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The unweighted average showed that past- defines problem drug use as “injecting drug use or long month prevalence was equivalent to 52% of annual prevalence purchase cipro 1000mg. The number of cannabis users was estimated between 125 and 203 million in 2009 order cipro 750 mg overnight delivery, equivalent to a prevalence 5 cipro 750mg cheap. The same applies to the broad ranges for ecstasy use (11-28 million people purchase 250mg cipro otc, or a prevalence rate ranging from 0. The third most widely used group of substances appears to be the opioids, with estimates ranging from 24 to 35 Generally stable trends for use of main drug million people, equivalent to a prevalence rate of 0. The most problem- atic opioids6 at the global level, as reflected in treatment The total number of users for the individual drug cate- demand, are the opiates, that is, the various psychoactive gories mentioned above does not appear to have changed substances derived from the opium poppy plant, notably significantly over the last few years. If there has been a gen- mated to have consumed illicit opiates in 2009, equiva- eral trend, it has been – for most drugs - towards a lent to a prevalence rate ranging from 0. In recent years, problem drug use has also been cal good practice, whereby prevalence estimates older related to the non-medical use of various prescription than 10 years are now not being used to estimate preva- opioids, such as oxycodone, fentanyl or pethidine. Since a large number of countries in Africa and Asia do not have recent data on drug use, the levels of Cocaine appears to rank fourth in terms of global preva- uncertainty increase. These 6 Opioid is a generic term applied to alkaloids from opium poppy, markets continue to evolve and every year new products, their synthetic analogues, and compounds synthesized in the body. Synthetic drugs are the fastest evolving substances in this 25 World Drug Report 2011 Fig. In addition, Piperazine was initially developed as an anthelminthic reports of drug-adulterant combinations involving phar- used in the treatment of parasitic worms. These amphetamine-like law enforcement pattern; ii) the use of substances which effects include a sense of euphoria and stimulant proper- are not nationally or internationally regulated and con- ties. Mephedrone The fact that new psychoactive substances are emerging on the drug markets is not a new development. In Europe, one of the controlled substance cathinone, one of the psychoactive most ‘innovative’ regions when it comes to new drugs, substances in the khat plant. Although mephedrone and ana- fied in the European early-warning system, compared to logues such as naphyrone produce effects similar to 24 in 2009. In the last few years, a number of new substances entered ‘Spice’ the illicit market imitating either the pharmacological properties or chemical structures of existing controlled The cannabis market has diversified with the introduc- substances such as amphetamines or ecstasy. Some of tion of synthetic cannabinoids which emulate the effect these contain unregulated substances and are known as of using cannabis. The piperazines and the cathinones, for nabinoids (‘spice’) have been detected in herbal smoking example mephedrone, are examples of unregulated sub- blends. These products typically contain about 3 grams stances which recently entered the markets. In response, a scription stimulants is reportedly a growing health prob- number of countries have placed ‘spice’ and similar lem in a number of countries. In the United States, products under control, leading to a decrease in the emergency room visits related to the non-medical use of extent of the problem. Prescription drugs may with levamisole replace certain illicit drugs since their use is perceived to be less harmful, being prescribed by physicians. They are Street dealers have traditionally ‘cut’ cocaine with dilu- legal, cheaper than illicit drugs and their use is more ents such as lactose to increase profits. Another factor for the growing pop- have been reports of the use of more pharmacologically ularity of prescription drugs is that patients who have active adulterants such as atropine, phenacetin and been prescribed medications share or sell them to family methyphenidate. The presence of some of these adulter- members, friends or others who approach them. Non- ants may serve to increase the desired effects of the illicit medical use of prescription drugs is a common phenom- substances or even reduce or eliminate some of its enon among young adults, women, elderly patients and adverse effects. Another issue of concern is by data from several other European and North Ameri- that the growing numbers of polydrug users among can countries) show that in 2008 and 2009, an increased illicit drug users also use prescription drugs in combina- number of cocaine samples contained levamisole, an tion with their illicit drug of choice to enhance the anthelminthic, effective in infections with the common effects of the main drug. Treatment demand Difficulties in controlling new substances… The need to enter treatment reflects problematic drug The large number of new substances that enter the use, associated with adverse effects on the health of market worldwide is posing a number of challenges to individuals. In most regions of the world, there continue public health and law enforcement systems which to be clear regional patterns regarding the main problem require improved monitoring and a coordinated response drug types. While some countries have opiates, and in particular heroin) are dominant for tried to address the problem via the application of ‘emer- problematic use. Other countries have started to bring the is also widespread in Oceania, North America and West rapidly growing number of new substances under imme- and Central Europe.

