. It's a big lab. Now, a big lab where you're taking, you've got the life of a human person in your hands, and you take that very seriously where you're inducing a state of unconsciousness during surgery.

And I did a, during this, we do our rotations during residency, I did a rotation on pain and absolutely expecting to hate it. Convinced I was gonna hate it, why? Because nobody likes taking care of these patients, nobody. And that's just a sad fact in healthcare. Now this was 25 years ago, I think it's gotten better, but we still have a long way to go. Why?

don't physicians in general like taking care of people with chronic pain because it's hard, it's complicated. Patients are in distress all the time and at least when I was doing my rotations we had very few tools and our understanding was more limited.

And so most try to shy away from engaging with these patients or you try to get them out of your clinic office very quickly. So I went into this thinking I wasn't gonna like it and I was exposed to faculty members then, who became my mentors, who showed me that they could help transform these patients' lives and help get them back to a quality of life and physical functioning that they missed. And it was a real eye-opener for me.

Sean Mackey (11:35.427)

And I looked at the field and I saw it was incredibly messy. And I saw though this tremendous opportunity because we're practicing in the dark ages in pain management. We're still using opioids that have been around for thousands of years. We're still fusing spines, right? You know, I knew going into it that at some point in the future we would look back on what we do and think we were practicing in the dark ages.

And there was an opportunity to try to be a part of that and to help. And what I've seen over the last 25 years is this veritable explosion in our understanding of pain, as well as the treatments we now have available. So one of the take-home messages for people listening in is every day, every year, there's more more hope that we're finding solutions. So that's what really

drew me into it was an opportunity to make a difference. And also, you know, there's the usual family connections of having people who had chronic pain in your family and, you know, feeling that urge to help pay it forward and make a difference. You talked about your back pain aspects of it. And I think I know just a little bit that sounds like this has been a really long journey for you to self-awareness and recovery.

Tim Doyle (12:48.66)

Wow, that's.

Tim Doyle (13:00.178)

Yeah, I mean, I'm proud to say that I'm in a point in my life and it feels like it's been like this for the past few years that the way that I describe it to people is it feels like it's never happened before. Like I deal with zero pain. I'm incredibly blessed. I honestly feel like I'm lucky to a degree that I found what was able to help me after a lot of treatments.

that didn't help me. And I think one of the key things for people with chronic pain is when you try a lot of different treatments, each failed one.

It makes the pain sink into your identity and psyche more and makes it feel like, okay, this is just something that's a part of who I am now rather than understanding of like, okay, this is still separate to me. And yeah, I mean, I could honestly say that if I didn't go through that experience, this topic of pain and, you know, helping people understand pain, it wouldn't be so important to me.

Sean Mackey (13:46.424)

Yeah.

Tim Doyle (14:12.81)

to get into your career and to show that evolution more, about, you know, feeling like, okay, like you started out in the dark ages and, know, metaphorically speaking, like, okay, how do we shine light on this? You've shared that within the last 15 years of your career, the real foundation has been spent on measuring pain in an objective and quantitative manner.

and almost like you went through a shift there where like your focus was on neuroimaging and then developing biomarkers for pain. How has that further developed the way that you treat people?

Sean Mackey (14:54.702)

Wow, you did your homework. I'm impressed. Yeah, I started off much in my career in an area of brain neuroimaging, opening up windows into people's brains to understand how pain is processed and perceived. was coming at this originally as kind of this engineer, this very linear guy, but connecting that with the people that I was seeing in the clinic.

And while I was very initially procedurally interventionally based, I was finding that if I just shut up and listen to people and I heard their fears, their anxieties, their beliefs around pain.

that working through that could make a huge difference in people's lives.

A core understanding that I believed in was that all things we refer to as psychological all have an underpinning from a neurophysiologic basis. The brain is not a black box where things just feelings and beliefs just appear. There is a neuronal basis for it. And that's why the neuro it's it is it is it's exactly it. So

Tim Doyle (16:09.236)

part of the body.

Sean Mackey (16:15.532)

got involved with the whole neuroimaging aspect and helped shape some of the field and understanding individual differences and the impact of fear and anxiety and catastrophizing and other aspects that shape pain. But along the way was questioning what, you know, real clinical impact I was having. And what I realized at the end of the day that the main clinical impact that at least I and I think others were having in this space was giving credibility.

to this notion that pain is a real neurophysiologic phenomenon and that it helped validate people's pain, particularly women, honestly. think women have had the brunt of a lot of being invalidated and stigmatized through conditions like fibromyalgia and others, but men too, let's be clear. Pain doesn't discriminate. But around this time,

15 years or so ago, we start to see the development, just the inkling of biomarkers, these objective measures that may have value in diagnosing pain and predicting pain and prognosing pain. And so I published the first work in brain imaging around this after having bet against myself.

