Your Brain on Pain
The statistics are shocking. At any given time, nearly one fourth of American adults are experiencing low back pain. Even worse, roughly one-third of the population will have to deal with chronic pain at some point in their lives. How does the brain react to pain? What can people with chronic pain do to alleviate their suffering? Our guest is a nationally recognized pain expert with a number of suggestions.
At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment.
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Chronic Pain:
We are all familiar with the instantaneous pain of having your hand contact a hot pan. In that case, pain serves its most important function, warning us not to do that again! Many people have known the pain of a sprained ankle or a twisted knee. In most cases, we recover from such mishaps in time, and the pain becomes a memory. But sometimes, the brain circuits get stuck, so to speak, and we end up with ongoing chronic pain. That can last and cause suffering well after the original stimulus has disappeared. There is no evidence that suffering is good for the soul.
The Experience of Pain Is Personal:
It is critical to remember that pain is subjective. The nerves may carry a sensation of “heat” from that hot pan or “pressure” if you slam your thumb in the door. It isn’t pain until the brain interprets it. And brain interpretations can and do vary from one person to the next. Past experience and levels of social support as well as expectations of relief influence the ways that people feel pain in response to injury.
Personalizing Treatment of Chronic Pain:
If the experience of pain, especially chronic pain, is highly individual, shouldn’t treatments be individualized as well? Every pain patient deserves an individualized assessment, with particular attention to red flags that might be warning of an imminent medical emergency. Ruling that out must not invalidate the patient’s experience. Then the patient and provider can proceed to work on a multi-modal approach to pain control.
How Will the New FDA Opioid Guidelines Affect Patient Care?
The FDA recently issued new guidelines on the use of opioid (narcotic) pain relievers. The agency will require much clearer warnings about the risks of such medications, especially when used for longer periods of time. Prescribers will be reminded to use the lowest effective dose for the shortest time needed. They will also be reminded that these drugs should never be stopped suddenly, because that could trigger withdrawal symptoms. Should people be avoiding opioids? Dr. Mackey thinks the new guidelines are in line with precautions that responsible prescribers are already observing.
What Non-Drug Approaches Can Help Chronic Pain?
We asked Dr. Mackey when non-pharmacologic approaches are appropriate, and he responded that they are always appropriate, sometimes in conjunction with rather than instead of medication. There are at least six categories of tools for pain, including medical interventions (surgery, for example), mind-body approaches such as mindfulness-based stress reduction (MBSR), physical therapy, nutraceuticals, complementary and alternative therapies (such as acupuncture) and medications. Each of these categories might have only a small effect by itself but taken together they can provide substantial relief.
What About Drugs?
There are probably a couple of hundred drugs that could be helpful, only a handful of which are opioids. So even for people who don’t tolerate opioids, there are plenty of tools to help alleviate pain. Dr. Mackey does prescribe opioids, but he also prescribes medicines such as topiramate, duloxetine, ketamine and low-dose naltrexone, among other medications. Keeping in mind that everyone is different, these will be used in a variety of methods and combinations, depending on patient response.
How Can Patients Find a Pain Doctor?
In some parts of the country, especially rural areas, it may be difficult to find a healthcare provider skilled at treating chronic pain. Dr. Mackey suggests utilizing the resources of the American Academy of Pain Medicine. Another resource, possibly more for providers than patients is Doximity.
This Week’s Guest:
Sean Mackey, MD, PhD, is a pain management specialist and anesthesiologist. He holds the titles of Redlich Professor and Professor of Anesthesiology, Perioperative, and Pain Medicine (Adult Pain) and, by courtesy, of Neurology and Neurological Sciences, all at the Stanford University Medical School. Dr. Mackey is Chief of Stanford’s Division of Pain Medicine and a past President of the American Academy of Pain Medicine. His website is https://seanmackey.people.stanford.edu/research
Sean Mackey, MD, PhD, Stanford University Division of Pain Medicine
Listen to the Podcast:
The podcast of this program will be available Monday, Sept. 22, 2025, after broadcast on Sept. 20. You can stream the show from this site and download the podcast for free, or you can find it on your favorite platform.
In the podcast for this episode, you’ll learn what is happening in the brain when we feel pain. We also discuss the anger and depression that so often accompanies chronic pain (and may unwittingly exacerbate it). You’ll also hear about two drugs often used to treat pain. The gabapentinoids gabapentin and pregabalin can be helpful in some situations. What side effects should patients be warned about?
Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.
Watch the Video:
Here is a clip from our interview with Dr. Mackey.
Transcript for Show 1445:
A transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. This transcript is copyrighted material. All rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission.
Joe
00:00-00:01
I’m Joe Graedon.
Terry
00:01-00:05
And I’m Terry Graedon. Welcome to this podcast of The People’s Pharmacy.
Joe
00:06-00:27
You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. The CDC estimates that almost one in four American adults suffers chronic pain. Are there successful treatment strategies? This is The People’s Pharmacy with Terry and Joe Graedon.
Terry
00:34-00:43
The experience of pain is deeply personal. Shouldn’t treatment strategies be personalized as well? What works for one person might not help someone else.
Joe
00:44-00:53
We’re honored to be speaking with one of the country’s leading pain experts. Dr. Sean Mackey is Chief of Stanford’s Division of Pain Medicine.
Terry
00:54-00:59
Dr. Mackey will offer insights into the multimodal approaches his patients have found helpful.
Joe
00:59-01:07
Coming up on The People’s Pharmacy, your brain on pain. Why chronic pain changes everything.
Terry
01:14-02:01
In The People’s Pharmacy health headlines, daylight savings time will come to an end on November 2nd, But scientists don’t agree on the health implications of turning the clocks back an hour. A Stanford University study published in the Proceedings of the National Academy of Sciences suggests that going back and forth between standard time and daylight savings time disrupts circadian rhythms. The researchers found evidence that this increases the risk for obesity and stroke. They calculated that sticking with standard time year-round would prevent 300,000 strokes each year and cut down on obesity. People who usually stay up late suffer greater biological consequences from shifts in time regimens.
