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February 26, 2014

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SAMHSA Prescription Drug Abuse Weekly Update
Issue 60  |  February 26, 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.
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Teresa Schmidt, Amanuel Zimam, Alexandra Nielsen, and Wayne Wakeland. 2014. "Data Sources Regarding the Nonmedical Use of Pharmaceutical Opioids in the United States." Reviews in Health Care 5(1), doi: 10.7175/rhc.v5i1.883.

This study offers a systematic categorization of data sources regarding the nonmedical use of pharmaceutical opioids in the United States. A list of keywords regarding the nonmedical use of pharmaceutical opioids was used to conduct systematic searches in PubMed®. Filtration of search results generated 92 peer-reviewed academic articles, published between January 1995 and April 2012, as well as numerous primary data sources. Lists of topics were developed independently by two researchers and were later compared and consolidated. All sources were then categorized according to their relevance to each of these topics and according to their capacity for geographical and longitudinal trend analysis. Tables cataloging data sources can be used to identify data relevant to specific topics in diversion, nonmedical use, and adverse outcomes associated with pharmaceutical opioids. A network diagram illustrates global trends in data coverage, showing variation among sources in the number of topics they cover, as well as variation among topics in the number of sources that cover them. Several topics, notably addiction relapse, have minimal data.

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Journal Articles and Reports

A.M. Bailey and D.P. Wermeling. 2014. "Naloxone for Opioid Overdose Prevention: Pharmacists' Role in Community-Based Practice Settings." Annals of Pharmacotherapy, doi: 10.1177/1060028014523730.

This article describes outpatient naloxone-dispensing practices, including methods by which practitioners implement dispensing programs, prescribing patterns that include targeted patient populations, barriers to successful implementation, and methods for patient education. The study relied on interviews with dispensers in community pharmacies and clinics in large metropolitan cities across the country. Among responding pharmacists, 33 percent were located in community-pharmacies and 67 percent in outpatient clinics. Dispensing naloxone begins by identifying patient groups that would benefit from access to the antidote. These include licit users of high-dose prescription opioids (50 percent) and injection drug users and abusers of prescription medications (83 percent). Patients were identified through prescription records or provider screening tools. Dispensing naloxone required a provider's prescription in five of the six locations identified. Only one pharmacy was able to exercise pharmacist prescriptive authority within its practice.

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Kathrine Barnes. 2013. "Do No Harm: Prescription Drug Abuse and the Paraprofessionalism of Pharmacists." Theses and Dissertations. Paper 276. University of Wisconsin, Milwaukee.

"Pharmacists have little official authority and autonomy on the job, relegating them to the level of paraprofessionals," the author asserts. Nevertheless they find ways of gaining agency in their day-to-day work. In conceptualizing the addicted person as a patient who lacks awareness and whose mind is fragmented by the action of drugs on his or her body, pharmacists are able to disturb such patients and attempt to bring awareness of their condition through an assemblage of patient records comingled with "notions of profit, care, biomedicine, a global pharmaceutical market, and morality." While relying heavily on physicians to do their work, pharmacists fault prescribers for the actions of their patients. In seeing patients' patterns of use, rather than the effects of the drug, as creating addiction to prescription drugs, pharmacists insulate their position of low authority, effectively relegating the problem to doctors' turf. Through pharmacists' work, those at risk for prescription drug abuse could learn what happens when drugs meant to heal the public become agents of harm. "Pharmacists and the rest of the medical community are subordinated by a language and conceptualizations rooted in the pharmaceutical industry," Barnes concludes.

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Gerald Cochran, Craig Field, and Kenneth Lawson. 2014. "Pharmacists Who Screen and Discuss Opioid Misuse With Patients Future Directions for Research and Practice." Journal of Pharmacy Practice, doi: 10.1177/0897190014522064

This study identified factors associated with pharmacists who currently screen and discuss prescription opioid (PO) misuse with patients. The authors conducted a cross-sectional Web-based survey of 3,945 pharmacists in Texas and Utah. They report their 19 percent response rate was typical of online surveys of pharmacists, but this does not mean the responses were representative of the surveyed population. The survey assessed whether pharmacists currently screened and discussed PO misuse with patients, along with pharmacists' attitudes and beliefs toward providing brief interventions. Multivariate models identified factors associated with pharmacists' currently screening and discussing misuse. Chain-based pharmacists (odds ratio [OR] = 6.16, 95 percent confidence interval [CI] = 1.16–32.72) and pharmacists interested in being directly involved in PO screening and brief intervention research projects (OR = 2.06, 95 percent CI = 1.35–3.15) were most likely to report current screening. Pharmacists who reported currently screening for misuse (OR = 4.27, 95 percent CI = 2.83–6.45) and who reported wanting to help patients who misuse POs (OR = 3.03, 95 percent CI = 1.50–6.15) were most likely to currently discuss abuse.

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D. Max Crowley, Damon E. Jones, Donna L. Coffman, and Mark T. Greenberg. 2014. "Can We Build an Efficient Response to the Prescription Drug Abuse Epidemic? Assessing the Cost Effectiveness of Universal Prevention in the PROSPER Trial." Preventive Medicine, doi: 10.1016/j.ypmed.2014.01.029.

