John Hickner, MD, MSc

Nutrition enthusiasts have been saying for years that “we are what we eat.” In this issue of JFP, Drs. Malone and Tsai review the evidence regarding the medicinal properties of certain herbal and botanical supplements. (See here.) Although there are many unfounded claims about the health effects of a wide variety of supplements, increasing evidence from well-conducted randomized trials and large epidemiologic studies demonstrates that certain items we ingest have therapeutic value for a variety of conditions.

However, as Dr. Malone points out, herbal supplements and botanicals are not regulated by the US Food and Drug Administration, so manufacturers are not required to provide proof of effectiveness or safety to market their products. Some of these products have adverse effects. For example, butterbur can cause liver toxicity.¹

At least I can feel better about the 4 cups of coffee I drink every day!

Because about 38% of Americans use supplements, all primary care clinicians should know which products do—and do not—have evidence of efficacy.² I suggest you read Dr. Malone’s 2-part article (part 2 is available here), but I can’t resist highlighting several of my favorites:

Coffee. Coffee used to be maligned because of its caffeine content, but more recent evidence suggests it protects against liver disease and has positive effects on cardiovascular disease and even mortality. (See Dr. Malone’s article for references.) There are no randomized trials, however, so we can’t be entirely sure if these associations are causal, but at least I can feel better about the 4 cups of coffee I drink every day!

Tea, especially green tea, appears to have many positive effects on health, including potential roles in reducing the risk of cancer, cardiovascular disease, type 2 diabetes, and even dementia. As with coffee, these associations are based on large observational studies and not randomized trials.

Chamomile. If your coffee gives you too much of a buzz and causes you to feel anxious, calm down with chamomile tea or oil. Evidence from randomized trials indicates it has positive effects on insomnia and anxiety.

Peppermint oil. The data for calming irritable bowel syndrome is fairly strong, and it may be effective in aborting migraines when applied to the forehead. It’s certainly worth a try for these difficult-to-treat conditions.

When patients ask you about botanicals and herbals, a great resource is the Natural Medicine Database (https://naturalmedicines.therapeuticresearch.com).

Now I will finish my fourth cup of coffee . . .

Nutrition enthusiasts have been saying for years that “we are what we eat.” In this issue of JFP, Drs. Malone and Tsai review the evidence regarding the medicinal properties of certain herbal and botanical supplements. (See here.) Although there are many unfounded claims about the health effects of a wide variety of supplements, increasing evidence from well-conducted randomized trials and large epidemiologic studies demonstrates that certain items we ingest have therapeutic value for a variety of conditions.

However, as Dr. Malone points out, herbal supplements and botanicals are not regulated by the US Food and Drug Administration, so manufacturers are not required to provide proof of effectiveness or safety to market their products. Some of these products have adverse effects. For example, butterbur can cause liver toxicity.¹

At least I can feel better about the 4 cups of coffee I drink every day!

Because about 38% of Americans use supplements, all primary care clinicians should know which products do—and do not—have evidence of efficacy.² I suggest you read Dr. Malone’s 2-part article (part 2 is available here), but I can’t resist highlighting several of my favorites:

Coffee. Coffee used to be maligned because of its caffeine content, but more recent evidence suggests it protects against liver disease and has positive effects on cardiovascular disease and even mortality. (See Dr. Malone’s article for references.) There are no randomized trials, however, so we can’t be entirely sure if these associations are causal, but at least I can feel better about the 4 cups of coffee I drink every day!

Tea, especially green tea, appears to have many positive effects on health, including potential roles in reducing the risk of cancer, cardiovascular disease, type 2 diabetes, and even dementia. As with coffee, these associations are based on large observational studies and not randomized trials.

Chamomile. If your coffee gives you too much of a buzz and causes you to feel anxious, calm down with chamomile tea or oil. Evidence from randomized trials indicates it has positive effects on insomnia and anxiety.

Peppermint oil. The data for calming irritable bowel syndrome is fairly strong, and it may be effective in aborting migraines when applied to the forehead. It’s certainly worth a try for these difficult-to-treat conditions.

When patients ask you about botanicals and herbals, a great resource is the Natural Medicine Database (https://naturalmedicines.therapeuticresearch.com).

Now I will finish my fourth cup of coffee . . .

Nutrition enthusiasts have been saying for years that “we are what we eat.” In this issue of JFP, Drs. Malone and Tsai review the evidence regarding the medicinal properties of certain herbal and botanical supplements. (See here.) Although there are many unfounded claims about the health effects of a wide variety of supplements, increasing evidence from well-conducted randomized trials and large epidemiologic studies demonstrates that certain items we ingest have therapeutic value for a variety of conditions.

However, as Dr. Malone points out, herbal supplements and botanicals are not regulated by the US Food and Drug Administration, so manufacturers are not required to provide proof of effectiveness or safety to market their products. Some of these products have adverse effects. For example, butterbur can cause liver toxicity.¹

At least I can feel better about the 4 cups of coffee I drink every day!

Because about 38% of Americans use supplements, all primary care clinicians should know which products do—and do not—have evidence of efficacy.² I suggest you read Dr. Malone’s 2-part article (part 2 is available here), but I can’t resist highlighting several of my favorites:

Coffee. Coffee used to be maligned because of its caffeine content, but more recent evidence suggests it protects against liver disease and has positive effects on cardiovascular disease and even mortality. (See Dr. Malone’s article for references.) There are no randomized trials, however, so we can’t be entirely sure if these associations are causal, but at least I can feel better about the 4 cups of coffee I drink every day!

Tea, especially green tea, appears to have many positive effects on health, including potential roles in reducing the risk of cancer, cardiovascular disease, type 2 diabetes, and even dementia. As with coffee, these associations are based on large observational studies and not randomized trials.

Chamomile. If your coffee gives you too much of a buzz and causes you to feel anxious, calm down with chamomile tea or oil. Evidence from randomized trials indicates it has positive effects on insomnia and anxiety.

Peppermint oil. The data for calming irritable bowel syndrome is fairly strong, and it may be effective in aborting migraines when applied to the forehead. It’s certainly worth a try for these difficult-to-treat conditions.

When patients ask you about botanicals and herbals, a great resource is the Natural Medicine Database (https://naturalmedicines.therapeuticresearch.com).

Now I will finish my fourth cup of coffee . . .

We see many patients in our office with acute or chronic musculoskeletal complaints. Most acute musculoskeletal injuries resolve with rest and a short course of a narcotic or over-the-counter pain medication.

But when pain lingers beyond a few weeks, patients get nervous and so do we. This is the critical time period during which patients may request more narcotic pain medication and/or develop chronic pain syndromes, which are enormously difficult to treat. What treatments can we suggest at this point that have good evidence of effectiveness?

Reassurance. The simplest effective intervention is reassurance—especially from a physician. Patients who are reassured are more likely to recover from low back pain.¹ Patients often have unrealistic goals, expecting to be pain free in a couple of weeks, whereas the natural healing of soft tissue injuries takes 8 to 12 weeks (and sometimes longer) for more severe injuries.

Physical modalities. Nearly all of the other non-medicinal, effective interventions for subacute and chronic musculoskeletal pain are physical in nature. The article by Slattengren et al provides an evidence-based review of osteopathic manipulation techniques (OMT) for pain and other conditions, as well. The evidence for the effectiveness of OMT for low back pain is the strongest.

There is evidence for the effectiveness of other types of physical techniques for low back pain, too. A recent meta-analysis of spinal manipulation for acute low back pain concluded that it is moderately effective in reducing pain and increasing function.² And although the evidence is not considered strong, the American College of Physicians included massage, tai chi, yoga, acupuncture, motor control exercises, and progressive relaxation in their recent recommendations for the treatment of acute, subacute, and chronic low back pain.³

Walking was as good as PT and exercise classes in one back pain study.

