Aligning unhealthy drug use policies with evidence

According to a health advisory from the Centers for Disease Control and Prevention, drug overdose deaths increased substantially during the first few months of the COVID-19 pandemic, rising by a record 2,146 and 3,388 deaths from March to April and April to May 2020, respectively. Overall, "approximately 81,230 drug overdose deaths occurred in the United States in the 12 months ending in May 2020," with synthetic opioids, particularly illicit fentanyl, driving the increases. In response, last year the U.S. Preventive Task Force (USPSTF) for the first time recommended routine screening for unhealthy drug use in adults age 18 years and older, reasoning that identifying persons who are using illicit opioids, stimulants, cannabis, and other drugs would facilitate appropriate treatment. However, the American Academy of Family Physicians (AAFP), after reviewing the USPSTF's summary of the underlying evidence, determined that it did not support this sweeping recommendation. Instead, the AAFP issued an insufficient evidence statement on screening for all drugs except for opioid use disorder (OUD), and advised that clinicians screen adults selectively for OUD "after weighing the benefits and harms of screening and treatment."

In an editorial in the January 15th issue of American Family Physician, Drs. Sarah Coles and Alexis Vosooney, members of the AAFP's Commission on the Health of the Public and Science (Dr. Coles is the current Chair) explained their reasoning for disagreeing with the USPSTF. They noted that the originally commissioned USPSTF evidence report found that "for screen-identified populations, psychosocial interventions and pharmacotherapy do not improve drug use or the consequences." Although the USPSTF then requested a second report that found some effective interventions to reduce unhealthy drug use in treatment-seeking populations,

The AAFP believes that it was inappropriate to rely on this indirect evidence and to generalize the benefits of OUD treatment to screening and treatment of other substance use disorders [SUDs]. Readiness for treatment and availability of effective treatment modalities are key in the successful treatment of SUDs. These data prompted the AAFP to issue an insufficient evidence grade for screening for unhealthy drug use in adolescents and adults, except for OUD.

In an independent commentary that accompanied the publication of the USPSTF recommendation statement in JAMA, Dr. Richard Saltz made similar points in calling screening for unhealthy drug use "neither an unreasonable idea nor an evidence-based practice." Regarding the USPSTF's reliance on studies demonstrating benefits in treatment-seeking populations, he wrote:

Considering this latter set of studies that included patients seeking treatment for drug use is akin to considering studies of chemotherapy for patients seeking care for breast cancer or thrombolysis for symptomatic myocardial infarction as relevant to questions of cancer and cardiovascular disease screening efficacy; efficacious treatment is necessary but not sufficient for making a case for screening. ... Many patients identified with drug use by screening will not have any intention of changing their use of drugs and are not ready to begin treatment, whereas a patient seeking treatment is more ready for change and willing to begin treatment (the success of which relies on readiness and adherence).

Further, Dr. Saltz observed, "the applicability of both [USPSTF] reviews to primary care in the US ... may be limited because many studies were conducted in settings outside primary care; the good-quality studies in primary care settings were null." He also expressed concern that universal screening for unhealthy drug use in pregnant persons and documentation of such use, as the USPSTF advised, could cause considerable harm since nearly half of states consider drug use in pregnancy to be child abuse; in contrast, the only two studies of psychosocial counseling for unhealthy drug use in pregnancy found no benefits.

Lack of access to medication-assisted treatment with buprenorphine remains a significant problem for patients with OUD who desire it; a Graham Center One-Pager found that only 11% of psychiatrists and 2.4% of family physicians prescribed buprenorphine to Medicare beneficiaries between 2013 and 2016. In order to encourage more clinicians to treat OUD with evidence-based medications, the U.S. Department of Health and Human Services (HHS) recently announced that it would allow all outpatient physicians registered with the U.S. Drug Enforcement Administration, rather than only those with a Drug Addiction Treatment Act of 2000 or "X" waiver, to prescribe buprenorphine to up to 30 patients at one time. Unfortunately, the Biden administration decided against implementing the new guidelines due to concerns that HHS does not have the legal authority to override the act of Congress that established the "X" waiver process in the first place. For many communities devastated by the opioid overdose epidemic during the COVID-19 pandemic, the lack of accessible and affordable treatment for OUD will continue to be a substantial barrier to care.

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This post first appeared on the AFP Community Blog.

