Pain Behaviors

All persons in pain usually display what doctors call "pain behaviors."  In short, a behavior is something that is observed or can be measured.  It is not feelings, emotions, or how pain feels to a person.   Pain behaviors are ways the person reacts to pain, and is the outward and interpersonal expression of a person's subjective experience of pain and, and to a degree, the outward sign of the physical effects of pain.   

Some behaviors are controlled by the body, like blood pressure and pulse rate, and to a lesser extent how one breathes.  (Although pain can sometimes change breathing, it is also possible for a person to consciously create a change in their breathing).  To a degree, blood pressure and pulse might be altered by conscious means also.  

Others are not exclusively body reactions, like sighing, crying, and other behaviors that a person can control, like verbal remarks, pacing, jiggling one's foot, or choice of body position.  

Doctors and personnel in the pain management field look at pain behaviors a person can control, since these behaviors can be modified completely or in part.  Here are some examples of pain behaviors.  See if you can identify ones that a person can control or modify.

Observable Pain Behaviors

In addition there are behaviors which are attempts to alleviate pain (warm baths, heating pad, pain medicine,) or relieve the source of pain (some of the physical items in the above chart, such as changing position).  

As you can see from this table, there is a wide range of how pain may be expressed.   In evaluating your pain and pain behaviors, doctors may assess many areas, such as:

endurance
strength
flexibility
pain expression (gestures and vocalization)
muscle tension
sitting tolerance
assertiveness
comprehension of chronic pain treatment
anxiety and depression
interpersonal interactions
family relationships and interactions
secondary gains (in short: What's in it for you, like: attention of others, getting others to "do" for you, having others feel sorry for you, not having to be as responsible for day-to-day life as you once were or could still be; financial gains even if an injury is real; victim-behavior and comments, etc.)

As I said in the discussion of Treatment of Chronic Pain, certainly society as a whole can have the same compassion towards people in pain as what we do for animals in pain.  Far too often, patients complain: "They wouldn't let a dog suffer in pain the way I am suffering!"   In fact, veterinarians are extremely concerned with relieving pain and conduct their own studies (especially since the late 1980s-1990s) of pain behaviors  in animals.  Not surprisingly, pain behaviors are much the same in animals as in humans, including the historical adaptations both species have made in trying to adapt to pain and hide disability, and the current "social" setting in which vocalizations or certain behaviors of pain by human or animals serve to draw the attention of humans who may be able to help.  See: http://dels.nas.edu/ilar_n/ilarjournal/44_3/v4403hansen.shtml  This article describes the "Melbourne Pain Scale (MPS¹) (Firth and Haldane 1999). This instrument consists of six broad categories (physiological data, response to palpation, activity, mental status, posture, and vocalization), each of which is divided into three or more levels and assigned a different numerical weight. For example, the category "mental status" contains four levels: submissive, overtly friendly, wary, and aggressive; and these levels are accorded scores of 0, 1, 2, and 3, respectively. In total, the maximum number of possible points for pain awarded by the scale is 27."  " Even if one attempted to force the administration of analgesia to similar dogs by application of the MPS (or other similar scales), some of those dogs would be assigned a low pain score because the scale would not capture the right information. For example, 2 days after limb amputation and without the use of postoperative analgesic therapy, a dog may lie quietly, be unwilling to move, fail to eat, and appear very depressed. If one were to apply the MPS to rate this dog's pain, observed responses would yield the results of a total MPS score of only 4 point of a possible 27 (Figure 1)."  Other pain behaviors and measurements to assess these behaviors in dogs are discussed.  The difficulties of knowing the pain level in animals, who cannot communicate directly, is obvious.  The article also discusses how animals hide pain, since the weakest in the animal world becomes an easy target of predators.

BIASES AND BELIEFS ABOUT PAIN CONTROL

Doctors observe how you move and handle your body in routine settings, from the first time they see you as you enter their office, through exams the doctor conducts, through the time you leave the office.   Judgments are often made by doctor's and medical personnel based on the observed pain behaviors.  

