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PHARMA/QUALITY/PHYSICIANS: Rational sense on opioid use for cancer sufferers, with reference to Kinsey and rationalism.

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A very important THCB reader — one that I have to be nice to if I want to feature in the will, and you might guess that I’m a couple of wickets down already — has forwarded me this BMJ article on opioid use for cancer patients.

Last night I saw the movie Kinsey, which told the story of how Kinsey’s research on human sexuality in the 1940s and 1950s created great advancement in human understanding, and helped remove the weight of hundreds of years of damaging religious bigotry — yup into the 1930s married couples were taught that any non-missionary position sex (including using the mouth or the fingers) was wrong and unnatural. There’s a harrowing scene were his father eventually tells him that he was fitted with a strap to prevent masturbation. I thought of this in the context of opioids, because apart from certain lunatics on the Christian right, rational people agree that the behaviors imposed by society on sexual "deviants" — homosexuality was a jailable offense as recently as the 1950s –were both morally wrong and harmful to individuals and society as a whole. We needed science (and I know there’s a lot of criticism of Kinsey, M&J and Hite’s methods, but they approached the issue from a scientific not a moralistic perspective) to show us the truth in a rational dispassionate way.

The war on pain doctors and patients is being fought by a similar band of lunatic puritans as attacked (and still attack) Kinsey.  Only these moralistic jihadists have the full force of the Justice Department behind them and are clearly bending every commonsense understanding of justice and ethics to imprison and destroy anyone who holds a different, more humane view.

Of course the main problem here is that the puritan jihadists have equated opioid use for pain as some kind of great moral failing. Well the scientific view is succinctly and excellently put by a leading British physician:

Concerns about morphine: Morphine has long been feared by the general public and the medical profession. Underlying this fear is the mistaken belief that the potential for misuse of opioids is linked with their use as analgesics. Unfortunately, concerns about addiction, respiratory depression, and excessive sedation cause healthcare professionals to avoid using opioids or to use them in suboptimal doses. Clinical experience has shown that these fears are largely unfounded and that addiction is not likely if morphine is used to manage pain responsive to opioids in doses titrated to the degree of pain. Withdrawal symptoms indicate physical dependence and should not be confused with psychological dependence (addiction).

It’s mainstream educated work like this that needs to be broadcast widely, and all physicians and other scientists need to continue to trumpet this loudly. Don’t forget that the puritan jihadists want to take us back to their equivalent of Sharia law, and the real fight among civilizations is not between Christians and Muslims, it’s between the rationalists and the zealots. And if you think I’m overstating it let me  use this quote from the Guardian of a smattering of leading anti-Kinsey campaigners (yup, they really exist)

The religious right still fear and despise Kinsey and all his works. Check out some of the (apparently coordinated) responses to the new movie. "Kinsey’s proper place is with Nazi doctor Josef Mengele," says Robert Knight of Concerned Women for America, inadvertently showing us what he thinks of the Holocaust. Robert Peters of Morality in Media: "That’s part of Kinsey’s legacy: Aids, abortion, the high divorce rate, pornography." Focus on the Family’s film critic (they have a film critic?), Tom Neven, calls the movie "rank propaganda for the sexual revolution and the homosexual agenda". And Judith Reisman, who has waged a decades-long war against Kinsey’s memory, refers to "a legacy of massive venereal disease, broken hearts and broken souls".

And is it a Jihad?  Well the lunatics certainly think so:

A recent newsletter of the abstinence-education group Why know? compared the publication of “The Kinsey Report,” in 1948, to the attacks of September 11th, and labeled Kinseyism “fifty years of cultural terrorism.”

BLOGS: World Mental Health Day

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Psychologist Deb Serani informs me that it’s World Mental Health Day.  Go to her blog to see more, and no snide remarks about which of our nation’s leaders this is aimed at!

BLOGS/PHYSICIANS: Enoch Choi in New Orleans

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oDr. Enoch Choi, a medblogger (and OT but BTW a liberal evangelical Christian just so you know there is one!) has packed up his black bag and spent the week in New Orleans following his medical calling.  Go read his blog and scroll down to the October 1 entry — then read up. Doesn’t take too long as he’s posting via his Treo and he’s mighty mighty busy. It’s an amazing read.

It’s very clear that the return to New Orleans is fraught with similar perils to the evacuation. Plaudits to Enoch to heading out and putting his God-given talents to work in a crisis. They still need doctors desperately down there.

UPDATE:  Enoch writes direct (promoted from the comments). Please consider donating once more to the organizations that are sending committed volunteers like him onto the very front lines.

thanks for the props, Matthew. i’ve come to new orleans with City Team ministries and serving under the local authority of Pastors Resource Council PRC Compassion, invited by the local churches in St. Bernard. Menlo Park Presbyterian Church MPPC paid all of our flights, expenses, medicines and supplies.

Any of those organizations would be able to immediately deploy your donations to people we’re seeing every day. Yesterday, one of our nurses gave us $1000 from their Kansas Church… Their entire disposable cash. We spent it today on natural tears, sunblock, nasal saline, sudafed, lozenges, cough syrup, hydrocortisone. We gave it away in 2 hours. There’s immesurable need here, and whatever you give to MPPC would be immediately consumed by that need by our medical team.

to give to MPPC:

to give to City Team:

to give to PRC Compassion:

This is so different than giving to Red Cross, what you give to them will be spent on the next disaster. The Red Cross doesn’t have physicians down here. I don’t see any other medical teams down here other than ours. There are plenty of individual physicians that have come down, and they’re very important, but as an organized group, we’re it.

