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August 27, 2014

 

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SAMHSA
SAMHSA Prescription Drug Abuse Weekly Update
WEEKLY
UPDATE
Issue 86  |  August 27, 2014
The Prevention of Prescription Drug Abuse in the Workplace (PAW) TA Center addresses prescription drug abuse—a growing public health problem with increasing burdens on workers, workplaces, and our economy. To subscribe colleagues, family members, or friends to this listserv sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), please click here or send their e-mail addresses to paw@dsgonline.com.
Table of Content Featured Article Journal Articles and Reports Professional Education News Other State and Local News Other Resources Video Request for Proposal National Take-Back Event Take-Back Events and Drop Boxes Save the Date Upcoming Conferences and Workshops

Featured

D.C. McDonald and K.E. Carlson. 2014. "The Ecology of Prescription Opioid Abuse in the USA: Geographic Variation in Patients' Use of Multiple Prescribers (Doctor Shopping)." Pharmacoepidemiology and Drug Safety, doi:10.1002/pds.3690.

Using IMS Health LRx data on 146 million opioid prescriptions dispensed in 2008, researchers counted opioid patients (by county of residence) with large numbers of prescribers. Approximately 30 percent of shoppers obtained prescriptions in multiple states, and shopping rates ranged from 0.6 to 2.5 per 1,000 residents. The overall opioid prescription rate in the county accounted for 30 percent of variation in shopper prevalence, after adjusting for physician supply, emergency department visits, inpatient hospital days, poverty rates, percentage of county residents living in urban areas, and racial/ethnic composition of resident populations.

Read more:
http://onlinelibrary.wiley.com/doi/10.1002/pds.3690/abstract

M.S. Cepeda, D. Fife, J. Berwaerts, Y. Yuan, and G. Mastrogiovanni. 2014. "Shopping Behavior for ADHD Drugs: Results of a Cohort Study in a Pharmacy Database." Drugs in R&D, doi:10.1007/s40268-014-0058-4.

Researchers used the IMS Health LRx pharmacy database, which covers 65 percent of U.S. retail pharmacies, to select 4,402,464 people who were dispensed attention deficit hyperactivity disorder (ADHD) medication and 6,128,025 people who were dispensed asthma medication between February 2011 and January 2012. They followed subjects for 18 months to assess how many had overlapping prescriptions from different prescribers, and the number of prescribers and pharmacies involved. Overlapping prescriptions from two or more prescribers dispensed by three or more pharmacies were four times more frequent in the ADHD cohort. Using this definition, ADHD medication shopping was more common among experienced than naïve users, and was most common in subjects aged 10–39. Among those who shopped, 57.4 percent did it only once (accounting for 22.4 percent of episodes), while 9.2 percent shopped six or more times (accounting for 42 percent of episodes).

Read more:
http://link.springer.com/article/10.1007/s40268-014-0058-4

Editor's note: In many states, the LRx database captures far more prescriptions than the states' prescription monitoring programs. Furthermore, LRx architecture is uniform across the country. One wonders if there is a way to integrate the systems.

Journal Articles and Reports

M.K. Bidwal, E.J. Ip, B.M. Shah, and M.J. Serino. 2014. "Stress, Drugs, and Alcohol Use Among Health Care Professional Students: A Focus on Prescription Stimulants." Journal of Pharmacy Practice, doi:10.1177/0897190014544824.

In early 2011, 730 pharmacy, medicine, and physician assistant students spread across 11 California schools started a 50-item, Web-based survey with questions on prescription stimulant use. Researchers analyzed 589 completed surveys. Among the 8.8 percent who admitted lifetime use of prescription stimulants, only 32.7 percent had a valid prescription. Of those users, 52 percent had taken prescription stimulants in the past year, including 13.5 percent who used daily, 7.7 percent who used 1 to 6 days per week, and 11.5 percent who used only during examination periods. When asked how prescription stimulants affected their academic performance, 38.8 percent noted an improvement, while 61.2 percent reported no change. Most students were not secretive about their prescription stimulant use: Almost two thirds (64.7 percent) had informed a friend; 43.1 percent had informed a family member/spouse; 39.2 percent had informed a colleague/classmate; 33.3 percent had informed a physician/healthcare provider; and 7.8 percent had informed a professor/preceptor. Only 7.8 percent of users had not informed anyone. Six percent had tried the drugs intranasally. Risk factors for nonmedical use included being Hispanic (odds ratio [OR] 5.66), Caucasian (OR 2.85), a heavy alcohol user (OR 3.83), or a smoker (OR 3.88).

