Pain - and how you quantify it?

[Tim Hall]

Without wishing to trivialise anyones pain experiences, is it time for some xkcd?

https://xkcd.com/883

The mouseover is where it's at.

[CrazyEnglishTriathlete]

An unnoticed insect bite doesn't itch.

Much of what you say makes sense, except this one.  I normally notice the critters have got me when it starts itching and, in investigating the itch discover the telltale red lump. 

[CrazyEnglishTriathlete]

There is also tolerance to regular pain.  Mrs CET, who has had problems with slipped discs is much more tolerant of that kind of pain than I would be.  On the other hand, I strongly suspect (from her complaints after hard gym sessions) that I am more tolerant of DOMS than she is. 

PS - on a comparative basis she rated childbirth as the same as an out-of-place disc, but with the benefit of it not being continuous. 

[citoyen]

But we must also remember that after 1 - 10 there's "giving birth", which may well be true in some cases.

I have no experience of giving birth but my own personal yardstick is an experience I had when I was 8.

I’d managed to get a foreign object lodged behind my kneecap - later transpired to be a sewing needle, or part of one. It was a freak occurrence - the needle had been dropped on the floor and I knelt on it at precisely the wrong angle.

Having it there was painful enough but was pretty mild compared to the pain when doctors tried to remove it.

They decided in their wisdom to conduct the op under local anaesthetic but as they started digging around, they just kept pushing the needle further in.

Eventually, the anaesthetic wore off and that’s when the real pain started. Sheer all-consuming agony.

Whenever a doctor asks me how bad it is, chances are it will be never be any more than a 6-7 relative to that experience (unless it’s the kind of situation where they don’t even need to ask the question).

I’m sure giving birth is worse. And I’m sure other yacfers have had other more painful experiences. But that’s my personal yardstick for what counts as a 10.

[TimC]

That reminds me. I had a vasectomy at a local clinic. It hurt - lots. I asked for more anaesthetic, but they'd run out. They'd hoped to get away with presumably less than recommended as I'd said I was fairly tolerant of pain. At the point where I asked for more, they were too far into it to stop. That's also never gone away!

[ian]

I don't know about pain, but good opiates make US tv bearable, which probably explains the prescription drug crisis over there.

[Rod Marton]

When I was in hospital after my crash earlier this year, they kept wanting to stuff me full of morphine, but I refused. OK, I hurt, I had broken rather a lot of bones, but the pain was bearable and I didn't particularly see the need. I also had the example of half the ward who were zonked out on morphine and it didn't look a very attractive option (the other half of the ward were bed blockers). The staff all seemed amazed at my attitude and (apparently) high tolerance, though it didn't seem particularly strange to me. Of course there was only one answer I could give to them:

"I'm a cyclist. I'm used to pain."

[Asterix, the former Gaul.]

I guess it is the cyclist thing.

When I broke my elbow last century I passed out with the pain. I didn't know I had broken it tho' so when I woke up I cycled home from just outside Ipswich home to Felixstowe, had a bath and went to bed. Next day I went to casualty where they eventually discovered it was broken.

More recently when I broke my neck and back they stuck me on a trolley. I remember only being in pain, despite paramedics administered painkillers, and I am told as they wore off I made so much noise the other patients in A&E said I had to be seen to first.  Doctor thought I was just badly bruised and told me I'd be ok in a few days, his was very shaken when he discovered I'd been lying there with spinal injuries.  Luckily the paramedics had done a proper job strapping me down.

I'd say the first experience must be a 10 and the second a 9 because I didn't actually pass out.

Later they put a halo on me while the neck fractures healed up. This goes around your head and is held there by four spikes driven into the skull.  I was given local anaesthetics and managed ok then they told me most people have a general but because of my back they didn't want to do that.

I'd rate that about 6-7.  You do get used to the spikes but every so often they have to tighten them because they get loose, painful but necessary, no painkillers. About 3-4.  Was on for 12 weeks, I can still remember when they took it off and I found I could move my head ok.  Better than a lottery win thanks to the NHS.

 

[barakta]

I found with my pelvic/femoral osteotomy (a notoriously painful procedure), when I was in too much pain I just froze up completely and couldn't move or sleep. I seem to not be that sensitive to morphine, so I needed a lot, and actually my eventual pain-managed dose 3 weeks post op, sorted by the GP was REALLY high (120mg zomorph a day + 5x 10mg oramorph topups ~4 hourly). But only once the pain was managed did I get stable enough to start dropping the doses quite quickly. 

