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In order to achieve full integration of cheap cozaar 50 mg with mastercard, and participation in generic cozaar 25mg fast delivery, arts and health activities purchase cozaar 50mg visa, it is important to consider barriers to access. For example, artists who are not trained expressive arts therapists may not know how to get involved in healthcare facilities, healthcare providers might have preconceived ideas about the nature of arts and culture activities and patients may think they are not skilled enough to participate. Additionally, practical barriers may include diffculty traveling to arts and health programs, lack of funding for programs and inadequate space to carry out programs. Collaborations can yield numerous benefts such as the sharing of expertise, access to resources and greater effciency and effectiveness of service delivery. When the arts and health felds intersect, partnership offers a way to further humanize healthcare settings and empower patients to share their stories and interact with others in different ways. As with any collaboration, success is achievable only when the parties involved communicate regularly, set clear and measurable goals and delineate expectations. Populations being served should also be given opportunities to share their experiences and talk about what best meets their needs. The collection and dissemination of verifable, high-quality data are essential to bolstering the case for continued integration of the arts and culture and health and human services sectors. The most powerful accounts meld quantitative data into a patient’s personal journey. In this way, the patient’s story humanizes the numbers in data tables, while the data tables can lend verifability to the intrinsic values of arts and culture experience. Community Partnership for Arts and Culture 63 Creative Minds in Medicine • Educating the public, healthcare professionals and artists about the intersection. In order to foster and strengthen the intersection between arts and health, it is essential for arts and health stakeholders to be given opportunities to share their experiences and educate others about the different ways arts and health intersect. Since the intersection runs along a continuum that varies according to factors such as engagement, programmatic structure and goals, it is important to think about arts and health defnitions broadly to invite new avenues for participation. When introducing arts and culture into healthcare settings, strategies to ensure the maintenance of sterile environments are essential to protecting the safety of patients. For artists, gaining a shared understanding with healthcare providers during the development of arts and health projects can allow them to customize programming to meet the special needs of patients and understand how to best engage them in arts and culture activities. Conversely, for healthcare providers who are inviting artists to do work in their facilities, orientation sessions can be useful because artists’ levels of clinical experience with patients may vary. Such training can include primers on privacy requirements, workplace safety regulations, management of emotionally challenging situations and working with different populations. Recommendations for Future Policy The health and human services sector provides assistance to people from all backgrounds at some of the most defning moments of their lives. This white paper has highlighted four overarching views of how arts and culture intersect with the health and human services feld: through arts and culture integration in healthcare environments; direct patient engagement in arts and culture activities; community-based, arts and culture projects that address public health issues; and the incorporation of arts and culture in medical curricula. This paper has also shown a breadth of examples of what is happening between the arts and health felds in Cleveland. While not exhaustive, this white paper’s goal was to defne and identify a sampling of the strong body of work that is resulting from collaboration among the wealth of local arts and health assets. While Cleveland’s legacy as an industrial city has left it with signifcant challenges, it is also responsible for giving the city key assets that are defning its future. The intersections of its arts and culture assets and health and human services institutions are driving innovative partnerships that are positively affecting the well-being of individuals, as well as the health of the broader place they call home. In order to foster the arts and health connection, a number of policy issues merit consideration: • Research. Greater attention must be given to the valuable contributions arts and culture provide to the health and human services feld. Through the design of research studies that quantify both the individual and public benefts of the intersection, practitioners will be positioned to teach others that arts and culture activities are not simply entertainment or something that is “nice to have,” but are an essential and necessary element of true patient- centered care and recovery. Community Partnership for Arts and Culture 64 Creative Minds in Medicine • Communications. All events and activities that illustrate the arts and health intersection must be promoted publicly through outreach to media outlets, medical practitioners and caregivers who may not be fully aware of the intersection’s value. Such outreach will further demonstrate the powerful momentum in Cleveland that is uniting the arts and health felds. Opportunities for practitioners to network, share