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January 7, 2016

PAW Weekly Update

    

                                          
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SAMHSA
           
SAMHSA Prescription Drug Abuse Weekly Update
         
         
WEEKLY
           
UPDATE
         
                             
 Issue 155  |  January 7, 2016          
   
                                                               
                                                                 
                                                                                                                   
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.                      
               
                                                                                                                 
                                                                                                                                                                     
                            Index                            
Featured                            
Journal Articles and Reports                            
Professional Development                            
National                            
Marijuana                            
International                            
Northeast/Mid-Atlantic News                            
South News                            
Midwest News                            
West News                            
Solicitation for Public Comment                            
Grant Announcements                            
Take-Back Events & Drop Boxes                            
Upcoming Conferences and Workshops                            
                       

Featured

 D.A. del Portal, M.E. Healy, W.A. Satz, and R.M. McNamara. 2016. “Pennsylvania Impact of an Opioid Prescribing Guideline in the Acute Care Setting.” Journal of Emergency Medicine, doi:10.1016/j.jemermed.2015.06.014.                        

Opioid prescriptions decreased significantly after a Philadelphia hospital in January 2013 implemented a voluntary opioid prescribing guideline in its emergency department. Researchers reviewed the charts of 13,187 adult patients and found the rate of opioid prescribing decreased from 52.7 percent before the guideline to 29.8 percent immediately after its introduction and to 33.8 percent in the first half of 2014. The decrease was observed in all diagnosis groups (dental, neck, back, and unspecified chronic pain) and all age groups. All 31 prescribing emergency physicians expressed support for the guideline.                        

Read more:                        
http://www.jem-journal.com/article/S0736-4679(15)00621-6/abstract                                                  

Where You Store Prescription Pain Relievers Is Important                        
Lisa Gill, Consumer Reports                        
December 25, 2015                        

More than 80 percent of people who take prescription medication do not lock up their narcotic pain relievers, according to a recent Consumer Reports survey of 2,000 people. Nearly three-quarters of people who take prescription medications also had children who live at home. The author recommends locking up narcotic medications and disposing of unused pills promptly and properly. (Includes video: 2:42 minutes)                        

Read more:                        
http://www.consumerreports.org/drugs/are-you-storing-your-prescription-pain-relievers-the-right-way                      
               
               

Journal Articles and Reports

C. Allen, A. Murphy, S. Kiselbach, S. VandenBerg, and E. Wiebe. 2015. “Exploring the Experience of Chronic Pain among Female Survival Sex Workers: A Qualitative Study.” BMC Family Practice 16:182, doi:10.1186/s12875-015-0395-6.                

In an analysis of 11 interviews conducted in Vancouver, Canada, with female sex workers (ages 42–56, mostly Native American, and all recruited through a peer support network) with chronic pain, themes that emerged included a sense of defeat as a consequence of persistent, debilitating pain; communication deficits of medical professionals (e.g., lack of respect, technical language) that discouraged accessing medical care even in emergency situations; polydrug use, including prescription misuse for pain management; easy access to opiates; and the need to continue working and lack of stable housing as barriers to adequately addressing the source of chronic pain.                

Read more:                
http://bmcfampract.biomedcentral.com/articles/10.1186/s12875-015-0395-6                                  

R. Ceasar, J. Chang, K. Zamora, E. Hurstak, M. Kushel, and C. Miaskowski. 2015. “Primary Care Providers’ Experiences with Urine Toxicology Tests to Manage Prescription Opioid Misuse and Substance Use Among Chronic Non-Cancer Pain Patients in Safety Net Healthcare Settings.” Substance Abuse doi:10.1080/08897077.2015.1132293.                

Researchers polled 23 primary care providers from six safety-net healthcare settings in the San Francisco area about management of patients with co-occurring chronic non-cancer pain and substance use. Perceived benefits of implementing urine toxicology tests included less reliance on intuition to assess misuse and the ability to identify unknown opioid or other substance misuse. Challenges of implementing urine toxicology tests included insufficient education and training about how to interpret and implement tests and a lack of clarity on how and when to act on tests that indicated misuse.                

Read more:                
http://www.tandfonline.com/doi/full/10.1080/08897077.2015.1132293                                  

Drug Overdose Deaths by State, 2013 and 2014                
Centers for Disease Control and Prevention                
December 18, 2015                

Opioid-driven drug overdose death rates in 2014 increased significantly in the Northeast, Midwest, and South Census regions. From 2013 to 2014, rates increased significantly in Alabama, Georgia, Illinois, Indiana, Maine, Maryland, Massachusetts, Michigan, New Hampshire, New Mexico, North Dakota, Ohio, Pennsylvania, and Virginia. In rank order, West Virginia, New Mexico, New Hampshire, Kentucky, and Ohio had the highest drug overdose death rates.                 

Read more:                
http://www.cdc.gov/drugoverdose/data/statedeaths.html                                  

L.B. Cottler, H. Hu, B.A. Smallwood, J.C. Anthony, LT. Wu, and W.W. Eaton. 2015. “Nonmedical Opioid Pain Relievers and All-Cause Mortality: A 27-Year Follow-Up from the Epidemiologic Catchment Area Study.” American Journal of Public Health, doi:10.2105/AJPH.2015.302961.                

Researchers linked 1981–83 Epidemiologic Catchment Area Program interviews with 9,985 adults in Baltimore, St. Louis, and Durham, North Carolina, to National Death Index data through 2007. Only 1.4 percent had a history of nonmedical prescription opioid pain reliever use in 1981–83. Compared with those with no nonmedical prescription drug use, mortality through 2007 was higher for nonmedical opioid pain reliever users (hazard ratio [HR] = 1.6), nonmedical users of other drugs (HR = 1.3), and beginning nonmedical opioid pain reliever use before age 15 (HR = 2.5).                

Read more:                
http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2015.302961                                  

R.C. Dart, H.L. Surratt, M-C. Le Lait, Y. Stivers, V.S. Bebarta, C.C. Freifeld, J.S. Brownstein, J.J. Burke, S.P. Kurtz, and N. Dasgupta. 2015. “Diversion and Illicit Sale of Extended Release Tapentadol in the United States.” Pain Medicine, doi:10.1093/pm/pnv032 pnv032.                

