Tuesday, August 21, 2007

Doctor's prognosticating; 'Painkillers'; Free Stuff!

The Journal of Clinical Oncology recently published an ambitious study by Gripp and colleagues looking at clinical prediction of survival (CPS) objective prognostic factors, and the psychological impact of coping. 216 consecutive patients receiving palliative radiation treatments consented to the study (adjuvant and curative patients were excluded). The CPS was divided into 3 groups:

  • less than 1 month - 15% died
  • 1-6 months - 36% died
  • >6 months - 49% died
The study has some great analysis of prognostic accuracy comparing pooled physician estimates (average years of experience 1.7!), tumor board estimates, and a single experienced physician. The correct predicted survival range was in the 55-62% range for each of the 3 groups of physicians, with the poorest accuracy coming with predicting those with less than 1 month to live. That level of accuracy is not bad considering diagnostic accuracy may have rates in the 85% range and we have much more research into diagnostic tests and acumen.

When comparing the accuracy of the various lab test and functional indices, they find that certain cutoffs are statistically significant, but it was not clear if they picked those levels before testing them or kept parsing the data until they found what was significant for decreased survival. Of course, what is missed here is that lab values may associate with a higher mortality but how do you get that into clinically useful information that can be communicated. "You have brain mets and only 28% of patients with brain mets are alive at 180 days. What that means for you? I don't know." Therefore future research needs to translate these multiple objective factors into communicable data otherwise it will never be used, patients will be left with no structure to plan their treatment. I really hope we are on the cusp of a prognostic research avalanche. (That's a good kind of avalanche.)

The authors do gloss over the association they found (p<.0001) that use of morphine was associated with increased mortality. It only receives one sentence in the discussion, but obviously there may be much more to this discussion. I would hope the authors go into more detail in analyzing this in a future article. I was surprised they did not use some of the prognostic scoring systems out there already. It would have been nice to have a head to head trial of some of these to see how they stack up with the same patients. One sentence in the discussion was slightly over the top is that 'disclosing prognosis to patients and relatives is a matter of controversial debate.' The authors are from Germany and it may be debated in Düsseldorf, but the paper they cite is from Boston, MA (Jen Mack) and is about pediatric patients. When you get down to it, good informed consent requires disclosure of prognosis to some extent as it involves expected and avoidable outcomes based on the therapy chosen. Take this and you may live, don't take this and you may not live, etc.

While the study really did not get into a focused analysis of the coping issue, the prognostic analysis makes for a great article for the teaching file. If you are interested in prognosis, pick it up. (no free pdf, too bad.)

(Note: Drew blogged on this at the end of July. I thought it sounded familiar, but I only looked at the August posts when I checked this, since the article is from August 1)

A couple of news outlets are reporting on an AP analysis of DEA data. Pain medication use/sales is rising, almost 90% in 8 years. Here is a quote that attempts to quantify the problem using social math (poorly):
More than 200,000 pounds of codeine, morphine, oxycodone, hydrocodone and meperidine were purchased at retail stores during 2005, the most recent year represented in the data. That is enough to give more than 300 milligrams of painkillers to every person in the country.
The problem with this quote is that it treats all opioids the same. 300mg of morphine is not the same as 300mg of codeine or meperidine. It makes people imagine, "Oh my gosh 300mg of morphine that is a lot of drugs! I can't imagine if everyone took 300mg of morphine. This really is a problem." Since we are calling opioids 'painkillers', lets make sure we stop saying diuretics and only say 'fluid squeezing pills' and instead of anti-arrhythmics, lets call them 'heart slower-downers.' No one calls their band or a song 'heart slower downers,' but their are a lot of musical references to painkiller. (Also, is it pain killer or painkiller? Maybe we could be hip and write it PainKiller)

Anyone know why is meperidine on there? Aren't most hospitals/clinics/doctors trying to inhibit its use secondary to the poor side effect profile, and low potency compared to other opioids?

