Dr Louise Newson: So today on the podcast, I’ve gotwith me Dr Deepak Ravindran, who I’ve known for a little while, who is aleading expert in pain. And pain is very common, we’ve all experienced pain atsome time. And actually, I was reading some of the stats which are huge aboutchronic pain, so long term pain, and how common it is. And I know how poorlymanaged it is for a lot of people. So we’re really privileged to have Deepakhere to share his knowledge and words of wisdom. So thanks ever so much forjoining me today.

Dr Deepak Ravindran: Thank you Louise, so much forhaving me on your podcast. I’ve been listening to a number of the episodes overthe years, so it’s really a pleasure to be on your channel today.

Dr Louise: That’s kind. Someone said to me a whileago, I can’t believe your podcast is still going. Surely you’ve spoken enoughabout menopause. And I sort of get it, but I was still also annoyed as wellbecause there’s so much to talk about. There’s so much that I feel every daythat I’m learning and I feel really cheated that I didn’t know about it before.And I don’t know about you Deepak, but in medical school, even if I went backnow and redid the course, there is still a lot that I should have been taughtthat I wasn’t.

Dr Deepak: I share that sentiment. I mean, you’resaying that about menopause, Louise, pain itself, the most common thing thatcomes for 70% of all GP consultations, that’s really changed so much since whatwe’ve been taught in medical school or all of your listeners and the generalpublic understands about pain. There’s a complete sea change in how we nowadvance and understand the neuroscience that I feel that we really need to betalking about these things and the understanding now of the links between painand menopause. My God, there’s enough to fill enough podcast episodes for youfor another few years at least.

Dr Louise: Totally, I totally agree. So before we getinto too much detail too quickly, I’m really keen to learn, so you’re apractising physician. And you’ve been you’ve been doing pain for many years, Iknow. And you’re an author of I’m just going to hold it up for these peoplethat are watching, but it’s called The Pain-Free Mindset: 7 steps to takingcontrol and overcoming chronic pain. And when we talk about chronic, it’s notchronic really bad. Chronic is that it’s persistent. So some people with theway they use language can be different to how we use language, but chronic isit doesn’t go away very quickly. So how did you get into specialising in painDeepak?

Dr Deepak: So I’ve, as you said, I’ve been nowpractising for over 25 years in medicine there. I’ve trained in India and I’vethen come over to the UK and I’ve been in the UK for more than two decades now.And I’ve done, my background is in anaesthesia. So most pain physicians in theUK come from a background of anaesthesia and I trained in Oxford and in London.And at that time itself, I realised that… obviously from an acute pain setting,I was very good in blocking nerves, doing all the procedural aspect there. Butit was around that time that I really got interested in the research potentialand the newer discoveries that we were making about pain signs, the brain, thenervous system, receptors, pathways. And that’s what led me to do my fellowshipin London. And I joined as a consultant in the Royal Berkshire Hospital inReading. From 2010 onwards, I’ve been there. And pretty soon within the firsttwo, three years of my consultant life, I realised that the skills that I hadbeen trained in, which is giving medications and doing interventions andblocking anything with a needle, was really not helping a lot of patients withchronic pain. And as you said, it’s what we now call persistent pain. It’ssomething that lasts for long and is difficult to get rid of. But I think we’veapproached it wrong, Louise, in a sense that by assuming that it can be got ridof with medicines and interventions, we’ve forgotten what actually pain is. Andit’s that knowledge that I began to understand. And when you look at theresearch and literature, there’s so much that has happened in the last 10,15years that I realised, well, actually, more and more has to be done aboutmaking other people understand so many different ways of managing andovercoming and actually getting rid of pain, but not by the conventionalmainstream ways of medicine and surgeries or injections. And all of thatknowledge is what I realised I needed to get out to the public. And soprogressively over the last 14 years, I’ve done less of anaesthetics, more ofpain management to the point now that I’m a full-time sort of consultant, painphysician, working in Reading. I have a private practice, but I’m also veryinterested in research. And so I’m what we call these days a physicianresearcher. So I have a professorial post at the Teesside University. I’m asenior visiting fellow at the University of Reading locally. And I’m interestedin a lot of research around trauma, around lifestyle medicine. And I see all ofthat as being very vital to understanding the different ways we can overcomepain. Part of the book is partly condensing some of that knowledge now in abook form, but a lot of it is around getting that message out to say, if weopen our eyes, if we understand pain neuroscience, it gives us so manydifferent ways to overcome pain than feel restricted by the straitjackets ofdrugs or interventions. And that’s really what I’m doing these days.

