Friday, April 20, 2007

BMJ on the DEA, delirium, and healing the world; Lancet on morphine & frailty

A brief summary of several notable pieces from the most recent BMJ and Lancet. And a note that one should not look at the photos linked to from Christian's post unless one is in a position where it is safe to cry for 10 minutes, as I did sitting at my computer at work this morning. Luckily the palliative care offices here are (kind of) a safe place to sit and cry at one's computer, but I realize not everyone's offices are. Thank you, Christian, for letting us know about the photo series.

First is an editorial about DEA regulation of opioid prescribing in the US, arguing it is onerous and leads to poor pain management, while acknowledging the therapeutic controversies around opioids for chronic non-malignant pain. It mentions the infamous FAQ affair.
"Friction between regulators and medical providers is perhaps inevitable, as they both have noble yet conflicting goals—the one to control diversion, the other to preserve treatment for pain. As drug misuse becomes a greater problem, legislators react by tightening regulations. The American experience teaches that over aggressive regulations that ignore legitimate needs for opiates compromise doctors' ability to treat pain. As the pendulum has swung here between medical underuse and overuse, patients have been harmed. Now that it is becoming clear that the outcome of chronic opioid treatment is often poor, studies are urgently needed to investigate who benefits and under what conditions. The bigger question may be whether regulations have succeeded at all in controlling drug misuse, but the more immediate question for doctors in the US and elsewhere is how they should control their own prescribing so that interference by regulators does not discourage appropriate medical use of opiates."

Second is a brief 'observation' on reintegrating death (culturally) into 'Western' society, focusing on the book A Social History of Dying which seems pretty interesting. Palliative care is mentioned, sort of, as a remedy for our lack of 'integration' of death into our society, which, sort of, makes me nervous. I realize there are people within our community who feel deeply that death & dying are 'broken' in our culture and feel that palliative care is or should be a remedy for that. This seems like an incredible tall order and a set up for failure, not to mention a vast overestimation of the scope and influence of the palliative care movement. Deep cultural, economic, and scientific-technological changes have caused all of this and a scrappy movement to improve the medical care of dying patients seems unlikely to change much. It may be a palliative for this, an anodyne, but likely not much else. Last fall at the Montreal conference there was a distinct current of despair and anger about just how broken death & dying are in our ('Western') culture which was linked to, among other things, secularization. While I don't necessarily disagree with this I was confused as to why it was being laid out at a palliative care conference--how were we going to 'fix' this? Should we be even engaged as a community in trying to 'fix' this? Caring for dying people, as whole, spiritual people, in an interdisciplinary way, including spiritual care, does not mean we are healing the world or the dislocations brought about by several centuries of capitalism, migration, secularization, and technological change. Perhaps a worthwhile project, but not one we should set ourselves up as being a part of in my humble opinion.

There is an 'interim summary' and update about a NHS project in the UK to improve palliative care services in the community via primary care practitioners.

Finally there's a clinical review of delirium in older people. It's a practical review of the topic and doesn't add much to the recent NEJM one (the papers share a common author). It would be a nice addition to one's teaching file though for medical & other students.

Lancet has an editorial about one of my favorite topics: morphine and the myth of hastened death and why it seems to be so persistent in our culture, even the larger medical culture. It's brief, but good fighting words, and I'm glad to see it in the Lancet. There's also a brief bit on the concept of fraility in the elderly, arguing the controversial point that it is a useful concept medically--a discreet medical condition/syndrome with its own evaluation and therapy.

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