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Early identification of those who are dependent on alcohol increases the possibility of successful treatment purchase super avana 160mg with amex, and 314 Stark and Norfolk brief intervention by the forensic physician seems both feasible and accept- able (124 discount 160 mg super avana free shipping,168) buy 160 mg super avana with visa. Although not yet validated in police custody generic 160 mg super avana overnight delivery, brief interven- tions show a high acceptance among drinkers in licensed premises (169) super avana 160 mg mastercard. However, obtaining accurate and reliable information about a person’s drinking habits can be extremely difficult because heavy drinkers tend to underestimate or deliberately lie about their alcohol consumption (170). The main features dif- ferentiating alcohol dependence from alcohol abuse are evidence of toler- ance, the presence of withdrawal symptoms, and the use of alcohol to relieve or avoid withdrawal. However, there is no need to treat those who simply abuse alcohol and who do not have a history of alcohol withdrawal. Alcohol Withdrawal Many alcoholics develop symptoms of withdrawal when in custody. When alcohol intake is abruptly stopped on incarceration, the com- pensatory changes give rise to signs and symptoms of withdrawal (176). The severity of the symptoms depends mainly on the amount and duration of alco- hol intake, although other factors, such as concurrent withdrawal from other drugs, like benzodiazepines, may contribute to the clinical picture (177). Uncomplicated Alcohol Withdrawal This is the most frequent and benign type, usually occurring some 12–48 hours after alcohol intake is reduced, although it can develop as early as 6 hours after drinking has stopped. The essential features are a coarse tremor of the hands, tongue, and eyelids, together with at least one of the following: Substance Misuse 315 • Nausea and vomiting. If symptoms are mild, it is safe to recommend simple observation, but significant tremor and agitation will usually require sedation. The drugs of choice are long-acting benzodiazepines, which will not only treat alcohol with- drawal symptoms but will also prevent later complications (178). The starting dosages depend on the severity of the withdrawal, but 20 mg of chlordiazep- oxide, or 10 mg of diazepam, both given four times a day, will generally be appropriate (179). Usually the benzodiazepines should not be started until such time as the blood alcohol level has reached zero (180). However, detained persons with marked alcohol dependence may develop withdrawal symptoms before this point is reached. In these circumstances, it is both safe and reasonable to initiate therapy when the blood alcohol level has reached 80 mg/100 mL or thereabouts. Alcohol Withdrawal Delirium The essential diagnostic feature of this disorder is a delirium that devel- ops after recent cessation of or reduction in alcohol consumption. Tradition- ally referred to as delirium tremens, this withdrawal state typically begins 72–96 hours after the last drink, so it is uncommon within the normal span of detention in police custody. The delirium is characterized by impaired atten- tion and memory, disorganized thinking, disorientation, reduced level of con- sciousness, perceptual disturbances, and agitation. The disorder usually coexists with other features of alcohol withdrawal, for example, autonomic hyperac- tivity, which is usually severe. Alcohol withdrawal delirium is a medical emergency with a mortality rate of approx 5%. Once diagnosed, the detained person with delirium requires urgent hospitalization. Complications of Alcohol Withdrawal Several complications of alcohol withdrawal have been recognized, any one of which may be encountered when alcoholics are detained in police cus- tody (176). They usually occur between 6 and 48 hours after the last drink and although in themselves are not life threat- ening, their importance lies in the fact that about one-third of those with sei- zures will go on to develop alcohol withdrawal delirium. Alcoholic Hallucinosis This is an infrequent disorder that tends to occur at about the age of 40 years in those who have been drinking heavily for more than 10 years. The essential features are vivid and persistent hallucinations, which develop shortly (usually within 48 hours) after cessation of alcohol intake. The hallucinations may be auditory or visual, and their content is usually unpleasant and disturb- ing. The disorder may last several weeks or months and is quite different from the fleeting hallucinations observed in other forms of alcohol withdrawal. Cardiac Arrhythmias The frequency of tachyrhythmias in alcohol withdrawal is high, probably because of high adrenergic nervous system activity.

