The sun rises over the San Joaquin Valley, California, today is October 9, 2020.
About one year ago, the American Thoracic Society and Infectious Diseases Society of America issued an official clinical practice guideline regarding the diagnosis and treatment of adults with community acquired pneumonia (CAP).
There you can find the answer to 16 common questions about CAP in adults. For example, question 8 refers to the antibiotics recommended for empiric treatment of CAP in adults as outpatients.
For healthy outpatient adults without comorbidities (chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancy; or asplenia) or risk factors for antibiotic resistant pathogens (prior respiratory isolation of MRSA or Pseudomonas, or recent hospitalization AND receipt of parenteral antibiotics in the last 90 d), It is recommended monotherapy with amoxicillin or doxycycline or a macrolide.
For outpatient adults with comorbidities, the antibiotics recommended (without specific order) are
1. Combination of amoxicillin/clavulanate or cephalosporin (such as Cefuroxime) PLUS Macrolide (such as azithromycin) or doxycycline or
2. Monotherapy with respiratory fluoroquinolone (such as levofloxacin).
CAP with no comorbidities in adult: Monotherapy with amoxicillin, doxy or a macrolide. CAP with comorbidities: Combined Augmentin or cephalosporin PLUS a macrolide or doxycycline. It’s a tongue twister, may it’s better if you take a look at the official recommendation.
This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program, from Bakersfield, California. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care since 1971.
“Courage isn’t having the strength to go on – it is going on when you don’t have strength. – Napoleon Bonaparte.
Dr. Arreaza: Courage means to keep going even when you don’t have strength. Feeling discouraged is not uncommon during residency. You may feel inadequate at times, you may feel like “you don’t know enough,” but don’t worry, it is not easy, but the extra work is worth it. Get the courage to keep going.
Dr. Patel: Hi listeners, I’d like to introduce myself, name is Ravi Patel, I’m a non-practicing MD who recently moved to Bakersfield and just met Dr. Arreaza, and his quote resonates with me because my journey to practicing medicine has been quite long and I definitely feel the importance in not giving up in the face of discouragement.
Dr. Arreaza: Can you tell us a little bit of your background on working with pain management and opioids?
Dr. Patel: I have several years of experience working in pain management and primary care with the Vegas metro population, huge indigent population which faces unique challenges especially in regards to opiate therapy. I’m here to discuss with Dr. Arreaza issues involving opiate usage, when it is appropriate, when it is not appropriate, and the importance of limiting usage, and in what cases long term usage is appropriate.
Dr. Arreaza: That’s going to be our first topic – opiate therapy. When is it appropriate? How do you screen patients for therapy?
Dr. Patel: It’s important to follow CDC guidelines, great place to begin, in screening patients it is inevitable due to the nature of opiates, to have drug-seeking patients. I like to begin with CDC guidelines. It’s important to stay under 90 MMEs per day, just in terms of efficacy and of course legal reasons, and most importantly patient safety. I like to follow the rule of 3 and 7, meaning acute patients, acute care in acute care settings, more so ED settings rather than urgent care, where 3-day courses of opiates are more suitable. Of course, there are other reasons as well, such as peri-surgical pain, 1-2 weeks may be appropriate, and then going case by case basis for chronic opiate therapy.
Dr. Arreaza: Acute pain is an indication for opiates, like a fracture, so do you say 2 weeks would be enough?
Dr. Patel: Every patient is different, look at it on case by case basis. More so than the number of days it’s the MMEs and the strength of the medication being prescribed. We want to start with longer acting medications; short-term, short acting medications tend to produce that feeling of euphoria, that instant rush that has a psychological addiction factor. I have seen many patients that go in for something as simple as a fracture and come out with an addiction to opiates. It can happen very quickly, in less than a week, in a matter of few days, opiate addiction takes place.
Dr. Arreaza: So, we can start an addiction by just prescribing one week of opiates.
Dr. Patel: Correct.
