 All right, it's nice to be here. I was going to start by saying I'm going to stand still because a funny story is that yesterday I was going to a meeting. I'm the medical director for behavioral health for Solano County in Northern California. And I was going to a meeting. My colleague has a Jeep Wrangler. And we went to get in her car. And I was stepped up high. And when I got to get out of her car, of course, my back was not happy. Something happened. So I'll be fine in three days. But I have acute pain. So I laugh about it. But it's nice to be here. My brother was an RA at the building right there when he went to UCLA. So I've been down here. Of course, we had H.S. 11 here. So I was going to tell a little backstory. So in 2007, I started a blog, Health Care Epistemocrat, and was having fun writing. But mostly the best part was connecting with new people. And so I met Erin. And that was wonderful and many other people. And in December of 2009, Erin and I came here to UCLA to a conference called New Directions in Physiology. And it was a good conference. And we were also joined by our friend Chris Owens at the time. And after the conference, we were like, why don't we have our own conference? There's like all these people with the time we had connected with through different blogs and activities on the internet. And we were hoping to, almost similar to now, take all the interactions online and bring people together in person and have a gathering that would bring together in kind of an egalitarian way that supports diversity and inclusivity and discussion of ideas. The whole spectrum. So lay people with lived experience all the way to scientists and physicians. And so I had appreciated Nassim Taleb's idea for the envelope of serendipity. And I put on my blog a post after the conference saying, we'd like to do this conference. And we literally just posted the idea. And fortunately, Jake was reading my blog at the time and said, if you do it, I'll help you out. And that's really how we got to today. Because then from there, we had, like we still have, is a group of people who are passionate, volunteer, work together as a team to form the nonprofit, to bring together all the presenters who were passionate and eager to contribute. And then by August 2011, we had the first conference. So here we are 11 years later. So it's pretty phenomenal. And then I went down the whole of going to medical school. So I mean, I remember I came to the conference in 2011. It was early August. And I think within the next week or two, I was in Baltimore. And it rained for 21 days. And I was doing anatomy. So things changed rapidly, obviously, for me. But one thing I was going to talk about today that's interesting is as I went through my journey at Hopkins and becoming a doctor and becoming a psychiatrist is finding mentors there working in chronic pain who essentially were stumbling upon and utilizing similar tools that people have been talking about at AHS for the last 11 years. So really, I think that pain, chronic pain, is an interesting area of medicine because it requires a very holistic approach. There's a lot that we don't know. It's very individualized. And there's a lot of different tools people can use to manage pain and chronic pain to help them function and have quality of life. So my mentor at Hopkins, who I give a lot of credit to, is Dr. Glenn Treisman. And he talks about interstitial medicine. There's different areas where clearly patients are suffering or dealing with certain problems that lie at the intersection or in between the spaces of the specialties that we have in medicine because we have such a siloed, specialty driven health care system and the way things work. But clearly everyone here can appreciate and while we have AHS is that in that space that's where you need creativity, you need an open mind and you have to be able to collaborate among specialties and among the silos to bring people together. So to me, if you're gonna talk about chronic pain, ancestral health and interstitial medicine have a lot in common. So I'll share a little bit about what I've learned as a psychiatrist working in chronic pain. And just to show you, you'll see some things that you may have stumbled upon over the years in the ancestral health world. But one of the reasons why this topic is important is this problem which does exist as a continuing challenge in our communities. So back in the 90s, chronic pain's not a new thing, obviously, there was a big push to treat pain and one idea that was proposed is thinking about pain as a vital sign. So you don't need pain to live, you need your vital signs to live. You need a pulse, you have to perfuse your organs, so you need a heart rate, you need a blood pressure. If you don't have those, you can't live. You need to oxygenate your blood, you need to ventilate your lungs. If you don't have a respiratory rate, if you don't have an O2 saturation, you can't live. You need those to live. You don't need pain to live, it's not a vital sign. But the push to make pain a vital sign within our healthcare system, before you know it, J.C.O. and all the regulatory bodies made the pain one to 10 scale so important and it started to kick off a cycle of utilizing opiates widely