Individual Harm Research Articles

The Pattern of Opioid Management by Australian General Practice Trainees.

With escalating opioid prescribing come individual and public health harms. To inform quality improvement measures, understanding of opioid prescribing is essential. We aimed to establish consultation-level prevalence and associations of opioid prescribing. A cross-sectional secondary analysis from a longitudinal multisite cohort study of general practitioner (GP) vocational trainees: "Registrar Clinical Encounters in Training." Four of Australia's seventeen GP Regional Training Providers, during 2010-13. GP trainees. Practice and trainee demographic data were collected as well as patient, clinical and educational data of 60 consecutive consultations of each trainee, each training term. Outcome factors were any opioid analgesic prescription and initial opioid analgesic prescription for a specific problem for the first time. Overall, 645 trainees participated. Opioids comprised 4.3% prescriptions provided for 3.8% of patients. Most frequently prescribed were codeine (39.9%) and oxycodone (33.4%). Prescribing was for acute pain (29.3%), palliative care (2.6%) or other indications (68.1%). Most prescribing involved repeat prescriptions for pre-existing problems (62.7% of total). Other associations included older patients; prescriber and patient male gender; Aboriginal/Torres Strait Islander status; rural and disadvantaged locations; longer consultations; and generation of referrals, follow-up, and imaging requests. Opioid initiation was more likely for new patients with new problems, but otherwise associations were similar. Trainees rarely reported addiction risk-mitigation strategies. Most opioids were prescribed as maintenance therapy for non-cancer pain. Demographic associations with opioid analgesic prescribing resemble those presenting for opioid dependency treatment. Our findings should inform measures by regulators and medical educators supporting multimodal pain management.

Reconsidering Fictitious Pricing

Advertised price discounting recently proliferated in retail markets, bringing with it deceptive discounting or "fictitious pricing." Many retailers advertise discounts based on fictitious or false prior-reference prices. In the immediate postwar era, the Federal Trade Commission regularly prosecuted fictitious-pricing cases. In 1969, the FTC ceased prosecution. In this Article, I explain why the FTC should resume measured enforcement today.Since the cessation of enforcement, the retail sector experienced several transformations. Over the past several decades, the behavioral economics explaining the power of prior-reference pricing emerged. According to the consensus, advertised discounts induce consumers to stop shopping sooner than otherwise, because consumers will absorb a signal that they have found the right bargain. However, the prevalence of fictitious advertised discounts decreases the chance that consumers will end their shopping on the most competitive offers. This Article addresses the nature of the welfare harm that results from fictitious pricing, noting the difficulty of shaping a remedy for individual harm from the practice. Private litigation and state prosecutions reveal that civil penalties and injunctive relief provide more appropriate avenues for addressing this practice. The challenge for federal and state regulators will be to find the level of regulation that maximizes welfare. I suggest that regulators renew enforcement efforts, and recommend where they might start.

Capsule commentary on Powell et al., Rates and correlates of potentially inappropriate colorectal cancer screening in the Veterans Health Administration.

An inescapable fact of all cancer screening is that (of those undergoing screening) vastly more people will be harmed than helped. The key question then becomes: What are the qualities of the harms? For colon cancer screening, the United States Preventive Services Task Force (USPSTF) has determined that on a population basis, the quantity and quality of benefits for the 3 % outweigh the harms for the 97 % of asymptomatic adults aged 50–75 years (A Grade recommendation).1On an individual basis, a colleague nearly died after suffering a pulmonary embolus during treatment of a perforation caused during a negative screening colonoscopy. This case illustrates that individual harm can be devastating. The USPSTF recommends against routine screening between ages 75 and 85 years, stating that there may be considerations supporting it in individual patients (C Grade) and against screening those 85+ years.1 The article by Powell et al.2 does not deal with informed decision-making (which should be but is not an integral component of clinical preventive service recommendations and quality metrics3). Rather, Powell et al.2 ask an equally important related question: How often do clinicians offer colon cancer screening when the net population benefit approaches zero? Among 1 million Veteran Administration Hospital patients > 50 years who had one or more colon cancer screening procedures, over a quarter of fecal occult blood test (FOBT) tests and 14 % of colonoscopies were potentially inappropriate. Appropriate colonoscopies were more likely to be conducted at facilities where primary care providers were assigned responsibility for completing the CRC clinical reminder. These estimates—one may quibble that they are too low or too high, or generalizable to other settings—should remind all clinicians of the responsibility to optimize the benefit and minimize the harms of all clinical services we recommend to asymptomatic people. Perhaps it is also time to favor individualized clinical judgment over monolithic population screening algorithms that ignore individual clinician and patient values.3 At the very least, shared decision-making with patients who are fully informed of both the risks and benefits is needed. A better method of selecting patients at higher risk of disease would also help target those most likely to benefit from screening.

