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The argument that prenatal selection is diVerent from ending such lives after birth order genuine keppra online medicine zocor, and aVects attitudes towards impaired fetuses only buy keppra 250 mg low cost medications names and uses, is unconvincing purchase discount keppra on-line medicine names. The interviewees show that some disabled people feel threatened and disad- vantaged by the prejudices which are keppra 250 mg otc medicine grace potter lyrics, perhaps inadvertently, promoted through prenatal screening. The emphasis on particular impairments when selecting an embryo or fetus as worth preserving suggests that any policy diVerence between preserving an embryo or a person with, say, thalassaemia is not one of principle but of practicality. Social exclusion, school exclusion and family exclusion (in numbers of teenagers living on the streets) are increasing rapidly, as are expectations that children should conform to ever more speciWc milestones, school tests and behaviour standards with an unjust ‘zero-tolerance’ which does not allow for contingencies and disadvantages. Prenatal programmes are not responsible for these changes, but they are part of them, and are powerful medical and oYcial indirect endorsements of them. Another theme of injustice is when public rejection, expressed through national prenatal programmes, is made to appear to be a matter of private grief and responsibility, as when each individual woman faces the ‘choice’ of termination of pregnancy, a choice constrained by social and economic circumstances. Tests which screen ‘negatively’ for one or a few speciWc impairments are soon likely to become multi-package tests to screen simultaneously for numerous impair- ments, and then tests to select ‘positively’ for growing numbers of preferred features such as intelligence or height. When the embryo and fetus, and implicitly the baby and child, are presented to women by health professionals as a means of fulWlling adults’ dreams of perfection, rather than as ordinarily imperfect mortals to love as ends in themselves, then maternal– child as well as maternal–fetal relationships are likely to become ever more tentative and conditional. I am grateful to everyone who took part in the research,and to my co-researchers,although I am responsible for any shortcomings and opinions in this chapter. Over time, the initial way a problem is deWned then crystallizes policy debates, producing what can then become a very rigid framework, all but impossible to expand or modify (Rochefort and Cobb, 1994: vii, pp. Constitutionally, in the course of nearly 30 years of Supreme Court reasoning, abortion rights have become rigidly deWned as a problem of decisional autonomy, that is, as a problem of privacy and choice. Politically, during that same time period, the problem of abortion has been deWned by pro-life activists (as we would expect), but also by pro-choice advocates (as we might not expect) on the basis of a very traditional model of motherhood, one invoking cultural and ethical depictions of women as maternal, self-sacriWcing nurturers. The combination of deWning the problem of abortion rights constitu- tionally in terms of the privacy of choice and politically in terms of a traditional view of motherhood has produced a rigid, serious policy conse- quence – namely, failure to obtain access to abortion services for women in the form of public funding of abortions. Correction of this policy conse- quence requires a redeWnition of the problem of abortion rights from both constitutional and political perspectives, which entails, as part of that re- deWnition, a transformation of the traditional model of motherhood to include nontraditional elements. To understand more clearly what is in- volved in this transformative process, let us review the current status of how a traditional model of motherhood underlies the current way the problem of abortion is deWned. McDonagh Problem definition: constitutionalism and politics In the United States, the Due Process Clause of the Fourteenth Amendment of the Constitution prohibits the state from depriving ‘any person of life, liberty, or property without due process of law’. This Due Process right of privacy has been interpreted by the Supreme Court to mean that a state may not interfere with a person’s choice about whom to marry, how to educate and raise one’s children, or the choice to use contraceptives. When the Supreme Court established the constitutional right to an abortion in Roe v Wade in 1973, it did so by ruling that the Due Process right to privacy was ‘broad enough to encompass a woman’s decision whether or not to terminate her pregnancy’ without interference from the state. This decision was a breakthrough for women’s rights because it immediately struck down nu- merous state laws that had severely limited procurement of an abortion (Ginsburg, 1985; Klarman, 1996). The Court reasoned that because a pregnant woman ‘carries [potential life] within her’, she ‘cannot be isolated in her privacy’ and her ‘privacy is no longer sole’. Thus, in Roe, the Court established that it is constitutional for the state to