Ep 126: How to treat pain in children? w/ Drs Lonnie and Paul Zeltzer, pioneers in the field of pediatric pain treatment

Drs. Lonnie and Paul Zeltzer are are pioneers in the field of pediatric pain treatment.  We discuss many different ways to treat pain--including alternative, non-pharmacological approaches to pain management, including sleep hygiene, breathing techniques, hypnotherapy, placebo and mindfulness. They also  explain when medications such as opioids may help helpful.  Additionally the role for herbs, topical anesthetics  and more! 

Dr Lonnie Zeltzer and Dr Paul Zeltzer are pioneers in the field of pediatric pain treatment.   Dr Lonnie Zelter’s impactful career includes being the immediate past-director of the UCLA pediatric pain and palliative care program, and the author of over 400 publications and 4 books.  Her husband, Dr Paul Zeltzer, co-directed the successful pediatric pain clinic  at UCLA.  After retiring from UCLA, they together created an online community for youth, called CHYP— the Creative Healing for Youth in Pain.  CHYP is an online nonprofit that provides free resources for anyone looking to heal from pain. 

Check out Creative healing for Youth in Pain: https://mychyp.org/

Dr Jessica Hochman is a board certified pediatrician, mom to three children, and she is very passionate about the health and well being of children. Most of her educational videos are targeted towards general pediatric topics and presented in an easy to understand manner.

For more content from Dr Jessica Hochman:
Instagram: @AskDrJessica
YouTube channel: Ask Dr Jessica
Website: www.askdrjessicamd.com

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Transcript

Unknown: 0:00

Hi everybody I'm Dr. Jessica Hochman, paediatrician, and mom of three. On this podcast I like to talk about various paediatric health topics, sharing my knowledge not only as a doctor but also as a parent. Ultimately, my hope is that when it comes to your children's health, you feel more confident, worry less, and enjoy your parenting experience as much as possible. Today we're going to talk about treating paediatric pain. So when kids are experiencing persistent pain, it can be quite a challenge to safely and effectively help them. Today I have the honour of introducing two extraordinary individuals, Dr. Lonnie zeltser and Dr. Paul zeltser and they are pioneers in the field of paediatric pain treatment. Dr. Lonnie seltzers impactful career includes being the immediate past director of the UCLA paediatric pain and palliative care programme, and the author of over 400 publications and four books. Her husband, Dr. Paul zeltser, co directed the successful paediatric pain clinic at UCLA. And after they retired from UCLA. Together, they created an online community for youth called C hyp. The creative healing for youth in pain. Ch yp is an online nonprofit that provides free resources for anyone looking to heal from pain. Now on to the interview with his answers, where we talk about how they met their thoughts on chronic pain and advice in general on how to treat pain. It was truly an honour to speak with them. And I thank them for coming on ask Dr. Jessica. So thank you guys so much for coming on the podcast, I have to tell you, I'm especially excited because I did my paediatric training at UCLA, and the most difficult cases. For children, we would definitely be consulting with the famous seltzers because everybody working with kids knows that treating pain can be very difficult, especially if pain has been chronic. And first I want to start off by thanking you guys so much for all the work that you did and for taking the time to come on the podcast. Good fun. Yeah, joy, looking forward to it. So okay, so first, tell me, how did you guys meet? And how did you end up taking the path that you guys took? I'm so curious how the two of you met, because you're so aligned on your mission and what you guys do, or didn't start out that way. I got my fifth choice for internship at Cincinnati Children's Hospital. And so I drove my VW out to Cincinnati and it was a it was a mixed paediatric half and half medicine internship. And that was July and then August. Lonnie shows up on the ward now I had seen her at Grand Rounds. And I thought she was an ophthalmology resident. And, and she was always around guys. And I, you know, strange to me, she was always surrounded by guys. So she shows up on the ward and she's the junior medical student, and I'm the big intern right on the medicine ward. So she switched to get on with me on call that night. And so I said, Let's go out to dinner. See, okay. And then we started dating, and I had a girlfriend back in LA that I forgot to tell her about. And so I went back to LA and I broke up with her. And then when I was in LA for like five days, the ex girlfriend broke up with me. And then I came back to Cincinnati and Lonnie was otherwise involved. And over a period of the next three or