Drug related deaths continue to rise in the UKBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b3536 (Published 01 September 2009) Cite this as: BMJ 2009;339:b3536
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I have very good reason to question the non-use of opiates for pain.
When i was last in hospital I was put on a morphine sulphate pump. The
relief was very, very welcome.
I believe that opiates are very useful and important in pain
treatment and especially palliative care.
It would be cruel and inhuman to stop the use of opiates in many
cases. I can divorce my own interests from this debate but I have often
wondered about the anti-opiate lobby whether they can be equally unbiased.
Treatment is a medical matter for a doctor and patient to decide on;
not an ideal or moral issue based on statistics.
Competing interests: Methadone user
I am very concerned at what appears to be inadequate cooperation
among medical practitioners who I had always assumed worked in harmony to
improve the quality of patients' lives and save lives that can be saved.
If I have understood correctly, in the first few years of training,
medical practitioners learn that opiates, notably morphine and heroin
(Diamorphine) have an effect on the cerebellum and deprive the system of
oxygen. It is therefore advised that as there are numerous alternatives
available, they should absolutely not be used as a pain killer unless a
patient is terminally ill, very near to death and in excruciating pain
which no other pain killer can relieve.
Do I understood that those physicians who continue to prescribe these
drugs have forgotten what they have been taught or choose to ignore the
fact even when reminded? What is happening to the life-saving dictum of
the profession where some doctors are concerned?
In November 2008, I went to an emergency room at a clinic in Geneva ,
Switzerland where I live, with a blasting chest pain. My condition was
soon further complicated by excruciating pain in my left hip.
My new lease on life is because medical practitioners did not contest
my refusal of a morphine injection to relieve excruciating pain in my
chest and hip. The physicians attending to me would have loved to relieve
me of the pain with morphine but respected the knowledge, however little,
and understanding I had of the way in which opiates affect the brain and
therefore the entire system. They deprive the system of oxygen which is
desperately vital in my condition, Sickle Cell Disease.
I had double pneumonia and pleurisy. The infection had provoked a
sickle cell crisis. Before they had realised the extent of my illness, the
fact that I was a sickle cell disease (SC) patient was enough for the
physicians attending me NOT to insist on administering morphine. One of
them said that my pain had reached the maximum the human body could
Unfortunately, some physicians force patients to have morphine.
Whether one is a sickle cell patient or not, opiates in my opinion, are
not to be recommended.
I am allergic to aspirin and therefore must avoid no fewer than 34
prescription and over-the-counter medications, including Ketorolac
(Toradol) which is very effective in relieving excruciating pain.
There are so many misconceptions about sickle cell disease that I
took the book "The Sickle Cell Disease Patient" by F I D Konotey-Ahulu to
the clinic and my daughter handed it to the physician attending to me. My
three adult children are well informed about my health issues and
therefore telephoned Professor Felix Konotey-Ahulu abroad for guidance. My
physicians were very happy to consult with him by telephone. He confirmed
that I was right to refuse the administration of morphine and together
they co-operated in making me comfortable and well again.
I was fortunate enough not to need a blood transfusion (neither total
It may help medical practitioners to know that over the 12-days that
I was in the clinic in Geneva, medication I was given was Dafalgan,
Valium, Tramal, Perfalgan, Rocephine, Klacid, Franxiperine, Nexium and
Tavanic and Motilium lingual. I also had Oxygen, NaCl and Glucose. No
Morphine or Diamorphine!
On leaving the clinic in Geneva , I went to a convalescence clinic. A
physician at the convalescence clinic asked why I had refused morphine.
When I explained why, a colleague of his pointed to the back of his head,
reminding him of the effect opiates have on the brain.
I am privileged to interact with physicians for whom I have the
highest respect, one reason being because they take due consideration of
what I, their patient, say and they listen to my children as well. The
physicians are humble enough to take hold of a receiver and cooperate with
another physician abroad in saving a life. They admit to me that they have
been very happy to deepen their knowledge and would be pleased to learn
Had I been given the morphine or any other opiate, because of my
double pneumonia with sickle cell disease, I would not be writing today,
pleading with physicians to have compassion on patients who sometimes
suffer very uncomfortable psychological problems (however temporary) as a
result of having been given opiates and those who die as a result of
having been given opiates.
The physicians who seem not to understand should try putting
themselves in the position of families plunged into unbearable grief
because of carelessness - a loved one was given opiates unnecessarily.