Dr Louise: It’s so interesting isn’t it when you’retalking about straitjacket of drugs and I was talking recently about peoplebeing given a chemical straitjacket as well with some of the you knowtreatments people give where they’re inducing menopause indirectly actually noteven realising some of the psychiatric drugs like anti-psychotic drugs andcertainly you know when I reflect my time as a doctor, you know, a lot of it isabout listening to patients. It’s a hands off approach, actually. Some of thebest doctors I know have spent 80% of their time listening and making adiagnosis and making a treatment plan that’s appropriate for that individual.Of course, often we use diagnostic tests, but actually it’s putting it intocontext. And I think with pain, it’s so important because…As you say, there aresome great drugs. You can numb all sorts of people, all sorts of things, can’tyou? But it’s not actually treating the underlying cause. And so, and there isa real problem. And we see a lot of people that are on painkillers, quitestrong ones, especially even opioids as well for muscle and joint pains thatthey’ve had no diagnosis for, and then they realise it’s related to theirhormones. But you’re just putting a sticking plaster on sometimes, aren’t you?If you’re not treating the underlying cause, but then also the way we perceivepain can be quite different. So, I mean, this is very simplistic and hear methrough, but I hope it makes sense. As you know, I get migraines and often mymigraines will only, only I say last like 24 hours, 48 hours if they’re bad,but I know I’ll come through it and I just have to wait for them to and I willtake medication. But if I don’t catch it early enough or whatever, but lastweek I had a migraine that lasted for five days and it’s not just the pain,it’s the cognition. I can’t think, I slur my words, I find it really difficultto concentrate. But my father had a brain tumour and he had, he was 40 and hepresented with a headache. And so if I didn’t have the knowledge that I have, Iwould then be worrying, have I got a brain tumour? Is there something elsegoing on? And there’s no doubt with migraines. I know that they’ll get better.I know they’re self-limiting. I just have to, and I’ve got a really supportivefamily and my husband, you know, because I forget to eat and then not eatingmakes it worse and not drinking makes it worse. And it’s just awful. I have togive into it. But actually, if I was worried, my pain would definitely beworse. And it might not be the actual pain. It’s the perception of that painand the anxiety that’s associated with it. And then if I don’t eat, things willget worse. If I don’t sleep my pain gets worse. And it’s that cycle sometimes.And I can see that that’s just for a few days. But if I was having pain for alot longer and I, does that happen with some of the people that you see? Itsort of snowballs in some ways. And I know it’s probably the way the brain isreacting as well sometimes with this pain as well.

