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Jade , Genocide and Burma

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Taint of Burma’s genocide gems | News | The Times & The Sunday …

https://www.thetimes.co.uk/article/taint-of-burmas-genocide-gems-6mtz2c7pn

Dec 10, 2017 – Cartier’s Tutti Frutti collection features sapphires from Burma. Activists from the International Campaign for the Rohingya (ICR) plan next to target Bulgari, which advertises several necklaces and earrings featuring Burmese rubies, sapphires and jade. In May, the American model Bella Hadid wore a Bulgari …

What Happened to Myanmar’s Human-Rights Icon? | The New Yorker

https://www.newyorker.com/…/10/…/what-happened-to-myanmars-human-rights-icon

Oct 2, 2017 – When Myanmar’s military regime released Aung San Suu Kyi from house arrest, in 2010, she had been the world’s most famous political prisoner for nearly … Democratic movements did not always triumph—the Chinese government’s massacre of student protesters near Tiananmen Square is the grimmest …

Cartier: Don’t Sell Burmese Genocide Gems – Action Network

https://actionnetwork.org/…/cartier-dont-sell-burmese-genocide-gems?…burmese-gen…

Burma produces over 95% of the world’s rubies and over 99% of the world’s jadeite. Jadeite is superior quality jade, or “imperial jade.” In its 2015 report “Jade: Myanmar’s “Big State Secret,” Global Witness stated that this multi-billion dollar jade trade is “tightly controlled by … military elites, US-sanctioned drug lords and …

Washington begins to sour on Aung San Suu Kyi amid mounting …

https://www.washingtonpost.com/…burma/…/56184e5e-93db-11e7-8754-d478688d23b…

Sep 7, 2017 – Washington lawmakers who once enthusiastically supported Aung San Suu Kyi’s rise to power in Burma have shifted this week to criticism of her … Obama made two trips to the country, and last year his administration lifted the remaining economic sanctions, including on the import of jade and rubies.

Miners find giant £140 million jade stone in Burma | The Independent

http://www.independent.co.uk › News › World › Asia

Oct 16, 2016 – Miners in Burma have found one of the world’s most valuable pieces of jade. The stone is valued at £140 million and was discovered in a remote mine in Kachin State, in the north of the country. The stone is is 18ft long, 18ft wide and 9ft high and weighs approximately 175 tonnes.

Giant jade stone uncovered in Myanmar – BBC News

http://www.bbc.co.uk/news/world-asia-37670305

Oct 15, 2016 – A giant jade stone weighing 175 tonnes has been uncovered by miners in Myanmar.

Giant jade stone uncovered in Myanmar – BBC News – BBC.com

http://www.bbc.com/news/world-asia-37670305

Oct 15, 2016 – A giant jade stone weighing 175 tonnes has been uncovered by miners in Myanmar.

Secret Genocide: Voices of the Karen of Burma – Google Books Result

https://books.google.com/books?isbn=1908518308
Daniel Pedersen – 2015

Tay Lay told mehehad gone into the jade business, teaming up with SPDC Vice Chairman Maung Aye’s sister-in-law (apparently known to all as’Cherry’), selling jade internationally. One would assume hewas selling to China, where jade is highly coveted. Burma’s jade isconsidered the world’s finest, but evenif it is sold …

There’s Strong Evidence of a Genocide in Myanmar – Newsweek

http://www.newsweek.com/theres-strong-evidence-genocide-myanamar-393096

Nov 13, 2015 – A new report by Yale Law School says the UN should urgently investigate the fate of the Rohingy

————
Connie’s comments: Stop buying Jade ladies.
Posted byconnie dello buonoDecember 18, 2017December 19, 2017Posted inMenuLeave a comment on Jade , Genocide and Burma

Washington Post on Leadership 12-18-17

The last year has been an epic one for leadership stories: A combative, unrestrained, ego-driven president in the White House. A divided, dysfunctional Congress with little to show — other than this week’s likely tax reform bill. A watershed workplace moment with the wave of sexual harassment. A reckoning in the C-suite as some lost their jobs — while many others spoke out more on current social issues.

These stories and more captivated our interest in 2017. Below, a look back at 10 highlights and lowlights of a monumental year for leading in Washington and managing America’s workplaces. Short edited excerpts of each story follow.

10. Why sexual harassment training doesn’t stop harassment

As a staggering wave of women and men divulge unwanted advances and illegal behavior in what seems like an epidemic of sexual harassment allegations, employers have been searching for solutions. From Hollywood to the halls of Congress, the topic of harassment training has taken center stage. Employment lawyers said they’ve heard from clients in droves who want to make sure their training and coaching are up to speed. “We’ve definitely had an uptick in requests for this kind of work in the last couple of months,” said Kevin O’Neill, a principal at the employment law firm Littler Mendelson who leads sexual harassment training.

Yet researchers don’t have much evidence that sexual harassment training is effective at certain key goals: reducing the number of incidents in a workplace; or helping to shift its culture toward one that takes the issue seriously. “In most cases, employers are creating these policies more to protect themselves than to protect employees,” said Lauren Edelman, a professor at the law school of the University of California at Berkeley. “We don’t know when harassment training is effective, and we have reason to believe that maybe it’s counterproductive in some cases.”

9. America’s most powerful woman is losing her job. What that means.

Federal Reserve Chair Janet L. Yellen earned widespread approval for her term at the helm of the U.S. central bank, a singularly powerful job in the global economy. On her watch, unemployment fell sharply, inflation stayed subdued, wages began to rise, and she managed a gradual start to the Fed’s unwinding of its $4.5 trillion balance sheet, a tricky task that could have undercut growth if mishandled. Yet despite all that, Trump said he would not name Yellen — the first woman to hold the post — for a second term when her tenure expires at the end of January, an unusual break with tradition.

His decision also, according to some female economists, sends a message to others who may want to follow in Yellen’s footsteps. “She set the bar so high, and as a result of her hard work she was ahead of the curve on so many things,” said Julia Coronado, president of MacroPolicy Perspectives and a former Fed staff member. “Despite that, she’s not getting the job back. What is a young woman economist supposed to make of that? That I can work harder than anybody else and be smarter than people around me and get fired? That’s a tough message.”

8. The iPhone is 10. Where does Apple go from here?

It was a high-stakes moment for a company 10 years after it released what was its most revolutionary product of the century: the original iPhone. In September, Apple introduced its 10th anniversary model, as tech enthusiasts and business analysts alike looked for a glimpse of Apple’s future. It was a test of its consumer tech dominance as it faced a bevy of challenges: Samsung had resumed its smartphone momentum with the new Galaxy Note 8, Apple trailed competitors such as Google in the home hub space, Siri’s artificial intelligence wasn’t as advanced as others, and it was losing to Amazon.com as an entertainment innovator.

Apple’s disruptive reputation was famously first forged by Cook’s predecessor, Steve Jobs, whose showmanship turned such product announcements into glimmering spectacles of consumer technology. While Cook’s tenure at Apple’s helm has been characterized by considerable financial success, many were — and still are — asking: Will this be the moment Apple reclaims its mantle as tech’s top innovator?

7. Trump’s business advisory councils disband as CEOs abandon president over Charlottesville views

President Trump’s relationship with the American business community suffered a major setback in August as the president was forced to shut down his major business advisory councils after corporate leaders repudiated his comments on the violence in Charlottesville. Trump announced the disbanding of the two councils amid a growing uproar by chief executives furious over his decision to equate the actions of white supremacists and protesters. According to people familiar with the CEOs’ thinking, those groups had already decided to dissolve on their own.

The dissolution was a remarkable moment for Trump, who had made his corporate experience and ability to leverage America’s business potential one of his chief credentials. It also marked a rapid descent for a president who has alternatively praised and attacked the decisions of corporate leaders, sometimes making unverified or false claims, and whose policy choices on issues such as immigration and climate change have been criticized as anti-business. He lashed out on Twitter at the first CEO to resign, Merck chief executive Ken Frazier; Frazier’s resignation was followed by a wide range of CEOs, including JP Morgan Chase CEO Jamie Dimon and Campbell Soup’s Denise Morrison.

