What's new in opioid prescribing, treatment, and education?

- Jennifer Middleton, MD, MPH

Coverage regarding the opioid epidemic shows no sign of slowing, and a flurry of articles this month -- 5 articles across 4 different Family Medicine journals -- bring several important insights and tools for family physicians to consider incorporating into their practices.

The first is an editorial published online in AFP this past week on "Treating Opioid Use Disorder as a Family Physician: Taking the Next Step." The editorial reviews 12 different models for providing buprenorphine-based medication assisted therapy (MAT) for opioid addiction in a primary care office, including outpatient models, inpatient models, and models that both do and don't incorporate behavioral counseling. Project ECHO is one model that may appeal to rural physicians, as it connects physicians interested in providing this treatment with experts via the internet. The editorial also includes a table with several valuable resources for physicians providing MAT, including the American Society of Addiction Medicine's website which has a wealth of resources for both physicians and patients.

A cross-sectional study regarding "Prescription Opioid Use and Satisfaction with Care Among Adults with Musculoskeletal Conditions" in the Annals of Family Medicine found greater satisfaction associated with prescription opioid use. The authors examined 6 years of data from the Medical Expenditure Panel Survey for adults with documented musculoskeletal diagnoses; patients receiving prescription opioid medications had higher patient satisfaction scores than those not receiving opioids (odds ratio = 1.32; 95% confidence interval, 1.18–1.49). The authors found that patients taking opioids reported more pain and greater disability, however, than those not taking opioids and cautioned that:

"The lack of an association between opioid prescribing and improvements in pain on a population health level has been highlighted by the Centers for Disease Control and Prevention, who report that since 1999, the quantity of prescription opioids sold in the United States has almost quadrupled, yet there has not been an overall change in the amount of pain that Americans actually report."

Two articles examining office-based strategies for managing patients on chronic opioids in the Journal of the American Board of Family Medicine each share interesting insights. "Structured Management of Chronic Nonmalignant Pain with Opioids in a Rural Primary Care Office" describes a rigorous office process required of all patients receiving chronic opioid prescriptions, including administration of several validated scales at each visit (Brief Pain Inventory Short Form, Zung depression scale, SOAPP-R diversion risk assessment tool, and the Roland disability rating scale for back pain), a standard patient handout describing opioid risks, and a standardized documentation template. This approach increased compliance with state and federal opioid prescribing regulations and also decreased the total number of opioid prescriptions written by their office. "Impact of Pharmacist Previsit Input to Providers on Chronic Opioid Prescribing Safety" found that adding a pharmacist previsit to appointments for chronic pain decreased overall opioid prescribing with no change in reported patient pain scores.

Finally, from the Society of Teachers of Family Medicine's Family Medicine journal comes "Teaching Chronic Pain in the Family Medicine Residency," a cross-sectional survey of Family Medicine residency program directors about their program's curricula regarding chronic pain. With a 53% response rate of program directors from across the United States, they found that an average of 33 hours (with a wide range of 2-180 hours across programs) of curricular time is devoted to teaching about chronic pain in Family Medicine residencies. The authors hypothesized that residency programs with directors who had negative attitudes about chronic pain and/or MAT would provide less education on these subjects, but this hypothesis was not borne out in their findings; the only predictor of higher curricular time, interestingly, was a strong belief in the benefit of nonopioid treatments for chronic pain. The wide range of curricular hours across the US suggests that residency programs have some work to do to validate and standardize effective teaching on this important subject.

Which of these ideas and/or tools will you consider incorporating into your own practice? Or, perhaps, you have a different model of success to share with AFP readers; we welcome your comments below.

Should your next prescription be a mobile app?

- Kenny Lin, MD, MPH

Earlier this month, a blog post from Dr. Jennifer Middleton highlighted recent content in AFP that can help family physicians support patients' resolutions to make healthy lifestyle changes. Increasingly, I also recommend that patients consider using smartphone apps to give them extra motivation and allow them to chart their progress toward personal goals. The latest in a series of articles on medical apps in FPM reviewed four mobile apps designed to encourage healthy habits, including healthy eating, physical fitness, substituting water for sugary drinks, and taking prescribed medications. Although the evidence that apps provide greater benefits than usual care remains limited (a randomized trial of a fitness app reviewed previously by FPM found no statistical differences in weight loss, blood pressure, or satisfaction), "digital therapy" is now being used to promote wellness and improve self-management of chronic conditions as diverse as substance use disorder and atrial fibrillation.

