Monday, September 10, 2007

International Pain Crisis; Surgeons Hip to Palliative Care


1) The NY Times highlights the difficulties in controlling pain (especially at the end-of-life) around the world. We have posted here at Pallimed before about international palliative care efforts and discrepancies (one, two, three, four posts). The article is well done with enough of the human side but still imparting the facts that show how poorly we as a international community are handling this. Some of the main fears about opioids (opiophobia) in the US seem to be amplified around the globe. If you take a cursory jaunt through the medical blogosphere you will find many physicians and pharmacists lamenting drug-seekers, pill-poppers, and addicts that come into their clinics, pharmacies and ER's. But this constant howl of the frustration of the dealing with this small population unknowingly reinforces the stereotype that these medications make addicts. The public hears this, the trainees hear this, and pain gets undertreated, unless it is 'cancer pain' (see previous post & comments about this fallacy).

The key stat in the article from the International Narcotics Control Board:

6 countries
(US, Canada, France, Germany, UK, Australia)
consume 79% of the world's morphine.


80% of the world's population
(poor/middle income countries)
get around 6%


Now some will look at the imbalance and conclude those 6 countries use too much, i.e., "A-ha! It is because of all those people who are coming into my ER and asking for hydrocodone." Alas, it is not that simple. Many international countries have laws that may allow for opioids to be utilized, but there are restrictions to location or amount, or these are laws in writing only but not in practice.

The article even paints a line between suffering in pain and utilizing suicide to avoid further suffering, which I think most people would say is inexcusable. Especially inexcusable because of lack of access to cheap, effective medications, often the same argument made for treating HIV, or preventable infections (vaccines). I am really impressed that they also highlight pediatric issues, since not many people in industrialized countries experience/think about children in pain or dying.

Although all kudos aside for the article, they do misuse the word narcotics when they intend to say opioids. I have said it before and I will say it again, 'Narcotics' is a primarily a law enforcement term, 'opioids' are a class of medications. Opioids can be enforced as narcotic medications, but not all narcotics are opioids (i.e. cocaine, which as a narcotic does not make you sleepy).

There is an accompanying article about Japan and pain meds and a slide show that is quite moving as well.

Thanks to Pam H for the tip!

2)
The City of Hope surgeons Podnos and Wagman have a great article about palliative care and surgeons in the recent Annals of Surgical Oncology (free pdf!). While most people in palliative care do not have surgical backgrounds, the ABMS and the American Board of Surgery recognize surgeons can be good palliative care doctors. This article reviews the frequency with which surgeons are already good palliativists, and builds on that. As an internist by training, I confess to being biased in considering how surgeons view medical problems, as evidenced by the mantra, "a chance to cut is a chance to cure." This article is written by surgeons and for surgeons which is the best way to make change occur. I was also introduced the Palliative Surgery Outcomes Score:

# of non-hospitalized days without symptoms /
number of hospitalized days (up to 180)


This score is relatively simple to conceptualize, but how to measure it accurately is more difficult. (Did you have 45 or 47 days of nausea in the last 180 days?) Obviously it would have to be kept prospectively for any accuracy. Since the article is free, feel free to pass it around the next time you get invited to the Surgery or Trauma ICU, and see what kind of response you get.

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