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At a full adult dose the plasma curve may rise above the therapeutic window cipro 250 mg without prescription, leading to side effects buy cipro 250mg without a prescription, especially 58 Chapter 8 Step 3: Verify the suitability of your P-drug anticholinergic and cardiac effects cheap cipro 250mg on line. Secondly discount cipro 250 mg free shipping, metabolism and renal clearance of the drug and its active metabolites may be reduced in the elderly, also increasing the plasma curve. Thus, in prescribing the normal adult dosage your patient will be exposed to unnecessary and possibly harmful side effects. For example, two tablets once daily are much more convenient than half a tablet four times daily. Complex dosage schedules decrease patient adherence to treatment, especially when more than one drug is used, and thus decrease effectiveness. If you had not adapted the schedule, the P-drug treatment would have been less effective, or unsafe. You can prevent this by carefully checking the suitability of the standard dosage schedule before writing the prescription. How to adapt a dosage schedule Figure 5: Relation between There are three ways to restore the mismatch between frequency and fluctuations curve and window: change the dose, change the in plasma concentration frequency of administration, or both. The daily dose determines the mean plasma concentration, while the frequency of administration defines the fluctuations in the plasma curve. For example, twice daily 200 mg will give the same mean plasma concentration as four times daily 100 mg, but with more fluctuations in plasma level. The minimum fluctuation would be obtained by delivering 400 mg in 24 hours by means of a continuous infusion (Figure 5). Beware of antibiotics, because some may need high peaks in plasma concentration to be effective. Doubling the dose while maintaining the same frequency not only doubles the mean plasma level, but also increases the fluctuations on both sides of the curve. In drugs with a narrow safety margin the curve may now fluctuate outside the therapeutic window. However, few patients like taking drugs 12 times a day and a compromise has to be found to maintain adherence to treatment. After changing the daily dose it takes four times the half-life of the drug to reach the new steady state. Table 7 lists those 59 Guide to Good Prescribing drugs for which it is advisable to start treatment with a slowly rising dosage schedule. Many doctors not only prescribe too much of a drug for too long, but also frequently too little of a drug for too short a period. In one study about 10% of patients on benzodiazepines received them for a year or longer. Another study showed that 16% of outpatients with cancer still suffered from pain because doctors were afraid to prescribe morphine for a long period. The duration of the treatment and the quantity of drugs prescribed should also be effective and safe for the individual patient. The patient receives unnecessary treatment, or drugs may lose some of their potency. Some reconstituted drugs, such as eye drops and antibiotic syrups, may become contaminated. The treatment is not effective, and more aggressive or expensive treatment may be needed later. Exercise: patients 21-28 For each of the following cases verify whether the duration of treatment and total quantity of the drugs are suitable (effective, safe). R/mefloquine 250 mg, 1 tablet weekly, give 7 tablets; start one week before departure and continue four weeks after return. Patient 21 (depression) A dose of 25 mg per day is probably insufficient to treat her depression.

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These are devices in which medication is dispensed for patients who experience difficulty in taking their medicines discount 750 mg cipro visa, particularly those who have difficulty in co-ordinating their medication regime or have large number of medicines to take 250 mg cipro amex. They have compartments for each day of the week and each compartment is divided into four sections purchase cipro 1000mg amex, i discount cipro 750mg fast delivery. They do not provide benefit to all types of patients and are not useful for patients who have visual impairment, dexterity problems or severe cognitive impairment. Adverse reactions An adverse reaction to a drug is likely to be two or three times more common in the elderly than in other patients. There are several reasons for this: • Elderly patients often need several drugs at the same time and there is a close relationship between the number of drugs taken and the incidence of adverse reactions. In addition, people who are confused, depressed or have poor memories may have difficulty in taking medicines. The following general principles may be helpful: 164 The elderly and medicines • A full medication history (including over-the-counter drugs) – this should highlight any previous adverse reaction, potential interactions and any compliance issues. Many older people are unable to read leaflets and labels due to failing eyesight, and may need specially written instructions. It provides essential information to ensure that the drug or medicine is used correctly, effectively and safely. The package insert contains the basic information necessary for the administration and monitoring of the drug. This is particularly true when dealing with parenteral products as they will have a more immediate and dramatic effect than oral preparations. It is not meant to be exhaustive, but a list of resources that should be readily available on the ward, either as a book or via the Internet. The paediatric books should be available on paediatric wards; if not, they will be available in the hospital pharmacy. Specialist books • Neonatal Formulary: Drug Use in Pregnancy & the First Year of Life – current edition (Latest edition = 5th, 2006) Northern Neonatal Network – Blackwell Publishing Updates are available from: http://www. During this time, a great deal of information is gathered about efficacy, side effects and toxicology. These can be viewed via the Electronic Medicines Compendium website (see list of Sources of Drug Information). In the following list you will find a brief description of each of these headings. Qualitative and quantitative composition The generic or chemical names of the active ingredients and the amount of each active ingredient, e. Clinical particulars How the medicine should be used; includes information for prescribers to ensure that patients are treated appropriately, taking into account the patient’s medical history, any co-existing diseases or conditions and other current treatments. The dose of the drug is given, including any changes in dose that may be necessary according to age or co-existing disease or condition, such as renal or hepatic impairment. Where relevant, information is also given on the timing of doses in relation to meals. The maximum single dose, the maximum daily dose and the maximum dose for a course of treatment may also be given. If the drug or any of its metabolites is excreted in breast milk, the probability and nature of any adverse effects in the infant are described, and whether breast feeding should continue or not. Pharmacological properties Information about how the medicine works and how it is handled by the body. Where appropriate, additional information may be included as to how the pharmacokinetics may change according to, for example, the patient’s age or state of health. Pharmaceutical particulars Information on the medicine ingredients, storage and packaging. Marketing authorization holder The drug company holding the marketing authorization granted by the licensing authority.

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