Read more:
http://jpp.sagepub.com/content/early/2014/08/12/0897190014544824.abstract

E.A. Evans and M.A. Sullivan. 2014. "Abuse and Misuse of Antidepressants." Dove Medical Press 2014(5):107–20, doi:10.2147/SAR.S37917.

This systematic review probed antidepressant misuse. The small (but growing) body of literature on antidepressant misuse consists largely of case reports. In this search of PubMed, Medline, and PsycINFO, the majority of antidepressant abusers had comorbid substance use and mood disorders. The most commonly reported motivation for abuse was to achieve a psychostimulant-like effect. Antidepressants were abused at high doses and through a variety of administration routes (e.g., intranasal, intravenous). Negative consequences, which varied by antidepressant class and pharmacology, included seizures, confusion, and psychotic-like symptoms.

Read more:
http://www.dovepress.com/abuse-and-misuse-of-antidepressants-peer-reviewed-article-SAR

A.R. Gallucci, R.J. Martin, and S.L. Usdan. 2014. "The Diversion of Stimulant Medications Among a Convenience Sample of College Students with Current Prescriptions." Psychology of Addictive Behaviors, doi:10.1037/adb0000012.

Among 1,022 18- to 24-year-old undergraduates enrolled at a large public southeast university who completed an in-class questionnaire, 151 reported having current stimulant prescriptions. Among prescription holders, 58.9 percent said they had occasionally given away or sold their medication. Those with a history of nonmedical use were almost five times more likely to divert their medication. The most common incentives for diversion were making extra money and getting help at a time of high academic stress.

Read more:
http://www.ncbi.nlm.nih.gov/pubmed/25134041

F.L. Lynch, D. McCarty, J. Mertens, N.A. Perrin, C.A. Green, S. Parthasarathy, J.F. Dickerson, B.M. Anderson, and D. Pating. 2014. "Costs of Care for Persons with Opioid Dependence in Commercial Integrated Health Systems." Addiction Science and Clinical Practice 9:16, doi:10.1186/1940-0640-9-16.

Using data from two health systems, researchers analyzed claims for 6,040 patients who had at least two opioid-dependence diagnoses during 2007–08. In a propensity-scored analysis, patients receiving buprenorphine and addiction counseling had significantly lower total healthcare costs than patients with little or no addiction treatment (mean of $13,578 vs. $31,055). Mean costs with addiction counseling were only $17,017. Compared with patients receiving buprenorphine plus counseling, those with little or no addiction treatment had significantly greater use of primary care, other medical visits, and emergency services. With counseling only, patients used less inpatient detoxification than patients with buprenorphine plus counseling, and had significantly more primary care visits, other medical visits, and mental health visits.

Read more:
http://www.ascpjournal.org/content/9/1/16/abstract

A.C. Marin, B.C. Kelly, M. Vuolo, B.E. Wells, and J.T. Parsons. "Prescription Drug Misuse Among Young Adults: The Role of Peer Relationships." Presented at the American Sociological Association 109th Annual Meeting, San Francisco, Calif., August 16–19, 2014.

This paper analyzed qualitative and survey data from 404 prescription drug misusers aged 18–29 who were recruited from popular New York City nightlife locations, such as bars and clubs. High perceived social benefits or low perceived social consequences within the peer network, number of drug sources in the peer group, and a desire to have a good time with friends were all associated with more frequent misuse, administering drugs in ways other than swallowing, and dependency symptoms. Peer pressure had no significant bearing on any outcome.

Read more:
http://www.purdue.edu/newsroom/releases/2014/Q3/study-peers,-but-not-peer-pressure,-key-to-prescription-drug-misuse-among-young-adults.html

C.B. Oser and K.L.H. Harp. 2014. "Treatment Outcomes for Prescription Drug Misusers: The Negative Effect of Geographic Discordance." Journal of Substance Abuse Treatment, doi:10.1016/j.jsat.2014.08.002.

