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The purpose of this study is to describe the use of complementary and alternative medicine (CAM), pain reliever use and the expectations refugees have of physicians about their practice of CAM use in the USA. Individuals with a refugee background are one of the populations who use CAM for treatment. However, to date, there is insufficient empirical evidence to describe CAM use among refugees resettled in the USA. In addition, collecting information about the use of pain relievers would help better understand the experiences of individuals with a refugee background.

Data was collected from August 2018 to November 2019 using a self- or interviewer-administered survey from 94 refugees 18 years of age or older who had settled in the USA.

This study found the following: CAM practice is very common among refugees resettled in the USA, most refugees use non-prescription pain medicine and refugees prefer to see physicians who understand CAM. This study contributes valuable findings in the usage of CAM among refugees and determines that CAM is commonly used among refugees resettled in the USA for pain management.

By better understanding CAM, physicians can address a direct need for the refugee population-seeking health care in the USA and other countries that host refugee resettlement.

How is medical knowledge produced and what are the implications of that knowledge production for medical practice? Using theoretical ideas on evidence-based medicine, standardization in medical research and practice, and biopower, I examine the relationship between medical knowledge and medical practice through the case of pelvic pain care in the US.

Data from ethnographic observations at two medical conferences as well as interviews with healthcare providers inform a critical analysis of the medical discourse.

The analysis reveals how evidence-based medicine is practiced in the context of medical conditions that lack objective evidence, as well as the unintended consequences of such practices. I provide an alternative approach to medical practice for conditions lacking traditional evidence through presenting outlier cases in the data.

In doing so, I make the broad theoretical argument that biomedical paradigms must emerge through the critical process of negative dialectics in order to reach past the limits of standardized medical care.

In sociologically analyzing the case of pelvic pain care, I reveal dire limits in the evidence-based approach to medical care for conditions and symptoms that may be deemed medical anomalies, demanding an alternative approach to care for such conditions.

This chapter discusses the genealogy and development of the ‘access abyss in palliative care and pain relief’ affecting 80 per cent of the world’s people. It argues that the larger context is an epistemic abyss constituted by incomplete information about the need for controlled medicines for pain relief, and that decades of drug policy based on supply control have prevented development of the necessary knowledge base in many countries. Transnational civil society organisations are working to map and bridge this abyss through education, advocacy and action. Deeper (original) systemic and tensions in the original multilateral drug control narrative produced the current epistemic/clinical abysses and now provide space for more participatory civil society involvement. Where the earlier narrative focussed on a fear-based drive to discipline and punish non-medical use of controlled substances, the evolving (and still contested) ‘world drug problem’ narrative foregrounds person centred, human rights based, public health approaches to drug policy that explicitly support improved access to internationally controlled essential medicines. Recommended policies can only be operationalised through a concerted ‘all hands on deck’ effort guided by the international law principle of ‘mutual and shared responsibility’ for improving access within the context of the 2030 Agenda for Sustainable Development. This calls for enhanced communication, concerted advocacy, collaboration and pluralist praxis to fill the often gaping abyss between ‘black letter law’ — what is actually written in the drug control conventions — and how member states learn to interpret and operationalise it.

To determine healthcare utilization issues for low-income Hispanic immigrants who have both excess weight and chronic pain.

Community health workers conducted at-home interviews with 101 middle-aged and older Mexican Americans (aged 40-79 years, M=52.1±8.8) associated with a community agency in southern California to evaluate healthcare underutilization and reported reasons for not using medical or pharmaceutical care.

Almost all participants (91 percent) reported having received at least some medical care in the year preceding the study interview. However, at some point during the prior year, 62 percent had not seen a doctor when it was needed and 45 percent had not taken a prescribed medication. While the primary reason for underutilization was financial, communication, and trust reasons were also reported.

Although cross-sectional and geographically restricted, this study lays the foundation for additional research on reasons for underutilization of recommended healthcare and lack of pain management in low-income Hispanic immigrants who are overweight and have chronic pain.

Policy implications include the urgent need for health insurance.

Implications for providers include the need for accurate pain assessment and better communication about medication to prevent non-adherence in this population.

The current study highlights the existence of healthcare underutilization among overweight and obese Mexican Americans with chronic pain and identifies specific barriers to care, care seeking, and pain management.

