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By T. Dan. Northwest Missouri State University. 2018.

Chemotherapy in locally advanced nasopharyngeal carcinoma: an individual patient data meta-analysis of eight randomized trials and 1753 patients cheap 50mg solian fast delivery. The additional value of chemotherapy to radiotherapy in locally advanced nasopharyngeal carcinoma: a meta-analysis of the published literature order 50mg solian fast delivery. Results of a prospective randomized trial comparing neoadjuvant chemotherapy plus radiotherapy with radiotherapy alone in patients with locoregionally advanced nasopharyngeal carcinoma generic 50mg solian with amex. A prospective, randomized trial comparing neoadjuvant chemotherapy with radiotherapy alone in patients with advanced nasopharyngeal carcinoma. Preliminary report of the Asian-Oceanian Clinical Oncology Association randomized trial comparing cisplatin and epirubicin followed by radiotherapy versus radiotherapy alone in the treatment of patients with locoregionally advanced nasopharyngeal carcinoma. A randomized trial on addition of concurrent- adjuvant chemotherapy and/or accelerated fractionation for locally-advanced nasopharyngeal carcinoma. Local control, survival, and late toxicities of locally advanced nasopharyngeal carcinoma treated by simultaneous modulated accelerated radiotherapy combined with cisplatin concurrent chemotherapy: long-term results of a phase 2 study. Cisplatin and 5-fluorouracil continuous infusion for metastatic nasopharyngeal carcinoma. Surveillance for recurrent head and neck cancer using positron emission tomography. Here are some things they would like you to know: n Tere are treatment choices—be sure to know them all. I chose radiation therapy because we thought it was the best choice for my situation. After talking with several doctors who specialize in prostate cancer, we decided that surgery was the best choice for me. And while it is good to have choices, this fact can make the decision hard to make. Yet, each choice has benefts (how treatment can help) and risks (problems treatment may cause). While you are waiting for treatment, you should meet with different doctors to learn about your treatment choices. Use this booklet to help you talk over treatment choices with your doctor before deciding which is best for you. After all, having prostate cancer and the treatment choice you make affect both of you. Its purpose is to help you learn about early-stage prostate cancer, diferent treatments, and the benefts and risks of each type of treatment. Most men will need more information than this booklet gives them to make a decision about treatment. For a list of groups that provide more information and support, please see the Ways to Learn More section on page 32. Also, see that section if you have prostate cancer that has spread beyond the prostate or that has returned after treatment. Semen is the milky fuid that carries sperm from the testicles through the penis during ejaculation. Te prostate surrounds part of the urethra, the tube that carries urine out of the bladder and through the penis. This means that it can take 10 to 30 years before a prostate tumor gets big enough to cause symptoms or for doctors to fnd it. Most men who have prostate cancer will die of something other than prostate cancer. Each has benefts (how treatments can help) and risks (problems treatment may cause). Te choice of treatment depends on many factors: n Your prostate cancer risk group. Doctors use details about your cancer to place you into a low-, medium-, or high-risk group. Having heart problems, diabetes, or other illnesses may affect your treatment options. The skills and experience of specialists and types of treatment available in your area may vary. You will need to ask tough questions to make sure you receive the best possible care. Your unique experiences in life shape your feelings and thoughts about how to deal with prostate cancer. Here are some things to think about: • How do you view the benefts and risks of the treatment choices that have been offered to you? Even though the treatment choice is yours, involving your spouse, partner, or other loved ones can help you sort out what is most important to you and your family. As we discussed on pages 4 and 5, your doctor will take into account your general health, the results of your tests and exams, and the Gleason score of your cancer when talking with you about your treatment choices.