Gender equity gaps persist among family physicians

In a Policy One-Pager in the January 1 issue of American Family Physician, Dr. Yalda Jabbarpour and Elizabeth Wilkinson from the American Academy of Family Physicians' Robert Graham Center examined the growing role of women in family medicine. Compared to 2010, when 34% of practicing family physicians in the American Medical Association Physician Masterfile were identified as women, the share of women rose to 42% in 2020, mirroring increases in the share of female physicians in primary care and all medical specialties during the past decade. Another recent analysis by Dr. Jabbarpour and others found a statistically significant increase in female first and last authorship of research articles published in 3 family medicine journals (Family Medicine, Journal of the American Board of Family Medicine, and Annals of Family Medicine) between 2008 and 2017. However, they noted that women represented less than 40% of the combined editorial boards of these journals, which did not change significantly during this time.

A Graham Center study utilizing 2017 and 2018 certification survey data from the American Board of Family Medicine found that women self-reported working an average of 49 total hours and 34 direct patient care hours per week compared to 54 and 39 hours, respectively, self-reported by men. In an accompanying commentary on this "gender penalty," Dr. Kathryn Hart (an academic family physician colleague of mine) observed:

Traditional gender roles are still very much at play. The “invisible work” of raising children often falls on mothers, regardless of employment status. This begins with breastfeeding (and the natural carry-over to the intensive caregiving responsibilities of infancy) and evolves into scheduling doctor's appointments, completing school forms, coordinating activities, and arranging childcare, among thousands of other small tasks that cumulatively take up hours over the course of the week.

The work disparities that affect female-male dual professional couples have widened over the past year. The widespread transition to virtual learning from home during the COVID-19 pandemic has substantially increased the burdens of unpaid work (domestic chores and family care) that employed women perform relative to employed men worldwide.

Whether the physician gender pay gap can be attributed solely to female physicians working fewer hours than men was the subject of a recent analysis of data from more than 24 million primary care office visits in 2017. Despite spending 2.6% more observed time in visits overall than male primary care physicians, female primary care physicians conducted 10.8% fewer total visits and consequently generated 10.9% less revenue. Female physicians spent 15.7% more time (2.4 minutes) with each patient than male physicians did, but generated no more revenue per visit. In addition to the many other good reasons to retire the antiquated fee-for-service payment system in primary care, this study suggested that it remains an inherent obstacle to pay equity between male and female physicians.

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This post first appeared on the AFP Community Blog.

Personally responsible: President Donald Trump and America's Plague Year

A notable historical site in Lancaster, Pennsylvania, where I completed my residency in Family Medicine, is Wheatland, the estate of the 15th American President, James Buchanan. Buchanan, who preceded Abraham Lincoln in office and is often considered by historians to be the worst President ever, did absolutely nothing as the first 7 states of the 11 that would go on to form the southern Confederacy seceded from the Union. Although Buchanan believed that secession was unconstitutional, he did not interpret his oath to "preserve, protect, and defend the Constitution of the United States" as giving him the authority to use force to prevent states from leaving. In the four months between Lincoln's election and inauguration (until 1937, Inauguration Day was March 4th), Lincoln watched helplessly as Buchanan's inaction and the scheming of his Southern-dominated Cabinet (including Secretary of War John B. Floyd, who later became a Confederate general) allowed the country to break in two.

Although there were some tense moments in early 1861 and in the summer of 1864, when Confederate General Jubal Early's Army of the Valley briefly skirmished with Union forces in the ring of forts surrounding Washington, DC, no insurrectionists would succeed in breaching the U.S. Capitol with a Confederate battle flag until January 6, 2021. On that date, a violent mob incited by the current President overpowered police and broke into the Capitol building, intending to stop the Congressional certification of November's election result, in which former Vice President Joe Biden defeated President Donald Trump by 7 million popular and 74 electoral votes. They threatened to hang Vice President Pence from a noose for not going along with Trump's illegal plan to disqualify enough electors to swing the election his way, and, before authorities reoccupied the building, mortally wounded one Capitol police officer and likely contributed to the suicide of a second officer three days later.

Take this in: Never once, in the years 1860-1865, was this flag ever paraded in the halls of the American capitol. pic.twitter.com/NFFVM0aSY0

— Sam Wineburg (@samwineburg) January 6, 2021

When historians assess the Trump Presidency, will they judge his anti-democratic actions to be worse for the nation than James Buchanan's inaction? Will they judge Trump to have been personally responsible for creating the movement that, if not for the quick thinking of courageous Capitol Police officer Eugene Goodman, could very well have resulted in live-streamed assassinations of Senators and staffers?

