TBD Meeting (5285-18)

SAN DIEGO – There are many potential treatments for fibromyalgia, but a large number of them – NSAIDs, opioids, cannabis and more – come with caveats and nothing beats an old stand-by: physical rehabilitation.

With exercise, “we’re getting the muscles moving, and we’re getting [patients] used to stimulation that will hopefully deaden that pain response over time,” David E.J. Bazzo, MD, said at Pain Care for Primary Care. Still, “it’s going to take multiple things to best treat your patients.”

Fibromyalgia is unique, said Dr. Bazzo, professor of family medicine and public health at the University of California, San Diego. Diagnosis is based on self-reported symptoms since no laboratory tests are available. For diagnostic criteria, he recommends those released by the American College of Rheumatology in 2010 and 2011 and updated in 2016. The criteria, he said, recognize the importance of cognitive symptoms, unrefreshing sleep, fatigue, and certain somatic symptoms (Semin Arthritis Rheum. 2016;46[3]:319-29).

Poor sleep is an especially important problem in fibromyalgia, Dr. Bazzo said, although it’s “a bit of a chicken-and-egg discussion.” It’s not clear which comes first, but “we know that both happen hand-in-hand. We need to work on people’s sleep as one of the primary targets.”

When it comes to treatment, “you have to validate this person’s symptoms and say, ‘Yes, I believe you. I know that you are suffering, and that you’re having pain,’ ” Dr. Bazzo said at the meeting held by the American Pain Society and Global Academy for Medical Education. He advised clinicians to keep in mind conditions that can accompany fibromyalgia, such as depression, that may require other treatment options.

Dr. Bazzo offered advice about these approaches to treatment:

• Exercise. Research supports treadmill and cycle ergometry (BMJ 2002;325:185).
• Opioids. “There’s no convincing evidence that opioids have a role in treating fibromyalgia initially. If you’ve tried everything and patients have had problems, are just not responsive or had side effects, you could consider opioids. But that should be at the tail end of everything because the data is not there,” he said.
• Tramadol. “It’s like an opioid with potential for addiction,” he said. “Don’t just use it willy-nilly. Make sure you have a reason and a good plan. Would it be my first thing? No. Is it something that I keep in my back pocket when other things aren’t working? Perhaps. Would I use it before an opioid? For sure.”
• Second-line therapies. According to Dr. Bazzo, these include antiepileptics such as gabapentin and pregabalin, low-dose cyclobenzaprine, and dual reuptake inhibitors such as duloxetine. There are many other second-line options, he said, from behavioral approaches to yoga to guided physical therapy.
• NSAIDs. Not helpful.
• Cannabis. May interact with other medications.
• Pain clinics. Make sure you refer patients to a pain clinic that embraces a multidisciplinary approach, he said, not one that only offers “pain pills or shots.”

Dr. Bazzo reported no relevant conflicts of interest. The Global Academy for Medical Education and this news organization are owned by the same parent company.

SAN DIEGO – There are many potential treatments for fibromyalgia, but a large number of them – NSAIDs, opioids, cannabis and more – come with caveats and nothing beats an old stand-by: physical rehabilitation.

With exercise, “we’re getting the muscles moving, and we’re getting [patients] used to stimulation that will hopefully deaden that pain response over time,” David E.J. Bazzo, MD, said at Pain Care for Primary Care. Still, “it’s going to take multiple things to best treat your patients.”

Fibromyalgia is unique, said Dr. Bazzo, professor of family medicine and public health at the University of California, San Diego. Diagnosis is based on self-reported symptoms since no laboratory tests are available. For diagnostic criteria, he recommends those released by the American College of Rheumatology in 2010 and 2011 and updated in 2016. The criteria, he said, recognize the importance of cognitive symptoms, unrefreshing sleep, fatigue, and certain somatic symptoms (Semin Arthritis Rheum. 2016;46[3]:319-29).

Poor sleep is an especially important problem in fibromyalgia, Dr. Bazzo said, although it’s “a bit of a chicken-and-egg discussion.” It’s not clear which comes first, but “we know that both happen hand-in-hand. We need to work on people’s sleep as one of the primary targets.”

When it comes to treatment, “you have to validate this person’s symptoms and say, ‘Yes, I believe you. I know that you are suffering, and that you’re having pain,’ ” Dr. Bazzo said at the meeting held by the American Pain Society and Global Academy for Medical Education. He advised clinicians to keep in mind conditions that can accompany fibromyalgia, such as depression, that may require other treatment options.

