Friday, May 13, 2022

The Peril and Privilege of Exploration: A Review of Subnautica

by Matt Tyler (@PalliDad)

In the survival game Subnautica, you play the role of a space voyager who has crash landed on an aquatic alien planet. You must find a way to escape while navigating the planet’s beautiful but dangerous flora and fauna. Exploration makes the core of Subnautica, and because I am a palliative care doctor, I couldn’t help but draw a parallel to serious illness conversations. Whether exploring shipwrecks and underwater caverns or the emotions and stories of patients, both require curiosity, methodical skill development, and respect for boundaries.

Any explorer must first and foremost be curious, even in the face of danger. You won’t make progress in Subnautica if you don’t get close to some scary sea monsters. The same is true for serious illness conversations, maintaining curiosity is essential even when encountering a strong emotion like anger. Rather than presuming an angry patient misunderstands the situation, a curious mind wonders about the origins of that anger and the suffering that may be beneath the surface. The empathy that flows from this curiosity can lead to new levels of understanding.

And yet, curiosity alone can only take you so far. At the beginning of Subnautica, your basic equipment will only let you explore a short distance below sea level. To discover the planet’s deepest secrets, you must gradually accumulate the resources necessary to upgrade your diving gear. Likewise, we need more than curiosity to explore the complexities of a patient’s physical, emotional, spiritual, social, and cultural needs in the face of serious illness. It takes time to develop the skillset needed to facilitate these conversations, ideally with observation and feedback from experts.

Even with the most advanced exploration equipment, there are depths in Subnautica that remain out of reach. There are no physical barriers to show that you’ve reached the world’s edge - that understanding only comes with your fully realized abilities. Similarly, seasoned communicators appreciate that although there are parts of a patient’s story that can be explored with advanced skills, there are always boundaries that must be respected. Though it requires a certain level of expertise to see these invisible walls, noticing their presence is vital for creating a patient-centered care plan.

Ultimately, survival in Subnautica depends not on rebuilding the world to suit your specific needs, but on learning how to work with the world on which you’ve crash landed. Building a relationship with our patients requires the same approach. If we are willing to dive into our patient’s world to understand and support what matters most to them, who knows what beauty can be discovered?

Subnautica is available to play on PC (Steam), macOS, PlayStation 5, Xbox and Nintendo Switch systems.

This post has a companion piece video hosted by Digital Doc Games (embedded below). Check out the Digital Doc Games YouTube channel hosted by Dr. Amiad Fredman for videos on how video games have a huge power to have a positive impact on people's lives.





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For more Pallimed posts by Dr. Tyler click here.



Matt Tyler is a palliative care doctor in Chicago. If he's not watching Cocomelon with his daughters, he is probably playing video games.

Friday, May 13, 2022 by Pallimed Editor ·

Monday, May 2, 2022

Simplifying Opioid Conversions

by Drew Rosielle (@drosielle)

A Satirical Monologue in One Act:

“Ok, 3rd year resident, let’s talk about rotating opioids. What do I mean by ‘rotating’ opioids? It’s just therapeutically switching one opioid with another. It’s um, like, a turnstile, I guess? Anyway--first let’s look at this equianalgesic table. Do you know what equianalgesia means? No? It is the concept that different opioids have the same analgesic power but at different milligram doses due to different potencies. That is, the idea that, say, 50 mg of oral morphine has the same analgesic power as 10 mg of hydromorphone. So 50 mg of oral morphine is equivalent to 10 mg of oral hydromorphone.

"Ok, let’s look at this table, every entry on this grid is equianalgesic, meaning that the 30 mg here of oral morphine has the same analgesic power as the 1.5 mg of IV hydromorphone. So, let’s say we have a patient on 100 mg oral morphine. How much hydromorphone is that “equivalent” to? Ok, so what we have to do is set up a cross multiplication problem…here’s how you do that.

[We’ll skip the painful talk-through of the cross multiplication.]

"Ok, so it looks like the answer is 5 mg of hydromorphone IV. Now we have to adjust that dose for incomplete cross-tolerance. Do you know what that is? No? Ok, so incomplete-cross tolerance is the idea that our patient on 100 mg of morphine is somewhat tolerant to the morphine. They are therefore also presumably somewhat tolerant to any other opioid agonist like hydromorphone. The problem is that the tolerance they have to morphine may not fully apply to the tolerance they have to the hydromorphone—the morphine tolerance “incompletely” transfers so to speak to the patient’s hydromorphone tolerance. So, what that means is that even though this table says 100 mg of PO morphine is equal to 5 mg IV hydromorphone, for safety’s sake we need to reduce that 5 mg somewhat to determine what we actually put the patient on. That’s what we mean by reducing for incomplete cross-tolerance.

"If you have 5 minutes, it’s actually an interesting story, because no one is really sure that ‘incomplete cross-tolerance’ is even physiologically a phenomenon, like on the cellular level, our field just calls it that because that’s what it’s always been called. In fact, the idea of ‘incomplete cross-tolerance’ only makes sense if you think there actually is a firm “equianaglesic” potency relationship between morphine and hydromorphone that applies to most patients. In fact, no one actually believes that and the broad consensus is that there is a pretty significant range of ‘equianalgesia’ between any 2 opioids in different patients. I.e., in one patient, 100 mg of oral morphine may end up providing equal analgesia to 12 mg IV hydromorphone, in another patient, 4 mg of IV hydromorphone, etc. It’s a little bit of a crap-shoot.

