Wednesday, September 9, 2009

'Exceptional rationalization, denial, and resistance techniques'

Mayo Clinic Proceedings recently had a theme issue on opioids - all available in free full-text.

First, and most practically, it has an excellent review of opioid metabolism (free full-text available). It's both detailed and readable, and one of the most useful single items I've ever read on this topic - and at the perfect level for the HPM fellow teaching file.

Steven Passik has a review article on long-term opioid use for chronic pain - focusing particularly on aberrant drug use (different types of, screening and identifying, responses to, etc.). It's directed at general practitioners and very specifically tries to address all the different flavors of 'aberrant use': simple ignorant misuse, pseudoaddiction/undertreated pain, chemical coping, diversion, frank addiction, etc. and very much keeps the discussion reality-based: patients need pain relief, some benefit from opioids, for those patients with 'red flags' it can be extremely challenging to figure out what is actually happening. The paper is actually refreshing in its mundane discussion of opioid use for chronic pain - no hand-wringing about whether opioids are Good or Bad - just a dispassionate discussion of a mundane (insofar as commonplace) clinical problem.

There's an article which reviews the literature comparing short acting with long acting opioids for chronic non-malignant pain. Summary: no clear benefit of one over the other (regarding analgesia, side effects). Not a huge surprise - the paper does have some academic interest for the wonkish in looking at the question.

Finally, a review on physicians and chemical dependency - particularly focused on anesthesiologists and others with easy access to opioids and other abusable drugs (accompanying editorial here), which made me wonder if this could be a problem for physicians in hospice settings, where access to such agents is a little freer (compared to a hospital ward or outpatient clinic)?

Anyway - I thought this sentence would be appreciated by the spouses and co-workers of doctors everywhere:

'The intellect that physicians rely on to learn their craft allows them to develop exceptional rationalization, denial, and resistance techniques.'

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