I need to clear something about about chronic primary pain – I don’t believe there is pain without pathology

I don’t personally believe there is such a thing as chronic primary pain, or pain where there is NO pathological cause.

I know I write about it all the time. The scientific literature accepts that there can be pain without nociception. That there can be pain with no pathological cause. That severe pain can be generated purely by emotion, or psychosocial issues. I respect the prevailing scientific view, without agreeing with it. I write about it, because it’s important to explain how defining ‘chronic pain’ as a disease in its own right has been weaponized against people who live with chronic secondary pain. Pain that is driven by pathology. How people with chronic secondary pain have been left untreated, and under treated, because everyone now believes in pain without pathology.

I don’t personally believe this. I haven’t seen any convincing evidence. I haven’t met anyone who has purely psychosocial pain. I think it’s a convenient theory…a theory that launched a million pain science education courses and books…and that’s all.

But, in my opinion, the ‘science’ does not stack up.

I may very well be wrong. I’ve been wrong before. I change my mind regularly when I learn new things. If only everyone who treated chronic pain responded to the evidence rather than evangelistic belief systems.

I believe there is always a pathological cause for pain. If doctors can’t find it, it means exactly that…doctors can’t find it. Perhaps there is no test available, or no test exists. Yet. Or maybe, very commonly, doctors haven’t looked hard enough.

Healthy people have NO idea how often this happens. How people – most often women – are ignored, dismissed, demeaned, and told to go see a psychologist when they present with ‘medically unexplained symptoms’. ‘Medically unexplained’ because the doctor didn’t look very hard for an explanation other than psychological issues.

Science is constantly discovering new mechanisms, new diseases, and new causes of pain. And yet, somehow, many people have been written off as having pain that is purely psychological.

And therefore, left untreated.

That’s the convenient myth chronic primary pain is built on.

Because once you can label someone’s pain as “primary,” you can stop looking for a physical cause. Or that’s the way it works in the real world. In fact, doctors are not supposed to label pain ‘primary’ until they have excluded ALL possible pathological causes for pain. This rarely happens. Chronic primary pain is a diagnosis of EXCLUSION. However, in the real world, Moseley’s cult of personality means that most often ‘chronic primary pain’ is immediately assumed to be the diagnosis. And people are immediately offered psychological therapies and education for what is severe, physical, biological, pathological pain.

This happens because chronic primary pain is a diagnosis of convenience.

As a doctor, you can immediately fob the patient off to a psychologist. You can suggest their pain is caused by stress, fear, or anxiety. And when they feel pain in their body, you can tell them it’s not their body at all, it’s their brain.

Your job, as a doctor, is done. Refer! Simples!

I’m being facetious, but when GPs have ten minutes to get to the bottom of a patient’s complaint, when they are time poor, overworked, under supported and appreciated…chronic primary pain is a gift.

But it’s rarely the correct diagnosis.

I believe all pain has a pathological cause.

I do not believe that pain can be spontaneously caused by anxiety or fear. Anxiety and fear can most definitely cause physical sensations: tightness in the chest, churning in the gut, trembling hands.

But those sensations are not pain.

Pain is different. Pain is not a flutter in your stomach. It’s not nerves before a job interview.

Pain is relentless, searing, crushing. Severe pain dominates your life.

And it always has a cause.

To be clear, I DO believe there are people with pathological pain whose suffering is worsened by fear, anxiety, and maladaptive beliefs and behaviours.

They have some mild or moderate pain. But they catastrophize. They overprotect themselves. They are afraid of movement, lest it cause pain. They are anxious, depressed and distressed. And they are afraid of pain. They are not constantly IN pain; they are in constant FEAR of pain.

But here’s the truth the pain science industry refuses to admit: these people are a small minority.

The vast majority of people who live with chronic pain, have chronic secondary pain. Pain due to disease or injury. Pain due to pathology. There may be psychological aspects, or there may not. Mostly, there’s not. The people I know and advocate for, are strong. Determined. Resilient.

People who push through pain every day, because we have no choice.

We not living in fear. We’re living in agony.

The vast majority of chronic pain patients, certainly those I’ve come in contact with online and off, are extremely determined, motivated and hard working. They push through pain every day, because they are forced to. They want to work, to socialize, to live full and active lives. But they can’t live full and active lives, because of pain.

NOT fear.

In the last decade, the only pain stories that get airtime, research funding, and sympathetic media coverage are those that fit the chronic primary pain model: mild/mod pain, no clear pathology, and a “recovery” achieved by changing thoughts beliefs and behaviours.

These are the people who initially took to their recliners, avoided movement, wrapped themselves in cotton wool, and were praised as heroes for finally getting up and doing what they should have done from the start. The stuff that the rest of us were doing all along – moving, living life despite pain.

Those people are the minority.

But if that’s the only story you’re told, you don’t know better. You believe that’s the only story.

Selection bias, on a grand scale.

And once you believe in this model, as a health care professional, you start square pegging every patient you see to squish them into your round hole. Whether they fit or not.

When all you have is a hammer, everything looks like a nail.

Those of us with chronic secondary pain, pain caused by identifiable disease, damage, or degeneration, are silenced.

Erased.

Abandoned.

Our stories were not elevated by researchers, thought leaders, politicians, the media.

Why?

Because we do not fit the preferred narrative. The manufactured narrative. The pain science education narrative. The anti-opioid narrative.

Two very strong ‘movements’ that have nothing to do with patient care. And everything to do with making money.

Real, physical pain is inconvenient. Because sometimes? Its easily treatable. Cheaply treatable.

A month’s treatment with opioids is very, very cheap. About $40. Much cheaper than 8-10 sessions of physiotherapy. 10-15 sessions with a psychologist. Oh and $100 to buy Explain Pain. And at the end of that, the person is still in pain.

It appears we don’t want people to have access to safe, effective, AFFORDABLE treatment.

We want people to spend thousands on psych and physio that is completely ineffective for their pain.

We want people to be referred to specialist pain doctors, who didn’t even exist 10-15 years ago.

An entire industry has been created around chronic primary pain. Making some people rich. Keeping many people in jobs. And keeping most people in pain.

Its deliberate. It’s by design. Its abhorrent.

The idea that pain can be “explained away” has become a multimillion-dollar industry.

Books. Seminars. Webinars. Certifications. World tours.

And behind it all?

A convenient little myth: that pain doesn’t come from the body, it comes from the brain. Or a hypersensitive nervous system.

Chronic primary pain was created as its on disease entity, for exactly this reason.

It was never about truth.

It was never about science.

It was about sales.

And now?

Doctors, therapists, and policymakers have swallowed this garbage whole.

They’ve stopped treating real pain. They’ve started gaslighting people with painful, progressive, incurable diseases.

They tell us to "retrain our brains."

They tell us we’re safe to move.

They tell us that hurt does not equal harm.

They tell us we don’t need medication.

But we are not safe.

Sometimes hurt DOES equal harm.

And yes — we do need medication. Disease modifying medication, and pain medication. Sometimes we need procedures, surgeries. Sometimes we need psychological support but receiving that support does not reduce pathological pain.

The idea that you can have pain without nociception was never proven.

It was very well-marketed.

And twenty years later, it’s still being sold, while people like me are being left to rot.