Monday, August 30, 2021

Supporting patients with stomas

 - Jennifer Middleton, MD, MPH

Family physicians are likely to care for patients with colostomies and ileostomies, so comfort with both the basics of stoma care and the common psychosocial challenges of managing a stoma are a must. Patients may have temporary colostomies for several reasons, including the need to divert stool away from the perineum for surgical procedures and with bowel resections for diverticular disease or malignancy. Patients with cancer, severe fecal incontinence, inflammatory bowel disease, and/or recurrent diverticular disease may have permanent colostomies or ileostomies. 

Patients should receive instructions from their colorectal care team about the frequency of emptying and changing their stoma bags. Some patients will be advised to empty their stoma bag 1-3 times a day and will then replace the bag every 2-4 days; some patients will be advised to simply replace the bag when full every 1-2 days. The odor of stool from a stoma can be more intense than with usual defecation, and patients may want to choose an air freshener product to keep handy during bag emptying and changing. Patients should be prepared for the potential of bag leaking by either carrying or keeping nearby an extra set of supplies (new ostomy bag, adhesive remover, new adhesive, small trash bag/plastic bag for disposal).

There are different types of ostomy bag systems and a wide variety of products to protect the skin around the stoma (including powders and barrier wipes). Although colorectal care providers usually manage product recommendations and orders, keeping track of the products your patients are using will help if they ever need you to reorder them. Familiarity with these supplies and general management of ostomy bags can also lead to more meaningful conversations with patients about ostomy management. This 5-minute video gives an overview of emptying and changing ostomy bags. Healthy stomas are pink or red and often have a somewhat raw or abraded appearance. Skin care around the stoma site is important, and patients should be checking the skin around the stoma with every bag change. If patients are experiencing skin irritation, encourage them to should reach out to their colorectal team to discuss skin care product options; if their stoma is blue, purple, or tender, urge patients to reach out to their colorectal care team immediately for evaluation.

Having provided care for a family member with a stoma, I can personally relate to the challenges of adapting to a colostomy or ileostomy. Talking about stool and bowel problems is often stigmatized, and, consequently, patients may not feel that they can discuss the challenges of dealing with a stoma with friends and family. It's not surprising that persons with a stoma have higher rates of depression and social isolation compared to the general population. Dyspareunia and erectile dysfunction are also more common in patients with stomas. This article contains several pragmatic tips for managing situations such as returning to work, traveling, and intimacy. Patients can also find positive depictions of life with a stoma on social media and connect with both local and online support groups for "ostomates." 

Although stomas may seem intimidating at first, family physicians are more than capable of learning the basics of stoma care and supporting patients with stomas throughout their experience.

Monday, August 16, 2021

What are the risks of tapering chronic opioids?

 - Jennifer Middleton, MD, MPH

The Centers for Disease Control and Prevention (CDC) recommends tapering chronic opioid doses when patients do not have meaningful pain benefit and/or show signs of a substance use disorder. Despite increased opioid tapering by physicians in the last few years, however, deaths from opioid use continue to escalate. A new study suggests that tapering long-term opioid doses may be contributing to this increased mortality by increasing affected patients' risks for mental health crisis and/or opioid overdose.

This retrospective cohort study of a national database included over 113,000 participants' records from 2008-2019. The study authors defined tapering as a "at least 15% relative reduction in mean daily dose during any of 6 overlapping 60-day windows within a 7-month follow-up period." Their main outcomes were emergency department and/or hospital visit for drug overdose, drug withdrawal, and/or mental health crisis. Patients with tapered opioid doses were more likely to present with drug overdose or withdrawal in the subsequent 12 months than patients maintained on their chronic opioid regimen (9.3 overdose events per 100 person-years compared with 5.5 events per 100 person-years), and patients with tapered opioid doses were also more likely to present with mental health crisis (depression, anxiety, and/or suicide) than patients maintained on their chronic opioid regimen (7.6 mental health crisis events per 100 person-years compared with 3.3 events per 100 person-years). The confidence intervals for both absolute risk differences were statistically significant (adjusted incidence rate difference, 3.8 per 100 person-years [95% CI, 3.0-4.6] and adjusted incidence rate difference, 4.3 per 100 person-years [95% CI, 3.2-5.3], respectively). 

This study's observational design can only determine correlation, not causation, though the authors cite earlier published studies demonstrating the "potential hazards of rapid dose reduction, including withdrawal, transition to illicit opioids, and psychological distress." They recommend "more gradual dose reductions" (the CDC recommends reducing doses by no more than 10% a month for patients taking chronic opioids) to reduce the risk of adverse events and call for further research to better define optimal patient selection and dose reduction protocols for opioid tapering. A 2020 AFP Curbside Consultation provides an overview of one current tool to manage opioid tapering, the BRAVO (Broaching the subject, Risk-benefit calculation, Addiction, Velocity and validation, Other strategies) protocolUnfortunately, some patients with chronic opioid use develop opioid use disorder, and these patients require additional treatment beyond tapering off opioids. The AFP By Topic on the Opioid Epidemic - Key Resources provides articles to guide diagnosis and management, including this overview of "Opioid Use Disorder: Medical Treatment Options." 

The COVID-19 pandemic is accelerating opioid-related mortality; as we await further research, tapering chronic opioid doses, when appropriate, remains a useful tool if we proceed slowly and engage in thoughtful patient-centered decision making regarding its potential risks.

