Christus trinity clinic family medicine longview

Age-Related Macular Degeneration: Promoting Good Eye Health in Later Life

2023.06.06 02:50 eyeconcepts Age-Related Macular Degeneration: Promoting Good Eye Health in Later Life

A major hazard to eyesight, age-related macular degeneration (AMD) affects millions of people worldwide. The macula, which is in charge of central vision, can degrade with age, resulting in visual impairment and a lower quality of life. In this extensive blog post, we will go deeper into the causes, kinds, risk factors, symptoms, diagnosis, prevention, and treatment options for AMD in this extensive blog post. People can actively protect their eyesight and advance eye health as they age by being aware of this issue and the resources that are accessible.

Educating Oneself About Age-Related Macular Degeneration

The macula produces clear and precise central vision, a little area of the retina close to its center. Age-related macular degeneration happens when the macula is harmed, resulting in distorted or blurred central vision. Wet AMD and dry AMD are the two main kinds of AMD. Wet AMD involves the development of aberrant blood vessels beneath the macula, whereas dry AMD is characterized by the accumulation of tiny yellow deposits called drusen in the macula. While wet AMD can result in a quick and severe visual loss if untreated, dry AMD advances slowly.

Knowing the Risk Factors

AMD is a risk factor for several conditions. The most important risk factor is aging, with AMD becoming increasingly common in people over 60. Given that AMD frequently runs in families, genetic factors also have an impact. Other risk factors include eating a diet poor in fruits, vegetables, and omega-3 fatty acids, smoking, which doubles the chance of getting AMD, high blood pressure, and obesity. People who have fair skin, light eyes, and a history of extensive sun exposure may also be at a higher risk. Individuals can make wise lifestyle decisions and take precautions to protect their vision by being aware of these risk factors.

Finding a diagnosis and Recognizing Symptoms

Regular eye exams are essential, especially for people who are at risk for AMD because early-stage symptoms may be slight or nonexistent. Common signs of AMD progression may include central vision distortion, reading challenges, a reduction in color perception, an increase in glare sensitivity, and dark or empty patches in the visual field. It is vital to get immediate medical attention from a qualified eye care practitioner if any of these symptoms are observed. AMD can be diagnosed and monitored with the help of dilated eye exams, visual acuity tests, and imaging exams like optical coherence tomography (OCT).

AMD Prevention Techniques

Even though it might not be feasible to completely prevent AMD, establishing good lifestyle choices can lower the risk or postpone its start. One of the most important strategies is to stop smoking, as this greatly raises the risk of AMD. Including dark leafy greens, fruits, seafood, and nuts in your diet will help you get the vitamins, minerals, and antioxidants you need for good eye health. Outdoors, wearing caps and sunglasses to shield the eyes from damaging ultraviolet (UV) radiation is also crucial. Overall eye health is influenced by regular exercise, eating a balanced diet, reducing blood pressure and cholesterol levels, and managing long-term illnesses like diabetes.

Options for Treatment and Management

Although AMD cannot be cured, numerous treatments can be used to control the condition and halt its development. It may be advised to take over-the-counter vitamins and minerals, including vitamins C and E, zinc, copper, and lutein, in cases of dry AMD. These vitamins may help some people lower their chance of developing advanced AMD, according to research. Additionally, certain experimental therapies are being studied and may hold promise, including stem cell-based therapies and gene therapies.


Age-related macular degeneration is a common and difficult eye condition that has to be understood, treated and prevented. People can actively participate in protecting their eyesight and keeping their quality of life by recognizing the risk factors, comprehending the signs and symptoms, getting a prompt diagnosis, and putting preventive measures in place. A balanced diet rich in eye-protective nutrients, a healthy lifestyle, and routine eye exams can all greatly lower the risk of AMD or slow its progression.
Current AMD therapies are geared toward managing the condition and maintaining vision, but ongoing research and improvements in medical technology raise the prospect of future discoveries. Clinical trials investigating cutting-edge medicines, like stem cell and gene-based therapies, appear to hold promise for creating more specialized and efficient interventions for AMD.
In the end, raising awareness of AMD and promoting early detection and intervention can significantly improve the lives of those who are impacted by this ailment. Prioritizing eye health enables people to enjoy their older years with clear, vibrant vision, allowing them to stay active and independent throughout their golden years. Keep in mind that your vision is priceless; cultivate it, safeguard it, and appreciate the beauty that appears before your eyes.
submitted by eyeconcepts to u/eyeconcepts [link] [comments]

2023.06.05 19:41 Junior-Broccoli1271 The future of Rural healthcare, thanks to our UCP voter friends.

Doctors leaving practices that have been in place for years. No chance of getting a new family doctor. Without family doctors most rural clinics are unwilling to book an appointment.
You have to go sit in their walk-in all day to get a prescription now. If you even get seen(I waited for 5 hours last week and nothing). 4+ hour wait for some offices. Online/telephone appointments ARE available for people, for a charge..... Can go into the city to do a walk-in there, same thing. You need a family doctor to book an appointment at many of them.
The future of medicine is now people. And this is for a clinic that's still open. Which I imagine it won't be for much longer given what the UCP is doing. I could go to Emergency, but i'd be looking at setting up a tent outside the hospital just to get a prescription.
I can't wait to be paying 100+ bucks a month just so that I can see a doctor sometime in the next 4 months without having to wait 8+ hours. Fun. Systematic breakdown of healthcare that's so bad, people can't even be guaranteed to get a prescription that they've been taking for half their life even if they wait an entire day at the doctors office.
Anyone who voted UCP because they promised healthcare was good needs to get their head checked.
Oh wait.. You can't anymore.
submitted by Junior-Broccoli1271 to alberta [link] [comments]

2023.06.05 17:13 That-Focus7957 Need Advice- Nursing Job Issues

I’m feeling stuck in my nursing career…. I’ve been a nurse since 2020. Before that, I was a Medical Assistant in family medicine and specialty clinics for 11 years. Since 2020, I’ve gone from specialty clinical nursing, to supervising, to infusion, med/surg and just resigned from dialysis. I love nursing and I’m passionate about being a part of taking care of others even in the most vulnerable situations. I love learning new things, using my skills and assessing. I’m finding when I start a new job, it takes me awhile to get trained and “catch on.”When it gets tough, i question myself and my confidence. I also get so caught up in quality, safety and cleanliness as well as workflows and the work environments that I’m in. Some of my managers/preceptors have been great and other not so much. What is also challenging for me is working with other teammates that don’t have the same work ethic as me…. How do I navigate this and let this go? It’s so distracting. Im questioning if nursing is still for me….I haven’t found my niche in nursing yet.
submitted by That-Focus7957 to nursing [link] [comments]

2023.06.05 10:21 Obvious_Breath_6225 Thankyou for Korean Medicine and Doctor of Korean Medicine

I am John, a regular office worker living in Calgary, a city located in the central-western part of Canada.
First of all, I would like to express my gratitude to the Korean traditional medicine doctor who enabled me to write this message.
For several years, I have been suffering from persistent neuralgia and related issues. Initially, I thought the pain was due to work-related stress. However, as time went on, the pain became more severe.
I wanted to receive treatment at a hospital, but in Canada, it is very difficult to see a specialist and receive treatment. In Canada, when you have an illness, you go to a family doctor. When you describe your symptoms to the family doctor, they refer you to a specialist, who becomes your attending physician.
The problem was that I often had to wait for more than six months to be assigned a specialist. The pain kept recurring more frequently, and I couldn't even get an appointment for treatment.
One day, while walking down the street, I was hit by a severe bout of pain, and I had to sit down on the roadside. I had to continue working, but without any treatment, my body couldn't endure it anymore.
At that moment, a man approached me. Seeing me in agony, he introduced himself as a Korean traditional medicine doctor and asked if it would be okay to assess my condition briefly.
Feeling so much pain and distress, I naturally replied that it was fine. He examined my condition and symptoms carefully and then said that treatment would be difficult in this situation but he would take me home.
After arriving at my place, he thoroughly examined my condition and symptoms. The Korean traditional medicine doctor explained that acupuncture, using needles, is effective in relieving pain and restoring the body's balance. He believed that acupuncture treatment would be effective for me.
Initially, it was a foreign concept to me, but since it was nearly impossible for me to receive medical treatment at a hospital, I decided to have a glimmer of hope and agreed to the treatment.
Fortunately, the Korean traditional medicine doctor had acupuncture needles with him and immediately offered to treat me. Initially, I felt some pricking sensation and pain as the needles were inserted, but gradually, I started feeling the effects.
The severe pain started to diminish, and the numbness in my body gradually decreased. It was truly an astonishing experience. With just a few needles, the Korean traditional medicine doctor made the pain that had tormented me for so long disappear.
I asked him how this was possible. He explained that while some people may find conventional Western medicine like orthopedics or internal medicine more effective, others may find traditional Korean medicine more suitable. In my case, he believed that the pain was caused by an imbalance in my body, and Korean traditional medicine was well-suited for such conditions.
However, he mentioned that this treatment was temporary, and to completely restore the balance of my body, I would need further treatment. He also acknowledged that even in Canada, getting medical treatment takes a long time. He suggested that if it was possible, I should consider completing the treatment in Korea.
Having just experienced the amazing treatment with Korean traditional medicine, I immediately booked a flight to Korea.
After receiving treatment at a Korean traditional medicine clinic for three months, the pain that had plagued me completely disappeared, and I was able to live a healthy life again.
Now, I have returned to Canada and resumed my work. However, the three months I spent in Korea for medical treatment were incredibly precious and brought me great happiness.
The healthcare system that allows you to receive treatment at any time you want and the friendly medical staff, and above all, the various Korean foods and tourist attractions, not only restored my physical health but also rejuvenated my mind.
submitted by Obvious_Breath_6225 to u/Obvious_Breath_6225 [link] [comments]

2023.06.05 06:14 Educational-Nose223 Puradrop Gummies Reviews Reddit : ⚠️Scam?⚠️Must Read! Before Buy - Puradrop Gummies Review - Puradrop Gummies Does Work?

Puradrop Gummies Reviews Reddit : ⚠️Scam?⚠️Must Read! Before Buy - Puradrop Gummies Review - Puradrop Gummies Does Work?

Puradrop Gummies Reviews Reddit : ⚠️Scam?⚠️Must Read! Before Buy - Puradrop Gummies Review - Puradrop Gummies Does Work?

In this article, we will be talking about one such dietary supplement - Puradrop extra strength gummies that helps you manage weight naturally and detoxifies your body. We will discuss its characteristics, the benefits offered by it, the working and scientific evidence behind it, the pricing, the money-back guarantee, and the customer reviews.
Weight loss and weight gain are among the few things that every individual goes through in their lives at some point in time. This happens because of several reasons. Weight gain can happen because of a sedentary lifestyle, work-life imbalance, unhealthy diet, hormonal imbalances, health issues, etc.
This weight gain can cause several health issues sometimes. It can cause Obesity, joint pain, stress, anxiety, digestive issues, and many more such health problems. These health problems could make your life difficult by hampering your day-to-day activities.
To get rid of the accumulated fat in your body, you can take medications, pills, capsules, gummies, powders, liquid solutions, etc., available on the market by big pharmaceutical companies. But, these come at the cost of your health, as these may have side effects on your body. So, to avoid these side effects, certain supplements are available on the market for weight loss. These dietary supplements help you lose weight naturally and are also very beneficial for your health.
In this article, we will be talking about one such dietary supplement - Puradrop extra strength gummies that helps you manage weight naturally and detoxifies your body. We will discuss its characteristics, the benefits offered by it, the working and scientific evidence behind it, the pricing, the money-back guarantee, and the customer reviews.

