NICE’s apparent war on pain relief medication – namely paracetamol – shows no signs of abating. Their recent back pain and sciatica guideline, released at the end of November, stuck with their draft recommendation of relegating paracetamol to second-line treatment, only to be co-prescribed with weak opioids.Weak opioids themselves are also second line, behind NSAIDs, while traditional strength opioids should not be routinely offered for acute low back pain. Instead, the focus is on self-management and exercise. Now GPs are meant to advise patients with back pain to continue with normal activities, and if appropriate, refer for group exercise classes. That’s all well and good, and the shift in focus to self-management and exercise is generally welcome, but there’s a real issue in asking patients to continue ‘normal’ activities when they haven’t got adequate pain relief. Most of them don’t present to a GP asking to be referred for group exercise, in fact a large percentage of patients don’t even believe exercise will help them with their back pain, they present because the pain is too much and they want something to relieve it. So GPs are potentially left in a bizarre position of prescribing pain relief that won’t be completely effective, and then suggesting that the patient continues with normal activities as far as they can. And we haven’t even broached the subject of referring to physiotherapy – the usual next step for patients with low back pain, and normally where group exercise classes are delivered in the NHS. There are few things more frustrating for a physiotherapist than a patient who has presented with back pain that hasn’t been controlled. You approach the situation with the best of intentions, planning to get them performing exercises you know can be helpful, only to find that they can’t because the pain is too bad. They then get sent back to their GP to get more pain relief, and then have to return to physio to start their treatment properly. All in all, around a week of patient time wasted (best case scenario), an unhappy patient and healthcare professionals looking like they don’t know what they’re doing.