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Wilson and others cheap lasix 100 mg with visa, “The cost-effectiveness of harm reduc- 65 “International standards for the treatment of drug use disorders: tion” purchase lasix 100mg amex, International Journal of Drug Policy discount lasix 40mg without a prescription, vol. Economic aspects can also have an in the management of pain and other medical uses, in impact on the evolution of illicit drug markets, as varia- some countries the strategies in place to prevent the abuse, tions in income levels and purchasing power may influence misuse and diversion of controlled substances may some- drug consumption patterns. Human has an impact on illicit drug markets, the drug problem Rights Watch reviewed the national drug control strategies can also have economic ramifications. The economic cost of 29 countries and found that 25 of them failed to iden- of drug use that is incurred, for example, when drug-using tify the issue of ensuring availability of controlled sub- segments of the workforce do not receive adequate treat- stances for medical and scientific use as an objective or to ment, can impact on productivity. These aspects are discussed below, in the sections on economic development and environmental sustainability. Impact of economic development on the drug problem Furthermore, when the response to illicit drug use neglects the health aspects of drug use and treats the problem exclu- One way to look at how economic development affects sively as a criminal offence, excessively focusing on pun- the drug problem is to compare the latter across different ishment, consequences can ensue for the well-being of countries on the basis of their economic development. These aspects are discussed below, in the sub- multitude of factors that can play a role in shaping the section on criminal justice. Proximity to a drug-pro- Finally, when the response to the drug problem fails to ducing area or to a major drug trafficking route, for exam- take into account the particular needs of women, it may ple, explains more than economic development the higher contribute to undermining the objectives of gender parity than global rates of opiate use in the Near and Middle East and of the empowerment of women and girls. This applies and South-West Asia or the higher rates of cocaine use not only to direct interventions against the drug problem (including “crack” cocaine) in South America and West but also to the monitoring of drug use, as women are likely Africa. Nevertheless, a global macrolevel analysis can still to be under-represented in research identifying prevalence, provide insights into how economic development may needs, risks and outcomes of drug use, leading to a gap in have a bearing on the drug problem, although the rela- tionship between development and the drug problem needs to be viewed in dynamic terms. Drugs: A Review of Their Risks, Experiences and Needs (Sydney, 70 Human Rights Watch, “National drug control strategies and access National Drug and Alcohol Research Centre, University of New to controlled medicines” (2015). As figures 8 and 9 show, cocaine is the the prevalence of past-year use of cocaine in South America drug most clearly associated with high income. The asso- is not very different from the figure for North America, ciation between the problem of drug use and development the majority of cocaine users in the United States use can also be noted in terms of disability-adjusted life years cocaine in salt form, whereas in South America the use of (see figure 3, page 65). Moreover, some of the “products” con- Development and the evolution of drug use sumed in base form in South America are siphoned off and consumer markets from intermediate stages of the cocaine-processing chain, Drugs that command a relatively high price, and ulti- when they may still contain high levels of impurities and mately greater profits for traffickers, may find an easier are thus usually considered to have less potential to fetch foothold in countries with relatively higher levels of per high prices. Although historically there have been dif- smoking) in the United States is believed to be obtained ferent dynamics (including licit use) that have triggered from a reverse step that reverts to base form (in this case, the onset of the use of certain drugs, it is likely that income “crack”) from salt form. Another possible illustration of levels play an important role in enabling drug use to take this pattern is the case of the domestic heroin market in hold and consolidate. Reports by the Government of India indicate that ties show the magnitude of the amounts spent on drugs: heroin in the domestic retail market is considered to be of in 2010, people in the United States who used a drug at “low value” and that this reflects a distinct market from least four times a month spent an average of $10,600 a the heroin transiting India from Afghanistan and headed year on cocaine, $17,500 on heroin and $7,860 on meth- for other destinations. This is particularly the case for cocaine and socioeconomic well-being, such as income levels and heroin, which originate in confined and well-defined areas employment status, are only visible at the subnational or of production, creating a scenario in which consumers community level. In contrast, cannabis and, to a certain extent, some the section entitled “Social development”). The study ten- some of them becoming cocaine or heroin transit areas), tatively suggests that, given typical transaction sizes in whereas the same cannot be said of the prevalence rates of practice, the minimum cost for achieving intoxication was cannabis use, which have tended to be even higher than frequently lower. The use of unprocessed drugs such as cate that the median costs of “crack” and cocaine transac- opium and coca leaf remains largely confined to the places tions are comparable ($27 for cocaine salt versus $25 for in which they are cultivated, where they have been used “crack” cocaine). Because of their different modes of for centuries, while their derivatives have not always found administration, the typical experience associated with a large market in the countries of origin. Heroin use, for “crack” use