Annals for Educators - 5 September 2017

Darren B. Taichman

doi:10.7326/AFED201709050

Clinical Practice Points

The Effects of Cannabis Among Adults With Chronic Pain and an Overview of General Harms. A Systematic Review

Benefits and Harms of Plant-Based Cannabis for Posttraumatic Stress Disorder. A Systematic Review

These systematic reviews examine available evidence about the benefits and harms of plant-based cannabis preparations for treating chronic pain and posttraumatic stress disorder in adults.

Use these reviews to:

Start a teaching session with a multiple-choice question. We've provided one below!
Ask your learners whether and for what purposes cannabis use is legal in your state. What are the laws?
What did these systematic reviews find with regard to the benefits and risks of use? Why do your learners think the evidence base is so weak in this area?
Do your learners ask their patients about cannabis use? Should they?
Have their patients asked them about it? If so, under what circumstances? How should your learners advise their patients? Do your learners agree with the often-heard reasoning among patients seeking help for a chronic and perhaps poorly treated condition that using cannabis “couldn't hurt”? Why or why not?
What more do we need to know? Use the accompanying editorial to help frame your discussion.

Prescription Opioid Use, Misuse, and Use Disorders in U.S. Adults: 2015 National Survey on Drug Use and Health

Despite the continuing epidemic of opioid misuse, data about the prevalence and correlates of misuse are scarce. This study used data from the National Survey on Drug Use and Health to estimate the prevalence of prescription opioid use, misuse, and use disorders among civilian, noninstitutionalized U.S. adults.

Use this study to:

Ask your learners to guess what percentage of U.S. adults used opioids in 2015. What percentage do they think misused them or had a use disorder?
How would your learners define misuse and use disorder?
Share the results of this national survey. Do the numbers surprise your learners? Do they think that a third of their patients have used opioids in the past year? Look at the reasons respondents gave for using opioids. Do your learners think about these reasons in their practice? Should they? Would asking patients about them be useful?
Teach at the bedside! Ask each of your team's patients whether they have used opioids for any reason in the past year. Where did they get them? Did you learn anything that might be helpful in the care of your patients, either during their hospitalization or in long-term follow-up?
The authors note that certain groups reported use more frequently. Do these groups surprise your learners? Where do the solutions lie? Use the accompanying editorial to help frame your discussion.

In the Clinic

In the Clinic: Influenza

Influenza affects persons of all ages and is associated with millions of medical visits, hundreds of thousands of hospitalizations, and thousands of deaths during annual winter epidemics of variable severity in the United States. Are your learners prepared?

Use this paper to:

Ask who should receive influenza vaccination. What vaccines are available, and how effective are they?
Which patients with acute febrile illness should and should not be vaccinated? What about patients with a reported egg allergy? Pregnant women?
How should your learners reply to a patient who declines vaccination and says, “The last time I got the flu shot, I got the flu”?
In whom should chemoprophylaxis with a neuraminidase inhibitor be considered? When should these agents be considered for treatment of influenza? How should these drugs be prescribed? What are the potential adverse effects? Use the information in Table 3.
When and how should a diagnosis of influenza be confirmed?
What complications of influenza should your learners be mindful of? Which patients should be hospitalized?
Use the multiple-choice questions to introduce topics during a teaching session. Be sure to log on and enter your responses to earn CME and MOC credit for yourself!
Download the teaching slides to help prepare a teaching session.

Humanism and Professionalism

Annals Graphic Medicine - Dear Doctor I

The artist depicts a patient's surprise at and appreciation of a physician's blush during an initial medical encounter.

Use this work to:

Have your learners read the graphic narrative. What is their reaction?
What about the physician's reaction made the patient feel at ease?
What might we learn about situations in which we feel a bit uncomfortable and about how our reactions influence the experience of our patients? Is it always necessary for a physician to seem imperturbable?

Our Profession: Maintenance of Certification

Effect of Access to an Electronic Medical Resource on Performance Characteristics of a Certification Examination. A Randomized Controlled Trial

Closed-book medical certification examinations have been criticized for not mimicking real-life practice, in which physicians frequently look up information to inform care. This randomized trial assessed whether allowing examinees to use an online medical information resource altered the test's ability to differentiate those who perform adequately from those who do not.

Use this study to:

Ask your learners if they know what they need to do in order to become and remain certified by the American Board of Internal Medicine.
Do your learners think high-stakes examinations should allow the use of external sources, as was tested in this study?
Why do your learners think maintenance of certification is controversial? What do they think should be required of physicians? Use the accompanying editorial to help frame your discussion.

