• Current Issue
• ACP Hospitalist Weekly
  • Archives
• Supplements
• Blog
• Archives
• Career Connection
• Subscribe
• RSS Feeds

ACP HospitalistWeekly 4-28-10

Internal Medicine 2010 Highlights

• Recognizing and treating opioid dependence
• Anti-coagulation risks are known, but manageable
• ACP announces high-value, cost-conscious care initiative

From the ACP Hospitalist blog

• Blog highlights from Internal Medicine 2010

Cartoon caption contest

• Vote for your favorite entry

Editor's note: This issue of ACP HospitalistWeekly summarizes coverage relevant to hospital medicine from Internal Medicine 2010, the annual meeting of the American College of Physicians.

Internal Medicine 2010 Highlights

.

Recognizing and treating opioid dependence

A patient at your hospital claims she's going through heroin withdrawal and wants treatment. How do you know if she's telling the truth?

Check out her pupils, said Jeffrey H. Samet, FACP, chief of general internal medicine at Boston Medical Center, at a session at Internal Medicine 2010 on managing patients who use illicit drugs.

"Dilated pupils can't be faked," Dr. Samet said, while other symptoms of withdrawal can be seen in the hospital for a host of reasons. These include nausea, restlessness, a heart rate above 100 beats/min, abdominal cramps, sweating, runny nose and watery eyes.

When verified, withdrawal should be promptly treated. Not addressing it can prevent fully dealing with any other medical/surgical condition the patient has. In other words, this is not the time to make the patient go cold turkey.

"Withholding opioids will not cure the patient's addiction, and giving opioids won't worsen the addiction," Dr. Samet said. "You can't expect to cure the dependence during this hospital stay."

Methadone is the best treatment choice for opioid-addicted inpatients, he said. It's available in tablet, oral solution and parenteral forms; has an onset time of 30 to 60 minutes; and lasts about 6 hours for pain and 24 hours in preventing withdrawal.

Start with a 20-mg dose ("People don't stop breathing with this amount," Dr. Samet said) and reassess every two to three hours, giving an additional 5 to 10 mg until withdrawal signs abate.

"Again, rely on the pupils to gauge withdrawal," Dr. Samet said.

Be sure not to exceed 40 mg of methadone in 24 hours, and monitor the patient for central nervous system and respiratory depression. On the following day, give the patient the same total dose you gave in the previous 24 hours.

"Remember, the goal is to alleviate acute withdrawal; the patient will continue to crave heroin," Dr. Samet said.

If the patient's drug test is positive for opiates on the second day of hospitalization, it is not the result of the methadone, he added; as a synthetic opioid, methadone won't show up. The results probably can be explained by residual heroin from before the patient's admission; any morphine the patient was given after admission; illicit opioid use during hospitalization (for example, if the patient left the floor to use); or even ingestion of a poppy seed bagel.

When it's time to discharge the patient, refer him or her to long-term substance abuse treatment, he said. Methadone can't be prescribed in the outpatient world, he added.

There are a few options for treating patients who present to a primary care clinic needing treatment for heroin addiction: referral to Narcotics Anonymous ("a helpful adjunct"); clonidine plus an NSAID plus a benzodiazepine ("not great but not terrible"); naltrexone ("not used much in North America"); buprenorphine maintenance therapy; and referral to a detoxification program, needle exchange, outpatient therapy or methadone maintenance program.

Opioid detoxification doesn't work terribly well; it has low rates of retention in treatment, and fewer than 20% of participants remain abstinent at 12 months. "This is why we push patients to get into opioid-agonist treatment," Dr. Samet said.

In a comprehensive rehabilitation program, methadone treatment has been shown to increase overall survival and treatment retention, and lower illicit opioid use. Maintenance treatment programs are highly regulated and structured, with daily nursing assessment, weekly counseling, random supervised toxicology screening and dosing that's observed daily until a patient "earns" take-home doses, he said.

The limitations to methadone programs are access (five states don't have them at all); inconvenience (daily clinic visits to receive medication); lack of privacy; stable and unstable patients being mixed together; and a stigma among physicians and peers.

An alternative to outpatient methadone that's equally effective is buprenorphine plus naloxone (trade name Suboxone). When taken as sublingual tablets, as intended, the naloxone isn't absorbed. If patients try to crush the tablets and take intravenously, however, the naloxone causes a reaction that will put the patient into acute withdrawal, Dr. Samet said.

Top

.

Anti-coagulation risks are known, but manageable

Clopidogrel (Plavix) is one of the best-selling drugs in the U.S., but its risks and limitations have been highlighted recently by both FDA warnings and new research. During a precourse session on “Cardiology for the Internist,” speakers at Internal Medicine 2010 discussed some of the problems that the popular drug is posing for internists coordinating care with subspecialists.

