Pain - and how you quantify it?

[Cudzoziemiec]

This. Someone (not me) was asked by a nurse, a short time after a surgery, the OP question:

On a scale of one to ten, how much pain are you in?

Not knowing what a pain of "one" or "ten" was supposed to be, the person replied 5. She was then given morphine by said nurse. Fortunately for her, the morphine end up in the bin, as the pain was bearable without relying on that kind of stuff, but I can imagine easily that half-conscious persons after a severe surgery or disease would take whatever they are given.

Gosh. Usually scales of one to ten run from "utterly hate it" to "totally love it" (or vice versa), making 5 a neutral.

That implies there must be "negative pain", which I'd say there is – we call it "pleasure".

[Cudzoziemiec]

Also, the "correct" or most useful answer for any given pain and person is probably going to vary according to the purpose of the question: is it to assess painkillers, estimate the extent of an injury, get an idea of psychological state, or something else?

[chrisbainbridge]

This. Someone (not me) was asked by a nurse, a short time after a surgery, the OP question:

On a scale of one to ten, how much pain are you in?

Not knowing what a pain of "one" or "ten" was supposed to be, the person replied 5. She was then given morphine by said nurse. Fortunately for her, the morphine end up in the bin, as the pain was bearable without relying on that kind of stuff, but I can imagine easily that half-conscious persons after a severe surgery or disease would take whatever they are given.

Gosh. Usually scales of one to ten run from "utterly hate it" to "totally love it" (or vice versa), making 5 a neutral.

That implies there must be "negative pain", which I'd say there is – we call it "pleasure".

The scales actually start at zero but as they are generally only applied to people thought to be in pain then we often default 1 - 10.

The pain was merely something telling me I was injured, not overwhelming or frightening.

This is the difference between coping with pain and not coping.

There are however some pains that are so awful that they transcend all ability to cope.  Brachial plexus avulsion injury is the absolute classic.  Described usually as akin to having an HGV parked on you arm allied to the psychology of knowing it will  never, ever, ever stop. 

[mrcharly-YHT]

In hospital, the medical staff are not really interested in you being pain-free. They are interested in you recovering from illness/injury/surgery.

Too much pain impedes healing and recovery.

'Too much' is entirely subjective. Hence enquiring about emotional feeling (response) to the levels of pain. With children, they often show them a series of pictures of smiley faces. The faces have smiles, frowns etc. The child is asked to point to the one that they feel like. Now, when my son was very very ill in hospital, he would always point to the really happy face, because he was an attention hog and absolutely *loved* having all these medical staff bustle around him.

Some kids (adults as well) can't bear so much as a creased sock.

[ian]

As a child, I feel out of a conker tree and into a hawthorn bush, which shoved a stout thorning branch up through my armpit and out the other side. I staggered home covered in blood impaled on about half a metre of hawthorn branch. My dad* just yanked it out over the bath and poured TCP into the hole. I think that hurt. The first of my many scars.

Never knew they were prescribing anti-convulsants for musculoskeletal pain – that seems like a form of madness only made favourable by the alternatively stupid mass prescription of ineffective opioids (in the US, at least).

Surprising (or perhaps not) how much modern prescribing isn't really based on much evidence (there's no evidence that most anti-depressants work other than in small, defined groups, and even then, probably not – the entire serotonin reuptake hypothesis is long gone, and the final nails hammered into the coffin recently).

*who recently died, having stage 4 pancreatic cancer, having left the morphine untouched in favour of nothing stronger than the occasional paracetamol. Of course, his lack of faith in the power of modern medicine probably hastened his demise.

[barakta]

I hate pain scales, they're patronising and the person asking the question never explains what 0-10 stages actually mean. They don't have a chart that the patient can read and think about and discuss together with the clinician.