In spite of myself I begin to wonder whether Professor Felix Konotey-
Ahulu's very practical and uncomplicated life-saving advice is being
ignored by some medical practitioners because of his African origins. I
believe his advice is based on what every medical practitioner learns at
Mawunu Chapman Nyaho
Competing interests: No competing interests
It is certainly worrying that deaths from drug poisoning(both legal & illegal) are on the rise. Similarly, it has been reported recently that fatal or serious medication errors in the NHS have doubled in two years.Do those terrifying statistics indicate various highly trumpeted professional safeguards aimed at improving patient-safety have failed to deliver their desired aims?
Competing interests: No competing interests
UK drug related deaths are still rising: So where is NICE?
Susan Mayor, 5 September, has done well to draw attention to 2
reports that reveal “the numbers of people dying because of poisoning from
legal and illegal drugs are still increasing”  The first report said
“Almost a third of the deaths where specific drugs were mentioned on the
death certificate were related to heroin or morphine” [1, 2] The second
report from St George’s University of London showed a 2.7% rise in the
number of drug related deaths confirmed by inquest. Here too “Heroin and
morphine accounted for most of these deaths” . And these were the very
drugs that the NCEPOD Report  found had produced deaths in sickle cell
disease patients from overdose, and about which I continued to protest [5-
HOW LONG WILL THIS CONTINUE FOR?
How long this situation is destined to continue is not clear. Writing
to the Prime Minister and Health Ministers as I did, produced a response
from Downing Street , but other ministers did not even bother to
acknowledge my letters of concern. The United States of America has
banned Diamorphine (Heroin) from all clinical practice , and that great
country does not even have a National Institute of Health and Clinical
Excellence (NICE). I would dearly want to know what percentage of the
members of NICE are practicing Clinicians. Do they not know that
Diamorphine suppresses respiration thus producing more in vivo sickling in
sickle cell crisis [10, 11, 12]? Never mind how many UK Professors of
Haematology approve of the practice, but do the Clinicians on NICE not
know that it is this “legal” Diamorphine that (as Susan Mayor writes) is
pushing up “the numbers of people dying because of poisoning from legal
and illegal drugs” ?
IS MY PROTEST JUSTIFIED OR NOT?
But why do I continue protesting like this? ANSWER: First of all, I
did not train in the bush somewhere in Africa. I was trained in London
University’s Westminster Hospital School of Medicine by Physicians and
Surgeons of King George VI and Queen Elisabeth II. My teachers taught me
never to give Diamorphine or morphine to someone who could not breathe and
whose red cells were bound to sickle further and clog up vital organs
. Secondly, I was second born of my parents’ 11 children 3 of whom had
sickle cell disease, allowing me to know much about the disease before I
went to university . Thirdly, I was once in charge of the largest
sickle cell disease clinic in the world, seeing personally hundreds of
patients in sickle cell crisis [15, 16], salvaging many to grow up to use
their brilliant non-sickling genes to achieve great things later in life,
an experience which led me to begin writing about the sickle cell disease
patient more than 44 years ago .
MY ADVICE TO NATIONAL INSTITUTE OF HEALTH AND CLINICAL EXCELLENCE
In the light of the above I make no apologies to take it upon myself
to advise NICE to stop standing on the sidelines, and add to their many
pronouncements one that forbids the “legal” use of Heroin (Diamorphine)
for sickle cell disease patients. This, at least, was one thing NICE could
learn from the USA .
GENETIC COUNSELLING AND VOLUNTARY FAMILY SIZE LIMITATION
The real answer for now, and the future, as I have been saying for
decades is Genetic Counselling and Family Planning [18, 19] warning my
fellow Africans that if they did not check themselves for a beta-globin
gene variant (an ACHE gene) they might suddenly find themselves with a
child born with an ACHEACHE phenotype (ACHE from father and ACHE from
mother), like Sickle Cell Disease, and “the genetic burden on the National
Health Service will go up and up” . If born in the UK, the child could
never escape Diamorphine treatment in sickle cell crisis. Was that really
a prospect my country men and women would cherish?
Felix I D Konotey-Ahulu MD(Lond) FRCP DTMH Dr Kwegyir Aggrey
Distinguished Professor of Human Genetics, University of Cape Coast, Ghana
and Consultant Physician Genetic Counsellor in Sickle & Other
Haemoglobinopathies, 10 Harley Street London W1G 9PF.