Dr. Arreaza: Well the symptoms you mentioned, the patients who get this energy bust or euphoria, those are the patients who are more at risk of being addicted, and of course there is a genetic and biological component to it as well. I can tell you by experience that my patients usually say they feel sleepy; it has a sedative effect. Those are usually the lower addiction risk, right?
Dr. Patel: Correct.
Dr. Arreaza: Well I’m glad to say that one day I took opioids, I had a cornea transplant, I had horrible pain, a leaky eye, and every time I took opioids I fell asleep, it was the only way to mitigate my pain, and it also gave me empathy for patients. I know that there is a big component of genetics, so when they have this euphoria because of opioids and become addicted to opioids, sometimes it’s out of their control, sometimes opioids is something they need to live. It’s described as needing water when you are thirsty. That is the addiction; we had an episode on suboxone with the residents and they explained it very well. So, let’s discuss ways and importance of incorporating multi modal treatment in therapy.
Dr. Patel: I find in my experience that is important to limit patient’s expectations of how much pain can be relieved from the get-go. Develop an onboarding plan and discuss what the therapy will entail. Many patients go in with the expectation that opiates are a magic pill that will remove all their pain, which is true, which is responsible for a lot of this addiction as well, but it is important to have an end date, let them know what the maximum you will prescribe, because it is extremely difficult once the patient is in therapy one or two weeks, because they are not often dependent on the opiate, and suddenly you want to take away this magic pill that is making them feel better than they ever have – patients can become aggressive. It’s hard, and plus with this addiction now you have to wean the patient off the medication as well. It’s important to incorporate other treatment modalities as well. I personally think physical therapy is extremely important, and, depending on the nature of the pathology, the nature of the injury, things like epidural injections, steroid injections, things to address the source of the pain over the long term rather than just giving an opiate. An opiate is a blanket you put over the pain, and any kind of pain, it brings it down. But we as providers, we need to focus on the source of the pain, to eliminate or reduce the source of this pain so we can then wean the patient off opiates and they are not dependent on them for the long term.
Dr. Arreaza: I had the opportunity to work in a clinic with a patient population who was using a lot of opioids. The provider had prescribed a lot of opioids, and he had left the clinic, so when the patients came to me, they wanted refills, so there was some friction and arguments because I was always concerned about the opioid epidemic. But now that you mention the multi-modal approach, it is probably something I applied without realizing it, incorporating things like gabapentinoids or physical therapy, and then referring a lot of those patients to pain management to get the proper treatment, etc. The way I explained it to my patients is that the opioid will mask the pain, but the pain will always be there, we must address the root of the pain to cure it (if possible).
Dr. Patel: As primary care providers, we always see patients who are following up with us, so if they have an acute injury, they go to Urgent Care, they go to the Emergency Room, there are many providers unfortunately who will provide strong opiates to patients. Just as Dr. Arreaza mentioned, like a blanket to reduce all their pain. To get the patient out of the door, especially in larger cities, busier emergency rooms, many times I have seen patients go to the Emergency Room, then see their primary care and they now have an addiction, they want their refill.
Dr. Arreaza: So how can we set realistic pain management levels? How can we have that discussion with the patients? Do we agree to a pain level? “Your pain level won't be a 0 it may be a 2”? How do you address that with the patient?
Dr. Patel: I think it's important to start a discussion like that by helping the patient realize that pain is a part of life. Most people have some sort of aches and pains, as we get older, part of the aging process, it’s common to have aches and pains and no medication is going to remove 100% of that pain permanently. Having that conversation, make sure the patient understands that the therapy won't be permanent, it won't be chronic. Get the patient used to the idea that they may have to deal with some level of pain in the long term. The patient needs to realize that yes, the opiates will make the pain go away, but when we take you off of it, the pain may come back.
