Ati physical therapy

Topics in Physical Therapy

2012.02.10 07:33 neuroPT Topics in Physical Therapy

If you are not a licensed PT or currently under the care of a PT please do not post here. This is a sub for practicing physical therapists to discuss cases, research, old and new tricks, or other therapy-relevant topics. Requests for advice or education regarding your personal health issues will be removed and you may be banned. These questions should be discussed directly with your physical therapist.

2010.04.19 01:50 chags Collabarative space for all rehab professionals. Physical therapy, occupational therapy, SLP etc.


2021.09.17 15:17 mercer3333 ATIPStock

All ATIP investors are welcome here, as well as, those who are interested in physical therapy. Feel free to discuss all activity in regards to ATIP. neverbrokeabone's safe haven

2023.06.04 15:35 UpperPrompt Undergrad professor “i’ll never go to grad school for physical therapy”

it was 2020, i was getting my application materials together to apply for PT school and needed a letter a rec from a professor. Since it was a large state school getting a letter a rec was a challenge. I asked one of the professors in my department who i took a class with in my freshman year and received an B+ and the conversation went like this (over email) “while your practical experience is substantial, your academics show that you don’t have what it takes to realistically pursue a clinical doctorate of physical therapy, have you tried considering other professions such as social work?”. Long story short i ended up asking my internship coordinator who was more than happy to write one, it’s 2023 and i’m on my 2nd to last rotation away from graduating with my DPT degree. Grades aren’t everything, trival numbers don’t define people who bust their ass off to achieve what they want to.
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2023.06.04 15:25 honeybee820 Help me before appt. narrow it down...

I (34/f, 103lb 5'6") have always been told that I've experienced hormonal migraines, and I certainly think that's an element, but I'm trying to narrow down exactly what's going on so I can finally get some relief. I don't think it's just hormonal.
I have had migraines since I was a kid, probably late elementary school. One sister, grandmother, and dad have them too. I remember coming home from school in the afternoons and opening up the freezer and just laying my forehead on the ice box to get relief not realizing what they were. They've gotten worse as I've aged, to the point now where they are so debilitating I cannot drive or form a coherence sentence. I vomit often from them. I can go 3 months without a migraine, but they seem to go in waves, where 3 months will pass and then I will have 2 weeks of migraines that never really go away for more than a couple of hours at a time only to come roaring back. I always always have a monstrous one in early December and another wave in the sping, usually around late March when it warms up.
I have done physical therapy, chiropractic, and currently see a neurologist. Neurologist won't/can't do anything for me until I'm done nursing in 3mo or so. I want to be prepared for my next appointment and know what questions to ask.
My biggest issue is that I feel the ease with which they're triggered is incredibly small. I can't sit on a couch like a normal person anymore- hard chairs are fine- but when I watch TV or whatever I have to either be laying horizontal or sitting on the floor leaned up against the couch. I feel like a dog. I can't lay flat on my back for more than about 120 seconds without triggering a migraine that starts at the base of my skull (always one side or the other) and ends up feeling like a needle in the back of that eye. I had kidney surgery while pregnant and bc I obviously couldn't be on my side, woke up with one of the worse migraines of my life that had me down for over a week, vomiting and unable to take pain meds. Sinus pressure can trigger too. Last night my baby kicked me at the top of my nose between my nose and eye and triggered one.
I take fiorcet. It helps sometimes- they either go away or get worse. They rarely get "better" until they're gone, and I can go from vomiting to totally fine, playing with my kids in the space of an hour. They come on so fast, but go away so fast too. (Hope that makes sense- the improvement isn't gradual--- its usually all or nothing).
Triptans are a no for me, I've fainted on one and my throat gets tight on another. Have tried cyclobenzaprine, valium, oxycodone, and naproxen. (All legal leftover from surgeries or births). All have help seemed to numb the pain but nothing truly helps and I hate taking those long term. They seem to numb the pain til my body decides to stop overreacting to the trigger. Ive taken magnesium and b2 at the advice of neurologist for about 4mo now. Doesn't seem to help or hurt really.
Please tell me what's going on and how to fix it (or suggest to my neurologist). I'm sure the inflammation and the position of my neck has something to do with it given how fast sitting on a couch or laying flat can trigger a migraine, but I don't know how to fix it.
Thanks all.
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2023.06.04 15:23 VenBein How long do epidural injections last for back pain?

The duration of pain relief provided by epidural injections for back pain can vary depending on the individual, the underlying cause of the pain, and the type and amount of medication used. In general, the effects of epidural injections can last anywhere from a few days to several months.
For acute back pain, a single epidural injection may be sufficient to provide significant pain relief for several weeks. However, for chronic back pain, multiple injections may be needed over a period of weeks or months to achieve long-term pain relief.
In some cases, epidural injections may not provide significant pain relief, or the relief may be temporary. If this is the case, other treatments may be considered, such as physical therapy, oral medications, or surgery.
It's important to note that epidural injections are not a cure for back pain, but rather a tool to help manage symptoms. To achieve the best results, it's often recommended that epidural injections be combined with other treatments, such as physical therapy, exercise, and lifestyle modifications.
submitted by VenBein to u/VenBein [link] [comments]

2023.06.04 15:21 Namjoonloverr Cervical Radiculopathy Pain

Hi I am 23f and I have had on and off shoulder blade and neck pain for over a year. Last year around may- I started to have shooting pain down my right shoulder after 2 weeks of no real improvement I went to the doctor and he wrote me a script for physical therapy and did no imaging/ gave nothing for pain relief. I did 2 and half months of physical therapy and it made my symptoms mildly better. The PT is the one who gave me a diagnosis of cervical radiculopathy. Every time I think I can become active again (I used to exercise 4-5 times a week) It ends up hurting me. I have even tried to modify exercises. Now it’s a year later and my pain has improved. I still have mild shooting pain but it general I just have a very sore neck and it’s very stiff. I’m considering going to a doctor again but I’m not sure if there’s anything they can do. I miss being active. The pain is honestly really affecting me mentally. Any advice?
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2023.06.04 15:19 Friendly_Quantity770 Stepmother called cps on me.

