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Table of contents
- Exhibit Show Tasks
- Evidence-based pain medicine for primary care physicians
- Assessment of Addiction Medicine Training in Family Medicine Residency Programs: A CERA Study
- The ASAM Review Course 2018
Unfortunately, research demonstrates that many primary care physicians are uncomfortable with providing SUD care. The most recent survey on addiction medicine training in primary care residencies was completed in Our study aimed to describe the current state of addiction medicine training in US FMRs, including the prevalence of required curricula, resident pursuit of addiction training or certification, barriers to improving curricula, and faculty addiction medicine training.
The survey includes a set of recurring general questions as well as a set of invited topical questions that change with each survey. The recurring questions describe FMR characteristics including residency director gender and years in position; number of non-US graduates; whether the program was university-based or community-based; geographic region; and community size. The invited questions are proposed by family medicine faculty and selected by the CERA steering committee. The survey is sent by email via Survey Monkey and three follow-up emails are sent to nonrespondents.
We added to the December CERA survey 12 questions about addiction medicine residency training that aimed to address the following domains: To validate the questions, the CERA steering committee reviewed draft questions for consistency with the study aims and overall readability. Draft questions were pretested with FMR faculty who were not part of the target population. Questions were then modified based on feedback. These questions were similar to the questions from the addiction medicine survey. Program directors were then asked to select the expected competency of residency graduates in addiction medicine with options including: To assess for potential workforce production, program directors were asked whether 1 any graduating residents pursued fellowship training in addiction medicine in the past 3 years and 2 any graduating residents obtained a buprenorphine prescription waiver in the past year.
We considered obtaining a buprenorphine prescribing waiver as a measurable surrogate for the future provision of addiction medicine since buprenorphine, one of the primary medications used in the treatment of opioid use disorder in primary care, requires a Drug Enforcement Agency waiver to prescribe. To determine barriers to improving or implementing addiction medicine curricula, program directors were asked to rank the top three barriers from a multiple choice list of seven.
These options were selected in consensus among co-authors. Next, respondents were asked to rank on a scale of zero to ten, with zero being not a priority and ten being a high priority, how high a priority teaching addiction medicine was for their program. Three questions queried program directors about faculty training in addiction medicine. These questions asked whether any faculty member in their residency program had 1 board certification in addiction medicine; 2 fellowship training in addiction medicine; and 3 a buprenorphine prescribing waiver.
We used SAS 9. Categorical measurements were summarized with frequencies and proportions, and numerical measurements were summarized with means and standard deviations. Chi-square tests were used to determine if the distribution of survey responses was significantly associated with other categorical survey responses and t-tests were used to compare numerical survey responses against categorical survey responses. Logistic regression was used to calculate the odds ratio of having at least one graduate obtaining a buprenorphine prescribing waiver and at least one graduate pursuing addiction medicine fellowship training based on other categorical survey responses.
The response rate for the overall survey and the addiction medicine subset of questions was Of those that do not have a required curriculum, an additional 28 An optional specialized area of concentration or specialty training track in addiction medicine is only offered at 27 programs FMRs serving mid-sized communities with a population of 75,,, are most likely to have a required curriculum Additionally, there was a trend, although not statistically significant, for FMRs in the Northeast to have a required curriculum Furthermore, FMRs in the Northeast are significantly more likely to have a structured elective offered Despite the paucity of FMRs with an addiction curriculum, Of programs that expected residents to be comfortable prescribing medications for SUD, Of program directors, 8.
FMRs that required addiction training or offered additional elective opportunities or areas of concentration had higher odds of having resident graduates with buprenorphine waivers or pursuing fellowship training. Program directors identified teaching addiction medicine in FMRs as a moderate priority 5. Lack of faculty expertise was most commonly identified as the top barrier and lack of faculty time was most commonly identified as one the top three barriers Figure 1.
Having board-certified or buprenorphine waivered faculty was associated with higher odds of having a required or elective addiction medicine curriculum. Most family medicine residencies do not have a required addiction medicine curriculum. Despite the increased national attention to the growing SUD epidemic and the multifaceted sequelae from drug abuse, program directors only rank teaching addiction medicine as a moderate priority.
