By Y. Mine-Boss. Alfred University. 2018.

With prompting order 200mg modafinil with amex, Katherine agrees that home visits may assist consumers to remain adherent cheap 200 mg modafinil with mastercard, which should occur more regularly when consumers are particularly unstable (“if they’re really bad modafinil 100mg overnight delivery, they get, might get two visits a day”). Margaret refers back to when she experienced difficulties remembering to take her medication (“there was one time when I would forget my tablet”) when her 263 illness symptoms were severe (“my psychosis was quite bad at times”), which her case manager reportedly supported her through. Regarding the type of support her case manager provided, Margaret states that she telephoned him when she missed a dosage and he would ask her questions related to her how she was feeling, any potential illness triggers (“What’s been happening? On the basis of her presentation, the case manager would then provide instructions to Margaret, to support her sustained adherence to her medication routine (“He’d guide me through it”). Below, Amy highlights another role that her case worker has fulfilled; namely, to liaise between her and the psychiatrist to discuss medication issues: Amy, 10/2/09 L: What has your relationship been like with your case manager? A: (laughing) Yeah, um got off to a reasonable start um had a few problems, uh, because we’re so different and I didn’t give her the respect she deserved (inaudible). Um, yeah, I found it, I thought she was being bitchy and nosy and we just had a bit of a personality clash but like mum said, she’s like a friend, a professional friend, she’s been a good friend like someone who can stick up for me and she’s liaised really well with me when I’ve been having problems from my perspective with my psychiatrist and really not getting through my opinion and my, what I believe my founded fears of the negative impact of medication and the type of medication I was on. She implies that her case manager has assisted her by defending and communicating her perspective to her psychiatrist (“someone who can stick up for me”), particularly in relation to her “fears of the negative impact of medication and the type of medication I was on”. Thus, Amy could be seen to suggest that in instances when her psychiatrist may have dismissed her concerns about her medication, her case manager has acknowledged her concerns and attempted to communicate these to the psychiatrist, thereby providing a voice for Amy in relation to her treatment. Whilst the previous extracts described intensive, consumer-focused case work aimed at preventing non-adherence and relapse, this was not consistent with other consumers’ experiences with case workers. In the following extracts, for example, Rachel and Nathan describe their case managers as absent and lacking thoroughness: Rachel, 25/2/09 L: Yeah. I only ever saw her once every six weeks or spoke to her once every six or seven weeks. According to Rachel, she only had contact with her case worker “every six or seven weeks”. When asked how workers could assist with adherence, Nathan indicates that they could conduct home visits (“come round”) and “actually ask if you’re taking your medication”. Whilst Nathan later acknowledges that his workers visit, he states that they “don’t ask” him about his adherence. These extracts, considered in conjunction with the previous extracts, which described case worker intervention positively, suggest that there are varying degrees of intensity of case work. The main service-related factors mentioned were the therapeutic alliance between the prescriber and consumer, interactions with case managers and peer workers and experiences of community centres. The therapeutic alliance has been established in the literature as an influence on adherence and, consistent with this, it was frequently discussed by interviewees. Interview data highlighted which components of the therapeutic alliance were considered important to adherence to interviewees. Specifically, interviewees indicated that collaboration and shared decision-making regarding treatment were important predictors of adherence. An authoritative or punitive prescriber 266 approach to treatment was generally linked to non-adherence (often as an expression of resistance), however, some interviewees attributed adherence to a fear of the prescriber’s response to non-adherence. Interviewees indicated that they wanted their prescribers to ask them relevant questions to assist with their illness and treatment management, which was contrasted with experiences of an impersonal service from prescribers, who forgot simple details including those related to the medication regimen. Consistent with previous research, experiences of a rotational system of psychiatrists in a medication clinic setting were framed negatively. Specifically, it was reported that such a system compromised consumers’ abilities to build relationships with prescribers and to talk openly about issues due to shorter durations of treatment from the same psychiatrist. The most important element of the therapeutic alliance that was consistently raised in interviewees’ adherence talk related to prescribers tailoring the medication regimen to consumers’ unique circumstances. Arguably, tailoring also encompasses collaboration and genuine interest in, and knowledge of, consumers, as covered in previous sub-codes. In addition to tailoring the medication regimen to symptom fluctuations and periods of stability, interviewees also stated that it was important for prescribers to take into account their daily routines and to target information according to their intellectual abilities or levels of understanding. Interviewees consistently described their experiences with case workers and community centres positively. They additionally often supported a greater role for peer workers in assisting with adherence due to their shared experiences. One interviewee also reported an enhanced sense of purpose associated with working as a peer worker, consistent with recovery 267 research, which relates consumers’ involvement in such programs to empowerment. In particular, recovery research supports people to build and sustain self-defined, purposeful lives and identities, which can be accomplished through roles including peer work (as opposed to clinical recovery, which focuses primarily on symptom reduction and return to premorbid functioning). Whilst one interviewee indicated that her case manager communicated her treatment-related concerns to her prescriber and, thus, represented a mediator of sorts, others indicated that their case managers had minimal involvement in their lives. In approaching the study, a qualitative research design that involved interviewing consumers about their experiences with antipsychotic medications made intuitive sense given the research aim was to enhance understanding of medication taking and consumers were considered the experts in their own illness and treatment experiences.

