So if you whack your thumb with a hammer, you think pain is in your thumb. Physicians have a more sophisticated understanding. We know that it's an alarm that goes, on nerves, to your spine, where it is translated to your brain, and pain actually happens ... somewhere. It's a little vague.
如果你用锤子捶你的大拇指, 你以为疼的是你的大拇指。 医生有一种更复杂的解释。 我们知道,这是一种警报, 通过神经传到脊柱, 然后再传导到你的大脑, 疼痛其实发生在…… 某个地方。 有点说不清楚。
We actually only get two days of pain education throughout all of medical school, so ... In fact, the only pain lecture I remember from the '90s was in a dark room like this, after being awake for 30 hours and hungry, and finding out our noon lecture was sponsored by OxyContin. We got pens, we got great lasagna, and they had very cool slides that showed pain stopped by opioids. And we learned that home opioids aren't addictive, and if you stay ahead of pain --
我们在医学院时, 其实总共只上过两天的疼痛课。 其实,我唯一记得的一节疼痛课, 还是 90 年代, 当时就是在这样一个比较暗的房间里, 连续 30 个小时保持不睡不吃后, 发现我们中午的课 是奥施康定赞助的。 他们给我们发了笔, 提供了很好吃的千层面, 做了一些非常酷的幻灯片, 展示了阿片类药物如何止痛。 我们了解到家用阿片类药物 并不会让人上瘾, 如果你能赶在疼痛袭来之前——
(Laughter)
(笑声)
you can keep your patients pain-free.
那你就可以让你的病人免于疼痛。
And beyond the obviously egregious marketing, I think it was framing "pain-free" as the goal that has destroyed countless lives.
除了很明显的极端营销外, 它标榜以“无痛”为目标, 而这个目标毁掉了无数生命。
My friend's son Christopher started having severe abdominal pain during this "no-pain" era. Eventually, he was diagnosed with a colon disease and had surgery his senior year. They sent Christopher home with 90 OxyContin, and then 90 more, and then, as the pain started getting faster and faster ... Uncontrolled pain is terrifying. So when his ran out and his friends' medicine cabinets ran out, Christopher tried heroin. And Christopher Wolf lost his battle with substance use at age 32.
我朋友的儿子克里斯多弗 开始有严重的腹痛问题, 正是在那个“无痛”的时代。 最终,他确诊为得了一种结肠病, 高三的时候做了手术。 克里斯多夫弗出院时, 医院给他开了 90 盒奥施康定, 之后又开了 90 盒, 再后来,随着疼痛 发生得越来越频繁…… 不受控制的疼痛是很可怕的。 所以当他的药吃完了, 他朋友家的药也吃完了, 克里斯多弗开始尝试海洛因。 克里斯多弗·沃尔夫 最终死于过度使用药物,终年 32 岁。
So did we misunderstand pain? What if pain isn’t an alarm to silence but a learning system for survival? TED pose.
是我们误解了疼痛吗? 假如疼痛并不是一个 需要你关掉的警报, 而是一个生存学习系统呢? TED 专属姿势。
(Laughter)
(笑声)
(Cheers and applause)
(欢呼、鼓掌)
Pain is every organism's primary learning system for survival. I mean, it's like, "Ouch. Don't touch that." Or, to paraphrase "The Princess Bride," "Life is pain, Highness." "Pain-free" was marketing, and it made physicians think that one pill could solve pain. It still makes people feel like you can't be happy if you have some pain, and we now know that if you want to move past pain, it takes work. Setting the bar at "pain-free" was too high. Plenty of people could have been more comfortable, but they gave up because pain-free was out of reach.
