Lesson № 8
Evidence-based medicine and pharmacy. Clinical and
pharmacological safety of prescription and non-prescription drugs. Medical
The essence of evidence-based medicine.
Responsible self-treatment and its
Side effects of the drugs.
Psyche and behavioral health disorders
due to drugs usage without prescription.
essence of evidence-based medicine.
Evidence-based medicine (EBM) (also called evidence-based health care (EBHC)
or evidence-based practice (EBP) to broaden its application
from medicine to the allied health
professions) is "the conscientious, explicit and judicious
use of current best evidence in
making decisions about the care of individual
patients." Trisha Greenhalgh and Anna Donald define it more specifically
as "the use of mathematical estimates of the risk of benefit and harm,
derived from high-quality research on population samples,
to inform clinical decision-making in the diagnosis, investigation or management
of individual patients."
EBM seeks to assess
the strength of the evidence of risks and benefits of treatments (including lack of
treatment) and diagnostic tests. This helps clinicians predict whether a
treatment will do more good than harm.
Evidence quality can
be assessed based on the source type (from meta-analyses and systematic reviews of triple-blind randomized clinical trials with concealment of
allocation and no attrition at the top end, down to conventional wisdom at
the bottom), as well as other factors including statistical validity, clinical
relevance, currency, and peer-review acceptance. EBM recognizes that many
aspects of health care depend on individual factors such as quality- and value-of-life judgments, which are only
partially subject to quantitative scientific methods. Application of EBM data
therefore depends on patient circumstances and preferences, and medical
treatment remains subject to input from personal, political, philosophical,
religious, ethical, economic, and aesthetic values.
medicine (EBM) has evolved from clinical epidemiology, a discipline promoted by
the creation of the Journal
of Clinical Epidemiology in 1988. Clinical epidemiology
aims to bridge the gap between clinical practice and public health using population health
sciences to inform clinical practice. Thus, the methodology that underpins EBM
applies methods used in the field of epidemiology to the clinical context (i.e.
clinical epidemiology). In essence, EBM incorporates this quantitative (as well
as qualitative) methodology in the "art" of clinical practice, so as
to make the framework for clinical decisions more objective by better
reflecting the evidence from research. By introducing scientific
methods – particularly the methods of the population
sciences – in clinical decision making, EBM has driven a
transformation of clinical practice in medicine.
In 1996 David Sackett wrote that
"evidence-based medicine is the conscientious, explicit and judicious use
of current best evidence in making decisions about the care of individual
patients." This definition, put forward by one of the original proponents
of evidence-based medicine, has since been adopted by major organizations,
including the Cochrane
Collaboration and the Centre for Evidence Based Medicine.
Assessing the quality of evidence
medicine categorizes different types of clinical evidence and rates or grades
them according to the strength of their freedom from the various biases
that beset medical research. For example, the strongest evidence for
therapeutic interventions is provided by systematic review of randomized, triple-blind, placebo-controlled
trials with allocation concealment and complete follow-up
involving a homogeneous patient population and medical condition. In contrast,
patient testimonials, case reports, and even expert opinion (however some
critics have argued that expert opinion "does not belong in the rankings
of the quality of empirical evidence because
it does not represent a form of empirical evidence" and continue that
"expert opinion would seem to be a separate, complex type of knowledge
that would not fit into hierarchies otherwise limited to empirical evidence
alone.") have little value as proof because of the placebo effect, the biases
inherent in observation and reporting of cases, difficulties in ascertaining
who is an expert and more.
U.S. Preventive Services Task Force (USPSTF)
Systems to stratify
evidence by quality have been developed, such as this one by the United States Preventive Services Task Force for
ranking evidence about the effectiveness of treatments or screening:
Level I: Evidence
obtained from at least one properly designed randomized
Level II-1: Evidence
obtained from well-designed controlled trials without randomization.
Level II-2: Evidence
obtained from well-designed cohort or case-control analytic studies,
preferably from more than one center or research group.
