The GP Show

Today we will cover opioid prescribing guidelines for chronic non-cancer non-palliative care pain in adults.

Contents:

•New codeine laws 2018

•Opioids prescription facts and harms

•Evidence for opioids

•Types of opioids and equivalence dosing

•Side effects – short and long term

•Initiating and ongoing presciprtion

•Break through pain management

•Discontinuing

•Aberrant behaviour management and assessment

•Follow up

PSA and DRE screening – to do or not to do, where is the evidence? And intensive lifestyle changes in early prostate cancer.

1. Digital rectal examination - recommendations

2. PSA test– what is it, the benefits and risks, medicare implications, the review of guidelines for screening for average to high risk and follow up, what to do with a + result, age related reference ranges and the PSA variables – free/total %, double, velocity, PHI, MRI

3. Intensive lifestyle change in early prostate cancer

References:

Prostate Cancer Foundation of Australia and Cancer Council Australia Expert Advisory Panel – Clinical practice guidelines PSA testing and early management of test detected prostate cancer PSA Testing 2015, http://wiki.cancer.org.au/australia/Guidelines:PSA_Testing

Urological Society of Australia and New Zealand April 2017 statement

http://www.racgp.org.au/your-practice/guidelines/prostate-cancer/

http://www.racgp.org.au/afp/2013/januaryfebruary/prostate-cancer/

https://www.ncbi.nlm.nih.gov/pubmed/16822843

Intensive lifestyle change in prostate cancer, 2005 - https://www.ncbi.nlm.nih.gov/pubmed/16094059

Gene expression changes in intensive lifestyle changes in prostate cancer, 2008 - https://www.ncbi.nlm.nih.gov/pubmed/18559852

https://www.cancer.org/cancer/prostate-cancer/detection-diagnosis-staging/how-diagnosed.html

http://www.snp.com.au/media/305331/item_44879_prostate_cancer_testing_november_2016.pdf

http://www.sapathology.sa.gov.au/wps/wcm/connect/sa+pathology+internet+content+new/content/news/what+is+psa

PSA and DRE screening – to do or not to do, where is the evidence? And intensive lifestyle changes in early prostate cancer.

1. Digital rectal examination recommendations

2. PSA test– what is it, the benefits and risks, medicare implications, the review of guidelines for screening for average to high risk and follow up, age related reference ranges , PSA variables – free/total %, double, velocity, PHI, MRI

3. Intensive lifestyle change in early prostate cancer

Today we will cover a case on weight with question and answers. Questions include:

Question 1 What further history do you want to obtain for weight loss?

Question 2 What examination do you want to perform?

Question 3 Are there any investigations to perform?

Question 4 How does this change your management when prescribing the pill?

Question 5 She asks you – "what about the low carb high fat diet?"

Question 6 How successful are lifestyle weight loss programs in the long run?

Question 7 What medication options are there and the indications and side effects?

Question 8 When would you refer for a bariatric surgical opinion?

Main references:

http://www.nejm.org/doi/full/10.1056/NEJMoa1614292?rss=searchAndBrowse&

https://www.urmc.rochester.edu/news/story/4217/commonly-prescribed-drug-for-lower-back-pain-not-effective.aspx

http://www.cochrane.org/CD012087/BACK_non-steroidal-anti-inflammatory-drugs-chronic-low-back-pain

NHMRC, Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults, Adolescence and Children in Australia, Aus Gov, 2013, https://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/n57_obesity_guidelines_140630.pdf

Effects of Low-Carbohydrate versus low fat diets on metabolic risk factors: Meta-analysis, 2012, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3530364/

Grima et al, Obesity, RACGP AFP, 2013 http://www.racgp.org.au/afp/2013/august/obesity/

Hamdy et al, Obesity, Medscape, 2017 http://emedicine.medscape.com/article/123702-clinical

Bray et al, Obesity in Adults, UpToDate, 2017

UKMEC criteria, 2016, http://www.fsrh.org/standards-and-guidance/documents/ukmec-2016/

Today we will cover a case on weight with question and answers.  Questions include:

 

 

Question 1 What further history do you want to obtain for weight loss?

Question 2 What examination do you want to perform?

Question 3 Are there any investigations to perform?

Question 4 How does this change your management when prescribing the pill?

Question 5 She asks you – “what about the low carb high fat diet?”

Question 6 How successful are lifestyle weight loss programs in the long run?

Question 7 What medication options are there and the indications and side effects?

Question 8 When would you refer for a bariatric surgical opinion?

