By: Devin Pinaroc, MSN, FNP-C

Takeaways

• Regardless of age, sex, race, ethnicity, or current health fitness level, the more a person moves, the more benefits gained. 

• Youths from ages 6 through 17 years are recommended to achieve a total of 60 minutes or more of moderate-to-vigorous-intensity physical activity each day.

• Adults should achieve at least 150 to 300 minutes of moderate-intensity aerobic physical activity or 75 to 150 minutes of vigorous-intensity aerobic physical activity per week to gain the optimal health benefits from exercise. 

In 2018, the Department of Health and Human Services released the 2nd edition of Physical Activity Guidelines for America (PAG), outlining  physical activity recommendations across specific age groups. Regardless of age, sex, race, ethnicity, or current health fitness level, the more patients move, the more benefits gained (p. 8). These health benefits occur with any amount of movement, both immediately and as an accumulation of long term commitment. However, patients who achieve recommended amounts of exercise optimize the associated health outcomes, such as improving sleep, reducing anxiety and depression, preventing weight gain, lowering risk of all-cause mortality and chronic lifestyle diseases, and promoting healthy growth and aging (p. 32). 

Children (3 to 17 years)

Preschool: While there is lacking research of the specific amount of exercise to optimize health benefits for preschool aged children (3-5 years), active play of any intensity throughout the day is encouraged (p. 46). There is some research suggesting that 3 hours a day of physical activities, like hopping, skipping, bike riding, and tumbling, will promote strong bone formation, healthy muscle growth, and appropriate weight gain (p 46). 

School Aged and Adolescents: Youths from ages 6 through 17 years are recommended to achieve a total of 60 minutes or more of moderate-to-vigorous-intensity physical activity each day (p. 48). Ideally, this time should include aerobic activity and age appropriate muscle and bone strengthening exercises to support adequate bone development before and during puberty. Still, actual time exercising does remain the most important factor in achieving health benefits, regardless of the activity. 

There appears to be a reduction of physical activity in later adolescence, and sports and structured programs can provide more than just health benefits of regular exercise. With set practice times and dedicated periods to exercise, children can learn to establish a routine that prioritizes physical activity, building a foundation of commitment to exercise which may continue throughout the lifespan.

Adults 

18 to 64 years: Adults should achieve at least 150 to 300 minutes of moderate-intensity aerobic physical activity or 75 to 150 minutes of vigorous-intensity aerobic physical activity per week to gain the optimal health benefits from exercise (p. 56).  Moderate-intensity exercise is achieved during activities such as brisk walking 2.5mph or faster, active forms of yoga (ex: Vinyasa), or ballroom dancing. Vigorous-intensity exercises include activities where a “person cannot say more than a few words without pausing for a breath“ (p. 60). This includes, but is not limited to, jogging, cycling faster than 10mph, HIIT classes, or heavy yard work (p. 59). Additional health benefits are gained with more physical activity, especially when adults add muscle strengthening activities of moderate or greater intensity that involve all major muscle groups 2 or more days of the week (p. 56). If possible, aerobic activity, colloquially known as “cardio”, should be spread consistently throughout the week on at least 3 days as this can produce even more health benefits from exercise (p. 58). 

65 years and over: For older adults with no chronic conditions and good baseline fitness, the guidelines are similar to the recommendations for adults ages 18 to 64 years old. If chronic conditions restrict adults from safely performing 150 minutes of moderate-intensity activity a week, being as physically active as abilities allow is recommended. Clinicians should be aware of the effects of chronic conditions on physical activity and address concerns with patients to promote safe, but adequate exercise. Older adults may also benefit from incorporating balance training into their aerobic and muscle strengthening exercises (p. 68). 

Unfortunately, nearly 80% of adults in the US are not meeting the key guidelines for activity and this can be linked to about $117 million in annual healthcare costs (p. 2). Being and staying active is one the most important factors in promoting health and should be at the top of any clinician’s plan of care for both prevention and treatment of diseases. 

For more information, read the entire 2020 Physical Activity Guidelines for America, 2nd edition, at https://health.gov/sites/default/files/2019-09/Physical_Activity_Guidelines_2nd_edition.pdf . 

References

U.S. Department of Health and Human Services. (2018). Physical Activity Guidelines for Americans, 2nd edition. https://health.gov/sites/default/files/2019-09/Physical_Activity_Guidelines_2nd_edition.pdf

By: Tara Harris, MSN, DNP, FNP-BC

Spring is here and with it comes runny/congested noses as well as watery/itchy eyes. Seasonal allergic rhinitis, commonly known as hay fever, affects both children and adults. According to the American Academy of Allergy, Asthma, and Immunology (2021), about 8% of Americans 18 years of age and older are affected annually. Worldwide between 10% and 30% of the population are affected.

Seasonal allergies typically occur from exposure to outdoor pollen. The immune response is triggered during the blooming season causing over-production of IgE antibodies and an allergic response. Symptoms most commonly seen include congestion and rhinorrhea, watery and itchy eyes, itchy sinuses, throat, or ear canals, ear congestion, and postnasal drainage. These symptoms can range from mild to severe, depending on other risk factors the patient may have, such as asthma. If the patient has both allergic rhinitis and asthma, precautions should be taken as an asthma attack can also be triggered.

The current treatment recommendations include reducing exposure to allergens as well as pharmacologic therapy. Pharmacologic treatments include antihistamines (intranasal and oral), decongestants (intranasal and oral), corticosteroids (intranasal and oral), intranasal cromolyn, intranasal anticholinergics, and oral leukotriene receptor antagonists (LTRAs) (Croke, 2018). Allergen immunotherapy has also proven its benefit to allergy sufferers. Numerous well-designed controlled studies demonstrate allergen immunotherapy is efficacious in the treatment of allergic rhinitis, allergic conjunctivitis, allergic asthma, and stinging insect hypersensitivity (Cox et al, 2011).

Treatment recommendations differ for children. The Joint Task Force on Practice Parameters (2017) provides the following recommendations based on a systematic literature review and patient oriented outcomes:

• Patients 12 years and older should be treated with intranasal corticosteroid monotherapy over combined intranasal corticosteroid and oral antihistamine therapy to treat seasonal allergic rhinitis.
• Combined intranasal corticosteroid and intranasal antihistamine therapy can be considered for allergic nasal symptoms for patients 12 years and older.
• For patients 15 years and older, an intranasal corticosteroid is preferred over a leukotriene receptor antagonist.

Seasonal allergies usually occur during a specific time of the year. With proper assessment and evaluation, adequate treatment can help patients enjoy their outside activities.

References

Coker, L. (2018). Treatment of Seasonal Allergic Rhinitis: A Guideline from the AAAAI/ACAAI Joint Task Force on Practice Parameters. American Family Physicians, 97(11):756-757.

Cox, L., Nelson, H., & Lockey, R. (2011). Allergen immunotherapy: A practice parameter third update. Journal of Allergy and Clinical Immunology,127(1):S1-S55. 