6. How Trump’s speech to the Boy Scouts could put AT&T’s CEO in a tricky spot

AT&T chief executive Randall Stephenson was hardly the first corporate leader to have also been national president of the Boy Scouts of America. Secretary of State and former ExxonMobil CEO Rex Tillerson held the role from 2010 to 2012. The CEO of Dreyer’s Grand Ice Cream, Rick Cronk, did so in the mid-2000s.

But Stephenson was almost certainly the first to find himself in that role while the president of the United States made a political speech at a Boy Scout event at a time when his company faced a Justice Department antitrust review. At the time, AT&T was awaiting word on its proposed $85 billion takeover of Time Warner — putting Stephenson in a potentially difficult scenario as many parents and former Boy Scouts called for an apology about Trump’s speech. In November, the Department of Justice sued to block AT&T’s $85 billion bid for entertainment conglomerate Time Warner, setting the stage for one of the biggest antitrust cases in decades.

5. GE CEO Jeffrey Immelt to step down after 16 years

General Electric said in June that its longtime chief executive, Jeffrey R. Immelt, would retire, closing out a 16-year run at the helm of the industrial giant, which included a vast overhaul of the conglomerate’s portfolio but also an underperforming stock price that trailed well below market indexes and competitors.

On Immelt’s watch, GE, the only remaining member of the original Dow Jones industrial average, was the Dow’s worst performing stock among companies that hadn’t gone bankrupt or left the group of blue-chip stocks. His inability to move the stock price — it fell by more than a quarter during his tenure — was thought by many to be his undoing. “Why the change? Two words: stock price,” said Ivan Feinseth, chief investment officer at Tigress Financial Partners. “There is no question. The board and shareholders have given Jeff Immelt a long time. He was CEO for almost 16 years in one of the biggest upmarkets cycles in history and the stock has underperformed.”

4. Trump invited the CEO comparisons, and now he’s being held to them

On the campaign trail, Donald Trump never shied away from touting his business skills, running as the outsider whose supposed management acumen would bring executive sensibilities to Washington. As a result, one of the most popular genres for political and business news and op-ed writers has been the Trump-as-CEO comparison. But in May, following a stunning week of upheaval and self-inflicted crises in the White House, those comparisons were taken to their logical next step. Not one but two publications asked whether the CEO president was performing in a way that should let him keep the corner office.

“If Donald Trump were a CEO, he’d probably be fired today,” blared the headline of a story in The New Yorker. And Bloomberg News editor-in-chief John Micklethwait, writing in the cover story titled “If America were a company, would you keep this CEO?,” suggested the White House was “more like a court than a company, with the king retiring to bed with a cheeseburger and spontaneously tweeting orders.” The CEO-as-president analogy, in other words, has not worn well.

3. Uber’s CEO says ‘I need leadership help.’ What should it look like?

The first step to solving a problem is admitting you have one. And in March, then-Uber CEO Travis Kalanick did just that, making an unusually public call for help after a dashcam video of a heated exchange with one of his company’s drivers went viral online. “This is the first time I’ve been willing to admit that I need leadership help and I intend to get it,” Kalanick wrote in a post on the company’s web site to employees, titled “A profound apology.”

In the weeks and months that followed, Kalanick’s cry for assistance, a rare admission of vulnerability from the top of a booming start-up, can be seen in hindsight as a warning sign. The company lost a slew of top-ranked executives, found itself under investigation by the U.S. Justice Department, fired 20 employees after a workplace investigation turned up harassment and bad behavior, and as a result, committed to 47 changes suggested by investigators. In June, Kalanick took a leave of absence, and resigned shortly thereafter.

2. The cost of silence: Why more CEOs are speaking out in the Trump era

More and more, consumers and employees expect the companies they buy from or work for to take a stand on social issues. And increasingly, CEOs have responded. American companies emerged as a force for social change earlier this year and were among the most vocal critics of Trump’s executive order to temporarily ban migrants from seven Muslim-majority countries. In the days after Trump’s travel ban was issued, more than a dozen top executives at rival companies in Silicon Valley traded a flurry of candid emails to discuss the response. And although Silicon Valley led the opposition, companies as diverse as Chobani, Nike, Ford, Goldman Sachs and MasterCard all said they were against the order or expressed concerns about it.

The risks for companies in speaking out can cut both ways. Doing so can alienate consumers who disagree with the company’s views. But not doing enough doesn’t work either. “Silence used to be the default posture,” said Duke University professor Aaron Chatterji, but political polarization, Facebook and Twitter have changed that. “It’s a choose-a-side mentality. The middle is harder to occupy. And with the proliferation of social media, it’s kind of like a microphone that’s always on. If you’re not speaking out, it’s more conspicuous.”

1. In his dark ‘America First’ inaugural address, Trump has a message for the world

Inaugural speeches tend to be remembered for their soaring rhetoric aimed at unifying a nation after it’s endured the divisions that emerge in a campaign season. And indeed, until Trump’s inaugural address — one that sounded to rhetoric scholars more like a stump speech to his campaign supporters — that has been their most common purpose, to articulate shared values in a democracy.

But the outside world is another audience for the inaugural speech that often gets less attention. Unlike the State of the Union address, presidents have used their inaugural speeches to send a signal to the world community about the new presidency. Trump did not shy away from that audience, speaking to the broader world not only with his opening, but with a thread of nationalism that ran throughout his campaign and his speech. He derided the enriching of “foreign industry at the expense of American industry” and subsidizing “the armies of other countries” in the speech. “Every decision on trade, on taxes, on immigration, on foreign affairs will be made to benefit American workers and American families,” Trump said in the address. “We will follow two simple rules: buy American and hire American.”


More on leadership in Washington:

*Omarosa Manigault’s departure highlights lack of diversity in Trump White House (The Washington Post)

*Paul Ryan sees his wild Washington journey coming to an end (Politico)

*Trump assails FBI leadership, touts loyalty to police (The Washington Post)

*A checklist for when it’s time to quit a job, from the ethics chief who walked out under Trump (Quartz)

Posted byconnie dello buonoDecember 18, 2017Posted inPoliticsLeave a comment on Washington Post on Leadership 12-18-17

The World’s Top Call-Center Nation Has a People Problem

call piThe World’s Top Call-Center Nation Has a People Problem

By

Ditas B Lopez

and

Siegfrid Alegado
  • Philippine industry group to create roadmap to boost skills
  • Half of outsourced jobs at risk from automation, study shows

Since the early 2000s, the Philippines added more than a million jobs as foreign companies outsourced customer support and sales tasks to the Southeast Asian nation.

Northern Lights Technology Development’s call center in Cebu, Philippines.

Photographer: Kuni Takahashi/Bloomberg

Now a looming wave of automation is threatening employment at call centers and forcing the industry to retrain workers to meet the demand for higher skilled jobs in areas such as healthcare, banking, finance and insurance.

“The biggest challenge is people,” Jojo Uligan, president of the Contact Center Association of the Philippines or CCAP, said in an interview at his office in Manila on Wednesday. “We lack people with enough technical expertise and experience to service emerging needs.”

Top 69 call center in the Philippines March 2012 | The Summit Express

http://www.thesummitexpress.com/2012/08/top-69-call-center-in-philippines-march.html

Aug 2, 2012 – It also seems that BPO jobs are one of the priority options for most newly college graduates. Here is the list of top 69 call centers in the Philippines released March 2012. Rank Name of Company 1 TI (Philippines), Inc. 2 Accenture, Inc. 3 Teletech Customer Care Management Phils. Inc 4 Convergys Phils.

List of Filipino & India Call Centers: Manila, Cebu, Mumbai, Delhi …

http://www.123outsource.net/call_center_outsourcing.htm

Find call centers anywhere in the world. Africa, Costa Rica, Europe, India, Philippines, and more!

