In "An Institutional Approach to Managing the Opioid Crisis," the authors describe the elements of Mayo Clinic's Opioid Stewardship Program. The study's first author, Halena Gazelka, M.D., an anesthesiologist, is chair of the program. She works together with the study's senior author, Elizabeth Habermann, Ph.D., deputy director of research in the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, and many others across Mayo Clinic, to identify prescribing practices for opioids — in both acute and chronic pain situations. Together the team has led transformation of postsurgical prescribing patterns — developing, implementing and validating patient-centric guidelines.

"The opioid crisis had not escaped the attention of anyone, and we stepped up quickly to find out where we could make a difference," says Dr. Gazelka. "Mayo Clinic was in the same place as everyone else — we didn't know how many opioids were being prescribed, how much variance we had between providers, procedures or conditions — or frankly, how much waste and potential for misuse was occurring on our watch."

Under Dr. Gazelka's leadership, Mayo began reviewing current practices, workflows, and internal and external guidelines.

"Very little evidence was out there about opioids," says Dr. Habermann. "We realized very quickly that we, Mayo Clinic, needed to build the evidence to not only guide our prescribing clinicians regarding the needs of our patients, but prescribers and patients everywhere."

This is where the Mayo Clinic Kern Center for the Science of Health Care Delivery came into play. Center-based work (center co-authors identified with bold type) has helped determine Mayo's baseline prescribing habits across practices and specific surgeries.

"Center colleagues partnered across the surgical practices to first determine the baseline, and then implement and validate evidence-based prescribing guidelines specific to each practice," says Dr. Habermann. Read more about that work in Advancements in opioids research, transformations in postsurgical prescribing.

As these efforts were ongoing, in Minnesota, Twin Cities Public Television (TPT) ran an award-winning, several segment program, The Opioid Fix, which included an episode with Drs. Habermann and Gazelka describing some of the center's research, along with two other patient care and education-focused segments originating at Mayo Clinic.

"We are continuing our efforts, refining postsurgical prescribing, expanding our patient and provider education, and building tools and processes to reduce excess opioids in our communities," says Dr. Gazelka.

Now research efforts are moving into non-surgical prescribing practices, and the center is expanding collaborations with Pharmacy.

"Initially a lot of the center's opioid work came out of the Surgical Outcomes Program, and was focused on post-operative prescribing," says Dr. Habermann. "We have a number of our surgical outcomes team and other Kern Center faculty and analysts who have been collaborating to examine the appropriateness and effectiveness of opioids in other pain management contexts."

Some of those non-surgical publications are described here:

• Characteristics of Opioid Prescribing in Non-surgical Medicine Patients with Acute Pain at Hospital Discharge.

Engstrom K, Brown CS, Ubl D, Hanson K, Bates R, Cunningham J. J Gen Intern Med. 2021 Aug 11.

This 6-month-long quality improvement retrospective study sought to characterize the quantity, type and indication of opioids prescribed for non-surgical patients upon hospital discharge and how the patients actually used those prescriptions.

A median of 112.5 total morphine milligram equivalent (MME) quantities were prescribed to patients at hospital discharge. Of the 200 patients included in the study survey, the median consumption was much lower, at only 45 MME. Only 5.9% of patients who had leftover opioids reported disposal of the medication.

The results indicate that there is room for standardization and reduced opioid prescribing among non-surgical medical services in the hospital setting.

• Acute Treatments for Episodic Migraine in Adults: A Systematic Review and Meta-analysis.

VanderPluym JH, Halker Singh RB, Urtecho M, Morrow AS, Nayfeh T, Torres Roldan VD, Farah MH, Hasan B, Saadi S, Shah S, Abd-Rabu R, Daraz L, Prokop LJ, Murad MH, Wang Z. JAMA. 2021 Jun 15;325(23):2357-2369.

A migraine is common and debilitating headache for which a number of therapeutic interventions are used to lessen or prevent the full onset of migraines. In this study, the researchers reviewed the available evidence for a number of medicinal and nonpharmacological therapies.

The systematic review and meta-analysis was led by investigators from the Kern Center's Knowledge Synthesis Program and Mayo Clinic's Evidence-based Practice Center.

They included 15 systematic reviews and 115 randomized clinical trials for which the main outcomes included pain freedom, pain relief, sustained pain freedom, sustained pain relief, and adverse events.

The authors noted, "there are several acute treatments for migraine, with varying strength of supporting evidence. Use of triptans, nonsteroidal anti-inflammatory drugs, acetaminophen, dihydroergotamine, calcitonin gene-related peptide antagonists, lasmiditan, and some nonpharmacologic treatments was associated with improved pain and function."

