Transcript of Rachel Zoffness (on pain) New

Welcome, welcome, welcome to Armchair Expert. Experts on Expert. I'm Dan Shepherd. I'm joined by Lily Padman.

Hi.

We have a guest today with the cutest last name perhaps we've ever had. Rachel Zoffness.

Yeah, this was a great episode.

I just love that last name.

It's a good last name. It's a little misleading because this isn't a Zoff episode, although it is in also another way, I guess.

She is a leading pain psychologist and neuroscientist. You guys, this episode is so incredible. I think it's one of the best of the year. It's— it's so many of us know, as you learn in here, there's 1.8 billion people in the world suffering from chronic pain, and there's 100 million Americans, and we don't understand how we experience pain truly.

Yeah.

And this is an incredible explanation of how it actually works, and it's quite an empowering take on it.

It is.

Yeah. So her book is called Tell Me Where It Hurts: The New Science of Pain and How to Heal. I have already sent it to 2 people. Who I know who suffer from chronic pain. Um, this is a great one. Please forward it to anyone in your life who's experiencing chronic pain. Uh, please enjoy Rachel Zoffness. Hi!

It's such a pleasure to meet you.

Are you a hugger?

Yes! Let's do it!

Monica, you must know how this started.

This is terrifying for me. I'm like a library mouse bookworm. I'm like not a public-facing person.

Okay, well, you're already so warm feeling.

Well, listen to what happened. I saw Rob by the staircase when I left the house. So by the time I got out and went up the stairs to grab my drink, I saw that he was in the bathroom. And I go, Jesus, what are you taking a shit in there? It was Rachel.

I was like, don't you wish I was?

Oh no, that's terrible. It's funny.

Oh my God, did you get really scared?

Good Lord, I know where I am. Come on, even for me.

Yeah, even for you, you would not do that.

We have a friend in common also.

Who?

Do you see the person who wrote the endorsement on the top of the book?

Who did it?

Oh, I did see that. Yes. I'm obsessed with her.

Oh, yes.

She's the reason I teach at Stanford because addiction medicine and pain are best friends.

Yeah.

Surprising.

So you're down presumably from San Francisco. Do you live there?

Yeah, I'm in the Bay Area, but I'm originally a New Yorker, which is why I have an attitude problem and I wear too much black and I curse all the time. I feel like I'm in good company.

Those are good attitudes.

I thought you said you were like a church mouse.

Library mouse. Very, very different than church mouse. Yeah, super different.

People are perv. Oh, I think they're like in the nurse's office. Catapult.

I don't know what's happening. Don't know what's happening. Yeah, no, I was like the kid who was shy and quiet. Shy and quiet. Quiet and shy. And was in the library reading all the time. Books were my friends. Different than a church mouse.

That is different. You're right.

How has teaching been for you? Because that requires a ton of get up in front of people and speak.

What's funny is that during the pandemic, this thing happened where I was supposed to give all these talks and I was actually doing that because it was partially a treatment for my own performance anxiety and public speaking anxiety. The treatment is exposure therapy, right? Like, if you never do it, you never get through it. So I had all these talks planned and then everything got canceled. I was like, okay, what do I do now? So I started planning virtual talks and I started cold pitching podcast hosts. And I pitched a couple of people who actually had really big platforms and I didn't realize it at the time. As I started doing more and more podcasts, I think I did like 42 of them.

Wow.

Oh my goodness. Ezra Klein came calling. And by the time I did that one, I had done so many that I felt pretty secure in what I wanted to say. And I feel very passionate about the topic. And I keep my patients in my mind when I talk about the topic. So I'm sweating through my clothes.

Well, that's also because it's 500 degrees. I'm so hot.

It's also 90 degrees.

Oh my God, I never know.

But you can also take off your sweater.

I'm considering it.

It's not going to happen.

It's a cute outfit. Yeah, it's not going to happen. She would be dying of heat exhaustion. We'd say, can we remove the sweater?

I don't know.

No, it's a cute coat. I'll die doing what I love.

Thank you. Being in this cute sweater. Okay, so you're originally from New York. You really could write a book on universities of America, probably.

You mean because I've been to so many?

Yeah, you've been to so many.

Did I tell you I was a nerd? I think I did coming in here.

You started at Brown, yeah?

Yeah, yeah.

You were biology?

Yeah, I was brain and behavior. I couldn't decide what I wanted to study when I was at Brown. I loved neuroscience. I loved human biology. I thought psychology was so interesting. I couldn't decide if I wanted to do research or clinical work or teach kids. So human biology, brain, and behavior was sort of an amalgamation of everything. And then when I learned about pain in my first neuroscience class, it lived at the intersection of everything I thought was so rad.

Because why?

Because why? It just depends on how far down the rabbit hole you want to go.

I mean, I've heard you say that you were drawn to it because you were so afraid of pain.

Yeah, and that's another reason. Pain scares the shit out of me, and it should, right? Pain is designed to be aversive. It's designed to save your life. If it doesn't grab your attention and get you to stop doing the thing you're doing, there's a chance you could hurt yourself/die. So that's pain's job. But I always found pain to be very scary.

Physical pain?

Well, my friend. Oh, my friend.

Fasten your seatbelt.

That's the number one question I get, especially because I study pain psychology. So to answer your question very briefly, guess where pain is made? It's not in your bad back and it's not in your aching knee.

In the brain.

And the parts of your brain that make emotions also make pain. Pain. Like, your amygdala and your limbic system are a critical part of the pain machinery. And we all know that our bodies feel worse during times of stress and duress. Of course they do. But does anyone ever tell you that at any point in your effing life?

Yes. And we're gonna march through that granularly. But her question still stands, because prior to you understanding that there is no difference between psychological pain and physical pain in one regard, were you someone that was afraid you were gonna get physically hurt, or were you afraid you were gonna get emotionally hurt?

It is a fair and good question. And yes, physically. Physical pain is what I was scared of. But of course, no one likes emotional pain either.

Yeah.

I don't know. Some people—

And some people like physical pain too. Like, there's a whole BDSM community where pain is pleasurable, and there's a reason for that. And maybe we'll even get to that. But it all goes back to pain being made in the brain.

Were you sheltered? Were they very nervous kind of parents?

I would say I had very overprotective parents. And by nature, I was shy, quiet, indoor cat. Library mouse. Yeah, yeah, library mouse. So I was self-protective. Like, my sister and brother would be running around playing sports, hitting each other with lacrosse sticks. I was in the backyard reading books by myself, self-directed. No one told me to do that. It wasn't because my parents were like, you're going to get hurt.

Were you the older?

I'm the oldest.

Yeah, yeah, yeah. Because they get crazier. We can't have the library mouse at the end.

Yeah, no.

It's got to be at the beginning.

Library mouse is at the beginning.

Yeah, yeah, because it kicks the party off. Okay, so after Brown, you go to— is it San Diego State? Columbia. Columbia next, and we do teaching master's there.

I got a master's in psychology. I was interested potentially in education, like teaching psychology or maybe being a professor one day. Like, I really couldn't decide what direction to go. I mentioned I was a science teacher at the Bronx Zoo. I was like, I love biology, I love animal behavior. Do I go that route where I'm a science educator? I was a science writer at Natural History magazine.

Oh, cool.

Out of the Museum of Natural History in New York City. I was like, I was like, that's rad, you're science writing, you're learning so much stuff, you're translating complicated science for the lay public. Do I wanna do that? I realized it was just me with my computer, and that wasn't satisfying enough. So for me, the education piece, I am also a glutton when it comes to information, especially science. So I was like, what can I do where I could consume the most amount of science over the course of my life? So I just went to school for as long as I could.

Yeah, were your parents at all getting frustrated? Like, we gotta figure out what direction, or they were just supportive?

I was working really hard and I'm very self-driven. They were not at any point worried about me.

Okay.

I think they were probably worried 'cause I was so stressed out. Figuring out your life path is not a casual thing and it can feel scary and intimidating for as long as you're wondering that. And you can be on this journey for forever. Hopefully we'll all have different points in our career where we pivot and do different things. But for me, I've been on this path from the beginning. Like I knew I wanted to help people. I knew I thought neuroscience was amazing. I knew that I wanted to do something with medicine. It really just naturally led me here. I did my honors thesis at Brown on the neuroscience of pain, and I studied with a pain neuroscientist there. We studied endogenous neurochemicals that regulate pain.

Okay, so those are ones that emanate from your body. They're not exogenous, right? It's your body's pharmacy kit.

You got it.

Yeah.

Chemicals that are made by your body's pharmacy.

And what was the most fascinating aspect of that? I love telling people that, like, when you take a drug, the drug itself isn't the thing that's giving you this sensation.

That's right.

It's either regulating uptake or down— it's just letting the chemicals in your body go crazy.

And it's binding to receptors that your brain has because your brain already makes those chemicals.

Yeah. Exactly.

Which is why you adjust. It's in you. It's not whatever you're putting in. Right.

So, like, if you're taking a drug for a very long period of time, your brain does a thing where it downregulates. You probably have heard this term from the other science nerds you've had on, where your brain stops producing as much of that thing. So if you're taking chronic opioids, for example, your brain doesn't need to produce as many. Because you're giving them from an external source. So you downregulate. You don't have as many now neurotransmitters in your brain, and the receptors are just picking up what you're giving it instead of like the homemade ones.

Take me to San Diego State.

All right.

Let's go on the education journey. This is hard for me, by the way. I hate talking about myself.

I guess what I'm trying to figure out when I asked about your parents and you, I guess there's two versions of this. One is I have anxiety. I'm afraid to pick. I don't really know what my calling is. I'm scared. Another one is I'm at this salad bar and I just can't stop going up to it and trying something new. It was the latter.

Yeah. And also, I really wanted to make sure I was going in the right direction because it's a lot of time when you go to school for that long, like you really want to be sure as shit that this is the right direction. So I just kept honing it and honing it. So San Diego State, UCSD was where I went for my PhD, and I studied clinical psychology because I decided I wanted to work with patients. And I really was fascinated by the brain-body overlap. I still feel this way. I felt like if I had gone to med school, I would have gotten like one slice of the pie. And if I went for my PhD in psychology, I would get another. And I wanted the intersection and I had to kind of go get that on my own, to be perfectly honest.

Yeah, we just had Michael Pollan on last week.

I just saw him at a diner. He lives in my neighborhood. I almost went up to him and I was like, that's rude. I'm not going to do that.

Oh, he probably would have liked it.

That must be so annoying.

Oh, I don't think so.

It's only annoying if you go and tell him about your shroom trip.

Like how people come up to me and tell me their pain story.

Yeah, yeah, yeah.

I actually don't mind that much because I'm like, oh my God, tell me everything.

Right, more data.

Yeah.

Okay, so at what point do you start seeing patients and specialize in pain psychology?

I wanted to hang up a shingle right away. I did the PhD 'cause I wanted to get really good at research. Like, if you're a real nerd, you want to make sure that the papers you're reading are high quality, the data's good data. So in my PhD program, I got that. I got what I was looking for. But I really wanted to work with patients, and I was obsessed with the science of pain. People think I'm a masochist when I talk about how much I'm interested in pain, but I'm not saying that I enjoy inflicting pain. Doing it or receiving it. Just the science is mind-blowing. So I wanted to treat patients right away. And, you know, I had been teaching a bit at UCSF and at Stanford, and I just told my colleagues, like, I'm opening my doors. I want to specialize in chronic pain. I got the hardest patients. I want to say this clearly: absolutely no one wants to see a psychologist for pain. I am like the used car salesman of pain medicine, right? Of course not. The stigma attached is like, you're saying it's all in my head, you're saying it's just emotional, it's like somatic, it's not real.

Yes.

I just want to see a medical doctor. 96% of our medical schools have zero dedicated compulsory pain education. I'm going to say that one more time: 96% of med schools in the United States and Canada have zero dedicated compulsory pain education. The real pain science is out there and it exists. It's just not being taught in med school.

And of the 4% that have it, the total is in the 4 to 6 hour range or something, right? It's very small.

And check this shit out, we're going to talk about this, I'm sure. The current model of understanding and treating pain is the medical model. It means when we talk about pain and when we treat pain, we talk about anatomy and physiology and bones and body parts. And yes, that's important, but neuroscience has known for 65 effing years that pain is this word— it's biopsychosocial— which means yes, there's bio components, there's also cognitive and emotional components, there's also social components. But it makes me crazy. I had to study pain on my own for 700 years to really distill down, like, what is this and what are we getting wrong and how has this happened in pain that we've created an opioid epidemic, and we're still doing it today.

So, Michael Pollan was in, and his new book is on consciousness. And similarly, it's riddled with the same challenges in that René Descartes broke the mind and the body into two things for us 300 years ago. And we are stuck in that paradigm where there's two different things. There's your thoughts and emotions, and then your physiology or your physicality. More and more, we now know there's no such thing as a division in any one of these components. This is one complex system that's talking at all times with itself, and it's integrated, and there's no division that can be made. And to put a super fine point on what you're saying, because I'm currently dealing with it with a loved one, to say that it's more than just the physical pain is not to say it's not real. It's 100% real. And the question is, what's contributing to it? Right? It's very relevant. How are we getting to this pain, which is 1,000% real? And anyone who's listening to Preventing Defensiveness, it's real, real, real. No one is suggesting that the pain is not real. So to your point, the patients you're getting have generally gone through years, in some cases, of exploring every single medical option for their pain.

