Opioid agonist treatment, including methadone, is the safest and most effective method for treating opioid use disorders and reduces opioid overdose deaths. While access to methadone is highly regulated by federal law, a substantial portion of states impose stricter barriers.

Dr. Brown, a hospitalist, admits Mark, a patient transferred from a local jail for management of cellulitis. The patient, who was taken into custody two days prior to hospital admission, has a history of intravenous heroin use. Mark explains that he had been prescribed buprenorphine-naloxone maintenance therapy for opioid use disorder for several years prior to being arrested and had not used other opioids during that time. As a policy, the jail where Mark is detained does not prescribe (...) class='Hi'>opioid agonists, and his maintenance therapy was stopped upon his arrival there. Dr. Brown discovers that Mark is diaphoretic and appears distressed. Mark's symptoms suggest to Dr. Brown that, in addition to having cellulitis, Mark is actively withdrawing from opioids. Mark tells Dr. Brown that he has felt “horrible” since his buprenorphine-naloxone therapy was stopped and that he now has intense cravings for opioids. He asks Dr. Brown to help alleviate the withdrawal symptoms. Dr. Brown, who is accustomed to treating opioid withdrawal with opioid replacement therapy, wonders if she should initiate ORT for Mark while he is in the hospital. (shrink)

The spinal mechanisms of action of opioids under normal conditions are reasonably well understood. The spinal effects of opioids can be enhanced or reduced depending on pathology and activity in other segmental and nonsegmental pathways. This plasticity will be considered in relation to the control of different pain states using opioids. The complex and contradictory findings on the supraspinal actions of opioids are explicable in terms of heterogeneous descending pathways to different spinal targets using multiple transmitters and receptors – therefore (...) opioids can both increase and decrease activity in descending pathways. These pathways could exhibit considerable plasticity. There is increasing evidence that delta opioid receptor agonists have the potential to replace morphine as major analgesics with reduced side-effect profiles. The concept of preemptive analgesia, based on preventing the induction of some of the negative plastic influences on opioid controls and the detrimental effects of pain, is sound, but experimental verification in the clinical setting is difficult. For example, a delayed compensatory upregulation of inhibitory systems, particularly in inflammation, may counter persistent painful inputs. Combination therapy with opioids may be beneficial in many pain states where either negative influences are blocked or inhibitory controls are enhanced. Finally, developmental aspects of these systems are discussed in connection with the treatment of pain in young children, where inhibitory systems in the spinal cord are immature. (shrink)

Although activated spinal cord glia contribute importantly to neuropathic pain, how nerve injury activates glia remains controversial. It has recently been proposed, on the basis of genetic approaches, that toll-like receptor 4 may be a key receptor for initiating microglial activation following L5 spinal nerve injury. The present studies extend this idea pharmacologically by showing that TLR4 is key for maintaining neuropathic pain following sciatic nerve chronic constriction injury. Established neuropathic pain was reversed by intrathecally delivered TLR4 receptor antagonists derived (...) from lipopolysaccharide. Additionally, -naltrexone, -naloxone, and -naloxone, which we show here to be TLR4 antagonists in vitro on both stably transfected HEK293-TLR4 and microglial cell lines, suppressed neuropathic pain with complete reversal upon chronic infusion. Immunohistochemical analyses of spinal cords following chronic infusion revealed suppression of CCI-induced microglial activation by -naloxone and -naloxone, paralleling reversal of neuropathic pain. Together, these CCI data support the conclusion that neuron-to-glia signaling through TLR4 is important not only for initiating neuropathic pain, as suggested previously, but also for maintaining established neuropathic pain. Furthermore, these studies suggest that the novel TLR4 antagonists -naloxone and -naloxone can each fully reverse established neuropathic pain upon multi-day administration. This finding with -naloxone is of potential clinical relevance. This is because -naloxone is an antagonist that is inactive at the -opioid selective receptors on neurons that produce analgesia. Thus, these data suggest that -opioid antagonists such as -naloxone may be useful clinically to suppress glial activation, yet -opioid agonists suppress pain. (shrink)

Buprenorphine is a form of opioid agonist treatment that has been demonstrated to be an effective medication for opioid addiction. It is available in different formulations and marketed under various trade names, including commonly as a buprenorphine/naloxone combination. This paper provides an overview of existing literature on the supply of buprenorphine treatment, the ability of people to access treatment with buprenorphine, and the quality of treatment received. We argue that better data for each of these aspects of (...) treatment could inform policy to expand effective treatment with buprenorphine, and we suggest steps to obtain and act on such data. (shrink)

Injury to the central or peripheral nervous system is often associated with persistent pain. After ischemic injury to the spinal cord, rats develop severe mechanical allodynia-like symptoms, expressed as a pain-like response to innocuous stimuli. In its short-lasting phase the allodynia can be relieved with the [gamma]-aminobutyric acid (GABA)-B receptor agonist baclofen, which also reverses the hyperexcitability of dorsal horn interneurons to mechanical stimuli. Furthermore, there is a reduction in GABA immunoreactivity in the dorsal horn of allodynic rats. Clinical (...) neuropathic pain of peripheral and central origin often cannot be relieved by opiates at doses that do not cause side effects. The loss of sensitivity to opiates may be associated with the up-regulation of endogenous antiopioid substances, such as the neuropeptide cholecystokinin (CCK). CCK and its receptor (CCK-R) protein is normally not detectable in rat dorsal root ganglion cells. After peripheral nerve section, both CCK and CCK-R are up-regulated in the dorsal root ganglia. Furthermore, CI 988, an antagonist of the CCK-B receptor, chronically coadministered with morphine, reduces autotomy, a behavior that may be a sign of neuropathic pain following peripheral nerve section. Thus, opiate insensitivity may be due to the release of CCK from injured primary afferents. Similarly, in the chronic phase of the spinal ischemic model of central pain, the allodynia-like symptom is not relieved by systemic morphine, but is significantly reversed by the CCK-B antagonist. Consequently, up-regulation of CCK and CCK-R in the CNS may also underlie opiate drug insensitivity following CNS injury. Thus, dysfunction of central inhibition involving GABA and endogenous opioids may be a factor underlying the development of sensory abnormalities and/or pain following injury to neural tissue. (shrink)

