Fentanyl is a potent opioid analgesic and has been the center of the opioid and overdose epidemic. As an illicit agent, fentanyl is often in the form of a powder, which is then either insufflated (the fancy medical term for snorting) or dissolved in water and injected intravenously. It is fifty to one-hundred times more potent than heroin, the drug it replaced as the illicit opioid of choice. It can cause significant euphoria and analgesia, which is why it is so widely used. It can also cause respiratory depression or complete respiratory arrest, the reason it can be so deadly. It is readily absorbed when insufflated or injected and the actions are almost immediate. These are the facts.
Wait times and length of stay in emergency departments are a hot topic and often result in a variety of identifiable harms that include medical error and failures to meet quality care measures. Patients with psychiatric conditions, including suicidal ideations, risk for harm to others, or psychosis, are particularly vulnerable to increased emergency department (ED) lengths of stay. The length of ED holds for psychiatric patients can be three-fold that of similar holds for medical patients. Lack of access to appropriate care, comorbid medical illness, or violent behavior can all contribute to this.
Increased length of stay impacts the efficiency of the ED itself, increasing wait times, utilizing human resources and physical space. It has a more important impact, however, on the patient. Patients may be held in a small room with constant observation for days with little or no access to natural light, bathing facilities or contact with family or friends. They may be dressed in paper gowns, told when to eat, when to sleep and confined to their room for days at a time, emulating the conditions in a maximum security prison. Emergency Departments, through no fault of their own, are becoming holding cells for patients who are both vulnerable and often marginalized.
As a nurse practitioner in a busy suburban emergency department, pain is my job. Pain is one of the most common reasons people come to an emergency department (ED). It could be abdominal pain, chest pain, back pain or even emotional pain, including depression or suicidal ideations. Pain is a driver for people seeking medical care. We have made pain into a vital sign, and we ask, “How would you rate your pain on a scale of 1 to 10?” a mandatory question for any patient who steps through our door.
This whole concept evolved circa 1987 when the Institute of Medicine urged healthcare providers to use a quantified measure for pain. It gained even more traction in 1990 when then president of the American Pain Society, Dr. Mitchell Max, called for improved means to assess and treat pain. The term “oligoanalgesia” gained popularity in the published literature, meaning that we weren’t giving enough pain medication to patients in the ED, in clinics or in any other healthcare setting. Healthcare providers responded. We asked about and we thought, more effectively treated pain to address this issue.
I had always considered my field of expertise to be emergency medicine. I worked through the ranks as an emergency medical technician, then onward as a paramedic, which included a nine-year stint on a busy medical helicopter. I worked in disaster medicine, and was the associate director of a Harvard-affiliated disaster medicine fellowship in Boston. My current practice is as a nurse practitioner in a busy suburban emergency department (ED) and I am still active in emergency medical services as a SWAT medic and as an educator.
The emergency part of what I do is the exciting part —the part that stimulates the excitatory neurotransmitters that flood the brain, preparing it to act quickly and concisely.
We are selling ourselves short, however, when we label this role as “emergency” providers. Instead, “public health provider” is a much more appropriate term to use, because emergency departments and those who provide care there are really public health workers.
All of us who practice in emergency medicine know that real emergencies are few and far between. Our day-to-day is much more mundane. We deal with many urgent issues as well as some less urgent, primary care problems. We may even spend time filling printer paper or bringing a patient their lunch. We may help to find someone a homeless shelter, send a family home with warm coats for the kids, or pack up a bag with food and toiletries for a young girl we feel is being trafficked.
In light of all this, the purpose and the policies of the emergency department need to be redefined. Read More
An unnamed columnist writing for the National Rifle Association Institute for Legislative Action blog advised physicians and other healthcare providers to “stay in their lane” when it comes to advocating for gun control.
This appears to have been sparked by the position paper published in the October, 2018 Annals of Internal Medicine authored by the Health and Public Policy Committee of the American College of Physicians. The author of the blog post argues that the paper and subsequent position statement is flawed, claiming that there is “not enough evidence” to suggest that stricter gun laws would have any effect of the rates of gun violence in the United States.
The conclusion is that medical providers should keep to doing what they do best (practicing medicine) and leave the discussion of gun control to the “experts”, by which the author apparently means gun owners and the NRA.
This article would have likely been just another throw-away piece had it not caught the attention of thousands of medical providers on Twitter. Retweets carrying the hashtag #ThisIsMyLane went viral, relaying stories of gun-shot victims that physicians, nurses, EMS providers and others have had to treat. Some were accompanied by pictures of blood-stained trauma bays or operating room suites.
It seems like an odd move to criticize the very people who have to deal with the carnage of gun violence, and given the response, the NRA picked the wrong people to bully. There were more than 16,000 comments within just a few hours, mostly from healthcare providers denouncing the article and the accompanying tweet.
San Pedro Sula in Honduras was the murder capital of the world for decades, a title it lost only a few years ago to Caracas, Venezuela in 2016.
At its peak, there were an average of three murders a day, which is alarming for a city with a census population of around only 765,000. This violence is fueled by a booming drug and weapons trade, one-third of the population facing unemployment, the presence of violent gangs, and political strife that make living in Honduras a daily life or death struggle.
