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George Bush Senior apology to Heather Lind after sex assault claim

Actress Heather Lind, photographed on June 15, 2017Image copyright
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Ms Lind said the alleged incident took place in 2014

Former US President George Bush Senior has apologised for any distress caused after an actress accused him of sexual assault.

Heather Lind said the 93-year-old former president had “touched me from behind from his wheelchair” and told a “dirty joke” while posing for a photo.

Ms Lind made the allegation on social network Instagram, in a post which has since been deleted.

A spokesman for Mr Bush said the incident was an attempt at humour.

“President Bush would never – under any circumstance – intentionally cause anyone distress, and he most sincerely apologises if his attempt at humour offended Ms Lind,” a statement supplied to outlets including the Daily Mail and People magazine said.

Both websites preserved the contents of Ms Lind’s post before it was deleted.

Mr Bush served one term as US president from 1989 to 1993, and is the father of George W Bush, who served two terms in the office between 2001 and 2009.

He suffers from a form of Parkinson’s disease.

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Ms Lind said a photo of Barack Obama shaking Mr Bush’s hand had disturbed her

The incident allegedly took place during an event for the television show Turn: Washington’s Spies, in which Ms Lind is one of the main cast members.

In her Instagram post, Ms Lind said she was spurred to make the claim after seeing a photo of Barack Obama shaking Mr Bush Senior’s hand at a recent fundraiser for hurricane victims, which she said had “disturbed” her.

“He sexually assaulted me while I was posing for a similar photo. He didn’t shake my hand. He touched me from behind from his wheelchair with his wife Barbara Bush by his side,” she wrote, according to the Daily Mail’s transcript of the deleted post.

“He told me a dirty joke. And then, all the while being photographed, touched me again,” she added.

Ms Lind finished her post with the hashtag #metoo, which has seen widespread use by victims of sexual assault to share their experiences in the wake of the Harvey Weinstein Hollywood scandal.

“What comforts me is that I too can use my power, which isn’t so different from a president really,” she said.

“I am grateful for the bravery of other women who have spoken up and written about their experiences.”

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Poker player Phil Ivey loses £7.7m casino case

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One of the world’s top poker players, Phil Ivey, has lost a Supreme Court bid to reclaim £7.7m of winnings withheld by a London casino for five years.

The American was challenging a Court of Appeal judgement that Crockfords Club could refuse to pay up when Ivey won the cash playing card game punto banco.

The club said Mr Ivey had broken its rules by using an “edge-sorting” technique to spot advantageous cards.

Mr Ivey had consistently argued that he had merely used a legitimate advantage.

The 40-year-old, a former winner of the World Series of Poker, had arranged to play a private game of punto banco – a form of baccarat – at the casino in Mayfair, along with a fellow gambler, Cheung Yin Sun, during a visit to London in 2012.

Crockford’s owner, Genting Casinos UK, said the two players jointly used the technique of “edge-sorting”, which involves identifying minute differences in the patterns on the back of playing cards and exploiting that information to increase the chances of winning. Genting said this was not a legitimate strategy.

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Phil Ivey is one of the world’s most successful poker players but was playing punto banco on his London trip

However, Mr Ivey contended that the technique was not a form of cheating because it did not involve dishonesty.

He said that he had merely exploited Crockfords’ failure to take proper steps to protect itself against a gambler of his ability – and he was therefore entitled to his full winnings, rather than just having his initial £1m stake returned to him.

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Media captionPaul Willcock, for the club, gives his reaction to the Phil Ivey verdict

The five Supreme Court justices unanimously upheld the Court of Appeal’s decision on the case, with Lord Hughes saying it was essential that punto banco remained a game of pure chance with neither the casino nor the player being able to beat the randomness of the cards that were dealt.

He said: “What Mr Ivey did was to stage a carefully planned and executed sting.”

Speaking outside court, president and chief operating officer of Genting UK Paul Willcock said: “This has been a landmark case in how the courts approach cheating in the modern day.

“This entirely vindicates Genting’s decision not to pay Mr Ivey, a decision that was not taken lightly.”

Who is Phil Ivey?

Mr Ivey is a 40-year-old world champion poker player who was born in Riverside, California, but now lives in Las Vegas.

According to the Hendon Mob poker ranking website, he is the sixth biggest earner of all time from tournament play – but he is known to have earned many more millions from private cash games.

He once played heads-up poker (a one-on-one version of the game) against Texan billionaire Andy Beal for three straight days and walked away $16m richer as a result.

