Underappreciated ER Drugs (Part 1) by Michael Heller, M.D.
Sunday, October 4, 2009 
Michael Heller, M.D.Some things just take time. Learning what techniques, phrases and drugs work best (and worst) in Emergency practice is one of those things that take time and by that I mean years. The 3 drugs listed below (actually only one this month, the others will come next month) will surprise many readers but I urge you to give them a try, despite the bad things you may have heard about them from Emergency Medical Abstracts and elsewhere.
1) Darvocet (especially N-100). Especially in Little Old Ladies (and Little Old Men). Yes, I know you have all heard the rantings of so-called pain experts that propoxyphene is no better than placebo and has a high abuse potential, to boot. These experts are wrong; more precisely they have studied too many papers and too few patients. First, it is astonishingly easy to demonstrate using the analog scale or a simple question regarding pain relief that almost any analgesic is doesn’t do anything appreciable. The Annals did just that recently with .1mg/kg of morphine. And it’s incredibly easy to find literature which “proves” that placebo is about like codeine which is about the same as hydrocodone which is not much different than oxycodone etc. This sort of reasoning also proves that the varsity football team from the Parsons School of Design is about as good as Notre Dame.
Next, let’s not forget that there’s a good slug of acetaminophen in Darvocet, which is an effective and safe drug (recent FDA advisories notwithstanding). Giving Tylenol alone, however, is not a good idea because everyone knows it’s over-the-counter and therefore weak and anyway, they already tried it and it didn’t work. That’s why they are in the ED. By prescribing this (now) uncommon and controlled substance patients will get better results precisely because they expect to get better results. This is called being a good doctor.
And what options do you have? NSAIDs? In a Little Old Person? Are you kidding? Only if you like elevated BUN’s as an appetizer and bleeding for the main course. Codeine, Hydrocodone (Vicodin and others), or Percocet?? The Little Old People I see get constipated just looking at one of these pills. Even without narcotics they’re grateful to produce one rat pellet twice a week. No, my friends. You have only one good choice. Only one drug that is perfectly benign, and will help them get over their mild-to-moderate pain without side effects.
So let’s deal with that claim that it’s benign. First, the anecdotal. I have used this drug for 30 years, mostly in old folks and have never seen an adverse effect. That’s right, hundreds or thousand of uses and not one. Compare this to any narcotic (I would guess adverse effects in the majority of old folks) or Ultram, which seems to MAINLY have adverse effects.
And finally, the abuse thing. It seems every toxicologist has memorized those papers from the 60’s and 70’s which talked about propoxyphene abuse, mostly parenteral in young druggies. It does not exist in Old Folks and I’m not sure it exists anymore much anywhere. I’ve practiced in San Francisco, Baltimore, Pittsburgh and New York and it was not a problem in any of those places.
So, do yourself and your patients a favor and give this much-reviled, safe, inexpensive drug a try in the next Old Patient you see and sleep tight in the knowledge that they won’t come back tomorrow for either disimpaction or dialysis.
Darvocet, Drugs, Heller in Pharmacology
Reader Comments (6)
Close Vote by FDA Advisers Favors Propoxyphene Withdrawal
BETHESDA, MD 02 March 2009—A bare majority of FDA advisers agreed that propoxyphene-containing products should be removed from the U.S. market because they offer little benefit and may harm patients.
“In the absence of a demonstrated benefit, there is no acceptable risk,” said pharmacist Sean Hennessey of the University of Pennsylvania School of Medicine, during a January 30 joint meeting of FDA’s Drug Safety and Risk Management and Anesthetic and Life Support Drugs advisory committees.
propoxyphene-containing products have “one of the most unfavorable benefit-to-risk ratios ever seen for a drug.
“The usefulness of propoxyphene to treat pain is limited, and . . . the risks clearly outweigh any potential benefit,”
Regulators in the United Kingdom in 2005 began a gradual withdrawal of the propoxyphene-and-acetaminophen combination coproxamol from the market
FDA believes that propoxyphene “shows weak analgesic effects in some acute pain trials” when used as monotherapy. When used in combination with acetaminophen, he said, study results are “variable” as to whether propoxyphene contributes anything to the analgesic effect
extremely marginal positive data
“I can’t think of any rational reason to keep it,” she said of the drug. “We don’t need propoxyphene anymore.”
“There are many options,” she said. “It’s ridiculous to keep this drug around.”
Meta-Analysis (Moore et al, 2008)
(Cochrane Database Syst Rev: CD001440 (3), 2008)
Propoxyphene vs. placebo
Of 6 comparisons of propoxyphene vs. placebo, 5 showed no statistical difference, 1 showed minor statisical benefit from propoxyphene.
The experience of a single practicioner vs the pooled meta-analysis data of the Cochrane Database and FDA= anecdotal experience vs evidence-based medicine
Placebo Science Medicine Voodoo.
I thought Michael was talking about the art of medicine how do you get patients to take simple analgesics like Tylenol. You could painstakingly educate them, but you need time (do we ever have enough time) and they never really believe you, if you suggest the same old thing. Maybe using something "different" (but scientifically much the same) will get them to take it, get relief, not have too much in the way of side effects and get out of your hair.
How much of what else we do is placebo?
I'm Australian I'm Salaried so patients do go home with "Tylenol" and seem to be OK with this. Maybe they don't have a choice?
I've been using Darvocet N100 for a good long time too. Drug seekers hate it and the rest take it and get better. How much more could we ask of an outpatient analgesic?
The "simply MD" writer maybe didn't really read the blog. Obviously propoxyphene with tylenol is only a tiny bit better than tylenol alone. But it's almost completely benign and certainly safer than any likely alternative, ie narcs and/or NSAIDS especially in the elderly. It's not too late to try it: maybe you'll learn something.
Propoxyphene also makes the Beers List of inappropriate medications to use in the elderly. Granted, the Beers List is expert consensus but there are better analgesics out there with a lower risk of falls. I take care of way too many hip fractures from falls already! When a patient comes in who uses propoxyphene chronically and has fallen, I try to persuade them to discontinue the drug. Perhaps in acutely painful conditions, we need to do a better job of prescribing a bowel regimen with pain medicines instead of using a medication which has been shown not to work better than placebo and, even worse, cause harm.