The thing with chronic pain is that it's very difficult to quantify.

I have small fibre neuropathy (nerve damage) in my arms and legs, and when it first started I thought I was going to go crazy - I just couldn't stand that amount of pain, constantly. I cried a lot, I begged doctors to make it go away, I went to the ER.

The fact is you can't stay like that forever - you either kill yourself, or you somehow learn to live with it.

You don't get used to chronic pain, but you adjust to a new "normal" level of pain. You develop coping mechanisms and learn to "bury it", get on with it as best you can. If you're lucky, you find some medication that actually helps somewhat. You research your condition and possible remedies, a lot. All of this isn't to say it gets easy, believe me it fecking well does not.

A lot of people (doctors included) don't seem to believe that you can be in severe pain, while sitting and conversing with them - "he seems fine to me!".

I'll add as well that I'm one of the "lucky" ones for whom a diagnostic test (skin biopsy) has shown concrete evidence that doctors believe in - without that, you'll get nothing but platitudes and shown the door. You'll probably also get told you have fibromyalgia, even if you don't remotely fit the criteria. I know this firsthand, because I have had to research and guide clueless doctors and insist on tests, and insist on re-tests when they've messed up.

> A lot of people (doctors included) don't seem to believe that you can be in severe pain, while sitting and conversing with them - "he seems fine to me!".

That's very familiar. "I feel like I'm being stabbed in the eye" "But you seen fine" "It's been doing that for the last two years; at some point I just stopped reacting to it"

> I'll add as well that I'm one of the "lucky" ones for whom a diagnostic test (skin biopsy) has shown concrete evidence that doctors believe in

Having visible evidence definitely seems to help - my dermatologist seemed to be sceptical that my dermatographic urticaria[1] was as bad as I was saying given the dose of antihistamines I was on. She did a challenge test, and her first comment was words to the effect of "Huh, that _is_ severe". She ended up doubling the does of antihistamines. The "hidden" symptoms are much more of an uphill battle.

[1] https://en.wikipedia.org/wiki/Dermatographic_urticaria

Something different for every person, which is why I hate the 1-10 pain score. Some people will declare a stubbed toe a 10; others will self-amputate an arm and deem it a 6 because they weren't on fire while doing it. Medical staff don't really help by describing a 10 as "the worst pain you can imagine", given variance in imaginations.

I much prefer the "Hyperbole and a Half" author's pain scale. http://hyperboleandahalf.blogspot.com/2010/02/boyfriend-does...

There's various pain scales, but all the good ones aren't different for every person.

They're the same because they don't quantify how much it hurts, but instead how the pain affects you.

A 10 would be pain so severe you are unable to perceive anything besides your pain or do anything except writhe.

An 8 on such a scale would be pain that makes it difficult to focus on anything else, let alone listen calmly to a person and give a coherent answer.

A 5, while being distracting, would still allow you to function on some level.

A 3 would be pain that is somewhat easy to ignore.

You see how this is a scale that can actually be measured by an outside observer and is much more useful in figuring out what medication to give. Because while two people may have the same injury, one of them may be able to completely ignore the pain even without medication - so giving medication would only do harm - while the second person may need medication in order to function.

Assuming such a scale was used, it would make sense for the nurse to say "it isn't an 8" - because if it was an eight you wouldn't have been able to listen calmly and explain that to her, by definition.

> one of them may be able to completely ignore the pain even without medication - so giving medication would only do harm

Well, it won't only do harm though, right? It will still get rid of that person's pain.

If I fracture my ankle, but I learn to compensate by constantly shifting my weight onto my good leg as I limp so that I can still do my job -- in that scenario, I still want my ankle fixed. I don't want a doctor saying, "ah, but you have the special limp, so a cast and crutches would only do you harm." I want the cast, because the cast is probably easier, more comfortable, and in the long term less dangerous than what I'm currently doing.

Why would pain be different? Should someone not be able to get relief from suffering just because they've gotten good at mentally focusing through it?

