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July 9, 2014

 

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SAMHSA
SAMHSA Prescription Drug Abuse Weekly Update
WEEKLY
UPDATE
Issue 79  |  July 9, 2014
The Prevention of Prescription Drug Abuse in the Workplace (PAW) TA Center addresses prescription drug abuse—a growing public health problem with increasing burdens on workers, workplaces, and our economy. To subscribe colleagues, family members, or friends to this listserv sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), please click here or send their e-mail addresses to paw@dsgonline.com.
Table of Content Featured Article Journal Articles and Reports Professional Education News Other State and Local News Other Resources Request for Proposal Take-Back Events and Drop Boxes Save the Date Upcoming Conferences and Workshops

Featured

Neonatal Abstinence Syndrome—Strategies for States and Health Plans
National Institute for Health Care Management Foundation and the Association of State and Territorial Health Officials
July 16, 2014
1:30 p.m. (EST)

This Webinar will highlight strategies for preventing and treating neonatal abstinence syndrome (NAS). Speakers will discuss recent trends in opioid abuse and NAS, with an overview of federally led prevention efforts, the impact of rising NAS rates across states, implications for Medicaid, examples of state-level action, a health plan–led initiative to improve care coordination and social support for pregnant women in addiction treatment, the latest in NAS treatment, and an assessment of where public and private investments would be most beneficial.

Read more:
http://www.nihcm.org/webinar-neonatal-abstinence-syndrome-strategies-for-states-and-health-plans

H. Johnson, L. Paulozzi, C. Porucznik, K. Mack, and B. Herter. 2014. "Decline in Drug Overdose Deaths After State Policy Changes—Florida, 2010–2012." Morbidity and Mortality Weekly Report 63:1–6.

From 2003 to 2009, the number of deaths caused by drug overdoses in Florida increased 61.0 percent, from 1,804 to 2,905. In 2010, Florida's legislature implemented laws regulating pain clinics; in 2011, the state prohibited prescribers from dispensing opioid analgesics from their offices. After the legislation took effect, overdose death rates for opioid analgesics declined 27.0 percent, from 13.6 to 9.9 per 100,000 population, and overdose death rates for benzodiazepines declined 28.4 percent, from 6.9 to 5.0 per 100,000. Heroin overdose death rates increased 122.4 percent, from 0.3 to 0.6 per 100,000. But the overall drug overdose death rate declined 17.7 percent, from 17.0 to 14.0 per 100,000.

Read more:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm63e0701a2.htm?s_cid=mm63e0701a2_w

Journal Articles and Reports

L. Ashrafioun, P.C. Edwards, A.S.B. Bohnert, and M.A. Ilgen. 2014. "Nonmedical Use of Pain Medications in Dental Patients." The American Journal of Drug and Alcohol Abuse 40(4):312–16, doi:10.3109/00952990.2014.930152.

Patients (n=369) completed a survey in the waiting area of a university dental school's low-cost emergency and routine dental services training clinic. Approximately 38 percent reported nonmedical use of pain medications within the past 30 days. Use was associated with medication diversion, as well as use of tobacco, marijuana, and sedatives.

Read more:
http://informahealthcare.com/doi/abs/10.3109/00952990.2014.930152

Y.P. Balhara. 2014. "A Chart Review Based Comparative Study of Retention Rates for Two Dispensing Regimens for Buprenorphine for Subjects with Opioid Dependence at a Tertiary Care Substance Use Disorder Treatment Center." Journal of Opioid Management 10(3):200–6, doi:10.5055/jom.2014.0208.

A tertiary-level substance use disorder treatment center used case records of opioid-dependent patients to compare daily dispensing and alternate-day dispensing regimens for buprenorphine. Neither 1-year retention nor prescription refill rate differed between the 52 subjects on daily dispensing and the 62 subjects on alternate-day dispensing.

Read more:
http://www.ncbi.nlm.nih.gov/pubmed/24944070

B. Blanch, S. Pearson, and P.S. Haber. 2014. "An Overview of the Patterns of Prescription Opioid Use, Costs and Related Harms in Australia." British Journal of Clinical Pharmacology, doi:10.1111/bcp.12446.

