By A. Temmy. Indiana University - Purdue University, Indianapolis. 2018.

Mansfeld notes that: Whilst previously cozaar 25 mg sale, these countries had been satisfed with using seized opium for their domestic opiate needs cheap 50 mg cozaar with visa, in recent years they have sought to sell seized opiates, or products derived from them internationally. Diversion to illicit market The levels of leakage into the illicit market vary greatly from country to country. Country quotas are set using offcial estimates of interna- tional demand using fgures from the past two years’ consumption. However, according to offcial fgures, ‘even in these countries only 24% of moderate to severe pain-relief 145 need was being met’. There is a real issue here regarding the access of pain relief by developing world countries that do not have a licence to grow poppies. International legal framework The international licensing control system seeks to permit and regulate legitimate production and use, while at the same time prevent diversion to the illicit market for non-medical use. Domestic legal framework arrangements Each of the countries that grows opium poppies for export has its own set of legal frameworks in order to prevent diversion into the illicit market. United Kingdom Farmers do not need a licence for poppy growing; however, the police must be informed of the location. The Home Offce confrms this: Although we do not licence growers, we do issue them with a letter confrming that we are aware that growing is taking place at their farm and detailing the locations. We advise each grower to produce a copy of this letter to their local police station in order that they may be aware of what is taking place. Anyone can grow opium poppies because the process itself is not controlled by the Misuse of Drugs Act 1971, but any processing of the plant to extract the opiates is controlled and can only be carried out 146 under licence. Farmers must also have obtained a security clearance from Tasmania Police and provided a detailed plan of the cultivation site. Licences are issued annually for a crop year which commences from 1st October and ends on 30th September of the following year. For this purpose, the central government announces a Minimum Qualifying Yield of a certain number of kilos of 150 opium per hectare. In 2001 there were only fve provinces in which opium poppies were licitly grown compared to 13 in 1933; the limit was reduced in order to manage the scale of production. Discussion Expanded production of opium and derived products under the existing framework is clearly both feasible and non-problematic. It is likely that the expansion of legally regulated opiate use would initially take place within existing medical prescription models—in- deed this process is already underway, albeit slowly. More signifcant shifts from illicit to licit production (be it via more substantial expan- sion of prescribing models, or some other appropriate form of licensed sales, see: page 25) would take place incrementally over a number of years allowing for a manageable transition period during which the relevant regulatory and enforcement infrastructure could be developed or expanded, with any emerging challenges responded to. As this phased process continues demand for illicit products will correspondingly diminish, and with it the economic incentives for diversion or illicit production to occur. This raises potentially signif- cant development issues for Afghanistan which currently produces an 151 D. Legal production of both does take place but, compared to the legal production of opium, it is on a much smaller scale and there is much less publicly available information— indeed the whole process is somewhat shrouded in secrecy. Coca leaves as a favouring agent The 1961 Convention specifcally allows for de-cocainised coca leaves to 154 be used as a favouring agent. In the case of Coca-Cola, coca leaves are purchased from South American suppliers by the American conglom- erate, Stepan Chemicals Company. Separation of the cocaine and favouring involves a fairly elab- orate process in which the leaf is ‘ground up, mixed with sawdust, soaked in bicarbonate of soda, percolated with toluene, steam blasted, mixed with 155 powdered Kola nuts, and then pasteurized’. A number of smaller product brands also use coca favouring, many (unlike Coca-Cola) specifcally building their marketing around the 156 coca leaf being an ingredient, despite their drinks having no active coca-derived content. Cocaine-based pharmaceuticals There is relatively little information in the public domain about the production and use of pharmaceutical cocaine for medical use. No fgures are available regarding the balance of global production (from the de-cocainised leaf based favourings process), or demand, or whether there is any leakage into the illicit market at any point during the coca/ cocaine production process. In practice, cocaine now has relatively few mainstream medical 155 ‘The Legal Importation of Coca Leaf’, University of Illinois, Class module 9. Its former role in anaesthesia has been progressively displaced by newer, more effective synthetically derived alternatives including Novocaine, Lidocaine and Xylocaine. Under the 1961 Single Convention, countries that legally produce coca and cocaine are expected to have established an agency to control and oversee the cultivation of coca and production of cocaine. Peru also manufactures a small amount of raw cocaine to 162 be exported to other countries for the production of medical cocaine. This statement understandably caused outrage in Bolivia and Peru where coca leaf chewing is a long established tradition amongst 159 The use of various coca preparations in South America as a traditional medicine in various forms remains widespread. The traditional use of coca leaf has increasingly become a political fashpoint in the international arena, as such long established cultural and traditional indigenous practices have collided with the prerogatives of Western governments determined to stamp out the source of illicit cocaine production that exists in parallel with sources for traditional use.

