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N E W   S C I E N T I S T     6 April, 1996

Give a drug a bad name...

Morphine is the world's most effective painkiller, yet because of its reputation as a dangerous drug it is rarely prescribed even to terminally ill patients

Rita Carter

EACH year in Britain thousands of cancer patients die in agony. Their deaths may be unavoidable, but the severe pain they suffer in their final few months can nearly always be safely and totally relieved. Tragically, it rarely is.

The magic solution that would allow the vast majority of terminally ill people to die in relative comfort is not expensive or dangerous. It is one of the oldest medicines known: morphine. For the past twenty years the use of morphine and related drugs to relieve pain has been strongly recommended by the WHO.

But because morphine is a narcotic and associated with heroin-a derivative of morphine-it has gained a reputation among the medical profession and the public as a dangerous drug. Care workers and experts in palliative medicine complain that too many patients in Europe are being denied the most effective painkiller available because doctors are scared of prescribing it. Indeed, in some European countries restrictive legislation makes it almost impossible for them to do so.

In 1994 Julia Addingtonhall, a psychologist at University College London, published a survey of the relatives of 2000 recently deceased cancer patients. It showed that 88 per cent of those patients had experienced chronic, and sometimes severe, pain before they died. Addingtonhall claims that the chances of a terminally ill patient obtaining adequate pain relief in a hospital in Britain are little better than if they were treated at home by their GPs.

"If you are tucked away in a general ward in some small district hospital, the chances of dying painlessly are probably no better than they were in the mid-Sixties. In some ways the pain is more tragic now because expertise in this area has increased phenomenally and there is no need for people to suffer."

Doctors' reluctance to prescribe morphine centres on a trio of enduring myths, say pain experts. The first is that morphine, even when used as an analgesic, is addictive. The second is that the dose has to be continuously increased to maintain the same effect. The third is that narcotics used for pain relief can hasten death. These beliefs are widely held by doctors, nurses, patients and governments, even though they were debunked long ago.

Minimal risk

"It hardly matters if a person on the brink of death becomes addicted," says Mike Harmer, senior lecturer in anaesthesia at the University of Wales College of Medicine. "But even if it did, I would say the risk is practically nil. We sometimes give patients in severe pain massive doses of narcotic-sixty or seventy times the usual amount. When the pain subsides they turn down the next dose you offer, walk away, and that's it."

A paper in The New England Journal of Medicine in 1980 revealed that the risk of creating addiction in a patient treated with morphine for pain relief is about 1 in 3000. Healthy people who take morphine for recreational purposes, however, are much more likely to become addicted. This is because narcotics work differently on people in pain. Patrick Wall, one of Britain's leading pain specialists at University College London, believes the condition brings about a change in the brain which causes morphine to be "mopped up" in a way that does not happen with healthy people.

"If you give morphine for the first time to someone who is not in pain they will feel nauseous and headachy," he says. "These side effects are quite rare in people in pain-the pain itself seems to protect them against most of the undesirable actions of the drug, including the ability to induce addiction." Wall also dismisses the second myth-that it must be given in increasing doses. He claims that if morphine is being used for pain relief "there is no need to up the dose unless the pain gets worse".

The most potent and widespread myth of all-that medicinal morphine can cause early death-is also largely groundless, according to Harmer. He claims a fairly small dose could kill a person who is not in pain, but that with someone in chronic pain who has been taking morphine for some time "you can pump the stuff in almost without limit and not do them any harm . . . If anything, opiates will lengthen a terminal patient's life, because pain relief will allow them to eat, sleep and function better."

For the past two decades these findings have been trumpeted by pain specialists, the hospice movement and the WHO. But ridding morphine of the "demon drug" image has proved an almost impossible task in the face of the campaign against addictive recreational drugs with which, in many minds, morphine is inextricably linked. Bruno Simini, an Italian pain expert at Hospedale Generale Provinciale, Lucca, believes the drug will be adequately prescribed only if its name is changed. "Morphine evokes ideas of immorality, illegality, addiction and death," he says. "The very word is an obstacle to its prescription."

Even when doctors are not hampered by prejudice about narcotics, their patients often are. A Gallup Poll carried out in 1994 found that one in two adults would not want to take opiates for pain relief, even if they badly needed them. Some doctors, confronted with a terminal patient who is reluctant to start taking morphine, may hesitate before trying to persuade them for fear that they may be accused of euthanasia after the patient has died.

But the law in Britain on this subject is remarkably clear. Doctors are entitled to do whatever is necessary to ease suffering. Even if drugs were found to have "incidentally shortened life", provided they had been used primarily to ease pain a doctor could not be convicted of manslaughter.

If this does little to reassure GPs, the position in hospitals is no better. According to Ilora Finlay, chairman of the Association of Palliative Medicine, narcotics are often so tightly controlled in hospitals that staff cannot get them when their patients most need them. "Nurses are terrified of making errors with these drugs," she explains. "Some of them seem to be more worried about getting into trouble with their administrators than about having patients in pain." And yet, she adds, nurses are often better placed than doctors to monitor patients' pain because they see them the whole time.

One solution is to hand over control for dispensing morphine to the person who is actually feeling the pain. Patient-controlled analgesia (PCA) allows the sufferer to self-administer drugs according to need by using a small button-activated device connected to a drip. Studies have shown that PCA patients usually take less than they might otherwise have been given.