For a study funded by a manufacturer of tapentadol (a Schedule II prescription opioid pain reliever), researchers analyzed drug diversion program data from 260 drug diversion investigators in 49 states and data from the StreetRx system on street prices for licit and illicit drugs. Rates of diversion were 0.03 per 1,000 prescriptions dispensed for tapentadol immediate release (IR), 0.016 for tapentadol extended release (ER), and 0.172 for other Schedule II opioid tablets. The median street price per milligram was $0.18 for tapentadol IR, $0.10 for tapentadol ER, and $1.00 for other Schedule II opioid tablets.                

Read more:                
http://painmedicine.oxfordjournals.org/content/early/2015/12/14/pm.pnv032                                  

P. Dilokthornsakul1, G. Moore, J.D. Campbell, R. Lodge, C. Traugott, J. Zerzan, R. Allen, R.L. Page II. 2015. “Risk Factors of Prescription Opioid Overdose among Colorado Medicaid Beneficiaries.” Journal of Pain, doi:10.1016/j.jpain.2015.12.006.                

A retrospective case-control study selected 2,448 controls matched on age, gender, and opioid prescription to 816 Colorado Medicaid beneficiaries who had a medical claim for an emergency department visit or hospitalization associated with opioid overdose between July 2009 and June 2014. Multivariate analysis found six factors were associated with opioid overdose: mean morphine dose equivalent >50 mg/day (odds ratio [OR] = 2.0), switching opioid to methadone versus no methadone use (OR = 7.2), drug/alcohol abuse (OR = 3.1), other psychiatric illness (OR = 1.7), benzodiazepine use (OR = 2.0), and four or more pharmacies used by the beneficiary (versus just one pharmacy; OR = 1.5).                 

Read more:                
http://www.jpain.org/article/S1526-5900(15)00985-2/abstract                                  

J. Fogela and A. Shlivko. 2015. “Reality Television Programs are Associated with Illegal Drug Use and Prescription Drug Misuse among College Students.” Substance Use & Misuse, doi:10.3109/10826084.2015.1082593.                

A 2011 survey of 576 New York City undergraduate college students found that watching reality television, identifying with reality TV program characters, and following a reality TV character on Twitter were each associated with greater odds of illegal drug use. Following a character also was associated with greater odds of prescription drug misuse. Students born in the United States had greater odds for illegal and prescription drug misuse. Female and Asian students had lower odds for illegal drug use. African American and Asian students had lower odds for prescription drug misuse.                

Read more:                
http://www.tandfonline.com/doi/full/10.3109/10826084.2015.1082593                                 

S. Lake and M.C. Kennedy. 2015. “Health Outcomes Associated with Illicit Prescription Opioid Injection: A Systematic Review.” Journal of Addictive Diseases, doi:10.1080/10550887.2015.1127712.                

Prescription opioid injection is associated with hepatitis C infection, substance dependence and other mental health indicators, and lower general health, according to a systematic review of 31 studies. Associations with HIV, overdose, and cutaneous infection were less consistent and varied according to prescription opioid type.                

Read more:                
http://www.tandfonline.com/doi/abs/10.1080/10550887.2015.1127712                                  

M.R. Larochelle, J.M. Liebschutz, F. Zhang, D. Ross-Degnan, and J.F. Wharam. 2015. “Opioid Prescribing After Nonfatal Overdose and Association with Repeated Overdose: A Cohort Study.” Annals of Internal Medicine, doi:10.7326/M15-0038.                

Researchers analyzed claims data from a large U.S. health insurer for 2,848 patients ages 18–64 who had a nonfatal opioid overdose during long-term opioid therapy for non-cancer pain. Over a median follow-up of 299 days, opioids were dispensed to 91 percent of patients after an overdose. Seven percent overdosed again. At 2 years, the cumulative incidence of repeated overdose was 17 percent for patients prescribed high dosages of opioids after the index overdose, 15 percent for those prescribed moderate dosages, 9 percent for those prescribed low dosages, and 8 percent for those not prescribed opioids.                

Read more:                
http://annals.org/article.aspx?articleid=2479117                                  

C. Leonardi, R. Vellucci, M. Mammucari, and G. Fanelli. 2015. “Opioid Risk Addiction in the Management of Chronic Pain in Primary Care: The Addiction Risk Questionnaire.” European Review for Medical Pharmacological Sciences 19 (24): 4898–905.                

Researchers propose a 28-item questionnaire for general practitioner use in preliminary evaluation addiction risk of patients with chronic pain. The questionnaire has not yet been tested.                

Read more:                
http://www.europeanreview.org/article/10048                                 

R. Lev, S. Petro, J. Lucas, A. Stuck, G.M. Vilke, and E.M. Castillo. 2015. “A Description of Medical Examiner Prescription Related Deaths and Prescription Drug Monitoring Program Data.” The American Journal of Emergency Medicine, doi:10.1016/j.ajem.2015.12.023.                

Combining 2013 San Diego Medical Examiner data on 254 unintentional prescription-related deaths with data from the California Prescription Drug Monitor Program (PDMP) revealed that 73 percent had been prescribed controlled substances in the 12 months prior to death. Ingesting prescription medications with illicit drugs, alcohol, or over-the-counter medications accounted for 40 percent of the unintentional deaths. Opioids were responsible for the majority of single medication deaths (71 percent). Of patients with PDMP data, 69 percent were chronic prescription users, average number of prescriptions was 23.5 per patient, and the average patient used 3 pharmacies and had 4.5 providers.                

Read more:                
http://www.ajemjournal.com/article/S0735-6757(15)01079-7/abstract                                  

S.P. Novak, R. Bluthenthal, L. Wenger, D. Chu, and A.H. Kral. 2015. “Initiation of Heroin and Prescription Opioid Pain Relievers by Birth Cohort.” American Journal of Public Health, doi:10.2105/AJPH.2015.302972.                

People who inject drugs born after 1980 are more likely than ones born before 1980 to initiate opioids through nonmedical use of prescription opioids rather than heroin, according to a survey of 483 people who injected drugs in Los Angeles and San Francisco and contemporaneous National Survey on Drug Use and Health data. Study findings align with changes in prescribing patterns, showing that more favorable prescription opioid prescribing was associated with population-level changes in ways that people started using opioids.                 

