Medical Humanities Blog

Puzzling AHA Statement on Chronic Pain

Guest blogger extraordinaire Kelly Hills brings word of this story regarding the American Heart Association's new recommendations regarding usage of the class of NSAIDs known as Cox-2 inhibitors:

The scientific statement said that, with the exception of aspirin, there is now strong evidence that NSAIDs are associated with an increased risk of heart attacks and stroke. If 100 patients who have had heart attacks in the past or are at risk for heart disease take these drugs for a year, researchers would expect to see six additional deaths in this group. NSAIDs reduce fever, pain and inflammation.

The statement expressed particular concern over a subgroup of these drugs known as Cox-2 inhibitors. The only drug in this group currently on the market in the United States is Celebrex.

So far, nothing particularly novel.  Concern over the Cox-2 inhibitor drugs has grown since Merck removed Vioxx from the market in 2003, so one would presumably not be shocked that the AHA has reassessed the risk-benefit calculus related to this class of drugs and recommended that such drugs not be used as frontline therapy for chronic pain.  But the AHA went much further.  Not only did they advise against using the Cox-2 inhibitors, they recommended that physicians avoid using all medications for chronic pain:

Patients should be treated first with nonmedicinal measures such as physical therapy, hot or cold packs, exercise, weight loss, and orthotics before doctors even consider medication, said the AHA scientific statement published in the journal Circulation.

Patients who get no relief after those measures have been exhausted can be considered for drug therapy, but doctors should try drugs only in a certain order, the statement said . . . .

Umm, what? I am no physician, but moving from the premise that Cox-2 inhibitors ought not be used as frontline therapy for chronic pain to the conclusion that chronic pain patients should be treated first with nonmedicinal measures requires a host of additional inferences that are left totally unsaid by the AHA.  The seriousness of this recommendation cannot be overstated.

Though this blog is not a chronicle of my own academic pursuits, I have made no secret of the fact that pain and pain management is my central area of interest (it will be my dissertation topic, in fact).  Given that the undertreatment of pain is such a staggeringly widespread problem -- and that part of the problem is undermedication of pain -- the AHA's recommendation that medication be avoided for chronic pain patients at risk for cardiac disease is highly likely to exacerbate the problem.  This is not necessarily to condemn the AHA's position outright, but is rather to suggest that the the stakes of the AHA position are incredibly high.  One might analogize this to a constitutional law question where the court must examine whether the regulation at issue passes strict scrutiny.  By this I mean that the AHA recommendation would have to demonstrate a highly compelling interest in recommending avoidance of pharmacological treatment for chronic pain patients at risk for cardiac disease, because the consequences of such a recommendation are likely to be profound where pain is so undertreated to begin with.

Jean Jackson, among others, has extensively documented that the problems of pain management are particularly serious among chronic pain patients, who consistently report the worst, most conflict-ridden relationships with physicians.  The AHA recommendation is unlikely to ameliorate this problem.

Kelly, who suffers from chronic pain, sums it up well:

There are many ways to treat chronic pain problems, and how the treatment happens should depend on the individual scenario. While it would have been perfectly fine for the AHA to come out and say "look, there are some serious risks associated with both the Cox-2 and NSAIDs, and here they are, and this is how we'd recommend using them" - well, okay, that's one thing. But that's a far cry from recommending not how to use medication but to treat patients, and from declaring that no chronic pain patient should receive painkillers until after they've jumped through a long and potentially detrimental (without relief) series of hoops.

I cannot disagree with her.  Consider that some chronic pain patients at risk for cardiac disease are unlikely to experience much relief from their pain without pharmacological interventions (of course, there are all sorts of pain which respond well or even better to nonpharmacological therapies).  The AHA position means that such patients are consigned to suffer through their pain while the physician, who, based on the empirical evidence, is unlikely to manage their pain adequately under the best of circumstances, prescribes all sorts of interventions that do little to ameliorate the patient's pain, while all along there exists some (pharmacological) interventions that may actually be therapeutic.  The patient will suffer through this pain until the physician exhausts the nonpharmacological interventions and finally prescribes pharmaceutical therapy.

This strikes me as ethically problematic.  Thoughts?

