Authors' Response

Abstract

To the Editor: Goudas and Carr touch on some interesting points. Central is the issue of who to treat, and with what. Evidence can help in several ways. For instance, knowing the relative efficacy of interventions for acute pain1McQuay H.J. Moore R.A. An evidence-based resource for pain relief. Oxford University Press, Oxford1998Google Scholar, 2Oxford League Table of Analgesic Efficacy. Available at http://www.jr2.ox.ac.uk/bandolier/booth/painpag/index.htmlGoogle Scholar demonstrates that some interventions are clearly better than others. Oral NSAIDs at standard doses, and combinations like paracetamol 1000 mg plus codeine 60 mg, do particularly well. A problem is that adverse event information is not well collected, nor is it presented in standard format,3Edwards J.E. McQuay H.J. Moore R.A. Collins S.L. Reporting of adverse effects in clinical trials should be improved. Lessons from acute postoperative pain.J Pain Symptom Manage. 1999; 81: 289-297Scopus (52) Google Scholar so that we do not have equivalent relative harm to go with relative efficacy. The cost of individual interventions can be widely different between countries, and availability is a particular issue in many parts of the world, either because of supply or regulation. For these and other reasons (like the unique biology of the patient) we always hesitate before recommending any particular treatment, because evidence can be used only as a tool to aid our own judgment, not a rule to enforce judgments of others. Combination analgesics can be effective and provide more analgesia than either alone, as with paracetamol and codeine.4Collins S. Moore A. McQuay H. Paracetamol-codeine combinations versus paracetamol alone. Actual size of increase needs to be measured.Brit Med J. 1996; 313: 1209Crossref PubMed Google Scholar, 5Smith L.A. Moore R.A. McQuay H.J. Gavaghan D. Using evidence from different sources an example using paracetamol 1000 mg plus codeine 60 mg.BMC Med Res Methodol. 2001; 1: 1Crossref PubMed Scopus (24) Google Scholar The difficulty is demonstrating it, because single small trials will not have the power to do so.6Moore R.A. Gavaghan D. Tramer M.R. et al.Size is everything—large amounts of information are needed to overcome random effects in estimating direction and magnitude of treatment effects.Pain. 1998; 78: 209-216Abstract Full Text Full Text PDF PubMed Scopus (494) Google Scholar Our experience is that this is an agenda driven more by patents than science. NB: The quotation “The combination is good but ibuprofen is better” is not from our paper, but may mislead readers into thinking that it is.