#*** I explained to the patient the risks of combining opioids and benzodiazepines based on medical literature. We agreed to slowly taper the patient off benzodiazepines and trial safer alternatives for sleep and anxiety issues.
#*** I showed the patient their fibromyalgia screening questionnaire results, which were consistent with a fibromyalgia diagnosis. Fibromyalgia can amplify other painful conditions and is often the primary source of morbidity when present with other chronic pain diagnoses.
#*** We discussed the patient's high risk opioid regimen based on their dose exceeding CDC guidelines. While willing to work on a harm reduction plan, it will require a taper or switching to buprenorphine due to safety concerns.
Planning for the future - when does the future start? Laura-Jane Smith
Presentation at PLAN Network event, on advance care planning in chronic respiratory disease. NB last few slides are resources for the group task, and references. Let me know i I missed any!
Planning for the future - when does the future start? Laura-Jane Smith
Presentation at PLAN Network event, on advance care planning in chronic respiratory disease. NB last few slides are resources for the group task, and references. Let me know i I missed any!
Depression is an insidious issue in the US and elsewhere. Lifestyle habits that are very different from our ancestral environment may be to blame, and one particularly problematic area is food choice. Depressive symptoms share much in common with the adaptive features of sickness behavior, which is functional when operating in an environment of ancestrally normal immune stressor. Modern diets likely activate the immune system (primarily the inflammatory response) and induce the cascade of adaptive responses that collective make up sickness behavior. Due to their similarities, these may then diagnosed as depression. In this talk, I discuss the links among diet, depression, and inflammation, as well as highlighting some specific dietary components that contribute to this response.
Impact of potential inappropriate nsai ds use in chronic painAbout Silvia Ussai
Pain remains one of the main reasons for medical consultation worldwide: moderate- to severe-intensity pain occurs in 19% of adult Europeans, seriously affecting the quality of their social and working lives. Nonsteroidal anti-inflammatory drugs (NSAIDs) are not recommended for long-term use and a careful surveillance to monitor for toxicity and efficacy is critical.
Sleep is a crucial health issue - but it is often ignored by both individuals and the medical community. Sleep has been shown to substantially impact almost every major health condition including Diabetes, Cancer, Obesity, Heart Disease, and Mental Health. It's time for sleep to take it's rightful place in keeping us health. This presentation gives some of the cold, hard facts behind why sleep is such a silent killer.
A Possible Role of Rosmarinic Acid against CD2 Associated Protein for the Tre...YogeshIJTSRD
Multiple sclerosis is a chronic inflammatory neurodegenerative disorder which directly affects Central Nervous System CNS . People with MS suffer with an episodic reversible memory loss during the initial stages and later it leads to the neurological deterioration. Number of research and studies has been done on the natural compounds and phytochemical compounds in order to develop the particular drug for the treatment of MS in vivo andin vitro. The present study focuses on the inhibitory effect of Rosmarinic acid against the effect of CD2 Associated protein with the help of Molecular Docking. Molecular Docking basically screens the ligand and the target protein and shows the interaction between them on the basis of the minimum binding affinities and drug likeliness properties. In our research, docking was performed between CD2 Associated protein and selected ligands with the help of docking software. Ligands were selected on the basis of their minimum Binding affinities and finally by their drug likeliness properties. Rosmarinic acid BA 5.6 was the resultant ligand of our recent study. It showed the perfect interaction with CD2 Associated protein. Therefore, we may conclude that Rosmarinic acid may act as a compound which may be used as a drug for the treatment of multiple sclerosis fromfurther in vitro and in vivostudies in future. Jitin Kumar | Tejaswee Anand | Ritika Sharma | Noopur Khare | Abhimanyu Kumar Jha | Yamini Dixit "A Possible Role of Rosmarinic Acid against CD2-Associated Protein for the Treatment of Multiple Sclerosis through in Silico Approach" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-5 | Issue-5 , August 2021, URL: https://www.ijtsrd.com/papers/ijtsrd44979.pdf Paper URL: https://www.ijtsrd.com/biological-science/biotechnology/44979/a-possible-role-of-rosmarinic-acid-against-cd2associated-protein-for-the-treatment-of-multiple-sclerosis-through-in-silico-approach/jitin-kumar
iCAAD London 2019 - Mel Pohl - CHRONIC PAIN AND ADDICTION: HOW WE MISSED THE...iCAADEvents
Chronic Pain occurs as a complicated web of emotions and physical symptoms. The most common way to treat pain is to use opioid medications, which actually complicate the course of chronic pain.
