Episode 228 -- April 2025 -- Part 2 AFP: American Family Physician

Summary

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AFP: American Family Physician Podcast

Episode 228 – April 2025 (Part 2)
Release Date: May 1, 2025
Hosts: Dr. Steve Brown (A), Dr. Marian Dawson (B), Dr. Sierra Voy (C)
Produced by: University of Arizona College of Medicine-Phoenix Family Medicine Residency

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Overview of Episode

In this rich and clinically-focused episode, faculty and residents review the latest evidence and guidelines across a range of topics central to family medicine. The primary segments address:

• Buprenorphine for opioid use disorder
• Comparative efficacy of triptans for acute migraine
• Diagnosis and management of PMS and PMDD
• Pain management for IUD insertion
• Noninvasive staging for liver fibrosis in chronic hepatitis C
• Cold water immersion for muscle soreness

The hosts combine key takeaways from recent American Family Physician articles with practical discussion and evidence grading, maintaining a friendly and approachable tone throughout.

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Segment Highlights & Key Discussion Points

1. Buprenorphine for Opioid Use Disorder (00:34–05:28)

• Key Points:

  • Opioid agonist therapy (methadone, buprenorphine) is highly effective for moderate/severe opioid use disorder, reducing mortality by >50%.
  • Methadone requires specialty clinics; buprenorphine can be prescribed by family physicians with Schedule 3 authority.
  • Buprenorphine/naloxone combinations are accepted to deter misuse, except in pregnancy.
  • Induction protocols:
    • Standard: Start after mild withdrawal, titrate to 16–32 mg/day.
    • High-dose induction (≥16 mg): For immediate withdrawal prevention, may suit settings with limited follow-up.
  • Buprenorphine ≥16mg’s Number Needed to Treat (NNT) for retention: 2 ([04:41]).
  • Behavioral therapy is recommended but not required; does not alter outcomes.
  • Concurrent benzodiazepines/stimulants are not absolute contraindications.
  • Urine testing (including norbuprenorphine) supports monitoring; confirmatory testing for positives is highlighted.
  • Discontinuation of therapy should be carefully considered, given high relapse/overdose risk.

• Notable Quotes:

  • “Dang, that is super impressive.” – Marian, on buprenorphine’s NNT for retention ([03:53])
  • “The mortality risk of untreated opioid use disorder means that the use of opiate agonist medications... should be considered in almost every circumstance.” – Marian ([05:16])

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2. Triptans for Acute Migraine: POEM Review (05:39–06:55)

• Key Points:

  • Large meta-analysis (137 RCTs, ~89,000 adults): Triptans outperform both older and newer acute migraine medications in efficacy.
  • Only “ella triptan” outperformed sumatriptan.
  • Newer agents (ubrogepant, rimegepant, lasmiditan) were less effective for acute migraine episodes.
  • Limitation: Results not applicable to patients with chronic or status migrainosus.

• Notable Quotes:

  • “137 randomized controlled trials is insane.” – Steve ([06:08])

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3. Premenstrual Syndrome (PMS) & Premenstrual Dysphoric Disorder (PMDD) (06:55–10:30)

• Key Points:

  • PMS diagnosis: ≥1 affective/somatic symptom in luteal phase, resolving <4 days after menses, over ≥2 cycles.
  • PMDD: Requires ≥5 affective/somatic symptoms causing significant distress, distinctly timed to luteal phase.
  • Exclusion of other diagnoses (e.g., thyroid dysfunction, depression, substance use) is essential.
  • First-line treatment: SSRIs (fluoxetine, escitalopram), with continuous dosing more effective than pulse.
  • Combined oral contraceptives help somatic, not mood, symptoms.
  • Third-line: GnRH agonists (e.g., leuprolide) for refractory PMDD.
  • Non-pharmacologic approaches:
    • CBT is as effective as fluoxetine at 6 months, though slower onset.
    • Exercise offers modest benefit; evidence limited by study heterogeneity.
    • Vitex agnus-castus (Chaste Berry): Possibly effective, but evidence is low quality and beware of interactions.
  • Side notes: Chaste Berry reduces libido and may cause GI side effects.

• Notable Quotes:

  • “It's named that because it can decrease libido.” – Steve, on Chaste Berry ([10:04])
  • “Good to know there are effective treatments for PMS and PMDD.” – Sierra ([10:30])

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4. Pain Management for IUD Insertion (11:15–12:32)

• Key Points:

  • IUD placement is painful; past guidelines did not recommend routine analgesia.
  • 2024 US SPR guidelines now recommend counseling and patient-centered pain management plans.
  • Effective interventions: Lidocaine paracervical block, topical lidocaine; supported by multiple RCTs.
  • Post-insertion: Tramadol and naproxen are effective.
  • Barriers: Time, medication stock, procedural training.
  • Trauma-informed care should be emphasized to avoid perpetuating systemic biases.
  • Family physicians should feel “empowered” to offer a spectrum of pain relief options.

