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July 3, 2013

SAMHSA Prevention of Prescription Drug Abuse in the Workplace Listserv

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July 3, 2013 (PDF version)
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This week's listing is chock-full of notable studies--more so than any prior issue. Two are featured here and eight others are starred below.
Prescribers with Questionable Patterns in Medicare Part D
Office of the Inspector General, U.S. Department of Health and Human Services
June 2013
Sponsors submit Prescription Drug Event (PDE) records to the Centers for Medicare & Medicaid Services for each drug dispensed to beneficiaries enrolled in their plans. Each record contains information about the beneficiary, pharmacy, prescriber, and drug. The Office of the Inspector General (OIG) matched the one billion-plus 2009 PDE records to data from the National Plan and Provider Enumeration System.
More than one million individual prescribers ordered drugs paid by Part D in 2009. OIG focused on 86,818 general-care physicians in non-rural areas. They collectively accounted for 540,581,871 PDE records. Less than 1 percent (736) had questionable prescribing patterns, which may indicate these prescriptions were medically unnecessary. Medicare paid $352 million for Part D drugs ordered by these physicians. More than half of the 736 physicians ordered extremely high percentages of Schedule II or III drugs. Seventy-eight percent of a Florida-based physician's prescription orders were for Schedule II drugs, including oxycodone and morphine. For one beneficiary, this Florida physician prescribed a 605-day supply of morphine and 524-day supply of oxycodone. The report also said 108 of the 736 physicians ordered an average of 71 or more prescriptions per beneficiary, compared with the national average of 13 among general care physicians and 6 among all Medicare providers. Thirty-five general-care physicians had prescriptions filled by at least 342 pharmacies--more than six times the national average of 52 per general-care physician.
OIG determined whether general-care physicians with questionable patterns were associated with any of the 2,637 retail pharmacies with questionable billing identified in an earlier report. They considered a physician to be associated with a pharmacy if the pharmacy billed at least 25 percent of the cost of all drugs the physician prescribed in 2009. Of the 736 physicians, 110 (15 percent) were associated with one or more of the pharmacies previously described.
A related OIG report found Medicare Part D inappropriately paid $25 million for Schedule II drugs billed as refills in 2009. Sponsors should not have paid for any of these drugs because federal law prohibits refilling of Schedule II controlled substances without a new prescription. Also, three fourths of Part D sponsors paid for Schedule II drugs billed as refills, indicating that many sponsors do not have adequate controls to prevent such refills. A third OIG report found Medicare Part D paid $1.2 billion in 2007 for drugs with invalid prescriber identifiers (the identifiers had never been assigned or had been retired).

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Related News Article
Massage Therapists, Chiropractors Wrote Drug Prescriptions They Shouldn't Have--and Medicare Paid
ABC News
June 21, 2013
An Inspector General's report from the Department of Health and Human Services revealed that massage therapists, athletic trainers, chiropractors, and other professionals wrote hundreds of thousands of fraudulent drug prescriptions. In 2009, Medicare Part D paid $26.2 million filling these prescriptions. Massage therapists ordered 12,082 prescriptions and chiropractors ordered 70,681.

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FDA Takes Action to Protect Consumers from Dangerous Medicines Sold by Illegal Online Pharmacies
U.S. Food and Drug Administration
June 27, 2013
The U.S. Food and Drug Administration, in partnership with international regulatory and law enforcement agencies, took action against more than 9,600 Web sites that illegally sold unapproved prescription medicines to consumers. They seized and shut down 1,677 illegal pharmacy Web sites and issued regulatory warnings.

