Paracetamol for managing persistent pain

A recent study showed that paracetamol has little or no value in the management of two of the most common forms of persistent pain; spinal pain and osteoarthritis. This prompted the Pain-Ed team to reflect on why this might be the case for back pain, and what alternatives are worth considering. The relevant editorial was published here.

In summary, the scientific evidence is pretty conclusive that back pain is related to a wide range of factors. This is the case for most musculoskeletal pain in fact. These factors include not just the physical (e.g. posture or movements like bending/lifting) and anatomical (e.g. disc bulges) factors which are often blamed for back pain, when in fact they only explain a small proportion of back pain not getting better. Other relevant factors include lifestyle (e..g sleep, fitness, activity, stress, diet), social (e.g. relationships, financial stresses, work dissatisfaction), cognitive (e.g. what a person thinks is wrong with their back) and psychological (e.g. mood, fear) factors. The precise mix of these factors that is important for someone with back pain might actually vary between individuals.

Unfortunately, management of back pain (and many other persistent pain conditions) often remains focussed on treating symptoms, rather than the person. In other words, it often appears easier to give medications, massage, manipulation, or some other simple “quick fix” than to sit down with a person in pain and provide a personalised evidence-based understanding of the problem and help them develop a self-management programme incorporating exercise and lifestyle advice.

To reduce the disability associated with persistent painful conditions such as back pain, as well as the huge associated costs, there is a need for a fundamental shift in how persistent pain is perceived, and consequently managed. This is unlikely to happen until both healthcare professionals and wider society stop viewing pain as always being an accurate indicator of local tissue damage, when in fact pain is influenced by a much larger range of factors.

Finally, the fact that paracetamol is not very effective at treating persitent pain should not taken as a reason to consider stronger medications earlier, as these have been shown to have several side-effects, as illustrated well in  this video.


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