Joe
02:02-02:59
Previous research blamed changing clocks for higher rates of car crashes and heart attacks. That may have inspired the Stanford scientists. However, researchers at Duke University have just published their analysis of data from 168,870 patients over the course of a decade. The study in JAMA Network Open found no differences in heart attack rates in the weeks before and after changes to daylight savings time. In addition, they found no increase in stroke or mortality. These dueling findings could leave policymakers in a quandary. Should we stop switching times twice a year because of the possible risks involved? Or is it actually relatively safe to switch into and out of daylight savings time? Clearly, the answer is the common and extremely unsatisfying conclusion. More research is needed.
Terry
03:00-04:10
Another topic that has been controversial for decades is hormone replacement therapy to relieve menopausal symptoms. HRT is unquestionably effective, but the Women’s Health Initiative raised serious doubts about its safety over 20 years ago. Instead of reducing the risk of coronary heart disease, as expected, HRT actually appeared to increase heart risks. A new analysis of these data, published in JAMA Internal Medicine, found that women in their 50s did well on hormone replacement therapy, But women in their 70s appeared to have an increased risk of atherosclerotic coronary vascular disease if they were taking estrogen, alone or with progestin. The authors conclude, the findings support guideline recommendations for treatment of vasomotor symptoms with hormone therapy in women aged 50 to 59 years. caution if initiating hormone therapy in women aged 60 to 69 years, and avoidance of hormone therapy in women 70 years and over.
Joe
04:11-05:05
The FDA has announced that it will be cracking down on direct-to-consumer prescription drug advertising. The Commissioner of the Food and Drug Administration, Dr. Marty McCary, offered a viewpoint in JAMA outlining the new approach. The agency will be rolling back a 1997 loophole that allowed pharmaceutical manufacturers to shorten the length of cautions and side effects in ads or commercials. The FDA will now require much more complete disclosures of risks. That could make advertising prohibitively expensive and less appealing. Commissioner McCary concluded, quote, we will no longer tolerate deceptive practices that distort the patient-doctor relationship and waste billions of dollars in health care resources that could be better spent lowering drug prices for Americans.
Terry
05:06-06:17
Israeli scientists have been studying a green Mediterranean diet for years. This eating pattern follows the Mediterranean approach of lots of vegetables, fruits, and whole grains, and very little meat, sugar, or processed foods. In addition, a green Mediterranean diet includes green tea and a green smoothie containing the water plant mankai every day. The study examined the status of approximately 90 proteins found in the blood. Two, in particular, were lower in people whose brains were functioning well. They’re called galactin-9 and decorin. Following a green Mediterranean diet seems to lower the levels of these proteins and might help slow cognitive aging. And that’s the health news from the People’s Pharmacy this week. Welcome to the People’s Pharmacy. I’m Terry Graedon.
Joe
06:17-06:28
And I’m Joe Graedon. Have you ever burned yourself on a hot frying pan or hurt your back lifting something too heavy? Describing your pain level to someone else can be difficult.
Terry
06:28-06:36
Acute pain like that is something almost everyone has to deal with. Chronic pain, on the other hand, can be far more challenging.
Joe
06:36-06:55
To help us better understand the nature of pain and how to treat it, we turn to Dr. Sean Mackey, a pain management specialist. He holds the title of Redlich Professor at Stanford University Medical School, where he’s also Professor of Anesthesiology, Perioperative, and Pain Medicine, and by courtesy, of Neurology and Neurological Sciences.
Terry
06:56-07:02
Welcome back to The People’s Pharmacy, Dr. Sean Mackey.
Dr. Sean Mackey
07:03-07:22
Hey, it’s great to be back. I heard a lot of wonderful comments about the last show, and it always makes me feel good when the information that you folks are putting out there related to pain is making an impact in everyone’s lives. So thanks for all you’re doing and appreciate the opportunity to come back.
Joe
07:22-07:52
And thank you for your work, Dr. Mackey. We are so grateful to be able to speak with you again about pain. And, you know, pain, it’s such a personal thing. And it’s so hard to measure. So many times, you know, if a doctor is asking you, well, what’s your pain level on a scale of one to 10? And of course, that’s somewhat qualitative. And it’s hard for one person’s pain to compare to another person’s pain. It’s totally qualitative.
Terry
07:53-07:59
And it also depends on what your experience of pain may have been in the past.
Joe
07:59-08:49
Yeah, I do have
a quick story to tell you about a dear friend of mine who recently had to undergo a medical procedure. And it was supposed to be, you know, kind of a minor procedure, no surgery involved, a little lidocaine, no big deal. He said it was the most excruciating pain of his life. This is a big guy. He’s like 6’4″, probably weighs about 230 pounds, lifts weights, does all kinds of stuff. And it was like, I couldn’t bear it. I was screaming inside. And some of those screams came out. So tell us about this thing about personal pain and how variable it is from one person to another.
Dr. Sean Mackey
08:49-11:24
Yeah, I think you hit it. You hit it perfectly. And therein lies the challenge we have with understanding, getting our heads wrapped around this concept of pain, because we all believe we know what it is because we base it on our own personal experiences. But the problem is that our personal experiences don’t translate to anybody else.
And it’s getting back to what you said, this nature that pain is an individual and subjective experience. And that’s counter to everything that our beliefs are, our eyes see, and what we understand, meaning we all expect that there to be this direct one-to-one link between the amount of tissue damage and the amount of pain that somebody experiences. And that model, that mechanistic model was put forward by Rene Descartes back in the 17th century. And while he is a really smart guy. He gave us Cartesian geometry. He gave us some modern philosophical beliefs. He was completely wrong when it came to pain.
You have to think about pain in the context of how you would think about love. Like, how much do you love your child on a scale of zero to 10? How much do you love your dog? And then, you know, but it’s such a silly thing. Nobody, how many times have you ever been ask, hey, how much love do you feel? Nobody would ever ask that. But that is the same concept that we have to do when we’re talking about pain.
And the message that I would give people is pain is individual. And it is encapsulating all our prior life experiences, all of our thoughts, our moods, our emotions, everything we’re bringing into that experience right now. And whatever that person is experiencing, just accept it. We put a pain scale to it, which is probably more to get a sense of how much impact the pain is having, how much distress they’re having, than it meaning something really objective. And that is one of the key messages also, that this individual variability, we have to take care and not putting it onto others, particularly when making policy decisions and making broad statements about what somebody should be taking or not taking, what treatment they should be getting or not taking. Use it as a guide, no more or less.
Terry
11:26-11:47
Dr. Mackey, maybe we could ask a very simple question that may have a really complex answer, And that is, how do we feel pain? How do the sensors in our skin or elsewhere in our bodies send signals to our brain that become our pain experience?
