Coffee House Spectator Health

Paracetamol might not ease back pain – but doctors should prescribe it anyway

28 July 2014

Upon seeing the headline ‘Paracetamol does not help lower back pain’, I found myself emitting a small (well – actually quite a large) sigh. The image of queues of angry patients brandishing pitchforks and newspapers, demanding to know why I’ve been withholding ‘the good stuff’ and tricking them into taking pointless pills, came to my mind. I worry about health articles in the general press, particularly the transformation of clinical trials and evidence into headlines and soundbites; that the reader won’t necessarily read the whole article, or account for the limitations of the evidence, just taking home a simple one-liner: in this case, that paracetamol – arguably the most widely used painkiller in the country – is useless.

In this story, the study seems strong. A trial in Australia, published in the Lancet, concluded that paracetamol did not improve pain intensity, sleep quality or recovery time versus placebo among 1652 people with acute back pain. Notable limitations are that the participants’ pain was not severe enough to warrant time off work, nor in most cases to require additional painkillers. Despite the headline, the study doesn’t suggest that paracetamol is ineffective against all types and severities of back pain, or other pains. However it does highlight some interesting points, not least the issue of placebo effect, but also that paracetamol is largely considered to be one of our safest painkillers, and a blanket move towards prescribing other drugs first would likely bring with it problems relating to side effects as well as other risks.

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People in pain generally want to determine that the cause is not serious, treat that cause and stop the pain. For simple back pain, treatment is normal movement, exercise, and time. Painkillers help people achieve the normal movement and exercise, and allay the symptoms as the condition improves. Patients vary from those who refuse painkillers – not wanting to ‘mask’ the pain for example – to those with a willingness to try anything to stop it. The placebo effect shouldn’t be disregarded, particularly in treatment of highly subjective symptoms like pain (in contrast to conditions, such as high blood pressure, with more measurable outcomes). In my experience the evidence that paracetamol is an effective painkiller is strong. With respect to simple back pain, even if a proportion of this success was down to placebo effect, one might argue that as a safe, cheap, widely available drug, this doesn’t necessarily weaken its usefulness. It would be interesting to see if reading an article like this has an effect on patients’ perception of paracetamol. This remains to be seen, but until then, and until further research is carried out, back pain treatment will likely remain much the same.

Michael Banna is a GP in West Sussex with an interest in Mental Health and Medical Education, who can generally be found either eating cake or wishing he had eaten less cake.

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Show comments
  • Jennifer Lawrence

    Paracetamol has done nothing to help me with back pain. The best thing I
    have tried except prescription drugs are a Posture Right from lutaevono. It
    really keeps you’re back posture correct and relieve any pain.

  • Picquet

    Bearing in mind that the article referenced here is based on research which produced a measured conclusion, and that: “The researchers say the mechanisms behind lower back pain may differ to those in pain felt in other conditions…”, I should say that the writer above is wasting his breath; his experience, lengthy and very relevant as it may be, can’t equal the rigor of the study.

  • Shenandoah

    Great, use pain relief if you need it: but why are people resistant to the idea of movement? This is, or can be, different from ‘exercise’ (i.e. something you don’t really want to do and which you’ll find exhausting). Gentle back stretches can help a lot, but non-exercisers mostly don’t know what these are. Sometimes the real answer is developing suppleness of body — and learning to hinge at the hip when you bend and not to move in jerky, over-taxing ways.

    This comes down to body awareness: people that move and have an interest in movement tend to develop it. Those that are not interested in themselves as physical beings don’t develop it. This is unfortunate, but everything we need to be healthy is actually given to us in the first place by nature. We all have a responsibility to ourselves, therefore, to keep nature in our lives — to be responsible for ourselves. No one else can do the work of staying alive FOR you.

  • Jackthesmilingblack

    Still limited as to the quantity of OTC Paracetamol you can buy at Boots, Britisher pals? Be advised that Boots have branches all over Bangkok, so next time you find yourself in the city of fallen angels, fill your boots … at half UK prices.

    • George Smiley

      GSL, P or POM. Nothing pharmaceutical is actually classed and scheduled as OTC in the United Kingdom.

  • Alexsandr

    paracetamol by mouth is not that effective. but intravenous its quite effective. I saw it give relief for a broken dislocated shoulder when morphine and codeine hadnt hit the spot.
    but Ibroprufen is a better bet. And the gels like Voltarol, and ketoprofin are quite effective if rubbed in well..
    there are some old remedies, like putting a door under your matress, and putting a hot water bottle on the sore bit. (some say put something very cold, not hot)
    and dont forget your osteopath.

    • SimonToo

      My grandmother was a great believer in the door under the mattress, but she did insist on the door handles being removed first.

    • El_Sid

      (some say put something very cold, not hot)

      It depends on the pain – joint pain needs cold, muscle pain needs warmth. It’s important not to do one when the other is needed, as it can make things much worse – but these days I would always use a hot/cold gel pack before resorting to painkillers.

  • Mark1984

    No, paracetamol should not be prescribed for types of pain-relief we know, now through research, will be ineffective. This is the same argument I’ve heard for giving obstinate patients antibiotics when they have viral infections. It’s better to be honest and educate people, than give them platitudes and hope the placebo effect (and time) will sort things out.

    • SimonToo

      You misunderstand the placebo effect. You go to the trouble of giving me some medicine and I shall go to the trouble of feeling better.

      • Mark1984

        Thank you for your reply, but I do understand the placebo effect (from what you wrote, I think it you that misunderstands it).
        We should be honest with patients, and not prescribe unnecessary medication, especially when simply giving them sugar pills would have the same effect.
        I would remind you that all medication has side-effects, and overdosing, even with paracetamol, can be harmful (and who doesn’t know/heard of someone who pops ‘pain-pills’ like tic-tacs). Moreover, knowingly prescribing analgesics, or any medication, in this fashion is unethical.

  • HookesLaw

    I would tend to agree with the doctor,
    I suffered from a back sprain causing significant pain and was taking big doses of paracetamol but its effects were very brief.
    Ibuprofen helped a lot more – I think because it reduced the inflammation.
    On the other hand tramadol had some very woozy side effects.

    • Charles

      Are you surprised that tramadol, a morphine derivative, made you woozy…?

  • London Calling

    I know its a right pain in the ass……a warm bath with lavender helps and you get a good nights sleep. I should know. I have suffered with lower back pain for many years now………..:(

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