To the Editor: We congratulate Kaye and colleagues on their efforts to educate and influence prescribing practice in reducing the use of pethidine.1 The adverse effects of pethidine and its lack of efficacy over other opiates have been known and taught since the early 1990s.2 A decade on, we are still seeing significant use of this drug,3 which has multiple disadvantages when compared with other opioid analgesics.

The difficulty lies in doctors’ attitudes to quality improvement and change in health care. It has been noted that doctors’ responses to concern about the quality of health care range widely, from opposition to whole-heartedly embracing legitimate opportunities for improvement.4 While there is such variance, the implementation of evidence-based medicine into practice will lag, sometimes by decades, resulting in unnecessary adverse effects in patients.

With clinical guidelines in place, a rigorous education campaign and many hours of research time and resources, Kaye and colleagues have significantly reduced, but not eradicated, pethidine prescribing in New South Wales. In comparison, O’Connor et al report combining a similar educational program with formulary restrictions to effectively eliminate the use of meperidine (pethidine) in their single centre study.5 We can only conclude that clinical evidence, even when combined with quality improvement campaigns, remains less effective than policy changes which restrict doctors’ behaviour.

From available evidence, the liberal use of pethidine may cause adverse effects which are preventable by a simple system-oriented approach — in this case, the appropriate risk-management step is restricting pethidine use to very limited situations. We cannot continue to justify use of a drug with poor efficacy, toxicity and serious drug interactions.

Pethidine prescribing as a percentage of total narcotics in Launceston General Hospital emergency department, 1992–2004

Note: data not available for some quarters.

To the Editor: I was interested to read the article by Kaye and colleagues about reducing pethidine use in the emergency department by means of evidence-based prescribing.1

In view of published reports describing the disadvantages of pethidine, it was decided in late 1996 to attempt to reduce the amount of pethidine prescribed in the emergency department of Launceston General Hospital. Narcotics were supplied as ampoules of 100 mg pethidine, 10 mg morphine, 15 mg papaveretum (the use of which was trivial) and fentanyl, which was used mainly for anaesthetic induction. Before mid-1996, 50%–72% of all ampoules of narcotics used in the emergency department were of pethidine. Of narcotics used for acute pain management, pethidine would have been much higher as a proportion because it was not used for acute pulmonary oedema, ischaemic myocardial pain, anaesthetic induction and in patients being ventilated. The use of narcotics was monitored by quarterly reports from the pharmacy department of the quantities of the various parenteral narcotics supplied to the emergency department. Papaveretum was removed from the pharmacopoeia in 1999.

In 1996, an informal education program was instituted within the emergency department, strongly supported by the nurses, with the aim of convincing junior medical staff on rotation from other areas within the hospital to prescribe morphine rather than pethidine. It had long been observed that such staff prescribed pethidine almost exclusively for acute pain management, and a cultural change was required. As shown in the Box, the percentage of narcotics dispensed as pethidine was steadily reduced over the following years, reaching 5% in 2002. After 2 years at this level it was decided to remove pethidine from the pharmacopoeia. In February of 2005, hydromorphone was introduced and pethidine removed. There have been no complaints or problems as a result, and the whole process was unexpectedly painless and successful.

In reply: As Mitra and Cameron point out, policy change can be effective in influencing prescribing practice. Indeed, use of a restrictive formulary is a strategy used by drug and therapeutics committees in most Australian hospitals. However, where support among clinicians for policy change is lacking, significant time and effort is required by those responsible for policy implementation. Confrontation and lack of interdisciplinary cooperation can be expected.

Quality use of medicines (QUM) means selecting management options wisely, choosing suitable medicines if a medicine is considered necessary, and using medicines safely and effectively. Australia is fortunate in having a National Medicines Policy1 and a national strategy for QUM.2 This strategy recognises the importance of active and respectful partnerships, and of consultative, collaborative, multidisciplinary activity to improve the quality use of medicines.

To attain QUM, “. . . key partners must be involved at all stages in designing, implementing and evaluating QUM programs . . . Multiple activities and strategies are needed to raise awareness about issues related to QUM. Attitudes, knowledge, skills and behaviours that support QUM need to be developed and maintained”.2

Our approach was based on these principles. Pielage provides another example of the successful use of this approach to limit pethidine prescribing in a large teaching hospital, which should be applauded.

Doctors, pharmacists, nurses and consumers are important partners in QUM. An educative, multidisciplinary approach that respects each partner is the most appropriate way to ensure sustained practice change and promote QUM in hospitals and the wider community.