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I remember that after I had surgery on my finger (the bone healed wrong so they had to cut it and rotate it), a nurse asked me to rate my pain 1-10, and I said: "it's alright, like a 7?", and she was like "that's not alright, let me give you some meds".

It did actually feel like a 7/10, it really hurt, but somehow it didn't bother me. And it was like that for weeks after the surgery, I didn't really end up taking any pain meds when I got home.

And I wouldn't say my pain tolerance is generally particularly high, pain does usually bother me as much as anyone. Not sure what that was about.

I never understand those charts. To me a 10 is a state that only briefly exist before I passed out from agony. If I was at a 7 pain scale you wouldn't need to ask me, it would be obvious.

I’ve never understood that scale. Is a “10” the worst pain I’ve ever experienced in the past or the worst pain I can imagine? Either way, how can my relative approximation to that “10” be enough information for the doctor to decide what to do next?

It’s much easier and more fruitful to ask “mild, moderate, or severe?” regarding pain. It frames the question in terms of how it affects you instead of trying to relate it to other types of pain you may or may not have experienced before

Of course, relevant xkcd: https://xkcd.com/883/

I’ve had what was told to me is a 10, you don’t always pass out, unfortunately

As a medical doctor friend of mine used to say, if the patient is still screaming they can't be experiencing 10/10 pain.

Live with that 7 for years and it won’t be so obvious

I think mental disposition is a huge component of perceiving pain, and it can be entirely sub-conscious. I can't speak for your case of course, but perhaps you were "ready" for the pain in your finger and what is to come and thus the panic inducing element was gone. You could be almost just an observer of the pain rather than the subject.

Fear of the pain can make things much-much worse. If that fear is removed, you won half the battle.

Of course, there are levels of pain where all of the above goes out the window and it is absolutely debilitating, but maybe that's the 13/10 pain level that hopefully most of us never have to experience.

Coming out of a surgery once, the nurse asked me if I was in pain.

I said “No, I don’t think so. I feel like crying, though.”

“Well, that’s probably because you’re in pain.” At that point what I considered as pain hadn’t really manifest yet.

That sounds a bit like pain asymbolia. I'm surprised it would happen in just one instance, but I don't know much about it.

Where on the finger? From personal experience, the finger tips can be excruciating. Anybody that’s gotten stitches knows that nothing compares to the initial administration of localized anesthesia.

If a level ten is passing out, that one would win via Price Is Right rules.

> There are already far, far too many examples of physicians not trust patients about pain.

I am friends with a couple of ER doctors, who are probably the worst offenders (self-acknowledged) in this space. It's based on a real phenomenon, though, of drug-seeking behavior.

As people with chronic pain communicate with each other (through things like Reddit) on the best way to communicate to doctors that their pain is legitimate, those techniques are also inadvertently taught to other people who are seeking pain medication for recreational purposes.

I think the cause of widespread drug legalization has been weakened by a couple of real world efforts in that direction, but I still stubbornly cling to the belief that if people are allowed to make their own choices, then you can partition the recreational users from the chronic pain sufferers and maybe let medical science have a slightly better change of addressing the latter case. That said, given factors like cost and insurance coverage, it may just be a realigning of incentives rather than fixing the problem itself.

> but I still stubbornly cling to the belief that if people are allowed to make their own choices, then you can partition the recreational users from the chronic pain sufferers

I can empathize with this thought (having had an episode of pain disbelief in a hospital myself) but the idea of partitioning recreational users from chronic pain sufferers isn’t reflective of the reality.

They aren’t two mutually exclusive groups. In fact, many recreational users get their start from over-prescribed opioids. Some people experiencing pain and all of the associated emotional difficulties will see the sudden access to opioids as an opportunity or even an excuse to indulge in opioid excess.

Self-medication with opioids also produces a very quick on-ramp to dependence in average users. If you’re anything like me, you prefer to use the minimum dose of any medication and get off as quickly as possible. I’d rather have mild lingering headache pain than take an extra Ibuprofen.

Not so with the much of the general public. I have friends in medicine who believe even Tylenol should be prescription only because of how frequently they see people destroying their livers by taking excessive amounts. Look at simple drugs like Afrin nasal spray and people who become severely dependent for months or years because they can’t even read the directions on the bottle. Open this same door to something euphorically reinforcing like opioids and the number of people walking themselves straight into addictions because they wanted something stronger for the occasional headache would be massive.

>> you can partition the recreational users from the chronic pain sufferers

Except that you can't. There is no bright line between those two groups. Many recreational users/abusers started their journey when prescribed drugs for legitimate pain. Steady use becomes dependency, then you look for other sources, and quickly you are crawling dark web for a dealer in your neighborhood.

I'm fascinated by the athletic side of all of this.