OK take two. This is very important I say this here since ppl don't know how to read. This is my now sitch. I have a good job making ok money and so does my husband. I will add the OG text becailse I deleted the OG since idk how to edit my posts I'm new to reddit.
Please keep in mind this all happend over a year ago and I want to just get it off my chest because things have DRASTICLY CHANGED. So here it goes.
So this will be a long one and I apologize for that. A year ago my step mom called Cps (child protective services) on me. And now my dad is gaslighting me to try to make me feel guilty and to have me to apologize for her doing it.
Here is a little back story to understand how this got so bad. I (f 27) met my fiance (m28) 5 years ago, we got pregnant 6 months after we met. It was not on purpose, and I admit we weren't careful because I was told at 19 I'd never be able to have kids due to some medical issues.
Now I moved in with my fiance after we had the baby (f), and I was a SAHM I worked Uber and Doordarsh and instacart while I was a SAHM. My fiance let's call him J, worked full time at a box store. We rent from Inlaws and it's a decent place just small. We had to fit two lives in one area and when H was a baby it was easy to keep up. Now she's three and we are teaching her to clean up after herself.
Fast forward to Dec 2021, J had quite his job and we were both driving for DD and Uber eats (this was not permanent since he was looking for a job right after he had quit his job for good reasons)not really making much at all, and my step mom and dad kept telling me that I needed to do better. I already was trying to do better and was secretly looking for a job. I say secretly because then I knew they would say something along the lines of good your finally listening to us. And I did not need that. So in Dec my step mom had a party. We had talked and agreed I'd let them take my daughter until the day of the party. When my dad came to get my daughter she was in the bath because she had woken up from her nap completely drenched in pee since her diaper leaked. I told him it'll be a couple minutes and then she would be ready, I went to check on her. When I came back he was in her room and I saw his phone was in photo mode. I saw red! I berated him about taking photos of my home and how disrespectful it was. He at first tried to deny it but when I pushed the issue he finally admitted he was doing it at my Step mom's orders.
I was so upset. I told him to delete the photos and he told me if he didn't bring them he would get into trouble with my step mom. I said if I ever catch you taking photos of my home secretly again we would have a different convo. I did end up letting him take H (daughter) because I didn't want her to not have fun. I had told myself I would just talk to my step mom at the party and tell her that is a boundary that was crossed. (Yes in hindsight not a smart move for me but I didn't think it'd had gotten as bad as it did)
The party came and as I was just enjoying it everyone in my family was really heavily telling me I needed to spend the night, and I kept saying no because I had planned to work the next day and knew I'd stay and never work. I finally cornered my step mom and asked her to talk with me. She was refusing originally but I was persistent. I told her how bad it looked she was taking pictures of my home and she said "if I wanted to call CPS on you I wouldn't need pictures " 🚩number 2. I then told her it was a boundary for me for her to secretly take photos and have me feel like a poor parent because my home was messy. Her response to this was "honestly, I'm tempted to take H until you get your shit together."
I was dumb founded! I took my daughter and left. For three weeks I did not talk to them. After a week I let H face time them but I was not in the video chat and I would not say anything if very minimal. During those three weeks I worked non stop on the delivery apps and didn't really get any rest I was working mon-sun from 6am to 7 pm just to get gas and food money. I DID HEAR BACK AND HAD SEVERAL JOB INTERVIEWS LINED UP BY THIS TIME. By week three my dad and step mom asked me to come up and I felt I could handle it finally and said I'd come that Sunday. Well that Saturday I had a babys shower and my mom was teaching me how to cook turkey. I still worked in the am and was a little late to the shower. Mom and I had a blast at cooking turkey and the next day I woke up late. H didn't and by the time I woke up we had an hour before her nap. And if I'm honest I still didn't want to see my family. So I laid her down and fell back asleep untill about 3pm. I woke up in a panic because I knew I was in deep shit with my step mom. I rushed to get my kid and our stuff into my car and try to get up there as alfast as I could ( the drive was an hr from my moms 2 1/2 from my home) and as I was pulling out of my.moms street I got a text
" don't bother coming up because I wanted to spend the whole day with H not a few hrs." But I went anyways and the whole time my step mom tried to ignore me. She kept saying how she wanted H to stay the weekend and just have some time alone with her. Side note me and my husband both agreed by then our daughter would not be going to spend the night by herself for a very long time because I had reason my step mom was going to try and take her or try ro stop me from taking her back.
I kept I'd love to join them so I could reconnect with the family. My step mom did not sound happy with my suggestion. Well around 9 I finally said we had to leave because I needed to drive the 2 and a half hours back home. We said our good byes and headed out About 20 minutes into the drive I called my mom to see if I could spend the night again becaise she was closest, because I was worried with how tired I was I'd get into an accident. She of course agreed and I stayed the night. I stay lied at her house talking how the rest of that day had gone and she was weirded out too. I got to my home about 5 pm and 30 minutes later my MIL come knocking at the basement door in a tizzy because there was a CPS worker at her door. My heart stopped. My husband and I went up greeted the worker and let her in. She said that she was there because there had been a complaint against us. I knew right away who. And asked her if it was my step mom. She said she couldn't disclose that because her job was to keep the peace. Well she came to see the home and inspect it. After she asked questions and looked around. She stated that other then a few things around the house needed to be fixed (easy fixes too) she didn't see a reason for the call. She said the complaint was there was cat pee smell everywhere and it was bad. She said she knew we had two cats but couldn't smell them... that was kinda prideful for me. She said to clean the home and fix the few things physically. she would came back for a follow up in two weeks (it was early 3 months by the time she came back) she told me that she felt that she'd be able to close our case relatively easy. We bid her goodbye. And the first call was to my mom screaming and crying on how I didn't have a dad and that my step monster had really overstepped. I told her everything she was seething! So was my husband and MIL. I was in Shock and tears, I blocked my SM and called my dad crying and upset on what he just let happen and I got nothing back. Then I told my mom he didn't puck up she called him a cowered. She then took a call to him and cussed him out. I blocked him then unblocked him. And it wasn't until three days later he called me back i didnt answer. He said he didn't know I had called and that he would try my mom. When I heard that on the voice mail I took a little pleasure because he did not know what he was in for. J had to hold me because I had started to shake after hearing my dad's voice. I called my mom told her he would call and to call me when she was done. She did told me she cussed him out and told him how he has abandoned me yet again and how much of a shifty father he was to not protect me or to warn me what was transpireing from his wife. He defended himself and said he had no knowledge my mom didn't let him get away with that. And he admitted to knowing somthing but sisnt think she would go through with it.
I ignored his calls for two weeks. He called everyday. Which is sad to say he never did that before he would call maybe every other week. Then I got a message from my SM. " A it's obvious you don't see me as a mother but if you don't let your dad see H I will blast you on FB and put all the evidence out there. Becaise obviously I'm not your mother it hurts your dad that you rnt talking to him. I am a grown women who makes her own decisions and i called csp with out your fathers knowlage. (She mentions that obviously I don't see her as a mom again even though prior I did call her mom.)" I screen shotted the message and sent it to my dad and said this has to stop I will talk when I'm ready. About a week later I finally picked up my dad's call and I had him on speaker. I told him I felt I had no father and how he abandoned me. How he didn't tell me what was happening. And so much more.
But after that I started to forgive him because being mad is more work. Plus he isn't soly responsible. Now I see home on and off. But recently he has been gaslighting me when he brings the whole situation up. Saying things like
"It's hard on me because I want my whole family back", and "how SM didn't really call out of spite but to get you to do what she wanted. I had told him through the first meet up that I had a job lined up and had worked hard on the house. (At this point the house was immaculate its amazing what organization can do. Ps somthing i had been working on doing before all this happed!) During the first few days I couldn't work while we were cleaning because we were cleaning all day everyday. For two weeks I couldn't go work alone the apps because I was waiting for the cps worker to show up. J had started to work the apps and doing interviews during that time as well. my mom helped us with getting strage and food during the time I couldn't work. BTW I knew stroage is what we needed all along to our mess, and have been telling them all that. He praised me for the job and cleaning and I told him I didn't need his validation and I didn't get the job because of cps I had started looking before this all transpired. He asked why I didn't say anything because it would have had SM calm down and probably not call CPS. (Highly doubt it) I told him because it's my life and I'm going to live it the way I see fit not him and definitely not my SM.
But anyway like I said now he just gas lights me to day I have to make the first move because i made a TT when I was mad calling her a narcissistic abuser and she saw it and hurt her feelings and how she was not afraid she had hurt all of us.... 🙄. So am I the asshole for the TT and should I apologize for everything and speak first or what should I do now? I will say I wrote a note to her that I haven't sent expressing my feelings and what I needed to say. Thank you for any advice plus for reading this long story! Also sorry for bad Grammer and bad spelling lol. The messiness of the house consisted of laundry in baskets because I didn't have a place for towels and bedding and loads of books and other things I use on a regular with no storage. It's now organized and put away thanks to my amazing mom who helped me through this time of my life.
Now this is where I give what life looks like now.
The house is still a little messy but that's just home life with a toddler. The dishes are still done and laundry put away but now her toys are EVERYWHERE she finished her first year of PreK (it's for her speech therapy) and my fiancé and I are bis drivers and make ok money. It's still our first year of it but hey!
I worked at HD for a year and for several months of that year I worked both bus and HD working in till 5 at bus and from 530 to 10 pm. I quite HD to focuse on bus. No the catalyst for the job was NOT my sms doing and I don't care what she thinks
Yes I still have a relationship with my dad but he is at arms length at all times. Yes I left a lot out originally and now I see why that is bad.
I want to thank all the commenter before who wasn't tearing me down and shaming me for my PAST and trying to give me good vibes and helpful tips! I don't know how to delete comments I'm new to reddit. Please do not come for me for my PAST issues I'm not that pathetic person anymore. I have refound my original self and going strong and hard to figure out all the possibilities I can do to better my family every day.
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2023.06.04 15:13 annyeonghihello Thoughts about education in SunMoon Uni, Daegu Uni, Keimyung, Konyang Uni, Kangwon Uni