Depression is an insidious issue in the US and elsewhere. Lifestyle habits that are very different from our ancestral environment may be to blame, and one particularly problematic area is food choice. Depressive symptoms share much in common with the adaptive features of sickness behavior, which is functional when operating in an environment of ancestrally normal immune stressor. Modern diets likely activate the immune system (primarily the inflammatory response) and induce the cascade of adaptive responses that collective make up sickness behavior. Due to their similarities, these may then diagnosed as depression. In this talk, I discuss the links among diet, depression, and inflammation, as well as highlighting some specific dietary components that contribute to this response.
Impact of potential inappropriate nsai ds use in chronic painAbout Silvia Ussai
Pain remains one of the main reasons for medical consultation worldwide: moderate- to severe-intensity pain occurs in 19% of adult Europeans, seriously affecting the quality of their social and working lives. Nonsteroidal anti-inflammatory drugs (NSAIDs) are not recommended for long-term use and a careful surveillance to monitor for toxicity and efficacy is critical.
Sleep is a crucial health issue - but it is often ignored by both individuals and the medical community. Sleep has been shown to substantially impact almost every major health condition including Diabetes, Cancer, Obesity, Heart Disease, and Mental Health. It's time for sleep to take it's rightful place in keeping us health. This presentation gives some of the cold, hard facts behind why sleep is such a silent killer.
A Possible Role of Rosmarinic Acid against CD2 Associated Protein for the Tre...YogeshIJTSRD
Multiple sclerosis is a chronic inflammatory neurodegenerative disorder which directly affects Central Nervous System CNS . People with MS suffer with an episodic reversible memory loss during the initial stages and later it leads to the neurological deterioration. Number of research and studies has been done on the natural compounds and phytochemical compounds in order to develop the particular drug for the treatment of MS in vivo andin vitro. The present study focuses on the inhibitory effect of Rosmarinic acid against the effect of CD2 Associated protein with the help of Molecular Docking. Molecular Docking basically screens the ligand and the target protein and shows the interaction between them on the basis of the minimum binding affinities and drug likeliness properties. In our research, docking was performed between CD2 Associated protein and selected ligands with the help of docking software. Ligands were selected on the basis of their minimum Binding affinities and finally by their drug likeliness properties. Rosmarinic acid BA 5.6 was the resultant ligand of our recent study. It showed the perfect interaction with CD2 Associated protein. Therefore, we may conclude that Rosmarinic acid may act as a compound which may be used as a drug for the treatment of multiple sclerosis fromfurther in vitro and in vivostudies in future. Jitin Kumar | Tejaswee Anand | Ritika Sharma | Noopur Khare | Abhimanyu Kumar Jha | Yamini Dixit "A Possible Role of Rosmarinic Acid against CD2-Associated Protein for the Treatment of Multiple Sclerosis through in Silico Approach" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-5 | Issue-5 , August 2021, URL: https://www.ijtsrd.com/papers/ijtsrd44979.pdf Paper URL: https://www.ijtsrd.com/biological-science/biotechnology/44979/a-possible-role-of-rosmarinic-acid-against-cd2associated-protein-for-the-treatment-of-multiple-sclerosis-through-in-silico-approach/jitin-kumar
iCAAD London 2019 - Mel Pohl - CHRONIC PAIN AND ADDICTION: HOW WE MISSED THE...iCAADEvents
Chronic Pain occurs as a complicated web of emotions and physical symptoms. The most common way to treat pain is to use opioid medications, which actually complicate the course of chronic pain.
April 3, 2017
The current opiate epidemic has spurred long-overdue scrutiny on the pharmaceutical production and distribution of opiate medication, but it also raises questions of public policy and law regarding the regulation of medical access to and use of opiate medications with high potential for addiction. Expert panelists will address the challenges that arise from efforts to balance restrictions on access to opiates to limit addiction while also preserving sufficient access for legitimate medical management of pain.