What are some examples?

MRIs.

That was sort of what triggered when you asked me about opening the private practice, I was getting the patients who weren't getting better. So I have this patient who lives in my brain, and of course I'm changing names and personal details because that's what you're supposed to do, and it's very important for patient privacy. But I have this patient in my mind, and I still see him all the time when I talk about pain. One of the chronic pain patients that really sticks in my mind is Sam.

It was really Samuel.

Sammy. He had been in bed for 4 years. And he had been on 40 medications. He had seen 14 specialists. And I want to describe him to you because I see him in my mind's eye every time I talk about him. He had long unwashed hair, and his skin was pasty and pale, and he was rocking himself back and forth on my couch with pain. What's funny is I remember thinking to myself, "Who do I think I am?" This kid had been to Stanford.

So the punchline is this person who's been bedridden for 4 years—

Yes.

—is only 17? Correct. Oh my God.

And at 17, when you've missed 4 years of life, that is really significant. Like, those are all the milestones. You really only get those once. But I did have imposter syndrome. I absolutely was like, who do I think I am? So we talked about my training and how I'm a nerd and studying pain neuroscience and endogenous brain chemicals that make pain and pain psychology and biology. But I really think of myself as a pain detective. And when someone comes to my office It's my job to figure out all of the factors that are contributing to the pain, that are amplifying the pain, and are perpetuating the pain cycle. So when I assessed Sam, I had his records. Like, yes, family history of migraine, diagnosed with migraine and diffuse amplified body pain of unknown etiology, meaning he was riddled with pain all over his body. No one knew where it was coming from. He had had a million tests. He had been on all the drugs. So when I assess my patients, yes, I want to know your medical history. If you haven't had all the tests and the scans, I'm going to send you. I want to know that your blood and body parts are okay.

Then I want to know about the rest of you. We use this word biopsychosocial. That means that there are a lot of factors contributing to pain in any given moment all the time. Sam was depressed and suicidal. Shocking. He had been in bed for 4 years. He had no friends, no life, no hope.

He left in 7th grade. He detaches from playing soccer, from having friends.

But what happened? The first thing is he had a migraine.

He had crippling migraines. Okay. In his 7th grade, he had crippling migraines and then diffuse amplified body pain. So severe body pain, all the tests, no one knew what was going on. He couldn't go to school. His loving parents were like, what are we supposed to do? He was like, I can't go to school. So he stopped going and that just never ended.

Oh my God.

You would be surprised by how common this is in the pain world. So I started getting all of those patients, but I want to tell you what happened with Sam. Yeah, yeah. He was depressed and suicidal. He was socially anxious, like crippling social anxiety. Couldn't talk to kids. His pain was always worse Sunday nights and Monday mornings. So there's a pattern to the pain. Of course. Yeah. He was on a white food diet.

Oh, like rice and bread.

He didn't like fruits and vegetables.

Hot dogs and fries.

I doubt he was eating— Pizza, pasta, chips, bread.

Oh, you would pray for rice, I think, for Sam.

Rice is white.

I mean, like, that's not uncommon for a big chunk of the American pediatric population. Like, you just don't like fruits and vegetables, and so don't eat them.

If they're saying that, they can't eat or they're too sick to eat, then yeah, your parents can be like, fine, just eat these chips, I guess. Eat something.

And his only activity at this point was reading books and playing video games. Playing video games.

So he's up till 4 in the morning playing video games. His sleep hygiene was off. So in order to help Sam, I knew I needed to help him look at the whole recipe and fix the whole recipe. So we changed his nutrition, had a come-to-Jesus talk with mom and dad. We were like, how is his body supposed to fight this thing if he's not getting appropriate nutrition? Put him on a sleep hygiene protocol. He had to wake up at like 10 instead of like 2 in the afternoon.

Oh, this is— You're peeling it back. Exactly. I like how small you started. You had really tiny steps for him to take. I think the first one was to go outside.

It's called a pacing protocol. It's one of the most fundamental parts of a pain plan for people with chronic pain. So week 1, he was standing outside in the sun on his porch and texting just one friend. Week 2, he was walking to the corner mailbox and mailing a letter. His mom would actually give him bills she had to pay. Week 3, he was taking his dog to the dog park and having a conversation, and we scripted it. Cute dog. Remember, paralyzing social anxiety, isolated, stuck at home. By the way, that will amplify pain. All of these ingredients. He got a tutor, started catching up in school, went for his first haircut. When that kid came to my office after his first haircut, he also had gone and bought a backpack He was a child transformed. That was like 1 month in. 1 month in. Some sunlight, some social exposure. By the way, the more he did, the more he realized he could do. Mood started going up, stress and anxiety started going down. And oh, shit, the brain's connected to the body. When stress and anxiety started going down and mood started going up, all these things started changing.

His pain started changing too.

The virtuous cycle or the destructive cycle is spinning. So the one he was in was just gonna get worse and worse and worse until probably suicide or something else was on the table. And just the fact I love the notion that one thing's feeding into another and then slowly it's all gaining momentum. And the fact that he was happy when he came to your office with a haircut and a backpack is— He was just shining. Yes. And he spoke at his graduation. He returned to school.

I love that he had an impact on you. Oh, I still think about him. He graduated from high school and he walked across the stage and he said, if you had told me 4 years ago I'd be graduating high school, I never would've believed you. I maybe cried. That kid got asked to prom by 2 girls, not by one, when he went back to school.

And he went with both somehow. I would love to talk to him how he juggled that. Yeah, they were too beautiful.

2 girls. Oh, okay.

I thought it was like the same problem.

I'm like, how did Sam? I still hear from his parents. Aw. I have to tell you. You saved his life. Very selfishly. You did. It changed my life. I'm not joking. That kid, I was like, I'm never doing anything else. When I met that kid, he was on opioids and Thorazine. I also worked on an inpatient psych unit. If you're homicidal or suicidal, you will go to an inpatient psych unit. Where they lock the doors, and if someone's having an acute psychotic episode, they will shoot you full of Thorazine and knock you the fuck out. This child was on opioids and Thorazine for his pain because we tell people that pain is a purely biomedical problem that requires a purely biomedical solution. I want to say clearly, I am not a magician, but that kid got out of bed and back to life. He will never again be the kid who's in bed for 4 years. That will never happen to him again. What are we doing to people in pain? It makes me crazy. Yeah, it's not beyond anybody's understanding.

Yeah, so Let's talk about, first of all, the subjectivity of pain. You've got a lot of different great examples of how we can illustrate that it's not just the broken bone, although that is definitely part of it. But I think a good place to start is amputee phantom limb pain. I'm obsessed with phantom limbs. Explain phantom limb pain.

Only if I get to hear after why Monica's obsessed with phantom pain.

Or before. I'm kind of obsessed with pain. Well, not pain, but I'm a little bit I'm kind of what Dax would say, a hypochondriac. I don't identify that way, but he identifies me that way. Dax would say. So, you know, I am hyper-aware of what will cause distress and pain. I avoid those things pretty much at all costs. So in a psychology class, we learned about phantom limb. I was like, what? That's horrifying.

Okay, so we have all been sold a big fat lie about pain and what it is. So pain is the body's warning system. It's our danger detection system. We have been told that pain lives exclusively in our body, in the part that hurts. You have back pain, you see 762 back doctors, and you probably get back surgery, and maybe you get a prescription. You have chronic knee pain, you see 40 million knee specialists, maybe you have surgery, maybe you take medications. Now, I want to say clearly, surgeries are important and useful, medications are important and useful. They are not the only treatment for pain, and they are not the best treatment for chronic pain, not by a long shot.

It's really important because we're going to primarily be talking about chronic pain. And acute pain is pain that lasts 3 months or fewer. And that is your stomach hurts, you might have gotten food poisoning. So great.

Broken bone, acute illness. Yes.

So anything that persists for longer than 3 months. Now we're into the chronic pain category. You got it. And this is where we really want to focus.

So I am going to be talking about the definition of pain across the board, but you are right. Generally speaking— God, my language is so bad. The fuckery comes when we talk about chronic pain. So sorry for people who are listening, but I know where I am, so hopefully the audience is okay. But the chronic pain world is where we really screw people. But this is true for acute pain too, just the basic science of pain. So we've all been told pain lives just in our body part that hurts. One of the reasons we know pain isn't constructed just by the body part that hurts, is because of this thing called phantom limb pain. Phantom limb pain is when someone loses a limb, an arm or a leg, and they continue to have terrible pain—Monica's knocking on wood—they continue to have terrible pain in the missing body part.

Debilitating pain. Yeah.

If you can have terrible leg pain in a leg that is no longer attached to your body, that tells us pretty definitively that pain cannot live exclusively in the body part that hurts. I had a patient with phantom hand pain who had lost his hand and his arm in a terrible firework accident.

Mateo. Another young boy. Mateo.

He felt like his hand was constantly spasming, cramping. Cramping. Like, sometimes it was picking things up. So if you can have hand pain in a hand that is no longer attached to your body, that tells us pretty definitively that pain is constructed somewhere else, and that somewhere else is the brain. And we said before that the parts of the brain that make emotions also make physical pain. Yeah, so the nervous system—

Yes. —is kind of mapped in your brain. You have a neural network that knows where all the nerve endings are, and it's communicating. And it's interesting, this phantom limb pain is an outgrowth of the fact that your brain believes you still have— Yes. —the same nervous system you had before some of it was removed, and it takes a while to update it. That's right. I mean, that's mind-blowing, isn't it? It's like it has a map of what it's supposed to have, and it hangs on to the map long after a piece has been removed. So Mateo, what did you do with Mateo?

Yeah, what you're talking about is you have a map of your body that lives in your brain. It's called the homunculus. Actually, when I teach this, I see patients of all ages, adults and kids, but when I teach kids, I ask them what they think a homunculus might look like, and they draw me pictures. And I used to have a whole wall full of drawings.

I see, like, a triceratops with an elephant's trunk. See? Oh, yeah.

Definitely it's homunculus.

It's a pachyderm. Sure. No, I went hippo, but that's good stuff.

Yeah, that's a pachyderm.

That's good stuff. Yeah, you're good.

Yeah, right. And it's a really cool map. So, like, if I tell you right now without doing anything to sense into your right foot, like, what is your right foot doing? Can you feel it? Can you feel it on the table? Yeah, yeah. Is it warm or cold? You can do that. And the reason you can do that is because of your homunculus. It's like, like a sensory and motor map. With phantom patients, there's a treatment called mirror therapy. And with mirror therapy— there's a lot of books on this, so interesting— you erect a mirror. So they have their functional arm and the damaged arm, and you put a mirror up. They hide the damaged arm, and the good arm stays up, and there's a mirror reflecting back to the brain the undamaged arm doing things. So they engage in activities and exercises, and it feeds back to the brain an image of two healthy arms, and it helps update the out-of-date brain map.

It's kind of counterintuitive.

Your left arm's hidden. Your damaged left arm sits, like, behind you. But your brain sees your left arm and your right arm doing things together. Like Dax said, the map in your brain just hasn't caught up with the damage that has occurred. That arm is gone. Like, it's not in danger anymore, but pain is the body's danger system. So your brain is gonna continue making— Yeah. Yeah, yeah, yeah, yeah.

It's not gonna trick your brain into thinking, "No, I'm good." Plugging the association with your left damaged arm by seeing your right damaged arm in its place.

Yes, yes. It's quieting the danger alarm. That's the whole trick with pain, is pain is the body's danger system. So credible evidence of danger will amplify the alarm. Credible evidence of safety will lower the alarm. So like one of my favorite examples of this is if you get slapped and bitten when you're having sex with a hot partner and you want it, it will feel good. If you get slapped and bitten when you're getting mugged, you bet your ass that is gonna feel completely different to your danger alarm. Because pain is biopsychosocial, which means it takes into account bio information, but also contextual and social information, and also emotions, and where you are in the moment, and who you're with, and what's happening. And intention. And intention. Safety. Yeah. Safety.

Yeah, think of a massage. There's so many great examples. A massage, which would otherwise be painful, is, like, euphoric because you— the way you have put it in this framing.

You're there on purpose. Yeah. You desire it. You're paying the person to do this to you.

Yeah. You have some notion that it's medicinal. I mean, I always think, "Oh, they're getting the knot out." No, I don't know if physiologically that's even true, but I think we're making progress towards my health. Yes. Some control over it.

That is huge. When you think about safety, control is a big part of that, right?

Yeah, everything, really. Yeah, enjoying capsaicin, like eating hot, hot foods. The winner of the Hot Ones. Yeah, we enjoy that pain.

Tattoos, MMA fighting. What are you kidding? There's a million examples of enjoying pain on purpose. It's expectations. It's your context. It's emotions. It's predictions.

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If I could give you a grade, you would get A++. Oh, thank you. But that's the thing we don't know. Even now, if you Google what a nociceptor is, a nociceptor are the neurons that live in your body, in your tissues, in your skin, your organs, and they feed information about potential danger. To your brain, potential danger. But if you look it up, you're gonna be told that it's a pain receptor. It makes me crazy. That is sensory data. Sensory data isn't pain until it reaches the brain and the brain uses all available information to decide whether or not to make pain and how much. Yes. So it isn't a pain receptor. It's like temperature, it's touch.