"Actually, it’s probably far worse even with fentanyl, we’re talking about a far, far wider range of individual responses, and don’t even get me started talking about methadone and buprenorphine [self-knowing chuckle here]!

"So, back to incomplete cross-tolerance. If you’re going to argue that it would just be easier to say ‘dose reductions due to safety’ or ‘dose reductions due to individual variability in responding to opioids’, you’d be right. That’s much easier to understand, and probably more accurate, but maybe it makes us feel like we’re the keepers on secret knowledge to say incomplete cross-tolerance? Who knows?

"Regardless, this is where it gets really interesting, because to properly account for ‘incomplete cross-tolerance’ we have to decide how much less opioid we need to put someone on after we do the initial calculation. Yes, there are 2 calculations: the equianalgesic one, then a 2nd incomplete cross-tolerance one in which we reduce the first amount by a further amount, most people recommend 25-50%.

"How do you choose how much you actually dose reduce? Well, there’s about 10 patient factors you need to balance when making that decision. Yes, I said 10, but don’t worry, if you do this for a couple years it’ll become second nature to you [self-knowing chuckle]!

"Ok, so let’s talk about these 10 patient factors….”

[End]

Dear friends and colleagues, I think we can all do better than this, and here is my current thinking as to a better approach.

In my last post I outlined why I think equianalgesic tables (EATs) are broken and proposed we collectively move instead to using Conversion Tables (CTs) when teaching others how to switch opioids. Briefly, this is because CTs engender much simpler and clearer math; and we can easily adjust the conversion factors in CTs based on emerging data, without having to rejigger every ‘equianalgesic’ relationship which EATs force us to do. My offer from the last blog post still stands: it would be ideal if there could be a consensus process to generate a consensus CT that our professional community can broadly adopt. While I like the CT I made, I don’t think any one person should be setting the conversion ratios alone, even if it is standing on the shoulders of giants! I’m not an investigator but am willing to lend any support I can to this. It is also possible the best option is for organized medicine to lead this, and I’ve been chatting with some folks about this a little already. I’m not sure where it will lead, nor if AAHPM has any appetite for that, we’ll see.

Regardless, I’ve been thinking and talking with others a lot about the entire enterprise of how we teach and talk about opioid switching and I have a lot of ideas that go beyond CTs for potential ways we can improve our approach to this. This post is simply to capture those ideas, none of which I’m claiming are independently mine.

1) We should never utter the phrase “incomplete cross-tolerance” again.

I hope this is not controversial, I’ve yet to meet anyone in the “Incomplete Cross-Tolerance: What a Super Helpful Concept!” camp, but its use continues to pervade discussions of opioid switching. My fundamental objections to incomplete cross-tolerance: it is a concept that requires an entire paragraph of explanation (!!) to someone unfamiliar with it, plus it may not even be a ‘real’ thing, plus there are readily available, broadly understood, completely accurate alternatives to it (e.g., dose reductions for safety, dose reductions due to individual variability, etc.). While the monologue that started this post is satire, I’m sure I’ve uttered every phrase in it for real at one point or the other in the past 20 years. I know I am not alone.

2) We should talk about ‘methods for safe opioid switching’ and not equianalgesia. Equianalgesia is unnecessarily jargony and I don’t think it even exists on the population level.

Incomplete cross-tolerance only makes sense if we think equianalgesia itself is a firm and helpful concept. If you believe that we can announce, without qualification, that 20 mg of IV hydromorphone is ‘equianalgesic’ to 100 mg of oral morphine then maybe it makes sense to talk about incomplete cross-tolerance. But I don’t know of anyone who thinks that “100 mg of oral morphine is equivalent to 20 mg of IV hydromorphone” in any sort of widely generalizable, arbitrary way. I think all of us operating in this realm may acknowledge that across 100 patients maybe the averages end up close to 100:20, but who cares? Honestly, that factoid is a DISTRACTION because the way EAT switching has currently been set up has encouraged us to first focus on this fake-and-based-in-less-science-than-we’d-want notion of equianalgesia, then prompted us to do this secondary work-around-caused-only-by-the-fact-that-we-set-a-ratio-in-the-first place. Why do it this way? Why not just switch at a ratio that works most of the time, instead of nearly none of the time?

The clinical task we are faced with is not an abstract exercise in the variable potencies of different opioid molecules averaged across the human population, instead it’s a practical task of How do I safely switch this patient’s opioids? Safely means two things here: that the patient does not have significant sedation from the switch nor a major worsening of their pain. I do think what I’m arguing here is more than semantics—that going from equianalgesia to ‘methods of safe switching’ is not just me renaming it. It is a significant conceptual frame shift in this critical and common.

Using a concept like ‘equianalgesia’ promotes this idea that there’s a “right answer” to the question of “If I’m switching someone from 100 mg of morphine in a day to IV hydromorphone how much hydromorphone do I prescribe?”

