Manual New York Advance Sheet March 2013

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He was jaundiced and losing weight. In conversations, he seemed dazed. So when he started having issues with his colon, his stomach, all that stuff, we attributed them to the accident. By the time McAlary got his diagnosis of colon cancer, it had already progressed to an advanced stage. Nevertheless, he underwent surgery to remove as much of the cancer as possible, then started chemotherapy in He was hooked up to the chemo drip when he received a tip that a man had been severely assaulted by a police officer.

He drove from his treatment to see Abner Louima in the hospital. He was the first reporter to interview the victim. In a series of articles, he not only exposed a monstrous incident of police brutality but started the earliest debate about the Giuliani-era approach to law enforcement. Because then you might as well be dead. As she saw him, McAlary was a role model not so much in life, but in death, in the way that he used writing to maintain his sense of purpose and find release from his illness.

In the six years my mother had MDS, she wrote blog posts, two books and two plays and directed a movie. There was nothing she could do about her death but to keep going in the face of it. Work was its own kind of medicine, even if it could not save her when her MDS came roaring back.

I dropped everything, got into a cab and headed up to see her at NewYork-Presbyterian Hospital. Now she would need a brutal form of chemotherapy if she hoped to survive. Max and his girlfriend, Rachel, were getting on a plane from L. When I arrived in her room, my mother was crying. She cried a lot that first night, and then, the next day, she cried some more because she was certain Christopher Hitchens had done no such thing, and she was devastated at the thought that she might not be as brave as him about death.

It terrified me to see her cry like that. She loved me, showered me with gifts, e-mailed or called every time I wrote something that made her proud. But even after all the weekly meals, the shared vacations, the conversations about movies and journalism and the debt ceiling and Edith Wharton, I still viewed her with a mix of awe and intimidation. As she explained it that first night, the odds of the chemo working were below 50 percent, and even if it did, it would probably not buy her more than a year and a half or so. I told her that I hoped she would reconsider, that a year and a half is a lot of time during which something else may emerge as a viable treatment.

Still, I said I would respect whatever she wished to do, that it was her body, her life, her choice. I think this is what she needed to hear, that we wanted her to live more than anything but that she was still in control. Because within minutes, she seemed resigned to the idea that she was going to be nuked, as she put it. Forty-eight hours later, she was hooked up to an IV. Her sadness seemed to lift, and her humor returned. So was Richard Cohen, the Washington Post columnist and one of her oldest friends. At first, there were some encouraging signs.

Then, about a week and a half later, she got pneumonia. As her doctors explained it, the body often takes three weeks or so to begin producing neutrophils after chemotherapy of this type. And neutrophils are the good guys that defend the body from infections. One day, she would seem to be getting better; the next, worse. At night she was experiencing heart palpitations. It was confusing to all of us, including my mother. We waited as she went on and off oxygen. We waited as her appetite left her. We waited as she lost her hair, and this I remember vividly, because I did not see her cry at all.

Instead, she seemed sort of numb. My mother loved looking good. She had her hair blown out weekly.

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She wore makeup. She had a closet filled with Prada and Armani. She had fallen in love with and married a man who was as fastidious about presentation as she was. All sorts of men had rejected her when she was younger as cute but not beautiful. She wrote about it, turned it into a comic riff — everything is copy — but privately, it was heartbreaking for her until this noble man came along and made her feel that she was as fabulous to look at as she was to talk to.

And now, here she was without her hair, confined to a bed, using a nurse to help her go to the bathroom. It was the beginning of her losing her dignity. It was the beginning of a bad death. In the days that followed, conversation became harder, and the silences grew longer. People who live thousands of miles from their parents often express regret at not being able to say goodbye, or about having spent too little time with them during their final days. But being there every day, as I was, produced its own kind of sorrow. It was the sadness of having run out of news to deliver, gossip to report, new books and movies to discuss.

I actually believe that had Tom Cruise and Katie Holmes announced their separation a week earlier, we might have kept her smiling one more night. On June 18, four weeks after my mother went into the hospital, the Public Theater held its annual benefit to raise money for Shakespeare in the Park. For more than a decade, my mother attended the gala every year, considering it the unofficial beginning of summer. Often it would start to rain in the middle of the show, and everyone would pull out their umbrellas and wait for it to pass.

It was an evening when her favorite park in her favorite city turned into an enchanted forest.

