The old lady's friend

Distalgesics

Distalgesic (Cosalgesic, Coproxamol) is a compound analgesic. Each tablet contains Dextropropoxyphene Hydrochloride BP 32.5mg & Paracetamol BP 325mg (for those in the colonies, paracetamol = acetaminophen). Dextropropoxyphene is an opiate like drug. It may have addictive properties. It can be prescribed alone or in combination with paracetamol.

Compound analgesics are illogical and dangerous. If you need two pain killers, better to prescribe them separately so that you can adjust the dose of each independently. A classic case of do what I say, not what I do, for all doctors prescribe compound analgesics, usually combinations of paracetamol and codeine, such as Co-codamol. (paracetamol 500 mg + codeine 8mg or 30mg).

Two paracetamol four times a day provide excellent analgesia, and are a good starting point on the analgesic ladder. Patients may truly need something stronger than paracetamol but, in many cases, they are only benefiting from the placebo effect of something perceived to be “stronger” than over the counter preparations.

Despite theoretical objections, there is not much harm in a compound co-codamol type of analgesic, and Big Pharma has obliged with a plethora of preparations, all gift wrapped and heavily marketed.

Distalgesic probably slipped through on the bandwagon with no one noticing. It was an instant success and soon had a devoted following. Part of its success was due to its easily swallowable torpedo shape. The drive towards economic prescribing brought the arrival of Cosalgesics (cheaper) and then, horror, the truly generic “Co-proxamol” – which meant the pharmacist could dispense whatever formulation he had in stock. Patients travelled miles to find a chemist who stocked the original “Distalgesic”

Its success was baffling. All the research showed that dextropropoxyphene was not a particularly good pain killer even in combination with paracetamol. It was even said that two paracetamol were just as effective as two Distalgesics. All well and good in the laboratories, but try telling that to the patients.

Then more disturbing data began to emerge.

A review of all dextropropoxyphene poisoning episodes in a stable representative population during the past 10 years showed that Distalgesic accounts for most overdoses, and it has become an increasingly popular component of self-poisoning coktails. Sudden respiratory depression due to dextopropoxyphene potentiated by other common ingested agents is the main danger, and at least one-third of patients take a potentially lethal dose (20 tablets of Distalgesic and alcohol or benzodiazepine)…..

….consequently Distalgesic has become the ingested agent principally responsible for self-poisoning deaths over the age of 12 years. This rise to prominence has paralleled a pronounced increase in prescriptions for the drug. (source)

As a practice, we made a policy decision twelve years ago to stop prescribing co-proxamol, and to change all patients on it to something else. The first part of the task was easy. The second was not. We were staggered by the difficulties we encountered.

We rapidly became convinced of two things; for some people – for whatever reason, be it psychological or physical, and despite what the research scientists say – Distalgesic is a potent and effective painkiller; secondly, Distalgesic is addictive.

The Committee on Safety of Medicines finally decided to withdraw Distalgesic in all its forms in January 2005, but agreed it should be a phased withdrawal “to allow users an opportunity to adopt suitable alternative pain management strategies" (a.k.a break their addiction.)

Even after ten years we still have a handful of (mostly) little old ladies who are devoted to Distalgesics. Is it better to leave them be? Iain Dale certainly wants his mother left alone (and postulates that the drug was only banned because David Kelly committed suicide with it).

As all GPs know, patients can be very determined about their perceived "rights" to medication. A Mr de Quincey writes from the Lake District:

Hi, I was taking opium for several years, I have multiple spine and other joint problems and terrible nerve pain. I was very satisfied with opium, I was able to manage my pain and stiffness and continue to work part time, I took it only when needed at low dosage levels. Imagine my surprise when my doctor informed me that all his patients were to be instructed that opium was being discontinued, and I was taken of it. I tried to argue that it worked for me and that I was responsible with my medicines and did not drink, but the doctor insisted and told me he would be struck off if he continued to prescribe it for me.

Actually, the real email was from Helen Jones-Gill and was for the attention of the Department of Health (full text here ). Dr Crippen has naughtily substituted one little word. Apologies, Helen.

But Helen Jones-Gill email demonstrates that, if Distalgesic was to go, something new was needed. Enter Tramadol. This is currently a much in-vogue drug. No one seems to know where it has come from. Most doctors have not got a clue what is in it or how strong it really is or what side effects it has. But it seems to help and the punters like it, so doctors are now prescribing it in shed loads.

Tramadol originates from Germany. It is a synthetic opiate like drug. It may have addictive properties. It can be prescribed alone or, guess what, in combination with paracetamol. Where have I heard that before? Maybe they should call it Tramalgesic.

Here we go again.