Alternative Energy Sources Essay Example | Topics and Well Written Essays - 500 words

Alternative Energy Sources - Essay ExampleThe liquefaction and gasification processes for coal may soon be as frugal as obtaining liquid and gaseous fuels from conventional sources, and both processes seem likely to be used commerci wholey within the 1970s. Reliance on coal for all fogy fuel needs would of course shorten the life expectancy of our coal reserves considerably. One possible alternative is the oil shelf, which constitute a potential energy resource much larger even than coal. Hydroelectric energy and the energy of the wind and tides will always be available (Manwell and Rogers 41). The gait at which these energy sources can be exploited, however, is limited by the global flow of energy in the form of falling water, wind, and tides at any precondition time. It is also limited by the number of sites where these processes can be exploited economically. Power is the rate at which energy flows or is used. Continuous energy sources, such(prenominal) as the water cycle, are usually characterized in terms of power -- say in kilowatts -- although they could easily be characterized by the amount of energy menses per day or per yea (Beggs 76).The worlds potential production of hydroelectric power is roughly half of the amount of power now being produced by fossil fuels.

Sales Manual for Strategically Planning a Sales Presentation Term Paper

Sales Manual for Strategically Planning a Sales Presentation - Term Paper ExampleHowever, the party has established sales distribution chain to reach the customers. The company has distributors worldwide to distribute the products to the wholesalers. In most occasions, the company has standardized supply chain to transport its products. The distributors get the products directly from the company. They distribute mainly to the wholesalers. However, Cadbury products are very perishable and they require few distribution channels. These distributors may sell the products to the final examination consumers but at a retail price. The wholesalers, on the early(a) hand, sell directly to the retailers and to the final consumers. Although the chain of distribution is flexible, they are guided by the regulations. For instance, the price per unit to the final consumers is the same, but B2B price is subsidized. This will ensure business harmony in all transactions.Personal selling refers to o ral or verbal communication with the authority customers of the Cadbury products with the aim of increasing the sales. This approach has been very important because it focuses on developing a concrete relationship with the consumers or the buyers. Furthermore, it is one of the elements of the promotion mix as well as an effective tool of promotion.Prospecting-the company has used personal selling in looking for new customers to buy the products. Like any other business, the company continuously looks for new markets for its products as this is the way to measure the growth of the company. By looking for many markets, the company can increase its sales and maximise the profits. Personal selling plays a significant role in realizing this.Communicating- personal selling is more expressional than any other approach. This is the most suitable way of explaining to both the existing and new clients of the range of the products. Customers get instant feedback to their questions about the products hence easy to persuade them to make purchasing decisions.Information

Strategic Marketing Essay Example | Topics and Well Written Essays - 1500 words

Strategic Marketing - Essay ExampleBusiness processes were reengineered by changing reward criteria and performance matrices as wellspring as marketing activities. The idea of providing custom built solutions for the clients proved to be a handy tool for reaching customer satisfaction. Companys idiom also shifted to the global market where it tried to provide the business services by divesting itself on low margin industries. This enabled it to capture new markets and work towards customer satisfaction through different venues using different marketing techniques by adapting to cultural changes in different countries. Perhaps the most important competency that the association inculcated was that of becoming a brand worker ensuring to provide customized and integrated technologies to the customers even if that meant using a rival companys product. This led to pervasive customer loyalty. IBM also bolstered its services di romance by acquiring a management consultancy solid that he lped it to increase its business consultants worldwide. This led to the communication of companys vision in a much effective way. 2. ... He did thorough research on the business units of the company and tried to integrate them into one so that they may follow standard procedures to create enhanced value for the customers. This move was an audacious termination as it was a contra act of the policy made by his predecessors. He also seemed to follow an adaptive onward motion in formulating new plans of action. This was evident when he tried to grab the opportunities to make profitable initiatives. Louiss proactive approach towards business environment led him to gain advantage over his competitors in all respects. Louis also was apt at making bold decisions such as that of exiting the consumer market and playing in the larger business market only. Louis also viewed that IBM was a social entity at large and therefore employees and the workforce played a major role in the organisation al success. That is why he took steps to reengineer the human resource management practices of the company making them more employee-centric at the basic level. In order to align the organisational performance with the proposed goals, Louis tried to focus on developing the brand concept. This later helped it to create loyal customers. He also redesigned the marketing campaigns of the firm in order to ensure that the all promotion activities boasted the same value proposition of the firm. All this shows that he was keen to follow a rigorous decision making process. In a nut shell, Louiss style of implementation is analogous to that of a capable leader. He took bold decisions based on immense research and tried to retain their viability. He also looked for new avenues to approach and cater through his judicious work style. 3. What are the implications

Horse Slaughter Essay Example for Free

