Summary
Andrew Huberman interviews Dr. Sean Mackey, Chief of the Division of Pain Medicine at Stanford, for a comprehensive exploration of pain science and management. Mackey explains that pain is not simply a signal from the body but a complex, subjective experience created by distributed brain networks integrating sensory, emotional, and cognitive inputs. They discuss the critical distinction between nociception (nerve signals from the body) and pain (the brain's interpretation), debunking Descartes' outdated model of a one-to-one relationship between stimulus and pain experience.
The episode covers an extensive toolkit for pain management: NSAIDs and their anti-inflammatory (not analgesic) mechanism, gate control theory and why rubbing an injury helps, gender differences in pain perception, the use of heat and cold for shifting pain thresholds, mindfulness-based stress reduction, the 'hurt vs. harmed' framework for chronic pain, nutritional approaches including elimination diets for food-sensitized pain, and supplements like acetyl-L-carnitine, alpha-lipoic acid, and creatine. They also address the opioid crisis, the appropriate clinical use of opioids, the current evidence on acupuncture, chiropractic care, and the importance of pacing as a strategy for chronic pain management.
Key Points
- Pain is not nociception: the signals from the body are electrical impulses, and pain only becomes pain when the brain interprets those signals through emotional, cognitive, and memory networks
- NSAIDs like ibuprofen are anti-inflammatory and anti-hyperalgesic, not true painkillers; they reduce sensitization at the injury site rather than blocking pain perception directly
- Heat generally increases pain threshold while cold decreases it, though cold can reduce inflammation; alternating heat and cold may be optimal for many conditions
- Mindfulness-based stress reduction and cognitive behavioral therapy are among the most effective non-pharmacological approaches for chronic pain management
- Supplements with evidence for pain management include acetyl-L-carnitine for neuropathic pain, alpha-lipoic acid for diabetic neuropathy, and creatine for general tissue support
- The 'hurt vs. harmed' framework helps chronic pain patients distinguish between pain that signals danger and pain that is safe to work through during rehabilitation
- Romantic love activates endogenous opioid and reward systems that genuinely reduce pain, highlighting the powerful connection between emotional and physical pain circuits
Key Moments
Huberman has practiced meditation since his teens and uses yoga nidra to restore mental vigor
Meditation of varying durations places the brain into different states. Yoga nidra (lying still, active mind) is distinct from most meditations.
"Element contains a science-backed electrolyte ratio of 1,000 milligrams, that's one gram of sodium, 200 milligrams of potassium, and 60 milligrams of magnesium. I typically drink Element first thing in the morning when I wake up in order to hydrate my body and make sure I have enough electrolytes. And while I do any kind of physical training and after physical training as well, especially if I've been sweating a lot. If you'd like to try Element, you can go to DrinkElement, that's LMNT.com slash Huberman to claim a free Element sample pack with your purchase. Again, that's DrinkElement, LMNT.com slash Huberman. Today's episode is also brought to us by Waking Up. Waking Up is a meditation app that includes hundreds of meditation programs, mindfulness trainings, yoga nidra sessions, and NSDR, non-sleep deep rest protocols. I started using the Waking Up app a few years ago because even though I've been doing regular meditation since my teens, and I started doing Yoga Nidra about a decade ago, my dad mentioned to me that he had found an app, turned out to be the Waking Up app, which could teach you meditations of different durations and that had a lot of different types of meditations to place the brain and body into different states and that he liked it very much. So I gave the Waking Up app a try and I too found it to be extremely useful because sometimes I only have a few minutes to meditate, other times I have longer to meditate. And indeed, I love the fact that I can explore different types of meditation to bring about different levels of understanding about consciousness, but also to place my brain and body into lots of different kinds of states depending on which meditation I do. I also love that the Waking Up app has lots of different types of yoga nidra sessions."
Cold exposure may raise pain thresholds through habituation, but cross-modality transfer is unclear
Regular cold exposure likely builds habituation to cold pain, but whether it raises heat or pressure thresholds is unknown.
"I think one of the questions that would come up with, for instance, the cold exposure, and I don't know the answer to this, but I'm sure maybe somebody out there does, is their cross-modality changes in pain thresholds. I mean, if you expose yourself a lot to cold, does it change your heat thresholds? I would be surprised if it did or your pressure."
Mindfulness-based stress reduction works for pain, anxiety, and depression -- should be in every school
MBSR addresses pain through nonjudgmental acceptance. Jon Kabat-Zinn developed it for low back pain and studies consistently show it works.
"But mindfulness-based stress reduction has been shown effective for anxiety, for depression, for pain, just about everything. I think they should put it into all the schools."
Six categories of chronic pain treatment: medications, nerve blocks, psychology, PT, acupuncture, and self-empowerment
A pain medicine framework covers medications, procedures, psychology, physical therapy, acupuncture, and self-empowerment.
"As a pain physician within the field of pain medicine or pain management, I think about six broad categories of therapies that we provide for people with chronic pain."
Acupuncture activates peripheral adenosine receptors and engages different brain regions than sham
Medicare now covers acupuncture for back pain. The mechanism involves peripheral nerve stimulation and central brain changes.
"In some patients, in some circumstances, I found acupuncture useful and it's worth a try. CMS is now paying for acupuncture for Medicare patients."
Chiropractic has mixed evidence -- and high-velocity neck manipulation carries stroke risk
Some studies show chiropractic helps low back pain, others don't. High-velocity neck manipulation risks vertebral artery dissection.
"CMS, a center for Medicare, is now paying for acupuncture for people over the age of 65, for Medicare patients. That's something recent, and we were happy to see that. I believe that was for back pain. That should be fact-checked. But chiropractic, mixed data, well-controlled studies, some have shown that it can be helpful for low back pain."
