I tested this on myself this month. Shortly before six on Sunday morning, October 11 (5:50 or so), a car was on fire on the highway along my route to the gym, and I stopped to pull the woman inside clear of it. As I walked her toward the shoulder, a car struck me at high speed and fled. She came through fine. The fuller story is in why the first opioid exposure matters.

My left leg took fractures of the medial malleolus and the fibula. An ankle wound roughly 15 cm long split the tibial artery. I bled away about 40% of my blood volume, a trauma activation followed, and two of my ribs fractured. No operation; the wound was simply closed. Opioids came up repeatedly in the ER, and I declined every offer. Chronic use tends to begin at a first exposure, so why open that door for a drug I might do fine without? Also, my endorphins and epinephrine were surging, which kept those first hours oddly mild. That decision was mine, for my body. It may not fit yours. I am no martyr, and plenty of patients need opioids.

What is the anterior midcingulate cortex?

It is a band of cortex in the middle of the brain, folded along the inner surface of each hemisphere, just above the corpus callosum. Three things that feel unrelated all converge there: bad feelings, physical pain, and the effort it takes to override an impulse. A major review placed all three in an overlapping zone of the aMCC and described it as a junction where information about rewards and punishments is wired to the motor centers that carry out a goal.

In plain terms, this is where the brain decides whether something unpleasant is worth pushing through, and then commits the body to doing it.

How does the brain decide an effort is worth it?

By pricing it. The aMCC is described as the hub that runs the cost-benefit numbers for tenacity, meaning persistence in the face of a challenge. It forecasts how much energy a goal will demand and weighs that bill against the payoff. People spread out along a range from tenacious to apathetic, and part of what sets a person’s place on that range is whether the cost of effort looks worthwhile.

The most striking evidence came from the operating room. In two patients undergoing brain mapping, electrical stimulation of the aMCC changed their heart rate and gave them the feeling that a challenge was about to arrive, along with a resolve to beat it. The authors suggested the region may matter in conditions where people have less capacity to endure physical or emotional distress.

It also seems to age well when it is used. “Superagers” between 60 and 80, whose memory matched or beat people two or three decades younger, held on to their aMCC cortical thickness, and thickness tracked memory across the older adults studied.

Can pain care strengthen persistence, or wear it down?

Both. One trial randomized 151 people living with long-standing back pain. With pain reprocessing therapy, two-thirds (66%) finished pain-free or close to it; the placebo group managed 20%, and usual care just 10%. On scans, back pain provoked less response in the aMCC and anterior prefrontal cortex afterward, and a year later the gains were intact. The therapy taught people that their pain was safe to move through. The persistence circuit responded.

Fear does the opposite. A meta-analysis pooled 335 studies (65,340 people living with clinical pain). The more people catastrophized or feared pain, the more disabled, anxious, depressed and negative they were, at medium-to-large effect sizes; pain intensity rose with it at a medium size. When fear sets the price of every step too high, the rational move becomes to stop moving.

Why does relief from pain feel like a reward?

Because it is one. Lab volunteers reported bigger relief after stronger pain, and they called that relief pleasant. The circuitry for that reward, mostly mapped in animals, needs opioid signaling in the anterior cingulate, midbrain dopamine neurons, and dopamine release in the nucleus accumbens.

Here is the catch I see. When relief arrives after you walked the extra block or finished the exercise, the cingulate gets paid for effort. A pill can deliver the payment without the effort. That says nothing bad about the people who need one. It does explain why we try, when it is safe, to let movement and the plan earn the relief first.

Does training raise pain tolerance or pain threshold?

Tolerance. A review of 15 studies covering 899 people found that athletes tolerated more pain than active non-athletes (g = 0.87), while the threshold gap lost significance once high-bias studies were dropped. Nineteen triathletes outlasted 17 non-athletes on pain tolerance, feared pain less, and showed stronger built-in pain inhibition, which was stronger the less they feared pain. Ultramarathoners who covered 4,487 km in 64 days without a rest day outlasted matched controls on a cold-pain test; whether the race built that or the race attracted it is unknown.

So the alarm still rings at the same point. What training changes is how long you can hear it and keep going.

What did a lot of pain with little suffering feel like?

Once the adrenaline faded, the ankle hurt a lot. Suffering, though, stayed modest, and the reasons are specific: the injury made sense to me, a plan was in place, the hurt had a purpose (I stopped to help someone), I was surrounded by people, and I fully expected to heal. Fear, uncertainty, isolation and meaninglessness are what convert pain into suffering, and every one of them is something a patient and a clinician can work on together.

Viktor Frankl, in Man’s Search for Meaning, quoted Nietzsche: “He who has a why to live for can bear almost any how.” In aMCC terms, a strong why lowers the price of the effort.

The Stoics had a blunter tool. Death has been near me, directly and at one remove, on more than one occasion, and that Sunday on the highway took about 40% of my blood volume. Their phrase was memento mori. In Latin it means “remember that you will die,” and they used it to cut a hardship down to its real size, never to invite gloom. Marcus Aurelius, in Meditations 7.33 (tr. George Long), wrote: “About pain: the pain which is intolerable carries us off; but that which lasts a long time is tolerable.” When you are clear on what matters, the fear and the pointlessness drain out of the pain, and persistence gets cheaper. Being Stoic does not mean keeping quiet or gutting it out. Give your clinician an exact account of how bad it is, since that account shapes the plan, and a person who requires an opioid has not fallen short in any way.

What does that look like in our clinic?

In practice that means four habits: we explain what is injured, put the plan on paper, keep you tied to the people in your life, and spell out what recovery should look like. We start with non-opioid tools when they fit. When 411 emergency patients with fresh limb pain were randomized, the ibuprofen-and-acetaminophen pair performed as well at the two-hour mark as three opioid combinations did. My own first days ran on those two medicines plus TENS, EMS, infrared light and a vibration plate aimed at one spot, tools that give the nerves competing input, nothing more mysterious than that. Our physiotherapy services include TENS therapy and graded exercise. I never missed a workday, and by October 26 my function and my procedure schedule were both fully back.

When someone needs an opioid, they get one, sized to them. Patients already taking opioids who choose to taper get interventional procedures to cover the pain while the dose drops, and we keep withdrawal from setting in. That is what opioid stewardship means here: individual harm reduction, never a ban. If you are coming in for the first time, here is what to bring to your first appointment.

Common questions