Effect of THNPs on Heroin OD Mortality | Methodology

Effect of THNPs on Heroin OD Mortality | Methodology Chapter 2. Methods 2.1 Introduction This chapter contains a precise description of the process used to search and appraise the evidence for this systematic literature review. The search was carried out during August and September 2014. An in-depth description of how evidence and research available related to the PICO question were generated, will be discussed. As mentioned in the previous chapter, the aim of this dissertation is to determine the effect of THNPs to heroin users, on heroin OD mortality. The analysing process of the PICO question, whether THNPs reduces the incidence of fatal heroin OD deaths, will be amplified through a description of the actual search strategy, and the methods used to appraise the retrieved studies. Through specific criteria, a systematic approach was applied in obtaining and selecting the relevant literature. Identified keywords used for the search syntaxes will be presented, together with the databases used for the retrieval of evidence, and the number of hits produced from each database. Search syntax is the relationship of a sequence of words used in a search strategy. A discussion of the inclusion and exclusion criteria set for this systematic review (SR) will follow, together with the methods of appraisal chosen to evaluate the studies. 2.2 Keywords and databases used PICO Element Description Keywords Population Heroin injection users in the community heroin users, injection drug users, drug users, opioid users Intervention Take-home naloxone program take-home naloxone program, naloxone distribution program, Comparison No comparison Outcome Reduced incidence of fatal heroin OD deaths OD reversal, OD prevention, opioid OD prevention, heroin OD prevention, harm reduction According to Timmins and McCabe (2005) the cornerstone of an effective search strategy is the use of proper keywords. A number of keywords were formulated from the PICO question elements, and from the preliminary search of the literature. These were mainly identified from titles and keywords used in articles found from the preliminary search. Table 2.1 below, shows the keywords used in relation to each PICO element. Table 2.1 Keywords developed to describe the PICO framework The main electronic systematic search with the search syntaxes explained further on in this chapter was carried out using different databases accessed from the Hybrid Discovery (HyDi) available from the online library at the University of Malta. Relevant databases were found on HyDi by choosing the category ‘Health Sciences’ and sub-category ‘Nursing’ since the other sub-category is ‘Midwifery’ which is unrelated. Six databases were used to conduct a search for the literature. These were Academic Search Complete, Cumulative Index to Nursing and Allied Health CINAHL Plus with Full Text, Cochrane Central Register of Controlled Trials, and Cochrane Database of SRs; via EBSCO host search engine together with Medline via ProQuest search engine, and Science Direct. In addition to these databases Google Scholar was also utilised, but the search syntaxes combinations could not be used since the search engine does not have an advanced search strategy, a nd the search resulted in large thousands of articles. Therefore simple keywords alone were used to search for any other relevant studies, or to obtain full text versions which are not available in other databases. Strengths and limitations of each database are described below in table 2.2. Database Strength Limitation Academic Search Complete Daily updates Provides full text journals Available only from EBSCO host CINAHL Plus with Full Text Weekly updates Over 950 journals Covers references and abstracts from 1982 onwards Available only from EBSCO host English and American language bias Cochrane Library Cochrane Central Register of Controlled Trials Cochrane Database of SRs Research analyzed using trustworthy methods Large source of literature Up-to-date Complete text reviews Limited by restrictions Medline Records indexed with Medical Subject Heading (MeSHÂ ®) Provides a large source of life sciences evidence needed by health professionals Limited by restrictions Science Direct Provides full text from Elsevier Science journals Provides full text articles Limited by restrictions Google Scholar Free access web based search engine Large amount of results due to lack of an advanced search strategy Table 2.2 Databases strengths Limitations 2.3 Inclusion and Exclusion Criteria For readers to assess reliability and validity of a SR they have to be provided with a set of inclusion and exclusion criteria (Cronin, Ryan, Coughlan, 2007). Furthermore, Torgerson (2003) suggests that a set of inclusion and exclusion criteria are important so that throughout the search, only the articles that will answer the PICO question are extracted while others are eliminated. During the preliminary search it was noted that