What Is Puradop Supplement?

Puradrop is a dietary supplement that helps in maintaining or managing your body weight with the help of its natural formulation. It is an extra-strength gummy that contains powerful natural ingredients and comes in a bottle in the form of easy-to-chew gummies.
Puradrop extra strength gummies formulation is a blend of goodness-packed ingredients that help in the process of fat-burning, thus eliminating the unwanted and unhealthy fat stored in your body. It helps burn this fat and then uses it as fuel or energy to carry out different functions.
The supplement uses natural weight management techniques to help you lose weight effectively and efficiently. It focuses on ramping up your metabolic rate and increasing your energy levels.
The Puradrop extra strength gummies are entirely natural, plant-based, Gluten-Free, Vegan, Non-GMO, Gelatin-Free, Stimulant-Free, Dairy-Free, Soy-Free, Artificial Coloring-Free, Artificial Flavoring-Free, Non-Habit Forming, and Easy-to-Chew. It is GMP-Certified and has been manufactured in the USA in an FDA-Approved and Registered Facility by following all the safety guidelines strictly.

Core Ingredients In Purodrop Gummies

Let us have a look at the ingredients in the Purodrop Gummies that are potent and effective at weight loss:
Apple Cider Vinegar
Apple cider vinegar is made from fermented apple juice. Apple cider vinegar is high in acetic acid. Acetic acid helps your body burn calories. Studies show that drinking one tablespoon of ACV before a meal reduces appetite and helps people consume fewer calories.
ACV may also boost metabolism. In one study, participants drank a mixture containing ACV and caffeine before breakfast and lunch. They were then given a buffet meal. Those who had consumed the drink burned up to 20 percent more calories than those who did not.

Beet Juice
Beets are members of the beet family (the same family as chard, spinach, beets, radishes, turnips, etc.). Beets have long been used as medicine. The root of the beet is edible. It's full of nutrients like potassium, iron, calcium, magnesium, phosphorus, vitamin B6, folate, fiber, and betaine.
Beets contain nitrates, which are converted to nitrites when they're cooked. Nitrites are believed to be responsible for the pink color of cured meats. But there's another reason why beets are good for you: They contain betalains, compounds that give them their red color. Betalains are antioxidants that protect against heart disease and certain cancers.
In addition to its health benefits, beet juice can enhance athletic performance. One study found that athletes who drank beet juice prior to exercise experienced an improvement in endurance compared with those who drank water or orange juice. Another study showed that beet juice improved running speed and endurance among cyclists.

Iodine is a trace mineral that plays a role in thyroid function. Iodine deficiency leads to hypothyroidism, a condition characterized by low thyroid activity. Hypothyroidism can cause fatigue, depression, hair loss, dry skin, constipation, and other symptoms.
Iodine is important for proper brain development. Children born with iodine deficiencies often have mental retardation.

Vitamin B12
B vitamins play many roles in the human body. Vitamin B12 is essential for healthy nerve cells. It's needed to make DNA and RNA, two types of molecules that carry genetic information.
Some research suggests that vitamin B12 may reduce hunger. A small study published in the journal Appetite found that men who took 1,000 mcg of vitamin B12 per day ate about 200 fewer calories at each meal over four days.
Another study found that obese adults who took 2,400 mcg of vitamin B2 (also known as riboflavin) daily for three months reduced their waist circumference by an average of 3 inches.

Pomegranates are rich in polyphenols, powerful antioxidants that may help prevent cancer and cardiovascular diseases. Polyphenols are also thought to increase energy expenditure and fat oxidation during physical activity.
A recent study from Iran found that people who regularly eat pomegranates tend to weigh less than those who don't. Researchers believe this could be because pomegranates contain ellagic acid, a compound that has been shown to suppress appetite.

The Working Of Puradrop Gummies And The Scientific Evidence Behind It

The Puradrop extra strength gummies have a natural formula that works toward helping you manage your weight efficiently. This dietary supplement has been formulated in such a way that it helps accelerate the process of fat-burning in your body for fuel. This eliminates the unwanted and unnecessary fat from different parts of your body like thighs, hips, arms, etc.

The formula of Puradrop extra strength gummies has been inspired by the Greek island of Ikaria.
Puradrop works amazingly when compared to the medications by big pharmaceutical companies. This is because of the presence of 6 powerful and vegan ingredients in the gummies. These natural and plant-based ingredients are Vitamin B12 - 0.6 mg, Vinagre de Sidra de Manzana - 250 mg, Beet Juice Powder - 20 mg, Pomegranate Juice - 20 mg, Iodine - 25 mg, and Vitamin B6 - 0.25 mg.

The most important ingredient used in Puradrop extra-strength gummies is Vinagre de Sidra de Manzana. The quantity of this ingredient used in these gummies is 250 mg. It is backed by various types of clinical research and studies.

According to one study, Vinegar is an element that helps you lose body weight effectively and also helps lower the triglyceride levels in your body. Another study stated that Vinegar also plays a role in making you feel full. It acts as a great suppressant of appetite or food cravings.

Benefits Of Consuming Puradrop Gummies

The Puradrop extra strength gummies provide you with several health benefits due to their natural and plant-based formulation, as discussed below.
Helps In Eliminating Fat From Your Body
This dietary supplement works toward accelerating the process of fat-burning in your body. This helps eliminate unwanted fat from your body, thus reducing your weight and making you healthy. It also focuses on maintaining a healthy body mass index.

Helps Improve The Rate Of Metabolism
Puradrop helps improve your metabolic rate with the help of its natural and powerful ingredients. As a result of this improved metabolism, energy levels also are increased.
The fact that Puradrop extra strength gummies act as a detoxifying agent for your body also helps improve the rate of metabolism.

Helps Improve Your Overall Health
This weight loss dietary supplement helps improve your overall health. It helps boost immunity, improve the health of your digestive system and gut, suppress food cravings and appetite, prevent fatigue, etc.

Presence Of Power-Packed Ingredients
Puradrop extra strength gummies are made up of 6 powerful ingredients - Vitamin B12, Vinagre de Sidra de Manzana, Beet Juice Powder, Pomegranate Juice, Iodine, and Vitamin B6.
● Vitamin B12 - Helps maintain the health of your DNA and improves energy levels.
● Vinagre de Sidra de Manzana - Helps boost your metabolism and accelerates fat-burning.
● Beet Juice Powder - Helps maintain your heart health and also supports stamina.
● Pomegranate Juice - Contains a lot of nutrients that are helpful for your body like Vitamin C, Potassium, Vitamin K, etc.
● Iodine - Helps boost your immunity and strengthens your bones.
● Vitamin B6 - Rich in antioxidant properties.

How To Use Puradrop Gummies?

As per the manufacturer of the Puradrop extra strength gummies, you are recommended to consume one gummy daily in the morning before breakfast for a better start to the day and also for improving your overall functioning throughout the day.
One Puradrop bottle contains 30 gummies, and it lasts for 30 days. Regular consumption of these gummies in the recommended dosage for at least a few weeks would provide you with the best weight loss results.

Where Can You Purchase Puradrop Gummies?

The original Puradrop gummies can be bought from its official website only, that too at discounted pricing and a 100% money-back guarantee as well.
The pricing of the Puradrop bottles and the money-back guarantee are discussed below.

What Is The Cost Of Puradrop Gummies?

You can buy the Puradrop extra strength gummies for natural management of your body weight from its official website in any of the following 3 packages:
  • 30-day Supply Package: You get 1 Puradrop Bottle at $59 + pay an additional shipping charge.
  • 90-day Supply Package: You get 3 Puradrop Bottles at $49 per bottle + pay an additional shipping charge. You will save $420 on the purchase of this package and also get 2 free bonuses along with it.
  • 180-day Supply Package: You get 6 Puradrop Bottles at $39 per bottle + pay zero shipping charges. You will save $900 on the purchase of this package and also get 2 free bonuses along with it.
⇒ Visit the Official Website of Puradrop Weight Loss Gummies

Is There A Money-Back Guarantee Offered On Puradrop Gummies?

You can purchase the Puradrop extra strength gummies for maintaining your body weight naturally and for detoxifying your body from its official website with an assured 180-day 100% satisfaction money-back guarantee, thus making the product risk-free to purchase.
So, in case you are unsatisfied with the product or don’t see any results, then you can contact their support team via a call or email and get your complete amount refunded back to you with no questions asked at all.

What Are The Customer Reviews About Puradrop Gummies?

Puradrop gummies have helped many consumers with their natural and plant-based formulations. The credit for this formulation goes to the goodness-packed and powerful ingredients that have been used in making these easy-to-chew gummies.
There are several Purodrop reviews by consumers that state that this weight loss supplement has worked the best for their bodies as compared to the other medications and pills. It has provided them with several health benefits.
This dietary supplement has helped men and women, irrespective of their age, in weight management. It acts as a brilliant detoxifier for their bodies, thus removing all the harmful toxins and cleansing the body thoroughly.
The Purodrop natural ingredients have made the supplement free from any side effects. These extra strength gummies have helped customers boost immunity, improve energy levels and metabolism, remove toxins, burn accumulated unhealthy fat, suppress appetite, cleanse the gut, improve digestion, reduce fatigue, etc.

Final Verdict

In the end, it can be said that the formulation of Puradrop is so well done for managing the body weight of men and women as well as for detoxifying the body as well. This dietary supplement has been trusted by many users, as seen from the above customer reviews.
Puradrop also comes with a 100% satisfaction 180-day money-back guarantee on the purchase of all of its packages, as mentioned on its official website . So, purchase the Puradrop bottles now and experience the results for yourself!
⇒ Visit the Official Website of Puradrop Weight Loss Gummies
submitted by Educational-Nose223 to PuradropGummiesReview [link] [comments]

2023.06.05 04:50 crowbutt grandmother often sick and not getting better but refuses to go to hospital (serious)

if there's any trolls or smartasses im gonna take this down immediately but i just need a place to share my feelings and get relevant, helpful advice.
so my grandmother lives a sedentary lifestyle and frequently gets sick as she's not so active anymore due to old age, fragile muscles etc. she's almost 80. she often gets symptoms like headaches, nausea, coughing and lack of appetite which she would constantly complain about but still continue to eat spicy/fried foods whenever she "feels better". she'd say that it's fine because she already has the medication for it. which i know is not wise but she refuses to listen to me or my family members. so it's just this endless cycle of getting sick and going to the clinic for medicine and then not making efforts to get better. she'd always complain about it too but my mum just gave up and brushes her off as being dramatic.
now i wouldn't dare say anything bc i know I'd be outcasted by my family- but i feel like her behaviour is just killing her slowly. she could probably have some underlying illness that we don't know about but she absolutely refuses to go to the hospital. it's already so difficult for her to take a simple ART test for covid which made some clinic visits hectic for me and the staff there. she'd often lie to me & my brother about her symptoms too (e.g saying she had a cough for a week when it's actually been nearly a month) so the doctor would've probably diagnosed or prescribed her incorrectly.
sure call me careless and not observant towards my own grandmother but she'd just beg me to lie to the doctor and would guilt trip me. I'm still in poly and all this can be so stressful when it shouldn't be. i don't know what to tell my parents how i really feel bc i feel like they also gave up with her attitude. what can i do in this situation?? like how do i tell a medical professional about this?? any advice would be appreciated.
TLDR: grandmother is over reliant on over the counter medication and refuses to go to the hospital and be honest about her symptoms.
submitted by crowbutt to askSingapore [link] [comments]

2023.06.05 03:08 MD-PhSki Final WAMC! ORM/518/4.0/rural state

So grateful for this community, and can't believe my time to submit is finally here! Tweaked some details for privacy, but the idea is the same. WAMC please?

cGPA: 4.0 – sGPA: 4.0
MCAT: 518 (130/127/131/130)
Background: Idaho resident, ORM (Asian), state school, microbio
Clinical: will have 1200+ hours as a patient care tech, ~120hrs hospital volunteer
Research: ~1100hrs, 2 undergrad poster sessions, 2 publications
Shadowing: ~75hrs – general surgery, foot surgeon, family medicine
Non-clinical volunteering: ~250hrs elderly community
Other ECs: pre-med club president, lots of outdoor activities, lab SA
Relevant honors/awards: highest tuition/honors scholarship
Anything else: 1st gen college student, somewhat rural hometown

School List: looking to take a couple schools off my list (probably some “Reach” schools?). ISO a med school in an outdoorsy area (at least nice parks to run in), or urban where I can do city things (nice food, attractions, etc.). Aiming for 15-20 schools. Thanks again for your help!