Horse Slaughter EssayThe topic of horse cavalry assassinate doesnt usually come up very often in everyday conversation. Horse slaughter is more of an implicit subject, which your everyday person doesnt know much about. Because it is highly controversial, it has g hotshot through the cycle of being banded and then reinstated twice in the last 5 years. With being voluminous in the horse industry my entire life, I have witnessed the effects first hand. Some people see it as killing pets, animal cruelty, and morally wrong. However, I see it as a source of income, a way to stop the starvation and abuse of horses, an export industry for the United States, as puff up as a reference meal for in times of despair. The history of people eating horse nerve dates back to the early 1800s when the french were at war with Russia. Emperor Napoleon advised his starving soldiers to eat the dead battlefield horses. Because horse meat is sweet, lean, protein-rich, and finely textured, it suf ficed as a quality meal.Due to the high cost of living in France, in 1866, the French government legalized the inspiration of horse meat because it could be bought at a trim back price than pork or beef. (Sherman) Countries like France, Belgium, Germany, Chili, Japan and many others still consume horse meat today. The history of horse meat for human consumption in the United States has a similar story. No longer entrust the will the worn-out horse w destination his way to the boneyard instead he will be fattened up in order to give the thrifty a nonher source of food supply.This new meat is to be put upon the urban centers platter under the protection and encouragement of the Board of Health. The Board at its meeting yesterday made several radical changes in the vigorous Code, and one of them was to revoke the present section that forbids the sale in this city of horse flesh as food. (Allow Horse Meat for Food in City) This is a segment from an article by the New York Times, p ublished in 1915. Also in the article, Health Commissioner Haven Emerson discussed that the houses that slaughter horses are to follow the same protocol and inspections as any other slaughter house does.During the 1930s low supply and high cost of pork and beef made horse meat rise in popularity. Again during World War II, people were again in the same predicament. Inflation during the early 1970s raise the cost of conventional meats Time Magazine reported from Carlsons, a butcher shop in Westbrook, CT, that they were selling over 6,000 pounds of horse meat a day. (Weil) In 2006, the House of Representatives voted to end horse slaughter the bill passed to make the killing and selling American horses for human consumption an illegal practice in the United States.Today in the US, people do not consume horse meat on a whole sale basis. But because many other counties do, the exporting of horse meat is a huge industry. When the ban was in place, US horses were being transported to C anada and Mexico to be slaughtered instead. From 2006 to 2010 the increase in horses being exported to Canada and Mexico was 148 and 660 percent. They are loaded up on trailers and shipped across the boarders, often times going days without food or water until they reach their destination. The regulations, or lack thereof, are different than in the US. Shesgreen) valley Meat Co. owner Rick De Los Santos brings up valid points in his interview with NBC News last week. The majority of people, who are against slaughter, are getting caught up on the ick factor of killing our pets. However, the process is the exact same for cows and pigs.The horse is struck in the forehead with a tool known as a captive gun. The captive gun an air pressured gun which launches a metal bolt against the horses head rendering it unconscious before it is exsanguinated, bled out. Meat plants are inspected regularly, pass judgment to follow code, and are fined heavily if found otherwise. He also makes mention that he is sending horse carcasses to Mexico instead of live horses. If the horses are killed in the US they are still under regulation. (NM Meat Plant Owner Defends Horse Slaughter Plan)I often hear the statement Dead horses dont help the economy But before it was banned the export industry in the US was nearly $65 one million million million dollars a year. That is $65 million dollars that could be coming into the US, but isnt. Shesgreen) Mr. De Los Santos mentioned in his interview that due to the closing of his plant, he laid off over 160 workers at his small plate plant. With our economy in its current state, I believe we should not be cutting corners with people losing jobs or missing out on opportunities to make money. On the contrary, Horses were never raised or bread specifically as a source of food because they have a much lower grain and skunk efficiency rate then cows do. They take a lot more food and time to fatten up.Their immune systems are also not as strong s co ws and they have the tendency to get sick easier which can cause weight loss, explained beerinarian Kathy Ott, owner and senior vet of Clearly Lake Equine Hospital. I did an interview with Dr. Ott knowing that I would receive a perspective of the opposing argument. She referenced that because horses are not specifically raised to be consumed the vaccines, medications, injections and feed that they receive have not all been certified or regulated by the FDA. (Ott) Humane Society says owner responsibility is the answer. It is a matter of personal responsibility when someone takes on a horse as a companion or work animal.If an owner can no longer care for a horse, that person has a responsibility to seek out other options for placing the horse or to have it humanely euthanized, rather than just now try to profit by selling it to slaughter. This is a valid point however, in the state and federal legislation passed thus far in the US, the in good order to kill horses humanely has neve r been challenged, with the exception of those falling under the Bureau of Land Management (BLM), National Wild Horse and Burro Adoption Program. In the USA, horses tarry property and anyone can humanely kill his or her own horse without fear of sanction including euthanasia or gunshot.How are do we know everyone one out there kills there horse on the first try? They could have possibly miss the vein or miss the shot. PETA is not against horse slaughter PETA is disgusted by the idea of transporting of horses to foreign destinations, which increases their stress, probability of sickness and injury. They believe that the previous congressional action that ended the slaughter of horses in the U. S. was horribly inadequate solution, and had only made matters worse for the problem of unwanted and abandoned horses. The organization is a major advocate of local euthanasia or gunshot.They are constantly looking to find a better solution to unwanted and abandoned horse problem. Slaughterin g is at the bottom of their list however, right now it is incumbent to prevent more suffering and starvation of the unwanted horse. (PETA) On November 11th, 2012, President Obama signed the ban to abolish the ban on horse slaughter. Horse meat, for the past(a) 100 years, has had an influential effect on America. It has helped us in times of need, as well has been a huge amount of income for the US. With it still being so controversial on an ethical basis, I am sure it will continue to go through the cycle of being banned and reopened.

