Misuse Problems Research Articles

The Features of the Shadow Economy Impact’ on Biomass Energy Sector

The shadow economy is a significant factor in impoverishing the economies of countries and unequal operating and competitive conditions distort the market economy system, as opaque parallel activities impoverish socially responsible business units. The biomass energy sector faces this risk because the biomass supply chain is not yet fully secure and balanced. The study conducted by the authors showed that the manifestations of the shadow economy in the biomass energy sector are possible in the biomass production and transportation sub-sectors. Lack of digitization and poor resource management can lead to the problem of misuse of resources, which has non-transparent economic activities. The evaluation methodology developed by the authors allows to investigate the directions of shadow economy in the biomass energy sector and to measure the possible extent of such activities. The measurements were made in order to compare the official activities of enterprises with the factors attributable to the shadow economy. This is also due to the lack of innovation and digital solutions. The application of innovative solutions would help to reduce the size of the shadow economy, which would increase the income of regions and the state, and reduce the level of poverty.

Audit of epilepsy healthcare provision in a large UK category B prison

PurposeWe reviewed all prisoners diagnosed with epilepsy within a large UK category B prison: collecting demographic information and the prevalence and nature of their seizure disorder; and reviewed standards of their epilepsy healthcare provision. Previous work has highlighted poorer seizure control and limited access to specialist services in this patient group. MethodsFifty-five male prisoners with a previously established diagnosis of epilepsy were identified by the prison healthcare manager during the six-month audit period. Anonymised audit data was collected during clinical interviews undertaken by members of a regional specialist epilepsy service and recorded on a standardised proforma. Data collection occurred during six prison visits within the audit period. ResultsPoint prevalence of epilepsy was 2%. Data suggest that demographics are complex and challenging in this patient group. We found increased rates of alcohol (40%) and drug (82%) misuse and mental health problems (85.5%). Just over one third of cases were prescribed medications with potential for misuse (diversion). Further optimization of anti-seizure medication (ASM) regimens was required in 67.3% of the study sample, with only 12.7% of cases being free of seizures for the last 12 months. Access to specialist epilepsy services was limited; only 38.2% had a specialist review in the last 12 months. Most cases (76.4%) did not recall receiving guidance on precautions that should be taken regarding duties or cell arrangements in relation to having a diagnosis of epilepsy. ConclusionsTighter collaboration between prison healthcare and local NHS specialist services is recommended to optimise epilepsy healthcare in UK prison settings.

Editorial

Kate Harding Women’s health continues to make headline news both in the UK and globally. There is increasing data on the safety of COVID-19 vaccinations in pregnancy, with benefits not just for the pregnant woman but also her yet-to-be-born baby (with decreased infant admission for COVID-19 in the first 6 months of life for those born to vaccinated mothers). In my practice, the message seems to be getting through, but we must still listen to those who are worried by vaccination and explore their fears individually. The impact of the pandemic on our patients is often hidden, with reduced attendance at screening programmes, prolonged waiting lists (particularly affecting those with ‘benign’ disease) and the effect on home life with potentially increased (and less recognised) domestic abuse; this last impact is discussed in this issue of TOG in a timely commentary by Dey and Thakar. The impact on those of us practicing in O&G is clear, too: we are all tired and yet being asked to work harder than ever. Please make use of whatever resources you have available to ensure that you maintain some balance in your life. Get outside for a walk in the spring air, relax with friends, family or just a good book, remind yourself of the times when you made a positive difference to your patients. We all need to look after ourselves if we are going to be able to look after others. As usual in TOG we have something for everyone and – I hope – learning for all. I particularly recommend the article on oophorectomy at the time of benign hysterectomy. This article challenges the previous belief that in women, approaching or beyond the menopause, oophorectomy at the time of hysterectomy was a sensible prophylactic procedure. Jakes et al. discuss in detail the function of the ovary post-menopause, the risk of malignant change later in life and alternative risk reduction procedures. These benefits and risks should be discussed with all women undergoing hysterectomy for benign conditions; perhaps an information leaflet could be produced based on this article to improve information sharing and the consent process. Brown et al. discuss the important topic of paraneoplastic syndromes, explaining the breadth of paraneoplastic presentations that may be associated with gynaecological malignancies. Greater awareness of these may both improve our ability to manage them and increase our level of ‘suspicion’ in patients with these complications, leading us to explore the possibility of underlying malignancy. While pregnancy may be a risky time for the fetus, there has been little focus on the outcome of babies born following high-risk pregnancy. Aiken and Dunkerton explore this in their article Impact of the intrauterine environment on future reproductive and metabolic health. Currently there is little we as clinicians can do during pregnancy to ‘improve’ the intrauterine environment, and the focus therefore needs to be on prepregnancy optimisation and possibly long-term follow-up of at-risk individuals. Thomson et al. have described the sadly common (and increasing) problem of opioid misuse in pregnancy. They discuss in detail the complications associated with opioid misuse and the need for a full multidisciplinary approach to supporting these often complex families. Yates et al. explore fetal cardiac arrhythmias. These are not an uncommon finding, occurring in up to 3% of all pregnancies, but few are pathological or associated with poor outcome. It is these babies that this article focuses on. The authors discuss in detail the management of the various tachy- and bradyarrhythmias, including both pharmacological treatments (usually given via the mother) and peripartum care (including the difficulty of intrapartum monitoring). While care plans may come from tertiary centres, we all need to understand them so we can support our women locally. Jo Morrison has written a comprehensive Spotlight on… gynaecological cancer, in which she highlights the breadth of papers in TOG on this subject in just the past 5 years. I strongly recommend this excellent overview not just for our trainees (and those doing their exams) but for anyone wanting an update on this subject.

