Low-Dose Ketamine for Chronic Pain: A Biopsychosocial Approach with Michelle Weiner, DO, MPH

This is the Psychedelic Medicine Podcast.

Hello and welcome to the next episode of the Psychedelic Medicine Podcast.

I'm Dr. Lim Morsky, your guide on this journey,

and today we're going to be discussing low-dose ketamine

with adjunct therapies for chronic pain with Dr. Michelle Weiner.

Dr. Weiner is a double-board certified physician

in interventional pain medicine and physical medicine and rehabilitation.

She is also the founder of NeuroPaint Health,

delivering personalized integrative care,

treating the root cause of pain and suffering,

both physical and emotional,

using a multidisciplinary biopsychosocial approach

with many years of clinical experience

with ketamine-assisted therapy.

Now, before we get to Dr. Weiner,

just a reminder that the Psychedelic Medicine Podcast

is for educational and informational purposes only,

nothing here is to be construed as medical or legal advice.

And one last reminder is that the Psychedelic Medicine Association,

as I tell you every episode,

is your one-stop shop if you are a clinician

and you'd like to learn more about psychedelics

for things like chronic pain.

Maybe you thought they were just good for mental health.

We talk about psychedelics use across the board,

mental health, physical health, well-being.

So, if you are a clinician and you would like to learn more,

please check us out at psychedelicmedicineassociation.org.

Now, without further ado,

thanks so much for joining us today, Michelle.

Thank you for having me.

I truly respect you.

I think it's amazing that you're always giving education

to medical professionals about things

that we never learned in medical school.

Well, thank you so much.

I very much appreciate you.

And the work that you are doing,

I mean, I think we could do like 10 episodes

because you're tackling the things

that so many people suffer with

and suffer greatly.

And chronic pain is the one we're going to be talking about today.

So, I would love if you could start us off by,

I know we had a conversation a few years ago on this podcast.

Can you tell us what has changed or evolved since then?

What is the latest in how we're thinking

about psychedelics and chronic pain?

So, I think pain is defined

as an unpleasant sensory and emotional experience.

So, if you think about the definition of pain,

if it's an experience,

everyone experiences pain differently.

And it's not just about tissue damage

or physical pain in the body.

So, it makes us start to think,

well, if we are not really able

to alter the physical body to change the pain,

then obviously we need to start to think about the brain,

which is involved in chronic pain.

And so, I think that once I understood that

pain is just a message, right?

It's just a signal telling you something has to shift.

You're stuck somewhere and there's a message telling you

things are not going the way they should

and we have to dig a little bit deeper.

And so, we talk about the root cause, right?

So, how do we investigate what's the root cause?

Well, a lot of pain management

is really based on acute pain management.

And what I mean by that is you enter your back,

you do some physical therapy, maybe an MRI,

and then you get some injections or take some pills.

And that really may not be the source of someone

developing chronic pain.

And so, the way we treat chronic pain

has to be very different,

because now this is a abnormal sensory processing

in the body that's going up the spine to the brain,

to different regions within the brain,

and then back down to the body.

So, there's many medications, injections that we can do,

but over time, when it becomes chronic,

it's no longer trying to alter the physical body,

it's actually trying to reprocess what's happening in the brain.

That makes sense.

Yeah, I think neuroscience has really given us

a lot of information for us to start to take advantage of.

And I think that's really what changed.

Like, over time, past 15 years of me in private practice,

having thousands of patients in chronic pain,

if I understand that it's an experience,

I have to understand that their pain is real,

and the way that they're perceiving their pain,

or the way that their brain is telling them

to avoid activity,

or maybe certain beliefs that they have about

why they have pain,

or why their pain is not getting better,

those are the things that we need to investigate a little bit more.

Yeah, that's so interesting.

So, if I'm understanding you correctly,

there's areas in the brain that may be overreacting

to sensations that are coming in,

like you said, through the nerves of the spinal cord.