Their supplies are purchased from a criminal dealing/traffcking infrastructure that can be traced back to illicit production in Afghanistan generic solian 50 mg line. The second uses legally manufactured and prescribed pharmaceutical heroin of known strength and purity in a supervised clinical setting order 50mg solian overnight delivery, with clean injecting paraphernalia order 50 mg solian fast delivery. There is no criminality, profteering or violence involved at any stage of the drug’s production supply or use, no blood borne disease transmission risk, a near zero risk of overdose death, and no offending to fund use. Signifcantly, with this example no speculative modelling is required; these two individuals coexist in a number of countries, where legal heroin maintenance is available alongside the parallel illicit trade. While efforts to disaggregate drug risks/harms from policy risks/ harms are of vital importance in taking the policy discourse forward, there are demonstrable social and secondary risks/harms associated with drug use. They fow specifcally from the nature of a given drug’s effects, and relate to intoxication related behaviours, the propensity for 78 4 5 6 Making a regulated system happen Regulated drug markets in practice Appendices dependency, and harms that can result from dependency related behav- iour. Risks/harms associated with driving, operating machinery or similar whilst competence is impaired by drug use should be included. However, it is not always appropriate for fne tuning policy responses for specifc sub-populations or individuals. As they currently stand, drug harm assessments and rankings can help with such generalisations. We have tried to point out some of the factors that can support such fne tuning; these are demonstrably not present in existing generalised three or four tiered systems. Such systems are frequently oversimplifed, and both unaware of and unresponsive to sub-cultural population behaviours. They also confate a number of harm vectors whose rankings are demonstrably different. In terms of public health education, current, former, and potential drug users, as well as non-drug users, need tailored information about drug risks and the potential harms they face as individuals. Such information should be responsive to the very different needs of, for example, a healthy 18 year old wondering about ecstasy, a 26 year old with a history of psychotic illness using cannabis, a 36 year old diabetic concerned about cocaine, or a 66 year old with hypertension considering their alcohol use. Each and every user needs to be able to understand the risks they person- ally run using a particular drug, at a particular dose, at a particular 39 frequency, administered in a particular way, in a given setting. They need to fnd ways of making the complexity that has been alluded to above understandable and accessible to a broad population. In partic- ular, they need to address those who are the most vulnerable to drug related harm, but often the hardest to reach. The detail of how this challenge is best tackled is beyond the scope of this publication, but from this discussion it is clear that the key variables, or vectors of drug harms, need to be separated, quantifed and ranked independently. These include: acute and chronic toxicity, propensity for dependency (both physiological and psychological), issues relating to dosage, potency, frequency of use, preparation of drug and mode of administration, individual risk factors including physical and mental health, age and pharmacogenetics, and behavioural factors including setting of drug use, and poly drug use. It is important to understand at what political level such choices and legislation should take place. In prin- ciple, they do not signifcantly differ from similar issues in other arenas of social policy and law dealing with currently legal medical and non- medical drugs. On this basis, we suggest below how new drug legislation and management could be integrated into and managed by a range of different kinds of political bodies, running from the international to the intensely local. They would provide the foundation, ground rules and parameters within which individual states can operate, as well as offering guidance and providing a central hub for international drug research and data collection. This would set basic standards of justice and human rights that would have—as a baseline—implications for the use of punitive sanctions against drug users, although they would 81 1 2 3 Introduction Five models for regulating drug supply The practical detail of regulation neither impose nor preclude issues around legal access/supply, or internal domestic drug trade. This would all sit within the parameters and targets established by the national government, and by implication broader interna- tional law. Similar frameworks are already well established in a number of countries with regards to licensing of alcohol sales. The federal/state power dynamic generally sees responsibility for most serious crimes falling to federal govern- ment with flexibility over less serious crimes and civil offences falling to state authorities. Its importance has been driven more by a desire to deal frmly with a perceived ‘evil’, and be seen to be doing so, than by a desire to engage directly with a very challenging and complex set of health and social issues. The need to justify such an 40 Federal and international law, however, currently prevents exploration of options for 82 legal regulation of non-medical supply. Directly and indirectly, it has encouraged research to be skewed towards demonstrating drug harms, in order to justify and support punitive responses to the ‘drug threat’. This focus on research that justifes frm, punitive action has led to an avoidance of policy research that meaningfully evaluates and scrutinises the actual outcomes of prohibition. There is, therefore, a clear need to shift the research agenda away from its historical skew towards medical research of drug toxicity and addic- tion, and towards meaningful policy research. Of course, it remains very important to fully explore and understand drug related health harms.