Deconstruction of TR/RT: does TR/RT contribute to the negative construction of disability? Part I

The purpose of this paper is to deconstruct the medical model approach to therapeutic recreation/recreation therapy (TR/RT) in the USA using a disability studies approach. The paper begins by identifying the trend in TR/RT towards defining itself more narrowly, more closely with the medical model, likely a result of increasing pressure from managed care in the USA. Next, the medical model is exposed as a contradiction to the expressed ethics of the professional TR/RT organization in the USA, especially the principle of “Do no harm.” Harm is then revealed at two levels: harm to the individual disabled person and harm through obstruction of progress the profession might have made, sans the medical model. The paper concludes by suggesting that a different approach to recreation with disabled persons in a global community is required; one more in touch with respecting differences and including the disabled population.

Deterring the spread of misinformation on social network sites: A social cognitive theory‐guided intervention

ABSTRACTAs more individuals turn to social network sites (SNSs) for information, the spread of misinformation in these sites is becoming a greater concern. Not only can misinformation cause individual users anxiety and harm, but it can also prevent SNSs from realizing their full potential as trustworthy sources of information. This study proposed and tested an intervention‐based strategy that was designed to discourage behavior that promotes the spread of misinformation. Guided by the social cognitive theory (SCT), the intervention sought to modify users' outcome expectations by presenting them with a message that highlighted the negative consequences of misinformation. To investigate the effectiveness of this intervention message, a classical experiment was conducted on‐line with 131 college‐student participants. In the study's experimental group, the ANOVA results showed that the intervention effectively reduced the total number of “Likes” and “Shares” for postings that provided misinformation. Future development and testing of this SCT‐guided, outcome‐expectations‐based intervention is promising.

Amicus Brief of 46 Social Science Researchers and Professor in Support of Petitioners-Appellees/Cross-Appellants and Urging Affirmance, <em>Robbins v. Rodriguez</em>, Nos. 13-56706 & 13-56755 (9th Cir. Sept. 29, 2014).

Amici curiae are 46 scholars and researchers in the fields of sociology, criminology, anthropology, psychology, geography, public health, medicine, Latin American studies, and law, whose work relates to incarceration and detention, migrant populations, and the effect of U.S. immigration detention and removal policies on migrant populations. A full list of amici curiae — who join this brief as individuals, not as representatives of any institutions with which they are affiliated — is set forth in the Appendix to this brief. At issue in this appeal is whether the District Court properly granted the class Petitioners-Appellees’ motion for summary judgment and ordered, inter alia, rigorous bond hearings for all class member immigrant detainees who have been detained by the government for longer than six months pursuant to one of the general immigration detention statutes (i.e., 8 U.S.C. §§ 1226(a), 1226(c), 1225(b), and 1231). The objective of the amici curiae in this brief is to provide the Court with an empirically grounded understanding of the individual, familial, and societal harms of detention for prolonged periods of time.

BY ITS FRUITS? MYSTICAL AND VISIONARY STATES OF CONSCIOUSNESS OCCASIONED BY ENTHEOGENS

AbstractA new era has emerged in research on entheogens largely due to clinical trials conducted at Johns Hopkins University and similar studies sponsored by the Council for Spiritual Practices. In these notes and queries, I reflect on implications of these developments for psychological studies of religion and on what this research may mean for Christian churches in the United States. I conclude that the aims and methods of this research fit well within Jamesian efforts of contemporary psychology of religion to assess religious practices by their fruits for life. Furthermore, some communitarian religious concerns that religious experiences occasioned by entheogens pose risks to the integrity of religious community are shown to be largely unfounded. However, it is suggested that certain risks for religious life posed by all investigations/interventions by knowledge experts—in particular, the colonization of the religious life world and the commodification of its practices—also attend these developments for Christian churches. Additionally, risks of individual harm in the use of entheogens appear to be significant and, therefore, warrant earnest ethical study.

