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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)

  • Well Papaver Somniferum is a good example of a herbal (opium) turned into a pharmaceutical and was one of the useful things advised by NICE.
    Don't expect to get a similarly high high on cayenne,tumeric and black pepper (although cayenne is thought to work by stimulating endorphines like opium to give its pain killing and wellbeing boost) but you should get a better back!

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  • More NSAIDS ..more over prescription of PPIs....

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  • Mr Mephisto

    Dr Aseem Malhotra the "TV Cardiologist" or "Sugar Cardiologist" (take your pick) railed against NICE Guidelines on statin use earlier this week at Pulse Live.

    This guidance is ludicrous.

    NICE are getting increasingly out of touch with reality.

    Lets ban NICE

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  • what happened to patient centric approach and experience
    what about 65 year olds with or without renal failure
    paracetamil is safe and perhaps should be tried
    -as usual some experts are not in the real world
    Whatever GPs prescribe is criticised
    May be we should try placebo - sorry they might be too expensive

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  • More therapeutic nihilism Dont bother seeing a GP theyll tell you to just put up with it (if they follow the guidance) Why is it noone mentions the pain -apprehension-avoidance cycle? Isnt every patient different and isnt it the job of a GP to treat the patient in front of him/ her to the best of their ability imperfect though this mapy be? Isnt part of this to do with the theraoeutic personality of the person to whom the patient goes to for help. NICE =Nihilism instead of clinical experience (D.Grant GP Diploma orthopaedic medicine)

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  • When will NICE start listening to front line clinicians? We know what works and in which carefully-selected setting. These patients are not robots. So, if I understand correctly: don't prescribe anything you can't buy at Tesco's petrol station, and send everyone to physio and it will all be lovely and they'll never come back. What utter b*llocks. I think the NICE advisers need to get back to work and see some patients for a change, presuming anyone will want to see them.... We have been reminded so many times: "lack of evidence of benefit is not the same as evidence of lack of benefit".

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  • Doctor Dog

    It's only guidelines.

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  • Took Early Retirement

    NICE= Well-meaning morons. Ignore.

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  • Back pain is greatly misunderstood and ranges from simple musculoskeletal pain to serious conditions often missed. Restricting pain medication, restricting access to proper imaging and trying to curtail referrals is not going to help. The introduction of a risk stratification tool is a positive aspect of this draft, perhaps the only one. I have sadly witnessed numerous spinal tumors missed by GPs. We should be ensuring GPs, often the first port of call, are fully trained on back pain assessment (which goes well beyond simple sciatica), they should be empowered to scalate pain medication, empowered to access correct imaging so that right diagnosis can be identified and right referral made.

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  • To anonymous GP partner.
    I don't know why you are so angry with NICE. All the reports says is that there is NO effective treatment for low back pain. That's been known for quite a long time. The only mystery is why it took so long for NICE to say so.

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