But then, I think you're saying that there's also an interaction

between other areas of the brain that are thinking about

how that initial area of the brain is receiving those signals.

Yeah, so there's actually this triple network model,

and it was created for a lot of neuropsych conditions.

And we have these different networks,

like the salience network, default mode network,

which we hear a lot about psychedelics and the central executive.

So, the way that these networks communicate with each other

will dictate how our chronic pain

either starts to get worse,

or maybe starts to get better.

And so, what I mean, you know,

what the actual science is,

is that we have these ascending pathways

from the body up to the spine,

and the ascending pathways actually have two pathways.

There's a medial and a lateral.

The lateral is kind of like where and what?

Where's the pain, what's happening,

and the medial is more of the suffering.

So, pain is really, you know, a signal,

but then these medial pathways are associated

with the salience network,

and that tells us to pay attention to something.

And so, now these medial pathways

are abnormally processing sensations,

and the pain doesn't really go away.

It becomes chronic.

The person starts suffering.

Then the salience network is connected to the default mode network.

Someone starts thinking about their pain more.

Their identity is now defined by their pain.

Their default mode becomes hyperactive,

because they're in chronic pain.

And then it's less connected to the central executive network,

which is the goal-oriented,

functional way of moving forward in your life.

So, these, I think the understanding

of this triple network model

has changed the way we look at chronic pain,

because we used to look at it more from, you know,

the brain and different parts of the brain,

the insular cortex, the limbic system,

all those types of areas.

Now we're looking at functional connectivity.

And I think that's where psychedelics and ketamine

really start to come into play,

because we could either decrease activity

within a network,

or we could increase the connectivity

amongst the network.

So, there's been some progress and evolution

of chronic pain,

and now we can't really just treat chronic pain

the same way we've been treating acute pain.

That, which is great for all these patients

that weren't getting better on whatever was happening before.

So, are you seeing an improvement in patients

now that we've got a better understanding

of how these networks interact?

So, I think number one is educating the patient

about the neuroscience of pain.

And that's because many patients were told,

you know, look at the imaging,

and we relied on all of these MRIs,

and therefore they were just thinking,

well, I have this condition,

so I'm always going to have this condition,

or they were continuously doing epidural injections,

steroid injections,

for a condition that's now chronic.

So, again, if we're just treating imaging,

then you think you can alter the physical body

and change the pain,

but once it becomes chronic,

it's more of a centrally mediated pain.

It's in the central nervous system.

We have to start to reprocess the brain,

and these networks are really what create

the chronicity of it.

So, you know, someone who is now thinking

that their identity is defined by pain,

they have fear about exercising,

or they, you know, their lifestyle changes,

they start to isolate,

they start to say,

no, the things that they once were saying,

yes, too.

And it's that neurons that fire together,

wire together, type of concept.

So, now they're in chronic pain,

and it just becomes part of who they are.

And the way I look at it is they need some type of disruption

within the nervous system to create some type of shift.

And they, you know, a lot of times they're stuck

in these mindsets,

but the thing is that we have given them this psychosomatic,

you know, a term,

and it's really not.

It's more of a neurological issue.

It's not a mindset.

It's not like they're not motivated,

like they want to be in, you know,

in that place that they're in right now.

It's actually that their brain is keeping them stuck.

And so, there has to be some type of disruption,

which I think is also the advancement of things

that create neuroplasticity.

I was, yeah, even before you re-broad that up,

I was going to ask about the challenges related to

when pain has become part of somebody's identity,

because there's the negative and the,

I mean, some gain to it,

potentially, right, if perhaps they had a maybe distance partner,

and now the partner is more caring because they're in pain,

you know, it's like, how do you address that gently

with patients that, you know,

like addressing anybody's identity

and potentially changing identity?

I mean, one of the things that scares a lot of people

about psychedelics is the ego-disillusion part,

like, oh, what if my identity isn't my identity anymore?

