By A. Tizgar. Niagara University.
In a small study in which skills training alone was compared with a no-skills training control condition generic kamagra 50mg with visa, no difference was found be- tween the groups (unpublished 1993 study of M kamagra 50mg amex. The research- ers concluded that the specific features of individual dialectical behavior therapy are necessary for patients to show greater improvement than control groups. Linehan and Heard (150) re- ported that more time with therapists does not account for improved outcome. Nonetheless, other special features of dialectical behavior therapy, such as the requirement for all therapists to meet weekly as a group, could contribute to the results. The patients with borderline personality disorder exhibited improvement in depression, hopeless- ness, and suicidal ideation, but the improvement was not greater than it was for a control group. In this study, compared with control subjects, patients receiving the dialectical behavior therapy treatment showed a paradoxical increase in parasuicidal acting out during the brief hospitalization (average length of stay was 12. Barley and colleagues (152) compared dialectical behavior therapy received by patients with borderline personality disorder on a specialized personality disorder inpatient unit with treat- ment as usual on a similar-sized inpatient unit. They found that the use of dialectical behavior therapy was associated with reduced parasuicidal behavior. It is unclear whether improvement was due to dialectical behavior therapy per se or to other elements of the specialized unit. Perris (153) reported preliminary findings from a small uncontrolled, naturalistic follow-up study of 13 patients with borderline personality disorder who received cognitive behavior ther- apy similar to dialectical behavior therapy. Twelve patients were evaluated at a 2-year follow-up point, and all patients maintained the normalization of functioning that had been evident at the end of the study treatment. Other controlled studies reported in the literature of cognitive behavior approaches are dif- ficult to interpret because of small patient group sizes or because the studies focused on mixed types of personality disorders without specifying borderline cohorts (154–156). Treatment of Patients With Borderline Personality Disorder 51 Copyright 2010, American Psychiatric Association. In summary, there are a number of studies in the literature suggesting that cognitive behavior therapy approaches may be effective for patients with borderline personality disorder. Most of these studies involved dialectical behavior therapy and were carried out by Linehan and her group. Replication studies by other groups in other centers are needed to confirm the validity and generalizability of these findings. Instead, longer forms of treatment, such as “schema-focused cognitive therapy” (147), “complex cognitive therapy” (144), or dialectical behavior therapy (17), are usually recommended. The standard length of dialectical behavior therapy is approximately 1 year for the most commonly administered phase of the treatment. It involves 1 hour of individual therapy per week, more than 2 hours of group skills training per week (for either 6 or 12 months), and 1 hour of group process for the therapists per week. Other versions of dialectical behavior therapy, such as that administered in a brief inpatient setting (151), may be useful but are not necessarily more effective than other forms of inpatient treatment. For example, as Linehan (17) pointed out, focusing on “therapy-interfering behavior” is similar to the psychodynamic emphasis on trans- ference behaviors. Beck and Freeman (19) noted that cognitive therapists and psychoanalysts have the common goal of identifying and modifying “core” personality disorder problems. However, psychodynamic therapists view these core problems as having important unconscious roots that are not available to the patient, whereas cognitive therapists view them as largely in the realm of awareness. It is not clear how successfully psychiatrists who have not been trained in cognitive behavior therapy can imple- ment manual-based cognitive behavior approaches. Although dialectical behavior therapy has been well described in the literature for many years, it is not clear how difficult it is to teach to new therapists in settings other than that where it was developed. Variable results in other settings could be due to a number of factors, such as less enthusiasm for the method among therapists, differences in therapist training in dialectical behavior therapy, and different patient populations. Although the Linehan group has developed training programs for therapists, certain characteristics recommended in dialectical behavior therapy (e. Group therapy a) Goals The goals of group therapy are consistent with those of individual psychotherapy and include stabilization of the patient, management of impulsiveness and other symptoms, and examina- tion and management of transference and countertransference reactions. Groups provide special opportunities for provision of additional social support, interpersonal learning, and diffusion of the intensity of transference issues through interaction with other group members and the ther- apists. In addition, the presence of