is shorter but reportedly more intense than example, is quite low in Latin American countries, that of cocaine salt, so it can be argued that users of cocaine although opium is cultivated in the subregion and is also salt would need to spend more to achieve the same level processed into heroin. The differences may also extend to the poten- tial for users to develop tolerance and dependence. Just as different drug categories display different patterns, different drug subcategories may also explain some of the complexities of illicit drug markets. Kilmer and others, What America’s Users Spend on Illegal Drugs: 75 Kilmer and others, What America’s Users Spend on Illegal Drugs: 2000-2010 (Santa Monica, California, Rand Corporation, 2014). Generally, even though wealthy societies appear to be more This pattern is also consistent with data on drug use in vulnerable to drug consumption, within those societies, Colombia, which show very distinct patterns for past-year economic and social disadvantage is a significant risk factor drug use and for drug use disorders in different socioeco- for drug consumption to translate into drug dependence nomic classes. Poverty is associated with drug use example, there is a progressive increase in rates of occa- disorders, not because of any link with discretionary sional (past-year) use with higher levels of socioeconomic income but because poor people are more vulnerable and status (see figure 10), but overall drug use disorders are more likely to live on the margins of society. Higher socioeconomic groups may play a separate role in facilitating the onset of recreational use as a first step in the subsequent formation and consolidation of illicit drug As mentioned earlier, poverty is a significant risk factor markets. The mechanisms that drive this interaction merit for drug use; conversely, drug use itself frequently places further study, but they may be attributable to a higher a significant strain on the finances of people with drug propensity to experiment, higher income levels, higher dependence and on their families’ finances. The extent of association with an urban location of residence and dif- the financial strain brought about by drug use may be related not only to the price of a drug but also to the ferent patterns of entertainment among people in the potential of the person using the drug to develop a toler- higher socioeconomic brackets. A study on cannabis use ance to that particular drug, and hence to its pharmaco- demonstrated this phenomenon by drawing on evidence logical properties. In the case of heroin, for example, it is from France, Germany and the United States. The study believed that experienced users may seek much higher showed how, at the outset, it was mostly well-educated doses than first-time users. People with fewer economic men in the countries examined who started to experiment resources who use drugs may also be exposed to higher with cannabis use. Gradually, this shifted to men with low levels of harm as they resort to cheaper variants of drugs. Women followed at lower rates and Lower prices may be associated with lower purity levels, the change was not as marked; moreover, the people who which imply higher health risks because of the presence transitioned to daily cannabis use were predominantly 76 of adulterants, by-products and other substances. The financial difficulties experienced by people with drug 76 Legleye and others, “Is there a cannabis epidemic model? This ers or had exchanged sex for money, 6 per cent had resorted is clear from the history of the illicit use of synthetic drugs to illicit activities linked to the sale or distribution of drugs and cocaine and, based on historical qualitative assess- and 9 per cent had resorted to other illicit activities. After emerging in developed countries, over time, individual lives, as income inequality within a society may consumption eventually tends to catch on in countries contribute to the marginalization of the less wealthy. More broadly, the evo- discussed in the World Drug Report 2012, an analysis based lution of consumer markets in developing countries seems on Gini coefficients indicated that countries with high to follow patterns seen in developed countries (see the discussion below). However, even though the causes of poverty and 80% deprivation are to some extent social, they are experienced individually and those who experience them have their own set of reasons and motivations for responding to their 60% circumstances in a particular manner. In 2000, 79 per cent of the In sum, poverty, together with other forms of social world populaton 81 Cocaine, 2000 accounted for 27 per disadvantage, is strongly associated with drug use disor- cent of users. Consumption of most synthetic drugs and new psychoac- 79 World Drug Report 2012 (United Nations publication, Sales No. Young, From War to Work: Drug Treatment, Social Inclusion and countries before expanding in less developed countries. Prime examples are the emergence of methamphetamine 81 In addition to the discussion of poverty in this section, see the in Japan and North America near the middle of the twen- discussion of social exclusion in the section entitled “Social develop- tieth century, the subsequent emergence of “ecstasy” and ment”. It is at a later stage when the use of these substances expanded in less devel- oped countries; for example, the peak in methampheta- mine use in the United States happened between 1995-2002, while in China methamphetamine use is a more recent occurrence and the available indicators do not yet show signs of reaching a peak (see figure 12). Market 1 peak The drivers of the emergence of synthetic drug markets in developed countries may be a combination of supply- side and demand-side factors. On the demand side, greater purchasing power, as well as potentially greater inclination and opportunities to experiment with substances for rec- reational purposes, may play a role. As with many other social phe- 1 nomena, development may accelerate the diffusion and a certain homogenization of the drug problem. Facilitating trade and easing trade barriers are features of globalization that can potentially have an impact on drug a trafficking.

