The CDC guidelines, with accompanying editorials attached (JAMA, March 15) and the FDA’s response (NEJM, Feb 4 early online), provide a blueprint for opioid prescribing for primary care clinicians treating adult patients with chronic pain “outside of active cancer treatment, palliative care and end-of-life care.” “There are 12 recommendations. Of primary importance, non-opioid therapy is preferred for treatment of chronic pain. “Opioids should be used only when benefits for pain and function are expected to outweigh risks. Clinicians should evaluate benefits and harms of continued opioid therapy with patients every three months or more frequently. For patients with opioid use disorder, clinicians should offer or arrange evidence-based treatment, such as medication-assisted treatment with buprenorphine or methadone. The guideline is intended to improve communication about benefits and risks of opioids for chronic pain, improve safety and effectiveness of pain treatment, and reduce risks associated with long-term opioid therapy.” The FDA supports the CDC guidelines and has crafted its own responses for addressing these issues by refining these goals and “ensuring that all available effective tools are brought to bear on this epidemic,” and that “the evidence base for proper pain management and appropriate opioid use is optimized and translated into practice.” Of note (and addressed in an editorial attached), this guideline does not adequately address children. Click here to read the full text.
News You Can Use
Perspective from NEJM, 3/3: “Unreliable service, inconvenience, uncomfortable surroundings, and high prices make customers unhappy, and given the opportunity, they will go elsewhere. Uber, Silicon Valley’s response to the shortcomings of urban taxi and limousine services, has managed to upend an established industry by offering an appealing alternative. Uber’s technology-enabled incursion into a highly regulated market suggests that if consumers gain enough from a new solution, it can overcome powerfully entrenched economic and political interests. Is U.S. healthcare ripe for disruption by a medical Uber? This perspective is thought provoking…” Click here to read the full text.
“New sepsis diagnostic guidelines shift focus to organ dysfunction”‘ Assessment of clinical criteria for sepsis for the third International Consensus definitions for sepsis and septic shock”; Developing a new definition and assessing new clinical criteria for septic shock”; and “The Third International Consensus Definitions for Sepsis and Septic Shock”by jmiller on February 24, 2016
“Definitions of sepsis and septic shock were last revised in 2001. These updated definitions and clinical criteria should replace previous definitions, offer greater consistency for epidemiologic studies and clinical trials, and facilitate earlier recognition and more timely management of patients with sepsis or at risk for developing sepsis.” (JAMA, Feb) Click here to read full text.
“Proton pump inhibitor use and the risk of chronic kidney disease” and editorial “Adverse effects associate with proton pump inhibitors”by jmiller on February 17, 2016
(Jama Intern Med, early online) The article concludes: “Proton pump inhibitor use is associated with a higher risk of incident CKD.” See separate entry on PPIs causing dementia. Click here to read full text.
“Association of proton pump inhibitors with risk of dementia: A pharmacoepidemiological claims data analysis” and accompanying editorial “Do proton pump inhibitors increase the risk of dementia?”by jmiller on February 17, 2016
Published online first (Jama Neurol), the article concludes: “The avoidance of PPI medication may prevent the development of dementia. This finding is supported by recent pharmacoepidemiological analyses on primary data and is in line with mouse models in which the use of PPIs increased the levels of beta-amuloid in the brains of mice. Randomized, prospective clinical trials are needed to examine the connection in more detail. Click here to read full text.
According to The Medical Letter (Dec. 7), “When no suitable alternative is available, outdated drugs may be effective. How much potency they retain varies with the drug, the lot, the preservatives (if any), and the storage conditions, especially heat and humidity; many solid dosage formulations stored under reasonable conditions in their original unopened containers retain up to 90% or greater of their potency for at least 5 years after the expiration date on the label, and sometimes much longer. solutions and suspension are generally less stable. There are no reports of toxicity from degradation products of currently available drugs. Click here to read full text.
Great review article (NEJM Dec 24, 2015) that reviews the need for comfort-care skills in hospital practice; setting goals at the end of life: the importance of communication; understanding comfort care; evidence-based management of symptoms in dying patients; pain; dyspnea; cough; xerostomia; nausea and vomiting; constipation; anorexia and cachexia and the role of hydration and nutrition; fever; anxiety and insomnia; delirium; palliative sedation to unconsciousness at the end of life. The information presented “should provide clinicians in fields other than palliative care with a framework for delivering basic comfort care to hospitalized patients who are near death.” Click here to read full text.
Understanding variation in 30-day surgical readmission in the era of accountable care: effect of the patient, surgeon, and surgical subspecialtiesby jmiller on January 27, 2016
Article concludes: “Readmission occurred in more than 1 in 10 patients, with considerable variation across surgical subspecialties. Variation in readmission was overwhelmingly owing to patient-level factors while only a minority of the variation was attributable to factors at the surgical subspecialty and individual surgeon levels”. (Jama Surgery, Nov 1015) Click here to view full text.