I have a friend who has had the aspiration to become a regular exerciser for years, but he says everything he tries just hurts too much. I exercise regularly myself, but we haven't found a way to talk about it, because it's so hard to share subjective sensations of pain. In some sense, everything I do hurts, too, and everyone who works out or plays a sport acknowledges a lot of pain. People differentiate routine pain from pain that requires effort to endure and distinguishes both of those from pain that indicates an injury happening or being aggravated, and people value and hone their ability to distinguish the second two from each other, because they don't want to get injured but also don't want to let pain hold them back from doing something that makes their body healthier and stronger.

I've known people who have endured through pain and suffered terrible consequences from it. Five years ago, my wife's aunt loved to say "I'm a tough old bird," and she has since lost a leg unnecessarily, because she thought that having high pain tolerance was a viable alternative to going to a doctor. Now she's in a wheelchair and does everything the doctors say.

Other people have had opposite experiences, where learning to disregard pain led to breakthroughs for them. One woman I know set a big triathlon PR a year after having a kid, and when people asked her how she was able to do that, she said, "After having a kid, the pain just wasn't a big deal to me anymore." She's big into the science, so I expected to hear something about hormones, but for her, her expanded pain tolerance was the entire explanation for her better performance.

Personally, just doing normal exercise presents me with an incredibly rich variety of "painful" sensations and a lot of difficult decisions. Right now I have a nagging shoulder injury, and every time an exercise generates a "painful" sensation in my shoulder, I have to decide, is this reflective of something making this injury worse? better? neutral impact? Should I stop right away so I don't aggravate the injury, or should I do this exercise more often because it's stimulating the tissue in just the right way? There's so much said and written about it, but it often seems frustratingly tautological. You have to know what the sensations mean before you can figure out which words refer to which sensations.

It's complicated. Do any kind of sports and muscle pain will just mean you worked hard, which is generally good.

Do a martial art and you'll learn to ignore pain from hits to non sensitive areas too.

But if you have a brain you'll still care about joint pain and pain from hits to areas where it could cause serious damage.

I'd let that shoulder heal a bit :)

Personally I've always figured I should pay attention to the derivative of pain over longer periods when doing sports.

Yeah DOMS sucks, but the average derivative over time is zero. It doesn't get worse with more sport. If your shoulder is the same it's probably fine to keep sporting, if it gets worse over time you should definitely give it rest and probably get it looked at.

Not surprised either, I've met a doctor who trusted me that I was in pain exactly once, every other doctor or nurse has looked at me like I was some kind of drug addict.

The strongest such look I've ever gotten was a nurse in the ER when I went in with a splinter under my nail. I already felt kinda silly to go to the ER for something so obviously harmless, but it was late I just couldn't handle the pain. She'd offered me ibuprofen, but I had already taken the largest recommend dose of that, so I asked if maybe I could be given a local anaesthetic. She looked like she was considering whether to call the cops, since I was obviously a... Well what, actually? Local anaesthetic addict?Is that even a thing? Why would that be a thing?

I've come to the conclusion that healthcare in my country is better at judging you than they are at caring for you, which is really fucked up

I'm not sure how this fits in, but in my experience a further complication as someone with chronic pain/illness is that often the thing that bothers me the most isn't what I would describe as painful. I would describe it as very uncomfortable but on a different axis than pain. As a simple example that I think most people can relate to - I do not think of being dizzy as painful, but it's very impactful if you are dizzy all of the time. I had an episode of vertigo that was one of the most miserable experiences of my life but I don't think I experienced much pain during it.

I guess if the goal is to tell whether the person needs pain meds that complication may not matter as much since they don't help (afaik) with those symptoms. But I do sometimes feel like my health problems get taken less seriously if I report on my pain levels rather than my discomfort and/or how it impacts me. Eventually I found a migraine pain scale that focuses on how it affects your life rather than directly how physically painful it is and that helped me have a normalized system for reporting.

Even neuroimaging isn't enough. fMRI doesn't have a great track record for predicting pain. It works to an extent, but it's not like there's a simple area that lets you accurately and directly decode the pain level someone is experiencing. And there's no new neuroimaging in the pipeline that would let us do this in a clinically relevant setting. There's a lot of hype around various optical methods, but it'll be a long road even if they work.

In the meantime, we should take much more advantage of the gap between the sensory and the affective components!

There are many other science-based pain management methods than just drugs. These other methods don't change the sensory part, the pain is there, but they can dramatically change the quality of your life with how you feel the pain.

CBT is very effective for pain management. Even something as simple as distracting yourself from a painful stimulus like a medical procedure can make a huge difference.

For example, your doctor doesn't routinely tell you to show your kids a fun video while they get a shot. But it makes a massive quality of life difference. Without Elmo, my daughter will cry for 5-10 minutes and just be miserable for half an hour. With Elmo, the shot comes, she's annoyed, there are tears for a 5-10 seconds, and then she's fine. There's no reason to not make this routine, except that we think of pain as something entirely objective instead of something that is largely subjective.