During his divorce hearing in 2011 it was revealed in news reports that he received almost £700,000 a month from his stake in a poker company.

What is punto banco?

Punto banco is a form of the card game baccarat.

It is not unlike blackjack but the aim is to have cards that add up to nine, or as close as you can get.

It has a complex set of rules: when the total value of the cards goes into double figures, the first digit of the total does not count – so two sixes add up to two rather than 12. And there are further set instructions on what further cards must be drawn, unlike in blackjack where the player has the option.

Compared to other card games, it is not that widely played in casinos but is a popular choice with some high-stake gamblers.

A form of baccarat called “chemin de fer” was played by James Bond in the casino scene of the 1962 film Dr No.

What does this mean for Phil Ivey?

Analysis by John Hand, BBC News

For those who don’t know their cards, it is hard to overstate how big a superstar Phil Ivey is in the poker world.

Dubbed the “Tiger Woods of poker”, he has raked in tens of millions of pounds from a game that he mastered as a teenager – and coined in many more millions from sponsorship and by exploiting his carefully-built personal image. His mass appeal is such that he became the face of a Chrysler cars ad campaign.

For nearly two decades, Ivey has perfectly played the part of a cool, calm, calculating card-player with steely nerves and ice in his blood. Casinos fly him around the world as his presence can attract thousands of other punters.

But will Ivey be as big a draw after going “all-in” against the British legal system and losing? It is helpful for him that the case was not about poker – and that some of the gamblers he competes with will empathise with his explanation that he was merely being the best punter he could be, in using his savvy to try to beat a casino.

It was noticeable that this year Ivey skipped the main event in the World Series of Poker – the equivalent of Roger Federer taking a fortnight off during Wimbledon – and also mothballed his slick Ivey League poker school website.

Whether that marks the start of a general wind-down with more days to spend his millions and fewer days spent “grinding” for 12 hours at a poker table remains to be seen.

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Canada bans Soylent meal replacement over nutrition claims

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The makers of Soylent, an on-the-go meal replacement powder for busy professionals, say they are no longer allowed to sell the product in Canada.

The Canadian Food Inspection Agency told the company the food does not meet their standards for “meal replacement”.

The powdered substance is advertised as providing all the nutrients a person needs, without the hassle of chewing.

It was developed in 2013 for busy Silicon Valley-types who do not have the time for proper meals.

“Our products do not meet a select few of the CFIA requirements for a ‘meal replacement,'” Rob Rhinehart, founder and chief executive of Soylent-maker Rosa Foods, said on the product’s website.

“Although we feel strongly that these requirements do not reflect the current understanding of human nutritional needs, we respect the CFIA’s regulations and will fully comply with any regulatory action they deem appropriate.”

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Media captionThe story behind Soylent

The product is named after the dystopian 1973 science fiction film Soylent Green, in which overpopulation and global warming have forced the human race to subsist on engineered food, including a product made from human remains.

The company says each bottle contains 20% of your daily nutrients and 400 calories, and is made from soy protein and other natural supplements.

It has grown rapidly over the past few years, with about 300% growth in sales between 2015-16.

After a successful crowdfunding campaign, the company has gone on to raise $74.5m (£56m) in funding.

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Fats Domino: Rock and roll legend dies aged 89

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Media captionFats was the father of eight children, whose first names all began with the letter A

Fats Domino, one of the most influential rock and roll performers of the 1950s and 60s, has died aged 89.

The American rock and roll artist was best known for his songs Ain’t That A Shame and Blueberry Hill.

The New Orleans singer sold more than 65 million records, outselling every 1950s rock and roll act except Elvis Presley.

His million-selling debut single, The Fat Man, is credited by some as the first ever rock and roll record.

An official from New Orleans coroner’s office confirmed the death, which was earlier announced by Domino’s daughter to a local television station.

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Fats Domino had more than 30 hit singles

Fats Domino – whose real name was Antoine Domino Jr – was one of the first rhythm and blues artists to gain popularity with a white audience and his music was most prolific in the 1950s.

Domino had a string of number ones and more than 30 top 40 hits.

His music is also credited as a key influence on artists during the 1960s and 70s.

Elvis Presley referred to Fats Domino as “the real king of rock n roll” and Paul McCartney reportedly wrote the Beatles song Lady Madonna in emulation of his style.

In 1986 he was among the first inductees into the Rock and Roll Hall of Fame, but by his later life Domino would no longer leave his Louisiana hometown – not even to accept the award.