The Enlightenment and Its Social and Ideological Consequences Worldwide Essay Example for Free

The judiciousness and Its Social and Ideological Consequences Worldwide EssayThe information in Europe, roughly from 1600 to the French Revolution in 1789, was an era that straininged, most of all, the rationalistic basis of science, and its industry to all element of life. This essay argues that much of this rhetoric, such as from Bacon or Kant, is a mystification, and that the staple structure of the Enlightenment was about the rationalization of force-out and subordination. This paper will begin its discussion on the Enlightenment with Immanuel Kants What is Enlightenment? front to the critique of this view from Adorno and Horkheimer, and see the more empirical approach of the Enlightenment worldwide through an analysis of some modern works on colonialism and the post-colonial ideology. Immanuel Kant wrote a in truth short piece on What is Enlightenment? in 1784. It is the chief work in this mystification. This is a piece that is comfortably accessible for the lay menrare for Kantand lays out the basic concepts of Enlightenment in the freeing of the mind from the shackles of tradition and pietism. Kant holds that such shackles are created by the self from the motivation of slothfulness or complacency.It is easier to accept conventional truths than to struggle to find ones own. Kant then holds that moral virtue, particularly courage, is necessary for true Enlightenment, since that courage is needed to go against acquire opinion. The truly enlightened individual needs to think for himself, develop their own conclusions, and hence, take nothing from authority. This movement is little more than a move from immaturity to adulthood from the infantile life of the middle ages to the adult life of modern times. The formal properties of this motion is the release of the understanding from the prison of authority and received opinion.Hence, from this view of Kant, the Enlightenment and its scientific consequences have been associated with the rhetori c of liberation. The Enlightenment defines itself in the negative terms of the last of feudal relations based on religion and received opinion. The positive side (derive largely from Bacon and Descartes) is based on the concept that the release of the understanding can be done through the rigorous natural covering of scientific methods to all areas of life, reaching an era of complete and true have directge based on rational methods and principles.Hence, from Kant, science and its resultant technology is seen as liberation, and the invention of a new, utopian social order based on mechanization of all labor and the love of knowledge deriving from true principles. This rhetoric allay dominates discourses about the Enlightenment and its negation of the barbaric middle ages. II. Adorno and Horkheimer on the Dialectics of Enlightenment It does not take long to get from Kant to Nietzsche. In fact, the amoral world of the infamous German is a mere brief step from the hyper individua lism of Kant and his followers.Nietzsche took the Baconian dictum seriously that knowledge is former and of course, power is control. The Kantian mystification of the Enlightenment had been exposed for generations in European letters from the conservative reaction against modern science to the leftist agitation of the above authors. In their 1944 work, Adorno and Horkheimer seek to eliminate the mystification that Kant had ushered in as the basic sense of Enlightenment self-definition. Their argument is a complex one, except it can easily be interpreted apart into eight specific movements or moments. 1.The Enlightenment, with its stress on science and hence technology, has not led to liberation, but to a hyper-centralization of power and technical authority. The knowledge necessary for specialized science and its administration are, by definition, available only to a few specialists. This means that Enlightenment individualism has led to a Nietzschian stress on the will to power of science. This will to power has resolved itself into a fetishization with central power and authority, and an esoteric sense of science as the new priesthood, available only to a few specialist and the pie-eyed powers who finance them. 2.This centralization of power and the domination of a scientific and technocratic elite has led to the construct of a uniform ideology a sense of the power of science and the moneyed powers who control them. The issue here is that the scientific ideology is the only one, and that all problems can be solved by the judicious application of the scientific method, only if they receive enough money and power to do it. Science, at first a limited method of solving problem, has resolved itself into the domination of materialism and the creation of a scientific establishment, a set of institutions that identifies itself with science proper.In other words, the scientific establishment has taken the propose of science and pinned it to themselves. 3. The domination of science and enlightenment capital relations has led to new forms of scientific consciousness like sociology, which has led to the standardization of society, and this standardization of social life has taken the form of labeling consumers. Creating consuming pockets of people who are seen not as people but as machines that buy the products that the capitalist technocracy has created.Citizenship has been replaced by consumption and being a part of the great chain of capitalist relations. 