protect the fetus from the moment of conception and that a pregnant woman’s right of privacy to make a choice to terminate pregnancy can be limited by, or balanced against, the state’s interest in protecting the fetus as a separate entity from the consequences of that choice. Prior to viability, although the state may not prohibit an abortion per se, the state may protect the fetus by requiring restrictive regulations, such as 24-hour waiting periods and informed consent decrees, and by prohibiting the distribution of any information about abortion in publicly funded family planning clinics. What is more, law scholars concur that the Due Process foundation for abortion rights, as interpreted by the Court, means that it would be constitutional for a state to prohibit the use of public resources to assist a woman in obtaining an abortion, even if her pregnancy is subsequent to rape or incest, and even if her pregnancy threatens her with death. After the stage subsequent to viability, the state in promoting its interest in the potentiality of human life may not only prohibit state assistance in obtaining an abortion, but may also prohibit a woman from choosing an Models of motherhood in the abortion debate 215 abortion, ‘except where it is necessary. Thus, although Roe has proved resilient in the ensuing decades for retaining the constitutional right to choose an abortion, deWning the problem of abortion rights in terms of privacy has proved completely inadequate for establishing a constitutional right to state assistance for obtaining one. This is consistent – the Due Process right of privacy to be free of government interference when making choices about one’s own life or reproductive options does not usually include a constitutional right to government assistance in exercising one’s choice. Hence, the constitutional right to choose to use contraceptives, as established in 1965 in Griswold, does not include the constitutional right to government funding to purchase contraceptives. Thus, the constitutional problem with using privacy and the Due Process Clause for deWning abortion rights is that a Due Process depiction of the abortion issue reinforces the Court’s disconnection between the constitu- tional right to an abortion and abortion funding. Since the right to make a choice without government interference – such as the right to choose an abortion or whom to marry – does not include the right to government assistance in exercising that choice, there is little, if any, constitutional leverage to apply to the abortion access issue. When we turn to the political arena, we run into a similar dead-end to procuring access to an abortion, as a result of the problem deWnition of abortion. Based on his experience, he draws attention to the conservative political message developed not only by pro-life activists, but also by the pro-choice community over the last decade. Starting at least in the mid-80s, around the time of the Thornburgh decision, pro-choice activists became so fearful that the right to an abortion would be overturned in court that they began to develop powerful conservative strategies with which to reach out to the American public. The conservative message, as Saleten analyses it, was premised on convey- ing a persuasive view of abortion rights that would be suitable for the mass media and for electoral campaigns. As a result, the right to an abortion came to be politically framed as the right to get the govern- ment out of your life; that is, the government should have nothing to do with your right to have an abortion. Thus, rather than getting the state out of a woman’s uterus, access to public funds, public facilities, and public personnel for abortion services involves getting the state into a woman’s uterus, so to speak. The pro-choice strategy of politically deWning the abortion message to be getting the government out of women’s lives, therefore, is counterproductive as a claim for public funding of abortion services. The traditional model of motherhood and abortion rights Underlying the problem deWnition of abortion rights is a traditional view of motherhood – one that rests upon a relational view of women, deWned in terms of an ethic of care, inclusive of a nurturing, if not a sacriWcial, relationship between mother and fetus. Relying on the traditional model of motherhood to deWne the problem of abortion, however, does not give us the necessary arguments to justify public funding of abortions. To gain for women state assistance in procuring abortion services, therefore, requires a redeWnition of the problem of abortion, one that draws upon a model of motherhood that incorporates non-traditional elements into the way women are envisioned when seeking an abortion. To reframe the abortion debate to make it possible to secure a constitu- tional right to abortion funding, we must reconsider the central ethical and legal issue that haunts abortion policies – what justiWes killing the fetus? When we look more closely at the way pro-choice advocates answer that question when explaining why they support abortion rights or why they themselves procured an abortion, we Wnd that their justiWcation for abortion