Healthcare is in a state of flux. As extraordinary measures are taken to stem the spread of the coronavirus, regular medical care—from routine checkups and screenings to in-office treatments and procedures—has been subject to significant disruptions and challenges. Social distancing requirements of the 

 pandemic have created new limitations on in-person physician visits. 

Office closures and safety concerns have resulted in the delay or cancelation of medical appointments for some patients. Compounding matters is the dynamic and uncertain nature of the pandemic. The issues that patients and physicians are confronting today have evolved since the COVID-19 shutdowns began in March—and further change is undoubtedly on the horizon.

 patients and their eye care professionals, the pandemic has led to an array of stressors, given the progressive but indolent nature of a disease that can lead to blindness and requires close ongoing monitoring and treatment. The current health environment is particularly worrisome for elderly patients because they are most at risk for vision loss from glaucoma and are also among the highest risk groups for COVID-19 mortality.

To better understand the concerns and experiences of glaucoma patients during the pandemic, the Glaucoma Research Foundation (GRF) commissioned an online survey in May 2020. The aim was to gain valuable, real-time patient input that can help eye care professionals better address patients’ emotional needs as they adapt to the new, and continually changing, care requirements of COVID-19. 

The GRF survey, which was supported by Aerie Pharmaceuticals, assessed patients’ confidence in their disease management during the pandemic; specific disease management concerns; patients’ experience with telemedicine; and patients’ comfort in returning to eye professionals’ offices. The survey drew a national response, with 1051 adult glaucoma patients from 49 states participating in the questionnaire.

The survey findings bring to light several key considerations for ophthalmology practices evolving glaucoma care in the COVID-19 environment.

Notably, the survey found that more than half of respondents (53%) had to delay and/or cancel an eye care appointment during the first months of the pandemic. These disruptions seem to have significantly impacted patients’ confidence in their disease management, with approximately one-third (36%) of glaucoma patients surveyed saying they were not confident that their disease was well-managed. Those who had the lowest confidence levels in their glaucoma management were 30% more likely to have had an eye care appointment delayed or canceled.

This feedback highlights the central role of communication in enhancing glaucoma care and the importance of nurturing the physician-patient relationship during the pandemic. With physician offices open again, personal and direct doctor-patient communication is paramount to helping patients understand their unique level of risk and rebuild confidence in their disease management. 

Without scaring patients, it’s important that they understand the consequences of delaying an office visit and the real risk it may have for further, even permanent, vision loss.

At my practice in San Francisco, we went through every patient record that had an appointment during the early phase of the pandemic and conducted a risk assessment. We then communicated with each patient to make them aware of their particular situation and the risk of not coming in to be evaluated when our office reopened.

The first step was to speak with our staff about our responsibility to be safe, not just in the office, but also outside of work, with specifics about how to minimize risk. I sought their input and we developed together an action plan with new office protocols.

We also invested in an expansion of our office team. With this increased staff, we are able to directly answer more patient calls and engage in longer, in-depth conversations. In addition, we have placed a greeter at our main entrance who screens patients, which includes basic health questions, a temperature check, and a check for an appropriate mask. 

After completing these safety protocols, the greeter asks patients to use hand sanitizer prior to entering the clinic. These new measures have played a valuable role in boosting our patients’ confidence in their disease management during the pandemic.

The “COVID-19 Office” and Telemedicine

The survey also reveals that glaucoma patients place high value on being able to see their physician in person. Six in 10 (63%) respondents said they are comfortable returning to their eye doctors’ offices as long as social distancing measures, such as face masks and less crowded waiting rooms, are implemented. This preference for in-person physician visits, coupled with technology challenges, make patients largely uninterested in telemedicine. A vast majority (87%) of glaucoma patients surveyed said they would rather wait six weeks for an in-person office visit than have a telemedicine visit in two weeks.

While telemedicine has been a valuable tool in other medical specialties during the pandemic, it has significant limitations for standard diagnostic procedures in glaucoma care. Since intraocular pressure (IOP) checks, visual field evaluation, and other tests cannot be easily conducted virtually, practitioners may lose considerable clinical information by trying to manage glaucoma via telemedicine.

During these unprecedented times, the safety and well-being of patients is the principal concern of all eye care professionals. It is also important to consider the needs of your staff as well. At my center, we have modified several standard procedures that not only have enhanced patient safety during COVID-19 but have also made us operate more efficiently and safely as an eye care practice. 

I have found that when members of my office team feel safe at work, their calmness and confidence extend to the patient-provider relationship, helping patients feel more comfortable about the visit. By fostering a caring and professional approach to glaucoma care in the midst of uncertainty, we can all navigate the COVID-19 pandemic while continuing to protect the vision of our patients.

