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Criminalization of drugs was historically one way that dominant buy levitra 10mg without a prescription, white social groups sought to maintain control over racial and ethnic minorities who troubled cheap 10 mg levitra otc, angered, or scared them (Musto 1999). Advocates of criminalization have consistently painted drug users as morally weak (if not depraved), dangerous, and a threat to community standards and upstanding people. Advocates of criminalization have also tended to be most concerned about drugs associated with racial and ethnic groups that, in various ways, they thought threatened white America. Overt and virulent racism was2 pervasive in alcohol and drug control debates from the 1870s through the 1960s, giving social and political heft to public health messages and the efforts of prohibitionist “moral entrepreneurs. Although overt racism disappeared from drug policy debates after the civil rights movement took hold, racial concerns nonetheless helped propel the modern “war on drugs” launched during the Reagan administration (Reinarman and Levine 1997; Tonry 1995, 2011). The use of cocaine, primarily powder cocaine, increased in the late 1970s and early 1980s, particularly among whites, but did not provoke the “orgy of media and political attention” that occurred in the mid-1980s when a cheaper, smokable form of cocaine, in the form of crack, appeared. Although the use of crack was by no means limited to low-income, minority neighborhoods, it was those neighborhoods that more visibly suffered from addiction to crack and the violence that accompanied competition among drug-dealing groups to establish control over its distribution. Sensationalist media stories portrayed African Americans as the paradigmatic users and sellers of crack. Sentencing Commission 1995), poor urban minority neighborhoods have remained the principal “fronts” in the war on drugs. The emergence of crack cocaine offered American policy makers an important opportunity to think carefully about the best way to address addictive and dangerous drugs. They could have emphasized a public health and harm-reduction response, giving priority to drug education, substance abuse treatment, and increased access to medical assistance. They could have sought to stem the spread of drug use and the temptations of the drug trade in crumbling inner cities by making the investments needed to build social infrastructure, improve education, increase medical and mental health treatment, combat homelessness, increase employment, and provide more support to vulnerable families. They could have restricted the use of imprisonment to only the most serious drug offenders (e. Unfortunately, crack emerged when the country was in no mood to consider anything but a punitive response. The belief that severe sentences were needed to restore law and order to America reflected a “perfect storm” (Austin et al. As Reinarman and Levine have noted, crack was a “godsend to the Right,” as it offered the opportunity to reinvigorate a conservative moral and political agenda (Reinarman and Levine 1997, p. A punitive response to crack was in perfect harmony with a politically vigorous assertion of “traditional family values”—individual moral discipline and abstinence—and with the demand for serious consequences for those who failed to conform to them, including hippies, war protesters, and restive black youth. Subscriber: Univ of Minnesota - Twin Cities; date: 23 October 2013 Race and Drugs Democrats who were anxious and angry about their declining status in the post civil rights era. Avoiding explicit racial appeals to resentful whites, the strategy relied on racially coded messages about drugs, crime, and welfare (Beckett 1999; Tonry 2011). A “seemingly race- neutral concern over crime” became a vehicle to continue to fight racial battles (Loury 2008, p. Not to be outdone by the Republicans, the Democrats became equally fervent apostles of tough-on-crime policies. With little debate or reflection, the federal and state governments responded to crack specifically and drug use more generally with soaring law enforcement budgets and ever more punitive laws and policies that increased arrests of low-level drug offenders, the likelihood of a prison sentence upon conviction of a drug offense, and the lengths of prison sentences. The federal Anti-Drug Abuse Act of 1986 and the Anti-Drug Abuse Act of 1988 imposed far higher penalties for the sale of crack cocaine than for powder cocaine. Under the notorious federal 100-1 law governing powder and crack sentences, federal defendants with 5 grams of crack cocaine received the same mandatory minimum 5-year sentence imposed on defendants with 500 grams of powder cocaine. Fourteen states also imposed harsher sentences for crack compared to powder cocaine offenses (Porter and Wright 2011), and all states ratcheted up sentences for drug law violations regardless of the drug involved (Human Rights Watch 2000, 2008; Mauer 2006). Harsh penalties for crack were easily enacted because that drug was uniquely linked in the mainstream’s collective consciousness with dangerous, poor, minority inner-city dwellers who supposedly threatened white suburban America. Federal District Judge Clyde Cahill described the racial underpinnings of federal crack sentencing legislation: The fear of increased crime as a result of crack cocaine fed white society’s fear of the black male as a crack user and as a source of social disruption. The prospect of black crack migrating to the white suburbs led the legislators to reflexively punish crack violators more harshly than their white, suburban, powder cocaine dealing counterparts.