POLICY/POLITICS: Linking Katrina, Medicare Part D and bird Flu

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Here’s my FierceHealthcare editorial today:

FierceHealthcare has been following two stories all year that both had big moments this week. One is the avian flu that’s been popping up in Asia and may end up being as deadly as the 1918 epidemic. The other is the new Medicare Part D roll-out. For Medicare Part D, the complex mix of plans being offered to seniors will test their ability to understand the options on hand — anyone who’s bought insurance in the individual market knows that’s not easy — and will also challenge the Federal government’s ability to run and police a complex program with many different private and public agencies taking part. Given the nation’s recent experience with a similar challenge on the Gulf Coast, we can be forgiven for looking at the Medicare roll-out as the next great test of government, and hope that it shows improvement. Especially if we have a real crisis in the near future if avian flu becomes the pandemic we all fear.

QUALITY: DM has been counting it wrong but Al Lewis sets it straight

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Over the last year or so the DM listserv has been buzzing with the concept put about from Al Lewis, Ariel Linden, and Ian Duncan that to this point ROI for disease management programs has been calculated wrongly. But in an interview with Managed Care magazine Al explains how to get it right, and also predicts that this will help DM finally take off.

My cynicism has been detailed — and refuted — before in THCB, but at some point getting DM right will make sense. My fears of course revolve around problem that the the incentive for a insurer to get rid of a sick member is much greater than the incentive for them to manage that member well, and it’s a damn site easier to do the former.

PHYSICIANS/POLICY: Malpractice explained

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Susan Sheridan, whom I wrote about last month, is even more famous. She and her son Cal who has kernicterus syndrome are the hook for a piece in The New Republic by Robert Berenson. (You may only be able to get to the first page…) It largely tells the truth about malpractice, but just to reiterate, my reading of the data is that:

1) The tort system only picks up about half of malpractice2) The medical system barely ever apologizes (Susan never got an apology), but when it does law suits are much less likely3) Too much of the money goes to lawyers and expert witnesses, and lawyers and Democrats don’t want to change that, but as they don’t hold power–so what.4) Doctors, whose Republican allies now do hold power, are only interested in reducing caps on damages, which may reduce their rates a bit but does nothing to help severely injured victims of malpractice and more importantly nothing much to reduce medical costs for the rest of us. (I live in California where we have the MICRA caps and my insurance premiums ain’t going down — sufficient proof to me that the Republican talking points about this are bunk).5) Defensive medicine makes the system and the doctors more money and until they stop getting paid for it, the whole "8-10% savings" concept is a myth6) Special courts, non-binding arbitration, apologies, openness, and a near-miss reporting system are all good ideas and are the eventual solution, but the AMA won’t back them, and their Republican allies won’t either. Why not? For them tort reform has nothing to do with patients, and not much to do with doctors, but much, much more to do with stopping what are mostly legitimate lawsuits against malfeasant corporations — and it’s much better if that all gets mixed up with an evil lawyer suing Marcus Welby MD in their PR campaign.

So unless there is some real concession from organized medicine, we’ll keep what we’ve got and it doesn’t work.  The "good" news is that it’s only a minor issue compared to the complete morass of the rest of the health care system.

(Hat-tip to Brian Klepper for the article)

HOSPITALS: Sutter and Kaiser getting pissy, and fiddling while Rome burns

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Just to follow up on the recent "SEIU hates Sutter but loves Kaiser" piece, this morning I was up at CPMC as a patient, having a doctor looking at my bum knee in the medical office building next door. (And no, I didn’t cross a picket line as the doctor I was seeing was in a medical group that’s not owned by Sutter, at least I think it’s not and it wasn’t being picketed). The pickets were out in force with a SEIU RV parked outside.

Meanwhile, on the issue of giving free care to the uninsured (or not, as the case seems to be) Sutter is now pointing out that it thinks it gives lots of charity care because it "writes off" some $40m a year in discounts that it gives Medicaid and Medicare off its charges. After you pick yourself up from rolling on the floor laughing about that one, there is the slightly more serious issue that they raise which is that everyone else does it (or actually, doesn’t do it). "Everyone else", in this case, of course means Kaiser.

This is an old and perhaps even valid meme, in that Len Schaeffer brought it up years ago when he noted that Kaiser gives very little charity care at its hospitals, which he too converted into the concept that Blue Cross was paying for the "extra" charity care delivered at non-Kaiser hospitals, because of some mystic cross-subsidy from the care that Kaiser wasn’t giving.

So what’s the solution?  Well of course it’s to form a committee, provided that Blue Shield’s Foundation comes up with $75,000 to pay the committee. Yup that’ll solve the uninsurance problem overnight.

However, if I was in Sutter’s position, I might just be trying to get my head a little lower out of the firing range and not just using the "Officer, everyone else was speeding too" excuse.

THCB: Email problems

Some a-hole spammer is spoofing ATmatthewholtDOTnet as their outbound address, luckily so far without the correct first name. The result is that I’m getting hundreds of bounce-backs with "undeliverable" email (you know, the MAILER DAEMON ones), as all emails to matthewholtDOTnet by default go into my main account. Not that it’s their fault in the first place but my email and web-hosting service has been unable to figure out how to block them all and just let the correct email go through (i.e. the ones sent to my correct email address).

Worse, this morning some bright spark at my hosting company switched off my incoming email all together, including the proper address.  It’s back on now, but if you sent me an email between 1 am and 9.30 am PST, please send it again.

And any advice about dealing with this would be appreciated!

TECH/BLOGS: HISTalk nails it again

Mr HISTalk and I have a mutual love affair with each others blogs, and his news sections are always gems. Today he has a story that I’ve missed about a payroll system in Ireland (no jokes from you Brits), and a great remark about RHIOs — both total classics. Go over there and read them.

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