A friend of mine who has chronic pain shared this great pain scale that explains what each level might mean. When I saw pain management in 2019 for my crappy dislocating shoulder which is surgically fucked, I printed that scale out and took it with me to my assessment appointment. The otherwise pretty decent pain physio (who did a better shoulder assessment than her shoulder physio colleagues) refused to read or discuss my printed pain scale, or define her pain scales. I argued that without us having a common metric the question was meaningless and annoying but absolutely no willingness to calibrate a scale. So I answered based on that one and left the print out in the room and asked her to put it in my notes with my summary history notes.

Another issue with pain scales is that I always feel like unless I say 8 or higher that I am not going to be taken seriously by medics. There's almost a badassery attitude (and I even see it in this thread) where people brag (possibly not even intentionally) about the pain they've survived/ignored etc and that having a higher pain threshold is treated like some moral goodness that a person has a choice about.

There also isn't enough conversation or reassurance from clinicians that it's OK to raise lower levels of pain and have those taken seriously especially when that pain is frequent or constant. As it was, my pain clinic did take baseline of 4-5 rising to 6-7 at its worst pretty seriously. Unfortunately pain management's medication, nerve block and denervation options didn't work so pain management clinic didn't do me much use except a few medical letters I might throw at the DWP one day.

The gabapentin discussion is interesting. My pain management service gave me a note to ask GP to try gabapentin and didn't tell me they were discharging me - I found out from the clinic letter... I am even less impressed that they're fobbing people off to GPs for gabapentin after the thread here!

Gabapentin gave me hideous migraines like neurology's attempt to treat my migraines with anti-epileptics. I also get hideous migraines off paracetamol, Cox2 inhibitors, mefenamic acid and flurbiprofen. Cannabis is also one of my major lifelong migraine triggers, hate the stuff, can't smell it distinct from cigs which I also loathe until it's made me ill, evil stuff.

I wish a patient could know in advance which pain clinics are good and which are either not good enough like mine was or evil shitty "everything is psychological and using any meds mean you're an addict and we'll treat you punitively like an addict" like a friend had once. There seems to be such variation.

[Tigerbiten]

Interesting read ....

The daft thing is on a scale of 1 to 10 on "how much pain was I in when I ripped free from the Tiger" then I'd have to answer
It was hurting badly when the Tiger was eating my hand and the missing hand was starting to hurt like mad when the helicopter was landing.
But for a time between those two points, I was so overloaded on natural pain killers that it didn't hurt.

And then you get "phantom pain".
Which is "all in the mind" as the part generating the pain is no longer there.
Mines a weird type of "pins and needles" in the fingers, ranging from 0 when I forget about it, backgrounds ~2 when I think about it, up to about 7 when I knock it and it goes "twinge".

Luck ......... 

[Polar Bear]

When I broke my leg I knew something was wrong but the brand had already bunged in the natural protection.  Everything felt surreal until I saw the x-ray and then the pain hit me so hard and fast that I almost blacked out. 

And then they dosed me up so much that the world faded into oblivion for the next 48 hours and post surgery.

[Cudzoziemiec]

And then you get "phantom pain".
Which is "all in the mind" as the part generating the pain is no longer there.
Mines a weird type of "pins and needles" in the fingers, ranging from 0 when I forget about it, backgrounds ~2 when I think about it, up to about 7 when I knock it and it goes "twinge".

Luck ......... 

But presumably the nerves in your arm that used to lead to the hand are still there.

[mrcharly-YHT]

That is an interesting pain scale.
My very very worst kidney stone episode would be about a 9 on that scale:

Pain level nine is excruciating pain, so intense you cannot tolerate it and demand painkillers or surgery, regardless of the side effects or risk. If this doesn't work, suicide is frequent since there is no more joy in life whatsoever. Comparable to throat cancer.

Fortunately, that only lasted for about 24hours.

Most kidney stone episodes have been more like a 7

Pain level seven consists of very intense pain. Much the same as level 6, except the pain, completely dominates your senses, causing you to think unclearly about half the time. At this point, you are effectively disabled and frequently cannot live alone. Comparable to an average migraine.