This study examined geographic discordance (traveling from one's home to a county with a different sociocultural context to receive substance abuse treatment—typically rural residents going to urban treatment centers) as a predictor of treatment outcomes (relapse, self-help attendance, anxiety, and incarceration) among a random sample of 187 Kentucky prescription drug misusers in 2010. Follow-up data were collected a year after treatment. Geographic discordance was associated with increased risk of prescription drug misusers reporting relapse, anxiety, or any incarceration, or attending a self-help group (perhaps due to lack of convenient availability).

Read more:
http://www.journalofsubstanceabusetreatment.com/article/S0740-5472(14)00169-X/abstract

Professional Education

M.M. Islam and I.S. McRae. 2014. "An Inevitable Wave of Prescription Drug Monitoring Programs in the Context of Prescription Opioids: Pros, Cons, and Tensions." BMC Pharmacology and Toxicology 15:46, doi:10.1186/2050-6511-15-46.

This article discusses the pros and cons of prescription monitoring programs (PMPs) in reducing prescription opioid diversion without hampering access by those with genuine needs. The paper highlights tensions surrounding PMP implementation.

Read more:
http://www.biomedcentral.com/2050-6511/15/46/abstract

L. McKay and U.A. Pritham. 2014. "Safe Management of Chronic Pain in Pregnancy in an Era of Opioid Misuse and Abuse." Journal of Obstetric, Gynecologic, & Neonatal Nursing, doi:10.1111/1552-6909.12487.

Safe and effective chronic pain management for pregnant women is challenging. Over-the-counter analgesics, opioids, opioid substitution therapies, complementary and alternative therapies, antidepressants, and anxiolytics have both benefits and risks for the mother and baby. Because of their potency, opioids are often used despite associated risks for adverse effects, abuse, diversion, and addiction. Treatment facilities need a pain management protocol for the counsel and care of pregnant women with pain.

Read more:
http://onlinelibrary.wiley.com/doi/10.1111/1552-6909.12487/abstract;
jsessionid=AAD441C80727FBE7DC0BECBA02C4F398.f01t02?

News

How to Talk to a Cop's Kid About Drugs
Keith Graves, PoliceOne
August 15, 2014

Keith Graves, a police officer and Drug Recognition Expert instructor, discusses how law enforcement officials can keep children away from drugs like heroin, prescription opiates, and methamphetamine.

Read more:
http://www.policeone.com/drug-interdiction-narcotics/articles/7467482-How-to-talk-to-a-cops-kid-about-drugs

In Move to Curb Drug Abuse, D.E.A. Tightens Rule on Widely Prescribed Painkiller
Sabrina Tavernise, The New York Times
August 21, 2014

The Drug Enforcement Administration (DEA) has tightened hydrocodone prescribing with rules that take effect in 45 days. Doctors will no longer be able to call in prescriptions by telephone, and instead of getting refills, patients will have to return to a healthcare professional for a new prescription. Hydrocodone will be kept in special vaults in pharmacies. Dr. John Mendelson, an addiction specialist and professor of medicine at the University of California, San Francisco, said he expects the change will lead to increased use of other prescription drugs and a rise in heroin use.

Read more:
http://www.nytimes.com/2014/08/22/health/vicodin-prescription-drug-abuse-hydrocodone.html

FedEx Faces New Charges
Laura Stevens, The Wall Street Journal
August 18, 2014

A second indictment alleges that FedEx knew payments from certain pharmacies were generated from invalid prescriptions. It also states the company collected payments on some of those prescriptions.

Read more:
http://online.wsj.com/news/articles/SB20001424052702304414104580094192751121122?
mod=itp_wsj&mg=reno64-wsj&url=http%3A%2F%2Fonline.wsj.com%2Farticle%
2FSB20001424052702304414104580094192751121122.html%3Fmod%3Ditp_wsj


Opinion: Bill Would Reduce Infant Drug Addiction
Mitch McConnell, Cinncinnati.com
August 18, 2014

Senator Mitch McConnell (R-Ky.) discusses the Protecting Our Infants Act he introduced in the U.S. Senate. The bill is designed to address opiate addiction in newborns and their mothers. It would help identify and disseminate recommendations for preventing and treating maternal addiction and promote recommendations for identifying babies suffering from withdrawal. Finally, it would encourage the Centers for Disease Control and Prevention to work with states to improve the availability and quality of research data that could help them respond more effectively to this problem.