other patients provides opportunities for patient-based lim- it-setting and for altruistic interactions in which patients can consolidate their gains in the process of helping others. However, these studies had no true control condition, and the efficacy of the group treatment is unclear, given the complexity of the treatment received. Another small chart review study of an “incest group” for patients with borderline personality disorder (159) suggested shorter subsequent inpatient stays and fewer outpatient visits for treated patients than for control subjects. A randomized trial (160) involving patients with borderline person- ality disorder showed equivalent results with group versus individual dynamically oriented psy- chotherapy, but the small sample size and high dropout rate make the results inconclusive. This quasi-experimental, nonrandomized study showed that patients with borderline personality disorder discharged from a day program with continuing outpa- tient group therapy (N=12) did better than those who did not have group therapy (N=31). There were, however, important differences between the two compar- ison groups that could account for outcome differences. Perhaps the most interesting aspect of group therapy is the use of groups to consolidate and maintain improvement from the inpatient stay. Linehan and colleagues (8) combined individ- ual and group therapy, making the specific effect of the group component unclear. They re- ported that, contrary to expectations, the addition of group skills training to individual dialectical behavior therapy did not improve clinical outcome. Such groups provide a milieu in which their current emotional reactions and self-defeating behaviors can be seen and understood. Groups may also provide a context in which patients may initiate healthy risk-taking in relationships. Group treatment has also been included in studies of psychodynamic psychotherapy; although the overall treatment program was effective, the effectiveness of the group therapy component is unknown (9, 162).
Providers should be obligated to adhere to standards on storing discount 50 mg kamagra visa, reporting and keeping records (including on recommendations and other information provided to customers and on the purchase and sale of all medicines) for a minimum period of two years 100mg kamagra mastercard. Controlled substances should only be sold to customers with valid prescriptions from a medical practitioner; such prescriptions should be in a format (whether on paper or in the form of an e-prescription) that conforms with national legislation. Governments should prohibit the issuance of prescriptions prepared merely on the basis of an online questionnaire or consultation. Prescription drugs should only be pro- vided in the framework of a qualiﬁed medical relationship, which is expected to involve at least one medical examination during which the patient is in the presence of a medical practitioner. Guideline 6: The Board recommends that Governments establish standards and publish guidelines for doctors providing their services to Internet pharmacies on patient evaluation, treatment and consultation, on the issuing of prescriptions and on the maintenance of medical records. Governments are advised to raise the medical community’s aware- ness of the legal requirements, risks and implications with respect to the sale of internationally controlled substances through Internet pharmacies. Legislation concerning internationally controlled substances The prerequisite for adequately controlling internationally controlled substances is the implementation of all the provisions of the international drug control treaties, Commission on Narcotic Drugs resolutions 43/8 and 50/11 and Economic and Social Council resolutions 1981/7 of 8 Guidelines for Governments on Preventing the Illegal Sale of Internationally Controlled Substances through the Internet 6 May 1981, 1985/15 of 28 May 1985, 1987/30 of 26 May 1987, 1991/44 of 21 June 1991, 1993/38 of 27 July 1993, 1996/30 of 24 July 1996 and 2007/9 of 25 July 2007, including the provisions con- cerning international trade (such as the import and export authorization system), the system of estimates for narcotic drugs and the system of assessments for psychotropic substances. Guideline 7: Governments of countries where Internet pharmacies are permitted to dispense internationally controlled substances within and beyond the national territory are advised to evaluate whether their national regulatory and legal controls, including sanctions for offences, are sufficient for ensuring that Internet pharmacies operate in full compliance with the provisions of the three international drug control treaties. Guideline 8: The Board recommends that Governments whose national and regulatory controls are not adequate to prevent and sanction the illegal sale of internationally controlled substances through Internet pharmacies and other websites should adopt corrective measures. General measures Monitoring supply channels Most narcotic drugs and psychotropic substances sold illegally through the Internet are either pharmaceuticals containing controlled substances that have been diverted from licit supply channels (including licit manu- facturing, international trade and domestic distribution channels) or illegally manufactured