Decreasing opioid use with mind-body therapies

Jennifer Middleton, MD, MPH

Decreasing the amount of opioids patients with acute or chronic pain use is often desired, as opioid medications carry a sizable risk of adverse effects, including the risk of addiction. Less well understood, though, has been just how to decrease the amount of opioid pain medication needed without undertreating patients' pain. A recently published systematic review may have the answer; the studied "mental techniques to ameliorate pain" may improve pain and decrease the amount of opioid pain medication patients require.

The researchers' literature search identified 60 articles, including Cochrane meta-analyses, that examined the effect of adding various mind-body techniques (MBTs) to opioid pain medication for patients with either acute or chronic pain. They sought to focus on psychological treatments:

We elected to focus our review on MBTs that primarily use mental techniques because they may be more accessible to people whose mobility is compromised by pain or used for pain relief during inpatient procedures when patients are immobilized.

Most of the included studies were randomized controlled trials. Outcome variables included pain severity, opioid misuse, time to opioid cessation, and amount of opioid use. The most effective modalities were meditation, hypnosis, and cognitive behavioral therapy. Included studies regarding relaxation, guided imagery, and therapeutic suggestion found less consistent benefit for these modalities. The authors included a bias assessment which found most included studies designated an appropriate control group and had a low risk of bias.

Although hypnosis and cognitive behavioral therapy typically require referral to a trained practitioner, patients can engage in simple meditation techniques with only a little guidance. A 2018 FPM article reviews "Five Mobile Apps for Mindfulness," some of which are subscription-based, but all of which include at least some content for free (and Insight Timer, available for iOs and Android, has thousands of free mediations). Mindfulness-based interventions, such as meditation, have shown promise for improving mental health and quality of life in the primary care setting. Most patients are willing to consider alternative treatment modalities after discussion with their primary care physician. Expanding our toolkit for treating pain beyond medication may not only benefit our patients but may also protect them from unnecessary opioids.

There's a recent Curbside Consultation on "Tapering Long-Term Opioid Therapy" and an AFP By Topic on Complimentary and Alternative Medicine that includes a sub-section on Mind-Body Modalities if you've like to read more.

America needs more family doctors: working toward the 25 x 2030 goal

- Kenny Lin, MD, MPH

Last summer, a Graham Center Policy One-Pager reported that the percentage of the active U.S. physician workforce in primary care practice declined from 32 percent in 2010 to 30 percent in 2018. Although family physicians represent 4 in 10 primary care physicians, in several states a large percentage of family physicians are older than 55 years and anticipated to transition to part-time practice or retire by 2030. Recognizing the imperative to not only maintain, but expand the family medicine workforce to meet the population's needs, the Workforce and Education Development team of Family Medicine for America's Health recommended adoption of a shared aim known as 25 x 2030: to increase the percentage of U.S. medical students choosing family medicine from 12% to 25% by the year 2030. Supported by the American Academy of Family Physicians and seven other national and international family medicine organizations, the America Needs More Family Doctors: 25 x 2030 collaborative was officially launched in August 2018.

In an editorial in the January 15 issue of American Family Physician, Dr. Jacob Prunuske, a member of the 25 x 2030 Steering Committee, described the collaborative's guiding principles, benefits to physicians at all levels of experience, and how family doctors in the trenches can support progress toward this ambitious aim:

Recruit before medical school. Encourage children and young adults to not only go to medical school, but to become a family doctor. Active recruitment is especially valuable in underserved or rural communities and for those underrepresented in medicine.

Change the medical school experience. When you have the opportunity to work with medical students, say yes. If you must say no, reflect on what it would take to get you to say yes, and share your reflections with your health care system, institution, or the 25 × 2030 working groups so that they can address barriers to teaching. As preceptors for medical students, family doctors not only teach family medicine principles, but also serve as mentors and role models. Embrace this role. Debunk myths and counter negative stereotypes of family medicine. Family doctors provide high-value care by delivering high-quality outcomes while controlling costs. Medical students need this experience with practicing family doctors to combat the alternative messages of other specialties.

Advocate for family medicine. Legislative leaders need to hear about the value of family medicine from voters. Respond to advocacy calls, and advocate at the local, state, and national levels for changes that support family medicine. Share your advocacy efforts with your patients and tell them why these issues matter to you, them, and all of us.

Embrace change. Patient expectations, technology, and health systems will evolve. Rather than react, help guide these changes to fit the principles of family medicine.

An excellent resource for interested medical students is AFP's 2016 article, "Responses to Medical Students' Frequently Asked Questions About Family Medicine," which answers common questions about the importance of the specialty, residency and fellowship training, procedural skills and scope of practice, economic realities, and future prospects. The article advised students that "the best way to know if family medicine is the right fit for you is to work with family physicians in action, by doing a rotation with a family physician in practice." An upcoming AFP editorial will discuss why even more community family physicians should take the time and effort to precept students in their practices.

