418 - No More Routine EKGs, Medical Cannabinoids for Chronic Pain
Take 3 – Practical Practice Pointers©
From Choosing Wisely and the MedInsight Health Waste Calculator
1) Routine Screening EKG – Time to Stop
In 2018, the USPSTF re-issued the following recommendation: The USPSTF recommends against screening with resting or exercise electrocardiography (EKG) to prevent cardiovascular disease (CVD) events in asymptomatic adults at low risk of CVD events. (D recommendation)
The AAFP has based one of its Choosing Wisely initiatives off the USPSTF recommendation:
- There is little evidence that detection of coronary artery stenosis in asymptomatic patients at low risk for coronary heart disease improves health outcomes.
- False-positive tests are likely to lead to harm through unnecessary invasive procedures, over-treatment, and misdiagnosis.
- Potential harms of this routine annual screening exceed the potential benefit.
Carilion Clinic participates in Smarter Care Virginia – a statewide, multi-institution project to help reduce unnecessary or wasteful care. Wasteful care, in the case of EKG screening, is defined as an EKG done in the absence of a symptom-driven or other recognized indication for EKG (such as prior to starting an exercise program, a high risk for heart disease, or a prior history of heart disease, etc.). EKGs done prior to surgery are the subject of a separate initiative and are not included as screening EKGs.
How do we do at Carilion?
Carilion primary care data from the Milliman MedInsight Health Waste Calculator for Q1-Q4 2019:
Estimated Wasteful Spend
Routine EKG Screening
As a comparison, in the US as a whole, the rate of wasteful EKG screening hovers around 20% for all Medicare fee-for-service. In Carilion Clinic primary care, it appears we order 50% more screening EKGs than the rest of the US.
Screening an asymptomatic population for cardiovascular disease has downstream consequences for patient health and cost of care. While the screening test itself may not be expensive, it can result in a cascade of other services to evaluate abnormalities, most of which will not yield an important diagnosis and could cause harm from unnecessary procedures or side effects.
This is a good opportunity to reflect on our performance and consider the ways in which we can decrease unnecessary testing in our practices.
- AAFP - Annual cardiac screening for low-risk patients | Choosing Wisely [Internet]. 2012 [cited 2021 Sep 27]. Link
- US Preventive Services Task Force. Screening for Cardiovascular Disease Risk With Electrocardiography: US Preventive Services Task Force Recommendation Statement. JAMA. 2018 Jun 12;319(22):2308–14. Link
- Mafi JN, Reid RO, Baseman LH, Hickey S, Totten M, Agniel D, et al. Trends in Low-Value Health Service Use and Spending in the US Medicare Fee-for-Service Program, 2014-2018. JAMA Network Open. 2021 Feb 16;4(2):e2037328. Link
From the Guidelines
2) Medical Cannabis or Cannabinoids for Chronic Pain
Chronic pain is common and distressing and associated with considerable socioeconomic burden globally. Medical cannabis is increasingly used to manage chronic pain, particularly in jurisdictions that have enacted policies to reduce use of opioids; however, existing guideline recommendations are inconsistent, and cannabis remains illegal for therapeutic use in many countries.
Cannabinoids are thought to affect pain through various pathways, including the endocannabinoid system, which has receptors in the central nervous system, periphery, immune and hematologic systems. Cannabis contains over 100 cannabinoids; the 2 most studied of which are delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). THC inhibits glutamate and 5-hydroxytryptamine release and increases dopamine secretion. CBD enhances adenosine receptor signaling, and decreases reactive oxygen species, tumor necrosis factor, and T cell proliferation, without the psychoactive effects of THC. The multifaceted analgesic and anti-inflammatory properties of cannabinoids may positively influence the perception of pain across different conditions.
Opioids are prescribed for 1 in 3 people living with chronic pain but increasing recognition of the harms associated with long term opioid use and greater appreciation for their, at best, modest benefits have generated enthusiasm for alternatives, including medical cannabis. In the US, 36 of 50 states and the District of Columbia have legalized cannabis for medical use, and some US states have passed laws encouraging cannabis as a substitute for opioids when managing chronic pain.
