Finding the Hurt in Pain – With Irene Tracey, Ph.D.



hi I'm Bill glove an editor of cerebrum today's guest on our monthly cerebrum podcast is irene tracy all the way from the oldest english-speaking university in the world oxford dr. traci is author of our article finding the hurt in pain the article examines how brain imaging is opening our eyes to the richness and complexity of the pain experience this includes such things as neural chemistry network activity wiring and structures dr. Tracy holds the Nuffield chair of anaesthetic science and is the head of the department of clinical sciences neurosciences at the University of Oxford she helped to co-found and for ten years was director of the Oxford Centre for fMRI at the University in 2015 she was elected a fellow of the academy of medical sciences and in 2017 awarded the Feldberg prize welcome dr. Tracy let's start with the articles interesting turn of the phrase title can you tell us what you mean by finding the hurt in pain sure bill if I could to be here with you all I was interested to write this article to communicate to both the scientists and the interested in a listener or reader the challenge we have as either paint scientists or pain clinicians and for pain patients anybody out there that has pain as to what it is we've been discovering to unravel this mystery of why it is that pain hurts what's the point of pain hurting and importantly when it goes wrong in chronic pain sufferers where is that hurt based and whether the science can help us try and come up with better ways of treating both acute and chronic pain so for me I wanted to describe some of the excitement in the science I wanted to alert people to you know the fact that paints been around for a long time it's one of our oldest sensory and emotional experiences and yet we still haven't really nailed this question and and well we've got the question but we haven't nailed the answer to the question in terms of what actually constitutes the her experiencing pain hmm I couldn't help but notice that your husband is a climate physicist at the University I'm sure you consult with him on raising your three children but do you ever consult with each other on your respective disciplines absolutely I think for a lot of people who are in Sciences even though you work in very different topics and areas there's a commonality about science and both in terms of the approach one uses and the sort of philosophy and the logic behind how you formulate a hypothesis and how you go about testing that question and our hypothesis with experiments or with theory and then interpreting the data accordingly and when you're working in the physical sciences as he is in sort of climate physics and in my own technique of neural imaging which requires quite a lot of computation and mathematical algorithms and methods to analyze the data that we're getting from the human brain actually then surprisingly quite a lot of commonalities in the methods and the image analysis and the data analysis approaches that we both use so we find often not quite pillow talk but certainly you know over breakfast or dinner that we do talk about sometimes the experiments and where maybe you know we're struggling a little bit with a different way of maybe trying to analyze the data and then he'll share what they're doing in the physics world and they've been quite nice examples of where both sides have benefited each other in wool incidents some of our image analysis software one of our image analysis guys has used some of what we called the brain registration methods when we were able to register everybody's brains into the same sort of space and people's brains around I think bit if you like so that we can be sure that a blob of activity and one person's brain can be represented similarly in another person's brain and that approach can be applied to weather patterns and the movement of clouds from one day to another and trying to sort of rearrange and overlay things and register again complex weather patterns interest him in a way and then vice versa some of the work that my husband's been doing looking at how you would predict a next event if you like we could apply to some of our brain imaging data more related to our work in anesthesia and how the brain goes to sleep during anesthetics and again we could take up some of his algorithms and applied it to our own data so that's been really exciting hmm is there anything in your life experience that inspired you to devote your research efforts to better understanding pain not particularly not have I was a very sporty individual growing up so it was always you know in their teens I was a hockey player field hockey player and rower and things I did have a bad knee injury playing field hockey during my doctorate and really bust my knee badly on astroturf I had to have an operation and of course willingly volunteered myself to be on the post-operative trial for analgesics and I was put family on the shamon so I was not given any and and then you know really witness myself with really painful post-operative pain which went on for hours and hours they actually don't forgot but I was all the trial and forgot to give me some about four hours later so I was really suffered for quite a long time so I'm not going to pretend that was sort of what alerted me but certainly it made an impression on me that wow this is quite an extraordinary experience and you know as I was moving into neurosciences at that point using again brain imaging it taught me that this is an area that you know we really knew very little about and here were some tall you know these non-invasive brain imaging tools where we could actually look at the very organ the brain from which the