True Confessions On Why I Prescribe Things Without'Evidence '

by Drew RosielleWe have a'required reading'list for our fellowship, which includes a bunch of what I think are landmark or otherwise really important studies. One of them is thisvery well done RCT of continuous ketamine infusions for patients with cancer pain, which showed it to be ineffective (and toxic).We also recently have seen another high-quality study published with negative results for ketamine. This was a Scottish, multi-center, randomized, placebo-controlled, intention-to-treat, and double-blinded study oforal ketamine for neuropathic pain in cancer patients. The study involved 214 patients, 75% of whom were through cancer treatments and had chemotherapy-induced peripheral neuropathy (CIPN), and the median opioid dose was 0 mg. They received an oral ketamine (or placebo), starting at 40 mg a day, with a titration protocol, and were followed for 16 days.There were exactlyzero measurable differences in outcomes between the groups (on pain, mood, or adverse effects). Zip.All this got me thinking about a conversation I had with a palliative fellow this year, who, upon reading the continuous infusion study, confronted me with the question -Why do you even still use ketamine, then? The answer to this has a lot to do with the nature of evidence and how that is different for symptom management than it is for other outcomes, as well as the challenging reality of the placebo effect in everything we do.I should note that you can'dismiss'these studies based on generalizability ...
Source: Pallimed: A Hospice and Palliative Medicine Blog - Category: Palliative Care Tags: fatigue ketamine methylphenidate neuropathic pain research research issues rosielle The profession Source Type: blogs

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