David Praill on access to pain relief

TheUK,birthplace of the modern hospice movement, is a pioneer in palliative care and boasts some of the best and most widely available hospice and palliative care services in the world. One would expect, therefore, that people facing terminal illness here should not suffer unnecessary pain.

In fact, although the vast majority of the UK population - unlike most of the world - has access to essential healthcare, not everyone experiencing severe pain caused by cancer or other diseases such as AIDS, heart disease, chronic obstructive pulmonary disease or renal disease receives sufficient analgesic medicine to control their pain.

Anecdotal evidence fromUKhospices shows patients are frequently referred experiencing unacceptable levels of pain and other symptoms that hospice staff can usually bring under control. But often this is not before intense emotional trauma has been inflicted on all concerned.

If there is one thing worse than experiencing unbearable pain and distress, it is watching someone you love suffer it. As the daughter of one hospice cancer patient said of her father’s period of treatment in a hospital stroke unit: 'Sitting beside him, listening to him moan in pain was one of the most miserable experiences of my life.'

Why is this still happening? What is preventing hospital doctors and GPs from prescribing the pain relief that is so desperately needed?

For once, it is not about the cost of the medicines. It has more to do with insufficient training and understanding of how modern pain relieving drugs work and how safely they can be used.

Unfounded fears

Doctors, healthcare workers and the public are sometimes fearful of opioid analgesics such as morphine. Some fear dependency, even though this fear is unfounded if safeguards are followed.

The view, often supported by the media, is that if someone receives enough morphine to stop their pain, it may well kill them. Some doctors share this view or fear that patients or relatives may believe that a life is being shortened if large doses of opiates are used - and that ultimately they risk ending up in court, perhaps even facing a murder charge.

In reality, just like paracetamol, which presents a high risk if taken incorrectly, research shows that morphine - when properly used - is safe. A recent study from the US National Hospice Outcomes Project, the largest and most sophisticated to date, confirms this. It compared opioid use and survival at the end of life in 725 hospice inpatients with end-stage cancer, lung disease or heart disease and showed that even when the dose exceeded 15 times the average for such patients in theUKandJapan,there was no impact on survival.

In his commentary on the study published in The Lancet in March this year, Morphine Kills the Pain Not the Patient, Nigel Sykes, medical director at St Christopher’s Hospice in London, wrote: 'A physician who truly is killing his or her patient in the name of pain relief is not merciful, just incompetent.'

Dr Sykes is far from alone in this view, yet as he himself points out: 'Clinicians can readily be found who will "confess" to having shortened the life of their patients to achieve pain control.' Therefore, there is clearly a gap in understanding that needs to be bridged. Greater coverage of palliative care and pain control in standard medical training is sorely needed, together with refresher courses for experienced practitioners - such as those offered by hospices to professionals in their local communities - to debunk these harmful morphine myths.

Rather than be swayed by fear and misunderstanding, health service managers and workers should ask themselves: 'Are we prescribing enough to control our patients’ pain?' Because if not, that, in my view, is as inhumane and negligent as over-prescribing.

To download Access to Pain Relief – an essential human right, click here