literature about the subject lacks randomized controlled trials (RCTs’), meta-analysis, and SRs. As shown in figure 2.1, these study designs are found at the top of the hierarchy of evidence as described by Aslam et.al (2012). Hence, all types of study designs were part of the inclusion criteria. Sibbald Roland (1998) said that clinical trials are known to be a gold standard to perform good evidence based practice and although they were in the inclusion criteria, the results were negative since up-to date no RCTs have taken place. Although this is a major limitation for this literature review, one must keep in mind that currently, the first and largest RCT is being carried out as described in chapter 1. Source type selected in all databases was ‘Academic Journals’ since books, newspaper articles, and magazines are not of strong evidence for evidence based healthcare because sometimes they do not have any type of study design, and may be narrative. Each search was limited to English language literature only. Studies that administered intranasal (IN) naloxone were excluded since this method is an off-label method (Doe-Simkins, Walley, Epstein, Moyer, 2009), and in an RCT by Kelly et al. (2005) it was found that IM naloxone was clinically more effective than IN naloxone (6 minutes vs 8 minutes). Table 2.3 and table 2.4 below describe further in detail the inclusion and exclusion criteria respectively. Figure 2.1 The Hierarchy of Evidence Pyramid (adapted from Aslam et al. 2012, p.3) Table 2.3 Inclusion Criteria Inclusion Criteria Rationale Literature had to be in English language Not possible to translate to English Studies published from 1980’s till September 2014 Studies about THN commenced in the 90’s, and so all studies are obtained (Darke Hall, 1997) Involving heroin injection drug users above 18 years of age Since the population are adults injecting heroin, and in all studies found, drug users were of 18 years and above Involving THNP Since this review concerns the outcome of THNP Experimental studies including RCTs’, reviews, observational studies including cohort studies and longitudinal studies To include all study designs and to not eliminate valuable literature Study needed to have an outcome of survival rates or OD reversals associated to THNP If outcomes were different, studies would not answer the PICO question Exclusion Criteria Rationale Studies researching attitudes, views and opinions of health care practitioners providing THN and other stakeholders such as police Outcome of studies unrelated to PICO question Studies about experiences of fatal OD victims where naloxone was not provided to heroin users as a preventive measure of fatal OD Studies had to have THNP studied as a preventive measure rather than other measures Development of instrument tools for THNP evaluation These instruments do not answer the PICO question Users of prescription opiates including methadone Since population is specifically heroin injection drug users Studies including HIV, AIDS, buprenorphine, methadone, and supervising injecting facilities as a main topic For the fact that THNP is the main subject and intervention of this SR Studies were intra nasal naloxone was used Naloxone nasal spray is not yet approved or licensed anywhere in the world Studies where naloxone was not administered by any of the participants The outcome was not attributed directly to naloxone administration Studies not published in English Not possible to translate to English Table 2.4 Exclusion Criteria 2.4 Search Strategy The keywords mentioned in table 2.1 were developed so that each PICO element has its own search syntax as identified by Bettany-Saltikov, (2012). The use of search syntaxes has assisted in narrowing the search to the most relevant studies to the PICO question. Table 2.5 below, shows the search syntax used for each PICO item. PICO element Search syntax number Search syntax Population Search syntax 1 heroin users OR injection drug users OR drug users OR opioid users Intervention Search syntax 2 take-home naloxone program OR naloxone distribution program Outcome Search syntax 3 overdose reversal OR overdose prevention OR opioid overdose prevention OR heroin overdose prevention OR harm reduction OR overdose mortality Table 2.5 Search syntaxes Search syntaxes were combined as described here: Population (syntax 1) AND Intervention (syntax 2) Population (syntax 1) AND Outcome (syntax 3) Intervention (syntax 2) AND Outcome (syntax 3) Boolean logic operator ‘OR’ was used to combine each keyword of each PICO element syntax, while the operator ‘AND’ was used to combine the PICO elements together as described above. In all search fields of the databases used except Google Scholar, ‘In All Text’ was selected for all searches. In Google Scholar the keywords searched independently were ‘take-home naloxone’ and ‘naloxone distribution’. These keywords were searched in titles only, since when searched for anywhere in the article the results were over 