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Journal Articles
J. Beckmann. 2013. "G209 Managing Substance Misuse in Young People--What Works?" Archives of Disease in Children 98:A93-94. doi:10.1136/archdischild-2013-304107.221.
This study used a retrospective analysis of attendance data for 9- to 17-year-olds at a busy district general hospital accident and emergency department during a peak festive and school holiday season. Young people presenting with potential substance misuse risk factors were identified from diagnosis codes and filtered for specific substance misuse concerns. Highly suspect cases were then audited for management and discharge outcome at the point of departure. A total of 334 young people presented to the accident and emergency department between December 2011 and January 2012. Forty (12 percent) had diagnosis coding for alcohol intoxication, alcohol withdrawal, deliberate drug overdose, head injury, alleged assault, road traffic accident injuries undetermined, psychiatric problems, hyperventilation, collapse, and injury to face. Of these, nine (22.5 percent) were young people between 15 and 17 years of age who identified as high risk for substance misuse. Only one case was referred and admitted to the adult medical team; none of the remaining patients were referred to a pediatric team and were discharged to go home or had absconded. Only one patient had a documented use of a "Substance Misuse Assessment Tool" and none had psychiatric or child and adolescent mental health services input, nor were they referred to a young person-specific substance misuse service. Health professionals who regularly manage young people in the accident and emergency department, including accident and emergency nursing staff, need essential training in assessing young people for substance misuse. Young person-specific substance misuse clinical guidelines would be helpful to increase case management confidence for pediatricians, junior accident and emergency doctors, and adult physicians. A valuable resource for the National Health Service, referral to young person-specific services in substance misuse should be considered in these guidelines. Multidepartmental, multidisciplinary agreement is imperative for successful implementation.

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***M.L. Fleming, H. Chandwani, J.C. Barner, S.N. Weber, and T.T. Okoro. 2013. "Pharmacists Requests for Prescription Monitoring Program (PMP) Data: Does PMP Structure Matter?" Journal of Pain and Palliative Care Pharmacotherapy 27(2):136-42. doi:10.3109/15360288.2013.788598.
This study describes Prescription Monitoring Program (PMP) use (e.g., requested reports) among prescribers, pharmacists, and law enforcement for active state PMPs; PMP use among healthcare providers with and without online access; average annual operational costs for PMPs from 2008 to 2009; and PMP requests based on PMP housing authority (law enforcement vs. non-law enforcement [e.g., board of pharmacy]). Researchers used a cross-sectional study employing a Web-based survey. A 16-item questionnaire was e-mailed to the 33 operational state PMP administrators, and responses were collected from January to March 2011. Only 15 PMPs (45.5 percent) completed the survey, so the results may not be representative. Among all authorized users, prescribers had higher mean (±SD) requests per 100,000 population (2198.2 ± 3218.0) compared with pharmacists' requests (268.9 ± 261.2). Online accessibility resulted in higher request rates per 100,000 population (2996.4 ± 3021.5) compared with mail/fax access (14.6 ± 2.8). On average, PMP annual costs were $12,515 ± $14,911 per 100,000 population. In law enforcement-governed PMPs, healthcare provider utilization was lower compared with PMPs under health or pharmacy boards.

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***K. Hempstead. 2013. "Supply-Side Response to Declining Heroin Purity: Fentanyl Overdose Episode in New Jersey." Health Economics. doi:10.1002/hec.2937.
This paper suggests increasing availability of prescription opioids may threaten heroin sellers' profit margin and force them to find alternative methods for compensating buyers in the event of a supply shock. Researchers investigated the 2006 fentanyl overdose episode in New Jersey and argue the introduction of non-pharmaceutical fentanyl, its spatial distribution, and the timing of overdose deaths may be related to trends in heroin purity. Using medical examiner data and data from the Drug Enforcement Administration on prescription opioid retail sales, they show month-to-month fluctuations in heroin purity have a significant effect on fentanyl-related overdoses, particularly in areas where prescription opioids are highly available.

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***J.D. Jones, P. Roux, S. Stancliff, W. Matthews, and S.D. Comer. 2013. "Brief Overdose Education Can Significantly Increase Accurate Recognition of Opioid Overdose Among Heroin Users." International Journal of Drug Policy. doi:10.1016/j.drugpo.2013.05.006.
This study assessed if New York State Department of Health training increased accurate identification of opioid and non-opioid overdose and naloxone use among heroin users. Eighty-four participants completed a test on overdose knowledge with 16 putative overdose scenarios. Forty-four people completed the questionnaire immediately prior to and following standard overdose prevention training. A control group (n=40), who opted out of training, completed the questionnaire just once. Overdose training significantly increased participants' ability to accurately identify opioid overdose (p<0.05) and scenarios where naloxone administration was indicated (p<0.05). Training did not alter recognition of non-opioid overdose or non-overdose situations where naloxone should not be administered. The data indicate that overdose prevention training improves participants' knowledge of opioid overdose and naloxone use, but naloxone may be administered in some situations where it is not warranted. The training curriculum could be improved by teaching individuals to recognize symptoms of non-opioid drug over-intoxication.

