Correspondence
Anaesthesia 2014, 69, 1172–1182
accountability, it is a matter of time before this comes about. N. C. L. Cassells D. R. Ball Dumfries and Galloway Royal Infirmary, Dumfries, UK Email: [email protected] No external funding declared. DRB was a co-author of the ‘Airway Alert’ scheme. Published with the written consent of the patient. Previously posted on the Anaesthesia correspondence website: www.anaes thesiacorrespondence.com.
References 1. Greenland KB, Irwin MG. Airway management – ‘spinning silk from cocoons’ (抽丝剥茧 – Chinese idiom). Anaesthesia 2014; 69: 291–305. 2. Barron FA, Ball DR, Jefferson P, Norrie J. ‘Airway Alerts’. How UK anaesthetists organise, document and communicate difficult airway management. Anaesthesia 2003; 58: 73–7. 3. Difficult Airway Society. Airway alert form. http://www.das.uk-com/guidelines/downloads.html (accessed 26/ 05/2014). 4. Reason J. Human Error. Cambridge: Cambridge University Press, 1990. 5. Benumof JL. The ASA difficult airway algorithm. New thoughts and considerations. http://www.sambahq.org/ (acc essed 26/05/14). doi:10.1111/anae.12834
Oral morphine is a prescription-only medicine We read with interest the recent editorial by Professor Palanisamy and Dr Bailey regarding the use of codeine in mothers and children [1]. Working in a busy obstetric unit, we have recently reviewed our opioid prescribing policy for post-
natal women. We now use dihydrocodeine as our first-line opioid with oral morphine (10 mg per 5 ml) as step-up medication. We dispute the argument against the use of oral morphine citing its position as a controlled drug (Schedule 5 under the Misuse of Drugs regulations 2001 [2]). Schedule-5 controlled drugs are exempt from the majority of regulations placed upon controlled drugs, the only legal requirement being the retention of invoices for two years following their purchase. Codeine and dihydrocodeine are also classified under this schedule [2] but this has never been seen as a barrier to their use. In fact, the British National Formulary [3] cites oral morphine as a prescription-only medicine (POM), its only limitation being that it has to be prescribed by a qualified prescriber (in the same way as diclofenac). Concentrated oral morphine (100 mg per 5 ml) is a Schedule-2 controlled drug with strict restrictions on its storage and prescription, but concentrations of oral morphine below 13 mg per 5 ml remain POMs [3]. Therefore, they can be stored in a normal drugs cupboard and be dispensed by a single qualified nurse. We argue that concerns about the ease of prescribing and dispensing of oral morphine should not limit its use in the postnatal period. K. Whitehouse R. Marr Royal Victoria Infirmary, Newcastle upon Tyne, UK Email: [email protected] No external funding and no conflicts of interest declared. Previously
© 2014 The Association of Anaesthetists of Great Britain and Ireland
posted on the Anaesthesia correspondence website: www.anaesthesiacorrespondence.com.
References 1. Palanisamy A, Bailey CR. Codeine in mothers and children: where are we now? Anaesthesia 2014; 69: 655–60. 2. Great Britain, Home Office. The Misuse of Drugs Regulations, 2001. www.legis lation.gov.uk/uksi/2001/3998/schedule/ 5/made (accessed 05/07/2014). 3. Joint Formulary Committee BMJ Group and Pharmaceutical Press. British National Formulary (online), 2014. www.medicinescomplete.com (accessed 05/07/2014). doi:10.1111/anae.12821
Paediatric codeine use after adenotonsillectomy Both the ear, nose and throat department at our hospital and the Medicines and Healthcare products Regulatory Agency have recently recommended that codeine should not be prescribed postoperatively for children undergoing either adenoidectomy or tonsillectomy, or both in patients with obstructive sleep apnoea [1]. We audited take-home analgesia prescribed after adenotonsillectomy between May 2011 to April 2013 by retrospective analysis of the pharmacy database and theatre system at our hospital. Twelve (1.3%) of 941 patients undergoing adenotonsillectomy were given codeine to take home, five of whom had obstructive sleep apnoea. Reasons included postoperative bleeding proscribing nonsteroidal anti-inflammatory drug (NSAIDs) prescription, sensitivity to paracetamol/NSAIDs/both, significant asthma, and breakthrough
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Anaesthesia 2014, 69, 1172–1182
accountability, it is a matter of time before this comes about. N. C. L. Cassells D. R. Ball Dumfries and Galloway Royal Infirmary, Dumfries, UK Email: [email protected] No external funding declared. DRB was a co-author of the ‘Airway Alert’ scheme. Published with the written consent of the patient. Previously posted on the Anaesthesia correspondence website: www.anaes thesiacorrespondence.com.
