The Pharmaceutical Journal
Vol 277 No 7422 p458
14 October 2006

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Palliative care pharmacists study day

Hospices have their own set of arrangements with regard to CDs

Changes to Controlled Drug regulations and the introduction of new roles as a result of the Shipman Inquiry have been set out clearly for primary care but, as often the case, implications for hospices are more complex as they are mostly registered as independent hospitals and charities. Sarah Billington, a senior assessment manager pharmacist at the Healthcare Commission, clarified a number of points in her CD update.

Each hospice will need to set up its own accountable office, which should be in place ideally by the expected date of the new regulations becoming law: 1 January 2007 and certainly by self assessment at the end of the year in March 2007. An accountable officer will be responsible for ensuring that safe practice and standard operating procedures are in place throughout the hospice. They will be supported in their role by a network of other accountable officers in the locality, such as those from primary care trusts and acute trusts, with a view to sharing information and governance issues. The PCT-accountable officers will lead intelligence networks within their geographic area.

Ms Billington also clarified the new arrangements for FP10PCD forms. She explained that CDs being prescribed on an NHS prescription do not need to be written on one of the new forms, which are intended only for private CD prescriptions. In addition, any hospice that uses private prescriptions but has an agreed arrangement or contract with a community pharmacy will not need to issue individual FP10PCD forms for each prescriber, provided that any private CD prescriptions are dispensed by that community pharmacy.

Ms Billington shared data to show that the total number of prescriptions for schedule 2 CDs has not decreased since the Shipman case became public. However, the number of prescriptions for injectables has decreased, although the number for transdermal patches has increased to compensate. The ongoing diamorphine shortage clearly has had an effect here too. It is encouraging that the outcome of the Shipman Inquiry takes seriously the need for patients who require CDs to have timely access to them.

New approach to hyperalgesia and allodynia

Zbigniew (Ben) Zylicz practised and taught palliative medicine in his native Poland and the Netherlands before coming to the UK to St Elizabeth Hospice in Ipswich. His expertise in the pharmacology of symptom control provided the background for a presentation on a new approach to the problems of hyperalgesia and tolerance to opioids, and a potential role for buprenorphine in their management.

Hyperalgesia (an exaggerated response to noxious stimuli) and allodynia (production of pain by normally innocuous stimuli) can be induced by both chronic pain and chronic opioid administration, which makes assessment and management of pain confusing and the resultant treatment often illogical. On a cellular level, chronic opioid administration and neuropathic pain share mechanisms and features.

Professor Zylicz discussed cases where patients experience an increase in pain intensity with further opioid administration, often accompanied by diffuse pain extending beyond that of pre-existing pain and how, for such patients, the usual medical response is to increase the opioid dose further, thus exacerbating the situation. His suggestions for overcoming this problem are threefold:

· The use of n-methyl-d-aspartate antagonists such as methadone, although often these are not as effective as experimental evidence would suggest

· Combinations of opioid agonists with ultra-low dose antagonists, such as naloxone

· The use of opioids with novel receptor mechanisms, such as buprenorphine

The use of ultra-low dose antagonists at the same time as opioids can enhance their analgesic potency, prevent or reverse tolerance and prevent hyperalgesia. Professor Zylicz is confident that the use of a drug such as buprenorphine may have a part to play in preventing or reversing hyperalgesia in the future.

Contradictions and dangers of herbal remedies

Colin Hardman has been providing a pharmacy service to St Barnabas’s Hospice in Lincoln since 1980. He spoke about herbal medicines and palliative care, uncovering some of the contradictions and dangers of herbal remedies sold to the public on the basis of unpublished data via commercial websites with scant evidence.

Mr Hardman used examples of such remedies as carctol and black cohosh. Black cohosh was the subject of a recent warning from the Medicines and Healthcare products Regulatory Agency because it may cause liver damage. However, in spite of this warning, which is now listed on the BBC website, it is still recommended as being useful therapeutically.

The principles to remember when being asked about herbal remedies by vulnerable patients are that herbalism is not homoeopathy and that “natural” does not necessarily mean “safe”. Herbal medicines may interact with conventional medicines so must be included in medicines reviews and at admission. It is also important to be aware of spurious claims for the efficacy of herbal remedies.