Dr. Sean Mackey
11:48-14:05
Yeah. And that’s such an important foundational question because you’ve got to start there before you can really understand the nature of pain. So pain all starts typically with something happening out in your periphery, your periphery meaning in your body, your fingers, your hands, your legs, your arms, your abdomen, what have you. And in that, we have these little tiny sensors called nociceptors, technical term, but they’re just simply acting like a transducer.
Now, a transducer is defined as something that converts one form of energy into another form of energy. It just, this microphone is a transducer. It converts sound energy into electrical energy. Those nociceptors are converting pressure, temperature in the form of heat or cold into a little electrical signal that transmits up nerves. And we have special nerve fibers that transmit what will be the perception of pain. But it’s not pain yet, still in the body. It’s what we refer to as nociception.
Those signals go to our spinal cord. Back here, this long set of nerve fibers and nerve cells that are in our spine. And there’s some processing. There’s some little computers back there that are processing the signals, altering them, changing them, and then they’re sent up to the brain. And this is the key point. Until it hits your brain and it becomes the perception of pain, before then it’s all still nociception. But once it hits the brain, that’s where this experience, this wonderful and terrible experience of pain occurs. Wonderful. Because this experience of pain keeps us out of danger. We only had to touch a hot stove once to learn not to do it again. It keeps us away from injury, from harm. And back in the cave people days, it kept us away from being eaten and being prey.
Joe
14:06-14:21
Well, you know, Dr. Mackey, there are people who don’t have pain. And they are in terrible trouble because they do burn their fingers and hurt themselves because they don’t know how to avoid that hot stove.
Dr. Sean Mackey
14:22-15:25
You’re right. The problem that we’ve had is that those people are typically the protagonists in a TV show or a movie. And they’re made to look like supermen or women, where they can jump off buildings and land without getting hurt. Well, they don’t feel pain when they jump off the building or when they get stabbed, but they are getting injured. They leave that part out of the movie or the TV show.
It is a tragic, tragic situation to be born with this thing called congenital insensitivity to pain. These unfortunate children have to be continually protected from themselves because they can’t tell when they’re injured. And they typically die at an early age unless the parents go to extreme efforts to keep them safe. So you don’t under any circumstances, despite the movies and the TV shows, ever want to have that condition.
Terry
15:26-15:27
I’m assuming it’s very rare.
Dr. Sean Mackey
15:28-15:35
Very, very rare. I can’t even quote you how many zeros are before the final digit and the percentile. Very rare.
Joe
15:37-16:09
So pain is protective, but it also causes incredible agony and affects tens of millions of people. What worries me is that there are people who believe that suffering is good for the soul. If it didn’t kill me, it’ll make me stronger. And for those people, I think that is a real misnomer. It’s like, oh, no, pain is not good for the soul. Yeah, I’ve heard that one.
Dr. Sean Mackey
16:10-17:32
First of all, if you’ll allow me to gently add a zero to your numbers, it actually affects probably hundreds of millions. And I’ll even take it bigger if you want to go global and say billions. You know, you’re probably looking at a prevalence rate of around 30% or so. So, you know, close to one in three people on this planet probably have some level of chronic pain.
Now, people will listen to that and some will be skeptical and they’ll say one in three. I don’t see one in three suffering from chronic pain. And what you have to do is add some context to that. Meaning you have people with chronic pain that are self-managing at home. These are people like my father who, you know, had from all the sports injuries and everything else, a lot of back pain, a lot of arthritis, and wouldn’t see a doctor about it, wouldn’t even listen to me. And he just kind of sucked it up and dealt with it until it got too much.
And then you have people that end up in our clinic at Stanford, a tertiary referral center who have terrible high-impact chronic pain, who are seeking medical care, and everybody in between.
But pain is with us in society. It takes a terrible toll. In the United States alone, over half a trillion dollars we spend in chronic pain.
Joe
17:33-17:47
Dr. Mackey, we’re going to take a short break, but when we come back, we need to talk about what people can do for that chronic pain. One in three, that’s an astronomical number.
Terry
17:47-18:13
You’re listening to Dr. Sean Mackey, Redlich Professor and Professor of Anesthesiology, Perioperative, and Pain Medicine at Stanford University School of Medicine. Dr. Mackey is a past president of the American Academy of Pain Medicine.
After the break, we’ll reconsider the idea that suffering is good for you. The FDA is changing its recommendations on opioids again.
Joe
18:13-18:25
Should patients avoid opioids? How have the new guidelines affected doctors and patients? You’ll hear about alternatives to opioids. When are non-drug approaches to chronic pain most appropriate?
Terry
18:39-18:42
You’re listening to the People’s Pharmacy with Joe and Terry Graedon
Terry
20:42-20:35
Welcome back to The People’s Pharmacy. I’m Terry Graedon.
Joe
20:45-21:08
And I’m Joe Graedon. Chronic pain, it’s debilitating. It can take over your life and make it hard to focus on anything else. There was a time when opioids were among the most prescribed drugs in the country. But now, most health care professionals are very cautious about prescribing medications such as hydrocodone, oxycodone, or fentanyl.
Terry
21:09-21:22
What other options are there for people in pain? Are there non-drug approaches that can be helpful in alleviating pain? Our guest today has a six-point strategy for pain relief that involves a number of different disciplines.
Joe
21:23-21:53
We’re talking with Dr. Sean Mackey, Redlich Professor and Professor of Anesthesiology, Perioperative, and Pain Medicine at Stanford University School of Medicine. Dr. Mackey specializes in treating people with chronic pain. He’s chief of Stanford’s Division of Pain Medicine. His research aims to translate scientific discoveries into real-world pain relief. Dr. Mackey is a past president of the American Academy of Pain Medicine.
Terry
21:55-22:17
Dr. Mackey, we have just floated the idea that seems to be popular in some quarters, probably not among the one in three people who are suffering chronic pain, that suffering itself is good for the soul in some way. Why is that such a questionable premise?
Dr. Sean Mackey
22:20-23:48
You know, I think where it’s come from, or at least the camps that I’ve seen it from in particular, are those who want to deny or restrict certain treatments from patients. And the problem is that once you cut those off, those people aren’t left with anything, anything else.
