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Opium (raw and prepared) 48 Opium production in 2008 is considered along with that in 2009 to allow for the time required for processing and for the opiates to reach Morphine the markets where they are seized order nimodipine 30 mg fast delivery. The global Heroin from northern Myanmar enters China via increase in opium seizures since 2002 is mainly due to Yunnan province buy nimodipine 30 mg mastercard; according to Chinese authorities buy cheap nimodipine 30mg on line, increasing quantities seized in the Islamic Republic of heroin seizures in Yunnan province rose from 2 discount nimodipine 30 mg with visa. In 2006 nimodipine 30 mg with visa, in Afghanistan registered a more pronounced increase, the Islamic Republic of Iran replaced Turkey as the rising from 390 kg (seized in 234 cases) in 2008 to 1. Since then, the Islamic Republic of Iran and Turkey have seized the largest and second-largest, respectively, annual Heroin trafficking from Afghanistan to the Asia-Pacific heroin totals worldwide. Over the period 2002-2008, region is increasing, also supported by drug seizures heroin seizures in both these countries increased mark- reported by Pakistan. Among those cases in which the edly, but in 2009, seizures stabilized both in the Islamic destination of the consignment was identified as a coun- Republic of Iran, at 25 mt (compared to 23 mt in 2008) try or region other than Pakistan, the proportion of and in Turkey, at 16 mt (compared to 15 mt in 2008). The emergence of this new route countries have been erratic in recent years, but over the around 2005-2006 also appears to have caused a drop in long term, a distinct increase has been observed. Over heroin seizures in the region, suggesting that regional the period 2003-2009, heroin seizures in East Europe law enforcement needs time to adapt to the new route. This was also concurrent with a sharp increase in opium production in Afghanistan. This increase may have led West and Central Europe to a surplus of opiates, some of which may have found The trend in bulk heroin seizures in West and Central their way to the Asia-Pacific region. Europe does not mirror the increased supply of Afghan opium or the increased levels of heroin seizures in the 49 National Narcotics Control Commission of China, presentation at the Twentieth Anti-Drug Liaison Officials’ Meeting for International Islamic Republic of Iran and Turkey. Expressed in heroin equivalents assuming 1kg of heroin to be equivalent to 1 kg of morphine and 10 kg of opium. In 2008, the Heroin seizures also increased sharply in Canada, from wholesale purity of heroin of Mexican origin was at its 16 kg in 2007 to 102 kg in 2008 and 213 kg in 2009. Canada assessed In recent years, heroin seizures have increased signifi- that 94% of the ‘dode’ that reached its market originated in the United States, with the remaining 6% originating cantly in Egypt. In 2008, Egypt seized 211 kg of heroin, in the Netherlands, and that the affordability of ‘dode’ accounting for two thirds of total heroin seizures in had the potential to create a market beyond the tradi- Africa, and registering the third consecutive year-on- tional cultural groups. In 2009, seizures fell to 159 kg, remaining significantly higher than the levels registered in this The United States is also affected by non-medical use of country over the period 1995-2006. In the past, Egypt prescription opioids, and reported significant seizures of has also reported seizures of opium and opium capsules. In 2009, significant quantities of heroin were also seized Africa in Nigeria, 104 kg. Although this represents a sharp Heroin seizures in Africa rose sharply, from 311 kg in increase from the level in 2008 (12 kg), seizures were 2008 to 515 kg in 2009. South Africa registered the largest seizure total as Nigeria may serve as a transit point for limited quanti- 69 World Drug Report 2011 Fig. Over the 2004-2008 period, Pakistan reported tems capable of producing scientifically sound demand, significant, albeit declining, numbers of seized heroin supply and seizure statistics. Accordingly, the statistics consignments intended for Nigeria (36 such seizures in and estimates provided on opiate demand and flows 2008 and 16 in 2009). According to the United States should be viewed as the best current approximations. Department of Justice, organizations responsible for Heroin flow figures used in this section are indicative trafficking heroin originating in South-West Asia into and should be taken with caution. The purpose of pro- the United States included some that were based in West ducing these statistics is to estimate i) the main flows Africa. Nigeria has been mentioned as a transit country and changes in the routes over time, and ii) provide for heroin by Australia and the United States in recent threat and risk analysis for production, transit and des- years. The volumes and routes discussed are ficked on its territory in 2009 was intended for the not fixed and change according to changes in demand, United States, with 40% intended for Europe and 10% drug availability, or risk perceptions of drug traffickers. Therefore, it is essential to monitor flows every year to observe changes in the market and routes, which can Trafficking routes and volumes inform global strategies and policies regarding public health and security ramifications. Heroin from Myanmar is mainly trafficked to Heroin trafficking from production countries to con- China and Mexican heroin is mainly trafficked to the sumer markets requires a global network of routes and United States of America. Afghan heroin, however, is facilitation by domestic and international criminal trafficked to every region of the world except Latin groups. As such, trafficking routes for Afghan heroin ing, the global movement of heroin from Afghanistan are the main focus of this section. Estimating the graphic reasons, while others are preferred due to a lack volumes, that is, the global flow of opiates, requires data of law enforcement. Global heroin and opium seizures are used to identify opiate trafficking routes and It is estimated that some 460-480 mt of heroin was to help estimate the size of the flows in each country. Of this, some addition to seizure data, information was drawn from 375 mt reached consumers and the rest was seized. Afghanistan continued to be the main supplier for the global heroin market, producing 380 mt (83%). Available demand data was used as the key variable to estimate the size of the global heroin and opium flows.

