Injuries incurred at “roller discos”

SIR,-In the course ofDrAM Hoy's comments (20 March, p 898) on Dr J D J Havard's leading article (27 February, p 612) he quoted a case report to support the view that the respiratory depressant effect of morphine is reduced provided oral morphine dosage is titrated against a patient's level of pain.' There is more substantive supportive evidence from a prospective study, a preliminary report of which appeared elsewhere.2 This study is now complete (paper in preparation), and there is no evidence that chronic ventilatory failure is either common or severe in persons with severe pain from advanced cancer given oral morphine (in individual doses four-hourly) with dosage titrated against the level of pain. This is true in patients who are pain-free with significant amounts of morphine in their plasma3 and in those with active respiratory tract disease-for example, carcinoma of the bronchus. Indeed, used in this fashion, oral opiates may have little clinically significant effect on respiratory function, and given correctly seem unlikely to cause death by respiratory depression. Thus given good practice the concern that relief of pain may shorten life seems misplaced-indeed, experienced physicians often comment on the manner in which patients "bounce back" once pain from malignancy has been adequately controlled. Perhaps it is time the profession established widely what is good medical practice in an area plagued by myths and misunderstandings. T D WALSH St Christopher's Hospice, Lonldon SE26 6DZ