And so then the narrative turns to, well, it’s good for the soul. Back in the day when things were better, people would just suffer and it made them stronger. Well, it makes for a nice story, but the reality is it’s far from true. What you end up with is just increases in disability, further drags on the individual, society as a whole. There is zero evidence that suffering is good for the soul.
Now, is it true that some level of stress can help make people stronger? Yeah, but the data on stress is rather clear. You know, it’s when stress is controllable. It’s when it’s time limited. When you’re talking about chronic pain, this persistent type of stress, every study to date has shown that it is bad for the individual, bad for their family, and bad for our society.
So this is one of those comments, those premises that I think is rather easy to dismiss.
Joe
23:50-25:19
Dr. Mackey, the Food and Drug Administration has just recently changed its opioid regulations again, and it’s going to be making it harder for people to get opioid pain medicine. And I think a lot of Americans think, oh, that’s a good idea. We have problems with addiction in this country.
We went back and we looked at 2010, and the number one most prescribed drug in 2010 in the United States was hydrocodone with acetaminophen. 122 million prescriptions were dispensed that year, and oxycodone was another 29 million. By the year 2017, it was down to $40 million for hydrocodone.
And in 2022, it was half that, roughly $23 million. So from 122 million prescriptions dispensed down to $23 million because I think people are so afraid of opioids. Even people who go in for surgery, you know, like knee replacement surgery, they come back and they say, well, I didn’t take any opioids. I was tough. It hurt, but I was tough. I managed to survive without opioids.
Is that a good idea? And has this whole FDA and CDC initiative to dramatically cut back on opioids affected both physicians and patients?
Dr. Sean Mackey
25:21-31:20
Wow, there’s a lot to unpack there. These are great questions. So let’s try and take on a few of these. In answering this question, for people who don’t know me, it’s helpful for me to put my position forward. My usual mantra is that I’m not pro-opioid. I’m not anti-opioid. I’m pro-patient.
I come from personal experiences with a family history deep in addiction. I’ve lost close family members to opioid overdose, to alcoholism, and to other substances. And at the same time, I prescribe opioids for people with chronic pain, cancer pain, and acute pain. And I’ve helped people come down on those agents voluntarily.
So you can hold these concepts both in your head, and both can be true. They can be terribly damaging, and they can be incredibly helpful for patients. And that’s why I said, I’m not pro, I’m not anti, I’m pro-patient. They’re a tool. They’re a tool that physicians, clinicians need to learn how to use responsibly.
We were prescribing far too many opioids in the years that you mentioned. There’s no question about it. I think the data is rather clear there was too much being prescribed. And there were a lot of people that were getting prescription opioid addiction and opioid use disorder back then. Most of that wave, a large part, not entirely, a large part of that wave has moved into illicit opioids now, as I know you’re well aware. the question i think for all of us is has the pendulum swung too far from this very permissive state which was going on back in the late 90s the 2000s into this rather extreme now anti-opioid state that in in many cases exists now personally I think it has and I think we need to come back to the center.
This occurred in the state of California. I was a senior editor for the California Medical Guide for prescribing controlled substances that we just released this last year. And in that, we recognized that things had moved too far into the other extreme and that we needed to put forward guidance on how to use opioids as an effective tool for the right patient in the right context.
Opioids should never be a first-line drug for chronic non-cancer pain. I think everybody would generally agree with that, and it’s probably not a second line. It’s probably not a third line. It is to be used when there has been failure to all of the more conservative therapies that are available to that patient. And what I mean by available to that patient is the narrative sometimes from groups that want to severely restrict all opioids is, well, you know, they can go get cognitive behavioral therapy or they can go get acupuncture or they can go get this.
And the problem is people have to realize that a lot of those resources aren’t available to people with chronic pain. Most of the multidisciplinary, interdisciplinary, comprehensive resources are all consolidated in large centers in the big cities, but we have huge swaths of America that are rural, where people have very little access to healthcare. And we have to recognize those people and what they have available. And in some circumstances, opioids are indicated.
Now, getting to your point, I saw the FDA, you know, new guidance. Candidly, I didn’t see anything in there that caused me real concern. I thought what they did was they’ve updated the language and they’ve included in some contemporary data that has come about from two post-marketing studies where they followed people over time who were taking opioids. One in which they followed prospectively, that means forward in time, and one in which they looked retrospectively back in time. And they were able to put real numbers to the incidence of people misusing or abusing opioids over time and people having an overdose risk. In the past, they gave warnings that there are risks of misuse and abuse and overdose, but they didn’t have real hard numbers, and now they’re able to put those forward.
We’ve also been able to see language where they’re recognizing more and more that there is a dose-related increase in adverse events. Well, that’s kind of common sense. The higher the dose, the higher the risk you are. I don’t think many people would disagree with that notion either. So there are some languaging changes. I haven’t seen anything, and I’d love to hear your perspectives, by the way, if you think otherwise. But most of this is to clarify what we’ve already known and add in that additional language. What are your thoughts about it? You mentioned that it’s going to be more restrictive.
Joe
31:21-32:30
Yeah. Just briefly, Dr. Mackey, and then Terry has a question about other alternatives. But what worries me is that they have really come down hard against long-acting opioids. And for people who are in excruciating pain, who cannot function, who otherwise are bed-bound and unable to work, taking away or making it restrictive for people to have access to the longer-acting opioids that would otherwise allow them to work, allow them to engage in activities that allow them to, you know, be, you know, I won’t say normal, but allow them to function in society.
That’s what I think concerns me because we’ve heard from so many people who have been able to take longer acting opioids and just function pretty, pretty well in society. Your thoughts? Well, you’re right. So I get your concerns and they’re real.
Dr. Sean Mackey
32:33-33:33
Here’s the thing to be clear. The FDA guidance simply says that you should start and focus on intermediate, excuse me, immediate release opioids first. And they make a clarification that you shouldn’t be jumping right to extended release opioids and that start with the short acting and then if needed, move into the extended release.
Now there’s all this language. I read that language, I’m not that concerned about it. However, the problem is how that language is spun and how it’s interpreted by others. And we saw that with the original CDC guidelines on opioids in 2016. Because it’s really easy to take that language and weaponize it or misinterpret it and come out with the messages that you just suggested, which is to restrict, restrict,
Joe
33:33-33:45
restrict. That would be sad. Well, it’s time now to, Dr. Mackey, it’s time now to, I think, shift over to alternatives, because as important as opioids are for some people, many people, in fact, Terry, there are alternatives.