Specifically in Physical Therapy course, does anyone know the reputation of these schools regarding the program? But any insights regardless of degree program would be really helpful. Thank you
submitted by annyeonghihello to korea [link] [comments]

2023.06.04 15:13 ht1992 I don’t know what to do next: not ready for surgery but in pain.

I know this sub gets lots of posts like this, so if you make it through, thanks for reading.
I’ve just been diagnosed with a hip impingement with cam (left hip, 31f, athlete). I’ve been having pain in my groin, down the front of my hip, in my glutes for several years now, off and on, and then in January strained my left hamstring due to what I’m guessing is compensation for my weak, unstable hip.
I’ve been in physical therapy working on fixing my pelvic tilt, strengthening my core and trying in vain to improve hip internal rotation. The pain only got worse, so I’ve seen an ortho and had imaging. No tears, but ortho says a steroid shot and surgery to remove the cam lesion could help.
It wasn’t always this way: A year ago I was doing yoga and running and lifting with only intermittent pain. Now, my hip hurts daily. It gets worse while sitting and overall just feels disconnected from my body and weak.
I’ve never had surgery of any kind and a hip surgery at 31 sounds daunting. I want to try other interventions before that—but don’t know if there are any others. The practitioners I’ve seen have given up: basically get surgery or we don’t know how to help you.
My Achilles tendon and heel on the same side of my impinged hip have now started to hurt. I recognize my other muscles and their functions are starting to break down.
I read all sorts of advice that contradicts each other: do stretch your hip, don’t stretch your hip, do deadlift hinges, don’t do anything with a hip hinge, etc.
For those of you without tears, and who didn’t opt for surgery…yet…were there exercises you did to strengthen your hip function?
Did you find PT that actually helped you? What kinds of protocols did you do?
Did you stop all exercise activity to heal? I want to keep working out, but I fear I’m harming my body by doing so.
I’m not ready for surgery because I feel like I’m young and can do more work to help ease my pain…but I just feel lost at this point.
submitted by ht1992 to HipImpingement [link] [comments]

2023.06.04 15:11 user738372 Am I giving too many gifts to my T

Hello, I'm a 17 year old girl and I have severe "mommy issues" or whatever you want to call it. I grew up without being able to experience parental love, I was also abandoned by my father in elementary school after being raped which is why I am terrified of men. Since then, my mind automatically chooses an older woman who's nice to me and considers her my mom. My first one was a teacher in middle school who hugged me when I hadn't been hugged by an adult in years. Then I had my doctor, and now it's my therapist. Actually right now it's mainly my therapist but still a lot my doctor. I'm not going into detail about my relationship with them because it's long and unnecessary, just keep in mind that I am terrified that they'll abandon me. I have been in therapy for two years and I have given her three handmade gifts on three different occasions. I do it to thank her for not hurting me and to make sure that when she'll leave me she won't forget about me. I also gave my doctor (psychiatrist, I have anorexia) two handmade bracelets over the course of the last two and a half years.
Lately I have been particularly scared of my T leaving me because it's gotten to a point where if she was ever to leave me I think I'd fall apart. I think I'd never recover from that, she literally has my heart in her hands.
I'm scared that if I tell her how much I depend on her she'll send me to someone else. She knows about the mom thing, it was really hard and took months but I managed to tell her. But telling her how terrified I am that she'll get tired of me, or that she'll see that I'm recovering and won't want to see me anymore feels like giving her the precise instructions on how to rip me apart and then trusting her not to do it. Plus I'm shy, I'm physically unable to talk about certain things and I'd never be able to beg her to stay with me. I had written her a note begging her not to abandon me but I never gave it to her because of reasons above. Giving her a handmade gift sounds like a good way to thank her for being so sweet to me and maybe having the occasion to tell her to please don't leave me. But it would be the fourth in 1 year and 11 months and if she doesn't accept it I'd be devastated. She keeps the previous ones in her office and they're taking up all of the space on the shelf that isn't taken up by books.
I don't know what to do I'm sorry
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2023.06.04 14:56 lvndr131 Loving a drug addict