There is converging evidence that high doses of hallucinogenic drugs can produce significant alterations of self-experience, described as the dissolution of the sense of self and the loss of boundaries between self and world. This article discusses the relevance of this phenomenon, known as “drug-induced ego dissolution (DIED)”, for cognitive neuroscience, psychology and philosophy of mind. Data from self-report questionnaires suggest that three neuropharmacological classes of drugs can induce ego dissolution: classical psychedelics, dissociative anesthetics and agonists of the kappa (...) class='Hi'>opioid receptor (KOR). While these substances act on different neurotransmitter receptors, they all produce strong subjective effects that can be compared to the symptoms of acute psychosis, including ego dissolution. It has been suggested that neuroimaging of DIED can indirectly shed light on the neural correlates of the self. While this line of inquiry is promising, its results must be interpreted with caution. First, neural correlates of ego dissolution might reveal the necessary neurophysiological conditions for the maintenance of the sense of self, but it is more doubtful that this method can reveal its minimally sufficient conditions. Second, it is necessary to define the relevant notion of self at play in the phenomenon of DIED. This article suggests that DIED consists in the disruption of subpersonal processes underlying the “minimal” or “embodied” self, i.e., the basic experience of being a self rooted in multimodal integration of self-related stimuli. This hypothesis is consistent with Bayesian models of phenomenal selfhood, according to which the subjective structure of conscious experience ultimately results from the optimization of predictions in perception and action. Finally, it is argued that DIED is also of particular interest for philosophy of mind. On the one hand, it challenges theories according to which consciousness always involves self-awareness. On the other hand, it suggests that ordinary conscious experience might involve a minimal kind of self-awareness rooted in multisensory processing, which is what appears to fade away during DIED. (shrink)

Agonism is a political theory that places contestation at the heart of politics. Agonistic theorists charge liberal theory with a depoliticization of pluralism through an excessive focus on consensus. This paper examines the agonistic critiques of liberalism from a normative perspective. I argue that by itself the argument from pluralism is not sufficient to support an agonistic account of politics, but points to further normative commitments. Analyzing the work of Mouffe, Honig, Connolly, and Owen, I identify two normative currents of (...) agonistic theory: emancipatory agonism, aimed at challenging violence and exclusion, and perfectionist agonism, aimed at the cultivation of nobility. From a normative perspective the former presents an internal challenge to liberalism, while the latter constitutes an external challenge to liberalism by providing a competing account of the ends of politics. Recognition of the distinction between emancipatory and perfectionist agonism is crucial in assessing the purchase of agonistic critiques of liberalism. Furthermore, this analysis draws us beyond the simple opposition between contestation and consensus. It is not simply a question of valuing genuine pluralism and therefore criticizing consensus; rather the question comes to be: what are the ends of politics? (shrink)

Opioid treatment agreements are written agreements between physicians and patients enumerating the risks associated with opioid medications along with the requirements that patients must meet to receive these medications on an ongoing basis. The choice to use such agreements goes beyond the standard informed consent process, and has a distinctive symbolic significance. Specifically, it suggests that physicians regard it as important to hold their patients accountable for adhering to various protocols regarding the use of their opioid medications. (...) After laying out a taxonomy of accountability relationships between physicians and patients, I argue that opioid treatment agreements are only justifiable for physicians to use in their provision of care if they improve public health outcomes, which has yet to be demonstrated. (shrink)

Artificial intelligence-based (AI) technologies such as machine learning (ML) systems are playing an increasingly relevant role in medicine and healthcare, bringing about novel ethical and epistemological issues that need to be timely addressed. Even though ethical questions connected to epistemic concerns have been at the center of the debate, it is going unnoticed how epistemic forms of injustice can be ML-induced, specifically in healthcare. I analyze the shortcomings of an ML system currently deployed in the USA to predict patients’ likelihood (...) of opioid addiction and misuse (PDMP algorithmic platforms). Drawing on this analysis, I aim to show that the wrong inflicted on epistemic agents involved in and affected by these systems’ decision-making processes can be captured through the lenses of Miranda Fricker’s account of hermeneutical injustice. I further argue that ML-induced hermeneutical injustice is particularly harmful due to what I define as an automated hermeneutical appropriation from the side of the ML system. The latter occurs if the ML system establishes meanings and shared hermeneutical resources without allowing for human oversight, impairing understanding and communication practices among stakeholders involved in medical decision-making. Furthermore and very much crucially, an automated hermeneutical appropriation can be recognized if physicians are strongly limited in their possibilities to safeguard patients from ML-induced hermeneutical injustice. Overall, my paper should expand the analysis of ethical issues raised by ML systems that are to be considered epistemic in nature, thus contributing to bridging the gap between these two dimensions in the ongoing debate. (shrink)

More than twenty-five years after the first signs of potential harm, the US remains locked in the grip of an opioid epidemic, with more Americans dying from overdoses than ever before.1 Diversion of prescription opioids plays an important role in opioid-related harms. Much of the scientific and public health focus on diversion has been on end-users, given how commonly non-medical prescription opioid use occurs, as well as the proportion of individuals who report that their source of non-medical (...) opioids was friends or family. However, diversion of opioids, as well as their rampant oversupply, can be discerned higher up the supply chain, including among wholesalers, pharmacies and rogue prescribers whose behavior may trigger well-described “flags” warranting further evaluation and action. (shrink)

