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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)

  • 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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