By Ruth Craig, Emerita Professor, Pharmacology and Toxicology, Dartmouth College. Beds with patients in an emergency hospital in Camp Funston, Kansas, during the influenza epidemic around 1918. National Museum of Health and Medicine., CC BY Vaccination is underway for the 2017-2018 seasonal flu, and next year will mark the 100-year anniversary of the 1918 flu pandemic, which killed roughly 40 million people. Continue Reading →
A duo of French scientists said Wednesday they may have found a physiological, and seemingly treatable, cause for dyslexia hidden in tiny light-receptor cells in the human eye. In people with the reading disability, the cells were arranged in matching patterns in both eyes, which may be to blame for confusing the brain by producing “mirror” images, the co-authors wrote in the journal Proceedings of the Royal Society B. Continue Reading →
America’s opioid crisis is getting worse. The role of prescription opioids has both the medical establishment and the government justifiably worried.
In response, the National Academies of Science, Engineering and Medicine released an official report on the crisis earlier this year. And, on September 21, the National Academy of Medicine released a special publication calling clinicians to help combat the crisis.
As a bioethicist working on the ethical and policy issues regarding prescription opioids, I am grateful to the National Academy of Medicine for inviting me to serve on this publication’s authorship team, and for taking seriously the ethical component of the prescription opioid crisis. The opioid epidemic is shot through with ethical challenges.
There are many discussions we could have, but I will here focus on just one of them: the issue of morally responsible prescribing. Should prescription opioids be used at all? And if so, how? The question is obviously important for clinicians, but the rest of us – patients – should understand what our doctors and nurses owe us regarding our care.
Two public health crises
One of the central challenges of the opioid epidemic is figuring out how to respond without harming pain patients.
If opioids prevent significant suffering from pain, then the solution to the prescription opioid problem cannot simply be to stop using them. To do so would be to trade one crisis (an opioid crisis) for another (a pain crisis).
The data suggest, however, that pain patients’ interests will not always run counter to the goal of curbing the opioid crisis. The evidence favoring opioid therapy for chronic, noncancer pain is very weak, and there’s some evidence that opioid therapy can actually increase one’s sensitivity to pain.
Opioid therapy also comes with significant costs – the risk of addiction and the potential for drowsiness, constipation, nausea and other side effects.
As a result, more of the medical community is realizing that opioids are simply not good medications for chronic, noncancer pain. Getting patients off long-term opioid therapy may well improve their lives.
Should we use opioids at all?
It would be nice if we could simply stop using opioids. But the situation is rather more complicated than that.
Even if opioid therapy shouldn’t be first-line (or even second-line) treatment for chronic pain, that doesn’t mean that it won’t work for anyone. Patients are individuals, not data points, and risks of opioid therapy – as well as the risks of not providing pain relief – are not the same for everyone.
This is important because debilitating chronic pain can lead to a life that seems not worth living, and sometimes even to suicide. In the face of life-destroying pain, if we run out of other options, it’s not clear that we should avoid using a third-line treatment in the hopes of saving a life.
Those who have been on high doses of opioids for years or decades pose another serious challenge. Many of these patients are concerned about the backlash against opioids. Some believe that the opioids are saving their lives. Others may be terrified of going into withdrawal if their medication is taken away.
If we move away from opioid therapy too abruptly, physicians may abandon these patients or force them to taper before they are ready. Tapering, under the best of circumstances, is a long, uncomfortable process. If it’s badly managed, it can be hell. The health care system created these patients, and we don’t get to turn our backs on them now.
Finally, opioids are important medications for acute, surgical and post-traumatic pain. Such pain can require long-term treatment when a series of surgeries stretches out for months, or when a traumatic injury requires a long, painful recovery. In these cases, opioids often make life manageable.
Although calls to limit opioid prescriptions generally don’t target these patients, we might reasonably worry about shifting attitudes. If medical culture becomes too opioid-phobic, who will prescribe for these patients?
