#531 - Anticoagulation Duration for PE, Opioids For Pain, Toxic Positivity

A Question From a Colleague.

1)  Anticoagulation Duration for Pulmonary Embolism

Question:  “Can you please address the reasons for continuing treatment for pulmonary embolism (PE) for 6 months (rather than the standard 3 months) in Take 3? We all can determine who needs indefinite anticoagulation, but the decision to increase to 6 months duration seems murky.”

Answer:  Venous thromboembolism management has changed dramatically in the last 20 years and the accepted guideline for anticoagulation practice is a periodic issue of the journal Chest from the American Thoracic Society. For a PE that is provoked by surgery, a transient non-surgical risk factor (not cancer), or is unprovoked, 3 months of anticoagulation with a direct oral anticoagulant (DOAC) medication is recommended regardless of bleeding risk. Three months is preferred over six, twelve, and twenty-four months specifically. For patients with cancer, low molecular weight heparin (LMWH) is recommended for 3 months, followed by either continued LMWH or DOAC indefinitely.

The choice about “extended” anticoagulation therapy comes when the patient has had an unprovoked PE and has only a low-moderate bleeding risk (0-1 bleeding risk factors) or experiences a recurrence of PE. But “extended,” in this guideline, means “indefinite” or “no stop date.”  If extended therapy is being considered, at the 3-month mark stop the anticoagulants for 4 weeks and check a d-dimer (d-dimer is not reliable on anticoagulants). If the d-dimer is elevated, the patient has double the risk of VTE. If the patient is male, that increases the risk by 75% also.  There are no recommendations for 6 or 12 months of therapy. Studies used to make this recommendation showed that risk of recurrent VTE remained low while on the anticoagulant but rose back to the same baseline level regardless of how long anticoagulation lasted. Of note, these studies were done with vitamin K antagonists (warfarin), but the guideline noted that they have insufficient evidence to make separate recommendations for DOACs.

A systematic review from 2020 found only three studies with data that addressed the issue of length of anticoagulation with DOAC. It showed a benefit to longer anticoagulation (one year or more) in terms of both recurrence of VTE and mortality. The study pointed out an increased bleeding risk with the DOAC vs. placebo, but the absolute risk of bleeding in either group was fairly low. The results were heterogenous and dominated by a single study.

John’s Comments:

The decision to start or continue anticoagulation is about a risk-benefit discussion of bleeding vs. prevention of further clotting. The evidence for long-term anticoagulation with DOAC for PE is fairly scant, and the recommendations are based on evidence about VKA and a collection of evidence favoring DOACs (especially apixaban and rivaroxaban) for bleeding risk. The Chest guidelines advocate either 3 months of anticoagulation or indefinite anticoagulation for most VTE, depending on risk of further embolus and amount of bleeding risk. There are no current recommendations for any of the intermediate durations. Given that risk of recurrence upon discontinuation of anticoagulation is no different with 3, 6, 12 or 24 months of treatment, three months seems to be the best choice unless there is a reason to continue to suppress that risk indefinitely.

References:

• Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease. Chest. 2016;149(2):315-352. Link
• Ebraheem M, Alzahrani I, Crowther M, et al.  Extended DOAC therapy in patients with VTE and potential risk of recurrence: A systematic review and meta‐analysis. Journal of Thrombosis and Haemostasis. 2020;18(9):2308-2317. Link

From the CDC and the Guidelines

2)  Prescribing Opioids for Chronic Pain – A Guideline Reminder

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.  In 2022 the CDC updated their 2016 guideline on the use of opioids to treat pain.  Based on some recent conversations, we thought a reminder was in order.  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 exclusively (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, 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 therapy, work closely with patients to optimize nonopioid therapies.  If benefits do not outweigh risks of continued 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. 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 or rapidly reduced (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 (A4).
• Before starting and periodically during continuation of opioid therapy, evaluate risk for opioid-related harms and discuss risk with patients.  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 thereafter, review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data (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.   I recently facilitated an American Board of Family Medicine (ABFM) maintenance of certification “Group Knowledge Self-Assessment” workshop on Pain Management for the Virginia Academy of Family Physicians, and this guideline was highlighted numerous times.  The guideline provides extensive additional detail on “implementation considerations,” and I would strongly recommend reading these if you prescribe opioids in your practice.  

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 PeerRxMed ( www.PeerRxMed.org )

3)  It’s Time to Do More Attending and Less Pretending

“Toxic positivity is positivity given in the wrong way, in the wrong dose, at the wrong time.”  David Kessler, author of “Finding Meaning: The Sixth Stage of Grief.”

“We just need to be more positive!”  These words from a healthcare executive in the midst of a discussion about the sobering results of a physician well-being survey still haunt me.  In this case, it felt much more like a disingenuous denial of reality rather than a misguided attempt at encouragement.  The impact was a “poisoning” of the conversation and shutting down of any meaningful dialogue.  In other words, it felt toxic.

In the midst of our demanding work, positivity is often seen as a beacon of hope guiding both clinicians and patients through the darkest of times.  Yet, there exists a shadow, a phenomenon known as "toxic positivity," which can undermine the very essence of genuine support and understanding.  Toxic positivity is the belief that one should have a positive mindset and express only positive emotions and thoughts at all times, particularly when things are difficult.   It often comes disguised as a simplistic attempt to circumvent a challenging circumstance, using phrases such as “No worries,” “It’s all good,” or “It could be worse.”  Although perhaps well-intentioned, it has the effect of discounting, dismissing, or even denying emotions that are not positive. 

Hopeful optimism is a process of anticipating positive circumstances and desirable outcomes without denying present reality and is a constructive coping strategy.  Forced optimism or toxic positivity, on the other hand, encourages us to deny any “negative” emotions we might be experiencing, even if they seem appropriate to the circumstances.  In healthcare, where emotional and physical stakes are high the resulting damage can be quite real, including the erosion of trust, emotional harm by devaluing a cry for help, and the suppression of vital dialogue or glossing over adverse circumstances that need to be addressed. Research has shown that acknowledging a range of emotions can lead to better coping strategies, resilience, and support networks in medical settings, and that imagining the future in a hopefully optimistic way can help promote thriving and sustain us during challenging times. 

How do we emphasize the positive without denying or suppressing the negative so we can break this all too pervasive tendency toward toxicity?  By practicing!  I found this wonderful resource on the website positivepsychology.com called “Harmful to Helpful Toxic Positivity Phrases” that provides a starting point for reframing some of the well-intended but often harmful reflexively used “just be positive” phrases.

This upcoming week, be aware of any tendencies you might have to dismiss or minimize the struggles of those around you (and your own!) and note when “positivity phrases” might be inappropriately used by yourself or others.  It’s likely not “all good” right now.  Far from it.  Pretending isn’t fooling anyone.  But there is good news.  You don’t have to navigate any “this is hard for me” alone.  The antidotes to our regular challenges are hopeful optimism and positive connection.  Let’s remember to use them generously and frequently to ensure that no one cares alone …. not now, not ever.

______________

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