The nonpharmacological options that appeared to have significant pain reduction benefits were:

• Remote electrical neuromodulation.
• Transcranial magnetic stimulation.
• External trigeminal nerve stimulation.
• Noninvasive vagus nerve stimulation.

The evidence for many other interventions, including opioids, was limited.

• Opioid Use in Fibromyalgia Continues Despite Guidelines That Do Not Support Its Efficacy or Risk.

Bruce BK, Allman ME, Rivera FA, Abril A, Gehin JM, Oliphant LM, Nordan LM, White LJ, Martinez D, Niazi SK. J Clin Rheumatol. 2021 Aug 1;27(5):187-193.

Mayo Clinic regularly hosts an intensive 2-day Fibromyalgia Treatment Program to support people who suffer from fibromyalgia. It is a cognitive behaviorally based multicomponent treatment program focused upon evidence-based education and strategies to decrease central sensitization, including management tools to decrease pain and fatigue, assist with sleep disturbance, and improve cognitive issues associated with fibromyalgia. It is a group-based program that consists of 16 hours of treatment time focused on pain management strategies, exercise, sleep assistance, relaxation strategies, pacing, moderation, behavioral activation, and family involvement.

The researchers collected information from 698 patients admitted to the program over a 2-year time period. In addition to collecting fibromyalgia impact, pain catastrophizing and depression information through validated surveys, the team also gathered demographic and self-reported opioid use.

Despite widespread agreement in multiple guidelines that do not recommend opioid therapy as helpful for patients with fibromyalgia, 27% of the patients reported taking prescription opioids at the time of entry into the program.

The investigators found that opioid use correlated with a number of factors, including:

• Longer duration of symptoms — in excess of three years.
• Higher degree of functional impairment.
• Increased pain catastrophizing.

Their findings led the researchers to suggest that more education or outreach needs to occur among health care providers who treat patients with fibromyalgia. In order to assist in disseminating more helpful strategies, the authors included discussion of alternative approaches to the management of fibromyalgia that do not involve opioids are reviewed in an effort to improve care.

• Provision of a Drug Deactivation System for Unused Opioid Disposal at Surgical Dismissal

Ramel CL, Habermann EB, Thiels CA, Dierkhising RA, Cunningham JL. Mayo Clin Proc Innov Qual Outcomes. 2020 Aug; 4(4): 357–361.

Based on previous Kern Center research, the researchers knew that more than 75% of elective surgery patients have unused opioids remaining after their pain has resolved. It has been well established that leftover opioids pose risks to families and community members. In an effort to reduce the potential for misuse, the study team included education materials and a drug deactivation system for 200 patients filling their opioid prescription at a Mayo Clinic pharmacy after undergoing one of several different surgeries.

Subsequently the team conducted a phone survey, reaching 149 patients. The investigators found that providing information about safe and effective disposal of excess opioids, along with a convenient drug deactivation packet led to an increase in disposal. Patients who used the disposal system reported high satisfaction with the process.

"Based on the results of our study, the Mayo Clinic Pharmacy and Therapeutics Committee endorsed distribution of a drug deactivation system with new opioid prescriptions through all Mayo Clinic Pharmacies," says Julie Cunningham, Pharm.D., Mayo Clinic's associate chief pharmacy officer for Practice and Research and senior author of this study.

"Alluma, the Mayo Clinic pharmacy benefit manager, enthusiastically supported the risk aversion effort and supplied the deactivation systems for all Mayo Clinic insured lives at no charge, with financial support from the Mayo Medical Plan," says Dr. Cunningham. "It’s extremely gratifying to see the translation of our research into the hands of patients."

• Emergency Department Visits for Nonfatal Opioid Overdose During the COVID-19 Pandemic Across Six US Health Care Systems

Soares WE 3rd, Melnick ER, Nath B, D'Onofrio G, Paek H, Skains RM, Walter LA, Casey MF, Napoli A, Hoppe JA, Jeffery MM. Ann Emerg Med. 2021 Mar 19:S0196-0644(21)00226-2.

In this study, the team found that in the first 12 months of COVID-19, total visits for nonfatal opioid overdoses in adults increased more than 10% over 2019 and 2018. These data came from reviewing the records of 25 emergency departments at health care facilities in six U.S. states and in diverse rural, urban and suburban populations.

The COVID-19 pandemic has caused numerous disruptions around the world, including in employment, education, physical and psychological wellbeing. People with opioid use disorder are vulnerable to disruptions in access to addiction treatment and social support, both of which have been adversely impacted by the pandemic.