AAAAI (2021). Allergy Statistics. American Academy of Allergies, Asthma and Immunology. Retrieved from https://www.aaaai.org/about-aaaai/newsroom/allergy-statistics

Dykewicz, M.S., Wallace, D.V, and Baroody, F. (2017). The Joint Task Force on Practice Parameters. Treatment of seasonal allergic rhinitis: An evidence-based focused 2017 guideline update. Annuals of Allergy, Asthma, and Immunology.119(6):489–511. Retrieved from http://www.annallergy.org/article/S1081-1206(17)30656-7/fulltext

Takeaways

• Healthy People 2030 addresses health problems in the US with 355 core objectives that detail the impact of the problem, latest research, evidence based interventions, and goal status. 
• For clinicians applying these goals to their community, prioritize objectives to those that are most relevant to the population and implement the Healthy People 2030 researched interventions, tailoring them to the population’s needs. 

Every decade, the US Department of Health and Human Services releases a “Healthy People” report that establishes objectives and goals to improve the wellbeing and health of people. The most recent, Healthy People 2030 includes 355 core objectives as well as developmental or research objectives with the vision to create “a society in which all people can achieve their full potential for health and well-being across the lifespan” (Healthy People 2030 Framework, 2020, para “Vision”).

Objectives

The Healthy People 2030 objectives work to solve health related issues faced across the lifespan, including both medically focused goals, like to reduce the number of newly diagnosed with diabetes, as well as socioeconomic factors that address health disparities, like increase the number of high school students who graduate in 4 years. (Education Access and Quality, 2020; Leading Health Indicators, 2020).

Topics for objectives are categorized into Leading Health Indicators, Social Determinants of Health, and Overall Health and Well-being Measures. Each health indicator holds information on societal impact, primary goal to improve the overall health of people, and several, more specific objectives to aid in achieving the overarching goal. High priority public health issues associated with evidence-based interventions are reflected in core objectives, and the developmental objectives encompass those health issues with evidence-based interventions but no baseline data. 

Healthy People 2030 has also included some research objectives that include public health issues in need of evidence-based interventions. Each objective holds resources to understand intervention information and implementation. Transparency in the goal is included with each objective, noting the different stages of achievement: at baseline, target met or exceeded, improving, little or no detectable change, or getting worse (About the Objectives, 2020). 

Healthy People 2030 in Your Community

Healthy People 2030 has hundreds of objectives to promote and improve health outcomes regarding communities and populations. For individual providers to effect change in their specific community, the Healthy People reports advise identification of the issues that most affect a population to narrow down health goals and the priorities of health improvement in a specific area. Then, setting local targets that are based on the Healthy People’s national goals and their available data, will help the goals become more attainable. Once the most relevant objectives are identified, the clear goal statements and data tracking make implementation of programs or interventions with  evidence-based resources understandable and easily manageable. Lastly, by comparing the progress of a specific community to the Healthy People’s stage of achievement for each objective gives a reference point for evaluations of strategies. (Use Healthy People 2030 in Your Work, 2020). 

Want more information… 

Healthy People 2030 | health.gov

Criteria for Selecting the Leading Health Indicators for Healthy People 2030

References 

Office of Disease Prevention and Health Promotion. (2020, January 16). About The Objectives. Retrieved February 22, 2021, from https://health.gov/healthypeople/objectives-and-data/about-objectives

Office of Disease Prevention and Health Promotion. (2020, January 16). Education Access and Quality. Retrieved February 25, 2021, from https://health.gov/healthypeople/objectives-and-data/browse-objectives/education-access-and-quality

Office of Disease Prevention and Health Promotion. (2020, January 16). Healthy People 2030 Framework. Retrieved February 22, 2021, from https://health.gov/healthypeople/about/healthy-people-2030-framework

Office of Disease Prevention and Health Promotion. (2020, January 16). Leading Health Indicators. Retrieved February 25, 2021, from https://health.gov/healthypeople/objectives-and-data/leading-health-indicators

Office of Disease Prevention and Health Promotion. (2020, January 16). Use Healthy People 2030 in Your Work. Retrieved February 22, 2021, from https://health.gov/healthypeople/tools-action/use-healthy-people-2030-your-work

Office of Disease Prevention and Health Promotion. (2020, January 16). Leading Health Indicators. Retrieved February 25, 2021, from https://health.gov/healthypeople/objectives-and-data/leading-health-indicators

Takeaways

• Prevention is the cornerstone to addressing CVD with early identification of modifiable risk factors. 
• Traditional risk factors known to correlate with increased risk of CVD are used in calculating absolute risk for cardiovascular disease or event. The categorization of the score into low, intermediate, and high risk helps providers understand the potential benefits of various lifestyle modifications, non-pharmaceutical interventions, and pharmaceutical treatments at each stage.
• The most widely used algorithm in the US is the Pooled Cohort Equations (PCE) that produces a 10 year risk for acute cardiovascular events. 
• Absolute CVD risk scores and other nontraditional risk factors help clinicians understand an asymptomatic patient’s risk for cardiovascular disease or acute cardiovascular events. Knowledge of this risk guides management decisions and improves health outcomes. 

Cardiovascular disease (CVD) refers to different conditions affecting the heart and blood vessels, including coronary heart disease (CHD), cerebrovascular disease, peripheral artery disease, and aortic atherosclerosis/aneurysms (Wilson, 2020). Heart attack and stroke are common colloquialisms that are ubiquitous for potentially devastating cardiovascular events. In 2011, the American Heart Association (AHA) predicted by 2030 roughly 40% of the US population would suffer from some form of cardiovascular disease (2017). Fifteen years earlier than predicted and just 4 years later in 2015, this projection was met with over 100 million Americans holding a diagnosis of some form of heart disease (AHA, 2017). Heart disease is the leading cause of death among men, women, and most ethnic groups in the United States, claiming over 600,000 lives a year (CDC, 2020). 

The impacts of CVD exceed the obvious cost to physical health, but also affects individuals and society with significant economic ramifications. Given this burden and increasing prevalence in the US, expert groups stress the importance of prevention through assessing and addressing risk factors early, rather than after a serious cardiovascular event, to optimize cardiovascular and other health outcomes. 

Cardiovascular Disease Risk Assessment With Traditional Risk Factors

Traditional risk factors for CVD include male sex, older age, hypertension, diabetes, obesity, current smoking, abnormal cholesterol levels, and physical inactivity (Curry et al., 2018).  Accurate assessment of individual risk factors and progression to actual diagnosis is key to effective primary prevention in asymptomatic individuals. Despite lack of conclusive studies, expert groups advise using an individual’s “absolute/total CVD risk” to evaluate disease status, predict future CVD events, and guide management decisions (Studziński, Tomasik, Krzysztoń, Jóźwiak, & Windak, 2019). Absolute CVD risk is the actual risk of developing disease within a defined population and period of time, giving clinicians and patients a stratification framework for potential benefits of treatment decisions (Studziński, Tomasik, Krzysztoń, Jóźwiak, & Windak, 2019). The categorization of the score into low, intermediate, and high risk helps providers understand potential benefits of various lifestyle modifications, non-pharmaceutical interventions, and pharmaceutical treatments at each stage. The 2019 ACC/AHA guidelines are the most up-to-date recommendations on frequency of screening and timing of medication intervention.