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Its main use is by mouth to replace causes similar respiratory depression order super avana 160 mg amex, vomiting and gastro- morphine or diamorphine when these drugs are being with- intestinal smooth muscle contraction to morphine best 160mg super avana, but does drawn in the treatment of drug dependence super avana 160mg fast delivery. It once daily under supervision is preferable to leaving addicts to produces little euphoria buy generic super avana 160mg line, but does cause dependence generic 160mg super avana overnight delivery. Pethidine is sometimes used in obstetrics abuse are related to parenteral administration, with its attend- because it does not reduce the activity of the pregnant uterus, ant risks of infection (e. The object is to reduce craving by (common to all opioids) is of particular concern in obstetrics, occupying opioid receptors, simultaneously reducing the as gastric aspiration is a leading cause of maternal morbidity. The slower onset follow- ing oral administration reduces the reward and reinforcement Pharmacokinetics of dependence. The relatively long half-life reduces the inten- Hepatic metabolism is the main route of elimination. Its effect has a rapid onset and if a satisfactory Codeine is the methyl ether of morphine, but has only about response has not been obtained within three minutes, the dose 10% of its analgesic potency. As a result, it has been used for many Naloxone is used in the management of the apnoeic infant years as an analgesic for moderate pain, as a cough suppres- after birth when the mother has received opioid analgesia sant and for symptomatic relief of diarrhoea. Naltrexone is an orally active opioid antagonist that is used in Pharmacokinetics specialized clinics as adjunctive treatment to reduce the risk of relapse in former opioid addicts who have been detoxified. Such Free morphine also appears in plasma following codeine patients who are receiving naltrexone in addition to supportive administration, and codeine acts as a prodrug, producing a therapy, are less likely to resume illicit opiate use (detected by low but sustained concentration of morphine. However, the drop-out rate is high due to non-com- codeine to morphine, and consequently experience less, if any, pliance. Its use is not recom- has not been extensively studied in non-addicts, and most of the mended. It antagonizes full agonists and can precipitate pain and cause The relief of pain in terminal disease, usually cancer, requires withdrawal symptoms in patients who are already receiving skilful use of analgesic drugs. For mild Like other opiates, buprenorphine is subject to considerable pain, paracetamol, aspirin or codeine (a weak opioid) or a pre-systemic and hepatic first-pass metabolism (via glu- combined preparation (e. It is important to use a large enough dose, if necessary given intravenously, to relieve the pain completely. Minor alterations in the chemical structure of opioids result in • It is much easier to prevent pain before it has built up than drugs that are competitive antagonists. This a smoother control of pain, without peaks and troughs of causes fear, which makes the pain worse. This vicious analgesia, which can still be supplemented with shorter circle can be avoided by time spent on pre-operative duration morphine formulations for breakthrough pain. Regular use of mild analgesics can be highly laxatives, such as senna, and/or glycerine suppositories should effective. Spinal administration ketorolac, which can be given parenterally) can have of opioids is not routinely available, but is sometimes useful for comparable efficacy to opioids when used in this way. Opioids are effective in visceral pain Key points and are especially valuable after abdominal surgery. Breakthrough pain can be treated by additional parenteral morphine is often needed initially, followed oral or parenteral doses of morphine. They are only required by a minority of – anti-emetics: prochloperazine, metoclopramide; patients, but should be available without delay when – laxative: senna. When • Prevention of post-operative pain is initiated during patients are provided with devices that enable them to control anaesthesia (e. The doctor – relief of left ventricular failure; on call prescribes morphine 10mg subcutaneously, four- – miosis (pupillary constriction); hourly as needed, and the pain responds well to the – suppression of cough (‘antitussive’ effect); first dose, following which the patient falls into a light – constipation; sleep. The Senior – for this reason gives a rapid ‘buzz’; House Officer was concerned not to cause respiratory depres- – may therefore have an even higher potential for sion, so did not prescribe regular analgesia, but unfortunately abuse than morphine; neither medical nor nursing staff realized that the patient – is more soluble than morphine. He had not himself • Codeine and dihydrocodeine are: asked for additional analgesia (which was prescribed) – weak opioid prodrugs; because his personality traits would lead him to lie quietly – slowly metabolized to morphine; and ‘suffer in silence’. The good initial response suggests – used in combination with paracetamol for moderate that his pain will respond well to regular oral morphine, and pain; this indeed proved to be the case. A non- – metabolized to normeperidine which can cause seizures; steroidal drug (e. He – can cause respiratory depression in neonates; remained pain-free at home for the next four months and – is less liable than morphine to cause bronchial was then found dead in bed by his wife. One of several possibilities is that he died from pul- – does not cause miosis; monary embolism.