Level II-3: Evidence
obtained from multiple time series with or without the intervention. Dramatic
results in uncontrolled trials might also be regarded as this type of evidence.
Level III: Opinions
of respected authorities, based on clinical experience, descriptive studies, or
reports of expert committees.
UK National Health Service
The UK National Health
Service uses a similar system with categories labeled A, B,
C, and D. The above Levels are only appropriate for treatment or interventions;
different types of research are required for assessing diagnostic accuracy or
natural history and prognosis, and hence different "levels" are
required. For example, the Oxford Centre for Evidence-based Medicine suggests
levels of evidence (LOE) according to the study designs and critical appraisal of
prevention, diagnosis, prognosis, therapy, and harm studies:
Controlled Clinical Trial, cohort study, all or none (see note below),
clinical decision rule validated in different populations.
Level B: Consistent
Retrospective Cohort, Exploratory Cohort, Ecological Study, Outcomes
Research, case-control study;
or extrapolations from level A studies.
Level C: Case-series study or extrapolations
from level B studies.
Level D: Expert
opinion without explicit critical appraisal, or based on physiology, bench research or first
Categories of recommendations
In guidelines and
other publications, recommendation for a clinical service is classified by the
balance of risk versus benefit of the service and the level of
evidence on which this information is based. The U.S.
Preventive Services Task Force uses:
Level A: Good
scientific evidence suggests that the benefits of the clinical service
substantially outweigh the potential risks. Clinicians should discuss the service
with eligible patients.
Level B: At least
fair scientific evidence suggests that the benefits of the clinical service
outweighs the potential risks. Clinicians should discuss the service with
Level C: At least
fair scientific evidence suggests that there are benefits provided by the
clinical service, but the balance between benefits and risks are too close for
making general recommendations. Clinicians need not offer it unless there are
Level D: At least fair
scientific evidence suggests that the risks of the clinical service outweighs
potential benefits. Clinicians should not routinely offer the service to
Level I: Scientific
evidence is lacking, of poor quality, or conflicting, such that the risk versus
benefit balance cannot be assessed. Clinicians should help patients understand
the uncertainty surrounding the clinical service.
pharmacy is the practice of pharmacy in which the pharmacist makes decisions,
taking into account the best available current research evidence, their
expertise, and the needs and preferences of the patient.
In statistics, a meta-analysis refers
to methods that focus on contrasting and combining results from different
studies, in the hope of identifying patterns among study results, sources of
disagreement among those results, or other interesting relationships that may
come to light in the context of multiple studies. In its simplest form,
meta-analysis is normally done by identification of a common measure of effect size. A weighted average of that
common measure is the output of a meta-analysis. The weighting is related to
sample sizes within the individual studies. More generally there are other
differences between the studies that need to be allowed for, but the general
aim of a meta-analysis is to more powerfully estimate the true effect size as
opposed to a less precise effect size derived in a single study under a given
single set of assumptions and conditions. A meta-analysis therefore gives a
thorough summary of several studies that have been done on the same topic, and
provides the reader with extensive information on whether an effect exists and
what size that effect has.
often, but not always, important components of a systematic review procedure. For
instance, a meta-analysis may be conducted on several clinical trials of a
medical treatment, in an effort to obtain a better understanding of how well
the treatment works. Here it is convenient to follow the terminology used by
Collaboration, and use "meta-analysis" to refer to
statistical methods of combining evidence, leaving other aspects of 'research
synthesis' or 'evidence synthesis', such as combining information from
qualitative studies, for the more general context of systematic reviews.
part of a framework called estimation
statistics which relies on effect sizes, confidence intervals and
precision planning to guide data analysis, and is an alternative to null
hypothesis significance testing.
Responsible self-treatment and its
Self-medication is a human behavior in
which an individual uses unprescribed drugs to
treat untreated and often undiagnosed medical ailments.
