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By R. Leif. Washington & Lee University.

The emergence of Africa as a heroin traffick- involves both African networks discount haldol 5 mg overnight delivery, including Nigerians and ing hub is likely due to corruption discount 10mg haldol visa, limited law enforce- Tanzanians discount haldol 1.5mg on line, as well as foreign networks, including Chi- ment capacity and increased pressure on ‘traditional’ nese and Pakistanis. East Africa’s minimal law The United States of America dominated regional enforcement at ports of entry has encouraged drug traf- demand for heroin, with a heroin market worth an esti- fickers to transit heroin through that region. North America-based flows of heroin to Africa have also led to increases in organized crime groups (such as Mexican drug cartels) drug use across the continent. Anecdotal information points to and alter trafficking routes to exploit international paths a shortage in some countries, but not in all, suggesting of least resistance. Numerous global vulnerabilities that increased law enforcement efforts and decreased remain and some new areas are emerging. Global seizures of Most indicators and research suggest that cocaine is – cocaine have been generally stable over the period 2006- after heroin – the second most problematic drug world- 2009. Since 2006, seizures have shifted towards the wide in terms of negative health consequences and source areas in South America and away from the con- probably the most problematic drug in terms of traffick- sumer markets in North America and West and Central ing-related violence. Some secondary distribution countries in South America seem to have acquired increasing importance as The overall prevalence and number of cocaine users cocaine trafficking transit countries. There are regional differ- West Africa continues to be significant, in spite of a ences in recent trends, however, with significant decreases reduction of seizures since 2007 (from 25% of European reported in North America, stable trends in West and cocaine seizures that transited countries of West and Central Europe and increases in Africa and Asia. The area estimated consumption of cocaine in terms of the quan- remains vulnerable to a resurgence. Some countries in tities consumed appears to have declined, mainly due to the Asia-Pacific - with large potential consumer markets a decrease in the United States and low levels of per - have registered increasing cocaine seizures in 2008 and capita use in the emerging markets. While demand in the and, more recently, in South America and beyond, high- United States was more than four times as high as in lights the need to treat cocaine as a global problem, and Europe in 1998, just over a decade later, the volume and to develop strategies on the scale of the threat. Member Member Percent Percent Percent States States Use Use Use use use use Region providing perception problem problem problem problem problem problem perception response increased* stable decreased* increased stable decreased data rate Africa 8 15% 4 50% 2 25% 2 25% Americas 15 43% 5 33% 7 47% 3 20% Asia 13 29% 7 54% 3 23% 3 23% Europe 27 60% 14 52% 13 48% 0 0% Oceania 1 7% 0 Global 64 33% 30 47% 26 41% 8 13% * Identifies increases/ decreases ranging from either some to strong, unweighted by population. The information on the extent of cocaine use in South or main difference from previous years is the widening of Central Asia. In 2009, a substantial decrease in the esti- the ranges, arising from a lack of recent or reliable infor- mates of cocaine users was recorded for North America, mation in Africa - particularly West and Central Africa2 while cocaine use in Europe appeared to have stabilized. In geographical terms, however, cocaine use appears to 1 In 2008, the estimated annual prevalence number of cocaine users have spread. Source: Substance Abuse and Mental Health Services Adminis- tration, Results from the 2009 National Survey on Drug Use 3. This was particularly noticeable in Africa and Asia, where increasing seizures of cocaine, though still at low levels, users worldwide. Household surveys in the countries of have also been reported in countries that had never North America reveal a prevalence rate of annual cocaine reported any in the past. The main stabilization or decrease in cocaine use trends is perceived to be taking Since 2006, among the population aged 12 years and place in the Americas. As in the United States, use from the previous year, whereas the treatment cocaine use has also been decreasing considerably in demand for cocaine as the primary substance of concern Canada since 2004, when it was reported as 2. Cocaine use in the annual prevalence of cocaine use is much lower, at South and Central America remains at levels higher than 0. Experts in Mexico perceived an increase in cocaine 7 Health Canada, Canadian Alcohol and Drug Use Monitoring Survey, 8 This decline in treatment demand may stem from a change in treat- 2009. The estimated annual prevalence national survey conducted in 2009 among university among the adult population ranges between 0. The prevalence of cocaine use in South Amer- much lower among female students than male. Among ica, though much lower than North America, is compa- the students aged 18-24 and 25-34, comparable levels of rable to that in Europe. The upward trend of cocaine use recent and current cocaine use were reported, which was reported in previous years did not continue in 2009. In 14 European countries, more than a time, in combination or consecutively – is commonly quarter of clients seeking treatment in 2006 reported observed among drug-using populations. In a Canadian the United States of America, cocaine use is commonly study, equal proportions of drug users were using cocaine reported among polydrug users. A Mexican study among reported as being higher among cocaine users than can- drug users in prison settings reported that nearly all of nabis users, while cocaine users also reported higher rates them (92%) were injecting drugs and less than half were of concurrent stimulant use.

