Local Policy and Programmatic Activity to Address the US Opioid Crisis: A Cross-Sectional Survey of County Governments.

CONTEXT: Despite attention to federal and state governments' response to the US opioid crisis, few studies have systematically examined local governments' role in tackling this problem. OBJECTIVES: To determine what opioid policy and programmatic activities local governments are implementing, which activities are more challenging and require a greater latent ability to implement, and what community, environmental, and institutional factors shape such ability. DESIGN: A cross-sectional survey and multistage sampling procedure. SETTING/PARTICIPANTS: Of all 358 county governments in 5 purposively selected states (Colorado, North Carolina, Ohio, Pennsylvania, and Washington) surveyed, 171 counties (response rate = 47.8%) with complete data on self-reported policy and programmatic activities and predictor variables were eligible for analysis. MAIN OUTCOME MEASURES: Nineteen opioid policy and programmatic activities were analyzed individually and combined into a latent implementation ability index using empirical Bayes means estimates. RESULTS: Item response theory and bivariate analysis were applied. Item response theory estimates suggested that having police officers carry naloxone and establishing a task force of community leaders were easier to implement than more challenging activities such as establishing needle exchanges and allowing arrest alternatives for opioid offenses. Covering individuals' treatment costs was predicted to involve the highest ability. County population size (r = 0.34; 95% confidence interval [CI], 0.20-0.47), population density (r = 0.35; 95% CI, 0.21-0.47), and being a Pennsylvania county (r = 0.45; 95% CI, 0.32-0.56) showed the strongest associations with latent implementation ability. CONCLUSIONS: Counties appear engaged in opioid policy and programmatic activity, although some activities are likely more difficult and may require greater ability to implement than others. More sparsely populated counties appear more disadvantaged in implementing activities for tackling the opioid crisis and may need additional assistance to leverage their ability to build a comprehensive policy and programmatic infrastructure.

Surviving Benzodiazepines: A Patient's and Clinician's Perspectives.

Although benzodiazepines have been used for 6 decades, many questions remain unanswered by research. The lived experiences of those adversely affected long term can provide insights into how these agents might be more thoughtfully prescribed. Here, perspectives of one such experience encompassing benzodiazepine initiation, ongoing use with adverse consequences and difficult discontinuation are presented through the eyes of an affected individual and a clinician. This experience highlights the importance of limited initiation and duration of use (2-4 weeks) as well as a supported, slow tapering process led by patients. Because researched evidence about deprescribing benzodiazepines is insufficient and because individual experiences vary so widely, it is the patient's expertise-that of her or his lived experience-that should assume a primary role in determining the course and pace of discontinuing these medications.

Limited Utility for Benzodiazepines in Chronic Pain Management: A Narrative Review.

INTRODUCTION: Controversy and uncertainty exist about the use of benzodiazepine receptor agonists (BZRAs) in pain management. This article curates available research to determine the appropriate role of BZRAs in the course of pain management, and how prescribers might address these challenges. METHODS: A narrative review was performed to determine the appropriate role of BZRAs in pain management and to develop practice recommendations. Publications were identified by a search of PubMed, references of retrieved reports, guidelines, and the author's personal files. RESULTS: BZRAs were found to have analgesic benefit for two pain conditions: burning mouth syndrome and stiff person syndrome. Absence of research, heterogeneity of trials, and small sample sizes precluded drawing conclusions about efficacy of BZRAs for the other 109 pain conditions explored. Data supports the use of BZRAs to treat co-occurring insomnia and anxiety disorders but only when alternatives are inadequate and only for short periods of time (2-4 weeks). The utility of BZRAs is limited by loss of efficacy that may be seen with continued use and adverse reactions including physiologic dependence which develops in 20-100% of those who take these agents for more than a month. CONCLUSIONS: BZRAs are often used inappropriately in pain management. Their initiation and duration of use should be limited to a narrow range of conditions. When prescribed for 4 weeks or more, patients should be encouraged to discontinue them through a supported, slow tapering process that may take 12-18 months or longer.

Viewing angle performance of medical liquid crystal displays.

Cathode-ray tube (CRT) and liquid crystal display (LCD) are currently two main technologies for displaying medical images. LCDs possess a number of advantages, but their performance varies as a function of viewing angle. Our purpose in this study was to characterize the angular response performance of five medical-grade LCDs, and to substantiate their impact on their compliance with the DICOM gray scale display function (GSDF). Furthermore, the study aimed to test a framework to define an angular acceptance range for medical LCDs based on the recent AAPM TG18 guidelines. Measurements were made on five calibrated dual-domain LCDs, including two 3 megapixel monochrome LCDs, two 5 megapixel monochrome LCDs, and one 9 megapixel color LCD. The luminance performance of each display device was measured as a function of the viewing angle at 17 discrete levels using TG18-LN test patterns and a Fourier-optics-based luminance meter. The luminance data were analyzed according to the AAPM TG18 methodology. The displays showed notable variation in luminance and contrast performance as a function of the viewing angle, particularly in diagonal viewing orientations. Overall, the luminance ratio remained greater than 175 within +/-20 degrees and +/-33 degrees viewing angle cones (beta175 = 20 degrees-33 degrees). Aiming to maintain a maximum deviation from the GSDF contrast less than 0.3, i.e., kappa17 < or = 0.3, acceptable viewing angle cones of +/-22 degrees and +/-35 degrees were indicated (alpha 0.3= 22 degrees-35 degrees). The findings demonstrate the significant impact of angular response on image contrast, and the utility of alpha 0.3 and beta175 quantities for defining the viewing angle cones within which a medical LCD device can be effectively utilized.