perception of pain arises and it struck me that actually you know your experience of pain can change quite a lot due to things like you know whether you're attending tonight or distracting and depending on your mood and so I was you know again reflecting you know automatic service for myself interested to know whether those influences how do they play out of a sort of physiological level in terms of what brain networks are bringing you know coming and being used to make that pain experience worth if you paid too much attention to it all you feel very anxious about it so you know that was an experience that happened to me and you know it's sort of go into the states and doing a postdoc there for a couple of years which really consolidated the fact I wanted to move the you know magnetic resonance techniques that I was sort of trained in into this area of neuroscience and and specifically into the era of pain sort of that that journey I guess that brought me to where I am today I think quite often in science there isn't sort of a light bulb moment but there's things happen on your sort of life journey that intrigued you or just their latent and and then on that sort of journey of life you you know you realize actually they've been influencing you and guide anyone on the past for why did you end up you know as an academic working specifically in in a particular area do your do your kids or or other people tease you about pain as your as your discipline oh yeah no I get a lot of teasing about that and I move them yeah so you get yes because pain is you know people are pretty terrified of pain and rightly so and so and it's something that everybody has experienced you know in their lives and so I think it does puzzle people and it intrigues people why you would choose to work on it but then you know in conversation quite quickly they realize yeah actually wow this is something that's actually so so old you know Brittany Belushi terms and so important in terms of its warning and so intriguing you know as Western offices have puzzled over it and the fact that it's such a subjective private experience and it's really hard to know and understand and it had all these societal influences of you know biases and culture and stuff of course got this great clinical need that is suddenly when you were in a packet you realize there's an awful lot to it and I think then people quite quickly realized yeah actually that's makes total sense why you'd want to add in your scientists particularly using these non-invasive techniques you know direct all your energy and attention to that because it allows you to really answer some very fundamental questions about the brain and how it works and perception and what we mean by perception but also understand you know a very fundamental experience that we all share but then it's also got this huge clinical relevance and again I think a lot of society is rings unaware of just the enormity of the chronic pain problem in modern society hmm boy if you're my mom you'd be wide open to some some some quips about fact that my mother's an expert in pain because she delivers it to me all the time go there Oh Mac me you know I could I don't I don't like good friends my kids because we've got all sorts of wonderful ways we can inflict pain on their on our subjects well it's like a loud question I should quickly add but yes no sometimes I'm also a Roman Catholic so of course you know we'll get teased a little bit there that sort of goes with that territory too this is this is really the reason why I work on pain oh boy yeah no but for my kids yes sometimes I can whip out you know alright guys I'll take you to the lab if you don't get a bed it could be quite handy yeah that's great why is it that two people who experienced the same injured injury experienced pain differently oh that's a great question though well we're still trying to understand that I think you know historically we sort of thought that was largely explained by their attitudes but maybe their cultural upbringing as to what level of expression they were taught to give you know something aversive an unpleasant like pain and I think quite you know we're quite confident now in the last decade or so with again research both from a genetic level and a sort of what we call systems neuroscience so again looking at the whole person would say techniques where you can see what's going on inside the brain and the spinal cord but we're more clear now that these differences aren't and cannot just be simply explained only by cultural differences they really are physiological difference that are genetic and so variances in people's genes will influence their threshold variances in the how they have been brought up the whole sort of nurture nature influence and so this concept of the epigenetic profile the idea of how your genes are altered if you like dependent on your environmental influences as you develop I think people should remember that the central nervous system is you know very rapidly developing from you know a baby through to infant years and adolescence and through to adulthood and so your life journey and all the bumps and scrapes that you've had on that journey and the different experiences you have both psychologically and physically and culturally we're all influenced how your central nervous system has been wired up and increasingly we think this is you know really quite important therefore what it explains not only just the differences in if I gave somebody a you know a thermal burn how they would describe that as maybe more intense or less intense but importantly and more importantly it might explain why one individual ends up to what seems like the same injury in a persistent chronic pain State