疼痛是每个有机体的 主要生存学习体系。 就好像疼痛在告诉你: “啊,痛!别碰那里。” 或者改动一下 《公主新娘》里的台词: “人生就是疼痛,殿下。” “无痛”是营销, 让医生觉得一片药 就能解决疼痛问题。 这依然让人觉得, 如果你哪儿痛的话, 就不会快乐, 现在我们知道, 如果你想尽快摆脱疼痛的话, 需要花些功夫。 “无痛”这个标准太高了。 很多人本可以更舒服一些, 但因为无法达到“无痛”, 于是他们就放弃了。
We have really good new information that I'm going to share, and so from now on, I want you to think about pain as a Venn diagram, with physiology, fear and control. I'm going to tell you how each of these can give you power over pain.
我有一些好消息要分享给大家, 从现在开始,我希望你把疼痛 想象成一个文氏图, 里面有生理学、恐惧和控制。 我会告诉你每一部分 如何帮你克服疼痛。
Right now, I'm translating these, in my research, into a low-back pain device to reduce opioid use. But 20 years ago, I just wanted to have a fast cure for needle pain, for IV access and my kids' shots. I was driving home one night after a graveyard shift, and my hands were vibrating on the steering wheel, because we needed to get the tires balanced. I was ignoring that to think about pain, and when I got home and reached for the door in my house, my hand was numb. Vibration. So I burst in, my Boy Scout husband grabbed some frozen peas, and we had ourselves a genuine eureka moment, where cold and vibration blocked pain. Over the next decade, I found the right frequency to block pain, I got a grant, and I created Buzzy, which is vibration plus ice ... in a bee shape. And you put it on your arm when you’re getting an injection. And to date, 45 million needle procedures had decreased pain, and over 80 randomized controlled trials, independently, all around the world, have been published. But ...
目前我也正在研究把这些概念转化到 一种应对腰背痛的设备上, 以减少阿片类药物的使用。 但 20 年前, 我只想快速解决打针的疼痛问题, 包括静脉注射和我孩子打针时的疼痛。 一天晚上,我值完夜班开车回家, 我握着方向盘的手在颤抖, 因为我需要让车轮保持平衡。 所以我当时没有注意到痛, 等我回到家,准备伸手开门时, 我的手麻了。 因为(方向盘的)震动。 于是我冲进家里,我那参加过童子军的丈夫 拿来了一些冻青豆, 突然,我俩灵光乍现, 发现低温和震动可以止痛。 在接下来的十年里, 我发现了止痛的震动频率, 我拿到了一笔经费,做出了 Buzzy 这款产品, 它就是利用震动加冰…… 是小蜜蜂形状的。 你打针的时候 可以把这个小蜜蜂放在手臂上。 到今天为止,在全球范围内, 我们减轻了 4500 万次打针时的疼痛感, 进行了 80 次独立随机对照试验, 并公布了相关情况。 但是……
(Cheers and applause)
(欢呼声和掌声)
At about 30 randomized controlled trials in, one of my colleagues came to me and confided that he was in opioid recovery. And he asked whether or not Buzzy could let him get through a total knee replacement drug-free. I'd never thought about it. It's the same pain nerve for knees as for needles, so I said maybe. And he did it. Vibration plus cold replaced OxyContin.
在大概第 30 次随机对照试验时, 我的一个同事找到我, 跟我透露, 他当时正在戒阿片类药物。 他问我 Buzzy 能否帮助他 不用药物就能挺过膝关节置换手术。 我之前从未往这方面想过。 膝盖和打针的疼痛神经是一样的。 于是,我说那试试吧。 然后他做到了。 震动加低温取代了奥施康定。
(Applause)
(掌声)
So at that point, I went all in, to figure out why. And here is what we know. So the reason that vibration decreases pain is because the physiology of the nerves of light touch, pressure, stretching and motion all races pain to the spine. Now people have tried electricity to trigger the light-touch nerves, but we now know that motion, shown in green, is what's most effective at shutting the gate on sharp pain. This is called gate control, and the exact right frequency of vibration triggers the nerves that decrease pain.