When framed this way, it is clear to see that the term “migrant caravan” doesn’t at all describe this group marching from Honduras, through Mexico to the United States border. Let’s not let politicos or the media brand them as anything else. Terminology is important here, and the term “migrant caravan” doesn’t even begin to describe this group.These people are victims of torture, fleeing a violent landscape to seek asylum for themselves and their families. Anything less than that is a disgraceful mischaracterization of who they actually are.
While there has been a great deal in the literature that discusses the ethics of neurologic, cardiopulmonary and biologic death in the context of organ donation, there has been very little attention to this application with regard to zombies. Zombies are often referred to as “living-dead” which creates both a scientific, operational, and ethical conundrum with regard to classification. To date, there is no definitive answer as to whether zombies are truly “dead” or whether they are “living” or that they exist along the spectrum of conscious to coma, from living to dead. In the event of a zombie apocalypse, it is currently unclear whether or not zombies could be considered suitable organ donors.
Zombies: A Definition and Brief History
Zombies are a class of “living dead” that also includes vampires, ghouls, mummies, and wights. The term “zombi” was reportedly first used by the poet Robert Southey in his description of Brazilian history. One of the earliest references to zombies dates back to Mesopotamia in the Descent of Ishtar when the goddess Ishtar threatens to “raise up the dead, and they shall eat the living.”
Since then, there have been hundreds, if not thousands, of descriptions of undead, zombies, and reanimated humans in comics, books, television programs, and movies. Some cultures have an extensive history of zombies, the most well-described and studied being the Haitian Zombies of Voodoo.
Zombies are further divided into subcategories: zombies reanimated by black magic (Voodoo), those created by sorcery (necromantic), viral- induced (Solanum) and those created by mutation from radiation (atomic). There have been case reports of drug-induced zombies, but these were later re-classified as this state was reversible without intervention. There is a movement to utilize the more descriptive terminology Ataxic Neurodegenerative Satiety Deficiency Disorder (ANSDS).
Culturally, the term differently-animated has been used as a more politically correct term for identifying zombies. The varied terms, means by which zombification can occur and the newer, more descriptive and politically correct terminology however, has done little in the way to describe the actual physiologic state of zombies. This requires a more in-depth analysis of what we do and do not know about zombie biologic and specifically neurologic function.
By Stephen Wood
Medication Replacement Therapy (MRT), Medication Assisted Therapy (MAT). Opioid Substitution Treatment (OST). Opioid Replacement Therapy (ORT). Opioid Agonist Therapy (OAT). This confusing array of acronyms are all terms that have made their way into the dictum of patients, healthcare providers, policy leaders, politicians and journalists —and new ones pop up every day.
Buprenorphine Enabled Recovery Pathway (BERP) is one I just came up with but could just as easily make its way into the menagerie of acceptable buzzwords for using an agonist-antagonist (or other drug) for the treatment of substance use disorder.
It doesn’t stop there.
Safe Consumption Facilities (SCF), Safer Injection Facilities (SIF), another SIF in Supervised Injection Facilities, Supervised Injection Sites (SIS), Medically Supervised Injection Sites (MSIS), and Drug Consumption Sites (DCS) only begin to round out the list of areas that people who use intravenous drugs can go to use in a safe, clean and supported environment.
We see these terms bantered about in the media, among healthcare providers, legislators and policy makers. We hear them from patients with SUD, their families as well as advocate organizations. These terms are in published research reports and clinical studies. To even the savviest person though, it is a confusing alphabet soup of acronyms that are all trying to describe an array of programs, possibly something similar or maybe even the same.
There were approximately 64,000 deaths from opioid overdose in 2016, including deaths from both prescription and illicit drugs. The incidence of opioid overdose has continued to escalate despite a number of efforts. Increasing treatment beds, limiting opioid prescriptions, distribution of naloxone and other efforts have not demonstrated a significant impact on non-medical opioid use or on opioid-related deaths.
The continuing rise in opioid overdose and overdose death has resulted in the declaration by the current executive administration of the opioid epidemic as a “Public Health Emergency”.
Medication assisted treatment (MAT) with agents such as methadone or buprenorphine/naloxone has been demonstrated to be one of the more effective measures in the reduction in high-risk opioid use among individuals with substance abuse disorder. Specifically, treatment with buprenorphine/naloxone has demonstrated efficacy in harm reduction with the advantage of a reduced potential for abuse, a safer therapeutic profile than alternatives, and it can be safely prescribed in the outpatient setting. Use of this therapeutic however, is currently restricted to only certain licensed providers in certain clinical settings, limiting access to this important life-saving intervention.
There were 240 million opioid prescriptions in the U.S. in 2016, a number that accounts for about 30 percent of the world’s opioid prescriptions, and is enough for one opioid prescription for every adult American.
Experts believe the overprescribing of opioids is at least somewhat responsible for the current opioid crisis. This led to a national discussion around prescribing stewardship, as well as the development of policy and regulation with regard to opioid prescribing. Included among this have been limits on the duration of therapy, partial fills, and requirements that providers access their state’s prescription monitoring program before prescribing. These policies have had some success and there has been a decline in the number of opioid prescriptions in the last several years.
This should be good news, but unfortunately, opioids aren’t the only thing filling America’s medicine cabinets. Looking again at 2016, there were more than 190,000 kilos of amphetamines, drugs like Adderall and Ritalin, produced for consumption in the United States. The estimates are that about 16 million adults and more than 3.5 million children are taking these stimulants.