Where can I find an UP TO DATE list of call centers in the …

https://www.quora.com/Where-can-I-find-an-UP-TO-DATE-list-of-call-centers-in-the…

Here is a good and up-to-date list of call centers in the Philippines (Manila): Find Filipino Call Centers in Cebu, Manila, Davao,Quezon City You may want to directly message Magellan Solutions — one of the leading call centers in the Philippines…

Top 36 BPO (Call Center) Companies in the Philippines in Terms of …

mattscradle.com/top-36-bpo-call-center-companies-in-the-philippines-in-terms-of-rev…

Jan 15, 2017 – top call center company philippines. image credits to the owner. Do you want to start your career in the Business Process Outsourcing (BPO) and Call Center industry? Below are the top 36 BPO companies that you should target when applying for a job. Although the list is based on their respective revenue …

[Updated] The TOP Call center companies in the Philippines for 2017

https://auxbreak.com/top-call-center-companies-philippines-2/

Aug 15, 2017 – Working in the BPO industry consumes so much of your time and energy, so make sure it’s all worth it. JP Morgan Chase. This shouldn’t ccome as a surprise. ANZ. If you hate working at night, this is one place where you should be. Convergys Philippines. Accenture. American Express.

The Philippines has become the call-center capital of the world – LA …

http://www.latimes.com/business/la-fi-philippines-economy-20150202-story.html

Feb 1, 2015 – Today, it’s the job of choice for many young people here. More than 1 million Filipinos now work at call centers and in related outsourcing businesses, mostly serving American companies. The combination of cheap labor and specialized skills has made the Filipino workforce invaluable to a growing list of …

List of Outsourcing Companies in the Philippines | Staff.com Blog

https://blog.staff.com/list-of-philippine-outsourcing-companies/

Jul 3, 2014 – Based on my research they just don’t offer online jobs but they are also operating a call center in the Philippines of the same city where some of the outsourcing companies on your list is located like Live2sell and Taking you Forward. I just cant find reviews about them. I was wondering if you have one?

List of all call centers in the Philippines – Tsikot

https://www.tsikot.com › … › The Pitstop Cafe › Politics, Economy and Religion Talk

Oct 2, 2005 – 9 posts – ‎7 authors

Meron ba kayong alam na website na may list ng call centers here in the Philippines or kahit Metro Manila lang? Thanks in advance!

Philippine Call Centers in Manila – Philippine Country Guide

http://www.philippinecountry.com/philippine_call_centers/manila.html

24X7 Communications Inc URL: http://www.24x7communications.com/. 24X7 Communications Inc MakatiPeak Tower Makati City, Philippines. 24X7 Communications Inc ManilaChamp Building, Anda Circle, Port Area, Manila, Philippines Tel no.: (63) 02-495-0243. 2. 2GO (an Aboitiz company) URL: http://www.2go.com.ph/.

Call Center Companies in Philippines – Call Center Jobs in …

https://call-center-bpo.jobstreet.com.ph/call-center-industry/call-center-companies.htm

Search call center jobs in Philippines. Offering call center job openings, call center agent, call centerdirectory, BPO jobs, interview questions and training.

—————
Connie’s comments: Email motherhealth@gmail.com as I will be in the Philippines (between Dec 26 to Jan 4,2018) to search for a  Philippines call center to work for sustainable – renewable energy project based in California.

The Philippines is the world’s top call center destination with companies like Accenture Plc and American Express Co. among those that have set up shop in the Southeast Asian nation. They’ve been lured by cheaper wages, Filipinos’s cultural affinity with the West, and a 100 million population that’s mostly fluent in English.

With technology constantly advancing, machines are now able to replicate some of the tasks that people do, including customer relations. More than half of outsourced jobs could be lost in a few years unless significant retraining is done, according to a study by Tholons Capital, a New York-based consultancy.

In India, robots are now replacing warehouse workers, for example.

Click to read: Butler, a stubby, orange robot, crawls along the aisles to fetch everything from smartphones to shampoos from warehouse shelves.

Leaders of some of the biggest outsourcing companies in the world will meet this month in the Philippines to craft fresh strategies to counter the impact of automation, Uligan said.

Companies are increasingly seeking workers who are college educated, experienced, have technical expertise and can easily be retrained, he said.

“There is a lot of complex work now,” Uligan said. “It’s no longer mere directory assistance or taking orders.”

These concerns are tempering the outlook for the industry. The CCAP estimates that revenue will grow as much as 8 percent this year until 2022, compared with growth rates exceeding 10 percent in the past.

“People don’t evolve as fast as technology,” Uligan said.

Posted byconnie dello buonoDecember 18, 2017Posted inMenuLeave a comment on The World’s Top Call-Center Nation Has a People Problem

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Trump’s untruth is damaging to our democracy
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The ‘elder orphans’ of the Baby Boom generation by Carina Storrs
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Papaya Leaf Extract renews muscle tissue
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Intestinal mucus, immune system , and gut microbiome and colon cancer
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Dr Mercola on Knee Osteoarthritis
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Healthy Mitochondria Could Stop Alzheimer’s
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Norovirus causing gastroenteritis
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Top health and aging hacks 12-8-17
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Yoga for Parkinson’s balance and gait
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YOUR MOOD DEPENDS ON THE FOOD YOU EAT, AND WHAT YOU SHOULD EAT CHANGES AS YOU AGE
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Top health and aging hacks
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Eye Contact With Your Baby Helps Synchronize Brainwaves
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Quora highlights – answering your health related questions
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Nitric Oxide for strong blood vessels’ cells , up with exercise, melons, cucumber, Vit C, E, amino acid – L-arginine, L-citrulline
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Liver cleanse to help your vision and memory
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New York Times 12-13-17
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Disease condition and odor symptom
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Fasting, sun bathing ,Vit C, Lysine, turmeric, green tea, carrots and raw food diet to reduce tumor size
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Anti-Stress Compound Reduces Obesity and Diabetes Risk
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Inflammation Linked to Chemo Brain
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Effects of altitude and airplane flight on the heart, blood, brain and retina
Posted byconnie dello buonoDecember 15, 2017Posted inMenuLeave a comment on Top health and aging hacks 12-15-17

Washington Post 12-15-17

Opinions

  • The Post’s View
  •  Local Opinions
  •  PostEverything
  •  Letters to the Editor
  •  Global Opinions
Tom Toles
Donald Trump says Happy Tax Holiday to all his friends and loved ones
  • By Tom Toles
Ann Telnaes
Two scoops with PDB sprinkles
  • By Ann Telnaes
Columns

Trent Franks rescinded my internship when I wouldn’t come to his house

I didn’t speak up, but you should.

  • Melissa Richmond
  • ·
  • 16 minutes ago

Democrats should be heartbroken that Roy Moore lost

“Sen. Moore (R-Ala.)” would have been the gift that kept on giving.

  • Marc A. Thiessen
  • ·
  • 8 hours ago

All men should be facing the mirror on sexual harassment

None of us can be disinterested bystanders if things are going to change.

  • Ari Wilkenfeld
  • ·
  • 11 hours ago

To save the GOP, Republicans have to lose

The Alabama election was like looking into the abyss.

  • Michael Gerson
  • ·
  • 21 hours ago

What Trumpists should really worry about

Alabama could be a sign of things to come.

  • Eugene Robinson
  • ·
  • 21 hours ago

A feast for regulatory parasites

The GOP tax proposal is stunningly complex on the corporate side, meaning lawyers and accountants would make out like bandits.

  • Catherine Rampell
  • ·
  • 21 hours ago

How Trump can win the GOP’s great war of ideas

He must make the case for a new conservatism.

  • Christopher Buskirk
  • ·
  • 21 hours ago

Newtonian physics will crush the GOP

The harder Trump fights women and minorities, the harder they will push back.