preparations, i. Counterfeits are manufactured either using diverted raw materials, illegally manufactured base substances or other substances used as substitutes for the original narcotic drug or psychotropic substance. Guideline 9: The Board recommends that Governments assess the ade- quacy of existing regulations on manufacture and trade control, including reporting and inspection systems, identify weaknesses in such control systems and strengthen them if necessary. Information exchange To allow rapid action to be taken against illegal activities carried out through Internet pharmacies, States need to establish effective mecha- nisms that allow information to be exchanged on speciﬁc cases and on the modi operandi adopted by those illegally selling internationally controlled substances, at the national and international levels, through the Internet. Such information exchange should take place between, inter alia, Government ofﬁces and industries involved in Internet services. Guidelines 9 Should assistance be needed, the Board is prepared to support Governments in that respect. Guideline 10: In order to ensure a rapid exchange of data and experiences, Governments are advised to establish mechanisms for sharing information on suspicious transactions with the competent authorities of other States concerned as well as with the Board, through the creation of a single national contact point. Guideline 11: Governments detecting the illegal sale of internationally controlled substances through the Internet are requested to immediately submit information on such sale to the competent authorities of States involved and inform the Board. Guideline 12: The Board recommends that Governments provide informa- tion to the Secretary-General on national laws affecting the activities of Internet pharmacies, such as legal provisions regarding the importation of internationally controlled substances by mail and regulations governing prescription requirements. Guideline 13: Governments are advised to inform industries involved in Internet transactions about the illegal sale of preparations containing internationally controlled substances through the Internet. Guideline 14: Government agencies are advised to establish, in accord- ance with national legislation, relations with industries whose services are misused for the illegal sale of internationally controlled substances through the Internet, such as Internet service providers, postal and courier services and financial services such as banking, credit card and electronic payment services, and request their support in investigating illegal operations. National and international cooperation National cooperation mechanisms Prerequisites for effective national cooperation include the establishment of cooperation mechanisms and the clear identiﬁcation of the role and responsibility of all regulatory and law enforcement ofﬁces and agencies concerned. Guideline 15: The Board recommends that Governments encourage inter- ministerial cooperation on issues regarding the control of Internet pharma- cies and similar websites with a view to developing policies and conducting operational activities within a well-coordinated and focused framework. Such inter-ministerial cooperation should include all the main responsible authorities, including those responsible for health (the 10 Guidelines for Governments on Preventing the Illegal Sale of Internationally Controlled Substances through the Internet ministry of health, the pharmaceutical board or inspectorate etc. Governments are encouraged to ensure that adequate training is available to enable law enforcement ofﬁcers, members of the judiciary and staff of regulatory and drug control authorities to strengthen control of narcotic drugs and psychotropic substances in general and to take action against the illegal sale of internationally controlled substances via the Internet. The speciﬁc ofﬁce or ofﬁces responsible for initiating law enforce- ment and judicial proceedings should be designated and informed as soon as an illicit sale has been detected. Guideline 16: The Board recommends that Governments make efforts to gather information on drug trafficking through the Internet, including on the illegal sale of internationally controlled substances, and consider establishing appropriate control entities, such as “cyberpatrol units”. In a number of countries, speciﬁc police or other law enforcement units are investigating various aspects of cybercrime, including child pornography, Internet fraud, system damages, drug and arms trafﬁcking and terrorism. If Governments are not in a position to establish a special unit dedicated to monitoring the illegal sale of internationally controlled substances through the Internet, general cybercrime units should be charged with monitoring the Internet to detect whether narcotic drugs and psychotropic substances are being sold illegally. Alternatively, Governments could establish special teams charged with investigating drug trafﬁcking, including the illegal sale of internationally controlled substances, through the Internet. To ensure complementarity, authorities should inform each other about such activities. Professional associations such as pharmacy guilds and medical chambers should be encouraged to look for suspicious websites through which