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J. Levinson and K.A. McKinney. 2013. "Consuming an Edge: ADHD, Stimulant Use, and Psy Culture at the Corporate University." Transcult Psychiatry.
Researchers examined "psy"--ways of knowing and acting on ourselves that shape everyday life psychologically--on the college campus. They suggested there is an "elective affinity" between psy and the neoliberal management strategies that dominate the "corporate university" and described ways psy organizes college life by drawing on the history of college health services; interviews about mental health and services at a Canadian university; and historical, social, and media accounts of student mental health and pharmaceutical drug use--both prescribed and not--on campus in the United States and Canada. By the 1990s, for the first time, many students were arriving at college as already experienced consumers of psy with diagnoses and prescriptions. Researchers considered this and the increased use of medication as an aspect of the psy campus. They focused on stimulants, using attention deficit hyperactivity disorder to illustrate the blurred line between treatment and enhancement. Students who used stimulants, with or without a prescription, did so in the same way: instrumentally in relation to academic demands. The blurred line between academic stress and psychiatric distress is further illustrated by "clinic notes," an institutionalized practice that enables all students to act on academic pressure as a matter of mental health. Researchers described the links between psy and institutional branding and marketing to illustrate the role of mental health and wellness services in the corporate university.

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***B.E. McCabe, D.A. Santisteban, M.P. Mena, D.M. Duchene, C. McLean, and M. Monroe. 2013. "Engagement, Retention, and Abstinence for Three Types of Opioid Users in Florida." Substance Use and Misuse 48(8):623-34. doi:10.3109/10826084.2013.800112.
This study consisted of 1,648 opioid users in Florida Access to Recovery (2004-07). Participants engaged in methadone or buprenorphine maintenance had better retention than those in non-maintenance treatment. Heroin-only users had better engagement in non-maintenance treatments and had worse retention than prescription opioid-only users (PO). In methadone maintenance, PO were more likely to report opioid abstinence during treatment than heroin and prescription opioid users.

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***H.D. Wilson, E.J. Dansie, M.S. Kim, B.L. Moskovitz, W. Chow, and D.C. Turk. 2013. "Clinicians' Attitudes and Beliefs About Opioids Survey (CAOS): Instrument Development and Results of a National Physician Survey." The Journal of Pain 14(6):613-27. doi:10.1016/j.jpain.2013.01.769.
This study was designed to develop a reliable and valid measure (Clinicians' Attitudes about Opioids Scale [CAOS]) to assess current and evolving beliefs regarding opioids and opioid use among patients with chronic non-cancer pain and survey those beliefs in a nationally representative sample of providers from multiple medical specialties throughout the United States. Researchers started with a similar national survey administered 20 years ago (Turk et al., 1994). They revised the questionnaire in three phases: 1) focus groups and content development; 2) pilot testing and subsequent revisions; and 3) formal survey (n=1,535) and assessment of stability (n=251). The resulting 38-item measure assessed five domains: 1) Impediments and Concerns; 2) Perceived Effectiveness; 3) Schedule II Versus III Opioids; 4) Medical Education; and 5) Tamper-Resistant Formulations. The survey was sent to all physicians in targeted specialties among the approximately 100,000 physicians participating in the Toluna Inc. Web-enabled survey panel. Respondents were paid $50-$75 depending on their specialty. The response rate was 47 percent.
Results: Controlling for weekly volume of pain patients, pain medicine specialists and physical medicine and rehabilitation specialists were the most confident in efficacy. Both in 1992 and 2012, orthopedists were most troubled by impediments/concerns from long-term opioid use and had the least confidence in opioid efficacy. They were more positive about prescribing on an as-needed basis and less confident in tamper-resistant formulas. Belief in efficacy was higher among male physicians, physicians over age 45, and physicians with a higher percentage of chronic pain patients. Physicians with at least half their patients in chronic pain were least concerned about prescribing scheduled substances. Similar to perspectives gauged 20 years ago, physicians judged their education regarding pain evaluation and treatment as inadequate. Physicians under 45, however, more often indicated that education and training for treatment of chronic non-cancer pain were appropriate and consistent with practice. No significant differences were identified among geographical regions.