Dr. Arreaza: They have to develop some coping mechanisms to deal with pain. There is a lot of evidence that if you practice yoga, you can reduce chronic pain. I have a great experience, I don’t know if it is evidence-based or not, hydrotherapy/water therapy - aquatics, so my patients with fibromyalgia they get a lot of relief with that therapy, and it’s part of that multi modal approach you are suggesting, so think of all different options for patients on opioids, to work on different receptors, different areas, to improve their quality of life.
Dr. Patel: Patients with chronic pain will almost always have associated psychiatric issues, so bringing in social workers, psychiatrists, psychologists, someone the patient can speak with. In Vegas like Bakersfield there is a large indigent population, and in my experience, I find more drug seeking behavior in that population. We can help by providing them more resources, allowing their concerns to be heard. They have multiple issues which we may not be aware of, that are causing them to seek these medications, because the whole picture of the patient should be considered.
Dr. Arreaza: I'm just thinking right now, even financial reasons, the problem with diversion, the patients could be using the opioid as a way to get some income, so there is a lot of factors implicated in the opioid usage of patients. How do you identify addiction to opioids?
Dr. Patel: Well there are the typical signs like you mentioned earlier. The aggressive patient coming in for a follow-up in a primary care clinic looking for a refill on a medication that some doctor somewhere gave them. I think that’s important to be aware of one tool I used where pharmacies report to a central agency so we know if patients are doctor hopping. I’ve caught many patients myself who would visit more than one physician in the same day, and physicians who don’t pay attention to these databases, would refill their prescriptions, and some mentions would get 2-3 different prescriptions in one day and then go around filling them. But in terms of identifying behaviors that are indicative of addiction, patients will have vague complaints, patients who want to come see you once or twice a week, every week attempting to get the medication. Many patients employ different strategies. Patients try to play to your emotions. I would talk about primary care issues, general checkups, blood work, and you'll find that these patients are not interested in anything but getting their medication. Behavior definitely plays a role in identifying addiction patients.
Dr. Arreaza: I was looking for the right term, Prescription Drug Monitoring Programs, PDMP. In California, it’s called CURES. We can check CURES for every patient, and now it is required by the DEA, it’s a good tool to have. Also for the residents, you can do a urine drug screening randomly for the patient to see if they are positive for any other illegal drugs or if they are being compliant with the opioids.
Dr. Patel: Very important, because there's a lot of comorbid drug use as well. Patients will use opiates as currency to buy other medications, to get illicit drugs, random screening is very important. We would give patients 24 hours to show up, we randomly call them, they have 24 hours to show up with their pills in their pill bottle, we would count them, to verify that they are taking them as prescribed. And anytime you are prescribing any controlled substance, you want to check that database.
Dr. Arreaza: People with addiction are not necessarily bad people, some people are regular people addicted to a substance. That’s why we have these programs to help people get those addictions under control. We have some replacements like buprenorphine and suboxone. We will probably have an opportunity to talk about that more in depth later. Let’s talk about the frequent flyers, we have patients who come all the time so what strategies can we use to assist these patients?
Dr. Patel: That’s a bit more difficult to deal with because you cannot disregard patients like that. There are patients who have valid concerns that need to be seen frequently, but you develop a sense of judgment about these patients in the sense that, like I mentioned earlier, patient is not concerned about any other issues. They may have an infection or may be limping, but they don’t care at all, they are not interested in multi-modal therapy they just want their prescription and that’s it. It’s an obvious sign of addiction and drug-seeking behavior. Due to laws like ENTALA for example, patients cannot be turned away from the Emergency Room. I have friends in the ED who see the same patient 3 times a week, they come in regularly seeking some kind of medication whether it’s a Toradol shot, or even 1-2 doses of a narcotics. You can’t avoid that, sooner or later we will end up running into those patients, but with patients like that, I always get psychiatry on board to see if there's any underlying factors. Why are they seeking medication attention repeatedly? Is it just drug seeking or are there any other underlying issues? What's going on?
