A foolish consistency: topical NSAIDs for acute pain and lung cancer screening

I confess that I don't recall having read Ralph Waldo Emerson's essay "Self-Reliance," which contains the quotation: "A foolish consistency is the hobgoblin of little minds, adored by little statesmen and philosophers and divines." Instead, this sentence permanently etched itself into my mind after watching the 1998 romantic comedy "Next Stop Wonderland," which remains my favorite movie set in Boston. And it feels more applicable today than ever, as health officials from Dr. Anthony Fauci to Surgeon General Jerome Adams have been unfairly pilloried for changing their early positions on the threat that COVID-19 posed to Americans and the need to wear face coverings in public. In both cases, compelling new data convinced them to change their minds; rather than adhering to "a foolish consistency," they adapted their public statements to reflect current scientific understanding of the virus and how it is transmitted from person to person.

In the past week, I've done a couple of about-faces on major medical topics in the face of new evidence. A panel for which I represented the American Academy of Family Physicians published a clinical practice guideline that recommends topical non-steroidal anti-inflammatory drugs (NSAIDs) as first-line therapy for adults with acute pain from musculoskeletal injuries (strains, sprains, and nonoperative fractures) not involving the low back. (A previous guideline covered what to do for patients with acute or chronic low back pain.) I was surprised when the systematic review and meta-analysis we commissioned for this guideline showed that topical NSAIDs were as effective as oral NSAIDs for acute pain; I previously had only prescribed topical NSAIDs for patients with chronic osteoarthritis. In February, in approving the the first topical NSAID for over-the-counter use, the U.S. Food and Drug Administration actually stated that it "is not for immediate relief" and "has not been shown to work for strains, sprains, bruises or sports injuries." That was a true statement at the time, but our understanding of the science has evolved since then. Although cost will be an obstacle for some patients - topical NSAIDs are substantially more expensive than oral NSAIDs - there is now good evidence to prefer the topical versions, which have fewer adverse effects, for acute musculoskeletal pain when feasible.

On a different subject, I announced in a Medscape commentary that "I've Changed My Mind on Lung Cancer Screening." I acknowledge that I am the same Dr. Kenny Lin who nearly a decade ago posted "4 Reasons Not to Be Screened for Lung Cancer" on my now-defunct U.S. News and World Report "Healthcare Headaches" blog. I don't disavow what I wrote previously; it's still important to consider the potential harms I mentioned in 2011 in any conversation with a patient eligible for lung cancer screening (according to the USPSTF's 2020 draft recommendations, adults age 50 to 80 years in good health who have at least a 20 pack-year smoking history and currently smoke or have quit in the past 15 years), and some patients may choose not to be screened, just as some patients decline mammograms or screening tests for colorectal cancer. Given the current evidence that overall benefits of lung cancer screening outweigh the harms, I will recommend this screening test to my patients at the same time I urge them to quit smoking.

How do primary care physicians prioritize preventive services?

Although many clinical preventive services, including childhood immunizations, have unfortunately been deferred during the COVID-19 pandemic, it was difficult to address the lengthy list of screening tests, counseling, and preventive therapies with an "A" or "B" letter grade from the U.S. Preventive Services Task Force (USPSTF) even when most primary care visits were in person. In a previous AFP Community Blog post, I wrote about the National Commission on Preventive Priorities' (NCPP) ranking of preventive services based on population health impact and cost-effectiveness. The NCPP's highest-ranked services were the childhood immunization series; counseling and medications to assist smoking cessation in adults; and counseling to prevent initiation of tobacco use in children and adolescents. However, it isn't known how family physicians and other primary care clinicians actually prioritize the services we provide at health maintenance visits.

In a recent study published in JAMA Network Open, researchers from the Cleveland Clinic and Case Western University surveyed 137 internists and family physicians in their health system about 2 hypothetical adult patients who were each eligible for at least 11 preventive services. Based on the patient profiles and visit lengths (20 or 40 minutes), physicians were asked if they would find it necessary to prioritize preventive services, the factors they considered, and what their top 3 priorities were. The researchers compared physicians' stated priorities with a mathematical model that predicted what preventive services were most likely to improve life expectancy.

Unsurprisingly, physicians were more likely to need to prioritize services during a shorter visit, and they selected services that they thought would improve the patient's quality of life, help the patient live longer, and were strongly recommended by their professional organization or guidelines. Cost and patient adherence were less important in determining the services physicians discussed. Across both hypothetical patients, smoking cessation, hypertension control, glycemic control, and colorectal cancer screening were the most highly prioritized services. Only 35% of physicians included a lifestyle intervention (diet and exercise or weight loss) in their top 3 services, even though the mathematical model ranked both lifestyle interventions among the top 3 improving life expectancy for both patients.

As the researchers acknowledged, the intensive behavioral counseling interventions recommended by the USPSTF for adults with cardiovascular risk factors are not feasible in most primary care settings; lifestyle change presents substantial adherence challenges; and diet and exercise counseling are not generally included in quality of care metrics. However, brief evidence-based strategies to encourage health behavior change, as described in a 2018 FPM article, may be effective to prevent cardiovascular disease in individual patients. A recent post on FPM's Getting Paid Blog suggested three steps for family physicians to improve patients' utilization of preventive services during the pandemic.

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This post first appeared on the AFP Community Blog.