The articles reasons for the increase:
  • aging population - (check)
  • increased drug marketing - (hmmm...not so sure on this one. Yes big pharma advertising (DTC and DTP) has increased, but I do not recall the last time I saw Fentora, Oxycontin or Lortab being hawked on the national evening news. Now Flomax, sure.)
  • major change in pain management philosophy - (check - more pain clinics, more interventional pain doctors, more palliative medicine doctors, more hospice services as none of these are mentioned individually)
The article then covers some of the high profile prosecutions of physicians for prescribing pain medications in high quantities. I am still holding my breath for the article that says pain control is not too hot or too cold but just right.

-Addendum (8/23/07)
After seeing some comments on this part of the post, I found a graph associated with this study, that tells a very interesting story, the article fails to note.

Here is the picture:
From 55 tons (groan...tons) to 104 tons. Over eight years as the article says. But wait the period is the full years from Jan 1 1997 to Dec 31, 2005. That is actually 9 full years. Count them. 97, 98, 99, 00, 01, 02, 03, 04, 05. Actually even over 9 years, it really is not a major change. A growth rate in use of about 10% per year. Nothing shocking.

The article uses the following words to describe this rise:
"Painkiller use rising at an alarming rate"
"reflecting a surge in use"

That surge sounds alarmist when the graph (especially when ignoring that 2000 dip) really shows a gradual change.

Also the article notes that oxycodone use jumped 6 fold over those 8 (actually 9) years. Well Oxycontin was introduced to the US market in 1995, so you would expect that a new extended release opioid (where there had only been MS Contin), might be prescribed more frequently. And even take off rapidly, regardless of diversion.

Speaking of diversion, the article quotes a 2004 'Government study' that notes 2-3 million doses (oxycodone, hydrocodone, codeine) are stolen from pharmacies annually. let's do some more social math like the AP did.

2 million doses x 5mg* = 10,000,000,000 mg
10,000,000,000mg = 11 tons

3 million doses x 10mg = 30,000,000,000
30,000,000,000 mg = 33 tons

11 tons would be a conservative estimate. So the larger story here, that is missed, is that diverted and illegally obtained opioids is equal to 10-30% of what is legally prescribed.

*Lowest dose of oxycodone = 5mg
Lowest dose of codeine = 10mg
Lowest dose of hydrocodone = 5mg

The reason I am so passionate about this is that often times we (palliative professionals) have to try and reverse this stigma because patients who truly do have pain, don't want to be like 'all the people' they read about in the news who are addicted. Addiction, diversion, and abuse are surely problems that need to be dealt with in a fair and rational manner and I do not want to trivialize any impact that they can have on an individual, a family or on public health. But not to the point that those who earn the right to have good pain control end up suffering because of media/public stigma, and fear of health care professionals to do good symptom control.

--back to the original post--

The British are planting more poppies to produce diamorphine (aka heroin, legal in the UK for pain treatment) to make sure they don't get to reliable on outside sources in case of a flu pandemic. This is really surprising thinking ahead, but it is nice to see that if we had a major pandemic with many many deaths, that some of the palliative care needs would be addressed. Obviously the Afghan poppies-to-pills program I blogged about earlier would not work for this particular case. I have not heard if the US gov't is thinking of such a plan. An interesting stat from the article:

Hectacres of poppies planted (according to the International Narcotics Control Board):
  • UK 166,000
  • Turkey 70,000
  • Hungary 13,000
  • France 6,000
  • US ??
(via Avian Flu Diary)

The National Cancer Institute is offering the newly made EPEC-O materials for free. If you are not familiar with the EPEC materials, they are of very good quality. These CD's include PowerPoints and video vignettes. You may also want to attend one of the Train the Trainer sessions too. Now there are other places where you can pay to get some similar high quality materials so if you have the budget go support some of these projects, but if money is tight and you want to teach some oncologists some palliative care principles go see the NCI.

Image 1 - Dusseldorf, Germany, courtesy of flickr.com user Mareen Fischinger
Image 2 - Poppy (non-opioid), courtesy of flickr.com user ToniVC

Woo-hoo!!!!! I fixed the stupid line spacing problem after inserting a quote! Thank you Med Journal Watch! That was really bugging me.
We are now adhere to the Healthcare Blogger Code of Ethics. Always had (just had not applied for the rights)

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