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It is also used for initiating treatment in patients transferring from methadone solian 50mg without a prescription, in preference to products containing naloxone buy 50 mg solian with amex, because of the risk of precipitating withdrawal in these patients trusted 100 mg solian. Extended- 380mg/vial disorder Act release injectable naltrexone is recommended to prevent relapse to opioids or alcohol. The prescriber need not be a physician, but must be licensed and authorized to prescribe by the state. Acamprosate Alcohol Delayed-release tablet: Not Provided by prescription; use 333mg Scheduled acamprosate is used in the disorder under the maintenance of alcohol Controlled abstinence. The prescriber need Substances not be a physician, but must Act be licensed and authorized to prescribe by the state. Disulfram Alcohol Tablet: Not When taken in combination with use 250mg, 500mg Scheduled alcohol, disulfram causes severe disorder under the physical reactions, including Controlled nausea, fushing, and heart Substances palpitations. The knowledge that Act such a reaction is likely if alcohol is consumed acts as a deterrent to drinking. For these reasons, only appropriately trained health care professionals should decide whether medication is needed as part of treatment, how the medication is provided in the context of other clinical services, and under what conditions the medication should be withdrawn or terminated. Prescribed in this fashion, medications for substance use disorders are in some ways like insulin for patients with diabetes. Insulin reduces symptoms by normalizing glucose metabolism, but it is part of a broader disease control strategy that also employs diet change, education on healthy living, and self-monitoring. A chemical substance that use of methadone as an effective treatment for opioid use binds to and activates certain receptors disorder. Long-term methadone maintenance treatment for opioid use disorders has been shown to be more effective than short-term withdrawal management,132 and it has demonstrated improved outcomes for individuals (including pregnant women and their infants) with opioid use disorders. Under regulations dating back to the early 1970s, the federal government created special methadone programs for adults with opioid use disorders. Originally referred to as “methadone treatment programs,” these treatment facilities were created to provide special management of the medical and legal issues associated with the use of this potent, long-acting opioid. Many people, including some policymakers, authorities in the criminal justice Drug diversion. A medical and legal system, and treatment providers, have viewed maintenance concept involving the transfer of any treatments as “substituting one substance for another”85 and legally prescribed controlled substance from the person for whom it was have adhered instead to an abstinence-only philosophy that prescribed to another person for any avoids the use of medications, especially those that activate illicit use. Moreover, withholding medications greatly increases the risk of relapse to illicit opioid use and overdose death. For individuals who are already on a stable low to moderate dose of buprenorphine, the implant delivers a constant low dose of buprenorphine for 6 months. Buprenorphine is associated with improved outcomes compared to placebo for individuals (including pregnant women and their infants) with opioid use disorders,140 and it is effective in reducing illegal opioid use. As a result, there is an upper limit to how much euphoria, pain relief, or respiratory depression buprenorphine can produce. However, if the combined medication is injected, the naloxone component can precipitate an opioid withdrawal syndrome, and in this way serves as a deterrent to misuse by injection. When they frst receive their waiver, physicians can provide buprenorphine treatment for only up to 30 individuals. Although approximately 435,000 primary care physicians practice medicine in the United States,148 only slightly more than 30,000 have a buprenorphine waiver,149 and only about half of those are actually treating opioid use disorders. Naltrexone is an opioid antagonist that binds to opioid receptors and blocks their activation; it produces no opioid-like effects and is not abusable. It prevents other opioids from binding to opioid receptors so that they have little to no effect. It also interrupts the effects of any opioids in a person’s system, precipitating an opioid withdrawal syndrome in opioid-dependent patients, so it can be administered only after a complete detoxifcation from opioids. Naltrexone may be appropriate for people who have been successfully treated with buprenorphine or methadone who wish to discontinue use but still be protected from relapse; people who prefer not to take an opioid agonist; people who have completed detoxifcations and/or rehabilitation or are being released from incarceration and expect to return to an environment where drugs may be used and wish to avoid relapse; and adolescents or young adults with opioid dependence. Oral naltrexone can be effective for those individuals who are highly motivated and/or supported with observed daily dosing. Extended-release injectable naltrexone, which is administered on a monthly basis, addresses the poor compliance associated with oral naltrexone since it provides extended protection from relapse and reduces cravings for 30 days. Prescribing health care professionals should be familiar with these side effects and take them into consideration before prescribing. Thus, once disulfram is taken by mouth, any alcohol consumed results in rapid buildup of acetaldehyde and a negative reaction or sickness results. The intensity of this reaction is dependent on the dose of disulfram and the amount of alcohol consumed. Disulfram is most effective when its use is supervised or observed, which has been found to increase compliance. Thus, an individual who wants to reduce, but not stop, drinking is not a candidate for disulfram.

