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Guidelines for Methadone Safety

Guidelines for Methadone Safety

Methadone is used for the treatment of opioid addiction and for chronic pain, but safety of the drug has recently been called into question. “Methadone is increasingly being prescribed for pain even though it was previously used almost exclusively for the treatment of addiction,” explains Roger Chou, MD. “Recent data indicate that accidental overdoses associated with the use of prescription methadone have increased substantially. Methadone accounts for around 5% of opioid prescribing but about 30% of accidental overdose deaths.” Comprehensive Recommendations on Methadone Safety Recently, the American Pain Society (APS) released its first methadone safety guideline in partnership with the College on Problems of Drug Depen-dency and in collaboration with the Heart Rhythm Society. “Guidelines on methadone safety have been published by other groups, but these have focused on cardiac arrhythmias, which account for a small minority of deaths relating to use of the drug,” says Dr. Chou, who was lead author of the APS methadone safety guideline. “In addition, other guidelines have not used a formal process for grading evidence and recommendations.” The APS expert panel reviewed more than 3,700 scientific abstracts on various topics relating to methadone safety to prepare its guideline, which was published in the Journal of Pain. “All clinicians who prescribe methadone should use the guideline because it gives general recommendations as well as more specific advice,” Dr. Chou says (Table). “This includes information about starting doses and how to increase them. It also provides guidance on when to perform baseline ECGs and repeat them.” Recommendations were rated as strong or weak; a strong recommendation was indicated if potential benefits outweighed harms or burdens...
Malnutrition Among the Elderly in EDs

Malnutrition Among the Elderly in EDs

According to published research, malnutrition is a common but underdiagnosed condition among older adults and has been linked to physical and cognitive decline, a lower quality of life, and a higher risk of death. Studies suggest that the elderly are particularly vulnerable because of loss of appetite, comorbidities, medications, and environmental factors. These factors can influence the availability and desirability of food and the ability to eat and absorb nutrients. Although there are accurate instruments to screen for malnutrition, implementation of these screening protocols is often inconsistent in different healthcare settings, including EDs. Taking a Deeper Look at Malnutrition In a cross-sectional study published in Annals of Emergency Medicine, Timothy F. Platts-Mills, MD, MSc, and colleagues assessed the feasibility of screening for malnutrition and its prevalence among cognitively intact older adults in the ED. The investigators found that more than half of older adults who visited the ED were either malnourished or at risk for malnutrition. “We found that 16% of elderly patients in the ED were malnourished, which is higher than malnutrition rates seen in the community,” says Dr. Platts-Mills. “We also found that despite clear signs of malnutrition or risk of malnutrition, more than 75% had never previously been diagnosed with malnutrition.” Importantly, cases of malnourishment did not appear to result from a lack of access to healthcare, critical illness, or dementia. Nearly all patients had a primary care physician, lived in a private residence, and had some type of health insurance, and more than one-third had a college education. The prevalence of malnutrition was not appreciably different between men and women or between those living in...

New Missouri Law: Practicing Without Residency Training

Everyone knows there’s a shortage of primary care physicians, especially in rural areas. The state of Missouri has decided to alleviate this problem with a bill, signed into law by the governor this month, authorizing medical school graduates who have not done any residency training to act as “assistant physicians.” The assistant physicians will come from the pool of 7000 to 8000 graduates, mostly of offshore medical schools, who were unable to match to any residency. After spending 30 days with a “physician collaborator,” assistant physicians would be allowed to practice independently as long as they were within 50 miles of their collaborator. The physician collaborator is also required to review 10% of the assistant physician’s charts. Assistant physicians would be expected to treat simple problems and could prescribe Schedule III [including hydroxycodone or codeine when compounded with an NSAID as well as synthetic tetrahydrocannabinol], IV, and V drugs. Opponents of the bill included the American Medical Association, the Accreditation Council for Graduate Medical Education, and the American Academy of Physician Assistants. According to healthleadersmedia.com, the Missouri State Medical Association supported the bill. Its government relations director and general counsel, Jeffrey Howell, said the new rules would be no different than those for older doctors. “A lot of those guys didn’t have to go through a residency program. They just graduated from medical school and went back to the farming communities they grew up in, hung out their shingles, and treated people.” Perhaps Mr. Howell hasn’t heard that medicine is a bit more complex than it was 50 or 60 years ago. Proponents of the bill felt that rural...
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