Anonymous identity sampling and reusable synthesis for face camouflage

An increasing amount of face images are being captured, shared, or applied in various applications. These images usually contain lots of sensitive information that may lead to privacy disclosure and misuse problems. Some pioneering works show that face image anonymization is one of the promising solutions. We present an innovative identity (ID) camouflage approach by synthesizing anonymous faces so that both artificial intelligence algorithms and humans are unable to recognize them and misuse them freely. Given a face image, our approach consists of two steps. First, we sample an anonymous ID feature point in the feature space. Then, we synthesize a camouflage face by training an anonymous deep generative adversarial network model. To reduce the risk of re-identification, we optimize our anonymous face generator based on the k-nearest neighbors to make a good balance between anonymity and utility of the original face image. The experimental results over the public dataset have verified the feasibility and state-of-the-art efficacy of our approach.

Chronic Pain and Prescription Opioid Use Among Socially Marginalized Nigerian Women: Exploring Supply Channels and Pathways to Misuse

This study explores pathways to prescription opioid misuse and supply channels based on in-depth interviews with 16 socially marginalized Nigerian women suffering chronic pain. The pathways identified were medical pain treatment, prior substance use and opioid use for recreation and coping with psychological distress. Facing barriers to prescription opioids due to prescribing restrictions and provider stigma, many resorted to unlicensed chemist stores and street drug dealers for opioid analgesics, including fake and potentially harmful products. Patterns of prescription opioid misuse were woven into multiple and overlapping dynamics of marginalization shaping the lives of these women, including homelessness, sex work, substance use and intimate partner violence. Findings show a need to improve access to prescription opioids and other evidence-based approaches, framed within a trauma-informed approach to pain management. Further, integrating substance abuse treatment and pain management could make services responsive to the inter-related problems of chronic pain and prescription opioid misuse.