Well, these people are not in a psychedelic state,

but you're addressing to them, like,

hey, your identity may need to change.

How do you do that, like, gently with the patients?

Yes.

Well, I think that's where the whole biopsychosocial model

comes into play, because, you know,

they've probably already done some biological

or physiological treatments, right?

So they've probably tried to take different medications

to alter what's happening within their neurotransmitters,

they've tried, you know, different exercises

or maybe injections, and then, you know,

for chronic pain, you have to address the psychosocial aspects.

And what that means is maybe they're attached to a certain belief

or maybe they are in an environment with, you know,

surrounded by other people who also have very negative attitudes.

So what I do is I try to understand a little bit more of the whole person,

and I don't really look at pain as a diagnosis.

Again, it's just a message, it's a signal telling us

that something has to be explored a little bit deeper.

So usually I ask them, you know, like, in a very comfortable way,

like, tell me about what you think is causing the pain,

or tell me what you think could potentially improve your pain,

or what makes your pain better or worse,

or what are your sleep habits like?

Or, you know, are you able to do something,

and now you can't do that anymore,

and is that really contributing to you feeling depressed?

And, you know, people think, well, what's the connection

with pain and depression, right?

A lot of times people who are depressed, their sense of pain

or their perception of pain changes over time,

but then a lot of people who are in chronic pain start to feel depressed

because they can't do the things they once did.

So when I, you know, I think a lot of people are nervous to go to pain management

because they think they're going to get opioids or more needles.

And I want to allow people the option to really change the psychosocial aspects of their life,

because when one thing shifts, it could be a belief, right?

Like, maybe they have a belief that they are not good enough,

or that, you know, they're not worthy that they don't belong,

and that belief could actually change their biology.

So once you get to know the whole person, again,

even if they present with back pain or migraines or something like fibromyalgia,

you know, there could be multiple different conditions,

but again, if their identity is defined by pain

and their identity is attached to a belief,

and we start to explore that belief,

then we're able to understand a little bit more of what they think is causing their pain,

or what they think could improve their pain.

And a lot of times, similar with mental health,

there are these rigid narratives that keep them stuck.

And so things that open up their mind or create some type of, you know, even awe, right?

Like, when we do ketamine and they're able to, you know, see themselves

from a different perspective or just get a time out from feeling their pain,

it allows them a little bit of hope.

A lot of them start to feel very helpless,

and that helplessness causes them to have to, you know, rely on other people,

and then they're not feeling confident within themselves and independent.

And so it's really, pain is really chronic pain,

is really, you know, only properly treated when you treat the whole person.

And that's really why we use the biopsychosocial model,

and not just biological treatments.

I love that.

And you said something that segues us into what my next question was going to be,

so you were talking about those rigid beliefs.

And so that leads me to ask,

what are the proposed mechanisms that led you to think that ketamine

would have an effect on chronic pain?

And like you said, some of those rigid thought patterns.

So I think that when we learn about chronic pain,

we learn about the wind up phenomenon,

or the gate control theory of pain.

And in that theory, there is actually an imbalance of glutamate and GABA.

And those are the main neurotransmitters involved.

And when I started to learn more about ketamine and the mechanism,

and you realize that it blocks the NMDA receptor,

which is responsible for modulating glutamate,

I realized that also it's not just synanesthetic,

but it can create neuroplasticity because it can increase glutamate.

And so I started to think that none of the other drugs with pain management

really affect change within glutamate and GABA.

And so ketamine to me started to become more interesting

because I realized that this wind up phenomenon that is so responsible

for a lot of people's chronic pain can actually start to be reversed

when we start using medications that can change the balance of glutamate and GABA.

So it's interesting because when you ask, and patients ask all the time,

you know, why, if I do a few ketamine sessions,

will there be long-term change, right?

Like, you know, you're using ketamine for a short period of time.

It's a dissociative anesthetic.

So, yes, the anesthetic creates less pain or no pain in the body for a short period of time.