New Orleans-born musician and actor Harry Connick Jr is among those who have paid tribute to Domino on Twitter, saying he had “helped pave the way for New Orleans piano players”.

Rapper LL Cool J paid tribute to Domino for being an inspiration to so many:

And Samuel L Jackson cited the lyrics of one of Domino’s best loved songs:

Fats Domino: A life in music

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Antoine “Fats” Domino Jr was born in New Orleans on 26 Feb 1928, the son of a violinist. His parents were of Creole origin, and French Creole was spoken in the family.

He was musically inclined from an early age and learned piano from his brother in law, the jazz banjo player, Harrison Verrett.

He was given his nickname by bandleader Bill Diamond for whom he was playing piano in honky-tonks as a teenager. He said the youngster’s technique reminded him of two other great piano players, Fats Waller and Fats Pichon.

Domino left school at the age of 14 to work in a bedspring factory by day, and play in bars by night. He was soon accompanying such New Orleans luminaries as Professor Longhair and Amos Milburn.

In the mid-1940s, he joined trumpeter Dave Bartholomew’s band, and the two co-wrote Domino’s first hit The Fat Man. Suddenly, the New Orleans sound became popular nationwide.

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“Clean living keeps me in shape. Righteous thoughts are my secret…And New Orleans home cooking”

In an interview with the BBC in 1973, Domino spoke about his early life.

He said: “I was 17 when I made my first record in 1949. I never thought about being professional. I used to work in a lumberyard and that’s where I first heard a number on a jukebox and I liked it. It was a piano number. It was called ‘Swanee River Boogie’ by Albert Ammonds.”

Despite both musical heavyweights coming from New Orleans, Fats Domino said he only met Louis Armstrong twice in his life.

He told the BBC in a later interview: “I liked the way he was singing ‘Blueberry Hill’. See, a lot of people think I wrote ‘Blueberry Hill’ but I didn’t.

“That number was wrote in 1927 and I recorded that song in 1957. We just put a different background and I just sing it the way it would fit me and it came out great for me.”

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One in five Canadians is immigrant, highest in 95 years

Prince Charles and his wife Camilla pose for a photograph with newly sworn in Canadian citizens following a swearing-in ceremony in Saint John, New BrunswickImage copyright
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Prince Charles and Camilla watch as new Canadian citizens pose for a photograph after their swearing-in

Canada is growing increasingly diverse and its share of immigrants is the highest in almost a century.

New census figures show over one in five Canadians report being immigrant, some with permanent residency.

Over 1.2m people settled permanently in Canada between 2011 and 2016, most coming in as skilled economic immigrants.

The proportion of visible minorities has also grown and is now over 22% of the population.

Figures released by Canada’s statistics agency on Wednesday give a snapshot from the 2016 national census of the country’s increasing diversity and growing share of newcomers.

The country is also becoming more culturally diverse, with immigrants increasingly coming from Africa, Asia, and the Middle East.

Statistics Canada is predicting that if population trends continue, by 2036 up to 30% of the country’s population could be made up of immigrants.

The agency also predicts that within 20 years up to 35% of the population will be made up of visible minorities.

Most newcomers still settle in the big cities of Toronto, Vancouver and Montreal, though more are beginning to move into prairie and maritime provinces.

Toronto, Canada’s biggest city, is still the primary destination for newcomers. Over 46% of the city’s population are immigrants and over 51% of the city’s residents identify as being a visible minority.

The increase in the percentage of new Canadians is linked to immigration policies as well as the relatively low birth rate and aging population.

Between 1951 and 1991, the share of immigrants fell as low as 14.7%, but slowly began to increase in the early 90s.

The majority of newcomers come to Canada under economic immigration programmes for skilled workers. About three in 10 came in under the family reunification category.

One in 10 came to Canada as refugees, though that was number increased slightly between January and May 2016 when over 25,000 Syrian refugees were admitted into the country.

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The US and Iranian battle over the pistachio nut trade

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Relations between the US and Iran the two have an outsized impact on the global trade in pistachios

There are lots of casualties in international conflicts but this one is nuts, you might say – although strictly speaking the pistachio is a seed.

The international pistachio trade has faced unexpected headwinds due to the tensions between Iran and the US.

The global pistachio industry is a multi-billion dollar a year sector that is continuing to grow in value as its popularity as a foodstuff grows.

The US and Iran dominate the world’s trade in pistachios – collectively controlling between 70% and 80% of yearly output for the last decade.

Over the last forty years, Iran’s growers have faced pressures from sanctions, tariffs and restrictions on their ability to access international financial tools.

