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June 16, 2016

PAW Weekly Update

SAMHSA Prescription Drug Abuse Weekly Update
Issue 178  |  June 16, 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.
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V. Thumula, D. Wang, and T-C. Liu. “Interstate Variations in Use of Opioids, 3rd Edition. June 2016.” Workers Compensation Research Institute, WC-16-22.

A comparison of workers’ compensation claims in 25 states shows opioid prescriptions have declined in most, but vary state to state. In 2012–14, 65–80 percent of injured workers with pain medications received opioids in most states. That rate was highest in Arkansas (86 percent) and Louisiana (85 percent) and lowest in New Jersey (54 percent) and Illinois (56 percent). In Louisiana and New York, the average worker who missed at least 7 days from work received over 3,400 mg of morphine-equivalent opioids per claim, which was double the median state dosage of 1,600 mg and more than 3 times the dose in states with the lowest use (Missouri, for example). Pennsylvania was also high at 2,860 mg, well above the state median. Many factors may be associated with the interstate variations, including workers’ compensation policies for pharmaceuticals, policies outside workers’ compensation, and industry practices.

Read more:

E. Sundstrup, M.D. Jakobsen, M. Brandt, K. Jay, J.Z.N. Ajslev, and L.L. Andersen. 2016. “Regular Use of Pain Medication Due to Musculoskeletal Disorders in the General Working Population: Cross-Sectional Study among 10,000 Workers.” American Journal of Industrial Medicine, doi:10.1002/ajim.22612.

The 2010 round of the Danish Work Environment Cohort Study obtained data from 10,024 employed workers (a 53 percent response rate). Twenty-two percent used pain relievers regularly in the past year due to musculoskeletal disorders, with 8 percent using prescription drugs and 14 percent using over-the-counter drugs. Pain intensity increased the odds for using pain medication in a dose–response fashion. With seated work as reference, the odds for using pain medication were 1.3 for workers engaged in standing or walking work that is not strenuous and 1.6 for workers engaged in standing or walking work with lifting tasks or heavy and fast/strenuous work. Usage was 31 percent in the latter work group, including 11.5 percent use of prescription pain relievers. Women had higher odds than men for using pain medication (odds ratio = 1.4). Odds for using rose .02 per year of age and .04 per point of body mass index.

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Medical Marijuana Legal in Ohio: What Do Employers Do Now?
Stephen Richey, Thompson Hine LLP
June 9, 2016

Ohio has become the 25th state to legalize medical marijuana. Starting in 2017, patients with specific conditions will be able to use an oil, edible, tincture, or vapor form of marijuana prescribed by a licensed physician. They will not be allowed to smoke or grow their own marijuana. And, a commission will be created to regulate and license all operations of the drug. Employers can continue to set drug policy, including drug testing and maintaining a drug-free workplace and zero tolerance, including for marijuana. Or, employers can adopt a more lenient policy for employees who use marijuana under a doctor’s guidance. Employers should review all drug-related policies, such as onboarding drug tests, injury reporting policies, leave policies, and policies regarding the use of legally prescribed drugs.

Read more:

Journal Articles and Reports

Y. Bao, Y. Pan, A. Taylor, S. Radakrishnan, F. Luo, H.A. Pincus, and B.R. Schackman. 2016. “Prescription Drug Monitoring Programs are Associated with Sustained Reductions in Opioid Prescribing by Physicians.” Health Affairs 35(6):1045–51, doi:10.1377/hlthaff.2015.1673.

Multivariate analysis of 2001–10 National Ambulatory Medical Care Survey patient data from 24 states showed that implementation of a prescription drug monitoring program (PDMP) was associated with a 30 percent reduction in the prescribing of Schedule II opioids. This reduction immediately followed PDMP launch and was maintained in the 2nd and 3rd years afterward. Effects on overall opioid prescribing and prescribing of non-opioid analgesics were limited. In the 10-year pooled sample of 26,275 visits, 5 percent resulted in prescription of at least one Schedule II opioid, 15 percent in at least one opioid analgesic of any kind, 41 percent in any pain medication, and 24 percent in at least one non-opioid analgesic. None of the PDMPs studied mandated provider participation.

Read more:

M.M. Bassiony, U.M. Youssif, R.A. Hussein, and M. Saeed. 2016. “Psychiatric Comorbidity Among Egyptian Patients with Opioid Use Disorders Attributed to Tramadol.” Journal of Addiction Medicine, doi:10.1097/ADM.0000000000000231.

This study of 100 patients with opioid use disorders attributed to tramadol and a control group of 100 patients (matched for age, sex, and education) recruited from Zagazig University Hospital in Egypt found that 24 percent of patients with use disorders used tramadol only and 76 percent also used other substances; 91 percent had tramadol dependence. Forty-nine percent had psychiatric comorbidity, especially mood disorders (59 percent), whereas only 24 percent of control patients had psychiatric comorbidity, especially anxiety disorders (83 percent). The most common personality disorders among use disorder patients were borderline (24 percent) and antisocial (22 percent). In the control group, the most common personality disorders were obsessive compulsive personality disorder (8 percent) and avoidant personality disorder (7 percent).

Read more:

E.E. Bonar, and A.S.B. Bohner. 2016. “Perceived Severity of and Susceptibility to Overdose Among Injection Drug Users: Relationships with Overdose History.” Substance Use & Misuse doi:10.3109/10826084.2016.1168447.