The HCR-20 Version 3: A Case Study in Risk Formulation

The third edition of the HCR-20 (HCR-20V3, Douglas, Hart, Webster, et al., 2013) consolidates essential recent thinking about risk assessment and management using the structured professional judgement approach. As with the preceding Risk for Sexual Violence Protocol (Hart, Kropp, Laws et al., 2003), risk factors for violence are now assessed for their relevance as well as presence, scenario planning has a central place in anticipating the nature, severity, imminence and likelihood of future harm, and risk management strategies must incorporate a combination of treatment, supervision, monitoring and victim safety planning interventions and recommendations. However, the key process now proposed for linking the assessment and overall management of risk is risk formulation—the act of understanding the underlying mechanism of an individual's harm potential in order to develop sensitive and proportionate hypotheses to facilitate change (embodied within the risk management plan). In this paper, the process of risk formulation is described and illustrated with a case study—Paul. A brief report of the risk assessment, formulation and management recommendations for Paul illustrate the key features of what is recommended in the new version of this internationally renowned violence risk guide. However, empirical research into risk formulation remains outstanding.

Non-Human Animal Abuse and Wildlife Trade: Harm in the Fur and Falcon Trades

AbstractUntil recently, the field of criminology has largely ignored the suffering and abuse of non-human animals in the variety of forms in which it occurs. In order to address one aspect of this suffering, this article explores the non-human animal abuse inherent in the trade of wildlife. To demonstrate both the individual harm to non-human animals and the institutionalized abuse in this market, the fur and falcon trades will be detailed. First, since non-human animal abuse and harm have been largely invisible to the criminological community, this article sets out one justification for the adoption of a harm-based discourse. The result is examination of the these two forms of wildlife trade from an animal rights and species justice perspective of harm that is now one of the three broad conceptions of justice in the rapidly growing field of green criminology.

American DNA

As genotyping technologies have precipitously decreased in cost since the completion of the Human Genome Project, personal genetic testing has increasingly been marketed to consumers. Genetic testing is now available for an ever-expanding list of genetic mutations associated with diseases—including breast cancer, Parkinson’s, and Alzheimer’s—as well as traits such as ancestry, intelligence, and athleticism. Close examination of the direct-to-consumer personal genomic industry reveals several forms of potentiality at work that are informed by imagined and real power over bodily information. The marketing and consumption of personal genetic information relies on constructions of biological potential that result from struggles over the ability to control and act on individualized genetic information and to translate it into meaning. This paper explores the emerging discourse over personal genetic testing—and the marketing and consumption of the alluring and carefully tailored idea of potentiality that fuels American entrepreneurialism—and concepts of freedom and self-actualization. Policy debates over rights of access to genotyping fail to recognize the shifting landscape of human genomics in the United States. Genes in the marketplace are justified by liberalism, civic republicanism, and multiculturalism propelling a paradigm shift away from traditional models of governance toward open access to genetic testing and minimization of individual harm. The turn to the market emboldens the consumer and creates a new set of social meanings and ethical quandaries over who may harness the potential attributed to genetic information and for what purposes.

Dementia Screening in Primary Care: Not Too Fast!