My personal favorite treatment for chronic low back pain is walking. In a clever randomized trial, Irish researchers randomized patients with chronic low back pain to 3 groups: standard physical therapy, weekly exercise classes designed for people with low back pain, and a tailored, gradually increasing walking program.⁴ Participants in the last group were instructed to walk at least 4 days a week, starting with 10 minutes/day and working up to 30 minutes of brisk walking 5 days/week. The improvement in pain and disability after 2 months, although modest, was as good in the walking group as in the other 2 treatment groups.

So let’s try relying more on physical activity to help our patients manage their aches and pains. It may produce benefits for other health problems, too, and start many patients down a road to healthier living.

We see many patients in our office with acute or chronic musculoskeletal complaints. Most acute musculoskeletal injuries resolve with rest and a short course of a narcotic or over-the-counter pain medication.

But when pain lingers beyond a few weeks, patients get nervous and so do we. This is the critical time period during which patients may request more narcotic pain medication and/or develop chronic pain syndromes, which are enormously difficult to treat. What treatments can we suggest at this point that have good evidence of effectiveness?

Reassurance. The simplest effective intervention is reassurance—especially from a physician. Patients who are reassured are more likely to recover from low back pain.¹ Patients often have unrealistic goals, expecting to be pain free in a couple of weeks, whereas the natural healing of soft tissue injuries takes 8 to 12 weeks (and sometimes longer) for more severe injuries.

Physical modalities. Nearly all of the other non-medicinal, effective interventions for subacute and chronic musculoskeletal pain are physical in nature. The article by Slattengren et al provides an evidence-based review of osteopathic manipulation techniques (OMT) for pain and other conditions, as well. The evidence for the effectiveness of OMT for low back pain is the strongest.

There is evidence for the effectiveness of other types of physical techniques for low back pain, too. A recent meta-analysis of spinal manipulation for acute low back pain concluded that it is moderately effective in reducing pain and increasing function.² And although the evidence is not considered strong, the American College of Physicians included massage, tai chi, yoga, acupuncture, motor control exercises, and progressive relaxation in their recent recommendations for the treatment of acute, subacute, and chronic low back pain.³

Walking was as good as PT and exercise classes in one back pain study.

My personal favorite treatment for chronic low back pain is walking. In a clever randomized trial, Irish researchers randomized patients with chronic low back pain to 3 groups: standard physical therapy, weekly exercise classes designed for people with low back pain, and a tailored, gradually increasing walking program.⁴ Participants in the last group were instructed to walk at least 4 days a week, starting with 10 minutes/day and working up to 30 minutes of brisk walking 5 days/week. The improvement in pain and disability after 2 months, although modest, was as good in the walking group as in the other 2 treatment groups.

So let’s try relying more on physical activity to help our patients manage their aches and pains. It may produce benefits for other health problems, too, and start many patients down a road to healthier living.

We see many patients in our office with acute or chronic musculoskeletal complaints. Most acute musculoskeletal injuries resolve with rest and a short course of a narcotic or over-the-counter pain medication.

But when pain lingers beyond a few weeks, patients get nervous and so do we. This is the critical time period during which patients may request more narcotic pain medication and/or develop chronic pain syndromes, which are enormously difficult to treat. What treatments can we suggest at this point that have good evidence of effectiveness?

Reassurance. The simplest effective intervention is reassurance—especially from a physician. Patients who are reassured are more likely to recover from low back pain.¹ Patients often have unrealistic goals, expecting to be pain free in a couple of weeks, whereas the natural healing of soft tissue injuries takes 8 to 12 weeks (and sometimes longer) for more severe injuries.

Physical modalities. Nearly all of the other non-medicinal, effective interventions for subacute and chronic musculoskeletal pain are physical in nature. The article by Slattengren et al provides an evidence-based review of osteopathic manipulation techniques (OMT) for pain and other conditions, as well. The evidence for the effectiveness of OMT for low back pain is the strongest.

There is evidence for the effectiveness of other types of physical techniques for low back pain, too. A recent meta-analysis of spinal manipulation for acute low back pain concluded that it is moderately effective in reducing pain and increasing function.² And although the evidence is not considered strong, the American College of Physicians included massage, tai chi, yoga, acupuncture, motor control exercises, and progressive relaxation in their recent recommendations for the treatment of acute, subacute, and chronic low back pain.³

Walking was as good as PT and exercise classes in one back pain study.

My personal favorite treatment for chronic low back pain is walking. In a clever randomized trial, Irish researchers randomized patients with chronic low back pain to 3 groups: standard physical therapy, weekly exercise classes designed for people with low back pain, and a tailored, gradually increasing walking program.⁴ Participants in the last group were instructed to walk at least 4 days a week, starting with 10 minutes/day and working up to 30 minutes of brisk walking 5 days/week. The improvement in pain and disability after 2 months, although modest, was as good in the walking group as in the other 2 treatment groups.

So let’s try relying more on physical activity to help our patients manage their aches and pains. It may produce benefits for other health problems, too, and start many patients down a road to healthier living.

It depends on whom you ask. But if you ask me, obesity should not be labeled a disease.

I understand the rationale for calling obesity a disease—it helps legitimize the time we spend treating obesity and aids in getting paid for that time. Some people have distinct diseases, such as Prader-Willi syndrome, hypothyroidism, and Cushing’s syndrome that can cause obesity, and perhaps massive obesity is best categorized and treated as a disease. But the “garden variety” obesity that affects nearly 40% of the US adult population¹ behaves more like a risk factor than a disease. Think of other continuous variables like blood pressure and cholesterol—the higher the measurement, the higher the risk of a plethora of medical problems.

Obesity is a global public health problem that is due largely—at least in this country—to the widespread availability of inexpensive, calorie-packed foods, as well as a desire by a screen-addicted society to stay home and “play” online rather than outdoors. Obesity is a health risk factor produced by our current social milieu and modified by genetics and personal health habits.

Remember that a 5% to 10% weight loss is beneficial—especially for patients with diabetes.

So what can we do? We need to recognize our limited, but important, role and remain nonjudgmental with our overweight and obese patients when they are unsuccessful at losing weight. It is easy to play the blame game, even in subtle ways. Recognizing that obesity is more of a social issue than a personal behavioral issue is a great place to start. Asking patients what they want to do and helping them set goals and find the resources to reach their goals can be helpful. Celebrating even small decreases in weight or increases in physical activity is always good medicine. Remember that a 5% to 10% weight loss has medically beneficial effects, especially for patients with diabetes.²

In addition to recommendations (and referrals) to help patients reduce calories and increase exercise, we have other weight-loss tools to draw upon. Gastric bypass surgery is certainly effective—especially for obese patients with diabetes. And while medication is no replacement for proper diet and exercise, it is another option to consider. Randomized trials have demonstrated some effectiveness for up to 4 years, although no long-term trials (lasting ≥5 years) have been performed. (See “Obesity: When to consider medication.”)

So whether you consider obesity a disease, or not, we now have even more ways with which to combat it.

It depends on whom you ask. But if you ask me, obesity should not be labeled a disease.

I understand the rationale for calling obesity a disease—it helps legitimize the time we spend treating obesity and aids in getting paid for that time. Some people have distinct diseases, such as Prader-Willi syndrome, hypothyroidism, and Cushing’s syndrome that can cause obesity, and perhaps massive obesity is best categorized and treated as a disease. But the “garden variety” obesity that affects nearly 40% of the US adult population¹ behaves more like a risk factor than a disease. Think of other continuous variables like blood pressure and cholesterol—the higher the measurement, the higher the risk of a plethora of medical problems.