It's reflex. So you touch a flame. Yes. A hot burner, nociception, makes your body move before you even think about it or process it. You have an instinctual reaction to that. And I learned all this from Ed Yong's book Immense World. So all these different animals have nociception. Yes. But they don't necessarily have pain. Some do, some don't. We're figuring out which ones do. But all animals have this nociception. Yes.

So what happens is those danger detectors in your skin, organs, send data first to your spinal cord, and your spinal cord initiates that automatic instant response.

Again, there's a lot of animals that demonstrate constantly they have these survival reflexes. Yes. But they don't have any of the other signatures for pain. So we are somewhat unique in how sophisticated our interpretation is. Yeah, it's true. Okay, I think now is a great time to talk about a tale of two nails. Oh ho ho! Sometimes things are so interesting that I'm reading about that they make it to my dinner table. So last night I had to tell my daughters about this. So let's talk about our First construction worker.

So I was reading these great papers. There was this one from, I believe it was like 1995, in the British Medical Journal. And they wrote about this construction worker who had been on a job site, and he jumped off a plank straight onto a 7-inch nail. So he was in terrible pain. They rushed him to the emergency room. They gave him really good drugs. He was in terrible pain. They gave him a bunch of opioids, and fentanyl was one of them. He got all the good stuff. And when the good doctors removed his boot, They discovered that a miracle had occurred. The nail had passed between the space between his toes. No. There was no puncture wound. There was no tissue damage. Everything's groovy. No blood. But his pain was real. How is that possible? Wow. His brain, AKA his danger detector, used all available information to decide whether or not to make pain and how much. Pain is your body's danger alarm. It exists to save your life. So it used knowledge of his dangerous work environment, memories of past pain experiences and injuries on the job site. It used the horror of the construction workers' faces, his friends around him, the visual data of this crazy nail, and his brain perceived potential danger, and it made pain to protect him.

Tale of nails number 2. Second construction worker, most dangerous job apparently ever, on a job site using a nail gun. Nail gun misfires. He sees a nail shoot across the room, bury in the wall across from him. Nail gun ricochets backwards, clocks him in the jaw.

He hits himself in the chin with the nail gun.

But he sees the nail shoot across the room, and he has mild jaw pain, mild toothache, mild headache. Continues on with work and life for 6 days. No! At the end of 6 days, he says to his wife, you know, maybe I'll check out this tooth.

Yeah, I can still feel this tooth a little bit.

Goes to the dentist, scans the patient's jaw.

And Rob, please put up the X-ray of him. Okay, so listen up.

Much to both men's surprise, they discover a 4-inch nail embedded in his face. I spoke with Dr. Seth Ranier on the phone. That's how big of a nerd I am. I was tracking down this photo. I wanted it so bad for the book.

He said, "This is the luckiest guy ever." And for the listeners, so the nail has entered the top of his jaw, and it has passed all the way through his zygomatic, everything all the way up into the frontal lobe. The brain is spanning from his upper jaw into his brain.

Yes. And the whole story and the picture is also in the book for people who can't see it.

Yes. This guy has an enormous chunk of metal in his face.

And I want to say clearly, very real damage, very little pain. Now, if pain were a reflection of how much damage we have to our body, gentleman number 2 with the giant nail in his face should be in crippling, excruciating pain. Gentleman number 1, who has a nail in his boot but not his foot should actually be fine. We have all had experiences like this. This is a stark example. If you've ever gotten into the shower and you have black and blue marks on your body, you're like, how did those get there? That's evidence of damage to your body without the pain. We know that pain and damage are not the same thing, but we continue to get sold that lie.

Okay, so now— and this is the area that I'm constantly saying on here out loud because I heard it from Lane Norton, but I'm relieved to Layne Norton is a buddy of mine. Oh, is he? He's the greatest. I talk about this one often, but you have two examples of it. But now I have the precise numbers, which I'm grateful for, which is there's been two incredibly compelling studies because back pain is among the most common pains.

Like 80% to 85% of people develop chronic back pain at some point.

Chronic back pain. Yeah. So they scanned 3,000 healthy individuals, meaning people who have zero back pain, no reported back pain. And nearly all of the individuals scanned, 90% of subjects ages 60 to 69 and 80% of subjects aged 50 to 59, had bulging disks, disk degeneration, and other anatomical abnormalities with no accompanying pain.

I want to reiterate that. Yeah. Almost all of us with no back pain are wandering around with slipped and bulging disks, and we don't know it. You want to know why we don't know it? We don't have pain, so we've never gotten our backs scanned. However, if you have chronic back pain and you go to get your back scanned and they find a bulging disk, guess what you will be told is causing your pain?

They think they have a smoking gun, but you can't have a smoking gun if 90% of us have the same smoking gun.

But then that's why when they do those full body scans, what's it called?

Prenuvo is the brand of one I got.

That's tricky to do because it will tell you, oh, you have a bulging disk here, and then you might be like, oh fuck, and then you're bringing a problem.

Have you done that? Please don't do that.

Hold on, I did. I don't want her to do it.

No, you'll be my third argument I have.

I have about this. I want to hit the second one though. Yeah, yeah. So there was another study too, 1,200 healthy subjects who had no pain. Nearly 90% of them had bulging disks. So this is enormous. Less than 5% of back pain is from structural issues, right? And that is not unique to back pain. Those are similar results when you study the hip, the pelvis, the jaw, the uterus, the wrist, the knee, and neck pain.

I went so far down that rabbit hole. There are study after study after study showing that pain and damage, the The things we find on scans, that's what we're blaming pain on, but there seems to be very little relationship between the abnormalities found on scans and chronic pain.

It's the ultimate correlation, not causation.

Yes. But are people listening gonna be like, "Oh, okay, well, when I have chronic back pain, I'm not gonna go—" That's the thing. Because of this thing we're sold, which is that pain and damage are the same, it's a really, really hard relationship to break. So I'm gonna tell you a quick story. 30 years ago, there was a little kid growing up in Jamaica, and he loved to run. He was really fast. And as he grew, something strange was happening to his spine. It started twisting into an S-shape. [Speaker:JULIA] Scoliosis. [Speaker:LULU] And he was diagnosed with scoliosis. But it didn't stop him. He didn't get surgery. He wasn't in terrible pain. He kept running. He was faster and faster and faster until he was fast enough to qualify qualify for the Olympics. And by the time he qualified for the Olympics, his body was so twisted, his spine was so abnormal, and his body was so asymmetrical that his right leg was, I believe, half an inch shorter than his left.

00:37:56

And his left leg could only put down 14% as much power as the right leg.

00:38:01

He won not one Olympic gold but 8 of them. Do you want to guess the name of this gentleman who has extremely severe scoliosis but has never been treated for it and has very little pain?

Usain Bolt. And still holds the world record in the 100, the 200, and the 4x100.

Usain Bolt is the fastest man alive. You should see this man's spine. It is absolutely gnarly. And so if the lie was true, that damage and pain are the same, that That gentleman should be relegated to a hospital bed. He should not be the fastest man alive. And in fact, we are often told that asymmetry is the cause of our pain. Yeah, yeah. I will say again, he's so asymmetrical that his right leg is half an inch shorter than his left.

You would think that would affect a run. Well, check this out.

He's running like lightning.

The scientists who study his biomechanics have discovered or believe that it is his very asymmetry that helps him go faster.

Listeners, do not chop off some of your leg just to be fast.

It's not gonna make you usable. Now here's where we get to my own personal story, which is I did the Prenuvo scan. Yeah. And I'm going through the different categories. They do heart, they do lungs, all this stuff. And I get to skeletal system and I have abnormalities. I'm like, oh, what's that? This. And yeah, I have significant scoliosis. Yeah, at the top of my back, my spine curves to the right pretty dramatically. I went, oh my God, all the times my mom was yelling at me like, you always drop your left shoulder in photos, and we had no explanation other than it was my laziness, I guess. Come to find out, oh yeah, I've had scoliosis significantly. It's visible in photographs now that I have seen the X-ray. But yeah, I have zero issues up there. I've had lower back pain, but nothing where the scoliosis is at all. No issues. Wild. And the same thing, I'm like, oh yeah, if I were in pain and I went and got the X-ray, it would be definitive.

I think this is the complexity of it, is yes, biological factors matter. Yes, of course you can have pain with scoliosis. It's just not the only factor that matters. Biopsychosocial, it means biological factors matter, cognitive and emotional factors matter, social and environmental factors matter too. And together those create the pain we feel.

Does it work the opposite way though? So often do people people go and they're like, oh wow, oh my God, I have scoliosis, yeah, my back. Then does the brain start sending the signal because you're aware now of it?

There's a story in the book called How Cancer Cured a Kidney Stone. I should say— should I say that I wrote a book? I wrote a book called Tell Me Where It Hurts. Yeah, yeah, yeah, yeah. That's why I'm here. It's called Tell Me Where It Hurts. I took sort of like the most fascinating patient stories and put them in because pain is gnarly and it generates these incredible and counterintuitive stories. So one of the stories I put in the book is called How Cancer Cured a Kidney Stone. So I had a who had regular kidney stones, and they appeared like clockwork. She would have a 6 out of 10 pain, abdominal pain. There would be a host of accompanying symptoms, and the stone would pass within— I can't remember exactly. I think a max of, like, a couple of weeks, and then the pain would go away. She would be fine. So she was having the normal constellation of symptoms. Her pain was a 6 out of 10. Her father had recently died of cancer. She was having a pain flare, and her husband said to her, "Are you still having pain? It has been like 6 weeks.

Are you sure this is a kidney stone and not something else?" And she immediately thought to herself, "Shit, I have cancer too." Right.

I think we all think we have cancer at least once a week. If you're a normal, healthy human being, you have. Thank you for that validation. Yeah, yeah.

And I think her dad had died of maybe abdominal cancer, something like this. So she— yeah, the knocking on the wood. I understand.

I didn't want you to see it, but I—

Sorry, I won't call it out again.

You did your own little— You showed it to me. You know your hand was wood on your— I did hold my hand out.

Oh no.

You did it small, but you still got it.

I won't call it. Sorry, I can't help it. I observe behavior all day. So she had the thought, maybe this is cancer pain, and she shared that with her husband. They both freaked out. Her pain went to an 11 out of 10, her report. She fell to the floor screaming. Oh my God. Her husband called 911. She got rushed to the emergency room. They did a scan. They found the kidney stone. Her pain went back down. Oh my God. Don't remember the number. 3 out of 10. And she went home. Went home, and the kidney stone passed. Pain is the brain's danger alarm. It's subjective. It thrives on data. Any data we give the brain that amplifies danger will amplify pain. Data we give the brain that makes us feel safe will lower the brain's danger alarm. So that story to me was so revealing. The things we think, the images our brains feed us, the images we get from our doctors, they are going to affect the brain's pain alarm. And of course they should. It is adaptive and evolutionary for our to use all available information. Why should we only use data from the body part?

We should use all available data, right?

Now let's explore these 3 pillars that attribute to our experience of pain. So the first one's biometric. We understand that one. I think we all understand your bone's broken, you have the flu.

The biological domain.

Yes. Yes, so let's talk about the psychological and how it impacts.

Can I add to the biodomain of pain? Yeah, yeah. Okay, so, So, like you said, it's the obvious stuff. It's like tissue damage, system dysfunction, genetics, like Sam's family history of migraine. It's also diet, sleep, and exercise. And I like putting them there because those are biological imperatives. The reason I'm gonna go into this is because what I want everyone listening to remember is that you have so much more control and agency over pain in your body than anyone has ever told you. If sleep and diet and exercise affect your body, body. You maybe can't change your genetics. You can change your sleep. You can change your nutrition protocol. You can change your sleep hygiene. I'm always sort of keeping in mind, like, pain is terrifying. It's overwhelming. It feels unmanageable and incurable. So if I can help people feel like, oh, there's actually 72 things I can do, maybe starting today, if I can seed some hope, I have done my job.

So that's the bio domain. That's the bio domain. And let's talk about psychology now.

Yeah, so I want you to imagine that there's a Venn diagram with 3 overlapping circles, and I should have said this at the very beginning. Of course, the first circle is the bio circle, the one we just talked about. Then we've got the psych circle, psychological factors, and the social or the sociological domain of pain. So pain lives in the middle of these 3 circles in our Venn diagram. Okay, so you asked about bio, covered. In the psych domain of pain, This domain of pain is so full of stigma and misunderstanding, so I really front-load with just the science. So, in the psych domain of pain, we have emotions. We said at the beginning, the limbic system, our amygdala, the parts of our brain that make emotions also make physical pain. So our bodies hurt more during times of stress and duress. We know that's true. Anxiety and depression will amplify the brain's pain alarm. There's like 4,000 papers on that. Our emotional health affects our physical health.

And we're in a broken paradigm, which is it's either physical or mental. So if it's physical, go see a doctor. If it's mental, go see a psychologist. Yes. That's not a real distinction.

I feel so much gratitude. Like, this is the line that I go around repeating. In Western medicine, we're told either your pain is physical and you need to see a physician, or your pain's emotional, you should go see a psychotherapist. But pain is both physical and emotional 100% of the time. You can't separate them out. That's just not how the brain works. Right. When we're treating chronic pain, I actually want us to be thinking about our emotional health, and I am not saying it's all in your head. I am not saying it's all psychological. You just can't deny that the brain is connected to the body. Part of it. Yeah, it's part of the recipe.