Dr. Bazzo offered advice about these approaches to treatment:

• Exercise. Research supports treadmill and cycle ergometry (BMJ 2002;325:185).
• Opioids. “There’s no convincing evidence that opioids have a role in treating fibromyalgia initially. If you’ve tried everything and patients have had problems, are just not responsive or had side effects, you could consider opioids. But that should be at the tail end of everything because the data is not there,” he said.
• Tramadol. “It’s like an opioid with potential for addiction,” he said. “Don’t just use it willy-nilly. Make sure you have a reason and a good plan. Would it be my first thing? No. Is it something that I keep in my back pocket when other things aren’t working? Perhaps. Would I use it before an opioid? For sure.”
• Second-line therapies. According to Dr. Bazzo, these include antiepileptics such as gabapentin and pregabalin, low-dose cyclobenzaprine, and dual reuptake inhibitors such as duloxetine. There are many other second-line options, he said, from behavioral approaches to yoga to guided physical therapy.
• NSAIDs. Not helpful.
• Cannabis. May interact with other medications.
• Pain clinics. Make sure you refer patients to a pain clinic that embraces a multidisciplinary approach, he said, not one that only offers “pain pills or shots.”

Dr. Bazzo reported no relevant conflicts of interest. The Global Academy for Medical Education and this news organization are owned by the same parent company.

SAN DIEGO – There are many potential treatments for fibromyalgia, but a large number of them – NSAIDs, opioids, cannabis and more – come with caveats and nothing beats an old stand-by: physical rehabilitation.

With exercise, “we’re getting the muscles moving, and we’re getting [patients] used to stimulation that will hopefully deaden that pain response over time,” David E.J. Bazzo, MD, said at Pain Care for Primary Care. Still, “it’s going to take multiple things to best treat your patients.”

Fibromyalgia is unique, said Dr. Bazzo, professor of family medicine and public health at the University of California, San Diego. Diagnosis is based on self-reported symptoms since no laboratory tests are available. For diagnostic criteria, he recommends those released by the American College of Rheumatology in 2010 and 2011 and updated in 2016. The criteria, he said, recognize the importance of cognitive symptoms, unrefreshing sleep, fatigue, and certain somatic symptoms (Semin Arthritis Rheum. 2016;46[3]:319-29).

Poor sleep is an especially important problem in fibromyalgia, Dr. Bazzo said, although it’s “a bit of a chicken-and-egg discussion.” It’s not clear which comes first, but “we know that both happen hand-in-hand. We need to work on people’s sleep as one of the primary targets.”

When it comes to treatment, “you have to validate this person’s symptoms and say, ‘Yes, I believe you. I know that you are suffering, and that you’re having pain,’ ” Dr. Bazzo said at the meeting held by the American Pain Society and Global Academy for Medical Education. He advised clinicians to keep in mind conditions that can accompany fibromyalgia, such as depression, that may require other treatment options.

Dr. Bazzo offered advice about these approaches to treatment:

• Exercise. Research supports treadmill and cycle ergometry (BMJ 2002;325:185).
• Opioids. “There’s no convincing evidence that opioids have a role in treating fibromyalgia initially. If you’ve tried everything and patients have had problems, are just not responsive or had side effects, you could consider opioids. But that should be at the tail end of everything because the data is not there,” he said.
• Tramadol. “It’s like an opioid with potential for addiction,” he said. “Don’t just use it willy-nilly. Make sure you have a reason and a good plan. Would it be my first thing? No. Is it something that I keep in my back pocket when other things aren’t working? Perhaps. Would I use it before an opioid? For sure.”
• Second-line therapies. According to Dr. Bazzo, these include antiepileptics such as gabapentin and pregabalin, low-dose cyclobenzaprine, and dual reuptake inhibitors such as duloxetine. There are many other second-line options, he said, from behavioral approaches to yoga to guided physical therapy.
• NSAIDs. Not helpful.
• Cannabis. May interact with other medications.
• Pain clinics. Make sure you refer patients to a pain clinic that embraces a multidisciplinary approach, he said, not one that only offers “pain pills or shots.”

Dr. Bazzo reported no relevant conflicts of interest. The Global Academy for Medical Education and this news organization are owned by the same parent company.

SAN DIEGO – Clinicians have few tools to monitor pain medication use and abuse in their patients. However, addiction specialist and internist Edwin Salsitz, MD, says an inexpensive and simple tool, the urine test, can provide an impressive amount of useful information.

copyright toeytoey2530/Thinkstock

“The urine drug test, or another matrix for testing, gives one of the only objective factors we have to see how a patient is doing, if they’re following the treatment plan,” said Dr. Salsitz, of Mount Sinai Beth Israel, New York, in a presentation at Pain Care for Primary Care, a symposium offered by the American Pain Society and the Global Academy for Medical Education.

Dr. Salsitz offered these tips about urine tests in pain care:
 

Consider urine tests before beginning opioid therapy

Dr. Salsitz pointed to this 2016 recommendation from the Centers for Disease Control and Prevention: “When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.” As Dr. Salsitz puts it, these tests “can help identify misuse, which hopefully hasn’t gotten to addiction yet.”

Ask the patient what the urine test will reveal

Dr. Salsitz likes to tell patients: “If you tell me the truth, no matter what’s in the urine, it’s going to be OK. I’m not going to stop prescribing or do anything harmful to you.” But, he tells patients, if they lie, “you’re going to start breaking the trust between us. Once you do that, it becomes a problem. I don’t know what’s true or not.” In some cases, he said, patients will fess up to drug use that wouldn’t have shown up in the urine tests because it didn’t happen recently enough. “We’ll talk about whether it’s a problem,” he said.