In 2002, sixth graders from 28 rural public school districts in Iowa and Pennsylvania were randomly assigned to experimental or control conditions by district. In intervention districts, all families, when their child was in the sixth grade, were offered the Strengthening Families 10–14 program, but only 827 of 5,026 decided to participate. For seventh grade, prevention teams selected a school-based program from a menu of three evidence-based-preventive-interventions: All Stars, LifeSkills Training, and Project ALERT. All students received the selected interventions. Outcomes were tracked through early 2010 or completion of 12th grade. Students in Project ALERT, with or without Strengthening Families, misused prescription drugs as often as students in the control group. Among students in All Stars, a decline in misuse was observed only among those whose parents participated in Strengthening Families. Both groups in LifeSkills Training experienced significant declines, with roughly 5 percent fewer of all students reporting misuse by 12th grade (a 20 percent decline in students who misused). The authors cite a study that found a case of prescription drug misuse by a youth lasts for an average of 2.17 years. From published studies on costs of prescription misuse, they estimate that nonmedical opioid use costs $4,132 per user per year. The present value of one youth's misuse through the end of high school is thus $7,500. LifeSkills Training alone cost $613 per case averted; and in combination with Strengthening Families, $3,959. All Stars plus Strengthening Families cost $4,923 per case averted. Although the authors attempted to separate estimated efficacy and cost effectiveness of each school program by itself versus with the family-based program by applying propensity and marginal structural models, the latter finding should be treated cautiously. The Weekly Update's editors believe statistical adjustment could not fully overcome the selection bias imposed, because those opting into the family program differed from those opting out of it.

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Jason A. Ford, Amy Reckdenwald, and Briana Marquardt. 2014. "Prescription Drug Misuse and Gender." Substance Use and Misuse, doi:10.3109/10826084.2014.880723.

Researchers analyzed data on adolescents from the 2010 National Survey on Drug Use and Health. Logistic regression models estimated the relationship of prescription drug misuse with sex, strain, and depression. Females were at increased risk for prescription drug misuse. Strain and depression were significantly related to misuse. Elements of general strain theory accounted for the relationship between prescription drug misuse and sex.

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Jeffrey Fudin and Timothy J. Atkinson. 2014. "Opioid Prescribing Levels Off, but Is Less Really More?" Pain Medicine 15(2):184–87, doi: 10.1111/pme.12340.

The article discusses the expansion in the United States of prescribing opioids to manage chronic pain. The authors probe the social issues inherent in balancing opioid use for chronic pain treatment and avoiding drug abuse. They suggest that a risk-stratification approach can manage risk associated with opioid prescribing.

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Anne Hirsch, Scott K. Proescholdbell, William Bronson, and Nabarun Dasgupta. 2014. "Prescription Histories and Dose Strengths Associated With Overdose Deaths." Pain Medicine, doi: DOI: 10.1111/pme.12391.

Researchers investigated whether short-acting or extended-release opioids were more frequently prescribed to those who died of an overdose and whether a linear relationship existed between dose strength and associated overdose deaths. The study population was North Carolina residents in 2010. Researchers conducted a retrospective, population-based, descriptive study of medication histories of overdose decedents using data from vital statistics, medical examiner records, and a prescription drug monitoring program. Unintentional or undetermined drug overdoses were responsible for 892 deaths. Medical examiner narratives mentioned a history of substance abuse for more than half of overdose decedents and a history of chronic disease, chronic pain, or a mental disorder for more than one third. Out of 191 deaths involving methadone, only 44 had methadone prescribed within the past 60 days and only 2 were patients in opioid treatment programs. Immediate-release oxycodone was involved in the greatest number of opioid-related deaths. Out of 221 oxycodone decedents, 61 percent filled a prescription for oxycodone in the 60 days before death. The most common strength dispensed within 60 days to people who died of oxycodone overdose was 10 mg for immediate-release (72 prescriptions). Forty percent of fentanyl decedents had a prescription for the drug in the past 60 days. Immediate-release oxycodone products (rho = 1.00, P < 0.01) and extended-release fentanyl products (rho = 1.00, P < 0.01) showed strong increasing linear trends between dose strength and proportion of prescriptions dispensed to decedents. A significant proportion of overdose decedents had been prescribed the same type of drugs that contributed to their death, especially for decedents who died from overdoses involving oxycodone, hydrocodone, and alprazolam. Higher dose strengths typically had higher associated mortality. Immediate-release opioids at higher dosages may be considered targets for public health prevention efforts.

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Paolo Mannelli, Li–Tzy Wu, Kathleen S. Peindl, Marvin S. Swartz, and George E. Woody. 2014. "Extended Release Naltrexone Injection Is Performed in the Majority of Opioid Dependent Patients Receiving Outpatient Induction: A Very Low Dose Naltrexone and Buprenorphine Open Label Trial." Drug and Alcohol Dependence, doi: 10.1016/j.drugalcdep.2014.02.002

An open-label study tested whether the transition from opioid addiction to extended release injectable naltrexone (XR–NTX) can be safely and effectively performed in an outpatient setting using very low dose naltrexone and buprenorphine. Twenty treatment-seeking opioid-addicted individuals were given increasing doses of naltrexone, starting at 0.25 mg, with decreasing doses of buprenorphine starting at 4.0 mg during a seven-day outpatient XR–NTX induction procedure. Withdrawal discomfort, craving, drug use, and adverse events were assessed daily until the XR–NTX injection, then weekly over the next month. Fourteen of the 20 participants received XR–NTX, and 13 completed weekly assessments. Withdrawal, craving, and opioid or other drug use were significantly lower during induction and after XR–NTX administration, compared with baseline, and no serious adverse events were recorded. Outpatient transition to XR–NTX combining upward titration of very low-dose naltrexone with downward titration of low-dose buprenorphine was safe, well tolerated, and completed by most participants.

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Shani Ofrat, Robert F. Krueger, Nicholas R. Eaton, Katherine M. Keyes, Andrew E. Skodol, Bridget F. Grant, and Deborah S. Hasin. 2014. "Nonmedical Prescription Drug Use Comorbidity: Developing a Cohesive Risk Model." Journal of Psychopathology and Behavioral Assessment, doi: 10.1007/s10862–014–9409–2.

