If she indicates she is unsure about her pregnancy atrial fibrillation aceon 2 mg fast delivery, she may be struggling with her options heart attack demi lovato mp3 generic aceon 8 mg visa. You can help a woman in this situation by outlining all the options available to her blood pressure yogurt order aceon 2 mg mastercard. A pregnant minor is eligible for a special kind of Medi-Cal called "sensitive services" or "minor consent services blood pressure medication cost discount 2 mg aceon visa. Parents are not responsible for payment Page updated 2019 Outline the options for her stage of pregnancy and then explore how each could fit into her situation. Discuss practical and emotional resources that might affect her choice, such as teenage parenting programs, public assistance, prenatal diagnosis of birth defects, and single parent support groups. Find out if there is someone she trusts who can give emotional support during this time. Unwanted Pregnancy Keeping the Baby Some clients become more attached to the baby later in the pregnancy. If the client continues to consider the child "unwanted," help her consider life with the child. A therapist or counselor can help her explore her feelings in more depth before the baby is born. A session with a social worker can help explore the support options that may be available to her. Give special attention to adolescents, those who have developmental disabilities, those with psychiatric problems, and undocumented women. There may also be sexual abuse involved including forced sex or reproductive coercion (putting pressure on a woman to get pregnant against her wishes, which may or may not include birth control sabotage). There are a variety of adoption placement arrangements, depending on the wishes of the birth parents and adoptive parents. Abortion If after considering her options, the client wishes to terminate the pregnancy, have the health care provider refer her to the most appropriate medical resource. Encourage counseling before and after the procedure to help manage emotions, provide information about the procedure, and help her understand and cope with her feelings. There may be a continuing relationship between the birth parents and child following adoptive placement. Closed Adoption (confidential adoptions) Once the most common form of adoption, these are still an option. Ongoing pictures and letters can also be exchanged through the agency as the child grows. Adoption There may be a great deal of pressure on the woman-from her partner, family members, friends, or institutions-to either keep the child or place the child for adoption. Encourage her to make a decision that she believes is truly in her best interest and that of her unborn child. They provide the best protection for the birth mother, who is their client, and her child. Families are carefully screened and receive extensive education and counseling regarding the adoption process. Inform the woman that she does not have to be sure of her decision before contacting an adoption agency. She can receive special counseling to sort out her feelings without any charge or requirement to place her child for adoption at birth. The State Department of Social Services will interview both the birth parents and adoptive parents. Native American clients: Federal rules apply when placing Native American babies for adoption. You must act as an advocate for your pregnant client, not for a person or couple wanting to adopt or an attorney. When her decision is made, be sure her choices are honored and her plan is carried out. Independent (Private) Adoption Independent (private) adoptions focus more on the needs of the adoptive couple, who are often paying for the services of the attorney or other adoption facilitator. While many satisfactory adoptions happen through the private route, caution your client there is a greater chance that her needs may not be addressed. If she has already chosen to work with a private, nonlicensed resource, honor her decision. You can refer her to an additional legal resource to be sure her legal rights are protected. Encourage her to request counseling from a neutral individual-someone who is not employed by the adoptive family or the adoption attorney. Be sure she receives a referral for family planning services so she can avoid an unwanted pregnancy in the future. Informal Adoption Informal adoption takes place when a family member or close associate raises the child. This is a serious decision that needs careful consideration of the short and long-term effects for the woman and her child. Encourage her to seek counseling during pregnancy to sort out feelings and explore this option. Refer her for legal advice so that she understands the legal consequences of having an informal arrangement for the care of her child. Any decision you make-keeping the baby, having an abortion, or planning an adoption-will come with changes in your life. You will actually be making two decisions if it is early in the pregnancy: n n Do I want to continue the pregnancy? Ask Yourself these Questions n Am I able to give a child what he/she needs-emotionally and financially? Do I have problems, like drinking or using drugs, which will keep me from being the kind of parent my baby needs? Las mujeres a menudo sienten una mezcla de emociones cuando tienen un embarazo no planificado. Cualquier decisiуn que tome - quedarse con el bebй, tener un aborto o planear una adopciуn serб difнcil y resultarб en grandes cambios en su vida. Si estб de novia con el padre del bebй, quizбs le ayude hablar con йl de lo que piensa sobre las distintas opciones. En realidad estarб tomando dos decisiones, si es suficientemente temprano en el embarazo: n n їQuiero continuar con el embarazo? Hбgase estas preguntas n їPuedo darle a un niсo lo que necesita, tanto emocional como econуmicamente? If it is still early in the pregnancy, you have three choices: keep the baby, have an abortion, or plan an adoption. Si su embarazo es reciente, tiene tres opciones: quedarse con el bebй, tener un aborto, o planear una adopciуn. Quedarse con el bebй significa: n La adopciуn significa: n Aceptar la responsabilidad por el niсo durante por lo menos 18 aсos. Poner a un lado su independencia, para poder cumplir con las necesidades de su hijo. Tener la paciencia y el amor necesarios para lidiar con las necesidades de su bebй