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:

Of Pain Clinics and Education

The doubts about the safety of NSAIDs are having a significant impact
on the ability of doctors to treat acute and chronic pain. It is a pity
therefore that Messrs Shaughnessy and Gordon did not mention that there is
a specialty of medicine dedicated specifically to managing pain.

A large proportion the work of my pain management colleagues and I is
spent working with older patients, helping them manage their problems
which are primarily degenerative musculo-skeletal. Our focus is partly on
the use of therapeutic agents (such as analgesics, acupuncture etc), but
more on the understanding of the pain problems, the reality of the
underlying situation (we are all getting old) and then addressing the
lifestyle changes that need to be made, dealing with the associated
depression and so on.

Perhaps one of the difficulties is the failure to see chronic pain as
a “chronic disease” like COPD, asthma, diabetes, stroke etc. Patients and
doctors often think that the pain can be cured with a well-placed
injection or a simple treatment. However, commonly the causes not only
don’t go away but also may progress. Therefore patients need help with
pain management rather than fruitless attempts to find a cure. Pain can
also be lethal disease. As examples, depression and despair can lead to
suicide and NSAIDs can lead to gastro-intestinal catastrophe.

Life without COX2 inhibitors will not change my personal practice.
Over the years I have spent much more of my time taking patients off these
drugs rather than initiating them. I now worry though that the reduced
usage of NSAIDs by GPs is going lead to an increased referral rate to our
Pain Clinics as they struggle to help their patients.

The authors are wrong to consider that opioids are "the last
pharmacological resort". There many other treatments that would qualify
for this title. Used appropriately, opioids are probably much safer than
NSAIDs even over the long term. However, doctors need to have the
appropriate skill and training in their use. This highlights the serious
deficiency in teaching about pain management in the curricula of medical
schools and postgraduate education programs (1). Personally I feel that no
doctor should qualify without being able to demonstrate the ability to use
the drug morphine for acute and chronic pain. Yet day after day I and my
colleagues see the most basic mistakes being made.

Thomas Sydenham, a 17th century physician wrote “Among the remedies
which it has pleased Almighty God to give to man to relieve his
sufferings, none is so universal and so efficacious as opium.” William
Serturner first purified morphine in May 1805. Both must be turning in
their graves knowing that even now in the 21st century we still can’t get
it right.

1. Notcutt WG. Purchasers should require providers to set standards for
pain relief
BMJ, Feb 1997; 314: 442

Competing interests:
None declared

Competing interests: No competing interests

06 June 2006
William G Notcutt
Consultant Anaesthetist
James Paget Hospital, Great Yarmouth, NR31 6LA, UK