Editorials from VA Research Scientists
'Our other prescription drug problem'
High rates of opioid misuse and addiction have precipitated a public health crisis in the U.S.—driving opioid-related overdoses and deaths. However, opioids are not the only problematic class of drugs with the potential for abuse. In a New England Journal of Medicine editorial, Dr. Keith Humphreys, a researcher with the VA Palo Alto Health Care System, and his colleagues write about the dangers of inappropriate prescribing for benzodiazepines. Benzodiazepines are a group of anti-anxiety drugs that, when taken long-term, have the potential for dependence and misuse.
The authors fear that concerns over excessive opioid prescribing may have masked concern for the very real potential for abuse of benzodiazepines. They note that three-quarters of the deaths related to benzodiazepines also involve an opioid medication. "We believe that the growing infrastructure to address the opioid epidemic should be harnessed to respond to dangerous trends in benzodiazepine overuse, misuse, and addiction as well," write the authors.
Humphreys and his coauthors also recommend the use of state prescription-drug monitoring programs and expanded education targeted to physicians who prescribe benzodiazepines.
Benzodiazepines cause a range of negative side effects including over-sedation, rebound anxiety, cognitive decline, falls, and even death. They can also precipitate dangerous drug interactions when taken along with opioid medications. During the period 1999-2015, overdose deaths related to benzodiazepines increased from 1,135 to 8,791, a nearly 700 percent increase, according to the National Institute on Drug Abuse.
'General internists in pursuit of diagnostic excellence in primary care: A #ProudtoBeGIM thread that unites us all'
In an editorial written to accompany a study published in Journal of General Internal Medicine, Dr. Hardeep Singh, a researcher at the VA medical center in Houston, and his colleague Dr. Janice Kwan write about the importance of making a correct and timely diagnosis in patient care. Given a lack of time and competing priorities in the typical primary care office, the history and physical can be given short shrift, said the authors. An abbreviated history and physical can delay a prompt diagnosis for an urgent condition such as cancer.
Researchers at Harvard University and other institutions conducted a cross-sectional record review that identified 300 adults with rectal bleeding. Of those patients, 90 percent met the criteria for a colonoscopy, yet only 74 percent were actually referred for the procedure. Of those patients referred for colonoscopy, less than 60 percent actually underwent the test within a year's time.
Singh and his colleague attribute failures like this to widespread system-level breakdowns. They recommend a physician-led push to ramp up diagnostic safety efforts in outpatient care.
"We have learned from many studies," they said, "that faulty data synthesis and an inadequate history and physical are leading contributors to diagnostic error." The authors suggest that the creation of systems that build in oversight; diagnostic reliance on clinical reasoning and bedside skills; and improvements in measuring the success of patient diagnoses can do much to reduce diagnostic error.
'Hypertension limbo: Balancing benefits, harms, and patient preferences before we lower the bar on blood pressure'
In the March 2018 issue of the Annuals of Internal Medicine, VA researcher Dr. Timothy Wilt and colleagues laid out their concerns about adopting a more stringent guideline for managing blood pressure control. The American College of Cardiology recently came out with new guidelines for defining and treating high blood pressure. Those guidelines were a significant departure from the current standards of care, and are much more aggressive than those of other organizations like the American College of Physicians.
While the newer ACC guidelines do espouse the importance of lifestyle modification and blood pressure measurement techniques, the authors worry that there is not enough consideration given to potential patient harms. "The guideline falls short in weighing the potential benefits against potential harms, costs, and the anticipated variation in individual patient preferences," they write.
Aggressively lowering systolic blood pressure in older adults could put them at greater risk for symptomatic hypotension and fainting. The authors also note that there are no randomized controlled trials that show a benefit in treating adults to diastolic pressures of less than 80.
Older guidelines define high blood pressure as a measurement of 140 over 90 or greater. For adults who are older than 60, the guidelines recommend pharmacologic treatment for a systolic blood pressure greater than 150. The ACC has lowered the threshold for high blood pressure to 130 over 80, and advocates pharmacologic treatment for low-risk individuals whose blood pressure is 140 over 90 or greater.