• Notable Quotes:

  • “We can further perpetuate manifestations of trauma by minimizing pain. This can further add to trauma rooted in oppressive systems of sexism and racism...” – Steve ([12:01])
  • “Hopefully family physicians feel empowered by this new recommendation...” – Sierra ([12:23])

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5. Noninvasive Liver Fibrosis Staging in Chronic Hepatitis C (12:32–14:37)

• Key Points:

  • Staging fibrosis affects treatment decisions for hepatitis C.
  • Scores:
    • FIB-4, FORNS: Use age/lab data to estimate fibrosis.
    • Both show moderate accuracy—at low cutoffs, sensitivity ~81%, specificity ~62% for advanced fibrosis.
    • High FORNS index is 97% specific at higher thresholds.
  • Guideline: Use FIB-4 plus other noninvasive tests (e.g., FibroSure, FibroScan).
  • Both scores can be used for initial staging (Strength of Recommendation C).

• Notable Quotes:

  • “The take-home here is both measures may be used for initial fibrosis staging.” – Steve ([14:25])

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6. Cold Water Immersion for Muscle Soreness (14:37–16:14)

• Key Points:

  • Evidence supports cold water immersion (<10–15 min, <15°C) improves perceived recovery and may delay onset of muscle soreness after high-intensity/resistance exercise.
  • A-level recommendation (consistent, good-quality patient-oriented evidence).
  • Superior to passive recovery for strenuous exercise, but not for eccentric exercise.
  • Longer immersion (>15 min) offers no added benefit.
  • Host skepticism about blinding due to psychological effects of cold water exposure; acknowledged as a research limitation.

• Notable Quotes:

  • “If you put yourself through the torturous experience of a cold water immersion, you're going to believe that it's helpful.” – Steve ([15:53])
  • “So maybe I should consider cold water immersion if I ever start exercising regularly.” – Sierra ([16:14])

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Notable Quotes & Memorable Moments

• “Dang, that is super impressive.” – Marian ([03:53]), reflecting on buprenorphine’s efficacy.
• “137 randomized controlled trials is insane.” – Steve ([06:08]), on the scale of the migraine meta-analysis.
• “We can further perpetuate manifestations of trauma by minimizing pain.” – Steve ([12:01]), discussing trauma-informed care with IUDs.
• “If you put yourself through the torturous experience of a cold water immersion, you're going to believe that it's helpful.” – Steve ([15:53]), questioning study blinding.

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Timestamps for Major Segments

• Buprenorphine for Opioid Use Disorder: 00:34–05:28
• Triptans for Acute Migraine: 05:39–06:55
• PMS and PMDD: 06:55–10:30
• IUD Pain Management: 11:15–12:32
• Liver Fibrosis Staging: 12:32–14:37
• Cold Water Immersion for Muscle Soreness: 14:37–16:14

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Closing Remarks

This episode provides concise, evidence-based updates on core questions in family medicine, blending authoritative guidance with practical, real-world discussion. The hosts’ conversational tone, use of notable evidence summaries (e.g., NNT values, meta-analyses), and patient-centered advice make this episode especially valuable for practicing clinicians aiming to keep pace with advances across multiple domains of family care.

Transcript

[A]

The AFP Podcast is sponsored by the American Academy of Family Physicians and by the journal fpm. FPM Journal provides you with simple yet powerful solutions to your everyday practice challenges. Available in print and online. Subscription information is [e-mail] FPM welcome to the American Family Physician Podcast for part two of the April 2025 issue. I'm Steve.

[B]

I'm Marian.

[C]

And I'm Sierra.

[A]

We are residents and faculty, mostly residents, from the University of Arizona College of Medicine, Phoenix Family Medicine Residency. Today on the podcast we're going to talk about buprenorphine for opioid use disorder, triptans for acute migraine premenstrual syndrome, pain management for IUD insertion, liver fibrosis, stage and chronic hepatitis C infection, and cold water immersion for muscle soreness.

[C]

The opinions expressed in the podcast are.

[B]

Our own and do not represent the.

[C]

Opinions of the American Academy of Family.

[B]

Physicians, the editor of American Family Physician or Banner Health. Do not use this podcast for medical advice.

