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Bad medicine: the rise of duloxetine

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g139 (Published 17 January 2014) Cite this as: BMJ 2014;348:g139

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Re: Bad medicine: the rise of duloxetine

Pain is indeed a very important issue. But the problems arises around the current definition "pain is what the patient says it is" is far too loose. For the reported incidence of pain varies ten fold by country [1 ] so this current definition is simply biologically implausible. Pain is cultural, not merely medical, and is the major medically unexplained symptom. To suggest 1 in 5 adults suffer chronic pain is counter-intuitive, defies common sense and experience. If we do not challenge this definition, flawed epidemiology and research, we risk widespread medicalisation.

The USA and other parts of the world are in the grip of an epidemic of deaths linked to these flawed assumptions with overuse of opioid medication for pain.[1 ] Also there are increasing concerns about the dangers of gabapentoids.[2] And today dangerous polypharmacy is the norm not the exception in pain management. But some in the pain international community seem unwilling to accept these concerns. Emotional defensiveness helps no one.

As for "declared interests" these are the same as "conflict of interest" , these links to Big Pharma being the rotten core of modern medicine and giving us a blinkered therapeutic mindset. As for a positive Cochrane review, this is indeed an endorsement, a medical marketing department gift. For pain is big business offering companies polypharmacy of lifelong branded medication.

Duloxetine may indeed be effective for some who have a narrow and definable condition like diabetic neuropathy. The point of my article is to express concern over the rapid rise of duloxetine prescribing and its potential use in unlicensed pain syndromes. I passionately believe we have a duty to the sick, but an equal duty to protect the well from iatrogenic harm.

[1] Spence D. The painful truth: deaths and misuse of prescribed drugs. BMJ 2011;343 http://dx.doi.org/10.1136/bmj.d7403

[2] Spence D. Bad medicine: gabapentin and pregabalin. BMJ 2013; 347 http://dx.doi.org/10.1136/bmj.f6747

Competing interests: No competing interests

11 February 2014
Des Spence
GP
general practice
Glasgow G20 9DR