>Sender: >To: >X-Original-Message-ID: <06ae01bf260f$89f4ccf0$9acf69cf@pacbell.net> >From: "Peter McWilliams" >Subject: Treatment of pain >Date: Wed, 3 Nov 1999 07:24:36 -0800 >X-Mozilla-Status: 8001 >X-Mozilla-Status2: 00000000 > > >Heroin is also not available for medical use in the United States, although >it is available for sale within a few blocks of most metropolitial >hospitals. > >Heroin was developed by the Bayer company, the inventors of aspirin, 100 >years ago and remains the best single pain-relief medication known. > >Sad, sad, sad. > >Peter > > >Pubdate: Wed, 27 Oct 1999 >Source: Irish Times (Ireland) >Copyright: 1999 The Irish Times >Contact: lettersed@irish-times.ie >Address: Letters to Editor, The Irish Times, 11-15 D'Olier St, Dublin 2, >Ireland >Fax: + 353 1 671 9407 >Website: http://www.ireland.com/ >Section: News Features >Author: Kathryn Holmquist > >THE POLITICS OF PAIN > >A palliative care nurse, whose brother died in great pain, believes a >drug banned in the State could have given him a peaceful end. Kathryn >Holmquist looks at the diamorphine debate > >'For many of us, the fear of our manner of dying is greater than the >fear of death itself," writes Dr Patrick Wall, one of the world's >leading experts on pain. And the suffering that many of us fear most >is cancer pain. > >Dr Wall, who himself has widespread cancer, writes that "cancer pain >is worse than useless. It provides absolutely no protective signal >because the disease is far advanced before it starts. Once started, it >announces the obvious and, if it goes untreated, it simply adds to the >miseries of impending death. Worse, untreated pain accelerates death. >Fortunately, the great majority of these pains can now be treated to >bring real comfort to the dying patient." > >Giving "real comfort" was an Irish-born nurse's experience as she >cared for dying patients in London. Then her 47-year-old brother came >home to die in Ireland. > >After many years working in the UK, her brother developed cancer of >the saliva glands in March 1998. By June 1999, the cancer had spread >to the bone. When he was told that he had little time left to live, he >chose to return home to die. At home, his pain was controlled by oral >morphine sulphate but this stopped working for him. At a district >hospital, he was given intravenous morphine, yet he cried out in agony >throughout the last 24 hours of his life. He died in August 1999. > >"I am a qualified general nurse of 27 years, having lived in England >for 31 years. I have seen many people of all ages and walks of life >die. Never have I experienced such distress in someone's last few >hours. His family witnessed his pain and distress, including our >mother and his 21-year-old son. Watching one's youngest child die is >traumatic enough, but for a mother to witness his enormous suffering >up to his last breath is barbaric," says the nurse. > >She believes her brother would not have died in such anguish if he had >been treated with diamorphine, the technical name for the opiate, >heroin, which is licensed for pain relief throughout Europe. In >British hospices, subcutaneous diamorphine administered by pump is >used routinely, after oral morphine sulphate, also an opiate, becomes >insufficient to stop pain. But the Irish Medicines Board has refused >to authorise diamorphine for use by palliative care doctors in the >Republic. > >"Too late to help my brother, I urge for the change in the pain >management of the terminally ill dying in our so-called enlightened >modern Ireland . . . there are 12-year-old children on the streets of >Dublin able to obtain illegal drugs with what appears little trouble, >yet in Irish hospitals and hospices, sick and dying are crying out in >pain." > >Should the use of diamorphine as a prescribed pain reliever be made >legal in the Republic? Would it have made a difference in this case? > >Dr Dympna Waldron, clinical specialist in palliative medicine, of Our >Lady's Hospice and the Royal College of Surgeons, felt very strongly >that diamorphine should be legalised for pain control in the Republic >when she returned from working in UK hospices seven years ago. >However, since that time, hydromorphone - an analogue of morphine >sulphate which is up to seven times stronger than the equivalent dose >of morphine sulphate - has become available as an alternative to >morphine sulphate. Hydromorphine is extremely effective in cases where >morphine sulphate stops working for the patient. > >At the same time, she remains convinced diamorphine would be a >valuable pain reliever for her Irish patients. "The more drugs you >have, the greater chance of fine-tuned pain control with minimal side >effects," she says. > >"There are other factors in relief of pain that we are becoming more >aware of with increasing research, in that it can be very valuable for >some patients that develop complications with one painkiller, to have >an alternative drug to rotate to with a different profile. And >diamorphine could be very helpful in that situation and would give us >a lot of added advantages. It would add ease to our daily work if we >had more availability of drugs rather than a rigid number, because all >have different breakdown profiles and maybe slightly different >actions," she explains. > >The Irish Medicines Board will not say why diamorphine has not been >approved. According to sources in the medical profession, the >Department of Health objects to diamorphine because it is heroin, and >there is a serious problem of heroin abuse in Dublin. > >There may also be cultural factors at work. There is a popular myth >that morphine and its related strong opioids are addictive and hasten >death, when in fact the opposite is the case. "The actual pain works >as the physiological antagonist to the side effects. A strong pain >with a strong dose can make the person brighter and more alert because >pain is relieved," says Dr Waldron. Morphine, diamorphine and other >opiates can help the suffering patient to live longer by relieving >pain. > >Palliative care has developed in the Republic in the absence of >diamorphine to a level that satisfies most doctors. Dr Michael >Moriarty, an oncologist in Dublin and medical spokesman for the Irish >Cancer Society, says that there has been "no strong demand" for >diamorphine. "The fact that the man in this case died in pain is the >issue, rather than diamorphine. Dying in pain is not just due to a >lack of diamorphine," Dr Moriarity asserts. > >This is also the view of Dr Michael Kearney, palliative care >consultant at Our Lady's Hospice in Harold's Cross. "People do die in >pain and that is not unique, unfortunately, although they are becoming >more of a rarity. Those stories were very commonplace 10 to 15 years >ago . . . I cannot comment on an individual case. I don't know why >this man had such an awful time, there's no excuse for it." But the >problem was not necessarily diamorphine, in his view. "Something else >may have gone wrong," he says. > >He explains that managing pain in bone cancer would involve several >drugs and that not everyone had expertise in the total management of >pain. Diamorphine would not have made any difference, in his view. The >drug, he explains, is rapidly broken down in the liver into morphine >and has exactly the same pain-killing effect. At St Christopher's >Hospice in London, studies comparing diamorphine and morphine have >revealed that both drugs work equally well. > >The difference between them involves administration. Morphine is less >potent than diamorphine, and therefore double the amount must be used, >which is less comfortable for the patient and less convenient for the >medical staff. > >This fact is stressed by Dr Nigel Sykes, head of medicine at St >Christopher's Hospice, London, where the hospice concept was created >in the 1960s by Dame Cicely Saunders. He uses morphine orally, and >diamorphine intravenously. He insists, however, that if deprived of >diamorphine, he would have no problem treating pain just as well with >morphine. The case of the nurse whose brother died in pain "sounds >like a problem with the total pain relief approach, rather than with a >lack of diamorphine," he says. > >Asked to comment, the local health board replied that it could not >discuss individual patients' cases with the media, even with the >permission of the family, although its spokeswoman defended the >expertise and quality of its palliative care. However, with her vast >experience of caring for dying patients, the nurse remains convinced >the unavailability of diamorphine was at the core of her brother's >appalling last hours. > > >================================================================ > >This message is sent to you because you are subscribed to > the mailing list . >To unsubscribe, E-mail to: