Statement of the International Association for the Study of Pain (IASP)
The International Association for the Study of Pain (IASP) was established in 1974 in response to the
recognition that pain should be better managed. IASP brings together scientists, clinicians, health-care
providers, and policymakers with the common mission to improve pain relief throughout the world.
IASP supports the view that every nation should have policies on the management of pain that describe
the burden of pain, its impact, and what should be done in terms of policy interventions to reduce these
problems.
Commendations
IASP commends the draft U.S. National Strategy for Pain (USNSP) for its comprehensiveness and
accordance with IASP’s recommendations regarding national pain strategies (“Desirable Characteristics
of National Pain Strategies,” http://www.iasp-pain.org/DCNPS?navItemNumber=655), in which IASP
highlighted common professional, public, and system barriers to implementation of better pain care.
In addition, IASP commends the strategy for its whole-population approach, including attention to
vulnerable populations and health disparities. The USNSP also incorporates the main public health
principles of prevention and control and identifies key population subgroups at higher risk of pain
burden. Similarly, recognizing the importance of triggering events in the evolution of chronic pain
conditions is noteworthy.
The USNSP’s vision is ambitious: reduced prevalence of pain. As it is unclear whether this will be
achievable, IASP suggests that a significant reduction in distress and disability related to pain is a worthy
and achievable vision.
Recommendations
Research
IASP recommends explicit inclusion of a statement that, as included in the IASP Desirable Characteristics
of National Pain Strategies, “direct and dedicated funding for pain be committed.” Also, IASP
recommends that needs for research be detailed and specific and include effectiveness, comparative
effectiveness and basic science research.
Life-Course Pain
The USNPS would be strengthened by a whole-of-life or life-course approach [1] that addresses
important public health goals specific to particular life stages, as follows:
1. There is a need to address the well-established finding that a high burden of chronic pain exists by
mid-to-late adolescence in the United States. [2] Interventions specifically tailored to younger
populations would potentially result in large gains in years of life lived without pain-related disability.
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2. As is the case of other high-income countries, the United States faces an aging workforce and an aging
population. It needs to encourage older workers to stay in the workforce and accumulate retirement
savings to a greater extent than has been required in the past. There is existing evidence that chronic
pain conditions such as back pain limit workforce participation and retirement savings [3], and explicit
strategies to address this are required.
3. In older populations, multi-morbidity involving chronic pain conditions in combination with other
chronic conditions is usual. Therefore, interventions to reduce the burden of chronic pain disability in
older people must explicitly address this phenomenon. [4]
Chronic Pain as a Target for General Health Interventions
Risk exposures increase vulnerability to onset of chronic pain in the absence of triggering events and are
shared across other commonly occurring chronic conditions (for example, overweight/obesity and low
levels of physical activity). [5] There are existing population interventions to address these common risk
exposures, but it is rare for chronic pain conditions to be included as a target for general health
interventions. Chronic pain conditions need to be considered alongside cardiovascular disease, diabetes,
and other common, chronic non-communicable conditions with serious sequelae.
Acute Pain
The focus on chronic pain in the USNSP is understandable given its prevalence, but it appears to be at
the exclusion of acute pain, including pain after major and minor trauma (e.g., back sprain). Post-surgical
and post-injury chronic pain are recognized and relatively common events that should be addressed in
any strategy aimed at reducing the burden of chronic pain. [6] Evidence demonstrates that
unrecognized and improperly treated acute pain has a significant impact on the health-related quality of
life of many patients. Such pain also has the potential to evolve into chronic pain, while causing
significant morbidity, with associated direct and indirect costs.
Categorization of Pain States for the Purpose of Provision of Services and Research
IASP has historically been a world leader in developing taxonomies and standardized research
methodologies that can be applied so that comparability is possible. In terms of chronic pain definitions,
the USNSP uses an alternative definition for chronic pain, as well as a separate category of high-impact
chronic pain. The former will cause the usual problem of incomparability with previous studies on the
prevalence of chronic pain; the latter should be quantified, taking into consideration the disability
caused by chronic pain, as measured by standardized instruments that can be applied across population
studies.
