Responding to the Opioid Crisis in North America

“The Stanford–Lancet Commission on the North American Opioid Crisis was formed in response to soaring opioid-related morbidity and mortality in the USA and Canada over the past 25 years. The Commission is supported by Stanford University and brings together diverse Stanford scholars and other leading experts across the USA and Canada, with the goals of understanding the opioid crisis, proposing solutions to the crisis domestically, and attempting to stop its spread internationally. Unlike some other Lancet Commissions, this one focuses on a long-entrenched problem that has already been well characterised, including in several reviews by the National Academies of Sciences, Engineering, and Medicine. This Commission therefore focused on developing a coherent, empirically grounded analysis of the causes of, and solutions, to the opioid crisis.

Since 1999 more than 600,000 people in the USA and Canada have died from opioid overdose and a staggering 1.2 million more are estimated to die due to overdose by 2029. The Stanford-Lancet Commission  was formed in response to the soaring opioid-related morbidity and mortality that the USA and Canada have experienced by analyzing the state of the opioid crisis and proposing solutions to it domestically while attempting to stop its spread internationally. The Commissions identifies where renewed commitment to reform and progress must be made, including regulation, healthcare and treatment, the criminal justice system, prevention, innovation to the opioid response, and curtailing the global spread of the epidemic.”

More on Responding to the opioid crisis in North America and beyond: recommendations of the Stanford–Lancet Commission via The Lancet.

Medical Neutrality & Conflict

“People who practise modern medicine are governed by a set of ethical rules both at times of peace and times of war. We are to treat all our patients equally and without prejudice. A physician’s ethical responsibility during a time of war is identical to that during a time of peace.

Medical neutrality refers to a principle of non-interference with medical services in times of armed conflict and civil unrest: physicians must be allowed to care for the sick and wounded, and soldiers must receive care regardless of their political affiliations. It is a fragile thing to maintain, as it requires opposing sides of a conflict to uphold the agreed principles. Medical staff are not permitted to discriminate against patients based on factors like politics or race, and in exchange, conflicting parties allow medical care to continue unimpeded.

As Dr Joanne Liu, former president of Doctors Without Borders (Medecins Sans Frontieres, or MSF), stated in 2016 in reference to attacks in Aleppo, Syria on medical neutrality, ‘We say loud and clear: The doctor of your enemy is not your enemy.’ These principles allow medical professionals to treat the sick and wounded from either side of a conflict, the idea being they, themselves, will not be targeted as a result while they do this. In times of war, medical care and field hospitals are essential and it is important that they remain safe.”

More on Is Russia committing war crimes by bombing hospitals in Ukraine? And what happens when the principle of medical neutrality is abandoned during times of conflict? via Doctor’s Note.

Pregnant woman and baby die after attack on hospital in Mariupol: Woman was taken to another hospital in city in south-east Ukraine where medics could not save her or her child via The Guardian.

The Power of Collective Action

Figure 1 distinguishes between two interior conditions that we as human beings can choose to operate from. One is based on opening the mind, heart, and will — a.k.a. curiosity, compassion, and courage — and the other one is based on closing the mind, heart, and will — ignorance, hate, and fear. The upper half of figure 1 briefly summarizes the collective cognitive dynamics that have led us to Putin’s war in Ukraine. The freezing and closing of the mind, heart, and will have resulted in six debilitating social and cognitive practices.

“‘The world will never be the same.’ These are, according to New York Times columnist Tom Friedman, the seven most dangerous words in journalism. It’s not only Friedman who has used them to make sense of our current moment. Many of us are doing the same. Watching Putin’s invasion of Ukraine happen in real-time since February 24 makes most of us feel stuck and paralyzed by the horrific acts that are unfolding in front of us.

It feels as if we are crossing a threshold into a new period. This new period has been likened to the cold war era that ended in 1989. Some suggest that Vladimir Putin is trying to turn back the clock by at least 30 years in his effort to make Russia ‘great again.’ I believe, though, that we are in a quite different situation today. The cold war was a conflict between two opposing social and economic systems on the basis of a shared military logic that experts refer to as mutually assured destruction — or MAD, a rather fitting acronym. The MAD ‘operating system’ worked because it relied on a shared logic. It was grounded in a shared set of assumptions, and a shared sense of reality on both sides of the geopolitical divide.”

More on Putin and the Power of Collective Action from Shared Awareness: A 12-Point Meditation on Our Current Moment via Otto Scharmer, MIT Lecturer & Co-founder of the Presencing Institute.

Legal Rights of Transgender Youth

Mother and Child, 2007 by Ukrainian artist Matvey Vaisberg.

“Medical care providers have specific legal duties in relation to youth: to respect their human rights and to assess their capacity to consent to treatment. In AB v CD (2020), the BC Court of Appeal clarified the responsibilities of health care providers when their patient is under 19 years of age,[1] addressed how the Infants Act[2] and Family Law Act[3] apply in situations where youth and parents disagree about medical treatment.[4] The Court confirmed that under the law, health care providers, not parents, are responsible for two things: assessing the capacity of a minor patient to consent to a treatment and determining whether a treatment is in the best interest of that patient. Where a health care provider assesses a young person to be capable and concludes that the treatment is in their best interests, the young person alone has authority to consent to or refuse treatment. In providing health care to a youth, providers’ responsibilities are subject to the scrutiny of their professional bodies and human rights tribunals.”

Learn more on Legal rights of transgender youth seeking medical care via BCMJ.

Thinking is an Exercise

“Visible Thinking is a flexible and systematic research-based conceptual framework, which aims to integrate the development of students’ thinking with content learning across subject matters.