Andrew Iwach, MD, is Executive Director of the Glaucoma Center of San Francisco, Associate Clinical Professor of Ophthalmology at the University of California, San Francisco, and a faculty instructor at the California Pacific Medical Center Department of Ophthalmology. 

The article reflects the views of the author, not necessarily those of the publication.

A new survey assessed patients’ confidence in their disease management during the pandemic, specific disease management concerns, and experiences with telemedicine.

Managing Glaucoma During COVID-19: Patients Point the Way to Improved Care

Andrew Iwach, MD

On February 10, 2022, the US Centers for Disease Control and Prevention (CDC) 

 of their revised guideline for prescribing opioids for chronic pain. While the 

 is more than 200 pages, the most important part is the actual guideline itself, which is 12 statements that take the place of the 12 statements that comprised the 2016 version that this draft is intended to replace.

Because it is likely that the primary intended audience of clinicians will not read the full document but will focus on the 12 statements, it’s key to examine what has changed, what has not, and the potential impact of this new guideline on the lives of millions of patients with chronic pain whose lives have been 

The biggest change is the removal of specific dosage cautions and limits in statement 4 and 5 and specific days duration of opioid therapy for acute pain in statement 6.These dosage and duration limits were arbitrary and unsupported by clinical evidence yet widely implemented across the country and even codified in law in at least 33 states. Prescribers, insurers, and even pharmacies, implemented them as strict limits. They have caused the most egregious harms over the past six years including forced tapering, hundreds of documented suicides, sudden loss of access to medication triggering withdrawal, dismissal from physician practices, inability to find medical care, and loss of function and quality of life.

In an acknowledgement of these harms to patients with chronic pain from abrupt discontinuation of opioid therapy, statement 5 now includes repeated cautions to “exercise care”, “gradually taper” and “not discontinue abruptly or rapidly” when reducing dosage.

The other less significant changes in the guideline itself are slightly easing the directives on patient surveillance and softening the absolute restriction on concurrent prescribing of benzodiazepines. Statement 9 changed checking the prescription drug monitoring program (PDMP) “ranging from every prescription to every 3 months” to when starting opioid therapy and periodically thereafter.Statement 10 changed the recommendation to use urine drug testing when starting opioid therapy and annually to “consider toxicology testing”.Statement 11 changed “avoid” concurrent prescribing of benzodiazepines and opioids to “use extreme caution” if doing so.

What has not changed in the revised guideline is the lack of balance in the discussion of whether to initiate, continue or discontinue opioid therapy.As in the 2016 version there is a focus on the risks and harms of opioids without any mention of the benefits of opioids for pain control when medically supervised or the risks and harms of inadequately managed pain, especially when other therapies have proven inadequate or contraindicated.

With their focus on patient surveillance through regularly checking the PDMP and using toxicology, the risk the guideline is most concerned about is the risk of addiction.Yet, repeated research has shown the risk of addiction in medically supervised pain patients on opioid therapy to be very small – between less than 1% to 8%. Stated another way, between 99% and 92% of chronic pain patients on opioid therapy do not become addicted to their medication.

However, millions of patients on stable doses of their medication have been forced to taper off their medication since 2016 due in large part to the widespread adoption of the CDC Guideline and the consequent fear of scrutiny and loss of licensure they have created in the minds of U.S. physicians. In 2015, the National Institutes of Health (NIH) reported that there were between 5 and 8 million Americans on opioid therapy for chronic pain.

Further, what has also not changed is the weak body of evidence most of the 12 statements are based on, as in the 2016 version.Using the Group Reading Assessment and Diagnostic Evaluation (GRADE) system which rates the strength of the evidence underlying each guideline statement, 7 out of 12 statements have a rating of 4 on a 1 – 4 scale, where 4 is the weakest level of evidence considered “very weak”. Three additional statements have an evidence rating of 3 or “weak”. Yet, 4 out of the 7 statements with very weak evidence were given the strongest “A” level recommendation rating by the CDC Guideline authors. That is, simply put, intellectual dishonesty.

This revised guideline again excludes certain pain conditions (cancer, sickle cell disease, palliative care, and end-of-life care) as more worthy of pain control where the stated risks and harms don’t apply. Pain is pain, and chronic pain is fundamentally a disease of the nervous system and brain regardless of the etiology. Due to great variation in individual differences regarding disease progression, severity of condition, sensitivity to pain, metabolic variables and more, benefits and risks must be considered on an individual basis. A person with any given pain condition could be in much worse pain for longer duration than a person with one of the excluded conditions.

Will the Revised Guideline Change Practice?