research and discuss best practices must also be frequently organized and made open to all, from those already doing arts and health work to those who are looking to get involved. By uniting the arts and health sectors, greater attention can be called to the specifc needs facing practitioners of arts and health as well as to possible strategies for addressing them. Such networking will also help the arts and health feld build a united force through which common cause issues can be addressed. Funding should focus on supporting the full design, implementation and evaluation of arts and health programming. In addition, strategies to further validate arts and health activities as medical practice, such as the development of state licensures for art and music therapists, can be explored as avenues for obtaining recognition and reimbursements from insurance sources. The development of local, formalized educational programs, such as the University of Florida’s Certifcate in Arts in Medicine or Certifcate in Arts in Public Health,258 can help bolster expertise in the work of the arts and health feld. It is also important for colleges and universities to make opportunities available to students from diverse academic backgrounds to learn about creative intersections and the roles their specialized knowledge can play in the arts industry. Conversely, for students studying arts and culture-related subjects, employment opportunities in sectors such as health and human services and community development should also be promoted. By using these strategies to reinforce existing intersections, Cleveland has the ability to capitalize further on its wealth of arts and culture and health and human services assets. While Cleveland is already widely celebrated for the merits of these local sectors individually, it has a unique opportunity to become the undisputed leader of arts and health partnerships that exist at the place where creativity and well-being meet. Community Partnership for Arts and Culture 65 Creative Minds in Medicine Conclusion Creative Minds in Medicine At this juncture, returning to the World Health Organization’s defnition of health is useful – “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infrmity. The health of a place is beholden to factors that span the economic, educational, social and environmental needs of the people living there. Satisfying such conditions is one essential element to improving the health of a city and consequently laying the foundation for supporting individual health. However, this is only one side of the equation, because the health needs of each individual are unique to that person’s life experiences and the point where they stand on their personal health journey. Personal experiences ultimately drive health needs, which in turn defne what factors of place are needed to meet those needs. The ability of arts and culture to draw connections to a particular place, unite communities and mobilize individuals in support of common causes directly affects community health. Similarly, the ability of arts and culture to foster creativity, inspire refection and draw out an individual’s interpretation of his or her world directly infuence personal health and well-being. Arts’ and health’s common impact on both the community and the individual is the clear point from which their intersection grows. Yet, on a deeper level, the arts and health intersection also grows from the inherent creativity that lives within the mind of every person. It lives in the doctor who is conducting clinical research in pursuit of a new treatment. It lives in patients and their caregivers who are trying to make sense of a diagnosis. The creative process ignites our passions, drives our perspectives of the world, and pushes us to challenge accepted conventions. In the end, the arts and health intersection is founded on the use of creativity to gain insights about what it is to be human – to experience life from birth to death. This shared purpose is what ultimately eases the tension between art and science, as each offers a different, but inseparable, path to improving the conditions inherent to our common humanity. Community Partnership for Arts and Culture 66 Creative Minds in Medicine case study Billy Bear’s Honey Chase Billy Bear’s Honey Chase Main Menu Screen capture courtesy of the Cleveland Institute of Art Community Partnership for Arts and Culture 67 Creative Minds in Medicine designing for the future The words “computer game” may mean pretty much the same thing as “lurid murder” to a lot of people. Nearly all screen games seem to involve bloody, nonstop shootings, beatings or explosions, usually carried out with high-tech metal weapons the size of Godzilla. The Cleveland Institute of Art Associate Professor of Biomedical Art and Chair of the Game Design program makes a point now of encouraging her students to design nonviolent entertainments. She’s even started revising the curriculum standards for the program to encourage courses focused on Games for Change, aiming for game design that promotes learning instead of virtual violence. So when Jared Bendis, Co-Owner of the app development company Lemming Labs Limited, needed an artist to design the images for an application that teaches sick children how to manage their pain, Almon came to mind faster than a wand comes to hand in a Harry Potter game. Bendis calls her an amazing illustrator who “came in and added the favor” to the game app, a task that perfectly married the skills and benefts of art with the goals of community health. What the app needed frst was a metaphor, explains Bendis, manager/designer for the project.

