Martes 13 de Octubre

Hola. Hace 8 días subí un artículo sobre el uso de toxina Botulinica en manejo del dolor. 

Vamos a revisar las bases farmacológicas y los usos clínicos. 

Nos vemos 

Martes 6 de Octubre

Hola.  Me encuentro fuera de la ciudad. Por ese motivo no habrá reunión. 

Les dejo este magnífico documento para que lo preparen. 

https://app.box.com/s/xm21onbgd2dse1bt7shvuu68nrhy62kc

Medscape: opioid agreement ethics challenged

Nancy A. Melville | Disclosures

NATIONAL HARBOR, MD — One of strongest testaments to the effect of the prescription drug abuse epidemic on clinical practice is the increase in state mandates for opioid or controlled substance agreements that clinicians are required to have patients sign when receiving opioid prescriptions.

But such agreements are not without significant controversy, raising a host of ethical issues, said bioethicist Richard Payne, MD, MPH, the Esther Colliflower Professor of Medicine and Divinity at Duke University, Durham, North Carolina.

Dr Payne discussed the issue in a keynote address at the recent American Academy of Pain Management (AAPM) 2015 Annual Meeting.

"The original clinical objectives for these treatment agreements were laudable goals — to be used as tools to educate patients about their treatment plan, to inform about risk and benefits of treatment, clarify treatment goals and to promote adherence to treatment," said Dr Payne, who is also the John B. Francis Chair in Bioethics at the Center for Practical Bioethics in Kansas City, Missouri.

"But with the opioid overdose epidemic, the agreements over the years have taken on layers of regulatory and legal objectives favoring the clinician's legal risk objectives."

As a result, concerns are that the agreements have evolved to include more punitive language conveying a paternalistic air, with the suggestion of mistrust of the patient and corrupting the practitioner-patient relationship, he said.

Agreements that imply a power differential between the provider and patient "would appear to be the antithesis of promoting a patient-centered relationship of shared decision making," Dr Payne asserted.

He cited comments once made by bioethicist Robert Fine, MD, from Baylor University, on the issue, arguing that the very notion of a physician 'contract' with patients was in fact alien to medical ethics.

"If anything, we should be talking more about a covenantal, trusting relationship instead of using these agreements as sledgehammers to highlight power differentials over patients," Dr Payne said.

Clouded Intent, Questionable Efficacy 

While the use of such agreements dates back to the 1980s, their primary purpose appears to have become clouded, as indicated in a survey published 2014 in the Journal of Opioid Management showing that primary care physicians commonly believed a basic goal for the contracts was in fact physician self-protection.

Importantly, few who took the survey said they believed that the opioid agreements even accomplished the clear goal of preventing opioid misuse — and the evidence appears to support that belief.

Dr Payne cited a systemic review of opioid agreement studies from 1966 to 2009 with and without urine testing, published in the Annals of Internal Medicine, which concluded that of 102 studies with and without urine testing identified, only 11 met strict inclusion criteria.

Four of the studies showed the agreements were linked to a reduction of opioid misuse by 7% to 23%, and the other seven, which included urine analysis, showed reductions in misuse ranging from 3% to 43%, prompting the authors of the review to conclude that "relatively weak evidence supports the use of opioid agreements in reducing opioid misuse in chronic pain patients."

With the efficacy of the agreements in helping patients uncertain, the potential for unintended consequences raises the question of whether they may in fact do more harm than good.

Among the biggest concerns is the possibly disastrous fallout of a highly vulnerable patient being let go, or "fired," from a practice as the result of breaking the stipulations in the agreement and facing the shame of having much-needed care forfeited.

"There are anecdotal stories of patients having trouble finding other practices or even some horrendous examples of patients harming or even killing themselves in the context of being 'dismissed' from a practice," Dr Payne said.

Letting the Agreement Say It All 

Yet another concern with the agreements is the potential of letting the agreement — and not the clinician — do the talking, Dr Payne noted.

"There is some evidence in the literature that the opioid contracts can become a way of noncommunicating with patients; rather than talking an issue out with the patient, the discussion is reduced to a matter of 'well, you broke the contract so we're tapering your medication,' so the contract becomes a means of avoiding communication."

An especially problematic issue with that scenario is evidence that many high-risk patients may not even realize they have signed agreements, much less fully comprehend their content.

Dr Payne noted that progress has been made, however. In response to the concerns about the agreements, the US Food and Drug Administration convened a multidisciplinary group of outside experts to draft a user-friendly patient-provider opioid agreement, and a survey of FDA employees with the Center for Drug Evaluation and Research with 209 respondents showed 67.5% felt the agreement was neutral in tone and 90.4% felt it was easy to understand.

The Department of Veteran's Affairs National Center for Ethics in Health Care meanwhile has published useful materials, including draft agreements, regarding informed consent for long-term opioid therapy for pain.

Dr Payne and his colleagues at the Center for Practical Bioethics are meanwhile continuing to work toward agreements that more closely follow the model of informed consent, with more patient-centered intent and language.