to treat pain. And unfortunately, opiates, while they may help acute pain and of course they have a role in medicine and they're very therapeutic and useful. We wouldn't be able to do the surgeries and all the things we can do that are definitely providing great value, but when it comes to long-term management of pain, for many people, opiates can be problematic because as I'll talk about is pain signals that are either amplified or malfunctioning don't go silent. They just get louder. So with opiates, which have a physiologic mechanism of essentially trying to block a pain transmission signal, we see tolerance, escalation of pain, dose escalation of opiates and we recognized that a few decades later and then we wanted to cut doctors off from prescribing opiates and it almost happened all of a sudden. So people still dealing with pain, dealing with opiate addiction, have found their sources of opiates. As you can see, fentanyl out in the community is sourced from all different manners and fentanyl, if you don't know, is much more potent. It's laced in many street drugs at the time and the big issue is the ease of taking too much without knowing it and overdosing and dying because your respiratory rate goes to zero. So this is this graph that was up to 2018 data and I put a line in because basically if you go get recent data, the fentanyl line just keeps going to the moon. So as a behavioral health medical director for a county, of course, this is something that's sad and continues to be difficult epidemic and then part of it is we don't have a healthcare system that's very good at managing people with chronic pain and with addiction and there's room to improve. But so if pain is not a vital sign, it's very important to realize that pain is an experience. So there's a lot of components to everyone's pain and that's very important to be empathetic to and realize that pain has a sensory component. Of course, humans are sentient beings, we've evolved fortunately, pain transmission signals, we can take in our environment, pain feedback, shapes our behavior, helps us avoid aversive or noxious stimuli, but those systems can go awry. But you can see how pain can be protective and so a good example in medicine is take someone with uncontrolled diabetes who unfortunately develops neuropathy in their foot, meaning the nerves in their foot are no longer sensing the environment properly. So someone like that is at risk as they're walking along, they get something on their foot, they get a breakdown in their skin tissue, they get an infection, they don't have the information being transmitted to their brain to modify their behavior to say, hey, I should check my foot, I have a wound. And people can get bad wound infections, they can require amputation and this is like a very sad progression, but clearly in this case, that lack of having that pain information is harmful, I mean, so having pain systems that we have is a good thing, but just like any physiologic system, it can malfunction, it can provide misinformation and we have vulnerabilities as a result. And so when you experience pain, you have your sensory component, but there's a cognitive element, pain is frustrating, it's distracting, it affects your concentration, they say cognitive or emotional, see I have pain, I can't even remember what I just said, but so there's a cognitive component, then there's emotional component, pain, if you're in pain constantly, of course it's gonna affect your mood and then your mood's gonna affect the inflammation in your body and that's gonna affect your pain experience and I'll talk a little bit about, of course in psychiatry, if someone has major depressive disorder and how that can affect their pain experience and a behavioral component because it's gonna affect your mobility, it's gonna affect your daily activities, it's going to condition you in certain ways without even knowing it, so important thing to realize is pain, we wanna look at it holistically, it's not a scale of one to 10, it's not a vital sign, it's part of someone's life. And if you work in mental health for even a day, not that you don't get this elsewhere, but one thing you really quickly realize is that we have many vulnerabilities and our vulnerabilities when it comes to pain are going to feed back and you're gonna have cycles where comorbidities and pain create amplification loops. And so here's just a list of things that you might have heard about, but when someone's experiencing pain, you wanna think about is, and when you're experiencing yourself is how are things interacting to affect your pain experience. And here's a little more specific to opiate. So say someone is given an opiate for their pain, well, that's probably going to block the pain for a short period of time, but then your body's gonna send an increased pain signal to the brain, and then you're gonna experience the same amount of pain that you had before, you're probably gonna be less active because opiates slow you down and you're gonna be inactive and we know inactivity begets more inactivity. And you can see that essentially the message your body sending to your brain saying I'm in pain, I'm in pain, I'm in pain, the volume is gonna go up, up, up. The activities that you're