I want to talk about some of the specific things within the psychology domain, which would be thoughts, attention, distraction, and emotions. So we said emotions. Let's talk about thoughts. Thoughts, attention, and distraction. Yes.

We tend to think that thoughts are just these air bubbles that appear in our head, you know, in the space between our ears. But thoughts trigger a neurobiological cascade of events in the human body. Right now, I want you to think about your to-do list, all the things you have to do and haven't gotten done. Maybe your taxes. That's true for me. How does your body feel? When we think stressful thoughts, our body has a physiological response. Our muscles get tense, we bump cortisol and other stress hormones. Heart rate goes up.

Heart rate goes up. Inflammation goes up.

Thoughts don't just live in your head. Thoughts affect your body 100% of the time. And then we have in there also, like you said, attention. That's a cognitive factor. So what we know about pain is that when we think about pain and talk about pain and focus on pain, what happens to the brain's danger alarm? Alarm. It magnifies the pain response. And of course, the opposite's also true. So if you have to give a kid a shot, for example, you shove a screen in front of their face, and they will be distracted and laughing, and they will not cry, and they will not scream. We all know this, even as grown-ups. If you've ever been so absorbed in some pleasurable activity that you didn't notice your pain, or you briefly forgot about your pain, which happens to everyone— that's not magic, that's just your brain's danger arm, right? So attention changes pain too.

Yeah, maybe even think about why opiates work. Oh, dude. As I was reading all this, because I have a very well-known issue with opiates at one point. They certainly cure the physical pain, but I think for me, they're only curing the physical pain because they distract me from the mental pain.

By the way, that is a known thing.

Yeah, it's like it's not sending anything that's making the inflammation go away like an NSAID would or something.

That's right. It's binding to the opioid receptors, and you have a disproportionate amount amount in your brain's emotion centers. And opioids medicate not just physical pain but emotional pain, and that's why they're so dangerous, and that's why they're so addictive.

Yeah, like, you think they're addressing this physical pain. For me, they're not. They're affecting the angst and discomfort of my emotional life. Yeah, they're muting everything.

By the way, what are we doing to people in pain, especially people with a history of addiction? It's like handing people a loaded gun when they already have a genetic loaded gun. To me, it feels unfair and unsafe, and I hope we'll talk about that.

Yeah, I was curious in this psychological pillar. I often think of identity as having a lot to do with this. So my identity is that I'm indomitable. I have reasons why I've made that my identity. I believe if I appear to be indomitable, you will not try to take advantage of me. And so in order to service this identity I have, Monica will tell you, that's why I had no business on opiates. My shoulder's in 4 pieces. I got I wait a week to get the surgery because I'm still filming, and I go film an episode in a sling racing a rally car with one hand and jumping. And I can do that. I don't know why I can do that. I don't have an explanation. I don't think I was born with that thing where I don't feel pain, but it's not on the table for me to be outwardly vulnerable. And so I do think I've willed my way out. I've been yelled at by my wife for carrying things while I just had surgery, right? And I'm like, you know, I can still fucking carry. The notion that I can't carry it is the most painful thing.

The pain's not the painful thing. And so I just feel like I have really reformatted my relationship with pain. And my only explanation is that it's this identity thing, that I will not threaten my identity by experiencing this pain. Or if I get tattoos, I don't give a fuck. So what do we think about our identity and how can that play a role in there?

I feel like every once in a while someone brings an ingredient to me that I haven't thought about before. So the way I frame this is like a pain recipe. Like there's a recipe for brownies. There's always a recipe for pain, and there's biological ingredients in there, there's psychological ingredients, there's sociological ingredients. And I feel like I spend a lot of time with each one of my patients, like, mapping out the ingredients. Like, what are the things in this recipe of yours that's amplifying your pain? And what can I do to help change those ingredients to help you lower pain volume? And one that I have absolutely, till this moment, never thought of is identity.

Anecdotally, it's so present in my best friend from childhood, Aaron Weakley, who also grew up around a lot of violence, and being vulnerable was not an option. I see it in my sister and my brother. My mother has it. We don't give a fuck about that. And then somehow some magic happens where I'm not experiencing it. So I think I'm lying to myself or fighting it. It's like, "I don't care." I don't think you're lying to yourself.

I think it's adaptive for you in some way. It's like a survival tool for you. I don't know you well enough to know why, but it has been adaptive for you throughout your life, and that's why you've been using it. And that's not a flaw. That's not a character flaw. It has helped you get where you are.

I think it's fascinating. It has.

Has a tail to the head of that coin. It does go somewhere. It goes into emotional distress that then needs medication, whatever that medication is, whether it be drugs or whatever it is, or adrenaline. It's not just like it's magically, oh, I don't have pain. It's that it gets funneled into somewhere else where people don't see it necessarily. It has pros and cons, and then that's not good either. Yeah, I hear you.

Okay, so let's talk about sociological, because I think you probably have a lot of interesting statistics, and I'm sure things differ in these different categories of sex, gender, race, ethnicity, socioeconomic status? How are these factors evident in people's experience with pain?

Yeah, so when I was first studying pain as this little library mouse, not church mouse, at Brown, with this pain neuroscientist, I was like, "Yeah, pain's biological. Feels pretty intuitive that there's an emotional component, but what is this social shit? Like, pain is social? What does that even mean?" So I really went down that rabbit hole, and I wanted to examine that. So I'm going to give a couple of examples, and I hope they're resonant, and you can ask me questions about it. So among the worst punishments you can give a human being is solitary confinement. What does it say about human beings that one of the worst things you can do to us is isolate us from others? Being social is biologically adaptive. It helps us survive. It's so fundamental to our very survival that our brains evolved a mechanism to reward us for engaging engaging in it. When we are social, our brains bump out serotonin, which bumps our mood, dopamine, pleasure and reward and motivation, and endorphins, our endogenous, homemade painkillers. When we are with other people, pain volume goes down. The opposite is also true. When we are isolated and lonely and alone, especially in solitary confinement, all of those good chemicals crash.

And we feel terrible not just physically, not just emotionally, but both, because it's connected.

This made me think of the weirdest thing while I was reading about this. When I worked for my mom, and I worked with all of my friends in my early 20s, and we would drink way, way too much on work nights, and we'd stay up till 3 in the morning, and we'd be out in the parking lot at 6 AM to fucking wash cars. But because all 8 of us were hungover, there was some bizarre joy in sharing that state. And I think people can relate to this on vacation with friends. When you're with a group of people and everyone's hungover, versus you're by yourself in your apartment dealing with a hangover, those are totally different experiences, aren't they, Monica?

Yeah, that's true. I think so.

I never cared about a hangover when I was with my friends. And when I was a solitary drinker, they were insufferable.

I mean, there's this old saying that when you share your joy, you double it. Double it. When you share your pain, you cut it in half. And that is definitely true for me. Like, if I'm suffering, my friends will tell you I will burden them, and for them, they seem to be able to carry it. You can tell me your stuff all day, I'll be fine, you know? Like, I can carry anyone's stuff. When I share my stuff, it definitely reduces my pain. Yeah. So that's one example of how pain is social.

So when people are isolated in their pain, obviously that's going to make it go up exponentially. It's going to feed that.

So that was another data point that was so fascinating to me. So former U.S. Surgeon General Vivek Murthy— yes, we love him—

had a mom He's all about ending loneliness.

He did that amazing study, like hundreds of thousands of people, where he showed— by the way, he wasn't the first to show this, but he gathered all the scientific data to show that when we are lonely and isolated and alone, it actually is a predictor of a whole host of chronic illnesses and also chronic pain.

That are worse outcomes than smoking a pack a day, which is the craziest comp. We all know how bad smoking a pack a day is, but being alone is worse.

Worse, not just emotionally, just to make that clear. Loneliness is bad for our physical health. It is a predictor of disease and pain. Yeah, that's so wild. I know. So like, all of these data points, to me, I was like, oh yeah, pain is social. Social medicine is real. But that's not being prescribed, and most of us roll our eyes like, yeah, I have chronic pain, blah blah blah, don't tell me I need to just hang out with more friends. And I want to say clearly, it's not that simple.

It's one of the things— it's one of the levers you can pull.

It's one of the ingredients in the recipe.

Yeah, we should probably be done with time timeouts, right? For kids.

There are a lot of psychologists who are anti-timeout, although there is a version of it which is— it is our baked-in learning mechanism because we're a social primate. Being excluded from the group is insanely powerful. Yeah. So is there a version of it that is not too terrible, right?

Yeah.

Like, it's all about degrees of it, I think. Yeah. But yes, in general, when your kid is dysregulated and you send them away to deal with their dysregulation by themselves, maybe not a great idea, right? Yeah. It's like not going to work really. Yeah. And the goal should be probably to first regulate, then teach the lesson. I think that's also a good order of events. So I wasn't a big timeout person, but there were a couple of occasions where it felt appropriate. Totally. What do we see with pain as it applies to gender? How does it differ with socioeconomics? I have my guesses, but what do we know about that? And race. Redheads.

That's physiological though. What is that?

I had to look that up. Someone asked me that on a previous podcast. I was on this podcast called Ologies, which is a science podcast, and she has red hair, and she was like, is that true? So there is some data to suggest that redheads do experience more pain. It's still very new science, and I would not say it's definitive, but there is some research suggesting that it is tied to, like, our sensitivity. This is the most fascinating thing. So all of us, as part of our recipe, have pain thresholds, and some people— and this may be true for you— have higher pain thresholds than other people. And like everything else to do with humans, it is on a spectrum. Some of us are very sensitive, and some of us are less sensitive. What? Don't look at me like that.

I can handle a good amount of pain.

Well, it's very, very clear to me if you choose it, you can, you can endure a ton. So your role as a cheerleader, you endured pain that you wouldn't otherwise be able to endure because you wanted to be a cheerleader. But you also cut your finger, and it is a very, very big deal. Well, hold on. Both things are true.

I opened a can of worms. You did.

Listen, the finger cutting is not a big deal because it hurts. It's a big deal because I'm— Alone. That's a huge part of it. Then I'm calling people and sending pictures like, is this okay? And as soon as they're like, like, oh no, whatever they say, the connection with another person is helpful.

It's like you're saying that loneliness amplifies the pain alarm and social support lowers the pain alarm.

And it's like, oh, what if I bleed out? It's about that. It doesn't hurt.

You just proved the point. When we are alone, we feel like this is just biological. We're more at risk of death cuz we don't have— we're vulnerable. We're more vulnerable. That's the word. And the second you have social support, I'd I love that example.

I wonder if your proximity to us is gonna lower or up your pain threshold because you're now across the street. Well, I have a good example.

This isn't really pain, although sort of, I guess, but my parents were in town recently and the alarm went off in the middle of the night.

Ooh, so scary. Yes. Normal. I was by myself.

Oh my God. I would've been so panicked. Cut to a week later, my doorbell rang in the middle of the night. I was by myself and I was like, oh, I'm dead. I'm dead. I don't know what to do. Do I call? Like, I didn't know. No, but when I was with my parents, I was just like, it's fine. I had no idea what was going on. Someone could have literally been burgling. A door blew open.

Yeah, but she didn't even care. But if you were by yourself, it's definitely a guy with a huge knife and a ski mask.

I assumed it was something fine when there were people around, and I assumed it was something bad when I was by myself.

I know, but we forget about how that affects our bodies. Yeah, we just forget.

This is like one of the many ingredients in these why married people live longer. This is one component of it. You're not having the cortisol dump. It's easier on your body. Yes. Stay tuned for more Armchair Expert, if you dare. Did we interrupt your mid— I don't really know. That's okay.

I have no idea and I don't care. I keep asking you. It's so much fun and so interesting.

How sex and race and socioeconomic— I'm curious how those— Oh, yeah, yeah. Yeah, yeah. We've got loneliness covered.

So there's a lot of data on socioeconomic status and gender and race and ethnicity. So something that comes to mind is a disproportionate number of people living with chronic pain are women. However, this one really got me. 80% of pain research has been conducted on men and male mice. There's also been a lot of pervasive racism in medicine. Like, this is well known. This is not my opinion. This is just what the research says. Says in general over the years there has been this myth, and there's a name for it, I'm forgetting the name of it, it's like the hero myth or something. It's like that Black people feel less pain than whites because they have thicker skin. Oh my God. Yeah, it's a holdover from the slave trade. And so in general, Blacks are prescribed something like 50% less pain medications in the emergency room.

And like, and the women are believed the least amount about their pain assessment. Black women, if they We tell you it's an 8, the person immediately cuts that in half.

Right. And that leads to this other thing that happens with women and minorities is not being believed, or the suggestion that you're histrionic. That word has somehow just found its way into modern medicine, or it's psychosomatic. So that's—

But let me ask you this. We're gonna try to punch from every angle at the risk of offending someone. Is it not conceivable that women in general are more vulnerable physically? You're going to die by the hands of a man more than I'm going to, unless I go to war. There's an objective threat because of the sexual dimorphism that feeling vulnerable— You get in an elevator with a guy that's 6'2", you have a different experience than when I get in an elevator, right? So, the feeling of vulnerability, if we're acknowledging that that's part of pain, couldn't that be in the recipe?