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Tabet N order lasix 100 mg with visa, Mantle D purchase lasix 40 mg on line, Walker Z buy 40 mg lasix visa, Orrell M: Vitamins, trace elements, and antioxidant status in dementia disorders, Int Psychogeriatr 13:265-75, 2001. Nilsson K, Gustafson L, Hultberg B: The plasma homocysteine concentration is better than that of serum methylmalonic acid as a marker for sociopsychological performance in a psychogeriatric population, Clin Chem 46:691-6, 2000. Reynish W, Andrieu S, Nourhashemi F, Vellas B: Nutritional factors and Alzheimer’s disease, J Gerontol A Biol Sci Med Sci 56:M675-M680, 2001. Christen Y: Oxidative stress and Alzheimer disease, Am J Clin Nutr 71: 621S-629S, 2000. John’s Wort, Ginseng, Echinacea, Saw Palmetto, and Kava, Ann Intern Med 136:42-53, 2002. Linde K, ter Riet G, Hondras M, et al: Systematic reviews of complementary therapies—an annotated bibliography. Anxiety may result from trying to meet family or work demands perceived as excessive, or it may be self-imposed through attempts to meet unrealistic personal expectations. In a survey on the use of complementary and alternative therapies for anxiety and depression, one in five subjects said they visited a complemen- tary medicine therapist, but more than half reported using alternative thera- pies to treat anxiety or severe depression during the past 12 months. Characterized by intense con- cern about trivial or unrealistic problems, anxiety is aggravated by somatic awareness. It is perpetuated and escalated by awareness of physical symp- toms such as a dry mouth, pounding heart, or tense muscles, induced by autonomic and motor changes. Panic attacks are experienced as recurrent, unexpected episodes of intense anxiety. In addition to attempts to change cognitive and somatic perceptions by behavioral means, chemical interventions can used to modify neurotransmitters. Monoamine changes in the brain are believed to be associated with anxiety disorders. This may ❑ diarrhea present as: ❑ hyperventilation and dizziness ❑ irritability ❑ urinary frequency ❑ impatience ❑ a clammy skin ❑ a dry mouth ❑ Cognitive difficulties. This may present as: ❑ difficulty in concentrating ❑ restlessness ❑ mental ‘blanks’ ❑ a tremble ❑ confusion ❑ aching muscles ❑ headache ❑ Sleep disturbance. This may present as: ❑ fatigue ❑ difficulty falling asleep ❑ residual muscle tension (see Handout ❑ early waking 12. These two neurotransmit- ters are believed to control anxiety, depression, and pain perception. Regular aerobic exercise is benefi- cial, and food sensitivity should routinely be ruled out. Avoidance of excess caffeine, alcohol, and sugar has long been surmised to be helpful. More recently, ingestion of fats has been recognized as influencing behavioral responses. Consumption of lard and a vegetable margarine with a high content of saturated fatty acids was found to decrease hypothalamic serotonin levels, whereas ingestion of a sunflower oil and an olive oil–enriched margarine, both high in polyunsatu- rated fatty acids, did not significantly affect serotonin levels. These changes were noted even when consumption occurred over a relatively short period in adulthood. Despite abundant evidence that serotonin is involved in anxiety in both animals and humans, acute trypto- phan depletion, although it enhanced the effect of a panic attack, was found to have little effect on general levels of anxiety. A double-blind, ran- domized, controlled trial of healthy male volunteers showed that Berocca (Roche), a multivitamin mineral supplement, was associated with consistent and statistically significant reductions in anxiety and perceived stress. Clinical trials in women with premenstrual syndrome have shown that calcium supplemen- tation effectively alleviates the majority of mood and somatic symptoms. Inclusion of 100 mg of pan- tothenic acid as part of a B complex has also been suggested for particularly stressful periods. A sleep laboratory study demonstrated that although the effects of 900 mg of valerian on sleep were not significantly dif- ferent from those of placebo, it did decrease subjective feelings of somatic arousal without affecting physiologic activation. A preliminary study