Expect analgesic failure; pursue analgesic success
BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f2690 (Published 03 May 2013) Cite this as: BMJ 2013;346:f2690
All rapid responses
In response to Adrian A Pierry (comment 1), although it sounds enticing, the use of placebos outside of trials is an ethical minefield, and not all placebos are as harmless as red sugar tablets. Here discusses these issues well. http://www.sciencebasedmedicine.org/answering-our-critics-part-2-of-2-wh...
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Your study shows that most of the effectiveness of taking medications comes from the placebo effect of taking the tablets and not from the active drug therein contained, for the harm almost certainly the opposite is the case.
This suggests that taking a placebo may be preferable for placebo responders.
The placebo responders can be found by their preference for taking placebos rather than active drugs, and the effectiveness of the placebos can be enhanced by the colour of the coating of the tablets as it has been shown for red coated analgesics, an empathetic approach of the practitioners, clear intuitive explanations and complicating the process of pill or potion taking.
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I entirely agree that the 'average' response to an analgesic is next to useless, but worse, it may be losing us the benefit of some valuable drugs.
I've not seen the population response curve for any common analgesics. Are they uni- or multimodal, as in the attached graph, where we clearly have two populations - one of which responds well, and the other of which responds poorly. The NHS is wasting money prescribing that particular drug to the poor responders.
We need somehow to obtain an analgesic profile for patients to prescribe according to need.
How many 'niche' analgesics have been discarded because their 'average' profile was too low, though they may have been very effective for a small minority who did not benefit from the more common analgesics.
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In my opinion, the analysis by Moore et al [1] was extremely informative, pragmatic and realistic. They suggest ‘a radical rethink of achievable analgesic effects, and explore how anticipating and recognising analgesic failure will help improve the management of pain’. Although the focus of their analysis is on the failure and subsequent use of pain drugs, a key component of chronic pain management has somehow been not given its due credence in terms of the pragmatic approach suggested regarding management.
Psychosocial factors play an equally important role as biomedical factors, especially in chronic pain [2], and even the authors highlight presence of considerable co-morbidity, and depression and quality of life as important measures [1].
Though it has been pointed out that there is lack of robust evidence for drugs to manage analgesic failures, a pragmatic approach suggested by the authors has been to continue to pursue analgesic success [1]. I agree with this approach but would like to emphasize the additional role of psychosocial management rather than a pure pharmacological-based approach. Moore et al [1] do mention, albeit briefly, about non-drug interventions. However, there is an increasing body of evidence that non-pharmacological management (especially cognitive behaviour therapy) is a key component in managing chronic pain [2,3], especially in light of the complex co-morbid issues mentioned earlier, and is an integral component of pain clinics across different parts of the world.
Non-pharmacological assessment and intervention can be efficacious and delivered in an integrated manner with analgesic-based services. Hence new research designs should address this aspect of management to provide evidence-based data, and pragmatic clinical management while pursuing analgesic success than failure.
REFERENCES
1. Moore A, Derry S, Eccleston C, Kalso E. Expect analgesic failure; pursue analgesic success. BMJ 2013; 346; f2690.
2. Moore JE. Chronic low back pain and psychosocial issues. Phys Med Rehabil Clin N Am 2010; 21: 801-15.
3. Williams AC, Eccleston C, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev 2012; Nov 14; 11: CD007407, doi: 10.1002/ 14651858 CD007407.pub3
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The 'analgesic' nightmare
The BMJ article by Andrew Moore et al entitled 'Expect analgesic failure; pursue analgesic success' (1) referred to the inability of opioid analgesics to cope with chronic pain.
This article has been cited five years later by David Cohen in the London Evening Standard (2). He seems to feel the BMJ clarion call was a decisive confrontation with Big Pharma - which nonetheless ignored Professor Moore's warnings.
Unlike Moore's BMJ article, the Evening Standard pieces explain how opioid addiction is 'America's nightmare'. The headline is 'The Opioid Timebomb.' Tens of thousands of victims have perished across the United States because of opioid overdose. David Cohen quotes one tragic individual: 'The whole pain industry is sick and it has completely ruined my life.'
The corporate misbehaviour of Big Pharma, in terms of issues such as tax avoidance, is grimly emphasized by David Cohen.
While the Moore article does not elucidate the dilemma of how 'pain-killing medicine' is actually destroying very vulnerable people, this subject is the focus of a subsequent BMJ editorial (3), by Becker and Fiellin. The latter details ploys on diverse fronts - from duped journals to sham advocacy groups to the aloof FDA - that contributed to the opioid disaster in today's America.
But the BMJ editorial does not cite another strategy of the giant opioid corporations - which is the funding of 'culture'. For example, the huge Serpentine Sackler Gallery, in South Kensington, depends on money from Big Pharma's involvement in the opioid crisis. Donations to the arts are a core ploy in providing Big Pharma with a bogus legitimacy.
REFERENCES:
(1) Expect analgesic failure; pursue analgesic success. Professor Andrew Moore et al. BMJ 2013; 346
(2) Evening Standard. David Cohen. Investigations Editor. March 15. May 11. 2018.
(3) The making of an opioid crisis. Becker and Fiellin. BMJ 2017;357:j3115
Competing interests: No competing interests