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News From The Annals Of Family Medicine: July/August 2012

Opioid Use and Misuse for Chronic Pain: What is the Appropriate Role of Prescription Painkillers?

A cluster of articles in the July/August issue of Annals looks at opioid use for the management of chronic pain, including the escalating levels of misuse, overdose and addiction associated with opioid pain relievers. The role of opioids in the management of chronic pain is timely and consequential – the volume of prescribed opioids has increased 600 percent from 1997 to 2007, and during roughly the same period, the number of unintentional lethal overdoses involving prescription opioids increased more than 350 percent, from approximately 4,000 in 1999 to more than 14,000 in 2007. Together, the articles attempt to clarify the appropriate role of opioids in long-term management of chronic noncancer pain.

Depressed Patients More Likely to Misuse Opioids

In a study of patients at two of the country’s largest health plans, researchers found patients were much more likely to misuse opioids if they were depressed. The survey of 1,334 patients with no history of substance abuse who were on long-term opioid therapy for chronic pain, found that patients with moderate and severe depression were 1.8 and 2.4 times more likely, respectively, to misuse their opioid pain medications for non-pain symptoms than patients who were not depressed. Patients with mild, moderate and severe depression were 1.9, 2.9 and 3.1 times more likely, respectively, than patients who were not depressed to misuse their opioid medications by self-increasing their dose. The study also identified other risk factors for misuse, including male sex, lower average daily dose, less education, younger age, higher pain severity and white race. The researchers conclude clinicians should be alert to the risk of patients with depressive symptoms using opioids to relieve those symptoms, and they call for future research to examine whether treatment of depression decreases the risk of opioid misuse.

Depression and Prescription Opioid Misuse Among Chronic Opioid Therapy Recipients With No History of Substance Abuse
By Alicia Grattan, MD, et al
University of Washington School of Medicine, Seattle

Editorial: Primary Care Physicians Should Take the Lead in Setting Opioid Prescribing Standards

An editorial by Michael Von Korff, ScD, coauthor of the aforementioned study on depression and opioid misuse, reports on a May 2012 meeting convened by the Food and Drug Administration’s Center for Drug Evaluation and Research to discuss the use of analgesics for the management of chronic noncancer pain. A participant and presenter at the meeting, Von Korff acknowledges the pendulum is swinging in the direction of more selective and conservative opioid prescribing. Because primary care is where long-term opioid prescribing most often occurs and is a gateway to nonpharmacologic approaches to chronic pain care, he asserts it is critical that primary care physicians take the leading role in defining how, when and for whom opioids should be used in long-term management of chronic pain.

Opioids for Chronic Noncancer Pain: As the Pendulum Swings, Who Should Set Prescribing Standards for Primary Care?
By Michael Von Korff, ScD
Group Health Research Institute, Seattle, Wash.

Editorial: Opioids Not Appropriate Therapy for Most Primary Care Patients

An editorial from a family physician at the University of Washington asserts opioids for chronic noncancer pain are not appropriate therapy for most patients in primary care settings because of their power to do harm and the availability of safer, alternative treatments for chronic pain, including physical therapy, cognitive behavioral therapy, low-dose tricyclic medications and treatment of co-occurring psychiatric illnesses. He suggests that when other interventions fail or are inadequate, cautious evidence-based consideration of low-dose opioids as an adjunct to other therapies may be considered. Entering into chronic opioid therapy, he concludes, requires a long-term commitment by clinician and patient alike to use this powerful, precious and dangerous medication with care and diligence.

Opioids for Chronic Pain: First Do No Harm
By Roger A. Rosenblatt, MD, MPH, and Mary Catlin, BSN, MPH
University of Washington, Seattle

Essay: Objective Evidence of Severe Disease Needed Before Prescribing Opioids

In an essay, a researcher at the University of California, San Francisco-Fresno proposes a new standard for the use of long-term opioids for chronic pain: the presence or absence of objective evidence of severe disease. The escalating number of deaths and overdoses associated with opioid pain relievers, he asserts, argues for more responsible prescribing. He concludes until we have measures of pain itself, clinicians should insist upon objective evidence of severe disease, including information from diagnostic studies or physical examination findings, before prescribing opioids for chronic pain.