My proposal is there isn’t a right answer. It is not a helpful goal or concept and we need to move onto the more salient task of switching safely. That framework focuses us on a practical clinical task. From talking to colleagues, many of us who prescribe methadone and buprenorphine long ago moved on from any idea that it was our task to somehow divine the ‘equianalgesic’ dose of methadone from another opioid. Instead, we have a protocol to make the switch, the protocol works (‘is safe’), all is well with the world. My proposal here is that this is how we conceptualize all opioid conversions.

3) We must start emphasizing that the absolute dose of opioids involved matters for safe switching.

Stepping back from the finer points of what conversion ratios we should be using for opioids—honestly, if what you’re talking about is doses in the range, say, of 40 mg of oral morphine, I don’t really think it matters what ratios you use to switch. Frankly, it probably doesn’t matter much if you reduce further for safety or not.

Consider someone is on 40 mg a day of morphine PO. You want to put them on IV hydromorphone:

-- Classic EAT: divide by 20 to get 2 mg of IV hydromorphone

-- DOC2 Table: divide by 12.5 to get 3.2 mg of IV hydromorphone

If you reduce further for safety, presumably you’ll still get an answer about 1.2 mg apart between the 2 tables. Honestly, I don’t think the difference there is much of a safety concern. Both are fine. No opioid- tolerant patient became sedated or had a pain crisis because of a difference of 1.2 mg of IV hydromorphone over 24 hours; of course, the ‘fine-tuning’ might be a bit different, but as long as a patient had close follow-up the analgesic outcomes would be about the same too.

But what if the patient was on 400 mg a day of oral morphine? Personally, I would not be so cavalier about saying there is no relevant difference between 20 and 32 mg of IV hydromorphone in a day.

Yet, if you read pretty much all the opioid conversion stuff out there, they all treat these opioid switching ratios as fixed across all ranges of opioid doses. They suggest the same approach for 400 mg of morphine as 40 mg of morphine. To me, this is shocking, and profoundly unsafe. I’ve never met a single person who treats opioid switching ratios as linear across all opioid doses, meaning they would be more ‘conservative’ in their switching for someone going from 400 mg of morphine than 40 mg. I believe I am merely naming here a clinical practice which is already widespread! Yet, for the last twenty years of journal articles, books, national presentations, and local presentations that I’m aware of, this is not splattered in flashing neon ALL CAPS at the top of every table. It is not a core part of our basic nor specialty teaching on this topic. I genuinely don’t understand it.

Fundamentally, I’m arguing that we’ve heaped HUGE amounts of attention on the complex subtleties and nuances of reducing for safety when it comes to opioid switching, and virtually no attention to the nuances of switching at higher dose ranges. I think we got this wrong.

All this leads me to a few practical proposals:

1) “We”* stop using EATs and instead use simple “going from X to Y” conversion tables (see this post for more details).

2) We frame this practice as methods of ‘safe switching’ and do away with ‘equianalgesia’ (at least as a core concept in teaching others about opioid switching) and ‘incomplete cross-tolerance’ (that we can discard completely).

3) We promulgate a conversion table without need for additional dose reductions in most patient scenarios. I appreciate this is in some ways the most radical thing I’m proposing here, and certainly it is the one I’m most tentative about. But I suspect that a lot of our need for “reducing for incomplete cross-tolerance” has come from the fact that in order for any of our EATs to make sense they’ve needed to have on them conversion ratios that are dangerously aggressive. E.g., the for the Classic EAT I would divide the PO morphine dose by 20 to get the IV hydromorphone dose and, truth be told, it would be rare I would dose reduce beyond that: it was a good safe ratio much of the time in my experience. However, the reverse conversion, multiplying the IV hydromorphone dose by 20 to get the PO morphine dose, I regularly, heavily dose reduced (often by 50%). My argument is that to a large extent our need to create that 2nd step of dose-reduction really comes from the fact that we locked ourselves into aggressive conversion ratios with EATs and if we had just a simple “Going from X to Y” conversion table with pre-set ‘safe’/conversative ratios, we can side step this incredibly complex beast we’ve created (the need to reduce for safety / “incomplete cross tolerance”).

How would we do this: my idea is that we create a conversion table which folks broadly agree they’d be comfortable handing to a first month medical intern and telling them: “Young doctor, within these parameters, just use this.” If this idea freaks you out, remember for decades we’ve handed them inscrutable equianalgesic tables with even more inscrutable and hand-waving suggestions about reducing for incomplete cross-tolerance and expected them to know what to do. My hypothesis here is that the method I’m proposing is safer and requires far less needless work for our generalist colleagues.

As an example, we’d create a conversion table for a hypothetical 70-year-old with an eGFR of 50 and mild frailty—something like that. The idea being that most of the conversions happening out there are for patients like that or more physiologically robust, so the table would be built-in safety for a broad range of patients. I think it could be close to my draft Conversion table (Dropbox, Google Drive), but some of the conversions would be more conservative for sure.

The table would need to be explicitly labeled with the dose limits (E.g., this is for patients on 100 mg or less a day of oral morphine, 20 mg a day or less of IV hydromorphone, etc. This would avoid unnecessary calculations of oral morphine equivalents (OMED, OMDD, OMD, or any variation on those abbreviations). What those ‘dose caps’ are would require, I imagine, vigorous discussion, and I don’t strongly believe the, e.g., 100 mg a day morphine cap is actually the right one.

