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It doesn’t take a rocket scientist to show that criminalising drugs and drug use has directly and indirectly led to a dramatic increase in drug- related harms purchase 10mg rizatriptan otc advanced diagnostic pain treatment center, and that controlling and regulating the production and distribution of all drugs would go a long way towards reducing those harms generic rizatriptan 10 mg amex pain medication for dogs hydrocodone. So long as we continue to defne the drug user as ‘other’ and defne the drug itself as the problem buy 10mg rizatriptan fast delivery pain after treatment for uti, we will be trapped in our misguided and harm-inducing programmes and policies order rizatriptan 10 mg visa pain treatment for bursitis. A number of Latin American governments, including Argentina, Brazil, Ecuador, Bolivia and Mexico have moved, or are moving, towards decriminalisation of drug possession and are shifting to a public health model to prevent and treat misuse of drugs. They are no longer able to tolerate the damage xii done to their societies by the War on Drugs. This is not a radical book, nor does it posit radical approaches to global drug policy. In fact, as it points out, the prohibitionist model is the radical approach, in that it is based exclusively on a moral judg- ment against drug use and drug users and not on an evidence based approach to reducing drug-related harms. Underscoring a century of prohibitionist policy is a deep-seated fear that moving from prohi- bition to a regulatory approach will lead to a ‘free-for-all’ situation vis-à-vis drug availability and use. In fact, as ‘Blueprint’ makes clear, it will be important that changes are phased in gradually and closely monitored through intensive policy research that comprehensively documents health and other outcomes. Various approaches currently in use for the regulation and management of alcohol, tobacco, cannabis, and pharmaceutical medicines can be adapted for regulating non-medical drugs and drug use. There often appears to be a vast gulf of irreconcilable differences between those of us advocating for harm reduction approaches to drug use, and those in the anti-drugs movement. To bridge the gap between these movements, harm reduction advocates must not be coy about the horrifc problems that can be associated with drug use. Individuals in the anti-drugs movement are motivated too by their experience of these xiii harms. Discussing these experiences openly and without prejudice could lead to a common language we can all share. If we are not able to reach out to the anti-drugs movement and fnd common ground, then our evidence will never overcome their fear. We must aim towards a unifed voice where public health and human rights are two sides of the same coin. Nothing less than the future health of individuals, families, communities and societies is at stake. Such concerns have driven a prohibitionist global agenda: an agenda that gives clear and direct moral authority to those who support it, while casting those who are against it as ethically and politically irresponsible. By defning the most stringent prohibition as the most moral position, it makes nuanced consideration of the impacts of prohibition diffcult. In particular, it makes it very diffcult to look at and learn from the impacts and achievements of prohibition. Historic attempts to do so have foundered on a sense that analysing prohibition means questioning prohibition, and that questioning prohibition is in itself an immoral act—one that allies the questioner with the well known infamies of the world’s illegal drug trade. Ironically, supporting the status quo perpetu- ates that trade, and the harms that it creates. In fact, a century of experience with prohibition teaches that it can often be counter-productive; failing to reduce the harms it sets out to address as well as creating a raft of catastrophic unintended consequences. The extent of this failure has been chronicled in detail by many hundreds of sober, independent and objective assessments undertaken by govern- ment committees, academics, and Non Government Organisations across the world, over many decades. It is not the purpose of this report to revisit these various fndings; they 1 are freely and easily available elsewhere. Rather, we seek to reconsider the management of illicit drugs in the light of the experience that they represent and embody. Using that experience, we will set out a blueprint for non-medical drug management policies that will minimise the harms that such drug use creates, both on a personal and on a societal level. In short, our goal is to defne a set of practical and effective risk and harm management and reduction policies. Such policies will represent a clear and positive step towards the positive outcomes that prohibition has tried, and failed, to achieve. A strictly prohibitionist stance would understand them to be immoral, because they call for the legally regu- lated production and availability of many currently proscribed drugs. Transform’s position is, in fact, driven by an ethics of effectiveness, and