Treatment decisions should be made short-term withdrawal may never achieve in the patientís best interest buy nizagara 25mg line erectile dysfunction pills herbal. If patient progress steady state order 50mg nizagara visa erectile dysfunction premature ejaculation treatment, and tapering from methadone is unsatisfactory at a particular level of care, may be too steep if it begins at a dose greater the physician should explore the possibility of than about 40 mg. In long-term withdrawal, increasing that patientís care while maintaining stabilization of dosage at a therapeutic range him or her on methadone. Involuntary taper- is followed by more gradual reduction (see ing and discontinuation of maintenance medi- Exhibit 5-7). Dosage Reduction If a patient is intoxicated repeatedly with alco- W hen patients violate program rules or no hol or sedative drugs, the addition of an opioid longer meet treatment criteria, involuntary medication is unsafe, and any dose should be tapering might be indicated although it should withheld, reduced, or tapered. For violent behavior or threats to staff and other example, if many days of dosing are missed and patients might be reasons for dismissal without repeated attempts to help a patient comply with Exhibit 5-7 Types of Detoxification From Illicit Opioids 80 Chapter 5 tapering or for immediate transfer to another decisions on dispensing take-home medication facility where a patient may be treated under are determined by the medical director in safer conditions. Absence of recent drug and alcohol abuse addiction treatment, a patientís sudden lack of 2. Acceptable length of time in comprehensive methadone before withdrawal because clinical maintenance treatment experience with methadone withdrawal is more extensive. At this writing, few correc- Once these clinical criteria are met, maximum tional institutions offer methadone mainte- take-home doses must be further restricted nance to nonpregnant inmates (National Drug based on length of time in treatment as follows: Court Institute 2002). Regardless of take-home doses per week which opioid medication is used, maintenance or medically supervised withdrawal is prefer- ï Fourth 90 days (months 10 through 12): 6 able to sudden discontinuation of the medica- daysí supply of take-home doses per week tion. No take-home doses are permitted for M edications patients in short-term detoxification or interim Take-home medication refers to unsupervised maintenance treatment. Beyond this, Clinical Pharm acotherapy 81 Specific Clinical Considerations concurrent disease, to avoid methadone-related complications of a concurrent medical disor- in Take-Hom e Status der, and to ensure that the pharmacological benefits of administering methadone are main- Dem ands of a concurrent tained during the course and treatment of the m edical disorder concurrent disease. The existence and severity of a concurrent medical disorder (see chapter 10) are additional Enhancem ent of rehabilitative considerations in determining whether take- potential home medication is appropriate. Under the disinhibiting effects avoided until a of other substances, patients might be unable patient is stable on to safeguard or adequately store their take- these new medica- home doses. They should be encouraged to tions and the risks of an undesirable outcome keep their medication in a locked cabinet away have diminished. In these instances, more from food or other medicines and out of the frequent observations are important to monitor reach of children. Staff members who accept these considered carefully because most such con- bottles should inspect them to ensure that tainers are large and visible, which might serve they are coming from the indicated patient more to advertise that a patient is carrying during the appropriate period. Staff should when methadone diskettes are reconstituted or consider discontinuing take-home medication liquid methadone oral concentrate is used and for these patients. Although methadone has a significant street value, a National Institutes of Health consensus Behavior, social stability, and statement refers to it as ìa medication that is not often diverted to individuals for recreation- take-hom e m edications al or casual use but rather to individuals with Patients appearing intoxicated; demonstrating opiate dependence who lack access to aggressive, seriously impaired, or disordered [methadone maintenance treatment] pro- behavior; or engaging in ongoing criminal gramsî (National Institutes of Health 1997b, p. Their home environments also are to methadone have increased significantly in keys to the safety and storage of medication. According to data from the Drug W here social relationships are unstable, a Abuse W arning Network, more than 10,000 significant risk exists that methadone take- emergency room visits related to methadone home doses will be secured inadequately from were reported in 2001 compared with more diversion or accidental use (e. This increase If patients with take-home privileges develop has occurred in the context of overall increases altered mental competency, such as in demen- in abuse