Pain, part 2: Options for Treating Pain

Anesthetic (e.g. Novocain):  This is a very good option for when you need to block an extraordinary amount of pain in a very specific area for a short period of time (e.g. dental work).  However, as someone who received nerve damage from surgery that exactly mimics the effects of local anesthetic, I can tell you that it is not a long term solution.  Feeling nothing is actually very weird, and makes it easy to injure yourself.

Non-steroidal anti-inflammatories (e.g. ibuprofen):  These are great for occasional use, and have their place for long term pain caused by inflammation (e.g. arthritis).  But they carry some heavy risks for long term use.  One, inflammation is often a helpful reaction.  Topical NSAIDs helped my cat’s pain but retarded the growth of blood vessels in the eye which ultimately made the problem worse*.  Suppressing a fever can prolong illnesses.

NSAIDS are also hard on the stomach, which is bad for everyone, but especially bad for someone like me, who has long running stomach problems that interfere with my ability to absorb nutrition.  I completely wrecked my stomach with naproxen the week before surgery.

COX-2 inhibitors are a subclass of NSAIDs that target pain pathways more specifically, while sparing the gastic pathways that cause so many problems.  The problem is they also increase the risk of coronary events, to the point many were taken off the market and others restricted to single use post-surgery.  They’re so out of favor for pain relief that the three different medical professionals I begged for dental pain relief didn’t think to suggest them, even though I have many gastric risk factors and essentially no coronary risk factors.

Even before realizing COX-2 inhibitors might be perfect for me, I was very angry that they had been taken off the market.  The coronary risk was limited to a small subset of patients, of even of those, some might very well choose to live a shorter life in less pain, because pain is depressing.

Non-NSAID analgesics (e.g. tylenol and asprin): You know how new drugs like to advertise themselves as “safer than asprin?”  That’s because asprin is actually pretty dangerous.  Not super dangerous, but dangerous enough it might well be denied FDA approval today.  Asprin is also a blood thinner, which is great for coronary patients but terrible for dental patients because it can melt the blood clot protecting the surgical site, leading to dry socket.  Some descriptions down play dry socket, but it is in fact both extremely painful (because it exposes a nerve to open air), and dangerous (because it leaves the wound open to infection).   Tylenol is the world’s worst way to commit suicide, because there are several days between the point of no return and actual death, and they are extremely painful.

Opioids (e.g. heroin): I’m told these are super fun for some people, but I have had many different kinds over the years (as one dentist after another fucked up trying to fix my mouth), and I hate them.  The milder ones (everything short of percoset) do nothing for me, and the stronger ones (percoset) are so supremely unpleasant I would rather be in pain.  The only exceptions were when I was literally dying of norovirus, and whatever opioid they gave me was apparently integral to me not dying, and when I got dry socket.  And even with dry socket, I only took them to sleep, because they were just so awful. I refused to even get a prescription this time, because they just don’t work for me.

But even for people who find opioids tolerable, they have serious risks.  They depress respiratory function, cause constipation, and reduce mental function.  They’re insanely addictive on a chemical level- which doesn’t mean everyone who takes them once is hooked forever, but does mean that most people who take them will go through an unpleasant withdrawal period, no matter how “legitimate” their reason for use.  People develop tolerance to the pain relief faster than to the negative side effects, and quitting them may leave them in more pain than they were when they started.  For all these reasons, opioids are pretty much exclusively used for acute pain management and terminal patients.  Doctors who stray outside this risk serious sanctions from the DEA and FDA.  Even if I found opioids tolerable, there is absolutely no way I could have safely used them for the months of surgery + recovery I am going through.

And because I’m working my cat into everything: he doesn’t like opioids either.  Even after having four teeth pulled he fought me on taking his medicine, and then he just stood around in a stupor and drooled.