694 IMPROVING OPIATE PRESCRIBING IN OLDER ADULTS WITH HIP FRACTURES TO COMBAT THE IATROGENIC FALLOUT

Abstract Background The number of opioid prescriptions in older patients has increased dramatically and it is recognised that opioids are the fourth most likely drug to cause preventable hospital admissions. The adverse effects of opioids occur more frequently in the geriatric population. Little is known about the impact of postoperative pain in older adults. NICE recommends paracetamol with additional opioids if there is insufficient postoperative pain relief. Multidisciplinary management with early and then daily physiotherapy is critical. We have assessed pre-morbid, immediate and prolonged use of opioids in patients following hip fracture. Local problem Pre-intervention analysis identified 79% (57/72) of all patients being discharged on opiates. At 4-months, 37% (17/46) of those were still using them. This represents 28% (17/61) of all patients. Methods Analysis of all patients (excluding poly-trauma) with hip fractures over the age of 60 years admitted to St Mary’s Hospital. Interventions Development of local guideline on analgesia prescribing; particularly focusing senior geriatrician led decision making. Prescribing oxycodone for first 72-hours and initially using nerve block. Avoidance of transdermal preparations and withdrawing stronger opioids prior to discharge. Clear instructions for GP’s on a stop date and need for community review. Patient information leaflet dispensed with all discharge opioid prescriptions. Results Post-intervention cycle; 17% (11/63) of patients were taking prescribed opioids prior to admission (similar to the pre-cohort). 52% (33/63) were discharged on opiates, down from 79%. At 4-months, of those discharged on opioids, 30% (9/30) were still using them; lower than in the first cycle (37%). Overall reduction from 28% to 16% of patients on opioids at 4-months. Conclusion The use of specific hip fracture analgesia guideline, senior geriatrician decision-making and support to community colleagues can reduce in-patient and community opiate prescribing, and stem the growing problem of opioid addiction, misuse and iatrogenic re-admission.

Experience of Choosing Wisely in a Medical Center

<p>明智選擇(Choosing Wisely)可以提高照護的品質、降低成本，避免醫療照護發生使用過度(Overuse)及使用不當(Misuse)的醫療品質或醫療爭議相關問題，使健保與醫療體系永續經營。高雄醫學大學附設中和紀念醫院於2020年啟動明智選擇推動專案，作為醫療適當性的檢討與改善機制。經首長宣示、建立推動架構、依任務分組、教育訓練及定時召開進度會議，再由醫品病安管理中心及實證醫學中心邀請並協助臨床科的選題及執行。共有7個團隊完成明智選擇主題，已舉辦成果發表會及跨院分享，並在各科開啟專業對話及醫療適當性的討論。藉由本院推動明智選擇的經驗分享，提升醫療的適當性，減少不必要的檢查、診斷或治療，可作為醫學教育及醫療先進的參考。</p> <p> </p><p>Choosing Wisely improves quality of care, reduces medical expenses, prevents overuse and misuse problems of medical care in relation to healthcare quality or medical disputes, and increases the sustainability of the National Health Insurance and medical systems. Since 2020, Kaohsiung Medical University Chung-Ho Memorial Hospital has promoted the Choosing Wisely program as part of the review and improvement mechanism for medical services to ensure their adequacy. Started up by the vice superintendent, we assigned tasks to relevant departments, executed educational programs and held regular meetings. With the assistance of the Medical Safety Management Center and Evidence-Based Medicine Center, we performed topic selection and implemented the Choosing Wisely program for seven clinical teams. All the teams completed the tasks successfully. We held a competition, presentation session, and experience-sharing meetings with other hospitals. The initiation of Choosing Wisely in our hospital enabled clinical professionals to participate meaningfully in peer discussion regarding the adequacy of medical care. Herein, we present our experience and strategies in promoting Choosing Wisely at our hospital, which improved the adequacy of medical services and reduced unnecessary testing, diagnoses, and treatments. This study may serve as a reference for those involved in medical education and medical professions.</p> <p> </p>

What can siblings and cousins tell us about the role of early life family income in the aetiologies of violent crime, substance misuse and psychiatric morbidity?

In our recent paper,1 we examined associations between family income during childhood and adolescence on subsequent risks of developing psychiatric disorders, having substance misuse problems and being arrested for a violent crime. We used nationwide population data on 650 680 individuals born in Finland between 1986 and 1996 and their siblings. Our initial analyses indicated, as expected on a population level, that higher family income was associated with lower risks of all examined outcomes. We then used a sibling-comparison design, where we compared risks of the outcomes between biological full-siblings who, owing to the fact that they were born during different years, grew up in the same households during periods when the parents had varying levels of income. If the reported associations were consistent with a causal inference, we would have expected the siblings who were exposed to lower family income relative to their co-siblings to have higher risks of the outcomes, but we did not find any support for this. In fact, the point estimates for the sibling-comparison estimates were all close to 1, indicating no difference between the siblings regardless of their family income exposure, and the confidence intervals were narrow, indicating a high level of precision of the estimates. Complementary sensitivity analyses indicated no moderation effects by demographic characteristics (e.g. sex, birth year and birth order) and stability of the findings across a wide range of alternative exposure and outcome definitions. In response to the points raised in the letter Rod et al.,2 we have the following comments.

