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The Liberation-sud resistance group was established by a group of French people including Emmanuel d'Astier, Lucie Aubrac and Raymond Aubrac. The first important French Resistance group to emerge after the German occupation, it began publishing Libération in July 1941. With the support of Daniel Mayer and the clandestine Socialist Party the Liberation-sud group grew rapidly.

In 1942 Emmanuel d'Astier entered talks with Jean Moulin about the possibility of uniting all the resistance groups working in France. After much discussion Moulin persuaded the eight major resistance groups to form the Conseil National de la Resistance (CNR). This included D'Astier's Liberation-sud as well as Combat (Henry Frenay), Francs-Tireur (Jean-Pierre Lévy) (Francs-Tireur), National Front (Pierre Villon), Comité d'Action Socialiste (Pierre Brossolette) and Armée Secrete (Charles Delestraint).

These three movements were born spontaneously and independently of the initiative of a few French patriots who had a place in the old political groups and parties. They started to assert themselves at different dates, soon after the conclusion of the armistice, however, and as a reaction against this instrument of submission to the enemy. In the beginning, their activities consisted in spreading by underground channels and in a rather restricted sphere typewritten propaganda pamphlets on every important occasion (speech of Mr. Churchill, of President Roosevelt, speeches of General de Gaulle, outstanding military operations, etc.), or else on every occasion which called for a rebellious attitude on the part of French patriots (annexation by Hitler of Alsace and Lorraine, violation of the clauses of the Armistice, the agreements concluded at Montoire, requisitioning by the Germans, etc.).

Next, with the development of material means and the increased adherence of willing partisans, they were able to publish real roneoed papers at tolerably regular intervals. Now, for several months, each group has been publishing at a fixed date one or several printed papers in addition to pamphlets and leaflets.

Liberation, the organ of the movement Liberation, is more particularly aimed at working-class circles. A large section is devoted to social problems, and its leaders are at present in contact with a certain person, who has maintained a very great influence on syndicalist circles.

Organizations similar to or like Libération-sud

Resistance group active between 1940-1944 and created in the Free Zone of France during the Second World War in order to fight against the Nazi occupation through coordinated sabotage and propaganda operations. Wikipedia

French Resistance group against the German occupation of France during the Second World War. Essentially composed of French railway workers from the SNCF and played an active role in the French Resistance. Wikipedia

Free French Resistance group, which fought against the 1940–1944 German occupation of France in World War II. Also given to the military conflict that opposed Resistance fighters to German, Vichy and Milice forces. Wikipedia

Collectively responsible for printing flyers, broadsheets, newspapers, and even books in secret in France during the German occupation of France in the Second World War. Used to disseminate the ideas of the French Resistance in cooperation with the Free French, and played an important role in the liberation of France and in the history of French journalism, particularly during the 1944 Freedom of the Press Ordinances. Wikipedia

Large movement in the French Resistance created in the non-occupied zone of France during the Second World War . One of the eight great resistance movements which constituted the Conseil national de la Résistance. Wikipedia

The Spanish Maquis were Spanish guerrillas exiled in France after the Spanish Civil War who continued to fight against Francoist Spain until the early 1960s, carrying out sabotage, robberies (to help fund guerrilla activity), occupations of the Spanish embassy in France and assassinations of Francoists, as well as contributing to the fight against Nazi Germany and the Vichy regime in France during World War II. Referring to the contribution of the Spanish Maquis to the French resistance movement, Martha Gellhorn wrote in The Undefeated (1945): Wikipedia

French history teacher and member of the French Resistance during World War II. Agrégation of history, and in 1939 she married Raymond Samuel, who became known as Raymond Aubrac. Wikipedia

Member of the French Resistance opposing the Nazi occupation of France during World War II. Notable for his youth, dying at age six, and is regarded as France's youngest resistance hero. Wikipedia

Moro National Liberation Front

In Mindanao, the followers of Islam - referred to as Moros or Moors by the Spaniards during the colonial period - make up a sizeable part of the population.

Nur Misuari founded the Moro National Liberation Front (MNLF) in 1971, with the goal of fighting the Philippine state for an independent Moro nation.

An intervention by the UN-backed Organization of Islamic Conference - later called the Organization of Islamic Cooperation - led to the signing of the often-referred to Tripoli Agreement in Libya in 1976. This agreement, however, failed to hold.

In 1986, President Corazon Aquino personally met Misuari to hold talks. In 1989, Ms Aquino signed a law that gave predominantly Muslim areas in the region a degree of self-rule, setting up the Autonomous Region in Muslim Mindanao (ARMM).

The ARMM is composed of the mainland provinces of Maguindanao and Lanao del Sur, and the island provinces of Sulu, Tawi-Tawi and Basilan.

But the significant peace agreement with the MNLF was signed in 1996, with President Fidel Ramos. This paved the way for Misuari to run for office and he was elected as ARMM governor the same year.

His term however ended in violence in November 2001, when he led a failed uprising. He was subsequently jailed, but eventually released, in 2008.

In February 2005, supporters loyal to Misuari launched a series of attacks on army troops in Jolo, the largest of the Sulu islands.

