477 - Opioids for Pain, Blood Pressure Targets, Sharing Our Stories

From the CDC

1)  Prescribing Opioids for Pain – A Clinical Practice Guideline

Pain is one of the most common reasons adults seek medical care.  Approximately one in five U.S. adults had chronic pain (lasting > 3 months) in 2019 and approximately one in 14 adults experienced “high-impact” chronic pain, defined as having pain on most days or every day during the past 3 months that limited life or work activities.  

Opioids can be essential medications for the management of pain; however, they carry considerable potential risk. A systematic review published in 2014 by the Agency for Healthcare Research and Quality (AHRQ) found insufficient evidence to demonstrate long-term benefits of prescription opioid treatment for chronic pain, and long-term prescription opioid use was found to be associated with increased risk for overdose and opioid misuse, among other risks.  In 2014, the FDA required new safety labeling changes for extended-release and long-acting opioids. Changes included a boxed warning on the “risks of addiction, abuse, and misuse, which can lead to overdose and death.” In 2016, these warnings were added to the labels for immediate-release opioids.

The CDC recently updated their 2016 guideline on the use of opioids to treat pain. 

Evidence was categorized into the following types: type 1 (high strength), type 2 (moderate strength), type 3 (low strength), or type 4 (low strength with serious limitations). When no studies were available or the evidence was too limited to estimate effects, evidence was assessed as insufficient.  Recommendations were also assigned one of two categories (category A or B) based on multiple factors of overall quality of the recommendation.   Recommendations include:  

·       Maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient and only consider opioid therapy for acute pain (B3) and subacute and chronic pain (A2) if benefits are anticipated to outweigh risks to the patient.

·       Before prescribing opioid therapy for acute pain, discuss with patients the realistic benefits and known risks of opioid therapy (B3).

·       Before prescribing opioid therapy for subacute and chronic pain, discuss with patients the realistic benefits and known risks, work with patients to establish treatment goals for pain and function, and consider how therapy will be discontinued if benefits do not outweigh risks (A2).

·       When starting opioid therapy for acute, subacute, or chronic pain, prescribe immediate-release opioids instead of extended-release and long-acting (ER/LA) opioids (A4).

·       When opioids are initiated for opioid-naïve patients with acute, subacute, or chronic pain, prescribe the lowest effective dosage. If opioids are continued for subacute or chronic pain, use caution when prescribing opioids at any dosage, carefully evaluate individual benefits and risks when considering increasing dosage, and avoid increasing dosage above levels likely to yield diminishing returns in benefits relative to risks to patients (A3).

·       For patients already receiving opioid therapy, carefully weigh benefits and risks and exercise care when changing opioid dosage. If benefits outweigh risks of continued opioid therapy, work closely with patients to optimize nonopioid therapies while continuing opioid therapy. If benefits do not outweigh risks of continued opioid therapy, optimize other therapies and work closely with patients to gradually taper to lower dosages or, if warranted based on the individual circumstances of the patient, appropriately taper and discontinue opioids. Unless there are indications of a life-threatening issue such as warning signs of impending overdose (e.g., confusion, sedation, or slurred speech), opioid therapy should not be discontinued abruptly, and do not rapidly reduce opioid dosages from higher dosages (B4). 

·       When opioids are needed for acute pain, prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids (A4).

·       Evaluate benefits and risks with patients within 1–4 weeks of starting opioid therapy for subacute or chronic pain or of dosage escalation. Regularly reevaluate benefits and risks of continued opioid therapy with patients (A4).

·       Before starting and periodically during continuation of opioid therapy, evaluate risk for opioid-related harms and discuss risk with patients. Work with patients to incorporate into the management plan strategies to mitigate risk, including offering naloxone (A4). 

·       When prescribing initial opioid therapy for acute, subacute, or chronic pain, and periodically during opioid therapy for chronic pain, review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or combinations that put the patient at high risk for overdose (B4). 

·       When prescribing opioids for subacute or chronic pain, consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and nonprescribed controlled substances (B4). 

·       Use particular caution when prescribing opioid pain medication and benzodiazepines concurrently and consider whether benefits outweigh risks of concurrent prescribing of opioids and other central nervous system depressants (B3). 

·       Offer or arrange treatment with evidence-based medications to treat patients with opioid use disorder. Detoxification on its own, without medications for opioid use disorder, is not recommended for opioid use disorder because of increased risks for resuming drug use, overdose, and overdose death (A1).

Mark’s Comments:

While none of this should be “news,” I am alarmed at how often many of these recommendations are not being followed by colleagues.  Thus, the reminder to proceed  with caution.  The guideline provides extensive additional detail on “implementation considerations,” and these should be required reading for anyone who prescribes opioids in their practice.  Much gratitude to Roanoke’s own Beth Macy, author of the book Dopesick (and inspiration for the Hulu miniseries) for helping to elevate this conversation to a very human one, and helping me have a change of heart about it.   

Reference:

Dowell D, et al.  Clinical Practice Guideline for Prescribing Opioids for Pain – United States 2022.  MMWR Recomm Rep 2022;71(No.RR-3):1-95.  Link

From the American Academy of Family Physicians

2)  Targets for Hypertension Treatment

The American Academy of Family Physicians (AAFP) endorsed the hypertension treatment guidelines from the Joint National Committee on Hypertension in 2014. In 2017, the Academy partnered with the American College of Physicians to write a guideline for hypertension management in patients 60 and older. Both these guidelines adhered closer to the empiric evidence than the contemporaneous American College of Cardiology/American Heart Association guidelines, which were considered to have extrapolated evidence that applied only to a narrow group of patients to make more stringent hypertension control recommendations.

