Pain Management of Budd Chiari Syndrome in the Primary Care Setting: A Case Study

Introduction: Budd Chiari Syndrome (BCS) is a very rare disease affecting approximately 1 in 100,000 people in the general population. It is caused by an obstruction of the hepatic veins leading to blood backing up in the liver. Treatment options to improve hepatic blood flow and relieve ascites are well documented. However, there are no established guidelines or treatment preferences for pain associated with BCS while patients are awaiting other treatment options. Case: A 22-year-old African American female was diagnosed with Budd Chiari Syndrome. The initial attempt at a transjugular intrahepatic portosystemic shunt (TIPS) procedure failed. While awaiting a second attempt at the procedure, the patient presented to her primary care provider complaining of abdominal and right upper quadrant pain. Treatment guidelines were searched for acute pain management options; however, no BCS pain management guidelines exist. Discussion: Individuals with BCS often present with abdominal pain, however, no guidelines outlining analgesic options in BCS exists. Acetaminophen, NSAIDs, and opioids are commonly used prescription medications for moderate to severe pain. Acetaminophen use was not considered due to acute liver injury and portal venous thrombosis. Anticoagulation with apixaban prevented concurrent use with NSAIDs. Opioid medications combined with acetaminophen were excluded to minimize exacerbating the liver injury. Tramadol 25 mg was chosen due to its lower abuse profile than other opioid analgesics, and was initiated for pain management. Conclusion: The patient reported adequate pain control with tramadol, tolerated the medication with no complications, and underwent a successful TIPS procedure one month later. Abdominal pain is a common symptom of BCS and needs to be effectively managed. Guidelines on treating pain associated with BCS in the outpatient setting would improve quality of life for patients and provide guidance to primary care providers requiring direction on how to address pain associated with Budd Chiari Syndrome safely and adequately.

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Impact of the New York State Prescription Drug Monitoring Program (IStop) on chronic pain management by primary care providers

Journal of Opioid Management ◽

10.5055/jom.2021.0612 ◽

2021 ◽

Vol 17 (1) ◽

pp. 39-54

Author(s):

Josiah D. Strawser, MD ◽

Lauren Block, MD, MPH

Keyword(s):

Primary Care ◽

Chronic Pain ◽

Pain Management ◽

Risk Reduction ◽

New York State ◽

Monitoring Program ◽

Primary Care Providers ◽

Care Providers ◽

Reduction Strategies ◽

Risk Reduction Strategies

Objective: To explore the impact of the New York State Prescription Drug Monitoring Program (IStop) on the self-reported management of patients with chronic pain by primary care providers.Design: Mixed-methods study with survey collection and semistructured interviews.Setting: Multiple academic hospitals in New York.Participants: One hundred and thirty-six primary care providers (residents, fellows, attendings, and nurse practitioners) for survey collection, and eight primary care clinicians (residents, attending, and pharmacist) for interviews. Interventions: Introduction of IStop.Main outcome measure(s): Change in usage of four risk reduction strategies (pain contracts, urine tests, monthly visits, and co-management) as reported by primary care providers for patients with chronic pain.Results: After the introduction of IStop, 25 percent (32/128) of providers increased usage of monthly visits, 28 percent (36/128) of providers increased usage of pain management co-management with other healthcare providers, and 46 percent (60/129) of providers increased usage of at least one of four risk reduction strategies. Residents indicated much higher rates of change in risk reduction strategies due to IStop usage; increasing in the use of monthly visits (32 vs. 13 percent, p = 0.02) and co-management (36 vs. 13 percent, p = 0.01) occurred at a much higher rate in residents than attending physicians. Interview themes revealed an emphasis on finding opioid alternatives when possible, the need for frequent patient visits in effective pain management, and the importance of communication between the patient and provider to protect the relationship in chronic pain management.Conclusions: After the introduction of IStop, primary care providers have increased usage of risk reduction strategies in the care of chronic pain patients.

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What Motivates Adolescent Behavior Change: A Content Analysis of Patient-Reported Strategies Delivered by Primary Care Providers

Journal of Adolescent Health ◽

10.1016/j.jadohealth.2017.11.180 ◽

2018 ◽

Vol 62 (2) ◽

pp. S89 ◽

Cited By ~ 1

Author(s):

Heather Spielvogle ◽

Adriana Arghira ◽

Elsie Rockers ◽

Carolyn McCarty ◽

Laura Richardson

Keyword(s):

Primary Care ◽

Content Analysis ◽

Behavior Change ◽

Primary Care Providers ◽

Adolescent Behavior ◽

Care Providers ◽

Patient Reported

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Tools, Time, Training, and Team—Military Primary Care Providers’ Perspectives on Improving Chronic Pain Assessment and Management

Military Medicine ◽

10.1093/milmed/usab367 ◽

2021 ◽

Author(s):

