Shipman's long shadow

After my shifts at the out of hours this weekend I noticed something about the morphine. In the last week I was the only GP that signed out any morphine to take on home visits.

Now there are a couple of possibilities: either I am the only doctor that has been required to go on any visits in an area that covers an area across three counties in the past week or I am the only doctor who took morphine out when I did it. I am pretty sure I know which it is.

I have had a lot of discussions with colleagues recently about using and carrying morphine. Many are deeply anxious about using a drug that has been demonised by Shipman and been the object of such severe scrutiny by the authorities. If anything goes wrong with morphine and it is highly likely you will be suspended pending a full police investigation. And things can go wrong. Even with the greatest care in the world, morphine, just like any other drug, has potential side effects. One of those side effects being that the recipient stops breathing. There is an excellent drug, naloxone, that reverses the effects of morphine. And it works just like this Trainspotting clip - a magical, instant recovery.



But the fact is that most GPs do not see the benefits of morphine to their patients outweighing the potential disadvantages to themselves.

However my opinion doesn't square with the evidence. The Healthcare Commission annual report on 'The safer management of controlled drugs' suggests that opiate use actually increased by in 2007. (Thanks to NHS Exposed for highlighting the report in this post last month).

Perhaps I could agree that I have seen an increase in prescribing of morphine and other opiates in palliative care in the past few years. I am also aware that amongst GPs that do prescribe 'core drugs' in palliative care it is common practice to prescribe a whole box to leave in readiness as the patient gets to the end stages. These often go unused and the data says nothing about actual morphine usage.

From the report:

"I am very pleased to hear the post-Shipman tighter governance arrangements have not been a barrier to patients receiving opioid treatment.

I suspect that the increased use of Schedule 2 controlled drugs is partly due to their increasing use in the management of persistent non-cancer pain "

Dr Roger Knaggs
Specialist Pharmacist - Pain Management
Nottingham University Hospitals NHS Trust

My practical experience as a GP is that there very much is a barrier to some patients getting morphine. Most GPs are not carrying it and that is a pretty sizeable issue to overcome. Of course, a doctorate pharmacist in a secondary care hospital would remain utterly ignorant of this.

It is encouraging that opiate prescribing hasn't dropped through the floor but I remain highly sceptical that morphine use has increased as a primary care drug for patients in acute pain or having a heart attack. While one can still expect morphine if one is dying or in chronic pain it is being eradicated as a drug for the acutely unwell in their own home. I wouldn't expect this to show up in these statistics - it is always going to make up a fraction of the total morphine prescribed.

The report doesn't go into these details but it does note the relatively greater increase in drugs such as oxycodone. I asked a palliative care specialist last year why oxycodone is a better drug than morphine and he freely admitted he couldn't give any clinical reasons. Perhaps it is the placebo effect of fancy packaging or perhaps simply because it is not morphine. (I also noticed the increased prescribing of benzodiazepines by nurses but that is a rant for another day.)

The Healthcare Commission's report should not lull anyone into complacency. It is very possible that we are leaving patients in pain on occasions and inadequately treating life threatening conditions as a consequence of a state noose of controlled drug regulation around the necks of clinicians that use morphine in patients' homes.

We need some further research into the actual patterns of use of morphine post-Shipman and and exploration of GP attitudes to this group of drugs. Any potential collaborators please feel free to email.