Learn more on our website: http://petrieflom.law.harvard.edu/events/details/opiate-regulation-policies
ICH Guidelines for Pharmacovigilance.pdfNEHA GUPTA
The "ICH Guidelines for Pharmacovigilance" PDF provides a comprehensive overview of the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines related to pharmacovigilance. These guidelines aim to ensure that drugs are safe and effective for patients by monitoring and assessing adverse effects, ensuring proper reporting systems, and improving risk management practices. The document is essential for professionals in the pharmaceutical industry, regulatory authorities, and healthcare providers, offering detailed procedures and standards for pharmacovigilance activities to enhance drug safety and protect public health.
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
Health Education on prevention of hypertensionRadhika kulvi
Hypertension is a chronic condition of concern due to its role in the causation of coronary heart diseases. Hypertension is a worldwide epidemic and important risk factor for coronary artery disease, stroke and renal diseases. Blood pressure is the force exerted by the blood against the walls of the blood vessels and is sufficient to maintain tissue perfusion during activity and rest. Hypertension is sustained elevation of BP. In adults, HTN exists when systolic blood pressure is equal to or greater than 140mmHg or diastolic BP is equal to or greater than 90mmHg. The
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
The Importance of Community Nursing Care.pdfAD Healthcare
NDIS and Community 24/7 Nursing Care is a specific type of support that may be provided under the NDIS for individuals with complex medical needs who require ongoing nursing care in a community setting, such as their home or a supported accommodation facility.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
1. Structured Opioid Refill Clinic Epic Smartphrases
Alternatives to Benzodiazepines:
#*** I explained to @FNAME@ that the combination of opioids and benzodiazepines has
proven to be unsafe. [1,2] Moreover, a variety of non-benzodiazepine alternatives exist for sleep
disorders, anxiety, panic attacks, and agoraphobia. Consequently, I agreed to work with
@FNAME@ on a slow taper off *** and a trial of a safer alternative for @HIS@ ***sleep
disorder/anxiety/panic attacks/agoraphobia.
1.Patterns of Opioid Use and Risk of Opioid Overdose Death Among Medicaid Patients.
Garg RK, Fulton-Kehoe D, Franklin GM. Med Care. 2017 Jul;55(7):661-668.
2. Association between concurrent use of prescription opioids and benzodiazepines and
overdose: retrospective analysis. Sun EC, Dixit A, Humphreys K, Darnall BD, Baker LC, Mackey
S. BMJ. 2017 Mar 14;356:j760. doi: 10.1136/bmj.j760.
Breakthrough Pain:
#***Breakthrough pain: is a concept from palliative care that was introduced into the non-
cancer pain literature in the late 1980s. [1] Unfortunately, while the concept of transient
increases in pain at the end of life has a great deal of empirical evidence
to support it, the same is not true for non-cancer pain. Many non-cancer pain
and addiction specialists today feel that the term ‘breakthrough pain’ was introduced
Into the non-cancer pain lexicon without rigorous study. In hindsight, many experts today
would argue that, in the chronic non-cancer pain setting, the phenomenon
Likely represents little more than the development of tolerance.
1.Oncology (Williston Park). 1989 Aug;3(8 Suppl):25-9. Breakthrough pain: definition and
management. Portenoy RK1, Hagen NA.
Doctor Shopping (Z76.5):
#*** Doctor shopping: In 2013 fewer than 0.5% of Oregonians obtained opioid prescriptions from
4 or more prescribers or pharmacies. Data from the CDC suggest that > greater than 4
prescribers or pharmacies increases the risk of an unintentional opioid overdose by ~6.5 fold.
[1] It is important to note that @FNAME@'s PDMP file indicates @HIS@ has obtained opioids
from *** prescribers in the prior year.
1. JAMA Intern Med. 2014 May;174(5):796-801. High-risk use by patients prescribed opioids for
pain and its role in overdose deaths. Gwira Baumblatt JA, Wiedeman C, Dunn JR, Schaffner W,
Paulozzi LJ, Jones TF.
2. FMS (M79.7):
#*** FMS: I showed @FNAME@ @HIS@ formal ACR fibromyalgia screening questionnaire and
explained that @HIS@ score of *** is consistent with the diagnosis. Fibromyalgia is a
‘centralized pain’ or ‘central sensitivity syndrome’ that results in a state of chronic hyperalgesia
or pain. Fibromyalgia accentuates other painful diagnoses by functioning as a pain amplifier.