The article examines the compatibility of agonistic democracy and populism as well as their relationship to the idea of constitutionalism. The first part shows that Chantal Mouffe’s recent attempts to reconcile her normative approach of an agonistic pluralism with a populist style of politics are not fully convincing. Although there are undeniable commonalities between an agonistic and a populist understanding of politics – the appreciation of conflict, the rejection of moralistic and juridical modes of conflict resolution etc. – the populist (...) mode of the construction of the people (and the denunciation of political opponents as enemies of the people) risks impeding the transformation of antagonistic into agonistic modes of political contest. The tensions between agonism and populism are especially evident in matters of constitutionalism. This topic is examined in the second part of the article, which provides some ideas for reducing the normative and institutional blind spots of contemporary theories of agonistic democracy. It focuses on elementary principles for an agonistic concept of democratic constitutionalism that differs from the populist view of the relationship between politics and law, especially in respect of its interpretation of the concept of ‘resistibility’ of legal norms. (shrink)

Agonistic Democracy explores how theoretical concepts from agonistic democracy can inform institutional design in order to mediate conflict in multicultural, pluralist societies. Drawing on the work of Foucault, Nietzsche, Schmitt, and Arendt, Marie Paxton outlines the importance of their themes of public contestation, contingency and necessary interdependency for contemporary agonistic thinkers. Paxton delineates three distinct approaches to agonistic democracy: David Owen's perfectionist agonism, Mouffe's adversarial agonism, and William Connolly and James Tully's inclusive agonism. Paxton demonstrates how each is fundamental to (...) enabling citizens to cultivate better virtues for themselves and society (Owen), motivating democratic engagement (Mouffe) and enhancing relations of respect and understanding between conflicting citizens (Connolly and Tully). Situated within the context of a deeply polarised post-Trump America and post-Brexit Britain, this book reveals the need to rethink our approach to conflict mediation through democratic institutions. Pulling together insights from experimental research with deliberative democratic innovations, Paxton explores how agonistic theory might be institutionalised further. Through discussing ways in which agonistic institutions might be developed to render democracy more virtuous, more engaging, and more inclusive, Agonistic Democracy provides a unique resource for students of contemporary political theory. (shrink)

Traditional approaches to conflict are oriented towards establishing (or re-establishing) consensus, either in the form of a resolution of the conflict or in the form of an ‘agree-to-disagree’ standstill between the stakeholders. In this paper, we criticize these traditional approaches, each for specific reasons, and we propose and develop the agonistic approach to conflict. Based on Chantal Mouffe’s agonistic democratic theory, the agonistic approach to conflict is more welcoming of dissensus, replacing discussion stoppers with discussion starters and replacing standstills with (...) contestation. We illustrate such replacements and develop this approach, we analyse technological conflicts in a concrete R&D setting: the global hydrogen economy. From this context, we focus on the conflict between the proponents of blue hydrogen (drawn from fossil fuels) and those of green hydrogen (created through electrolysis). We conclude by highlighting the advantage of the agonistic approach but also drawing attention to its own specific risk, namely, antagonism. (shrink)

Agonism emerged three decades ago as an assault on the overemphasis in political theory on justice and consensus. It has now become the norm. But its character and relation to core values of democracy are not as unproblematic today as is often thought, an issue that becomes more pressing as contemporary politics increasingly seem locked into notions of unrelenting conflict between “friends” and “enemies.” This essay traces alternative ontological roots and ethical implications of agonism, distinguishing between “imperializing” and “tempered” modes. (...) The former, exemplified in the popular Schmitt-Mouffe formulation, is shown to be fundamentally flawed in its failure to conceive politics in a fashion that does not allow the dynamic of friend–enemy to imperially trump appeals to democratic norms. In a world of insurgent white nationalism in democratic polities, this is no small fault. “Tempered” agonists, such as William Connolly and Bonnie Honig, offer ontologies where democratic norms can gain traction. Despite the admirable qualities of these alternatives, their formulations are nevertheless not fully persuasive. The difficulty lies in their underarticulated accounts of equality. I suggest an alternative formulation of agonism that embraces a central role for the idea of the moral equality of voice, a value that resides in the seam between notions of difference, resistance, and conflict emphasized by agonists, on the one hand, and the idea of fairness emphasized by notions of democratic justice, on the other. (shrink)

The goal of this article is to understand the value of data and to call for efforts to explore improved data sharing and collection among local, state, and federal agencies. It discusses the data available and existing barriers to sharing it. It also looks at examples of data sharing initiatives and analysis, such as mapping and visualization tools. The article then examines relevant regulations and calls for reforms. Finally, the article considers objections, including privacy interests, data security, and the costs (...) and benefits of data sharing initiatives. (shrink)

This paper provides a critique and re-evaluation of the way that ethics is understood and promoted within mainstream Human Resource Management (HRM) discourse. We argue that the ethics located within this discourse focuses on bolstering the relevance of HRM as a key contributor to organizational strategy, enhancing an organization's sense of moral legitimacy and augmenting organizational control over employee behaviour and subjectivity. We question this discourse in that it subordinates the ethics of the employment relationship to managerial prerogative. In response, (...) we suggest a different model of the relationship between ethics and HRM—one that finds the possibility of ethics in the contestation and destabilization of HRM. Such ethics arises through resistance to moral normalization and the constraint of freedom and difference. The contribution of our paper is in theorising the possibilities of a relationship between ethics and HRM that does not place HRM at its centre, as chief intermediary of the ethics of the employment relationship, but rather sees HRM as being a powerful player in a set of what Mouffe calls 'agonistic' socio-ethical relations. (shrink)

