Annals for Educators - 19 June 2018
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2018)

Web Exclusives19 June 2018Annals for Educators - 19 June 2018FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201806190 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsPatterns of Potential Opioid Misuse and Subsequent Adverse Outcomes in Medicare, 2008 to 2012Providers are increasingly being expected to examine their patients' opioid treatment histories before writing new opioid prescriptions. This study uses data from 2008 to 2012 from a 5% sample of Medicare beneficiaries with an opioid prescription and no cancer diagnosis to explore the relationship between a range of patterns of potential opioid misuse and adverse outcomes.Use this paper to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners whether they consider the potential for misuse when prescribing opioids to their patients. If so, what variables do they consider?Which variables do your learners predict would be associated with opioid misuse and adverse outcomes? Which adverse outcomes?Review the findings of this study. How might we use them to inform the care we provide? Do your learners think these findings will alter their approach to prescribing opioids?Do your learners look up their patients' records in a prescription drug monitoring program's database before prescribing an opioid? Are they required to do so in your state? Do they know how?The data used in this study are from 2008 to 2012. What are the limitations of this? The editorialists discuss this. The editorialists believe that with the privilege of prescribing opioids comes a responsibility for appropriate stewardship. What are our responsibilities? Projected Cancer Incidence Rates and Burden of Incident Cancer Cases in HIV-Infected Adults in the United States Through 2030Persons living with HIV (PLWH) have a greatly improved life expectancy due to the introduction of potent antiretroviral drug therapies. Projecting future rates and number of incident diagnoses of both AIDS-defining and non–AIDS-defining cancer in PLWH is important to inform the design of programs for prevention, screening, and treatment.Use this paper to:Ask your learners to list the AIDS-defining cancers.Why are patients with HIV at increased risk for both AIDS-defining and some non–AIDS-defining cancers? Why has HIV treatment reduced the risk for some cancers? The authors provide answers in their discussion.Do cancer screening recommendations for PLWH differ from those for persons without HIV infection?Look at Figure 2. What is happening to the age distribution of PLWH? How will this affect the comorbidities that will require attention and care?Health Care and SocietyWomen's Health Policy in the United States: An American College of Physicians Position PaperIn this position paper, the American College of Physicians (ACP) provides policy recommendations to improve the health of women in the United States through a health care system that supports their needs throughout the lifespan. The recommendations cover reproductive health care, nondiscriminatory health care coverage, paid family leave, intimate partner violence, and improved representation of women in clinical research.Use this paper to:Ask your learners what unique challenges women face in the receipt of health care.How do your learners think these issues would best be addressed?Do your learners agree with the ACP's recommendations? Which ones call for direct action by each of us as physicians in the care we provide? Do your learners do what the ACP calls for? What do they need to learn or change in order to do so?The editorialists recommend that “all health care providers who do not have moral objections to providing abortions should consider offering medical abortions as part of their comprehensive practice”. Do your learners agree? What information and/or medical services does your practice provide to patients? Video LearningAnnals Consult Guys - Talking to Our Patients About Firearm InjuryDrs. Merli and Weitz (the Consult Guys) and their expert guest address the questions of a viewer who wants to help reduce his patients' risks for firearm-related harms but is not sure how to talk about firearms or whether it is legal.Use this feature to:Watch the short video with your learners.Ask your learners whether they inquire about firearms when seeing at-risk patients. Discuss with your learners whether they will commit to doing so here. Look at the list of more than 1300 physicians who have done so under the Comments tab. Which patients should be asked about firearms in their homes?What advice should your learners provide? Use the resources available here to learn how to quickly help at-risk patients. Sign in and answer the brief multiple-choice questions to earn CME/MOC credit for yourself.Humanism and ProfessionalismOn Being a Doctor: The Persian PoetDr. Fitzgerald's patient teaches us just how much can be lost in translation.Use this essay to:Listen with your learners to an audio recording of the essay, read by the Associate Editor for On Being a Doctor, Dr. Michael LaCombe. Ask your learners if the progress notes they read—whether electronic or paper—communicate something about who the patient is as a person. Could they? Would it be beneficial to our patients? To us?Would it require much of our time or effort to communicate more about who our patients are in our notes?On Being a Doctor: To a PatientDr. Kaplan asks whether less than everything is failure.Use this essay to:Listen with your learners to an audio recording of the essay, read by Dr. Virginia