The psychology of such behavior within the
specific context of using recreational drugs, psychoactive drugs, alcohol, and other self-soothing forms of
behavior to alleviate symptoms of mental distress, stress and anxiety, including mental illnesses and/or psychological trauma, is
particularly unique and can serve as a serious detriment to physical and mental health if motivated by addictive mechanisms.
often seen as gaining personal independence from established medicine, and
it can be seen as a human right,
implicit in, or closely related to the right to refuse professional medical
self-medication is defined as "the use of drugs to treat self-diagnosed
disorders or symptoms, or the intermittent or continued use of a prescribed
drug for chronic or recurrent disease or symptoms"
surveillance (PMS) (also post market surveillance) is the practice of
monitoring the safety of a pharmaceutical drug or medical device after it has been
released on the market and is an important part of the science of pharmacovigilance. Since drugs are approved
on the basis of clinical trials,
which involve relatively small numbers of people who have been selected for
this purpose - meaning that they normally do not have other medical conditions
which may exist in the general population - postmarketing surveillance can
further refine, or confirm or deny, the safety of a drug after it is used in
the general population by large numbers of people who have a wide variety of medical
surveillance uses a number of approaches to monitor the safety of licensed
drugs, including spontaneous reporting databases, prescription event
monitoring, electronic health
records, patient registries and record linkage between health
databases. These data are reviewed to highlight potential safety concerns
in a process known as data mining.
Side effects of the drugs.
In medicine, a side effect is an effect, whether therapeutic or adverse, that
is secondary to the one intended; although the term is predominantly employed
to describe adverse effects,
it can also apply to beneficial, but unintended, consequences of the use of
are prescribed or procedures performed specifically for their side effects; in
that case, said side effect ceases to be a side effect, and is now an intended
effect. For instance,X-rays were historically (and are
currently) used as an imaging technique; the discovery of their oncolytic
capability led to their employ in radiotherapy (ablation of malignant tumours).
Use of drugs for
unapproved indications—that is, for their side effects—is termed off-label use. For instance, opioids, which
are approved as palliative treatment
for pain, may also be used for theireuphoriant properties as anxiolytics or antidepressants, whether medically or recreationally.
Off-label use of
drugs, although similar in meaning to side effects, is not to be confused with
them; side effects describe the mechanism of action that
a drug used off-label takes, whereas off-label use implies the desired
consequences of using a drug for its side-effects.
Off-label use of
drugs is legal; the manner in which prescription medication is to be used is
solely at the discretion of the prescriber. However, the marketing of drugs
towards unapproved indications is illegal; in fact, several pharmaceutical
development firms have been fined for unapproved promotion of their products.
Examples of therapeutic side-effects
Bevacizumab (Avastin) has been used against dry
age-related macular degeneration,
as well as macular edema from
diseases such as diabetic retinopathy and central
retinal vein occlusion.
been shown experimentally (1982–1995) to be effective against severe,
Bupropion, an anti-depressant sold as Wellbutrin, is
also used as a smoking cessation aid; this indication was later approved, and
the name of the smoking cessation product is Zyban. In Ontario, Canada, smoking
cessation drugs are not covered by provincial drug plans; elsewhere, Zyban is
priced higher than Wellbutrin, despite being the same drug. Therefore, some
physicians prescribe Wellbutrin for both indications.
Sildenafil was originally intended
hypertension; subsequently, it was discovered that it also
produces erections, for which it was later marketed.
Carbamazepine is an approved treatment
for manic depression and convulsions, but has side effects useful in
hyperactivity disorder (ADHD), schizophrenia, phantom limb syndrome, paroxysmal
extreme pain disorder, neuromyotonia, and post-traumatic
Dexamethasone and Betamethasone in premature labor, to enhance pulmonary
maturation of the fetus.
Doxepin has been used to treat Angiodema and severe allergic reactions
due to its strong antihistamine properties.
Gabapentin, approved for treatment of seizures and postherpetic
neuralgia in adults, has side-effects which are useful in
treating bipolar disorder, essential tremor, hot flashes, migraineprophylaxis, neuropathic pain syndromes, phantom limb syndrome, and restless leg
Magnesium sulfate in obstetrics
for premature labor and preeclampsia.
