Wednesday, June 26, 2013

Pain Is The Fifth Vital Sign - And If You Don't Have Any, You Might Be Almost Dead

"The cure is worse than the disease", it has been said about some supposed remedies.  We might be at that point in the treatment of acute and especially chronic pain with opioid (narcotic) analgesics.  In this article in the May 9th issue of JAMA Dowell et al make the astute observation that as opioid related deaths have quadrupled in the last decade or so, people have not become more susceptible to the drugs - it's just that their exposure has increased.  Exposure increased because several alleged patient advocacy groups (American Pain Society, Veteran's Health Administration, the Joint Commission) campaigned to convince physicians that they were not adequately recognizing and treating pain, callously leaving countless patients unnecessarily writhing in abject misery.  Led by these and other coalitions of busybodies, we went from possible undertreatment of pain (with narcotics) straight to guaranteed bona fide undeniable overtreatment (with a brief pass through [but not a stop at] optimal treatment).  Part of this overzealous campaign was the coining (original source unknown) of the contagious catchphrase "pain as the fifth vital sign."  

This is interesting because pain is a SYMPTOM, something reported by a patient (part of the HISTORY), whereas a [vital] SIGN is an observation or measurement (part of the PHYSICAL EXAMINATION) made by a practitioner such as blood pressure, heart rate, a bruise on the skin, a pulsatile uvula (Muller's sign), or some other finding.  (The more rare, uncontemporaneous, and useless a sign is, the more likely its name is an eponym.)  But the pain coalition (PC) successfully circumvented this convention by cooking up pain scales and cutesy numbered diagrams bounded by smiley faces and sad faces, adding a cloak of objective legitimacy to the subjective experience of pain.

Thursday, June 20, 2013

Logic Based Medicine: The Case of Activated Charcoal

Like all good things, Evidence Based Medicine (EBM), when taken to far, runs the risk of making us overwrought and becoming cliche.  I think we are reaching this point.  Given Ioannidis' meta-research findings that most published research findings are false (does he consider the irony that that may apply to his findings too?) the corrupting and corrosive influence of industry on research programs and guideline construction, the biases of academic researchers intent on grants, prestige and promotions (as well as honoraria to supplement paltry academic salaries - I was there once, and I did it too), and the zealousness of "experts" who wish to interpret the evidence in the form of an edict for all to follow (euphemistically called "guidelines"), and several other disturbing trends, it becomes apparent that in the end we must rely upon our own judgment and logic to discern the proper path to follow.  And so it is with Activated Charcoal (AC) administration, an agent used in overdoses and toxic ingestions that has a remarkable capacity to adsorb ingested substances and theoretically limit their toxicity.  (It is not barbecue charcoal, the photo is tongue-in-cheek.)

Monday, June 3, 2013

I Know it When I See it: Antibiotic Resistance, the Chronically Dying, and Futile Medical Care

Today's issue of the New York Times features (yet another) article sounding alarms about antibiotic resistance and the supposed need for new antimicrobial agents.  There are several common hackneyed reasons why we have the current predicament of drug resistant organisms such as:

  • Use of antibiotics in livestock, which accounts for 80% of use in the United States.  This should be the prime target for efforts to reduce resistance, not use in humans.  
  • Inappropriate use of antibiotics in outpatients who have mild/minor illness and who have viral illness (not responsive to antibiotics) 75% of the time.
  • Inappropriate drug, dose, duration of therapy, etc., in both outpatients and inpatients.
The article calls for reducing the hurdles needed to develop and test new agents.  Well and good.  But I have another idea:  fund testing of antibiotic dosing duration for several common infections such as pneumonia, cellulitis, urinary tract infection, etc.  Right now, it's all over the board, with some patients getting two weeks for pneumonia, some getting five days (my patients).  Moreover it is my suggestion that such trials stratify patients on the basis of the prior probability of the infection being treated.  I would posit that the lower the probability of infection, the more likely it is that a shorter course will suffice.  Clinical improvement criteria could also be built into these studies so that courses could be truncated when patients improve.  If we could cut the duration of exposure from 10 days to 5 days, we would remove selective pressure for development of resistant organisms and opportunistic infections (fungemia; C. diff; ESBL).  I'm not sure we need new toys so much as we need to play properly with the toys we already have.  (And no, I'm not a fan of biomarkers like procalcitonin to guide duration of administration.)