The trigger for the violence was thought to be the launch of a huge military operation to target the armed Muslim group Abu Sayyaf - which is alleged to have ties with the Misuari faction.

In August 2007, the group said it was behind an ambush on troops in Jolo, which led to nearly 60 deaths.

In 2008, Misuari was ousted as MNLF chairman. Muslimim Sema succeeded him.

Over the years, the MNLF is believed to have become weaker, and many factions have splintered from the main group.

Our History

From the very beginning

Comptoir Sud Pacifique gets another makeover! New, blue labels and sleek silver cap to introduce the new collections.

Comptoir Sud Pacifique gets a makeover! Now packaged in glass bottles for a sleek and modern look.

Comptoir Sud Pacifique delves into the mysteries of the Middle East and creates four Oud scents: Aouda, Nomaoud, Oud Intense and Oud de Nuit.

Comptoir Sud Pacifique develops an international celebrity fan base with celebrities such as Cher, Britney Spears, Nicole Kidman, Jessica Simpson, and Charlotte Ronson.

The #1 best seller Vanille Abricot is created. Hugely popular for women of all ages, and adored by men everywhere. Vanille Abricot becomes a celebrity favorite.

Comptoir Sud Pacifiques's first Vanilla scent is born seducing a whole young generation which largely contributes to the reputation of the brand.

The "color years" are born a mix of turquoise and fawn colors that quickly dominated the collections.

The first Comptoir Sud Pacifique store opens its doors in one of the most prestigious of Paris streets, 17 Rue de la Paix.

Original scents are preciously sealed in metal bottles, miniature replicas of those used to ship essential oils.

Pierre and Josée Fournier took their first trip to the islands of Polynesia. the lasting impressions from that first trip reinforced the Fournier's desire to be different through exoticism and refinement of their fragrant creations.

The Specificities of Resistance Historiography: Realities and Representations

From 1944 until the beginning of the 1980s the idea prevailed that as a clandestine activity the resistance necessarily possessed few archives. Yet this was only partly the case, and the assumption persisted mainly because many archives were closed. There was also a widespread conviction that only a minority had been involved in clandestine activity: the general public knew, deep down, that the resistance had always been the preserve of a minority, a kind of elite. Footnote 12 Everybody agreed that oral testimonies were therefore crucial. Indeed, two official committees were created in October 1944 and June 1945 in order to preserve the knowledge needed to write the future history of the resistance, Footnote 13 subsequently merging in 1951 to become the Committee on the History of the Second World War (Comité d’histoire de la deuxième guerre mondiale CH2GM). Under the supervision of Édouard Perroy, professor of medieval history at the University of Lille and former resister, these two committees collected more than 2,000 testimonies from resisters, mostly between 1945 and 1947. As late as the 1980s and 1990s nobody studied the French resistance without using these sources and carrying out their own oral history. In the 1980s, for example, those of us studying a resistance movement, such as Alya Aglan, Olivier Wieviorka and myself, collected as many testimonies as we could. Footnote 14 Yet this period now belongs to the past. We have reached a turning point: the very last resisters are fast disappearing, with fewer than five Compagnons de la libération still alive in August 2018 (out of approximately 700 in 1945). Footnote 15

Another very particular influence on resistance historiography has been the axiom that only those who participated in the movement are suitably qualified to write about it: unlike other heroic moments of twentieth-century history, the resistance was a clandestine and elusive adventure intimately known only by its members. For at least thirty years the result of this axiom was that historians of the resistance tended to be former resisters. For many it was a crucial period in their lives: little wonder, therefore, that they should scrutinise everything published on the subject and react so strongly whenever they disagreed. This superposition – one might even say confusion – of actors and historians lasted a considerable length of time. Indeed, former resisters have continued to play a key role, with Jean-Louis Crémieux-Brilhac being by far the best historian of Free France Footnote 16 and Daniel Cordier a major contributor to the knowledge of the resistance as viewed from the top (la Résistance des chefs) through his books on Jean Moulin, his boss for a year during the resistance itself. Footnote 17

For political and ideological reasons communists tried hard to make their presence felt in this historiographical field. Because of the Cold War they wanted their part in the resistance to be acknowledged and even magnified. Obsessed with the hazy period between 1939 and 1941 when the party apparatus linked to Moscow was not committed to outright resistance, they endeavoured – though failed – to control the history that was written. Footnote 18 In practice Gaullist memory gradually triumphed over its communist counterpart. Footnote 19

Yet even beyond this consideration the historiography of the resistance has retained a very particular and even precious status, linked to the assumption that it must be written only with the utmost care and respect. To be sure, many of the books appearing on the subject from the 1950s to the end of the 1970s were serious and reliable works of scholarship. Footnote 20 Yet it is striking to notice that they remained on the methodological sidelines of the new approaches then dominant in the writing of History, not least with the success of the Annales school. In contrast, resistance historiography remained strongly positivist in approach.

