Heroin not the issue

To the editor:

We are writing in response to a column regarding the lack of use of heroin
in Canada (The Doctor Game, Oct. 14). The article contains some serious
distortions.

The reality of treatment of pain of terminal cancer is that 80 to 90 per
cent of it can be controlled with adequate doses of oral morphine. Given
orally at regular intervals (as a syrup every four hours or as a continuous
release formulation), morphine has a sustained action that prevents
breakthrough pain.

Studies in the U.K. and the U.S.A. that compared heroin directly to
morphine found that there was no difference in the degree of pain relief
provided, or in the incidence of side effects, only in the dose required to
produce these effects. The pharmacological advantage that heroin does offer
over morphine is that it is more potent (two to four times, i.e. need about
1/3 of the dose to produce an equivalent effect), and is more soluble in
water and can be injected in a smaller volume if injections are required.

Both Canada and the U.S.A. have an alternative high potency opioid
available (Dilaudid or hydromorphone), which offers the same potency and
solubility advantages that heroin does. It is the use of Dilaudid when a
high potency opioid is required that is most likely the basis for the
minimal use of heroin in Canada for the last decade or so.

The most important issue raised in the article is the lack of optimal pain
control in terminal cancer. The most important factors that contribute to
this are (a) underutilization of appropriate agents (e.g. using Tylenol #3
as quoted by Dr. Gifford-Jones rather than morphine), and (b) the use in
inappropriate doses of morphine (i.e. too low to achieve adequate pain
control) due to fear of addiction. This issue must be and currently is
being addressed through physician and health care provider education. It is
very important to appreciate that the root of the problem identified by
this article is not the lack of availability of a particular drug in
Canada, but the less than optimal use of the agents that are currently
available.

Jana Sawynok, PhD
Professor of Pharmacology
Dalhousie University