Visible Thinking began as an initiative to develop a research-based approach to teaching thinking dispositions. The approach emphasized three core practices: thinking routines, the documentation of student thinking, and reflective professional practice. It was originally developed at Lemshaga Akademi in Sweden as part of the Innovating with Intelligence project, and focused on developing students’ thinking dispositions in such areas as truth-seeking, understanding, fairness, and imagination. It has since expanded its focus to include an emphasis on thinking through art and the role of cultural forces and has informed the development of other Project Zero Visible Thinking initiatives, including Artful Thinking, and Cultures of Thinking.”

More at Harvard’s Graduate School of Education Project Zero.

Approaching a Sensitive Conversation

Ukrainian Madonna. Ukrainian family. Artist Valentina Samoilik-Artyuschenko, Ukraine

“There’s a conversation you’re avoiding. It feels important, the stakes are high, there are strong feelings involved and you are putting it off: ‘The time isn’t right’; ‘I can’t find the words’; ‘I don’t want to get emotional’.

But delaying doesn’t solve anything and anticipation is often far more uncomfortable than the conversation itself. Getting started might involve some awkward moments, but, after that, the situation is open for discussion and exploration.

Tried and tested approaches can help to smooth the way. Here are 10 useful tips from my experience as a psychotherapist and, developed while working in some of the highest-stakes discussions – the tender conversations taking place as people face the end of life. These principles apply whether you are chatting in person, over the phone or during a video call. You can even use them in text message conversations.

Instead of ‘difficult’ conversations, I call them ‘tender’ – and that attitude can make all the difference.”

Read the 10 tips via How to Say the Unsayable: 10 Ways to Approach a Sensitive, Daunting Conversation.

Watching a Memory Form

“Researchers have now directly observed what happens inside a brain learning that kind of emotionally charged response. In a new study published in January in the Proceedings of the National Academy of Sciences, a team at the University of Southern California was able to visualize memories forming in the brains of laboratory fish, imaging them under the microscope as they bloomed in beautiful fluorescent greens. From earlier work, they had expected the brain to encode the memory by slightly tweaking its neural architecture. Instead, the researchers were surprised to find a major overhaul in the connections.

What they saw reinforces the view that memory is a complex phenomenon involving a hodgepodge of encoding pathways. But it further suggests that the type of memory may be critical to how the brain chooses to encode it — a conclusion that may hint at why some kinds of deeply conditioned traumatic responses are so persistent, and so hard to unlearn.

‘It may be that what we’re looking at is the equivalent of a solid-state drive’ in the brain, said co-author Scott Fraser, a quantitative biologist at USC. While the brain records some types of memories in a volatile, easily erasable form, fear-ridden memories may be stored more robustly, which could help to explain why years later, some people can recall a memory as if reliving it, he said.”

More on Scientists Watch a Memory Form in a Living Brain via Quanta Magazine.
Read the study here Regional synapse gain and loss accompany memory formation in larval zebrafish via PNAS.

Mental Health Consequences of War

Support by Olga Shtonda
“I’m from Kharkiv, Ukraine’s second-biggest city, 40km from the Russian border. Two weeks before the war began, I went to Mexico to see a friend. Being away from those you love in such a terrible time is hard. There is constant bombing where my parents live. At first I felt hopeless. Sometimes I still feel guilty that they see horror while I see a peaceful sky. But I realised that I can give them my best support even from another continent. Knowing you are not alone helps a lot.”
Instagram @olga.shtonda

“War has a catastrophic effect on the health and well being of nations. Studies have shown that conflict situations cause more mortality and disability than any major disease. War destroys communities and families and often disrupts the development of the social and economic fabric of nations. The effects of war include long-term physical and psychological harm to children and adults, as well as reduction in material and human capital. Death as a result of wars is simply the “tip of the iceberg”. Other consequences, besides death, are not well documented. They include endemic poverty, malnutrition, disability, economic/ social decline and psychosocial illness, to mention only a few. Only through a greater understanding of conflicts and the myriad of mental health problems that arise from them, coherent and effective strategies for dealing with such problems can be developed.”

More on Mental health consequences of war: a brief review of research findings via World Psychiatry.

See “Art from a Nation under Attack” via The New Statesmen.

Understanding & Communicating Uncertainty

The Son of Man, 1946. Artist: Magritte

“Uncertainty pervades the diagnostic process. In health care, taxonomies of uncertainty have been developed to describe aspects such as personal (eg, individual knowledge gaps), scientific (eg, limits of biomedical knowledge), and probabilistic (eg, imprecise estimates of risk or prognosis) dimensions of uncertainty.1

When clinicians encounter diagnostic uncertainty, they often find themselves in an unfamiliar situation, without a clear method to proceed confidently, comfortably, and safely. Being unable to explain to patients what causes their symptoms may be perceived as a failure for all involved. When clinicians and patients dwell in diagnostic uncertainty, it can trigger feelings of concern and anxiety, may lead patients to mistrust clinicians’ competence, and could contribute to clinician burnout (feeling exhausted, disconnected, and personally inadequate), especially for early-career clinicians.2,3

Excellent diagnosticians should understand how uncertainty manifests. They should acknowledge and embrace uncertainty, and openly discuss it with other clinicians and patients to normalize its ubiquitous and inevitable part in the diagnostic process.4 Such a reimagining, focused on the inevitable and beneficial aspects of diagnostic uncertainty, relies on identifying how uncertainty is understood, managed, and communicated.”

More on Understanding and Communicating Uncertainty in Achieving Diagnostic Excellence via JAMA.