and somebody else recovers from that after three or four months so this idea of a resilience or a vulnerability in your central nervous system towards developing particularly persistent chronic pain and I think for a lot of other central nervous disorders and diseases as well I think the neuroscience community is getting more confident it's still early days but we're very more confident that these influences really probably can explain and loss about why won't patient ends up on one trajectory and another ends up on a different one and it comes down to these issues of vulnerable networks and resilient networks and that's a big part of what we're trying to understand the research and what are those networks can we fix them can we you know unwire bad wiring if you like and make it better again and then can we do to make a vulnerable turn from there a resilient one since since I think you're alluding to the fact there is a genetic and perhaps cultural tie have you found them that there are some cultures where the people are more resilient or can withstand a greater amount of pain so when we don't do research on that but certainly the community the painting is very interesting these questions are there large studies being done in various countries studies been done with twins who have again shared genetic backgrounds at different upbringing experiences some communities which have been quite remote and so quite homogeneous in their sort of gene pool and so that date has been gathering is being gathered at the moment and the genetics being looked at there's no particular answers yet but we hope that that work that's ongoing and again quite recent will give us some clues as to what are those explanation factors as to why some people are more resilient and more historical and others are not certainly we know sort of just by observation and anecdotally that certain either going to the cultural influence in certain cultures are a different so you know I don't mean to be glib but you know sort of more Nordic countries where again the expectation is not to express necessarily you know so much the suffering again you know there are studies being done looking at again how we're in poverty child birth compared to other countries where it is encouraged to be very expressive and very sort of if you like Latin and very vocal and passionate about describing your pain again this is an expression it's it's the the way somebody describes an extend you know the ports their pain is another component to the whole picture of pain if you like so here we need to understand is what what is going on physiologically the background in terms of what their experience is which might be very very related to how they express it or it might be different to have expressive because they're expressing you're due to a cultural influence but actually what they're feeling physiologically if you like might be quite similar they're twenty different cultures but the way they describe and express it would give you maybe the impression that they're feeling it more or less knew these things are very interesting and what we're looking at is you know the same again for men and women you know the question I often get out is you know do do do men you know the sort of man flu thing you know do they really feel it more and that is an area that we're doing some work on and looking at again differences of how hormones and differences in hormones play out and how even the difference in hormones that women experience throughout their period and the month recycle how does that influence the experience and these things I think of you know quite surprised us how powerful they are changing away these signals are processed in changing the experience so I think you know early days but again it's an area of science that people now mu going into and it's very important because this cut is on for the miracle social neuroscience where you're asking questions about society and cultures and these things which I think historically haven't been studied as much under the sort of broad Neera science and runner but they're really really important for us to understand in your article you write them out about the placebo effect can you tell us about what the placebo effect means in pain research very important the whole concept to see those always linked closely to pain and pain relief and goes back to time began where people didn't have you know drugs and lotions and potions were given to individuals and without any proof of efficacy and people would have good efficacy from them and that was understood they really believed there was some you know active agent in there but chances are you know there was nothing and it was very much a Percy birth hangs formally really recognizing you know the idea that you could have pursued by Wu Jie Jie was really understood better and Henry Beecher was a very pivotal physician who really proved he was significantly statistics that the placebo effect even giving soldiers you know saline injection rather than walking mounted similar good pain relief effects and therefore the pseudo analgesia in the absence of an actual agent you know was a true thing and existed and was very very powerful and so what's interesting about it what I try to touch on the article is actually the sort of almost irony of how we use the word placebo what it means I think what the science has taught us particularly your imaging in the past decade and a range of experiments is what the physical basis of Perceval analgesia is so how is it and why is it that people have analgesia what is the network being used and and we're very clear now on what that is it's probably an area that in terms of brain science that we know best have any sort of