Can you tell us a little about your background and how you got into the field of pain medicine?

I did my medical school training and residence in Brazil and then I immigrated to Canada. I am now a doctor, scientist, and Professor of Medicine at the University of Toronto in Canada. I chose medicine because I wanted to help people. My mom says that even when I was a child, I wanted to become a doctor.

During my teenage years, I suffered from terrible, debilitating menstrual period cramps every month. There were medications that helped a little, but I would still miss several days of classes. Even in medical school, I remember some days that I had to call my mother and say, “Come pick me up. I can’t stay here the whole day”. I found that pain was dehumanizing because it rips you off of your dreams and from your plans.

When I was in medical school, I had to choose a residency and I was thinking about neurology in occupational medicine. I had never heard of Physiatry or physical medicine rehab until one day when I was in the general internal medicine ward. We had admitted a patient and she was having pain all over her body and we wanted to investigate what was going on. She was crying and depressed and we could not find anything wrong. Someone decided to call a consult from a physiatrist.

Doctor Vu came in with acupuncture needles in his pocket because he’s also an acupuncturist. He stuck the needles on her and started talking to me about physiatry. By the time he took the needles out, she was pain free. She was happy and we discharged her the next day.

So I said, “Dr. Vu, what is this? Is this voodoo?” And he said, “No, we just opened her internal pharmacy in her brain and she released a lot of opioids in her body. These opioids are going to be there for about 7 days until they are degraded. Her pain will come back”.

That was fascinating to me that you can help someone open their internal pharmacy without giving them pills and you can help them open their pharmacy in the brain to release their own medications. So I became a physiatrist and pain specialist because pain science is so exciting and that’s how I got here.

I graduated from medical school 30 years ago and I can tell you I’ve seen so many people who have had an amazing experience with or without medications. I’m not against giving medications if they need pain killers, but not all pains are the same. For each kind of mechanism we need a different treatment.

On your YouTube channel, you mention that there are three types of pain. Can you explain what the different types of pain are and how they are treated differently from each other?

This is very important to discuss because not even many healthcare professionals know about this because they didn’t learn this in school. The names are nociceptive, neuropathic, and nociplastic. Don’t shoot me because the names are complicated. I didn’t invent them. The people who created these definitions of pain come from the International Association for the Study of Pain which is a world organization that publishes the Journal of Pain.

I like to compare these three types of pain to the system of a house. Pain is the alarm system of our body. In our houses we install alarm systems. We have sensors for smoke, fire, burglars, and flooding. We can modulate the volume of those sensors and determine if we need to send a fire truck, the police, or an ambulance. Our pain system is exactly the same. We have sensors for pain to protect us from danger. These sensors can be in the skin to detect exterior danger. We have sensors internally in our organs, heart, muscles, tendons, although they’re not defined so well and there are less which is why when a person has heart pain, it’s hard to define where the pain is. Sometimes they feel pain in the shoulder, the jaw, or the back because there few sensors in the internal organs.

If there is something broken in the body, you want this alarm to go off and make noise. Nociceptive pain means something is wrong. You have a bone fracture and you need to stop what you’re doing. The bone will heal. So that’s nociceptive pain. Something was broken, you fixed it, and the pain goes away.

Neuropathic pain is where the wires are damaged. This could be trigeminal neuralgia, shingles, carpal tunnel syndrome, or anything involving compression of the nerves. It could be diabetes affecting the nerves so the person may have a different kind of pain. It can feel like it’s burning, tingling, or electric shocks. People who have multiple sclerosis, spinal cord injury, and strokes can also have neuropathic pain.

The treatment for nociceptive pain is different than the treatment for neuropathic pain. With nociceptive pain you treat what is broken. You can take medications like anti-inflammatories or antibiotics. With neuropathic pain, you don’t give anti-inflammatories because there is no inflammation. We treat neuropathic pain with anticonvulsants, antiepileptic, and antidepressants medication because we need to calm down the nerves that are firing.

The third type of pain is nociplastic because it involves plasticity of the nervous system. This is the equivalent of the alarm system of the house malfunctioning. The alarm is constant and very loud, but no one else can hear it, so the person thinks that they are going crazy. They start to think, “How come I am feeling pain and doctors don’t know where my pain is? They give me all these medications and treatments, but nothing is working”. It’s because the alarm system of your house is malfunctioning so there is no point in you calling for a firetruck or the police. They’re not going to find anything wrong. You have to call the alarm company to come and fix the alarm system. So that’s what nociplastic pain is and it’s the most common type of pain.

