M. HENRY GAULT, M.D., M.SC., F.A.C.P.; T. CHRISTOPHER RUDWAL, M.D.; W. DENNIS ENGLES, B.SC., M.D.; JOHN B. DOSSETOR, M.A., B.M., B.CH., PH.D., F.R.C.P.(C)
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Twenty-two patients with renal disease seen over a 4-year period had abused analgesics containing acetylsalicylic acid, phenacetin, caffeine, and in all but one instance codeine. The minimum duration of abuse was 3 years and the average, 12. Average total consumption was estimated to be 11 kg of ASA, 8 kg of phenacetin, 2.5 kg of caffeine, 0.4 kg of codeine, or 50,000 tablets. Papillary necrosis was demonstrated bilaterally in 15 patients and when active was often associated with hematuria and abdominal or loin pain. The 24-hr creatinine clearance was less than 50 ml/min in 18. Proteinuria was slight or absent, and an increase in urinary leukocyte excretion in the absence of infection was common. Acidosis, passage of papillae, and hypertension were important considerations in some patients. Bacterial infection of the kidney did not appear to be an important factor in the majority.
Although features of renal disease may dominate the clinical picture, they are often absent until late in its course; related symptoms often occur only after many years of abuse and are frequently preceded by long-standing evidence of psychiatric disorder and headache and the more recent onset of upper gastrointestinal disease and anemia. These disorders occur in the same patient often enough in association with abuse of aspirin, phenacetin, and caffeine-type analgesics, both in this series and the literature, to warrant referring to them as a syndrome. Psychiatric abnormalities include long-standing personality disorders often associated with immaturity, dependence, emotional instability, anxiety, depression, and habituation to other drugs and alcohol; in most cases the psychiatric disorder must be considered the primary factor in the development of abuse and an essential aspect of treatment. Peptic ulceration of stomach or duodenum is a common association, and in this series resistance to treatment or bleeding led to gastrectomy in 12 patients. Anemia may be due to one or more of several causes.
A history of abuse has to be sought carefully and may be denied. Demonstration of a positive ferric chloride test in urine or of sulfhemoglobin in blood provides suggestive evidence; these tests are also useful in follow-up studies.
The majority of such patients can be persuaded to stop abusing this type of analgesic; hence, the complications of abuse must be considered preventable in the majority and require publicity.
GAULT MH, RUDWAL TC, ENGLES WD, et al. Syndrome Associated with the Abuse of Analgesics. Ann Intern Med. 1968;68:906–925. doi: https://doi.org/10.7326/0003-4819-68-4-906
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Published: Ann Intern Med. 1968;68(4):906-925.
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