The role of the pharmacist in low back pain management: A narrative review of practice guidelines on paracetamol vs Non-steroidal anti-inflammatory drugs

Main Article Content


Low Back Pain, Pain Management, Guidelines as Topic, Anti-Inflammatory Agents, Non-Steroidal, Acetaminophen, Pharmacies, Pharmacists, Australia


Low back pain (LBP) is a common and costly condition and a leading cause of disabilities across the globe. In Australia and other countries, there has been changes in LBP management guidelines and evidence in recent years, including the use of pharmacotherapy. Inadequately treated LBP is a burden with significant health and economic impacts. Although there is some variability, non-steroidal anti-inflammatory drugs (NSAIDs) have largely replaced paracetamol as the first-choice analgesic for non-specific LBP in many international clinical guidelines, including the current Australian Therapeutic Guidelines. More recent clinical evidence also supports that targeting LBP with the use of NSAIDs can provide superior and more effective relief of LBP symptoms compared with paracetamol. Community pharmacists are one of the most accessible and frequently visited health professionals that offer vital primary healthcare services aimed to provide enhanced clinical outcomes for patients. The position of a community pharmacist is pivotal in LBP assessment and management, from both a pharmacological and non-pharmacological standpoint, including the use of clinical guidelines, yet their roles are often not fully utilized in LBP therapy. Studies investigating the community pharmacist’s views, practices, knowledge, and roles, specifically in LBP management in Australia are variable and limited. This narrative review will briefly cover the impacts of LBP, and to provide a summary on recent evidence, updates and a comparison of the Australian and international low back pain management guidelines on paracetamol vs NSAIDs in LBP, as well as pharmacists’ roles and interventions in a primary healthcare setting in this context.