Toch jammer dat het zo verdomd lastig is ervoor te zorgen dat die bacterie chlooramfenicol gaat produceren generic 100 mg modafinil otc. Ooit gaat het ons lukken… Het is erg leuk om met jullie samen te werken modafinil 100 mg amex, juist omdat onze achtergronden zo verschillend zijn 200mg modafinil sale. Mede daardoor ga ik iedere dag (nou ja, bijna iedere dag) met plezier naar mijn werk. Iedereen is altijd bereid om bij te springen waar nodig en o klaren we met ’n allen toch steeds weer iedere klus. Ook wil ik alle studenten bedanken die een bijdrage hebben geleverd aan het werk in dit proefschrift. Jullie hebben met ’n allen o ont ettend veel werk verzet dat ik niet anders kan dan concluderen dat dit proefschrift zonder jullie een stuk dunner was geweest. Ik heb het altijd leuk gevonden jullie te begeleiden en te zien hoe jullie je ontwikkelden. Richetti, bedankt voor het uitzoeken van goede condities om die nare chlooramfenicolisomeren op de chirale kolom te scheiden. Vooral de reproduceerbaarheid viel in het begin nogal tegen, maar het is toch gelukt. Cynthia, super dat je de methode voor de analyse van ceftiofur met behulp van de hydrolyse met ammoniak hebt geoptimaliseerd. Later is weliswaar overgestapt op piperidine, maar jij hebt de basis van de monstervoorbewerking. Sven, bedankt voor het implementeren van de verschillende methodes voor de analyse van ceftiofur en de analyse van al die vleesmonsters. Mathilde, bedankt voor het onderzoek naar de invloed van de 342 Dankwoord maalprocedure op de vorming van degradatieproducten van ceftiofur. Hoewel jouw werk niet direct in dit proefschrift is opgenomen (ik zou het misschien nog eens moeten publiceren), vormt het wel een heel belangrijke basis van het onderzoek. Ik ben blij dat je hebt kunnen aantonen dat er wel degelijk metabolieten gevormd worden na injectie van kippen met ceftiofur. Jouw werk vormde een mooie basis om de uiteindelijk gerapporteerde methode op te zetten. Het was een enorme klus: ik denk dat het je nog steeds duizelt als je bedenkt dat je meer dan 15000 pieken hebt geïntegreerd gedurende je stage. Ik schrik er elf een beetje van… In dit dankwoord uiteraard ook een mooie plek voor Freek. Iedereen weet wel dat dat niet waar is, maar uiteraard houd ik dat gerucht graag in stand. Met name tussen 2008 en 2010, de jaren waarin ik hele avonden en weekenden heb gestudeerd, heb jij alle andere taken uit handen genomen, zodat ik me op mijn opleiding kon concentreren. Hele weekenden zat ik opgesloten in de voorkamer te werken en ik heb jou daar niet één keer over horen mopperen. Hetzelfde geldt voor de laatste fase van mijn PhD: ik kon me volledig focussen op mijn proefschrift, omdat jij altijd voor me klaar staat en me steunt. Als ik na mijn promotie in het bekende zwarte gat val, zal ik jullie allemaal weer wat vaker gaan vervelen. Hoewel, de puzzel die ik van Sinterklaas heb gekregen met duizend stukjes uitsluitend grijskleurige olifant houdt me nog wel even van de straat (moet ik dat als subtiele hint van Sinterklaas beschouwen? Bjorn 343 344 Curriculum Vitae th Bjorn Berendsen was born on the 10 of March 1978 in Bemmel, The Netherlands. He started his Bachelor study, Higher Laboratory Education, at Hogeschool van Arnhem en Nijmegen. Nielen, The occurrence of chloramphenicol in crops through the natural production by bacteria in soil, J. Nielen, Comprehensive analysis of ß-lactam antibiotics including penicillins, cephalosporins and carbapenems in poultry muscle using liquid chromatography coupled to tandem mass spectrometry, Anal. Nielen, The (un)certainty of selectivity in liquid chromatography tandem mass spectrometry, J. Nielen, Assessment of liquid chromatography–tandem mass spectrometry approaches for the analysis of ceftiofur metabolites in poultry muscle, Food Add. Nielen, Quantitative trace analysis of eight chloramphenicol isomers in urine by chiral liquid chromatography coupled to tandem mass spectrometry, J. Nielen, Discrimination of eight chloramphenicol isomers by liquid chromatography tandem mass spectrometry in order to investigate the natural occurrence of chloramphenicol, Anal. Elliott, Evidence of natural occurrence of the banned antibiotic chloramphenicol in herbs and grass, Anal. Stolker, Newly identified degradation products of ceftiofur and cephapirin impact the analytical approach for quantitative analysis of kidney, J. Stolker, Determination of the stability of antibiotics in matrix and reference solutions using a straightforward procedure applying mass spectrometric detection, Food Add. Van Rhijn, Residue analysis of tetracyclines in poultry muscle: Shortcomings revealed by a proficiency test, Food Add. Brinkman, Liquid chromatographic–tandem mass spectrometric determination of selected sulphonamides in milk, J.