所以,从那时起,我开始全面投入, 试图弄清楚背后的原因。 以下是我们了解到的。 震动可以减轻疼痛的原因是 神经的生理机能, 感受轻触、压力、拉伸和运动 的神经比痛觉神经 能更快地传导到脊髓。 现在,人们已经尝试 用电击来刺激轻触神经, 但我们现在了解到, 显示为绿色的运动感受神经, 能最有效地关闭 剧烈疼痛感受的大门。 这被称为大门控制, 是触发减轻疼痛作用神经的 准确震动频率。
The physiology of ice is different. So the cold goes up to the brain, where the conductor goes, "Obnoxious, but not dangerous. I will decrease sensations coming from everywhere." And it decreases pain everywhere.
而冰块的作用是不同的。 冷的感觉传导到大脑, 那里是控制中心, “有点难受,但是不危险。 那我就把所有的感知能力都下调吧。” 于是所有的痛觉都降低了。
If a child was so freaked out from previous experiences that even the swab hurt ... physiology wasn't as helpful. So we added distraction, like a monkey poster. And what we discovered was combining counting plus making a decision cut pain in half. So, for example, "How many monkeys are actually touching the bed?" activates the decision switchboard. I know what you guys are doing. It's five.
如果小孩子 因为之前的经历太害怕打针, 哪怕只是消毒都觉得痛…… 那生理学就没什么用了。 于是我们加上了分散注意力的东西, 比如一张猴子海报。 我们发现 结合数数和做出决定 能把疼痛减少一半。 比如,“有几只猴子碰到了床?” 会激活决策枢纽。 我知道你们都在数,答案是 5。
(Laughter)
(笑声)
Here is your pain hack for the day, though. If you do not have monkeys on hand, then find any sentence and count how many of the letters have holes in them. Counting, deciding. So, like, you've got a g-hole, o-hole, a ... hole.
这就是今天你们得到的止痛秘诀。 如果你们手边没有猴子, 就随便找一句话 数一下有多少个字母是带洞的。 数数,做决定。 比如,这里有 g 是带洞的, o 是带洞的,a……也带个洞。
(Laughter)
(笑声)
(Laughter and applause)
(笑声和掌声)
I guarantee you and your family will use this.
我保证你和你的家人 一定能用得上这个。
(Laughter)
(笑声)
The biggest hack, though, is understanding why distraction works. And now, through functional MRI, we can actually see pain happen. And it's not one place. Pain is a symphony of connections, from the sensation area to the conductor, to the decision switchboard, and then to fear, memory, meaning, control. So if the decision switchboard is occupied sorting monkeys, it can't notify fear and meaning, and you feel less pain. What you feel is mostly what you expect to feel.
但其实最大的秘诀,是弄清楚 为什么转移注意力会有效。 如今,通过有效的磁共振成像, 我们能够真的看到疼痛的发生。 它并不只发生在一处。 疼痛是一系列连接, 从感觉区到指挥区, 到决策枢纽, 然后再到恐惧、记忆、 意义、控制等区域。 因此,如果决策枢纽正忙着数猴子, 那它就无暇顾及恐惧和意义, 你就不会觉得那么痛。 你的感觉 其实大部分时候是你期待的感觉。
Stay with me. If you're a kid, the same punch hurts more from a bully than from your buddy. And if you're an adult and you feel something, the second you think it's cancer, it hurts more and more, until you find out it's not. And those same kids who had horrible shot experiences can tolerate all kinds of needle pain ... to look cool.
容我举个例子。 如果你是个孩子, 同样一拳,欺负你的孩子打的, 跟你好朋友打的相比,会更痛。 如果你是个成年人, 你感到哪里有点痛, 如果你开始想,可能是癌症, 那就会越来越痛, 直到你检查完,发现并不是。 而同样的孩子, 哪怕经历过非常痛的打针, 也可以忍受各种针头带来的痛苦, 只为了显得很酷。
(Laughter)
(笑声)
Because it is a different context. These patterns, called connectomes, are very personal, because experiences lay down more of the same sensation. And we now know that people who have certain areas in the brain connected feel more pain than people with different areas connected. And more importantly, untreated pain or intense pain can lay down heavier connections, so that even when your body is healed, you will still feel more pain. It's this very plasticity and personalization which makes the physiology, fear, control matrix so useful. Because choosing physiologic options that you can layer, that work for you, decreases pain, like heat, cold, vibration, deep relaxation, acupuncture, capsaicin, exercise, meditation ... There's more. Christopher probably had 10 of these around his house and just didn't know it. Having control over your options decreases pain. Deep breathing increases control. Choosing what to focus on increases control.