four months, she got engaged to a, an aspiring neurosurgeon, and wound up breaking up with him and around April or Mellie, Stewart Kaufman, theoretical biologist, who was also my intern, mate. So he and his wife said, Go call on me. I think she broke up and I said, Man, but then the next thing I know happens, we're driving back to LA and I finished my residency at UCLA. And she finished her medical student career at UCLA. The reason I was surrounded by male med students all the time, is there only four women in a class? There weren't a lot of women in medical school. So of course, I'm surrounded by you look at the odds. That's a very fair explanation, I think. No, so what happened? Lonnie went into adolescent medicine around that time, she started developing an interest in chronic pain and had developed an interest in chronic pain in adolescent medicine. And then we were in San Antonio at our first academic job, I was head of the paediatric oncology, haematology oncology programme there. And she was head of adolescent medicine we got recruited back to children's in LA and we both came back to LA and then she started was on her pain career and I was a you know, haematologist oncologist for a long time until I sort of reached a point where I didn't have any new ideas. So I went out and wound up starting a couple of startup Well, one startup company and a couple of others. One called navigating cancer which is still going on and seems to be real productive. And then, about 15 years ago, Lonnie said, Do you want to get back into clinical medicine? And because I'd been out for about four years. And so we started the whole child clinic because she couldn't fit all the patients in the clinic time that she had at UCLA. So I became her intern for a year, and learning about chronic pain. So we've been doing this and having really, you know, this time in our lives really have a very challenging and enjoyable career. It's satisfying. And mentally, it is intense because of the panorama of problems that the kids come in with genetically, as well as the epigenetic factors in terms of family dynamics. And then what pain does in terms of interrupting the careers and life cycles of families because it doesn't get easily figured out in our current healthcare system. I think it's so perceptive of Lonnie, that you recognise the need for a chronic pain clinic. My clinic UCLA was Zoe's we sort of called it the last resort clinic, it would be the place where all of the sub specialists and or department send patients that still have pain, even though they did you know, they had migraines, and they went through all the migraine meds and the operatives and Botox and whatever else and they still had migraines at work, going to school, or getting out of bed. In a send him to zeltser, I don't know, she does weird things there. If the pain goes on, and on and on, they send to me, you know, we get a lot of referrals from paediatricians, and we work closely with paediatricians mean, which is my goal, it's and then educating about modern concepts of pain. Is it psychological? Or is physical, organic? No. And of course, if you're in pain, you're going to have more stress. If you're more stressed, you're going to have pain. And then who knows what underlying things contributed in the first place. So it's, it's complex, but I love complexity, you know, then add adolescence and hormonal changes and neural development and neuroplasticity. So it's, it's complex, but it's like solving a multi piece puzzle, I can attest to the fact that you were the clinic of last resort, because I remember firsthand when they were difficult cases, and we didn't know what else to do, we would send them your way, I want to ask you first, some basic questions about pain just for parents that are listening? Sure, if their kid come to them, and they are voicing that they are experiencing pain? What's your first recommendation as to how parents should treat their pain? It's a really good question, because that's what comes up every day. And I think the first thing, if, you know, the ideal parent would take a minute, take a deep breath and ask him about the pain literally, not as a physician, but as the parent, you know, and you're, you know, where is it a little bit of history? What does it feel like? And what does it prevent you from doing? So I think that's the first thing if that is reaches a wall, I think the next thing is for the paediatrician really, or the family, the primary care provider, but inherent in that is the assumption that the primary care provider has a depth of understanding of inquiring about pain. And I think, with the development of really great scanning and visualisation techniques, like the MRI scanner, the city, and we actually evolved, while those things were being developed, there is a reflection to Well, let's find out about the structure and get an MRI scan or CT scan, without sort of going through the logic of