But how does that relate to the next day or two weeks later or a month later?

And I started to, you know, research what are the guidelines for using ketamine for chronic pain.

And the last consensus guidelines were in 2018.

So, eight years ago, so if you are a pain doctor and you're trying to use ketamine to treat chronic pain,

you're using guidelines that were set eight years ago.

And there's nothing that has come out since.

And so, and those guidelines basically say there's moderate evidence for a condition called complex regional pain syndrome

and mild for pretty much everything else.

However, there's moderate evidence for any chronic pain condition where there's an associated mental health condition.

So, if you have chronic pain and PTSD, depression, anxiety, there's moderate evidence.

And that also made me start to explore why ketamine can be used for chronic pain,

not because, well, it can treat their depression and therefore they feel better and so now they're more active

and then their pain goes away.

But there's really this relationship within the circus.

And I think the networks of the brain and so that started to make me a little bit more interested in understanding how to use it properly.

And when I first was trained, we would use ketamine very high doses, four hour infusions, five days in a row.

Okay, with no preparation, no integration, you know, this is like pain doctors just using ketamine like an anesthetic trying to block pain.

But we didn't pay any attention to their insight to any thoughts or beliefs that they may have about why they have pain.

And then we gave no instructions about that critical window after using ketamine and how your brain is very flexible and we can really make some change within the few days after it.

So when I started to learn about that, especially just neuroplasticity and that window, I realized it's actually best if we give ketamine and then we will be prepared them properly.

And then we give ketamine at a low dose just to create a little bit of neuroplasticity and then use the three days after as a window to start to, you know, really put in what we would want affect in terms of the change in their life.

And that's usually their lifestyle habits, the way that they're talking to themselves, the way that they're thinking their beliefs, their emotions, all of that.

And so I started doing ketamine very similar to psychiatrists for mental health, but for pain in the sense that I would do it twice a week for three weeks.

And I would use that window to really get in there and try to explore what changes we can make.

And I also tried to use the lowest dose possible where I wouldn't have to, you know, sedate them in any way where we would bring up insight.

And usually the insight can be very valuable. And I know that there's like a lot of, you know, a lot of controversy whether or not the psychedelic experience, you know, and the insight is needed in order to have positive change, but I just look at it as an opportunity.

Why would you shut down the potential for someone to really explore something a little bit deeper, it could be a past trauma, it could be chronic stress that they're just kind of stuck in a story.

And that's a lot of times what it is, you know, they create a story about who they are and how they got here.

And now they're in pain and that kind of, you know, starts to amplify all these different signals.

And so I just started to think, how can we use the lowest dose of ketamine to create neuroplasticity, guide them in a way that they're able to move and shift the story.

And then that's how you can create long-term change. And I also realized if the guidelines are eight years old, then, you know, it's not like I'm doing anything, you know, against what, what they say really, it's just more, how can we create better evidence?

And the sad part is that there's not a lot of research going on using ketamine, obviously, because it's already an FDA approved medicine that's been around for a long time, so people don't have the incentive to do these type of trials.

And at the same time, it is available.

So, you know, I will look at it like, how can we use a low dose of ketamine with proper integration to treat chronic pain. And also, it probably will affect their mental health as well. Why not capitalize on that.

I love it. I love all of that. And wow, eight years old. Yeah, time for time for some, some new thinking, some new guidelines.

So, in your paper that is released, and we've got it linked in the show notes, you treated some patients, all the patients in your clinic, but the patients specifically mentioned were treated with ketamine and some other interventions.

Can you talk about those other interventions?

Yeah, so one of the big parts of my practice is called pain reprocessing therapy. And this is a type of therapy that should be the first line for anyone in pain.

And the reason why is basically a mindfulness-based therapy that also includes some somatic work. So, it's cognitive and functional. And it was created by a man named Alan Gordon in Colorado.