las 24 horas al dнa. Posiblemente recibir ayuda de la familia con su atenciуn mйdica y otras necesidades. Common terms for such loss are: n Perinatal Loss Refer immediately to the health care provider if the woman is severely depressed and/or has made statements about hurting herself. Miscarriage; fetal death before 20 weeks gestation Stillbirth; after 20 weeks Intra-uterine fetal demise; death after 20 weeks Neonatal death or newborn death; the death of an infant after birth Abortion; another kind of loss, especially if the procedure is done because a fetus has genetic or other severe abnormalities Steps to Take When the loss is suspected during the pregnancy, help the client find a support person to accompany her for the tests to check on the fetus. If the diagnosis is confirmed and the fetus is dead, the woman and her partner may need a period of privacy to express shock and disappointment. You can help in the following ways: n n n n n Sometimes a pregnancy will progress normally but a loss will occur at labor and delivery. Although the situations and reactions differ, many of the issues surrounding different kinds of loss are similar. Families from different cultures will have different attitudes toward the death of an infant, an autopsy, preferences for burial, and normal expressions of grief. Remain available to offer support when the woman and her family are ready Be prepared for anger and hostility, a common reaction for parents who need to identify a cause for their tragedy Give factual information about causes Acknowledge their feelings of fear and anxiety and allow them to express negative feelings Encourage additional support from family, friends, or someone from their religious or spiritual community When the family is ready, help them prepare for the many decisions that need to be made n n n n n Assist the family in preparation for the upcoming labor and delivery. For example: n n n n n Perinatal Loss Assessment and Ongoing Help Allow the family to describe their experiences at the hospital and after discharge. Evaluate symptoms of grief: n n Seeing the baby Holding, bathing, or dressing the baby Naming the baby Taking pictures Saving mementos such as foot and hand prints or a lock of hair Planning a funeral or memorial Lack of appetite Inability to return to normal activities (such as taking care of other children, working, socializing with others, etc.
Journal Discussion Should Women with Transplanted Organs Be Discouraged from Becoming Pregnant? The choice to become pregnant gets tested blood pressure simulator order 4mg aceon amex, though arrhythmia mayo clinic discount aceon 2mg without prescription, when the woman is an organ transplant recipient because pregnancy may endanger the graft arteria jugular discount 4mg aceon with visa, the mother hypertension and exercise order 8 mg aceon fast delivery, and the child. Whether or not women who are transplant recipients should be discouraged from becoming pregnant is a discussion that is a complex kaleidoscope of science, law, and ethics. Even though a consensus on the consequences of pregnancy in transplant patients has yet to be reached, more and more women with transplanted organs are becoming mothers, and greater attention should be given to the issue. In "Ethical Considerations Related to Pregnancy in Transplant Recipients," Lainie Friedman Ross asserts that women who have received transplants are having children in significant numbers [1]. She notes that since the first documented pregnancy in a transplant recipient in 1958, more than 7,000 such pregnancies have occurred. That transplant recipients are becoming pregnant with greater frequency has been corroborated by other authors who cite increasing rates in patients with liver, heart, lung, bone marrow, and pancreas-kidney transplants [2, 3]. Clinical Considerations Ross begins by eloquently framing her ethical discussion with a review of the clinical implications of organ transplantation on pregnancy by examining, in turn, its effect on the allograft, the mother, and the fetus. Regarding the first of these-effects of pregnancy on the allograft-Ross says that, in renal transplant patients, one of the concerns has been that ". She then states that, while there is evidence of decreased renal function during pregnancy, this impairment mirrors the natural course of organ dysfunction in all kidney recipients, which would seem to rule out pregnancy as an independent contributor to allograft morbidity. Finally Ross highlights current recommendations based on data from the National Transplantation Pregnancy Registry that organ recipients wait two years after transplantation before considering pregnancy, allowing sufficient time for graft stability, after which pregnancy should be feasible with lower risks of permanent decrease in function of the allograft [6]. She notes that having transplanted organs has been correlated with an increased risk for conditions such as ectopic pregnancy, preeclampsia, and infection. There also seems to be a greater need for cesarean delivery, particularly in renal transplant patients [5]. The magnitude of this increased risk is unclear, however, as Ross does not further elaborate on this point. Ross invests more detail in describing risks to the child, discussing the potential teratogenic effects of transplant immunosuppressive therapy that have been demonstrated in animal models. She summarizes her view about the lack of compelling evidence on the risks of these drugs by saying that, "To date, the frequency of birth defects in infants born to women receiving immunosuppressive agents is not statistically different from that in the general population" [5]. Ross does concede that rates of prematurity and low birth weight are higher in infants born of mothers with transplants. This in itself is cause for concern because both prematurity and low birth weight have been decisively linked to increased risk of cognitive and neurodevelopmental abnormalities. Ethical and Legal Considerations the discussion of pregnancy in transplant recipients would be incomplete if only the science were considered. Pregnancy and the creation of life spark diverse reactions throughout society, and Ross concisely reviews the major ethical and legal considerations of pregnancy in transplant recipients. Ross initiates the ethics portion of the discussion by stating