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What Is Pain?
— For the first time in 40 years, IASP revises pain's definition

by Judy George, Senior Staff Writer, MedPage Today July 17, 2020


For the first time in 40 years, the International Association for the Study of Pain (IASP) has revised the definition of pain, which the group hopes will lead to new ways of assessing and managing pain.

The revised definition is "an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage," wrote Srinivasa Raja, MD, of Johns Hopkins University and chair of the IASP task force, and co-authors, in PAIN.

This replaces the 1979 definition, which was "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage."

The revised IASP definition also includes six notes and the etymology of the word "pain" for context. The notes expand the definition to include the following:

Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors
Pain and nociception are different phenomena, and pain cannot be inferred solely from activity in sensory neurons
Through life experiences, people learn the concept of pain
A person's report of an experience as pain should be respected
Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being
Verbal description is only one of several behaviors to express pain, and an inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain

IASP set out to redefine pain in broad terms, consistent with the current understanding of multiple factors that potentially contribute to a person's pain experience, Raja said.

"IASP and the task force that wrote the revised definition did so in hope that a better understanding of the nuances and the complexity of pain result in improved assessment and management of persons with pain," he told MedPage Today.

"The notes emphasize the need to assess the adverse effects of pain on an individual's function and social and psychological well-being to help personalize their pain management," he continued.

"If we gain a better understanding of the patient's pain experience through an interdisciplinary approach, we may be able to examine the benefits of a variety of approaches to manage their pain, including non-addictive pharmacological agents, and non-pharmacological treatments such as cognitive behavioral therapy, physical and occupational rehabilitation, and interventional approaches such as nerve blocks and electrical neuromodulation," Raja said.

Pain derives from the Latin word "poena" (punishment), which stems from the Greek "poine" (payment, penalty, or recompense), Raja and colleagues noted.

"We included the etymology of the word pain because it frames our entire reference point; this English word stems from a Greek root meaning penalty or punishment," IASP task force member Daniel Carr, MD, of Tufts University in Boston, said in a statement. "Other words in daily use by the ancient Greeks emphasized pain's location or the distress it may cause. We would do well to return to thinking about pain as having multiple dimensions, so that we can assess and treat it more holistically."

The process of redefining pain was a major effort that included multiple stakeholder opinions and a public commentary period, noted Beth Darnall, PhD, of Stanford University, who was not part of the IASP task force.

"These efforts, when done correctly, thoughtfully, and engaging international stakeholder feedback, require a considerable amount of time and resources to appreciate the range of perspectives. The challenge is to be highly inclusive, not just of stakeholder perspectives, but also inclusive of results for pain science," Darnall told MedPage Today.

"The revised definition gives more room and respect for self-report by emphasizing that tissue damage is not required," she observed. "In other words, language about tissue damage is de-emphasized, and this aligns with scientific data for some conditions."

While the revision was undertaken "during a time of considerable focus on and concerns about the use of prescription opioid medications for chronic pain, the task force was initiated independently of those issues," wrote Lars Arendt-Nielsen, PhD, DMed, of Aalborg University in Denmark and IASP president, and Judith Turner, PhD, of the University of Washington in Seattle and past IASP president, in an accompanying commentary.

"Upon quick glance, the changes in the definition of pain and accompanying notes might seem minor, but they are important," they added. For example, "we know now that some types of pain, while not associated with tissue injury, are associated with nervous system dysfunction," they continued.

"In such cases, all too often, healthcare providers still communicate a message to patients with pain that 'there is nothing wrong' when imaging and other test results are normal," Arendt-Nielsen and Turner pointed out.

"All too often, such patients feel dismissed by their healthcare providers and perceive them as viewing their pain as all due to stress or psychological problems, leading to frustration, anger, anxiety, and an endless search for new providers, tests, and treatments," they added.

"As one of the revised notes states, 'A person's report of an experience as pain should be respected.' This understanding has important implications for optimal treatment," they wrote.

The new definition of pain has potential benefits for both research and patient care, Raja and co-authors said. Already, work by the IASP to update pain disease classification has been included in ICD-11. "A revised definition of pain is very timely and aligns with this and other current efforts to advance ontological frameworks in which pain resides," they noted.

https://www.medpagetoday.com/neurology/painmanagement/87628?xid=nl_mpt_DHE_2020-07-18&eun=g350924d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=Daily%20Headlines%20Top%20Cat%20HeC%20%202020-07-18&utm_term=NL_Daily_DHE_dual-gmail-definition