If this is 263 not feasible generic 200mg modafinil with amex, then the use of co-solvents such as ethanol and/or propylene glycol can be considered generic 200 mg modafinil visa. However order 100mg modafinil, such solvents change both the surface tension and viscosity of the solvent system which in turn influence aerosol output and droplet size. Water insoluble drugs can be formulated either by micellar solubilization, or by forming a micronized suspension. Nebulizer solutions are often presented as concentrated solutions from which aliquots are withdrawn for dilution before administration. Both excipient types have been implicated with paradoxical bronchospasm and hence the current tendency to use small unit-dose solutions that are isotonic and free from preservatives and antioxidants. Atomization is the process by which sprays are produced by converting a liquid into aerosolized liquid particles. The large increase in the liquid-air interface, together with the transportation of the drops, requires energy input. The forces governing the process of converting a liquid into aerosolized liquid particles are: • surface tension—serves to resist the increase in the liquid-air interface; • viscosity—resists change in shape of the drops as they are produced; • aerodynamic forces—cause disruption of the interface by acting on the bulk liquid. The primary drops may be further dispersed into even smaller drops or coalescence may occur. They have in-built baffles to ensure that large primary drops are returned to the reservoir and thus the aerosol emitted from the device has a size distribution which will aid airway penetration. Nebulizers generate aerosols by one of two principal mechanisms: • high velocity airstream dispersion (air-jet or Venturi nebulizers); • ultrasonic energy dispersion (ultrasonic nebulizers). Drug solution is drawn from the reservoir up the capillary as a result of the region of negative pressure created by the compressed air passing over the open end of the capillary (Venturi effect). The larger drops are removed by the various baffles and internal surfaces and return to the reservoir. The smaller respirable drops are carried on the airstream out of the nebulizer and via either a mouthpiece or face mask into the airways of the patient. However, generally less than 1% of entrained liquid is released from the nebulizer. There are many commercially available nebulizers with differing mass output rates and aerosol size distributions which will be a function of operating conditions, such as compressed air flow rate. As described above, for maximum efficacy, the drug-loaded droplets need to be less than 5 μm. Output is often assessed by weighing the device before and after the nebulization period. Output is usually expressed as volume/unit time (mL min−1) or volume per unit airflow (mL L−1 air) although density of solutions is not always considered. Such measurements of mass output do not, however, provide information on drug delivery rates. This in turn produces an aerosol output in which the drug concentration increases with time. Concentration of the drug solution in the reservoir can lead to drug recrystallization with subsequent blockage within the device or variation in aerosol particle size. The compressed gas source is from either cylinders or air compressors and hence air-jet nebulizers tend to be more frequently encountered in hospitals than in the domiciliary environment. The waves give rise to vertical capillaries of liquid (“fountains”) which, when the amplitude of the energy applied is sufficient, break up to provide an aerosol. The increase in temperature may eliminate the use of this type of nebulizer for the administration of thermolabile drugs to the lung. Strategies to overcome this limitation include the use of: • breath-enhanced nebulizers—which direct the patient’s inhaled air within the nebulizer, to produce an enhanced volume of aerosol during the inhalation phase; • dosimetric nebulizers—which release aerosol only during the inhalation phase. This ensures mechanical strength so that the container can withstand internal pressures of >400 kPa. An alternative to aluminum is plastic-coated glass vials; however, these are only suitable for use with propellants generating lower internal pressures. Metering valve 266 This hermetically seals the container and is designed to release a fixed volume of the product during each actuation. An elastomer seal This is critical to the valve performance as it controls propellant leakage and metering reproducibility. Chemical constituent extraction from the seals by the propellants should be tightly controlled. The actuator This permits easy actuation of the valve, provides an orifice through which the spray is discharged and directs the spray into the patient’s mouth. Orifice size can vary: large orifices in combination with large- volume metering valves permit the administration of concentrated, i.

