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Sean Mackey is a professor of pain medicine at Stanford University and the director of the Stanford Systems Neuroscience and Pain Lab, where his research explores the neural mechanisms of pain and the development of novel treatments for chronic pain. In this episode, Sean joins Peter for a wide-ranging discussion on the multifaceted nature of pain—as both a sensory and emotional experience—and its evolutionary purpose as a critical survival mechanism. He dives into how pain is transmitted through the nervous system, the different types of pain, and why different individuals perceive pain so differently. Sean shares insights into pain management strategies ranging from medications like NSAIDs and opioids to neuromodulation techniques such as transcutaneous electrical nerve stimulation (TENS). Additionally, this episode explores the interplay between sleep and chronic pain and the psychological and emotional dimensions of pain, and it includes a personal story from Peter about his own experience with pain and how Sean’s expertise helped him more than two decades ago.

We discuss:

• The definition of pain, and how our understanding of pain has evolved from a simplistic body-mind separation to a nuanced biopsychosocial model [2:30];
• The biological mechanisms behind how we perceive pain [9:30];
• The role of consciousness in the perception of pain, and how nociception functions during unconscious states [14:30];
• The four types of pain [22:00];
• Using fMRI to identify objective biomarkers of pain in the brain [31:30];
• The evolutionary role of pain in human behavior and survival [36:00];
• How the brain processes and modulates pain signals, Gate Control Theory, the variability in individuals’ pain perception, and effectiveness of neuromodulation techniques like TENS [41:00];
• The brain’s influence on pain: the role of emotion, beliefs, sleep, and individual differences in perception and tolerance [53:45];
• Peter’s personal journey with chronic back pain, and how the emotional consequences of pain can be more distressing than the pain itself [1:04:30];
• The pharmacology of common pain medications—NSAIDs, COX-2 inhibitors, and acetaminophen [1:09:30];
• Muscle relaxants: benefits, drawbacks, and personalized strategies [1:20:30];
• The definition of chronic pain [1:29:15];
• The role of antidepressants in pain management [1:30:15];
• Opioids: their controversial and nuanced role in pain management [1:33:45];
• Alternative therapies: acupuncture and cannabis [1:54:15];
• Fibromyalgia and chronic pain: clinical features, brain mechanisms, and emerging treatments like low-dose naltrexone [2:01:00];
• Possible brain benefits of low-dose naltrexone (LDN) for people with mild cognitive impairment [2:15:00];
• Peter’s recovery from severe chronic pain—how he went from immobility and high-dose opioids to full functionality [2:20:15];
• Breaking the pain cycle: how physical rehabilitation and psychological recovery work together in chronic pain treatment [2:30:45];
• Sean’s struggle with cluster headaches, and the value of knowledge, preparation, and empathy in both managing chronic pain and caring for patients [2:39:15]; and
• More.

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View the Show Notes Page for This Episode

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Sanjay Mehta is a radiation oncologist with over 20 years of experience at St. Joseph's Medical Center in Houston, Texas. In this episode, Sanjay explores the rapidly evolving field of radiation oncology, addressing common misconceptions about radiation exposure. He delves into radiation's critical role in modern oncology, examining recent advancements that precisely target tumors while minimizing damage to surrounding healthy tissues and reducing side effects, with specific insights into breast, prostate, and brain cancers. Sanjay discusses fascinating international practices involving low-dose radiation therapy for inflammatory conditions such as arthritis, tendonitis, and sports injuries, highlighting its effectiveness and potential for wider adoption in the United States. Wrapping up on a lighter note, Peter and Sanjay discuss their mutual passion for cars and reveal how this shared interest first brought them together.

We discuss:

• How radiation oncology became a distinct, rapidly evolving medical specialty [2:45];
• Defining radiation, ionizing vs. non-ionizing, and common misconceptions about radiation exposure [5:30];
• How radiation doses are measured, real-world examples of radiation exposure, and safety practices [9:00];
• Radiation doses from common medical imaging tests, and why benefits of routine imaging outweigh risks [14:15];
• Therapeutic radiation oncology: the evolution of breast cancer treatment toward less invasive surgery combined with targeted radiation [23:30];
• Modern radiation oncology treatments for breast cancer—minimizing risks and maximizing patient comfort and outcomes [27:15];
• How advances in radiation dosing, technology, and treatment precision have significantly reduced side effects [39:45];
• How breast implants affect radiation treatment [44:45];
• Radiation therapy for prostate cancer: advancements in precision, effectiveness, and patient selection criteria [48:00];
• Radiation therapy options for inoperable prostate cancer or those seeking alternatives to surgery, and a remarkable patient case study [55:15];
• How patients can effectively evaluate and select a high-quality radiation oncologist [1:05:45];
• Radiation therapy for brain cancer: the shift toward precise, targeted techniques that minimize cognitive side effects, and remaining challenges [1:08:30];
• The origins of radiophobia and how it influenced perceptions of radiation use in medicine [1:18:00];
• Treating chronic inflammatory conditions such as tendinitis, arthritis, and more with very low-dose radiation [1:23:45];
• Using low-dose radiation to treat spine injuries, scar tissue, fibrosis, keloids, and more [1:30:00];
• The current barriers preventing widespread adoption of low-dose radiation therapy for inflammatory conditions [1:35:45];
• The durability and versatility of low-dose radiation therapy in treating chronic inflammatory and arthritic conditions [1:40:45];
• Sanjay’s talent as a drummer [1:44:45];
• Peter and Sanjay’s shared passion for cars and racing [1:47:15]; and
• More.

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