pain science is about the placebo network and what's interesting is it's a network that we use when we distract ourselves from pain it's a very old network something in the brainstem we use it a lot when we're you know me watching a very gripping movie or very distracted on the sports field and we don't feel the pain of injuring and afterwards and at a high arousal situation is over you suddenly realize oh my goodness you know I've been cut it's really for and you feel that pain but you've blocked it at the time this is a very powerful Network and that's the network that surrounds your hijacks and uses so there's nothing particular out if it's using a very old very powerful endogenous system that the body has given us in order to you know combat pain in situations where we don't want to be distracted by the pain so you've got something else new pressing to deal with and so quite a few of us are quite keen to sort of refrain placebo because the word Percy both comes from the Latin it's the word that our birth chants in Latin that we use by monks who were hired and paid money to in order to come and mourn at your funeral if you didn't have any friends and so the very word and what it means or what it signifies is fate and fakery and so you have the whole problem around the use of the word and people's impression of what the word means that they equate if you have a perceiver effect well then you didn't really have a thing in the first place so you're faking it and that couldn't be more wrong it just is flawed it's all a fraud understanding of what a placebo active manipulation is so I think the science in the past decade has been you know really important at raising in society and an ethics committees and in from the drug trials and what do we mean by the perceive alarm actually what do we mean by the placebo arm and is that the right word we should be using do we really all now understand what we mean by that and how does that change the way we fundamentally think about a whole host of situations where before he thinks they know what they mean but to see those but actually that's coming up we should rethink it speaking of baking then how does this differ from let's say psychosomatic disorder well but you know again people have different definitions of what they mean by that so maybe I sort of we we described possibly what you're asking is this very challenging question of people having pain where you can't determine well the origin of the injury is you know so we're we're very comfortable when we can see you know some physical damage often you know in the sort of little peripheral part of the body or somewhere that we could see it structurally damaged internal organs or you know a gash on the skin or a crushed knee or something so we're very comfortable receive damage equals pain but we're not comfortable with it is when we can't see with our crew technologies where the damage is but the person stays in excruciating pain all we see that we think is not very much damage but the person stays there in excruciating pain and we'll bring all sorts of judgments as to well it can't possibly be that painful for that level of damage and this is where biases if our cultural upbringing come into play and this is women can wreak havoc in understanding and appropriately diagnosing and treating and respecting an individual's pain it will always be paramount to what they say this and their subjective experience so psychogenic pain is the word that's been used for pain where you can't determine and show what the peripheral cause might be and and again a bit like this of placebo is unfortunately people have a negative impression of it and they're negative usage of it which is quite incorrect because psychogenic pain is genuine pain it's not a second-class citizen to physical pain where I'm being cautious now that I'm using the definition that's not mine but one that society likes to use which is pain that you can see a damaged area to pain is pain and pay the murders when the brain gets it and I don't this ambiguous what the origin of that is and I don't rank first order second order if I can see the physical peripheral origin of the pain or it is centrally generated brain generators at the end of the day the brain is the organ that produces the experience of pain so if the appropriate regions are actively switched on for whatever reason and that person is experiencing pain then they are having pain and that goes you know that speaks of a very core definition that the International Association for the study of pain which is the largest worldwide international organization of scientists and clinicians interested in pain in its scientific sensitive clinical sense our very definition of pain is you know sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage so that very definition speaks to the fact that you don't actually have to have actual damage your potential tissue damage and it's essential emotional experience described in terms and so therefore the very heart of our definition allows for the fact that pain of whatever origin is real and we should understand what the origin of it is because that will help guide us how to treat it but let's shift gears for a minute last week you were a featured speaker in a seminar entitled evidence of pain from the legal and neuroscientific perspective challenges and pitfalls in your view can or will we ever be able to use imaging to quantify the impact of pain in terms of jury awards from injuries it's a great question and it's one which again as conversations that many of us are having with lawyers and judges and personal injury lawyers both on this side and your side of the pond it's a very it's a question that has a great topical and relevance