The pulverized kernel has been used as a sternutatory for the relief of headache and facial neuralgia 100mg modafinil otc. The nuts were also thought to possess some special influence over hemorrhoids and rheumatism buy 200mg modafinil. This probably will be its best field of action purchase 200mg modafinil mastercard, standing midway between Belladonna on the one hand and Nux Vomica on the other. It exerts the same influence upon the circulation as the Æsculus Glabra, and has been successfully employed in the treatment of hemorrhoids. It will doubtless be found to improve the circulation generally, and may be employed whenever there is want of power in the heart, capillary stasis, or tendency to congestion. It may be recommended in active delirium, when patients become excited from slight causes, and are liable to transports of rage. They absorb a great amount of oxygen with evolution of hydrogen and carbonic acid gas, and contain considerable proportions of nitrogen. Those species formerly included in Boletus, and whose hymenium is composed of pores, now form the genus Polyporus. The Polyporus Officinalis (Boletus Laricis), known by the name of White Agaric, Purging Agaric, etc. It is in masses, varying from the size of an ordinary apple to that of a large nutmeg-melon; its shape somewhat resembles a horse’s hoof; it is reddish gray or yellow externally, whitish internally, and of a spongy, friable consistence; hymenium concrete; substance of the pileus consisting of subrotund pores, with their simple dissepiments; pileus corky-fleshy, ungulate, zoned, smooth; pores yellowish; it has a feeble odor, and a bitter, acid, somewhat sweetish taste. Braconnot found in it 72 parts resinous matter, 2 bitter extractive, 26 of a nutritious animalized principle, which he termed fungin. It is collected in August and September, deprived of its outer covering, and then dried and placed in the sun. Polyporus (Boletus) Ignarius, Agaric of the Oak, is a fungus found on the oak, cherry, willow, plum, and other trees; when young it is soft, but gradually becomes hard and woody. In shape it somewhat resembles the preceding; its upper smooth surface is marked with dark circular ridges, and its under is very porous, and of a yellowish-white color It is tasteless and inodorous. Ignarius, when cut in slices, beaten, soaked in a solution of nitre, and dried, forms an inflammable substance, known as Spunk, Amadou, or German Tinder. The Polyporus Pinicola grows upon the pine, birch, tamarac, fir, and similar trees; with absolute alcohol the fresh fungus forms a dark-red, intensely bitter tincture. It has a bitter taste, is soluble in alcohol and oil of turpentine, forms a paste with boiling water, and has the formula C14H12O4 Properties and Uses. In doses of from three to ten grains, gradually increasing to sixty grains, in the course of the twenty-four hours, it has been found efficacious in arresting the nocturnal perspiration of consumptives. Externally, it has been used, together with the Agaric of the Oak, as a styptic, and said to restrain not only venous but arterial hemorrhages, without the use of ligatures. It does not appear, however, to possess any real styptic power, or to act otherwise than dry lint, sponge, or other soft applications. Pinicola, in doses of from three to four grains of the powder, repeated every three or four hours, or of the concentrated tincture in doses of five drops, have both been found valuable in the cure of obstinate and long standing intermittents, and other diseases common to malarial districts; as obstinate bilious remittent fever, chronic diarrhœa, chronic dysentery, periodical neuralgia, nervous headache, ague cake, and increased flow of urine. They have likewise proved useful in long standing jaundice, and in the chills and fever common among consumptive patients. The tincture of Boletus exerts a marked influence upon the spinal and sympathetic nervous system, in certain cases of disease. It has been successfully employed in the treatment of epilepsy and chorea, and to check the rapid pulse with hectic fever and night sweats in phthisis. It has also been recommended in insanity where there is a feeble cerebral circulation and imperfect nutrition. Pressing pain in the occiput and an inclination to fall backwards is also a very good indication. The most marked evidences of improvement were observable at every successive visit. From observing the effects of the Maguey in the cases which have occurred in this command, I am compelled to place it far above that remedy which, till now has stood above every other - lime juice. The manner in which I use it is as follows: The leaves are cut off close to the root. They