New draft NICE guidelines for chronic pain emphasises exercise, CBT and acupuncture over medication

That seems to miss the point of your comment: "There will be many critical responses to NICE’s recommendation of acupuncture, and rightly so: the evidence it is based on is very weak. But equally, why are the recommendations of exercise and psychotherapy not being criticized?"

Why is it that so many in academia seem to feel comfortable condemning the problems with the evidence underlying claims for the efficacy of 'SCAM' interventions, yet ignore identical problems with the work coming from colleagues who avoid explicitly 'SCAM' interventions? Is it the aesthetics of SCAM interventions that are the problem, or the poor quality of the research? Is it that there's a culture in academia that dissuades people from criticising work that is not clearly absurd?

 

I don't see in what way exercise and therapy are not alternative medicine, especially in a specific context like chronic pain. Alternative medicine doesn't become real medicine just because it is recommended and practiced by medical professionals, it's the lack of any theoretical underpinning that differentiates. They even feature the big tell of benefits being wildly exaggerated beyond what any evidence shows and a not-very-subtle admission that it largely rests on belief for it to work, pretty much the hallmark of CAM.

We are talking about those modalities used as treatments, a very different thing from being generally good for health in healthy people. If we use such lax definitions, knowing that socialization is good for overall health, for a number of reasons, many of which are practical, it would make as much sense for doctors to prescribe having a conversation as treatment for something or another, which is obviously absurd. In fact it makes as much sense in this very context here, which is to say: none.

All I see is medicine basically having abandoned trying to solve those problems and choosing simply to put the sole responsibility on the patients, who fail the treatments, rather than being failed by a profession that has truly given up working on hard problems. It puts the problem even further out of sight and completely out of mind, and entirely out of any accountability, guaranteeing maximum failure in the end.

 

I am not sure this is so much a problem with academia as a problem with VPWH (vocal people with hobbyhorses). That would include Paul Garner, Peter Gotzsche, Trish Greenhalgh, Clare Gerada, Paul Glasziou and a string of others. The key is that the vocal championing of some altruistic cause is in fact a manifestation of a different agenda. These are people who have deliberately gone in to the championing of altruism business and one should always smell a rat there.

I of course got dragged kicking and screaming into real championing of altruism!!

 

Not an answer to your questions but a commenter's reply that gives rise to more questions:

https://edzardernst.com/2021/04/acupuncture-for-chronic-pain-the-new-nice-guideline/#comment-131112

 

I added some teasing.

 

Wasn't hopeful that this guidance would change - especially as I'd heard that NHS pain-management clinics had adopted the new approach - but disappointing nonetheless. NICE have set up a false dichotomy with the primary vs. secondary pain concepts; there is little evidence that the conditions considered to be "primary" have anything in common beyond the fact that they're unexplained. Given some of the conditions included - fibromyalgia, CRPS - doctors are going to conceptualise "primary pain" as a euphemism for "psychogenic pain", with all of the baggage such labels carry; this will create two distinct classes of chronic pain patient, with only one seen as fully legitimate.

Something else that concerns me (personally) is that one of the news articles in the Independent (in which Prof. Edwards is quoted) claims that chronic migraine will be considered a "primary pain" disorder. If true, this seems absurd - it's well known that medications not used in the treatment of other painful conditions, such as beta-blockers and calcium-channel blockers, can modulate the effects of migraine (hard evidence for vascular & ion-channel involvement emerged in GWASes in 2013 and 2016); also, highly specific migraine therapeutics, such as the anti-CGRP mAbs, have already been approved and are in use. Anyone know if this claim is true?

The ME/CFS guidance is a work of art compared to this.

 

Well Bethany Dawson did not misquote me but I am sorry to say the article as a whole is a damp squib!
Finishes off with some nice CBT and exercise and treating the whole patient.

 

Welll, intense exercise can take your mind off things. I remember someone I met in the weight room who stated that the only thing she could do to manage migraines was weightlifting. She moved considerably more weight than the other females at the gym. Did that cure the headaches? No, but she got enough relief out of it to keep at the weights.

 

Shouldn't be too challenging for open-minded people to digest that:

https://edzardernst.com/2021/04/acupuncture-for-chronic-pain-the-new-nice-guideline/#comment-131116

Thank you, Jonathan.

Plus another good comment by Chucky.

And another reply that ignores the issue at stake.

https://edzardernst.com/2021/04/acupuncture-for-chronic-pain-the-new-nice-guideline/#comment-131122

I think it's legitimate to point out the health benefits of exercise and of health education. Also, I think that nobody should take away the possibility to offer psychotherapy where it's actually useful and wanted by people, e.g. actually traumatized patients.

But there is no science behind the claim that either health education or behavioral interventions automatically help with any illness especially if it's 'medically unexplained'. I think there's also no science behind the claim that all or most people suffering from medically unexplained conditions don't already have a healthy lifestyle or don't have tried to maintain / resume a healthy lifestyle and need advice about "general healthy changes".

