Sir.—Dr Mallouh,1 in responding to Dr Buchanan's discussion on the use of intravenous narcotics in sickle cell disease, raises an interesting consideration.
I agree that any physician treating a patient with a painful occlusive crisis of sickle cell disease must provide effective analgesia regardless of the means needed to do so. I also agree that through the proper use of morphine, in the presence of significant pain induced through nociceptive stimuli, the pain can be quite easily managed with the use of morphine sulfate by the oral route. I agree that carefully administered analgesia is essential and should not lead to drug addiction if properly used in a clinical titration manner, as used in terminally ill patients at my institution.
I only argue that this treatment can be done quite effectively by mouth using sublingual morphine or morphine solutions titrated carefully until the pain is controlled without affecting