What a true American hero looks like. Thank you for your service. https://t.co/Q7HbsUSKKE

— Kenny Lin, MD, MPH (@kennylinafp) January 11, 2021

I hold President Trump personally responsible for a large portion of the 375,000 U.S. deaths from the pandemic to date. Admittedly, it's impossible to assign an exact number. As convincingly argued in the tour-de-force New Yorker article "The Plague Year," there were 3 critical missed opportunities to decisively alter the trajectory of COVID-19 deaths in the U.S.: 1) China's initial suppression of evidence of SARS-CoV-2's human-to-human transmission capability, including refusing to allow the CDC to conduct its own outbreak investigation; 2) the CDC's failure to develop and distribute an error-free test for the virus in February when doing so could have facilitated effective isolation of small numbers of infected patients by state health departments; and 3) Trump's refusal to wear a face mask in public and repeatedly suggesting that doing so was a sign of weakness, particularly when the mask-wearer was his election opponent. It's hard to blame the President for the first two, but the third was all on him.

Trump's responsibility - personal and historical - is even clearer for what happened at the Capitol last week. When you spend months telling supporters that if you don't win the election it will have been due to "massive voter fraud"; when you refuse to concede that you've lost a free and fair contest and file a blizzard of lawsuits that are so legally feeble that conservative judges that you appointed dismiss them out of hand; when you encourage supporters to show up in force on January 6th, appear before them in person to fire them up even more, then send them marching toward America's seat of democracy - you knew exactly what would happen, Mr. President. It's why you deserve to be removed from office before your term expires in 9 days, or failing that, be impeached by the House and convicted by the Senate so that you can never hold public office and wound or sicken this country again.

Common Sense Family Doctor's 2020 Year in Review

With a total of 48 posts (this will be the 49th), this has been my most prolific year of blogging since 2017. Nearly a third of these were on or related to the COVID-19 pandemic and its public health consequences, but I wrote about many other topics, too. With a nod to the ongoing 12 days of Christmas, I've picked 12 posts to highlight here, one from each month.

January 15 - When a cancer diagnosis predicts future good health

For early prostate, breast (including ductal carcinoma in situ, which was considered separately), thyroid cancer, and melanoma, relative survival was not only better than disease-specific survival, but greater than 100%. In other words, patients with these particular early cancer types were more likely to survive than similar individuals without cancer.

February 6 - Inspire future family physicians by teaching them about direct primary care

A year's membership in a DPC practice can generally be had for about one month of Presidential candidate Andrew Yang's Freedom Dividend, making it accessible not only to the middle and upper classes, but to patients who are can't afford traditional primary care. Medical schools should prioritize exposing more students to this new primary care model for us to have any hope of attracting one-quarter of them into family medicine.

March 30 - Breast cancer screening is likely to be harmful after age 75

While women age 70 to 74 years who continued to have screening mammograms had a 22 percent lower risk [of death from breast cancer] than those who stopped being screened, there was no mortality benefit for women who continued screening after age 75 years.

April 9 - Learning health policy during a pandemic

Social distancing, widespread testing, contact tracing, and vaccine development won't be enough to halt the pandemic if we leave millions of Americans behind; it's no wonder that Medicaid expansion has been proposed as a potent policy tool for mitigating the health and economic impact of COVID-19.

May 31 - An epidemic of inequality

Whether it's the President of the United States repeatedly lying about the impact of COVID-19; the closing of essential hospitals in underserved minority or rural communities; or a modern-day epidemic of amputations in black Americans in Southern former slave states; these protests are an expression of deep-seated rage about an epidemic of inequality that men and women in power have long minimized, dismissed or ignored.

June 18 - Less medicine, more health? COVID-19 pandemic provides a natural experiment

Just as COVID-19 has accelerated an overdue transition to providing more health care virtually, I hope that it will also inspire researchers to "study what was gained" from postponed or cancelled appointments with family doctors and surgeons. If the pandemic has a silver lining, this might be it.

July 27 - A meaningful best hospitals list, and a temporary relocation

For their "Best Hospitals for America" rankings, Lown created a Hospital Index that incorporated not only patient outcomes (mortality, safety, and satisfaction), but also civic leadership (community benefit, representativeness of patients compared to the surrounding community, and institutional salary distribution) and medical overuse.

August 11 - Defining hypertension, personally and professionally

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.

September 20 - How inequality explains America's uneven experience of the coronavirus

Although age and race inequalities largely explain America's uneven experience of COVID-19 to date, that is no assurance that it will stay that way. HIV/AIDS was a viral disease that only affected urban gay men and intravenous drug users - until it wasn't.

October 23 - Cancer survivorship: what is the family physician's role?