My smashed wrist was only about a 4-5.

The subjective part is still strong though. I have a friend who can't stand headaches. He takes a paracetamol if he *thinks* a headache might be starting. So, for him, an actual headache is 'worst imaginable'. He has no problem working through injuries though.

[Cudzoziemiec]

I found that scale rather difficult to relate to. Probably I've simply never experienced many of those things or levels of pain, but where I have, I don't find them necessarily comparable. For instance level 4:

Pain level four is a distressing strong, deep pain, like an average toothache, the initial pain from a bee sting, or minor trauma to part of the body, such as stubbing your toe hard. So strong, you constantly notice the pain and cannot completely adapt. This pain level can be simulated by pinching the skin fold between the thumb and first finger with the other hand, using the fingernails, and squeezing hard. Note how the simulated pain is initially piercing but becomes dull after that.

For me, stubbing my toe hard is a far more intense pain than any of the others, and toothache is different in quality from the others in that it's ongoing whereas the others are short lived. Which isn't necessarily a criticism of the particular comparisons used, as I expect whatever was used, there would be different experiences. It is probably better to have some sort of description, even if imprecise and variously understood, rather than a totally unquantified scale.

[mrcharly-YHT]

I found that scale rather difficult to relate to. Probably I've simply never experienced many of those things or levels of pain, but where I have, I don't find them necessarily comparable. For instance level 4:

Pain level four is a distressing strong, deep pain, like an average toothache, the initial pain from a bee sting, or minor trauma to part of the body, such as stubbing your toe hard. So strong, you constantly notice the pain and cannot completely adapt. This pain level can be simulated by pinching the skin fold between the thumb and first finger with the other hand, using the fingernails, and squeezing hard. Note how the simulated pain is initially piercing but becomes dull after that.

For me, stubbing my toe hard is a far more intense pain than any of the others, and toothache is different in quality from the others in that it's ongoing whereas the others are short lived. Which isn't necessarily a criticism of the particular comparisons used, as I expect whatever was used, there would be different experiences. It is probably better to have some sort of description, even if imprecise and variously understood, rather than a totally unquantified scale.

Adaption.

That is the key word in the description.

An event like stubbing a toe can be, in the instant, very distressing, however the duration is very short. You very quickly adapt to the signals. What is momentarily quite overwhelming, diminishes to a discomfort.

Extreme pain is very difficult to adapt to. It overwhelms senses and there is no letup. As described in the list, the pain itself disables you.

[Cudzoziemiec]

I don't think it's only adaption though. With a stubbed toe or "pinching the skin fold between the thumb and first finger with the other hand, using the fingernails, and squeezing hard" the stimulus itself is short-lived and related to an obvious physical impact. With toothache, the inflammation from those bacteria or whatever is itself active over a much longer timeframe, measured (without medical intervention) in days, weeks or months rather than minutes or seconds.

[L CC]

I spent a night in A&E last September because a bike ride triggered knee pain (in the usually less bad left knee) that had me wishing I would die so it would stop.
Oramorph doesn't stop the pain, but you stop caring about it. X-Rays showed nothing (other than the known-present arthritis) and eventually I went home for it not to happen again. It had pretty much vanished.

I think it's very easy to overthink this. I've never had a problem quantifying the pain I'm in. 0= what pain. 5= present but I can live with it 10= kill me now.

I'm living with 5 in my knee most days these days, and if I do more than a couple of thousand steps a day, that'll increase to a 7, maybe 8.
Giving birth- maybe an 8. Breaking my wrist. 7. Falling off the bike on Monday- 6 fading rapidly to 3.

[ian]

I can't find it now and my google-fu needs charging, but there was some controversy a few years back when a [female] obstetrician suggested that they stop telling women that childbirth was the most painful thing either, since it often became a self-fulfilling prediction as they have potentiated the experience. The usual online spat between women who declared it the most painful thing ever, how could anyone even dare otherwise versus women who declared it so painless they had worse headaches. I think there's an über-war about drugs versus no-drugs during childbirth, which I'll understandably stay out of.

