668 BRITISH MEDICAL JOURNAL 12 MARCH 1977 into the anterior chamber (hyphaemia). Later intractable due to dextropropoxyphene include rapid onset of symptoms. glaucoma arises from the aqueous humour's being caught inthe During the first 24 hours the patient's condition fluctuates posterior chamber and so squashing out the anterior chamber. appreciably, with delirium leading at times to convulsions, loss The pace varies from the explosive course of Fusorium solani to of consciousness, and respiratory and cardiac depression. This Br Med J: first published as 10.1136/bmj.1.6062.668 on 12 March 1977. Downloaded from the slow meandering of Phialophou. fluctuating course means that sudden cardiac or respiratory Treatment is primarily medical. Later, surgery may be arrest may occur at any time during the first 24 hours, even necessary: a conjunctival flap or a corneal graft. Formerly, when the patient's progress may have seemed satisfactory. treatment with polyene drugs and mercurioles was limited by Many doctors have been lulled into a false sense of security in their toxicity, but pimaricin is a useful first-line treatment.4 The their management of patients poisoned with dextropropoxy- newer antifungicides, such as chloromycine or flucytosine and phene, and Carson and Carson"' have recently emphasised the thiabendazole of the imidazole group, are more effective and particular danger of acute respiratory depression. Pulmonary specific, but as fungi are plants treatment must be for weeks oedema has also featured as a major cause of death." 12 rather than days. Infected patients are best treated in specialist The increasing number of deaths due to acute overdosage centres; but (as can be seen from the Nigerian report) many of dextropropoxyphene6 "'' 3 is causing growing concern, cases occur in areas far from such centres, and a plea has been especially in the United States. Carson and Carson"' have made in the British Journal of OphthalMologv& for the prepara- claimed that a similar trend is occurring in Britain but that so tion of a combination of drugs that can cover a wide range of far it has not received sufficient recognition. A consistent bacterial and fungal infections. Such a preparation could be feature in recent papers6 "I has been that deaths have occurred made up in one medication so that treatment could be started mainly when too much dextropropoxyphene has becn taken before the actual fungus has been identified. It is possible, together with central nervous system depressants-particu- however, to send scrapings by airmail to the Institute of larly alcohol. These other preparations make dextropropoxy- Ophthalmology for identification so that, if necessary, specific phene especially hazardous when taken in acute overdosage, treatment may be given at a later stage. and any doctor prescribing the drug should emphasise to the patient that alcohol should be avoided when taking it. Any IGugnani, H C, et al, British Yournal of Ophthalmology, 1976, 60, 607. patient taking other types of central nervous depressant drugs 2 Jones, B R, Richards, A B, and Morgan, G, Transactions of Ophthalmic to as an Society of the United Kingdom, 1969, 89, 727. should be given an alternative dextropropoxyphene 3Jones, B R, American Journal of Ophthalmology, 1975, 79, 719. analgesic. Care should also be exercised in prescribing for 4 Forster, R K, Rebell, G, Archizes of Ophthalmology, 1975, 93, 1134. pregnant women and for patients with personality or other 5 British J1ournal of Ophthalmology, 1976, 60, 605. psychological disorders likely to increase their susceptibility to drug dependency. With all these caveats, how good is the case for using the drug at all ? Despite the popularity of dextropropoxyphene as an analgesic, no substantial scientific evidence has shown that Dangers of it has advantages over many other analgesics with little or no central action. Miller and his colleagues'4 made a compre- dextropropoxyphene hensive survey of 243 published reports of dextropropoxy- phene and found few hard data on its therapeutic value and its http://www.bmj.com/ side effects compared with other analgesics. The unusual and Dextropropoxyphene is an analgesic drug similar in structure unpredictable dangers of dextropropoxyphene in overdosage to methadone which acts directly on the central nervous have to be set against its popularity based, presumably, on system.' It was synthesised first by Pohland and Sullivan in doctors' and patients' clinical impression of its effectiveness. 19532 and has come to be widely used in Britain, where there Thus many would agree that any doctor prescribing the drug were 2-5 million NHS prescriptions for the drug in 1970. rather than a simpler, less expensive, and potentially less toxic Various proprietary preparations are available containing preparation should be aware of the hazards and able to justify on 23 September 2021 by guest. Protected copyright. different strengths of dextropropoxyphene hydrochloride, his choice. alone or in combination with other analgesics and sedatives such as paracetamol, phenacetin, aspirin, caffeine, and amylobarbitone. These preparations include dextropropoxy- 1 Kiplinger, G F, and Nickander, R, _'ournal of the Amierican Medical Asso- ciation, 1971, 216, 289. phene capsules BP, Darvon, Depronal SA, Distalgesic, 2Pohland, A, and Sullivan, H R, Journal of the American Chemical Society, Dolasan, Doloxene, Doloxene Compound, and Napsalgesic. 1953, 75, 4458. At problems of drug dependency with dextropropoxy- 3 Jaffe, J H, in The Phar-macological Basis of Therapeutics, 4th edn, ed L S first, Goodman and A Gilman, p 263. New York, Macmillan, 1970. phene were considered unlikely,3 but more recently, and 4Matthew, H, and Lawson, A A H, in Treatmient of Commont Acuite Poison- especially in the United States, addiction has become com- ings, 3rd edn, p 141. Edinburgh, Churchill Livingstone, 1975. 5Salguero, C H, et al, Journal of the Amierican Medical Association, 1969, mon, and formal controls over the use of dextropropoxyphene 210, 135. have been introduced in many major hospitals in North ' Monforte, J R, and Spitz, W U, Preventivc Medicine, 1976, 5, 573. America.4 Several reports57 have confirmed that dependency 7 Quillian, W W, and Dunn, C A, Journal of the Amierican Medical Asso- ciation, 1976, 235, 2128. may develop. Quillian and Dunn7 described withdrawal Emmerson, J L, Gibson, W R, and Anderson, R C, Toxicology anid Applied symptoms from propoxyphene in an infant born to a woman Pharmizacology, 1971, 19, 445. treated regularly with the drug from the fourth month of 9 Sturner, W Q, and Garriott, J C, Jouirnial of thc Amtiericani Medical Asso- tion, 1973, 223, 1125. pregnancy. The drug was found in the cord blood, and urinary 1' Carson, D J L, and Carson, E D, British Mcdical journal, 1976, 2, 105. excretion from the baby continued for four days after birth. 1 Bogartz, L J, and Miller, W C,Journal of the Amcreican Medical Associati(n, a 1971, 215, 259. The other form of drug abuse in modern developed 12 Eshelman, F N, and Likes, K E, Drug Inttlligecnce and Clinlical Pharnmacy, society is that of self-poisoning. Availability of a drug is one 1976, 10, 596. factor determining how frequently it is used in self-poisoning: 13 McBay, A J, and Hudson, P,Journal of thc Amnerican Medical Association, 1975, 233, 1257. not surprisingly, therefore, acute overdosage ofdextropropoxy- Miller, R R, Feingold, A, and Paxinos, J,Journal of the Amierican Medical phene is common. The clinical features4 8 9' of acute toxicity Association, 1970, 213, 996.