Boston U
Case Western
Weill Cornell
U North Dakota
Oregon Health & Science University School of Medicine
Med College of Wisconsin
U of Utah
UWashington (WWAMI program)
SKMC at Thomas Jefferson U
submitted by MD-PhSki to premed [link] [comments]

2023.06.05 01:30 usernamemustbefunny hiding tags

hiding tags
Does anyone know how to hide the tags in the review screen? I'm assuming there's been some updates overnight because last night these weren't there. the only shortcut i know is to hit "C" on the card to hide them but I have to do that on each card... not ideal
submitted by usernamemustbefunny to medicalschoolanki [link] [comments]

2023.06.04 23:40 AdMental3475 Cat Pee

My cat Hazel, (4 YO, Female) has been peeing on our beds and blankets nonstop. She is spayed and has been doing this for a couple of years now. Sometimes very frequently and then she doesn't for a couple of weeks. But multiple times a month. There are times when she's been on a new blanket at least 7x in one week. We even put a new litter box in the room but she looks at it and doesn’t use it. I spray non-marking spray but it doesn’t work. I have tried UTI medicine, UTI food, more litter boxes, and covering the bed. My family wants to give her to the shelter, and I really don’t know what to do. Hazel also really doesn’t like humans, she runs away whenever we get near her. I don’t understand because she was born in this house and has 3 other siblings who are totally fine with us. She doesn't let us near her which makes it very hard for us to take her to the vet. The last time I did was 1-2 years ago for this exact problem but they unfortunately quoted me too much to run some tests (I was suspecting UTI) and I did not have the money to go through with it. After that vet visit, I was unable to go neasee her for a very long time. She does not seem to have any other issues though, she plays, eats, drinks, sleeps just fine, and never shows any discomfort. Does anyone have any advice? Thank you so much! :(
submitted by AdMental3475 to vet [link] [comments]

2023.06.04 23:40 AdMental3475 Cat Pee

My cat Hazel, (4 YO, Female) has been peeing on our beds and blankets nonstop. She is spayed and has been doing this for a couple of years now. Sometimes very frequently and then she doesn't for a couple of weeks. But multiple times a month. There are times when she's been on a new blanket at least 7x in one week. We even put a new litter box in the room but she looks at it and doesn’t use it. I spray non-marking spray but it doesn’t work. I have tried UTI medicine, UTI food, more litter boxes, and covering the bed. My family wants to give her to the shelter, and I really don’t know what to do. Hazel also really doesn’t like humans, she runs away whenever we get near her. I don’t understand because she was born in this house and has 3 other siblings who are totally fine with us. She doesn't let us near her which makes it very hard for us to take her to the vet. The last time I did was 1-2 years ago for this exact problem but they unfortunately quoted me too much to run some tests (I was suspecting UTI) and I did not have the money to go through with it. After that vet visit, I was unable to go neasee her for a very long time. She does not seem to have any other issues though, she plays, eats, drinks, sleeps just fine, and never shows any discomfort. Does anyone have any advice? Thank you so much! :(
submitted by AdMental3475 to AskVet [link] [comments]

2023.06.04 22:30 gimmetimetravel Help with my school list? Low stats applicant 3.41/3.5 507

State/Country of Residence: California, USA
Ties to other States/Regions: No ties
URM? (Y/N): N
Year in School: 2021 BS + 1.5ish years of post-bac
Undergraduate Major(s)/Minor(s): Bio Major
Graduate Degrees (if applicable): None
Cumulative GPA: 3.5
Science GPA: 3.41
MCAT Score(s): 507 (126/125/126/130)
Research Experience: N/A
Publications/Abstracts/Posters: N/A
Clinical Experience (paid or volunteer): 250 hours of hospital volunteering, applying for clinical jobs to work throughout the application cycle to gain more clinical experience (any advice on this would be appreciated!!)
Physician Shadowing: 24 hours of shadowing (14 in Neurology and 10 in private practice Peds)
Non-Clinical Volunteering: Secretary of a pre-health club & Event coordinator for a dance club
Other Extracurricular Activities: 200 hours college cheerleading
Other Employment History: 122 hours personal assistant
Immediate family members in medicine? (Y/N): N
Specialty of Interest (if applicable): Nothing set rn
Interest in Primary Care (Y/N): Maybe?
Interest in Rural Health (Y/N): N
School List:
MD Programs
DO Programs
submitted by gimmetimetravel to premed [link] [comments]

2023.06.04 21:52 Beneficial-Engine593 Highish Stats URM. School list Feedback please

Is this list completely delusional?
List: Brown, Dartmouth, Boston University, Duke, Wake Forest, UNC, ECU, Harvard, Hopkins, NYU, Mayo Clinic, Northwestern, Yale, Columbia, Cornell, UPenn, Stanford, Vanderbilt, UCSF, WashU, Icahn, UCLA, Case Western, Albert Einstein, Emory
URM African American male
State: NC
College: Average State School
GPA: 3.92
MCAT:515 (129/126/131/129)
No gap Years
Clinical Experience: 180 hours as a CNA
Shadowing: 20 hours shadowing a family medicine doc
Research: About 500 hours in a biochem based lab. Currently in a summer REU program for the same lab(No posters/pubs)
-Crisis Text Line(50 hours)
-Organic Chem TA for 1 semester(100 hours)
-Volunteer for a Nonprofit cleaning and organizing books to be donated(200 hours)
-American Red cross volunteer mainly just checking people in and providing snacks(20 hours)
-Volunteer with nonprofit dedicated to supporting kids fighting cancer as well as their families(16 hours)(Volunteered to play with the kids at a picnic event and did a fundraising event)
-Mission trip to mexico(religious)(1 week)
-Hobbies: Spikeball club, pickup basketball and working out
-As an eagle scout, Volunteered with my old boyscout troop(10 hrs)
submitted by Beneficial-Engine593 to premed [link] [comments]

2023.06.04 21:44 jdf-347580 Has anyone been in a similar situation to me and have any advice?

Ok, so I have not had your average college experience. I started at one college during COVID and then transferred. I had no solid career plan at the time and I was highly depressed, struggling with my sexuality, and was suicidal. I was working part-time as a babysitter that whole year and had an online business. I was enjoying my science classes a lot and the caregiving aspect that came with babysitting, so I started to look a little bit more into pre-med and began talking to my doctors and family members in medicine about it. They all thought it would be a great idea for me to explore, and I agreed.
Fast forward to that summer, and I was transferring schools. At the time, it was just not wise for me to go far away from home and I had always lived in a small area (I graduated with a small class of fewer than 75 people), so I was not used to big changes and big classes. I opted to go to a smaller school even though it cost a little bit more for me to go than the bigger school nearby and paid about $80k for my undergrad (mostly private loans since my parents make too much for me to qualify for much in federal and they also can't help me pay them back for the most part due to their own financial struggles). I didn't get a bio degree but instead got a degree in applied math concentrated in modeling and analytics in the natural sciences with three minors (bio/chem/biostats). Before transferring to my new school, I was unable to secure a job or volunteer work in the local hospital due to COVID concerns still. So, I worked as a full-time nanny and I loved it.
I went onto my new school and was still very depressed and suicidal, but eventually got some professors and people who really started to believe in me, and made some great new friends. I got offered to be a student leader and a full-time research position for the summer which I continued through last school year and am working in again this summer, as well as the student leader position. I have also picked up a volunteering role with a suicide crisis line for LGBTQ+ youth that I am very passionate about, and the only real clinical stuff I have is less than 10 hours of shadowing. I have a cumulative college GPA of about 3.85 and a BCPM GPA of 3.77 (last I checked).
I knew I was going to have to take a gap year, but some people on Reddit/otherwise have advised me to not even consider going to med school until I'm 30 because I have to pay off my $80k in loans first, which I am incredibly terrified about while I am in the gap year (or several) since I am not sure any job that I would get with relevant experience to a med school app would pay me enough to even feel comfortable paying that off. My parents said I may have to get two jobs which is just crazy to me because I would also have to pay for MCAT prep/studying and also apps. I just feel lost, and I'm not sure if anyone else has ever been in a situation like mine that was also pre-med, and knew what to do? This is giving me the MOST amount of anxiety I have ever experienced and I'm not sure what is the best plan of action as so many different people are in my head.
submitted by jdf-347580 to premed [link] [comments]

2023.06.04 17:17 Honest_Activity_1633 What specialties should I explore?

Hello MSC,
Im an incoming MS1 - I don't know what specialties interest me yet. However, I currently value
- Broad scope of practice (FM, General IM, general surgery, not sure what else....)
- Spending time with family / loved ones
- Not having crazy on-call / night shifts (so no EM or surgery?)
-Clinical/translational/educationl research, not basic science research
-Having my own practice. I value my independence and taking time off and don't mind making less to have this flexibility.
So based on these experiences, I feel like FM is for me (with maybe + 1 surgical skills or hospital medicine). However, given the state of FM in Canada (lots of paperwork, decreasing billing comp, etc), I'm not sure if it's worthwhile to pursue.
How should I explore my interests in medical school? Are there any other specialties I should look into? Do you think FM is worthwhile to pursue? TIA
submitted by Honest_Activity_1633 to MedSchoolCanada [link] [comments]

2023.06.04 16:08 No-Werewolf-8092 Angela Davis on MPR - Addressing rising alcohol use among women

Firstly, IWNDWYT!!
Wanted to share about a Minnesota Public Radio episode with Angela Davis that aired last week called “Addressing rising alcohol use among women.” I was able to call in towards the top and shared some of my story (and had a cathartic cry at the guests’ reflections). The second caller mentioned this sub and how helpful it’s been for her as she’s recently made the decision to stop drinking! The entire conversation is illuminating, affirming, and helpful.
The synopsis is below, and the episode can be found via the ole Google or on MPR’s website:
Alcohol use and misuse among women is on the rise and it’s causing severe health problems for some women.
Women who drink have a higher risk than men for certain health problems, including liver disease, heart disease and cancer.
And research suggests that the stress of the COVID-19 pandemic was associated with more drinking among women but not among men.
MPR News host Angela Davis talks with a researcher who studies sex differences in alcohol use, and a drug and alcohol counselor who specializes in women’s addiction.
MacKenzie Peltier is an assistant professor in the Department of Psychiatry at the Yale School of Medicine. She researches sex differences in alcohol use disorders.
Jasmin Boelter is a licensed drug and alcohol counselor and the clinical director at Wellcome Manor Family Services in Garden City, Minn.
submitted by No-Werewolf-8092 to stopdrinking [link] [comments]

