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Comment by jnovek | Hacker News Reader

“Babies feeling pain is something that should be self-evident, shouldn't it?”

I have yet to understand the historical underpinnings of this phenomenon, but as someone who deals with chronic pain, doctors don’t seem to be aware that people feel pain _in general_.

I’m being sort of facetious, but any chronic pain community is full to the brim with stories of various medical professionals being skeptical of patients’ pain reports or treating pain like it’s not a particularly important quality of life concern.

I have my own stories about this, of course, and some of them are pretty horrible.

It doesn’t surprise me, then, that we assumed at some point that infants don’t feel pain: after all, if we don’t take the pain of adult humans seriously, then why would we consider the pain of a creature who cannot even directly complain about it?

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Even worse for you is how concerns about fentanyl are now a defacto war on pain relief. States have demonized long lists of pain meds, driving people in chronic pain to buy much riskier drugs on the street (something I witness fairly regularly).

States used to blame today's bans on the pill mill problem that was addressed over 20 years ago - but now don't even bother to do that. Now the argument reads like 'because fentanyl exists, you must live the rest of your life in pain'.

Yes.

To make matters worse, the opioid epidemic is real; regardless of the cause, it’s not just war on drugs hysteria.

It ends up that opioids are terrible drugs. Aside from the obvious habit forming stuff, there’s things like hyperalgesia and central sensitization — long-term opioid use can screw up how your brain processes pain.

I witnessed the decline of opioids in the latter-half of the 2010s firsthand from the patient’s perspective. The response to these problems from the medical community was _sheer panic_. No one was concerned with “what are we going to do next”, it was just “we have to get these patients off of opioids”. Lots of people suffered. There were suicides. There were, as you mentioned, people who moved to street opioids. The whole thing was a fucking travesty.

Rolling up on a decade we’re just finally _starting_ to get a handle on this thing with responsible alternatives for pain management. The stench lingers; I think we will look back on this era with a similar lens to how we see surgeries before the work of Joseph Lister.

> It ends up that opioids are terrible drugs.

Opioids ruin lives. Opioids restore lives. People die from taking them. People are functionally dead when they're unobtainable.

The most false thing about opioids is that they are any one thing.

I've used hydrocodone for months at a time. It's addictive so there are protocols that need to be followed. Stick with the dose and taper when done. However, that was in the past. For severe pain, legal pain relief is no longer available - to me and to millions of others.

My state now has a hard 3 day limit and few Dr.s are willing to write even that. What has become routine everywhere is being Rx'd Tylenol for moderate to severe post-op surgical pain. I personally had to beg for tramadol following abdominal surgery. I recently had to enter into a protracted negotiation with my Dr - again, for tramadol - so I could exercise and get a little more life out of my failing knees.

The pendulum has swung way too far and the number of lives that are being ruined by that is nearly incalculable.

> My state now has a hard 3 day limit and few Dr.s are willing to write even that.

I don’t mean to de-anonymize you, but what state is this? I know state laws vary, but I haven’t heard of anything close to those sorts of restrictions.

Florida

ref: https://www.beckershospitalreview.com/opioids/florida-law-pu...

“The most false thing about opioids is that they are any one thing.”

That’s fair. A better way to say what I mean might be “our opioid therapy protocols aren’t very good” or “we’ve relied on opioids in ways that cause more harm than good”.

There are situations where opioids are the obvious right answer. I have a similar anecdote, having to beg for an opioid refill when I was suffering from post-op pain.

While I admit I don’t know the details, I wonder if your knee pain is one of those situations where opioids aren’t close to an ideal solution, but we never actually developed an ideal solution because it was easier to throw opioids at every pain problem. Now opioids are no longer allowed and you get to replace opioids with nothing.

Fully agree. Spent 5 years going on and off Tramadol. If I found myself craving it I would stop for a month. I was basically in bed in pure agony during those weeks off. I've seen others that literally kidnap their own mothers to get opioids.

Eventually found LDN and that stopped the pain.

It’s because people lie for many reasons. To get out of work, get disability, make a claim, to get opioids because they’re addicted to them etc. As a doctor, you’re probably going to become cynical after a while.

This is very different from a baby because they have little motivation to lie and you can see them reacting to simple painful situations like bumping their head.

And if doctors are worried, the first step should be doing actual tests to see if people are experiencing pain. Not making some judgement based on their cynical bias whether someone is lying or being truthful.

It is amazing how much of the medical community states they believe in science, yet they seem entirely disconnected from it at times.

How can you, with an objective test, determine whether or not I am experiencing chronic pain, or if I'm just pretending to be experiencing chronic pain?

Brain imaging would be a good example, but there is cortisol screenings among several other tests that can help determine that someone is actually in pain.

I could be wrong, but don't people with long-term chronic pain have normal cortisol levels?