what this could be. And when it isn't structural, then the physician can hit a roadblock because then what is it? And if it's outside their experience, they say, well, it's in your head. Well, they're right about being in their head, but it's in their brain, not in their imagination. And we knew physicians back in the 60s, who understood functional abdominal pain and irritable bowel syndrome, but nobody would listen to them because they didn't have the studies like functional MRI, to really show that that area of the brain was involved. And so as the new tests, for instance, functional MRI, have sort of have given credence to how pain develops and the location of memory pain so that the example of wartime injuries where somebody had their leg blown Knock off, in, in combat, but they could still feel the pain in their leg, even though they didn't have a leg. That was a clue that there's something about brain memory, but that we get translated to things like your bowel syndrome or chronic regional pain syndrome. But now we sort of accept. But the clues were there, we knew physicians who were really great clinicians, who treated patients like that, even though nobody believed them. It's fascinating how the mind works when you talk about feeling leg pain, even without a leg there, it's so true how the mind plays an incredible role and the feelings that we feel, right. Yeah, I think the newest things in with new tools, and research in chronic pain is we know where in the brain is a pain neural circuit, there's a pain neural circuit, it passes by hippocampus, and memories play a role that passes by the limbic system. And especially in adolescence, you still have further development of the frontal cortex, note the new brain. So planning, decision making a lot of that is not there to impact that neural circuit. And there's some kids that form what I call a sticky neural loop. They make pain neural loops, and then they get stuck. So these are the kids. If you get a good history, there they have per separation, they could keep going on and on and on. But they have difficulty with transitions. So again, that sticky neural loop. And if that sticky neuro loop is pain, then they have a hard time getting off it. And so knowing how to work with that understanding that and giving them tools to unstick the sticky neural loop and we know a lot now, mindfulness, how Dan's how creative arts, how drawing writing, hypnotherapy actually changes that neurobiology and unsticks it better than a lot of the medications. Fascinating. I love talking about non pharmacological ways to treat pain. So I want to talk about basic scenarios or common scenarios that come up for parents with their kids. Let's say a kid first, maybe hits their head or sprains their ankle or bumps their arm and they're crying that they're in pain. What would your first go to for pain management be? Good question. I mean, it's the basic, I think if you if there's inflammation, if there's swelling, the anti inflammatory agents, whether for that particular child, the NSAIDs, you know, ibuprofen, works fine. For some kids, it's Tylenol. And that works works fine. The problem that we see in maybe five to 10% of those injuries, depending on the population you're dealing with, is the pain goes away for a while, and then it comes back or never goes away. And the clues there, if it doesn't go away, is to consider the kid of malingering and make a judgement that is negative. And we see that very frequently in terms of the kids that, again, that population that we see, who haven't responded to the, quote, regular medical treatment. And then with the injuries, you're talking about a whole set of disorders that go along with brain function. And it's called it used to be called sympathetic dystrophy, because they thought the sympathetic nervous system and dystrophy because the limb wasn't working well or as painful or swollen. But it's now known as chronic regional pain syndrome, complex activity Complex Regional Pain Syndrome, CRPS. And the there are still some doctors who live under a rock who don't appreciate it. For what it is, is a very complex disorder that really needs to be attacked in a comprehensive manner for and for people that are listening that haven't heard of CRPS yet, which I agree is a very complicated diagnosis. I've heard the average patient it takes four plus doctor visits until they finally get correctly diagnosed. Can you explain to people to help spread awareness what is CRPS? Sure. It's really whatever the injury that started it for some kids, they don't even know what started it. Suddenly a part of the body could be a leg and arm it could be any part of the body. In the face. Yeah, suddenly become seems painful. And it becomes painful to things that are normally not painful, like touching something lightly, you know, touching the face like that they are the arm or the foot becomes super painful. And we call that Ella