  • Joe Scarborough
  • ·
  • 21 hours ago
Load More
The Post’s View

Congress should help Puerto Rico — not hurt it

The situation is more dire than we know.

  • Editorial Board
  • ·
  • The Post’s View
  • ·
  • 21 hours ago

Corruption makes Ukraine even more vulnerable to Russia

As long as the country fails to embrace the rule of law, it is in danger.

  • Editorial Board
  • ·
  • The Post’s View
  • ·
  • 21 hours ago

The Supreme Court gets a second chance to quash gerrymandering

A new case challenges extreme partisan redistricting.

  • Editorial Board
  • ·
  • The Post’s View
  • ·
  • 21 hours ago
PostEverything
The CIA tailors its briefings so it doesn’t anger Trump. That’s good.
The CIA reportedly tailors its briefings to avoid enraging President Trump. (MICHAEL REYNOLDS/EPA-EFE/REX/Shutterstock)
Intelligence officials have always adjusted their briefings to suit a president’s style. It’s changing their conclusions that’s dangerous.
  • By David Priess

The two expat bros who terrorized women correspondents in Moscow

Matt Taibbi and Mark Ames trafficked in hideous stereotypes and body-shaming.

  • Kathy Lally
  • ·
  • 28 minutes ago

Stop asking black women to ‘save America.’ Start organizing your own people.

After Alabama, white liberals need to talk to their friends and families, not thank black voters.

  • Brittney Cooper
  • ·
  • 4 hours ago

The Fed’s playbook says raise rates. What if that’s an obsolete game plan?

As congressional Republicans prepare to pass their tax bill , the Federal Reserve is about to say goodbye to Janet Yellen as chair. She’s had a good run: The United States and the world recovered from…

  • Zachary Karabell
  • ·
  • 5 hours ago

Clerkships are invaluable for young lawyers. They can also be a setup for abuse.

When things go wrong, too often law clerks — about half of whom are women — feel they have nowhere to turn.

  • Catherine Crump
  • ·
  • 5 hours ago

America’s chaotic, crazy, challenging, great, tumultuous, horrible, disappointing year

A look back at the ups and downs of public opinion in 2017.

  • Scott Clement, Emily Guskin, Shelly Tan
  • ·
  • 7 hours ago

Want to thank black voters for defeating Roy Moore? Tackle voter suppression.

Voter suppression tactics didn’t work in Alabama this time, but they could have.

  • Mikki Kendall
  • ·
  • 11 hours ago

A three-tiered solution for Puerto Rico

This is a way to meet the challenges faced by our fellow citizens in Puerto Rico. Is there a will?

  • Jared Bernstein
  • ·
  • 1 day ago

Tell me how Trump’s North Korea gambit ends

I do not see a conceivable military option that would not lead to a catastrophic loss of life.

  • Daniel W. Drezner
  • ·
  • 1 day ago

Donald Trump cannot stop endorsing losers

Donald Trump’s losing streak in endorsements is now at three.

  • Daniel W. Drezner
  • ·
  • 2 days ago

The Republicans have momentum on the tax cut. How did it come to this?

It’s worth trying to figure out how and why we may be on the verge of legislating a terribly damaging tax plan.

  • Jared Bernstein
  • ·
  • 2 days ago

I’m Jewish. My husband is Christian. What do I tell our daughter about Santa?

We’re still writing the holiday script in our multifaith home.

  • Jessica Grose
  • ·
  • 2 days ago

How Silicon Valley’s blind spots and biases are ruining tech for the rest of us

An industry obsessed with “disruption” hasn’t bothered to think about who’s being left behind, alienated and insulted by its products.

  • Sara Wachter-Boettcher
  • ·
  • 2 days ago

Who belongs in the anti-Trump coalition?

Those in political opposition need all the political allies they can muster.

  • Daniel W. Drezner
  • ·
  • 3 days ago

I don’t like the GOP tax bill, but now my life depends on beating it

I begged Sen. Jeff Flake to listen to my story.

  • Ady Barkan
  • ·
  • 3 days ago

If you miss Gawker, don’t let Peter Thiel buy its archives

The billionaire already put the site out of business. Now he wants what’s left of it.

  • J.K. Trotter
  • ·
  • 3 days ago

Four thoughts on the story that almost broke the #ToddlerinChief thread

Regarding the 60-source New York Times story confirming that the president has the emotional maturity of a 4-year-old.

  • Daniel W. Drezner
  • ·
  • 4 days ago

Why doesn’t Apple make its devices as carefully as it’s making Apple Park?

Its fancy new headquarters may be perfect. Not much else is.

  • Rob Pegoraro
  • ·
  • 4 days ago

Weary of the Internet, I went back to mail. 108 letters later, here’s what I learned.

I wrote one letter every day, to someone I knew or used to know or wanted to know better.

  • Tim Johnson
  • ·
  • 4 days ago

There are dolls for all Barbie’s weddings. Here are the ones for her divorces.

Barbie is the plastic Larry King — she’s had more weddings than anybody could hope to keep track of. Mattel is exceedingly talented at mashing up the words “bride” and “Barbie.” There’s Barbie…

  • Amy Collier, Susan Burghart
  • ·
  • Dec 8

This is how nuclear war with North Korea would unfold

In one all-too-plausible worst-case scenario, millions die from mistakes and a tweet.

  • Jeffrey Lewis
  • ·
  • Dec 8
Load More
Outlook
America’s chaotic, crazy, challenging, great, tumultuous, horrible, disappointing year
A look back at the ups and downs of public opinion in 2017. (Shelly Tan/The Washington Post)
A look back at the ups and downs of public opinion in 2017. (Shelly Tan/The Washington Post)
A look back at the ups and downs of public opinion in 2017.
  • By Scott Clement, Emily Guskin and Shelly Tan

The two expat bros who terrorized women correspondents in Moscow

Matt Taibbi and Mark Ames trafficked in hideous stereotypes and body-shaming.

  • Kathy Lally
  • ·
  • 28 minutes ago

Five myths about bitcoin

No, the currency isn’t beyond the reach of the law, and it won’t replace cash.

  • Joseph Bonneau, Steven Goldfeder
  • ·
  • 4 hours ago

The Fed’s playbook says raise rates. What if that’s an obsolete game plan?

As congressional Republicans prepare to pass their tax bill , the Federal Reserve is about to say goodbye to Janet Yellen as chair. She’s had a good run: The United States and the world recovered from…

  • Zachary Karabell
  • ·
  • 5 hours ago
Local Opinions

Why does D.C. have so few public restrooms?

Options dwindle further at night.

  • Marcia Bernbaum
  • ·
  • 1 hour ago

How to give Maryland workers sick leave without killing businesses

The finger-pointing from the legislature helps no one.

  • Larry Hogan
  • ·
  • 1 hour ago

Virginia took a bold step in tolling I-66. And it’s likely to pay off.

Officials eschewed a Sisyphean strategy and tired something different to deal with intractable transportation problems in the region.

  • Robert Puentes
  • ·
  • 1 hour ago

Let’s really open the roads in Montgomery County

Cars are here to stay, so traffic planning must focus on adding more routes for them.

  • Jason Neuringer
  • ·
  • Dec 8
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Campus rapes aren’t being reported to D.C. police, and that’s dangerous

Federal law mandates that universities share campus rape statistics with the Education Department but not with law enforcement.

Posted byconnie dello buonoDecember 15, 2017Posted inPoliticsLeave a comment on Washington Post 12-15-17

New York Times 12-15-17

Editorials

More in Editorials »

  1. Photo

    Who Will Judge the Judge?

