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There is growing concern among US-based clinicians, patients, policy makers, and in the media about the personal and community health risks associated with opioids. Perceptions about the efficacy and appropriateness of opioids for the management of chronic non-cancer pain (CNCP) have dramatically transformed in recent decades. Yet, there is very little social scientific research identifying the factors that have informed this transformation from the perspectives of prescribing clinicians. As part of an on-going ethnographic study of CNCP management among clinicians and their patients with co-occurring substance use, we interviewed 23 primary care clinicians who practice in safety-net clinical settings. In this paper, we describe the clinical and social influences informing three historic periods: (1) the escalation of opioid prescriptions for CNCP; (2) an interim period in which the efficacy of and risks associated with opioids were re-assessed; and (3) the current period of “opioid pharmacovigilance,” characterized by the increased surveillance of opioid prescriptions. Clinicians reported that interpretations of the evidence-base in favor of and opposing opioid prescribing for CNCP evolved within a larger clinical-social context. Historically, pharmaceutical marketing efforts and clinicians' concerns about racialized healthcare disparities in pain treatment influenced opioid prescription decision-making. Clinicians emphasized how patients' medical complexity (e.g. multiple chronic health conditions) and structural vulnerability (e.g. poverty, community violence) impacted access to opioids within resource-limited healthcare settings. This clinical-social history of opioid prescribing practices helps to elucidate the ongoing challenges of CNCP treatment in the US healthcare safety net and lends needed specificity to the broader, nationwide conversation about opioids. [ABSTRACT FROM AUTHOR]

Abstract: Research on labeling mental illness has focused relatively little attention on practical organizational concerns in the process of labeling in community mental health services. This paper examines this issue through an ethnographic study of two multi-service community mental health services organizations for people labeled severely and persistently mentally ill in the Midwest United States. The findings show that the labeling process is structured by cultural and policy environments in which mental health services are able to provide resources otherwise difficult to obtain. Within organizations, official labels can be applied for reasons other than clinical practice; they channel resources to both organizations and clients. Informal organizational labels regarding client mental illness are not tethered to the bureaucratic apparatus granting access to and paying for services. Instead, they reflect workers'' real assessments of clients, which can differ from official ones. These informal labels determine how organizations deal with clients when rules and routines are violated. [Copyright &y& Elsevier]

Japan and the United States are both post-industrial societies, characterized by distinct trajectories of dying. Both contain multiple "cultural scripts" of the good death. Seale (Constructing Death: the Sociology of Dying and Bereavement, Cambridge University Press, Cambridge, 1998) has identified at least four "cultural scripts", or ways to die well, that are found in contemporary anglophone countries: modern medicine, revivalism, an anti-revivalist script and a religious script. Although these scripts can also be found in Japan, different historical experiences and religious traditions provide a context in which their content and interpretation sometimes differ from those of the anglophone countries. To understand ordinary people's ideas about dying well and dying poorly, we must recognize not only that post-industrial society offers multiple scripts and varying interpretive frameworks, but also that people actively select from among them in making decisions and explaining their views. Moreover, ideas and metaphors may be based on multiple scripts simultaneously or may offer different interpretations for different social contexts. Based on ethnographic fieldwork in both countries, this paper explores the metaphors that ordinary patients and caregivers draw upon as they use, modify, combine or ignore these cultural scripts of dying. Ideas about choice, time, place and personhood, elements of a good death that were derived inductively from interviews, are described. These Japanese and American data suggest somewhat different concerns and assumptions about human life and the relation of the person to the wider social world, but indicate similar concerns about the process of medicalised dying and the creation of meaning for those involved. [ABSTRACT FROM AUTHOR]