[C]

Instead, see your own family doctor for medical care. We're on a mission Delivering the Best.

[A]

From American Family Physician.

[C]

Delivering the Best.

[A]

All right, we're going to start with common questions about buprenorphine treatment for opioid use disorder. This is from Dr. Teamstra from Wisconsin.

[C]

Opioid agonist medications are the most effective treatments for moderate or severe opioid use disorder.

[B]

Methadone, a full opioid agonist, is only distributed by regulated specialty clinics.

[A]

Buprenorphine is a mixed agonist antagonist and can be prescribed by all family physicians with Schedule 3 authority.

[C]

Both treatments lower patient mortality rates by more than 50%, and they have similar retention rates and efficacy. Compared to methadone, buprenorphine has been shown to have a lower risk of misuse, cardiac arrest and death.

[B]

The United States Preventive Services Task Force recommends screening all adults for for unhealthy drug use if services are available.

[A]

The US Food and Drug Administration has approved buprenorphine and the combination of buprenorphine naloxone for use in patients 16 years and older.

[C]

Naloxone is a full opioid antagonist, poorly absorbed, buccally and sublingually. Its combination with buprenorphine, then, is to discourage the misuse of prescribed oral buprenorphine through injection or insufflation.

[B]

The usefulness of these combination formulations is questioned in recent research, but their use.

[A]

Is still accepted practice except for in pregnant patients. Naloxone is not approved for use in.

[C]

Pregnancy because buprenorphine is a partial opioid agonist. Patients undergoing standard induction therapy should stop their usual opioids for 12 to 24 hours until they are in mild withdrawal which is a result of eight or more on the clinical opioid withdrawal scale.

[B]

The standard induction approach uses doses of 2-8mg per day with daily titration for the highest rates of treatment success. Target maintenance dosage is between 16 to 32 milligrams per day.

[A]

Also, there's a high dose induction approach which starts at 16 milligrams per day or more to immediately prevent spontaneously withdrawal and that can be useful if close follow up is not available.

[C]

Our [e-mail] report a number needed to treat of two with buprenorphine greater than or equal to 16 milligrams to retain a patient in treatment compared to placebo.

[B]

Dang, that is super impressive. Behavioral therapy should be offered to patients but should not be a required treatment for buprenorphine therapy as it does not change treatment outcomes.

[A]

Also, the discontinuation of concurrently prescribed benzodiazepines or stimulants should not be a requirement to start or continue buprenorphine. While these medications combined with buprenorphine may be associated with a little higher risk of overdose, this risk is outweighed by the risk of withholding treatment for opioid use disorder.

[C]

Patients should have frequent drug testing to confirm patient use of treatment and to evaluate for illicit drug use which correlates to an increase in overdose risk.

[B]

The metabolite norbufenorphine at a level roughly equal to or greater than the level of buprenorphine in urine confirms regular dosing rather than a sample alteration.

[A]

I did not know that sample validity can be confirmed through means other than observation of collection. That's great. Positives on point of care Testing should be sent for confirmatory testing when there.

[C]

Are concerns about inconsistent buprenorphine use or other substance use. Discontinuing treatment may not be appropriate given the risks of overdose and death. Instead, providers should consider closer follow up, engaging other resources and or referral to inpatient or intensive outpatient programs.

[B]

In short, the mortality risk of untreated opioid use disorder means that the use of opiate agonist medications to treat moderate to severe opioid use disorder should be considered in almost every circumstance.

[C]

These medications should be continued indefinitely if they provide benefit. The risk of relapse after discontinuation only starts to decrease after 12 months or more of treatment.

[A]

Now we have a poem. Poems are patient oriented evidence that matters. This poem is entitled Triptans outperform older and newer treatments for acute migraine. This is from Dr. Shaughnessy.

[B]

This meta analysis looked at 137 randomized control trials with about 89,000 adults who were treated for an acute migraine with 17 different medications ranging from analgesics to triptans. The study did not include adults who went to the emergency department for their migraines.

[A]

137 randomized controlled trials is insane. The meta analysis used sumatriptan as the standard and only found Ella Tryptan produced on average greater pain relief at 2 hours and also requirement of less rescue drugs in the first 2 to 24 hours.

[C]

Thus, this study found triptans to be more effective than other migraine agents, including newer treatments like use Ubrogepant, Remedipant and Lasmiditan.

[B]

It's important to note that although triptans were superior, this poem did not look at medications that may be superior for patients with status migrainosis or chronic migraines.