gonna be able to do are gonna go down, down, down and you're gonna get into a feedback loop that is gonna impair your function in lower quality life and unfortunately a lot of people have been caught in this loop. And then when they go to the doctor and they access care with this specialist or that specialist, depending on the specialty and how they deal with abstract kind of complaints like an experience of pain, you're gonna find in healthcare that this kind of false dichotomy of pain kind of exists. So it's even present in the language we use and if you look at just how neurology for instance, nothing against neurology but the words they will use to describe pain and if you look in the literature, you get this idea that somehow some people have real pain and some people have psychological or unreal pain or whatever. So one of the main things when I work with a patient is recognizing that everyone's pain is real because it's their experience and this false dichotomy doesn't actually exist, it doesn't even make physiologic sense but it is out there and so people get the sense that somehow they fall on the right that they don't have a medical problem, they have this other problem and unfortunately that gets perpetuated and it makes it frustrating for a person trying to access care to get support and treatment for a chronic pain experience. So partly why I think that you get this, this is this false pain dichotomy is kind of a reflexive way for a doctor who has a very specialized thing where they see this problem and they can fix it with this intervention and if it falls outside that silo then well it's kind of frustrating for them because they don't know what to do and this is a complicated thing and I don't have enough time so I don't know how to handle this but partly because when we look at pain as it presents to the healthcare system through people's complaints, experiences, symptoms and everything they say is you have to really think through the differential diagnosis of someone's pain experience and there's a whole spectrum of things that can be going on when you see a patient who's sharing about pain so you could be in an ER and there's truly someone malingering pain symptoms because all they want is a narcotic and that can happen but that doesn't mean everyone's doing that that's just one of the things on the differential diagnosis you could be in an ER and someone comes in with pain and it could be the other end of the spectrum they've already been to 15 doctors but they actually have an undiagnosed medical condition and that can be presenting similarly with the exact same kind of constellation of signs and symptoms as the patient accesses care so you really have to think across what I would call like an illness behavior spectrum not in a negative connotation just saying if someone has an illness or ailment or a pain syndrome and they're presenting with these behaviors and these symptoms you really have to take the time and energy to dig into the case and get to know the patient know what medical work has been done be able to come up with a plan work with people longitudinally and all that I just said is almost longer than what a typical doctor visit takes so making this happen is difficult in our healthcare systems so this is where there's clearly external vulnerabilities to developing chronic pain syndromes such as the pain amplification loop you can get caught in if you present with a pain complaint someone gives you a narcotic you come back you're saying I'm still in pain they give me more narcotic there's external vulnerabilities that patients encounter that feed into the development of chronic pain syndrome similarly pain is a vital sign was a big example of something where some of this was conditioned on people without them even knowing by how we were operating our healthcare system but then also each patient has their own and each person we all have strengths vulnerabilities and some are adaptive in some environments and some are challenging in other environments but everyone brings to the table vulnerabilities individually and in psychiatry depression is a large vulnerability that we see and if people have chronic pain and an affective illness this is a big vulnerability to feeding back and amplifying pain experiences and so treatment has to be holistic and oriented towards both so for instance they've done research people who have multiple sclerosis that's a vulnerability it's a comorbidity more likely to develop depression so something with the immune system obviously in the inflammatory process affects people's moods that affects the depressive syndrome and those interact but many things that we try to modulate through all the things we learn about in ancestral health such as increased sympathetic drive in our physiologies because of our modern environment stimulating our sympathetic nervous systems to the excess we think about when we're working with patients so you don't need to look at the detail here but if someone has an affective disorder what we found from that experience is that medications use to treat depression there's groups of them that modulate physiology in ways that actually help pain so for the appropriate case where medication is beneficial if you