Intended for healthcare professionals

Rapid response to:


Life without COX 2 inhibitors

BMJ 2006; 332 doi: (Published 01 June 2006) Cite this as: BMJ 2006;332:1287

Rapid Response:

Life without COX 2 inhibitors

Shaughnessy and Gordon write in their editorial on the loss of COX 2
inhibitors that “there is good evidence that other pharmacological and non
-drug options may be reasonably effective, equally safe and less costly”¹.
They go on to give examples of both drug and non-drug measures which have
been shown to be effective in osteo-arthritis. However, their discussion
of opioids was not referenced. We find the omission of studies supporting
the use of opioids surprising, particularly when references for the non-
drug measures discussed were included, even when the effect sizes were
reported as small, or the data limited by small numbers.

Two systematic reviews of opioids in chronic non-cancer pain²,³
report several papers showing efficacy of opioids (morphine and oxycodone)
in osteoarthritis, demonstrating an average 30% reduction in pain
intensity, a level generally considered to be clinically meaningful4.
Whilst the authors of the Kalso systematic review note the worries of
addiction and drug diversion (presumably the reason they are referred to
as “a last pharmacological resort” by Shaughnessy and Gordon) and caution
that not all patients respond to opioids, in a more recent BMJ editorial
Professor Kalso observes that the British Pain Society has published
recommendations for the appropriate use of opioids in persistent non-
cancer pain5. The guidelines offer a framework for the safe prescribing of
opioids in conditions such as osteoarthritis6. A recent paper highlighted
that a quarter of GP’s sampled did not prescribe opioids for patients with
persistent chronic pain, and that prescription patterns were influenced by
the doctor’s beliefs about the appropriateness of opioids in chronic pain,
in spite of these guidelines7.

We are currently conducting a trial focusing on the patient’s
acceptability of opioids for osteoarthritis pain, which will add to this
debate and highlight the patient’s experience of opioid treatment. In
addition, one of us (CR) has recently completed a qualitative study
examining the views of patients with cancer pain when offered morphine.
Interestingly, the phrase most commonly used by these respondents was
“last resort” and this association meant that these patients delayed the
use of drugs like morphine for as long as possible, suffering from
uncontrolled pain as a consequence. Given the prejudice of this BMJ
editorial, perhaps we should not have been surprised that some of these
patients seemed to be reflecting the views of their physicians.

1. Shaughnessy, A.F. Gordon, A. E. Life without COX 2 inhibitors BMJ
2006;332: 1287-8

2. Kalso, E. Edwards, J.E. Moore, R.A. and McQuay, H.J. Opioids in
chronic non-cancer pain: systematic review of efficacy and safety. Pain
2004; 112: 372-380

3. Bloodworth D. Issues in opioid management. American Journal of
Physical Medicine and Rehabilitation 2005;84:S42-S55.

4. Farrar, J.T. Portenoy, R.K. Berlin, J.A. Kinman, J.L. Strom,
B.L.Defining the clinically important difference in pain outcome measures.
Pain 2000;88: 287-94

5. Kalso, E. Opioids for persistant non-cancer pain BMJ 2005;330: 156

6. The Pain Society. Recommendations for the appropriate use of
opioids in persistent non-cancer pain. A consensus statement prepared on
behalf of the Pain Society, the Royal College of Anaethetists, the Royal
College of General Practitioners and the Royal College of Psychiatrists.
March 2004.

7. Hutchinson, K. Moreland, A. Williams, A, Wienman, J. and Horne R.
(2006) Exploring beliefs and practice of opioid prescribing for persistent
non-cancer pain by general practitioners. European Journal of Pain. In
Press, Corrected Proof, Available online 17 February 2006

Competing interests:
None declared

Competing interests: No competing interests

07 June 2006
Colette M Reid
Specialist Registrar in Palliative Medicine
Jeremy Horwood, Research Associate, MRC Health Services Research Collaboration
Department of Palliative Medicine, BHOC, Horfield Road, Bristol BS2 8ED