The misuse of pharmaceutical opioid analgesics is identified as a global public health concern. Codeine represents an interesting quandary in terms of its regulated status, with individuals varying in their metabolism of codeine, estimation of safe dosages, risk of adverse health consequences and abuse potential. Efforts to quantify and address hidden non-compliant medical codeine use, overuse and intentional misuse is compromised by availability to the public in prescribed and over the counter forms. The paper aims to discuss these issues.

A review of literature on codeine use, misuse and dependence, and associated innovative medical and pharmacy interventions is presented, and was conducted as part of a larger scoping review on codeine.

The review highlights the complexities associated with monitoring public health awareness of codeine's abuse potential, and customer/patients trends in non-compliant codeine use for therapeutic and recreational purposes. Aberrant codeine behaviours centre on visiting multiple doctors for prescriptions, repeated lost or stolen prescriptions, forging prescriptions and use of multiple pharmacies. Innovations to monitor misuse of codeine include national prescription databases and recent developments in real-time monitoring of dispensing activity.

Further development of real-time monitoring processes with process evaluation is advised.

This viewpoint is intended to demonstrate how efforts to quantify and address codeine use are compromised by its availability. It intends to encourage further policy and practitioner dialogue on how to monitor, support and intervene with consumers misusing codeine.

Financial constraints, an increase in the demand for health-care from an ageing population, multiple comorbidities in both mental and physical health and delivering care closer to the community, are amongst the factors creating a need for innovation in the NHS. The purpose of this paper is to explore leader behaviours that promote innovation in a multidisciplinary musculoskeletal (MSK) service.

Qualitative semi-structured interviews were conducted to explore the experience and views of the multidisciplinary team (MDT) members on leadership and innovation. A total of 13 MDT members participated in the study.

Inter-professional collaboration and the absence of hierarchical behaviours are associated with a positive experience. Traditionally established hierarchy and inter-professional barriers for interaction were associated with challenging experience in MDT. There was an expression of fear of and vulnerability to being “taken over” or “eaten up” by other professions. Supportiveness, consulting behaviour, provision of time, vision and inspiring and risk-taking behaviours are associated with innovation. Target drove and monitoring behaviours or hierarchical expression of authority, directive or supervisory behaviours are negatively associated with innovation.

Day to day leader’s behaviours and interactions influences the work environment for innovation. Knowledge gained through Informal interaction, understanding each other’s professional strengths and weaknesses are implicit strengths of an MDT but when a member perceives their skills as less valuable to that of another member, they hold less power and influence. Therefore, a flat hierarchy provides a more effective structure for knowledge translation and maximising MDT productivity.

MSK services are complex adaptive systems with several pathways and interactions flowing between various specialities. For improving innovation and effective functioning of the MSK MDT, it is important to provide informal training for team leads on self-awareness of the behaviours associated with innovation.

Acute and chronic pain affects more Americans than heart disease, diabetes, and cancer combined. Conservative estimates suggest the total economic cost of pain in the United States is $600 billion, and more than half of this cost is due to lost productivity, such as absenteeism, presenteeism, and turnover. In addition, an escalating opioid epidemic in the United States and abroad spurred by a lack of safe and effective pain management has magnified challenges to address pain in the workforce, particularly the military. Thus, it is imperative to investigate the organizational antecedents and consequences of pain and prescription opioid misuse (POM). This chapter provides a brief introduction to pain processing and the biopsychosocial model of pain, emphasizing the relationship between stress, emotional well-being, and pain in the military workforce. We review personal and organizational risk and protective factors for pain, such as post-traumatic stress disorder, optimism, perceived organizational support, and job strain. Further, we discuss the potential adverse impact of pain on organizational outcomes, the rise of POM in military personnel, and risk factors for POM in civilian and military populations. Lastly, we propose potential organizational interventions to mitigate pain and provide the future directions for work, stress, and pain research.

The purpose of this paper is to report on the dynamics of “identity leadership” with a quality improvement project undertaken by an International Medical Graduate (IMG) from Sri Lanka, on a two year Medical Training Initiative (MTI) placement in the National Health Service (NHS) [Academy of Medical Royal Colleges (AoMRC), 2017]. A combined MTI rotation with an integrated Fellowship in Quality Improvement (Subedi et al., 2019) provided the driver to implement the HEART score (HS) in an NHS Emergency Department (ED) in the UK. The project was undertaken across ED, Acute Medicine and Cardiology at the hospital, with stakeholders emphasizing different and conflicting priorities to improve the pathway for chest pain patients.

