State-Trait Anxiety Inventoryによるペインクリニック外来患者の不安の評価

The treatment of chronic pain, therapeutic opioid use and abuse, and the nonmedical use of prescription drugs have been topics of intense focus and debate. After the liberalization of laws governing opioid prescribing for the treatment of chronic non-cancer pain by state medical boards in the late 1990s, and with the introduction of new pain management standards implemented by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in 2000, opioids, in general, and the most potent forms of opioids including Schedule II drugs, in particular, have dramatically increased. Despite the escalating use and abuse of therapeutic opioids, nearly 15 to 20 years later the scientific evidence for the effectiveness of opioids for chronic non-cancer pain remains unclear. Concerns continue regarding efficacy; problematic physiologic effects such as hyperalgesia, hypogonadism and sexual dysfunction; and adverse side effects - especially the potential for misuse and abuse - and the increase in opioid-related deaths. Americans, constituting only 4.6% of the world's population, have been consuming 80% of the global opioid supply, and 99% of the global hydrocodone supply, as well as two-thirds of the world's illegal drugs. Retail sales of commonly used opioid medications (including methadone, oxycodone, fentanyl base, hydromorphone, hydrocodone, morphine, meperidine, and codeine) have increased from a total of 50.7 million grams in 1997 to 126.5 million grams in 2007. This is an overall increase of 149% with increases ranging from 222% for morphine, 280% for hydrocodone, 319% for hydromorphone, 525% for fentanyl base, 866% for oxycodone, to 1,293% for methadone. Average sales of opioids per person have increased from 74 milligrams in 1997 to 369 milligrams in 2007, a 402% increase. Surveys of nonprescription drug abuse, emergency department visits for prescription controlled drugs, unintentional deaths due to prescription controlled substances, therapeutic use of opioids, and opioid abuse have been steadily rising. This manuscript provides an updated 10-year perspective on therapeutic use, abuse, and non-medical use of opioids and their consequences.

Therapeutic use, abuse, and nonmedical use of opioids: a ten-year perspective

The politics of the budgetary process

Shortages of Medical Personnel at Community Health Centers

Canada's universal health-care system: achieving its potential.

Background The undertreatment of pain in older adults who reside in long-term care (LTC) facilities has been well documented, leading to clinical guideline development and professional educational programs designed to foster better pain assessment and management in this population. Despite these efforts, little improvement has occurred, and we postulate that focused attention to public policy and cost implications of systemic change is required to create positive pain-related outcomes. Objective Our goal was to outline feasible and cost-effective clinical and public policy recommendations designed to address the undermanagement of pain in LTC facilities. Methods We arranged a 2-day consensus meeting of prominent United States and Canadian pain and public policy experts. An initial document describing the problem of pain undermanagement in LTC was developed and circulated prior to the meeting. Participants were also asked to respond to a list of relevant questions before arriving. Following formal presentations of a variety of proposals and extensive discussion among clinicians and policy experts, a set of recommendations was developed. Results and conclusions We outline key elements of a transformational model of pain management in LTC for the United States and Canada. Consistent with previously formulated clinical guidelines but with attention to readily implementable public policy change in both countries, this transformational model of LTC has important implications for LTC managers and policy makers as well as major quality of life implications for LTC residents.

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Transforming Long‐Term Care Pain Management in North America: The Policy–Clinical Interface

In January 1997, the government of Quebec, Canada, implemented a public/private prescription drug program that covered the entire population of the province. Under this program, the public sector collaborates with private insurers to protect all Quebecers from the high cost of drugs. This article outlines the principal features and history of the Quebec plan and draws parallels between the factors that led to its emergence and those that led to the passage of the Medicare Prescription Drug, Improvement and Modernization Act (MMA) in the United States. It also discusses the challenges and similarities of both programs and analyzes Quebec's ten years of experience to identify adjustments that may help U.S. policymakers optimize the MMA.

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Public/Private Partnerships for Prescription Drug Coverage: Policy Formulation and Outcomes in Quebec's Universal Drug Insurance Program, with Comparisons to the Medicare Prescription Drug Program in the United States

The Canada Health Act requires provinces and territories to provide medically necessary services and to provide equal access to such services. Since 1995, the governing Liberal Party has issued statements indicating that it views abortion services as medically necessary services. Yet the operation of health delivery systems in Canada is primarily reserved for the provinces and territories. Provincial and territorial access to abortion services is significantly affected by bottom-up political implementation, where national policy is often undermined and "trumped" by the politics and pressures operative within provincial and territorial political systems and by other intense interest group pressures.

Canadian Abortion Policy: National Policy and the Impact of Federalism and Political Implementation on Access to Services

Since the 1960s, South Korea has shifted from being mainly an agrarian, rural society to an urbanized and industrial, newly modernizing one. Of the Asian modernized or modernizing societies such as Japan, Taiwan, Hong Kong, Singapore, and Thailand that have Confucian ethical heritages, it appears that South Korea is one of the most closely bound to the relational aspects of this heritage. The Republic of Korea (ROK) is a society of some 44 million people in which 98 % of the population is literate and in which, in 1987, 78.1% of the labor force was in the secondary and tertiary industrial sector and 69% of the population lived in urban areas. Per capita GNP in 1989 was $4,550, and in 1990 an average wage earner's monthly family income was about $1,235. In 1990 the South Korean fertility rate was about 1.7 children per family and was expected to remain less than two children per family during the 1990s. On the other hand, life expectancy at birth in 1990 was 69.3 years for men and 75 years for women. In 1990, 4.7% of Korea's population was over 65 years old with the expectation that, by 2020, that figure would rise to 11%. ' Modernization, accompanied by demographic changes, urbanization, and industrialization, has contributed to changes in South Korea's family structure. Average household size for a family declined from 5.6 persons

Howard A. Palley

Papers

Transforming Long‐Term Care Pain Management in North America: The Policy–Clinical Interface

Public/Private Partnerships for Prescription Drug Coverage: Policy Formulation and Outcomes in Quebec's Universal Drug Insurance Program, with Comparisons to the Medicare Prescription Drug Program in the United States

Canadian Abortion Policy: National Policy and the Impact of Federalism and Political Implementation on Access to Services

Social Policy and the Elderly in South Korea: Confucianism, Modernization, and Development

The U.S. Experiment in Social Medicine: The Community Health Center Program, 1965–1986