Assistant Professor of Family Medicine and Psychiatry
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa
This certification may include O P E R A T I O N S D E N V E R P O L I C E M A N U A L D E P A R T M E N T 505 symptoms after miscarriage lumigan 3ml on line. Officers who are off-duty due to illness or injury will authorize the attending physician to release information regarding their condition and ability to perform their duties to the Safety Human Resources Manager (or designee) medications mobic cheap 3ml lumigan visa. Serious Illness: An illness medicine to increase appetite buy 3ml lumigan otc, injury medicine valium buy 3ml lumigan, impairment treatment with chemicals or drugs order 3ml lumigan mastercard, or physical or mental condition that involves inpatient care in a hospital medicine recall discount lumigan 3ml otc, hospice treatment tendonitis lumigan 3 ml mastercard, or residential medical care facility medications 8 rights cheap 3 ml lumigan otc, or continuing treatment by a health care provider. Qualifying Exigency includes any one or more of the following non- medical, non- routine activities and no others Short-notice deployment activities Military events and related activities Child care and school activities Financial and legal arrangements Counseling activities Rest and recuperation activities Post-deployment activities Additional activities O P E R A T I O N S D E N V E R P O L I C E M A N U A L D E P A R T M E N T 505. Maximum amount of leave is 26 weeks in a single 12-month period on a per-covered service member, per-injury/illness basis, measured forward from the date an employee first takes caregiver leave. The provisions of this Act apply to officers who have completed twelve (12) months of continuous service and have completed 1,250 hours of work within the previous twelve (12) months. Up to twelve (12) weeks of parental leave may be granted to care for a child at the time of birth or adoption. Officers who are married to each other are limited to a combined total of twelve (12) weeks taken for reasons other than personal illness, including parental leave. In all but emergency cases, officers requesting Family and Medical Leave will contact Safety Human Resources at least thirty (30) days in advance so that the eligibility process can begin. Safety Human Resources personnel will determine if the officer meets the eligibility requirements. Officers who are not eligible for Family and Medical Leave will be notified in writing and will be advised to seek other leave type options. Safety Human Resources will contact the officer to establish a calendar and discuss leave options. Officers requesting leave under the provisions of the Family and Medical Leave Act have the option of using unpaid leave in lieu of paid leave. Petition the Chief of Police for a leave of absence without pay not to exceed one (1) month. Petition the Civil Service Commission, through the chain of command, for a leave of absence without pay for longer than one (1) month. Officers on leave under Family and Medical Leave for an extended period of absence may apply to Safety Human Resources for a reduced or intermittent work schedule (i. The officer may be required to transfer to another assignment to better accommodate the reduced work schedule. The Chief of Police has the ultimate authority to grant or deny a request for a reduced or O P E R A T I O N S D E N V E R P O L I C E M A N U A L D E P A R T M E N T 505. Officers on Family and Medical Leave are not permitted to perform any secondary employment or non-police secondary employment work, without written authority from the Chief of Police. The authorization must be provided and kept on file with the Secondary Employment Coordinator. Officers using extended leave under the provisions of the Family and Medical Leave Act will return to work at their same position or equivalent. Prior to returning to work, if the officer is out for a personal illness or injury, officers must submit a Fitness for Duty Pass from their health-care provider. Officers will not be allowed to return to work until Safety Human Resources receives the Fitness for Duty Pass. Officers are required to complete any missed firearms qualification or required weapons certifications and achieve a passing score on the course of fire specified by the Firearms Unit, prior to working a line assignment, but no later than thirty (30) days after their return from Family and Medical Leave. Officers are required to contact the Training Section to schedule and make up any department mandated training that was instituted or provided during the time the officer was on leave. Except for paid leave, and as otherwise required by law, leaves of absence will not count toward longevity or seniority in sick and vacation time will not accrue during the extended absence unless the officer elects to use a minimum of 15 days of accrued leave per month. To be eligible for an extended leave of absence, the member must have completed at least five (5) years of continuous service. The officer must complete the Leave of Absence Request Form which can be obtained through Safety Human Resources. If the request for leave of absence is denied, the reason for denial will be provided to the officer in writing. While on extended absence, the Chief of Police will hold all members of the classified service to the standard of conduct expected of an active member, regardless of the length of absence. The completed form will be given to the Limited Duty Coordinator for review, and if necessary, scheduling of exams. No member of the department who has been continuously absent for ninety (90) consecutive days or more will be permitted to return to work until the reason for the extended period of absence and the responses to the Extended Leave Questionnaire are reviewed to determine if a fitness for duty evaluation is required. The pass verifies that the officer can perform the essential functions of his or her position. Officers will not be allowed to return to work until the Safety Human Resource Division receives the pass, or a fitness for duty evaluation will be required. A fitness for duty examination may include: a medical/physical examination; a psychological examination; a background investigation; and/or a polygraph examination; as determined by the Limited Duty Coordinator. The Limited Duty Coordinator will consult with the Commander of the Internal Affairs Division on officers returning from disciplinary suspensions or if otherwise necessary. A mandatory drug and alcohol screen is required of all returning officers and will be scheduled by the Limited Duty Coordinator. Once the form is complete and includes the findings of any required exams, the entire packet will be brought to the Office of the Chief of Police for the Chief (or designee), to review for consideration of fitness for duty. The chief or designee will sign off, authorizing the officer to return to full duty, modified duty or provide further instructions. Any officer who missed two or more firearms qualifications while on extended leave will attend remedial training if the officer fails to qualify upon their return. Officers are required to contact the Training Division to schedule and make up any department mandated training that was instituted or provided during the time the officer was on leave. At the discretion of their commanding officer, officers returning to a patrol function may be temporarily assigned to work with a police training officer. First 30 days of leave without pay: the officer is responsible for only the employee portion of the insurance premiums. First pay period following the 31st day of leave without pay: the officer may remain enrolled in the benefit plans, however, the officer is then required to pay both the employee and the employer portion of the insurance premiums. Insurance premium payments during leave without pay must be made directly to payroll in order to avoid loss of coverage. Continually monitor officers on medical leave/modified duty to ensure that the officers are returned to full duty assignments at the earliest date that is medically authorized. Medical Leave for officers who sustain injuries, illnesses, or for those who are pregnant and who are expected to be off work for more than five (5) days. All TeleStaff attendance records will be kept by their supervisors at their present assignment. If the leave is for a non-Line of Duty injury/illness, the supervisor will choose the sick work code in TeleStaff, or the appropriate code if on Family Medical Leave. The written authorization must be provided and kept on file with the Secondary Employment Coordinator. If an officer is unable to complete mandatory qualification at the range, and they had time to qualify prior to the injury/illness, they will submit a letter documenting the reason they have not qualified. Modified Duty for officers who sustain on-the-job or off-the-job injuries, illnesses, or are pregnant and will be in a temporary modified duty for any duration in length. All modified duty assignments will be offered to the officer in compliance with state law pursuant to the City and County of Denver modified duty policy. Any modified duty established for an officer at his/her present assignment will be reported to the Limited Duty Coordinator as soon as reasonably possible. When an officer has experienced a Line of Duty injury/illness and is working reduced hours, supervisors will use the "Modified Duty" Work Code for the hours worked and the "Workers Comp" Work Code for the appropriate time the officer was off work. Officers on modified duty will not perform secondary employment police work or nonpolice work without prior written authorization from the Chief of Police. Officers on modified duty will not be allowed to participate in any detective or specialized training program without prior written