Although pistachios themselves were not on the list of sanctioned products, restrictions on global banking made trade difficult for Iranian farmers.

All that changed in 2016 following the Iran nuclear deal, officially The Joint Comprehensive Plan of Action (JCPOA). This agreement with the US and its allies removed sanctions.

It wasn’t just Iranian oil that came flowing back onto the international market, pistachio exports began gaining overseas markets.

Trump’s threat

That progress could face challenges though. US President Donald Trump called the agreement created under his predecessor the “worst” deal the US has ever made.

In October he decertified the agreement. The move passes responsibility to the US Congress to evaluate and determine whether it believes Iran is compliant with the terms and if the US should remain in the deal.

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Over 90% of US pistachios are grown in California

President Trump said in the speech announcing his decision that the agreement “threw Iran’s dictatorship a political and economic lifeline,” but had failed to prevent Iran’s “sprint” towards nuclear weapon development.

For Iran’s pistachio industry the threat of losing the deal and reinstating sanctions could mean the return of what Hojat Hassani Sadi, deputy director of the Iran Pistachio Association calls “unfair and unequal competition”.

Ancient roots

The pistachio industry in Iran dates back thousands of years. By contrast, pistachio farming in the US started in the 1930s with Persian seeds.

The boom in commercial pistachio cultivation came after the US severed ties with Iran following the 1979 hostage crisis, after which the US and its allies placed sanctions on Iran.

Over the next several decades, even in countries where Iranian pistachios were welcomed, restrictions on its companies’ ability to access international financing made it hard for the industry to flourish.

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Archaeological evidence suggests pistachios were first grown in what is now Iraq in 7,000BC

During that time the US market expanded, with farmers – mainly across California – planting the crop.

But in 2014. hot and dry weather conditions across the western US cost the industry nearly half its crop and cut profits for 2015 – the year those nuts were sold – by close to $1.4bn (£1bn).

Globally, pistachio prices rose, but for Iran’s growers it was also an opportunity.

Price competition

The price of pistachios has been on the rise since 2002. Richard Matoian, executive director of the American Pistachio Growers (APG) trade association, attributes this to increased awareness of their health properties and global demand for healthy snacks.

“The industry has been pushing the products with advertising,” he says, adding that middle-class demand in developing markets has also boosted exports.

Global Trade

More from the BBC’s series taking an international perspective on trade:

Increased demand in China has been key to sector growth. Between 2008 and 2013 Chinese imports of US pistachios rose 146% according to APG.

But the 2014 drought saw the price of California’s nuts rocket from $3/lb (453g) to over $5/lb.

By contrast Iran’s pistachio yield that year was strong. In markets like China, they were able to undercut American prices by close to $0.20/lb.

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Pistachio plants grow best in arid climates but that leave crops vulnerable to water shortages

A strong growing year in 2016 has helped the US market recover and led to a moderation in price.

But Iran has another advantage that helps it in global trade – its location.

“Iran has a transportation advantage. They can certainly take markets away and China is an example of that,” says Mr Matoian.

Uphill march

The advantages and disadvantages for Iran are not only linked to sanctions. Iran claims its pistachios have a better taste, as do several large European distributors, though the US and Iran mainly grow the same strain. (Turkish pistachios, for example, are a different variety.)

The US also imposes a 241% tariff on Iranian pistachios meaning even without sanctions the US market has been all but cut off for Iran.

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Aging water infrastructure in Iran is a major difficultly for Iran’s farmers

Water shortages are another problem for Iran. According to Mr Sadi it is the “major obstacle to growth” for his industry.

Iran’s pistachio sector is second in the world following the strong 2016 season in the US. And with the two countries dominating so much of the global market, Iran isn’t in dire need of a comeback.

But for the growing number of pistachio fans around the world increased access to Iran’s pistachio exports and decreasing prices would be a sweet outcome.

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American Airlines accused of racism after ‘disturbing incidents’

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A top African-American rights group has warned black flyers to exercise caution when flying American Airlines after a string of “disturbing incidents”.

The National Association for the Advancement of Colored People (NAACP) issued a “national travel advisory”.

The organisation warned the airline “could subject [travellers to] disrespectful, discriminatory or unsafe conditions”.

The airline insisted it does “not tolerate discrimination of any kind”.

The NAACP “national travel advisory” was issued as the advocacy group cited a series of incidents suggesting a “corporate culture of racial insensitivity and possible racial bias” at the airline.

It warned black travellers that American Airlines could subject them to “disrespectful, discriminatory or unsafe conditions”.

