DC DEPARTMENTOf health made a serious mistake: the evidence

                           Doctors For Equal Rights For Physical And Mental Pain

        8409 Carlynn Dr. Bethesda, MD 20817               alensalerian@gmail.com

                                           dralensalerian.blogspot.com 
       Founding members Siobhan Reynolds Kevin Byers Vanessa Mullin Alen J Salerian

February 9, 2015

Dear friends

  Attached are two peer-reviewed articles that suggest The DC Department of Health decision to shut down the Salerian Center For Neuroscience And Pain was not in the best public interest and possibly caused several fatalities.

  17 case studies offer evidence of the dangers associated with bureaucracy making clinical decisions. Sensitive dependence of mental function on prefrontal cortex introduces a new paradigm for psychiatry.

The traumas my family and I have endured in the process have been overwhelming. I don't plan to practice psychiatry again. I hope by sharing my pain I would spare other doctors from similar tragedies.

Respectfully

Alen J Salerian MD

Case Report

Case Studies of 17 Patients

Salerian AJ*

Salerian Centre For Neuroscience and Pain, USA

Journal of Case Reports and Studies Volume 2 | Issue 5 ISSN: 2348-9820

Open Access

*Corresponding author: Salerian AJ, Salerian Centre For Neuroscience and Pain, 8409 Carlynn Dr., Bethesda, MD 20817, USA, E-mail: alensalerian@gmail.com

Citation: Salerian AJ (2015) Case Studies of 17 Patients.. J Case Rep Stud 2(5): 506

Abstract

Background: Heightened risk of adverse events following opiate discontinuation has been reported.

Findings: This retrospective review of 17 patients suggests an increased risk of adverse events including premature death with opiate discontinuation long after withdrawal stage. The results are consistent with previously reported yet not fully understood – opiate associated neuro protective mechanism – against premature death for some vulnerable subgroups.

Conclusion: For some vulnerable people termination of opiates – regardless of why or how – may represent a heightened risk of premature death.

Keywords: Opiates; Addiction; Pain; Withdrawal; Premature death

Findings

This study suggests an increased risk of adverse events including premature death following opiate discontinuation long after withdrawal stage.

Case studies of 17 patients

Information

In general people with dual diagnosis – psychiatric and substance use disorders – may represent a high risk of premature death consistent with the study by Grant et al [1]. Kakko and colleagues reported 20% death rate among patients taking buprenorphine versus 0% death in a control group in one year [2]. There is also compelling neuroimaging evidence of neurodegeneration and brain atrophy associated in chronic pain patients who are often treated with opiates [3]. Risk of death associated with opioid treatment or dependence has been a subject of controversy. The validity of opioids related vital statistics due to recording errors has also been raised [4].

The focus of this study is narrow

To review clinical states of 17 patients in 12 months following discontinuation of treatment triggered by the temporary closure of a treatment center. Prior to their discharge, 17 patients were stable on opioids without any life-threatening medical conditions. No evidence of potential suicidal behavior, overt signs of depression or functional impairment were observed in medical records.

All patients had appropriate referrals for follow up. For unknown reasons not all patients received follow-up treatment with opiates. All patients were informed of potential risk of adverse events associated with discontinuation of treatment.

Method

Medical records of 17 patients at the treatment center were reviewed. Routine documentation included DSM-IV based diagnosis and pain – mood assessment on a scale of 1 to 10 with 1 representing the worst and 10 representing the best response. This was the essential measure. Also reviewed were follow-up medical records. Brief phone evaluations were completed for patients who did not receive follow-up care. Vital statistics were obtained from official documents and death notices. Opiates included oxycodone, methadone, oxymophone, fentanyl.

Results

10 patients received follow-up care. 7 patients did not receive follow-up care. Among 10 patients receiving follow-up care 1 patient was off opiates (Table 1).

The youngest was age 22 and the oldest age 57, 10 men and 7 women. The primary diagnosis of 12 patients was chronic pain versus 5 with dual diagnosis of pain, addiction or treatment resistant depression.

    

 

Annex Publishers | www.annexpublishers.com Volume 2 | Issue 5

Journal of Case Reports and Studies

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Patients Age Race Gender

157AAF 222CM 337CM 433CF 557CM 620CM 750CM 821CF 937CF 1037CM

1145CF 12 46AA F 1350CM 1430CM 1545AAM 16 40AA F 1745CM

Follow up And opiates

NO YES YES YES NO YES NO NO YES NO YES NO YES YES NO YES NO

Table 1: Demographics of 17 patients
Patients who did not take opiates reported worsening of mood and pain scores. There were two fatalities both receiving outpatient

treatment. 1 by suicide and 1 from postsurgical complications. Review of two fatalities

Patient 1: Age 22, three months after reduction of opiates while attending an outpatient methadone clinic, this college student committed suicide. On the day of suicide he was evaluated in an emergency room for depression and suicidality and referred back to the methadone clinic.