Disability Blog Carnival # 9

Okay, so I am a few days late, but do yourself a favor and go check out Disability Blog Carnival # 9 over at The 19th Floor, put together by Mark Siegel.  Lots of good links.

Literature Review

Today's review will collate abstracts from:

Sociology of Health & Illness

Bulletin of the History of Medicine

Pathblography

The Houston Chronicle sports an interesting collection of blogs, both via its own staff and via readers.  A new one that looks particularly interesting and engaging is CancerDiva:

My name is Terry Hayes.

I'm a single, 40-year-old woman living in Houston with my sister and her two dogs. I have a kitty cat named Sasha. I love to shop, read, watch movies and listen to music. I enjoy a challenging jigsaw puzzle, "This American Life" and "Prairie Home Companion". I like plays, traveling, and art cars. I love my job and my co-workers. I can't get enough of "CSI," "Law & Order," or "The Closer," and I'll watch anything on BRAVO. My favorite color is pink.

Oh, and I'm dying of cancer.

No use sugarcoating it. When my oncologist told me in April 2006 that I have metastatic colon cancer, I nodded my head and said, "Okay." When she told me I had about 24 months to live, "give or take a few," I nodded my head and said, "Okay."

My cancer had spread from my colon to distant sites in my body, namely my ovaries, liver and abdominal wall. Last week, I thought I might have a brain tumor. Luckily, my MRI was normal (normal for now anyway).

Recommended.

(h/t blogHouston)

Abigail Alliance

Glenn Cohen (guest-blogging at Prawfsblawg) has an excellent post on the significance of the upcoming en banc rehearing of the Abigail Alliance decision.  The case is extremely important for a variety of reasons, and Cohen brings considerable insight and perspective on the case (while working at DOJ, he helped draft the government's petition for rehearing).

Here is the issue: whether

the due process clause of the federal constitution provides a fundamental right that prevents the Food and Drug Administration (FDA) from blocking competent, terminally ill patients from having access to potentially lifesaving drugs that have cleared Phase 1 clinical testing but have gone no further in the drug approval process, when usage is based on the advice of doctors.

The panel opinion, authored by J. Rogers and joined by C.J. Ginsburg, concluded that such a right does exist:

The D.C. Circuit panel majority held that the due process clause creates a fundamental “right of a mentally competent, terminally ill adult patient to access potentially life-saving post–PhaseI investigational new drugs, upon a doctor’s advice, even where that medication carries risks for the patient.” The majority found this right to be “deeply rooted in this Nation’s history and tradition," as reflected in various common law doctrines (the defense of necessity, the freedom from battery, the tort of intentional interference with a rescue).

Judge Griffith dissented, arguing that he could find no compelling reason for removing the power to balance the risks and benefits of pharmaceuticals from the democratic branches of government.

Cohen suggests that the first question is "does the Constitution compel Congress and FDA to adopt a certain policy as to the regulation and approval of drugs as applied to terminally ill patients?" He argues that it does not, contra to the majority's assessment, and I happen to agree with him on this point.  This is a technical question of constitutional law, and is not equivalent to the arguably more difficult policy question: "Even if we assume Congress and FDA have the power to regulate drugs for the terminally ill in the way they are already doing, should they switch to a system with increased access?"

The entire post is eminently worth reading.  I am hesitant to stand athwart a potential door to lifesaving treatment for desperately ill patients, and yet, commentators (notably, Cassell) have explained the extreme fear and vulnerability of such patients makes it all the more important to (paternalistically, perhaps) attempt to shield them from an arguably unethical exposure to risks of pain and suffering for little benefits.  This contention, of course, is contestable for a variety of reasons, but I agree with Cohen that it is at the heart of some of the difficult policy issues presented by this case.

The sad saga of the litigation over the use of high dose chemotherapy with autologous bone marrow transplants for patients with advanced breast cancer seems quite analogous here.  These patients sued insurers and HMOs for denying coverage for the procedure; the latter argued that it was experimental.  Several of these suits were successful, but a worldwide study eventually proved -- after a significant case of research fraud in South Africa that falsified findings of efficacy -- that the study was of no benefit.  It is possible that some women suffered and even died more hastily because of the intervention (note: I intentionally did not term it "therapy" in this instance).