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Access to capital for high-growth entrepreneurs has improved significantly since , with venture capital investment up an estimated percent, far exceeding its pre-recession peak, and angel investment up 40 percent, approaching its pre-recession peak. At the first-ever White House Demo Day in , engineering deans pledged to develop concrete diversity plans for their programs to tap into diverse talent. Since then, the American Society for Engineering Education ASEE has worked with its members to share best practices and to promote the inclusivity in engineering schools of all students regardless of visible or invisible differences.

ASEE is creating a platform to disseminate best practices among participating engineering schools that will help them implement the diversity initiative. Today, at , the number of engineering deans that have signed the pledge has more than doubled since ASEE will continue promoting and enhancing diversity and inclusion through all its participating members.

Read letter HERE. At the Global Entrepreneurship Summit this past summer, President Obama announced a commitment by senior leadership from 33 companies of all sizes to fuel American innovation and economic growth by increasing the diversity of their technology workforce. Today, 46 additional companies, including Xerox, TaskRabbit, and Techstars, are joining this Tech Inclusion Pledge, committing to take concrete action to make the technology workforce at each of their companies representative of the American people as soon as possible.

Early-stage investors are making a new commitment to promote inclusive entrepreneurship. For example, MassMutual Foundation and Valley Venture Mentors are partnering to create a scalable model for rural startup accelerators, while Pipeline Angels is bringing its training programs for underrepresented investors to 20 additional cities. Permanently eliminated capital gains tax on certain small business stock. First enacted on a temporary basis in the Small Business Jobs Act of and now permanent, this measure eliminates capital gains realized on the sale of certain small business stock held for more than 5 years, providing a major incentive for private-sector investment in high-growth entrepreneurial firms that fuel economic growth.

Scaled up I-Corps, a rigorous entrepreneurship training program for scientists and engineers. The Innovation Corps I-Corps program, first launched in by the National Science Foundation NSF , provides entrepreneurship training for Federally funded scientists and engineers, pairing them with business mentors for an intensive curriculum focused on discovering a truly demand-driven path from their lab work to a marketable product.

The I-Corps model has been adopted in 11 additional Federal agency partnerships, including an expansion to 17 Institutes and Centers at the National Institutes of Health and the Centers for Disease Control and Prevention, and is implemented through a National Innovation Network across more than 70 universities.

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Facilitated personnel exchanges between Federal labs, academia, and industry. Increased access to Federally-funded research facilities and intellectual property for entrepreneurs and innovators. Funded by NIST, the Federal Laboratory Consortium launched online tools for finding specific information and open data on more than Federal laboratories with 2, user facilities and specialized equipment, as well as over 20, technologies available for licensing.

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Seeded startup accelerators in diverse communities. From to now, SBA has funded over startup accelerator programs in every corner of the country, serving well over 5, startups that have collectively employed over 20, people and raised over 1. Pioneered a regional innovation strategy. Incentivized regional partners to work together on tech entrepreneurship. Among the 35 organizations receiving EDA support are a female-focused early-stage capital fund in Texas, a Native American-focused proof-of-concept program in Oklahoma, and urban innovation hubs focused on fashion technology in Brooklyn and on social innovation in New Orleans.

To date, business owners report more than , jobs will be created or retained due to the new loans and investments stimulated by SSBCI funds. More than half of all SSBCI loans or investments went to young businesses less than 5 years old, and over 40 percent of the loans or investments were in low- or moderate-income communities. Over 30 states have allocated nearly half-a-billion SSBCI dollars to venture-capital programs—a dramatic increase in funding for the programs that are critical to expanding high-growth entrepreneurship into diverse regions around the country.

Strengthened investment fund program for small businesses. This Administration has created new pathways for impact investment funds that devote growth capital to companies in underserved communities and emerging sectors, as well as for early-stage innovation funds. SBA created the InnovateHER Business Challenge, where organizations throughout the country hold local competitions for new and innovative products and services to empower women and their families; in , over 1, entrepreneurs participated in over competitions, and these numbers doubled in Women-owned small businesses reached an important milestone in , meeting the Federal contracting goal for such businesses for the first time in history; overall last year, the Federal government awarded an all-time high of Unlocked the potential of Federal inventions with entrepreneurs from all backgrounds.

The National Institute of Standards and Technology, the Minority Business Development Agency, and the Federal Laboratory Consortium partnered together to launch the Inclusive Innovation Initiative I-3 , designed to increase minority business participation in Federal technology transfer. Trained veteran entrepreneurs for 21st century opportunities. The Department of Veterans Affairs Center for Innovation is helping to expand the 3D Veterans Bootcamp, a program that provides Veterans with technical training in 3D printing and design skills to accelerate designs to market.