Hi. I don't really know how to start this so I guess I'll start with the fact my mom was a drug addict for most if not all of my life. She seemed to always put her drug addiction before me. She died of an overdose a few years back. I've felt guilty over it because all I wished was that I did more to help her. I'm currently or was dating a man that I love with all of my heart, but he's also on drugs. To the point that he has gotten physical and hurt me. He's told me horrible things and threatened my life when he was high stress. He's paranoid and he's scared me multiple times. The week leading up to me leaving, he started breaking furniture kicking in doors and threatened my life and his. Everyone I knew was scared for me. When he choked me I ran and I feel like his family lied to protect him, they didn't know about the drugs he was doing. I tried to talk to him a few times about drugs but he is prodrug and said as long as they aren't hurting anyone and can keep a job to pay for the drugs and aren't stealing its OK. He never told me about the drugs because he thought I would leave him. I had written him a letter months ago, telling him I didn't want him to die. That I loved him. He left it on the bathroom sink for weeks and now it's in the bathroom drawer. I don't think he ever read it. I love him but everyone including myself are scared he's going to kill me if I go back. I would shut down because it made me feel like i was back with my mom. I hated myself. I'm hurt because he was supportive, trying to get me out of the house so I wasn't depressed. Tried to get me to go fishing with him, tried to get me to have friends, tried to get me to go to therapy. I got friends, I went to therapy, I was feeling better about myself away from the house. He would take the things I told him and throw them back into my face. He would yell at me but I couldn't raise my voice. I got a restraining order and I told him about it before it went through, he said it was messed up and it hurt his feelings. Said that he wouldn't hurt me,but he had. I feel like he opened up about a few things when we talked on the phone, but he didn't trust me enough to tell me everything. I want him to get help, I would get mad because I felt like I shouldn't have to come home and be worried he overdosed. I was mad because he was breaking things, I was mad because he would hurt me verbally. I was mad because he told me he would protect me but he hurt me instead. I upset my friends because they don't want me going back. I'm back and forth because I love him. I want things to be good between us again. I want him to love me more than he loves the drugs just like I loved him more than what he put me through. I want to be enough for someone to not chose drugs over me. I started to hate what the drugs were doing to him. He mentioned going to therapy for his anger from childhood, he told me he wanted to be like normal people. I wanted to believe that the drug addiction wasn't real. That it was all in my head because he was good to me at times. I know I didn't make the relationship easier. I got so mad seeing my house destroyed, I was so mad that he was mentally abusing me. Gas lighting me and manipulating me. He would tell me that's what i was doing to him. I have unhealed trama from my childhood and he does too. I want him to get help and to love himself but I didn't love myself either because the things he would say to me to hurt my feelings. There's a no contact order in place and I think it's more so I don't go back to him. I know he has to want to get help for himself. I've been actively trying to get a therapist that will help me but no one is calling me back. I feel lost and I don't know what to do. I'm losing everything again like when I was with my mom. My home, my family, potentially my job, and him. Someone who was suppose to be my safe place. Someone who said they loved me and that the family would be nothing without me. I feel like he pushed me away because of the drugs, he isolated himself and I isolated myself because of his drugs. I know everyone is telling me I need to run. That I need to just forget about it. Let him ruin his own life but I don't want to give up on him. I feel like everything is telling me not to give up on him. He never gave up on me with my depression, he even said he knew he was causing it but he didn't realize why. I wish I would of been there for him like he was there for me.
I know this is long. I'm also going to post in the drug addiction reddit.
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2023.06.04 14:56 dancerbancer attachment to therapist - how do you cope?

(tl;dr at the end)
i've recently started therapy (not for bpd, i don't technically have it, i just relate to many symptoms and many posts on this thread) and of course i got attached to my therapist (as happens when i meet someone who seems to care about me). this attachment is very strong though, to the point where i feel like i'm almost becoming dependent. obviously attachments like that are problematic in 'normal' relationships too but i feel like it's worse in therapy because that's where my healing is supposed to take place. i don't know how to (and if!) talk to him about it, how he'd react, etc... i'm very scared he'd say i need another type of therapy or with someone else, which would be fair, except i cannot cope with the thought of not seeing him anymore. the idea that therapy will one day end makes me physically sick, which ofc puts my recovery in danger bc the whole point of therapy is to stop going at some point - if i get upset every time i make progress bc that means i'm closer to ending therapy, then there's no point in going anyway. anyone else going through this/has gone through this? how do you cope? i know there's no magical cure to this but even if just one person understands this pain i'd feel less alone and empty. i just hate this situation so much, and i'm so ashamed of how my brain works

tl;dr - recently started therapy, got very attached to my therapist and now anything that makes me closer to 'ending' therapy makes me freak out bc i can't cope without him and idk what to do
submitted by dancerbancer to BPD [link] [comments]