suggested that kava may exert a favorable effect on reflex vagal control of heart rate in generalized anxiety disorders. The improved baroreflex control of heart rate induced by kava paralleled the patient’s clinical improvement. The kavapyrones affect the glutamate systems and inhibit sodium and calcium channels, resulting in centrally acting skeletal muscle relaxation and an anti- convulsant effect. The uptake of norepinephrine, a “feel good” neurotrans- mitter, is also inhibited. Clinical trials have shown that kava is superior to placebo, and roughly equivalent to oxazepam, 15 mg/day, or bromazepam, 9 mg/day. At a daily therapeutic dose of around 200 mg, kava may cause mild gastrointesti- nal complaints and/or allergic skin reactions in up to 1. Kava extract is increasingly regarded as an effective alternative to antide- pressants and tranquilizers in the treatment of anxiety of nonpsychotic ori- gin. The adaptogenic qualities of Siberian ginseng (100-300 mg three times a day) may benefit anxious patients who are stressed and fatigued. In animal studies Hypericum perfora- tum and Panax ginseng were found to be associated with significant and qual- itatively comparable antistress activity as judged by a variety of behavioral and physiologic changes in rats exposed to long-term stress. Findings from ani- mal studies have indicated that a combination of Ginkgo biloba and Zingiber officinale (ginger) has anxiolytic effects comparable to those of diazepam; however, in high doses, anxiogenic properties were also noted. She had experienced an abrupt onset of dizziness, lightheadedness, and uncomfortable “electric sensations” 230 Part Two / Disease Management in her trunk and limbs. These symptoms were followed by moderately severe anxiety, verging on panic, and a feeling of breathlessness. Over the next few weeks, these sensations followed a fluctuating course with an over- all increase in severity, but neurologic and cardiologic investigation failed to demonstrate any identifiable problem. Left with no clear-cut diagnosis and continuing to have inexplicable symptoms, Merran began having frank panic attacks, and she was referred to me. She had not been treated for psychological problems before, but neither had her life been as stressful as it had been in the previous 18 months with worry over her depressed, unemployed husband and a mildly anorexic daughter preparing for final year school examinations. Merran’s general health was good, and she had passed smoothly through menopause 2 years previously without significant physical or psychologic symptoms. She took no medication or supplements except calcium carbon- ate as an osteoporosis preventive, although results of a recent bone density test had been normal. Her digestion was good, but her dietary history revealed a low protein intake in the context of a very light breakfast and lunch and animal protein at tea time on only three to four occasions per week. At our first interview, her original symptoms were still prominent, together with marked initial and middle insomnia and some mild depressive symptoms, such as loss of confidence and drive and occa- sional tearfulness. On examination, Merran showed herself to be a quiet, likeable, intelligent woman who expressed herself well, was psychologically minded, and appeared tense but not clinically depressed. Her blood pressure was on the low side, 110/70 mm Hg sitting, and she appeared to be a chest breather with occasional sighs. Mg deficiency) Chapter 11 / Anxiety 231 Merran was not keen on taking any medication, even for temporary night sedation, so we decided initially on tryptophan, 500 mg, at night with a low dose (<25 mg) multi-B vitamin, pending further nutritional investigation. At the same time, symptoms of dizziness and chest tightness appeared but rapidly resolved with rebreathing from cupped hands. Tryptophan (500 mg) had not improved sleeping greatly, but more protein at lunchtime had reduced her tendency to experience more prominent symptoms later in the afternoon. When prescribing tryptophan, I always explain the history and symptoms of eosinophilia-myalgia syndrome so that patients can recognize the symp- toms in the (extremely) unlikely event that they experience this problem.

