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Background: In 2009, the European Medicines Agency recommended withdrawal of dextropropoxyphene (DXP); in March 2011 it was withdrawn from the market in France. Up until that time the combination dextropropoxyphene-paracetamol (DXP/PC) was widely used for analgesia. At withdrawal, French regulators recommended that DXP/PC be replaced by other step 2 analgesics, i.e. tramadol, codeine, or opium-containing drugs, or by PC for a weak level of pain. To investigate prescribing behaviours after DXP/PC withdrawal, dispensations of analgesics before and after withdrawal were analysed., Methods: Aggregated dispensation data of analgesics prescribed between January 2009 and December 2012 in the Rhône-Alpes region were obtained from the general health insurance claims data; changes in analgesic dispensation over time were analysed with the ATC/DDD methodology. Pre (Jan-June 2009) and post-withdrawal (Jan-June 2012) changes of DDDs where computed for each analgesic step., Results: The dispensations of DXP/PC experienced a two-step decrease until 2011. Over the withdrawal period 2009-2012, there was a 14% decrease in the overall use of analgesic (from 109 to 94 DDDs), while the use of step 2 analgesics declined by 46% (- 22 DDDs, from 47 to 25 DDDs). This latter decline included a cessation of use of DXP/PC (29 DDDs in 2009) that were only in part (+ 7 DDDs, from 18 to 25 DDDs) compensated by increased use of codeine, tramadol and opium, in monotherapy or combined with PC. For step 1 analgesics, use increased with 9%, mostly PC (+ 8 DDDs, from 31 to 39 DDDs). Step 3 analgesics dispensations remained largely unchanged over this period (around 3 DDDs)., Conclusions: In the Rhône-Alpes region, DXP/PC withdrawal was accompanied in part by an increased use of same level analgesics, and in part by an increased use of PC in monotherapy. The extent of DXP/PC use before withdrawal, and the increased use of PC after DXP withdrawal, underline the complexity of pain management.

Objective: To assess the effect of the UK Committee on Safety of Medicines' announcement in January 2005 of withdrawal of co-proxamol on analgesic prescribing and poisoning mortality., Design: Interrupted time series analysis for 1998-2007., Setting: England and Wales., Data Sources: Prescribing data from the prescription statistics department of the Information Centre for Health and Social Care (England) and the Prescribing Services Unit, Health Solutions Wales (Wales). Mortality data from the Office for National Statistics., Main Outcome Measures: Prescriptions. Deaths from drug poisoning (suicides, open verdicts, accidental poisonings) involving single analgesics., Results: A steep reduction in prescribing of co-proxamol occurred in the post-intervention period 2005-7, such that number of prescriptions fell by an average of 859 (95% confidence interval 653 to 1065) thousand per quarter, equating to an overall decrease of about 59%. Prescribing of some other analgesics (co-codamol, paracetamol, co-dydramol, and codeine) increased significantly during this time. These changes were associated with a major reduction in deaths involving co-proxamol compared with the expected number of deaths (an estimated 295 fewer suicides and 349 fewer deaths including accidental poisonings), but no statistical evidence for an increase in deaths involving either other analgesics or other drugs., Conclusions: Major changes in prescribing after the announcement of the withdrawal of co-proxamol have had a marked beneficial effect on poisoning mortality involving this drug, with little evidence of substitution of suicide method related to increased prescribing of other analgesics.

Aim: To determine what effect the withdrawal of co-proxamol from the UK market has had on mortality from poisoning in Scotland., Methods: This was a retrospective, observational study of mortality relating to poisoning by single agents in Scotland for the period 2000-2006. Mortality data were obtained from the General Register Office Scotland, and primary care prescribing data from the Information and Statistics Division of the Scottish Executive Health Department., Results: A significant reduction in the proportion of poisoning deaths due to co-proxamol was observed following legislation [mean 2000-2004, 37 deaths (21.8% of total poisoning deaths); 2006, 10 (7.8%); P < 0.0001]. The most significant reduction was seen in male out-of-hospital deaths [mean 2000-2004, 17 (21.8%); 2006, two (2.9%); P < 0.0001]. This was associated with a decline in prescriptions by 60% within 6 months of legislation. The total number of poisoning deaths also fell, slightly earlier than the full impact on co-proxamol deaths (mean 2000-2004, 171.2; mean 2005-2006, 129.5; P = 0.005)., Conclusions: Legislation has resulted in a major reduction in the number of deaths associated with co-proxamol poisoning in Scotland, with no compensatory rise in mortality from poisonings from other common analgesics. We estimate from this study that a minimum of 300 lives across the UK will have been saved by the withdrawal of co-proxamol.