Consequently, patients with fibromyalgia and other painful diagnoses - like back pain, or neck
pain, or abdominal pain, or arthritis pain - experience much higher pain levels than their non-
fibromyalgia counterparts. Most experts agree that, when present among an array of chronic
non-cancer pain diagnoses, fibromyalgia is the primary source of morbidity. [1-3]
I gave @FNAME@ our 'centralized pain' handout along with a link to Dr. Dan Clauw YouTube
video (https://www.youtube.com/watch?v=pgCfkA9RLrM&t=4s ) on evidence based treatment
for FMS. @CAPHE@ can return to clinic to discuss evidence-based treatment options after
watching Dr. Clauw's video.
1.Clin Exp Rheumatol. 2016 Mar-Apr;34(2 Suppl 96):S120-4. Epub 2016 Apr 6.The impact of
concomitant fibromyalgia on visual analogue scales of pain, fatigue and function in patients with
various rheumatic disorders.Levy O1
, Segal R, Maslakov I, Markov A, Tishler M, Amit-Vazina M.
2.Arthritis Care Res (Hoboken). 2017 Feb 9. doi: 10.1002/acr.23216. [Epub ahead of
print]Fibromyalgia Predicts Two-Year Changes in Functional Status in Rheumatoid Arthritis
Patients. Kim H, Cui J, Frits M, Iannaccone C, Coblyn J, Shadick NA, Weinblatt ME, Lee YC.
3.Clin Exp Rheumatol. 2017 May-Jun;35 Suppl 105(3):35-42. Epub 2017 Feb 8.Patient
phenotypes in fibromyalgia comorbid with systemic sclerosis or rheumatoid arthritis: influence of
diagnostic and screening tests. Screening with the FiRST questionnaire, diagnosis with the ACR
1990 and revised ACR 2010 criteria.Perrot S1
Peixoto M, Dieudé P, Hachulla E, Avouac J,
Ottaviani S, Allanore Y.
High risk opioid regimen:
#*** High risk opioid regimen: Prior to my entering the exam room my medical assistant ***
opened the Oregon Opioid Dose Calculator
(https://www.oregonpainguidance.org/opioidmedcalculator/) and showed @FNAME@ @HIS@
dose juxtaposed against the recent CDC dosing guideline recommendations. Both *** and I
explained to @FNAME@ that our clinic has adopted the CDC guidelines for safety reasons.[1-
3] Consequently, while we are certainly willing to work with @FNAME@ on a harm-reduction
plan, it will by necessity involve either a taper or a rotation to buprenorphine. @FNAME@
appeared ***receptive/resistant/precontemplative to my message.
1.Opioid prescriptions for chronic pain and overdose: a cohort study. Dunn KM, Saunders KW,
Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, Weisner CM, Silverberg MJ, Campbell CI,
2.Opioid dose and drug-related mortality in patients with nonmalignant pain. Gomes T, Mamdani
3.A history of being prescribed controlled substances and risk of drug overdose death. Paulozzi
LJ, Kilbourne EM, Shah NG, Nolte KB, Desai HA, Landen MG, Harvey W, Loring LD. Pain Med.
2012 Jan;13(1):87-95.
3. Impact of FMS & Pain Catastrophizing on Surgical Outcome:
#***@FNAME@ mentioned that @HE@ anticipates a *** due to *** pain. But given @HIS@
elevated FMS and PCS scores I urged @HIM@ caution about expectations for pain relief. An
abundance of medical literature suggested that elevated FMS and PCS scores forebode
delayed recovery from most surgeries as well as prolonged opioid use postoperatively. [1-4]
Consequently, I urged @FNAME@ to talk to @HIS@ surgeon about realistic goal-setting and
early, aggressive, rehabilitation.
1.Characteristics of fibromyalgia independently predict poorer long-term analgesic outcomes
following total knee and hip arthroplasty. Brummett CM, Urquhart AG, Hassett AL, Tsodikov A,
Hallstrom BR, Wood NI, Williams DA, Clauw DJ.
Arthritis Rheumatol. 2015 May;67(5):1386-94.