Although increasingly prescribed or authorized, the use of medicinal cannabis or cannabinoids for chronic pain remains contentious for many clinicians because of the suspected or known dangers associated with use. Some have criticized the substitution of one addictive substance (opioids) for another with uncertain benefit (cannabis).
An international guideline development panel including patients, clinicians with content expertise, and methodologists was assembled to examine evidence surround the clinical question as to the role of medical cannabis or cannabinoids for people living with chronic pain due to cancer or non-cancer causes. The panel produced this recommendation in adherence with standards for trustworthy guidelines using the GRADE approach. The recommendation was informed by a linked series of four systematic reviews summarizing the current body of evidence for benefits and harms, as well as patient values and preferences, regarding medical cannabis or cannabinoid use for chronic pain.
The panel issued a weak recommendation to offer a trial of non-inhaled medical cannabis or cannabinoids, in addition to standard care and management (if not sufficient), for people living with chronic cancer or non-cancer pain. The evidence synthesis was largely informed by oral preparations of medical cannabis or cannabinoids, including sprays, tablets, and oil drops administered sublingually, and does not apply to inhaled forms of cannabis, which entails pulmonary exposure to particulate matter and toxins.
In their recommendation, the panel was confident that non-inhaled medical cannabis or cannabinoids:
- Result in a small increase in the proportion of people living with chronic pain experiencing an important improvement in pain and sleep quality (high and moderate certainty evidence, respectively)
- Result in a very small increase in the proportion of people living with chronic pain experiencing an important improvement in physical function (high certainty evidence)
- Do not improve emotional functioning, role functioning, or social functioning (high certainty evidence)
- Result in a small to very small increase in the proportion of people living with chronic pain experiencing cognitive impairment, vomiting, drowsiness, impaired attention, and nausea, and a moderate increase in the proportion of individuals experiencing dizziness that increased with longer follow-up (moderate to high certainty evidence).
The panel was less confident about:
- Whether use of medical cannabis or cannabinoids resulted in reduced use of opioids (very low certainty evidence)
- Whether the use of medical cannabis or cannabinoids was associated with increased risk of cannabis dependence, road traffic accident-causing injury, falls, suicidal ideation or suicide, and other potential serious harms (GRADE very low certainty evidence).
The panel issued the following practical guidance:
- Therapeutic trials should start with low dose, non-inhaled cannabidiol (CBD) products, gradually increasing the dose and THC level depending on clinical response and tolerability (such as starting at a dose of 5 mg CBD twice daily and increasing by 10 mg every 2-3 days to a maximum daily dose of 40 mg).
- If response is unsatisfactory, clinicians may consider adding 1-2.5mg THC per day and titrating 1-2.5 mg every 2-7 days to a maximum of 40 mg/day.
- Prior cannabis experience should be considered, and adverse event monitoring should be carefully conducted.
- For younger or adolescent patients, CBD-predominant preparations should be preferred because of uncertain effects of THC on neurocognitive development.
A confession. I have become aware of the bias I carry regarding these products likely based on how “trendy” they’ve become as a seeming cure all tonic for whatever ails. Having said that, there are enough people I have cared for who swear by these products to at least leave me feeling curious, and this guideline helps to synthesize and summarize what is presently known.
Certainly I’m much more supportive of a patient using a CBD product than taking chronic opioids, and though all of the potential harms of these products are not know, it is hard for me to imagine they approach the ongoing damage being done to countless lives due to the potential harms of chronic opioid use. So my conclusion more and more has been consistent with the authors of this guideline: For selected patients, there is enough evidence for potential benefit for a condition that is quite challenging to treat that it sure seems worth a try.
Busse J, et al. Medical cannabis or cannabinoids for chronic pain: a clinical practice guideline. BMJ. 9 September 2021; 364:n2040. LInk
Mark and John
Carilion Clinic Department of Family and Community Medicine
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