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Synthesis and precursors A number of methods for synthesizing synthetic can- * Howlett et al generic cozaar 50mg with amex. The resulting total area under cannabis world buy discount cozaar 50 mg online, making it the most widely produced illicit drug. The Cannabis herb is mostly produced for domestic or calculations were based on the minimum and maximum regional markets, whereas cannabis resin is trafficked levels from reported cultivation and production, seizures over larger distances. In 2010, these indicators did sources by the cannabis resin consumer markets are not show significant changes that would justify an Afghanistan, Morocco, Lebanon and Nepal/India. Therefore, the severe deficiencies in the data, which were extensively production estimates were not updated for this World described in former World Drug Reports and is reflected Drug Report. In the 2009 World Drug Report, it was trends found in the last year, with a focus on trends in estimated that the production of cannabis herb ranged potency. The results of the first cannabis The amount of cannabis herb produced in the United survey in 2009 indicated that Afghanistan is among the States is unknown but believed to be high and rising. The prelimi- lands by foreign criminal groups (attributed to Cauca- nary 2010 survey gave no indications for major changes sian, Asian, Cuban and Mexican criminal groups/drug in the levels of cultivation and production compared to trafficking organizations. It showed a cultivation range of 9,000 to 29,000 believed to be increasing as well; however, the number hectares, compared to 10,000-24,000 hectares in 2009. Cannabis production in Europe is believed to be This suggests that Morocco continued to be a major 31 in creasing, mostly in indoor settings and increasingly producer of cannabis resin. Herbal cannabis in Europe suggest that the supply of cannabis resin from is now commonly produced inside Europe (29 Euro- Morocco to the region has remained the same or slightly pean countries reported domestic cultivation in 2008), decreased. Note: The boundaries and names shown and the designations used on thismap do not imply official endorsement or acceptance by the United Nations. This is attributed to the increas- show a growth trend similar to that of sinsemilla. The ingly common use of improved breeds, indoor cultiva- level in the Netherlands increased from 20% to almost tion and the use of sophisticated techniques. Although 40% in the early 2000s, after which it dropped to around these techniques were already available in the 1980s, the 30% during 2005-2010. Reports of cannabis sei- countries that provided information about the country zures refer mainly to cannabis herb and cannabis resin, of origin of cannabis herb trafficked in their territories, but also cannabis plant, cannabis oil and cannabis seed. For these countries, on while seizures of cannabis resin are concentrated mainly average 75% of all herb originated from their own coun- try. The fact regional as well as intra-regional variation, even when that production of cannabis resin occurs to a large extent adjusted for purchasing power parity. Retail prices in countries removed from the main consumer markets appear to be driven both by the availability of cannabis brings about the necessity for trafficking of cannabis herb, which is in turn linked to domestic production resin across different regions, in contrast with the more levels, as well as the disposable income of consumers. Overall, prices were significantly lower in Africa and in Central and South America and the Caribbean. Some of Cannabis herb the lowest prices were registered in Togo, India, Guate- Following a slight drop (8%) in 2008, in 2009, global mala and the United Republic of Tanzania, while the cannabis herb seizures returned to the levels of 2006 and highest price was registered in Japan. North America accounted some of these countries could be partly due to high production, but income levels likely also play a signifi- for 70% of global seizures, followed by Africa (11%), cant role. Similarly, the price in Japan may be high South America (10%), Asia (6%) and Europe (3%). The other 11 countries pointed to their own country without specifying the proportion. Canada reported that increases in both Mexico and the United States, which Asian organized crime groups continued to specialize in continued