The table and associated teaching strongly emphasize the structure of care and close follow up is what’s most important for switching opioids safely. Don’t switch and walk away, switch and follow up!

Importantly, I’m proposing this is a conversion table for ‘generalists’ who switch opioids. I think the role of palliative and pain specialists is to have a deep knowledge of all this, including the history of opioid switching, and the nuances of dose reductions for safety, etc. All our fellows (and all our colleagues) should read Demystifying Opioid Conversions 2 Ed (aka DOC2) if they haven’t already! However, that book is not for generalists, they aren’t reading it and we can’t expect them to read it. To be clear—I’m not suggesting we jettison that book or the accumulated knowledge of opioids switching, I’m more proposing there are simpler and arguably a little safer way to teach our generalist colleagues about this, keeping in mind that to date we’ve made it so difficult for them most of them are using online calculators of various levels of reliability!

This is just a proposal which has come out of one person’s brain. I very much believe that ideally this is best decided by consensus and committee (in the absence of good clinical data for which there are zero). So, it is meant as a starting point for discussion. Ideally, I’m hoping others will join me and I am talking with CAPC about this and plan on with AAHPM too. I think the new data from MD Anderson which lead to the change in the DOC2 Table are a great opportunity for us as a field to collectively look at all this and try to do something that is far simpler, and at least a little safer. If you’re interested, let me know!

(This post was updated May 3, 2022 to correct an error in the opioid calculations!)

For more Pallimed posts about opioids.
For more Pallimed posts by Dr. Rosielle click here.


Drew Rosielle, MD is a palliative care physician at the University of Minnesota M Health Fairview in Minneapolis. He founded Pallimed in 2005. You can occasionally find him on Twitter at @drosielle.



Monday, May 2, 2022 by Drew Rosielle MD ·

Monday, March 21, 2022

Opioid Equianalgesic Tables are Broken

by Drew Rosielle (@drosielle)

I am proposing we do away with equianalgesic table (EAT) as a tool to inform clinical decisions about opioid rotations/conversions. Fundamentally, EATs create too many problems, and there are simpler and safer ways to teach clinicians how to convert between different opioids.

Part 1: New Data Can't Fix the EAT

A couple HPM fellows every year ask me which table do I prefer to use—the old EAT or the new one? By the old one, they refer to the table most of us used or were at least deeply familiar with for the last 10-20 years. By the new one, they mean the one created by Dr. Mary Lynn McPherson, PharmD in her landmark book Demystifying Opioid Conversions, 2nd Ed. If you haven’t read the book, please do, it’s really one of the best things ever written about opioid conversions. My disagreement with the book, which is admittedly a big one, is that the book promulgates the use of EATs, and my entire argument today is really in some ways inspired by the conversations I’ve had with my fellows and others as we grapple with the new EAT in her book. (From here, I’ll refer to the tables as ‘Classic’ and ‘DOC2’.)

Fundamentally, my argument is EATs themselves are intrinsically flawed: they ‘force errors’ in a way that’s entirely unnecessary and avoidable if one just doesn’t use EATs as clinical decision aides (I’ll elaborate on that statement below). Dr. McPherson’s curating and teaching new, reliable clinical data is critically important, yet better data in a flawed model like the EAT creates as many problems as it solves. I feel a little awkward putting all this out like this. Dr. McPherson is one of my heroes. The DOC2 EAT crystallized concerns I’d had over the years, and the followinghas come from conversations about EATs prompted by me and my colleagues grappling with a new table. The new DOC2 EAT is clearly better in important ways, but I also think recapitulates all the problems intrinsic to EATs, so much so we collectively should consider doing away with them.

The 2010 table is the Classic EAT, the 2018 table is the DOC2 EAT. You can see it’s changed throughout, but the big changes are the around hydromorphone, with the biggest changechanging the20:1 PO morphine:IV hydromorphone ratio to a 12.5:1 ratio.



The big changes in the DOC2 EAT are based on this study by Dr. Akhila Reddy and colleagues looking at real life data about converting hospitalized cancer patients from IV hydromorphone to PO morphine, PO hydromorphone, or PO oxycodone. Reddy et al found that the average IV HM to other drug ratios were 1:2.5 for oral hydromorphone, 1:11 for oral morphine, and 1:8 for oral oxycodone (meaning in this population, a patient on 10 mg/24 hours of IV HM, on average would end up on 25 mg PO HM / 110 mg PO MS / 80 mg PO oxycodone per 24 hours). Importantly these doses are lower than what the Classic EAT would predict, and for PO morphine and hydromorphone, a lot lower (Classic EAT promotes a 1:5 ratio for IV HM:PO HM; 1:20 ratio for IV HM:PO MS; and 1:10 ratio for IV HM:PO oxycodone)!

To the best of my knowledge, the DOC2 EAT exists largely to better account for these ratios going from IV hydromorphone, considering that Reddy et al is undoubtedly the best/biggest real-patient study looking at this very relevant real-life clinical question. (It also tweaked the IV to PO morphine ratio in a small manner, going from 1:3 to 1:2.5. Probably small enough not to matter for patient care, but enough to make for more challenging math, but that is a small quibble).

I want to observe that I think the Reddy et al study is a landmark study, and I think it provides the best evidence we have of ‘real-world’ “equianalgesia” when going from IV HM to those other opioids. I absolutely think we should all be modeling our clinical practice of opioid conversions on these data as best we can!