Abstract 1346 | pdf Downloads 592


1. Borenstein D, Calin A. Fast Facts: Low Back Pain. Oxford: Health Press; 2012.
2. Gowan J, Roller L. Disease state management: Low back pain and the pharmacist's role. Austr J Pharm. 2014;95(1126):72-77.
3. Maher CG, Williams C, Lin C, Latimer J. Managing low back pain in primary care. Austr Prescriber. 2011;34(5):128-132.
4. eTG complete. Low back pain. Available at: (accessed Apr 14, 2020).
5. eTG complete. Acute pain: a general approach. Available at: (accessed Apr 14, 2020).
6. Pillastrini P, Gardenghi I, Bonetti F, Capra F, Guccione A, Mugnai R, Violante FS. An updated overview of clinical guidelines for chronic low back pain management in primary care. Joint Bone Spine. 2012;79(2):176-185.
7. Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J, Maher C. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J. 2010;19(12):2075-2094.
8. Buchbinder R, Blyth FM, March LM, Brooks P, Woolf AD, Hoy DG. Placing the global burden of low back pain in context. Best Pract Res Clin Rheumatol. 2013;27(5):575-589.
9. Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, Williams G, Smith E, Vos T, Barendregt J, Murray C, Burstein R, Buchbinder R. The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014;73(6):968-974.
10. Walker BF, Muller R, Grant WD. Low back pain in Australian adults: the economic burden. Asia Pac J Public Health. 2003;15(2):79-87.
11. Lin CC, Li Q, Williams CM, Maher CG, Day RO, Hancock MJ, Latimer J, Mclachlan AJ, Jan S. The economic burden of guideline-recommended first line care for acute low back pain. Eur Spine J. 2018;27(1):109-116.
12. John Murtagh's General Practice, 5th edition. Sydney: McGraw-Hill; 2011.
13. Goodman DM, Burke AE, Livingston EH. JAMA patient page. Low back pain. JAMA. 2013;309(16):1738.
14. Mishriky J, Stupans I, Chan V. An investigation of the views and practices of Australian community pharmacists on pain and fever management and clinical guidelines. Pharm Pract (Granada). 2019;17(2):1436.
15. Oliveira CB, Maher CG, Pinto RZ, Traeger AC, Lin CC, Chenot JF, van Tulder M, Koes BW. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. Eur Spine J. 2018;27(11):2791-2803.
16. Australian Medicines Handbook. Adelaide: Australian Medicines Handbook Pty; 2020.
17. eTG complete. Pain assessment tools. Available at: (accessed Apr 14, 2020).
18. Low back pain and sciatica in over 16s: assessment and management. London: NICE; 2016.
19. National Health Committe. New Zealand acute low back pain guide. Available at: (accessed Jul 30, 2020).
20. Qaseem A, Wilt TJ, McLean RM, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166(7):514-530.
21. Almeida M, Saragiotto B, Richards B, Maher CG. Primary care management of non-specific low back pain: key messages from recent clinical guidelines. Med J Aust. 2018;208(6):272-275.
22. Maher C, Underwood M, Buchbinder R. Non-specific low back pain. Lancet. 2017;389(10070):736-747.
23. Wilk V, Palmer HD, Stosic RG, McLachlan AJ. Evidence and practice in the self-management of low back pain: findings from an Australian internet-based survey. Clin J Pain. 2010;26(6):533-540.
24. Koes BW, Enthoven WT. Do patients with acute low-back pain need paracetamol?. Lancet. 2014;384(9954):1556-1557.
25. O'Sullivan K, O'Sullivan P. The ineffectiveness of paracetamol for spinal pain provides opportunities to better manage low back pain. Br J Sports Med. 2016;50(4):197-198.
26. Williams CM, Maher CG, Latimer J, McLachlan AJ, Hancock MJ, Day RO, Lin CW. Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet. 2014;384(9954):1586-1596.
27. Williams CM, Maher CG, Hancock MJ, McAuley JH, McLachlan AJ, Britt H, Fahridin S, Harrison C, Latimer J. Low back pain and best practice care: A survey of general practice physicians. Arch Intern Med. 2010;170(3):271-277.
28. Hussein A, Choy C, Singh D. Malaysian low back pain management guideline. Available at: (accessed Jul 30, 2020).
29. Van Wambeke P, Desomer A, Ailiet L, Berquin A, Dumoulin C, Depreitere B, et al. Low back pain and radicular pain : assessment and management. Belgian Health Care Knowledge Centre (KCE). Available at: (accessed Jul 30, 2020).
30. Chenot J-F, Greitemann B, Kladny B, Petzke F, Pfingsten M, Schorr SG. Non-Specific Low Back Pain. Deutsches Arzteblatt international. 2017;114(51-52):883-890.
31. Stochkendahl MJ, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J. 2018;27(1):60-75.
32. Bernstein IA, Malik Q, Carville S, Ward S. Low back pain and sciatica: summary of NICE guidance. BMJ. 2017;356:i6748. Published 2017 Jan 6.
33. Chou R, Deyo R, Friedly J, Skelly A, Weimer M, Fu R, Dana T, Kraegel P, Griffin J, Grusing S. Systemic Pharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017;166(7):480-492.
34. O'Connell NE, Cook CE, Wand BM, Ward SP. Clinical guidelines for low back pain: A critical review of consensus and inconsistencies across three major guidelines. Best Pract Res Clin Rheumatol. 2016;30(6):968-980.