I had some young research coordinators and grad students in my group, I had given lectures on how you'd go about doing this, but was absolutely convinced it couldn't be done because it's such an individual experience, and I didn't think we could distill it down into a common brain system. And these young researchers came to me and asked me for some research funding to do it, and I said, sure.

And I said, I'll do this because failure is a really wonderful lesson for all of us. And you're going to fail. And they came back and the reality was phenomenal findings. And that, I think, set us on the stage for moving forward. Now, the original work was rather boring. It's just diagnosing whether somebody's in pain or not in pain. people would say, do you really need that? And I'd say, well, no, because you can just ask them. But you have to lay a foundation. Now we're moving.

Sean Mackey (18:40.608)

is predicting a future state. Can we take somebody now, take a snapshot of their brain, of their physiologic system, and can we predict where you will be three months, six months down the line? And I'll tell you, we're getting pretty darn close. And the next move, the holy grail, is obviously can we use this objective information to predict whether a particular treatment will be of more benefit to you?

than another? Are you more likely to respond to a particular medication, a physical therapy intervention, a mind-body intervention? And that is the holy grail of precision pain medicine that drives my life, my work, my passion. So that's the evolution of it and where we hope this will all go. My next step in this

is developing something called a digital twin, which is not just building a signature at a group level, but building a software representation of an individual person and being able to predict their response and their trajectory. And this sounds like science fiction. I get it.

But it's already been done in oncology for cancer, in tumor modeling, and it's now being taken on in cardiology, in mapping out and doing simulations of the heart. And I'm convinced we can do this working together in pain.

Tim Doyle (20:22.026)

are the most common types of pain that people come to see you for?

Sean Mackey (20:25.75)

Well, the one you have. The one you had. Back pain, spine pain. So when we look at the numbers, depending on how you ask the question, 50 to 100 million Americans suffer from pain. Now that's across the severity continuum. Within those, probably spinal pain, back pain, neck pain are the biggest.

Tim Doyle (20:27.796)

Back then.

Sean Mackey (20:51.69)

A back pain is the biggest and then probably neck pain and headache are number two and three. Those are the big ones. These musculoskeletal type conditions. You start to get into some of the more neuropathic pain, nerve injury type pain problems, facial pain aspects, and then smaller prevalence numbers on abdominal pain, pelvic pain.

The list goes on and on.

Tim Doyle (21:23.914)

So diving a little deeper into that precision pain care. So somebody comes to see you, what's the process like of...

Tim Doyle (21:37.162)

seeing it as experimentation versus having a pretty good understanding early on that you think you know what will work.

Sean Mackey (21:49.127)

okay. I pick up when I hear the term experimentation, the academic in me immediately stops because experimentation has a very particular meaning in our world. And when you say experimentation, by definition, I have to get your consent to enroll you in an experiment because we don't experiment on patients without their consent. But I think Tim, or what you're getting at is

the difference between mentally flipping a coin in my head on one treatment versus another, because both may be equally beneficial, or maybe one of a series, they may have what we call equipoise, versus my being able to say, yeah, this is it. This is definitely it. And I'm going after it. Is that is that the nature of your question?

Tim Doyle (22:47.028)

Yeah, I appreciate you making that distinction. That's exactly what it is.

Sean Mackey (22:49.612)

Now, I think you were clear. It's just in our world, you know, we live within these rules.

Great question.

Sean Mackey (23:05.506)

I think most of the time.

It is a bit of trial and error. It's more than a bit of trial and error. And I'll tell you that that is also one of the more frustrating things for patients. People come in, it's 2026. I think people have an expectation that in modern healthcare and science, we've got it figured out. And we can target the thing. And we can open up our textbook, point to a journal and say, this is it.

And unfortunately, we're just not there. We often have to go through this laborious, frustrating trial and error process of trying one thing after another until we find a win or frequently it's a series of things where we get a little bit from this, a little bit from that, and we build up. What was your experience like?

Tim Doyle (24:01.448)

Yeah, so I mean, I talk about that more because I think it's really, really crucial. I mean, I feel like we get pain care backwards to a degree. And I really didn't have this realization until diving deeper into your work because your focus is around pain care. Like we're putting pain at the center. Whereas within my experiences,

you know, we have physical therapists, have chiropractors, have acupuncturists. And so we put the philosophy at the center and then the person and somebody's pain revolves around that. Whereas it feels like with your work, it's like, okay, we're putting the person and we're putting in the pain at the center. And then we're going to try a lot of different things around the person.

Sean Mackey (24:51.704)

Yeah. Could I take a stab at this? Are you describing the classic Indian parable of the blind men and the elephant? it that the physical? Well, so the parable is that you've got these blind men and they're surrounded, they're next to an elephant and one feels the elephant's leg and thinks it's a tree. Another one feels the elephant's trunk and thinks it's a snake, you know, and

Tim Doyle (24:59.966)

I've never heard that parable.