The training will annually prepare over Veterans and transitioning service members for careers in advanced manufacturing and will provide guidance and resources for those wishing to launch their own business. Additionally, SBA launched Boots to Business , an entrepreneurship education program that provides transitioning service members with introductory business training and technical assistance.

Since , over 20, transitioning service members, including many spouses, participated in the Boots to Business introductory class on over military installations worldwide. Launched TechHire to train people for entrepreneurial opportunities and well-paying jobs. Since then, 50 communities in partnership with over 1, employers have initiated local efforts that have placed over 2, people into tech jobs and entrepreneurial opportunities. Expanded entrepreneurial opportunities for the unemployed and underserved. Released a rule tailored for international entrepreneurs.

Once this rule is finalized, it will provide much-needed clarity for entrepreneurs who have been validated by experienced American funders, and who demonstrate substantial potential for rapid growth and job creation—benefiting American workers and the U. Thus, the body of evidence for KQ1 is rated as insufficient 0 studies contributing For KQ2, the body of evidence is rated as type 3 12 studies contributing; 11 from the original review plus one new study. One fair-quality cohort study found that long-term opioid therapy is associated with increased risk for an opioid abuse or dependence diagnosis as defined by ICDCM codes versus no opioid prescription Rates of opioid abuse or dependence diagnosis ranged from 0.

Ten fair-quality uncontrolled studies reported estimates of opioid abuse, addiction, and related outcomes 55 — Factors associated with increased risk for misuse included history of substance use disorder, younger age, major depression, and use of psychotropic medications 55 , Two studies reported on the association between opioid use and risk for overdose 66 , One large fair-quality retrospective cohort study found that recent opioid use was associated with increased risk for any overdose events and serious overdose events versus nonuse It also found higher doses associated with increased risk.

A similar pattern was observed for serious overdose. A good-quality population-based, nested case-control study also found a dose-dependent association with risk for overdose death Findings of increased fracture risk for current opioid use, versus nonuse, were mixed in two studies 68 , Two studies found an association between opioid use and increased risk for cardiovascular events 70 , Indirect evidence was found for endocrinologic harms increased use of medications for erectile dysfunction or testosterone from one previously included study; laboratory-defined androgen deficiency from one newly reviewed study 72 , For KQ3, the body of evidence is rated as type 4 14 studies contributing; 12 from the original review plus two new studies.

A fair-quality retrospective cohort study based on national Veterans Health Administration system pharmacy data found that methadone was associated with lower overall risk for all-cause mortality versus morphine 81 , and a fair-quality retrospective cohort study based on Oregon Medicaid data found no statistically significant differences between methadone and long-acting morphine in risk for death or overdose symptoms However, a new observational study 83 found methadone associated with increased risk for overdose versus sustained-release morphine among Tennessee Medicaid patients.

The observed inconsistency in study findings suggests that risks of methadone might vary in different settings as a function of different monitoring and management protocols, though more research is needed to understand factors associated with safer methadone prescribing. For dose escalation, the AHRQ report included one fair-quality randomized trial that found no differences between more liberal dose escalation and maintenance of current doses after 12 months in pain, function, all-cause withdrawals, or withdrawals due to opioid misuse For example, evidence on the comparative effectiveness of opioid tapering or discontinuation versus maintenance, and of different opioid tapering strategies, was limited to small, poor-quality studies 85 — For KQ4, the body of evidence is rated as type 3 for the accuracy of risk assessment tools and insufficient for the effectiveness of use of risk assessment tools and mitigation strategies in reducing harms six studies contributing; four from the original review plus two new studies.

The AHRQ report included four studies 88 — 91 on the accuracy of risk assessment instruments, administered prior to opioid therapy initiation, for predicting opioid abuse or misuse. Results for the Opioid Risk Tool ORT 89 — 91 were extremely inconsistent; evidence for other risk assessment instruments was very sparse, and studies had serious methodological shortcomings. For the ORT, sensitivity was 0. No study evaluated the effectiveness of risk mitigation strategies use of risk assessment instruments, opioid management plans, patient education, urine drug testing, use of PDMP data, use of monitoring instruments, more frequent monitoring intervals, pill counts, or use of abuse-deterrent formulations for improving outcomes related to overdose, addiction, abuse, or misuse.