Tricyclic antidepressants: This is a cutting edge use of a very old drug.  I was prescribed topical doxepin by the doctor who did the research proving it was useful for oral pain- and even then, he was researching a different kind of oral pain.  It had some ugly side effects: I fell asleep immediately upon taking it, and couldn’t stand being touched (anywhere) the next day.  It left some numbness that lasted indefinitely- when I ate spicy food I could feel in my throat where the liquid had trickled down.  On the plus side- it left some numbness that lasted indefinitely.  That was a huge improvement over the shooting pain I’d had before.  I eventually stopped because the permanent effects had boosted me to the point it didn’t hurt that much, and the side effects were getting worse, but it was overall a great experience.  If I hadn’t found something better it’s what I’d ask my doctors for now.

Capsacin (aka spicy food): This really only works for dental pain.  When you eat capsacin it activates all your pain receptors at once.  Which hurts a lot, but then you’re good for a couple of hours.

Cannibidiol (i.e. marijuana): This one isn’t as well researched as the others because it’s illegal at the federal level (although, I must stress, legal in my state for both medical and recreational use).  But everything we know about it is awesome.  People tend to use THC and marijuana interchangeably, but that’s not true at all.  Any given strain can very in the amount of THC and CBD, and some strains may not have any THC at all, or the treatment may not activate it.  THC causes a lot of the symptoms traditionally associated with marijuana use, like munchies everything being funny.  CBD causes nerves to stop hurting for no reason, and may do a bunch of other awesome things like reduce inflammation, encourage bone growth, decrease anxiety, fight cancer, and (I can only assume) whiten your teeth while you sleep.  There is essentially no way to kill yourself with it** and there’s no physical dependency.  I used this off and on after all three surgeries, and my use naturally trailed off after each one.  It either doesn’t have any effect on me mentally, or the effect was less than the pain it was stopping.

THC may work synergisticly with CBD.  In my case it makes me sleepy, which is a terrible trait for a recreational drug but an amazing one for convalescent therapy.

A note for dental use in particular:  you are not even allowed to use a straw, so you definitely cannot smoke anything.  The nice people at the medical dispensaries have precisely dosed pills, and if you are lucky, CBD tinctures.  These are meant to be taken sublingually, but if your pain is in your mouth you can apply them to the area and everything stops hurting really really rapidly.  It gave me an amazing sense of control over my pain and enabled me to take more risks, in terms of eating and talking to people, which really sped up my recovery.

I don’t want to get too much on the “yay marijuana” bandwagon, because it’s entirely possible that as its usage becomes more widespread we’ll find out it has some rare but nasty side effects too.  But I do think it’s a travesty it is treated as worse than ibuprofen or alcohol, when it is clearly better.

*I think his infection was also resistant to the first antibiotics they gave him.

**Weirdly, this may be true for humans but not pets.  When I investigated using CBD to treat pain from my cat’s corneal ulcer, I discovered that we are pretty sure there is no amount so high it can kill your pet in one sitting, but chronic use may lead to something resembling serotonin syndrome (aka the reason you have to be so careful when taking MAOI inhibitors).

Pain, part 1: Pain is bad.

This seems obvious, and yet we as a society seem to have chosen to ignore it.  The problem is not just that pain is painful, although that is a terrible start.  It’s how pain effects you.

Humans on the whole are remarkably adaptive.   Parapelegics can emotionally bounce back from spinal cord injuries in two months.  One of the very few things human beings never, ever adapt to, meaning they produce a permanent lessening of happiness, is pain.  Pain (and long commutes) will continue to depress your happiness forever.  If you lose a limb, phantom limb syndrome is actually a vastly bigger threat to your happiness than the physical disability.

Pain also effects what you are capable of doing.   In the months leading up to dental surgery, I felt like Harrison Bergeron; I had to race to finish my thoughts before shocks of pain broke up the chain entirely, and I couldn’t have a thought that took longer than the space between shocks.  I couldn’t really enjoy books anymore.  I clung desperately to the feeling of accomplishment I got from “finishing a seven season TV series”, because I really couldn’t do anything else. * This is depressing in general, and endangered my ability to keep the job that gave me the money to fix the problem.