Obesity is a global public health problem that is due largely—at least in this country—to the widespread availability of inexpensive, calorie-packed foods, as well as a desire by a screen-addicted society to stay home and “play” online rather than outdoors. Obesity is a health risk factor produced by our current social milieu and modified by genetics and personal health habits.

Remember that a 5% to 10% weight loss is beneficial—especially for patients with diabetes.

So what can we do? We need to recognize our limited, but important, role and remain nonjudgmental with our overweight and obese patients when they are unsuccessful at losing weight. It is easy to play the blame game, even in subtle ways. Recognizing that obesity is more of a social issue than a personal behavioral issue is a great place to start. Asking patients what they want to do and helping them set goals and find the resources to reach their goals can be helpful. Celebrating even small decreases in weight or increases in physical activity is always good medicine. Remember that a 5% to 10% weight loss has medically beneficial effects, especially for patients with diabetes.²

In addition to recommendations (and referrals) to help patients reduce calories and increase exercise, we have other weight-loss tools to draw upon. Gastric bypass surgery is certainly effective—especially for obese patients with diabetes. And while medication is no replacement for proper diet and exercise, it is another option to consider. Randomized trials have demonstrated some effectiveness for up to 4 years, although no long-term trials (lasting ≥5 years) have been performed. (See “Obesity: When to consider medication.”)

So whether you consider obesity a disease, or not, we now have even more ways with which to combat it.

It depends on whom you ask. But if you ask me, obesity should not be labeled a disease.

I understand the rationale for calling obesity a disease—it helps legitimize the time we spend treating obesity and aids in getting paid for that time. Some people have distinct diseases, such as Prader-Willi syndrome, hypothyroidism, and Cushing’s syndrome that can cause obesity, and perhaps massive obesity is best categorized and treated as a disease. But the “garden variety” obesity that affects nearly 40% of the US adult population¹ behaves more like a risk factor than a disease. Think of other continuous variables like blood pressure and cholesterol—the higher the measurement, the higher the risk of a plethora of medical problems.

Obesity is a global public health problem that is due largely—at least in this country—to the widespread availability of inexpensive, calorie-packed foods, as well as a desire by a screen-addicted society to stay home and “play” online rather than outdoors. Obesity is a health risk factor produced by our current social milieu and modified by genetics and personal health habits.

Remember that a 5% to 10% weight loss is beneficial—especially for patients with diabetes.

So what can we do? We need to recognize our limited, but important, role and remain nonjudgmental with our overweight and obese patients when they are unsuccessful at losing weight. It is easy to play the blame game, even in subtle ways. Recognizing that obesity is more of a social issue than a personal behavioral issue is a great place to start. Asking patients what they want to do and helping them set goals and find the resources to reach their goals can be helpful. Celebrating even small decreases in weight or increases in physical activity is always good medicine. Remember that a 5% to 10% weight loss has medically beneficial effects, especially for patients with diabetes.²

In addition to recommendations (and referrals) to help patients reduce calories and increase exercise, we have other weight-loss tools to draw upon. Gastric bypass surgery is certainly effective—especially for obese patients with diabetes. And while medication is no replacement for proper diet and exercise, it is another option to consider. Randomized trials have demonstrated some effectiveness for up to 4 years, although no long-term trials (lasting ≥5 years) have been performed. (See “Obesity: When to consider medication.”)

So whether you consider obesity a disease, or not, we now have even more ways with which to combat it.

It makes sense to think that treating patients who have congestive heart failure (CHF) and depression with an antidepressant would be effective. But common sense is not always supported by empiric observation or evidence.

In this month’s PURL, the authors summarize the MOOD-HF study,¹ a randomized controlled trial (RCT) of escitalopram for the treatment of patients with CHF and depression. After 2 years, no outcomes—including depression scores—were better in the treatment vs the placebo group. One can only speculate as to why this antidepressant was not effective in this population. Clearly, this group differs somehow from subjects enrolled in traditional depression trials; notably, their depression was diagnosed after the onset of CHF, suggesting the depression was a reaction to their illness.

Not the first time. This is the second large trial to find no benefit to using a selective serotonin reuptake inhibitor (SSRI) to treat depression in patients with CHF; the previous trial to do so looked at sertraline.² In fact, when it comes to patients with chronic diseases, such as diabetes and coronary artery disease, there is scant evidence to support the common belief that screening them for depression and treating them with SSRIs improves patient outcomes.³ On the other hand, there are no definitive clinical trials investigating other antidepressants in the treatment of depressed patients with chronic illness, so it is possible that other drugs could be effective. There is evidence, however, from a recent RCT that cognitive behavioral therapy—compared with usual care—improves depression, anxiety, fatigue, and social functioning in patients with CHF.⁴

Where does that leave us? In our practice, we annually screen all adults, including those with chronic illness, for depression with the 2-question Patient Health Questionnaire. As a matter of course, we should acknowledge and explore all patients’ depressed mood, offer emotional support, and refer for psychotherapy when appropriate. And since collaborative care has been shown to improve outcomes in patients with depression and, for that matter, diabetes (see this month’s audiocast), consider this model of care if it is available.⁵

One can only speculate as to why this antidepressant was not effective in this population.

I believe it’s worthwhile to discuss the use of antidepressants with patients who have CHF. It’s reasonable to be optimistic with them and to expect that their depression will improve with time, as noted in the placebo groups of the randomized trials mentioned above.^1,2 And giving patients hope is always good medicine.

It makes sense to think that treating patients who have congestive heart failure (CHF) and depression with an antidepressant would be effective. But common sense is not always supported by empiric observation or evidence.

In this month’s PURL, the authors summarize the MOOD-HF study,¹ a randomized controlled trial (RCT) of escitalopram for the treatment of patients with CHF and depression. After 2 years, no outcomes—including depression scores—were better in the treatment vs the placebo group. One can only speculate as to why this antidepressant was not effective in this population. Clearly, this group differs somehow from subjects enrolled in traditional depression trials; notably, their depression was diagnosed after the onset of CHF, suggesting the depression was a reaction to their illness.

Not the first time. This is the second large trial to find no benefit to using a selective serotonin reuptake inhibitor (SSRI) to treat depression in patients with CHF; the previous trial to do so looked at sertraline.² In fact, when it comes to patients with chronic diseases, such as diabetes and coronary artery disease, there is scant evidence to support the common belief that screening them for depression and treating them with SSRIs improves patient outcomes.³ On the other hand, there are no definitive clinical trials investigating other antidepressants in the treatment of depressed patients with chronic illness, so it is possible that other drugs could be effective. There is evidence, however, from a recent RCT that cognitive behavioral therapy—compared with usual care—improves depression, anxiety, fatigue, and social functioning in patients with CHF.⁴

Where does that leave us? In our practice, we annually screen all adults, including those with chronic illness, for depression with the 2-question Patient Health Questionnaire. As a matter of course, we should acknowledge and explore all patients’ depressed mood, offer emotional support, and refer for psychotherapy when appropriate. And since collaborative care has been shown to improve outcomes in patients with depression and, for that matter, diabetes (see this month’s audiocast), consider this model of care if it is available.⁵

One can only speculate as to why this antidepressant was not effective in this population.

I believe it’s worthwhile to discuss the use of antidepressants with patients who have CHF. It’s reasonable to be optimistic with them and to expect that their depression will improve with time, as noted in the placebo groups of the randomized trials mentioned above.^1,2 And giving patients hope is always good medicine.

It makes sense to think that treating patients who have congestive heart failure (CHF) and depression with an antidepressant would be effective. But common sense is not always supported by empiric observation or evidence.