2.Survey criteria for fibromyalgia independently predict increased postoperative opioid
consumption after lower-extremity joint arthroplasty: a prospective, observational cohort study.
Brummett CM, Janda AM, Schueller CM, Tsodikov A, Morris M, Williams DA, Clauw DJ.
Anesthesiology. 2013 Dec;119(6):1434-43.
3.Pain. 2016 Jun;157(6):1259-65. doi: 10.1097/j.pain.0000000000000516. Trends and
predictors of opioid use after total knee and total hip arthroplasty. Goesling J1, Moser SE, Zaidi
B, Hassett AL, Hilliard P, Hallstrom B, Clauw DJ, Brummett CM.
4.Riddle, DL, Wade, JB, Jiranek, WA, Kong, X Preoperative pain catastrophizing predicts pain
outcome after knee arthroplasty. Clin Orthop Relat Res. (2010). 468 798–806
Nasal Naloxone:
#*** Nasal naloxone: The CDC 2016 opioid guidelines recommend co-prescribing naloxone to
all individuals receiving > 50 MED per day. Consequently, I prescribed nasal naloxone for
@FNAME@ today and my MA *** explained how to assemble and use the atomizer in the event
of an overdose. We gave @HIM@ the Lazarus handout (http://www.prescribetoprevent.org/wp-
content/uploads/2012/11/naloxone-one-pager-in-nov-2012.pdf).
4. Pseudoaddiction:
#*** Pseudoaddiction is concept from the palliative care literature that was introduced into
chronic non-cancer pain treatment in the mid 1990s. [1] The concept arose from a single case
report of a 17y/o with leukemia and chest wall metastases who craved more opioids for pain
relief and behaved as if he were addicted. An author of the case report - David Haddox -
subsequently went to work for Purdue pharma. Not surprisingly, this single case report was
subsequently picked up as a marketing tactic by Purdue pharma. A pamphlet was produced
explaining how patients who are prescribed Oxycontin sometimes behave as if they are
addicted due to ‘pseudoaddiction’ an iatrogenic condition caused by inadequate pain control.
Purdue sales representatives suggested that by simply escalating the patient’s dose a
prescriber can abort the ‘pseudo-addictive’ behaviors.
Time, and the opioid epidemic, has proven the concept of ‘pseudoaddiction’ to be little more
than the development of tolerance, craving, and with. In fact requests for rapid dose escalations
are now a well recognized risk factor for the development of opioid use disorder. [2]
1.Opioid pseudoaddiction--an iatrogenic syndrome. Weissman DE, Haddox JD.
Pain. 1989 Mar;36(3):363-6.
2. Pain Med. 2015 Apr;16(4):733-44. doi: 10.1111/pme.12634. Epub 2014 Dec 19. Dose
escalation during the first year of long-term opioid therapy for chronic pain. Henry SG1, Wilsey
BL, Melnikow J, Iosif AM.
Opioid Use Disorder (F11.20):
#*** Opioid use disorder: In my medical opinion @FNAME@ meets DSM-V criteria for opioid
use disorder.[1] @capHIS@ formal score was ***/11. I explained to @FNAME@ that opioid use
disorder is a chronic, relapsing-remitting, lifelong disease. Once it is diagnosed in our clinic full
agonist opioids are prohibited as a treatment for chronic non-cancer pain forever thereafter as
the risk of relapse is too high. Unlike chronic non-cancer pain, addiction is a potentially fatal
disease. However, I did offer @FNAME@ treatment with buprenorphine for @HIM@ addiction.
Moreover, I mentioned that a side-effect of buprenorphine treatment is analgesia. In fact,
buprenorphine has a morphine equivalence of approximately 30:1
1.https://en.wikipedia.org/wiki/Opioid_use_disorder
5. Pain Catastrophizing (F45.1):
#*** Pain Catastrophizing: @FNAME@'s pain catastrophizing scale today was highly elevated
at ***/52. This is a powerful predictor of pain severity and sensitivity, disability, pain chronicity,
satisfaction with care, and opioid misuse. [1] Moreover, pain catastrophizing is a target for
behavioral interventions aimed at diminishing rumination, magnification, and helplessness. In
the future @HIS@ may benefit from a referral to behavioral health for CBT/ACT/MBSR.