Fighting the epidemic with nuance will require constant vigilance. In the new National Academy of Medicine publication, we suggest a number of ways that clinicians can work toward responsible prescribing and management of opioids.
In short, clinicians must prescribe opioids only when appropriate, employing nonopioid pain management strategies when indicated. Evidence supports the use of acetaminophen and ibuprofen, as well as physical therapy, exercise, acupuncture, meditation and yoga.
Clinicians must also be willing to manage any prescriptions they do write over the long term. And, at every stage, prescribers should collaborate with others as needed to ensure that patients receive the necessary care.
Although clinicians shouldn’t be “anti-opioid,” they should be justifiably wary of prescribing for chronic, noncancer pain. And when a prescription is appropriate, the clinician should not write for more than is needed.
Patients should go into opioid therapy with a rich understanding of the risks and benefits. They should also have a plan of care, including an “exit strategy” for getting off the medication.
A role for nonclinicians?
The suggestions above may seem straightforward, and perhaps even obvious. So it’s important to point out that this work is time-consuming and sometimes – as in the case of high-risk patients – challenging. Counseling, advising and trying to avoid unnecessary opioid use is much more difficult than writing a quick prescription.
Although this difficult work is still the clinician’s responsibility, the rest of us can make it easier for them to do their job well. After all, no one likes to experience unnecessary pain. Our expectation of powerful pain relief is part of the cultural backdrop of the epidemic.
That expectation is going to have to change. Moderate acute pain from injury, dental procedures or whatever may have yielded a prescription for Percocet or Vicodin in the past. And when we are the ones in pain, we might still prefer that doctors hand out such medication like candy. But the opioid epidemic is teaching us that we don’t, in fact, want that to be clinicians’ standard practice. We shouldn’t demand exceptions for ourselves.
My parents both smoked, and I always complained it was making me sick. My mother accused me of “just wanting attention!” Yeah, I wanted her to pay attention and stop making me sick.
“Medical Daily is pleased to announce it will soon be part of Newsweek. There, you will find the same stories on the latest news about health, fitness, nutrition, and relationships to enhance your life.” Cigarette smoke seeps into everything—clothing, furniture, rugs. Now, researchers at the University of California, Riverside, suggest that even this third-hand smoke (THS)… Continue Reading →
I was just arguing with a friend about this. He thought I would be a lot more productive if I didn’t watch so much teevee.
I said that was how my brain rests, and that it actually made me more productive.
Now there’s a whole book about resting your brain, which I am all for! (It’s on my Amazon wish list and my birthday’s in two weeks. Just saying.) And Ian Welsh has reviewed it:
Too many people today think that working more equals working better. It’s not that that’s never the case; in many jobs and disciplines, the simplest and best way to increase what you get done is to just add more hours.
But that prescription, startlingly popular among many, has always struck me as dubious when it comes to anything creative. Speaking personally, even when perfectly healthy and happy, after more than about four hours of concentrated creative work my brain turns to mush. Work done after that time is not only non-productive, it’s likely to be so filled with mistakes that it’s counterproductive.
If I want to work more than that, the best strategy is to work about three hours and then rest. Best is to take a full sleep cycle nap of about 90 minutes to two hours. Then I can do another two to three hours.
And that’s it.
Further, the best strategy when working on a specific project which requires me to come up with ideas is to completely splurge, learning everything I can about the subject, over however long that takes (in four to five hour daily segments), and then to do something else.
The “something else,” and ideally that involves not work, but rest or play, is necessary, and it is during that time at some point, perhaps in the shower, after a nap, or during a long walk, that the key ideas will occur. They rarely occur during the study period, unless they are fairly obvious.
This is the prescription given by Graham Wallas in The Art of Thought and far more succinctly by ad-man James Webb Young in A Technique For Producing Ideas and it is at the core of Rest:
Prepare by immersing yourself.
Try to solve the problem.
Give up and rest.