Then there’s what fear of pain does to you.  Imagine if every time you socialized, there was a 10% chance you received massive convulsing shocks that took days or weeks to recover from.  That would probably depress your socializing a lot more than 10%.  Now imagine that applied to everything you ever do.  And that fear made the effect worse.  It would take series efforts of will to even hold a job, much less a full and satisfying life.  And while any given bout of socializing could be dismissed as a luxury, human beings inevitably get depressed when deprived of social contact entirely.

Pain makes it harder to treat the root cause of problems.  Exercise helps back pain, but back pain makes it hard to exercise.  I couldn’t get my cat to accept eye drops for his extremely painful corneal ulcer until I started giving him pain medication.  It only took two days for the eye drops to help enough that he no longer needed pain medication, but without those two days he might very well have lost the eye.

So I’m going to proceed from here in the understanding that pain is not only very bad, but often a bigger threat to people’s total well being than physical limitations or even fear of death.

*In fact, you can track my discovery of useful pain relief and when the root problem was fixed via my blogs and my goodreads queue.  I cannot tell you what a relief it is to be able to enjoy reading again.

Depression, symptoms and definition

Slate Star Codex consistently makes me feel bad about the quality of my most sciencey entries by blowing them away.  Here he does it with SSRIs.  One of the many, many data points he offers is that there is a very well known and consistent effect that doctors (and other observers) notice their patients acting less depressed (as measured by sleep patterns, appetite, ability to leave the house, hygiene standards, etc) well before patients report themselves feeling less depressed.

There are a lot of possible explanations for this.  One possible one is that we’ve reversed cause and effect: rather poor sleep, appetite, and executive function being side effects of depression, depression is a consequence of poor sleep, appetite, and executive function.  Moreover, it’s a delayed consequence.  One night of good sleep doesn’t even make up for a week of bad sleep, much less months.  So even if antidepressants instantly removed all the road blocks in someone’s life, it will take a while for those lack of road blocks to translate to feeling better.  Under this model, wondering why you’re still sad a week after starting anti-depressants makes as much sense as wondering why you’re still weak after two sessions of physical therapy. *   If the depression led to some choices with lasting consequences- quitting school, ending a relationship-it might well be impossible to give them back the life they would have had without depression.  That doesn’t mean the drugs aren’t working or aren’t useful, it just means they aren’t magic.

I didn’t intend this, but I think I just re-arrived at my model of depression as a symptom.

*This analogy was originally “starting a diet and being shocked you don’t immediately lose 30 pounds”, but that would reinforce the screamingly incorrect idea that diet has a simple causal effect on weight.

Patterns of pain

When I first regained feeling in my lower right jaw, I could feel everything.  I could feel the vibrations when I talked or drove.  I could feel the change in air pressure when I breathed (even through my nose) or had a fan on me.  I could feel the change in blood pressure driven by my heart beat in the lower right of my jaw.

And by “feel” I mean “felt pain in response to” (the vibration was a separate sensation that accompanied the pain).

The pain ebbs and flows, but I stopped feeling my heartbeat and breath a few days ago .  The fan is still uncomfortable (which is awesome in the middle of a heat wave), there’s a constant ache that is much less susceptible to pain medication, chewing (even on the other side) hurts some, and if I tap my two front right teeth together I want to die.  I nonetheless keep doing it completely on purpose, because I just cannot believe that something so light hurts so much.  If I put something- even hard metal- between them, I can apply much more pressure before it hurts.  I used to have a milder version of the same thing with my right molars and pre-molars, but that has subsided for now.

When I’m not actively experiencing this, it’s kind of fascinating.  I can occasionally feel my heartbeat in my fingers while meditating, but nothing like this.  And how on Earth could teeth detect anything to do with air?  The implication is that my and everyone else’s nerves are always capable of this sensitivity, but choose to ignore it.

I am limited in how much I can research this right now, because nothing breeds neuropathic pain like reading about it.  But my OT found me this continuing dental education article on the teeth as sensory organs.  The gist seems to be that teeth have nerves, and they use this to avoid breaking themselves by biting too hard.  The article doesn’t discuss it, but teeth are temperature sensitive as well, so I assume cold is bad for the teeth as well.  Teeth that have their nerves removed via root canal are more prone to breaking, and the author’s conclusion is that this is because they’re incapable of noticing when they apply too much pressure, the same way lepers injure themselves.