that, "A major issue is how and when physicians should address fertility issues with female transplant recipients of childbearing age" [5]. Given that as many as half of all pregnancies are unintended [7] is it safe for physicians to wait until a woman expresses an interest in becoming pregnant before initiating a conversation about the implications of organ transplantation on pregnancy? A related point made by Ross is that, even though some doctors discourage women from becoming pregnant when they have shorter-than-average 616 Virtual Mentor, September 2007-Vol 9 Ross also offers insight concerning the ethics of a second transplant should the first graft fail after pregnancy. Since, in most cases, retransplantation is riskier for the patient, and the second organ is less stable than the primary transplant, should a woman whose first graft may have been compromised by the burden of pregnancy have the chance for a second graft, when some patients on the waiting list have yet to receive a first? Ross compares this situation to that of patients who continue to abuse alcohol while waiting for a liver. Though intuitively it seems inappropriate to equate pregnancy with alcoholism, the underlying tie is the choice of voluntary behaviors that predispose one to an increased risk of graft failure. Based on this model of allocation, Ross feels that women who lose an organ during pregnancy should be eligible for a second transplant. Perhaps the most controversial aspect of this discussion is raised when Ross asks, "When a transplant recipient becomes pregnant, who is actually the patient? Should a woman have complete control over the health of her unborn child in addition to the rights over her own body? Is it appropriate for society to intervene if certain behaviors of the mother place the fetus in jeopardy? Though the same questions apply in every case of pregnancy, they take on added significance when known risks are greater than those for pregnancies in which the mother does not have a transplanted organ. Approaching the Ethics of Maternal-Fetal Conflict in Transplant Recipients: Lessons from a Parallel Case Though maternal-fetal conflict is often thought of as a matter of maternal choices, including behaviors that can impact fetal health during pregnancy, it can also apply to the decision to become pregnant in situations where parents have genetic or infectious conditions that may be passed to the child. Minkoff and Santoro believe that a new perspective on assisting these women with pregnancy is warranted by the change of disease status. Conclusion Similarly, Ross concludes with regard to this conflict of interest that, ". But the potential for conflicting interests continues to inspire varied reactions from expecting mothers and physicians to lawyers and the rest of society. Given the theoretical risks to children from immunosuppressive drugs, the higher rates of prematurity, and the low birth weight in infants, to what extent should women be discouraged from becoming pregnant after having received a transplant? Though there is no compelling evidence that immunosuppressives can be blamed for malformations in developing children, the long-term implications of many of these agents are not clearly defined at this time [13]. How aggressive should physicians be with contraception education in this patient population considering the high prevalence of unintended pregnancies in the general population? Though the legality of transplant recipients becoming pregnant and having children is not yet in dispute, the unanswered societal question weighs the wishes of transplant recipients to have children against the health implications for the child that results from the pregnancy. Kolappa is a fourth-year medical student at the University of North Carolina at Chapel Hill. His clinical and research interests include pediatric craniofacial reconstruction as well as human rights and the ethics of global medicine. Affecting 5-8 percent of all pregnancies, preeclampsia can cause substantial maternal, fetal, and neonatal morbidity and mortality. The term eclampsia is derived from Greek meaning "sudden flashing" or "lightning" and refers to the seizures that can accompany this syndrome. In the developing world, preeclampsia and hypertensive disorders of pregnancy are among the leading causes of maternal mortality [1]. Although maternal death due to preeclampsia is less common in developed countries, maternal morbidity remains high worldwide and is a major contributor to intensive care unit admissions among pregnant women. Iatrogenic preterm delivery and the associated complications of prematurity may also lead to neonatal death or serious neonatal morbidity [2]. Diagnosis the nomenclature for preeclampsia has changed over the years, with terms such as "toxemia" and "pregnancy-induced hypertension" now considered outdated. The Working Group Report on High Blood Pressure in Pregnancy [3] defines mild preeclampsia as: · · new onset of sustained elevated blood pressure (140 mmHg systolic or 90 mmHg diastolic), and proteinuria (at least 1+ on a dipstick or 300 mg in a 24 hour urine collection) first occurring after 20 weeks of gestation. Preeclampsia is considered severe when any of the following is also present: · · · · blood pressure greater than or equal to 160 mmHg systolic or 110 mmHg diastolic, urine protein excretion of at least 5 grams in a 24 hour collection, neurologic disturbances (visual changes, headache, seizures, or coma), pulmonary edema, Virtual Mentor, September 2007-Vol 9 Elevated blood pressure alone after 20 weeks of gestation is referred to as gestational hypertension, and gestational hypertension that resolves postpartum is called transient hypertension. Hypertension that persists beyond the postpartum period is considered to be chronic hypertension. These diagnoses often can be made only in retrospect, unless hypertension precedes pregnancy or develops before 20 weeks of gestation. This superimposed preeclampsia is characterized by a sudden and sustained increase in blood pressures with or without substantial increase in proteinuria. Risk Factors Preeclampsia is more common in first pregnancies and new paternity and in women with personal or family histories of preeclampsia, multifetal gestation (twins and above), obesity, or certain medical conditions such as hypertension, diabetes, certain