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Avoidance of excess caffeine generic cozaar 50mg overnight delivery, alcohol 50mg cozaar with mastercard, and sugar has long been surmised to be helpful generic cozaar 25mg on line. More recently, ingestion of fats has been recognized as influencing behavioral responses. Consumption of lard and a vegetable margarine with a high content of saturated fatty acids was found to decrease hypothalamic serotonin levels, whereas ingestion of a sunflower oil and an olive oil–enriched margarine, both high in polyunsatu- rated fatty acids, did not significantly affect serotonin levels. These changes were noted even when consumption occurred over a relatively short period in adulthood. Despite abundant evidence that serotonin is involved in anxiety in both animals and humans, acute trypto- phan depletion, although it enhanced the effect of a panic attack, was found to have little effect on general levels of anxiety. A double-blind, ran- domized, controlled trial of healthy male volunteers showed that Berocca (Roche), a multivitamin mineral supplement, was associated with consistent and statistically significant reductions in anxiety and perceived stress. Clinical trials in women with premenstrual syndrome have shown that calcium supplemen- tation effectively alleviates the majority of mood and somatic symptoms. Inclusion of 100 mg of pan- tothenic acid as part of a B complex has also been suggested for particularly stressful periods. A sleep laboratory study demonstrated that although the effects of 900 mg of valerian on sleep were not significantly dif- ferent from those of placebo, it did decrease subjective feelings of somatic arousal without affecting physiologic activation. A preliminary study suggested that kava may exert a favorable effect on reflex vagal control of heart rate in generalized anxiety disorders. The improved baroreflex control of heart rate induced by kava paralleled the patient’s clinical improvement. The kavapyrones affect the glutamate systems and inhibit sodium and calcium channels, resulting in centrally acting skeletal muscle relaxation and an anti- convulsant effect. The uptake of norepinephrine, a “feel good” neurotrans- mitter, is also inhibited. Clinical trials have shown that kava is superior to placebo, and roughly equivalent to oxazepam, 15 mg/day, or bromazepam, 9 mg/day. At a daily therapeutic dose of around 200 mg, kava may cause mild gastrointesti- nal complaints and/or allergic skin reactions in up to 1. Kava extract is increasingly regarded as an effective alternative to antide- pressants and tranquilizers in the treatment of anxiety of nonpsychotic ori- gin. The adaptogenic qualities of Siberian ginseng (100-300 mg three times a day) may benefit anxious patients who are stressed and fatigued. In animal studies Hypericum perfora- tum and Panax ginseng were found to be associated with significant and qual- itatively comparable antistress activity as judged by a variety of behavioral and physiologic changes in rats exposed to long-term stress. Findings from ani- mal studies have indicated that a combination of Ginkgo biloba and Zingiber officinale (ginger) has anxiolytic effects comparable to those of diazepam; however, in high doses, anxiogenic properties were also noted. She had experienced an abrupt onset of dizziness, lightheadedness, and uncomfortable “electric sensations” 230 Part Two / Disease Management in her trunk and limbs. These symptoms were followed by moderately severe anxiety, verging on panic, and a feeling of breathlessness. Over the next few weeks, these sensations followed a fluctuating course with an over- all increase in severity, but neurologic and cardiologic investigation failed to demonstrate any identifiable problem. Left with no clear-cut diagnosis and continuing to have inexplicable symptoms, Merran began having frank panic attacks, and she was referred to me. She had not been treated for psychological problems before, but neither had her life been as stressful as it had been in the previous 18 months with worry over her depressed, unemployed husband and a mildly anorexic daughter preparing for final year school examinations. Merran’s general health was good, and she had passed smoothly through menopause 2 years previously without significant physical or psychologic symptoms. She took no medication or supplements except calcium carbon- ate as an osteoporosis preventive, although results of a recent bone density test had been normal. Her digestion was good, but her dietary history revealed a low protein intake in the context of a very light breakfast and lunch and animal protein at tea time on only three to four occasions per week. At our first interview, her original symptoms were still prominent, together with marked initial and middle insomnia and some mild depressive symptoms, such as loss of confidence and drive and occa- sional tearfulness. On examination, Merran showed herself to be a quiet, likeable, intelligent woman who expressed herself well, was psychologically minded, and appeared tense but not clinically depressed. Her blood pressure was on the low side, 110/70 mm Hg sitting, and she