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.

Anyone wanting to be enlightened on the folly of our current approaches to
drugs might want to look at the work of The Beckley Foundation, which also
includes a magnificent online library about drugs politics:
www.beckleyfoundation.org/