[C]

Like the title says, triptans outperform other medications for acute migraine. This is level of evidence 1a next.

[A]

Premenstrual syndrome and Premenstrual Dysphoric Disorder Common questions and answers from Drs. Biggs, Rameau and Godard from Central Michigan in Saginaw, Michigan.

[B]

We'll use the word women here to describe cisgender women and other people with.

[A]

Female sexual anatomy okay Sierra, so what is PMS or premenstrual syndrome?

[C]

PMS is a clinical diagnosis where women must report at least one effective or somatic symptom five days prior to the start of their menses, and the symptoms must resolve within four days after starting their menses. It also must happen for at least two cycles.

[B]

The timing of this is important in premenstrual dysphoric disorder as well. If the symptoms occur outside of the luteal phase and menses, it's not PMS or pmdd.

[A]

Affective symptoms include anger, outbursts, anxiety, confusion, depression, irritability, and social withdrawal.

[C]

Somatic symptoms can include things like abdominal bloating, breast tenderness or swelling, headaches, joint or muscle pain, swelling in the extremities, and weight gain.

[B]

Lets discuss PMDD or Premenstrual Dysphoric Disorder Next. PMDD is a type of depressive disorder in the DSM 5.

[A]

We've already talked about the timing of the symptoms, but with pmdd, patients must have at least five somatic or affective symptoms and these symptoms must lead to clinically significant distress and interfere with daily activities of life.

[C]

Another similarity between PMS and PMDD is that neither can be better explained by another disease like hyperthy or depressive disorder, alcohol use or drug use.

[A]

All right, so Marian, we discussed how to diagnose these disorders. What about treatment?

[B]

First line treatment for PMS and PMDD are SSRIs like fluoxetine or escitalopram. There is a grade evidence showing that SSRIs are an effective treatment and a systematic review showing that continuous dosing of SSRIs appear to be more effective than pulse dosing.

[C]

There is also evidence showing that combined oral contraceptives may improve somatic PMS symptoms but are unlikely to help with mood symptoms.

[B]

A third line treatment is gonadotropin releasing hormone agonists to suppress ovulation like leuprolide, but this should only be used in refractory pmdd.

[A]

If you have patients who are not interested in medications, there's evidence that cognitive behavioral therapy can reduce some of the somatic and effective symptoms of PMS and pmdd. One small randomized study found fluoxetine and CBT were equally effective at six months, but that fluoxetine was with a more rapid improvement.

[B]

There is also some evidence that exercise can reduce physical and psychological symptoms of PMS compared to no exercise, although the conclusions from these studies were hard to interpret since the exercise regimens differed in each study.

[C]

Another complementary treatment is Vitex, Agnus Castus or Chaste Berry. There is a meta analysis suggesting that it may be as effective as SSRIs or some oral contraceptives in treating PMS. However, the evidence was limited, low quality data and had publication biases.

[A]

I know Sierra, that you love fun facts. So the interesting fact about Chaste Berry. It's named that because it can decrease libido.

[B]

Chaste Berry can also come with other side effects like diarrhea, vomiting, fatigue and headaches. However, it's generally well tolerated and is possibly effective for pms. However, there are theoretical interactions with contraceptive medications and antipsychotics, so use it with caution in these groups of people.

[C]

Good to know there are effective treatments for PMS and pmdd.

[B]

We'll be right back.

[A]

The AFP podcast is brought to you by the American Academy of Family Physicians and by the AAFP's upcoming Family Centered Pregnancy Care course happening August 25th through the 28th in Denver, Colorado. Arrive early for Advanced Life Support Obstetrics courses for providers and instructors early Register [e-mail] fcpc2025. Okay, we have an editorial. Pain Management for IUD Insertion in primary care from Dr. Charles Nagarsheth and Oschman from Southern Illinois University and the University of Michigan.

[B]

I'm so glad to be talking about this because IUD insertion is known to.

[C]

Be painful and guidelines historically have not recommended routine analgesia.

[A]

Now we have a guideline that recommends all patients be counseled and provided with a patient centered plan for pain management.

[B]

This guideline is the 2024 US Selected Practice Recommendations for Contraceptive Use two interventions.

[C]

That may reduce pain are lidocaine, paracervical block and topical lidocaine.

[A]

This recommendation is based on multiple randomized controlled trials.

[B]

A recent article, an American Family Physician concluded that tramadol and naproxen are effective in the post insertion period.

[C]

Barriers to use of appropriate analgesia include time, office stock of pain medications and procedural training in paracervical block.