Flagging labor governance in far-flung supply networks has prompted greater scrutiny of instrumental CSR and calls for models that are tethered more closely to accountability, constraint, and oversight. Political CSR is an apt response, but this paper seeks to buttress its deliberative moorings by arguing that the agonist notion of ‘domesticated conflict’ provides a necessary foundation for substantive deliberation. Because deliberation is more viable and effective when coupled with some means of coercion, a concept of CSR solely premised on (...) reciprocal corporate-stakeholder engagement is pre-mature; efforts should first be directed toward the antecedents of reciprocity and how it is to be achieved, and only then does deliberation become a reliably substantive exercise. The resulting account of agonistic CSR is generated through agonistic principles of realism, pro-action, contestation, and countervailence, and illustrated by the Bangladesh Accord. (shrink)

We read with interest the extended essay published from Riisfeldt and are encouraged by an empirical ethics article which attempts to ground theory and its claims in the real world. However, such attempts also have real-world consequences. We are concerned to read the paper’s conclusion that clinical evidence weakens the distinction between euthanasia and normal palliative care prescribing. This is important. Globally, the most significant barrier to adequate symptom control in people with life-limiting illness is poor access to opioid (...) analgesia. Opiophobia makes clinicians reluctant to prescribe and their patients reluctant to take opioids that might provide significant improvements in quality of life. We argue that the evidence base for the safety of opioid prescribing is broader than that presented, restricting the search to palliative care literature produces significant bias as safety experience and literature for opioids and sedatives exists in many fields. This is not acknowledged in the synthesis presented. By considering additional evidence, we reject the need for agnosticism and reaffirm that palliative opioid prescribing is safe. Second, palliative sedation in a clinical context is a poorly defined concept covering multiple interventions and treatment intentions. We detail these and show that continuous deep palliative sedation is a specific practice that remains controversial globally and is not considered routine practice. Rejecting agnosticism towards opioids and excluding CDPS from the definition of routine care allows the rejection of Riisfeldt’s headline conclusion. On these grounds, we reaffirm the important distinction between palliative care prescribing and euthanasia in practice. (shrink)

Traditional approaches to conflict are oriented towards establishing consensus, either in the form of a resolution of the conflict or in the form of an ‘agree-to-disagree’ standstill between the stakeholders. In this paper, we criticize these traditional approaches, each for specific reasons, and we propose and develop the agonistic approach to conflict. Based on Chantal Mouffe’s agonistic democratic theory, the agonistic approach to conflict is more welcoming of dissensus, replacing discussion stoppers with discussion starters and replacing standstills with contestation. We (...) illustrate such replacements and develop this approach, we analyse technological conflicts in a concrete R&D setting: the global hydrogen economy. From this context, we focus on the conflict between the proponents of blue hydrogen and those of green hydrogen. We conclude by highlighting the advantage of the agonistic approach but also drawing attention to its own specific risk, namely, antagonism. (shrink)

This pioneering book delivers a systematic account of agonistic democracy, and a much-needed analysis of the core components of agonism: pluralism, tragedy, and the value of conflict. It also traces the history of these ideas, identifying the connections with republicanism and with Greek antiquity. Mark Wenman presents a critical appraisal of the leading contemporary proponents of agonism and, in a series of well-crafted and comprehensive discussions, brings these thinkers into debate with one another, as well as with the post-structuralist and (...) continental theorists who influence them. Wenman draws extensively on Hannah Arendt, and stresses the creative power of human action as augmentation and revolution. He also reworks Arendt's discussion of reflective judgement to present an alternative style of agonism, one where the democratic contest is linked to the emergence of a militant form of cosmopolitanism, and to prospects for historical change in the context of neoliberal globalisation. (shrink)

Context Opioid treatment agreements (OTAs) are documents that clinicians present to patients when prescribing opioids that describe the risks of opioids and specify requirements that patients must meet to receive their medication. Notwithstanding a lack of evidence that OTAs effectively mitigate opioids’ risks, professional organizations recommend that they be implemented, and jurisdictions increasingly require them. We sought to identify the jurisdictions that require OTAs, how OTAs might affect the outcomes of lawsuits that arise when things go wrong, and instances (...) in which the law permits flexibility for clinicians and health care institutions to adopt best practices. -/- Methods We surveyed the laws and regulations of all 50 states and the District of Columbia to identify which jurisdictions require the use of OTAs, the circumstances in which OTA use is mandatory, and the terms OTAs must include (if any). We also surveyed criminal and civil judicial decisions in which OTAs were discussed as evidence on which a court relied to make its decision to determine how OTA use influences litigation outcomes. -/- Findings Results show that a slight majority (27) of jurisdictions now require OTAs. With one exception, the jurisdictions’ requirements for OTA use are triggered at least in part by long-term prescribing. There is otherwise substantial variation and flexibility within OTA requirements. Results also show that even in jurisdictions where OTA use is not required by statute or regulation, OTA use can inform courts’ reasoning in lawsuits involving patients or clinicians. Sometimes, but not always, OTA use legally protects clinicians from liability. -/- Conclusions -/- Our results show that OTA use is entwined with legal obligations in various ways. Clinicians and health care institutions should identify ways for OTAs to enhance clinician–patient relationships and patient care within the bounds of relevant legal requirements and risks. (shrink)

This book explores the implications of agonistic democratic theory for political practice. Fuat Gürsözlü argues that at a time when political parties exacerbate political division, political protesters are characterized as looters and terrorists, and extreme partisanship and authoritarian tendencies are on the rise, the agonistic approach offers a much-needed rethinking of political practice to critically understand challenges to democracy and envision more democratic, inclusive, and peaceful alternatives. Inspired by Chantal Mouffe’s agonistic theory and drawing on insights of other prominent agonistic (...) scholars, Gürsözlü offers a distinctive approach that develops the connections between the agonistic approach and political practice. His main claim is that approaching democratic politics from an agonistic perspective changes the way we understand the nature of democratic society, the place of political protest in democracy, the nature of adversarial engagement, and the democratic function of political parties. The book also advances an account of agonistic peace that is best fitted to the pluralistic and inherently conflictual nature of democratic societies. This book should be of interest to anyone working in the field of contemporary political theory, political philosophy, peace studies, and philosophy of peace. (shrink)

This article examines how federal law enforcement has responded to the opioid epidemic nationally and in a variety of locales. We focus in depth on two initiatives, including prosecution in opioid-death cases, undertaken by the U.S. Attorney's Office in Connecticut.