2023.06.04 14:34 Dirtclodkoolaid AMA RESOLUTION 235

“Resolution 235 asks that our AMA applaud the CDC for its efforts to prevent the incidence of new cases of opioid misuse, addiction, and overdose deaths; and be it further, that no entity should use MME thresholds as anything more than guidance and that MME thresholds should not be used to completely prohibit the prescribing of, or the filling of prescriptions for, medications used in oncology care, palliative medicine care, and addiction medicine care: and be it further, that our AMA communicate with the nation’s largest pharmacy chains and pharmacy benefit managers to recommend that they cease and desist with writing threatening letters to physicians and cease and desist with presenting policies, procedures and directives to retail pharmacists that include a blanket proscription against filling prescriptions for opioids that exceed certain numerical thresholds without taking into account the diagnosis and previous response to treatment for a patient and any clinical nuances that would support such prescribing as falling within standards of good quality patient care; and be it further, that AMA Policy opposing the legislating of numerical limits on medication dosage, duration of therapy, numbers of pills/tablets, etc., be reaffirmed; and be it further, that physicians should not be subject to professional discipline or loss of board certification or loss of clinical privileges simply for prescribing opioids at a quantitative level that exceeds the MME thresholds found in the CDC Guidelines; and be it further, that our AMA encourage the Federation of State Medical Boards and its member boards, medical specialty societies, and other entities to develop improved guidance on management of pain and management of potential withdrawal syndromes and other aspects of patient care for “legacy patients” who may have been treated for extended periods of time with high-dose opioid therapy for chronic non-malignant pain.
RESOLVED, that our American Medical Association (AMA) applaud the Centers for Disease Control and Prevention (CDC) for its efforts to prevent the incidence of new cases of opioid misuse, addiction, and overdose deaths
RESOLVED, that our AMA actively continue to communicate and engage with the nation’s largest pharmacy chains, pharmacy benefit managers, National Association of Insurance Commissioners, Federation of State Medical Boards, and National Association of Boards of Pharmacy in opposition to communications being sent to physicians that include a blanket proscription against filing prescriptions for opioids that exceed numerical thresholds without taking into account the diagnosis and previous response to treatment for a patient and any clinical nuances that would support such prescribing as falling within standards of good quality patient care.
RESOLVED, that our AMA affirms that some patients with acute or chronic pain can benefit from taking opioid pain medications at doses greater than generally recommended in the CDC Guideline for Prescribing Opioids for Chronic Pain and that such care may be medically necessary and appropriate, and be it further
RESOLVED, that our AMA advocate against misapplication of the CDC Guideline for Prescribing Opioids by pharmacists, health insurers, pharmacy benefit managers, legislatures, and governmental and private regulatory bodies in ways that prevent or limit patients’ medical access to opioid analgesia, and be it further
RESOLVED, that our AMA advocate that no entity should use MME (morphine milligram equivalents) thresholds as anything more than guidance, and physicians should not be subject to professional discipline, loss of board certification, loss of clinical privileges, criminal prosecution, civil liability, or other penalties or practice limitations solely for prescribing opioids at a quantitative level above the MME thresholds found in the CDC Guideline for Prescribing Opioids.””
Pain Management Best Practices Inter-Agency Task Force - Draft Report on Pain Management Best Practices: Updates, Gaps, Inconsistencies, and Recommendations Official Health and Human Services Department Released December 2018
“The Comprehensive Addiction and Recovery Act (CARA) of 2016 led to the creation of the Pain Management Best Practices Inter-Agency Task Force (Task Force), whose mission is to determine whether gaps in or inconsistencies between best practices for acute and chronic pain management exist and to propose updates and recommendations to those best practices. The Task Force consists of 29 experts who have significant experience across the disciplines of pain management, patient advocacy, substance use disorders, mental health, and minority health.”
In addition to identifying approximately 60 gaps in clinical best practices and the current treatment of pain in the United States, HHS PMTF provided recommendations for each of these major areas of concern. In alignment with their original charter, the PMTF will submit these recommendations to Congress to become our ‘National Pain Policy’. The 60+ gaps and inconsistencies with their recommendations will serve to fill gaps in pain treatment at both the state and federal level; and the overwhelming consensus was that the treatment of pain should be multimodal and completely individualized based on the individual patient. The heart of each recommendation in each section was a resounding call for individualization for each patient, in regards to both non-pharmacological and pharmacological modalities; including individualizations in both opioid and non-opioid pharmacological treatments.
While each of the gap+recommendation sections of what is poised to become our national pain policy is extremely important, one that stands out the most (in regards to opioid prescribing) is the Stigma section. Contained in this section is one of the core statements that shows our Health and Human Services agency - the one that should have always been looked to and followed - knew the true depth of the relationship (or lack of) between the overdose crisis and compassionate prescribing to patients with painful conditions:
“The national crisis of illicit drug use, with overdose deaths, is confused with appropriate therapy for patients who are being treated for pain. This confusion has created a stigma that contributes to raise barriers to proper access to care.”
The recommendation that follows - “Identify strategies to reduce stigma in opioid use so that it is never a barrier to patients receiving appropriate treatment, with all cautions and considerations for the management of their chronic pain conditions” - illustrates an acknowledgment by the top health agency of the federal government that the current national narrative conflating and confusing compassionate treatment of pain with illicit drug use, addiction, and overdose death is incorrect and only serving to harm patients.
Since March of 2016 when the CDC Guidelines were released, advocates, patients, clinicians, stakeholders, and others, have began pointing out limitations and unintended consequences as they emerged. In order to address the unintended consequences emerging from the CDC Guidelines, this task force was also charged with review of these guidelines; from expert selection, evidence selection, creation, and continuing to current misapplication in order to provide recommendations to begin to remedy these issues.
“A commentary by Busse et al. identified several limitations to the CDC guideline related to expert selection, evidence inclusion criteria, method of evidence quality grading, support of recommendations with low-quality evidence, and instances of vague recommendations. In addition, the CDC used the criterion of a lack of clinical trials with a duration of one year or longer as lack of evidence for the clinical effectiveness of opioids, whereas Tayeb et al. found that that was true for all common medication and behavioral therapy studies.
Interpretation of the guideline, in addition to some gaps in the guideline, have led to unintended consequences, some of which are the result of misapplication or misinterpretation of the CDC guideline.
However, at least 28 states have enacted legislation related to opioid prescription limits, and many states and organizations have implemented the guideline without recognizing that the intended audience was PCPs; have used legislation for what should be medical decision making by healthcare professionals; and have applied them to all physicians, dentists, NPs, and PAs, including pain specialists.441–444 Some stakeholders have interpreted the guideline as intended to broadly reduce the amount of opioids prescribed for treating pain; some experts have noted that the guideline emphasizes the risk of opioids while minimizing the benefit of this medication class when properly managed.”
“The CDC guideline was not intended to be model legislation for state legislators to enact”
“In essence, clinicians should be able to use their clinical judgment to determine opioid duration for their patients”
HHS Review of 2016 CDC Guidelines for responsible opioid prescribing
The Pain Management Task Force addressed 8 areas that are in need of update or expansion with recommendations to begin remediation for each problem area:
Lack of high-quality data exists for duration of effectiveness of opioids for chronic pain; this has been interpreted as a lack of benefit Conduct studies Focus on patient variability and response for effectiveness of opioids; use real-world applicable trials
Absence of criteria for identifying patients for whom opioids make up significant part of their pain treatment Conduct clinical trials and/or reviews to identify sub-populations of patients where long-term opioid treatment is appropriate
Wide variation in factors that affect optimal dose of opioids Consider patient variables for opioid therapy: Respiratory compromise Patient metabolic variables Differences in opioid medications/plasma concentrations Preform comprehensive initial assessment it’s understanding of need for comprehensive reevaluations to adjust dose Give careful considerations to patients on opioid pain regimen with additional risk factors for OUD
Specific guidelines for opioid tapering and escalation need to be further clarified A thorough assessment of risk-benefit ratio should occur whenever tapering or escalation of dose This should include collaboration with patient whenever possible Develop taper or dose escalation guidelines for sub-populations that include consideration of their comorbidities When benefit outweighs the risk, consider maintaining therapy for stable patients on long term opioid therapy
Causes of worsening pain are not often recognized or considered. Non-tolerance related factors: surgery, flares, increased physical demands, or emotional distress Avoid increase in dose for stable patient (2+ month stable dose) until patient is re-evaluated for underlying cause of elevated pain or possible OUD risk Considerations to avoid dose escalation include: Opioid rotation Non-opioid medication Interventional strategies Cognitive behavior strategies Complementary and integrative health approaches Physical therapy
In patients with chronic pain AND anxiety or spasticity, benzodiazepine co-prescribed with opioids still have clinical value; although the risk of overdose is well established When clinically indicated, co-prescription should be managed by specialist who have knowledge, training, and experience with co-prescribing. When co-prescribed for anxiety or SUD collaboration with mental health should be considered Develop clinical practice guidelines focused on tapering for co-prescription of benzodiazepines and opioids
The risk-benefit balance varies for individual patients. Doses >90MME may be favorable for some where doses <90MME may be for other patients due to individual patient factors. Variability in effectiveness and safety between high and low doses of opioids are not clearly defined. Clinicians should use caution with higher doses in general Using carefully monitored trial with frequent monitoring with each dose adjustment and regular risk reassessment, physicians should individualize doses, using lowest effective opioid dose that balances benefit, risk, and adverse reactions Many factors influence benefits and risk, therefore, guidance of dose should not be applied as strict limits. Use established and measurable goals: Functionality ADL Quality of Life
Duration of pain following acute and severely painful event is widely variable Appropriate duration is best considered within guidelines, but is ultimately determined by treating clinician. CDC recommendation for duration should be emphasized as guidance only with individualized patient care as the goal Develop acute pain management guidelines for common surgical procedures and traumas To address variability and provide easy solution, consideration should be given to partial refill system
Human Rights Watch December 2018 (Excerpt from 109 page report)
“If harms to chronic pain patients are an unintended consequence of policies to reduce inappropriate prescribing, the government should seek to immediately minimize and measure the negative impacts of these policies. Any response should avoid further stigmatizing chronic pain patients, who are increasingly associated with — and sometimes blamed for — the overdose crisis and characterized as “drug seekers,” rather than people with serious health problems that require treatment.
Top government officials, including the President, have said the country should aim for drastic cutbacks in prescribing. State legislatures encourage restrictions on prescribing through new legislation or regulations. The Drug Enforcement Administration (DEA) has investigated medical practitioners accused of overprescribing or fraudulent practice. State health agencies and insurance companies routinely warn physicians who prescribe more opioids than their peers and encourage them to reduce prescribing. Private insurance companies have imposed additional requirements for covering opioids, some state Medicaid programs have mandated tapering to lower doses for patients, and pharmacy chains are actively trying to reduce the volumes of opioids they dispense.
The medical community at large recognized that certain key steps were necessary to tackle the overdose crisis: identifying and cracking down on “pill mills” and reducing the use of opioids for less severe pain, particularly for children and adolescents. However, the urgency to tackle the overdose crisis has put pressure on physicians in other potentially negative ways: our interviews with dozens of physicians found that the atmosphere around prescribing for chronic pain had become so fraught that physicians felt they must avoid opioid analgesics even in cases when it contradicted their view of what would provide the best care for their patients. In some cases, this desire to cut back on opioid prescribing translated to doctors tapering patients off their medications without patient consent, while in others it meant that physicians would no longer accept patients who had a history of needing high-dose opioids.
The consequences to patients, according to Human Rights Watch research, have been catastrophic.”
Opioid Prescribing Workgroup December 2018
This is material from the Board of Scientific Counselors in regards to their December 12, 2018 meeting that culminated the works of a project titled the “Opioid Prescribing Estimates Project.” This project is a descriptive study that is examining opioid prescribing patterns at a population level. Pain management is a very individualized process that belongs with the patient and provider. The Workgroup reviewed work done by CDC and provided additional recommendations.
SUMMARY There were several recurrent themes throughout the sessions.
Repeated concern was voiced from many Workgroup members that the CDC may not be able to prevent conclusions from this research (i.e. the benchmarks, developed from limited data) from being used by states or payors or clinical care systems to constrain clinical care or as pay-for- performance standards – i.e. interpreted as “guidelines”. This issue was raised by several members on each of the four calls, raising the possibility that providers or clinical systems could thus be incentivized against caring for patients requiring above average amounts of opioid medication.
Risk for misuse of the analysis. Several members expressed concerns that this analysis could be interpreted as guidance by regulators, health plans, or clinical care systems. Even though the CDC does not plan to issue this as a guideline, but instead as research, payors and clinical care systems searching for ways to reign in opioid prescribing may utilize CDC “benchmarks” to establish pay-for-performance or other means to limit opioid prescribing. Such uses of this work could have the unintended effect of incentivizing providers against caring for patients reliant upon opioids.
…It was also noted that, in order to obtain sufficient granularity to establish the need for, dosage, and duration of opioid therapy, it would be necessary to have much more extensive electronic medical record data. In addition, pain and functional outcomes are absent from the dataset, but were felt to be important when considering risk and benefit of opioids.
...Tapering: Concerns about benchmarks and the implications for tapering were voiced. If tapering occurs, guidance was felt to be needed regarding how, when, in whom tapering should occur. This issue was felt to be particularly challenging for patients on chronic opioids (i.e. “legacy” patients). In addition, the importance of measuring risk and benefit of tapering was noted. Not all high-dose patient populations benefit from tapering.
Post-Surgical Pain
General comments. Workgroup members noted that most patients prescribed opioids do not experience adverse events, including use disorder. Many suggested that further discussion of opioids with patients prior to surgery was important, with an emphasis on expectations and duration of treatment. A member suggested that take-back programs would be more effective than prescribing restrictions.
Procedure-related care. Members noted that patient factors may drive opioid need more than characteristics of a procedure.
Patient-level factors. Members noted that opioid-experienced patients should be considered differently from opioid-inexperienced patients, due to tolerance.
Chronic Pain
It was noted that anything coming out of the CDC might be considered as guidelines and that this misinterpretation can be difficult to counter. There was extensive discussion of the 50 and 90 MME levels included in the CDC Guidelines. It was recommended that the CDC look into the adverse effects of opioid tapering and discontinuation, such as illicit opioid use, acute care utilization, dropping out of care, and suicide. It was also noted that there are major gaps in guidelines for legacy patients, patients with multiple diagnoses, pediatric and geriatric patients, and patients transitioning to lower doses.
There were concerns that insufficient clinical data will be available from the dataset to appropriately consider the individual-level factors that weigh into determination of opioid therapy. The data would also fail to account for the shared decision-making process involved in opioid prescribing for chronic pain conditions, which may be dependent on primary care providers as well as ancillary care providers (e.g. physical therapists, psychologists, etc).
Patient-level factors. Members repeatedly noted that opioid-experienced patients should be considered differently from opioid-experienced patients, due to tolerance.