  2. Photo

    In Myanmar, Echoes of Past Horrors Are Amplified

  3. Photo

    No, Mr. Trump, Torture Doesn’t Work

  4. Photo

    The Pentagon Is Not a Sacred Cow

  5. Photo

    When the People’s Lawyer Breaks the Law

Sunday Review

More in Sunday Review »

  1. Photo

    Roy Moore’s Alabama

  2. Photo

    Office Secret Santa Guidelines for 2017

  3. Photo

    The Baker, the Gay Couple and the Wedding Cake

  4. Photo

    The Importance of Dumb Mistakes in College

  5. Photo

    The Looting of America’s Public Lands

Latest

  • Search

Latest Articles

  1. LETTER

    An Israeli View on Peace

    Israel’s consul general in New York responds to an editorial.

    Dec. 15, 2017
  2. LETTERS

    The Effects of Ending Net Neutrality

    Is the F.C.C. decision a victory for special interests that will harm consumers, or a fairer system in which heavy internet users might pay more?

    Dec. 15, 2017
  3. LETTER

    How #MeToo Threatens Equality

    A reader argues that not distinguishing between different forms of harassment — a clumsy advance versus an assault — “diminishes women.”

    Dec. 15, 2017
  4. LETTER

    The Tax Bill: ‘This Abomination’

    The United Food and Commercial Workers International Union writes that “hard-working families deserve better than this bill.”

    Dec. 15, 2017
  5. LETTER

    Parents, Kids and Tech

    A reader is grateful that her concerns about her children’s tech use are in the past.

    Dec. 15, 2017
  6. Defeat in Alabama

    President Trump tried to distance himself from Roy Moore’s loss.

    By PATRICK CHAPPATTE

    Dec. 15, 2017
  7. DISABILITY

    My Supercharged, Tricked Out, Bluetooth Wheelchair Life Force

    The bond I have with my fellow bus commuter isn’t just tolerant. It’s fully embracing of me.

    By KATIE SAVIN

    Dec. 15, 2017
  8. OP-ED CONTRIBUTOR

    What’s Stifling Pay Raises Is Also Curbing Economic Growth

    As productivity growth lags, living standards for American workers do, too.

    By RYAN AVENT

    Dec. 15, 2017
  9. CONTRIBUTING OP-ED WRITER

    The Deserving Rich and the Deserving Poor

    Americans are a generous people, but our generosity comes with moral judgments.

    By TIMOTHY EGAN

    Dec. 15, 2017
  10. OP-ED CONTRIBUTOR

    How I Went From the Governor’s Office to a Jail Cell

    Ukraine’s corrupt elites have turned what could be one of Europe’s wealthiest countries into one of its poorest.

    By MIKHEIL SAAKASHVILI

Posted byconnie dello buonoDecember 15, 2017Posted inPoliticsLeave a comment on New York Times 12-15-17

Prostate flush and masturbation

Why Men Should Masturbate 21 Times A Month According To Science …

http://www.iflscience.com/health…/masturbating-frequently-reduces-risk-of-prostate-cancer/

Jul 6, 2017 – Masturbating frequently may actually result in a significantly lower risk of prostate cancer. … It is currently unconfirmed why, but some scientists believe a successful orgasm may flush out cancer-determining toxins that build up in the prostate. Around one in seven men will experienceprostate cancer in the …

Frequent ejaculation may decrease prostate cancer risk – National …

https://www.ncbi.nlm.nih.gov/…/2017-07-06-frequent-ejaculation-may-decrease-pros…

Jul 6, 2017 – Despite any lurid tales you may have heard growing up, masturbation is entirely safe. So if you want to do it as a … The Sun’s claim that “having 21 orgasms a month could be the key to preventing CANCER in men because it helps the prostate ‘flush out toxins'” is unsupported. The claim that it flushesout …

Science Says Men Should Masturbate 21 Times A Month — Here’s …

https://www.huffingtonpost.com/…/science-says-men-should-masturbate-21-times-a-…

Jul 13, 2017 – Beyond the prostate flush, Dr. Kerner says masturbation comes with a whole slew of benefits, such as giving a dude the chance to experience pleasure and relaxation. “It’s an opportunity to engage in self-care,” he explains. “Masturbation can also be a healthy distraction mechanism and a natural way of …

Happy news! Masturbation actually has health benefits

theconversation.com/happy-news-masturbation-actually-has-health-benefits-16539

Dec 4, 2013 – For men, masturbation helps reduce risk of prostate cancer, probably by giving theprostate a chance to flush out potential cancer-causing agents. Masturbation also improves immune functioning by increasing cortisol levels, which can regulate immune functioning in small doses. It also reduces depression …

prostate health and ejaculation – WebMD

https://www.webmd.com › Prostate Cancer › News

Apr 6, 2004 – April 6, 2004 — Frequent ejaculation, whether it happens during sexual intercourse,masturbation, or a dream, isn’t likely to increase men’s risk of prostate cancer. In fact, new research suggests it may have the opposite effect and help protect the prostate. Researchers say it’s too soon to recommend that …

Masturbation and Prostate Cancer Risk – WebMD

https://www.webmd.com › Prostate Cancer › News

Jan 27, 2009 – Frequent masturbation is a sign of higher prostate cancer risk in younger men, but a sign of lower risk in older men, a U.K. study shows.

Masturbating may protect against prostate cancer | New Scientist

https://www.newscientist.com/…/dn3942-masturbating-may-protect-against-prostate-c…

Jul 16, 2003 – Frequent ejaculation by men may cut the risk by a third – the flushing out of carcinogens is one possible explanation.

Re: Masturbation flushes toxins, cuts cancer risk at News Forum …

https://www.curezone.org/forums/am.asp?i=588340

3 posts – ‎2 authors

not so fast. there is much more to this than meets the eye. first of all, the best thing to do is to not ingest the toxins to begin with. secondly, staying well hydrated and doing physical activity which stimulates circulation, particularly the kind that makes the lymph system flow, will flush not only the prostate but also the rest of the …

10 benefits of masturbating – Men’s Fitness

https://www.mensfitness.com/women/sex-tips/12-benefits-0

A 2004 Harvard study found that men who ejaculated 21 times per month were less likely to faceprostate cancer compared to those who ejaculated four to seven times a month. The exact link betweenmasturbation and prostate cancer risk is unclear, but flushing the prostate of carcinogens that could cause problems is the …

You Won’t Go Blind: Men’s Health.com

https://www.menshealth.com/sex-women/health-and-sexual-benefits-of-masturbation

May 24, 2012 – Learn the sexual benefits and health benefits of masturbation, from Men’s Health. … A 2003 Australian study found that men who ejaculated more than five times a week were a third less likely to develop prostate cancer. Regularly flushing your system, so to speak, keeps your semen healthy and prevents …

Posted byconnie dello buonoDecember 15, 2017Posted inMenuTags:masturbation, prostate cancerLeave a comment on Prostate flush and masturbation

Disrupted Internal Clocks Play Role in Liver Disease

via Disrupted Internal Clocks Play Role in Liver Disease

Posted byconnie dello buonoDecember 15, 2017Posted inMenuLeave a comment on Disrupted Internal Clocks Play Role in Liver Disease

Disrupted Internal Clocks Play Role in Liver Disease

It’s About Time: Disrupted Internal Clocks Play Role in Disease

Study uncovers circadian disruption as risk factor in alcoholic liver disease.

Thirty percent of severe alcoholics develop liver disease, but scientists have not been able to explain why only a subset is at risk. A research team from Northwestern University and Rush University Medical Center now has a possible explanation: disrupted sleep and circadian rhythms can push those vulnerable over the edge to disease.

The team studied mice that essentially were experiencing what shift workers or people with jet lag suffer: their internal clocks were out of sync with the natural light-dark cycle.

Another group of mice had circadian disruption due to a faulty gene. Both groups were fed a diet without alcohol and next with alcohol, and the team then examined the physiological effects.

The researchers found the combination of circadian rhythm disruption and alcohol is a destructive double hit that can lead to alcoholic liver disease.

The study was published last month by the journal PLOS ONE.

“Circadian disruption appears to be a previously unrecognized risk factor underlying the susceptibility to or development of alcoholic liver disease,” said Fred W. Turek, the Charles E. and Emma H. Morrison Professor of Biology at Northwestern’s Weinberg College of Arts and Sciences and one of the senior authors of the paper.