因为情况完全不同。 这些模式,被称为连接组, 是非常因人而异的, 因为经历会加强相似的感觉。 我们发现,大脑连接区域不同的人, 对于疼痛的感受程度也不同, 某些人会更容易感到痛。 更重要的是, 未经处理的或者剧烈的疼痛, 会形成更强烈的连接, 因此即便你的身体已经痊愈, 但你仍然会感到更多的疼痛。 就是这种易受影响的、 非常个人化的特点 才使得这个生理学、 恐惧和控制的矩阵如此有用。 因为选择那些对你有用的, 你可以使用的生理学选项, 可以减轻疼痛, 比如热、冷、震动、深度放松、针灸、 辣椒碱、运动、冥想…… 还有很多。 克里斯多弗可能有 10 个选项, 只是他当时不知道而已。 拥有控制权能减轻疼痛。 深呼吸可以增加控制。 选择关注点放在哪里能增加控制。
Fear and control are the volume knobs for pain. Fear controls so many of our sensations, this shouldn't be unusual, but we don't practice it for pain. So if you're home alone and you hear a clunk ... your hearing becomes hypersensitive. But when you remember your kid's home from college, your fear dials down and your brain overrides it and says, "Don't worry about it." Saint Augustine called pain the greatest of evil. But if it is a survival system, it cannot be all evil. So instead, think of pain as your nagging, safety-obsessed, exaggerating friend who’s sometimes wrong. And it’s OK to ignore or override your friend if you know that you're safe.
恐惧和控制是疼痛的调节按钮。 恐惧掌控着我们许多感觉, 这没什么可惊讶的, 但我们从未练习过用它来控制疼痛。 如果你独自在家,听到一些声响, 你的听觉会变的超级敏感。 但如果你想起来, 孩子从学校回家了, 你的恐惧会变低, 你的大脑会无视它,说, “不要担心。” 圣奥古斯丁把疼痛称为最大的恶。 但如果疼痛是一种求生机制, 那就不全是恶了。 因此要换个想法, 把疼痛看做你一个爱唠叨的、 很重视安全的、有时有点夸张的朋友, 他/她时不时会犯点错。 有时无视或者冷落 你的朋友是没关系的, 只要你明白自己是安全的。
This takes practice. On a flight that was turbulent, I had an entire cup of scalding-hot coffee dumped straight on my ankle. Electric jolt through my scalp. I ripped off my sock; it was already red. It was going to blister. There was no way I could get my foot into that little sink to get cold water on it. And then I remembered. Physiology hack. I had an unopened cold beer.
这个需要练习。 有一次我坐飞机,有点颠簸, 我把一整杯滚烫的咖啡 倒在我脚踝上。 我的头皮一阵发麻。 我脱下袜子,脚踝已经变红。 马上就要出现水泡了。 飞机上的洗手盆那么小, 我根本没法把脚放进去, 淋冷水帮助降温。 这时我想起来。 用生理学的方法。 我有一罐没开的冰啤酒。
(Laughter) Medical-grade cold beer went on my ankle, stat.
(笑声) 医疗级别的冰啤酒 放在了我脚踝上。
(Laughter and applause) I had a vibrator in my carry-on, because I would. On my ankle. And then --
(笑声和掌声) 我随身行李里还有一个震动器, 我肯定要带着的。 绑在了我脚踝上。然后……
(Laughter and applause) The pain kind.