An important change occurred at the very beginning of the 1980s, when a new laboratory was founded to replace the CH2GM that had controlled the field since the 1950s: The Institute of Contemporary History (Institut d’Histoire du Temps Présent IHTP). As the founder and director of this new laboratory, François Bédarida chose to insist on a theoretical reflection about the history of the present time. In particular, he emphasised that writing a history still in living memory could not be done without meditating on the difficulties that every historian would inevitably encounter on such a path. Footnote 21 Here he worked closely with one of the leading specialists on the French resistance, Jean-Pierre Azéma. Footnote 22 In parallel, a new generation of scholars was also taking to this historiographical field, which initiated a further substantial shift. Most of these scholars found a kind of logistical and intellectual shelter at the IHTP, which was an extremely welcoming, attractive and efficient research centre. This generation – the term is used here not to imply proximity in age but rather to denote a shared set of questions and approaches – worked on subjects such as public opinion, including representations and what is described as ‘the imaginary’ (‘l’imaginaire’, Pierre Laborie), Footnote 23 the sociology of the resistance (Jacqueline Sainclivier), Footnote 24 underground publications (François Marcot), Footnote 25 foreigners in the French resistance and the role of the Parisian police (Denis Peschanski), Footnote 26 resistance and daily life (Dominique Veillon), Footnote 27 resistance seen from below (Jean-Marie Guillon), Footnote 28 anthropological approaches to the French resistance (Rod Kedward) Footnote 29 and resistance in a specific locality (e.g. John Sweets, who focused closely on Clermont-Ferrand). Footnote 30 During the 1990s these historians organised a series of six conferences that deeply revisited the history of the French resistance. Footnote 31 These focused on three aspects: first, an attempt to give some elements of definition to what we call the resistance second, the resistance as seen from below, a kind of ‘résistance au village’ Footnote 32 and third, a comparison with other resistances in European countries. What gradually emerged was a history that was both more conceptual and more complex.

At the same time these specialists in the history of the French resistance in France also became increasingly independent from the IHTP. Though the writing of this history continued to advance, it also fragmented – perhaps unsurprisingly, given the evolution of the discipline as a whole. The results of this movement of renewal culminated in 2006 with the Dictionnaire de la Résistance. Footnote 33

I would like at this point to emphasise some of the most promising new directions taken in recent years. These original approaches have often been the hallmark of young scholars supervised by a number of top-rank academic historians. The time when the whole field of resistance historiography was encompassed by a single institution – whether the CH2GM under the direction of Henri Michel between 1951 and 1980, or more recently the IHTP – has clearly passed, and research is now more closely dependent on the personal interests and curiosity of the individual scholar. In this sense the ‘third generation’ of resistance scholars seems to be more open minded and freer than their predecessors (including myself). Partly this can be traced to a decline in the deep-rooted centralisation for which France is so well known, partly to a dramatic change in the questions posed to the past by the present.


Founded in 1989 by a group of five South Asian women—Anannya Bhattacharjee, Mallika Dutt, Tula Goenka, Geetanjali Misra, and Romita Shetty—who were from diverse professional fields such as banking, film, law, and public health, Sakhi, meaning “woman friend,” was created to fill a critical need. In spite of an abundance of religious and cultural centers, professional associations, and ethnic-specific groups within New York’s large South Asian immigrant population, there was no place for survivors to address the oft-silenced subject of gender-based violence. Through Sakhi’s efforts to serve survivors and mobilize community members to condemn abuse, Sakhi has changed the conversation on gender-based violence in our community. Margaret Abraham, author of Speaking the Unspeakable: Marital Violence Among South Asian Immigrants in the United States , has noted, “What Sakhi did was bring together issues around ethnicity and gender, which were previously not discussed in our communities. They shifted domestic violence from a private family problem to a public social issue.”

Femmes Résistantes: World War II’s Unsung Warriors

Lest we forget, the brave and dauntless resistance fighters of the Second World War counted among them numerous women, from all walks of life. Jennifer Ladonne looks at some of their stories.

On a beautiful day in May 2015, President François Hollande, standing on the vast steps of Paris’s Pantheon, facing four caskets draped with the French Tricolore, paid homage to four heroes of the French Resistance on the 70th anniversary of the end of the Second World War. A relatively unremarkable event but for the fact that two of the renowned resistance fighters about to join such historic figures as Voltaire and Zola in France’s famous monument “to great men” were, in fact, great women.

Before this day in 2015, only two other women had gained entry: the wife of a worthy great who insisted on her presence and Marie Curie, honoured in 1995.

President François Hollande outside the Pantheon in Paris in May 2015. Photo credit © Alamy

The two female honourees, Germaine Tillion and Geneviève de Gaulle-Anthonioz, both began their resistance work at Paris’s Musée de l’Homme. Tillion was already a noted anthropologist, and de Gaulle, niece of the famous general, was a university student infuriated by Marshal Pétain’s armistice with the Nazis in June 1940. In the course of their work, both women were captured and survived the horrors of Germany’s Ravensbrück concentration camp. Tillion escaped in 1945, and de Gaulle, having been kept alive only as a potential bargaining chip thanks to her illustrious name, was rescued in April 1945. Both women spent the rest of their long lives (Tillion died in 2008 at the age of 100 and de Gaulle-Anthonioz in 2002, aged 81) as committed activists and illustrious figures in French politics and letters.