dnn, meaning something that shouldn't be painful, is painful. It's pain, pain out of proportion to what you would expect. Exactly, exactly. And then for some kids on the foot, it keeps them from standing on the foot putting pressure walking, so suddenly, they're not walking, they're brought to an orthopedist and an orthopedist may put them in a boot. Well, the longer the fit is in the boot, the less stimulation that part of the body is getting. And you're really perpetuating the development of CRPS, which is a brain electrical system abnormality, that's causing increased electrical signalling along sensory nerves, and also the autonomic nervous system. So that part of the body let's say a foot might become swollen, or might become read or modelled, because you're talking about vascular instability related to autonomic nervous system, the fight or flight part of our nervous system that gets out of balance. And, and then what happens is, besides Allah Denisa, something that shouldn't hurt. That's is painful with light touch, for example, you know, somebody at school and Kid touches it, then the pain lasts longer. So the pain turnoff system isn't working well, either. So if we think about it, same thing with irritable bowel syndrome, which is brain intestinal nervous system, the system, the electrical system gets out of balance, and the treatment is getting it back in balance. And there are a lot of strategies for that. I think these examples really illustrate how tricky and complicated pain can be to manage because I think a lot of people can't relate to having chronic pain. But if you're somebody who's going through chronic pain, it is so debilitating, and all consuming. So I think it's really helpful just to draw awareness to these conditions so that people, honestly so that the kids are believed, yes, I think a lot of people don't believe kids when they experience pain in that way. But what happens at with that spreading is that the autonomic system becomes unbalanced in other ways. And so the child will say, or the parent when I was the child is dizzy, when he gets up from going from a sitting to standing position goes to the paediatrician who may notice either low or high blood pressure is that oh, well, at a high heart rate. And will this needs to go to a cardiologist? Well, what happens is if you do a sitting and standing pulse and blood pressure, and you see a greater than 30 beats per minute difference between the sitting and the standing, that's called Potts, paroxysmal orthostatic, tachycardia syndrome. And so then they go to the now they're a cardiology patient. And they have the recipe for dealing with pots are experiences that that's almost always secondary to the dysregulation. And once you get the irritable bowel syndrome, the CRPS, the pain and other areas resolved, that goes back to normal. And it can be complicated with depression, anxiety. So if you want, you can have four or five specialists involved, and they're each prescribing different medications that they are used to, but not understanding about the effect on the whole child and maybe a more comprehensive understanding of this process, you realise that there's one central problem. And as soon as you figure out that central problem, everything else gets better. And it may take two weeks, or it may take a year and a half, depending on the substrate, the individual. I mean, a lot of what Paul and I do what I did in pain clinic at UCLA for 30 years, we look at the whole problem describe all of what's going on maybe how it started and what's happened and what are the other factors that have resulted from this or contributing to it. And we coordinate the different care providers so everybody is working as a team So if a parent has done Tylenol, Advil, maybe ice their kid and their child is still in pain, can you give some examples of non medication paths to take to help treat pain? Sure, the most important thing to start with is sleep. So without good sleep, everything else stays dysregulated. So that's the very first thing. And what are the things I mean, paediatricians know, if kids are up all night on their iPhones or whatever, their brain isn't going to turn off, especially if they still have the blue light on there, I found that, of course, their brains going to be activated, and then they're not going to get enough sleep. And then they have to get up early for school, and they're wiped out all day. So that's not healthy. And of course, or schools are not geared to, to Chrono biology of the adolescent. But it's what we have. So adolescents need kids need to get a certain amount of sleep. So there's something called good sleep hygiene, you don't have to go to sleep psychologist. The other is obviously, how is he preparing his brain to go to sleep. And I know there's a controversy over melatonin. And melatonin doesn't work if you keep taking it all the time and need a break from it. So getting over the counter