(笑声和掌声) 别想歪,是用来镇痛的(震动器)。
(Laughter)
(笑声)
And then my fear hack. I'm like, "There's a barf bag that has holy letters, but I'm going to put it in the pocket pouch and save it, because then, I have increased control." And, pain , I was no longer that concerned.
然后开始处理我的恐惧。 我想,“这里有个呕吐袋, 上面有神奇的字母, 但我要把它放到前面的 置物袋里,留着它, 因为之后,我就能提升我的控制。” 我就不再那么在意我的疼痛了。
(Cheers and applause)
(欢呼声和掌声)
Although then, I realized I'm that guy, with my bare foot sticking out in the aisle on a plane, with a beer on it.
尽管之后,我意识到, 我一只脚光着,伸在飞机过道中间, 上面还绑着一罐啤酒。
(Laughter)
(笑声)
Power over pain isn’t always pretty, but it is possible and it is absolutely critical. Because there’s one more misconception we have not talked about. I honestly thought that opioids turned off some pain switch. They turn on our reward system. So some people feel amazing, but most people just still feel pain, but don't care. Now, this is a godsend for people with chronic pain diseases. We should not take them away. And in the trauma bay, the more morphine in the first 24 hours after a burn or a wound, the less post-traumatic stress, the less chronic pain later. But studies show that recovery after surgery is just as well accomplished with coaching and physiologic options. And if you're one of the people who feel amazing with opioids, it's too risky. A study in 2019 found that one in 15 young adults who got opioids for their wisdom tooth removal had substance-use disorder within a year. Ibuprofen works better.
击败疼痛的力量并不一定光鲜亮丽, 但是是有可能的 而且绝对非常重要。 因为我们还有一个 错误观念没有谈到。 我真心认为阿片类药物 能关闭一些疼痛开关。 它们也打开了我们的奖励系统。 因此有些人会感觉很美妙, 但是大部分人还是会感到疼痛, 却不在乎。 这对那些有长期疼痛疾病的人 来说是天赐之物。 我们不该全盘否定他们。 在创伤治疗室, 针对烧伤或者外伤, 如果在头 24 小时使用吗啡量越大, 创伤后应激反应就会越小, 长期疼痛也会越少。 但研究表明,术后恢复 同样也可以通过训练 和物理疗法来完成。 如果阿片类药物让你感觉很好, 那风险太大了。 2019 年的研究发现, 有十五分之一的年轻成年人, 如果在拔除智齿后使用阿片类药物, 会在 1 年内产生药物滥用症。 布洛芬会好一些。
So what do we do? Well, in my dream world, we have health-care systems -- paid-for options and coaching -- for Christophers everywhere. And we quit giving double-digit prescriptions for opioids for home recovery. In the real world, 80,000 people died in the US last year from opioid overdoses, and 80 percent of substance-use disorders start with a pill prescribed for pain ... Usually taken from your friend's medicine cabinet. People can’t afford options. Doctors, 20 years later, still don't know them. But you do. You all now know to throw away the opioids in your medicine cabinet. You now know that there are options you can use to decrease pain, and you know that "pain-free" should be ditched for "more comfortable." And whether you dump scalding coffee or pain wakes you and exhausts you every day ... Options that are in your control ... can allow you to reframe pain.
那我们应该怎么做? 在我的理想世界里, 我们的医疗系统, 能负担我们的物理治疗和训练, 帮助像克里斯托弗这样的人。 我们不再给家庭康复的病人 开出 2 位数的阿片类药物处方。 但现实是, 去年在美国就有 8 万人 死于阿片类药物过量, 有 80% 的药物依赖 始于一片处方止痛药。 通常来自于你朋友的药柜。 人们没钱做物理治疗。 而医生们,在从业 20 年之后, 依然不知道怎么对付疼痛。 但是现在你们知道了。 你们明白要扔掉 药柜里的阿片类药物。 你们明白有哪些方法 可以减轻疼痛, 你们明白要摈弃“无痛”, 而是追求“更舒服”。 无论是咖啡洒了, 还是半夜被痛醒, 每天被折磨得精疲力尽…… 那些你掌握的物理疗法, 能让你重塑疼痛。
Thank you.