Germaine Tillion, who was honoured at the Pantheon in 2015. Photo credit © MRN Photos

Hollande’s long overdue gesture both satisfied and disappointed French feminists and historians, who’d hoped to see four women distinguished that day. Many considered it meagre atonement for an omission that has yet to be rectified in either the history books or the public mind. In a movement that demanded anonymity by its very nature, women’s roles were the most anonymous of all. Yet their work pervaded every aspect of the resistance. Women willingly undertook any task offered to men no matter how perilous, from distributing clandestine newspapers and espionage to parachute drops and armed combat. At the same time, women performed all the roles of their traditional domain in service to the cause – caregivers, nurses, providers of food and shelter, seamstresses, secretaries – mundane tasks that would prove crucial to the resistance effort and that many men couldn’t – or wouldn’t – assume.

If caught, women resisters suffered the same fate as their male counterparts. Internment and concentration camps were filled with résistantes, who were subject to the same beatings, torture and execution as men, yet female resisters were much more vulnerable to having their children and loved ones held hostage, brutally beaten or murdered before their eyes to induce them to talk. Many resisters, both women and men, remarked after the war that women held up better under torture than men.

Women performed all kinds of tasks during the war. Photo credit © MRN Photos

Undercover Heroines

There are countless more French heroines than could ever be packed into the Pantheon. So why have they been largely overlooked or ignored? Sadly, for all the obvious reasons, but also because, as Margaret Collins Weitz observed while conducting dozens of personal interviews with resisters for her book Sisters in the Resistance: How Women Fought to Free France 1940-1945, no matter the danger, women did not see themselves as doing anything particularly “heroic” or even out of the ordinary.

Nor did many men see them that way, including those with ample evidence to the contrary. After the liberation, General de Gaulle, who’d spent the duration of the war leading his Free France resistance movement from the relative safety of London, issued a list of 1,038 resistance heroes only six were women. De Gaulle, slow to recognise the many resistance movements that sprang up after Pétain’s Vichy collaboration, only grudgingly, and belatedly, admitted women to his own organisation at the urging of his French and British compatriots.

A mural of Germaine Tillion and Geneviève de Gaulle-Anthonioz on the shutters of a bookshop in Paris’s 20th arrondissement. Photo credit © Alamy

But if De Gaulle was reluctant, other leaders were not. Georges Loustaunau-Lacau, a French major and intelligence officer who had anticipated both France’s military weakness in the face of Nazi aggression and Pétain’s capitulation, had the foresight to recruit Marie-Madeleine Fourcade, first in 1936 at his publishing house, then, after his arrest in 1941, as his replacement at the head of the spy network Alliance. The boldness of choosing a woman to lead one of the war’s most important spy networks cannot be overstated. But with a car, a pilot’s licence, a good job and a good pedigree, Fourcade was no ordinary woman. Shaped by an adventurous childhood spent in Shanghai, this chic Parisienne was also “born to privilege and known for her beauty and glamour”, recounts Lynne Olson in her real-life thriller, Madame Fourcade’s Secret War. Steely and quick-witted, the 32-year-old Fourcade was also a master of disguise, which came in handy on more than one occasion. Among her many hair-raising exploits, she survived a freezing night stuffed in a mail sack in a train freight car and escaped twice from the Gestapo, once asking permission from a priest to take the cyanide pills she carried before finding a way to squeeze her naked body out of a barred window.

As the head of Britain’s M16 noted, the average resistance fighter lasted six months in the field before being captured or killed. Fourcade lasted four years, and at Alliance’s high point commanded 3,000 active members. Under her leadership, Alliance provided the British and Allied forces with some of the war’s most crucial intelligence, including the location of a new Nazi superweapon, the V2 rocket, that might well have reversed the war’s outcome – thanks to a woman.

Fourcade’s agent Jeannie Rousseau, a pretty 20-year-old graduate from an elite university who was fluent in German, applied at the Nazi’s Brittany headquarters for the job of translator. The intelligence she gathered, due to the carelessness of Nazi officers disarmed by this charming, seemingly guileless blond, permitted the Allies to obliterate the German weapons site.

Women kept daily life going. Photo credit © Alamy

Though Fourcade was the sole female leader of a major resistance network, dozens more held positions of incalculable importance to the effort. Berty Albrecht, a co-founder and powerhouse behind the major clandestine organisation Combat, created and oversaw its social services section to provide much-needed support to the wives and children of captured agents, a blueprint that other clandestine groups readily copied. Due to extreme shortages of food, clothing, shoes, bicycles and the basic necessities of life, all requisitioned by the Nazis, Albrecht’s initiative proved vital, especially after the mass deportation of French men to Germany in the Vichy government’s compulsory forced labour program (STO), initiated in 1942. She also co-founded the journal Combat (whose contributors included Jean-Paul Sartre and Albert Camus), which was edited by her friend Jacqueline Bernard until Bernard’s arrest in 1944. A tireless activist and feminist before the war, Albrecht was a champion of social causes even after her capture in 1942, drawing up a report on the shocking conditions of the French prison where she was being held. Married earlier in life to a banker in London, Albrecht joked while scrubbing prison toilets how she’d shared a dressmaker with the Queen.

