Rebecca Andrews

Prescribing opioids in primary care: Safely starting, monitoring, and stopping.

Chronic noncancer pain is common and often managed in the outpatient setting with chronic opioid therapy, even though the efficacy of this approach is uncertain and adverse effects are common. Some patients report meaningful benefit from opioids, but prescription drug abuse has reached epidemic proportions, and many suffer harm from opioid misuse, abuse, and diversion. Primary care providers and their care teams often struggle to balance these risks and benefits with little outside support. The authors review common challenges when starting, monitoring, and discontinuing opioids, and offer strategies for risk-reduction and patient communication. Prescription drug abuse has reached epidemic proportions. Some patients benefi t from opioids, but many suffer harm.

Preventability of 30-Day Readmissions for Heart Failure Patients Before and After a Quality Improvement Initiative

The objective of this study was to estimate the frequency of heart failure (HF) readmissions that can be prevented through a quality improvement (QI) program. All HF patients at the University of Connecticut Health Center who had a readmission within 30 days of discharge in the year before (2008) and the year after (2011) a QI program were studied. Through chart review, the percentage of patients who had preventable readmissions in each year was estimated. Prior to the QI initiative, chart reviewers identified that 20% to 30% of readmissions were preventable. The decrease in readmissions after the QI program was similar at 28%. Fewer readmissions after the QI initiative were deemed preventable compared with before. In conclusion, this study found a percentage of preventable readmissions similar to the actual 28% reduction in readmissions after a QI program was launched. Preventable readmissions were less common after the QI program was in place.

Information management for clinicians.

Clinicians are bombarded with information daily by social media, mainstream television news, e-mail, and print and online reports. They usually do not have much control over these information streams and thus are passive recipients, which means they get more noise than signal. Accessing, absorbing, organizing, storing, and retrieving useful medical information can improve patient care. The authors outline how to create a personalized stream of relevant information that can be scanned regularly and saved so that it is readily accessible. How to create a personalized stream of relevant information that can be saved so that it is readily accessible.

X + Y (or Why Not?)

T o The Editor: In the December issue of JGIM, Ray et al. examined several models of ambulatory training including an X + Y block schedule, a full-day clinic, and a hybrid clinic model. Previous studies have also examined combination continuity clinics in search of a configuration that enhances patient and resident continuity, improves outcomes, and promotes high patient satisfaction. In Table 2 of their article, Ray and colleagues highlight possible advantages and disadvantages of the three systems. We question two elements in this table. First, one of the purported advantages of an X + Y block schedule is Bnumerous long gaps in residents’ outpatient presence.^ We wonder whether this was meant to be designated as a disadvantage. Second, we would question whether Bresidents maintain[ing] primary ownership of patients including follow up results and response to patient calls^ is actually a disadvantage, particularly in light of the authors’ statement that Bresidents should never be completely absent from their role as primary care physicians.^

Opioids and Substance Abuse: Education or Just Regulation?

H ardly a week passes without a headline decrying opioid deaths, opioid addiction, new opioid prescribing laws, lawsuits against pharmaceutical companies for opioids, or some other dimension of the Bopioid epidemic.^ This term reflects the pervasive and ubiquitous nature of the issue. Each time a physician sees a patient with a pain or addiction issue, there is some fear. However, physicians are not the only ones who are afraid; patients with acute and chronic pain also wonder with considerable anxiety whether their pain will be appropriately treated. The current situation did not arise overnight. A recent perspective succinctly documents the path to our current situation. During the 1970s, physicians typically prescribed opioids only when patients were Bon the cusp of death.^ In the 1980s, several publications, based on small sample sizes, reported a low incidence of addiction in patients. These articles focused the conversation on the very real problem of under-treatment of pain, but led most physicians to assume that there would be few adverse consequences of aggressive use of opioids. However, the debate over the proper use of opioids has resurfaced in light of recent revelations surrounding opioid overuse and abuse. There are many diverse and conflicting voices that are part of the debate regarding the use of long-term opioid therapy (LTOT), including advocates for patients receiving palliative care, patients with chronic pain, families who have lost members to overdoses, and physicians. Amidst the turmoil, many possible solutions are being discussed. As highlighted in the 2011 Institute of Medicine (IOM) report, Brecommendation[s] for improving overall pain care [fall]... in six key areas: population research; prevention and care; disparities; service delivery and payment; professional education and training; and public education and communication.^ The report describes moving away from opioid-focused treatments by Bimproving provider education on pain management practices and team-based care.̂ 2 In addition, the recent Centers for Disease Control and Prevention (CDC) guidelines, routine prescription monitoring, and regulations to curb inappropriate prescribing may also be part of the solution; however, they are far from the complete answer. In this month’s Journal of General Internal Medicine, Nugent and colleagues examine another aspect of LTOT. They focus on patients receiving LTOT who were found to have concurrent substance use disorder (SUD) and on their SUD-related outcomes. Using data from the Department of Veterans Affairs (VA) national health care system, the authors examined the rates of patients on LTOT and SUD referred for SUD treatment, as well as the reasons affecting both the referral to, and completion of, SUD treatment. They examined 600 patients receiving LTOTwho were also identified as using alcohol, cannabis, illicit substances, or non-prescribed controlled substances. A total of 223 of these patients had their LTOT discontinued for aberrancy: either a urine drug test (UDT) identifying a non-prescribed/illicit substance or a UDT not detecting the prescribed opioid. After those with previous SUD treatment were excluded, 169 patients qualified as Bnew SUD.^ The characteristics of the group are representative of what many would expect, with 82% of the patients taking LTOT for musculoskeletal pain and more patients with alcohol use disorder (21%) than cocaine (9%) and cannabis (8%) combined. Surprisingly, opioid use disorders were found in only 5% of patients with newly diagnosed SUD, and sedatives were the lowest, at 1%. Overall, the majority of the 169 patients identified with new SUD were non-Hispanic whites (66%), male (99%), and living in urban settings (72%). Despite the intense attention currently focused on LTOT, there is a dearth of evidence examining current SUD among individuals with LTOT. Prior studies have focused almost exclusively on identifying concurrent opioid use disorders in patients on LTOTwith no history of SUD. Data on coexisting SUDs such as cannabis, cocaine, and alcohol have been lacking. This study provides important insights into a Breal-world^ population that many primary care physicians see frequently. Additional research is sorely needed to further examine both incident and coexisting SUDs in those receiving LTOT. This paper also examined the relationship between specific SUD and referral patterns for treatment. Of the patients identified with both LTOT and SUD, only 43% were referred for SUD treatment. Those with a UDT positive for cocaine were more likely to be referred than those with other SUDs. Patients who had a UDT positive for cocaine and who received a SUD referral, were also more likely to attend treatment. Interestingly, patients who had a UDT positive only for cannabis were less likely to be referred for SUD treatment, despite this being the reason for LTOT discontinuation. Overall, 47% of those referred for an SUD had at least one visit for SUD therapy in Published online July 28, 2017

Staying afloat in a sea of information: Point-of-care resources

Physicians can use a variety of electronic resources at the point of care to help them make decisions about patient management. The authors address the need for these resources, characterize the elements of good resources, and compare several popular ones, ie, Clinical Evidence, Dynamed, Evidence Essentials, First Consult, Medscape, and UpToDate. We can refine our skills in accessing, sorting, and interpreting scientific evidence.