Thursday, July 28, 2005

Transdermal fentanyl to methadone conversion

The current J of Clinical Oncology has a nice little article about one group's experience converting TTS fentanyl to methadone or vice versa.  They chose an ratio of fentanyl to methadone of 1:20 [eg 175mcg/h of TTS fentanyl = 4.2mg fentanyl/24hrs = 84mg methadone/24h] &, to make a long story short, had pretty good luck with this as a starting conversion ratio (these were inpatients whose pain was actively managed during the conversion).  The article is also an argument for opioid rotation:  the patients in the study were all switched because of inadequate analgesia and most of them achieve significantly better analgesia with the opioid switch (in either direction). 

Thursday, July 28, 2005 by Drew Rosielle MD ·

Tuesday, July 26, 2005

This month's JGIM: focus group on cultural differences in end of life communication

This month's J of General Internal Medicine has an article about cultural differences in preferences about communication about end of life issues.  It's a qualitative study based on focus groups with non-Hispanic whites and African Americans.  One of the most striking findings of the study was just how fundamentally important spiritual matters were for the African-American participants--especially w/r/t involving spiritual leaders in end of life discussions/family meetings.  Also the participants unanimously agreed that it is important for the physician to inquire about the faith of the patient and family and how that impacts end of life decision making. 

Tuesday, July 26, 2005 by Drew Rosielle MD ·

Monday, July 25, 2005

Neurologic outcome in coma

I was Googling the difference in defining "irreversibility" w/r/t people in persistent vegetative states due to trauma vs anoxic brain injuries when I stumbled upon a very nice review of predicting neurologic outcome in people in comas from the J Neurol Neurosurg Psychiatry (2001).  Free full text appears to be available.  It summarizes prognosis based on etiology of coma, length of coma, & clinical signs.  There's nothing new here, but the article is a tidy summary that would be handy for quick reference. 
As an aside, my biggest frustration in researching this topic is the reporting of outcomes.  Most of the papers I've looked at have presented outcome dually (Bad being death/persistent coma/pvs/severe neurologic impairment-disability; Good being full recovery or moderate disability).  This is a problem because for some families that are struggling with goals of care for a loved one in a coma there is a big difference between a PVS and severe disability.  For some, severe disability (in which the patient would need lifelong care & would have some cognitive impairment but will still be able to interact/communicate on some level) would be acceptable/compatible with the patient's wishes, whereas PVS would not.  Most of the literature doesn't really differentiate between these two and isn't helpful for these situations.

Monday, July 25, 2005 by Drew Rosielle MD ·

Tuesday, July 19, 2005

This week's JAMA: advance directive disasters

This week's JAMA has another installment in its outstanding Clinician's Corner series about end of life issues.  This one is about difficult issues surrounding advanced directives.  The case is one of the more horrific unclear-advance-directive-leading-to-terrible-death situations I've ever heard of & frankly I appreciate the article just for putting this in print as most of us have seen situations like this.  At one point the patient's wife tries to physically stop the code-blue resuscitation of the poor patient.  It's that bad of a situation.  The article describes some of the more complicated elements of advance directives, especially in hospitalized patients whose conditions are rapidly changing.  It would make a great teaching article for med students & residents.

Tuesday, July 19, 2005 by Drew Rosielle MD ·

Sunday, July 17, 2005

Cicely Saunders has died

Dame Cicely Saunders, founder of the modern hospice movement in the 1960's, died at St. Christopher's Hospice in London on July 14th.  What she did for the world is incalculable.

Sunday, July 17, 2005 by Drew Rosielle MD ·

Thursday, July 14, 2005

Palladone where art thou?

Well Palladone's (extended release hydromorphone/dilaudid) release in the US is being suspended.  It appears that if you take Palladone with alcohol, it becomes immediate-release and this, obviously, can be a problem.  Purdue I'm sure is not too happy.  On the other hand I'm not too sad.  While I'm all for more options in controlled release oral opioids I have had a big problem with the name "Palladone."  I just find names like Palladone Orwellian and uncomfortable.  It's like the name of the drug is promising blissful relief.  The antipsychotic "Abilify" annoys me in the same way. 

Thursday, July 14, 2005 by Drew Rosielle MD ·

Tuesday, July 12, 2005

This week's JAMA: a simple intervention increases hospice referrals in nursing home patients

This week's JAMA has an interesting article about a simple intervention to increase hospice referrals in NH residents.  Basically patients were asked a few screening questions (about desire for CPR/ventilation, preference for a more palliative mode of care, etc.) and for those that seemed amenable to hospice a fax was sent to their PCPs.  About 20% of those whose PCP's received the fax were enrolled in hospice at 1 month compared to 1% of those whose PCP's didn't receive the fax.  Secondary measures like family satisfaction, total days spent in hospice, & hospital admissions were different between the groups; mortality, place of death, and percentage who died under hospice care did not differ between the groups.  Referral of appropriate patients to hospice earlier is a well recognized need in end of life care & it appears this intervention (which the authors noted took 5-10 minutes to complete) would be helpful in the NH population.

Tuesday, July 12, 2005 by Drew Rosielle MD ·

New FDA Duragesic warning

The FDA announced a new warning label for Duragesic (transdermal fentanyl patch) today.  Most of it is pretty straightforward, reasonable stuff--a little bit of it dumbfoundingly basic (avoid concomitant use of alcohol, etc).  The bulk of the warning seems to be about not using duragesic in opioid naive patients and that patients should have proven tolerance to moderate doses of opioids--60mg of morphine a day for instance.   This is probably a good thing:  I have seen several opioid naive elderly people put on the 25mcg/hr Duragesic patch for chronic pain because it's "such a low dose."  The prescribing doctors would never have considered starting MSContin 30mg bid in these patients. The .pdf of the release is here.

by Drew Rosielle MD ·

Monday, July 11, 2005

Depression & desire for death in late-stage ALS

July 12th's Neurology has 2 articles about depression and desire for death in advanced ALS (along with an editorial by the esteemed Timothy Quill).  In brief, they find that depression is rare in ALS (~10%), doesn't seem to become more common as people approach death, and (discounting those who are actively suicidal) depression and a desire for death don't seem to be particularly related.  ALS has often been used as the model to describe a circumstance in which a desire for death/to hasten death could be rational & these articles at least would argue that this desire is not based in depression.  Either way I'll always argue skilled palliative care, not physician assisted suicide, is the answer.

Monday, July 11, 2005 by Drew Rosielle MD ·

Thursday, July 7, 2005

This month's Journal of Palliative Medicine: a simplified methadone conversion ratio?

This month's J of Palliative Medicine has an interesting gem buried in the correspondence section--a simplified morphine to methadone conversion scheme. Dr. William Plonk averaged published conversion ratios from 5 sources (Lawlor, Cancer 1998, 82:1167–73; Ripamonte, J Clin Oncol 1998, 16:3216–21; Mercadante, J Clin Oncol 1999, 17:3307–12; Mercadante, J Clin Oncol 2001, 19:2898–904; Mercadante, Supp Care Cancer 2003, 11:326–31), performed some math, and came up with this formula:

Estimated daily oral methadone dose (in mg) = (Daily oral morphine equivalents in mg)/15 + 15.
So 200mg of oral morphine a day converts to 28mg of oral methadone a day.

Thursday, July 7, 2005 by Drew Rosielle MD ·