of prescription opioids, in particular tia, frequent loss of consciousness, or delusional hydrocodone and oxycodone. Local reports states, then take-home privileges should be indicate that most diverted methadone comes reevaluated. Although the slow M onitoring Patients W ho onset of methadone makes it less attractive Receive Take-Hom e than prescription opioids to potential abusers, M edications it also makes methadone more dangerous because respiratory depression can become Monitoring should ensure that patients with significant hours after ingestion. To guard take-home medication privileges are free of against the possibility of methadone-related illicit drug use and consume their medication as respiratory depression, the consensus panel directed. This goal can be met through random recommends the following diversion control drug testing and periodic interdisciplinary policies for take-home medication: assessment of continuing eligibility. It usually is helpful to provide Issues for review psychiatric consultation to medical or surgical The rationale for providing take-home staff members, especially for patients with co- medication should be reviewed regularly occurring disorders. W ritten patient consent is and documented to determine whether initial necessary for this kind of program-to-hospital justifications continue to apply. Reviewing the original rationale for take-home Hospitalization, particularly of unconscious medication is a necessary but insufficient patients, raises the issue of using identification condition for increased patient monitoring. Smart cards con- taining a complete medical history are already Disability or illness. Various forms of this treatment have been stud- Concerns should include whether a patient has ied in the United States and found to be safe been using illicit drugs or taking other medica- and efficacious (King et al. Patient selection for this treatment option should focus on a history of negative drug tests, One dose missed. Outcomes have been out of treatment for a significant time and uniformly positive, with few relapses and little might have lost tolerance, dosage reduction or or no diversion reported (King et al. Level of care refers to the intensity of a ChapterÖ treatment (in terms of frequency, type of serviceóindividual, group, familyóand medication) and the type of setting needed for treatment Steps in delivery. The chapter also provides information on developing a treatment plan with short- and long-range goals for each patient. In general, patientñtreatment matching involves individualizing, to the extent possible, the choice and application of treatment resources to each patientís needs. The chapter explains recommended elements of a patientñtreatment-matching process, including ways to accommodate special populations with distinct needs and orientations that affect their responses to specific treatments and settings. Many also have co-occurring medical and mental health conditions that can be lifelong. M utual-help program s Steps in Although not a form of treatment, mutual-help programs (e. Such pro- Patient Assessm ent grams provide social support from others who Patientñtreatment matching begins with a thor- are in recovery from addiction (W ashton 1988). However, patients with opioid are matched to appropriate levels of care and addiction who are maintained on treatment types of services. Assessment should include medication can feel out of place in some group the extent, nature, and duration of patientsí settings where continued opioid pharmacother- opioid and other substance use and their treat- apy may be misunderstood. Researchers have ment histories, as well as their medical, psychi- described a variety of specialized groups and atric, and psychosocial needs and functional inventive strategies for mutual-help programs status. Chapter 8 presents some of language, motivation to comply with treatment, these strategies. Some programs may provide psy- and behavioral needs as part of addiction chosocial services to patients in other settings. Based on its assessments of patients, withdrawal or residential treatment programs), the treatment team should collaborate with and those who require opioid pharmacothera- patients to determine the most appropriate py for long-term stabilization. Therefore, medical and psy- required to help treatment matching in some cases can lead to chosocial treatment multiple settings for an individualís treatment. For all phases of treatment and at most levels of example, one report from a 16-month prospec- care. At this writing, settings, such as those described below, for ser- the number of hospital-based programs offer- vices that match patient needs.