right now people are very interested in this I think in the US you have many companies that are offering this service I have to say from the pain community we're very skeptical of that yes at this point in time we're very nervous that people are using it when the technique is not ready yet in that way certainly at the individual level that the science is too not there to back that up yet we are in fact a combination of people from different countries of producing a series of recommendations of what one should be thinking about when wanting to use these technologies to prove or disprove or quantify the magnitude of pain in order to appropriately give the right award for say you know disability benefit that would need to be done to get the technology to that level and I think at this point it's fair to say that we're not sure it will ever get there you know at the sort of absolutely DNA fingerprinting type level of evidence I think many of us are very confident that the tools got incredible capacity to tell us a lot about the mechanisms that constitute people's pain that tell us and can be hopefully use going forward as a diagnostic tool and if we can get it to that level in you know the next decade or so then there might be some youth for it by certain you know cases where it would be another component of most diagnostic evidence as just one piece of evidence amongst many other pieces of evidence to help explain and understand why this particular individual is in pain but to be used as a sort of simple you know on/off binary lie detector then no I don't believe it's appropriate to use it in that context because I don't think that's really what you're doing with with these very imaging techniques pain is not this final experience what brain imaging can do is really help you understand and explain the person's pain but to use it as a sort of intensity gauge where you're quantifying how much you know this person's four out of ten is equivalent to this other person seven out of ten I think there's very dangerous to use in that context are there any other neuroethics issues that are tied to pain in imaging yes well in terms of pain in imaging I think the main one at the moment that we're struggling with is is this one of because if it's you know youth already by companies for lawyers and their concern that you know that's galloping off at a pace that you know we're not comfortable with yet that their solidity and hopefully my description say sort of where we're at and what we hope needs to be done in order to deliver on that one of course there are other ethical areas which pain impacts society too and I think some of the challenging ones which again linked a little bit to why lawyers would want to use it in this context is where there isn't the luxury of having the subjective report the description by the individual that we because they're babies maybe they're premature babies in their native units who you don't know what level of pain or suffering they're in it could be in comatose patients patients in intensive care units patients who are having operations who are anesthetized are elderly who are maybe cognitively impaired and have dementia and are unable to display or describe that they have some you know painful condition so there are these other areas where I think you know we we are challenged in understanding what pain are they in first of all are they in pain and if they are what level of pain and should we therefore treat it even though we don't know actually what's going on and they can never tell us and this is where I would hope that again you know some of these tools could be helpful in giving us some about what I call behind-the-scenes information as to what's going on what might be underpinning you know what you think might be a behavior display of discomfort and and pain but you don't know because they can't tell you and again this is all new areas for us to go into that again is is relevant clinically but also just relevant more broadly to society I think some of the other areas which have been where I think again is pain scientists we we are we have to be mindful of our ethical duties to society is in situations where people want to use pain for torture people want to avoid pain maybe on death row and again where you are brought into or asked and again you know inappropriate demands on pain scientists possibly and again we have codes of conduct and guidelines under our society's you know in order not to abuse our knowledge and our understanding in those situations where pain is used as a weapon now you talked about potential biases inherent in a clinical sense assessment what are some of those biases yes not first the clinical it's more just I think as people growing up in society where there's a lot of subliminal messaging about toughness and pain and no game without pain and you know it's you know to go through childbirth know pain relief and there's a lot of you know messaging out there and a lot of historical messaging in our literature and in our religions about the virtues of suffering this world again in the next that without realizing we arrived as an adult with you know again implicit poverty biases towards what we expect people's pain to be what people how much people should complain about their pain etc etc and it's impossible to divorce yourself from those biases but I think to recognize that you have them and then when you are confronted with an unexplained pain and you think well hold on a minute you know it can't be as much as that because blah blah blah to catch yourself at and remind yourself that actually you know okay hold on here you know this is what the person is describing and I need to be open minded about this and balance and I