I think it’s unlikely that there will be a renewed willingness on the part of physicians to prescribe opioids again to chronic pain patients who were removed from opioid treatment against their will. According to a report from the US Department of Health and Human Services (HSS) to Congress in April 2020, at least 33 states have adopted statutory limits on opioid analgesic prescriptions. It’s doubtful that any of these codified restrictions will be repealed anytime soon. Once laws are on the books it’s very hard to change them. And, as long as the intense scrutiny of opioid prescribing continues as a result of these laws, regulations and US Drug Enforcement Administration (DEA) investigations of prescribers, I don’t anticipate that access will improve for chronic pain sufferers.

Of course, nothing will bring back all the pain sufferers who committed suicide as a result of being forced off their medication. And nothing can give back all the years lost to relentless pain and suffering of the innocent people living with debilitating chronic pain who were forced off their medication since 2016.

What is more likely to improve in the short term is payer coverage of non-opioid restorative, behavioral and complementary treatments, and medical devices for those with chronic pain, and perhaps with increased recognition of the harms caused by the guideline, a lessening of the punishing stigma associated with being a person in pain in the US. In the long term, I remain hopeful that the current trend of significant increases in public and private investments in neuroscience pain research will lead to novel therapeutics to more effectively treat chronic pain.

Listen to Cindy Steinberg discuss the implications of these changes in an 

interview featured on our DocTalk podcast.

Cindy Steinberg is the Director of Policy and Advocacy for the 

and Policy Council Chair for the Massachusetts Pain Initiative. She is a nationally prominent and articulate spokesperson for the needs of people living with pain and has won numerous awards for her pain policy accomplishments. In 2018, she was appointed by HHS Secretary Alex Azar to serve on the 

HHS Pain Management Best Practices Task Force 

and in 2019 she was invited to testify before the US Senate HELP Committee.

The Director of Policy and Advocacy for the US Pain Foundation addresses the important changes made to the updated draft of the CDC Clinical Practical Guideline for Prescribing Opioids 2022.

Assessing the Draft Revised CDC Clinical Practice Guideline for Prescribing Opioids 2022

Cindy Steinberg

 What’s really important—and we’re not here to give advice to the manufacturer of inclisiran—is the reputation a drug develops when it’s brought to the marketplace. It sticks. To Dean’s point, if you look at data published by Seth Baum and others, they found that the utilization of PCSK9 was somewhere about 0.3% of those who were eligible.

What happened was you had the insurance payers creating these incredible speed bumps. It didn’t really matter. The manufacturers of PCSK9 inhibitors cut their price in half. As Dean, Manesh, and Linda have said, the access to the PCSK9 inhibitors has certainly become easier. But the doctors just aren’t interested in prescribing. As far as they’re concerned, it’s a drug that’s very difficult for patients to access. It’s an “expensive” drug. I urge the manufacturer of inclisiran to think the process through, so that when this drug finally comes to market, it is accessible. 

Otherwise, you’re going to have the same issues that we face with PCSK9 inhibitors. Perhaps we need to inject some artificial intelligence into value-based care instead of what seems to be artificial insanity. We need to be able to count on really good algorithms to determine appropriate use for these compounds.

I still have heterozygotes being turned down for PCSK9 inhibitors. It’s insanity out there. What we really need is really good artificial intelligence, not artificial insanity, in terms of making sure these drugs are being used in the appropriate patient at the appropriate time.

 Norman, that was a wonderful take-home message. In fact, I’m going to start with Dean, Manesh, and Linda; you’ll be last. Give me a similar take-home message, something you think our audience needs to hear from you. Dean?

 In secondary prevention, the LDL [low-density lipoprotein] goal is less than 70 mg/dL and probably lower for all our patients. That’s going to require combination therapy, the best statin dose you can get them on, and then other drugs.

If the cost of the medicine is too expensive, then use ezetimibe. For primary prevention, family history, pay attention to risk-enhancing factors in the guidelines and calcium scoring. That’s how we can get these patients treated earlier, so we’re not in the situation where they’ve already had events and you’ve got to be that much more intensive with regard to their treatment.

 We’re at the age where we have an explosion of possible therapies for our patients, which is great. The take-home message for me is this isn’t about cardiology or specialty care; it’s about primary care. This is about getting the message and the care pattern and the access to the primary care. That’s how we’re going to affect the population health, by getting these therapies—statin, inclisiran if it comes on the market, PCSK9 as we’ve just heard—into the hands of our primary care doctors and getting them comfortable with having the conversation with patients to get the therapies to them.

 That’s a great comment. Linda, you have the last take-home.

I just want to reemphasize lifestyle. Diet is absolutely critical. You can have somebody who is not at goal and they’re eating a terrible diet, and they can have really good results from changing that diet. Using our licensed nutrition folks and getting these people to improve their diet is very much a part of the picture.

