Barak Gaster

Systematic Review of Antidepressants in the Treatment of Chronic Low Back Pain

Background. Three previous reviews have reached conflicting conclusions regarding the efficacy of antidepressants for patients with back pain. Objectives. To systematically review the efficacy of antidepressants for the treatment of patients with back pain and to determine whether there is evidence that outcomes vary between classes of antidepressants. Materials and Methods. Best evidence synthesis of randomized, placebo-controlled trials of oral antidepressive agents in patients with back pain. Studies were identified by searching MEDLINE, PsycINFO, and the Cochrane Controlled Trials Registry. Two independent reviewers performed data extraction and assessed included studies with a 22-point methodologic quality assessment scale. Effect sizes were calculated if sufficient data were available. Results. Twenty-two trials of antidepressants for the treatment of back pain were identified, of which seven studies of chronic low back pain met inclusion criteria. Among studies using antidepressants that inhibit norepinephrine reuptake (tricyclic or tetracyclic antidepressants), four of five found significant improvement in at least one relevant outcome measure. Assessment of these agents’ impact on functional measures produced mixed results. No benefit in pain relief or functional status was found in three studies of antidepressants that do not inhibit norepinephrine reuptake. Conclusions. Based on a small number of studies, tricyclic and tetracyclic antidepressants appear to produce moderate symptom reductions for patients with chronic low back pain. This benefit appears to be independent of depression status. SSRIs do not appear to be beneficial for patients with chronic low back pain. There is conflicting evidence whether antidepressants improve functional status of patients with chronic low back pain.

Physicians' Use of and Attitudes Toward Electronic Mail for Patient Communication

To assess physicians’ use of and attitudes toward electronic mail (e-mail) for patient communication, we conducted a mailin survey of physicians who see patients in outpatient clinics affiliated with a large academic medical center (N=283). Seventy-two percent of physicians reported using e-mail to communicate with patients, averaging 7.7 e-mails from patients per month. The lowest level of use was by community-based primary care physicians (odds ratio, 0.22; 95% confidence interval, 0.08 to 0.59). Those physicians who reported using e-mail with patients reported high satisfaction with its use. Although physicians were concerned about the confidentiality of e-mail, few discussed this issue with patients.

Brief report: Training internists in shared decision making about chronic opioid treatment for noncancer pain.

AbstractBACKGROUND: The use of chronic opioids for noncancer pain is an increasingly common and difficult problem in primary care. OBJECTIVE: To test the effects on physicians’ self-reported attitudes and behavior of a shared decision-making training for opioid treatment of chronic pain. DESIGN: Randomized-controlled trial. PARTICIPANTS: Internal Medicine residents (n=38) and attendings (n=7) were randomized to receive two 1-hour training sessions on a shared decision-making model for opioid treatment for chronic pain (intervention, n=22) or written educational materials (control, n=23). MEASUREMENTS: Questionnaires assessing physician satisfaction, physician patient-centeredness, opioid prescribing practices, and completion rates of patient treatment agreements administered 2 months before and 3 months after training. RESULTS: At follow-up, the intervention group reported significantly greater overall physician satisfaction (P=.002), including subscales on relationship quality (P=.03) and appropriate use of time (P=.02), self-reported completion rates of patient treatment agreements (P=.01), self-reported rates of methadone prescribing (P=.05), and self-reported change in care of patients with chronic pain (P=.01). CONCLUSIONS: Training primary care physicians in the shared decision-making model improves physician satisfaction in caring for patients with chronic pain and promoters the use of patient treatment agreements. Further research is necessary to determine whether this training improves patient satisfaction and outcomes.

Randomized trial of web-based training about opioid therapy for chronic pain.

ObjectivesThe treatment of chronic noncancer pain with chronic opioid therapy has increased rapidly, but medicine residents receive little training concerning this therapy. Therefore we conducted a trial to determine if an interactive web-based training focusing on shared decision-making for chronic opioid therapy improves knowledge and competence compared with exposure to practice guidelines. MethodsA randomized controlled educational trial of 213 internal medicine residents from 5 medicine residencies participating in the Residency Review Committee for Internal Medicines Educational Innovations Project comparing access to interactive web-based training (COPE: Collaborative Opioid Prescribing Education) or access to the Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain. Pretraining and immediate posttraining knowledge test; pretraining and 60-day posttraining self-reported competence, satisfaction, patient-centeredness, and selected clinical behaviors were analyzed using t tests, Pearson χ2, and Generalized Estimating Equations. ResultsThe web training group had greater increase in knowledge with training (χ2=72.06, P<0.00001) and greater self-rated competence in the management of outpatients with chronic pain (χ2=6.48, P=0.01), and specifically in the use of opioids in this management (χ2=5.17, P=0.02). Residents in both groups reported more satisfaction with managing chronic pain care after training (χ2=52.72, P<0.0001), though the web training was superior on subscales concerning training adequacy (χ2=4.94, P=0.026) and relationship quality (χ2=5.79, P=0.016). ConclusionsExposure to an interactive web-based training focused on shared decision-making and communication skills was more effective than exposure to compatible practice guidelines for knowledge and self-reported competence in the management of chronic noncancer pain.