Australian researchers studied national prescription opioid trends using dispensing claims from the subsidized Pharmaceutical Benefits Scheme, hospitalizations from the National Hospital Morbidity Database, and deaths according to the Australian Bureau of Statistics. Between 1992 and 2012, opioid dispensing in Australia increased 15-fold (500,000 to 7.5 million), and the cost to the Australian government increased 32-fold ($8.5 million to $271 million). Opioid-related hospitalizations increased from 605 to 1,464 cases (1998–2009), outnumbering hospitalizations due to heroin poisonings since 2001. Deaths resulting from accidental poisoning (pharmaceutical opioids and illicit substances combined) increased from 151 to 266 (2002–11), resulting in a rise in the death rate from 0.78 to 1.19 deaths per 100,000 population over 10 years. Death rates increased 1.8-fold among males and 1.4-fold among females.

Read more:
http://onlinelibrary.wiley.com/doi/10.1111/bcp.12446/abstract

S. King. 2014. "Oxycontin in Ontario: The Multiple Materialities of Prescription Painkillers." International Journal on Drug Policy 25(3):486–93, doi:10.1016/j.drugpo.2013.12.016.

This jargon-laden article examines OxyContin marketing and how the drug's use became a problem in Ontario. The analysis draws on a broad range of media, legislative, and research reports from 2009–13, and the author concludes that the pharmaceutical industry and state government's different views of the problem diverged even more as media pressure helped produce the notion of a public health crisis. By focusing on the impossible task of distinguishing proper from improper use, the drug's advocates sought to protect the concept of opioid pain relievers as maintaining a body that is normal, stable, and in control.

Read more:
http://www.ncbi.nlm.nih.gov/pubmed/24612641

J.L. McCauley, M.A. Mercer, K.S. Barth, K.T. Brady, and S.E. Back. 2014. "Pain Management Perceptions Among Prescription Opioid Dependent Individuals." Drug and Alcohol Dependence, doi:10.1016/j.drugalcdep.2014.06.024.

This study examined perceptions of medical chronic pain management among a convenience sample of 39 people who were prescription–opioid dependent and reported a history of chronic pain treatment. Reports of insufficient pain management were common (46 percent), as was use of emergency room services for pain management (56 percent). Nearly half reported a physician as their initial source (46 percent) and pain management as their primary initial reason for prescription opioid use (54 percent); 36 percent reported pain relief as their primary reason for current prescription opioid use. Symptoms of depression were common (51 percent), as was other substance abuse and a history of substance abuse treatment.

Read more:
http://www.sciencedirect.com/science/article/pii/S0376871614009466

S. Nielsen, M. Hillhouse, L. Mooney, A. Ang, and W. Ling. 2014. "Buprenorphine Pharmacotherapy and Behavioral Treatment: Comparison of Outcomes Among Prescription Opioid Users, Heroin Users and Combination Users." Journal of Substance Abuse Treatment, doi:10.1016/j.jsat.2014.06.006.

Researchers from a buprenorphine treatment program tested whether 54 prescription opioid abusers had better treatment outcomes than 54 heroin abusers or 71 combination heroin and prescription opioid abusers. The prescription opioid group provided more opioid-negative urine drug screens over the treatment period (prescription opioid: 70 percent, combined: 40 percent, heroin: 38 percent). Retention was lowest in the heroin group (prescription opioid: 80 percent, combined: 65 percent, heroin: 57 percent). Buprenorphine dose did not differ between groups.

Read more:
http://www.sciencedirect.com/science/article/pii/S0740547214001147

L.J. Paulozzi, K.A. Mack, and J.M. Hockenberry. 2014. "Vital Signs: Variation Among States in Prescribing of Opioid Pain Relievers and Benzodiazepines—United States, 2012." Morbidity and Mortality Weekly Report, 63:1–6.

