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!Oxymorphone (brand) 5mg tab = 2.28
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.
9 comments:
Now I feel like a doofus. Drew had two posts in the last 18 months that mentioned oxymorphone. I guess I breezed right past it, because I still have yet to see it in practice.
Cherished colleague: not to mention a Fast Fact on oxymorphone that I wrote: http://www.eperc.mcw.edu/fastFact/ff_181.htm
Pancuronium: was the article suggesting pancuronium wasn't on the verge of acceptable? Seems straight-forwardly unacceptable to me: a killing and not a comfort medicine.
I'm sure y'all know that pancuronium is at the core of the current controversy over lethal injection. One might surmise that that issue, inasmuch as it involves criminal justice, has nothing to do with palliation, PAS, and euthanasia, but I submit that's not quite true.
This is because the same rationale many physicians -- e.g. Orin Guidry -- cite as a reason for refusing to participate in executions shows up in an important rationale for opposing PAS: it requires physicians to kill, and therein violates something fundamental about the practice of medicine.
I'm not saying I agree with this, just that it is fascinating that the same justification is used in such seemingly different end-of-life scenarios.
Thanks for the kind words about the MH Blog, btw.
The search engine on the Pallimed page is not picking up on either Opana or oxymorphone. here's another review article: Prommer E. Oxymorphone: A review. Supportive Care in Cancer. 2006;14:109-115. I haven't read the Chamberlin paper yet, but in previous papers I extrapolate that oral oxymorphone is about 2 times more potent than morphine and about half as potent as hydromorphone.
Tom I'm getting 3 hits when I search for oxymorphone: are you using the blogger toolbar at the top of the blog page?
Daniel thanks for your comments. Both PAS and state sanctioned execution by lethal injection both involve the use of medicines/drugs to stop a life & if you believe deliberately stopping a life is wrong then there you go. Proponents of PAS argument seems to be that there are extreme circumstances (intractable suffering due to an otherwise terminal illness) that make deliberate life-taking permissible - it seems that if you accept this you accept PAS.
Pancuronium, as a solo agent (without first inducing pharmacologic coma), seems to me to a particularly cruel form of euthanasia and I trust it's not in the toolbag of the more responsible advocates of the practice.
The technocrati one is not appearing to reference the current blog. Will look into it and fix. For now use the blogger search bar at upper left. Well take down technocrati one for now until I debug it.
C
Drew,
I agree re pancuronium, and in fact its use was banned by the National Veterinary Association for euthanizing animals. But what does it say about the permissibility of lethal injection by pancuronium if, as you suggest, its use is cruel and if it has been deemed unfit for use in dogs?
One answer might be, "well, we're using it on condemned felons," but that point proves too much insofar as it gets mighty close to suggesting what those litigating the lethal injection issue are claiming: it constitutes cruel and unusual punishment and thereby does not pass constitutional muster.
Dr. Crippen at NHS Blog Doctor has a post on the latest ruling from the GMC, which is I guess the National Medical Board in the UK?
http://nhsblogdoc.blogspot.com/2007/07/killing-babies-gmc-sanctions-euthanasia.html
His blog notes that pancuronium is used in Netherlands as part of their protocol for euthanasia. (and his source is Wikipedia, but I do not have more to back of that fact.)
And to fill in more details apparently, he gave 23 times the standard dose (whatever that is) of pancuronium. And the GMC did not discipline him on account that he was treating the distress of the babies, and not intending to hasten death, even though they cite poor record keeping in this matter.
I highly suggest the post at NHS Blog Doctor for further reading. The comments section gives a flavor for public reaction.
Here is the link in html since it appears to have been cut off.
NHS Blog Doctor
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