By G. Umbrak. Randolph College. 2018.
Tobacco consumption is becoming more popular in large swathes of the devel- oping and newly industrialising world discount 500 mg actoplus met. In these areas effective 500 mg actoplus met, tobacco is being aggressively marketed buy actoplus met 500mg, often as an aspirational Western lifestyle 107 1 2 3 Introduction Five models for regulating drug supply The practical detail of regulation product—somewhat ironic generic actoplus met 500 mg line, given its waning popularity in the West. The commercial forces that have so effectively distorted policy priori- ties in the past have not lost any of their potential power. They sound a clear cautionary note on the corrupting nature of proft motivations in drug markets. In common with the regulatory/harm gradient theme explored in the previous chapters, there are public health gains to be had from exploring and developing the market for, and use of, safer, non-smoked nicotine/tobacco products, as alternatives to smoked tobacco. The increasing use of various nicotine delivery systems, (such as inhalers, gum and patches) as cessation aids is a welcome development, is already widespread, and should be actively supported. Such support could include increased access, as well as a reduction in price (subsidised where necessary) so that those most dependent on nicotine—in particular, those on low income—can afford to access these products. However, the use of nicotine delivery systems as cessation aids takes place within a medical model that is specifcally aimed at achieving abstinence. This is an important and proven part of the public health response to tobacco; it does not, however, cater for those who want to continue consuming nicotine, or will continue regardless of other interventions. Certain non-smoked oral tobacco products (including ‘Snus’ and ‘Bandits’) offer potential alternative tobacco preparation/consumption methods that are (it is estimated) 90% safer than smoked tobacco. This is despite a prohibitionist drug policy position that is, in most other respects, the most stringent in Europe. It has been convincingly argued that this high level of oral tobacco use correlates with the fact that the country has the lowest rate of smokers in the developed world. There has been a large drop in the number of smokers in Sweden, in particular within the male population—from 40% in 1976 to 15% in 2002—partially attributed to a roughly corresponding increased use of Snus. However, there is plenty of evidence from the Swedish model to suggest that Snus and other similar products can help users give up smoking, as well as providing a safer tobacco alternative. There are obviously diffcult ethical and practical questions regarding how such products can be brought to the market, and then regulated and promoted responsibly; that is, so as to encourage existing smokers to quit or switch from smoked tobacco, while not inducing a fresh tobacco consumption habit in new users. The potentially enormous public health gains are such that the relevant agencies should, on pragmatic public health grounds alone, seriously consider the options for appropriate legislative reforms. Research and pilot studies should be commissioned, as appropriate, to explore potential ways forward. Further reading * ‘50 Best Collection: Tobacco Harm Reduction’, International Harm Reduction Association, 2008 * R. It should also be acknowledged that the models proposed here refect the authors’ Western background. Other environments, and other user populations, will require different, regionally appropriate ways of thinking. In particular, we have highlighted potentials for greater or lesser levels of regulation, enforcement and/or deployment of additional controls. A large body of literature, research and real world experience can be drawn on to help plot out legal models for cannabis supply and use. Of particular relevance is the Netherlands’ experience with its unique ‘coffee shop’ system, a de facto legal licensing of supply and use that has been running since 1976. A primary issue is the so-called ‘back door problem’; that is, the fact that while both possession and supply from the coffee-shops is tolerated, with the former being effectively legal and the latter licensed, cannabis production itself remains illegal. This means that coffee shops are forced to source it from an illicit market 110 4 5 6 Making a regulated system happen Regulated drug markets in practice Appendices place. The fact that the Netherlands’ de facto legal supply is unique amongst its immediate geographic region has also caused problems of ‘drug tourism’ at its borders, with substantial numbers of buyers entering the country solely for procurement. The Netherlands’ pragmatic approach has also made them the subject of concerted political attacks and critique from reform opponents on the international stage. Nonetheless, the licensing models for the coffee shops themselves are well developed. Where specifc problems have emerged policy has evolved, regulations have been introduced or tightened, and some coffee shops have been closed. However, the overall success of the approach has, since its mid-70s introduction, led to growing support from key domestic audiences including the police, policy making and public health bodies, and the general public.
