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LETTERS: Gail Eva, Gregory Luke Larkin, Peter Leman, J M Kendall, B C Reeves, and V S Latter Nasal diamorphine in children with clinical fractures BMJ 2001; 322: 1367 [Full text]

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Oral morphine works too!

Gareth Greenslade   (5 June 2001)

Adequate take home analgesia for children

Julian Kennedy   (15 June 2001)

Oral morphine works too! 5 June 2001
Gareth Greenslade, Consultant in anaesthesia and pain management Pain Clinic, Macmillan Centre, Frenchay Hospital Send response to journal: Re: Oral morphine works too!	I do not wish to get involved in the debate about intranasal diamorphine's appropriateness, except to say that oral morphine is not ineffective, as asserted in the author's reply. Patients receiving oral morphine solution for severe pain usually experience its effects within 30 minutes of administration. Of course, if gasto-intestinal motility has been impaired by injury, the oral route is inappropriate. McQuay's group, in Oxford, has shown that oral analgesia could be used in many of the situations where we would instinctively reach for a parenteral preparation. This is particularly true when dealing with the post-operative pain of body surface surgery. If Eva Gail's son was fit for discharge home, then he was fit for oral morphine. An hour of observation, after the drug's administration, would have helped to ensure that the analgesia was adequate and that the dose had not been excessive. After all, why give analgesia without ensuring that it has worked and that it will continue to work for a reasonable period? This is akin to treating diabetes without checking the blood sugar again!
Adequate take home analgesia for children 15 June 2001
Julian Kennedy, Staff Grade A/E Bournemouth as above Send response to journal: Re: Adequate take home analgesia for children	EDITOR-Kendall et al in their letter of 2nd June issue state that ‘ none of the opioids would provide analgesia after discharge from the emergency department ‘ for the child with the fractured clavicle ’ and these agents are not suitable for outpatient use’. Is this research or evidence-based knowledge? I have recently got into serious trouble for using co-dydramol for a child with a fractured clavicle (not recommended in BNF)--I knew that paracetamol and ibuprofen would not suffice. What is wrong with oral codeine syrup (30mg per 5mls ) in a dose of 1mg/Kg? I find that it is one of the few analgesics I prescribe that works in adults and of course it can be used synergistically with ibuprofen. I always give advice about trying to avoid the inevitable constipation! Emergency departments (yes lets give up the’accident ‘ bit) need analgesics for children that are effective and can be taken away--there ought not to be a gap between the intravenous/intranasal opiates and the non-steroidals and paracetamol. Dr Julian Kennedy, Staff Grade, Emergency dept.,Royal Bournemouth Hospital.