Sean Mackey (25:21.226)

Everybody is perceiving the elephant incorrectly by their piece that they've got. And the message, obviously, in this Indian parable is you have to put it all together and look at the elephant as an elephant and not individual pieces.

Tim Doyle (25:39.914)

That's exactly what it is. Because I, you know, from my personal experiences, it's like, okay, I saw five or six different people with different philosophies and telling me different things. So, you know, we put the philosophy at that treatment in the center and then me being the individual with the pain had to revolve around that rather than, okay, let's put the individual in the center.

Sean Mackey (25:49.4)

Yeah.

Tim Doyle (26:09.573)

and have the treatment to revolve around the person.

Sean Mackey (26:13.506)

Yeah, what's clear in listening to you, we haven't talked before, is you've developed an incredible amount of resilience through this transformation and through that tremendous amount of growth and learning through this.

I wish everybody could be like you, but it's not the case. I think that's where clearly your podcasts and your messages are working to help people. And in large part, that's what I'm doing as well, is often a bit of a life coach or somebody who's helping to connect all these things. And as you said, I think eloquently, see the person for a person and not just a body part. But in our super specialization of health care,

That's frequently what happens though is we approach a patient through the cognitive lens upon which we were trained. If you're an orthopedic surgeon, you see them as bones and ligaments. if you're a neurologist with a nervous system and you're a GI doc, you're seeing everything around the gastrointestinal system.

that's healthcare. And to be very clear, those were just examples because there's a lot of orthopedic surgeons, neurologists and GI docs and others that are really good with comprehensively putting it all together. It's more a message around healthcare than the specialties.

Tim Doyle (27:47.018)

think an important distinction that also needs to be made when understanding pain and having more appreciation for it. And I think it can be difficult to understand at the onset, but this distinction you make when it comes to pain between hurt versus harm. Can you explain that more?

Sean Mackey (28:08.802)

Yeah, yeah. One of the most critical pieces for people to understand is that pain is fundamentally our harm alarm.

it is a experience, a signal to us that there is potential damage, danger. And with that, and frequently missed in the definition of pain is a motivational aspect.

meaning that one of the primary goals of pain is to motivate you to get away from danger, from harm. And the beauty of it is, in an acute pain situation, it's terrific. mean, pain is so wonderful because it's so terrible in an acute situation. Without pain, we would have died out as a species, clearly.

Sean Mackey (29:11.17)

Where it becomes a problem is when those alarming signals are no longer serving a survival basis for us. When the source of danger of injury is gone, but we're left with pain. And that's where you can get into this continuous state of hypervigilance around the pain. You guard.

you splint, brace yourself, and you get into a cycle of disuse, dysfunction, and then disability. That can lead, I hope you don't mind, Tim, I'm just kind of taking down the path here.

Tim Doyle (29:56.658)

No, this is really important, so I love it.

Sean Mackey (29:59.629)

That can lead to this concept of the fear avoidance model of pain. And this has been described decades and decades ago. think Vilean has gotten a lot of the early credit for this, and appropriately so, and where what happens is you tend to get into this fear avoidance cycle of pain that spirals out of control.

and you tend to start to reappraise or think about your pain in a rather, what the term is, catastrophizing or catastrophic manner. And you don't tend to weigh as much the values, the positive values in your life meaning to the extent that you did. Now, I used a term catastrophizing.

terrible term. It was a term invented by this guy Albert Ellis back in the early 60s. He's a godfather of psychology, one of the forerunners for modern cognitive behavioral therapy. And he was a real character. came up with all these new neologisms, new terms. He just made up words. One of the words he made up was catastrophizing. And catastrophizing, it was not meant for pain, but it

is used, we frequently use it for pain. It means rumination about pain. It's repetitive thoughts. You can't get the pain out of your head. You're just continually thinking about it. It's amplification of your pain, meaning you perceive it as being worse and worse and worse despite the amount of injury or damage not really changing. And three, there's a sense of helplessness.

or loss of control over pain.

Sean Mackey (32:01.688)

And that catastrophizing, term, terrible term, but there's a neurophysiologic basis for it, is probably one of the biggest predictors of people having persistent pain and having poor treatment response. And this fear avoidance of pain,

Sean Mackey (32:24.244)

is one of those that lends itself well to these mind-body treatments or interventions that maybe we'll get into. But did I cover the hurt and harm aspect?

Tim Doyle (32:40.561)

Yeah, that was awesome. And I think you kind of get into a Pavlovian programming where you feel the sensation and then that sensation triggers thoughts and emotions. So you're not really actually

even thinking or focusing on the pain or what's, you know, you're feeling within your body, but you're thinking about sort of like the story and the narrative of what that sensation means and why it's happening and why it's so bad. And I think an important counteracting force can be mindfulness based stress reduction. Can you talk more about that?

Sean Mackey (33:22.924)

I can't, may I ask you a question before getting into it to help frame this is when you were going through this experience of back pain and you were talking about this unconscious aspect, did you equate your back pain with ongoing injury in your back? Did you perceive there was something structurally wrong, something that when you move,

and you experienced pain that you equated that with more tissue injury or more tissue damage and that there was something fundamentally wrong there. Yeah.

Tim Doyle (33:57.514)

100 % every single time that I feel and I became so hyper vigilant that like the tiniest sensation I'd be able to feel and that's what I mean by that Pavlovian programming is that the sensation would then trigger in my head and my thoughts. this means because discs are pushing, you know, deep onto spinal nerves and that's why I'm feeling this pain. So I think for

A lot of people, especially when it gets into mind, body care, because that's sort of what I understand most, because that's what helped me. It's about unraveling that story and that narrative. And I think for a lot of people, especially me, it wasn't a story or a narrative that I created for myself or felt natural, but it was just what was told to me. So I was like, okay, I'm going to take this as gospel. You know, this is what's going on. And then what truly helped me was

especially early on, was literally just like sitting with the sensation, just not allowing my mind go to those thoughts anymore, but just sitting with that sensation and understanding that going to this hurt versus harm, it's like, yes, this doesn't feel good, but it doesn't mean something's wrong.

Sean Mackey (35:15.404)

What shifted you? See, there was a cognitive shift at some point in your process between thinking about your back pain as something damaging, threatening, sinister, to having an awareness, a cognitive awareness that your back was stable, your spine was stable, and that you weren't undergoing more injury. What was that process? What?

Tim Doyle (35:43.37)

So I think a few big things were, so the book, The Mind Body Prescription by Dr. John Sarno, I mean, that completely changed the game for me. Like that completely rewired my belief system of what was going on. I had also worked with Dr. Ira Rauschbaum at NYU Langone Health, who was the protege of Dr. John Sarno.

and I had a consultation with him. He looked at my MRI. He's like, yeah, the image doesn't look good, but that's not what's causing your pain. So I think a lot at the start was just almost like buy-in to a degree, but then sort of like putting those tools to use and being able to get evidence pretty quickly. But I guess my claim to fame, so to speak, or this story that I share with a lot of people, because like I said,

the book, The Mind Body Prescription had such a huge impact on me. Read it in literally one sitting, probably like three to four hours on my bed, completely blew my mind and got off my bed. Didn't look or feel pretty, but I bent over and touched my toes. And then was like, do it again, do it again. And that was the first time that I had touched my toes in seven months. And so that was like, and going back because like for six months, it was like, nothing is helping me.

Sean Mackey (37:00.834)

Wow. Wow.

Tim Doyle (37:08.721)

And so I finally got that taste of like, dude, you're getting past this.

Sean Mackey (37:08.942)

Yeah.

Sean Mackey (37:14.018)

Yeah, that's a great story. That's a great story. know, Sarno popularized concepts that had been around for many decades. One of the early people to really popularize it. he got a number of things right. And there was some overlap in this kind of fear avoidance model. They're conceptually different. They both put forward that...

the experience of pain doesn't have to be associated with tissue damage. Sarno's model, I've not read his books, but I'm familiar with the messages, was more of, I think, a psychodynamic message and kind of repressed interpersonal conflict and repressed emotions. More of that valet and fear avoidance model is based on more cognitive behavioral therapy tenants of reappraising

your pain and re thinking about it in in different terms. There's some overlap in those Venn diagrams. The process that you describe was sitting there with your pain and being aware of it and being non-judgmental. That is you brought up a question that I didn't actually answer earlier, which is mindfulness based stress reduction. And that is a key component of that.

I was fascinated by that as an early faculty member at Stanford and I kept sending patients to it and they kept getting better. The scientists in me just wanted to know why, so I went and I took the training and sat in through the courses. It was fascinating and I learned a lot. think honestly, I think everybody, whether they have pain or not, should do MBSR.

I think they should be teaching that in the schools. I went to it a second time with my son when he was a kid at the time. He was unfortunately just like me, but without any impulse control. And I think the MBSR training did him well, just to kind of be with yourself in the moment. And they're good skills for all of us, whether you have pain or not.

Tim Doyle (39:38.603)

100 % yeah, just creating that little bit of that gap between the stimulus and how you respond to it. What are the key factors? Because there obviously there are a lot of people who deal with chronic pain, but then there's people who would say, I've never felt pain before. I've never felt with these chronic types of issues. What are the key factors that make some people more susceptible than others to feeling chronic pain?