In 2009–10, 91 injection drug users attending needle exchange programs in Cleveland OH and Grand Rapids MI completed self-report surveys. Fifty-five percent of participants reported lifetime overdose, with a mean of 2.9 overdoses. In multivariate regression, younger current age, older age of first injection, non-Caucasian race, higher perceived severity of overdose, and lower perceived susceptibility to overdose were significantly correlated with fewer lifetime overdoses.

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H. Carliner, K.M. Keyes, K.A. McLaughlin, J.L. Meyers, E.C. Dunn, S.S. Martins. 2016. “Childhood Trauma and Illicit Drug Use in Adolescence: A Population-Based National Comorbidity Survey Replication–Adolescent Supplement Study.” American Academy of Child and Adolescent Psychiatry, doi:10.1016/j.jaac.2016.05.010.

The National Comorbidity Survey Replication–Adolescent Supplement (NCS-A) included 9,956 adolescents ages 13–18. Thirty-six percent were exposed prior to age 11 to potentially traumatic events that could cause posttraumatic stress disorder. Logistic regression showed exposure was associated with higher risk for misuse of marijuana (risk ratio [RR] = 1.5), prescription drugs (RR=1.8), cocaine (RR = 2.8), other drugs (RR=1.9), and multiple drugs (RR=1.7). Relative risk rose with number of potentially traumatic events for marijuana, other drug, and multiple drug misuse. Among adverse events, interpersonal violence was associated with all drug use outcomes. Unintentional injuries were associated with higher risk for marijuana, prescription drug, and cocaine misuse.

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K. DeBeck, E. Wood, H. Dong, S. Dobrer, K. Hayashi, J. Montaner, and T. Kerr. 2016. “Non-Medical Prescription Opioid Use Predicts Injection Initiation Among Street-Involved Youth.” International Journal of Drug Policy, doi:10.1016/j.drugpo.2016.05.009.

Among 462 injection-naïve, street-involved youth in Vancouver, Canada, recruited from September 2005 to May 2014, 39 percent reported having ever misused a prescription opiate via non-injection. During study follow up, 21 percent started injecting opiates. In multivariable Cox regression analysis, a baseline history of prescription opiate misuse was independently associated with time to injection initiation ((adjusted relative hazards [AHR] = 1.7). In sub analysis, Dilaudid was the category of prescription opiate most highly associated with injection initiation (AHR = 1.9).

Read more:

N. Gisev, S. A. Pearson, B. Blanch, B. Larance, T. Dobbins, S. Larney, and L. Degenhardt. 2016. “Initiation of Strong Prescription Opioids in Australia: Cohort Characteristics and Factors Associated with the Type of Opioid Initiated.” British Journal of Clinical Pharmacology doi:10.1111/bcp.13026.

Pharmaceutical Benefits Scheme dispensing records were extracted for a 10 percent sample of Australians who were prescribed buprenorphine, fentanyl, hydromorphone, morphine, or oxycodone between October 2009 and December 2013 but were not prescribed these drugs in the preceding 90 days. The cohort consisted of 125,335 people: 58 percent were female and 64 percent were age 65 and over. The most commonly initiated strong opioid was oxycodone (73 percent), usually 5 mg immediate-release tablets (76 percent). Compared to people ages 18–44, those age 85 and older were 14.2 times as likely to initiate morphine than oxycodone. Compared to people without a cancer treatment history, those with a cancer treatment history were 2.3 times as likely to initiate morphine than oxycodone.

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L. Kann, T. McManus, W.A. Harris, S.L. Shanklin, K.H. Flint, J. Hawkins, B. Queen, R. Lowry, E. O’Malley Olsen, D. Chyen, L. Whittle, J. Thornton, C. Lim, Y. Yamakawa, N. Brener, and S. Zaza. “Youth Risk Behavior Surveillance – United States.” Morbidity and Mortality Weekly Report 65(6):1–174. June 10, 2016.

This report summarizes results from the 2015 Youth Risk Behavior Surveillance System national survey, 37 state surveys, and 19 large urban school district surveys conducted among students in grades 9–12. Nationally, lifetime prescription drug misuse among youth decreased from 20 percent in 2011 to 17 percent in 2015. Across 32 states, the prevalence of having ever taken prescription drugs without a doctor’s prescription ranged from 11–19 percent. Across 17 large urban school districts, the prevalence ranged from 8–16 percent. The prevalence of having ever used marijuana decreased from 47 percent in 1997 to 39 percent in 2015. Nine percent had used synthetic marijuana.

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A. Kennedy-Hendricks, E.E. McGinty, and C.L. Barry. 2016. “Effects of Competing Narratives on Public Perceptions of Opioid Pain Reliever Addiction During Pregnancy.” Journal of Health Politics, Policy and Law, doi:10.1215/03616878-3632230.

Researchers fielded a six-group randomized experiment among a nationally representative sample of U.S. adults to test the effects of differing narratives portraying a woman with opioid pain reliever addiction during pregnancy. Portraying a high socioeconomic status (SES) woman in the narrative lowered perceptions of individual blame for addiction and reduced public support for punitive policies. Depicting the barriers to treatment faced by a low SES woman lowered support for punitive policies and increased support for expanded insurance coverage for treatment.

Read more:

H.S. Kim, K.J. Heard, S. Heard, and J.A. Hoppe. 2016. “Opioid Prescription Fill Rates after Emergency Department Discharge.” American Journal of Health-System Pharmacy 73(12): 902–7, doi:10.2146/ajhp150528.