When it comes to chronic pain, the fracture has healed and the orthopedic surgeon will say that they don’t know why you’re having pain. If it’s several months later and you’re still having pain, it’s because the pain has transformed from nociceptive to nociplastic pain. Now the problem is sensitization in the pain system and this transforms within three to six months. If you’re not diagnosed right away and the diagnosis keeps being delayed, we say people who have pain years later with this plasticity ingrained in their pain system. It’s harder to revert. It’s possible, but it’s hard. 

Not all people who have chronic pain have nociplastic pain. Sometimes they have multiple types of pain. They may have all three together. It’s important to diagnose exactly what they have because physicians are using this nociplastic diagnosis to dismiss patients and not believe them. They’ll tell patients that it’s not serious and that they need to lose weight, go for walk, or find a distraction.

The problem that I find is that patients are reluctant to accept that they have nociplasctic pain because they think I’m telling them that the pain is in their head and that they’re imagining the pain when this is not the case. The medical system is not helping because they’re not giving these patients the messages that they need to hear to heal and to retrain their pain system.

This is very important for both side, healthcare professionals and patients. Both sides need to have more knowledge about the three types of pain because they are treated differently. Once patients realize that they have nociplastic pain and they start studying what the treatments options are, that is when we see transformation because the treatment for this kind of pain is heavily dependent on self management. We give them the tools, but they’re the ones who have to practice.

The way we talk to these patients and the words we use matter. We have to make sure that we’re not givine them messages of danger or saying things that cause more fear. If we say things like “You must have something really bad” or “Your MRI doesn’t look good”, this only makes the alarm system more sensitized. They will feel more pain

I saw that you published a book called “Eight Steps to Conquer Chronic Pain”. Could you tell us about this book and go over what the steps are?

I wrote the book because I have a YouTube channel that I opened in 2019. My son convinced me to start the YouTube channel. I started recording myself with my cell phone. The reason I started this is because I thought that people needed to hear more about chronic pain. I wanted to spend more time with my patients and give them explanations, lectures, and to teach them all about their pain. But they were tired and I had other patients to see. So I opened the channel.

It’s more of a compliment to my clinic so my consults and patients could go home and relax and pay attention to what I’m saying.

Then the channel exploded during the pandemic. I got hundreds of thousands of subscribers and millions of views. People got confused because the channel was not organized by themes and they would have trouble finding certain videos. That’s why I decided to write a book. I wanted to organize my thoughts.

Before the first step, I start out talking about what pain is, the three types of pain, and how doctors diagnose pain. Then we go to the first steps and they follow an order. The first step is retraining the pain system. When I see people who have multiple types of pain, such as nociplastic pain and something else, it’s really hard for me to treat the something else. It’s like there’s an alarm system in your house that is so loud and noisy so it hurts everywhere. When there is so much noise, it’s hard to figure out what type of pain someone has.

So I tell them, let’s reduce all of these fears that you have and let’s work with retraining your pain system. Sometimes this is enough and the pain disappears. 

Now the second step, we talk about emotions because emotions like stress, anger, and frustrations compound the experience of pain. If we can help them to regulate and understand what’s going on in the area of emotions, then that’s another thing that can help reduce pain.

Then we start talking about step three which is sleep. We cover nutrition, socializing, medications, modalities, massage, and other things. The last thing we talk about is now that you are at the top of the mountain and you have conquered your mountain of pain, what are you going to do differently?

Conquering chronic pain may mean you are not feeling pain anymore or it can be you are living your best life. You’re living the purposes of your life and you are happy with your life. 

You do your mindfulness and you ground yourself. I love mindfulness because when a person does mindfulness, they are in control. One of the worst things that patient say to me is that they are not in control of their pain. They say, “I never know when I’m going to have a flare and if I have a flare, I don’t know what to do”. It seems that exterior things control their life. Now when the patient is in control, they think, “This is what I’m feeling right now, but my body is not broken. I’m not putting myself in danger if I move my back and I feel pain. It’s just a sensation. I can walk down the street and come back. I’m not going to damage my back. I’m safe”. That’s the main message that patients need to feel- that they are safe. That they’re alarm system doesn’t need to be going off all the time.

Can you tell us a little more about the correlation between healing from chronic pain and sleep?

I’ve seen it over and over where once you regulate sleep, you may not need to go through all of this stuff. That’s why I put the sleep step as #3. It goes before medications and even exercise. In my book, I compare it to a mountaineer climbing a mountain. Imagine if the mountaineer had a completely dysregulated sleep cycle. If they have insomnia during the night, the next day when they need to climb the mountain, they may die because they feel fatigued and sleepy.