 

Main references:

http://www.nejm.org/doi/full/10.1056/NEJMoa1614292?rss=searchAndBrowse&

https://www.urmc.rochester.edu/news/story/4217/commonly-prescribed-drug-for-lower-back-pain-not-effective.aspx

http://www.cochrane.org/CD012087/BACK_non-steroidal-anti-inflammatory-drugs-chronic-low-back-pain

NHMRC, Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults, Adolescence and Children in Australia, Aus Gov, 2013, https://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/n57_obesity_guidelines_140630.pdf

Effects of Low-Carbohydrate versus low fat diets on metabolic risk factors: Meta-analysis, 2012, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3530364/ 

 

Grima et al, Obesity, RACGP AFP, 2013 http://www.racgp.org.au/afp/2013/august/obesity/

Hamdy et al, Obesity, Medscape, 2017 http://emedicine.medscape.com/article/123702-clinical

Bray et al, Obesity in Adults, UpToDate, 2017

UKMEC criteria, 2016, http://www.fsrh.org/standards-and-guidance/documents/ukmec-2016/

In this episode we will review acute and chronic low back pain. •Overview of assessment of back pain •Quick review of some red flags and yellow flags •Review differential diagnosis in LBP •Review of the evidence for some back imaging •Review of radiation risk of some common imaging •Screening tools for assessing risk of chronicity •Review of management principles •What is self management •Acute vs chronic LBP management •Review of latest guidelines and previous evidence for the 4 Ps (Physical, psychological, pharmacological, procedural) References:

Annals of Internal Medicine, Noninvasive treatments for Acute, Subacute, and Chronic Back Pain, 2017, http://annals.org/aim/article/2603228/noninvasive-treatments-acute-subacute-chronic-low-back-pain-clinical-practice

National Institute for health and care Excellence (2016). Low back pain and sciatica in over 16s: assessment and management. NICE guideline [NG59]. Retrieved from https://www.nice.org.uk/guidance/ng59

http://clinicalevidence.bmj.com/x/systematic-review/1116/overview.html

http://www.racgp.org.au/your-practice/guidelines/handi/interventions/musculoskeletal/mindfulness-and-cbt-for-chronic-low-back-pain/

http://www.racgp.org.au/your-practice/guidelines/handi/interventions/musculoskeletal/exercise-for-chronic-low-back-pain/

Deyo RA. Real help and red herrings in spinal imaging. N Engl J Med, 2013

https://www.mja.com.au/journal/2011/195/8/back-pain-and-leg-weakness

http://www.bmj.com/content/347/bmj.f7095

http://www.imagingpathways.health.wa.gov.au/radiation/pages/jop_principles.html

https://www.keele.ac.uk/sbst/

http://www.cochrane.org/CD001351/BACK_acupuncture-and-dry-needling-for-low-back-pain

http://www.cochrane.org/CD004059/BACK_prolotherapy-injections-for-chronic-low-back-pain

Bardin, L D, King P, Maher C G. (2017). Diagnostic triage for low back pain: a practical approach for primary care MJA 206 (6) 3 April. O'Sullivan P., Lin I.B. (2014). Acute low back pain. Beyond drug therapies. Pain Management Today; 1(1): 8-13. 15. NSW Agency for Clinical Innovation (2016). Management of people with acute low back pain: model of care. Chatswood; NSW Health. Retrieved from https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0007/336688/acute-low-back-pain-moc.pdf

In this episode we will review acute and chronic low back pain.    •Overview of assessment of back pain •Quick review of some red flags and yellow flags •Review differential diagnosis in LBP •Review of the evidence for some back imaging •Review of radiation risk of some common imaging •Screening tools for assessing risk of chronicity •Review of management principles •What is self management •Acute vs chronic LBP management •Review of latest guidelines and previous evidence for the 4 Ps (Physical, psychological, pharmacological, procedural)   References:  

Annals of Internal Medicine, Noninvasive treatments for Acute, Subacute, and Chronic Back Pain, 2017, http://annals.org/aim/article/2603228/noninvasive-treatments-acute-subacute-chronic-low-back-pain-clinical-practice 

National Institute for health and care Excellence (2016). Low back pain and sciatica in over 16s: assessment and management. NICE guideline [NG59]. Retrieved from https://www.nice.org.uk/guidance/ng59

http://clinicalevidence.bmj.com/x/systematic-review/1116/overview.html 

http://www.racgp.org.au/your-practice/guidelines/handi/interventions/musculoskeletal/mindfulness-and-cbt-for-chronic-low-back-pain/ 

http://www.racgp.org.au/your-practice/guidelines/handi/interventions/musculoskeletal/exercise-for-chronic-low-back-pain/ 

Deyo RA. Real help and red herrings in spinal imaging. N Engl J Med, 2013

https://www.mja.com.au/journal/2011/195/8/back-pain-and-leg-weakness 

http://www.bmj.com/content/347/bmj.f7095

http://www.imagingpathways.health.wa.gov.au/radiation/pages/jop_principles.html 

https://www.keele.ac.uk/sbst/ 

http://www.cochrane.org/CD001351/BACK_acupuncture-and-dry-needling-for-low-back-pain 

http://www.cochrane.org/CD004059/BACK_prolotherapy-injections-for-chronic-low-back-pain

Bardin, L D, King P, Maher C G. (2017). Diagnostic triage for low back pain: a practical approach for primary care MJA 206 (6) 3 April.   O'Sullivan P., Lin I.B. (2014). Acute low back pain. Beyond drug therapies. Pain Management Today; 1(1): 8-13. 15.   NSW Agency for Clinical Innovation (2016). Management of people with acute low back pain: model of care. Chatswood; NSW Health. Retrieved from https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0007/336688/acute-low-back-pain-moc.pdf