Read more:
http://www.cincinnati.com/story/opinion/contributors/2014/08/18/opinion-bill-help-infant-drug-addiction/14232373

Drug Czar Promotes Treatment, Tells Personal Story
Dave Kolpack, ABC News
August 20, 2014

Michael Botticelli, acting director of the White House Office of National Drug Control Policy, visited North Dakota to warn people about potential death and destruction from substance abuse. He shared personal stories about treatment and recovery and encouraged others to share their stories.

Read more:
http://abcnews.go.com/US/wireStory/drug-czar-promotes-treatment-tells-personal-story-25058126

Prescription Drug Abuse: There Is Help
Ashley N. Vaughn, CNN
August 15, 2014

SAMHSA says millions of people are nonmedical users of pain relievers. Those affected by prescription drug abuse can call 1-800-662-HELP (4357).

Read more:
http://www.cnn.com/2014/08/15/us/iyw-prescription-drug-abuse-how-to-help

Opioid Painkillers to Get Stronger Warning Labels, Health Minister Says
CBC News
August 18, 2014

Canada is requiring stronger warning labels for extended-release pain relievers like OxyContin in hopes of reducing abuse. New labels will emphasize risks and safety concerns associated with the drugs. They will remove any reference to "moderate" pain, clarifying that opioids should only be used to manage severe pain.

Read more:
http://www.cbc.ca/news/health/opioid-painkillers-to-get-stronger-warning-labels-health-minister-says-1.2739523

Health Canada Statement on the Health Risks to Youth of Marijuana and Prescription Drug Use
Government of Canada
August 16, 2014

This statement discusses Health Canada's commitment to use evidence-based communications to raise awareness about the prevalence and health risks of prescription drug use and abuse. When developing campaigns, Health Canada seeks partnerships and invites professionals to share insight and experience, ensuring public messages accurately capture risks.

Read more:
http://news.gc.ca/web/article-en.do?mthd=index&crtr.page=1&nid=876549

Other State and Local News

Magee, Insurers Launch Recovery Center for Drug-Addicted Pregnant Women
Mackenzie Carpenter, Pittsburgh Post-Gazette
August 21, 2014

Magee-Womens Hospital of the University of Pittsburgh Medical Center and several local insurers launched an outpatient recovery center for pregnant women addicted to opiates, which they claim is the first of its kind in the United States. Dennis English, a physician and vice president of Medical Affairs at the hospital, said the center will use buprenorphine prescribed in weekly outpatient visits. Babies can be weaned off the drug in 5 to 6 days. Mothers will be able to meet with midwives and social workers for routine prenatal care and behavioral counseling during and after pregnancy.

Read more:
http://www.post-gazette.com/news/health/2014/08/21/Magee-Womens-insurers-launch-recovery-center-for-pregnant-addicts/stories/201408210240

Settlement Reached in Kentucky Drug Record Case
The Courier-Journal
August 16, 2014

This article discusses a settlement by multiple treatment programs and two pharmacies in Eastern Kentucky that agreed to pay more than $1 million for failing to maintain accurate drug-keeping records. The U.S. Attorney's office said the settlements may be the largest federal penalty ever obtained in a civil case involving methadone treatment programs in Kentucky's Appalachian region. The Drug Enforcement Administration found the facilities improperly documented types of drugs, dosage strength, drug names, and quantities dispensed.

Read more:
http://www.courier-journal.com/story/news/local/2014/08/15/settlement-reached-kentucky-drug-record-case/14118851

Tennesseans Had More Opportunities to Properly Dispose of Prescription Drugs in 2013
Rick Amburgey, Herald Citizen
August 16, 2014

The number of take-back events in Tennessee increased from 53 in 2012 to 46 in the first 6 months of 2013. Permanent prescription drug drop boxes in the state rose from 36 in 2012 to 74 in September 2013. Memphis has only one prescription drug drop box.

Read more:
https://www.herald-citizen.com/newsx/item/2308-tennesseans-had-more-opportunities-to-properly-dispose-of-prescription-drugs-in-2013

Drug Overdoses
State of Rhode Island
Accessed August 20, 2014

Rhode Island tracks drug overdoses to assist public and private health and social service agencies, as well as healthcare providers, in the treatment and rehabilitation of drug abuse victims. This webpage provides statistics on the causes of death attributed to 2014 accidental drug overdoses and the use of naloxone by emergency medical technicians.

