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November 12, 2015

PAW Weekly Update

SAMHSA Prescription Drug Abuse Weekly Update
Issue 148  |  November 12, 2015
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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J.A. Phillips, M.G. Holland, D.D. Baldwin, L. Gifford–Meuleveld, K.L. Mueller, B. Perkison, M. Upfal, and M. Dreger. 2015. "Marijuana in the Workplace: Guidance for Occupational Health Professionals and Employers: Joint Guidance Statement of the American Association of Occupational Health Nurses and the American College of Occupational and Environmental Medicine." Workplace Health and Safety 63(4):139–64, doi:10.1177/2165079915581983.

A task force of occupational health professionals recommends that marijuana use be closely monitored for all employees in safety-sensitive positions, whether or not covered by federal drug-testing regulations. It recommends employers review eight points when developing workplace policies that address marijuana use in the workplace, among them prohibiting the use of marijuana on or off the job for employees covered by federal drug testing regulations; establishing clear written policies and procedures for supervisors to follow regarding the criteria for identifying potential impairment and the process for referring an employee suspected of impairment for an occupational medical evaluation; and establishing a policy regarding off-work use of marijuana by employers residing in or near states that allow use of recreational marijuana.

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New Warning Issued on Sleeping Pill
Nick Tate, Newsmax Health
November 5, 2015

British health authorities have issued a warning about the prescription sleeping pill zopiclone (brand names Zimovane, Imovane, and Lunesta). They said the drug—similar to a benzodiazepine—should not be used for more than 2 to 4 weeks because of concerns about dependence and addiction. A related study found 37 websites sold zopiclone tablets in quantities of up to 2,000; 35 sites also sold other similar drugs; and 15 sites offered bulk purchase discounts. Only one website stated a prescription is needed to purchase zopiclone.

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Journal Articles and Reports

E. Argento, J. Chettiar, P. Nguyen, J. Montaner, and K. Shannon. 2015. "Prevalence and Correlates of Nonmedical Prescription Opioid Use Among a Cohort of Sex Workers in Vancouver, Canada." International Journal on Drug Policy 26(1):59–66, doi:10.1016/J.Drugpo.2014.07.010.

In 2010, of 692 female sex workers recruited through outreach from Vancouver outdoor street locations and indoor venues at baseline, 18.8 percent had used opioids without a prescription in the past 6 months. In multivariate analysis, users were more likely to report exchanging sex while high (odds ratio [OR] = 3.3), police harassment/arrest (OR = 1.8), an intimate partner injecting their drugs (OR = 1.7), and recent physical/sexual intimate partner violence (OR = 1.6).

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L. Ashrafioun, S. Gamble, M. Herrmann, and G. Baciewicz. 2015. "Evaluation of Knowledge and Confidence Following Opioid Overdose Prevention Training: A Comparison of Types of Training Participants and Naloxone Administration Methods." Substance Abuse, doi:10.1080/08897077.2015.1110550.

Opioid overdose prevention trainings were offered throughout a mid-sized metropolitan area in the Northeast. Participants (n = 428) were trained to administer naloxone via intramuscular injection (n = 154) or intranasal spray (n = 274). Participants' knowledge about opioid overdose and confidence to recognize and respond to opioid overdose situations increased significantly from pre- to post-training. Confidence was higher among those trained using intranasal naloxone compared with intramuscular injection naloxone.

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A. Cares, E. Pace, J. Denious, and L.A. Crane. 2015. "Substance Use and Mental Illness Among Nurses: Workplace Warning Signs and Barriers to Seeking Assistance." Substance Abuse 36(1), doi:10.1080/08897077.2014.933725.

In an anonymous survey of all 441 nurses who participated in a Colorado peer health assistance program from June 2008 to March 2010, 302 (69 percent) responded. Half were mandatory referrals from the state board of nursing, with another 18 percent referred by their employers. Eighty-five percent sought services because of drug or alcohol problems, with 48 percent using at work, and 40 percent admitting their competency level was affected by their use. More than two thirds of respondents thought their problem could have been recognized earlier. The most highly rated barriers to seeking assistance for substance use and mental illness included fear and embarrassment and concerns about losing one's nursing license. Respondents recommended greater attention to early identification of risk factors during nurses' professional training as a prevention strategy. Half of substance misusers reported using opiates at the time of seeking services, with 9 percent (some of them opiate users) using benzodiazepines and 5 percent using tramadol or Soma. The survey did not ask about prescription antidepressants or stimulants. One fourth of respondents obtained drugs in the workplace. Of these, 12 percent ordered drugs for their own use, 9 percent obtained waste from sharps containers, 8 percent replaced drugs they had taken with other drugs, and 4 percent forged prescriptions. Two respondents said they replaced sterile needles with used needles.

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A. Case and A. Deaton. 2015. "Rising Morbidity and Mortality in Midlife Among White Non-Hispanic Americans in the 21st Century." Proceedings of the National Academy of Sciences, doi:10.1073/pnas.1518393112.

All-cause mortality of middle-aged, white, non-Hispanic men and women in the United States increased markedly between 1999 and 2013. This change reversed decades of progress in mortality and was unique to the United States. Black non-Hispanics, Hispanics at midlife, and those aged 65 and above in every racial and ethnic group continued to see mortality rates fall. The midlife mortality increase for white men and women reflected increasing death rates from drug and alcohol poisonings, suicide, chronic liver disease, and cirrhosis. Those with less education saw the most marked increases. Rising midlife mortality rates of white non-Hispanics were paralleled by increases in midlife morbidity. Self-reported declines in health, mental health, ability to conduct activities of daily living, increases in chronic pain and inability to work, and clinically measured deteriorations in liver function all point to growing distress in this population.

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J.W. Frank, I.A. Binswanger, S.L. Calcaterra, L.A. Brenner, and C. Levy. 2015. "Non-Medical Use of Prescription Pain Medications and Increased Emergency Department Utilization: Results of a National Survey." Drug and Alcohol Dependence, doi:10.1016/j.drugalcdep.2015.10.027.

