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      "body": "Congratulations @lottoid! You received a personal award!\n\n<table><tr><td>https://steemitimages.com/70x70/http://steemitboard.com/@lottoid/birthday3.png</td><td>Happy Birthday! - You are on the Steem blockchain for 3 years!</td></tr></table>\n\n<sub>_You can view [your badges on your Steem Board](https://steemitboard.com/@lottoid) and compare to others on the [Steem Ranking](https://steemitboard.com/ranking/index.php?name=lottoid)_</sub>\n\n\n###### [Vote for @Steemitboard as a witness](https://v2.steemconnect.com/sign/account-witness-vote?witness=steemitboard&approve=1) to get one more award and increased upvotes!",
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      "body": "@@ -1087,17 +1087,17 @@\n   Then, \n-Y\n+y\n ou have \n@@ -6542,24 +6542,27 @@\n or that, you\n+'ll\n  need to go \n@@ -10253,23 +10253,23 @@\n ctor\n+s\n  when \n-s/\n+t\n he\n+y\n  say\n-s\n  %E2%80%9Cdo\n@@ -10303,19 +10303,17 @@\n rch for \n-our\n+a\n  medical\n@@ -10319,17 +10319,16 @@\n l degree\n-s\n .%E2%80%9D The d\n@@ -10409,23 +10409,16 @@\n See, it \n-really \n is consi\n@@ -10966,18 +10966,17 @@\n ary \n-calculates\n+works out\n  to \n@@ -11067,11 +11067,11 @@\n xtra\n-; s\n+. S\n o wh\n@@ -11225,16 +11225,18 @@\n nets to \n+a \n less-tha\n@@ -11245,19 +11245,16 @@\n nothing \n-in \n income o\n",
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      "body": "Sometimes I say \"I can explain it to you, but it'll take about 12 years.\" Yes, I'm a smart-ass, but consider the education required to become a physician:\n\nBefore Med School:\n   Most people finish high school. About 28% of people finish college. So, completing the requirements for a 4 year degree is something a lot of people have done, and a lot more people understand. Not all med schools require an undergrad degree, but getting into medical school requires some specific coursework that often leads to a little bit more than a 4 year degree. It’s not that much, honestly, particularly when compared to what comes later.\n\n   “Pre-requisites” for medical school are generally specific college courses. The Medical College Admission Test, or MCAT, tests achievement in these pre-requisite courses, among other things. The typical courses are: \n   2 biology courses - typically including cell biology; 2 general chemistry courses; 2 organic chemistry courses; 2 physics courses; Lab courses for each of the science classes; Calculus (usually); English - from one to three courses;  \n\n   Then, You have to score well on the MCAT. You need to have a pretty good GPA (mostly \"A\"s), and you have to interview in person at the school. This can be intense, or it can be pretty laid back. \n\n   In medical school, you take classes that are essentially graduate-school-level study in several specific subjects, called “Pre-clinical” subjects. This takes about 2 years in most medical schools. You have to pass each class, and you typically  have to pass the National Board of Medical Examiners’ tests at the end of those classes. They are usually:\nGross Anatomy\nMicroanatomy / Cellular Biology\nMicrobiology\nEmbryology\nImmunology\nPhysiology\nBiochemistry\nPharmacology\nNeuroscience\nBehavioral Sciences \nGenetics\nEthics\nPathophysiology\n\n   After completing these courses, you have to take and pass the U.S. medical licensing exam, (USMLE) part 1. If you fail, you get two more tries. If you fail 3 times, you’re out. This is the most difficult exam I have ever taken. \n\n   The typical third year of medical school consists of “Clinical” rotations. You actually have substantial patient contact in addition to didactic lectures, periodic exams, educational rounds, etc. The areas of medicine required in the 3rd year are:\n--Family Medicine: This includes public health modules, sports medicine, occupational medicine, as well as the typical general practice components of internal/adult medicine, obstetrics, pediatrics, mental health, geriatrics, etc.\n--Internal Medicine: This includes exposure to the subspecialty areas, such as cardiology, gastroenterology, allergy/immunology, rheumatology, endocrinology, nephrology, pulmonary medicine / intensive medicine, infectious disease, oncology/hematology, etc.\n--Neurology\n--Neurosurgery\n--Obstetrics/Gynecology: including Maternal/Fetal Medicine, Gynecologic Oncology, Urogynecology, and Reproductive Endocrinology. \n--Pediatrics: Including the pediatric subspecialties similar to the Internal Medicine subspecialties, along with Developmental Pediatrics, Behavioral Pediatrics, and Genetics.\n--Psychiatry\n--Surgery: General, Trauma, Surgical Intensive Care, Cardiovascular/Thoracic, Colorectal, Head/Neck (ENT), Orthopedics, etc.\n\n   After the third year, you take Step 2 of the USMLE. Same rules as before: Three strikes and you’re out. It’s easier, though, if you’ve been paying attention.\n\n   The fourth year consists largely of “electives” to allow exploration of potential specialty selections and other interests, but some requirements may be included. This also allows for flexibility in scheduling travel to visit other training sites and potential residency programs.