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NICE dramatically reduces drug options for low back pain

GPs should not prescribe TCAs, SSRIs or strong opioids for lower back pain, and only offer paracetamol for second-line use, under planned revisions to NICE guidelines unveiled today.

The draft guidelines – which now also cover sciatica – say GPs should offer NSAIDs as first-line for pain relief, and should offer paracetamol only alongside a weak opioid. 

The guidelines also say GPs should avoid acupuncture altogether – which they say is no better than sham treatment – and call for exercise, such as stretching, strengthening, aerobics or yoga, to be the first step to help patients manage their condition.

The guidance also states massage and manipulation by a therapist should only be offered alongside exercise.

The proposed recommendations downgrade the use of paracetamol, which should no longer be offered first-line for pain relief, or used on its own. Instead GPs should suggest patients try an NSAID such as ibuprofen or aspirin first.

GPs should only consider using weak opioids such as codeine – which may be given with or without paracetamol – if patients cannot tolerate an NSAID, or find they do not work. Stronger opioids are completely ruled out.

The guidance calls for GPs to use a risk assessment and stratification tool such as Keele University’s STarT Back tool to help make a decision with the patient on the best course of management, depending on the severity of the condition.

And it says they should consider offering a combined physical and psychological programme – preferably in a group – for people with ‘significant psychosocial obstacles to recovery’.

GPs should avoid imaging if possible, however, and the guidelines rule out use of electrotherapies such as TENS (transcutaneous electrical nerve stimulation), and spinal injections.

But GPs can consider referral for radiofrequency denervation in patients with moderate to severe pain that has not responded to other treatment, and epidural steroid injections for people with acute sciatica.

Of potential surgical interventions, only spinal decompression is recommended – in people with sciatica that has not responded to non-surgical approaches.

Previously GPs could offer a course of 10 sessions of acupuncture, or manual therapy, as alternative options to an exercise programme. However, NICE guidelines advisors say the most up-to-date evidence shows that acupuncture is no better than sham treatment and that there is no evidence to support physiotherapy on its own.

Dr Ian Bernstein, a GP expert in musculoskeletal therapy who advised on the updated guidelines, says: ‘The diagnosis of back pain includes a variety of patterns of symptoms.

‘This means that one approach to treatment doesn’t fit all. Therefore the draft guidance promotes combinations of treatments such as exercise with manual therapy or combining physical and psychological treatments, and the choices made should take into account people’s preferences as well as clinical considerations.’

NICE Draft CG88 Update - Non-specific low-back pain and sciatica: management

NICE draft guidelines on management of low back pain and sciatica - key points for GPs

Assessment and diagnosis

GPs should consider carrying out risk stratification (for example, the STarT Back risk assessment tool) when a patient first presents with non-specific low back pain with or without sciatica, ‘to inform shared decision-making about stratified management’.

GPs should not routinely offer scans in a non-specialist setting, and explain to patients that referral to a specialist does not necessarily mean they need to have a scan


  • Do not offer acupuncture, but offer patients a suitable group exercise programme, including biomechanical, aerobic, mind-body exercises or a combination of these.
  • Consider manipulation and massage – but only alongside exercise as part of multimodal treatment
  • Prescibe an NSAID for managing pain where possible – but at the lowest dose possible for the shortest possible amount of time
  • Only offer paracetamol second line, and in combination with a ‘weak’ opioid like codeine
  • Other opioids should not be prescribed for low back pain, nor antidepressants such as SSRIs, SNRIs or TCAs, or anticonvulsants

Readers' comments (66)

  • Chinese medicine works in a different way, but it still works. Nice should keep their nose out of things.
    Acupuncture has been used for thousands of years and I think if it did not work, some one might have twigged by now!

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  • Dear Anonymous

    Acupuncture has not been used for thousands of years. What you see on the High Street is pretty much an invention of Mao's cultural revolution coupled with Western orientalism.

    And yes, we have now twigged that acupuncture is superstitious and pseudoscientific nonsense that does not work. Took NICE a little longer but they have got there.

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  • Vinci Ho

    Glancing through the 15 pages of the 'draft'(hence not finalised) , there are more 'don't' s than do s . I can see that it tried to categorise non specific vac pain away from sciatica with clinically evident radiculopathy. But the reality is the former constitutes the majority of cases seen in general practice . It is a struggle to have treatment options and perhaps somebody would want to say we really don't fully understand low back pain .....

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  • Vinci Ho

    back not vac pain

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  • ...Do not offer a sick note?

    I wonder how harmful the issue of a sick note is in terms of back pain outcome?
    Its a poor use of the NHS to be validating people taking time off work / school / claiming for insurance etc.
    This is an aspect of NHS privatisation I would be completely in favour of. We are not in any position to make an impartial judgement regarding these requests.

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  • coalface medicine at it's best. Paracetamol as 2nd line, no TCAs, SSRI or strong opioids?
    Have I missed the memo, aren't these the medications prescribed by the pain team when injections, physical therapy etc haven't worked, or chronic NSAID use (1st line remember) has lead to peptic ulcer disease, renal impairment or just doesn't work.
    Nice work NICE!!

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  • I love NICE's input in all things medical -especially as I dont see how any of it can be valid- 50% of clinical trial results arent published most of the time if the trial doesnt achieve the result the company /investigator wants it isnt published ,or the trial is stopped early ,or the end point changed (ie bp lowering instead of ischaemic/thrombolic events /death)- the trial data is usually way out of date , and trial patients usually arent allowed to live in the real world-ie have too many other medical problems -totally wrong in an ageing population -I know of one trial where the clinical advisory board said the trial was unethical and the trial was taken to the far east where individual informed patient consent wasnt required.