Terry
33:46-34:08
There are, but one thing we haven’t yet clarified is how do people end up in chronic pain? I’m assuming that most chronic pain starts as acute pain. What’s the transformation process like?
Dr. Sean Mackey
34:09-34:58
Yeah, we’re still trying to figure that out. We know that, as you said, most chronic pain almost all starts with an acute pain episode, an injury, an infection, some episode that the normal healing processes may have healed up the tissues, but the abnormal signaling that is related to pain still persists. And over time, that persistence transforms what was a symptom of an acute situation into a disease in and of its own right, much like diabetes, which initially starts as impaired glucose tolerance to eating a donut, becomes pre-diabetes and then moves into the frank disease of diabetes. We’re still trying to identify the vulnerabilities and the mechanisms of that so that we can have treatments that will prevent it.
Terry
35:01-35:15
Well, let me follow up then with this question of treatment. Especially non-pharmacologic approaches to pain relief, can you tell us what some of them are and when they might be appropriate?
Dr. Sean Mackey
35:17-36:32
Sure. I would suggest that non-pharmacologic approaches are always appropriate. That doesn’t mean that people should be excluded from pharmacologic approaches. It means that the best way to treat chronic pain is when you approach it from, we call it a multimodal standpoint. It simply means use all the tools at your disposal.
And we have at least six categories of tools for pain. Only one of categories are medications, interventional procedures. These are typically your nerve blocks to minimally invasive surgeries. Mind-body therapies are behavioral interventions. options, physical and rehabilitative options. We have complementary alternative medicine options, which is a little bit of a dated term, but we’ll probably get to it. And then the last one, the sixth one is self-empowerment, which is broad strokes. It’s getting educated and empowering yourself with that education.
Hopefully the people that are listening to your show being an example in that sixth category. So of those six categories, we recommend dipping into all six of them and not relying on just one.
Terry
36:33-36:56
Give us an example, if you would, please, of how somebody who has consulted you for a chronic pain problem, tell us a little bit about their situation and how each of these categories might contribute to them being able to cope with their chronic pain.
Joe
36:56-37:06
And we just have about a minute before the break. So when we come back, we’ll ask you to kind of extend that six categories in a little more detail.
Dr. Sean Mackey
37:07-37:54
Yeah. First, it all starts with an assessment. So it has to be individualized. This gets back to the earlier part of pain being an individual experience. And so, you know, you’ve got to take the person for whom they are and what they bring into it. Some people may benefit from more of a rehabilitative approach as a frontline.
Some may be from a more pain psychology behavioral approach. Some, there may be some simple interventional procedures to knock out that nociception, those electrical signals. And that may be an appropriate approach. It’s all about the initial comprehensive assessment of that person and putting together a tailored treatment plan for them. And I think that’s where things start.
Joe
37:55-38:07
When we come back from this break, we’re going to ask you to give us maybe a story, an example, so that people can understand how you come up with that tailored treatment approach.
Terry
38:08-38:42
You’re listening to Dr. Sean Mackey. He is Redlich Professor and Professor of Anesthesiology, Perioperative, and Pain Medicine at Stanford University School of Medicine. Dr. Mackey specializes in treating people with chronic pain. He’s Chief of Stanford’s Division of Pain Medicine. Dr. Mackey’s research strives to translate scientific discoveries into real-world pain relief. He is a past president of the American Academy of Pain Medicine.
Joe
38:43-38:50
And Terry, you know, this idea of cookie-cutter medicine just doesn’t work when it comes to pain. It has to be tailored or personalized.
Terry
38:50-38:51
Exactly right.
Joe
38:51-38:55
After the break, we’ll hear what can be done for lower back pain.
Terry
38:56-39:01
Dr. Mackey describes how a patient used a multimodal approach and how that worked.
Joe
39:02-39:09
What are the top five medications for chronic pain, not counting non-steroidal anti-inflammatory drugs or opioids?
Terry
39:10-39:15
You may have heard of low-dose naltrexone. Dr. Mackey shares his experience.
Joe
39:15-39:18
Which alternative therapies might be helpful?
Terry
39:30-39:33
You’re listening to The People’s Pharmacy. with Joe and Terry Graedon.
Joe
39:42-39:45
Welcome back to The People’s Pharmacy. I’m Joe Graedon.
Terry
39:45-40:03
And I’m Terry Graedon.
Joe
40:03-40:22
Have you ever experienced back pain? If not, you’re a rarity. It’s estimated that 80% of Americans will experience low back pain at some point in their lives. As we speak, about one-fourth of the population may be experiencing some discomfort in their lower back.
Terry
40:22-40:36
Coming up, we’ll learn what people do for back pain and other chronic pain problems. Our guest will discuss low-dose naltrexone, acupuncture, alpha-lipoic acid, cannabidiol, and self-hypnosis, among other things.
Joe
40:36-41:00
We’re talking with Dr. Sean Mackey, Redlich Professor and Professor of Anesthesiology, Perioperative, and Pain Medicine at Stanford University School of Medicine. Dr. Mackey specializes in treating people with chronic pain. His goal is to develop precision pain care. Dr. Mackey is past president of the American Academy of Pain Medicine.
Terry
41:01-41:38
Dr. Mackey, I know that in your clinic you see people with chronic lower back pain. They’ve probably, if they’re in your clinic, they’ve probably seen a lot of other doctors and maybe some other types of practitioners. Can you tell us about an individual who came to you, used some of these multimodal options that we’ve just been discussing, and what options did they use, and what was the outcome?
Dr. Sean Mackey
41:39-44:34
Delighted. So why don’t we take Bob as a patient? Bob’s a guy in his 40s. He’s working hard. He’s got a couple young kids. and Bob has chronic low back pain. And so Bob comes into the clinic and he, Bob represents America. Like Bob represents, he’s everybody’s person with low back pain.
Everybody’s situation is going to be a little bit different, but you’ll get the, you get the point. Bob injured his back. It kind of laid him up for a while, but the pain persisted and he comes in to see. And part of Bob’s problem is that nobody believes he’s got back pain. So one of the first things that we do is we make sure that we believe that Bob has real pain because Bob’s been typically invalidated everywhere he’s gone. So first rules are to assess Bob for any, what we refer to as red flags. And these are causes of his pain that represent a potentially severe issue, infection, tumor, nerve impingement, things that need an immediate medical response.