Though Albrecht managed a daring escape with the help of her daughter, she was recaptured by the Gestapo five months later, in May 1943. To avoid the risk of divulging any of her vast covert knowledge under torture, she committed suicide.

Lucie and Raymond Aubrac. Photo credit © MRN Photos

Lucie Aubrac, another co-founder of a major resistance network, Libération-sud, with her husband Raymond Aubrac, and a founder of the underground journal Libération, was one of the rare women to bear arms, even while pregnant. Aubrac helped organise railroad sabotage attacks and carried out a daring armed rescue mission to free her husband, along with 15 other prisoners, from a Vichy jail.

Weitz points out that despite her bravery, Aubrac believed that, “the women who hid arms had a much more dangerous assignment than she did as leader of a hit squad… Attacks were rapid and soon over while the farm women spent months not knowing when the enemy might discover their arms caches. They had to live daily with that fear”. Aubrac survived the war, becoming the first woman to serve in the French parliament, appointed by de Gaulle in 1944 for her contribution to the cause.


The Wehrmacht stormed into France on 10 May 1940, and after six weeks of combat and 100,000 French dead, achieved victory. Nazi soldiers marched in Parisian streets, and swastika banners were unfurled over the city that had symbolised Allied resilience on the mainland. 1.8 million French soldiers became POWs, many not to return until 1945.

This was a calamity for resistance forces across Europe who hoped for an early end to the war. So crushing was the defeat that the French resistance writer Jean Bruller (AKA Vercors) predicted that the Germans might remain in France for a century.

France was divided, the north under German occupation, and the south so-called “Free Zone” administered by a new government based in Vichy under Marshal Pétain. Pétain’s tenure was defined by powerlessness and collaboration, and by November 1942, the whole of France was occupied. Pétain’s armistice was initially greeted with widespread relief. Memories of WWI loomed large, and compared to the savage depredations in the East, the occupation was, in the early days, relatively restrained.

However, life under the Nazi boot soon turned opinion decisively against Pétain. Unemployment was widespread, and the German commandeering of France’s agriculture led to mass deprivation and hunger in towns and cities, stunting children’s growth by up to 11cm. France became a brutal police state, and between March 1942 and July 1944, 75,000 Jews were deported to death camps. In January 1943, the far-right paramilitary group Milice Française formed to hunt Jews and resisters, numbering 30,000 at its peak. Punishments became increasingly harsh, with an estimated 30,000 French killed in anti-resistance executions.

Resistance forces increasingly received support from the French government-in-exile and the Special Operations Executive (SOE)

Against this conflicted backdrop, the diverse, multifaceted and fluid French resistance burst into life. From 1942 onwards, resistance forces increasingly received support from the French government-in-exile and the Special Operations Executive (SOE), who sent over 470 operatives, and air dropped supplies into the country. However, as historian Olivier Wieviorka writes, for the early years, without direction from London, these groups had to “invent the terms of its battle on its own”. In doing so “they invented an original type of organization, the resistance movement”, a force of volunteers engaging in numerous forms of battle.

Such forms included: tens of thousands of armed partisans in the forests and mountains an underground press, circulating two million newspapers a month elaborate escape lines that enabled thousands of Allied service personnel to return to Britain hundreds of thousands marching in demonstrations intelligence agencies that passed the Allies vital information and brave individuals who saved Jews.

The French resistance included people of all classes, and many political stripes, and nationalities for example, Polish coal miners fought alongside the French in the north, and as many as 60,000 Spanish refugees from Franco’s fascist regime resumed their antifascism in a new country. In all, as many as 500,000 uncommonly courageous individuals risked all to actively combat the Vichy regime and the Third Reich.

Opioids for Chronic Pain in Patients with History of Substance Use Disorders – Part 1: Assessment and Initiation

When is it appropriate to use opioids in the palliative care setting for a patient with a history of a substance use disorder (SUD)? This Fast Fact addresses strategies for initiating opioids for patients with a history of SUD Fast Fact #312 will address best practices for monitoring opioids for these patients.


SUD: a maladaptive pattern of substance use leading to clinically significant impairment or distress.

Aberrant drug behaviors: medication-related behaviors that depart from strict adherence to the prescribed therapeutic plan of care.

Addiction: overwhelming involvement with the acquisition and use of a drug, characterized by: loss of control, compulsive drug use, and use despite harm (see Fast Facts #68, 69).

Diversion: the illegal transfer of a pharmaceutical controlled substance from the person it was prescribed to another person for use. Patients with SUDs are at higher risk for diversion of opioids.

Risks of Opioid Therapy in Patients with a history of SUD:

  • Inability to achieve effective analgesia due to opioid tolerance.
  • Adverse opioid effects when higher doses are used including unintentional overdose, aberrant drug behaviors, diversion, delirium, and even death.