Dr Deepak: I think Louise, I mean, thank you forsharing that really. And it does what I try to teach people and not even forgetteaching, just try to help people understand. You’ve really highlighted theimportance of that aspect of listening and feeling validated. So that’s oneaspect of supporting the patients. However, fundamentally, what we now know,and you rightly point out that overlap between there, is I talk about in thebook as well, and I talk about this concept of and difference between what Icall nociception and what we have as the pain experience. So nociception isessentially when chemicals get released. So when you have chemicals getreleased at the migraine zone that triggers your migraine, when people mighthave a flare up of IBS or might have a flare up of their endometriosis or apelvic pain that comes along or for any any other surgery or injury, you havechemicals that are released at the site of that physical structure. Thosechemicals get converted into signals within the nerves. That conversion part,that word is called nociception. That phenomenon there is nociception. Thatsignals have to then travel along these electrical nerve pathways and they goaround pinging different parts of the brain, different areas, the hearing zone,the memory zone, your emotional zone. So there are receptors in every part ofthe brain. Now, we were taught in our medical school, the health school, thatthere are, there is a pain centre and there is a specific pain pathway, butthat’s entirely wrong now. There are no pain pathways. There is no specificpain centre. So then that information gets going to every part of the brain andthe brain has this complicated aspect of saying, how can I predict the contextin what this is happening? How is the signal going to be processed? Andultimately, if the brain decides that it needs to protect you, it needs to kindof tell you that this is a threat that I did the previous time, the first timewhen it happened, this is what I did to protect you, then it will bring about theprotective element. That protective element is what is manifested as the painexperience. And so realistically, nociception may be one aspect of the problem,but the pain experience is determined by the context, by the decision toprotect, by other life experiences you may have, by all other emotional factorsthat go into it. And so the intensity of your migraine that you may have, whatlasts between five days or 24 hours, for every other patient I get in myclinic, when I tell them, why do some days your pain last for a few hours,other days it goes on for days, then it means that it is influenced by so manyother factors. And surprisingly, even things like sleep, nutrition, lack ofactivity, lack of social connectedness, all of those aspects make a differenceto the intensity of pain experience. And I think understanding fundamentallythe distinction between what can influence your pain experience versus what isthe nociception that comes out, really is eye-opening to a lot of patients andsaying, well, you know what, those are the things I can still influence. Can Imake a change? And that is the opportunity I think that’s there in trying tomodify the pain experience.

Dr Louise: So important, I’m very interested inneuroscience and I’ve been reading lots of neurophysiology papers recently. AndI’m very also interested in inflammation and neuroinflammation as well and howwe protect our brain, but our body as well. Of course our body is important,but without our brain, you know, we’re nothing, aren’t we? But how our…nervecells work, how our brain cells work, what influences them? And there is a lotmore talk about inflammation. I’m very interested in mitochondrial functions,so mitochondria are the powerhouse of the cells. And we’ve got trillions ofcells and goodness knows how many trillions of mitochondria, but they’re reallyimportant and they can be influenced. And whenever the brain is sort oftwitched and the nerve cells are twitched, of course pain, but the perceptionof pain is going to be different as well. And so, looking at all of thesethings, which is something we weren’t or I was never taught at medical school,is that, you know, the way we eat what we eat, the timing that we eat, theexercise, the mindfulness, how we worry or not worry about pain or things thatare happening in our lives, any trauma that’s gone on.

But also, you know, that sort of micro environment. And it’snot just when we’ve got the pain, because when I have a migraine, for example,there’s no way I could do any yoga, I can’t do a headstand, I can’t do anyexercise. And I will only eat because somebody gives me food. But, and this isa big but, if I don’t do yoga, and eat badly when I’m pain free, my migraineswould be a lot worse. But I need…I’ve learned that myself, but if I didn’tknow, I would need someone to tell me, Louise, it’s not just about the acutephase. It’s what you’re doing. And I know that I’m very anti-inflammatory inthe way that I function and also my hormones that I take are veryanti-inflammatory too.

But that’s really important. That bigger picture, isn’t it?When we’re trying to dampen down the inflammation in our brain, becausepresumably when we’ve got more inflammation, our our pain receptors are onhyper alert and our pain perceptions are different. Would that be fair to say?