Objective Evidence of Severe Disease: Opioid Use in Chronic Pain
By John A. Zweifler, MD, MPH
University of California, San Francisco-Fresno

Meditation and Exercise Training Associated with Reduced Acute Respiratory Illness Burden

Training in mindfulness meditation and sustained moderate-intensity exercise are associated with reduced illness severity and fewer days of missed work from acute respiratory infections. A study of 149 patients randomized to one of three study groups: 8-week training in mindfulness meditation, matched 8-week training in moderate intensity sustained exercise or observational control found substantial reductions in ARI illness among those randomized to exercise training and even greater benefits among those receiving mindfulness meditation training. Incidence, duration and global severity of ARI illness were 29 percent, 43 percent and 31 percent lower, respectively, in the exercise group, and 33 percent, 43 percent and 60 percent lower, respectively, in the mindfulness group, compared with the control group. Implications for the workplace, the authors note, may be especially important. Compared with the control group, all-cause absenteeism was 31 percent lower in both intervention groups. Looking at ARI-related absenteeism in particular, there were 48 percent fewer days missed in the exercise group, and 76 percent fewer in the meditation group. The authors assert these findings are especially notable given that no ARI prevention strategies, apart from hand washing, have ever been proven.

Meditation or Exercise for Preventing Acute Respiratory Infection: A Randomized Controlled Trial
By Bruce Barrett, MD, PhD, et al
University of Wisconsin, Madison

Patient-centered Personal Health Records Increase Preventive Service Delivery

An interactive preventive health record that provides patients access to their medical record, explains information in lay language, and provides individualized recommendations, resources and reminders is associated with a greater rate of being up to date on recommended preventive services. The trial, involving 4,500 patients in eight primary care practices, randomized patients to either receive a mailed invitation to use an IPHR or to usual care. Despite fairly low rates of use among patients invited to use the IPHR (10 percent at 4 months and 17 percent at 16 months), the proportion of patients up to date with all preventive services increased between baseline and 16 months by 3.8 percent among intervention patients and by 1.5 percent among control patients. Greater increases were observed among patients who used the IPHR. At 16 months, 25.1 percent of users were up to date with all services, double the rate among nonusers. Moreover, at four months, delivery of colorectal, breast and cervical cancer screening increased by 19 percent, 15 percent and 13 percent, respectively, among users. The authors conclude information systems that feature patient-centered functionality, such as the IPHR, have potential to increase preventive service delivery.

Interactive Preventive Health Record to Enhance the Delivery of Recommended Care: A Randomized Trial
By Alex H. Krist, MD, MPH, et al
Virginia Commonwealth University, Richmond

Postpartum Depression Screening Program is First to Demonstrate Improved Patient Outcomes

Primary care physicians given postpartum screening tools and education are more likely to diagnose and treat postpartum depression, and their patients have lower depressive symptoms at six and 12 months of follow-up. A practice-based study involving 28 practices randomized to either receive education and tools for postpartum depression screening or usual care found rates of diagnosis, treatment initiation and referral for psychiatric evaluation were all higher in the intervention group, indicating the program effectively raised awareness. Specifically, of the 1,897 patients included in the analysis, 654 had elevated screening scores indicative of depression, with comparable rates in the intervention and usual-care groups. Among the 654 women with elevated postpartum depression screening scores, those in the intervention practices were more likely to receive a diagnosis (P = .0006) and therapy for postpartum depression (P = .002). They also had lower depressive symptom levels at 6 months (P = .07) and 12 months (P = .001) postpartum. The study is the first large effectiveness study of screening and follow-up care for postpartum depression that has shown any improvement in maternal outcomes at 12 months. These findings, the authors assert, warrant dissemination efforts and continued evaluation of similar practical primary care-based programs that have minimal requirements for referrals to outside mental health services.