A fundamental tenet of any screening program is that it should “reduce individual and societal burden from specific disorders.”1 Screening is predicated on the assumption that early detection and subsequent treatment will improve the clinical course for individuals without symptoms. Conversely, when an individual presents with complaints of memory problems, the physician engages in case-finding. 1 Screening for some conditions in some populations has resulted in improvements in individual and societal burdens of diseases (e.g., colon and breast cancer), but screening can also cause individual and societal harm (e.g., prostate-specific antigen testing). According to the 2003 report of the U.S. Preventive Services Task Force, there is insufficient evidence to recommend for or against routine screening for dementia in primary care.2

Anti-Semitism and the Law in Quebec City: The Plamondon Case, 1910-15

On March 30 1910, a Quebec City notary named Plamondon gave a lecture describing Jewish residents as morally debased, parasitic, and a threat to Christians. As a result, residents vandalized and assaulted numerous Quebec City Jews. Benjamin Ortenberg and Louis Lazarovitch launched a defamation suit against Plamondon. They claimed Plamondon harmed their businesses and social affairs, and caused humiliation and grief by portraying them as, “dangerous beings who ... deserve to be persecuted. Plamondon responded that he had simply repeated other authoritative works on the Jewish faith. Many academics, Jewish and Christian religious leaders were called to testify about whether Plamondon's accusations constituted defamation. Counsel for the plaintiffs considered the pamphlets outrageous, unfounded, and calculated to harm every Jewish person in Quebec City. The defence argued Plamondon was exercising his right to freely speak about a national issue. The trial judge dismissed the action with costs, as the pamphlet incriminated the Jewish race in general and did not sufficiently target the plaintiffs by name. The Quebec Court of Appeal unanimously overturned the trial decision, noting that Plamondon had not proven the accusations he made, and the plaintiffs had suffered individual harm as a result of his denigration of Quebec City Jews, “with no exception .... The ruling has been considered a high water-mark in the law of group defamation, but did not result in significant new directions in this area for the future.

Intersectional Resistance and Law Reform

Critical race theory generally and intersectionality theory in particular have provided scholars and activists with clear accounts of how civil rights reforms centered in the antidiscrimination principle have failed to sufficiently change conditions for those facing the most violent manifestations of settler colonialism, heteropatriarchy, white supremacy, ableism, and xenophobia. These interventions have exposed how the discrimination principle’s reliance on individual harm, intentionality, and universalized categories of identity has made it ineffective at eradicating these forms of harm and violence and has obscured the actual operations of systems of meaning and control that produce maldistribution and targeted violence. This essay pushes this line of thinking an additional step to focus on the racialized-gendered distribution schemes that operate at the population level through programs that declare themselves race and gender neutral but are in fact founded on the production and maintenance of race and gender categories as vectors for distributing life chances. In the context of intensifying criminal and immigration enforcement and wealth disparity, it is essential to turn our attention to what Michel Foucault called “state racism”—the operation of population-level programs that target some for increased security and life chances while marking others for insecurity and premature death. This essay looks at how social movements resisting intersectional state violence are formulating demands (like the abolition of prisons, borders, and poverty) that exceed the narrow confines of the discrimination principle and take administrative systems as adversaries in ways that pull the nation-state form itself into crisis.

Autonomy and the patient's right ‘not to know’ in clinical whole-genomic sequencing