"Doctors tend to go for total pain relief and may end up with pain-free, but semiconscious zombies," explains Chris Wells, director of the Pain Research Institute in Liverpool. "Left to themselves patients are often prepared to accept some pain in order to stay clear-headed. PCA also allows them to match the dose precisely to their needs, so you get better pain relief for the same amount of drug." PCA has revolutionized postoperative analgesia, but it is rarely used in terminal care, partly because each device costs about 2000.

Finlay believes that pain relief comes low on the list of priorities in most hospitals in Britain, because they gauge their performances in terms of cures rather than quality of life. "We have got the expertise but the knowledge is not getting down to the doctors and nurses who need it," she says. "There are hundreds of pain experts, but most patients don't realise that referral to one is possible, so they suffer in silence. Things are getting better, but we still have a long way to go." Belief v. relief Elsewhere in Europe the situation is getting worse. In Catholic countries, where suffering is strongly associated with martyrdom and religious redemption, pain relief is seen as unimportant compared with the need to stop drug abuse. Morphine is therefore controlled so tightly that even doctors find it difficult to get hold of.

In Italy, Spain and Portugal doctors have to apply to the authorities in person to get the special forms needed to write narcotics prescriptions. In Spain and Portugal they even have to pay for the forms. Information and legislation on morphine varies remarkably from nation to nation, as does the frequency with which it is prescribed. A UN survey published in 1991 found that doctors in Denmark hand out an average of 3000 daily doses of morphine per million people, while those in Greece prescribe just 30 doses per million. British doctors distribute an average of 1450 daily doses.

Michael Zenz of Bergmannsheil University Hospital in Germany published a survey last year showing that between September 1990 and August 1993 only 2 per cent of terminally ill cancer patients in Germany were given morphine. "If their doctors had followed the WHO guidelines, 98 per cent of them would have got it," he says.

British legislation is remarkably liberal compared to the rest of Europe, though few doctors are prepared to take advantage of it. Any doctor can write any patient a prescription for morphine on an ordinary form. A special licence is required only if they are prescribing for addicts. "Your system is the envy of the world and we would dearly love to adopt it here," says Zenz. "But although we have demonstrated that there is no link between free opiate prescribing and drug abuse, our authorities do not seem to be convinced."

There are fears that the German phobia about narcotics could eventually dominate European practice to the extent that Britain would also have to adopt stronger restrictions on morphine. A working party in the Netherlands is holding talks about harmonising prescribing policy within the European Union. "Germany has the strongest voice in Europe," says Zenz, "and it is correctly-determined to continue the war against drugs. What is deeply tragic is that dying cancer patients should turn out to be the unwitting victims of that war."

Letter to New Scientist:

After the fall

Some 18 months ago I was unwise enough to slide off a roof while fixing a TV aerial. I fell 30 feet, landing flat on my back in the garden and leaving a noticeable crater (I'm 18 stone). I broke my collarbone and practically all my ribs, and comprehensively shattered my right wrist. Luckily, I was promptly attended to by paramedics and rushed to hospital, where my survival was in doubt for a week or so.

I spent some four weeks in what my wife (a nurse and midwife) refers to as the Intensive Scare Unit, where I had to be anaesthetised for a week or so because of uncontrollable pain. Then, after progressing through all the non-morphine painkillers available (Voltarol, and so on), none of which worked in the slightest (a period I would prefer to forget), I was rescued by a beneficent anaesthetic consultant who prescribed morphine ("Give a drug a bad name", 6 April, p 14, and Letters, 27 April, p 54) . This immediately made life bearable and I progressed rapidly .

When I transferred to an ordinary ward, an immediate battle broke out between myself and my wife on the one hand, and the junior doctors and ward sister on the other.

They expressed universal horror at my being on morphine ("We've got much better and safer things than that"). When asked by my wife to list them, they went through all the drugs that I had tried in intensive care.

Eventually, exasperated by this difficult patient and wife, the ward sister said: "Well, I'm not happy at his being on morphine at all. I think I'll call in Mr X, the pain consultant." We then gleefully informed her that it was Mr X who had put me on morphine in the first place. She glowered at us and disappeared, never to be seen again.

The ordinary nursing staff's attitude was interesting. I was aware of being rather disapproved of for needing morphine---as if I was a rather degenerate type, lacking in willpower, like an alcoholic or child molester.

When the consultant, Mr X, came back to prescribe oral morphine (instead of the injections I had been on), he set the dose at 140 milligrams, several times a day. I was to be on this regime for 3 or 4 days before discharge, to try it out.

Later that day, the junior doctor (a German---see your article for attitudes to morphine in Germany) reduced it to 80 milligrams, thinking 140 milligrams excessive. The resulting agony I experienced caused the consultant to be recalled, and he was less than happy with the houseman for altering his prescription.

When I got home, my GP and I agreed on a progressive dose reduction of 10 milligrams every 3 or 4 days. This was entirely without side effects. No withdrawal effects occurred in the 7 or 8 weeks it took to reduce the dose to zero.

Finally, I concur with J. Pryce's letter (18 May, p 57). Bearing in mind the medical trade's general attitude to pain, if ever there is the prospect of my being admitted to hospital with some terminal condition, such as cancer, I will purchase a small cylinder of nitrogen and sit at home and inhale the lot. I would never again willingly put myself at their mercy.

R. M. Buck, Sheffield England.



  




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