4. Even more than this, not only has political and economic power been tightly centralized, but even the very ideas of the population and their perceptions of the world are created and maintained by the stopping point industry that complex of capital and modern science that has sought to entertain the masses for profit, but have also replaced their own perceptions with that of the cultural elite. From the individualism of Kant, science and Enlightenment has created a new kind of human being the slave that does not know hes a slave. The entertainment industry that is so often a target of both left and right has taken upon itself, in the name of both profit and Enlightenment, to recreate the very perceptual matrix of the population as a whole. Replacing actual perception with their own, and hence, dictating music, dress, even cuisine fit to its taste, quickly adopted by the masses who think they are thinking for themselves.5. The movies, as well as the mass production entertainment industry of the technocracy, has recreated the person according to its own will. Reality itself is the creation of the illusion industry and has destroyed the last vestiges of individuality. Kant is exposed as a naive writer at best. 6. The creation of genre is part of the cultural domination of the technocracy. Genre is a pseudo-intellectual method of both standardizing production, but more importantly, the standardization of consumer taste.Genre is the destruction of culture for this reason. 7. This destruction of culture by forcing it into the standardization of genre means that art has been taken from the realm of the individual or the culture and placed into the realm of the machine the culture machine that seeks to standardize art so as to make it amenable to scientifically planned consumption and production. Art is merely another commodity. 8.Finally, the culture itself becomes a single, commodified and standardized reality the creation of the scientific technique as applied to film, entertainment and art. What has begun as a drive to liberate consciousness and the intellect has led to a scientific dystopia of enslavement to a series of media illusions, themselves based around profit and a centralized technocratic apparatus that has stamped out all free mentation and has even commodified dissent from its own order.

Discuss the role of emotion in psychology Essay Example for Free

Discuss the role of emotion in psychology EssayEmotion is much the greatest cause for either enhanced recall or impaired recall. Through many studies psychologists have comprise that it is not only facts we store in our memory but the emotion meet them.Flashbulb memories involve an enduring imprint of events surrounding an important incident, the memory is not the event itself but where you were and what you were doing when you comprehend about it. Sheingold and Tenney (1982) provided evidence to support the concept of flashbulb memories. Participants were asked about personal memories and engraft most had good memories for when they were told and who told them. They found the flashbulb memories were strong and remained consistent everyplace time however there is no way of checking the accuracy of these memories.As shown by Sheingold and Tenney, a flashbulb memorys characteristic involves consistency and has an unchanging nature and they withal involve a high level of em otional arousal which leads to better recall of the event. However Wright (1993) found evidence that goes against this definition, the acquire involved looking at peoples memories of the Hillsborough football disaster in 1989, 5 moths after the event. It was found that most of the participants didnt report strong flashbulb memories in fact many people had retrace their memories and had mixed their own with other peoples accounts. This evidence therefore goes against the idea that flashbulb memories remain consistent over time.On the other hand Conway (1994) suggested that the reason around studies dont support flashbulb memories is because the event wasnt significant to the individuals. Conway et al used Mrs Thatchers resignation as the basis for the creation of flashbulb memories. 11 months after 86% of the UK participants has a strong and consistent flashbulb memory comp ared to only 29% participants from other countries. This research suggests that flashbulb memories will only be strong if the event surrounding it is significant to the individual the UK participants would have been more(prenominal) aware and connected to Mrs Thatchers resignation than participants from other countries.The role of emotion is memory can also cause impaired memory. Freud proposed the idea of repression unwanted memories are pushed down into the unconscious mind so you forget them. Freud described this process as a way of the ego defend itself from emotional conflict which is oftentimes the result of harsh experiences. Williams (1994) interviewed women who has been admitted to hospital on the grounds of sexual assault, 20years previously, (they were told the study was a follow up of medical care). Williams found that 38% of the women did not show any recall of being sexually