Researchers investigated how Nonmedical Prescription Drug Use (NMPDU) fits within the multivariate meta-structure of psychiatric comorbidity and how this might vary as a function of gender. Data were collected as part of the National Epidemiological Survey on Alcohol and Related Conditions in 2001–02 on 43,093 individuals 18 or older living in the United States. The Alcohol Use Disorder and Associated Disabilities Interview Schedule DSM–4version 4 (AUDADIS–4) assessed psychiatric diagnoses and sedative, tranquilizer, opioid, and amphetamine NMPDU. Using confirmatory factor analysis, NMPDU was introduced into the internalizing–externalizing model of common mental disorders to determine where it best fits. Models were examined separately for men and women and tested for gender invariance. NMPDU was strongly associated with the externalizing factor, and also showed a very small secondary association with the fear subfactor of internalizing. This structure was gender invariant. Differences between male and female prevalence rates originate at the level of the latent factors. Results indicate a shared liability to NMPDU and other forms of externalizing psychopathology such as other substance use disorders, as well as antisocial behaviors.

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P. Oulis, S. Kalogerakou, E. Anyfandi, G. Konstantakopoulos, V. Papakosta, V. Masdrakis, and E. Tsaltas. 2014. "Cognitive Effects of Pregabalin in the Treatment of Long-Term Benzodiazepine-Use and Dependence." Human Psychopharmacology: Clinical and Experimental, doi: 10.1002/hup.2391.

This study investigated the changes in several core cognitive functions after successful treatment of long-term benzodiazepine (BDZ) antidepressant use and dependence with pregabalin (PGB). Fourteen patients with long-term BDZ use (mean duration >15 years) underwent neuropsychological assessment with the minimental state examination and four tests from the Cambridge Neuropsychological Test Automated Battery (CANTAB) battery before initiation of PGB treatment and at two months after cessation of BDZs. Patients improved on cognitive measures of global cognitive functioning, time orientation, psychomotor speed, and visuospatial memory and on learning with strong effect sizes. By contrast, they failed to improve on measures of attentional flexibility. Despite their significant improvement, patients' scores on most tests remained at lower percentiles of CANTAB normative scores.

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S. Paksu, L. Duran, M. Altuntas, H. Zengin, O. Salis, S.N. Ozsevik, H. Albayrak, N. Murat, A. Guzel, and M.S. Paksu. 2014. "Amitriptyline Overdose in Emergency Department of University Hospital." Human and Experimental Toxicology, doi: 10.1177/0960327113520019.

Researchers evaluated demographics, clinical, laboratory, and electrocardiographic (ECG) findings of 250 patients who overdosed on amitriptyline antidepressants. They studied predictive measures for the development of serious complications. Median patient age was 14.6 years; 70 percent of patients were female, and 66 percent were in the pediatric age group. The most common pathological clinical finding and the most common laboratory abnormality were alteration of consciousness and hyponatremia. The rate of convulsive seizure, arrhythmia, and respiratory depression were 17 (6.8 percent), 16 (6.4 percent), and 11 (4.4 percent), respectively. These complications were seen more often in pediatric patients than in adults (15.8 percent and 1.2 percent, respectively). The incidence of hyponatremia appeared more often in pediatric patients and severe poisoning groups (38.8 and 53.4 percent, respectively). The levels of amitriptyline and nortriptyline were significantly higher in the group with complications than in the group without complications (p < 0.05). All adult patients were discharged with good prognoses. Among pediatric patients, one was discharged with severe neurological sequelae and one died. QRS duration >100 ms, long corrected QT duration interval, and low Glasgow Coma Score at admission were identified as independent risk factors for the development of life-threatening complications (odds ratio: 69.4, 1.9, and 1383, respectively; p < 0.05).

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Natasha Slesnick, Xin Feng, Brittany Brakenhoff, and Gregory S. Brigham. 2014. "Parenting Under the Influence: The Effects of Opioids, Alcohol and Cocaine on Mother-Child Interaction." Addictive Behaviors, doi: 10.1016/j.addbeh.2014.02.003.

This study reports the findings from a sample of treatment-seeking opioid-, alcohol-, and cocaine-using mothers and their 8- to 16-year-old children. Findings from a mother–child observational task and a self-reported parenting measure indicated less undermining autonomy and mother maternal acceptance among opioid, compared with alcohol-addicted mothers. African American mothers were observed to have fewer negative interactional behaviors than whites, and both African American mothers and children self-reported higher firm control and maternal acceptance. Overall, mothers appeared to struggle with effective discipline with older versus younger children.

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B. Wills, P. Reynolds, E. Chu, C. Murphy, K. Cumpston, P. Stromberg, and R. Rose. 2014. "Clinical Outcomes in Newer Anticonvulsant Overdose: A Poison Center Observational Study." Journal of Medical Toxicology, doi: 10.1007/s13181–014–0384–5.

Researchers aimed to evaluate clinical effects of newer anticonvulsant overdose, determine whether a relationship exists between dose and clinical effect, and whether a particular agent appears more toxic in overdose. This was a retrospective study using electronic poison center data, evaluating clinical outcomes from newer anticonvulsant overdose. The Toxicall database from Jan. 1, 2002, to Dec. 31, 2011, was queried using key words "gabapentin," "lamotrigine," "levetiracetam," "tiagabine," "topiramate," "zonisamide," "pregabalin," and "oxcarbazine." Polypharmacy overdose and children under 15 were excluded. Charts were reviewed by two abstractors for pharmaceutical, self-reported dose, clinical effect score, and clinical signs, symptoms, and vital signs recorded in the chart. Ordinal logistic regression was used to evaluate the relationship involving drug type, dose, age, and sex to clinical effect score. Out of 501 cases identified, 347 met the final inclusion criteria. There were 116 gabapentin, 67 lamotrigine, 56 topiramate, 55 oxcarbazepine, 23 pregabalin, 15 levetiracetam, and 15 tiagabine cases. Overdose of newer anticonvulsants frequently results in altered mental status. Seizures may be more common with tiagabine, lamotrigine, and oxcarbazepine. There was one death reported from intentional overdose of topiramate. An information index was created to rank drug toxicity based on reported signs and symptoms for each overdose. There was no significant effect of dose on severity of outcome (β = 0.12, p = 0.23). However, the risk of a more severe outcome score was significantly increased with tiagabine relative to other drugs (β = 2.8, p = 0.001). Lamotrigine ranked highest in terms of toxicity (HT = 1.66) and number of interventions performed (HI = 1.17), and levetiracetam the lowest (HT = 0.98; HI = 0.88). Researchers could not identify a dose-effect in these data, which likely reflects the limitations of self-reported doses. Despite limitations of these data, the risk of more severe outcome scores appears to be higher with tiagabine overdose, while lamotrigine overdose appears to result in more reported signs, symptoms, and interventions.

