I want that till 11/10/2021 exactly at 12 AM
Case Study Assignment Using Beauchamp and Childress’s Principlism theory, analyze what happened in Torree McGowan’s “Will You Forgive Me for Saving You?”. Your case study should be no more than 2 pages, and should conform to the requirements on the Powerpoint included on Blackboard, “How to Write a Case Study”. There is also a grading rubric attached. Will You Forgive Me for Saving You? PERSPECTIVE 8 Methadone in Primary Care n engl j med 379;1 nejm.org July 5, 2018 ed with methadone (from 36.1 per 1000 person-years among people not receiving methadone to 11.3 per 1000 person-years with meth- adone treatment); 3 of the 16 stud- ies described care by general prac- titioners and showed similar safety profiles.1 The ability to obtain a pre- scription for methadone in the course of routine primary care is especially valuable for people liv- ing in nonurban areas, in which the infrastructure required for a methadone clinic may be too ex- pensive and disproportionate to the level of need. Regardless of cost, establishing a new metha- done clinic can be challenging in any setting, given the common “not in my backyard” sentiment, which pits perceived local con- cerns against public health ben- efits. Allowing physicians to pre- scribe methadone in primary care settings obviates both of these challenges. What’s more, it could reduce the stigma associated with opioid use disorder and place its management more in line with that of other medical conditions that are treated seamlessly in pri- mary care. In the United States, metha- done has been prescribed in pri- mary care settings under rare circumstances in which extensive efforts were made to meet all pertinent regulations. Our expe- rience in Boston over a 10-year period with a very limited num- ber of patients who were transi- tioned into a primary care–based methadone program after being stable on treatment at a metha- done clinic was excellent. Medi- cation prescriptions and clinical care were provided without ad- verse incident. Indeed, one patient in the program, in which she re- ceived a prescription for metha- done treatment as well as general health care in a primary care set- ting, told us that the experience “is to me like winning the lottery — better actually.” The last act of Congress that expanded access to effective med- ications for opioid use disorder in primary care, the Drug Addic- tion Treatment Act of 2000, en- abled buprenorphine to become available to thousands of patients in the United States. Expanding access to methadone in primary care will require more than legis- lation. It will also be necessary to enhance training for physicians on opioid use disorder, consider incentives for prescribing medi- cations to treat it, and integrate treatment into existing models of care. But the solution to a complex problem often begins with small, pragmatic steps. We believe the time has come to update laws that regulate the prescription of metha- done in primary care in order to reduce barriers to access and ex- tend the benefits of a proven, effec- tive medication to people through- out the country. Disclosure forms provided by the au- thors are available at NEJM.org. From the Boston University Schools of Medicine and Public Health and Boston Medical Center ( J.H.S.), the Grayken Center for Addiction, Boston Medical Center (J.H.S., M. Botticelli), and the Massachusetts Depart- ment of Public Health (M. Bharel) — all in Boston. 1. Sordo L, Barrio G, Bravo MJ, et al. Mor- tality risk during and after opioid substitu- tion treatment: systematic review and meta- analysis of cohort studies. BMJ 2017; 357: j1550. 2. Dole VP, Nyswander M. A medical treat- ment for diacetylmorphine (heroin) addic- tion: a clinical trial with methadone hydro- chloride. JAMA 1965; 193: 646-50. 3. Fiellin DA, O’Connor PG, Chawarski M, Pakes JP, Pantalon MV, Schottenfeld RS. Methadone maintenance in primary care: a randomized controlled trial. JAMA 2001; 286: 1724-31. 4. Merrill JO, Jackson TR, Schulman BA, et al. Methadone medical maintenance in pri- mary care: an implementation evaluation. J Gen Intern Med 2005; 20: 344-9. 