Chasing Life

You know, it's not lost on me that many of us walk into a doctor's office only when something hurts. After all, pain is one of the body's first and most primal ways of saying, hey, pay attention. Something's going on here. Something is wrong. But the thing is, even though we all experience pain, words often fall short. Sometimes we lack the vocabulary to truly describe what we are experiencing. The pain of burning your hand on a hot pan; that is not the same as a broken ankle, even though we might say 'ouch' to both of them. A pounding migraine is different than a suddenly dislocated shoulder. And chronic pain, which more than 51 million people experience, that is really a completely different beast than the acute pain most of us are familiar with when we, for example, stub our toe. Pain can be so hard to describe. That's my point. And yet for so many people, it's a major part of their lives. After years of thinking about pain, after treating pain, after seeing my friends and family experience pain, I've come to believe that talking about it and really digging into it makes a big difference.

You know, pain has always been my ultimate teacher.

That's my friend, Rich Roll. We've been friends now for close to 20 years. He is a podcast host, an author, and an Ultraman who is no stranger to pain.

Like all of the transformations and changes that I've made in my life have been a consequence of pain trying to tell me something and me refusing to listen and the pain growing more and more intense until whatever pain I was experiencing exceeded the fear of making the change or doing something different.

Between the insane physical demands of endurance sports and then recently recovering from spinal fusion surgery, Rich has been through a lot, but he's also one of the most resilient and thoughtful people I know. And that's why I wanted him to join me on the stage the other night to talk about my new book called "It Doesn't Have to Hurt." Because one of things I've learned while researching pain is this: The brain actually creates pain, but it can also drastically reduce pain. And maybe even eliminate pain. And I know that sounds hard to believe, but we're gonna get into the science behind this so that suffering does not have to be an option. I'm Dr. Sanjay Gupta, CNN's chief medical correspondent, and this is Chasing Life. The conversation you're about to hear took place at the 92nd Street Y in New York City, and we had a wonderful live audience. Hi, everybody.

So happy to be here with my friend, Sanjay, tonight to celebrate his new book and have, I think, a really important conversation around pain, perhaps a conversation long overdue. And I thought it would probably be wise to define our terms here a little bit. When you say pain, what are you talking about? What is pain?

Pain, I think, is one of the most mysterious sensations that we humans experience. If I can't measure it, if I can define it exactly, if it's so variable, not just between people, but even within the same person, my pain on a Tuesday could be very different than my pain a Wednesday, then I think it's presented a real challenge for the medical world to say, what exactly are we treating and how do we define success? Having said all that, pain is an unpleasant physical and emotional experience. And the emotional part of the definition was something that was added rather recently.

What's interesting about pain is that it is this phenomena that defies our capacity to measure it. And we're in 2025. We have extraordinary technology, and all of these advances in medicine with diagnostics and scanning and yet pain remains this very elusive concept. To your point, it's this subjective experience that is very confusing to get our arms around and really kind of like hone down on what it is and what it means.

I think with pain, the holy grail is being able to measure it in some way, to being able to quantify it, being able truly understand someone's experience, and then also to be able to measures success. The story about what's going on now in San Francisco with these researchers really blew me away. They were trying to get at this idea of can we measure pain? And they found these patients who had chronic refractory pain syndromes, they're called CRPS. They had people who had had thalamic strokes, and as a result of that had this pain on one side of their body and just got no relief. They took them and basically put in two arrays of deep brain stimulators on either side of the brain, right side, left side, and basically just put 140 different electrodes in, and frankly just listened to the brain for weeks. And to give you context for that, they're about the same number of neurons in the brain as there are stars in the sky. So this would be like basically pointing a telescope up at the sky and just seeing what you see. Now what the patients would be doing is when they had pain, they would basically push a button or record it and then they'd go back using big data analysis and say what did we see in the pain at the time this person was experiencing pain? What kind of energy transfer did we see? And then they would slowly zero in on that and say, okay, every time this person has pain, we're seeing a star way off in the distant galaxy fire a little bit. So let's start zooming in on that star. And they zoomed in more and more on that particular star and they got to the point where they could actually, when something happened in that star, even before the patient experienced pain, they would start to see that energy change in the star and they could measure how much of an energy change in the start was happening. And then they could basically give a little stimulation to the star before the person actually ever experienced pain. So think about that. So what we're basically saying is that pain is in the brain, you can find it, you can measure it, you can predict it, and then you can interrupt it. In some ways, it was the perfect biomarker. This doesn't mean people are going to get brain surgery for pain, but what it has taught us is that all these things are happening in the pain, and they're predictable and interruptible. So I think it's going to pave a whole new path for how we think about pain in the future.