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Judge: Patients' Prescription Histories Not Protected from Government Searches
February 19, 2014

A Florida appeals judge has dismissed a case challenging the release of the prescription drug histories of more than 3,300 patients. His ruling says the government's interest in regulating drugs outweighs patients' expectation of privacy. [audio duration: 47 seconds]

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A Push to Crack Down on Prescription Drug Abuse [AUDIO]
New Jersey 101.5
February 21, 2014

New Jersey officials are adding high-tech safeguards to prescription blanks used by doctors, so they cannot be copied or forged. One feature includes a heat-activated thermochromatic ink; when warmed by touch, it appears one way, and when cool, it appears another way. The blanks will have unique 15-digit identifiers so they can be verified. [audio duration: 33 seconds]

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These Charts Show Just How Bad America's Heroin Problem Has Become
Huffington Post
February 21, 2014

Heroin users seldom start out seeking the drug. Data show that 80 percent of heroin users start with prescription pain relievers. These charts show how big the problem has become.

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Critics' Calls for Tougher Pain Pills Are Resisted
Boston Globe
February 19, 2014

Congress is considering a proposal that will require drug companies to market only abuse-resistant versions of oxycodone and other prescription opiate pain-relief pills. Currently, the U.S. Food and Drug Administration (FDA) allows one pain reliever to be marketed as abuse resistant. Drug companies that make the cheaper generic forms of oxycodone and other pain relievers are resisting the proposed changes. Last year, the FDA issued draft voluntary guidelines encouraging the development of pain-relief pills that would curb abuse, but it did not address how the new formulations would apply to generic drugs. Generic manufacturers gain access to markets once the patent on a brand-name drug expires. Advocates say cheaper generics have the potential to cause more harm than good. The main objection is that manufacturing techniques used to render one type of opiate drug resistant to crushing may not work on similar drugs, because of variation in molecular composition. Pharmaceutical companies contend they need congressional help to protect their market share from generics without the safeguards.

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Drug Smugglers Have a New Cargo: Cheap Prescription Meds From Mexico
February 18, 2014

Physicians and the U.S. Department of Homeland Security are tracking the smuggling of medicine in bulk from Mexico to U.S. patients. Mexican pharmacist Jorge Sandoval says people who buy his medicines often buy for people they do not know. He wonders whether cartels that control smuggling routes are involved. Juan Nieto of Presidio, a physician working at an emergency room on the border of Texas, says patients are at risk and they are increasingly showing up with medications that do not look right. Branwyn Maxwell–Watts, a small business owner in West Texas, crosses the border to buy medicine for friends and herself. Don Culbertson, a physician's assistant licensed to prescribe prescription medicine, traveled to Mexico to help a patient who could not afford to buy the medicine in the United States. Culbertson knew it was illegal to cross the border with someone else's medicine but did it anyway.

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Heroin Laced With Powerful Prescription Drug Fentanyl Causing Fatal Overdoses
U.S. News and World Report
February 16, 2014

The Drug Enforcement Administration issued a bulletin warning local authorities of what it dubbed "killer heroin," a mixture that was up to half fentanyl. It urged first responders to "exercise extreme caution" when coming into contact with any heroin because fentanyl can be absorbed through the skin. The Maryland Department of Health and Mental Hygiene reported that at least 37 Marylanders have died from heroin combined with fentanyl. Authorities in western Pennsylvania said the mixture caused 22 deaths in their state in recent weeks. In Rhode Island, 25 persons have died from the laced heroin. Vermont state police have warned that pure fentanyl is being sold as heroin. Various authorities nationwide have said bags bearing the stamps "Bud Light," "Theraflu" and "Income Tax" have tested positive for fentanyl.

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Medical Middle Ground Between Marijuana and Pain Pills
Mail Tribune
February 16, 2014

This article tells a story about an Oregon man caught in a medical middle ground between marijuana and pills. Robert Kridel's doctor gave him a choice: give up Oxycontin or give up marijuana. He chose not to give up marijuana. He signed a pain management agreement with his doctor but asked for an exception for the marijuana prohibition. The doctor will continue to reduce doses of his prescription. Doctors and public health officials have been discussing the issue of use and abuse of pain relievers and the effects of mixing those pain relievers with marijuana. Lee Berger, a Portland, Ore., attorney and marijuana advocate, claimed studies exist that show marijuana is an effective drug to help patients get off prescription pain relievers. Jackson County Health and Human Services Medical Director Jim Shames said he personally does not have an absolute conviction against mixing medical marijuana with opiate, despite the possible dangers. Alan Bates, a Medford doctor and supporter of medical marijuana, said there have not been enough scientific studies to determine whether medical marijuana makes sense along with prescription drugs. The Oregon Medical Board has not taken a position on the use of medical marijuana along with opiates for acute pain relief.

