Prevention, Aiding Veterans, Opioid Abuse Take Center Stage for FPs

The AAFP played a key role in new recommendations for immunizations and clinical preventive services that came down the pike in 2012. In addition, the Academy wholeheartedly threw its support behind helping veterans struggling with post-traumatic stress disorders (PTSD) and related ailments and ramped up its efforts to combat the rise of opioid abuse.

Family physicians and other health care professionals also found themselves in a reactive mode last year, as different disease outbreaks and other public health threats swept across portions of the country.

Changes to immunization recommendations for tetanus, diphtheria and acellular pertussis (Tdap), human papillomavirus (HPV), and hepatitis B vaccines led off the year, when the CDC issued its child, adolescent and adult immunization schedules in late January.

Developed in conjunction with the AAFP and other groups, several of the changes were especially pertinent to family physicians; among them was the CDC's call for routine hepatitis B immunization of unvaccinated adults with diabetes who are younger than age 60, with optional immunization recommended for adults 60 and older who have diabetes.

Regarding the HPV vaccine, the CDC backed recommendations made by its Advisory Committee on Immunization Practices (ACIP) to administer the quadrivalent human papillomavirus vaccine (HPV4) to boys ages 11-12 years, with catch-up vaccination at ages 13-21. The schedule also noted that it now is acceptable to begin HPV4 vaccination in boys as young as 9.

The schedule also called for pregnant women who have never received the Tdap vaccine to be immunized during their second or third trimester, rather than in the immediate postpartum period, and for health care personnel to receive a single dose of Tdap vaccine if they'd not received it previously. In November, the ACIP went even further, making a provisional recommendation that pregnant women receive a Tdap dose during each pregnancy, regardless of immunization history.

The ACIP also agreed in June on a provisional recommendation to expand the age recommendation for administration of the 13-valent pneumococcal conjugate vaccine (PCV13) to adults 19 and older who have certain immunocompromising conditions. To date, that recommendation has not been approved by the CDC.

In August, the Academy adopted the CDC's influenza vaccine recommendations for the 2012-13 influenza season, including a recommended two doses of influenza vaccine -- administered a minimum of four weeks apart -- for children ages 6 months through 8 years during their first season of vaccination to optimize immune response.

The U.S. Preventive Services Task Force (USPSTF), in conjunction with the AAFP, made a number of recommendations intended to improve clinical practice in 2012.

The task force made significant changes to its cervical cancer screening guidelines in March, offering women ages 30-65 an alternative to the blanket recommendation that women ages 21-65 who have a cervix have a Pap smear every three years. The older subset now may choose to undergo a combination of Pap smear and HPV testing every five years.

In July, the AAFP and the USPSTF recommended that primary care physicians screen all adults for obesity and offer or refer patients with a body mass index of 30 kg/m2 or higher to an intensive, multicomponent behavioral intervention program. USPSTF Co-vice Chair Michael LeFevre, M.D., M.S.P.H., a family physician from Columbia, Mo., told AAFP News Now the task force specifically recommended health care professionals offer or refer obese patients to a comprehensive weight loss and behavior management program consisting of 12-26 sessions in the first year.

The task force and the Academy waded into the fray concerning prostate-specific antigen (PSA)-based screening in May, making a final recommendation against PSA screening for prostate cancer in asymptomatic men. The task force cited evidence that indicates that "nearly 90 percent of U.S. men with PSA-detected prostate cancer are treated with surgery, radiation or androgen deprivation," with many of these men being harmed by treatment rather than helped.

The USPSTF also cited a high incidence of false-positive PSA testing results, pointing to data that indicate about 80 percent of PSA test results are false-positive when a PSA threshold between 2.5 micrograms per liter and 4.0 micrograms per liter is used.

In light of these updated recommendations, the Academy revised its patient education resources on prostate cancer and added a newly developed handout covering the pros and cons of PSA-based screening to aid doctor-patient discussions on the topic.