\n\n   Then you GRADUATE MEDICAL SCHOOL. Congratulations! You are now a medical doctor--except that you know nothing; you aren’t licensed, certified or even certifiable, and you’re more dangerous than helpful. That’s okay, at least you are ready for:\n\nInternship:\n   Internships are hard to explain. You work hard. You get paid a little bit, but it’s a “stipend” more than a salary. You don’t even pay SS taxes on it. You are lower than the lowest staffer or student in the hospital. You practice under the supervision of at least one resident, and usually under a “Junior” and “Senior” resident. A “Chief” resident may also be involved, but mostly as a liaison. An “Attending Physician” is the doctor of record. S/he has finished residency, often a fellowship, has passed all three licensing exams, and has usually passed one or more board certification exams. Even the medical students are more important than you because they are being recruited by the residency program for future employment.\n\n   But, you’re a doctor, so get to work! Specifically, work 80 hours per week for 49 weeks of the year. It used to be more (when I was in school), but we’ve gotten soft. Now the rules prevent such dangerous things as working more than 30 consecutive hours. At this point, you have help, but they are at least as busy as you. You have had 4 years to learn how to look stuff up, and you have observed enough to be aware of your own limitations. By the way, you need to get rid of those limitations, buddy, and the best chance you have for that is to be ready when called in the middle of the night. You can’t wait on someone else when your patient needs a needle thoracotomy, or you won’t have a patient any more. \n\n   Typically, during internship, you will rotate through some of the areas of sub-specialization. You may go to the ER for a month, then the ICU, then nephrology consults, then you may be the “mole”-the designated overnight doctor, then general medicine inpatient, maybe an outpatient rotation. If you are doing a “transitional” internship, you may be abused a little. You’ll fill in the rotations that nobody else wants to do prior to your departure for your regular residency.\n\nOh yeah, if you screw up too much, you’re out. No pressure. \n\n   After your 4000 closely supervised hours, you will have the chance to take Step 3 of the USMLE. You can wait on that if you wish, though. Generally, you must complete this step within 7 years from the date you took the first step. The \"Three strikes\" rule still applies, but it isn’t as universal. After you pass this, you are eligible to apply for full licensure in some states. You could hang a shingle! Except--you usually can’t get hospital privileges (i.e., the right to work in a hospital.) Aaaannnndd--you probably won’t be able to accept many insurance policies. For that, you need to go ahead and finish your residency.\n\nResidency:\n   Residency is highly variable in length and specific duties. On the shorter-duration side of the medical residency world are Internal Med, Pediatrics, Family Medicine, and Emergency Medicine. They usually have an integrated internship and three “Post-Graduate Years.” So, a PGY-1 is an intern, a PGY-2 is a junior resident, and a PGY-3 is a senior resident.\n \n   For OB/Gyn, Psychiatry, Neurology, Dermatology, Pathology, et al., you have a 4-year to 5-year training requirement. Internships may or may not be integrated. Your PGY-2 year, therefore, feels a lot like another internship. You are the low-man again, but you aren’t so clueless, so it’s not as bad.\n\n   For Surgery, count on at least 5 years. Surgical specialists take 6 to 8 years. \n\n   When you are a “junior” resident, you have to supervise interns and students while you are supervised by senior residents and attendings. Senior residents get first choice of procedural cases and are usually on “backup” call, meaning that they get to leave the hospital sometimes.   As a resident, you will rotate through every sub-specialty possible. You will have a “continuity” clinic where you see patients who you discharged from the hospital or who have come to the clinic for general care within your specialty. You still take “in-service” exams. In most specialties, if you flunk an in-service exam, you’re out. In other specialties, the exams are intended more as assessments of the program itself or as practice for board certifications. \n\n   After residency, you are typically eligible to take a board certification exam from your primary specialty board. If you pass (NOT a given--AT ALL), you are usually going to be able to practice independently. You could even be an “Attending” clinical instructor at your school, all in as little as 11 years since your finished high school! \n\nFellowship:\n   Additional training is often needed to deal with complex or difficult cases. In a fellowship, a board-certified specialist will focus intensely on training in a division within the specialty.  