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Heroin and Painkiller Deaths Require Public Health Policies
Huffington Post
February 15, 2014

Helena Hansen, an addiction specialist and researcher, and Julie Netherland, the New York deputy state director at the Drug Policy Alliance, think the United States should adopt harm-reduction approaches to drug policy that put public health above the fear and stigma of addiction. They discuss how other countries use Suboxone, compared with use in the United States. Hansen and Netherland believe the nation needs to equip doctors and the healthcare system to respond more effectively to addiction. The Drug Enforcement Administration licenses that permit doctors to prescribe narcotics should require them to train in the safe use of opioids for pain, in the distribution of naloxone overdose reversal kits to opioid treated or dependent patients, in the use of Suboxone, and in skillful assessment and referral of patients to addiction treatment, they believe. In addition, they continue, the nation needs to make provision for a wide range of substance abuse treatments and services, as well as for patient retention and satisfaction—key quality indicators in evaluation and reimbursement protocols. This will also require investment in harm-reduction programs. These steps would retool drug policies to prioritize public health over punitive responses, say Hansen and Netherland.

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Center for Substance Abuse Research. Six-State Study Finds Drugs Other Than Alcohol Increasingly Detected in Fatally Injured Drivers; Cannabinoids Most Prevalent Other Drug Detected. CESAR Fax, Feb. 17, 2014, Vol. 23(6).

While the prevalence of alcohol detected in drivers remained stable at around 39 percent from 1999 to 2010, the prevalence of other drugs increased from 16.6 percent in 1999 to 28.3 percent in 2010. The greatest increases were for cannabinoids and narcotics, both of which roughly tripled over the period (from 4.2 percent to 12.2 percent and from 1.8 percent to 5.5 percent, respectively), followed by depressants, which increased from 2.1 percent to 4.8 percent. The authors conclude that the "results suggest that drugged driving, specifically driving under the influence of cannabinol and narcotics, may be playing an increasing role in fatal motor vehicle crashes."

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Drug of Destruction
Boston Globe
February 19, 2014

Haider Javed Warraich, a resident in internal medicine at the Beth Israel Deaconess Medical Center, shares his views about prescription drug abuse and heroin. He believes the heroin epidemic is strongly related to the spread of prescription drug abuse. He mentions that doctors need more protection to avoid prescribing potentially harmful drugs. Nonopiate options for pain relief need to be better researched and made available. A more open electronic system of health records would help physicians track opiate abusers who have been doctor shopping. In addition, he said, patients need to think long and hard about just how aggressively they want to treat their pain and whether they wish to be prescribed opiates.

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Be Aware of These Common Medication Mistakes, and Learn How to Avoid Them
Durango (Colo.) Herald
February 15, 2014

The Office of Member and Family Affairs coordinator for Axis Health System discusses the most common medication mistakes to avoid and offers some solutions.

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Do Efforts to Crack Down on Prescription Drug Abuse Drive Users to Heroin?
February 18, 2014

Tessie Castillo, the advocacy and communications coordinator at the North Carolina Harm Reduction Coalition, answers whether reducing prescription drug abuse contributes to an increase of heroin use. She reported that nearly 80 percent of recent heroin initiates started by misusing prescriptions. She discusses the government's efforts to reduce diversion and abuse. She believes supply-based interventions do not decrease addiction, but instead diverts it. She cites the 2010 Purdue Pharma's decision to reformulate Oxycontin as an example. She argues that if there is a cause-and-effect relationship between crackdowns on prescription opiates and an increase in heroin use, it is imperative that efforts to reduce drug abuse include prevention and treatment options. The government should also include new laws and programs designed to prevent accidental deaths from overdose, Castillo says. She reports that some overdose laws have been gaining momentum.

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Kids and Study Drugs: Is Your Child Using?
Mother Nature Network
February 18, 2014

This article discusses five things parents need to know about study drugs. Kids ask friends who have prescriptions for Adderall or Ritalin to share pills when they need a boost or help studying for a test.

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Heroin Overdose 'Cure' Exists, but Can Users Find It?
NBC News
February 20, 2014

The article discusses the need for widespread use of naloxone, a nasal spray or injection that reverses an opiate overdose. The author interviews a former addict who advocates for the use of the drug. In addition, the article includes information about laws being considered and some states that have expanded access.

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Marino, Blackburn Introduce Legislation to Combat Prescription Drug Abuse, Ensure Patient Access
February 19, 2014

U.S. Rep. Tom Marino introduced H.R. 4069, the Ensuring Patient Access and Effective Drug Enforcement Act of 2014, to help prevent prescription drug abuse and diversion and ensure patient access to necessary medications by creating a more collaborative partnership among drug manufacturers, wholesalers, retail pharmacies, and federal enforcement and oversight agencies. H.R. 4069 has been referred to the House Judiciary Committee and the House Energy and Commerce Committee.

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When a Prescription for Pain Pills Becomes a Gateway to Addiction
February 15, 2014

Leana Wen, an attending physician and director of patient-centered care research at George Washington University, shares an emergency room story about a construction worker who refused to take a Percocet for his pain. He explained that he was addicted to the drug in his 20s and it took him 10 years to get clean. His first exposure to the narcotic was in the ER. Dr. Wen believes most patients are seeking relief from pain and are unaware of the risks of opioids, and most doctors struggle with how to responsibly help patients in pain without driving them to addiction. She thinks doctors need resources to enable them to address patient expectations while upholding their oath to first do no harm. Hospital policies can help, with limits on the amount of narcotics prescribed and prompt follow-up with pain specialists.

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'Leading Edge' With Host Jimmy Johnson Looks Into Prescription Medication Abuse
PR Web
February 20, 2014

This media release discusses the upcoming episode of "Leading Edge," hosted by Jimmy Johnson, which will feature a segment on prescription drug abuse. The main purpose of the segment is to inform the public of the toll prescription drug abuse is taking on society as well as what citizens can do to help prevent it.

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States Combat Alarming Drug Overdose Deaths
USA Today
February 20, 2014

Several states have expanded access to naloxone. Seventeen17 states and the District of Columbia have passed "Good Samaritan" laws that grant limited immunity to drug users who seek help for someone who has overdosed. Other strategies include mandatory use of prescription drug monitoring programs.