35. Koes BW, van Tulder MW, Ostelo R, Kim Burton A, Waddell G. Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine (Phila Pa 1976). 2001;26(22):2504-2514.
36. van Tulder M, Becker A, Bekkering T, Breen A, del Real MT, Hutchinson A, Koes B, Laerum E, Malmivaara A; COST B13 Working Group on Guidelines for the Management of Acute Low Back Pain in Primary Care. Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J. 2006;15 Suppl 2(Suppl 2):S169-S191.
37. Abdel Shaheed C, Maher CG, Williams KA, McLachlan AJ. Interventions available over the counter and advice for acute low back pain: systematic review and meta-analysis. J Pain. 2014;15(1):2-15.
38. Kuijpers T, van Middelkoop M, Rubinstein SM, Ostelo R, Verhagen A, Koes BW, van Tulder MW. A systematic review on the effectiveness of pharmacological interventions for chronic non-specific low-back pain. Eur Spine J. 2011;20(1):40-50.
39. Enthoven WT, Roelofs PD, Deyo RA, van Tulder MW, Koes BW. Non-steroidal anti-inflammatory drugs for chronic low back pain. Cochrane Database Syst Rev. 2016;2(2):CD012087.
40. Machado GC, Maher CG, Ferreira PH, Day RO, Pinheiro MB, Ferreira ML. Non-steroidal anti-inflammatory drugs for spinal pain: a systematic review and meta-analysis. Ann Rheum Dis. 2017;76(7):1269-1278.
41. Yabuki S, Ip AKK, Tam CK, Murakami T, Ushida T, Wang JH, Shin HK, Sun WZ, Williamson OD. Evidence-Based Recommendations on the Pharmacological Management of Osteoarthritis and Chronic Low Back Pain: An Asian Consensus. Asian J Anesthesiol. 2019;57(2):37-54.
42. Machado GC, Maher CG, Ferreira PH, Pinheiro MB, Lin CW, Day RO, McLachlan AJ, Ferreira ML. Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials. BMJ. 2015;350:h1225. Published 2015 Mar 31.
43. Saragiotto BT, Machado GC, Ferreira ML, Pinheiro MB, Abdel Shaheed C, Maher CG. Paracetamol for low back pain. Cochrane Database Syst Rev. 2016;2016(6):CD012230. Published 2016 Jun 7.
44. Miki K, Ikemoto T, Hayashi K, Arai YC, Sekiguchi M, Shi K, Ushida T. Randomized open-label [corrected] non-inferiority trial of acetaminophen or loxoprofen for patients with acute low back pain [published correction appears in J Orthop Sci. 2019 Jan;24(1):192]. J Orthop Sci. 2018;23(3):483-487.
45. Benrimoj SI, Frommer MS. Community pharmacy in Australia. Aust Health Rev. 2004;28(2):238-246.
46. Cannings J, Francis C, Jessop R. Consumer needs executive summary - 5th community pharmacy agreement. Australian Government Department of Health; 2015.
47. Roberts AS, Benrimoj SI, Chen TF, Williams KA, Hopp TR, Aslani P. Understanding practice change in community pharmacy: a qualitative study in Australia. Res Social Adm Pharm. 2005;1(4):546-564.
48. Hinnant D. Avoiding polypharmacy in treating chronic pain. Nursing. 1995;25(9):78.
49. Cairns R, Brown JA, Buckley NA. The impact of codeine re-scheduling on misuse: a retrospective review of calls to Australia's largest poisons centre. Addiction. 2016;111(10):1848-1853.
50. Hamer AM, Spark MJ, Wood PJ, Roberts E. The upscheduling of combination analgesics containing codeine: the impact on the practice of pharmacists. Res Social Adm Pharm. 2014;10(4):669-678.
51. McCoy J, Bruno R, Nielsen S. Attitudes in Australia on the upscheduling of over-the-counter codeine to a prescription-only medication. Drug Alcohol Rev. 2018;37(2):257-261.
52. Mishriky J, Stupans I, Chan V. Pharmacists' views on the upscheduling of codeine-containing analgesics to 'prescription only' medicines in Australia. Int J Clin Pharm. 2019;41(2):538-545.
53. Bennett MI, Bagnall AM, Raine G, Closs SJ, Blenkinsopp A, Dickman A, Ellershaw J. Educational interventions by pharmacists to patients with chronic pain: systematic review and meta-analysis. Clin J Pain. 2011;27(7):623-630.
54. Mishriky J, Stupans I, Chan V. Expanding the role of Australian pharmacists in community pharmacies in chronic pain management - a narrative review. Pharm Pract (Granada). 2019;17(1):1410.
55. Abdel Shaheed C, Maher CG, Williams KA, McLachlan AJ. Pharmacists' views on implementing a disease state management program for low back pain. Aust J Prim Health. 2016;22(3):211-217.
56. Downie AS, Hancock M, Abdel Shaheed C, McLachlan AJ, Kocaballi AB, Williams CM, Michaleff ZA, Maher CG. An Electronic Clinical Decision Support System for the Management of Low Back Pain in Community Pharmacy: Development and Mixed Methods Feasibility Study. JMIR Med Inform. 2020;8(5):e17203.
57. Lugtenberg M, Burgers JS, Besters CF, Han D, Westert GP. Perceived barriers to guideline adherence: a survey among general practitioners. BMC Fam Pract. 2011;12:98. Published 2011 Sep 22.
58. Slade SC, Kent P, Patel S, Bucknall T, Buchbinder R. Barriers to Primary Care Clinician Adherence to Clinical Guidelines for the Management of Low Back Pain: A Systematic Review and Metasynthesis of Qualitative Studies. Clin J Pain. 2016;32(9):800-816.

Most read articles by the same author(s)