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.

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.

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.

Cis and Trans

I assume almost everyone is familiar with transgender or transsexual, meaning someone whose gender identity doesn’t match up with what they were assigned with at birth based on their genitals.  For a long time there was no good way to describe some who was not transsexual.  “Biological” and “natural” implied trans people were artificial or unnatural.  “Women born women” was at odds with trans people’s image of themselves as having always been the gender they identify as*.

[Actually, it’s more complicated than that.  According to Julie Serano’s Whipping Girl, while some trans women did always feel like a woman trapped in a man’s body, the dominance of that paradigm was driven by medical gatekeeping.  Doctors would not let male-appearing people get treatment to make them appear more feminine (e.g. hormones, breast removal) unless they were convinced the person fell into a very specific narrative, including being very stereotypically feminine and having always considered themselves women.  This means that there are a bunch of people who would have identified as trans women under more open circumstances who aren’t being counted, and those that did get through the process have a deep memory that their continued access to treatment that makes them psychologically whole is dependent on other people believing they believe they have always been women.]

Finally, someone came up with cis, which I loved because it was the only time between graduating college and starting this blog that anything I learned in organic chemistry came up in the real world.   In chemistry, cis is the opposite of trans.  A molecule’s molecular formula doesn’t tell you everything about it.  If you want to read the exact definition it’s here, but the important point is that cis and trans are roughly opposites (just like L- and R-), and trans means roughly “on opposite sides” and cis means roughly “on the same side.” (in Latin, of course).  So when I heard cis-woman I knew exactly what it meant, with no explanation.  When you throw in that it is shorter and more accurate than the terms it was attempting to replace, I was sold.

It only recently occurred to me that most people have not taken organic chemistry or Latin, so to them cis was one more g-ddamned thing to memorize.  But now you know, and you can tell your friends, and everyone can adopt this much shorter, simpler, more precise term.

What doctors can learn from day care workers

So if being fat is bad for people, than doctors should tell them not to be fat, right?  Or at least tell them to eat vegetables and hit the elliptical, right?

Well, maybe.  But sometime around age two humans realize that they are independent beings who do not physically have to do everything an authority tells them to do.  Unfortunately, most doctors’ patients are over the age of two, and those that aren’t have their own issues.

vomiting baby
They’re gross

Telling people to do things they already know they need to do has mixed results.  Scott Alexander suggests alcoholism could be decreased by as much as 13% if doctors would spend five minutes telling alcoholics it was bad for them.  What this doesn’t capture is how lectures change the doctor-patient relationship.  It is very difficult to give a non-judgmental lecture when your billing model gives you 10 minutes per patient.  Patients might avoid or delay visits for problems- alcohol related or not- in order to avoid the lecture.  This is a pretty big issue with overweight patients, and apparently without upside: patients lectured by their doctors are more likely to attempt weight loss but no more likely to achieve it.

In this TED talk, Thomas Goetz talks about a study of dental patients (no cite, unfortunately) that found that scaring them had no effect, but patients’ belief in their own ability to floss had a large one.  It’s impossible for me to separate my personal experience from this data.  Multiple dentists and hygienists told me my pain was my fault for terrible oral hygiene, and if I brushed and flossed it would go away.  This turned out to be untrue on a couple of levels.  The pain was caused by structural damage and internal infection, which may have been made incrementally worse by oral plaques but wasn’t caused by it.  And I was actually brushing pretty regularly, it just wasn’t do anything.  Then I started treating a completely unrelated digestive problem, and suddenly my teeth were cleaner.  I didn’t even tell my dentist anything had changed, she asked spontaneously.  So I guess, yeah, patients belief in their own ability to effect change matters, and if they don’t believe it, maybe consider that they’re correct and investigate why.

But let’s go one step farther.  Crum and Langer did an interesting experiment on two groups of hotel maids.  Both were told exercise is good for you.  One was given additional information about the intensity level of the work they did all day, and told just by going to work they were exceeding the surgeon general’s RDA of exercise.  Four weeks later, the informed group was slightly thinner (they even checked body fat %.  I am so pleased) and had lower blood pressure .  Not astoundingly lower(10 points on diastolic BP), but it was only four weeks, and a pamphlet is even less work than a doctor lecture.