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News and Reports
***System Gives Authorized Users Access to Interstate Information on Controlled Substance Prescriptions, Assisting Them in Identifying Cases of Potential Misuse
Agency for Healthcare Research and Quality
June 19, 2013
Owned and operated by the National Association of Boards of Pharmacy (NABP), NABP InterConnect is a secure communications exchange platform that facilitates transmission of prescription monitoring program data across state lines to authorized requestors while ensuring each state's data-access rules are enforced. Authorized users including pharmacists and other healthcare providers in 15 states have collectively accessed the system more than two million times since its implementation. This policy innovation profile describes the background and development of NABP InterConnect, as well as its impact. Approximately 25 states are expected to share data or agree to share data using NABP InterConnect by the end of 2013.

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Maine Legalizes Prescription Drug Imports
Bloomberg Business
June 28, 2013
In 90 days, a new law will go into effect allowing Maine residents to purchase mail-order prescription drugs from licensed out-of-country drug companies.

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N.J. Prescription Monitoring Program Not Doing the Job
June 24, 2013
Since the New Jersey Prescription Drug Monitoring Program began in 2012, prescribers have conducted 1.1 million searches and received 419 calls for investigation requests from enforcement agencies, according to the state of New Jersey. Only 14 percent of New Jersey's pharmacies and physicians have enrolled. Some physicians have expressed concerns about breaching a patient's confidentiality and find it time consuming.

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Pain Management Physicians Offer Tips to Help Your Patients
e-Reports, Indiana State Medical Association
June 24, 2013
The Indiana State Medical Association provides suggestions from pain management physicians for treating pain and addiction.

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Hannon Drug "Take Back" Bill for Pharmacies Passed by Senate
Long Island Exchange
June 21, 2013
This news release discusses New York's decision authorizing pharmacies to take back controlled substances. Senate Bill 3944 encourages disposal of unused medications and ensures necessary, safe, and permissible methods for disposal. The senate and assembly have passed the legislation--it awaits action from the governor. In addition, the bill would allow retail pharmacies to administer mail-back programs and maintain collection boxes.

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***Profiting from Pain
The Soaring Cost of the Opioid Economy
The New York Times
June 22, 2013
This article and accompanying page of statistics from the author of the New York Times e-book, A World of Hurt: Fixing Pain Medicine's Biggest Mistake, documents revenue growth related to prescription opioids in the past decade. OxyContin costs about $6,000 per year, while less risky physical therapy and behavior modification might cost $15,000-$25,000. In the United States, drug screening went from an $800 million industry in 2000 to $2 billion in 2013. In 2013, California workers' compensation alone expects to spend $100 million on testing. An opioid other than heroin was coded as a reason for emergency department treatment for 299,498 visits in 2004 and 885,348 in 2011. Doctors are allowed to dispense drugs in 20 states and frequently do for patients covered by workers' compensation. In Illinois, pharmacy-dispensed Vicodin was $.53/pill in 2011 and $.54/pill in 2007, while physician-dispensed Vicodin was $1.44/pill in 2011--up from $.50 in 2007. In Connecticut, physician-dispensed Vicodin rose from $.66/pill to $1.43/pill, while pharmacist-dispensed Vicodin fell from $.41/pill to $.37/pill. At Hazelden's Minnesota treatment facility, patients treated for opioid addiction rose from 15 percent in 2011 to 41 percent in 2011. Inpatient treatment at a private facility costs $20,000 to $32,000.

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Know the Risks: Understanding Prescription Drug Misuse and Abuse
Navy and Marine Corp Public Health Center
Accessed June 27, 2013
This article discusses how to take prescription drugs appropriately so military personnel can be safe and fit for duty. It highlights that drug misuse and abuse include inappropriate use of prescription medications, even if prescribed by a healthcare provider.

