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Parliamentary Commissioner for Standards


13 Jul 2005 : Column 935

Committee on Standards and Privileges


Standards And Privileges (Nomination)



Exmouth (Development)

6.32 pm

Mr. Hugo Swire (East Devon) (Con): Exmouth in my constituency is now the largest town in Devon. It is therefore only right that there should be a proper discussion about the town's future in order to revitalise the local economy, particularly in the light of the weekend's announcement that the university of Plymouth may be planning to relocate the remaining faculty at Rolle college to Plymouth.

There are many different views about what form the development should take, but there is considerable dismay among my constituents at the thought that Exmouth's most valuable asset, its waterfront along the estuary, might be developed. The 10,970 Exmouthians and visitors to Exmouth have signed a petition. The petition of Exmouth Citizens Forum and its supporters

To lie upon the Table.

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Motion made, and Question proposed, That this House do now adjourn.—[ Tony Cunningham.]

6.34 pm

Miss Anne Begg (Aberdeen, South) (Lab): I am delighted to have the opportunity to call an Adjournment debate on the availability of co-proxamol, which is a mild analgesic that is used to treat those who have mild to moderate chronic pain. The debate stems from the advice that was given to general practitioners in January this year by the Committee on Safety of Medicines, which recommended that co-proxamol should be withdrawn entirely over the next six to 12 months.

I must declare an interest: I have been prescribed the drug, which I have used regularly for some years, and I take four co-proxamol a day. However, I am not here tonight because I use the drug and might be affected. I am here because a number of my constituents who use the drug contacted me when the withdrawal of co-proxamol was first announced in the press because they are worried about what might happen. When my constituent, Jonathan Russell, who has ankylosing spondylitis, came to one of my constituency surgeries, I began to take an even greater interest in the debate.

Jonathan has been taking co-proxamol, which he has found to be an effective response to his chronic condition. I have known him for a number of years in his professional capacity: he is a social worker who works with disabled people and gets them into employment and he leads an extremely active life. He contends that he can lead his busy life because of co-proxamol, which allows him a good night's sleep and also keeps him supple.

When Jonathan heard about the concerns associated with co-proxamol, he went to his GP, who took him off the drug. Over the past few months, he has tried various other drugs, which are supposed to be as good as, if not better than, co-proxamol, but he has told me that none of them are working. Indeed, some of the new drugs are making him feel very unwell and not allowing him to get the night's sleep that he requires, which is affecting his ability to work.

The desperation caused by his not feeling well and the fear that he can never return to co-proxamol drove Jonathan to seek an appointment with me and to complain. He is not the type of person who normally complains—he deals with a chronic condition extremely well and with an extremely cheery disposition. The effect that the withdrawal of co-proxamol has had on his life must be extremely serious for him to complain. He has learned to live with and manage his pain, which is the meaning of chronic pain, but he cannot do so without access to co-proxamol. The effects of the other drugs mean that he has been unable to loosen up in the morning and that he has been late into work. Indeed, he is afraid that he may have to give up work if he cannot continue to use what he regards as a mild, effective drug that has no side effects.

Why has the withdrawal of co-proxamol been proposed? Is it because the drug is ineffective? The answer appears to be, "No"—patients report that it is extremely effective. Is it because the drug has serious
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side effects? The answer is also, "No"—patients who use co-proxamol feel that out of all analgesics and other alternative drugs, whether they are COX-2 inhibitors or non-steroidal anti-inflammatories, it is the drug with the fewest side effects. Has co-proxamol been withdrawn because it increases the likelihood of a heart attack, a stroke or any other major health problem in the individual who is taking the drug? Again, the answer is "No"—the alternative drugs, which I shall discuss later are associated with a higher risk of such major health problems.

The reason why co-proxamol has been withdrawn, as was confirmed to me in a letter from the Secretary of State for Health, is that some people might abuse the drug and use it to commit suicide—not that the drug leads to people having suicidal impulses but that it is a mechanism for those who want to commit suicide. The Department of Health says that between 400 to 500 suicides a year are associated with co-proxamol, and that is why it has to take action.

Co-proxamol is quite different from most other drugs that have been withdrawn from the market. In those cases, there is usually an associated health risk for those who take the drug; in this case, the associated health risk is to those who may not have been prescribed the drug but take it in order to commit suicide or those who have been prescribed it but take it in overdose and therefore unconsciously or unwittingly commit suicide.

People who are on co-proxamol are aggrieved about the different approach that has been taken to that drug which means that they are losing an effective analgesic not because of anything that they do in terms of their behaviour or prescribing practices but because of what others might do. If that thinking was applied to all drugs, almost all would probably have to be taken off the market, because all drugs have some kind of associated risk; certainly, many opiates can be used to commit suicide.

Several years ago, we had the same debate about paracetamol. It is interesting that the advice that GPs have been given by the Committee on Safety of Medicines is that paracetamol, the drug that was controversial a few years ago, is just as effective as an analgesic. In medical terms, it might well be, but the people who use co-proxamol believe, from their own experience, that it is a superior drug. What is different about it is that it contains destropropoxyphene, which can give people a high and be mildly addictive. It is probably that feeling of well-being that people get that makes them believe that it is a drug. But that is not a reason for withdrawing co-proxamol; many drugs, including opiates, will give people a sense of well-being.

