Intended for healthcare professionals

Practice Guidelines

Chronic pain (primary and secondary) in over 16s: summary of NICE guidance

BMJ 2021; 373 doi: (Published 21 April 2021) Cite this as: BMJ 2021;373:n895
  1. Serena Carville, associate director1,
  2. Margaret Constanti, senior health economist1,
  3. Nick Kosky, consultant psychiatrist2,
  4. Cathy Stannard, consultant in complex pain and clinical lead of pain programme3,
  5. Colin Wilkinson, lay member of Guideline Committee4
  6. on behalf of the Guideline Committee
  1. 1National Guideline Centre, Royal College of Physicians, London NW1 4LE, UK
  2. 2Dorset HealthCare NHS Foundation Trust, Poole, UK
  3. 3NHS Gloucestershire CCG, Gloucester, UK
  4. 4Stockton-on-Tees, UK
  1. Correspondence to: S Carville serena.carville{at}

What you need to know

  • A collaborative and supportive relationship between healthcare professional and person with chronic pain and a comprehensive person-centred assessment are central to good management

  • With the exception of antidepressants, initiation of pharmacological management is not recommended.

  • Offer supervised group exercise to people with chronic primary pain

Chronic pain—defined as pain that lasts for more than three months—is common, debilitating, and often difficult to treat.1 Chronic pain is classified in ICD-11 as being either primary or secondary. In chronic primary pain there is no clear underlying condition that adequately accounts for the pain or its impact; chronic secondary pain is pain linked to an underlying condition.2 Clinical judgment is required to determine whether the pain is primary, secondary, or a combination of the two (box 1).

Box 1

Identifying chronic primary pain

Chronic primary pain has no clear underlying condition, or the pain or its impact seems to be out of proportion to any observable injury or disease. All forms of pain can cause distress and disability, but these features are particularly prominent in presentations of chronic primary pain.

The guideline is consistent with the ICD-11 definition of chronic primary pain: “Chronic primary pain is chronic pain in one or more anatomical regions that is characterised by significant emotional distress (anxiety, anger/frustration or depressed mood) or functional disability (interference in daily life activities and reduced participation in social roles). Chronic primary pain is multifactorial: biological, psychological and social factors contribute to the pain syndrome. The diagnosis is appropriate independently of identified biological or psychological contributors unless another diagnosis would better account for the presenting symptoms.”4


This article summarises recommendations from the National Institute for Health and Care Excellence (NICE) guideline for chronic pain (primary and secondary) in people over 16 years old for use in all NHS settings where pain is managed.3 The …

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