abused and that 16% of the women that did, said that at one time they couldnt remember they had. This study therefore provides strong evidence to support the repression theory, a traumatic event was r epressed and some couldnt recall it even 20 years later.Repressed memories are defined as a traumatic event placed beyond conscious awareness. Because of this placement, these memories can also affect conscious thought. Forgetting a traumatic event, manage Williams (1994) research, has also been studied through persona studies. One of the most famous is Bavers (1981) study on sirhan sirhan, the man who shot Robert Kennedy, who has no recall of doing so.In this case the emotions of regret and shame were probably the cause of the repression and the reason he cannot remember what he did. It has also been suggested that repressed memories can also cause anxiety and split behaviour. A study that supports this concept was carried out by Karon and Widener (1997) who found that once trauma was recalled in therapy, mental illness in World War 2 veterans completely alleviated, therefore supporting Freuds theory.However Loftus and Pickrell (1995) found evidence against Frueds repression the ory. The study was called lost in the mall and the false memory of getting lost in a shopping centre as a child was implanted into the participants. After the debriefing 20% still held to their belief that this happened to them, even though it was a false memory showing trauma has a great affect on memory even though the memory was false but departure against Frued as the memory wasnt real.Another study by Loftus and Palmer created a theory called the Weapon effect this was during a highly emotional event such as a robbery or assault, an eye witnesses recall was altered due to their focus on a weapon being used.Finally a depressive deposit also has an influence on memory. Negative emotions often create a negative recall bias which makes depressed people only focus on negative and unhappy experiences a mood dependent memory. Lyketsos (2001) found in support of this that depression may lead people to be inattentive and so they dont encode new memories into the long term memory well, therefore recall is much poorer. In further support of this Antikainen et al (2001) studied 174 depressed patients and found they performed better on memory tasks and had fewer memory problems after 6 months treatment.In conclusion emotion plays an important role in memory. It can often lead to enhanced memory, such as flashbulb memories, or impaired memory such as the repression of traumatic experiences. Negative emotion is also liable for a lack of memory such as when someone is depressed. Overall memories are largely influenced by emotion the more positive we are the more likely we are to recall, the more negative the less likely we will recall and are more likely to forget.

Effect of Buprenorphine on Postoperative Pain Levels

Effect of Buprenorphine on Postoperative Pain LevelsKatelyn ShultzNurse AnesthesiaABSTRACTIn recent years, buprenorphine has become an increasingly pop choice for managing opioid dependence however, buprenorphines unique mechanism of action can make treating astute distressingness more than complicated. In opioid-dependent unhurrieds managed with buprenorphine, would continuing buprenorphine therapy during the perioperative period run postoperative distract levels? The research method for this study is a formal literature review. I predict that continuing buprenorphine through egress the perioperative period will emend postoperative distressingness levels in opioid-dependent patients maintained on buprenorphine.INTRODUCTIONIn recent years, buprenorphine has become an increasingly popular choice in the treatment of opioid dependence. redden though it is a partial mu booster, buprenorphine is known to have higher(prenominal) mu-receptor affinity. When buprenorphine is conti nued throughout the perioperative period, this billet whitethorn reduce the effectiveness of other honorable mu supporter opioids. As a result, this pharmacological trait introduces an obstacle for successful treatment of subtle working(a) hassle in the patient taking chronic buprenorphine. The clinician must choose the best option for this patient, to continue or discontinue buprenorphine therapy during the perioperative period.BACKGROUND AND SIGNIFICANCEIt is imperative to establish evidence-based practice guidelines regarding the best method of acute pain direction for patients taking chronic buprenorphine. As buprenorphine use pluss, healthcare providers will encounter opioid-dependent patients taking chronic buprenorphine with higher frequency in the surgical setting.1 Although the domineering outcomes of buprenorphine use are comprehensively researched and well put down, the evidence regarding the perioperative continuation or suspension of buprenorphine is limited and inconsistent. As a result, prescribers may avoid buprenorphine altogether, ultimately preventing more patients from receiving a potentially superior treatment.Perioperative is defined as the phase immediately prior, during, and immediately after a surgical procedure. Postoperative period is defined as the phase after a surgical procedure is performed. Buprenorphine maintenance therapy (BMT) is defined as a sustained pane of buprenorphine taken by an