Identifying changes in emergency department use by people with different needs helps build an understanding of what resources and interventions need to be expanded or modified to serve community needs during the pandemic. In previous research, the team found that overall use of emergency department for other health concerns declined during COVID-19.

The Mayo Clinic Kern Center for the Science of Health Care Delivery is fully embedded in Mayo Clinic's medical Practice. Its scientists collaborate across the Practice to identify and solve challenges for patients, providers and the health care system at large.

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JACKSONVILLE, Fla. — Fibromyalgia, a disorder that causes pain, fatigue, chronic headaches and a host of other symptoms, is often misunderstood by patients, families and health care providers. A new book from Mayo Clinic Press aims to change that.

"Mayo Clinic Guide to Fibromyalgia: Strategies to Take Back Your Life," by Andy Abril, M.D., a Mayo Clinic rheumatologist, and Barbara Bruce, Ph.D., a Mayo Clinic psychologist, aims to dispel myths about fibromyalgia and offer practical strategies for patients to manage it successfully. Drawing on decades of Mayo Clinic research and clinical expertise, the book is a resource to help people with fibromyalgia find solutions that lead to better health. Drs. Abril and Bruce are based at Mayo Clinic in Florida.

The 272-page paperback is the first under the imprint Mayo Clinic Press. Mayo Clinic has issued health-oriented books for consumers with other publishers for many years, self-publishing books such as "The Mayo Clinic Family Health Book." Mayo Clinic Press will publish new titles on important health issues, and its books will be distributed by Simon & Schuster Inc.

Fibromyalgia is a disorder that commonly involves aches and pain in all parts of the body, often with fatigue, sleep, memory and mood issues. Symptoms also may include tension headaches, irritable bowel syndrome, anxiety and depression. Women are more likely to develop fibromyalgia than men.

"Every day, we see patients who are hurting, who aren't sleeping well and are exhausted, and who have trouble concentrating," says Dr. Abril. "By the time they get to us, many of these people have been told that their symptoms are related to stress or depression. Others have been told that they are wasting their doctor's time."

Medications can help control symptoms, and many patients also have found exercise, relaxation and stress reduction measures helpful, Dr. Abril says.

"Many patients are struggling to get through their daily activities because of their symptoms," says Dr. Bruce. "They don't know what's wrong with them or how to make it better. They just want their lives back. Fibromyalgia doesn't have to define a person's life, and we can offer help and hope."

The authors share personal stories of patients who have lived with fibromyalgia and found that relief and management of symptoms is possible. The book outlines comprehensive treatment options based on the latest research, with actionable steps to reduce pain and other symptoms.

"Mayo Clinic Guide to Fibromyalgia: Strategies to Take Back Your Life" is available online and in retail outlets nationwide. Proceeds from the book will support medical education and research at Mayo Clinic.

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About Mayo Clinic
Mayo Clinic is a nonprofit organization committed to innovation in clinical practice, education and research, and providing compassion, expertise and answers to everyone who needs healing. Visit the Mayo Clinic News Network for additional Mayo Clinic news and An Inside Look at Mayo Clinic for more information about Mayo.

Media contact:

• Kevin Punsky, Mayo Clinic Public Affairs, 904-953-0746, punsky.kevin@mayo.edu

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DEAR MAYO CLINIC: Is there a specific test to definitively diagnose fibromyalgia? If not, how do doctors confidently diagnose this disorder?

ANSWER: No one test can be used to diagnose fibromyalgia. But unlike in the past, fibromyalgia is no longer a diagnosis of exclusion, which means that all other conditions that could trigger similar symptoms are ruled out before fibromyalgia can be diagnosed. Instead, the diagnosis is based on specific symptoms, and it’s now understood that fibromyalgia can, and often does, coexist with other chronic pain disorders.

Fibromyalgia is a disorder characterized by pain all over the body. Fibromyalgia pain is widespread and amplifies existing pain generators, such as arthritis. People with fibromyalgia often have widespread, migratory muscle aches without any underlying muscle injury, and they generally experience pain more intensely than others. Researchers believe this widespread, amplified pain occurs because fibromyalgia affects the way the brain processes pain signals.

Fibromyalgia pain is not the same in everyone with this disorder. Some people may have extreme skin sensitivity to gentle pressure. Some may have tender finger joints without redness or swelling. Others may have significant tenderness of the muscles of the upper back and neck.

Because fibromyalgia tends to amplify pain generated by other conditions, patients with lupus or rheumatoid arthritis may have much greater joint pain than would be expected based on objective measures of inflammation. One of the hallmarks of fibromyalgia is pain out of proportion to the degree of tissue injury.