An analysis of 2008–13 National Survey on Drug Use and Health data found 10.5 million adults annually reported past-year nonmedical use of prescription pain medications, and 4.1 million adults annually reported at least one emergency department visit. Regression showed nonmedical prescription pain medication users had increased odds of past-year emergency department use (odds ratio = 1.3). The survey does not distinguish whether the drug misuse or the emergency department visit came first.

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L.L.M. Hanson, H. Westerlund, H.S. Chungkham, J. Vahtera, M. Sverke, and K. Alexanderson. 2015. "Purchases of Prescription Antidepressants in the Swedish Population in Relation to Major Workplace Downsizing." Epidemiology, doi:10.1097/EDE.0000000000000414.

A study of Swedish residents ages 22–54 who were gainfully employed with a stable labor market position in 2006 examined the effects of major downsizing (greater than an 18 percent staff reduction) from 2006 to 2009. Among the findings, prescription antidepressant use was slightly higher among people exposed to downsizing who had not previously taken a long-term absence due to sickness or disability compared with people in workplaces that did not downsize.

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H. Howard. 2015. "Reducing Stigma: Lessons from Opioid-Dependent Women." Journal of Social Work Practice in the Addictions 15(4):418–38, doi:10.1080/1533256X.2015.1091003.

Group interviews elicited the shared experiences of 20 self-identified postpartum women who used opioids during pregnancy. Themes developed around internal shame and guilt because their babies were born opioid dependent. Most experienced external stigma.

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E.D. Kantor, C.D. Rehm, J.S. Haas, A.T. Chan, and E.L. Giovannucci. 2015. "Trends in Prescription Drug Use Among Adults in the United States from 1999–2012." Journal of the American Medical Association 314(17):1818–30, doi:10.1001/jama.2015.13766.

Analysis of seven cycles (1999–2012) of National Health and Nutrition Examination Survey prescription data found an age-adjusted increase in overall use of prescription drugs among U.S. adults. The proportion with at least one prescription rose from 51 percent to 59 percent, and the proportion prescribed five or more drugs rose from 8 percent to 15 percent. Among the 18 drug classes used by more than 2.5 percent of the population at any point over the study period, the prevalence of use increased in 11 drug classes, including antihyperlipidemic agents, antidepressants, prescription proton pump inhibitors, and muscle relaxants. Use of antidepressants increased from 7 percent to 13 percent. Prescription analgesic use remained stable at 11 percent, with COX-2 inhibitor use declining (but opioid use increasing) before 2003–04, then stabilizing.

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K. Kolar. 2015. "Study Drugs 'Don't Make You Smarter': Acceptability Evaluations of Nonmedical Prescription Stimulant Use Among Undergraduate Students." Contemporary Drug Problems, doi:10.1177/0091450915614050.

Open-ended interviews with a convenience sample of seven first-year college students who use nonmedical prescription stimulants and 29 first-year students who do not use them found commonalities in how the two groups weigh the risks and advantages of nonmedical prescription stimulant use. Both groups opposed recreational use but thought it was okay for students to use stimulants in pursuit of scholastic success. Most of the study cohort used other drugs. All seven users and 18 nonusers were current cannabis users. Three of the seven stimulant users and nine of the 29 nonusers admitted to using other illicit drugs.

Read more:

R. Lev, S. Petro, A. Lee, O. Lee, J. Lucas, E.M. Castillo, J. Egnatios, and G.M. Vilke. 2015. "Methadone Related Deaths Compared to All Prescription Related Deaths." Forensic Science International 257:347–52, doi:10.1016/j.forsciint.2015.09.021.

Prescription Drug Monitoring Program (PDMP) queries on all 254 prescription-related deaths that occurred in San Diego County in 2013 found 46 involved methadone. Only 14 of the deceased had methadone prescriptions listed in PDMP reports, and methadone was not involved in four of those deaths. Of the 51 deaths that involved only one prescription drug, 12 involved methadone—the most common. Methadone-related deaths were more likely to involve illicit drugs or alcohol than other overdoses (85 percent versus 59 percent, respectively).

Read more:

S. Mathis, R. Pack, and B. Brooks. "Non–Medical Use of Prescription Drugs in the Workplace." Abstract from the American Public Health Association Annual Meeting, Chicago, Illinois, Oct. 31–Nov. 4, 2015.

Consistent with prior studies, in 2011–12 National Survey on Drug Use and Health data on adults, the prevalence of nonmedical use of prescription drugs in the past year was 9.2 percent. The industries with the highest number of users (as opposed to the highest usage rates) were arts, entertainment, recreation, accommodation, and food services (14.5 percent); construction (10.8 percent); and retail trade (10.0 percent; 95 percent confidence interval: 9.34–10.74). Multivariate regression showed nonmedical use did not vary by business size. It more often happened in firms with no written alcohol or drug use workplace policy (odds ratio = 1.15) and no employee assistance program (odds ratio = 1.1).

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L.M. Papp and S.M. Blumenstock. 2016. "Momentary Affect and Risky Behavior Correlates of Prescription Drug Misuse Among Young Adult Dating Couples: An Experience Sampling Study." Addictive Behaviors 53:161–67, doi:10.1016/j.addbeh.2015.10.016.

Among a convenience sample of 46 young adult couples in Wisconsin who misused prescription drugs, women over a 10-day period experienced relatively higher levels of negative affect and sexual regret while using than men. Women who misused prescription drugs more during the study period evidenced lower levels of sexual enjoyment and engaged in more unprotected sex, alcohol use, and heavy alcohol use. Men with more misuse were also more likely to engage in heavy drinking. Women who spent relatively more time with their partner across 10 days engaged in less misuse.

