Annals for Educators - 15 November 2016
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2016)

Web Exclusives15 November 2016Annals for Educators - 15 November 2016FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201611150 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsHas the Increase in Disability Insurance Participation Contributed to Increased Opioid-Related Mortality?Performance of the Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS) Tool for Substance Use Screening in Primary Care PatientsThe United States is in the midst of an epidemic of opioid-related morbidity and mortality. Concerns for the under treatment of pain and increased prescribing have been cited among the “supply side” factors responsible for this epidemic. The authors of the first paper hypothesize that changes in welfare policy and federal disability programs may have contributed to the widespread use (“demand side”) of opioid analgesics. Regardless of whether the problem's source is increased supply, demand, or both, primary care providers play an essential role in identifying and treating addiction to opioids and other substances. The second paper reports the development of a single tool to screen for many types of substance use disorders in primary care clinics.Use these papers to:Start a teaching session with a multiple-choice question. We've provided one below.Ask your learners to list possible reasons for increases in opioid abuse, addiction, and overdose. What factors have contributed to the increase in the provision of opioids to patients? The demand for them? Use the first paper to help frame your discussion.What roles should physicians play in addressing nonmedical societal problems (e.g., deficiencies in social support systems) that impact medical care and disease?Do your learners routinely screen each of their patients for substance abuse disorders? How do they do it?What criteria did the authors use to evaluate a novel screening tool's performance? Can your learners explain sensitivity, specificity, and the tradeoff between them in developing a diagnostic test?What criteria must be met for a screening tool to be worthwhile?Use freely available and comprehensive teaching resources to plan educational activities about the science of screening. These resources include teaching slides, handouts, worksheets with sample cases to work through with residents, and more. They are part of a host of freely available resources for medical educators available from the ACP's High Value Care Curriculum .A Call for a Patient-Centered Response to Legalized Assisted DyingThe Annals of Medical Assistance in DyingA growing number of U.S. states has legalized physician-assisted suicide (PAS), but many physician organizations have refused to provide clinical guidance on the care of patients actively seeking assistance in dying. The authors of the first paper argue that this refusal does a disservice to the organizations' members and propose that active engagement can help clinicians responsibly meet the needs of patients while still respecting the diverse opinions and choices about PAS. In the second paper, the authors discuss the recent landmark ruling by the Supreme Court of Canada that the criminal code ban on medical assistance in dying (MAID) for persons with grievous medical conditions and intolerable suffering was unconstitutional. The commentary discusses the road to legalizing MAID and reflects on the controversy and aftermath of the ruling.Use these papers to:Ask your learners whether they have ever been asked by a patient if they would provide them with assistance to end his or her life. How did they respond? How would they respond to such an inquiry?Is PAS legal where you practice? What are the requirements for PAS in jurisdictions where it is legal?Ask your learners to list the potential benefits, and potential dangers of, permitting PAS.Do your learners believe that professional medical societies have an obligation to “actively engage” in providing guidance to care for patients who actively seek assistance in dying?Teach at the bedside! Ask patients with terminal illnesses if they would be amenable to discussing their thoughts about dying with your team. What questions will your team want to ask?Invite a palliative care specialist to discuss with your team how she/he would approach a request from a patient for assistance in dying. What would she/he want to know? What would she/he offer?On Being a DoctorMeaningful UseOn GivingMeaningful Use: “I have mixed feelings when I see that Bob is on my schedule today. It is a 3-hour drive, and today it is windy and raining on the Pass. The roads will be dangerous, and he is 82 years old.”On Giving: “Before we start cutting, the circulating nurse asks us to take a moment of silence to thank you for the gift you are about to give: Your organs will save the lives of at least four people.”Use these essays to:Find a quiet spot to listen to audio recordings of these essays with your team, read by Dr. Michael LaCombe.Sit quietly afterward to allow your team members to reflect and react. Don't ask questions at first, or perhaps at all. These essays describe joyful, painful, and uplifting experiences of our profession.History of Medicine“I Haven't Time to Write”: Martha May Eliot and American Medical Education ReformLetters from a young physician to her parents in the decade after publication of the Flexner Report in 1910 provide insight into the rapid changes in standards for medical training, testing, and licensing at the time. They also showcase the formative experiences of a rare woman physician who became a leader in 20th-century medicine and public health. Today's physicians and medical educators, as well as those completing graduate training, will find much to draw on from the experience revealed by this rich archive.MKSAP 17 QuestionOn 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;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 15 November 2016Volume 165, Issue 10Page: ED10KeywordsDrug screeningGraduate medical educationOpioidsPatientsPeriodic acid SchiffPrescription drug abuseRisk assessmentsTherapeutic drug monitoringTreatment guidelinesUrine ePublished: 15 November 2016 Issue Published: 15 November 2016 Copyright & PermissionsCopyright © 2016 by American College of Physicians. All Rights Reserved.Loading ...