Opioid use disorder in anaesthesia and intensive care: Prevention, diagnosis and management.

Opioid misuse is common, as is opioid agonist treatment of opioid dependence. Almost 3% of Australians and over 3.5% of those living in New Zealand report misuse of analgesics. Over 50,000 Australians receive opioid agonist treatment with methadone or buprenorphine for management of severe opioid use disorder.The perioperative period is an opportunity to identify pre-existing opioid misuse, and to introduce interventions to reduce the risk of development of opioid use disorder. Challenges of acute perioperative pain management or intensive care management of patients receiving opioid agonist treatment include opioid tolerance and ongoing prescribing of methadone or buprenorphine. There has been some ambiguity about the optimal perioperative management of buprenorphine, a partial agonist at the mu receptor.In this article, a framework to identify emerging opioid misuse problems, identify risk of overdose and to manage the opioid-dependent patient on opioid agonist treatment perioperatively or in the intensive care unit is provided. Diagnostic criteria and risk stratification criteria are presented. Management strategies include trauma-informed care, care planning and care coordination with community practitioners and opioid agonist treatment providers. Continuing methadone or buprenorphine perioperatively with additional opioid and non-opioid analgesia is generally recommended. Increased opioid agonist treatment doses may be required on discharge. An algorithm for decisions about opioid agonist treatment management in the intensive care unit based on the risks of opioid withdrawal and toxicity is considered. Strategies for managing the opioid-dependent patient who is not in treatment are also discussed.

Measuring recent cannabis use across modes of delivery: Development and validation of the Cannabis Engagement Assessment

IntroductionMethods of cannabis engagement have proliferated in recent years, which many self-report measures do not adequately capture. There is a clear need for self-report measures that capture current patterns of cannabis use across a range of methods, and that can be used to track changes over time. The current study developed the Cannabis Engagement Assessment (CEA), a self-report measure of past month cannabis use across dry flower, concentrate, and edible products. MethodsA sample of 349 participants from the undergraduate student population and broader community were recruited. To examine convergent validity of the CEA, participants completed measures of cannabis engagement, cannabis misuse, and use-related problems. To assess divergent validity, participants also completed measures of depression and alcohol use problems. Criterion and test–retest reliability were examined in a subset of 65 participants who re-completed the CEA and a timeline follow-back interview (TLFB). ResultsIndicators of cannabis use frequency and quantity showed good convergence with measures of cannabis use patterns, problematic engagement, and cannabis use-related problems. Divergent validity of the CEA was supported by lower associations with alcohol use problems and depression symptoms. The CEA also showed good test–retest reliability and convergence with estimates of frequency and quantity of cannabis use from the TLFB. ConclusionsThe CEA is a viable self-report measure of cannabis use that is representative of current patterns of recreational cannabis engagement. Its focus on cannabis use in the preceding 30 days also lends itself to measuring changes in use over time.

Transcending the Shadow of Alcoholism

This paper explores potential reasons why a high proportion of children of alcoholics develop significant substance misuse problems. The author suggests it is potentially indicative of transgenerational trauma, which results in developmental deficits that may be managed by substance misuse. The paper describes how Jung's concept of the transcendent function provides a powerful therapeutic tool to link divided and split off parts of the self in a containing matrix. This is contrasted with Kleinian approaches to addictive states of mind. The alcoholic defence or ‘solution’ is examined through a Jungian lens. The transformative potential lies in holding the tension between wanting to ‘give up’ the family cycle of alcoholism versus ‘giving in’ to the alcoholic solution. Moving away from an identification with the alcoholic solution involves mourning and loss which is often vehemently resisted. The value in Jung's idea of the transcendent function is in the creative potential leading to growth arising from the dynamic tension of these opposites. The paper describes how they come together in fantasy, symbols and transference using a clinical case.

