The current IASP definition of pain as "An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" was recommended by the Subcommittee on Taxonomy and adopted by the IASP Council in 1979. This definition has become accepted widely by health care professionals and researchers in the pain field and adopted by several professional, governmental, and nongovernmental organizations, including the World Health Organization. In recent years, some in the field have reasoned that advances in our understanding of pain warrant a re-evaluation of the definition and have proposed modifications. Therefore, in 2018, the IASP formed a 14-member, multinational Presidential Task Force comprising individuals with broad expertise in clinical and basic science related to pain to evaluate the current definition and accompanying note and recommend whether they should be retained or changed. This review provides a synopsis of the critical concepts, the analysis of comments from the IASP membership and public, and the committee's final recommendations for revisions to the definition and notes, which were discussed over a 2-year period. The task force ultimately recommended that the definition of pain be revised to "An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage," and that the accompanying notes be updated to a bulleted list that included the etymology. The revised definition and notes were unanimously accepted by the IASP Council early this year."Scientific and medical definitions are tools. Even when we recognize them as imperfect or provisional, awaiting replacement by an improved version, they perform work that cannot be accomplished by less precise instruments." David B. Morris [27] * Letter to the task force from M. Aydede titled "On the IASP Presidential Task Force's proposal for a new definition of 'pain'," dated

Background Chronic opioid therapy for chronic non-cancer pain (CNCP) is increasingly common in community practice. Concomitant with this practice change, rates of fatal opioid overdose have increased. It is not known to what extent overdose risks are elevated among patients receiving medically prescribed chronic opioid therapy. Objective To estimate rates of opioid overdose and their association with average prescribed daily opioid dose among patients receiving medically prescribed chronic opioid therapy. Design Cox proportional hazards models were used to estimate overdose risk as a function of average daily opioid dose (morphine equivalents) received at time of overdose. Setting Health maintenance organization. Patients Individuals (n=9940) who received 3+ opioid prescriptions within 90-days for CNCP between 1997 and 2005. Measurements Average daily opioid dose over the previous 90 days from automated pharmacy data. Primary outcomes, non-fatal and fatal overdoses, were identified through diagnostic codes from inpatient and outpatient care and death certificates and confirmed by medical record review. Results Fifty-one opioid-related overdoses were identified, including six deaths. Compared to patients receiving 1-20mg of opioids per day (0.2% annual overdose rate), patients receiving 50-99 mg had a 3.7 fold increase in overdose risk (95% C.I. 1.5, 9.5) and a 0.7% annual overdose rate. Patients receiving 100mg or more per day had an 8.9 fold increase in overdose risk (95% C.I. 4.0, 19.7) and a 1.8% annual overdose rate. Limitations Increased overdose risk among patients on higher dose regimens may be due to confounding by patient differences and by use of opioids in ways not intended by prescribing physicians. The small number of overdoses in the study cohort is also a limitation. Conclusions Patients receiving higher doses of prescribed opioids are at increased risk of opioid overdose, underscoring the need for close supervision of these patients.

Background-Heart failure has an annual mortality rate ranging from 5% to 75%. The purpose of the study was to develop and validate a multivariate risk model to predict 1-, 2-, and 3-year survival in heart failure patients with the use of easily obtainable characteristics relating to clinical status, therapy (pharmacological as well as devices), and laboratory parameters. Methods and Results-The Seattle Heart Failure Model was derived in a cohort of 1125 heart failure patients with the use of a multivariate Cox model. For medications and devices not available in the derivation database, hazard ratios were estimated from published literature. The model was prospectively validated in 5 additional cohorts totaling 9942 heart failure patients and 17 307 person-years of follow-up.

The recently-proposed ACTTION-APS Pain Taxonomy provides an evidence-based, multidimensional, chronic pain classification system. Psychosocial factors play a crucial role within several dimensions of the Taxonomy. In this paper, we discuss the evaluation of psychosocial factors that influence the diagnosis and trajectory of chronic pain disorders. We review studies in individuals with a variety of persistent pain conditions, and describe evidence that psychosocial variables play key roles in conferring risk for the development of pain, in shaping long-term pain-related adjustment, and in modulating pain treatment outcomes. We consider both “general” psychosocial variables such as negative affect, childhood trauma, and social support, as well as “pain-specific” psychosocial variables that include pain-related catastrophizing, self-efficacy for managing pain, and pain-related coping. Collectively, the complexity and profound variability in chronic pain highlights the need to better understand the multidimensional array of interacting forces that determine the trajectory of chronic pain conditions.