opioid-dependent patient for an indeterminate period of duration. Methadone maintenance therapy (BMT) is defined as a sustained dose of methadone taken by an opioid-dependent patient for an indefinite period of time. all-embracing mu opioid agonists activate mu receptors until a maximum effect is reached or the receptor is unspoilty activated. Methadone, morphine, and oxycodone are examples of honorable mu agonists. Partial mu opioid agonists bind to receptors and partially activate them, but not to the same degree as do full a gonists. Partial mu agonists can in admission displace full mu agonists from receptors. Buprenorphine is a partial mu agonist. Patient- pull stringsled analgesia (PCA) is any method of allowing a person in pain to administer their own pain relief.METHODSThe research method for this study was a formal literature review. The purpose of this study was to exercise the question, in opioid-dependent patients managed with buprenorphine, would continuing buprenorphine therapy during the perioperative period affect postoperative pain levels? I searched the database SuperSearch. The key terms for this search were (pain management OR treatment), buprenorphine, and (perioperative OR intraoperative OR postoperative) apply the Boolean operator AND. I limited results to peer-reviewed academic journal articles published in English from 2004-2014. Initial results were refined using the inclusion criteria of patients maintained on buprenorphine therapy prior to mental process and perioperative p ain management, and the exclusion criteria of animal studies and buprenorphine administration techniques epidural, intrathecal, perineural, subcutaneous, and transdermal.REVIEW OF THE LITERATUREThe purpose of these studies is to examine perioperative acute pain management in opioid-tolerant patients taking BMT.The type of studies include a retrospective cohort study, literature reviews, and case reports examining a population of people taking chronic buprenorphine.Buprenorphine may be a more preferable method than methadone for chronic opioid replacement therapy. The use of buprenorphine has been associated with improvement in education, social life, and toxicological conditions when compared to methadone.1 Buprenorphine is also perceived to have little adverse effects and social stigma than methadone.2 In gain, buprenorphines full opioid agonist effects are lour compared to methadone, improving its safety profile.3 Buprenorphine may also induce less hyperalgesia than full agonis ts, although this has yet to be confirmed.2 In support of this statement, however, Koppert et al4 found that the antihyperalgesic effects of buprenorphine were stronger and of longer duration as compared with the pure mu receptor agonist studied in the same model.Though some researchers recommend a transition from buprenorphine to a full mu agonist preoperatively, an interruption in BMT is not ideal. A drug holiday or transition to other chronic opioids, such as methadone, prior to surgery may lead to simplified sedation techniques however, it is time consuming and unnecessary, and alternatives should be considered.1 It is best that patients with opioid dependence be in some early withdrawal before initiating treatment with buprenorphine.5 As a result, when a patient transitioned to methadone prior to surgery returns to their previous dose of buprenorphine postoperatively, withdrawal may occur.1 Additionally, for patients switched from BMT to MMT preoperatively, methadone must be ce ased for at least 36 hours and the patient should flummox mild withdrawal symptoms before buprenorphine is restarted.6 In contrast to these recommendations, the retention of buprenorphine was found to be better in heroin addicts with less morbidity if buprenorphine was not rapidly withdrawn, but continued for up to 350 days.5When chronic buprenorphine doses were continued throughout perioperative period, patients were able to achieve good pain control with additional opioids and/or additional buprenorphine doses. In a small series of 5 patients, adequate pain control was achieved when other full mu agonist opioids were given as needed in addition to the patients usual daily dose of buprenorphine.7 In another study,8 the patient achieved adequate pain control on postoperative day 1 and 2 with a total daily buprenorphine dose of 72 mg, and was able to successfully and comfortable taper to her baseline dose of 24 mg/d by day 11. Furthermore, Jones et al9 reported the buprenorphine-ma naged patient scored 0 out of 10 on all 6 post morphine-PCA pain assessments, and 0 to 5 out of 10 on all post discharge pain assessments while taking buprenorphine and oxycodone/acetaminophen.Only 1 study10 reported severe postoperative pain control with the continuation of buprenorphine during the perioperative period. The study10 highlighted a case report for one patient with Type I Chiari malformation receiving buprenorphine for chronic pain who underwent two identical surgical procedures. For the head start procedure, the patients usual dose of buprenorphine was continued throughout the perioperative period, and a full mu agonist was used for postoperative pain.10 The patient reported severe postoperative pain after this procedure.10 This information is limited, however, by self-report. No documentation was obtained from the outside hospital where