There's multiple studies that have been published. They actually just had a five-year study published in JAMA that actually was the follow-up to the work that they've done where they took chronic pain patients. They all had low back pain. They had 50 in each group.

One was given pain reprocessing, one was placebo, and one was how we would usually treat pain. And so pain reprocessing is this way of mindfulness technique where you're able to sense things in your body, understand where that's coming from, perhaps you're feeling a sensation.

But maybe it's because you were just in an argument with someone in your stress, or maybe there's something coming up that's creating some fear that's amplifying the signals. Maybe you didn't sleep well, right?

So it's a mindfulness technique to try to track sensations in your body. And then use some somatic techniques to help you stop having fear and stop avoiding certain movements.

So the combination of the two is like exposure therapy with mindfulness. And it sounds pretty simple, and it really makes a lot of sense. And obviously there's no medication. There's nothing involved besides the person changing their experience to their pain by understanding that their sensations in their body don't they don't have to be scared of sensations.

They just have to realize that the emotion, which is usually fear, is amplifying these signals. So the study that was done, it actually looked at 50 people with low back pain, gave them pain reprocessing therapy, and 66% of them were pain free after doing pain reprocessing versus 10% from usual care, and 20% from placebo.

So, you know, the way I look at it again, pain management has to advance, but pain reprocessing should be our first line for any type of pain.

And it's just a simple technique. There's a book called The Way Out. People can read that. I recommend that to all the patients. And it's a great book because really the way out is, you know, a lot of people just feel stuck. So how there is a way out and the only way out is through.

You got it. You got to feel it. You got to sense it. So, you know, what we did was we use pain reprocessing therapy and some functional movement exposure type therapy with patients who had chronic pain, but where their chronic pain was a little bit different.

For example, one had a spinal cord injury, one had lower extremity dystonia, which is like contractions of their muscles.

The other one had some facial pain after a cycling accident. And so these patients, you know, as we did the pain reprocessing, and we use very low dose ketamine, and we use it in very personalized ways.

Sometimes we would use a psycholytic dose where we would give them a lasage. They would work doing pain reprocessing therapy with a coach.

Or they would come to the office and we do inter muscular IV ketamine. But the point is the reason why such there was such a big shift was usually not because of the signals in their body that have changed, but it was more because beliefs have shifted.

For example, the one guy who had a cycling injury and he had facial pain, the biggest issue was that his face looked different and he didn't like that.

And, you know, and trying to deal with the fact that his anatomy had changed and how he looked and felt about himself was actually the key that was keeping him stuck in pain.

And so when we can start to unravel, then he can start to realize he's grateful to be alive. And, you know, he still is able to practice and work and cycle and do all these things.

But he realized that the belief of the physical change in his face was actually the core of what was keeping him stuck and keeping him in pain.

Another guy was wanting to be a pilot and had an injury and then had a spinal cord injury and couldn't do that anymore. And that was his dream forever.

So now his dream was unable to be fulfilled. And that was really the core of it. And the woman with dystonia, she realized that her dystonia got worse when she was stressed.

And just to make that relationship allows them to realize they can affect change within their body.

Once they start to feel the sensation, now we give them techniques to basically calm the nervous system down and then exposure therapy.

If you move, you're not going to hurt yourself, you know, like we rate like it's like a graded exposure where we kind of pace them through these different protocols.

So it's really a combination of the pain reprocessing with the functional movement and trying to minimize the dose of ketamine.

And that's that was really the goal. And also using this multidisciplinary team approach, where it's not just me, but I have amazing coaches and nurses and therapists that I work with.

And we all really have our own value and working together as a team really can benefit the patient the most.

I love that. And I also think that, you know, I think we discussed this maybe like once per episode, but having even just that community of people on their side that they get to interact with, right.

We're finding out just so much of everything is loneliness these days. And you get to come in and have a whole team that cares about you.

I think that's that's, you know, it's not a thing that in studies, we can really evaluate. But I do think that like you said, having so many caring people on your side, showing up for you, rooting for you.