Analysis of 2012 IMS Health data showed prescribers wrote 82.5 opioid pain relievers and 37.6 benzodiazepine prescriptions per 100 U.S. residents. State rates varied 2.7-fold for opioid pain relievers and 3.7-fold for benzodiazepines. Rates were higher in the South census region, with three Southern states at least two standard deviations above the mean. Rates for long-acting/extended-release and high-dose opioid pain relievers were greatest in the Northeast. Rates varied 22-fold for oxymorphone.

Read more:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm63e0701a1.htm
RELATED NEWS
AMA Statement on Centers for Disease Control and Prevention Vital Signs Report Regarding Prescription Drug Abuse and Prevention
American Medical Association
July 2, 2014

American Medical Association (AMA) President Robert M. Wah strongly agrees with the Centers for Disease Control and Prevention that the United States needs to stop pill mills and illegal prescribing practices. The AMA supports enhanced educational opportunities for physicians and robust prevention efforts that allow physicians to track patients' care in real time, broader implementation of take-back programs, and overdose prevention measures, such as increased access to the lifesaving medicine naloxone.

Read more:
http://www.ama-assn.org/ama/pub/news/news/2014/2014-07-02-cdc-prescription-drug-abuse-prevention.page
R.L. Toblin, P.J. Quartana, L.A. Riviere, K. Clarke Walper, and C.W. Hoge. 2014. "Chronic Pain and Opioid Use in US Soldiers After Combat Deployment." JAMA Internal Medicine, doi:10.1001/jamainternmed.2014.2726.

This study assessed pain and opioid use in non-treatment-seeking active duty infantry 3 months after their return from Afghanistan in 2011. Eighty percent of invitees attended group recruitment briefings, and almost all agreed to participate, with 2,507 soldiers completing surveys. Respondents were predominantly male (93 percent), 18 to 24 years old (41 percent), high school educated (48 percent), married (55 percent), and of junior enlisted rank (56 percent). Nearly half (45 percent) reported injuries during combat, and 15 percent reported past-month opioid use. Among opioid users, 18 percent reported severe pain, 38 percent reported moderate pain, 38 percent reported mild pain, and 6 percent reported no pain; 44 percent reported chronic pain lasting at least 3 months, including 22 percent with durations of 1 year or more. Of those with chronic pain, 56 percent reported nearly daily or constant frequency, 51 percent reported moderate to severe pain, and 23 percent reported often sporadic past-month opioid use.

Read more:
http://archinte.jamanetwork.com/article.aspx?articleid=1885986

H. Wang, J. Deng, X. Zhou, C. Lu, J. Huang, G. Huang, X. Gao, and Y. He. 2014. "The Nonmedical Use of Prescription Medicines Among High School Students: A Cross-Sectional Study in Southern China." Drug and Alcohol Dependence 141:9–15, doi:10.1016/j.drugalcdep.2014.04.004.

From 2007 to 2009, 21,672 middle and high school students were surveyed in seven cities of Guangdong Province, China. Six percent of respondents reported lifetime nonmedical use of prescription medicines—typically, occasional analgesics or cough medicine with codeine. Living arrangements, available money, social friends, and smoking correlated with nonmedical use of prescription drugs.

Read more:
http://www.ncbi.nlm.nih.gov/pubmed/24875678

Professional Education

E. Harstad and S. Levy. 2014. "Attention-Deficit/Hyperactivity Disorder and Substance Abuse." Pediatrics 134:e293–e301, doi:10.1542/peds.2014-0992.

This clinical report presents practical strategies for reducing the risk of substance use disorders in patients with attention deficit hyperactivity disorder, and provides suggestions for safe stimulant prescribing.

Read more:
http://pediatrics.aappublications.org/content/134/1/e293.full.pdf+html

R. Morrison, C. Haller, and R. Harwood. "State Substance Abuse Agencies, Prescription Drugs, and Heroin Abuse: Results from a NASADAD Membership Inquiry (2014 Update)." National Association of State Alcohol and Drug Abuse Directors, Washington, D.C., 2014.