medicines are sold and cooperate in investigations. Governments in a position to do so could enlist public support by establishing appropriate websites for public/private cooperation and national and international telephone hotlines, thus enabling individuals to report any illegal sale of such controlled substances. Governments may want to consider measures for strength- ening cooperation mechanisms that are already functioning successfully in a number of countries. Pharmacists are made available to assist post ofﬁce staff dealing with parcels at all times, either by assigning their presence at the post ofﬁce while on duty or by requiring them to be on call, thus ensuring permanent coverage. Parcels can only enter a country through a limited number of special and properly equipped customs entry points. Customs authorities handling mail are empowered to seize suspicious mail and parcels and initiate investigations. Guideline 18: The Board recommends that Governments alert private postal and courier service providers about the illegal sale of internationally controlled substances through the Internet and give such service providers the information and training they need to identify suspicious shipments. Private postal and courier service providers should be informed about cases involving the illegal sale of internationally controlled substances through the Internet with a view to helping them enhance their screening process by making use of the known addresses of suspicious senders and receivers. Private postal and courier service providers should be informed that suspicious consignments of nationally or internationally controlled sub- stances must be reported immediately to the competent authorities. Guideline 19: The Board recommends that Governments establish coop- eration mechanisms with all industries involved in the sale of controlled substances through the Internet.
Also kamagra 50 mg otc, apart from the baths and showers with which the camps shall be furnished purchase kamagra 100 mg otc, prisoners of war shall be provided with sufficient water and soap for their personal toilet and for washing their personal laundry; the necessary installations, facilities and time shall be granted them for that purpose. Isolation wards shall, if necessary, be set aside for cases of contagious or mental disease. Prisoners of war suffering from serious disease, or whose condition necessitates special treatment, a surgical operation or hospital care, must be admitted to any military or civilian medical unit where such treatment can be given, even if their repatriation is contemplated in the near future. Special facilities shall be afforded for the care to be given to the disabled,in particular to the blind,and for their rehabilitation, pending repatriation. Prisoners of war shall have the attention, preferably, of medical personnel of the Power on which they depend and, if possible, of their nationality. Prisoners of war may not be prevented from presenting themselves to the medical authorities for examination. The detaining authorities shall, upon request, issue to every prisoner who has undergone treatment, an official certificate indicating the nature of his illness or injury, and the duration and kind of treatment received. A duplicate of this certificate shall be forwarded to the Central Prisoners of War Agency The costs of treatment, including those of any apparatus necessary for the maintenance of prisoners of war in good health, particularly dentures and other artificial appliances, and spectacles, shall be borne by the Detaining Power. They shall include the checking and the recording of the weight of each prisoner of war. Their purpose shall be, in particular, to supervise the general state of health, nutrition and cleanliness of prisoners and to detect contagious diseases, especially tuberculosis, malaria and venereal disease. In that case they shall continue to be prisoners of war, but shall receive the same treatment as corresponding medical personnel retained by the Detaining Power. They personnel shall, however, receive as a minimum the benefits and protection of the present Convention, and shall also be granted all facilities necessary to provide for the medical care of, and religious ministration to prisoners of war. They shall continue to exercise their medical and spiritual functions for the benefit of prisoners of war, preferably those belonging to the armed forces upon which they depend, within the scope of the military laws and regulations of the Detaining Power and under the control of its competent services, in accordance with their professional etiquette. They shall also benefit by the following facilities in the exercise of their medical or spiritual functions: a) They shall be authorized to visit periodically prisoners of war situated in working detachments or in hospitals outside the camp. For this purpose, the Detaining Power shall place at their disposal the necessary means of transport. For this purpose, Parties to the conflict shall agree at the outbreak of hostilities on the subject of the corresponding ranks of the medical personnel, including that of societies mentioned in Article 26 of the Geneva Convention for the Amelioration of the Condition of the Wounded and Sick in Armed Forces in the Field of August 12, 1949. This senior