The occurrence and clinical features of analgesic abuse in Western Scotland

The radiological diagnosis of analgesic nephropathy

A study was made of the radiological findings in 57 patients with a clinical diagnosis of analgesic nephropathy. The ages of the patients ranged from 27 to 72 years, and females predominated over males in the ratio 4-7 to 1. Renal failure varied from mild to very severe and the patients showed the usual high incidence of analgesic-induced gastro-intestinal, haematological and neurological disorders. In 82% of cases, kidneys were of normal size, but there was radiological evidence of reduced renal function in 85%. Thus, a small kidney with good renal function was unlikely to be due to analgesic nephropathy. Medullar necrosis was observed in 65%, and papillary atrophy and papillary necrosis each in 46%. Although usually gradual, acute massive sloughing of necrotic papillae could occur and occasionally led to ureteric obstruction. Papillary cavitation was seen in 39% but fistulae and ring shadows were observed in only 11% and 14% respectively, while renal calcification occurred in 26%. With the use of high dose techniques and retrograde pyelography, it is almost always possible to make a positive radiological diagnosis of analgesic nephropathy, even in patients with markedly reduced renal function.

The use and abuse of analgesics

Of 740 Glasgow citizens studied 13.6 per cent denied ever taking analgesics while 12.3 per cent took them weekly and a further 5.0 per cent daily. Three fifths of those taking daily analgesics did so without reference to a doctor. Aspirin and paracetamol were most popular in social classes I and II while Askit were mainly used by social classes IV and V. Aspirin was the preparation of choice of those who rarely took analgesics but its popularity declined the more frequently analgesics were taken. Askit, however, were twice as popular amongst the daily self-medicators as amongst those who rarely took analgesics. Patients with renal disease, psychiatric patients, and those with psychogenic pain were much more likely to have abused analgesics than the general population. Although the risks of excessive analgesic ingestion are considerable, in Glasgow alone over 8,000 people may be abusing analgesics.

Phenacetin-induced haemolytic anaemia

Haemolytic anaemia, rarely severe, is a common yet often unrecognized complication of the prolonged use or abuse of phenacetin-containing analgesics. Irregularly contracted (pyknocytes) or fragmented erythrocytes (schistocytes) are commonly present in the peripheral blood in this form of anaemia. It is emphasized that their recognition during screening of blood films may reveal patients previously unsuspected of analgesic abuse and at a stage before the development of the more serious complication of nephropathy. Fourteen such patients, detected during the last 18 months, are briefly described and the pathogenesis and laboratory features of the anaemia reviewed.

Extended therapy in patients with established urinary tract infection

Sixty-six patients with established urinary tract infection were given a 3-month course of antibacterial therapy and the effect of this upon the recurrence rate of urine infections investigated.

Even in patients with no radiological evidence of renal damage the recurrence rate was 40 per cent at 2 years and this rose to 75 per cent in the group with impaired renal function and abnormalities present on intravenous pyelography.

It is concluded that an initial 10 day course of therapy is indicated in females suffering from their first or second attack of acute urinary tract infection. If this becomes established, a 3-month course of therapy is suggested and following this, further recurrences demand careful renal investigation. In the male, all cases of urinary tract infection should be investigated after the initial therapy. Finally, the management of those patients with no anatomical lesion who suffer from recurrent attacks of infection after a 3-month course of therapy has not yet been clearly defined. There is no evidence that either ampicillin, nitrofurantoin or nalidixic acid is superior to sulphadimidine in the treatment of patients with established urinary tract infection.

Analgesic nephropathy: clinical syndrome and prognosis

Over a five-year period 86 patients presented to a renal unit with a history of prolonged analgesic abuse and no other obvious cause of renal damage. Anaemia and peptic ulceration were common, and neurological states suggestive of chronic analgesic intoxication occurred in 22 patients. Thirty-two patients died during follow-up, but the prognosis was much better in patients who ceased abuse of compound analgesics, and improvement could occur even in advanced renal failure. While 84 patients had taken mixtures containing both aspirin and phenacetin, papillary necrosis was also found in two patients who had abused only aspirin, and when phenacetin was withdrawn from several leading compound analgesics, renal function continued to deteriorate in patients ingesting those preparations.

Phenacetin nephropathy, with particular reference to the effect of surgery

Sixteen patients suffering from phenacetin nephropathy were seen at one London hospital between June 1964 and January 1970. There were five deaths, three of them following a surgical operation. Phenacetin nephropathy occurs far more frequently than is generally considered. Unless patients are asked about the consumption of phenacetin routinely the diagnosis is usually missed. It is recommended that phenacetin and paracetamol should be available only on a doctor's prescription.