I mean, yeah, that does seem to be a pretty monumental breakthrough. What wasn't said was the fact that there is no central pain center in the brain. Like, you know, there seems to be a center in the brain for everything, and yet, when it comes to pain, this universal experience, there is not discreet location within the brain that people like yourself can point to and see when it's activated or not.

I think for a long time we believed there was, and there was a lot of focus on that. There was even these early operations performed of people with refractory pain where they would try and target that cortex and maybe even try and cut it or stimulate it in some way, but it didn't work really well because there is no constant pain center for everybody. It's not in the same place for everybody, but we also know that the pathways for pain go through all these different areas of the brain, a big one being memory. So if you've had a pain experience before, and now you're having another pain experience, your brain is immediately evaluating this new pain experience through its memory stores. This is familiar. I've experienced this before. Is it going to hurt? Did it hurt last time? How much did it hurt? All these sorts of things. So it's remarkable how quickly the brain starts to evaluate all of that. All pain is in the brain. And 40 years ago, John Sarno, wrote a book about back pain. He was getting at this idea. People refer to it as psychosomatic. But I think what he was trying to get at was this idea that the pain is in the brain. And if you don't, the brain decides you don't have pain, then you don't have pain. But the flip side of that as well is if the brain decide you have pain then you have to pain. And it can even occur in a limb that no longer exists, which is phantom limb pain. And I think the data around phantom limb pain taught us a lot about this, because the brain is the ultimate regulator of all this, both in terms of not having pain or diminishing your pain, or creating it and worsening it. And a lot of that is very dependent on your expectations of pain. A lot of it is dependent on things that seems totally arbitrary, adverse childhood experiences, what you had for dinner the night before, whether you had a tough call with your mom. Whatever it might be, those things can greatly determine what your pain experience is gonna be in the moment. That's all coming from the brain.

There's something very empowering about that. It gives all of us agency to develop a relationship with our own pain and go on a journey to try to find ways to heal it or ameliorate it, right? But when you bring up Sarno and this idea that it is this subjective experience, it's also a very confronting idea. Like if we do have agency to develop this relationship with our pain and figure out practices and modalities for having a different experience with it, that is incredibly encouraging.

When I heard this, when I really started to do the deep dive into the research, I looked at that as an opportunity for more potential relief for people. You know this well, I mean, you've gone through this.

I had a spinal fusion surgery about four months ago. I had been dealing with chronic lower back pain for more than a decade.

2012.

Yeah, I mean, Sanjay's aware of this. I would hit him up from time to time.

I was his guy.