But let’s assume that we eliminate all those. And by the way, those only represent a small percentage of people with back pain, but you got to do the first principles. So what you’re left with is Bob has his chronic mechanical low back pain, and we’re not going to break it down into the different components that could be contributing to that because we don’t have the time for this show.
But let’s just say that Bob is also expressing a lot of fear of movement because every time he moves, he gets increases in pain. And the problem is that that develops into this fear avoidance approach where over a period of time, Bob doesn’t want to move around. So he walks around like he’s got a stick up his butt. He’s real rigid because he’s heard that his discs are exuding these chemicals that are causing irritation on his nerves.
So we want to look at Bob from a holistic standpoint. And typically that involved having to see a pain physician, a physical therapist that specialized in taking care of people with pain, and a pain psychologist. And then we typically would all come together for a team conference. Let’s assume we’ve done all that. And what we’re doing is an interdisciplinary type of treatment plan for Bob that would include maybe some options around medications. And we have over 200 medications that have shown analgesic benefit now for pain, only 20 or so of which are opioids.
Joe
44:35-44:59
And could you give me your top five, if we were to look at your prescription pad for someone like Bob, what would be your top five non-opioid pain relievers? and let’s get rid of the NSAIDs if you don’t mind because of the stomach damage and some of the other problems that go with NSAIDs. But they might be on that list, Joe. They might be on your list, but give us your top five.
Dr. Sean Mackey
45:00-45:46
Yeah, NSAIDs wouldn’t be on my list, but there’s a selection bias because by the time people have come to see me, everybody’s already tried NSAIDs, right? Of course. Yeah, that’s the easy stuff. So you wouldn’t see NSAIDs high on my list because everybody’s gone through them with some exceptions. You’d probably see duloxetine high on that list just because it’s an FDA-approved medication for musculoskeletal pain. You’d probably see a desipramine on that list, which is a tricyclic antidepressant but effective for pain. You’d probably see one of the gabapentinoids on the list. Gabapentin or pregabalin is on the list. In my hands, You frequently would see me prescribing low-dose naltrexone that maybe we’ll get to.
Joe
45:47-46:05
Whoa, whoa, whoa. You stop right there. Low-dose naltrexone is one of the more controversial treatments. Please, as quickly as you can, explain why it’s such an interesting drug and how some people are benefiting from this amazingly small dose.
Dr. Sean Mackey
46:06-47:27
Yeah, yeah. Naltrexone’s got its perhaps controversy because at the regular dose, it’s used to treat addiction. opioid and alcohol addiction. At lower doses, it works in a completely different mechanism. It blocks some of the neuroimmune systems that are playing a role in pain.
And so it doses like four and a half milligrams or so. We’ve seen in some people rather miraculous benefits for their pain, particularly in conditions like fibromyalgia, complex regional pain syndrome, and some other pain conditions. Why I prescribe it so much is because it is probably the safest medication that I can prescribe. There’s almost no side effects to it. It’s also dirt cheap. It’s been generic for decades. Insurance typically doesn’t cover it, but its cost from a pharmacy is usually very reasonable.
I have no financial relationship with any medication or devices, by the way. But I love its safety profile, and I love the wins in patients when they get them. And not only do they win on pain, but it frequently will improve their sleep, their fatigue, and their mood. So you get this triple or quadruple whammy. What are your thoughts about it? What are you hearing? You said controversial.
Terry
47:27-47:40
Well, I’m assuming that if you are able to improve patients’ sleep and their mood, that also all by itself would improve their pain, wouldn’t it?
Dr. Sean Mackey
47:40-48:29
It does. But, you know, we did some of the initial studies on this. I have to credit Jared Younger, who was with our group at the time with, you know, the initial studies. And we looked at daily assessments of people over time taking this medication. And what we found is the first thing that was improving was typically people’s sleep, followed by their mood, then followed by their pain.
Now, we didn’t publish that data, and it needs to be replicated. And we also know there’s this bidirectional relationship between sleep and pain. Bad sleep worsens next day pain. Increased pain worsens next day sleep. So we have to disentangle all of that. But what I can tell you is all of these seem to get better in some people.
Joe
48:29-48:36
So the controversy, Dr. Mackey, is that we hear from some people who describe what you’re talking about.
Dr. Sean Mackey
48:36-48:36
Yeah.
Joe
48:36-49:02
Wow. Tiny dose, great relief. And other people say, eh, didn’t do much, didn’t do anything, big waste of time. Yeah. And I think what it reminds me is that what for one person is excruciating pain, for another maybe, you know, no big deal. And so we’re all different. I guess that’s the take-home message.
Dr. Sean Mackey
49:02-50:16
Isn’t that wonderful? Yeah. We have to embrace that differences and stop thinking that we’re all, you know, wired the same way. This differences is what leads to the biggest challenge that we have in pain medicine and medicine writ large, and that is on average, the effect sizes, the impact of any treatment we have on pain is rather small. It’s typically on the range on average of about one point out of 10 on a 10 point scale. That’s pretty poor. But within that average, you typically have people that got hit the ball out of the park, amazing wins. And you probably also have people that got worse on that medication.
So this is where in our world, this is what my research is all about. And others is working to develop this field of precision pain medicine, which is to understand those individual differences, take the information and then tailor treatments so that we can be better at choosing the right treatment for the right person in the right context.
Joe
50:16-50:29
Now, you were about, I’d say, three to four medications into your top five or six. What else do you prescribe besides the low-dose naltrexone that for some might be a home run and for others might be barely a bunt?
Dr. Sean Mackey
50:29-51:00
Yeah. So, you know, I will sometimes reach into the sodium channel blocking medications, sometimes like the topiramate. to the, sometimes mexiletine. It depends on the clinical condition that I’m treating, but we try to use medications from different categories that impact pain processing pathways.
Joe
51:01-51:02
You haven’t mentioned ketamine.
Dr. Sean Mackey
51:03-51:19
I occasionally send people over for a ketamine infusion that we do. These days, we do those in a hospital environment. We’re doing those in the clinic. But ketamine can be effective for some people.
Joe
51:20-51:27
And it’s now being tested orally. Terry, you wanted to talk about some of the other non-pharmacological approaches.