At the end of a fellowship, usually from one to three years in length, you should have increased ability and understanding in an area beyond that which is common to general specialty members. For example, a cardiologist goes to fellowship for 3 years after residency. An electrophysiologist or interventional cardiologist or transplant cardiologist may go another year or two after a fellowship. They are “sub-specialists” or “sub-sub-specialists.” A surgeon may specialize in Urology via a hybrid residency/fellowship, then become a uro-oncologist and take on difficult cancer cases. A neurosurgeon may specialize in cancer or spinal diseases or neurovascular disease. You get the point? All of these people have a HUGE base of primary knowledge on which they build a HUGE base of speciality knowledge.\n\nBoard-Certification:\n   This is a test or series of tests your doctor has to take after having completed a residency. S/he may be able to practice without a certification, but his options will be limited. S/he may not be able to maintain hospital privileges or may not be eligible to participate in come insurance panels. \n\nContinuing Medical Education:\n   Various requirements exist. They are state-specific and specialty specific, and individual hospitals have their own internal requirements. \"Maintenance of Certification\" exams and reporting requirements are now commonplace. Your doctor may have to devote more time education each year than some people have to complete to get college degrees. That's not a bad thing, but it is a real thing.\n\n   So, please forgive your doctor when s/he says “don’t mistake your google search for our medical degrees.” The doctors are not trying to be trite; in fact, they are trying to be polite. See, it really is considered rude to tell people how much training and education you really have. (If your doctor wanted to be trite, s/he would say “don’t mistake your searches for our MDs, or for our scientific backgrounds, our licenses, internships, residencies, fellowships, board certifications, experience, etc.”)\n\n\nFinancial note:\n   All of these residencies are 80-hours per week and 49 weeks per year. With knowledge comes  a few efficiencies, so it isn’t necessarily so horrible as an upper-level resident. However, you are still paid a pittance. The salary calculates to MUCH less than minimum wage (Mine worked out to $1.70/hr), and you can’t earn much extra; so while you are training, you are usually deferring your quarter-million dollar student loans and adding interest to the principle exponentially. This nets to less-than-nothing in income over your internship and residency. But, hey, you are getting an education equivalent of TWO YEARS of experience per one year of real-time. (4000 hours per year for 3 to 8 years = 12000 to 32000 hours of training.) You can pack a lot of knowledge in a head in that amount of time, and saving a life may be worth that, particularly if that life is yours. \n\n   Consider that your doctor had to wait 11 to 18 years before he got a real job after high school, and s/he had to borrow a ton of money just to live, let alone pay for school, and s/he works 55 to 100 hours per week, depending on specialty, coverage, location, and other factors, before you give him a hard time about his bill, and remember that all of his expenses, fees, nurses' salaries, required insurances, etc., all have to come out of that payment, so overhead is between 40 and 70%.",
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      "body": "Opioid overprescribing is a big deal right now. I am a psychiatrist who often has to treat complicated cases that other types of docs think are rare, but which are actually very common.\n\nThis is a short version of my standard talk to physicians regarding opioid prescribing:\n\nPAIN CONTROL MEASURES: \nThe Number Needed to Treat (NNT) to accomplish a 50% reduction in acute pain (considered a \"response”) using oxycodone 15mg is 4.6. NNT for a combination of Ibuprofen 200mg and Tylenol 500mg is 1.6. In other words, you are about 3 times as likely to be helped by IBU+APAP as you are by OXY. Confirmation studies keep coming out: the same trends apply to dental pain, post op pain, acute injuries and acute LBP. Chronic pain studies are lacking, but chronic pain is often complicated by \"Opioid Induced Hyperalgesia.\" \n\nTranslation: Opioids cause worsened pain. \nSee ( http://www.nsc.org/RxPainkillers )\n\nAnd no one ever believes me when I tell them that, until they're off of the pills.\n\nWHY IS THIS SUCH A BIG PROBLEM?\nWe've been conditioned in medicine to think of pain as vital sign. It's not. We've been conditioned by administrations, insurance companies, and patients to think that the only outcome that matters is patient satisfaction. It isn't.