[A]

An ACOG committee notes that we need to be trauma informed when recommending IUDs. We can further perpetuate manifestations of trauma by minimizing pain. This can further add to trauma rooted in oppressive systems of sexism and racism in our healthcare system.

[B]

Table 1 shows your pain medication options.

[C]

Hopefully family physicians feel empowered by this new recommendation to offer the full spectrum of pain management options for IUD insertion.

[A]

Okay, let's do a Cochrane for Clinicians Liver fibrosis stage based on the Fibrosis 4 score or the FORNS index in adults with chronic hepatitis C virus infection. This is from Doctors Sonoda and messenger from St. Louis and Pittsburgh.

[C]

The clinical question here is can the fibrosis 4 score and or the FORNS index accurately predict significant or severe liver fibrosis in adults with chronic hepatitis C virus infection?

[B]

Before we prescribe direct acting antiviral drugs for chronic hep C we need to know the liver fibrosis stage.

[A]

Yeah and it would be nice to be able to determine the stage non invasively.

[C]

Stages go from F0 absence of fibrosis to F3 severe or advanced fibrosis and F4 cirrhosis.

[B]

Both the Fib4 score and the foreign score use age and lab values to predict a level of fibrosis.

[A]

This Cochrane review included 84 cross sectional or case control studies with a total of over 100,000 patients.

[C]

It's rated as low or very low quality evidence.

[B]

Like with all tests, when you adjust the cutoff it changes the sensitivity and specificity dial up the sensitivity and the specificity dial goes down.

[A]

They're linked forever at a low cutoff 1.45. On the Fib 4 score the sensitivity is 81% and specificity 62% for predicting F3 or higher fibrosis. This is a negative likelihood ratio of 0.3, so not that great.

[C]

The foreigns index is similar.

[A]

Yeah, although a high foreigns index is 97% specific. When you use a super high cutoff likelihood ratio of 12.5, that pretty much rules insignificant fibrosis.

[B]

A recent guideline recommends the use of fib4score in combination with other non invasive testing like a fibrochure or fibroscan.

[A]

The take home here is Both measures may be used for initial fibrosis staging.

[C]

This is a C strength recommendation, but.

[B]

These scores seem like a good place to start.

[A]

Okay, we have an FPIN Help Desk Answer this edition's Family Physician Inquiries Network's Help Desk answer addresses the clinical question question, which is a good clinical question. Does cold water immersion after exercise reduce muscle soreness? This article is written by Drs. Carden and Pulsifer from Nellis Air Force Base in Nevada.

[B]

So Sierra, what's the evidence based answer?

[C]

I'm glad you asked. Cold water immersion immediately after exercise can improve perceived recovery and delay the onset of muscle soreness in the 24 hours after high intensity and resistance exercise. Short immersion times of less than 10 to 15 minutes at temperatures below 15 degrees Celsius have the most consistent benefits. Both of these answers are A level recommendations according to the Strength of Recommendation Taxonomy.

[A]

An A level recommendation for those of us who don't remember, this is a recommendation based on consistent and good quality evidence of patient oriented outcomes. In this case, it came from a systematic review and meta analysis of dozens of randomized controlled trials.

[B]

These trials did indicate that cold water immersion was superior to passive recovery for high intensity or strenuous exercise. They did not show statistically significant benefit of cold water immersion after eccentric exercise.

[A]

Wait, I have an editorial comment.

[C]

I'll allow it.

[A]

All right. I'm concerned about the blinding because obviously if you put yourself through the torturous experience of a cold water immersion, you're going to believe that it's helpful.

[C]

Fair enough.

[B]

Also, longer immersion times after strenuous exercise of greater than 15 minutes did not show the same positive effects on recovery.

[C]

So maybe I should consider cold water immersion if I ever start exercising regularly. Please email us at AFPP podcastafe or tweet fppodcast. Please rate and comment wherever you get your podcasts.

[B]

Escucha nos en espanol en Revista America A ffp. Our podcast team is Christopher Alvarez, Jake Anderson, Steve Brown, Sarah Coles, Marian Dawson.

[C]

Hayley Hochstein, Nadia Mohammed, Satyam Patel, Valeria Vasquez Sydney Vowles and Sierra Voy.

[B]

Our sound and technical guru is Tyler Coleslaw. Our theme song is written and recorded by family physicians Bill Dabbs, Ryan Evans and Justin Jenkins.

[C]

This podcast is brought to you by the residents and faculty of the University of Arizona College of Medicine, Phoenix Family Medicine Residency.

[B]

We'll talk to you soon for the.

[A]

Next edition of the American Family Physician Podcast.