There are several methods to calculate CVD absolute risk. The 2013 ACC/AHA Cardiovascular Risk Assessment Guidelines introduced a now widely used method: a race- and sex-specific Pooled Cohort Equations (PCE) predicting 10-year risk of an ASCVD event (Goff et al.)  The 2018 Cholesterol Clinical Practice Guidelines and 2017 Hypertension Clinical Practice Guidelines also recommended PCE use for CVD risk calculation (Lloyd-Jones et al., 2019). The Framingham 10-year CHD Risk score and Reynolds Risk Score are other common calculations, but are limited due to the white male sample population and calibration specifically to heart disease rather than a cardiovascular event (Goff et al., 2013). 

Nontraditional CVD Risk Factors and Other Assessment Tools

While algorithms provide absolute CVD risk, the score is only a piece of the puzzle.  These methods often under or overestimate certain cohort groups, and some ethnicities are not well represented (Lloyd-Jones et al., 2019). Furthermore, the CVD risk assessment tools incorporate very specific data and are unmodifiable for other potential determinants of cardiovascular risk. Additional risk factors are especially important when the CVD risk score is “borderline” or “intermediate”, defined by the ACC/AHA guidelines as a 10 year CVD risk between 5% and 7.5% using their ASCVD risk calculator (Arnett et al., 2019). Clinicians should use risk score in conjunction with other significant factors such as diet, physical activity, socio-economic issues, other comorbidities, and family history of CVD; adjusting interventions as needed (Arnett et al., 2019). 

Other screening tools and tests, such as the ankle brachial index and high sensitivity CRP testing, help clinicians further understand individual CVD risk when things are unclear (Curry et al., 2018). The newest ACC/AHA guidelines specifically advise the use of coronary artery calcium scan in individuals with borderline ASCVD risk score (Arnett et al., 2019). 

 In 2018, USPSTF sought to understand the role of electrocardiogram in assessing cardiovascular risk in asymptomatic individuals – given prominent use in diagnostic evaluations (Curry et al., 2018). There is inconclusive evidence to advise against or for screening ECG in asymptomatic adults at intermediate to high risk for CVD events, but adequate evidence to conclude with moderate certainty that screening ECGs in asymptomatic adults at low risk for CVD events produced no net benefit (Curry et al., 2018). The AHA notes low levels of cardiorespiratory fitness are associated with high rates of cardiovascular disease and may be a stronger predictor of mortality risk than traditional risk factors (Ross et al., 2016).

More research is needed to articulate the most effective ways to use these tools as screening tests in cardiovascular risk assessments and how they ultimately affect CVD mortality and morbidity outcomes. Clinicians are encouraged to continue in shared decision making with patients to combine their unique cardiovascular risk factors and develop a comprehensive, effective treatment plan.

To learn more and earn CE credit, register for our June 9-11 Virtual Conference, which has sessions on ASCVD and Dyslipidemia, as well as CV risk and treatment.

Want To Learn More…

Heart Disease | cdc.gov

Heart Disease and Stroke Statistics—2020 Update: A Report From the American Heart Association

2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

USPSTF Final Recommendation Statement: Cardiovascular Disease: Risk Assessment With Nontraditional Risk Factors

Brachial-Ankle Pulse Wave Velocity and the Risk Prediction of Cardiovascular Disease: An Individual Participant Data Meta-Analysis

Coronary Calcium Score and Cardiovascular Risk

ASCVD Risk Estimator +

References: 

Arnett, D., Donna K. Arnett Search for more papers by this author, Blumenthal, R., Roger S. Blumenthal Search for more papers by this author, Albert, M., Michelle A. Albert Search for more papers by this author, . . . Al., E. (2019, March 17). 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: A report of the American College OF CARDIOLOGY/AMERICAN Heart Association Task force on clinical practice guidelines. Retrieved February 9, 2021, from https://www.ahajournals.org/doi/10.1161/CIR.0000000000000678

CARDIOVASCULAR DISEASE: A COSTLY BURDEN FOR AMERICA PROJECTIONS THROUGH 2035 (pp. 6-11, Rep. No. American Heart Association CVD Burden Report). (2017). Washington, DC: The American Heart Association Office of Federal Advocacy.

Curry, S. J., Krist, A. H., Owens, D. K., Barry, M. J., Caughey, A. B., Davidson, K. W., . . . Wong, J. B. (2018). Risk assessment for cardiovascular disease with nontraditional risk factors. JAMA, 320(3), 272. doi:10.1001/jama.2018.8359

Curry, S. J., Krist, A. H., Owens, D. K., Barry, M. J., Caughey, A. B., Davidson, K. W., . . . Wong, J. B. (2018). Screening for cardiovascular disease risk with electrocardiography. JAMA, 319(22), 2308. doi:10.1001/jama.2018.6848

Goff, D. C., Lloyd-Jones, D. M., Bennett, G., Coady, S., D’Agostino, R. B., Gibbons, R., . . . Wilson, P. W. (2013). 2013 ACC/AHA guideline on the assessment of cardiovascular risk. Circulation, 129(25 suppl 2). doi:10.1161/01.cir.0000437741.48606.98

Lloyd-Jones, D., Braun, L., Ndumele, C., Smith, S., Sperling, L., Virani, S., . . . A., P. (2019, June 01). Use of risk assessment tools to GUIDE decision-making in the primary prevention of ATHEROSCLEROTIC cardiovascular disease: A special report from the American Heart Association and American College of Cardiology. Retrieved February 13, 2021, from https://www.jacc.org/doi/10.1016/j.jacc.2018.11.005

National Center for Chronic Disease Prevention and Health Promotion, Division for Heart Disease and Stroke Prevention. (2020, September 08). Heart disease facts. Heart Disease.  Retrieved February 09, 2021, from https://www.cdc.gov/heartdisease/facts.htm

Ross, R., Blair, S. N., Arena, R., Church, T. S., Després, J., Franklin, B. A., . . . Wisløff, U. (2016). Importance of Assessing Cardiorespiratory fitness in clinical Practice: A case for fitness as a CLINICAL Vital Sign: A scientific statement from the American Heart Association. Circulation, 134(24). doi:10.1161/cir.0000000000000461

Studziński, K., Tomasik, T., Krzysztoń, J., Jóźwiak, J., & Windak, A. (2019, January 9). Effect of using cardiovascular risk scoring in routine risk assessment in primary prevention of cardiovascular disease: An overview of systematic reviews. Retrieved February 13, 2021, from https://www.ncbi.nlm.nih.gov/pubmed/30626326

Wilson, P., MD. (2020, May 29). Cardiovascular disease risk assessment for primary prevention in adults: Our approach. Retrieved February 08, 2021, from https://www.uptodate.com/contents/cardiovascular-disease-risk-assessment-for-primary-prevention-in-adults-our-approach?search=cardiovascular+risk+assessment&source=search_result&selectedTitle=1~125&usage_type=default&display_rank=1#H1

By:  Jennifer Hayes, DNP, FNP, CPC  and Tania Celia PhD, APRN, FNP-C, CNE

The new year, 2021, brings some significant changes to the CPT® codes Evaluation and Management (E/M) codes 99201-99215, which are commonly used by providers in outpatient settings. The descriptors have been updated to reflect new criteria for selection and CPT® code 99201 has been removed due to redundancy in medical decision making (MDM) requirements with code 99202.