It sure could, but there isn't data to suggest, in general, that women are more sensitive to pain than men at a biological genetic level?

Oh, I don't think they are at all. They're giving birth. I would argue they have a higher threshold.

Yeah, that's what makes it so complicated is like, because there's all these ingredients and they're always interacting. Is it cultural? Is it sociological? Is it learned? Is it biological? What is the recipe that's creating this thing?

And then are poor people experiencing more or less pain?

Yeah, also access to care. Access to care is in this recipe too. Can we talk about insurance companies? So many of the treatments we're talking about aren't affordable. So, like, you can have 42 surgeries and take 72 medications, but, like, if you want to come see me, it's not reimbursed by insurance companies. It's really crazy. So access to care, being able to afford treatment, access to healthy foods, there's a lot that's stacking up against people who are economically disadvantaged. And so, of course, that affects their pain too.

Okay, so we have a sense of all the things now that are contributing to this, again, phenomenological experience of pain. But you don't stop there, luckily. The last third of the book, Tell Me Where It Hurts, is dedicated to addressing these things. Other than the three you mentioned in the bio, under that umbrella, not a lot you're going to do about your genetics or your tendon strength. No. But there's a ton of stuff that you can do in the pain protocol. So how do you identify and track your pain recipe?

Yes, part 3 is a pain protocol, and my mission in life is not only to change the way we talk about pain and the way we understand it, but also the way we treat it, because we are completely effing people living with chronic pain by telling them that the only solution is a pill or a procedure. So if you came to my office, part 3 is the pain protocol, and it's exactly what I would do with you. And you'll see in the pain protocol that we walk through, like, what are the things in the bio domain of pain that you have the power to change? And what are the strategies and tools that I can offer you to help walk you through that in a very approachable, digestible, not overwhelming way? Because it can feel so overwhelming.

A quick part of a lot of people's pain recipe will be like, the pain starts when I've been sitting for a while. Yeah, totally. Right?

Like, so what are some common examples? I'll say my pain recipe. My pain recipe is like sitting for too many hours staring at my screens, not getting up and stretching and moving my body, not drinking water and just like being extremely dehydrated, eating a crap diet. Sure. When I'm hungry, eating chips or something. Poor sleep. Thank you so much. I really appreciate you very much as I talk about my pain recipe.

Do you have chronic back pain?

I don't, thank God. Okay. But I'm aging, and so like my body— It hurts. Yeah. So crap diet, sitting too long, not moving my body, poor sleep. Like, I am someone who has insomnia on and off, so like if I have a bad night of sleep, my body will hurt more. Not protecting time to exercise. I don't exercise to lose weight. I exercise because if I don't, my body feels terrible, my mood is shit. Those things for me are sort of like fundamental. Oh, and stress. Stress is so fundamental to my pain recipe. Like, if I have too many things to do, which is all the time, and I'm not protecting that, and I'm not like managing my stress well, and I'm doom scrolling at night or watching the Yeah. So all those things together will come together for me and create a high pain recipe.

Yeah, you got to be aware of what your self-medication is because it's often a part of why you're suffering. Right.

You mean like scrolling?

We all have a lot of ways to regulate ourselves. Yeah. And many of them make us worse in the same way that drugs do. It's like they temporarily relieve your discomfort, but at a much bigger cost.

Like I'm a workaholic. That's one of my—

And that's a distraction. And distraction is a good tool.

Cool, but when you overwork, you're overstressed, you're sitting too long, your body feels worse. But so just as there's a recipe for high pain, there is always a recipe for low pain. And like this high pain recipe I just outlined, the cool thing is that it has an opposite. I know poor sleep is going to mess up my body, make my pain feel worse, so I know I have to put myself on a sleep hygiene protocol. I have been doing this for like 25 years now. My sleep hygiene protocol is like dimming my lights a couple hours before bed, not doom scrolling. Sometimes that means I have to put my phone in another room, and I will do it because insomnia messes me up. It means getting out of bed after about 20 minutes if I'm not sleeping, so that I'm not lying in bed being like, why aren't I sleeping? This is so annoying. And then stress goes up, anxiety goes up, likelihood of sleeping goes down. So I know what my high pain recipe is, I know what my low pain recipe is, and I know how to get there. That's actually what part 3 is.

So sleep, nutrition, movement, activity, functioning. How about strategies targeting emotional health, including brain-based treatments known to adjust pain volume?

So can I ask, what are things that you guys do for emotional health that's helpful? I have a bonkers—

I'm like the most creature of habit-y. I have such a routine every single day, and mine is like exercise is number 1, meditation Meditation's very important. Journaling's very important. My diet's very important. Sauna's very important. It's embarrassing how much time I put in to prevent me from being in pain. Embarrassing in that I can't believe it takes this much shit, but I don't care because I am not in pain. Admirable. I've had a bunch of motorcycle accidents. I work out like crazy and I am not in pain. And I am generally very stable emotionally and mentally. And these are— I know because I've lived without these routines and I've I've lived in flaring my arthritis with the foods I'm allergic to, and I've done all the things that were miserable, and now I am just very, very regimented about my schedule.

Great. So you have figured out your low pain recipe?

Other than I can't hack sleep, but whatever. There's gonna be some categories that suck. I have forgiveness for myself. Yeah. Good.

So you're taking care of your emotional health, and by the way, also your physical health with that routine. Can I ask you too? You don't have to answer.

Yeah, of course. Yeah. I think for me, the main thing thing is being social. I like really make time for that. I try to do that daily, like hang out after work with people. There was one period of time where two of my friends who I hang out with a ton were both gone, and I was like, I'm going to die. I don't know what to do.

I need these people. Social medicine is real.

Yes. Obviously, if I exercise, I feel better. I'm not as regimented as—

Okay, I'm also 12 years old.

If I'm in a good routine, I used to exercise all the time, so if I'm in a good routine, yes. But I think the social medicine is a huge one.

I want to add, I don't want to pat myself on the back, you do what you have to do. Yeah, you're humming along. Again, you're 12 years younger than me. I do what I have to do to not be miserable. If I got to do less and not be miserable, I would do it. I had to go to AA because I was going to die. I didn't go because I wanted to go. Like, I also think I think you can look at someone else's routine and feel some kind of shame that you're not executing all this stuff, but you should only be doing what you have to do. This is what I have to do. That's true.

Like, there are moments where I'm like, I have to go on a walk. My body and brain know that I just don't maybe need to do it on the same frequency or I don't know, whatever. But yeah, maybe that. Beautifully said. Fanatical schedule. Well, no, I didn't say that.

I found your low pain recipe and I think it's really amazing. And you guys listed all the things that I would put, like taking care of emotional health. Health other than when I think of emotional health support, I actually think it's great to talk to someone. And there's so much stigma around that still. It's like 2020, and here we are, and we're still talking about like, it's so shameful to have to see a therapist. So like, I wanna see if I can frame this differently.

Sorry, I can't believe I didn't say that. I can't believe I didn't start that. Yeah, therapy. I'm in therapy. Yeah. Yeah. And it's everything.

It's hard to find someone who's available at the times you want, who's qualified, who you like and trust and wanna talk to. So I'm not saying it's easy, but research shows it can be extremely, extremely extremely helpful. Just as we go to the gym all the time to exercise our bodies and make our bodies stronger, why would we not engage in some form of brain exercise for our emotional health? When I think of therapy, that's what I think of. We're going to a trained professional who's helping us with our emotional health, with our history of trauma, with our fucked-up relationships with our families. Doesn't everybody need that just as much as we need to go on a jog? How much better a place would the world be if we were all engaging in as much brain exercise as body exercise. So I think about that also.

Yeah, I think my reservation there a little bit is I am always conscious, I think because of where I came from, with how lofty a lot of these are. If you have two jobs and you have two kids and you're a single parent, A, I don't have the money for therapy, and I don't have the free time to exercise like you're saying. These are all real, real pressures. But even to that, I would argue like AA is free. There's a lot of different groups that are free. You can actually engage in group therapy in in a lot of ways for free. I would also argue that to prioritize 20 minutes of movement in the day— you could go for 5— you'd really be shocked how much time that buys you the rest of it, because you're no longer in that destructive cycle, you're in the virtuous cycle. So you might be shocked with how taking more time for that thing ends up adding time.

I think it's a fair and a good point, and the affordability piece is a really huge one. And I think there are a lot of resources out there. There are There are even workbooks that can help with certain things like depression and anxiety.

That's why I like your book. Someone can get your book and go through this.

The purpose of writing the book was sort of like to put the power into hands of anybody who wants to understand it and treat it.

You have techniques for modifying negative thoughts. True story. That's great. Social medicine, we just talked about that. Some things that could help that will weirdly downriver affect pain is like better boundaries, creating healthy social connections, healing trauma. These things all impact your experience with pain. My other curiosity was, again, I brought up AA. AA has abysmal success numbers. Is that true? Oh, yeah. It's in the, like, 30%.

But— I did not know.

I mean, relative to the other treatments, it's an absolute miracle. You can look at it one of two ways. If you want to just go like, only 30-some percent of people who go there end up getting long-term sobriety, sure. But versus the alternative is, like, single digit. People don't just quit. I mean, very few people do. White-knuckle it for the rest of their lives. So I'm curious, we know how abysmal the outcome of chronic pain treatment is with doctors. It's in the low, you know, it's under 50%. What kind of success would you say you were experiencing with this more holistic—

sound like a jerk? Okay, like a brat. Here's why I'm sitting here on your couch despite performance and public speaking anxiety. Yeah, my patients get better. They get out of bed and they go back to life. I am not saying that their pain disappears completely all of the time. That would make me a liar. Sam continued to have pain flares, but he knew what to do. They didn't paralyze him and they didn't keep him bedridden. He knew what to do. If he needed to rest, he would rest, but he wasn't on the white food diet. He wasn't socially isolating. He wasn't not moving his body. The treatment for chronic pain is known. There is always hope for treating chronic pain. It just isn't told to our doctors. It's not told to us. The treatment for chronic pain is identifying your pain recipe with all of the ingredients and mapping them out, hopefully with someone else, but you can also do it on your own, and then figuring out what you need to do to change the ingredients in your pain recipe. There is always hope for treating chronic pain, and it makes me crazy because, like, if you Google the treatment for fibromyalgia, it will tell you there is none.

I can't tell you how many of my patients were told that there's just no treatment for their pain. They've been through all the medications. In fact, in medicine, if you've had 4 back surgeries and you still have back pain, you will get diagnosed— check me— with failed back surgery syndrome, as if you failed the treatment instead of the other way around. Yeah. There is always a treatment for chronic pain. The treatment exists. It's looking at the recipe and figuring out what we can do to lower pain volume. And there's a million things we can do.

The great challenge to me still seems like asking patients for behavioral modifications versus pills or procedures is a tall order. Getting people to change their behavior is really, really hard.

I agree with you. I would say it's a combination of things. I am not telling people to go off their pills, absolutely not. Like, pain medications are a godsend. We're no longer biting on wooden spoons. Yeah, thank God for drugs.

Think of Ulysses S. Grant dying of throat cancer for months. Like, what was that experience like in the— you know? Yeah.

I mean, no. And I want to say also that opioids are appropriate for post-surgical pain and end-of-life care and cancer pain. I just feel like we are screwing people. Can I ask a question? Oh yeah, you can ask. Did it start with an injury?

Yeah. So I had been 8 years sober when I had a motorcycle accident. I was prescribed— I asked my sponsor, am I allowed to take this? Oh boy. I took it, it was completely fine. Very misleading. I filed it as a mental note. I'm like, oh, that's weird. That was a drug that I was fine. I didn't take them all, still did my shit. So that was a very bad data point. And then over the years I had more injuries. And then what really set it off to the races was, yeah, I had back-to-back hand shoulder surgery and this bullish, arrogant view that this was a drug that didn't seem to affect me in the way that cocaine or alcohol did, and that this was kind of a manageable thing. And then, yeah, I was off to the races. But I mean, I want to take 90% of the responsibility for it. I also was open to the idea that there was still something I could do that wasn't the other things I had admitted I couldn't do. Can I ask a question? Yeah.

Would it be fair for me to say, like, I don't prescribe, I don't prescribe, but I observe, and I see patients with pain all day. It makes me angry that this is what we're doing to people who have a history of addiction. So my question for you is, do you feel like it's inappropriate for me to say, like, maybe we can recommend different pain medications for people with a history of addiction than opioids? Do I have a leg to stand on?

It's tricky because— I'll give you an example. Like, what screamed bullshit to me about the James Frey book, which I love— was he did not have all that dental work without anesthetic. That doesn't happen. No one does that. No one should be expected to do that. Addicts shouldn't be expected to do that. I don't love putting the responsibility on the doctors, if I'm being honest. But I'm in an addict community. The responsibility is mine to say to the doctor, "Hey, I'm an addict. The pills should go to my wife." This happens in the program all the time. People are responsible for other people's pills. As long as you take it as prescribed and as you're supposed to, you're fine. So that's on me going in to go like, I should never be holding pills. If there's some range of how long someone should be on these pills, I should be on the shorter end of these pills. But I don't think it's fair for the surgeon to take on and understand your level of addiction. My dad died 28 years sober. He had many different bouts of being on opiates. It never got him. There wasn't a thing for him.