Meeting humans is an everyday experience for most companion dogs, and their behavior in these situations and its genetic background is of major interest. Previous research in our laboratory reported that in German shepherd dogs the lack of G allele, and in Border collies the lack of A allele, of the oxytocin receptor gene (OXTR) 19208A/G single nucleotide polymorphism (SNP) was linked to increased friendliness, which suggests that although broad traits are affected by genetic variability, the specific links between alleles (...) and behavioural variables might be breed-specific. In the current study, we found that Siberian huskies with the A allele approached a friendly unfamiliar woman less frequently in a greeting test, which indicates that certain polymorphisms are related to human directed behaviour, but that the relationship patterns between polymorphisms and behavioural phenotypes differ between populations. This finding was further supported by our next investigation. According to primate studies, endogenous opioid peptide (e.g. endorphins) receptor genes have also been implicated in social relationships. Therefore, we examined the rs21912990 of the OPRM1 gene. Firstly, we found that the allele frequencies of Siberian huskies and gray wolves were similar, but differed from that of Border collies and German shepherd dogs, which might reflect their genetic relationship. Secondly, we detected significant associations between the OPRM1 SNP and greeting behaviour among German shepherd dogs and a trend in Border collies, but we could not detect an association in Siberian huskies. Although our results with OXTR and OPRM1 gene variants should be regarded as preliminary due to the relatively low sample size, they suggest that (1) OXTR and OPRM1 gene variants in dogs affect human-directed social behaviour and (2) their effects differ between breeds. (shrink)

The use of opioid contracts, which often require patients to submit to random drug screens, have become widespread amongst physicians using opioids to treat chronic pain. The main purpose of the contract is to improve care through better adherence to opioid therapy but there is little evidence as to its efficacy. The author suggests the use of opioid contracts and random drug testing destroys patients' trust which impacts health outcomes, and that physicians' motivation for their use are (...) concerns about prosecution, medication abuse and misuse, and addiction. Statistics are provided to counter fears, and evidence is offered suggesting opioid contracts are unenforceable and lack efficacy; random drug testing is often inconclusive, and a patient's trust improves adherence to treatment. (shrink)

Philosophos Agonistes: Imagery and Moral Psychology in Plato's Republic RICHARD PATTERSON THE COMPETITIVE IMPULSE in its simplest, first and best expression -- be best and first in everything, as Peleus advised Achilles -- seems foreign to the spirit of philosophy for a number of reasons. The most important of these finds metaphorical expression in a "Pythagorean" gnome of uncertain provenance: "Life, said [Pythagoras], is like a festival; just as some come to the festival to compete, some to ply their trade, (...) but the best people come as spectators, so in life the slavish go hunting for fame or gain, the philosophers for the truth" . Plato's celebrated tripartite soul of the Republic provides a psychological underpinning for these observations about the festival crowd, and in particu- lar the distinction between the agonistes -- the competitor hunting victory and fame -- and the philosophical seeker after truth. Bk. IV distinguishes a reason- ing, a spirited, and an appetitive part or aspect of the soul, each having its own proper function and the three together providing a basis for Socrates' discus- sion of the virtues of wisdom, courage, sophrosyne, and justice. Bk. IX is explicit about all three parts having their own particular and natural pleasures and desires: the two lower parts, "spirit" and "appetite," appear respectively as lovers of victory and glory, on the one hand, and money, food, drink, and sex, on the other;.. (shrink)

Brain opioids regulate social emotions in several distinct ways. The abundance of neuroscientific detail in the target article helps familiarize the uninitiated with the true and humbling complexities of mammalian brains, but little of it translates to research strategies, with robust predictions, at the human level. Only global neurochemical affective state variables derived from animal research have clear implications for human research.

The relevance of double effect for end-of-life decision-making has been challenged recently by a number of scholars. The principal reason is that opioids such as morphine do not usually hasten death when administered to relieve pain at the end of life; therefore, no secondary “double” effect is brought about. In my article, I argue against this view, showing how the doctrine of double effect is relevant to the administration of opioids at the end of life. I contend that the prevailing (...) view suffers from a misunderstanding of the nature of double effect, which includes application to risking a grave harm. (shrink)

Post-foundational politics and democracy -- Agonism and democracy -- A typology of agonistic democracy -- Agonistic democracy and the question of institutions -- Agonistic democracy and the limits of popular participation -- Populism, representation, and the popular will -- Political liberalism, contingency and agonistic pluralism -- Liberalism, agonism, and democracy.