I'm sure they can, but it can be a very indicator as well:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4263906/ https://www.practicalpainmanagement.com/pain/cortisol-screen...

Sure, just like instead of prescribing anti-depressants, we should first do a depression test.

Unfortunately, neuroscience is not at a level where we can actually perform these tests. There is no objective measure to see if someone is in pain, or depressed, or suffering many other psychological symptoms.

Actually, there are tests now for depression. And yes, you can do objective tests like brain imaging to see people's responses to stimuli among other things. What should not happen is for doctors to meet someone for 20 minutes, do nothing but talk to the person and say.. oh, I don't trust them they must be lying. Except, that is what doctors do all the time and there is no scientific basis for their decisions.

Sounds expensive, wouldn't it just be easier to trust them? I think the bigger problem is if a doctor doesn't know what's wrong or how to fix it, then they disengage.

Yes it is easier to trust the patient, but unfortunately many medical professionals have implicit bias and don't.

Can you point to some tests for depression? A quick Google only turned out some studies, nothing approved and usable in clinical settings (and one of the studies had a test that couldnt differentiate between depression and bipolar disorder).

Similarly, brain imaging for pain is at the research level, and may come with several other risks. I doubt there are such tests that could be used to conclusively prove that someone is or is not in pain.

One that I can think of, but I think it may be more "early access":

https://mindxsciences.com/

There are blood and urine tests for seratonin, but studies are mixed on how reliable they are. Since depression can also be accompanied by other factors though, there is a wide range of tests that can help provide objective evidence.

So, just as the person you replied to said, nothing approved and usable in clinical settings.

Do you mean like as common as a rapid test, cause they are approved and usable but more specialized medicine.

Wondering if it might be possible to measure the pain people are feeling somehow. It’d be interesting to compare a person with a traumatic past vs one without

It’s because people lie for many reasons.

So? The first response should always be to take folks seriously. Always. Even if they are really searching for opioids. No doctor should assume folks are lying upfront.

Even if that means that a couple people are getting off work when they don't need it. And I'd much rather have a disability system that occasionally gives the wrong people benefits than to withhold benefits from someone and make their life torturous. Much like theft an loss are costs of retail, this should be the cost of a disability system: A few folks take advantage.

Spitballing, but maybe the problem is that no doctors wants to be the guy in town who's the most generous with opioid prescriptions, as then he'll get swamped by people seeking opioids?

People who look at the statistics after that, finding our doctor prescribing a significant amount of all opioids in the community, are liable to think that he's some sort of unscrupulous stooge of a pharmaceutical company.

That'd cause a race to the bottom of pain medication skepticism. To fix that you'd need some sort of liability reform (as just changing guidelines will never work if it's opposed to a self-sustaining incentive gradient), though I'm not sure what that would actually entail.

It's because of the chilling effect of lawsuits and the risk of losing their DEA license that doctors in the United States are skeptical of issuing pain medication. Americans with genuine pain problems that cannot be effectively treated by local doctors despite persistent good-faith efforts should instead find a doctor in a Mexican border town where pain medication is more readily available.

Spitballing, but maybe the problem is that no doctors wants to be the guy in town who's the most generous with opioid prescriptions, as then he'll get swamped by people seeking opioids?

Nope. In a well-designed system, this just be minimal. Design a better system with better access to medical records throughout the system, lesser liability (the US, mostly), and paid medical leave so that people can actually heal. The alternative is simply that we leave folks in different levels of pain. Heck, even just being able to see prescriptions nationally would be a bonus (Right now, in Norway, when I get an electronic prescription, I can go to any pharmacy to fill it and they can see my prescription history) Innocent people shouldn't have to go to the black market for pain relief because they can't get things figured out legally.

Again, I firmly believe that the first response should always be to believe the patient.

Wasn't the problem with opioids in the US that doctors already did prescribe them too freely? The fact that there's now a backlash after it caused a massive problem cannot be the reason that doctors have historically been sceptical about pain (and not just in the US but elsewhere where prescription opioid abuse has not been a problem!)

Was being given opioids for chronic pain (nerve pain from autoimmune). but not consistently, so I'd often run out.

I was constantly pushing doctors to try alternate treatments so I can deal with actual issue rather then take pain meds. They had no interest. Took me 3 years to finally get a prescription to LDN, which finally worked for me.

> As a doctor, you’re probably going to become cynical after a while.

We should probably focus more on finding ways to reduce cynicism and lack of empathy in this profession than fighting false positives in the system.

> It’s because people lie for many reasons.

You should err on the side of caution and default to "they're probably not lying".

Most of us can agree that applying the logic you're describing to the law would be wrong. Imagine that instead of having the presumption of innocence, we'd assume that certain types of people are probably guilty, so we'll punish them pre-emptively.