So essentially, I'm also an athlete and I sort of trained through chronic pain and just was doing everything in my power to avoid surgery. I live in Los Angeles, and if you're in Los Angeles and you tell somebody you have some kind of chronic pain, God forbid a lower back issue, everyone will tell you that you have to go see their guy. Everyone's got a guy. And there's a lot of savior complexes out there. Many of the types that I explored are you talk about in the book. I saw all kinds of interesting people who tried to help me. And some were helpful, some less so, but I was cultivating this relationship with my own pain. In my scenario, ultimately, surgery was an inevitable conclusion for the condition that I had, which was a grade two spondylolisthesis. I had a vertebrae that was compressing the nerve roots and out of whack, and the only way to fix that really was through surgical intervention. And so now I'm in this healing process, and that's been a journey with a different kind of pain. And when I was in surgery and in the aftermath of that, the only questions I got about pain were, how's your pain from a scale of zero to 10? Like, that's it. Everything else is super high tech. But when it comes to pain, that all they got, you know? Which is crazy, right? But in my life experience, and I'm just speaking for myself, pain has always been my ultimate teacher. Like, all of the transformations and changes that I've made in my live have been a consequence of pain trying to tell me something. And me refusing to listen and the pain growing more and more intense until whatever pain I was experiencing exceeded the fear of making the change or doing something different. And in this healing process that I'm in right now, I'm really intentional about my mindset and I'm approaching the challenges that I have right now as opportunities like. Oh my God, I get to wipe the slate clean and start over and what would it look like if I could rebuild my body from the ground up and do it right and make it bulletproof as I go into my older years or I can relearn how to run and learn how to do it the correct way. How often in your life are you in a position where you have to stop everything you're doing and you can't do anything else except be with yourself and life's greatest truths are found only in the present moment. But. We distract ourselves, and here I have this amazing opportunity where the world is giving me permission to do that. And I don't want to let that opportunity pass without learning those lessons.

I love you, brother. That was really good. And how are you today, though?

I feel great. I'm at the 92nd Street Y talking to Sanjay Gupta. Thank you. I just started PT, like I'm four months in and I only started PT a week ago. Like all I'm allowed to do really is walk and I have a couple little exercises that I can do. And yeah, I have discomfort. My left foot is entirely numb and I have numbness up my leg and I could focus on, you know, feeling fragile and like I can lament that and be resentful or like I shared earlier, treat it as a positive experience as an opportunity, right? And so. That's what I'm doing, and because of it, I get to talk to you about pain here. Like, talk about mysteries. You know, the fact that we're here doing this together, so I'm doin' great, that's the answer to that.

That's fantastic. I love hearing that, that's really interesting.

Because pain, to me, Sanjay, like I know that your focus is on chronic physical pain, but the pain that has been most difficult for me to master and transmute and overcome have been like emotional pains. And if you're an addict in the throes of addiction and you're craving, like that's a pain. And there's a physiological aspect to that that's very different from lower back pain. But is it really all that different? It's a subjective experience that you're having, and that applies, I think, to grief, sorrow, depression, and thinking about pain as this holistic sort of thing and a bilateral relationship between the physical and the mental and the emotional.

'And understanding that two-way connection between the physical and the emotional can transform the way we treat chronic pain. We'll discuss that right after the break. There is no question that probably using just one term, pain, is short-changing the conversation. In fact, when I was writing the book, I almost thought, I wish there were different terms for this. Acute pain is almost a distinct entity than chronic pain. So again, acute pain is something that we're probably all going to experience in our lives. But for some people, it becomes chronic. And I think that that is the real question. Like in your case, you had pain since 2012. You clearly were in chronic pain And you needed an operation, I saw your scans, but the idea that your chronic pain needed to be treated differently than your acute pain, I think is really important. And what does that mean? As someone said to me, a guy named Robert Jensen at Mayo Clinic, he said, chronic pain never occurs in isolation. It always comes with baggage attached. And that baggage can be a variety of things. Again, it can be depression, anxiety, whatever it might be, but so often, when we're treating chronic pain, we are treating it like acute pain, even though they are nearly distinct entities. But I think we are getting to the point where ERs, if someone comes in with chronic pain they might see a psychologist at the same time they might a pain doctor, which I think could be really, really helpful. But, it is truly a bi-directional relationship. And I'll use the example of sleep to sort of make this point. I think for most people who have pain and also have poor sleep, the general sort of guidance I think that they've probably heard is if you can get your pain managed better, it'll probably improve your sleep. And I think that fundamentally makes sense. But if you start to look at what the data really shows is that people who instead focused on their sleep first they were able to have much greater success in managing their pain. So that is the bi-directional. Yes, the pain can exacerbate your sleep problems, but poor sleep can exacerbated your pain. Same thing with depression, anxiety, all these other things. But I think in a monotherapy culture where we want the quick fix, I want to just be able to fix both problems at once. I'm going to focus on the pain. That'll help my sleep. And again, I get that. I've had pain episodes in my life where I was sort of thinking the same thing. There's some wisdom there. But the idea that all these things are bi-directional, because the brain makes it that way, and if the brain is now processing a pain experience in someone who's gotten good sleep, it's likely to say, hey, this is a more relaxed state, whatever it might be, I'm gonna mitigate the pain as a result of the better sleep. Someone's inflamed because of depression or anxiety, addressing those things can mitigate the pain, which isn't, you know, I think, how we've thought about things very much. We've always thought about it only in a one direction sort of way.