The problem is, however, when you try to ‘map’ these data onto the rigidity of an EAT, in which every ‘relationship’ between opioid doses/routes is fixed and bidirectional, you encounter all sorts of problems, ALL OF WHICH exist due to fact that you are using an equianalgesic table in the first place. What I mean is that all the problems that are introduced by creating a new EAT from this study, merely exist because we, as a professional community, have decided that EATs are the best format for presenting information to guide opioid conversions. The fixed and bidirectional nature of EATs itself creates the problem, and my argument is that all this will go away if we discarded EATs entirely as teaching tools/clinical decision aides for opioid switching.

Let’s look at the IV HM to PO MS ratio in the EATs as an example. In the Classic EAT there is a 1:20 (look at the table: 1.5:30 is a 1:20 ratio). Meaning you’d convert 1 mg of IV hydromorphone to 20 mg of PO morphine, and you’d convert 20 mg of PO morphine to 1 mg of IV HM (before dose-adjusting due to ‘incomplete cross tolerance, patient factors, safety, etc).

Reddy et al gave us good reason to believe that when converting from IV HM to PO MS, that 1:20 is too aggressive: the morphine dose is too high. So, if you change the EAT from 1:20 to 1:12.5 which is what the DOC2 EAT recommends, you get a conversion that’s more in line with current knowledge.

So far, so good! But, now look at what happens when you use the tables to convert from PO MS to IV HM. 100 mg PO morphine in 24 h converts to 5 mg IV HM in 24 h using the Classic EAT ratio of 20. Using the DOC2 EAT ratio of 12.5 you get 8 mg of IV hydromorphone. We’ve all of a sudden made the conversion in the reverse direction far more aggressive than it previously was with the Classic EAT! Is there any data to support being far more aggressive in this direction? No, not that I know of; the data are only about going from IV HM to other opioids, not to IV HM.

So, in making a conversion more conservative/more evidence based in one direction, we’ve made it substantially more aggressive in the opposite direction, and done so without any evidence backing it up.

The same thing happens with IV to PO HM. Reddy et al suggests IV HM going to PO HM is a 1:2.5 ratio which is reflected in the DOC2 EAT (Classic EAT has a 1:5 ratio). However, that makes a user of that table use twice the amount of IV HM when going from PO HM than the Classic EAT suggests. This doubling-of-how-aggressive-we-should-be with that conversion, as far as I can tell, is not based on any data, and I argue it’s no small thing to put out a EAT which encourages doubling the dose of IV hydromorphone compared to prior practice without safety data, but it’s an unavoidable byproduct of the Reddy data being forced into the format of an EAT.

My point here is that using an EAT forces us to do this. There is no way around this in the format of an EAT: the fixed bidirectionality of EATs causes this. So—why do we even use EATs?

The best data we have about going from IV HM to PO oxycodone is that it’s a 1:8 ratio. However, the new DOC2 EAT uses the Classic EAT 1:10 ratio. Why? I’m assuming it’s an effort to keep the DOC2 EAT coherent. Think about what it would look like if you used a 1:8 ratio. In the DOC2 EAT, 2 mg of IV HM would map to 16 mg of PO oxycodone. But that means that 16 mg PO oxycodone would map to 25 mg of PO morphine! What a bleeding mess!

And that’s the point: EATs exist in some sort of fantasy universe in which we have for some reason assumed, based as far as I can tell, on no data whatsoever, that the RATIO of morphine to hydromorphone, has to exist in a fixed and eternal relationship with the relationship between, say, oxycodone and hydromorphone. Based on EATs, if you tweak the relationship between oxycodone and hydromorphone it impacts the potency relationship between morphine and oxycodone! They all are forced to shift together because the whole idea behind an EAT is that every value in every cell of that table is ‘equianalgesic’ with the other values.

Why? I don’t see any data to think this has to be the case, at all. All of this strikes me as an overly simplistic and rationalistic assumption of how incredibly complex things work, that creates all of these issues I’ve been elaborating above when you try to do the right thing, which is what Dr McPherson did when she updated her EAT based on good data! The problem is that the format of the EAT itself undermines any effort to use better data to improve it.

Dear colleagues, we don’t have to keep doing this to ourselves. There is another way, some of you are probably already using different methods anyway, and I’ll propose one in a bit, but first I want to make one more argument against EATs in general: they force people into doing unnecessarily complex math.

Part 2: Complex Math is Complex

EATs encourage people to do unnecessarily complicated math. I’m sure I’m not the only greying palliative clinician who’s realized the last several years that a large number of the fellows and residents I work with don’t actually know how to use an EAT. They instead use opioid conversion smartphone apps or websites. Years ago they didn’t know how to use EATs either for the most part, what’s changed now is that they can avoidlearning how to use them completely due to the software converters. (By the way, every single app/website I’ve looked at base their math on EATs and so have in them all the fixed bidirectional problems I mentioned above).

A few months into the fellowship year when I’m working with fellows and one is using an app I’ll ask them to walk me through an opioid conversion calculation. It’s not uncommon for me to realize that they just can’t do it. These are physicians, these are people who are highly educated and know their way around algebra, but they still avoid doing EAT math because it’s clunky, it’s easily confusing, and legitimately easy to make mistakes. This is because they are taught that the way you use EATs to calculate the dose of the new opioid is this:



Holy smokes we make them do cross multiplication!