Journal of Consulting and with cognitive-behavioral therapy generic 500 mg actoplus met mastercard, constituting a more Clinical Psychology 66(3):541–548 actoplus met 500mg with visa, 1998 buy actoplus met 500 mg online. Development cocaine purchase actoplus met 500mg, nicotine) and for adolescents who tend to use and initial demonstration of a community-based multiple drugs. Addiction 97(10):1329–1337, counseling approach that helps individuals resolve their 2002. Motivational internally motivated change, rather than guide the enhancement therapy for nicotine dependence in patient stepwise through the recovery process. Psychology of therapy consists of an initial assessment battery session, Addictive Behaviors 18(3):289–292, 2004. Journal of Consulting and discussion about personal substance use and eliciting Clinical Psychology 72(3):455–466, 2004. Motivational interviewing principles are used to strengthen motivation and build a plan for change. Motivational A number of studies have demonstrated that participants interviewing in drug abuse services: A randomized trial. One- to-one: A motivational intervention for resistant pregnant Further Reading: smokers. Integrating treatments for The Matrix Model (Stimulants) methamphetamine abuse: A psychosocial perspective. The Matrix Model provides a framework for engaging Journal of Addictive Diseases 16(4):41–50, 1997. An intensive outpatient approach for cocaine direction and support from a trained therapist, and abuse: The Matrix model. A comparison coach, fostering a positive, encouraging relationship of contingency management and cognitive-behavioral with the patient and using that relationship to reinforce approaches during methadone maintenance treatment positive behavior change. Archives of General Psychiatry therapist and the patient is authentic and direct but not 59(9):817–824, 2002. Therapists are trained to conduct treatment sessions in a way that promotes the 12-Step Facilitation Therapy patient’s self-esteem, dignity, and self-worth. A positive (Alcohol, Stimulants, Opioids) relationship between patient and therapist is critical to patient retention. Journal of Child and Adolescent Substance potential role of 12-Step self-help group involvement in Abuse 3:1–16, 1994. Therapists seek to engage families in applying the behavioral strategies taught in sessions and 60 61 Behavioral Therapies Primarily Edwards, J. Below are examples of Juvenile drug court: Enhancing outcomes by integrating behavioral interventions that employ these principles and evidence-based treatments. Four-year follow-up of multisystemic therapy in the home, or with family members at the family court, with substance-abusing and substance-dependent juvenile school, or other community locations. Journal of the American Academy of Child and During individual sessions, the therapist and adolescent Adolescent Psychiatry 41(7):868–874, 2002. Parallel sessions are held interactions that are thought to maintain or exacerbate with family members. Journal of Substance Abuse at least in part, of what else is occurring in the family Treatment 27(3):197–213, 2004. The American Journal of Drug broad range of family situations in various settings (mental and Alcohol Abuse 27(4):651–688, 2001. Multidimensional family social service settings, and families’ homes) and in various therapy for adolescent substance abuse. London: Pergamon/ an aftercare/continuing-care service following residential Elsevier Science, pp. Brief Strategic Family Therapy versus of a randomized clinical trial comparing multidimensional community control: Engagement, retention, and an family therapy and peer group treatment.
