Bibliographic record
Abstract
The hospice database survey by Bercovitch et al.1 generates some evidence with which to dispel some of the underlying myths associated with the phenomenon of “opiophobia” in the treatment of the terminally ill. Unfortunately, the apparent preoccupation with this agenda has resulted in the authors inadvertently ignoring the potential for opioid side effects, commonly referred to as opioid toxicity in this patient population. Our comments therefore are offered to redress the balance in relation to the use of high dose morphine and opioid toxicity. The authors report constipation in 41 of 55 patients (74.6%) receiving high dose morphine and mild myoclonus in 1 patient. The absence of any other reported side effects in the total group of 453 patients (all of whom were within an average of approximately 2 weeks from death in a hospice setting) begs the obvious question: what was the level of assessment of these patients in relation to cognitive impairment and other side effects? Furthermore, the authors fail to acknowledge that a retrospective study might fail to capture an accurate recording of such side effects. The authors draw a simple conclusion that survival is not influenced by the average daily morphine dose, which is true in the context of their study findings. However, the extrapolation of these findings to all advanced cancer patients is potentially misleading. Unfortunately, the authors do not comment on the complex clinical reality in which the occurrence of adverse opioid effects often is manifested with even lower doses against a clinical background of multisystem failure (particularly renal impairment) and increased patient vulnerability to side effects.2 Furthermore, use of the average morphine daily dose as an index fails to reflect the dynamic of temporal variation truly, in which a dramatic increase in daily morphine consumption over 2 or 3 days clearly can be associated with adverse effects. The authors failed to mention many reports that have documented opioid-induced neurotoxicity associated with high dose morphine and hydromorphone, particularly in the context of renal failure.3, 4 We applaud the authors in their efforts to allay some of the mythic fears surrounding opioid use. However, instead of allowing the promotion of high dose opioids to dominate our educational agenda, we suggest that our efforts could be more appropriately used to promote the judicious use of opioids (whatever the dose) in the context of a disciplined multidimensional assessment of terminally ill patients. The goal of opioid therapy is to achieve a favorable balance between analgesia and side effects through careful dose titration.5 Furthermore, we need to appreciate that opioid side effects are not uncommon, while reassuring clinicians and patients that these side effects can be managed effectively in the majority of situations with simple measures such as dose reduction, opioid switching, and rehydration.6 Peter Lawlor M.B.*, Gary Frank R.N.*, * Edmonton Regional Palliative Care Program, Grey Nun's Hospital, Edmonton, Alberta, Canada
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.005 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.000 | 0.001 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.001 |
| Insufficient payload (model declined to judge) | 0.002 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".