“What we and many other investigators are doing is bringing time to medicine for the diagnosis and treatment of disease,” Turek said. “We call it circadian medicine, and it will be transformative. Medicine will change a great deal, similar to the way physics changed when Einstein brought time to physics.”

The image shows the different stages of liver damage.

A number of years ago, Ali Keshavarzian, M.D., a gastroenterologist at Rush University Medical Center who has worked with and studied patients with gastrointestinal and liver diseases, had a hunch disrupted circadian rhythms could be a contributing factor to the disease.

Keshavarzian had noticed that some patients with inflammatory bowel disease (inflammation in the intestine and/or colon) had flare-ups of symptoms when working nights, but they could control the disease when working the day shift. He sought out Turek, director of Northwestern’s Center for Sleep and Circadian Biology, to help investigate the relationship between circadian rhythms and the disease.

The two investigators and their groups first studied the effect of circadian rhythm disruption in an animal model of colitis and noted that disruption of sleep and circadian rhythms (caused by modeling shift work and chronic jet lag in the animals) caused more severe colitis in mice.

Keshavarzian has been studying the effect of “gut leakiness” (the intestinal lining becomes weak and causes dangerous endotoxins to get into the blood stream) to bacterial products in gastrointestinal diseases for two decades. Because the mouse model of colitis is associated with leaky gut, he proposed that disruption of circadian rhythms from shift work could make the intestine more susceptible to leakiness. He wanted to test its effect in an animal model of alcoholic liver disease — where a subset of alcoholics develop gut leakiness and liver disease — in order to find out whether shift work is the susceptibility factor that promotes liver injury.

“Non-pathogen-mediated chronic inflammation is a major cause of many chronic diseases common in Western societies and developing countries that have adopted a Western lifestyle,” said Keshavarzian, one of the senior authors of the paper. He is director of the Division of Digestive Diseases and the Josephine M. Dyrenforth Chair of Gastroenterology.

Crohn’s and ulcerative colitis, Parkinson’s disease, diabetes, multiple sclerosis, autoimmune disease and cardiovascular disease are examples of these diseases, to name just a few.

“Recent studies have shown that intestinal bacteria are the primary trigger for this inflammation, and gut leakiness is one of the major causes,” Keshavarzian said. “The factor leading to gut leakiness is not known, however. Our study suggests that disruption of circadian rhythms and sleep, which is part of life in industrial societies, can promote it and explain the susceptibility.”

In the study, the Northwestern and Rush researchers used two independent approaches, studying both genetic and environmental animal models. The circadian rhythms of one group of mice were disrupted genetically: Each animal had a mutant CLOCK gene, which regulates circadian rhythms. The second group’s circadian rhythms were disrupted environmentally: The animals’ light-dark cycle was changed periodically, leading to a state similar to chronic jet lag.

Mice in both groups, prior to ingesting alcohol, showed an increase in gut leakiness.

Next, both groups of mice were fed alcohol. After only one week, animals in both groups showed a significant additional increase in gut leakiness, compared to control mice on an alcohol-free diet. At the end of the three-month study, mice in both groups were in the early stages of alcoholic liver disease.

“We have clearly shown that circadian rhythm disruption can trigger gut leakiness, which drives the more severe pathology in the liver,” said Keith Summa, a co-first author of the study and an M.D./Ph.D. candidate working in Turek’s lab.

“For humans, circadian rhythm disruption typically is environmental, not genetic, so individuals have some control over the behaviors that cause trouble, be it a poor sleep schedule, shift work or exposure to light at night,” he said.

Sleep and circadian rhythms are an integral part of biology and should be part of the discussion between medical doctors and their patients, the researchers believe.

“We want to personalize medicine from a time perspective,” Turek said. “Our bodies are organized temporally on a 24-hour basis, and this needs to be brought into the equation for understanding health and disease.”

Notes about this circadian rhythm and health research

The paper, titled “Disruption of the Circadian Clock in Mice Increases Intestinal Permeability and Promotes Alcohol-Induced Pathology and Inflammation,” is available online.

In addition to Turek, Keshavarzian and Summa, other authors of the paper are co-first author Robin M. Voigt, Christopher B. Forsyth, Maliha Shaikh and Yueming Tang, of Rush University Medical Center; Martha Hotz Vitaterna and Kate Cavanaugh, of Northwestern; and Shiwen Song, of the American Society for Clinical Pathology.

Contact: Megan Fellman – Northwestern University
Source: Northwestern University press release
Image Source: The liver damage image is credited to the NIH and is in the public domain.
Original Research: Full open access research for “Disruption of the Circadian Clock in Mice Increases Intestinal Permeability and Promotes Alcohol-Induced Hepatic Pathology and Inflammation” by Keith C. Summa, Robin M. Voigt, Christopher B. Forsyth, Maliha Shaikh, Kate Cavanaugh, Yueming Tang, Martha Hotz Vitaterna, Shiwen Song, Fred W. Turek and Ali Keshavarzian in PLOS ONE. Published online June 18 2013 doi:10.1371/journal.pone.0067102

Posted byconnie dello buonoDecember 15, 2017Posted inMenuTags:alcohol, autoimmune, disease, liver, sleep1 Comment on Disrupted Internal Clocks Play Role in Liver Disease

Trump’s untruth is damaging to our democracy

via Trump’s untruth is damaging to our democracy

Posted byconnie dello buonoDecember 15, 2017Posted inMenuLeave a comment on Trump’s untruth is damaging to our democracy

Trump’s untruth is damaging to our democracy

Trump is different. When he is caught lying, he will often try to discredit people telling the truth, be they judges, scientists, F.B.I. or C.I.A. officials, journalists or members of Congress. Trump is trying to make truth irrelevant. It is extremely damaging to democracy, and it’s not an accident. It’s core to his political strategy.

 

As for Obama: His falsehoods tended to be attempts to make his own policies look better or to overstate a problem he was trying to solve. In a few cases, they seemed to be careless exaggerations he avoided repeating.

 

Over all, Obama rarely told demonstrable untruths as president. And he appears to have become more careful over time. We counted six straight-up falsehoods in his first year in office. Across his entire second four-year term, we counted the same number, six, only one of which came in his final year in office.

 

In all, we found 18 different bald untruths from Obama during his presidency. Trump told his 18th separate untruth in his third full week in office, and his list keeps growing.

https://www.nytimes.com/interactive/2017/12/14/opinion/sunday/trump-lies-obama-who-is-worse.html?rref=collection%2Fsectioncollection%2Fopinion&action=click&contentCollection=opinion&region=stream&module=stream_unit&version=latest&contentPlacement=12&pgtype=sectionfront&_r=0

Posted byconnie dello buonoDecember 15, 2017Posted inPolitics2 Comments on Trump’s untruth is damaging to our democracy

Changes in Opioid Prescribing in the United States, 2006–2015

Vital Signs: Changes in Opioid Prescribing in the United States, 2006–2015

Gery P. Guy Jr., PhD1; Kun Zhang, PhD1; Michele K. Bohm, MPH1; Jan Losby, PhD1; Brian Lewis2; Randall Young, MA2; Louise B. Murphy, PhD3; Deborah Dowell, MD1 (View author affiliations)

View suggested citation and related materials

Key Points

• The amount of opioids prescribed in the United States peaked in 2010 and then decreased each year through 2015. Despite reductions, the amount of opioids prescribed remains approximately three times as high as in 1999.

• Opioid prescribing varied substantially across the country, with average per capita amounts prescribed in the top-prescribing counties approximately six times the amounts prescribed in the lowest prescribing counties in 2015.

• Higher amounts of opioids were prescribed in counties with a larger percentage of non-Hispanic whites; a higher prevalence of diabetes and arthritis; micropolitan counties; and counties with higher rates of unemployment and Medicaid enrollment.