appeared to be a chest breather with occasional sighs. Mg deficiency) Chapter 11 / Anxiety 231 Merran was not keen on taking any medication, even for temporary night sedation, so we decided initially on tryptophan, 500 mg, at night with a low dose (<25 mg) multi-B vitamin, pending further nutritional investigation. At the same time, symptoms of dizziness and chest tightness appeared but rapidly resolved with rebreathing from cupped hands. Tryptophan (500 mg) had not improved sleeping greatly, but more protein at lunchtime had reduced her tendency to experience more prominent symptoms later in the afternoon. When prescribing tryptophan, I always explain the history and symptoms of eosinophilia-myalgia syndrome so that patients can recognize the symp- toms in the (extremely) unlikely event that they experience this problem. Breath re-education was obviously a priority for Merran; she agreed to undertake this with instruction from me (with the help of a biofeedback device) and also in the ongoing context of a yoga class. Orosco M, Rouch C, Dauge V: Behavioral responses to ingestion of different sources of fat. Evidence from studies using acute tryptophan depletion, Adv Exp Med Biol 467:43-55, 1999. Carroll D, Ring C, Suter M, Willemsen G: The effects of an oral multivitamin combination with calcium, magnesium, and zinc on psychological well-being in healthy young male volunteers: a double-blind placebo-controlled trial, Psychopharmacology (Berl) 150:220-5, 2000. Pearlstein T, Steiner M: Non-antidepressant treatment of premenstrual syndrome, J Clin Psychiatry 61(suppl 12):22-7, 2000. Thys-Jacobs S: Micronutrients and the premenstrual syndrome: the case for calcium, J Am Coll Nutr 19:220-7, 2000. Diefendorf D, Healey J, Kalyn W, editors: The healing power of vitamins, minerals and herbs, Surry Hills, Australia, 2000, Readers Digest. Kuhlmann J, Berger W, Podzuweit H, Schmidt U: The influence of valerian treatment on “reaction time, alertness and concentration” in volunteers, Pharmacopsychiatry 32:235-41, 1999. Malsch U, Kieser M: Efficacy of kava-kava in the treatment of non-psychotic anxiety, following pretreatment with benzodiazepines, Psychopharmacology (Berl) 157:277-83, 2001. John’s Wort, Ginseng, Echinacea, Saw Palmetto, and Kava, Ann Intern Med 136:42-53, 2002. Bourin M, Bougerol T, Guitton B, Broutin E: A combination of plant extracts in the treatment of outpatients with adjustment disorder with anxious mood: controlled study versus placebo, Fundam Clin Pharmacol 11:127-32, 1997. This multifac- torial disease results from the interaction of genetic, allergic, environmental, infectious, emotional, and nutritional factors. The underlying pathophysiol- ogy involves bronchial inflammation associated with airway hyperrespon- siveness and increased mucus production. Although few well-controlled studies support the efficacy of complemen- tary therapies in the treatment of asthma or other atopic disorders, such interventions are popular self-care measures among patients. Such omission is of clinical relevance because herbal preparations have been cited as the third most popular complementary treatment modality by British patients with asthma. They may also be triggered by factors as diverse as food and psy- chosocial stress. Regardless of the trigger, the pathophysiologic changes in asthma are characteristic. An imbalance between an exaggerated humoral and suppressed cell- mediated immune system may influence genetic susceptibility to asthma. The T-helper 2 subset produces cytokines, including vari- ous interleukins that stimulate the growth, differentiation, and recruitment of mast cells, basophils, eosinophils, and B cells. IgE, plentiful in mast cells and basophils, mediates bronchospasm, a characteristic of asthma. Over the last 20 years, an increased intake of linoleic acid has coincided with an increased prevalence of asthma, eczema, and allergic rhinitis4 and has also paralleled a decrease in fish consumption. A decreased cellular capacity to cope with oxidative stress is a potential risk factor for an asthma attack. This can be caused by direct inflammatory damage or induction of an autonomic imbalance between muscarinic receptor-mediated contraction and the β-adrenergic–mediated relaxation of pulmonary smooth muscle. Reduction of platelet glutathione peroxidase activity in the most severe cases suggests a diminished capacity to restore part of the antioxidant defenses; however, a case-control study failed to demonstrate any association between antioxi- dant intake and asthma. However, food sensitivities are only likely to contribute to asthmatic symptoms in a few people and only those with nonseasonal asthma. A practical approach to managing perennial asthma is to initially remove all foods eaten at least twice a week from the diet. However, in a review Ardern and Ram7 con- cluded that routine tartrazine exclusion may not benefit most patients, except those few individuals with proven sensitivity. Despite conflicting evi- dence as to whether tartrazine causes exacerbations of asthma, some studies have demonstrated a positive association, especially in individuals with cross-sensitivity to aspirin.