rights, far from carrying a non-traditional message about women’s rights, relies upon and reinforces some of the most traditional components of motherhood by invoking the principles of ‘lifeboat’ ethics. In order to fulWll her role as nurturer, a woman is forced to choose how to provide the greatest good for the greatest Models of motherhood in the abortion debate 217 number; to do so, she must make a calculation of whom or what to sacriWce. Presumably, she would gladly sacriWce herself, if this would be most beneW- cial to all concerned, which, in the case of an abortion, could include the decision to continue a pregnancy. However, when using the traditional model of motherhood to justify the non-traditional goal of obtaining an abortion, it turns out that the pro-choice utility calculation can indicate that the best way to help the most people is to sacriWce the fetus by aborting it. From a political vantage point, this is a strategic way to ‘have your cake and eat it too’, since such a justiWcation leaves in place traditional cultural assumptions about women as care-givers, even while expanding the non- traditional options open to women in the form of the right to an abortion as an instrument of care-giving not to the fetus, of course, but to others. What is signiWcant about Kate Michelman, therefore, is that when she tells her story about why she obtained an abortion, that story reveals a premise that the best way to present the abortion issue is to embed it within a traditional model of motherhood. To put it another way, Michelman’s justiWcation for abortion exempliWes the political power of obtaining non- traditional goals for women by infusing those goals with the most traditional imagery associated with women. Michelman’s story employs a traditional view of a woman whose identity is deWned in terms of her childbearing goals, child care responsibilities and economic dependency on a husband. The killing of the fetus by means of an abortion, therefore, is justiWed as a sacriWce necessary for the survival, if not the good, of the greater whole. Lifeboat ethics and justification for killing Michelman’s story not only illustrates a traditional view of motherhood in the context of obtaining a non-traditional goal for women – abortion rights – it also corresponds to a speciWc ethical model that justiWes killing – lifeboat ethics.
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According to Owen ea cheap 500mg keppra visa symptoms of kidney stones,(2005) the genes likely to be 1081 Synaptic glutamate is chiefly taken up by the surrounding astrocytes and converted into glutamine by glutamine synthetase keppra 500mg discount treatment spinal stenosis. The glutamine is then taken up by neurones and converted back into glutamate by glutaminase buy keppra discount medications like prozac. Glutaminase-deficient mice display parahippocampal hypoactivity purchase 500mg keppra visa medications similar to gabapentin, insensitivity to pro-psychotic drugs and potentiated latent inhibition. It is possible that changes in cortical glutamatergic transmission lead to dopaminergic changes as a secondary phenomenon, but, as the authors admit, the truth is often more complicated than any simple theory. Neuregulin-1 (at chromosome 8p) is highly expressed in brain and signals through 1086 tyrosine kinase receptors, thereby being involved in neurodevelopment. Neuregulin-1 seems to play a role in influencing susceptibility to schizophrenia and bipolar disorder,(Green ea, 2005) although not all studies are positive. Lieberman ea (2008) point out that muscarinic and nicotinic receptor numbers may be reduced in schizophrenia, that a functional polymorphism of the alpha-7 nicotinic receptor has been linked to this condition, that acetylcholine modulates striatal and cortical dopamine, that people with schizophrenia smoke heavily, and that clozapine’s muscarinic receptor agonism may be important for its effects on positive and negative symptoms. It may have a role in improving verbal learning and short term memory in schizophrenia. Starvation, heavy cigarette smoking, and excess alcohol consumption all increase oxidative tone with the production of oxyradicals. Studies suggest that oxidative injury may be present at the start of non-affective psychosis, whether or not the patient has received antipsychotic drugs. Vitamins E and C supplements and fats from fish or vegetables rather than from animals or birds may be of some protection. Glutathione is important in the phospholipid pathway and there has been some benefit from giving the glutathione precursor N-acetyl-cysteine adjunctively to people with schizophrenia. There is some evidence that antibodies to these proteins are increased in schizophrenia. Do the peaks of schizophrenic births in winter and early summer increase the likelihood of an infectious aetiology? Against horizontal transmission of schizophrenia: Cooper ea (1987) - no greater an incidence of schizophrenia in psychiatric nurses 1955-1979 than in general nurses during same period Mednick ea (1987) - rates of schizophrenia in young adults exposed during foetal life to influenza epidemic in Helsinki in 1957 - those exposed