TRIPPD: A Practice-Based Network Effectiveness Study of Postpartum Depression Screening and Management
By Barbara P. Yawn, MD, MSc, et al
Olmsted Medical Center, Rochester, Minn.

Chemical Intolerance Prevalent in Primary Care

Evaluating the prevalence, comorbidity and impact of chemical intolerance on functional status and health care use in a sample of 400 primary care patients, researchers found chemical tolerance is prevalent, commonly comorbid with a range of medical and psychiatric conditions, and associated with poorer functional status with trends toward increased medical service use. Overall, 20 percent of the sample met criteria for chemical intolerance. The chemically intolerant group reported significantly higher rates of comorbid allergies and more often met screening criteria for possible major depressive disorder, panic disorder, generalized anxiety disorder, and alcohol abuse disorder, as well as somatization disorder. Controlling for demographics, patients with chemical intolerance were significantly more likely to have poorer functional status, with trends toward increased medical service use when compared with non-chemically intolerant patients. The authors conclude that although chemical intolerance is common in primary care, it often goes unrecognized and requires active investigation by the primary care physician. The presence of chemical intolerance among relatives, a history of medication intolerances/adverse drug reaction, complex multisystem conditions or a prior diagnosis of somatization disorder, they assert, should raise the index of suspicion of chemical intolerance and prompt screening using the Quick Environmental Exposure and Sensitivity Inventory tool.

Chemical Intolerance in Primary Care Settings: Prevalence, Comorbidity, and Outcomes
By David A. Katerndahl, MD, et al
University of Texas Health Science Center

Practice Intervention Shows Promise in Reducing Depression and Self-Harm in Older Patients

An educational intervention targeting general practitioners in Australia reduced the prevalence of depression and self-harm behavior among their older patients. The trial including 373 physicians and 21,762 patients aged 60 years and older testing an intervention that consisted of a practice audit with personalized feedback and printed educational material about screening, diagnosis and management of depression and suicide behavior in later life found those in the intervention group experienced a 10 percent reduction in the odds of depression and self-harm behavior over 2 years of follow up. The authors note the beneficial effect was primarily due to the relative reduction of self-harm behavior among patients who did not report symptoms at baseline. It did not reduce the prevalence of depression or self-harm behavior in patients who had symptoms at baseline. The authors call for the replication of these results with future research.

A Randomized Trial to Reduce the Prevalence of Depression and Self-Harm Behavior in Older Primary Care Patients
By Osvaldo P. Almeida, MD, PhD, FRANZCP, et al
University of Western Australia

Strong Physician-Patient Relationship Critical to the Diagnosis and Management of Depression in Palliative Care Patients

Family physicians in The Netherlands perceive the diagnosis and management of depression in palliative care patients as challenging, but generally feel competent to address the issue. Focus group discussions with 22 family physicians with varying experience in palliative care revealed physicians do not strictly apply criteria of depressive disorder when evaluating patients, but rather rely on their clinical judgment, and strongly considered patients’ context and background factors. The participants acknowledged difficulty in discerning depression from normal sadness and identified a lack of knowledge, time and additional support sources as challenges. The authors recommend improving family physician education in this area by building on the elements the study participants identified as key in diagnosing depression and distinguishing it from normal sadness: strengthening continuity of care and relationship- building with patients and their families through the palliative trajectory and explicitly addressing sadness as part of the normal process of coming to terms with the prospect of end of life. They conclude that guidelines, criteria and other tools will provide valuable support only when applied in the context of such a patient-centered approach.

How Family Physicians Address Diagnosis and Management of Depression in Palliative Care Patients
By Franca Warmenhoven
Radboud Univeristy Nijmegen Medical Centre, The Netherlands


American Academy of Family Physicians