Mary Beth Plane

Opioids and the Treatment of Chronic Pain in a Primary Care Sample

Chronic pain is a widespread, difficult problem facing clinicians. This study assessed the current medical management of a general population of patients with chronic pain in 12 family medicine practices located throughout the state of Wisconsin. Medical record audits were conducted on a sample of 209 adults. Sixty-seven percent were female with an average age of 53 years. The most common pain diagnoses included lumbar/low back (44%), joint disease/arthritis (33%), and headache/migraine (28%) pain. The most frequently prescribed opioids were oxycodone/acetaminophen (31%), morphine ERT (19%), Tylenol #3 (15%), and hydrocodone/acetaminophen (14%). Depression/affective disorders were reported in 36% of the patient charts, anxiety/panic disorders (15%), drug abuse (6%), and alcohol abuse (3%). Written drug contracts were utilized by 42% (n = 31) of the practitioners, pain scales 25% (n = 29), and urine toxicology screens 8% (n = 6). This study suggests that primary care practitioners have unique opportunities to identify and successfully treat patients with chronic pain.

Efficacy of patient letter reminders on cervical cancer screening: a meta-analysis.

OBJECTIVE: To perform a meta-analysis on existing randomized controlled trials to investigate the efficacy of patient letter reminders on increasing cervical cancer screening using Pap smears.METHODS: A search was conducted for all relevant published and unpublished studies between the years 1966 and 2000. Eligibility criteria included randomized controlled studies that examined populations due for Pap smear screening. The intervention studied was in the form of a reminder letter. The Mantel-Haenszel method was used to measure the summary effect of the intervention. A test for homogeneity using the Mantel-Haenszel method was performed.RESULTS: Ten articles fulfilled the inclusion criteria, including one unpublished study. The test for homogeneity showed evidence of heterogeneity (x2=31, 9 df, P<.001). An analysis for causes of heterogeneity was pursued. Division into subpopulations based on socioeconomic status resolved the heterogeneity (x2=5.2, 8 df, P=.75). The studies evaluating those in lower socioeconomic groups had a smaller response (odds ratio [OR], 1.16; 95% confidence interval [CI], 0.99 to 1.35) than those studies using mixed populations (OR, 2.02; 95% CI, 1.79 to 2.28). The pooled odds ratio showed that patients who received the intervention were significantly more likely to return for screening than those who did not (OR, 1.64; 95% CI, 1.49 to 1.80).CONCLUSIONS: Patient reminders in the form of mailed letters increase the rate of cervical cancer screening. Patient letter reminders have less efficacy in lower socioeconomic groups.

Secondary Outcomes of a Pilot Randomized Trial of Azithromycin Treatment for Asthma

Objectives: The respiratory pathogen Chlamydia pneumoniae (C. pneumoniae) produces acute and chronic lung infections and is associated with asthma. Evidence for effectiveness of antichlamydial antibiotics in asthma is limited. The primary objective of this pilot study was to investigate the feasibility of performing an asthma clinical trial in practice settings where most asthma is encountered and managed. The secondary objectives were to investigate (1) whether azithromycin treatment would affect any asthma outcomes and (2) whether C. pneumoniae serology would be related to outcomes. This report presents the secondary results. Design: Randomized, placebo-controlled, blinded (participants, physicians, study personnel, data analysts), allocation-concealed parallel group clinical trial. Setting: Community-based health-care settings located in four states and one Canadian province. Participants: Adults with stable, persistent asthma. Interventions: Azithromycin (six weekly doses) or identical matching placebo, plus usual community care. Outcome Measures: Juniper Asthma Quality of Life Questionnaire (Juniper AQLQ), symptom, and medication changes from baseline (pretreatment) to 3 mo posttreatment (follow-up); C. pneumoniae IgG and IgA antibodies at baseline and follow-up. Results: Juniper AQLQ improved by 0.25 (95% confidence interval; −0.3, 0.8) units, overall asthma symptoms improved by 0.68 (0.1, 1.3) units, and rescue inhaler use decreased by 0.59 (−0.5, 1.6) daily administrations in azithromycin-treated compared to placebo-treated participants. Baseline IgA antibodies were positively associated with worsening overall asthma symptoms at follow-up (p = 0.04), but IgG was not (p = 0.63). Overall asthma symptom improvement attributable to azithromycin was 28% in high IgA participants versus 12% in low IgA participants (p for interaction = 0.27). Conclusions: Azithromycin did not improve Juniper AQLQ but appeared to improve overall asthma symptoms. Larger community-based trials of antichlamydial antibiotics for asthma are warranted.