Begin with an immunoassay panel test (IA)

The CDC recommends using an immunoassay panel first in most situations. “You can do this in the office,” Dr. Salsitz said, using a dipstick-style test. Or you can “send it out to a lab, and they’ll do the same thing.”

Understand what IA tests do and don’t do

Standard 5-drug IA screening tests detect marijuana, cocaine, amphetamine/methamphetamine, PCP, and opiates (morphine/codeine). Keep in mind, Dr. Salsitz said, that opiates and opioids aren’t the same. That means IA tests don’t pick up oxycodone use, for example, he said. More sophisticated (and more expensive) tests can distinguish between types of drugs (for example, morphine vs. codeine) and can detect drugs that aren’t included in the IA tests.

Don’t make assumptions about positive or negative tests

A positive drug test for cocaine doesn’t necessarily mean the person is addicted, Dr. Salsitz said. “It just means they used that molecule in the last 3 days. It’s up to you to figure out what it actually means.” And if a patient’s urine fails to show that he or she is taking a prescribed medication, that doesn’t necessarily indicate that the drug is being illegally diverted. The patient could have run out of the drug or lost insurance coverage, Dr. Salsitz said.
 

Be aware that patients may fake urine tests

“Cheating is a huge problem,” Dr. Salsitz said. “Is it their urine or not their urine?” Many kits promise to help people provide fake urine, and some have even provided fake penises to foil observed urine collection. What to do? Alternative tests that rely on hair, saliva, and even sweat are available, Dr. Salsitz said, and these make cheating more difficult. However, they have various limitations. Saliva, for example, only tells you what patients are using now, not what they used days ago, he said, and it’s not sensitive for marijuana.

Dr. Salsitz reported no disclosures.

The Global Academy for Medical Education, which offered the Pain Care for Primary Care symposium, and this news organization are owned by the same parent company.

SAN DIEGO – Clinicians have few tools to monitor pain medication use and abuse in their patients. However, addiction specialist and internist Edwin Salsitz, MD, says an inexpensive and simple tool, the urine test, can provide an impressive amount of useful information.

copyright toeytoey2530/Thinkstock

“The urine drug test, or another matrix for testing, gives one of the only objective factors we have to see how a patient is doing, if they’re following the treatment plan,” said Dr. Salsitz, of Mount Sinai Beth Israel, New York, in a presentation at Pain Care for Primary Care, a symposium offered by the American Pain Society and the Global Academy for Medical Education.

Dr. Salsitz offered these tips about urine tests in pain care:
 

Consider urine tests before beginning opioid therapy

Dr. Salsitz pointed to this 2016 recommendation from the Centers for Disease Control and Prevention: “When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.” As Dr. Salsitz puts it, these tests “can help identify misuse, which hopefully hasn’t gotten to addiction yet.”

Ask the patient what the urine test will reveal

Dr. Salsitz likes to tell patients: “If you tell me the truth, no matter what’s in the urine, it’s going to be OK. I’m not going to stop prescribing or do anything harmful to you.” But, he tells patients, if they lie, “you’re going to start breaking the trust between us. Once you do that, it becomes a problem. I don’t know what’s true or not.” In some cases, he said, patients will fess up to drug use that wouldn’t have shown up in the urine tests because it didn’t happen recently enough. “We’ll talk about whether it’s a problem,” he said.

Begin with an immunoassay panel test (IA)

The CDC recommends using an immunoassay panel first in most situations. “You can do this in the office,” Dr. Salsitz said, using a dipstick-style test. Or you can “send it out to a lab, and they’ll do the same thing.”

Understand what IA tests do and don’t do

Standard 5-drug IA screening tests detect marijuana, cocaine, amphetamine/methamphetamine, PCP, and opiates (morphine/codeine). Keep in mind, Dr. Salsitz said, that opiates and opioids aren’t the same. That means IA tests don’t pick up oxycodone use, for example, he said. More sophisticated (and more expensive) tests can distinguish between types of drugs (for example, morphine vs. codeine) and can detect drugs that aren’t included in the IA tests.

Don’t make assumptions about positive or negative tests

A positive drug test for cocaine doesn’t necessarily mean the person is addicted, Dr. Salsitz said. “It just means they used that molecule in the last 3 days. It’s up to you to figure out what it actually means.” And if a patient’s urine fails to show that he or she is taking a prescribed medication, that doesn’t necessarily indicate that the drug is being illegally diverted. The patient could have run out of the drug or lost insurance coverage, Dr. Salsitz said.
 

Be aware that patients may fake urine tests

“Cheating is a huge problem,” Dr. Salsitz said. “Is it their urine or not their urine?” Many kits promise to help people provide fake urine, and some have even provided fake penises to foil observed urine collection. What to do? Alternative tests that rely on hair, saliva, and even sweat are available, Dr. Salsitz said, and these make cheating more difficult. However, they have various limitations. Saliva, for example, only tells you what patients are using now, not what they used days ago, he said, and it’s not sensitive for marijuana.

Dr. Salsitz reported no disclosures.