Read more:                
http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2015.302972                                 

S.P. Novak, N.C. Peiper, and G.A. Zarkin. 2015. “Nonmedical Prescription Pain Reliever and Alcohol Consumption among Cannabis Users.” Drug and Alcohol Dependence, doi:10.1016/j.drugalcdep.2015.11.039.                

Higher levels of cannabis use were associated with more frequent consumption of prescription pain relievers in 2003 and 2013, according to National Survey on Drug Use and Health data. The prevalence of dual users was 2.5 percent in 2003 and 2.3 percent in 2013. Average days of dual use per dual user increased by 20 days. Changes largely occurred among people who were age 35 or older, male, white, and non-illicit drug users. Past-year marijuana use increased from 10.8 percent to 12.6 percent while nonmedical prescription pain reliever use decreased from 4.9 percent to 4.2 percent. The largest changes occurred after 2011. People who used the most cannabis generally drank more alcohol than those who used the least amount.                

Read more:                
http://www.drugandalcoholdependence.com/article/S0376-8716(15)01819-0/abstract                                 

G.M. Oderda, J. Lake, K. Rüdell, C.L. Roland, and E.T. Masters. 2015. “Economic Burden of Prescription Opioid Misuse and Abuse: A Systematic Review.” Journal of Pain & Palliative Care Pharmacotherapy 29(4):388–400.                

A systematic review of 2009–14 publications identified 16 that examined the cost of prescription opioid misuse and misuse disorders to payers. Annual health care costs to third-party payers for insured people with opioid misuse disorders averaged $23,000–$25,000, about $15,000 per person more than costs for other insured people. Three papers presented societal costs, including criminal justice costs and costs associated with lost productivity, with the best U.S. estimate in excess of $50 billion annually.                

Read more:                
http://europepmc.org/abstract/med/26654413                                  

E.M. Oliva, A. Nevedal, E.T. Lewis, M.D. McCaa, M.F. Cochran, P.E. Konicki, C. S. Davis, and C. Wilder. 2015. “Patient Perspectives on an Opioid Overdose Education and Naloxone Distribution Program in the U.S. Department of Veterans Affairs.” Substance Abuse, doi:10.1080/08897077.2015.1129528.                

Four focus groups between December 2014 and February 2015 convened 21 patients, from a Department of Veterans Affairs residential facility in California, who were trained in Opioid Overdose Education and Naloxone Distribution (OEND). Veterans thought OEND training was interesting, novel, and empowering, and that naloxone kits will save lives. Some veterans expressed concern about using syringes in the kits. A few patients who never used opioids were not interested in receiving kits. Veterans had differing opinions about legal and liability issues, whether naloxone kits might contribute to relapse, and whether and how to involve family in training. Some veterans expressed uncertainty about the effects of naloxone. Suggested improvements included active learning approaches, enhanced training materials, and increased advertisement.                

Read more:                
http://www.tandfonline.com/doi/full/10.1080/08897077.2015.1129528                                  

J. Salas, J.F. Scherrer, P.J. Lustman, and F.D. Schneider. 2015. “Racial Differences in the Association between Non-Medical Prescription Opioid Use, Abuse/Dependence and Major Depression.” Substance Abuse, doi:10.1080/08897077.2015.1129523.                

A simplistic univariate analysis of 2012–13 National Survey on Drug Use and Health data showed white and black respondents had similar past-year prevalence of non-medical prescription opioid use (3.7 percent versus 3.5 percent) and misuse disorder (0.9 percent versus 0.7 percent). Major depressive episodes were significantly more prevalent among white respondents than black respondents (7.4 percent versus 5.5 percent). Among white respondents, but not black respondents, nonmedical use and use disorders correlated with depressive episodes.                

Read more:                
http://www.ncbi.nlm.nih.gov/pubmed/26675823                                  

S. Sattler and R. Schunck. 2015. “Associations between the Big Five Personality Traits and the Non-Medical Use of Prescription Drugs for Cognitive Enhancement.” Frontiers in Psychology 6:1971, doi:10.3389/fpsyg.2015.01971.                

A 2012–13 telephone survey (with a 30-percent response rate) of a 6,454 employees in Germany found a 3.0 percent lifetime prevalence of cognitive enhancement drug use and 10.4 percent willingness to (re)use the drugs in the future. Less conscientious and more neurotic respondents had a higher probability of prior cognitive enhancement drug use and a greater willingness to use cognitive enhancement drugs in the future.                

Read more:                
http://journal.frontiersin.org/article/10.3389/fpsyg.2015.01971/abstract                                  

M.R. Shaw, C. Lederhos, M. Haberman, D. Howell, S. Fleming, and J. Roll. 2016. “Nurses’ Perceptions of Caring for Childbearing Women who Misuse Opioids.” American Journal of Maternal Child Nursing 41(1):37–42, doi:10.1097/NMC.0000000000000208.                

Semi-structured interviews with eight inpatient obstetric nurses who work in large, urban birthing centers in Washington drew comments on four themes: needing more knowledge about how to care for childbearing women on opioids, feeling challenged, expressing concern for mother and infant, and distinguishing truth from deceit.                

Read more:                
http://journals.lww.com/mcnjournal/Abstract/2016/01000/Nurses__
Perceptions_of_Caring_for_Childbearing.6.aspx
                                  

S.G. Weiner, L.C. Horton, T.C. Green, and S.F. Butler. 2015. “A Comparison of an Opioid Abuse Screening Tool and Prescription Drug Monitoring Data in the Emergency Department.” Drug and Alcohol Dependence, doi:10.1016/j.drugalcdep.2015.12.007.                

Among 92 Boston emergency department patients considered for discharge with a prescription for an opioid pain medication, 88 percent agreed to complete the Screener and Opioid Assessment for Patients with Pain. Among those who completed the screener, 33 percent were identified as possible misuses. Among the 16 percent that prescription drug monitoring program screening suggested might have disorders, 54 percent screened as at-risk. The screener had modest sensitivity (54 percent) and specificity (71 percent). Its positive predictive value was just 26 percent, and its negative predictive value was 89 percent.                

Read more:                
http://www.drugandalcoholdependence.com/article/S0376-8716(15)01822-0/abstract                                 

M.B. Weimer, D.M. Hartung, S. Ahmed, and C. Nicolaidis. 2015. “A Chronic Opioid Therapy Dose Reduction Policy in Primary Care.” Substance Abuse, doi:10.1080/08897077.2015.1129526.                