Members noted that the current CDC guidelines have been used by states, insurance companies, and some clinical care systems in ways that were not intended by the CDC, resulting in cases of and the perception of patient abandonment. One option raised in this context was to exclude patients on high doses of opioids, as those individuals would be qualitatively different from others. A variant of this concern was about management of “legacy” patients who are inherited on high doses of opioids. Members voiced concerns that results of this work has caused harm to patients currently reliant upon opioids prescribed by their providers.
Acute Non-Surgical Pain
Patient-level factors. Members felt that opioid naïve versus experienced patients might again be considered separately, as opioid requirements among those experienced could vary widely.
...Guidelines were also noted to be often based on consensus, which may be incorrect.
Cancer-Related and Palliative Care Pain
It was noted that the CDC guidelines have been misinterpreted to create a limit to the dose of opioids that can be provided to people at all stages of cancer and its treatment. It was also noted that the cancer field is rapidly evolving, with immunotherapy, CAR-T, and other novel treatments that affect response rates and limit our ability to rely upon historical data in establishing opioid prescribing benchmarks.
Concern that data would not be able to identify all of the conditions responsible for pain in a patient with a history of cancer (e.g. people who survive cancer but with severe residual pain). Further, it was noted that certain complications of cancer and cancer treatment may require the least restrictive long-term therapy with opioids.
The definition of palliative care was also complicated and it was suggested that this include patients with life-limiting conditions.
Overall, it was felt that in patients who may not have long to live, and/or for whom returning to work is not a possibility, higher doses of opioids may be warranted.
CDC Scientists Anonymous ‘Spider Letter’ to CDC
Carmen S. Villar, MSW Chief of Staff Office of the Director MS D­14 Centers for Disease Control and Prevention (CDC) 1600 Clifton Road Atlanta, Georgia 30329­-4027
August 29, 2016
Dear Ms. Villar:
We are a group of scientists at CDC that are very concerned about the current state of ethics at our agency. It appears that our mission is being influenced and shaped by outside parties and rogue interests. It seems that our mission and Congressional intent for our agency is being circumvented by some of our leaders. What concerns us most, is that it is becoming the norm and not the rare exception. Some senior management officials at CDC are clearly aware and even condone these behaviors. Others see it and turn the other way. Some staff are intimidated and pressed to do things they know are not right. We have representatives from across the agency that witness this unacceptable behavior. It occurs at all levels and in all of our respective units. These questionable and unethical practices threaten to undermine our credibility and reputation as a trusted leader in public health. We would like to see high ethical standards and thoughtful, responsible management restored at CDC. We are asking that you do your part to help clean up this house!
It is puzzling to read about transgressions in national media outlets like USA Today, The Huffington Post and The Hill. It is equally puzzling that nothing has changed here at CDC as a result. It’s business as usual. The litany of issues detailed over the summer are of particular concern:
Recently, the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) has been implicated in a “cover up” of inaccurate screening data for the Wise Woman (WW) Program. There was a coordinated effort by that Center to “bury” the fact that screening numbers for the WW program were misrepresented in documents sent to Congress; screening numbers for 2014 and 2015 did not meet expectations despite a multi­million dollar investment; and definitions were changed and data “cooked” to make the results look better than they were. Data were clearly manipulated in irregular ways. An “internal review” that involved staff across CDC occurred and its findings were essentially suppressed so media and/or Congressional staff would not become aware of the problems. Now that both the media and Congresswoman DeLauro are aware of these issues, CDC staff have gone out of their way to delay FOIAs and obstruct any inquiry. Shouldn’t NCCDPHP come clean and stop playing games? Would the ethical thing be to answer the questions fully and honestly. The public should know the true results of what they paid for, shouldn’t they?
Another troubling issue at the NCCDPHP are the adventures of Drs. Barbara Bowman and Michael Pratt (also detailed in national media outlets). Both seemed to have irregular (if not questionable) relationships with Coca­Cola and ILSI representatives. Neither of these relationships were necessary (or appropriate) to uphold our mission. Neither organization added any value to the good work and science already underway at CDC. In fact, these ties have now called into question and undermined CDC’s work. A cloud has been cast over the ethical and excellent work of scientists due to this wanton behavior. Was cultivating these relationships worth dragging CDC through the mud? Did Drs. Bowman and Pratt have permission to pursue these relationships from their supervisor Dr. Ursula Bauer? Did they seek and receive approval of these outside activities? CDC has a process by which such things should be vetted and reported in an ethics review, tracking and approval system (EPATS). Furthermore, did they disclose these conflicts of interest on their yearly OGE 450 filing. Is there an approved HHS 520, HHS 521 or “Request for Official Duty Activities Involving an Outside Organization” approved by Dr. Bauer or her Deputy Director Ms. Dana Shelton? An August 28, 2016 item in The Hill details these issues and others related to Dr. Pratt.
It appears to us that something very strange is going on with Dr. Pratt. He is an active duty Commissioned Corps Officer in the USPHS, yet he was “assigned to” Emory University for a quite some time. How and under what authority was this done? Did Emory University pay his salary under the terms of an IPA? Did he seek and receive an outside activity approval through EPATS and work at Emory on Annual Leave? Formal supervisor endorsement and approval (from Dr. Bauer or Ms. Shelton) is required whether done as an official duty or outside activity.
If deemed official, did he file a “Request for Official Duty Activities Involving an Outside Organization” in EPATS? Apparently Dr. Pratt’s position at Emory University has ended and he has accepted another position at the University of California ­ San Diego? Again, how is this possible while he is still an active duty USPHS Officer. Did he retire and leave government service? Is UCSD paying for his time via an IPA? Does he have an outside activity approval to do this? Will this be done during duty hours? It is rumored that Dr. Pratt will occupy this position while on Annual Leave? Really? Will Dr. Pratt be spending time in Atlanta when not on Annual Leave? Will he make an appearance at NCCDPHP (where he hasn’t been seen for months). Most staff do not enjoy such unique positions supported and approved by a Center Director (Dr. Bauer). Dr. Pratt has scored a sweet deal (not available to most other scientists at CDC). Concerns about these two positions and others were recently described in The Huffington Post and The Hill. His behavior and that of management surrounding this is very troubling.
Finally, most of the scientists at CDC operate with the utmost integrity and ethics. However, this “climate of disregard” puts many of us in difficult positions. We are often directed to do things we know are not right. For example, Congress has made it very clear that domestic funding for NCCDPHP (and other CIOs) should be used for domestic work and that the bulk of NCCDPHP funding should be allocated to program (not research). If this is the case, why then is NCCDPHP taking domestic staff resources away from domestic priorities to work on global health issues? Why in FY17 is NCCDPHP diverting money away from program priorities that directly benefit the public to support an expensive research FOA that may not yield anything that benefits the public? These actions do not serve the public well. Why is nothing being done to address these problems? Why has the CDC OD turned a blind eye to these things. The lack of respect for science and scientists that support CDC’s legacy is astonishing.
Please do the right thing. Please be an agent of change.
CDC Spider (CDC Scientists Preserving Integrity, Diligence and Ethics in Research)
January 13, 2016
Thomas Frieden, MD, MPH Director Centers for Disease Control and Prevention 1600 Clifton Road Atlanta, GA 30329-4027
Re: Docket No. CDC-2015-0112; Proposed 2016 Guideline for Prescribing Opioids for Chronic Pain
Dear Dr. Frieden:
There is no question that there is an opioid misuse epidemic and that efforts need to be made to control it. The Centers for Disease Control and Prevention (CDC) is applauded for its steps to undertake this lofty effort. However, based on the American Academy of Family Physicians’ (AAFP’s) review of the guideline, it is apparent that the presented recommendations are not graded at a level consistent with currently available evidence. The AAFP certainly wants to promote safe and appropriate prescribing of opioids; however, we recommend that the CDC still adhere to the rigorous standards for reliable and trustworthy guidelines set forth by the Institute of Medicine (IOM). The AAFP believes that giving a strong recommendation derived from generalizations based on consensus expert opinion does not adhere to evidence-based standards for developing clinical guideline recommendations.
The AAFP’s specific concerns with the CDC’s methodology, evidence base, and recommendations are outlined below.
Methodology and Evidence Base
All of the recommendations are based on low or very low quality evidence, yet all but one are Category A (or strong) recommendations. The guideline states that in the GRADE methodology "a particular quality of evidence does not necessarily imply a particular strength of recommendation." While this is true, it applies when benefits significantly outweigh harms (or vice versa). When there is insufficient evidence to determine the benefits and harms of a recommendation, that determination should not be made.
When evaluating the benefits of opioids, the evidence review only included studies with outcomes of at least one year. However, studies with shorter intervals were allowed for analysis of the benefits of nonopioid treatments. The guideline states that no evidence shows long-term benefit of opioid use (because there are few studies), yet the guideline reports "extensive evidence" of potential harms, even though these studies were of low quality. The accompanying text also states "extensive evidence" of the benefits of non-opioid treatments, yet this evidence was from shorter term studies, was part of the contextual review rather than the clinical systematic review, and did not compare non- opioid treatments to opioids.
The patient voice and preferences were not explicitly included in the guideline. This raises concerns about the patient-centeredness of the guideline. The Myth of Morphine Equivalent Daily Dosage Medscape Neuro Perspective
For far too many years, pain researchers and clinicians have relied on the concept of the morphine equivalent daily dosage (MEDD), or some variant of it, as a means of comparing the "relative corresponding quantity" of the numerous opioid molecules that are important tools in the treatment of chronic pain.
...And, most unfortunately, opioid prescribing guideline committees have relied on this concept as a means of placing (usually arbitrary) limits on the levels of opioids that a physician or other clinician should be allowed to prescribe. Although these guidelines typically bill themselves as "voluntary," their chilling effect on prescribers and adaptation into state laws[2] makes calling them "voluntary" disingenuous.
Although some scientists and clinicians have been questioning the conceptual validity of MEDD for several years, a recent study[3] has indicated that the concept is unequivocally flawed—thereby invalidating its use empirically and as a tool in prescribing guideline development.
The authors used survey data from pharmacists, physicians, nurse practitioners, and physician assistants to estimate daily morphine equivalents and found great inconsistency in their conversions of hydrocodone, fentanyl transdermal patches, methadone, oxycodone, and hydromorphone—illustrating the potential for dramatic underdosing or, in other cases, fatal overdosing.
Patients with chronic pain (particularly that of noncancer origin) who are reliant on opioid analgesia are already sufficiently stigmatized and marginalized[7] to allow this type of practice to continue to be the norm.
Although the use of MEDD in research and, to a greater extent, in practice, is probably due to unawareness of its inaccuracy, we posit that the use of MEDD by recent opioid guideline committees (eg, the Washington State Opioid Guideline Committee[8] and the Centers for Disease Control and Prevention Guideline Committee[9]) in the drafting of their guidelines is based more heavily on disregarding available evidence rather than ignorance. Furthermore, their misconduct in doing so has been more pernicious than the use of MEDD by researchers and individual clinicians, because these guidelines widely affect society as a whole as well as individual patients with persistent pain syndromes. We opine that these committees are strongly dominated by the antiopioid community, whose agenda is to essentially restrict opioid access—irrespective of the lack of data indicating that opioids cannot be a useful tool in the comprehensive treatment of carefully selected and closely monitored patients with chronic pain.
Above 100% extracted from: Medscape Journal Brief
Actual Study
Are Non-Opioid Medications Superior in Treatment of Pain than Opioid Pain Medicine? Ice Cream Flavor Analogy...
In the Oxford University Press, a November 2018 scientific white paper[5] was released that examined the quality of one of the primary studies that have been used to justify the urgent call to drastically reduce opioid pain medication prescribing while claiming that patients are not being harmed in the process.
The study is commonly referred to as ‘the Krebs study’. “The authors concluded that treatment with opioids was not superior to treatment with non opioid medications for improving pain-related function over 12 months.”
Here is an excerpt from the first paragraph of the design section (usually behind a paywall) from the Krebs study that gives the first hint of the bias that led to them to ‘prove’ that opioids were not effective for chronic pain:
“The study was intended to assess long-term outcomes of opioids compared with non opioid medications for chronic pain. The patient selection, though, specifically excluded patients on long-term opioid therapy.” 
Here is an analogy given in the Oxford Journal white paper to illustrate how the study design was compromised:
If I want to do a randomized control study about ice cream flavor preferences (choices being: vanilla, chocolate, or no preference), the results could be manipulated as follows based on these scenarios:
Scenario A: If a study was done that included only current ice-cream consumers, the outcome would certainly be vanilla or chocolate, because of course they have tried it and know which they like.
Scenario B: If a study was done that included all consumers of all food, then it can change the outcome. If the majority of study participants do not even eat ice-cream, than the result would certainly be ‘no preference’. If the majority do eat ice-cream it would likely be ‘chocolate’. Although this study is wider based, it still does not reflect real world findings.
Scenario C: In an even more extreme example, if this same study is conducted excluding anyone who has ever ate ice-cream at all, then the conclusion will again be ‘no preference’ and the entire study/original question becomes so ludicrous that there is no useful information to be extracted from this study and one would logically question why this type of study would even be conducted (although we know the answer to that)
Scenario C above is how the study that has been used to shift the attitudes towards the treatment of pain in our nation's medical community was designed. “One has to look deep into the study to find that they began with 9403 possible patients and excluded 3836 of them just because they had opioids in their EMR. In the JAMA article, they do not state these obvious biases and instead begin the explanation of participants stating they started with 4485 patients and excluded 224 who were opioid or benzo users.” That is the tip of the iceberg to how it is extremely misleading. The Oxford white paper goes into further detail of the studies “many flaws and biases (including the narrow focus on conditions that are historically known to respond poorly to opioid medication management of pain)”, but the study design and participant selection criteria is enough to discredit this entire body of work. Based on study design alone, regardless of what happened next, the result would be that opioids are no more effective than NSAIDs and other non-opioid alternatives.
The DEA Is Fostering a Bounty Hunter Culture in its Drug Diversion Investigators[8]
A Good Man Speaks Truth to Power January 2019
Because I write and speak widely on public health issues and the so-called “opioid crisis”, people frequently send me references to others’ work. One of the more startling articles I’ve seen lately was published November 20, 2018 in Pharmacy Times. It is titled “Should We Believe Patients With Pain?”[9]. The unlikely author is Commander John Burke, “a 40-year veteran of law enforcement, the past president of the National Association of Drug Diversion Investigators, and the president and cofounder of the International Health Facility Diversion Association.”
The last paragraph of Commander Burke’s article is worth repeating here.
“Let’s get back to dealing with each person claiming to be in legitimate pain and believe them until we have solid evidence that they are scamming the system. If they are, then let’s pursue them through vigorous prosecution, but let’s not punish the majority of people receiving opioids who are legitimate patients with pain.”
This seems a remarkable insight from anyone in law enforcement — especially from one who has expressed this view in both Pain News Network, and Dr Lynn Webster’s video “The Painful Truth”. Recognizing Commander Burke’s unique perspective, I followed up by phone to ask several related questions. He has granted permission to publish my paraphrases of his answers here.
“Are there any available source documents which establish widely accepted standards for what comprises “over-prescription?” as viewed by diversion investigators?” Burke’s answer was a resounding “NO”. Each State and Federal Agency that investigates doctors for potentially illegal or inappropriate opioid prescribing is pretty much making up their own standards as they go. Some make reference to the 2016 CDC Guidelines, but others do not.
  1. “Thousands of individual doctors have left pain management practice in recent years due to fears they may be investigated, sanctioned, and lose their licenses if they continue to treat patients with opioid pain relievers.. Are DEA and State authorities really pursuing the worst “bad actors”, or is something else going on?
Burke’s answer: “Regulatory policy varies greatly between jurisdictions. But a hidden factor may be contributing significantly to the aggressiveness of Federal investigators. Federal Agencies may grant financial bonuses to their in-house diversion investigators, based on the volume of fines collected from doctors, nurse practitioners, PAs and others whom they investigate.

