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The U.K. government recommended a risky drug combination for COVID-19 patients in 2020, just 16 days after warning doctors to use the medications together only as a last resort, medical commentator John Campbell, Ph.D., said this week.
For years, Campbell has criticized the widespread use of midazolam and morphine and other palliative drugs to treat COVID-19 patients, questioning why so many patients appeared to receive drugs commonly associated with end-of-life care — even though they didn’t necessarily have a terminal illness.
But in his latest video, he said he had overlooked a key piece of the puzzle: The U.K. government itself had backed guidance recommending the combined use of opioids and benzodiazepines for certain COVID-19 patients — just days after warning that the drug combination could cause fatal respiratory depression.
Campbell, who said a former member of the British Parliament brought the issue to his attention, called the apparent reversal “a national scandal which is being ignored.”
“I’d actually missed it because it was so obvious,” Campbell said. He called the allegations “pretty incendiary,” but promised viewers “full evidence for it.”
“‘On the 18th of March, government guidelines are saying … do not mix opiates and benzodiazepines,’” Campbell said. “‘Then, 16 days later, complete contradiction. If you’ve got COVID-19, all of a sudden you can be given this potentially lethal combination.’”
Government warning: Combine drugs only if there is no alternative
On March 18, 2020, the U.K.’s Medicines and Healthcare products Regulatory Agency (MHRA) issued a drug safety update warning that benzodiazepines and opioids can both suppress breathing and that combining them increases that risk, Campbell said.
The guidance told healthcare professionals to prescribe the drugs together “only … if there is no alternative” and to closely monitor patients because the combination can cause “potentially fatal respiratory depression.”
Campbell said the warning left little room for interpretation. “It can cause death,” Campbell said. “Completely unambiguous … no question about it.”
The warning from the MHRA, the U.K.’s equivalent of the U.S. Food and Drug Administration (FDA), also pointed to a 2018 European medicines review. The review referenced a 2016 FDA safety action requiring stronger warnings that combining opioids and benzodiazepines could lead to respiratory depression, coma and death.
COVID guideline changed course 16 days later
Campbell said that 16 days after the MHRA warning, the National Institute for Health and Care Excellence published its COVID-19 rapid guideline, NG163.
The guidance recommended clinicians “consider an opioid and benzodiazepine combination” for COVID-19 patients who were considered to be at the end of life, had moderate to severe breathlessness and were distressed.
It also stated that “sedation and opioid use should not be withheld because of a fear of causing respiratory depression.”
Campbell strongly disagreed with that recommendation.
“Of course it should,” he said. “Let me paraphrase what that’s saying in my understanding. Sedation — that’s giving benzodiazepines and opiates — should not be withheld just because there’s a risk it will kill your patient.”
The guidance also noted that, at the time it was published, opioids and benzodiazepines were not authorized in the U.K for treating COVID-19.
“But the guidelines are patently saying here, ‘Don’t let that put you off. Just get on with it. Give both together,’” Campbell said. “A lot of people probably died from this combination … who otherwise would not have died.”
People simply diagnosed with COVID ‘were going on end-of-life care’
Campbell stressed that opioids and benzodiazepines can provide tremendous relief for people who are clearly dying, such as patients with terminal cancer.
He said morphine and midazolam are “both wonderful drugs. … But used incorrectly, they can kill you.”
What concerns him is that the COVID-19 guidance appeared to assume many patients were already at the end of life and encouraged use of the drug combination far more broadly than the government’s own safety warning issued only two weeks earlier, he said.
“People were going on end-of-life care, basically, sometimes when they [were] just diagnosed with COVID, when they could have made a very good recovery,” he said.
NG163 remained in effect until March 2021, when it was replaced by updated guidance, NG191.
Campbell noted that the health guideline remained in force for nearly a year. He questioned how many patients may have received the drug combination even though they had a realistic chance of recovery.
“You couldn’t make this up,” Campbell said. “How many tens of thousands could have died as a result of this?”
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‘A dark chapter in English medical history’
Campbell’s interpretation echoes concerns raised at the time.
A BMJ analysis published just weeks after NG163 warned that the guideline appeared to blur the distinction between patients who were truly approaching the end of life and those with COVID-19 who might still recover.
The authors noted that opioid-benzodiazepine combinations can be appropriate in specialist palliative care for patients who are genuinely dying.
However, they warned that many people with COVID-19 were not terminally ill and would recover — meaning use of those medications in patients not clearly at the end of life risked “unintended serious harm” without specialist oversight.
“It is worrying that … there is no counterpoint that most patients without the preconditions above will eventually recover,” the authors wrote.
They concluded that parts of NG163 “should be revised to prevent inadvertently adding to that suffering.”
Campbell said the contradiction between the government’s March 18 drug safety warning and the April 3 COVID-19 guideline in 2020 deserves a full investigation.
“So, a dark chapter in English medical history basically completely ignored,” he said. “There are all the facts on it, and this should be investigated.”
“Is it incompetence? Is it professional negligence, or is it something else?” he asked.
Watch Campbell discuss the UK COVID guidance here:
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