melatonin if you've been stressed, or you know, the kids been stressed, or as pain, whatever general stress can help prepare the brain to go to sleep in the sleep specialists say you want to prepare the brain. So you want to take it one or two hours before you're ready to go to sleep. And then you set up routines at night. What is the routine for going to sleep. And, you know, maybe listening to music, learning breathing technique is a yoga technique called the JE breathing and it's breathing in through the nose, and out through the back of the throat, your mouth can be closed. So you know it's like, but your mouth can be closed. So but what that does is it acts like positive pressure in your lungs because you're moving the air out slowly. And in doing that there's a lot of research from Yogi's and Steve Porges. And looking at vagal tone autonomic nervous system, they ear really quieting down the active vagal nerve. And so you're you're really changing your autonomic nervous system from fight or flight with a lot of adrenaline around adding to pain to quieting the whole system. And that's doesn't need a specialist that's parents can learn that and work with their kids. And part of what we do the nonprofit online that I started, because a lot of adolescents if the parent says it, forget it, but if they hear it from a friend or someone else, they're more likely to follow up on it. So it's another 700 year old technique that I often suggest. And it's these papers that have print on them. And they're and they have they're bound together. And they call them I think books of the truth. And I think to get to sleep to have a kid reading a book, as opposed to the iPhone, which is being getting messaged every 10 seconds from their friends. That's a difficult challenge for a parent. I mean, you talk to a parent and ask them about well how do you get your kid to put down the iPhone, and you sort of have to become a parent again and be a dictator in your family. Because this is for your health and we need to take the phone away from 11 o'clock till seven in the morning. It is so true. If I want to sleep well and put myself to bed early. All I have to do is read my read to my children. If I read to my kids, it's better than any melatonin any medication I can take. Literally lying in bed with the kids. I had a cup of coffee and oftentimes the kids would have to take the coffee cup away from my my my belly because I was the one that fell asleep. Yeah. So true. Great advice. Great advice. Okay, so So getting to sleep helps with pain. Anything else that's not medication. and related that would help relieve pain for kids. What happens for kids that have recurrent pain, let's say irritable bowel syndrome, they get stomach aches. And maybe they have a background of stomach ache all the time. And then they get stomach ache flares, and they can't go to school. So think of this as a brain intestine, electrical system that's not in balance. So the goal is, how do you get it in balance? First of all, for kids that are not moving, they're not doing any sports, they're not dance, and they're lying in bed all the time, because they're in so much pain, that's just going to keep pain going. And there's a difference between pain that's harmful. In pain, that's hurtful. So if you break your arm, you don't want to keep using your arm because it's not gonna heal. That's pain that's harmful. So you want it in a cast from the orthopedist and you want to let it heal. Pain that's signalling problem. To get a back and balance, you have to use those muscles. And a lot of times physical therapist, which then develops a plan for helping you move your body, and hopefully giving you some tools to do at home. And that's part of the pathway to healing. And the doctor has to explain to the parent, why physical therapy is not harming the kid. It's she has a hurtful problem. But this is the cure to start moving again. And that's where I think the judgement and the authority of the paediatrician becomes really important, because it's counterintuitive to what your grandmother would have done. Yes, no, my husband always says my husband's an adult doctor. And he says the best way to help with back pain, which so many adults suffer from, is to move their bodies and it's very counterintuitive. You think I'm suffering from back pain, I should rest I should lay down. But for most people, the opposite is the case you want to get up and move and take a walk. Right? I talked about a system and electrical system, if you pain anywhere, it's an electrical system that's gotten out of balance brain and body and nervous system. And the way to get it back in balance and get rid of the pain and get your functional again, is working from the body up in the brain down. And that's where and getting enough sleep. So bottom up can be physical therapy can be yoga can be beginning to do things with your body. If you can ride a bike, ride your bike, if you