"No law enforcement agency at any level should be rewarded with monetary gain and/or promotion due to their work efforts or successes. This practice has always worried me with Federal investigators and is unheard of at the local or state levels of enforcement.”

Commander Burke’s revelation hit me like a thunder-clap. It would explain many of the complaints I have heard from doctors who have been “investigated” or prosecuted. It’s a well known principle that when we subsidize a behavior, we get more of it. Financial rewards to investigators must inevitably foster a “bounty hunter” mentality in some. It seems at least plausible that such bonuses might lead DEA regulators to focus on “low hanging fruit” among doctors who may not be able to defend themselves without being ruined financially. The practice is at the very least unethical. Arguably it can be corrupting.
I also inquired concerning a third issue:
  1. I read complaints from doctors that they have been pursued on trumped-up grounds, coerced and denied appropriate legal defense by confiscation of their assets – which are then added to Agency funds for further actions against other doctors. Investigations are also commonly announced prominently, even before indictments are obtained – a step that seems calculated to destroy the doctor’s practice, regardless of legal outcomes. Some reports indicate that DEA or State authorities have threatened employees with prosecution if they do not confirm improper practices by the doctor. Do you believe such practices are common?”

Burke’s answer: “I hear the same reports you do – and the irony is that such tactics are unnecessary. Lacking an accepted standard for over-prescribing, the gross volume of a doctor’s prescriptions or the dose levels prescribed to their patients can be poor indicators of professional misbehavior. Investigators should instead be looking into the totality of the case, which can include patient reports of poor doctor oversight, overdose-related hospital admissions, and patterns of overdose related deaths that may be linked to a “cocktail” of illicit prescribing. Especially important can be information gleaned from confidential informants – with independent verification – prior patients, and pharmacy information.”

