August 2017

Opioid Analgesics For Chronic Musculoskeletal Pain: Risks May Outweigh The Benefits

I am honored to serve as the new President of the U.S. Bone and Joint Initiative (USBJI) succeeding my friend and colleague, Dr. David Pisetsky.  This is my first column as President and I would like to start off by acknowledging the accomplishments of Dr. Pisetsky, the Executive Committee and the staff of the USBJI, particularly Toby King, Shari Maier, and new staff member Mary Ellen Hendricks, over the past two years.  USBJI has several excellent programs including publishing The Burden of Musculoskeletal Diseases in the United States (BMUS), the Young Investigator Initiative, Project 100 for Undergraduate Musculoskeletal Education, and the Pediatric Specialty Group that provides a focus on musculoskeletal diseases in childhood and adolescence.  During the past year, USBJI has reinforced its collaboration with the Osteoarthritis Action Alliance (OAAA) and transferred the ongoing activities of the Chronic Osteoarthritis Management Initiative to that entity while remaining involved. Dr. Bruce Browner, our newly elected Secretary, has taken on the responsibility of developing a new program entitled “MS4”; briefly, this will be a one-month elective for fourth-year medical students that will provide intense exposure to musculoskeletal diseases.  Dr. Browner outlined plans in our last newsletter, and will provide more information on this exciting new program in this newsletter.
 
As you know, musculoskeletal diseases are the most common chronic conditions among adults in the U.S.; this includes almost 60 million adults with chronic low back pain and over 50 million adults with arthritis and other related conditions. The mission of USBJI is to advocate for and promote multidisciplinary, coordinated and patient-centered care to improve prevention, diagnosis and treatment of musculoskeletal conditions.

The primary symptom of musculoskeletal disease is acute and chronic pain; chronic pain is defined as pain lasting more than three months. We all are aware of the recent public health concerns related to the use and abuse of opioid analgesics that were initially prescribed for management of acute pain and then are used for chronic pain.  Opioid analgesics have been shown to be moderately effective for relief of acute pain based on clinical trials of 12 week’s duration or less.
 
Last year, the Centers for Disease Control and Prevention (CDC) published recommendations for primary care providers about prescribing opioid analgesics for chronic pain, including pain from chronic musculoskeletal diseases. These recommendations were based on a systematic review of the scientific literature that focused on the long-term effectiveness and risks of opioid therapy for chronic pain that was conducted originally by the Agency for Healthcare Research and Quality and was updated by the CDC.
 
The review addressed five questions: 1) effectiveness and comparative effectiveness of opioid therapy, 2) harms and adverse events, 3) dosing strategies, 4) risk assessment and risk mitigation strategies, and 5) effects of opioid therapy for acute pain on long-term use. In addition, the CDC examined the effectiveness of alternative treatments, including non-opioid drug therapies such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) and non-pharmacologic modalities.
 
The CDC found that there was no evidence of a long-term benefit of opioid therapy for relief of chronic pain and improvement in functional limitation compared to no opioid therapy, and extensive evidence of possible harms of opioid therapy including opioid overdose, motor vehicle injury, and development of opioid use disorder. Hence, persons with chronic pain due to musculoskeletal diseases should speak with their providers about the use of non-pharmacologic as well as non-opioid pharmacologic therapies for treatment and only start opioid therapy after an inadequate response to these modalities and after discussing the known risks and limited benefits of long-term opioids.
 

Sunday, October 22 – Monday October 23, 2017 - Berlin, Germany

“Integrated Care for Older People – The Path to Universal Health Coverage”
in partnership with the German Ministry of Health and the World Health Organization

This year’s G-MUSC Symposium and Annual General Meeting will be held jointly with the World Health Organization (WHO) with support from the Federal Ministry of Health of Germany and the Japan Ministry of Labor and Social Welfare.

Integrated Care for Older People - the Path to Universal Health Coverage will be the topic of a WHO Global Consultation meeting, to take place later in the week, and informed from the discussions of G-MUSC delegates and WHO representatives during the G-MUSC symposium.

The G-MUSC meeting will begin on Sunday, October 22. On the Monday morning G-MUSC delegates will participate with the WHO consultation group. Monday afternoon content will include National Action Network-hosted workshops for the group to share experiences of collaborative working related to musculoskeletal health and aging. The USBJI is the U.S. National Action Network of the Global Alliance for Musculoskeletal Health. USBJI Members are invited to participate in this meeting to represent the US/USBJI.