can take a walk. If you can only walk to the mailbox and back start with that and gradually increase. And then the brain stuff are how to use your smart brain to reprogram the pin circuit. And we know that using your imagination, hypnotherapy, mindfulness, you know cognitive behavioural therapy, because there's a lot of baggage that comes along with chronic pain. Now hypnotherapy is something I find I want to ask you about because that's something I did not learn about in my training. But I've come across a few patients over the years where hypnotherapy has really helped them, especially with pain and stopping bad habits in particular, can you elaborate more on hypnotherapy? How long does it take to see progress? And what would that experience look like for a patient? I want to give a quick intro before Lonnie talks about it. And that is the paediatrician has to know the child. And by the know the child, you know, if you have two kids, one is going to be an engineer and one is going to be a stand up comedian. Their brains work differently. And you have to understand the neurobiology of the child. There are some kids who are on the neurodiverse, you know, autism spectrum who have fantastic imaginations and where hypnosis is going to work well, where others are so concrete, they can they can they just can't imagine that and forcing them to get hypnosis, in a way is a death knell because they can't do it. And it's going to reemphasize their lack of agency and power. And so you have to taper the therapy to the neurobiology of the environment. For instance, biofeedback where they can actually see that muscle tension on the screen, and they can breathe and actually see that those fibres moving less. So again, it's tape. It's tailoring the therapy and To the neurobiology, where most of the time we say, well, we give an antibiotic or we give a medication for add, we don't think of that diversity, whereas you really have to with chronic pain. And can you explain what is the difference between acute pain and chronic pain? Yeah, so like, is there? Can you give the definition of acute pain? And what is chronic pain? Sure. So acute pain is something that usually starts with an injury, inflammation, virus, whatever gets it turned on. But then we have a pin turn off system that addresses you know, I get all these cytokines and if it's a bruise, and the bruise might get swollen, or, you know, or infection, and infection, and our cytokines, go to rescue and get rid of the infection, whatever that is. So we our body responds to acute bodily injury, whether with virus or infection, or physical injury, and repairs itself. So a couple of weeks, typically, a week or two weeks at the most. And same thing with surgery, surgery after surgery, most kids should be able to have that repaired time and not have it be prolonged. Chronic Pain is when the pain turn off system, poops out doesn't work well, so you have pain lasting. For most kids, the definition is three months or longer. But chronic pain and chronic pain can be like with chronic cancer pain, there's an ongoing reason for the pain. So it's not a nerve impingement. So it's cancer related pain, or some other disease related pain where there's ongoing inflammation, but most pain in kids that becomes chronic is a system, a pain signalling system that's gotten out of balance. And so the pain continues. And then it might have flares, like kids with belly pain, or headaches or, and so this system keeps going. But then what happens is it picks up baggage. So if you have belly pain or head pain, then your muscles in that area might begin to contract to protect you. So now you have what we call myofascial or muscle tension, pain, on top of what they have started as headache, or what or neck pain and shoulder pain that's keeping the headache going, or stomach muscle pain. You know, the rectus abdominal muscles that go from the bottom of your chest along the middle down to your pelvis, those muscles if you do an exam, those field tender and the kid will say, Wow, that hurts if you press on them, and that's muscle pain. It's not internal belly pain. That's why physical therapy may work and heat and breathing and certain belly exercises and massage. So it's a pain that goes beyond its usefulness. Its usefulness is a warning something's wrong fix it take notice. Chronic Pain is beyond usefulness and usually it's when the pain turn on system is working full blast and the pain turn off system is pooped out. Okay. I really like brainstorming with you guys about ways to think about treating pain because there are so many options that I think just it's helpful to have on our radar. So beyond hypnotherapy, neurofeedback, you talk about massage being helpful as well. I like that. And now what about more alternative types of therapy, like capsaicin, or certain supplements? Yeah, so what capsaicin does, it pulls out this substance P from the lens of the the nociceptors