must bring some of those attitudes of what my pain experience is and what I would do if I have pain like that to the table and and that's hard because that's sort of naturally what we do is again to go back to sort of why do we why do we as living mammals display pain and report pain and grimace and gives these very clear behavioral manifestations in order to elicit you know a reaction in your fellow man or your fellow you know animal so that you are looked after and cared for so it's a very complex social contract the pain and again that can be a very beneficial thing because it can provoke empathy and kindness and caring but it can also provoke resistance and biases and neglect if you like and attitudes that you know again can mask and confuse I think we just have to be careful about some of those things and again I think historically go back to that percy boat thing you know it used to be the case that in in medicine people did placebo tests on patients to catch them out and if they got caught out had a perceiver analgesic effect then that was the elimination test that they didn't really have a pain problem and that's you know it's one of many descriptions of where again that was the knowledge as good as it was then but the new knowledge tells us that based on flawed science and luckily you know that doesn't happen anymore so medicine science progresses as we learn and again I think pain been a very good illustration of that as that sort of rule if you like that as the science tells us something new we rethink about you know how we conduct you know diagnostic tests and how we conduct interviews and even those sort of conversations that I have between you know physicians and patients you research I think as well establish that when people feel sad their pain is worse but is it is it possible to measure emotional swings with imaging yes so another experiment we sort of made people sad and then we made them use neutral and we get in the same sort of thermal burn throughout the experiments and showed that they both felt as I said they described that pain is more painful and then we looked with the imaging of you know was the brain like this when they described it to small paper when they were sad and we showed that it was so that's the same sort of burning the more if you like there was just a sort of sadness amplifier if you like inside the brain and we sort of worked out the circuitry by which it did that part of that experiment we did also just look at you know what was the sort of brain activity during just the sadness condition itself versus the neutral mood condition and again I don't work in mood disorders many many people use new imaging to look at moods and how and again both in the everyday setting and in the clinical setting and certainly that's a very rich area of neuroimaging where you know the interesting insights of common bias about what is the fundamental base and banks are and depression and some of these very key components of you know sort of emotions and what do we really mean by an emotion is that a physical thing that can be labeled to brain regions or is that something that again is societal sort of description overlay because you know lots of work being done on that for me you know specifically what we're interested in is that intersection between how emotions and emotional states that they're defined how do they intersect with a physical called nociceptors stimulus in a burn or a cut or maybe a chemical you know stimulus or earth you know mechanical leavening general ways that one experiences pain from the environment how do they how does the processing of those inputs has that influenced when the brain is in a different emotional state because this is very very important again for the clinical condition where comorbid problems related to particularly depression and anxiety are really dominant in the chronic pain State and so we really do need to understand what the consequence of that sort of double whammy if you like is on that person's pain experience again because that can help us in the appropriately guide where we need to to treat and fix all these different bits that have gone wrong I don't know if there's been an opioid explosion in Europe but there certainly has been one in the United States first our doctors trained properly to prescribe opiates for different kinds of pain and second is there a way a adopter a patient can gauge where their opiate use is appropriate for the level of pain they are experiencing that's a really great question I mean I'm not a clinician so you know it's it's you know my answers will be restricted to sort of what I've observed as a pain scientists you know very much involved you know doing some work looking at how opioids produce their analgesic state and how different people have different analgesia to the same opioids to what what makes somebody have good annal teas in one person not me I think Europe and certainly Britain has watched with great interest what's happened in America and context of the opioid sort of explosion and very rapidly learned from that and you know we have this government agency nice and our British Pain Society very very active and communicating to our general practitioners which is the equivalent to your primary care physicians what has happened over there and and again strong advice and guidelines around okay prescribing so whilst we were having a growing problem I believe it's been very much nipped in the bud and I play guidelines being put about the consequences and the negative consequences of again high dose long-term youth so that I think is you know having been a bad news story is now becoming a better news story certainly over here I think again going forwards what we