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SIR, We thank Dr Kittisupamongkol for raising the important question of analgesic drug use [1] in our cohort study of the mortality experience of individuals with musculoskeletal pain [2]. To analyse the effect of these drugs it would have required the collection of continuous drug information for the whole period of follow-up which was out-with the design of the study. The study was of a population cohort and all types of musculoskeletal pain were recorded. Over half (52.1%) of all subjects reported experiencing pain in the past month that had lasted for 51 week. Only a minority of those reporting pain would have arthritis and it is unlikely that a significant proportion of subjects with pain would be taking COX-2-specific drugs, although ibuprofen and diclofenac use would be more widespread. Although data showing an increased cardiovascular risk for these drugs do exist, the size of the risk is moderate [3]. The use of NSAIDs for pain should have resulted in a reduction of colorectal cancer risk [4]. Although we were unable to directly assess that relationship in the current study, this was one of the cancers researched in excess in our previous study [5]. The increased risk of cardiovascular deaths attributable to analgesic drugs in our study population is likely to be minimal and would be unlikely to explain the magnitude of the effect observed.

Comment on: Musculoskeletal pain is associated with a long-term increased risk of cancer and cardiovascular-related mortality: reply