The History & Physical Exam (H&P) previously accounted for the determination of E/M levels. The new guidelines state the history and physical should be “medically appropriate”, determined by the provider based on the condition being addressed and the standard of care. The H&P are no longer key factors in determining the level of the CPT® code for levels 99202-99215. Additional changes in determining E/M use the MDM or time elements:

• CPT® codes can be determined by weighing the three components of the medical decision making: the number and complexity of the problems addressed during a visit, the amount of data reviewed or analyzed during a visit, and the risk of complications and morbidity or mortality based on the patient’s condition and management. The new guidelines still allow for addressing multiple conditions (new or ongoing) at the same visit using the components mentioned.

Some additional caveats providers should be familiar with:

• • • • Tests or studies billed separately, including performing or interpreting these tests, cannot be used when determining the level of MDM for the encounter.
      • Tests or studies performed during the visit, not reported separately, but part of the encounter, can be used in determining MDM, but must be clearly documented in the chart. One example might be “I independently interpreted ____ test and this was used to determine the diagnosis of______”.

• CPT® codes can be determined by using the total time for the visit provided and includes time spent with patients face to face and also for non-face to face activities done on the same day for management of the patient.
  • • • Time can be used for office or outpatient E/M selection (99212-99205), whether or not the counseling or coordination of care is the primary reason for the visit. Documentation should still include the time spent for the visit and other activities (ex. collaboration with other providers, adding orders, interpreting tests, patient education, etc.)
      • The times are specific to the E/M codes selected. Note: 99211 does not have a time specified and cannot be used for a visit coded based on time.

The American Medical Association has a new chart which will help to guide providers in determining the correct CPT® code: https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

References:

CPT® Evaluation and Management. American Medical Association. https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management Accessed January 23, 2021.

CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356) Code and Guideline Changes.. American Medical Association. https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf  Accessed January 20,2021

CPT® E/M Office Revisions Level of Medical Decision Making (MDM).  American Medical Association. https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf  Accessed January 20,2021

What’s Changing for E/M Codes 99201-99215 in 2021? American Academy of Professional Coders. https://www.aapc.com/evaluation-management/em-codes-changes-2021.aspx#2021CPT® EMGuidelinesOverview Accessed January 20,2021

Takeaways

• Almost all cervical cancers are caused by the human papillomavirus, genotypes 16 and 18 being the most high risk types. 
• The 2018 USPSTF cervical screening recommendations advise screening average risk women ages 30-65 years of age every 3 years with cervical cytology alone, every 5 years with high risk human papillomavirus (hrHPV) testing alone, or every 5 years with co-testing (cytology and hrHPV testing). 
• The American Cancer Society (ACS) recommends cervical cancer screenings from 25 to 65 years of age with primary HPV testing, repeated every 5 years. If primary HPV testing is not available, co-testing every 5 years or cytology alone every 3 year is recommended as an alternative. 
• Clinicians are responsible for increasing adherence to screenings through appointment reminders, performing testing during other appointments, and educating patients on screening intervals. 
• Adherence to HPV immunization schedules are important in the prevention of cervical cancer, although the role has not been fully established. 

Widespread cervical cancer screening practices began in earnest in the United States in the 1950’s. Since then, mortality has markedly decreased. In 1975, 5.55 per 100,000 women died from cervical cancer; while in 2000, that rate dropped to 2.8 deaths per 100,000 women (American College of Obstetricians and Gynecologists [ACOG], 2016; Curry et al., 2018). New research, advancement in treatments, vaccine prevention strategies, and health promotion guidelines continue to evolve, coupled with cervical cancer screening process improvements, have continued the steady decline in mortality to only 2.3 deaths per 100,000 women in 2015 (Curry et al., 2018). 

Currently, cervical cancer screening tests include Papanicolaou test (cytology) or the HPV testing, either alone or in combination. The goals of screening are to detect treatable abnormalities and precancers as well as detect early stages of invasive cervical cancer, thereby initiating early intervention and improving outcomes (Fontham et al., 2020).   

Who Is At Risk? 

There are different screening and surveillance guidelines based on a risk stratification. Average risk individuals are women without symptoms, immunocompetent, and with a negative prior screening history (Feldman et al., 2020). Even though sexual intercourse increases the risk of potential exposure to high risk human papillomavirus (hrHPV), the screening recommendations consider all average risk individuals independent of sexual history (Curry et al., 2018). 

Women with HIV infection, are immunocompromised, have exposure to diethylstilbestrol, or a medical history of cervical cancer or high-grade precancerous lesions are at a higher risk and require individualized follow up (Curry et al., 2018).

Updates to Recommendations by Expert Groups 

Multiple expert groups produce recommendations regarding cervical cancer screenings. Each set of screening guidelines similarly juggle benefits of early detection of disease and reduction in incidence and mortality from cervical cancer, with consideration for potential false positives, unnecessary procedures, and harms from invasive, intimate procedures (Feldman et al., 2020). Likewise, cost, ease of testing, and adherence are considerations.

The 2018 United States Preventive Screening Task Force (USPSTF) recommendations included a major update to screening guidelines for women 30 to 65 years of age. The panel concluded that screening every 3 years with cervical cytology alone, every 5 years with high risk human papillomavirus (hrHPV) testing alone, or every 5 years with co-testing (cytology and hrHPV) showed similar effectiveness in detection of cervical cancer (Curry et al., 2018). Research did not support screening intervals less than 5 years for primary HPV testing and co-testing due to the potential for unnecessary procedures (Sawaya et al., 2015). The USPSTF recommendations advise cervical cancer screening for women ages 21 to 29 every 3 years with cytology alone; against screening women under age 21; and against screening women older than 65 with adequate prior screening and who are not at high risk for cervical cancer, and women who have undergone a complete hysterectomy (including the removal of the cervix) with no past medical history of high-grade precancerous lesions or cervical cancer (Curry et al., 2018).

The American College of Physicians’ recommendations were last updated in 2016 and recommend screening women starting at age 21 with cytology alone, repeated every 3 years. At age 30 years testing should move to every 5 years and include HPV testing and cytology testing (also called co-testing). At age 65, screenings should stop after 3 consecutive negative cytology results or 2 consecutive negative cytology and HPV testing within the last 10 years (Sawaya et al., 2015). 