From this, I conclude that my teeth were detecting very minor sensations as dire threats.  This is one reason I think it’s important to keep doing things that hurt (when you know they won’t cause actual injury): the nerve needs to experience a range of experiences so it can learn what genuine danger feels like, so it stops overreacting to minor sensation changes.  This is also why good pain meds are so key to recovery: without them, I couldn’t risk heavier sensations.  I also think they might “train” my nerve to not freak out so much, which would be why at first a tiny dab of topical pain killer brought me hours of relief.

It’s also clear that the nerves on the top and bottom of my jaw are “talking” to each other, or that something in the jaw muscle recognizes “closed” as a state.  That’s the only way it makes sense for two teeth touch to hurt when the same teeth holding a piece of paper or a metal spoon don’t.  Even though the pain feels like it’s only in the lower right front tooth, it’s actually a product of synthesis of several different nerves (or rather, several different branches of the trigeminal nerve).  You have to admit this is pretty cool, even when it’s excruciatingly painful.

Monday morning quarterbacking

The infection in my jaw has been growing for either 1.5 or 6 years, depending on how you count the first surgery to remove it.  I was already practiced at ignoring dental pain because I’d had trigeminal neuralgia on the other side for even longer.  In retrospect it’s obvious the pain had been life altering for at least several months, but I either didn’t consciously notice the effects or didn’t link them to the cause.  Now I’m looking over the last six months or so and analyzing what else might have been a side effect of the pain.  I’ve already talked about my concentration and focus, but today it occurred to me my relationship with alcohol had changed too.

I’ve always been a very, very light drinker, a drink or two every few months, because that was the frequency with which it was fun.  It wasn’t a conscious decision, and the frequency was highly variable- I might drink twice in one month if two drinking occasions came up, and then go six months without when none did.  It’s a matter of social environment, and I don’t have a good definition of what the “right” time is, I just know it when I see it.

So it wasn’t really weird that the last drink I remember having was at New Years.  Except it was. My reason for not drinking at a given event was no longer “eh, this is not the day” but “no, that will take something I can’t spare.”  I couldn’t have told you what it was, but I knew I didn’t have enough.  And this isn’t just me applying 20/20 hindsight, I told someone this exact thing before the new infection was diagnosed.

Looking back now, it seems entirely plausible that alcohol would be competing for the cope that was being used to cushion the pain, or would have weakened one of the systems that was fighting the infection (immune,  liver).  I would expect chronic infection to be a drain on the immune system and alcohol to be a tax on the liver, which means one of them has to be crossing over in order to see this effect.  Eyeballing it, I find the liver the more likely crossover point.  I definitely wasn’t drinking enough to have even a marginal effect on the liver of a healthy person, and while I was not healthy, I also wasn’t drinking hardly anything.  If the liver was the shared resource, that implies the infection (and/or the parasite I may have) was kicking out enough toxins to tax my liver.  That’s pretty concerning, given that the liver is enormous and however impressed the dentist was, the absolute volume of the infected tissue was just not that big.

“But look how much bigger it is” is not an actual medical argument, even if you could fit all of my gum tissue in the liver many times over.  A quick googling reveals that bacterial periodontitis leads the liver to produce more C-reactive protein.  I had “cardiac” CRP, which I believe is the same thing, tested a month after my last surgery (timing is a coincidence) and it was low normal.  I don’t have any numbers for the intervening period.  There are several studies showing an association between liver damage and periodontitis.  Most are mostly small, retrospective, and unable to distinguish cause and effect, but this one used both animal models and treatment to demonstrate that bacterial gingivitis taxed the liver.

There’s no way to prove the liver is what I was keying in on, but it certainly looks plausible.  And in a situation where I’ve had almost no information or control, I’m kind of proud of myself for listening and protecting myself, even when I didn’t know from what.

