When the Best of Intentions Leads to Bad Outcomes.

There is no question that the opioid use problem in America has reached unacceptable proportions. What is in question, however, is the best way to address this problem. Unfortunately, this is a multidimensional problem that will not be solved with a simple unidimensional solution.

Reality and responsibility revisited: Stakeholder accountability in the effort to develop safer opioids.

This supplement is dedicated to an exploration of the science, potential utility, and the current state of abuse-deterrent formulations (ADF) of opioid analgesics. There are many stakeholders in the search for safer pain treatments in general, and safer opioid therapy in particular. Healthcare providers, patients, third-party payors, law enforcement and government regulators, the pharmaceutical industry, and the media all have a stake in seeing pain treated and addiction and overdose avoided.

Reasons for relativism: Feyerabend on the 'Rise of Rationalism' in ancient Greece.

This paper argues that essential features of Feyerabend's philosophy, namely his radicalization of critical rationalism and his turn to relativism, could be understood better in the light of his engagement with early Greek thought. In contrast to his earlier, Popperian views he came to see the Homeric worldview as a genuine alternative, which was not falsified by the Presocratics. Unlike socio-psychological and externalist accounts my reading of his published and unpublished material suggests that his alternative reconstruction of the ancient beginnings of the Western scientific tradition motivate and justify his moderate Protagorean relativism.

Trends in drug use from urine drug testing of addiction treatment clients.

Objective: Urine drug testing (UDT) can play an important role in the care of patients in recovery from addiction, and it has become necessary for providers and programs to utilize specific, accurate testing beyond what immunoassay (IA) provides.

Design: A database of addiction treatment and recovery programs was sampled to demonstrate national trends in drug abuse and to explore potential clinical implications of differing results due to the type of testing utilized.

Setting: Deidentified data was selected from a national laboratory testing company that had undergone liquid chromatography tandem mass spectrometry (LC-MS/MS).

Specimen validity testing in urine drug monitoring of medications and illicit drugs: clinical implications.

Objective: To discuss the importance of specimen validity testing (SVT) in urine drug testing (UDT) and the clinical role it plays in identifying efforts to subvert the UDT process.

Methods: A discussion of the clinical impact of SVT is presented.

Results: A discussion of pH, specific gravity, creatinine, and oxidation for monitoring the adulteration of UDT samples is presented along with the clinical significance of such tests.

Using urine drug testing to support healthy boundaries in clinical care.

Risk management is first and foremost about protecting patients. This article will examine risk management in general, and urine drug testing (UDT) in particular, as core constituents in an effective, comprehensive risk management strategy. The article will explore UDT as a tool to help practitioners and patients make better choices in the clinical management of chronic pain.

Universal precautions revisited: managing the inherited pain patient.

"Universal Precautions in Pain Medicine: A Rational Approach to the Treatment of Chronic Pain" was published in 2005. In it, a unified 10-step approach to the assessment and management of patients suffering from chronic pain was proposed. As well, a triage scheme of risk stratification was offered.

Pain and addiction: managing risk through comprehensive care.

The use of controlled substances, including opioids, in people who may suffer from concurrent substance use disorders presents challenges to the healthcare professional. Pain and addiction can coexist either as a continuum or separate comorbid conditions. Success in the treatment of either condition requires an approach that encompasses the biopsychosocial needs of the patient.

Buprenorphine: new tricks with an old molecule for pain management.

Sublingual buphrenorphine is a unique opioid medication based on its pharmacokinetics and pharmacodynamic properties. It may be used "on label" as an alternative choice to methadone for the treatment of opioid addiction or "off-label" for the treatment of both acute and chronic pain. Because of high mu receptor affinity and resultant blockade, it has been suggested that this might interfere with the management of moderate to severe pain in patients on opioid agonist treatment.

Reality and responsibility: a commentary on the treatment of pain and suffering in a drug-using society.

While opioids are a necessary part of the armamentarium of pain management, there has been a growing trend toward prescription drug abuse and diversion in our society. Meeting the goal of treating pain while not contributing to drug abuse and diversion requires vigilance and education. Physicians and patients have been singled out as the main players in the societal problem of diversion of prescription drugs.

Evidence of morphine metabolism to hydromorphone in pain patients chronically treated with morphine.

Minor metabolic pathways in human subjects have been shown to exist for the conversion of codeine to hydrocodone but have not been reported for the metabolic conversion of morphine to hydromorphone. In this study, urine specimens were collected in an out-patient setting from 13 pain patients who were chronically treated with morphine and other opioids (methadone, oxycodone, and fentanyl). The chronic pain patients were chosen for study because they were treated with high-dose morphine and had no personal or family history of addiction.

Universal precautions in pain medicine: a rational approach to the treatment of chronic pain.

The heightened interest in pain management is making the need for appropriate boundary setting within the clinician-patient relationship even more apparent. Unfortunately, it is impossible to determine before hand, with any degree of certainty, who will become problematic users of prescription medications. With this in mind, a parallel is drawn between the chronic pain management paradigm and our past experience with problems identifying the "at-risk" individuals from an infectious disease model.