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Thursday, December 16, 2010

Opioids on the Chopping Block

Having a healthy level of respect for opioids is critical for any physician. For those of us who prescribe or recommend this class of medicines on a daily basis, this statement rings all the more true.Recent events and research reinforce this reality.

“Oxycontin, Other Opioid Painkillers Tied to Higher Health Risks” was the title of a recent Businessweek article that references a study in Archives of Internal Medicine about opioid safety in patients with non-cancer pain. In this study, 6300 patients taking one of five analgesics for chronic (non-cancer) pain were followed between 1996-2005.

Rus Portenoy, Chair of Pain Medicine and Palliative Care at Beth Israel Medical Center in NYC and former President of AAHPM responded to the study with caution, recognizing the confounding factors that could influence the data – including clinician knowledge of effective and safe opioid titration rates.

In the same journal, Daniel Solomon and colleagues evaluated the safety of opioids compared with NSAIDS and coxibs in elderly patients with arthritis, and finding that patients on opioids had higher incidence of falls, cardiovascular events, hospitalizations and all-cause mortality.

picture from

Oxycontin new formulation – MedAlert:

The study was released 9 months after Purdue announced its reformulation of Oxycontin, a move made to attempt to prevent abuse. The new forumulation makes crushing the pill difficult: instead of turning to a fine powder, it gelitinizes. Despite its release in April, patients have only started to routinely receive this new formulation in the last 6 weeks or so. Since that time, a Medwatch alert has already been released, announcing:

The following events have also been reported, potentially due to the swelling
and hydrogelling property of the tablet: choking, gagging, regurgitation,
tablets stuck in the throat and difficulty swallowing the tablet.

Furthermore, alive on the webchats, patients have discussed lack of efficacy of the new formulation, increased side effects – including GI symptoms and new headaches. As a physician prescribing Oxycontin, I have had patients whose breakthrough opioid demand increased dramatically with the change in formulation, with or without the other stated side effects. My approach has been to convert the long-acting oxycodone to another opioid in each case: to methadone or morphine extended release, based on patient's pain pattern, history of opioid side effects and using principles of opioid conversion.

I wonder whether others of you have had any recent experience with this and how you are addressing the concern.

So far, my experience with these problems has only been related with patients whose Oxycontin requirements were exceptionally high (>1g per day). My concern with what I am starting to see is the risk of undertreatment of pain – the potential assumption that patients who have been on higher doses of Oxycontin for a longer period of time might be labeled as “drug seekers” if they suddenly have an increased need for breakthrough pain medication due to lower efficacy of Oxycontin.

Pain and Palliative Care physicians may be increasingly under the gun to teach our colleagues, make our EDs, oncology and primary care centers aware of this possibility, educate about safe opioid conversion practices, and alert the FDA of observed side effects or change in efficacy through the MedWatch mechanism.

Thursday, December 16, 2010 by Unknown ·

Wednesday, December 15, 2010

Rationing: the debate is back on the table

Driving home tonight, as usual, I was listening to NPR. This time, the voice on the radio was honestly confronting the controversial topic of rationing – specifically, rationing in England. In recent evaluation of palliative care and end-of-life care around the world, England was ranked #1 – and as a result many countries healthcare leaders have visited the UK to learn from them. One of these countries was the United States – and as pointed in in Public Radio International (PRI) – this dialogue between England and the US was stopped after controversy about the “death panels” hit the front pages.

Around that time, Time Magazine published a story putting the pricetag on life – adding to the controversy.

More recently, in April of 2010, PBS hosted a debate on the topic featuring Ira Byock, Physician and Director of Palliative Care at Dartmouth-Hitchock Medical Center, Ken Connor, Lawyer and Chair of the Center for a Just Society, who represented Jeb Bush in Terri Shaivo’s case, and Marie Hillard, Nurse and Director of Bioesthics and Public Policy at the National Catholic Bioethics Center.

PRI has put this story back on the news – and given our place in healthcare, we cannot hide from the controversy as inevitably, in one way or another, we live smack-dab in the middle of it all. Our views on this topic also differ – and so I invite a discussion here.

Note: PRI has created a series about healthcare rationing in England, South Africa, Zambia, and India. Additionally – for all you TweetChatters: @PRITheWorld, @SheriFink and @dhbaron are also hosting another tweetchat on Thursday 1pm EST with the hashtag #rationinghealth.

Wednesday, December 15, 2010 by Unknown ·

Monday, December 13, 2010

Mediastinal Lymphadenopathy in Lung Cancer

Pop Quiz:

  1. What is the sensitivity and specificity of a CT scan of the chest for detecting mediastinal involvement in a patient with non-small cell lung cancer?
  2. What about a PET scan? 
Palliative medicine practitioners frequently see patients with stage IV lung cancer.  Usually the stage has been fully elucidated prior to the initial palliative care consultation, but not always.  Admittedly, this biased my assumptions about the sensitivity/specificity of these tests and I would have guessed much higher than the actual answers (even though I knew neither was 100% sensitive).
Lung cancer cell dividing.  Source: Wellcome Images

Read more »

Monday, December 13, 2010 by Lyle Fettig ·

Letters to the Editor on the NEJM Palliative Care in Lung Cancer Trial

The trial published earlier this year in NEJM on early palliative care in metastatic non-small lung cancer remains highly publicized after the initial brisk response to the study.  As I review my Google Reader RSS feed that searches for the term "palliative," I still routinely come across references to this study, most which highlight the survival advantage seemingly conferred to the palliative care group.  (See our initial reactions to the study herehere, and here.)

