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NICE dramatically reduces drug options for low back pain

GPs should not prescribe TCAs, SSRIs or strong opioids for lower back pain, and only offer paracetamol for second-line use, under planned revisions to NICE guidelines unveiled today.

The draft guidelines – which now also cover sciatica – say GPs should offer NSAIDs as first-line for pain relief, and should offer paracetamol only alongside a weak opioid. 

The guidelines also say GPs should avoid acupuncture altogether – which they say is no better than sham treatment – and call for exercise, such as stretching, strengthening, aerobics or yoga, to be the first step to help patients manage their condition.

The guidance also states massage and manipulation by a therapist should only be offered alongside exercise.

The proposed recommendations downgrade the use of paracetamol, which should no longer be offered first-line for pain relief, or used on its own. Instead GPs should suggest patients try an NSAID such as ibuprofen or aspirin first.

GPs should only consider using weak opioids such as codeine – which may be given with or without paracetamol – if patients cannot tolerate an NSAID, or find they do not work. Stronger opioids are completely ruled out.

The guidance calls for GPs to use a risk assessment and stratification tool such as Keele University’s STarT Back tool to help make a decision with the patient on the best course of management, depending on the severity of the condition.

And it says they should consider offering a combined physical and psychological programme – preferably in a group – for people with ‘significant psychosocial obstacles to recovery’.

GPs should avoid imaging if possible, however, and the guidelines rule out use of electrotherapies such as TENS (transcutaneous electrical nerve stimulation), and spinal injections.

But GPs can consider referral for radiofrequency denervation in patients with moderate to severe pain that has not responded to other treatment, and epidural steroid injections for people with acute sciatica.

Of potential surgical interventions, only spinal decompression is recommended – in people with sciatica that has not responded to non-surgical approaches.

Previously GPs could offer a course of 10 sessions of acupuncture, or manual therapy, as alternative options to an exercise programme. However, NICE guidelines advisors say the most up-to-date evidence shows that acupuncture is no better than sham treatment and that there is no evidence to support physiotherapy on its own.

Dr Ian Bernstein, a GP expert in musculoskeletal therapy who advised on the updated guidelines, says: ‘The diagnosis of back pain includes a variety of patterns of symptoms.

‘This means that one approach to treatment doesn’t fit all. Therefore the draft guidance promotes combinations of treatments such as exercise with manual therapy or combining physical and psychological treatments, and the choices made should take into account people’s preferences as well as clinical considerations.’

NICE Draft CG88 Update - Non-specific low-back pain and sciatica: management

NICE draft guidelines on management of low back pain and sciatica - key points for GPs

Assessment and diagnosis

GPs should consider carrying out risk stratification (for example, the STarT Back risk assessment tool) when a patient first presents with non-specific low back pain with or without sciatica, ‘to inform shared decision-making about stratified management’.

GPs should not routinely offer scans in a non-specialist setting, and explain to patients that referral to a specialist does not necessarily mean they need to have a scan


  • Do not offer acupuncture, but offer patients a suitable group exercise programme, including biomechanical, aerobic, mind-body exercises or a combination of these.
  • Consider manipulation and massage – but only alongside exercise as part of multimodal treatment
  • Prescibe an NSAID for managing pain where possible – but at the lowest dose possible for the shortest possible amount of time
  • Only offer paracetamol second line, and in combination with a ‘weak’ opioid like codeine
  • Other opioids should not be prescribed for low back pain, nor antidepressants such as SSRIs, SNRIs or TCAs, or anticonvulsants

Readers' comments (66)

  • NICE as usual is talking in tick box medicine world where patients are clones and have all read and behave in the way that the scientific papers and textbooks tell them to.

    It fails to differentiate between people with acute back pain who are desperate to get back to or to keep working and those who clinically are in danger of developing chronic low back pain syndrome.

    It also assumes working GP's throughout the country have access to structured exercise programmes and STarT Back schemes at their fingertips.

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  • Vinci Ho

    A 'helpful' guidance should address options for both acute crisis and ongoing contributing factors.
    Cannot see this one size fits all crises....