Sedation is unlikely to be acceptable to a student but an older patient with insomnia may welcome this side effect cheap 100 mg solian mastercard. However generic 100 mg solian amex, once the interval is decreased to 3 times a day there is a sharp drop in adherence which deteriorates further on a 4 times a day regimens cheap solian 100mg on line. Use one of the following: Weight Dose Susp Capsule Age kg mg 125mg 250mg 250 500 Months/years /5mL /5mL mg mg ˃8 months–7 ˃11–25 kg 250 mg 10 mL 5 mL 1 cap – years ˃25 kg 500 mg – – 2 caps 1 cap ˃7 years Adults  Amoxicillin, oral, 500 mg 8 hourly for 5 days. Commonly presents as painful creamy white patches that can be scraped off the tongue and buccal mucosa. Risk factors for candida include: » poor oral hygiene » immunosuppression (may be responsible for severe cases of oral thrush) » prolonged use of broad spectrum antibiotics or corticosteroids (including inhaled) » certain chronic diseases, e. It is characterised by: » foul smelling breath » necrosis and sloughing of the gum margin, especially of the interdental papillae » loss of gingiva and supporting bone around teeth » presence of underlying disease, e. Children < 15 years of age 2  Aciclovir, oral, 250 mg/m /dose, 8 hourly for 7 days. Children > 15 years of age and adults  Aciclovir, oral, 400 mg, 8 hourly for 7 days. Symptoms often associated with teething include: » fretfulness » biting or chewing on hard objects » drooling, which may often begin before teething starts » gum swelling and tenderness » refusing food » sleeping problems Teething is not a cause of severe or systemic symptoms, such as high fever or diarrhoea. Exclude conditions other than teething in infants who are systemically unwell or in distress. Advise caregivers to seek medical advice if the infant becomes systemically unwell. Do not use local oral anaesthetic preparations in infants, as these have been associated with severe adverse events. A thorough evaluation is necessary to exclude a surgical abdomen or other serious conditions. The history should include: » duration, location, type, radiation and severity of pain » relieving or aggravating factors e. These conditions often present with epigastric discomfort and minimal change in bowel habits. Caused by organisms spreading through the wall of the anus into peri-anal soft tissues. Clinical features include: » rice water appearance of stools: – no blood in stools – no pus in stools – no faecal odour » possible vomiting » rapid severe dehydration Note: Prevent and treat dehydration. In all children who are able to take oral medication  Zinc (elemental), oral for 14 days: o If < 10 kg give 10 mg/day. The volume of fluid required for oral rehydration depends on the severity of the dehydration. Antibiotic treatment Children  Ciprofloxacin, oral, 20 mg/kg as a single dose immediately. Constipation may have many causes, including: » incorrect diet (insufficient fibre and fluid) » lack of exercise » pregnancy » old age » medicines, e. The cause of acute diarrhoea cannot be diagnosed without laboratory investigation. Treatment child is reclassified especially » Instruct the as B: Some breastfeeding. Homemade sugar and salt solution is recommended for home use and to prevent dehydration. Age range Dose Capsule Capsule units 100 000 u 200 000 u Infants 6–11 months old 100 000 1 capsule – Children 12 months to 5 years 200 000 2 capsules 1 capsule Administration of a vitamin A capsule o Cut the narrow end of the capsule with scissors. Giardiasis is a common cause of chronic diarrhoea in adults, and may be difficult to diagnose on stools. Therefore empiric treatment for giardiasis is recommended before referring such patients. If there is no clinical response within three days manage as amoebic dysentery or refer for formal assessment. Antibiotic therapy Indicated for: » Children > 1 year of age and adults with blood in the stools. Infestation may be caused by: » beef tapeworm – Taenia saginata » pork tapeworm – Taenia solium 2. Type of worm Description Signs and symptoms Common Roundworm » Long pink/white worms with » Cough. Short-term treatment with proton pump inhibitors, H2-receptor antagonists and prokinetics for gastro-oesophageal reflux disease-like symptoms and endoscopy negative reflux disease. Zinc supplementation for preventing mortality, morbidity, and growth failure in children aged 6 months to 12 years of age. Group for Enteric, Respiratory and Meningeal disease Surveillance in South Africa.

