Re: Opioids for chronic non-cancer pain
Opioids for chronic non-cancer pain – Chemotherapy – Clinical Guidelines: Where does Ultimate Responsibility Lie?
With the current pages of the BMJ showing misgivings about (a) Opioid use for chronic non-cancer pain , (b) Chemotherapy , (c) Clinical Guidance and Guidelines  – most diligent doctors are forced to ask “Who takes ultimate responsibility for the satisfactory care of our patients?”
DOES “MODERN” MEAN “BETTER” IN HEALTH CARE DELIVERY?
Dr R Freynhagen and colleagues present 19 excellent recommendations for doctors “prescribing opioids” – recommendations which challenge modern trends and the “aggressive marketing (that) have driven a dramatic increase in (opioid) use with more adverse events including deaths from over-dosage” . Indeed, the UK National Confidential Enquiry into Patient Outcome and Death (NCEPOD) revealed that “Nine out of the 19 patients with sickle cell disease who had pain on admission and who then died had been given excessive doses of opoids” [4 5]. I voiced my displeasure at this revelation , having pointed out previously that directing the largest Sickle Cell Clinic in the world I had never used morphine or diamorphine for a single one of the hundreds of patients I had supervised in Ghana with sickle cell crisis [7-10], nor had Graham Serjeant, the English man who in Jamaica directed the second largest clinic and who also had treated hundreds of sickle cell disease patients in pain [11-13]. Clinicians in the UK and USA are also prescribing oral morphine, in my opinion inappropriately, for the chronic arthritic pain from avascular necrosis of the femoral head in these patients. Has “aggressive marketing”  anything to do with this? 
IMPERSONAL GUIDELINES VERSUS CONSULTANT RESPONSIBILITY
Dr Des Spence, in his usual forthright manner, bemoans the received wisdom that makes doctors just follow what Guidelines recommend – often leading to individual clinical judgement being abandoned in favour of prescribed Guidelines that are inimical to the patient’s well being. “History will judge our era as one of iatrogenic harm” concludes Des Spence . Consultants no longer appear to take responsibility for what goes wrong – preferring rather to defer to Guidelines, sometimes very “nice” ones . The recent question mark over Guidelines, namely that “guidelines continue to be followed despite concerns about bias”  makes it all the more necessary that Consultants under whom patients are admitted take responsibility when things go wrong.
BRITISH MINISTERS OF HEALTH ECHO SIMILAR SENTIMENTS
Please do not dismiss my comments as the frustrated cogitations of a mid-20th Century British-trained African physician longing for the “good old days” when Consultants did what they knew was right and did not go round saying “The Guide Lines say this is what we should be doing”. British Ministers of Health would agree with me, because less than a fortnight ago, on Thursday 13th June, when interviewed for ‘The World at One’ News Bulletin Health Secretary Mr Jeremy Hunt said: “Where poor care exists we should not tolerate it. This is about Responsibility and Accountability”. One previous Health Secretary, Mr Stephen Dorrell, on the same programme also said that “Doctors should be accountable for the service delivered”. Neither Health Minister looked to blame Guide Lines and Guidance. Expertise does not at all appear to be the problem. Last Tuesday 19th June 2013, WORLD SICKLE CELL DAY, Tunu Louise Roberts, that accomplished former BBC interviewer, broadcast a 25-minute interview  for listeners in Africa and world wide, during which she asked me about the success of our work with sickle cell disease patients in Ghana whom we aimed at helping to become “Achievers in various professions”. My answer was simple: “Dedication, not so much expertise, is what is required to produce achievement in sickle cell disease patients whom I call ACHEACHE (ACHE gene from father and ACHE gene from mother). When we admitted patients at 5 pm very ill I, the consultant physician, would visit the ward at 11 pm to see if the nurses were doing what we ordered”. Graham Serjeant also did the same, enabling a sickle cell anaemia patient from Jamaica to go to Oxford University, just as we helped another ACHEACHE lady, now in her seventh decade of life, from Ghana to become Professor of Law after postgraduate work also in Oxford University. Serjeant and I, with our superb mid 20th Century British undergraduate and post-graduate training need no NICE Guide Lines to manage our patients [17 18]. We never gave regular blood transfusions to our sickle cell disease patients as if they had beta-Thalassaemia major, we never treated them with morphine or diamorphine for pain, and we never prescribed 500 mg Hydroxyurea daily as the Guide Lines stated. When the iatrogenic renal failures get out of hand Des Spence’s words will be remembered.