In this month’s PURL, the authors summarize the MOOD-HF study,¹ a randomized controlled trial (RCT) of escitalopram for the treatment of patients with CHF and depression. After 2 years, no outcomes—including depression scores—were better in the treatment vs the placebo group. One can only speculate as to why this antidepressant was not effective in this population. Clearly, this group differs somehow from subjects enrolled in traditional depression trials; notably, their depression was diagnosed after the onset of CHF, suggesting the depression was a reaction to their illness.

Not the first time. This is the second large trial to find no benefit to using a selective serotonin reuptake inhibitor (SSRI) to treat depression in patients with CHF; the previous trial to do so looked at sertraline.² In fact, when it comes to patients with chronic diseases, such as diabetes and coronary artery disease, there is scant evidence to support the common belief that screening them for depression and treating them with SSRIs improves patient outcomes.³ On the other hand, there are no definitive clinical trials investigating other antidepressants in the treatment of depressed patients with chronic illness, so it is possible that other drugs could be effective. There is evidence, however, from a recent RCT that cognitive behavioral therapy—compared with usual care—improves depression, anxiety, fatigue, and social functioning in patients with CHF.⁴

Where does that leave us? In our practice, we annually screen all adults, including those with chronic illness, for depression with the 2-question Patient Health Questionnaire. As a matter of course, we should acknowledge and explore all patients’ depressed mood, offer emotional support, and refer for psychotherapy when appropriate. And since collaborative care has been shown to improve outcomes in patients with depression and, for that matter, diabetes (see this month’s audiocast), consider this model of care if it is available.⁵

One can only speculate as to why this antidepressant was not effective in this population.

I believe it’s worthwhile to discuss the use of antidepressants with patients who have CHF. It’s reasonable to be optimistic with them and to expect that their depression will improve with time, as noted in the placebo groups of the randomized trials mentioned above.^1,2 And giving patients hope is always good medicine.

Although the concept of the living will was first proposed in 1969,¹ the idea caught on slowly. In fact, the first scholarly article discussing the topic didn’t appear until 16 years later.²

In contrast, an informal search of PubMed reveals that at least 38 articles on advance directives and end-of-life care have been published during the first 7 months of 2017. And a feature article in this month’s issue of JFP makes one more. Why is there such strong interest now in an issue that seldom arose when I began practice in 1978?

More complex, less personalized medicine. As medical care has become more sophisticated, there is a great deal more we can do to keep people alive as they approach the end of life, and a great many more decisions to be made.

Now, most dying hospitalized patients are cared for by hospitalists who may be meeting the patient for the first time.

Additionally, people are much less likely today to be cared for in their dying days by a family physician who knows them, their wishes, and their family well. In my early years in small-town practice, I was present when my patients were dying, and I usually knew their family members. Family meetings were easy to arrange, and we quickly came to a consensus about what to do and what not to do. If I was not available, one of my practice partners was. We cared for our patients in the office, nursing home, and hospital. Now, most dying hospitalized patients are cared for by hospitalists who may be meeting the patient for the first time.

Getting more people to participate. Consequently, it is important to understand patients’ wishes for end-of-life care and to document those wishes in writing, using things like a POLST (Physician Orders for Life-Sustaining Treatment) form. Although randomized trials support the value of advance care planning, especially in primary care settings,^3,4 two-thirds of Americans have not completed an advance directive.⁵ Rolnick suggests we “delegalize” the process to remove barriers and make it easier for people to execute such documents and integrate them into health care systems.⁶

Make it part of your office routine. A 70-year-old patient of mine with advanced COPD arrived at his office visit last month with advance directive and POLST forms in hand. We had an excellent, frank conversation, spiced with humor that he supplied, about his wishes for end-of-life care. Just like so many other tasks that we must squeeze into our busy schedules, this is one that we should hard-wire into our office systems and routines.

Although the concept of the living will was first proposed in 1969,¹ the idea caught on slowly. In fact, the first scholarly article discussing the topic didn’t appear until 16 years later.²

In contrast, an informal search of PubMed reveals that at least 38 articles on advance directives and end-of-life care have been published during the first 7 months of 2017. And a feature article in this month’s issue of JFP makes one more. Why is there such strong interest now in an issue that seldom arose when I began practice in 1978?

More complex, less personalized medicine. As medical care has become more sophisticated, there is a great deal more we can do to keep people alive as they approach the end of life, and a great many more decisions to be made.

Now, most dying hospitalized patients are cared for by hospitalists who may be meeting the patient for the first time.

Additionally, people are much less likely today to be cared for in their dying days by a family physician who knows them, their wishes, and their family well. In my early years in small-town practice, I was present when my patients were dying, and I usually knew their family members. Family meetings were easy to arrange, and we quickly came to a consensus about what to do and what not to do. If I was not available, one of my practice partners was. We cared for our patients in the office, nursing home, and hospital. Now, most dying hospitalized patients are cared for by hospitalists who may be meeting the patient for the first time.

Getting more people to participate. Consequently, it is important to understand patients’ wishes for end-of-life care and to document those wishes in writing, using things like a POLST (Physician Orders for Life-Sustaining Treatment) form. Although randomized trials support the value of advance care planning, especially in primary care settings,^3,4 two-thirds of Americans have not completed an advance directive.⁵ Rolnick suggests we “delegalize” the process to remove barriers and make it easier for people to execute such documents and integrate them into health care systems.⁶

Make it part of your office routine. A 70-year-old patient of mine with advanced COPD arrived at his office visit last month with advance directive and POLST forms in hand. We had an excellent, frank conversation, spiced with humor that he supplied, about his wishes for end-of-life care. Just like so many other tasks that we must squeeze into our busy schedules, this is one that we should hard-wire into our office systems and routines.

Although the concept of the living will was first proposed in 1969,¹ the idea caught on slowly. In fact, the first scholarly article discussing the topic didn’t appear until 16 years later.²

In contrast, an informal search of PubMed reveals that at least 38 articles on advance directives and end-of-life care have been published during the first 7 months of 2017. And a feature article in this month’s issue of JFP makes one more. Why is there such strong interest now in an issue that seldom arose when I began practice in 1978?

More complex, less personalized medicine. As medical care has become more sophisticated, there is a great deal more we can do to keep people alive as they approach the end of life, and a great many more decisions to be made.

Now, most dying hospitalized patients are cared for by hospitalists who may be meeting the patient for the first time.

Additionally, people are much less likely today to be cared for in their dying days by a family physician who knows them, their wishes, and their family well. In my early years in small-town practice, I was present when my patients were dying, and I usually knew their family members. Family meetings were easy to arrange, and we quickly came to a consensus about what to do and what not to do. If I was not available, one of my practice partners was. We cared for our patients in the office, nursing home, and hospital. Now, most dying hospitalized patients are cared for by hospitalists who may be meeting the patient for the first time.

Getting more people to participate. Consequently, it is important to understand patients’ wishes for end-of-life care and to document those wishes in writing, using things like a POLST (Physician Orders for Life-Sustaining Treatment) form. Although randomized trials support the value of advance care planning, especially in primary care settings,^3,4 two-thirds of Americans have not completed an advance directive.⁵ Rolnick suggests we “delegalize” the process to remove barriers and make it easier for people to execute such documents and integrate them into health care systems.⁶

Make it part of your office routine. A 70-year-old patient of mine with advanced COPD arrived at his office visit last month with advance directive and POLST forms in hand. We had an excellent, frank conversation, spiced with humor that he supplied, about his wishes for end-of-life care. Just like so many other tasks that we must squeeze into our busy schedules, this is one that we should hard-wire into our office systems and routines.