Methotrexate (MTX), approved for the
treatment of choriocarcinoma,
is frequently used for the medical treatment of an unruptured ectopic pregnancy.
The SSRI medication sertraline is approved as an anti-depressant, but delays conjugal climax in men, and thus may be supplied
to those in which climax is premature.
An adverse drug reaction (abbreviated ADR)
is an expression that describes harm associated with the use of given medications at a normal dosage during
normal use. ADRs may occur following a single dose or prolonged administration
of a drug or result from the combination of
two or more drugs. The meaning of this expression differs from the meaning of
"side effect", as this last expression
might also imply that the effects can be beneficial. The study of ADRs is the
concern of the field known as pharmacovigilance. An adverse drug
event (abbreviated ADE) refers to any injury caused by the drug (at
normal dosage and/or due to overdose) and any harm associated with the use of
the drug (e.g. discontinuation of drug therapy). ADRs are a special type
ADRs may be
classified by e.g. cause and severity.
Type A: Augmented
pharmacologic effects - dose dependent and predictable
Type A reactions,
which constitute approximately 80% of adverse drug reactions, are usually a
consequence of the drug’s primary pharmacological effect (e.g. bleeding from
warfarin)or a low therapeutic index (e.g. nausea from digoxin), and they are
therefore predictable. They are dose-related and usually mild, although they
may be serious or even fatal (e.g. intracranial bleeding from warfarin). Such
reactions are usually due to inappropriate dosage, especially when drug
elimination is impaired. The term ‘side effects’ is often applied to minor type
Type B: Bizarre
effects (or idiosyncratic)
- dose independent and unpredictable
Type C: Chronic
Type D: Delayed
Type F: Failure of
Type G: Genetic
Type I: Idiosyncratic
Types A and B were proposed in the 1970s, and the
other types were proposed subsequently when the first two proved insufficient
to classify ADRs.
Seriousness and severity
The American Food and Drug
Administration defines a serious adverse event as one when
the patient outcome is one of the following:
(initial or prolonged)
significant, persistent, or permanent change, impairment, damage or disruption
in the patient's body function/structure, physical activities or quality of
to prevent permanent impairment or damage
Severity is a point
on an arbitrary scale of intensity of the adverse event in question. The terms
"severe" and "serious" when applied to adverse events are
technically very different. They are easily confused but can not be used
interchangeably, requiring care in usage.
A headache is severe,
if it causes intense pain. There are scales like "visual analog
scale" that help us[who?] assess the severity.
On the other hand, a headache is not usually serious (but may be in case of
subarachnoid haemorrhage, subdural bleed, even a migraine may temporally fit
criteria), unless it also satisfies the criteria for seriousness listed above.
Overall Drug Risk
While no official
scale exists yet to communicate overall drug risk, the iGuard Drug Risk Rating System is a
five color rating scale similar to the Homeland
Security Advisory System:
Red (high risk)
Yellow (guarded risk)
Blue (general risk)
Green (low risk)
Adverse effects may be local, i.e.
limited to a certain location, or systemic, where a medication has caused
adverse effects throughout the systemic circulation.
antihypertensives cause systemic effects, although
they are administered locally as eye drops, since a fraction escapes to the
As research better
explains the biochemistry of drug use, fewer ADRs are Type B and more are Type
A. Common mechanisms are:
pharmacokinetics due to
comorbid disease states
Synergistic effects between either
a drug and a disease
Comorbid disease states
especially those that cause renal or hepatic insufficiency, may alter drug
metabolism. Resources are available that report changes in a drug's metabolism
due to disease states.
Abnormal drug metabolism
may be due to inherited factors of either Phase I oxidation or Phase II
conjugation. Pharmacogenomics is
the study of the inherited basis for abnormal drug reactions.