thrombophilias, renal disease, and lupus. It is a syndrome involving multiple organ systems that is characterized by vasoconstriction, endothelial dysfunction, activation of the coagulation cascade, oxidative stress, metabolic changes, and an excessive inflammatory response. Although extensive research in this arena is ongoing, the precise pathophysiology of preeclampsia is not yet known. The first stage-abnormal vascular remodeling of the maternal uterine spiral arterioles by invasive placental trophoblasts and reduced placental perfusion-occurs early in pregnancy and is considered the cause. The second stage-which includes the maternal syndrome of vascular dysfunction and multi-organ system involvement-is considered to be a consequence of the first stage. Current research focuses on two key questions: (1) why do some, but not all women, with reduced placental perfusion develop preeclampsia? Such maternal-fetal interactions may, in part, explain the increased risk of preeclampsia in first pregnancies or new paternity and in women who have received donor eggs to achieve pregnancy.
If one or more teeth have fallen out blood pressure medication dosages order aceon 8mg on line, you can put them in a clean closed container in fresh egg white blood pressure medication types generic 2mg aceon otc, fresh coconut water or fresh whole milk blood pressure 5640 discount aceon 4 mg without prescription. Make sure the container is transported to the hospital together with the casualty one direction heart attack generic 4 mg aceon fast delivery. Always immediately transport a casualty who has sustained an injury to the head or face, or who is suspected having fracture(s) in the face or head to the nearest healthcare facility. Shoulder fractures are rare; they might be caused by a crush injury or a direct blow. You might observe following signs and symptoms: the casualty complains of severe pain, increased by movement. The casualty tends to relieve the pain by supporting the arm of the injured side and by inclining his head towards the injured side. A casualty with a suspected shoulder fracture or dislocation should be transported or referred to a healthcare facility. You might observe following signs and symptoms: the arm on the injured side is partially incapable. Tell the person to immobilise the arm on the injured side by holding that arm close to his body. Bandage the upper arm to the side of the chest with a triangular bandage, leaving the forearm free. A casualty with a suspected collar bone fracture should be transported or referred to a healthcare facility. Indirectly, a crush caused by a pressure over the front and back of the chest can also cause rib fractures. In this case the fracture ends are pushed outwards and may cause lesser injuries to the lungs. Following signs and symptoms may be observed: the casualty complains of pain at the injury area. Help the casualty to sit in the most comfortable position (usually half sitting position). If there is a penetrating wound in the chest, air might be sucked into the chest cavity. Always transport a casualty with potential rib injury or factures to the nearest healthcare facility for further medical follow up. Fractures of the ribs may injure internal organs such as the lungs, liver and spleen and cause internal bleeding. These fractures can be dangerous as the heart and underlying blood vessels might be injured as well. You might observe following signs and symptoms: the casualty complains of pain in the area of the fracture. Always urgently transport a casualty with a suspected breast bone fracture to the nearest healthcare facility. Tell the person to immobilise the affected arm by holding his arm close to his body until he obtains medical care. If the person cannot support the arm, provide a sling with a triangular bandage or improvise by turning up the lower end of the clothing and pining it above the arm to form a sling. You might also immobilize the arm using a triangular bandage (see the chapter on bandages) to support the wrist and arm. In case of a suspected upper arm fracture, you might bandage the upper arm to the chest. Always tie the knots (reef knot) on the opposite side of the thorax and not on the fractured forearm. The bandaging should be fairly firm so there is no movement of the fracture ends, but it should not be too tight in which case the circulation of blood might be stopped. There might be further swelling of the injured area and readjustment of the bandages might be necessary. In case of a suspected forearm fracture, you might apply a splint (only when the necessary expertise is available): A splint is a rigid piece of wood, plastic or metal that is applied to the fractured limb to support it and to prevent further movement of the broken bone(s). In emergency cases splints can be improvised: a folded newspaper, a piece of wood or a book can be used. The splint should be long enough to immobilize the elbow and the wrist of fractured forearm. The splint should be padded with cotton or cloths to make it fit softly and snugly on the injured forearm. Do not raise an injured arm to ensure that there is no further damage or increase in pain. Always transport or refer a casualty with a suspected upper or lower arm fracture to a nearby healthcare facility. You might observe following signs and symptoms: the casualty complains of pain that increases with movement. If the elbow can be bent, provide broad or narrow triangular bandage in figure of eight and strap the arm to the chest and support the forearm in a triangular sling. Strap the arm and forearm on the side of the body using three folded (narrow) triangular bandages. A casualty with an expected elbow fracture should always be transported or referred to a nearby healthcare facility. You might observe following signs and symptoms: the casualty complains of pain, increased by movement. Pelvis fractures often are complicated by internal injuries to the tissues and organs located inside the pelvis. You might observe following signs and symptoms: the casualty is unable to walk or even stand, although his legs appear to be uninjured. The casualty complains of pain and tenderness in the region of the hip, groin or back. The casualty might have difficulty in passing urine and there might be traces of blood in the urine. Transfer the casualty to the healthcare