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Many have criticized the centralized and unaccountable governance of prominent online social platforms, leading to renewed interest in platform governance that incorporates multiple centers of power. Decentralization of power can arise horizontally, through parallel communities, each with local administration, and vertically, through multiple hierarchies of overlapping jurisdiction. Drawing from literature on federalism and polycentricity in analogous offline institutions, we scrutinize the landscape of existing platforms through the lens of multi-level governance. Our analysis describes how online platforms incorporate varying forms and degrees of decentralized governance. In particular, we propose a framework that characterizes the general design space and the various ways that middle levels of governance vary in how they can interact with a centralized governance system above and end users below. This focus provides a starting point for new lines of inquiry between platform- and community-governance scholarship. By engaging themes of decentralization, hierarchy, power, and responsibility, while discussing concrete examples, we connect designers and theorists of online spaces. [ABSTRACT FROM AUTHOR]

Context: Prescription opioid abuse and misuse is a significant public health crisis. In 2012, an opioid prescribing pathway for patients with chronic pain presenting to the Emergency Department (ED) was implemented. The objective of this study is to determine the impact of the pathway for administration of opioids in the ED as well as the prescribing of opioids for home use after discharge. Methods: Retrospective pre- and post-intervention time series study of consecutive patients presenting to the ED with acute and chronic pain complaints before and after implementation of the pathway. For the purposes of this study, we included patients with chronic abdominal or back pain - defined as pain present for greater than three months - and acute pain as acute long bone fracture. Results: Before pathway implementation, there was no statistically significant difference in the mean morphine equivalent (MEQ) dose administered for chronic or acute pain patients. After pathway implementation, there was a decrease in IV/IM morphine administered to patients with chronic pain (p = .0200) but not to patients with acute pain (p = .0820). Overall, MEQs administered did not change in either group. In the acute pain group, no significant differences were found in the number of patients who received opioid prescriptions upon discharge (p = .7749). However, in the chronic pain group, the number of patients who received opioid prescriptions upon discharge decreased with statistical significance (p = .0017). Conclusions: After the implementation of a chronic pain management pathway in an ED, there is a decrease noted in opioids administered to patients with chronic pain both in the ED and prescriptions on discharge. In patients presenting with acute pain, there was no change in administration or prescription of opioids. [ABSTRACT FROM AUTHOR]