In their recent publication on whole-genomic sequencing (WGS), Ayuso et al1 identify ethical challenges around the disclosure of ‘incidental findings' (IF) and propose recommendations for informed consent (IC) in a clinical setting. They note that WGS could become clinically routine as technologies develop and time and cost of testing decreases. Based on a comprehensive review and analysis of relevant literatures, they propose an ethical return of clinical IF. The authors suggest that at a minimum, the IC form for WGS for diagnostic purposes should include pre-test counseling and general information common to all genetic tests as well as additional content specific to WGS regarding IF (p1).1 Their proposed recommendations draw on Berg's2 category-based binning framework model of disclosure. Ayuso et al1 provide helpful recommendations on both the process and content of IC in clinical WGS. Although we agree with the authors regarding the ethical challenges in clinical WGS, we disagree with one aspect of their recommendations: ‘...it is suggested that… clinically manageable disorders affecting the patient... must always be disclosed to the patient… on the other hand, the possible disclosure of other types of information.... should be discussed and agreed upon in advance with the patient during the informed consent process'1(p 4). In our view, the first part of this statement is paternalistic, in that the clinician denies the patient the choice of ‘not to know' and is predicated upon the ‘physician as gatekeeper' model as opposed to a model of ‘patient as partner' or ‘patient as gatekeeper' of his or her own genomic information. The authors' stance appears counter to the current shift in patient–doctor relationships and the move toward greater patient autonomy, shared decision-making and empowerment in healthcare. It is also inconsistent with the European Convention on Human Rights and Biomedicine3 which states, ‘Everyone is entitled to know any information collected about his or her health. However, the wishes of individuals not to be so informed shall be observed (p 436).' Honoring a patient's choice ‘not to know' respects an individual's autonomy.4 However, taking the position that particular types of WGS information ‘must always be disclosed' with no prior discussion, significantly undermines patient autonomy. There is some evidence in support of this. Participants in our focus group study, which explored lay and patient attitudes about WGS IF clinical disclosure, strongly supported the right to say no to disclosure.5 Following Andorno3 we maintain that the right not to know must be offered but cannot be presumed, and must be ‘activated' by a person's explicit choice. Also, it is not an absolute right; it may be restricted when disclosure relates to serious harm to third persons (p 435).3 Exercising this right ‘not to know' should be an informed choice. The patient and doctor need to discuss the risks and implications of both knowing the results and not knowing them including the reliability of the information. Individuals may have valid reasons for not knowing results. The ‘objective' clinical utility of knowledge may have very different meaning ‘subjectively' for patients in terms of its relevance and manageability for them; all things considered, they simply may make an informed choice not to have the information disclosed to them. The impact that all genetic information has on the individual, including psychological, social and financial consequences or harms, needs to be recognized by clinicians at all stages of disclosure. For instance, discrimination by insurance companies and employers or societal stigma may be a real threat. Other ethical issues may arise; the results may negatively impact autonomy in a broad sense of the word, that is impinge on a person's self-determination, autonomous lifestyle and future life plans.6 Crucially too, regardless of any potential consequences or negative effects that might derive from test results, the right not to know is an essential requirement for a person to decide freely whether or not to undergo WGS (p 147).6 Rather than assume disclosure of selective results with no discussion, it is important to understand why some people choose not to know, and to understand what that knowledge might mean in their life/personal contexts, beyond the clinic. As Andorno3 has noted, autonomy understood broadly, offers a theoretical basis for a right not to know one's genetic status.3 We agree with the authors that more dialogue is needed around these issues and our comments are intended to contribute to this debate as new ethical challenges emerge around IF and WGS clinical disclosure.

Intrinsic connectivity networks and personality: The temperament dimension harm avoidance moderates functional connectivity in the resting brain

Recent functional imaging studies that examined functional connectivity in the resting brain have demonstrated various intrinsic connectivity networks (ICNs). Certain patterns of over- and underactivity in various ICNs have been hypothesized to form the neural basis of psychiatric disorders. Furthermore, activity in the ICNs does not reflect ongoing mental activity but the maintenance of neural circuits in a ready state suggesting not only relationships between ICNs and disorders but also correlations between ICNs and personality. In the present study, we assess the relationship between trait anxiety, a well established endophenotype of anxiety disorders, and functional connectivities within the insular salience ICN in a sample of healthy female subjects. Based on a previous study that demonstrated the functional relevance of the insular salience ICN for state anxiety, we used the harm avoidance scale from the Temperament and Character Inventory (TCI) as a trait marker to demonstrate increased functional connectivity within the insular salience ICN. Specifically, the functional connectivity between the anterior insula and the anterior cingulate and between the anterior insula and the dorsolateral prefrontal cortex were positively correlated with individual harm avoidance scores. The results fit into previous work, provide evidence for a potential biomarker of anxiety disorders and, most importantly, demonstrate a direct neural correlate of the personality trait harm avoidance in the absence of external stimulation.