facility: If the healthcare facility is nearby, transport the casualty on a stretcher in the most comfortable position. Tie another broad bandage so that it overlaps with the first by half its breadth and tie similarly. Always urgently transport a casualty with an expected pelvis fracture to the nearest healthcare facility. A fracture of the neck of the thigh bone occurs quite frequently in elderly, mostly as a result of a fall. There will be bleeding into the surrounding tissues and this might result in shock. The healing of the bone takes long time and is even more prolonged in older people. Fractures of the lower leg include fractures of the shin bone (tibia) and the splint bone (fibula). You might observe following signs and symptoms: the casualty complains of pain at the injury site. To transport the injured person, keep the leg still by bandaging or splinting one leg to the other non-broken/non-dislocated one. The bandaging should be passed through the natural hollows such as knees or just above the ankles to avoid unnecessary movement of the bones. The bandaging should be fairly firm so that there is no movement of the fracture ends, but it should not be too tight in which case the circulation of blood might be stopped. Eventually you can apply a splint (only when the first aider has the necessary expertise): A splint is a rigid piece of wood, plastic or metal that is applied to the fractured limb to support it and to prevent further movement of the broken bone(s). In emergency cases splints can be improvised: a walking stick, an umbrella or a piece of wood can be used. Splints should be long enough to immobilize the joints above and below the fractured bone. Splints should be padded with cotton or cloths to make them fit softly and snugly on the injured limb. Do not raise the injured leg as it may further worsen the injury and increase the pain. Always urgently transport a casualty with a suspected fracture to the thigh to the nearest healthcare facility. Always transport or refer a casualty with suspected lower leg fracture(s) to a nearby healthcare facility. Displaced cartilage or internal bleeding might make it impossible to straighten the knee joint.
Furthermore pulse pressure 12 cheap aceon 2mg visa, the attainment of significant periods of abstinence during treatment was associated with abstinence during follow-up blood pressure medication increased heart rate purchase aceon 8 mg free shipping, emphasizing that the inception of abstinence is an important goal of treatment (194 arrhythmia unspecified icd 9 discount aceon 2 mg otc, 1275) blood pressure dehydration order aceon 4mg without a prescription. Cocaine use was significantly reduced relative to baseline use after intensive treatment (36 individual and 24 group sessions over 24 weeks, for a total of 60 sessions) with group drug counseling alone; cognitive therapy (1306) plus group drug counseling; or supportive-expressive therapy, a psychodynamically oriented approach (217), plus group drug counseling. However, the greatest reductions in cocaine use were noted with 12-step-based individual drug counseling plus group drug counseling (219); 12-step-oriented standard group counseling also appears to be comparable in efficacy with relapse prevention aftercare (229). In addition to these considerations, specific sequelae and patterns of co-occurring disorders need to be considered for patients with a cocaine use disorder. Specific co-occurring psychiatric disorders Co-occurring psychiatric and medical disorders are common among cocaine-dependent patients (1307). Several reports have addressed the treatment of patients with a psychiatric disorder who also have a cocaine-related disorder (13081315). In addition, the results of a randomized, double-blind, placebo-controlled trial (445) suggest that desipramine or amantadine treatment for depressed cocaine-abusing, methadone-maintained patients may reduce cocaine use. Several focused and reasonably well-controlled studies have shown that patients with schizophrenia who primarily abuse cocaine experience some decreases in craving with antipsychotic agents (401, 13171319). Given the evidence to date, however, these treatments alone cannot be expected to reduce cocaine use in these patients and must therefore be accompanied by appropriate psychosocial treatment for a cocaine use disorder (1309, 1310). Comorbid general medical disorders A range of general medical conditions are associated with cocaine use, depending on the route of administration of cocaine. Intranasal use may cause sinusitis, irritation and bleeding of the nasal mucosa, and nasal septum perforation. Smoking cocaine is associated with respiratory problems, such as coughing, bronchitis, bronchospasm, and pneumonitis, resulting from irritation and inflammation of the tissues lining the respiratory tract (1320, 1321). Barotrauma such as pneumothorax, pneumomediastinum, and pneumopericardium may occur as a result of coughing or a Valsalva-like maneuver that is performed to better absorb the drug (1322, 1323). Treatment of Patients With Substance Use Disorders 109 Copyright 2010, American Psychiatric Association. Puncture marks and "tracks," most commonly in the forearms, occur in individuals who inject cocaine. General medical conditions independent of the administration route of cocaine include weight loss and malnutrition from appetite suppression, myocardial infarction, and stroke (657, 1225, 1324). Seizures, palpitations, and arrhythmias have also been observed in cocaineusing individuals. Although earlier studies suggested that cocaine use during pregnancy results in adverse effects on fetal development. The cocaine-exposed infants were significantly more likely to be premature and have smaller birth weight, length, and head circumference but showed no other major or minor anomalies to a greater degree than non-cocaine-exposed infants. They found that although all of the complications they examined (prematurity, abruptio placentae, low birth weight, prevalence of major malformations, premature rupture of membrane, and mean birth weight, head circumference, and length) demonstrated worse outcomes in infants who had been exposed to cocaine in utero than those who had not, only the risk for abruptio placentae and premature rupture of membrane remained statistically associated with cocaine use. Thus, although