to the editor: I was pleased to read the article¹ on management of nonmalignant pain. The undertreatment of pain is a widespread issue in the United States, and helping to educate practicing family physicians in the most current pain management techniques is an important, even critical, goal.

I was disappointed, however, by the relative lack of information in the article on the two newest classes of oral analgesics: (1) tramadol (Ultram) and (2) cyclooxygenase-2 (COX-2) inhibitors, which represent a new type of non-steroidal anti-inflammatory drug (NSAID).

Tramadol has been available in the United States for five years. It is effective not only for an acute episode of neuropathic pain (as suggested in the article), but also for chronic neuropathic pain syndrome, fibromyalgia, osteoarthritis pain² and chronic low back pain.³ Tramadol may be most notable for what it is not—tramadol is not an NSAID, nor is it a typical opioid. Tramadol has a dual mechanism of action: it acts centrally at μ-opioid receptors and acts spinally, inhibiting the reuptake of monoamines (serotonin and nor-epinephrine). This may explain why tramadol and antidepressants are effective for some analgesic-resistant pain states.⁴

COX-2 inhibitors (rofecoxib [Vioxx] and celecoxib [Celebrex]) are used for a variety of indications: acute pain, dysmenorrhea and osteoarthritis. Further research is needed on the use of these drugs in the treatment of other painful states, but it is reasonable to assume, based on the available evidence, that COX-2 inhibitors are generally as effective as nonselective NSAIDs. Therefore, in cases of acute low back pain or chronic nonmalignant pain, COX-2 inhibitors should be especially useful for patients with inflammation and who are at high risk for gastrointestinal bleeding. Patients with such risk factors include those receiving treatment with “dual” NSAIDs, those receiving concomitant gluco-corticoid treatment, those with a history of gastroduodenal ulcers or bleeding and those receiving anticoagulation therapy.^5,6

The use of COX-2 inhibitors may be appropriate in chronic and acute pain states; however, they may still be associated with non-gastrointestinal adverse events (e.g., renal, hepatic, cardiovascular).^5,6

It is critically important that family physicians continue to be familiar with all aspects of pain management. I commend your efforts to call attention to the importance of this subject in primary care.

editor's note: A copy of this letter was sent to the author of “Treatment of Nonmalignant Chronic Pain,” who declined to reply.