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M.R. Oreskovich, T. Shanafelt, L.N. Dyrbye, L. Tan, W. Sotile, D. Satele, C.P. West, J. Sloan, and S. Boone. 2014. "The Prevalence of Substance Use Disorders in American Physicians." The American Journal on Addictions, doi:10.1111/j.1521-0391.2014.12173.x.

Researchers polled a random sample of 27,276 physicians with 7,288 (27 percent) responding. Self-reports indicated 12.9 percent of male physicians and 21.4 percent of female physicians met DSM–4 diagnostic criteria for alcohol abuse or dependence. Misuse of prescription drugs and use of illicit drugs was rare.

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A.M. Pickover, B.G. Messina, C.J. Correia, K.B. Garza, and J.G. Murphy. 2015. "A Behavioral Economic Analysis of the Nonmedical Use of Prescription Drugs Among Young Adults." Experimental and Clinical Pharmacology, doi:10.1037/pha0000052.

At Auburn University, 339 undergraduate students who used prescription drugs nonmedically in the past year completed an online questionnaire for course credit. Among them, 138 used sedatives, 258 used stimulants, and 189 used pain relievers. Consumption consistently decreased as price rose. Demand was higher among users with substance use disorder symptoms.

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Drug Enforcement Administration. 2015. "2015 National Drug Threat Assessment Summary." Washington, D.C.: U.S. Department of Justice.

The annual National Drug Threat Assessment for 2015 found opiate overdose deaths continue to be the leading cause of injury death in the United States—ahead of deaths from motor vehicle crashes and firearms. Since 2002, prescription drug deaths have outpaced those of cocaine and heroin combined, and misuse of controlled prescription drugs is higher than that of cocaine, methamphetamine, heroin, MDMA, and PCP combined. Fentanyl caused more than 700 deaths in the United States between late 2013 and early 2015.

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J. P. Vakkalanka, J.D. King, and C.P. Holstege. 2015. "Abuse, Misuse, and Suicidal Substance Use by Children on School Property." Clinical Toxicology 53(9): 901–7, doi:10.3109/15563650.2015.1085998.

According to National Poison Data System data about calls to poison control centers between 2004 and 2013, of the 50,379 intentional child exposures (misuse or suicidal acts) on elementary and secondary school property, the most frequent pharmaceutical exposures were sedatives (8 percent), analgesics (8 percent), and cough and cold preparations (7 percent).

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N. Wright, O. D'Agnone, P. Krajci, R. Littlewood, H. Alho, J. Reimer, C. Roncero, L. Somaini, and I. Maremmani. 2015. "Addressing Misuse and Diversion of Opioid Substitution Medication: Guidance Based on Systematic Evidence Review and Real-World Experience." Journal of Public Health, doi:10.1093/pubmed/fdv150.

Opioid substitution treatment medication, such as methadone or buprenorphine, may be misused or diverted. This results in failure to recover from addiction, increased crime, and the spread of blood-borne viruses. Based on a systematic review, the authors conclude that preferred response strategies include promotion of access to treatment and use of product formulations less likely to be misused.

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A. Alam and D.N. Juurlink. 2015. "The Prescription Opioid Epidemic: An Overview for Anesthesiologists." Canadian Journal of Anesthesia, doi:10.1007/s12630-015-0520-y.

In the 1980s and early 1990s, opioids were infrequently used to treat chronic pain. Thereafter, physicians repeatedly received pharmaceutical company messages that long-term opioid therapy was a safe and effective treatment option for patients with chronic noncancer pain. The companies employed aggressive and sometimes misleading marketing strategies for new opioid formulations. As a result, the practice of prescribing opioids flourished in the late 1990s. The surge in prescribing was accompanied by marked increases in opioid-related morbidity and mortality. This change in practice transpired despite the absence of randomized trials showing clinically significant benefit from long-term opioid use. A large and growing body of evidence has emerged quantifying the harms associated with long-term opioid therapy. Anesthesiologists widely prescribe opioids for acute and chronic pain; yet, as a group, they may be largely unaware of the current state of this growing epidemic and the role they can play in addressing the problem.

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R.W. Bailey and K.E. Vowles. 2015. "Chronic Noncancer Pain and Opioids: Risks, Benefits, and the Public Health Debate." Professional Psychology: Research and Practice 46(5):340–47, doi:10.1037/pro0000022.

This paper reviews the evidence of the benefits and risks associated with opioid use as a treatment for chronic pain. It also explores areas of significant concern relevant to public health policy. It suggests more research is needed to help clinicians make more informed decisions.

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M. Costello. 2015. "Prescription Opioid Analgesics: Promoting Patient Safety with Better Patient Education." American Journal of Nursing 115(11):50–56, doi:10.1097/01.NAJ.0000473315.02325.b4.

Patients and caregivers must have an adequate understanding of safe use, storage, and disposal of opioids to prevent adverse drug events in patients and others. Nurses play a key role in providing this patient education. This case study highlights the risks and important aspects of opioid medication use in the post-operative patient.

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E.M. Wachman, K. Saia, R. Humphreys, S. Minear, G. Combs, and B.L. Philipp. 2015. "Revision of Breastfeeding Guidelines in the Setting of Maternal Opioid Use Disorder: One Institution's Experience." Journal of Human Lactation, doi:10.1177/0890334415613823.

Based on the available evidence and review of the institutional data, the authors revised breastfeeding guidelines for mothers with opioid use disorder. The aims of the new guidelines are to safely promote breastfeeding in all mothers with opioid use disorder who are in recovery, improve neonatal abstinence syndrome outcomes through use of breastfeeding as a key nonpharmacologic treatment modality, and improve staff communication and consistency on the subject of breastfeeding in this patient population.