I couldn't have answered pain on a 1-10 cos it wasn't perceived as pain, but for the freezing up and my heartrate being too fast and possibly the spiking temperature. The procedure is known to make some people like me very shocky for a while. My BP was very low and I was discovered to be surprisingly anaemic the day after surgery despite "not much blood loss" reported by the surgeons... The pain people when we eventually saw them said this was probably all contributory to the pain.

I'm still on morphine, albeit a lower dose of 30mg zomorph a day, pelvis is healed but the femur is taking its time and now my hip subluxates a lot. We don't know if it's the metalwork causing issues or a labral tear that we can't explore till metal is out and I've had even more physio.

[yoav]

yoav, I am also interested to understand why you think chronic pain is different to acute pain.

Maybe people conflate the two. Could you explain why you would separate them (if it's possible without going to a different forum)?

This is not just my thinking but a massive body of research and clinical practice. But seeing as you asked ...

Acute pain is generally what most people would think of as pain. You injure a part of your body, pain receptors are stimulated and nerves transmit the pain signal to your brain and you go 'Ouch!'. Except it's not quite so simple. Pain signals can be modified on their way to the brain, think rubbing an injured part to reduce pain. Pain signals are also processed and modified in the brain. What you feel, or 'experience' which would be a better word, depends very much on your previous experience of pain, your psychological state at the time, how the society you live in regards pain and many other factors.

Practically all the evidence for the efficacy of analgesics is based on the management of acute pain and for most people, most of the time, they are effective in acute situations, provided they are used appropriately. But as I can see from comments above, this is not always the case, not just by patients but by health care staff too.

Chronic pain is officially defined as pain that persists beyond 12 weeks despite treatment. In reality, someone is labelled as having chronic pain when their doctor doesn't know what is causing the pain or knows what is causing it but can't fix it, and (and this is the crucial bit) is fed up with the patient.

In (very) simplistic terms, chronic pain turns the acute pain model on its head, whereas the peripheral part of the body that is hurt, or more precisely. where the patient says their pain is, is almost completely irrelevant in that either there is nothing abnormal to find at the site or whatever it is has healed to the point where it is unlikely to be source of the pain.

In patients with chronic pain, what is going on in the brain is of far more significance. We can talk about it in physical terms, such as that the brain sensitivity to pain is heightened (turning the volume up), in psychological terms so that patient who is depressed might experience worse pain that a patient who is not, and in social terms, such as whether the people around them are supportive, or not. In reality, of course, all these factors and more play a part, and managing such patients requires trying to understand these various factors.

Patients sometimes used to ask me,'Is it all in my head, doctor?' to which I'd have to say, yes, of course. Where else can you experience pain? Your brain isn't in your hip, or your knee but in your head. They would usually appreciate my honesty. Of course, the implication is that if it's in your head then it can't be real pain. But to that I would ask, what is the difference between 'real' pain and 'imagined' pain? To the patient, it feels exactly the same so why treat them differently?

Compared to the treatment of acute pain, management of chronic pain is difficult and messy. Practically every study of the treatment of chronic pain shows that drugs, injections, operations, physiotherapy etc are no better than placebo. Or as good as placebo, depending on your view of placebos. Which is why I had no objection to patients taking complementary therapies as long as the NHS didn't have to pay for them.

Sometimes, when managing chronic pain, all I could do was to try and enhance the placebo effect. That's not to say that sometimes even the most unproven treatments worked surprisingly well in some patients. You just had to keep trying different things until you found something that worked for that person, or more commonly, didn't.

(In clinical trials, the placebo response is around 30%. If the treatment tested has this level of response it would be regarded as ineffective, but in chronic pain situations, 30% is about the best you are going to get)

In the end, just about the only 'effective' management (not treatment) strategies for chronic pain is what is called a pain management programme  when patients undergo a series of sessions to educate them about pain, teach them strategies to cope with it and provide support. A service that is much under resourced in the UK.

I always reminded myself that there are many people out there, who are experiencing chronic pain and never go anywhere near a doctor. They may have good coping resources, and good support around them that they can manage their pain without any, or minimal, intervention.

Well, I've gone on long enough. I found this Youtube video quite helpful in explaining pain and I used to show it to patients as well as to trainee doctors:

https://www.youtube.com/watch?v=C_3phB93rvI

[TimC]

Interesting post.