An Oregon academic primary care clinic implemented a provider education intervention and a 120 mg morphine equivalent per day opioid dose limitation policy on May 15, 2012. The policy stated that patients prescribed doses over 120mg needed to initiate an opioid taper unless the prescriber asked for an exception. New clinic patients prescribed doses in excess of 120mg would be accepted if they agreed to a more expeditious (3–6 month) opioid taper. Of 516 patients prescribed chronic opioid therapy in January through August 2011, 116 were prescribed high-dose opioid therapy. Of 112 still in the practice when the policy was implemented, 41 tapered their doses below 120 mg. Average daily dose of opioids declined by 64 mg per day under the policy. Multivariate analysis showed female patients were less likely to taper to a safer dose.                

Read more:                
http://www.tandfonline.com/doi/abs/10.1080/08897077.2015.1129526                                  

E.L. Winstanley, A. Clark, J. Feinberg, and C.M. Wilder. 2015. “Barriers to Implementation of Opioid Overdose Prevention Programs in Ohio.” Substance Abuse, doi:10.1080/08897077.2015.1132294.                

A late 2014 survey of 18 of Ohio’s 20 opioid overdose prevention programs found that one opened in 2012, another in 2013, and 16 in 2014. All but two distribute their nasal naloxone kits for free. Six are funded by the Ohio Department of Health, three by a local health foundation, and others a variety of public and private sources. In total, they had funding to distribute 8,670 overdose kits and had distributed 1,998 by October 2014. Fifteen programs reported implementation barriers, including stigma, cost, staffing, legal, regulatory and client-related problems. Recent legislative fixes should remove obstacles.                

Read more:                
http://www.tandfonline.com/doi/full/10.1080/08897077.2015.1132294                
               

Professional Development

Academy of Managed Care Pharmacy Partnership Forum. 2015. “Proceedings of the AMCP Partnership Forum: Breaking the Link between Pain Management and Opioid Use Disorder.” Journal of Managed Care Specialty Pharmacy 21(12):1116–22.                

A September 2014 Academy of Managed Care Pharmacy meeting recommended activities and programs that it can promote to improve pain management, prevent opioid use disorder, and improve medication-assisted treatment outcomes. Recommendations included conducting continuing pharmacy education programs, developing a best practices toolkit on pain management, and actively promoting quality standards for opioid use disorder prevention and treatment.                

Read more:                
http://www.ncbi.nlm.nih.gov/pubmed/26679961                                  

B. Meshkin, K. Lewis, S. Kantorovich, N. Anand, and L. Davila. 2015. “Adding Genetic Testing to Evidence-Based Guidelines to Determine the Safest and Most Effective Chronic Pain Treatment for Injured Workers.” International Journal of Biomedical Science 11(4), 157–65.                

The authors propose the addition of genetic testing to consensus guidelines for treating injured workers to improve patients’ functional status, increase productivity, improve safety of prescribing, decrease likelihood of substance use, and reduce healthcare costs. They describe challenges facing chronic non-cancer pain claimants and clinicians and describe how genetic information may guide treatment decisions and, thus, result in better outcomes for injured workers with chronic non-cancer pain.                

Read more:                
http://www.ijbs.org/User/ContentFullTextFrame.aspx?VolumeNO=11&StartPage=157                 
               

 National

 2016 Workplace Safety Predictions: An Outlook on Managing Risks                
Liz Griggs, Canterbury Healthcare                
December 30, 2015                

Trends that companies need to be aware of to mitigate business liabilities and risks in 2016 include opioid addiction; psycho-social, depression, and obesity issues; predictive analytics and big data, and temporary and contractor worker liabilities. To prevent drug misuse and addiction, the author suggests businesses should increase injury prevention efforts to prevent injuries that often trigger the addiction cycle. Simple prevention solutions include work site evaluations, on-the-job fitness solutions, functional job analysis, and on-site ergonomics training.                 

Read more:                
https://ohsonline.com/blogs/the-ohs-wire/2015/12/2016-workplace-safety-predictions.aspx                                  

The Opioid Overdose Epidemic and the Workplace                
Dawn Castillo and John Howard, National Institute for Occupational Safety and Health Science Blog                
December 21, 2015                

The National Institute for Occupational Safety and Health (NIOSH) has compiled resources that may be useful for workers, employers, and healthcare providers on its website to address prescription drug overdose prevention. It welcomes suggestions for additional resources and relevant research that might be addressed through the NIOSH Center for Workers’ Compensation Studies. NIOSH also encourages interested stakeholders to provide input on the Centers for Disease Control and Prevention’s draft opioid prescribing guidelines.                 

Read more:                
http://blogs.cdc.gov/niosh-science-blog/2015/12/21/opioid-overdose                                  

2015: What Kept Us Up At Night and What Will Keep Us Busy in 2016                
Centers for Disease Control and Prevention                
December 21, 2015                

In 2015, the Centers for Disease Control and Prevention focused efforts on prescription drug overdose. In 2016, it plans to finalize its opioid prescribing guideline for chronic pain. It will also provide all 50 states with funding for the Prevention for States program to better track opioid and heroin abuse and deaths and investigate health emergencies related to opioid misuse.                

Read more:                
http://www.cdc.gov/media/dpk/2015/dpk-eoy.html                                  

Report: Construction Workers Use Most Opioid Pain Relievers                
Johanna Knapschaefer, Engineering News-Record                
December 30, 2015                

CNA Financial reported that construction workers use opioid pain relievers more than any other workers. Spending on these prescription pain relievers is 5–10 percent higher in construction than in all other industries combined (see weekly update July 9, 2015 for report.) The report recommends employers combat opioid misuse through prevention, including educating employees about responsible use of prescription opioids; understanding and communicating risk factors of opioid abuse; and providing support and safe return to work for injured employees.                

Read more:                
http://www.enr.com/articles/38523-report-construction-workers-use-most-opioid-painkillers                                  

Doping Cops Take Aim at Amateur Athletes                
Frederick Dreier, Wall Street Journal                
December 23, 2015                

The U.S. Anti-Doping Agency has sanctioned at least 20 amateur cyclists and 3 amateur triathletes in the past 4 years for testing positive, skipping drug tests or purchasing drugs. Four bans have been issued since October against amateur athletes. The average amateur faces little chance of being tested; only overall winners or age-group winners are targeted. In 2016, Ironman triathlons and many amateur bicycle races plan to increase testing of elite-performing amateurs. USA Cycling plans to triple the number of drug tests at amateur events.                 

