Pain - Its Complexity, and a Lesson in Humility

I did not write this article; it came from a blast email (fun-fact-feed.com), but it reminds me that, as a clinician, I should not judge.  When I see patients who are in severe pain, it is not up to me to judge how severe the pain is.  Many factors go into the sensation of pain; this is just one. But I cannot know all the factors, so I must remember to look at my patients with compassion rather than derision, knowing that I cannot fathom the complexities of the human body to pass judgment on others.

Why Some People Feel Pain Completely Differently Than Others

 Pain tolerance is one of those things people tend to treat as a personality trait — something you either have or you don't, a measure of toughness or willpower. Research tells a different story. How much  pain you feel in response to a given stimulus is significantly determined by your  genetics, varies measurably from person to person, and has nothing to do with how tough you are. Two people can have the exact same injury and experience two completely different levels of pain — and neither one is exaggerating.

Pain Management

One of the most studied genes in pain research is COMT — short for catechol-O-methyltransferase. The COMT gene regulates the breakdown of dopamine and other neurotransmitters in the brain, and a specific variant of it directly affects how intensely pain signals are processed. People who carry one version of the variant break down these neurotransmitters more slowly, leaving higher levels circulating in the brain — which amplifies pain perception. People with a different version process them faster, resulting in lower pain sensitivity. The difference between these two groups, measured in controlled experiments, is significant and consistent.

COMT isn't the only gene involved. Researchers have identified variants in the OPRM1 gene — which encodes the brain's main receptor for opioids — that affect both how intensely people feel pain and how well they respond to pain medication. People with certain OPRM1 variants need significantly higher doses of morphine to achieve the same pain relief as people without them. In a 2008 study of cancer patients receiving morphine for pain management, OPRM1 variants reliably predicted how much medication a patient would require — a finding that has direct implications for how doctors should be dosing painkillers.

The redhead connection is one of the most striking examples of genetic pain sensitivity in action. People with red hair carry variants in the MC1R gene — the gene responsible for their hair and skin pigmentation — that also affect how their nervous system processes pain. Multiple studies have found that redheads require significantly more anesthesia during surgery than non-redheads — on average, about 20% more — and are more sensitive to certain types of pain, particularly thermal pain. Anesthesiologists have known about this for years, and it's now a standard consideration in surgical planning for redheaded patients.

Beyond specific gene variants, pain perception is also influenced by the overall density of nerve fibers in a given person's skin. Some people simply have more pain-sensing nerve endings per square centimeter than others — a difference that's measurable under a microscope and that has nothing to do with psychology or attitude. Areas of the body with higher nerve density, like the fingertips and face, are universally more sensitive than areas like the back — but the baseline density varies person to person in ways that compound everything else.

Genetics

The practical consequences of ignoring this extend well beyond surgery. Pain that goes undertreated because a doctor assumes a patient is being dramatic is a documented medical problem — one that disproportionately affects women, who studies consistently show are more likely to have their pain dismissed or undertreated compared to men reporting equivalent symptoms. The genetic basis of pain sensitivity adds an important layer to that conversation: not only is undertreated pain a bias problem, it may also reflect a failure to account for real, measurable biological differences.

The field of pain genetics is still relatively young, but it's already beginning to reshape clinical practice. Some hospitals are now using genetic screening to help predict how patients will respond to pain medication before surgery, allowing anesthesiologists to adjust doses preemptively rather than reactively. The idea that pain is purely subjective — that it exists only in the mind and can be willed away — is becoming increasingly difficult to defend. Your pain tolerance was partly decided before you were born.