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Assistant Professor, University of Nevada, Reno School of Medicine

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In 2014 the skyrocketing number of 911 calls and overdoses related to heroin and prescription drugs are traumatizing communities they never touched before, and the problem is not going away. To give this sum context, Suboxone revenue is three times that 8 of Super Bowl advertiser/provocateur Go Daddy and dwarfs brands including Urban Outfitters and Ameritrade. Other companies have arrived or plan to enter the market including Orexo (Zubsolv) and BioDelivery Sciences (Bunavail). Some patients who have been prescribed the drug decide they want to discontinue it. The reasons vary, ranging from financial pressures arising out of the cost of doctor visits and medication to side effects, potential future side effects and finally, the patient who wants to be 100 percent drug free. Regardless of the reason one has for ending replacement therapy, making the choice presents a whole new set of challenges. From anecdotal reports, the least disruptive way to achieve a Suboxone-free life is to cut down the amount used very slowly week by week until titration is complete. This scenario is complicated by two facts: fi the lowest strength Suboxone comes in is 2 mg. If you ask the doctor who has been prescribing you the drug for months or years, you may find him/her woefully lacking in experience or a plan for tapering. Confusing the rhetoric of a pharmaceutical company with studies on the outcome of addiction treatment is a mistake. Four doctors I spoke to while researching this article told me they have successfully tapered patients formerly on replacement therapy. A successful taper requires adopting a combination of daily cardio exercise and mindful nutrition to repair and rebuild body and brain. While there are lower strength formulations of buprenorphine on the market (that would make tapering a more simple and accurate process) they are created for pain management and are illegal to prescribe to recovering addicts. Physicians routinely prescribe medications for "off label" use, but there are many laws directed towards prescribers of buprenorphine and they have serious repercussions. A doctor could lose his/her license for prescribing a Butrans patch to help taper a patient off of Suboxone. The amount of time in the course agenda dedicated to taking patients off of the drug is nil. No doctor I spoke with recalled the topic of withdrawal from Suboxone being mentioned during the certification process. Patients are desperate when they come in, willing to pay significant sums of cash for services, and rarely shop around for the perfect fit between patient and practitioner.

Syndromes

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Journal of the American Academy of Child and Adolescent Psychiatry, 41(2), 166-173. A treatment outcome study for sexually abused preschool children: Initial fndings. Preschooler witnesses of marital violence: Predictors and mediators of child behavior problems. The posttraumatic stress disorder diagnosis in preschool and elementary school-age children exposed to motor vehicle accidents. Practice parameter for the assessment and treatment of children and adolescents with posttraumatic stress disorder. Traumas and posttraumatic stress disorder in a community population of older adolescents. Prevalence, comorbidity and course of trauma reactions in young burn injured children. Children and adolescents injured in traffc-associated psychological consequences: A literature review. Psychological consequences of road traffc accidents for children and their mothers. Violence exposure and traumatic stress symptoms as additional predictors of health problems in high-risk children. Heart period and availability fndings in preschool children with posttraumatic stress symptoms. A meta-analysis of risk factors for post-traumatic stress disorder in children and adolescents. Parent and child agreement for acute stress disorder, post traumatic stress disorder and other psychopathology in a prospective study of children and adolescents exposed to single-event trauma. Multiple informant agreement and the Anxiety Disorders Interview Schedule for parents and children. Differences in trauma symptoms and family functioning in intra and extrafamilial sexually abused adolescents. Proceedings of the National Academy of Sciences of the United States of America, 101(49), 17316-17321.

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First, the magnitude of trauma in Aboriginal and Torres Strait Islander families may be overwhelming to practitioners and lead them to feel powerless and be inclined to give up. Second, as noted in Chapter 2, with people who have experienced prolonged or repeated traumatic experiences, more preparatory work is required before trauma-focussed work begins. As such, unless the practitioner has the capacity to make a commitment to being available in the longer term, it is often more appropriate to address current life and behavioural problems, focussing on issues of structure and problem solving, rather than delving into a potentially long history of trauma. There are signifcant challenges in the application of these Guidelines to Aboriginal and Torres Strait Islander peoples. In addition to the historical and current sociopolitical factors referred to above, the pervasive and enduring social disadvantage and the prevalence and complexity of traumatic experience, geographical isolation and limited availability of appropriately trained mental health practitioners all combine to create considerable barriers to effective care for posttraumatic mental health conditions. Perth: Curtin University of Technology and Telethon Institute for Child Health Research. Working together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice. Ways forward: National Aboriginal and Torres Strait Islander mental health policy. Although a few studies identifed in the systematic review included participants that were refugees or asylum seekers, there is no evidence to suggest that radically different treatment approaches are required. Rather, it is a question of adapting the guideline recommendations to the specifc needs of this population. Practitioners working with refugees and asylum seekers need to be aware of their own ethnocentricity, need to be culturally skilled and informed, and need to be open to different cultural perspectives on psychological problems. Detailed information about the specifc background and experience of the individual is, of course, still required. For asylum seekers, government policies relating to detention, visa options, and fundamental rights and entitlements such as access to medical care have the potential to signifcantly infuence mental health and wellbeing. The traumatic experiences of refugees need to be understood also in the context of sociopolitical factors in their country of origin. There are three defning characteristics of the refugee and asylum seeker experience common to most, and based on deliberate and targeted prosecution against their ethnic, cultural, religious or political beliefs or values: 1. Trauma (experienced or witnessed situations where their lives have been threatened or people close to them have been threatened, injured, raped, tortured or killed). In the case of asylum seekers, environmental and policy factors such as mandatory or indefnite detention and temporary protection (see additional issues specifc to this group below). Practitioners should be mindful of the following issues when working with interpreters. First, with regard to perceptions of confdentiality, interpreters should not be known to clients.

Diseases