children of women who used cocaine during pregnancy did appear to have worse perinatal outcomes, this may have been due to other factors associated with cocaine or other substance use during pregnancy. The possible effects on early childhood development that have been reported in cocaineexposed newborns include hypertonicity, spasticity, convulsions, hyperreflexia, irritability, and inattention. However, the role of exposure to cocaine or other substances, poor maternal nutrition, birth prematurity, low infant birth weight, and neonatal withdrawal in the development of these signs and symptoms remains unclear (1330, 1331). A recent review of early child development after prenatal cocaine exposure (1333) systematically examined 36 studies on this subject and documented no independent effects of cocaine exposure on most measures of child development, although it did find that some reduction in attentiveness and emotional expressivity may occur. In addition, as stated above, many children of women who used cocaine during pregnancy have other risk factors that may affect their development. A clinician who is developing a treatment plan for a pregnant patient who is withdrawing from cocaine should take into account the risks and benefits to the mother and fetus in deciding about the use and choice of pharmacotherapies. When present, the concurrent use of other substances will also need to be addressed. Of these lifetime users, 314,000 individuals had used heroin in the previous year and 169,000 reported heroin dependence at some point in the previous year. This suggests that a high proportion (54%) of individuals who used heroin in the previous year were dependent on this opiate. These numbers are likely to be significant underestimates because of the difficulty in ascertaining community rates of heroin dependence; the Office of National Drug Control Policy estimates that 750,000 to 1,000,000 individuals are heroin dependent (1333a). Heroin is not the only opiate that is abused; there has been a growing awareness of misuse or "nonmedical use" of prescription pain relievers. Although a considerably lower proportion of individuals with past-year use were dependent on prescription opioid pain relievers compared with heroin (8% vs. Given the number of individuals who are using and are dependent on opiates, it is not surprising that the most commonly studied substance-related conditions, and those for which treatments have been most extensively studied, are opioid dependence, opioid abuse, opioid intoxication, and opioid withdrawal. Interventions include pharmacological treatments with agents such as methadone, buprenorphine, and naltrexone and nonpharmacological services such as behavioral therapies and counseling. The treatment of opioid dependence, in particular, is one of the most extensively researched areas in the field of addictions, and the range of available treatments is more extensive than for most other substance use disorders. Despite the number of effective treatments for opioid dependence and the scientific basis for their efficacy and safety, the availability of treatment programs for this and other illicit drug use is limited. Among the multiple factors that probably contribute to the limited availability of such treatment generally and opioid dependence treatment in particular are the social stigma associated with treatment facilities and their patient population, limited funding for treatment, and a history of variability in the quality of treatment supplied by clinicians and existing programs. In addition, social ambivalence about the nature of addictions and the medicalization Treatment of Patients With Substance Use Disorders 111 Copyright 2010, American Psychiatric Association. There are two general thoughts regarding the treatment goals for patients with an opioid use disorder: 1) there should be abstinence from all illicit opioid use or 2) there should be a substantial decrease in use but abstinence is not an absolute requirement. The logic of the latter is that decreased use of illicit substances will translate into lower rates of risky behavior and that this is a worthy goal of treatment. Although these two general goals may seem opposed, it may be helpful to conceptualize the latter as an acceptable intermediate stage toward the ultimate achievement of the first goal-abstinence. Additional goals of treatment include addressing other substance use, psychosocial outcomes. Treatment goals will vary depending on the circumstances of the particular patient, the specific opioid-related disorder for which the patient seeks treatment, the treatment setting, the resources available to the practitioner, and the resources available to the patient. Defining specific goals that are applicable to all patients is unrealistic, but a few further general points regarding treatment goals are worth noting. For example, cessation or stabilization of substance use should be an early and primary treatment goal. It is probably premature to attempt to rectify many early psychiatric symptoms or psychosocial problems while a patient is actively using opioids. However, exceptions may be made in certain circumstances, such as with a patient who has a clear history of a psychiatric disorder that is independent of the substance use or a patient who is acutely suicidal. In particular, the patient who maintains that he or she needs pharmacological treatment for anxiety or depressive symptoms to control illicit opioid use is probably best initially managed with a focus on the substance use. Another general treatment goal may include educating patients about the possibility of relapses during treatment and the importance of making a plan to prevent further substance use if a relapse occurs. As in the treatment of all patients, the least restrictive setting that is likely to facilitate safe and effective treatment is preferred. There are some general guidelines and recommendations for treatment settings for opioidrelated disorders. An opioid overdose, which in severe cases can be a life-threatening emergency, should be evaluated and initially managed in a supervised medical setting such as an emergency department or inpatient service. Treatment typically includes reversal of opioid effects with an opioid antagonist. Opioid withdrawal may also be treated in an inpatient setting and can be effectively