medical officer, as well as chaplains, shall have the right to deal with the competent authorities of the camp on all questions relating to their duties. Such authorities shall afford them all necessary facilities for correspondence relating to these questions. During hostilities, the Parties to the conflict shall agree concerning the possible relief of retained personnel and shall settle the procedure to be followed. They shall be allocated among the various camps and labour detachments containing prisoners of war belonging to the same forces, speaking the same language or practising the same religion. They shall enjoy the necessary facilities, including the means of transport provided for in Article 33, for visiting the prisoners of war outside their camp. They shall be free to correspond, subject to censorship, on matters concerning their religious duties with the ecclesiastical authorities in the country of detention and with international religious organizations. Letters and cards which they may send for this purpose shall be in addition to the quota provided for in Article 71. For this purpose, they shall receive the same treatment as the chaplains retained by the Detaining Power. This appointment, subject to the approval of the Detaining Power, shall take place with the agreement of the community of prisoners concerned and, wherever necessary, with the approval of the local religious authorities of the same faith. The person thus appointed shall comply with all regulations established by the Detaining Power in the interests of discipline and military security. Prisoners shall have opportunities for taking physical exercise, including sports and games and for being out of doors. Such officer shall have in his possession a copy of the present Convention; he shall ensure that its provisions are known to the camp staff and the guard and shall be responsible, under the direction of his government, for its application. Prisoners of war, with the exception of officers, must salute and show to all officers of the Detaining Power the external marks of respect provided for by the regulations applying in their own forces. Officer prisoners of war are bound to salute only officers of a higher rank of the Detaining Power; they must, however, salute the camp commander regardless of his rank. Copies shall be supplied, on request, to the concerning prisoners who cannot have access to the copy which has been prisoners posted. Regulations, orders, notices and publications of every kind relating to the conduct of prisoners of war shall be issued to them in a language which they understand. Such regulations, orders and publications shall be posted in the manner described above and copies shall be handed to the prisoners’ representative. Every order and command addressed to prisoners of war individually must likewise be given in a language which they understand. The use of weapons against prisoners of war, weapons especially against those who are escaping or attempting to escape, shall constitute an extreme measure,which shall always be preceded by warnings appropriate to the circumstances. Titles and ranks which are subsequently created shall form the subject of similar communications. The Detaining Power shall recognize promotions in rank which have been accorded to prisoners of war and which have been duly notified by the Power on which these prisoners depend. In order to ensure service in officers’ camps, other ranks of the same armed forces who, as far as possible, speak the same language, shall be assigned in sufficient numbers, account being taken of the rank of officers and prisoners of equivalent status.
There remains 100 mg kamagra mastercard, however discount 100mg kamagra overnight delivery, one key difference between managing legal and illegal drugs. The alcohol and tobacco management improvement process has been able to ask, and to some degree answer, questions about which forms of regulation are most effective. These are ques- tions of vital importance; the current legal framework for most other drugs denies us the opportunity to explore them in the context of those drugs, and thus with the full depth and rigour that they both deserve and demand. A consistent approach to policy across all drugs will help reverse this research gap. It thus holds the prospect of dramatically improving not only policy around currently illegal drugs, but also alcohol and tobacco policy. Some of this research has been alluded to throughout this book; rather than revisit this well established analysis, this brief discussion will focus more on some of the wider themes that have emerged from it, and their implications for other drugs. This value is added to by the various beverages, and sometimes foods, with which it is mixed and consumed. Over and above this, many alcoholic beverages have them- selves assumed cultural roles and importance only tangentially related to their intoxicating effects. For example, they have been used in cooking, or as components of religious rituals. It is For alcohol policy to acknowledged that, for example with wine have an effective future connoisseurs, alcoholic beverages are not it is clear that potentially consumed exclusively for intoxication. With the possible exception of caffeine, alcohol is the most widely used non-medical psychoactive drug. The