Phase I reactions
abnormal alleles of cytochrome P450 can alter drug metabolism. Tables
are available to check for drug interactions due to P450 interactions.
abnormal butyrylcholinesterase (pseudocholinesterase)
may affect metabolism of drugs such as succinylcholine
Phase II reactions
abnormal N-acetyltransferase which
conjugated some drugs to facilitate excretion may affect the metabolism of
drugs such as isoniazid, hydralazine, and procainamide.
S-methyltransferase may affect the metabolism of the thiopurine drugs mercaptopurine and azathioprine.
Interactions with other drugs
The risk of drug interactions is increased
are usually transient and mild until a new steady state is achieved. These
are mainly for drugs without much first-pass liver metabolism. The principal
plasma proteins for drug binding are:
interactions with warfarin are
due to changes in protein binding.
abnormal metabolism by cytochrome P450 due to either inheriting
abnormal alleles or due to drug interactions.
Tables are available to check for drug interactions due to P450 interactions.
An example of
synergism is two drugs that both prolong the QT interval.
is used to determine the likelihood that a drug caused a suspected ADR. There
are a number of different methods used to judge causation, including the Naranjo algorithm, the Venulet algorithm and
the WHO causality term assessment criteria. Each have pros and cons associated
with their use and most require some level of expert judgement to
apply. An ADR should not be labeled as 'certain' unless the ADR abates
with a challenge-dechallenge-rechallenge protocol
(stopping and starting the agent in question). The chronology of the onset of
the suspected ADR is important, as another substance or factor may be
implicated as a cause; co-prescribed medications and underlying psychiatric
conditions may be factors in the ADR.
to a specific agent often proves difficult, unless the event is found during a
clinical study or large databases are used. Both methods have difficulties and
can be fraught with error. Even in clinical studies some ADRs may be missed as
large numbers of test individuals are required to find that adverse drug
reaction. Psychiatric ADRs are often missed as they are grouped together in the
questionnaires used to assess the population.
Psyche and behavioral health disorders
due to drugs usage without prescription.
A study by the Agency
for Healthcare Research and Quality (AHRQ) found that in
2011, sedatives and hypnotics were a leading source for adverse drug events
seen in the hospital setting. Approximately 2.8% of all ADEs present on
admission and 4.4% of ADEs that originated during a hospital stay were caused
by a sedative or hypnotic drug. A second study by AHRQ found that in 2011,
the most common specifically identified causes of adverse drug events that
originated during hospital stays in the U.S. were steroids, antibiotics,
opiates and narcotics, and anticoagulants. Patients treated in urban teaching
hospitals had higher rates of ADEs involving antibiotics and opiates/narcotics
compared to those treated in urban nonteaching hospitals. Those treated in
private, not-for-profit hospitals had higher rates of most ADE causes compared
to patients treated in public or private, for-profit hospitals.
In the U.S., females
had a higher rate of ADEs involving opiates and narcotics than males in 2011,
while male patients had a higher rate of anticoagulant ADEs. Nearly 8 in 1,000
adults aged 65 years or older experienced one of the four most common ADEs
(steroids, antibiotics, opiates and narcotics, and anticoagulants) during
Substance abuse, also known as drug abuse, is a patterned use of a substance (drug)
in which the user consumes the substance in amounts or with methods which are
harmful to themselves or others.
The term "drug
abuse" does not exclude dependency, but is otherwise used in a similar
manner in nonmedical contexts. The terms have a huge range of definitions
related to taking a psychoactive drug or performance
enhancing drug for a non-therapeutic or non-medical effect.
All of these definitions imply a negative judgment of the drug use in question
(compare with the term responsible drug use for
alternative views). Some of the drugs most often associated with this term
include alcohol, substituted amphetamines, barbiturates, benzodiazepines (particularly alprazolam, temazepam,diazepam and clonazepam), cocaine, methaqualone, and opioids. Use of these drugs may lead to
criminal penalty in addition to possible physical, social, and psychological
harm, both strongly depending on local jurisdiction. There are many cases
in which criminal or antisocial behavior occur
when the person is under the influence of a drug. Long term personality changes
in individuals may occur as well. Other definitions of drug abuse fall
into four main categories: public health definitions, mass communication and
vernacular usage, medical definitions, and political and criminal justice
definitions. Substance abuse is prevalent with an estimated 120 million users of
hard drugs such as cocaine, heroin, and other synthetic drugs.