Family physicians' expertise in cancer mostly involves screening and diagnosis, while treatment is managed by medical and/or surgical oncologists. However, as the long-term survival of patients with cancer improves, the important care role of primary care clinicians in survivors of childhood and adult cancers has been increasingly recognized.

November 15 - Incarceration, restorative justice and health

I don't believe that prisons should be abolished, any more than I believe that police departments should be defunded. But if the U.S. is going to continue to pour hundreds of billions of dollars into incarceration every year, a large chunk of those dollars ought to be devoted to peacemaking - making the offender whole and less likely to offend again - rather than punishment.

December 13 - Long-term benefits of newborn metabolic screening

State-mandated screening at birth for rare, serious medical conditions occurs in 4 to 5 million newborns and detects 5,000 to 6,000 affected infants each year. With a combined incidence of 1 out of every 1,500 births, inborn errors of metabolism are the most common conditions detected by newborn screening.

My favorite public health and health care books of 2020

Christmas Eve may be a little late in the holiday season to be recommending books, but then again, e-books can be a great last-minute gift for procrastinators. One constant that has helped keep me sane during this tumultuous pandemic year has been always having a physical or virtual shelf of intriguing books to read next. As in previous years (see 2019, 2018, 2017, 2016, and 2015), this favorite books list is ordered alphabetically and includes a few that were new to me even though they were published before 2020.

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1. Fallible: A Memoir of a Young Physician's Struggle with Mental Illness, by Kyle Bradford Jones

2. Heart: A History, by Sandeep Jauhar

3. Hidden Valley Road: Inside the Mind of an American Family, by Robert Kolker

4. Inside the FDA: The Business and Politics Behind the Drugs We Take and the Food We Eat, by Fran Hawthorne

5. Malignant: How Bad Policy and Bad Evidence Harm People with Cancer, by Vinay Prasad

6. The Long Fix: Solving America's Health Care Crisis with Strategies That Work For Everyone, by Vivian Lee

7. Together: The Healing Power of Human Connection in a Sometimes Lonely World, by Vivek Murthy

8. Upstream: The Quest to Solve Problems Before They Happen, by Dan Heath

9. When Death Becomes Life: Notes From A Transplant Surgeon, by Joshua Mezrich

10. When We Do Harm: A Doctor Confronts Medical Error, by Danielle Ofri

New guideline for managing acute pain from musculoskeletal injuries

In a 2017 practice guideline based on a systematic review of noninvasive treatments, the American College of Physicians (ACP) recommended superficial heat, massage, acupuncture, and spinal manipulation as initial treatment options for patients with acute low back pain, in addition to a nonsteroidal anti-inflammatory drug (NSAID) or skeletal muscle relaxant if desired. But is a similar approach effective for treating pain from acute musculoskeletal injuries not involving the lower back? To answer this question, the American Academy of Family Physicians (AAFP) joined the ACP in developing another practice guideline on management of acute pain from non-low back, musculoskeletal injuries in adults, a synopsis of which appeared in Practice Guidelines in the December 1 issue of American Family Physician. These are some key practice points from the guideline:

• Topical NSAIDs are the most effective intervention for acute musculoskeletal pain other than low back pain.

• Although oral NSAIDs and acetaminophen are effective for acute pain relief, combining them does not improve effectiveness.

• Although moderately effective for pain relief, opioids increase gastrointestinal and neurologic adverse effects and lead to long-term use in 6% of people treated.

• Acupressure and transcutaneous electrical nerve stimulation techniques are effective nonpharmacologic options for acute pain.

In an accompanying editorial, Dr. David O'Gurek and I, who represented the AAFP on the guideline committee, and Dr. Melanie Bird, AAFP Clinical and Health Policies Manager, discussed some of the guideline's highlights and limitations. A systematic review and network meta-analysis of randomized, controlled trials provided direct and indirect comparisons of various treatment options on outcomes that included pain relief and physical functioning, symptom relief, treatment satisfaction, and adverse events.

Topical NSAIDs improved all efficacy outcomes with minimal adverse effects, while oral NSAIDs and acetaminophen improved fewer outcomes and were more likely to cause adverse events. We suggested against using opioids, including tramadol, for acute musculoskeletal injury pain due to their poor adverse effect profile and the risk of prolonged use, ranging from 6% in low-risk to 27% in high-risk populations. We also noted that "equitable coverage and affordability of first-line treatments" are essential to reduce well-known racial and socioeconomic disparities in pain management; for example, though a topical NSAID is now available over-the-counter, it costs significantly more than oral NSAIDs and acetaminophen and may not be covered by health insurance plans.

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This post first appeared on the AFP Community Blog.