Terry
51:28-51:58
Dr. Mackey, you mentioned complementary and alternative therapies. And I did want to ask about acupuncture or cognitive behavioral therapy. Are there any complementary and alternative? As you say, it’s a slightly dated or maybe a really dated term. But we have a general idea what we’re talking about. Are there any of those therapies that are right at the top of your list?
Dr. Sean Mackey
52:00-52:50
Yeah. And candidly, I frequently don’t even think in terms of complementary alternative medicine, but I need a category there that fits outside of the, I don’t want to say the mainstream allopathic or otherwise medical area. And cognitive behavioral therapy would tend to fit more in pain psychology. Acupuncture is more in that CAM focus. I use a lot of acupuncture, and we do acupuncture in our clinic. Mindfulness-based stress reduction, MBSR, has historically been in that camp, although it’s now so mainstream that I’m not even sure it belongs there.
And some have used more of the term integrative medicine as a way to characterize these. But then one other big category that maybe what you’re getting at is nutraceuticals or over-the-counter agents.
Terry
52:50-52:50
Yes.
Dr. Sean Mackey
52:51-53:20
And these are agents that are not part of the FDA regulatory pathway, as you well know. some of these agents have shown in randomized controlled trials to have nice impacts on pain. Such as? Such as acetyl-L-carnitine, alpha-lipoic acid. And some of these agents are actually prescribed medications in Europe. But here- What about CBD?
Joe
53:20-53:29
What about this controversial non, shall we say, psychoactive part of marijuana?
Dr. Sean Mackey
53:30-54:08
Yeah, I think the verdict is still out on that. We need, we’re right at the still early stages of clinical trials in that. These days, they’re still on the small scale. We’re still trying to figure out dosing, delivery, frequency. There are some mechanistic reasons why there may be some value to CBD. I think the story remains to be written on it. Now, with that said, you’re going to find people in the audience that will swear by it. And similarly, there’ll be people in the audience who’ll say, no, tried it. It doesn’t work for me. It’s just like everything.
Joe
54:09-54:35
Right back to the low dose naltrexone. We are almost out of time, Dr. Mackey. And I would like to ask you two quick questions, one about auto hypnosis and how that can be beneficial for some. And then I’d like to get your perspective on how people can find a pain management specialist or program in the two minutes we have left.
Dr. Sean Mackey
54:35-56:03
Yeah. Yeah. Auto hypnosis can be effective in the moment for helping you with pain. I, I love going to treatments that don’t have any significant side effects, first of all, and that fits into one of those categories. And there are a number of these, whether it be auto hypnosis or binaural audio in some people that can be very effective. So give it a try.
It’s going to be like everything else. For some people, it’s going to work great and others, it’s not going to work at all. The last question is one of the challenging ones is how to find somebody. And, you know, ask your friends, you ask your family doc, and otherwise you can get a list of names through the American Academy of Pain Medicine has a website with a list of docs. I think Doximity these days is listing pain docs.
It’s actually a real challenge that we have is how to find high quality pain physicians who can help with your problem. Clearly a nut to be cracked. I think the key message is don’t suffer in silence. Seek out and get good quality help. And if you’re not getting it where you’re being treated, then look elsewhere because there is help that’s out there. And it is an exciting time in this field. We’re seeing more and more treatments and better and better approaches applied to chronic pain.
Terry
56:04-56:21
Dr. Mackey, you’ve laid out for us very clearly that pain isn’t actually pain until the brain processes it and says, ah, you’re in pain. So what is happening exactly in the brain when pain gets bad?
Dr. Sean Mackey
56:22-58:01
Yeah. What we find when there’s this persistent, continuous experience of pain, that circuits in the brain that are there to be released during stress, for instance, or during fear of pain become solidified.
They can become “sticky” and you can get into this “sticky” brain state. And we know that there are specific circuits involved from amygdala to the prefrontal cortex, from areas like the nucleus accumbens, which is involved with reward circuitries and mesolimbic areas into some of these frontal or thought-related processing circuits in the front of the brain, that they can also become solidified. And with these circuit stickiness, if you will, you get a perpetual state of pain. And a large part of what we’re trying to do is break up or reverse these sticky brain states and help return them to a sense of normalcy.
Most of our medications actually work on these brain circuits. All of the mind-body therapies that we have work on these brain circuits. And the beauty of working on these brain circuits is that you also can learn how to take some control of this and help reverse some of those states as well. That doesn’t remove the notion of going out and doing something out in the periphery or in your body. But if you’re going to treat pain, the key is to treat the whole person and not just a particular part.
Terry
58:01-58:02
Thank you.
Joe
58:02-58:57
Dr. Mackey, when people are in pain for a long time, what we call chronic pain, not just for a few weeks or a few months, but oftentimes for years, it can make them angry. I mean, really angry. And it can also lead to depression. And I cannot tell you how many messages we have received from readers of our newspaper column and visitors to our website who say, you know, if they take away my opioid medicine that I have been using absolutely according to the doctor’s instructions for 15 years. I’ve never increased the dose. I’ve never abused it. But if they take that away from me, I will have to contemplate suicide. I’ll be so depressed.
So help us understand the anger and the depression that goes with chronic pain.
Dr. Sean Mackey
58:58-01:01:33
Yeah. So we know that both of those, anger, depression, and if I may, there’s another one that is becoming increasingly recognized, which is social isolation. And indeed, social isolation, we find, is one of the biggest factors contributing to chronic pain.
All of those can be a consequence of that pain. And it takes a terrible toll on the individual. It just sucks their soul dry. And those are all associated with those circuits in the brain that I mentioned before, that can get really out of whack. Now, the second part of what you’re describing is related to the use of opioids.
In my practice, in my opinion, if somebody has been responsibly using opioids for a long period of time, they have tried all the other approaches and those approaches have failed. And the opioids are providing them with increased function and quality of life, my approach is typically to leave them alone and just support that. And I appreciate how they’re feeling because there’s a lot of fear out there around what we refer to as these legacy patients who have been using these medications appropriately. And I think we as a society and as a healthcare profession have to come to grips with this and figure out how to help these people.
Because the message is not simply take them away and don’t give something else back that’s going to help them. What we have found by running that experiment is tragic consequences. People commit suicide, They decompensate, they get worse, or they turn to illicit opioids. And I have seen that over and over again from stories and docs in the community that think they’re doing well by taking people off these long-acting opioids and those people turn to illicit substances.