I think this research falls into that trap of "This is an important problem, this solution is obviously bad, but we have no good ones, so let's do it." This is likely to cause far more pain than to help anyone.

There are other MR techniques that show promise. The below links are for disc pain assessment. As a tech at a high volume spine site, the DeVa technique is fairly appealing, as spectro is slow.

https://pmc.ncbi.nlm.nih.gov/articles/PMC11885163/

https://aclarion.com/

2. The affective-emotional component: how much does the pain hurt, and how does it affect emotional state?

I am going to add the spiritual aspect to this. I read a post on Reddit asking if Jesus truly suffered more than anyone else on earth, given that more people suffer for longer than his 24 hours ish on the cross.

Without believing the story of Christ at all, I was still able to do the mental exercise to see that the nature of the pain had nothing to do with the duration. For example, watching your mother watch you get crucified is heart stopping (or to watch another mother have to go through that).

So, what is the purpose of a human feeling that pain as an experiencer or as an observer? Why would our body elicit that psychic pain, why wouldn’t we just focus on the physical and ignore these other things? In that moment, your only concern should be the physical, but it’s not just physical.

The psychic pain almost has no use in a state of physical torture other than to inform the conscious of its duty to morality. Unfortunately, I do not believe science can ever conclude this is the answer (in no possible way, I’m open to being wrong).

Like it's a pretty interesting research question to see if this very major component of the human experience can be seen and measured, but I'm not entirely sure what the medical value of such a thing could be if what you get is basically just yes no in pain or not and a rough intensity because you can already get that and more from the patient.

My experience was/is annoyingly the opposite where I developed chronic neck pain on a relatively fast timeframe and I can't find a physician across all different disciplines that's actually interested in finding out the source. They almost immediately throw up their hands and want to send me to a pain management doctor.

I too suffer chronic neck pain after an overstretch injury. It's been life-changing. And immensely frustrating that no diagnosis can be done.

I've found meditation very useful in this regard. If you focus on observing in detail #1 type pain, you find that the #2 becomes much more managable. The technique is to get curious about the pain, ask what type it is (hot/cold/electric etc), where exactly is the pain. what shape is it? how does it change over time? It sounds counter-intuitive but by focusing on it it becomes easier to manage (because I think a lot of #2 is story and mental reactions to the pain rather than the actual pain itself and the mental reactions are self-fulfilling in a negative way).

Maybe this explanation is intentionally simplified, but what it’s telling me is that medical science is just lost.

The problem is that, despite medical science making advances abound, doctoring as a profession changes exceptionally slowly, and most doctors (especially male doctors IME) take an adversarial approach to patients who have questions.

I have a relatively common autoimmune disease. I have had much better experiences with NPs than doctors in explaining that certain medications are contraindicated for people with my disease.

Ego has always been a massive issue in medicine. I wonder if this is exclusive to the US, or if we see it everywhere.

You need to have a big ego to take on the responsibility of a doctor. A lot of people can’t handle it emotionally so the job selects for people with narcissism or psychopathy. This is a very rough generalization but from my interactions with surgeons it fits pretty well.

Judging pain is philosophy more than science.

How do we know what is in someone else's head?

We will soon enough know what's going on in people's heads. While it may help us better understand pain, it will probably cause all kinds of other unforeseen consequences.

Well, I wouldn’t go that far. The brain is incredibly complicated, and frankly we are still very far from understanding much about how it works.

But this doesn’t mean we aren’t making incredible advancements. Discoveries are constantly being made in the background and are continuing to build up over time.

For example, a non-addictive pain medication was just approved by the FDA [0]. This will undoubtedly improve millions of lives and prevent uncountable numbers of people from misusing opiates in the future.

[0] https://www.fda.gov/news-events/press-announcements/fda-appr...

But it's listed for acute pain, don't opiates already work well for that use-case? My understanding is that the time-limited nature of them and lack of continued access makes dependence unlikely and that the holy grail is a solution for chronic pain.

The lack of continued access leads a lot of people into fentanyl and other drugs.

Is it possible to have just 2 without 1? Do clinically depressed folks fall under this category of "the affective-emotional component without the sensory-discriminatory component"?

Absolutely, it is possible.

I’m not sure about the depression, but it sounds plausible, depending on the experience. That’s out of my expertise, though.

For a concrete example, phantom limb pain can be a form of affective emotional pain, with a huge asterisk in that, it’s more complicated that than only resulting from #2. Too complex to get into in this forum. Here’s reading if you’re interested:

https://pmc.ncbi.nlm.nih.gov/articles/PMC6051014/#:~:text=.n...

In the case of phantom pains, one can point out "where on my body, what type (hot? cold? chemical?), and how intense is the noxious stimulus?". That's the sensory-discriminative component. It is just that limb is missing. One explanation is that brain stores the map of various limbs, etc.

why do you think psychological types of pain won't cause discernible biomarkers? well known, for example, that stress has lots of effects on the immune system

it's all part of the same biological soup!