50,000 with most of them irrelevant to the dissertation. As shown in table 2.6 below, the defined search resulted in 2,260 articles. After the titles were evaluated whether they fit with the inclusion and exclusion criteria mentioned previously, and removing duplicate articles the search results were reduced to 160 articles by reading through the titles. The abstracts of these 160 articles were read and consequently 25 articles were noted to be directly related to the PICO question addressed in this dissertation, as they all met the inclusion criteria. One of the 25 articles which is a study by Lenton Hargreaves (2000) was not available online for free. The author, Professor Lenton was contacted via e-mail. Fortunately there was an immediate response, and the article was provided for free. However, after reading these 25 articles, 15 were eliminated because they had one or more of the exclusion criteria fit. The remaining 10 articles were identified and had fit all of the inclusion and exclusion criteria and were chosen for the critical a ppraisal of this systematic literature review. Furthermore the search was enhanced by looking up at all the reference lists of the final articles chosen for critical appraisal, but no new studies were found. Identified studies for critical appraisal are the following: Strang et al. (2008), Piper et al. (2008), Tobin, Sherman, Beilenson, Welsh, Latkin (2009), Enteen et al. (2010), Wagner et al. (2010), Bennett, Bell, Tomedi, Hulsey, Kral (2011), Bennett Holloway (2012), Lankenau et al. (2013), Banjo (2014), and Clark, Wilder, Winstanley (2014). In addition to the electronic search, a hand search was done within the University of Malta library which did not produce any results. Table 2.6 below presents the number of hits obtained from each of the databases above and the different search syntaxes combination. Database Keywords Number of hits Academic Search Complete search syntax 1 AND search syntax 2 274 search syntax 1 AND search syntax 3 272 search syntax 2 AND search syntax 3 55 CINAHL Plus with Full Text search syntax 1 AND search syntax 2 7 search syntax 1 AND search syntax 3 114 search syntax 2 AND search syntax 3 10 Cochrane Central Register of Controlled Trials search syntax 1 AND search syntax 2 0 search syntax 1 AND search syntax 3 0 search syntax 2 AND search syntax 3 0 Cochrane Database of SRs search syntax 1 AND search syntax 2 0 search syntax 1 AND search syntax 3 1 search syntax 2 AND search syntax 3 0 Medline search syntax 1 AND search syntax 2 31 search syntax 1 AND search syntax 3 228 search syntax 2 AND search syntax 3 28 Science Direct search syntax 1 AND search syntax 2 532 search syntax 1 AND search syntax 3 485 search syntax 2 AND search syntax 3 145 Google Scholar take-home naloxone, naloxone distribution 78 Total number of literature found = 2,260 Table 2.6 Number of articles found from each search 2.5 Refining of the research question After finding the relevant literature to the original PICO question, and considering properly the population being studied, the research question was duly refined since this systematic literature review will be based on the impact of THNP effect on heroin OD deaths amongst heroin injection drug users. Initial PICO question was: ‘Do naloxone take-home programs provided to drug users in the community reduce the incidence of fatal opioid OD?’ The question was refined to: Do naloxone take-home programs reduce the incidence of fatal heroin OD amongst heroin injection users? The refining of the PICO question was essential since some of the literature concerned prescription opioid users or general drug users, but the reviewer’s main interest is heroin injection users. 2.6 Methods of Appraisal After identifying the relevant studies and refining the PICO question, the next step for this dissertation was to critically appraise the literature. This will be covered in chapter 3. Critical appraisal is the evaluation of strength and quality of research studies in order to deliver evidence-based clinical decisions and after determining the worthiness of different studies through the use of different critical appraisal tools, multiple research findings can be synthesized together to develop evidence-based-practice (LoBiondo-Woods Haber, 2013). Furthermore, Burls (2009) argues that studies being biased can result in false outcomes and conclusions, because they are not composed of an acceptable quality. A bias is an orderly deviation of the results occurring from the way that a study is led, investigated or reported. In light of this, critical appraisal tools were developed to help researchers in identifying valid and reliable studies. Specific critical appraisal tools in the form of checklists are used to analyse different study designs. Commonly used appraisal tools are: Critical Appraisal Skills Programme (CASP) Scottish Intercollegiate Guidelines Network (SIGN) Centre for Evidence Based Mental Health (CEBMH) Critically Appraise Topic (CAT) After studying and considering all of the above methods of appraisal, together with other appraisal tools, it was decided that the CASP appraisal tools are to be used for critically appraising the identified studies relevant to the PICO question. The reason for choosing the CASP appraisal tools is because it is clear, concise, and easy to understand. CASP offers different checklists appropriate for different research designs where one can critically evaluate research through a set of questions and helps in determining the quality of the literature being appraised. At this phase, the studies were also rated and arranged according to the hierarchy of evidence adopted from Aslam (2012) as shown in figure 2.1. 