are placed in hot ashes until thoroughly cooked, when they are removed, and the juice expressed. Agrimonia exerts a slight stimulant influence upon all the vegetative processes, and under its use we find an improvement of appetite, digestion and nutrition. It exerts a specific influence upon mucous membranes, checking profuse secretion, and giving tone. But it is especially useful in chronic catarrhal disease of the kidneys and bladder, and will frequently prove curative. It gives tone and strength to these organs, and may well replace the more common tonic diuretics in many cases. The strongest indication for agrimonia is pain, simulating colic, pointing in the lumbar regions, or uterine pain associated with lumbar uneasiness. It has been recommended for the cure of epilepsy, but its reputation has not increased with use.

The ionized form of a drug displays a higher dissolution rate and greater solubility than the nonionized form (see Section 1 order modafinil 200mg without prescription. Drug solubility is also a function of the crystalline buy 100mg modafinil fast delivery, hydrate and salt form (see Section 1 order 200 mg modafinil. For example, the amorphous form of a drug moiety is usually more soluble than the corresponding crystalline form (e. The solubility of a salt form of a lipophilic drug is higher than the free form and conversion of the free base to the corresponding salt represents a common method of increasing drug solubility. Symposium on Drug Absorption, Metabolism and Excretion, Scientific section of the American Pharmaceutical Asso. The Noyes-Whitney equation describes the influence of surface area (S) and other factors on the dissolution rate: (Equation 6. A reduction in particle size results in an increase in the surface area, which facilitates an increase in the dissolution rate and therefore, also, an increase in the rate of absorption. Drugs administered as suspension are generally rapidly absorbed because of the large available surface area of the dispersed solid. For solid dosage forms such as tablets and capsules, decreasing the particle size facilitates dissolution and thus absorption. Peak blood levels occurred much faster with the smaller 148 particles (50 µm) than with large ones (800 µm), confirming that particle size must be considered in order to optimize absorption. For this reason, many poorly soluble, slowly dissolving drugs for oral drug delivery are marketed in a micronized or microcyrstalline form. These include: Wetting agents Wetting agents are surfactants that lower the interfacial tension and contact angle between solid particles and liquid vehicles. These agents are therefore commonly used to improve the wettability of hydrophobic compounds. Polysorbate 80 is the most widely used wetting agent because of its low toxicity and high compatibility with most formulation ingredients. For example, the common pharmaceutical wetting agent, sodium dodecyl sulfate, has been shown to increase the absorption of drugs and peptides across the human intestinal epithelium. Studies have confirmed that such agents enhance absorption via the paracellular pathway. Diluents Diluents are inert substances added to the active ingredient to bulk up the formulation, in order to make a reasonably sized tablet, or to fill a capsule. Carbohydrates are commonly used, such as lactose, dextrose, sucrose, and microcrystalline cellulose. Hydrophilic diluents promote rapid tablet disintegration and therefore liberate the drug quickly from the dosage form, which promotes absorption. Some diluents dissolve very slowly and therefore release of the drug occurs by tablet erosion, rather than tablet disintegration. However, a hydrophobic diluent impedes penetration of gastrointestinal fluids, so that dissolution of drug occurs only from the surface of the plug-shaped mass. Binders (adhesives) In tableting, binders are used to bind powders together in the wet granulation process. These agents coat the drug particles and therefore the rate of binder dissolution can determine the drug release rate. Disintegrants The purpose of a disintegrant is to cause the tablet to disintegrate rapidly, so as to generate an increased surface area which facilitates rapid drug dissolution. An alternative mechanism involves capillary action, in which liquid is drawn up through capillary pathways within the tablet and ruptures the interparticulate bonds, which serves to break the tablet apart. Obviously, disintegrants with high swelling and hydrating capacities promote rapid dissolution and thus a high bioavailability. Lubricants Lubricants act by interposing an intermediate layer between the tablet constituents and the die wall, to prevent adherence of the granules to the punch faces and dies. The most effective lubricants, such as magnesium