Patient Selection: The goal is to ensure that opioid prescribing is safe, effective, and does not contribute to worsening of an SUD. Opioids for acute severe pain (such as hospitalization for a broken bone) can be used in a closely monitored setting. Patient selection for moderate-to-severe chronic pain is more complex and involves the interplay of:

  • Prognosis of the serious illness
  • Status of the SUD: in recovery vs. active substance abuse
  • Pain severity/risk of adverse opioid effects.

Except those with a limited prognosis (e.g. < 2 months) or with an acute pain problem (e.g. bone fracture), we do not recommend starting opioidsfor patients who are actively using drugs to maintain a SUD (heroin, cocaine, methamphetamine, alcohol, prescription drugs). Marijuana use should be evaluated on a case-by-case basis. Patients with a more distant history of SUD, those who are established in a substance abuse treatment program, and those with aberrant drug behaviors without evidence of a SUD should be evaluated carefully in terms of risk. Long-term opioids for selected non-life-threatening conditions are potentially harmful (e.g. chronic headaches, fibromyalgia, chronic lower back pain, osteoarthritis) (4). The risks likely outweigh the benefits.

Initial Pain Assessment: The initial assessment is similar to patients without previously identified SUDs in that a comprehensive identification of the type of pain and its etiology is pivotal. Clinicians should:

  • Perform a careful history of past, present, and quantity of tobacco, alcohol, recreational drug use, and prescription drug misuse. Use a validated screening tool to stratify risk of opioid misuse (FF #244).
  • Differentiate active substance use, at-risk behaviors, recovery, and enrollment in a treatment program.
  • Evaluate for potentially treatable psychiatric disorders such as depression and anxiety, which are common both in chronic pain and those with SUDs.
  • Assess for current use of sedatives (like muscle relaxants and benzodiazepines).

Initial Opioid Management

  • Describe treatment expectations. Opioids will not completely eradicate pain and their effect on both pain and function may only be short term (4).
  • Counsel the patient on the associated risks of opioid therapy for patients with chronic pain and a history of SUD including addiction, overdose, delirium, and death (10).
  • Though access can be limited, ideally patients with an active SUD and chronic pain should be referred to an addiction medicine specialist (4). Multi-disciplinary teams engaging social workers, and mental health professionals can enhance treatment adherence and social support (5). See Fast Fact #127.
  • Use an opioid agreement at initiation of therapy to delineate safe practices and when opioids would be discontinued. Specify the consequences related to the presence of illicit drugs on a urine drug screen (UDS), requests for early refills, or attempts to obtain controlled substances from other clinicians.
  • For patients on maintenance therapy for opioid addiction such as buprenorphine or methadone, discuss the care plan with the addiction treatment program. If opioids are agreed to be appropriate, be prepared that higher doses may be needed to achieve therapeutic expectations (6,7).
  • Published data and expert opinion on the use of long acting opioids in SUDs offer conflicting advice (4,5,8). One study has shown a higher rate of unintentional overdose with long-acting opioids, most pronounced in the first 2 weeks after initiation (9). This may suggest clinicians have a difficult time identifying patients who misuse long-acting opioids.
  • A 1-2 week course of short-acting opioids with a follow up date less than 2 weeks may be the safest initial regimen. If available, offer a rescue naloxone prescription and opioid overdose education.
  • Combination opioid agonist/antagonist therapy (e.g. oxycodone/naloxone, buprenorphine/naloxone) under the guidance of a pain specialist has shown promise in the treatment of patients with SUD.
  1. Tsang A, Von Korff MV, Lee S, et al. Chronic pain conditions in developed and developing countries: gender and age differences and comorbidity with depression-anxiety disorders. Pain. 2008 9(10): 883-891.
  2. Morasco BJ, Gritzner S, Lewis L, et al. Systematic review of prevalence, correlates, and treatment outcomes for chronic non-cancer pain in patients with comorbid substance use disorder. Pain. 2011 152(3):488-97.
  3. Merikangas KR, McClair VL. Epidemiology of substance use disorders. Human Genetics. 2012. 131:779-789.
  4. Franklin, GM. Opioids for chronic noncancer pain: A position paper of the American Academy of Neurology. Neurology. 201483:1277-1283.
  5. Passik SD, Kirsh KL. Opioid therapy in patients with a history of substance abuse. CNS Drugs. 2004 18(1):13-25.
  6. Compton P, Charuvastra VC, Ling W. Pain intolerance in opioid-maintained former opiate addicts: effect of long-acting maintenance agent. Drug Alcohol Depend.200163:139-146.
  7. Doverty M, White JM, Somogyi AA, et al.Hyperalgesic responses in methadone maintenance patients. Pain.2001 90:91-96.
  8. Chang Y and Compton P. Management of chronic pain with chronic opioid therapy in patients with substance use disorders. Addiction Science & Clinical Practice. 2013. 8:21. http://www.ascpjournal.org/content/8/1/21.
  9. Miller M, Barber CW, Letherman S, et al. Prescription opioid duration of action and the risk of unintentional overdose among patients receiving opioid therapy. JAMA Internal Medicine. 2015 75(4): 608-615.
  10. Bohnert ASB, Valenstein M, Bair MJ, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA 2011 305(13):1315-1321.
  11. Chou R, Turner JA, Devine EB, et aal. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health’s Pathways to Prevention Workshop. Annals of Internal Medicine 2015 162(4):276-286.