Asha Mathew ◽

Honor McQuinn ◽

Diane M Flynn ◽

Jeffrey C Ransom ◽

Ardith Z Doorenbos

Keyword(s):

Primary Care ◽

Chronic Pain ◽

Pain Management ◽

Pain Assessment ◽

Insurance Coverage ◽

Primary Care Providers ◽

Stepped Care ◽

Chronic Pain Management ◽

Care Providers ◽

Pain Care

ABSTRACT Introduction Primary care providers are on the front lines of chronic pain management, with many reporting frustration, low confidence, and dissatisfaction in handling the complex issues associated with chronic pain care. Given the importance of their role and reported inadequacies and dissatisfaction in managing this challenging population, it is important to understand the perspectives of primary care providers when considering approaches to chronic pain management. This qualitative descriptive study aimed to comprehensively summarize the provider challenges and suggestions to improve chronic pain care in military primary care settings. Materials and Methods Semi-structured interviews with 12 military primary care providers were conducted in a single U.S. Army medical center. All interviews were audio-recorded and lasted between 30 and 60 minutes. Interview transcripts were analyzed using ATLAS 9.0 software. Narratives were analyzed using a general inductive approach to content analysis. The Framework Method was used to organize the codes and emergent categories. All study procedures were approved by the Institutional Review Board of the University of Washington. Results Four categories captured providers’ challenges and suggestions for improving chronic pain care: (1) tools for comprehensive pain assessment and patient education, (2) time available for each chronic pain appointment, (3) provider training and education, and (4) team-based approach to chronic pain management. Providers suggested use of the Pain Assessment Screening Tool and Outcomes Registry, more time per visit, incorporation of chronic pain care in health sciences curriculum, consistent provider training across the board, insurance coverage for complementary and integrative therapies, patient education, and improved access to interdisciplinary chronic pain care. Conclusions Lack of standardized multifaceted tools, time constraints on chronic pain appointments, inadequate provider education, and limited access to complementary and integrative health therapies are significant provider challenges. Insurance coverage for complementary and integrative health therapies needs to be expanded. The Stepped Care Model of Pain Management is a positive and definite stride toward addressing many of these challenges. Future studies should examine the extent of improvement in guidelines-concordant chronic pain care, patient outcomes, and provider satisfaction following the implementation of the Stepped Care Model of Pain Management in military health settings.

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Oncology team perception and patient experience discordances in triple-negative breast cancer (TNBC) care.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.15_suppl.e19176 ◽

2020 ◽

Vol 38 (15_suppl) ◽

pp. e19176-e19176

Author(s):

Sara A. Hurvitz ◽

Rebecca R Crawford ◽

Tamar Sapir ◽

Jeffrey D. Carter

Keyword(s):

Treatment Options ◽

Primary Care Providers ◽

Patient Centered Care ◽

Influential Factors ◽

Patient Treatment ◽

Care Providers ◽

Patient Centered ◽

Actual Patient ◽

Patient Reported ◽

Centered Care

e19176 Background: In TNBC, ensuring patients understand their treatment options and engaging them in shared decision-making (SDM) is vital to patient centered care; however, system-, team-, and individual-level barriers may challenge optimal SDM. As part of a quality improvement, accredited initiative, we identified areas of discordance between oncology healthcare professionals (HCP) perception and actual patient reported experiences. Methods: From 02/2019 – 10/2019, we administered surveys to assess challenges, barriers, attitudes, and experiences of HCP who care for patients with TNBC (N = 77) and their patients with TNBC (N = 65) at 6 community oncology practices. Results: Despite indications of high levels of SDM – 86% of patients indicated that they are always or mostly involved with treatment decisions – survey responses highlight discordances. For example, when asked to identify the most influential factors to patient treatment choice, HCP most commonly indicated side effects (94%), while patients most commonly indicated quality of life (48%). Additionally, when asked to identify the side effect of greatest concern to patients, 61% of patients indicated alopecia, while 45% of HCP indicated gastrointestinal (GI) distress. While both HCP and their patients indicate that the oncology team is the most useful source of patient education, HCP underestimated the extent to which patients rely on their primary care providers (PCPs). Patients and HCP each identified limited time as a barrier to SDM, but patients indicated not knowing what to ask, while HCP indicated that low health literacy was the top barrier to SDM. 31% of patients and their care team identified that improvements in discussions about realistic prognosis were vital to improved care. Conclusions: These survey findings reveal discordances between oncology HCP’s perceptions and patient reported experiences when receiving treatment for TNBC. These findings may highlight areas for improvement in co-productive patient-centered care. [Table: see text]

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Reduction in Schedule II opioid prescribing by primary care providers, orthopedic and general surgeons, and pain management specialists following the implementation of a State House Bill and an Institutional Controlled Substance Task Force

Journal of Opioid Management ◽

10.5055/jom.2021.0625 ◽

2021 ◽

Vol 17 (2) ◽

pp. 155-167

Author(s):

Lisa B. E. Shields, MD ◽

Timothy A. Johnson, BS ◽

Michael W. Daniels, MS ◽

Alisha Bell, MSN, RN, CPN ◽

Diane M. Siemens, PharmD ◽

...

