Sleep as a marker in the effective management of chronic osteoarthritis pain with opioid analgesics.

OBJECTIVES: Sleep disturbances frequently accompany chronic pain from osteoarthritis (OA), and their effective management may reflect successful treatment of chronic pain. The objective of this article is to provide a rationale for using improvement in sleep as a marker for effective management of chronic OA pain with opioid analgesics. For this purpose, available evidence evaluating the relationship between successful management of chronic pain with opioids and improvements in sleep in patients with OA is reviewed. METHODS: We conducted a comprehensive PubMed search to identify studies that systematically measured the impact of opioid treatment on pain and sleep parameters in the context of chronic pain from OA. Our search criteria included publication in a recognized peer-reviewed journal, randomized placebo-controlled design, and assessment of both pain intensity and sleep as outcomes. RESULTS: In each of the 10 placebo-controlled studies identified, concurrent improvements in pain intensity and measured sleep disturbances were observed in patients receiving the long-acting opioid analgesics under study. Improved overall sleep quality, reduced awakenings from pain, and increased duration of sleep were among the favorable changes observed in patients with OA treated with long-acting opioids. CONCLUSIONS: Current evidence suggests that various long-acting opioid analgesics simultaneously achieve pain control and improve sleep. However, the complex interaction between reduced pain and improved sleep requires further study.

Identity transformation in medical students.

This paper reviews the literature on the impact of medical school on personal development and consolidation of core identity. The limited literature relies on reports from medical students' journaling exercises, discussion groups, post-graduation surveys, and repeated personality testing. We review forces acting on medical students, with potential transforming effects. These forces include high external expectations and internal fear of superficial knowledge and skills, entry into the culture of medicine with its insider jargon and hierarchy, high academic workload, and the emotional burdens of confronting cadavers and death as well as bearing witness to patients' suffering. Potential developmental delay, emergence of substance abuse and hedonic acting out, cynicism, and loss of individual core values are possible consequences. Protections against these adverse outcomes include identification of strong mentors and role models, developing post-conventional morality and relativistic thinking, finding healthy coping strategies such as peer support, and remaining intellectually creative and personally reflective.

Ethical perspectives: opioid treatment of chronic pain in the context of addiction.

The authors apply eight ethical domains of analysis to the question of treatment of chronic pain with opioids in patients with histories of substance use disorders: autonomy, nonmaleficence, beneficence, justice, medical condition, patient preference, quality of life, and consideration of specific individual or sociocultural issues. These eight domains are drawn from principle-based and case-based ethical perspectives. The domains are developed by review of available literature and through application to a specific presented case. Factors that interfere with rational, ethical decision-making regarding opioid pain management are identified. Chronic pain and substance use disorders share a history of stigmatization, underdiagnosis, and undertreatment. Using the presented case as a point of departure, the authors discuss principles for prescription of opioids for treatment of chronic noncancer pain in the setting of history of substance use disorders.

Standards for Psychiatry Clerkship Directors.

The authors review the literature relevant to the position of Psychiatry Clerkship Director (PCD) and propose standards regarding the expectations for this position. The standards address qualifications, duties, and competencies in the areas of leadership, administration, education, mentoring, and scholarship, as well as the resources of time, administrative assistance, budget, and compensation required to carry out these duties. This paper has been endorsed by the Council of the Association of Directors of Medical Student Education in Psychiatry (ADMSEP), by the American Psychiatric Association's Committee on Medical Student Education, and by the Executive Committee of the American Association of Chairmen of Departments of Psychiatry.