Back in January, we highlighted a few clinical issues we thought would affect GPs in 2016. NICE featured a fair bit, primarily because there are a couple of important guidelines due this year that are likely to heavily impact a GP’s practice. We didn’t put low back pain in among them as we didn’t anticipate too many wide-ranging changes – a mistake, apparently. A few weeks ago, NICE released draft guidance for their new and updated low back pain guideline, now including sciatica. One of their key recommendations was to relegate paracetamol to second line, behind an NSAID, and to state that it should only be used alongside a weak opioid. It is not the first time NICE have attempted to downgrade paracetamol – they removed it altogether when publishing their draft osteoarthritis guidelines in 2013, only to reinstate it after mass outcry from GPs and health professionals. Perhaps learning from that error of judgement, NICE decided to push it back to second line for pharmacological treatment of back pain, rather than take it out of the guideline completely. To find NICE’s rationale for the move, you have to delve deep into the guideline – page 669, to be precise – for discussion on the sole randomised controlled trial used to inform the recommendation on paracetamol. The trial only considered ‘the short-term efficacy of paracetamol’, and the guideline development group felt that there was ‘no evidence to support paracetamol for the management of acute low back pain’. Yet it is still in the guideline. As it was when the final osteoarthritis guidelines were published in 2014. In that document NICE added a note about paracetamol, on page five, for all to see, bringing to attention a review demonstrating reduced effectiveness for paracetamol in osteoarthritis compared to what was previously understood, and the need for a deeper review of the evidence for paracetamol in this condition. The issue is that paracetamol is so ingrained in healthcare – both for prescribers and patients – that to remove it completely is going to take a lot of time, and a lot of evidence showing lack of effectiveness. What we might be seeing is the start of an attempt to phase out the drug from management, where appropriate, until more evidence is published. The heavy-handed approach from 2013 for osteoarthritis was too much, too soon. The small relegation to second-line treatment for back pain seems to have worked much better, perhaps helped by the fact that NICE have also advised against acupuncture – a recommendation that has garnered more criticism than anything else in the guideline. But even if that evidence arrives, there are still likely to be many people who experience enough benefit from the drug that it will remain in popular use long after it has disappeared from clinical guidance.