Sean Mackey (40:08.492)

Yeah, many. There are classically some genetic factors that play a role. And the geneticists and the psychologists and the neurosciences will debate each other. The geneticists think it's typically a large amount of the variants. The psychologists think it's a small, it's that gene environment argument. But there are some genetic consequences of that.

do much about your genes, but you can do about your environment, your early life experiences with pain and how you grew up as a kid. early adverse child events, early psychological, sexual, physical trauma makes your brain and your nervous system more vulnerable for subsequent traumas, including the experience of pain.

Now, the heck can you do about that if you are one of those unfortunate people that went through that? I think having awareness about it and getting educated about it and building up skills, the MBSR, CBT, understanding that your nervous system may have become more hypersensitized to it. What we've learned is,

Sean Mackey (41:38.041)

people coming into surgery, and surgery is nothing more than a controlled injury, by the way. It's a controlled injury in a sterile environment, but that's all surgery is. That a certain portion of those people coming out of surgery are gonna have chronic pain afterwards. And we've learned that while the surgery itself has some role in that, that what people bring to that surgery or an injury often has more to do with their likelihood of developing.

persistent pain. The amount of depression, anxiety, general catastrophizing, those early child events, all of those can set someone up after surgery, after injury to have that persistence and pain.

Beyond that.

We all have this wide range of individual experiences to the same stimulus. So I typically teach the neuroscience of pain in the Stanford med student classes. what I will do is bringing in this ice bucket, this big aquarium of circulating ice water. And I have the medical students stick their arm in it for 15 seconds.

pull their arm out and they whisper in my research coordinators here what their pain score is from zero to ten. Zero is no pain, ten is the worst imaginable. At the end of the class I plot like the hundred data points and it's like a straight line up. You've got some of the medical students saying that wasn't painful at all, zero. Some saying one, some saying two, all the way up to my god that was the most painful thing I've ever experienced.

Sean Mackey (43:22.38)

the reason for doing that demonstration.

is mainly to help those young doctors to be, to not project their own experience of pain for a given stimulus onto their patients. Because that's one of the biggest mistakes that we as physicians can do, or as people, think, in general, right? You know, we all come with our own pre-calibrated sense of what pain should be for a given injury or stimulus.

and then we project that on everybody else.

where it really becomes a problem and just galls me if you'll allow, is when I see legislators or people in big policy making positions say, yeah, I had surgery and I didn't need any pain medication.

Sean Mackey (44:18.636)

And that's a dangerous message.

We need to recognize we're all different and respect those differences in the way we perceive pain. Pardon me if I got on a soapbox there.

Tim Doyle (44:32.426)

That's what we're here for, to hear you talk. You're the expert and it's great to hear your own personal opinions on that.

You have shared that you understand chronic pain as pain that persists beyond the time of tissue or the body healing.

Tim Doyle (44:54.588)

In the cases of

people that don't have anything actually physically wrong. Like there wasn't any tissue or bodily problem, but they're still feeling these sensations and having this experience of pain. How do you navigate that?

Sean Mackey (45:20.472)

First, I trust everybody. I believe them. And I think that's one of the key messages is you have to validate their experience.

I mean, is it possible that somebody is malingering or making something up? Yeah, but I think I see so few of those people. There's very little motivation to drive all the way to our clinic through all that traffic to come and just make up something about their pain. So it's an issue of validating their experience. One. Two, it's a recognition that medical science

isn't yet there with being able to pick up where a source of pain may be coming from. I think that's the key thing. We tend to trust our scans, our images. Why can't I see this on an MRI? Well, MRIs are...

images of different tissue characteristics, but they may not pick up something that's resulting in pain. It can be some tiny little microscopic nerve that's injured or irritated, kind of pissed off and just firing off signals that are not going to be picked up on an MRI, certainly not on an X-ray. So first thing is validate what people are going through. Establish a trusting relationship.

Sean Mackey (46:54.83)

And then 90 % of what we do is in the history. It's trying to understand that person, their experience, what were they like before they had pain, what may have resulted in it. It's a bit of being a detective and then trying to figure out can we identify a unifying diagnosis or a differential diagnosis, a series of possibilities that

maybe the answer. And then we use our physical exam, we use our physical exam findings and our diagnostic tests and our images to support or refute that. But there's many conditions that we see where we can't specifically identify a source of pain. And at the same time, there's many situations where I've had patients come into a clinic setting who have

been given a label of what's causing their pain and I find out it's actually, it's wrong. That it's actually something else.

So it's one of the things that keeps it interesting. It's like Forrest Gump and the Box of Chocolates. You never know what you're going to get. And you have to approach everybody as a person and with kind of a clean slate and keep an open mind.

Tim Doyle (48:22.74)

Do you know or do you work with Anna Lemke at all at Stanford or do you guys have a relationship at all?

Sean Mackey (48:30.158)

We don't work closely anymore. We used to have a stronger relationship. helped her get her original clinic in addiction medicine set up at Stanford when she wanted to establish it. It was mainly giving her kind of clinic and business advice and setting up a clinic. And she used to come over and do some work within our clinic on the addiction medicine front.

really has kind of gone off in her, she's gone off in her own space in addiction medicine, but yeah.