[barakta]

I am sure childbirth pain is to some degree mediated by how safe and supported and prepared the woman giving birth is. But also combined with an individual's natural/developed pain threshold and other factors. Not all births are equal, some last a lot longer than others. I've never given birth myself, but some people I know who have had babies say it was difficult but it didn't last very long and for most of the labour there were pauses in the pain.

I don't know where the line is in treating pain and 'you should expect to be in some pain and that is OK'. It is going to depend on what else the person is trying to do and how much it affects their life etc.

Being in constant pain is very tiring and that's something that seems under recognised. You can ignore it and carry on, but that in itself takes a lot of energy.

In my case some of my pain is ignorable, my baseline is 2-3 and it is often 5 (by my chart) I know it's stupid joints, but some of it is concerning cos I know it's associated with loss of function of my arm or leg and if I am not careful it'll take days/weeks to restabilise.

[Kim]

I recall an account of giving birth (by the sound of it, a prolonged and fairly difficult one, with tearing and such) by someone with chronic back pain.  Their main concern, once the baby was safely delivered, was that the back pain had gone unmedicated since the start of labour.  The phrase "Why is everyone so concerned about my vagina?" was memorable.


I've had the wanting to die pain, but transiently and I've always been too stuck on the toilet to act on it.  Your bowels may vary.

[Flite]

Since Kim mentions bowels, I can confirm that having a blocked bowel is definitely pain level 10.
By the time the ambulance called by the GP arrived, I was drifting in and out of consciousness, a vague recollection of being carried downstairs and a bumpy blues and twos ride over the fells to the hospital.  At some stage I was begging a nurse for something to stop the pain, and being refused. Then there were the two men standing at the end of the bed - "We will just have to get in there and see what's happening".  I came round 3 days later.
(apparently the surgeon had spent several hours untangling scar tissue caused by a hysterectomy 10 years earlier that had wrapped around my gut and restricted it until it was totally closed)

[ElyDave]

Earlier today I recalled my time in isolation, recommissioning a circulating water system in late December, leaks everywhere. Bastard flu going round, I went down with it, we found legionella in the water. Cue isolation ward, armful of blood for testing, IV antibiotics.

It was not so much pain due to the antibiotics, but more the nature of the sensation being tip of finger to shoulder and seeming to originate inside out as a sensation of heat and intense irritation that I can still recall now. Probably no more in my mind than a 6-7 vs other 8-9 acute injuries, but I just couldn't manage the fact that there was no apparent end.

[Kim]

Sounds a bit like a potassium chloride drip (not actually that painful, but the 'armful of pain' sensation is definitely Type 2 Fun).

Or the blood transfusion I had as a small, which my immune system took objection too.  I was pleading for them to take the needle out, and no amount of telling me there wasn't a needle would persuade me that it wasn't hurting like there was one digging around in there.  Perhaps if someone had drawn me a diagram of how a venous cannula works we could have made more progress.

[tereck]

The most pain I've ever known was having stitches in a finger tip (a scaffolding pole fell on it and burst it) The doc said there was no point (ha ha) in giving me a pain-killer injection first as the injection would hurt as much as the stitch (note, singular) Then they saw the wound needed another stitch. So that is my 10. I've no idea if anything can hurt more than that. I hope not, or hope at least that I'll never find out, but consider myself deluded to think not. That'd be off my scale.

I have a problem in knowing whether something IS pain rather than simply being a discomfort, a severe discomfort etc. I have chest discomfort at the moment that probably merits a chat with my GP but I wouldn't class it as pain. So some things don't even have a number on my 'pain scale'

Of course, being in France, things are much simplified; anything anywhere simply 'hurts'. Is there a cultural dimension to pain perception too?