By Deirdre Conroy, Clinical Associate Professor of Psychiatry, University of Michigan. Results may vary. Stokkete/shutterstock.com If you speak to someone who has suffered from insomnia at all as an adult, chances are good that person has either tried using marijuana, or cannabis, for sleep or has thought about it. This is reflected in the many variations… Continue Reading →
It’s a big step forward for a controversial treatment. ‘Molly’ tablets often don’t contain much MDMA, because they’re packed with fillers. The purest way to get MDMA is in crystal form. Depositphotos Ecstasy doesn’t sound like something you do in a doctor’s office. But the Food and Drug Administration wants that to change. The FDA just… Continue Reading →
A new study published in the Journal of Athletic Training claims that girls are 56 percent more likely to sustain concussions in high school sports that are played by both girls and boys, including softball, cross-country, soccer, crew, lacrosse, baseball and basketball.
The concussion rates in girls were four times that of boys in softball and baseball. However, boys are less likely to report occurrences than girls are, which may account for the discrepancy, according to the authors of the study.
The study was conducted by Dr. Zachary Y. Kerr at the University of North Carolina at Chapel Hill using data from NATION (the National Athletic Treatment, Injury and Outcomes Network). Kerr and his team evaluated concussion rates between 2011 and 2014 in 27 sports played at 147 high schools in 26 states across the U.S.
They found that there were four concussions in all sports per 10,000 athletes playing in both practices and competitions. In addition, per 10,000 athletes, there were:
- 9.21 concussions in football
- 6.65 concussions in boys’ lacrosse
- 6.11 concussions in girls’ soccer
Sixty percent of the boys’ concussions, and 40 percent of the girls’ concussions, were the result of player-to-player contact. The most common cause of concussions in girls was improper contact with their equipment.
The authors suggested that in soccer, there is a larger ratio between the size of the ball and girls’ necks as compared to the size of boys’ necks; this may explain the higher rate of concussions in girls’ soccer than in boys’ soccer.
Repeat injuries were reported in only three percent of the injuries; these were most common in girls’ field hockey, followed closely by football and girls’ lacrosse. No concussions were reported in the following sports: swimming and diving, cross-country, golf and boys’ crew.
Also, concussions were much more common — up to three times — when the athletes were competing, rather than just practicing.
Furthermore, injuries in high school athletes were higher in boys’ soccer and football than in collegiate athletes, suggesting the need for greater preventative measures, player training for safer blocking and tackling, and game rules preventing or limiting risky contact, and awareness among younger athletes.
Symptoms of concussions, which usually disappear in two weeks, include the following:
- Difficulty concentrating
- Sensitivity to noise or light
However, nearly 25 percent of these students required more than 28 days to recover.
Attorney Sean Domnick commented, “With more than eight million high school students playing sports every year, and more than two million of these students competing in high-risk sports, parents, schools and student-athletes need to be more aware of the risks associated with these activities and proactively prevent situations that will lead to injury.”
I didn’t get any sleep at all Tuesday night, because I had this throbbing pain in my calf and I began to worry it was a blood clot.
But I had to work Wednesday morning, and then I was supposed to drive to a friend’s house for a few days off. Instead, I spent several hours in Penn’s emergency room. They finally said they couldn’t find anything on the ultrasound, but my blood test came back positive. So I’m supposed to have a followup.
I’m not all that worried, because I quickly came across research showing a high false-positive test in people over 60.
The guy who took my blood told me he voted for Gary Johnson. “I really wanted Bernie, and I hate Hillary. No way was I voting for her,” he said.
“You’re voting as if we have a parliamentary system. You handed your vote to Trump,” I said, testy.
“That’s what we need: a third party,” he said.
“And how do we do that without a constitutional convention, which is exactly what the Kochs and the Mercers want?” I said. “Most states are controlled by Republicans. You have no fucking idea what harm that could do.” I could feel my blood boil.
That why I’m off to a friend’s house today, and I am going to try to unplug for a few days. Boohunney and Ron will be filling in, so be good and don’t wreck the place while I’m gone. No keggers!