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Drug Deaths Becoming a 2016 Presidential Election Issue
Heather Haddon, Wall Street Journal
November 3, 2015

Drug misuse has become an important issue in the 2016 presidential campaign. An effort called the NOW Campaign will keep the pressure on presidential candidates from both parties to focus on drug misuse and mental health issues and to host forums on the topics. The NOW Campaign is expected to have a budget of at least $3.5 million and to hire staffers in early primary states to advocate on the issues. Drug misuse has become an economic problem for states and the private sector. Substance misuse led to an estimated $176 million in workplace productivity losses in New Hampshire alone. Employers in rural Virginia who were invited to economic forums said they are unable to find enough workers who can pass drug tests.

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Republicans Call on Administration to Halt Harmful Opioid Rule
November 2, 2015

Nearly two dozen Republican senators and representatives sent a letter to the Office of Management and Budget, calling on the Obama Administration to nix a pending rule that they argue would reverse course on curbing opioid drug misuse. Under the proposed rule, innovations for abuse-deterrent formulations would be subject to additional rebate obligations under the Medicaid program, which serves as a disincentive to developing abuse-deterrent products.

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Senator Tim Kaine Introduces Bill to Prevent Overdose Deaths
November 5, 2015

Virginia Senator Tim Kaine introduced the Co-Prescribing Saves Lives Act to help prevent overdose deaths by encouraging physicians to co-prescribe naloxone along with opioid prescriptions. The bill would require federal agencies to establish physician education and co-prescribing guidelines for federal healthcare settings, including veterans hospitals, military hospitals, Indian Health Service facilities, and federally qualified health centers. It also would authorize a grant program to help states establish co-prescribing guidelines, purchase naloxone, and fund training for health professionals and patients.

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Drug Abuse in the Military: Illicit and Prescription Drugs
Diana Davis, Patrick Air Force Base
October 29, 2015

A 2008 Department of Defense Survey of Health Related Behaviors found prescription drug misuse was higher among service members than among civilians, with 11 percent of service members misusing. The military's response includes expanding drug testing requirements to include prescription drugs containing hydrocodone and benzodiazepine and limiting the length of a valid prescription for commonly abused drugs to 6 months. Service members with prescriptions for these drugs are not subject to disciplinary action when the medicine is taken within the prescribed dosage and time limits.

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Senator Dick Durbin Leads Senators Calling for Expanded Availability of Life-Saving Drug on School Campuses
eNews Park Forest
October 29, 2015

Illinois Senator Dick Durbin led a group of nine other senators in writing to Health and Human Services Secretary Sylvia Matthews Burwell, urging the department to expand the availability of naloxone on school campuses. The letter was endorsed by the National Association of School Nurses, which recommends school nurses facilitate access to naloxone in schools.

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Cannabis Harm—Virtual Issue. Addiction. 2015

This virtual issue, which compiles articles from prior print editions and adds commentary on some of them, illustrates the richness of good-quality epidemiological studies, many of them longitudinal, of correlates and possible consequences of different patterns of cannabis use among young people in developed countries. The first set of papers reports epidemiological studies that describe associations between regular cannabis use in adolescence and the risk of developing mental health disorders as adults. The second set includes papers on the social and general health correlates of regular and dependent cannabis use.

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W. Hall. 2015. "What Has Research over the Past Two Decades Revealed About the Adverse Health Effects of Recreational Cannabis Use?" Addiction 110:19–35.

Research in the past 20 years has shown driving while cannabis impaired approximately doubles car crash risk, and that around 1 in 10 regular cannabis users develop dependence. Regular cannabis use in adolescence approximately doubles the risks of early school leaving, cognitive impairment, and psychoses in adulthood. Regular cannabis use in adolescence is also strongly associated with use of other illicit drugs. These associations persist after controlling for plausible confounding variables in longitudinal studies, which suggests cannabis use is a contributory cause of these outcomes. But some researchers still argue these relationships are explained by shared causes or risk factors. Cannabis smoking probably increases cardiovascular disease risk in middle-age adults, but its effects on respiratory function and respiratory cancer remain unclear, because most cannabis smokers have smoked or still smoke tobacco.

D.M. Fergusson and J.M. Boden. 2015. "Commentary on Hall: The Health Effects of Recreational Cannabis Use." Addiction 110:36–37.

M.F. H. Griffith–Lendering, J.T.W. Wigman, A.P. van Leeuwen, S.C.J. Huijbregts, A.C. Huizink, J. Ormel, F.C. Verhulst, J. van Os, H. Swaab, and W.A.M. Vollebergh. 2013. "Cannabis Use and Vulnerability for Psychosis in Early Adolescence—A TRAILS Study." Addiction 108:733–40.

Assessments of 2,120 Dutch adolescents observed significant associations between psychosis vulnerability and cannabis use. Also, cannabis use at age 16 predicted psychosis vulnerability at age 19, and psychosis vulnerability at ages 13 and 16 predicted cannabis use at ages 16 and 19.

G. Lewis, J. Heron, and S. Zammit. 2013. "Commentary on Griffith–Lendering et al. 2013: Cross-Lagging Cannabis and Psychosis Vulnerability." Addiction 108:741–42.

S.M. Bitter, C.M. Adler, J.C. Eliassen, W.A. Weber, J.A. Welge, J. Burciaga, P.K. Shear, S.M. Strakowski, and M.P. DelBello. 2014. "Neurofunctional Changes in Adolescent Cannabis Users with and Without Bipolar Disorder." Addiction 109:1901–09.

Comparisons among 14 Ohioan adolescents with bipolar disorder, 13 with cannabis use disorder, 25 with both disorders, and 15 with neither found adolescents with both disorders do not exhibit the same overactivation of the brain regions involved in emotional processing seen in adolescents with bipolar disorder only. The absence of these findings in patients with comorbid disorders suggests these individuals may have a unique endophenotype of bipolar disorder or that cannabis use may alter brain activation in bipolar disorder patients.