during second trimesters had increased risk of later schizophrenia Similar findings reported in the northern and southern hemispheres in some (e. T gondii ), the likey interaction of susceptibility (genes, development) and microorganisms, and the need for more rigorous research design (e. There was a significant increase in positive antibody titres in patients with schizophrenia only for Chlamydia trachomatis (p = 0. Combining the different agents, patients with schizophrenia had a significantly higher rate of positive titres to infectious agents as compared to controls (p = 0. The symptoms of ‘schizophrenia’ in cases with organic brain disease are often of a paranoid-hallucinatory type, with retention of rapport and warmth, and a more benign course than that associated with ‘true’ schizophrenia. One female with schizotypy known to the author has harassed many physicians, despite negative testing, in an effort to prove that her schizophrenic son has coeliac disease. Videos of schizophrenic patients taken during childhood have been interpreted as showing an excess of negative affect (Walker ea, 1993) or differences on measures of sociability and general neuromotor function from controls. The risk for schizophrenia is increased in the close relatives of patients with frontotemporal dementia. In a study using both twins and siblings, Picchioni ea (2010) found that schizophrenia was significantly associated with deficits in social adjustment and personality during childhood and adolescence and additive genetic effects best explained these phenotypic correlations. Johnstone ea (2005) examined high risk young adults with a strong family history of schizophrenia and found that those who later developed schizophrenia were socially anxious, withdrawn, and had other schizotypal features. Thirty cases of schizophrenia arose between ages 16 to 43 years, giving a cumulative risk of 0. The latter reached milestones, especially walking, later, had more speech problems, low educational test 1112 scores , solitary play preferences, less social confidence, and more social anxiety. Health visitors rated their mothers as having below average mothering skills and understanding of their children. Reports of less syntactically complex speech in premorbid children are contradictory, positive reports perhaps detecting state characteristics. In a 45-year follow-up study in Denmark (Sørensen ea, 2010) people who developed psychiatric diagnoses other than schizophrenia reached most developmental milestones earlier than did those with a diagnosis of schizophrenia but later than did controls (people who were never admitted to a psychiatric department) and the two patient groups differed significantly for the age at which they could walk unsupported. This finding is supported by a Finnish report of a failure to progress in education despite early academic normalcy. A study of draftees in Israel (Davidson ea, 1999) found that adolescents who later received a diagnosis of schizophrenia had poor social and intellectual functioning, as well as low organisational ability. They attributed this phenomenon to the prodromal effects of psychotic illness rather than to problems encountered in utero or around the time of birth. It is likely that young people at high genetic risk for schizophrenia perform poorly on all tests of intellectual function and memory. Cannon ea (2001) found that suspiciousness, sensitivity, and peer relationship problems among attendees at a child psychiatric department to be predictive of schizophrenia in adulthood. A follow-up of the 1966 birth cohort from Northern Finland to age 34 (Isohanni ea, 2006) found that impaired performance (e. Combining high-risk status with cognitive disturbance may prove useful in predicting transition to psychosis. The Bonn Scale for the Assessment of Basic Symptoms has been used to detect prodromal schizophrenia. In one study (Werry ea, 1991) only 61% of childhood onset cases of schizophrenia retained this diagnosed on follow up, the others being rediagnosed as bipolar disorder, schizoaffective disorder, or other psychoses. Insidious onset, poor premorbid functioning, and absence of prominent affective symptoms were found to predict diagnostic continuity as schizophrenia. Hollis (2003b) reported that premorbid social impairment was more common in early-onset schizophrenia than in other early-onset psychoses; overall, impaired premorbid development, enuresis and incontinence during psychosis were specifically associated with the negative psychotic symptom dimension. Childhood-onset schizophrenia is associated with the same eye-tracking dysfunction as that reported in adult schizophrenia. Owever, Bakalar ea (2009) followed up 49 right-handed childhood onset cases of schizophrenia (mean baseline age 14. Less than one in a hundred people with schizophrenia had this diagnosis as children. Commoner causes of psychosis in childhood are major depressive disorder, bipolar affective disorder, and severe cases of dissociation, as may be found in posttraumatic stress disorder. There may be suspiciousness, paranoid thinking, unresisted obsessionality, illusions (including somatosensory), depersonalisation/derealisation, and 