Patient 2: This 57-year-old woman died of postsurgical complications of exploratory surgery for abdominal pain 7 months post termination of treatment. She was receiving care but her methadone was discontinued.

A preliminary report 1 year post intervention suicides among patients at the center may also merit special mention. Out of 1200 total patient population 398 patients were discharged. Among them, there were 7 fatalities from suicides. This represented a 20 fold increase of self-inflicted deaths (Table 2).

Patient

With opiates Mood-Pain Score

Without opiates Mood–Pain Score

1 5.9 2

.    2  6.5

.    3  6.3

47
5 6.2 2.5

6 6.8
7 5.9 2.5

8 7.1 3.1

9 6.6

10 7.5 3.2

11 6.3

12 6.5 2.5

13 6 14 7.2

15 6.1 2.5

16 6.6

17 6.3 2.7

Average 6.4 2.9

Table 2: Mood-Pain scores of 17 patients with opiates Vs without opiates

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Discussion

The retrospective nature and small sample size are major limitations for this study. The findings are consistent with previously published reports by Kakko and Grant of heightened risk of premature death among people with discontinued opiate treatment [1,2].

Noteworthy are the 2 premature fatalities in a small group of 17 patients within one year termination of opiate treatment. The delayed occurrence of both fatalities – 3 and 7 months post termination is consistent with the observation that for these two individuals opiates might have been neuroprotective against premature death.

Conclusion

The review results are consistent with the safety and efficacy of opiates for chronic pain, addiction and complex psychiatric disorders. Healthcare professionals must be sensitized to the heightened risk of premature death upon discontinuation of stable treatment with opiates.

References

1. Grant BF, Stinson FS, Dawson DA, Chou SP, Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry 61: 807-16.

2. Kakko J, Svanborg D K, Kreek MJ, Hellig M (2003) 1-year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: a randomised, placebo-controlled trial. Lancet 361: 662-8.

3. Apkarian AV, Sosa Y, Sonty S, Levy RM, Harden RN, et al. (2004) Chronic back pain is associated with decreased prefrontal and thalamic gray matter density. J Neurosci 24: 10410-5.
4. Webster LR, Dasgupta N (2011) Obtaining adequate data to determine causes of opioid related overdose deaths. Pain Med 2: S86-92.

 Journal of Psychology & Clinical Psychiatry

J Psychol Clin Psychiatry 2015, 2(1): 00053

Submit Manuscript | http://medcraveonline.com

Sensitive Dependence of Mental Function on Prefrontal Cortex

Research Article

Volume 2 Issue 1 - 2015

Introduction

Compelling data suggest higher mental functions, executive function, awareness, consciousness, planning, strategic thinking, imagination and processing sensory input are the domain of prefrontal cortex function and in particular Brodman areas 8, 9, 10, 46 [1,2]. Recent studies have also suggested that the mediating influence of prefrontal cortex function is crucial in depression and in antidepressant strategies [3] is it possible that what is true for depression may also be true for other psychiatric disorders? And if this is true, does that suggest that prefrontal cortex is endowed with a unique mediating influence of mood, normalcy and psychiatric illness? And does this suggest that a small decline of prefrontal cortex influence may have large effects in brain function and human behavior similar to the butterfly effect of complex systems?

Method

This paper will review diverse examples of the mediating influence of prefrontal cortex in normalcy and mental illness. Observations consistent with natural laws in support of them ediating prefrontal cortex influence will be presented (Table 1). Examples of diverse correlations between mental disorders and decline of prefrontal cortex will also be shown under the following headings:

I. Phylogeny

II. Biology

III. Clinical observations

IV. Neuroimaging studies

Phylogeny supports the mediating influence of prefrontal cortex function

The idea that a brain region may enjoy greater influence over nervous system is partly rooted in natural observations consistent with the biological hierarchy of diverse living organisms [4-7] (Figure 1). A simple example is a logical one: head rules body and tail. A second example is an extension of the first. Brain rules peripheral nervous system. Of course head and body, brain and peripheral nervous system relationships are complex and bidirectional within the biological hierarchy of influence.

Governing influence of prefrontal cortex is also consistent with its highest biological complexity and evolutionary youthfulness (Nolte2008). Further, more over the last several decades data have accumulated to suggest that relative brain size, cellular complexity and division of labor of multicellular organisms are of crucial importance for intelligence and in essence, phylogenetically the youngest biological systems have been endowed with the highest complexity and with the greatest influence [4-6].

Neurophysiology supports the mediating influence of