14 July 2009

Mindfulness in cancer treatment

Go read Mindy Greenstein's WaPo piece:

Aided by a Proponent of Mindfulness, Cancer Patient Focuses on Joys of Today - washingtonpost.com

Why are you still here?

It's awesome. Trust me.

Okay fine. Don't believe me. Here's a small bit of its awesomeness to entice you:
Sanderson realized that this was what she was doing with her needle and, ultimately, with her illness: letting her experience of the present moment be overtaken by her fears for the future. Every hour she spent ruminating about the pain that was awaiting her was another hour she wasn't fully engaged with her life, another hour she couldn't enjoy. She couldn't pretend she didn't know her prognosis. So she chose a different route.

"I realized," she told us, "that the moments of pain -- even if the pain was excruciating -- were actually very short compared with the pain I put myself through by thinking about it ahead of time." If she could stay focused on the present moment no matter what she was doing -- washing dishes, talking to a colleague, even chatting with the doctor just before her treatment -- up until the moment the needle actually pierced her skin, she could cope. Even more, if she could keep that same focus from meandering to thoughts about what lay ahead in the future in general, she could continue to make the most of every moment that was not painful.

Some people think being positive means being certain of a cure. For others, it means enjoying the kindness of a friend or the mischief of a child or a rerun of "Battlestar Galactica" today, and leaving tomorrow's sorrows for tomorrow. For me, it meant.....

Oh you want to know how it ends don't you?

Now do you believe me?

Go read it. I'll still be here when you get back.


Confusing 'ameliorating' with 'obliterating'

I've seen several authors make this point, but in an email to me, reader SV put it in a very nice way:
"We physicians are called upon to "ameliorate" pain, which often is considered synonymous with "obliterating" pain."

This is a very important flip-side to the incredible advances that have been made in pain medicine and public expectations about treatment.

The way 'ameliorate' and 'obliterate' have gotten run together in the public's (and even in many physicians') expectations has a significant downside: In addition to being annoying and disappointing to all involved, there's a case to be made that this sometimes (often?) leads to worse treatment outcomes.

For example, if a patient expects complete relief from her pain, partial relief might leave her depressed, frustrated, and resigned. Attitudes like those can be some of the biggest factors in determining how bad a pain is.* This is especially the case with many chronic pain conditions.

Of course, we've come a long way from seeing pain as an inevitable concomitant of disease and treatment, and thus not a direct concern for the physician.

And, we've to a large degree gotten over the invidious tendency to heap moral condemnation upon those who don't suffer in silence, and to see all pains, including medical pains, as deserved (the words 'pain' and 'punishment' both have their roots in 'poena').

On that note, this story in the Boston Globe is important: The Day Pain Died: What Really Happened During the Most Famous Moment in Boston Medicine

So, I suppose its worth keeping some perspective on how much attitudes and expectations have come in a very short amount of time. Still, there's still a long way left to go.


*As always: These attitudes are not merely responses to the pain, they can become part of the pain itself.

It is a serious conceptual mistake to think of a patient who feels helpless and resigned in the face of her pain as (necessarily) being in two bad states:
(a) Her pain is bad to degree x
(b) Feeling helpless and resigned is bad to degree y.

Rather, these feelings are themselves parts of the pain. Their treatment is just as much a treatment of the pain itself as is the administration of morphine.

03 July 2009

Elderly headaches

Abstract Although the prevalence of headache in the elderly is relevant, until now few studies have been conducted in patients over the age of 65 years. We analyzed the clinical charts of 4,417 consecutive patients referred to our Headache Centre from 1995 to 2002. There were 282 patients over 65 years of age at the first visit, corresponding to 6.4% of the study population. Primary headaches were diagnosed in 81.6% of the cases, while secondary headaches and non-classifiable headaches represented, respectively, 14.9% and 3.5% of the cases. Among primary headaches, the prevalence was almost the same for migraine without aura (27.8%), transformed migraine (26.1%) and chronic tension- type headache (25.7%). The most frequent secondary headaches were trigeminal neuralgia and headache associated with cervical spine disorder."
By: C. Lisotto1, F. Mainardi, F. Maggioni, F. Dainese and G. Zanchin

01 July 2009

Percocet and Vicodin be gone (hopefully)

In light of my long-running antipathy toward the way acetominophen is currently used and regulated, this makes me very happy:

Panel Recommends Ban on 2 Popular Painkillers - NYTimes.com

Published: June 30, 2009

ADELPHI, Md. — A federal advisory panel voted narrowly on Tuesday to recommend a ban on Percocet and Vicodin, two of the most popular prescription painkillers in the world, because of their effects on the liver.

The agency is not required to [....] follow the recommendations of its advisory panels, but it usually does.

But they voted 20 to 17 against limiting the number of pills allowed in each bottle, with members saying such a limit would probably have little effect and could hurt rural and poor patients. Bottles of 1,000 pills are often sold at discount chains.

‘We have no data to show that people who overdose shop at Costco,’ said Dr. Edward Covington, a panel member from the Cleveland Clinic Foundation.

IIRC, the problem is that their parents do. The patients who intentionally take handfuls of acetaminophen are usually teenage girls in initial and not-fully-serious suicide attempts. Few other countries allow the sort of bulk packaging we do.

Finally, I find this very hard to bellieve:
Still, some doctors predicted that the recommendation would put extra burdens on physicians and patients.

‘More people will be suffering from pain,’ said Dr. Sean Mackey, chief of pain management at Stanford University Medical School. ‘More people will be seeing their doctors more frequently and running up health care costs.’

The recommendation doesn't attempt to ban acetominophen. And, the 1,000 pill bottles are relatively cheap, so its hard to see too much of an increase in marginal cost if a patient will also have to buy the acetominophen OTC.

Moreover, why would more people go to the doctor because they have to get their oxycodone and acetominophen separately? Why would they go more frequently?

“It ties the doctor’s hands when you put the two drugs together,” said Dr. Scott M. Fishman, a professor of anesthesiology at the University of California, Davis, and a former president of the American Academy of Pain Medicine. “There’s no reason you can’t get the same effect by using them separately.” Dr. Fisher said the combinations were prescribed so often for the sake of convenience, but added, “When you’re using controlled substances, you want to err on the side of safety rather than convenience.”

Fingers crossed that the FDA will follow the recommendation....