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Second purchase super avana 160 mg with mastercard, specific definitions will enable future researchers to replicate the research discount super avana 160mg without a prescription. Physicists are concerned about the potentially harmful outcomes of their experiments with nuclear materials buy cheap super avana 160mg line. Biologists worry about the potential outcomes of creating genetically engineered human babies buy generic super avana 160mg. Medical researchers agonize over the ethics of withholding potentially beneficial drugs from control groups in clinical trials purchase 160mg super avana with visa. For instance, researchers may require introductory psychology students to participate in research projects and then deceive these students, at least temporarily, about the nature of the research. Psychologists may induce stress, anxiety, or negative moods in their participants, expose them to weak electrical shocks, or convince them to behave in ways that violate their moral standards. And researchers may sometimes use animals in their research, potentially harming them in the process. Decisions about whether research is ethical are made using established ethical codes developed by scientific organizations, such as the American Psychological Association, and federal governments. In the United States, the Department of Health and Human Services provides the guidelines for ethical standards in research. Other procedures, such as the use of animals in research testing the effectiveness of drugs, are more controversial. Scientific research has provided information that has improved the lives of many people. Therefore, it is unreasonable to argue that because scientific research has costs, no research should be conducted. This argument fails to consider the fact that there are significant costs to not doing research and that these costs may be greater than the potential costs of conducting the [4] research (Rosenthal, 1994). In each case, before beginning to conduct the research, scientists have attempted to determine the potential risks and benefits of the research and have come to the conclusion that the potential benefits of conducting the research outweigh the potential costs to the research participants. Characteristics of an Ethical Research Project Using Human Participants  Trust and positive rapport are created between the researcher and the participant. The most direct ethical concern of the scientist is to prevent harm to the research participants. One example is the well-known research of Stanley Milgram [6] (1974) investigating obedience to authority. In these studies, participants were induced by an experimenter to administer electric shocks to another person so that Milgram could study the extent to which they would obey the demands of an authority figure. Most participants evidenced high levels of stress resulting from the psychological conflict they experienced between engaging in aggressive and dangerous behavior and following the instructions of the experimenter. Studies such as those by Milgram are no longer conducted because the scientific community is now much more sensitized to the potential of such procedures to create emotional discomfort or harm. Another goal of ethical research is to guarantee that participants have free choice regarding whether they wish to participate in research. Students in psychology classes may be allowed, or even required, to participate in research, but they are also always given an option to choose a different study to be in, or to perform other activities instead. And once an experiment begins, the research participant is always free to leave the experiment if he or she wishes to. Concerns with free choice also occur in institutional settings, such as in schools, hospitals, corporations, Attributed to Charles Stangor Saylor. In some cases data can be kept anonymous by not having the respondents put any identifying information on their questionnaires. In other cases the data cannot be anonymous because the researcher needs to keep track of which respondent contributed the data. In this way the researcher can keep track of which person completed which questionnaire, but no one will be able to connect the data with the individual who contributed them. Perhaps the most widespread ethical concern to the participants in behavioral research is the extent to which researchers employ deception. Deception occurs whenever research participants are not completely and fully informed about the nature of the research project before participating in it. Deception may occur in an active way, such as when the researcher tells the participants that he or she is studying learning when in fact the experiment really concerns obedience to authority. In other cases the deception is more passive, such as when participants are not told about the hypothesis being studied or the potential use of the data being collected. Some researchers have argued that no deception should ever be used in any research (Baumrind, [7] 1985).