On the one hand, it would seem difficult to tell these desperate, suffering patients that what they perceive as their last hope ought not be made available to them, and on the other hand, to paraphrase from Wittgenstein, one must be careful of attempting to open doors that are painted on to walls, especially when doing so may carry significant risk.  These are truly difficult issues of research ethics.

Gifts, Tobacco, & Narrative

Also recommended is Glenn Cohen's post on the University of Virginia's decision to accept a $25 million gift from Phillip Morris to go to research on addiction as well as development of an antismoking campaign.

Cohen writes that this seems "another clever move by Big Tobacco to attempt to at the same time re-habilitate their credibility and to institute a narrative of responsibility that is an attempt to avoid regulation."  He further elucidates the narrative: "This latest move by Big Tobacco can be seen as a push back to reclaim the narrative of responsibility.  If we are helping people to quit, then those who don't are choosing to smoke, and that choice should be respected."

I wonder if some of the recent attention given to the role of gifts in establishing relationships and notions of reciprocity in the context of industry gifts to physicians or investigators has any relevance here.  In any case, regardless of one's position on the merits of UVa's acceptance of the gift, identifying narratives that shape and inform our attitudes and practices with regards to public health (and private collaborations or gifts) seems important.   

Post on Disability

Thanks to "righteous babe" over at DailyKos for the link and the kind words.  Her post is a must-read on disability, with an outstanding collection of links and perspectives.

Using Language

This weekend's edition of The Scientist has an interesting on the war against war metaphors in science. Author Melinda Wenner runs us through a quick history of the war metaphor in science, and then looks at criticism from language and cognitive linguist professors, like George Lakoff, who notes that "this is not language, this is the way people think."

Perhaps not surprising, it seems that the words we use to describe a situation influence how we approach it. To use war metaphors creates an adversarial, binary us/them mentality that may very well close off avenues of research and solutions that focus more on the social and physical environment. Anyone who's read Susan Sontag's "Illness as Metaphor" will find this a familiar concept.

I think more interesting, though, is how the use, or dis-use, of war language in research can create a method of ostrasization for a researcher who doesn't embrace the battle mentality, if you don't see the disease as an invader to be vanquished. If, instead, you look for ways to work with or around the problem, you quite literally run the risk of collusion!

Why is this of interest? Well, I think that many of us in the medical humanities approach the field from interdisciplinary perspectives that, by their very nature, are more inclined to veer away from war metaphors and towards considering multiple factors behind disease and illness. So it becomes another way we unintentionally advertise ourselves as "not real." Of course, this is a potential weakness that can also become a strength. The very thing that is marking us as other allows us to stand as a reminder that the very words we use colour of perceptions and perceived solutions to the problems we face. The way we use language is important for more than just immediate transmission of information; it shapes our attitude as well as our knowledge.

Worldmapper Project

This is a map of private health care spending courtesy of Worldmapper, but the map is unusual in that territories on the map are imaged in proportion to the health care value being assessed.  Thus the U.S. seems to bulge at its seams, while the entire continent of Africa shrinks to a very long isthmus.

These maps really put global health inequities into stark relief, quite literally, and manage to capture something visually that is often more difficult to conceptualize.  Another map, reproduced below, shows a bulging Africa & India and an almost nonexistent U.S.; this one charts early neonatal mortality.  Fascinating stuff.

(h/t Stuart Rennie at Global Bioethics Blog)   

C-O-R-R-E-L-A-T-E-S

I want to apologize for the relative slowness in posting around here recently.  There have been some pressing deadlines, and especially now that the Texas Legislature is in session, some of my occupational responsibilities have taken on a different level of urgency.  I do hope to have a Literature Review up by the end of the week.

For now, take a look at this interesting post over at Concurring Opinions on the report of use of fMRI to "read [a person's] intentions before they act."  My comment on the report, in part:

Some of the claims advanced by some fMRI proponents as to their legal, ethical, and policy implications are often either overstated or even simply erroneous. Too many do not understand the significance of neural correlates as correlates, rather than the actual phenomena being considered (fMRI measures, among other things, blood oxygenation levels, which is not literally equivalent to the experience of consciousness, for example).

Adam Kolber touches on a related point here.  For the record, I've found John Searle's book, The Rediscovery of Mind, to be an indispensable resource for conceiving of the relationship between subjectivity, neurophysiology, and consciousness.