Drugs are valuable when they effectively relieve symptoms or prevent illness, but we all know they are double-edged swords when it comes to cost, adverse effects, and drug interactions. This “downside” is not lost on older Americans—especially when you consider that more than a third of Americans, ages 62 to 85 years, take 5 or more prescription medications daily.¹

Too often patients take prescription drugs that they either don’t need or that are harming them. That’s where deprescribing comes in. As this month’s feature article by McGrath and colleagues explains, deprescribing is the process of reducing or stopping unnecessary prescription medications.

The power of deprescribing. About a decade ago, a geriatrician/family physician friend of mine took over as medical director of a 160-bed nursing home. He lamented that the average number of prescription medications taken by the patients in the nursing home was 9.5. He and his team went to work deprescribing, and one year later, the average number of prescription medications per patient was 5.3. As far as he and the nursing staff could tell, the patients were doing just fine and were more alert and functional.

With a blood pressure consistently around 105/50 mm Hg, it was an easy decision to stop one of the patient’s 3 antihypertensive medications.

Another specialist, another Rx. In clinic, I saw a 54-year-old woman with the chief complaint of chronic, dry cough for which she had been on a specialist pilgrimage. A GI specialist prescribed omeprazole, an ENT physician prescribed fluticasone nasal spray and cetirizine, and a pulmonologist added an inhaled corticosteroid to the mix. (I’m not making this up!) I reviewed her medication list carefully and noted she had been placed on amitriptyline for insomnia shortly before the cough began. I was suspicious because the properties of anticholinergics can contribute to a cough. At my suggestion, she agreed to stop the amitriptyline (and endure some sleeplessness). Two weeks later, she returned with no cough. Over the next month, she stopped all 4 other medications, and the cough did not return.

Today in the office, a 64-year-old man complained of lightheadedness and fatigue and told me his blood pressure on home monitoring was consistently around 105/50 mm Hg. In addition to taking 3 antihypertensive medications, I discovered he had been prescribed doxazosin—an alpha blocker, which also lowers blood pressure—for symptoms of benign prostatic hypertrophy. It was an easy decision to stop one of his 3 antihypertensive medications.

I’m certain that you, too, have stories of successful deprescribing. Let’s remain alert to the problem of polypharmacy, keep meticulous medication lists, and deprescribe whenever it makes good sense. Doing so is essential to our roles as family physicians.

Drugs are valuable when they effectively relieve symptoms or prevent illness, but we all know they are double-edged swords when it comes to cost, adverse effects, and drug interactions. This “downside” is not lost on older Americans—especially when you consider that more than a third of Americans, ages 62 to 85 years, take 5 or more prescription medications daily.¹

Too often patients take prescription drugs that they either don’t need or that are harming them. That’s where deprescribing comes in. As this month’s feature article by McGrath and colleagues explains, deprescribing is the process of reducing or stopping unnecessary prescription medications.

The power of deprescribing. About a decade ago, a geriatrician/family physician friend of mine took over as medical director of a 160-bed nursing home. He lamented that the average number of prescription medications taken by the patients in the nursing home was 9.5. He and his team went to work deprescribing, and one year later, the average number of prescription medications per patient was 5.3. As far as he and the nursing staff could tell, the patients were doing just fine and were more alert and functional.

With a blood pressure consistently around 105/50 mm Hg, it was an easy decision to stop one of the patient’s 3 antihypertensive medications.

Another specialist, another Rx. In clinic, I saw a 54-year-old woman with the chief complaint of chronic, dry cough for which she had been on a specialist pilgrimage. A GI specialist prescribed omeprazole, an ENT physician prescribed fluticasone nasal spray and cetirizine, and a pulmonologist added an inhaled corticosteroid to the mix. (I’m not making this up!) I reviewed her medication list carefully and noted she had been placed on amitriptyline for insomnia shortly before the cough began. I was suspicious because the properties of anticholinergics can contribute to a cough. At my suggestion, she agreed to stop the amitriptyline (and endure some sleeplessness). Two weeks later, she returned with no cough. Over the next month, she stopped all 4 other medications, and the cough did not return.

Today in the office, a 64-year-old man complained of lightheadedness and fatigue and told me his blood pressure on home monitoring was consistently around 105/50 mm Hg. In addition to taking 3 antihypertensive medications, I discovered he had been prescribed doxazosin—an alpha blocker, which also lowers blood pressure—for symptoms of benign prostatic hypertrophy. It was an easy decision to stop one of his 3 antihypertensive medications.

I’m certain that you, too, have stories of successful deprescribing. Let’s remain alert to the problem of polypharmacy, keep meticulous medication lists, and deprescribe whenever it makes good sense. Doing so is essential to our roles as family physicians.

Drugs are valuable when they effectively relieve symptoms or prevent illness, but we all know they are double-edged swords when it comes to cost, adverse effects, and drug interactions. This “downside” is not lost on older Americans—especially when you consider that more than a third of Americans, ages 62 to 85 years, take 5 or more prescription medications daily.¹

Too often patients take prescription drugs that they either don’t need or that are harming them. That’s where deprescribing comes in. As this month’s feature article by McGrath and colleagues explains, deprescribing is the process of reducing or stopping unnecessary prescription medications.

The power of deprescribing. About a decade ago, a geriatrician/family physician friend of mine took over as medical director of a 160-bed nursing home. He lamented that the average number of prescription medications taken by the patients in the nursing home was 9.5. He and his team went to work deprescribing, and one year later, the average number of prescription medications per patient was 5.3. As far as he and the nursing staff could tell, the patients were doing just fine and were more alert and functional.

With a blood pressure consistently around 105/50 mm Hg, it was an easy decision to stop one of the patient’s 3 antihypertensive medications.

Another specialist, another Rx. In clinic, I saw a 54-year-old woman with the chief complaint of chronic, dry cough for which she had been on a specialist pilgrimage. A GI specialist prescribed omeprazole, an ENT physician prescribed fluticasone nasal spray and cetirizine, and a pulmonologist added an inhaled corticosteroid to the mix. (I’m not making this up!) I reviewed her medication list carefully and noted she had been placed on amitriptyline for insomnia shortly before the cough began. I was suspicious because the properties of anticholinergics can contribute to a cough. At my suggestion, she agreed to stop the amitriptyline (and endure some sleeplessness). Two weeks later, she returned with no cough. Over the next month, she stopped all 4 other medications, and the cough did not return.

Today in the office, a 64-year-old man complained of lightheadedness and fatigue and told me his blood pressure on home monitoring was consistently around 105/50 mm Hg. In addition to taking 3 antihypertensive medications, I discovered he had been prescribed doxazosin—an alpha blocker, which also lowers blood pressure—for symptoms of benign prostatic hypertrophy. It was an easy decision to stop one of his 3 antihypertensive medications.

I’m certain that you, too, have stories of successful deprescribing. Let’s remain alert to the problem of polypharmacy, keep meticulous medication lists, and deprescribe whenever it makes good sense. Doing so is essential to our roles as family physicians.

The Affordable Care Act (aka Obamacare) may soon be out and the American Health Care Act (AHCA) may soon be in. Despite all of the rhetoric about making health care affordable by reducing insurance premiums, one thing has been conspicuously absent from the debate: how we are going to reduce the actual cost of health care. Yes, the AHCA may help reduce premiums, but what is most likely to result is not less expensive health care, but rather people paying less money on premiums and more out of their pockets for medicines and treatments. Especially troublesome is that older and sicker patients will be hit the hardest.

The American conundrum. Why do Americans pay twice what citizens of most other developed nations pay and get health care outcomes that are worse?^1,2 Two reasons are that those who provide health care charge more in this country for services and medications, and physicians do a lot more testing and treatment here than their counterparts abroad.