It seems like the result of approaching pain from the perspective you're advocating for would just be to discourage people from trying to take any practical and/or psychological steps to manage their own pain, because every minor success they have will make it harder for them to get any additional help.

> Why would pain be different?

It is completely different. Your analogy isn't great.

A fractured ankle is a bad thing. A cast certainly won't do harm. Pain is a response of your body to a bad thing. Suppressing it can do harm in itself.

Some pain can often be desirable because it prevents a patient from further injuring themselves by, for instance, putting weight on an injured ankle. Pain is a warning system.

Add to that all the possible side-effects of painkillers.

On top of that there's context for everything. You should probably give a patient that experiences pain which can't be avoided painkillers earlier than a patient who experiences pain when they put weight on something they shouldn't.

> You should probably give a patient that experiences pain which can't be avoided painkillers earlier than a patient who experiences pain when they put weight on something they shouldn't.

You're describing someone with chronic pain. So... we should prioritize giving painkillers to someone with chronic pain over someone someone with temporary pain that will quickly go away if they don't do something dangerous? I agree with that.

If someone has chronic pain, that pain isn't helping them avoid doing something bad to their body. It's just pointless pain with no benefit. And even if I can force myself to function with chronic pain, I can still have long-term damage from stress, lack of sleep, damage to relationships, even just damage in terms of pure suffering. It's dangerous for a doctor to say, "you can hold a conversation with me, so medication would only do you harm." I don't think that's an objective scale, and I don't think it actually captures the risks of long-term damage and suffering.

If you want something with more downside than a cast, sub out something like surgery in my analogy instead. Either way, the point is that just being able to function in society is not an adequate measure by itself of whether or not someone needs medical help.

> all the good ones

People who are regularly in great pain would read this comment as saying "you are being mauled by a bear, but if you have ripped your own vocal cords out so that you're not constantly screaming, we judge that preventing the bear from mauling you won't affect the environment much (since the screaming level will not change), so we will not prevent the bear from mauling you".

That has its own issues.

Talk to a chronic pain patient and they'll likely tell you they have to suppress reactions to the pain in order to not be dismissed as "playing it up" and thus drug seeking. That they are used to dealing with pain does not mean the pain is not there.

Add in myths like "black people can handle more pain", too. https://www.aamc.org/news-insights/how-we-fail-black-patient...

> Something different for every person

I absolutely refuse to give a numerical answer unless they first give me an objective calibration for the numbers. I recently got into a minor argument with a nurse before a minor surgery. "If you won't tell me a number, how will I know if I need to give you a painkiller?" "If I'm in enough pain to need a painkiller, I will tell you."

The number scale attempts to turn a subjective interpretation into an "objective" value. Instead of having to actually listen to people and apply training and experience to judge which treatments are needed, the number system de facto pushes that decision onto the patient so the doctor/nurse/etc only needs to follow a simple set of treatment rules. Similar to black box "AI" used in e.g. criminal sentencing and employee evaluations, the numeric pain scale is yet another example of a fundamentally subjective situation being laundered into a supposedly "objective" value.

There can be some utility in comparing over time. If the patient indicates a 9 before intervention, and a 5 afterwards, that means something's helping. The relative weight of a 9 versus someone else's 9 is irrelevant in this usage.

"The patient indicates" is still based on their completely subjective process of turning a mental state into a number. If they indicate a 9 before intervention, they did so by comparing the feeling of this this trauma to the fuzzy memory of breaking a bone as a child and the more recent but less painful memory of burning their finger in the kitchen a couple weeks ago. Then they sit and suffer from this trauma at approximately that same level of pain for the next 2 weeks, they'll have a new baseline to compare against.

It really sucks that we have no objective measure of pain; a tricorder that you could aim at someone and get a number back would be infinitely better than what we have now.

I'm saying the 9, by itself, may not be useful, but the "it was a 9 an hour ago, and now it's a 5" may be.

Not really because people have a terrible memory for pain. It can be worse afterward and still be a 5 (vs 9) just because they have got used to the pain.

That's way more meaningful. Had gout, experienced at least an 8.

