Sister Morphine

This weeks BMJ has the Rolling Stones song reviewed as its "Medical Classic", in a slot generally reserved for worthy tomes like "The Conquest of Pain" or medical novels like "The Citadel". I'm a bit miffed, because I'd already decided on it for the title of this follow on post from the earlier post on heroin. Not actually miffed enough to change it though you'll notice.

The thing is it rather fits what I've got to tell you. Not so much the song as the title to be honest. You see Mick and the boys were rather reinforcing what I had to say last time with their plaintive song about addiction, but this time I want to point out the undoubted therapeutic value of this much maligned drug.

For years Morphine has been a "back of the cupboard" "painkiller of last resort" "fit only for the dying" sort of a drug. True there has been increasing use of morphine drips for post operative pain in recent years (these days even administered at a rate determined by-- of all people-- the poor soul who has the pain). And as suggested, Sister M and her bigger beefier cousin Diamorph' have been the mainstay of end of life pain relief since Hippocrates was in short chitons. Anyone with any involvement in such care will recognize the beatific change in countenance that comes when a pain ravaged patient finally achieves symptom control through their tender mercies.

There's a lot of guff talked about the "Doctrine of Double Effect" that implies it's o.k. to administer potentially lethal doses of opiate to relieve pain. Given methods of administration widely available for at least three decades this has never been a part of my reality or that of my patients. Used correctly opiate analgesics kill one thing and one thing only. Pain. Abuse and overdose are not and have never been therapy and should not be allowed to confuse the issue.

Once every eight to ten years we are sold a new "miracle" non-opiate pain killer. They tend to be derived from some species of anti-inflammatory, are heralded with a vast fanfare, tried with enthusiasm by many of us, and within twelve to eighteen months turn out to be no better than, more expensive than and often more toxic that all non-opiate analgesics that have gone before them. Then they disappear or dwindle to a background, occasional, niche painkiller for when everything else (except morphine) have been tried.

Recently we have had to appreciate that a whole class of painkillers-- the non-steroidal anti-inflamatories, can do bad things to aging kidneys, making them hard to use in severe arthritis (which is precisely where you might want to be able to use them). So the poor punters are left with paracetamol plus or minus a bit of codeine. This seldom works, but it's rare that a patient will welcome the offer of a tiny dose of morphine to help give back their pain control.

Which is a shame.