Author’s Affiliations: University of Pittsburgh Medical Center

Version History: Originally edited by Sean Marks MD and electronically published in February 2016 updated in April 2019.

Conflicts of Interests: none reported

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Pacific Ordeal

Given the fact that this is 'Pacific' ordeal, some thoughts:
1. The US can't grow Essex-class carriers any faster, but far, far more lift is available to the Pacific now.
2. More airpower as well.
3. With total US focus on the Pacific (unless Stalin does something spectacularly stupid in Europe), the IJN could be utterly crushed by late '43 (yeah, I know I just made the point about the Essex-class, but maybe more LBA makes up for them), and the Philippines/Marianas/Formosa invaded by early 1944. This could be mean Iwo/Okinawa by mid-1944, meaning the US could contemplate Japan by late 1944, one year ahead of schedule.

And nine months - year ahead of Manhattan.

Perhaps this is the 'Ordeal' that is spoken of?



Well, they *might* have been able to, if they had shunted even more other large surface ships to lower priority on the slip ways early enough in the war, possibly - but at this point, we're at mid-1943, and a ship laid down today won't be available any sooner than mid-1946 anyway.

The logistics and amphibious left will definitely be more ample now, certainly by 1944.

A lot more land-based airpower coming out east now. With veteran pilots.

I'm not sure the timeline moves up too much - Galvanic kicked off in November 1943, and that was dependent not just on amphibious lift, but having the carrier decks available to cover it. The USN also doesn't realize just how powerful its fast carrier force is becoming, and how much the IJN is struggling to rebuild its own. No amount of surrendered Nazis can change that.

The more interesting question, to my mind, is how this affects Japanese decisions. They know they now face the British and Americans alone now, without the Nazis taking much of the heat off their backs, occupation duties notwithstanding. It might even cause Koga, who was otherwise fairly conservative, to attempt to force a decisive battle earlier, before the inevitable avalanche of Anglo-American naval power - now available almost exclusively for the Pacific by 1944 - comes crashing down.


Here is the next update.

Comments and critiques always welcome.

The number one priority for commanders in all of the Pacific theaters was for long range aircraft. The distances involved, be it from Guadalcanal to Rabaul or Bougainville or from Imphal into Burma or “over the hump” into China the distances involved in the region were staggering. Especially vocal for support was General MacArthur, who, unsurprisingly saw his effort as the primary thrust that would defeat Japan (to be fair, all Theater commanders believed the same, MacArthur was simply the most vocal and media savvy). Even Admirals Nimitz and King were clamoring for increased number of the naval version of the B-24 heavy bomber, the PB4Y-2 Privateer to use as patrol and reconnaissance platforms. With the demise of the 3rd Reich, the enormous productivity of American aircraft manufacturing facilities were suddenly available for the, until then, aircraft poor Pacific War. The production capability would allow everyone to get every aircraft they desired there should have been no issues.

It started, innocently enough, with a USN request forward from Grumman, for an increased allocation of the Pratt & Whitney R-2600 and R-2800 radial engines that powered almost everything the USN flew off a carrier deck. The Navy, not unreasonably, saw its need for enough aircraft to populate the new warships coming off the ways, and having priority over what was now a much less needed long range escort fighter like the P-47 and a light attack aircraft like the A-20. General Arnold, the head of the U.S. Army Air Forces, however, say the request as an effort to undercut his still young branch (the intent to establish an entirely independent U.S. Air Force was already fully formed, if somewhat unstated on “mixed” company) and reacted, some would say overreacted, to the request. Arnold quickly received the backing of General Marshall, who still was the final commander of Army Air Force units, no matter how independent Arnold acted, and by General MacArthur, who was intent on reducing the Central Pacific offensive that he saw as a competitor, not a partner.

Faced by the Army’s protests, Chief of Naval Operations King, who saw everyone as a rival to his service, and as interlopers into the “Navy’s War” in the Pacific, managed to top Arnold’s reaction in a Combined Chiefs of Staff meeting to the bemused horror of the British attendees. Such was the infighting among the American services that the British never bothered to add their own concerns over the allocation of aircraft or engines (the British were users of both the B-24 in a patrol role and used the Martin Baltimore, which relied on the R-2600). Instead, they were content to watch as their American “cousins” showed anything but a stiff upper lip.

Lost in the debate was that there were still needs in Europe where the wheels had begun to wobble

Both London and Washington had anticipated issues with the USSR and with the German occupation it was, however, in France that the first massive issues appeared.