Objectives This paper describes characteristics of opioid use episodes for non-cancer pain and defines thresholds for the transition into Defacto Long-term Opioid Therapy. Methods CONSORT (CONsortium to Study Opioid Risks and Trends) includes adult members of two health plans serving over one-percent of the U.S. population. Opioid use episodes beginning in 1997–2005 were classified as Acute, Episodic, Long-term/Lower Dose, or Long-term/Higher Dose. Results Defacto Long-term Opioid Therapy was defined by opioid use episodes lasting longer than 90 days with at least 10 prescriptions and/or at least 120 days supply dispensed. Long-term/Higher Dose episodes (<1.5% of all episodes) were characterized by daily or near daily use, a mean duration of about 1000 days, and an average daily dose of about 55 milligrams. They accounted for more than half the total morphine equivalents dispensed from 1997–2006. Short-acting, less potent opioids (e.g. hydrocodone with acetaminophen) were by far the most commonly prescribed medications for acute, episodic and long-term episodes. Long-acting (sustained-release) opioids were the predominately prescribed medication in a minority of long-term episodes (6–12%). Discussion Defacto Long-term Opioid Therapy was characterized by considerable diversity in medications, dosage, and frequency of use. Long-term opioid therapy may evolve from acute or episodic use in the absence of an agreed upon treatment plan. Defined thresholds for Defacto Long-term Opioid Therapy provide a possible check point for physicians and health plans to ensure that patients receiving opioid medications long-term are managed according to a treatment plan that is documented and monitored.

Objective To report trends and characteristics of long-term opioid use for non-cancer pain. Methods CONSORT (CONsortium to Study Opioid Risks and Trends) includes adult enrollees of two health plans serving over one-percent of the US population. Using automated data, we constructed episodes of opioid use between 1997 and 2005. We estimated age-sex standardized rates of opioid use episodes beginning in each year (incident) and on-going in each year (prevalent), and the percent change in rates annualized (PCA) over the 9 year period. Long-term episodes were defined as > 90 days with 120+ days supply or 10+ opioid prescriptions in a given year. Results Over the study period, incident long-term use increased from 8.5 to 12.1 per 1,000 at Group Health (GH) (6.0% PCA), and 6.3 to 8.6 per 1,000 at Kaiser Permanente of Northern California (KPNC) (5.5% PCA). Prevalent long-term use doubled from 23.9 to 46.8 per 1,000 at GH (8.5% PCA), and 21.5 to 39.2 per 1,000 at KPNC (8.1% PCA). Non-Schedule II opioids were the most commonly used opioid among patients engaged in long-term opioid therapy, particularly at KPNC. Long-term use of Schedule II opioids also increased substantially at both health plans. Among prevalent long-term users in 2005, 28.6% at GH and 30.2% at KPNC were also regular users of sedative hypnotics. Conclusion Long-term opioid therapy for non-cancer pain is increasingly prevalent, but the benefits and risks associated with such therapy are inadequately understood. Concurrent use of opioids and sedative-hypnotics was unexpectedly common and deserves further study.

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A central question in prescribing opioids for chronic non-cancer pain (CNCP) is how to best balance the risk of opioid abuse and dependence with the benefits of pain relief. To achieve this balance, clinicians need an understanding of the risk factors for opioid abuse, an issue that is only partially understood. We conducted a secondary data analysis of regional VA longitudinal administrative data (years 2000-2005) for chronic users of opioids for CNCP (n=15,160) to investigate risk factors for the development of clinically recognized (i.e., diagnosed) opioid abuse or dependence among these individuals. We analyzed four broad groups of possible risk factors: (i) non-opioid substance abuse disorders, (ii) painful physical health disorders, (iii) mental health disorders, and (iv) socio-demographic factors. In adjusted models, a diagnosis of non-opioid substance abuse was the strongest predictor of opioid abuse/dependence (OR=2.34, p<0.001). Mental health disorders were moderately strong predictors (OR=1.46, p=0.005) of opioid abuse/dependence. However, the prevalence of mental health disorders was much higher than the prevalence of non-opioid substance abuse disorders (45.3% vs. 7.6%) among users of opioids for CNCP, suggesting that mental health disorders account for more of the population attributable risk for opioid abuse than does non-opioid substance abuse. Males, younger adults, and individuals with greater days supply of prescription opioids dispensed in 2002 were more likely to develop opioid abuse/dependence. Clinicians need to carefully screen for substance abuse and mental health disorders in candidates for opioid therapy and facilitate appropriate treatment of these disorders.