As a 'not a doctor' but experienced in pain(!), I'd slightly disagree with your explanation at least as I experience pain and manage it. Acute pain, to me, is temporary (as you said) and will fade as the injury or condition heals. It may or may not respond to pain management, but as it's going to go away anyway that's very often not so much of an issue. It may be agony briefly, but not for long. In my experience, that would be represented by a broken bone, a burn or a nasty bit of road rash. Chronic pain, on the other hand, is caused by a condition which won't go away and may get worse with time (arthritis, for instance). It may come and go to some extent, but it's never absent. Pain management is much more useful for this, and - with secondary arthritis, which I suffer from - may be tackled by behavioural changes as much as by medication. In my case, some are obvious - don't go running, for example (although it took some years before I acquiesced to that!) - or lose weight, or whatever. But in bad periods, medication may help. Whether or not it's psychological, Ibuprofen gives enough relief that I can continue with my day when things aren't good. Without it, getting out of bed and going to the bathroom is a major exercise in pain tolerance!

[chrisbainbridge]

YOAV has given an excellent description of pain but I think it falls down a bit with respect to the situation of TimC.  I would characterise TimC as having a chronic acute pain.  It has a defined cause and medication is effective with simple analgesics giving a predictable response.  There is a known underlying causation which Tim and his surgeons have decided is either not amenable to surgery or surgery has too many risks.

The other type of chronic pain is where there is little or no current evidence of pathology, the pain is rapidly increasing and is accompanied by frequently catastrophic thinking.  Instead of eventually accepting that running is a problem, this sort of pain is accompanied by expostulations to the effect that they will soon be in a wheelchair and what is the doctor going to do about it?

There is generally a high level of catastrophic thinking, anxiety and depression with a lack of self awareness.

  "TimC" type pain responds very well to pain management clinics.  advice on timing of drugs, booster drugs, nerve blocks (temporary or permanent), etc.

The second type will be helped by CBT and other counselling if the person is willing to engage.

Do not get me started on gabapentin for pain.  It does not even reach the 30% efficacy and is highly dangerous.

[yoav]

TimC - apologies if I gave the impression that I was dismissing or ignoring the situation you are in. It sounds as if you have found strategies to deal with your pain and I would say good on you.

Chris - indeed, you have described the two ends of the spectrum of people with, let's call it, long term pain. Although there are people who fit these these descriptions, most fall somewhere in between and may even move about between these extremes throughout their lives.

As a pain clinic doctor, I would see people who could not, or their health care providers could not, manage their pain. Unsurprisingly, the expectations of people I saw varied tremendously. Those seeking a 'cure' for their pain were bound to be disappointed. Others were much more realistic about what could be achieved.

(I agree with you about gabapentin. I had a few patients who found it helpful and could manage it, but I was terrified when the orthopaedic surgeons at my hospital decided to routinely use it for post joint replacement analgesia)

[Sergeant Pluck]

Do not get me started on gabapentin for pain.  It does not even reach the 30% efficacy and is highly dangerous.

An enormous and seemingly increasing number of patients are on it (as observed in cardiac outpatient setting) for musculoskeletal pain of one sort or another, e.g. “lower back pain”. 

[yoav]

Gapapentin, and its more expensive cousin pregabalin are anticonvulsants (drugs for epilepsy). They are of limited use in the management of some types of neuropathic pain (pain due to nerve damage) but due to some highly dubious research, and the unmet desire of health care professionals and patients for a 'miracle' pain killer seems to have become a mainstream analgesic. But it is not effective, has serious side effects and its addictive potential has led it to become a controlled drug (like opiates, subject to legal controls).

But the genie is out of the bottle

[chrisbainbridge]

Do not get me started on gabapentin for pain.  It does not even reach the 30% efficacy and is highly dangerous.

An enormous and seemingly increasing number of patients are on it (as observed in cardiac outpatient setting) for musculoskeletal pain of one sort or another, e.g. “lower back pain”.

Absolute total nonsense prescribing!  gabapentin and pregabalin were developed as anti epileptics.  They didn't work! But having invested a lot of money the company wanted to see if it could be used for anything else.  Some bright spark suggested neuropathic pain.  Not a bad idea if you think controlling nerve related pain by membrane stabilisation is a thing.  Probably is for some of the horrendous injuries we deal with such as brachial plexus or poly trauma.  For almost everybody else it is horrible.  Most people have a sense of isolation (being walled off from those around them), major mood disturbance and no real efficacy.  Certainly ineffective for musculoskeletal pain.  It is now a class C drug and probably worth more down the pub than the cost of the prescription .  I know one very sensible person prescribed it for shingles pain who now cannot come off it as he has a fit every time it is reduced!!

Not quite the Oxycodone level of damage thankfully

[Sergeant Pluck]

One issue is that I don’t think the prescription is reviewed. When I ask patients how long they have been on it, the impression I get is that they see it as something that has been permanently added to their list of meds, like a statin.