5. Saloner B, Karthikeyan S. Changes in substance abuse treatment use among indi- viduals with opioid use disorders in the United States, 2004-2013. JAMA 2015; 314: 1515-7. DOI: 10.1056/NEJMp1803982 Copyright © 2018 Massachusetts Medical Society.Methadone in Primary Care Will You Forgive Me for Saving You? Will You Forgive Me for Saving You? Torree McGowan, M.D. I remember the day I first met you. It was a quiet Sunday, ear- ly in the morning. I heard a com- motion out by the check-in desk, and your mom’s scream: “My ba- by’s not breathing!” The first time I saw you was in your mom’s arms. Heartbreakingly, you weren’t snuggled like a baby should be, or even limp. Your tiny body was twitching, seizing. The cold clin- ical term “decorticate posturing” that flashed in the physician part of my brain seemed too rigid to be applied to your chubby toddler arms. We rushed you to our trauma room, and the entire hospital came to help you. In moments, I had every hand available, every heart pulling for your tiny body. All those hands let me do the hardest thing: step back and start making decisions that would alter your life forever. Your tiny heart was so slow. Children’s hearts should be fast, like running feet and quick smiles. Yours beat at the slow stuttering pace of a heart about to surrender. The New England Journal of Medicine Downloaded from nejm.org at KENT STATE UNIV. LIBRARIES on August 28, 2018. For personal use only. No other uses without permission. Copyright © 2018 Massachusetts Medical Society. All rights reserved. PERSPECTIVE 9 Will You Forgive Me for Saving You? n engl j med 379;1 nejm.org July 5, 2018 I knew your heart was strong, but your brain was so hurt that your body was fading. The next minutes were a blur of activity. I barked sharp, pointed orders, like the needles we used to drill into your bones. Monitors started to beep, not a single num- ber reassuring. I was looking at you, every inch of you, measuring, assessing, cataloguing all the plac- es that needed our gentle fingers. My eyes kept wandering to your forehead. It was on your right side, just above your eyebrow. A big, vio- lent, purple lump — my gaze kept stumbling over it. Such an ugly wound on the surface, and still it was no match for the devastation hidden underneath. My team worked so hard for you. I had so many smart people helping me with medications, IVs, monitors. Hands so big there wasn’t enough of your minute body for them all to touch still reached for you, stroked gently, as we talk- ed softly so as not to scare you. I clearly remember the moment I put you on the ventilator. I’ve done this procedure hundreds of times, but I noticed that my view was shaky. No, it was my hand. I had to stop, stare at those trem- bling fingers until they steadied. Two deep breaths for me, and your breathing tube was in. After the ventilator began its metronome to mark the time, things quieted down. Your body started to respond to the seizure medicines, and your curling arms relaxed. Your heartbeat, once so frighteningly lethargic, had re- sponded to medication and ticked along. The pupils in your beauti- ful blue eyes shrank back, evenly sized once again. The beat of the helicopter an- nounced the arrival of your next phalanx of guardians. I had called for them in the first minutes you were here, shouting information across the trauma room as my hands prodded your body, plead- ing for help to come. This small- town hospital was not equipped for your tiny life and its huge in- jury, and I am forever grateful to those who answered my call and stood ready to help you. The frenetic pace of doing slowed as you rolled out the door, mummified in pumps and vents and tubing. As you left my care, I looked over to the people who loved you, who came to be with you during your fight. There was one man, the one who told me the first lies of your day, who would not meet my eyes. You fell and hit the corner of a wall, he said. He knew I knew better. I wondered about you and worried about you. On the backs of my eyelids, I can see your fore- head, the dividing line between that part of your life and this. I see your left hand, spasmed to your chest, then finally falling lax. I hoped for your miracle. In the way of small towns, I heard bits of your story. I heard rumors of your surgery, saw pic- tures of you in day care as a smiling, happy child before that Sunday. I felt a sad pride the day I heard you went home. I read the newspaper account of the evil of the man who did this to you, all because you wouldn’t hold still for a diaper change. Then one morning, I was back in the same ED, sitting in the same chair as when I first heard your mom scream. The radio crackled, fading in and out: “recent TBI, trach/peg . . . difficulty breath- ing.” My skin felt too tight; I knew it was you. The lump on your head was gone, replaced by a curlicue of scars. Your skin had taken on the slightly waxy appearance that seems so common in brain-injured patients. I’m not sure if that’s something that happens because