Can we talk a little bit about neuroplasticity, this idea that neurons that fire together wire together, right? And we can change these patterns, but there's also a less discussed negative aspect to this.

'I was spending time with these neuroscientists and one of them made this sort of off-handed comment that people who have really good memory are more likely to have chronic pain. What is the relationship here between memory, really good and chronic pain? And they went on to say that when you think about chronic pain, in many ways from a neuroscience standpoint, it is sort of like a memory that cannot be extinguished. That was the exact language that they used. Memory that cannot be extinguished. In some ways, it sounded like they were describing post-traumatic stress to me. And chronic pain does have a lot of components that are similar to post-traumatic stress. You don't have anything that should continue to cause you pain past three months or six months, whatever the number may be. So why do you continue to have pain? It's not like you continue have an injury, so why is the pain still there? The lesson has been learned. But you stubbed your toe, don't do that again. Why does the loop keep getting played over and over again? That is, again, is one of the great mysteries. For some people, they just tend to play that loop over and over again. And interrupting that memory loop is actually one of strategies to try and combat chronic pain. It's a totally different way of thinking about things. But what do we do instead? Powerful pain medications, procedures, things like that. Again, I wanna be clear, in your case, and I happen to have looked at your scans. Is very different because you had an anatomical problem where your bones were actually slipped one on the other and as a result they were pressing on the nerves that was causing your pain. But for people who have lower back pain with no identifiable anatomical problem, often times it is a memory that cannot be extinguished. So focusing on that makes a huge difference. That is a component of neuroplasticity. You've just started to fire those neurons together and now it just, so you kinda almost have to break that loop.

Yeah, I mean what Sanjay's referring to, I mean it was a crazy experience right after I had my surgery in the, you know, the sort of day one, day two, day three, I'm still in the hospital, and you know I'm Mr. Endurance Athlete Guy, and I thought like, well I have this, I'm gonna be out of here, this is gonna be no problem, and I had an extreme pain experience, much more extreme than the typical patient, which was confusing to me. And, my surgeon at some point had to sit me down and give me a hard talk like my dad or something like that. And he went through this whole thing about the subjective experience of pain and how I was having an extreme version of it, but I had to push through it to overcome whatever neural pathways were creating that experience for me to prove to my brain that I wasn't in danger because I couldn't sit up, I couldn't do anything without just extraordinary pain. I believe that my brain was trying to protect me. It's like, oh, if you move that way, you're gonna break, right? And once I could change the story and say, you're not broken, you're actually more stable than you were before. And yeah, it's gonna hurt when you move that way but you're no harming yourself. Very quickly, that experience, the intensity of that experience dissipated significantly. And that was a remarkable thing. When you first reached out to me about having this talk. And you were like, how was that? And I said, oh, I learned so much about the subjectivity of this experience because of what I just went through. And you're like, oh that's exactly what I talk about in my book. But it was profound.