 Thank you very much. I’m Dr Keith Ferdinand for HCPLive®. We’ve had a rich and informative discussion. Linda, Dean, Norm, and Manesh have given us a wealth of ideas and information, reviewed data, and given some opinions on where we are now with the intent of lowering risk in patients who are high risk, including the FH [familial hypercholesterolemia] patients, patients with ASCVD [atherosclerotic cardiovascular disease].

If you enjoyed watching this HCPLive® Peer Exchange, if you enjoyed the content, please subscribe to our e-newsletters to receive upcoming Peer Exchanges and other great content right in your in-box. Thank you very much for listening to this program.

Final thoughts from expert KOLs regarding treatment decisions and how they relate to patient accessibility when manage dyslipidemia. 

Treatment Decisions and its Relation to Patient Accessibility  

Dean Karalis, MD

Some practical tips to share with community physicians. IPF [idiopathic pulmonary fibrosis] can be a difficult diagnosis. Sometimes it’s black and white, clearly IPF or clearly not. But most of the patients fall in that gray zone of uncertainty. What I would say is if you’re uncertain, and this might be self-serving, contact your local ILD [interstitial lung disease] center. Get a second opinion and see what they have to say. I look to my colleagues all the time in our clinic, and I say, what do you think of this CT, or what do you make of this or that?

Talking among ourselves and putting these patients before multidisciplinary discussion, which typically happens at ILD centers, can be very important for validation of the diagnosis. Because probably the most difficult aspect of IPF is to make an accurate diagnosis first. The value of sending folks to ILD centers is that they can be looked at for clinical trials. Many ILD centers, such as ours, are transplant centers as well.

It becomes 1-stop shopping. You can get validation of the diagnosis concurrently. If you don’t want to start the therapy yourselves and leave it to the ILD docs, you can do it. They get looked at for clinical trials, and they get evaluated even in a cursory fashion as a potential lung transplant candidate.

To the community docs out there, don’t feel like you’re flying alone. I think I speak for all the ILD centers out there. We’re only too happy to partner with you in taking care of your patients and making sure they have the best possible outcomes.

I believe strongly that the primary care clinician should be the principal player in guiding patients and their caregivers through any disease process. I’ve had strong bias all along. I trained as a primary care physician years ago. My sense is that the primary care clinician needs to understand these disorders because of their severity and the implication for patient and their family members. That includes having a high index of suspicion of when this disease may be present.
So there have been a series of studies that are lovely and demonstrate that an older person presenting with a chronic cough is a tip-off to the primary care clinician that they should consider these disorders, and IPF in particular, as a potential diagnosis. Because it’s our suspicion that earlier diagnosis, particularly with these effective drugs, is likely going to be better in the long term. It makes sense, and the data would support that. Trying to work with our primary care clinicians to have a higher index of suspicion of when these disorders are present is crucial. The same thing for our radiologists, because we have a sense that early changes on a CT scan can be very instructive with regard to the early diagnostic process. 

That interaction has improved. If you think about how we consider optimizing the patient’s quality of life and survival, the importance of being able to address the potential tolerability issues of the drugs and how to manage them. The comorbid conditions and their interaction. In the middle of all that is a primary care clinician.

When we develop therapeutic plans with our patients and their caregivers, when we have a disease-management plan, it’s immediately transmitted to their primary care clinician, ideally by a phone call or a video chat, so the primary care clinician is fully aware of where we are at each stage and can aid the patient in making decisions at each stage.

The primary care clinician is a crucial player from the early diagnosis to the management at the end stage of disease. They are the quarterback in most of what happens with these patients.

Steven D. Nathan, MD, FCCP, and Fernando J. Martinez, MD, MS, share clinical pearls and advice for the management of IPF.

Clinical Pearls for the Management of IPF

Fernando J. Martinez, MD, MS

 In the little time that we have left, I want to go around and get some final thoughts from each one of you. I would like you to address the whole issue of using naloxone. How do you address this with patients? How do you address this with clinicians, and what is your view about going forward? How is this going to change the landscape of opioid use in the United States? Why don’t we start with Jeremy, and we will keep going from there? Take 30 seconds, and we will just keep going.

 I think we have covered a lot of ground today. We know, and have known for a long time, that opioids have certain risks. They pose risks to patients, and they pose risks in the community when they are taken unsupervised or misused. From a safety measure perspective, there are things we can do. We can do a better job identifying the patients at risk or when identifying those patients who should or should not receive opioids. At the same time, I think we need more community awareness, and we can do this by using the naloxone program or some of the other programs discussed today. Rhode Island sounds amazing, and I am interested to learn more about what is happening out there. The tools we have today can enhance the safety of what we are doing on the medical side and help out there in the community with the substance misuse and illicit side. That is outside of the reach for some of us who do not work in settings where one can reach out to the community, but I think that these types of tools are underutilized. If these tools are utilized on a more frequent basis, and in a more normalized way, we have the potential to reverse what we have seen here with opioids and the subsequent harm caused by them.

