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.
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.