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:
(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.
8 Responses to “International Pain Crisis; Surgeons Hip to Palliative Care”
September 10, 2007
Christian,
I cannot agree with you more about the misuse of the word "narcotics" to describe opioids. As a palliative care physician, I see the word used incorrectly by physicians on a daily basis, even by self-proclaimed palliative care physicians & nurses. It drives me nuts! There is no place in the clinical setting for a term that comes from the regulatory arena and does nothing to describe opioids other than to cast these drugs under a cloud of suspicion.
September 11, 2007
Thanks for the response. It is nice to know I do not stand alone on this one.
Surprisingly, whenever I bring this up, most palliative care people say, "Hmmm, interesting, I never thought of it that way" or "Yeah, but what are you going to do about it; people will keep saying narcotics anyway."
From countless family meetings, I think most people in palliative care have picked up that the words you use can be powerful and word choice needs to take into account semantics, context, audience, and many other things. Of course now that I have said this, it leaves me open to the grammar and spelling police for any past or future post I do. :-) For that, I ask that you do not critique my overuse of commas (I am quite aware of that, thank you), and if you find any major error in any of the Pallimed posts, please feel free to email us, as we will correct it.
September 11, 2007
RE (mis)use of the word 'narcotics,' from one comma abuser to another.
I am not in any health-care related field, but I am a medblog addict, and my impression is that the choice to use the word 'narcotic' instead of 'opioid' can be deliberate.
Physicians want to serve the best interests of their patients, but they need to do so in a real-world context in which the medications they prescribe are heavily policed and can fund or drive criminal activity. Even when opiates are prescribed for someone who clearly needs them for unquestionably legitimate reasons, the possibility still exists that they will be diverted by a family member.
My impression is that when physicians talk about prescribing 'narcotics' they mean precisely that: prescribing a controlled substance and the burden of all the baggage that goes with it.
From a pharmaceutical point of view, clearly 'opiates' is more accurate and there is no excuse for not using accurate terminology in a pharmaceutical context. A prescription for an individual, however, must take more into account than the physiological action of a medication.
September 11, 2007
Excellent point Allison! Thanks for the comment.
It is important to realize, (and I may have overlooked this in writing my original post) that the use of narcotic versus opioid/opiate may be more deliberate and not just the result of semantic 'laziness' (not pejorative laziness, just could not think of a better term to describe lack of effort).
My usual concern has to do with the media not getting these terms straight and for the media I could encourage a higher standard of word choice, given their profession is all about communication of words.
For physicians in general practice I try hard not to play 'word police.' For palliative care practioners, I usually try to make it out to be good natured ribbing that results in possible thought provocation.
And just a side comment since we are on the topic of medical semantics.
Opiate refers primarily to naturraly occurring medications like morphine and diamorphine.
Opioid refers to the synthetic compounds that are opiate-like (opi-oid), but also commonly includes opiates.
Many use these interchangeably in medicine but there is a subtle difference. Not a difference with horrible consequences, so that I can keep my 'word police' truncheon holstered.
September 11, 2007
Alison,
Your point is well taken, but I think the practice you describe continues to feed into the generalized paranoia. I think when a physician prescribes opioids s/he should have a goals of care, full disclosure, and consent conversatione with the patient and family. It should include a clear distinction between medical prescribing and illicit use. S/he can acknowledge that the term 'narcotic' is used in general parlance and law enforcement, but that 'opioid' or 'opioid analgesic' will be used in the medical context in his/her practice. There is plenty of information out there to frighten patients. I think we should be working to normalize the use of opioids in appropriate situations.
April 30, 2009
When you take a good look at the almost 100 year old history of drug prohibition it becomes clear that it is probably the most divisive & damaging social policy since slavery.
Its tentacles reach right around the world, & its problems are legion. Firstly the obvious ones that worry us at home; the rise in teenage drug use & increasing gang violence -both of which are directly linked to drug prohibition NOT to the use of drugs themselves, Criminalising the possession & use of drugs creates an aura of forbidden fruit around them & self-contained subculture which is attractive to many young people. The film Alpha Dog is shows precisely the effects on society of allowing the creation of a completely unregulated black market worth billions of dollars in our society. Today alcohol sellers do not settle their business disputes with kidnapping & murder because their trade is legal & regulated; but the crime wave across the USA during alcohol prohibition is a well known historical fact. On repeal of alcohol prohibition the US murder rate halved year on year for the following ten years; a fact not lost on police & prison guard unions, who are the strongest defenders of the status quo with regard to drugs, as they know it is their livelihood, & with drug peace as opposed to drug war many would soon no longer be needed.
