Joey Wahler (Host): It can be debilitating. So, we're discussing the connection between chronic pain and mental health. Our guest is Dr. Jedd Audry. He's an adult psychiatry and pain medicine physician for MyMichigan Health. This is Health Dose, a podcast from MyMichigan Health. Thanks so much for joining us. I'm Joey Wahler. Hi there, Dr. Audry. Welcome.

Jedd Audry, MD: How are you?

Host: Good. Yourself?

Jedd Audry, MD: Good.

Host: Excellent. We appreciate the time. So, this is an interesting topic. First, what's the connection in a nutshell between chronic pain and mental health?

Jedd Audry, MD: So in a nutshell, the two kind of access similar areas in the brain, right? So, we call it a bidirectional flow of information. So, the same areas that kind of influence your depression, your anxiety, your mood also correlate with those with chronic pain symptoms and so forth. So, they overlap in a lot of ways.

Host: Gotcha. And so, how exactly do our mind and our emotions influence the way we experience chronic pain, then?

Jedd Audry, MD: I'd say just from an emotional, probably stress level and threat level. So, all those components access different areas in the brain, like I said before. And depending on how you experience pain, your past trauma, this may either intensify the pain signals that you have or lessen them, right? So, some people have a higher tolerance for pain. And others have pretty low threshold, and that can be correlated to fluctuating mood symptoms, anxiety, depression. So, it's not necessarily that emotions or depression or mood symptoms cause pain. But they do influence the signal, basically how loud pain gets over time.

Host: So, you led me beautifully into my next question. In what ways can the brain amplify or calm pain signals, I guess, depending upon your state of mind, right?

Jedd Audry, MD: Yeah, absolutely. So, like I said, I mean, it's bidirectional, meaning it goes sort of both ways. So if you're in a great mood, if you have low anxiety, if you're rested, if you have good sleep, all of that's going to influence your experience of pain and it's going to contribute to kind of the cocktail of hormones and peptides and all this chemical stuff going on in the brain that either make the pain signals worse or make them better.

 So basically, better mood, your experience of pain is probably going to be a lot different than somebody who's in a worse mood, but it's not the mood or the anxiety that causes the pain necessarily. But we see that in chronic pain situations, the two go hand in hand.

Host: Because I guess one thing that might be at play here, am I right, is that if you are having a mental health issue, like anxiety, depression, sometimes a part of that is overthinking things, right? Overanalysis being, hypersensitive to certain things, and that can include physical pain, yes?

Jedd Audry, MD: Yeah, absolutely. There's something known as hypervigilance, right? And so, what happens is people will scan their area for past trauma, things like that. Well, you can correlate that to chronic pain as well. People will tend to scan their bodies and different body parts and experience pain at a level that may not necessarily be there from a physical perspective. Nobody can just sort of point it out or get some imaging, but they certainly feel the sensation at a threat level themselves in their body. So, increased vigilance with regards to exercise, increased vigilance with regard to bumping into things or even having procedures done, which is a big point there.

Host: If we're feeling good about ourselves, thinking positively at a given time, I presume that means the odds are much better, that we'll be willing to fight through some pain, accept it more, and not make it more of an issue than it needs to be. Am I right?

Jedd Audry, MD: Absolutely. So, there's a treatment in psychiatry called acceptance commitment therapy, right? So, we use it for a lot of patients with chronic pain symptoms or with some debilitating condition where the goal is not necessarily to combat the pain or make it go away. And I think that's an important point. Some chronic pain symptoms are here to stay, right? And no measure of procedures or anything like that is going to change how long you have these symptoms or how intense they are. However, if you accept your condition, then it only then can you kind of move forward and take the steps that you need to take to either do exercise, do therapy, start some medications, or really just meditate, and really have sort of a mind body thing going as far as like connecting with your pain symptoms and relieving them.

Host: You make a great point because I would imagine, for instance, as people get older and start to take on more chronic pain, typically, it's different than when you're younger because much pain when you're younger, of course, has a greater chance of being treated, going away, at least easing. Whereas when you're older, some things are just not going to get a whole lot better-- they're not going to go away. And I guess your point, Doc, is that the sooner you can accept that that's the case, the more you can move on because you're not living in false hope waiting for something that's just not going to happen, right?

Jedd Audry, MD: I think that's accurate. That's definitely consistent with the message that I have. It's interesting though because older patients, they've gotten to the point where they are where they've had the chronic arthritis, they've had their leg pain, the hip pain. They are, mentally, in a lot of ways more accepting of their condition versus a young person that comes in and that is used to a certain level of activity. And really, there's a lot of friction with whatever. Let's say they were in a debilitating car accident, that now changes their quality of life, changes what they're able to do. It is a real uphill battle. So, I think for younger people versus older people as far as accepting their condition to kind of move forward with therapy and treatment.

