Pain bites.
September 20, 2004 6:13 AM   Subscribe

No pain, no gain, they say, and when it comes to real pain, the inverse is true as well. "We now have research indicating there's a memory of chronic pain," said Dr. Doris K. Cope, director of chronic and cancer pain for the University of Pittsburgh Medical Center. It changes the genic code sometimes, it changes the biochemistry, and it causes new proteins to be formed." Or in other words, the more pain you have, the more pain you have. (More on this.) It's no wonder, then, that more money is spent on pain relief than any other medical problem, and that there has been so much pain research and so many clinical trials revealing such painful facts as redheads feel more pain, men feel less pain, and that there's a genetic difference between tough guys and wimps. (Much more pain inside.)

posted by taz (31 comments total) 4 users marked this as a favorite
The fact is that pain is too complex to be handled by any single therapy, no matter how aggressive,
and that scientists are still struggling to interpret their findings and deal with such fuzzy clues as research that suggests that psychological factors may be better predictors of lower back pain than diagnostic techniques, and that the behavior of partners can make chronic pain worse, not to mention that old bugaboo, the mysterious placebo effect, which seems to be getting something of a face lift these days with studies showing that placebos can effect measurable physical change in how the brain responds to pain. So, more and more, scientists are looking toward the brain for pain-combat techniques, and some have turned the tables by having pain-ridden patients view the activity of a pain-control region of their own brains, thereby learning to suppress their pain.

Despite the fact that pain is one of the few things that just about all of us share, it is notoriously difficult to describe and quantify, so much so that various pain scales have been formulated to help sufferers communicate what they are feeling to their doctors. If you ever find yourself in the position of having to relate your own chronic pain experience, you may find this Assessment Guide (pdf) very helpful. Finally, a good one-page pain primer; a quick MayoClinic pain quiz, and a couple of pain blogs. (By the way, the AMA has declared September Pain Awareness Month, and the links from here for the "Nurses' Toolkit" and "Myths about Controlling Pain", are very interesting. - both pdf.)
posted by taz at 6:18 AM on September 20, 2004

(sorry for that formatting blip after "aggressive", if you are seeing it; I did a cut and paste for the "more", and ended up with a bunch of unwanted line breaks I had to delete - this one didn't show up in the preview...)
posted by taz at 6:23 AM on September 20, 2004

"Male infants feel pain during circumcision and they remember that pain six months later when they receive their routine vaccination, according to a study led by Hospital for Sick Children (HSC) researchers."

"Circumcised infants showed a stronger pain response to subsequent routine vaccination than uncircumcised infants. Among the circumcised group, preoperative treatment with Emla attenuated the pain response to vaccination. We recommend treatment to prevent neonatal circumcision pain."

"EMLA cream is not approved for use in the first thirty days of life due to the threat of methemoglobinemia, a blood disease. The package insert from the manufacturer states that EMLA should not be used on mucosal tissue (which would rule out its use for circumcision), and in any case should not be used on children under 12 months of age, because of the risks of its use. Furthermore, it is not a sterile preparation and should not be used on open wounds."
posted by Feisty at 6:53 AM on September 20, 2004

I thought I had another kidney stone Friday and went to the ER (because my GP would have told me to do that anyway, even though the end result would only be pallative in any case). Turns out that it's not a kidney stone, but an outbreak of shingles. Which is also (or can be, but is in my case, anyway) very painful.

As mentioned many times elsewhere, I have a genetic bone disease that's resulted in severe osteoarthritis in all my major joints. I live with chronic pain.

And the whole pain thing is a bit of a mystery to me. I have a very high tolerance for pain and am always in pain, so, believe it or not, I have the most luck in trying to quantify the amount of pain I'm feeling indirectly, like how much my breathing and heartbeat are elevated, if I'm sweating, other ways in which I physically and psychologically react to pain. Because I've a very hard time directly evaluating the pain level at any given time.