No formal legal prosecution should ever proceed from the testimony of only one witness — even one as well informed as Commander John Burke. But it seems to me that it is high time for the US Senate Judiciary Committee to invite the testimony of others in open public hearings, concerning the practice of possible bounty hunting among Federal investigators.
C50 Patient, Civil Rights Attorney, Maine Department of Health, and Maine Legislature Collaborative Enacted Definition of Palliative Care
One suggestion that our organization would like to make is altering the definition of “palliative care” in such a manner that it can include high-impact or intractable patients; those who are not dying this year, but our lives have been shattered and/or shortened by our diseases and for whom Quality of Life should be the focus. Many of our conditions may not SIGNIFICANTLY shorten my life, therefore I could legitimately be facing 30-40 years of severe pain with little relief; that is no way to live and therefore the concern is a rapidly increasing suicide rate.
This is a definition that one of our coalition members with a civil rights attorney and the Maine Department of Health agreed upon and legislators enacted into statues in Maine. This was in response to a 100mme restriction. This attorney had prepared a lawsuit based on the Americans with Disability Act that the Department of Health in Maine agreed was valid; litigation was never the goal, it was always patient-centered care.
A. "Palliative care" means patient-centered and family-focused medical care that optimizes quality of life by anticipating, preventing and treating suffering caused by a medical illness or a physical injury or condition that substantially affects a patient's quality of life, including, but not limited to, addressing physical, emotional, social and spiritual needs; facilitating patient autonomy and choice of care; providing access to information; discussing the patient's goals for treatment and treatment options, including, when appropriate, hospice care; and managing pain and symptoms comprehensively. Palliative care does not always include a requirement for hospice care or attention to spiritual needs. B. "Serious illness" means a medical illness or physical injury or condition that substantially affects quality of life for more than a short period of time. "Serious illness" includes, but is not limited to, Alzheimer's disease and related dementias, lung disease, cancer, heart, renal or liver failure and chronic, unremitting or intractable pain such as neuropathic pain.
Here is the link to the most recent update, including these definitions within the entire statute:
January 23, 2019
Dear Pharmacists,
The Board of Pharmacy has had an influx of communication concerning patients not able to get controlled substance prescriptions filled for various reasons, even when signs of forgery or fraudulence were not presented. As a result of the increased “refusals to fill,” the board is issuing the following guidance and reminders regarding the practice of pharmacy and dispensing of controlled substances:
  1. Pharmacists must use reasonable knowledge, skill, and professional judgment when evaluating whether to fill a prescription. Extreme caution should be used when deciding not to fill a prescription. A patient who suddenly discontinues a chronic medication may experience negative health consequences;
  2. Part of being a licensed healthcare professional is that you put the patient first. This means that if a pharmacist has any concern regarding a prescription, they should attempt to have a professional conversation with the practitioner to resolve those concerns and not simply refuse the prescription. Being a healthcare professional also means that you use your medication expertise during that dialogue in offering advice on potential alternatives, changes in the prescription strength, directions etc. Simply refusing to fill a prescription without trying to resolve the concern may call into question the knowledge, skill or judgment of the pharmacist and may be deemed unprofessional conduct;
  3. Controlled substance prescriptions are not a “bartering” mechanism. In other words, a pharmacist should not tell a patient that they have refused to fill a prescription and then explain that if they go to a pain specialist to get the same prescription then they will reconsider filling it. Again, this may call into question the knowledge, skill or judgment of the pharmacist;
  4. Yes, there is an opioid crisis. However, this should in no way alter our professional approach to treatment of patients in end-of-life or palliative care situations. Again, the fundamentals of using our professional judgment, skill and knowledge of treatments plays an integral role in who we are as professionals. Refusing to fill prescriptions for these patients without a solid medical reason may call into question whether the pharmacist is informed of current professional practice in the treatment of these medical cases.
  5. If a prescription is refused, there should be sound professional reasons for doing so. Each patient is a unique medical case and should be treated independently as such. Making blanket decisions regarding dispensing of controlled substances may call into question the motivation of the pharmacist and how they are using their knowledge, skill or judgment to best serve the public.
As a professional reminder, failing to practice pharmacy using reasonable knowledge, skill, competence, and safety for the public may result in disciplinary actions under Alaska statute and regulation. These laws are:
(a)The board may deny a license to an applicant or, after a hearing, impose a disciplinary sanction authorized under AS 08.01.075 on a person licensed under this chapter when the board finds that the applicant or licensee, as applicable, …
(7) is incapable of engaging in the practice of pharmacy with reasonable skill, competence, and safety for the public because of
(A) professional incompetence; (B) failure to keep informed of or use current professional theories or practices; or (E) other factors determined by the board;
(14) engaged in unprofessional conduct, as defined in regulations of the board.
(a) In addition to acts specified in AS 08.80 or elsewhere in this chapter, each of the following constitutes engaging in unprofessional conduct and is a basis for the imposition of disciplinary sanctions under AS 08.01.075; …
(15) failing to use reasonable knowledge, skills, or judgment in the practice of pharmacy;
(b) The board will, in its discretion, revoke a license if the licensee …
(4) intentionally or negligently engages in conduct that results in a significant risk to the health or safety of a patient or injury to a patient; (5) is professionally incompetent if the incompetence results in a significant risk of injury to a patient.
(c) The board will, in its discretion, suspend a license for up to two years followed by probation of not less than two years if the licensee ...
(2) is professionally incompetent if the incompetence results in the public health, safety, or welfare being placed at risk.
We all acknowledge that Alaska is in the midst of an opioid crisis. While there are published guidelines and literature to assist all healthcare professionals in up to date approaches and recommendations for medical treatments per diagnosis, do not confuse guidelines with law; they are not the same thing.
Pharmacists have an obligation and responsibility under Title 21 Code of Federal Regulations 1306.04(a), and a pharmacist may use professional judgment to refuse filling a prescription. However, how an individual pharmacist approaches that particular situation is unique and can be complex. The Board of Pharmacy does not recommend refusing prescriptions without first trying to resolve your concerns with the prescribing practitioner as the primary member of the healthcare team. Patients may also serve as a basic source of information to understand some aspects of their treatment; do not rule them out in your dialogue.
If in doubt, we always recommend partnering with the prescribing practitioner. We are all licensed healthcare professionals and have a duty to use our knowledge, skill, and judgment to improve patient outcomes and keep them safe.
Richard Holt, BS Pharm, PharmD, MBA Chair, Alaska Board of Pharmacy
FDA in Brief: FDA finalizes new policy to encourage widespread innovation and development of new buprenorphine treatments for opioid use disorder
February 6, 2018
Media Inquiries Michael Felberbaum 240-402-9548
“The opioid crisis has had a tragic impact on individuals, families, and communities throughout the country. We’re in urgent need of new and better treatment options for opioid use disorder. The guidance we’re finalizing today is one of the many steps we’re taking to help advance the development of new treatments for opioid use disorder, and promote novel formulations or delivery mechanisms of existing drugs to better tailor available medicines to individuals’ needs,” said FDA Commissioner Scott Gottlieb, M.D. “Our goal is to advance the development of new and better ways of treating opioid use disorder to help more Americans access successful treatments. Unfortunately, far too few people who are addicted to opioids are offered an adequate chance for treatment that uses medications. In part, this is because private insurance coverage for treatment with medications is often inadequate. Even among those who can access some sort of treatment, it’s often prohibitively difficult to access FDA-approved addiction medications. While states are adopting better coverage owing to new legislation and resources, among public insurance plans there are still a number of states that are not covering all three FDA-approved addiction medications. To support more widespread adoption of medication-assisted treatment, the FDA will also continue to take steps to address the unfortunate stigma that’s sometimes associated with use of these products. It’s part of the FDA’s public health mandate to promote appropriate use of therapies.
Misunderstanding around these products, even among some in the medical and addiction fields, enables stigma to attach to their use. These views can serve to keep patients who are seeking treatment from reaching their goal. That stigma reflects a perspective some have that a patient is still suffering from addiction even when they’re in full recovery, just because they require medication to treat their illness. This owes to a key misunderstanding of the difference between a physical dependence and an addiction. Because of the biology of the human body, everyone who uses a meaningful dose of opioids for a modest length of time develops a physical dependence. This means that there are withdrawal symptoms after the use stops.
A physical dependence to an opioid drug is very different than being addicted to such a medication. Addiction requires the continued use of opioids despite harmful consequences on someone’s life. Addiction involves a psychological preoccupation to obtain and use opioids above and beyond a physical dependence.
But someone who is physically dependent on opioids as a result of the treatment of pain but who is not craving the drugs is not addicted.
The same principle applies to replacement therapy used to treat opioid addiction. Someone who requires long-term treatment for opioid addiction with medications, including those that are partial or complete opioid agonists and can create a physical dependence, isn’t addicted to those medications. With the right treatments coupled to psychosocial support, recovery from opioid addiction is possible. The FDA remains committed to using all of our tools and authorities to help those currently addicted to opioids, while taking steps to prevent new cases of addiction.”
Above is the full statement, find full statement with options for study requests:
Maryland’s co-prescribing new laws/ amendments regarding benzos and opioids
Chapter 215 AN ACT concerning Health Care Providers – Opioid and Benzodiazepine Prescriptions – Discussion of Information Benefits and Risks
FOR the purpose of requiring that certain patients be advised of the benefits and risks associated with the prescription of certain opioids, and benzodiazepines under certain circumstances, providing that a violation of this Act is grounds for disciplinary action by a certain health occupations board; and generally relating to advice regarding benefits and risks associated with opioids and benzodiazepines that are controlled dangerous substances.
Section 1–223 Article – Health Occupations Section 4–315(a)(35), 8–316(a)(36), 14–404(a)(43), and 16–311(a)(8) SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, That the Laws of Maryland read as follows: Article – Health Occupations (a) In this section, “controlled dangerous substance” has the meaning stated in § 5–101 of the Criminal Law Article.
Ch. 215 2018 LAWS OF MARYLAND (B) On treatment for pain, a health care provider, based on the clinical judgment of the health care provider, shall prescribe: (1) The lowest effective dose of an opioid; and (2)A quantity that is no greater than the quantity needed for the expected duration of pain severe enough to require an opioid that is a controlled dangerous substance unless the opioid is prescribed to treat: (a.) A substance–related disorder; (b.) Pain associated with a cancer diagnosis; (c.) Pain experienced while the patient is receiving end–of–life, hospice, or palliative care services; or (d.) Chronic pain
(C.) The dosage, quantity, and duration of an opioid prescribed under [subsection (b)] of this [section] shall be based on an evidence–based clinical guideline for prescribing controlled dangerous substances that is appropriate for: (1.) The health care service delivery setting for the patient; (2.) The type of health care services required by the patient; (3.) and The age and health status of the patient.
(E) A violation of [subsection (b) OR (D) of] this section is grounds for disciplinary action by the health occupations board that regulates the health care provider who commits the violation.
4-315 (a) Subject to the hearing provisions of § 4–318 of this subtitle, the Board may deny a general license to practice dentistry, a limited license to practice dentistry, or a teacher’s license to practice dentistry to any applicant, reprimand any licensed dentist, place any licensed dentist on probation, or suspend or revoke the license of any licensed dentist, if the applicant or licensee: (35) Fails to comply with § 1–223 of this article.
8–316. (a) Subject to the hearing provisions of § 8–317 of this subtitle, the Board may deny a license or grant a license, including a license subject to a reprimand, probation, or suspension, to any applicant, reprimand any licensee, place any licensee on probation, or suspend or revoke the license of a licensee if the applicant or licensee: (36) Fails to comply with § 1–223 of this article.
14–404. (a) Subject to the hearing provisions of § 14–405 of this subtitle, a disciplinary panel, on the affirmative vote of a majority of the quorum of the disciplinary panel, may reprimand any licensee, place any licensee on probation, or suspend or revoke a license if the licensee: (43) Fails to comply with § 1–223 of this article.
16–311. (a) Subject to the hearing provisions of § 16–313 of this subtitle, the Board, on the affirmative vote of a majority of its members then serving, may deny a license or a limited license to any applicant, reprimand any licensee or holder of a limited license, impose an administrative monetary penalty not exceeding $50,000 on any licensee or holder of a limited license, place any licensee or holder of a limited license on probation, or suspend or revoke a license or a limited license if the applicant, licensee, or holder:
(8) Prescribes or distributes a controlled dangerous substance to any other person in violation of the law, including in violation of § 1–223 of this article;
SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall take effect October 1, 2018.
Approved by the Governor, April 24, 2018.
submitted by Dirtclodkoolaid to ChronicPain [link] [comments]

2023.06.04 07:57 Nyxtrastar I just need this out; read or ignore, it doesn't matter.