modulate the mood the pain gets better and the pain gets better the mood gets better and they're interconnected and that's where appreciating the interconnected nature of our physiologic makeups is important so here's an example many potions that you can use that can modulate the norepinephrine feedback in the neurocircuits in our brain that are mapping our pain transmission and how we gate pain inputs and how pain is transmitted back out to our bodies but there's many other things that do the same types of things whether it's meditation whether it's that amazing movement session we just did which held my back dietary modifications all the things that we think about with ancestral health and the holistic lifestyle view we do that with patients who are struggling with chronic pain because the end goal is to have multiple tools working together to help support someone to regain function regain quality life and some people can get really debilitated by chronic pain to where it's baby steps getting people back out of this cycle that has fed back on itself to limit people's lives and as you work on this as was mentioned by our previous speaker certain groups of people have particular vulnerabilities that put them at risk for developing pain so we see this in psychiatry and have recognized conditions where this just tends to happen more often but you can think about the physiologic vulnerabilities that would bring this together so I remember I don't know what year, when and don't quote me on this but there was a study that I found intriguing I think many years ago it was they did I think it was in Japan but they, you know, in PE when we were kids we had to do this presidential, physical and one of the things was a sit and reach test and then you had to like run and do a shuttle run and a long run and push ups probably, I don't know anyways, but the sit and reach test so they did a study I think in Japan showing that people who did better on sit and reach test had less cardiovascular disease so perhaps people who do better on sit and reach test just have more pliant tissues, right? I mean, I have the hypermobility kind of pliancy thing even with the bad back since I was like whatever age other people can hardly touch their toes and that's just how they come into the world that's how their body developed so if you have increased pliancy or tissues you can imagine that your arterial arterioles are more distensible and can deal with atherosclerotic changes more effectively and prevent heart disease over time but at the same time you, with those pliant tissues could also make you a better at being a gymnast but at some point pliancy becomes a vulnerability and you could develop a chronic pain experience because of that physiologic predisposition. So one of those is postural orthostatic tachycardia syndrome, POTS, this one I joked it's like an infectious diseases because it's spread so fast but it became certain things have been recognized and we see that dysautonomia has become a very prevalent in terms of being recognized as a condition but it's been around for a long time so you go back through medical history and dysautonomia is nothing new it's just there's finally an appreciation for it and we have ways that we can modulate physiology to help people who when they try to stand up their heart rate doesn't kick up enough their blood pressure doesn't go enough and they can pass out maybe their tissues are too pliant the blood vessels pool too much blood and they can't respond fast enough so they're not gonna get as much heart disease but maybe they have more orthostasis meaning their blood pressure variability can't match what's needed when they move positions. Anyways this group we find a lot that we can help through a psychiatry lens with the right mindset of seeing that their needs fall at the intersection of different specialties. Rheumatologists can only do so much neurologists can only do so much medical doctors can only do so much and many of the people who have this constellation of needs can benefit from someone being able to look at the whole picture and put the pieces together and realize that the symptoms and experiences they're having are real and that there's things we need to do to support modulating physiology in ways that can help them function and ancestral health obviously many principles are relevant. So here's just an example of how like I might think about someone with chronic pain and how changes in their autonomic nervous system their dopaminergic function in their brain all interact in a very complex manner with their immune system and their genetic predisposition and their physiologic development and of course all these things are interrelated but we've had amazing talks at AHS over the years about dysbiosis and gut microbiota and the health of how your GI health affects your nervous system and all this we bears out in psychiatry and there's studies that show that if you have dysbiosis if you induce dysbiosis by irritating the colon of a study animal they are more likely to develop depression. If you cut the vagus nerve and there's no way for the GI tract to transmit that autonomic information to the brain they're much less likely to develop depression so clearly what's going