Since I was very sure that I had another kidney stone, having had four or five in the past and the location and type of pain was extremely familiar, this time around I went to the ER earlier Friday morning than I would have otherwise. That is, before the pain was so obviously really, really bad that I didn't feel weird about the melodrama of going to the ER. When I found out it wasn't a stone, but shingles, I was embarassed.

A close friend a few years ago, right after he moved in with me, developed a kidney stone one night. He banged on my bedroom door in the morning and I took him to the hospital. For hours (until they finally gave him IV narcotics) he was writhing and moaning and occasionaly screaming. To my shame and surprise, I found myself being irritated at that behavior. I don't much outwardly show pain, it seemed silly to me to do all that writhing and stuff. But then, he is someone who experiences severe pain only very rarely.

My high tolerance and lack of outward signs of being in severe pain can be a bit of a problem when I've been diagnosed in the past with kidney stones or, as in the case Friday, with these shingles.

On the other hand, earlier last week I had a bad migraine for a couple of days (which now I wonder if it weren't a symptom of the shingles) and I was a real baby about it. I was so miserable, I lied in bed whimpering. That was a form of pain, though actually less intense than even the shingles pain I've been feeling, that I couldn't distance myself from. Being in my head, the pain is like it's consuming my whole being. Is it this way for other people?

This disease is genetic, my sister has it too and also has a very high pain threshold. We've talked about this because it's a bit odd since we know that we don't react to pain the way most people do. And the question is whether or not we're feeling the pain as much as other people do. I've been tempted to think that we don't; but then, when you look at the secondary effects that I've mentioned like heart rate, blood pressure, breathing, sweating—they all indicate that I'm experiencing high levels of pain.

As far as partners and friends and family in terms of pain: there's all the problems that are there with disability in general. Pain makes almost everyone irritable. It made my dad next to impossible to live with, as his attitude was always that his irritability (because of his pain) was inherently someone else's fault. Me, I've learned to be aware that my irritability is my own problem and not to make it other people's problem. But I can still be terse and maybe a little unresponsive when I'm hurting badly.

Finally, in general I find that living with chronic pain isn't so hard because of the pain directly. Like I've said, I sort of always tune it out. But lately I've realized that suffering from chronic, constant pain is taking a toll on my mind and body, anyway, even if I am tuning it out. For example, it makes me very tired. Somehow I think these secondary effects are not appreciated for how much they actually affect chronic pain sufferers. Or maybe they are. I dunno. Just some thoughts from someone with whom pain is a constant companion. I know that Taz, too, has chonic pain.
posted by Ethereal Bligh at 6:58 AM on September 20, 2004

As a neurologist, I get a lot of chronic pain patients dumped on me by other physicians. My training is diagnosis of neurologic disease, not pain management, so I've had to learn to do it myself - my hospital has a pain clinic, but I've found that all they do is prescribe tramadol 50 mg and a small, probably ineffective dose of gabapentin.

I find pain management difficult, unrewarding, and boring. It's clear enough that chronic pain is a self-perpetuating state that has little or nothing to do with tissue injury, but it's not at all clear to me that we've developed an effective medical approach to this.

It's also pretty clear to me that narcotics cause as many problems as they solve. Getting past the old 'doctors underprescribe narcotics' thing, we've noticed that patients who take narcotics every day often become tolerant to the pain-reducing effects - and then when the narcotics are discontinued, the chronic pain state is intensified. This doesn't seem to me to be particularly beneficial, and when you factor in sedation, constipation, and the fact that a lot of patients don't want to take narcotics chronically, it becomes clear that they're not a very good option for everyone.

I've taken to managing pain with neuromodulators such as tricyclic antidepressants, anticonvulsants, and various other sorts of meds, with some success. The hardest part for me is coming to the point where I say, "Look, you're going to be in pain. We're going to have to find a way to deal with it so it doesn't ruin the rest of your life." I find that unsatisfactory on some level, but I get there with a lot of patients.
posted by ikkyu2 at 7:12 AM on September 20, 2004

Timely topic.