the pain nerves, but that can be very painful. It's like working with chilli pepper and then accidentally rubbing your eyes, you know, burns like crazy. So with kids, we tend not to use capsulation just because they have a hard time. But there's lighter DERM patches, which is by prescription because topical lidocaine cream from over the counter doesn't get through the skin well enough to get those nerves underneath it. A lighted DERM patches The nice thing is, they're like a big spongy square that you can cut them, unlike some other patches. So you can put it over the areas by your back or by your arm. Wherever the pain focal pain is, for some people it works great. And others it doesn't it you have to keep it on for 12 hours and then take it off for two hours. Another non pharmacologic technique that the paediatrician really needs to instruct the parent about, especially when you we know that the child has chronic pain. And that is not to ask them are they in pain, because the parent wants to know, because they can't do anything, but they want to know if the child is in pain. But what that child now let's say the kid is listening to their, their music, or their I got iTunes and they're, you know, or they're listening to a podcast, they've already dissociated, right? So they've already figured out how not to feel the pain and engage in another activity, the parent that asked them to scan their body, and then they're in pain again. So one of the lessons that we you know, certainly learned over the years is to try and encourage the parent, watch their behaviour. And keep it to yourself. And you'll know if they're engaging in more things, but don't ask them what their parent does, especially if it's an adolescent. Don't call attention to it, because that'll kill it. Right, right. I agree with you wholeheartedly. I gleaned so much just from watching a child when I walk into a room and I see them walk and I see them smile, and I see them playful, I immediately relax, where I noticed, you're totally right. Parents always ask kids, does your ear hurt? Does your eye heard what hurts? And oftentimes, even though the kids smiling, they'll say, they'll nod their head. Yes, it hurts. Sometimes, I think just to please the parent. But I think that's such great advice not to ask your kids, if they're in pain, just observe with your own eyes, look at their behaviour, and you'll get your answer. Now, remember, the parent isn't spending dollar after dollar hour after hour on this journey, right? So they're all pain is on their mind 24/7 And their inability to help it. So it just seems it's so natural to want to do that. And that's why I think the authority of the physician is so important to say, look, this is gonna get better, but it's not going to get better if you ask them for pain. Right, right. The other question I get a lot about is tumeric. You get a lot of questions about things like tumeric, lavender, peppermint oil, or any of those herbs that you would recommend. So there are a few things. We know that topical Eucalyptus is a topical anaesthetic. So things like Tiger Balm that have a lot of menthol menthol. Both of those are topical anaesthetics in high concentration. So over an injury area, parents can buy that over the counter and use that we know that turmeric can be useful, sprinkle it in food, we know that chia seeds sprinkled in food can help with constipation. I mean, there are a lot of remedies that naturopaths have studied and know. And for a lot of kids, if that's helpful without any downside, why not? If it's placebo, and it's not harmful, I'm all for it. I mean, I think that makes total common sense. placebo, very powerful, that you believe it. It's very powerful that we know in the brain, what placebos do. I mean, they work on changing neurobiology if you believe in it, and that's a there was a study in Boston where they took adults with severe chronic pain that have failed every single treatment and randomised them to placebo or usual care. They told them they were placebo, gel tablets with nothing in them. And a subgroup got amazingly better, they said for the first time in their lives there. So when the study ended, they wanted more placebos. And of course, the scientists and their gel tabs on can't just prescribe procedure. And then a company in France heard about this study and started making placebos. They're called placebos. They're in jail. And for a while there was a big market for it online. I have to say I have an eight year old who's a little bit Yeah, how do I say how do I save on the dramatic side. And so I find placebo works really well with her when she injured herself and she just wants some attention. I take out magic lotion, it's just lotion, and I rub it on her skin and I give her some a little light massage. And that seems to do the trick most of the time. But that's what hypnotherapy is. That's what that's what witchdoctors used to do. But it's, but