Hood. Dr. Kaplan says she doesn't know what being a doctor is anymore. Do your learners know?Why would one pray, “In the sufferer let me see only the human being”? Do we forget to do this?MKSAP 17 QuestionA 52-year-old man is evaluated during a follow-up visit for chronic back pain due to spinal injuries sustained in a motor vehicle accident 1 year ago. He underwent spinal stabilization surgery at the time of the accident and has experienced significant pain since recovery. His pain has not responded to appropriate trials of nonopioid pain medications, glucocorticoid injections, and physical therapy. Repeat orthopedic and neurosurgical evaluations indicate that no additional surgical interventions are indicated. He attended an intensive, multimodal pain rehabilitation program and continues to practice mindfulness-based stress reduction techniques. He exercises daily in the form of swimming. Although these interventions have helped to some degree, he remains functionally impaired due to his pain. He fears he will lose his job as a computer programmer due to his inability to sit in a chair all day. The patient has been reliable and engaged.On physical examination, vital signs are normal. The general physical examination is unremarkable except for postsurgical changes in the back. The neurologic examination is normal.The patient scores in the low-risk category for opioid therapy on DIRE (Diagnosis, Intractability, Risk, and Efficacy) risk assessment. Baseline screening urine drug testing is negative. The patient and physician both sign an opioid treatment agreement, and the patient is started on long-term opioid therapy.Which of the following is the most appropriate method for monitoring the patient's opioid therapy?A. Documentation of functional assessment twice annuallyB. Office visits monthly for 3 months, followed by as-needed visitsC. Regular 3-month office visits with urine drug testing at every office visitD. Use of a prescription drug monitoring program at every visitCorrect AnswerD. Use of a prescription drug monitoring program at every visitEducational ObjectiveMonitor a patient with chronic noncancer pain on opioid therapy.CritiqueThis patient's long-term opioid therapy should be monitored with surveillance of a prescription monitoring program, if available. Prescription monitoring programs are state-run systems that gather information on controlled substance prescriptions from pharmacies and prescribers, allowing prescribers to view a patient's controlled substance history and to monitor controlled substance use. This information is helpful in documenting adherence and for early detection of possible abuse.Although there is little to no evidence supporting the use of long-term opioid therapy for chronic noncancer pain, there are substantial documented risks, even in patients who are compliant and whose medication is prescribed within recommended guidelines. As such, the decision to treat patients with long-term opioid therapy should be made with great care. Although the evidence that shows improved outcomes with various risk mitigation strategies is weak, most guidelines strongly recommend employing a risk assessment tool (such as the DIRE [Diagnosis, Intractability, Risk, and Efficacy] score), baseline urine drug screening, and written treatment agreements. Guidelines also agree that adherence monitoring in the form of regular surveillance of prescription monitoring programs should be performed to reduce prescription drug abuse. With continuous adherence monitoring, opioid therapy can be maintained in appropriate populations with improvement in physical functional status and minimal adverse effects.Documentation of opioid side effects (cognitive impairment, sedation, constipation, falls), absence of aberrant opioid behavior (lost prescriptions, early refill requests, multiple concurrent opioid providers or “doctor shopping,” consistently missed appointments, or erratic follow-up), and the patient's enduring functional improvement is recommended at every visit in order to justify the ongoing benefit of continued opioid therapy.Experts recommend frequent and regularly scheduled office visits indefinitely as long as the patient remains on opioid therapy. Follow-up functional assessment twice yearly in a patient being started on long-term opioid therapy would not be adequate to monitor medication adherence, appropriateness of dosing, or potential side effects. Converting to as-needed follow-up after 3 months also would not be appropriate.Guidelines recommend baseline and periodic urine drug testing to assess adherence, but there is no recommendation that it be performed at every visit.Key PointIn patients on long-term opioid therapy for chronic noncancer pain, adherence monitoring in the form of regular surveillance of prescription monitoring programs should be performed to reduce prescription drug abuse.BibliographyManchikanti L, Abdi S, Atluri S, et al; American Society of Interventional Pain Physicians. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2—guidance. Pain Physician. 2012 Jul;15(3 Suppl):S67-116.Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Associate Dean of Graduate Medical Education and Affiliations, Thomas Jefferson University. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 19 June 2018Volume 168, Issue 12Page: ED12KeywordsCancer treatmentDrug screeningFirearm injuriesHIVHealth careOpioidsRisk assessmentsTherapeutic drug monitoringTreatment guidelinesUrine ePublished: 19 June 2018 Issue Published: 19 June 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...