1119 occasional transient quasi-psychotic episodes with little or no external provocation. Nevertheless it is often viewed as part of a ‘schizophrenic spectrum’, along with (very variably) schizophrenia, schizoaffective disorder, paranoid personality disorder (Hans ea, 2004), other non- affective psychoses, and psychotic affective illness. Features of this disorder can be found in relatives of patients with disorders other than schizophrenia or schizotypal (personality) disorder, especially in association with affective disorder, although schizotypal symptoms appear to be particularly common in the relatives of schizophrenic patients. Neuroimaging studies using schizotypal patients suffer from various methodological shortcomings (e. The 1121 onset if often insidious , the person becoming more withdrawn and introverted, avoiding friends, losing drive, dropping out of activities, and developing an interest in subjects like psychoanalysis, occultism or 1117 Once labelled as having ‘latent’ or ‘borderline’ schizophrenia (as were schizoid personalities).
Brain stimulation Several mechanisms of neuronal plasticity can be techniques and medication might add additional identified: benefit buy discount keppra line medicine 5443. Vicariation describes the hypothesis that func- Dysphagia occurs in the acute state of stroke in tions of damaged areas can be taken over by more than 50% of patients purchase keppra uk treatment under eye bags, probably leading to different regions of the brain order 500mg keppra amex medications contraindicated in pregnancy. In the central nervous system of the ventions generic keppra 250 mg amex medications 44334 white oblong, for example modification of bolus volume adult, however, this mechanism is reduced, but and viscosity, and rehabilitative techniques, such as not absent. Diaschisis describes the phenomenon that a focal Patients admitted with tracheostomy often also need lesion may also lead to changes in brain func- intense dysphagia management. Spasticity can be treated with physiotherapy, nursing care and occupational therapy. If physical Neuroplasticity can be supported by: treatment reaches a limit, oral agents, intrathecal A multidisciplinary team in a structured setting. Treatment in a stroke unit has been shown to For the treatment of spatial neglect, perception improve the outcome significantly (number via the affected side is enforced as much as possible needed to treat 7 for thrombolysis versus 9 for and additional alertness training as well as visual and stroke unit treatment). Only team of medical, nursing and therapy staff, opti- a few pilot studies have been published to evaluate mal timing and early initiation (i. Pharmacological interventions: in preliminary studies, some medications such as levodopa 5. Brain plasticity: from pathophysiological mechanism for recovery and rehabilitative training. Mechanisms for recovery of motor function interaction, and physical activity as determinants of following cortical damage. Curr Opin Neurobiol 2006; functional outcome after cerebral infarction in the rat. Noninvasive cortical representations in primary motor cortex following stimulation in neurorehabilitation: a review. Pattern-specific role of the current orientation used Use-dependent alterations of movement to deliver theta burst stimulation. Clin Neurophysiol representations in primary motor cortex of adult 2007; 118(8):1815–23. Influence of Training-induced changes of motor cortex somatosensory input on motor function in patients representations in stroke patients. Vicarious function within the human stroke survivors with severe motor loss of the upper primary motor cortex? Functional neuroimaging studies of motor recovery after stroke in adults: a review. Brain 2003; Inactive and alone: physical activity within the first 126(Pt 6):1430–48. The Immediate constraint-induced movement therapy Rivermead Mobility Index: a further development of causes local hyperthermia that exacerbates cerebral the Rivermead Motor Assessment. Balance in elderly exacerbate brain damage after focal brain ischemia in patients: the “get-up and go” test. Early ambulation training: a randomized controlled and long-term outcome of rehabilitation in stroke pilot study. Arch Phys Med Rehabil 2002; patients: the role of patient characteristics, time of 83(9):1258–65. Timing of initiation of rehabilitation after Neurorehabil Neural Repair 2000; 14(1):13–19. Retention of upper limb with body weight support: effect of treadmill speed and function in stroke survivors who have received practice paradigms on poststroke locomotor recovery. Repetitive task training for through body weight support and treadmill improving functional ability after stroke. Whole-body intensive rehabilitation on stroke outcomes: what is the rehabilitation is feasible and effective in chronic stroke evidence. In Barnes M, Dobkin B, Bougousslavsky J, survivors: a retrospective data analysis. Robot-assisted gait training in multiple exercise capacity and walking capacity in adult sclerosis: a pilot randomized trial. Water-based exercise for cardiovascular re-training for higher-level gait disorders in fitness in people with