1 Mayor Susan. UK drug related deaths are still rising say two
reports. http://www.bmj.com/cgi/content/full/339/sep01_1/b3536 BMJ 2009;
2 Deaths related to drug poisoning
3 The St George’s Annual Report August 2009
4 NCEPOD (National Confidential Enquiry into Patient Outcome and
Death). SICKLE: A Sickle Crisis? (2008) [Sebastian Lucas (Clinical Co-
ordinator), David Mason (Clinical Co-ordinator), M. Mason (Chief
Executive), D Weyman (Research), Tom Treasurer (Chairman)] firstname.lastname@example.org
5 Konotey-Ahulu FID. Poor care for sickle cell disease patients:
This wake up call is overdue BMJ Rapid Response May 28 2008 BMJ 2008; 336:
1152 http://www.bmj.com/cgi/eletters/336/7654/1152a#196224 to Susan Mayor
“Enquiry shows poor care for patients with sickle cell disease” on
National Confidential Enquiry into Patient Outcome and Death (NCEPOD)
REPORT “SICKLE: A Sickle Crisis? (2008) email@example.com
6 Konotey-Ahulu FID. Current “hit and miss” care provision for
sickle cell disease patients in the UK.
http://www.bmj.com/cgi/eletters/337/jul11_2/a771#199135 BMJ Rapid
Response 22 July 2008
7 Konotey-Ahulu FID. Management of sickle cell disease versus
management of the sickle cell disease patient.
http://www.bmj.com/cgi/elettrs/337/sep08_1/a1397#202088 BMJ Rapid
Response 17 September 2008
8 Konotey-Ahulu FID. Inquest into diamorphine deaths: Does NCEPOD
sickle patients report warrant a similar inquest? BMJ Rapid Response March
9 Ballas SK. Sickle Cell Pain. IASP Press. Seattle 1998.
10 . Konotey-Ahulu, FID. Morphine for painful crises in sickle cell
disease. BMJ 1991, 302(6792): 1604. (June 29 1991) (Comment on Professor
Chamberlain's recommendation of morphine in pregnancy in sickle cell
disease - BMJ 1991; 302: 1327-30.) doi:10.1136/bmj.302.6792.1604-c
http://www.bmj.com/cgi/reprint/302/6792/1604-c.pdf PMID: 1855060 PubMed-
indexed for MEDLINE
11 Konotey-Ahulu FID. Opiates for sickle-cell crisis? Lancet 1998;
351(9113): 1438. May 9. PMID: 9593444 PubMed-indexed for MEDLINE
12 Konotey-Ahulu FID. Opiates for sickle-cell crisis. Lancet 1998;
352(9128): 651-652. Aug 22. PMID:9746049 PubMed-indexed to MEDLINE
13 Opiates for pain in dying patients and in those with sickle cell
disease. 11 October 2007 BMJ Rapid Response
14 Konotey-Ahulu FID. Sickle Cell Disease in successive Ghanaian
generations for three centuries (Manya Krobo Tribe) In The Human Genome
Diversity Project: Cogitations of An African Native. Politics and the Life
Sciences (PLS) 1999, Vol 18: No 2, pp 317-322. http://www.konotey-
15 Konotey-Ahulu FID. The Sickle-cell Diseases: Clinical
manifestations including the Sickle Crisis. Arch Inten Med 1974; 133(4):
611-619. http://archinte.ama.assn.org/cgi/reprint/133/4/611-pdf or
4818434 PubMed – indexed for MEDLINE]
16 Konotey-Ahulu FID. The sickle cell disease patient: natural
history from a clinico-epidemiological study of the first 1550 patients of
Korle Bu Hospital Sickle Cell Clinic. Watford Tetteh-A’Domeno Company 1996
& The Macmillan Press Ltd, London 1991/1992.
17 Konotey-Ahulu FID. Publications annually from 1965 to 2009
18 Konotey-Ahulu FID. Sickle Cell Disease: The Case for Family
Planning. Accra. ASTAB Books, Ltd 1973; 32 pages.
19 Ringelhann B, Konotey-Ahulu FID. Hemoglobinopathies and
thalassemias in Mediterranean areas and in West Africa: Historical and
other perspectives 1910 to 1997 - A Century Review. Atti dell’Accademia
dell Science di Ferrara ( Milan) 1998; 74: 267-307.
20 Konotey-Ahulu FID. Need for ethnic experts to tackle genetic
public health. http://www.thelancet.com/journals/lancet/article/PIIS0140-
6736(07)61771-1/fultext Lancet 2007; 370: 1836 [doi:10.1016/50140-
Competing interests: None declared.
Competing interests: No competing interests