1.Theoretical perspectives on the relation between catastrophizing and pain. Sullivan MJ, Thorn
B, Haythornthwaite JA, Keefe F, Martin M, Bradley LA, Lefebvre JC. Clin J Pain. 2001
Mar;17(1):52-64. Review.
Structured Opioid Refill Clinic:
#*** The structured opioid refill clinic: My medical assistant *** reviewed our clinic's rules
outlined in our structured opioid refill clinic document with @FNAME@ and had @HIM@ sign it.
It will be scanned into @HIS@ chart.
Tolerance:
#*** Tolerance: I was careful to mention to @FNAME@ that opioids are not intended to be used
chronically. Moreover, the most pain relief one can expect with opioids is about 30%. [1] But this
often diminishes with time due to the development of tolerance. [2] Moreover, tolerance and
withdrawal are inextricably intertwined. Thus when tolerance ensues so does withdrawal. When
tolerance occurs the only options to mitigate its effects are either an opioid holiday, or a 35%
dose reduction and rotation to another opioid, but not a dose escalation. I will remind
@FNAME@ about this at future visits and @HIS@ PEG scores at success
1.Opioids in chronic non-cancer pain: systematic review of efficacy and safety. Kalso E,
Edwards JE, Moore RA, McQuay HJ. Pain. 2004 Dec;112(3):372-80. Review.
2.Reasons for opioid use among patients with dependence on prescription opioids: the role of
chronic pain. Weiss RD, Potter JS, Griffin ML, McHugh RK, Haller D, Jacobs P, Gardin J 2nd,
Fischer D, Rosen KD. J Subst Abuse Treat. 2014 Aug;47(2):140-5. doi:
10.1016/j.jsat.2014.03.004. Epub 2014 Apr 4.
6. Tolerance, Withdrawal, and DSM 5 OUD:
The 2013 DSM 5 criteria for the diagnosis of opioid use disorder include the following caveat
with respect to tolerance and withdrawal:
“Note: This criterion is not considered to be met for those taking opioids solely under
appropriate medical supervision.”
With the data accumulated since 2010 on OD deaths and addiction with high doses [1-4], the
long-standing outlier status of the US internationally for opioid overprescribing [5], and the 2016
CDC opioid guidelines, the standard of care has changed. While > 90 MED may have been
accepted practice in 2000 it no longer is. In my medical opinion high dose LTOT patients have
not had appropriate medical supervision, and thus tolerance and withdrawal DO apply to the
diagnosis of opioid use disorder in this cohort.
1.Opioid prescriptions for chronic pain and overdose: a cohort study. Dunn KM, Saunders KW,
Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, Weisner CM, Silverberg MJ, Campbell CI,
Psaty BM, Von Korff M. Ann Intern Med. 2010 Jan 19;152(2):85-92.
2.Association between opioid prescribing patterns and opioid overdose-related deaths.
Bohnert AS, Valenstein M, Bair MJ, Ganoczy D, McCarthy JF, Ilgen MA, Blow FC.
JAMA. 2011 Apr 6;305(13):1315-21.
3. Opioid dose and drug-related mortality in patients with nonmalignant pain. Gomes T,
Mamdani MM, Dhalla IA, Paterson JM, Juurlink DN. Arch Intern Med. 2011 Apr 11;171(7):686-
91.
4.Risk factors for serious prescription opioid-related toxicity or overdose among Veterans Health
Administration patients. Zedler B, Xie L, Wang L, Joyce A, Vick C, Kariburyo F, Rajan P, Baser
O, Murrelle L. Pain Med. 2014 Nov;15(11):1911-29. Doi:
5.J Pain Symptom Manage. 2013 Apr; 45(4): 681–700 Published online 2012 Sep 24. doi:
10.1016/j.jpainsymman.2012.03.01 Using a Morphine Equivalence Metric to Quantify Opioid
Consumption: Examining the Capacity to Provide Effective Treatment of Debilitating Pain at the
Global, Regional, and Country Levels Aaron M. Gilson, MS, MSSW, PhD,1 Martha A. Maurer,
MSSW, MPH, PhD,1,2 Karen M. Ryan, MA,1,2 James F. Cleary, MD,1,2 and Paul J. Rathouz,
PhD3