Worksheet 9-14 My Reﬂections If you ﬁnd yourself avoiding this exposure part of the program generic nizagara 100mg without prescription erectile dysfunction protocol amazon, we suggest you ﬂip back to Chapter 3 cheap nizagara 50 mg online erectile dysfunction medication does not work, which discusses ways of identifying and overcoming roadblocks to change. Essentially, obsessions are unwanted images, impulses, or thoughts that ﬂood the mind. These thoughts may take the form of excessive worry about contamination by germs, chemicals, radiation, and so on. Other obsessions include concerns about whether doors were left unlocked or appliances were turned off. Compulsions are undesired actions that people ﬁnd themselves doing over and over in order to temporarily reduce anxiety. Common compulsions include excessive hand washing, over- cleaning, hoarding objects, arranging objects in a particularly rigid manner, checking and rechecking things (such as locks), and creating strict rituals such as counting stairs or put- ting on clothing in the exact same order every day. Lots of people experience a few minor obsessions or compulsions, and that’s no problem. You can ﬁnd considerably more information about this particular problem in Overcoming Anxiety For Dummies (Wiley). You should only attempt the strategies that follow if your problems are fairly mild; consider using this book in collaboration with your therapist or counselor. However, as you can see in the following sections, there are a few minor differences. Beating obsessions Because obsessions consist of thoughts or mental images, exposure for obsessions typically takes place in the imagination. Also, imagination is the best approach because many obses- sions really couldn’t or shouldn’t be acted out. For example, if your obsession involves strange sexual perversions, we don’t recommend that you “expose” yourself to them! In fact, if you have obsessions that involve unacceptable sexual activities or physically hurt- ing yourself or others, you should consult a mental health professional rather than attempt imaginal or real exposure techniques. Most obsessions are focused on a single idea, so you may not have a Staircase of Fear to climb. However, you can still utilize exposure to help you deal with many different obses- sions. Rank how upsetting the thought or image is to you on a scale of 0 (no upset) to 100. Repeat the thought or image over and over and over and over and over and over and over and over and over and over and over (oops, we’re getting a tad compulsive here aren’t we? Continue repeating the thought or image for 20 to 30 minutes or as long as it takes to reduce your level of upset (in Step 2) by at least 10 to 20 points. Re-rate your thought or image on the same scale (0 [no upset] to 100 [totally disturbing]). They often try to immediately expunge obsessive thoughts and images from their minds when they occur. The problem with that approach is that attempting to suppress thoughts only makes them surface more frequently. Chapter 9: Facing Feelings: Avoiding Avoidance 147 Treating compulsions Treating compulsions, like the treatment of other anxieties and fears, involves exposure as the ﬁrst step. You gather materials for a Staircase of Fear, arrange your materials into an actual staircase, and start your climb. The only difference in the treatment of compulsions is that you have to do one extra thing: Not only do you expose yourself to the problematic activities or items, but you also must stop yourself from engaging in the compulsive behav- ior. The following example shows you how this treatment procedure works for a particular compulsion. However, the compulsion is ruining her life by unnec- essarily taking up huge amounts of time. In Worksheet 9-16, you see the partial results of her Climb to the Top Exercise, her repeated exposures to problematic events and activities while not washing her hands. In fact, Gina makes a con- certed effort not to wash for at least an hour after the exposure. Worksheet 9-16 Gina’s Climb to the Top Exercise Activity (Exposure without the Anxiety Ratings: 0 (no fear) to 100 (terriﬁed) compulsion) Handling garments at a 30, 20, 15, 10: This was sort of gross at ﬁrst clothing store because I kept thinking about all the other people who touched them before me. You may use different soap, arrange things a little differently, or make a slight change in your routine. Worksheet 9-17 My Reﬂections Chapter 10 Lif ting Mood T hrough Exercise In This Chapter Figuring out how much physical activity you need Giving yourself reasons to exercise Coming up with an exercise strategy Finding motivation to stick with the program hy devote a whole chapter to exercise in a book that deals with anxiety and depres- Wsion? Well, because getting up and moving increases the naturally occurring feel-good endorphins in the human body. When endorphins, substances occurring naturally in the brain that are chemically similar to morphine, spread through your brain, you get a sense of well-being and pleasure. In this chapter, we tell you how much exercise you need to get those endorphins going, and we tell you about all the known beneﬁts of exercise. You pick your top ten reasons for begin- ning or sticking with an exercise program and then ﬁgure out an exercise plan that ﬁts your lifestyle. We also offer some tips for ﬁnding the motivation to keep exercise going in your life. The best time to get into an exercise habit is when you’re young because exercise helps to keep you healthy throughout your life. However, it’s never too late to start — even 90-year- olds beneﬁt from regular exercise! However, for men over 40, women over 50, and anyone with a chronic disease or other health concerns, it’s best to check with a physician before beginning a vigorous exercise regimen. Every ﬁve years, the United States government updates its guidelines for nutrition and exer- cise. The 2005 recommendations signiﬁcantly increased the recommended amount of time for healthy people to engage in vigorous physical activity. Here they are: Children should be physically active about an hour a day on most days. Adolescents should engage in at least 60 minutes of exercise every day, most days of the week. You guessed it — that means you must communicate with your prescriber on a regular basis about the speciﬁc side effects you’re experiencing. Because it’s so important for your healthcare provider to know about your experience with side effects, we created the Side Effect Tracking Form, shown in Worksheet 14-5, for you to ﬁll out and take to your consultations (or use it as a guide during your telephone conversa- tions). We recommend you complete this form at the very least for one month after you start a new medication for depression or anxiety. Is this satisfaction-interrupting thought distorted, and can I come up with a more accurate replacement thought? In the left-hand column, use a few words to capture what should have been a satisfy- ing event. If you initially had satisfying thoughts about that event, record those in the middle column. Estimate the amount of time you’ve devoted to activities that are concordant with your top three values (see Worksheet 18-13).
There was evidence that participants had acquired knowledge regarding the levels of medication they needed to control their illness and proven 50mg nizagara royal jelly impotence, beyond those levels order nizagara without prescription otc erectile dysfunction drugs walgreens, had gained some freedom to adjust the medication to manage side effects and other problems involved. That is, whilst two thirds of the participants reported to take their medication as prescribed, some self- medicated by increasing or decreasing the dose or taking medication at a 52 different time of the day. In addition to several adaptive strategies to assist illness management, self-medication with non-prescription substances was also a reported method of coping with positive symptoms and the side effects of antipsychotic medications. Spirituality and resources which promoted autonomy, such as money, friends and independent living, were cited as ameliorating factors. Medication taking was frequently perceived to be in the control of others and influenced by a range of social sanctions. Significant others were reported to prompt or remind participants to take their medications, which was typically not described as impinging on their autonomy. However, many participants attributed adherence to awareness of health professionals’ abilities to implement legal and social consequences for non-adherence, which can include the loss of liberty for consumers (i. Carrick, Mitchell, Powell, & Lloyd (2004) conducted an interview study that investigated individuals’ experiences of the side effects of antipsychotic medication. The sample comprised of 25 outpatients from Exeter, South West England, and including a focus group who were recruited through day centres. The analysis reported that consumers did not perceive side effects and symptoms as separate issues. Rather, their positive or negative evaluations of medication related to the total impact of medication treatment on their functioning, feeling and appearance to the outside world (Carrick et al. Interviews of consumers and their family members were paired, then interviews were analysed for codes and integrated into a single model following a grounded theory approach. Multiple causal factors were identified to be associated with consumers’ non-adherence. Side effects were the most common reason for non-adherence, mentioned by almost all of the participants and confirmed by their caregivers. In some cases, participants indicated that they preferred the experience of illness symptoms to side effects. It was additionally found that none of the participants had been informed about side effects, possible remedies and coping mechanisms prior to commencing pharmacotherapy. Some participants stated that they discontinued medication as it was ineffective in treating symptoms. One consumer also expressed a fear of receiving depot medication, which he felt made him ill, thus, accounting for non-adherence. A lack of family support was also identified by three of the participants as an influence on adherence. Furthermore, one caregiver reported that they had attempted to coerce a consumer into taking their medication, which lead to resistance and non- adherence (Sharif et al. Lack of continuity of care was constructed as a deterrent to treatment for some consumers, who elaborated that they were required to tell their story repeatedly to new staff. Additionally, half of the participants reported a lack of ongoing assessment, such that once their symptoms were