\nAs an inpatient psychiatrist, I tend to treat difficult/refractory cases, and my patient population consists LARGELY (More than 1/2) of patients who have abused prescription meds. How did they abuse them? Their doctors let them. The docs are beholden to their hospital’s and clinic's patient advocates/satisfaction personnel, insurance companies, lawyers, and administrators. Those people, including extraordinarily well-meaning other providers such as nurses, techs, and outside caregivers, all put pressure on physicians to deliver an certain product. When the doc doesn't do it, he is fired, flamed on the internet, cursed at, threatened, sued, etc. I've had to respond to the most ridiculous complaints made by addicts because I diagnosed them with addiction and offered treatment for both pain and addiction. All providers have been through this. The reason?\n\nThe customer is NOT always right.\n\nSatisfied patients die more often than dissatisfied patients. (Several JAMA and NEJM articles confirm this.) The direct cost of inappropriate opioid prescriptions and diversion is in the tens of billions. The indirect costs may exceed that. This problem has arisen because in the 90s we were sold a bill of goods by makers of MS Contin, Opana, Duragesic, Oxycontin, etc., and in the 2000s we were marketed to by the Suboxone makers and clinics and chronic pain clinics. All of those people wanted us to believe that all pain ends, just like all bleeding stops. Well, that's true, and for the same reason. That doesn't mean we never use opioids any more than it means we never do surgery. But we've been irresponsible. Almost all of us have. The data are clear.\n\nFor what it's worth: \nIt usually takes me 4 days to get someone off of opioids entirely. They ALWAYS feel better. They have pain, but they note that the severity is either the same as or better than it was when they were on opioids. (It's surprising how often it is better, not just the same.) Well over 1/2 of patients in my practice have developed opioid-induced hyperalgesia. My practice is obviously selecting for the worst actors. Easy cases do not make it as far as me, but most practices weed out their problem cases and without realizing how much they are contributing to the problem.\n\nIf you don't work in psych, addictionology, or chronic pain clinics, it is possible (probable?) that you have a patient population selected for responsible use. The reason for this is because once you set a limit, the addicted patient finds another provider, then another, then another. They don't come back to you. You never have the chance to realize that you were their first drug dealer. You got them hooked, but you don't know it. I mean, you only saw them a couple of times! However, today they won't be able to shop around as easily. The new regs and recs mean they'll be cut off at their PCPs far more often. I'll see a boom in business from patients referred because they \"just need something for the pain\" when, in fact, the drugs themselves are causing it. \n\nThanks for the business, (sarcasm!) but anybody can treat this. It's not even dangerous to try at home, if opioids are the only problem. Here's how:\n\n*For tremors, anxiety, sweating, goosebumps:\nClonidine 0.1mg up to tid if blood pressure is sufficient. (Hold if Systolic BP is less than 100 or if pulse is less than 60 bpm)\n*For muscle spasms:\nCyclobenzaprine, Tizanidine, metaxolone, methocarbamol (NOT soma/carisoprodol) given two to four times daily per the PI.\n*For diarrhea:\nLoperamide 2mg per loose stool. Doesn't usually require a loading 4mg dose. Max 8mg per 24 hrs.\n*Nausea:\nOndansetron 4mg per 4 hours is preferred over phenergan. Ginger helps.\n*Insomnia:\nTrazodone 50 to 200mg QHS. If not effective, Seroquel 50 to 200mg qhs. \n*Pain:\nIBU 200mg + APAP 500mg Q.I.D. (unless the patient was using percocet or Vicodin or another combination drug. In that case, nothing really helps because they get rebound headaches from stopping the NSAID, but it is usually gone entirely within 96 hours) \n*Anxiety:\nHydroxyzine 25-50mg TID as needed for anxiety if the patient is under 55 y/o. Seroquel 25-50mg TID as needed for anxiety for over 55 y/o if clonidine isn't sufficient. Monitor BP with seroquel + clonidine; the orthostasis risk is high.\n\n*Each of the above is \"as needed,\" and patients taper themselves without prompting because the above agents are not reenforcing. \n\nCAVEAT !!! ---\nOne must always consider whether the patient is self-treating a mood or anxiety disorder by using opioids. That is incredibly common. If you fail to treat the primary condition, the opioid use will recur in greater than 85% of cases. However, using benzodiazepines causes a similar phenomenon with anxiety disorders. The anxiety symptoms will pass, and the patient won't die from a bit of anxiety. So don't shoot yourself and the patient in the foot by using benzos. If you have a bipolar patient or PTSD patient or MDD patient, talk to your friendly neighborhood psychiatrist for some suggestions, or send those folks to a dual diagnosis program.",
      "json_metadata": "{\"tags\":[\"pain\",\"narcotics\",\"medicine\"],\"links\":[\"http://www.nsc.org/RxPainkillers\"]}",
      "parent_author": "",
      "parent_permlink": "pain",
      "permlink": "opioid-induced-hyperalgesia",
      "title": "Opioid-Induced Hyperalgesia"
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