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British Pain Society president ousted after row over NICE guidelines

By Mark Pownall

The National Institute for Health and Clinical Excellence's controversial guidelines on low back pain have sparked an extraordinary row between its leaders, GPs and pain specialists, which has cost a key member of the guideline development group his job.

The institute has faced fierce criticism over the make-up of its guideline development group, and its alleged bias towards physical interventions such as acupuncture, manipulation, exercise and surgery.

Such is the anger among some specialists that Professor Paul Watson - president of the British Pain Society and among those who developed the guidelines - has been ousted by his organisation.

NICE chair Sir Michael Rawlins launched an outspoken attack on those who forced the professor out, accusing them of ‘victimisation of the worst kind'.

Pain specialists and some GPs object to NICE's rejection of injections for low back pain. They have also criticised the recommendation of early consideration of spinal surgery, claiming patients should have the opportunity to see a pain specialist first.

Advice that imaging should be delayed until pain has been present for a year or more also came under fire, amid fears of delayed diagnosis, while others fear NICE's support for acupuncture will suck funding from pain management centres.

The departure of Professor Watson followed criticism that the guideline group had pre-existing beliefs in manipulation and exercise and included no specialist in interventions to reduce pain.

He was forced out after a narrow vote by the organisation, leading Sir Michael to express his ‘outrage' in a letter to the BMJ.

GPs weighed in on both sides. Hampshire GP Dr Mark Aley attacked advice to consider acupuncture if simple analgesia did not work, calling it ‘costly in time and resources'.

‘In general practice we do not always have the time to bend people or stick needles in them. It is often easier to prescribe diazepam and wait for people to get better.'

Dr Tim Barling, a musculoskeletal GPSI in Hereford, called the guidance ‘inflexible and prescriptive' because of its failure to consider the views of interventional pain specialists who might have argued for use of therapeutic injections.

But GP academic Professor Martin Underwood, who chaired the guideline development group, defended NICE's recommendations: ‘For acupuncture there is a large number of trials that show a positive effect, whereas there were very small numbers of RCTs for other treatments.'

He said Professor Watson's departure ‘appears to send a message that the society rejects evidence-based medicine when it does not like the outcome'.

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