PrimeAnswers: A Practical Interface for Answering Primary Care Questions

This paper describes an institutional approach taken to build a primary care reference portal. The objective for the site is to make access to and use of clinical reference faster and easier and to facilitate the use of evidence-based answers in daily practice. Reference objects were selected and metadata applied to a core set of sources. Metadata were used to search, sort, and filter results and to define deep-linked queries and structure the interface. User feedback resulted in an expansion in the scope of reference objects to meet the broad spectrum of information needs, including patient handouts and interactive risk management tools. RESULTS of a user satisfaction survey suggest that a simple interface to customized content makes it faster and easier for primary care clinicians to find information during the clinic day and to improve care to their patients. The PrimeAnswers portal is a first step in creating a fast search of a customized set of reference objects to match a clinicians patient care questions in the clinic. The next step is developing methods to solve the problem of matching a clinicians question to a specific answer through precise retrieval from reference sources; however, lack of internal structure and Web service standards in most clinical reference sources is an unresolved problem.

Patient-centered discussions about prostate cancer screening: a real-world approach.

National guidelines recommend that primary care providers discuss the risks and benefits of prostate cancer screening with their patients but give little guidance on how to fit such a complex discussion into a busy clinic encounter. The authors propose a process-oriented approach (Ask-Tell-Ask) that promotes tailored conversations and value-based recommendations. The Ask-Tell-Ask approach includes diagnosing a patients informational needs, providing targeted education based on those needs, and making a shared decision about testing. This time-efficient model emphasizes the providers role as an interactive guide rather than a one-way supplier of information. Although there is no way to make these discussions simple, this streamlined strategy can help patients and providers efficiently negotiate the complex and important decision of screening for prostate cancer.

Teaching evidence-based medicine at complementary and alternative medicine institutions: strategies, competencies, and evaluation.

BACKGROUND As evidence-based medicine (EBM) becomes a standard in health care, it is essential that practitioners of complementary and alternative medicine (CAM) become experts in searching and evaluating the research literature. In support of this goal, the National Institutes of Health (NIH) National Center for Complementary and Alternative Medicine (NCCAM) provided R25 funding to nine CAM colleges to develop individual programs focused on teaching EBM. An overarching goal of these research education grants has been to provide CAM faculty and students with the skills they need to apply a rigorous evidence-based perspective to their training and practice. METHODS/RESULTS This paper reviews the competencies and teaching strategies developed and implemented to enhance research literacy at all nine R25-funded institutions. While each institution designed approaches suitable for its research culture, the guiding principles were similar: to develop evidence-informed skills and knowledge, thereby helping students and faculty to critically appraise evidence and then use that evidence to guide their clinical practice. Curriculum development and assessment included faculty-driven learning activities and longitudinal curricular initiatives to encourage skill reinforcement and evaluate progress. CONCLUSION As the field of integrative medicine matures, the NIH-NCCAM research education grants provide essential training for future clinicians and clinician-researchers. Building this workforce will facilitate multidisciplinary collaborations that address the unique needs for research that informs integrative clinical practice.

Building Bridges: Qualitative Assessment of a Clinical Faculty Exchange Between a Naturopathic and an Allopathic Medical Training Program

RESEARCH QUESTION What are the perceived benefits of a clinical exchange experience designed as part of a program to promote acceptance and use of evidence-based medicine (EBM) in naturopathic clinical practice? METHODS Nine faculty members participated in a focus group (n = 6) or a structured interview (n = 3) to assess experience in the program. Investigators independently analyzed transcribed notes for common experience themes. ANALYSIS AND INTERPRETATION: Six major themes emerged: integrating EBM into naturopathic clinical teaching, strengthening of professional relationships, exposure to clinical experiences outside the usual naturopathic scope, reaffirmation of naturopathic training and profession, observation of clinical and administrative resources and practices, and recommendations for future clinical exchanges. MAIN RESULTS A clinical exchange experience was viewed as a favorable way to promote EBM appreciation within the complementary and alternative medicine educational community and to foster improved clinical experiences for faculty and their students and patients.

Advance Directives for Dementia: Meeting a Unique Challenge

In the coming years, an increasing number of people will experience dementia. Worldwide, the number of people living with dementia is projected to increase from 47 million in 2015 to 132 million by 2050.1 Family members and clinicians are often unsure whether the care they provide for such patients is the care that patients would have chosen. Across the care spectrum, including skilled nursing facilities, hospital wards, intensive care units, and outpatient clinics, family members and clinicians commonly encounter this dilemma. National campaigns have increased awareness of advance care planning to guide care for patients who can no longer make decisions for themselves. The Conversation Project, for example, has developed partnerships with more than 400 community organizations across the United States to provide tools to promote end-of-life conversations.2 Advance directives, when incorporated into comprehensive goalsof-care discussions, are an important part of this planning and help reduce family anxiety about surrogate decision-making.3 Standard advance directives are often not helpful for patients who develop dementia. Dementia is a unique disease from the standpoint of advance directives. It usually progresses slowly over many years and leaves people

East meets West: current issues relevant to integrating Chinese medicine

This article describes the challenges that integration of Chinese medicine (CM) and biomedicine are likely to bring for improving safety, research, education, and cross-disciplinary communication. Potential strategies to meet these challenges are suggested, including the use of accessible language for the Western biomedical community, and further development of whole-system randomized controlled trials that support individualized treatment approaches.