Tim Doyle (49:05.406)

Gotcha. Yeah. The reason why I bring her up is because I had her on the show last summer and we talked about her work on addiction medicine and dopamine, but we also got into chronic pain a little, especially about talking about people dealing with chronic pain, but with not actually having the physical evidence of anything actually being wrong. And I thought she had a pretty interesting hypothesis on it. especially getting into the

dopamine side of things. She had shared, like she believes we've become so disconnected from our bodies that our brain is no longer used to like normal sensory input. And so it misinterprets those inputs as pain.

Sean Mackey (49:57.953)

yeah, yeah, okay. Yeah, I know this story.

Sean Mackey (50:06.488)

You know, I mentioned earlier that we all tend to look at the world through our own cognitive lens and the training that we bring to it.

I have great respect for Anna, Dr. Lemke as an addiction medicine doc.

and our views on pain diverge dramatically.

Sean Mackey (50:35.564)

I think the data does not support.

the notion that I think some of the messages are that historically, back in the day, 100, 150 years ago, pain was considered something good for you to toughen you up. And we've kind of lost that belief in society and that we tend to over pathologize it.

I disagree strongly with those messages. And I don't think, you the data doesn't support it. And let's face it, we sure as heck do not want to go back to 100, 150 years ago, you know, when honestly, I'd be about 20 years past my lifespan. And I don't know how old you are, but you would have already spent most of your life if not, you'd be done for.

Sean Mackey (51:40.012)

There's a danger between an oversimplifying these messages of pain. And I want your audience to understand the nuance of this. That.

Sean Mackey (51:55.605)

Yes, we can over medicalize pain sometimes, meaning.

We can go through the process of too many tests, too many images, too many scans, searching, searching, searching, and people get wrapped up into that as their identity and the medical system feeds that. And yes, the medical system, we are responsible for that. And that's one, the one, I think, real downside of this over pathologizing pain.

Sean Mackey (52:31.49)

But the danger in that message is that you come back again and you invalidate people. You dismiss their messages, you say that they're not tough, that pain is there to help make you stronger.

And that's just kooky talk. That's just wrong.

Tim Doyle (52:54.119)

Yeah, mean, you can obviously on the one end you can pathologize it, but then on the other end you can culturalize it to a degree.

Sean Mackey (53:05.314)

Yeah, yeah. Yeah, I know if I answered your question.

Tim Doyle (53:09.779)

No, yeah, that was great.

Tim Doyle (53:15.199)

What's the relationship between placebos and pen?

Sean Mackey (53:20.047)

fascinating topic. We're still trying to get this one all figured out. Placebo plate, placebo.

you know, bakes into it, you know, these, these aspects of expectancy related to, for instance, pain relief. And it is, you know, it's the placebo is thought to be it's an inert agent that results in a analgesic benefit when we use placebo for pain. And the fact of the matter is placebo is part and parcel of everything we do in pain treatment. Every

therapeutic intervention, every pill, every procedure, every mind-body intervention has a placebo component to it. What the science has been doing is to try to understand the neural sciences around placebo.

Benadette, Luana Coloca, they've done some seminal work and others in placebo. And we have learned that it's real, much like this concept of pain being a brain-related phenomenon, placebo is also baked into the brain. There's a lot of interest now in maximizing placebo because it works so darn good.

Sean Mackey (54:45.848)

People have done studies even where they tell you you're getting a placebo.

and you still get an analgesic benefit even knowing that it's a sugar pill.

Sean Mackey (55:05.824)

It confounds, it's a real problem when conducting FDA clinical trials on treatments because one of the requirements in an FDA trial is typically, you know, does your treatment beat placebo? You know, is it better? And that's what the drug companies and the device companies are always fighting for is to beat placebo statistically. And the problem is placebo works so darn well that sometimes it's really hard to get above.

What's your thoughts on placebo?

Tim Doyle (55:42.898)

It's the question that I ask myself about my own personal experiences or just a curiosity of like, was there a placebo effect to this? Like I finally had a doctor tell me like, hey, like you're good dude, like go to the gym. And was I able to...

buy into that or did I have the confidence and was that a placebo to a large degree? I don't know.

Sean Mackey (56:09.65)

yeah, yeah. I would say, first of all, accept it for what it is, whether, you no matter what it was, and you clearly have, but yeah. But I would submit to you that while there may have been some aspect of placebo through your patient-doctor relationship and the white coat and blah, blah, that actually what went down was less placebo and more...

Tim Doyle (56:17.821)

yeah, I'll take it. I'll take it.

Sean Mackey (56:37.686)

a cognitive reframing of the threat value of what was going on in your back, which is quite different. You ended up engaging, you know, some of your prefrontal cortical regions that were all this and now having awareness that the threat value to your back was now not there.

