Tuesday, October 2, 2007

Bridging the ‘know-do’ gap

1)
My title comes from the abstract [sorry, not yet indexed in PubMed; scroll down to page 67 for the abstract] of a short article, “eToolkits: Improving Pain Management” in the current Journal of Pain and Palliative Care Pharmacotherapy [I’d be interested to hear from our readers how many of you see this journal regularly. My impression is that it is not as widely read as it might be.] It describes an international demonstration/proof-of-concept project on the diffusion of innovation related to pain management. The idea is to harness the web to bring the latest information on pain management to the various groups who need it: patients, advocates, practitioners, and policymakers. This project is a collaboration of the International Union Against Cancer, the Centre for Global eHealth Innovation (at the University of Toronto), various partners in Latin America, and 2 pharmaceutical companies. Several tools are being developed or adapted. The aim is to “provide evidence and real-world experience . . . on the potential of the Internet to bridge the ‘know-do’ gap.”

Like television before it, the Internet is seen as having the potential for a great leap forward in education. Despite all the junk on both, the Internet might actually pull it off. The know-do gap is huge and systematic attempts to bridge it are to be encouraged.

This article also got me thinking about other disconnects in palliative care. We often bemoan the fact that the evidence base in palliative care is so weak. On the other hand, anecdote and N-of-one approaches may be all that we have to work with in certain situations. But shouldn’t they be the extremes—or at least the unusuals? It seems to me that for most patients and situations, even in the absence of strong evidence, systematic and rational approaches to addressing difficult symptoms can be made. Protocols, algorithms, care paths, and clinical guidelines are available for many major symptoms. Granted, many of these are based on “expert opinion” as much (or more than) actual evidence. So the next step is a systematic and rational approach to quality improvement: data collection on the efficacy and acceptability of the published (or your institutional) guideline for the population you work with. [Remember the discussion about how “evidence-based” guidelines are too often applied to a different population than the one on which the evidence was determined—and therefore may not be particularly applicable?]

2)
Increased attention to international pain management barriers
A couple of weeks ago we discussed a series of NY Times articles on improving pain management in Africa, India, and Japan. There is an article in this same issue of JPPCP on improving management of cancer pain in Japan. By the way, the Indian doctor featured in the NY Times article is on the Editorial Board of JPPCP. In the new BMJ, just out today, there is a news article about opiophobia and how it interferes with pain management in Africa.

3)
“Ignorance may no longer be bliss; it may be death”
This strong statement comes from Perry Fine’s review in the current issue of Journal of Pain and Palliative Care Pharmacotherapy of a study showing that 16% of hospitalized patients with a history of methadone maintenance had a prolonged QTc interval. This is significant, as previous observations were that the risk of prolonged QTc interval Torsade de Pointes was primarily limited to those on methadone infusion (perhaps because of the preservative, chlorobutanol, which is also known to cause a QTc prolongation), or in high-dose (>300 mg/day) oral methadone. Everyone in this study was on well under 100 mg per day. Synergistic factors were low serum potassium, low prothrombin level (interesting—haven’t heard of that association), or concurrent CYP3A4 inhibitors. Without being specific, Fine recommends a careful risk-benefit evaluation prior to initiating methadone for pain.

A recent case report and discussion from Memorial Sloan-Kettering recommends the following “considerations:”

  1. Awareness of non-drug-related causes of QTc prolongation, including hypokalemia, hypomagnesemia, or hypocalcemia, or underlying cardiac disease.

  2. Avoidance of other drugs that can prolong QTc

  3. Avoidance of other drugs that can inhibit the biotransformation of methadone such as CYP3A4 inhibitors

  4. Availability of preservative-free parenteral methadone

  5. Determination of the patient's QTc at specified time intervals during parenteral methadone therapy

  6. The goals of care, including the risk and consequences of TdP, should be discussed
This is an example of a guideline based on very weak evidence but which seems very prudent and for which data from serial patients can be collected, retrospectively and/or prospectively. In this case we’re getting perilously close to IRB territory, but maybe that’s a leap that should be taken more often.

Click on the Methadone Safety image for another perspective.

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