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12 November 2013 Annals of Internal Medicine Tip Sheet

Below is information about articles being published in the September 17 issue of Annals of Internal Medicine. The information is not intended to substitute for the full article as a source of information. Annals of Internal Medicine attribution is required for all coverage.

1. Insufficient evidence that multivitamins prevent cancer, cardiovascular disease or death

A systematic review of published studies found insufficient evidence that vitamin and mineral supplements are effective for preventing cardiovascular disease (CVD), cancer, or mortality from those diseases in healthy adults, according to an article published in Annals of Internal Medicine (http://www.annals.org/article.aspx?doi=10.7326/0003-4819-159-12-201312170-00729). Two studies included in the review found lower overall cancer incidence in men who took a multivitamin for over 10 years. Those same studies showed no cancer protection benefit for women. Researchers caution that these results should not be overgeneralized and that more research is needed before it can be determined whether or not multivitamin supplementation is beneficial. The evidence review was conducted by researchers for the United States Preventive Services Task Force (USPSTF) to update its previous recommendation. In 2003, the USPSTF found insufficient evidence to recommend for or against the use of vitamins A, C, and E, multivitamins with folic acid, or anti-oxidant combinations for the prevention of CVD or cancer. At the time, the USPSTF recommended against beta-carotene supplements alone or in combination with other supplements because they had no benefit and actually harmed patients at risk for lung cancer. The current research review reconfirmed the beta-carotene findings and also found good evidence that Vitamin E does not protect against cancer or cardiovascular disease.

2. Few high-quality guidelines exist for prescribing opioids to pain patients

Rigorous clinical practice guidelines could help physicians reduce rates of opioid misuse and overdose deaths among patients with chronic pain, according to an article published in Annals of Internal Medicine (http://www.annals.org/article.aspx?doi=10.7326/0003-4819-160-1-201401070-00732). Over the past two decades, rates of opioid abuse and overdose deaths have increased dramatically, highlighting the need for high-quality prescribing guidelines. Recent efforts have focused on redefining standards of care for patients with chronic pain, who may be prescribed opioids for long-term use. Researchers reviewed 13 published opioid prescribing guidelines to evaluate the quality of guidelines on using opioids to treat chronic pain and to compare recommendations related to mitigating risks for overdose and misuse. The quality of evidence that guidelines provided in support of their recommendations was also assessed. While the methods for development and clinical emphasis of the guidelines varied, the researchers found consensus across several important areas. All of the guidelines agreed on using upper dosing thresholds; exercising caution with certain medications; paying attention to possible interactions with other medications or diseases; and using risk assessment tools, treatment agreements, and urine drug testing to reduce abuse. The guidelines differed greatly in quality, however. Only two of the 13 guidelines assessed received high ratings based on their evidence and methods. Seven other guidelines were found to be of intermediate quality and the reviewers recommended against using the remaining four.