Client satisfaction to methadone maintenance treatment program in Myanmar

BackgroundTo tackle the long-standing opioid misuse problem, Myanmar introduced the methadone maintenance treatment (MMT) program in 2006, starting with 260 clients. Since then, the program has been expanded across different geographical sites in the country. This study was done in 2017 to explore the treatment satisfaction of the clients towards the MMT program.MethodA total of 210 clients with a minimum of six-month treatment history enrolled in five MMT program sites across Myanmar were recruited through stratified random sampling. Administering the Verona Service Satisfaction Scale for Methadone-Treatment (VSSS-MT), this study assessed the satisfactory responses under three categories viz., 1) clinic staff professional skills; 2) basic drug intervention; 3) specific intervention (individual rehabilitation and psychotherapy).ResultsThe majority (89%, n = 186) of the respondents were satisfied with the current MMT program. Specifically, 89.5% (n = 187) were satisfied with the clinic staff professional skills category, 91.9% (n = 192) with the basic program intervention and 74.6% (n = 156) with specific interventions. Among the respondents, treatment satisfaction with the MMT program was higher (p < 0.05) in those (i) with a higher quality of life score in physical, psychological, social and environmental categories, ii) who were satisfied with their current marital and leisure status, and those iii) who consumed alcohol. Results from stepwise binary logistic regression showed alcohol consumption and physical health status had a significant association with MMT treatment satisfaction.ConclusionTreatment satisfaction of the clients, in general is high. However, the lower percentage of satisfied clients (74.6%) for the specific interventions category compared with 89.5 and 91.9% respectively for staff and basic drug management categories highlights the need for improvement in this category for overall enhancement of the MMT program.

Perception of the Forest Area and Willingness to Pay for Household Waste Management Services in Villages around the Sawala Mandapa Education and Training Forest, Majalengka, Indonesia

Forest area with special purposes of Sawala Mandapa Education and Training Forest not only has a lot of progress in development but also challenges. The most important challenge is the misuse of the area as a waste dumpsite. The problem of accumulating waste in forest areas is caused by a lack of public awareness in managing and processing household waste. Meanwhile, support from the local government, the Environmental Service of Majalengka District, has limitations in the transportation and management of household waste. Therefore, efforts are needed in dealing with waste management in villages around forest areas to achieve public health and forest preservation. Efforts to deal with the problem of misuse of forest areas as places for accumulating waste require finding information about community perceptions of household waste management and forest area preservation. This study aims to determine community perceptions of forest areas and willingness to pay for household waste management. A survey instrument in the form of a questionnaire has been used as a basis for collecting data on the community’s perceptions and knowledge of forest areas and their willingness to pay for household waste management services. Multiple linear regression models were processed by SPSS 27 software were used to test the hypothesis.

POLICY OF PREVENTIVE WORK WITH JUVENILE DRUG USERS IN THE USA

This article deals with the problem of preventive work with young drug users. This is one of the most important problems in the world, including the USA. Substance misuse can put individual users and others among them at risk of harm. Early substance misuse and substance use disorders are associated with a variety of negative results, including deteriorating relationships, poor school performance, loss of employment, diminished mental health and increases in sickness and death. It is therefore critical to prevent the full spectrum of substance misuse problems in addition to treating those with substance use disorders. The aim of the study is to reveal the peculiarities of preventive work with young drug users in USA. Theoretical research methods have been used in this study: analysis of scientific sources, systematisation and generalisation of available data; defining of the essence of basic concepts; identification of the current state of the problem. The results of investigation give possibility to state that preventing or reducing early substance use initiation, substance misuse and the harms related to misuse requires the implementation of the effective programs and policies that address substance misuse across the lifespan. The effective prevention programs exist in the USA, and if implemented well, they can markedly reduce substance misuse and related threats to the health of population. There are three main categories of prevention interventions: universal, selected and indicated. Universal interventions are aimed at all members of a given population; selective interventions are aimed at a subgroup determined to be at high risk for substance; indicated interventions are targeted to individuals who are already using substance but have not developed a substance use disorder. It is recommended to provide a mix of universal, selective and indicated preventive intervention. Different programs are used for different categories of population. The program «Family Partnership» is focused on children younger than age 5. «The Good Behavior Game» and «Classroom-Centered Intervention» is an universal elementary school-based prevention program. For adolescents aged 10 to 18 programs «Life Skills Training» and «Towards No Drug Abuse» are used. There are also family-based programs («Strengthening Family», «For Parents and Youth»), program for College Students («Brief Alcohol Screening»), Internet-based program («I hear what you are saying») and many others. drug; juvenile; youth; preventive work; rehabilitation; programs of prevention; USA.

