Saturday, May 12, 2007

OxyContin guilty pleas; 1-year mortality post hospitalization; Dying art of the condolence letter; Opioids, pain, & addiction

If you haven't heard already, several top executives for Purdue Pharma have plead guilty to criminal charges from misleading doctors about the safety of OxyContin. NY Times has a pretty good story about it here. Some of the article's rhetoric is a little off - "OxyContin is a pure, high-strength version of a long-used narcotic, oxycodone," and suggests there is something uniquely sinister about OxyContin. There isn't, except in the way it was promoted, and I'm glad there will be some accountability for it.

The American Journal of Medicine has published a prognostic model for predicting 1-year mortality in hospitalized adults. Specifically it used prospectively gathered data from a single institution and looked at adults over 65 years, admitted to a general medical ward, who survived to discharge (~3000 patients each in the derivation and validation cohort). Administrative claims data was used (ICD-9 codes). Mean age was 78 years; 80% of the subjects were African American. The researchers created a prognostic scoring system to predict 1 year mortality by assigning points to various conditions that were associated with 1 year mortality in multivariate analyses: age, non-home discharge, chf, pvd, dementia, renal disease, cancer. Those in the highest point category had a 46% mortality in the derivation and 42% morality in the validation cohorts. Essentially the scoring system is a way of identifying those patients with a 'decent' chance of dying within a year, and might be useful as a way of, for instance, in a health care system, flagging those patients for special attention towards advance care planning, goals of care discussions, etc. A major problem with this is that it is derived from a single institution in the US (University of Chicago) whose patient population (largely African American) is well known to generally have worse health outcomes than the population as a whole. One would want to see the scoring system validated in other centers before generalizing it further.

Two cancer journals have had special issues:
Journal of Clinical Oncology's latest issue is on geriatric oncology. Many articles, none of which I read other than the introductory ones. There doesn't seem to be any article addressing an issue of great interest to me: cancer therapy for the cognitively impaired, but oh well.

Annals of Oncology has published a supplemental issue of consensus guidelines from the European Society for Medical Oncology which includes a few supportive cancer guidelines (including chemotherapy induced nausea/vomiting and the management of cancer pain). They are pretty basic and short. The cancer pain one bravely offers a morphine:methadone conversion ratio which is pretty reasonable\conservative: 12:1 for morphine doses >300mg.

Chest has a lovely piece about the "dying" art of the condolence letter, arguing that these should be a standard of practice for all physicians. It has practical recommendations for language, etc. It includes this condolence note written by Abraham Lincoln to a family member of a civil war soldier:

"It is with deep grief that I learn of the death of your kind and brave Father; and especially that it is affecting your young heart beyond what is common in such cases. In this sad world of ours, sorrow comes to all; and, to the young it comes with bitterest agony, because it takes them unawares. The older have learned ever to expect it."

As lovely as that is I can't imagine ever writing anything like that to a family member.

And, finally, Pain has e-published a long, detailed, cogent review article about opioid dependence and abuse in chronic pain patients. It covers everything from history, terminology (and all its confusing problems), genetics, psychiatric comorbidities, and current major and unresolved controversies in opioids and chronic pain (what percentage of patients have abuse problems, how do you tell, is it iatrogenic, what do we we do about it, etc. etc.). No answers here - because there are none - but a wonderfully detailed review of the field.

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