This already happens, of course, because of racism, xenophobia etc... but we do agree that it's morally wrong and at least we're trying to fix it.

They don't become cynical; they just don't really give a dam about pain, unless you are a high paying client.

And in this climate of all opiates are the devil, I get it.

We are in a weird state in pain managment.

We essentially don't have anything to cure chronic pain, except cutting nerves.

Opiates make people feel better physically, and emotionally.

They are addictive because they work. Unlike all those tricyclic/heterocyclic drugs.

Young people should never be on opiates, except during surgery.

Old people in pain should not be denied the drug. It should be a right.

(There are numerous studies of older people being given opiates for pain/misery, and most studies they did not want to increase their dosages.)

> As a doctor, you’re probably going to become cynical after a while.

As my go to story on these sorts of issues, my partner had an ER doctor tell them that they hadn't been stabbed. The fact that there was an open wound oozing blood and multiple witnesses was not sufficient evidence. That wound was obviously a diabetic sore. That my partner is not diabetic was also a lie and the fact that their medical records showed no history of diabetes was merely proof of the incompetence of the previous doctors. Stitching the wound had to wait for two blood sugar tests to be performed, because the first test was could only have been a machine glitch. After a second negative test for diabetes, the doctor finally conceded that he couldn't rule out a stabbing.

How do some people end up making clearly counterproductive interpretations that ignore not only evidence in general, but clear evidence of harm to others?

I remember a Google employee changed a popular font for headings. It broke the layout on a very large number of websites.

Several people discussed this with the employee, suggesting the font should be forked rather than force-updated. The employee engaged, but refused. Eventually they said that if enough users contacted them with complaints, that would be evidence they would consider. When it was pointed out that it was very difficult to know how to contact them (they were not required to engage on the forum, or anywhere else, no contact information for them was otherwise findable, etc) they barely shrugged. It was as if part of the logic function in this human was managed by a 4 year old child internally.

Your use of they makes this almost incomprehensible.

Writers should use the singular “they” in two main cases: (a) when referring to a generic person whose gender is unknown or irrelevant to the context and (b) when referring to a specific, known person who uses “they” as their pronoun. – apastyle.apa.org

I do not know the gender of the person under discussion, nor do I know if that person has pronoun preferences. I simply followed the "generic person whose gender is unknown" standard.

I've been using "they" in this manner for 50+ years. Never had anyone comment on it before. Are you attempting some kind of meta virtue signalling, considering "pronoun preferences" is a very recently added option?

If this is a genuine criticism some people would have, what would be the suggested rewrite for a person of unknown gender?

The same goes for fatigue or anything else they can’t actually test for. I would guess it mostly stems from them not having a way to objectively judge it. My pain tolerance is way higher than my wife’s, in part because I suffer from cluster headaches. 8/10 for me might be a broken bone. For her it might be a relatively superficial cut.

So what’s a doctor supposed to do when someone says something really hurts? Hell if I know.

It’s because they don’t want to admit they don’t know, so it’s easier to blame the patient

> as someone who deals with chronic pain, doctors don’t seem to be aware that people feel pain _in general_.

I don't know your situation, but I wonder if it seems this way because doctors don't have many options for treating chronic pain. There are medications for acute pain, but when you use them chronically over many years—well, that's how we ended up with the Opioid epidemic.

That's not how we ended up with the opioid epidemic. We ended up with the opioid epidemic when doctors working in concert with drug companies engaged in criminal fraud to prescribe medication far beyond its normal dosages and in cases where it was not necessary.

It was all of the above. Some doctors were prescribing them at higher doses than necessary; others were prescribing them in normal doses for longer than is safe. I am sure that at least some of these doctors were driven by compassion for their patients.

There was a massive push, “pain is the fifth vital sign” and all that. You were made to feel like a bad doctor if you weren’t in on it.

At least its changing these days now that THC is increasingly legal. Boomers have proved you can take it for six decades straight and be fine. Pro sports players are using it after getting beat up in games or practices too.

I am taking it for cca 25 years and I am fine too... sort of.

It can still become addictive, after tremendous amounts consumed over long time that don't make sense unless you just want to fuckup yourself as much as possible. But plenty of folks still end up there.

But its one of the easiest addictions to shed off, compared to say cigarettes, alcohol or well anything else (I would say even sugar is more difficult to wean off since its everywhere, joints not so much for now).

It has positive effects - pain management I guess especially with edibles, but for me its change of perspective/mindset on life matters, much higher creativity, michelin star level of taste experience even from relatively cheap food, and that sweet sweet high that is just so relaxing.

But it will make you overall less patient, which sucks. For parenting, for work, for life in general. Also, morning after is much better than alcohol binge night, but mental gears running on 20% isn't something that helps produce quality in your work. Plus most consumption methods mess up your lungs pretty badly, but quality vaping is I think cca good enough to not shorten your life considerably.