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Cognitive Impairment Several participants highlighted the cognitive effects of Parkinson’s disease on their day to day activities purchase cozaar 50mg overnight delivery. For some participants cozaar 50mg generic, cognitive impairment was manifested as being unable to remember words buy discount cozaar 50 mg line, particular periods of time and people. Participants shared specific instances: • “If you asked me, I wouldn’t [be able to] tell you what I had for breakfast. A wide range of sleep disturbances were reported, including difficulties falling asleep and staying asleep. Participants also mentioned that sleep disturbances sometimes lead to fatigue symptoms which may persist into the next day. One woman stated, “Using the restroom is difficult…because my stomach muscles are often too cramped. Some participants expressed the need for constant monitoring of their diet due to constipation. One participant shared, “I have to really watch meat…it will take me several days to digest and cause constipation. One participant commented that her anxiety occurred whenever she needed to “complete a particular task. Overall impact of Parkinson’s disease on daily life Throughout the meeting, participants described the physical and social impact that living with Parkinson’s disease has had on their lives. Many also highlighted the emotional burden of living with Parkinson’s disease, sharing that their condition felt “frustrating” and “incredibly scary. Several participants highlighted the effect of this reliance upon how they care for and are perceived by their family. One participant noted that family members sometimes become frustrated with his lack of ability to complete a task. He shared his family’s sentiments: “Better not give him that assignment if you want it done before the end of the day. The following examples illustrate the experiences shared in the discussion of this impact: o “I’m supposed to be the caregiver of my children…they’re only teenagers, and they’re beginning to help. Participants shared that their symptoms, particularly motor symptoms, impaired balance, and cognitive impairment, had significant impacts on their ability to perform at their job. One participant shared an experience of quitting a position due to impaired balance, stating, “the responsibility [of the position]…it was just haunting me and causing me to fall down. Many participants commented that the lack of energy, anxiety, and motor symptoms led to social isolation. One participant shared that she had increased anxiety when making social plans, saying, “, I often cancel at the last minute because I get so anxious going out. Some participants shared instances of being characterized as lazy or “looking a little slow. Topic 2: Patient Perspectives on Treatments for Parkinson’s disease The second discussion topic focused on patients’ experiences with therapies used to address their Parkinson’s disease symptoms. Five panelists, including four men and one woman, provided comments to start the dialogue. Two men discussed the hardships of pursuing treatment due to lack of timely diagnosis, one man shared detailed experiences with deep-brain stimulation, another man stressed the importance of seeking healthcare professionals which specialize in Parkinson’s disease management and one woman highlighted the importance of emerging research in stem cells and regenerative medicine. Panelists shared their experiences with complex regimens which included a variety of prescription treatments, alternative therapies, and lifestyle changes. In the large-group facilitated discussion that followed, experiences voiced by participants reflected those shared by panelists. Participants identified the importance of a personalized treatment regimen incorporating experiences of supplement and vitamin use, prescription drugs and lifestyle modifications in efforts to manage symptoms. Participants described in detail the benefits and downsides of their current treatment regimens. Participants also shared their considerations for what an ideal treatment for Parkinson’s disease would