as such represent an attempt to re-frame the global harm management debate in exclusively practical terms. Examples of inadequate regulation of currently legal drugs should not distract us from seeking more just and effective models for the regulation of currently illegal drugs. Indeed, historic failings in regulation of the tobacco and alcohol industries have more in common with the abrogation of control that prohibition exemplifes, than with best practice in regulation. Prohibitionist rhetoric frames drugs as menacing not just health, but also our children, national security (‘our borders’), or more broadly the moral fabric of society itself. The prohibition paradigm is very much framed as a response to such threats, which has cast prohibitionist discourse as a moral crusade against an ‘evil’ that threatens mankind itself. Full and immediate absence of all drug control infrastructure, disre- garding all hard won harm and risk management experience, would lead to serious personal and social harms, outweighing any potential 5 1 2 3 Introduction Five models for regulating drug supply The practical detail of regulation benefts. This remains true whether it is criminal anarchy or entirely Instead of understanding unfettered free markets. The need for the effec- drugs to be virulently, tive regulation of non-medical drug production existentially threatening, and availability and use has always been, and we see them as creating remains, paramount. Instead of understanding drugs to be social terms virulently, existentially threatening, we see them as creating issues that can be most helpfully defned in medical/health and social terms. Drug using motivations and behaviours are many and varied, as are the outcomes of this use; they exist on a continuum from benefcial use, through non-problematic use, to problematic and chronic dependent use. Whilst this book emphasises the application of legal regulation where drug related harms are most evident, we also need to recognise that the majority of drug use is not signifcantly harmful, is an informed adult choice, and is rationally motivated—primarily by plea- sure. So, rather than seeking to use statutory instruments to punish and eradicate moral evil, we look to help develop a clearly defned set of laws that will help local, national and global legislatures effectively manage the reality of the health and social issues we face, to the clearly defnable, and measurable, beneft of all. Supporters of prohibition present any steps towards legal regulation of drug markets as ‘radical’, and therefore innately confrontational and dangerous. However, the historical evidence demonstrates that, in fact, it is prohibition that is the radical policy. Legal regulation of drug produc- tion, supply and use is far more in line with currently accepted ways of managing health and social risks in almost all other spheres of life. Drug policy has evolved within a context of ‘securitization’, characterised by increasing powers and resources for enforcement and state security apparatus. The outcomes of this strategy, framed as a drug ‘war’, include the legitimisation of propaganda, and the suspen- sion of many of the working principles that defne more conventional social policy, health or legal interventions. Given that the War on Drugs is predicated on ‘eradication’ of the ‘evil’ drug threat as a way of achieving a ‘drug free world’, it has effectively established a permanent state of war. This has led to a high level policy environment that ignores critical scien- tifc thinking, and health and social policy norms. Fighting the threat becomes an end in itself and as such, it creates a largely self-referential and self-justifying rhetoric that makes meaningful evaluation, review and debate diffcult, if not impossible. Prohibition has become so entrenched and institutionalised that many in the drugs feld, even those from the more critical progressive end of the spectrum, view it as immutable, an assumed reality of the legal and policy landscape to be worked within or around, rather than a policy choice. It is in this context that we seek to highlight how the basics of normative health and social policy can be applied to developing effec- tive responses to drugs. In the absence of more fully realised answers to these questions, myths and misunderstandings fll the void. Without a frm sense of what a post-legalisation world would look like, and how 7 1 2 3 Introduction Five models for regulating drug supply The practical detail of regulation market regulation could function, it is diffcult for the discourse to move forward. Thus, we are putting forward a set of proposals for how drug regula- tion might operate when the War on Drugs fnally ends. In doing so, we have tried to create a very specifc and practical set of suggestions for managing a variety of different drugs in ways appropriate to the individual effects that they have, and harms that they can cause. In particular, we have considered how such drugs could be produced and supplied, with the aim of taking back control of the drugs market from those least likely to manage it in a constructive way.