Read more:
http://www.health.ri.gov/data/drugoverdoses

Wisconsin Prescription Drug Monitoring Program Comes to La Crosse
WKBT
August 20, 2014

This article and video (54 seconds) discuss a meeting sponsored by La Crosse's Heroin Task Force and the county's prevention network to educate local police and health providers about Wisconsin's prescription monitoring program.

Read more:
http://www.news8000.com/news/wisconsin-presription-drug-monitoring-program-comes-to-la-crosse/27648922

Born Addicted: Hospital Treats Drug-Exposed Newborns
Gabriella Souza, The Virginian-Pilot
August 17, 2014

During the past 14 years, Norfolk, Va., had the state's second-highest number of reports for suspected drug or alcohol abuse by mothers during pregnancy, according to Virginia Department of Social Services data. Janel Moore, a clinical manager at Norfolk General, estimates she sees four drug-exposed infants a day. Pregnant mothers often do not seek help because of the associated stigma. The Norfolk Community Services Board provided only 14 pregnant women with substance abuse services between July 2013 and July 2014.

Read more:
http://hamptonroads.com/2014/08/born-addicted-hospital-treats-drugexposed-newborns

Overdoses Kill Eight People Since April
Mark Caudill, Mansfield News Journal
August 21, 2014

In Richland County, Ohio, four people died from drug overdoses during a 2-week span in June, bringing the 2014 total to 17 fatal overdoses. Eight of the overdoses involved heroin—sometimes in combination with prescription drugs.

Read more:
http://www.mansfieldnewsjournal.com/story/news/local/2014/08/20/eight-people-die-od-months/14366113

Drug Abuse Council Backs Automated Analysis of Pain Pill Data
Joey Holleman, The State
August 18, 2014

South Carolina plans to develop software that can comb the prescription monitoring program database to find pain pill mills. Only about 20 percent of physicians are signed up for the program, and even fewer use it regularly. The governor's Prescription Drug Abuse Prevention Council will try to persuade more physicians to use the database. (Editor's note: But why would a pill mill provider or dispenser voluntarily participate?) The council hopes to get major physician groups involved in the planning process.

Read more:
http://www.thestate.com/2014/08/18/3627157_drug-abuse-council-backs-automated.html?sp=/99/132/&rh=1

Other Resources

Prescription Drug Abuse Epidemic: Spotlight on Methadone
The Pew Charitable Trust
August 18, 2014

This fact sheet provides an overview of methadone and discusses growing public health concerns about the drug. It also explains why methadone is still prescribed, and lists alternatives.

Read more:
http://www.pewtrusts.org/en/research-and-analysis/fact-sheets/2014/08/prescription-drug-abuse-epidemic

Video

Webinar: Using State Prescription Drug Monitoring Programs to Reduce Drug Overdoses
National Conference of State Legislators
August 14, 2014

This Webinar reviews effective prescription monitoring program components and highlights state successes. (Duration: 51:52)

Watch:
https://www.youtube.com/watch?v=dYe3ccQ1XSE

Request for Proposal

Chronic Pain Management Research Grant
Milbank Foundation
Postmarked by November 1, 2014
http://foundationforpmr.org/milbank-foundation-chronic-pain-management-research-grant-application-criteria-and-conditions

Interventions for Youth Who Misuse/Abuse Prescription Stimulant Medications in High School and/or College-Attending Youth (U01)
National Institutes of Health
Deadline: November 13, 2014, by 5 p.m.
https://grants.nih.gov/grants/guide/rfa-files/RFA-DA-15-010.html

National Take-Back Event

National Take-Back Initiative
Drug Enforcement Administration
September 27, 2014
http://www.deadiversion.usdoj.gov/drug_disposal/takeback

Take-Back Events and Drop Boxes

Countrywide Drug Drop-Off Seen as Success
Mike Carson, Journal Pioneer (Canada)
August 19, 2014
http://www.journalpioneer.com/News/Local/2014-08-19/article-3840027/Countrywide-drug-drop-off-seen-as-success./1

Two New Prescription Drug Drop Boxes for Hancock County
Acadia Chamber Press (Maine)
August 18, 2014
http://blog.acadiachamber.com/2014/08/two-new-prescription-drug-drop-boxes.html