If we control the cost of providing care, insurance premiums will follow suit.

One expert estimated that up to $700 billion could be saved by eliminating testing and treatments that provide marginal or no value to patients.³ For example, knee arthroscopy for moderate knee osteoarthritis produces no better outcomes than medical management.⁴ And many medications are much more expensive in the United States than in other countries. It seems that pharmaceutical companies are permitted greater profits here than elsewhere in the world, and these profits are at the expense of sick people and taxpayers.

How do we bend the cost curve downward? This is a tough question with no single correct answer, but we can all help. Some health care organizations have already reduced costs significantly without sacrificing quality by using team-based primary care as their foundation. Two examples are Nuka Health and Iora Health.^5,6

As primary care physicians, we are in an ideal position to constrain unnecessary testing and treatments by establishing trusting relationships with patients, who will believe us when we tell them they don’t need an antibiotic for their chest cold or an MRI for their back pain.

If we control the cost of providing care, insurance premiums will follow suit.

The Affordable Care Act (aka Obamacare) may soon be out and the American Health Care Act (AHCA) may soon be in. Despite all of the rhetoric about making health care affordable by reducing insurance premiums, one thing has been conspicuously absent from the debate: how we are going to reduce the actual cost of health care. Yes, the AHCA may help reduce premiums, but what is most likely to result is not less expensive health care, but rather people paying less money on premiums and more out of their pockets for medicines and treatments. Especially troublesome is that older and sicker patients will be hit the hardest.

The American conundrum. Why do Americans pay twice what citizens of most other developed nations pay and get health care outcomes that are worse?^1,2 Two reasons are that those who provide health care charge more in this country for services and medications, and physicians do a lot more testing and treatment here than their counterparts abroad.

If we control the cost of providing care, insurance premiums will follow suit.

One expert estimated that up to $700 billion could be saved by eliminating testing and treatments that provide marginal or no value to patients.³ For example, knee arthroscopy for moderate knee osteoarthritis produces no better outcomes than medical management.⁴ And many medications are much more expensive in the United States than in other countries. It seems that pharmaceutical companies are permitted greater profits here than elsewhere in the world, and these profits are at the expense of sick people and taxpayers.

How do we bend the cost curve downward? This is a tough question with no single correct answer, but we can all help. Some health care organizations have already reduced costs significantly without sacrificing quality by using team-based primary care as their foundation. Two examples are Nuka Health and Iora Health.^5,6

As primary care physicians, we are in an ideal position to constrain unnecessary testing and treatments by establishing trusting relationships with patients, who will believe us when we tell them they don’t need an antibiotic for their chest cold or an MRI for their back pain.

If we control the cost of providing care, insurance premiums will follow suit.

The Affordable Care Act (aka Obamacare) may soon be out and the American Health Care Act (AHCA) may soon be in. Despite all of the rhetoric about making health care affordable by reducing insurance premiums, one thing has been conspicuously absent from the debate: how we are going to reduce the actual cost of health care. Yes, the AHCA may help reduce premiums, but what is most likely to result is not less expensive health care, but rather people paying less money on premiums and more out of their pockets for medicines and treatments. Especially troublesome is that older and sicker patients will be hit the hardest.

The American conundrum. Why do Americans pay twice what citizens of most other developed nations pay and get health care outcomes that are worse?^1,2 Two reasons are that those who provide health care charge more in this country for services and medications, and physicians do a lot more testing and treatment here than their counterparts abroad.

If we control the cost of providing care, insurance premiums will follow suit.

One expert estimated that up to $700 billion could be saved by eliminating testing and treatments that provide marginal or no value to patients.³ For example, knee arthroscopy for moderate knee osteoarthritis produces no better outcomes than medical management.⁴ And many medications are much more expensive in the United States than in other countries. It seems that pharmaceutical companies are permitted greater profits here than elsewhere in the world, and these profits are at the expense of sick people and taxpayers.

How do we bend the cost curve downward? This is a tough question with no single correct answer, but we can all help. Some health care organizations have already reduced costs significantly without sacrificing quality by using team-based primary care as their foundation. Two examples are Nuka Health and Iora Health.^5,6

As primary care physicians, we are in an ideal position to constrain unnecessary testing and treatments by establishing trusting relationships with patients, who will believe us when we tell them they don’t need an antibiotic for their chest cold or an MRI for their back pain.

If we control the cost of providing care, insurance premiums will follow suit.

In this issue of JFP, Skolnik et al discuss ways we can assist patients with type 2 diabetes mellitus (T2DM) in lowering their cardiovascular (CV) risk. It is well established that the main predictors of the development of CV disease in patients with T2DM are blood pressure (BP) and lipid levels. Many randomized controlled trials (RCTs) have demonstrated the benefit of lowering BP and lipid levels on reducing CV disease in these patients.

The problem has been that other than a modest CV benefit from metformin, no glucose-lowering drug has been shown to have a significant effect on CV outcomes—until recently. Now there is solid evidence from RCTs that treatment with one of 3 newer agents—empagliflozin (a sodium-glucose cotransporter [SGLT]-2 inhibitor), liraglutide, and semaglutide (both glucagon-like peptide [GLP]-1 receptor agonists)—is associated with reductions in CV morbidity and mortality for patients with T2DM who have established, or are at high risk for, CV disease. (Of note: Semaglutide is not yet on the market. Its manufacturer submitted a New Drug Application late last year.)

For patients with T2DM who have established or are at high risk for CV disease, prescribing these drugs makes good sense.

For empagliflozin, an RCT involving more than 7000 patients calculated that the number needed to treat (NNT) over a 3-year period to prevent one CV event was 63 and the NNT to prevent one death from any cause was 38.¹ For liraglutide, a double-blind trial involving over 9000 patients reported the NNT to prevent one CV event in 3 years was 53, and the NNT to prevent one death from any cause was 71.² The RCT for semaglutide involved more than 3000 patients and reported the NNT to prevent one major CVD event was 43, but there was no significant difference in CV mortality between the semaglutide and placebo groups in that clinical trial.³

The jury is still out as to whether all patients with T2DM should be treated with one of these drugs. Caveats include that for each agent, there is only one RCT on the subject, and all 3 studies were sponsored by the agents’ manufacturers. Another caveat is the high cost for at least 2 of these agents. On the other hand, all 3 studies are well executed clinical trials that probably qualify as level I (high quality) evidence, according to SORT criteria.⁴ For patients with T2DM who have established or are at high risk for CV disease, prescribing these drugs makes good sense.

In this issue of JFP, Skolnik et al discuss ways we can assist patients with type 2 diabetes mellitus (T2DM) in lowering their cardiovascular (CV) risk. It is well established that the main predictors of the development of CV disease in patients with T2DM are blood pressure (BP) and lipid levels. Many randomized controlled trials (RCTs) have demonstrated the benefit of lowering BP and lipid levels on reducing CV disease in these patients.

The problem has been that other than a modest CV benefit from metformin, no glucose-lowering drug has been shown to have a significant effect on CV outcomes—until recently. Now there is solid evidence from RCTs that treatment with one of 3 newer agents—empagliflozin (a sodium-glucose cotransporter [SGLT]-2 inhibitor), liraglutide, and semaglutide (both glucagon-like peptide [GLP]-1 receptor agonists)—is associated with reductions in CV morbidity and mortality for patients with T2DM who have established, or are at high risk for, CV disease. (Of note: Semaglutide is not yet on the market. Its manufacturer submitted a New Drug Application late last year.)

For patients with T2DM who have established or are at high risk for CV disease, prescribing these drugs makes good sense.