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Instructions When to take buy 10mg rizatriptan with mastercard pain treatment center hartford ct; how to take buy discount rizatriptan 10 mg on-line knee pain treatment kansas city; how to store buy rizatriptan 10 mg otc pain treatment center hartford hospital; how long to continue the treatment rizatriptan 10mg mastercard pain treatment for pleurisy; what to do in case of problems; 4. Warnings What not to do (driving, machinery); maximum dose (toxic drugs); need to continue treatment (antibiotics); 5. Next appointment When to come back (or not); when to come earlier; what to do with left-over drugs; what information will be needed; 6. Monitoring the treatment enables you to determine whether it has been successful or whether additional action is needed. To do this you need to keep in touch with your patient, and this can be done in two ways. Passive monitoring means that you explain to the patient what to do if the treatment is not effective, is inconvenient or if too many side effects occur. Active monitoring means that you make an appointment to determine yourself whether the treatment has been effective. You will need to determine a monitoring interval, which depends on the type of illness, the duration of treatment, and the maximum quantity of drugs to prescribe. At the start of treatment the interval is usually short; it may gradually become longer, if needed. Even with active monitoring the patient will still need the information discussed in Chapter 10. You should use the same criteria for monitoring the effect, but in practice they can be condensed into two questions: is the treatment effective? History taking, physical examination and laboratory tests will usually provide the information you need to determine the effectiveness of treatment. If the disease is not yet cured or chronic, and the treatment is effective and without side effects, it can be continued. If serious side effects have occurred you should reconsider your selected drug and dosage schedule, and check whether the patient was correctly 4 Except in cases in which a standard duration of treatment is crucial, such as with most antibiotics. Many side effects are dose Table 8: dependent, so you may try to lower the Some examples of drugs in which dose before changing to another drug. When you have Corticosteroids determined the reason for the treatment Hypnotics/sedatives failure you should look for solutions. So benzodiazepines the best advice is to go again through the barbiturates process of diagnosis, definition of Opiates therapeutic objective, verification of the suitability of the P-drug for this patient, instructions and warnings, and monitor- ing. Sometimes you will find that there is no real alternative to a treatment that has not been effective or has serious side effects. When you cannot determine why the treatment was not effective you should seriously consider stopping it. If you decide to stop drug treatment you should remember that not all drugs can be stopped at once. Exercise: patients 39-42 In the following cases, try to decide whether the treatment can be stopped or not. Review visit after pneumonia, treated with oral ampicillin (2 grams daily) for one week. Has been on prednisolone (50 mg daily) and indometacin (10 mg daily) for a long time. Epigastric pain and pyrosis over several months, for which he takes aluminum hydroxide tablets from time to time. During the consultation he complains that the epigastric pain and pyrosis have not disappeared; in fact they have become worse. The maintenance dose has already been decreased twice because her blood pressure had dropped to around normal. Had been prescribed temazepam for one week, (10 mg daily) because of sleeplessness after his wife died six months ago. Patient 40 (epigastric pain) In this case the treatment has not been effective because the epigastric pain is a side effect of the drugs used for myalgia. The treatment that really needs monitoring is the anti-inflammatory drugs, not the aluminium hydroxide. The problem can be solved by finding out whether the pain occurs at certain times, rather than being continuous. In this case the dosage schedule could be adjusted to reach peak plasma concentrations at those times, and the total daily dose could be lowered. The lesson to be learned from this patient is that it is better to reconsider the original therapy rather than to ‘treat’ its side effects with another drug. Patient 41 (mild hypertension) This treatment seems effective and without side effects. The patient is no longer hypertensive and may not need continued therapy, especially since she regularly forgets to take the drug. You can stop the treatment for assessment but you must continue to monitor the patient. Patient 42 (insomnia) As the patient wants to continue the treatment it was obviously effective. However, benzodiazepines can produce psychological and physical dependence when taken regularly for more than a few weeks. In addition, tolerance develops quickly and this can lead patients to take more than the recommended dose. You should explain this to the patient and also tell him that the nature of the sleep induced by such drugs is not the same as normal sleep, but the result of suppressed brain activity. Encourage him to try to return to natural sleep patterns; possibly a warm bath or a hot milk drink will help to promote relaxation before bedtime. It may also help to encourage him to express his feelings about his loss; acting as a sympathetic listener is probably your major therapeutic role in this case, rather than prescribing more drugs. In this case the 81 Guide to Good Prescribing drug can be stopped at once because it was only used for one week. This cannot be done when patients have taken benzodiazepines for longer periods of time. It also includes practical advice on how to read scientific papers in general, and clinical trials in particular. Side effects become better known and new indications or ways of using existing drugs are developed. For example, if a drug-induced illness occurs which the physician could have known and prevented, courts in many countries would hold the doctor liable. This problem can be solved in the usual way: make an inventory of available types of information; compare their advantages and disadvantages; and choose your own source(s) of information. Make an inventory of available sources of information There are numerous sources of drug information, ranging from international data bases, journals and reference books, to national or regional drug information centres, and locally produced formularies and bulletins. Reference books Reference books can cover general or clinical pharmacology, or specialize in a particular aspect. Examples of general pharmacological reference books in English are Goodman and Gilman’s The Pharmacological Basis of Therpautics and Laurence and Bennett’s Clinical Pharmacology (see Annex 2). An important criterion in choosing reference books is the frequency of new editions. Only publications that are revised every two to five years can provide up-to-date knowledge. Martindale’s The Extra Pharmacopoeia is an excellent reference book with detailed drug information on most active substances and chemicals.