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American Airlines replied in a statement: “We are disappointed to hear about this travel advisory as our team members – a diverse community of gate agents, pilots, and flight attendants – are proud to serve customers of all backgrounds.”

In the advisory, the NAACP listed four incidents in which black passengers said they were discriminated against by AA employees.

One incident on a Washington DC to Raleigh, North Carolina, flight involved a NAACP state chapter president, who sued the airline.

He said he had been required by flight attendants to give up his seat after he responded to “disrespectful and discriminatory comments directed toward him by two unruly white passengers”.

In another incident, a black woman was moved to the coach section at the ticket counter despite having booked first-class tickets for herself and a travelling companion.

The woman’s travelling companion, who was white, remained assigned to a first-class seat, according to NAACP.

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Media captionCan removing Confederate statues help heal a nation?

Another incident involved a black woman who was ordered removed from a New York to Miami flight after a pilot overheard her complain to a gate agent about a change to her seat assignment without her consent, said NAACP.

American Airlines, which has 120,000 employees, has invited NAACP representatives to meet at the company headquarters in Fort Worth, Texas, for “a meaningful dialogue”.

The organisation, which has historically issued travel advisories “when conditions on the ground pose a substantial risk of harm to black Americans”, said the allegations they cite may represent “only the tip of the iceberg”.

The NAACP, which was founded in 1909, bills itself as the nation’s oldest and largest nonpartisan civil rights organisation.

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Why opioids are such an American problem

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When it comes to taking opioids, the United States has the dubious honour of leading the world.

For every one million Americans, almost 50,000 doses of opioids are taken every day. That’s four times the rate in the UK.

There are often good reasons for taking opioids. Cancer patients use them for pain relief, as do patients recovering from surgery (codeine and morphine are opioids, for example).

But take too many and you have a problem. And America certainly has a problem.

In two years, the town of Kermit in West Virginia received almost nine million opioid pills, according to a congressional committee.

Just 400 people live in Kermit.

Nationally, opioids killed more than 33,000 people in 2015, according to the Centers for Disease Control and Prevention.

That figure includes deaths from heroin, an illegal opioid. But almost half involved a prescription opioid – that is, a painkiller available from a pharmacy with a note from a doctor.

So why does America – more than any country in the world – have an opioid problem?

There is more than one cause. But these are some of the most important.

American doctors prescribe – a lot

Unlike most European countries, the US does not have universal healthcare paid for by taxes.

Instead, Americans must get their own insurance – usually via an employer or the government.

“Most insurance, especially for poor people, won’t pay for anything but a pill,” says Professor Judith Feinberg from the West Virginia University School of Medicine.

“Say you have a patient that’s 45 years old. They have lower back pain, you examine them, they have a muscle spasm.

“Really the best thing is physical therapy, but no one will pay for that. So doctors get very ready to pull out the prescription pad.

“Even if the insurance covers physical therapy, you probably need prior authorisation (from the insurer) – which is a lot of time and paperwork.”

The CDC says opioid prescriptions have fallen by 18% from their peak in 2010. But the total is still three times higher than in 1999.

‘I saw this drug on TV’

The US and New Zealand are the only countries that allow prescription drugs to be advertised on television.

According to the research firm Kantar, spending on advertising by pharmaceutical companies in the US reached $6.4 billion in 2016 – a rise of 64% since 2012.

None of the 10 most-advertised brands in 2016 was an opioid. But mass-marketing of drugs has an effect, says Professor Feinberg.

“As a clinician, people will come and say ‘I saw this on TV – can you give me this drug’.

“Sometimes they were so confused, they were already on the drug – they were using the brand name, where I used the generic name.”

In 2015, the American Medical Association called for a ban on adverts for prescription drugs. It didn’t happen.

Three months later, the extent of America’s opioid culture was seen at half-time of the Superbowl – the country’s most expensive advertising slot.

A 60-second ad was devoted to opioid-induced constipation. The advert – paid for by AstraZeneca – advised sufferers to visit their doctor and “ask about prescription treatment options”.

President Obama’s chief of staff was not impressed.

Gifts to doctors

In the US, it is common for drug companies to court doctors, in an effort to promote their products.

“When you’re a doctor in the US, these detailing people (salespeople) come in from the industry,” says Professor Keith Humphreys from Stanford University.

“They are invariably smooth, friendly, attractive, sharply dressed, adorable, they’re giving out gifts to everybody. They host dinners, they sponsor conferences, they sponsor junkets.