to report the largest cannabis herb seizures cannabis cultivation while Indo-Canadian and East worldwide. Large quantities of cannabis herb are pro- European organized crime groups were involved in duced in Mexico and trafficked to the United States. Seizures in the United States rose to a record level of 2,049 mt in 2009, up by one third on the previous year, Large quantities of cannabis herb, as well as cannabis and a similar increase was registered in Mexico, with plants, continued to be seized in South America. Sei- seizures rising from 1,658 mt in 2008 to 2,105 mt in zures in this region peaked at 946 mt in 2007 and since 2009. The largest seizures were registered in Colombia, Seizures in Mexico were made mainly close to the areas where seizures declined from 255 mt in 2008 to 209 mt, of cultivation or close to the border with the United and in Brazil, where seizures also fell, from 187 mt in States. In relative terms, a significant increase Durango, Chihuahua and Sonora accounted for 75% of was registered in the Bolivarian Republic of Venezuela, cannabis herb seizures, while Sinaloa, Chihuahua and where seizures rose by 58% in 2009, reaching 33 mt – Durango accounted for 76% of eradication, with the the highest level since 1990. The reported quan- the United States is partly locally produced and partly tities, which include predominantly cannabis plant, trafficked into the country from Mexico as well as, to a amounted to 320 kg in 1998, 28 mt in 2004 and 1,937 smaller extent, from Canada. For the purposes of aggregation, one cannabis plant is assumed to have a weight of 2,500 100 grams. Africa Seizures of cannabis herb in Africa have fluctuated con- siderably in recent years, but have followed a generally decreasing trend since the peak level of 2004. In 2009, Morocco, Egypt, 223 mt total seizures in Africa fell to 640 mt, from 936 mt in 63 mt 2008. Nigeria, Although cannabis herb continues to be trafficked 115 mt South Africa, throughout Africa, seizures tend to be concentrated in a 126 mt small number of countries. Morocco continued to seize large quantities of ‘kif,’ In 2007 and 2008, the largest annual seizures of can- selected parts of herbal cannabis which can be further nabis herb in Africa were reported by Nigeria.

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Total area under coca cultivation in 2010 is based on the 2009 figure for Bolivia and will be revised once the 2010 figure becomes available generic 50 mg cozaar amex. For Colombia quality cozaar 50 mg, the series without adjustment for small fields was used to keep comparability. Cultivation of coca from being primarily concerned with the area under bush decreased in all major growing regions of the coun- coca cultivation to getting a better understanding of try. The Pacific region remained the region with the how much cocaine is being produced. This is partly due largest coca cultivation, representing 42% (25,680 ha) to more appreciation of the fact that eradication, whether of the national total, followed by the Central (25% or carried out manually or by aerial spraying, does not 15,310 ha) and Meta-Guaviare regions (14% or 8,710 necessarily translate into a corresponding reduction of 1 ha). The impact of eradication carried out between date A and date B may or may not be seen by Table 22: Approaches to measure coca comparing the area under coca at these two points in cultivation (ha), 2010 time but it will certainly be noticeable in the coca yield Net cultivation Productive coca as farmers lose harvests or have to replant their fields. Total area under coca cultivation in 2010 is based on the 2009 figure for Bolivia and will be revised once the 2010 figure becomes coca cultivation is considered for the number of months available. An Peru, the area estimated from satellite imagery represents increasing proportion of coca was cultivated on small the average coca cultivation situation in the second half fields. This raised concerns because the type of satellite of the year, and it is used directly to estimate produc- imagery used to detect coca fields in Colombia works tion. Thus, a study using very high resolution imagery was conducted to determine the proportion of coca grown Efforts are being made in all three countries to improve on fields below the 0. Based on this the cocaine production estimates and the concepts of the net area and the productive area - detailed below - are an important