I usually have a pretty high tolerance for everyday aches and soreness, but over the past year, I've developed chronic lower back pain. It's sometimes so debilitating, I have to stop walking and sit on the curb every couple blocks. Sometimes a few beers or 3 advils will knock it out temporarily. Other times I'll just have to grit my teeth till I can get home and lie down. When I saw a doctor about it, he poked and prodded me for a while then wrote a scrip for Soma, which made me loopy. My medical plan is mediocre, he's kind of a ghetto doctor.

Then about a month ago, I suffered through back to back bouts of gastritis and UTI. Both of which had me writhing in pain. I'm only 33. I'm not ready to be an invalid yet. Butwhen I was a younger man, I've had broken fingers and teeth knocked out of my jaw, and been hit in the head (accidentaly) with a bat, none of which caused the kind of pain I have as an adult. Age must definitely be a factor.
posted by jonmc at 7:13 AM on September 20, 2004

EB - Actually, it was partly your AskMe migraine thread that started this. I was looking around about that, and found lots of interesting pain information, and then today I was looking up something totally unrelated, and ran into a couple of really interesting pain-related links, and started surfing those and came across more stuff... and so I figured the Post Gods were trying to tell me something. I don't, though, have chronic pain myself - I did suffer with horrible migraines in the past, but either age or a more low-key lifestyle has pretty much knocked them out. I've also had recurring back pain so severe that I basically couldn't move (when I was only in my 20s), which I am now entirely sure had to do with very real muscular reactions to high stress - so the whole question of pain, pain therapies, and the brain & pain questions, etc. are interesting to me.
posted by taz at 7:30 AM on September 20, 2004

I have a pet theory that men handle dull, generalized, chronic pain better than women, while women handle acute, localized, and temporary pain better than men.
posted by ChasFile at 8:24 AM on September 20, 2004

ikkyu- I'm glad you do get to that point with your patients. I have chronic pain associated with hyperprolactinemia, and have suffered migraines all my life. OTCs don't do much for me, narcotics are mostly ineffective and the ones that do have an effect don't make me hurt less, they just make me sleep more. I've gone to three different doctors looking for pain management, and none of them know what to do when I follow that up with, "And I don't want to take narcotics." Next stop? Accupuncture because at this point, I figure what can it hurt?
posted by headspace at 8:28 AM on September 20, 2004

jonmc - I have no idea whether we're brothers on this one, or if they're just similar symptons, but 8 months ago I started experiencing the same severe lower-back pain (while walking or standing), requiring me to sit down when on a trek. The doctor wasn't much help, but I did some reading on back-pain and tried someone's suggestion: I stopped lying on my back. I now sleep on my side, and whenever I wake or realize I'm on my back, I roll over to my side. This has helped to an astonishing degree - so long as I don't accidentally spend a night on my back, I almost never feel that back-pain.

Thought maybe that might help you as well.
posted by Marquis at 8:48 AM on September 20, 2004

jonmc, I know you may really hate this idea, but you might want to check around with some "alternative-medicine" type friends you have and see if they have any suggestions for practitioners. My husband has fairly debilitating back pain that sometimes occurs because he has a certain amount of scoleosis that has impacted his discs. As far as I know, the only remedy for this is surgery which ultimately may or may not help much, evidently, and which we can't afford in any case, but when this problem comes up, he goes to see this Russian guy who does some kind of magical deep massage thing... blah, blah, - but it works. It helps. The only reason he tried this was because he was in so much pain, and so many of our friends insisted on it. So it's not like my husband is some la-la-la new-age dude ready to heal himself with copper bracelets and pyramid hats; in fact he's the kind of laid-back-scientific-type-guy who built his own broadcasting pirate radio station completely from scratch when he was 12 - In other words, not a scary alternaperson!
posted by taz at 8:51 AM on September 20, 2004

taz, I'm actually willing to try anything. I'm not so much in agaonizing pain most of the time, just enough for it to interfere with me enjoying my life.

