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GPs buried under trusts' workload dump

Review everyone on paracetamol for back pain, recommends NICE advisor

Exclusive GPs will need to review any patients taking paracetamol for chronic low-back pain with a view to weaning them off it, according to the GP expert advisor on NICE’s proposed new guidelines.

GP and musculoskeletal expert Dr Ian Bernstein told Pulse that – assuming the plans go through – GPs have to be able to offer a ‘very good reason’ to justify prescribing paracetamol for low back pain at all.

The draft guidelines, which are currently out for consultation, are set to dramatically shrink the drug options available to GPs in general - and will mean they can no longer prescribe paracetamol on its own.

Instead they can consider cocodamol or another combination of paracetamol and ‘weak’ opioid as a second line option for acute episodes, if patients cannot take an NSAID or find they do not work.

Dr Bernstein, who helped develop the draft NICE low-back pain guidelines, told Pulse this means ‘GPs should review people who are on prescriptions of paracetamol and consider the NICE guidance in deciding whether to stop’.

This could be done at the next opportunity and not urgently, as the change in advice is not over safety of the drug, Dr Bernstein said.

Under the latest plans, Dr Bernstein said GPs would need to have a ‘very good and very individual reason’ to put patients on paracetamol on its own - simply because the evidence showed it does not work.

Dr Bernstein explained: ‘That would be outside the guidance, because actually for acute low back pain we have got good evidence it doesn’t work. We also have good health economic evidence that suggests it’s not cost-effective.’

He added that ‘for chronic low back pain there is just a lack of evidence [for paracetamol] but we have some parallels with osteoarthritis, where long-term studies have not shown benefit for paracetamol, for chronic pain’.

However, Dr Martin Johnson, RCGP clinical lead on pain, told Pulse that in practice there should still be room to prescribe paracetamol at least in the short term.

Dr Johnson said: ‘In general we are realising that the evidence for paracetamol is weak, but does this relate to the naturalistic environment?

‘I will continue to recommend it short term for musculoskeletal conditions as long as individual patients tell me that it is working, I am happy.’

Dr Johnson added that given the increasing pressure on primary care doctors not to prescribe opioids ‘it is difficult to know what GPs are able to prescribe - all we can do is treat patients as individuals, give them tailored advice and relevant follow up’.

NICE tries to cut down on prescribing paracetamol

Back pain - online

The draft NICE guidelines launched last week completely ruled out use of strong opioids as well as TCAs, SSRIs or SNRIs for acute low-back pain, and put much greater emphasis on offering a short-term group programme of exercise, including a much wider range of exercises than in previous guideline - including mind-body exercises, such as yoga, and and stretching and strengthening exercises.

The consultation on the draft is open until 5 May 2016.

 NICE previously tried to stop GPs from prescribing paracetamol for osteoarthritis, because of concerns it was associated with serious adverse events including bleeding and renal injury, but those plans were thrown out after outcry from pain experts who warned it would lead to patients potentially ending up on even more harmful drugs.

Readers' comments (36)

  • FFS!

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  • Dr Bernstein is a registered Osteopath.

    Hmmm....

    GP's on NICE committees should have no registered special interest in the condition they are appraising.

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  • Here's my advice. Prescribe paracetamol, but advise patient (and record in notes)'You should stop taking these if they don't help'. Then presumably we have covered all bases.
    I'm certainly going to avoid the alternative, i.e. when Mrs Jones comes for more paracetamol 'because they ease my back', I say to her 'No - you're wrong. NICE have assessed all the evidence and in fact those paracetamol are not working at all'
    What a joke!!!!!

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  • what planet!!
    Almost giving up time - how about referring all of them to secondary care as they clearly KNOW what to prescribe!!!

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  • Out of touch with reality. Self employed person with back pain. Cocodamol NSAID and nighttiem diazepam- maintains mortgage payments- sod guidelines

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  • Would be great if these suggested other options existed on the NHS. Patients are only going to ask for what is free. If you recommend yoga classes and no meds they will only see other GP of go to OOH of A&E and get paracetamol aswell as NSAIDs, benzodiazepine and TCA to follow up with own gp to continue!!!