Our expectations and our experience are inextricably linked. This was a teaching for me. You know, there were all sorts of teachings, but this idea that how we come to expect certain things based on all the things that we've talked about, past experience and all that sort of stuff, will dramatically affect what our experience is going to be. So it's pretty profound stuff. You know the other thing that someone said to me when I was working on this, is that you know there's a difference a little bit between suffering and pain. In fact, the equation that they sort of attach to it is that suffering equals pain times resistance. So the idea that the more that you're resisting this, it's actually increasing your overall suffering.

Speaking of resistance, you mentioned to me earlier today that you were reluctant to write this book. Can you talk a little bit about what that was about?

'Yeah, you know, first of all, I never have a real sense of what is already out there in terms of these books. You know, I knew that this was a fascinating topic, but I wasn't sure where we were sort of in terms of people's interest in this. And also this idea that the opioid epidemic had really hijacked the conversation for a long time, for a quarter century. If you talked about pain, it probably had something to do with opioids and the opioid crisis and addiction and all these different sorts of things. And I didn't want to write that book. I felt like that had been done. And then there was this idea that I knew where this research was going was really showing how much of pain really was in the brain. And I knew that that was a provocative topic. The conversation often goes to this idea, that you're saying it's all in my head, minimizing or diminishing people's pain experience. And that was not at all my intention. But I was worried that it could get perceived that way. So those you know, those were some of the the misgivings. But I think what I think I was really sold on when I started to write this was that there was all these other modalities for treating pain, some of which were things that have been around for a long time. And I spent time at this emergency room here in Brooklyn, Maimonides, and they created these what they call opioid-optimized shifts, opioids as a last resort instead of a first resort. This is a fascinating hospital, by the way. They speak 120 languages there, so super diverse population of people, very busy, level one trauma center. People come in for all sorts of things. They've been shot, they've been stabbed, they've broken their hip, they have kidney stones. Whatever it might be, pain is often what's bringing them there. And they went to this opioid optimized model. And all of a sudden they started doing things like nerve blocks, for example, for a broken hip. I saw a 76-year-old guy who came out with a broken hip. Absolutely did not want opioids, it was last resort, and got a nerve block, and his pain score went to a zero, and he never required opioids. I saw a woman who came in with bilateral knee pain who got a dose of virtual reality. They put on virtual reality goggles. Some of this sounds silly, maybe, to people, and yet her pain score dropped from an eight to a three within 20 minutes. She was on a nice trip to an Indonesian beach, some of her virtual reality. Ketamine. Ketamine is something that people have heard of. They've heard of it as a club drug or as an anesthetic going back to Vietnam. It is now being used in ERs to treat acute pain. Point being, Rich, that opioids, they hijack the conversation not only among patients but even among pain docs who believed that if I don't give patients opioids, they're not gonna be satisfied. And what they found as they started these opioid optimized programs was that it was quite the opposite. There was a reluctance for people to jump into opioids as a first-line therapy. And with these other modalities, patients were quite satisfied with their pain scores. And I think that really got me interested. It wasn't a new story. It was an old story in some ways. It was a pre-opioid story, but it was a story that we had forgotten.

'Essentially, the book flips the paradigm upside down. Rather than opioids first and then we'll look at all these other things, you're basically saying a lot of these mind-body modalities should be the first line of defense.

Yeah, I mean, look, the body can do a remarkable job of healing itself if we allow it to.

To be continued. All right. Ladies and gentlemen, Dr. Sanjay Gupta.

And Rich Roll.

Thank you.

Rich Roll, thank you.

Thank you for showing up.

'Thank you for coming. That was my conversation with ultra-endurance athlete, podcast host, author, and perhaps, most importantly, my friend, Rich Roll. Thanks to 92nd Street Y for having us, and thanks to all of you for listening. We'll be back next week.