2023.06.04 14:52 koorvus How I lost my sun - how a friendship dies

Hello to all, first-time poster here. I'm a 22 year old girl with a whole lot of baggage that I can't express to anyone who isn't a stranger, so I can't promise I won't be back here eventually. I've been having really bothersome reoccuring dreams lately so I feel like I need to throw this away somewhere at least for now, and I don't want to put any burden on people in my life. This is probably gonna be a long post so I'll leave a TL;DR for people who aren't fans of walls of text down below. I also apologise in advance for any mistakes as English is not my first language.
It all started in 2014, when I began high school. I did not know anybody in my soon-to-be class, then someone from my middle school class reached out telling me to say hi to someone who was gonna be in my high school for him. I screenshotted his text and sent it to the girl in question, let's call her Elle, and we never stopped texting since. We communicated for the whole two months before high school started and neither of us had ever known someone they clicked so well with before each other. We met up irl the week before high school and when school finally started we were deskmates for the entire 5 years.
We were tied to the hip, the kind of friendship that makes people start rumors about you two secretly being a gay relationship. She was like family to me. I made a lot of sacrifices to try and be the best version of myself for her. She really cared about physical touch as a love language, but due to childhood trauma I hated being touched at the time, however I learned to be more affectionate to make her feel loved in her own way. I've always struggled with mental health but had the tendency to bottle everything up, however she let me know it worried her more to see that something was wrong but to not know what it was, that she wanted to be there for me and listen to my issues, so I learned to open up more for her. She was, and still is, in a very socially conservative group of friends (the kind that doesn't really hang out with anyone except their inner circle, that doesn't appreciate people drinking, smoking or partying, etc), and I didn't really care about having the experiences that they disliked so much up until I turned 17, when I started to want to experiment a bit as it is normal at that age, but whenever I talked about doing anything spontaneous she'd look at me as if I said something scandalous, so I blocked everything out due to the fear of eventually changing too much and losing her. I also felt really protective over her because I had noticed she was someone who could easily be manipulated, so whenever I stated my opinion over something I'd constantly reiterate that it was okay to have a different opinion from mine out of fear of accidentally manipulating her.
I was a strong influence over her for sure. I'd get her - and consequently her whole friend group - into all my interests (I don't mean I was forcing her into them of course, I just included her in my stuff and she almost always ended up enjoying them as well), in more than one occasion I'd say something and she would repeat it to other people as if it was her own thought. We both have/had issues in our family, so we planned to study in the same city after high school and to move in together. I remember that she wanted to dye her hair but her family wouldn't let her, so I'd tell her that I'd dye her hair once we had moved out. I was supposed to study Psych and she was supposed to study Languages in the same city. She then changed uni plans last minute, and I was amongst the people who helped her figure out what she at the time thought it was her true calling opposed to what her parents were pressuring her to do, despite it was against my interests because it meant that I also had to review my uni plans since plan A was so tied to her decisions.
We eventually went to uni (in different places) and then covid happened. We kept in touch after high school and during the pandemic, it seemed as if nothing had changed, we even started watching a series together on discord during lockdown. Until one day, out of the blue, she texted me. She said that she was tired of pretending and that it didn't seem fair to her, she told me she wanted a break from our friendship, that she couldn't bear it anymore, that she had to think about her own mental health and that she tried to be there for me but it was all too much, but she worded it as if it was my own fault. She then accused me of being resentful of her other friends and of wanting to make our own friendship exclusive, when less than a week prior I literally stayed in call with her for over an hour trying to convince her to attend uni lectures irl once the pandemic would end to meet new potentially significant people in her life. It was a punch in the face and it didn't make sense at all.
For the following month I was in a pretty bad dissociative state as I was already struggling with important life events and I had just lost the one person I was starting to think actually loved me. She was the only thing in my life I felt somewhat safe and secure about. And she turned her back on me, just like that, she threw away a friendship of 6 years without even talking it out to me and potentially giving me a chance to fix things. She could have just said she did not care about me and it would have been fine, it would have hurt but it would have made sense. After her, all of the progress I had made just collapsed. I went back to not trusting people, not opening up, thinking nobody can love me. With her I also lost our mutual friends, some of whom were friends from my childhood. Afterwards I decided to have all the experiences I missed out on for her in the previous years, I started drinking, going to small parties after lockdown was over (obviously following the rules of my state about it), I even had my first kiss and dated someone for a bit. It was like I was born again, like a huge burden was lifted from my shoulders, but it felt incredibly lonely.
The year after I found out she started studying Psych in uni, ironically enough. I decided to write her an e-mail (I was blocked everywhere else) asking her for closure, to talk things out now that we were less emotional about it, not to be friends again, but to move on. She responded that she was studying for an exam and that she would consider it and come back to me, but she never did, and I never reached out again.
Lately I've been dreaming about it. It's always the same dream. We meet again, talk things through, and update each other on what happened in our lives after our break. We're not friends again, but we're cordial. I always wake up sad and it ruins my day.
I've been in therapy since early 2020 and was diagnosed with BPD in 2022, which put things into perspective. She was my favourite person and it still hurts to this day. It hurts that she just disregarded our friendship so easily, it hurts that she thinks I'm a monster for things I did for her own sake, it hurts that she's seen as the victim from people who were once my friends too, it hurts that I haven't opened up about myself to anyone else after her because I know that if someone sees my true self they will hate what they see and leave me or, even worse, be hurt. I still have our pictures on my wall, our chat archived, every pic from high school I have, every memory, has her in it. I can't think about me without her in the picture. I had to build a whole new identity to erase her from myself but she's still here. I can't get closure because she doesn't want to talk to me. I don't know if I'm a good person anymore and I hate myself more than ever. I still feel like I failed to protect her, I still don't hate her but I also can't bring myself to wish her well. I don't know how to move on, I don't know who I am, I had never planned a life without her in it so I'm completely lost. I still have the impulse to text her when something happens in my life to tell her about it and laugh it off with her. I resent and love her so much at the same time. I wish I had never met her.
TL;DR: best friend of six years ditched me during the first lockdown, I'm still not over it and I don't know how to cope.
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2023.06.04 14:48 Gold-Childhood-7956 Pillow that accommodates all sleeping positions for neck pain?

Hi all! I saw quite a few pillow threads, but I haven’t seen any solutions for my issue. I have horrible neck pain and physical therapy has been helping a ton, but I think my sleep is what’s keeping me in pain. I’ve been on the hunt for a new pillow and so far I haven’t found anything that works. I had a firm orthopedic pillow (the ones with a curve for your neck) that I used for years but now that PT has given me more neck mobility it’s not comfortable anymore. I’ve since tried a softer orthopedic pillow, a shredded memory foam pillow (coop), and a buckwheat pillow and none of them have done the trick. My issue is that I fall asleep on my back and then roll onto my side/stomach in the night. I haven’t been able to find a pillow that accommodates all positions-if it’s comfortable ok my back, then it’s too thin when I sleep on my side and I wake up with horrible shoulder pain. Please help because I am DESPERATE to resolve my pillow search and find some relief for my neck. I haven’t tried squish mallows yet, but I saw them at Costco and I gave them a squish and I don’t think they will be supportive enough for me.
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2023.06.04 14:40 BreadfruitSea2876 Trying to Formulate a Plan & Experimenting With Strategies.

