American College of Physicians: Internal Medicine — Doctors for Adults ®

Advertisement

Internal Medicine 2012 News



Scientific Meeting News for April 20, 2012




Highlights

Make opiates safer, more efficient in a primary care setting

A packed and waiting hallway, a full auditorium, long lines for the Q&A, and a session that would have run over had the speaker not halted further discussion. It's all evidence that internists crave more knowledge about prescribing opiates for chronic pain. More...

Allergies are more than just a runny nose

"Somebody once defined the allergic diseases as that group of diseases that's relatively unimportant to those that don't have them," said Raymond G. Slavin, MD, MACP. More...


Breaking news

ACP, Consumer Reports collaborate on patient education resources for high-value care

The American College of Physicians and Consumer Reports yesterday announced a new collaborative effort to create a series of high-value care resources to help patients understand the benefits, harms, and costs of tests and treatments for common clinical issues. The resources will be derived from ACP's evidence-based clinical practice recommendations published in Annals of Internal Medicine. More...


For attendees

Fellowship consultation sessions available

ACP is offering "Advancement to Fellowship" consultation sessions at Internal Medicine 2012. More...

Pulmonology update covers COPD, pneumonia, lung cancer

There will be something for everyone at this afternoon's Update in Pulmonary Disease, according to session leader C. Gregory Elliott, MD, MACP. More...

Screening out low-value screens

General internists are frequently called upon to decide whether a certain test or intervention has sufficient value. To help, the moderators of today's Update in General Internal Medicine will discuss challenging choices that general internists routinely make. More...


Highlights


.
Make opiates safer, more efficient in a primary care setting

A packed and waiting hallway, a full auditorium, long lines for the Q&A, and a session that would have run over had the speaker not halted further discussion. It's all evidence that internists crave more knowledge about prescribing opiates for chronic pain.

The talk, delivered Thursday morning by Barak Gaster, MD, FACP, who practices at the University of Washington in Seattle, focused on keeping opiate prescribing efficient and workable in a primary care practice.

In the 1980s, the problem with chronic pain management was undertreatment, Dr. Gaster said. By the 1990s, a huge push by oxycodone manufacturers led to a huge prescribing push, he said, which created a corresponding problem with drug abuse and fatal overdoses. The pendulum is now swinging the other way, and he said the goal of his talk at Internal Medicine 2012 was to continue to slow the pendulum down.

Randomized, controlled trials show opiates have only mild to moderate efficacy for chronic pain, and very low doses are as likely to work as very high doses, Dr. Gaster said. And high dosing and long-term prescribing may have effects on the neuroendocrine system, including hypogonadism, low cortisol levels, sleep apnea, permanent hyperalgesia (presenting as a change in how people perceive routine or mild pain), and even death.

Dr. Gaster's #1 pearl for safe and efficient management is to have clear upper limits on dosing. The common wisdom is 120 milliequivalents of morphine per day, although Dr. Gaster believes that's too much. "We should all have in our heads what we feel is a safe dose of opiate" to prescribe, he noted.

Be wary when patients request more and more medications. "The failure to respond to these low doses is a red flag for abuse," Dr. Gaster said. Especially beware of self-dose escalations, such as when patients run out of pills early.

Next, for more efficient clinic visits, practice the patient encounter and have a prepared sentence in mind for patients who seek more than you are comfortable prescribing. Dr. Gaster suggested the following: "Honestly, I don't believe that the higher doses would be safe for you. This is the maximum dose that I feel comfortable prescribing in a safe way."

Another efficiency tool is a written care agreement, which helps identify high-risk patients who can't abide by the limitations that are set. Keep the care agreement simple because "kitchen sink" agreements that include every possible contingency become a contract, Dr. Gaster warned. With too much fine print, it can become "something the people don't read," he noted.