The American Cancer Society (ACS) recommends initiation of screening at age 25 with primary HPV testing every 5 years. This is continued through age 65. However, if HPV testing is not available, individuals of ages 25 to 65 can be screened with co-testing every 5 years or cytology alone every 3 years. Screenings should stop at age 65 if the patient does not have a history of cervical malignancy within the past 25 years and has adequate negative screening for the past 10 years. The change to initiate screenings at 25 years of age, as opposed to 21, was likely due to low rates of cervical cancer in those ages 20 to 24 as well as multiple observational studies demonstrating spontaneous resolution of HPV infection in this age group (Feldman et al., 2020). 

Role of Human Papillomavirus in Cervical Cancer Screening

HPV is responsible for the majority of cases of cervical cancer. Of the over 150 HPV genotypes, 13 genotypes have been shown to cause cervical cancer (American College of Obstetrics & Gynecology [ACOG], 2020). Genotypes 16 and 18, the ‘high risk’ genotypes, are associated with 66% to 70% of cervical cancers and are included in screening tests (Wuerthner & Avila-Wallace, 2016). Approximately 90% of HPV infections clear within a few years, but persistent HPV infections produce a higher risk for cervical intraepithelial neoplasia, making early identification and surveillance through screenings important for good outcomes (Sawaya et al., 2015). 

Primary HPV testing alone has recently emerged as a capable and effective screening test to prevent cervical cancer. In fact, primary HPV screening in women >25 years was found to be significantly more sensitive for the detection of CIN3+ than cytology alone (Fontham et al., 2020). As of 2017, primary HPV testing was limited to a few US laboratories and access to testing may be lacking (Feldman et al., 2020). Another concern, the number of false positives is higher in primary hrHPV testing than cytology alone, especially in women in their 20’s, potentially causing an increase in unnecessary procedures, like colposcopies (Feldman et al., 2020).

Improving Prevention Methods 

Over 50% of women diagnosed with cervical cancers were not screened appropriately (Feldman et al., 2020). Given the efficacy of screenings, clinicians can improve adherence by actions such as developing a reminder system to actively notify patients of screening intervals as well as reaching out to schedule an appointment. Clinicians can look for opportunities to perform cervical cancer screening when patients are present for other complaints. Urgent care and emergency rooms are potential places to screen patients otherwise unlikely to comply with interval schedules. 

On the other hand, practitioners should adhere to the screening schedule as recommended by expert groups. In average risk patients, the “yearly pap” is no more, relieving patients of an unnecessary anxiety-provoking procedure, potentially more invasive subsequent testing and the cost that burdens both individuals and healthcare at large (Sawaya et al., 2015).

One important prevention tool that precedes cervical cancer screening is the HPV vaccine. The series targets boys and girls ages 11 to 12 years (but may be given as early as 9 years of age) and consists of 2 or 3 shots depending on age of initiation. The HPV immunization available in the U.S. covers 9 HPV genotypes, with a greater than 99% efficacy when administered prior to HPV exposure (ACOG), 2020). Increasing vaccine rates to 80% of eligible recipients, an estimated additional 53,000 cases of cervical cancer could be prevented (ACOG), 2020). The effect of vaccination on persons with high-grade precancerous cervical lesions and cervical cancer has not been established, and all women should continue cervical cancer screenings despite vaccination status (Feldman et al., 2020).

Want More Information…

Cervical Cancer Screening: More Choices in 2019 | Cancer Screening, Prevention, Control | JAMA

Screening for Cervical Cancer: US Preventive Services Task Force Recommendation Statement | Cancer Screening, Prevention, Control | JAMA

Practice Bulletin #168, Cervical Cancer Screening and Prevention

Cervical Cancer Screening – American Family Physician

Adult Immunization Schedule by Vaccine and Age Group

References

Cervical Cancer Screening and Prevention. (2016, October). American College of Obstetricians and Gynecologists [ACOG]. Retrieved January 11, 2021, from https://www.acog.org/en/Clinical/Clinical%20Guidance/Practice%20Bulletin/Articles/2016/10/Cervical%20Cancer%20Screening%20and%20Prevention

Curry, S. J., Krist, A. H., Owens, D. K., Barry, M. J., Caughey, A. B., Davidson, K. W., . . . Wong, J. B. (2018). Screening for Cervical Cancer. Jama, 320(7), 674. doi:10.1001/jama.2018.10897

Feldman, S., MD, MPH, Goodman, A., MD, MPH, MS, & Peipert, J. F., MD, PhD. (2020, December). Screening for cervical cancer in resource-rich settings. Retrieved January 15, 2021, from https://www.uptodate.com/contents/screening-for-cervical-cancer-in-resource-rich-settings?search=cervical+cancer+screening&source=search_result&selectedTitle=1~124&usage_type=default&display_rank=1

Fontham, E. T., Wolf, A. M., Church, T. R., Etzioni, R., Flowers, C. R., Herzig, A., . . . Smith, R. A. (2020). Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society. CA: A Cancer Journal for Clinicians, 70(5), 321-346. doi:10.3322/caac.21628

Human Papillomavirus Vaccination. (2020). ACOG Committee Opinion No 809. American College of Obstetrics & Gynecology. Obstetrics & Gynecology, 136(2), 435-436. doi:10.1097/aog.0000000000004001

Sawaya, G. F., Kulasingam, S., Denberg, T. D., & Qaseem, A. (2015). Cervical Cancer Screening in Average-Risk Women: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Annals of Internal Medicine, 162(12), 851. doi:10.7326/m14-2426

Wuerthner, B. A., & Avila-Wallace, M. (2016). Cervical cancer. The Nurse Practitioner, 41(9), 18-23. doi:10.1097/01.npr.0000490390.43604.5f

Takeaways

• Low back pain is one of the most common complaints seen in clinics with 84% of adults experiencing low back pain at some point in their lifetime (Allegri et al., 2016).
• When evaluating lumbar spine disorders, knowledge of key exam findings that are specific or more consistent with one disorder over another can aid in diagnosis and faster treatment.
• The role of imaging in evaluating low back pain and diagnosing lumbar spine disorders is controversial and may not be helpful due to the inconsistency in ability to detect and classify lumbar disorders and the high potential to detect incidental findings.
• Treatments of lumbar spine disorders focus on treatment of pain and slowing the progression of disease. This should be a multimodal approach involving pharmaceuticals, nonsurgical therapies, and procedural/surgical options. 

Lumbar spine disorders encompass a wide range of conditions including degenerative disc diseases, herniated discs, spondylothsthesis, spinal stenosis, fractures, and osteoporosis. Discovery of an underlying lumbar spinal disorder often begins with a patient seeking relief from low back pain – one of the most common chief complaints seen among medical facilities as 84% of adults experience low back pain at some point in their lifetime (Allegri et al., 2016). Another common initial presentation of lumbar spine disorders is pain or numbness in both or one lower extremity (Hegmann, 2019). Yet, this is still often accompanied by a varying degree of back pain. 