Between September 2011 and February 2012, 2,243 patients received an opioid prescription at discharge from a Denver hospital emergency department where they were diagnosed with dental pain, jaw pain, flank pain, abdominal pain, pelvic pain, back pain, neck pain, knee pain, headache, fracture, or sprain. Of the 2,273, 79 percent filled the prescription, generally on the same day. In multivariate regression, characteristics associated with filling the opioid prescriptions included Caucasian race, being insured by the federal government or through a state indigent assistance program, a chief complaint of back pain, and a history of filling an opioid prescription within the past year. No characteristics were predictive of a prolonged time to filling.

Read more:

S. Naeger, M.M. Ali, R. Mutter, T.L. Mark, and L. Hughey. 2016. “Prescriptions Filled Following an Opioid-Related Hospitalization.” Psychiatric Services, doi:10.1176/appi.ps.201500538.

Among 36,719 patients in 2010–14 MarketScan Commercial Claims and Encounters data who had an opioid-related inpatient admission and received substance use disorder treatment medications, 35 percent did not fill any prescriptions in the 30 days after discharge. One-sixth received opioid dependence medication in the 30 days following discharge. Forty percent filled prescriptions for antidepressants, 16 percent for antipsychotics, 14 percent for benzodiazepines, and 22 percent for opioids.

Read more:

A. Pulver, C. Davison, A. Parpia, E. Purkey, and W. Pickett. 2016. “Nonmedical Use of Prescription Opioids and Injury Risk Among Youth.” Journal of Child & Adolescent Substance Abuse, doi:10.1080/1067828X.2015.1115795.

Among students in grades 9–10 in the nationally representative Canadian Health Behavior in School-Aged Children study, prescription opioid misusers had twice the risk of injury as nonusers, with fighting-related injuries especially likely. This differential persisted after adjusting for demographics, peer drug use, and other substance use. But, it still may merely reflect a greater tendency to take risks.

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O.O. Shiyanbola, P.D. Smith, S.G. Mansukhani, and Y-M. Huang. 2016. “Refining Prescription Warning Labels Using Patient Feedback: A Qualitative Study.” PLoS One, doi:10.1371/journal.pone.0156881.

Hour-long semi-structured interviews with 21 patients ages 23–66 sought views on variations of the five most commonly used prescription warning labels: Do not Drink Alcohol, Take with Food, Take with a Full glass of Water, Do not Chew or Break, and Protect from Sunlight. Patients preferred including the word “WARNING” on the label to create alertness, a picture together with the text, yellow highlighting behind the text, and label placement on the front of the pill bottle. Although patients had positive opinions of the redesigned labels, they wanted further improvements to content and design for enhanced clarity and understandability.

Read more:

C. Tjagvad, S. Skurtveit, K. Linnet, L.V. Andersen, D.J. Christoffersen, and T. Clausen. 2016. “Methadone-Related Overdose Deaths in a Liberal Opioid Maintenance Treatment Programme.” European Addiction Research 22(5):249–58, doi:10.1159/000446429.

During 2008–11, 130 drug overdose deaths (71 percent of all overdose deaths) in the Denmark municipalities of Copenhagen, Aarhus, and Odense involved methadone. Among these, 63 percent were receiving methadone-assisted treatment (MAT). Among MAT deaths, 79 percent involved benzodiazepines. Concomitant detection of heroin, non-prescribed benzodiazepines, and younger age were associated with having non-prescribed methadone in the toxicological findings (adjusted odds ration = 3.1, 4.0 and 9.5, respectively). Of the decedents, 44 percent were prescribed a higher methadone dose than recommended (greater than 120 mg daily), and 80 percent of those did not have supervised intake of methadone.

Read more:

M.M. Van Handel, C.E. Rose, E.J. Hallisey, J.L. Kolling, J.E. Zibbell, B. Lewis, M.K. Bohm, C.M. Jones, B.E. Flanagan, AEA. Siddiqi, K. Iqbal, A.L. Dent, J.H. Mermin, H. Jonathan, E. McCray, J.W. Ward, and J.T. Brooks. 2016. “County-level Vulnerability Assessment for Rapid Dissemination of HIV or HCV Infections among Persons who Inject Drugs, United States.” Journal of Acquired Immune Deficiency Syndromes, doi:10.1097/QAI.0000000000001098.

This study used confirmed cases of acute hepatitis–C virus (HCV) infection reported to the National Notifiable Disease Surveillance System, 2012–13, as a proxy outcome for injection drug use (IDU). Of 15 county-level indicators, Poisson regression identified six that predicted HCV infection rates: drug overdose deaths; prescription opioid sales; per capita income; white, non-Hispanic race/ethnicity; unemployment; and buprenorphine prescribing potential by waiver. Based on these indicators, 220 counties in 26 states were within the 95th percentile of most vulnerable for HCV/IDU. Most of the 220 are rural, and 56 percent are in Kentucky, Tennessee, and West Virginia.

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Workplace Well-Being Linked to Senior Leadership Support, New Survey Finds
American Psychological Association
June 1, 2016

The American Psychological Association’s 2016 Work and Well-Being Survey, conducted online among more than 1,500 U.S. adults in March, showed that only one-third of American workers regularly participate in the health promotion programs provided by their employer. The survey also revealed that only 44 percent of working Americans say the climate in their organization supports employee well-being, and 1 in 3 reports being chronically stressed on the job. The survey suggests a key part of the solution is senior leadership support. Nearly three-fourths of employees with senior managers who show support through involvement and commitment to well-being initiatives said their organization helps employees develop a healthy lifestyle, compared with just 11 percent who work in an organization without that leadership support.