For KQ5, the body of evidence is rated as type 3 two new studies contributing. Two fair-quality retrospective cohort studies found opioid therapy prescribed for acute pain associated with greater likelihood of long-term use. Use of opioids within 7 days of surgery was associated with increased risk for use at 1 year. Versus no early opioid use, the adjusted OR was 2.

Contextual evidence is complementary information that assists in translating the clinical research findings into recommendations. CDC conducted contextual evidence reviews on four topics to supplement the clinical evidence review findings:. CDC also reviewed clinical guidelines that were relevant to opioid prescribing and could inform or complement the CDC recommendations under development e.

CDC conducted a contextual evidence review to assist in developing the recommendations by providing an assessment of the balance of benefits and harms, values and preferences, and cost, consistent with the GRADE approach. Given the public health urgency for developing opioid prescribing recommendations, a rapid review was required for the contextual evidence review for the current guideline.

Rapid reviews are used when there is a need to streamline the systematic review process to obtain evidence quickly Methods used to streamline the process include limiting searches by databases, years, and languages considered, and truncating quality assessment and data abstraction protocols. In brief, CDC conducted systematic literature searches to identify original studies, systematic reviews, and clinical guidelines, depending on the topic being searched. CDC also solicited publication referrals from subject matter experts. Given the need for a rapid review process, grey literature e.

Multiple reviewers scanned study abstracts identified through the database searches and extracted relevant studies for review. Findings from the contextual reviews provide indirect evidence and should be interpreted accordingly.

  • CDC Guideline for Prescribing Opioids for Chronic Pain — United States, | MMWR.
  • CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016?
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The studies that addressed benefits and harms, values and preferences, and resource allocation most often employed observational methods, used short follow-up periods, and evaluated selected samples. Therefore the strength of the evidence from these contextual review areas was considered to be low, comparable to type 3 or type 4 evidence.

The quality of evidence for nonopioid pharmacologic and nonpharmacologic pain treatments was generally rated as moderate, comparable to type 2 evidence, in systematic reviews and clinical guidelines e. Similarly, the quality of evidence on pharmacologic and psychosocial opioid use disorder treatment was generally rated as moderate, comparable to type 2 evidence, in systematic reviews and clinical guidelines. Several nonpharmacologic and nonopioid pharmacologic treatments have been shown to be effective in managing chronic pain in studies ranging in duration from 2 weeks to 6 months.

For example, CBT that trains patients in behavioral techniques and helps patients modify situational factors and cognitive processes that exacerbate pain has small positive effects on disability and catastrophic thinking Exercise therapy can help reduce pain and improve function in chronic low back pain 98 , improve function and reduce pain in osteoarthritis of the knee 99 and hip , and improve well-being, fibromyalgia symptoms, and physical function in fibromyalgia Multimodal and multidisciplinary therapies e.

Nonopioid pharmacologic approaches used for pain include analgesics such as acetaminophen, NSAIDs, and cyclooxygenase 2 COX-2 inhibitors; selected anticonvulsants; and selected antidepressants particularly tricyclics and serotonin and norepinephrine reuptake inhibitors [SNRIs]. Multiple guidelines recommend acetaminophen as first-line pharmacotherapy for osteoarthritis — or for low back pain but note that it should be avoided in liver failure and that dosage should be reduced in patients with hepatic insufficiency or a history of alcohol abuse Although guidelines also recommend NSAIDs as first-line treatment for osteoarthritis or low back pain , , NSAIDs and COX-2 inhibitors do have risks, including gastrointestinal bleeding or perforation as well as renal and cardiovascular risks FDA has recently strengthened existing label warnings that NSAIDs increase risks for heart attack and stroke, including that these risks might increase with longer use or at higher doses Several guidelines agree that first- and second-line drugs for neuropathic pain include anticonvulsants gabapentin or pregabalin , tricyclic antidepressants, and SNRIs — Interventional approaches such as epidural injection for certain conditions e.

Epidural injection has been associated with rare but serious adverse events, including loss of vision, stroke, paralysis, and death Balance between benefits and harms is a critical factor influencing the strength of clinical recommendations. In particular, CDC considered what is known from the epidemiology research about benefits and harms related to specific opioids and formulations, high dose therapy, co-prescription with other controlled substances, duration of use, special populations, and risk stratification and mitigation approaches.