authorization from the Chief of Police. If an officer is unable to complete mandatory firearms qualification following an injury/illness and there was time to qualify prior to the injury/illness, he/she will submit a letter explaining why qualification did not occur. This letter must then be submitted to the Limited Duty Coordinator, who will forward it to the Chief of Police for approval or denial. It is at the discretion of the officer if and when she chooses to disclose a pregnancy to the police department. However, the nature of this employment may subject an officer to strenuous physical activity and potential hazards in the workplace. Therefore, a pregnant officer may request a temporary modification to her work assignment during her pregnancy, and if needed, for the physical recovery from childbirth. The officer should consult with her medical provider to determine the appropriate level at which she may perform her duties. The officer should provide the appropriate job description to her medical provider to accurately determine any limitations or restrictions that may be appropriate. Prior to being allowed to return to work, all officers will obtain a written return to work report from the physician who took the officer off work. The officer will be returned to the same or a similar assignment as held prior to the injury at the discretion of the Chief of Police. Under no circumstance will the department provide an officer with a permanent modified duty assignment. When the recovery time to which an officer may be entitled under the collective bargaining agreement is exhausted, the officer must either: 1. It may involve a recommendation for urgent or emergency care when appropriate, based on the medical situation involved. In cases where obvious emergency medical attention is required, a request for emergency medical personnel will be made. They may direct the injured officer to be taken to the nearest adequate medical facility. Paramedic/ambulance personnel may be advised that the "divert status" of Denver Health Medical Center operating rooms is in effect. If necessary, the injured officer will then be transported to a participating alternate hospital. A supervisor or command officer may determine the need for medical attention is so critical and the proximity to a physician or adequate medical facility is close enough that waiting for a Denver Health Medical Center ambulance is not practical. A police car may be used to transport the injured officer for medical assistance without delay. If the officer experiences additional problems from an injury/illness, he/she should visit their authorized treating physician immediately. The officer should also immediately notify his/her supervisor who will in turn notify the Limited Duty Coordinator. An injured officer/employee may not be reimbursed for medical treatment administered at any medical facility or by any individual unless the procedures outlined have been followed. The supervisor must complete this report as soon as possible following notification, and it must be submitted to Risk Management within 5 days of being notified of the injury. Personnel will be assigned in a shift concept to provide this protection on a twenty-four (24) hour basis. Termination of such protection will be at the discretion of the commander to which the injured officer is assigned. The Limited Duty Coordinator will assist in resolving responsibility for payment in a timely manner. If an officer may not be able to drive themselves to a medical facility, a supervisor may arrange transportation. Limited Duty: Any period when an officer is not able to perform all normal duties as a sworn officer because of a Line of Duty or Non-Line of Duty injury. Modified Duty: A work assignment that is provided to officers to meet work restrictions imposed by medical providers during an injury recovery period or pregnancy (for work-related injuries and non-workrelated injuries). This includes any restriction that limits the number of hours per day an officer may work. An officer sustaining a work-related injury has two years of total usable limited duty time. After two years have passed from the date of injury, the officer will be separated from the department through medical disqualification. The total amount of Limited Duty time the officer may use for any one work-related injury will not exceed two years from the date of injury. During the Separation through Disqualification process, the injured officer may continue to work in a Modified Duty capacity until they reach the two-year post injury date or 260 modified duty shifts have been worked. If the department deems it necessary to enter the Separation through Disqualification process for an officer, it will commence the sooner of either: 1. At the 195th day of Modified Duty usage (of the allowable 260 days of Modified Duty), or 3. When the Separation through Disqualification process is initiated on the 195th day of Modified Duty, the officer can continue working in such a capacity through the 260th day of allowable Modified Duty time and be afforded the opportunity to enter the Interactive Process. Should the officer not return to full-duty within one year from the date of injury, he/she must file for separation from the department via retirement or resignation at the date of exhaustion of such time, or the department may initiate the Separation through Disqualification process. While the retirement or Separation through Disqualification process is pending, the officer may use up to 60 days of Personal Leave time. If the Verification Form is not turned in to confirm the time off, sick time will be deducted. The officer may then submit a request to the Chief of Police through the Police Pension and Relief Board, requesting that his/her sick time be returned. Every effort will be made to assist the officer O P E R A T I O N S D E N V E R P O L I C E M A N U A L D E P A R T M E N T 505. An officer with a line of duty injury requiring medical attention for such injury at times other than during regular scheduled work hours will not be entitled to receive overtime pay or compensatory time for such time spent away from work. If an officer receives an invoice or request for payment relating to medical care for a line of duty injury, he/she will contact the Limited Duty Coordinator who will assist in resolving responsibility for payment in a timely manner. Written notice for the request to a hearing must be submitted to the Secretary of the Pension Board. This rule is also intended to comport with the requirements of the consent decree entered by the U. Qualification standards may include a requirement that an individual will not pose a direct threat to the health or safety of the individual or other individuals in the workplace. Direct threat means a significant risk to the health or safety of others that cannot be eliminated by a reasonable accommodation. A qualified individual with a disability is an individual with a disability who can perform the essential functions of the position he or she holds or to which he or she seeks reassignment, with or without reasonable accommodation. Affecting a forcible arrest and firing a weapon are essential functions of all Classified Service positions within the department, regardless of rank or assignment. Other essential functions are included in the job descriptions for the Classified Service positions within the department or otherwise defined by the commanding officers. Such interactive process will be a flexible, informal process that involves both the department and the officer. The interactive process requires good faith participation from both the officer and the department. An officer who engages in bad faith in the interactive process may be denied a reasonable accommodation and, if applicable, disqualified from employment. The duty to engage in an interactive process is triggered by either of the following events: O P E R A T I O N S D E N V E R P O L I C E M A N U A L D E P A R T M E N T 505. When the department has actual or constructive notice that a police officer may have a disability for which that officer needs a reasonable accommodation. Any superior officer, supervisor, or manager who receives notice of a request for reasonable accommodation will contact either Safety Human Resources or the Limited Duty Coordinator in writing within forty-eight (48) hours of receiving such notice. Such examinations and evaluations will be reasonable and paid for by the department. If the officer is determined not to be disabled as defined in this rule, disqualification proceedings will be initiated if the officer nevertheless is unable to perform the essential functions of position. The preferred option always will be a reasonable accommodation that allows the employee to remain in his/her existing job as a Denver police officer. If it is determined, during an interactive process, that a disabled officer cannot be reasonably accommodated in his/her position as a Denver police officer, Safety Human Resources will notify the officer of the availability of reassignment to a vacant Career Service position as a possible reasonable accommodation. The disabled officer will be offered a reassignment to a vacant Career Service position which is O P E R A T I O N S D E N V E R P O L I C E M A N U A L D E P A R T M E N T 505. The officer does not need to be the best qualified individual for the position to obtain it as a reassignment. If the officer is reassigned to a vacant position, the officer will be provided any reasonable accommodation necessary for the officer to perform the essential functions of the reassignment position. A disabled police officer may exhaust all of his/her approved sick leave, recovery time authorized by the Collective Bargaining Agreement for line of duty injuries and other paid leave before requesting that the interactive process