Defining hypertension, personally and professionally

I recently started measuring my blood pressure at home at the recommendation of my new family physician in Salt Lake City, whom at a new patient visit had gotten readings that were somewhat higher than I'd had in the past. This finding was not completely unexpected: I'm in my mid-40s, have a family history of hypertension and cardiovascular disease, and my physical activity and dietary habits frequently fall short of optimal. On the other hand, he and I are well aware that out-of-office blood pressure readings are much better at predicting the risk of future hypertension-related events than those taken in the office; in a recent study of 90 family medicine patients with "uncontrolled" blood pressure in the office, nearly two-thirds had normal (defined as <140/90 mm Hg) readings at home.

Professionally, I struggle with hypertension too. As a former Clinical Practice Guideline subcommittee Chair and current scientific advisor for the American Academy of Family Physicians, I participated in the development of a 2017 guideline that suggested a target systolic blood pressure goal of <150 mm Hg for adults aged 60 years or older, and in the decision to not endorse a guideline from the American College of Cardiology / American Heart Association that set a blood pressure target of <130/80 mm Hg for adults of all ages, effectively redefining hypertension. Several publications have expressed concerns about the ACC/AHA hypertension guideline, including my Medscape commentary, an independent analysis of incremental benefits and harms, and a more recent research letter finding that "the clinical trials underlying new treatment thresholds are representative of less than one-third of the guideline target population."

Is it problematic that inconsistencies across recommendations in hypertension practice guidelines mean that family physicians and general internists may define high blood pressure differently than cardiologists? Yes and no. Although in an ideal world there would be a single (primary care-led, federally funded) hypertension guideline endorsed by all relevant stakeholders, including patient representatives, this is unlikely to be a national priority until the COVID-19 pandemic, which has caused the premature deaths of more than 163,000 Americans, is brought under some semblance of control. And just as emergency medicine physicians are often justified at taking a more aggressive testing and treatment approach to a patient with chest pain than a family physician evaluating a patient in his or her office, it's arguable that the greater long-term risk of cardiovascular events in patients who see cardiologists warrant more intensive treatment of blood pressure than patients in primary care settings.

I acknowledge that my training in family medicine and expertise in guideline development make me an atypical patient, better positioned than most to debate the pros and cons of blood pressure interpretation and treatment. At the same time, I have no interest in receiving "special treatment." I want my primary care physician to choose a hypertension guideline that makes sense given my individual circumstances and recommend a course of action supported by the best available evidence. Ultimately, that's what every patient deserves.

Syphilis and COVID-19: an epidemic within a pandemic

In many communities, the same people who work on preventing the spread of sexually transmitted diseases such as syphilis have been called on to help prevent the spread of COVID-19. Departments are reporting mass interruptions in STD care and prevention services. 

- Kaiser Health News, June 4, 2020

Contact tracing is a public health tool that was developed long before the COVID-19 pandemic. It is an essential element of sexually transmitted disease (STD) prevention and treatment programs that rely on notifying partners of infected persons so that they can be treated with antibiotics in time to stop the chain of transmission. As discussed in the article "Syphilis: Far From Ancient History" and my accompanying editorial in the July 15 issue of American Family Physician, the national increase in the number of primary and secondary syphilis infections since 2000 has fueled increases in the incidence of congenital syphilis, with 1306 cases diagnosed in 2018.

Although the essentially flat (40% decreased in inflation-adjusted dollars) Centers for Disease Control and Prevention (CDC) budget for STD prevention programs since 2003 has likely worsened this problem, a CDC analysis of year 2018 cases identified four types of missed prenatal prevention opportunities that can be addressed by family physicians, obstetricians, and other maternity care providers: 1) lack of timely prenatal care (and consequently no syphilis screening); 2) lack of timely syphilis screening despite timely prenatal care; 3) inadequate maternal syphilis treatment; 4) diagnosing syphilis less than 30 days before delivery. In my editorial, I added that "family physicians can prevent congenital syphilis by following national screening guidelines; taking accurate, detailed sexual histories; providing evidence-based interventions to people who use injection drugs; and advocating to reduce structural barriers to care."

COVID-19 has complicated congenital syphilis prevention by diverting health department personnel who would typically staff STD programs and discouraging expectant mothers from attending in-person prenatal visits due to infection concerns. In a Health Affairs blog post, Dr. Marcus Plescia and Elizabeth Ruebush from the Association of State and Territorial Health Officials affirmed that "there’s nothing non-essential about prenatal care and appropriate testing and treatment for syphilis," and discussed strategies for continuing to provide these critical health care services:

In our current environment, we’re seeing healthcare providers develop creative strategies to limit the number of in-person clinical visits by concentrating care around critical visits (e.g., for tests and ultrasounds) and leveraging the use of telemedicine when appropriate. Telemedicine visits should incorporate a comprehensive sexual history, and timely syphilis testing should be a key consideration when planning for prenatal care visits. ... It's also important to take a closer look at the maternal syphilis treatment regimen, which—depending on how long the mother has had syphilis—can involve three shots of penicillin, each seven days apart. ... Text and email reminders can be used to prompt individuals to return for their complete series of penicillin shots, and partnerships with clinical sites in the community can provide alternative models for delivering injectable therapy.

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This post first appeared on the AFP Community Blog.