Nonetheless, many programs still expect residents to graduate proficient in diagnosing SUD and prescribing medications for SUD. Expectedly, few residency directors report that their graduates obtain buprenorphine prescribing waivers. Residency directors recognize that a lack of faculty expertise is a key barrier to improving or providing addiction training. Multiple curricular and faculty development efforts have been attempted over the past decade to improve addiction medicine training. However, these efforts may fall short of their intended goal if family medicine faculty are not adequately trained to teach addiction medicine.
Improving continuing medical education opportunities for faculty, in addition to providing technical assistance to programs that may want to start an addiction medicine curriculum, may improve training for family medicine residents and expand the workforce to care for patients with SUD. This study has several limitations. First, the response rate of This may have resulted in differing answers by program directors based on their perceptions of what constituted addiction medicine. Further, obtaining a buprenorphine waiver was used as a graduate outcome proxy but may not necessarily be reflective of actual provision of SUD care.
Finally, the survey only assessed the state of family medicine residencies and did not include other primary care specialties. This study updates for the first time in almost 20 years the state of addiction medicine training in US family medicine residencies. It is possible that fewer residency programs have an addiction medicine curriculum in than This potential trend toward fewer programs teaching addiction is concerning given the increase in drug overdose deaths since Clearly, changes are needed in FMRs to better address the growing opioid epidemic.
CERA survey respondents identify lack of faculty expertise as the top barrier to training residents. Efforts to recruit faculty with addiction expertise or train current faculty to teach addiction medicine will be key prerequisites to improving addiction medicine curricula in FMRs. This is demonstrated by the lack of interest among faculty and residents, and the lack of required or elective addiction medicine training. However, comorbid psychosocial factors are the strongest predictors of disability from chronic pain. Because patients with chronic pain often lack adequate insight into their psychosocial situations, they will often underreport psychosocial issues.
Pursuit of disability is a common secondary gain issue. Disability determination should be carefully assessed by providers trained and skilled in functional evaluation. Disability should not be rewarded based on complaints of pain but based on objective physical impairments. Finally, it seems overly simplistic to assume that opioids will increase function through pain alleviation. Tolerance to the analgesic effect of opioids develops quickly in most individuals, diminishing safe therapeutic windows over time well within the expected duration of chronic pain.
Conversely, the presence of biopsychosocial comorbidities is common in the population with chronic pain, especially for people who are disabled. These comorbidities are risk factors for chemical coping i. Oversimplification of pain by referring to it as a fifth vital sign, ignoring its behavioral aspects, and aggressively using opioids as a first-line treatment has greatly contributed to the current epidemic of prescription drug abuse and accidental lethal drug overdoses.
Currently, the pharmacological management of pain is mired in controversy. At the center of this controversy is the role of opioids in the treatment of pain. Frequently forgotten is the concept that the pharmacological treatment of pain should almost always start with nonopioid medications.
The choice of drug should be dependent upon an understanding of the time course and pathophysiology of pain-producing processes.
For patients with acute musculoskeletal pain, the vast majority will improve significantly over the first month. If necessary, first-line pain medications should generally be a short course of an NSAID or a skeletal muscle relaxant not including carisoprodol. Current best evidence indicates that these medications can provide measurable reductions in pain with an increase in function in the acute setting.
Unfortunately, opioids are all too frequently prescribed for acute musculoskeletal pain. A recent randomized controlled trial demonstrated that the addition of opioids to NSAIDs in patients with acute low back pain did not improve either pain or function at 1 week but was associated with increased side effects. For patients with chronic musculoskeletal pain, a multidisciplinary care plan is essential. Optimizing pain and function will require continued physical rehabilitation medicine and biopsychosocial treatments as discussed in previous sections. In the event that these therapies produce an inadequate response, it can be reasonable to consider chronic pharmacological therapy.
As with the management of chronic musculoskeletal pain, treatment should almost always start with nonopioid medications. A recent randomized trial demonstrated a lack of efficacy for acetaminophen in both chronic spinal pain and pain related to osteoarthritis. However, there is a higher all-cause mortality among older people using opioids than among those using NSAIDs.