This suggests that one of the more helpful things public health officials can do is reinforce the good things people are already doing.  You did a stretch?  Hurray for you.  Check parking lot twice before accepting a far out spot?  Still counts.  It would not shock me if part of the health improvements attributed to standing desks turned out to be simply a halo effect of feeling like you made a healthy choice.  Which coincidentally is how you turn a two year old into a civilized human being.

r/fatlogic endorses creationism

Normally when I’m investigating something I like to read well regarded books on both sides, in the hopes that the ignorance will cancel out.  Finding a suitable counterpoint to Health At Every Size is hard, because its opposition is “everyone in the world”, and there has been no selective pressure to elevate the actual science away from the shame and aesthetic preferences.

For example, I spent a little bit of time on r/fatlogic which, as decisions go, was not my best ever.   r/fatlogic frames itself as a criticism of horrible “fat logic”- things like “700 pounds is no less healthy than 200 pounds.  Possibly healthier.”  This is not a great start.  I have a deep personal understanding of how frustrating it is when people are wrong, but I have found I am happier and a better person when I say “yup, wrong”, and then move on with my day.  For the truly awful I might e-mail a friend making fun of it (thanks, Rachel!).  Forming a whole club around criticizing people, especially people that are already having a pretty tough time in life, is bad for everyone.

r/fatlogic is even worse than that, because it has an extraordinary case of the cowpox of doubt.  Wrong people keep insisting body fat is independent of calories consumed and exercise?  Well then body fat must be solely dependent on calories consumed and exercise, and anyone who suggests it is affected by anything else is a fatty fat fathead making excuses for their fat.  They are literally denying  the possibility of individual variability in the translation of external environment into physical state.  For bonus points, they invoke “but thermodynamics”, which is the same argument creationists use against evolution itself.

Here I tried several ways to explain exactly how wrong they were and how that was terrible, but then I decided to take my own advice and stop before I endorsed the hollow Earth theory.  My current contender for an opposition book is Good Calories, Bad Calories, but I’m open to suggestions.

An Apple a Day Does Surprisingly Little?

How did apples get to be the standard bearer for all that is good and healthy? In terms of nutrient per calorie, they’re not that good. 1 cup has 65 calories, 3 grams of fiber (12% RDA), and 5.7 mg vitamin C (10% RDA), and very small amounts of a wide range of other nutrients. Pears are just slightly better: 1 cup has 81 calories, 4g fiber, 5.7 mg vitamin C, and enough potassium to be noticeable.  Meanwhile the same volume of grapes, so long derided as nature’s candy, have 104 calories, 1.4g fiber, 16.3 mg vitamin C, 22 mcg potassium.  Almost everything apples or pears have trace amounts of, grapes have slightly more of.

Wasting their lives
Wasting their lives?

I wonder how much of this is because of the skin:pulp ratio.  Produce skin tends to have a lot the bulk of the vitamins*.  Plus grapes are more colorful, and color intensity is a shockingly good proxy for nutritional value in produce.

I also wonder how apples got such a sterling reputation without the benefit of a good marketing firm.   My best guess is that they grow further north than most fruit and keep for much longer, and established cultural supremacy back when produce was scarce and fruit did not regularly fly.

Full disclosure: I was originally going to compare apples to iceberg lettuce, which I had previously seen described as nutritionally vacuous but easy to ship.  But when I looked it up I discovered iceberg lettuce actually has a pretty good nutritional profile.  1 cup has 10 calories, 1 g fiber, 2.0 mg vitamin C, and 22.0 mcg potassium (22% RDA), and trace amounts of other stuff, which makes it strictly better than apples on a per calorie basis.

While we are at it: spinach does not have that much iron.  It has a number of other vitamins and is very good for you, but the original reputation for iron-richness came from some guy putting the decimal point in the wrong place (source: some guy at a party 6 years ago).  In fact the oxalates in spinach bind iron, making it harder to absorb.

Apples aren’t bad for you.  If you want an apple, eat an apple.  But if don’t want an apple and are trying to cajole yourself into it to make doctors keep their distance, consider grapes instead.

*Also the pesticides.