SUSANNE UUSITALO,ANNA AXELIN | : Infants born to opioid-dependent women are typically admitted to neonatal intensive-care units for management of neonatal abstinence syndrome, and their treatment requires medical decision making. It is not only the infants’ vulnerability, in terms of their incompetence and medical condition, that is present in those circumstances, but also the mothers’ situational vulnerability, which arises with the possibility of their engagement in medical decision making regarding their infants. Vulnerability is a concept that has often, if (...) not always, been traced back to individuals. In this paper, we suggest that in some cases evaluations and attributions of vulnerability to either individuals or populations fall short of capturing all aspects of vulnerability. We ask whether this individual-based evaluation is sufficient for identifying all the vulnerabilities arising in the situation. Moreover, we suggest that the “unit” of vulnerability attribution, typically a person who is a likely target of harm and/or moral violations, should not simply be reduced to the individual. Rather, the unit should in some cases be seen as constituted by an entity that is interpersonal in nature. The kind of real vulnerability that we identify in this paper is inherently embedded in a dyadic relationship, and notions of vulnerability that decompose social relations into individuals run the risk of missing the vulnerability in question. We elaborate this kind vulnerability by discussing of role of opioid-dependent mothers in decision making about their infants’ treatment. | : Les nourrissons nés de femmes dépendantes aux opioïdes sont généralement admis dans des unités de soins intensifs néonatals pour la prise en charge du syndrome d’abstinence néonatale, et leur traitement nécessite une prise de décision médicale. Ce n’est pas seulement la vulnérabilité des nourrissons, en termes d’incompétence et de dépendance médicale, qui est présente dans ces circonstances, mais aussi la vulnérabilité situationnelle des mères, qui découle de la possibilité de leur participation à la prise de décision médicale concernant leurs enfants. La vulnérabilité est un concept qui a souvent, sinon toujours été relié à des individus. Dans cet article, nous suggérons que, dans certains cas, les évaluations et les attributions de vulnérabilité aux individus ou aux populations ne permettent pas de saisir tous les aspects de la vulnérabilité. Nous demandons si cette évaluation individuelle est suffisante pour identifier toutes les vulnérabilités qui apparaissent dans la situation. De plus, nous suggérons que l’« unité » d’attribution de la vulnérabilité, généralement une personne qui est une cible probable de dommages ou de violations morales, ne devrait pas simplement être réduite à l’individu. Au contraire, l’unité devrait dans certains cas être considérée comme une entité de nature interpersonnelle. Le type de vulnérabilité réelle que nous identifions dans cet article est intrinsèquement intégré dans une relation dyadique, et les notions de vulnérabilité qui décomposent les relations sociales en individus risquent de manquer la vulnérabilité en question. Nous développons ce type de vulnérabilité en discutant du rôle des mères dépendantes aux opioïdes dans la prise de décision concernant le traitement de leurs enfants. (shrink)

ABSTRACT:Many companies engage in dialogue with nongovernmental organizations about societal issues. The question is what a regulative ideal for such dialogues should be. In the literature on corporate social responsibility, the Habermasian notion of communicative action is often presented as a regulative ideal for stakeholder dialogue, implying that actors should aim at consensus and set strategic considerations aside. In this article, we argue that in many cases, communicative action is not a suitable regulative ideal for dialogue between companies and NGOs. (...) We contend that there is often an adversarial element in the relation between companies and NGOs, and that an orientation towards consensus can be in tension with this adversarial relation. We develop an alternative approach to stakeholder dialogue called ‘agonistic deliberation.’ In this approach, conflict and strategic considerations play a legitimate and, up to a certain point, desirable role. (shrink)

ABSTRACT:This paper argues that, although stakeholder engagement occurs within the context of power, neither market-centered CSR nor the deliberative model of political CSR adequately addresses the specter of power asymmetries and the inevitability of conflict in stakeholder relations, particularly for powerless stakeholders. Noting that the objective of stakeholder engagement should not be benevolence toward stakeholders, but mechanisms that address power asymmetries such that stakeholders are able to protect their own interests, I present a framework of stakeholder engagement based on agonistic (...) pluralism that seeks to structure and utilize discord rather than reduce or eliminate it. I then propose arbitration as an agonistic mechanism to address power asymmetries in stakeholder engagement and explore its implications. (shrink)

It is common for physicians who prescribe opioids for chronic pain to have their patients sign an opioid contract in order to receive opioid therapy. A vast majority of these contracts contain a stipulation requiring patients to submit to random drug testing which screens for both licit and illicit drugs. Physicians who prescribe opioids may be concerned about prosecution and disciplinary actions; medication abuse and misuse; and addiction. Steven Passik et al. write, “…physicians still fear the risk of (...) abuse or addiction as well as the potential legal consequences of their prescribing.”Issues surrounding OC/RDT need a closer look with a focus on enforceability and efficacy of the opioid contract; accuracy and complications of drug screens and their interpretation; and the importance of trust between patient and physician. In addition, it is vital to dispel fears with facts regarding prosecutions, nonmedical use of prescription opioids, and addiction. (shrink)

The national opioid epidemic is severely impacting Indian Country. In this article, we draw upon data from the Centers for Disease Control and Prevention to describe the contours of this crisis among Native Americans. While these data are subject to significant limitations, we show that Native American opioid overdose mortality rates have grown substantially over the last seventeen years. We further find that this increase appears to at least parallel increases seen among non-Hispanic whites, who are often thought (...) to be uniquely affected by this crisis. We then profile tribal medical and legal responses to the opioid epidemic, ranging from tribally-operated medication-assisted therapy to drug diversion courts rooted in traditional tribal cultures. (shrink)

This article considers how reconciliation might be understood as a democratic undertaking. It does so by examining the implications of the debate between theorists of ‘deliberative’ and ‘agonistic’ democracy for the practice of democracy in divided societies. I argue that, in taking consensus as a regulative idea, deliberative democracy tends to conflate moral and political community thereby representing conflict as already communal. In contrast, an agonistic theory of democracy provides a critical perspective from which to discern what is at stake (...) in the politics of reconciliation since it understands community as a contingent achievement of political action. As such, an agonistic account of democracy suggests the possibility of retrieving the concept of reconciliation from a statesanctioned project of nation-building for a democratic politics centred on the possibilities of self-determination and solidarity among citizens divided by a history of state violence. Key Words: agonism • deliberation • democracy • reconciliation • transitional justice. (shrink)