谢谢大家。
(Cheers and applause)
(欢呼声和掌声)
Whitney Pennington Rodgers: Amy, thank you, it's amazing. So how do you think that pain scales have set us back from this work that you're doing, and how is the NIH treating pain and addiction differently now?
惠特尼·彭宁顿·罗杰斯: 艾米,谢谢,非常精彩。 所以你认为疼痛量表在多大程度上 阻碍了你的工作, 美国国家卫生研究院 目前在对待疼痛和成瘾方面有哪些变化?
Amy Baxter: So in one of the 120 versions of this talk, I talked about how the thing is, in the '90s, if we wanted to “disease-ify” pain, it meant we had to be able to measure it. So that was where the FACES scales come from, and they're actually very useful in the emergency department to tell whether or not a medicine is working. In fact, we were one of the first ones that showed, with sickle cell, that the patient's report, based on those scales, was what was most indicative of whether they needed to be admitted, rather than any biologic marker. But what we're doing now is we're using something called the PROMIS scales, so it’s how intense pain is on five-point scales, how much it interferes, so there's pain interference, pain intensity. And the way we're looking at pain is much more on the impact for the person, rather than trying to pretend there's any kind of objective pain measurement.
艾米·巴克斯特:在 90 年代的时候, 我针对此做过 120 次演讲, 如果我们想把疼痛看做一种疾病, 那就意味着我们需要能够量化它。 面部表情评分表就是这么产生的, 实际上它在急诊还是非常有用处的, 能判断一种药是否有效。 事实上,在镰状细胞病的研究中, 我们是第一批明确表示, 病人基于那些疼痛量表的自述反应, 是判断他们是否需要住院 最具指示意义的依据, 而不是那些生物学的指标。 但我们现在使用的 是一种我们称为 PROMIS 的量表, 它用 1-5 分来评定疼痛强度, 以及疼痛对生活的影响程度, 所以它有两个维度, 疼痛强度和对生活的影响程度。 我们看待疼痛的方式 更侧重于关注它对人的影响, 而不是试图假装 有某种能客观测量疼痛的方法。
WPR: OK. And you mentioned that you're working on some new applications for Buzzy, specifically for back pain. What are some of the possibilities that we have here for what this could do for us in the future?
惠特尼:好的。 你刚刚提到 你在研究 Buzzy 新的应用, 专门针对背痛的。 目前取得了哪些进展 未来又能为我们带来哪些好处呢?
AB: On my tombstone, there's going to be a vibrating bee. It's actually called DuoTherm, not Buzzy. But what we've learned is that there are harmonics of interaction between the specific frequencies that cancel out the pain. So there’s one particular nerve called the Pacinian that has a very specific frequency range, and by causing them to interact, we're starting to explore more about the pain that's coming from the fascia between the skin and between the muscles, but that area is where we're unexplored, and so by interacting with different frequencies and then layering heat or cold, pressure options, giving people the choice of so many different ways to do it, it's really engaging all the different areas of the brain from which pain comes.
艾米:我的墓碑上 会有一只震动的蜜蜂的。 其实它叫 DuoTherm, 不是 Buzzy。 我们发现某些特定频率间能和谐共振, 它们能消除疼痛。 有一条特定的神经叫帕西尼小体, 它有非常特定的频率范围, 通过使不同频率的刺激产生相互作用, 我们开始进一步探索来自于 皮下结缔组织区域的疼痛, 它位于皮肤和肌肉之间, 是一个我们尚未完全了解的区域, 因此,通过不同频率的相互作用, 再叠加热或冷,压力等方式, 给人们不同的选择来应付疼痛, 这样可以真正刺激到大脑中 产生疼痛的不同区域。
WPR: Wow, OK. Well, thank you so much, Amy.
惠特尼:哇哦,好的。 非常感谢你,艾米。
AB: Welcome.
艾米:不客气。
Thank you, all.
谢谢大家。