Pain, Concentration, and Achievement

The timeline is as follows:

  1. [unknown number of months]: oral pain increases steadily
  2. surgery removes source of pain.  Surgery itself or sheer disorientation leave nerve completely numb.
  3. Two blissful days in which I am completely exhausted but mostly pain free.
  4. Nerve function returns, leaving me to experience the pain of having a portion of my jaw scraped off.  Although actually very little of the pain is at the surgery site.  It’s more likely a compressed nerve due to the influx of blood and lymph

I feel like this has given me a natural experiment of the effect of pain on productivity and concentration, since the shifts were so sharp.

I went to sleep pretty much as soon as I got home from the dentist.  When I woke up 16 hours later, I grabbed the book on my bed and read.  Eventually I looked up, it was two hours later and I’d finished half the book.  I couldn’t remember the last time that happened.  I finished a book a day in the pain free period.  Reading had a sense of flow that I didn’t remember it having in years.  And some of those books were not amazing, but they were pleasant and I felt absorbed, which also hadn’t happened in a long time.  The same thing happened with video games- I was able to enjoy some fun low-brain games instead of something socially worthy like Mass Effect or Papers, Please.  I began to entertain the idea that I might one day play an RPG again.

In the last four days I’ve struggled with two books by authors I’ve enjoyed before.  I dropped one and only finished the other because I figured out what I’m about to tell you:it was impossible for me to have a sense of reading flow.  I’ve always been a little fixated on updating my progress on books on goodreads- down to a percent or two if I’m listening to a mediocre book on my bus commute.  Less in other cases, but present.  That disappeared with the pain, and came back with it too.

Productivity wise, I at least felt way more productive while I was exhausted-but-unpained.  I would watch an episode of TV, do one little chore, then take a three hour nap.  My apartment was actually trending upwards, and I was getting very high quality sleep.  In pain, I don’t sleep well, so I don’t have that burst of energy that lets me clean, so I don’t tire myself, so now both pain and jitters are keeping awake, so I’m spending a lot of time in a stupor accomplishing nothing, including healing.  I have more energy in the sense of “I can walk farther without collapsing”, but am ever so slightly losing to entropy.  I’m not physically incapable of putting my dishes away, and I notice that it needs to be done, just not when I have any reserves to do it.

Elodie Under Glass (no relation) has a guest post up on Captain Awkward about the low mood cycle.  It’s brilliant and you should read it on those merits, but the important point for my story is that humans can get in a cycle of not doing anything because they don’t have any motivation, and not having any motivation because they never get anything done.  She calls it the thought->behavior->outcome cycle.  That point where outcome feeds thoughts and make you feel better?  I call it getting a hit of Accomplishment.*  When I’m in this much pain, there is no hit. I have a few possible explanations speculations for this:

  1. Body has narrowed success criteria for all actions to “did you make the pain go away?”  Moving my dirty dishes in the dishwasher did not make the pain go away, therefor it was a failure, therefor no Accomplishment.
  2. Normally there’s a mini flow state between initiating the action and evaluating the outcome.  When in pain, that walk from the couch to the dishwasher is interrupted every half a second asking if I’m done yet, and registering a failure when I haven’t.  With a 10 second walk, that’s 19 failures to one success- and that’s assuming the washer can accept the dish with no further work, and I don’t see any additional failures in the kitchen to deal with.
  3. Some combination of these
  4. Okay I thought I had more but apparently those are the only two.  In my defense, it’s amazing I’m writing this well considering the level of pain I’m in.

Whatever the explanation, pain clearly is constantly pushing me towards the low mood cycle.  I can break out of it with a big enough Thing, but Things that big are impossible to sustain, leading the cycle to collapse back down to low mood.  One of the few things I’ve been able to sustain for long periods is working at crisis chat, because when people talk it’s a jolt of energy, but then there’s some down time before they respond.**

You may blame the lack of proper closing paragraph on my screaming jaw or the fact that this post is completely speculative.  Or feel free to substitute your own reason.  Ideally something flattering.

*I am going to feel very dumb if there’s an actual drug with the street name of Accomplishment.

**After a few hours at crisis center I came home and couldn’t leave the apartment for two days.  I think that’s an energy thing.