I think you are correct, and that behavior is to the patients’ detriment.

Personally, I worked myself into the ground trying to both advance my career and to manage increasingly alarming health issues.

I would have benefitted from some “real talk” but that’s not baked into the contemporary western transactional model of medicine outside of those areas that routinely deal with terminal illness.

Individual doctors are rarely deserving of the implicit trust and praise they receive from proximity to the stereotypical hero doctor on this season's popular medical drama.

I went from a general naive faith in the profession to caveat emptor.

It is truly insane the things that doctors routinely recommend without doing any sort of real review. Get any of the asleep-at-the-wheel health organizations to support your finding and plenty of doctors will recommend even the laziest of new ideas with passion. General downward trend in SIDS over a decade? It's probably because babies that wear footie pajamas are less likely to get bad humors. You're a bad parent if you don't get Shekol brand sleepers.

I don’t think the AAP recommends footie pajamas to prevent SIDS. What you say may or may not happen, but your point would be a lot more poignant if you used a real example rather than contrived nonsense. If the issue you're talking about is widespread, then it should surely be easy to use a real example.

Criteria for c-section. Rates among doctors is 1/3 vs the 8% among midwives. Baby in bassinet and baby on back. SIDS is linked to improper sleep hormone regulation, not sleeping on your stomach. Breastfeeding only once every 4 hours during the day and giving a bottle the rest of the time. Supplimenting formula when mothers are trying to exclusively breastfeed. Waking the baby up to breastfeed despite no weight concerns. Circumcision. Prescribing amphetamines to prepubescent children. Prescribing hormone blockers to prepubescent children. Prescribing thalidomide to pregnant women. Continuing to gamble with mass casualties by railroading experiments that have not been adequately tested relative to the subject size (like Tdap for pregnant women or the COVID jab you probably got).

Doctors as a whole are not given the allowances they need to think about what they're doing. Today, they are little more than billable entities that follow someone else's flow chart to serve you McHealthcare as "efficiently" as possible.

My stock joke is that if the doctor or nurse says it won’t hurt, it will hurt at least a little. If they say it will hurt a little, it will hurt a lot. If they say it will probably hurt, time for serious anesthesia.

Also, there’s pretty much no such thing as minor surgery except maybe skin tag removal.

The book Enders Game opens with this premise.

Had completely forgotten about it. Rings so true:

https://www.orbitbooks.net/orbit-excerpts/endersgame/

Lucky you, if you dont have genetics were anesthesia do not work properly. Then find a doctor, who accepts that problem and gets it over with painful but fast.

The hardest part is if you have a dentists that insist on anesthesia must work, but it wont, so you must act your ass off to prentend to not be in pain, so he wont push syringe after syringe, doing nothing and waiting for 15 minutes in between while your tooth is already open with the root canal drills in.

So you’re one too. No dental anesthetics work on me. I have to go under general anesthesia, where you’re knocked out so deep a machine has to take over your breathing. So every procedure starts at about $10,000 and that’s not counting the dental work. All out of pocket. No insurance coverage.

Did you try nitrous oxide?

Doesn’t do a damn thing for me.

As someone with very low tolerance for pain, this seems like my worst nightmare. I’m curious though, did your tolerance for pain increase over the years as you had to endure it?

Decreased, if any. I think it’s probably because I know nothing has ever worked. FWIW I am old and get a major operation every two or three years: hernia, cancer, hydrocele, etc. I have no problem dealing with that kind of pain, even when it is considerable, which is often true post-op.

Interesting. Thank you for sharing. Wishing you the best.

"A minor surgury is one that's happening to somebody else."

-unknown

Man, words of wisdom. I’m stealing that one.

> then why would we consider the pain of a creature who cannot even directly complain about it?

As a parent of two of these creatures, I assure you they definitely do directly complain about pain!

The likelihood of someone understanding something is inversely proportional to the impact on their ability to pay the mortgage.

Pain is recognized as “bad” innately. So if you can assert that no pain exists, you’re not accountable for causing, preventing or doing anything about it.

Doctors caring at all about pain is relatively new. When medicine started it was just about keeping you alive not keeping you out of pain.[1]

There is a fantastic book that is half about the history of pain medicine and half about a small region in mexico that distributes a lot of the heroin in the US. Dreamland[2]

[1]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6311547/ [2]:https://www.amazon.com/Dreamland-True-Americas-Opiate-Epidem...

The roots of the practice are not very clear, but it seems that for operating on infants, risk of death from Anesthetic is very high. And historically, anesthetics were given to induce muscle numbness (so they don't thrash around).

The whole medicine industry in America is based on denying, not supplying.

Cornered market.

My cynical explanation is that babies don't vote

And they mercifully don't remember what happened to them once they're older.

Should knowledge ever be considered self evident especially if it's possible to experiment?

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