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Their value is enhanced if they contain comparisons between drugs discount 50 mg solian overnight delivery, evaluations and cost information discount solian 100 mg otc, but that is often not the case cheap 100mg solian fast delivery. Drug bulletins These periodicals promote rational drug therapy and appear at frequent intervals, ranging from weekly to quarterly. Drug bulletins can be a critical source of information in helping prescribers to determine the relative merits of new drugs and in keeping up-to-date. Drug bulletins can have a variety of sponsors, such as government agencies, professional bodies, university departments, philanthropic foundations and consumer organizations. They are published in many countries, are often free of charge, and are highly respected because of their unbiased information. A good independent drug bulletin in French is Prescrire; it is not free of charge. National drug bulletins are appearing in an increasing number of developing countries, which include Bolivia, Cameroon, Malawi, the Philippines and Zimbabwe. The main advantages of national drug bulletins are that they can select topics of national relevance and use the national language. Medical journals Some medical journals are general, such as The Lancet, the New England Journal of Medicine or the British Medical Journal; others are more specialized. The specialized journals include more detailed information on drug therapy for specific diseases. You can usually check whether journals meet this important criterion by reading the published instructions for submission of articles. They are usually glossy and often present information in an easily digestible format. They can be characterized as: free of charge, carrying more advertisements than text, not published by professional bodies, not publishing original work, variably subject to peer review, and deficient in critical editorials and correspondence. They sometimes report on commercially sponsored conferences; in fact, the whole supplement may be sponsored. Only a relatively small proportion publish scientifically validated, peer reviewed articles. If in doubt about the scientific value of a journal, verify its sponsors, consult senior colleagues, and check whether it is included in the Index Medicus, which covers all major reputable journals. Verbal information Another way to keep up-to-date is by drawing on the knowledge of specialists, colleagues, pharmacists or pharmacologists, informally or in a more structured way through postgraduate training courses or participation in therapeutic committees. Community based committees typically consist of general practitioners and one or more pharmacists. In a hospital setting they may include several specialists, a clinical pharmacologist and/or a clinical pharmacist. Using a clinical specialist as the first source of information may not be ideal when you are a primary health care physician. In many instances the knowledge of specialists may not really be applicable to your patients. Some of the diagnostic tools or more sophisticated drugs may not be available, or needed, at that level of care. Drug information centres Some countries have drug information centres, often linked to poison information centres. Health workers, and sometimes the general public, can call and get help with questions concerning drug use, intoxications, etc. Many major reference data bases, such as Martindale and Meylers Side Effects of Drugs, are now directly accessible 89 Guide to Good Prescribing through international electronic networks. Cartoon 5 When drug information centres are run by the pharmaceutical department of the ministry of health, the information is usually drug focused. Centres located in teaching hospitals or universities may be more drug problem or clinically oriented. Computerized information Computerized drug information systems that maintain medication profiles for every patient have been developed. Some of these systems are quite sophisticated and include modules to identify drug interactions or contraindications. Some systems include a formulary for every diagnosis, presenting the prescriber with a number of indicated drugs from which to choose, including dosage schedule and quantity. If this is done, regular updating is needed using the sources of information described here. In many parts of the world access to the hardware and software needed for this technology will remain beyond the reach of individual prescribers. In countries where such technology is easily accessible it can make a useful contribution to prescribing practice. However, such systems cannot replace informed prescriber choice, tailored to meet the needs of individual patients.

