Is pain ever "normal"?

This article analyzes the Pain Terminology adopted by the International Association for the Study of Pain (IASP), noting that most of their pain categories are defined in terms of a reference standard of "normal" pain. Given the lack of any officially adopted operational definition of the word "normal," we argue that the use of this word expresses and maintains a paradigm that drives many clinicians' reasoning about their patients' pain. We offer evidence that this uninterrogated paradigm is being tacitly used to differentiate legitimate pain reports from malingering and drug seeking. We consider this unsubstantiated "folk" sense of "normal" in light of evidence-based, rationalized prototypes based on statistical analysis of empirical evidence. We conclude that evidence for consistency in the experience and expression of pain and for clinician accuracy in evaluating the veracity of that pain is lacking; therefore, the logical preconditions needed for a rationalized, evidence-based prototype of "normal" pain have yet to be met. We conclude that the use of "normal" as a reference standard leads to ineffective and inhumane management of patient pain and to the danger that third parties, such as insurance companies and drug enforcement agencies, will use this unsubstantiated reference standard to arbitrarily limit pain therapy options. The authors recommend that the word "normal" be expunged from the International Association for the Study of Pain, Pain Terminology.