be. Prescriptions and over-the-counter drugs According to a polling question (Appendix 3, Q7), the majority of in-person and web participants reported experiences taking carbidopa-levodopa formulations, dopamine agonists, and other drug therapies. Prescription drug therapies were described as having widely varying degrees of effectiveness, 9 and many participants noted limited or decreased benefit over time because of Parkinson’s disease progression and harmful side effects. Many participants expressed specific improvements in managing tremor, balance, gait, and overall mobility with carbidopa-levodopa. Some participants described carbidopa-levodopa as a “miracle drug” which showed significant improvement in their condition. One participant shared that taking Sinemet with amantadine greatly improved his dyskinesia. Several participants commented that they had to increase the formulation strength or dosing frequency of Sinemet as their symptoms worsened. One woman shared that the dosage of her original regimen of carbidopa-levodopa nearly doubled over the course of five years. Several participants commented that despite the benefits of carbidopa-levodopa, they experienced significant down-sides. Most participants identified developing severe dyskinesia, which “became more of a problem than the actual symptom [the medication] was treating. Meeting participants acknowledged familiarity with the Duopa formulation; however, there were no comments provided on experiences using it. One caregiver shared that the lack of experience with new formulations may be due to, “debating the pros and cons of each medication and the hesitation to change something that seems to be working. One participant stated, “ropinirole has been very helpful for restless leg syndrome at bedtime. Some participants discontinued Mirapex due to “sleep attacks,” which were described as moments when “[your] conscious mind is switched off and [you] sort of go blind. Another participant said that she experienced orthostatic hypotension whenever she missed a Mirapex dose. Participants also described experiences of impulsive behavior and feet swelling as reason for reducing Mirapex use. Another participant shared an experience of using apomorphine to control unexpected symptoms in the work place. Additional treatments Participants also briefly mentioned the use of additional therapies to address their Parkinson’s disease symptoms. One participant shared that following deep brain stimulation surgery he was “disease-free from a motor standpoint. One participant shared his experience of using an assistive device to address the “head-drop” he has experienced with Parkinson’s disease. He shared that “without this [device] my chin would be on my chest” and also noted additional discomfort with use of the device. Non-drug therapies Nearly all meeting participants commented on the importance of a holistic approach to managing their Parkinson’s disease symptoms. Participants shared that exercise specifically improved sleep, cognitive function, mood and motor symptoms. The majority of meeting participants identified the importance of diet and nutrition modifications. Participants stressed throughout the meeting the positive effects of eating healthy foods as well as avoiding meat products to improve digestion and medication effects. In addition to diet changes, a few participants also reported vitamin and supplement use. Treatment downsides In addition to the medication side effects aforementioned, participants also described broader treatment downsides they experience while managing Parkinson’s disease. One participant mentioned taking 14 medications throughout the day and 15 pills at nighttime. Some participants discussed the large amount of planning involved in balancing food intake, 11 medication use and daily needs. Another participant described the task of balancing medication and food as tedious in nature and requiring a lot of focus. A few described the unpredictability that off-time brought into their lives on a daily basis. One participant shared, “[symptoms] can vary not only from day to day, but from hour to hour.