I saw a patient this last week and they told me that sleep is not important because they take a three hour nap every day in the afternoon. I said to her, “this is not acceptable because it is totally disrupting your next night. You’re not having quality sleep. The next night you need good quality sleep between seven to nine hours long to produce the neurotransmitters to relax your muscles and to rest your brain. Otherwise, the next day you’ll be fatigued”. 

I have patients who drink eight to ten cups of coffee with caffeine and they are experiencing pain. I tell them to stop drinking all of this caffeine and then they come back saying, “I’m sleeping the whole night now and my pain is getting better”.

If you want to provoke pain in a laboratory, you can do two things with sleep: you can deprive them of sleep or you can make them sleep too much. If someone sleeps less than seven hours every night, they can start having pain all over their body. If someone starts sleeping ten or eleven hours every night, they can still have pain all of their body.

Another thing that people neglect is nutrition. I’m not just talking about losing weight. You can have a normal weight and be malnourished. Refined sugars are poison to our body and they’re everywhere. We need to be very careful because if you don’t read the labels, you’ll be ingesting refined sugars. You can enjoy them every once in a while like if you go to a party or if it’s your birthday. Enjoy your sweets, but not every day.

What research are you involved with right now and does it impact the way you treat your patient?

I teach a lot of healthcare professionals, physicians, nurses, nurse practitioners, pharmacists, physiotherapists, social workers, psychologists, and anyone else that can help people with chronic pain. I have many different grants from the government of Canada to develop educational materials to teach them chronic pain because family doctors in Canada get about two hours of education in pain and two hours in family doctor training. I’m not even talking about chronic pain, but just pain in general. They could be learning about acute pain, post-op pain, neuropathic pain, and very little about nociplastic pain. When these doctors graduate and start practicing medicine, they’re going to see a lot of people with chronic pain and they won’t know what to do.

A lot of my projects are developing courses and one of them is called Project Echo that we bring via zoom platforms like this. I’ve been doing this for ten years now. We bring everyone who would like to learn about chronic pain and we meet via zoom with a team of experts. My team of experts contains 12 different professions. We discuss cases so medical professionals in the rural areas of Ontario that are dealing with complex chronic pain patients can discuss their cases. The patient doesn’t come to the session, but they summarize the case to all of us and then we spend several minutes brainstorming solutions for that case. We brainstorm what might be the diagnosis and what may be the best treatment for that patient. There are a lot of people watching this session and they’re all learning with that case.

Then we do research with this group. We are looking to see if providing education transforms the way that they are practicing. In their hometowns, there can be as little as 5,000 people and these healthcare professionals are transforming the pain care in that area. We collect quantitative data. Most of the research that I am doing is impacting patient care indirectly via those professionals.

The other research that I do is related to opioids for chronic pain. I participated in a randomized control trial published two months ago in the Journal of the American Medical Association where we looked at tapering and deprescribing opioids. We saw that deprescribing opioids did not make the pain worse and ⅓ of people who were randomized to our group educational intervention were able to stop taking opioids completely.

People with chronic pain will often try several different types of treatments to decrease their pain. Are there any treatments out there that you believe make pain worse and should be avoided?

It really depends on the type of pain so they need an accurate diagnosis. If the pain is nociceptive they can try medications and procedures. If these treatments don’t work, it’s probably not nociceptive pain. If the pain is nociplastic, the first big step is learning that your body is not broken. I’ll give you an analogy. If my computer stopped working, it could be that there is a peace that is broken. Maybe I dropped my laptop on the floor and a piece broke. Now I need to go and change that piece. Then my laptop works. That’s the equivalent to treating nociceptive pain. This is like if a person has knee pain and the surgeon says that they need a new knee because their knee is broken. The surgeon puts in a new knee and the pain is gone.

Now my laptop can also malfunction because of a software program. I can close all the windows and start all over again and that might fix it. I might have to try several other things. With nociplastic pain you can try psychotherapy, cognitive behavioral therapy, meditation, acceptance and commitment therapy, mindfulness meditation, yoga, and pain reprocessing therapy. There is a randomized trial published three years ago where they used graded motor imagery to expose the person to more and more movement while giving them messages of safety.

What is your advice for someone who has been newly diagnosed with chronic pain?

The first thing you have to do is validate that you believe they are in pain and that they’re not imagining this. Sometimes it is hard to find where the pain is coming from. They need to be confident that they are in the right hands of a professional at all times.

No imaging or blood tests will show what is wrong, but we do need those tests to exclude all the things that could be causing their pain. I need to make sure that it’s not a problem with the thyroid, that it’s not arthritis, and that it’s not a lack of vitamin B12.