They were in his house. He didn't care. He self-administered. He never abused them. I don't know why. That's what version of addict he was. And then I was this version So, I think it's too much to ask the person that's supposed to be really great at reassembling your bones to also be somehow an addiction specialist who can evaluate— I think that's on us addicts, to be honest.

I totally disagree. I want to hear your opinion.

Well, for one, we know that the doctors were part of the whole opioid epidemic to begin with. Absolutely. So, they do have a responsibility, in my opinion. I agree with you that ultimately it's the addict's responsibility, But when you're in your addiction— Yeah, that's the problem.

As soon as I had the pills in me, the game plan went out the window.

Exactly. When you're sober, you can say, hey, so my wife needs the pills. If you're in your addiction, you're not doing— the whole point is to get high. So I do think doctors should have to ask before they prescribe, what's your history with addiction? Ask you straight up. They still might lie, but at least it's there. And if the answer is, oh, I have a history, then I think they need to say, well, what's our plan then? That's correct.

We're also in a different era.

Need to acknowledge, because I've had surgeries in all the eras, right? So when the Sacklers were running— I mean, if there is a true villain in it, it is the Sackler family, who had a very well-financed campaign to convince doctors who hadn't studied pain.

Less than a 1% chance of addiction.

Yeah, so they don't know. And then they're seeing all this data that was bullshit data that the Sacklers had come up with. So again, I can't expect them to, like, go specialize in pain medicine if they're a thoracic surgeon. They have to rely on studies. And stuff. So they were the victims of a very good campaign by a very well-funded, dark-ass family. And so there was a period— I talk about this, most of my friends are stuntmen, they all have crazy injuries. Most stuntmen have a kit of opiates at their disposal. That doesn't exist anymore. The damn shot, it's not what it was. So I also don't think we need to overreact to a situation that no longer exists to a large degree. You're not walking in with a toothache and walking out with 2 weeks of Percocet anymore. But I think a lot of reaction, so that's good. Oh yeah, but they've slammed the door on it, so I don't know that it's the same issue as it was 10 years ago.

I respect both of your positions. I find myself landing in the middle because I feel like, as a provider, you bet your ass it's my responsibility to assess my patient, and I absolutely need to educate myself about my patient's history. That is my job. My oath is to do do no harm. Every doctor takes that oath. And I, having studied pain for like 35 years, I am doing harm if I am prescribing opioids to someone with a history of addiction. Because what happened to you could happen to anyone. It didn't happen to your dad, and bless, but why would I put you in that position? If I'm a good doctor, I am trained to ask that question. You don't have to be trained in addiction medicine to ask. We also might lie to you. That is 100% on you. That's 0% on me. But I did my job. Yes. I asked you, do you have a history of addiction? Am I putting you in harm's way by giving you this particular medication? Because as a doctor, a trained MD knows there are alternative painkillers out there. It doesn't have to be the most addictive one.

So someone could have given you a friendlier, less dangerous drug and could have saved you the fuckery that you found yourself in. Wouldn't that have been nice for you?

Just to say, you're not gonna like this answer, but I mean, I had to go through that.

You had an important life experience, and I'm not— and I am in no way discounting it minimizing it. But had I died—

yeah, had I OD'd— you came out on the other end.

A lot of people die.

I didn't end up shooting dope downtown. A lot of people end up shooting dope downtown.

So like, I think there's definitely— the responsibility is on the patient to be honest, to disclose, and even to bring it up if you feel comfortable. For people who don't feel comfortable, the onus is on the doctor. We as healthcare providers have to do our due diligence. We have to get to know our patients just a little bit. Can we we do that? If you're a healthcare provider and you're listening, spend 3 minutes. I literally just did this. I put like a pain assessment on my website because I don't think we assess pain properly. And one of the questions we need to be asking: do you have a history of addiction? It's very simple. You don't have to be trained in addiction medicine. You don't have to do anything. You have to treat the person for addiction.

Just ask. I would expect every doctor to ask that.

I feel so strongly about that, having seen so many nightmares. I was really honored when you invited me on because I have listened to your episodes where you about opioids and pain. And I teach the addiction medicine fellows at Stanford, the next generation of MDs, because they don't learn very much about pain. And pain and addiction in America are best friends. Our mutual friend Anna Lemke runs like a pain and addiction center.

Well, this is really great. It's in the book. We are, I think, 4.5% of the world population, and this country consumes 80% of the opioids on planet Earth.

Crazy. That is crazy.

I mean, that number's probably fallen in the last couple years, but still, there was a point where 4% of the population was consuming 80% of the opioids.

And I think it was specifically like OxyContin. Yeah, yeah, yeah. It's like similar numbers probably to guns.

Two things that kill everybody. Yeah, yeah, yeah, yeah.

I mean, I think we could just do a better job. Yeah. I think we can all agree that we can just like do a better job. You know?

Well, Rachel, this was awesome. The book is called Tell Me Where It Hurts: The New Science of Pain and How to Heal. It's awesome. It was worthy of a conversation at dinner. I think you'll find that to be the case. As well. And the cutest last name ever, Zoffness. It's almost softness.

It's like softness with a speech impediment, but with the hardest letter. Yeah, mixed messages.

X might have made it a little harder, but yeah, yeah, Zoffness. What a cute name. Okay, thanks for coming. I enjoyed this.

All right, to you both, I really appreciate it.

Thank you. Stay tuned for the fact check. It's where the party's at.

So I think I have a fun and ironic update. Okay, let's hear it about our debate. Oh, about skin marks? No, my arms. Oh, okay, with waving the flag.

Okay, if you recall, I think you need to tell people.

Yeah, so I was saying I was in a bit of a pickle because I wanted to both work my arms out in case I waved the flag at the MotoGP race and also my arms don't fit in my suit. Exactly. So I was really Sophie's Choice, didn't know what to do. Uh-huh. You were really urging me to skip arm day. Yes, I was. For the safety of the writing. Yes, I was. Big debate. Red carpets came into— high heels got invoked. What does that mean? I was pointing out that you're uncomfortable in high heels. Oh, during our debate. Yes, yes, yes. Just bringing back all the details. Yes, yes, yes, yes, yes. So I went to Austin with that on the table. And the question was, what was I going to do? Heed your advice, be responsible, or be vain?

But you made very clear to me that it wasn't a safety hazard. No, it wasn't. You could move, that I was overreacting. Just uncomfortable.

So I chose vanity. Okay. Definitely worked my arms out on Saturday, and they did not ask me to wave the flag.

Right. So, so that's That's funny.

So that right there is a win for you. That's like a win. No, it's not. Well, it is in a funny way, which is like, I did this thing which I shouldn't have done, and then I didn't even get to do the thing. Maybe I won't use the word win. I'll just say that's a funny mark in your category. And then we'll get to mine, which was, so I did, I got my arms all pumped up and vascularized. Yep. Didn't wave the flag. They didn't even ask me. Yeah, they did. I don't know. I don't know.

It's funny, you don't pay as much attention when you're not the one waving the flag, which then goes to show how many people are paying attention when it's you.

I did have someone last year text me and go, oh my God, you're waving— I mean, another MotoGP fan. Sure, notice I was waving the flag. Anyways, I did not wave the flag. Wasn't asked to wave the flag. I was like, well, that was for nothing. But then, and here's the irony, the ironic twist, yeah, went to the track on, on Monday. I don't know if it's because it was so hot in Austin, whatever, arms arms weren't tight.

You were fine. No issue. I know.

So both things happened in reverse. That's right. That's how I feel like it's a win for both of us.

It's a win for me if you're safe. That's all I care about. I'm not against you having big arms on a flag wave. Yeah, only if it comes at the risk of your safety, which you assured me it didn't, but I didn't believe you. And also, you— it was just a hilarious outcome.

Yeah. Harrison Barnes waved the flag. This year. He's an NBA player. Oh, for the San Antonio Spurs. Okay, great. So we got a San Antonio Spurs, and good, because presumably he was very tall. He's 6'7". 6'7". Get that flag up in the air. In fact, I might have to go back on my DVR and watch him wave the flag. That's nice. And I want to see how his arm— you know, these NBA players have really nice arms. I'd probably like to check out his arms. Okay, yeah, but okay, I was just talking side note. Oh yeah, great, really nice. Just put a picture up, and great delts, and he's got some vascularity in his delts, in his left. He looks handsome. Yeah, he looks like he's screaming in that photo. Yeah, yeah, of happiness. Victory was his. I think it says that's when he found out he was going to wave the flags. Oh, that probably makes sense if I just told him. Okay, okay. So I was talking to Ricky Glassman yesterday. Great. And, uh, it was ostensibly he called for advice, which is always so flattering. I love this role I get to have in Ricky's life.

It's very— yeah, I really cherish it. So we're talking about business stuff and everything, and I don't know how we got on the topic of muscles, but we just went off. And he's like, yeah, I don't know how to explain it. I guess because I grew up watching Schwarzenegger and Sylvester Stallone. I'm like, that must be it too. And he's like, yeah, I just love them so much. And then we were talking about, like, to what extent do we love them? And I'm like, you know, I want to squeeze them and stuff. Like, where is this line? This is very weird. Homoerotic. Where's that line?

You're attracted to it in a— I think there's layers—

in an aspirational way. Yeah. Oh, I'd like to look like that. Exactly. Yeah. But I also want to feel them. Like, I want to squeeze—

but you don't want to feel their dick, do you? No.

We went through, like, well, how far does it go? I would definitely want to squeeze, uh, Schwarzenegger's biceps, and I'd like feel— I'd even like to run my hands across Brad Pitt's abs in Fight Club. Okay, right. I'd like to feel that. What do you want to feel? All the definition and the ridges. Uh-huh. Yeah.

Can you relate to that?

Um, would you like to run your hand over his— No, but I'm straight. Yeah, yeah.

You know what I don't want to do is rub my hands over, like, Kristen's arm muscle, right? I have zero—

I know. This is why it was worth us discussing, is like like we're, we're on some trajectory, we're on some spectrum on the Kinsey scale. I don't think it's where we like want to touch and feel. That's like, that's interesting.

Well, because I think it's still like you want to touch and feel it so you can kind of see like what it would feel like if I could, right? It's still about you guys. You think so? Yeah. I mean, I mean, women have— I have this all the time, like with other women.

Do you want to feel any of women's boobs or No, but I do hear that from other women that are straight. Yeah, they're like, oh, I want to squeeze those boobs, and they're straight.

Okay, well, I've never ever wanted to—

You've never had a friend of yours ask if they could touch your boobs? Nope. Never? Even drunk? No. You could want to squeeze them without being sexually attracted?

No, I guess, but like, I— whatever, I, I don't know. I can't speak on behalf of anyone other than me.

You guys sidetracked.

Yeah. Okay. I, um, have no desire to to touch anyone, squeeze anyone's boobs, or touch their genital parts. Touch?

Yeah, like if you saw a big buoyant butt, you don't want to squeeze it to see what it feels like in your hand? No.

Oh wow. I might want to be— I might want to say like a female.

Yeah, yeah, yeah.

I might be like, oh my God, that person has such a nice body, like I wish my body looked like that. But I don't need to— you don't want to squeeze it? No, I don't need to touch it to know that. I just like, I'm like, oh, they have like great X, Y, or Z. I wish I had that. And then, you know, then you hate yourself for a little bit. Okay.

And then, um, what are you chomping on over there?

Oh, I have some lozenges. Okay, I'm still sick. Oh, and I haven't— I, I have a sick spray. I almost brought it since we both have sprays. No, it's like natural.

Oh, okay, so it's pageantry. For sure.

I mean, I'm not better.

It's just an activity to do. Well, yeah. Yeah. Okay. So no desire to touch.

Okay. I have no desire to touch, but I definitely have admiration, a lot of admiration for a lot of female bodies. But it's still about me. That's— it's still like, I wish I looked like that. It's never outward really towards them. Yeah, it's like, how can I look like that? And I think, I think I think that's what's happening with you guys too, but maybe the feeling is like, it's still, it's still about that. It's like, hey, what does it feel like to have that?

I want to feel the heft of things too, you know, the weight of things and the heft, right?

Yeah. But let me ask you something. Yeah, so you, so you want to, you want to feel it, squeeze and prod. Yeah, touch. You want to get your physical hands on it, um, with their consent. And, um, but do you want to do that for females? Like, when you see abs on a female, are you like, oh, I want to— I, I like— I want to touch that? Not really. No.

But I regularly see butts in spandex or something, or boobs, and I do want to like— I want to— yes, but that's sexual.

Those are sexual parts. Like, that's different than what you're feeling towards these men and their abs. That's true. Goes to show, if you're not wanting to touch the female abs, it's not about muscles. Exactly. No, it is a— it's about actual muscles. Okay. On, on the men and how you can get them, or like how you can relate to them or something. But yeah, I think most people out in the world are aware of other people's faces and bodies and whatever, sexually or not.

Yeah, they're probably seeing the ones, whatever one they want. Exactly.

That's That is your point. Or if, if whatever they feel sexually, their sexual orientation, they might see, you know, like if you're straight, you're gonna see the opposite sex a little with more curiosity sexually, but of their erogenous zones. Exactly. Mm-hmm. Because when you are attracted to someone, it could be really random things you're attracted to on their, on their body. Absolutely. Not just their erogenous zones. Right. You know, mons pubis, a shoulder bone, erogenous. That's the clear erogenous zone. But you know, I really like hands, and so I do tend to look at men's hands a lot. This is so fascinating.