A draft technical brief issued by the Agency for Healthcare Research and Quality reviewed the evidence on health outcomes for 11 commercially available mobile apps for self-management of type 1 or type 2 diabetes. For five apps, studies demonstrated clinically significant improvements in hemoglobin A1c levels at 3 to 12 months. However, no studies showed improvements in quality of life, blood pressure, weight, or body mass index.

Regarding apps for clinicians, the U.S. Food and Drug Administration (FDA) clarified in a recent guidance document how it intends to treat digital decision support software going forward. Software that functions as a diagnostic device will be regulated, while digital tools that merely assist clinicians in making diagnoses will be excluded from regulation and "cleared" for use. On its website, the FDA provides a list of examples of mobile medical apps that it has cleared or approved to date.

Whether mobile apps will complement traditional prevention, diagnosis and treatment in primary care, or replace them, remains to be seen. Do you routinely prescribe apps to your patients, and do you expect to do so more often in the future?

Supporting family physicians who provide maternity care

- Jennifer Middleton, MD, MPH

An editorial on Immediate Postpartum LARC: An Underused Contraceptive Option in the current issue of AFP has generated a lot of interest. Several comments have been left online, and (as of this writing), all of them are quite positive. At a time when family physicians' interest in obstetrics (OB) continues to wane, these commenters exemplify the vibrant community of family physicians who do choose to provide OB care; as a specialty, we should support these physicians and the often underserved communities they care for.

Family physicians who attend deliveries are a critical component of improving the health of rural communities. Obstetrician/gynecologists (OB/GYNs) tend to cluster in metropolitan areas, with many rural counties in the United States reporting that family physicians are their only source for OB care. Supporting training opportunities in residency is critical to encouraging future family physicians to consider including OB in their practices; exposure to models of care like prenatal group visits and physician group coverage models may reduce concerns about the feasibility of doing so.

Even those of us who do not attend deliveries, however, have an obligation to advocate for those who do. Several of the comments left on the current AFP LARC editorial point to the need for state and national advocacy efforts to eliminate reimbursement barriers to providing this valuable service. This advocacy does not have to be time-consuming or burdensome; it's easy to send messages to your state AFP chapter and/or state legislators.

We also have an obligation to support preconception and prenatal care. All family physicians should discuss contraception and family planning with not only our expecting patients but all of our patients of child-bearing age. We should encourage folic acid supplementation for all women capable of pregnancy. We should discuss healthy birth spacing intervals at well child visits. There's an AFP By Topic on Family Planning and Contraception if you'd like to read more.

The comments regarding the LARC editorial enriched future readers' experience with their ideas and references. The ability to comment on articles online is one way you can directly engage with AFP; find us on Facebook and Twitter to join those conversations. Don't forget, too, about the opportunity to comment below here on the Community Blog every week.

The top ten AFP Community Blog posts of 2017

- Kenny Lin, MD, MPH and Jennifer Middleton, MD, MPH

For the first time since we started putting together lists of the year's most-read posts, three guest posts made the 2017 list, including the top two. We welcome submissions of guest posts from readers on topics of interest to family physicians; please send inquiries and submissions to Kenneth.Lin@georgetown.edu.

1. Guest Post: I have a new patient (January 3) - 1952 page views

I realize, again, that sometimes we family physicians are called to comfort and not cure. I see how filling her remaining days by helping others continues to bring her a sense of purpose. I have learned a great deal from her in a short time and am grateful that I accepted a new patient.

2. Guest Post: On the front lines of the opioid epidemic (February 21) - 1843 page views

We decided to stop prescribing opioids for chronic pain management. All patients were reassessed and alternatives were chosen to manage pain. So many negative stories started with “A doctor prescribed these medications, so I thought they were okay.” Going forward, prevention, identifying those at risk, and asking questions about abuse is our focus.

3. What's in a name? Obesity, ABCD, and prediabetes (January 10) - 1558 page views

For all its limitations, obesity is a diagnosis with well-established clinical utility. It is less clear how many patients have been helped (or harmed) by being diagnosed with prediabetes. With more study, adiposity-based chronic disease might someday become a useful term, but the current case for more widespread use is unconvincing.

4. The 2017 ACC/AHA Clinical Practice Guideline for High Blood Pressure (November 27) - 1281 page views

It's difficult to argue with this CPG's emphasis on nonpharmacologic treatment, ambulatory BP monitoring, team-based care, integration of QI efforts, and population health advocacy. Its new BP diagnosis definitions and treatment goals, however, may be more open to discussion, especially as no primary care societies were involved in their development.