Host: Okay. Very interesting indeed. So, having said that, how often would you say chronic pain leads to the start of depression or anxiety? Because to your point, if you're a younger person and you've had something come out of nowhere, like an accident, et cetera, then that's a huge adjustment, not only physically but mentally as well, right?

Jedd Audry, MD: Absolutely. I, I think, depending, and we're talking about acceptance, right? And we're talking about realistic expectation, something I call expectation framing, right? So, with a young person, and let's say they've got a debilitating spine condition from an accident or something like that, now the realistic expectation is that they may or may not be able to ambulate or move around the way that they did before. I think to the extent that we address that and address that acceptance then and there really makes a difference in terms of their long-term outcomes. It doesn't always cause mood symptoms or mood symptoms don't always cause the chronic pain. However, getting your mood symptoms, getting your anxiety, getting your depression under control gives you a better shot at better treatment outcomes, I think, for pain.

Host: So, what are some non-medication treatments for pain and the moods that often come along with it?

Jedd Audry, MD: Yeah. So, non-medication treatments, and I love that because we do use a lot of pain psychology. The folks that I've worked with before have done things like cognitive behavioral therapy, which is basically like your thoughts influence your emotions, influence your behavior. Acceptance commitment is one of those. I think non-medical isn't taking medicine or taking treatment. Even just an active lifestyle, moving within the bounds of your range of motion or really like trying to do that on a daily basis and being consistent with that is a form of therapy, is a form of healing. Having good support systems and good support structure from friends and family, I think, is of the utmost importance, because that changes your mood, changes your perception of pain, and leads to better outcomes in general.

Host: Gotcha. And what's interesting about what you do, it seems, is the fact that often in psychology, am I right? You're treating people that have an issue with something that is hard to put a finger on, is hard to define. Whereas here, it is very clear there's chronic pain. So, how does that make your approach in teaching and imparting some of this wisdom, how does that make it different from what we normally think of as psychotherapy?

Jedd Audry, MD: Yeah, that's a fantastic point. I think I, you know, have the opportunity now to be able to do sort of this teaching at a patient level to help them understand, "Hey, look, if there's depression, if there's mood, if there's anxiety symptoms, chronic pain may or may not be associated with that, but it's good for us to try to address those mood anxiety, mood fluctuation, depression symptoms beforehand in addition to doing the pain treatments as well. So, it's an opportunity for us to discuss what that nexus is, what that bridge is between psychiatry, between psychology, and also chronic pain symptoms as well.

I think patients are pretty receptive to that when it comes to understanding, especially if they want better treatment outcomes, right? So, somebody living with, let's say, complex regional pain syndrome, which is not something you can necessarily put a finger on, we understand the broader pathology of what's going on, but we don't really have a clue as far as like what is going on from a physical level.

So, it helps to be able to have a mental model to say, "You know what, I'm just going to accept what's happening here. I'm going to make strides and partner with my provider, partner with my physician, partner with my physical therapist to improve my symptoms," but not necessarily thinking that they're going to go away ultimately. So, back to the acceptance side of things as well.

Host: What would you say are some of the newer interventional options for pain relief that are available now or maybe coming soon on the horizon?

Jedd Audry, MD: Yeah, I think neuromodulation always a big one, right? We do spinal cord stimulation as sort of kind of the last resort for patients that we've done other procedures on, injections into their back and so forth. And now, that artificial intelligence is coupled with that, we're noticing better outcomes for patients. In other words, we're adapting to their quality of life, to their function, to their basic average daily function. And the spinal cord itself-- the stimulator itself-- can dynamically approach the pain symptoms in ways that we couldn't necessarily target in the past. So, that's one of them.

Psychiatry interestingly has a treatment option called transcranial magnetic stimulation, which we use for depression and anxiety. However, like I said before, there's overlaps in the areas of the brain, the dorsal lateral prefrontal cortex, the amygdala, different areas in the brain where they share common signals with pain. We can target those areas specifically with magnetic signals. And sometimes we see it helps both depression, pain, the combination of the two. And then, we do the sort of bread and butter in back injections, facet injections, things under ultrasound guidance, anything that gives us a little bit more precision in terms of targeting if we have an area to target.

Host: So naturally, every patient is different, as you well know. But generally speaking, what can patients expect from these types of treatment? I'm sure many wonder, "Will I ever be pain-free?" But I guess, to your point, as you've said several times during our chat already, a lot of that comes down to acceptance, because sometimes you just don't know, right?