I’ve learned that cross multiplication makes some people really uncomfortable. And frankly I don’t blame them—it’s easymake mistakes— it’sto multiply when you should divide, etc. I myself, long before my current thoughts about wanting to discard the clinical application of EATs began to solidify, had just completely stopped using cross multiplication in doing these conversions over a decade ago. I have always looked at the table, calculated a conversion factor, and just used that.

For example, looking at the Classic EAT, it suggests 1.5 mg IV hydromorphone is ‘equipotent’ to 30 mg PO MS. That’s a conversion factor of 20: 1.5 x 20 = 30, right? So if a patient was on 10 mg of IV hydromorphone, I’d just multiply that by 20 to get 200 mg of PO morphine, and go from there (adjust the dose down for patient safety reasons etc). I would’t bother doing cross multiplication at all.

This math is much easier to my brain, and also easier to ‘gut check double check’ your math, because you ‘know’ a morphine dose is 20 times the HM dose. With cross-multiplication, those relationships are less obvious, and so easy to invert, especially for novice users, who don’t have an intuitive sense for instance if PO hydromorphone is more or less potent than, say, IV morphine!

Making people to cross-multiplication was a huge pedagogical error. Thankfully, it’s totally unnecessary.

Part 3: Conversion Tables as a Better Tool (?)

All this adds up to my modest proposal: that we do away with EATs entirely as we teach others how to convert between opioids, and replace them with Conversion Tables, that aren’t really tables, just a condensed clinical decision aide in prompting clinicians with easy math and individualized, conservative conversion recommendations that are specific to each conversion. For instance, the conversion tip for going from IV hydromorphone to PO morphine exists independently of the conversion tip for any other conversion including even a different ratio for converting from PO morphine to IV hydromorphone.

I want to acknowledge that I did not invent this idea. I’ll be honest, I’m not sure where in the depths of my memory it came from, but in some ways it’s such an obvious idea I hope when I post this people will comment with examples of opioid rotation decision tools which use the conversion factor approach instead of an EAT! I’m sure it’s out there. If anything is novel about what I’m writing today, it’s mostly in the call to broadly give up on the EAT as a clinical decision tools, not the novelty of using conversion factor tables.

From all this, I’ve mocked up a Conversion Table (pics below of an abbreviated pocket card sized Table and part of the full, annotated Table, with all my explanations and anxious thoughts about the factors, and links to more detailed (but not ready for clinical implementation-see below) versions: Dropbox, Google Drive).



This is one section of the longer, annotated Table:



Benefits and Caveats of Conversion Tables:

• Every single conversion can have its own ratio, and that ratio can evolve/change over time (due to new data or clinical wisdom) easily, without messing up any of the other conversions. You can change the IV HM to PO morphine conversion without that having ripple effects on every other conversion!
• Along those lines, we can have different ratios going from, e.g., IV HM to PO morphine than when we go from PO morphine to IV HM. My argument is that a key reason to do it this way is safety, mainly because if we as a professional community tighten up one conversion it doesn’t force us to ‘liberalize’ its reverse.
• It prompts easier math. Every conversion is just one multiplication or division problem.
• This is true in my opinion of all opioid conversions, regardless of which table you are using: we should increasingly become more and more cautious in all opioid conversions the higher the doses that are involved. I personally think all conversion tables and EATs should have a huge warning on them that says something like “DO NOT USE THESE RATIOS FOR OPIOID DOSES HIGHER THAN 150 MG OF ORAL MORPHINE EQUIVALENTS—CONSULT AN EXPERT” or something like that. (Feel free to argue with me about the 150 mg figure—I don’t myself know what the limit should be other than that number is something that feels good in my gut but that’s all.) I wrote about this in detail in 2019. The bottom line is that I think we should treat all opioid conversion ratios as non-linear at high doses, like we do with methadone at all doses, and that every single guide to opioid conversions needs to SCREAM this.
• Along those lines, I can imagine someone saying about all this, “Look, does it really matter which table we use because, let’s say we’re going from PO to IV hydromorphone, does it really matter if the final answer is 2 or 4 mg!” I would say I am highly sympathetic to that perspective. Look, the reality is, at lower doses, for the vast majority of our patients, it honestly doesn’t make that much of a difference! But, my argument is, the higher the doses involved, the more this stuff really starts making a difference. I am NOT going to lose sleep over if my fellow puts a patient on 2 vs 4 mg of IV hydromorphone a day. I am going to lose sleep over 20 vs 40 mg of IV hydromorphone a day though! This is why 1) I think whatever we put out there for the non-specialist clinician to use needs to be conservative because clinicians will use these at high doses if we put them out there, and 2) we need to signal/emphasize/warn on EATs or Conversion Tables that they are not to be applied at those higher doses! Honestly, I think that’s an even more critical safety practice than fine-tuning the actual conversion ratios.
• Please look through the draft/mock ups of the conversion tables. I don’t mean these to be implemented in clinical settings currently!! I have spent more time arguing with myself about the actual numbers (conversion factors) I put down on paper in those tables than I have writing this cruelly long blog post (you can see some of my comments about my decisions in the Annotated Tables—I’ll let you know that at one point these included conversions around IV fentanyl and I just gave up it’s such a mess). Part of the debate I have with myself is, from a pedagogical standpoint, just how conservative should these numbers be? Should we automatically make them so conservative that we can say that for the ‘average patient’ you don’t need to dose-reduce further? Should we still even be incorporating ideas of incomplete cross tolerance, which, I probably don’t need to tell you, is an incredibly complex, and nuanced thing we inflict upon others. I.e., we show people these tables, tell them to use them, then say, "Oh by the way once you’ve done that you need to make a highly complicated, patient-specific decision about manipulating the final dose ever further, based on these TEN DIFFERENT FACTORS!" I do wonder if we can do better than that.
• I’m not sure what the right answer is here. Certainly, I’m not the one to be deciding this, either! My dream would be that something like this is workshopped and researched with clinical and pedagogical leaders then tested in some way for safety, and I think the ‘best answers’ as to how conservative these numbers should be would come out of that dream process. What I’ve mocked up are things I’d feel comfortable handing a fellow personally, but I just want to be clear to the world I am not proposing my draft tables as anything more than an example of what a hypothetical conversion table could look like in the future. That’s it.