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Demonstrate commitment to using risk-benefit 20mg levitra for sale, cost-benefit purchase levitra 10 mg, and evidence- based considerations in the selection preventive health measures. Demonstrate ongoing commitment to self-directed learning regarding preventive health measures. Prevention for the 21st century: setting the context through undergraduate medical education. It is essential for the student to learn that the physician’s responsibility toward the patient does not stop at the end of the office visit or hospitalization but continues in collaboration with other professionals to ensure that the patient receives optimal care. Key personnel and programs in and out of the hospital that may be able to contribute to the ongoing care of an individual patient for whom the student has responsibility (e. The role of the primary care physician in coordinating the comprehensive and longitudinal patient care plan, including communicating with the patient and family (directly, telephone, or email) and evaluating patient well-being through home health and other care providers. The role of the primary care physician in the coordination of care during key transitions (e. The role of clinical nurse specialists, nurse practitioners, physicians assistants, and other allied health professionals in co-managing patients in the outpatient and inpatient setting. The importance of reconciliation of medications at all transition points of patient care. Discussing with the patient and their family ongoing health care needs; using appropriate language, avoiding jargon, and medical terminology. Participating in requesting a consultation and identifying the specific question to be addressed. Obtaining a social history that identifies potential limitations in the home setting which may require an alteration in the medical care plan to protect the patient’s welfare. Participate, whenever possible, in coordination of care and in the provision of continuity. Coordinating care across diseases, settings, and clinicians: a key role for the generalist in practice. Quality indicators of continuity and coordination of care for vulnerable elder persons. Management strategies need to take into account the effects of aging on multiple organ systems and socioeconomic factors faced by our elderly society. As the number of geriatrics patients steadily rises, the internist will devote more time to the care of these patients. Nutritional needs of the elderly and adaptations needed in the presence of chronic illness. Key illnesses in the elderly, focusing on their often atypical presentation, including: • Cardiovascular and cerebrovascular disease. Basic treatment plans for illness in the elderly, with an awareness of the pharmacokinetic and pharmacodynamic changes seen as we age. Principles of screening in the elderly, including immunizations, cardiovascular risk, cancer, substance abuse, mental illness, osteoporosis, and functional assessment. Principles of Medicare (including who and what services are covered) and prescription drug coverage (who and what drugs are covered). Taking a complete and focused history from a geriatric patient with attention to current symptoms, chronic illnesses, and physical and mental functioning. Always obtaining historical information from collateral source, whenever possible. Performing a mental status examination to evaluate confusion and/or memory loss in an elderly patient. Developing a diagnostic and management plan for patients with the with symptoms/conditions common in the geriatric population. Communicating the diagnosis, treatment plan, and subsequent follow-up to the patient and their family. Eliciting input and questions from the patient and their family about the diagnostic and management plan.

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Comorbidity levitra 10 mg overnight delivery, or the co-occurrence of an alcohol and other drug use disorder with one or more mental health conditions buy 10mg levitra with amex, can complicate treatment and services for both conditions. Twenty-one percent (21%) of illicit drug users have been diagnosed with or treated for a mental illness (double the rate of diagnosis compared to non-illicit drug users). Illicit drug users are more likely to report high levels of psychological distress (17. People with mental illness smoke at a much higher rate than the general population. In 2012 around 58 32 per cent of people with a mental illness smoked compared with a national smoking rate of 12. This rate is even higher among people with serious mental illness, with data showing that 67. Unlike the declining smoking rate for people without a mental illness, smoking 60 rates for people with mental illness have not substantially changed in the last 12 years. Best practice approaches to addressing the needs of people with mental illness include: • Implement smoke-free policies in mental health services • Routine assessment of alcohol, tobacco and other drug use when someone presents with a mental illness • Routine inquiry around mental illness or psychological distress when someone presents with alcohol, tobacco and other drug use • Management and treatment approach based around readiness for change • Client management should aim to increase the awareness of the relationship and effect the alcohol, tobacco and other drug use and mental illness have on each other • Approaches designed to address specific co-morbid mental illnesses and with specific cohorts where the evidence base is established. Rates of risky 61 behaviours are generally higher among young people than the broader population. Some drug use has higher prevalence among young people and associated harm can be reduced by delaying initiation. National Drug Strategy 2016-2025 27 Best practice approaches to addressing the needs of young people include: • Regulation of alcohol and tobacco retailers • Zero blood alcohol concentration requirements on novice drivers • Family interventions • Tailored services • Connections to services • School programs and curriculum • Restrictions on access • Price • Promotional restrictions • Tailored public education 6. Older people can be more susceptible to the harms arising from alcohol, tobacco and other drug use as a result of pain and medication management, isolation, poor health, grief/loss/life events and loss of independent living. Best practice approaches to addressing the needs of older people include: • Early identification of issues in primary care settings • Maintenance of social connections • Promotion of community inclusion, positive environments and full and active lives • Age appropriate treatment components • Longer treatments • Physically accessible services (hand rails, appropriate seating, transport etc) • Outreach and home visits • Workforce development to enable care for more complex co-morbidities. In 2012 half of all prison entrants reported using cannabis prior to entering prison and more than one-third (37%) reported using methamphetamines. Between 50- 90% of people who inject drugs