And those systems were impacting on things like hypothalamic and amygdala systems and other limbic-related systems that were maintaining some of that threat value and released it. similarly...

Sean Mackey (57:20.686)

you probably started to engage more systems that were valuing the positive things in your life, and those took precedent. Sometimes this happens quickly. I don't know if it happened quickly for you. I tell a story frequently that illustrates that a guy, Bob was a Silicon Valley executive that was wound really tight. And Bob had two small kids, Bob,

ended up with pain in his foot and Bob was a master's level tennis player and tennis was his outlet. mean, this was the thing that kept his anxiety down and his stress level down, but he couldn't play tennis because his foot hurt. He went to doctors that told him that, you know, he had arthritis and his foot was degenerating and to stay off his foot because it was very fragile. Bob comes in and sees me in the clinic on crutches and...

I listened to Bob and Bob's really depressed and anxious and wound up really, really tight. It's taken a huge toll on his life. It's terrible. It's tragic. And I examined Bob and I come to find out that, you know, Bob doesn't have arthritis in it. So Bob has something called a Morton's neuroma, which is just a little bundle of nerves that sometimes grow abnormally in your toes. And it can cause a lot of pain, but there's no damage.

to your foot. Structurally, Bob's foot was fine. And I'm giving you the short version here, but after an hour of sitting there, I told Bob this story. And Bob just looked at me, and he's like, you mean I can play tennis? And I'm like, Bob, can play all the tennis you want. Your foot's going to hurt, but it's not going to damage you. Bob just thought there for a moment, and he pondered, and he's like, OK, we're done here. And he just walked out.

is kind of those magical shifts that can happen. They're very uncommon. So don't let me give you the sense that you had it. You had that something similar.

Tim Doyle (59:21.132)

I had it.

Tim Doyle (59:25.516)

I, not so much of like walking out of the doctor's office and having it, but I remember towards the end of my consultation with Dr. Avera Rauschbaum at NYU Langone Health when it was, you know, getting deeper into the mind, body stuff. And I asked him at the end, I was like, so can I go to the gym? And he was like, do you think you can, if you think you can go to the gym, if you want to go to the gym, like, yeah, go to the gym and.

Sean Mackey (59:30.819)

Yeah.

Tim Doyle (59:54.445)

Two weeks after that, I was back into the gym consistently, four to five times a week.

Sean Mackey (01:00:01.049)

That's a great story.

Sean Mackey (01:00:06.254)

See, obviously you got in the hands of a really superb doc and you were receptive to hearing that message.

Sean Mackey (01:00:19.104)

It doesn't work all the time. And sometimes I think one of the key messages here again, this individual difference, because sometimes people do have things going on in their spine and their back that is damaging. And the key is to get that evaluation first to determine, are you safe? Are you safe?

Sean Mackey (01:00:42.636)

That's that distinction again between hurt and harm. You may have pain, but you may not be harming yourself. props to you for having an open mind and listening to that. then, then.

Tim Doyle (01:00:57.354)

Yeah, mean, full transparency, like getting into what you were saying. I mean, there was still a lot of fear. Like when I went to the gym, was still, you know, it wasn't like a hundred percent back to normal. I wasn't using the same weights that I was doing, but it was kind of just breaking through that wall and, you know, allowing myself to feel those sensations rather than allowing my mind to go haywire on me. I wanna talk a little bit,

Sean Mackey (01:01:26.316)

Yeah, and I want to just be clear that it took you a long time to get to where you were.

I would probably not have believed if you said that you were going back and deadlifting, you know, your PRs, what you were doing before. That just doesn't happen. You know, there's a lot of wiring that wiring in your brain gets sticky and it solidifies and it takes time to to break that cycle and to establish better patterns of

you know, thinking around your pain. And then also, you know, you people become deconditioned, you got to work your way back into it. So don't want to give people the impression that like there's some miraculous thing going on here and boom, you're back to doing what you were you you undoubtedly had to put a tremendous amount of hard work into getting back.

Tim Doyle (01:02:24.82)

Yeah, I'm glad that you say that because yeah, it did. It took probably eight to 10 months to feel like I was, okay, like I can do any type of exercise that I want now. And it's just going through those reps. I do wanna talk about the language component a little bit more.

You're very, cognizant of not using or throwing the word cure around a lot. And you use personally, I don't like the term. I don't like the term pain management. know that's a phrase that you use a lot because within my own beliefs and experiences, when I think of pain management, it connotes, okay, I can't get rid of this. This is just something that

I'm always going to be managing. How are you very careful of with the way that you talk to people in the language that you're using?

Sean Mackey (01:03:27.84)

Yeah. Wow. That's, that is so important because

Sean Mackey (01:03:37.964)

words and the language that we use in the healthcare system and as separately as a scientist, mean certain things to us, but to a person living with pain, it may mean something entirely different.