 While acknowledging that opioids are still commonly used as part of a multidisciplinary approach to pain management and that opiates are still being misused illicitly, we need to have strategies that emphasize the availability of naloxone so that people can be as safe as possible. As Dr Adler said, this must be normalized, and we need to realize, when we think about this, it is going to take more years than we would like before it will become normalized, but we need to step it up and work toward that.

 I cannot agree more with my colleagues. I think that, when it comes to normalizing naloxone, we need to take the lessons we have learned from what successfully normalizes this method of treatment. Whether it is enacting policy interventions, having naloxone everywhere, putting up billboards, or getting that access. What we are doing is studying people, saying what makes you dispense naloxone, to pharmacists? Saying what makes you dispense it, to primary care physicians? What makes you want to give it, to a caregiver? What are those barriers? How do we break them down? I look forward to the day of over-the-counter naloxone that is still covered by insurance so we do not have financial barriers. There is a lot that we know, areas where we have been successful, and I think that yes, it is going to be around a long time. We have seen how COVID-19 has created these divisions. I think, by solving those divisions during COVID-19, we will solve some of the divisions in access to care for people with opioid use disorder or people who use opioids.

I see naloxone as one part of the puzzle here, one part of the comprehensive approach that we try to take in the emergency department [ED], and that is decreasing the barriers that patients need to overcome to get naloxone. This is improving their access to naloxone not only in the ED but also in other areas of life where they have access to health care, and in their daily lives. Having it available works, whether it is having a naloxone box sitting next to an AED [automated external defibrillator] box somewhere or offering it to patients proactively and not requiring them to have to ask for it.

Additionally, I think that, as science for medication-assisted treatment continues to be redefined every day—how effective that is for treatment—it is our responsibility to not only make sure that our patients are safe as they go out and use this, or that their community is safer because naloxone is out there. But we also need to provide multiple opportunities for patients to get linked to treatment, to be linked to peers, and to have access to medication-assisted treatment. I think this is equally important and should be offered as routinely as possible.

Theresa, some people hate to be the last one to speak when all the good stuff is taken.

Theresa Mallick-Searle, MS, RN-BC, ANP-BC:

heresa Mallick-Searle, MS, RN-BC, ANP-BC: 

As the token nurse on the platform here, I am really big into listening to my patients. It is not that my colleagues are not, but I want to hear what is important to the patient. I want to be able to have them partner with me in their health care. I want to be able to encourage my peers to look at the bigger community and be in it for the long term, to decrease the amount of fear out there. As a health care provider, for anything that we do, we are trying to do the best we can to take care of our patients.

Thank you all very much. I want to thank you at home as well for watching this HCPLive® Peer Exchange. If you enjoyed this content, please subscribe to our e-newsletters to receive upcoming Peer Exchanges and other great content right in your inbox.

I am Dr Peter Salgo, and I will see you again next time.

The multidisciplinary panel of experts share final thoughts on strategies to normalize naloxone and decrease barriers to its obtainment and utilization. 

Final Thoughts on the Opioid Crisis and Normalizing Naloxone

Jeremy Adler, DMSc, PA-C, DFAAPA, Pacific Pain Medicine Consultants 

Margaret Bobonich, DNP, FNP-C, DCNP, FAANP: 

What do we do? How can we assist our colleagues in helping them look at one, how do we choose therapies, and when do we collaborate and refer these patients, and what kind of patient education can we provide for these patients?

Well, I think just to kind of bring this all the way back around, first off an accurate diagnosis always leads to successful treatments. So, make the diagnosis. Familiarize yourself with the different presentations of atopic dermatitis and the neonate versus the toddler versus the teen versus the elderly. And I think have a high clinical index of suspicion. If it is coming back, if it is very pruritic, if it’s life-altering, even if it doesn’t look like classic atopic dermatitis, it likely is a phenotypic presentation of that even if it’s not what’s inside your dermatology textbook. So, get the right diagnosis because the right diagnosis will then lead you to begin to move into the more, what I call the empathic side of treating this How is this impacting your life? How would your life change, how are the treatments that you’ve been using working? And so, begin that dialogue with patients and just kind of let them open up a little bit. It doesn’t have to be two-hour long visits for them to really feel like why this is different than other people have seen. Just asking a few questions lets them know that you're into the diagnosis, that you're not just going to run for a cream and send them out the door, and that you can make a difference. And if you don’t have that time to really tell them everything; you're not going to unload everything on the first visit. Tell them about comorbidities, tell them about every single systemic option, you're going to get their acute flare under control with topicals. And then you're going to bring them back in, you're going to earn their trust, you're going to continue to talk to them about it, and then you're going to begin – I’m always introducing non-steroidal options to patients right up front. If I feel like I have to use a topical steroid to calm it down – I may not need to once we get this new topical JAK out but I’m always introducing the idea of us moving off the topical steroids. I don’t use them much but systemics onto these new treatments. So it’s kind of a progressive revelation of talking to them about the disease, what you believe it is, how you want to open up the box and let them know that you know how this impacts you and the family, that we’ve got good treatments out there, we’re going to start off with this, but it’s important for me to see you back because we want to look into other treatments that are on the horizon that can control this for long periods of time without having to lead the anxiety about when am I going to break out next time. 