Dr Deepak: You’re absolutely right, Louise, becausewhen I talked about the nervous system being protective and making a predictionand a processing and a finally decision, the other big player who actuallytells the nervous system, do we protect or not, is the immune system. Andactually, the immune system and nervous system are doing this real yin and yangdance throughout the body, constantly looking out for protecting us. Now, whyis that important there? First of all, I think one of the statements we were taughtin our health care schools is that the brain is an immune privileged organ.That was at least the teaching until the early 2000s, which meant that therewas no representative of the immune system in the brain. But that is nowabsolutely wrong. We now know and the way I kind of explain it is. Imagine thata signal arrives at one nerve ending and then has jumps. So the synapse, thatis a junction where a signal travels from one nerve cell to the next nerve cellat each junction. And so there are billions of synapses, but at each of thesesynapses junctions, there is a representative of the immune cell constantlymoderating the traffic, looking at the signals, deciding to ramp it up or lowerit down. And this is what the immune cell is doing. And so when the immune celland let’s backtrack one bit, 80 to 90% of the immune system is present in andaround our gut. The next biggest place for our immune system is the skin.Clearly, these are the two parts of the body that are in contact with the outerenvironment, the micro and the macro environment. So this is where the immunesystem needs to be present. Our defence forces need to be maximally aggregatedat these two points to keep a watch out. So when they watch for these things,they are going to react and they then inform the nervous system to actuallysay, this is what you need to do mate to protect yourself. And so if they areinflamed, the brain is going to have that neuroinflammation, as you put it, andthat can affect, you know, one of the big things I realised when I set up sortof, I’d set up a community pain service in 2015 for my local area of Berkshire,and I then helped set up the Long COVID service. And conditions like this mademe aware of this importance between conditions like ME, like fibromyalgia, likeLong COVID, where we are now understanding that there can be changes to how theimmune system gets inflamed and how it impacts on the nervous system. Andfundamentally within the nervous system and immune system, how it changes thefunctioning of the mitochondria. And as you rightly said, there are about 400to 800, maybe thousand mitochondria in each cell. If those functions areaffected, it has an impact and on what makes the impact to the immune andnervous system? Well, it’s things like diet, things like nutrition, things likesleep. But at a second level, it’s the impact on the hormones. What changesthey bring to the thyroid hormone, to the sex hormones, to the growth hormones.Those are the changes we are now beginning to take apart and piece apart andunderstand that each of these can be modified, can be modulated before rushingto drugs. And I think that’s exciting times for us in this field because we nowhave so many other ways to modulate the immune system and the nervous system tobe less protective maybe, or at least to be assured of safety in another way.

Dr Louise: And it’s so important. I don’t know if youknow, I did a pathology degree a long time ago in 1992, but about 20% wasimmunology. And so we did a lot of work looking at, especially macrophages andmonocytes as well, looking at what happens when the body is anti-inflammatoryor pro-inflammatory and how very little can make a big difference. So thecells, especially the macrophages, they sort of gobble up anything bad. So ourbody’s constantly protecting us, not just from viruses and germs, but from diseasesas well. And so we need these cells to work really, really well. And when theywork well, we’re really good. We’re protecting our bodies from future illnessesand disease and being in health. Whereas it doesn’t take much for them to goagainst us. And not only do they not work, but they become pro-inflammatory. Sothey produce these chemicals, which go against us, which feels a bit strangereally, doesn’t it? But…when you look at how different levels of hormones and Iknow I did a lot of reading in COVID like we all did because we had a lot moretime and I remember like reading something about when there’s an optimaloestradiol level then your inflammatory cells work really well they’re veryanti-inflammatory but when you have low oestradiol becomes pro-inflammatory andI remember going up to the attic and digging out my notes from my pathologydegree. And thinking gosh it’s all there like it’s quite basic science and thenI’ve been reading a lot more about progesterone which is veryanti-inflammatory. We were just told progesterone protects the lining of thewomb if you have oestrogen. Of course it’s a really important neuro hormoneit’s produced by the brain and testosterone. I’m increasingly as you know, Idon’t stop talking about it – about the role of testosterone beinganti-inflammatory and how these hormones affect pain and neuromodulation aswell, and the way they interact with our immune system. And then when we lookat autoimmune diseases, it all fits into place really, but it’s been siloed andignored in medicine. And it’s such a shame because it’s not just hormones, it’snot just diet, it’s not just sleep, it’s everything together and everybody’sdifferent who responds most to what. But we’re missing big bits of the jigsawif we’re ignoring hormones in men and women actually.

