Cost regulators for the NHS in England and Wales are planning to significantly reduce the treatment options for patients with lower back pain and sciatica, dropping acupuncture from the list and pushing back paracetamol to the second-line setting.

In draft guidelines, the National Institute for Heath and Care Excellence is recommending that, in the first instance, patients with lower back pain with or without sciatica are sent into exercise programmes or treated with non steroidal anti-inflammatories (NSAIDs). 

If first-line strategies are ineffective or not tolerated, patients can be prescribed a weak opioid such as codeine, with or without paracetamol.

However, the Institute is no longer advocating the use of acupuncture, “because there is not enough evidence to show that it is more effective than sham treatment,” according to Mark Baker, clinical practice director for NICE. Under previous guidelines, doctors were able to prescribe 10 sessions of acupuncture to patients.

Also crossed off the list are electrotherapies, selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, anticonvulsants, and spinal injections, and NICE is now advising that massage and manipulation should only be offered to patients alongside exercise.

“Our aim with this draft guideline is to give clarity and set out the most clinical and cost effective ways to treat low back pain and sciatica based on the best available evidence,” said Professor Baker, explaining the move.

In the UK it is estimated that low back pain is responsible for 37% of all chronic pain in men and 44% in women, with a total cost to the economy estimated to be over £12 billion per year.