Australasian Anaesthesia 2011 - Australian and New Zealand ...

24 Australasian Anaesthesia 2011Pethidine: the case for its withdrawal 25If we know our medical colleagues have a preference for the misuse of pethidine over the equally effectivealternative opioids then it becomes an abrogation of our duty of care to tolerate the availability of pethidine. Weare obliged to eliminate the hazardous occupational exposure of our anaesthetic colleagues in the operating theatre,and we need to extend our concern to nursing staff in the operating room, the general wards and on the labourfloor. In 2006, out of concern for the personal misuse of pethidine by general practitioners, the Australian MedicalAssociation and Pharmaceutical Benefits Advisory Committee collaborated to enact just such a strategy, and hadpethidine removed from the Doctor’s Bag supply carried by general practitioners.The withdrawal of pethidine is a simple and effective means of minimising harm from the occupational exposureof doctors to the most addictive of opioids, particularly because there are suitable alternatives to pethidine. Concernfor fentanyl exposure on the other hand, would be somewhat impractical to address solely by advocating itswithdrawal since it is the cornerstone of many general and neuraxial anaesthesia practices. Continued vigilanceand education will provide the greatest protection from fentanyl misuse. 57SUMMARYA critical examination of the evidence fails to find support for the commonly held beliefs as to the benefits ofpethidine use. In stark contrast is the significant evidence for harm resulting from pethidine use.While evidence based medicine has provided, and will continue to provide real guidance for all doctors intherapeutic decision making, it must be acknowledged that our own personal experience with different medicationsis a powerful influence on patient management. Many anaesthetists have used pethidine for decades, possiblywithout any (known) complications, and will find articles such as these somewhat unpalatable. However, it mustbe acknowledged that the evidence against the continued use of pethidine is now so clear, and incontrovertible,and has been disseminated in so many forums, that should any patient experience any untoward effects due topethidine use, it will be difficult to sustain a defence based on the credo that “it has been my usual practice…”.In many Australian states inroads have been made by major teaching hospitals to completely withdraw, orseverely restrict use of pethidine. Hospitals regarded for their expertise in pain management that have removedpethidine from their formularies include Royal Adelaide in 1993 and Royal North Shore in 2006. Time will hopefullysee the private sector following in a similarly educated manner. Keys to the success of a hospital’s withdrawal ofpethidine are the involvement of the Drug Committee as well as a transition period of tolerated use in extenuatingcircumstances. For example, at the authors’ hospital when pethidine was withdrawn, provision was made to allowthe use of pethidine on an Individual Patient Use (IPU) basis – largely to appease a minority who were adamantpractice was not possible without pethidine. In the 5 years during which access to pethidine was available underIPU, there were reassuringly no applications for pethidine.Figures from the International Narcotics Control Board for 2004 place Australia in a desirable position on theinternational ranking of pethidine prescribing. 58 On a per head of population per annum basis, Australia consumes9 mg and is well behind our Canadian counterparts at the head of the table with 36 mg as well as the United Stateswith 19 mg. Data extracted by the New South Wales Department of Health tallied a total use of pethidine for thatstate of over 14 kg for the year of 2010. 59 Of this total: 4.5 kg is accounted for by administration in labour, assumingone in two of the approximating 90 000 labouring mothers for that year was administered a 100 mg ampoule ofpethidine (or part thereof). Whilst on an international basis Australian anesthetists have demonstrated a commendablyenlightened practice, the substantative ongoing use (at least from NSW data) indicates there is still further work tobe done. This may lie particularly in educating our colleagues in the other medical professions to whom much ofthe continued prescribing of pethidine is apportioned.CONCLUSIONIn 2011 we have reached the point where the case has been made for the appropriate and effective use of opioidsto manage pain, particularly in the acute setting. We need to continue these efforts to further refine our practice,ensuring the agents used are as safe and effective as possible.The seductive simplicity to the change in practice necessary to eliminate pethidine is that it is completely painless.Clinicians will not suffer and more importantly nor will our patients.REFERENCES1. Shipton E. Should New Zealand sign up to the pethidine protocol? The NZ Medical Journal 2006;116:1875.2. MacPherson R. 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