part of that process. The lack of precise measure- adjustment for 68,000 57,000 -16% ments of laboratory efficiency in the different countries small fields increases the level of uncertainty, but does not affect the With adjustment trend, which shows a clear decline in global cocaine 73,000 62,000 -15% for small fields production since 2007. This adjustment allows for the inclusion of coca already reached efficiency levels comparable to Colom- cultivated fields that are smaller than the detectable 3 bia. Thus, in other parts of this Report, the upper end threshold, and thereby improves the accuracy of the coca of the global cocaine production range has been area estimate in Colombia. This, despite the uncertainty associated with the In 2010, the area under coca cultivation was estimated estimate, is considered to be a better approximation of at 57,000 ha without the adjustment for small fields. To facilitate a comparison with 2009, the 2009 figure was also corrected, from 68,000 ha without Cocaine production in Peru has been going up since to 73,000 ha with the adjustment for small fields. Coca leaf Peru yields in Colombia have been regularly studied and In Peru, in 2010, the area under coca cultivation updated since 2005, and part of the decline in Colom- amounted to 61,200 ha, a 2% increase (+1,300 ha) on bian cocaine production is due to declining yields. However, Peru, on the other hand, information on coca leaf yields the coca-growing regions showed diverging cultivation dates back to 2004, and for some of the smaller cultivat- trends. Upper Huallaga, the largest growing region in ing regions, which experienced significant increases in recent years, experienced a strong decline of almost the area under coca, no information on region-specific coca leaf yields is available. In Apurímac-Ene, lenges involved in estimating the yield of new or reacti- the second largest growing region until 2009, a signifi- vated coca fields as opposed to mature, well-maintained cant increase in the area under coca of more than 2,200 ones, as well as the effects of continued eradication pres- ha was registered, and with 19,700 ha, it became the sure. As noted above, there are indications that the level largest growing region in 2010. Colombia Some smaller growing regions such as Aguatiya and Inambari-Tambopata, which have experienced a signifi- Cocaine production in Colombia decreased to 350 mt cant increase in the area under coca in recent years, in 2010. The drop since 2005 is the result of a decrease remained relatively stable in 2010. Within this framework, about the comparability of the estimates between coun- several studies analysed coca leaf to cocaine conversion methods. There are also indications of structural amounted to almost 155,000 mt, an increase by 16%. Unlike in the Plurinational State of Bolivia and that it happened despite an overall decline in coca leaf Peru, where farmers sun-dry the coca leaves to increase production in Colombia over this period. What could lead farmers to stop 24% of the coca leaf produced in that year was sold as processing coca leaves themselves and sell them instead? The estimated amount of coca leaf produced on 12,000 ha in the Yungas of La Paz where coca cultivation is authorized under national law, was deducted. Range: Upper and lower bound of the 95% confidence interval of coca leaf yield estimate. In the case of Bolivia and Peru, the ranges are based on confidence intervals and the best estimate is the mid-point between the upper and lower bound of the range. In the case of Colombia, the range represents the two approaches taken to calculate the productive area, with the lower bound being closer to the estimation used in previous years. The methodology to calculate uncertainty ranges for production estimates is still under development and figures may be revised when more information becomes available. Total 1,020 1,034 1,024 865 * * * Due to the ongoing review of conversion factors, no point estimate of the level of cocaine production could be provided for 2009 and 2010. Because of the uncertainty about the level of total potential cocaine production and about the comparability of the estimates between countries, the 2009 and 2010 figures were estimated as ranges (842-1,111 mt and 786-1,054 mt, respectively). Due to the introduction of an adjustment factor for small fields, 2010 estimates are not directly comparable with previous years.