stearate, are very hydrophobic and can also prevent wetting of powders and hence retard dissolution (Figure 6. Newer technologies may also incorporate additives such as enzyme inhibitors, to prevent premature degradation of enzymatically labile drugs. For example, the inclusion of trypsin inhibitors, such as soyabean trypsin inhibitor and aprotinin, have been shown to be effective in enhancing the effect of insulin in rats. Penetration enhancers may also be included to facilitate the uptake of poorly absorbed moieies. A brief overview of both the advantages and disadvantages of oral drug delivery is given below. Large surface area The total surface area of the small intestine in humans is approximately 200 m, which represents a large2 effective surface area for drug absorption. Rich blood supply The highly vascular surface of the gastrointestinal mucosa ensures rapid absorption and onset of action, as well as the maintenance of sink conditions. Zero-order controlled release Oral drug delivery offers the potential to achieve zero-order controlled release.

Research has suggested that persons tain whether a co-occurring disorder is primary with co-occurring disorders are at higher risk or secondary: of suicide purchase modafinil 100mg on line, psychiatric hospitalization discount modafinil 100 mg on line, legal difficulties and incarceration order 100mg modafinil overnight delivery, homelessness, ï Label the disorder according to predominant life-threatening infectious diseases, domestic symptom pattern and specified criteria (e. Patients with more than one Conversely, a review by Drake and Brunette co-occurring disorder engaged in treatment (1998) concluded that substance abuse compli- more readily than those who were addicted cates co-occurring disorders, often precipitat- only, and both groups were similar in average ing relapse to psychopathological symptoms, incidence of drug use or criminal activity. Despite these limita- believes that co-occurring disorders can tions, numerous studies have found that many improve substantially but that outcomes patients with co-occurring disorders did well depend heavily on additional treatment being when appropriate psychiatric and substance provided for these disorders and that patients abuse treatments were delivered. The consen- with severe symptoms may require longer, sus panel recommends more intensive and more intensive treatment. Early studies found that the severity cent of people seeking treatment for opioid of co-occurring disorder symptoms, particular- addiction (Brooner et al. The consensus panel special attention paid to depression and suici- believes that the best strategy is to stabilize dal ideation (Villagomez et al. Treatm ent of Co-Occurring Disorders 199 the condition that is most severe and threaten- oxazepam (SeraxÆ) rather than lorazepam, ing, it usually is best to address all of a patientís clonazepam, alprazolam or diazepam. Educating patients about co- disorders should Treatment for occurring disorders helps. Remission of co-occurring planning and imple- tion from admis- disorder symptoms should be an important mentation for this secondary goal. Physicians should be careful about drugs, benzodiazepines, or other sedatives may prescribing substances with abuse potential, be required to establish behavioral control such as benzodiazepines. Exceptions include patients who have with the lowest abuse potential for their condi- acute, substance-induced disorders such as tion. People with psychiatric treatment histories, or verified co-occurring disorders, particularly depression diagnoses and current prescriptions for medi- or dysthymia, were more likely than those with- cations to treat such disorders (regardless of out Axis I disorders to continue needle sharing whether they are used) should continue or and other high-risk behaviors (Camacho et al. Treatm ent of Co-Occurring Disorders 201 M odels of Care Risk factors and predictors for Although it is not always feasible to provide suicidal ideation and threats more specialized services on site, patient adher- People who are opioid addicted have high rates ence to medical treatment was found to drop of suicide and attempted suicide, ranging from dramatically when such services were provided 8 to 17 percent in some studies with even higher through offsite referral (Batki et al. Substance intoxication or withdrawal noncompliance may have significant conse- can cause or exacerbate suicidal ideation or quences for personal, social, and public health. Chapter 4 dis- If a program cannot provide onsite ancillary cusses risk factors for suicide and recommend- services, it is important that staff members ed treatment responses. Risk factors do not identify co-occurring disorders early so that predict individual behavior, but a high-risk