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They may try to maximize their health with methods of alrnative and natural medicine because of a lack of knowledge cheap rizatriptan 10 mg online st john pain treatment center. There is also a relad finding among hypernsive patients thainntional non-compliance is associad with the use of home remedies (e buy cheap rizatriptan 10mg online heel pain treatment stretches. Disease-relad beliefs and many other cultural and attitudinal factors may also be associad with inntional non-compliance (Delgado 2000) buy rizatriptan 10 mg amex advanced diagnostic pain treatment center yale. This is illustrad by the following commenby a hypernsive patient: �Iis really qui an insignificanillness purchase 10mg rizatriptan visa pain treatment centers of america little rock. Women who are neurotic and men who have stress because of their work have hypernsion. Some non-complianpatients have repord thathey do nounderstand the information given by the physician and information leaflets (Gascon eal 2004). They also feel thathey have been advised to change their lifestyle withouany explanation as how to do i(Gascon eal 2004). Successful information sharing requires the quality of the communication between the patienand the physician to be good. Non-complianpatients have repord thathe physician is busy, eye contacis rare, and there is no real conversation (Gascon eal 2004). Iwould thus be importanfor health care professionals to share detailed information with hypernsive patients aboutheir disease, so thathe patients would understand the benefits of treatmenbefore something serious happens. A good example of this could be a Swedish patienwho really understood the importance of antihypernsive medication when his father, who had been hypernsive for years, died of stroke: �I haven�taken my pills for several years. Patients have also repord their reason for complying to be a desire to avoid complications of hypernsion and to keep their blood pressure readings in control (Svensson eal. Some patients may also think thatheir antihypernsive medication has cured the hypernsion, because their blood pressure readings are now good, and may therefore think the medications as unnecessary. Future research, in the group of individualistic ways patients, may benefifrom the findings of the health belief model which tries to explain the probability of individuals to function in ways promoting their health (Janz and Becker 1984). This is affecd by the perceived benefits, barriers of treatmenand threaof disease. These three areas are also modified by demographic and socio-psychological background factors. Furthermore, the model is construcd so thaiis probably nouseful, if a majority of individuals do noregard health as having high value, which makes iimpracticable in priorities of life cases. Iis also possible thainntional non-compliance may improve some patients� health, which is called �inlligent� non-compliance. However, the concep�concordance� is more suitable to these inlligenchoices and the previously mentioned individualistic cases. In both groups of inlligenchoice and individualistic ways, the patienthinks thahis/her actions promo his/her health, i. Priorities of life In situations involving differenpriorities of life the central problem is noa lack of information. This group may have characrs thahave taken into consideration years ago by Jonsen (1979) who points outhanon-compliance may be an indicator of more deeper needs than justhe need for medication. There is no drug for finding a meaning of life or for dealing with the mosprofound questions of life, buthe physician should be able to discuss the meaning of life, and why there are so many priorities thaconflicwith the value of health and especially with the value of life, which is the prerequisi for all other priorities. A Finnish study on 1037 persons aged 60 years showed thathe third mosprevalenpersonal problem was the excessive idealization of youth in our society (Vaarama eal 1999). The moscommon problem was disease and deficiency in capacity, while financial problems came second. The excessive idealization of youth in our society was even more prevalenthan social problems, violence and criminality in neighbourhood, lack of hobby possibilities and lack of health and social services. Both of these findings may be connecd with the time distortion in health-relad behaviours. For some people health seems to have a high priority only in the shorrm, and excessive idealization of youth and desire to remain young