Note: The origins of the flow arrows do not necessarily indicate the source/manufacture of methamphetamine purchase cozaar 25mg on line. Flow arrows represent the direction of methamphetamine trafficking and are not an indication of the quantity trafficked generic 50mg cozaar fast delivery. The boundaries shown on this map do not imply official endorsement or acceptance by the United Nations discount cozaar 25 mg with visa. The dotted line represents approximately the Line of Control in Jammu and Kashmir agreed upon by India and Pakistan. Note: The arrows do not imply the involvement of any specific country in the regions mentioned nor do they represent the level of importance of any methamphetamine trafficking flow. The boundaries shown on this map do not imply official endorsement or acceptance by the United Nations. The dotted line represents approximately the Line of Control in Jammu and Kashmir agreed upon by India and Pakistan. The final status of Jammu and Kashmir has not yet been agreed upon by the parties. All regions with illicit to have been seized in the Middle East between March methamphetamine markets also have illicit methamphet- 2014 and November 2015. Seizure reports worldwide indicate that amphetamine, Although Lebanon was the only country in the Middle unlike methamphetamine, is largely trafficked and sup- East that reported the discovery of clandestine ampheta- plied on an intraregional basis and that there are only rare mine laboratories between 2009 and 2014, the availability linkages between regional amphetamine markets. This is of precursor chemicals and the existence of certain areas especially evidenced in Europe and the Middle East, where of limited government control in some countries in the countries continue to report large amounts of seized subregion are risk factors for potential amphetamine amphetamine. Amphetamine seizures reported in the Middle East in Variations in “ecstasy” purity and composition recent years point to trafficking dynamics that are mainly contained within the region. In 2013 and 2014, most of In recent years, there have been indications of an the amphetamine seized in the Middle East was considered increasingly diversified “ecstasy” market featuring three to have originated in Lebanon and the Syrian Arab Repub- different product types: “ecstasy” tablets containing little lic. Moreover, Israel, Jordan, Lebanon and the Syrian Arab Republic were perceived to be the main 219 Captagon was originally the trade name for a pharmaceutical transit countries for amphetamine consignments seized in preparation containing fenetylline, a synthetic stimulant. The boundaries shown on this map do not imply official endorsement or acceptance by the United Nations. Destination countries reported may not be the intended final destination of the shipment. The boundaries shown on this map do not imply official endorsement or acceptance by the United Nations. The dotted line represents approximately the Line of Control in Jammu and Kashmir agreed upon by India and Pakistan. The dotted line represents approximately the Line of Control in Jammu and Kashmir agreed upon by India and Pakistan. The final boundary between the Sudan and South Sudan has not yet beenDestination country may not be final destination of seized shipment. This situation poses addi- Over the years, global ketamine seizures have fluctuated tional challenges to prevention, treatment, control and greatly. Between 2012 and 14 14 2014, most substances reported for the first time belonged 12 to the group of synthetic cannabinoids. The data reported 12 10 for 2015 so far show a different pattern: first, 20 synthetic 10 8 cathinones (a group of substances with stimulant effects 8 6 similar to cocaine or methamphetamine) were reported 6 for the first time — almost as many as synthetic cannabi- 4 4 noids (21); and second, 21 “other substances” (substances 2 2 not belonging to any of the major groups identified in 0 0 previous years) were reported for the first time, including 2009 2010 2011 2012 2013 2014 2009 2010 2011 2012 2013 2014synthetic opioids (e. Clatts, “Ketamine injection among high risk youth: preliminary findings from New York”, Jour- 224 Multiple responses were possible (Natasha Sindicich and Lucy nal of Drug Issues, vol. Lankenau and others, “The first injection event: differences System (Sydney, University of New South Wales, National Drug and among heroin, methamphetamine, cocaine, and ketamine initiates”, Alcohol Research Centre, October 2015)). Dotted line represents approximately the Line of Control in Jammu and Kashmir agreed upon by India and Pakistan. The final status of Jammu and Kashmir has not yet been agreed upon by the parties. A dispute exists between the Governments of Argentina and the United Kingdom of Great Britain and Northern Ireland concerning sovereignty over the Falkland Islands (Malvinas). Note: The boundaries and names shown and the designations used on this map do not imply official endorsement or acceptance by the United Nations. Dotted line represents approximately the Line of Control in Jammu and Kashmir agreed upon by India and Pakistan. The final status of Jammu and Kashmir has not yet been agreed upon by the parties. A dispute exists between the Governments of Argentina and the United Kingdom of Great Britain and Northern Ireland concerning sovereignty over the Falkland Islands (Malvinas). For instance, N-benzyl-1-phenylethylamine was appear for a