Again, very anecdotal. I have no idea what the grand data would say, but certainly I'm aware of so many men who have foot fetishes, right? I don't really know any women that do. I've never heard a woman talk about—

so interesting, this just came up on Elizabeth and Andrew.

Oh really? But I know many women who are super into hands, and I don't know a ton of guys who are super into hands, right? What is going on? Why would one— well, I know why women do.

Hands are a huge part of sexual interaction, interaction, because they're going to be all over you. Yeah, they're all over you.

They're in you potentially. They're in you. They're on you. They're in you. Yeah. They're in charge of all the action.

Exactly. Yeah. So that's why I think women can be attracted.

So do you think these guys with foot fetishes want to be manhandled by their feet?

Well, that's probably—

I've seen pornography where guys are getting jerked off with a woman's feet. What? Yes, I have seen that.

That seems very hard to do.

For her. Yeah. Yeah. Yeah. You got to really coordinate.

That like gracefully? It feels like you'd look so weird. The woman. Yeah.

Also, how do you gently bring up like, hey, are you coordinated with your feet? Like, if that's a huge thing for you, that's like your ultimate— like the guy we interviewed for Armchair Anonymous.

Yeah, kinks.

Who liked his toes played with. So it's like, it's— he, he want— this is an important thing to have. Yeah. Is this foot job, we'll call it. For sake of time. Okay. How do you suss out whether that partner is going to be able to do that? Because I bet— I imagine there would be a lot of gals that were fully up for it and they just can't—

they can't do it. Yeah, I feel like most people can't do that. It's so corny.

Yeah, forget that. I mean, also, oh, the amount of leg strength you'd have to have.

That's what I'm saying. It's actually a lot more than the foot. You also have to be flexible depending on— those guys should be—

they should be more generous and just be like, can you lay down on your back and I'll pump your feet.

Okay, so are they putting the penis between their feet? This, like, like this? Yeah. Oh, okay. I imagine that requires a lot of, uh, yeah, quad and ab and core. I imagined it like that.

That could be fine, but that's hard. Yeah, that would work too. Actually, I'm not even sure of the way I said the first one. I mean, that feels more natural what you just did. Where is the inside of your feet?

Yeah, but then that also is hard on the legs.

On the it band.

Yeah, you have to be like at one of these, you know? Yeah, yeah, yeah. Okay, I hope nobody asks me to do that, 'cause I just, I'm gonna look, I'm just gonna look bad.

What if you said, give me a couple days to practice on a banana or something to see if I can even do that? Yeah. In concept, I'm fine with it. And like, there's nothing wrong with that in theory. Thank you.

Mm-hmm.

But I think, well, in this circle— so we got to circle back.

No, this like is more evidence to it, like why the hand and the foot fetish. And like I said, I think the hand makes sense. Sure. I think foot— I think people who have foot fetishes, I think women's feet like remind them of the vagina. I don't understand why. Really? Maybe because the bottom part's so soft.

What are you basing that on? Have you heard someone say that?

I just know it.

It's just you're leaping to that.

No, I just know it. I just know it in my heart. Oh, you do?

Should we call Eric?

Yeah, we can. I mean, just to find out if that's— remember, we've talked to him about this though, and his is weirder. His is not like— it doesn't— it's not as conventional. I don't think so.

Also, we should say Eric's not the kind of person who's buying photos off the internet. Exactly. Yeah, yeah, I think it's like— I think it's a low grade.

He just appreciates the esthetic a lot, and especially because he worked in women's shoes as a young boy. But he does— he's never said like he wants to like suck any toes or anything. So I don't—

so he didn't suck your toes at one point? No, he just cheese grated them.

Oh, okay.

He just manicured them, you know, like, again, like he wanted— yeah, I guess he wouldn't suck your toes. No. Yeah. Okay.

Oh my God, that would—

but if anyone— if we would let anyone, it'd be Eric.

Yeah, but like, I don't think— I, I don't, I don't know. That seems— that is intimate. Well, by the way, toe sucking is a sexual thing. Sure. Standard biz. Yeah. And I think it's because it's sense— your feet are very sensitive, just like your vagina. I think there's some similarities. Okay. I think that's what it's about.

Having no draw to the feet, I can't begin to figure out what's going on. I think I can relate.

I think you cracked it. I really do think I cracked it.

I just think it's interesting that you think the foot looks like the vagina. No, of all the body parts. Like, if that's the argument, then I think people would be way more into armpits.

Foot looks— there's just something about it that I think for these people— yeah, like the softness, the sensitivity. Well, if you have— if you have good feet, they're soft, but if you have bad feet, they're great for you.

The toenails, they're—

they're like— yeah, they're manicured in a way that like a lot of vaginas are, like, kempt, as we talked about last time. Kempt or unkempt. Okay. Sean Kemp. Yeah. So I just, I think that's what it is. And if you have a foot fetish, please weigh in. Let us know on whether or not I'm wrong.

Although you might not want to do it in public on the comments.

But people also, they don't know what it is. Like, I just decided that about hands and I think that's right. But that's not what's happening when I'm like at the grocery store and I see someone have nice men with like a strong hand. I'm not like, oh, I want that on me. It's just like, I— it's a visceral thing where I'm just like, oh, that's hot.

Yeah, you get a— yeah, you get a pique, you get a little bolt of electricity.

And some people— I think I actually don't get it from a lot of things that a lot of people get it from.

Like, well, like, what do you hear friends talking about and you're like, oh, I can't even relate? For me, that's like, I have a friend that's like, talks about ankles and talks about feet. What are you talking about? What, the ankles?

Like Because it's skinny. What is that?

I don't even want to go into it, but there are guys with things with ankles, and I'm just like, how could— of all the things to look at, why is that even where you would be focused on? You've got eyes, lips, uh, uh, the obvious ones, different body parts.

I'm okay. Just— I'm, I'm on fire.

Wow, you're really solving a lot of mysteries, age-old mysteries.

I think I now understand the ankles. Okay. Because conventionally you don't really— they're covered up.

Okay.

Mine are. Yeah. People are wearing socks, people are wearing pants, shoes, whatever. So it's kind of like, oh, I'm seeing something I'm not really supposed to be seeing. And I have that, like, with certain things. If I see that normally are covered, like, okay, like, I really like necks. Okay, those are always on display. Not Always, because people have jackets. You think everyone's wearing turtlenecks? Jackets and shirts and like hats. Okay, that one's a little more on display. Yeah, okay, that's probably right.

Um, but it's still just— you just like necks? No, it's not that they're not on display, you just like them.

Well, it feels like it's not like right in front of me. It's not eyes or lips or something. Specifically the back of the neck.

Oh, that's different. Yeah. Back of the neck. Okay, I'm with you. Front of the neck. You're getting as much from the neck as you are face.

I don't care. For most people, that's back of the neck.

Back of the neck.

Yes. And it's like, what are you looking for in the back of the neck? I don't know. It's just like, I just know when you see— I know when I see it that I like it. And I do think it's like, oh, I'm not really supposed to be looking at that. Oh, because like they can't see me looking at it. Maybe like there's some stuff. There's some stuff in there.

Okay, now back to the what your friends— do you find that you hear your friends talking about specific body parts, um, in men that you're like, I don't get it?

Well, I'm never like, I don't get it, because no one is saying anything weird. But like, yeah, like if you're like at a grocery store, this— all this stuff's happening at the grocery store.

Yeah, your inbox is hilarious because you— I never know what you order for all your groceries, but yeah.

Oh my God.

Um, it's like you're doing an improv about it. It's like, we need a location. Grocery— you're always going, grocery store. No, because can we get a location that these brother and sister would be in?

Grocery store. No, it's just where most, like, strangers are. You see a lot of strangers.

Yeah. And you're in lines and you're—

exactly, you're behind people. So if someone's at the grocery store— oh, Jess calls this something. Okay, so whenever he sees anyone wearing a shirt that's like kind of cropped or like right at the pants. Yeah. He calls that marinara. Oh, interesting. Because when you go to grab, in his head, when you go to grab the top of the shelf, you grab the marinara.

Which in his mind is always marinara. It's marinara.

Okay. It exposes the stuff. Arrows.

Yeah.

And the arrows. Like abs. Arrows are really powerful. Arrows are powerful. They are powerful. Yeah.

I feel like they're— of the many things a man could have, arrows are like really high up on the list.

Do you like arrows on a woman? Yeah. Yeah. Well, arrows are literally arrows.

They're pointing to your genitals. Yeah, yeah, yeah. It's funny. And it's not that I'm like an ab person, so it's not like I need a six-pack. But yeah, even arrows on a gal, you're like— definition. I think there's something that we know that we don't know about the arrows. And this goes for a lot of different fitness things, which is like arrows are really hard to get. You're really athletic if you have arrows. Oh. And so somehow your body knows evolutionarily, like, that person's very fit. Oh, interesting. And then there's other things where it's like every guy does bench press and has a big chest. You're just like, yeah, guys have big— it doesn't really say anything.

I think it's more that it's pointing to the genitals.

I think that's why butts too are really powerful.

So I don't have a thing for butts. At all?

Mm-mm. Really? When you watch like an NFL game, you're not like mesmerized by—

I'm not a butt girl. Yeah. But anyway, marinara. Yeah. Okay. So if someone is marinara, I sometimes it's, sometimes it's intriguing to me, but from, I think most women that's very intriguing.

Okay, there you go.

And I'm like, it's a push for you. Yeah, hit or miss. Not always, even if it's like really nice. Okay. Um, I'm just like, yeah, I like more, I like more random things.

Uh-huh. Hands, necks, earlobes.

Sometimes I just like, I'll see something random on someone's body, like their forearm or something, and I'm like, oh, you get a jolt. I get PQs. Wow. Wow. Stay tuned for more Armchair Expert, if you dare.

Uh, kneecap ever?

No. Um, no, I've never been attracted to anyone's kneecap. Me either. But you know, I remember we had, we had Hassan on, uh-huh, and he said, and I thought this was interesting, he said like he's really attracted to to like specifically Indian women. The little hairs, that one. He did talk about that. That's one of his things. He did talk about that. But he talked about in a woman's arm, an Indian woman specifically, like armpit, there's often like extra fat right here. Morphoids. I have it, I do. And I like, I despise it. Oh, you hate it? Oh my God, I hate it. Okay. But I remember him specifically talking about that. But he loved it. And that he liked it. And I was like, oh, you know, there really is— like, there is a lid for every pot, like an ass for every seat.

There really is. Like, yeah, you never know what people are attracted to, and you just decide, oh, no one likes this. And then, and then, and then you will confirm that. Exactly. And you're missing out on— like, yeah, dude, you see it all the time. We see people that are paired up and you're like, wow, that person clearly has all the options in the world, and and that's who they picked. That's so— that's interesting, and it should be comforting. Yeah, yeah, yeah, it should be.

It should be comforting. It's like, someone will like this. Yeah. But also, it's like, I don't know, I go back and forth, I guess, because, you know, I don't like that skin, fleshy, uh, fatty part of my arm. Armpit. Armpit. It's like, it's not really the pit. Well, I guess it is the pit, sort of, but it's more on the side. Anyway, um, I hate it. And I guess I could be like, well, somebody will like this. Like, that's— but I don't like it. And I think it's okay. It's like, I should probably just care about what I like. I don't like it, so I don't need to find someone who likes it.

It's a better rule of thumb to be making decisions for yourself and not what others will like about you in general. Yeah. But then you really got to ask yourself, well, why don't you like it? My hunch is you don't like it because you you think other people don't like it?

Probably, you know, cuz it's not on the bodies of the women that I look at and I'm like, oh, I want to look like that.

Yeah, but don't want to touch or squeeze.

I just don't want to touch. I don't want to touch like their armpit.

That— you never want to poke a big butt to see like what the consistency is?

Never. Wow. The thing is, we talk about this with Nikki, whoever you're attracted to, yeah, they like it, man.

They like—

you like, you like all the parts? Yes, totally, totally. Cool. Yeah, so great. That's why, that's why personality is real. Like, having a good personality and being someone somebody wants to be around and hang, hang out with. Like, once you're that person— I mean, I say this as someone with no boyfriends—

once you're that person, and I'm pretty strict.

God, does that mean I have a bad personality? Why? Because I'm saying if you have a good personality, you can get people.

No, I think this is the— what's funny is I think you're giving yourself this advice. What do you mean? I think you might be a little too— what's the word? Picky's the word, I guess. You gotta go with who's got a personality and then see if you would get attracted. You don't know anyone with a good personality?

The people I know who have good personalities are my friends, right? And they're all married, or they're Jess.

Yeah, you're not at the grocery store.

I don't go to the grocery store enough. Yeah, I'm not gonna get their personality really from the grocery store. It's funny, you're out a lot. I am out a lot.

Yeah, I know you're out a lot, so I'm a little confused.

Can I be— I— not to be— this— good personalities are few and far between. Are they? Yeah, they really are, across the board, women and men. Good personalities. I'm so misled. Really want— well, I'm misled. That's the problem. My friends, the people in my life, have great personality.