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High Doses of Loperamide (Imodium) Can Cause Heart Problems
June 7, 2016

The FDA has issued a warning that taking higher-than-recommended doses of loperamide (Imodium) can cause serious heart problems that can lead to death. The majority of reported serious heart problems occurred in individuals who were intentionally misusing high doses of loperamide in attempts to self-treat opioid withdrawal symptoms or to achieve a feeling of euphoria. The FDA makes some recommendations for health care professionals to follow. Patients and consumers should only take loperamide in the dose directed by their doctor or according to the over-the-counter drug facts label.

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FDA Targets Unlawful Internet Sales of Illegal Prescription Medicines
June 9, 2016

The FDA has taken action against 4,402 websites that illegally sell potentially dangerous, unapproved prescription drugs to U.S. consumers. This effort was part of a global cooperative effort, led by Interpol, to combat the unlawful sale and distribution of illegal and potentially counterfeit medical products on the internet. The FDA enforcement action ran from May 31 to June 7, 2016. FDA sent formal complaints to domain registrars requesting the suspension of the 4,402 websites. They also issued warning letters to the operators of 53 websites illegally offering unapproved and misbranded prescription drug products for sale to U.S. consumers. Preliminary findings from drug products screened at international mail facilities show that U.S. consumers had purchased unapproved drug products from abroad to treat depression, narcolepsy, high cholesterol, glaucoma, and asthma, among other diseases.

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Pfizer’s Abuse-Resistant Opioid Nears U.S. Market
Selina McKee, Pharma Times
June 9, 2016

An FDA advisory panel has recommended approval of Pfizer’s abuse-resistant opioid pain reliever ALO-02 (oxycodone hydrochloride/naltrexone hydrochloride), an extended-release capsules for round-the-clock management of pain severe enough to require daily long-term opioid treatment. ALO-02 consists of extended-release oxycodone pellets that surround a sequestered core of naltrexone. When the pellets are crushed, the naltrexone is released to counteract the effects of oxycodone. Clinical trials data showed that the drug is as safe as other opioids on the market, the most common side effects being headache, nausea, vomiting, and constipation.

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Campaign Aims to Promote Physical Therapy as Alternative to Opioids
Physical Therapy Products
June 6, 2016

The American Physical Therapy Association has launched #ChoosePT, a campaign to educate the public about opioid misuse and promote physical therapy as a healthy and safe alternative for pain management. The campaign will focus on the states which the Centers for Disease Control and Prevention identified as having the highest numbers of opiate overdose deaths (West Virginia, New Mexico, New Hampshire, Kentucky, Ohio, and Rhode Island), and the highest numbers of opioid prescriptions (Tennessee, Alabama, West Virginia, Oklahoma, Kentucky, and Mississippi).

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Chiropractors: Non-Pharmaceutical Pain Management Safer than Opioids
Business Wire
June 6, 2016

The Foundation for Chiropractic Progress has released a position paper that discusses the value of a conservative, non-pharmacologic approach as an important option for pain management—particularly for back, low back and neck pain, headaches, neuro-musculoskeletal, and other related conditions. The paper suggests prescribers should heed Centers for Disease Control and Prevention guidelines and begin prescribing safer alternatives, such as chiropractic care for chronic pain management; pharmaceutical manufacturers should institute more responsible marketing and physician education that will result in improved prescribing habits; hospital emergency rooms should evaluate their options for managing patients’ pain without the use of opioid pain relievers; payers and plan sponsors should make chiropractic care an accessible, affordable, option for chronic pain relief, with reimbursement of chiropractors as covered providers; and chiropractic services should be expanded in the Department of Defense and Veterans Health Administration systems.

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What Opioid Hysteria Leaves Out: Most Overdoses Involve a Mix of Drugs
Chelsea Carmona, The Guardian
June 8, 2016

Mixing at least one drug with another and tolerance changes are the primary predictors of opioid-related overdoses. This conversation remains absent from the education of users and practitioners. One coroner might attribute an opioid-related overdose death to heroin alone when in fact the death resulted from a combination of heroin and a legally prescribed, low-dose benzodiazepine. Another could attribute the death of a known drug user to overdose, when in fact the death resulted from dehydration, pneumonia or another health condition. The author suggests implementing a national overdose education strategy targeting the immediate factors of opioid-related overdose: drug mixing and tolerance changes.

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Prescription Drug Abuse Among Older Adults Harder to Detect
New York Times
June 10, 2016

Prescription drug misuse among older adults can sometimes be hard to detect. Some older adults become addicted to powerful pain pills to treat their aches and pains of aging, a request to stop back pain or with a low dose of opioids. They have access to multiple doctors and financial resources which can sometimes mask the warning signs. Aging adults build a tolerance for drugs over time and their body’s metabolism begins to slow, which gives drugs a bigger effect. Caregivers and doctors rarely notice the problem at its early stages. An addiction is often discovered only after a bad fall, confusion or an accidental overdose. Even then, it can be dismissed as symptoms of aging.

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A Vaccine for Drug Addiction in the Works
Danielle Prieur, Medill Reports Chicago
February 14, 2016

William Compton, M.D., deputy director of the National Institute on Drug Abuse, at the American Association for Advancement of Science conference in February said a vaccine, which has undergone tests in animal subjects, holds promise for treating drug addiction. The vaccine would “produce an antibody response which would latch onto the drug of use…and because they’re large molecules they will not be able to cross the blood-brain barrier,” he said. This vaccine would be part of a three-part strategy aimed at combatting the drug addiction epidemic which includes: helping addicts, reversing drug overdoses, and preventing addiction.

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The Opioid Epidemic: Finding a Better Prescription for Chronic Pain
Keith Rosenblum, Lockton Companies
February 2016

Outdated biomedical model of pain management have been replaced by the bio-psychosocial pain management model. Behavioral pain assessments, in the form of no-cost questionnaires easily can be conducted with claimants exhibiting early signs of chronic pain.