Jedd Audry, MD: Yeah, absolutely. Now, I will say the majority of people do experience an improvement in their pain symptoms. So, it's important to have that conversation beforehand. And I think we try to do that with every patient going into a procedure, saying, "Hey, look, this is not a cure-all." In other words, we're not going to go in and remove the pain that you have in your spine, or remove the pain that you have in your leg, your toes or the numbness. But we are going to see if we can get improvements, and I think gradual improvements over time, as long as the patient understands that, you have a happy patient, we've hit sort of consistent goals along the way that are realistic. And we can look forward to working with this patient for the long term, because it's not a just one and done. We want to create kind of a long-term relationship with that patient and say, you know, "Over time, we can provide relief, be it transient, be it a little bit longer term. I've seen people that we've expected to get six months of relief, end up with like three years of relief." That's true in a lot of cases.

And then, there's some people that we expect a little bit longer and maybe they take shorter. So, part of it is establishing and building that trust, building that relationship with the patient to say, "Hey, look, we're in this with you for the long term." And I think pain patients appreciate it and I think pain patients with psychiatric comorbidities appreciate that as well, because oftentimes providers don't make a space for that. And I think pursuing that is really good for them.

Host: Absolutely. Couple of other things for you. How about helping to manage these flare-ups many of us have and mood symptoms on our own? Is there a little tip or two you can give us to get started down that road by ourselves?

Jedd Audry, MD: I think, without medication, let's say you're just sort of on your own, you're kind of out in the wild and something happens and it upsets you, right? I think the first thing to do is to stop and just sort of breathe. It's something called box breathing, right? Where you kind of an inhale for four seconds, hold your breath for four seconds, exhale for four seconds, hold for four seconds. And what it does is it actually produces a physiological effect, it activates your parasympathetic, which is basically a fancy way of saying just the calming nerves that are in your body that allow your heart rate to go down in really stressful situations.

I would say seek support as soon as possible. So, let's say something happens, involve people that are in your close inner circle. It's important to have that support. And I think that alone will help to alleviate and assuage a lot of those pain symptoms and comorbid psych issues that happen.

Host: How about if experiencing chronic pain, at what point is it time to seek referral to a specialist like yourself? Where's the line there?

Jedd Audry, MD: I think if it's affecting, if it's encroaching on your day-to-day activities in a way that is really debilitating, I would say the minute you start to feel like, "Hey, gosh, I can't rake the leaves the way I want to, I can't go on this bike ride that I enjoy," I think even a conversation with a pain specialist to just pinpoint. Because a lot of times, you know, patients will come in and say, "Hey, I got a pain right here." And it may be that we may need to escalate that to a neurosurgeon or to another specialist. So, we're a good sort of waypoint, I think, for patients in terms of just finding out if there's anything to this. It might be that you come in and say, "Hey, I've got this little pinch right here," and it's really nothing to it. We refer them to a physical therapist and they really just need to get their muscles stretched or get some massage therapy or something like that, but it may be something more. And so, I think the minute you start noticing that there's an impact to your day-to-day function would be the right time to come in.

Host: And then ,in summary here, Doctor, what would you say in the way of hope and optimism here for those joining us that are living with chronic pain? I guess your message really here seems to be that there are things that can be done or at least tried, right?

Jedd Audry, MD: Absolutely. I think living with hope is obviously better than than not, right? Optimism is kind of a rare thing I find these days, but I'm super optimistic when I approach patients. And I think that there's like a placebo effect, but I think it actually has a real impact on patients when you approach them and you say, "Hey, look, I'm going to approach this expecting the best." Realistically, things may happen along the way that are not necessarily favorable. It doesn't fit in with what we anticipated, but I think approaching every single procedure, approaching every single patient with a hopeful outlook is better than not doing that at all.

And I think patients that are honestly more predisposed to having hope and so forth end up doing a lot better. And for that matter, patients that aren't necessarily predisposed to depression and anxiety and they have a lot of support in their lives, end up doing a lot better. So, my job as a provider and in our relationship dynamic with the patient is to be that point of hope for them and to make sure that we orient them towards the compass of hope, because I think it leads to better outcomes overall.

Host: Well, I know I feel better already just talking to you the last few minutes.

Jedd Audry, MD: Awesome. Very good.

Host: Well, folks, we trust you are now more familiar with the chronic pain and mental health connection. Interesting stuff indeed. Not something you often hear discussed publicly. So, a great topic indeed. Dr. Audry, keep up all your great, unique work and thanks so much again.

Jedd Audry, MD: Thank you.

Host: Absolutely. And keep in mind, Dr. Audry does practice full-time with MyMichigan Spine and Pain Program at MyMichigan Medical Center. And for more information, please call 989-356-8060 or visit mymichigan.org/spineand-- the word A-N-D-- pain. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. And thanks so much again for being part of Health Dose, a podcast from MyMichigan Health.