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Deal with requests for co-analgesics

Dr Frank Shapiro shares his techniques to avoid prescribing co-analgesics when faced with patient requests

Dr Frank Shapiro shares his techniques to avoid prescribing co-analgesics when faced with patient requests

The recent furore over co-proxamol caused me to reflect on my long-term resistance to prescribing co-analgesics. Does the fact that many patients request co-analgesics justify the fact that the majority of paracetamol prescribed in the UK is in the form of a co-analgesic? I have never believed so.

The way I deal with co-analgesic requests, and other, in my view, inappropriate requests, has earned me a reputation which has stuck for the quarter of a century I have been in practice.

Having this sort of reputation is quite useful in itself. While patients are not stupid, and they want what they want, they are also often quite well aware that what they are requesting is at best dubious, often inappropriate and sometimes plain harmful. Most of my patients know when they come in to see me all the things I will not agree to. One of these is co-analgesic prescriptions.

What I do

When faced with a request for co-analgesics I use a number of strategies. The first and perhaps the most important is to be consistent. 'No' is always no, and it means I can honestly say 'I never prescribe this class of drugs and have not done so for perhaps 10 years'.

This is often all I need to say, and the vast majority accept this without requiring any qualification and simply stop there.

The second is to quote research papers that have compared the analgesic properties of paracetamol alone with co-analgesics.

The minor gain in analgesic properties with the co-analgesics (around 5 per cent) must be balanced against the side-effects such as constipation, addiction, abdominal pain and analgesic headache. I have copies of these papers for any patient who challenges my veracity.

Following on from this I give these patients a standard letter from our local and very helpful prescribing adviser, outlining these issues. Most patients glance at it and then leave it behind, so I don't have to print very many.

Third, I show them the symbol listed alongside all co-analgesics in the BNF, and explain that the BNF should be the bible for most prescribers and that this symbol means a drug is considered by the Joint Formulary Committee to be 'less suitable for prescribing'.

By now most patients have either agreed to try using or changing to simple paracetamol. There are, however, those who perhaps don't know me too well and persist with their request. The usual reasons given are 'Dr A always gives it to me', 'paracetamol doesn't work', 'I took some of auntie's and they worked great', 'I got it from hospital' and often most surprisingly 'paracetamol always upsets me'.

I explain to the latter rather mystifying group that co-analgesics contain paracetamol. To the remainder I stress that the main reason they feel less well on paracetamol after a period of time on co-analgesics is that they are unfortunately suffering from mild withdrawal symptoms and that these will quickly pass if they do not take any more.

I inform them that many people addicted to more powerful opiates often resort to co-analgesics when they are short of more potent alternatives.

If a request comes in from a patient who does not want an appointment I always refuse the request, offer to issue a prescription for paracetamol and enclose a copy of my prescribing adviser's letter. I also advise the receptionist to offer the patient an appointment with me if they are not happy.

What I achieved

Using these techniques I have been able to avoid prescribing co-analgesics altogether for years. The practice of not prescribing has become easier and easier as patients accept that there is no point in debating the issue. Of course a number of patients will seek out the drugs from other sources, but the majority do not.

I never allow myself to be disheartened if this does happen as I have always believed that each individual prescriber has an obligation, while always being aware of guidelines, to prescribe as he or she feels is most appropriate.

Frank Shapiro is a GP in Strathaven, Lanarkshire

Competing interests None declared

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