Specific Diagnostic Findings

Differentiating between lumbar disorders in a clinical setting can be complex. However, key specific exam findings are consistent with certain conditions (Hegmann, 2019). Neurogenic (or pseudo) claudication is a hallmark of lumbar spinal stenosis, where pain is exacerbated with walking, standing, and/or maintaining certain postures, and relieved with sitting or lying (Levin, 2019). Lumbar disc herniation with radiculopathy can be evaluated and supported by manual muscle testing, supine straight leg raise, Lasègue sign, and crossed Lasègue sign (Hegmann, 2019). Degenerative lumbar spondylolisthesis can present as one or a combination of the following: asymptomatic with only occasional back pain; chronic low back pain with or without radicular symptoms and with or without positional variance; radicular symptoms with or without neurologic deficit, with or without back pain; and intermittent neurogenic claudication (North American Spine Society Evidence-Based Clinical Guidelines Committee, 2014). Osteoporotic lumbar fractures, also known as compression fractures, cause a sudden onset of pain and have localized pain and tenderness over the spine on examination (Wheeler, 2019). 

By knowing which questions to ask and the various tests to perform, clinicians can narrow their differential diagnoses list, which can provide a more specific treatment plan and potentially improve treatment outcomes. 

Imaging

In general, imaging studies may not necessarily be helpful unless symptoms are persistent; red-flag symptoms are present; treatment responses are inconsistent; or invasive treatment is a consideration (Hegmann, 2019). This may be due to difficulty in specifying or classifying lumbar disorders on imaging and the frequent detection of incidental findings, thereby delaying accurate treatment. Asymptomatic degenerative disk disease is an incidental finding in as many as 54% of persons who undergo imaging (Hegmann, 2019).

Within the first 4-6wks of symptoms, x-rays are not advised for lumbar back pain with the exception of red flag findings (Hegmann, 2019). MRIs are the preferred imaging method to diagnose and classify most lumbar spine disorders (Allegri et al., 2016).   CT scan can more be helpful in certain disorders, especially where MRI’s are contraindicated, such as in facet syndrome, or when the MRI result is inconclusive (Hegmann, 2019).

Treatment  

Treatment of lumbar spine disorders revolves around prevention of worsening pathophysiology and treating the pain caused by these conditions. Some pain treatments can address multiple different disorders as the treatment of pain is consistent among most lumbar spinal disorders with some exceptions. Therefore, identifying the specific diagnosis prior to treatment may be unnecessary and, in fact, can prolong a patient’s discomfort and increase patient costs. 

For pain, NSAIDs and muscle relaxers are often first line agents, followed by antidepressants, gabapentinoids, and other pharmaceutical pain relievers (National Institute of Neurological Disorders and Stroke [NINDS], 2020). Acupuncture, TENs unit therapy, physical therapy, and spinal manipulation are a few nonsurgical therapies that can improve pain and slow the progression of disease (NINDS, (2020). The National Associates for Spine Specialists (NASS) guidelines for low back pain recommends the use of a “back school” program to reduce pain and enhance functionality in patients with chronic low back pain (Cassidy, 2020). However, there was not a uniform “back school” program that the NASS identified as most effective. Usually the program is an in-person multiple course program and works to strengthen self-management of back pain, giving patients a feeling of independence and control.  

If invasive injections are needed, referral to a pain specialist is necessary (Levin, 2019). 

For more information…

VA/DoD Clinical Practice Guideline for Diagnosis and Treatment of Low Back Pain

North American Spine Society

Clinical Guidelines

Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College 

Management of Vertebral Compression Fractures

References 

Allegri, M., Montella, S., Salici, F., Valente, A., Marchesini, M., Compagnone, C., . . . Fanelli, G. (2016). Mechanisms of low back pain: A guide for diagnosis and therapy. F1000Research, 5, 1530. doi:10.12688/f1000research.8105.1

Cassidy, C.R., Enix, D.E., Robbins, D.S., Stout, A.A., & Tauzell, R.A.(2020). Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis & Treatment of Low Back Pain. North American Spine Society, 101 -157.

Hegmann, K. T., Travis, R., Belcourt, R. M., Donelson, R., Eskay-Auerbach, M., Galper, J., . . . Weiss, M. S. (2019). Diagnostic Tests for Low Back Disorders. Journal of Occupational and Environmental Medicine, 61(4). doi:10.1097/jom.0000000000001551

Levin, K. (2019, December 18). Lumbar spinal stenosis: Pathophysiology, clinical features, and diagnosis. Retrieved December 30, 2020, from https://www.uptodate.com/contents/lumbar-spinal-stenosis-pathophysiology-clinical-features-and-diagnosis?search=lumbar+spinal+stenosis

National Institute of Neurological Disorders and Stroke (NINDS). (2020, April 27).  Low Back Pain Fact Sheet. Retrieved December 30, 2020, from https://www.ninds.nih.gov/disorders/patient-caregiver-education/fact-sheets/low-back-pain-fact-sheet

North American Spine Society Evidence-Based Clinical Guidelines Committee. (2014). Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis 2nd Edition. North American Spine Society, (2), 25-28.

Wheeler, S. G., MD, Wipf, J. E., MD, Staiger, T. O., MD, Deyo, R. A., MD, MPH, & Jarvik, J. G., MD, MPH. (2019, June 25). Evaluation of low back pain in adults. Retrieved December 26, 2020, from https://www.uptodate.com/contents/evaluation-of-low-back-pain-in-adults?search=diagnosing+lumbar+compression+fractues

Takeaways

• Any patient can be a victim of human trafficking, but there are some indicators that may alert healthcare providers to a potential victim. 
• Vulnerable populations, such as those living in poverty or experience unstable living conditions, are most at risk for exploitation. 
• The National Human Trafficking Hotline (1-888-373-7888) or 9-1-1 should be alerted when there is a suspected human trafficking situatoin. 

A non-English speaking male presents for an injury that was sustained at work and has evidence of old bruising. A young woman that works as an au pair presents to Urgent Care with recurring UTI’s and is  underweight. A female teenager presents to the Emergency Department with abdominal pain. She acts nervous/anxious during her exam and is unable to identify where she is living. An elderly foreign-born male presents to the walk-in clinic with a severe, infected laceration, clearly days old, obtained while washing dishes. A homeschooled child with ear pain states they are not allowed to play outside. Each of these patients is a potential victim of human trafficking.

The U.S. Department of Health & Human Services [HHS] defines human trafficking as “a form of modern day slavery in which victims are subjected to force, fraud or coercion for the purpose of commercial sex, debt bondage, or involuntary labor” (2012). Any patient could be a potential victim of human trafficking. Victims can be permanent residents, foreign nationals, or even U.S. citizens (HHS, 2012). No age, race, gender, socioeconomic status is spared (Shandro et al., 2020). Victims can be any patient. 