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The social cost for patients with borderline personality disorder and their families is sub- stantial proven cozaar 25mg. Longitudinal studies of patients with borderline personality disorder indicate that even though these patients may gradually attain functional roles 10–15 years after admission to psy- chiatric facilities cozaar 50 mg visa, still only about one-half will have stable, full-time employment or stable mar- riages (40, 134). Recent data indicate that patients with borderline personality disorder show greater lifetime utilization of most major categories of medication and of most types of psycho- therapy than do patients with schizotypal, avoidant, or obsessive-compulsive personality dis- order or patients with major depressive disorder (135). The additional use of assessment instruments can be useful, especially when the diagnosis is unclear. Certain assessment issues relevant to all personality disorders should be considered when di- agnosing borderline personality disorder. For the diagnosis to be made, the personality traits must cause subjective distress or significant impairment in functioning. The traits must also deviate markedly from the culturally expected and accepted range, or norm, and this deviation must be manifested in more than one of the following areas: cognition, affectivity, control over impulses, and ways of relating to others. The clinician should also ascertain that the personality traits are of early onset, pervasive, and enduring; they should not be transient or present in only one situation or in response to only one specific trigger. It is important that borderline personality disorder be assessed as carefully in men as in women. The ego-syntonicity of the personality traits may complicate the assessment process; the use of multiple sources of information (e. Given the high comorbidity of axis I disorders with borderline personality disorder, it is important to do a full axis I evaluation. Useful approaches are to obtain a description of the patient’s personality traits and coping styles when prominent axis I symptoms are absent and to use information provided by people who have known the patient without an axis I disorder. If axis I disorders are present, both the axis I disorders and borderline personality disorder should be diagnosed. Because the personality of children and adolescents is still developing, borderline personal- ity disorder should be diagnosed with care in this age group. Often, the presence of the disorder does not become clear until late adolescence or adulthood. When assessing a patient with borderline personality disorder, the clinician should carefully look for the presence of risk-taking and impulsive behaviors, mood disturbance and reactivity, risk of suicide, risk of violence to persons or property, substance abuse, the patient’s ability to care for himself/herself or others (e. However, some features of borderline personality disorder may overlap with those of mood disorders, complicating the differential diagnostic assessment. However, in borderline per- sonality disorder, the mood swings are often triggered by interpersonal stressors (e. Depressive features may meet criteria for major depressive disorder or may be features of the borderline personality dis- order itself. Depressive features that appear particularly characteristic of borderline personality disorder are emptiness, self-condemnation, abandonment fears, self-destructiveness, and hope- lessness (91, 92). It can be particularly difficult to differentiate dysthymic disorder from bor- derline personality disorder, given that chronic dysphoria is so common in individuals with borderline personality disorder. In other cases, what appear to be features of borderline personality disorder may constitute symptoms of an axis I disorder (e. A more in-depth consideration of the differential diag- nosis or treatment of the presumed axis I condition may help clarify such questions. Although borderline personality disorder may be comorbid with dissociative identity disorder, the latter (unlike borderline personality disorder) is characterized by the presence of two or more distinct identities or personality states that alternate, manifesting different patterns of behavior. It is present in 10% of individuals seen in outpatient mental health clinics, 15%–20% of psychi- atric inpatients, and 30%–60% of clinical populations with a personality disorder. Borderline personality disorder is diagnosed predominantly in women, with an estimated gender ratio of 3:1. It is approximately five times more common among first-degree biological relatives of those with the disorder than Treatment of Patients With Borderline Personality Disorder 43 Copyright 2010, American Psychiatric Association. There is also a greater familial risk for substance-related disorders, antisocial personality disorder, and mood disorders. Early adulthood is often characterized by chronic instability, with episodes of serious affective and impulsive dyscontrol and high levels of use of health and men- tal health resources. Later in life, a majority of individuals attain greater stability in social and occupational functioning. In the largest follow-up study to date (137), about one-third of patients with borderline per- sonality disorder had recovered by the follow-up evaluation, having solidified their identity during the intervening years and having replaced their tendency toward self-damaging acts, in- ordinate anger, and stormy relationships with more mature and more modulated behavior pat- terns. Longitudinal studies of hospitalized patients with borderline personality disorder indicate that even though they may gradually attain functional roles 10–15 years after admis- sion to psychiatric facilities, only about one-half of the women and one-quarter of the men will have attained enduring success in intimacy (as indicated by marriage or long-term sexual part- nership) (137). One-half to three-quarters will have by that time achieved stable full-time em- ployment. These studies concentrated on patients with borderline personality disorder from middle-class or upper-middle-class families. Patients with borderline personality disorder from backgrounds of poverty have substantially lower success rates in the spheres of intimacy and work. Despite these somewhat favorable outcomes, the suicide rate among patients with bor- derline personality disorder is high—approximately 9%.