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Rosenblum: Skyrocketing Opiate Abuse Among Indians Needs Attention
Star Tribune
June 22, 2013
Opiate and heroin abuse has increased 3,695 percent among American Indians according to the Centers for Disease Control and Prevention. A Hennepin County Medical Center (HCMC) physician has seen a growing number of American Indian women seeking treatment at HCMC's addiction medicine clinics. Twenty-three percent of American Indian high school girls and 18 percent of American Indian boys said they used prescription pain pills not prescribed to them in the past 12 months. The Department of Human Services Assistant Commissioner of Chemical and Mental Health said many groups have been addressing opiate addiction, with emphasis on the American Indian community.

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Candyland 2013, a Short Film Written and Directed by Jouri Smit
The Huffington Post
June 21, 2013
This article discusses Candyland, a 19-minute silent film about prescription drug abuse in which a successful businessman self-destructs.

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Testimony Before the Energy and Commerce Subcommittee on Health on Prescription Drug Abuse
Substance Abuse and Mental Health Services Administration
June 14, 2013
On June 14, H. Westley Clark, Director of the Center for Substance Abuse Treatment, testified before the Energy and Commerce Subcommittee on Health. Dr. Clark addressed the Substance Abuse and Mental Health Services Administration's role in preventing non-medical use of prescription drugs and treating individuals who abuse the drugs.

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***Survey: 35% of Teens Think Stimulant Abuse is Major Problem
The Partnership at Drugfree.org
June 25, 2013
Along with her University of Florida colleagues, Dr. Linda Cottler surveyed 11,000 teens ages 10 to 18 living in Seattle, Los Angeles, Denver, Houston, St. Louis, Cincinnati, Tampa, Philadelphia, New York, and Boston. Youth anonymously completed two booklets. In the first, they were shown pictures of drugs and asked if they knew about the drugs. A second booklet showed pictures of stimulants and asked whether participants used them. If they said yes, they were asked where they got them, how they got them, how often they took the drugs, and why. Participants were also asked how they would prevent young people from using others' prescriptions and how young people should be informed about prescription drugs. Thirty-five percent thought prescription stimulant abuse was a big problem with their peers and 15 percent said they had used stimulants at some point. One tenth of respondents said they had diverted medications; 7.5 percent reported stimulant use in the last month (3.9 percent took the drugs for nonmedical reasons). Findings were presented at the College on Problems of Drug Dependence Annual Meeting.

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CADCA Statement on Release of 2013 World Drug Report
The Wall Street Journal
June 26, 2013
This press release discusses the 2013 World Drug Report from the Community Anti-Drug Coalitions of America (CADCA). It indicates that prescription drug abuse is a major problem in the United States and globally.

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Other Resources
Long-Term Care Advise-ERR
Institute for Safe Medication Practices
Accessed June 27, 2013
ISMP Long-Term Care Advise-ERR is a medication safety newsletter specifically designed to meet the needs of administrators, nursing directors, and nurses who transcribe medication orders, administer medications, and monitor effects of medications on residents. Free CEUs are available twice a year in January and July.

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The Medicine Abuse Project 2013 Sample Tweets: Parents360 Rx Action Toolkit
The Medicine Abuse Project, The Partnership at Drugfree.org
Accessed June 25, 2013
The Medicine Abuse Project provides sample tweets and Facebook posts to help spread the message about the Parents360 Rx Action Toolkit.

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Sharing Pills Can Kill-PSA
Burke Communications
May 22, 2013
This public service announcement (:30 seconds) was produced for the Carolinas Poison Center. It helps raise awareness about teens sharing prescription drugs.

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Other Local News
Prescription Pill-Related Deaths at an All-Time High in Iowa
June 25, 2013
This article and video (3:27 minutes) discuss prescription drug abuse in Iowa. A reporter interviews a lieutenant with the Woodbury County Sherriff's Office about the woman who stole prescription drugs from his mother's house. When he got to the suspect's car, he found prescription pill bottles that did not belong to her.

