Low back pain clinical guidelines: similarities and divergent views across the pond

Over recent months updated guidance on the management of low back pain in the United Kingdom and United States has been published by both the National Institute for Health and Care Excellence (NICE)¹ and the American College of Physicians (ACP),² respectively. It is interesting to reflect on the similarities and differences between the recommendations from each organisation and how recommendations change with time. Both organisations have transparent and rigorous procedures when reviewing evidence and assessing its quality, although perhaps NICE includes greater consideration of cost-effectiveness and health economic implications.

Both guidelines recognise the place of nonsteroidal anti-inflammatory drugs (NSAIDs) in the management of low back pain. However, the ACP recommends tramadol or duloxetine as second-line therapy for patients with persistent low back pain who have had an inadequate response to non-pharmacological treatments, whereas NICE does not recommend serotonin–norepinephrine reuptake inhibitors. The place of opioids is slightly different too. NICE recommends not to routinely prescribe opioids for acute low back pain and persistent low back pain. In contrast, the ACP considers opioids as an option only for patients in whom other treatments have been ineffective and only if the potential benefits outweigh the risks for individual patients.

In the previous versions, both organisations had recommended paracetamol (acetaminophen) for back pain; however, considering more recent evidence there is consensus that paracetamol is ineffective at improving pain and functional outcomes and that there are increasing concerns regarding harms. However, £68.6 million was spent on prescriptions for paracetamol tablets in England alone in 2015.³ Unlike for duloxetine, there is consensus from both NICE and the ACP that tricyclic antidepressants now have no role in the management of back pain, again different from previous versions.

Both guidelines highlight the lack of evidence in certain areas and both organisations propose different recommendations for further research. In addition to interventional procedures and spinal surgery, NICE suggests further studies of benzodiazepines, and codeine in combination with or without paracetamol, in the management of acute low back pain are required. On the contrary, the ACP proposes further research to compare benefits and harms of opioids and further evidence for most physical and manual therapies.

These updated recommendations from NICE and the ACP propose some significant changes for practice, particularly the perceived role for paracetamol by many healthcare professionals and patients, that will come with challenges for implementation. We need to consider the gaps in evidence and attempt to address them in future research. In addition, we must ensure that these changes in evidence and new recommendation are communicated to current and future students from all professions to ensure that older myths are not perpetuated for future generations.