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

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.

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])

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])

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])

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])

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])

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])

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.

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

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.