Professional articles state that pain behaviors are also influenced by cultural and ethnic differences as well as upbringing.  For examples, Mexican males may be stoic while Mexican females may be more vocal about pain, yet neither sex expect medical intervention and believe pain is just a part of living.  Chinese remain quiet during pain, neither communicating the amount of pain they feel nor expecting intervention.  African Americans and American Whites are often vocal and expect nurses and doctors to respond, to control or eliminate the pain.   There may be generational differences in how much a person communicates pain as well.

Additionally, medical staff bring their own cultural, ethnic, and upbringing biases to the observations of another person's pain, and in their response and intervention on behalf of others who exhibit pain.   One nurse's background includes a belief that patients should be stoic and face pain with "a stiff upper lip," while another nurse expects patients to yell out.   Nurses may not even offer medication, even though a person is suffering; most studies show that nurses under-treat pain, even for cancer patients during their last agonizing days.  In other situations, a different patient might refuse medication because of their own beliefs and upbringing.

These cultural, ethical. and upbringing differences are well-known and well-documented for both patient perception and displays of pain, and for how doctors and nurses respond to pain.  But the fact remains that professionals are still governed by their own biases, and these biases impact how they respond to patients who display pain.  And, overall, physicians and nurses under-treat patients' pain, regardless of the patient's ethnicity, race, background, and despite whether a patient requests pain medication.  In the United States, professionals are probably very influenced by the belief that all patients are potentially simply seeking drugs, are current drug addicts, or are exaggerating the pain for some secondary gain(s).  And it seems too difficult to leave these biases outside the hospital or examining room door.

Most Americans are aware of the scams some people use who claim to be in pain, but who are not truly suffering.   (See Treatment).  There has been widespread coverage of persons who make claims of injury and appear for doctor appointments or other evaluations using cane, walker, and wheelchairs, only to be later observed to be able to hoist heavy boxes, reach overhead to shelves, or even taped jogging when they claimed to not be able to walk.  Unfortunately, insurance carriers, worker's compensation, the Social Security Administration, and doctors have been lied to deliberately by many patients.  As well, physicians carry a special and difficult burden of making sure they are not prescribing controlled substances inappropriately.  "The Controlled Substances Act (CSA) of 1972, which supersedes and replaces the Harrison Act and all intervening federal drug legislation, makes it a federal offence to prescribe controlled substances to a drug addict for the purposes of treating or maintaining their addiction, except where the physician holds a separate DEA license to provide methadone maintenance." (Quoted from the website article which discusses pain treatment at: http://www.doctordeluca.com/Library/UWOD/UWOD5-DenominatorAbuse.htm) Having been duped before, with the burden of potential loss of license/fines/imprisonment, and believing the myth that all persons on pain meds will become "addicted," doctors have been wary to prescribe ANY pain medications, and especially narcotics.  

Repeatedly in research on the internet, I found the following quote: "The World Health Organization describes stress as a “World Wide Epidemic."  This was given with these two "statistics" -

• "72% of Americans experience frequent stress related physical or mental conditions.
  

• 75-90% of visits to Primary Care Physicians are for stress related problems.
  Source: Murphy, American Journal of Health Promotion, 1996."
  

* These statements are in conflict with the 2002 CDC's NCHS-NAMCS-NHAMCS report on "Physician Office Visit Data".

While the statistics credited to the World Health Organization may indeed be valid, the same WHO writings are used by some groups, agencies, and individual authors as further "evidence" that complaints of pain are invalid and should not be treated.  It is the same story as using depression stats and estimates as an argument against using opioid therapies to treat benign chronic pain.   Instead, BOTH and ALL may be true in and of themselves: a person may have external stressor and may have have very legitimate pain; a person may have legitimate external stressors and be depressed; a person may have very legitimate pain and concurrently be depressed.  