 Human trafficking is found in multiple industries like domestic labor, the hospitality industry, pornography, massage parlors, agriculural or ranch work, or factory work (HHS, 2012). However, there are some populations who are at greater risk. These include vulnerable persons such as those with language barriers, living in poverty, and/or with unstable living conditions (Shandro et al., 2020). Limited support and a lack of resources makes one especially vulnerable to exploitation and trafficking. 

Identification of a Victim in a Clinical Setting

Identification of human trafficking victims can be difficult as patients do not often self-identify as a victim or report abuse (Shandro et al., 2020). Besides identification of vulnerable populations, certain complaints can be suspect of human trafficking. However, victims can present to any clinical setting with any complaint. Chief complaints vary in trafficking studies but include injuries from the labor, suicide attempts and other mental health conditions associated with trauma, substance abuse, untreated chronic medical conditions, malnutrition, and injuries related to assault. However, any chief complaint may accompany a human trafficked victim (Shandro et al., 2020).

Other clinical warning signs presenting on exam may be indicative of human trafficking. These include inconsistent or a scripted story, hesitancy to answer questions, evidence of a controlling partner or dominating relationship, inability to provide an address, lack of awareness of current location or date/time, lack of identification documents, resistance to assistance, and/or demonstration of hostile or fearful/nervous behavior (National Human Trafficking Resource Center [NHTRC], 2010). Red flags during physical exams include old bruising, unhealed wounds, scars, malnutrition, dehydration, or physical exhaustion (NHTRC, 2010). A tattoo of a man’s name or a nickname in an unusual place (inner thigh, breast, back of neck) may suggest branding and should be taken as a warning sign (Shandro et al., 2020). Frequent sexually transmitted diseases and multilple abortions are common amoung sexually trafficked individuals (Shandro et al., 2020). Among agricultural, construction, or manufacturing workers, chronic back, visual, or hearing problems can be common presentations (Shandro et al., 2020). Uncommon infectious diseases such as tuberculosis and hepatitis are common among overcrowded living conditions and drug abuse (HHS, 2012). 

Unfortunately, human trafficking may present without a clear red flag and only a feeling of inconsistency during the visit. Health care providers should explore situations with a patient-centered approach, working to build trust and learn more information. 

How to Help 

If in a human trafficking situation, do not attempt to “save the victim” or keep them in the office. This may cause more harm to the victim or provider. The goal of the visit should be to establish a place of safety and provide resources if able – not to “disclose or rescue” (Shandro et al., 2020). While difficult, allowing the victim to leave the office may be the safest and best way to help. 

The first step should be to alert law enforcement at the National Human Trafficking Hotline (1-888-373-7888) (U.S Department of State [USDS], 2017). This is a national 24-hour, toll-free, multilingual anti-trafficking number that can take tips and provide information on local community resources. The hotline can also provide general anti-trafficking education and information.

If a patient has escaped a trafficking situation, alert law enforcement immediately.  Calling 9-1-1 is appropriate, especially in an urgent situation such as a recently escaped victim. The National Human Trafficking Hotline can also provide immediate information and further direction on how to help the victim, including information about shelters, legal assistance, and other critical resources. 

Interested in learning more? 

Human Trafficking

Indicators of Human Trafficking

Caring for Trafficked Persons: Guidance for Health Providers – | IOM Online Bookstore

The Role of the Nurse in Combating Human Trafficking : AJN The American Journal of Nursing

References 

National Human Trafficking Resource Center (NHTRC). Identifying Victims of Human Trafficking: What to Look for in a Healthcare Setting. (2010, January 03). Retrieved December 09, 2020, from https://humantraffickinghotline.org/sites/default/files/What%20to%20Look%20for%20during%20a%20Medical%20Exam%20-%20FINAL%20-%202-16-16_0.pdf

Shandro, J., Chisolm-Straker, M., Duber, H. C., Findlay, S. L., Munoz, J., Schmitz, G., . . . Wingkun, N. (2016). Human Trafficking: A Guide to Identification and Approach for the Emergency Physician. Annals of Emergency Medicine, 68(4). doi:10.1016/j.annemergmed.2016.03.049

U.S. Department of Health & Human Services. FACT SHEET: IDENTIFYING VICTIMS OF HUMAN TRAFFICKING. (2012, August 08). Retrieved December 09, 2020, from https://www.acf.hhs.gov/archive/otip/resource/fact-sheet-identifying-victims-of-human-trafficking

U.S. Department of Homeland Security. (2020, March 25).Indicators of Human Trafficking. Blue Campaign. Retrieved December 09, 2020, from https://www.dhs.gov/blue-campaign/indicators-human-trafficking

U.S. Department of State. (2017, December 13). Identify and Assist a Trafficking Victim – United States Department of State. Retrieved December 9, 2020, from https://www.state.gov/identify-and-assist-a-trafficking-victim/

Understanding the Epidemic

On October 26, 2017, the Department of Health and Human Services (HHS) declared a public health emergency to address the national opioid crisis, an epidemic claiming 91 lives a day at that time. The opioid crisis began in the 1990’s when pharmaceutical companies pushed these medications, assuring medical professionals that opioids had little to no risk of addiction. The 750,000 people who died from a drug overdose since 1999, 32% of which involved prescription opioids in 2018, tell a different story (Centers for Disease Control and Prevention [CDC], 2020).

In 2017 the U.S. government allotted $900M of the 2017 fiscal budget to opioid specific funding, executing a five-point plan to improve access to support services, increase distribution of overdose-reversing drugs, strengthen data collection methods, support research on addiction/pain, and advance pain management practices (HHS, 2017). This, coupled with efforts by the CDC, HHS, and a number of expert groups, helped contribute to a 4% decrease in drug overdose deaths from 2017 to 2018 (CDC, 2020). However, the number of 2018 drug overdose deaths was still four times higher than in 1999, with an average of 41 people dying daily from overdoses involving prescription opioids (CDC, 2020).

Principles of Pain Management

Pain is often first addressed by a primary care provider during the acute phase, and the goal begins with identification and resolution of the cause of pain (Mills et al., 2016). After a somewhat arbitrary 12 week time period, pain is deemed “chronic” and goals shift to maximizing function and quality of life, rather than total elimination (Mills et al., 2016). Pain is an individual experience, however, and successes in pain management can be largely subjective to each patient.

The HHS established a Pain Management Best Practices Inter-Agency Task Force (Task Force), and in 2019, this reported an extensive literature and research review outlining best practices when treating acute and chronic pain. The Task Force ultimately stressed a patient-centered, multidisciplinary approach for diagnosis and treatment that utilizes multimodal therapies (U.S. Department of Health and Human Services [HHS], 2019). These include non-opioid pharmaceuticals, alternative non pharmaceutical therapies, and safe opioid medication therapy (HHS, 2019).