2.7 Conclusion In conclusion, the study’s main objective is to determine whether THNPs reduces the mortality rate of heroin OD. Several keywords were identified from the PICO question elements, and from preliminary search results. These keywords were systematically searched in different databases using different search syntaxes combinations. A set of inclusion and exclusion criteria were then set up in order to get to the studies relevant to the PICO question. PICO question was then refined and then it was decided to use the CASP appraisal tools for evaluating the relevant studies which will be discussed in the next chapter. Words 1763

Drug Abuse Essays -- Drugs Narcotics Research Papers

Drug Abuse   Ã‚  Ã‚  Ã‚  Ã‚  Drug Abuse is generally defined as the use of a drug with such frequency that the user has physical or mental harm or it impairs social abilities. The substances that are discussed in this report are called psychoactive drugs; those drugs that influence or alter the workings of the mind, affect moods, emotions, feelings, and thinking processes. Drug Dependence/Addiction   Ã‚  Ã‚  Ã‚  Ã‚  There are three basic characteristics that indicate that the user is dependent on a drug. First, the user continues to use the drug for an extended period of time. Second, the user finds it difficult to stop using the drug. They may drop out of school, steal, go to jail, lose their jobs, or leave their families in order to keep using. Finally, the user has withdrawal symptoms when drug use is stopped. They may undergo physical pain or mental distress. The drug mimics a natural process in the brain called neurotransmission. This is when a brain cell releases a signal to another brain cell. The signal then returns to the first brain cell. The signal is called a neurotransmitter. One major neurotransmitter is called dopamine, which is involved in feelings of pleasure. When the drug is released into the brain, it blocks the dopamine from returning to the first brain cell. Repeated use changes the brain cells so that normal messages can't be sent between brain cells. The drug must always be present in order for neurotransmissions to take place. The user is only able to feel pleasure from the cocaine rather than the things he/she used to find pleasurable. This is called drug addiction or dependence. Drug Classification Drugs are generally categorized into two groups, stimulants and depressants. Stimulants are drugs that speed up signals through the nervous system. They produce alertness, arousal and excitability. They also inhibit fatigue and sleep. They include the amphetamines, such as cocaine, caffeine, and nicotine. Depressants slow down the signals through the nervous system. They produce relaxation, lowering of anxiety, drowsiness, and sleep. They include sedatives (such as barbiturates, alcohol, and tranquilizers) and narcotics (heroin, morphine, opium, codeine), which dull the mind's perception of pain.   Ã‚  Ã‚  Ã‚  Ã‚  Some drugs are not included in the stimulant/depressant categories. An example is the hallucinogens, such as PCP and LS... ...nclude nausea, diarrhea, and pain, but they vary between drugs. Cocaine users report depression when denied the drug. Since heroin is a very addictive drug, it has many withdrawal symptoms. For example, insomnia, muscle cramps, nausea, sweating, chills, panic, tremors, loss of appetite, yawning, runny nose, and watery eyes. Drug Treatment   Ã‚  Ã‚  Ã‚  Ã‚  A drug addict generally goes through denial before he/she accepts his/her drug addiction. When they are confronted by a family member or friend, they refuse to accept that they are addicted. This is sometimes called a mental block. The user isn't ready or able to deal with thier addiction. The time period of denial varies from person to person.   Ã‚  Ã‚  Ã‚  Ã‚  When the person has come to accepting their problem, they may go to therapy for treatment. Group therapy has had excellent results. They learn to come to terms with their problem with the support of other people who are going through the same thing that they are. They also learn tools that they can use to help them through the recovery period, such as prayer, excercise, and meditation. Drug abuse is a serious problem, but through treatment and therapy, it can be overcome.