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  • Mike Chadwick CCG Consultant Pharmacist
    Must agree with the majority -I always had the opinion that if it works (and the patient will know) why change if no harm is apparent (and the HP will know).I reserve further comment

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  • NICE & Dr. Bernstein may well be right that there's no point in prescribing paracetamol for ANY moderate to severe chronic pain BUT, if the patient cannot tolerate NSAIDs, OR codeine then what else do they suggest since the withdrawal of coproxamol ???

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  • I thought the latest current guidelines didn't recommend codiene,benzos,acupuncture or nsaids. Do we just refuse to see/treat backache?
    I could refer to physiotherapy but there is a more than 12 week wait

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  • NICE lost the plot a long time ago.

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  • Dear Dr Berstein - please get real- GPs have alot on their plate - unless u get NHSE to make it a DES, nobody will even think about it, just shut up as GPs have many many many other priorities.

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  • mmmm sounds like good advice. The next 18 stone six foot six self employed brick layer I see with back pain I will advise to take up yoga rather than spend 25p on some painkillers from the supermarket.

    I'm so glad NICE are making recommendations that are so applicable to the real World, because other wise we might think they were out of touch academics who hadn't seen a real patient since their last job as a houseman.

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  • Of course - go straight to addictive opiates with massive side effects, why didn't I think if that! With a 3-4 month wait for Physio, no access to osteopaths/chiropractors, there should be plenty of time to establish addictions to occupy the time of local drug and alcohol services and of course GPs, as we have nothing to do. I frequently wonder why I completed a medical degree, I should just have read the Daily Mail and joined NICE.

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  • Dear All,
    You should have this on a plaque on your wall;
    Sir Michael Rawlins, Chairman NICE, quoted 2012 in medical newspaper,

    "The institute’s recommendations are advisory for GPs and sometimes almost aspirational in nature. There appears to be confusion about the circumstances in which it is obligatory for GPs to follow NICE guidance. The quick answer is ‘never’."

    This guidance is about as bonkers as you can get and is a fine example of what Sir Michael was referring to.
    Regards
    Paul C

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  • Pipin Singh

    Hmmm! Straight to oramorph perhaps or naproxen leading to UGI bleed and AKI. Yes let's stop paracetamol......that evil harmful drug!

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  • So when I have reviewed them all over a coffee at lunchtime and decided that on balance things are usually best left alone, what then? Thumbscrews? A midnight visit from CQC ninjas in a helicopter?

    NICE should back off and get back to some real work.

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  • Vinci Ho

    Ha ha ha
    Last year we have madness with the type 2 diabetes draft before the final guidance was amended .
    This year we have back pain. I reckon this has become a natural habit of NICE, already look forward to next year's one........

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  • how much does NICE cost the taxpayer? is it cost-effective itself?

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  • Another DO NOT DO. No paracetamol, TCAs, opioids or anticonvulsants and definitely no sick notes. What the hell is left when these patents walk through the door?

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  • Vinci Ho

    Now I understand why 2/3 of GP appointments do not need a doctor !

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  • You give every NICE member a course of CoCodamol 500/30, then when the constipation kicks-in, and they have time to sit and think, you may get some sense..

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  • One thing is for sure....NICE and its cronies must be on some very very special mushrooms....where else would you get pure unadulterated crap coming out of all their collective orifices. Please someone get some genuine, coal-face, working doctors on the panel and also wake me from this mindless drivel of a nightmare.

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  • Dr Bernstein is an osteopath, really? I think that is just astonishing. I'm sure Dr B is lovely and intelligent and clinically excellent. I've had lbp for 25 years and a string of osteopaths have my gratitude for their treatment, but in what way does an osteopath have relevant knowledge skills and attitude to suggest let alone recommend GP care? When was the last time your average osteopath diagnosed spinal TB, or lymphoma let alone the day to day differentials & complications of back pain? More realistically when was the last time they saw 60 patients in a day and then dealt with another 100 patients paperwork? When was the last time that the 5 lbp patients they saw were actually about the least sick of their cases that day? To use the airline metaphor - it's like someone who's an expert stunt formation kite flyer trying to tell a 747 pilot to "fly a bit higher cos it's windy today".
    - and the evidence base??? Seriously NICE has lost sight of the fundamental ontology of "evidence based medicine". Who says that irrelevant, tangentially related studies about COST effectiveness are better evidence that expert opinion about clinical effectiveness?
    The culprit in this isn't of course any individual (after all they can be replaced) but the corporate attitude which is a complete anathema to the true nature of medicine which is that "I see YOU and through that relationship through what we each bring to that encounter I offer YOU comfort to ease you ills".