Throughout his writings Nietzsche suggests that battles waged with and for the benefit of readers and pupils are to take a form analogous to a Greek agon, a contest. The early Nietzsche anticipates a transfiguration of culture that will be brought about by means of agonistic institutions through which greatness will be cultivated in competition. Nietzsche identifies this mode of activity as healthy human striving, as an affirmative way of claiming human meaning, and as a creative process of individual and (...) cultural development that he identifies as Bildung. The free spirit books that Nietzsche writes following The Birth of Tragedy critique the contemporary culture for its paucity of outlets for this kind of activity. ;Nietzsche believed that education, like philosophy, occurs in observing and participating in moments of extraordinary challenge and tension. For him, significant opposition yields strengthened character because it demands active resistance to what one is not and requires the definition of personal style. Encounters with great educators communicate not simply a set of doctrines and theories, they stimulate the activity of self-creation and discovery, of becoming who or, more properly for Nietzsche, what one is. Nietzsche's works reflect a continuous concern with identifying the form of this kind of education. As a philosopher-educator, Nietzsche both exemplifies his own growth through his spiritual and intellectual agones and strives to be a worthy opponent and teacher for his readers. It is this Nietzsche, the philosophos agonistes, the exemplar and educator, that this dissertation describes. (shrink)

While much of the social and political attention surrounding the nationwide opioid epidemic has focused on the dramatic increase in overdose deaths among white, middle-class, suburban and rural users, the impact of the epidemic in Black communities has largely been unrecognized. Though rates of opioid use at the national scale are higher for whites than they are for Blacks, rates of increase in opioid deaths have been rising more steeply among Blacks than whites over the last five (...) years. Moreover, the rate of opioid overdose deaths among Blacks already exceeds that of whites in several states. The lack of discussion of Black overdose deaths in the national opioid discourse further marginalizes Black people, and is highly consistent with a history of framing the addictions of people of color as deserving of criminal punishment, rather than worthy of medical treatment. This article argues that, because racial inequalities are embedded in American popular and political cultures as well as in medicine, the federal and state governments should develop more culturally targeted programs to benefit Black communities in the opioid crisis. Such programs include the use of faith-based organizations to deliver substance use prevention and treatment services, the inclusion of racial impact assessments in the implementation of drug policy proposals, and the formal consideration of Black people's interaction with the criminal justice system in designing treatment options. (shrink)

Political conflict in our society is inevitable, and the results are often far from negative. How then should we deal with the intractable differences arising from complex modern culture? Developing her groundbreaking political philosophy of agnostics--the search for a radical and plural democracy--Chantal Mouffe examines international relations, strategies for radical politics, the future of Europe and the politics of artistic practices. She shows that in many circumstances where no alternatives seem possible, agonistics offers a new road map for change. Engaging (...) with cosmopolitanism, post-operaism, and theories of multiple modernities she argues in favor of a multipolar world with a real cultural and political pluralism. -- Publisher's website. (shrink)

BACKGROUND Patients with chronic pain face significant barriers in finding clinicians to manage long-term opioid therapy (LTOT). For patients on LTOT, it is increasingly common to have them sign opioid treatment agreements (OTAs). OTAs enumerate the risks of opioids, as informed consent documents would, but also the requirements that patients must meet to receive LTOT. While there has been an ongoing scholarly discussion about the practical and ethical implications of OTA use in the abstract, little is known about (...) how clinicians use them and if OTAs themselves modify clinician prescribing practices. OBJECTIVE To determine how clinicians use OTAs and the potential impacts of OTAs on opioid prescribing. DESIGN We conducted qualitative analysis of four focus groups of clinicians from a large Midwestern academic medical center. Groups were organized according to self-identified prescribing patterns: two groups for clinicians who identified as prescribers of LTOT, and two who did not. PARTICIPANTS 17 clinicians from General Internal Medicine, Family Medicine, and Palliative Care were recruited using purposive, convenience sampling. APPROACH Discussions were recorded, transcribed, and analyzed for themes using reflexive thematic analysis by a multidisciplinary team. KEY RESULTS Our analysis identified three main themes: (1) OTAs did not influence clinicians’ decisions whether to use LTOT generally but did shape clinical decision-making for individual patients; (2) clinicians feel OTAs intensify the power they have over patients, though this was not uniformly judged as harmful; (3) there is a potential misalignment between the intended purposes of OTAs and their implementation. CONCLUSION This study reveals a complicated relationship between OTAs and access to pain management. While OTAs seem not to impact the clinicians’ decisions about whether to use LTOT generally, they do sometimes influence prescribing decisions for individual patients. Clinicians shared complex views about OTAs’ purposes, which shows the need for more clarity about how OTAs could be used to promote shared decision-making, joint accountability, informed consent, and patient education. (shrink)

In the literature there are two well-established but opposite readings of Arendt: as an agonistic theorist and as a deliberative one. In between these two positions a smaller number of scholars have argued that in Arendt these two dimensions can to a large extent be reconciled. This paper follows this third path but tries to bring it one step further. In particular, it defends the idea that those scholars who have proposed this third reading of Arendt have fallen short of (...) revealing the degree to which deliberation and agonism are, for her, interwoven. Through an original reading of Arendt’s views on judgment, persuasion, distinction and Eichmann’s banality, the paper clarifies why, for her, agonism and deliberation are not only compatible but actually mutually dependent. In other words, it clarifies why she believes that there can be no deliberation without agonism and no agonism without deliberation. (shrink)

