Friday, August 11, 2006

Methadone & the QT; Opioid switching; "Choosing" chemotherapy at the end of life

1)
Lancet has a brief communication about QT interval prolongation and high(er) dose methadone use .  This is further reminder that increased use of this drug as an analgesic may have unwelcome effects

2)
The Oncologist has a review on the pharmacology of opioid switching.  It reviews the small amount of evidence supporting its practice and also reviews the possible reasons why it may work (why do some people, idiosyncratically, seem to do better--fewer side effects, more pain relief--with some opioids compared to others).  No answers to be sure, but if reading about receptor polymorphisms gets you going it's worth reading.  Of note, however, the review furthers the confusion surrounding the terms potency and efficacy which creates sentences like this:

In terms of analgesia, all opioids should be equipotent, provided appropriate equianalgesic doses are used.

(This should read: ...all opioids should be equally effective, provided appropriate equianalgesic doses are used.)

3)
A recent Journal of Clinical Oncology article attempts to review the literature on why patients "choose" chemotherapy near the end of life.  I say 'attempts to review' because while this is ostensibly a review article, the literature is so heterogeneous and scarce that the article is more of a polemic about the current sad state of affairs when it comes to decision making about cancer treatments in advanced cancer.  It takes on a wide swath of issues:  frequently poor communication to cancer patients about prognosis and expected treatment outcomes; payment systems which deny reimbursement for family conferences; the evidence that patients learn more about their progression of disease and what to expect from other patients in cancer center waiting rooms than their physicians; the NCI website which lists radiosurgery and clinical trials as treatments for recurrent non-small cell lung cancer but not palliative care*; etc.  There is a common theme throughout the article of fear:  patients fearing death and wanting chemotherapy that (frequently) has no realistic chance of helping them & physicians fearing patients (patients' emotions, damaging patients' hope, etc.) and so not disclosing to them what is going to happen, what to realistically expect from their treatment, etc.

*This is the second article I've read in the last couple of weeks which trashes the patient information on the NCI website.

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