In a policy brief issued in 2014, the team called for key language elements in opioid treatment agreements, including the rationale for therapy, such as clarification of the medical diagnosis and goals for therapy; discussion of the potential adverse effects of the therapy, including the risk for opioid tolerance and misuse; and behavioral expectations, including patient responsibilities and the consequences of "contractual violation" on the part of the patient.

Clinician Experts Chime in: Pro and Con 

While noting the validity of the issues Dr Payne concerned, AAPM incoming president Joanna G. Katzman, MD, said her experience with such agreements has generally been favorable.

"I have seen agreements that do exactly what Dr Payne described. My experience, however, is that controlled substances agreements are only as effective as the clinician presenting the information to the patient," she said.

"In other words, the most important aspect of the agreement is how they are used, how they are written, and how they are presented, rather than being a function of having an agreement per se."

In addition, well-written agreements can extend to benefiting the entire health care team, she added.

"The agreements can align all members of the clinic team, including clinician, nurse, medical assistant, et cetera, by educating medical practices to the safety risks of these medications."

In terms of perhaps the most controversial elements of dismissing a noncompliant patient from the practice, Dr Katzman noted that language can indeed be tailored to provide less severe alternatives.

"We prefer to see agreements that specify that deviations will trigger a re-evaluation of the terms under which controlled substance treatment is provided," she said.

Effective measures might include tightening the controls by, for instance, giving prescriptions a week at a time, rather than a month at a time, or, in some cases, it might include dismissing the patient from the practice, Dr Katzman said.

"But we should make every effort to help the patient use the medication safely and appropriately, or find alternative nonopioid medications and nonpharmacologic therapy that can help the patient's pain rather than just dismissing the patient from the practice."

Con: Agreements "Neither Necessary nor Sufficient" 

Gary M. Reisfield, MD, director of the Division of Addiction Psychiatry in the Departments of Psychiatry and Anesthesiology at the University of Florida College of Medicine in Gainesville, said his center uses controlled substance agreements under state mandate in Florida — but he has a less favorable view of them.

"The risks of opioid therapy are of sufficient frequency and magnitude that we must have discussions with our patients about these risks as well as realistic expectations regarding benefits and mutual expectations regarding the provision of this therapy," he told Medscape Medical News.

"In this regard, written treatment agreements are neither necessary nor sufficient."

Discussion, in the form of ongoing dialogue, regarding the dynamic risk-benefit ratio needs to happen, he said. "A sheet of paper is neither necessary nor sufficient for effecting these discussions."

"A well-written, patient-centered document may serve as a useful reference for our patients, but I do not believe that a signature is necessarily helpful to the therapeutic relationship."

Regarding dismissal of noncompliant patients, Dr Reisfield said the option is rarely even a reasonable measure.

Dr Gary M. Reisfield

"Dismissing patients from practices is almost never ethically justifiable," he asserted.

"Part of managing long-term opioid therapy is constructively dealing with aberrant behaviors — whether by counseling, tightening treatment boundaries, tapering and discontinuing opioid therapy, consultation with an addiction specialist, or referral to treatment," he said.

"Managing long-term opioid therapy is like flying a plane – if you can't land the plane, you shouldn't be flying it," he added.

"Absent compelling evidence of diversion or persistent disruptive behavior, with or without a written treatment agreement, patients should not be dismissed from practices."

Agreements Likely Here to Stay 

Whether favored or not, the requirement of opioid agreements is something clinicians are likely not going to have much of a choice about in coming years, Dr Katzman said.

"There are more and more states including mandates for these agreements in legislation, rules and regulations, and guidelines," she said.

"I don't expect that trend to stop, even though there is no consistent evidence that they accomplish their purpose."

Dr Payne, Dr Katzman, and Dr Reisfield have disclosed no relevant financial relationships. 

American Academy of Pain Management (AAPM) 2015 Annual Meeting. Presented September 19, 2015.

Martes 29 de Septiembre

Mañana retomaremos nuestra reunión, gracias a la interrupción patrocinada por nuestro eminente alcalde. 

DECIDI CANCELAR LA REUNION DE MAÑANA

Cortesía de ...... 

MARTES 22 DE SEPTIEMBRE

Hola a todos. 

Como lo mencioné la semana pasada, este día vamos a dividir la sesión en dos para poder finalizar con el caso clínico del 15 de septiembre. 

En la primera mitad: Síndrome Doloroso Regional Complejo.  ( sin tratamiento ) 

En la segunda mitad: Rotación de opioides. 

En este vínculo encontrarán el normograma para rotación de opioides ((CHANGE PAIN) Grunenthal. )

https://app.box.com/s/yp6bqkf1xo0m3eh0u82yxjo88o33ob36

Nos vemos. 

Este pertenece a un tema diferente. Pero es importante irlo revisando. 

https://app.box.com/s/yotcmgo38bgdkvzscwo3qaz3ivovq48g

Para los residentes y fellows de la Universidad de Antioquia.