Fall 2012 saw the release of two female-specific preventive recommendations. The first, an updated recommendation against screening for ovarian cancer in women, came in September. It reaffirmed both the Academy's and the task force's previous positions, citing the fact that no available screening method exists that is effective in reducing deaths.

In October, the task force recommended against the use of combined estrogen and progestin for the prevention of chronic conditions in postmenopausal women, as well as the use of estrogen for the prevention of chronic conditions in postmenopausal women who have had a hysterectomy. This stance, which mirrored an already-held AAFP position, does not apply to women considering using hormone therapy for the management of menopausal symptoms or women younger than 50 who have undergone surgical menopause.

The Academy joined forces with the White House early in 2012 to aid the significant number of U.S. veterans returning from combat in Iraq and Afghanistan with symptoms of PTSD, major depression and traumatic brain injury. Led by first lady Michelle Obama and Jill Biden, M.D., the Joining Forces campaign calls attention to the critical issues facing veterans and military families and aims to expand access to wellness programs and other resources for this population. Because most reservists and those released from active duty typically receive care through community-based resources, family physicians are uniquely positioned to help these veterans.

A March study in JAMA: the Journal of the American Medical Association, pointed to another way family physicians can help veterans returning from Iraq and Afghanistan who suffer from PTSD: Think twice before prescribing them opioids. According to the study authors, returning veterans with PTSD are at an "increased risk of receiving opioids for pain, high-risk opioid use and adverse clinical outcomes." The study also noted that the association between PTSD and opioid prescription -- which it found to be especially robust -- proved to be significant for all subgroups of veterans with PTSD. That said, extra care should be taken when prescribing opioids to relieve physical symptoms in these patients, the authors suggested.

Of course, opioid addiction is not limited to veterans alone. With the overall problem of prescription drug abuse reaching epidemic levels, the Academy joined a national campaign to educate the public about the dangers of abusing both prescription and OTC drugs while simultaneously highlighting the important role family physicians and other primary care clinicians play in effective pain management, including by prescribing opioid analgesics. The move followed other AAFP efforts to balance the need for effective pain management with legitimate patient access concerns.

One such effort was the Aug. 1 release of a formal position paper on opioid abuse and pain management in which the Academy stated its opposition to mandated CME and any other barriers to family physicians' ability to prescribe these drugs. According to the paper, the creation of additional prescribing barriers for primary care physicians could limit patient access when there is a legitimate need for pain relief.

Several large infectious disease outbreaks hit regions of the United States in 2012, starting with pertussis. In May, Montana, Washington and Wisconsin all reported significant increases in the number of cases of whooping cough, with Washington reporting 1,738 cases as of May 19. As of Dec. 8, the CDC said that number had climbed to 4,626 cases compared to only 739 cases for the same period in 2011. In Wisconsin, the number of cases sat at 5,668 as of Dec. 13.

West Nile virus (WNV) and influenza A variant (H3N2v) virus infections both hit hard in August, with WNV case numbers hitting their highest level since the disease first was detected in the United States in 1999. As of Dec. 11, the CDC reported a total of 5,387 cases of WNV disease in people, including 243 deaths. Of these, more than half were classified as neuroinvasive disease, such as meningitis or encephalitis.

In regard to H3N2v, the CDC reported a fivefold increase in the number of confirmed H3N2v virus infections. First detected in people in July 2011, the infections were mostly associated with prolonged exposure to pigs at agricultural fairs. As of September, the CDC reported 307 cases of H3N2v across 11 states.

Finally, in October, the CDC issued guidance for physicians in the wake of a fungal meningitis outbreak that had caused more than 110 illnesses and 11 deaths in 10 states as of Oct. 10. By Dec. 17, those numbers had risen to 367 illnesses and 39 deaths in 19 states. The cases are associated with a potentially contaminated steroid -- methylprednisolone acetate -- manufactured by New England Compounding Center in Framingham, Mass. The company has recalled all products compounded at and distributed from its Framingham facility, and the CDC said health care professionals should cease use of any product produced by the company.