Read more:                
http://www.wsj.com/articles/doping-cops-take-aim-at-amateur-athletes-1450913174                                  

Health Plans Share Best Practices to Combat Opioid Abuse                
Margaret Murray, Managed Healthcare Executive                
December 22, 2015                

The Association for Community Affiliated Plans convened representatives from 13 safety-net health plans to address prescription drug misuse, particularly opioids. This article lists strategies used and lessons learned by the plans. Some include screening, brief intervention, and referral to treatment and medication-assisted treatment.                

Read more:                
http://managedhealthcareexecutive.modernmedicine.com/managed-healthcare-executive/news/health-plans-share-best-practices-combat-opioid-abuse?page=0,0                
                 

Marijuana

K. Guttmannova, C.M. Lee, J.R. Kilmer, C.B. Fleming, I.C. Rhew, R. Kosterman, and M.E. Larimer. 2015. “Impacts of Changing Marijuana Policies on Alcohol Use in the United States.” Alcoholism: Clinical and Experimental Research, doi:10.1111/acer.12942.                  

Published research literature provides some evidence that liberalization of U.S. marijuana policies causes substitution of marijuana for alcohol and increased use of both substances in combination.                  

Read more:                  
http://onlinelibrary.wiley.com/doi/10.1111/acer.12942/abstract                                      

T. Subritzky, S. Pettigrew, and S. Lenton. 2015. “Issues in the Implementation and Evolution of the Commercial Recreational Marijuana Market in Colorado.” The International Journal of Drug Policy, doi:10.1016/j.drugpo.2015.12.001.                  

Colorado legalized recreational cannabis in 2014. This paper outlines the regulatory model and process and describes issues that have emerged in the first 20 months of its operation, including tension between public health and profit, all-cash business, new methods of consumption, the black market, and product testing. A further challenge is a “lack of an effective overarching federal regulatory structure, as a consequence of the federal prohibition on cannabis, combined with a rapidly growing cannabis industry which, like other industries, will seek to exploit loopholes to maximize profit.” The paper also reviews marijuana sales, ancillary sales, and investment data, notably a Colorado Cannabis Chamber of Commerce claim of 18,000 jobs created, some of which instead may have been transferred from the black market, and U.S. Securities and Exchange Commission approval of share registration of a marijuana dealer.                   

Read more:                  
http://www.ijdp.org/article/S0955-3959(15)00354-0/abstract                                      

New Jersey Senate Panel Approves Job Protection for Medical Marijuana Patients                  
Susan K. Livio, NJ Advance Media                  
December 22, 2015                  

A New Jersey senate committee has approved a bill that would prohibit employers from firing people who participate in the state medical marijuana program unless they can show these employees are impaired and unable to do their jobs. Employees faced with a drug test would get 3 days to explain in writing why they will test positive for cannabis and should be exempt. The legislation does not permit patients to use marijuana while they are working.                  

Read more:                  
http://www.nj.com/politics/index.ssf/2015/12/senate_panel_
approves_job_protection_for_medical_m.html
                                      

The Tricky Relationship between Marijuana and American Indians                  
Winona LaDuke, In These Times                  
December 19, 2015                  

In an October 2014 memorandum, the U.S. Department of Justice said it would treat the legalization of marijuana in sovereign Indian nations the same way it does in states like Colorado and Washington, where the drug is legal, as long as reservations meet the same guidelines. Tribes from California to New York subsequently legalized the drug. However, according to the blog post, the memorandum leaves a lot of gray area, especially in the 27 states which have not yet legalized marijuana in some form. Lance Morgan, a tribal law expert in Nebraska, said the memorandum does not actually allow tribes to legalize marijuana. Rather, it allows them to work with U.S. attorneys to do so. And, Morgan said U.S. attorneys in many states have been unwilling to let tribes move forward.                   

Read more:                  
http://inthesetimes.com/rural-america/entry/18712/marijuana-legalization-on-the-reservation-and-american-indians                                     

2016 Will Be Marijuana’s Big Year                  
Debra Borchardt, Forbes                  
December 28, 2015                  

Several marijuana-related bills in Congress may move forward in 2016. Hearings are most likely for the Compassionate Access, Research Expansion, and Respect States Act (S. 683/H.R. 1538), which would allow states to legalize medical marijuana without federal interference and reschedule marijuana to a Schedule II drug. It would also eliminate barriers to research and allow banks to work with marijuana companies. States that will consider initiatives this year that focus on legalizing or regulating marijuana for adult use include Arizona, California, Maine, Massachusetts, and Nevada. The Vermont and Rhode Island legislatures seem the most likely to legalize recreational marijuana. Illinois and New Hampshire seem likely to pass decriminalization of possession laws.                  

Read more:                  
http://www.forbes.com/sites/debraborchardt/2015/12/28/2016-will-be-marijuanas-big-year                                      

Massachusetts Secretary of State Certifies Petition to Regulate Marijuana Like Alcohol                  
Conor Berry, Mass Live                  
December 18, 2015                  

Massachusetts Secretary of State Bill Galvin certified signatures submitted by the Campaign to Regulate Marijuana Like Alcohol that would allow adults 21 and older to possess up to one ounce of marijuana and grow a limited number of plants in their homes. This measure does not affect employers’ current marijuana policies or their ability to establish workplace restrictions on marijuana consumption by employees. The measure now goes to the state legislature for approval. If state lawmakers reject the petition or fail to act on it by May 3, 2016, backers of the marijuana measure must collect an additional 10,792 signatures by early July to get the initiative on the November 2016 ballot.                   

Read more:                  
http://www.masslive.com/politics/index.ssf/2015/12/marijuana.html                                      

Hawaii Still Has Much to Clarify About Medi-Marijuana Dispensaries                  
Lorin Eleni Gill, Pacific Business News                  
December 28, 2015                  

As Hawaii prepares to open its first medical marijuana dispensary this summer, lawmakers during a recent informal briefing asked the state’s health department questions about interim rules for the new system. Applications for the first eight licenses will be accepted in January 2016, but the author thinks many questions remain unclear, including why greenhouses are outlawed, medical marijuana joints banned, and cannabis baked goods forbidden. Medical marijuana has been legal in Hawaii for more than a decade.                   

