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.

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.