NOAA Technical Memorandum NMFS-SEFSC-xxx
NOAA Technical Memorandum NMFS-SEFSC-xxx NOAA Technical Memorandum NMFS-SEFSC-xxx
Clinical Use of Extended-Release Injectable Naltrexone in the Treatment of Opioid Use Disorder: A Brief GuideASSESSING THE NEED FOR TREATMENT Patient AssessmentA patient who is identified with a potential opioiduse disorder should undergo a thoroughassessment to confirm the diagnosis. 16 Theobjectives of the assessment are to determinethe patient’s need for treatment, to develop atreatment plan, and to establish a baselinemeasure for evaluating the patient’s progress.Accordingly, the patient assessment should:Confirm the opioid use disorder diagnosisEstablish current opioid use—when, what,and how much opioid the patient used mostrecentlyDocument the patient’s substance use history,including alcohol and other drugs of abuseIdentify patients who require medicallysupervised detoxification from alcohol,benzodiazepines, or other sedatives, inaddition to opioidsDetermine where and when suchdetoxification should be accomplishedIdentify comorbid medical and psychiatricconditions and disorders and prioritize andcoordinate their managementScreen for infectious diseases for whichpeople who misuse opioids are at elevatedrisk, such as hepatitis B , hepatitis C andHIV/AIDSAssess the patient’s access to socialsupports, family, friends, employment,housing, finances, and assistance with legalproblemsEvaluate the patient’s degree of motivation forbehavior change and readiness to participatein treatmentThe physical examination should focus onproblems the patient is experiencing andinclude screening for common consequences orco-occurring problems associated with thepatient’s current and past substance use.Substance Use History. A completesubstance use history is essential to developmentof a safe and appropriate treatment plan. 17 Indepthinterviews, combined with the use ofstandardized assessment instruments, areeffective methods of gathering this information.Ideally, the substance use history should includethe nature of the patient’s substance usedisorders, underlying or co-occurring diseases orconditions, the effect of opioid use on the patient’sphysical and psychological functioning, and theoutcomes of past treatment episodes.It is essential to find out whether the patient iscurrently taking (or recently took) methadone orother long-acting opioids. 18,19 Urine toxicologyscreens must also be completed. It also isadvisable to access the patient’s prescriptiondrug use history through the state’s prescriptiondrug monitoring program (PDMP) 20 whereavailable, both to confirm compliance in takingprescribed medications and to detectunreported use of other prescriptionmedications. 17 Information about PDMPs andhow to access them is available from stateboards of medicine and pharmacy.Information about PDMPs and how toaccess them is available from stateboards of medicine and pharmacy.In addition to securing the patient’s PDMPrecord, obtaining information from familymembers and significant others can provideuseful perspectives on the patient’s behaviorand level of function, so consent to speak withfamily members and other providers must beobtained. Contact with or records from clinicianswho have treated the patient in the past andinformation from the prescription benefitprovider should also be sought out. 10Physical Examination. The physicalexamination of a patient who is being evaluatedfor a substance use disorder should focus onphysical findings related to addiction and itscomplications. For example, examination of skininjection sites can provide useful informationabout the duration of injection drug use. Recentinjection marks are small and red and sometimesare inflamed or surrounded by slight bruising.Older injection sites typically are not inflamed butsometimes show pigmentation changes (eitherlighter or darker), and the skin may have anatrophied or sunken appearance. A combinationof recent and old injection sites suggests that the2