Perhaps it could helpf if more people with an open mind see that the more obvious quackery called 'Lightning Process' is hyped as a treatment in the same way as psychotherapy and exercise -- and even by the same people.

[Edited, still muddled -- apologies.]

 

Having suffered my first migraine I can see that there was no way I could have attended a gym to lift weights. The light and noise for a start would have made that impossible.

Sounds like a very individual thing to me.

 

You've got a reply, did you see it?

No idea if it's worthwile to further engage with it.

There has develeoped a bit of an exchange between Chucky and the commenter replying to you, though.

Only able to skim now, but it seems to me that now someone just needed to spell out 'Lighning Process' and provide the relevant context, e.g.

https://www.statnews.com/2019/12/13...awed-chronic-fatigue-syndrome-research-paper/

and also Ernst's own take on it here.[*]


If you happen to see this: Well done, Chucky. And also @cassava7 and Jonathan, of course.

Sorry that I don't feel up to comment myself.

Edit: [*] which unfortunately shows that he didn't get the difference between improvement and trial participants' learning to report what people expect them to report:

 

The new NICE guidelines: the pain is not ‘all in our heads’

https://www.palatinate.org.uk/the-new-nice-guidelines-the-pain-is-not-all-in-our-heads/

 

the CBT/ACT gravy train :

Psychologically-informed practice for treating people with pain - 10-11 Jul.
by CPD University College of Osteopathy

https://www.eventbrite.co.uk/e/psychologically-informed-practice-for-treating-people-with-pain-10-11-july-2021-tickets-59953094319

 

When we talk of "the pain community", this will include us as far as much of the medical profession is concerned. I wonder whether "we" ought to take a look at the evidence base that NICE used (well, what pretends to be evidence) and see whether we can do something.

Claire Swain, through Change.org started a petition and has put in an FoI request to NICE for a list of its evidence base. They are considering that and intend to get back within 20 days. I suggested that she joined this group, looked at this thread and that we could at least give her some advice.

As @Jonathan Edwards says, the group do not have our kind of experience in things like this (does any patient group?), so it seems to me that we could be very helpful (and it would be in our own long-term interests as patients).

Now for the fantasy: I wonder whether a slightly wider attack on NICE is warranted, encompassing the fact that they haven't learned that subjective results in unblinded trials are not even worthy of being called weak evidence. Perhaps the Journal of Health Psychology could be interested in a follow-up to its PACE special edition – it was their best seller by far.

The editor who created that edition, David Marks, is retiring soon, so if we are interested, I could explore that possibility with him so that seeds are sown for his successor.

I know I'm presupposing a lot here, so feel free to slap me down, but it seems to me that @dave30th and @Brian Hughes could both dabble in this area, as it shows so little has been learnt.

 

MEAction UK did put in a brief feedback on the daft pain GDL. The GDL panel included a GO who had done an Acupuncture course and not many patients or charity orgs.

The composition of Guideline Committees is so important for NICE GDL. Their "science team" provides their views on the literature and their other function is to provide admin and "process" support.

Goodness knows what the GDL for MNYES (Medically Not Yet Explained Symptoms) will be. The GDL Committee is heavily psych weighted.
The term MNYES may be marginally better than MUS, but I still prefer YUMS (Yet to be Understood Medical Symptoms).

 

That was my view on it. Draft and final!

 

It is not clear to me that NICE have a specific political agenda. The main impression I get is of bureaucratisation-but with the possibility of responding to rational arguments - as happened tor ME. A lot depends on key individuals and they may have changed (I think Baker retired).

The key target for criticism I see as GRADE - because it lets garbage through. Targeting GRADE gets at NICE and Cochrane and Uncle Tom Cobley. I have some thoughts about taking that forward one the dust has settled from the ME guideline.

 

I don't feel that NICE do have an agenda: it is more one of unscientific and illogical thinking. But to talk about 'weak evidence' after a certain, well-known celebrity hammered home the point in his expert testimony, does rather show a lack of joined-up thinking.

What bothers me is that if their "analysis" for chronic pain is allowed to slip through, it will just continue that sloppy way. I'd be interested in your ideas about GRADE, but equally, what can we do about the chronic pain advice?

It's going to be a long process if people have to keep going through the process that we did to ensure that rational guidelines are produced. There has to be a better system, and it won't happen of its own accord.

 

I think the lack of joined up thinking is directly connected to GRADE, which is a recipe requiring no thinking.

Changing the system as whole is too large and amorphous a task I think. But opportunities to make significant changes may present themselves. It would be interesting to know who the patient representatives on the pain committee were and what their views are..

 

Link to Chronic pain GDL Committee:

https://www.nice.org.uk/guidance/ng193/documents/committee-member-list-4

I remember looking at the list when the draft came out and being unimpressed.