The Global Academy for Medical Education, which offered the Pain Care for Primary Care symposium, and this news organization are owned by the same parent company.

SAN DIEGO – Clinicians have few tools to monitor pain medication use and abuse in their patients. However, addiction specialist and internist Edwin Salsitz, MD, says an inexpensive and simple tool, the urine test, can provide an impressive amount of useful information.

copyright toeytoey2530/Thinkstock

“The urine drug test, or another matrix for testing, gives one of the only objective factors we have to see how a patient is doing, if they’re following the treatment plan,” said Dr. Salsitz, of Mount Sinai Beth Israel, New York, in a presentation at Pain Care for Primary Care, a symposium offered by the American Pain Society and the Global Academy for Medical Education.

Dr. Salsitz offered these tips about urine tests in pain care:
 

Consider urine tests before beginning opioid therapy

Dr. Salsitz pointed to this 2016 recommendation from the Centers for Disease Control and Prevention: “When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.” As Dr. Salsitz puts it, these tests “can help identify misuse, which hopefully hasn’t gotten to addiction yet.”

Ask the patient what the urine test will reveal

Dr. Salsitz likes to tell patients: “If you tell me the truth, no matter what’s in the urine, it’s going to be OK. I’m not going to stop prescribing or do anything harmful to you.” But, he tells patients, if they lie, “you’re going to start breaking the trust between us. Once you do that, it becomes a problem. I don’t know what’s true or not.” In some cases, he said, patients will fess up to drug use that wouldn’t have shown up in the urine tests because it didn’t happen recently enough. “We’ll talk about whether it’s a problem,” he said.

Begin with an immunoassay panel test (IA)

The CDC recommends using an immunoassay panel first in most situations. “You can do this in the office,” Dr. Salsitz said, using a dipstick-style test. Or you can “send it out to a lab, and they’ll do the same thing.”

Understand what IA tests do and don’t do

Standard 5-drug IA screening tests detect marijuana, cocaine, amphetamine/methamphetamine, PCP, and opiates (morphine/codeine). Keep in mind, Dr. Salsitz said, that opiates and opioids aren’t the same. That means IA tests don’t pick up oxycodone use, for example, he said. More sophisticated (and more expensive) tests can distinguish between types of drugs (for example, morphine vs. codeine) and can detect drugs that aren’t included in the IA tests.

Don’t make assumptions about positive or negative tests

A positive drug test for cocaine doesn’t necessarily mean the person is addicted, Dr. Salsitz said. “It just means they used that molecule in the last 3 days. It’s up to you to figure out what it actually means.” And if a patient’s urine fails to show that he or she is taking a prescribed medication, that doesn’t necessarily indicate that the drug is being illegally diverted. The patient could have run out of the drug or lost insurance coverage, Dr. Salsitz said.
 

Be aware that patients may fake urine tests

“Cheating is a huge problem,” Dr. Salsitz said. “Is it their urine or not their urine?” Many kits promise to help people provide fake urine, and some have even provided fake penises to foil observed urine collection. What to do? Alternative tests that rely on hair, saliva, and even sweat are available, Dr. Salsitz said, and these make cheating more difficult. However, they have various limitations. Saliva, for example, only tells you what patients are using now, not what they used days ago, he said, and it’s not sensitive for marijuana.

Dr. Salsitz reported no disclosures.

The Global Academy for Medical Education, which offered the Pain Care for Primary Care symposium, and this news organization are owned by the same parent company.

SAN DIEGO – Is pot a valid alternative to opioids for patients with chronic pain? The verdict on the use of medical marijuana is still hazy, a pain specialist told primary care colleagues. “There’s some evidence for pain, but it’s not extensive,” said Timothy Furnish, MD, of the University of California at San Diego.

Smithore

Still, he said, studies suggest that the expanding legal use of medical marijuana isn’t boosting opioid use or worsening traffic accident rates. (JAMA Intern Med. 2018;178[5]:667-72; Am J Public Health. 2016 Nov;106[11]:2032-7) And, he said, two things are clear: “There is no one who has overdosed and died specifically from marijuana ... and compared to opioids, cannabinoids have a relatively good safety profile.”

Dr. Furnish spoke in a presentation at Pain Care for Primary Care, a symposium held by the American Pain Society and Global Academy for Medical Education.

Thirty-three states and the District of Columbia allow – or will soon allow – the medical use of marijuana, although their laws and policies vary widely. The newest states to join the list are Utah, Missouri, and Oklahoma, where voters passed medical marijuana measures this year.

Ten states and the District of Columbia also allow the recreational use of marijuana.

However, most states in the South, including Texas and Georgia, don’t allow medical marijuana. The other states that continue to forbid it are in the Midwest and Rocky Mountain regions.

How does cannabis fare against pain? Dr. Furnish pointed to a 2011 systematic review of 18 randomized trials in noncancer chronic pain that showed that “overall there is evidence that cannabinoids are safe and modestly effective in neuropathic pain with preliminary evidence of efficacy in fibromyalgia and rheumatoid arthritis” (Br J Clin Pharmacol. 2011 Nov;72[5]:735-44).

