Is all substance misuse really abuse?

- Jennifer Middleton, MD, MPH

I appreciated AFP's article last week about "A Primary Care Approach to Substance Misuse" and its practical review of screening and treatment options for patients struggling with this issue.  The article appropriately included discussion about prescription drug abuse.

Prescription painkiller deaths have been on the rise in the United States. Drug overdose (60% of which are pharmaceutical drug overdoses) is now the number 1 cause of injury-related death in the U.S.  The Centers for Disease Control and Prevention (CDC) states that every 3 minutes a middle-aged woman presents to the Emergency Department for prescription opioid "misuse or abuse."   Every single one of those prescription medications originated from a doctor's prescription pad (paper or virtual).

I continue to ruminate, though, about the word "misuse" in the AFP article. Usually, when I think about problems with inappropriate substance use, I think of the word "abuse," not "misuse."  Clearly these words share a similar meaning, but, for me at least, the connotation of "misuse" is a bit gentler than "abuse."  "Misuse" sounds more like a mistake than the intentional impropriety of "abuse."

I have previously thought of the substance "abusers" as those who are inappropriately requesting prescription painkillers.  My office, as I'm sure many others do, has a controlled substance policy that supports frequent urine drug screens, and we discontinue prescribing for patients with discordant results.

But what about the "misusers?"  What about the patients who have some legitimate pain source but don't always use their prescription opioids as prescribed?  Or the patients who never tell me that they're borrowing someone else's prescription medications?  After all, the CDC found that 55% of the people misusing or abusing prescription pain medications obtain them for free from a friend or relative. Only 11% buy their pills from friends or family, and only 4% purchase their meds from a dealer.  Learning that most of my patients using these medications inappropriately are getting them at no cost from friends and family changes how I think about who those patients might be.

What I appreciate about the term "misuse" is its reminder that, as a prescriber of these medications, I need to be on the alert for more than just the "abusers."  I should probably be asking all of my patients the single question screen for substance disorders outlined in last week's AFP article (“How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”) on a regular basis.  I need to broaden who I think of as at risk from problems related to substance misuse and abuse.

How often do thoughts of prescription medication misuse and abuse occur during your practice day? Does the term "misuse" help you to think more widely about prescription medication problems, or is it an unnecessary term?

Estimating osteoporosis risk in older men

- Kenny Lin, MD, MPH

According to a recent review in American Family Physician, 1 to 2 million American men have osteoporosis, 13 percent of white U.S. men older than age 50 will experience an osteoporotic fracture in their lifetimes, and men are twice as likely as women to die in the hospital following a hip fracture. However, unlike screening guidelines in women, there is no consensus on when to screen for osteoporosis in men. The American College of Physicians recommends an individualized osteoporosis risk assessment for men age 65 or older, and dual energy x-ray absorptiometry (DXA) scans to measure bone density in men at increased risk. On the other hand, the U.S. Preventive Services Task Force found insufficient evidence to assess the balance of benefits and harms of screening for osteoporosis in men, although it observed that "men most likely to benefit from screening would have 10-year risks of osteoporotic fracture equal to or greater than those of 65-year-old white women with no additional risk factors."

Since neither organization recommends routinely screening older men for osteoporosis, family physicians require clinical tools to determine which men are at higher risk and therefore candidates for bone density measurement. One such tool, the Male Osteoporosis Risk Estimation Score (MORES), uses age, weight, and the presence or absence of chronic obstructive pulmonary disease to calculate a risk score and recommends further evaluation in men at a certain point threshold. However, since MORES was derived and validated in an historic national survey sample, until recently its utility in a present-day primary care setting was unknown.

In the July/August issue of the Journal of the American Board of Family Medicine, Drs. Alvah Cass and Angela Shepherd evaluated the performance of MORES in a cross-sectional sample of 346 men age 60 years or older presenting to family medicine, internal medicine, or geriatric outpatient practices at the University of Texas, Galveston. MORES correctly identified 12 of the 15 men in the study with osteoporosis of the hip, yielding a sensitivity of 80% and a specificity of 70%. Based on these results, 259 men would need to be screened with MORES to prevent one major osteoporotic fracture over 10 years, compared to 636 with a universal DXA strategy.

Will the results of this study make you more likely to use MORES to assess the risk of osteoporosis in older men in your practice? Or would you prefer to screen all men older than a certain age with DXA to avoid missing any patients with osteoporosis?

Steroids for pharyngitis?

- Jennifer Middleton, MD, MPH

This month, The Journal of Family Practice (JFP) published a review of a recent Cochrane meta-analysis regarding the use of steroids for patients with "exudative or severe sore throat." The Cochrane researchers found that even one dose of a corticosteroid (either dexamethasone PO, dexamethasone IM, or prednisone PO) increased the number of patients who reported resolution of pain in twenty-four hours (number needed to treat [NNT] = 4).  The Cochrane researchers included studies of patients with both viral and bacterial pharyngitis.