scale of alcohol use and its global cultural penetration help explain why its negative public health impact is only exceeded by tobacco. If there is any upside to this, it is that a wide spectrum of policy approaches to controlling alcohol have been experimented with, in widely varying social contexts, including unregulated free markets, various formulations of licensed sales, state monopolies, and prohi- bition. These experiments have taken place across the globe and 101 1 2 3 Introduction Five models for regulating drug supply The practical detail of regulation throughout recent history. Thus, in order to be effective, a comprehensive alcohol policy must not only incorporate measures to educate the public about the dangers of hazardous and harmful use of alcohol, or interventions that focus primarily on treating or punishing those who may be putting at risk their own or others’ health and safety, but also must put in place regu- latory and other environmental supports that promote the health of the population as a whole. This is advice that, with some necessary tweaks and variations, clearly describes the approach to drug policy and regulation being more widely advocated here. Indeed, it is often a revealing experience to read author- itative texts about alcohol control policy, changing the words ‘alcohol’ to 54 ‘drugs’, and ‘drinking’ to ‘drug use’. The fundamental confict between public health policy, and alcohol sale and consumption as a commercially driven activity, is a key issue, coming up repeatedly in alcohol policy literature. This issue raises a series of important concerns for the wider drug policy and law reform agenda. The production and sale of alcoholic beverages, together with the ancillary industries, are important 54 For a paired example see: ‘After the War on Drugs: Tools for the Debate’, Transform Drug Policy Foundation, page 16, 2006. These economic and fiscal interests are often an important determinant of policies that can be seen as barriers to public health initiatives. Dissemination of public health research that can counterbalance these economic and fiscal interests is paramount. Alcohol producers and suppliers see alcohol from a commer- cial rather than a public health perspective. They do not bear the secondary costs of problematic alcohol use; quite naturally, their primary motivation is to generate the highest possible profits. This is logically achieved by maximising consumption, both in total popula- tion and per capita terms. Public health issues become a concern only when they threaten to impact on the bottom line, and will invariably be secondary to profit maximisation. They have achieved this by deploying a now familiar menu of high level lobbying, manufactured outrage and populist posturing (the ‘nanny state’ against ‘a man’s right to have a drink after work’ etc. In many countries these efforts have been highly effective at distracting from, or delaying, any meaningful regulatory legislation. In addition, they have often successfully kept what regulation has been passed at a voluntary level, meaning that it can largely be ignored or sidelined to the point of being almost completely ineffectual. Yet this is exactly what is required to address particular issues of binge and problem drinking, and to support the general evolution of a more moderate and responsible drinking culture. It is important to remember that problem- atic and binge drinking constitute a signifcant proportion of alcohol industry profts; they are, quite simply, hugely proftable consumer behaviours. Such concerns have prompted adoption of government monopoly control models for sections of alcohol supply in some coun- 57 tries. Examples include the Systembolaget system in Sweden, under which the state controls all import and supply, and the provincial government control of alcohol off-licences in some Canadian prov- inces (Ontario and Quebec). These models have some similarities to the Regulated Market Model proposed for tobacco (see: page 27). These factors combine with the immense lobbying power of alcohol industry bodies, and the public unpopularity of restricting alcohol sales or increasing prices, to create massive political obstacles to effective reforms. This is the case even when knowledge of what works from a public health perspective (that is, encouraging reduced and/or moderate consumption) is clear. In effect, many governments have been complicit in the growing public health crisis associated with alcohol. For alcohol policy to have an effective future it is clear that poten- tially very unpopular decisions will have to be made that will involve increasing regulation and heavy restrictions on all aspects of marketing and promotions. How such reforms unfold, combined with historic successes and failures in alcohol control, will continue to provide a rich resource for future, legally regulated markets to learn from. It is, however, associated with a disproportionate level of health harms, on a scale that eclipses all other drugs combined. These huge public health impacts are predominantly associated with smoked 58 tobacco; they are related to its high propensity to produce dependency, alongside the fact that it does not intoxicate to a degree that signifcantly impairs functioning.
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