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How would you describe your current relationship with the doctor who treats you for thyroid disease? How does being a woman effective lasix 40 mg, as opposed to being a man purchase 40 mg lasix amex, influence your relationship with your doctor? How comfortable do you feel in talking with your doctor about symptoms or medical issues you have experienced that you believe might be related to thyroid disease? What do you believe might help you to feel more comfortable in sharing your experience of these symptoms with your doctor? Do you have a journal or diary about your experience with thyroid disease that you would like to share with me? If you would like to share your journal/diary with me generic lasix 100mg visa, please remove your real name from their journal/diary before emailing it to me. Would you mind reviewing the transcript of our chat to make sure everything is correct? McCormick, Based on my review of your research proposal, I give permission for you to conduct the study entitled “Women and Thyroid Disease: Treatment Experiences and the Doctor- Patient Relationship” within The Thyroid Support Group. As part of this study, I authorize you to invite members of my group to participate in the study as interview subjects. We reserve the right to withdraw from the study at any time if our circumstances change. Sincerely, ___________________, Group Owner-Moderator 311 Appendix C: On-List Group Email Invitation Hello everyone! My name is Laura McCormick and I am a doctoral student at Walden University (http://www. I obtained permission from the Group Owner and Moderator to seek participants for my study. If you are a woman age 18 or older, have a thyroid disease diagnosis, are a member of this support group, and if you are interested in participating in research about women’s experiences with thyroid disease treatment, then I invite you to take part in a research study of women with thyroid disease. A potential benefit to this study is that it gives participants the opportunity to share their experiences of thyroid disease with professionals and the general public (your real names will not be known or used). Email me off-list through my personal email address by January 26, 2014 to express your interest in participating. After reading the consent form, if you are still interested in participating, we will communicate via email using your fictitious name and email address to set up a date and time for your individual interview. Once we set a date and time for your interview, please be sure to participate in the interview in a private, non-public location. I want to assure everyone that you are in no way required to participate in my study. Likewise, if you choose to participate in my study, you may change your mind at any time and withdraw from the study without explanation. I will never know who does and does not participate in this study and I will never know the true identity of any participant. Warm regards, Laura 312 Appendix D: Consent Form You are invited to take part in a research study of women with thyroid disease. You were chosen for the study because you are a woman with a thyroid disease diagnosis and you expressed an interest in this study. Please read this form and ask any questions you have before agreeing to be part of the study. Background Information: The purpose of this study is to obtain an understanding of the experiences of women with thyroid disease. International Suicide and Crisis Hotlines are available here: http://suicidehotlines. At the end of the interview, you will be asked if you would like to follow up by e-mailing Laura your journal/diary (see below) and by reviewing your individual chat transcript. Please make sure that you participate in the interview in a private, non-public location, and use your fictitious name at all times. E-mail Laura not through the support group, but to her e-mail address and protect the journal with a password. This means that everyone will respect your decision of whether or not you want to be in the study. No one in The Thyroid Support Group will know whether you choose to participate and no one will treat you differently if you decide not to be in the study. You do not have to participate in any follow-up activities such as reviewing the transcript of your interview if you do not want to. Risks and Benefits of Being in the Study: A potential risk of participating in this study is the possibility of your e-mail being read by someone other than Laura. In order to prevent access to your e-mails, interview responses, and journal, Laura has password-protected her computer. No one will have access to the login information that you use to join the chat session, so no one will be able to see the transcript of your interview, which will be stored on a password-protected drive. Another possible risk is that you might feel emotional distress in talking about some aspects of your experience. If this is the case, you are free to end the interview, take a break, or withdraw from the study without consequences. A potential benefit of this study is to have your “voice” be heard about what it’s like to be a woman with thyroid disease. Laura will not use your information for any purposes outside of this research project. Also, Laura will not know your real name and will not include anything that could identify you in any reports of the study. If you want to talk privately about your rights as a participant, you can call the Director of the Research Center at Walden University. I acknowledge that the information must remain confidential, and that improper disclosure of confidential information can be damaging to participants. I will not disclose or discuss any confidential information with others, including friends or family. I will not in any way divulge, copy, release, sell, loan, alter, or destroy any confidential information except as properly authorized. I will not discuss confidential information where others can overhear the conversation. I understand that it is not acceptable to discuss confidential information even if the participants’ names are not used. I will not make any unauthorized transmissions, inquiries, modification or purging of confidential information. I agree that my obligations under this agreement will continue after termination of the job that I will perform. I will only access or use systems or devices I am officially authorized to access and I will not demonstrate the operation or function of systems or devices to unauthorized individuals. I acknowledge that I have read the agreement and I agree to comply with all the terms and conditions stated above. Printed Name of Mary Ann Cincotta Research Assistant 316 Research Assistant’s Mary Ann Cincotta Electronic* Signature Researcher’s Laura J. McCormick Electronic* Signature *Electronic signatures are regulated by the Uniform Electronic Transactions Act.

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