Keyword(s):

Primary Care ◽

Pain Management ◽

Primary Care Providers ◽

The United States ◽

Prescription Opioid ◽

Evidence Based ◽

Care Providers ◽

Prescribing Practices ◽

Opioid Prescribing ◽

General Surgeons

Objective: Prescription opioid misuse represents a social and economic challenge in the United States. We evaluated Schedule II opioid prescribing practices by primary care providers (PCPs), orthopedic and general surgeons, and pain management specialists.Design: Prospective evaluation of prescribing practices of PCPs, orthopedic and general surgeons, and pain management specialists over 5 years (October 1, 2014-September 30, 2019) in an outpatient setting.Methods: An analysis of Schedule II opioid prescribing following the implementation of federal and state guidelines and evidence-based standards at our institution. Results: There were significantly more PCPs, orthopedic and general surgeons, and pain management specialists with a significantly increased number who prescribed Schedule II opioids, whereas there was a simultaneous significant decline in the average number of Schedule II opioid prescriptions per provider, Schedule II opioid pills prescribed per provider, and Schedule II opioid pills prescribed per patient by providers. The average number of Schedule II opioid prescriptions with a quantity 90 and Opana/Oxycontin prescriptions per PCP, orthopedic surgeon, and pain management specialist significantly decreased. The total morphine milligram equivalent (MME)/day of Schedule II opioids ordered by PCPs, orthopedic and general surgeons, and pain management specialists significantly declined. The ages of the providers remained consistent throughout the study. Conclusions: This study reports the implementation of federal and state regulations and institutional evidence-based guidelines into primary care and medical specialty practices to reduce the number of Schedule II opioids prescribed. Further research is warranted to determine alternative therapies to Schedule II opioids that may alleviate a patient’s pain without initiating or exacerbating a potentially lethal opioid addiction.

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Primary Care Providers' Views on Chronic Pain Management Among High-Risk Patients in Safety Net Settings

Pain Medicine ◽

10.1111/j.1526-4637.2012.01443.x ◽

2012 ◽

Vol 13 (9) ◽

pp. 1141-1148 ◽

Cited By ~ 15

Author(s):

Maya Vijayaraghavan ◽

Joanne Penko ◽

David Guzman ◽

Christine Miaskowski ◽

Margot B. Kushel

Keyword(s):

Primary Care ◽

Chronic Pain ◽

Pain Management ◽

High Risk ◽

Primary Care Providers ◽

Safety Net ◽

Chronic Pain Management ◽

Care Providers ◽

High Risk Patients ◽

Risk Patients

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Depression in adolescence: a review

Middle East Current Psychiatry ◽

10.1186/s43045-020-00050-z ◽

2020 ◽

Vol 27 (1) ◽

Author(s):

Diogo Beirão ◽

Helena Monte ◽

Marta Amaral ◽

Alice Longras ◽

Carla Matos ◽

...

Keyword(s):

Mental Health ◽

Primary Care ◽

Treatment Options ◽

Clinical Manifestations ◽

Primary Care Providers ◽

Scientific Data ◽

Screening Tests ◽

Medical Community ◽

Main Body ◽

Care Providers

Abstract Background Depression is a common mental health disease, especially in mid to late adolescence that, due to its particularities, is a challenge and requires an effective diagnosis. Primary care providers are often the first line of contact for adolescents, being crucial in identifying and managing this pathology. Besides, several entities also recommend screening for depression on this period. Thus, the main purpose of this article is to review the scientific data regarding screening, diagnosis and management of depression in adolescence, mainly on primary care settings. Main body Comprehension of the pathogenesis of depression in adolescents is a challenging task, with both environmental and genetic factors being associated to its development. Although there are some screening tests and diagnostic criteria, its clinical manifestations are wide, making its diagnosis a huge challenge. Besides, it can be mistakenly diagnosed with other psychiatric disorders, making necessary to roll-out several differential diagnoses. Treatment options can include psychotherapy (cognitive behavioural therapy and interpersonal therapy) and/or pharmacotherapy (mainly fluoxetine), depending on severity, associated risk factors and available resources. In any case, treatment must include psychoeducation, supportive approach and family involvement. Preventive programs play an important role not only in reducing the prevalence of this condition but also in improving the health of populations. Conclusion Depression in adolescence is a relevant condition to the medical community, due to its uncertain clinical course and underdiagnosis worldwide. General practitioners can provide early identification, treatment initiation and referral to mental health specialists when necessary.

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