Hence, in the UK, there is very little ability to go from doctor to doctor to obtain more and more prescription drugs. In practice, patients occasionally “lose” their drugs or use an excess, although they quickly learn that their requests for replacement are rarely accepted. The ability for the well off and well connected to access such drugs from private practitioners is limited. Close oversight by regulators identifies aberrant and/or high cost prescribing of opioids prescribed in primary care in locality. Prescribing opiates for registered addicts is managed through the addiction services, in general. Therefore, the access to opiates is reasonably well controlled and GPs take part in the long-term management of patients using opiates for pain, often sharing care with the pain clinics and palliative care services.

Diversion of prescribed opioids does not appear to be a great problem in the UK. In the past, problems of diversion were well recognized with short-acting opioids such as Dipipanone (Diconal), Dextromoride (Palfium) and Pethidine (Meperidine). This was resolved by either the agreed local banning of the drugs, or by agreed tight restriction in prescribing. Furthermore, it is well recognized in primary care now through education that these drugs have no use for managing chronic pain. It is notable that, in the UK, the use of diamorphine (heroin) has never been discontinued, unlike most other countries. Its use is principally within hospital practice and in palliative care. There has neither been any evidence of a significant problem with diversion nor any contribution to the widespread problems of recreational heroin use. Some addicts have been prescribed pharmaceutical grade heroin regularly to manage their addiction and there is also open debate about the possibilities of this approach to reduce their health problems. For the addict then there would be little incentive to exchange a quality product for other street drugs.

In contrast, the mild opioid, Dextropropoxyphene, combined with Paracetamol is widely used and well tolerated by many patients. It has been withdrawn recently because of concerns over its potential lethal effect when taken in deliberate overdose. The withdrawal of the drug led to many patients suffering increased pain when they were unable to find a suitable alternative. The regulatory authorities however, did not appear to engage in any debate on the ethics of this with pain clinicians. There are many other aspects of modern life that are useful and safe, but dangerous in the hands of the irresponsible. The drug alcohol and the automobile are two good examples.

The British Guidelines also give examples of specific patient problems and how to deal with them. However, most patients present with a number of interconnected issues that are not easily resolvable, as in our case examples. The objective of achieving good pain control, good coping skills, and compliant, limited drug use is usually unattainable. Therefore, compromise and pragmatism are often needed to contain unsolvable problems. If this is supported by the explicit use of ethical principles, it may be possible to find the optimum way forward.