And providing you with information has to also help.

Yeah, I think you know, Dr. Pam, she says, come for the ketamine stay for the community.

I love it. Yes. Oh, we love we love Dr. Pam. So speaking of the ketamine, what did their actual protocol look like?

Well, so the whole point is it was personalized and that's the bottom line is that when we talk about ketamine, which usually this 0.5 milligram per kilogram up to 1.2 milligram per kilogram.

And you know, we started a low dose usually and we increase it slowly.

And in this case, one person lives far away. She actually lives in the keys. And so we would actually do low dose ketamine during a coaching session with her.

And the other one, he would come in twice a week for three weeks and had intramuscular ketamine and we would start a low dose and increase it from there.

And then and then it would be like, you know, the whole point is we're treating the person. I'm not treating the diagnosis. And I think that's where people realize, okay, well, you have, you know, chronic migraines or you have fibromyalgia or you have pelvic pain.

That doesn't mean that that dictates the dose that you're going to give someone. It's really you're treating the person. If they have a tremendous amount of anxiety and they're not able to let go and surrender into the experience, I'm probably going to start a lot lower.

If they are, you know, having difficulty with functional movement, maybe we can do a low dose, a lot of things and start to basically like desensitize them and have their nervous system start to understand that they're able to do certain things and realize that fear is probably what's creating more of that pain.

So the point is it was personalized and everyone got it, you know, different dose, depending on how they did. It was a process that happened over time and it still continues.

And that's the other thing to realize is that it's not like a one and done type of deal and people need multiple sessions. And the other thing I would say is that there, there is maintenance that is required and that can be because they, you know, hear about something that stresses them out.

Or they're, they have a new injury that then amplifies different signals in their body. So they're just because there is some type of maintenance. It doesn't mean that the ketamine didn't work. This is again to me is, how do we learn and grow and continue to evolve and not really just get stuck in these boxes of you have this diagnosis. And this is a treatment for you. But to be open and flexible to realize that the brain is constant.

The brain is constantly evolving. We're always learning new things. And so we can't really just get stuck in taking this medicine every day that's going to numb me, you know, like antidepressants like opioids or becoming dependent on a treatment outside of yourself. And I think that's the key is to understand that we are our own healers.

We're not involved in actively participating in our treatment. Then we're relying on someone else outside of us. And that's not really a long term plan.

Yeah, that makes total sense. And also I love the emphasis on lower dose. You know, I've worked spent the past year working in a ketamine clinic. And I think there was this overall thought by a lot of the patients that more was better.

And as you said earlier, more can shoot you past the point where you're able to have the insights and straight into just kind of this numbness. And so I love that emphasis on just getting them to the point that they need to get to with the ketamine to do the things that you think the biopsychosocial interventions that you think will be helpful.

Right. And I do believe that that's a really important point because more with ketamine is definitely not better when people feel so disconnected and so separate from themselves.

They can experience more fear. And I think that it's important to have that like sweet spot where they're able to get that time out.

They're not really feeling their pain. They're not in their ordinary mind and their conscious thoughts and they're able to have the brain connect in a different way and experience things differently.

Which then creates hope and allows them to really wake up and say, oh, there are other options out here for me. And I think the having support is the most important.

Having them, you know, feel safe with us, but also starting to regain feeling safe within their body because many of them who have pain are thinking that their body is telling them there's danger and their brain is like, oh, there's, you know, some type of threat.

And we're trying to calm that that alarm down the alarms going off, but there's no real damage. And it's really coming from these the way that these networks are communicating.

That makes sense. And and can we discuss now how those at least the patients in your your study or your your paper fared with this.

Yeah, so so we actually looked at so we actually, you know, the problem with pain management is they just look at pain scores and pain scores one through 10 are so subjective.

How many patients do I have that tell me my pains 10 out of 10. How was your pain a 10 out of 10. If you're in the office sitting talking to me, your scale then has to, you know, be recalibrated.

