"The analgesic stepladder--missing rungs.".

Editor,

“On a long enough timeline, the survival rate for everyone drops to zero.”

Risk is an inevitable aspect of medical care with recent studies illustrating the potential harm that can be done to patients using diclofenac with a cardiac history and codeine in paediatric patients. These studies apply in both cases to small subsets of each population however the implications have led health care bodies into disarray with the result that a large number of patients are no longer able to avail of these useful painkillers due to nationwide bans resulting in longer hospital stays and patients discharged on control drugs.

The background to the change in regulation of these two drugs is highlighted by The Medicines and Healthcare Products Regulatory Agency (MHRA) who have stated that diclofenac should not be used by people with underlying heart conditions or hypertension due to an increased risk of myocardial infarction and stroke1. The use of codeine in children and adolescents has also been restricted after a European safety review was triggered by case reports of children who received codeine after tonsillectomy for obstructive sleep apnoea (OSA) and developed rare, but life-threatening adverse events2.

A report, published in 2012, documented the cases of three children who died after receiving treatment with codeine after tonsillectomy3. Although the number of documented cases of codeine-related deaths remains small, the complications and legal outcomes of tonsillectomy malpractice claims found that the incidence of codeine-related deaths was much higher than expected. Using data from the Lexis Nexis Mega Jury Verdicts and Settlements database from 1984-2010 it was found that 18 percent of death claims and 5 percent of injury claims resulted from the use of opioids rather than haemorrhage which would be expected4.

Both medications are routinely used post operatively following a wide range of procedures in many specialities. While many of these patients are often well those with IHD other cardiovascular illnesses are encountered. Given the prevalence of children with OSA being less than 0.7% and those with CYP2D6 enzyme abnormalities (linked to abnormal codeine metabolism) being even less these patients are rarely encountered5.

Our patients' interest are first and foremost and providing them with adequate pain relief following surgical procedures is vitally important. Unfortunately we have blanketing guidelines which fail to take into account the low risk to most patients and certainly fail to take into account both medical expertise and patient choice and sensibility. Since the introduction of these restrictions data from the Northern Ireland Otorhinolaryngology audit suggests that complications have significantly increased in local hospitals specifically adhering to these policies. It is vitally important that a wide range of analgesic options are available to both adult and paediatric patients following what can often be painful surgery. While many new options are available the option to revert back to tried and tested analgesics should remain open to the clinician and be based on a balance of risk and benefit much like the option to operate in the first place.