Revised definition of pain by ‘International Association for the Study of Pain’: Concepts, challenges and compromises

Nasser Ali Malik
Pain Management Physician, Attock, Pakistan.

Correspondence: Dr Nasser Ali Malik, Attock, (Pakistan); E-mail: doc.malik14@gmail.com; Phone: +923340000203

Abstract

A new definition of pain has been formalized and adopted by International Association for the Study of Pain (IASP) in January 2020, which states that pain is “An unpleasant sensory and emotional experience associated with or resembling that associated with actual or potential tissue damage”. It has been a result of a number of feedbacks from the pain physicians from around the world about their dissatisfaction about the previous definition.
In this editorial the author endeavors to give his perspective on the concept of this definition, along with compromises made while incorporating this definition and challenges for future in the revising and updating it. But we must also acknowledge that this definition is a step in the right direction for considering pain as a disease, a standalone health condition, and not only a symptom.
Key words: Pain, concepts; Challenges; Pain, definition; IASP; Terminology
Citation: Malik NA Revised definition of pain by ‘International Association for the Study of Pain’: Concepts, challenges and compromises. Anaesth. pain intensive care 2020;24(5):481-483
Received: 20 June 2020, Reviewed: 24, 28 June 2020, Accepted: 1 July 2020

DOI: https://doi.org/10.35975/apic.v24i5.1352.

“Life is a painful experience, those who learn to overcome this pain become invincible”

To overcome pain, one needs to develop an understanding of pain along with its dimensions, and to understand pain we need to study pain and its clinical aspects. This is where the definition of pain steps in;

Box 11,2: “An unpleasant sensory and emotional experience associated with or resembling that associated with actual or potential tissue damage” 1,2
Note1,2
• Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.

• Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.

• Through their life experiences, individuals 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 functional and social and psychological well-being.

• Verbal description is only one of several behaviours to express pain; inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain.

Etymology1,2
Middle English, from Anglo-French peine (pain, suffering), from Latin poena (penalty, punishment), in turn from Greek poine (payment, penalty, recompense). *The Declaration of Montreal, a document developed during the First International Pain Summit on September 3, 2010, states that “Access to pain management is a fundamental human right.”
In Box 1 we elucidated new definition of pain given by International Association for the Study of Pain (IASP) in 2020, came with an improved note and added etymology of the word pain.1,2 But before reviewing this definition to understand better the concept behind this revision, we must consider the background about the need of this new definition of pain. Pain is a mystic sensation, it is philosophical, it is something that cannot be measured physically, but it can only be experienced by the patient suffering and regarded by the clinician treating him according to how he interprets and understands what the patient has expressed. Pain is fearsome for the patient himself and as well as his family, the agony of the pain plays a disturbing part in the life of the person and this increases the mental and psychological distress. The burden of pain is widespread and a good detailed assessment of the pain is necessary for the proper management because sometimes the intensity of pain expressed by the patient is more linked to the psychological factor and is associated with what the patient believes in comparison to what he actually experiences or what the injury can cause, even than the report of the patient should always be regarded. Keeping these facts in mind, pain can be called a multidimensional entity and should be addressed in an appropriate manner by focusing on its individual factors as well as a whole in its entirety.
The first definition of pain was formulated about 40 years back. Pain researchers and scientists then and now only used these mechanistic terms to acknowledge or assume the experience of pain and did not describe the actual feeling or make a definite diagnosis. These terms are meant to be upgraded and reviewed with the advancement of the knowledge of pain and its mechanisms involved. In 1978, under the presidency of John J. Bonica, IASP council prepared a taskforce that approved the first official definition of pain.3 The sub-committee report stressed that the definition can be revised in the light of new knowledge acquired and that the recommendations were intended to “serve as an operational framework, not as a constraint on future development”.3,4 Bonica in his accompanying editorial also stressed that “development and widespread adoption of universally accepted definitions of terms” was one of the primary objectives and responsibilities of the organization.3
Researchers, scientists, philosophers and other pain scholars over the years since then have made exceptional progress towards understanding and recognizing pain as a multidimensional entity, they have tried to explain nuanced elements of pain which sometime are not easy to apprehend when pain is measured in the standard qualitative metric. In 2018, Judith Turner, president of IASP constituted a Presidential Task Force comprising  a panel of 14  multinational members who possessed experience and a vast knowledge of pain and its clinical and basic science to “evaluate IASP’s current definition of pain and the accompanying note” and to recommend whether they “should be retained or changed based on current evidence-based knowledge” and to formulate a better definition of pain.1,5 The task force deliberated for a period of  two years, took the input from bioethicists, philosophers, a linguistic expert and also consulted ethicists. The task force also considered comments from a broader community that included the IASP members and the public. And after long deliberations and taking in view the suggestions and comments of the clinicians, researchers and patients alike in January 2020 a final definition of pain was published. 1,5
In the author’s view this definition is partial, yet being compact and simple at the same time, it attempts to cover almost all the subjects of pain. This definition attempted to explain the pain caused due to external stimuli with a potential damage and also to cover the pain that results from actual damage to the tissue or nerves. It also tried to encompass not only the sensory but also the psychological and emotional association of pain. The added ‘Note’ of this definition attempts to cover the flaws of this definition, it describes that pain cannot just be due to the disturbance of injury to the nerves but it can be psychological. Description of pain is different for every individual because it is solely based on what a person observes, feels and learns during his or her own individual life span. The pain can severely affect the life of the person suffering from it as it brings limitations to their daily life activities and brings a disturbance in their communal commitments and such clampdown of life leads to deterioration of the psychological health. The ‘Note’ also states that we should regard the account of pain given by the patient and also mention that oral expression of pain is not the only media to explain pain, inability to convey the experience of pain orally does not mean that the person is not experiencing pain.
We can regard this new and improved definition of pain as progress towards the right path of developing an apprehension of pain for the patients. This definition is also very impactful in terms of timing of release because it came in concurrence of adaption of International Classification of Disease-11 (ICD-11) by World Health Organization (WHO). ICD-11 is important because in its classification index we can find Chronic Pain as a listed ‘disease’. ICD-11 hopefully now will be recognized and embraced globally because of its adaption by WHO, these two events have lead us to acknowledge pain as a standalone health condition. Despite all the goods and benefits associated with these developments, this definition cannot be considered a complete or perfect one and as encompassing all the elements of pain. The author’s views about it being partial and incomplete are concurrent with many pain fellows around the globe.
Even if not many, we can pinpoint few compromises made during the development of this definition. If these elements were part of this revised edition it would have further enhanced the progression of research and a better patient care. Elements that can help in expansion of this definition if amalgamated include an array of social and cognitive perspective along with acknowledging that pain has functional adaptive value and that pain cannot solely be represented by verbal communication. The “Note’ of this definition does contain that verbal communication is not the only communication but lacks in explaining the methods of non-verbal expression and thus it neglects the issue of vulnerable population of newborns, infants, elderly and all those who cannot express their pain orally.
The challenges that lie ahead include replacing the term “unpleasant" because this sometime does not justify the experience of the patients especially those suffering from agonizing severe pain, either acute or chronic in nature. It also “fails to capture the full range of suffering".6 In the future the definition of pain needs to adopt the concept of ‘nocioplasticity’. The concept of nocioplasticity is “pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing activation of peripheral nociceptor or evidence of disease or lesion of somatosensory system causing pain".7,8 The new definition should also move more towards the psychological aspects of pain because every person has a different psychology; and the psychological concepts may be misleading when a person is suffering from either acute or chronic pain. His mind is equally involved in that, his body might be aching but his brain is also getting frustrated. So, treating physician should not only manage the pain but also cover the psychological impact due to pain, the depression caused by it, because we are treating a human being, and mind and body act alike.9 However, the fact that many patients react overtly to an ordinary stimulus and their expression of such pain is also exaggerated one, cannot be neglected. Thus the interpretation of pain is not accurate in such cases as well.
Finally, it can be concluded that it is time of reconsidering pain itself as disease with a due clinical timeline of progression and thus pain should be defined in a similar manner. This definition of pain along with its ‘Note' and ‘Etymology' is lacking in covering many dimensions of pain, yet its compactness and the revised ‘note’ covers many aspects of pain, and it is a step in the right direction.

Conflict of interest:

Nil declared by the author.

References
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