Online pharmacies are increasingly common, and some of them have been reported to inappropriately supply prescription-only medicines. Dextropropoxyphene-containing compounds are addictive and frequently implicated in fatalities occurring in the United Kingdom. We aimed here at assessing the online availability of dextropropoxyphene for purchase over a time-span of 2 years (September 2003-August 2005). A Google search was run in September 2003 using different sets of keywords and the first 100 links identified were thoroughly assessed. In March 2005, the same e-pharmacies websites identified at baseline were accessed again and a Google search using the same sets of keywords previously used was run as well. Furthermore, a specialized search with Froogle was run both in March and August 2005. Although an illegal practice in most countries, a number of websites willing to sell the compound internationally were identified at the time of the baseline search. In March 2005, the Google search for vending websites identified 361,000 links, compared with 40,000 18 months before. Only half of dextropropoxyphene vending e-pharmacies were still active by March 2005 but, at that point in time, access to Froogle apparently facilitated the task of online dextropropoxyphene purchase. By August 2005, however, the same Froogle search identified only one link aimed at online dextropropoxyphene shopping. In the United Kingdom, dextropropoxyphene-related products will be withdrawn later this year but this may have only limited impact on the availability of the compound. The emergence of Internet as an unregulated source of controlled substances is an important development that may have significant public health implications. This issue needs to be dealt with at both international and national level.

Background: Several pain management guidelines and explicit medication-use criteria identify propoxyphene as an inappropriate medication for use in older adults., Objective: This study was conducted to estimate trends in propoxyphene use among community-dwelling elderly (age > or = 65 years) Medicare beneficiaries from 1993 through 1999 and to determine whether beneficiaries' drug coverage and specific characteristics of their physicians were associated with receipt of propoxyphene in 1999., Methods: Data from the Medicare Current Beneficiary Survey (MCBS) were used to examine the prevalence of propoxyphene use in cross-sections of nationally representative samples of community-dwelling elderly Medicare beneficiaries from 1993 through 1999. The 1999 MCBS was linked with the 1999 Area Resource File to examine patient and physician factors associated with propoxyphene use in the community-dwelling elderly at the county level., Results: Rates of propoxyphene use were generally stable over the 7-year period, from an annual prevalence of 6.8% in 1993 to the slightly decreased prevalence of 6.6% in 1999. No protective effects against propoxyphene use were observed based on beneficiaries' drug coverage or type of drug coverage. Rather, Medicaid beneficiaries were more likely to receive propoxyphene than those without drug coverage (odds ratio [OR] = 1.40; 95% CI, 1.02-1.92). Among physician characteristics, male sex (OR = 1.34; 95% CI, 1.02-1.75) and medical specialty (OR = 0.81; 95% CI, 0.65-1.00) were strongly correlated with prescribing of propoxyphene., Conclusion: This study found a continuing high prevalence of propoxyphene use in the community-dwelling elderly Medicare population from 1993 through 1999, with > 2 million beneficiaries receiving the drug in 1999.

The effects of a Medicaid formulary restriction, adding propoxyphene napsylate to a Negative Drug List, were examined. The market shares of products in subgroups of the internal analgesic therapeutic category were compared for periods before and after the restriction. Data from Wisconsin Medicaid Management Information System claims records were analyzed to determine changes in the percent of recipients, prescriptions, and expenditures. For both noninstitutional patients, the market shares held by propoxyphene napsylate primarily were shifted to propoxyphene hydrochloride products. Secondarily, market shifts to nonsteroidal anti-inflammatory drugs (NSAIDs) occurred, and this effect was more pronounced for noninstitutional patients. The formulary restriction most affected the firm that solely marketed propoxyphene napsylate products prior to the change, since that entire market share was redistributed to other products.