be initiated to explore reassignment to a vacant Career Service position as a form of reasonable accommodation. However, a disabled police officer may request reassignment to a vacant Career Service position as a form of reasonable accommodation prior to the exhaustion of all approved sick leave and other paid leave. During the interactive process, an officer may decline a demotion reassignment position and request the Career Service Authority to continue looking for comparable vacant positions within the two-month (2) period. If no vacant position becomes available during the two-month (2) period, disqualification proceedings will be initiated. The responsibility to engage in the interactive process may terminate earlier if the officer withdraws his or her request for a reasonable accommodation. The interactive process need not be resumed if the employee has performance problems in the position that are unrelated to his/her disability, or if the employee is dismissed as a disciplinary measure for misconduct. In making this determination, several factors will be considered, including but not limited to the duration of the risk, the nature and severity of the potential harm, the likelihood that the potential harm will occur, and the imminence of the potential harm. Reassignment is limited to existing positions or to positions that become vacant in the Career Service within the two-month (2) period. A reassignment of an employee, including recruits and officers in the Police Training Program, cannot be denied because he/she is designated as probationary.
If there are any differences in the information the offender provides medications like tramadol cheap lumigan 3ml on line, such as a change in address medicine 360 buy lumigan 3 ml visa, officers will generate a Letter to Detective for "Failure to register as a sex offender" in place of the street check xanax medications for anxiety lumigan 3ml otc. The officer will issue the offender a Request to Appear for the following business day at 0900 hours to the Sex Offender Registration Unit medications with codeine order 3ml lumigan fast delivery, Police Administration Building treatment water on the knee purchase lumigan 3 ml, 1331 Cherokee Street medicine expiration dates generic 3ml lumigan fast delivery. If there are no differences medicine wheel colors buy lumigan 3ml low price, officers will complete a street check and route it to the Sex Offender Registration Unit treatment gonorrhea discount lumigan 3 ml without prescription. The officer will issue the offender with a Request to Appear for the following business day at 0900 hours to the Sex Offender Registration Unit, Police Administration Building, 1331 Cherokee Street, where an updated photograph will be taken of the offender. Arrests for registration violations will only occur when an active warrant exists or when directed by the Sex Offender Registration Unit. The Sex Offender Registration Unit works with all divisions, with emphasis on the Sex Crimes and the Missing and Exploited Persons Unit, in identifying sex offenders who may be suspects in other cases being investigated. The Sex Offender Registration sergeant is responsible for case management of all General Occurrence(s) or Letter(s) to Detectives related to sex offender registration violations. The Sex Offender Registration Unit is open Monday through Friday, 0800-1600 hours. After hours, a supervisor or on-call detective is available through Denver 911, 24 hours a day. Maintaining the schedule for address verifications of all sex offenders registered with the City and County of Denver. Completion of the majority of monthly house checks citywide; however, the unit relies on district officers to assist in completing the overflow in their respective district. Distribution of house checks to each district commander (or designee) for follow up and timely completion of the verification. Officers completing address verifications are required to complete, date, and sign the verification form. All victims reporting graffiti will be provided with graffiti removal resources offered through Denver 311. The following additional reports are required for both felony and misdemeanor charges: 1. Photograph suspect to document his/her clothing and the condition of his/her hands at the time of the offense. Charge an adult suspect directly with the appropriate municipal violation (38-61 Damaging, Defacing or Destruction of Public Property or 38-71 Damaging, Defacing or Destruction of Private Property). Contact the on-duty or on-call Graffiti Unit detective to determine if the suspect is someone they are looking for. Graffiti Unit personnel are available for consultation during normal business hours or can be reached after hours through Denver 911. Types of graffiti related material include, but are not limited to , broad tipped marker pens, glass etching tools and a can of spray paint. The vehicle impound facility of the Denver Sheriff Department is responsible for custodial functions relating to the storage and release of impounded vehicles. However, all investigative matters and/or problems relating to stolen vehicles and the release of a stolen vehicle will be handled by the assigned detective. At the time an officer is sent to make a stolen car report, the dispatcher will air the following information. Any suspect information or pertinent facts that might lead officers to the recovery of the vehicle and arrest of the suspects. In order to obtain the required information for a case filing, it is necessary to indicate on the report the year, make and model, exact license number and vehicle identification number, as shown on the registration certificate and/or title. Reports will be complete and should include a description of any accessories, special equipment and valuable contents, and a current phone number(s) for the listed victim/complainant. Officers should question complainants carefully to eliminate family quarrels over possession, pranks, repossessions, or other circumstances to ensure the validity of a criminal episode. The officer will notify his/her supervisor, or any supervisor who can approve the report, and have it approved in a timely manner (less than 15 minutes). If an officer has unusual or critical information not already detailed in the report, they will call Auto Theft Records personnel. Auto Theft Records personnel will no longer create a "Fast Add" report, but will "transcribe" the report and check for errors. After taking the report, the officer will search the immediate area/neighborhood for the reported stolen vehicle. When the investigation indicates the absence of the vehicle is the result of a family squabble over possession, a prank, or that the vehicle is possibly in the possession of another member of the family or business associate. The mental condition or emotional stability of the complainant is such that their statements are questionable, (i. Any other circumstances that lead the officer to believe that it is not a true case of auto theft. Serious crimes in connection with auto theft: If a serious crime occurs during the course of an auto theft, the reporting officer will call the Records Unit (Auto theft) and verbally provide information about the vehicle, including a request that it be held for prints. When an officer locates a stolen vehicle, he/she will advise the dispatcher of the exact location and condition of the wanted vehicle. The officer will then contact Records Unit personnel who will attempt to contact the owner. Officers may also (at their discretion) attempt direct communication with the owner. If the owner is contacted, Auto Theft Records will advise the owner they can respond to the location of recovery to personally take possession of his/her vehicle. If the owner is unable to respond in a timely manner, typically thirty (30) minutes, the vehicle will be impounded for safe-keeping. Records Unit personnel will advise the officer if the owner is responding and the time of contact. If the owner of the vehicle or his/her representative has not arrived within 30 minutes, the officer may impound the vehicle. The presence of a large amount of personal property in the vehicle which must be taken to the Evidence and Property Section and inventoried. The remaining three (3) copies will be turned in to the airport security officer for proper distribution. Officers will not make a new theft from motor vehicle or criminal mischief report. Instead, the same case number from the original motor vehicle theft report will be used. The officer will not place a hold on the vehicle unless there is a specific request to do so. If the person attempting to repossess the vehicle has no court order, officers should advise him/her to obtain one to prevent a breach of the peace. If the person attempting to repossess the vehicle has a court order, officers should advise the registered owner that it would probably be best to allow the vehicle to be taken, with the option of initiating legal action if he/she believes they have been wronged. Officers should also inform the registered owner that a refusal to release the vehicle could result in a contempt of court charge. If this person still refuses to let the vehicle be taken, officers should advise the person attempting to repossess the vehicle not to take the car, with an option of initiating contempt proceedings. If the registered owner of an automobile which has been repossessed has any questions concerning the legality of such repossession, they should be advised to consult an attorney. Officers may also call the appropriate district investigative unit to obtain further direction for the complainant. Examine the agreement for specific conditions regarding the location of storage, maintenance, etc. Colorado Revised Statute 18-4-401(e) requires seventy-two (72) hours to elapse beyond the time rented property is to be returned