It is now a class C drug

Very common as a street drug in Northern Ireland - but not as common as pregabalin, which GPs have had to stop. Involved in 186 deaths in 7 years.

https://www.belfasttelegraph.co.uk/news/northern-ireland/gps-to-stop-prescribing-pregabalin-linked-to-186-deaths-in-northern-ireland-40766634.html

They both seem to be readily available through whatever dubious channels. The gabapentin is snorted.

[TimC]

TimC - apologies if I gave the impression that I was dismissing or ignoring the situation you are in. It sounds as if you have found strategies to deal with your pain and I would say good on you.

Absolutely no worries! I didn't for a minute think either of those things.

[ElyDave]

I tend to share most experiences here in some way, but I do have to speculate as to habituation to self inflicted pain increasing the tolerance to other pain.

By that, thinking about the population on here, and my own sporting practices - rugby, ultramarathons, time trials, hill climbs, long distance cycling ... Does this give a threshold shift for pain?

I'd say my two most painful I juries were a serious dislocation of the shoulder (never went back straight) and my fractured pelvis, I'd not put either on more than 6-7, but was on serious painkillers after. Chronic pain I just find weird, in my case bone spurs in big toes make every step painful, but ignored when running, lower back pain due to muscle imbalance after the pelvis. Sitting here now my back is in non-ignorable pain, and varies to the point that I consider my stock of opiates, but never take any. On the bike today though, I thought about it for the first half hour and then forgot all about it. When I tell my physio "yes, it was a bit of a niggle after about 45 mins or so" he automatically tags that as my version of quite bad.

[Pedaldog.]

a bio-psycho-social experience.

.

Several Hospital, Project 2000, Colchester 1992. "The Bio-Psycho-Sociological Lifestyle of a Person the Acquires a "Learning Disability through Accident, Illness or Injury".
I got 97% scored by the Academy on that essay. Four Years Later I "Acquired a Learning Disability through Injury"

[chrisbainbridge]

I think we are seeing a generation who never knew pain. Young men especially with minor injuries needing/requesting opiates for injuries the grandparent would laugh about.

I think to answer ElyDave’s question, we learn that pain is something that is just a message and not the end of the world. So we cope better. But it is probably also reversible. Because we know pain is just a message we do stupid sports!

[arabella]

I wonder ^

Conversation with one of mine (a teenager at the time) about my reaction to knocks and bangs: "you'll be fine" vs. friend who was petted and cossetted, thus on occasion milking it; and recollection of another friend (back at primary school) who'd trodden on something barefoot (probably a twiggy lump) and screamed the place down swearing it was a wasp sting (there was no sign of one). 
The conclusion was that although the cossetting might have been nice, said (no longer a) child was happy to have ended up with a more robust attitude to knocks and bangs.

[Kim]

Treading on something is a bad example, because it'll cause different people to experience different amounts of pain in the first place, on account of what their feet are adapted to.  I've been a habitual wearer of shoes since I was about 3 years old, and walking barefoot on anything rougher than recently-swept lino is excruciating.  My brother was a staunch footwear-refusnik (other than when socially obligated), and could happily walk on anything that wouldn't actually cut or sting.  I remember a couple of particularly miserable beach holidays...

Meanwhile, if anything, I had the greater tolerance for pain from random ISO standard injuries.  (Though possibly I was just less inclined to making a fuss.)

Obviously as children of medics, if it didn't come with substantial blood loss, something worth x-raying, or potential for an interesting infectious disease, it didn't really count.

[ElyDave]

Obviously as children of medics, if it didn't come with substantial blood loss, something worth x-raying, or potential for an interesting infectious disease, it didn't really count.

This^^

If there's lots of blood and/or i can see something I shouldn't "I'm just going to see minor injuries, won't be long"

[mrcharly-YHT]

Pain and emotional connection . . .

As a kid, I couldn't stand anything that was 'sticking into me'. So, splinters, rusty nails, injections made me howl the place down. Impacts and bruises? Shrug, not bothered (that was useful, since I grew up on a horse stud and got frequently kicked, trodden on, trampled, etc).

Changed when I became older. Walking on pontoon in bare feet one evening, slipped at edge lifting something and jammed my heel *hard* into sharp edge of steel. Mrs C rushed over "I knew it was bad because you didn't make a sound."  Internally I was saying 'fuck' a lot and concentrating on holding my foot to keep the claret in.

Trip to A&E and a really pleased nurse, because he got to clean out the wound with tweezers "normally the doctors do this, but you don't seem to need an anaesthetic" (the steel had punched in quite a long way and there were fibrous bits sticking out, I guess ligament or tendon).

So odd, that is all about emotional feeling about the injury. The pain was merely something telling me I was injured, not overwhelming or frightening.