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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)

  • 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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