I’m very curious what people think about this. Who’s already moved away from EATs to conversion tables or something similar? What do people think of my draft Tables? I am not an investigator, but if someone who is, and knows how to lead an investigation into validating something like this (not that EATs themselves were ever validated), please ping me. I’d love to chat. I smell a Delphi study!

Post-script, because I sure someone is going to bring this up, and rightfully so: I’m not arguing that we entirely discard EATs for every single application out there, just the clinical/pedagogical ones. They arguably have a role in research and public health—e.g., the ideas in EATs give us a way to calculate OMEs/MEDDs (24 h oral morphine equivalent dose). I think the idea of the OME has its utility at least in research contexts, and we need some way to calculate it, and sure an EAT is an ok way to do that, although I’ll also point out that the OME has been weaponized in the last several years by those who insist, for example, that an OME of 50 mg is some sort of evidence-based hard limit on safe opioid dosing, and the insidious carceral/cops-in-medicine ‘tool’ that is the NarxCare Score.

For more Pallimed posts about opioids.
For more Pallimed posts by Dr. Rosielle click here.



Drew Rosielle, MD is a palliative care physician at the University of Minnesota & M Health Fairview in Minneapolis. He founded Pallimed in 2005. You can occasionally find him on Twitter at @drosielle.



Monday, March 21, 2022 by Drew Rosielle MD ·

Monday, January 24, 2022

The Annual Assembly and COVID

by Christian Sinclair (@ctsinclair)

Last week, many hospice and palliative care clinicians and advocates received the unfortunate news that the 2022 Annual Assembly of Hospice and Palliative Care (#hapc22) was moving from hybrid (both in person and virtual) to virtual only. The board of directors of AAHPM and HPNA "considered the current strain on health care systems, personnel and their families" when making the decision. And then one week later, many presenters found out their presentations were not going to be in the virtual-only assembly. That is immensely disappointing. I received notice that my talks - on which colleagues and I had spent hours working - were canceled too. I was shocked at first, then mad, a little incredulous, then sad I would not get to share my work with a wider audience. Online, others shared similar emotions about the bad news. It really stinks.

I think it is critical to direct the majority of ire at COVID, which threw us all a curve ball with omicron. Honestly going into October and November, many clinicians I know were beginning to regain that hope and return to normal. The clinic visits were more often in-person (rather than telehealth). We had meetings with small groups in big rooms. All signs pointed to "Yes!" An in-person Annual Assembly in Feb 2022 seemed possible. So when you feel angry, make sure to direct that anger at COVID..

As for mitigation of risk, or different strategies, or communication planning around this issue, it is reasonable to ask for more information from the two organizations, but let's make sure we are asking the right questions and the right people. The strategy is the responsibility of the board of an organization. The staff of an organization is responsible for executing on the plan set out by the board. Boards need to make very difficult decisions. From personal experience, those conversations before the decision can also be quite challenging. I think the business meetings for both HPNA and AAHPM should be high on your priority list if you want to hear more about how we got here. If you want more information or have issues with how things were handled, reach out to board members to tell them what is important to you.

One thing to keep in mind is that leadership is likely feeling some of the same emotions we are feeling. I know this from personally working with the AAHPM and HPNA staff. They put a lot of time and effort into making the 2022 Annual Assembly happen, and now a lot of that work is lost. So when reaching out to them for clarification or giving feedback, make sure to appreciate the ripple effects of COVID and that many of these decisions are often more difficult than they appear on the surface.

And if you still don't like how leaders are making decisions, then consider running for a volunteer position. Influence in a way that you think is best. There are always volunteer roles to fill. And it offers a perspective that things are often more difficult than they appear on the surface.