as an element of the crime "Theft of Rental Property". Complainants will be advised to wait the required 72 hours before making a report, except when a motor vehicle is leased, rented or loaned, and there has been any overt act or omission which indicates the lessee does not intend to return the vehicle, such as knowledge that the vehicle has or is being altered, sold, or moved out of state. The assigned detective will interview the complainant, determine if the case meets the statutory requirements and make any necessary reports. The inspection will be done only on vehicles that have been previously titled in another state, and on the form provided by the Division of Motor Vehicles Title Section of the Colorado Department of Revenue. In order to address incidents that arise from human-animal interaction within the context of applicable statutes, municipal codes and regulations, officers are reminded to use reasonable discretion when encountering animal related incidents. Officers will take into account their own safety, the safety of others in the area in any animal related incident. When reasonable, officers will make every attempt to allow the owner to bring their animal under control and/or remove their animal from the immediate area before taking enforcement action. Officers will take into account their own safety, the safety of others in the area and the feasibility of allowing the owner to act considering the totality of the circumstances; including the presence of an animal control officer and/or any circumstances that prevent such a response. Officers will need to make their own initial assessment of each animal related incident in order to formulate the appropriate response based on the behavioral traits of the animal and the environment. Officers should be mindful that domesticated animals are accustomed to human interaction and that it is common for a domesticated animal to run towards, jump and/or make an audible sound as a form of greeting rather than aggression. Officers need to differentiate between common behaviors associated with domesticated animals and those behaviors that put the officer and/or other persons in imminent danger. An unrestrained canine that communicates in the same way is conveying a warning, not necessarily intent to bite. Canines are stimulated by quick movement and will chase any rapidly moving object. Running from a canine stimulates chasing behavior, which may escalate to grabbing and biting. Canines that are snarling (tensing their lips to expose their teeth) and growling are conveying the clearest and strongest of warnings. When officers have sufficient advanced notice that a potentially dangerous domesticated animal may be encountered, such as the serving of a search warrant, officers will develop a reasonable contingency plan for dealing with the animal without the use of deadly force. When the officer reasonably believes, based on the facts and circumstances, that the animal on which the force to be used poses an immediate threat of injury to the officer or another individual, he/she will apply and use the minimum amount of force necessary to bring the animal under control. Nothing in this policy will prohibit any officer from resorting to lethal force to control a vicious or dangerous animal if circumstances reasonably dictate that a contingency plan has failed or becomes impracticable. Officers can mitigate liability and harm to themselves, fellow officers, bystanders and community perception by attempting to diffuse potentially harmful situations without the use of lethal force. Non-lethal options: Batons, flashlights and/or clipboards can all be used to block or redirect an attack. Fire extinguishers produce noise, cold and an expanding cloud a combination that frightens canines. If the injury involves an animal bite and immediate first aid is not required, the person will be advised to seek medical attention at the earliest opportunity. If the bite was sustained from a domesticated animal, officers will attempt to locate the owner and advise them that all animal bites must be reported to the Denver Animal Control Services (720913-1311) within twelve (12) hours so that the animal can be impounded for rabies observation. Officers encountering any injured domesticated animal will make all reasonable attempts to contact the owner or responsible party. If the owner cannot be located, the officer will advise Denver 911 of the location and request assistance from the Denver Animal Control Services. Animals that have sustained an injury are often fearful of further attack and/or injury and may become aggressive if not approached with caution. When making this decision, officers will consider the totality of the situation, to include the nature of the injury, whether the animal is an immediate danger to the community, the behavior the animal is exhibiting and whether the officer is capable of dealing with the type of injury. Officers will be mindful of the perception of the public when utilizing their discretion. The Domestic Violence Unit will investigate when cases of cruelty to animals is part of a domestic violence incident. If the animal was killed, officers will follow protocol for scene documentation, recovery of the corpse and preservation for necropsy. When an officer discharges a firearm in order to kill an animal, he/she will maintain their firearm in its condition at the conclusion of the event, making no changes to the firearm, except to make it safe. Empty magazines, speed loaders, spent shell casings etc, will remain where deposited, and will be documented and collected during crime scene processing. The involved officer will maintain custody of their firearm and the responding homicide detective, under the advisement of his/her sergeant, will decide if the firearm is to be relinquished. If the firearm is not relinquished, the responding homicide detective will ensure the weapon is documented prior to the involved officer being released from the scene. Vehicular traffic should be slowed or stopped to allow any roaming or grazing livestock to be herded off the roadway. Call Denver 311 for further information To process a complaint, animal control officers need the date and time of the most recent nuisance, the address where the animal is located, and a description of the animal. Animal control officers follow a prescribed process for addressing animal nuisances based on the type of violation. Complaints concerning property damage caused by wildlife will be referred to the Colorado Department of Wildlife. All calls for service requiring animal control officers will be dispatched by the Denver Health Medical Center dispatchers at Denver 911. Canine bites or vicious dog complaints; when the canine is a present threat to life or additional injury. When persons resist the lawful duties of an animal control officer, officers will take the necessary action to assist in identifying the owner, issue a summons, impound an animal and/or any other necessary action. In cases of serious injury, when other assistance is not available, the police department will respond to the scene. Service animals are working animals and provide aid to individuals with a wide array of disabilities. These include, but are not limited to , physical, sensory, psychiatric, intellectual or other mental disabilities. There is no requirement concerning the amount, type of training or certification process that an animal must undergo before being labeled as a service animal. Officers should not talk to , pet or otherwise initiate contact with the animal to not interfere with the important tasks they perform. When it is readily apparent the animal in question is there to provide aid to a disabled individual. If the individual responds by indicating that the animal is required because of a disability and has been trained to perform at least one task to assist the individual, the animal meets the definition of a service animal and no further questions should be asked. Under such circumstances, the individual must maintain control of the animal through voice, signal or other effective controls. Service animals may be excluded from areas of police facilities that are not open to the public, such as the inside of a patrol vehicle or the district station holding cells. A person with a disability cannot be asked to remove a service animal from the premises unless: (1) the dog is out of control and the handler does not take corrective action to control it, including when an animal exhibits vicious behavior and poses a threat to the safety of others; or (2) the dog is not housebroken. Barking alone is not a threat nor does a direct threat exist if the owner takes prompt, effective action to control the animal. When an officer takes an individual with a service animal into custody, the officer will explain that the service animal will not be allowed into a detention facility; however, the officer will make every effort to turn the service animal over to a caretaker designated by the owner/handler. If no caretaker is available, the animal will be turned over to Denver Animal Control. Denver Animal Control can be requested through dispatch and will respond 24 hours a day to all calls for placement of service animals. The officer must tell the responding animal control officer that the animal in question is a service animal, so that an administrative hold can be placed. The officer will note the disposition of all service animals on their log sheet when the owner/handler is arrested. Disabled individuals who possess a pit bull trained as a service animal may not be arrested or prosecuted for violating any Denver Revised Code prohibiting pit bulls. The purpose of contacting a O P E R A T I O N S D E N V E R P O L I C E M A N U A L D E P A R T M E N T 104. This procedure does not apply if there is a possibility that contact with management may in