Thank you - this seems a very reasonable scale. I think I might have never felt more than a six.

Yeah, you're right. Some people adjust way better than others...

I used to live with a paramedic who explained it like this: "It's difficult to quantify anything but the most extreme pain, so an easy benchmark is a 10. If your pain is a 10, then if the paramedic rushing you to the ER lights you on fire and throws you out the back of the ambulance, your pain would not increase."

It's supposed to be subjective; they aren't measuring pain against some objective measure or even against other patients, just how you're feeling personally.

This number will be used to determine if a more in depth tool is needed (like if you say 7-10). What type of treatment is needed (pain tolerance is different from person to person, so even if two people have the same injury or disease, one might say 8 and need pain killers and the other might say 3 and not). It will be used to gauge if a treatment is working (when you first came in you were at a baseline of 6, but after taking this treatment, you're at a 2), and so on.

Thus, a personal scale makes sense.

If you're trying to describe pain to a healthcare professional it's useful to either compare it to some other pain that you've had (childbirth, ear infection, dental abscess), or describe it's effects: "it hurts when I think about it", "it hurts when I move", "it distracts me from my day to day activities" "it's always there, it intrudes into my thoughts and I can't distract myself from it, it hurts even if I'm not moving", "it wakes me up at night, it's always painful, I'm struggling to have this conversation, it makes me think about ending my life".

Talk about the things you used to do that you are not able to do now because of the pain.

For short term pain number 8 is supposed to be able to read or converse but only with effort; dizzy and / or nauseous; limited physical activity; difficulty in functioning; and strong painkillers are not so effective.

Number 9 is unable to speak; crying out or moaning uncontrollably.

Number 7 is interference with sleep, difficulty concentrating.

It’s super subjective. For me 8 is. I can still talk at moment.

But if it goes on more than a few hours I will jump off a cliff to end suffering.

I stayed away from the really strong pain killers. But man it was hard. I did not want end up with an addiction on top of everything else.

Does anyone know if people have made serious attempts to do objective pain quantification? Of the ideas that come to mind, strategy 1 would be: let the patient press buttons that give her electrical shocks and let the patient say "This shock is worse than my pain, that shock is less bad, therefore my pain is between these two levels". (I once read about an early electrical scientist who would measure voltage by shocking himself and comparing the pain with known quantities. Googling, I find that "Kenneth Catania" has done this very recently to measure eels' output...) Strategy 2 would be to somehow observe pain nerves and/or the brain directly; I don't know if this is possible. Strategy 3 would be to describe hypothetical sources of pain and ask what the patient would prefer, though even a patient trying her best may not be able to correctly compare felt pain vs. imagined pain.

Wikipedia isn't much help[1]. It lists 30+ "pain measurement scales", but clicking a few of them doesn't tell me any specifics about how they work.

Looks like someone has in fact tried strategy 1. https://www.hindawi.com/journals/js/2018/6205896/ mentions: "Recently, a quantitative pain-assessing method using electrical stimulation was introduced [12–15]. PainVision™ devices measure perception threshold and pain produced by an electrical current. This system quantifies pain intensity by comparing the experienced pain with the intensity of electrical perceptions. The perception threshold indicates the minimal electric current sensed by the individual, and the pain produced is defined as the maximal electric current sensed by the individual. However, the skin resistance of an individual may affect the electrical measurement result [16–20]."

Their refinement continues: "our system measures from the patient’s skin resistance before measuring the pain." "In this work, we developed a pain measurement device that has two analysis methods, electrical stimulation and applying pressure, for more accurate cross-validation assessment. During electrical stimulation, electrical stress is applied on a nonpain site and then the observed stress can be compared to pain. ... During the pressure evaluation, pain was assessed by applying pressure on the pain site. Inflammation was induced on the rat’s hind paw by carrageenan, and then the inflamed hind paw was stimulated by a hand-type pressure stimulator. The pressure site was then compared with the inflammation levels." Seems like it might be workable.

[1] https://en.wikipedia.org/wiki/Pain_scale