Wednesday, May 9, 2007

Topical Methodone; Hispanics & Hospice

1) This last Monday I gave a talk to our palliative medicine fellowship program about topical and transdermal medication in palliative care. While I am generally not a big fan of topical/compounded medications (because of a general lack of efficacy research or basic science studies for many), I did come across a case series of 4 patients who received topical methadone for open wound pain management. I have worked with morphine gel before with mixed success, but never tried a different opioid. In 2005, Romayne Gallagher, MD, CCFP and colleagues mixed methadone and Stomadhesive powder and sprinkled it in the wound. 3 patients had dementia, and the patients could not use pain scales, so the staff rated their pain. (Obviously a weak part of the study) Now this was not successful in all cases which I give credit to the authors for admitting/publishing the 'negative' findings, as this is as important as positive 'findings' in research. But it may be something to try (and publish) for patients with bad wound pain and too much sedation from systemic opioids. If any of our readers have had luck with topical opioids feel free to post in the comments.

While we are on the topical/transdermal issue, I have one key point to make that is often confused....

  • Topical medications have a local effect without significant systemic absorption
  • Transdermal medications are systemic by nature of their absorption into the blood stream and effect at a location separate from the location of application
For example, scopolamine is transdermal (systemic), but the instructions (for no clear reason) state you must apply it to the retro-auricular area. Marketing, placebo effect (it is near your 'balance centers in your ear')? I am not sure. I wouldn't change your practices on this fact, because everyone is going to look behind the ear for the Scop patch not on their lower back if you put it there to prove my point.

2)PRI's The World had a 5 minute radio spot on hospice acceptance in Hispanic communities last week. They quoted some NHPCO statistics from 2005 noting 14% of the US population was Hispanic but only 4% of hospice patients. They do a good media review of the components of hospice, and the barriers to accessing hospice within the Hispanic community.

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