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County to Discuss Arming Deputies with Overdose Reversal Drug at Tuesday's Meeting
Watertown Daily Times
June 23, 2013
New York's Jefferson County Board of Legislators will discuss a policy that would allow the sheriff's deputies to administer naloxone. The sheriff is in favor of the idea as long as his staff receives training. They will get free kits from the New York City-based Harm Reduction Coalition, which is under contract with the state's Department of Health to administer an opioid overdose prevention program.

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Prescription Drug Sales, Overdoses Increase
June 21, 2013
This article and video (1:39 minutes) discuss the increase in prescription drugs and overdose deaths in Georgia. A Georgia Bureau of Investigations agent says Xanax is the most popular drug that has led to overdose. Of the top five illegally sold drugs, four of them are pain relievers.

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Med Drop Box Donated to DPD
Dexter Daily Statesman
June 25, 2013
The Southeast Missouri Drug Task Force donated a permanent prescription drop box to the Dexter Police Department. Residents can access it 24 hours a day, 7 days a week.

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Grant Announcements
Healthy Living Grant Program
Deadline: July 16, 2013

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Cooperative Agreements for Electronic Health Record and Prescription Drug Monitoring Program Data Integration
Deadline: July 24, 2013

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Upcoming Conferences and Workshops
Pharmacy Diversion Awareness Conference
July 13 and 14: Portland, Oregon
August 3 and 4: Baton Rouge, Louisiana
August 16 and 17: San Diego, California
August 18 and 19: San Jose, California
September 21 and 22: Boston, Massachusetts
The Generation Rx University Conference for Prescription Drug Abuse Prevention and Recovery
August 7-8, 2013
Columbus, Ohio
National Conference on Addiction Disorders 2013
September 21-25, 2013
Anaheim, California

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Harold Rogers Prescription Drug Monitoring Program National Meeting
September 25-27, 2013
Washington, D.C.

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2013 National Safety Council Congress and Expo
Congress: September 28-October 4, 2013
Expo: September 30- October 2, 2013
Chicago, Illinois
2013 American Association for Treatment of Opioid Dependence Conference
November 9-13, 2013
Philadelphia, Pennsylvania

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Please e-mail Rekaya Gibson at rgibson@pire.org with questions or comments about the SAMHSA Prevention of Prescription Drug Abuse in the Workplace Listserv.  

About PAW and the Listserv
The PAW TA Center addresses prescription drug abuse--a growing public health problem with increasing burdens on workers, workplaces, and our economy. Prescription drug abuse affects workplace productivity and increases employee absenteeism, employee presenteeism, and workers' compensation claims. On a wider scale, overdose deaths linked to prescription opioids tripled from 1999 to 2006, and prescription drug abuse killed more Americans in 2009 than died that year in auto crashes.
Send your request for PAW technical assistance to PAW-TA@pire.org or contact Rekaya Gibson at 504.261.8107 or Deborah Galvin at 240.276.2721. Requests are subject to SAMHSA approval. You will be notified of the status of your request.
We aim to conduct systematic and inclusive searches of professional journals, leading newspapers and magazines, and federal websites, as well as contributions from listserv subscribers (please e-mail suggestions to rgibson@pire.org). We will send links to articles along with brief descriptions of those articles. As we develop the listserv, however, we hope to add commentary and invite feedback from subscribers. Our goal is to expand the listserv to become a widely used and recognized source of the most current and authoritative information on prescription drug abuse--especially in workplaces.
The "SAMHSA Prevention of Prescription Drug Abuse in the Workplace Listserv" 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 viewpoints or opinions and are not assessed for validity, reliability, or quality. The "SAMHSA Prevention of Prescription Drug Abuse in the Workplace Listserv" 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 journal articles.
The Injury Control Research Center at West Virginia University (WVU-ICRC) archives past Listserv issues at http://www.hsc.wvu.edu/icrc/Pages/SAMHSA-Prevention-of-Prescription-Drug-Abuse-in-th. The partnership efforts of WVU-ICRC are supported by Grant Number 1 R49 CE002109 from the Centers for Disease Control and Prevention (CDC). The contents of the Listserv archive are solely the responsibility of the authors and do not represent the official views of CDC or SAMHSA.
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