The surrender left France with two governments, neither of them elected. One was the Vichy puppet government, the other the so-called “Free French” what consisted of those in the French colonies and elements of the French military who had escaped the Nazi tide as it rolled over France in a remarkable brief six-week long campaign. Heroes led both governments, Marshal Pertain, the great hero of World War 1 and General Charles de Gaulle, one of the few bright spots in the 1940 debacle. The WAllies considered Pertain’s government to be illegitimate, a construct of the Nazis (this was despite the quasi-legal way that Pertain came to power and the granting what amounted to dictatorial powers by the French Assembly). Both Churchill and Roosevelt also had concerns about de Gaulle (much of this was personal, de Gaulle was a difficult personality and both Churchill and especially Roosevelt disliked him). The American push for elections at the earliest possible moment, supported, somewhat less intensely by the British, angered de Gaulle, seeing it as unwarranted interference in France’s internal governance.

Moreover, de Gaulle nursed a serious grudge related to the actual surrender and the spring across Europe. He had been determined to have French forces liberate the symbolic regions, especially Paris, argued for it and, he believed, had received agreement. At the time of the surrender the Free French Army was almost entirely in North Africa, the Anglo-American leadership, understanding that the chance of the German Junta being itself overthrown was quite real, had not even considered waiting for the French to make the trek from Africa. As a result, the City of Lights was “liberated” by elements of the 1st Canadian Armored Division, who, per standing orders for large cities, dropped out their attached MP units and one battalion to maintain order while the rest of the division continued its steeplechase toward Germany. General de Gaulle and a company of Free French troops arrived two days later on a pair of American C-47s, landing in a pounding rainstorm, which ensured the crowd failed to match the predicted adoring throngs.

France was also unhappy with the overall size of its Zone of Occupation. France wanted at least an equal sized portion of the country to the other occupiers and was equally unhappy with the territory assigned to its forces. De Gaulle wanted all ALL of Western Germany, along a line running from Bremen to the Czech/Austrian/German borders, including the Rhineland and Bavaria and 1/3 of the German capital. He also had indicated that he wanted this region made a permanent demilitarized one with a written treaty requiring the U.S. and UK to join France in a new war against Germany if Berlin ever attempted to remilitarize the region. (Records in the French archives, released in the past three years, indicate that de Gaulle’s original plan was to demand that the British occupation zone be limited to Eastern Prussia and the U.S. zone encompassing German territory east of the Elbe.) He further wanted to require that all major decisions regarding Germany’s future be subject to consensus by the three main Allies (meaning, in this context France the U.S. and United Kingdom), something that would have given Paris (more specifically de Gaulle) a veto over all actions regarding the German state for an indefinite period of time. The Americans and British saw even the reduced demands of France to be outrageous and the height of arrogance from a government that was of shaky legitimacy and of an interim sort. The issue was resolved in what may have been the worst, if probably inevitable, manner. The Americans and British pointed out that they already had selected the zones of occupation, had large numbers of troops in place, and that France should consider its actual abilities to exercise control of a larger region with less and two divisions of troops, all of them currently armed and logistically supported by the American army. De Gaulle and his staff, quite understandably, expressed outrage at the high handedness, but were also helpless to do anything but gnash their teeth.

De Gaulle’s pride was further damaged when he was forces to ask the Canadians, who had more French speakers than any other Commonwealth contingent (and vastly more than the American forces available) to aid in reestablishing order in several cities following the establishment of drumhead courts where “collaborators with the Boche” subject to short extrajudicial trials followed by execution. Estimates are that some 5,000 individuals died in this manner. While the vengeance taken against collaborators in some cases was undoubted justified, the process quickly began to become a political purge, one that de Gaulle’s very limited Free French Army (roughly 15,000 men) was insufficient to contain. Making it worse, SHAEF (Supreme Headquarter Allied Expeditionary Force, the command originally developed to plan and conduct the counter invasion of Europe, commanded by General Dwight Eisenhower) willingly provided the forces requests to place the Canadian forces under direct French command met with flat refusal.

Despite the many issues, the situation in France was, if not approaching normal, had reaching general stability by late September 1943 in no small part due to the return of tens of thousands of Prisoners of War from Germany. The stability of France, along with Belgium and the Netherlands, was critical to the WAllied occupation and for the expedited release of troops to the Pacific, making the circumstances as autumn began very encouraging. It was a feeling that was not to last.

On October 8th, 1943 the Communist Parties of France, Belgium, and the Netherlands called for a General Strike until such time as the wartime damaged “caused by the English” was repaired and, in France, until free elections were held that excluded anyone who had ruled France between September 1, 1939 and October 7, 1943 from running for office. While less successful in Belgium and the Netherlands, the Strike brought much of France to a halt. Of particular concern to the WAllies was the paralysis of the rail network as strikers not only refused to work, but also damaged equipment and switching tracks to prevent operation by strikebreakers (especially Anglo-American troops). The strike also resulted in renewed street clashes between the Far Right and the Communist groups, many of whom, on both sides, received training in urban warfare from British Special Operations Executive (SOE) during the nearly three years of Nazi Occupation. Canadian troops, again pressed into service to support the enlarged but still somewhat disorganized French security services, found themselves fighting irregulars who had, in some cases, learned tactics, and methods from Canadian trainers. The overall situation resulted in the indefinite postponement of orders moving the 82nd Airborne Division to the Southwest Pacific.

Watch the video: Colonne Libération Sud (May 2022).