Substance abuse is a
form of substance-related
Public health practitioners have
attempted to look at substance use from a broader perspective than the
individual, emphasizing the role of society, culture, and availability. Rather
than accepting the loaded terms alcohol or drug "abuse," many public
health professionals have adopted phrases such as "substance and alcohol
type problems" or "harmful/problematic use" of drugs.
The Health Officers
Council of British Columbia —
in their 2005 policy discussion paper, A Public
Health Approach to Drug Control in Canada — has adopted a
public health model of psychoactive substance use that challenges the
simplistic black-and-white construction of the binary (or complementary) antonyms "use" vs.
"abuse". This model explicitly recognizes a spectrum of use, ranging
from beneficial use to chronic dependence(see
diagram to the right).
In the modern medical
profession, the three most used diagnostic tools in the world, the American
Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM),the World Health
Organization's International Statistical Classification
of Diseases and ICRIS Medical organization Related Health Problems (ICD),
no longer recognize 'drug abuse' as a current medical diagnosis. Instead, DSM
has adopted substance abuse as a blanket term to include drug abuse
and other things. ICD refrains from using either substance
abuse or drug abuse, instead using the term "harmful use"
to cover physical or psychological harm to the user from use. Physical
dependence, abuse of, and withdrawal from drugs and other miscellaneous
substances is outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)
). Its section Substance dependence begins
dependence When an individual persists in use of alcohol or other drugs
despite problems related to use of the substance, substance dependence may
be diagnosed. Compulsive and repetitive use may result in tolerance to the
effect of the drug and withdrawal symptoms when use is reduced or stopped.
These, along with Substance Abuse are considered Substance Use Disorders.
definitions differ; they may entail psychological or physical dependence, and
may focus on treatment and prevention in terms of the social consequences of
Legal drugs are not necessarily
safer. A study in 2010 asked drug-harm experts to rank various illegal and
legal drugs. Alcohol was found to be the most dangerous by far.
Drug misuse is a term
used commonly for prescription
medication with sedative, anxiolytic, analgesic, or stimulant properties are used for mood
alteration or intoxication ignoring the fact that overdose of such medicines
have serious adverse effects. Prescription misuse has been defined differently
and rather inconsistently based on status of drug prescription, the uses
without a prescription, intentional use to achieve intoxicating effects, route
of administration, co-ingestion with alcohol, and the presence or absence of
dependence symptoms. Chronic use leads to a change in the central nervous
system which means the patient has developed tolerance to the medicine that
more of the substance is needed in order to produce desired effects.When this
happens, any effort to stop or reduce the use of this substance would cause
withdrawal symptoms to occur.
The rate of
prescription drug abuse is fast overtaking illegal drug abuse in the United
States. According to the National Institute of Drug Abuse, 7 million people
were taking prescription drugs for nonmedical use in 2010. Among 12th graders,
prescription drug misuse is now second only to cannabis. "Nearly 1 in
12 high school seniors reported nonmedical use of Vicodin; 1 in 20 reported
abuse of OxyContin."
Avenues of obtaining
prescription drugs for misuse are varied: sharing between family and friends,
illegally buying medications at school or work, and often "doctor
shopping" to find multiple physicians to prescribe the same medication,
without knowledge of other prescribers.
enforcement is holding physicians responsible for prescribing controlled
substances without fully establishing patient controls, such as a patient
"drug contract." Concerned physicians are educating themselves on how
to identify medication-seeking behavior in their patients, and are becoming
familiar with "red flags" that would alert them to potential
prescription drug abuse.
