Friday 22 June 2018

The Brompton Cocktail and the decline of medicine

chloroform water

That rather remarkable combination of euphoriants is a recipe for the Brompton Cocktail, which was very successfully used in the treatment of terminal (fatal) cancer and other conditions; in the formulation as it was published by Cecily Saunders* in 1958 - and she (and her hospice movement) were responsible for propagating the BC into general usage. Later versions were improved by substituting heroin (diamorphine) for the morphine, since heroin is more powerful and less nauseating.

This was a strikingly effective, almost 'miraculous' drug combination for many dying people who were suffering extreme pain and dulled consciousness. The Brompton Cocktail would often (not always - of course; no drug suits everybody) relieve pain and breathlessness (morphine), maintain alertness (cocaine), induce calmness and sooth fear (the other components). But the BC was a combination that was greater than the sum of its parts.

(It also tasted pretty good, apparently.)

Nothing like the Brompton Cocktail had been seen before - it could, in minutes, transform the last weeks of somebody's life from a nightmare of in-turned agony into cheery and alert sociability. 

But nobody gets the Brompton Cocktail nowadays...

Why? Are the modern substitutes more effective? No - probably less.

The reason for replacing the Brompton Cocktail with inferior alternatives seems mainly to be stigma, partly inconvenience - and underlying these, the corruption of medicine by Big Pharma.

The stigma comes from prescribing drugs associated with abuse; the inconvenience is that the mixture needed making-up freshly, by the pharmacy, every few days. And, because all the ingredients are off-patent, generic - Big Pharma can't make money from them. 

The extinction of the Brompton Cocktail is representative of many ways in which highly effective treatments have been discarded, and indeed demonised, by modern medicine over the past half century; and replaced by new, expensive, worse alternatives. Other examples include diazepam (Valium) being replaced by SSRIs and Z-drugs, the removal of the uniquely effective barbiturate/ psychostimulant combination Dexamyl; and the near-universal replacement of heroin by morphine (medical use of heroin is, indeed, illegal in the USA - indeed, probably the only place in the USA where heroin cannot be obtained is a hospital). 

Since the 1960s the pharmacopoeia (list of drugs from which doctors can prescribe) has shrunk - from being repeatedly purged of old, cheap and well-understood drugs (e.g. the tranquilliser meprobamate, the psychostimulant pimozide) to make way for new, expensive alternatives of uncertain profile, often with inferior effects and inferior side effects.

The medical profession has been complicit in the process; going along with the antiscientific- progressivist assumption that newer means better/ old means worse. Looking around - this is a general phenomenon; exacerbated by managerialist indifference to functionality and outcomes and the politicisation of... everything.

So, as with so many other good things, it's a case of 'down the memory hole' for the Brompton Cocktail...  

*Note: This post was prompted by today's Google Doodle for the 100th anniversary of Cecily Saunders's birth - justly celebrating her as the pioneer of what is now called 'palliative care' medicine; but airbrushing her development and championship of the Brompton Cocktail - for which she was perhaps most famous among doctors. The Brompton name comes from the London specialist chest hospital, where the combination was developed for use in lung cancer, fibrosis etc.)


Karl said...

What, no LSD?

Bruce Charlton said...

@Karl - You can see what I mean, then? The Brompton Cocktail was an embarrassing medicine for doctors to prescribe, so it was modified to something more 'scientific' but somewhat less effective. This is the same factor holiding-back the adoption of ketamine - the only qualitative breakthrough in psychiatry for the past half century:

Chiu ChunLing said...

There is probably a darker motive at work as well.

Having so many major recreational drugs visibly associated with palliative care would tend to hurt their image with popular (i.e. illegal) use, as well as highlighting the fundamental nature of social pathology that drives their popularity...the widespread and profound hopelessness of even physically 'healthy' life being anything more than a terminal decline towards death.

If the energy people currently spend towards futile forms of criminality such as obtaining drugs to palliate the pointlessness of their lives were to be redirected towards removing modern power structures that make life fundamentally pointless, those modern power structures could be in real jeopardy. Along with those who have bet their futures on such power.

dbk_999 said...

I've heard it said that Mother Teresa would deny dying patients morphine, and I know in
some Buddhist literature there are some accounts of dying that talk of a spiritual 'purification' process that comes from the experience of pain.

I am curious as to your opinion on the this view.

Bruce Charlton said...

I'm taking a medical perspective here.

Karl said...

Oncology not ontology!