You know I think you summarized it very well Doug. I think it’s exciting where we’ve been and where we’re going. We don’t have to use systemic agents with these high toxicities that are really rescue agents, like the cyclosporine. We have choices now. And letting the patients know that and one of the interesting things is I’ve heard people say well that’s an injection. But guess what, let’s let our patients make that choice. Let’s give a fair representation of all the treatment options that we have and the ones that are coming because the truth is that an injection may be nothing compared to the quality of life that atopic dermatitis is having on these patients. A lot more to come for us especially our adult, some of the newer agents will be anticipated FDA-approved for adults. Some of the resources you like to give your patients Doug, what are they? 

Well certainly the National Eczema Association, the NEA, I think is an excellent resource with information about clinical trials that we may have mentioned in this presentation, great patient support, practical data that’s there, practical recommendations on bathing and moisturizing. I really, really like the NEA as a great resource. Do you have others? 

Margaret Bobonich, DNP, FNP-C, DCNP, FAANP:

 The National Eczema Foundation is my choice. But I think as far as resources for you as clinicians, I think one of the best ammunitions I would have for you is if you're in primary care or if you're in derm and you're not comfortable with prescribing some of these agents that are here now or the newer ones that we anticipate that will be FDA-approved in the near future, if you're not comfortable, reach out to a local dermatologist or dermatology NPPA and let us help you. One, we’ll help you with that patient and supporting them and getting them the best treatment and optimal outcomes, but also to help you learn about it. We really, really want to support you as colleagues and that’s my suggestion. Any last words Doug? 

 I just want to echo that. You know the study is a few years old, but it showed that only 19 percent of patients with severe atopic dermatitis got referred from primary care to dermatology. I think that’s improved, especially with some of the commercials that have been out about eczema and dupilumab’s campaigns. But we just want to say that this is – our medicine is a collaborative effort. We’re not living in silos here. We want to – we in dermatology want to partner with our primary care providers, we want to partner with our allergy specialists, we want to partner with the folks that are going to help us out too. I want to tell Margaret, you're helping your patients and you're helping yourself because these folks are living with infections, they’re living with scratching, they’re living with anxiety and depression. And we now have treatments out there that can radically change and improve that. So that’s the biggest message of today’s time together is that there is help out there, that we can get these medicines covered by most insurances, and that they can really change patients’ lives. 

 Thank you so much Professor Doug. This is why we call him Professor Doug. And thank you so much. Thank you for watching 

. If you’ve enjoyed this content, please subscribe to our newsletters to receive the upcoming programs and great content right in your inbox. So thank you everyone. Be safe and live well.

Experts in dermatology discuss patient education and clinical pearls to assist colleagues in the management of atopic dermatitis.  

Care Collaboration in Atopic Dermatitis 

Margaret Bobonich, DNP, FNP-C, DCNP, FAANP

Discussions about migraine treatment often revolve around a single topic: triggers. Patients with migraine are always eager to learn about factors that activate migraine in order to avoid them. Tracking and avoiding triggers is often one of the few means of control migraine patients feel they have over an otherwise unpredictable disease. However, this is an oversimplification. In practice, trigger avoidance is usually ineffective, and sometimes even detrimental to patients. That’s because:

Many supposed “triggers” are not triggers at all, but rather are premonitory symptoms signaling an attack is already underway.

Rarely does a single trigger produce a migraine attack.

Avoiding triggers can erode patients’ quality of life, since it can lead to avoidance of enjoyable activities

 as well as feelings of helplessness and self-blame.

Migraine Triggers Versus Prodromal Symptoms

Research has confirmed several triggers of migraine attacks:

 are perhaps the most common migraine trigger among women. The drop in estrogen levels just prior to menses is likely the cause.

, including for religious reasons such as Ramadan

 Links between chronic stress, pain, migraine, and catastrophic thinking have been demonstrated by many studies.

 However, removing a stressful situation alone is unlikely to improve migraine. In fact, the abrupt cessation of stress is often itself a migraine trigger.