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Other State and Local News

Regulation, Suboxone Clinics, and Unintended Consequences Re: Prescription Drug Abuse and the Affordable Care Act
National Law Review
February 19, 2014

This article, written by a law firm, discusses the possibility that overdose death declined in Kentucky because of its regulations and the establishment of addiction recovery services. It argues that it is not economically viable for a single physician to establish a fulltime practice that solely provides addiction-recovery services. The Affordable Care Act has rendered addiction medicine services more complicated. Kentucky's Department of Medicaid Services has expanded its coverage of physician services for managing substance disorders and established fee schedules. Rather than incentivizing physicians to provide addiction medicine services, the Department of Medicaid has established a schedule payment of $21.53 for physicians to treat these substance disorders. Physicians cannot afford to treat these patients at that fee, much less provide the supporting services such as assessment, development of treatment plans, counseling, and the monitoring that lead to a successful recovery.

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Mallory Powell. 2014. "Drug Overdose Deaths, Hospitalizations, and Emergency Department Visits in Kentucky, 2000–12." Kentucky Injury Prevention and Research Center January.

This report analyzes drug overdose morbidity and mortality among Kentucky residents and documents the societal and financial toll on the commonwealth's population. Overall, overdose deaths and emergency room (ER) visits leveled off from 2011 to 2012, and the contribution of prescription opioids and benzodiazepines to drug overdoses decreased. In 2012, there were 6,496 overdose ER visits and 1,031 overdose deaths, compared with 6,492 and 1,022, respectively, in 2011. Pharmaceutical opioids remained the primary cause of overdose deaths in the state. Benzodiazepines remained the primary drugs involved in overdose ER visits and hospitalizations, but decreased 9 percent from a high of 939 visits in 2011 to 856 visits in 2012. Intent to self‐harm was the primary reason for hospitalizations attributable to overdose, similar to years 2000–11. Heroin-involved overdose deaths increased to 129 in 2012, from 42 in 2011. Heroin-related inpatient hospitalizations rose 174 percent, and ER visits rose 197 percent.

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Expert: Kentucky Prescription Drug Abuse Law Has Unintended Consequences
Partnership at Drugfree.org
February 19, 2014

William T. Fannin, an addiction medicine specialist, discusses Kentucky's House Bill 1 that is designed to reduce prescription drug abuse. It requires that all pain clinics be licensed, specifies requirements for ownership and employment, and obliges Kentucky's licensure board to develop regulations for pain clinics. It gives law enforcement easier access to the state's prescription drug monitoring database. Before writing prescriptions for opioids, doctors must examine patients, take full medical histories, screen for drug use, and check the electronic prescription database. The law also requires continuing medical education for doctors authorized to prescribe or dispense controlled substances relating to the use of the state prescription monitoring database, pain management, and addiction disorders. While the new law calls for continuing medical education for physicians who prescribe opioids, Dr. Fannin says it does not go far enough. He recommends adding training that advises doctors what to do when a drug test comes back positive.

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Special Report: Vermont Spends Millions on Addiction-Fighting Drug That Is Diverted for Street Sale
Brattleboro Reformer
February 16, 2014

Vermont lawmakers are considering legislation to crack down on buprenorphine diversion. Last year, the state spent $8.25 million in Medicaid money on buprenorphine, a narcotic prescribed to help overcome dependency on opiates. Some addicts sell their medication on the street to buy cheaper drugs. Hundreds of addicts in Vermont are waiting to see a doctor who can prescribe buprenorphine. State officials know there are not enough doctors prescribing buprenorphine. They also know about buprenorphine trafficking and have systems in place to curb it. State officials say they are encouraging more doctors to prescribe buprenorphine because of the long waitlists. They are asking those who already prescribe to accept more patients. Problematically, doctors prescribe too much buprenorphine or do not oversee patient care with enough scrutiny. Buprenorphine for the past two years has ranked third for the most frequently trafficked prescription drug in the state, accounting for 11 percent of all diversion cases in 2013. Last year, the state police worked 236 cases, up 163 from the prior year. The Senate Judiciary Committee asked its attorney to draft an amendment about buprenorphine diversion to add to a bill the committee is considering related to opiates. The new legislation would require more doctors to provide counseling services to buprenorphine patients. It would also lower the threshold for medication-assisted therapy regulations. Doctors with as few as 10 patients taking buprenorphine would be subject to the state rules. The committee wants to require out-of-state doctors who accept Vermont Medicaid to log their prescriptions in the Vermont Prescription Monitoring System. Lawmakers say they also want to encourage the pharmaceutical company to create more tamper-resistant packaging.

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Killing Pain
(Toledo, Ohio) Blade
February 16, 2014

This editorial discusses prescription drug abuse leading to heroin use in Ohio. An estimated 8 out of 10 heroin addicts started their addiction with prescription opioids. Ohio will need education efforts aimed at physicians, patients, and the public along with treatment programs for those who are already addicted. Medical school curricula and clinical practice must include far more instruction on opioid dependence. State medical boards ought to require a minimum amount of continuing education on addiction for physicians. State law should require pharmacies to distribute warnings with opiate prescriptions. The editorial concludes that expanding treatment options and raising awareness of the dangers of opioid addiction must become even higher priorities for Ohio this year.

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Students Take Adderall to Cope and Concentrate on University Workload
February 19, 2014

This article discusses Adderall misuse on college campuses. It also mentions the risks for using the drug. Some students use Adderall to help them concentrate. The Eastern Washington University (EWU) Director of Health, Wellness, and Prevention Center said studies indicated that Adderall usage is not linked to better grades. EWU Detective Quincy Burns reminds students that it is illegal to use someone else's prescription and a felony to sell prescription medicine.

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Campus: Neurochemical Advantage?
February 12, 2014

This article discusses stimulant abuse among college students at Purdue University and the risks of using drugs such as Adderall.