NEJM recently published four letters to the editor regarding the study and yes, almost everyone is focused on the survival result and how to explain the survival advantage.  Points made about the survival result included the following:

  •  Could the palliative care wing have received more chemotherapy (not less as I hypothesized), thus resulting in improved survival?  Could the mechanism of improved survival have been that palliative care leads to improved performance status, thus leading to more chemo, thus improved survival? (Authors respond that a preliminary analysis suggests that the number of chemo regimens did not differ between the groups.  They highlight some logistical challenges in measuring PS independently in this study over time. )
  • Could the palliative care group have had fewer comorbidities? (Authors acknowledge this possibility but also point out that randomization which resulted in similar pt characteristics between groups should have negated this possibility.)
Only one published letter tried to poke holes in the HQROL conclusion, with the letter writer suggesting that the statistically significant results might not be clinically relevant or perhaps borderline.   In response, the study authors point out that results for the the FACT-L and TOI scores differed enough to be considered clinically significant but did agree that the Lung Cancer Subscale (of the FACT-L) difference was not clinically significant.  This is one of the most challenging aspects of HRQOL research, and those of us who are not researchers need to be aware of meaningful cutoffs.

The letters do nothing to change the evolving significance of this study but should be reviewed by those developing future research to examine similar interventions (perhaps especially the co-morbidity issue). 

by Lyle Fettig ·

Tuesday, December 7, 2010

How Much Does a Palliative Medicine Doctor Make?

Well besides just putting down some rampant speculative numbers here, I suggest if you really want to know the answer,you have to be a CEO or CFO of a hospital or hospice organization, department chair, a palliative care/hospice doctor, spouse of said doctor, or in a few months time you will be to see the results of the AAHPM's brand new survey on palliative medicine and hospice physician compensation.

The deadline was extended until Wednesday December 8th, so if you have procrastinated thus far, you better ask your billing department to collect a few numbers and head on over to the survey.

Here is the link to the AAHPM page with more info about it

Hopefully then the 1,466 of you that land here on Pallimed looking for some salary information will actually have some good info to work with!  (image below taken from keyword search data including the term 'salar*' from Jan 2007 to Dec 2010)


Tuesday, December 7, 2010 by Christian Sinclair ·

Celebrities, Illness and Hospice

As our country mourns the death of Elizabeth Edwards who died today, many are recalling her legacy of health care reform and advocacy for hospice.  She was named NHPCO's 2009 Person of the Year. Her writing and her advocacy focused on bringing the humanity back to patients.  I was particularly struck by a blog post she wrote about the death of political commentator and Bush press secretary Tony Snow.  Despite being on opposite sides of the spectrum of American politics, they struck up a friendship as Edwards writes:

"We each chose to reach for something larger than the life and body with which we were saddled when we kept our course after the last diagnoses. We did it because we thought it was important and because (although it is chic to say that one detests politics) we actually loved the give and take it, the struggle to find what you think is right and the imperative to make others understand and agree. But what, in the end, does it tell us about what we each found to be really important? I am guessing it is not school vouchers or the expensing of stock options or class action lawsuits about salacious material in video games."

Any news hound will also realize that it was only yesterday, a day before she died, when it was formally announced that after a recent admission to the hospital, Edwards (with the advice of her doctors) would be forgoing any 'anti-cancer treatments.'  When I first heard the news yesterday about Edwards forgoing anti-cancer treatments, I casually wondered if there would be much discussion about palliative care or hospice.  I will tell you this is something I find hard to stop myself from thinking about given my interest in how hospice, palliative medicine, prognostication and medical decision making is portrayed and communicated in the news and entertainment media.  So my question to all of you is: Is this something you have wondered yourself too?

Now this is much different that wishing or hoping that someone does poorly or dies, that is not what I am talking about at all.  That is plain wrong.

I felt somewhat validated when I saw conversation on a different social media site about how this was a public example of a common challenge seen in hospice and palliative care: late utilization of the hospice benefit.  Someone mentioned we should capitalize on this story to highlight this challenge, which I do not think is appropriate, but I wanted to give a forum for rational discussion about this rarely discussed but (probably) often thought about topic for our community.

I'll leave with a quote from Edwards:

"Hospice and palliative care professionals support and care for people at a time when hope can be hard to find.  The professionals of NHPCO know more than I will ever know about providing that care; I know more than I wish I knew about receiving it and I am happy to share my perspective with them.”

NOTE: Eleanor Clift writes about hospice and Elizabeth Edwards here.

by Christian Sinclair ·

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