The USNPS identifies the importance of measurement and surveillance of chronic pain at the population
level. The development of a suite of brief measures to identify low back pain in population surveys was
key to the identification of the global burden of low back pain. [7] This approach resulted in an
expandable and articulated set of measures that could be deployed depending on the “question space”
available in general population surveys. A similar approach to other commonly occurring regional pain
sites (neck, shoulder, knee, hip) would be advisable and achievable and allow the relative burden of
these common regional pain conditions to be identified for the purposes of health funding priorities.
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As a side note, diagnostic clusters for population pain research proposed in Appendix F are anatomically
defined, except for clusters 10 and 11, which may be confounding factors (clusters should be defined
either anatomically or etiologically). Lack of consistent coding for pain conditions makes it difficult to
acquire accurate epidemiological data related to pain and hinders research. In response to
shortcomings and inconsistencies in international coding (ICD), IASP established a Task Force for the
Classification of Chronic Pain. The task force has developed a new and pragmatic classification of chronic
pain for the upcoming 11th revision of the ICD [9] that offers an internationally agreed-upon framework
for categorizing pain states. [8] IASP recommends that the USNPS consider collaborating with IASP on
developing sharable coding systems.
Health Education
The focus on education for primary care physicians in the strategy is important, but so is the role of
other physician specialists (e.g., orthopedic specialists, neurosurgeons, internists, and rheumatologists),
as well as nurses, physical therapists, psychologists, pharmacists, and others. Many may need additional
training and resources to use a biopsychosocial framework to understand and treat pain, especially
chronic pain. Chronic pain is best treated using multidisciplinary and multispecialty care, but the USNPS
is more physician-focused.
IASP has been actively involved in pain education since its inception. IASP has developed and updated its
curricula, which have proved to be important foundations for the development of educational programs
and materials across the globe. IASP curricula emphasize the multifaceted nature of pain and the
necessity for a biopsychosocial approach. IASP also produces high-standard, non-industry-funded
educational texts, meeting materials, refresher courses, a premier journal (PAIN®), and clinical updates
and newsletters. IASP recommends that the USNPS collaborate with IASP and its members in developing
unbiased, evidence-based educational materials and guidelines.
Implementation Strategies
The USNPS would further benefit from a greater focus on implementation strategies to strengthen the
effective translation of interventions at the population level. There have been significant developments
in implementation methodologies in the last decade that should be identified and evaluated to
maximize gains at a population level in the prevention and control of the burden of chronic pain. [9]
Although the document is a strategy and not a plan, it would be important to specify, or at least address:
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Which body/entity will be responsible for overseeing/monitoring and evaluating the outcomes?
Which body/entity will be responsible for implementing and evaluating the strategies for
achieving each of the objectives, in cooperation with the stakeholders and collaborators
mentioned for each objective?
What funds are necessary to implement the strategies to achieve each of the objectives, and
where might they come from?
How might the gains expected compare with the funding invested? (Modelling can be applied.)
It would be important to demonstrate the economic value of productivity gains, reduced longterm health-care costs and disability, and decreases in morbidity/mortality obtained by better
pain health care.
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What will be the involvement/responsibility of the stakeholders and collaborators listed for each
objective? What will be contingency plans should cooperation among the independent entities
fail?
How might each state or health authority be encouraged to develop local policies that address
specific pain-related concerns in the state or region?
Conclusion
To conclude, this is an excellent and comprehensive strategy that, if implemented, will produce a very
significant improvement in the care for people with chronic pain in the United States, and it has the
potential to influence other nations. In addition, the pain field in general will dramatically benefit, and
our understanding advance, if even 50 percent of the proposed research studies are implemented.
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