February 16, 2014

The Double-Edged Sword

I just read a report describing the state of palliative care around the world that made me appreciate how far we have come in the US. Here, about 45% of people who die were receiving hospice care at the time of death; worldwide, the figure is 14%. 

We still have an enormous amount of work to do at home. Many of those who die with hospice services were enrolled in the program for only a few days, giving them little chance to benefit; and palliative care, a more comprehensive approach than hospice, (hospice is focused on the last six months of life and is generally limited to comfort care), is available in only two-thirds of American hospitals. But according to the recently released “Global Atlas of Palliative Care,” the majority of countries in the world have no palliative care services at all.

The report endorses the World Health Organization definition of palliative care as an approach to patients with life-threatening illness and their families that focuses on improving quality of life. It supports the idea that palliative care should be a basic human right for the 20 million people who die each year with medical conditions such as chronic heart disease, cancer, and chronic lung disease. By treating pain and other physical symptoms and by addressing psychosocial and spiritual issues, palliative care improves the final phase of life in a compassionate and cost-effective way. And since nearly 70% of the 20 million deaths are in older individuals, the issue is primarily although not exclusively a geriatric concern.

What struck me about the report is that one of the major barriers to patients’ receiving palliative care is restrictions on opioid prescribing (morphine and its cousins): 80% of the world’s population lack adequate access to opioid medications for pain control. In fact, the US, Canada, Australia, New Zealand and a few other western countries account for 90% of the world’s use of these medications that are so essential to good care near the end of life.

At the same time, we read in the newspapers about the epidemic of deaths from opioid overdose.  The death of actor Philip Seymour Hoffmann with a needle in his arm is just the most recent example. In 2011, a landmark study found that opioid overdose is the second most common cause of unintentional death in the US, close behind motor vehicle accidents: 74% of the unintentional deaths involving medications were related to opioids. 

How are we to reconcile the need for more palliative care, which will require greater opioid use, and the rising rate of morphine-related deaths in those parts of the world where morphine is widely available? First, it’s important to realize that most, probably almost all, of the overdoses occur in patients who are not receiving palliative care or hospice. In one study of the association between opioid prescribing patterns and opioid-overdose-related deaths, only 2 patients were enrolled in a palliative care or hospice program at the time of the overdose. While the cause of death might have been misclassified in some of the palliative care patients, the evidence so far suggests that overdoses are not common in this population. Second, the best way to address opioid overdose involves a variety of strategies other than limiting use in situations of need. Many states have recently introduced regulation to prevent “diversion” of narcotics (funneling of prescription drugs from the intended recipient to a drug addict). Another promising approach involves providing narcan, an opioid antagonist, to members of the community where people at risk of overdosing live. When such a program was introduced in North Carolina, the result was a drop in the proportion of opioid deaths due to prescription drugs from 82% to 10% in 2 years. 

I would regret to see the many older patients with pain or shortness of breath (another symptom that responds to morphine) refuse opioids because they are afraid of their potential for abuse. Yes, we have a problem with the abuse of opioids in the US. But patients in the final stage of life who are receiving palliative care are not the problem.

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