Many environmental factors may affect migraine (such as altitude, lightning, and barometric pressure changes) but the effects are relatively mild and in some cases nonsignificant.

It’s important to emphasize that rarely does any single trigger invariably produce a migraine attack. Much depends upon the patient’s own migraine threshold, which fluctuates over time. For example, sudden changes in daily activity or environment increase migraine susceptibility,

 making triggers more potent than usual. This can be disorienting for patients, who may find that activities that were tolerable one day become triggering the next.

Further confusing for patients is the difficulty figuring out which of the events or symptoms that preceded a migraine attack was the trigger. This has led to a plethora of reported triggers, most of which have not been borne out by research. Rather, data supports the idea that many of these symptoms are actually premonitory, or prodromal symptoms,

 which occur 2 to 48 hours prior to the headache phase of a migraine attack.

 Seen in this light, such symptoms are not triggers that can be avoided; rather, they signal to the patient that an attack is already underway.

Common premonitory symptoms often confused for triggers include:

Chocolate is probably the best example of a food craving misunderstood as a trigger. Although patients rank chocolate number one of all food-based triggers, placebo-controlled studies have failed to show that chocolate triggers migraine.

 The same can be said of caffeine, an oft-cited food “trigger” that 

Prodromal symptoms are individual to each patient. Identifying their prodromal symptoms can help a patient with migraine recognize that the headache phase is imminent, lessening the element of surprise and allowing them to take mitigation steps such as leaving work early, seeking out a dark room, notifying caregivers, or obtaining childcare for during the attack.

Reframing Triggers for Effective Migraine Treatment

Asking patients to avoid triggers does not appear to be effective, based on studies comparing the practice to a control group that didn’t change their behaviors. Trigger avoidance was also found less effective than cognitive therapy or an approach of learning to cope with triggers.

 Avoiding stress, for example, has been found less effective for chronic pain than coping or adaptive strategies and may lead to anxiety, increased disability, and catastrophic thinking.

Focusing extensively on migraine triggers during an office visit is not only an ineffective use of provider-patient time, but it may also have a host of negative consequences on the person with migraine’s quality of life:

Patients can feel blamed or self-blame for a migraine attack (e.g., “This is my fault because I drank wine”).

A patient may find it impossible to identify their triggers, especially in those with very frequent attacks (where everything can appear to be a trigger) or infrequent attacks (where it’s difficult to find consistent patterns).

The triggers identified may not be avoidable, such as stress or weather.

Focusing on triggers can increase anxiety or lead to anticipation of attacks. It may even pave the way to more migraine attacks. Nocebo is a major problem in headache, both in clinical trials and practice.

 Studies of other pain disorders have shown that increased pain expectations cause an increase in symptoms

; the suggestion that a specific trigger will cause a migraine attack may create similar expectancy mechanisms.

It does not address the underlying cause of the disorder.

With all this in mind, here are a few strategies when advising patients on triggers.

 Maintaining a regular diary or calendar eliminates recall bias and focuses on overall migraine control. It may also allow the discovery of unrecognized triggers amenable to treatment, such as caffeine withdrawal on weekends or menstrual migraine. In addition to tracking attacks, ask patients to write down strategies that worked, both preventively and abortively (medical and non-medical), to reduce their migraine symptoms.

Focus on healthy lifestyle choices that raise migraine threshold. 

Rather than trigger avoidance, focus on engaging in proactive behaviors that, done consistently, raise patients’ threshold for migraine triggers. Those include good sleep, regular nutrition patterns, regular exercise, and stress management techniques.

For further practical details on healthy lifestyle changes that improve migraine, see my colleagues’ Stephen Silberstein, MD and William Young, MD’s article “Lifestyle Changes for Migraine: Practical Tips for the Neurologist & PCP.”

To help patients understand the concept of threshold and their ability to raise their own migraine resistance level, try this patient-centric article from Ctrl M Health.

Recognize and treat “cephalgiaphobia.” 

Ask patients if they worry about migraine when they are headache-free or restrict activities due to fear of migraine. Fear of migraine between attacks is an important predictor of chronification and medication overuse.

 Finding effective acute medication may reduce the risk of chronification.

 Cognitive behavioral therapy can be particularly effective.

 Patients with very frequent migraine—for whom triggers appear to be everywhere—may benefit from effective preventive medication.

Expect that patients will be new to the idea of replacing trigger-avoidance strategies with proactive behaviors. They will need encouragement and guidance to follow through. Until recently, evidence-based, expert-reviewed programs to help patients with lifestyle change for migraine were rare. That is a guiding reason why we at the Jefferson Headache Center and Thomas Jefferson University Hospital have partnered with Ctrl M Health, whose app-delivered program makes this information widely accessible.