Beyond co‐occurrence: Addressing the intersections of domestic violence, mental health and substance misuse

AbstractThis paper reports an Australian project designed to simultaneously explore and capacity build professional practice when working at the intersection of parental mental health and/or problematic substance use and domestic violence (DV). Data from this paper are derived from two main sources: observations and ethnographic notes obtained during 28 Community of Practice (CoP) meetings and semi‐structured interviews with 28 CoP participants. Participants were front‐line workers from a range of government and non‐government organizations providing services to families experiencing DV across three Australian states who participated in The STACY Project: Safe and Together Addressing ComplexitY. Thematic analysis was employed to examine the research questions: How do professionals and organizations understand and respond to families experiencing DV, parental mental health difficulties and problematic substance use issues? How did practitioners report participation in the STACY Project reorienting professional practice with families experiencing DV, parental mental health difficulties, and substance misuse issues? This paper reports workers' exploration of practice implications. The research found that ‘domestic violence blind’ practice has become entrenched at the intersections of child protection, substance misuse and mental health problems, but a shared framework could bring practitioners from diverse sectors together to generate new ways of working with these complex problems.

Enforcement of Immigration Law Against Human Smuggling Especually Illegal Foreign Labor in Indonesia : Normative – Empiric Axiology

Transnational crime has the potential to occur in Indonesia, which is a developing country. Transnational crime is not only driven by the free trade factor and weak law enforcement in Indonesia, but also by the geographical area of ​​Indonesia itself. In the midst of many national problems that are currently happening and require serious attention, one of the serious concerns is people smuggling or people smuggling. Law enforcement against immigration crimes, especially the problem of misuse of foreign workers' residence permits by law enforcement officers, especially PPNS investigators is still very weak. This can be seen in the development of the issue of illegal foreign workers which is being discussed in the community. This situation needs serious attention from the government, especially law enforcement. Enforcement of illegal foreign workers can be carried out administrative actions in the form of paying fees/fines, deportation, revocation of business licenses, and if the conditions for employing foreign workers are not met, the licensing agency can repatriate foreign workers to their countries of origin, and deterrence or criminal sanctions with the threat of imprisonment. The policy of determining in the future should stipulate a special minimum and a special maximum in criminal sanctions, in addition to mapping the division of roles so that there is no generalization of the imposition of criminal sanctions accompanied by the determination of criminal rules that are oriented towards smugglers and the people being smuggled.

Prevalence and Correlates of Prescription Drug Misuse in a Nationwide Population Survey in Taiwan.

Background: Prescription drug misuse (PDM) is a critical mental health issue relating to psychiatric morbidity. This study investigated the prevalence of PDM and its associated psychopathology and psychosocial factors in the general population in Taiwan. Methods: The survey randomly selected a representative sample >15 year-olds using the stratified proportional randomization method. The measurements included demographic variables, previous experience with PDM, self-rated physical and mental health, health self-efficacy, risk factors for suicidality, and psychological distress. Results: The weighted one-year prevalence of PDM was 8.5% (n = 180) among 2126 participants. Those with psychological distress and lifetime suicide ideation (23.3%) or suicide attempts (5.0%) were significantly associated with PDM. PDM was also prevalent among those with poorer self-rated health and lower self-efficacy. Insomnia (OR = 1.52), depression (OR = 1.77), and low self-efficacy (OR = 2.29) had higher odds of PDM after adjustment in the logistic regression model. Conclusions: Individuals who misused prescription drugs had a higher prevalence of psychological distress and suicidality and lower levels of self-rated health. Prescription drug misuse problems should be screened for early prevention when prescribing medications for people with insomnia, depression, or lower perceived health beliefs or conditions.