controlled, they were not reassessed according to changing contexts or on the basis of the 54 changing magnitude of their illnesses. In most cases, participants and their families expressed frustration in relation to their non-involvement in management plans and the lack of information given to them in relation to the nature of illness and the pattern of therapy. Autonomy and ego, in particular, the desire for independence and self-control, exerted a pivotal role in most of the participants’ accounts of non-adherent behaviour. This was particularly relevant to cases when participants were not involved in their illness management and the treatment approach was confrontational and coercive, which participants reportedly responded to with rebellion and resistance to attempts to control their lives through medication. Specifically, two consumers and their family members reported that they became non- adherent in order to be eligible for disability pensions (which had cancelled when their illness symptoms were controlled as a result of adherence). Adverse social stigma was also associated with non-adherence to treatment amongst some participants, who reported feeling embarrassed by their “mentally ill” identities and, thus, failed to attend appointments. Different belief systems were also proposed to influence adherence, such as a belief that witchcraft or stress was the underlying cause of the illness (Sharif et al. In particular, the article did not identify who conducted interviews but it was reported that they were translated from participants’ first language, Tswana, into English once completed. Furthermore, the study’s sample size of six was extremely small, even for a qualitative study. Whilst a purposive sampling approach was selected to ensure variation in medication regimen, gender and marital 55 status, the selection of only non-adherent consumers and the small sample size hinder the generalisability of study findings. Carder, Vuckovic and Green (2003) conducted qualitative interviews with 83 adults with chronic illnesses, including schizophrenia and schizo affective disorder, which investigated consumers’ perceptions of their need to take medication during the course of their illnesses. Unfortunately, it was not noted how many of the participants had schizophrenia or schizo affective disorder. Semi-structured interviews were transcribed and analysed following a grounded theory approach. For some, medications successfully managed their symptoms whilst others reported ongoing efforts to find the right medication, or combination of medications, to manage symptoms and minimise side effects. Most described changes over time, with periods of stability marred by either medication resistance or side effects that required a change in dose or type. The results of the study indicated that participants negotiated their need for medication internally (including struggles over self identity) and externally (through negotiations with health care providers). Interview data indicated that medication taking may prompt consumers to re-negotiate their self-identities as formerly well persons (Carder et al. When symptoms are under control, they may question whether they are cured, in remission, or if the medication is treating symptoms. Some participants resisted taking medication because it conflicted with their identities as a healthy person or someone who normally did not take medication. Some participants stated that they reduced their intake of medication to curtail side effects or discover the dosage that best met their personal threshold for 56 symptom management. Regarding external negotiations, participants described both battling and working with their physicians over medications, including decisions regarding whether to take medication, type of medication, how much and by what route. Many of the participants had taken medication for years and, thus, knew what worked and did not work for them. One source of resistance derived from participants’ dissatisfaction with physicians who simply prescribe medications whenever the individual has new or additional symptoms, leading to complex medication regimens. In addition to the physical effects of taking medication for an extended period of time, some participants reported an emotional toll associated with the trial and error involved in finding the right medication regimen (Carder et al. Indeed, two participants with schizophrenia reported feeling like a “human experiment” as a result of the long process of finding the right medication or combination of medications (Carder et al. More recently, Shoemaker and Ramahlo de Oliveira (2008) conducted a study focussing on the meaning of medication for 41 consumers, which included participants with diagnoses of schizophrenia (as with the previous study, the number of participants with schizophrenia was, unfortunately, not reported). A meta-synthesis of three different but complementary qualitative studies was conducted by researchers, which included unstructured and in- depth interviews as parts of phenomenological and ethnographic studies.
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