More recently, a 2018 systematic review and meta-analysis of 104 studies found that “it seems unlikely that cannabinoids are highly effective medicines” for chronic noncancer pain (Pain. 2018 Oct;159[10]:1932-54).

In cancer pain, Dr. Furnish said, evidence supporting marijuana is limited and mainly involves nabiximols (Sativex), a cannabis-based inhaled spray that is approved in several nations outside the United States as a treatment for muscle stiffness and spasm in MS. The drug is still an investigational medication in the United States.

How much marijuana should patients with pain take? In the clinic, Dr. Furnish said, “patients actually do best on a relatively modest dose or low dose. High doses are probably more escape than pain relief.”

Dr. Furnish said that because of safety concerns, he never advises patients to smoke marijuana. “Vaporizing may be safer,” he said, noting that the inhaled route has a relatively rapid onset (2-10 minutes) and lasts for 2-4 hours.

Be aware, he said, that cannabis taken orally may not kick in for 30-90 minutes – “it will depend on what they’ve already ingested, and if they have recently consumed a fatty meal” – and patients may have trouble titrating their doses properly. “It’s a little bit easier to ingest more than they intended,” he said.

If you do want to give patients guidance about medical marijuana, keep in mind that “we can’t write a prescription. We only make recommendations,” he said.

“Use some of the same criteria that you’d use in suggesting a patient for opioid therapy,” he said. For example, exclude patients with active psychosis and schizophrenia.

Another red flag is a significant substance abuse history, since there is “abuse and dependence” in marijuana, he said. “Regular heavy users can experience withdrawal, but it tends to be a lot lighter than opioid withdrawal.”

Also be aware, he said, that there’s no federal oversight of medical marijuana, and “production, purity, potency, and state oversight vary widely.”

Global Academy for Medical Education and this news organization are owned by the same parent company.

Dr. Furnish has no disclosures.
 

SAN DIEGO – Is pot a valid alternative to opioids for patients with chronic pain? The verdict on the use of medical marijuana is still hazy, a pain specialist told primary care colleagues. “There’s some evidence for pain, but it’s not extensive,” said Timothy Furnish, MD, of the University of California at San Diego.

Smithore

Still, he said, studies suggest that the expanding legal use of medical marijuana isn’t boosting opioid use or worsening traffic accident rates. (JAMA Intern Med. 2018;178[5]:667-72; Am J Public Health. 2016 Nov;106[11]:2032-7) And, he said, two things are clear: “There is no one who has overdosed and died specifically from marijuana ... and compared to opioids, cannabinoids have a relatively good safety profile.”

Dr. Furnish spoke in a presentation at Pain Care for Primary Care, a symposium held by the American Pain Society and Global Academy for Medical Education.

Thirty-three states and the District of Columbia allow – or will soon allow – the medical use of marijuana, although their laws and policies vary widely. The newest states to join the list are Utah, Missouri, and Oklahoma, where voters passed medical marijuana measures this year.

Ten states and the District of Columbia also allow the recreational use of marijuana.

However, most states in the South, including Texas and Georgia, don’t allow medical marijuana. The other states that continue to forbid it are in the Midwest and Rocky Mountain regions.

How does cannabis fare against pain? Dr. Furnish pointed to a 2011 systematic review of 18 randomized trials in noncancer chronic pain that showed that “overall there is evidence that cannabinoids are safe and modestly effective in neuropathic pain with preliminary evidence of efficacy in fibromyalgia and rheumatoid arthritis” (Br J Clin Pharmacol. 2011 Nov;72[5]:735-44).

More recently, a 2018 systematic review and meta-analysis of 104 studies found that “it seems unlikely that cannabinoids are highly effective medicines” for chronic noncancer pain (Pain. 2018 Oct;159[10]:1932-54).

In cancer pain, Dr. Furnish said, evidence supporting marijuana is limited and mainly involves nabiximols (Sativex), a cannabis-based inhaled spray that is approved in several nations outside the United States as a treatment for muscle stiffness and spasm in MS. The drug is still an investigational medication in the United States.

How much marijuana should patients with pain take? In the clinic, Dr. Furnish said, “patients actually do best on a relatively modest dose or low dose. High doses are probably more escape than pain relief.”

Dr. Furnish said that because of safety concerns, he never advises patients to smoke marijuana. “Vaporizing may be safer,” he said, noting that the inhaled route has a relatively rapid onset (2-10 minutes) and lasts for 2-4 hours.

Be aware, he said, that cannabis taken orally may not kick in for 30-90 minutes – “it will depend on what they’ve already ingested, and if they have recently consumed a fatty meal” – and patients may have trouble titrating their doses properly. “It’s a little bit easier to ingest more than they intended,” he said.

If you do want to give patients guidance about medical marijuana, keep in mind that “we can’t write a prescription. We only make recommendations,” he said.

“Use some of the same criteria that you’d use in suggesting a patient for opioid therapy,” he said. For example, exclude patients with active psychosis and schizophrenia.

