Part 2 - We Were Wrong 20 Years Ago, Our Current Response to the Opioid Crisis is Wrong, But We Should Still Be Helping Most of our Long-Term Patients Reduce Their Opioid Doses

by Drew Rosielle (@drosielle)This is the second in a series of several posts about many aspects of my current thinking about opioids.The first post is here:Part 1 – Introduction, General Disclaimers, Hand-Wringing, and a Hand-Crafted Graph.Over-prescribing fueled the current drug overdose epidemic, and many of us who thought we were stamping out needless suffering contributed to the epidemic.A lot of what I read and believed about opioids early on in my career was wrong.I ’m old enough to remember those heady days in which there was a pretty large and ‘successful’ movement in American medicine to greatly liberalize opioid use for all sorts of pain syndromes...pain as the 5th vital sign, discussions of there being a tort for undertreating pain, etc. In my own wa y, I was part of the movement, although I was trained at the beginning of the end of the movement.There was a utopian feeling in the air at the time:pain is a terrible scourge, it ’s under-diagnosed and under-treated, it’s this huge cause of all this disability and needless suffering, and liberalizing the availability of opioids would be a key intervention to transform all these suffering people’s lives for the better.We were wrong.Opioid prescribing and availability did increase markedly, but population levels of pain and disability didn ’t improve. Most people’s lives were not transformed for the better, and at least some were ruined via iatrogenic opioid use diso...
Source: Pallimed: A Hospice and Palliative Medicine Blog - Category: Palliative Care Tags: opioids pain rosielle The profession Source Type: blogs

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Papillary thyroid cancer (PTC) is the most common form of differentiated thyroid cancer in the pediatric population and represents the second most common malignancy in adolescent females. Historically, PTC has been classified on the basis of histology, however, accumulating data indicate that molecular subtyping based on somatic oncogenic alterations along with gene expression profiling can better predict clinical behavior and may provide opportunities to incorporate oncogene-specific inhibitory therapy to improve the response to radioactive iodine (RAI). In this issue of the JCI, Y.A. Lee, H. Lee, and colleagues showed th...
Source: Journal of Clinical Investigation - Category: Biomedical Science Authors: Source Type: research
Dementia resulting from small vessel diseases (SVDs) of the brain is an emerging epidemic for which there is no treatment. Hypertension is the major risk factor for SVDs, but how hypertension damages the brain microcirculation is unclear. Here, we show that chronic hypertension in a mouse model progressively disrupts on-demand delivery of blood to metabolically active areas of the brain (functional hyperemia) through diminished activity of the capillary endothelial cell inward-rectifier potassium channel, Kir2.1. Despite similar efficacy in reducing blood pressure, amlodipine, a voltage-dependent calcium-channel blocker, p...
Source: Journal of Clinical Investigation - Category: Biomedical Science Authors: Source Type: research
BACKGROUND Molecular characterization in pediatric papillary thyroid cancer (PTC), distinct from adult PTC, is important for developing molecularly targeted therapies for progressive radioiodine-refractory (131I-refractory) PTC.METHODS PTC samples from 106 pediatric patients (age range: 4.3–19.8 years; n = 84 girls, n = 22 boys) who were admitted to SNUH (January 1983–March 2020) were available for genomic profiling. Previous transcriptomic data from 125 adult PTC samples were used for comparison.RESULTS We identified genetic drivers in 80 tumors: 31 with fusion oncogenes (RET in 21 patients, ALK in 6 patients,...
Source: Journal of Clinical Investigation - Category: Biomedical Science Authors: Source Type: research
Herculean efforts by the Wellcome Sanger Institute, the National Cancer Institute, and the National Human Genome Research Institute to sequence thousands of tumors representing all major cancer types have yielded more than 700 genes that contribute to neoplastic growth when mutated, amplified, or deleted. While some of these genes (now included in the COSMIC Cancer Gene Census) encode proteins previously identified in hypothesis-driven experiments (oncogenic transcription factors, protein kinases, etc.), additional classes of cancer drivers have emerged, perhaps none more surprisingly than RNA-binding proteins (RBPs). Over...
Source: Journal of Clinical Investigation - Category: Biomedical Science Authors: Source Type: research
Intratumoral T cells that might otherwise control tumors are often identified in an “exhausted” state, defined by specific epigenetic modifications and upregulation of genes such as CD38, cytotoxic T-lymphocyte–associated protein 4 (CTLA4), and programmed cell death 1 (PD1). Although the term might imply inactivity, there has been little study of this state at the phenotypic level in tumors to understand the extent of their incapacitation. Starting with the observation that T cells move more quickly through mouse tumors the longer they reside there and progress toward exhaustion, we developed a nonstimula...
Source: Journal of Clinical Investigation - Category: Biomedical Science Authors: Source Type: research
BACKGROUND Germline mutations in telomerase and other telomere maintenance genes manifest in the premature aging short telomere syndromes. Myelodysplastic syndromes and acute myeloid leukemia (MDS/AML) account for 75% of associated malignancies, but how these cancers overcome the inherited telomere defect is unknown.METHODS We used ultra-deep targeted sequencing to detect somatic reversion mutations in 17 candidate telomere lengthening genes among controls and patients with short telomere syndromes with and without MDS/AML, and we tested the functional significance of these mutations.RESULTS While no controls carried somat...
Source: Journal of Clinical Investigation - Category: Biomedical Science Authors: Source Type: research
INTRODUCTION: Major trauma often results in long-term disabilities. The aim of this study was to assess health-related quality of life, cognition, and return to work 1  year after major trauma from a trauma network perspective. METHODS: All major t...
Source: SafetyLit - Category: International Medicine & Public Health Tags: Economics of Injury and Safety, PTSD, Injury Outcomes Source Type: news
OBJECTIVES: Sexual trauma poses a significant concern and is associated with heightened stress, negative health repercussions, and adverse economic effects. A history of abuse may increase a woman's risk of developing cancer, in particular cervical cancer....
Source: SafetyLit - Category: International Medicine & Public Health Tags: Economics of Injury and Safety, PTSD, Injury Outcomes Source Type: news
FYI, limitations are being proposed for Epidural Injection as treatment option for chronic pain This proposed LCD on Epidural Procedures for Pain Management services was announced on June 10, 2021. This nationwide policy contains many onerous changes that will detrimentally affect patient access to care. ASIPP is aware and already contacting congress members, but getting your patients to complain can also help. Please see below for important points but one of the bigger points... Read more
Source: Student Doctor Network - Category: Universities & Medical Training Authors: Tags: Pain Medicine Source Type: forums
So I'm an applicant for this cycle to pain. I've been fortunate enough to receive 10ish interviews. Im an average applicant and therefore my interviews were from average programs. None of the BWHs and CCs for me. I'm having a hard time coming up with a rank list. I keep wanting to change things around. There is so little information about fellowships outside of interviews that its becoming hard for me to make decisions. Those of you that have gone through the process, what would you... Read more
Source: Student Doctor Network - Category: Universities & Medical Training Authors: Tags: Pain Medicine Source Type: forums
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