Disintermediation and Reintermediation of the Travel Agents Essay

1. INTRODUCTION Nowadays, the travel distribution channel is very complex and characterized by the presence of many different kind of intermediaries which operate in a very competitive market. Since the beginning of the travel industry, intermediaries have always played an important role for the development of tourism products and services. Indeed, intermediaries have the ability to organize and aggregate a large amount of data into one price. Moreover, they have a fundamental role for counseling and delivering a personalized service according to the specific need of customers (Kracht and Wang, 2009). Before the advent and further development of communication technology, the market was dominated by the large suppliers such as airlines, hotel chains and resorts. Travel agents were the conventional intermediaries which were independent from each other and represented a portion of the dominant players in a non-competitive market (Gharavi and Sor, 2005). Later on, with the high spread of ICT and the need of cutting costs the position of the travel agents has been threatened. New kind of middlemen emerged adding additional layers of intermediation, disintermediating certain players by bypassing the traditional intermediaries (Buhalis and Law, 2008). Technology has also allowed suppliers to directly communicate with consumers who have seen their choices enormously increased. This has increased the competition and the complexity of the market and has raised an important issue for the presence in the market of traditional travel agents. The aim of this paper is to investigate how disintermediation and re-intermediation have affected the way travel agents operate and whether there is still a place and a prospective of growth for travel agents in the market. 2. DISINTERMEDIATION AND RE-INTERMEDIATION OF THE TRAVEL AGENTS In the last twenty years several changes occurred in the tourism distributional channel. Every component of the chain value has been affected and particularly travel agents. Traditional travel agencies are being threatened not only by integrated tour operators, which control their own distribution channels, but also by the expansion of alternative distribution channels such as the Internet, Teletext, call centers, and even travel TV channels. This process is called disintermediation (Kracht and Wang, 2009). According to Bennett and Buhalis (2003) disintermediation is the process of eliminating intermediaries within the distribution channel driven by electronic means that enable consumers to access and transact directly with suppliers and destinations†. Before 1993, the traditional tourism system consisted of consumers, traditional retail travel agents, corporate travel agents, tour operators, GDS’s and suppliers. The 1993 was the year of the first commercial usage of int ernet. After that year many changes occurred and many more players enter into the market thanks to the reduction of barrier entry costs. However, the starting point of disintermediation was in the 1960s, when the American airline lunch the first GDS allowing consumers to buy tickets directly from the airline company (Kracht and Wang, 2009). Travel agents’ main source of revenue at the time was commissions paid to them by the airlines on tickets sold by them on the airlines’ behalf. Pressures to reduce costs in an increasingly competitive industry caused airline companies to look for ways to reduce their payments to travel agents. Initially, airline companies progressively reduced the amount of commission paid to travel agents while, at the same time, they opened up new channels and expanded existing channels to reach travelers directly. Airline companies encouraged travelers to book direct channel by various means with a very successful results. For instance, easyJet, a successful British low-cost carrier, in 2002 was already selling 90% of its seats through its own site (The Economist, 2002). After the public debut of the web, suppliers began establishing web sites to connect directly with customers, thereby beginning the disintermediation of traditional retail travel agents(McCubbrey, 1999; cited by Krac ht and Wang, 2009). For example, Hotels  also created their own websites to reach their customer. Establishing a direct relationship with clients allows suppliers to put in place various price polices and loyalty schemes. Suppliers believe they no longer need an intermediary to sell their products. They discover the internet to be a powerful and cheap distribution channel, and not just an online brochure (The Economist, 2002). Indeed, using