Saturday, January 30, 2021

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.


This post first appeared on the AFP Community Blog.

Wednesday, January 20, 2021

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.


This post first appeared on the AFP Community Blog.

Monday, January 11, 2021

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.

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?

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.