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In addition best solian 100 mg, they can cause other side effects such as dry eyes order solian 50 mg with visa, a dry mouth and constipation discount 50 mg solian visa. If you need to pass urine a lot during the night, your doctor may recommend that you take a desmopressin tablet before you go to bed. This causes you to pass a large amount of urine before you go to bed, which makes it less likely that you will need to get up during the night. Complementary therapies Some men fnd that herbal remedies, such as saw palmetto and red stinkwood (African plum), help to control their symptoms. There are studies that show that some herbal remedies may improve symptoms of an enlarged prostate. However, we don’t know whether herbal remedies affect other medicines you may be taking. We need more research before herbal remedies can be recommended as a treatment for an enlarged prostate. Many companies make claims that are not based on proper research, and there may be no real evidence that they work. Remember that a product is not necessarily safe simply because it is called ‘natural’. Just as with conventional medicines, herbal remedies can interfere with your enlarged prostate treatment. There is no evidence at the moment to suggest that acupuncture or homeopathy can help control symptoms of an enlarged prostate. It is very important that you tell your doctor if you are taking any kind of herbal or complementary medicine. Reporting unusual side effects: The Yellow Card Scheme If you think you are experiencing a side effect from a medicine or herbal remedy that is not mentioned in the information leafet that comes with it, then you can report it using the Yellow Card Scheme. There are three ways you can report a side effect: • use the online Yellow Card form at www. There are several different types of surgery available for treating an enlarged prostate. There are some other less common procedures that are usually only available as part of a clinical trial or through private healthcare. They include: • photoselective vaporisation of the prostate • minimally invasive surgery, such as transurethral needle ablation or transurethral microwave therapy • transurethral vaporisation resection of the prostate. The types of surgery available will vary from hospital to hospital depending on the training and experience of the doctors. The types of surgery available to you may also depend on the size of your prostate and any other health problems you have. Your doctor or nurse will discuss the advantages and disadvantages of each type of surgery they offer, to help you decide what is right for you. Although many men fnd surgery effective, some men will not see a signifcant improvement in their symptoms after surgery. The tube has a small camera on the end so that the surgeon can get a good view of the prostate. They then pass an electrically-heated wire loop through the tube and use it to remove small pieces of prostate tissue. During the operation, fuid is passed into your bladder to clear away the small pieces of prostate tissue that have been removed. You will have a catheter to drain urine from your bladder for two to three days after surgery. Before you go home, your nurse will remove your catheter and check that you are passing urine easily. If you have any of these symptoms after surgery, tell your doctor or nurse straight away. The pieces of prostate tissue that are removed pass into the bladder and are removed with a different instrument. You will either be asleep during the operation (general anaesthetic) or you will be awake but unable to feel anything in the area being Specialist Nurses 0800 074 8383 prostatecanceruk. After surgery, you will have a catheter to drain urine from your bladder for 12 to 24 hours. An electric current is passed into a roller ball (like a computer mouse ball) and this heats up the prostate tissue blocking the urethra, causing it to burn away. You will either be asleep during the operation (general anaesthetic) or awake but unable to feel anything in the area being operated on (spinal anaesthetic). After surgery, you may have a catheter to drain urine from your bladder for 9 to 24 hours.