So, you know, we look at pain scores, but that's not really a great measure because it's so subjective. So we looked at quality of life. We looked at function and we looked at suffering. And I think that, you know, suffering to me is really what they're resisting.

Like, like, you know, I think it's I think suffering is basically pain plus resistance. Like what what what is it that they're getting that where are they stuck? Why where what has to shift and a lot of them, you know, again, it could be a belief. It could be a thought. It could be some some social environment that they're in that's not working for them.

But I think the resistance is what amplifies the suffering and I think the suffering happens to really create more of that mental health component where they feel depressed or anxious. So what what ended up happening, you know, the three patients, they had a significant reduction of their pain scores.

They also had a reduction of suffering and they improved in their overall function. And so a lot of like one of them was able to he he now is in school trying wanting to be a therapist.

The other one is a veterinarian. He went back to work and the other woman was she got marriage, you know, like so many things change in her social life because she wasn't attached to this identity of I have chronic pain.

So so there's you know, I think the important part of the paper is really to think about what's the lowest dose of ketamine you can use to affect change. How can we support people prepare them properly integrate them to have longer lasting effects. So we need to use less medicine.

And also for pain management, we should really be asking them more about their overall function, their lifestyle habits and quality of life and not just asking what's your pain one through 10.

And if we you know that the easiest thing when someone is in chronic pain is to help them sleep better. If they're sleep is poor, their pain is going to be worse. If they're not moving their body, if they're not eating well, if they're not socially connected to others.

So, you know, the foundation of health is the most important. And then we could talk specifically about the pain, but over time they'll realize it's less in their body and more in their brain.

And therefore the things that we do have to really focus more on the brain and reprocessing things as opposed to putting needles in the body and taking more medicine to kind of numb different symptoms.

Yeah, and I think that the way you put that to some people, they may think, what do you mean it's just all in my head, but actually this is this is probably a good thing because that says like you said, your body is okay. I mean, maybe not in all instances, but it's less that like your body needs to be protected and more that we just need to address some some neuron interactions and then things may improve.

Right. And a lot of it could be mindfulness, you know, like just tracking these different sensations and understanding that an emotion is amplifying a signal. And therefore then they realize, oh, they have the ability to make this change on their own.

That, you know, that's kind of the like, why does someone, why does someone who has a cupane develop chronic pain versus others who have a cupane, the pain goes away. That's really what we have to understand. And most of the time it's a trauma that was never treated properly.

They're chronically stressed and their lifestyle habits are poor. This is how we develop chronic pain. That's kind of that central sensitization where their nervous system is hyper reactive.

And so no matter what's happening, they're sensing things in an amplified way. And the best way to do this is really to have them understand that there is support. There are ways out.

And even just, you know, reading that book the way out or trying pain reprocessing therapies, not like people need ketamine. They need pain reprocessing therapy, like a very conservative thing.

But when you do, you know, the problem is when they're really stuck for a long time, the ketamine is that catalyst to really like the spark, you know, it really starts to change within the nervous system.

The pain reprocessing therapy helps move them forward. And then they're able to do a lot of this on their own. And then later on, they can use these techniques for any other message that their body is sending them.

I love that. I love it so much. And a great place to wrap up this conversation unless I've left anything out.

I think I think we hit on most effects. Yeah. Excellent. Michelle, can you tell people where to find out more about your work and your research and your clinic?

Sure. So my practice is called Neuro Pain Health. We are in South Florida.

Website is Dr. Michelle Wiener.com, Instagram linked in same thing.

And anyone who wants to come and work or shadow with me in South Florida, you're always welcome. I also have a palliative care fellows who work with me and some medical students just to show them the integrative pain management side.

That is such a generous offer. I love it so much. Thank you so much for the really important work that you do and the research and all of the things. And of course for sharing it with us.

Thanks for having me. Absolutely. Okay, for everybody else out there. Until next time.

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