Thursday, April 9, 2009

Pall-Pourri - JAMA Edition

A few from recent JAMAs.

Most notably is a brief, chatty commentary about words not to use with seriously ill patients. It discusses the inaccuracy and potential damage done by the phrases: 'nothing more to do,' 'would you like us to do everything possible?,' 'stop the machines,' and 'withdrawal of care.' Besides describing why these phrases are confusing and unhelpful, the commentary also offers alternatives (e.g. 'I wish there were something we could do to cure your illness.... Let's focus on what we can do to help you."). A good one for the teaching file.

There is also a brief new story noting that the FDA is warning that patients should remove transdermal patches prior to receiving an MRI. Apparently some patches have a small amount of metal and can cause burns. I've never heard of this or seen this; the article doesn't specify which patches (e.g. transdermal fentanyl). Any readers know any more about this, particularly with regards to 'palliative'-type drugs?

There is another news story about the FDA opioid REMS program (see here & here), in the context of the growth of prescription drug abuse. Reading the article I was struck by how little we know at this point as to what the problems really are: is the increase in opioid deaths and complications due to physician behavior (careless prescribing etc. - the article gives examples about opioid naive patients being given transdermal fentanyl prescriptions - this is a problem to be sure, but is physician behavior like this really at the root of the problems?) vs. criminal activity via pharmacy thefts and diversion vs. drug companies vs. etc. etc. I am not convinced physician behavior is a major contributor to the problem - show me the evidence. And if it is not, then focusing on physician education (ie mandating pain training in order to prescribe) will likely not solve things and will mostly punish patients in pain who can no longer find clinicians to care for them.

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