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Why Georgia Desperately Needs Naloxone
Huffington Post
February 18, 2014

This article discusses how Narcan saved Kathy Fletcher's life twice from an accidental overdose. One day, she took her regular dose of Oxycontin and then suddenly she felt strange. Her friend took her to a primary care physician, who soon realized that Kathy had had a drug overdose. She was rushed to the local hospital and given Narcan, which reversed her opiate overdose. The doctors concluded that the overdose had been caused by a defective coating on the Oxycontin pill she had taken; instead of releasing the medication over a 12-hour period, the pill released it all at once. During the second incident, Kathy was in the hospital lobby waiting to go home after a month-long stay recovering from radiation treatment. She took the exact dose of Oxycontin the doctors had prescribed, and she overdosed again. She was rushed to the intensive care unit for Narcan. No one knows for sure why Kathy overdosed, but it was likely caused by a change in her body's chemistry after the cancer treatment. Kathy still takes Oxycontin to cope with pain. But now she keeps a vial of naloxone (obtained from an overdose prevention program in North Carolina) at home and has trained her 25-year-old son and her best friend to recognize an overdose and administer the medication. Georgia has not adopted laws that make naloxone easier to access. Georgia lawmakers have introduced 9–1–1 Good Samaritan and naloxone legislation in 2014.

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ER Doctor Reports Treating Patients Who Have Used Heroin Laced With Prescription Drug
February 17, 2014

This article and video (2 minutes, 13 seconds) discuss doctors in Colorado treating patients who have used heroin combined with fentanyl. Donald Ross Patrick, an emergency medicine physician at Parkview Medical Center, said the heroin problem is directly related to prescription drug abuse.

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Senate Approves Bill for Drug Overdose Antidote
February 20, 2014

The Ohio Senate has passed House Bill 170, which would provide friends and family of addicts with naloxone, a drug used to reverse an overdose of heroin and other opioid-type drugs. The bill also authorizes law enforcement and other first responders to carry naloxone. The bill now returns to the House for consideration of changes made in the Senate. Senate Bill 57 established a pilot project in Lorain County, Ohio, to study the impact of giving law enforcement officers the ability to administer Narcan to overdose victims. The Lorain County Alcohol and Drug Addiction Services Board reported the drug has been credited with saving at least 15 lives.

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'Alarming' Rise Seen in Drug-Addicted Infants
New Hampshire Union Leader
February 15, 2014

New Hampshire has seen an increase in babies born addicted to opioid, a condition known as Neonatal Abstinence Syndrome (NAS). Dr. William H. Edwards, section chief of neonatology at Children's Hospital, said that reported incidents of addicted babies increased 600 percent in six years, from 2003 to 2009. The New Hampshire Bureau of Drug and Alcohol Services and the New Hampshire Charitable Foundation reported that, in 2009, NAS was diagnosed in 116 infants, more than five times as many as in 2000. The rise in addicted mothers and babies coincides with rising incidents of prescription drug abuse and heroin use. Four hospitals in New Hampshire treat newborns with withdrawal symptoms. Babies with severe addictions are treated in Dartmouth–Hitchcock Medical Center's neonatal intensive care unit, where they are given doses of liquid morphine. In August, the governor created the Prenatal Substance Exposure Task Force to examine issues related to NAS. The task force has concentrated on developing statewide procedures for hospitals to respond to NAS.

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Bill to Combat Prescription Drug Abuse Becomes Law
State of Delaware
February 20, 2014

Delaware's governor signed House Bill 154 into law, which aims to reduce illegal prescription drug diversion. The measure creates a new criminal offense of "Medication Diversion" that applies to anyone who intentionally diverts prescription narcotics from patients who are under the care of a healthcare program in medical or other 24-hour facilities such as hospitals, group homes, or nursing homes. This felony-level charge subjects offenders to potential jail time and, if convicted, places them on the Adult Abuse Registry and professional licensing discipline.

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Feds Launch Tip Line for Prescription Drug Abuse
February 20, 2014

The Drug Enforcement Administration launched a prescription drug abuse tip line in Georgia to allow pharmacy industry professionals and the public to make anonymous reports.

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Study Drugs: Students Turn to ADHD Medicine for Academic Boost
February 18, 2014

This article and video (3 minutes, 55 seconds) discuss the nonmedical use of stimulant drugs with a student at Auburn University. She illegally obtains Adderall to study for tests. She gets the drug from her roommate's medicine cabinet.

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Dangers of Not Taking Prescription Medicine Properly
February 19, 2014

This article and video (1 minute, 49 seconds) report on Univera Healthcare's announcement about its new multimedia campaign to inform the public of the dangers associated with not taking prescription drugs properly. It will include billboards, radio and TV spots, and advertisements in local newspapers. TAD, the "Take as Directed" superhero, is stylized as a prescription bottle with a cape and utility belt. TAD conveys a message: "If you're not taking your prescriptions as directed, you're taking a chance."

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Invisible Epidemic: Prescription Drugs Cause Most Overdoses
February 19, 2014

This article and video (4 minutes, 30 seconds) discuss overdose death and prescription drug abuse. A reporter interviews three former addicts who had difficulties getting off of pain relievers. Georgia legislators are considering two bills in committee to reduce overdose deaths. One would grant immunity from prosecution to those who report an overdose to police. The other bill would remove civil liabilities for doctors who prescribe naloxone.

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West Virginia Attorney General Teams With Law Enforcement to Battle Rx Drug Abuse
February 18, 2014

West Virginia Atty. Gen. Patrick Morrisey announced that his office is teaming with law enforcement agencies across the state to fight the prescription drug abuse epidemic. They plan to expand access to secure disposal locations for unwanted or expired prescription drugs. Morrisey will send a letter to law enforcement agencies, giving them the opportunity to apply for permanent prescription drug disposal boxes.