INTRODUCTIONGeographically widespread (e.g. Aronson and Precht 2001) and locally intense(e.g. Miller et al. in press) declines in populations of the only two fast-growing reefbuildingcorals in the Caribbean, the elkhorn coral Acropora palmata and the staghorncoral Acropora cervicornis, led to their designation in 1999 as Candidate Species underthe US Endangered Species Act (Diaz-Soltero 1999). Aronson and Precht (2001) offeran extensive review of this regional decline and argue that white band disease was theprimary culprit on the Caribbean-wide regional scale, with more localized losses beingcaused by hurricane damage. Jamaica was an area devastated by Hurricane Allen in1980. A. cervicornis suffered a 100-fold decrease in density, whereas the densities of itspredator, the gastropod Coralliophila abbreviata remained close to pre-storm levels(Knowlton et al. 1981, 1990). Live coral fragments, potentially able to reattachthemselves and form new, healthy stands, were eaten by surviving C. abbreviatapopulations, arresting the recovery process of the staghorn corals.As recently emphasized by the Florida Keys National Marine Sanctuary(FKNMS) Science Advisory Panel(http://www.fknms.nos.noaa.gov./research_monitoring/sap2000.html), declining coralpopulations in the Florida Keys demand attention to identifying causes and implementingmanagement strategies aimed at arresting this decline. Given the documented decline inAcroporid coral abundance throughout the Sanctuary, the current study was begun in1998 to monitor remnant Acropora palmata patches in the upper Keys and the status ofresident corallivorous snails, Coralliophila abbreviata, as one of these causal threats.Snail feeding has been shown to remove an average of 3.37 cm -2 colony -1 day -1 of live A.palmata tissue on FKNMS reefs (Miller 2001).HYPTOTHESESThe primary hypothesis that instigated the study was that snail impact on A.palmata had been enhanced over time due to fishery removal of predators of the snail.With no-take reserves established in FKNMS in 1997, the opportunity arose to comparesnail populations in reserves where predation should resume and in reference sites.Similarly, we hypothesized that declining snail populations would result in A. palmata1
- Page 9 and 10: 3. Ultimately our initial hypothese
- Page 11 and 12: of LD versus thicket and reserve vs
- Page 13 and 14: Host EffectInspection of the size s
- Page 15 and 16: at the three LD stand sites do not
- Page 17 and 18: FIGURE LEGENDSFigure 1. Map (A)show
- Page 19 and 20: Table 1. Study sites and summary of
- Page 21 and 22: REFERENCES:Aronson RB, Precht W (20
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- Page 25 and 26: Total # Colonies + Fragments2502001
- Page 27 and 28: Proportion of Ap with df0.80.70.60.
- Page 31 and 32: Snail length (mm 1/2 )6.05.65.24.84
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INTRODUCTIONGeographically widespread (e.g. Aronson and Precht 2001) and locally intense(e.g. Miller et al. in press) declines in populations of the only two fast-growing reefbuildingcorals in the Caribbean, the elkhorn coral Acropora palmata and the staghorncoral Acropora cervicornis, led to their designation in 1999 as Candidate Species underthe US Endangered Species Act (Diaz-Soltero 1999). Aronson and Precht (2001) offeran extensive review of this regional decline and argue that white band disease was theprimary culprit on the Caribbean-wide regional scale, with more localized losses beingcaused by hurricane damage. Jamaica was an area devastated by Hurricane Allen in1980. A. cervicornis suffered a 100-fold decrease in density, whereas the densities of itspredator, the gastropod Coralliophila abbreviata remained close to pre-storm levels(Knowlton et al. 1981, 1990). Live coral fragments, potentially able to reattachthemselves and form new, healthy stands, were eaten by surviving C. abbreviatapopulations, arresting the recovery process of the staghorn corals.As recently emphasized by the Florida Keys National Marine Sanctuary(FKNMS) Science Advisory Panel(http://www.fknms.nos.noaa.gov./research_monitoring/sap2000.html), declining coralpopulations in the Florida Keys demand attention to identifying causes and implementingmanagement strategies aimed at arresting this decline. Given the documented decline inAcroporid coral abundance throughout the Sanctuary, the current study was begun in1998 to monitor remnant Acropora palmata patches in the upper Keys and the status ofresident corallivorous snails, Coralliophila abbreviata, as one of these causal threats.Snail feeding has been shown to remove an average of 3.37 cm -2 colony -1 day -1 of live A.palmata tissue on FKNMS reefs (Miller 2001).HYPTOTHESESThe primary hypothesis that instigated the study was that snail impact on A.palmata had been enhanced over time due to fishery removal of predators of the snail.With no-take reserves established in FKNMS in 1997, the opportunity arose to comparesnail populations in reserves where predation should resume and in reference sites.Similarly, we hypothesized that declining snail populations would result in A. palmata1
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