Read more:                  
http://www.bizjournals.com/pacific/blog/2015/12/hawaii-lawmakers-officials-still-have-a-lot-to.html                                      

New York’s Marijuana Start-Ups Gear Up For Sales                  
Kate Rogers, CNBC                  
December 22, 2015                  

Vireo Health New York is preparing to become the first dispensary to sell medicinal cannabis in the state. It had its first local harvest in November. Vireo Health was one of five start-up companies that received an operator’s license. Several dispensaries will open in Queens, White Plains, Binghamton, and Colonie. Smoking marijuana is not legal in New York, so patients will have to use oil and liquid orally through a tube or a capsule. Health practitioners are gearing up for the launch by taking classes, and patient certification will begin soon. (Includes video: 2:03 minutes)                  

Read more:                  
http://www.cnbc.com/2015/12/22/new-york-states-marijuana-start-ups-gear-up-for-sales.html?__source=synacor&par=synacor                                     

Lane County (Ore.) Worker with Cancer Fired for Using Medicinal Marijuana                  
Christian Hill, Register-Guard                  
December 24, 2015                  

Michael Hirsch, a former Lane County (Ore.) senior programmer and systems analyst, has advanced prostate cancer. He smokes medicinal marijuana on his off-hours to deal with the pain. When a coworker smelled marijuana on Hirsch’s jacket, he reported him. His employer fired him for violating the county’s drug-free workplace policy even though it had no effect on his job performance. The county policy bars use of any controlled substance “prior to reporting to work or during breaks or lunch period.” Hirsh admitted that he did not notify the county about his use when he got his prescription. American Federation of State, County and Municipal Employees Local 2831 is challenging the decision and plans to file a grievance seeking reinstatement.                  

Read more:                  
http://registerguard.com/rg/news/local/33888499-75/lane-county-worker-with-cancer-fired-for-using-medicinal-marijuana.html.csp                                      

After Successful Lawsuit, First New Hampshire Resident Legally Obtains Medical Marijuana                  
Ella Nilsen, Concord Monitor                  
December 19, 2015                  

Linda Horan, who suffers from terminal Stage IV lung cancer, successfully sued New Hampshire to get the state’s first medical marijuana identification card. Now, Horan can buy medical marijuana legally in Maine, Vermont, and Massachusetts. New Hampshire is set to open four marijuana dispensaries in 2016, more than 2 years after legalizing medical marijuana.                  

Read more:                  
http://www.concordmonitor.com/news/20115700-95/after-successful-lawsuit-linda-horan-becomes-first-nh-resident-to-legally-obtain-medical-marijuana                                      

Air Canada Grounds Medicinal Marijuana User                  
Shawn Jeffords, Toronto Sun                  
December 23, 2015                   

Air Canada would not let passenger Michael Korchak board a plane because he was carrying a leaf form of medicinal marijuana. The Canadian Armed Forces member, who suffered a traumatic injury on duty, was prescribed medicinal marijuana for chronic pain and showed the airline workers his prescription. Air Canada’s policy only allows medicinal marijuana in pill form. Korchak eventually flew Porter Airlines, which had no problem with his medicinal marijuana. Air Canada issued an apology to Korchak, changed its medicinal policy, and plans to issue him a refund.                   

Read more:                  
http://www.torontosun.com/2015/12/23/air-canada-grounds-medicinal-marijuana-user                                      

Illinois Medical Cannabis Pilot Program in Trouble Because of Lack of Patients                  
Mike Fitzgerald, Belleville News-Democrat                  
December 19, 2015                  

The Illinois Medical Cannabis Pilot Program currently has only 3,600 patients due to a shortage of doctors willing to sign medical marijuana cards. An investment firm had predicted that Illinois would now have 30,000 patients with medical marijuana cards and 70,000 by the end of 2017. Illinois is in its third year of a 5-year pilot program; state lawmakers may vote to extend the law that launched the program. Entrepreneurs will struggle to break even by the fifth year and are pressing to allow use for anxiety and posttraumatic stress disorders. They also want the state to educate physicians about the benefits of medical marijuana.                  

Read more:                  
http://www.bnd.com/news/local/article50653235.html                  
               

International

Katusha Doctor Claims Use of Sleeping Pills Worse Than Doping in Cycling                
Omnisport                
December 28, 2015                

A doctor with the Russian road bicycle racing team, Katusha, claims misuse of sleeping pills in cycling is more widespread than doping. Riders combine sleeping pills with alcohol to create an “explosive effect.” Katusha team member Luca Paolini, who was thrown out of the 2015 Tour de France after testing positive for cocaine, admitted to taking the drug and having an addiction to sleeping pills. The doctor stopped giving Paolini a prescription for lormetazepam, but the cyclist got it elsewhere.                

Read more:                
http://www.aol.co.uk/2015/12/28/katusha-doctor-claims-use-of-sleeping-pills-worse-than-doping-in-cycling                                 

Unauthorized Drugs Seized from Retailers in Canada                
Canadian Press                
December 23, 2015                

Health Canada seized unauthorized drugs from retailers in Ontario and British Columbia. Five drugs (Mega Power, Herba Pini Syrop, Biseptol 480, Naproxen Emo, and Oxycort) pose serious risks because they were labeled as containing prescription drugs or narcotics or were found to contain a prescription drug that was not listed on the label.                

Read more:                
http://globalnews.ca/news/2418770/health-canada-says-unauthorized-drugs-seized-from-retailers-in-ontario-and-b-c                                  

Overprescription of Pain Relievers Behind Heroin Resurgence in Australia                
Liz Burke, News.com.au                
December 22, 2015                

More Australians are becoming addicted to pain relievers because of overprescribing, according to the Australian Drug Foundation. Some addicted users switch to heroin when doctor shopping for prescription drugs fails. Heroin use is increasing nationally.                 