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Other Resources

Accessed February 17, 2014

The AAA Foundation for Traffic Safety developed Roadwise Rx, a free online tool designed to allow individuals to record prescription and over-the-counter medications in one central location.

The tool generates personalized feedback on how medications, herbal supplements, and foods interact with one another and how they can affect safety behind the wheel. Drivers are encouraged to discuss the confidential results with their doctor or pharmacist to learn how to mitigate possible crash risks.

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Prescription Painkillers Sold in the United States
Boston Globe
February 19, 2014

This map shows the pounds of prescription pain relievers sold per 10,000 people in 2010. It also lists the data by state.

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Which Drug Is Your State Most Addicted to? America's Drug Problem, Mapped
Policy Mic
February 11, 2014

This map depicts the drug was most commonly cited among primary drug treatment admissions in each state. Alcohol is not included in the data.

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The Parent's 20-Minute Guide
Center for Motivation and Change
Accessed February 18, 2014

The Parent's 20-Minute Guide was written for parents who want to help, stay involved, and provide a loving environment for their children. Based on the research-supported CRAFT (Community Reinforcement and Family Training) approach, the guide provides specific strategies and ideas for parents to help prevent and constructively address substance abuse issues with their children, ranging from first experimentations to behavior that requires formal treatment.

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Safe Use, Storage, and Disposal of Opioid Drugs
Family Doctor
July 2013

This fact sheet gives an overview of opioids. It includes signs of overmedication or overdose and what to do if either happens. Also, it discusses how to safely store and dispose of opioids. The primer lists the "Dos and Don'ts" of opioid use.

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The Generation Rx Initiative
The Ohio State University, College of Pharmacy
Accessed February 20, 2014

This Web site provides medication safety and prescription drug abuse prevention resources for schools, colleges, and communities. Links are provided to various external resources and to materials developed at The Ohio State University College of Pharmacy. Everyone is encouraged to use any of these resources that may be helpful. The developers are interested in partnering with other groups to enhance medication safety and prescription drug abuse prevention.

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Generation Rx Toolkits
The Ohio State University, College of Pharmacy
Accessed February 20, 2014

The Cardinal Health Foundation and The Ohio State University College of Pharmacy developed toolkits for prescription drug abuse prevention and medication safety for youths, teens, college students, other adults, and seniors.

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Webinar Archive

RECORDED WEBINAR: Preventing Prescription Drug Abuse Among Adolescents: The Role of Poison Control Centers
Colorado's Violence and Injury Prevention Network
February 17, 2014

This Webinar explores poison control centers as a resource to prevent and treat drug overdoses among adolescent populations and introduces participants to the work poison centers are undertaking to educate teens and their families about prescription drug misuse.

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Path From Pain Pills to Heroin Addiction Nothing New in San Diego County
February 17, 2014

This video (6 minutes, 40 seconds) and audio (17 minutes, 28 seconds) discuss prescription drug abuse and heroin use in San Diego County, Calif.. The host speaks to Los Angeles Times reporter Sam Quinones of, who has cover heroin and prescription drug abuse extensively, and Sherrie Rubin, executive committee member for the San Diego County Prescription Drug Abuse Task Force and founder of the Hope2gether Foundation. Rubin's Aaron overdosed on prescription pain pills a few years ago. He now is quadriplegic and requires 24-hour care.

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The Right Way to Handle Prescription Drugs
February 16, 2014

In the Our Doctor Is In segment, Dr. Vijay Bindingnavele discusses prescription drugs and what people should and should not do with their medicines. [Duration: 2 minutes, 45 seconds)


Grant Announcements

Research to Prevent Prescription Drug Overdoses
Centers for Disease Control and Prevention, Department of Health and Human Services
Letter of Intent Deadline: February 14, 2014
Proposal Deadline: 5:00 p.m. (EST), March 19, 2014
http://www.grants.gov/search-grants.html?agencies percent3DHHS percent7CDepartment percent20of percent20Health percent20and percent20Human percent20Services

Research on Integration of Injury Prevention in Health Systems
Centers for Disease Control and Prevention, Department of Health and Human Services
Letter of Intent Deadline: February 14, 2014
Proposal Deadline: 5:00 p.m. (EST), March 19, 2014
http://www.grants.gov/search-grants.html?agencies percent3DHHS percent7CDepartment percent20of percent20Health percent20and percent20Human percent20Services

2014 Drug-Free Communities Support Program Grants
White House Office of National Drug Control Policy and Substance Abuse and Mental Health Services Administration
Deadline: March 24, 2014

Take-Back Events and Drop Boxes

Windham County, Vt., Prescription Drug Disposal Locations
Accessed February 19, 2014

Prescription Drug Collection Box Helping Rid Romulus, Mich., Streets of Dangerous Medicines
February 18, 2014

Middletown Police Have Drop Box for Expired Prescription Drugs
Providence (R.I.) Journal
February 18, 2014

Safe Medicine Disposal for Maine Program
University of Maine
Accessed February 18, 2014

Save the Dates

National Take-Back Initiative
Drug Enforcement Administration
10:00 a.m. to 2:00 p.m.
April 26, 2014

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

Upcoming Conferences and Workshops

Collaborative Perspectives on Addiction: 'Changing Addictive Behavior: Bench to Bedside and Back Again'
February 28 to March 1, 2014
Atlanta, Georgia

Pain Management Through a Wide Lens: Balancing Safety and Effectiveness
March 8, 2014
St. Louis, Missouri

Eleventh Annual World Health Care Congress
April 7–9, 2014
National Harbor, Maryland

National Rx Drug Abuse Summit
April 22–24, 2014
Atlanta, Georgia

2014 Harold Rogers PDMP National Meeting
Brandeis University, Prescription Drug Monitoring Program Training and Technical Assistance Center
September 23–25, 2014
Marriot Metro Center
Washington, D.C.
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.


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