Neha Pathak, MD, FACP, DipABLM: Welcome to the WebMD Health Discovered podcast. I'm Dr. Neha Pathak, WebMD's chief physician editor for health and lifestyle medicine. If you've ever wondered why some aches seem to fade with time while others linger, intensify, or pop up in new spots, this is the conversation you've been waiting for.

In today's episode, we're exploring the increasingly complex world of pain management—how to tell the difference between acute and chronic pain, why our brains sometimes become amplifiers instead of shutting pain signals down, and how conditions like fibromyalgia provide a window into understanding pain that can't always be traced back to a single injured body part.

We'll tackle the tough questions that so many of us grapple with: When is pain medication appropriate? Where do opioids fit in—or not fit into—a long-term pain plan? Why do older, non-opioid drugs still have a role in modern pain management? And how do therapies that seem far removed from a pill bottle, like mindfulness and cognitive behavioral therapy, make a real difference for people living with persistent pain?

If you or someone you love has struggled to find lasting relief, get ready to learn more about the changing science of pain and the importance of turning down an overactive pain system.

First, let me introduce my guest, Dr. Daniel Clauw. Dr. Clauw is a professor of anesthesiology, medicine, and psychiatry at the University of Michigan. He serves as director of the Chronic Pain and Fatigue Research Center.

Welcome to the WebMD Health Discovered podcast, Dr. Clauw.

Daniel Clauw, MD: Hey, how are you?

Pathak: Before we jump into our discussion around chronic pain, I'd love to ask about your own personal "aha" moment or health discovery when it comes to your work and research on chronic pain.

Clauw: Well, very early in my career—I am clinically trained as a rheumatologist—there were individuals being referred to me with what was then called fibrositis. No one really knew anything about the condition. People even wondered whether these patients had anything wrong with them or if they were making it up.

But I always believed that there really was something wrong with these individuals. So it's been very gratifying over the last 30 or 40 years as a researcher, as tools like brain imaging and other diagnostic methods have become available. We were able to show that conditions like fibromyalgia are, in fact, very real. But the pain is really coming more from the brain than from damage or inflammation in a specific area of the body. That requires people to rethink both how they diagnose pain and how they treat it.

Pathak: I'd love to dig into that some more, but first, let's start with the basics.

Can you help us define pain—specifically acute pain versus chronic pain?

Clauw: Acute pain is almost always adaptive. You bang your thumb with a hammer, you have surgery—something happens that’s supposed to hurt, and it’s time-limited.

Chronic pain is typically defined by how long it lasts. For most regions of the body, pain that persists for three months or longer—at least half the time—is considered chronic pain.

We know that the mechanisms underlying chronic pain are quite different from those of acute pain, which is one of the reasons these distinctions are made.

Pathak: Help us break this down even more. When we think about pain, we often recognize different types—nerve pain, muscular pain, joint pain.

Can you explain why the root cause of pain might predispose someone to chronic pain? Or why one type of pain might be more likely to create changes in the brain than another?

Clauw: There are thought to be three overarching mechanisms of pain.

The first is called nociceptive pain—the kind of pain most people think of when they think of pain. In nociceptive pain, there’s damage or inflammation in a specific region of the body, which activates nerves in that area. The signal then travels up to the brain, where it’s perceived as pain.

The second type is neuropathic pain or nerve pain. This occurs when the nerves carrying pain signals from the body to the brain are damaged or compressed. Neuropathic pain typically follows the distribution of a specific peripheral nerve.

The third type, which has gained more recognition in the past decade, is the kind of pain seen in conditions like fibromyalgia, headaches, or irritable bowel syndrome. The term now used—nociplastic pain—was previously called central sensitization, a term I prefer because it better conveys the idea of a centrally driven problem.

Brain imaging and other studies suggest that in conditions like fibromyalgia, the brain and central nervous system become sensitized. One analogy I frequently use is that pain perception is like the loudness of an electric guitar. You can make an electric guitar louder either by strumming the strings harder or by turning up the amplifier.

In conditions like fibromyalgia, the issue is more about the amplifier being turned up too high. These individuals have a central nervous system that is overly sensitive—not just to pain but also to bright lights, loud noises, and other sensory stimuli.

Although we talk about these three types of pain separately, they often overlap in an individual. Someone might have joint pain from arthritis but also have an overactive amplifier, making their pain feel more intense than it would if they only had nociceptive pain.

Pathak: That’s a great description. It helps us understand why pain management needs to be multifaceted—because the cause of pain could stem from multiple sources.

How should we think about evaluating our own pain so we can manage it effectively?

Clauw: The first step is to create a body map. This can be done formally or just by drawing a simple mannequin on a piece of paper and marking all the areas where pain is experienced.

This is incredibly helpful because the more locations someone has pain, the more likely it is that an overactive amplifier—central sensitization or nociplastic pain—is playing a role. If pain is widespread rather than limited to one or two areas, it’s less likely that there are multiple separate problems in each location and more likely that the central nervous system is amplifying pain signals.