Additional information on benefits and harms of long-term opioid therapy from studies meeting rigorous selection criteria is provided in the clinical evidence review e. CDC also considered the number of persons experiencing chronic pain, numbers potentially benefiting from opioids, and numbers affected by opioid-related harms. Finally, CDC considered the effectiveness of treatments that addressed potential harms of opioid therapy opioid use disorder. Time-scheduled opioid use was associated with substantially higher average daily opioid dosage than as-needed opioid use in one study Methadone has been associated with disproportionate numbers of overdose deaths relative to the frequency with which it is prescribed for pain.

Regarding high-dose therapy, several epidemiologic studies that were excluded from the clinical evidence review because patient samples were not restricted to patients with chronic pain also examined the association between opioid dosage and overdose risk 23 , 24 , — Consistent with the clinical evidence review, the contextual review found that opioid-related overdose risk is dose-dependent, with higher opioid dosages associated with increased overdose risk. A listing of common opioid medications and their MME equivalents is provided Table 2.

Regarding coprescription of opioids with benzodiazepines, epidemiologic studies suggest that concurrent use of benzodiazepines and opioids might put patients at greater risk for potentially fatal overdose. In one of these studies 67 , among decedents who received an opioid prescription, those whose deaths were related to opioids were more likely to have obtained opioids from multiple physicians and pharmacies than decedents whose deaths were not related to opioids.

Regarding duration of use, patients can experience tolerance and loss of effectiveness of opioids over time Patients who do not experience clinically meaningful pain relief early in treatment i. Regarding populations potentially at greater risk for harm, risk is greater for patients with sleep apnea or other causes of sleep-disordered breathing, patients with renal or hepatic insufficiency, older adults, pregnant women, patients with depression or other mental health conditions, and patients with alcohol or other substance use disorders.

Interpretation of clinical data on the effects of opioids on sleep-disordered breathing is difficult because of the types of study designs and methods employed, and there is no clear consensus regarding association with risk for developing obstructive sleep apnea syndrome However, opioid therapy can decrease respiratory drive, a high percentage of patients on long-term opioid therapy have been reported to have an abnormal apnea-hypopnea index , opioid therapy can worsen central sleep apnea in obstructive sleep apnea patients, and it can cause further desaturation in obstructive sleep apnea patients not on continuous positive airway pressure CPAP Reduced renal or hepatic function can result in greater peak effect and longer duration of action and reduce the dose at which respiratory depression and overdose occurs Older adults might also be at increased risk for falls and fractures related to opioids — Opioids used in pregnancy can be associated with additional risks to both mother and fetus.

Some studies have shown an association of opioid use in pregnancy with birth defects, including neural tube defects , , congenital heart defects , and gastroschisis ; preterm delivery , poor fetal growth , and stillbirth Importantly, in some cases, opioid use during pregnancy leads to neonatal opioid withdrawal syndrome Patients with mental health comorbidities and patients with histories of substance use disorders might be at higher risk than other patients for opioid use disorder 62 , , Recent analyses found that depressed patients were at higher risk for drug overdose than patients without depression, particularly at higher opioid dosages, although investigators were unable to distinguish unintentional overdose from suicide attempts Regarding risk stratification approaches, limited evidence was found regarding benefits and harms.

Potential benefits of PDMPs and urine drug testing include the ability to identify patients who might be at higher risk for opioid overdose or opioid use disorder, and help determine which patients will benefit from greater caution and increased monitoring or interventions when risk factors are present. For example, one study found that most fatal overdoses could be identified retrospectively on the basis of two pieces of information, multiple prescribers and high total daily opioid dosage, both important risk factors for overdose , that are available to prescribers in the PDMP However, limited evaluation of PDMPs at the state level has revealed mixed effects on changes in prescribing and mortality outcomes Potential harms of risk stratification include underestimation of risks of opioid therapy when screening tools are not adequately sensitive, as well as potential overestimation of risk, which could lead to inappropriate clinical decisions.

Regarding risk mitigation approaches, limited evidence was found regarding benefits and harms. Although no studies were found to examine prescribing of naloxone with opioid pain medication in primary care settings, naloxone distribution through community-based programs providing prevention services for substance users has been demonstrated to be associated with decreased risk for opioid overdose death at the community level Concerns have been raised that prescribing changes such as dose reduction might be associated with unintended negative consequences, such as patients seeking heroin or other illicitly obtained opioids or interference with appropriate pain treatment With the exception of a study noting an association between an abuse-deterrent formulation of OxyContin and heroin use, showing that some patients in qualitative interviews reported switching to another opioid, including heroin, for many reasons, including cost and availability as well as ease of use , CDC did not identify studies evaluating these potential outcomes.