Athens Police Install Medication Drop Boxes to Keep Drugs from Falling into Wrong Hands
Athens Banner-Herald (Georgia)
August 17, 2014
http://onlineathens.com/local-news/2014-08-15/athens-police-install-medication-drop-boxes-keep-drugs-falling-wrong-hands

Toledo Installs 5 Permanent Drug Drop-Off Boxes
The Blade (Ohio)
August 20, 2014
http://www.toledoblade.com/local/2014/08/20/Toledo-installs-5-permanent-drug-drop-off-boxes.html

Prescription Drug Drop Vault Permanently Located in Police Department
City of Ormond Beach (Florida)
August 20, 2014
http://www.ormondbeach.org/CivicAlerts.aspx?AID=873

Every Day Is Now Drug Take-Back Day in Freeport, Yarmouth, and Cumberland
Kate Gardener, The Forecaster (Maine)
August 20, 2014
http://www.theforecaster.net/news/print/2014/08/20/every-day-now-drug-take-back-day-freeport-yarmouth/207237

Westmont Police Offer Safe Way to Dispose of Drugs
MySuburbanLife.com (Illinois)
August 15, 2014
http://www.mysuburbanlife.com/2014/08/11/westmont-police-offer-safe-way-to-dispose-drugs/al4kgn2

Drug Take Back Date Set for Clark County
Liz Welter, News-Herald (Wisconsin)
August 19, 2014
http://www.marshfieldnewsherald.com/story/news/local/2014/08/19/clark-county-drug-take-back/14284421

Attleboro to Provide for Pill Disposal
The Sun Chronicle (Massachusetts)
August 15, 2014
http://www.thesunchronicle.com/news/local_news/attleboro-to-provide-for-pill-disposal/article_d226c61c-003d-5414-92c4-78941c960ffc.html

Steuben Co. Prescription Drug Take Back Day Set
Jeff Stone, WETM (New York)
August 20, 2014
http://www.mytwintiers.com/story/d/story/steuben-co-prescription-drug-take-back-day-set/26153/6Tj5Ahu_tUO86Camk8qw4Q

Save the Date

Overdose Awareness Day Is August 31st
Joy Strickland, The Huffington Post
August 19, 2014

August 31, 2014, is Overdose Awareness Day. Numerous organizations will act to raise awareness about substance use disorder, overdose, and the need for increased access to naloxone.

Read more:
http://www.huffingtonpost.com/joy-strickland/overdose-awareness-day-is_b_5688824.html?utm_hp_ref=black-voices&ir=Black+Voices

Sixth Annual American Medicine Chest Challenge: National Day of Awareness and Safe Disposal of Rx and OTC Medicine
American Medicine Chest Challenge
November 8, 2014
http://www.americanmedicinechest.com

Upcoming Conferences and Workshops

2014 Arkansas Prescription Drug Abuse Summit
University of Arkansas, Criminal Justice Institute
September 10, 2014
Little Rock, Arkansas
http://www.cji.edu/2014-rx-drug-abuse-summit

27th Annual NPN Prevention Research Conference
National Prevention Network
September 15–18, 2014
Hartford, Connecticut
http://swpc.ou.edu/npn

2014 Harold Rogers PDMP National Meeting
Brandeis University, Prescription Drug Monitoring Program Training and Technical Assistance Center
September 22–24, 2014
Washington, D.C.
http://www.pdmpassist.org/content/events

5th Annual Prescription Drug Abuse Symposium: Reversing the Tide of Opioid Abuse
Office of the Indiana Attorney General
October 16–17, 2014
Indianapolis, Indiana
http://www.in.gov/bitterpill/symposium.html

142nd Annual Meeting and Exposition
American Public Health Association
November 15–19, 2014
New Orleans, Louisiana
http://www.apha.org/meetings/annual
The Weekly Update is a service provided by the SAMHSA Preventing Prescription Abuse in the Workplace Technical Assistance Center (PAW) to keep the field abreast of recent news and journal articles to assist in forming policy, research, and programs to reduce prescription drug misuse or abuse. Please note, the materials listed are not reflective of SAMHSA's or PAW's viewpoint or opinion and are not assessed for validity, reliability or quality. The Weekly Update should not be considered an endorsement of the findings. Readers are cautioned not to act on the results of single studies, but rather to seek bodies of evidence. Copyright considerations prevent PAW from providing full text of journal articles listed in the Weekly Update.