Dr. Gaster recommended that physicians focus on some key features. First and foremost, medications cannot be refilled early. Pseudoaddiction is a common patient presentation, when patients might run out of medication early because they are desperate and in a lot of pain.

"You can easily imagine how they'd take more pills in the course of the month than they were prescribed, and they are going to ask for an early refill that from afar will look like aberrant behavior [or] drug-seeking behavior. It will look like drug abuse," Dr. Gaster said.

Communicate that pills need to last the allotted prescription duration, Dr. Gaster advised.

"If you really communicate that point and people are still not able to keep to that schedule, then your suspicion for drug abuse goes up and your suspicion for pseudoaddiction, for desperate pain behavior, goes down," he said.

Another important point is to emphasize that lost or stolen medications or prescriptions cannot be refilled. Warn the patients that "This bottle of pills is like cash and I cannot replace it," he said.

The other key points to communicate are:

  • Refills are done by appointment only.
  • There can be no urgent requests. Appointments for refills must be requested at least two business days in advance.
  • Failure to follow these points will result in discontinuation of pain medications.

View the agreement as a communication tool, one that should be discussed three or four times throughout the continuum of care. The worst case scenario is when the contract is signed and filed in the medical record without discussion.

"It's a powerful tool, but not the be-all and end-all of whether to continue opiates," Dr. Gaster said.

Finding whether there is a signed contract in the chart is far less important than documenting the repeated reviews of expectations. For example, aberrant behavior doesn't have to be in the care agreement for a physician to decide whether to discontinue opiates. When red flags arise, it's always the physician's prerogative to stop or continue opiates, Dr. Gaster stressed.

Stopping opiates can involve years of tracking red flags in the patient record, Dr. Gaster said. But if serious red flags occur, then the medication should be stopped. It's the only safe option for care, he noted. Instead of firing the patient, provide ongoing care, but say in as straightforward a manner as possible, "In my medical opinion, this type of pain medication is simply not safe for you."

Again, to smooth the bad news during the visit, Dr. Gaster recommends physicians practice saying this beforehand, since patients aren't likely to take the news well.

"It's right up there with delivering a cancer diagnosis," he said.


.
Allergies are more than just a runny nose

"Somebody once defined the allergic diseases as that group of diseases that's relatively unimportant to those that don't have them," said Raymond G. Slavin, MD, MACP.

Despite his dire characterization, a group of inquisitive internists joined Dr. Slavin at 8:15 a.m. on Thursday to hear his thoughts on "Overcoming Diagnostic and Treatment Dilemmas in the Patient with Allergies" and ask questions about their own dilemmas.

Dr. Slavin, an allergist and professor of internal medicine and microbiology at St. Louis University in Missouri, encouraged his audience to take their patients' allergy complaints seriously, noting that allergic rhinitis affects more than 50 million Americans each year and incurs substantial costs in lost work and health care expenditures.

"I recoil when I hear folks told, 'You live in St. Louis, you just have to live with allergies,'" he said. Instead, clinicians should offer some of the many effective treatments for allergies, both seasonal and perennial.

The first treatment is making environmental adjustments to reduce exposure to the allergen. "Keeping the windows in the house and car closed is tremendously advantageous," Dr. Slavin said. Some good news for patients forced to do this in the summer is that the Internal Revenue Service allows a tax deduction for the cost of air conditioning to prevent allergic reactions, he added.

The most common seasonal allergens get their start before air-conditioning season, however. Tree season is in February and March, followed (with a week of overlap) by grass season. Then comes ragweed, a very common allergen, with a season running from August to October. Mold can be active from spring until it gets quite cold, Dr. Slavin said.

Knowledge of these seasonal patterns can be useful in diagnosing a patient's allergen. "If a patient tells you that when they go to a picnic on Labor Day, they have terrible problems with their nose or their chest, you don't need an allergist to tell you it's ragweed," he said.