• The substantial variation in opioid prescribing observed at the county-level suggests inconsistent practice patterns and a lack of consensus about appropriate opioid use and demonstrates the need for better application of guidance and standards around opioid prescribing practices.

• Health care providers can follow the CDC’s Guideline for Prescribing Opioids for Chronic Pain, which provides evidence-based recommendations about opioid prescribing for primary care clinicians treating adult patients with chronic pain, outside of active cancer treatment, palliative care, and end-of-life care.

• Additional information is available at https://www.cdc.gov/vitalsigns/.

Abstract

Background: Prescription opioid–related overdose deaths increased sharply during 1999–2010 in the United States in parallel with increased opioid prescribing. CDC assessed changes in national-level and county-level opioid prescribing during 2006–2015.

Methods: CDC analyzed retail prescription data from QuintilesIMS to assess opioid prescribing in the United States from 2006 to 2015, including rates, amounts, dosages, and durations prescribed. CDC examined county-level prescribing patterns in 2010 and 2015.

Results: The amount of opioids prescribed in the United States peaked at 782 morphine milligram equivalents (MME) per capita in 2010 and then decreased to 640 MME per capita in 2015. Despite significant decreases, the amount of opioids prescribed in 2015 remained approximately three times as high as in 1999 and varied substantially across the country. County-level factors associated with higher amounts of prescribed opioids include a larger percentage of non-Hispanic whites; a higher prevalence of diabetes and arthritis; micropolitan status (i.e., town/city; nonmetro); and higher unemployment and Medicaid enrollment.

Conclusions and Implications for Public Health Practice: Despite reductions in opioid prescribing in some parts of the country, the amount of opioids prescribed remains high relative to 1999 levels and varies substantially at the county-level. Given associations between opioid prescribing, opioid use disorder, and overdose rates, health care providers should carefully weigh the benefits and risks when prescribing opioids outside of end-of-life care, follow evidence-based guidelines, such as CDC’s Guideline for Prescribing Opioids for Chronic Pain, and consider nonopioid therapy for chronic pain treatment. State and local jurisdictions can use these findings combined with Prescription Drug Monitoring Program data to identify areas with prescribing patterns that place patients at risk for opioid use disorder and overdose and to target interventions with prescribers based on opioid prescribing guidelines.

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Introduction

In 2015, drug overdoses accounted for 52,404 deaths in the United States, 63.1% of which involved an opioid (1). Among opioid-related deaths, approximately 15,000 (approximately half) involved a prescription opioid (2). In addition, an estimated 2.0 million persons in the United States had opioid use disorder (addiction) associated with prescription opioids in 2015 (3). The economic burden of prescription opioid overdose, abuse, and dependence is estimated to be $78.5 billion each year in the United States (4). Prescription opioid-related overdose deaths and admissions for treatment of opioid use disorder have increased in parallel with increases in opioids prescribed in the United States, which quadrupled from 1999 to 2010 (5). This increase was primarily because of an increase in the use of opioids to treat chronic noncancer pain (6,7). Previously, opioids had primarily been reserved for severe acute pain, postsurgical pain, and end-of-life care. This change in prescribing practice increased the amount of opioids prescribed for three reasons. First, opioid use for chronic noncancer pain increased the number of opioid prescriptions. Second, the use of opioids to treat ongoing chronic conditions increased the average lengths of time for which opioids were prescribed (6,7). Third, average dosages of opioid prescriptions tend to be higher for patients who are prescribed opioids for long periods of time, effectively increasing the average amount of opioids supplied per prescription (6,7). Together, these changes placed more persons at risk for opioid use disorder and overdose (8–11).

Chronic pain is one of the most common reasons for seeking medical attention in the United States, and prescription opioids are frequently prescribed to manage pain (12). However, opioids should only be used when benefits are expected to outweigh risks. Ensuring that patients have access to safe, effective treatment is critical and involves improving the way opioids are prescribed. To improve understanding of opioid prescribing trends in the United States before the release of CDC’s 2016 Guideline for Prescribing Opioids for Chronic Pain (Guideline), CDC analyzed changes in national and county-level opioid prescribing and characteristics associated with higher prescribing rates at the county-level (13).

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Methods

Data on opioid prescribing come from the QuintilesIMS Transactional Data Warehouse, which provides estimates of the number of opioid prescriptions dispensed in the United States based on a sample of approximately 59,000 pharmacies, representing 88% of prescriptions in the United States.

Changes in opioid prescribing at the national level were analyzed from 2006 to 2015. Prescribing rates included overall opioid prescribing rates, high-dose prescribing rates, and prescribing rates by days’ supply (≥30 days and <30 days). Annual opioid prescribing rates were calculated by dividing the number of opioid prescriptions by the U.S. Census population estimates each year. High-dose prescribing rates include prescriptions with daily dosage ≥90 morphine milligram equivalents (MME) (13). All rates are per 100 persons. Additional measures included MME per capita, average daily MME per prescription, and average days’ supply per prescription. Cold and cough products containing opioids and buprenorphine products indicated for conditions other than pain were excluded.

To determine where prescribing changes occurred, opioid prescribing at the county level was examined in 2010 (when prescribing levelled off nationally) and 2015. Quartiles were created using MME per capita to characterize the distribution of opioids prescribed. The percentage of counties experiencing changes in opioid prescribing measures from 2010 to 2015 was calculated. A change of ≥10% was considered to be an increase or decrease, whereas changes <10% were considered stable. County-level characteristics were examined in 2015 by MME per capita quartiles. County characteristics were obtained from the U.S. Census Bureau (age, urban/rural status); American Community Survey (race/ethnicity, percent uninsured, percent unemployed, income); U.S. Diabetes Surveillance System (diabetes prevalence); Dartmouth Atlas of Health Care (provider supply); Centers for Medicare and Medicaid Services (Medicaid and Medicare coverage); Behavioral Risk Factor Surveillance System (arthritis prevalence); and the Area Health Resource File (percent disabled, suicide rate). To identify county-level factors associated with MME per capita in 2015, a stepwise multivariable linear regression model incorporating age, race/ethnicity, insurance status, education, unemployment rates, poverty rates, median income, urban/rural status (metropolitan, micropolitan [i.e., town/city; nonmetro], and noncore [i.e., rural; nonmetro]), suicide rates, dentist and primary care physician density, and diabetes, arthritis, and disability prevalence was estimated.

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Results

In the United States, annual opioid prescribing rates increased from 72.4 to 81.2 prescriptions per 100 persons from 2006 to 2010, were constant from 2010 to 2012, and then decreased by 13.1% to 70.6 per 100 persons from 2012 to 2015 (Figure 1). Annual high-dose opioid prescribing rates remained stable from 2006 to 2010 and then declined by 41.4% from 11.4 per 100 persons in 2010 to 6.7 in 2015. Annual prescribing rates for prescriptions of ≥30 days’ supply increased 58.9% from 17.6 per 100 persons in 2006 to 28.0 per 100 persons in 2012 and leveled off from 2012 to 2015. Annual prescribing rates for prescriptions of <30 days’ supply were stable from 2006 to 2012 and decreased 20.2% from 53.2 per 100 persons in 2012 to 42.4 in 2015. Average daily MME per prescription remained stable from 2006 to 2010 and then decreased 16.9% from 58.0 in 2010 to 48.1 in 2015. Average days’ supply prescribed increased 33.0% from 13.3 in 2006 to 17.7 in 2015.

From 2010 to 2015, the amount of opioids prescribed in the United States decreased from 782 to 640 MME per capita (data not shown). In 2010 and 2015, the amount of opioids prescribed across counties varied substantially (Figure 2). From 2010 to 2015, among counties with sufficient data MME per capita decreased in 49.6% of counties, remained stable in 27.8% of counties, and increased in 22.6% of counties (Table 1). Overall prescribing rates decreased in nearly half (46.5%) of counties, whereas high-dose opioid prescribing rates and average daily MME per prescription decreased in the majority of counties, with 86.5% and 72.1% of counties, respectively, experiencing decreases. From 2010 to 2015, average number of days’ supply increased in 73.5% of counties.