on in your gut is affecting your mood affecting your likelihood of developing depression but we've been talking about this since 2011 here and now these kind of topics are like more mainstream in the literature which is really great to see. So I'm just stopping with this last slide just to drive home the point that if someone is caught up in the opiate epidemic they have chronic pain and they're struggling with opiates and what you're seeing is a very complicated picture behind the scenes when you actually dig into that person's lives and what they're experiencing what are their vulnerabilities, what are their strengths and we have a healthcare system that makes it difficult for them to get their needs met and our needs met as patients and there's constantly gonna be room to improve how we coordinate and tackle these more nuanced interstitial medicine kind of conditions but going back to when we started AHS the whole point was appreciating that in order to take on a challenge like that you need everyone working together and it has to be taking inputs from people all walks of life from different perspectives and trying to put the pieces together to see what are some practical tangible things that people can do in their day to day lives that can help them function and manage something like chronic pain which is of course a pain. So this is how you need to think as a doctor when you're trying to help someone with chronic pain and also as we try to model and think about how do we develop medical interventions for chronic pain and it's complicated but that's what makes it interesting as well. So I will stop there. Hi Brett, good to see you. Good to see you. After all these years. The reach, what's it called? What in reach? Sit and reach. Sit and reach. What is that a metric like a good score and a bad score? Is that a proxy for some other health issues and is it validated for children and adults or you don't know, I just, I'm very pertinent to what I do. Yeah, so in terms of the validation, I mean we, it was the government picked it as part of their pet, you know this, these programs that used to be in the schools, it was one of the tests that they picked obviously to assess physical health I guess but in terms of research protocols, this study, you know, I have to go back. I was just thinking about it today when I was preparing for the talk but you know, it's clearly measuring ability of stretch of tissues. I mean, and that's not, yes there's some, there's a scope of that to practice, makes better, right? You do yoga, you get better yoga but if you've ever been to a yoga studio you know that certain people can only stretch so far and other people they just show up and they just stretch. So there's clearly a spectrum but in terms of use and research I just don't know anymore like with the formality part but I view it as just a measure of tissue pliancy that it's more of a predisposition than anything, yeah. And what you said about pain. So reduced comorbidity for heart disease was what that study showed. Oh what, okay. Yeah, for specifically of heart disease. So then if you think about it, you know that would, but that group of people who also have tissue pliancy we see joint hypermobility, ilos danlos, that whole spectrum, much higher rates of developing chronic pain and GI dysfunction, the whole constellation at the same time. So I mean I've had patients who have ilos danlos, hypermobility, POTS, colonic inertia, you know you do a defecation study and they have essentially no transmission of fecal material over 24 hours, right? And we've had to give them IVIG to modulate the immune system to change the immune process. And so they also have this predisposition to autoimmunity but like it's, we notice that this group of people has more likely to have autoimmune diseases, more likely to have these tissue pliancy kind of syndromes and develops you know obviously depression and chronic pain. The, what you said about pain being a vital sign by the medical industry is the most useful thing I have heard in a long time. Thank you for that. I gotta know more about it. Yeah, yeah, you're welcome. I love your approach of integrating you know different areas of specialty. So my question is I have a 12 year old son and he's taking Zoloft every other day and it's affecting his gut. He's had anxiety and gut issues kind of his whole life and you know I'm looking into like CBT and other things to treat as OCD. But my question sort of is you know the psychiatrist is like oh just keep taking the Zoloft and don't worry about the gut. You know and then somebody with a more holistic approach is like well you know he's probably gained about five pounds of belly fat and he has a lot of gas and sort of it's like where's the balance and is the goal to get him off the Zoloft as soon as possible or you know like how would you approach that? Yeah, so it's a good question but so I would start with you have to look at all the pieces of the puzzle. So if someone actually has OCD, obsessive-compulsive disorder, it's one of the you know when you think of psychiatry like defining states in psychiatry. OCD is a condition that is like defines the field of psychiatry. If you're a neurologist you treat seizures. Like if you see a