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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)

  • 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.
    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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