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For about one in ten boys cheap cozaar 25 mg fast delivery, the original hole opens up again generic 50 mg cozaar with amex, so that your son passes urine through two holes. This can happen at any point after the operation, and will need to be fxed in an operation. Occasionally, the new hole at the tip of the penis becomes too small as it heals and your son will need another operation to make the hole larger. Your child will recover from the anaesthetic and operation on the ward and will be able to eat and drink soon afterwards, if he feels like it. When he comes back from the operating theatre, there will be thin, plastic tube (catheter) draining urine from your child’s bladder and a large dressing covering the penis; usually these will both need to stay in place for one week. The drainage tube can irritate the inside of the bladder, causing ‘bladder spasm’, but we can give your child some medicine to reduce this as well as pain relief medicine. Usually paracetamol (Calpol® or Disprol®) will be enough to relieve any pain if you give it every four to six hours for the next day. Please see the table in our pain relief advice leafet and check with your nurse the medicines to give and when they should be given. The nursing staff will explain how to look after the dressing and drainage tube before you go home. Baths and showers should be avoided until after the dressing and drainage tube are removed. If the dressing gets dirty during nappy changing, gently dab off any urine or faeces with a damp cloth. Putting your son in two nappies, one on top of the other will help to keep the dressing dry. It can also give valuable padding to the healing area and prevent accidental knocks. You will need to come back to the hospital a few days after the operation so that the dressing and drainage tube can be removed. This can be painful, so on the morning your are coming in to have the dressing removed, give your son the maximum amount of pain relief according to the instructions on the bottle, but do not give any bladder spasm medicine. When the dressing has been removed, the penis will look red and swollen; this is normal and it will settle down within a few days. The doctor will see you and your child for a check up about three months after the operation. How to contact us If you have any questions or concerns about the information in this leafet, you may telephone: Tom’s ward (01865) 234108 or 234109 Further information http://www. The new journal is designed to promote better patient care by serving the expanded needs of all health professionals committed to the care of patients with diabetes. As such, the American Diabetes Association views Diabetes Care as a reaffirmation of Francis Weld Peabody’s contention that “the secret of the care of the patient is in caring for the patient. 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Requests for permission to translate should be sent to Permissions Editor, American Diabetes Association, at permissions@diabetes. The American Diabetes Association reserves the right to reject any advertisement for any reason, which need not be disclosed to the party submitting the advertisement. Commercial reprint orders should be directed to Sheridan Content Services, (800) 635-7181, ext. Single issues of Diabetes Care can be ordered by calling toll-free (800) 232-3472, 8:30 A. Rates: $75 in the United States, $95 in Canada and Mexico, and $125 for all other countries. Cardiovascular Disease and Risk S3 Professional Practice Committee Management S4 Standards of Medical Care in Diabetes—2017: Hypertension/Blood Pressure Control Summary of Revisions Lipid Management S6 1. Promoting Health and Reducing Disparities in Antiplatelet Agents Populations Coronary Heart Disease Diabetes and Population Health S88 10. 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