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Dr Messenger: The argument for co-proxamol

“Patients will insist that you continue to prescribe... and promise not to sue"

Some patients still have faith in the controversial analgesic, says Dr Messenger

You may well be surprised to hear that some GPs are still prescribing co-proxamol. I’m not. Particularly as I’m one of them.

The trouble is, I can see both sides of the argument. On the one hand, I like to think that my prescribing is rational, cost-effective and evidence-based. And I’m aware that co-proxamol doesn’t score too well on any of these criteria. Plus, there are the potential legal pitfalls and the fact that plenty of analgesic alternatives exist. With the drug being withdrawn from the UK market in 2007 in response to its link with suicide attempts, you would think it would be something of a no-brainer to deny it to patients.

But that ignores the ‘on the other hand’ argument. With some patients, you can plea – using logic, science and even scaremongering – until you’re blue in the face. But they have such utter faith in, and psychological addiction to, their chosen pill that they will not be swayed. They will insist that you continue to prescribe, they don’t care how much it costs the NHS and they will promise not to sue if it all goes pear-shaped.

Besides, those ‘alternatives’ are looking less viable by the day. Paracetamol is not the benign drug we’ve always assumed it to be. Even the weakest co-codamol strength carries dire, restrictive warnings. NSAIDs cause all sorts of problems and often require a proton pump inhibitor (PPI) co-prescription. So what then? Opioids? Pregabalin? Gabapentin? No wonder drug abuse and misuse is escalating.

True, I should have enough gumption to simply say, "enough and no more" to my tiny handful of co-proxamol devotees. But, in reality, when you’re running late, they’ve got numerous other symptoms still to sort, the 10-minute clock is ticking and the waiting room is heaving, it’s hard not to bail out by doing what’s most expedient.

So why doesn’t the Department of Health simply blacklist it?

Should the Department of Health blacklist co-proxamol?

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Jack Nealson, Senior Management

The biggest problem with Co-Proxamol is that it is an extremely efficatious analgesic, especially for chronic musculoskeletal ailments. Its use in historic cases of suicide was exageratingly reported; it was not amongst the ten most common modes of suicide. Paracetamol alone was and still prevalent in suicide statistics. Though suicide by hanging or hypoxia remains top of the list. Co-Proxamol was phased out because of its low production cost and wholesale pricing. Newer analgesics were more profitable and subject to intellectual property rights.

Snake Plissken, Student

I'm not sure where to draw the line between "psychological addiction" or throwing rattle out the pram. I had a lady complain she needed her Almus made medication in a gold coloured box and we had given her Actavis in their orange coloured box. What Almus were doing on this instance was using stock from Actavis and repackaging it into their own gold coloured boxes. 

So how'd you go about resolving this problem even after telling her the tablets she so desperately needs are the ones supplied to her?

Maybe, doctors need to start making more use of private prescriptions for these individuals. I know many that write out private scripts for co-prox and get their patients to pay for it.

Leon The Apothecary, Student

I believe AAH currently charge £100 per box at the moment. Unfortunately, lazy prescribing is still lazy prescribing, but it is also a symptom of larger problem of not enough doctors, surgical staff, pharmacy staff, and training. Today, I surprised someone when I was told them I didn't need them to fax a prescription, I'd already pulled the information from the spine. Abilities like this are still constantly been responded with shock and awe. 

Michael Stewart, Community pharmacist

"it’s hard not to bail out by doing what’s most expedient"

Is this the same reasoning behind excessive antibiotic prescribing? Should the NHS blacklist amoxicillin to save us from MRSA?

"I know I shouldn't have prescribed that patient 400 morphine 200mg tablets for their mild headache, but I was running late, so what could I do?" 

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