Tuesday, August 10, 2021

Should risk calculators be used in lung cancer screening decisions?

 - Kenny Lin, MD, MPH

The American Academy of Family Physicians recently endorsed the U.S. Preventive Services Task Force (USPSTF)'s 2021 recommendation to offer annual lung cancer screening with low-dose computed tomography (LDCT) to adults aged 50 to 80 years with at least a 20 pack-year smoking history who have smoked within the past 15 years. Although a meta-analysis of 8 randomized controlled trials found that people screened with LDCT are 19% less likely to die from lung cancer (NNS = 250), it also concluded that about 20% of tumors are overdiagnosed, in line with a previous report from the U.S. National Lung Screening Trial. Unfortunately, doctors do not often discuss harms of lung cancer screening such as overdiagnosis, overtreatment, and complications of diagnostic procedures performed for positive tests.

Deciding if the potential benefits outweigh the harms of lung cancer screening for an individual patient requires a way to personalize estimates of benefit based on patients' risk factors. In a Letter to the Editor regarding a 2019 American Family Physician article on the pros and cons of lung cancer screening, Dr. Abbie Begnaud and colleagues suggested:

If an eligible patient is reasonably healthy, clinicians could consider calculating individualized lung cancer risk using one of several well-validated risk models. We and others have developed web-based tools to help clinicians incorporate individualized risk calculations into decision-making. Individualized risk assessment can be helpful because patients at higher risk of developing lung cancer are also more likely to benefit from early detection through screening. When lung cancer risk increases, uncertainty about whether to recommend screening decreases when the person has a reasonable life expectancy.

Unlike risk prediction tools for cardiovascular disease and breast cancer, however, there is no consensus on which lung cancer risk calculator should be used. A systematic review published earlier this year in the Journal of General Internal Medicine identified 10 publicly available risk calculators and assessed their performance in 16 hypothetical patients across the continuum of lung cancer risk. The calculators used varying inputs (demographic factors, cancer history, smoking status, and personal and environmental factors) to generate lung cancer risk estimates; unsurprisingly, there were substantial differences in risk estimates for 10 of the 16 hypothetical patients. The authors concluded that the lack of standardization of lung cancer risk factors and consistency in risk estimates from web-based calculators may be an obstacle to shared decision making.

Notably, the USPSTF statement "recommends using age and smoking history to determine screening eligibility rather than more elaborate risk prediction models because there is insufficient evidence to assess whether risk prediction model–based screening would improve outcomes relative to using the risk factors of age and smoking history for broad implementation in primary care." In a Putting Prevention Into Practice case study in the July issue of AFP, Drs. Howard Tracer and James Pierre explained how to apply the Task Force recommendations in clinical practice.

Monday, August 2, 2021

COVID vaccine boosters: now, later, or never?

 Jennifer Middleton, MD, MPH

As COVID-19 infection numbers continue to rise, and with continued breakthrough cases in persons who have been fully vaccinated, questions about booster shots are circulating. The delta variant is wreaking havoc in many places across the world, especially in pockets of the US with low vaccination rates including Missouri, Arkansas, Louisiana, and Florida. Reports of breakthrough infections in persons fully vaccinated have contributed to many alarming headlines, though public health experts have been quick to emphasize that the vast majority of severe infections are occurring in unvaccinated persons.

Data from Israel, which has vaccinated 60% of its population against COVID-19, is fueling fears as well. Estimates that the vaccine was just 39% effective at preventing infection in the last couple of months there have been heavily publicized, though Israeli researchers have been quick to point out that the vaccine has consistently remained highly effective (>90%) at preventing severe COVID-19 infection:

Experts suggested several possible explanations for the seeming decline, including the possible waning of immune protection in people vaccinated early in the year....[b]ut it's also possible that the apparent decline is a mathematical fluke. Case numbers are much lower in Israel now that they were earlier in the year..."I think that data should be taken very cautiously because of small numbers," [according to] Eran Segal, a biologist at the Weizmann Institute of Science.

With these concerns swirling, Pfizer announced preliminary results regarding its investigation into the efficacy of a 3rd COVID-19 vaccine dose, finding "[p]ost dose 3 [antibody] titers vs. the Delta variant are >5-fold post dose 2 titers in 18-55 [year-olds] & >11-fold post dose 2 titers in 65-85 [year-olds]." These numbers sound impressive, but this antibody titer study was only conducted in 23 individuals, and it's unclear precisely how antibody titers correlate with more important patient-oriented outcomes such as severe illness and death. In a joint statement issued earlier this month, the FDA and the CDC asserted that "Americans who have been fully vaccinated do not need a booster shot at this time....We are prepared for booster doses if and when the science demonstrates that they are needed." The stark inequity of worldwide vaccine distribution also raises ethical concerns regarding devoting more vaccine product to the US when most of the world's population still does not have access to even a first COVID-19 vaccine dose.

The Advisory Committee of Immunization Practices (ACIP) has been discussing the possible benefit of a booster dose for immunocompromised persons, though ACIP declined to make any recommendations at its meeting last week. While we wait for more data and possible recommendations on boosters, the CDC is now advising all Americans, even those who have been fully vaccinated, to mask indoors if they are in areas of high COVID-19 transmission (which is most of the US as of this writing), especially if they live with persons unable to be vaccinated and/or at higher risk of complications from COVID-19 disease. We should still continue to advise our patients, even our vaccinated ones, to exercise caution and thoughtfulness as the delta variant continues to spread.