Category: Uncategorized

The Kitten Pain Scale

I very briefly flirted with Quantified Self and then jumped off the bandwagon because it was making my personal signal:noise ratio worse.  But my neuroendodontist* has given me several drugs, and he wants to know how they work.  Allow me to give you a brief list of things that make measuring this difficult

  • Treatments are all on varying schedules- some daily, some daily with a build up in blood stream leading to cumulative effects, some as needed to treat acute pain, some on my own schedule but hopefully having longer running effects.  Some are topical and some are systemic.
  • I have several home treatments like tea and castor oil.  I’m not going to not take them in order to get more accurate assessments of the drugs, both because ow and because pain begets pain.
  • Taking treatments as needed + regression to the mean = overestimate of efficacy.
  • Pain is affected by a lot of non drug things: sleep, stress, temperature, how ambitious I got with food, amount of talking, number of times cat stepped on my face in the night, etc.
  • We are hoping some of these drugs will work by disrupting negative feedback loops (e.g. pain -> muscle tension -> pain), which means the effect could last days past when I take in.  In the particular case of doxepin it might have semi-permanent effects.
  • Or I could develop a tolerance to a drug and my response to a particular drug will attenuate.  That is in fact one reason I was given so many choices as to medication: to let me rotate them.
  • We have no idea how these drugs will interact with each other in me.  We barely have an idea how the interact in people in general.
  • If I believe something will help my pain will lessen as soon as I take it, long before it could actually be effective.  Not because I’m irrational, but because my brain reinforces the self-care with endorphins, which lessen pain.
  • At the same time, having more pain than I expected to feels worse than the exact same pain level if it was anticipated.
  • Side effects: also a thing.

“I think I feel better when I take this one” was not going to cut it.

Then there was the question of how to measure pain.  Ignoring the inherent subjectivity of pain, neuralgia is a weird beast.  I already hate the 1-10 pain scale because pain has threshold effects and is exponential.  I could create a single pain number at the end of the day, but my pain is not constant: it spikes and recedes, sometimes for reasons, sometimes not.  What I would ideally like to track is area under the curve of pain**, but that requires polling, which would create horrible observer effects.  If I ask myself if I’m in pain every 15 minutes, I will increase my total pain level.  I could poll less often, but the spikes are random and short enough that this was not going to be accurate enough to evaluate the treatments.  I could count pain spikes, but that ignores duration.  Determining duration requires polling, so we’re back where we started.  I could deliberately poke a sore spot and see how bad the resulting pain is, but

  1. Ow
  2. A treatment that doesn’t affect sensitivity but does keep me from spontaneously feeling pain because the nerve is bored is a success.  If we wanted me to be numb we would do that.

It’s just really hard to measure something when your goal is for it to be unnoticeable, and measuring it creates it.

So I came at it from the other side.  What happens when pain is unnoticeable?  I enjoy life more and I get more things done.  Could I measure that?  Probably.  They have the bonus of being what I actually care about- if something left me technically in pain but it no longer affected my ability to enjoy or accomplish things, that would be a huge success.  If something took away the pain but left me miserable or asleep, it is not solving my actual problem.**

So one metric is “how much I get done in a day”.  Initially this will be the first number between 1 and 10 that I think of when I ask the question at the end of the day, but I’m hoping to develop a more rigorous metric later.  You’d think enjoyment of life couldn’t ever be rigorously measured, since it’s so heavily influenced by what is available to me in a given day, but I say that brave men can make it so.  And so I introduce to you: the kitten pain scale.  Kitten videos vary a little in quality, but I think my enjoyment of any single video reflects my internal state more than it does the video. Three times a day (shortly after waking up, shortly before screen bed time, and sometime mid-day that can vary with my schedule but must be selected ahead of time to avoid biasing the data), I will watch a cute kittens video and record how much I enjoy it.  The less pain I am in the more I should enjoy the video.  This will give me a (relatively) standardized measure of pain without risking inducing it.

This is still not what you would call a rigorous study.  An individual choosing what to take among known options never will be.  But I seriously think the kitten pain scale could be a contender to replace the stupid frowny faces.  My first draft is available here.  Right now it’s set to measure over the course of a day, because that’s the scale I expect from these meds, but you can add bonus measurements at set times after taking meds if you like.