Despite evidence-based tools such as the modified Centor score, which can determine the pre-test probability of streptococcal pharyngitis and guide treatment (described nicely in this AFP article), physicians still overprescribe antibiotics for upper respiratory infections, including pharyngitis.  This AFP by Topic on Upper Respiratory Infections provides a useful review of current treatment guidelines for these prevalent conditions; several articles in that grouping advise caution regarding overuse of antibiotics.  It may be that patients with painful pharyngitis don't necessarily want antibiotics, though, but just something to control their pain.  This new Cochrane meta-analysis, with that excellent NNT regarding improvement of pain after only one day of treatment with a steroid, suggests that steroids may be another useful tool in our pharyngitis treatment kit.

The JFP reviewers are quick to point out that these corticosteroids weren't used alone; the studies in the meta-analysis used them in addition to either antibiotics or analgesics.  Hopefully we will see some randomized controlled trials (RCTs) in the next few years that determine whether steroids are useful by themselves for patients not needing an antibiotic. In the meantime, since the RCTs in the Cochrane meta-analysis used varying methods, we don't have a clear guideline about which patients might benefit or what dose and administration route of corticosteroid to use.

Do you already prescribe steroids for patients with severe pharyngitis (viral or bacterial)?  If not, would this Cochrane meta-analysis encourage you to try it?

Medicating mild hypertension: is more evidence needed?

- Kenny Lin, MD, MPH

In the July 1st issue of American Family Physician, Dr. Janelle Guirguis-Blake commented on a Cochrane Review that found no benefits from pharmacotherapy for mild hypertension (systolic blood pressure of 140 to 159 mm Hg and/or diastolic blood pressure of 90 to 99 mm Hg) on cardiovascular outcomes or mortality. However, the randomized trials' relatively small number of participants (fewer than 9000) and short follow-up periods (five years or less) left open the possibility that a significant benefit could still exist. Therefore, Dr. Guirguis-Blake concluded: "Larger double-blinded RCTs in this population of patients with stage 1 hypertension are needed to clarify the potential long-term benefits of pharmacologic therapy."

When existing research does not adequately answer an important clinical question - in this case, are medications superior to lifestyle modifications or no treatment for mild hypertension? - researchers invariably recommend collecting more evidence. But is performing a large randomized trial of mild hypertension management feasible, given that the standard of care set in 2003 by the Seventh Report of the Joint National Committee (JNC-7) (and reflected in this AFP Point-of-Care Guide) is to routinely identify and treat blood pressures in this range? The U.S. Preventive Services Task Force apparently thinks so; after previously declaring that the benefits of screening were "well established," the USPSTF has released an extensive draft research plan to reevaluate benefits, harms, best methods, and recommended intervals for screening for high blood pressure in adults.

With the next USPSTF statement at least a few years down the road, current evidence-based guidance on hypertension management is limited. The U.S. National Heart, Lung, and Blood Institute, which convened the previous JNC panels, recently announced in a cardiology journal its intention to stop producing guidelines. Instead, it says it will partner with outside medical groups to release its long-delayed JNC-8 hypertension guideline. Since guidelines sponsored by subspecialty societies are less likely to adhere to Institute of Medicine standards for producing unbiased guidelines, family physicians and other primary care clinicians should advocate for their organizations to participate in this process.

Another strike against NSAIDs?

- Jennifer L. Middleton MD, MPH

One of the issues family docs deal with on a daily basis is pain control.   I usually think about pain medication as falling into one of three categories: acetaminophen, NSAIDs, and opioids.  I frequently recommend acetaminophen, but patients often tell me "it's not strong enough for me" (maybe an unintentional consequence of those commercials touting Tylenol's gentleness?).  And, of course, I defer opioid regimens if possible given the risks of addiction and diversion.

Perhaps you've already heard about The Lancet's NSAID meta-analysis article from about a month ago.   The authors performed a robust literature search and included hundreds of trials with several outcome measures, one of which was the rate of "major coronary events" (a composite of non-fatal myocardial infarction and coronary death).  The authors found that long-term use of all non-steroidal anti-inflammatory drugs (NSAIDs), selective COX-2 or non-selective, doubled the risk of heart failure.  I'd like to focus on two non-selective NSAIDs, ibuprofen and naproxen, for the rest of this post.

I found this meta-analysis unsettling, as I like having an option in between acetaminophen and opioids to offer my patients.  True, the authors only examined patients taking high dose NSAIDs (2400 mg ibuprofen/day and 1000 mg naproxen/day) for at least 4 weeks.  Is it safe, then, to extrapolate that lower doses and/or shorter periods of time are safer?

AFP had a nice article about osteoarthritis treatment last year that discussed the pros and cons of all of these medication classes. Rereading that article this past week reminded me that every 12th patient taking an NSAID, even short-term, will experience a gastrointestinal (GI) bleed, kidney problem, or elevated blood pressure (number needed to harm [NNH] = 12 for that composite outcome).  As NNHs go, that's a pretty impressive number.

For now, at least, NSAIDs probably should be off the table for patients at an increased risk of heart disease.  Myself, I will probably continue recommending NSAIDs in patients without a history of GI bleed, with normal kidney function, and without a history of heart disease, but I will recommend more modest doses and shorter periods of use.  I will probably spend more time counseling patients, too, about the risks of ibuprofen and naproxen.

I encourage you to take a look at these related AFP By Topic collections:
Heart Failure
Pain: Chronic 
Arthritis and Joint Pain (includes this AHRQ-EHC review's discussion of NSAID risks)

How frequently have you been recommending NSAIDs?  Will this meta-analysis change your NSAID prescribing?