Lesson 8

 

Evidence-based medicine and pharmacy. Clinical and pharmacological safety of prescription and non-prescription drugs. Medical recipe..

 

1.     The essence of evidence-based medicine.

2.     Evidence-based pharmacy.

3.     Responsible self-treatment and its risks.

4.     Pharmaceutical surveillance.

5.     Side effects of the drugs.

6.     Psyche and behavioral health disorders due to drugs usage without prescription.

7.     Drugs abuse.

8.     Medical recipe.

1.     The 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.

Evidence-based 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

Evidence-based 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 randomizedtriple-blindplacebo-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 controlled trial.

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:

Level A: Consistent Randomised Controlled Clinical Trialcohort 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 principles.

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 eligible patients.

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 individual considerations.

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 asymptomatic patients.

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.

2.      Evidence-based pharmacy.

Evidence-based 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.

Meta-analysis

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.

Meta-analyses are 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 the Cochrane 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.

Meta-analysis forms part of a framework called estimation statistics which relies on effect sizesconfidence intervals and precision planning to guide data analysis, and is an alternative to null hypothesis significance testing.

3.      Responsible self-treatment and its risks.

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 drugspsychoactive drugsalcohol, and other self-soothing forms of behavior to alleviate symptoms of mental distressstress 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.

Self-medication is 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 treatment

Definition

Generally speaking, 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"

 

4.     Pharmaceutical surveillance.

Postmarketing 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 conditions.

Postmarketing surveillance uses a number of approaches to monitor the safety of licensed drugs, including spontaneous reporting databases, prescription event monitoring, electronic health recordspatient registries and record linkage between health databases. These data are reviewed to highlight potential safety concerns in a process known as data mining.

5.     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 a drug.

Occasionally, drugs 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.

Buprenorphine has been shown experimentally (1982–1995) to be effective against severe, refractory depression.

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 for pulmonary 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 treating attention-deficit hyperactivity disorder (ADHD), schizophreniaphantom limb syndrome, paroxysmal extreme pain disorderneuromyotonia, and post-traumatic stress disorder.

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 disorderessential tremorhot flashesmigraineprophylaxis, neuropathic pain syndromes, phantom limb syndrome, and restless leg syndrome.

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 of ADEs.

Classification

ADRs may be classified by e.g. cause and severity.

Cause

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 A reactions.

Type B: Bizarre effects (or idiosyncratic) - dose independent and unpredictable

Type C: Chronic effects

Type D: Delayed effects

Type E: End-of-treatment effects

Type F: Failure of therapy

Type G: Genetic reactions

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:

Death

Life-threatening

Hospitalization (initial or prolonged)

Disability - significant, persistent, or permanent change, impairment, damage or disruption in the patient's body function/structure, physical activities or quality of life.

Congenital anomaly

Requires intervention 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)

Orange (elevated risk)

Yellow (guarded risk)

Blue (general risk)

Green (low risk)

Location[edit]

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.

For instance, some ocular antihypertensives cause systemic effects, although they are administered locally as eye drops, since a fraction escapes to the systemic circulation.

Mechanisms

As research better explains the biochemistry of drug use, fewer ADRs are Type B and more are Type A. Common mechanisms are:

Abnormal pharmacokinetics due to

genetic factors

comorbid disease states

Synergistic effects between either

a drug and a disease

two drugs

Abnormal pharmacokinetics

Comorbid disease states

Various diseases, 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.

Genetic factors

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

Inheriting abnormal alleles of cytochrome P450 can alter drug metabolism. Tables are available to check for drug interactions due to P450 interactions.

Inheriting abnormal butyrylcholinesterase (pseudocholinesterase) may affect metabolism of drugs such as succinylcholine

Phase II reactions

Inheriting abnormal N-acetyltransferase which conjugated some drugs to facilitate excretion may affect the metabolism of drugs such as isoniazidhydralazine, and procainamide.

Inheriting abnormal thiopurine S-methyltransferase may affect the metabolism of the thiopurine drugs mercaptopurine and azathioprine.

Interactions with other drugs

The risk of drug interactions is increased with polypharmacy.

Protein binding

These interactions 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:

albumin

α1-acid glycoprotein

lipoproteins

Some drug interactions with warfarin are due to changes in protein binding.

Cytochrome P450

Patients have 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.

Synergistic effects

An example of synergism is two drugs that both prolong the QT interval.

Assessing causality

Causality assessment 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.

Assigning causality 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.

6.     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 hospitalization.

 

7.     Drugs abuse.

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 alcoholsubstituted amphetaminesbarbituratesbenzodiazepines (particularly alprazolamtemazepam,diazepam and clonazepam), cocainemethaqualone, 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 disorder.

Classification

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).

Medical definitions

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 with:

Substance 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.

However, other definitions differ; they may entail psychological or physical dependence, and may focus on treatment and prevention in terms of the social consequences of substance uses.

Drug misuse

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 sedativeanxiolyticanalgesic, 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.

Increasingly, law 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 problemsmorbidityinjuriesunprotected sexviolencedeathsmotor vehicle accidents,homicidessuicidesphysical dependence or psychological addiction.

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 abusedomestic violencerapesburglaries 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 the withdrawalstate. In some cases these substance induced psychiatric disorders can persist long after detoxification, such as prolonged psychosis or depression after amphetamine or cocaine abuse. Aprotracted 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.

Drug abuse 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.

Traditionally, new 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

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.

Psychological

From the applied behavior analysis literature, behavioral psychology, and from randomized clinical trials, several evidenced based interventions have emerged: behavioral marital therapy,motivational Interviewingcommunity reinforcement approachexposure therapycontingency management

In children and adolescents, cognitive 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.

Medication

Pharmacological 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.

Antipsychotic medications have not been found to be useful.

8.      Medical recipe.

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,dentistnurse practitionerpharmacistpsychologist, or other health care providers. Prescriptions may include orders to be performed by a patientcaretakernursepharmacistphysician, 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 treatment.

Prescription symbol Описание: http://upload.wikimedia.org/wikipedia/commons/thumb/a/a2/Rx_symbol_border.svg/160px-Rx_symbol_border.svg.png. 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.

Описание: http://upload.wikimedia.org/wikipedia/commons/thumb/a/a2/Rx_symbol_border.svg/160px-Rx_symbol_border.svg.png 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.