Read more:                
http://www.news.com.au/lifestyle/health/health-problems/experts-say-overprescription-of-painkillers-behind-heroin-resurgence-in-australia/news-story/8017ab844df868fe6b33c7382c537ddc                
               

Northeast/Mid-Atlantic News

Massachusetts to Spend $6.2 Million on New Prescription Database                
Jessica Bartlett, Boston Business Journal                
December 18, 2015                

Massachusetts will pay $6.2 million to Appriss to revamp its prescription drug monitoring program database. The new system will make it easier for prescribers to access and submit information, allow for enhanced reporting for physicians and the state’s public health department, allow interaction among states, and will be linked with electronic medical records.                

Read more:                
http://www.bizjournals.com/boston/blog/health-care/2015/12/state-to-spend-6-2m-on-new-prescription-database.html                                  

Massachusetts House Releases Version of Opioid Abuse Bill                
Steve LeBlanc, Associated Press                
December 28, 2015                

Lawmakers in Massachusetts’s house of representatives introduced legislation that would limit initial opiate pain reliever prescriptions to a 7-day supply. It would also require a licensed medical professional to conduct an in-depth evaluation on anyone who shows up in an emergency department with an opiate-related overdose; it protects anyone administering naloxone to a person during an opiate overdose; and requires a doctor to check the prescription drug monitoring program every time a patient is prescribed a high-risk opiate. The bill must win support of several legislative committees before heading to the full house for debate. The state’s senate has passed a version of the bill.                

Read more:                
http://boston.cbslocal.com/2015/12/28/massachusetts-house-releases-version-of-opioid-abuse-bill                 
               

 South News

Kentucky Settles Lawsuit with OxyContin Maker for $24 Million                
Adam Beam, Associated Press                
December 23, 2015                

Purdue Pharma has settled a lawsuit with Kentucky for $24 million, to be paid over the next 8 years. The state filed the lawsuit in 2007, accusing Purdue Pharma of marketing OxyContin as nonaddictive because the pill slowly released the drug over 12 hours. However, when crushed, the pill lost its time-release qualities and created an instant high. State officials claimed this led to addiction and increased medical costs, particularly in eastern Kentucky where many injured coal miners were prescribed the drug. The court ordered the state to spend the money on addiction treatment programs. Purdue Pharma did not admit any wrongdoing in the settlement agreement. In another case, Johnson & Johnson and its subsidiary Janssen Pharmaceuticals settled their lawsuit with Kentucky for $15.5 million. Janssen makes Risperdal, an antipsychotic prescription drug used to treat schizophrenia. The lawsuit accused the companies of marketing the drug without disclosing its side effects. The companies did not admit wrongdoing.                

Read more:                
http://bigstory.ap.org/article/5eba8e71298d41849a94ad1017a90aea/ky-settles-lawsuit-oxycontin-maker-24-million                                  

University of Alabama Quietly Testing Fraternity Brothers for Drugs                
Connor Sheets, Alabama Media Group                
December 18, 2015                 

The University of Alabama drug tests members of multiple fraternity organizations every week throughout the school year. Some think testing has driven many marijuana smokers to turn to Xanax, which has become the most popular drug after marijuana at the university. The police chief in Tuscaloosa, where the university is located, identified Xanax misuse as a “public health crisis.”                 

Read more:                
http://www.al.com/news/index.ssf/2015/12/university_of_alabama_quietly.html                                  

Virginia’s Drug Problem: Heroin and Opioid Deaths Continue to Rise                
Gary A. Harki, Virginian-Pilot                
December 25, 2015                

The Virginia Medical Examiner’s Office recorded 115 heroin and prescription opioid deaths in the Hampton Roads area during the first 6 months of 2015. Virginia was on pace to have more than 850 such deaths statewide, a 9 percent increase from 2014. Heroin deaths started to accelerate in 2013, when the rate jumped from 1.6 to 2.6 deaths per 100,000 population.                

Read more:                
http://www.pilotonline.com/news/local/crime/virginia-s-drug-problem-heroin-and-opioid-deaths-continue-to/article_08e2373b-1760-52eb-b512-26742e251655.html                
               

Midwest News

Report: Drug Thefts Common in Minnesota                
Beatrice Dupuy, StarTribune                
December 28, 2015                

Minnesota Department of Health reported that drug theft by healthcare workers has become so common that it accounts for nearly one-fifth of all abuse cases affecting elderly Minnesotans. State investigators examined 192 allegations of drug theft during the 12 months ending in June 2014; they substantiated 27 cases perpetrated by 14 healthcare workers. In some cases, nursing home staff replaced patients’ oxycodone or Vicodin with over-the-counter pills; in others, they forged documents to obtain medications. Overall, the agency substantiated 141 cases of abuse, neglect, or financial exploitation of vulnerable adults during the period. About 70 percent of the substantiated cases of employees who stole medication from residents took place in nursing homes.                 

Read more:                
http://www.startribune.com/drug-thefts-turn-up-big-in-state-report-on-abuse-and-neglect-of-vulnerable-minnesotans/363642041                                  

Two Cleveland Browns Football Players Arrested, Reportedly with Gun, Pills on Christmas                
Jared Dubin, CBS Sports                
December 26, 2015                

Two professional football players for the Cleveland Browns were arrested on Christmas morning. Police found a gun and Adderall in the vehicle. One player was charged with driving under the influence of drugs or alcohol. Both had been arrested in the past for selling or possessing marijuana.                 

Read more:                
http://www.cbssports.com/nfl/eye-on-football/25426761/two-browns-arrested-reportedly-with-gun-pills-on-christmas-morning                                  

Missouri Pharmacy Association Joins Coalition Supporting Drug Monitoring Program                
Missouri Times                
December 18, 2015                

The Missouri Pharmacy Association has joined the Missouri Prescription Drug Monitoring Program (PDMP) Coalition, which supports the Narcotics Control Act. The legislation would create a PDMP database for the state.                

Read more:                
http://themissouritimes.com/25385/missouri-pharmacy-association-joins-coalition-supporting-drug-monitoring-program                
               

West News

California Attorney General Launches New Prescription Drug Monitoring Program                
State of California, Department of Justice, Office of the Attorney General                
December 22, 2015                

California has announced its new Controlled Substance Utilization Review and Evaluation System (CURES 2.0), a state-of-the-art prescription drug monitoring program. Starting January 8, 2016, current CURES users will be automatically redirected to the new system, which provides faster, more reliable access to patient activity reports. The system features cutting-edge analytics for flagging at-risk patients. It will streamline the registration process, allowing users to apply for access and verify their credentials online using secure Web browsers.                