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Synthetic Drugs Pose Alarming U.S. Overdose Risk
Julia Harte, Reuters
June 7, 2016

U.S. Drug Enforcement Administration Acting Administrator Chuck Rosenberg told a U.S. Senate Committee that synthetic designer drugs pose an “unprecedented” threat for U.S. overdoses and deaths, especially among youth. Synthetic designer drugs continue to spiral because each one needs to be separately banned through a “clunky and cumbersome” process. Sen. Dianne Feinstein (D-Calif.) suggested creating a committee to decide how to classify new synthetic drugs as they appear on the market. Rosenberg has seen an alarming rise in illicit use of fentanyl and overdoses are likely to increase as it is introduced to that market.

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National Strategy to Inform Chronic Pain Disorders in Veterans and Civilians
Florence Chaverneff, Clinical Pain Advisor
June 8, 2016

Robert Kerns, Ph.D., professor of psychiatry, neurology, and psychology at Yale University, is working within the Veterans Health Administration to address chronic pain. Data from Dr. Kerns and other groups suggest that as many as 50 percent of male veterans and 75 percent of female veterans experience chronic pain, largely back pain. Chronic pain in veterans is associated with mental health conditions, high use of healthcare resources, low social support, high levels of emotional distress, and higher rates of military sexual trauma. The largest cluster of medical conditions and diagnoses among veterans returning from Iraq and Afghanistan fall under the category of musculoskeletal and connective tissue disorders. These conditions surpass mental health disorders including traumatic brain injury and posttraumatic stress disorder. Recently, Kerns and his colleague published a special topic issue in Journal of Rehabilitation Research and Development showcasing noteworthy pain research conducted at veterans hospitals.

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P.J. Gates, P. Sabioni, J. Copeland, B. Le Foll, and L. Gowing. 2016. “Psychosocial Interventions for Cannabis Use Disorder.” Cochrane Database of Systematic Reviews, doi:10.1002/14651858.CD005336.pub4.

The authors searched for randomized controlled trials (RCT) published through July 2015 that used a nonpharmacological intervention for cannabis use disorder. The search included any treatment delivered in an outpatient or community setting. They found that 4,045 people participated in 23 RCTs. Fifteen trials took place in the United States, two in Australia, two in Germany and one each in Switzerland, Canada, Brazil, and Ireland. On average treatment was delivered over 7 sessions (range 1–14 sessions) and 12 weeks (range 1–56 weeks). The more intense and longer lasting interventions were the ones that reduced frequency of use and dependency on cannabis. A combination of cognitive behavioral therapy and motivational enhancement therapy offered the best chance of participants reducing their cannabis use in the early stages of treatment. Five of the six studies that looked at providing vouchers in addition to treatment as an incentive to reduce cannabis use found that this type of reward had a positive impact. Little evidence supported use of generic interventions such as drug counseling, social support, relapse prevention and mindfulness.

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W. Hall, and M. Lynskey. 2016. “Evaluating the Public Health Impacts of Legalizing Recreational Cannabis Use in the United States.” Addiction, doi:10.1111/add.13428.

Researchers reviewed the drug policy literature to identify: (1) plausible effects of legalizing adult recreational use on cannabis price and availability; (2) factors that may increase or limit these effects; (3) pointers from studies of the effects of legalizing medical cannabis use; and (4) indicators of cannabis use and cannabis-related harm that can be monitored to assess the effects of these policy changes. Legalization of recreational use will probably increase use in the long term, but the magnitude and timing of any increase is uncertain. It will be critical to monitor: cannabis use in household and high school surveys; cannabis sales; the number of cannabis plants legally produced; and the tetrahydrocannabinol content of cannabis. Indicators of cannabis-related harms that should be monitored include: car crash fatalities and injuries; emergency department presentations; presentations to addiction treatment services; and the prevalence of regular cannabis use among young people in mental health services and the criminal justice system.

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L-T. Wu, H. Zhu, and M.S. Swartz. 2016. “Trends in Cannabis Use Disorders among Racial/Ethnic Population Groups in the United States.” Drug and Alcohol Dependence, doi:10.1016/j.drugalcdep.2016.06.002.

In 2005–13 National Survey on Drug Use and Health data, 1.5 percent of adults met criteria for a cannabis use disorder in the past year, with 66 percent dependent. In all racial/ethnic groups, disorder prevalence remained stable over time despite increasing marijuana use. Odds of weekly cannabis use, monthly cannabis use, and cannabis dependence were greater among black, Native American, and mixed-race adults than white adults, as were odds of cannabis use disorder. Multivariate regression found younger age, male sex, and low education were associated with increased odds of cannabis dependence. The study did not examine if the disorder rate varied among users by demographics.

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M. Zaurova, R.S. Hoffman, D. Vlahov, and A.F. Manini. 2016. “Clinical Effects of Synthetic Cannabinoid Receptor Agonists Compared with Marijuana in Emergency Department Patients with Acute Drug Overdose.” Journal of Medical Toxicology, doi:10.1007/s13181-016-0558-4.

Among 3,739 drug overdose emergency department patients at two New York City teaching hospitals between 2009 and 2013, 87 patients reported proximate exposure to any cannabinoid, with 17 using synthetic cannabinoids. Agitation was likely in the synthetics users, as was cardiotoxicity with dysrhythmia.