chronic stroke: a randomized cerebrovascular disease. Task-related stroke survivors in the early stages of rehabilitation: circuit training improves performance of a randomized study. J Rehabil Res Dev 2001; locomotor tasks in chronic stroke: a randomized, 38(1):69–78. Exercise hemiparetic stroke patients: a randomized controlled training in a predominantly African-American group trial. Arch Phys Med Rehabil 1990; function in subacute stroke: a randomized controlled 71(9):649–54. Effect of constraint-induced movement Intensive language therapy in chronic aphasia: which Chapter 20: Neurorehabilitation aspects contribute most? Intensity of aphasia screening for acute-stroke patients: the Gugging therapy, impact on recovery. Long-term stability of improved language für die Diagnostik und Therapie von Patienten mit functions in chronic aphasia after constraint-induced neurologischen Schluckstörungen. Nervenarzt endoscopic examination of swallowing safety: 2009; 80(2):149–50, 152–4. Current to the brain improves word-finding review on the efficacy and safety of botulinum toxin-A difficulties in aphasic patients. Dysphagia after stroke: contralateral neglect by neck muscle vibration and incidence, diagnosis, and pulmonary complications. Shindo K, Sugiyama K, Huabao L, Nishijima K, first cerebral infarction: a population-based study. Compensatory visual field training for syndrome after stroke: a prospective clinical trial. Students are expected to master basic principles and theo- ries as well as to obtain suffcient knowledge and experience to practice medicine. The education must convey the continually expanding body of medical science and prepare students for a lifetime of competent and thoughtful interactions with patients at a time of rapid change in technol- ogy and societal needs. To meet these educational goals, schools of medicine must be at once conservative and creative. They may often seem overly conser- vative, but this can be attributed to the physician’s painfully acquired distrust of panaceas. There is a generally accepted need to preserve certain fundamental principles—the axiom, for example, that the rational practice of medicine rests on a frm understanding of the basic medical sciences. Yet the great advances in medicine, the need to reasonably limit the number of years of formal education, the increasing number and complexity of special felds, and the diversity of interests and talents among students all demand continual examination of our educational aims and process.
This practice may be associated with Candida blood infection with cutaneous purchase genuine keppra on line 7r medications, eye and osteoarthritic consequences order 500 mg keppra otc treatment in spanish. An injection leads to intense pleasure keppra 250 mg visa symptoms bone cancer, flushing generic keppra 500 mg treatment plan for depression, itching (histamine release), slowed breathing, lowered body temperature, hypotension, and bradycardia, followed by drowsiness giving way to sleep. This effect wears away quite soon however, and any attempt to stop the drug is met with withdrawal symptoms. Three types of opiate receptor2381 μ (mu) κ (kappa) Δ (delta) Short-term use reduces noradrenergic neuronal activity in the locus coeruleus - mu (μ) opioid receptors activate the same potassium ion conductance as the alpha-2-adrenoceptors. Clonidine reduces noradrenaline release and ameliorates some aspects of the abstinence syndrome. Opiate abstinence syndrome Starts 4 - 6 hours after last dose of heroin May last for over a week Anxiety, fear, restlessness Sleep disturbance for days (heroin) to weeks (methadone) Mydriasis Rhinorrhoea, lacrimation, sneezing Aches and pains ‘Cold turkey’ or ‘clucking’: excess perspiration with goosefleshing of the skin Abdominal cramps, diarrhoea, anorexia, loss of weight, dehydration and insomnia Sudden leg spasms explain the term to ‘kick’ a habit, i. Opiate withdrawal is dangerous if the patient has an accompanying significant somatic disorder such as cardiac disease. Rifampicin increases methadone elimination and can likewise induce opiate abstinence symptoms. Whilst found widely in the nervous system it is concentrated in dorsal root ganglia of the spinal cord and in ventral striatum. Needle sharing is a highly dangerous and common habit (even in those collecting sterile needles from official outlets) and some injectors may attend only once. Unfortunately, needle exchange has been used by police to target drug users for arrest in some countries. Other opiate antagonists may induce withdrawal states in established opiate users (e. The use of a narcotic antagonist during pregnancy carries the risks of spontaneous abortion, early labour, or stillbirth. Clonidine exacerbates the central depressant effects of other sedatives, including alcohol. Clonidine adverse effects Dry mouth and dry eyes Fatigue, sedation, dizziness Nausea, constipation Hypotension Uncommon - insomnia, anxiety and depression Rare - vivid dreams, nightmares, and hallucinations Fluid retention may occur, necessitating diuretic therapy Ghodse ea (1994) found clonidine to be of no value as an adjunct to gradual opioid detoxification. Another α-2 