some way allow the escape of an employee who is to be arrested. Any crime of violence reported as a violation of state statute (murder, kidnapping, robbery, assault, sexual assault, harassment by stalking, ethnic intimidation etc. Any domestic violence related crime including city ordinance violations (simple assault, disturbance, threats, etc. Careless driving that results in the death of another, or failure to stop at the scene of an accident where the accident results in the death of another. The telephone number for the Denver Police Department Victim Assistance Unit (720-913-6035). The Victim Assistance Unit will contact victims and provide the needed information and assistance. The demonstration leader, or the group, will be advised of the laws pertaining to the free movement of pedestrian and/or vehicular traffic while demonstrating and/or any other statute that may be violated during their presence. The squad size will be determined by the officer in charge, in accordance with the individual situation. Each sergeant will be responsible for; instructing their officers in the techniques of employing arrest teams, designating the arresting officers, and actively directing the activities of the team members. I hereby inform all persons assembled that you are in violation of (City ordinance or State statute violated in general terms). In the name of the people of the City and County of Denver, I command all of you here assembled, to disperse. Both of these announcements, along with any statements by the demonstration leadership, may be tape recorded as evidence, if such is possible. Large data cards, General Sessions Summons and Complaints, and property documentation. Whenever possible, dual loop flex cuffs will be utilized for arrests which feature an embossed unique identification number along with six detachable labels featuring the same unique number. The number will be used to track the prisoner and the labels shall be attached to accompanying documentation. One of the flex cuff labels will be affixed to the property bag or the number handwritten onto it. If possible, arresting officers in pairs will arrest suspects with one officer generally maintaining control of the suspect and the other documenting the event.
When serving as the ranking officer of the involved investigative bureau symptoms your period is coming cheap 3 ml lumigan with visa, section medications for anxiety order lumigan 3 ml mastercard, or unit at the scene of a crime or serious vehicle collision medicine 3202 lumigan 3ml low price, they will be in charge of the immediate crime or crash scene without regard to the rank of officers present from any other bureau anima sound medicine cheap lumigan 3ml overnight delivery. The detective will not have either the responsibility or authority for the protection of the area 911 treatment for hair purchase lumigan 3 ml on-line, perimeter control treatment mononucleosis purchase 3 ml lumigan amex, traffic direction symptoms 5-6 weeks pregnant quality 3 ml lumigan, command post medications or drugs 3ml lumigan otc, or any other functions normally assigned to uniformed officers. Request any needed assistance or the assignment from the concerned patrol command post officer (if one is present) or through the regular chain of command of the affected district or section of uniformed officers to their supervision. If requested, provide all available information about the case to the on duty commanding officer of the affected district or section. Provide reasonably requested information and assistance to other bureaus of the police department and maintain an efficient level of cooperation and coordination in affected areas. Establish and maintain effective lines of communication with patrol personnel, using face to face contact situations such as roll call training sessions. Detectives are encouraged to appear at roll calls to give information about wanted persons, crime patterns, and on-going investigations. In the absence of a commander or captain, the senior ranking lieutenant will be in charge of the district, bureau, section, or unit unless otherwise directed. During the prolonged absence of the captain or commander, a lieutenant may be designated as acting captain or commander. They will see to the coordination and follow up of all programs originating from their section with the plans and policy of other department divisions, bureaus, districts, or sections. When applicable, be responsible for the safe condition of cells and detention rooms, and the security of all parts of their assigned station or facility which are designed for the safekeeping of arrestees. Inter-bureau or inter-section procedures or policies that do not affect the entire department will be by directive from the level initiating to the level of execution. Inter-bureau or inter-section procedures or policies will be forwarded to the Planning, Research and Support Section for possible incorporation into the operations manual. When applicable, captains are responsible for the proper and efficient enforcement of all laws and ordinances, which the police department is authorized to enforce within their area of responsibility. Captains will also enforce departmental rules, regulations, policies, and procedures. Captains will organize and direct their commands for the efficient operation of all police service within their respective area of responsibility. When applicable, captains will so regulate their command that, at all times during their absence, to the degree possible it will be under the command of a competent officer not lower in grade than lieutenant. Captains will focus their attention on the effective and efficient delivery of police service within their area of responsibility. Within their area of responsibility, they are also responsible for supporting and implementing policies, procedures, and programs established by the department. Captains will formulate solutions to problems and coordinate an effective response. Direct and supervise planning and policy programs within their bureau or district. They will see to the coordination and follow up of all programs originating from their bureau or district with the plans and policy of other department bureau, districts, or sections. When applicable, be responsible for the planning and execution of programs designed to prevent and suppress crime and traffic accidents, detect and apprehend criminal and traffic offenders, protect and recover property, and solve problems of concern to the department. When applicable, make inspections of their area of responsibility, personnel, facilities, and equipment at irregular intervals and hours of the day and night. For information purposes, directives will also be forwarded to the next highest level of command. When applicable, commanders are responsible for the proper and efficient enforcement of all laws and ordinances, which the police department is authorized to enforce within their area of responsibility. Commanders will also enforce departmental rules, regulations, policies, and procedures. Commanders will organize and direct their commands for the efficient operation of all police service within their respective area of responsibility. Commanders will so regulate their command that, at all times during their absence, it will be under the command of a competent officer not lower in grade than a lieutenant. Commanders will focus their attention on the effective and efficient delivery of police service within their area of responsibility. Commanders will formulate solutions to problems and coordinate an effective response. Division chiefs will carry out the policies, orders, and duties assigned by the Deputy Chief of Police and Chief of Police. They will coordinate the efforts of all officers of their command toward achievement of police objectives, eliminating friction, criticism, and inefficiency. They will promote harmony and always concern themselves with the care and welfare of their personnel. They will ensure coordination and follow up of all programs originating from their divisions with the plans and policy of other department divisions. When applicable, be responsible for oversight of the planning and execution of programs designed to promote public safety and/or other functions and problem solving specific to their division. Inter-division or inter-section procedures or policies that do not affect the entire department will be by directive from the level initiating to the level of execution. Inter-division or inter-section procedures or policies, and bureau or section directives will be forwarded to the Planning, Research and Support Section for possible incorporation into the operations manual. When applicable, division chiefs are responsible for the proper and efficient enforcement of all laws and ordinances, which the police department is authorized to enforce within their area of responsibility. Division chiefs will also enforce departmental rules, regulations, policies, and procedures. Division chiefs will organize and direct their division commands for the efficient operation of all police service within their respective area of responsibility. Division chiefs will so regulate their division to ensure a continuity of command in the event of their absence. Any acting division commanding officer will be a competent officer not lower in grade than a lieutenant. Division chiefs will focus their attention on the effective and efficient delivery of police service within their area of responsibility. They are also responsible for supporting and implementing policies, procedures, and programs established by the department within their area of responsibility. Division chiefs will formulate solutions to problems and coordinate an effective response. The Deputy Chief of Police will carry out the policies, orders, and duties assigned by the Chief of Police. The Deputy