Possible additions: cups of tea drunk in day.  Right now that seems like too much work to measure, but when tea is available it’s a pretty good indicator of how much pain I’m in.

*I am still angry that I know what that is, much refer to one using possessive case.  But given that, I am extremely grateful I live within biking distance of a world class research facility in the discipline.  Even if the physical facility could be a case study in how economic insulation leads to bad user experience.

**This is why none of my treatment options are opioids.  Strong ones technically reduce pain, but they also leave me miserable.  The fact that some people take them for fun is all the proof of human variability I could ever need.

Adventures in Dentistry and Neurology

I forget if I mentioned it, but I had nerve damage from the first dental surgery, way back in June.  Everything else healed up more or less all right, but that one kept hurting.  Actually it felt like two damages- one that was healing, albeit slowly, and one that was staying static or getting worse.  The prospect of living with that pain for the rest of my life was really daunting.  Medical marijuana, which had been so helpful at first, was having more side effects with fewer desirable effects every day.  It eventually became clear my surgeon had no idea what was going on or how to fix it so I went to a neuroendodontist, a subspeciality I really wish I wasn’t already familiar with.

A toenailectomy looks awful but feels like nothing at all.  A neuroendodontal exam is the exact opposite.  It looks like some guy very gingerly touching around your mouth, but he is not only deliberately provoking pain, he needs you to pay attention to the pain and report on in it excruciating detail, while you remind yourself that inaccurate reporting leads to inaccurate diagnoses.

For all that pain, I actually got very good news.  Even though it feels like I have two distinct damages, it’s actually only one, and it is healing.  Nothing is guaranteed in neurology but existing data is consistent with this eventually healing itself.  And in the meantime, he gave me new and different medicines.  We’ll see what the side effects are, but at the very least I have options to rotate through.

Adventures in Podiatry and Neurology

WARNING: THIS ONE IS GRAPHIC EVEN BY MY STANDARDS.  NEEDLES, PAIN, AND TOENAILS.

Recently I learned toenails aren’t supposed to be under the skin of your foot and hurt constantly; this is an ingrown toenail and it’s a solvable problem.  By “recently” I mean a year and a half ago, but a little pain when I flexed my toes in a shoe did not seem as important as the pain in my mouth or my inability to digest food, so I only got around to seeing a podiatrist now.  If you develop an ingrown toenail there are home treatments to coax it better, but if you’ve always had it the cure is a little more drastic: they cut off the bit of the nail that has grown under the skin and cauterize the nail bed so it never grows back. If you are curious, here’s a video of the actual medical procedure:

The worst part is the lidocaine injection. There’s a topical anesthetic, but they root the extremely thin nail around under your skin in order to find the nerves and inject directly over them. The podiatrist will describe it as slightly painful, but they are lying, and it will make you doubt them when they promise the rest of the procedure is painless. That part turned out to be true: with enough lidocaine you genuinely can’t feel them slip the scissors/pliers under the nail bed, or the burny stuff*, unless you are a freak who processes -cain very quickly, in which case they will give you more and it will stop hurting.  But the anesthetic injection was pretty brutal.

That is not actually the interesting part. In between the lidocaine and the scissors/pliers, they test your numbness with what looked like a large blunt toothpick. My podiatrist, which more flourish then was strictly necessary, brought it down from a great height onto my toe.

I screamed.

Then I realized it didn’t hurt at all. My brain had combined the memory of the painful needles and the visual information about incoming sensation and preemptively sent a scream response before it noticed I couldn’t feel anything. I never had quite that strong a reaction again, but there was an extremely weird dissonance as I watched something I knew should hurt, yet got only vague reports of pressure from the area.

This works in reverse too.  Phantom limb syndrome is a condition in which people missing a limb (even one they never had) experience excruciating pain where their brain thinks that limb should be.  One of the only effective treatments is mirror therapy, where a mirror is used to simulate the appearance of the missing limb, and somehow the brain goes “oh, I guess it’s fine.”  This clip from House is not quite as accurate as the matrixectomy one (mirror therapy rarely involves kidnapping), but the science is sound.