Dr. Slavin offered some additional advice on allergy diagnosis. "The most naïve question a clinician can ask of a patient is, 'What's brand new in your environment?'" he said. Development of an allergy requires repeated exposure, because a patient's system must first be sensitized to the allergen. The tricky part is that there's no rule about how many exposures will be required; a child may develop a penicillin allergy on the second encounter with the drug, or a middle-aged woman could become allergic on her tenth time.

The good news is that incidence of new allergies does decrease with age. New food allergies, especially to common foods like wheat or dairy, are vastly more likely to develop in children than adults. But you can't rule out allergies entirely based on age, he warned. "We see patients who have never owned a cat until they were 60 years of age" developing new allergies, he said.

The bad news is that allergies are definitively on the rise for a number of reasons. "We're seeing so much more house dust mite sensitivity," said Dr. Slavin. This is likely due to people spending more time indoors and having better insulation of their homes. "House dust mites need heat and they need humidity," he added.

Seasonal allergies, on the other hand, may rising be due to warmer weather. "The only group that has benefitted from climate change is allergists," Dr. Slavin joked.

Experts have also theorized about the causes of a general increase in allergies across all Western societies. According to Dr. Slavin, the most accepted theory is the hygiene hypothesis—that less early exposure to dirt and disease has led to allergy development. "The moral is let your kids play in dirt and get infected," he concluded.



Breaking news


.
ACP, Consumer Reports collaborate on patient education resources for high-value care

The American College of Physicians and Consumer Reports yesterday announced a new collaborative effort to create a series of high-value care resources to help patients understand the benefits, harms, and costs of tests and treatments for common clinical issues. The resources will be derived from ACP's evidence-based clinical practice recommendations published in Annals of Internal Medicine.

"We are excited to work with Consumer Reports to extend the reach of ACP's High Value, Cost-Conscious Care Initiative to patients," said Steven Weinberger, MD, FACP, ACP's executive vice president and CEO. "ACP began this initiative two years ago to help physicians provide the best possible care to their patients while simultaneously reducing unnecessary costs to the health care system. The High Value Care resources will help patients understand the benefits, risks, and appropriateness of tests and treatment options for common clinical issues so that they can make informed decisions about how to improve their health."

The two organizations unveiled the initial pieces of the High Value Care series, two patient brochures about diagnostic imaging for low back pain and oral medications for type 2 diabetes. The High Value Care resources will be available on the websites of ACP, Consumer Reports, and Annals of Internal Medicine.

"We are pleased and excited to have the American College of Physicians as a partner in this sustained effort," said John Santa, MD, MPH, director of the Consumer Reports Health Ratings Center. "We are jointly committed to putting the brakes on overtesting and overtreatment and we agree that consumers will benefit when either patients or doctors initiate conversations about these delicate issues."

The organizations chose the initial topics because they are frequently experienced by patients. Low back pain is one of the most common reasons for a patient to see a physician and many patients with low back pain receive routine imaging. However, in its evidenced-based clinical practice guideline, ACP found strong evidence that routine imaging for low back pain with X-ray or advanced imaging methods such as CT scan or MRI does not improve the health of patients.

Type 2 diabetes is the most common form of diabetes, which affects 25.8 million Americans, or 8.3% of the U.S. population. In its evidence-based clinical practice guideline, ACP found that metformin is more effective, less expensive, and has fewer adverse effects compared to other oral drugs as initial drug therapy for type 2 diabetes. The guideline also notes that metformin reduces body weight and improves cholesterol profiles.

In addition to producing patient education brochures and video versions of the High Value Care content, Consumer Reports plans to publish information about the clinical topics in Consumer Reports magazine, the Consumer Reports On Health newsletter, and on its website.

Copies of the two High Value Care pieces are available at the Consumer Reports booth in the Exhibit Hall (Booth 1854), where attendees can also view a video about back pain.



For attendees


.
Fellowship consultation sessions available

ACP is offering "Advancement to Fellowship" consultation sessions at Internal Medicine 2012.