Alongside our problems with violent crime & addiction is the corruption & destruction of the producer nations. Colombia & Mexico are today almost overwhelmed by the violence between the government & the drug traffickers, & in Afghanistan we face the ultimate farce: our soldiers protect a government known to be deeply enmeshed in the heroin trade. Our soldiers are sent on patrol through poppy fields they cannot destroy as doing so would be to condemn ordinary Afghans to starvation & thus drive them into the arms of the Taliban, yet those same poppy fields are the source of all the money for the Taliban's weapons. Yet the most sensible solution to the problem of Afghanistan's opium industry -to use it for medical painkillers to solve this criminal shortage of pain relief for the world's poorest citizens was written off on the grounds that controlling the legal production of opium in Afghanistan would be almost impossible; an utterly Kafkaesque approach given that today there is absolutely NO control whatsoever over the production of opium in Afghanistan
We must demand our political representatives put an end to the "War on Drugs" now. Only when politicians see there are votes to be gained by opposing drug prohibition publicly will they do something about it, & the world can at last put an end to this horrific policy; one that future generations will be astounded as to why we continued with it for so long.
March 27, 2011
Alison,
Your point is well taken, but I think the practice you describe continues to feed into the generalized paranoia. I think when a physician prescribes opioids s/he should have a goals of care, full disclosure, and consent conversatione with the patient and family. It should include a clear distinction between medical prescribing and illicit use. S/he can acknowledge that the term 'narcotic' is used in general parlance and law enforcement, but that 'opioid' or 'opioid analgesic' will be used in the medical context in his/her practice. There is plenty of information out there to frighten patients. I think we should be working to normalize the use of opioids in appropriate situations.
March 27, 2011
When you take a good look at the almost 100 year old history of drug prohibition it becomes clear that it is probably the most divisive & damaging social policy since slavery.
Its tentacles reach right around the world, & its problems are legion. Firstly the obvious ones that worry us at home; the rise in teenage drug use & increasing gang violence -both of which are directly linked to drug prohibition NOT to the use of drugs themselves, Criminalising the possession & use of drugs creates an aura of forbidden fruit around them & self-contained subculture which is attractive to many young people. The film Alpha Dog is shows precisely the effects on society of allowing the creation of a completely unregulated black market worth billions of dollars in our society. Today alcohol sellers do not settle their business disputes with kidnapping & murder because their trade is legal & regulated; but the crime wave across the USA during alcohol prohibition is a well known historical fact. On repeal of alcohol prohibition the US murder rate halved year on year for the following ten years; a fact not lost on police & prison guard unions, who are the strongest defenders of the status quo with regard to drugs, as they know it is their livelihood, & with drug peace as opposed to drug war many would soon no longer be needed.
Alongside our problems with violent crime & addiction is the corruption & destruction of the producer nations. Colombia & Mexico are today almost overwhelmed by the violence between the government & the drug traffickers, & in Afghanistan we face the ultimate farce: our soldiers protect a government known to be deeply enmeshed in the heroin trade. Our soldiers are sent on patrol through poppy fields they cannot destroy as doing so would be to condemn ordinary Afghans to starvation & thus drive them into the arms of the Taliban, yet those same poppy fields are the source of all the money for the Taliban's weapons. Yet the most sensible solution to the problem of Afghanistan's opium industry -to use it for medical painkillers to solve this criminal shortage of pain relief for the world's poorest citizens was written off on the grounds that controlling the legal production of opium in Afghanistan would be almost impossible; an utterly Kafkaesque approach given that today there is absolutely NO control whatsoever over the production of opium in Afghanistan
We must demand our political representatives put an end to the "War on Drugs" now. Only when politicians see there are votes to be gained by opposing drug prohibition publicly will they do something about it, & the world can at last put an end to this horrific policy; one that future generations will be astounded as to why we continued with it for so long.
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