During the NANS meeting, a physician approached me to discuss the Polyanalgesic Consensus guidelines for intrathecal therapy treatments. His question was, “Who do they serve?” He was concerned about his own treatment regimens, as he seemed to be outside the guidelines in some cases. I stated to him that the guidelines were being re-assessed, and there would be more to come for the 2011/2012 publication. I have been involved in some of the working documents of the new publication, and my advice was sought after regarding compounding pharmacy issues, as well as dosing.
A lot has changed over the years. In the past, clinicians were dosing at higher concentrations and higher daily doses, and these guidelines have been established, in part, to steer people toward more conservative measures to reduce adverse events and optimize patient care. Additionally, they are established to assist and aid individuals who are initially getting into intraspinal infusions. However, there are still situations where more experienced clinicians will treat patients outside those guidelines. The doctor expressed some concern, essentially asking, “Am I exposed?” or “Is there a problem with my treatment of my patients?” And I think all doctors, in all parameters, experience this.
The guidelines, in my opinion, are designed for those with less familiarity; but you have clinicians who have been in the practice for 25-30 years and understand the intrathecal space and the drugs involved for intraspinal infusion. The issue with the guidelines is that they are thinking on behalf of all practitioners. Experienced practitioners have a proven track record, and there are exceptions to the guidelines that they fall outside of.
The doctor posed the question, “How hard and true are these?” I expressed to him that I don’t think they are hard and true, but rather to simply guide people. One shoe doesn’t fit all – nor does one guideline fit all practices. You have to be aware of the guidelines while simultaneously understanding your treatment programs.
The conversation continued with, “How do doctors decide on dosing?” It’s a consensus panel, and these individuals put forth their opinion based on what they are doing to treat patients, but they also understand that what they are stating is there to provide guidance.
During the conversation, we discussed trial dosing. We talked about the polyanalgesic panel meeting that I attended and how, for trial dosing, some panel members recommended a 24-hour hospitalization. However, other panel members said, “I do not always do this.” These members expressed that they are comfortable monitoring for a shorter period of time, then sending the patient home – and they have many years of experience with this. So, do they fall outside the guidelines?
These guidelines are conservative, but people with greater experience, those with some latitude in their practice, feel comfortable operating outside the guidelines. Is there a legal component to this? I do not know. This is a difficult conversation. I am trying to convey that these guidelines are good for everyone – both clinicians and patients – but what your practice is, what your experience has been, and what is best for the patient all must be taken into consideration.
I would like to end by referring to the movie Pirates of the Caribbean: The Black Pearl. In the movie, there is a scene where Keira Knightley’s character was abducted by pirates, and in order to be brought in front of the ship’s captain, Captain Barbosa, she used the pirate’s code-word “parlay.” After negotiating with the captain – who ultimately breaks his bargain with the young woman – she expresses that he is a pirate and must follow the pirate’s code. His response was, “The code is more what you’d call ‘guidelines’ than actual rules.”