Friday, May 4, 2018

Brompton Cocktail - The Magical Qualities of Addictive Drugs....

I was talking to a colleague today about problems in the addiction field.  She was referring to problem with opioids and suddenly I had the association: "Brompton Cocktail."  The Brompton Cocktail was a mixture of alcohol, cocaine, morphine and other ingredients that had purported superior pain alleviating qualities compared with any other available medication at the time.  I first encountered the term on a medicine rotation as a medical student.  Our attending physicians at the time were two very bright hematologist-oncologists.  One was older and more cerebral with many publications.  The other was younger, outspoken and generally edgier.  He had just completed his fellowship.  When the conversation turned to pain relief for patients with cancer pain he made it very clear that his preference was "Brompton's Cocktail" but that it was not available in the United States.  He railed against the regulations in this country that prevented him from providing Brompton's to his American patients.

That piqued my interest at the time.  The natural question is why Americans were being denied a superior analgesic?  The second question was - why all of the polypharmacy?  Alcohol was an analgesic out of the old west - why would it need to be mixed with morphine and cocaine?  And why the cocaine?  It could certainly be a local anesthetic that could restrict blood flow in ENT procedures - but would it really provide widespread pain relief if it was ingested and systemically absorbed?  Further research in the matter showed that in addition to gin - vodka and whiskey were being used as the alcoholic beverage.  Some people added tincture of cannabis.  Others added anti-nausea medication like phenothiazines or antihistamines.

These combinations in elixir form were popular in Europe where their original use was in mainstream surgery in the late 1890s.  They became widespread in the 1920s and 1930s when many formulations were listed in the medical literature and practitioners often had their own custom formulations.  One of the references I read suggested that the patient could be given a choice in terms of the alcohol component (vodka, whiskey, or gin) and it gave them a sense of control over their medication.  There were some modifications of the original formula based on economic considerations - like the cost of cocaine.  The most striking feature of this mixture is that it persisted in use in medical facilities for nearly 100 years!  My medical school professor was telling me it was the ultimate pain medication in 1982.  Available evidence accumulating in the 1970s eventually illustrated that for pain relief there was no advantage of an exotic mixture over morphine monotherapy (1).   And that (in addition to more permissive use of opioids) brings us into the current period of opioid and nonopioid treatment of chronic pain, although the Brompton mixture was used almost exclusively for severe postoperative pain or pain associated with malignancy.

One of the strong themes in medical care as in the rest of American culture is the lack of appreciation of how past history factors into current medical care.  Although there were probably two biases in the early 20th century leading to the use of Brompton - the lack of manufactured pharmaceuticals and the potent effects of both cocaine and morphine, the same biases exist today.  The common bias noted on this blog has been the idea that opioids are universally effective for acute and chronic pain.  We are seeing an emphasis on cannabis as a treatment for pain and tincture of cannabis was an element of Brompton a century ago and it was eventually eliminated.  Unusual combinations of prescription medications are combined with the hope that they will provide some pain relief including opioids, sedative-hypnotics for sleep, benzodiazepines for anxiety and muscle spasm, muscle relaxants, gabapentinoids, and antidepressants.  I see patients who are taking extended release forms of opioids who are also given immediate release forms of the same opioid and told that they are "rescue" medications in the event that they have breakthrough pain not treated by their maintenance extended release medication.  I see people with implanted opioid pumps who are given immediate release medications for the same reason.  In both cases they tell me that their pain is the same but they continue using the rescue medication.

In a previous post on medical cannabis, I posted that some physician advocates talk about the entourage effect and why the whole plant needs to be smoked for pain relief.   The uniting thread in all of these approaches is that there is a predominance of potentially addictive drugs.  Addictive drugs always seem to be imbued with magical qualities - whether it is pain relief or the recent push to use psychedelics for whatever ails you. That always leads me to ask - is this medication working for pain or is it just reinforcing its own use?

All of these approaches strike me as being not much more scientific than Brompton Cocktail.  Like all historical lessons about addictive drugs and their purported effects - Brompton is nearly forgotten.

I nearly forgot it myself.

George Dawson, MD, DFAPA


1: Melzack R, Mount BM, Gordon JM. The Brompton mixture versus morphine solution given orally: effects on pain. Can Med Assoc J. 1979 Feb 17;120(4):435-8. PubMed PMID: 376079.


1 comment:

  1. Nice historical lesson there. Here's the endless joke with the cannabis crowd for psychiatry at least, these people come in touting the wonderful benefits of pot, and then in the next sentence complain how they need controlled substances to function. It never ceases to amaze me how disingenuous and manipulative most of these folks are.

    As a bit of an aside, I know this harsh and rude to write, but, if more people would die from xanax and valium use as primary substances found in tox screens, maybe, just maybe the FDA would consider making these two benzos at least controlled 2 substances. And watch the frequency of Rxs provided for these two drugs plummet to levels seen with opiates of late...

    Joel H