Dr Deepak: I agree really, you know, when you talkedabout the silos, Louise, that is a big problem. For example, in painmanagement, even in the fellowship that I did and as I did my pain clinic andthe work that I have with my team, which is, you know, I work in amultidisciplinary team with fellow pain consultants, with nurses, withphysiotherapists, with occupational therapists, with psychologists. We don’thave a dietician as well, but we’ve got some physios who are trained in there.But what we as a whole team never really understood until the last four or fiveyears. And some of it is due to the work like people like yourself is thisoverlap between menopause and perimenopausal periods and pain. Because I didsome sort of limited audit and it’s, you know, it’s very common to know thatchronic pain and autoimmune conditions are much more common in women. And whenI looked at my practice and sort of thought, you know, let me just see over thelast two weeks how many women come in what age groups. About 70 to 80% of mywomen patients who came to my clinic are between the ages of 30, 35 to about60, 65. And we understand the overlap between perimenopause and pain, or ratherperimenopause in this age group, but it has never really occurred to us in thepain clinic that do we need to be actually thinking more actively whether…exactly as you said, the influence of oestrogen, progesterone, testosterone,thyroid hormones. What does it mean? We do a thyroid function test before theycome to the pain clinic that we understand that relation between low thyroidand fatigue and pain or vitamin D being low and pain. But we have never reallytested or looked for and understood the challenges of having possibly low sexhormone levels or low testosterone levels and pain. And the data, as you said,is there. There is enough to suggest that we probably need to work that on thatlevel. And in terms of treatment, it was a very interesting question. A GPasked me recently saying, we have all these problems with the pain medication. Youknow, the antidepressants are really getting hammered in the press because oftheir long-term issues and challenges. Gabapentinoids like Gabapentin andPregabalin have their challenges in terms of weight gain in women as well astheir dependence problems they have. So they asked me actually, when we havethe drugs for fibromyalgia or for persistent pain, they are having so many sideeffects and you have patients who are in the perimenopausal age period as well.Should we be thinking about giving them something more safer now like HRTrather than medications. And I must say, well, actually, that seems like a veryfair question to ask. And is it that pain clinics across the UK in the NHS needto be actively thinking about how do we assess for that? How do we recognisethat? How do we make people aware of the holistic options and maybe more saferoptions to managing this age group of pain, fatigue, and all the other symptomsrather than just doling out more medications that we now know are probably notthat safe?

Dr Louise: I wish that would happen. I would love todo joint pain clinics and hormone clinics and help educate because you’reabsolutely right. And there is evidence that actually people perceive paindifferently just before their periods when oestradiol levels at their lowest.And with oestrogen, even if you’ve got the same stimulus, your perceptions ofpain will be very different when you’ve got hormones and all theanti-inflammatory effects. And certainly… fibromyalgia I used to, I shudderreally when I think back to general practice because I would see a lot of womenin their 40s with fibromyalgia, I would be the one with prescribing theGabapentin and the Pregabalin but because the pain clinic had asked me, neveronce did I ask the women about any periods, any PMS, could it be related totheir hormones I never even had prescribed testosterone until about 10 yearsago because I didn’t know women even had it. And now if someone comes to me inthe clinic and has fibromyalgia, I will always say, look, I’m going to optimiseyour hormones, all three of them, to a physiological response. And then let’ssee what’s left. And fibromyalgia usually melts away. And it’s usually thetestosterone that makes the biggest difference and might not get themcompletely better. But I’ve never once seen a patient that hadn’t improved whenshe’d been given hormones. And I’m giving the hormones for their other symptomsand their future health, not for their fibromyalgia, because we don’t knowwhether it will help. But actually there’s no harm and in medicine it’s alwaysbalancing and it’s always very easy isn’t it to say they shouldn’t be on theopioids, they shouldn’t be on these drugs, but what do we give to them instead?Do we just say sorry, have nothing and suffer? Of course we can’t do that asdoctors, but actually I parallel prescribe, so I’ll give them the one thatthey’re on already, add in hormones and then I tell you within three to sixmonths they’re reducing the doses of their other medications and oftenstopping, which is wonderful isn’t it as a doctor if we can stop anddeprescribe as well.