The advice to GPs goes on to suggest that if paracetamol is not enough they should consider prescribing a non-steroidal anti-inflammatory such as ibuprofen. There have recently been reports about the risk factors inherent in ibuprofen. We also know that other non-steroidal anti-inflammatories can cause gastro-intestinal bleeds, so they are not risk-free drugs. If that is not enough, GPs are advised that perhaps they could think of prescribing dihydrocodeine, which is a very strong analgesic but has severe side effects—it makes people feel very sleepy and leads to constipation. The alternative drugs that are proposed to replace co-proxamol are not without associated side effects or risks.
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The advice recognises that for some people none of this may work, and in such cases taking antidepressants such as amytriptyline is suggested. That is bizarre, because that class of drug is indicated in more suicide attempts than co-proxamol, since antidepressant drugs are generally used by those who may be more likely to have suicidal tendencies in the first place.

Why has it taken six months for us to get this far and have a debate in the House? It is probably because problems are only now beginning to appear. In some cases, patients who were on co-proxamol went to their GP, who prescribed something different and, six months later, they are realising that none of the alternative drugs work. That happened in the case of my constituent, Jonathan Russell. He has found that nothing else works. He has tried everything else and concluded that co-proxamol was the best drug for him.

The second group of patients comprises people such as me. I have not been to my GP but I know about the risks and that, at some point, I shall have to address the matter. However, that will be sometime in the future and I shall worry about it then. Many patients on co-proxamol may fall into that category. Perhaps some are not aware of what is going to happen. As time goes on and more practices determine their strategy on prescribing co-proxamol, that group, like my constituent Jonathan, will become more distressed.

People who are working in health are worried that not only co-proxamol is affected. If the suggestion had been that co-proxamol should be withdrawn from use, there would be less concern. However, many drugs that are used as alternatives to or alongside co-proxamol for chronic pain, especially the anti-inflammatories that are prescribed for people with arthritis, have large question marks over their use and the associated risks. Some have been withdrawn.

For example, the COX-2 inhibitors have proved remarkably effective in dealing with arthritic pain. Again, I speak from personal experience because I was on Vioxx. It was withdrawn and I went back on to co-proxamol. That was ironic because Vioxx was extremely effective and, when I took it, I did not need co-proxamol—as an anti-inflammatory, Vioxx reduced the pain and I did not need the analgesic effects of co-proxamol. Withdrawal of some of the COX-2 inhibitors has meant that people are more reliant than they had been on co-proxamol.

We must consider the exact risk that we ask patients to take. Almost all drugs have some associated risk and side effects, which can differ in different people. It is important that, when patients and GPs make decisions together on the most effective drugs for dealing with pain, they can make an informed choice. It should be up to them to weigh up the risks and benefits associated with their drug. If a drug is extremely effective, as the COX-2 inhibitors seemed to be, would patients be willing to put up with the associated increased risk of heart attack if they could be almost pain free for the next 20 years? Patients, with their doctors, should be allowed to make that informed choice.

Groups such as Arthritis Care have been keen to emphasise that informed choice. It is not a case of asking for all drugs to be available to all people at all times but of making a correct choice. I pay tribute to Arthritis Care. After I had applied for the Adjournment debate,
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I realised that I needed a little more background information about what patient groups felt about the withdrawal of co-proxamol and whether the issue was more widespread than the case of my constituent. Arthritis Care has been extremely helpful in providing me with a great deal of background information.

Groups such as Arthritis Care do not ask for co-proxamol to be freely available. It recognises that the Committee on Safety of Medicines has to take account of the public health aspects of any drug's use and misuse. It has to take account of misuse, even by those who have not been prescribed the drug.

I am normally supportive of medical opinion. I am unlikely to go against informed medical opinion and it is therefore strange for me to be in the position of asking the Government to reconsider the advice from one of its committees, which has been established to provide such advice. I have always supported the work of the National Institute for Health and Clinical Excellence, and I believe that we must have independent committees to consider these issues.

It is important that the Government look again at the prescribing arrangements for co-proxamol. Why should a person who lives alone and who takes four co-proxamols a day—which is well below a dangerous dose—be denied a drug with minimal side effects that he or she finds effective, just because other users cannot keep their drugs secure and might allow them to get into the hands of people who want to use them for the wrong reasons? There is a middle way. Arthritis Care does not necessarily want co-proxamol to be made available as a front-line drug. It would like GPs to be given the chance to find another suitable drug. If they cannot, however, it would like them to be able to prescribe co-proxamol, perhaps having sat down with the patient and provided a demonstration, either written or otherwise, to ensure that they are aware of the risks inherent in the drug, and of the risks involved if the drug is misused or left lying around.

Perhaps we could also consider changing the packaging of the drug, as was done with paracetamol. Co-proxamol is packaged in strips of 10 at the moment, which constitutes an overdose, whereas eight would be a safe dose. Perhaps we could consider packaging it in strips of eight. I hope that the Minister will take those suggestions on board.

In the past couple of days, I have noticed a difference in approach. In response to a media request, the Medicines and Healthcare products Regulatory Agency has now said that

That is not what patients are being told, however. The least that the Minister could do tonight would be to clarify the situation with regard to the availability of co-proxamol. Is it to be withdrawn completely? Is it to be available only while stocks last? Or will it continue to be available under certain conditions? If it is to continue to be available, that information needs to be well publicised. Organisations such as Arthritis Care which have large numbers of members who use co-proxamol will be delighted to have the issue clarified. There is confusion at the moment, and a great deal of distress in the wider community, and I hope that the Minister will be able to give us some reassurance tonight.
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6.53 pm

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