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NICE pushes through guidance limiting GP prescribing options for low back pain

NICE is going ahead with a drastic curb on drug options available to GPs for managing low back pain, advising GPs instead to focus on exercise and psychological therapies.

NICE has confirmed in its final clinical guidelines, 'Low back pain and sciatica in over 16s: Assessment and management’ that GPs should not offer paracetamol alone and should ‘consider’ prescribing oral NSAIDs - such as ibuprofen or aspirin - for low back pain only at the ‘lowest effective dose and for the shortest possible time’.

The guidance, published in draft in March this year, stresses that GPs should ‘consider weak’ opioids (with or without paracetamol) for managing acute low back pain, only if an NSAID is ‘contraindicated, not tolerated or had been ineffective’.

It adds that GPs should not ‘routinely offer’ opioids for acute low back pain and not offer them at all for managing chronic back pain.

The final guidance also rejects therapies including acupuncture and a range of electrotherapies such as ultrasound and PENS (percutaneous electrical nerve simulation, as well as invasive treatments such as spinal injections - advising GPs to only consider referrals for the assessment for radiofrequency denervation when non-surgical treatment has not worked.

Imaging in a non-specialist setting should not be offered routinely, according to NICE. Instead, GPs are being urged to consider a range of options that do not involve medication or invasive procedures, including providing advice and information for patients to self manage their condition.

GPs are also asked to consider a group exercise programme – whether biomechanical, aerobic, mind-body or a combination. Manual therapies, such as massage, could be considered but only as apart of a treatment package, including exercise, with out without psychological therapy.

Like in the draft guidance, GPs are advised to consider risk stratification tools. But the final guidance also adds that for patients 'likely to improve quickly and have a good outcome' GPs should consider 'simpler and less intensive support', such as for example reassurance, advice to keep active and guidance to self-management.

For patients with a risk of poor outcome, GPs should consider more complex and intensive support such as exercise programmes with or without manual therapy or using a psychological approach, it adds.

Other changes from the draft guidance include adding ‘incorporating a cognitive behavioural approach’ to the recommendation on considering a combined physical and psychological programme.

And on pharmacological interventions NICE has downgraded its recommendation on NSAIDs, changing ‘offer’ to ‘consider’.

GP Dr Alastair Dickson, who provided evidence to NICE on behalf of the Primary Care Rheumatology Society, said he acknowledged the new guidance would be 'a challenge' to GPs and patients.

But he added that he was 'very pleased' by them as 'the evidence is that drugs don’t work, especially paracetamol'.

'They are dangerous and ineffective and it is good that NICE has backed away from this and followed the evidence,' he said.

Dr Dickson also welcomed the guidance not to offer opioids for chronic low back pain because 'we know that lots of people become addicted'.

RCGP chair Professor Helen Stokes-Lampard said: 'We understand that some of the recommendations might be controversial. But the purpose of updating clinical guidelines is to take into account the latest research findings, and with a growing body of evidence suggesting that paracetamol has little more benefit for patients with lower back pain than a placebo, it makes sense that NICE reflects this.'

She also said RCGP agrees with 'the important caveat in today’s guidance that [NSAIDS] should only be prescribed at the lowest possible dose for the shortest possible time' because of the risk of side effects.

‘What is clear is that there is no one size fits all solution for patients with lower back pain, so the emphasis on combination therapies – be these physical, psychological or pharmacological – is very welcome and offers flexibility for both GPs and our patients,' she added.

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Readers' comments (10)

  • Vinci Ho

    As expected .
    Send your comments, please

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  • Actually, this is mostly in line with the policy and practice of the pain clinic I work in. Nothing more important than early mobilisation, a daily walk, paced activity and a good physiotherapist. There isn't a medication for every situation. Sorry.

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  • - "Right Mr Bloggs, drugs won't help your agonising chronic back pain, so I'm stopping your prescriptions and referring you to physio which didn't help last year"
    NICE World -"Cheers Doc, that sounds great, thanks"
    Real World - "You having a laugh?? Make with the tramadol you prat, I'm in agony here. And if you refuse I'll pester your partners, go to OOH or rock up in A&E until I get some pills. Shove your NICE guidelines where the sun don't shine. Idiot!"

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  • Consider offering ibuprofen as well as paracetamol. Are we insinuating that patients are too stupid to have tried that before they make an appt to sit in a waiting room full of sick people before seeing their GP. Well patient satisfaction rates will be going through the roof i can already see the 'customer reviews' on our website. 'my GP is wonderul managed to drag myself in to the surgery all though i could hardly walk and he told me to keep taking the pills i had in my pocket and go for a run. Grade A service!'

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  • This guidance is simplistic rubbish. Clinicians ommonly treat patients with LBP using these interventions, including opioids with some success. NICE is following its American masters with this ruling. In the USA it resulted in a massive increase in purchase of illegal painkillers by patients who had been deprived of effective prescription painkillers by their physicians.
    As to cognitdive behaviour therapy, this is being touted as the cure-all for everything. It's a bloody fad that has no place in evidence-based medicine. If a patient feels real pain and disability, it is insulting to suggest that they are in some way mentally defective or a dope addicted degenerate.

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  • "Pushes through" seems a very pejorative way to describe one of the most honest bits of NICE guidance. It comes as close as its possible for an official document can to admitting that there is, in most cases, no very effective treatment for non-specific low back pain. Much harm has been done by the pretence that this isn't the case. At least NICE no longer endorses outright quackery like acupuncture. The guidance has resisted the temptation to clutch at straws. That should be welcomed.

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  • Good to see NICE do occasionally produce something useful.

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  • I can only offer up my gratitude to the experts at NICE for providing this much needed clinical advice, especially clarification on the role of paracetamol which causes daily angst as I struggle with my irrational desire to suggest it's use.

    I eagerly await NICE guidance on the treatment of excessive sniffing - which I'm sure they must currently be working on - marvellous.
    Keep up the good work guys!

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  • I notice in the comments here (mostly the anonymous ones) and alarming tendency to ignore the evidence.
    I have every sympathy with doctors. It must be hard to say to patients that there isn't much we can do. Bu I have little sympathy for doctors who solve that problem by offering false hope and ineffective treatments.

    Nicholas Cooke sums it up nicely "There isn't a medication for every situation. Sorry."

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  • pathetic
    in a word
    we knew this last century

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