The pain is usually in my lower-right back. I think it probably has something to do with working at a computer all day after years of more active jobs where I stood up more. I get the most relief when I'm either lying down with my feet elevated or sitting down leaning forward.
posted by jonmc at 9:03 AM on September 20, 2004

Jon - those are the exact same "relief" positions as I had. I really recommend that you try the stay-off-your-back-in-bed thing (and you could put a pillow btwn your knees, as well).
posted by Marquis at 9:13 AM on September 20, 2004

My pain tends to be more of a discomfort pain than an actual piercing pain. That's the other thing that is so complicated about pain -- what type of pain is it. Sometimes you don't have the words, ones your doctor understands at least, to describe it and you get nowhere. My pain isn't piercing or really high, but when you are in a lot of discomfort (or achiness I guess) it drives you crazy.

When I got help for my depression, my psychiatrist made me realize that chronic pain was another factor of my depression (having hurt my back when I was 12, long story short finally got surgery when I was 18). Living with it is tiring as others have mentioned above; it wears you down psychologically. And when you're young it has got to be worse because you realize you're screwed for the rest of your life. When the pain is bad you think, how many more years of this have I got? 50? Great.

So that said, I look forward to browsing the links.

By the way, I love my body pillow. It is longer than most I've seen in the stores (ordered it online), and I hug/cuddle it on the bad nights (hugging makes the upper portion not twisted, then of course between the legs as well). On the really bad nights, I have to lay on top of it -- it seems to take the pressure off the back and stretch it out or something (with arms and legs "hanging" off and head slightly off -- again making so back fees suspended). Only thing that will work (Advil - hah!).

Something else that helped my back a lot was taking ballet. It makes you really focus on your posture, esp. with the idea of lengthening your spine. Imagine you have a string coming from your head and someone is pulling on it. That did wonders stretching it out.
posted by evening at 9:42 AM on September 20, 2004

One thing I have found to be true of pain is that it's very relative. People who, for example, have broken a bone are often much more tolerant of the pain of a second break, in part (I believe) because they have some idea of what to expect in terms of intensity and duration of pain, as well as treatment. My mother has the highest pain threshold of anyone I know, in part I'm sure because she has had to deal with a substantial amount of it in her life, from painful early childhood illness to gall stones to chronic arthritis - the sorts of things that many people find extremely painful are water off a duck's back to her. I do think that there's a very large psychological component (which the placebo theory fits with) - not only with regard to previous experience, but also with simple things like breathing imagery (where you imagine the pain being blown out with exhalations), which actually do work for many people (including children) - and some people manage it best by yelling and screaming, others manage it best by being stoic, it's a very individual thing. Pain is a very interesting subject, we don't understand it very well at all.
posted by biscotti at 9:47 AM on September 20, 2004

jonmc - I've been through similar bouts of lower & mid-back pain for what I think are similar reasons. Here's what I've done that helps:
1.) When something causes a flareup, I see a chiropractor a few times to take the edge off. Whether or not I really believe in "subluxations," the adjustments are satisfying and the associated therapy offered (TENS stimulation, heat, cold, ultrasound massage) helps relax some of the muscles that are tensed up in pain response.
2.) Yoga. A good yoga instructor can help you get into it at your own pace, gradually building the trunk strength and body awareness to improve your posture.
3.) I got a new, quality mattress. My old mushy one was definately a problem. I would probably have been helped by anything different... maybe a decent futon, or sleeping on the floor on a foam pad. The saggy mattress was stressing my spine no matter which way I slept on it.
4.) This inexpensive Sissel SitFit chair pad makes any crappy desk chair better to sit on by encouraging upright, balanced posture and not letting your back & torso muscles fall into a passive slump.
posted by Tubes at 9:52 AM on September 20, 2004

[sometimes confuses Metafilter with AskMetaFilter. ]
posted by Tubes at 9:54 AM on September 20, 2004

Taz, this is weird. I was going to do a pain post, inspired by the idea of visual vs. verbal pain scales, particularly the FACES pain scale. I'm interested in the difficulty of expressing pain through language. Most of the sources I've seen indicate it for pediatrics and adults with diminished capacity, but there are studies that support their efficacy, and some that don't. I personally think both verbal and visual scales are useful to me as a way to accurately express physical pain.