For empagliflozin, an RCT involving more than 7000 patients calculated that the number needed to treat (NNT) over a 3-year period to prevent one CV event was 63 and the NNT to prevent one death from any cause was 38.¹ For liraglutide, a double-blind trial involving over 9000 patients reported the NNT to prevent one CV event in 3 years was 53, and the NNT to prevent one death from any cause was 71.² The RCT for semaglutide involved more than 3000 patients and reported the NNT to prevent one major CVD event was 43, but there was no significant difference in CV mortality between the semaglutide and placebo groups in that clinical trial.³

The jury is still out as to whether all patients with T2DM should be treated with one of these drugs. Caveats include that for each agent, there is only one RCT on the subject, and all 3 studies were sponsored by the agents’ manufacturers. Another caveat is the high cost for at least 2 of these agents. On the other hand, all 3 studies are well executed clinical trials that probably qualify as level I (high quality) evidence, according to SORT criteria.⁴ For patients with T2DM who have established or are at high risk for CV disease, prescribing these drugs makes good sense.

In this issue of JFP, Skolnik et al discuss ways we can assist patients with type 2 diabetes mellitus (T2DM) in lowering their cardiovascular (CV) risk. It is well established that the main predictors of the development of CV disease in patients with T2DM are blood pressure (BP) and lipid levels. Many randomized controlled trials (RCTs) have demonstrated the benefit of lowering BP and lipid levels on reducing CV disease in these patients.

The problem has been that other than a modest CV benefit from metformin, no glucose-lowering drug has been shown to have a significant effect on CV outcomes—until recently. Now there is solid evidence from RCTs that treatment with one of 3 newer agents—empagliflozin (a sodium-glucose cotransporter [SGLT]-2 inhibitor), liraglutide, and semaglutide (both glucagon-like peptide [GLP]-1 receptor agonists)—is associated with reductions in CV morbidity and mortality for patients with T2DM who have established, or are at high risk for, CV disease. (Of note: Semaglutide is not yet on the market. Its manufacturer submitted a New Drug Application late last year.)

For patients with T2DM who have established or are at high risk for CV disease, prescribing these drugs makes good sense.

For empagliflozin, an RCT involving more than 7000 patients calculated that the number needed to treat (NNT) over a 3-year period to prevent one CV event was 63 and the NNT to prevent one death from any cause was 38.¹ For liraglutide, a double-blind trial involving over 9000 patients reported the NNT to prevent one CV event in 3 years was 53, and the NNT to prevent one death from any cause was 71.² The RCT for semaglutide involved more than 3000 patients and reported the NNT to prevent one major CVD event was 43, but there was no significant difference in CV mortality between the semaglutide and placebo groups in that clinical trial.³

The jury is still out as to whether all patients with T2DM should be treated with one of these drugs. Caveats include that for each agent, there is only one RCT on the subject, and all 3 studies were sponsored by the agents’ manufacturers. Another caveat is the high cost for at least 2 of these agents. On the other hand, all 3 studies are well executed clinical trials that probably qualify as level I (high quality) evidence, according to SORT criteria.⁴ For patients with T2DM who have established or are at high risk for CV disease, prescribing these drugs makes good sense.

In this month’s issue of The Journal of Family Practice, we are pleased to launch a new department called “Behavioral Health Consult.” This bimonthly column will feature behavioral and mental health topics such as depression, anxiety, obesity, and substance abuse.

Drawn from real patient encounters. As you read the inaugural item on depression, written by Michael Maksimowski, MD, and Michael Raddock, MD, you'll notice that the article starts with a brief case report. Cases will play an important role in this column and will either describe a single patient whom the author(s) cared for or be an amalgam of several (as was the case this month).

Practical and to the point. We have asked the authors, who are family physicians (FPs) and psychiatrists or psychologists who work closely with FPs, to provide a concentrated and practical summary of the elements of diagnosis and treatment that are most important and pertinent to primary care clinicians.

The column will address topics like depression and substance abuse.

Addressing an overwhelming need. The need for FPs and other primary care clinicians to stay current on the management of mental and behavioral health issues is obvious. Mood and anxiety disorders (eg, depression, anxiety, panic disorder, agoraphobia) affect almost 30% of the US adult population¹ and many of these patients are seen at least initially by their primary care physicians. According to the Centers for Disease Control and Prevention, 4 health risk behaviors—tobacco use, poor nutrition, excess alcohol consumption, and insufficient exercise—cause much of the illness, suffering, and early death related to chronic diseases and conditions.² My personal experience in our urban Chicago clinic definitely supports these statistics.

No lack of research. I teach several evidence-based medicine courses each year that focus on the review of recent randomized trials and meta-analyses that are important for FPs to know about. Every year, one of my talks is about either mental health or behavioral health research. Every year I wonder whether there will be enough new research to report on, and every year, I find that there is an abundance of research that helps us to better manage these common problems. “Behavioral Health Consult” is this journal’s way of helping to keep you current and informed.

In an effort to make this addition as useful to you as possible, please feel free to email me at jfp.eic@gmail.com with suggestions for topics you would like to see in “Behavioral Health Consult.” We look forward to your reactions—and your comments.

In this month’s issue of The Journal of Family Practice, we are pleased to launch a new department called “Behavioral Health Consult.” This bimonthly column will feature behavioral and mental health topics such as depression, anxiety, obesity, and substance abuse.

Drawn from real patient encounters. As you read the inaugural item on depression, written by Michael Maksimowski, MD, and Michael Raddock, MD, you'll notice that the article starts with a brief case report. Cases will play an important role in this column and will either describe a single patient whom the author(s) cared for or be an amalgam of several (as was the case this month).

Practical and to the point. We have asked the authors, who are family physicians (FPs) and psychiatrists or psychologists who work closely with FPs, to provide a concentrated and practical summary of the elements of diagnosis and treatment that are most important and pertinent to primary care clinicians.

The column will address topics like depression and substance abuse.

Addressing an overwhelming need. The need for FPs and other primary care clinicians to stay current on the management of mental and behavioral health issues is obvious. Mood and anxiety disorders (eg, depression, anxiety, panic disorder, agoraphobia) affect almost 30% of the US adult population¹ and many of these patients are seen at least initially by their primary care physicians. According to the Centers for Disease Control and Prevention, 4 health risk behaviors—tobacco use, poor nutrition, excess alcohol consumption, and insufficient exercise—cause much of the illness, suffering, and early death related to chronic diseases and conditions.² My personal experience in our urban Chicago clinic definitely supports these statistics.

No lack of research. I teach several evidence-based medicine courses each year that focus on the review of recent randomized trials and meta-analyses that are important for FPs to know about. Every year, one of my talks is about either mental health or behavioral health research. Every year I wonder whether there will be enough new research to report on, and every year, I find that there is an abundance of research that helps us to better manage these common problems. “Behavioral Health Consult” is this journal’s way of helping to keep you current and informed.

In an effort to make this addition as useful to you as possible, please feel free to email me at jfp.eic@gmail.com with suggestions for topics you would like to see in “Behavioral Health Consult.” We look forward to your reactions—and your comments.

In this month’s issue of The Journal of Family Practice, we are pleased to launch a new department called “Behavioral Health Consult.” This bimonthly column will feature behavioral and mental health topics such as depression, anxiety, obesity, and substance abuse.

Drawn from real patient encounters. As you read the inaugural item on depression, written by Michael Maksimowski, MD, and Michael Raddock, MD, you'll notice that the article starts with a brief case report. Cases will play an important role in this column and will either describe a single patient whom the author(s) cared for or be an amalgam of several (as was the case this month).

Practical and to the point. We have asked the authors, who are family physicians (FPs) and psychiatrists or psychologists who work closely with FPs, to provide a concentrated and practical summary of the elements of diagnosis and treatment that are most important and pertinent to primary care clinicians.