managed with pharmacological agents such as opioid agonist medications. Although management of opioid withdrawal symptoms can be effectively achieved relatively quickly in an inpatient setting. Drug-free programs can provide services to patients who have undergone an inpatient, medically supervised opioid withdrawal. Although these programs do not provide opioid agonists to patients, they may provide naltrexone for the treatment of opioid dependence. There also has been interest in developing office-based methadone treatment, which is generally not available in the United States except under certain circumstances in which a physician works with an opioid treatment program (1334). Outpatient opioid treatment programs, a third treatment setting, are primarily methadone maintenance programs, although buprenorphine can also be provided in this setting. These operate under special federal and state regulations, and expansion of this modality has been difficult in many parts of the United States. However, when properly operated, these programs can be highly effective for patients who have been unable to maintain abstinence from illicit opioid use. Methadone maintenance is the most common form of pharmacological treatment for opioid dependence, with more than 240,000 individuals estimated to be receiving methadone treatment in the United States in 2004.
First blood pressure ranges low discount 2mg aceon otc, medications frequently affect only part of the substance dependence syndrome while leaving other aspects untouched arteria umbilical discount 4 mg aceon. Second blood pressure beta blocker proven aceon 2 mg, side effects or delayed effects of medications may limit acceptability and adherence blood pressure medication with water pill cheap aceon 4 mg without a prescription. Third, medications typically target only one class of substances, whereas abuse of multiple substances is the norm in treatment populations (174). Fourth, gains made while taking the medication tend to diminish when the treatment is discontinued, whereas vulnerability to relapse is lifelong. The importance of psychosocial treatments is reinforced by the recognition that there are only a handful of effective pharmacotherapies for substance use disorders and that, for the most part, these therapies are limited to the treatment of opioid, alcohol, and nicotine dependence (175). Effective pharmacotherapies for dependence on cocaine and other stimulants, marijuana, hallucinogens, and sedative-hypnotics have yet to be developed. For individuals who abuse these latter substances, psychosocial therapies remain the principal treatments. Although the foregoing discussion has emphasized the need for psychotherapy to enhance the effectiveness of pharmacotherapy, this section would not be complete without considering the role of pharmacotherapy in enhancing the efficacy of psychotherapy. These two treatments have different mechanisms of action and targeted effects that can counteract the weaknesses of either treatment alone. Psychotherapies effect change by psychological means in the psychosocial aspects of substance abuse, such as motivation, coping skills, dysfunctional thoughts, or social relationships. The weaknesses of these treatments include a limited effect on the physiological aspects of substance abuse or withdrawal. Also, the impact of behavioral treatments tends to be delayed, requiring practice, repeated sessions, and a "working through" process. In contrast, the relative strength of pharmacological treatments is their rapid action in reducing immediate or protracted withdrawal symptoms, craving, and the rewarding effects of continued substance use. Because of the complementary actions of psychotherapies and pharmacotherapies, combined treatment has a number of potential advantages. As is reviewed later, research evidence on combined treatment is sparse but generally supportive. Although factors such as patient acceptance can limit the use of combined approaches, it is important to note that for the treatment of substance use disorders, no studies have shown that combined treatments are less effective than either psychotherapy or pharmacotherapy alone. These therapies target two processes conceptualized as underlying substance abuse: 1) dysfunctional thoughts, such as the belief that the use of substances is completely uncontrollable, and 2) maladaptive behaviors, such as acceptance of offers to use drugs. Early versions of this approach (177, 178) were derived from cognitive therapy for depression and anxiety by Beck and Emery (179) and placed primary emphasis on identifying and modifying dysfunctional thinking patterns. Other adaptations of this approach have broadened the focus of therapy to help the patient master an individualized set of coping strategies as an effective alternative to substance use (176, 180). This strategy has been successfully used as an adjunct to a more comprehensive treatment plan and can be delivered in a wide variety of outpatient treatment settings. It may be particularly useful in certain dually diagnosed populations, such as patients with schizophrenia (182) and adolescents at risk for beginning substance abuse (183). In more recent clinical trials (43, 187), techniques drawn from cognitive therapy and relapse prevention have been combined with the aims of initiating abstinence and preventing relapse. Treatment of Patients With Substance Use Disorders 39 Copyright 2010, American Psychiatric Association. It continues the use of motivational interviewing and moves a patient closer to a readiness to change substance use behaviors (reviewed in DiClemente et al. It combines techniques from cognitive, client-centered, systems, and social-psychological persuasion approaches and may be provided by trained clinicians in substance abuse facilities, mental health clinics, and private practice offices. This treatment modality is effective even for patients who are not highly motivated to change, which gives it a practical advantage over other therapies for substance use disorders in many settings. Behavioral therapies Behavioral therapies are based on basic principles of learning theory (188), which deals with the role of externally applied positive or negative contingencies on learning or unlearning of behaviors that can range from simple autonomic reactions such as salivation to complex