Hola a todos. 

Para mi será un placer reunirme con ustedes para charlar acerca del uso de la radiofrecuencia en el manejo del dolor. 

Con este fin le estoy enviando una base de datos con documentos pertinentes.  En esta base de datos encontraran bastantes documentos que pueden servirles de marco teórico para nuestro taller del sábado.  Obviamente no espero que se los sepan todos.

Me parece importante enfatizar cuales son las metas del taller: 

1. Entender las bases físicas de la radiofrecuencia, sus tipos y características eléctricas. 

2. Conocer las indicaciones médicas según el nivel de evidencia. 

3. Vamos a revisar a fondo la radiofrecuencia de las facetas lumbares con todos sus  aspectos técnicos y clínicos. 

Base de datos:  https://app.box.com/s/mwvqu1dqdp9lmfmgj6vzip409jnh9y1n

Nos vemos el sábado. 

Martes 15 de Septiembre 2015

Adriana tiene 52 años. Tiene un dolor crónico secundario a una lesión traumática  del nervio ciático que ocurrió hace 2 años.  Desarrolló un síndrome doloroso regional complejo tipo 2. No ha tenido respuesta a 3 bloqueos simpáticos lumbares que se le han realizado en los últimos 6 meses. Esta recibiendo 60 mg de duloxetina y 600 miligramos de pregabalina lo cuales manifiesta no modifican significativamente su dolor. Esta en espera de que se le autorize la colocación de un estimulador espinal. 

Desde hace 6 meses esta siendo manejada con dosis crecientes de hidromorfona. Inicialmente con excelente respuesta analgésica.  Sin embargo, ha requerido un incremento paulatino y sostenido de las dosis. En este momento era tomando 7,5 mg por vía oral cada 4 horas. Usa dosis extras ínterdosis de 5 mg. Tiene un estreñimiento importante con deposiciones duras cada 5 días. 

Los últimos incrementos de las dosis no han proporcionado un cambio en el nivel de analgesia.  Manifiesta tener dolor severo 8/10 la mayoría del tiempo. 

1. Identifique los problemas 

2. Que propuesta farmacológica le tiene? 

3. Referencie sus respuestas 

Martes 8 de Septiembre

Luisa Fernanda tiene 48 años.  Tuvo una hepatitis auto inmune hace 10 años por lo que recibió un trasplante hepático de donante cadavérico. Desde entonces ha presentado varios episodios de rechazo que han sido manejados con esteroides en forma intrahospitalaria. 

Por el uso crónico de esteroides desarrolló una osteoporosis severa y ha presentado diferentes fracturas patológicas. En estas situaciones ha sido manejada con codeína con pobre respuesta analgésica. 

En condiciones no claras, presenta un episodio de pérdida de conocimiento. Al parecer cae desde su propia altura.  Es traída a urgencias. 

Al examen físico se encuentra una paciente con una ascitis leve, estable hemodinaámicamente, esta somnolienta RAMSEY 4.  Manifiesta dolor lumbar con la movilización. No tiene déficit motor ni sensitivo en las extremidades, 

Le realizan paraclínicos: HB 8, leucocitos en 13000 , plaquetas 65000.  Bilirrubinas totales 3 mg/dl, albumina sérica 2,5 g/L. Un INR 2,7. 

Una resonancia de columna muestra fracturas de apariencia reciente en L1,L2, L3 y L5. No hay compromiso del canal medular ni de los forámenes de conjugación. 

El medico de urgencias le formula morfina 2 mg cada 8 horas. Pero debido a que esta sedado no recibió sino las primeras 2 dosis. Ha recibido acetaminofén 500mg cada 8 horas. 

Usted es interconsultado para optimizar el manejo analgésico. 

1. Cual es el problema 

2. Cual es el manejo analgésico que va a proponer. 

Martes 2 de Septiembre

Oswaldo tiene 47 años y hace cinco años fue diagnosticado con una esclerosis múltiple. Ha recibido manejo con interferón beta uno. 

Hace cuatro meses inició un cuadro doloroso consistente en un dolor severo tipo corrientazo en la parte superior y media  de su cara ( solo a la derecha ) . Ese dolor se presenta en salvas y se asocia con una contracción muscular que dura unos segundos lo califica en una intensidad de 10/10. Entre esos episodios Oswaldo está asintomático.  Ha sido manejado por su neurólogo con Carbamazepina 300 mg dos veces al día con una disminución importante en la frecuencia aparición de los eventos dolorosos. 

Sin embargo manifiesta que la intensidad del dolor no se modifica. No ha tenido respuesta a Tramadol, codeína ni pregabalina,  Por este motivo su neurólogo decir remitirlo a su consulta para evaluar la posibilidad de la aplicación de radiofrecuencia con fines analgésicos. 

1. Cuál es el problema ? 

2. Por que se presenta ? 

3. En qué consiste la radiofrecuencia qué tipos hay y en donde se aplica. Qué estudios justifica su uso en este paciente