Chief of Police will take the necessary steps to rectify such situations. Organize for efficient operation all activities of divisions, bureaus, districts, sections, and units. Exercise control over all personnel assigned to divisions, bureaus, districts, sections, and units to ensure that all duties and responsibilities are performed effectively and efficiently. Hold frequent staff meetings with division chiefs where problems and suggested procedural changes may be discussed. Critically observe procedures affecting division operations, and when appropriate, implementing or recommending changes designed to increase their effectiveness. Coordinate efforts of all officers under his/her direct command toward achieving police objectives, eliminating or reducing friction, criticism, and inefficiency. Approve all requisitions for divisions, bureaus, districts, sections, and units and have them prepared for presentation to the Executive Director of Safety, subject to approval of the Chief of Police. This function may be delegated by the Deputy Chief of Police to a lower ranking command or supervisory officer. The Deputy Chief of Police is responsible for the preparation of records and forms, and for daily, monthly, and annual reports. All orders and directives to the police department emanating from the Executive Director of Safety will be directed through the Office of the Chief of Police. The Chief is responsible for the proper and efficient enforcement of all laws and ordinances which the police department is authorized to enforce. The Chief will discharge the responsibilities imposed on this office by charter and ordinance. All orders will conform to the law and the rules and regulations of the police department, and will remain in full force and effect until rescinded. Assign one or more persons of the rank of captain or lieutenant in the classified service of the police department to perform the duties of commander or division chief. With approval of the Executive Director of Safety, assign one or more persons of the rank of commander, captain, or lieutenant in the classified service of the police department to perform the duties of Deputy Chief of Police. The Chief will assure that all evidence relating to alleged offenses is discovered and properly documented. The chief will formulate and publish departmental procedures and revise procedures and duty assignments as needed. For this period the deputy chief will be regarded as the representative of the Chief of Police, and as such, his/her directions will be obeyed throughout the department. The Chief will establish a logical and clear chain of command with defined channels of communication, responsibility, and authority. The Chief will prepare or cause to be prepared a department organization chart showing the functions and control of the various units. The chief will revise the organization as needed to maintain effective operation and control. The Chief of Police will then implement the distribution of goals and objectives to affected personnel. Police reserve officers will only work assignments approved by their chain of command at their assigned district, or by the Police Reserve Coordinator. Service as a police reserve officer neither possesses nor acquires any employment right or benefit either through the Denver Police Department, or the Denver Civil Service authority. Service in the Reserve Program does not in any way guarantee acceptance in the future into the lateral/reserve entry program of the Denver Police Department. Any expense or cost incurred by police reserve officers as part of service in the Police Reserve Program will not be reimbursed upon termination. Each decision and subsequent decisions will continually require this process of evaluation. In conjunction with the decision making model, personnel will continually make these specific assessments: Authority Do personnel have the legal authority or mandate to act in a particular instance? Reasonable Would a reasonable officer act similarly under the totality of circumstances? De-escalation, in combination with the decision making model, is the foundation for achieving positive police-community interactions and internal employee relations. Personnel will continually assess whether their considered and initiated actions are reasonable and necessary, recognizing that circumstances are fluid and their actions should be adjusted accordingly. General principles: the Denver Police Department recognizes the value and sanctity of all human life and is committed to respecting human rights and the dignity of every individual, in every interaction. All department personnel must recognize that their actions, both verbal and non-verbal, can play a significant role in the outcome and escalation or de-escalation of an interaction. When reasonable and practical, personnel should take actions that reduce the negative momentum of volatile situations, thus de-escalating; however, it is understood that delivering public safety services may require immediate and decisive action to protect the community, themselves, or other department members. Considerations/Factors in non-compliance: There are many reasons an individual may be uncooperative or fail to respond to verbal direction, including but not limited to: c. Medical condition Psychological or emotional crisis Developmental disability or dementia Drug / alcohol interaction Language barrier Methods of de-escalation all interactions: 1. Remain calm, actively listen, be courteous and respectful, show empathy, demonstrate patience, use persuasion, avoid arguments, request resources, suggest alternatives, use supportive language, and utilize critical incident techniques. When sworn personnel are taking protective or enforcement action, or using force, appropriate tactical options may be used in accordance with training and applicable policies. The assignment of talk groups will be determined by the commander of the Operations Support Division. The daily detail will clearly list all command officers and supervisors and/or any officer working in an acting capacity. When clear, depress the transmit button, pause one to two seconds, identify yourself by the proper call sign, release the button and wait for the dispatcher to acknowledge your call. After acknowledgement, again depress the transmit button, pause and continue with the transmission, keeping the button depressed continuously during each transmission. Once the emergency is resolved, the initiating radio user must press and hold the orange button for three and a half (3. The emergency identifier is to be used in situations where an officer fears bodily injury, when conditions are escalating requiring an immediate police response, and when an officer is unable to verbally use the radio to call for help. Department personnel are expected to have this information on their persons and such information will not be furnished by the dispatcher. Long transmissions should only be done over a secondary talk-group or via a cell phone (if available). Officers will ask the dispatcher if they are clear for a Code 7 and give their location. If the dispatcher determines the car is clear, the dispatcher will acknowledge and hold the car out on the air, at that location. During radio transmissions, all members are prohibited from using derogatory language relating to race, color, creed, national origin, age, sex or sexual orientation or any other language that might reasonably be regarded as offensive to any other person. Until the dispatcher announces that normal operations have resumed, department personnel will not use the radio for any reason other than to address the emergency operation unless the transmission is necessary for safety concerns. Department personnel will immediately return to their assigned dispatch channel at the conclusion of their transmission. Officers should avoid calling Denver 911 for updates or additional information on any call type being handled unless necessary in furtherance of their duties. Officers will not air, cause to be aired, or release publicly, any personal information over the police radio or any other unsecured communication method. Denver 911 should inquire, when practical, if complainants would like direct contact by the officer responding to their calls. In some situations, contact is necessary, regardless of the individual wishes of the person. Solo officers must respond after three (3) radio calls within two (2) minutes or be subject to a missed call designation. Two officer assignments must respond after three (3) calls within one (1) minute or be subject to a missed call designation. When non-urgent calls may require overtime, officers will inform an on-duty supervisor for direction. All patrol, Gang Unit, and officers assigned to Traffic Operations (below the rank of sergeant) will begin their tour of duty by going in-service on the radio and end their shift by going out of service on the radio. Officers may use a telephone to notify the dispatcher that they are beginning or ending a shift only when a radio is not available. At the beginning of a shift, supervisors or command officers will personally notify the dispatcher when officers are unavailable for calls for service. Whenever an officer is unable to come in-service within twenty (20) minutes of the beginning of a shift, a supervisor will notify the dispatcher. This will include reporting late to work, administrative duties at the station, or any other activity preventing the officer from calling inservice. If a roll call extends beyond twenty (20) minutes, a supervisor will notify the dispatcher and will monitor radio traffic. If the dispatcher does not respond, officers will repeat the process until acknowledged. All patrol, Gang Unit, and officers assigned to Traffic Operations (below the rank of captain) are required to be available by radio unless on