The column will address topics like depression and substance abuse.

Addressing an overwhelming need. The need for FPs and other primary care clinicians to stay current on the management of mental and behavioral health issues is obvious. Mood and anxiety disorders (eg, depression, anxiety, panic disorder, agoraphobia) affect almost 30% of the US adult population¹ and many of these patients are seen at least initially by their primary care physicians. According to the Centers for Disease Control and Prevention, 4 health risk behaviors—tobacco use, poor nutrition, excess alcohol consumption, and insufficient exercise—cause much of the illness, suffering, and early death related to chronic diseases and conditions.² My personal experience in our urban Chicago clinic definitely supports these statistics.

No lack of research. I teach several evidence-based medicine courses each year that focus on the review of recent randomized trials and meta-analyses that are important for FPs to know about. Every year, one of my talks is about either mental health or behavioral health research. Every year I wonder whether there will be enough new research to report on, and every year, I find that there is an abundance of research that helps us to better manage these common problems. “Behavioral Health Consult” is this journal’s way of helping to keep you current and informed.

In an effort to make this addition as useful to you as possible, please feel free to email me at jfp.eic@gmail.com with suggestions for topics you would like to see in “Behavioral Health Consult.” We look forward to your reactions—and your comments.

You are probably one of the million+ physicians who received a letter from the Surgeon General urging us to use opioids judiciously,¹ and you are likely familiar with the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.² (See JFP’s “Opioids for chronic pain: The CDC’s 12 recommendations,” 2016;65:906-909.) Most of these recommendations are common-sense practices, such as reducing doses, using alternative medications and treatments, monitoring prescribing through state databases, conducting random drug tests, consulting pain and addiction specialists, and establishing clear treatment goals.

But the guidelines only go so far. They don’t address the empathy, perseverance, and insight needed to stick with these patients and oversee their care. And they don’t directly address the patients who are already taking opioids for chronic pain when they arrive at our offices. Despite nearly 40 years of practicing family medicine, I can count on one hand the number of patients for whom I initiated opioid medication. Yet I have managed many patients with chronic pain who were already on hefty doses of narcotics when they became my patients. Rather than refuse to care for them, we should seek to understand their story, continuously try other medications and therapies, repeatedly attempt to reduce dosages, and frequently check substance databases.

It's no wonder some of us just say "No" to caring for patients with chronic pain.Following the guidelines is no guarantee that our prescribing practices won’t be called into question. I have seen excellent family physicians censured by state licensing boards unjustifiably. One colleague was accused by a patient of “getting him addicted,” only after the physician refused to continue prescribing narcotics. Based on this single complaint, the physician had his license temporarily revoked with no due process whatsoever. He got his license back after an appeals process that took several months, cost many dollars, and inflicted significant emotional trauma. No wonder some of us just say “No” to caring for patients with chronic pain.

Perseverance and motivation. I remind myself that good, well-intentioned, and careful primary care physicians are NOT the cause of this epidemic. I encourage you to stick with these patients (lest they turn to the streets to obtain heroin laced with fen­tanyl), and look for sources of motivation. You may be motivated, as I was, by a physician’s story in JAMA about his 49-year-old younger sister, a vibrant, accomplished, caring woman whose chronic pain led to her death in a jail cell after she became combative in the ED.³ Had she been treated as a patient with a chronic illness, rather than a criminal with a character flaw, I suspect she would be alive today.

You are probably one of the million+ physicians who received a letter from the Surgeon General urging us to use opioids judiciously,¹ and you are likely familiar with the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.² (See JFP’s “Opioids for chronic pain: The CDC’s 12 recommendations,” 2016;65:906-909.) Most of these recommendations are common-sense practices, such as reducing doses, using alternative medications and treatments, monitoring prescribing through state databases, conducting random drug tests, consulting pain and addiction specialists, and establishing clear treatment goals.

But the guidelines only go so far. They don’t address the empathy, perseverance, and insight needed to stick with these patients and oversee their care. And they don’t directly address the patients who are already taking opioids for chronic pain when they arrive at our offices. Despite nearly 40 years of practicing family medicine, I can count on one hand the number of patients for whom I initiated opioid medication. Yet I have managed many patients with chronic pain who were already on hefty doses of narcotics when they became my patients. Rather than refuse to care for them, we should seek to understand their story, continuously try other medications and therapies, repeatedly attempt to reduce dosages, and frequently check substance databases.

It's no wonder some of us just say "No" to caring for patients with chronic pain.Following the guidelines is no guarantee that our prescribing practices won’t be called into question. I have seen excellent family physicians censured by state licensing boards unjustifiably. One colleague was accused by a patient of “getting him addicted,” only after the physician refused to continue prescribing narcotics. Based on this single complaint, the physician had his license temporarily revoked with no due process whatsoever. He got his license back after an appeals process that took several months, cost many dollars, and inflicted significant emotional trauma. No wonder some of us just say “No” to caring for patients with chronic pain.

Perseverance and motivation. I remind myself that good, well-intentioned, and careful primary care physicians are NOT the cause of this epidemic. I encourage you to stick with these patients (lest they turn to the streets to obtain heroin laced with fen­tanyl), and look for sources of motivation. You may be motivated, as I was, by a physician’s story in JAMA about his 49-year-old younger sister, a vibrant, accomplished, caring woman whose chronic pain led to her death in a jail cell after she became combative in the ED.³ Had she been treated as a patient with a chronic illness, rather than a criminal with a character flaw, I suspect she would be alive today.

You are probably one of the million+ physicians who received a letter from the Surgeon General urging us to use opioids judiciously,¹ and you are likely familiar with the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.² (See JFP’s “Opioids for chronic pain: The CDC’s 12 recommendations,” 2016;65:906-909.) Most of these recommendations are common-sense practices, such as reducing doses, using alternative medications and treatments, monitoring prescribing through state databases, conducting random drug tests, consulting pain and addiction specialists, and establishing clear treatment goals.

But the guidelines only go so far. They don’t address the empathy, perseverance, and insight needed to stick with these patients and oversee their care. And they don’t directly address the patients who are already taking opioids for chronic pain when they arrive at our offices. Despite nearly 40 years of practicing family medicine, I can count on one hand the number of patients for whom I initiated opioid medication. Yet I have managed many patients with chronic pain who were already on hefty doses of narcotics when they became my patients. Rather than refuse to care for them, we should seek to understand their story, continuously try other medications and therapies, repeatedly attempt to reduce dosages, and frequently check substance databases.

It's no wonder some of us just say "No" to caring for patients with chronic pain.Following the guidelines is no guarantee that our prescribing practices won’t be called into question. I have seen excellent family physicians censured by state licensing boards unjustifiably. One colleague was accused by a patient of “getting him addicted,” only after the physician refused to continue prescribing narcotics. Based on this single complaint, the physician had his license temporarily revoked with no due process whatsoever. He got his license back after an appeals process that took several months, cost many dollars, and inflicted significant emotional trauma. No wonder some of us just say “No” to caring for patients with chronic pain.

Perseverance and motivation. I remind myself that good, well-intentioned, and careful primary care physicians are NOT the cause of this epidemic. I encourage you to stick with these patients (lest they turn to the streets to obtain heroin laced with fen­tanyl), and look for sources of motivation. You may be motivated, as I was, by a physician’s story in JAMA about his 49-year-old younger sister, a vibrant, accomplished, caring woman whose chronic pain led to her death in a jail cell after she became combative in the ED.³ Had she been treated as a patient with a chronic illness, rather than a criminal with a character flaw, I suspect she would be alive today.