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  • thanks to everyone - this has been the most amusing mid-patient read this year!

    I wonder if the responses could be collated & sent to NICE?

    Actually - rather like the Daily Telegraph books of obituaries could Pulse compile the best threads? would make a good Christmas pressie

    As for the guidance what a load of B******s!!!

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  • thanks to everyone - this has been the most amusing mid-patient read this year!

    I wonder if the responses could be collated & sent to NICE?

    Actually - rather like the Daily Telegraph books of obituaries could Pulse compile the best threads? would make a good Christmas pressie

    As for the guidance what a load of B******s!!!

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  • NICE, CQC, GMC, HUNTING YOU. I AM AWAY. GOOD LUCK TO ALL THE WONDERFUL, STOICAL, RESILIENT PEOPLE WHO STAY. I CANNOT COPE ANYMORE WITH THE PENANCE.

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  • NICE, CQC, GMC, HUNTING YOU. I AM AWAY. GOOD LUCK TO ALL THE WONDERFUL, STOICAL, RESILIENT PEOPLE WHO STAY. I CANNOT COPE ANYMORE WITH THE PENANCE.

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  • Right, don't prescribe this or that. Right. What do we prescribe then? Don't tell us what not to do,tell us what to do.

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  • Right, don't prescribe this or that. Right. What do we prescribe then? Don't tell us what not to do,tell us what to do.

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  • So paracetamol is ineffective and some studies show harm e.g. GI bleeding risk/harm in excess use. Why are we to combine it as co-codamol rather than codeine alone?

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  • So paracetamol is ineffective and some studies show harm e.g. GI bleeding risk/harm in excess use. Why are we to combine it as co-codamol rather than codeine alone?

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  • I wonder what use NICE is.It keeps some people in employments, and enables a few people to sit on committees. Nobody really reads their guidelines. Have you ever been to their website.. it is appallingly bad...the guidelines even if they are reasonable are written in impenetrable waffle....

    Even if you were trying to make it bad, you would be hard pushed to do a worse job.

    Hopeless organisation.! One of an increasing number of unaccountable quangos surrounding healthcare.

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  • I wonder what use NICE is.It keeps some people in employments, and enables a few people to sit on committees. Nobody really reads their guidelines. Have you ever been to their website.. it is appallingly bad...the guidelines even if they are reasonable are written in impenetrable waffle....

    Even if you were trying to make it bad, you would be hard pushed to do a worse job.

    Hopeless organisation.! One of an increasing number of unaccountable quangos surrounding healthcare.

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  • 'Kick Me' says NICE Adviser

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  • I have chronic lbp. I know why, I understand it cannot be 'cured', but it is manageable and I am able to work full-time as a healthcare professional . I can work full-time as I can manage my pain with paracetamol.I have anaphylactic reaction to NSAIDS, get spaced out and my judgement is impaired with codeine, not to mention the issue of driving on opioids......I do exercise, but I have specific exercises through a support group which help but as a mum, wife and with full time work I don't do them as often as I should! And most importantly, exercising when you have pain is agony......
    Where is the focus on the patients needs from NICE? Lbp is not a one size fits all,it is multifactorial and if chronic the underlying cause known. Many patients want to keep working and functional, it is ridiculously short sighted of NICE just to look at one aspect without considering the wider economic, social and financial implications of this guideline, let alone the individual patients needs.

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  • David Banner

    Relax, folks. As Captain Barbossa said, "The (Pirates') Code is more what you'd call "guidelines" than actual rules". This edict will have little impact on what happens in surgery, where patients will continue to climb the analgesic ladder as they always have done. With their risible, baffling and unworkable guidelines on asthma, diabetes and LBP NICE have rapidly declined from didactic irritant to irrelevant laughing stock.

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