There is no doubt that smoking injures the health and it would be a wonderful world if nobody smoked: cleaner and safer. All the NHS money that now goes on smoking-related diseases could go into other areas of medicine. Smoking is a pernicious addiction because it both calms and stimulates the nervous system. It is possibly because of this, and also the masked allergy factor, that some people find giving up so difficult. (A hidden or masked allergy can happen with any substance which is taken into the body daily; when the body is denied the substance the symptoms appear. This is explained fully in A Little Bit of What You Fancy by Dr Richard Mackarness, published by Pan.)

Why Some People Fail Repeatedly

Some people give up smoking without any problems at all; they just stop. Others crave cigarettes and feel they don’t know what to do with their hands, but can distract themselves with a cup of coffee, eating sweets or doing something active. These two groups often scorn the person who fails again and again to give up the awful weed, and proclaim loudly that it is just a matter of will-power. Will-power certainly comes into it, and for those who do not suffer physical or psychological symptoms perhaps it is all that is needed to stop; but for the physically addicted/allergic smoker, there is a lot more to it – lack of will-power or weakness cannot be the cause of swollen joints, skin problems, and so on.

*36\326\8*

Morphine is the drug of choice for the management of severe pain in advanced cancer but opioids are frequently denied to patients who could benefit from them.

The belief that morphine should be only given when patients are dying is archaic. Morphine may be used for months or years and, correctly administered, is compatible with a normal life style. That morphine should be reserved for the ‘crescendo of pain’ which occasionally occurs before death is incorrect because the broad therapeutic range of morphine allows for increasing doses if need be.

Morphine will be ineffective in controlling pain if it is being incorrectly administered, used for morphine-insensitive pain or if matters of psychosocial concern have not been addressed. The correct dose of morphine is that which relieves the patient’s pain whilst causing acceptable side effects and must be individually titrated for each patient. Neuropathic pain is relatively

opioid-insensitive and may respond better to one of the adjuvant analgesics. Physical pain may be caused or aggravated by psychosocial problems and no amount of well prescribed analgesia will relieve this pain until the psychological and social concerns are addressed.

Side effects should not be severe. In patients with cancer, respiratory depression is very uncommon except in opioid naive patients who are commenced on parenteral therapy. Constipation occurs inevitably and requires explanation and advice about diet and laxative therapy. Patients should be warned of the possibility of somnolence and nausea and reassured that these usually improve after several days.

The most frequent reasons why morphine is withheld relate to misunderstandings about tolerance, physical dependence and psychological dependence. In contrast to intravenous drug users who develop rapid tolerance, patients with cancer rarely develop clinically significant tolerance and frequently require little increase in the dose over weeks or months. Physical dependence requires explanation and patients must be reassured that morphine can be weaned (by 25% a day) if their pain is relieved by other means. Psychological dependence occurs extremely rarely in patients with cancer and pain. Concerns about tolerance, physical dependence or psychological dependence are never a reason to delay treatment with morphine if it is indicated.

*52\55\2*

“Peter has been a terror for years now. We’ve had him to several psychologists, and we’re on our third psychiatrist. Now he’s in a residential school for further evaluation. Something has to be done to control these outbursts before he kills someone. They did an EEG, and now they say that this is epilepsy because the EEG is abnormal. I’ve read about epilepsy, and Peter has never had a seizure. It’s just that when someone frustrates him, or does something he doesn’t like, he erupts like a volcano. There’s no controlling him. He hits and bites and punches. I’m afraid he’ll hurt somebody. Gradually he’ll calm down and act as if he’s sorry. Could this be epilepsy? I almost hope so, since then we’ll have medicine to treat him.”

Sudden outbursts of bizarre, often violent behavior are not uncommon among emotionally disturbed children and also among those who are mildly or moderately retarded. Psychiatrists often ask their neurological colleagues if such episodes can be seizures. The answer is virtually always no! Studies have shown that apparently intentional violence almost never occurs during a seizure. If, during the confusion that commonly occurs during the “post-ictal” state, that is, after the seizure, a child is restrained or threatened, a child may react in a combative but random fashion. In this post-ictal, confused state, the child does not mean to fight back or even understand what he is doing.

Episodic behavioral outbursts are almost always precipitated by an event or by frustration. Seizures never are. Seizures usually have a postictal state in which the child is tired or confused. Behavioral outbursts never do. However, the EEG obtained between seizures or behavioral episodes may be either normal or abnormal and, therefore, does not help differentiate seizures from behavioral outbursts. Spikes on an EEG (see Chapter 7) can be observed in children who never have seizures.

Repeated episodic behavioral changes, in the absence of obvious seizures, are virtually never seizures and, therefore, do not respond to anticonvulsants.

Rare patients have confused even the best neurologists. In these cases, trying to capture the episode on video-EEG monitoring may be the only method of ascertaining what is a seizure and what is not. Needless to say, the same individual may experience behavioral problems and seizures also.

*27\208\8*