The lesson here is that even something that feels incredibly simple and real, like pain, is in fact an artifact of post-processing on several different inputs.

*Dr. Internet says phenol but I could have sworn it started with an M. In my defense, he gave me the proper name after the needles bit and I was fuzzy.

Depression as a false negative

Slate Star Codex points out that rates of suicide and depression are weirdly terrible metrics for how good a society is.  I wonder if some of that is a definitional effect.  Depression is more or less defined as occurring for no reason.  If you have a reason for sleeping poorly and feeling unable to do everyday things (e.g. fibromyalgia), you’re diagnosed with that instead.  As society gets worse, people who were chemically destined to be depressed are given reasons to be sad, and so stop contributing to the depression statistics.

This is related to but slightly distinct from the idea that depressed people are less likely to commit suicide when conditions are objectively miserable than when they are good because bad conditions leave room for hope in a way good conditions don’t.  That is about individuals specific reaction to their depression.  My hypothesis is about how the number “% depressed” is measured.

Of course, my suggestion doesn’t account for increased suicide rate.  The expectations hypothesis does account for that.  One other factor I think may be in the mix is coping mechanisms.  Before the AIDS cocktail, someone noticed AIDS patients actually got better when co-infected with another virus.  The reason turned out to be interferon, an intercellular signal to ramp up anti-viral defenses.  HIV didn’t trigger it, or didn’t trigger it enough, but when another virus did the resulting interferon protected from HIV as well as the original virus.  Maybe external bad events trigger coping mechanisms in a way depression doesn’t, and they incidentally fight depression.  This could be true even if  “coping mechanism” just means disassociating until things get better.

The FDA strikes a blow for HIV virus everywhere

Part of the FDAs job is making sure the pill you swallow is the pill you think you are swallowing.  It would be very bad if you thought you were taking penicillin and instead took sugar, or Prozac.  This is a government task even a libertarian could love.

But.

Sometimes enforcing a definition is harder than penicillin vs. Prozac.  For example, condoms.  The FDA has definition of a condom, and if your product doesn’t meet it, you can’t sell it, or at least you can’t call it a condom.  Some of this is good.  You want condoms tested for structural integrity, and you don’t want flat pieces of latex being sold as sexual health devices.

But.

The FDAs definition of a condom does not appear to account for human variation.  Condoms must be at least 160 mm in length.   Condoms are not allowed to be wider than 54 mm (-> diameter of 170 mm).   I’m not sure exactly how closely condom dimensions need to match penis dimensions, but that is longer than ~70% of penises and (using a condom width to girth conversion I don’t understand) narrow than ~18% of penises (source).  Yes, condoms are stretchy and will fit over your leg if you try- but they’re more prone to break, and your leg isn’t kept rigid via blood flow.  A too loose condom will just fall off, but a too long condom bunches, which also causes breaks and reduces blood flow.

I understand why we had to put up with this 100 years ago, but condoms used to be custom made, and some genuises in England are bringing that back.  But thanks to our FDA and its scrupulous definition of condoms, it is illegal to sell them in the states.  And it would definitely be illegal to use the cheap package forwarding service they link to, unless you are an EU citizen.

Why I donated to the EFF this year

I applied for a patent this year.  While I sincerely believe my invention is patentable under the current definition applied by the US Patent Office, I also believe the US Patent Office’s current definition is bullshit, and is stifling innovation by giving exclusive rights to obvious ideas and creating a culture of fear that hurts start ups more than big companies.

The incremental effect of my patent in reinforcing this bullshit system is very small.  Even if you internalized all the negative externalities, I believe the cost is trivial next to the benefits of applying (shiny resume line and a $5,000 bonus).  But no single snowflake believes it’s to blame for the avalanche, and I was really not comfortable justifying material gain because everyone else was doing it.  My compromise was to donate half the bonus to the Electronic Frontier Foundation, which fights for a variety of pro-individual and pro-start-up positions, including patent reform.  There’s no way my patent did $2500 worth of damage to society, so everyone comes out ahead except the patent trolls.