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Vermont Governor Signs Expanded Medical Marijuana Bill
June 6, 2016

Vermont’s governor has signed a law expanding the state’s medical marijuana system to cover patients with glaucoma, chronic pain, or under hospice care. The law adds childproof packaging and increased labeling requirements to marijuana infused products sold at dispensaries. The new qualifying conditions for medical marijuana take effect immediately.

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Marijuana Legalization: What’s on the Horizon for California Employers?
Continuing Education of the Bar, California
June 6, 2016

The Adult Use of Marijuana Act is likely to appear on the California ballot in November. If it passes, adults age 21 and over will have the right to possess, use, and grow limited amounts of marijuana for personal, recreational use. This means employers will have to balance the pros and cons inherent in following the regulatory status quo against responding to changing societal views. Employers have the right to maintain a drug-free workplace and they are not required to accommodate “the use, consumption, possession, transfer, display, transportation, sale, or growth of marijuana in the workplace.” This language preserves and clarifies the status quo under the existing Compassionate Use Act. The author believes employers might begin evaluating the possibility of (1) treating recreational marijuana more like alcohol and (2) treating medical marijuana like prescription drugs that have similar side effects. Employers may also need to take a closer look at their testing protocols. Perhaps unwisely, employers may focus more on perceptions of an employee’s actual job performance and less on scientifically debated medical tests or standards. Employers may have to think more creatively about the realities of marijuana use and its effect in the workplace if the initiative passes.

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[Webinar Archive] Human Rights, Accommodation and Medical Marijuana in the Workplace
HR Insider
Recorded: June 8, 2016

This recorded webinar discusses how medical marijuana can impact workplaces in Canada. Topics include: What is Medical Marijuana, Medical Marijuana Laws, Discrimination in Employment, Accommodating Medical Marijuana, Creating Policies for Medical Marijuana in the Workplace, Drug Testing, and more. The webinar includes a downloadable slide deck. (Duration: 1:38:35 minutes)

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Worrying Rise in Accidental Overdose of Prescription Drug Methotrexate
Kate Aubusson, Sydney Morning Herald
June 7, 2016

Methotrexate, a prescription drug used to treat rheumatoid arthritis, psoriasis, and inflammatory bowel disease, has caused 22 deaths in Australia and 91 cases of serious incorrect dosing (patients took the drug three days in a row). Methotrexate is often dispensed in packs of 50 tablets, a year’s supply of the drug that can be mistaken for daily prescription medications. Common reasons for accidental overdosing include mistaking the drug for folic acid, packaging errors at pharmacies, or patients misunderstanding instructions by a doctor or pharmacists. Doctors warned that accidental overdose risk would continue to increase with the ageing population. They recommended reducing pack sizes to just one month’s supply of the drug, or four tablets. They also recommended clear warning on the pack, formulating distinctive colored tablets, and providing prescriber alerts in dispensing software.

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[Video] Maria Sharapova Banned for Two Years over Doping
Washington Post
June 9, 2016

The International Tennis Federation banned Russian tennis player Maria Sharapova for 2 years after she tested positive for the newly banned drug meldonium. Though she had been taking the drug for 10 years, an investigation found that Sharapova had deliberately concealed her use of meldonium from authorities. She will appeal the ban. (Duration: 0:48 minutes)

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Northeast/Mid-Atlantic News

Vermont Governor Signs Law to Set Opiate Pill Limits for Some Procedures
Vermont Biz
June 9, 2016

Vermont’s governor has signed a law that requires the state’s health commissioner to adopt rules governing prescription of opioids for acute pain and limit the number of pills that can be prescribed for some procedures. The rules would apply to all prescribers, including dentists. The law requires prescribers to provide all patients with information and education concerning safe use, storage, and disposal of prescription opioids, and the co-prescribing of naloxone. The law strengthens Vermont’s prescription drug monitoring system by requiring pharmacies to upload data daily and query the system when dispending any opiates. The bill also enhances required training for prescribers and pharmacists on the safe and effective prescribing of controlled substances and identifying misuse and diversion.

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New Hampshire Law Allows Pharmacies to Run Drug-Take Back Boxes
Allie Morris, Concord Monitor
June 8, 2016

New Hampshire’s governor has signed a bill that allows New Hampshire pharmacies to set up drug take-back programs, so long as they comply with federal regulations. The law will take effect in the coming months.

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New England Governors Sound Off on Opioid Crisis
Andy Metzger, Lowell Sun
June 8, 2016

Governors of Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont have pledged to crack down on drug trafficking and share data from prescription drug monitoring programs across state lines. They blame illegal drug dealers, the pharmaceutical industry, and federal regulators for the opioid crisis.

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Oxycontin Maker Accused of Distributing ‘Misleading Information’ to Doctors
Jeremy Blackman, Concord Monitor
June 9, 2016

New Hampshire’s attorney general has accused Purdue Pharma of distributing “misleading information” to doctors about OxyContin. Preliminary findings show that Purdue routinely engaged in deceptive marketing, misrepresenting the “risks and benefits of long-term opioid use for chronic pain,” according to a lawsuit filed by the attorney general. The company’s employees “continue to tell New Hampshire prescribers that OxyContin lasts a full 12 hours; fails to disclose end-of-dose failure and its relationship to addiction; and advises doctors who complain about OxyContin’s shorter-than-promised duration to increase patients’ dosage, which further increases the risk of overdose and addiction.”

