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The adjustment varies from year to year discount arimidex 1 mg on-line, avoid this lengthy process generic arimidex 1 mg with amex, yield surveyors measure the depending on the proportion of small fields present in number of poppy capsules and their size in sample plots arimidex 1mg overnight delivery. Thus, the adjust- poppy capsule volume indicates how much opium gum ment factor has to be calculated for each year separately. Thus, the per hectare Efforts are under way to recalculate the time series for opium yield can be estimated. In the Plurinational State of Bolivia and Peru, the coca area as estimated from satellite imagery in the second For coca bush, the number of harvests varies, as does the half of the year was used as a proxy for the net produc- yield per harvest. In calculate the potential cocaine production from coca leaf Colombia, where the security situation does not allow or the heroin production from opium - are not known. In all three coca cocaine content of the coca leaf, as well as detailed infor- cultivating countries, yield surveys are carried out only mation on the efficiency of clandestine laboratories. In the case of opium gum, for example, traffickers extract the mor- 1,300 1,232 1,264 phine contained in the gum in one process, transform 1,200 1,201 1,125 1,111 the morphine into heroin base in a second process, and 1,034 1,024 1,054 1,100 1,020 finally produce heroin hydrochloride. In the case of 1,000 cocaine, coca paste is produced from either sun-dried (in 865 842 the Plurinational State of Bolivia and Peru) or fresh coca 900 786 leaves (in Colombia), which is later transformed into 800 cocaine base, from where cocaine hydrochloride is pro- 700 duced. Such conversion factors are based on interviews with the Applying the new conversion factors to Bolivia and Peru people involved in the process, such as farmers in Using previous conversion factors Colombia, who report how much coca leaf they need to produce 1 kg of coca paste or cocaine base. Tests have also been conducted where so-called ‘cooks’ or ‘chemists’ Many cannabis farmers in Afghanistan and Morocco demonstrate how they do the processing under local conduct the first processing steps themselves, either by conditions. A number of studies conducted by enforce- removing the upper leaves and flowers of the plant to ment agencies in the main drug-producing countries produce cannabis herb or by threshing and sieving the have provided the orders of magnitude for the transfor- plant material to extract the cannabis resin. This and resin yield per hectare can be obtained by multiply- information is usually based on just a few case studies, ing the plant material yield with an extraction factor. The yield study included observation of the actual production of resin, always possible due to the sensitivity of the topic, espe- which is a process of threshing and sieving the dried cially if the processing is done by specialists and not by cannabis plants. Establishing conversion ratios is by using information from farmers on the methods used complicated by the fact that traffickers may not know and on results from scientific laboratories. Information the quality of the raw material and chemicals they use, on the yield was obtained from interviews with cannabis which may vary considerably; they may have to use a farmers. For years before 2010, the net productive tion in many cannabis-cultivating countries. In addition, significant quantities of the inter- Potential cocaine production in the Plurinational State mediate products, coca paste or morphine, are also con- of Bolivia is estimated from potential coca leaf produc- sumed in the producing countries. Some products such tion after deducting the amount of coca leaf produced as opium can be stored for extended periods of time and on 12,000 ha in the Yungas of La Paz where coca cultiva- be converted into intermediate or final products long tion is authorized under national law. These factors are partly taken into account: for example, consumption of coca leaf consid- Drug trafficking ered licit in the Plurinational State of Bolivia and Peru Seizures is not taken into account for the transformation into cocaine. In reality, clandestine laboratories do not thus the most comprehensive indicator of the drug situ- produce 100% pure cocaine but cocaine of lower purity ation and its evolution at the global level. For heroin, zures may not always reflect trafficking trends correctly not enough information is available to estimate the pro- at the national level, they tend to show reasonable repre- duction of heroin of 100% purity. Countries may report seizures of drugs using a variety of units, primarily by weight (kg) but also in litres, tablets, Although it is based on current knowledge on the alka- doses, blotters, capsules, ampoules, et cetera. The concept of potential production is different For the purposes of aggregation, conversion factors are from the theoretical maximum amount of drug that used to convert the quantities into ‘kilogram equiva- could be produced if all alkaloids were extracted from lents’ (or ‘ton equivalents’). The difference between the theo- retical maximum and the potential production is The conversion factors affect seizure totals of ampheta- expressed by the so-called laboratory efficiency, which mine-type stimulants in particular, as a significant share describes which proportion of alkaloids present in plant of seizures of these drug types is reported in number of material clandestine laboratories are actually able to tablets. For reasons of comparability, 7 More information on the results of the two approaches and the the latter was presented as the point estimate. In these tables, seizure quantities are tablet form are also sometimes reported by weight, and reproduced as reported. For the weight usually refer to the bulk weight of seizures, purposes of the calculations a ‘typical consumption unit’ including adulterants and diluents, rather than the was assumed to be for cannabis herb, 0. For opiate seizures (unless specified differently in small minority of cases, as they would require informa- the text), it was assumed that 10 kg of opium were tion on purity on a case by case basis or statistically equivalent to 1 kg of morphine or heroin.