As an outcome of the G-MUSC Symposium, at the request of the Federal Ministry of Health of Germany, a consensus document will be drafted on the importance of musculoskeletal health, maintaining mobility over the life course, and the role of integrated care in delivering this. Maintaining mobility and a healthy musculoskeletal system is essential for quality of life and is particularly important in older people. This document will help to support the prioritization of musculoskeletal health in the WHO’s work on Healthy Aging. The G-MUSC looks forward to receiving input from USBJI members into the development of this consensus document.

The Annual General Meeting (AGM) of the Global Alliance for Musculoskeletal Health will be held during the afternoon of Monday, October 23.

If you would like to attend the G-MUSC Symposium and Annual General Meeting please register your interest by contacting office@bjdonline.org, and copy usbji@affinity-strategies.com.

American Chiropractic Association

The American Chiropractic Association has partnered with THE SPINE INSTITUTE FOR QUALITY (Spine IQ) to encourage doctors of chiropractic to participate in the Spine IQ conservative care for spine registry. 

Spine IQ is an independent, not-for-profit organization whose mission is to define quality, demonstrate value and build trust for the conservative evaluation and management of spine related disorders through the use of clinical data registries. 

The Spine IQ registry has been approved as a qualified clinical data registry (QDCR) for the CMS Quality Payment Program Merit-based incentive payment system for 2017. The Spine IQ registry includes 27 performance measures, 24 existing QPP (formerly PQRS) measures and 3 custom measures relevant to chiropractic practice. 

The Spine IQ data registry will gather information to better understand the natural history of spine related disorders as well as clinical effectiveness and the value of conservative services. The ultimate goal is to guide the clinician in providing more patient centered, evidence influenced, high-value conservative spine care. The patient will be the ultimate beneficiary. 

The American Chiropractic Association is the largest professional association in the United States representing doctors of chiropractic. The American Chiropractic Association promotes the highest standards of ethics and patient care. www.acatoday.org

National Association of Orthopaedic Nurses

The National Association of Orthopaedic Nurses (NAON) looked at numerous aspects of orthopaedics throughout 2016 and 2017. Below are just a few successful initiatives NAON undertook this past year.

The NAON Research Committee awarded their inaugural research grant to NAON member, Deborah Witting-Wells, PhD, RN, NE-BC. Deborah and her team are using their funding to explore the use of available technology and an existing app to promote adherence to aspirin (ASA) taken in order to prevent deep vein thrombosis (DVT) in post-orthopaedic surgery patients.

This study is significant to NAON as orthopaedic surgical procedures have some of the highest rates for post-operative DVT. Anticoagulant treatment is critical for these patients and ASA is an effective treatment for this particular patient population. While medication adherence is known to be of critical importance, adherence rates are typically low. Poor rates of adherence have been linked to the need for more medical treatment, higher expenses for patients, a greater financial burden on the healthcare system, less optimal health care outcomes, and increased morbidity and mortality. Reminders are critical for individuals to improve outcomes and help prevent DVTs.

The results of this study will be translatable to clinical practice and used to address ongoing adherence of aspirin (ASA). If found effective, the app could easily be used to promote medication adherence self-management by reminding patients to take medications for other chronic health conditions.

NAON also published the following position statement: Promoting Musculoskeletal Health through Physical Activity for All Children and Adolescents, by Elizabeth A. Aronson. NAON supports the position that children and adolescents should engage in at least 60 minutes of moderate to vigorous physical activity daily.

NAON released a new edition of its Orthopaedic Surgery Manual, 3^rd Edition. This manual is a wealth of knowledge and information for practitioners new to the orthopaedic OR environment. It also serves as a working reference for nurses who want to know more about surgical interventions for preoperative and postoperative care considerations and patient/family education. This book is a must for Perioperative Services Departments, Orthopaedic Inpatient Units and Ambulatory Care Settings. 