5. Strategies to limit antibiotic resistance and overuse (June 26) - 1170 page views

According to a report from the Centers for Disease Control and Prevention (CDC), more than 2 million Americans become infected with antibiotic-resistant bacteria each year, leading directly to at least 23,000 deaths and contributing indirectly to thousands more.

6. Safety net doesn't shield patients from low-value care (April 17) - 1147 page views

The study authors found no consistent relationship between insurance status and quality measures, and they concluded that safety net physicians were just as likely as other physicians to provide low-value services.

7. After emergency contraception: what next? (January 21) - 1011 page views

Discussions about EC should include options for initiating a regular form of contraception along with information about ulipristal's effectiveness and possible interactions. Providing this information to women will allow them to choose both an EC method and a regular contraceptive method that best fit their priorities and wishes.

8. Simplifying treatment of acute asthma (March 27) - 978 page views

For the time being, we'll need to use patient-centered decision making to arrive at the best treatment plan for each patient with acute asthma, though it certainly seems reasonable to consider shorter durations of oral corticosteroids in uncomplicated pediatric and adult patients.

9. Guest post: innovating connections in family medicine (February 6) - 970 page views

While I delight in new technology that enhances our care for patients, some aspects of family medicine won’t change. Technology won’t change the reassuring words we can offer to a worried parent or acutely ill patient. It won’t alter the power of our receptive ears being present for a scared patient. And it definitely won’t replace the wisdom, laughs, perspectives, and connections we encounter with our patients each day.

10. Vaccines in the news: controversies & updated recommendations (February 15) - 970 page views

Countering anti-vaccine messages can feel challenging, but the best predictor of being vaccinated is still hearing a physician's recommendation to vaccinate. Arming ourselves with information and strategies can help our patients make informed choices about vaccination.

Supporting patients' New Year's resolutions

- Jennifer Middleton, MD, MPH

The beginning of a new calendar year often sparks plans to improve health behaviors. When patients share these goals with us, we have many tools and resources available to help them succeed.

A recent AFP article reviews evidence showing that weight loss may be more successful in patients who set simple dietary goals as opposed to attempting to follow a complex diet regimen. Setting permissive (eat more vegetables) instead of restrictive (eat less sweets) goals may also be more effective for meaningful weight loss. Increasing consumption of nutrient-dense foods (whole grains, vegetables, fruits) benefits all patients, and motivational interviewing by a physician can help patients lose an average of an additional 3.3 pounds. A comprehensive review of available medications for weight loss along with when to consider a referral to bariatric surgery can be found in this article and in the AFP By Topic on Obesity.

Another recent AFP article reminds us that many smokers want to quit and have failed quit attempts in the past. This article reviews the 5 A's framework (ask - advise - assess - assist - arrange) as well as the stages of change model to increase our counseling effectiveness. Just one minute spent in tobacco cessation counseling can increase quit rates. The article also reviews nicotine replacement therapies, which have been shown to increase the success of a quit attempt by 50-70%, and encourages use of dual therapy (for example, patch and gum) for those patients smoking more than 1 pack a day. Calling or contacting patients at least 4 times after their planned quit date increases quit rates; AAFP's Office Champions model is one way of involving the entire office in providing this follow-up and helping patients stay smoke-free for good. The AFP By Topic on Tobacco Abuse and Dependence provides many more helpful resources.

A final recent AFP article cites the disappointing statistic that most individuals do not report ever receiving counseling from their physicians regarding physical activity. Engaging in shared decision making with patients, writing an exercise prescription, and providing handouts with exercise instructions have all been shown to increase physical activity. Patients who feel that they don't have the time for prolonged periods of exercise may be glad to know that even 10-minute bursts of exercise can be beneficial. Patients intimidated by demanding exercise regimens may be relieved to learn that the overall time spent in exercising seems to be more important than overall intensity. Individuals should aim for no more than 2 days off between exercising to prevent losses in metabolic activity gains from a regular exercise program. The AFP By Topic on Health Maintenance and Counseling includes this recent review regarding the United States Preventive Services Task Force (USPSTF)'s report on the benefits of behavioral counseling interventions for physical activity.

Perhaps one of your new year's resolutions is to increase your office's capacity for supporting patients' behavior change efforts; this Family Practice Management article describing the AAFP's "AIM-HI" office intervention model might provide some inspiration. Or, perhaps your office has a successful model already in place that you might share with other AFP Community Blog readers in the comment space below.

Here's to a healthy 2018!