Another red flag is a significant substance abuse history, since there is “abuse and dependence” in marijuana, he said. “Regular heavy users can experience withdrawal, but it tends to be a lot lighter than opioid withdrawal.”

Also be aware, he said, that there’s no federal oversight of medical marijuana, and “production, purity, potency, and state oversight vary widely.”

Global Academy for Medical Education and this news organization are owned by the same parent company.

Dr. Furnish has no disclosures.
 

SAN DIEGO – Is pot a valid alternative to opioids for patients with chronic pain? The verdict on the use of medical marijuana is still hazy, a pain specialist told primary care colleagues. “There’s some evidence for pain, but it’s not extensive,” said Timothy Furnish, MD, of the University of California at San Diego.

Smithore

Still, he said, studies suggest that the expanding legal use of medical marijuana isn’t boosting opioid use or worsening traffic accident rates. (JAMA Intern Med. 2018;178[5]:667-72; Am J Public Health. 2016 Nov;106[11]:2032-7) And, he said, two things are clear: “There is no one who has overdosed and died specifically from marijuana ... and compared to opioids, cannabinoids have a relatively good safety profile.”

Dr. Furnish spoke in a presentation at Pain Care for Primary Care, a symposium held by the American Pain Society and Global Academy for Medical Education.

Thirty-three states and the District of Columbia allow – or will soon allow – the medical use of marijuana, although their laws and policies vary widely. The newest states to join the list are Utah, Missouri, and Oklahoma, where voters passed medical marijuana measures this year.

Ten states and the District of Columbia also allow the recreational use of marijuana.

However, most states in the South, including Texas and Georgia, don’t allow medical marijuana. The other states that continue to forbid it are in the Midwest and Rocky Mountain regions.

How does cannabis fare against pain? Dr. Furnish pointed to a 2011 systematic review of 18 randomized trials in noncancer chronic pain that showed that “overall there is evidence that cannabinoids are safe and modestly effective in neuropathic pain with preliminary evidence of efficacy in fibromyalgia and rheumatoid arthritis” (Br J Clin Pharmacol. 2011 Nov;72[5]:735-44).

More recently, a 2018 systematic review and meta-analysis of 104 studies found that “it seems unlikely that cannabinoids are highly effective medicines” for chronic noncancer pain (Pain. 2018 Oct;159[10]:1932-54).

In cancer pain, Dr. Furnish said, evidence supporting marijuana is limited and mainly involves nabiximols (Sativex), a cannabis-based inhaled spray that is approved in several nations outside the United States as a treatment for muscle stiffness and spasm in MS. The drug is still an investigational medication in the United States.

How much marijuana should patients with pain take? In the clinic, Dr. Furnish said, “patients actually do best on a relatively modest dose or low dose. High doses are probably more escape than pain relief.”

Dr. Furnish said that because of safety concerns, he never advises patients to smoke marijuana. “Vaporizing may be safer,” he said, noting that the inhaled route has a relatively rapid onset (2-10 minutes) and lasts for 2-4 hours.

Be aware, he said, that cannabis taken orally may not kick in for 30-90 minutes – “it will depend on what they’ve already ingested, and if they have recently consumed a fatty meal” – and patients may have trouble titrating their doses properly. “It’s a little bit easier to ingest more than they intended,” he said.

If you do want to give patients guidance about medical marijuana, keep in mind that “we can’t write a prescription. We only make recommendations,” he said.

“Use some of the same criteria that you’d use in suggesting a patient for opioid therapy,” he said. For example, exclude patients with active psychosis and schizophrenia.

Another red flag is a significant substance abuse history, since there is “abuse and dependence” in marijuana, he said. “Regular heavy users can experience withdrawal, but it tends to be a lot lighter than opioid withdrawal.”

Also be aware, he said, that there’s no federal oversight of medical marijuana, and “production, purity, potency, and state oversight vary widely.”

Global Academy for Medical Education and this news organization are owned by the same parent company.

Dr. Furnish has no disclosures.
 

SAN DIEGO – Patients with somatic symptom and related disorders can get better in primary care when clinicians use a few key strategies, according to an expert.

When it comes to these disorders, “a lot of our anxiety and gallows humor comes from a place of not knowing what we want to do, how we can treat these individuals,” said Matthew Reed, MD, MPH, a psychiatrist and pain specialist at the University of California, Irvine. “It became more appealing once I learned a little bit more about what was going on with some of these disorders and how I might be able to intervene.”

Dr. Reed spoke at Pain Care for Primary Care, held by the American Pain Society and Global Academy for Medical Education. Global Academy and this news organization are owned by the same company.

Throughout his presentation, Dr. Reed drew upon the listing of somatic symptom and related disorders as outlined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Among the disorders he discussed:
 

Somatic symptom disorder

This disorder causes significant distress because of at least one somatic symptom and is persistent (lasting over 6 months). A medical illness might be present, and depression and anxiety are common.

“This diagnosis says you have pathology – this somatic disorder – which is making your life miserable,” Dr. Reed said.