As a value judgment
Philip Jenkins points out that there
are two issues with the term "drug abuse". First, what constitutes a
"drug" is debatable. For instance,GHB,
a naturally occurring substance in the central nervous system is considered a
drug, and is illegal in many countries, while nicotine is not officially considered a
drug in most countries. Second, the word "abuse" implies a recognized
standard of use for any substance. Drinking an occasional glass of wine is
considered acceptable in most Western countries, while drinking several bottles
is seen as an abuse. Strict temperance advocates, who may or may not be
religiously motivated, would see drinking even one glass as an abuse. Some
groups even condemncaffeine use in
any quantity. Similarly, adopting the view that any (recreational) use of marijuana or substituted
amphetamines constitutes drug abuse implies a decision made
that the substance is harmful, even in minute quantities.
Signs and symptoms
Depending on the
actual compound, drug abuse including alcohol may lead to health
problems, social problems, morbidity, injuries, unprotected sex, violence, deaths, motor vehicle
accidents,homicides, suicides, physical dependence or psychological
There is a high rate
of suicide in alcoholics and
other drug abusers. The reasons believed to cause the increased risk of suicide
include the long-term abuse
of alcohol and other drugs causing physiological distortion
of brain chemistry as well as the social isolation. Another factor is the acute
intoxicating effects of the drugs may make suicide more likely to occur.
Suicide is also very common in adolescent alcohol abusers, with 1 in 4
suicides in adolescents being related to alcohol abuse. In the USA
approximately 30 percent of suicides are related to alcohol abuse. Alcohol
abuse is also associated with increased risks of committing criminal offences
including child abuse, domestic violence, rapes, burglaries and assaults.
Drug abuse, including
alcohol and prescription drugs, can induce symptomatology which resembles
mental illness. This can occur both in the intoxicated state and also during
In some cases these substance induced psychiatric disorders can persist long
after detoxification, such as prolonged psychosis or depression after amphetamine or cocaine
withdrawal syndrome can also occur with symptoms persisting
for months after cessation of use. Benzodiazepines are the most notable
drug for inducing prolonged withdrawal effects with symptoms sometimes
persisting for years after cessation of use. Abuse of hallucinogens can trigger delusional
and other psychotic phenomena long after cessation of use and cannabis may trigger panic attacks
during intoxication and with use it may cause a state similar to dysthymia. Severe anxiety and
depression are commonly induced by sustained alcohol abuse which in most cases
abates with prolonged abstinence. Even moderate alcohol sustained use may
increase anxiety and depression levels in some individuals. In most cases these
drug induced psychiatric disorders fade away with prolonged abstinence.
makes central nervous
system (CNS) effects, which produce changes in mood, levels
of awareness or perceptions and sensations. Most of these drugs also alter
systems other than the CNS. Some of these are often thought of as being abused.
Some drugs appear to be more likely to lead to uncontrolled use than others.
pharmacotherapies are quickly adopted in primary care settings; however, drugs
for substance abuse treatment have faced many barriers. Naltrexone, a drug originally marketed under
the name "ReVia," and now marketed in intramuscular formulation as
"Vivitrol" or in oral formulation as a generic, is a medication
approved for the treatment of alcohol dependence. This drug has reached very
few patients. This may be due to a number of factors, including resistance
by Addiction Medicine specialists
and lack of resources.
The ability to
recognize the signs of drug use or the symptoms of drug use in family members
by parents and spouses has been affected significantly by the emergence
of home drug testtechnology
which helps identify recent use of common street and prescription drugs with
near lab quality accuracy.
Treatment for substance
abuse is critical for many around the world. Often a formal intervention is
necessary to convince the substance abuser to submit to any form of treatment.
Behavioral interventions and medications exist that have helped many people
reduce, or discontinue, their substance abuse.
