Rachel Zoffness

I do not think in any way that chronic pain is a stress disease. And I want to be very clear. We know that stress is an amplifier, but it’s one of 642 amplifiers. It’s not the only one. Chronic pain is not a stress disease. And that is not what I’m saying, so if I’m giving that impression, I want to make sure to undo that damage because not true.

Pain is not purely emotional. Pain is never purely physical. It’s always both. Pain lives at the intersection of neuroscience, and biology, and mental health, and social health, and environmental health always. It is never, ever, ever purely emotional or purely to do with stress.

I do think that we live in a culture that is incredibly stressful. Chronic pain during the pandemic was a crisis. Chronic pain exploded during the pandemic. And people who had chronic pain were suffering more, and people who didn’t have chronic pain started developing chronic pain.

And it turns out that opioid related overdoses during the pandemic exploded as well, which is not a coincidence. They went up by something like 30 percent. So part of the reason the pandemic was a perfect pain recipe is because we were all isolated at home, mood crashed, people were depressed, suicidality went through the roof.

Ask any doctor who works in an inpatient unit, any psychiatrist, does demand for medications and inpatient hospitalizations — in some parts of the country, calls to suicide hotlines went up 8,000 percent during the pandemic. People were really suffering.

And stress and anxiety also went through the roof. Obviously, we didn’t want to die. We didn’t want our loved ones to die. And we were being told that our groceries were potentially contaminated. And watching the news was like this environmental trigger and stressor for everybody.

So there was sort of this recipe of things that made the pandemic really challenging for people. So your question about stress is an important one. And I think we have a lot of comforts in life right now, but I don’t think that means that life is less stressful.

Sometimes my patients will come to my office and say, when I explain this concept of a pain recipe or the pain dial, and they’ll say, I’m not stressed out at all. So I want to back up and say there are many stressors on the human body. Moving cross country is one of them, and divisive politics is another one, and death of a loved one is another one.

But living with pain day in and day out is a major stressor on the human body. So it’s sort of this thing that we can’t escape. We can’t avoid. And there’s a million things that trigger stress. [MUSIC]

雷切尔·佐夫内斯

我不认为慢性疼痛是一种应激性疾病。我想说得很清楚。我们知道压力是一个放大器，但它是 642 个放大器之一。它不是唯一的。慢性疼痛不是压力性疾病。这不是我要说的，所以如果我给人这样的印象，我想确保消除这种印象，因为这不是真的。

痛苦不仅仅是情绪上的。疼痛从来都不是纯粹的身体上的。它总是两者兼而有之。疼痛始终存在于神经科学、生物学、心理健康、社会健康、和环境健康的交叉点。它永远、永远、永远都不是纯粹的情绪化或纯粹与压力有关。

我确实认为我们生活在一种压力非常大的文化中。疫情大流行期间的慢性疼痛是一场危机。慢性疼痛在大流行期间爆发。患有慢性疼痛的人遭受的痛苦更多，而没有慢性疼痛的人开始感受慢性疼痛。

事实证明，大流行期间与阿片类药物相关的过量服用也激增，这并非巧合。他们上涨了大约30%。因此，大流行病是一个完美的止痛药的部分原因，是因为我们都被隔离在家里，情绪崩溃，人们很沮丧，自杀倾向达到顶峰。

询问任何在住院病房工作的医生，任何精神科医生，是否需要药物治疗和住院治疗——在该国的一些地区，在大流行期间拨打自杀热线的电话增加了 8,000%。老百姓真的很痛苦。

压力和焦虑也从屋顶蔓延开来。显然，我们不想死。我们不想让我们所爱的人死去。我们被告知我们的食品可能受到污染。看新闻就像是每个人的环境触发因素和压力源。

因此，有些事情的秘诀使大流行病对人们来说确实具有挑战性。所以你关于压力的问题很重要。我认为我们现在的生活很舒适，但我不认为这意味着生活压力减轻了。

有时我的病人会来我的办公室说，当我解释止痛药或止痛仪的概念时，他们会说，我一点压力都没有。所以我想再次说，人体有很多压力源。跨国搬家是其中之一，分裂的政治是另一回事，亲人的死亡又是另一回事。

但是日复一日地忍受疼痛是人体的主要压力源。所以这是我们无法逃避的事情。我们无法避免。有一百万种事情会引发压力（stress）。 [音乐]

Ezra Klein

We’ve been talking here a lot about the ways in which the brain constructs pain, the ways in which pain can be affected by prediction or by mood or by sleep. How do you think about how you know when it actually is harm?