Should schools screen for adolescent idiopathic scoliosis?

- Jennifer Middleton, MD, MPH

I still remember lining up with my female peers in junior high gym class, clad only in undergarments (quite the height of teenage mortification), to bend over and have our spines checked for scoliosis. Such school-based screenings remain commonplace across the US, though there is considerable debate regarding their benefit. The January 1 AFP review on "Adolescent Idiopathic Scoliosis: Common Questions and Answers" discusses the current United States Preventive Services Task Force "I" statement regarding screening and its rebuttal by several medical organizations including the American Academy of Pediatrics and the American Academy of Orthopedic Surgeons. Although the evidence base leans away from screening, family physicians are still likely to encounter adolescents and their worried parents with positive screens in our offices.

Repeating the forward bend test in the office and looking for an abnormal appearance of the back or ribs is a reasonable first step. The AFP authors review a study that found the forward bend test has a 92-100% sensitivity for detecting a Cobb angle of at least 20 degrees. While the patient is bending over, clinicians may also use a scoliometer or a scoliometer app to quantify trunk rotation. Sensitivity to detect a Cobb angle of at least 10 degrees is highest with a scoliometer cutoff of 5%, but a cutoff of 7% has a better specificity (87% compared to 47%) with a small corresponding loss of sensitivity (down to 83%). Radiography can definitively make the diagnosis and quantify severity.

The AFP authors point out that evidence is lacking regarding the benefit of referring all but the most severe cases of scoliosis (Cobb angle of 40 degrees or greater) to an orthopedic surgeon. Family physicians should also discuss the prognosis for mild to moderate scoliosis with their patients and parents; the evidence review that informed the USPSTF's "I" decision found that:

Quality of life [measures]...were similar between observed and braced participants at adult followup, though braced participants felt their body appearance was more distorted than did untreated participants, and braced participants reported more negative treatment experiences than those treated surgically. No significant adult outcome differences were found between braced and surgically-treated participants on the Oswestry Disability Index, general well-being, or self-esteem and social activity. Pulmonary outcomes and childbearing and pregnancy outcomes were similar in braced and surgically-treated participants.

School-based nursing programs might more effectively target their efforts toward other disease processes (and their risk factors). In an era of school nursing shortages across the US, prioritizing school-based health efforts is more important than ever. The National Association of School Nurses does not include reference materials about scoliosis anywhere on their website, focusing instead on more prevalent and more impactful issues such as childhood obesity, drugs of abuse, mental health, and reproductive health.

There's an AFP By Topic on Musculoskeletal Care if you'd like to read more, and here is additional AFP content specifically regarding scoliosis as well.

AAFP-endorsed practice guideline supports limiting testosterone prescriptions

- Kenny Lin, MD, MPH

Is age-related low testosterone normal or a disease? If it is a disease, what are the benefits and harms of testosterone therapy? A previous AFP Community Blog post reviewed the controversy surrounding screening for low testosterone in older men and the U.S. Food and Drug Administration's requirement that prescription testosterone product labeling include warnings about a possible increased risk of heart attacks and strokes. A recent analysis of Medicare data found that testosterone prescribing peaked in 2013 and has since declined, but that prescribing rates were actually higher for men with coronary artery disease (CAD) than men without CAD. Meanwhile, another study suggested that men prescribed testosterone therapy have an increased risk of developing venous thromboembolism in the first 6 months of use.

Today the American College of Physicians (ACP) published a clinical practice guideline, endorsed by the American Academy of Family Physicians (AAFP), to provide evidence-based recommendations for primary care and subspecialist clinicians on treatment of men with age-related low testosterone. Based on an independent systematic review of the efficacy and safety of testosterone treatment, the ACP and AAFP suggested that clinicians discuss potential benefits, harms and costs of therapy with patients with age-related low testosterone and sexual dysfunction. The guideline recommended against initiating testosterone treatment for the purpose of improving energy, vitality, physical function, or cognition, due to the lack of benefits in randomized trials. Since some men will not respond to treatment, the guideline suggested re-evaluating symptoms within 12 months of initiating testosterone therapy, and discontinuing treatment if sexual function does not improve.

Studies assessing patient preferences reviewed by the ACP showed mixed preferences for injectable versus topical testosterone; the most bothersome symptoms were erectile dysfunction, decreased sex drive, and loss of energy; and moderately high therapy discontinuation rates in two studies (30 and 62 percent). Since transdermal testosterone costs an average of 14 times as much as intramuscular ($2135 vs. $156 for a year's supply in 2016, respectively) and has similar clinical effects and harms, the ACP and AAFP suggested considering intramuscular rather than transdermal formulations.

Although the guideline did not directly address the relatively common phenomenon of testosterone treatment in men without low testosterone levels, the American Society of Clinical Pathology, the American Urological Association, and the Endocrine Society have all advised against this type of prescribing to improve erectile dysfunction or any other symptom.