PAIN, AGONY, HURT!

Studies suggest that about 10% of one’s nervous system is dedicated to sensing pain. Given what else the nervous system does—sight, smell, taste, hearing, thinking, moving, digestion, etc., etc., etc.—that’s a lot!

Why so much attention to pain? As it turns out, there are benefits to feeling poorly.

Pain for Gain

Foremost is survival: without unpleasant sensations, we wouldn’t know to avoid fire, allow injuries to heal, attend wounds such as broken bones or cuts, etc.

There are additional ways in which negative feelings lead to have positive consequences.

Pain facilitates pleasure by providing an important contrast for pleasurable experiences, increasing sensitivity to sensory input, and facilitating self-rewarding behavior.

In many communities, the ability to withstand pain or physical endurance marks a child’s elevation to adult status.

Pain augments self-regulation and enhancement by increasing cognitive control, reducing rumination, and demonstrating virtue.

Pain promotes affiliation by arousing empathy from others, motivating social connection, and enhancing group formation.

Pain Reduction

Mesopotamian goddess Nisaba, with opium poppies growing from her shoulders. c 2430 BCE

But for all of that, we try to avoid or minimize feeling bad. Indeed, pain is the most common reason why people seek medical care. Seeking relief is not a new phenomenon, but getting it is.

Surgeons have been using general anesthesia in the Islamic world for nearly two thousand years. In the 1600s, many European doctors gave their patients opium to relieve pain.

The earliest European surgeons operated while keeping patients wide awake and physically restrained. By the 1800s, the nicest surgeons introduced ether and chloroform anesthetics for surgery. And why was this controversial?

Several major religions view physical suffering as intrinsically linked with atonement or moral goodness. Some, such as Buddhism and Taoism, hold that it is caused by an imbalance within the individual and can only be resolved through personal effort. Others, such as Christianity, have historically believed that suffering brings one closer to an ideal spiritual state.

Surgeons operating on patient under ether anesthesia, 1847

Some doctors questioned the ethics of operating on unconscious patients. Others were concerned that relieving pain might hamper healing. “But the surgeons could not long resist their new power to perform longer and more complex procedures, and most patients thought anesthesia a divine blessing,” wrote Marcia Meldrum, an associate researcher in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles.

By the 1900s, people were using morphine and heroin as pain medications. At first, doctors thought these “safe.” However, over time, it became clear that these treatments also made people vulnerable to addictions.

Until this time, the medical field considered pain to be primarily a problem to manage in acute care (related to injury, for example, or surgery) or during a painful death from cancer.

“Flavors” of Pain

Acute pain is what you feel when you become hurt or injured. You may have experienced acute pain from an injury such as a cut or a broken limb or from disease or inflammation in the body. Acute pain can be intense and severe, but it typically resolves as your body heals from whatever caused it.

Nociceptive pain is caused by tissue damage. Most acute pain is nociceptive. 

According to NIH, chronic pain is a sensation that lasts much longer than acute pain―usually months and sometimes years. Chronic pain sometimes has a clear cause, such as an acute injury, a long illness, or damage to and dysfunction of your nervous system. However, it sometimes happens without any obvious reason.  Medical providers have often assumed that patients complaining of on-going pain are delusional, hypchrondiacal, malingering, or addicts. Patients often turn to psychotherapy, or sometimes neurosurgery.

Neuropathic pain is caused by nerve damage or dysfunction. You can experience neuropathic pain from injuries or illness that affect the spinal cord and brain (for example, a slipped disc in your spine) or the peripheral nervous system (the nerves throughout the rest of your body). This kind of discomfort often feels similar to burning, shooting, or stabbing. 

Inflammatory pain happens when your immune system activates in response to injury or infection. In addition to causing redness or swelling, it can also make you more sensitive to feelings of pain.

Everyone’s pain feels differently, and the only way to know whether someone is hurting is to ask. Has a medical practitioner asked you to rate your discomfort on a scale from 1 to 10? They may also ask you to describe what you feel: dull, throbbing, aching, shooting, stabbing, etc.

Treatment Options

Just as there isn’t a way to measure it objectively, there isn’t one single treatment that will work for everyone. It often involves a combination of treatments, which may include:    

  • Over-the-counter and prescription medications (such as pain relievers and drugs that reduce inflammation)
  • Physical and occupational therapy to improve function and limit discomfort
  • Counseling and therapy to teach skills for coping with pain
  • Medical treatments (such as medications and injections) to interrupt the brain’s signals or change how nerves process painful sensations 
  • Neuromodulation therapies (devices that stimulate nerves or the spinal cord) to reduce pain 
  • Complementary and integrative therapies (such as acupuncture and mindfulness meditation). 

And When Nothing Helps…

Chronic pain is an enormous problem.

More than 1 in 5 adults in the United States experience chronic pain.  Chronic conditions, such as low back pain and migraine, are the leading causes of disability around the world.

Not surprisingly, rates of chronic pain, including conditions that severely limit work or life activities, are highest among adults ages 65 and older.

