Wednesday, July 11, 2007

Opana; Hastened death in the news

How did I miss this?
Did anyone else know about this?
How come no one told me?
Do you know about Opana aka oxymorphone?

If you have not heard about oxymorphone and you count yourself as an expert in opioidology and palliative medicine, you should probably read Chamberlin et al's review of oral oxymorphone in the Annals of Pharmacotherapy. I stumbled across this medication initially in "Pain Medicine News" that shows up in my mailbox without me ever subscribing to it. Many of the articles in the last issue kept mentioning oxymorphone, and I thought I needed reading glasses, because I kept seeing 'oxycodone' or 'morphine' as I glanced over it. Luckily I work with a great hospital pharmacist who found this recent article.

Some quick facts about oxymorphone:
Approved by FDA: June 2006
Brand Name: Opana (o-pawn-NA; O-pahna; o-pan-na; I 'm not sure-a)
Class of med: semi-synthetic opioid
Avail forms: PO IR 5, 10mg; PO ER 5, 10, 20, 40mg; IV
Past life: Numorphan tablets and PR taken off the market in the 70's secondary to fears of abuse as IV
Equianalgesic equiv: 30mg of PO morphine = 10 mg oxymorphone

Costs as quoted in the article:

Morphine (generic) 15mg tab = 0.19
Oxymorphone (brand) 5mg tab = 2.28

Oh! now I see why Opana probably has not filtered its way into the HPM community. Nearly 10x the cost. Other price points are not so wide, but that's a pricey meatball!

That will get you off to a good start, but you should really try to read the article as it covers some of the studies that proved efficacy for oxymorphone, and it is a good primer if you may be encoutering this medicine anytime soon. The authors do a good job of demonstrating some of the strengths and weakness of the oxymorphone placebo and comparison studies.

By the way, if any of you were wondering, neither Drew nor myself are on any pharmaceutical speaker's bureau's. Also, please read the medicine insert or the article and don't depend on just this post to become familiar with oxymorphone.

------>Hastened death in the news

'Hastening death' seems to be hitting the editorial pages a lot these days, maybe coinciding with the release of Dr. Kevorkian. The Times (UK) covers a UK physician accused of hastening the death of two premature newborns. Apparently, with the parents endorsement, he gave pancuronium in one case and a drug ' on the verge of what society finds acceptable' in the other case. I am still scratching my head over the pancuronium and that statement, although I do not want to make judgment in a case I know only a little about. What the second drug was will have to await further Googling by me. The journalist has a few good quotes but I would hope we have more optimism and civility in our societies to strive for better than this (bold is mine):
We possess immense medical technology, but have not studied the moral consequences of having it. We are incapable of addressing the concept of a good death. And we are failing disastrously to nurture doctors who, to those ends, seek only to reduce the suffering of dying patients.
Change in medical culture and public education takes time, and in life and death matters, our society may require more subtle shifts in acceptance, lest we become to hasty and then regret our actions.

NEJM has an article on the Texas Medical Futility by Dr. Truog (free article). It is very even and the best part is the audio interview(free) along with it, where you can learn how to pronounce his last name. There is also a perspective piece on when you can't fix everything.

Penny Richards, Ph.D. at the Disability Studies Blog covers the last 100 years in assisted suicide with her review of a 1907 novel. Pretty good read and interesting to look at the perspective of hastened death from disability advocates standpoint. (via the very interesting Medical Humanities Blog)

And finally, this special article in the Boston Globe about a physician helping his father die. He even got in touch with Tim Quill about his dad. I had some issues with the article and don't have the time in this post to go into them here, maybe I will get to it in the comments section. But here is one part that I think is open for debate:
The doctors said we'd first have to stop infusing the paralyzing drugs, and then wait hours or even days as my fathers' failing kidneys tried to excrete what was already in his body. Only then could the ventilator be switched off. This plan would require my father to die much more slowly, increasing the chance that he might suffer.

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