Post-its from Practice:
Patient defined recovery and using morphine sulphate (Apr 2008)
I felt a bit proud when Stuart came to see me to show me his first pay packet. It wasn't enormous but it was more than the benefits he had been on for years, and as he said: "It's mine and I earned it". We also chatted about his health and his maintenance script of morphine sulphate.
We laughed about the journey he had taken to get to this point but it was far from funny in reality. He had registered with us about 6 years ago having moved into the area and had lost his private script due to his doctor going before the General Medical Council. At that time Stuart was confrontational and demanded that I gave him the same script of 4x50mg (200mg) ampoules of methadone, 20x5mg (100mg) of dexamfetamine tablets and 3x10mg (30mg) of diazepam. He was also quite unwell with swelling and ulcers on his legs.
We concentrated on improving his health and after a few months he settled on 150mg of injectable methadone and 30mg of diazepam. After 2 years his legs had improved and he decided he wanted to stop injecting as a first move to getting off all drugs, and he requested a move to methadone mixture. He kept trying but he didn't settle and for a time returned to street heroin. A few weeks later he represented and said he would like to try buprenorphine.
Again he really tried to settle but was unable to, so after a few weeks he asked to go back on his injectable script because his life had become so chaotic in such a short time. We agreed and he soon settled and decided to remain on maintenance again.
Stuart remained well for a further six months on injectable maintenance but unfortunately developed an acute deep vein thrombosis in his leg. Because of this he again decided he must stop injecting. He asked me if there was anything else he could try.
I explained I had some experience of using oral morphine sulphate, codeine and dihydrocodeine and had found all these drugs helpful in certain individuals. I explained that none of them were licensed in the UK for the treatment of opioid dependency but they had some evidence base. Morphine sulphate is used extensively in Europe for maintenance and dihydrocodeine has a small evidence base in the UK (Robertson R et al 2007).
After hearing all the evidence, Stuart decided he would like to try morphine sulphate. When transferring people to it, I find each patient is different on the amount they need, but it is usually double the methadone (because of shorter half-life, which is about 12 hours) plus around a third more. We started him on MST 60mgx3 twice/day = 360mg and he settled on MST 2x100mg twice daily = 400mg.
He felt well on this and then began to talk about detoxification. But in his counselling sessions he identified how scared he was of going back to injecting and realised he wanted to work on developing skills and getting a job and stay on maintenance. We did not have a problem with his plan and directed him to the local "back to work" scheme and continued his script.
It is clear that morphine sulphate is not right for everybody and should only be used when other options have failed. But let's use them if necessary and not reduce our limited prescribing tool box more than we have to. It is also clear that maintenance is not right for all but a person's own choice about "treatment" and recovery is fundamental, and "recovery" needs to be self-defined. Stuart has defined his recovery as getting his first pay packet.