In addition, adverse gastrointestinal and renal events were lower in the celecoxib group. A unique class of patients includes those with neuropathic pain such as diabetic peripheral neuropathy, phantom limb pain, sciatica, spinal arachnoiditis, and postherpetic neuralgia. Among these patients, chronic treatment with NSAIDs is unlikely to produce significant pain reduction.
First-line pharmacological treatments should focus on membrane-stabilizing medications such as gabapentin, 53 pregabalin, 54 tricyclic antidepressants, 55 duloxetine, 56 and topical local anesthetics. Considering a trial of opioids is a critical step in clinical decision making. This step should generally only be considered after multiple other therapies have failed and the patient is determined to have an appropriate risk profile using risk stratification techniques. Thus, given the significant risks associated with COT, this is an excellent time to consider referring the patient to a pain medicine specialist for a second opinion.
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Combined with a growing acceptance of opioid therapy among medical professionals in addition to a robust advertising campaign by opioid manufacturers, the last several decades have seen a surge in COT for the treatment of pain. Despite initial hopes, the efficacy of COT for the treatment of pain remains controversial. Several recent meta-analyses did not demonstrate a significant pain or functional change with COT. Given the complexities of pain assessment, lack of evidence does not necessarily demonstrate lack of effect.
However, it is difficult to rationalize the current national opioid prescribing patterns when the literature clearly illustrates the risk of COT while concurrently providing questionable evidence of benefit. Though studies of opioids may demonstrate short-term pain relief, there is no difference in function, sleep, or mood.
In fact, the use of opioids has been associated with delayed recovery, increased disability, and lower function. It has been suggested that opioids worsen outcomes by promoting physical deactivation and apathetic mood. For example, success rates for lumbar facet denervation for back pain were lower in patients receiving opioids. Older observational studies did not identify any impairment in driving related to opioids.
However, a new population-based study demonstrated a dose-related risk of road trauma i. Concurrent with the rise in opioid prescriptions, there was a staggering increase in opioid-related morbidity and mortality. The unfortunate utilization of opioids as a first step in the treatment of pain has both increased access to opioids and led to an increase in opioid addiction, abuse, overdoses, and drug-related deaths. Many opioids reach their victims through diversion transfer. Recent data estimate that In two studies, it was reported that risk of overdose death increases exponentially as the prescribed doses increase.
These facts suggest a lack of appropriate risk assessment prior to starting opioids and inadequate monitoring of COT. Along with monitoring the long-term physiologic consequences of COT, the standard of care for physicians who prescribe COT is to employ appropriate risk assessment tools and closely monitor patients for misuse, abuse, and diversion. Given the well-documented risks associated with COT and the opioid overdose epidemic, in the Centers for Disease Control and Prevention CDC issued guidelines for primary care providers when prescribing opioids for the treatment of chronic pain.
The fundamental tenet of this document is that comprehensive pain management should take a multimodal and multidisciplinary approach. Rehabilitation treatments, psychological assessment and treatment, nonopioid pharmaceuticals, and interventional procedures should all be considered prior to initiating COT. In addition, risk stratification and continued monitoring are absolutely essential if COT is utilized. All physicians who prescribe opioids should be well versed in the CDC guidelines. Opioids can produce a wide array of side effects following both acute and chronic usage.
COT produces a dose-dependent central hypogonadism state in both men and women. The hypogonadism mechanism appears to be direct inhibition of gonadotropin-releasing hormone release. Decreased serum testosterone levels and COT are associated with osteoporosis and osteoporotic fractures. Symptoms suggestive of hypogonadism include loss of libido, impotence, infertility, depression, anxiety, loss of muscle mass and strength, loss of gender role, fatigue, amenorrhea, irregular menses, possibly galactorrhea, osteoporosis, osteoporosis-related fractures, and lower pain threshold.
Unfortunately, these symptoms are common in patients with chronic pain, even without abnormal sex hormone levels. Therefore, individuals using COT should be assessed for gonadal function, and all at-risk individuals should have bone mineral density measurements. Because endocrine supplementation is complex, referral to an endocrinologist may be prudent. Opioids are powerful analgesic agents in the short term. Opioids attenuate the nociceptive experience by interacting with both central and peripheral mu opioid receptors. Unfortunately, persistent nociceptive experiences are associated with DNA activation of previously inactive genomes, resulting in protein synthesis and expression of numerous previously unavailable receptor complexes, thus allowing maladaptive intercellular communications.
