Author: Emily Cocker // Editor: Erin Pallott

What is Pain?

Pain is an individual experience, yet something that unites the masses in its non-discriminatory targeting of the young and old alike. Unless you were born with congenital insensitivity to pain (CIP), chances are you know what pain is and how it feels for you. Acute pain (AP), meaning pain that lasts less than 12 weeks regardless of its severity, is typically a biological protective mechanism that alerts us to probable dangers and illicits a proactive response, such as the hand automatically retracting when touching boiling water. AP is crucial to preserving life, which is likely why those with CIP have a lower life expectancy as they cannot identify internal or external dangers immediately. For example, having pain due to appendicitis alerts us that we need medical attention, (hopefully) before becoming septic or fatal, which those with CIP may not be able to identify.

However chronic pain (CP), also known as persistent pain, is less constructive and lasts longer than 12 weeks. It is not always indicative of stimulative wrongdoing. By this I mean, you can have CP with no identifiable cause, or you once had a cause, but it has since resolved (idiopathic). This can frustrate a lot of pain patients, as it can feel like they are being betrayed by their own body and mind. 

Pain Definitions

Many have tried to define pain, despite its unique phenomenon and presentation in different subjects. Some include McCaffery’s (1968) definition of:

“Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does”.

Or the International Association for the Study of Pain’s (IASP) (2020) take, that:

“Pain is an unpleasant sensory and emotional experience, associated with, or resembling that associated with, actual or potential tissue damage.”

It’s no surprise that agreeing on a definition is difficult, as no two people may have the same experience. An example of this is two patients having total knee arthroplasties, with one requiring only simple analgesics (such as paracetamol and ibuprofen) whilst the other required strong opioids regularly like oxycodone. Why is it that the same surgery, in the same area, with the same theatre and postoperative team, had such differentiating pain results?

Pain, Beliefs and Race

Well, as we go through life from birth to death, we develop beliefs, experiences, and opinions on various aspects such as religion, education, and health. We also learn through observation. Our biopsychosocial experiences of the world also impact our biopsychosocial relationship with pain. These then contribute to our perception of pain and the development of our own personal pain behaviours, pain beliefs and how we communicate our pain to others. An example of this is when people of two different races (such as White and Black) have different pain experiences to the same stimuli. It is typically the cultural and environmental beliefs that can cause pain discrepancy, and not necessarily race itself. There are still misconceptions surrounding race, pain, and health in general. A study found that half of the sample of medical students and residents had racially biased beliefs ranging from black people being less sensitive to pain, to black people having literally thicker skin than white people. This led to black people having lower satisfaction of care due to not being believed about their pain score and their pain was under-treated when compared to white patients.

This is worth noting in the medical field, as most professionals would not self-identify as racist, yet inherent or taught racially motivated beliefs are still a barrier to race-health equity and outcomes. Reflection is part of most governing bodies’ Code of Conduct (i.e. GMC, NMC), and I implore you to regularly reflect on your decision-making skills, and what factors may be subconsciously influencing them. Being in denial about racially motivated medical decisions only encourages the systemic issue to persevere, and learners watching you may be taking on some of these discriminatory behaviours as the “norm”.

Is Pain a Disease?

Pain is something that the majority of people will experience at some point in their lives, at multiple points, transiently or continuously. Yet, pain is something that is still not well understood, and still isn’t taken as seriously as many other specialities. CP was even described as early as the 1950s as a “destructive force” by the founding father of pain medicine; John Bonica. Nevertheless, CP wasn’t even considered a disease or “autonomous entity” within its own right until the 1990s. The clear difference between AP and CP is that AP is typically categorised by peripheral centralisation, which in its most basic form means the pain is originating from a signalling site that’s receiving information about a negative stimulant that is present or has recently been present. Whereas CP is essentially the presentation of central sensitisation, which means these pain signals are now in a loop within the central nervous system (the brain and spinal cord) and can continue to signal long after the stimulant has disappeared or in the complete absence of a stimulus. 

Pain and Public Health

Despite CP affecting millions of people in the UK alone, the World Health Organization (WHO) does not yet classify it in any of their agendas as a public health issue. But, in 2015 an IASP Task Force started working on improving chronic pain’s recognition as a disease through the WHO Revision of the International Classification of Diseases (ICD), with an aim to improve chronic pain classification in the disease spectrum. The authors noted that “the lack of adequate coding in the ICD makes the acquisition of accurate epidemiological data related to chronic pain difficult”. This means epidemiological research on CP is hindered, and we need better acknowledgement of pain as a disease pathway from WHO, to improve research quality and reliability.