Finally, regarding the effectiveness of opioid use disorder treatments, methadone and buprenorphine for opioid use disorder have been found to increase retention in treatment and to decrease illicit opioid use among patients with opioid use disorder involving heroin — Although findings are mixed, some studies suggest that effectiveness is enhanced when psychosocial treatments e.

Clinician and patient values and preferences can inform how benefits and harms of long-term opioid therapy are weighted and estimate the effort and resources required to effectively provide implementation support. Many physicians lack confidence in their ability to prescribe opioids safely , to predict or detect prescription drug abuse, and to discuss abuse with their patients Clinicians do not consistently use practices intended to decrease the risk for misuse, such as PDMPs , , urine drug testing , and opioid treatment agreements This is likely due in part to challenges related to registering for PDMP access and logging into the PDMP which can interrupt normal clinical workflow if data are not integrated into electronic health record systems , competing clinical demands, perceived inadequate time to discuss the rationale for urine drug testing and to order confirmatory testing, and feeling unprepared to interpret and address results For example, patients taking hydrocodone for noncancer pain commonly reported side effects including dizziness, headache, fatigue, drowsiness, nausea, vomiting, and constipation Patients with chronic pain in focus groups emphasized effectiveness of goal setting for increasing motivation and functioning Patients taking high dosages report reliance on opioids despite ambivalence about their benefits and regardless of pain reduction, reported problems, concerns, side effects, or perceived helpfulness Resource allocation cost is an important consideration in understanding the feasibility of clinical recommendations.

CDC searched for evidence on opioid therapy compared with other treatments; costs of misuse, abuse, and overdose from prescription opioids; and costs of specific risk mitigation strategies e. Although there are perceptions that opioid therapy for chronic pain is less expensive than more time-intensive nonpharmacologic management approaches, many pain treatments, including acetaminophen, NSAIDs, tricyclic antidepressants, and massage therapy, are associated with lower mean and median annual costs compared with opioid therapy COX-2 inhibitors, SNRIs, anticonvulsants, topical analgesics, physical therapy, and CBT are also associated with lower median annual costs compared with opioid therapy There are 12 recommendations Box 1.

Each recommendation is followed by a rationale for the recommendation, with considerations for implementation noted. In accordance with the ACIP GRADE process, CDC based the recommendations on consideration of the clinical evidence, contextual evidence including benefits and harms, values and preferences, resource allocation , and expert opinion.

For each recommendation statement, CDC notes the recommendation category A or B and the type of the evidence 1, 2, 3, or 4 supporting the statement Box 2. Expert opinion is reflected within each of the recommendation rationales. Where differences in expert opinion emerged for detailed actions within the clinical recommendations or for implementation considerations, CDC notes the differences of opinion in the supporting rationale statements. Category A recommendations indicate that most patients should receive the recommended course of action; category B recommendations indicate that different choices will be appropriate for different patients, requiring clinicians to help patients arrive at a decision consistent with patient values and preferences and specific clinical situations.

Consistent with the ACIP 47 and GRADE process 48 , category A recommendations were made, even with type 3 and 4 evidence, when there was broad agreement that the advantages of a clinical action greatly outweighed the disadvantages based on a consideration of benefits and harms, values and preferences, and resource allocation. Category B recommendations were made when there was broad agreement that the advantages and disadvantages of a clinical action were more balanced, but advantages were significant enough to warrant a recommendation.

All recommendations are category A recommendations, with the exception of recommendation 10, which is rated as category B. Recommendations were associated with a range of evidence types, from type 2 to type 4. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient.

If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate recommendation category: A, evidence type: 3. Patients with pain should receive treatment that provides the greatest benefits relative to risks. The contextual evidence review found that many nonpharmacologic therapies, including physical therapy, weight loss for knee osteoarthritis, psychological therapies such as CBT, and certain interventional procedures can ameliorate chronic pain. There is high-quality evidence that exercise therapy a prominent modality in physical therapy for hip or knee 99 osteoarthritis reduces pain and improves function immediately after treatment and that the improvements are sustained for at least 2—6 months.

Exercise therapy also can help reduce pain and improve function in low back pain and can improve global well-being and physical function in fibromyalgia 98 , Multimodal therapies and multidisciplinary biopsychosocial rehabilitation-combining approaches e. Multimodal therapies are not always available or reimbursed by insurance and can be time-consuming and costly for patients. Interventional approaches such as arthrocentesis and intraarticular glucocorticoid injection for pain associated with rheumatoid arthritis or osteoarthritis and subacromial corticosteroid injection for rotator cuff disease can provide short-term improvement in pain and function.

