Annals of Internal Medicine tip sheet for Jan. 13, 2015

1. NIH publishes final report on the use of opioids for chronic pain

The National Institutes of Health (NIH) Pathways to Prevention Workshop final report on the role of opioids in the treatment of chronic pain identifies several key evidence gaps and research priorities that must be addressed so that physicians can make informed decisions when prescribing opioids. The abridged report is published in Annals of Internal Medicine. According to the report, lack of research and inadequate knowledge about the best approaches to treating various types of pain leave providers to rely on their own clinical experience. Until research is done, a better approach is for clinicians to follow guidelines issued by professional societies and for systems of care to facilitate this practice. The paper includes a summary of the panel's major recommendations. Comments about specific research issues that merit further exploration are included in the full report at the NIH web site.

Note: URLs will be live when the embargo lifts. For a PDF, contact Megan Hanks. For an interview, call the NIH at 301-496-5787 to be connected to the appropriate person.

2. Evidence suggests that some serious risks of long-term opioid therapy may be dose-dependent Long-term opioid therapy is associated with increased risk for serious harms - some of which may be dose-dependent - according to a systematic review published in Annals of Internal Medicine. Prescriptions of opioid medications for chronic pain (pain lasting longer than 3 months past the normal time for tissue healing) have increased dramatically, as have prescription opioid overdose, abuse, addiction, and diversion. Since most opioid trials do not extend beyond 6 weeks, they are of limited relevance for aiding clinical decision-making regarding long-term opioid use. Researchers conducted a systematic review of published research to evaluate evidence on the effectiveness and harms of long-term opioid therapy for chronic pain in adults. They found insufficient evidence to determine the effectiveness of long-term opioid therapy for improving pain and function. Serious harms of long-term therapy, such as risk for overdose and abuse and fractures, seemed to depend on opioid dose.

Note: URLs will be live when the embargo lifts. For a PDF, contact Megan Hanks. To speak with the lead author, contact Todd Murphy at murphyt@ohsu.edu or 503-494-7009.

3. ACP publishes recommendations to improve clinical documentation in electronic health records

The American College of Physicians (ACP) tackles the complexities of clinical documentation within electronic health records (EHR) in a new policy position paper published in Annals of Internal Medicine. "Clinical Documentation in the 21st Century:

A Policy Position Paper from the American College of Physicians" outlines a set of guiding principles and actions to help clinicians, provider institutions, technology vendors, government regulators, payers, and other interested groups to improve the quality of clinical documentation and to better use this documentation to improve care.

Clinical documentation is used to document and track a patient's condition and communicate treatment decisions and commentary to other members of the care team, and more recently, to the patient. Defensive medicine and evaluation and management coding (E&M) guidelines have added substantial pressure to modify both the format and content of documentation. The EHR has added further challenges, but also opportunities. Authors of the ACP policy paper argue that EHR should be leveraged for what it can do to improve care and documentation, including effectively displaying prior information that shows historical information in rich context; supporting critical thinking; enabling efficient and effective documentation; and supporting appropriate and secure sharing of useful and usable information with others, including patients, families, and caregivers. E&M mandated documentation format and verbosity and EHR mandated structured data entry have introduced barriers to efficiently documenting narrative entries, and may further be barriers to the use of documentation to improve care.

In its policy paper, ACP offers seven detailed policy recommendations and rationale for clinical documentation and five recommendations and rationale for EHR system design to support 21st century clinical documentation. The recommendations were informed by a literature review and input from the various College constituencies and nonmember experts in the field. The full paper and an executive summary are published together online.

Note: The policy paper is accompanied by an editorial. The URLs will be live when embargo lifts. For a PDF, please contact Megan Hanks. To interview the lead author, please contact David Kinsman at dkinsman@acponline.org or 202-261-4554.

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