However cheap 500mg actoplus met, challenges remain 500mg actoplus met with mastercard, such as low levels of testing purchase actoplus met 500mg overnight delivery, unclear referral and It is estimated that at least 7 585 overdose deaths buy cheap actoplus met 500mg line, treatment pathways in many countries, and the high cost involving at least one illicit drug, occurred in the European of the new drugs. Tis rises to an estimated 8 441 deaths if Norway and Turkey are included, representing a 6 % increase from the revised 2014 fgure of 7 950, and increases have been reported in almost all age bands (Figure 3. As in previous years, the United Kingdom (31 %) and Germany (15 %) together account for around half of the European total. Tis relates partly to the size of Drug use is a recognised the at-risk populations in these countries, but also to the under-reporting in some other countries. Focusing on cause of avoidable mortality countries with relatively robust reporting systems, revised among European adults data for 2014 confrm an increase in the number of overdose deaths in Spain, while increases in the number of overdose deaths reported in 2014 in Lithuania and the United Kingdom have continued into 2015, and increases are also now reported in Germany and the Netherlands. A continued upward trend is also observed in Sweden, though it may be partly due to the combined efects of changes in investigation, coding and reporting practices. Turkey is continuing to report increases, but this appears to be largely driven by improvements in data collection and reporting. However, 10 % of the overdose cases are younger than 25 years, and Heroin or its metabolites, often in combination with other there has recently been a slight increase in the number of substances, are present in the majority of fatal overdoses overdose deaths reported among those aged under 25 in reported in Europe. Te most recent data show an increase several countries including Sweden and Turkey. In England and Wales, heroin or morphine was mentioned in 1 200 deaths registered in 2015, representing a 26 % increase on the previous year and a 57 % increase in relation to 2013. Deaths related to heroin also increased in Scotland (United Kingdom), Ireland and Turkey. According to the most Reducing fatal drug overdoses and other drug-related recent data, the number of recorded methadone-related deaths is a major public health challenge in Europe. In the United Kingdom (England and Wales), reducing mortality (overdose and all causes) among deaths involving cocaine increased from 169 in 2013 to opioid-dependent people. Te mortality rate of clients in 320 in 2015, although many of these are thought to be methadone treatment was less than a third of the heroin overdoses among people who also used crack. Analysis of Spain, where cocaine-related deaths have been stable for risk of death at diferent stages of treatment suggests a some years, the drug continued to be the second most need to focus interventions at the start of treatment often cited illicit drug in overdose deaths in 2014 (269 (during the frst 4 weeks, in particular with methadone) cases). Supervised drug consumption facilities aim both to prevent overdoses from occurring and to ensure professional support is available if an overdose occurs. In 2016, 2 consumption Te mortality rate due to overdoses in Europe in 2015 is rooms opened in France for a 6-year trial, and new estimated at 20. Mean age at death, however, is lower among males: 38 compared with 41 among females. According to the latest data available, rates of over 40 deaths per million population were reported in 8 northern European countries, with the highest rates reported in Estonia (103 per million), Sweden (100 per million), Norway (76 per million) and Ireland (71 per million) (Figure 3. In France, a new nasal formulation of the medication has been granted a temporary authorisation for Naloxone is an opioid antagonist medication that can use. After being scaled up in community settings since reverse opioid overdose and is used in hospital emergency 2013, naloxone take-home provision in Estonia was departments and by ambulance personnel. A recent systematic review of there has been a growth in the provision of ‘take-home’ the efectiveness of take-home naloxone found evidence naloxone to opioid users, their partners, peers and families, that its provision in combination with educational and alongside training in recognising and responding to training interventions reduces overdose-related mortality. Naloxone has also been made available for use Some populations with an elevated risk of overdose, such by staf of services that regularly come into contact with as recently released prisoners, may particularly beneft, drug users. Take-home naloxone programmes currently and an evaluation of the national naloxone programme in exist in 10 European countries. Naloxone kits provided by the United Kingdom (Scotland) found that it was drugs and health services generally include syringes associated with a signifcant reduction in the proportion of pre-flled with the medication, although in Denmark and opioid-related deaths that occurred within a month of Norway an adaptor allows naloxone to be administered prison release. Evaluating drug policy: a seven-step guide to support 2013 the commissioning and managing of evaluations. Drug consumption rooms: an overview of provision and evidence, Perspectives on Drugs. Due to uncertainty of data collection procedures, Latvia data may not be comparable.
