Paracetamol: What you said

AJP asked readers if this ‘go-to’ drug is effective for acute and chronic pain conditions

Recently the Director of Pain Research at the University of Oxford, Professor Andrew Moore, argued that evidence – including a Cochrane review on acute back pain – shows paracetamol doesn’t work.

Professor Moore wrote in a guest blog published on Evidently Cochrane that the evidence for use of paracetamol in acute or chronic pain conditions such as back pain, osteoarthritis, neuropathic pain, cancer pain, postoperative pain and migraine is lacklustre.

In light of his post, we asked: should paracetamol be used? Here were your responses…

First-line drug for osteoarthritis

YES but depends on what is causing the pain,” commented Susan Edwards.

“For example for osteoarthritis:

  • Paracetamol is the first line analagesic recommended in the NICE guidance for the management of osteoarthritis, where it states, “Paracetamol and/or topical non-steroidal anti-inflammatory drugs (NSAIDs) should be considered ahead of oral NSAIDs, cyclo-oxygenase 2 (COX-2) inhibitors or opioids”
  • Australian Therapeutic Guidelines also recommend paracetamol first line for the management of osteoarthritis.

“The BMJ systematic review frequently quoted for lack of efficacy actually states in its conclusion, “For hip or knee osteoarthritis there was high quality evidence that paracetamol provides a significant, although not clinically important, effect on pain”.

“The authors of this systematic review have chosen a threshold for being “clinically significant” on average for the population. But this does not account for individual effects and for some individuals it is effective whilst for others it may not be.

“Let us not throw out paracetamol as being ineffective, it is worth trying for an individual with osteoarthritis and then following up (as with all medicines) to review the effectiveness (and adverse effects) for that individual patient,” said Edwards.

“Be critically questioning”

“In recent times there have been numerous studies and systematic reviews that have questioned the efficacy of paracetamol in osteoarthritis and low back pain. And paracetamol is not without side effects and toxicity in overdose,”  Consultant Clinical Pharmacist Debbie Rigby told AJP.

“I think it is important to practice evidence-based medicine, using the best available evidence together with your own clinical expertise and the patient preferences. So pharmacists should be critically questioning the ongoing use of paracetamol for chronic pain and osteoarthritis.

“If the patient perceives a benefit, and is not experiencing any harm, then I think paracetamol may be continued. But if there are alternatives supported by evidence, then we should discuss the options with the patient and their GP.

Is codeine the answer?

Regarding Professor Moore’s statements, Beefarmer responded: “This is why you need codeine.”

However, others disagreed.

“Nooooo,” said Debbie Rigby. “Evidence for codeine is lacking too, and has well-documented adverse effects plus potential for misuse, overuse and tolerance. Best evidence is for a biopsychosocial model.”

Chris Dickson agreed with Rigby. “Exercise is also more effective. Also for overweight people with OA, 5-10% weight loss will lead to pain reductions of up to 50%.”

Peter Bayly shared a past conversation on the topic.

“I recall a survey of pharmacists on Auspharmlist some years ago where the consensus of personal use was that paracetamol alone was useless,” he wrote.

“However,  many stated that combination with codeine even at low doses works for headache and now a study at home where n=2 shows that NSAID + paracetamol is also effective including pain relief of vertebral fractures.”

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