L. Degenhardt, C. Coffey, H. Romaniuk, W. Swift, J.B. Carlin, W.D. Hall, and G.C. Patton. 2013. "The Persistence of the Association Between Adolescent Cannabis Use and Common Mental Disorders into Young Adulthood." Addiction 108:124–33.

An analysis of data on 1,943 adolescent Australians as they aged found regular (particularly daily) adolescent cannabis use is consistently associated with anxiety but not depressive disorder in adolescence and late young adulthood, even among regular users who then cease using the drug.

A.C. Huizink. 2013. "Commentary on Degenhardt et al. (2013): Specific Effect of Adolescent Cannabis Use on Anxiety—Tentative Explanations." Addiction 108:134–35.

A.P. van Leeuwen, H.E. Creemers, K. Greaves–Lord, F.C. Verhulst, J. Ormel, and A.C. Huizink. 2011. "Hypothalamic–Pituitary–Adrenal Axis Reactivity to Social Stress and Adolescent Cannabis Use: The TRAILS Study." Addiction 106:1484–92.

A study of 591 Dutch adolescents (mean age 16.1) that oversampled cannabis users found lifetime cannabis users had significantly lower stress-reactivity levels when compared with abstainers (odds ratio [OR] = 0.7) and lifetime tobacco users (OR = 0.8). Repeated cannabis users also exhibited lower stress-reactivity levels when compared with lifetime users of either tobacco or cannabis (OR = 0.7).

P. van der Pol, N. Liebregts, R. de Graaf, M. ten Have, D.J. Korf, W. van den Brink, and M. van Laar. 2013. "Mental Health Differences Between Frequent Cannabis Users with and Without Dependence and the General Population." Addiction 108:1459–69.

A study compared community samples of 521 Dutch adult (ages 18–30) who were frequent cannabis users, 252 of whom had DSM–4 cannabis dependence and 269 without dependence, and 1,072 young adult nonusers from the general population. Externalizing disorders were more prevalent in nondependent users (odds ratio [OR] = 8.9) and most prevalent in dependent users (OR = 17.8), but internalizing disorders were associated only with dependency (mood disorder OR = 4.2, anxiety disorder OR = 2.2). Associations were attenuated (and often became nonsignificant) after correction for childhood adversity and substance use other than cannabis. The prevalence of mental health disorders remained higher in dependent compared with nondependent users (OR = 2.4), although cannabis use patterns were remarkably similar.

A. Agrawal and M.T. Lynskey. 2013. "Cannabis Controversies: How Genetics Can Inform the Study of Comorbidity." Addiction 109:360–70.

This review concludes that genetic factors play a critical role in the association of cannabis use—particularly early-onset use and use of other illicit drugs—with psychosis and depression, as well as suicide, albeit via differing mechanisms. For other illicit drugs, while there is strong evidence for shared genetic influences, residual association that is attributable to causal or person-specific environmental factors cannot be ruled out. For depression, common genetic influences were solely responsible for the association with cannabis use; for suicidal attempt, evidence for person-specific factors persists. Even though rates of cannabis use are inordinately high in those with psychotic disorders, no evidence exists of shared genetic etiologies underlying this comorbidity. Instead, limited evidence suggests adolescent cannabis use might moderate the extent to which environmental triggers influence psychosis in genetically vulnerable individuals.

S. Baggio, A.A. N'Goran, S. Deline, J. Studer, M. Dupuis, Y. Henchoz, M. Mohler–Kuo, J–B. Daeppen, and G. Gmel. 2014. "Patterns of Cannabis Use and Prospective Associations with Health Issues Among Young Males." Addiction 109:937–45.

Analysis of data on 5,084 Swiss men surveyed at age 20 and 15 months later found that 84.5 percent remained in the same cannabis use and intensity categories. Cannabis disorder symptoms at age 20 predicted later depression and health consequences. Reverse paths from health issues to cannabis disorder symptoms and between frequency of cannabis use and health issues were not significant.

A.I. Stiby, M. Hickman, M.R. Munafo, J. Heron, V. L. Yip, and J. Macleod. 2015. "Adolescent Cannabis and Tobacco use and Educational Outcomes at Age 16: Birth Cohort Study." Addiction 110:658–68.

Among a sample of 1,155 children born between April 1991 and December 1992 in Avon, UK, multivariate models showed both cannabis and tobacco use at age 15 were associated with subsequent adverse educational outcomes. In general, the dose–response effect seen was consistent across all educational outcomes assessed. Weekly cannabis use was negatively associated with grades in English and math (differences of -5.9 and -6.9, respectively). Corresponding decreases associated with daily tobacco smoking were larger: -11.9 and -16.7, respectively. The greatest attenuation of these correlations was seen on adjustment for other substance use and conduct disorder.

R.J. Tait, A. Mackinnon, and H. Christensen. 2011. "Cannabis Use and Cognitive Function: Eight-Year Trajectory in a Young Adult Cohort." Addiction 106:2195–203.

Among 2,404 Australians recruited at age 20 in 1999, 1,978 completed a follow-up survey in 2007. Cessation of cannabis use was associated with improved capacity for recall of information that had just been learned. No other measures of cognitive performance were related to cannabis use after controlling for confounds.

C. Hyggen. 2012. "Does Smoking Cannabis Affect Work Commitment?" Addiction 107:1309–15.

Analysis of a 25-year Norwegian panel survey initiated in 1985—with follow-ups in 1987, 1989, 1993, 2003, and 2010—found cannabis use was associated with a reduction in work commitment among adults. When the respondents were in their mid-20s, those who were involved or had experimented with cannabis displayed lower levels of work commitment than those who were abstaining or merely exposed to cannabis through friends. Work commitment among those who experimented with cannabis converged toward the levels reported by abstainers and the exposed as they grew older, whereas those involved reported decreasing work commitment into adulthood. Multivariate regression showed these patterns remained significant after controlling for socioeconomic background, education, labor market experiences, mental health, and family characteristics.