Hi, all. Well, I'm afraid I still haven't stopped shopping on Amazon in spite of my good intentions. Part of my downfall is looking at the site in the first place - I can spend hours browsing, and keep checking my long wish-list. That was my problem yesterday - I saw that an item in my list now had 25% off. I then kept looking at the item, obsessing over it, and then bought it. My brain needs serious rewiring. I am making a list of ways and strategies of tackling this problem (without therapy - I can't access it just now). Here is the list so far:
  1. I'm going back to CODA (Co-Dependents Anonymous - a 12 step programme) - they have Zoom meetings nearly every day. I stopped going a year ago - oddly, this coincided with my getting COVID (which affected me mentally as well as physically) and my shopping problem really taking off).
  2. Constant social media scrolling has affected my ability to concentrate and eroded my executive function and impulse control. I will therefore check FB just twice a week, on Wednesdays and Saturdays.
  3. I will not browse Amazon at all, and only go onto the site if I've got something necessary to buy (by that I mean medical or household, not books or DVDs), or a birthday gift for someone else.
  4. If I can get an essential from elsewhere other than Amazon, I will.
  5. I will continue to develop my hobbies, meditation and prayer life.
This is going to be a struggle! Checking social media and Amazon is now a reflex action! But apart from actually getting an electric shock when going onto Amazon (that might actually help lol!), there's not much I can do.
Thanks for reading!
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2023.06.04 14:35 Pajeenis I don’t know how to be happy.

A couple years ago, everything was going so well. I loved my job, I was getting ready to move out with my boyfriend of two years who I was incredibly happy with, shit was great. But now I feel like I have nothing. Ever since one of his parents died at the end of 2021, my boyfriend has turned into such a piece of crap. He won’t get a job, he developed a pretty bad porn addiction (like, watching it in the other room while I’m home instead of having sex with me bad), he never wants to be affectionate with me or even really talk or go out together at all, and he doesn’t care about anything anymore except music and video games. We live together in his relative’s house, just the two of us and our cat, but due to legal reasons we’re unsure if we’re going to be able to continue living here. I haven’t had any real friends since high school, and as soon as I got one and we became really close they decided to move to the other side of the country. I know with the way I talk about it it sounds like I should just leave my boyfriend, but there’s a few things holding me back. The biggest one I know is probably stupid and hopeless, but there’s a part of me that thinks he’ll get better. He used to be the perfect boyfriend, we got along so well and made each other so happy, and I want that back more than anything. I love him so much, it physically hurts thinking about how unhappy we are when we used to be perfect. I miss him when he’s right here next to me. I’ve tried so hard to be here for him, emotionally and financially, through all the endless shit he’s been through the past few years, but he acts like it doesn’t matter because “money isn’t everything,” etc. Any time I try to talk to him about how I feel, he just gets irritated and says that I’m annoying and a baby, which makes me get upset, and then he acts like everything is my fault and says the reason he treats me like that is because of how upset I get?? The more I say about him, the worse he sounds, I know. But I’m terrified of being alone. If we break up, I’ll have no one. I don’t get along with most of my family and I can’t afford to live on my own(California, fucking expensive), and I don’t even have any friends I feel like I can turn to for emotional support of any kind. I keep trying to convince my boyfriend to go to therapy, and I feel like I’ve gotten so close a couple times, but he never follows through. I think he’s ashamed. I should probably go to therapy too, but I had a bad experience with a therapist when I was a kid and it made me really scared to try again. I don’t really know what the point of saying any of this is, I don’t even really think anyone will see it, I just need to feel like I’m talking to someone about it I guess. (Also I don’t want to lose our cat if we break up but I know I will)
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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 14:27 DrRiverRocket OB/GYN referring to chiropractor for perinatal back pain

My sister is seven months pregnant and has mild upper back pain. Her OB/GYN office has recommended her twice now (once from the MD and once from a midwife) to a chiropractor. Is this standard practice? I plan to recommend her to physical therapy, but I’m a bit surprised by her medical team’s support for pseudoscience.
submitted by DrRiverRocket to medicine [link] [comments]

2023.06.04 14:22 cjtusa27 My (48m) stepson (17m) assualted my wife (48f) and she wants me to stay out of it.

My wife and her son got into a physical altercation in January. Left her bruised and cops were called but since he was a minor, they didnt do anything except suggest that the son live with his dad for awhile and that he seek therapy. The police noted that had he been 18, he would have been charged with a Class B felony.
He is back living at the house and I am struggling. Everytime I look at him, I just want to beat the living crap out of him and I am just repulsed at how she treats him like the prodigical son.
To me, there is no coming back from hitting and kicking your mom while calling her an "ugly w__re" and "nasty c_nt". A person who does that is a piece of scum in my opinion.
She says I need to stay out of it because I am not his father and I need to support what she is doing..
The level of tension I feel when he is around is overwhelming. I am afraid this is going to destroy our marriage.
TL/DNR: My stepson assualted his mother and is back living at the House and my wife is telling me to stay out of it. .
submitted by cjtusa27 to relationships [link] [comments]

2023.06.04 14:06 HomotoChan I found less harmful alternatives and am slowly getting better ❤

I started to SH as a teen to overshadow my emotional pain with physical pain. I'd dig my nails into my skin at first and later I started scratching my skin raw. After I was in a better living situation I started scratching during difficult conversations and when I was stressed. It got better after I was medicated and after therapy, but I still have occasional relapses.
Right now, I started to crack my fingers during conversations instead of scratching. I also make sure I have gel nail polish on, since they make my nails thicker and thus duller (it also makes me feel pretty ❤).
I'm working on better recognising my stress levels and being able to stop a relapses early.
submitted by HomotoChan to selfharm [link] [comments]

2023.06.04 13:52 kadybabs Chronic Headaches with These Physical Therapy Techniques

