Monday, March 12, 2007
Pharmacogenetics of opioids; Pain meds & race & palliative care; Society-wide advance care planning; Addiction
The latest Clinical Pharmacology & Therapeutics has an article on the pharmcogenetics of opioids (related Pallimed post here). I have to admit my excitement for this article waned as I read it: it's incredibly basic-science heavy and difficult for the average clinician (at least me) to read (another article in this issue about methylphenidate and alcohol caught my eye although I realized I couldn't even make it through its abstract before going cross-eyed). In retrospect I don't know what I was expecting. I find the topic interesting, I guess, because it offers a promise of "hard" answers to many of the vagaries and seemingly-random hazards of my clinical practice; this, however, is currently wishful thinking on my part.... Anyway, for those of you who share my curiosity about this topic this review is an exhaustive, albeit exhausting, reference. The authors' penultimate words summed things up nicely:
"Many of the studies described in this review have increased our knowledge and understanding of how pharmacogenomics can influence the response (efficacy, toxicity, pharmacokinetics, metabolism, transport) of the opioid drugs and contribute to intersubject and interpatient variability. It is another matter for this to be translated into clinical practice."
A recent Cancer had an article on insurance, religiosity, and palliative care in urban African-American and Latino patients. This was an incredibly complex (for me, too complex) study involving patients receiving community-based palliative care which looked at an interesting outcome: pain medication "stress." That is--not access to pain meds or happiness with pain control but levels of 'stress' and 'hope' surrounding their pain (meds). How they actually measured this--what this really meant--remained obscure to me after reading the article--perhaps explaining my initial reaction above. One of their major findings is that a lack of insurance predicted less 'stress' about pain meds. Huh? I'm coming off a week-long illness and perhaps my brain remains addled, but I remain perplexed. Perhaps I need a guide.
BMJ, in an article related to one I recently blogged, has a nice piece about providing appropriate/timely services for those with advanced/chronic or terminal illnesses. It's mostly a concise and incredibly valuable summary of what I (lazily and unfairly to all those others who have helped develop it) call the Joanne Lynn model. What's nice is to see this discussion in a widely read general journal like BMJ. What is discussed is true, society-wide "advance care planning." Some choicer quotes:
"Most people believe their lives will be relatively healthy, punctuated by episodes of illness that last no more than a few weeks. On the rare occasions that we think about dying, we imagine short and overwhelming illness in old age. Healthcare systems are designed as if disability and ill health were aberrations, rather than a phase that lasts months or years near the end of our lives, despite the contrary evidence all around us."
"Although hospice programmes have been an important and instructive initial response, they do not meet the needs of most patients who are sick enough to die. A minority of people who die with chronic conditions use hospices, and then only for an average of a few weeks. In the US, enrolling in a hospice requires acknowledging a prognosis of "less than six months" and forgoing "curative" treatments. The inability of doctors to prognosticate with precision and the reticence of patients and doctors to accept these conditions restrict the use of hospice services. This has led to the conclusion, in the US and in the United Kingdom, that "end of life care" should encompass all people sick enough to die soon, even though some will live in fragile health for some years."
They go on to describe programs developed to care for people, in ways that focuses on quality of life, staying at home, etc., who are experiencing different illness trajectories nearing the end of life.
The NIH & Robert Wood Johnson Foundation (& affiliated organizations) are releasing a variety of media & publications (including an HBO documentary) on addiction with an eye, it seems, to improving public awareness and rates of treatment. The tone of the project seems to be, very much, one of "addiction is a brain disease that can be treated" (a quote from the promotional material). True--although that may imply to the casual observer that it can be easily & successfully treated & while that's better than suggesting those with addiction problems are moral failures it may end up implying that those who get 'brain treatment' and still aren't 'cured' are nevertheless in some way failures. News releases here (NIH), here (RWJF), and here (NIDA/NIH).
Thanks as always to Tom Quinn for letting us know about this.