P. van der Pol, N. Liebregts, T. Brunt, J. van Amsterdam, R. de Graat, D.J. Korf, W. van den Brink, and M. van Larr. 2014. "Cross-Sectional and Prospective Relation of Cannabis Potency, Dosing and Smoking Behaviour with Cannabis Dependence: An Ecological Study." Addiction 109:1101–09.

In the Netherlands, 98 heavy cannabis users brought their own cannabis, rolled a joint, and smoked it in a naturalistic setting. Participants were surveyed again 18 months later. Tetrahydrocannabinol (THC) concentration in cannabis (range 1.1 percent to 24.7 percent) was positively correlated with cannabis dose per joint but negatively associated with inhalation volume. Smoking behavior measures (number of puffs, inhaled volume, reduction of puff volume, and puff duration while smoking) predicted follow-up dependence severity, independently of baseline dependence severity and monthly THC dose (number of joints x cannabis dose x cannabis THC concentration). Monthly THC dose only predicted follow-up dependence severity when unadjusted for baseline severity.

E.C. Temple. 2014. "Commentary on van der Pol et al. (2014): Reconsidering the Association Between Cannabis Exposure and Dependence." Addiction 109:1110–11.
H. Meng, J.G. Hanlon, R. Katznelson, A. Ghanekar, I. McGilvray, and H. Clarke. 2015. "The Prescription of Medical Cannabis by a Transitional Pain Service to Wean a Patient with Complex Pain From Opioid Use Following Liver Transplantation: A Case Report." Canadian Journal of Anesthesia, doi:10.1007/s12630–015–0525–6.

A 57-year-old man with a history of hepatitis C cirrhosis underwent liver transplantation. Preoperatively, he was taking 2–8 mg per day of hydromorphone for chronic abdominal pain. Postoperatively, he was given intravenous patient-controlled analgesia through which he received 30 mg per day of hydromorphone. The multidisciplinary transitional pain service was involved with managing his moderate-to-severe acute postsurgical pain in the hospital and continued with weaning him from opioid medications after discharge. It was difficult to wean the patient from opioids, and he was subsequently given medical cannabis at 6 weeks after the operation "with remarkable effect." By the fifth postoperative month, his use of opioids had tapered to 6 mg per day of hydromorphone.

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Marijuana in the Workplace: The Growing Conflict Between Drug and Employment Laws
Nathaniel M. Glasser and Jonathan K. Hoerner, National Law Review
October 29, 2015

Twenty-three states and the District of Columbia have legalized medical or recreational use of marijuana. These jurisdictions provide marijuana users with varying levels of protection against employment discrimination. However, the federal government still classifies marijuana as a Schedule I drug (high potential for misuse, no acceptable medical use), and the drug remains illegal under the federal Controlled Substances Act. The authors advise employers to continue to prohibit the on-duty use of, or impairment by, marijuana. They outline steps to reduce potential liability, including engaging in an interactive process to determine whether medical marijuana use can be accommodated and developing or reviewing policies that expressly address the right to take adverse action upon a finding of marijuana use.

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Report Examines Marijuana Positive Drivers Involved in Deadly Crashes
Washington Traffic Safety Commission
October 2015

Washington's state toxicology laboratory tested blood samples for both alcohol and drugs for 1,773 drivers involved in deadly crashes between 2010 and 2014. Of this not-necessarily-representative subset of drivers in fatal crashes, nearly 60 percent tested positive for alcohol, marijuana, or drugs. Most drivers tested had multiple substances in their system, generally combinations of alcohol, marijuana, and other drugs. One third tested positive for alcohol only, and 8 percent for marijuana only. Overall, 20 percent tested positive for marijuana. In 2014, of 89 drivers who tested positive for marijuana, 84 percent were positive for tetrahydrocannabinol (THC), with half exceeding the state's 5 ng/ml per se limit. This is much higher than in 2010, when 81 drivers were positive for marijuana but only 44 percent of them were positive for THC. A majority of deadly crashes involving drivers who tested positive for THC alone or in combination with other drugs (except alcohol) occurred during daytime hours.

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Bernie Sanders Files Marijuana Bill in Senate
Tom LoBianco, CNN
November 4, 2015

Vermont Senator Bernie Sanders, a Democratic candidate for President, filed a bill in the Senate that would allow states to decide whether to legalize recreational use of marijuana and would decriminalize the drug at the federal level. The bill would allow growers and dispensers in states where marijuana is already legal to use banks as part of their commercial activity with impunity. (Includes video: 2:16 minutes)

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Two Reasons Ohio Voters Overwhelmingly Rejected Marijuana Legalization
Jacob Sullum, Forbes
November 4, 2015

Despite surveys showing a majority of Ohioans think marijuana should be legal, voters in that state quashed an initiative that would have legalized it statewide. This article suggests the two reasons why Ohio voters rejected marijuana legalization may be 1) they do not like crony capitalism and 2) voters who participate in off-year elections are not very keen on legalization.

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House Leaders to Carefully Explore Medical Marijuana
Jim Siegel, The Columbus Dispatch
November 5, 2015

Ohio House leaders are exploring legalization of medical marijuana in the state. They plan to engage the medical community, are considering state funding for studies, and expect to release a series of bills and resolutions in coming weeks, with potential action next year. Lack of quality clinical research is a key reason why the Ohio State Medical Association remains opposed to medical marijuana.

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Panel Opposes Letting Pain Patients into Medical Marijuana Program
Jennifer Brooks, Star Tribune
November 4, 2015

A Minnesota state–convened panel of pain management experts opposed expanding the state's medical marijuana program to pain patients. Panel members said they were troubled by the lack of scientific evidence. The panel agreed medical cannabis should not be the first line of therapy in treating intractable pain. Minnesota Health Commissioner Ehlinger will make the final decision by the end of the year.