it's, you know, saying, here's, here's the magic bandaid, here's the mat. And this will start making things feel much better. And kids get that and they want the magic, whatever it was the do special landing, the contact is what helped reorganise the brain. You know, I think a lot about just sort of, to to bridge now into talking about opioids for a minute. My husband, he works as a doctor for the homeless, and a lot of his patients are addicted to opiates. But he tells me the key is never to start in the first place, the longer that we can wait and hold off and hopefully never use opioids at all. That's the best way to not get addicted. Can you comment on that at all? What's your approach with kids? Have you experienced that? Avoiding opiates is possible and the way to go? Yeah, I think we're learning. First of all, for most outpatient chronic pain, you really don't need opioids. And there are a lot of studies where NSAIDs and alternating with Tylenol, and there are other ways ketoprofen cream, I mean, and using the placebo model, on top of that is really, really healthy. So I think, belief and expectation is hugely for kids that are on opiates, do you find that a certain amount of time will keep them from being addicted? In other words, you know, sometimes that's unavoidable if a child's on it for a short period of time, do you find that that's okay. And acceptable, you know, when I mean, when I did inpatient palliative care at UCLA, you know, we were much more liberal and using opioids. And, you know, so if kids are on it, because they needed, I mean, they were in horrible accidents and whatever else, then, if it's more than a week, it need to wean off. And that's just, you know, building up tolerance dependence. And that's different from addiction. Addiction is when kids begin using it, to cope with other stressors and not pain. But you know, there's another rhyme to this. And that is for the rare, and it's the rare child, or adolescent, who will say doesn't need an opioid, to feed them basically short acting so that they have to experience pain before they get the next dose. And I think in those children, it's better to use a longer acting opioid, so that you can get a smooth blood level. And they know they're going to be on it either twice or three times a day. Bye, but at least they won't have these spikes where they have to ask for help. And they're pain free. And then it's easier when the illness is dissipating, to slowly taper them off that because they haven't had that cycle of pain, pain relief, pain. So those are like basic strategies for giving meds. And there are kids who may need opioids. I'm on the CDC. I'm on a group of 14 of us around the country who are coming up with new guidelines for opioids and adolescents from the CDC. And, you know, I think the biggest thing about adolescents in opioids is make sure that you've addressed as well as you can. The other reasons that might contribute to the development of an addiction problem, as opposed to pain control. I think this is such an important conversation. I think anybody out there who's experienced pain knows that when you are experiencing pain, it's all consuming and it's so helpful to know where to go and where to turn to to get help. Can you explain to everybody about your amazing nonprofit that you started? Give us some information, where can they find more about it? Well direct them to the website, tell them everything.my Chip, N Y ch yp.org. And it's creative healing for youth in pain is for kids aged 13 to 24 and for their parents. And basically it's not a treatment programme. But we provide all kinds of information, self help strategies, how to cope, how to parent, the kid who has chronic pain for parents, we have webinars with experts from around the country, talking about functional neurologic disorders neuro diversity, anxiety, depression, etc. We also have social support groups for kids from all around the country and Canada, and for parents. And then we have creative arts. So we're introducing kids to yoga, and to ballet ballet for the kid in wheelchairs, you know, for screenwriting. So it's a lot of how to really use your creative brain to pull electrical activity away from pain circuits on to other areas of your brain and actually have control and turning off your central pain circuit. Incredible, incredible. I will link the website below. Thank you guys so much for what you're what you do what you've done. You've made such a difference in so many lives. And I'm so appreciative to know you guys, and thank you for coming on the podcast. Thank you. Bye. Thank you for listening, and I hope you enjoyed this week's episode of Ask Dr. Jessica. Also, if you could take a moment and leave a five star review wherever it is you listen to podcasts, I would greatly appreciate it. It really makes a difference to help this podcast grow. You can also follow me on Instagram at ask Dr. Jessica See you next Monday.