they can refer patients to appropriate profile merits immediate and ongoing attention resources. In an early work, attempts or difficulty controlling violent behav- Kosten and Rounsaville (1988) found that acci- ior during their lifetimes (Cacciola et al. More recently, Darke and selves or others or have psychotic symptoms or Ross (2001) reported that 92 percent of disordered thinking that could interfere with patients who overdosed characterized the their safety or that of others should receive overdose as accidental. In that study, of the 40 immediate, aggressive intervention on admis- percent who acknowledged a previous suicide sion and throughout treatment. Staff members attempt, only 10 percent deliberately overdosed should be trained to notice indications of with heroin compared, for example, with 21 suicidal or homicidal risks. These observations percent who deliberately overdosed with should be documented and communicated to benzodiazepines. This is 202 Chapter 12 important for patients who appear withdrawn, other mood stabilizers or antidepressants take depressed, angry, or agitated or are known to hold, which can take several weeks. Medication- have experienced a recent significant loss or assisted treatment of acute suicidality should be other source of stressóespecially if a co- on an inpatient basis unless family members or occurring disorder is suspected or diagnosed or friends are willing to be responsible for adminis- if a patient still is intoxicated or withdrawing tering the drugs regularly, keeping the at-risk from a psychoactive substance. Some key factors in this decision are clearly To aid in screening and referral for suicidality expressed intent, specific and lethal plans, and homicidality, all programs should have accessible means, limited social or familial protocols in place that specify resources, severe symptoms of mental illness or psychosis, command hallucinations, hopeless- ï W ho asks what questions or uses what ness, and previous suicide or homicide attempts. Programs should encourage participation in Decisions should be made about using antipsy- mutual-help groups that focus on the needs of chotic medications, benzodiazepines, or other people with co-occurring disorders. Exhibit 12- sedatives to establish behavioral control rapid- 3 lists some of the best known of these groups, ly (Minkoff 2000). Patients can patients attend daily (at least in the early stages explore relevant themes by emphasizing positive of treatment) and onsite physicians and other coping strategies and sharing experiences. Exhibit 12-4 Topics for Psychoeducational Groups for People W ith Co-Occurring Disorders ï Causes, symptoms, and treatment for substance use and co-occurring disorders ï Medical and mental effects of co-occurring disorders ï Psychosocial effects of co-occurring disorders ï The recovery process for co-occurring disorders ï Medications to treat co-occurring disorders, their side effects, and medication management ï Coping with cravings, anger, anxiety, boredom, and depression ï Changing negative or maladaptive thinking ï Developing a sober support system ï Addressing family issues ï Learning to use leisure time constructively ï Spirituality in recovery ï Joining 12-Step and co-occurring disorder recovery mutual-help groups ï Risk factors in ongoing recovery ï Understanding and getting maximum benefits from psychotherapy and counseling Adapted from Daley 2000. The psychiatric ï All prescribed psychotropic medications medications should be, in most instances, should be to treat suspected or confirmed adjunctive to other ongoing interventions, not a co-occurring disorders, not to alleviate nor- substitute for them. From a practical viewpoint and group, but all information should be commu- assuming sufficient time to observe patients nicated both in writing and orally. Methadone withdrawal fluoxetine do not increase methadone levels symptoms may occur after discon- (ProzacÆ), significantly. Increase and/or split opioid withdrawal symptoms (Eap the methadone dosage to increase et al. Tricyclics Methadone impairs the metabolism Adjust doses of tricyclic desipramine, of tricyclics and can cause medications as needed; monitor increased tricyclic medication blood levels if clinically indicated. However, evidence sug- example is a study of patients with chronic gests major differences in the abuse liability of depression who were treated with the tricyclic benzodiazepines. Fifty-seven percent of action such as oxazepam rarely are mentioned imipramine-treated patients showed both signifi- as substances of abuse, have a wide margin of cant improvement in mood and some decreases safety, and are effective in reducing anxiety, in illicit drug use according to self-reports, com- even over extended periods (Sellers et al.