Chronic Headaches with These Physical Therapy Techniques
For those who suffer from chronic headaches, it can be a constant struggle to find relief. Medications may provide temporary relief but often come with unwanted side effects. However, physical therapy techniques have been found to alleviate headache symptoms and even prevent them from occurring altogether.
Physical therapists work to identify the root cause of a patient's headaches and develop a personalized treatment plan that targets specific areas of tension or weakness in the body. Through a combination of gentle exercises, stretches, and manual therapies, physical therapy can help patients achieve long-lasting relief and improve their overall quality of life.
Understanding the causes of chronic headaches
Chronic headaches are a common ailment that can have a significant impact on an individual's quality of life. Understanding the causes of chronic headaches is essential to finding effective treatments. One potential cause of chronic headaches is tension in the muscles, which can be caused by poor posture or stress. In some cases, chronic headaches may also be a symptom of an underlying medical condition such as migraines or sinusitis.
Physical therapy techniques such as massage and stretching can help alleviate muscle tension and reduce chronic headache frequency and intensity. In addition to these techniques, physical therapists may also recommend exercises to improve posture and strengthen neck and shoulder muscles. Identifying triggers such as certain foods or environmental factors can also help prevent chronic headaches from occurring.
Overall, understanding the causes of chronic headaches is crucial to finding effective treatment options. Physical therapy techniques offer a non-invasive approach that can provide relief for those suffering from this debilitating condition. By working with a physical therapist, individuals with chronic headaches can learn how to manage their symptoms and improve their overall quality of life.
Physical therapy as a non-invasive treatment option
Physical therapy is a non-invasive treatment option that can help relieve chronic headaches. Physical therapists use a variety of techniques to address the root cause of headaches, including manual therapy, therapeutic exercise, and education on posture and ergonomics. Manual therapy involves hands-on techniques such as massage or joint mobilization to improve the range of motion and reduce tension in the muscles and joints.
The therapeutic exercise involves targeted strengthening and stretching exercises to improve posture and reduce muscle imbalances that can contribute to headaches. Education on posture and ergonomics helps patients make changes to their daily habits that may be contributing to their headaches, such as adjusting computer monitor height or avoiding prolonged sitting.
One major advantage of physical therapy as a non-invasive treatment option is that it avoids the potential risks associated with medications or invasive procedures. Additionally, physical therapy is often covered by insurance plans, making it an accessible option for many patients. With the right physical therapy techniques tailored to individual needs, chronic headache sufferers can say goodbye to debilitating pain and regain control over their lives.
Techniques for relieving tension headaches
  1. Massage Therapy: Massage can help relieve tension headaches by increasing blood flow to the affected area, relaxing tense muscles and reducing stress. Targeting specific trigger points in the head, neck and shoulders can help release built-up tension and reduce pain.
  2. Stretching Exercises: Stretching exercises for the neck, shoulder and upper back can also be beneficial in relieving tension headaches. These exercises can improve flexibility in these areas, which can help reduce muscle tension that contributes to headache pain.
  3. Posture Correction: Poor posture is a common cause of tension headaches. Physical therapy techniques such as postural correction can help correct this issue by improving body alignment and reducing strain on muscles in the neck and upper back region.
Overall, physical therapy techniques are an effective way to manage chronic tension headaches. By using a combination of massage therapy, stretching exercises and postural correction, individuals suffering from chronic headaches may find much-needed relief from their symptoms while improving their overall quality of life.
Exercises to strengthen neck and shoulder muscles
The neck and shoulder muscles play a crucial role in supporting the head's weight and maintaining proper posture. Weakness or tension in these muscles can lead to chronic headaches, neck pain, and even migraines. Physical therapy exercises can help strengthen these muscles, improve flexibility, reduce tension, and alleviate pain.
One of the most effective exercises for strengthening the neck muscles is cervical retraction. It involves pulling your chin back towards your spine while keeping your eyes fixed on a point straight ahead. This exercise strengthens the deep cervical flexor muscles that support the neck's vertebrae.
Another useful exercise is shoulder blade squeezes. This involves sitting up straight with arms at your sides and gently squeezing your shoulder blades together while keeping your shoulders relaxed. This exercise targets the rhomboid muscles between the shoulder blades that are often responsible for upper back pain and tension headaches.
Overall, incorporating these simple physical therapy techniques into daily routines can significantly improve neck and shoulder muscle strength leading to reduced occurrence of chronic headaches in individuals who suffer from them frequently.
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2023.06.04 13:47 PumpkinLassie 37F, fourth retinal tear of the year!

Somehow I knew this would happen. I just had a hysterectomy 3 weeks ago. I'm exhausted and still having pain. And I just knew my eye would do this.
In January, I had 2 tears in my right eye. The third occurred in April. Now I'm having all the symptoms of it happening again and hope my retina doesn't detach before I can get to my retinal specialist office in the morning.
I had a retinal detachment in my left eye as a child. I barely use it because my vision in it is so poor. All I have is my right eye and since these tears started happening my vision has gone from 20/25 and clear to 20/40, needing +2 reading glasses, and lots of floaters.
On top of this I have chronic pain in my back, neck, and hips due to scoliosis. I worked hard since the pain hit severely in 2018 to get some job skills/education and get an office job in healthcare administration and find a career path I could physically do. Now I might lose all my goals and plans...again... as I lose my vision. It's so scary.
I'm intelligent and capable and motivated, but no matter what I do my body just won't let me function like a normal human being.
I feel worst of all that I can't function better for my kids. I just feel so overwhelmed. And I know it's a mixture of my hormones being all over the place since I just had surgery a few weeks ago, and with my eye I will likely need a more extensive surgery on it to hopefully stop it tearing and not lose my vision.
But then what, what else can go wrong? I struggled for years with severe ptsd due to all the trauma I had in childhood and early adulthood. Took years of therapy. Then the chronic pain hit from my scoliosis and I had to relearn how to live with it. Then my uterus was a mess and causing even more pain, so I finally got it out. And my eye now keeps trying to make me blind. And it's all out of my control and so frustrating. It's just ridiculous. I'm so over it all!
I have plenty to be grateful for and I hold onto that...but I'd just like to say that this constant barage of medical issues is bullshit and I'd like to catch a break soon please universe.
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2023.06.04 13:46 Unique-Instruction76 Tips on How to Take Care of Your Mental Health Solutions to mental health issues

Tips on How to Take Care of Your Mental Health. Discover practical tips and expert advice on taking care of your mental health. Learn how to prioritize self-care and seek the support you need. Explore effective solutions to mental health issues in English. From therapy and medication to lifestyle changes, find the right path to healing.


Tips on How to Take Care of Your Mental Health


In today's fast-paced world, taking care of your mental health is essential for overall well-being. Just like physical health, mental health plays a vital role in our daily lives. It affects how we think, feel, and act, influencing our relationships, work, and overall happiness. In this article, we will explore effective tips and strategies to help you prioritize and maintain your mental well-being.