This slide presentation reports on a membership survey of the National Association of State Alcohol and Drug Abuse Directors (NASADAD). The survey found the following: state substance abuse agencies rate prescription drug abuse and heroin abuse as very important issues, a majority of states have seen an increase in heroin treatment admissions over the past 2 years, and recent state efforts include expanding medication-assisted treatment and access to naloxone/overdose prevention, enacting legislation, and convening task forces. The presentation also covers the problem's scope, federal agency actions and influences, and state efforts to combat prescription drug and heroin abuse.

Read more:
http://www.ncjrs.gov/App/publications/abstract.aspx?ID=268921

News

The Obama Administration Does Not Approve of a Law Making It a Crime to Use Drugs While Pregnant
The Washington Post
July 1, 2014

In Tennessee, a woman found using drugs is charged with a misdemeanor. But the charges will be dropped if she enters treatment while pregnant and completes it after giving birth. Some are concerned that Tennessee law and other punitive measures aimed at pregnant addicts nationwide could drive women away from prenatal care because they are afraid they will be arrested or charged with child abuse. Michael Botticelli, acting director of the White House Office of National Drug Control Policy, said it does not seem to serve anyone well to attach criminal penalties to people who have addiction disorders, particularly pregnant women.

Read more:
http://www.washingtonpost.com/blogs/post-politics/wp/2014/07/01/the-obama-administration-does-not-approve-of-a-law-making-it-a-crime-to-use-drugs-while-pregnant

RBCC Developing New Tech to Help Prevent Deaths from Prescription Overdoses
The Wall Street Journal
July 2, 2014

Rainbow Biosciences and TheraKine are developing an injectable, sustained-release technology to improve patients' use of naltrexone. This summer, Rainbow Coral Corporation will focus on demonstrating the new technology's readiness for market.

Read more:
http://online.wsj.com/article/PR-CO-20140702-902843.html

FDA Looks to Twitter to Raise Drug Awareness
Jason Wahler, The Huffington Post
June 30, 2014

The Food and Drug Administration has proposed a bill requiring prescription drug manufacturers and dispensers to use Twitter to warn prescription fillers about drug-related risks. This author is skeptical such use of social media will educate the public about prescription drug abuse.

Read more:
http://www.huffingtonpost.com/jason-wahler-/healthy-living-news_b_5523484.html?utm_hp_ref=healthy-living

Other State and Local News

Tennessee Teens' Appetite for Hard Drugs Grows
Tom Wilemon, The Tennessean
July 2, 2014

The 2013 Youth Risk Behavior Surveillance Report showed Tennessee teenagers are using heroin and injecting drugs at twice the national average. Nineteen percent of Tennessee's high school students said they had taken prescription drugs without a prescription.

Read more:
http://www.tennessean.com/story/news/health/2014/06/30/tennessee-teens-appetite-hard-drugs-grows/11710573

Critics: Docs Part of Crisis
Matt Stout, Boston Herald
July 2, 2014

Massachusetts physicians rank eighth nationally and third in New England—behind Maine and New Hampshire—in prescribing OxyContin and other opiates. Dr. Leonard Paulozzi, a medical epidemiologist at the Centers for Disease Control and Prevention, said the state's surge in prescribing opiates could stem from a "non-consensus among providers ... where doctors are going based on their opinion or norms of their community" instead of solid guidelines. Dr. Andrew Kolodny, president of Physicians for Responsible Opioid Prescribing and chief medical officer of Phoenix House, blamed the surge on one of Massachusetts's mandated educational programs for physicians. It was developed by Boston University with funding from the pharmaceutical manufacturers of OxyContin and other opiates.

Read more:
http://bostonherald.com/news_opinion/local_coverage/2014/07/critics_docs_part_of_crisis

R.I. Use of Prescription Sedatives Is 4th Highest in Nation
Lynn Arditi, Providence Journal
July 1, 2014

Rhode Island ranked fourth highest in the nation for its use of prescription sedatives in 2012, primarily benzodiazepines prescribed in combination with opioid pain relievers. The state's healthcare providers wrote an average of 60 prescriptions for benzodiazepines per 100 people, compared with a national average of 38 per 100. The state ranked 17th nationally in its prescribing rate for high-dose opioid pain relievers, and 19th for long-acting/extended-release prescription opioids.

