I am concerned that an injustice is being done to the NSAID analgesics by the paper from Hawkey et al. due to inadequate controls [1]. Moreover, if it causes patients to stop taking these analgesics it could even have the perverse effect of increasing the incidence of myocardial infarction (MI). The reason is their control patients did not have the same risk factors for MI because they were not in pain and chronic pain is known to increase mood-related stress factors such as anger. For example, in placebo controlled conditions we have found significantly increased anger, anxiety, fatigue and sadness within a week of stopping NSAIDs that were given for chronic pain due to osteoarthritis of the knees [2]. Anger alone has repeatedly been linked to an increased incidence of MI. When I was seeking references to confirm this I found myself agreeing emphatically with another paper in this edition of the Journal [3] when a Google search on: ‘anger, myocardial infarction, stress’, produced over 91 000 pages in 0.55 s. To quote but one of these: The relative risk of myocardial infarction in the 2 h after an episode of anger was 2.3 (95% confidence interval 1.7, 3.2) [4]. Our work also showed that during a second week of active treatment these mood changes reverted towards the norm, suggesting that it is important to maintain good pain relief rather than risk patients reducing their medication to levels that cause frequent breakthrough episodes and possibly even adding to their troubles by worries about how much of the analgesic they should take.
I also noticed that a third paper in the same issue [5] made no mention of stress as a possible cause of increases in aldosterone during NSAID treatment. A Google search on ‘aldosterone, stress and mood’ produced ‘52 000 English or French pages’ in 0.33 s. They included a report of studies showing a clear link between experimental stress in volunteers and increased aldosterone concentrations in plasma [6]. Hence the cause of the rise in aldosterone that this paper seeks could well be the same one that seems to be undermining the reputation of the NSAIDs.
References
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