A social identity approach to leadership provided a framework to understand the insider/outsider approach to leadership which helped RH to negotiate and navigate the conflicting priorities from each departments’ perspective. A staff survey tool was undertaken to identify reasons for the lack of implementation of a clinical protocol for chest pain patients, specifically with reference to the use of the HS. A consensus was reached to develop and implement the pathway for multi-disciplinary use of the HS and a quality improvement methodology (with the use of plan do study act (PDSA) cycles) was used over a period of nine months.

The results demonstrated significant improvements in the reduction (60%) of waiting time by chronic chest pain patients in the ED. The use of the HS as a stratified risk assessment tool resulted in a more efficient and safe way to manage patients. There are specific leadership challenges faced by an MTI doctor when they arrive in the NHS, as the MTI doctor is considered an outsider to the NHS, with reduced influence. Drawing upon the Social Identity Theory of Leadership, NHS Trusts can introduce inclusion strategies to enable greater alignment in social identity with doctors from overseas.

More than one third of doctors (40%) in the English NHS are IMGs and identify as black and minority ethnic (GMC, 2019a) a trend that sees no sign of abating as the NHS continues its international medical workforce recruitment strategy for its survival (NHS England, 2019; Beech et al., 2019). IMGs can provide significant value to improving the NHS using skills developed from their own health-care system. This paper recommends a need for reciprocal learning from low to medium income countries by UK doctors to encourage the development of an inclusive global medical social identity.

This quality improvement research combined with identity leadership provides new insights into how overseas doctors can successfully lead sustainable improvement across different departments within one hospital in the NHS.

This paper aims to explore the role of tramadol in pain management and the impact of regulatory measures on supply and medical access in Ghana and other African countries.

The study adopted an exploratory design and qualitative methods to explore the perspectives of different actors, including officials of regulatory agencies, law enforcement agents, health-care providers and non-medical tramadol users. Data were collected through individual and group interviews, and transcripts were subjected to thematic analysis.

Findings show that tramadol fills a critical gap in treating pain across Ghana in areas with an acute shortage of opioid analgesics due to scheduling-related barriers. This was partly due to porous borders allowing for an influx of tramadol into the countries. The study further found that most tramadol purchases in Ghana and other West African countries were made from market traders rather than from health-care settings and were mainly generic medicines categorised as “substandard/spurious/falsely-labelled/falsified/counterfeit medical products” within the World Health Organization standards.

Although the findings are instructive, there were some limitations worth noting. The study encountered several limitations, especially with the non-medical users, because the environment is highly criminalised, People who use drugs were unwilling to avail themselves for fear of law enforcement officers’ harassment. Obtaining ethical clearance had its own bureaucracy – challenges that delayed the study time frame.

Placing tramadol under the list of internationally controlled substances would create barriers to access to effective pain medications, particularly by the poor, and encourage victimisation of users by law enforcement authorities.

The study is based on empirical research on tramadol use and regulation in African countries, contributing to knowledge in an under-researched subject area on the continent. The comparative approach further adds value to the research.

The process of chronic pain (CP) and strategies is to improve the patient’s health and well-being. CP is a frequent medical problem that presents a major challenge to healthcare providers because of its complex natural history, imprecise aetiology, and inadequate response to pharmacological treatment. Although different definitions exist it is widely accepted that CP is an ongoing pain that lasts more than 3 months or that persists longer than the reasonably expected healing time for the involved tissues. Also, it is acknowledged that its treatment is much different than the treatment for acute pain. When addressing a person with CP, one should always keep in mind that pain is much more about the individual than the underlying medical condition. Every person is different, and healthcare providers should take a tailor-made approach to managing their pain. This is the only way to ensure good results in pain treatment. Treatment goals should be discussed and adapted to the patient profile. It is fundamental to have clear goals from the beginning and to ensure these are realistic, individualized, and measurable. Effective treatment for CP is only achieved through a holistic framework in which the patient’s well-being is the first concern and an interdisciplinary and societal approach is implemented from the first day.