Therapists should en- courage the patient to engage in a process of self-observation to generate a greater understand- ing of how behaviors originate from internal motivations and affect states rather than coming from “out of the blue purchase nimodipine 30mg fast delivery. As previously noted order 30 mg nimodipine otc, splitting is a major defense mechanism of patients with borderline per- sonality disorder order nimodipine 30mg with mastercard. A major thrust of psychotherapy is to help pa- tients recognize that their perception of others buy cheap nimodipine 30 mg on line, including the therapist discount nimodipine 30mg visa, is a representation rather than how they really are. Because of the potential for impulsive behavior, therapists must be comfortable with setting limits on self-destructive behaviors. Similarly, at times therapists may need to convey to pa- tients the limits of the therapist’s own capacities. Individual psychodynamic therapy without concomitant group therapy or other partial hos- pital modalities has some empirical support (20, 21). These studies, which used nonrandom- ized waiting list control conditions and “pre-post” comparisons, suggested that twice-weekly psychodynamic therapy for 1 year may be helpful for many patients with borderline personality disorder. In these studies, as in the randomized controlled trials, the therapists met regularly for group consultation. There is a large clinical literature describing psychoanalytic/psychodynamic individual ther- apy for patients with borderline personality disorder (12, 14, 15, 18, 22–38). Most of these clinical reports document the difficult transference and countertransference aspects of the treatment, but they also provide considerable encouragement regarding the ultimate treatabil- ity of borderline personality disorder. Therapists who persevere describe substantial improve- ment in well-suited patients. Some of these skilled clinicians have reported success with the use of psychoanalysis four or five times weekly (22, 24, 34, 39). These cases may have involved “higher level” patients with borderline personality disorder who more likely fit into the Kern- berg category of borderline personality organization (a broader theoretical rubric that describes a specific intrapsychic structural organization [27]). Some exceptional patients who do meet criteria for borderline personality disorder may be analyzable in the hands of gifted and well- trained clinicians, but most psychotherapists and psychoanalysts agree that psychoanalytic psy- chotherapy, at a frequency of one to three times a week face-to-face with the patient, is a more suitable treatment than psychoanalysis. The limited literature on group therapy for patients with borderline personality disorder in- dicates that group treatment is not harmful and may be helpful, but it does not provide evidence of any clear advantage over individual psychotherapy. In general, group therapy is usually used in combination with individual therapy and other types of treatment, reflecting clinical wisdom that the combination is more effective than group therapy alone. Studies of combined individ- ual dynamic therapy plus group therapy suggest that nonspecified components of combined in- terventions may have the greatest therapeutic power (40). Clinical experience suggests that a relatively homogeneous group of patients with borderline personality disorder is generally rec- ommended for group therapy, although patients with dependent, schizoid, and narcissistic per- sonality disorders or chronic depression also mix well with patients with borderline personality disorder (12). It is generally recommended that patients with antisocial personality disorder, un- treated substance abuse, or psychosis not be included in groups designed for patients with bor- derline personality disorder. The published literature on couples therapy with patients with borderline personality dis- order consists only of reported clinical experience and case reports. This clinical literature sug- gests that couples therapy may be a useful and at times essential adjunctive treatment modality, since inherent in the very nature of the illness is the potential for chaotic interpersonal relation- ships. However, couples therapy is not recommended as the only form of treatment for patients with borderline personality disorder. Clinical experience suggests that it is relatively contrain- dicated when either partner is unable to listen to the other’s criticisms or complaints without becoming too enraged, terrified, or despairing (41). There is only one published study of family therapy for patients with borderline personality disorder (12), which found that a psychoeducational approach could greatly enhance commu- nication and diminish conflict about independence. Published clinical reports differ in their recommendations about the appropriateness of family therapy and family involvement in the treatment. Whereas some clinicians recommend removing the patient’s treatment from the family setting and not attempting family therapy (12), others recommend working with the patient and family together (42). Treatment of Patients With Borderline Personality Disorder 23 Copyright 2010, American Psychiatric Association. Clinical experience suggests that family work is most apt to be helpful and can be of critical importance when patients with borderline personality disorder have significant involvement with, or are financially dependent on, the family. The decision about whether to work with the family should de- pend on the degree of pathology within the family and strengths and weaknesses of the family members. Clinical experience suggests that a psychoeducational approach may lay the ground- work for the small subset of families for whom subsequent dynamic family therapy may be ef- fective. Family therapy is not recommended as the only form of treatment for patients with borderline personality disorder. Pharmacotherapy and other somatic treatments A pharmacological approach to the treatment of borderline personality disorder is based upon evidence that some personality dimensions of patients appear to be mediated by dysregulation of neurotransmitter physiology and are responsive to medication (43). Pharmacotherapy is used to treat state symptoms during periods of acute decompensation as well as trait vulnera- bilities. Although medications are widely used to treat patients who have borderline personality disorder, the Food and Drug Administration has not approved any medications specifically for the treatment of this disorder.

