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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)

  • 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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