Given the additional data and recommendations that have come out in the last five years, the AAFP wanted to update their hypertension management guidance. There has generally been less focus in most recent guidelines on which medication is used for hypertension therapy, and more focus on the blood pressure targets for treatment, and this most recent AAFP guideline did the same.

The guideline was based on evidence from a systematic review from 2019 in the Cochrane Library with an update search performed by AAFP staff members. The guideline committee took pains to adhere to the principles of trustworthy guideline development from the National Academy of Medicine’s standards – including mechanisms to include the patient voice and peer review, using a modified version of the GRADE evidence synthesis and rating methods, and managing conflicts of interest.

The guideline has only two recommendations:

1.     For average risk individuals, the blood pressure target for hypertension treatment should be below 140/90 (strong recommendation; high-quality evidence). After a shared decision-making discussion, it is acceptable to aim for lower targets. The guideline committee found no evidence of improvement in all-cause or cardiovascular mortality and, while there was no difference in serious adverse events, minor adverse events were greater in the lower target group.

2.     Clinicians can recommend a target of below 135/85 to prevent myocardial infarction (MI, but not stroke) as it may provide a small additional benefit beyond treating to 140/90 (weak recommendation; moderate-quality evidence). In the principal systematic review, eight RCTs (N = 38,198) showed a reduction in MI (2.55% vs. 1.82%; RR = 0.84; 95% CI, 0.73 to 0.96, number needed to treat of 137 over 3.7 years).

The guideline makes several recommendations about implementation – coordinating with specialists who may have different hypertension management recommendations, measuring blood pressure appropriately in the office, helping patients with medication affordability issues, and discouraging the use of race as a proxy for biology or genetics in clinical decision making about specific antihypertensive agents. The guideline committee note the limitations of short follow up time in the evidence (3.7 years), heterogeneity in cardiovascular risk status in the subjects, inconsistent reporting of harms, and a lack of information to guide choice of medication.

John’s Comments:

This makes the eighth active guideline directed at primary care clinicians for the management of hypertension (there is a table in this publication that compares them all). While I appreciate the methods of this guideline, it’s hard to know how to interpret or implement the inclusion of a second separate recommendation that constitutes an alternative to the first recommendation based on less evidence and a different outcome. In addition, while it has become fashionable to talk about shared decision-making (SDM) in guidelines, too often we are not provided with the resources (not to mention the time) to conduct true SDM with our patients. Instead, I wish guidelines emphasized the nature of hypertension primarily as a risk factor for cardiovascular disease (rather than a disease in its own right), and offered patients targeted treatment based on risk. Most of our quality metrics have moved to 140/90 as a blood pressure target in the last 1-2 years, so at least the first recommendation is consistent with those measures.

Reference:

·       Coles, Sarah, Lynn Fisher, Kenneth W Lin, Corey Lyon, Alexis A Vosooney, and Melanie D Bird. “Blood Pressure Targets in Adults With Hypertension: A Clinical Practice Guideline From the AAFP” 106, no. 5 (2022). Link

From PeerRxMed ( www.PeerRxMed.org )

3)  We Need to Share Our Stories … With Each Other

“Everybody is a story ….  The most basic and powerful way to connect to another person is to listen. Just listen.”   Rachel Naomi Remem, MD

As physicians, we know how quickly the trajectory of a life can change.  We see that with our patients all the time.  We all have our patient stories.  But what about our own lives?   What about our own stories?   Specifically, where do we go to tell our stories of the tragedy, despair, powerlessness, woundedness, pain and loss we see daily in our work?  Where do we go to grieve?  

“Tell me the story about your loss.” she said.  “I’m here to listen.  We’ve got time.”   So, after carrying that story around in my head, in my heart, and in my throat for more than a year, I did.  I shared, and I cried, and I shared some more. 

I told her of the night when the trajectory of my own life and the lives of many others changed in a way that was completely unanticipated, uninvited, and unwanted.  It started with what initially appeared to be one of the 100’s of normal obstetric deliveries I had assisted with to that point in my professional career.  Instead, things went very quickly in a different direction, and what was supposed to have been a time of joy for new life instead became the agony of the death of a young mother and the neurologic devastation of a newborn baby. 

I revealed that over the next year, I gave the impression all was fine; that I had processed this tragedy, incorporated the lessons into my life, and moved on, because that is what we physicians do.  Too often we believe we’re somehow magically invulnerable to the tragedy and suffering surrounding us each day.  But on the inside, I was a shell of a human, living in constant distress and experiencing a myriad of emotions, including shame, guilt, embarrassment, despondence, anger … and grief.  And though some colleagues tentatively reached out to offer support, the forces of “I’m fine” were too great and I kept them at a safe distance even as I felt totally alone.  Eventually, after exhausting all rationalizations that insisted I could handle this on my own, I finally did reach out for help, to the only option I could think of at that time – a therapist who became an angel and a lifeline for me. 

That was only the first of many stories shared, and over time the sharing of those stories led to healing of open emotional wounds from my professional journey that I wasn’t even consciously aware I was carrying.  As I healed, I vowed that I would do what I could to help other colleagues struggling on our professional journey so they would never have to go through even one moment of the unnecessary emotional turmoil I experienced.  So here we are, traveling the PeerRxMed journey together. 

“Tell me about your recent loss,”  one of my PeerRx partners encouraged.  “I’m listening.”  PeerRxMed was created to help break down the many barriers the culture of medicine has created which interfere with our fundamental human need to connect with and support each other, including in our grief.  In my PeerRx partners, I’ve found a safe space where we can share our stories – stories of grief, of burdens, of loss, and also of the many blessings of our work.  So don’t keep those stories bottled up inside.  The work we do is good and important work, but it can take a significant toll if we don’t have a place to process it.  We need to share our stories with each other.  No one should care alone. 

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org