Pragmatic but flawed: the NICE guideline on chronic pain (original) (raw)

With the publication of 'Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain NICE guideline [NG193]' NICE has stumbled clumsily into a complex field. Arrogantly refusing any help, the guidelines are likely to make a terrible situation worse, substantially increasing the risks of harm patients face from mistreatment and the absence of care. We consider three examples of egregious failure in this report. The first is nosological, the second evidential, the third communicative. Chronic primary pain is a recent category adopted in ICD11 (https://icd.who.int/en) to capture the experience of pain as the primary problem when there is no identified disease and thus disorder of the nociceptive system is the positive feature to assess. When recommending 'thinking about the possible causes of pain' (points 1,1,3-1.1.7), NICE falls into the trap of presenting 'primary pain' as something out of proportion with observable disease or injury, or a diagnosis of exclusion. "1.1.4 … if there is no clear underlying (secondary) cause or the pain or its impact is out of proportion to any observable injury or disease, particularly when the pain is causing significant distress and disability." This category error is well known in pain science and one that should have been avoided. Propagating it can only do people with chronic pain a serious disservice. Further, this group of pain disorders is highly heterogeneous, including fibromyalgia, complex regional pain syndrome, chronic primary headache and orofacial pain, chronic primary visceral pain, and chronic primary musculoskeletal pain. That we cannot describe in detail the mechanism for each is testimony to the poverty of our science: ignorance should humble us. Too often ignorance in chronic pain emboldens observers to claim that patient suffering is disproportionate, exaggerated, unnecessary, and unworthy of medical attention.