Pain the fifth vital sign....was it a mistake

Rethinking Opioid Prescribing to Protect Patient Safety and Public Health. Alexander GC et al. JAMA 2012 Nov 13;308:1865-1866.

The authors of this “Viewpoint” piece begin by noting that the rates of death and complication from prescription drug abuse have been increasing astronomically:

The annual number of fatal drug overdoses in the United States now surpasses the annual number of motor vehicle deaths, and overdose deaths attributable to prescription opioids — nearly 15000 in 2008 — exceed those attributable to cocaine and heroin combined.

This marked increase has coincided with “Pain as the 5th Vital Sign” campaign, a push that some have suspected was encouraged and supported by pharmaceutical companies as a marketing tool.

The authors recommend “changes to clinical guidelines to treat chronic pain that are less reliant on opioids”. This would involve re-evaluation of the role of opioids in treating chronic pain:

Grater clinical judiciousness is especially warranted given the limited evidence to support many clinical applications in which opioids are used. For example, although opioids may be efficacious for acute lower back pain, the safety, efficacy, and abuse data are limited for chronic back pain

The paper conclusion :

Prescription drug abuse is a complex problem, and there are no simple solutions for effective prevention. Efforts to prevent abuse and diversion to the illicit market should continue, but prescribing practices also must change to reverse what has become a pervasive epidemic leading to widespread morbidity, mortality, and community strife.”

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The pressure volume loop...

In the pressure-volume loop below, cardiac work is best represented by: the area of the curve the slope of the line from points C to D the distance of the line from points C to D the slope of a line from points A to D .. .. ... .... ... .... .... .... In the pressure-volume loop below, cardiac work is best represented by: the area of the curve Cardiac work is the product of pressure and volume and is linearly related to myocardial oxygen consumption. Cardiac work is best represented by the area of the curve of a pressure-volume loop.

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