And, again, the arguments of depression and stress can be argued from two points of view: Is the person depressed, thus causing psycho-somatic pain? OR did the depression arise FROM the experience of ongoing, untreated, or under-treated pain?  Is the person stressed, thus causing psycho-somatic pain?  OR have a number of stressors come or has existing stress increased because or from ongoing pain? 

When a person is in ongoing and untreated pain, various sources of stress and depression naturally follow.  It is almost impossible to rate these stressors in order of importance because each person might rate them differently.  Financial stress might be ranked the highest among most people when untreated pain results in loss of income because a person cannot hold gainful employment.  Interpersonal stress might be next highest, when pain interferes with marriage and family relationships, not to mention loss of friends.  Quality of life is often ranked as third highest after the first two, because pain interferes with many everyday normal activities like sex, sleep, household chores, errands, and hobbies.  When sleeplessness and depression increase and other stresses mount, quality of life may become so bad that persons with untreated pain may contemplate or attempt suicide, or ask for assisted-suicide.  Dr. Kathleen M. Foley, chief of the pain service at Memorial Sloan-Kettering Cancer Center stated to the The New York Times Magazine, "those asking for assisted suicide almost always change their mind once we have their pain under control." (Who Will Stop the Pain by Jacob Sullum, senior editor of REASON.  This article was reprinted on the cited web site, with permission, from the January 1997 issue of REASON Magazine. Copyright 1997 by the Reason Foundation, 3415 S. Sepulveda Blvd, Suite 400, Los Angeles, CA 90034.)  

Mr. Sullum writes of the "Torture, despair, agony, and death are the symptoms of "opiophobia," a well-documented medical syndrome fed by fear, superstition, and the war on drugs. Doctors suffer the syndrome. Patients suffer the consequences."  Mr. Sullom describes "opiophobia" as the phobia of doctors who are reluctant to prescribe opioids to control pain.  The phobia can be so severe that doctors do not even obtain the necessary paperwork for DEA license and for prescription pads that they are required to have in order to prescribe opioids.  Thus, if they don't possess these needed items, they cannot write the prescriptions - easy!  One minus one equals zero - for the patients.  Instead, doctors prescribe antidepressants and muscle relaxers, and refer patients to "pain management clinics" based on supposed "pain behaviors observed" in the patient. 

ADVERSARIAL OR HELPFUL?

The focus on pain behaviors can feel very adversarial to a patient.  In fact, the way a patient is spoken to about suspected pain behaviors can seem pretty attacking - and oftentimes, doctors are deliberately attacking.  Unfortunately, sometimes this is also driven by the same myths already discussed, and the belief that all patients are somatizing other problems of their life into "pain".  

Doctors may want you to focus on any pain behaviors you can change.  For example, do you hold your emotions in and end up with tense, tight muscles?  Muscle tension can increase the level and perception of pain.  If you can release muscle tension, you may reduce some of your pain.  You may be asked to try hypnosis, guided imagery, biofeedback or therapy through attending a pain management program.

But, almost all physicians tend to use "pain management programs" as their own back door to not give treatment to their own patient.  "I will not prescribe pain medication for you, but I will refer you to (the back door) the pain management center."

If you would like to read more about why doctors are afraid to prescribe opioid narcotics, see these web articles:

Who'll Stop The Pain?

Treating Doctors as Drug Dealers: The DEA's War on Prescription Painkillers

Ideas on Liberty

Dr. Hurwitz Convicted on 50 Counts, Faces Life in Prison 

"A Bad Prescription from DEA; The drug agency's misguided campaign against a painkiller" 
by Eric M. Chevlen, published in The Weekly Standard,  June 4, 2001.  Full article online at http://www.cpmission.com/main/misguided.html 

Dr. Chevlen also testified on April 25, 2000 as an expert witness before the Senate Judiciary Committee Concerning "The Pain Relief Promotion Act"  --- see http://commdocs.house.gov/committees/judiciary/hju62489.000/hju62489_0.htm

See also: Assessing Pain in Older Adults (with Dementia)