The sessions will be held at 10:30 a.m. and 3:45 p.m. on Friday, April 20, at the Membership Booth in the ACP Resource Center (Booth 1039 in the Exhibit Hall). Each session will be led by Capt. Jeffrey B. Cole, MC, USN, FACP, chair of ACP's Credential Committee. The Friday afternoon session is intended especially for international members, and Spanish-speaking staff will be present to translate information and questions. Fellowship application materials will be available for all eligible members.


.
Pulmonology update covers COPD, pneumonia, lung cancer

There will be something for everyone at this afternoon's Update in Pulmonary Disease, according to session leader C. Gregory Elliott, MD, MACP.

Dr. Elliott, a professor of internal medicine in the pulmonary division at the University of Utah, will summarize recent pulmonary research and place it into perspective for internists practicing in different settings. The update will be held in Auditorium A from 2:15-3:45 p.m.

"What I hope to do is cover important new information published in 2011 for clinicians who confront pulmonary problems," he said. "It was an important year for advances in pulmonary medicine."

Internists who practice primary care may appreciate the discussion of recent findings in lung cancer screening, specifically the National Lung Screening Trial's assessment of low-dose computed tomography scanning for patients who smoke. Dr. Elliott will discuss the benefits and some of the limitations of lung cancer screening.

Hospitalists, on the other hand, will want to focus in on the year's pneumonia research. Dr. Elliott plans to discuss two studies on this subject. One evaluated the use of steroids to reduce length of stay for patients with community-acquired pneumonia, and another explored the association between acid-suppressive medications and pneumonia.

Research on chronic obstructive pulmonary disease (COPD) is relevant to physicians practicing in either setting.

"I'll highlight important studies on preventing exacerbations of COPD," said Dr. Elliott. He'll discuss recent trials that assessed the effectiveness of azithromycin, salmeterol and multiple forms of tiotropium.

Dr. Elliott's review of these top six studies will provide a brief explanation of the results and methods before getting down to the key point: "As a clinician, this is what I'm going to do with this information."

This Update in Pulmonary Disease is Dr. Elliott's first for ACP, but he has done similar presentations at the American Thoracic Society meetings. "I'm looking forward to the session. I always do," he said. "I've never worried about whether there are a thousand people in the room. The ones that are there are the ones who are interested."

For those who are interested but unable to make the session, Dr. Elliott has also summarized the studies for an article in Annals of Internal Medicine, which will be published in a future issue, but was released on the journal's website Wednesday.

The article in Annals includes the latest in critical care as well, an oral presentation of which will be offered today in Auditorium A from 8:15-9:15 a.m., led by Polly E. Parsons, MD, FACP. Topics to be covered during the Update in Critical Care include ultrasound guidance for procedures, delirium assessment, novel therapeutic agents in acute lung injury, interventions to decrease hospital-acquired infections, use of procalcitonin to guide antibiotic therapy and disability after critical illness.


.
Screening out low-value screens

General internists are frequently called upon to decide whether a certain test or intervention has sufficient value.

To help, David Macpherson, MD, MPH, FACP, of the division of general internal medicine at University of Pittsburgh School of Medicine, and co-moderator Peggy B. Hasley, MD, MHSc, ACP Member, will discuss challenging choices that general internists make routinely during the Update in General Internal Medicine.

A large national survey published this year asked primary care physicians whether they think they provide too much care, whether their colleagues do, and whether subspecialists do. The majority response was yes, for all three categories, Dr. Macpherson said.

"The primary care physician workforce and general internal medicine sense is that there's too much care being delivered," he added.

The update, which will be held today from 4:30-5:30 p.m. in Auditorium B, will delve into the latest research findings on the value of such care. "Most of the articles we talk about get to this issue of not doing things that you used to do," Dr. Macpherson said.