Advertisement for treatment to cure morphine addiction, c 1900

In the 1980s, several prominent pain specialists suggested that opiods had a “low incidence of addictive behavior.” They pushed for increased use of the drugs to treat long-term, non-cancer pain, as Meldrum noted in her paper “The Ongoing Opioid Prescription Epidemic: Historical Context.” Today we all know how wrong they were, and we are still trying to undo the opioid crisis.

Where Does Aspirin Come From?

1923 advertisement

Apart from prescription medications, over-the-counter options are popular. Aspirin, as it is known today, was first developed in 1895 in Germany. By 1915, Bayer Pharmaceuticals developed the first tablet form, which they then sold throughout the world as a medicine.

The active ingredient in aspirin is acetylsalicylic acid, which is formed by the acetylation of salicylic acid, which is derived from natural plant sources such as jasmine, willow and poplar trees, as well as certain species of legumes.

This gives credence to the efficacy of willow bark tea for minor aches and pains, as long claimed by folk medicine practitioners.

Aspirin molecule, acetylsalicylic acid (ASA)

However, aspirin is no longer made from willow bark. Today, pharmaceutical companies derive aspirin from plants of the Spiraea genus. Compounders then convert the salicylic acid into acetylsalicylic acid via acetylation.

Aspirin is very useful in many ways besides pain relief. Indeed, doctors use it as a blood thinner to treat clots. At a daily dose of 81mg, it is helpful in preventing future heart attacks.

But beware: You should not use aspirin if you have a bleeding disorder such as hemophilia, a recent history of stomach or intestinal bleeding, or if you are allergic to an NSAID (non-steroidal anti-inflammatory drug) such as Advil, Motrin, Aleve, Orudis, Indocin, Lodine, Voltaren, Toradol, Mobic, Relafen, Feldene, and others.

OTC Alternatives

A common alternative to aspirin is Tylenol. Acetaminophen, commonly sold under this brand name, is a non-opioid analgesic that relieves pain and reduces fever. Acetaminophen regulates the body’s temperature and alters its perception of pain.

Tylenol is generally safe at recommended doses. For adults weighing more than 110 pounds (50 kg), the recommended acetaminophen dosage is 1000 mg every six hours or 650 mg every four hours.

Risks

However, elderly individuals may face higher risks of certain side effects due to physiological changes, including:

  • Liver Damage: Aging decreases liver efficiency. This raises the risk of liver damage from acetaminophen, especially if taken in high doses or with alcohol.
  • Kidney Damage: As kidney function naturally declines with age, long-term or high-dose use of acetaminophen may lead to kidney damage in the elderly, particularly if their kidneys are already compromised.
  • Gastrointestinal Issues: Although Tylenol is easier on the stomach than nonsteroidal anti-inflammatory drugs (NSAIDs), it can still cause gastrointestinal discomfort. This may include nausea, constipation, or diarrhea.
  • Acetaminophen toxicity occurs when a person takes more than the recommended dosage of this medicine. Tylenol overdose leads to 56,000 emergency department visits, 2,600 hospitalizations, and 500 deaths each year in the United States, making it one of the most common poisonings. Too much of a good thing is not a good thing!

Apart from any hedonistic motives to “just feel good,” pain is an economic drain: the estimated yearly national cost of pain, including medical treatments, disability, and lost productivity, is $560 billion to $635 billion in the U.S. alone!

Bottom Line: Pain is universal, and treating it is only human. But proceed with caution!

PAIN IS GOOD

Well… Perhaps not good, but certainly useful for writers!

If you are a writer, you don’t have to be a masochist to appreciate pain. It’s a great tool for plot, tension, and character traits. I won’t bother defining pain. We all know it when we feel it. Instead, I’ll focus on types, implications, and uses.

Three Pain Anomalies 

Any of these can twist the action of your story.

  • Experiencing pain in response to a stimulus that is normally painless (allodynia). It has no protective biological function. 
  • Feeling pain in a part of the body that has been amputated (phantom pain). Actually not so anomalous: it’s experienced by 82%of upper limb and 54% of lower limb amputees.
  • Insensitivity to pain stimuli (asymbolia). Indifference to pain present from birth. These people don’t avoid situations/activities that cause pain and bodily damage. Some die before adulthood, all have a reduced life expectancy.

Temporary (Acute) vs. Long-term (Chronic) 

Sometimes, the effects aren’t all that different.