Whether physiological and psychological dependence should be pooled together in rank- ings remains a moot point—as does the question of whether ‘addiction’ remains a useful term solian 50 mg with amex, as opposed to dysfunctional discount 100mg solian mastercard, problematic or dependent use order 100mg solian otc. Alexander, ‘The Globalisation of Addiction: A Study in Poverty of the Spirit’, Oxford University Press, 2008. In particular, risk assessment is made more diffcult by the wide variation in physiological and psychological makeup of individual drug users. Key variables include general phys- ical and mental health, and age (young and old are more vulnerable). Specifc physical and mental health conditions can have a major impact on individual risk, and pharmacogenetic factors can also cause vulner- abilities to certain drug harms in certain individuals. This is largely unaccounted for by broadly generalised drug harm categories and rankings. Clearly, a small amount of a Class A or Schedule 1 drug will be less risky than a large dose of a drug from a lower schedule. However, in a regu- lated market, with standardised products and packaging information, the specifc risks of unknown potency (and in particular, of unexpectedly high potency) will largely be removed. The issue of relative potency- related risk has probably been overstated as users, if possessed of the requisite dosage information, will rationally dose control to regulate their own risk exposure—or auto-titrate, to achieve the level of intoxica- tion they are seeking. The nature of the drug preparation, how the drug is administered, and the physical and social/peer environment in which consumption takes place are also crucially important linked variables in determining risk. This is usefully illustrated with the example of coca based drugs—from 76 4 5 6 Making a regulated system happen Regulated drug markets in practice Appendices chewed coca leaf, through coca drinks, snorted cocaine powder, to smoked crack cocaine (see: page 120). It is worth noting that the risk of lung damage can be signifcantly reduced if the drug can be inhaled in a vaporised form,36 rather than as smoke from a burning process. By contrast to the seconds associated with injection, this is lower intensity and gives some degree of control over dosage. Some drugs, including tobacco and coca leaf are held in the mouth and absorbed through the gums. The reform position is substantially predicated on the observation that both health and secondary social drug risks/harms are increased in the context of illicitly controlled production and supply, and illicit using environments. Whilst there is a great deal of complexity in teasing out these relative risks/harms, the broader point is simply illustrated with a real world example. Compare two injecting heroin users; the frst is committing high volumes of property crime and street sex work to fund their illicit habit. They are using ‘street’ heroin (of unknown strength and purity) with dirty, often shared needles in unsafe environments. Their supplies are purchased from a criminal dealing/traffcking infrastructure that can be traced back to illicit production in Afghanistan. The second uses legally manufactured and prescribed pharmaceutical heroin of known strength and purity in a supervised clinical setting, with clean injecting paraphernalia. There is no criminality, profteering or violence involved at any stage of the drug’s production supply or use, no blood borne disease transmission risk, a near zero risk of overdose death, and no offending to fund use. Signifcantly, with this example no speculative modelling is required; these two individuals coexist in a number of countries, where legal heroin maintenance is available alongside the parallel illicit trade. While efforts to disaggregate drug risks/harms from policy risks/ harms are of vital importance in taking the policy discourse forward, there are demonstrable social and secondary risks/harms associated with drug use. They fow specifcally from the nature of a given drug’s effects, and relate to intoxication related behaviours, the propensity for 78 4 5 6 Making a regulated system happen Regulated drug markets in practice Appendices dependency, and harms that can result from dependency related behav- iour. Risks/harms associated with driving, operating machinery or similar whilst competence is impaired by drug use should be included. However, it is not always appropriate for fne tuning policy responses for specifc sub-populations or individuals. As they currently stand, drug harm assessments and rankings can help with such generalisations. We have tried to point out some of the factors that can support such fne tuning; these are demonstrably not present in existing generalised three or four tiered systems. Such systems are frequently oversimplifed, and both unaware of and unresponsive to sub-cultural population behaviours. They also confate a number of harm vectors whose rankings are demonstrably different. In terms of public health education, current, former, and potential drug users, as well as non-drug users, need tailored information about drug risks and the potential harms they face as individuals. Such information should be responsive to the very different needs of, for example, a healthy 18 year old wondering about ecstasy, a 26 year old with a history of psychotic illness using cannabis, a 36 year old diabetic concerned about cocaine, or a 66 year old with hypertension considering their alcohol use. Each and every user needs to be able to understand the risks they person- ally run using a particular drug, at a particular dose, at a particular 39 frequency, administered in a particular way, in a given setting. They need to fnd ways of making the complexity that has been alluded to above understandable and accessible to a broad population. In partic- ular, they need to address those who are the most vulnerable to drug related harm, but often the hardest to reach.

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