Providers should not only be aware of the many options to treat pain, but should also understand barriers to care, individual healthcare provider variables, and system obstacles that affect chronic pain management. This may include a prescriber’s biases, access to different treatments, and other conditions that may affect perception of pain. 

For example, one study suggested chronic pain treatments should address depression as well as maximize a patient’s self-efficacy in their pain control as this leads to low pain interference of daily life (Adams et al, 2018). Low pain interference was associated with a better quality of life overall with fewer depression/anxiety symptoms, less pain catastrophizing, and greater pain management (Adams et al, 2018). 

Addressing Pain: Non-opioid Therapy

Opioids should not be first-line therapy for chronic pain (Dowell et al., 2016).  Non-opioid pain therapies can effectively manage chronic pain and are much safer (HHS, 2019). The Task Force recommendations outline all classes of medications that can address pain, encouraging non-opioid pharmaceutical use and alternative pain therapies if appropriate (HHS, 2019).

Addressing Pain: Opioids

Despite negative outcomes, opioids can be effective when addressing pain and can alleviate living with debilitating chronic pain. The 2016 CDC guidelines for the treatment of chronic pain in primary care with opioid therapy addresses initial opioid prescribing as well as ongoing monitoring. These 12 recommendations are aimed at improving communication between health care providers and patients, while reducing risks and incidence rates of negative outcomes associated with opioids (Dowell et al., 2016). 

While the guidelines direct prescribing practices for primary care clinicians, pain specialists are an important resource in the appropriate management of chronic pain.   The CDC advises pain management consult in cases where substance abuse (or a recent history of), concurrent use of benzodiazepines or other central nervous system depressants, or adequate pain control is not achieved (Dowell et al., 2016). 

However, primary care clinicians are often without the ability to consult a specialist or do not have access to a referral program. Either way, knowledge of chronic pain management for primary care providers is imperative in decreasing negative outcomes of opioid therapy. 

If you are interested in learning more…

Understanding the Epidemic | Drug Overdose

Pain Management Best Practices Inter-Agency Task Force Report: Updates, Gaps, Inconsistencies, and Recommendations

Opioid Pain Medication Prescription for Chronic Pain in Primary Care Centers: The Roles of Pain Acceptance, Pain Intensity, Depressive Symptoms, Pain Catastrophizing, Sex, and Age

Pain Management for Primary Care Providers: A Narrative Review of High-Impact Studies, 2014-2016 

Alternative Treatments Fact Sheet

Lessons for Better Pain Management in the Future: Learning from the Past

References 

Adams, M. H., Dobscha, S. K., Smith, N. X., Yarborough, B. J., Deyo, R. A., & Morasco, B. J. (2018). Prevalence and Correlates of Low Pain Interference Among Patients With High Pain Intensity Who Are Prescribed Long-Term Opioid Therapy. The journal of pain : official journal of the American Pain Society, 19(9), 1074–1081. https://doi.org/10.1016/j.jpain.2018.04.005l

Centers for Disease Control and Prevention. (2020, March 19). Drug Overdose Deaths. Opioid Overdose. Retrieved December 25, 2020, from https://www.cdc.gov/drugoverdose/data/statedeaths.html

Centers for Disease Control and Prevention. (2020, March 19). Understanding the Epidemic. Opioid Overdose. Retrieved November 25, 2020, from https://www.cdc.gov/drugoverdose/epidemic/index.html

Dowell, D., MD, Haegerich, T. M., PhD, & Chou, R., MD. (1970, January 01). CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016. November 24, 2020, http://dx.doi.org/10.15585/mmwr.rr6501e1

Mills, S., Torrance, N., & Smith, B. H. (2016). Identification and Management of Chronic Pain in Primary Care: a Review. Current psychiatry reports, 18(2), 22. https://doi.org/10.1007/s11920-015-0659-9

U.S. Department of Health and Human Services: HHS Press Office. (2017, October 26). HHS Acting Secretary Declares Public Health Emergency to Address National Opioid Crisis. Retrieved November 24, 2020, from https://www.hhs.gov/about/news/2017/10/26/hhs-acting-secretary-declares-public-health-emergency-address-national-opioid-crisis.html 

U.S. Department of Health and Human Services (2019, May). Pain Management Best Practices Inter-Agency Task Force Report: Updates, Gaps, Inconsistencies, and Recommendations. Retrieved from U. S. Department of Health and Human Services website: https://www.hhs.gov/ash/advisory-committees/pain/reports/index.html

Terri Schmitt, PhD, APRN, FNP-BC, FAANP, Lead Nurse Planner, NPACE

With National Influenza Vaccination Week coming up on December 6th, I’m reminded of my yearly routine regarding speaking with patients about getting vaccinated. “Have you had a flu shot yet?” I ask this question of every single patient, each fall. Frequently I hear a negative response, followed quickly by a statement of hesitancy or outright refusal. For influenza I have all the answers down. I present the science and emphasize the need for protecting others. Still, many patients refuse. Other times, I run out of vaccine long before I run out of patients to vaccinate. Frankly, the combination of informing and convincing patients, and the possibility and logistics of vaccination for COVID concerns me.

In the 2018-2019 influenza season the CDC reported a vaccination rate of 62+% in children up to age 17 and 45+% in adults, with both rates being up from prior years (CDC, 2019). Although herd immunity needs of a population vary by disease, influenza vaccine rates are not high enough to convey such a benefit to the unvaccinated.

Many Americans do not receive an influenza vaccine for a variety of reasons including fear that the vaccine will give them the ‘flu’; the belief that they are healthy and don’t need a vaccination because they have never gotten the ‘flu’ before; that the vaccine is not effective at preventing the disease; and even that it is better to actually get a disease and build antibodies than to take a vaccine. Such myths must be handled skillfully by clinicians and with facts.

Clinicians need the right tools and information to answer patient questions concerning vaccines. And these providers have questions themselves, such as which vaccines are recommended and how often for patients with autoimmune disease, Sickle Cell variations, or a positive HIV status, to name a few. Specific information on mRNA technology, how it works, and what makes it different from other vaccine technology is likewise needed.

Tackling vaccine administration, and patient questions, reluctance and misinformation, particularly in a time of a pandemic, is paramount. NPACE is working hard to incorporate the latest information in an upcoming pharmacology conference and will be presenting immunization updates and providing guidance on vaccine reluctance. Further information on vaccine reluctance and immunization schedules can be found at the following websites:

• CDC updated immunization schedules: https://www.cdc.gov/vaccines/schedules/index.html
• WHO systematic review on addressing vaccine hesitancy:  https://www.who.int/immunization/sage/meetings/2014/october/3_SAGE_WG_Strategies_addressing_vaccine_hesitancy_2014.pdf
• CDC Vaccinate with Confidence series: https://www.cdc.gov/vaccines/partners/vaccinate-with-confidence.html

References:

CDC (2019). Flu Vaccination Coverage, United States, 2018-2019 Influenza Season. Retrieved from https://www.cdc.gov/flu/fluvaxview/coverage-1819estimates.htm