Competing Interest: Three of my parents’ 11 children had sickle cell disease (www.konotey-ahulu.com/images.generation.jpg) hence my critical scrutiny at how patients are managed or mismanaged.
1 Freynhagen Rainer, Geisslinger Gerd, Schug Stephan A. Opioids for chronic non-cancer pain. BMJ 2013; 346: 1237 doi:10.1136/bmj.12937 June 22, pages 38-41.
2 Spence Des. Saying ‘No’ to chemotherapy. BMJ 2013.346.doi. http://dx.doi.org/10.1136/bmj.14023 June 21 2013
3 Lenzer Jeanne. Why we can’t trust Clinical Guidelines. BMJ 2013; 346: f3830. June 22 2013, pages 20-22.
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 Mayor Susan. Enquiry shows poor care for patients with sickle cell disease. BMJ 2008, 336: 1152.
6 Konotey-Ahulu FID. Poor care for sickle cell disease patients: This wake-up call is overdue. BMJ Rapid Response 29 May 2008. http://www.bmj.com/rapid-response/2011/11/02/poor-care-sickle-cell-disea...
7 Konotey-Ahulu FID. Morphine in sickle cell disease. BMJ 1991; 302: 1604
8 Konotey-Ahulu FID. Opiates for sickle cell crisis? “The question that puzzles me is: Why do West African and West Indian patients with sickle cell disease who did without morphine in their countries have to be given morphine pumps during sickle cell crises when they come to the UK?” Lancet 1998; 351: 1438.
9 Konotey-Ahulu FID. Opiates for sickle cell crisis. “When I say routine opiates for sickle cell crisis are not the way to bring out these patients’ best potential in the long term I am glad to hear white physicians say the same … White physicians who, at the risk of being misunderstood by (named British Consultant Haematologist), voice their displeasure at what they see happening on their wards deserve commendation, not condemnation” Lancet 1998; 352: 651-652.
10 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. London: Macmillan 1991; Watford: Tetteh-A’Domeno Company, 1996.
11 Serjeant Graham. Sickle Cell Disease. Oxford: Oxford University Press, 1985, page 204 > “In Jamaican experience morphia or its derivatives are rarely used or necessary”.
12 Serjeant Graham. Sickle Cell Disease. Oxford: Oxford University Press, 1992.
13 Serjeant Graham R. Sickle Cell Disease. Lancet 1997; 350: 725-30.
14 Konotey-Ahulu FID. The politics (and economics) of pain relief in the West and World h
BMJ Rapid Response 24 June 2010. http://www.bmj.com/rapid-response/2011/11/02/politics-and-economics-pain...
15 Konotey-Ahulu FID. Management of acute painful sickle cell episode in hospital: NICE Guidance is frightening! BMJ Rapid Response Sept. 7 2012. http://www.bmj.com/content/344/bmj.e4063/rr/599158
16 WORLD SICKLE CELL DAY Broadcast on The Sickle Cell Disease Patient 19 June 2013 Tunu Louise Roberts interviews F I D Kootey-Ahulu [Can be heard again on Home Page of www.sicklecell.md or on YouTube]
17 Serjeant Graham. The case for dedicated sickle cell centres. BMJ 2007; 334: 477 (3 March).
18 Konotey-Ahulu FID. Dedicated sickle cell centres. BMJ Rapid Response March 20 2007 http://www.bmj.com/rapid-response/2011/11/01/dedicated-sickle-cell-teams
Competing interests: Three of my parents' 11 children had sickle cell disease (www.konotey-ahulu.com/images.generation.jpg) hence my critical scrutiny at how patients are managed or mismanaged.