References 1. Greenland KB, Irwin MG. Airway management – ‘spinning silk from cocoons’ (抽丝剥茧 – Chinese idiom). Anaesthesia 2014; 69: 291–305. 2. Barron FA, Ball DR, Jefferson P, Norrie J. ‘Airway Alerts’. How UK anaesthetists organise, document and communicate difficult airway management. Anaesthesia 2003; 58: 73–7. 3. Difficult Airway Society. Airway alert form. http://www.das.uk-com/guidelines/downloads.html (accessed 26/ 05/2014). 4. Reason J. Human Error. Cambridge: Cambridge University Press, 1990. 5. Benumof JL. The ASA difficult airway algorithm. New thoughts and considerations. http://www.sambahq.org/ (acc essed 26/05/14). doi:10.1111/anae.12834
Oral morphine is a prescription-only medicine We read with interest the recent editorial by Professor Palanisamy and Dr Bailey regarding the use of codeine in mothers and children [1]. Working in a busy obstetric unit, we have recently reviewed our opioid prescribing policy for post-
natal women. We now use dihydrocodeine as our first-line opioid with oral morphine (10 mg per 5 ml) as step-up medication. We dispute the argument against the use of oral morphine citing its position as a controlled drug (Schedule 5 under the Misuse of Drugs regulations 2001 [2]). Schedule-5 controlled drugs are exempt from the majority of regulations placed upon controlled drugs, the only legal requirement being the retention of invoices for two years following their purchase. Codeine and dihydrocodeine are also classified under this schedule [2] but this has never been seen as a barrier to their use. In fact, the British National Formulary [3] cites oral morphine as a prescription-only medicine (POM), its only limitation being that it has to be prescribed by a qualified prescriber (in the same way as diclofenac). Concentrated oral morphine (100 mg per 5 ml) is a Schedule-2 controlled drug with strict restrictions on its storage and prescription, but concentrations of oral morphine below 13 mg per 5 ml remain POMs [3]. Therefore, they can be stored in a normal drugs cupboard and be dispensed by a single qualified nurse. We argue that concerns about the ease of prescribing and dispensing of oral morphine should not limit its use in the postnatal period. K. Whitehouse R. Marr Royal Victoria Infirmary, Newcastle upon Tyne, UK Email: [email protected] No external funding and no conflicts of interest declared. Previously
© 2014 The Association of Anaesthetists of Great Britain and Ireland
posted on the Anaesthesia correspondence website: www.anaesthesiacorrespondence.com.
References 1. Palanisamy A, Bailey CR. Codeine in mothers and children: where are we now? Anaesthesia 2014; 69: 655–60. 2. Great Britain, Home Office. The Misuse of Drugs Regulations, 2001. www.legis lation.gov.uk/uksi/2001/3998/schedule/ 5/made (accessed 05/07/2014). 3. Joint Formulary Committee BMJ Group and Pharmaceutical Press. British National Formulary (online), 2014. www.medicinescomplete.com (accessed 05/07/2014). doi:10.1111/anae.12821
Paediatric codeine use after adenotonsillectomy Both the ear, nose and throat department at our hospital and the Medicines and Healthcare products Regulatory Agency have recently recommended that codeine should not be prescribed postoperatively for children undergoing either adenoidectomy or tonsillectomy, or both in patients with obstructive sleep apnoea [1]. We audited take-home analgesia prescribed after adenotonsillectomy between May 2011 to April 2013 by retrospective analysis of the pharmacy database and theatre system at our hospital. Twelve (1.3%) of 941 patients undergoing adenotonsillectomy were given codeine to take home, five of whom had obstructive sleep apnoea. Reasons included postoperative bleeding proscribing nonsteroidal anti-inflammatory drug (NSAIDs) prescription, sensitivity to paracetamol/NSAIDs/both, significant asthma, and breakthrough
1179