Read more:
http://www.providencejournal.com/breaking-news/content/20140701-r.i.-use-of-prescription-sedatives-is-4th-highest-in-nation.ece

Pain Pills on the Streets Rarely Come from Dealers
Curt Brown, South Coast Today
July 1, 2014

While speaking at a meeting about the prescription drug problem and how it relates to the workplace, Carl Alves, director of Drug Free New Bedford, said people get pain relievers from families and friends who do not secure or safely dispose of their medication. (Editor's note: More recent research shows opioid abusers typically get their drugs from dealers or by doctor shopping.) Katie Gilfeather, director of Outlook Employee Assistance Program of New Bedford, said the problem surfaces in the workplace through employee accidents, absenteeism, higher healthcare costs, loss of productivity, employee morale, turnover, and litigation. She urged Massachusetts businesses to stop denying the problem exists and to promote drug-free workplaces, including employee assistance.

Read more:
http://www.southcoasttoday.com/apps/pbcs.dll/article?AID=/20140701/NEWS/407010338/1001

MGH to Screen All Patients for Substance Abuse
Liz Kowalczyk, The Boston Globe
June 30, 2014

Soon, Massachusetts General Hospital will ask all patients questions about their use of alcohol and illegal drugs. If the battery of four questions reveals possible addiction, doctors can summon a special team to conduct a "bedside intervention" and, if needed, arrange treatment. As part of a 10-year strategic plan, Massachusetts General plans to spend at least $1.4 million annually on a new addiction screening and treatment program. It will hire five "recovery coaches" to work at the hospital and three community health centers. The hospital also plans to phase in screening for outpatients and establish an addiction discharge clinic.

Read more:
http://www.bostonglobe.com/lifestyle/health-wellness/2014/06/29/mass-general-hospital-plans-screen-all-patients-for-alcohol-and-illegal-drug-use/RmDqYAUpFuQql1e1LLicKI/story.html

FBI: Wisconsin Heroin Abuse Growing as Abusers Seek Cheap Alternative to Prescription Pills
Dinesh Ramde, Star Tribune
July 1, 2014

The Wisconsin Heroin Assessment conducted by the FBI, Drug Enforcement Administration, and three state anti-drug agencies revealed a spike in heroin use since about 2008. Users, typically white males ages 21–25, generally started by abusing prescription opioids.

Read more:
http://www.startribune.com/politics/national/265420241.html

Westmoreland Drug Deaths Outpace 2013's Record Rate
Richard Gazarik, Trib Total Media
July 1, 2014

Coroner Ken Bacha said Westmoreland County, Pa., recorded 86 drug-related deaths in 2013 and expects to see about 100 deaths in 2014. Nineteen of the 49 overdose deaths this year were caused by heroin; the coroner believes four of eight pending cases also involve heroin. Pennsylvania and the United States Attorney's Office in Pittsburgh have set up task forces to study the problem and draft recommendations for reducing the death rate.

Read more:
http://triblive.com/news/westmoreland/6376681-74/drug-heroin-overdose#axzz36KfBehpQ

Prescription Drugs Impair Drivers Without Their Knowledge
Karissa Shatzer, WHTM
July 3, 2014

The Pennsylvania Driving Under the Influence (DUI) Association said the number of people driving under the influence of alcohol is decreasing, but the number of people driving under the influence of drugs is increasing. DUI drug arrests in Pennsylvania nearly tripled, from 5,529 in 2004 to 16,564 in 2013—many for prescription drugs. Some were taking doctor-prescribed medications and did not know they were driving under the influence. George Geisler of the Pennsylvania DUI Association said the medical community has to do a better job of educating consumers about the drugs they are prescribing.

Read more:
http://www.abc27.com/story/25927940/dui-and-didnt-know-it

Local Woman Looks to Phone App to Curb Prescription Drug Abuse
Roland Beres, KIVI
June 30, 2014

This article and video (2:55 minutes) discuss prescription drug abuse in Idaho and how one woman hopes a free phone app will help children in grades K–3 realize the dangers of prescription medications. (Editor's note: Is this too young for health education?) Her son was prescribed pain pills for a soccer injury and overdosed after becoming addicted.