Well, I was gonna say, we interview insanely interesting people all week. Yes. And then generally if I hang out with somebody, it's one— someone in our friendship group. So I probably don't have a great read, uh-huh, on the general options personality-wise, other than when I'm in Nashville, I'm just hanging with my neighbors and stuff and out at restaurants, right?

I do think that Jess being my best friend is problematic, is a hindrance. Yeah. Big time. He is the most— he has the most special personality of anyone I've ever met in my entire life, and I spent all my time with him.

Uh-huh. I know. Even Marinara.

Like, who am I gonna meet that is— that is— is Marinara? Like, no one. Yeah. And so this is where I really think sometimes I'm like, look, I got so lucky.

You should send him to conversion camp.

No, we're not attracted to each other, and that's what's great about us. He has an incredible personality, and I get to spend— I get, I get free access to that personality, and it's, it's so lucky.

That is a problem. If you're, if you're deciding— you meet a guy, you've been on a date with them, and then you're deciding the next night, do I hang out with Jess or do I hang out?

Exactly.

That's— yeah, this is interesting. This is a problem. It is.

And that is what goes through my head. Of Of course it is. Like, okay, I have 2 hours to hang out tonight. Am I gonna go on a date? Yeah. Or am I gonna hang out with this person that's gonna make me laugh for 2 hours? Yeah. I'm always gonna pick that. Yeah. So sometimes I think like, oh, maybe I should just, in fact, most days I think, I think this, like, I'm just so lucky. I have these incredible people in my life, multiple incredible people. Uh-huh. I think if anyone would be so lucky to have one of these people in their life, and I have so many. Yeah, maybe I should just be lucky and grateful for that, and like, that's enough.

How about this? If, if I said there's this new breakthrough, AI figured this out. Okay, you and Jess could take this pill. They took your DNA and they engineered it, and when you— after you wake up tomorrow morning, you're gonna be insanely attracted to Jess, and he's gonna be insanely attracted to you. Would I do it?

Yeah, right? I know, but what if it ruined everything? This is a Black Mirror episode. This should be a Black Mirror It could ruin everything. Yeah, I think you just got to be grateful for what you have.

All right. You know? Yeah. Let's say you're both attracted to each other, but now all of a sudden he wants to have sex with you more than you want to have sex with him.

Now you have this— or what if he's like selfish in bed or something like that? Like, you know, bad parts of personalities can come out when these things get involved. Jealousy.

Like, there could be a lot of jealousy when he's making other people laugh. All of a sudden it bothers you. 100%. Yeah. 'Cause right now you don't care. No, I— But if he was making some girl just laugh uncontrollably and he was your boyfriend and he was straight.

Yeah. You'd be— No, I, I— You'd tell him to shut up.

No, no. Shut up. No, your, your comedy's only for me.

I, I know it is funny 'cause now when we're out places and he's making people laugh and, um, and he's my, you know, buddy, I'm like, so I, I feel so proud. Yeah. I'm like, oh my God. Yeah. Jess is my best friend. Like, I'm so lucky. Yeah.

And but yeah, if he was into girls, he's making some hot chick laugh uncontrollably and you could see she was looking at him like, I wish this guy was my boyfriend.

Yeah. And then she's like pulling her titties down and I'm like, fuck you, get out of here, I break up with you, Jess. Yeah, see, it could go badly. I'm leaving it.

We wouldn't take it.

Yeah, I'm okay with it. All right, should we do one?

Yeah.

Okay, this is for Rachel Zoffness.

What a name. Great name. Yeah, Zoffness. I wish my name was Dax Softness. It'd be too many weird letters, but it does soften everything.

God, do you want to hear something embarrassing? Yeah. I can't believe I'm going to admit this.

Oh, good. It's a day of admissions.

So when I was young, I would like, you know, write a lot of fiction stories on my computer. And I would create— I was basically like writing what I wish my life was. Of course. Yeah. The main character. And I was always like thinking about what name— who would I like name the characters and stuff. And I did really like the last name Shepherd. Really?

Yes, I did. Where did that come from?

I don't know. I must have heard it and I was like, oh, I really wish that was my last name. My life. Very white. Yeah, but it's like, it sounds nice. It sounds really nice. I'm grateful for Shepherd.

Yeah, don't get me wrong, it's good. Yeah, it's a good name. And then of course I like that it's not spelled the way, so I still have some uniqueness, you know. I love you.

I don't like that, it's annoying.

You would want H-E-R-D?

Actually, no, I like the way yours is spelled esthetically.

Yeah, it looks better, right? Yeah, it looks better.

Yeah, we don't even have H in there, but it bothers me when people spell it wrong, like when they're like reaching out. Oh, it's almost exclusively wrong.

I get offers or I get these ones that are kind of like, they're very flattering letters begging me to be a part of something. And I'm like, but you didn't even look up how.

You don't even.

You're acting like a super fan, but you don't know how to spell my name. But I don't get that, but not a shape of. Rob McElhenney famously. Oh, well his is awful. He's let people go over it.

Yeah. Oh, wow. Yeah, yeah. I get it. It's like, just take a second. But I've also made that mistake too.

I don't care. Thank God. I mean, I care about so many dumb things, but I don't happen to care too much. I just— it's ironic. I see the irony of like, I'm your biggest fan. I know it would happen with Kristen too. S-H-E-P-H-E-R-A-R-D.

Yeah, yeah, yeah, yeah. When I was Kristen's assistant and people would reach out asking for things and they would misspell her name, I was like, no.

Yeah, yeah, yeah.

You're not getting it. You can't even take the time. So, um, anyway, so I wanted it to be that. I wanted that as a last name.

Monica Shepard?

No, it wasn't Monica. Oh, I hate it.

It's gonna be Gail Shepard?

No, it was like Sky, um, like Ansley. Ansley? Yeah, that's cool. I know. Yeah, it is cool.

Um, okay, you never wanted Hollis? Sorry, I didn't know about it. With a bunch of crazy letters slammed in there. I would have written a character. No one spells my name right. Well, Rob, we've been working together for 8 and a half years, and honestly, every time I have to write your last name, I get a sharp pang of anxiety. I'm like, I'm never doing this right.

Yeah, how dare— how dare you? I'm gonna try right now in public.

I'm gonna try. Okay, I think it's Hollis. H-O-L-Y-C-Z? No, S-Z. C. Yep. Okay. Wow. I thought it was CZ for a second. You can definitely see where there would be a C in there, right? Hollis? No, I don't normally get a C in the wrong spot.

You get— do you get H-O-L-L-I-S? Well, phonetically, yes.

Yeah. Could we— you ever thought about changing?

No. Rob, you be you.

I think it was already changed technically from like the real Polish. Oh, probably pronunciation at least. Okay, so I blew it in public. Yeah, so it's a tough one for me. I know there's a Z in there.

Oh, having a Y and a Z in your name is tough. It's gonna be tough. Yeah. Yeah. Speaking of names that someone could mispronounce, um, Usain Bolt. It's just— that's a tough one. Yeah. Yeah. Uh, so just some stuff about his back. Scoliosis. To manage his back issues and protect his spine, Bolt focused heavily on core strength, sometimes doing up to 700 sit-ups per day. At age 15, he became the youngest male world junior champion ever in the 200-meter running at under 20 seconds. Wow. During the 2008 Beijing Olympics, he ate roughly 1,000 McNuggets over 10 days because he was picky about the food. 1,000 McNuggets?

That's a— that's a scientific experiment. Yeah, like what would happen if someone ate 1,000 nuggets in 2 weeks? They would set all the World Records.

That Pink Sledge video is one of the best— mark— I, I don't know what they were marketing. I get Burger King probably was behind that, like. And I cannot hear the word McNugget and not think of that Pink Sledge.

Oh, thank God I don't. I have no association.

It is, it is permanent. It's cemented. I mean, I'll still maybe eat it.

They're delicious. Oh yeah, they're delicious. Oh, they're fucking delicious.

By the way, I wish I had an excuse to eat 1,000 of them in 2 weeks.

Well, you could. I wouldn't look like Usain Bolt.

If you do 700 sit-ups a day, you might.

I think I'll also have to be running very fast for— oh, very frequently.

Probably. Um, at what margin do women experience chronic pain more than men? Data suggests that approximately 70% of chronic pain cases are women, and they suffer from higher pain sensitivity, more severe pain, and higher rates of conditions like fibromyalgia and migraines. Fibromyalgia, remember? Classic. Classic. There used to be so many commercials about fibromyalgia. Yeah, especially on 60 Minutes. Yeah, yeah, the old— older person programs. Older demo.

Yeah, yeah, which I am out of officially. You're what? I'm not in the demo anymore. It's 18 to 49. I'm not a valued viewer anymore. Oh no.

Yeah, but you're in the fibromyalgia Nausea.

Yeah, that's why I said the older demo, but this is kind of a throwaway demo. It's not what advertisers care about. They care about 18 to 40.

That's silly. They should care about the older people because the older people, they have more money but they spend less, right?

Yeah, they're done. They're done buying crap. Huh.

How much of the world's opioids does the U.S. consume? The U.S. has less than 5% of the world's population but consumed roughly 30% of the world's opioids in 2009, including more than 99% of the world's hydrocodone. Whew. And 80% of the world's oxycodone. Mm. As of 2017, that was a long time ago, the US and other affluent nations, Canada, Western Europe, consume roughly 95% of the global opioid supply, leaving only 5% for the rest of the world. Some Sackler family fun facts. Oh great, owners of Purdue Pharma made approximately $35 billion in revenue from OxyContin sales. In 2025, family agreed to a $7.4 billion settlement as part of a bankruptcy deal which required them to give up control of Purdue Pharma and bans them from selling opioids in the US of A. Okay, this— so this is some stats on AA and its success rate.

But like, before you read them, I'm gonna, um, I'm just gonna say something very smart and astute that Drew Pinsky said about the success rate of AA. AA is a very hard thing to evaluate because you can evaluate a cancer medication because you take the one pill, they took it or they didn't, and then you measure the outcome. Whereas AA is advise, go to meetings, get a sponsor, work the steps, sponsor someone else, do service, right? So there's a lot of components. So it's hard to measure. I know. If someone has the full dosage, if they do all 5 of those things, yeah, consistently, you're gonna get one outcome, right? And then a person who does one meeting a week and never gets a sponsor, doesn't do the steps, you know, that's why— that's the caveat, I would say.

I don't want to read this. I don't think that's—

what does it say, 10% or something? This says—

this is 2014. Well, yeah, this says it's 7%.

Yeah. And then also, how are you defining— it's like relapse within the first year, right?

Then, okay, so it says addiction specialists cite success rates slightly higher, between 8 and 12%, but then it says 27% of the participants were sober for less than a year, 24% were sober from what? Oh, a 2014 study conducted by IAA found the following among over 6,000 members. 27% of participants were sober for less than a year. 24% were sober 1 to 5 years. 13% were sober 5 to 10. 14% were sober 10 to 20. 22% were sober for 20 or more years. The 8-year follow-up showed that 46% of those who chose formal treatment were abstinent, while 49% of individuals who attended AA were abstinent. Those are actually some more. Yeah. But they're saying these are studies.

Yeah. What's success? If someone drinks once within a year versus they drank 7 days a week, that's pretty successful. Yeah. Over the course of 20 years, they have 8 relapses. Does that mean it's not successful? No. To me, that person used 8 times in 20 years and they used to use 365 days a year. I know it's hard.

It's really— I don't know.

It's almost impossible to evaluate.

I agree. That's it. Okay, great.

Well, I enjoyed Rachel. I've been telling so many people about the tale of two nails is so fun at a derm party. Oh, it is, yeah. Especially if you have the X-ray on your phone like I do. Yep. And then the back data's fascinating.

The back data is really fascinating. Just pain in general. I mean, it relates to the other episode we had on overdiagnosis. This where there's phantom seizure, you know, there's— people can have seizures that are not caused by epilepsy. You can have, you know, it's similar, like your body is still reacting.

Yeah, it's on high alert survival mode, and it doesn't need to be.

It just— every— you know when people will ask, like, you've had so many experts on in the past 8 years, what have you learned? Or like, what's the— your biggest takeaway? I always kind of like trip on that because there's so much. But I think the main takeaway is just the brain is so powerful. It can do anything. It can kill you and it can—

Take you to another— Take you out of this planet to another place. Yes.

It can save you. It can— I mean, it's like— You can learn to fly. It's all fucking here. Yeah, yeah, yeah.

No, it's the great enigma still. I know. Yeah. We all got one.

Some of us didn't get one. That's my disk. Did you even get a brain?

Yeah, when God was handing out brains, you must have went, "Oops, I thought that." Did you miss that day? There was a thing in the outro, it was like, "When God was handing out somethings, you thought he said somethings." ring a bell? Like shirts, and you thought he was saying shits. It's not that, but it's like, it's a burn. Yeah, I was like, oh, oh, it's when God was handing out brains, you thought he said stains and said no thanks. That's a thing? That's a third grade thing.

And that's a Christian diss?

No, that's a, um, what's the name of my elementary school? Spring Mills Elementary diss on third grade. When God was handing out brains, you thought he said stains and said no thanks.

Be honest, did you invent that? No, I can barely remember it.

Okay, okay. I never forget something I create. All right.

All right. Love you.