As a result, multiple receptor interactions are involved in the production and communication of chronic nociceptive pain perception. Therefore, pharmaceutical manipulation of opioid receptors may not be the best route to produce analgesia in a chronic pain state. In the last several years, laboratory and clinical research has provided compelling evidence that opioid exposure can create an abnormally low pain threshold sensitivity.
There is new evidence suggesting that hyperalgesia and allodynia may occur while on uninterrupted opioid therapy. Clinically, opioid-induced hyperalgesia is similar to the development of opioid tolerance i.
Exhibit Show Tasks
Clinical indicators suggesting opioid-induced hyperalgesia include chronic requirement for high-dose opioids, poor function and quality of life despite reasonable doses of opioids, expansion of pain to previously nonpainful sites, and escalation of pain complaints in parallel to opioid dose increases.
Hyperalgesia can develop rapidly. It has been observed within 1 week or even after a single exposure to opioids in laboratory animal models. Therefore, patients prescribed COT would benefit from a referral to comprehensive pain management specialists for evaluation and consideration of other modalities of care. Perhaps the best option is to reserve COT for well-selected individuals who have been compliant with multimodal therapies and quality multidisciplinary functional restoration attempts but failed to make adequate progress.
Opioid-induced respiratory depression tends to be a short-lived phenomenon. Recent data suggest that COT increases the risk for central sleep apnea and may aggravate obstructive sleep apnea. This risk is potentiated when opioids and benzodiazepines are combined. Tolerance to central sleep apnea or obstructive sleep apnea does not occur.
Thus, significant risks exist with COT, particularly in patients with sleep apnea who take benzodiazepines. Coadministration of opioids with other central nervous system sedatives, especially benzodiazepines, should be avoided. Opioid use has been found to cause depression, and recent studies have demonstrated that new-onset depression is directly related to both dose and duration of exposure. The patient's depression may not respond to therapy until his or her opioids are discontinued.
The incidence of aberrant drug-taking behavior in the chronic pain population is very difficult to determine. This stems in part from a reluctance of those misusing or abusing opioids to readily admit it to their physician. A proxy measurement for misuse and abuse is the frequency of urine drug tests UDTs that are inconsistent with the specific pain prescription for the patient. Clearly, it is a good standard of care to screen for risk factors predictive of aberrant drug-taking behavior prior to initiating COT.
Aberrant drug-taking behavior is a patient and public safety concern requiring corrective action. Risk factors associated with aberrant drug use have been identified by numerous studies and include the following Screening metrics are available for stratifying COT risk factors. The CAGE questionnaire and other screening tools can assess problematic alcohol use. Unfortunately, patients with unstable biopsychosocial factors are those most likely to be prescribed COT.
Evidence-based pain medicine for primary care physicians
Prescription monitoring programs have the ability to provide quasi-real-time dispensing data about a patient's use of controlled substances. Once the database became available to clinicians online, it became a powerful tool to identify aberrant drug-taking behavior or the presence of dangerous drug combinations i. In addition, prescription monitoring programs are a powerful tool to help physicians identify patients who may be doctor shopping and or diverting opioids transferring them to others.
In conclusion, the appropriate utilization of pharmacological therapies for the treatment of pain requires an understanding of both the nature of the pain and the type of person experiencing the pain. First-line drugs for the treatment of pain should almost always be nonopioids. COT may be a friend to some, but is a foe to many.
Only an unknown fraction of patients with chronic pain will benefit from COT. The majority will experience more risk and harm than benefit. COT appears to delay recovery and promote declining function for many. Only well-selected patients appear to benefit from COT. Ignoring the biopsychosocial aspects of pain ultimately comes at the patient's peril. The ideal time to perform a pain procedure is generally following a good faith trial of conservative management.