the first procedure was performed.10 The author is a representative for the hospital where the second procedure was performed.10 F or the second procedure, the patients buprenorphine was discontinued 5 days prior to surgery, and the patient was transitioned to a full opioid agonsist.10 Again, the patients postoperative pain was managed with a full opioid receptor agonist.10 Though the patient reported acceptable pain control on postoperative day 1, the patients pain was reported at 7 to 8/10 immediately after surgery.10Although some researchers suggest that buprenorphine decreases full mu agonist opioids effectiveness, many found the addition of full mu agonists in the perioperative setting to be beneficial for buprenorphine-maintained patients. Buprenorphines long half-life, high opioid receptor affinity, partial agonist activity, and slow up dissociation from the mu receptor may reduce analgesic effectiveness of full mu opioid agonists however, the data does not support the commonly held belief that high dose BMT will interfere with the activity of full mu agonist opioids given for the relief of postoperativ e pain.6 Morphine has been shown to be an effective breakthrough medication to control postoperative pain in buprenorphine-maintained patients.11 In a retrospective cohort study, Macintyre et al6 confirmed BMT patients who were not given buprenorphine the day after surgery had significantly higher (P=.02) PCA morphine equivalent requirements in the first 24 hours after surgery compared with those who were given their usual dose of buprenorphine. In another uncontrolled comparison of BMT and MMT groups, researchers12 found that the first 24 hour postoperative PCA opioid requirements were lower for BMT and MMT groups when maintenance drugs were continued compared with BMT and MMT groups whose maintenance drugs had been ceased perioperatively.Despite the fact that one report6 showed a reduction in whole brain mu receptor availability with high doses of buprenorphine, some(prenominal) studies demonstrated that there is no pileus effect for the analgesic properties of buprenorphine, on ly for an opioids euphoric effects and respiratory falling off. It has been shown that buprenorphine attenuates the effects of additional opioid agonists rather than manage an absolute ceiling effect, and this minimizes euphoric properties of concurrently administered opioids and discourages the likelihood of ongoing opioid abuse.2 Macintyre et al6 also revealed that PCA opioid requirements were lower when BMT was continued after surgery, implying that buprenorphine may still have analgesic effects. Walsh et al13 documented no ceiling effect for analgesia in patients that received sublingual buprenorphine up to 32 mg. As there are no additional opioid effects with escalating doses, this property limits abuse potential and minimizes respiratory depression with high doses.2 In a study of 20 volunteers, Dahan et al14 confirmed buprenorphines ceiling effect on respiratory depression, but not on its analgesic effects.As buprenorphine demonstrates a ceiling effect for respiratory depres sion, it is safe for outpatient use in high doses however, when used in conjunction with sedatives, a synergistic effect in respiratory depression may occur. One case report8 verified that a high daily dose of buprenorphine (72 mg) was safely used as an outpatient dose, though no other respiratory depressants were used. Combining benzodiazepines with buprenorphine can exert a synergistic effect on the key nervous system resulting in sedation and respiratory depression.11 Deaths from buprenorphine have been reported, but it has been suggested that these deaths predominantly occurred as a result of prolonged respiratory depression when administered with sedatives, particularly benzodiazepines.2There is no consensus on recommendations regarding acute pain management for buprenorphine-maintained patients presenting to the perioperative setting and more research is needed. Some articles2,5,11 recommend the cessation of buprenorphine preoperatively and conversion to a full opioid agonis t throughout the perioperative period. Conversely, others1,2,5,8 demonstrate successful pain management in the acute pain setting with divided daily and/or additional doses of buprenorphine. The bulk of researchers,2,3,5,9,11,15 however, support the continuation of usual buprenorphine maintenance therapy with the addition of full mu agonist opioid analgesics for effective perioperative pain control. There are no recommendations based on high level evidence,15 and data is sparse regarding the best method of treatment for pain in the opioid-dependent population.5 Regardless of point of view, most studies agree that additional research regarding acute pain management for patients taking chronic buprenorphine is urgently needed.5,10,11DISCUSSIONIt is clear that buprenorphine is a better alternative than methadone for the treatment of opioid dependence. Associated with less respiratory depression and a lower abuse profile, buprenorphine is a safer medication than methadone and can be use d without difficulty in outpatient therapy. With a long half-life and slow dissociation time, buprenorphine can also be dosed less frequently. Buprenorphine has also been known to cause less side effects than methadone. All of these features can increase