Read more:                
http://oag.ca.gov/news/press-releases/attorney-general-kamala-d-harris-launches-new-prescription-drug-monitoring                                  

Help! My Employee is a Pill Popper                
Stefanie K. Vaudreuil, California Public Agency Labor and Employment Blog                
December 29, 2015                

The Americans with Disabilities Act (ADA) does not protect employees who are currently using illegal drugs, including employees who are illegally using prescription drugs, according to the California Public Agency Labor and Employment Blog. The ADA does protect employees “who are no longer using drugs illegally and are receiving treatment for drug addiction or who have been rehabilitated successfully.” Employers need to consider how their current drug policies deal with employees who misuse substances and whether changes are necessary to existing policies. Employers should train supervisors to recognize potential drug misuse and educate employees about available employee assistance programs. Employees who were previously misusing drugs but successfully completed treatment, no longer illegally use drugs, and have returned to work are protected individuals under the ADA. Adequate policies and procedures will help employers save valuable time and money by retaining employees and assisting them with recovery.                 

Read more:                
http://www.calpublicagencylaboremploymentblog.com/employment/help-my-employee-is-a-pill-popper                
               

Solicitation for Public Comment

Federal Register Notice: Proposed 2016 Guideline for Prescribing Opioids for Chronic Pain                
Centers for Disease Control and Prevention                
Due: January 13, 2016, 11:59 p.m. (ET)                
http://www.regulations.gov/#!documentDetail;D=CDC-2015-0112-0001                 
http://www.cdc.gov/drugoverdose/prescribing/guideline.html                 
               

Grant Announcements

New Jersey Health Initiative 2016: Building a Culture of Health in New Jersey—Communities Moving to Action, Round 2                
Robert Wood Johnson Foundation                
Due: January 14, 2016                
http://www.rwjf.org/en/library/funding-opportunities/2015/njhi-2016--building-a-culture-of-health-in-new-jersey---communiti.html                 

Generation Rx Medication Disposal Grant Program                
Cardinal Health                
Due: January 22, 2016                
http://www.cardinalhealth.com/en/about-us/community-relations/population-health/rx-drug-misuse-and-abuse.html                                  

Research on Prescription Opioid Use, Opioid Prescribing, and Associated Heroin Risk (RFA-CE-16-003)                
Centers for Disease Control and Prevention                
Due: February 18, 2016                
http://www.grants.gov/view-opportunity.html?oppId=280151                 

Increasing Access to Medication-Assisted Treatment in Rural Primary Care Practices (R18)                
Agency for Healthcare Research and Quality                
Due: March 4, 2016                
http://grants.nih.gov/grants/guide/rfa-files/RFA-HS-16-001.html                                  

Drug-Free Communities Support Program (SP-16-001)                
SAMHSA                
Due: March 18, 2016                
http://www.samhsa.gov/sites/default/files/grants/pdf/sp-15-001_0.pdf                                  

National Institute on Drug Abuse Challenge: Addiction Research: There’s an App for that                
U.S. Department of Health and Human Services                
Submission period begins November 3, 2015, 9:00 a.m. (ET)                
Submission period ends April 29, 2016, 11:59 p.m. (ET)                
http://nida.ideascale.com/a/pages/addiction-research-theres-an-app-for-that                
               

Take-Back Events & Drop Boxes

Take It to the Box Program Disposes Nearly 16,000 lbs. of Unwanted Prescription Pills Since 2009                
Brittney Neset, Faribault Daily News (Minnesota)                
December 25, 2015                
http://www.southernminn.com/faribault_daily_news/news/article_52052eee-0cea-5f6f-a02b-22145536201b.html                                  

3,017 lbs. of Drugs Collected During ‘Drop the Drugs’ 2015                
The Pine Tree (California)                
December 28, 2015                
http://thepinetree.net/index.php?module=announce&ANN_user_op=view&ANN_id=46274                                  

Baton Rouge Police Agencies Start Prescription Drug Collection Programs                
Steve Hardy, The Advocate (Louisiana)                
December 24, 2015                
http://theadvocate.com/news/14218706-123/baton-rouge-area-police-agencies-start-prescription-drug-collection-programs                                  

Drop-Off Boxes for Unwanted Meds Available                
Herald-Palladium (Michigan)                
December 23, 2015                
http://www.heraldpalladium.com/news/local/drop-off-boxes-for-unwanted-meds-available/article_aa215bf2-c6e5-5d8a-b542-0399d0ff3f78.html                                  

Drop Box Available for Unwanted Prescription Drugs                
Smithville Herald (Missouri)                
December 29, 2015                
http://www.smithvilleherald.com/news/article_0ba54b2d-1976-5593-a2d8-8995f09a2514.html                                  

Dispose of Old Prescriptions at Cohasset Police Station                
Cohasset Mariner (Massachusetts)                
December 21, 2015                
http://cohasset.wickedlocal.com/article/20151221/NEWS/151229569                
               

Upcoming Conferences and Workshops

Pharmacy Diversion Awareness Conference                
U.S. Drug and Enforcement Administration                
January 9–10, 2016                
Jackson, Mississippi                
February 27–28, 2016                
Charleston, West Virginia                
http://www.deadiversion.usdoj.gov/mtgs/pharm_awareness                                  

26th National Leadership Forum and SAMHSA’s 12th Prevention Day                
Community Anti-drug Coalitions of America & SAMHSA                
February 1–4, 2016                
http://www.cadca.org/forum2016                 

Register:                
http://www.cadca.org/events/26th-national-leadership-forum-including-samhsas-12th-prevention-day/registration                                  

Ensuring Access to Pain Care: Engaging Pain Medicine and Primary Care Teams                
American Academy of Pain Medicine                
February 18–21, 2016                
Palm Springs, California                
http://www.painmed.org/annualmeeting                                  

2016 National Rx Drug & Heroin Summit                
March 28–31, 2016                
Atlanta                
http://nationalrxdrugabusesummit.org                                  

Third Annual Smart Approaches to Marijuana Education Summit                
March 31, 2016                
Atlanta                
http://nationalrxdrugabusesummit.org/sam-summit-2                 

Register:                
https://www.123contactform.com/form-1486587/2016-National-Rx-Drug-Abuse-Summit                 
         
                                 
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.