may make this trend even worse by leading to an illusion of ernal youth. These people may ask: why use medications thaprevendeath or complications of disease, i. Non-compliance is also relad to an irregular lifestyle or disturbances of everyday life (Balazovjech and Hnilica 1993, Dusing eal. Pride and a desire noto appear weak or non-macho may also be obstacles of treatmen(Rose eal. Iis possible thamedicines are used, to some exnt, when their use does noconflicwith anything thahas higher priority. This may also be visible in our study, which suggesd tha�frustration with treatment� (including aspects of lifestyle changes, health centre visits and inadequaly effective medication) is associad with inntional non-compliance. If some unhealthy living habits are more importanthan health itself, there will be a priority conflict. From the patient�s perspective, medication should be so effective as to make the modification of lifestyle unnecessary. The treatmenof hypernsion may also take time and require visits to the health centre, buif the priority of health is low, imighbe difficulto accepthis, because there would be more importanthings to do. Similarly, costs as a reason for inntional non-compliance (Delgado 2000) may be associad with priority conflicts. Furthermore, iis possible thamedicines are used more regularly prior to scheduled blood pressure measurements (whi coacompliance (Feinsin 1990)), because patients try to please health care professionals or to hide their non-compliant/non- concordanbehaviour. In this situation, one of the patients� high priorities is to give a positive image abouhim/herself to health care professionals. Ethical/moral or religious values Our modern medicine has been builto rely on values. Sometimes the values of modern medicine and the patiendiffer buboth of these sets of values are essential rules of treatment. The reasons for non-compliance may be relad to ethical/moral or religious values of life, in which iis nomeaningful to speak abou�compliance�, burather abou�concordance�. In Finland, there are differenminorities thabelong to this group, and several immigrants groups have further increased the multiplicity of these groups. In this cagory, iis essential to understand thathese are the real values of the patient. Iis therefore importanto identify the situations where this cagory have been used as an excuse for refusing treatment, which in reality involve a problem in the priorities of life. This cagory includes the patients with ethical/moral or religious values, for whom their own health and its treatmenare a matr of high priority, buwho find certain treatmenmethods unacceptable. An example of this mighbe Jehovah�s Witnesses, who refuse blood transfusion (Gyamfi eal 2003). Ihas also been repord thapork- and beef-derived gelatin and/or saric acid, which are used as inercomponents in some drugs, are unacceptable to some patients in the Muslim, Orthodox Christian, and Seventh Day Adventisfaiths (Sattar eal 2004). In birth control some people cannoaccepmethods thahave postfertilization effects, such as intraurine devices, hormonal emergency contraception and oral contraceptives (Larimore 2000, Larimore and Stanford 2000, Kahlenborn eal 2002, Stanford and Mikolajczyk 2002). Ihas been found in Finland that, of several therapeutic classes gynecological patients (the main subgroup was oral contraceptives) received leascounseling from pharmacists (Vainio eal 2002). Furthermore, future embryonic sm cell treatments are considered non- acceptable for those patients who find thaa patient�s sickness should nobe healed with a method tharequires the life of a human embryo to be destroyed. If these ethical/moral or religious values are combined with the patient�s view thahealth is noa high-priority matr, the case does nobelong to this cagory, buto the priorities of life cagory. For example, if the day of death is unchangeable, actions to improve one�s health mighseem unnecessary. However, this view conflicts with all findings of modern medicine showing thaa group of patients taking a certain medicine survive longer than another group of patients taking placebo. And even if the day of death is unchangeable, from a patient�s view, is the quality of life unchangeable? Preventing a hearattack or stroke n years before death mighbe very beneficial for the quality of life. Between inntional and non-inntional non-compliance and non-concordance Inntional and non-inntional non-compliance can also be partly simultaneous.

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