Scenario

Dispensing assistant Ellen is talking to pharmacy technician Vicky during a quiet period in the dispensary. “Mum has been to the doctor about her backache, just to check that it wasn’t anything serious, and he told her that her tests were fine and to take paracetamol as and when she needs to. To be honest, she doesn’t take it that often, but I heard this thing on the news about how paracetamol shouldn’t be taken by people with backache. Is that true?”

Answer

The news item that Ellen has heard is probably the research conducted by a team at the University of Sydney in Australia, which concluded that paracetamol was ineffective at treating back pain and osteoarthritis, and could increase the risk of liver problems. Rather than being a study that directly involved patients, the researchers conducted a systematic review and meta-analysis of 13 randomised placebo-controlled trials, which are considered the gold standard in healthcare research, involving over 5,000 patients.

While the paper – which was published in the well-regarded and influential British Medical Journal (BMJ) – certainly grabbed headlines, it is important to weigh up its findings against other treatment options. As Royal Pharmaceutical Society pain management expert and British Pain Society Council member Professor Roger Knaggs commented: “There are other medicines, such as non-steroidal anti-inflammatory drugs and opioids, which may provide better pain relief, but these are associated with a range of other side effects.”

Ellen’s mum, who takes paracetamol only occasionally, should seek advice from her GP if she is concerned about how she manages her back pain.

The bigger picture

Paracetamol is recommended by the National Institute for Health and Care Excellence (NICE) as the first pharmacological management option for lower back pain, although this guidance is currently under review, with publication expected towards the end of 2016. One of the reasons for the amount of time it is taking to overhaul the document is that NICE is waiting for the Medicines and Healthcare products Regulatory Agency (MHRA) to complete its work investigating the safety of OTC analgesics. According to NICE, there are other measures Ellen’s mum can take that might ease her back pain, including staying physically active and exercising (rather than resting, which many people still believe to be beneficial), having a course of manual therapy such as physiotherapy or osteopathy, and trying a course of acupuncture.

It is also worth her trying to work out what factors trigger her back pain (e.g. poor posture caused by driving or sitting at a desk for long periods of time, or perhaps lifting heavy weights or objects) and addressing these issues if she can. The fact that she doesn’t suffer with her back to the extent that she feels the need to take painkillers all the time is encouraging, but she may also want to look at ways of trying to prevent further deterioration by losing weight if she needs to, wearing flat, supportive shoes, and considering her sleeping position and whether she might benefit from stress management measures such as learning relaxation techniques.

Extend your learning

• The thought of reading NICE guidance can be daunting, but in many cases, the main recommendations are quite easy to understand. Have a look at the relevant section in the guidance on the management of lower back pain at: NICE: Low back pain in adults: early management
• Similarly, many people shy away from reading clinical papers. A good way around this is to look at the abstract of a paper, as this gives a short and succinct overview of what the research was aiming to achieve, how it was conducted and what was found. Have a look at the abstract of the paper referred to in this scenario
• Are you aware that the devastating effects of a paracetamol overdose are due to the damage the drug can cause to the liver? Find out how much paracetamol you would need to take for liver damage to occur (you will need to know your weight in kg and have a calculator to hand), and how long it takes after overdose for the worst damage to become apparent by reading the section on paracetamol in the “Emergency treatment of poisoning” section of the British National Formulary.