So it’s a complex problem. It’s going to need a complex set of solutions, but let’s not lose sight of the fact that these are people’s lives. And as healthcare professionals, We’re here to help them. And yes, to do it in a responsible manner, but working in a clinician-patient partnership.
Joe
01:01:35-01:02:15
Dr. Mackey, there is a category of medications. They’re called gabapentinoids. It includes gabapentin and something called pregabalin. And they have never been approved by the FDA for general pain. They’ve been prescribed for nerve pain, for example, after a shingles attack. But as far as treating a variety of pain problems, they’ve never gotten the green light from the Food and Drug Administration. And yet the number one most prescribed pain medicine in America is gabapentin.
Terry
01:02:16-01:02:21
But pregabalin has been approved for treating fibromyalgia. Fibromyalgia, right.
Joe
01:02:22-01:02:57
And so I guess what we have heard is some people love gabapentin. Some people hate gabapentin. They say it makes me spacey. It makes me unsteady. There are a lot of side effects associated with it. And there are other people who say, don’t cut back on gabapentin. It’s the only thing that allows me to function. So sort of back to the low-dose naltrexone story, and that is some people benefit. Some people get no real relief, and some people feel horrible on this drug. Help us understand gabapentin better.
Dr. Sean Mackey
01:02:58-01:06:45
Yeah. You know, gabapentin is in this class of anti-epileptics or anti-seizure medications. It was originally, it has been used by the neurologist, as I mentioned, for seizure. And it was found to have some pain-relieving properties over 25 or more years ago.
It did get FDA approval for postherpetic neuralgia, as you mentioned, which is a terrible nerve-like pain condition after shingles. But we all started prescribing it off-label, and we found that it was having benefit for a variety of different pain conditions. And most importantly, it had a relatively low side effect profile.
Rule number one in being a physician is do no harm. We tend to be conservative. We don’t want patients to get harmed. So this was an easy drug to prescribe, and we still prescribe it all the time. Now, its use is broadened out well beyond the FDA guidance, and that’s pretty typical of medications.
Low-dose naltrexone does not have FDA approval for anything, but we prescribe it off-label. And as you alluded to, individual variability in it. For some people, again, it’s a major win. For others, they can’t tolerate some of the side effects.
I’m very careful about prescribing it to what I refer to as knowledge workers. These are people that are using their brain for a living. I live in Silicon Valley, so a lot of the people I care for, they may be software programmers or engineers. And at the higher doses, gabapentin can lead to word finding problems and some cognitive slowing. It reverses if you reduce the dose or come off it. But for those people, they can’t afford to have their work impacted.
So it’s a medication worth trying, starting low, going slow, and seeing if people get benefit. If they do, great. If they don’t, just come off it. When you come off it, and this is on the new labeling that’s out there, come down slowly. You don’t want to just abruptly stop this medication because it can be associated abruptly stopping with seizures and agitation and increased excitability. And you don’t want any of that. So one of the common medications we use, you’re seeing more and more media out there that are playing up the potential adverse effects related to this medication. And this is now because it has gotten out in so many millions of people that researchers like me can go into administrative databases now and we can study millions of people.
And from that, we can pull out tiny little signals that show increased incidences of bad things with this particular drug. And that’s useful because that gives us a signal that we should look for in better controlled studies. So there are recent studies that show potentially an increased incidence of dementia on gabapentin or an increased incidence of fractures on gabapentin. Well, these are what we refer to as observational studies. They should be treated as hypothesis generating, simply meaning there’s something interesting there and maybe we should look further into it. but by no means should we use this new information to set policies. So, I don’t know, did I get at your question?
Joe
01:06:46-01:07:28
You did. I think we’re back to the individual variability situation. Some people get great benefit, some people not so much, and other people have too many adverse reactions to be able to tolerate it. And so we’re basically recognizing that everybody’s different and everybody responds to some medications in a positive way and others in a negative way and many people in the middle. And that’s why it’s, I think, critical for people to have personalized medicine with a physician who is really knowledgeable about how to treat chronic pain.
Terry
01:07:29-01:07:34
Dr. Sean Mackey, thank you very much for talking with us on The People’s Pharmacy today.
Dr. Sean Mackey
01:07:34-01:07:35
Thank you for having me.
Terry
01:07:37-01:08:08
You’ve been listening to Dr. Sean Mackey, Redlich Professor and Professor of Anesthesiology, Perioperative, and Pain Medicine at Stanford University School of Medicine. Dr. Mackey specializes in treating people with chronic pain. He’s Chief of Stanford’s Division of Pain Medicine. His research strives to translate scientific discoveries into real-world pain relief. Dr. Mackey is a past president of the American Academy of Pain Medicine.
Joe
01:08:09-01:08:17
Lynn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Liederman composed our theme music.
Joe
01:08:36-01:08:43
This show is a co-production of North Carolina Public Radio, WUNC, with The People’s Pharmacy.
Terry
01:08:43-01:09:12
Today’s show is number 1,445. You can find it online at peoplespharmacy.com. The show notes now include a written transcript of this conversation. At peoplespharmacy.com, you can also share your comments about today’s interview. Let us know about your experience with pain and its treatment. You can also reach us through email, radio at peoplespharmacy.com.
Joe
01:09:13-01:09:46
Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. In this podcast, learn what’s happening in the brain when we feel pain. We’ll also look at the anger and depression that can accompany chronic pain and talk about the pros and cons of gabapentinoids. That’s gabapentin and pregabalin to help people feel more comfortable. Look for video with Dr. Mackey on the People’s Pharmacy YouTube channel.
Terry
01:09:46-01:10:07
At peoplespharmacy.com, you could sign up for our free online newsletter and get the latest news about important health stories. When you subscribe, you also get regular access to information about our weekly podcast. We’d be grateful if you would write a review of The People’s Pharmacy and post it to the podcast platform you prefer.
Joe
01:10:08-01:10:10
In Durham, North Carolina, I’m Joe Graedon.
Terry
01:10:10-01:10:42
And I’m Terry Graedon. Thanks for listening. Please join us next week. Thank you for listening to the People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money.
Joe
01:10:43-01:10:52
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Terry
01:10:53-01:10:57
All you have to do is go to peoplespharmacy.com/donate.
Joe
01:10:58-01:11:11
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