Evidence is insufficient to determine the extent to which repeated glucocorticoid injection increases potential risks such as articular cartilage changes in osteoarthritis and sepsis Serious adverse events are rare but have been reported with epidural injection Several nonopioid pharmacologic therapies including acetaminophen, NSAIDs, and selected antidepressants and anticonvulsants are effective for chronic pain. Selected anticonvulsants such as pregabalin and gabapentin can improve pain in diabetic neuropathy and post-herpetic neuralgia contextual evidence review. Pregabalin, gabapentin, and carbamazepine are FDA-approved for treatment of certain neuropathic pain conditions, and pregabalin is FDA approved for fibromyalgia management.

In patients with or without depression, tricyclic antidepressants and SNRIs provide effective analgesia for neuropathic pain conditions including diabetic neuropathy and post-herpetic neuralgia, often at lower dosages and with a shorter time to onset of effect than for treatment of depression see contextual evidence review. Tricyclics and SNRIs can also relieve fibromyalgia symptoms.

Because patients with chronic pain often suffer from concurrent depression , and depression can exacerbate physical symptoms including pain , patients with co-occurring pain and depression are especially likely to benefit from antidepressant medication see Recommendation 8. Nonopioid pharmacologic therapies are not generally associated with substance use disorder, and the numbers of fatal overdoses associated with nonopioid medications are a fraction of those associated with opioid medications contextual evidence review. For example, acetaminophen, NSAIDs, and opioid pain medication were involved in , , and 16, pharmaceutical overdose deaths in the United States in However, nonopioid pharmacologic therapies are associated with certain risks, particularly in older patients, pregnant patients, and patients with certain co-morbidities such as cardiovascular, renal, gastrointestinal, and liver disease see contextual evidence review.

NSAID use has been associated with gastritis, peptic ulcer disease, cardiovascular events , , and fluid retention, and most NSAIDs choline magnesium trilisate and selective COX-2 inhibitors are exceptions interfere with platelet aggregation Clinicians should review FDA-approved labeling including boxed warnings before initiating treatment with any pharmacologic therapy. Although opioids can reduce pain during short-term use, the clinical evidence review found insufficient evidence to determine whether pain relief is sustained and whether function or quality of life improves with long-term opioid therapy KQ1.

While benefits for pain relief, function, and quality of life with long-term opioid use for chronic pain are uncertain, risks associated with long-term opioid use are clearer and significant. Based on the clinical evidence review, long-term opioid use for chronic pain is associated with serious risks including increased risk for opioid use disorder, overdose, myocardial infarction, and motor vehicle injury KQ2. At a population level, more than , persons in the United States have died from opioid pain-medication-related overdoses since see Contextual Evidence Review.

Integrated pain management requires coordination of medical, psychological, and social aspects of health care and includes primary care, mental health care, and specialist services when needed Despite this, these therapies are not always or fully covered by insurance, and access and cost can be barriers for patients. For many patients, aspects of these approaches can be used even when there is limited access to specialty care.

A randomized trial found no difference in reduced chronic low back pain intensity, frequency or disability between patients assigned to relatively low-cost group aerobics and individual physiotherapy or muscle reconditioning sessions Low-cost options to integrate exercise include brisk walking in public spaces or use of public recreation facilities for group exercise.

CBT addresses psychosocial contributors to pain and improves function Primary care clinicians can integrate elements of a cognitive behavioral approach into their practice by encouraging patients to take an active role in the care plan, by supporting patients in engaging in beneficial but potentially anxiety-provoking activities, such as exercise , or by providing education in relaxation techniques and coping strategies.

In many locations, there are free or low-cost patient support, self-help, and educational community-based programs that can provide stress reduction and other mental health benefits. Patients with more entrenched anxiety or fear related to pain, or other significant psychological distress, can be referred for formal therapy with a mental health specialist e.

Multimodal therapies should be considered for patients not responding to single-modality therapy, and combinations should be tailored depending on patient needs, cost, and convenience. To guide patient-specific selection of therapy, clinicians should evaluate patients and establish or confirm the diagnosis.

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Detailed recommendations on diagnosis are provided in other guidelines , , but evaluation should generally include a focused history, including history and characteristics of pain and potentially contributing factors e. For complex pain syndromes, pain specialty consultation can be considered to assist with diagnosis as well as management. The underlying mechanism for most pain syndromes can be categorized as neuropathic e.