At the 2017 Annual Congress, NAON’s official journal, Orthopaedic Nursing, presented several awards recognizing both authors and manuscripts that made significant contributions to nursing literature.The first award presented was the Nan Hilt Writers Award which was presented to Bryan Combs and Karen Heaton for their manuscript “Shoulder Injuries in Commercial Truck Divers: A Literature Review.” The second award presented was the Teresa Pellino Research Writers Award which was presented to a team of researchers: Rosemary Wilson, Judith Watt-Watson, Ellen Hodnett, and Joan Tranmer for their manuscript, “A Randomized Controlled Trial of an Individualized Preoperative Education Intervention for Symptom Management after Total Knee Arthroplasty.”The journal announced a new award this year, the Reviewer of the Year Award which was presented to Dr. Janie Trogdon Best , acknowledging her outstanding work as a reviewer for the journal.

NAON has had a successful year thus far and looks forward to continuing the work that supports orthopaedic nurses in their various roles.


Karen Heaton and Bryan Combs                          Dr. Janie Trogdon Best

The USBJI’s Project 100 works to increase formalized instruction in musculoskeletal medicine in medical schools. Under its auspices, the MS4 Task Force is developing an innovative, standardized 4-week MSK education elective for fourth year medical students that will enter primary care residencies.  The elective will employ the latest concepts in medical education, including the “flipped classroom” with extensive use of on-line mini lectures, small group discussions, case studies, hands-on physical examination labs for each region of the anatomy and varied clinical experiences. These are being developed with a focus on increasing the students’ knowledge about correct and timely diagnosis, treatment, and appropriate and timely referral to specialists for conditions affecting each region of the musculoskeletal system.
 
Team Leaders
The course is organized by anatomic region and specific disorders. Team leaders from different MSK specialties and primary care were recruited to lead the development of each segment (see the list below). The teams they lead will produce the on-line mini lectures that students will view independently, create the case presentations, design the hands-on laboratories for physical examination and set the goals for recommended clinical experiences.  A separate team of anatomists lead by Kelly M. Harrell, PhD, MPT, will create a series of consistent MSK anatomy videos that will be included with the on-line mini-lectures for each anatomic region.

The team leaders have reviewed the draft course outline, revised and shortened the excessively long list of subjects proposed for the mini-lectures, taken from the table of contents of the course text, Essentials of Musculoskeletal Care. Charged with limiting the content to one-hour of viewing per evening or weekend, they chose the most important subjects to present and organized them into a series of ten-minute mini-lectures.

1. Low Back Pain - Jonathan Kirschner, MD, RMSK, Physiatrist, HSS-Cornell, NY
2. Cervical Spine - Nora Foster, MD, Orthopaedic Spine Surgeon, Duke, NC
3. Shoulder  - Vani Sebesan, MD, Orthopaedic Shoulder and Elbow Surgeon, Cleveland Clinic, FL 
4. Upper Extremity - Marty Boyer, MD, Hand Surgeon, WUSL MO and Fraser Leversedge, MD, Hand Surgeon, Duke, NC
5. Hip & Thigh - Mike Bolognese, MD, Total Joint Surgeon, Duke, NC and Sam Wellman, MD, Total Joint Surgeon, Duke, NC
6. Pain Management - Andre Boezaart, MD, PhD, Anesthesiologist, UFL, FL, Ajay Antony, MD, Anesthesiologist, UFL, FL and Richa Wardhan, MD, Anesthesiologist, UFL, FL
7. Knee and Lower Leg - Priya Radhakrishnan, MD, Primary Care, Honor Health, AZ, Kristina Wilson, MD, Primary Care Sports Med, U Arizona, AZ  and Sameer Dixit, MD Johns Hopkins, MD, Primary Care Sports Med
8. Foot & Ankle - Lauren Geaney, MD, Orthopaedic Foot and Ankle Surgeon, UCHC, CT
9. Osteoarthritis - Beth Jonas, MD, Rheumatologist, UNC, NC
10. Inflammatory Arthritis - Christine Jones, MD, Rheumatologist, CVMC, VT
11. Osteoporosis - Bart Clark, MD, PhD, Endocrinologist, Mayo, MN and Cathleen Colon-Emeric, MD, MHS, Geriatrician, Duke, NC
12. Mechanical & Postural - Gene Lewis, DC, MPH, Duke, NC and Mike Reiman, PT, DPT, OCS, SCS, ATC, Duke, NC
13. PCP, Specialist Coordination - Claudia Campos, MD, Wake Forest, NC
14. MSK Anatomy - Kelly Harell, PhD, MPT, Anatomist, ECU, NC

Model Sample Videos Created
The short, recorded mini-lectures on Low Back Pain by Anand Joshi, MD, MHA, Duke Orthoapedic Director of PM&R, were recognized as a potential model for the MS4 on-line mini-lectures, but they were made as Power Points with disembodied voice over narration. On July 7, Dr. Derek Clewey and Dr. Sterling Lyon, from the DPT program in the Duke Orthopaedic Department, used their studio to film Dr. Joshi giving two of his mini-lectures.  The edited versions created subsequently are outstanding model samples, and will be used as format guides for the MS4 mini-lectures.  They will be shown, and the filming of videos will be discussed at the meeting outlined below.