Understanding Mental Health

Before we dive into the tips, it's important to understand what mental health encompasses. Mental health refers to a person's emotional, psychological, and social well-being. It affects how individuals think, feels, and handle daily stressors. Mental health is not merely the absence of mental illness but rather a state of overall well-being where one can cope with the normal stresses of life, work productively, and contribute to their community.

Click Here for more details

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2023.06.04 13:31 boredLeopard4587 Best Massage Chair Reddit in 2023: A Comprehensive Guide

If you are looking for the best massage chair Reddit in 2023, you might be wondering how to choose the right one for your needs and preferences. There are many factors to consider when buying a massage chair, such as your budget, space, health conditions, and personal taste. You also want to find a massage chair that has good reviews and feedback from Reddit users who have tried it.

In this guide, we will help you find the best massage chair Reddit in 2023 by giving you some tips on how to choose a massage chair and recommending some of the top-rated massage chairs that have received positive feedback from Reddit users. We will also answer some of the most frequently asked questions about massage chairs and provide you with some resources to learn more about them.

How to Choose a Massage Chair

When choosing a massage chair, you need to consider four main factors: your budget, space, health conditions, and personal taste. Here are some tips on how to evaluate these factors and find the best massage chair for you.


Your budget is one of the most important factors to consider when buying a massage chair. Massage chairs can vary widely in price, from a few hundred dollars to several thousand dollars, depending on the quality, functionality, and design. You need to decide how much you are willing to spend on a massage chair and what features are essential for you.

Generally speaking, the more expensive a massage chair is, the more advanced and comprehensive its massage functions are. For example, some high-end massage chairs can offer full-body massage, zero-gravity recline, air compression, heat therapy, music synchronization, and voice control. However, these features may not be necessary for everyone and may not fit your budget.

If you are looking for a more affordable option, you can still find some good massage chairs that can provide basic massage functions such as kneading, tapping, rolling, and vibration. You can also look for discounts, coupons, or refurbished models to save some money.


Another factor you need to consider when buying a massage chair is the space you have in your home or office. Massage chairs can take up a lot of space and may not fit in small rooms or tight corners. You need to measure the dimensions of the area where you want to place your massage chair and compare it with the dimensions of the massage chair you are interested in.

You also need to consider the clearance space around the massage chair for reclining and moving. Some massage chairs can recline up to 180 degrees or slide forward to save space. You need to make sure there is enough room for these functions without blocking any doors, windows, or furniture.

If you have limited space or want to move your massage chair around easily, you can opt for a portable or foldable massage chair. These types of massage chairs are usually lighter and smaller than regular massage chairs and can be stored away when not in use.

Health Conditions

The third factor you need to consider when buying a massage chair is your health conditions. Massage chairs can offer various benefits for your physical and mental health such as relieving stress, pain, tension, fatigue, improving blood circulation, posture, flexibility, mood, and sleep quality. However, some massage chairs may not be suitable for certain health conditions or may require medical consultation before use.

For example, if you have any injuries, inflammation, infections, fractures, or wounds on your body, you should avoid using a massage chair or consult your doctor first. If you have any cardiovascular problems such as high blood pressure or heart disease, you should also be careful with using a massage chair or seek medical advice first. If you are pregnant or have any other medical conditions that may affect your sensitivity or response to massage therapy, you should also check with your doctor before using a massage chair.

You should also pay attention to the intensity and duration of the massage sessions. Some massage chairs can offer adjustable levels of intensity and speed for different parts of your body. You should choose the level that is comfortable and safe for you and avoid overdoing it. You should also limit your massage sessions to no more than 15 to 30 minutes per day or as recommended by your doctor.

Personal Taste

The last factor you need to consider when buying a massage chair is your personal taste. Massage chairs can come in different styles, colors,
and designs that can match your personality and preferences. You should choose a massage chair that appeals to you aesthetically and functionally.

Some people may prefer a more traditional or classic look for their massage chair while others may like a more modern or futuristic look. Some people may prefer a more soft or plush feel for their massage chair while others may like a more firm or sturdy feel. Some people may prefer a more simple or minimalist design for their massage chair while others may like a more complex or sophisticated design.

You should also consider the user-friendliness and convenience of the massage chair. Some massage chairs can offer easy-to-use controls such as remote controls, touch screens, or voice commands. Some massage chairs can also offer smart features such as Bluetooth connectivity, USB ports, speakers, or memory functions. You should choose a massage chair that is easy to operate and customize according to your needs and preferences.

Best Massage Chair Reddit in 2023: Recommendations

Now that you know how to choose a massage chair, here are some of the best massage chairs Reddit in 2023 that we recommend based on our research and experience. We have selected these massage chairs based on their features, quality, performance, reviews, and feedback from Reddit users who have tried them.

Osaki OS-4000T Zero Gravity Massage Chair

This massage chair is one of the most popular and best-selling massage chairs on the market. It offers a full-body massage with zero-gravity recline, air compression, heat therapy, and six pre-programmed modes. It also has a user-friendly remote control, a built-in speaker, and a timer function. It is available in four colors: black, brown, charcoal, and cream.

Reddit users who have tried this massage chair have praised its comfort, quality, and functionality. They have also reported that it helps with pain relief, relaxation, and stress reduction. Some of the drawbacks that they have mentioned are its weight, size, and noise level.

This massage chair is suitable for people who are looking for a comprehensive and advanced massage chair with zero-gravity recline and heat therapy. It is also suitable for people who have moderate to high budgets and enough space in their homes or offices.

Snailax shiatsu Neck & Back Massager

This massage chair is another great option for a full-body massage with zero-gravity recline, air compression, heat therapy, and four pre-programmed modes. It also has a computerized body scan, a three-stage foot massage, and a spinal decompression feature. It is available in two colors: charcoal and chocolate.

Reddit users who have tried this massage chair have complimented its comfort, quality, and performance. They have also reported that it helps with pain relief, relaxation, and blood circulation. Some of the drawbacks that they have mentioned are its weight, size, and customer service.

This massage chair is suitable for people who are looking for a full-body massage chair with zero-gravity recline and heat therapy. It is also suitable for people who have moderate to high budgets and enough space in their homes or offices.

Human Touch WholeBody 7.1

This portable and foldable massage chair is a great option for those who are looking for a relaxing massage without breaking the bank. It features a variety of massage modes, including shiatsu, kneading, tapping, and rolling, as well as heat therapy. The chair is also adjustable to fit different body types and can be used on any chair, sofa, bed, or car seat.
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