And lastly,I'm sorry that your work and the work of your colleagues and mentees won't get the attention of a national meeting. And yet, the good work is done. It just needs a little extra effort to find a home. Like one of my favorite quotes from Austin Kleon, "Do good work, and put it where people can see it." Already online, there are venues like HAPC Virtual Didactics, Friday Chalk Talk, GeriPal, and even Pallimed, making themselves available to repurpose or rework content. Honestly, this is something I would love to see our field do more of. Don't stop at "Well, I presented at the Annual Assembly. My work is done here." Call up colleagues at other institutions and let them know you have an excellent presentation for their next grand rounds. Do a media tour for the field: pitch your content to your local news media or write an editorial for national outlets like NYT, WaPo, The Atlantic, etc. Write a paper and publish it in an academic journal. Some of this you can do all on your own, some of it may require activating your mentor and peer network. So yes, feel your feelings, and then get to work finding a home for your great work. All is not lost.



For more Pallimed posts about AAHPM.
For more Pallimed posts about conferences.
For more Pallimed posts by Dr. Sinclair click here.



Christian Sinclair, MD, FAAHPM is a palliative care physician at the University of Kansas Health System, editor-in-chief of Pallimed,and trying to keep up a resolution to write more about palliative care in 2022.

Monday, January 24, 2022 by Christian Sinclair ·

Monday, January 17, 2022

Difficult Conversations About Racism

by Christian Sinclair (@ctsinclair)

There are many difficult situations we encounter in palliative care and hospice. Our training and experience equip us with words and skills to explore emotion-inducing topics. Yet there are still moments many clinicians can be caught speechless, and one of those is when we encounter racist language in the midst of our work.

If I had to pick the most influential article in 2021, it would be "Power, Silence, and Debriefing: Hidden Harms When Palliative Teams Encounter Racism" by Rev. Florence Moss and Dr. Kate McKillip, published in the Journal of Pain and Symptom Management in June 2021. I have shared it numerous times with colleagues and trainees, so much so, "Moss McKillip" regularly autofills on my search engine.

I was reminded of the power of this article with Rev Moss and Dr. McKillip presented for Friday Chalk Talk* led by Dr. Martin Bazelak this past week. If you are looking for speakers for your next Grand Rounds, I would put these two on your 2022 short list.

The article is a case based format, stemming from a real consult in which a patient used a racial slur, and there was no response in the moment. What follows is a very open portrayal of the debrief, which touches on the harm caused and the missed opportunities for responding in a way which supports the anti-racist work we should be supporting in health care. I am so appreciative of the thoughtful and honest writing by the authors. It was difficult for me to read the first few times, because I would frequently reflect on missed opportunities I have had in my career. It hurts to reflect on moments you could reduce harm to others, but you didn't. This is an important step, and it gets easier to read, because you can focus on the framework McKillip and Moss give to make better choices in the future.

One critical point is our communication tools of empathic silence and immediate debrief are not enough to handle these situations. McKillip and Moss let us in on their inner thoughts as they work through this case. They did a lot of work together to make things better for their own future work alone and together. They could have kept this work private, but they transformed it into something that could have a much larger impact in the world. I am so appreciative. I have already put some of their work into practice.

This article differs from other important work like the 2016 NEJM article Paul-Emelie, Smith, Lo and Fernández, "Dealing with Racist Patients." Most articles focus on what to do about the care of the patient now and in the future if they ask to be reassigned. That is important to consider as well, but what I appreciate about McKillip and Moss' work is that it focuses on the team, and the role we all must have in working towards a more caring and supportive community at work.

COI: Peer-to-peer mentorship - Mckillip, Bazelak

*Friday Chalk Talk is a great weekly resource. I need to write about that too!

For more Pallimed posts about race and healthcare.
For more Pallimed posts about ethics.
For more Pallimed posts by Dr. Sinclair click here.



Christian Sinclair, MD, FAAHPM is palliative care physician working in outpatient clincs at the University of Kansas Health System in Kansas City, KS. He currently is inspired to learn more about low-car transportation planning in cities like Berlin.

Monday, January 17, 2022 by Christian Sinclair ·

Monday, January 3, 2022

Cloaked Suffering

by Lyle Fettig (@FettigLyle)

The suffering in our hospital is cloaked by tinted windows and shiny new steel, a serene architectural specimen which betrays the internal chaos of each person who experiences illness behind each door.

Even for people who work there, it is sometimes surreal to approach the building in its beauty with the dissonant knowledge of what can happen in all manner of disease in between the walls. It’s the perfect place to hide the devastation of a pandemic.

Were the death and agony in the streets for all to see, perhaps the choices that are obvious to you and me would be obvious to all. How could a person not take every step they could to prevent this ongoing calamity?

This is not the bubonic plague to be seen in the gutters but rather a plague silenced by the plastic of the tubes you have placed in many airways hoping that after days, Weeks, Months, those voices will be heard again, knowing that some will go unheard for all of eternity.

Speak the truth with the ferocity and compassion I always hear from you. Tell the world what you have witnessed. Then go back into it with pride that no matter how your message has been received, you can rest your weary head knowing you have done the best this world will allow.

Originally published on Twitter Dec 27, 2021



For more Pallimed posts about COVID.
For more Pallimed posts by Dr. Fettig click here.



Dr. Lyle Fettig is an Assistant Professor of Clinical Medicine in the Department of Medicine/Division of General Internal Medicine and Geriatrics. Dr. Fettig directs the IUSM Palliative Medicine Fellowship and works clinically with the Eskenazi Health Palliative Care Program.



Monday, January 3, 2022 by Pallimed Editor ·

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