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Heroin-Related Deaths Remain Growing Concern in Maryland
Vanessa Herring, WBAL
June 10, 2016

Maryland reported that the number of heroin-related deaths in the state rose 29 percent between 2014 and 2015. During that same time, the number of fentanyl-related deaths nearly doubled. Overall, 1,259 people died from an overdose in 2015. Of those, 86 percent involved illicit or licit opioids. (Includes video: 2:03 minutes)

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New York Releases Plan to Combat Heroin and Opioid Addiction
June 10, 2016

New York’s Heroin and Opioids Task Force has recommended a 25-point plan to address the heroin and opioid epidemic. Recommendations include mandating prescriber education on pain management and addiction; limiting opiate prescriptions for acute pain from 30-days to no more than a 7-day supply, with exceptions for chronic pain and other conditions; removing insurance barriers to inpatient treatment by eliminating prior approval for admission for necessary medical care as long as such inpatient treatment is needed; and expanding access to overdose-reversal medicine.

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New Jersey Terminates Downtown Printing Center’s Ability to Print Prescription Blanks
Mark Iandolo, Legal News Line
June 2, 2016

New Jersey’s acting attorney general has terminated Downtown Printing Center’s ability to print prescription blanks for physicians after allegations the company failed to follow security requirements. The company issued 25,000 blanks to unauthorized individuals. Downtown Printing has agreed to surrender its authority to print blanks for at least three years.

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South News

Insurer Joins Fight Against Prescription Drug Abuse
Joshua Silavent, Gainesville Times
June 9, 2016

Blue Cross and Blue Shield of Georgia has launched the Pharmacy Home program to provide education, monitoring, proper disposal, and enforcement for high-risk members in individual and employer-sponsored plans. The goal is to reduce addiction to opioids and other prescription drugs and improve drug safety and health care quality by establishing one “home” pharmacy to fill patients’ prescriptions. The program notifies prescribers in writing of the decision to include the insured member in the program. The prescriber also receives a three-month member prescription history. This program should help businesses lower workers’ compensation premiums.

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Court: Termination for Conduct Caused by Prescription Side Effects Not Discrimination
Kathryn Russo, Jackson Lewis, P.C.
June 6, 2016

A federal court in Florida has ruled that a Chipotle employee’s termination was not discrimination based on her disability, but rather, it was the result of her employer’s application of a neutral policy that prohibited employees from reporting to work under the influence of drugs or alcohol. Plaintiff Lisa Caporicci, who had informed her employer that she takes medication for bipolar disorder, was fired in 2013 after a supervisor observed her working slowly and incoherently. Chipotle’s drug and alcohol policy prohibits employees from reporting for work or being at work under the influence of alcohol, drugs or controlled substances, or with any detectable amount of alcohol, drugs or controlled substances in their system. Furthermore, employees who take prescription medication that may adversely affect their ability to perform their job must notify their manager prior to starting work. Caporicci filed a disability discrimination claim under federal and state law, arguing that firing her for medication side effects was equal to firing her for her disability.

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Arlington (Texas) Police Seize 72,000 Xanax Tablets from Apartment
Ryan Osborne, Star-Telegram
June 9, 2016

Police recently seized 72,000 Xanax pills, four handguns, and 22 lbs. of marijuana from an apartment in Arlington, Texas. A maintenance worker inspecting an apartment for storm damage noticed marijuana and reported it. The tenant was arrested and charged with possession of a controlled substance with intent to deliver and possession of marijuana.

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Alabama Officials: Greater Access to Heroin Overdose Antidote Will Save Lives
Associated Press
June 9, 2016

Alabama will now allow pharmacists to distribute naloxone and provide unlimited refills to people who may be at risk of having an overdose.

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Opioid Epidemic Drives More Goergia Kids into State Care
Michell Eloy, WABE
June 3, 2016

The Georgia Division of Family and Children Services reported as of mid-April, drug abuse has been a factor in about 40 percent of the nearly 2,400 cases in the state where a child was removed from a family, up from about 25 percent over the same time period just two years ago. In Gilmer County, drug abuse has factored into nearly 80 percent of removals this year. Children most often are removed because of methamphetamine use. Pain reliever misuse is easier to hide. Heroin is also growing in popularity. Statewide, the number of children in foster care has increased to more than 12,500. There are 93 children in state custody right now, about double the norm. The state cannot handle the volume of cases because there are not enough foster homes. (Includes audio: 5:07 minutes)

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Health Insurer, Pharmacists Partner to Battle Opioid Abuse in Kentucky
Louisville Business First
June 3, 2016

WellCare of Kentucky and the Kentucky Pharmacists Association have formed a partnership to encourage drug addicts to use Naloxone. WellCare will provide 1,000 twist-on nasal atomizer devices for certified pharmacists to distribute for free to people who are on Medicaid or do not have insurance coverage. The pharmacists would include the atomizers in overdose kits, which addicts could give to friends or family members.

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The Fight to Stop Fentanyl Abuse in Oklahoma
Mireya Garcia, KTUL
June 3, 20166

Oklahoma’s health department reported that from 2015 to February 2016, 47 people in Oklahoma died of a fentanyl overdoses. The state plans to increase the use of naloxone. The drug is available without a prescription and some police officers carry the antidote when sent to an overdose call. Health professionals recommend that individuals lock up their prescription medications. (Includes video: 2:09 minutes)

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Midwest News

Opioid Prescriptions Fall in Ohio, But Addiction Continues to Kill at Alarming Rates
Casey Ross, Plain Dealer
June 8, 2016