To assemble the lecture, he and Dr. Hasley sought articles where the result was a low number needed to treat, indicating that the intervention had lots of value. "We didn't find many of those," he said. Again and again, studies showed a small amount of incremental benefit at great cost.

"We should stop doing things that we've done for a long time that are almost traditional in medicine," he said. "The general internists of America are saying 'I think we do too much.' And we can say, 'The literature that's coming out agrees with you.'"

For example, Dr. Macpherson said, an article that appeared last year in the New England Journal of Medicine showed that CT scans to screen for lung cancer had some potential benefit. But there are some major downsides to screening, including that 95% of the positive findings on a CT scan turn out not to be cancer.

Another article in the Journal of the American Medical Association showed that ovarian cancer screening doesn't save lives.

"For some things that the practitioner does in his office for screening, the literature now suggests that it's not as valuable as we once thought it was, and we should perhaps stop," Dr. Macpherson said.

Screening isn't the only tricky issue that will be tackled during the update. Studies published last year in BMJ and Annals of Internal Medicine showed that effective hypertension treatment requires more than one reading in the clinic before making medication decisions, Dr. Macpherson said.

According to the research, at least five readings are needed to diagnose hypertension, and ambulatory blood pressure monitoring may help as well.

"It fits into the value stream," Dr. Macpherson said. "We're arguing that we're overtreating this disorder, and to minimize that in the future, more readings are going to be necessary."

A systematic review published in Annals of Internal Medicine suggested that universal deep venous thrombosis (DVT) prophylaxis in hospitalized patients is not as valuable as once thought and does not reduce mortality.

"In the hospital setting, having everyone on subcutaneous heparin to prevent DVT is no longer believed wise," Dr. Macpherson said. "It shouldn't be subjected to a quality measure."

Also on the slate for the update session are studies from the New England Journal of Medicine on the new oral anticoagulants, rivaroxaban and apixaban, which are equivalent to warfarin, have no food interactions, require no anticoagulant monitoring, and offer convenience to patients.

But the benefits have to be weighed against the drugs' greater costs, Dr. Macpherson said.

"It gets into this issue of value, and is it really worth it in today's age of medical environment?" Dr. Macpherson said. "We're going to argue that we need to be careful about new-age, high-cost agents and widespread rapid adoption of them because the value is uncertain."

Finally, Dr. Macpherson will discuss developments in the treatment of pulmonary embolism, specifically a Lancet study suggesting that outpatient treatment can be safe and can avoid hospital stays.

The take-home message of this year's update, Dr. Macpherson said, is "Many things that we do have less value than we or our patients might think. They prolong life a few weeks, or one out of 300 patients may benefit but at enormous cost. As internists, we have to better inform our patients of their chances to benefit and the cost so we can be better stewards of the nation's health care spending."





Has Your Contact Information Changed?

To change your e-mail address or other contact information in our records, go here or call 800-523-1546, ext. 2600 (M-F, 9 a.m. - 5 p.m. ET).

About Your Subscription

You are receiving this newsletter as a benefit of your ACP membership. To unsubscribe, simply send a blank e-mail to leave-105814-17003158N@acpnews.org.

This is a daily newsletter providing updates from this year's Internal Medicine meeting. Please forward any comments or suggestions to the editor.

ACP respects your privacy and will not sell, lease or share your e-mail address with any other organization. The College will only use e-mail for the purpose of conducting College business and for communicating with College members.

Copyright © by American College of Physicians.

Share

 
 

What will you learn from your Annals Virtual Patient?

Reviews of the World's Top Medical Journals—FREE to ACP Members! Annals Virtual Patients is a unique patient care simulator that mirrors real patient care decisions and consequences. CME Credit and MOC Points are available. Start off with a FREE sample case. Start your journey now.

Products and Resources for Patients

Products and Resources for PatientsACP has developed easy- to-use materials designed to help educate your patients on self-management of a wide variety of common health conditions. Order yours today!