The best book I ever read on the subject is The Body in Pain: The Making and Unmaking of The World, by Elaine Scarry. Lacking language to pain doesn't just do damage to the self; it permits us to damage others more easily, and that's what she writes about with great skill.

I am sorry for anyone here who lives with chronic pain. People talk a lot about race, gender, class, and religious distinctions, but the difference between those in pain and those who are not is an even wider gulf. When I have serious pain, I feel so reduced and humbled, so alone in it. I can't speak or defend myself: I rely totally on others' understanding, sympathy, and kindness, which I'd prefer never to do. That's the worst of it: the blank impatience even the best people can feel toward a person in pain, even people who have felt horrible pain themselves. Much of Scarry's book deals with that sort of "pain amnesia" and its consequences for health care, pain management, even the use of torture as a political tool. It's pretty amazing how bad our species is at helping those in pain, when we've had so much experience feeling it. We seem to save our most special genius for dishing it out.
posted by melissa may at 10:25 AM on September 20, 2004

Oh! I'm really sorry that I sort of stumbled on this before you did the "pain scales" thing, which should really be a post of its own. Anyway, I am thrilled at your incredible personal ability to articulate certain fundamental, yet "invisible" feelings about pain: " I feel so reduced and humbled, so alone in it. I can't speak or defend myself: I rely totally on others' understanding, sympathy, and kindness, which I'd prefer never to do". This is precisely how I feel.
posted by taz at 11:01 AM on September 20, 2004

Next stop? Accupuncture because at this point, I figure what can it hurt?

You should try it, it might help. I've had chronic hip pain over the last 2 years or so. I've been to the doctor 6 times, had cortisone injections, X-rays, etc. None of that helped. Physical therapy was helpful, but acupuncture has been the most effective therapy I've had. It's worth a try, and maybe it will help you, too.
posted by vorfeed at 11:31 AM on September 20, 2004

Great post, taz. Thanks.
posted by homunculus at 12:27 PM on September 20, 2004

I suffered chronic pain for years due to severe achilles tendonitis in both ankles.

After several failed attempts at treatment, I just learned to live with it, but on our return to Korea in 2001, my wife convinced me to try acupuncture (and the other treatments that go with it, at least in Korea, like bleeding and cupping and electrical current).

After 10 years of living in perpetual pain, the nodes on my achilles tendons disappeared, as did the pain.

I heartily recommend those who suffer things like lower back pain to give a reliable acupuncturist a try. Worked for me.
posted by stavrosthewonderchicken at 11:24 PM on September 20, 2004

Great post.

Regarding back pain:

I agree with Tubes. I've dealt with much back pain. All his advice is good; don't listen to your doctor. On preview: Stavros's, too.

Melissa May, how truly good are the people which you mention, if they are short with a person who is suffering?
posted by halonine at 12:20 AM on September 21, 2004

If I recall what I learned about chiropracty via reading I did after that post last year on the Frontline episode that was so harsh, lower back pain is the one thing that chiropracters aren't full of it about and they actually can help with it quite a bit.

For now, I don't have much trouble with my back, thank God. I don't know why—both my sister and dad have a lot of back trouble as a result of our disease. My impression is that there really aren't any good answers for back pain. This whole walking upright thing has created as many problems as it's solved. Stupid evolution.
posted by Ethereal Bligh at 1:21 AM on September 21, 2004

I'm used to pain for a variety of reasons. I deal with it UNTIL too many places hurt at once. Then I get quite tired of being alive. At least for me, ibprofen still offers worthwhile results.

I've learned to recognize when my pain makes me short-tempered, and then I apologize. Once I know that's the case, its rather easy for me to compensate.