  • Behavioral deficits caused by being in pain: attention/focus, working memory, mental flexibility, problem solving, and information processing speed
    • Use the deficits to ramp up the tension when your hero/ine is trying to achieve a goal
    • Use success in spite of these deficits to make your character come across as stronger, more resourceful, more reliable
  • Intensified negative emotions of depression, anxiety, fear, and anger, when in pain
    • Use any of these to create tension between characters 
    • Use any of these as challenges for the hero/ine to overcome and remain functional
  • Following an acute pain episode, people reported feeling better than people who hadn’t been in pain. It feels so good when it stops?
Medieval Torture
  • Chronic pain is associated with several long-term negative side effects: 
    • Weight gain or loss associated with medications (steroids, nerve pain drugs, opioids) and decreased exercise and activity
    • Unpredictable mood swings and increases in scores on tests of hysteria, depression, and hypochondriasis 
    • Decrease in patience
    • Grief for the person s/he once was
    • Lifestyle changes:
      • Unable to work or provide for family
      • Need help to function (get dressed, bathe, eat)
      • Loss of prior skill (e.g., can’t play the harp any more)
    • Skin, hair and nails can take a beating: increased sensitivity, intermittent spots on face, hair loss
    • Intimacy often suffers:
      • Sex may be painful
      • Ill person may be less energized in finding what works and adapting
    • Financial hardship adds to stress, which makes things worth; money goes to medications, lotions and potions, treatments, travel to and from appointments

How to Show Pain When the Character Isn’t Telling  

Sometimes, people/characters try to hide their pain. Other times, s/he isn’t able to communicate it. Using these behaviors, you can let the reader or another character know the person is in pain.

  • Facial grimacing
  • Guarding (trying to protect a body part from being bumped or touched)
  • Increase in vocalizations such as sighs or moans
  • Changing routines
  • Decreased range of motion
  • Appearing withdrawn, anxious, depressed, or fearful
  • Decrease in social activities
  • Decreased appetite
  • Increases in confusion or display of aggression or agitation
  • Decline in self-care
  • Side effects from hidden medication
    • Over-the-counter pain medication often causes stomach irritation and nausea; people taking these medications may uncharacteristically refuse alcohol
    • Prescription pain medication, even when taken responsibly, often cause random itching, slowed breathing, constipation, and nausea; drowsiness and confused thinking (agitation, euphoria, etc.) are probably the most noticeable side effects

Why Would Someone Want to Hide Pain?

  • Don’t want to look weak
  • Showing pain is impolite
  • Showing pain is shameful
  • Pain is seen as a deserved punishment
  • Pain was self-inflicted as a maladaptive coping mechanism
  • To avoid treatments against one’s religious beliefs
  • Afraid it means death is near
  • To avoid treatment that might lead to addiction
  • Don’t want to admit needing help
  • To avoid being disqualified from certain careers or activities
  • To shield another character from the knowledge
  • Showing pain would lead to more pain being inflicted

Gender and Pain  

  • Socially and culturally, acknowledging pain is more acceptable for women than for me. Women are expected to be emotional, men stoic.
  • Female pain is often stigmatized, leading to less urgent treatment, longer wait times in emergency rooms, and doubting the accuracy of women’s reports of pain.
  • Statistically, women are more likely to be prescribed sedatives for pain; men are more likely to be prescribed actual painkillers.
  • Study shows men more prone to hypersensitivity when exposed to an environment in which they remembered feeling pain.

Beauty Knows No Pain

Many activities require some amount of pain, if only at the beginning. Lifting weights, running, bicycling, and other workout routines can cause severe soreness and muscle aches the first few times a character exercises. What would make a character get up and do it again? Training to compete in a sport is likely to cause some pain as the human body is pushed beyond its previous limit. How much is too much, enough to make a character quit?

Developing the callouses necessary for manual labor, martial arts, playing stringed instruments, some types of dancing, etc. almost always involves blisters and bleeding along the way. Some activities always involve some level of pain, such as dancing en pointe, Tough Mudder runs, or boxing. What might make a character work past the pain to perform any of these? How might characters convince themselves to repeat the necessary movements, knowing how much they will hurt?

Beauty and fashion often come with pain of their own: tattoos, corsets, high heels, neckties, piercings, trendy clothes too hot or too cold for the environment… Why? Consider the different standards of beauty at different time periods or in various cultures; how much pain would a character be willing to undergo to achieve these standards?

Describing Pain More Vividly 

Here. It hurts right here.

Be precise about location, intensity, whether it’s continuous or intermittent, whether it’s burning, sharp, deep or superficial, diffuse or focused. In a medical environment, patients are often asked whether their pain is new (acute) or ongoing (chronic). There is a difference between shooting pain and stabbing pain; there is a difference between a stomachache and a pressure ache in the upper, right abdomen. Pain in ligaments, tendons, bones, blood vessels, fasciae, and muscles is dull, aching, poorly-localized. For example, sprains and broken bones are felt as deep pains. Minor wounds and burns are superficial. Is this pain burning, tingling, electrical, stabbing, pins-and-needles? Further examples of pain descriptors can be found here or here.

Give That Baby Sugar? 

Fun tidbit: sugar taken by mouth reduces pain in newborns resulting from lancing of the heel, venipuncture, and intramuscular injections. It does not remove pain of circumcision. The reduced pain of injections might last till age 12 months.  Mary Poppins was right: a spoonful of sugar really does help the medicine go down!

Bottom line for writers: pain is incredibly useful in numerous ways.

It’s lucky for us that pain is so easily treated! Even for children!