Gender Differences in Violence Exposure Among University Students Attending Campus Health Clinics in the United States and Canada

PURPOSE To explore gender differences in prevalence, types, perpetrators, and correlates of recent violence experiences among university students at campus clinics at five universities in the Midwest and Pacific Northwest U.S. and Canada. METHODS Systematic survey of students presenting for routine primary care visits (N=2,091), pencil-and-paper screen for recent emotional and physical violence exposure (past 6 months), demographics, plus sensation-seeking, at-risk alcohol use, and depression. Chi-square tests compared prevalence by gender; correlates for types of violence were analyzed separately for men and women using chi-square with adjusted standardized residuals comparing no violence, intimate partner violence (IPV) and other violence (Other). RESULTS Similar rates of men (17%) and women (16%) reported any violence in the past 6 months; women were more likely to report emotional and men to report physical violence. Of those reporting emotional violence, 45.5% women and 50% men indicated it was IPV, and 23.7% women and 20.9% men reported physical IPV. Correlates differed by gender; demographics were not linked to IPV. At-risk drinking was associated with both IPV and Other violence for women, but only Other violence for men. Depression was the only correlate significantly linked to IPV for men. CONCLUSIONS Recent violence exposure among university students affects nearly one in five attending campus clinics. Screening for violence exposure should include both men and women, especially students who indicate heavy drinking patterns or depressive symptoms. Campus health promotion interventions should address healthy dating relationships. Further research on IPV among college men is needed.

History, Physical and Laboratory Findings, and Clinical Outcomes of Lactating Women Treated With Antibiotics for Chronic Breast and/or Nipple Pain

This chart review study describes the history, physical and laboratory findings, and clinical outcomes in patients who presented to a lactation specialist between 1997 and 2002 and were treated with antibiotics for their chronic breast and/or nipple pain. A total of 69 charts were reviewed. Five were excluded because of loss of follow-up. Eighty-two percent of patients described postpartum breast tenderness, 74% had nipple sores postpartum, and 79% were tender on physical examination. Nipple lesions were present among 73% of the women. Breast milk or nipple cultures were performed for 60 of 64 patients and were positive for pathogenic bacteria among 50% of the patients cultured. The average duration of antibiotic treatment was 5.7 weeks, and 94% of the women had pain resolution. Symptoms of deep breast aching, breast tenderness on palpation, and nipple lesions may be suggestive of a bacterial lactiferous duct infection. Treatment with antibiotics for 4 to 6 weeks may be appropriate.

Nonresponse bias: Does it affect measurement of clinician behavior?

Background.Previous studies of nonresponders have not assessed the effects of nonresponse on the accuracy of clinician behavior measurements. Knowledge of these effects is critical to both research and quality improvement. Objective.To evaluate the hypothesis that nonresponders to a survey would not adversely affect the ability to measure rates of preventive services. Research Design.Four primary-care medical practices participating in a randomized clinical trial provided an unusual opportunity to compare the medical record-documented care of both responders and nonresponders to a survey of their patients. Subjects. Three hundred forty-five nonresponders and 321 responders to a questionnaire requesting participation in the study. Measures. Differences in patient characteristics and diseases and documentation of screening and management of tobacco use, hypertension, and hypercholesterolemia. Results. Although the survey process resulted in a response rate of only 52.5% and some statistically significant differences in responder and nonresponder characteristics, there were no differences in management behavior regarding cardiovascular risk factors. Responders were more likely to have adjusted documentation of tobacco use (OR = 1.4), blood pressure measurement (OR = 9.8), and cholesterol testing (OR = 2.0), but not family history of cardiovascular disease. The most striking difference in subject characteristics was that 22.0% of nonresponders and only 12.1% of responders were tobacco users (P = 0.002). Conclusions. This study confirms that survey nonresponders may have some different characteristics and risk factor screening rates than responders. However, if confirmed by others, nonresponders who have risk factors identified may not be managed differently than responders.