short time or only locally). One such example is the series of the United States, accounting for the largest quantities 2,5-dimethoxy ring-substituted phenethylamines (2C seized worldwide. Modelled on 4-bromo-2,5-dimethoxyphenethyl- 229 noids seized worldwide in 2014, 26. In 2014, the Russian Fed- try in Asia (Japan) in 2008; after several fluctuations, the eration also reported significant seizures of aminoindanes reporting of that synthetic cannabinoid reached its peak (438 kg). Over the past few usually observed in combination with ketamine and other years, various countries in Europe and South-East Asia phencyclidine-type substances, phenethylamines and have reported seizures of “ecstasy” tablets containing tryptamines. Mixtures can arise substances concurrently, including mixing street drugs intentionally (for example, if the producer believes that with alcohol and/or prescription drugs. Synthetic can- mation is available to determine the psychoactive effects nabinoids were found to be present in more than 55 per that these combinations may have. There are signs of declining use of syn- Dissociatves, 3% thetic cannabinoids among secondary school students in Stmulants, 35% the United States. The prevalence of past-year use of syn- Sedatves/Hypnotcs, 2% thetic cannabinoids among twelfth-grade students Opioids, 2% decreased from 11. The prev- According to the Crime Survey for England and Wales,238 alence of the use of synthetic cannabinoids among eighth, over the period 2014-2015, 279,000 adults (0. Plant-based substances were excluded from the analysis, as they Compared with the previous period, the prevalence of usually contain a large number of different substances, some of past-year use of mephedrone in England and Wales in the which may not even be known or may have effects and interactions that are not fully understood. The pharmacological effects of the financial years 2014-2015 remained stable at 1. In a study conducted in Hungary,248 alence of past-year use of synthetic cannabinoids: 0. There are indications that synthetic users often reusing syringes and sharing filters. According cannabinoids, in particular, have emerged as a major prob- to Public Health England, within five years of the first lem. Although synthetic who injected the substance for use in a sexual context cannabinoids were identified as a concern in 37 per cent (“chemsex”), often sharing injecting equipment and engag- of the male prisons inspected in the financial year 2013- 251 ing in unprotected sex. These findings indicate an 2014,243 this proportion increased to 64 per cent in the increase in the number of people who inject synthetic financial year 2014-2015. Almost a third (30 per cent) of the detainees who had used synthetic cannabinoids in the past twelve months reported perceived dependence in 2014, up from 17 per cent in 2013. Lewisham (London, Sigma Research, London School of Hygiene and Tropical Medicine, 2014); Victoria L. It use, the world drug problem, with all its ramifications, is clusters the discussion around five topics — social devel- intertwined with a vast array of social, economic and envi- opment; economic development; environmental sustain- ronmental issues. This exerts great pressure on develop- ability; peaceful, just and inclusive societies; and ment efforts, which in turn have an influence on the drug partnership — in the light of the world drug problem and problem. Specifically, the present chap- lem themselves generate further interplay with the broader ter seeks to elucidate the interplay between each of these development and social context and introduce additional, aspects of sustainable development on the one hand, and sometimes unforeseen, complexity to this dynamic. The the issue of drugs on the other, while distinguishing importance of this interaction is increasingly being recog- between the drug problem as a phenomenon (illicit drug nized by the international community, as reflected in the use, production and trafficking) and the response to the discussions on the Sustainable Development Goals and drug problem. In analysing the interaction between social development and the world drug problem, the first section in this chap- The concept of development, together with the engage- ter summarizes the evidence of the social costs of illicit ment by the international community in this area, is drug use, the most important being its effects on the health reflected in the Millennium Development Goals, followed of people who use drugs. The section also investigates the by the recently formulated 2030 Agenda for Sustainable health impact of drug use across levels of development. The new development agenda also drugs and the repercussions of that, particularly on their recognizes that sustainable development cannot be realized employment opportunities. The section also addresses the without peace and security, and that peace and security impact of the response to the drug problem on social devel- will be at risk without sustainable development. Factors opment, with reference to, for example, alternative devel- that give rise to violence, insecurity and injustice, such as opment, as well as the availability of drugs for medical and inequality, corruption, poor governance and illicit finan- scientific purposes. The analysis attempts to identify patterns describing the evolu- tion of the drug problem and the role of development.

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