


Optimizing Migraine Care
The American Headache Society (AHS) recently joined the Choosing Wisely initiative of the American Board of Internal Medicine in an effort to draw attention to tests and procedures that are associated with low-value care in headache medicine. An AHS committee of headache specialists produced a list of five such tests and treatments, and their methods and rationale were published in Headache. “We wanted the list to address common but often unnecessary or potentially risky tests and treatments for headache that in many cases do not represent evidence-based strategies,” explains Elizabeth W. Loder, MD, MPH, FAHS, who was lead author of the study. Imaging According to the AHS, neuroimaging studies should not be performed in patients with stable headaches who meet criteria for migraine. In addition, CT scans should not be used in non-emergency situations as a diagnostic tool for headache patients when MRI is available. “MRIs can diagnose more underlying conditions that may cause headache that can otherwise be missed with CT,” says Dr. Loder. In addition, MRIs do not expose patients to radiation like CT scans. The recommendations note that MRI is of better value and safer than CT for migraineurs in all but a few emergency situations. Treatments The AHS also recommends against prescribing opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders. “The effectiveness of opioids is not in question,” Dr. Loder explains, “but these agents pose serious long-term risks and should be reserved for select patients. Effective long-term treatments will in most cases be necessary to manage this chronic disorder.” In addition, the risk of dependency and abuse associated with opioid...
“Doctor Shopping” After Orthopedic Trauma
Recent reports have shown that the negative consequences of narcotic use are increasing, and diversion of these drugs for non-medical use is growing, with Americans consuming about 80% of the global opioid supply and 99% of the global hydrocodone supply. There has been an alarming rise in unintentional overdose deaths in the United States over the past decade due largely from increases in prescriptions of narcotics. It has been estimated that up to 20% of prescription drug abusers receive their narcotics from one physician prescriber, but a growing percentage obtain these medications by seeking multiple providers, a phenomenon dubbed “doctor shopping.” Few studies, however, have looked at narcotic use in patients who have experienced orthopedic trauma. While some investigations have focused their attention on positive toxicology screenings at the time of admission after orthopedic trauma, there is limited research exploring the impact of postoperative doctor shopping and the role of orthopedic surgeons in this phenomenon. “It has been suspected that many orthopedic trauma patients may be at a higher risk for pre-injury narcotic use and doctor shopping,” says Hassan R. Mir, MD, MBA, FACS. Exploring the Problem Dr. Mir, Brent J. Morris, MD, and colleagues sought to identify the prevalence of patients who have had orthopedic traumas and were seeking multiple providers for narcotics after surgery in a study published in the Journal of Bone and Joint Surgery. For the analysis, the researchers reviewed prescription records for 151 adults who were admitted to an orthopedic unit over a 1-year period and assessed data on narcotic prescriptions obtained 3 months before and within 6 months after each orthopedic procedure. Patients...