Fibromyalgia causes other symptoms beyond pain, too. Problems with fatigue; chronic headaches; irritable bowel syndrome; interstitial cystitis; unrefreshing sleep; and impaired concentration, attention and mental focus also may plague those with fibromyalgia.

To diagnose fibromyalgia in the past, health care providers would firmly press 18 specific points on a person’s body to see how many of these points were painful. Diagnosis required 11 or more positive tender points. Then health care providers would rule out other painful conditions, such as injuries, neuropathy, arthritis or a connective tissue disorder, that could explain symptoms. Now it is clear an individual can have conditions that cause chronic pain and have fibromyalgia, as well.

Consequently, it is not necessary to eliminate the possibility of all other chronic pain disorders before arriving at a fibromyalgia diagnosis. It is important, however, to receive a comprehensive assessment to evaluate for other underlying conditions, as that information will guide an effective treatment plan. Reducing pain being caused by coexisting chronic pain conditions also can reduce fibromyalgia-associated pain.

A fibromyalgia diagnosis now is made based on symptoms of widespread pain, fatigue, unrefreshing sleep and cognitive impairment — typically after a person has had widespread pain for more than three months. “Widespread” is defined as pain on both sides of the body, as well as above and below the waist.

Part of what makes diagnosing fibromyalgia difficult is that its symptoms tend to be inconsistent, waxing and waning over time. Also, the disorder can be hard to distinguish from other conditions. For patients with chronic widespread pain, if the pain is more intense and persistent than would be expected based on the amount of tissue injury present, then fibromyalgia could play a role. A common example would be a patient with well-treated rheumatoid arthritis without evidence of joint inflammation or erosions who has severe joint pain.

If fibromyalgia is suspected, it’s important to be evaluated by a specialist with expertise in caring for people with the disorder. A timely and accurate fibromyalgia diagnosis is vital because it can become debilitating and disrupt daily life significantly. Although there is no cure, early recognition of fibromyalgia can reduce the need for further diagnostic testing to explain chronic, widespread pain. And once fibromyalgia is identified, pain management strategies often can help control symptoms. — Dr. Christopher Aakre, Fibromyalgia and Chronic Fatigue Clinic, Mayo Clinic, Rochester, Minnesota

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Related Articles

• Mayo Clinic Radio: Fibromyalgia published 3/21/19
• Fibromyalgia: Mayo Clinic Radio Health Minute published 4/5/18
• Mayo Clinic Q and A: Understanding myofascial pain syndrome and fibromyalgia published 12/1/17

The post Mayo Clinic Q and A: How is fibromyalgia diagnosed? appeared first on Mayo Clinic News Network.

On the Mayo Clinic Radio podcast, Dr. Christopher Aakre, an internal medicine specialist in Mayo Clinic's Fibromyalgia and Chronic Fatigue Clinic, discusses diagnosing and managing fibromyalgia. Also on the podcast, Dr. Andrew Bentall, a Mayo Clinic nephrologist, explains what can be done to help sensitized transplant patients who can be difficult to match with organ donors. And Dr. Victor Karpyak, a Mayo Clinic psychiatrist, shares research on how your genetics can affect your response to treatment for alcohol use disorder. This research is funded by the National Institute on Alcohol Abuse and Alcoholism.

The post #MayoClinicRadio podcast: 3/23/19 appeared first on Mayo Clinic News Network.

On the next Mayo Clinic Radio program, Dr. Christopher Aakre, an internal medicine specialist in Mayo Clinic's Fibromyalgia and Chronic Fatigue Clinic, will discuss diagnosing and managing fibromyalgia. Also on the program, Dr. Andrew Bentall, a Mayo Clinic nephrologist, will explain what can be done to help sensitized transplant patients who can be difficult to match with organ donors. And Dr. Victor Karpyak, a Mayo Clinic psychiatrist, will share research on how your genetics can affect your response to treatment for alcohol use disorder.

Here's your Mayo Clinic Radio podcast.

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The post Mayo Clinic Radio: Fibromyalgia appeared first on Mayo Clinic News Network.

Fibromyalgia is a disorder that causes pain all over the body, sleep problems, fatigue, and often emotional and mental distress. Fibromyalgia amplifies painful sensations by affecting the way your brain processes pain signals, meaning people with fibromyalgia are more sensitive to pain than those without the disorder. According to the Centers for Disease Control and Prevention, fibromyalgia affects around 4 million U.S. adults, or about 2 percent of the adult population.