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  • Advice comes and goes continually. Interesting Comments about people with multiple medication being excluded from trials. A link to a very very interesting TEDMED talk concerning this issue and how an independent group of people managed to find out a number of side effects of drugs when used together through the use of Google and what people search for.

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  • patient I have lower back pain
    clinician what are you taking
    patient otc analgesia not working
    clinician would you like to try an exercise group
    I think we all know the answer dont we !!!

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  • Do the people who advice NICE live in the real world? NSAID & paracetamol are sold in shops for 25p. If people are attending to see a GP its because this method hasn't worked. This is why the internet drug market is booming and GP's feel like children being told what to do by over zealous parents. Its just unbearable.

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  • I don't know how they formulate these badly misguided edicts but they are so wrong. I have had back trouble for 40 years including two lots of surgery, no medicines available on scripts work for me but ACUPUNCTURE DOES. Let them suffer then see what they say then.

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  • I have seen more codeine than paracetamol addicts amongst my fit and (generally) healthy population of service personnel with back pain. This contradicts previous guidance on the use of MR opiates (we use tramadol) for a defined period (usually 2-3 months) with cessation if no benefit.

    I didn't think there was a huge evidence base for epidural injections.

    Amitriptiline can work wonders especially for breaking the chronic pain cycle with sleep disturbance. It makes one question what outcomes were being looked at.

    Psychological therapies do help & are life transforming if one can access them. The problem with this guidance is it is detached from what is actually available in the real world.

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  • NICE is so disheartening. Where is the evidence that GPs "routinely" order x-rays and scans? Who gets sued when a GP misses a tumour? This guidance is scientifically flawed on many levels. I think NICE committees comprise idée fixe types, who have already made up their minds and just grab a few supporting studies to prop up their recommendations.

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  • "Only offer paracetamol second line, and in combination with a ‘weak’ opioid like codeine". Huh? Not so long ago the government was telling us that the paracetamol/codeine combination was useless for LBP.

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  • Andy Lewis

    Acupunture has a proven modality through fMRI scanning tests and a fairly reasonable evidence base.

    There are even systematic reviews on the BMJ, on Cochrane and elsewhere that show effect above placebo/sham treatment.

    How it compares to 500mg BD of naproxen is a different matter.

    It seems distinctly offensive that your retort to the first post is to suggest acupuncture is a Maoist initiative. Its not.

    try looking through some evidence before you make ignorant posts.

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  • theres something a bit off here. Are there really some meta-analyses of double blind placebo-controlled trials of exercise for low back pain - or is the evidence used of that low level type that is deemed inadmissible for the acceptance of acupuncture? There should be a level evidential playing field. In clinical practice the choice is not between a real treatment and a placebo it is between different real options. Pragmatic RCTs (many) have compared various standard biomedical treatments for back pain with acupuncture and found acupuncture superior. The nature of placebo controlled RCTs means that the great majority of biomedical treatments are also little or no better than placebo. The evidence suggests that acupuncture is effective as a treatment for the majority of patients.the large GERAC trials concluded that "Our researches “indicate that acupuncture is effective in the treatment of migraine, tension type headache, osteoarthritis of the knee and chronic low back pain. For the latter two indications acupuncture showed an even higher success rate than conventional standard treatment. In migraine acupuncture showed an effect comparable to pharmacological treatment.” (Backer, Tao & Dobos in Deutsch Med. Wochenschrift 2006; 131;506-11) a great number of other trials have also indicated significant benefit in roughly 70% of patients. Also, it is much safer that NSAIDs or Paracetemol or surgical interventions.

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  • I wouldn't normally wish sciatica on anyone, but it's evident that Dr. Bernstein has NEVER had it or a slipped disc or a trapped nerve of any kind ! Like dentists who blithely recommend paracetamol for the relief of pain of a tooth or gum abscess ! Try it ! Sheer arrogance & ignorance !

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  • I used to work as a medical doctor and academic but got bored as conventional medicine mainly deals with suppressing symptoms (and can have lots of toxic side effects) rather than identifying the problem and rebalancing the body.
    I now work in Natural medicine using herbal treatments and different aspects of Chinese and Indian medicine (as you know they work on these similar principles) and find while it takes much longer to deal with patients, the end results usually are far better and regularly amaze me.
    However as many know unfortunately few medical doctors have been exposed to these different forms of treatment and once they have qualified they have little time to study them and realise they offer so much to many of the conditions that conventional medicine find 'untreatable' or 'heart sink' patients.
    Anyway I regularly find those who do not understand these different concepts often get very aggressive about another forms of treatment they do not understand.
    For me though, I would never go back as I admit I get a buzz from fixing so many different health problems that conventional medicine cannot.

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  • Good ol NICE. Advice sits perfectly with AKI prevention. Ermm.... 'Ang on a mo. They've completely missed the point re paracetamol mono therapy. It's no better than placebo. Agreed. But placebo effect in analgesia can be quite beneficial. I don't know much cos only been doing job for 33 years but if you tell someone their analgesic is weak crap they won't get benefit. Conversely tell 'em its heap strong medicine, specially selected for 'em and bingo. Often works a treat. I'm not saying it works for majority but neither do NSAIDs in my experience. It's also worth noting that when ibuprofen was red shiny Brufen tabs., patients thought it was the dogs doodahs. Now dull white tabs - they don't work anymore. Why would that be?

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