have spent time in prison and 34% continue to inject while 62 incarcerated. For those injecting drugs in prison, 90% report sharing needles/injecting equipment. Best practice approaches to addressing the needs of people in contact with the criminal justice system include: • Implement smoke-free policies in correctional facilities. National Drug Strategy 2016-2025 28 • Improve the capability, capacity and confidence of the workforce to work with people who have a range of complex needs • Access to education, health promotion, treatment and support services while in prison and during their transition back into the community • Provision of a range of treatments, including detoxification and withdrawal management, pharmacotherapy, drug free units or therapeutic communities • Testing, education and treatment for blood borne viruses • Restorative justice conferencing • Strengthen existing harm reduction efforts in prison settings, such as opioid substitution therapy, and to support inmates to adopt safe behaviours and assist inmates connect with health and social services post-release • Aftercare and support post release • Drug detection units and searching of offenders, staff, visitors, vehicles. For example, some members of new migrant populations from countries where alcohol is not commonly used may be at greater risk when they come into contact with Australia’s more liberal drinking culture. Some types of drugs specific to cultural groups, such as kava and khat, can also contribute to problems in the Australian setting and some individuals may have experienced torture, trauma, grief and loss, making them vulnerable to harmful use of drugs. In 2013, use of licit and illicit drugs was more common in people who identified as homosexual or bisexual in Australia than for those 68 identifying as heterosexual. However, priority drug types change over time and differ due to local circumstances. In addition to these priority drug types, jurisdictions should be aware of emerging trends or drugs with concentrated use in specific communities. These include image enhancing drugs (steroids) and volatiles (fuel, paint and aerosols). Poly-drug use is also a significant concern and strategies that address this can be very effective at reducing harm. Tobacco smoking also carries the highest burden of drug-related costs on the Australian 73 community. Australia’s implementation of a range of multifaceted tobacco control measures has been effective in reducing smoking rates over recent decades, with daily smoking for those aged 14 years or older declining in Australia from 24. Smokers are also having fewer cigarettes 74 per week (96 in 2013 compared to 111 in 2010). Challenges remain for tobacco, including addressing the inequality in smoking rates between some disadvantaged populations and the broader community.

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However levitra 20mg overnight delivery, they may worsen heart failure and should not be given to individuals with decompensated heart failure (302) cheap 10mg levitra mastercard. Evidence Many studies have shown that the benefits of cholesterol-lowering therapy depend on the initial level of cardiovascular risk: the higher the total risk, the greater the benefit. This is because the relative reductions in risk as a consequence of lipid lowering are approximately the same at differ- ent levels of cardiovascular risk. The effectiveness of statins in patients with established atherosclerotic disease (principally coronary artery disease) is well established. Primary prevention trials, on the other hand, are more limited; however, the benefits seen in these trials, as demonstrated by meta-analyses, are consistent with the overall results for all statin trials. Those in the treatment group had 31% fewer primary cardiovascular events than those given placebo (P<0. There were also significant reductions in non-fatal myocardial infarction and death from all cardiovascular causes. In addition, the risks of myocardial infarction, unstable angina, coronary events, and cardiovascular events, and the need for coronary revascularization procedures, were signifi- cantly reduced in the treatment group. This was a mixed primary and secondary prevention trial, with 14% of patients having had prior coronary disease and 35% being diabetic. The failure to show a reduction in coronary heart disease events was attributed to this increased use of statins and other hypolipidaemic therapy in the patients given “usual care”. Thus, the difference in cholesterol levels in the two groups of patients was not as large as expected. In the Heart Protection Study (321), a wide range of high-risk individuals aged 40–80 years (n = 20 536) were randomly allocated to receive 40 mg of simvastatin daily or a placebo. Simvastatin reduced the rates of myocardial infarction, stroke and revascularization by about one-quarter. The size of the 5-year benefit depended on the individuals’ overall risk of major vascular events rather than on their blood lipid concentrations. About one-third of the participants in this study were free of coronary heart disease. In this group, statin therapy reduced major vascular events by 22% compared with placebo (P = 0. All patients had at least one of the following: retinopathy, albuminuria, current smoking, or hypertension. Patients (n = 2102) were randomly assigned to receive fluvastatin or placebo, and followed up for 5. This was a mixed primary and secondary prevention study, designed to test the benefits of statin treat- ment in the elderly. Participants either had existing vascular disease (coronary, cerebral or periph- eral) or were at risk of such disease (because of smoking, hypertension or diabetes). The primary endpoint was a composite of coronary death, non-fatal myocardial infarction, and fatal and non- fatal stroke. Four studies met these criteria: the Lipid Research Clinic Primary Prevention Trial, the Helsinki Heart Study, the West of Scotland Coronary Prevention Study, and the Air Force/Texas Coronary Prevention Study (318, 319, 327, 328). Lipid-lowering drug treatment reduced the odds of a coronary heart disease event by 30% (summary odds ratio 0. When the analysis was limited to trials that used statins a slightly stronger effect on all outcomes was found, but there was still no significant reduction in all-cause mortality (although none of these studies was individually powered for this endpoint). Another review of lipid-lowering treatment with statins found that coronary heart disease events and all-cause mortality were reduced in primary prevention populations (329). This review, unlike the meta-analysis mentioned above (326), did not include the large Air Force/Texas trial, which was conducted later. It included the Kuopio atherosclerosis prevention study, a trial in which about 10% of subjects had a history of myocardial infarction (330), and which was not included in the more recent meta-analysis. Data from 15 trials with 63 410 participants and a mean duration of treatment of 3.

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