Prevalence of Interpersonal Abuse in Primary Care Patients Prescribed Opioids for Chronic Pain

BackgroundInterpersonal abuse is associated with clinical problems including chronic pain disorders.ObjectivesThe objective of this study is to describe 30-day and lifetime prevalence of emotional, physical, and sexual abuse found in men and women prescribed opioids for chronic pain.DesignCross-sectional interview is the design of this study.ParticipantsPatients, 1,009, currently prescribed opioids for chronic noncancer pain. They were recruited from the practices of 235 Family Physicians and Internists in Wisconsin. The most common pain diagnoses were arthritis, low back pain, headache, and fibromyalgia/myofascial pain.MeasurementData for this secondary analysis on rates of interpersonal abuse were based on 3 questions from the Addiction Severity Index (ASI) regarding 30-day and lifetime emotional, physical, and sexual abuse.ResultsForty-seven percent of women and 22% of men reported a history of lifetime physical abuse. Thirty -five percent of women and 10% of men reported lifetime sexual abuse. Binary logistic regression identified the following variables associated with lifetime physical abuse: female gender (RR 2.81, CI 2.01–3.94), age 31–50 (RR1.77, CI 1.30–2.41), Caucasian (RR1.67, CI 1.19–2.35), increased psychiatric symptoms as measured by the ASI (RR 2.14, CI 1.56–2.94), and lifetime suicide attempts (RR 3.98, CI 2.76–5.74).ConclusionsThis study reports prevalence of abuse in both men and women prescribed opioids for chronic pain in primary care settings. Subjects who report experiencing interpersonal abuse also report significantly higher rates of suicide attempts and score higher on the ASI psychiatric scale. Screening patients taking opioids for chronic pain for interpersonal abuse may lead to a better understanding of contributors to their physical and mental health.

Clinician and Staff Perspectives on Participating in Practice-based Research (PBR): A Report from the Wisconsin Research and Education Network (WREN)

Background: The success of practice-based research (PBR) depends on the willingness of clinicians and staff to incorporate meaningful and useful research protocols into already demanding clinic schedules. The impact of participation on those who implement multiple projects and how to address the issues that arise during this complex process remain incompletely described. This article reports a qualitative evaluation of the experiences of primary care clinicians and clinic staff who participated in multiple PBR projects with the Wisconsin Research and Education Network (WREN). Also included are their suggestions to researchers and clinicians for future collaborations. Methods: For program evaluation purposes, WREN conducted 4 focus groups at its 2014 annual meeting. The main focus group question was, “How has participation in PBR affected you and your clinic?” A total of 27 project members from 13 clinics participated in 4 groups (physicians, nurses, managers, and other clinical staff). The 2-hour sessions were recorded, transcribed, and analyzed to identify recurring themes. Results: Five major focus group themes emerged: receptivity to research, outcomes as a result of participation, barriers to implementation, facilitators of success, and advice to researchers and colleagues. Focus group members find research valuable and enjoy participating in projects that are relevant to their practice, even though many barriers exist. They indicated that research participation produces clinical changes that they believe result in improved patient care. They offered ways to improve the research process, with particular emphasis on collaborative early planning, project development, and communication before, during, and after a project. Conclusions: Clinics that participate in WREN projects remain willing to risk potential work constraints because of immediate or impending benefits to their clinical practice and/or patient population. Including a broader array of clinic personnel in the communication processes, especially in the development of relevant research ideas and planning for clinic implementation and ongoing participation in research projects, would address many of the barriers identified in implementing PBR. The themes and supporting quotes identified in this evaluation of WREN projects may inform researchers planning to collaborate with primary care clinics and clinicians and staff considering participating in research endeavors.