So I think a key part is when we have these conversations is to make sure we're talking about the same thing, have common ground on what the terms mean. I mentioned earlier that catastrophizing is a terrible term. Probably the most despised term in people who live with pain because it has been weaponized. They have been told by docs.

you're catastrophizing. You're a catastrophizer. You're labeled.

It should have never happened. The term has a real scientific meaning that is of value in science, but it got weaponized and got out of control. Getting back to your point.

Sean Mackey (01:04:47.532)

I think the message is that we will work with you, the person living with pain, to try to work to find an answer for what is causing the pain. We will work to find things that, you know, in an ideal world may eliminate it, but letting people know, setting expectations that sometimes we can't cure, we can't eliminate, but what we can do.

is help people gain control of their life back so that they can get back to doing the things that gave them joy in their life. And a large part of what we're doing is trying to find out what were those things that gave people joy? What were those things that they're no longer able to do that they want to do? And give them assurances that we'll work with them to help them get back there.

Yes, everybody wants their pain to go away.

Underneath that is a notion that what people often want is control of their life back. Because pain has taken over and has taken control of their life and robbed them of something. And so people typically have a tremendous amount of grief, loss over what they had that they no longer have. And so it's a bit about working with them to help get them back.

where possible to that.

Tim Doyle (01:06:25.386)

What energizes you the most about your work now and what do you see the future of pain care looking like?

Sean Mackey (01:06:32.78)

Yeah, I'm so jazzed about the possibilities.

Sean Mackey (01:06:41.422)

What I'm most excited about is translating the research and technologies that I've developed at Stanford. So we've talked a lot about the brain imaging work, the neurosciences and biomarkers. There's another big area of my research that's involved with something called learning health systems. And learning health systems are software platforms where

we are capturing detailed information about a person's experience of pain and using that in a clinic setting. Now you might think that the electronic medical record is doing that, but it's not. The electronic medical record was never designed to do that for you. It was designed to bill you and schedule you and order your labs. What I've created through a, it's a platform called Choir, which just gets a deep understanding of the person

as a whole and all the things that are driving their pain and their experience in their life. And we use that for clinical care purposes and to track people over time. And where my excitement is, is in bringing the objective data and these signatures that we're building together and then putting those to use with the learning health system. And we've been slowly over the last 15 years been doing that at Stanford. And what I realize now, having made a lot of mistakes.

is academic institutions are really good with discovery and innovation, but we're terrible at scaling, at taking things that we build and spreading those out broadly. So this platform that I developed is used at other academic medical centers, but slowly. So what I've created with my wife, Beth Darnell, who is a faculty member, I'm paying psychologist and all.

mentioned most in a second, is to create a nonprofit. And take all this technology, put it into a nonprofit. What Beth does, you'd love talking with her, by the way. She's much smarter than I am. She creates brief behavioral interventions. So take cognitive behavioral therapy and it's 16 hours or eight weeks and she's distilled it down into two hours, one single session and found its equivalent.

Sean Mackey (01:09:06.83)

And so we've integrated in brief behavioral therapies into the platform. And the goal here is to provide high quality data capture and behavioral interventions broadly to people who have low access and to scale it out. Because, Tim, we have a real problem with healthcare. We've got a lot of problems with healthcare, but one of those is

that most of the highest quality comprehensive health care is concentrated in like small places that are typically in big cities. You know, I live in California, the fourth largest economy on the planet, biggest state. But once you get outside San Diego, Los Angeles, San Francisco, it is just a healthcare desert.

There's some great single docs, there's docs and there's systems out there, but it's difficult for people to get really comprehensive care. And what we need to do is take the kind of care that we deliver at Stanford and at other really good centers and make it available, make these things that you're saying and that we're doing more broadly available and capture the high quality data that will help us to predict which patient is gonna respond to which treatment and deliver that.

So that's what I'm doing. I'm self-funding this nonprofit. I'm not taking any money from it and wanting to scale this out broadly. And that gets me excited. That ties in with work that I did with co-leading the National Pain Strategy, which was this United States national effort to define the future of pain care. And that's what keeps me working on nights and weekends and gets me jazzed. And that's what, you know,

gets Beth Jazz too, so it's nice to be married to somebody who has the same mission.

Tim Doyle (01:11:05.344)

Dr. Mackie, I've thoroughly enjoyed this conversation. this is, I wouldn't just call it a great conversation, but it's an important one. And just really thankful for you taking the time to speak with me and sharing all of your insights.

Sean Mackey (01:11:20.62)

It's been my pleasure, Tim, and my really props to you. Congratulations to you for getting out there and educating people, spreading the word. We need more people like you, and just wish you all the best.

Tim Doyle (01:11:33.301)

Awesome. Thank you so much.