Read more:
http://www.jrn.com/kivitv/news/Local-woman-looks-to-phone-app-to-curb-prescription-drug-abuse-265311431.html

Podiatrist Charged with Writing Thousands of Illegal Prescriptions
The Daily Journal
June 30, 2014

The Alameda County District Attorney charged a California podiatrist with unlawfully dispensing addictive narcotics to patients. Dr. Tan Nguyen wrote more than 5,000 prescription opioid scripts between June 2013 and June 2014, often without examining patients or asking any health-related questions. Nguyen was convicted in 2008 of selling illegal narcotic prescriptions.

Read more:
http://www.smdailyjournal.com/articles/lnews/2014-06-30/podiatrist-charged-with-writing-thousands-of-illegal-prescriptions/1776425125778.html

Other Resources

2014 Harold Rogers PDMP South Regional Meeting
Prescription Drug Monitoring Program Training and Technical Assistance Center, Brandeis University
Accessed July 2, 2014

Copies of presentations from the April 29–30, 2014 South Regional Meeting in Charleston, S.C., are available. Among the topics covered were Mandatory Enrollment and Use of Prescription Drug Monitoring Program Data, Prescription Drug Monitoring Program Data for Research or Surveillance Tools, Interstate Operability Between Hubs, and New Initiatives with the PMIX Architecture.

Read more:
http://www.pdmpassist.org/content/2014-south-regional-meeting

Request for Proposal

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

Take-Back Events and Drop Boxes

Ames Police Install New Prescription Drug Drop Box
Ames Tribune (Iowa)
June 28, 2014
http://amestrib.com/news/ames-police-install-new-prescription-drug-drop-box

Free Prescription Drug Collection Event Set
Corning Observer (California)
July 1, 2014
http://www.appeal-democrat.com/corning_observer/free-prescription-drug-collection-event-set/article_35a859c8-0187-11e4-a65d-001a4bcf6878.html

City Police to Take Back Drugs, Paraphernalia
Foster's Daily Democrat (New Hampshire)
July 2, 2014
http://www.fosters.com/apps/pbcs.dll/article?AID=/20140702/GJNEWS_01/140709867/-1/FOSNEWS

Save the Date

Sixth Annual American Medicine Chest Challenge
National Day of Awareness and Safe Disposal of Rx and OTC Medicine

American Medicine Chest Challenge
November 8, 2014
http://www.americanmedicinechest.com

Upcoming Conferences and Workshops

Prescription Drug Abuse: Crisis in Oklahoma Workshop
Oklahoma Bureau of Narcotics & Dangerous Drugs Director Darrell Weaver
July 11, 2014
Ada, Oklahoma
https://www.ecok.edu/event/prescription-drug-abuse-crisis-oklahoma-workshop

Clinical Challenges in Opioid Prescribing: Balancing Safety and Efficacy
Colorado Prescription Drug Abuse Prevention Program of Peer Assistance Services, Inc. and SAMHSA
July 11, 2014
Denver, Colorado
http://peerassistanceservices.org/events/clinical-challenges-in-opioid-prescribing

Pharmacy Diversion Awareness Conference
U.S. Department of Justice, Drug Enforcement Administration
July 12–13, 2014—Sheraton Philadelphia (Pa.) Downtown Hotel
August 2–3, 2014—Denver (Colo.) Marriott Tech Center
http://www.deadiversion.usdoj.gov/mtgs/pharm_awareness

CADCA's Mid-Year Training Institute 2014
July 20–24, 2014
Orlando, Florida
http://www.cadca.org/events/detail/mid-year-training-institute-2014

Prevention of Youth Substance Abuse in Rural Communities Conference: Bringing Hope to Communities in Despair
Coalition for Healthy Youth
August 6–8, 2014
Lancaster, South Carolina
http://www.lcpartnersforyouth.org/Coalition

Preventing Prescription Drug Abuse—Non-Members
New Jersey Pharmacists Association
August 7, 2014
Secaucus, New Jersey
http://njpharmacists.org/events#id=107&cid=955&wid=201&type=Cal

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

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

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