Oral sucralfate (Carafate) acts chemically with predicate device nimodipine 30mg overnight delivery, but the quality standards of the manufactur- hydrochloric acid in a patient’s stomach to form a barrier paste ing facility were not adequate purchase 30 mg nimodipine free shipping. Heparin flushes are also not cov- through the 510(k) process 30 mg nimodipine sale, with each claiming substantial ered under Medicare Part D because they are not prescription equivalence to the others generic 30 mg nimodipine visa. Yet cheap 30mg nimodipine with amex, all of these products employers, union groups, Medicaid, and Medicare) are typi- require a prescription, and their costs are not insignificant: cally processed at point-of-sale through a pharmacy benefit average prices range from $54 per 90 grams (Biafine) to $122 per 140 grams (Tropazone) from drugstore. Unless a health plan specifically coded these products for quantity limits, and any number of plan coverage parameters. Coverage rules are typically established at the current limitations of the drug product files available to process highest possible level of product classification, on an exclu- claims can assist payers in making informed prescription drug sion basis, with continued greater specificity as required to coverage decisions. Many pharmacy benefit plans have rules obtain the third-party payer’s coverage intent. Because the highest level of exclusion is typically the vide the needed information in a user-friendly manner. Unfortunately, the current system is not well equipped in the drug and device review processes (i. There are primarily 2 companies that market product files to pharmacy claims processors: First DataBank (First DataBank, Inc. Federal Food, Drug, and evaluating the safety and effectiveness of medical devices? Medical device regulation: an introduction for the practicing Accessed December 1, 2010. Report to the Ranking ProductsandMedicalProcedures/DeviceApprovalsandClearances/ Member, Committee on Finance, U. Pharmacy entails a realize this mistake once they have returned home health science specialty which embodies the and have taken the first dose. Latent errors can be knowledge of pharmacology, toxicology, described as “accidents waiting to happen “ The pharmacokinetics and therapeutics for the care of causes of these types of errors are usually patients. Health care is nearly 10 years behind other identifiable and can be corrected before the error industries in its efforts to reduce the errors. According to studies cited in the institute of Medicine report, “to Err is Human; Building a Safer Health? Incomplete patient information (not knowing System” 44,000 to 98,000 Americans die each year about patients’ allergies, other medicines as a result of medical errors. Medication error may they are taking , previous diagnoses, and lab be nobody’s baby, but when it happens, it could results for example) well turn out to be everyone’s worry and the reasons given for medication error range from silly to the? Miscommunication of drugs orders, which can economically inefficient use of pharmaceuticals is involve poor handwriting , confusion between commonly observed in the health care system drugs with similar names, misuse of zeroes throughout the world especially in the developing and decimal points, confusion of metric and countries. Some of the errors though are serious other dosing units, and inappropriate and require attention. Lack of appropriate labeling as a drug is hospital stays, additional treatment, and prepared and repackaged into smaller units malpractice litigation. Environmental factors, such as lighting, heat, noise, and interruptions that can distract health “A medication error is an preventable event professionals from their medical tasks. Such events may be related to prescription and inaccurate calculation of doses *Adapted with gratefulness from The Pharma Review, August 2005 ** Indraprastha Apollo Hospital, New Delhi 60 especially in children. Workplace environmental problems increasing drug or dose) and those of omission (failure to the job stress. Access to drugs by non-pharmacy personnel with ineligible prescriptions or verbal medication orders and errors are likely. Lack of patient information perceived the following as causative factors for medication errors-? Overload/ unusually busy day (59%) symbols that occur practically are given in Table 1:? No time to counsel (29%) that they observe, the denominator is called “opportunities for errors” and includes all the doses? Failed communication: handwriting and oral communications, especially over the telephone, drugs with similar names, missing or misplaced zeroes and decimal points, confusion between metric and apothecary systems of measure, use of nonstandard abbreviations (table-1) ambiguous or incomplete orders 61 Ta. D/C Discharge, also discontinue Patients’ medications have been prematurely discontinued when “D/C” was intended to mean “discharge” versus discontinue”! Failure to “shake well”: The failure to with its drug distribution system and a deficiency should “shake” a drug product that is labeled “shake be written. This will almost always lead to an Medication errors due to failure to follow under dose or over dose depending on the label instruction suspending abilities of the diluent’s and the elapsed time since the last “shake “. Also included under this category is the failure to 62 “roll” insulin suspensions.