Teaching Scholarship Opportunity for Chief Residents

Herbert S. Waxman Clinical Skills Center Teaching Scholarship

Chief residents who are members of ACP are eligible to apply for a Herbert S. Waxman Clinical Skills Center Teaching Scholarship. Waxman Scholars assist in teaching popular workshops under the guidance and mentorship of expert faculty at ACP's annual Internal Medicine Meeting. Workshops provide hands-on, small-group learning opportunities for clinical and procedural skills (e.g., central line placement, paracentesis, thoracentesis, and lumbar puncture). The scholarship includes the cost of meeting registration, travel, and accommodations for the ACP Internal Medicine Meeting 2018, to be held April 19–21 in New Orleans, Louisiana.

This is an opportunity to build your CV and gain valuable experience teaching a workshop.

The submission deadline for applications is September 29, 2017. Visit this page to complete your application.

MKSAP 17 Question

A 35-year-old man is evaluated for a 2-year history of nausea and vomiting. He describes the nausea as nearly constant. Vomiting, occasionally accompanied by diarrhea, occurs for 2 to 4 days once or twice a month before resolving spontaneously. The patient reports no problems with eating in between episodes of vomiting and no abdominal pain. He also has chronic pain syndrome related to injuries from a motor vehicle accident 3 years ago. He uses medical marijuana to control the pain. Over the last 2 years, he has increased marijuana use to address his nausea and stimulate his appetite. The vomiting is severe enough to interrupt marijuana use; he notes that the vomiting subsides when he stops marijuana use or takes hot showers. In addition to marijuana 4 to 5 times daily, he takes ondansetron as needed.

On physical examination, vital signs and other findings are normal.

Upper endoscopy is normal. Duodenal biopsies are negative for celiac disease. A gastric emptying study reveals 5% retention of food at 4 hours.

According to the Rome IV criteria, which of the following is the most likely diagnosis?

A. Cannabinoid hyperemesis syndrome

B. Cyclic vomiting syndrome

C. Gastroparesis

D. Narcotic bowel syndrome

Correct Answer

A. Cannabinoid hyperemesis syndrome

Educational Objective

Diagnose cannabinoid hyperemesis syndrome.

Critique

Cannabinoid hyperemesis syndrome is the most likely diagnosis in this patient. Cannabinoid hyperemesis syndrome is a new diagnosis in the Rome IV category of functional gastroduodenal disorders. It is defined by the presence of the following three clinical criteria: (1) episodic vomiting resembling cyclic vomiting syndrome in terms of onset, duration, and frequency; (2) presentation after prolonged, excessive cannabis use; (3) relief of vomiting episodes with sustained cessation of cannabis use. This young man's recurrent episodes of vomiting are typical of cyclic vomiting syndrome, with acute onset and short duration of vomiting. Although the characteristics of his vomiting fit a diagnosis of cyclic vomiting syndrome, his history reveals longstanding, excessive cannabis use and relief of vomiting with cessation of cannabis use. Therefore, the most likely diagnosis is cannabinoid hyperemesis syndrome. An effort should be made to discontinue marijuana use, but this recommendation is frequently met with resistance by patients. Tricyclic antidepressants are used in the treatment of cyclic vomiting syndrome, and similarly, a trial of a tricyclic antidepressant can be considered in patients with cannabinoid hyperemesis syndrome who are unwilling to discontinue marijuana use.

This patient's gastric emptying study shows retention of 5% of gastric contents at 4 hours, which is normal. Retention of 10% or more is required to make a diagnosis of gastroparesis.

Because the patient is not taking an opioid analgesic and does not report abdominal pain, the diagnosis of narcotic bowel syndrome can be excluded.

Key Point

Cannabinoid hyperemesis syndrome is defined by the presence of three clinical criteria: (1) episodic vomiting resembling cyclic vomiting syndrome in terms of onset, duration, and frequency; (2) presentation after prolonged, excessive cannabis use; (3) relief of vomiting episodes with sustained cessation of cannabis use.

Bibliography

Stanghellini V, Chan FK, Hasler WL, Malagelada JR, Suzuki H, Tack J, et al. Gastroduodenal Disorders. Gastroenterology. 2016;150:1380-92. doi:10.1053/j.gastro.2016.02.011

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Clinical Practice Points

The Effects of Cannabis Among Adults With Chronic Pain and an Overview of General Harms. A Systematic Review

Benefits and Harms of Plant-Based Cannabis for Posttraumatic Stress Disorder. A Systematic Review

Prescription Opioid Use, Misuse, and Use Disorders in U.S. Adults: 2015 National Survey on Drug Use and Health