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  • Having spent much of the week looking at MRI reports (none ordered by me)it is clear that a lot of disability is due to disc lesions ,Yes most get better in practice but those that don't need a rational plan of action ,a clear lesion can be refered a normal spine told it will get better ,ok I am seeing the failures but thee are a lot of them ,perhaps NICE should do my job.

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  • Well guidance fots with what I know about pain relief in acute its mostly spasm and often need a lot pain relief....also GPs using start back tool and giving advice or exercises is not GP core and therefore should refer physio

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  • Actually this is not a joke. For anyone out there who would like to try some herbals for back pain, two good ones to start would be cayenne pepper in capsules (this improves blood flow and has an analgesic reaction) and tumeric capsules with black pepper (as the black pepper aids tumeric absorption). Tumeric is an excellent natural anti-inflammatory.
    A previous post mentioned omega 3 oils, which also are excellent.
    Also an epsom salt bath (use a teaspoon of epsom salt in a warm bath) and the warm water and the salts (magnesium sulphate) will ease the muscle spasm in the back within a short time.
    If nothing else works, what can you lose? As many pharmaceuticals are based on natural substances, these make sense, but as they dont make much money for big pharma, these are not promoted.
    I use these and many other nutrients and herbals all the time to reduce soft tissue injuries successfully. They not only are effective but do not have the gastric side effects of steroids or non steroidals.
    I know many will not want to understand this or want to know any more but I have found there is a world of treatment outside of conventional medicine which really really works!
    However since they are not 'licenced' they will not be used.
    Have fun with your aching back......

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  • I disagree with no acupuncture for back pain. Acupuncture is used in Pain Clinics run by Anesthetist in hospitals and NICE may discourage its use in Pain Clinic as well. In my experience it is helpful and and coupled with electroacupuncture is 60-70% effective in relieving or stopping pain. If sham acupuncture is no better than than the traditional point acupuncture but is effective be it placebo wise, or stimulating endorphan release or other non Chinese scientific theories of how it works then no use relegating acupuncture as worthless. Physiotherapist are using acupuncture - needling tender points - so called "dry needling". What are the Physiotherpist saying about it?

    Paracetamol has been widely recommended for back pain and a report from The George Institute for Global Health and the University of Sydney published in the British Medical Journal published 01 April 2015 stated Paracetamol doesn't bring any benefit for patients with back pain (and it brings only trivial benefits to those with osteoarthritis.

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  • Vinci Ho

    Nigel , is there any way to ensure NICE and its 'subordinates' will read these interesting comments.
    Please keep sending in ,folks.

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  • Very odd indeed,most patients would have tried paracetamol,ibuprofen,codeine / paracetamol tablets ,all available over the counter.If i say " take paracetamol " whats the reply? Err,but i have done that !!!!!!!! I have come for something stronger. " However there is some truth in these recommendations,as i have seen dozens of patients especially those who have been to the pain clinic having had acupuncture,physiotherapy,and are on pregabalin,patches,strong opiods,duloxetine,and are no better .but its so hard to take the drugs off them,after all'the hospital doctor prescribed them,i have onçe added up the cost--- pregabalin,patches duloxetine are up to 70 pou ds a month,they have several hundred pounds worth of medication but are no better. This is the scandal. In my darker days i just think. " why dont we give them this money instead,it will be better spent .,simply because these people are often on long term benefits,and live drab boring lives compared to many others. As regards acupuncture i never believed it worked. However i have mid foot arthritis and chronic pain. I we t to a chinese high street acupuncturist. Had acupuncture on my foot,with electrical stimulation between the needles ,and the pain went away for a whole two months. I could walk without limping. I also had steroid injections xray giuded at the local hospital,this'also worked but again only for two months ,neither were placebo.

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  • Memo from Ivory Towers; use no drugs please, we are skint, and if you can just involve the physiotherapists we'll be saved.

    Memo in reply; you just dont understand me anymore, do you?

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  • Don't knock herbal remedies folks- I had a patient who grew Papaver Somniferum in his garden and he informs me a tea made from the pods really helped his backache.Haemorrhoids were, in his opinion, a tolerable side-effect.

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