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RBCC Maps Out Strategy to Curb Addiction in Canada's Indigenous Communities
Business Wire
November 2, 2015

Rainbow Coral Corporation is working to increase naltrexone use through clinics and expand access to treatment in Canada's First Nations, Inuit, and Métis indigenous populations. Rainbow Coral has embraced the "First Do No Harm: Responding to Canada's Prescription Drug Crisis" strategy. It is working hard to ensure Canadian clinics have access to a durable, long-lasting naltrexone protocol and will continue to explore low-cost addiction treatment.

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State Board of Medicine Adopts Emergency Rules on Opioid Prescriptions
Megan Doyle and David Brooks, Concord Monitor
November 5, 2015

The New Hampshire Board of Medicine approved emergency rules for prescribing pain relievers. These rules require prescribers to educate acute pain patients on the risks of their prescriptions and how to dispose of unused pills. For chronic pain patients who use opioids, the rules require a prescriber to use informed consent, a risk assessment, a written pain agreement, and toxicology screening. The rules also adopt federal guidelines for best practices on prescribing opioids.

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Escalating Opioid Crisis Hits Home on the Vineyard, State Statistics Show
Steve Myrick, Vineyard Gazette
November 5, 2015

Opioid overdose deaths are on the rise and appear to be undercounted on Martha's Vineyard, Mass. According to state vital statistics data, Martha's Vineyard had 15 fatal opioid overdoses from 2000 to 2014, including 1 in 2013 and 5 in 2014. Dr. Charles Silberstein, a local psychiatrist who is certified in addiction psychiatry and treats recovering addicts, counted at least 6 deaths last year and at least 10 this year. Police and medical providers say emergency calls for overdoses are steadily on the rise, and local police have seen a dramatic increase in response calls for nonfatal overdoses. In 2014, medical providers on Martha's Vineyard wrote 8,704 prescriptions for opioid pain medications, which totals 595,884 pills for 2,462 individuals.

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Health Department to Staff Overdose Prevention Team
Kristin Gourlay, Rhode Island Public Radio
October 31, 2015

The Rhode Island Health Department is adding four positions to address addiction and overdose. This includes an outreach coordinator, who will help promote the state's Prescription Drug Monitoring Program and encourage doctors to use the database; an epidemiologist; a data analyst; and a policy expert.

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South News

Prescription Pain Medicine Still the Drug of Choice in Tennessee
Tennessee State Government
November 4, 2015

The Tennessee Department of Mental Health and Substance Abuse Services has identified generational preferences in drug use statewide over the past 20 years. Many middle-age Tennesseans prefer alcohol; and marijuana is the primary high of choice among those in their 20s and 30s. Prescription pain medication continues to be the drug of choice across most age groups. Data on state-funded substance abuse treatment admissions, collected from 1992 to 2012, confirm the trend of prescription drug misuse across multiple age groups.

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Data: More Likely to Die from a Drug Overdose in Tri-Cities, Than Other Areas of the State
Nate Morabito, WJHL
November 3, 2015

Substance misuse killed 580 people in northeast Tennessee between 2009 and 2014, with deaths at an all-time high in 2014 in that area and statewide. The death rate in northeast Tennessee is well above the state average and rising. Dr. Kenneth Ferslew, toxicology director at East Tennessee State University's Quillen College of Medicine, said people are mixing opiates and muscle relaxers, with bad results. (Video included: 5:25 minutes)

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How People in Hampton Roads Are 'Doctor Shopping' to Get Prescription Drugs
Margaret Kavanagh, WTKR
November 5, 2015

Doctor shopping is a problem in Hampton Roads, Va. For example, after 4 years as a police officer, Harry Kephart was arrested and accused of doctor shopping. He pleaded guilty to fraudulently obtaining prescription medication. The Virginia Beach Police Department was tipped off by Bayside Hospital Emergency Department after Kephart tried to get prescription drugs for pain 3 days in a row. He went into several different medical facilities—even after he had been turned down by a doctor. (Includes video: 4:23 minutes)

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County May Add Drug Testing
Brian Smith, Jacksonboro Newspaper
October 31, 2015

In Jacksonboro, Texas, county commissioners are looking into the prospect of random drug and alcohol testing for county vehicle operators. The testing would also cover courthouse employees who appear to be under the influence and any employee involved in a fatal crash, a crash where a vehicle cannot be driven away from the scene, or a crash that results in property damage.

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Survey: Coastal Bend Employers Still Worry About Drugs in Workplace
Chris Ramirez, Corpus Christi Caller Times
November 4, 2015

In 12 counties around Corpus Christi, Texas, 43 employers who responded to a survey said it is difficult to find workers who are qualified to fill jobs and able to pass a drug test. Only two thirds of the businesses have a drug-testing policy in place. Some employers said the cost of drug testing is prohibitive. A second survey found the volume of positive drug tests in the region has not gotten noticeably worse, despite recent job growth.

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Midwest News

Surgeon General: Indiana Can Do More to Combat Opioid Epidemic
Maureen Groppe, Indy Star
October 29, 2015

U.S. Surgeon General Vivek Murthy said Indiana is making progress but can do more to combat its opioid abuse epidemic. He said physicians who prescribe pain medication need better training and information about opioid risks. He also said the state's Prescription Drug Monitoring Program could be more accessible to all providers and could have more up-to-date information.

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Six Dead of Drug Overdoses in 24 Hours; Milwaukee to Add Anti-Heroin Position Through City Budget
David Ade, WDJT
November 2, 2015

The Milwaukee County Medical Examiner confirmed six "probable drug overdose" deaths during a 24-hour period that started October 31 and ended November 1. The victims, three men and three women between the ages of 24 to 61, had used either heroin, cocaine, or prescription drugs. So far this year, the county has documented almost 200 overdose deaths. The new City of Milwaukee budget will likely add a government position to focus on reducing overdose deaths. (Includes video: 2:47 minutes)

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Senate Judiciary Committee Approves 'Good Samaritan' Prescription Drug Legislation
Michigan House Republicans
November 5, 2015

The Michigan Senate Judiciary Committee approved House Bill 4843, which would exempt individuals under age 21 from facing prescription drug–related charges when reporting a medical emergency. The bill will be presented to the full senate for the chamber's consideration.