The risks of mixing clopidogrel with proton-pump inhibitors (PPIs) have become fairly well-known in the past year or so, and have discouraged clinicians from overusing the latter, but sometimes there’s a real need to use both drugs, noted David L. Fischman, FACP, associate professor of medicine at Thomas Jefferson University in Philadelphia. In those cases, it may be safest to go with pantoprazole (Protonix), he advised.

The advantage of pantoprazole is that it has less effect on liver enzyme CYP2C19, which metabolizes clopidogrel. The differences in patients’ capacities to metabolize the drug became big news in March when the FDA added a boxed warning to the clopidogrel label, advising that some patients metabolize the drug poorly and that genetic tests are available to determine which patients these are.

“You can do a test,” acknowledged Dr. Fischman. But, he added, “Most insurance companies don’t cover this.” The test, which runs about $500, is obscure enough that even the Mayo Clinic doesn’t offer it, according to Steven L. Kopecky, FACP, who also spoke during the precourse and is a professor of cardiology at Mayo in Minnesota. There is one simpler test to identify some higher-risk patients—ethnicity. About 14% of people of Chinese origin metabolize the drug poorly, compared to 1% or 2% in other races, Dr. Kopecky noted.

As for what to do once you’ve found the patients, he wasn’t too keen on one of the FDA’s possible solutions, a higher-dose regimen of a 600-mg loading dose followed by 150 mg once daily. The agency noted that the dose hasn’t been tested in a trial and Dr. Kopecky doesn’t plan to be the first. “None of us at Mayo feel comfortable doing that,” he said.

The warning also mentioned alternate antiplatelet medications, and one of those, prasugrel (Effient), does appear to have some potential advantages over clopidogrel, Dr. Fischman said. It poses less risk of interaction and has greater antiplatelet effect, but it’s got disadvantages, too. “The downside is higher incidence of bleeding,” Dr. Fischman said.

The bleeding risk posed by clopidogrel and other drugs is likely to be a particular concern to surgeons and anyone else who plans to cut your antiplatelet-taking patients open, the experts noted. “It comes up every day: Can this patient come off their Plavix?” described Dr. Fischman.

If the patient is taking the drug because they’ve received a bare-metal stent and it’s been at least a month, then it’s OK to halt it for surgery. But if the patient got a drug-eluting stent less than a year before, internists need to take a hard line because recommendations call for continuing antiplatelet therapy for a year in order to prevent late stent thrombosis.

“We’re trying to change the mentality of eye surgeons, dentists,” said Dr. Fischman. At the very least, patients should stay on their aspirin if not clopidogrel. And, if there’s any way to know before the stent goes in that the patient is going to require surgery within a year, opt for the bare-metal version. “You get your crystal ball out in the cath lab,” joked speaker Howard H. Weitz, FACP, a clinical associate professor of medicine at Jefferson.

Top

.

ACP announces high-value, cost-conscious care initiative

Building on its existing foundation of clinical and public policies, the American College of Physicians (ACP) announced during Internal Medicine 2010 its plans to provide physicians and patients with evidence-based recommendations for specific interventions for a variety of clinical problems. ACP’s High-Value, Cost-Conscious Care Initiative will assess benefits, harms, and costs of diagnostic tests and treatments for various diseases to determine whether they provide good value—medical benefits that are commensurate with their costs and outweigh any harms.

“Physicians and patients need evidence-based information so they can make the right decision about the right treatment at the right time,” said Joseph W. Stubbs, FACP, outgoing president. “High-value, cost-conscious care is about eliminating overused and misused medical treatments that do not improve patient health or might even be harmful.”

---

(From right) Joseph W. Stubbs, MACP, outgoing president; Paul G. Shekelle, FACP, PhD, Chair, Clinical Efficacy Assessment Technical Advisory Committee; and Steven E. Weinberger, FACP, Senior Vice President for Medical Education and Publishing, discuss the ACP High-Value, Cost-Conscious Care Initiative.

---

According to ACP, it is essential to assess benefits, harms, and costs of an intervention to determine whether it provides good value. Evaluation of the costs of an intervention is insufficient to assess value; inexpensive interventions may provide little value, and expensive interventions may provide good value and meet accepted thresholds for clinical effectiveness and cost-effectiveness.

The initiative will include the development of ACP’s High-Value, Cost-Conscious Care Recommendations by ACP’s Clinical Efficacy Assessment Technical Advisory Committee that will be submitted for review and consideration for publication in Annals of Internal Medicine. The effort will address common medical conditions for which inappropriate use of resources is known to be an issue, such as low back pain.

