The FDA has required manufacturers of propoxyphene-containing products (Darvon, and others) to strengthen boxed warnings to include the potential for overdose.1 This action followed disclosure of fatal overdoses linked to propoxyphene-containing products taken alone or concurrently with other CNS depressants, including alcohol. Many of the overdoses occurred in patients with a history of emotional instability or suicide attempts. Accumulation of metabolites of propoxyphene can lead to central nervous system, cardiac and respiratory depression; convulsions and cardiotoxicity have occurred.

A Schedule IV controlled substance, propoxyphene is a weak full agonist opioid indicated for relief of mild to moderate pain.2 It is often prescribed in combination with acetaminophen (Darvocet, and others). One reasonable alternative would be codeine with acetaminophen; 32 mg of codeine has an analgesic effect similar to that of 65 mg of propoxyphene. Another would be 400 mg of ibuprofen, which may be more effective than either propoxyphene or codeine combined with acetaminophen.

1. FDA News Release. FDA takes actions on Darvon, other pain medications containing propoxyphene. Available at www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm170769.html. Accessed August 23, 2010.

2. Drugs for pain. Treat Guidel Med Lett 2010; 92:25.

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Pain can be acute or chronic. Chronic pain has been broadly classified into two types: nociceptive and neuropathic. Nociceptive pain can be treated with nonopioid analgesics or opioids. Neuropathic pain is less responsive to opioids; adjuvant medicines such as antidepressants and anticonvulsants are often used to treat neuropathic pain. Combining different types of analgesics may provide an additive analgesic effect without increasing adverse effects.

Concerns have surfaced again at the FDA and in the media about the safety of acetaminophen and the multiplicity of products on the market in the US that contain various amounts of it.

Pain can be acute or chronic. Chronic pain has been broadly classified into two types: nociceptive and neuropathic. Nociceptive pain is generally treated with nonopioid analgesics and opioids. Antidepressants and anticonvulsants have been used to treat neuropathic pain. Combining two different types of analgesics may nprovide an additive analgesic effect without increasing adverse effects.