These data provide assurance in counselling women exposed to an antimalarial drug early in the frst trimester and indicate that there is no need for them to have their pregnancy interrupted because of this exposure generic actoplus met 500 mg without prescription. The current standard six-dose artemether + lumefantrine regimen for the treatment of uncomplicated falciparum malaria has been evaluated in > 1000 women in the second and third trimesters in controlled trials and has been found to be well tolerated and safe actoplus met 500 mg. In a low-transmission setting on the Myanmar–Thailand border buy actoplus met 500mg cheap, however actoplus met 500 mg on-line, the effcacy of the standard six-dose artemether + lumefantrine regimen was inferior to 7 days of artesunate monotherapy. The lower effcacy may have been due to lower drug concentrations in pregnancy, as was also recently observed in a high-transmission area in Uganda and the United Republic of Tanzania. Although many women in the second and third trimesters of pregnancy in Africa have been exposed to artemether + lumefantrine, further studies are under way to evaluate its effcacy, pharmacokinetics and safety in pregnant women. Use of amodiaquine in women in Ghana in the second and third trimesters of pregnancy was associated with frequent minor side- effects but not with liver toxicity, bone marrow depression or adverse neonatal outcomes. Dihydroartemisinin + piperaquine was used successfully in the second and third trimesters of pregnancy in > 2000 women on the Myanmar–Thailand border for rescue therapy and in Indonesia for frst-line treatment. Mefoquine is considered safe for the treatment of malaria during the second and third trimesters; however, it should be given only in combination with an artemisinin derivative. Quinine is associated with an increased risk for hypoglycaemia in late pregnancy, and it should be used (with clindamycin) only if effective alternatives are not available. Those available indicate that pharmacokinetic properties are often altered during pregnancy but that the alterations are insuffcient to warrant dose modifcations at this time. With quinine, no signifcant differences in exposure have been seen during pregnancy. Studies are available of the pharmacokinetics of artemether + lumefantrine, artesunate + mefoquine and dihydroartemisinin + piperaquine. Most data exist for artemether + lumefantrine; these suggest decreased overall exposure during the second and third trimesters. Simulations suggest that a standard six-dose regimen of lumefantrine given over 5 days, rather than 3 days, improves exposure, but the data are insuffcient to recommend this alternative regimen at present. Limited data on pregnant women treated with dihydroartemesinin + piperaquine suggest lower dihydroartemisinin exposure and no overall difference in total piperaquine exposure, but a shortened piperaquine elimination half-life was noted. The data on artesunate + mefoquine are insuffcient to recommend an adjustment of dosage. No data are available on the pharmacokinetics of artesunate + amodiaquine in pregnant women with falciparum malaria, although drug exposure was similar in pregnant and non-pregnant women with vivax malaria. Tetracycline is contraindicated in breastfeeding mothers because of its potential effect on infants’ bones and teeth. Primaquine should be avoided in the frst 6 months of life (although there are no data on its toxicity in infants), and tetracyclines should be avoided throughout infancy. With these exceptions, none of the other currently recommended antimalarial treatments has shown serious toxicity in infancy. The uncertainties noted above should not delay treatment with the most effective drugs available. In treating young children, it is important to ensure accurate dosing and retention of the administered dose, as infants are more likely to vomit or regurgitate antimalarial treatment than older children or adults. Taste, volume, consistency and gastrointestinal tolerability are important determinants of whether the child retains the treatment. Mothers often need advice on techniques of drug administration and the importance of administering the drug again if it is regurgitated within 1 h of administration. Because deterioration in infants can be rapid, the threshold for use of parenteral treatment should be much lower. This approach does not take into account changes in drug disposition that occur 52 5 | Treatment of uncomplicated P. Adjustments to previous dosing regimens for dihydroartemisinin + piperaquine in uncomplicated malaria and for artesunate in severe malaria are now recommended to ensure adequate the drug exposure in this vulnerable population. Limited studies of amodiaquine and mefoquine showed no signifcant effect of age on plasma concentration profles. In community situations where parenteral treatment is needed but cannot be given, such as for infants and young children who vomit antimalarial drugs repeatedly or are too weak to swallow or are very ill, give rectal artesunate and transfer the patient to a facility in which parenteral treatment is possible. Rectal administration of a single dose of artesunate as pre-referral treatment reduces the risks for death and neurological disability, as long as this initial treatment is followed by appropriate parenteral antimalarial treatment in hospital.