(Conditions: Autism, ADHD, Severe Clinical Depression, Anxiety, PTSD)
I saw a post on Instagram basically reminding people that neurodivergent folks' abilities to function are not consistent. They come and go based on many factors. And as reassuring as that is... Fuck.
I spent at least 2 months deep cleaning my room. It had been so bad that my dad compared it to a lower scale hoarders house, with pathways and all. It smelled like pet dander. It was gross.
I took time to apply for many full time jobs to start a career. And even got a couple interviews.
I fought to remember to take my meds since with a dosage change I have to take one in the morning and one at night for the first time ever. My ADHD ass can hardly manage once a day.
Then my motivation crashed. My room's progress halted, even though I was extremely close to finishing. Applications stopped going out. Daily household chores became burdensome and a hassle. Work went from enjoyable to a chore. And masking in the workplace became that much harder.
A few days ago, my mom got sick of my procrastination and made me finish my application for an online college course that would help me be more hireable in a career. An application I asked for and voiced interest in. One I was excited to do.
And I was immediately angry, irritable, and overwhelmed. I was hit with severe executive disfunction and started crying. And I could tell my mom was frustrated, even if she didn't say it. It was yet another time she had to regulate her adult child's emotions. Like she would a 9 year old. (She's never said this directly, but the comparison is accurate). She asked why I was giving up. She said I had worked so hard and made a lot of progress. Why on Earth would I want to lose that momentum and give up? And she was right.
I had no right to be upset. It was an application I ASKED HER TO PRINT FOR ME. I was sleeping almost 12 hours a night. I would feel drained despite doing literally nothing productive all day. And doing things literally every other adult on Earth does without issue is exhausting and feels intimidating. I can't even look at a tax form without wanting to throw it across the room and hide in my room. The thought of moving into an apartment and living on my own makes me cry almost immediately because I'm terrified.
And all of this is the bare. Minimum. The minimal things expected of an adult. Maintain a home. Go to work. Eat well. Manage finances. Maintain a social life. And the only thing I can do is go to work. But even then, it's only part time and I still feel like I have no free time.
If I can't maintain my strong moments, then I'll never get to where I'm expected to be. Even at my best, I'm nowhere near where I need to be. And I have almost a year of being a legal adult under my belt. And I'm more confused and scared than I was before I graduated. And I genuinely don't believe it gets better. You have early adulthood where you have no fucking idea what to do, then later in life you've kinda figured a few things out, but now you have a fuck ton to lose if you screw up. Maybe a home, a career, a family, kids. The situation just shifts. It doesn't get better. And some would argue it's worse. I honestly don't think I will survive once I move out. Whether its because I do something dumb and get evicted and freeze or starve, or end it myself. And if I do survive, it won't be by much. It'll be miserable, constantly scared of fucking it all up.
And the worst part of it all? I know my failures make things harder for my family. My siblings have an older sister they can't look up to. My parents have a daughter that's disfunctional whom they fear for. A child they can't be proud of. They fear what will happen in the future, despite their best efforts. Every time I have a breakdown, or have a crisis, it's a hassle. Its a chore, and it's exhausting. I genuinely wish they skipped me and went straight to my sister's birth. They don't deserve the burden I bring. At least my siblings are kids they can be proud of.
My sister loves to sew. She's sporty, social, and as my mom puts it, her "social justice warrior." My brother is kind, silly, intelligent, and just enjoys life, despite his own ADHD.
When I spent a week in emergency inpatient, I was told that there was almost no fighting between... Anyone. Between siblings? Nope. And tension dropped. I know I was told in order to motivate me, but it's just further evidence that I just make things so much harder. And I don't know how long they spent paying off that hospital stay.
Therapists, medicine, whatever. It's all a waste of money. I'll never get where I need to be. I'll always be the stain on the family. Whether they admit it, believe it or not. Life is better when I'm not around. But their hearts won't let them believe it because they care about me when I've given them no reason to.
And that just makes it all the worse. The fact that I'll never be enough. Do enough. The worry, fear, and literal trauma I've put on them. For what? So they can watch me live through life miserably and wonder what they did wrong? It's not fair. And the alternative of ending it all is worse. I can't risk them blaming themselves for my actions. Not when I have two younger siblings who need them. A rock and a fucking hard place man...
Life sucks. Fuck whatever god decided this life was worth a damn thing. Fuck them for thinking putting this on a human being was okay. And fuck my life.
submitted by Nyxtrastar to depression [link] [comments]

2023.06.04 02:19 uga_med27 School list help! URM, 513 MCAT, 3.78/3.65 GPA

Hi everyone, I'd like some thoughts on my school list as I begin to finalize it. I'd appreciate suggestions on schools to add/remove. Thanks in advance!

School List:
submitted by uga_med27 to premed [link] [comments]

2023.06.04 00:41 blood2016 Bariatric Help?

I am autistic and had a mild case of untreated sleep apnea that didn't effect my independent life living in a National Park dormitory at all when I was 25 years old and hiked after work with friends.
I developed my first signs of bipolar disorder out there and after some persuasion to give up my independence my dad drove us back to our family home.
I was very frightened about which new symptom of bipolar will I unexpectedly be experiencing for the first time next while having zero coping skills nor medicine for that specific symptom ready to use but I had a strong desire to get back to hiking with friends and assured my parents that my time here with them would be temporary.
Feeling very depressed and not working and not hiking made me gain some weight and my sleep apnea reached a level where it was now making me sleep too much. In America, you lose your health insurance, you can't be on your parent's plan anymore, and there was a rush to get treatment before the deadline.
I ended up getting the sleep study, getting diagnosed with central and obstructive sleep apnea, getting a CPAP machine programmed with the settings from the sleep study, and my doctor was feeling good about my central going away by giving the obstructive treatment a first try for a little and then I lost my health insurance, didn't go back, and I was just so resistant to being reliant on a machine when I felt like an alternative, getting back down to my old weight, was just as easy of a solution, but it didn't work out that way.
I'm going to say that I was 250 lbs at 6 feet 3 inches tall out on the trails, moved up to 318 lbs at my parent's house, got put on a big handful of bipolar meds to keep me stable, Lisinopril, and vitamin d because I don't get out much, vitamin e to keep my triglycerides in check while treating weight lifting as my big hobby, quit weight lifting after 5 years, just got tired of it and covid closing the gym played a role too, and then I experienced a very sudden increase all the way up to 438 lbs! Wtf?
After much resistance, mom stepped into her rescue her adult son role as she does sometimes and bought me a whole new $500 wardrobe of clothes because nothing fit anymore.
Last week, my pulmonary doctor mentioned stomach reduction surgery to me as CPAP has never worked for me, I'll be getting back a rental machine for my third try this month.
My nurse practitioner is wanting to double my blood pressure meds, start me on 1000mg metformin and regular finger pricking, a statin drug, omeprazole because I throw up a little after I eat now.
My knees feel like they're going to explode upon standing up from my recliner.
I fall asleep in weird places like sitting on the toilet to pee and wake back up with two legs that have fallen asleep and I'm stuck there can't getting them to wake back up after intense wiggling.
My vitamin d is still low after supplementation and vitamin e isn't controlling my triglycerides anymore,
I don't understand why I have an iron deficiency, I love hamburgers.
I've quit all of my bipolar meds since two weeks ago except for my Wellbutrin as it's supposed to decrease appetite and promote wakefulness, I take 400mg a day. The bioolars that I quit were Vraylar and Lamictal,.
Probably one of the worst things is that I can't masturbate anymore starting 6 months ago. The nurse has me down as hypogonadism, low testosterone, and erectile dysfunction.
I know from my reading online that mens health clinics screen for sleep apnea before starting testosterone shots because testosterone shots make sleep apnea worse so not sure how that one's going to get solved.
Im currently putting off picking my all my new goodies from the pharmacy.
I have a little complaint about my nurse practitioner. She ordered knee xrays which I'm feeling like why do I need this, it's just extra weight on the joints, and she was a good listener and typed accurate notes into the computer but maybe ran out of time because it wasn't until the next day that she went back into my chart and added her new meds of choice, I have no training on how to use, just got a Walgreens alert, and there are now errors in her expanded set of notes like I never said anything about hemorrhoids and it also says me and patient talked about such and such as a trial option before referral and he nodded his head in understandment, never did that. My mom says that she sees the same kind of stuff in her chart, completely different providers, and there's a whole section discussing body parts that she doesn't even have anymore.
Not sure how to get back on track at this weight. Everything hurts. I need low impact. My hunger is huge. My windows of awakeness from sleep apnea are so small that I can't even do video gaming.
submitted by blood2016 to AskDocs [link] [comments]

2023.06.03 19:05 PoetLaureddit Re-Post from r/cancer: Resources for cancer patients ideas?

How do you do, fellow carcinomies?
I recently went into remission from stage 4 melanoma, and it was a much quicker treatment time than I had anticipated. Past the obvious shock and elation, it gives me a lot more time in both the near and long-term future to pursue things I care about.
One of those things has become advocacy for cancer patients and the chronically ill. I've started a vlog that is somewhat dedicated to that, I'm volunteering at my oncology clinic, and now I'm looking to start an organization that formally creates resources for patients.
I don't have an org. structure yet, but that part is less important to me. I also don't want to base my early focus solely on my own anecdotal time(s) with cancer; obviously there's a big, diverse world of people that need different kinds of help.
There are some easy/obvious services or assistance points such as:
--Financial aid --Food and household goods --Medicinal or prescription aid --Billing advocacy --Transportation --Mental health services --Caretaking & scheduling --Support groups
There are also some less overt things like having other patients to talk to, maybe some sort of meetups, or resources on specific treatments/side effects.
I'm compiling my own list, but would love to hear about things that would help or could have helped you get through whatever situation you were in - whether it's as a patient, caretaker, family member, or whatever.
Thanks for reading/potentially helping :)
Mike Linn
submitted by PoetLaureddit to melahomies [link] [comments]

2023.06.03 19:04 PoetLaureddit Resource List For Cancer Patient Services Organization

How do you do, fellow carcinomies?
I recently went into remission from stage 4 melanoma, and it was a much quicker treatment time than I had anticipated. Past the obvious shock and elation, it gives me a lot more time in both the near and long-term future to pursue things I care about.
One of those things has become advocacy for cancer patients and the chronically ill. I've started a vlog that is somewhat dedicated to that, I'm volunteering at my oncology clinic, and now I'm looking to start an organization that formally creates resources for patients.
I don't have an org. structure yet, but that part is less important to me. I also don't want to base my early focus solely on my own anecdotal time(s) with cancer; obviously there's a big, diverse world of people that need different kinds of help.
There are some easy/obvious services or assistance points such as:
--Financial aid --Food and household goods --Medicinal or prescription aid --Billing advocacy --Transportation --Mental health services --Caretaking & scheduling --Support groups
There are also some less overt things like having other patients to talk to, maybe some sort of meetups, or resources on specific treatments/side effects.
I'm compiling my own list, but would love to hear about things that would help or could have helped you get through whatever situation you were in - whether it's as a patient, caretaker, family member, or whatever.
Thanks for reading/potentially helping :)
Mike Linn
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2023.06.03 16:25 Life_Valuable_177 Passed the PANCE!

I found out I passed the PANCE last week and before my exam, I lived on Reddit trying to see everyone’s stats to help ease my anxiety. I figured I’d share mine too!!
Pre-clinical PACKRAT: 126, no studying prior Emergency Medicine EORE: 401 Pediatrics EORE: 435 Family Medicine: 445 Internal Medicine: 426 PACKRAT II: 155 General Surgery: 415 OBGYN: 423 Psych: 410 End of curriculum exam: 1555 PANCE: 473
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