We’ve learned over the last decade that a body map is a simple yet powerful tool. Often, when someone comes in with a chief complaint—like low back pain—they won’t initially mention that they also have pain in multiple other areas. If you don’t ask, you might not start treatment in the right place. Multi-site pain needs to be approached differently than pain localized to one or two areas.

Pathak: What's next in your thought process when it comes to helping someone manage their pain?

Clauw: So, for a person with more focal pain, you would use more peripherally directed treatments. You would use medications like nonsteroidal anti-inflammatory drugs or acetaminophen. You would use injections or surgical procedures if those happen to be options for pain in that region of the body. You could use ointments or similar treatments.

Physical therapy would work better for that kind of pain because it's confined to a region of the body. You really have to try to fix the bones, muscles, joints, and nerves in that area. So, you're focusing your treatments on the periphery.

In contrast, if someone's pain is much more widespread—if they have had other chronic pain conditions over the course of their lifetime—these centrally driven pain syndromes are often accompanied by other central symptoms like sleep problems, memory problems, fatigue, and sensitivity to bright lights, odors, or noises.

When you see more of that kind of pain, your treatments have to be more centrally driven. You need to help people sleep better, get them exercising, or at least increase their activity levels. You’re using different types of treatments, including integrative treatments—what we used to call complementary and alternative treatments but now refer to as integrative treatments. Those are the preferred treatments.

You're also keeping opioids away from that latter group of people because they don’t work for this kind of pain. In fact, they might even make it worse. When you use medications, you're using non-opioid, centrally acting drugs like serotonin-norepinephrine reuptake inhibitors, tricyclic drugs, and gabapentinoids—drugs that work primarily in the central nervous system.

Pathak: Can you talk a little bit about where opioid medications have a role and where they do not?

Clauw: They work really well for acute pain, but they don’t work very well at all for chronic pain. They seem to especially not work for chronic pain like fibromyalgia—pain that originates from the central nervous system. My concern is that they often make that kind of pain worse. There are a lot of studies that suggest that.

I don’t have any problem with using an opioid for acute pain. The problem is that sometimes, we don’t know when acute pain is going to remain acute and when it’s going to transition to chronic pain. That’s where the issue lies. I don’t think the average prescriber of opioids fully understands how little data exists to support their long-term use for chronic pain. There aren't really good studies showing that they work for chronic pain, and there are concerning studies suggesting they may actually make pain worse in a subset of people.

Pathak: I’d like to go through some of these options piece by piece. Going back to integrative therapies, are we talking about things like yoga? Acupuncture? Can you talk more about these types of therapies and the evidence supporting their benefits?

Clauw: Yes, we’re talking about all of those things—many of which we used to be dismissive of, especially in the United States. In fact, I encourage people not to use labels like “complementary” and “alternative” because those terms imply these are second-choice options.

But these therapies work just as well as many of our drugs for chronic pain conditions, and they are much safer. So, why would we consider them alternative or complementary? They should actually be first-line therapies based on the evidence.

Many of these therapies weren’t well tested in randomized controlled trials until about 15 or 20 years ago. About 25 years ago, the NIH established a new institute focused on complementary and alternative medicine, now referred to as integrative medicine. Over time, that institute funded many high-quality studies on yoga, acupuncture, tai chi, and similar treatments.

More often than not, these therapies work for chronic pain conditions. Some of the latest meta-analyses examining non-drug therapies show that the evidence base continues to grow. The more studies accumulate, the clearer it becomes that while no single therapy works for everyone, these approaches are valid and effective.

When treating chronic pain, you often have to try different things. It’s rarely one therapy alone that makes the difference—it’s usually a combination. For example, acupuncture and yoga might work well for one person, while another benefits from a certain medication in combination with physical therapy. Meanwhile, some treatments may not work for them at all. Unfortunately, managing chronic pain often involves a lot of trial and error.

A lot of the research being funded now—by the NIH and others—is focused on better identifying what treatments work best for which patients. For example, if someone has low back pain, is the problem in the back, the nerve, or the brain? We’re working to improve patient phenotyping so we can better understand the mechanisms behind an individual’s pain and choose treatments accordingly.

Pathak: I’d love to transition to some of the other treatment options you mentioned, especially regarding the amplifier effect. Can you talk about tricyclic medications and serotonin-norepinephrine reuptake inhibitors? How do they work?

Clauw: Both tricyclics and serotonin-norepinephrine reuptake inhibitors work by increasing activity in the descending analgesic pathways—the pathways that run from the brain down to the spinal cord. The more active those pathways are—especially with norepinephrine and, to a lesser extent, serotonin—the less pain is transmitted upward.

Gabapentinoids work differently, but they are another major class of centrally acting analgesics. Instead of working on GABA, as their name might suggest, they actually reduce glutamatergic activity.

Pathak: I’d love to ask about a recent announcement from the FDA. They just signed off on the first new type of pain reliever in over two decades, and it has a different mechanism of action. It seems to work by preventing pain-signaling nerves around the body from firing in the first place. Can you talk about this new therapeutic option?

Clauw: Yeah, you described it quite nicely. It is a drug that works on a channel in the nerve, and in helping block that channel, it blocks conduction of pain. As you said, it's very peripherally focused, peripherally acting, and that's why the two conditions that it was shown to be effective in—and it's approved for—are acute pain conditions. They did studies in sciatica that didn't look for it to be effective compared to placebo.