special assignment or out-of-service at a specific location where radio communication is not appropriate or possible. This may be accomplished by phone, radio, or immediate transmission of the daily detail. All out-of-service activity is subject to the approval of the dispatcher or by order of a supervisory officer. Out-of-service activities include, but are not limited to: vehicle and/or radio maintenance or repairs, short/long breaks, personal errands and/or administrative duties. All officers assigned to investigation units will be available according to regulations and orders issued by the commanding officers in charge of their specific division, and with the approval of the Division Chief of Investigations. Should officers receive an emergency call while in the process of handling an in-service call, they will respond at once to the emergency. The officers may complete the minor call later, or if the emergency situation results in a significant time delay, another car will be sent to complete the inservice call. This includes updating the dispatcher with premise descriptors should the officer feel they are in a secluded area of the location. This information is essential should the officer require emergency assistance at a later time. Notify the dispatcher on their assigned channel of their car number and location and advise that they will be on the inquiry channel. Switch to the inquiry channel and, when the radio traffic is clear, state their car number. On license plate checks give the State and type of plate first, then the plate number. Test clearances or test inquiries are defined as those clearances requested when a subject, vehicle, or property is not in-sight or in-hand. Remain on the inquiry channel until the information is received or you are instructed to return to your assigned channel. If you are instructed to return to your assigned channel and await the requested information, do so, then advise the dispatcher that you are awaiting information from the inquiry channel. The dispatcher of your assigned channel will then give you the information requested. Dispatchers will notify their supervisors on each call where officers are sent out of the city. When Denver police officers are sent outside of the City and County of Denver on emergency assistance calls, their supervisor or commanding officer will be notified.
One effcient workfow strategy is to have clinical assistants or nurses administer the screening instrument in an interview or provide patients with a paper or computer tablet version for self-administration ad medicine order 3 ml lumigan otc. Tobacco Screening More than 80 percent of patients who are opioid dependent smoke cigarettes treatment centers near me purchase 3ml lumigan fast delivery. Among preventable causes of premature death medications routes buy lumigan 3 ml with mastercard, smoking remains most prevalent chi royal treatment proven 3 ml lumigan, with more than 480 medicine 513 purchase lumigan 3ml mastercard,000 deaths per year in the United States symptoms gerd lumigan 3 ml amex. Providers should reinforce healthy behaviors among patients who report "no use" and direct those who report "some use" for further screening and assessment to obtain a diagnosis treatment 12mm kidney stone purchase lumigan 3ml with mastercard. Several brief screening instruments for drug use can help primary care practitioners identify patients who use drugs symptoms testicular cancer 3ml lumigan with visa. Drug Screening Screening for illicit drug use and prescription medication misuse is clinically advantageous. How often during the last year have you needed an alcoholic drink frst thing in the morning to get yourself going after a night of heavy drinking? How often during the last year have you been unable to remember what happened the night before because you had been drinking? Has a relative, friend, doctor, or another health professional expressed concern about your drinking or suggested you cut down? Heaviness of Smoking Index Ask these two questions of current or recent smokers: 1. Still, drug testing can confrm recent drug use in patients receiving diagnostic workups for changes in mental status, seizures, or other disorders. Motivational brief interventions to promote safer behavior and foster effective treatment engagement. Education for patients who inject drugs on how to access sterile injecting equipment. A targeted physical exam for signs of opioid withdrawal, intoxication, injection, and other medical consequences of misuse. Motivational Interviewing: Helping People Change52 discusses specifc applications of motivational interviewing in health care. Help providers consider interactions among various medications and other substances. Although substance-induced depression and anxiety disorders may improve with abstinence, they may still require treatment in their own right after a period of careful observation. When obtaining patient histories, staff should address these domains before starting treatment. Histories should also explore current patterns of use,55 which inform treatment planning and include: · Which drugs patients use. Patients coerced into treatment-such as through parole and probation or drug courts-are as likely to succeed in treatment as patients engaging voluntarily. Substance misuse substantially increases the risk of intimate partner violence; screen all women presenting for treatment for domestic violence. I did not experience a moment of ease for the frst 3 months, and it was 6 months until I started to feel normal. Symptoms are similar to experiencing gastroenteritis, severe infuenza, anxiety, and dysphoria concurrently. The duration of withdrawal depends on the specifc opioid from which the patient is withdrawing and can last 1 to 4 weeks. See the "Resources" section for links to standardized Grade 3 Grade 4 Total duration of withdrawal: · Short-acting opioids: 710 days · Long-acting opioids: 14 days or more scales. During ongoing pharmacotherapy with buprenorphine or methadone, drug testing can confrm medication adherence. Patients who inject opioids may develop: - Sclerosis or scarring of the veins and needle marks, or "track marks," in the arms, legs, hands, neck, or feet (intravenous use). Provider: Patient: Provider: When we assess patients for medication for opioid addiction, we always check urine samples for drugs. There are many drug testing panels; cutoffs for positive results vary by laboratory. The typical screen will not detect methadone, buprenorphine, or fentanyl and may not detect hydrocodone, hydromorphone, or oxycodone. When assessing benzodiazepine use, note that typical benzodiazepine urine immunoassays will detect diazepam but perhaps not lorazepam or clonazepam. N/A Immunoassays may not be sensitive to therapeutic doses, and most immunoassays have low sensitivity to clonazepam and lorazepam. Barbiturates Benzodiazepines Barbiturates Benzodiazepines Up to 6 weeks 13 days; up to 6 weeks with heavy use of long-acting benzodiazepines *Detection time may vary depending on the cutoff. N/A Cocaine Cocaine, benzoylecgonine Morphine, codeine, high-dose hydrocodone Fentanyl 24 days; 1022 days with heavy use 12 days Codeine Will screen positive on opiate immunoassay. Heroin Morphine, codeine 12 days Hydrocodone Hydrocodone, hydromorphone May not be detected Tetrahydrocannabinol 2 days Hydromorphone 12 days Marijuana Infrequent use of 13 days; chronic use of up to 30 days 211 days 12 days Methadone Morphine Methadone Morphine, hydromorphone Will screen negative on opiate screen. Positive methadone or buprenorphine tests are expected for patients receiving these treatments. Consider that the opioid the patient reports using may not be detected on the particular immunoassay. Screening tests are not defnitive; false positive and false negative test results are possible. Urine drug testing will detect metabolites from many prescription opioids but miss others, so it is easy to misinterpret results in patients taking these medications. Hepatitis B and C serology, which can indicate: · · Patients with positive tests (evaluate for hepatitis treatment). See Medication-Assisted Treatment for Opioid Addiction: Facts for Families and Friends (ttp://mha. Treatment Planning or Referral Making Decisions About Treatment Start by sharing the diagnosis with patients and hearing their feedback. A great deal of time is spent in activities to obtain the opioid, use the opioid, or recover from its effects. Recurrent opioid use resulting in a failure to fulfll major role obligations at work, school, or home. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused by or exacerbated by the effects of opioids. A need for markedly increased amounts of opioids to achieve intoxication or desired effect b. A markedly diminished effect with continued use of the same amount of an opioid 11. The same-or a closely related-substance is taken to relieve or avoid withdrawal symptoms *This criterion is not met for individuals taking opioids solely under appropriate medical supervision. Whether to access potentially benefcial mental health, recovery support, and other ancillary services, whether or not they choose pharmacotherapy. Consider discussing: · · · · · · Indications, risks, and benefts of medications and alternatives to pharmacotherapy. Understanding Treatment Settings and Services Support patient preferences for treatment settings and services. Others choose outpatient treatment programs that provide opioid receptor agonist treatment for medically supervised withdrawal (with or without naltrexone) or for ongoing opioid receptor agonist maintenance treatment. Many patients initially form a preference for a certain treatment without knowing all the risks, benefts, and alternatives. Providers should ensure that patients understand the risks and benefts of all options. Strategies to engage patients in shared decision making include: · · · · Indicating to patients a desire to collaborate with them to fnd the best medication and treatment setting for them. Exploring what patients already know about treatment options and dispelling misconceptions. Offering information on medications and their side effects, benefts, and risks (Exhibit 2. Additional methadone take-home doses are possible at every 90 days of demonstrated progress in treatment. Referring them to treatment elsewhere will likely result in delay or lack of patient access to care. Develop a treatment plan to determine where patients will receive continuing care (see the "Treatment Planning" section). Continue to provide naltrexone for patients who were already receiving it from some other setting. Some programs also offer case management, peer support, medical services, mental disorder treatment, and other services. If such treatment is indicated, determine whether the residential program allows patients to continue their opioid receptor agonist medication while in treatment. Some residential programs require patients to discontinue these medications to receive residential treatment, which could destabilize patients and result in opioid overdose. These programs range from low intensity (individual or group counseling once to a few times a week) to high intensity (2 or more hours a day of individual and group counseling several days a week). A good transition plan maximizes the likelihood of continuity of care after discharge. Key points include: · Referrals to other behavioral health services require consent for sharing information on treatment progress. Follow up with the patient later to determine whether he or she kept the appointment. Drug Addiction Treatment Act of 2000 legislation requires that buprenorphine prescribers be able to refer patients to counseling, but making referrals is not mandatory. New prescribers can beneft from mentorship from experienced providers in their practice or community. Every visit is a chance to help patients begin healthy changes and move toward treatment and recovery. Accepting, nonjudgmental attitudes help patients overcome shame and discuss concerns honestly while also instilling hope. Preventing opioid overdose (see the "Preventing Opioid-Related Overdose" section). For information about all forms of naloxone, Refer patients to syringe exchange sites. Opioid Overdose: Risk, Prevention, Identifcation, and Response Overdose risk · Using heroin (possibly mixed with illicitly · · · · Overdose identifcation manufactured fentanyl or fentanyl analogs) Using prescription opioids that were not prescribed Using prescription opioids more frequently or at higher doses than prescribed Using opioids after a period of abstinence or reduced use. Use a small "test dose" if returning to opioid use after a period of abstinence, if the substance appears altered, or if it has been acquired from an unfamiliar source. If certifed to provide cardiopulmonary resuscitation, perform chest compressions if there is no pulse. Put the person in the "recovery position," on his or her side and with the mouth facing to the side to prevent aspiration of vomit, if he or she is breathing independently. Opioids (including prescription opioids and heroin) killed more than 33,000 people in 2015, more than in any prior year. Municipalities with community-based naloxone distribution programs have seen substantial decreases in opioid overdose death rates. It addresses issues for healthcare professionals, frst responders, treatment providers, and those recovering from opioid overdose as well as their families. Points allotted are: a = 0 points, b = 1 point, c = 2 points, d = 3 points, e = 4 points · In men, a score of 4 or more is considered positive, optimal for identifying hazardous drinking or active alcohol use · In women, a score of 3 or more is considered positive (same as above). Segment: Visit Number: Date of Assessment: / / these questions refer to drug use in the past 12 months. Opioids are often taken in larger amounts or over a longer period of time than intended. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids. How often have you used any tobacco product (for example, cigarettes, ecigarettes, cigars, pipes, or smokeless tobacco)? How often have you used any prescription medications just for the feeling, more than prescribed, or that were not prescribed for you? Each of the following questions and subquestions has two possible answers, yes or no. If "Yes," answer the following questions: Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No · Have you had a strong desire or urge to use marijuana at least once a week or more often? If "Yes," answer the following questions: · Did you use cocaine, crack, or methamphetamine (crystal meth) at least once a week or more often? If "Yes," answer the following questions: · Have you tried and failed to control, cut down, or stop using heroin? Did you use a prescription opiate pain reliever (for example, Percocet or Vicodin) not as prescribed or that was not prescribed for you? If "Yes," answer the following questions: · Have you tried and failed to control, cut down, or stop using an opiate pain reliever? Did you use medication for anxiety or sleep (for example, Xanax, Ativan, or Klonopin) not as prescribed or that was not prescribed for you? Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health. Final recommendation statement: Alcohol misuse: Screening and behavioral counseling interventions in primary care. The Alcohol Use Disorders Identifcation Test: Guidelines for use in primary care (2nd ed. Tobacco smoking cessation in adults, including pregnant women: Behavioral and pharmacotherapy interventions. A short form of the Fagerstrцm Test for Nicotine Dependence and the Heaviness of Smoking Index in two adult population samples. The Fagerstrцm Test for Nicotine Dependence: A revision of the Fagerstrцm Tolerance Questionnaire. Mutual mistrust in the medical care of drug users: the keys to the "narc" cabinet. Management of mood and anxiety disorders in patients receiving opioid agonist therapy: Review and meta-analysis. Prescription drugs monitoring program, nonmedical use of prescription drug and heroin use: Evidence from the National Survey of Drug Use and Health. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Randomized trial of long-acting sustainedrelease naltrexone implant vs oral naltrexone or placebo for preventing relapse to opioid dependence. The role of behavioral interventions in buprenorphine maintenance treatment: A review. A randomized trial of cognitive behavioral therapy in primary care-based buprenorphine. Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence: A 2-phase randomized controlled trial. Current status of co-occurring mood and substance use disorders: A new therapeutic target. Medication-assisted treatment models of care for opioid use disorder in primary care settings. Double trouble: Psychiatric comorbidity and opioid addiction-All-cause and cause-specifc mortality. Identifying mortality risks in patients with opioid use disorder using brief screening assessment: Secondary mental health clinical records analysis. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: Interrupted time series analysis. Scope of the Problem the United States is experiencing an opioid addiction epidemic. Bioavailability: Proportion of medication administered that reaches the bloodstream. If a drug is continued at the same dose, its plasma level will continue to rise until it reaches steady-state concentrations after about fve half-lives. Key Terms (continued) Intrinsic activity: the degree of receptor activation attributable to drug binding. Opioid blockade: Blunting or blocking of the euphoric effects of an opioid through opioid receptor occupancy by an opioid agonist. Opioid receptor agonist: A substance that has an affnity for and stimulates physiological activity at cell receptors in the nervous system that are normally stimulated by opioids. Unlike with full agonists, increasing their dose in an opioid-tolerant individual may not produce additional effects once they have reached their maximal effect. Methadone and buprenorphine can blunt or block the effects of exogenously administered opioids. Opioid receptor antagonist: A substance that has an affnity for opioid receptors in the central Opioids: All natural, synthetic, and semisynthetic substances that have effects similar to morphine. Risks and benefts of pharmacotherapy with all three types of medication, treatment without medication, and no treatment. Opioid receptor partial agonist Reduces opioid withdrawal and craving; blunts or blocks euphoric effects of selfadministered illicit opioids through cross-tolerance and opioid receptor occupancy. Opioid receptor agonist Reduces opioid withdrawal and craving; blunts or blocks euphoric effects of selfadministered illicit opioids through cross-tolerance and opioid receptor occupancy. Administration Daily (or off-label less-thandaily dosing regimens) administration of sublingual or buccal tablet or flm. Daily oral administration as liquid concentrate, tablet, or oral solution f rom dispersible tablet or powder (unless patients can take some home). Implants have been found to be more effective than placebo in reducing illicit opioid use among opioid-dependent patients receiving counseling. Buprenorphine Buprenorphine is effective in retaining patients in treatment and reducing illicit opioid use, as demonstrated by many clinical trials comparing buprenorphine with placebo or no medication. An expert panel did not agree on whether women already receiving treatment with naltrexone at the onset of pregnancy should remain on that medication during pregnancy. However, comparing only the subgroups of those participants who did start their assigned medication, there were no signifcant between-group differences in returnto-use rates.