From the applied behavior
analysis literature, behavioral
psychology, and from randomized clinical trials, several evidenced based
interventions have emerged: behavioral
reinforcement approach, exposure therapy, contingency
In children and
behavioral therapy (CBT) and family therapy currently have the most
research evidence for the treatment of substance abuse problems. These
treatments can be administered in a variety of different formats, each of which
has varying levels of research support
Social skills are significantly
impaired in people suffering from alcoholism due to the neurotoxic effects of alcohol on the
brain, especially the prefrontal cortex area of the
brain. It has been suggested that social skills training adjunctive to
inpatient treatment of alcohol dependence is probably
efficacious, including managing the social environment.
therapy - A number of medications have been approved for the treatment of
substance abuse. These include replacement therapies such as buprenorphine and methadone as well as antagonist
medications like disulfiram and naltrexone in either short acting, or
the newer long acting form. Several other medications, often ones originally
used in other contexts, have also been shown to be effective including bupropion and modafinil.
medications have not been found to be useful.
A prescription is
a health-care programme that governs the plan of care for an individual patient
and is implemented by a qualified practitioner. A qualified practitioner
might be a physician,dentist, nurse practitioner, pharmacist, psychologist, or other health care
providers. Prescriptions may include orders to be performed by a patient, caretaker, nurse, pharmacist, physician, othertherapist, or by automated equipment, such as
an intravenous infusion pump. Formerly, prescriptions often included
detailed instructions regarding compounding of medications but as medications
have increasingly become pre-packaged manufactured products, the term
"prescription" now usually refers to an order that a pharmacist
dispense and that a patient take certainmedications. Prescriptions have legal
implications, as they may indicate that the prescriber takes responsibility for
the clinical care of the patient and in particular for monitoring efficacy andsafety. As medical practice has become
increasingly complex, the scope of meaning of the term "prescription"
has broadened to also include clinical assessments, laboratory tests, and
imaging studies relevant to optimizing the safety or efficacy of medical
symbol . Prescriptions may be entered into an electronic medical record
system and transmitted electronically to a pharmacy. Alternatively, a
prescription may behandwritten on
preprinted prescription forms that are assembled into pads, or printed onto
similar forms using a computer printer. The content of a
prescription includes the name and address of the prescribing provider and any
other legal requirement such as a registration number (e.g. DEA Number
in the United States).
Unique for each prescription is the name of the patient. In the United Kingdom and Ireland, the patient's name and address must
also be recorded. Each prescription is dated and some jurisdictions may place a time limit on
the prescription. In the past, prescriptions contained instructions for
the pharmacist to use for compounding the pharmaceutical product but most prescriptions
now specify pharmaceutical products that were manufactured and require little
or no preparation by the pharmacist. Prescriptions also contain directions for
the patient to follow when taking the drug. These directions are printed on the
label of the pharmaceutical product.
is a symbol meaning "prescription". It is
sometimes transliterated as
"Rx" or just "Rx". This symbol originated in medieval
manuscripts as an abbreviation of the Late Latin verb recipe, the
imperative form of recipere, "to take" or "take
thus". Literally, the Latin word recipe means simply
"Take...." and medieval prescriptions invariably began with the
command to "take" certain materials and compound them in specified
ways. Today, when a medical practitioner writes a prescription beginning
with "Rx", he or she is completing the command.
Folk theories about
the origin of the symbol Rx note its similarity to the Eye of Horus, or to the ancient symbol
for Zeus or Jupiter,
(Rx), gods whose protection may have been sought in medical contexts.
The word "prescription",
from "pre-" ("before") and "script"
("writing, written"), refers to the fact that the prescription is an
order that must be written down before a compound drug can be prepared. Those
within the industry will often call prescriptions simply "scripts".
The fact that a
prescription instructs someone to "take" rather than "give"
is not a trivial distinction, but makes clear it is directed at the patient,
and is not directly an instruction to anyone else. In certain states medical
marijuana legislation has been drafted calling for a health care professional's
written or oral "recommendation", in the belief that a written one
would be legally distinguishable from a prescription, but since written advice
to a patient is what a prescription is, that belief is mistaken. Jurisdictions
may adopt a statutory definition of "prescription" which is
applicable as a term of art only to the operation of that statute (see below
about prescriptions that may legally be filled with prescription-only items),
but the general legal definition of the word is this broad one.