Wednesday, June 20, 2007

Opioids, opioids, opioids, cadavers

Anesthesia and Analgesia has an article urging medicine to conceptualize pain relief as a fundamental human right, and several editorials in response (one on improving access to analgesics worldwide; one on legal aspects of pain management; a general supporting editorial ; and a cautionary editorial warning of overuse of opioids to control chronic and postoperative pain). The main article is a comprehensive review at how and why pain is undertreated and the health and societal costs of this, and focuses a lot on international (WHO, etc.) efforts to improve pain relief. One sobering tidbit: 6 nations use 79% of the world's supply of morphine and 120 countries use virtually zero. (One assumes that in most of these countries the strong opioid of choice is nothing, and not Actiq or OxyContin.) The most interesting aspect of the article was its relatively lengthy summary of legislative and judicial efforts in 'developed' countries to define pain relief as a right, a medical standard, and inadequate pain relief grounds for civil liability.

While the position that pain relief is good/important is rather uncontroversial, the counter editorial reveals that decades into the pain control movement the issue remains very polarized, and polarized specifically around the use of opioids. One side is the opioids are safe and effective and the best we've got camp, the other is the opioids aren't safe, aren't effective, and not worth it camp, and in between the great mass of medical professionals remain afraid to treat pain, and ignorant of how to do it even if they wanted to. It's like a yelling match between one group saying WE ARE NOT TREATING PAIN DOCTORS ARE OPIOPHOBIC PATIENTS ARE SUFFERING and the other WE ARE OVERTREATING PAIN OPIOIDS KILL WE ARE CREATING ADDICTS. And like I've blogged before there's a sense out there that there's a backlash growing against opioids for chronic non-malignant pain and this editorial quite effectively spells out the issues at hand. They note, and I can't argue with them, that there are a lack of quality, long term data supporting the safety and efficacy of opioids for chronic non-malignant pain (however see this post for how research findings can be twisted). While true, there is evidence that a substantial minority of people really benefit, although (and this is my grand gloss on the entire field) - across a population of patients with chronic non-malignant pain a majority of them won't benefit from long-term opioids (and in many studies people just stop using them after a while because the toxicity seems to outweigh the benefit they're getting). Taking this as true it seems like the reasonable public policy should be to, in fact, through clinician education and training, make sure physicians know how to treat pain and effectively use opioids, and, per the 'pro-opioid' camp, make sure the regulatory environment is such that physicians who prescribe opioids for legitimate purposes don't have to worry about 30 year prison terms.

Along these lines Annals of Internal Medicine has a short piece about strategies to stop abuse of prescription opioids . It reviews some of the evidence but is mostly based on interviews with experts. A worthwhile, quick read.

The May Harper's, in the Readings section, had an amazing excerpt from remarks from the undertaker Thomas Lynch made to the President's Council on Bioethics about the treatment of cadavers (these were from hearings about organ transplantation). (Looks like the full transcript of his remarks is here...scroll down a little). Read this.

Some choicer quotes (sorry about the length of this but it's in the public domain, & he does ramble a little, and I can't help myself):

"And there is a difference, as one of your panel pointed out, between the notion of medical death, metabolic death and the notion of social death and spiritual death and actual death as far as your family is concerned, and those are the things this council must wrestle with when you seek to set forth useful policy. I might know, for example, that at the end of a process with cremation, we end up with say 14 pounds of bone fragment and dessicated tissue that we can put in a box and hand to the family. But when you see the elderly sister come to claim the ashes of a sister whose own children couldn't come and get her, when she bears that box like Viaticum, when she walks out the door, flips the button to open the trunk and then reconsiders and goes to the back door and opens it up and then thinks better of it and closes it again, when she goes to the passenger — front seat passenger door, opens it up, places the box on the front seat and then clicks a seatbelt around it, you can see that whether we are remnant or icon or relic is not up to you or me. It's up to the living that bear us in their memory and in fact, that bear our mortality because we are mortals, we are humans. We are tied to this humus, this layer of earth from which our monuments and our homes and our histories rise out of."

"Right between the inhale and exhale of the bone-wracking sob such hurts produce, some frightened and well-meaning ignoramus is bound to give out with, "It's okay, it's not her. That's just a shell." I once saw an Episcopalian deacon nearly decked by the swift slap of a mother of a teenager dead of leukemia to whom he had tendered this counsel. "I'll tell you when it's just a shell," the woman said. "For now and until I tell you otherwise,
she's my daughter." The woman was asserting the longstanding right of the living to declare the dead, dead. Just as we declare the living alive through baptisms and lovers in love by nuptials, funerals are the way we close the gap between the death that happens and the death that matters. It's how we assign meaning to our little remarkable histories. And the rituals we devise to conduct the living and the beloved and the dead from one status to another have less to do with performance than they do with meaning."

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