Dr Deepak: I have had now patients in that samesituation wherein I tell them that, look, you’re in this age group. We have tobe aware of the role of perimenopause. I’m still learning about it. So I atleast refer them to a women’s health specialist in the local area. Or I ask theGP if they have got someone, can we test it? Can we replace that and then seewhether the drugs still need to be taken? When I do a follow up three or sixmonths, I’m starting to get patients more and more who actually say things haveimproved, I’m now on less of the tricyclic or less of the Gabapentin orPregabalin or one of the other anti-neuropathics, and they have managed toreduce off that. And I think that I would agree with you that it is somethingwe need more training and, first of all, I think we as healthcare professionalsitself need more awareness raising and education. I think the British PainSociety itself recently, have done a webinar just to talk about this overlapbetween menopause and chronic pain. And I would be the first one here and bothof us, I think, would be first one to say the evidence is emerging. I don’tthink there is like awesome evidence that there is causation. But when we takein the simple thing of, you know, what as healthcare professionals can we do thatsafe, that’s easy to give, that’s easy to control for, I think good lifestylemedicine based principles plus appropriate safe treatments like HRT whereappropriate, I would say I’m more and more leaning towards saying, can wecontrol for all of that before we go down the anti-neuropathic drugs?

Dr Louise: I never thought the day would come that Iwould hear that from you, Deepak! That is just brilliant. I’m going to framethose words because it’s so important.

And working together is also really important. In medicine,we get really stimulated working with like-minded people who have gotprofessional curiosity, who are prepared to pivot and change according to thescience, but also what we hear from patients, because those two together arecrucially important. We can’t learn everything from papers and textbooks and wecan’t learn everything from our patients. But when we join the dots and worktogether with our patients, it can be transformational. And I know that youlove your job as much as I enjoy mine. So we’re very fortunate in that way. Sobefore I finish, because I’m very, it’s just been great. I could talk all dayto you. I would like to ask you three take home tips, if that’s okay. I alwaysdo it on my podcast. So three things that if someone’s listening and thinking,yeah, it’s all very well. They sound really happy and you know, managing painis really easy, but I have pain and I’m not being listened to because there isa lot of people diminish the effects of pain. Sometimes I hear a lot of storieswhere people really just say, you’re just stressed. It will calm down andimprove. So what three things if people are struggling, do you think they coulddo to help them receive the help and treatment in the way that’s right forthem?

Dr Deepak: I think the first one is for all of yourlisteners to really understand and take on board that the science of persistentpain and chronic pain is that please don’t feel that you’re making it up. Yes,you may still have professionals who are in that mindset there, but it is notthe case at all. The chronic pain is very real. There is a very good biologicalreason why that happens now. And we know that. The second tip I’d suggest is,please try to understand or maybe have a bit more patience with yourself, compassionwith yourself to read up about or at least listen to the resources now to saywhat is the difference between nociception and pain and therefore what are theopportunities for you. So how do you understand your pain so that you canrealise that there are other ways to manage it? And the third tip I probablywould say is to really look at the various other lifestyle medicine options. Imean, it may sound corny when I say lifestyle medicine, but it is a solidscience. It now shows that if you can find a way to make your immune andnervous system feel safe, the question you ask is, how can I make my nervoussystem and immune system feel safe? It will open up a world of options in whichrecovery is possible, overcoming pain is possible and indeed, I have patientswho have become pain free after many years of chronic pain. So getting ‘rid ofit’, which we thought was very difficult 10 years ago, we now have patients, ifthey understand the pain, that’s possible.

Dr Louise: Amazing. And I would add that nothinghappens overnight. It can take a while and that’s really important. Butstarting small steps in the right direction can be transformation of yourfuture health. So thank you so much for today. It’s really wonderful. And Iwill put a link to your wonderful book in the notes as well, because I thinkeveryone should look at it and learn as well. So thanks ever so much, Deepak.It’s been great.

Dr Deepak: Thank you so much. Thank you so muchLouise for having me. Our audio book has also come out now for your listeners afew months ago. So for those of you who like to do your listening runningabout, then absolutely go for that as well. But thank you once again for havingme and it’s been wonderful talking to you today.

Dr Louise: Thank you. You can find out more aboutNewson Health Group by visiting www.newsonhealth.co.uk, and you can downloadthe free balance app on the App Store or Google Play.

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