Patients living with chronic pain require appropriate access to opioid therapy along with improved access to pain care and additional therapeutic options. It's both medically reasonable and ethical to consider opioid therapy as a treatment option in the management of chronic, non-cancer pain for a subset of patients with severe pain that is unresponsive to other therapies, negatively impacts function or quality of life, and will likely outweigh the potential harms. This paper will examine opioid therapy in (...) the setting of the opioid epidemic, why critics feel that the CDC guideline has resulted in harsh consequences for patients and their physicians, and the rationale for opioid therapy as a means of providing ethical and compassionate pain care. (shrink)

Pain management has improved in the past few decades. Opioid analgesics have become the mainstay in the treatment of cancer pain whilst inter-disciplinary pain management programmes are the generally accepted approach to chronic pain of non-malignant origin. Recently some pain specialists have advocated the use of opioids in the long-term management of non-cancer pain. This has raised some fundamental questions about the purpose of pain management. Is it best to opt for maximum pain relief and comfort, or should one (...) emphasise function and activity as higher priorities? Will the use of opioids create more autonomy for pain sufferers or will this add handicaps to lives which are already limited? Until more clinical outcome data are available we advocate caution in the use of opioid analgesia. Such caution can, and does, raise questions about the rights of the patient and the rights of the prescriber in a context where the facts do not point to a clear course of action. (shrink)

This paper assesses the claim that an agonistic model of democracy could foster greater accommodation of citizens' social, cultural and ethical differences than mainstream liberal theories. I address arguments in favor of agonistic conceptions of politics by a diverse group of democratic theorists, ranging from republican theorists - Hannah Arendt and Benjamin Barber - to postmodern democrats concerned with questions of identity and difference, such as William Connolly and Bonnie Honig. Neither Arendt's democratic agonism nor Barber's republican-inflected account of strong (...) democracy purports to include citizens' group-based cultural identities, and so cannot further the claim that agonistic politics is more inclusive of cultural and social differences. Postmodern agonistic democrats such as Connolly and Honig rely upon Arendt's account of the relationship between agonism and pluralism, and wrongly assume that her view of politics is compatible with formal respect and recognition for citizens' cultural group identities. While agonistic democracy helpfully directs us to attend to the importance of moral and political disagreement, I argue that the stronger claim that an agonistic model of democracy could more readily include culturally diverse citizens is simply unfounded. By contrast, recent liberal variants of agonistic democracy that conceive of legal and political institutions as tools for recognizing and mediating citizens' moral and cultural differences may suggest ways to deepen our democratic practices in plural societies. Key Words: agonism • agonistic democracy • Hannah Arendt • citizenship • cultural minorities • pluralism • republican theory. (shrink)

Identifying the role of opioids in the mediation of learned sexual behaviors has been complicated by the use of differing methodologies in the investigations. In this review addressing multiple species, techniques, and pharmaceutical manipulations, several features of opioid mediation become apparent. Opioids are differentially involved in conditioned and unconditioned sexual behaviors. The timing of the delivery of a sexual reinforcer during conditioning trials, especially those using male subjects, acutely influences the role that opioids have in learning. Opioids may be (...) particularly important in the maintenance of conditioned sexual behaviors during periods of non-reinforcement. This appears to be true both for probe trials and procedures designed explicitly to extinguish a sexual conditioned response. These features of opioid mediation of learning do not appear to be restricted to sexual conditioning paradigms. This suggests that, as for other aspects of sexual learning that despite distinctive features conform to underlying behavioral principles, the mediation of conditioned sexual behavior by opioids relies on processes common across reinforcement systems. Keywords: opiate; conditioning; extinction; persistence; naloxone; learning (Published: 15 March 2012) Citation: Socioaffective Neuroscience & Psychology 2012, 2 : 14874 - DOI: 10.3402/snp.v2i0.14874. (shrink)

In this issue of the Hastings Center Report, Joshua Rager and Peter Schwartz reframe the justification for the use of opioid treatment agreements. Instead of documents used to define the roles and responsibilities of doctors and patients to one another in the course of opioid treatment for chronic pain and to describe the risks and benefits of therapy for the individual, OTAs are now proposed for use as “surveillance and monitoring” instruments. As such, they are specifically meant to (...) disclose the risks of opioid therapy and to describe the other processes and tools used to monitor abuse and diversion of medications. Given the crisis of the opioid overdose and death epidemic, along with this repurposing of OTAs as disclosure documents primarily, Rager and Schwartz argue that patient consent is not needed and that OTAs should be universally applied in clinical practices. We can all agree on the big picture goal of limiting the number of opioid prescriptions in order to minimize the tragedy of opioid overdose deaths. We disagree, though, about the acceptable level of collateral damage to people in pain who fall victim to fighting the war against the so-called opioid epidemic. (shrink)

Agonistic recognition in education has three interlinked modes of aesthetic experience and self-presentation where one is related to actions in the public realm; one is related to plurality in the way in which it comes into existence in confrontation with others; and one is related to the subject-self, disclosed by ‘thinking. Arendt’s conception of ‘thinking’ is a way of getting to grips with aesthetic self-presentation in education. By action, i.e., by disclosing oneself and by taking initiatives, students and teachers constitute (...) their being. The way Arendt theorizes action (vita activa) makes it essentially unpredictable and destabilizing, which does not seem to fit into what should be expected from education. In the article I will argue that it should have a place by virtue of the debate, challenge and contest it offers. But education should also be defined from a specific kind of contemplation called ‘thinking’ to become the cultivation of a faculty of judgment in education—thinking (vita contemplativa) as a common virtue in education. Arendt’s demarcation between truth and meaning does from the point of view of agonistic recognition in education call for ‘thinking’ as a qualification of political and moral meaning–the ‘taste’ to be established in the individual, by individual judgements but always judged in relation to members of a community. (shrink)