Reclaiming the Equitable Heritage of Habeas

Equity runs through the law of habeas corpus. Throughout the seventeenth and eighteenth centuries, prisoners in England sought the Great Writ primarily from a common law court — the Court of King’s Bench — but that court’s exercise of power to issue the writ was built around equitable principles. Against this backdrop, it is hardly surprising that modern-day habeas law draws deeply on traditional equitable considerations. Criticism of current habeas doctrine centers on the risk that its rules — and particularly the five gatekeeping doctrines that preclude consideration of claims — produce unfair results. But in fact four of these five bars exhibit significant equitable characteristics. The only outlier is the Court’s retroactivity bar, which prohibits relief whenever an applicant relies on a new rule of constitutional procedure. Taking no account of the blamelessness of the applicant’s conduct or the nature of the claim, the law of retroactivity applies in a wooden fashion that is at odds with principles of equity. The nonequitable nature of the retroactivity bar causes both individual and institutional harms. Of particular importance, because it operates irrespective of how compelling the individual claim of error may be, it blocks the opportunity to secure relief on claims in approximately one quarter of all capital cases. The nonretroactivity rule also thwarts the efforts of courts to recognize new rights applicable to collateral proceedings, no matter how sound such new rights might be. This Article argues that the Court should modify its nonretroactivity doctrine to reflect equity’s traditions. In particular, the Court should adopt three individualized equitable exceptions to the now-absolute retroactivity bar that take account of applicants’ conduct in pursuing claims, the merits of the claim and the stakes involved, and the unavailability of alternative remedies. These exceptions might not alleviate all of the inequities created by the nonretroactivity rule. They would, however, bring it more in line with its four companion habeas bars, providing a measure of coherence to these gatekeeping doctrines and reconnecting the nonretroactivity rule with the writ’s deep equitable roots.

Standing a Little Bit Above the Rest: Establishment Clause Enforcement & Taxpayer Standing after Winn

This paper joins the ongoing dialogue about the relationship between the Establishment Clause and Article III, and particularly the Supreme Court’s narrow expansion of standing for such claims. The paper first suggests that the Establishment Clause recognizes both individual rights-based harms as well as a structural restraint, which like other structural constitutional provisions may not result in individualized harm. It then tracks the creation and preservation of limited taxpayer standing that the Court has permitted for the Establishment Clause, including the Court's most recent decision in Arizona Christian School Tuition Org. v. Winn. Finally, after exploring scholarly views on judicial enforcement of the Establishment Clause and considering whether full judicial enforcement of the Establishment Clause is necessary, and if so, whether it would be possible while respecting the boundaries of Article III, the paper concludes with some reflections on the future of taxpayer standing.

¿Cuáles y qué tan graves son los daños a la salud individual y a la sociedad causados por el consumo de drogas lícitas e ilícitas?

En vista del amplio consumo de drogas lícitas e ilícitas en casi todo el mundo occidental, nosotros sospechamos que no eran tantos ni tan graves los daños que causan, como se afirma, y decidimos evaluar la solidez de tal sospecha. La sospecha resultó correcta en términos de la salud física individual de los usuarios, pues las drogas no aparecen entre las primeras quince causas de Morbilidad ni de Mortalidad en los habitantes de México, EUU, Canadá, España, el Reino Unido y Holanda. En cambio, las drogas sí causan daño psicológico y social al individuo por propiciar indolencia motivacional, cuadros psicóticos serios, potencialmente irreversibles, e inducir la comisión de conductas riesgosas (accidentes de tránsito) y hasta criminales (robos, asaltos, violaciones). El consumo de drogas también lesiona la integridad y economía de las familias de los usuarios y daña a la comunidad, pues se eleva la tasa de desempleo, disminuyen los ingresos fiscales, incrementan los costos de los programas de desarrollo, de seguridad y de beneficencia, así como propician la exclusión de los usuarios en el trabajo, escuelas, clubes y servicios públicos diversos. Nuestros resultados son de interés para el diseño de las acciones destinadas al control del consumo de drogas para que sean congruentes con el tipo, gravedad y extensión del daño individual y social que las drogas causen.