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Eight Fatal Heroin Overdoses Since June
Seth Slabaugh, The Star Press
October 31, 2015

In Delaware County, Ind., seven men and one woman have died from heroin overdoses since June. Twenty-five others have died this year from prescription opioid overdoses.

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Lester: Why One Suburban School Is Stocking Heroin Antidote
Kerry Lester, Daily Herald
November 2, 2015

Citing rising heroin deaths in the community, Stevenson High School in Lincolnshire, Ill., approved naloxone use on campus. Nurses will be trained this month to use Evzio auto injectors, which the school will get from Live4Lali, a nonprofit agency. Four of the auto injectors will be kept on campus: two in nurses' offices, one with the campus police officer, and one in the office of the school's substance abuse prevention coordinator. Illinois's state board of education recently approved rules that allow schools to administer the antidote in emergencies.

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Binge Drinking, Smoking Down Among ND High Schoolers, But Suicide Results Concerning
Mike Nowatzki, Inforum
November 2, 2015

According to the 2015 Youth Risk Behavior Survey, marijuana use fell by 1 percent and prescription drug misuse by 3 percent among North Dakota high school students since 2013.

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West News

County Breaks Record: 39 Overdose Deaths in 2014
Wheeler Cowperthwaite, Rio Grande Sun
October 29, 2015

The number of overdose deaths in Rio Arriba County, N.M., increased from 26 deaths in 2012 to 39 in 2014. The county's overdose rate is at 1 death per 1,000 residents.

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Other Resources

[Video] Prescription Drug Abuse Public Service Announcement—Rockland
U.S. Attorney General's Office, Southern District of New York
October 28, 2015

The death toll from prescription pain relievers has tripled in the past decade, and the problem is getting worse. Over 16,000 people die every year from prescription pain reliever overdoses—more than the number of overdoses from heroin, cocaine, and all other illegal drugs combined. (Duration: 2:02 minutes)


[Webinar Archive] A Parents Webinar: Evidence-Based Strategies to Prevent Substance Use
Office of National Drug Control Policy
October 26, 2015

This Webinar discusses how communities and parents can help prevent substance use. Speakers include Office of National Drug Control Policy Director Michael Botticelli, National Institute on Drug Abuse Deputy Director Wilson Compton, and dozens of parents and community leaders. (Duration: 1:25:06)


Grant Awards

Grant Awarded to Support Minnesota Community Behavioral Health Clinics
Hometown Media Partners
October 30, 2015

The Substance Abuse and Mental Health Services Administration has awarded the Minnesota Department of Human Services a grant in the amount of $982,373 to support community-based mental and substance use disorder health clinics.

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Grant Announcements

Indiana Grant Program to Fund Surge in Naloxone Distribution
Indiana Attorney General's Office
October 30, 2015

Indiana Attorney General Greg Zoeller announced a grant program to fund naloxone distribution, with the goal of ensuring all first responders are equipped with the opioid overdose antidote and trained to administer it. Award amounts will be determined by the geographic service areas eligible nonprofit applicants can reach and the quantity of law enforcement agencies and first responders within that specific area per approved application. Applications will be accepted through Dec. 1, 2015.

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Iowa Department of Public Health Seeks to Battle Opioid Abuse
Polly Carver–Kimm, Iowa Department of Health
October 29, 2015

The Iowa Department of Public Health plans to award four medication-assisted treatment grants to state providers. The grants are designed to decrease substance misuse, expand and improve medication-assisted treatment services, and increase the number of Iowans who receive these services.

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Partnership for Clean Competition
Pre-applications due November 1, 2015
Full applications due December 1, 2015

National Institute on Drug Abuse Translational Avant-Garde Award for Development of Medication to Treat Substance Use Disorders
U.S. Department of Health and Human Services, National Institutes of Health
Deadline: December 3, 2015

New Jersey Health Initiatives 2016: Building a Culture of Health in New Jersey—Communities Moving to Action, Round 2
Robert Wood Johnson Foundation
Deadline: January 14, 2016


Prescription Drug Take-Back Event Set for November 14, 2015
Herald-Progress (Virginia)
November 4, 2015

Pet Meds: Plan for Disposal
White Mountain Independent (Arizona)
November 3, 2015

River Vale Police Acquire Mobile Prescription Drop Box
NewJersey.com (New Jersey)
November 5, 2015

Drop Boxes Set Up Outside LVHN for Prescription Drug Disposal
Sam Kennedy, Morning Call (Pennsylvania)
October 30, 2015

Prescription Drug Take Back
City of Bridgeport (West Virginia)
Accessed November 3, 2015


Twenty-Eighth Annual National Prevention Network Conference: Bridging Research to Practice
National Prevention Network
November 17–19, 2015
Seattle, Washington


University of Michigan Injury Center Prescription Drug Overdose Summit
University of Michigan Injury Center
December 1, 2015
Ann Arbor, Michigan

Ensuring Access to Pain Care: Engaging Pain Medicine and Primary Care Teams
American Academy of Pain Medicine
February 18–21, 2016
Palm Springs, California

2016 National Rx Drug Abuse and Heroin Summit
March 28–31, 2016
Atlanta, Georgia

Third Annual Smart Approaches to Marijuana Education Summit
March 31, 2016
Westin Peachtree Plaza Hotel
Atlanta, Georgia

This day-long conference will be held in conjunction with the National Rx Drug Abuse and Heroin Summit. Smart Approaches to Marijuana's leaders are among the world's most prominent voices calling for science-based marijuana education and awareness.

Read more:
http://nationalrxdrugabusesummit.org/sam-summit-2/ n

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.