adherence to opioid replacement therapy by allowing the opioid-dependent patient a less restrictive lifestyle.There is a great deal of uncertainty regarding the best method for treating acute surgical pain in patients taking chronic buprenorphine. There are multiple recommendations regarding perioperative pain management and BMT however, most methods are developed from the results of uncontrolled studies with genuinely small sampling sizes. Consequently, few are able to establish actual significance in their findings. Without concrete evidence, concise standard recommendations are difficult to establish. coatingBased on the literature, the continuation of BMT during the perioperative period with the addition of short acting full mu opioids and/or additional buprenorphine doses is the best approach to treating acute surgical pain.For proximo research, more controlled studies with larger sample sizes are needed in order to confirm the best method of acute pain management in the surgical setting for patients taking chronic buprenorphine.ReferencesWasson M, Beirne O. Buprenorphine therapy an increasing challenge in oral and maxillofacial surgery. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013(2)142. uncommitted from Academic OneFile, Ipswich, MA. Accessed June 3, 2014.Roberts D, Meyer-Witting M. High-dose buprenorphine perioperative precautions and management strategies. Anaesth Intensive Care. February 200533(1)17-25. Available from MEDLINE, Ipswich, MA. Accessed June 10, 2014.Bryson E, Lipson S, Gevirtz C. Anesthesia for Patients on Buprenorphine. Anesthesiol Clin. January 1, 201028(Perioperative Pharmacotherapy)611-617. Available from ScienceDirect, Ipswich, MA. Accessed June 3, 2014.Koppert W, Ihmsen H, K orber N, et al. Different profiles of buprenorphineinducedanalgesia and antihyperalgesia in a human pain model. Pain 2005118(12)1522. Cited by Vadivelu N, Anwar M. Buprenorphine in Postoperative Pain Management. Anesthesiol Clin. January 1, 201028(Perioperative Pharmacotherapy)601-609. Available from ScienceDirect, Ipswich, MA. Accessed June 3, 2014.Vadivelu N, Mitra S, Kaye A, Urman R. Perioperative analgesia and challenges in the drug-addicted and drug-dependent patient. Best Pract Res Clin Anaesthesiol. March 201428(1)91. Available from Supplemental Index, Ipswich, MA. Accessed June 10, 2014.Macintyre P, Russell R, Usher K, Gaughwin M, Huxtable C. Pain relief and opioid requirements in the first 24 hours after surgery in patients taking buprenorphine and methadone opioid substitution therapy. Anaesth Intensive Care. March 201341(2)222-230. Available from Academic Search Premier, Ipswich, MA. Accessed June 3, 2014.Kornfield H, Manfredi L. Effectiveness of full agonist opioids in p atients stabilized on buprenorphine undergoing major surgery a case series. Am J Ther 201017523-528. Cited by Huxtable C, Roberts L, Somogyi A, Macintyre P. Acute pain management in opioid-tolerant patients a growing challenge. Anaesth Intensive Care. family line 201139(5)804-823. Available from Academic Search Premier, Ipswich, MA. Accessed June 3, 2014.Book S, Myrick H, Malcolm R, Strain E. Buprenorphine for postoperative pain following general surgery in a buprenorphine-maintained patient. Am J Psychiatry. June 2007164(6)Available from PsycINFO, Ipswich, MA. Accessed June 3, 2014.Jones H, Johnson R, Milio L. Post-cesarean pain management of patients maintained on methadone or buprenorphine. Am J Addict. May 200615(3)258-259. Available from MEDLINE, Ipswich, MA. Accessed June 3, 2014.Chern S, Isserman R, subgenus Chen L, Ashburn M, Liu R. Perioperative Pain Management for Patients on Chronic Buprenorphine A Case Report. J Anesth Clin Res. October 20123(10)1. Available from Supple mental Index, Ipswich, MA. Accessed June 3, 2014.Vadivelu N, Anwar M. Buprenorphine in Postoperative Pain Management. Anesthesiol Clin. January 1, 201028(Perioperative Pharmacotherapy)601-609. Available from ScienceDirect, Ipswich, MA. Accessed June 3, 2014.Russell R, Usher K, Macintyre PE. A comparison of postoperative opioid requirements and effectiveness in methadone- and buprenorphine-maintained patients. Anaesth Intensive Care. 201139726-727. Cited by Huxtable C, Roberts L, Somogyi A, Macintyre P. Acute pain management in opioid-tolerant patients a growing challenge. Anaesth Intensive Care. September 201139(5)804-823. Available from Academic Search Premier, Ipswich, MA. Accessed June 3, 2014.Walsh SL, Preston KL, Stitzer ML, et al. Clinical pharmacology of buprenorphine ceiling effects at high doses. Clin Pharmacol Ther. 199455(5)56980. Cited by Vadivelu N, Anwar M. Buprenorphine in Postoperative Pain Management. Anesthesiol Clin. January 1, 201028(Perioperative Pharmacotherapy )601-609. Available from ScienceDirect, Ipswich, MA. Accessed June 3, 2014.Dahan A, Yassen A, Romberg R, et al. Buprenorphine induces ceiling in respiratory depression but not in analgesia. Br J Anaesth. 200696(5)62732. Cited by Vadivelu N, Anwar M. Buprenorphine in Postoperative Pain Management. Anesthesiol Clin. January 1, 201028(Perioperative Pharmacotherapy)601-609. Available from ScienceDirect, Ipswich, MA. Accessed June 3, 2014.Huxtable C, Roberts L, Somogyi A, Macintyre P. Acute pain management in opioid-tolerant patients a growing challenge. Anaesth Intensive Care. 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