Panel Roster and Financial Disclosures Leadership (Last Reviewed: February 1 buy haldol 1.5mg fast delivery, 2016 cheap haldol 1.5mg online; Last Updated: February 1 purchase 10mg haldol, 2016) Financial Disclosure Member Company Relationship Benson, Constance University of California, San Diego None N/A Brooks, John T. Centers for Disease Control and None N/A Prevention Holmes, King University of Washington School of None N/A Medicine Kaplan, Jonathan* Centers for Disease Control and None N/A Prevention Masur, Henry National Institutes of Health None N/A Pau, Alice National Institutes of Health None N/A Note: Members were asked to disclose all relationships from 24 months prior to the updated date. Clinton University of Texas Medical Branch None N/A Xiao, Lihua Centers for Disease Control and • Water Research Foundation • Research Support Prevention * Group lead Note: Members were asked to disclose all relationships from 24 months prior to the update date. Contributors As part of the revision process, a Clinical-Community Panel was convened to review these guidelines and advise the author panel as to their usefulness for practicing clinicians with regard to content and format. Bradley Hare; San Francisco General Hospital and University of California, San Francisco— San Francisco, California • Robert Harrington; University of Washington—Seattle, Washington • E. This document replaces as policy and is in part a revision of an earlier document, health care organizations, government agencies, professional 1 the Template for Developing Guidelines: Interventions for Mental Disorders associations, or other entities. First, guidelines of varying qual- force included David Barlow, chair; Susan Mineka, co-vice chair; Elizabeth ity, from both public and private sources, have been pro- Robinson, co-vice chair; Daniel J. The cific professional behavior, endeavor, or conduct in the work group included Daniel J. The work group’s efforts were informed by extensive commentary from a wide range of gated to encourage high quality care. Walsh provided the horse- guidelines, which are not addressed in this document, con- power needed to steer this endeavor through multiple revisions and logistical roadblocks. Finally, the work group expresses its deepest ap- sist of recommendations to professionals concerning their preciation to Geoffrey M. Reed, without whose inspiration, intellectual conduct and the issues to be considered in particular areas challenge, sense of humor, and true leadership we could not have sus- of clinical practice rather than on patient outcomes or tained this effort. In this regard, guidelines differ from what are The purpose of treatment guidelines is to educate sometimes called standards in that standards are considered mandatory 2 and may be accompanied by an enforcement mechanism. The Criteria for health care professionals and health care systems about the most effective treatments available. When there is suffi- Evaluating Treatment Guidelines should be regarded as guidelines, which means that it is essentially aspirational in intent. It is intended to facilitate cient information and the guidelines are done well, they can and assist the evaluation of treatment guidelines but is not intended to be be a powerful way to help translate the current body of mandatory, exhaustive, or definitive and may not be applicable to every knowledge into actual clinical practice. The at times to professional, to refer to the trained and legally authorized most common classification system is the International person who delivers health care services. The disorder-based ap- terms such as client, consumer,orperson in place of patient to describe 3 proach has limitations: Patients commonly present issues the recipient of services. Although it will be tems, such as the World Health Organization’s functionally helpful to those wishing to construct treatment guidelines, based International Classification of Functioning, Disabil- it does not provide sufficient specificity to serve as the sole ity, and Health (World Health Organization, 2001), might basis for such efforts. It is not intended to promote the also provide a basis for the development of treatment application of a particular set of treatment techniques or guidelines. Finally, this document is not intended to imply uating guidelines to consider the adequacy and limitations that the treatments provided by individual practitioners of the nosological systems on which they are based. Treatment guidelines have the potential to influence The treatment strategy most likely to succeed usually com- the health care of many patients, and therefore the guide- bines the most effective specific interventions with a strong lines and the process used in their development should be therapeutic relationship and a mutual expectation of and open to public scrutiny. Such factors, which are com- scientific justification for a guideline violates a basic prin- mon to most treatment situations, can be powerful deter- ciple of science, which requires open scrutiny and debate. Good guidelines allow for Without the disclosure of adequate scientific information, flexibility in treatment selection so as to maximize the guidelines are mere expressions of opinion. This document is organized on the basis of two related The judgment of health care professionals, although always dimensions for the evaluation of guidelines. The first di- needed, is particularly important in the treatment of condi- mension is treatment efficacy, the systematic and scientific tions for which research data are limited. The second di- should take these factors into consideration and particularly mension is clinical utility, the applicability, feasibility, and should avoid encouraging an overly mechanistic approach usefulness of the intervention in the local or specific setting that could undermine the treatment relationship. This dimension also includes It is often assumed that the use of treatment guidelines determination of the generalizability of an intervention will significantly reduce the cost of services. It is possible that guideline implementa- countability, criteria for evaluating the process of guideline tion may cause some services to be discontinued because of production are also provided. Treatment Efficacy However, it is also possible that the adoption of guidelines will lead to a shift toward more effective but not necessar- This dimension asks the question, How well does the ily less costly services. The term treatment effi- treatment via guidelines will always be beneficial because cacy refers to a valid ascertainment of the effects of a given it reduces practice variation.

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