Sexuality’s Law

For J.T. To die for the love of boys: What could be more beautiful? --Michel Foucault (1) Il m'aime signifie en clair: il accepte queje le capture, l'apprivoise, et le viole, et le tue, et l'enterre. --Tony Duvert (2) I. Introduction The contemporary history of gay sexuality--the full history--has not been written. Within it, increasingly attested to in various ways, appears an ideology of sexual freedom that has played a significant role in shaping, conditioning, controlling, and defining the sweep of gay sexuality, identity, and social life. This Article describes the ideology of sexual freedom, including its valorization of sexual violence, abuse, and injury, up to and including death, traces the ideology's implications for HIV/AIDS, and documents its actual operation in theorizing about sexuality by and among gay men in the high years of the epidemic. (3) After that, it examines some ways in which the ideology of sexual freedom has shaped some more recent debates about same-sex sex and its proper relation to proposing that in a number of ways this ideology has been sexuality's tougher and truer law, (4) more important than the formal legal rules promulgated and enforced by the political State. In consequence, it is suggested, efforts to understand and address same-sex sexual violence and its consequences both for individuals and society, more generally, need to grapple with the ideology of sexual freedom directly--and not ignore it--if there is to be any realistic hope for the liberal State to satisfy its obligations to protect private individuals against interpersonal harms. Before coming to that, some preliminary facts that frame a puzzle. Since the earliest known days of the HIV/AIDS epidemic in the United States, more than 555,000 men diagnosed with AIDS--many of them gay--were infected with HIV through sex with other men. (5) Also since the earliest known days of the HIV/AIDS epidemic, legal rules, both criminal and civil, have been able to capture many forms of the sex-based transmission of HIV as an individual harm. (6) Nevertheless, the number of cases seeking legal redress for HIV-transmission by gay men against one another has remained very small, both in absolute and relative numbers. (7) Why? Why have gay men not regularly laid claim to what was done to them as an injury that the law's remedial harm provisions should recognize and address? From the top, some conventional explanations that might appear to solve the puzzle, in whole or in part. Comparisons to cross-sex transmissions aside, given the special meanings and experiences of HIV/AIDS to gay men, (8) in the early days of the epidemic, few gay men could say (and fewer say with certainty) what exact sexual event (or events) had, some time (often years) before, caused them to become infected with HIV. Transmission of the virus was commonly and practically thought to be a doer-less deed. Even in those instances in which a doer could be identified, he was regularly not seen as responsible for what he did. Nobody back then knew what he was doing, gay sex being generally seen, by gay men at least, as essentially consequence-free. (9) If anyone were to be legally liable for inflicting this injury, then practically anyone who was sexually active and versatile could be. It is, then, as Robin Hardy reports: I have chosen to think that Rollo is my murderer, but I attach no blame to him. I only love his memory more. Everyone was ignorant then. It was no fault of his. It could have just as easily been me, because I'm certain that in those years of ignorance, through no intention of my own, I was a bringer of disease to other men. (10) No doubt, countless other gay men, speaking for themselves, would agree. Or would have, had they lived. In the early years of the HIV/AIDS epidemic, ignorance of HIV and its ordinary modes of transmission could thus supply a norm of blamelessness that defined gay life across the sexual and social board, accounting for why gay men did not tap into the legal system to name what was done to them as an injury inflicted on them by other gay men. …

An Evaluation of the Prescription of Opioids for Chronic Nonmalignant Pain by Australian General Practitioners

Our objective was to evaluate the quality of opioid analgesia prescribing in chronic nonmalignant pain (CNMP) by general practitioners (GPs, family physicians). An anonymous, cross-sectional questionnaire-based survey. The setting was five Australian divisions of general practice (geographically based associations of GPs). A questionnaire was mailed to all division members. Outcome measures were adherence to individual recommendations of locally derived CNMP practice guidelines. We received 404 responses (response rate 23.3%). In the previous fortnight, GPs prescribed long-term continuous opioids for CNMP for a median of 4 and a mean of 7.1 (±8.7) patients with CNMP. Guideline concordance (GLC) was poor, with no GP always compliant with all guideline items, and only 31% GPs usually employing most items. GLC was highest for the avoidance of high dosages or fast-acting formulations. It was lowest for strategies minimizing individual and public health harms, such as the initiation of opioids on a time-limited trial basis, use of contracts, and the preclusion or management of aberrant behaviors. GLC was positively associated with relevant training or qualifications, registration with the Australian Prescription Drug Monitoring Programme, being an opioid substitution therapy prescriber, and female gender. In this study, long-term opioids were frequently initiated for CNMP without a quality use-of-medicine approach. Potential sequelae are inadequate treatment of pain and escalating opioid-related harms. These data suggest a need for improved resourcing and training in opioid management across pain and addictions.