Because it’s very alluring if you’re often in pain to come up with this theory that oh, my brain has just become too sensitive. I’ve just overlearned it. I just need to meditate more. But maybe there really is something there.

You have this great metaphor in the book about, sometimes a car alarm goes off and nobody’s trying to break into the car. But of course, sometimes somebody is trying to break into the car. How do you distinguish?

埃兹拉·克莱因

我们一直在这里谈论大脑产生疼痛的方式，疼痛受预测、情绪或睡眠影响的方式。你如何看待，你如何知道它（疼痛）真的是有害的？

因为如果你经常有疼痛，于是想出这个理论，是非常诱人的，哦，我的大脑变得太敏感了。我只是过度学习了。我只需要多打坐。但也许那里真的有东西。

你在书中有一个很好的比喻，有时汽车警报器响起，但没有人试图进入这辆汽车。但当然，有时真的有人试图进入这辆汽车。你怎么区分？

Rachel Zoffness

So what we know about chronic pain — this is not a theory of mine — what we know about chronic pain is that the brain does become more sensitive over time, and it does misinterpret these danger messages as amplified when they don’t need to be.

So if someone’s experiencing chronic pain and they haven’t had the tests and the pokes and the scans, I will send them out to have them, obviously, because again, I do not want to miss that there’s a broken bone or some chronic illness. There’s some biological biomechanical contributor to the pain recipe that I am not paying attention to.

Again, I am not saying that medications don’t treat pain. I am not saying that biomechanical and biological processes aren’t involved here. Of course they are. So what we know is there’s this difference between acute pain and that process and chronic pain and that process.

So I think what you’re asking about, if someone comes to me and they’ve had chronic pain for 10 years, and we’ve not investigated all the biomechanical drivers, or the bio part of their pain recipe, then I haven’t done my job.

雷切尔·佐夫内斯

所以我们对慢性疼痛的了解——这不是我的理论——我们对慢性疼痛的了解是，大脑确实会随着时间的推移变得更加敏感，并且它确实会在不需要时将这些危险信息误解为放大了。

因此，如果有人正在经历慢性疼痛，并且他们没有接受过检查、戳一戳和扫描，我会让他们去接受检查；显然，因为我不想错过骨折或某些慢性病。有一些我没有关注的关于疼痛治疗方法的生物力学因素。（There’s some biological biomechanical contributor to the pain recipe that I am not paying attention to.）

同样，我并不是说药物不能治疗疼痛。我并不是说这里不涉及生物力学和生物过程。当然会。所以我们所知道的是，急性疼痛和那个过程与慢性疼痛和那个过程之间存在差异。

所以我想你问的是什么，如果有人来找我，他们有 10 年的慢性疼痛，而我们没有调查所有的生物力学驱动因素，或者他们的疼痛治疗方法的生物部分，那么我就没有做好我的工作。

Ezra Klein

When somebody has chronic pain, and they walk in to get care, after I mean the initial doctor looks at them and nothing is broken, how should the medical system be structured for them? What kinds of care teams, or resources, or sort of new specialties — I get the sense — I have never in my years of reporting on healthcare policy I’ve never found a doctor who thinks a medical system is correctly structured.

Rachel Zoffness

Fair.

埃兹拉·克莱恩

当有人患有慢性疼痛，他们来接受治疗时，我的意思是最初的医生看了他们之后没有发现任何问题，那么医疗系统应该如何为他们服务？什么样的护理团队、资源或新专业——我似乎明白了——在我报告医疗保健政策的这些年里，我从未找到过认为医疗系统结构正确的医生。

雷切尔·佐夫内斯

是这样。

Ezra Klein

And I’m curious in this respect, we have this huge pain problem for awhile. We tried to treat it through opioids. We’ve realized that’s a disaster. But how should teams be set up? What should we have? What should a person have access to they don’t now?