Deans of MS Education
July 14, Dr. David Pisetsky and Dr. Bruce Browner met with Vice Dean of Education Dr. Edward Buckley, Duke School of Medicine, to discuss the MS4 Course and consider establishing it as an MS4 Elective at Duke. He validated the need for the course nationally, noted it would be reasonable to implement as an elective at Duke and other medical schools and thought it might eventually be incorporated as a required course. Dr. Buckley applauded the use of the flipped classroom methodology, but cautioned that fourth year medical students would want to spend most of the day in clinical settings with patients rather than classrooms. He liked the immediate application of knowledge acquired from independent viewing of on-line min-lectures in hands-on labs and clinical settings. He reviewed our proposed distribution of time and said that spending afternoons only in the clinic would constitute minimal compliance with the expectations of students and education deans, and thus this should be revised. He noted the challenges of moving students between locations during the day and organizing faculty to teach each segment.  Dr. Browner agreed to take the lead in applying for and organizing the elective at Duke, and met subsequently with Associate Curricular Dean Dr. Coleen Grochowsky to begin the process.

Day One of Course
Jonathan Kirschner, MD, and Paul Levin, MD are working together to develop the plan and material for the opening day of the course. After an introductory welcome by the local course coordinator and discussion of course logistics, the course will begin with a series of short videos designed to provide essential overview topics.  Stuart Weinstein, MD, Co-Chair of the BMUS Steering Committee has already made a wonderful short video about BMUS which contains data on the prevalence, societal and economic cost of MSK diseases in the US, which represent a high level of the complaints seen in primary care practice. This video will be used as an introduction to the course. Similar videos will be made by Kim Templeton, MD, about sex, gender and cultural disparities; Paul Levin, MD, about abuse of imaging; Jonathan Kirschner, MD about the general approach to the MSK patient; a talk from an expert on the opioid epidemic and the use of alternatives for pain management.  A session on motivated interviewing and comprehensive MSK patient physical examination will be developed.

September 16 Team Leaders Meeting at Duke
To achieve consistency across the course segments, in creation of the videos, case studies, lab designs and clinical experiences, a face-to-face meeting for the Team Leaders has been scheduled for September 16. Since half of the leaders come from Duke, UNC, Wake Forest and ECU, the one-day meeting was scheduled at Duke to allow local participants to drive and save on travel expenses.  Fortunately, at least one of the leaders from each team will be able to attend.

The main agenda items are:

• MS4 MSK Rationale & organization 
• Medical Education-new pedagogy
• Course schedule-four week general and two week supplements
• Role of local course coordinators
• USBJI produced resources-videos, cases, labs, assessments
• Management of USBJI Course Material-copyright, website, fees, course text
• Daily activities-discussions, case presentations, PE labs, clinics, logistics, faculty availability
• Videos for independent viewing-anatomy, Joshi demo, Essentials PE videos, time per evening, credit for speakers
• Video production-Studio filming, Mediasite/Camtasia, resources, timing
• Initial Implementation in Medical Schools
• Funding
• Subsequent MSK Education Projects

We hope the meeting will lead to the Team Leaders developing a sense of shared ownership for the MS4 Course.  Their collective input during discussions will be important to revise and perfect the course design. After working together to coordinate the design of course resources, learning about video production, the Team Leaders will be well positioned to work with their teams. In addition to people who have volunteered to work on the project team, they will engage others to help them with the creation of videos and case studies. We will seek to establish the MS4 MSK Elective in a variety of medical schools to trial the course. It is hoped that the Team Leaders will apply for elective in the schools where they work. We have generated great enthusiasm and momentum, but we now have to acquire sufficient funding to enable the next phase of development, and implementation.