There is little trials of melatonin have evaluated its effcacy as a chronobiotic empirical evidence available to guide decisions regarding which (phase-shifting agent) rather than as a hypnotic order arimidex 1 mg line. Effcacy and safety data for most logical treatment need to be based primarily on common clinical over-the-counter insomnia medications is limited to short-term practice and consensus cheap arimidex 1 mg otc. If hypnotic medications are used long- studies order arimidex 1 mg with visa; their safety and effcacy in long-term treatment is un- term, regular follow-up visits should be scheduled at least every known. These facts, the frequency and dose in order to minimize side effects and however, do not provide the clinician with a clear set of practice determine the lowest effective dose may be indicated. The literature that has examined the issue few days’ use, rebound insomnia (worsening of symptoms with of individual pharmacotherapy or cognitive behavioral treat- dose reduction, typically lasting 1-3 days), potential physical as ment versus a combination of these approaches demonstrates well as psychological withdrawal effects, and recurrence of in- that short-term pharmacological treatments alone are effective somnia may all occur. Tapering the frequency of administration (such as improvements appear sustained at follow-up for up to two every other or every third night) has also been shown to minimize years. As noted elsewhere, tapering and discontinuation of demonstrate a clear advantage for combined treatment over hypnotic medication is facilitated by concurrent application of cognitive behavioral treatment alone. Buysse has consulted to and/or been on the advisory board of Actelion, The guidelines presented are generally appropriate for older Arena, Cephalon, Eli Lilly, GlaxoSmithKline, Merck, Neuro- adults as well as younger adults. However, lower doses of all crine, Neurogen, Pfzer, Respironics, Sanof-Aventis, Sepracor, agents (with the exception of ramelteon) may be required in Servier, Somnus Therapeutics, Stress Eraser, Takeda, and Tran- older adults, and the potential for side-effects and drug-drug scept Pharmaceuticals. The other authors have indicated no f- interactions should be carefully considered. International classifca- of insomnia comorbid with depression or anxiety disorders tion of sleep disorders, 2nd ed. Littner M, Hirshkowitz M, Kramer M; Standards of Practice at recommended doses, or an effcacious psychotherapy for the Committee of the American Academy of Sleep Medicine. Practice pa- rameters for clinical use of the multiple sleep latency test and the is used as monotherapy for a patient with comorbid depres- maintenance of wakefulness test. In many cases, this dose will be higher eters for the nonpharmacologic treatment of chronic insomnia. Standards of or olanzapine may be specifcally useful in individuals with bi- Practice Committee of the American Academy of Sleep Medi- polar disorder or severe anxiety disorders. In for the psychological and behavioral treatment of insomnia: an some cases, medications such as gabapentin or pregabalin may update. Practice parameters with a longer-acting analgesic medication near bedtime may for the use of actigraphy in the assessment of sleep and sleep also be useful, although narcotic analgesics may disrupt sleep disorders: an update for 2007. Rules of evidence and clinical recommendations for bid insomnia may beneft from behavioral and psychological the management of patients. The burden of chronic insomnia on society: awaken- Combined Therapy for Insomnia ing insomnia management. Characteristics of insomnia in the United Hypnotic medications are effcacious as short-term treatment States: results of the 1991 National Sleep Foundation Survey. Epidemiology of insomnia: what we know and what sleep in a model of transient insomnia related to a novel sleep we still need to learn. Beneft-risk assessment of zaleplon in the miology of insomnia: prevalence, self-help treatments, consul- treatment of insomnia. Philadelphia: Elsevier mary insomnia: results of a polysomnographic double-blind con- Saunders, 2005:714-25. A review of the evidence for the effcacy and safe- Psychophysiological insomnia: the behavioural model and a neu- ty of trazodone in insomnia. Quantitative criteria on sleep physiology measures with major depression and insom- for insomnia. Vale- diagnostic criteria for insomnia: Report of an American Academy rian-hops combination and diphenhydramine for treating in- of Sleep Medicine Work Group. National Institutes of Health State nightly use of zolpidem in chronic insomnia: results of a large- of the Science Conference statement on Manifestations and Man- scale, double-blind, randomized, outpatient study. Certifed behavioral sleep clone over 6 months of nightly treatment: results of a randomized, medicine specialists. Rebound insomnia: dura- zolpidem for chronic insomnia: A meta-analysis of treatment ef- tion of use and individual differences. Eszopiclone co-admin- mals and patients with insomnia after abrupt and tapered discon- istered with fuoxetine in patients with insomnia coexisitng with tinuation. Trazodone for antide- chological treatment for insomnia in the management of long- pressant-associated insomnia Am J Psychiatry 1994;151:1069-72.