When something really exceptional happens, I essentially let people know what's wrong, then put my mind on stand-by. This was what I did when my appendix went bad. The ER paperwork idiots didn't seem to understand that. Past that, the staff were wonderful.
posted by Goofyy at 2:54 AM on September 21, 2004

You can see from this list of clinical trials focusing on lower back pain (sponsored by the National Center for Complementary and Alternative Medicine), that research is exploring some of the things we've mentioned here. Here's a good page all about acupuncture from them, and here's a great resource page on back pain from Medline. EB, here's a pdf page about acupuncture and osteoarthritis. Also, for migraine-people. a good look at migraine medications here and many migraine articles, plus WebMD's migraine page (here's their alternative treatment page, with some encouraging words about acupuncture for headache related to neck and shoulder pain). There's also a questionnaire (pdf) that can help you figure out what kind of headache you have - migraine, tension, cluster, or "other".
posted by taz at 3:30 AM on September 21, 2004

how truly good are the people which you mention, if they are short with a person who is suffering?

Halonine, I honestly think that good people can be insensitive to others' physical pain because their ability to feel it varies so widely, and because they've been raised to be. The US is particularly weird on this point. We love talking and obsessing about psychological pain and dysfunction but we rarely talk about the physical. Men are especially pressured to deny it. It's training that starts in childhood, for the purposes of toughening them up and improving their character.

And I think it affects most people terribly. For instance, why is it so hard for adults to remember how much more things hurt when you are a child, and live so much in the present? Children are already so physical, the way they drink in big lip-smacking gulps or hug you with every inch of themselves. When you're small, it's bewildering and shocking to see your own blood, to feel hurt, because when you're in pain, it obliterates everything else. Children don't know they're going to feel better in five minutes, because while it's happening, they don't know anything but pain. But, despite having been kids themselves, many adults react with strong revulsion to the howling weeping way children express physical pain, especially if it carries on more than a few minutes. And so you learn from childhood that you keep your pain to yourself, and minimize it, and as an adult, grow to be intolerant of its expression in others.

I think that this necessarily affects how pain is medically treated. There's a lot of money and effort and study time spent on getting people to report pain accurately, because it's a huge problem. Ikkyu2, in his very interesting post, echoes many physicians on treating pain: it's unrewarding. There are few predictable trajectories, few cures, and compounding it all for most people is that we don't grow up with a language for pain, or acceptance of it. There's such a need and desire for non-narcotic pain management, but its development is crippled by these weird cultural taboos. And often, so is compassion, even in people who are otherwise loving and good-hearted.
posted by melissa may at 9:08 AM on September 21, 2004

I had severe lower back pain when I was in my twenties. X-rays showed virtually no disc at L1, and huge bone spurs at L5-6 with a ruptured disc. I didn't want surgery, as I'd never seen it go well. Time passed, and I seemed to sort of grow out of it. My back hasn't bothered me, except on rare occasions, for 15-20 years.

Then, in my early forties, my right shoulder hurt so bad that I could no longer sleep. I had surgery. Arthroscopy, and a repair of a torn rotator cuff muscle (supraspinatus). A year later, I was almost in the same amount of pain as before the surgery. I went for three sessions of acupuncture, and have been fine ever since.

Perhaps the reason that we are so callous to the pain of others is because we are intuitively aware that by coddling and over-sympathizing, we can contribute to the pain being worse.
Those patients with partners who habitually focused on the pain showed almost a three-fold increased sensitivity to an electrical shock to the back compared with distracting partners.
Sure, this study looked at the behavior of "partners", but it also may apply to all who interact with the patient. Maybe also, it is just to painful for people to empathize with everyone else's pain.
posted by gnz2001 at 11:21 AM on September 21, 2004

MetaFilter: We don't need to feel your pain, we have enough of our own already, but thanks!
posted by billsaysthis at 1:19 PM on September 21, 2004

By the way, for what it's worth, my successful acupuncture treatments were several times a week for a couple of months (mostly because of the way that the nodes on my tendons had accreted over years). Instant gratification may not occur, but that's no reason to be turned off.
posted by stavrosthewonderchicken at 5:53 PM on September 21, 2004

Thanks, melissa may, for your very thoughtful answer. It saddens me to see how extensive the problem is, but perhaps all the research on pain will keep teaching us more about the rest, too.
posted by halonine at 1:21 AM on September 22, 2004

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