Providers have the ability to help patients redirect their efforts into the factors within their control that are shown to actually make a difference. I find patients also benefit from the empowerment this behavioral approach brings, making them more confident in their ability to manage migraine. Those gains, in turn, allow them to continue making progress in reducing migraine frequency and severity, improving their quality of life.

The Jefferson Headache Center and Thomas Jefferson University have partnered with Ctrl M Health to create comprehensive, evidence-based programming and support for people with migraine. For free provider resources, best practice tips, and patient handouts, visit their For Providers page.

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Forget what you think you know about red wine or chocolate ‘activating’ migraine. Many commonly accepted “triggers” aren’t triggers at all.

Helping Your Patients Avoid the Migraine Trigger Trap

Michael Marmura, MD

There had been more 200,000 pre-exposure prophylaxis (

) initiations in North America from 2016-2020, according to data from the AIDS Vaccine Advocacy Coalition (

) earlier this year. While the US is highly contributory to the gradually increasing rate of 

-risk persons gaining access to PrEP annually, it’s not enough to consider the work accomplished on a national scale.

There are millions of untreated people that could benefit from its use, and the drivers of PrEP underutilization are multifactorial. Despite its proven benefits over the last decade, PrEP is plagued by provider challenges, limited understanding of the market for eligible patients, and prospective PrEP users’ lack of awareness of the prophylaxis therapy.

The challenge of adhering to daily oral PrEP can also pose challenges for its indicated population. Homelessness, injection drug use, and poverty are all factors that limit use. Additional demographic factors, like race, gender, and sexuality, have also been associated with challenges to PrEP uptake. For example, despite their disproportionately high HIV incidence rate, Hispanic and Latino adults were the 

 to be referred for PrEP, per a Centers for Disease Control and Prevention (CDC) study this year.

PrEP disparities are also widened by marketing tactics. Although 

heterosexuality accounts for the identified sexuality of 23% of all new HIV diagnoses annually

, HIV and AIDS are still commonly perceived to only occur among men who have sex with men (MSM), and they are the most likely to be prescribed PrEP. Lingering homophobia creates an intensely negative stigma around HIV that discourages many at-risk persons from seeking PrEP.

Because HIV is a sexually transmitted infection, 

 out of fear their family, partner, or community will view them as promiscuous. HIV is the world’s leading cause of death in women 15-49 years of age, but proportionally very few women are taking PrEP.

All these disparities in PrEP uptake and coverage have the potential to be remedied with long-lasting injectable PrEP. Cabotegravir, VIIV Healthcare’s PrEP injectable, could receive Food and Drug Administration (FDA )approval 

Dawn K. Smith, MD, MS, MPH, medical officer for the CDC noted in a statement that the FDA has set a PDUFA target date of January 24, 2022 for the new cabotegravir indictation. “(The_ CDC added a section about cabotegravir to the latest version of 

…so that providers can begin prescribing this new long-acting injectable without delay if and when it is approved,” Smith said.

If approved, cabotegravir would be the first long-acting PrEP therapy available, meaning populations unable or unwilling to adhere to a daily PrEP regimen would have an infrequent, discreet option for HIV prevention.

Suzan Walters, PhD, research assistant professor in the NYU School of Global Public Health, affiliated investigator at the 

Center for Opioid Epidemiology and Policy

, studies injection drug use and societal inequities in biomedical intervention, such as PrEP.

® that she believes it important “to offer different modalities for all drugs as people have different lives and preferences…All communities stand to benefit from injectable PrEP.”

“I do want to take a moment to express how structural conditions, such as housing and poverty create challenges not only for PrEP but for health in general,” Walters continued. “People who use drugs who also experience 

 often have challenges keeping their property, which could include PrEP, and thus injectable PrEP could mitigate this issue. There have been cases of stollen medications and as such having an option to take PrEP without the obligation to carry it around stands to benefit drug using populations, and likely many other populations.”

Walters added that drug-using populations at high HIV risk have shown capability to adhere to the demands of a daily PrEP pill, but nonetheless have expressed preference in a once-monthly injection option. For the homeless HIV-risk population, the new cabotegravir indication could have the potential to mitigate “structural burdens” associated with homelessness.

“The simple fact of having a choice in how one receives PrEP has the potential to increase uptake,” Walters said. “Choosing the best option for one’s body and lifestyle gives a patient autonomy over their healthcare journey, increasing PrEP uptake and adherence."

That said, there’s a tendency for widening treatment disparities and distribution inequities in instances when health care technological advances are reached. “We have seen this with PrEP in general, with a widening gap in uptake between white communities and communities of color,” Walters explained.

Stigma, and a lack of communication and awareness all inhibit HIV PrEP uptake, but digital health and new forms of PrEP could boost users. 

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