Brompton cocktail
The Brompton cocktail, also known as Brompton's mixture or hospice mix, is a palliative elixir historically used to alleviate pain and distress in patients with terminal illnesses, particularly advanced cancer. This mixture typically contained morphine, cocaine, ethanol, and other ingredients, and was originally formulated in the 1950s at the Royal Brompton Hospital in London. Its development is attributed to the efforts of medical professionals, including English surgeon Herbert Snow and prominent figures in the hospice movement like Cicely Saunders and Elisabeth Kübler-Ross.
Initially popular in hospice care during the 1970s, the cocktail aimed to provide an effective and cost-efficient alternative for managing intractable cancer pain. However, studies conducted in the late 1970s demonstrated that oral morphine alone was as effective as the cocktail, leading to a decline in its use due to concerns about safety, potential for addiction, and the risk of misuse. As palliative care evolved, the need for individualized treatment regimens became apparent, diminishing the role of the Brompton cocktail in modern practice. Despite these challenges, the cocktail has not entirely disappeared, and it is occasionally utilized in contemporary care settings, albeit rarely. Side effects associated with the cocktail include sedation, confusion, and the risk of addiction, highlighting the complexities involved in pain management for terminally ill patients.
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Brompton cocktail
ALSO KNOWN AS: Brompton’s mixture, hospice mix
DEFINITION: Brompton cocktail is a palliative elixir containing morphine, cocaine, ethanol, and other ingredients to lessen or prevent the pain and distress associated with terminal illness, especially advanced cancer. It is no longer part of standard care.
Cancers treated: Previously used for advanced, painful tumors in patients near death
Delivery routes: Oral as a liquid
How this substance works: Elixirs of morphine and cocaine were first described in 1896 as treatments for the pain associated with advanced cancer by the English surgeon Herbert Snow. A specific mixture was published under the auspices of the Royal Brompton Hospital in London in 1952; the ingredients included morphine hydrochloride, cocaine hydrochloride, alcohol, and chloroform water. Several different formulations calling for heroin (diacetylmorphine), cannabis, antiemetics, distilled spirits, and sedatives have been promoted over the years. Flavoring syrup is sometimes added. It was widely used in the early 1970s, mostly in hospice care. Two of its main proponents were Cicely Saunders, founder of the modern hospice movement, and Elisabeth Kübler-Ross, a psychiatrist and authority on end-of-life care. The active ingredients are intended to provide a welcome combination of analgesia, disinhibition, and stimulation. Cough suppression was an important effect in patients with lung or airway malignancies (or end-stage tuberculosis). The mixture was promoted as more cost-effective at treating intractable cancer pain than parenteral narcotics.
Several significant liabilities have contributed to the disappearance of the Brompton cocktail from modern oncology practice. In 1979, controlled trials showed that oral morphine alone gave pain relief equivalent to the cocktail, that oral morphine and oral heroin were equally effective, and that oral cocaine had no effect on patients’ alertness or sociability. One study concluded that “the Brompton Cocktail is no more than a traditional British way of administering oral morphine to cancer patients in pain.” The potential for diversion and abuse was illustrated by a case report in which an individual obtained the mixture illicitly and injected it in lieu of heroin. Each of the cocktail’s active ingredients has addictive and tolerization potential, making discontinuation difficult. Even though terminal cancer patients often require multiple drugs for symptom management, the convenience of an “all-in-one” mixture of drugs, such as the Brompton cocktail, is outweighed by the benefits obtained by monitoring and adjusting analgesics, antineoplastics, antiemetics, and psychoactive drugs individually. Still, despite pain management options, new advances in palliative care, and safety concerns, in the 2020s, the Brompton cocktail was in use, though rarely.
Side effects: The side effects include sedation, confusion, constipation, decreased breathing, tolerization, and addiction.
Bibliography
Clark, David. “The Brompton Cocktail: 19th Century Origins to 20th Century Demise.” End of Life Studies, 1 Aug. 2014, endoflifestudies.academicblogs.co.uk/the-brompton-cocktail-19th-century-origins-to-20th-century-demise. Accessed 11 June 2024.
Clark, David. "The Rise and Demise of the 'Brompton Cocktail." Opioids and Pain Relief: A Historical Perspective. Ed. Marcia Meldrum. Seattle: IASP, 2003, pp. 85–98.
Davis, A. J. "Brompton's Cocktail: Making Good-Byes Possible." American Journal of Nursing, vol. 78.4, 1978, pp. 610–12.
Hanks, Geoffrey W. C., et al. Oxford Textbook of Palliative Medicine. 4th ed. Oxford: Oxford UP, 2011.
Kastenbaum, Robert. Macmillan Encyclopedia of Death and Dying. New York: Macmillan Reference, 2003.
“Last Orders: Pain Relief at the End of Life.” Medium, 5 Nov. 2016, medium.com/@beinganddying/last-orders-pain-relief-at-the-end-of-life-442a8043cda. Accessed 11 June 2024.