One of the advantages of interventional procedures is that they may prevent some of the risks and side effects associated with pharmacotherapy options, particularly opioids. Unfortunately, following the initiation of opioids, procedural interventions can be less effective. Due to a surge in clinical research, numerous randomized controlled trials have demonstrated the efficacy of many pain procedures. There is good to excellent evidence to support the following procedures: In conclusion, the treatment of chronic pain is important, but it is also extremely important to deliver safe and effective treatments using evidence-based treatments as first-line strategies.
Fortunately, there are evidence-based treatments for chronic pain that are conservative therapies: Unrecognized and unstable biopsychosocial comorbidities are common in the population with chronic pain, particularly in the poorly functioning population with chronic pain. Unstable biopsychosocial comorbidities are barriers to recovery and risk factors for aberrant drug-taking behaviors. National Center for Biotechnology Information , U.
Proc Bayl Univ Med Cent. Published online Jan 8. Owen , MD, a Brian M. Eckmann , MD, d Erik C. Hustak , MD, e and Mitchell P.
Assessment of Addiction Medicine Training in Family Medicine Residency Programs: A CERA Study
Engle , MD, PhD f. Author information Copyright and License information Disclaimer. Acute pain, chronic pain, opioids, pain interventional procedures, pain medicine, psychological treatment for pain, rehabilitation treatment for pain. This evaluation should include the following: Physical modalities Physical modalities are agents used to produce therapeutic tissue responses. Therapeutic exercise and activity Though physical modalities may temporarily reduce pain and provide an alternative to pharmacological therapy, they are passive approaches to pain management.
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Complementary modalities The most recent treatment guidelines from the American College of Physicians ACP recommend nonpharmaceutical treatments for acute and chronic low back pain as first-line treatments. Psychological pain therapy Psychosocial comorbidities are commonly seen in patients with chronic pain. Disability Disability is the result of a complex interaction between physical, psychosocial, cultural, and educational processes.
Nonopioid pharmaceuticals For patients with acute musculoskeletal pain, the vast majority will improve significantly over the first month. The risks of chronic opioid therapy Though studies of opioids may demonstrate short-term pain relief, there is no difference in function, sleep, or mood. Side effects and complications of COT Opioids can produce a wide array of side effects following both acute and chronic usage. Opioid-induced endocrinopathies COT produces a dose-dependent central hypogonadism state in both men and women. Opioid-induced hyperalgesia Opioids are powerful analgesic agents in the short term.
Opioid-induced central sleep apnea Opioid-induced respiratory depression tends to be a short-lived phenomenon. Opioid-induced mood disorders Opioid use has been found to cause depression, and recent studies have demonstrated that new-onset depression is directly related to both dose and duration of exposure. Opioid misuse and abuse The incidence of aberrant drug-taking behavior in the chronic pain population is very difficult to determine.
Screening metrics Screening metrics are available for stratifying COT risk factors. Prescription monitoring programs Prescription monitoring programs have the ability to provide quasi-real-time dispensing data about a patient's use of controlled substances. Pharmacological conclusions In conclusion, the appropriate utilization of pharmacological therapies for the treatment of pain requires an understanding of both the nature of the pain and the type of person experiencing the pain.
Competency and certification of pain physicians. Pain terms, a current list with definitions and notes on usage. Accessed November 1, Criticisms of the biopsychosocial model in spine care: Spine Phila Pa Predictors of postoperative pain and analgesic consumption: Long-term opioid management for chronic noncancer pain. Cochrane Database Syst Rev.
American Pain Society presidential address. Measuring pain as the 5th vital sign does not improve quality of pain management. J Gen Intern Med. The efficacy and safety of pain management before and after implementation of hospital-wide pain management standards: Unidimensional pain rating scales: Chou R, Shekelle P.
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Will this patient develop persistent disabling low back pain? Psychosocial predictors of disability in patients with low back pain. The effects of depression and chronic pain on psychosocial and physical functioning. Management of chronic low back pain. Am J Phys Med Rehabil. Is cold therapy really efficient after knee arthroplasty? Ann Med Surg Lond. Transcutaneous electrical nerve stimulation for the treatment of chronic low back pain: Nicholson B, Verma S. Comorbidities in chronic neuropathic pain.
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Prospective study on the relationship between depressive symptoms and chronic musculoskeletal pain.