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Letters to the Editor
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Modified release morphine
Frustrated at Society’s guidance
From Mr A. R. Dickman, MRPharmS, and others
We read, with some surprise, the prescribing
guidance issued by the
Royal Pharmaceutical Society on 14 November 2006 (PJ, 18 November 2006,
p620). Not only were we frustrated with the content of the statement,
but we were surprised by the use of the misleading title, “Prescribing
of modified morphine preparations”. Within the first sentence we
see that the news release actually relates to modified release morphine
and fentanyl preparations.
The original statement issued by the Society in February 2006 appeared
to be rightly based on the recognition that the prescribing of strong
opioids is a potential source of error. The new direction that the Society
has taken is seemingly established on a completely different argument,
ie, that the modified release preparations in question are essentially
bioequivalent, therefore no problem exists. The Society’s new statement
suggests that, while not recommended, dispensing pharmacists can change
the brand, providing the patient or relative understands the reason for
change. We now find ourselves with contradictory advice: on the one hand
prescribing of modified release strong opioids does not need to be brand
specific, but dispensing pharmacists should avoid unintentional alterations
in brand.
Under controlled conditions there is usually no problem in swapping a
patient from one brand to another; as the Society rightly states these
products are essentially bioequivalent. The problem with generic prescribing
of these products, however, is unrelated to the pharmacokinetics. It
is the practical issues that pose the greatest concern. For example,
professionals do become confused between MST and MXL, so we see “MXL
twice daily”. Or we see immediate release morphine tablets dispensed
or prescribed instead of MST. Or we have patients apply a fentanyl matrix
and reservoir patch because of confusion. In addition to these issues,
the reasoning behind the choice of a particular product has to be borne
in mind. For example, a specialist may wish for Zomorph capsules to be
used for a particular patient because the capsules can be opened. In
the community, this is often changed to MST.
The problem that exists with the prescribing of strong opioids is not
the same as that for other modified release products that are prescribed
by brand. The issue with the strong opioids is the variety of formulations
and the potential for possible fatal mistakes that could occur if the
brand a patient or prescriber was expecting is not dispensed. We have
on record a number of occasions where patients were given the wrong type
of morphine product, which is not surprising given the range available.
The problems are often poorly understood by prescribers, who do not see
the consequences that can occur as patients move through different care
settings.
It is unfortunate that, before making its decision, the Society did not
approach organisations that represent professionals who work in this
area, such as the Palliative Care Pharmacists’ Network, the Association
of Palliative Medicine, or the National Council for Palliative Care.
We wonder if it would have been prudent to contact the National Patient
Safety Agency.
The potential for error, possibly fatal, still remains and we hope the
Society makes a sensible decision and reviews this statement. The use
of brand names, alongside the generic, would undoubtedly impact on risk
management and patient safety.
Andrew Dickman
Mary Allen
Margaret Gibbs
Colin Hardman
Christine Hirsch
Palliative Care Pharmacists’ Network
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The
Pharmaceutical Journal