Despite reductions in prescribing, the amount of opioids prescribed in 2015 remained high relative to 1999 levels and varied substantially across the country, from an average of 203 MME per capita in the lowest quartile to 1,319 MME per capita in the highest quartile. Opioid prescribing amounts varied across several county-level characteristics (Table 2). After adjustment in the multivariable model, the following characteristics were associated with higher amounts of opioids prescribed: a larger percentage of non-Hispanic whites; higher rates of uninsured and Medicaid enrollment, lower educational attainment; higher rates of unemployment; micropolitan status; more dentists and physicians per capita; a higher prevalence of diagnosed diabetes, arthritis, and disability; and higher suicide rates. Together, these factors explain approximately 32% of the variation in the amount of opioids prescribed at the county-level.

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Discussion

The amount of opioids prescribed in the United States began to decrease in 2011. However, in 2015, at 640 MME per capita, it remains approximately three times as high as in 1999, when 180 MME per capita were sold in the United States (5), and nearly four times as high as the amount distributed in Europe in 2015 (14).

Two prescribing changes appear to be associated with the decrease in MME prescribed per capita in the United States from 2010 to 2015. First, average daily MME per prescription decreased after 2010, both nationwide and in most counties. The largest decreases occurred from 2010 to 2012, following publication of two national guidelines defining high-dose opioid prescribing as >200 MME/day (15,16). It also coincided with studies demonstrating progressively increasing overdose risk at prescribed opioid dosages exceeding 20, 50, and 100 MME per day (9–11) and publications highlighting associations of prescribed opioids with overdose deaths (5,17). Second, the rate of opioid prescribing decreased nationwide and in many counties. Nationally, opioid prescribing rates leveled off from 2010 to 2012, and then decreased by 13.1% from 2012 to 2015. These decreases might reflect growing awareness among clinicians and patients of the risks associated with opioids. Throughout this period, however, the average duration of opioid prescriptions increased, in part because of the continued increase in longer opioid prescriptions (≥30 days) through 2012, followed by a stabilization of the rate, and a substantial decrease in shorter prescriptions (<30 days) after 2012. This pattern, along with the trends in overall numbers of opioid prescriptions, might reflect fewer patients initiated on opioid therapy after 2012, whereas patients already receiving opioids were more likely to continue receiving them. Patients are at risk for continuing opioids long-term once they have received them for >5 days (18), and are unlikely to discontinue opioids after they have received them for 90 days (19), highlighting both the importance of minimizing unnecessary initial opioid exposure and potential challenges in reducing opioid use among patients already receiving them.

From 2010 to 2015, half of counties in the United States experienced reductions in the amount of opioids prescribed, with substantial decreases in certain states. In 2011 and 2012, Ohio and Kentucky, respectively, mandated that clinicians review Prescription Drug Monitoring Program (PDMP) data and implemented pain clinic regulation (20). MME per capita decreased in 85% of Ohio counties and 62% of Kentucky counties from 2010 to 2015. In Florida, where multiple interventions targeted excessive opioid prescribing from 2010 through 2012, (e.g., pain clinic regulation and mandated PDMP reporting of dispensed prescriptions) (21), the amount of opioids prescribed per capita decreased in 80% of counties from 2010 to 2015. During this time, Florida also experienced reductions in prescription opioid-related overdose deaths (21).

Despite reductions, the amount of opioids prescribed in 2015 remained high relative to 1999 levels and varied substantially across the country, with average per capita amounts prescribed in the top quartile of counties approximately six times the amounts prescribed in the lowest quartile. Larger amounts were prescribed in micropolitan counties and in counties with a higher prevalence of diagnosed diabetes and arthritis. The latter finding might represent treatment for pain associated with these or co-occurring painful conditions. However, there are effective nonopioid treatments for pain whose benefits outweigh the harms (13). Reasons for higher opioid use in micropolitan counties might include less access to quality health care and other treatments for pain, such as physical therapy. In addition, persons in rural areas might travel to micropolitan areas, which often serve as an anchor community for a much larger rural region, to receive medical care and pick up medications.

Despite reductions in opioid prescribing in recent years, opioid-involved overdose death rates continue to increase. However, these increases have been driven largely by use of illicit fentanyl and heroin (1). There is no evidence that policies designed to reduce inappropriate opioid prescribing are leading to these increases. Combined implementation of mandated provider review of PDMP data and pain clinic laws reduced the amount of opioids prescribed, prescription opioid-involved overdose deaths, and all opioid-involved deaths (20). The policies were also associated with reductions in heroin overdose deaths that were not statistically significant (20). By reducing the number of persons exposed to opioids and the subsequent risk of opioid use disorder these policies might reduce the number of persons initiating illicit opioid use in the longer term (20).

The findings in this report are subject to at least four limitations. First, QuintilesIMS estimates of dispensed prescriptions have not been validated, and they do not include prescriptions dispensed directly by prescribers (although this likely represents a small minority of prescribed opioids), potentially biasing opioid prescribing downwards. Second, county-level analyses are aggregated by the county where an opioid is dispensed, and cannot account for prescriptions obtained by persons outside of the county. Third, the analysis does not include clinical outcomes. However, previous analyses have found associations between population-level amounts of opioids prescribed and opioid overdose death rates (5), and between prescribed dosages and individual overdose risk (9–11). Finally, because data on the indications for which opioids were prescribed were not available, the appropriateness of opioid prescriptions, or whether opioids were prescribed for acute, chronic, or end-of-life pain, could not be determined.

Although some variation in opioid prescribing is associated with characteristics such as the prevalence of possibly painful conditions (e.g., arthritis), differences in these characteristics explain only a fraction of the wide variation in opioid prescribing across the United States. This variation suggests inconsistent practice patterns and a lack of consensus about appropriate opioid use and demonstrates the need for better application of guidance and standards around opioid prescribing practices (13). CDC’s Guideline provides evidence-based recommendations about opioid prescribing for primary care clinicians treating adult patients with chronic pain outside of active cancer treatment, palliative care, and end-of-life care (13). The Guideline can help providers and patients weigh the benefits and risks for opioids according to best available evidence and individual patients’ needs and safely taper opioids if risks outweigh benefits. The Guideline recommends the use of nonopioid therapies, such as acetaminophen, nonsteroidal anti-inflammatory medications, exercise therapy, and cognitive behavioral therapy for chronic pain (13).

Given associations between opioid prescribing, opioid use disorder, and opioid overdose rates (5), states and local jurisdictions can use these findings to target high-prescribing areas for interventions such as academic detailing for clinicians or individual educational visits to clinicians (22), and increased access to medication-assisted treatment for patients with opioid use disorder. Innovative approaches such as virtual physical therapy sessions with pain coping skills training (23,24) can be used to improve access to effective treatment for chronic pain. In addition, states can consider policies that can reduce opioid overdose, including mandated PDMP use and pain clinic laws (20). Changes in opioid prescribing can save lives. The findings of this report demonstrate that substantial changes are possible and that more are needed.

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Acknowledgments

Puja Seth, PhD; Rose Rudd, MSPH; Lyna Schieber, DPhil; Felicita David, MS, National Center for Injury Prevention and Control, CDC.

Posted byconnie dello buonoDecember 14, 2017Posted inMenuTags:abuse, opioids, prescription, useLeave a comment on Changes in Opioid Prescribing in the United States, 2006–2015

Top health and aging hacks 12-14-17

via Top health and aging hacks 12-14-17

Posted byconnie dello buonoDecember 14, 2017Posted inMenuLeave a comment on Top health and aging hacks 12-14-17

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Posted byconnie dello buonoDecember 14, 2017Posted inMenu2 Comments on Top health and aging hacks 12-14-17

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