information technology to develop supply chain relationships can reduce costs and bring higher quality of travel products into the market. Internet, perhaps, has been the most powerful means of disintermediation and it has radically changed the travel industry, adding more layers of intermediation and more players (Kracht, 2009) The travel industry, in fact, is undoubtedly one of the most interesting sector in terms of the possibilities offered by the internet. Internet travel reservations have increased dramatically in the last years with more and more users confi dent with the technology, and it represents the fastest growing segment of electronic commerce (Bernstein and Awe,1999; cited by Anckar, 2003). The success of internet in this respect, is perhaps due to the nature of the tourism product, which is a little more than an information product, easy to convey through the web (UNCTAD, 2000; cited by Anckar, 2003). However, as stated by Palmer and McCole (1999; cited by Bennett and Lai, 2005) â€Å"the internet does not change the principal role of intermediaries who exist to simplify buyers’ choice processes†. Indeed, even though internet allowed suppliers and consumers to communicate directly bypassing the travel agents, there were some important issues related to the internet. According to Bloch et al. (1996, cited by Wynne 2000), when potential tourists try to book directly with suppliers on the internet, they face a wide range of problems. For example, they require to know in which website to look. It takes at lot of time considering different options and prices. Often, it is not possible to book online. Thereby, the necessity of one stop-shopping, aggregation of information and comparison of price led to the formation of new e-mediaries or cybermediaries. Disintermediation indeed, push back to re-intermediation with new players coming into the markets and existing ones which re-intermediate themselves by reinventing their business. Re-intermediation has been defined by Bennet and Buhahs (2003) as â€Å"the utilization of ICT and internet tools for the development of either new intermediaries or new methods for existing intermediaries that  enable them to re-engineer the tourism distribution channel†. Re-intermediation is evident through the development of new electronic intermediaries such as Expedia, Yahoo Travel, lastminute.com and Travelocity which are based only online. Based on the premise that intermediaries exist because they provide value added services, these e-mediaries have the potential to pass economies of scale directly to the consumer, offering reduced fares as well as the convenience of making reservations 24/7 (Lai, 2005). As a result of both disintermediation and re-intermediation travel agents have been reduced in numbers and have to face a very competitive market. In fact, from one side they are threaten by the disintermediation put in place by the suppliers, and from one other by online reservation and therefore, by the e-mediaries or cybermediaries. The latter, in particular, with no established high-street presence, threaten established retailers by changing the distribution channel for consumer products. Reservations made online are probably the most important danger that traditional intermediaries like travel agents have to face. Figures show an increase of online bookings over the years both in Europe and United States but also in other markets (http://www.emarketer.com). According to Cheung and Lam (2009), to secure their position in the marketplace, and avoid disintermediation, travel agents must be able to acquire the new technology and be able to compete into the new channels as electronic -able intermediaries, without losing their advantage in the conventional market. To minimize the risk of disintermediation, travel agents need to reduce their dependence into simple transaction and increase revenues by focusing on more complex activities, like counseling and personalization of the service. 