On the next Mayo Clinic Radio program, Dr. Christopher Aakre, an internal medicine specialist in Mayo Clinic's Fibromyalgia and Chronic Fatigue Clinic, will discuss diagnosing and managing fibromyalgia. Also on the program, Dr. Andrew Bentall, a Mayo Clinic nephrologist, will explain what can be done to help sensitized transplant patients who can be difficult to match with organ donors. And Dr. Victor Karpyak, a Mayo Clinic psychiatrist, will share research on how your genetics can affect your response to treatment for alcohol use disorder.

The post Mayo Clinic Radio: Fibromyalgia / sensitized transplant patients / genetics and treatment for alcohol use disorder appeared first on Mayo Clinic News Network.

Fibromyalgia

The post Fibromyalgia: Mayo Clinic Radio Health Minute appeared first on Mayo Clinic News Network.

DEAR MAYO CLINIC: What’s the difference between myofascial pain syndrome and fibromyalgia? How are they diagnosed?

ANSWER: Both of the conditions you mention are chronic pain disorders, meaning they cause pain that lasts for long periods of time and can be difficult to manage. Myofascial pain syndrome involves mainly muscular pain; whereas, fibromyalgia includes more widespread body pain, along with other symptoms, such as headaches, bowel problems, fatigue and mood changes.

In people with myofascial pain syndrome, sensitive areas of tight fibers form within a muscle or an adjoining muscle group, typically due to muscular injury or overuse. As a result, a tender, painful knot develops in the muscle. When pressure is placed on that area, called a tender point or trigger point, it leads to deep, aching muscle pain.

The pain of fibromyalgia is different, because it’s diffuse, migratory and involves both muscles (myalgia) and joints (arthralgia). It affects both sides of the body — above and below the waist. Furthermore, the pain may move — a process called migratory phenomenon — from one part of the body to another over time. The discomfort of fibromyalgia usually is felt as both joint and muscle aches and pain, without any redness or swelling caused by inflammation. Researchers believe that fibromyalgia causes pain because the disorder affects the way the brain processes pain signals, amplifying painful sensations.

Fibromyalgia causes other symptoms beyond pain, too. One of the most common is fatigue. People who have fibromyalgia often wake up in the morning still feeling tired, even when they have slept for long periods of time. Problems with concentration, attention and mental focus also may plague those with fibromyalgia.

There aren’t any specific tests available that can definitively diagnose myofascial pain syndrome or fibromyalgia. Both are diagnosed clinically.

Myofascial pain syndrome often can be identified based on symptoms and a physical examination. During the exam, a health care provider may apply gentle pressure to the painful muscle, feeling for tense areas. Certain ways of pressing on a tender point can elicit specific responses, such as a muscle twitch. Because muscle pain can have many possible causes, additional tests may be recommended to rule out other diseases or conditions before making a diagnosis of myofascial pain syndrome.

Diagnosing fibromyalgia is a two-stage process. First, because many other disorders can mimic the symptoms of fibromyalgia, it’s important that those be ruled out. Blood tests and other diagnostic tests should be performed to confirm that the pain is not the result of another condition, such as arthritis, lupus, a connective tissue disorder or a thyroid disorder.

The second step in fibromyalgia diagnosis is assessing an individual’s symptoms using a tender point count and validated survey criteria, such as the Widespread Pain Index and Symptom Severity Scale. In most cases, if the pain is widespread, has lasted for three months or more, is not associated with an underlying medical condition that could cause the pain, and meets the validated survey criteria, then the diagnosis of fibromyalgia is made.

After diagnosis, it’s usually best for people with these disorders to work with a health care provider who is trained in, and has experience working with, chronic pain conditions. Although no cure is available for myofascial pain syndrome or fibromyalgia, these conditions often can be effectively managed with a personalized treatment plan that minimizes pain, improves overall health and enables an individual to engage in normal routines and activities. — Dr. Arya Mohabbat, General Internal Medicine, Fibromyalgia and Chronic Fatigue Clinic, Mayo Clinic, Rochester, Minnesota

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On the next Mayo Clinic Radio program, Dr. Jamie Bakkum-Gamez, a gynecologic surgeon at Mayo Clinic, will cover diagnosis, treatment and prevention of gynecologic cancers. Also on the program, Kate Zeratsky, a dietician at Mayo Clinic, will discuss detox diets. And Dr. Arya Mohabbat, the practice chair of Mayo Clinic’s Fibromyalgia and Chronic Fatigue Clinic, will talk about improving care for fibromyalgia patients.

To hear the program, find an affiliate in your area.

Here's your Mayo Clinic Radio podcast.

Follow #MayoClinicRadio, and tweet your questions.

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Mayo Clinic Radio produces a weekly one-hour radio program highlighting health and medical information from Mayo Clinic.

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