need to do is as you into that is better education for all parties both for the patient and for the physician through our young doctors being trained I think you know very clear guidelines around their youth some more appropriate selection of which patients will benefit better and not and again terms of use and what longer-term consequences of being on particular doses of opioids and what is the consequence of that on the body again these are all studies that we are now actively involved with ourselves so that we can contribute some data to this either a very very important topic and we hope that you know the next couple of years we'll have clarity on issues related to you know what are the long-term consequences on the brain and other parts of the body of being on long-term opioids whether that then should guide you know maintaining a very short use of them only ever also we've been doing work characterizing ahead of even going onto an opioid based therapy who's likely to have good analgesia to an opioid versus not very good in which case don't put them on an opioid base medication because it's all going to work for them again it's early days yet but we're starting to see signals that might be able to help us what we call personalized or stratify patients ahead and predict who's likely to have good he's likely not to have good outcome in which case there's no point putting somebody on a treatment if that's not going to work for them and this is not just for opioids this is for all of our medications around pain it's a big push right now is to do the sort of more patient stratification creative ways of using different tools not just imaging to characterize the patients and find out okay well I think for you it should be this type of therapy but for you it should be this one so that we can get people you know one on two there the right therapy that's going to work for them and we're doing that as early as possible so we can really you know reign in this chronic pain as quickly as possible and bring it down mm-hmm great stuff um are you finding that there's more student interest in specializing in this field and and is it is it a growing field in your estimation and is there enough funding going on well again there's a great question still you know we are very fortunate since actually fantastic people in the pain field and great scientists and clinicians working in it but we always want more I think all disciplines would give the same answer but what sometimes you need in the field particularly to really shake it up and they're a big paradigm shift and you know bringing some new ideas of fresh blood is to get people who have been working me in other areas to come in and take on this problem without any of sort of preconceptions of theories and things are just coming with a fresh fresh set of ideas and so I do encourage any young budding scientist out there or clinician if they're not thought about pain to think about it because it is an absolutely incredibly fascinating topic there is plenteous have they recognized of interest in it from the pure science of philosophy and the clinical perspective to get your teeth into and there's many many unanswered questions so there's a whole careers worth there so certainly I would like to encourage people to come in and I think you know people coming in here or you know again willing to be you know creative and challenge the dogma and the way we're thinking about it to be welcomed terms of funding I think it is fair to say that you know pain because people don't sort of die of pain it's been this sort of slightly orphan area in terms of politicization of it and funding of something that again all countries like the US has in the UK and certainly you know Europe France and Germany listen in other countries have been very active with our societies to raise the profile of pain have global pain days focusing on different conditions to get the politicians interested because the enormity of it I think people just didn't realize you know one in five of the island populations have it you know it's six hundred billion dollars a year in the u.s. lost income people not going to work for pain and treatment and management two hundred billion euros in Europe you know this is a huge financial burden it's a huge suffering burden and I think those facts and that data which you know some of the societies have done them and ordered and pull together a very powerful pieces of data to communicate to our governments and our government funding agencies that you know this is a really big problem for society and we haven't addressed it with the level of funding that should have maybe been prioritized for it and we do need to raise the profile more so you know things you know certainly better I'd say in these latter years and they have been you know when I started 20 years ago but much more work to be done social mmm I think that's a great note to end on dr. Tracy I know you have to go pick up one of your children so I'm gonna let you go and again tremendous work on the article and thanks for explaining all of this to us and being so patient and and good luck with your research going forward well thank you very much but I'd like to thank the Dana Foundation for their support and and congratulate them on the wonderful way they communicate the excitement of neuroscience to society it's a great great work that you're doing so good luck to you too okay thank you very much okay right and that wraps up another cerebrum podcast for this month thanks for listening and remember to go to Dana org to find out the Tracy's article and for all the latest news and information on brain research thanks for listening you

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