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None the less order 1 mg arimidex with visa, the widely reported eff- cacy of herbal cannabis relative to standard prescribed drugs for a large number of individuals with chronic illnesses order 1 mg arimidex with amex, who do not ft the bill as stereotyped drug users generic arimidex 1 mg fast delivery, has forced the issue. Thirteen states now allow the use of medical cannabis—they are Alaska, California, Colorado, Hawaii, Maine, Maryland, Montana, Nevada, New Mexico, Oregon, Rhode Island, Vermont, and Washington. As a result, there have been a series of unpleasant enforcement incidents, with federal police closing down medical production and dispensaries that were offcially sanctioned by state governments. These patients have been provided with medical cannabis for between 11 and 27 years. Material is shipped to the Research Triangle Institute in North Carolina where it is chopped and rolled on modifed tobacco cigarette machines, then stored partially dehydrated and frozen. Legal cannabis production in Canada A similar scenario has played out in Canada where, in 2001, medical use of cannabis was legalised in restricted circumstances through the 180 Canadian Department of Health’s Medical Marihuana Access Division. According to their Marihuana Medical Access Regulations, individuals can get licences to produce their own supply of cannabis, or a licence can be given to another designated individual to grow on their behalf. In 2000 Canada’s department of health, Health Canada, contracted Prairie Plant Systems, on behalf of the federal government, to grow cannabis in an underground mine at Flin Flon Manitoba for research purposes, and in 2003 to distribute to the expanding number of medical users in the 180 Health Canada website: 210 www. Along with the estimated 600 users of the Prairie Plant Systems 183 cannabis there are over 11,000 users of ‘compassion clubs’ in Canada. These clubs act as medical cannabis dispensaries, supplying cannabis for therapeutic use upon a valid recommendation or confrmation of 184 diagnosis from a licensed health care practitioner. Whilst the Senate 185 Special Committee on Illegal Drugs and other government bodies have recommended that these organisations be licensed and legally recogn- ised, currently they are operating without legal sanction. They set clearly defned standards, including demands that a variety of strains be offered 181 Health Canada’s Medical Marihuana Access Division website: www. Report of the Senate Special Committee on Illegal Drugs’, Summary Report, September 2002, page 20. Cultivators must also protect the cannabis from yeasts, moulds, mildews and fungi. Whilst small scale cultivation for personal use is tolerated (as elsewhere in Europe), larger scale production or importation for supplying the coffee shops is not, and has been the subject of an increasing enforcement effort over the last few years. In previous decades Dutch criminal enterprises were more closely involved in European and international cannabis trafficking but an enforce- ment push in the late 1990s dismantled much of this activity and coincided with the expansion of domestic illicit production, both in the Netherlands and elsewhere. Domestic production of herbal cannabis now constitutes 75–80% of coffee shop sales, and whilst it is unregulated in terms of strength and contamination it is considered to be of generally good quality. There is no reliable data available, however, a substantial proportion of domestic Dutch production is still thought to be for export to neighbouring countries. The exported cannabis is rumoured to be of lower quality, and thus not acceptable in the coffee shops—it is supplied as vacuum sealed product more easily bulked up with non-cannabis materials. Most hash/resin form cannabis in the coffee shops is still imported from Morocco, through established illicit routes. It is associated with one of the main Hindu gods—Shiva—and is also used openly during tradi- tional annual festivals, most commonly the spring festival of Holi. Government bhang shops were, and in some cases still are, prevalent throughout large parts of India. Under the 1961 Single Convention they, like many other countries who had what was described as ‘traditional use’ of scheduled drugs, were obliged to end the use of such substances within 25 years. In a similar fashion to the traditional use of the coca leaf in the Andes this has, perhaps unsurprisingly, not happened (the 25 year window perhaps being a signal that it was never likely to either). There are still ‘official’ government bhang shops in some cities such as Varanasi and Puri (and others across Rajasthan), and it is still widely used during religious festivals, as well as on a more regular basis by a small number of holy men or Sadhus. Production of the bhang, which is relatively low potency and most commonly eaten or in a beverage, is essentially unregulated, operating much like production of herbs and spices. These cannot be legally restricted or controlled as they have a wide range of other legitimate uses. Given this reality, small scale domestic produc- tion has become increasingly popular and widespread, supported by a burgeoning industry in growing guides and literature, technology and paraphernalia. This development has been facilitated by the diffculty in legislating against the distribution of cannabis seeds, which do not 186 themselves contain the active drugs.

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