It’s very good if we catch nociplastic pain in the early stages because we can tell them with reassurance that at this stage when the pain is transitioning from acute to chronic, having some form of emotional support can de-escalate your emotions and stress. Talking to a professional can keep you moving. This can be a physiotherapist, chiropractor, occupational therapist, nurse, or just someone that will keep you moving because if you stop you can go into a downward spiral. You have to live a life that is as close to normal as possible. Try to participate in social events, do things that bring happiness and joy, because that will open the pharmacy in the brain if their brain realizes that they’re not in danger. Their brain will release opioids, dopamine, cannabinoids, and that will help the body. 

If you are in a fight-flight-freeze response, the pain now becomes overprotective and will paralyze them. There has to be a mind shift in this, especially in the transition from acute to chronic pain.

I see this with post-operative surgery. My husband had an inguinal hernia repair 15 years ago and we know from statistics that ⅓ of people who have inguinal hernia develop chronic pain. My husband needed the surgery badly because his hernia was debilitatingly painful. His surgery was very successful. The surgeons discharged him and said that he’s fine, but it’s going to be painful for quite some time. A couple of weeks after the surgery he started what we call catastrophizing which is where someone makes a catastrophe out of something small. Because the hernia was still very big and painful in his head he told himself that this is going to get worse. He said, “I need to see my surgeon and this is not right. Something is wrong her. I don’t think they did it right”. He didn’t want to move or use that leg. He didn’t want to go for a walk even though they told him, “The more you walk, the better”.

I had a hard conversation with him. I said, “Listen. You are afraid of this thing. If you let this thing dominate you, you’re going to downward spiral. If you believe that the doctors did a good job, you don’t have anything to worry about. You can move. Let’s go for a walk. You’re not going to damage anything”.

If you talk to him today, he doesn’t have any pain and he said that that conversation was very crucial. He said that he was in a crossroad and he was going to go into a downward spiral. 

Our brain is able to do amazing things. Either creating pain or suppressing pain. We know it can create pain because people who have amputations can sometimes have pain in the limb that was amputated. Does it mean that it’s an imaginary pain? No, it’s real pain, but it’s not coming from the limb, it’s coming from the memory it created in your brain. This memory becomes ingrained in a matter of anywhere between three and six months.

Cognitive behavioral therapy is an excellent method to help a person see that catastrophizing thoughts are not reality. Your brain believes what you think. But there are cognitive behavioral therapy professionals and they will help you to see that your predictions of the future will not happen and you don’t need to think that way.

What is your advice for someone who has had pain for years and years and they have completely given up hope that they will ever be pain-free?

There is hope. I had this patient who was nearly 80 years old and she had bad arthritis all over her body and she was hurting everywhere. She was on medications and she had been referred to me because nobody knew what to do with her. We talked about her 60 years of pain. I explained to her that the brain has a lot of power and that it can amplify and suppress the pain. So let’s try to suppress this pain. I said let’s start with exercise. She was not doing exercise because everything hurts. I recommended to her to get into a warm pool. She came back to me a couple of months later and said, “What a difference that made in my life”. She was swimming and doing exercises in warm water twice a day and that she didn’t have any pain during the day. Her arthritis is still in her body, but she is now mobilizing her joints because motion is lotion. She is lubricating those joints. She is also sending messages of safety to her brain. She is in control. She found something that she can control instead of the pain dictating how her life is going to be. All of those things reduce stress. All of those things made her brain resilient to that pain. The brain is saying, “Okay, I don’t need to alert you”.

Most people do not feel the benefits right away and that’s the problem. They may go one time and they try to stay the whole hour, but the won’t feel the benefits after one session. They need to trust the process. Start slow, keep increasing gradually and then you will see the benefits with time.

Once someone has resolved or at least significantly decrease their pain, what is your advice for preventing the pain from coming back?

There is an analogy in my book. I talk about how once you reach the top of the mountain and you’re going to see all the mountains. Now you’re ready to tackle the next challenge in your life. Find peer support and groups where you can brainstorm ideas. Find other people who have experienced chronic pain. They might be your best pals in continuing this journey.

Takeaways

• There are three types of pain: nociceptive, neuropathic, and nociplastic. Each one is treated differently.

• Reducing fear and retraining the pain system can reduce pain.

• Improving sleep and nutrition can reduce pain.

• Cognitive behavioral therapy can help prevent catastrophizing thought processes.

Thank you so much to Dr. Andrea Furlan for doing this interview with me. She is an amazing doctor and scientist who is helping people all over the world reduce their chronic pain. I hope you guys learned a lot from her in this interview. If you want to learn more, check out her book “8 Steps to Conquer Chronic Pain”. https://www.doctorandreafurlan.com/