“That is going to affect prescribing.”

For the past four years, the US government has published the amounts paid by drug and device companies to doctors and teaching hospitals.

The total in 2016 was more than $8bn. More than 630,000 physicians had payment records.

For example, Purdue Pharma – which makes OxyContin, a popular opioid painkiller – made almost 80,000 transactions in 2016, worth more than $7m in total.

In 2016, a study looked at the link between doctors, the free meals they received from drug companies, and the medication they prescribed.

The study found receiving free meals was “associated with an increased rate of prescribing the promoted brand-name medication”.

Pharmaceutical companies say their reps are merely sharing information with doctors. But Professor Humphreys says there is a “corrupting” influence.

“We need a pharma industry, it’s not that it’s wrong,” he says. “But you can’t let the fox guard the hen house.

“I would create completely clear blue water between the people that manufacture drugs and all the training and operation of the healthcare system.”

Pharmaceutical companies also spend money on health care workers and organisations in other countries.

In the UK in 2016, companies gave £116m ($153m) to health workers and organisations for non-research and development in 2016.

But, although the UK figure is 7% higher than in 2015, it is less than 2% of the amount paid in the US.

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Media captionThe grandparents’ burden: ‘We don’t resent the kids – but life’s hard’

Poor training

Dr Richard Frank is professor of health economics at Harvard Business School, and served in the Health Department from 2009 to 2016, during President Obama’s administration.

He thinks medical training in the US has not been good enough.

“Physicians have received almost no training in pain management,” he says.

“Until recently they have been under some pretty important misconceptions about how addictive various products are.”

He adds: “A couple of years ago I testified before congress when I was in government. One of the representatives, before going into congress, was a thoracic surgeon.

“He noted that he had gotten almost no training in pain management – and what he had learned came entirely from the nursing staff he worked with.”

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Media captionThe heroin-ravaged city in West Virginia fighting back against drug companies

Dr Frank says medical training isn’t the only reason for America’s opioid problem. “There’s plenty of blame to go round,” he says.

But his criticism is echoed by Professor Judith Feinberg.

“Doctors didn’t learn anything about addiction at medical school,” she says.

“That is now changing, but everyone who’s a doctor already, didn’t learn anything. I learned about opioid drugs in the part of pharmacology where we learned about anaesthesia.

“Probably the whole topic of anaesthesia-like drugs was two hours. People don’t have much knowledge about opioids. There was no curriculum that includes addiction.”

Bad science?

In 1980, Dr Hershel Jick wrote a short letter to the New England Journal of Medicine.

It said that “despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction”.

The claim has been debunked, and the letter now carries an online warning note. But Dr Jick’s letter had a big impact.

This year, Canadian researchers said the letter had been cited 600 times – usually to claim opioids weren’t addictive.

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Media caption“We’re going to spend a lot of time, a lot of effort and a lot of money on the opioid crisis”

In the late 1990s the Veterans Health Administration – which runs healthcare for military veterans – pushed for pain to be recognised as the “fifth vital sign”.

This gave pain equal status with blood pressure, heart rate, respiratory rate, and temperature.

Then in 2001, the Joint Commission – which certifies almost 21,000 US health organisations and programmes – established standards for pain assessment and treatment.

In 2016, the JC released a statement that claimed that “everyone is looking for someone to blame” for the opioid problem. It insisted that its 2001 standards did not “require the use of drugs to manage a patient’s pain”.

But Professor Feinberg says the VHA and JC’s moves meant doctors were under pressure to prescribe strong painkillers – such as opioids – when they may not have been necessary.

“By the time you reach middle age, it’s a rare person who doesn’t ache somewhere,” she says.

She adds that – in a country where patients rate their doctors, and low ratings can affect doctors’ earnings – the score can be influenced by whether patients receive opioids.

A culture of medication

Some Americans, says Professor Keith Humphreys from Stanford University, believe that life is “fixable”.

“I’m 51,” he says. “If I go to an American doctor and say ‘Hey – I ran the marathon I used to run when I was 30, now I’m all sore, fix me’, my doctor will probably try to fix me.

“If you do that in France the doctor would say ‘It’s life, have a glass of wine – what do you want from me?'”

In 2016, a study compared how Japanese and American doctors prescribed opioids. It found that Japanese doctors treated acute pain with opioids in 47% of cases – compared to 97% in the US.

“There is obviously a willingness, and a habit, of giving opioid pain relief that is not shared elsewhere,” says Professor Feinberg.

“Other countries deal with pain in much healthier ways.”

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