He’s often thrilled when patients also have comorbid depression and/or anxiety. “You treat that primary issue, and the somatic disorder melts away,” he said. “It’s harder when you have the pure version of somatic disorder, and there is no anxiety or depressive disorder.”
 

Illness anxiety disorder (formerly known as hypochondriasis)

Patients with this disorder have been preoccupied about having a serious illness for at least 6 months but do not have somatic symptoms. Reassurance typically is not effective, Dr. Reed said. In response to a statement such as “nothing’s wrong,” he said, patients might reply with a statement along the lines of “something’s wrong because I’m suffering.”

Patients with this condition can command “high rates of medical utilization, often pretty inappropriate,” especially if they are VIPs, he said.
 

Conversion disorder (also known as functional neurological symptom disorder)

This is less common than the other disorders. Patients with this condition develop “one or more symptoms of altered voluntary motor or sensory function” that’s “not better explained by another medical condition.”

A “listening ear” and physical therapy can prove helpful, Dr. Reed said.
 

Factitious disorder

Patients with this condition falsify or induce signs of illness, impairment, or injury. “There’s more of an overt feigning of symptoms in order to maintain that sick role,” said Dr. Reed, who cautioned that some people with this condition actually might be suffering.

Protocol can guide treatment

How can these conditions be treated in patients? Dr. Reed pointed to the protocol discussed by Robert McCarron, DO, and embedded in the mnemonic “CARE MD”: Cognitive-behavioral therapy (CBT)/consultation, regular visits, empathy, med-psych interface, and do no harm.

“Reassure them that you value them,” he said. Perhaps say something like: “I get your suffering is real. I’m going to be here to help you. Let’s get you back in a month.” Under CARE MD, the idea of multiple visits is to help the patient develop coping strategies and stop overusing medical care.

Return visits should not be too frequent, Dr. Reed said, and they should be short. Physicians must remember to take care of themselves and other patients, he said, and not spend too much time with these patients. “We need to be compassionate,” he said, but “we don’t need to be compassionate in a way that we don’t have our sanity after clinic.”

As for CBT, Dr. Reed likes to suggest it in a way that doesn’t aggravate patients who are sensitive to the idea that their condition is all in their heads.

Physicians, he said, can say: “Wow, this is really affecting your life. You have 17 specialists working on you. You’ll continue to see them, I know. But I worry. I look at your chart, and we’re missing a whole area of treatment.”

He then mentions CBT. “Other providers may have told you about it,” he’ll say. “I’ve seen such good benefits with CBT, even with patients who were in motor vehicle accidents. It doesn’t matter where it’s coming from. This CBT seems to work.”

Ideally, he said, patients agree to try it.

Dr. Reed had no disclosures.

SAN DIEGO – Patients with somatic symptom and related disorders can get better in primary care when clinicians use a few key strategies, according to an expert.

When it comes to these disorders, “a lot of our anxiety and gallows humor comes from a place of not knowing what we want to do, how we can treat these individuals,” said Matthew Reed, MD, MPH, a psychiatrist and pain specialist at the University of California, Irvine. “It became more appealing once I learned a little bit more about what was going on with some of these disorders and how I might be able to intervene.”

Dr. Reed spoke at Pain Care for Primary Care, held by the American Pain Society and Global Academy for Medical Education. Global Academy and this news organization are owned by the same company.

Throughout his presentation, Dr. Reed drew upon the listing of somatic symptom and related disorders as outlined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Among the disorders he discussed:
 

Somatic symptom disorder

This disorder causes significant distress because of at least one somatic symptom and is persistent (lasting over 6 months). A medical illness might be present, and depression and anxiety are common.

“This diagnosis says you have pathology – this somatic disorder – which is making your life miserable,” Dr. Reed said.

He’s often thrilled when patients also have comorbid depression and/or anxiety. “You treat that primary issue, and the somatic disorder melts away,” he said. “It’s harder when you have the pure version of somatic disorder, and there is no anxiety or depressive disorder.”
 

Illness anxiety disorder (formerly known as hypochondriasis)

Patients with this disorder have been preoccupied about having a serious illness for at least 6 months but do not have somatic symptoms. Reassurance typically is not effective, Dr. Reed said. In response to a statement such as “nothing’s wrong,” he said, patients might reply with a statement along the lines of “something’s wrong because I’m suffering.”

Patients with this condition can command “high rates of medical utilization, often pretty inappropriate,” especially if they are VIPs, he said.
 

Conversion disorder (also known as functional neurological symptom disorder)

This is less common than the other disorders. Patients with this condition develop “one or more symptoms of altered voluntary motor or sensory function” that’s “not better explained by another medical condition.”

A “listening ear” and physical therapy can prove helpful, Dr. Reed said.
 

Factitious disorder

Patients with this condition falsify or induce signs of illness, impairment, or injury. “There’s more of an overt feigning of symptoms in order to maintain that sick role,” said Dr. Reed, who cautioned that some people with this condition actually might be suffering.