behavioral routines such as purchasing drugs. When these theories are applied to substance use disorders, the target behavior is habitual excessive substance use, which is altered through systematic environmental manipulations that vary widely depending on the specific substance use behavior. The shared goals of behavioral therapies are to interrupt the sequence of substance use in response to internal or external cues and substitute behaviors that take the place of or are incompatible with substance use. There are two broad classes of learning theory-based treatments: 1) those that are based on classical conditioning and focus more on antecedent stimuli such as cue exposure therapy (189) and 2) those that are based on operant conditioning and focus more on consequences such as community reinforcement therapy (190). As an adjunctive treatment, contingency management has been used with a variety of substances of abuse, including cocaine (193196), opiates (197200), and marijuana (201). Incentives to be offered, behaviors to be reinforced, and the reinforcement schedule vary widely by substance and also depend on the role of contingency management within the larger treatment plan (188). Although most studies have centered on abstinence from substance use, contingency management procedures are potentially applicable to a wide range of target behaviors and problems, including treatment retention, adherence to treatment. Contingency management is effective when desired behaviors are rewarded with vouchers that can be exchanged for mutually agreed-on items such as movie tickets. Contingency contracting is a subtype of contingency management based on the use of predetermined positive or negative consequences to reward abstinence or punish, and thus deter, drug-related behaviors. The effectiveness of this approach depends heavily on the concurrent use of frequent, random, supervised urine screening for substance use. Cue exposure can also be paired with relaxation techniques and drug-refusal training to facilitate the extinction of classically conditioned craving (213, 214). As an alternative, relaxation training has been used alone to provide a nonsubstance response to counteract dysphoric affects or anxiety. This treatment seeks to eliminate substance use behaviors by pairing them with punishment. Systematic testing of the efficacy of psychodynamic treatments for substance use disorders has occurred only with supportive-expressive therapy (217), a comparatively brief psychodynamically oriented treatment based on the use of interpretation and a supportive therapeutic relationship to modify negative views of the self and others. Two trials have supported the efficacy of supportive-expressive therapy for methadone-maintained, opioid-dependent paTreatment of Patients With Substance Use Disorders 41 Copyright 2010, American Psychiatric Association. However, an additional randomized trial found that combined individual and group drug counseling was superior to a combination of individual support-expressive therapy and group drug counseling in treating patients with cocaine dependence (219). By discovering the relation between interpersonal problems and substance use, the patient can move toward making changes aimed at building a social network that is supportive of recovery. Group therapy Group therapy is viewed as an integral and valuable part of the treatment regimen for many patients with a substance use disorder. In addition, aspects of group therapy may make this modality more effective than individual treatment for individuals with a substance use disorder. For example, given the social stigma attached to having lost control of substance use, the presence of other group members who acknowledge having a similar problem can provide comfort. In addition, other group members who are further along in their recovery can act as models, illustrating that attempts to stop substance use are not futile. These more experienced group members can offer a wide variety of coping strategies that go beyond the repertoire known even by the most skilled individual therapist. Furthermore, group members frequently can act as "buddies" who offer continued support outside of group sessions in a way that most professional therapists do not. Finally, the public nature of group therapy provides a powerful incentive to individuals to avoid relapse. The ability to publicly declare the number of days sober coupled with the fear of having to publicly admit to relapse is a strong force that helps group members fight a disorder that is characterized by a breakdown of internalized control mechanisms. Individuals with substance use disorders have been characterized as having poorly functioning internal self-control mechanisms (227, 228), and the group process can provide a robust source of external control. Although clinical trials of group therapy for substance use disorders are comparatively rare, the available data suggest that the efficacy of group treatment is comparable with that of individual therapies (229, 230). No compelling empirical evidence is available to document the advantages or disadvantages of choosing group or individual treatment for substance use disorders. Because many patients have experience with group or individual therapy, patient preferences should be considered when choosing between the two types of treatment delivery or when developing a combined treatment program. Family therapies Dysfunctional families, characterized by impaired communication among family members and an inability of family members to set appropriate limits or maintain standards of behavior, are associated with poor short- and long-term treatment outcome for patients with substance use disorders (231). Family therapy may be delivered in a formal, ongoing therapeutic relationship or through periodic contact. Even the brief involvement of family members in the treatment program can enhance treatment engagement and retention. Controlled studies have shown positive outcomes of involving non-alcohol-abusing family members in the treatment of an alcohol-abusing individual (236). More recent studies have demonstrated the effectiveness of family involvement in substance use disorder treatment for both women and men (237, 238), including patients on methadone maintenance (170).
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