埃兹拉·克莱因

在这方面我很好奇，我们有一段时间有这个巨大的疼痛问题。我们试图通过阿片类药物来治疗它。我们已经意识到这是一场灾难。但是团队应该如何设置呢？我们应该有什么？一个人应该如何获取那些他们现在不能获取的治疗方法？

Rachel Zoffness

So when I think about the answer to that problem, I think about — and again, like I am just a nerd and I want to synthesize all the research. And what the research says is that the treatment of pain has to be multidisciplinary.

This is not my opinion. None of this, by the way, is my opinion. It’s just a synthesis of what I’m reading, that treatment has to be multidisciplinary. And what that means is, again, treatment for chronic pain — and I am talking about chronic pain, not a broken leg — needs to involve everybody on the team.

We want physicians. We want pain psychologists. We want PTs. We want OTs. We want to consider things like biofeedback and mindfulness-based stress reduction, which I rolled my eyes at my entire life until it helped my pain volume go down.

雷切尔·佐夫内斯

所以当我思考这个问题的答案时，我会想——再一次，就像我只是一个书呆子一样，我想综合所有的研究。研究表明，疼痛的治疗必须是多学科的。

这不是我的意见。顺便说一下，这些都不是我的意见。这只是我正在阅读的内容的综合，治疗必须是多学科的。这意味着，慢性疼痛的治疗——我说的是慢性疼痛，而不是断腿——需要让团队中的每个人都参与进来。

我们需要医生。我们需要疼痛心理学家。我们想要PT(physical therapy)。我们想要OT(occupational therapy)。我们想考虑诸如生物反馈和基于正念的减压之类的事情，我一生都在翻白眼(即表示无奈)，直到它帮助我减轻了疼痛。

【译者注：

The most basic difference between physical therapy and occupational therapy is that a PT focuses on improving the patient's ability to move their body whereas an OT focuses on improving the patient's ability to perform activities of daily living. Additionally, PT’s foundation was in physical rehabilitation whereas OT was founded in mental healthcare and physical rehabilitation.

物理疗法(PT)和职业疗法(OT)之间最基本的区别在于，PT 侧重于提高患者移动身体的能力，而 OT 侧重于提高患者进行日常生活活动的能力。 此外，PT 的基础是身体康复，而 OT 的基础是心理保健和身体康复。】

But we want the multidisciplinary picture. We want to look at your whole pain recipe and the full biopsychosocial recipe of all the ingredients that are in there that are contributing to your pain, including sleep, and diet, and movement, and of course biomechanics. We want everything in there.

And if you think about, again, what’s going to make a low pain recipe or what’s going to lower pain volume, most of the time, I’m not saying always for everyone, it’s not just going to be a pill or a procedure. And we know this. Again, this has been said in the literature for many decades that pills and procedures alone for pain are not enough.

And all the major governmental institutions and medical institutions are calling for a multidisciplinary approach to pain, and we’re just not seeing it happening. So what we want is for, more in my mind, what we want is for more healthcare providers across disciplines to be trained in pain because what’s happening now in medical education is that almost nobody is getting trained in pain.

There’s this paper that came out in 2018 that showed that 96 percent of medical schools in the United States and Canada are lacking pain education. And that the four percent medical schools that are teaching pain are focusing on the erroneous and outdated biomedical model, again, where we’re just looking at the body part that hurts. We’re just looking at the back. We’re talking about mechanistic.

但我们想要多学科的考虑。我们想看看你的整个疼痛治疗方法和完整的生物心理社会治疗方法，其中包含导致你疼痛的所有成分，包括睡眠、饮食、运动，当然还有生物力学。我们想要里面的一切。

而且，如果你再考虑一下，什么可以制作低疼痛治疗方法、或什么可以降低疼痛量，大多数时候，我并不是说总是对每个人来说，这不仅仅是药丸或手术。我们知道这一点。同样，几十年来文献中一直在说，仅靠药物和手术来止痛是不够的。

所有主要的政府机构和医疗机构都在呼吁采用多学科方法来治疗疼痛，但是我们没有看到它出现。所以我们想要的是，在我看来，我们想要的是让更多跨学科的医疗保健提供者接受疼痛方面的培训，因为现在医学教育的现实是，几乎没有人接受过疼痛方面的培训。

2018 年发表的这篇论文表明，美国和加拿大 96% 的医学院缺乏疼痛教育。而 4% 教授疼痛的医学院，关注的是错误和过时的生物医学模型，即只关注受伤的身体部位。我们只看背部。我们只是“背痛医背”。

（待续）