Dr. Arreaza: Treating addictions is important but I think we can learn a lot on how to treat pain, as it is the root of the problem here. If you learn how to treat pain we will able to help in this opioid epidemic we are in right now. A reminder to residents; opioid use is linked to obesity as mentioned in a previous episode.
Dr. Patel: Another note, as we see more geriatric patients especially in primary care it is a growing problem, opiate usage amongst the elderly because now you have this wonderful drug that makes them feel 20-30 years younger, because who would not want to take that? It’s a tough conversation to have because the elderly patients have valid concerns, growing old is painful, right? At some point, we have to draw a line in the sand, especially with the U.S. using upwards of 80% of the world’s opiate supply, it is unfortunately part of our culture that when something is wrong, something is hurting, we want a pill for that. It is hard to combat, but it is something we have to do every day with our patients.
Dr. Arreaza: Maybe next time we can discuss the use of opioids in palliative care.
Dr. Patel: Of course, that is a completely valid use
Dr. Arreaza: Yea, different topic. Thanks Dr. Patel
Dr. Patel: Thanks for the opportunity.
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Speaking Medical: Hematospermia
by Dr Steven Saito
In honor of Halloween, we are going to talk blood. Blood in your ejaculate.
Hematospermia is having blood in your semen. I understand seeing red shoot from your snek is scary, but there are things that the doctor can evaluate you for. Causes can include:
Recent instrumentation. That means events like prostate surgery or a traumatic Foley placement.
Infections: both sexual and nonsexual variety
Excessive ejaculation particularly if you have been at home during a pandemic with nothing else to do.
Cancer: particularly in men over 40
And sporadic: caused by nothing, totally benign. And it usually resolves with time.
After working it up, most commonly reassurance is all that is required for your patients.
So, tell them to suck it up, walk it off, and rub some dirt in it.
Remember the medical word of this week, hematospermia.
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Espanish Por Favor: Hongos
by Dr Hector Arreaza
The letter H is usually silent in Spanish. So, my name “Hector” is actually pronounced “ek-tor” in English. Among our Spanish’speaking patients is common to hear the word “OS-pit-al” for hospital. Today, I want to teach you the word hongos. Hongos in medical terms refers to fungus or fungal infection. You can add a body part to the words hongos de and get, for example, hongos de las uñas for nail fungus or onychomycosis, hongos de los pies for tinea pedis… they are all hongos. Strangely, hongos is also the word commonly used in Latin America for mushrooms. So, remember the word of this week, hongos, which means fungus.
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For your Sanity: 789
by Dr Tana Parker
What do you call a drug addiction counselor addicted to prescription opiates? An Oxymoron.
Do you know what 50 did when he got hungry? 58.
Have you noticed we don’t have an iPhone 9? Yes, it’s because 789.
Of all the inventions in the last 100 years, the whiteboard must be the most remarkable.
Conclusion: Now we conclude our episode number 31 “Opioids in Bako.” Talking about opioids is always educational and pertinent. Dr Patel explained the importance of multi-modal treatment of pain, and we discussed different strategies to decrease the use of opioids in our community. Dr Saito explained that hematospermia is the proper way to say bloody semen, a feared symptom in men with a low probability of malignancy, think of infections or trauma before getting into a complicated workup for hematospermia. Dr Arreaza then taught us the Spanish word hongos (pronounced ON-goes, do not pronounce the h) which means fungus. Did you get the joke about 789? You may ask Dr Parker for an explanation.
Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Ravi Patel, Steven Saito, and Tana Parker. Audio edition: Suraj Amrutia. See you next week!
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References:
American Journal of Respiratory and Critical Care Medicine, Volume 200, Issue 7, 1 October 2019, Pages e45-e67, https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST
Published: 01 October 2019. Download PDF: https://www.atsjournals.org/doi/pdf/10.1164/rccm.201908-1581ST
CDC Guideline for Prescribing Opioids for Chronic Pain, United States, 2016. https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6501e1.pdf