The diagnosis and pathophysiologic mechanism of pain have implications for symptomatic pain treatment with medication. For example, evidence is limited or insufficient for improved pain or function with long-term use of opioids for several chronic pain conditions for which opioids are commonly prescribed, such as low back pain , headache , and fibromyalgia In addition, improvement of neuropathic pain can begin weeks or longer after symptomatic treatment is initiated Medications should be used only after assessment and determination that expected benefits outweigh risks given patient-specific factors.

For example, clinicians should consider falls risk when selecting and dosing potentially sedating medications such as tricyclics, anticonvulsants, or opioids, and should weigh risks and benefits of use, dose, and duration of NSAIDs when treating older adults as well as patients with hypertension, renal insufficiency, or heart failure, or those with risk for peptic ulcer disease or cardiovascular disease.

The facts about pension advances

Experts agreed that opioids should not be considered first-line or routine therapy for chronic pain i. Rather, expected benefits specific to the clinical context should be weighed against risks before initiating therapy. In some clinical contexts e. In other situations e. In addition, when opioid pain medication is used, it is more likely to be effective if integrated with nonpharmacologic therapy. Nonpharmacologic approaches such as exercise and CBT should be used to reduce pain and improve function in patients with chronic pain.

Nonopioid pharmacologic therapy should be used when benefits outweigh risks and should be combined with nonpharmacologic therapy to reduce pain and improve function. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate, to provide greater benefits to patients in improving pain and function. Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks.

Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety recommendation category: A, evidence type: 4. The clinical evidence review found insufficient evidence to determine long-term benefits of opioid therapy for chronic pain and found an increased risk for serious harms related to long-term opioid therapy that appears to be dose-dependent. In addition, studies on currently available risk assessment instruments were sparse and showed inconsistent results KQ4.

Studies of opioid therapy for chronic pain that did not have a nonopioid control group have found that although many patients discontinue opioid therapy for chronic noncancer pain due to adverse effects or insufficient pain relief, there is weak evidence that patients who are able to continue opioid therapy for at least 6 months can experience clinically significant pain relief and insufficient evidence that function or quality of life improves These findings suggest that it is very difficult for clinicians to predict whether benefits of opioids for chronic pain will outweigh risks of ongoing treatment for individual patients.

Experts agreed that before opioid therapy is initiated for chronic pain outside of active cancer, palliative, and end-of-life care, clinicians should determine how effectiveness will be evaluated and should establish treatment goals with patients. Because the line between acute pain and initial chronic pain is not always clear, it might be difficult for clinicians to determine when they are initiating opioids for chronic pain rather than treating acute pain.

Pain lasting longer than 3 months or past the time of normal tissue healing which could be substantially shorter than 3 months, depending on the condition is generally no longer considered acute. However, establishing treatment goals with a patient who has already received opioid therapy for 3 months would defer this discussion well past the point of initiation of opioid therapy for chronic pain.

Clinicians seeing new patients already receiving opioids should establish treatment goals for continued opioid therapy. Although the clinical evidence review did not find studies evaluating the effectiveness of written agreements or treatment plans KQ4 , clinicians and patients who set a plan in advance will clarify expectations regarding how opioids will be prescribed and monitored, as well as situations in which opioids will be discontinued or doses tapered e.

Experts thought that goals should include improvement in both pain relief and function and therefore in quality of life. However, there are some clinical circumstances under which reductions in pain without improvement in physical function might be a more realistic goal e. Experts noted that function can include emotional and social as well as physical dimensions. In addition, experts emphasized that mood has important interactions with pain and function.

Monitoring progress toward patient-centered functional goals e. Clinicians should use these goals in assessing benefits of opioid therapy for individual patients and in weighing benefits against risks of continued opioid therapy see Recommendation 7, including recommended intervals for follow-up.

Because depression, anxiety, and other psychological co-morbidities often coexist with and can interfere with resolution of pain, clinicians should use validated instruments to assess for these conditions see Recommendation 8 and ensure that treatment for these conditions is optimized. If patients receiving opioid therapy for chronic pain do not experience meaningful improvements in both pain and function compared with prior to initiation of opioid therapy, clinicians should consider working with patients to taper and discontinue opioids see Recommendation 7 and should use nonpharmacologic and nonopioid pharmacologic approaches to pain management see Recommendation 1.