Efficacy of a minimally guided internet treatment for alcohol misuse and emotional problems in young adults: Results of a randomized controlled trial

ObjectiveMany young adults struggle with comorbid alcohol misuse and emotional problems (i.e., depression and anxiety). However, there is currently a paucity of evidence-based, integrated, accessible treatment options for individuals with these comorbidities. The main goal of this study was to examine efficacy of a novel online, minimally guided, integrated program for comorbid alcohol misuse and emotional problems in young adults. Method: The study was an open-label two-arm RCT. Participants (N = 222, Mage = 24.6, 67.6% female) were randomized to one of two conditions: the Take Care of Me program (an 8-week, online integrated treatment condition consisting of 12 modules), or an online psychoeducational control condition. Intervention modules incorporated content based on principles of cognitive behavioral therapy and motivational interviewing. Participants completed assessment data at baseline, at the end of treatment (i.e., 8 weeks), and at follow-up (i.e., 24 weeks). Data were analyzed using generalized linear mixed models. Results: We observed that participants in the treatment condition showed larger reductions in depression, hazardous drinking, as well as increases in psychological quality of life and confidence at the end of treatment. We did not find group differences on total alcohol use at follow-up, but participants in the treatment group reduced their hazardous drinking and improved their quality of life at 24-week follow-up. Conclusions: Our study provides promising initial evidence for the first iteration of the comorbid alcohol misuse and emotional problems online program.

Systematic review and meta-analysis of opioid use at 3, 6 and 12 months post-operatively by opioid naïve orthopaedic surgery patients.

There is evidence that opioid initiation post-surgery is contributing to the problem of chronic misuse and/or abuse of over the counter medications in the community, and that orthopedic patients may be particularly at risk. The aim of the systematic review with meta-analysis was to identify research that examined opioid use at 3, 6, and 12 months post-operatively by previously opioid naïve orthopedic surgery patients. Design, databases, and data treatment: A searched review with meta-analysis was undertaken. Eight databases were search. Meta-analyses conducted at all three time points (3 months, 6 months, and 12 months). The search yielded 779 records, and after screening, 13 papers were included in meta-analysis. Results provide strong evidence that post-operative opioid use amongst the opioid naïve is a real effect (7 percent at 3 months, 4 percent at 6 months, and 2 percent at 12 months). A Z-test for overall effect revealed strong evidence that this proportion was nonzero for opioid use at 3, 6, and 12 months (p < 0.001 for all time points). A small but significant proportion of opioid naïve patients who are prescribed opioids remain on these medications up to 12 months post-operatively. The nature of the studies included in the meta-analysis were varied, hence subanalyses regarding surgery type, characteristics of the patient group or other potential factors that might influence the progression to longer term opioid use after these surgeries could not be explored. Given this, further research in this area should explore such specific orthopedic subgroups.

The impact of internal and external factors of the competitive environment on the competitive performance of the Iraqi Company for Seed Production (ICSP)

Competitive performance is one of the important means in companies, as most companies suffer from the problem of misuse of economic resources in an optimal manner, which affects their ability to create added value and consequently the decline of the company’s contribution to raise the gross domestic product. To reach to final results of the company, we have to identify its strengths and weaknesses and choose the appropriate strategy to improve the reality of the facility and work on increasing productivity and reducing losses to the least possible. The aim of the research is to develop solutions to correct the company's performance competitive in line with the company's objectives.The research is divided into two sections, the first section deals with the concept of competitive performance, its elements and indicators, and the analysis of the internal and external competitive environment. The second section deals with the analysis of the internal and external environment within the Porter model of Iraqi Company for Seed Production (ICSP) and improving competitive performance and rehabilitating it. The research concluded with a number of conclusions and recommendations.