The next edition of ACP’s Medical Knowledge Self-Assessment Program (MKSAP) will also have a focus on optimal diagnostic and treatment strategies, based upon considerations of value, effectiveness, and avoidance of overuse and misuse. Additional phases of the initiative may include patient education materials and curricula for medical students and residents.

“Shared decision-making between physicians and patients is an integral part of high-value, cost-conscious care,” said Steven Weinberger, FACP, ACP’s deputy executive vice president and senior vice president of medical education and publishing. “ACP’s High-Value, Cost-Conscious Care Recommendations will provide evidence about which evaluation and management strategies work best for individual patients.”

According to ACP’s 2009 policy paper, “Controlling Health Care Costs While Promoting the Best Possible Health Outcomes,” the Congressional Budget Office (CBO) estimates that 5% of the nation's Gross Domestic Product—$700 billion per year—is spent on tests and procedures that do not actually improve health outcomes. ACP contends in that paper that savings can be achieved by reducing inappropriate utilization of services and by encouraging clinically effective care based on comparative effectiveness research.

“By eliminating medical treatments that do not directly improve a patient’s health, physicians and patients can significantly reduce waste and preserve high-quality care,” said Dr. Stubbs.

Top

From the ACP Hospitalist blog

.

Blog highlights from Internal Medicine 2010

Thrombophilia, vaccines and pain medication are just some of the topics we blogged about from Internal Medicine 2010. To read more, visit our blog. Also, check out the ACP Hospitalist Twitter feed.

• Thrombophilia: To test or not to test? To hear hematologist Mark Crowther, MD, tell it, there's way too much testing for thrombophilia going on."Just because we can test, doesn't mean we should test," said Dr. Crowther. Test results rarely change the duration or intensity of treatment, he noted. And positive results can cause insurance problems, as well as sentence patients to a condition that may never cause him or her any problems. On the other hand, if a patient shows up with an unprovoked DVT and a family history of DVTs, this might warrant testing because it could affect treatment. Or, if a young woman is considering taking oral contraceptives but her mother and aunt had unprovoked PEs in the past, one might want to test "because it's very likely there is a thrombophilia in the family," Dr. Crowther said.
• Bugs and screens: It wasn't the ideal lunchtime subject, especially when we learned about probing diabetic foot ulcers with a pointy object until you hit bone, but Stan Deresinski, FACP, offered a lot of interesting info during the "Infectious Disease Potpourri" session. It used to be that hospitalized patients got their recommended influenza and pneumococcal vaccines at discharge. Then hospitals found that the vaccinations were slipping through the cracks, so they moved them to admission. But that strategy doesn't work perfectly either, Dr. Deresinski suggested. "I think it's likely that when [patients] come in acutely ill, they don't respond to the vaccine very well." So he'd favor moving the vaccines later, but acknowledged that you would probably risk missing some patients. In response to a questioner, Dr. Deresinski leaned against MRSA screening. "A lot of people think we've been chasing our tail," he said. Some hospitals in California, where screening is required by law, find it so pointless that they screen patients and then do nothing with the results. "They consider it part of the local flora." Hospitals might do better to focus on wider precautionary measures like hand hygiene, he suggested.
• Doc, am I an addict? What to tell a cancer patient who is in pain, but is afraid he or she will get addicted to pain meds? Explain that while addicts use drugs to escape life, people with pain use drugs to get back to their lives, said Janet Abrahm, FACP, in a session on inpatient pain management. "If a patient is clock-watching, it doesn't mean s/he is an addict," Dr. Abrahm said. "Addicts seek to use drugs even when doing so is to their own detriment."Another pearl? Prescribe something for constipation when you start a patient on morphine. Colace and Senna work nicely, she said.

Top

Cartoon caption contest

.

Vote for your favorite entry

ACP HospitalistWeekly's cartoon caption contest continues. Readers can vote for their favorite caption to determine the winner.

"I guess we've got some bad news for each other. Do you want yours first?"
"You drug reps will do just about anything to get my attention."
"OK, OK, I admit it. I should have called hospice sooner."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting continues through May 3, with the winner announced in the May 5 issue.

Top

---

About ACP HospitalistWeekly

ACP HospitalistWeekly is a weekly newsletter produced by the staff of ACP Hospitalist. Please forward any comments or suggestions to acphospitalist@acponline.org.

To change your e-mail address or other contact information in our records, please click here.

Copyright 2010 by the American College of Physicians.

Prepare with the Experts: Live Recert Prep Courses from ACP

ACP Launches Depression Care Guide

© ACP Hospitalist and American College of Physicians

ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated