temperature, respiratory rate, blood pressure, and pulse rate, emphasizing the importance of pain assessment. This recognition further established pain assessment as an important step in pain management. Inadequate pain assessment and management adversely affect patient outcomes, including prolonging the length of hospital stay and delaying patient recovery (Liyew et al., 2020). Medical professionals are directly and indirectly laden with the responsibility of appropriately assessing and managing
patients’ perceptions of pain in different medical conditions. However, these responsibilities are not without a few bottlenecks and barriers. Some of the factors identified as barriers to effective pain assessment and management in modern medicine include personnel who lack of knowledge and skills, poor teamwork, high workload, lack of medical team–patient communication, and inadequate time. Further progresses toward the acknowledgment of the specific nature of persistent pain was made in the 1980s, although this recognition was still based only on the difference in terms of behavioral manifestations between this condition and acute pain in patients and animal test models. In two different studies published in 1980, Pilowski and Sternbach submitted that: “Chronic pain, that is, the pain persisting after the healing of the injury, is different from acute pain because of its pathologic psychobehavioral manifestations.” Another researcher, Doley’s, submission on chronic pain also received wide publicity at this time. Doley described chronic pains as “a set of behaviors or responses to some type of insult or injury that exceeded expectations and extended beyond the normal healing time.” Chronic pain, in Doley’s submission, was that which was “left over after the ‘real’ disease had resolved” (Raffaelli et al., 2021). In the 1990s, a crucial step forward in the definition of pain as a disease was attained. During this period, chronic pain was described as an autonomous entity, not only in opposition to acute pain. In the 1990 edition of The Management of Pain , Bonica devotes an entire chapter to chronic pain and defines it as the pain “which persists a month beyond the usual course of an acute disease or reasonable time for an injury to heal, or pain that recurs at intervals for months or years.” The acknowledgment of the specificity of chronic pain supported an earlier submission published in the 1986 edition of the classification of chronic pain syndromes by the IASP Subcommittee on Taxonomy. The new concept of pain as an autonomous entity gained huge acceptance and developed into a central subject of widespread international debate (Pan et al., 2022). At the Second Congress of the Italian Society of Pain Clinicians held in 1992, Raffaeli proposed an idea that there could not be a system so complex as the endogenous pain system, consisting of several receptors involved, at the neurophysiological level, in the integrative pain modulation without a pathologic counterpart. Raffaelli’s view failed to explain the underlying mechanism of the pathologic counterpart. However, this view recognized pain as an autonomous pathology, that is, a “chronic pain status” characterized by the sole and imperative presence of the pain requiring a therapeutic response (Koesling & Bozzarro, 2022). In 1995, Raffaeli reinforced this view by organizing the ISAL (Istituto di Scienze Algologiche) School—a symposium entitled “Pain as a disease.” The change in the view of chronic pain that occurred in the 1990s was so dramatic that in 1999, Michael Cousins stated that: “chronic pain will be regarded as the disease of the 21st century.” In a 2004 work, Siddall and Cousins further strengthened this view by claiming that chronic pain is a disease with its pathology, symptoms, and signs, based on the pathophysiological changes brought about by pain itself (Butera et al., 2021). In the 21st century, the identification of pain as a disease in its own right is supported by further
Evolution of pain descriptions in modern medicine: A disease or an autonomous entity? In the history of medicine, the attempt to understand pain represents one of the oldest challenges. Pain has a valuable role in medical action as the symptom par excellence and, therefore, as a precious and meaningful tool. An important step forward in the scientific characterization of pain has been taken with Sherrington’s definition of the phenomenon as “the psychical adjunct of an imperative, protective reflex”
and the description of its neurophysiological aspects.1 Nevertheless, it is only with the discovery of abnormal pains that the phenomenon and its role start to be directly addressed in medicine, and that is when the traditional interpretation of pain as a symptom of disease starts to weaken. Drawing medical inspiration from his research on this subject, John J Bonica, the founding father of Pain Medicine, 1953, wrote: “Pain, in its late phases, when it becomes intractable, it no longer serves a useful purpose and then becomes, through its mental and physical effects, a destructive force.” In John’s view, the peculiar nature of pain is revealed in its complexity, particularly because of the double value of the phenomenon, that is, pain is biologically a protective tool, but it can also lose its adaptive function and become a pathologic condition severely impacting the quality of life. An attempt to formulate a generally accepted understanding of this concept partially contributed to the establishment of the International Association for the Study of Pain (IASP) (Petrucci et al., 2022). In this regard, the first proposals of the association there were, indeed, centered on the definition of pain and the classification of chronic pain syndromes. These first efforts have contributed to stimulating a worldwide debate on pain terms and classification, which continues today. These first proposals, however, were not without a few controversies. Although there seems to be a general agreement nowadays on the definition of pain, the recognition of pain as a disease remains debated. Based on their duration, different types of pain are currently classified as chronic pain, whose commonly accepted definition is “that pain which persists past the normal time of healing.” However, although this definition has historically been helpful to distinguish between pain as a symptom of an underlying disease and more complex long-lasting pain states, this definition does not identify this condition as a distinct disease state. The roots of the conception of pain as a disease have to be retraced in the work of the pioneers of pain medicine, the medical branch established in the USA in the 1960s to create a specific discipline for the study and management of pain. The leader of this movement, John J. Bonica, distinguishes between normal and abnormal pain based on time and physiology: Pain becomes pathologic when, if persisting, it loses its biological damage signaling function and, with its devastating psychophysiological consequences, becomes a destructive force hard to manage with traditional therapeutic means. Thus, in his perspective, this so-called intractable pain has to be considered a pathologic entity requiring a specific therapeutic approach.
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