Correspondence

1348 BRITISH MEDICAL JOURNAL 19 NOVEMBER 1977 CORRESPONDENCE Value of cocaine in opiate-containing Hexachlorophane-yes or no? Doctors and the global population crisis elixirs J M Gowdy, MD ...................... 1353 Sheila A Adam, MRCP, and Ann McPher- R G Twycross, DM .................... 1348 Indomethacin in pleurisy 4 son, MB .............................. 1356 The perilous skateboard K P Goldman, FRCP .................. /reatment of hepatic hydatid disease D H Wilson, FRCSED; C D Jefferiss, FRCS; 1353/ M Danis, MD, and others Quality v quantity in children .1356 Margaret I Little, MRCPSYCH ............ 1349 Relapse in leprosy Primary excision of brain abscess H P Dunn, FRCOG ...... .............. 1354 K Jesudasan .1356 J S Garfield, FRCS; A J Keogh, FRCS ...... 1349 Fatal chlormethiazole poisoning in Indomethacin, prostaglandins, and Treating dissenters chronic alcoholics schizophrenia S Bloch, MB, and P B Reddaway, MA .... 1349 Joan M Horder, MRCPATH .............. 1354 D F Horrobin, BM .1357 Science, race, and intelligence Outpatient chemotherapy for breast Alpha-fetoprotein in antenatal B R Silk, MRCP ...... ................ 1350 cancer diagnosis of neural tube defects Incidence and mortality of acute B V Palmer, FRCS ...................... 1354 R Carachi, FRCS ....... ............... 1357 pancreatitis Asymptomatic gonorrhoea in men M J McMahon, FRCS; C W Imrie, Blood for antenatal tests M J Balsdon, MRCOG, and H S K Singha, L G R Hull, MRCS .................... 1354 FRCSGLAS .............. .............. 1350 FRCS ................................ 1357 Role of the hospital in primary Association of autoimmune diseases SI units paediatric care with HLA-B8 J E Trapnell, FRCS .1357 G M Komrower, FRCP ...... .......... 1350 J von Knorring, MD ...... ............ 1354 Cancer of the lung and bladder Names of drugs Renal failure associated with ergot S Walter, MD, and others .1357 R Ham, MRCGP ...... ................ 1351 poisoning Long-term Althesin infusion and ECT and the media J R Webb, MRCP ...................... 1355 hyperlipidaemia J M MB ............... Bird, ..........1351 Mobilisation after myocardial A R W Forrest, MRCP, and others 1357 Gamma-glutamyl transferase in ascitic Management of children with nephrotic fluid in infarction primary hepatoma R B Stott, MRCP, and (Miss) Susan Joyce, syndrome W W Noll, MD; T J Peters, FRCP, and J R T Gabriel, MRCP .1358 MCSP ....... ......................... 1355 G Neale, FRCP ...... .................. 1351 Obstetric audit in general practice Problems with IUCD tails Bilateral injuries in childhood: an B Bedford, MB .1358 R A Sparks, MRCOG ....... ............. 1351 alerting sign? Advisory Committee on Borderline Beta-blocking drugs and thyroid Stephanie A Laing, MFCM .............. 1355 Substances function Treatment of depression A J Cooper, MD .1358 J Feely, MRCPI, and others; B I Hoffbrand, S Lieberman, MRCPSYCH .............. 1355 Matching resources to needs FRCP ...... .......................... 1352 Propranolol and thyroid surgery A K Thould, FRCP .1358 Liquorice-induced cardiac arrest R L Ward, FRCP, and W G Paley, FRCS .... 1355 Emergency in emergency departments J Montoliu, MD; Barbara A Bannister, Noxythiolin-resistant organisms C C Slack, FRCSED .1359 MRCP, and others ...................... 1352 Decline of visiting K G Edwards, MB .................... 1355 Dermatitis from cosmetics A E Loden, MB .1359 I W Caldwell, FRCP .................... 1353 Vertigo in children Points from Letters Human tick infestation in Erythema nodosum and oral A B Alexander, FACS .................. 1356 Britain (I P Gormley and J A Raeburn; T contraceptives Hot flushes after hypophysectomy Norman; Eleanor P Butler; Elizabeth J F A G Taaffe, MRCP, and others .......... 1353 I F Larsen, MD ......... ............. 1356 Harries; T L Henderson) ...... ........ 1359 Correspondents are urged to write briefly so that readers may be offered as wide or, where indicated, with an antiemetic such a selection of letters as possible. So many, are being received that the omission as prochlorperazine. I add cocaine only if a of some is inevitable. Letters should be signed personall by all their authors. patient remains drowsy after three or four days on a steady dose of morphine. Even then my policy is to give a test dose of dexamphet- Value of cocaine in opiate-containing elixirs amine or methylphenidate in order to help determine whether the addition of cocaine is SIR,-The Brompton Cocktail' continues to determined four-hourly regimen only 61 out likely to be of benefit. I have, in fact, used enjoy considerable popularity as a convenient of 400 patients were well enough to cross over, cerebral stimulants on only two or three method of administering morphine or dia- a statistic that highlights the problems of occasions during the past year. morphine orally to relive pain in advanced treatment evaluation in the terminally ill. I regard it as a matter of regret, therefore, cancer. The failure of this year's coca crop Surprisingly, it was found that although intro- that the current British National Formulary may, however, force physicians to reconsider ducing cocaine (10 mg/dose) resulted in a includes both morphine- and diamorphine- the need for cocaine in opiate-containing small, statistically significant increase in alert- cocaine elixirs since inclusion lends official elixirs. ness, stopping cocaine had no detectable effect. blessing to the efficacy of such combinations. Cocaine was first used with morphine by Although debatable, it was considered that Even more regrettable is the inclusion of Herbert Snow at the end of the last century these findings could be explained if, in this variant mixtures containing chlorpromazine. on the grounds that it helped "sustain dose, cocaine was of borderline efficacy and Although open to correction, I would suggest vitality."2 More recently it has been claimed that tolerance to this borderline effect occurred that, given their respective doses, any stimu- that the addition of cocaine enhances the mood within a few days. That tolerance does not lant action of cocaine will be antagonised by of the patient: "The euphoria renders the always readily occur, however, is indicated by the chlorpromazine. patient comparatively cheerful, and relieves the occasional phenomenon-not seen in this ROBERT TWYCROSS his mental and physical distress."3 On the trial-of the patient who becomes restless, Churchill Hospital, other hand it has been reported that the longer agitated, confused, or hallucinated when pre- Headington, Oxford an opiate-cocaine elixir is administered, the scribed cocaine and whose symptoms abate Martindale: The Extra Pharmacopoeia, ed A Wade, greater is the likelihood that the patient will only when cocaine is withdrawn. 27th edn, p 973. London, Pharmaceutical Press, 1977. become depressed.4 As a result of the trial I have stopped using 'Snow, H, British Medical Journal, 1896, 2, 718. In order to clarify matters a randomised cocaine routinely. Moreover, because patients 3 Love, M, British Medical journal, 1962, 2, 1192. 'Twycross, R G, and Wald, S J, in Advances in Pain controlled trial of morphine and diamorphine frequently find the traditional cocktail too Research and Therapy, ed J J Bonica and D Albe- elixirs with and without cocaine was under- sickly or complain of its alcoholic bite I now Fessard, vol 1, p 653. New York, Raven Press, 1976. sTwycross, R G, DM Thesis, University of Oxford, taken.5 After stabilisation on an individually prescribe morphine alone in chloroform water 1976..

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