Protocol can guide treatment

How can these conditions be treated in patients? Dr. Reed pointed to the protocol discussed by Robert McCarron, DO, and embedded in the mnemonic “CARE MD”: Cognitive-behavioral therapy (CBT)/consultation, regular visits, empathy, med-psych interface, and do no harm.

“Reassure them that you value them,” he said. Perhaps say something like: “I get your suffering is real. I’m going to be here to help you. Let’s get you back in a month.” Under CARE MD, the idea of multiple visits is to help the patient develop coping strategies and stop overusing medical care.

Return visits should not be too frequent, Dr. Reed said, and they should be short. Physicians must remember to take care of themselves and other patients, he said, and not spend too much time with these patients. “We need to be compassionate,” he said, but “we don’t need to be compassionate in a way that we don’t have our sanity after clinic.”

As for CBT, Dr. Reed likes to suggest it in a way that doesn’t aggravate patients who are sensitive to the idea that their condition is all in their heads.

Physicians, he said, can say: “Wow, this is really affecting your life. You have 17 specialists working on you. You’ll continue to see them, I know. But I worry. I look at your chart, and we’re missing a whole area of treatment.”

He then mentions CBT. “Other providers may have told you about it,” he’ll say. “I’ve seen such good benefits with CBT, even with patients who were in motor vehicle accidents. It doesn’t matter where it’s coming from. This CBT seems to work.”

Ideally, he said, patients agree to try it.

Dr. Reed had no disclosures.

SAN DIEGO – Patients with somatic symptom and related disorders can get better in primary care when clinicians use a few key strategies, according to an expert.

When it comes to these disorders, “a lot of our anxiety and gallows humor comes from a place of not knowing what we want to do, how we can treat these individuals,” said Matthew Reed, MD, MPH, a psychiatrist and pain specialist at the University of California, Irvine. “It became more appealing once I learned a little bit more about what was going on with some of these disorders and how I might be able to intervene.”

Dr. Reed spoke at Pain Care for Primary Care, held by the American Pain Society and Global Academy for Medical Education. Global Academy and this news organization are owned by the same company.

Throughout his presentation, Dr. Reed drew upon the listing of somatic symptom and related disorders as outlined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Among the disorders he discussed:
 

Somatic symptom disorder

This disorder causes significant distress because of at least one somatic symptom and is persistent (lasting over 6 months). A medical illness might be present, and depression and anxiety are common.

“This diagnosis says you have pathology – this somatic disorder – which is making your life miserable,” Dr. Reed said.

He’s often thrilled when patients also have comorbid depression and/or anxiety. “You treat that primary issue, and the somatic disorder melts away,” he said. “It’s harder when you have the pure version of somatic disorder, and there is no anxiety or depressive disorder.”
 

Illness anxiety disorder (formerly known as hypochondriasis)

Patients with this disorder have been preoccupied about having a serious illness for at least 6 months but do not have somatic symptoms. Reassurance typically is not effective, Dr. Reed said. In response to a statement such as “nothing’s wrong,” he said, patients might reply with a statement along the lines of “something’s wrong because I’m suffering.”

Patients with this condition can command “high rates of medical utilization, often pretty inappropriate,” especially if they are VIPs, he said.
 

Conversion disorder (also known as functional neurological symptom disorder)

This is less common than the other disorders. Patients with this condition develop “one or more symptoms of altered voluntary motor or sensory function” that’s “not better explained by another medical condition.”

A “listening ear” and physical therapy can prove helpful, Dr. Reed said.
 

Factitious disorder

Patients with this condition falsify or induce signs of illness, impairment, or injury. “There’s more of an overt feigning of symptoms in order to maintain that sick role,” said Dr. Reed, who cautioned that some people with this condition actually might be suffering.

Protocol can guide treatment

How can these conditions be treated in patients? Dr. Reed pointed to the protocol discussed by Robert McCarron, DO, and embedded in the mnemonic “CARE MD”: Cognitive-behavioral therapy (CBT)/consultation, regular visits, empathy, med-psych interface, and do no harm.

“Reassure them that you value them,” he said. Perhaps say something like: “I get your suffering is real. I’m going to be here to help you. Let’s get you back in a month.” Under CARE MD, the idea of multiple visits is to help the patient develop coping strategies and stop overusing medical care.

Return visits should not be too frequent, Dr. Reed said, and they should be short. Physicians must remember to take care of themselves and other patients, he said, and not spend too much time with these patients. “We need to be compassionate,” he said, but “we don’t need to be compassionate in a way that we don’t have our sanity after clinic.”

As for CBT, Dr. Reed likes to suggest it in a way that doesn’t aggravate patients who are sensitive to the idea that their condition is all in their heads.

Physicians, he said, can say: “Wow, this is really affecting your life. You have 17 specialists working on you. You’ll continue to see them, I know. But I worry. I look at your chart, and we’re missing a whole area of treatment.”

He then mentions CBT. “Other providers may have told you about it,” he’ll say. “I’ve seen such good benefits with CBT, even with patients who were in motor vehicle accidents. It doesn’t matter where it’s coming from. This CBT seems to work.”

Ideally, he said, patients agree to try it.

Dr. Reed had no disclosures.