One friend asked if I thought patent reform was truly the most important cause in the entire world, and if not, why not donate to the more important one?  I have a few explanations, but I must acknowledge I made the decision first and then looked for why I made it.  The easy answer is that the world is complicated, and when the developing world catches up with us, I want what they catch up with to be not just materially comfortable, but… well honestly I want some sort of Star Trek utopia where all material needs are sated and people do things for sheer love of learning.  But failing that, I at least want a world where individuals can invent things that improve the world.  I don’t want us getting stuck at any particular rung on the ladder.

The other reason is that donating to the EFF isn’t supposed to be penance or an indulgence, it’s supposed to undo a specific harm I did.  I am deeply uncomfortable with justifying unethical behavior by helping some greater good.  For one, humans are bad at math, so it’s easy to see that doing net harm.  But even if all the trades are strictly advantageous it complicates the system, which ultimately makes it harder to get my Star Trek utopia.  Sometimes that complication is necessary and moral, but if you are in a situation where that is necessary you should probably find someone else to do it.  My talents lie in simplifying.

Problems in need of generalizable solutions

What to do if you have some intrinsic motivation but not enough?

Sometimes I spontaneously feel like exercising.  Sometimes I don’t, but I prod myself a bit and am really glad I did.  Sometimes I prod myself a bit and am not glad I did.  Sometimes I didn’t want to be because of important but subconscious reasons, and doing the Healthy Thing makes me feel actively worse.  I worry that every time I push without getting a reward at the end I’m making myself ultimately worse off by eroding my intrinsic motivation.  That worry is itself a negative reinforcement that makes the outcome more likely.  If someone could send me a general solution that works for regular exercise, physical therapy exercise, cooking, eating well, cleaning, work, and extroverting I would super appreciate it.

What to do with an initial burst of enthusiasm?

I assume we’ve all had the experience of getting an initial burst of enthusiasm for something (e.g. clean all the things), only to overdo it and burn out.  Then we are sad, because our hopes have been dashed.  I assume many of us have learned from this to scale back our initial efforts and channel that enthusiasm into long term sustainable action, only to discover the enthusiasm has an expiration date either way, so now our hopes are dashed *and* we had the unpleasant feeling of bridling ourselves *and* we accomplished strictly less than we would have if we’d run with the initial enthusiasm.  Is there a third way that would let me accomplish all the things without every feeling burnt out or overextended several of the things with a minimal amount of overextension or artificially holding myself back?

Reason to believe maybe this year will be better than the last

This has been a hard year, and I thought it would be done by now, but it’s not.  Objectively I’m in a much better state than I was in June, but I got really bad news at the surgeon’s yesterday.  I’m not dying, it’s fixable, but my new projections fr when it is fixed are much worse than my old projections and that feels terrible.

One good thing about this year is that my observer-self has gotten much stronger, especially when measured in real time.  This translates to being more aware and more able to acknowledge outside events and how I feel about them.  I would like to do more of this in the coming year.

This isn’t a New Years Resolution so much as the type of experiment I try all the time, and now happens to be New Years.  But: I’ve had trouble getting to sleep.  Could be pain, could be low exertion during the day, could be screen usage (h/t: Iodine).  I don’t find a study of 12 that had people read for 4 hours before bed particularly compelling, nor do I consider a 10 minute delay in sleep statistically significant, but…  I’m going to try no screens after midnight.  Even if the blue light effect is bullshit, I think there’s a good chance limiting myself to a few modes of entertainment, as opposed to infinite and instantaneous variety, will lead to more thoughtfulness and more sleep. If it goes well I may push the deadline up or put a cap on total screen time.

Complication: I’m not sure reading counts as a calming activity if you read things like The Child Catchers and The New Jim Crow.  I have trouble finding books that are both interesting and calming.  That may also be a thing to work on.

Why I donated to the ACLU and Planned Parenthood

Neither is a neglected cause.  I mean, I wish they had more money, but in the scope of finite resources to billions of worthy causes, they’re relatively unneglected.  Certainly they have non-EA movements supporting them.  Which is why I didn’t give them much money.  But they both also politically tenuous, and benefit from donations not just with what they buy, but with evidence of a supporter they can brandish threateningly to politicians.  That’s a pretty cheap way for me to influence policy.