It didn't work any better than placebo. So, so far, it looks like it might work quite well in acute pain. And again, because it's working peripherally like that, that would make sense.

Pathak: Really, really helpful discussion. I just love to sort of talk to you about your toolkit or what someone might think about in their multimodal pain management kit. How would you want folks that are listening today who are dealing with chronic pain to think about their toolkit for managing this pain?

Clauw: Try new things that you haven't tried—new non-drug therapies that you haven't tried. There are at least 15 or 20 non-drug therapies: acupuncture, acupressure, mindfulness, all sorts of different types of meditation, cognitive behavioral therapy for insomnia, emotional awareness therapy. I could just keep naming, but there are so many non-drug therapies that have been shown to be effective.

The problem is, when people have chronic pain, they get tired of trying new things. They've tried a lot of things that don't work, and they're sort of sick and tired of trying things. And I get why people almost give up. But what I say to people is that all of these non-drug therapies that I'm listing—and many more that I forgot to mention—work in about one out of three people.

So if you're a chronic pain patient and you try three of those therapies over the next year, odds are one of them is going to help you enough that you keep doing it. And that's a win—you can incorporate that into your routine and then move on.

The other thing is, as a patient, discard the therapies that don't work. People have a tendency to accumulate drugs and even non-drug things—someone said, "Do this, do this." Try one thing at a time and give it a trial. If it works, keep doing it. If it doesn't work, discard it. But don't keep taking drugs or doing non-drug therapies that haven't really been effective for you.

You have to become your own pain researcher—try different things, see if they work, retain the ones that do work, and move on to try something new.

Pathak: In your research, do you also think about expectation management? Because I imagine that also has some role in whether or not you perceive a treatment as being effective. If you are sort of expecting that a treatment is only going to be considered effective if you can get to a pain level as close to zero as possible, when—based on everything we discussed—you might need several different strategies together to get yourself to a pain level that's manageable, how do you approach this idea of expectation management when it comes to chronic pain?

Clauw: That's embedded in several types of cognitive behavioral therapy. In fact, one type, called acceptance and commitment therapy, essentially says, "You are going to continue to have chronic pain in all likelihood, even if we find treatments that are working." And so, let's focus on function—improving function—but not focus as much on pain intensity or pain level. Instead, let's ask: What are some things that you would like to be able to do that you can't do?

Let's figure out ways you can do those things—use patient-set functional goals as a way of motivating individuals to try new things. Again, as physicians, we shouldn't think that our patients are going to be motivated to get their visual analog pain score from a seven down to a five.

If they can get their pain better so that they can play nine holes of golf or pick up their grandchild, that's highly motivating to them. We should use those types of motivation in partnership with our patients—a functional motivation, not just pain scores and numbers.

Any final thoughts or strategies for someone who's listening today? What would you like them to start thinking about incorporating as they're listening to this, or right after they stop listening to us talking?

I think the biggest revelation is that the brain and the central nervous system are playing a much more prominent role in most pain conditions than we thought or understood. So, embrace the use of some of these treatments that are more centrally focused as well as peripherally focused.

And even consider changing the way we talk about some of these integrative therapies—ones we may have been dismissive of because they started 3,000 years ago.

Clauw: But things like yoga, acupuncture, tai chi, and other more mainstream treatments can be extremely helpful.

Pathak: Well, I want to thank you so much for your time. This has been a really helpful discussion, and I hope anyone listening who is struggling themselves or helping a loved one manage can take some of these tips home and start using them right away.

Clauw: Thanks for having me.

Pathak: Thank you so much for joining us as we explored the topic of pain management. Dr. Clauw covered some really important topics—from the different ways pain can arise in our bodies to how our brains can actually turn up the volume on discomfort.

We learned that the more widespread or long-lasting pain is, the more it may be driven by processes within the central nervous system. That means our treatment has to go beyond just fixing what's happening in the muscles, joints, or nerves.

From mapping out all the painful areas on a simple diagram to exploring nontraditional therapies like acupuncture or yoga, we have a wealth of tools at our disposal that can help dial back that internal amplifier.

We also heard how crucial it is to take a personalized approach to pain management. What works for someone with a clear injury in one area might not be the answer for someone with multi-site pain that has persisted for years. Rather than a one-size-fits-all solution, it's about layering strategies: physical therapy, medication if needed, integrative therapies, and even mind-body techniques.

The ultimate goal is not always to eliminate every twinge of pain, but to restore function and quality of life. If this episode inspired you to try something new, remember that it often takes trial and error to find the combination that works best for you or a loved one.

Keep exploring, stay proactive, and don't be afraid to enlist all the resources available to you. To find out more information about Dr. Clauw, make sure to check out our show notes.

Thank you so much for listening! Please take a moment to follow, rate, and review this podcast on your favorite listening platform. If you'd like to send me an email about topics you're interested in or questions for future guests, please send me a note at [email protected].

This is Dr. Neha Pathak for the WebMD Health Discovered podcast.