3. TRAVEL AGENCIES RESPONSES TO A CHALLENGING MARKET Despite the severe competition, and the possibility for booking online, many customers still prefer to purchase from travel agents. TTI chairman, Tony Allen stated that there would always be people who â€Å"didn’t trust the internet† and wanted face-to-face advice (Taylor, The Guardian, 2003). Indeed, travel agents have still many cards to play and can benefit from several advantages in the marketplace: * They are situated wherecustomers come, in shopping centers and in high streets; * Aggregation of the offer from various suppliers into one package; * They can offer a personalized service; * Human relationship; * Travel agents can offer an advisory service, and assist the customers in making a decision before processing with transactions; * Less time spent by the customers to buy a travel product. It can also be argued, that not all the effects of the disintermediation and re-intermediation have had a negative effect on travel agents. Gharavi and Sor (2005) have suggested, in fact, that because of internet and other forms of disintermediation, the bonds between the small travel agents and the dominant large suppliers like the airline companies, hotel chains and resorts owners, was finally broken. As a result of that, many independent travel agents, which continue to based their business on conventional methods such as commissions from suppliers, were pushed out of the market. However, many others entrepreneurs were stimulated to reinvent their business. Travel agents were allowed to deal with a variety of suppliers and organize into cooperative. Moreover, others entrepreneurs developed fran chises or merged, in order to have more bargaining power against competitors. Therefore they fight back the disintermediation and re-intermediate themselves. Organizing into franchising or into other forms of collaboration has allow several advantages to travel agents. First of all, it leads to gain more bargaining power which make more convenient for travel agents to dealing with suppliers. Second of all, it helps travel agents to focus only on the front office activities, while the centre office is in charge of the administrative procedures and of the marketing activities, such as brand building and advertising. Another reason, why this kind of collaborations are successful is that they can allow a better training of human resources and lead to better prospects for income. A great example of travel agency organized into franchising is definitely Harvey World Travel with over 170 stores in Australia and more than 70 in the UK which offer to its branches a very sophisticate software to create a very personalized package for customers (Harris and Duckworth, 2005). In order to fight disintermediation many travel agents differentiate themsel ves and/or focus on niche markets. They try to offer something different that clients could not find online. EuroTravel is a great and successful example of how a small independent travel agent can compete in the market. This company was able to leverage technology effectively in order to specialize and fight back against disintermediation. It specializes in sales to only the European destination, but has used the internet as its primary communication channel in order to acquire customers from a broader geographic area. This strategy seems to have paid off. In fact, in 2004, sales were  £ 6.5 m and in 2008 they reached more the  £8.5 m (Haris and Duckworth, 2005). Similarly, Thomas Cook is another successful experience. By being the first travel agent in the UK, Thomas Cook can count on a very long history and tradition. Over the years it has experienced many changes in order to adapt to a competitive market. In 2007, it merged with the competitor MyTravel, and nowadays Thomas Cook is the UK’s largest retai l travel network. It aims to dominate both, conventional and innovative channel (Williamson A., 2001). Thomas Cook has indeed, a very strong position online and continues to open new branches every year. Therefore, Thomas Cook demonstrates not only how a travel agent can fight disintermediation, but also how to grow and prosper in the marketplace. CONCLUSION Upon the introduction of Internet technology, travel industry has been strongly affected by electronic commerce that contributed the most to the disintermediation of the channel. This is true in particular for travel agents. It is clear that disintermediation and re-intermediation exist in the travel sector. In the intermediate phase, traditional travel agencies dominate the market. However, as new EC-only travel agencies emerge in the market and build up their competitive abilities, traditional travel agencies lost over 50% market shares (Cheung and Lam, 2009). As a result of that many travel agencies merged or organized themselves into some form of collaboration such as franchising. In order to survive in this competitive travel market, agents need to reposition themselves as travel consultants, but also must be more technologically oriented. They must focus on consulting and niche markets. As suggested by the Economist (2002), travel  agents future will be based on helping custo mers to buy what they want, rather than selling what is left unsold by suppliers. They now must look out for consumers’ best interest