seizure it's a real thing. It's a physiologic thing and there's a treatment for it. OCD I would say is similar. If you see someone who is manic in a manic episode you'll realize this is a real medical condition that is very you know. So treatment for OCD you know standard of care is high dose SSRI but high dose SSRI. We know that serotonin affects gut function. I mean that's basic and some people with SSRIs increase serotonin can have issues with affecting you know their gut health of course. So you have to kind of try to work on both things at the same time. So perhaps there's another medication that can help address the side effect of the Zoloft you know and I wouldn't give up on the treatment though because there are treatments for OCD that are helpful. And it's like you don't want to throw out the baby with the bath water. Right and I heard CBT is very effective. Yeah so the best thing for OCD is exposure and response prevention therapy. You know someone has to really, someone has to work with people to help them recognize their compulsions and prevent them and be able to sit with the discomfort and modulate the circuits in the brain that are on overload and are forcing people to have this need to do a compulsion. But again it's like trying to have as many levers as you can to help treat the condition. It is the best. Yeah. Thank you. Brett, hi nice to see you. Hi, good to see you. So I have a follow up on that. Yes. You know through your talk you mentioned the autonomic nervous system about five times. But you never mentioned the word serotonin until just now the last question. Serotonin is awfully complicated, but it affects the amygdala in a big way. And the amygdala is one of the things that basically is the gait for whether pain becomes an issue of coping versus an issue of breakdown and activation of the HPA axis and going out of control. Yeah. There's a lot of data on serotonin and SSRIs in chronic pain syndromes which you didn't mention. I would like you to address that question. And lastly you mentioned cutting the vagus nerve impacts pain and certainly does. But the question is, is the serotonin in the brain coming from the gut or is it coming from de novo production in the brain? There is this enter grade transport because 90% of the serotonin is in your belly from your gut microbiota. And in fact that after in Vegas is the transport mechanism to get it up to the amygdala. So do you wanna speculate on the role of serotonin and the role of the vagus in the interpretation of chronic pain and what weak as physicians can do about that? Yeah. So I can say that in practice something we notice is that SSRIs which are just geared towards serotonin you know these things are so complicated obviously but the medications used to treat that are affecting serotonin are less effective for treating chronic pain experiences. So if someone has and if you look at even just the FDA approvals for treatments of neuropathic pain syndromes, SNRIs are clearly in practice and in the literature more effective at treating most chronic pain syndromes and perhaps it has to do with when you think about chronic pain is the sympathetic over activation of the chronic pain state and norepinephrine being modulated by an SNRI somehow is reducing or modulating the pain transmission process, the signals that are being sent. So that's changing the pain experience because you might, you're taking in sensory information but the way it's being transmitted to the brain, interpreted in the brain is different because of norepinephrine's, the changes in the norepinephrine. Now I don't know any further than that, I mean that's as far as I can go to postulate but if you have a neurosurgery that is over amplified, it's a signal transmission cycle and if a pain signal is sending too frequently the amount of signal being transduced is too high. An intervention to break the cycle or disrupt the cycle could be done by just increasing norepinephrine at the synapse and then that creates a feedback to the system and how electrical chemical conductance is happening to send a signal. So clearly in other NTCAs, tricyclic antidepressants which also have a norepinephrine component are much more effective than Zoloft, Prozac, these SSRIs. So in terms of serotonin and pain, I, in terms of just thinking about chronic pain syndrome generally, I'm not so sure modulating serotonin is as effective to the experience of pain because we don't see that in practice. But when it comes to the gut, that's a whole different ballgame in the vagus nerve transmission. In patients who have either constipate, so in some of the irritable bowel syndromes, it seems like SSRIs can be more helpful. So I think there's something unique about gut health versus just chronic pain syndromes generally. So that's where it's complicated. Often the people that we see with chronic pain syndromes also have GI dysfunction. And yeah, I'm not like, I guess I'm not in a position to make any further scientific. But the way, but the thing I always go back to when I'm thinking about a patient is that this is an entire loop of information. And there are ways to modulate that loop so that their experience of pain is different. Thank you so much. We are now officially on break. And...