adrenergic agonist, lofexidine, a failed anti-hypertensive and structural analogue of clonidine, has been used to ameliorate the withdrawal symptoms from opioids. It does not share clonidine’s effects on blood pressure but the blood pressure should be monitored. According to Lingford-Hughes,(2002) lofexidine can be employed in outpatients but clonidine should be used in hospital. Acetorphan Inhibits peptidases responsible for enkephalin breakdown 2387 Many practitioners administer a naloxone challenge prior to prescribing naltrexone, e. Naltrexone- induced withdrawal can usually be ameliorated with alpha-2 adrenergic agonists (clonidine or lofexidine) and, if required, other medications such as benzodiazepines. Higher doses, just as with methadone, may be more effective in reducing craving and blocking euphoria from additional opiate intake. Buprenorphine, a partial opioid agonist, slowly dissociates from opioid receptors, which may be used to antagonise the effects of other opioids and to offer a more gradual withdrawal from this class of drugs. Conflicting results have been reported concerning the value of electro-acupuncture in the management of withdrawal from opioids. There is some evidence that methadone may lessen the euphoria induced by illicit opiate use (so-called ‘agonal blockade’) for as long as 72 hours. Whether or not a patient should be kept on daily or twice-daily methadone is a complex issue and is best decided after a thorough knowledge of the individual has been gained. It is safer to underdose at the start, although higher doses (say 60-80 mgs) in the long run may ensure better retention in treatment. Two-fifths of methadone deaths in Manchester during the period 1985-94 were in people prescribed the drug, and the death rate from methadone increased eight times over those years. Also, while methadone prescribing may reduce other opiate use, it has no effect on cocaine use. It is important to avoid mixed agonist-antagonist drugs such as pentazocine and butorphanol in this population because they can precipitate abstinence symptoms in opiate-dependent individuals. If a 2393 painkiller is required, the patient should be prescribed a short-to-medium-acting opioid, like oxycodone (Oxycontin) or morphine, and continued on the usual methadone dosage. It can be given once daily for managing opioid addiction but needs to be given every 6 to 8 hours for pain relief. If there is no response after a total of 10 mgs naloxone the diagnosis should be reconsidered. Respiratory depression may return after the action of naloxone wanes, so continued monitoring is mandatory. It is often used postoperatively (epidural), when it has been reported to cause a psychotic state with hallucinosis. Buprenorphine has also been used as an opiate substitute because it is associated with less physical dependence and toxicity than methadone. Sublingual preparations are ‘often injected’ and use of the drug can give rise to abstinence effects because of its ‘higher affinity than methadone for opiate receptors’. While all of these are associated with occasional abuse, only meprobamate and the barbiturates will be considered further. Meprobamate: Marketed first in the 1950s, meprobamate is a derivative of the muscle relaxant 2403 mephanesin. Restrictions on benzodiazepine prescribing in New York State led to an increase in prescriptions for the more toxic meprobamate! In overdose it formed a lump or bezoar in the stomach, which, if not extracted by gastroscopy, could break up and cause a second relapse into a comatose state. Barbiturates (Barbs, Goof Balls): Barbiturates are metabolised by the hepatic microsomal enzyme (P450) system and metabolites are mainly excreted through the kidneys. The medical uses of these drugs are dwindling: prophylaxis in convulsive states, general anaesthesia, and, possibly, abreaction. Their use as a hypnotic in narcosis or a sedative in very disruptive patients is now very rare. It is therefore important to withhold this drug until at least mild abstinence symptoms occur. Phenytoin, an anticonvulsant, is ineffective in 2404 preventing seizures secondary to barbiturate withdrawal. If a patient has become dependent on opiates and barbiturates or other sedative-hypnotic agents should be kept on the opiate until withdrawn from the sedative-hypnotic. Older people on barbiturates for many years (a rarity today) should not be forced to undergo heroic detoxification if their dependence is not causing problems. Short-acting and long-acting barbiturates can be detected in urine for 1 day and 3 weeks respectively. Estimated cocaine use over the previous 12 months in Europe and 15-64-year-olds rose from 3. According to Farren (2008) 1% of the Irish population used cocaine during the last month and lifetime use increased from 2. Cocaethylene is a toxic metabolite of cocaine 2406 that is produced in the presence of alcohol; simultaneous users of alcohol and cocaine report enhanced euphoria; as well as cardiotoxicity, there may also be a propensity to violence. Low doses of cocaine may cause toxicity in the presence of congenital pseudocholinesterase deficiency.
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