by using IT resources to help them find the best product. Indeed, it is necessary an integration of conventional business with the new opportunities offered by the web, in order to add value for the client. That is probably one of the most difficult challenge that travel agents have to face. ICT must seen as an opportunity more than as a threat which allows travel agent to reach more customers, get more information and therefore, adding more value for the latter. The ability to use new technology will also make possible for travel agents to compete with the e-mediaries. Porter (1999, cited by Anckar, 2003) claimed that the internet is going to be the death of a lot of intermediaries. However, if this prevision may be true for certain intermediaries, at the moment and perhaps in the long run, it appears not to be valid for travel agents. REFERENCES Anckar, B. (2003) â€Å"Consumer Intentions in Terms of Electronic Travel Distribution†. E-service Journal, Vol. 2, No. 2, pp. 68-86 Anckar, B. (2006) Reassessment of the Efficacy of Self-booking in Travel. 39th Hawaii International Conference on System Sciences. Available at: http://www.virtual-community.org/images/e/ef/250760132b.pdf Bennet, M. and Kevin Lai C. W. (2005) The impact of the internet on travel agencies in Taiwan. Tourism and Hospitality Research, Vol. 6, No. 1, 2005, pp. 8-23. Bennett, M. and Buhalis, D. 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Opioids A Wicked Addiction - 1102 Words

A Wicked Addiction Opioids, otherwise known as prescription pain medication, are used to treat acute and chronic pain. They are the most powerful pain relievers known. When taken as directed they can be safe and effective at managing pain, however, opioids can be highly addictive. Ease of access helps people get pain medications through their physician or by having friends and family get the medication for them. With their ease of access and being highly addictive the use and misuse of opioids have become a growing epidemic. Patients should be well educated on the affects opioid use can have. More importantly instead of the use of opioids, physicians should look into alternative solutions for pain management. While pain medication is helpful with chronic pain, it is also highly addictive, doctors should be more stringent to whom and how often they prescribe pain medication. By attaching to opioid receptors in the brain, spinal cord, and other areas of the body they reduce the sending of pain messages to the brain and reduce feelings of pain. The part of the brain that controls emotions are also changed and cause a person to feel relaxed and extremely happy, a euphoric state of being. This is when a person starts to crave the drug, the brain is saying it wants more. Natural endorphins are produced by a healthy brain on its own. Powerful cravings and physical dependence are due to the brain no longer producing the natural kind of endorphins because afterShow MoreRelatedThe Problem Of Opioid Addiction In The United States704 Words   |  3 Pagesunder the surface of the water in the Cape Fear River. The wicked problem facing New Hanover County is the opioid epidemic. Many communities across the United States share in this struggle. Over two million people become dependent on prescription pain pills and street opioids every year in the United States . Of those addicted, the deaths because of a heroin overdose have increased 533% between 2002 and 2016 i n the United States. If the opioid crisis had been a wildfire or hurricane, state, local,Read MoreOxycontin Abuse2542 Words   |  10 Pagesside effects of using opioids are: constipation, nausea, sedation, dizziness, vomiting, headache, dry mouth, sweating, mood changes, flushing, loss of appetite, and weakness (drugfree.org, 2013). Long Term Effects With OxyContin, as with all drugs, when one uses it chronically, a tolerance can result, which means that users need to take larger amounts of it in order to achieve that first original impact. Long-term use also can lead to physical dependence and addiction the body adapts to theRead MoreDrug Abuse : A Large Drawback Within The U. S1910 Words   |  8 Pagesthere s much nobody to curtail the wicked efforts of those fiends. Drug accessibility, is a serious issue touching the increasing use of medication is that the accessibility in our markets.‘The political and economic scenario in Islamic State of Afghanistan is up, however narcotic production and also the resultant trafficking of narcotic and its derivatives still accounts for roughly one third of Afghanistan’s total (combined licit and illicit) GDP.’Drug addiction is the continued use of any substance