Is it ethical to prescribe paracetamol for acute low back pain and osteoarthritis?

For patients with uncomplicated back pain or osteoarthritis, clinicians have long recommended paracetamol as the first-choice analgesic. However, a large randomised controlled trial (the PACE trial) established that paracetamol, on average, was no more efficacious than placebo for acute uncomplicated low back pain,

a finding corroborated by a meta-analysis examining the safety and efficacy of paracetamol.

Despite the increased precision provided by the meta-analysis regarding the size of the effect of paracetamol in acute low back pain, heterogeneous effects of the drug might not be revealed, a possibility that warrants further attention. With regard to osteoarthritis, the aforementioned meta-analysis noted a statistically significant but not clinically relevant effect of paracetamol on pain and disability compared with placebo,

although a larger, more recent, network meta-analysis found no such effect.

Taken together, this growing body of research indicates that there is little evidence to support the prescription of paracetamol for acute low back pain

and, at best, only weak evidence for its use in osteoarthritis. Despite this evidence, not only do many clinicians continue to recommend paracetamol for these conditions, but treatment guidelines also seem to be equivocating, having acknowledged the insufficient efficacy of the drug but at the same time continuing to support its use, albeit less enthusiastically.