In 2012, Ohio health regulators enacted limits on the amount of opioids prescribed to patients, cutting the number of doses by 11.5 percent over the next three years. However, unintentional deaths from opioids jumped 59 percent between 2012 and the end of 2014. Preliminary data from 2015 indicates the death rate is continuing to climb. In 2014, nearly a quarter of overdose deaths (502) were attributable to fentanyl. The drug was responsible for 84 deaths the year prior. Advocates argue the issue must be dealt with at a legislative level. Federal rules require hospitals to survey patients on how their pain was managed. Poor reviews can result in reimbursement cuts and lower bonuses for physicians. (Includes video: 1:59 minutes)

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Wisconsin Officials Seek Improvements to Opioid Monitoring Database
Shamane Mills, Wisconsin Public Radio
June 7, 2016

Wisconsin officials continue to seek improvements to the state’s prescription drug monitoring program. New rules require physicians to use the database starting by next April; however, there is no penalty for not doing so. The state is also working on making the software more user-friendly. There have been complaints that the system is complicated and time-consuming. (Includes audio: 0:43 minutes)

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Many Job Applicants Can’t Pass Drug Test
Kris Turner, Indianapolis Star
June 4, 2016

Gregg Fore, president of Dicor Corporation in Indiana, has trouble finding workers who can pass a drug test. He disclosed that more than half of all applicants cannot pass the controlled substance requirements at his recreational vehicle supply business. Employees using drugs while operating heavy machinery, driving a transport vehicle or working around hazardous materials can lead to serious injury or death. Indiana employers are reporting an increase in the number of potential employees who are drug users and the ongoing issue of finding qualified workers.

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Michigan Doctor Indicted On Unlawful Distribution of Prescription Opioids, Other Charges
Nathan Clark, MLive Media Group
June 6, 2016

Horace Junior Davis, M.D., a family physician with offices in Albion and Jackson, Mich., has been indicted by a federal grand jury on 14 counts of unlawful distribution of prescription drug controlled substances, 13 counts of health care fraud, and one count of conspiracy to use false documents to defraud a health benefit program. Dr. Davis wrote 18,381 prescriptions for controlled substances from May 2012 to May 2013. His license to practice medicine and prescribe medications still is active.

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West News

New Mexico Overdose Deaths Dropped in 2015
Bruce Krasnow and Andrew Oxford, Santa Fe New Mexican
June 9, 2016

Preliminary data from 2015 shows that drug overdose deaths among New Mexicans dropped to 492 in 2015 from 540 in 2014. In 2014, the overdose death rate in New Mexico was 26.4 residents per 100,000, the second highest in the United States, behind West Virginia (35.5 per 100,000). That represented a 20 percent jump from 2013. Some attribute the decline to multiple prevention strategies such as physicians exercising greater care and discretion when prescribing opiates, increased use of the prescription drug monitoring program, and the availability of naloxone.

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California County Inches Toward Pharmacy-Financed Drug Disposal
Kelsey Brugger, Santa Barbara Independent
June 8, 2016

Santa Barbara County, Calif., supervisors have voted to require drug producers to fund and operate a drug take-back program. After the proposed ordinance returns to the Board of Supervisors once more, drug producers of both brand name and generic drugs will have about a year to create stewardship plans that fulfill requirements defined by the county’s public health department. Currently, 4 times a year, the county sheriff’s department properly disposes of about 1,000 lbs. of pills in Los Angeles.

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Other Resources

How to Deal with Adderall Abuse #infographic #Adderall #health
Adderall Addiction Support
May 31, 2016

This infographic shows the problem of Adderall abuse, the negative health effects, and treatment options.

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Grant Announcements

Enhanced State Surveillance of Opioid-Involved Morbidity and Mortality
National Center for Injury Prevention and Control
Due: June 27, 2016

Bottle Tracking Program
National Association of Drug Diversion Investigators
Due: None Specified

Take-Back Events & Drop Boxes

Drive-Thru Medicine Drop-Off June 18 in Somerset (N.J.)
June 8, 2016

Yorktown (N.Y.) Police Dispose of 254 Lbs. of Drugs
Alliance for Safe Kids
June 8, 2016

Call to Action Yields 148 Lbs. of Unused Meds in Shelby Township (Mich.)
Sarah Wojcik, CandGNews.com
June 8, 2016

Schaumburg (Ill.) Prescription Drug Program Hits Milestone
Chicago Daily Herald
June 8, 2016

New Prescription Drop Box Installed in Caswell (N.C.) Sheriff’s Department
Patti OKeefe, Caswell Messenger
June 8, 2016

Canton (Mich.) Cops Make Drug Drop-Off Effort 24/7
Darrell Clem, Hometown Life
June 7, 2016

Upcoming Events, Conferences, & Workshops

The Harold Rogers Prescription Drug Monitoring Program National Meeting
Bureau of Justice Assistance, and Prescription Drug Monitoring Program Training and Technical Assistance Center at Brandeis University
Aug. 17–19, 2016
Washington, D.C.


2016 Annual Conference
International Health Facility Diversion Association
Sept. 13–14, 2016
Cincinnati, Ohio


Twenty-Ninth Annual National Prevention Network Conference
National Prevention Network
Sept. 13–15, 2016
Buffalo, N.Y.


2016 Conference: Saving Lives: Access to Improved Health & Recovery
American Association for the Treatment of Opioid Dependence
Oct. 29 – Nov. 2, 2016
Baltimore, Md.


Bridging the Gaps: Reducing Prescription Drug and Opioid Abuse and Misuse Summit
National Association of Attorneys General and Association of State and Territorial Health Officials
Nov. 14–16, 2016
Arlington, Va.

National Rx Drug Abuse & Heroin Summit
Operation Unite
April 17–20, 2017
Atlanta, Ga.

Call for Presentations:
Submission Deadline Date: Friday, Aug. 5, 2016
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.