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Intentional miscon- duct by the expert may void any of these coverages or protections cheap super avana 160 mg otc, similar to the rules on awarding punitive damages purchase 160 mg super avana. Te foundation case establishing bitemarks in American jurisprudence is a 1954 Texas criminal case discount super avana 160 mg mastercard, Doyle v buy cheap super avana 160mg line. State buy super avana 160mg cheap,6 wherein the court accepted the testimony of a frearms examiner who had made plaster casts of a piece of cheese found at a crime scene that bore several bitemarks and another plaster cast of a piece of cheese bitten by the Jurisprudence and legal issues 391 suspect in the case. Te frearms examiner, using “caliper measurements,” testifed that both pieces of cheese had “been bitten by the same set of teeth. State of Indiana, the court accepted the testimony of a dentist in his frst bitemark case based upon his years of practice and teaching experience in conjunction with his training in the feld, which consisted of attendance at lectures and advanced reading. Te court stated, “Te determination of whether or not a witness is qualifed to testify as an expert lies in the sole discretion of the trial court and may not be set aside unless there is manifest error or abuse of discretion. While many appeals mention the fact that dental identifcation was utilized to establish the identity of a victim, the issue itself is not part of the appeal argument and is only mentioned in passing. Brigano a dentist who was also the coroner testifed that the den- tal records and the teeth he examined in the body “matched … perfectly. Te Fourth Amendment claim was denied due to the lack of any reasonable expectation of privacy by a defendant over what a person knowingly exhibits (in this case his smile) to the public coupled with the fact that a dental examination does not constitute a “search” (quotation marks in original). State a dentist identifed a skull with- out the use of mathematics/percentages, but rather by comparison and based on the outline of a single flling, the bone pattern, and the outline of another tooth. Te court was satisfed that even without specifc forensic training, the dentist was qualifed to make the identifcation and that any objections by the defense should go to the weight given the testimony by the jury rather than to its admissibility. Although there was minor variation in two antemortem dental charts used in the process, the court accepted the expert dentist’s opinion without the use 392 Forensic dentistry of probabilities or without any declaration that the body was in fact the victim to the exclusion of all other individuals in the world. Singletary,14 and later afrmed on appeal,15 a dental identifcation using casts, records, x-rays, and an unusual dental feature cited by the forensic dentist was sufcient to establish the identity. Mayens16 confrms the business record foun- dation for admission of dental records used in identifcations. A New York case afrmed the granting of an order to exhume cremains and deliver them to Drs. Because the body was not recovered for over two years, dental identifcation was the sole means of positive identifcation. Te forensic dentist is aforded an opportunity to interact with individuals and systems outside the normal realm of dental practice. Both general dentists and dental specialists enter with equal foot- ing in the feld. However, success requires dedication and a willingness to learn and become comfortable with the legal system, the legal profession, law enforcement, and the world of the coroner/medical examiner. Te forensic dentist must be dedicated to the pursuit of the truth and must adhere to the highest ethical standard. A good forensic dentist can, without breach- ing ethical standards, be a good witness—one that advances the cause of justice by presenting the truth on the stand and fulflling the expert’s role to educate the attorneys, the judge, and the jury about the dental facts at issue. Failure to comply with appropriate evidence management procedures can lead to signifcant adverse results during litigation. It is, therefore, incumbent upon all forensic dentists to become knowledgeable in evidence handling, not only for the ultimate court- room success, but also for the profession as a whole. Tis knowledge base can be established via the clear and concise evidence management guidelines presented in this chapter. All supplies and equipment required for the collec- tion of forensic dental evidence should be on hand and ready for deployment to a remote crime scene if warranted. Professional credentials, business cards, and other forms of professional identifcation should be immediately available for presentation to law enforcement as required. Te most impor- tant preparatory step in evidence management for forensic dentists is the establishment of excellent liaison with other forensic professionals and all law enforcement agencies within their jurisdictions well in advance of any evidence collection/interpretation event. Odontologists operating out of a medical examiner’s facilities (or consulting from their private ofces) receive evi- dence from law enforcement or legal consultants that may have already been entered into some type of evidence management system. Te mandate is to document the arrival of this physical evidence into the odontologist’s custody. Should the dentist travel to a scene containing forensic dental evidence, his or her foremost responsibility is to ensure safe entry into the scene. In some instances the odontologist will be required to provide appropriate identifca- tion to on-scene law enforcement or emergency responder personnel, to sign into an entry log, and to don appropriate personal protective gear prior to entering the scene.

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