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September 3, 2014


SAMHSA Prescription Drug Abuse Weekly Update
Issue 87  |  September 3, 2014
The Prevention of Prescription Drug Abuse in the Workplace (PAW) TA Center addresses prescription drug abuse—a growing public health problem with increasing burdens on workers, workplaces, and our economy. To subscribe colleagues, family members, or friends to this listserv sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), please click here or send their e-mail addresses to paw@dsgonline.com.
Table of Content Featured Article Journal Articles and Reports Professional Education News Other State and Local News Other Resources Request for Proposal National Take-Back Event Take-Back Events and Drop Boxes Save the Date Upcoming Conferences and Workshops


J.B. Rice, N.Y. Kirson, A. Shei, C.J. Enloe, A.K. Cummings, H.G. Birnbaum, P. Holly, and R. Ben–Joseph. 2014. "The Economic Burden of Diagnosed Opioid Abuse Among Commercially Insured Individuals." Postgraduate Medicine 126(4):53–58, doi: 10.3810/pgm.2014.07.2783.

J.B. Rice, N.Y. Kirson, A. Shei, A.K. Cummings, K. Bodnar, H.G. Birnbaum, R. Ben–Joseph. 2014. "Estimating the Costs of Opioid Abuse and Dependence From an Employer Perspective: A Retrospective Analysis Using Administrative Claims Data." Applied Health Economics and Health Policy 12(4):435–46. doi: 10.1007/s40258–014–0102–0.

These two parallel studies used the Truven MarketScan Commercial Claims and Encounters Database to replicate an analysis of prevalence and excess healthcare costs of diagnosed opioid abuse in the OptumHealth Reporting and Insights Database of commercial claims. In Marketscan data, prevalence of diagnosed opioid abuse increased steadily from 15.8 diagnosed opioid abusers per 10,000 patients with medical encounters in 2009 to 26.6 diagnosed opioid abusers per 10,000 in 2012. These rates exceeded rates in 2006 to 2012 OptumHealth data. Relative to statistically matched comparison patients, diagnosed abusers had excess annual per patient healthcare costs of $11,376 in the Marketscan data, compared with $10,627 in the OptumHealth data. In the OptumHealth data, abusers averaged $1,244 in excess annual work-loss costs. Together, this implied an employer burden for diagnosed abuse of US$1.71 per member per month.

Read more:

Journal Articles and Reports

Marcus A. Bachhuber, Brendan Saloner, Chinazo O. Cunningham, and Colleen L. Barry. 2014. "Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999–2010." JAMA Internal Medicine. Doi:10.1001/jamainternmed.2014.4005.

M. Hayes, and M. Brown. 2014. "Legalization of Medical Marijuana and Incidence of Opioid Mortality: Invited Commentary." JAMA Internal Medicine. Doi:10.1001/jamainternmed.2014.2716.

As the commentary states: "The incidence of opioid analgesic–associated mortality rose dramatically between 1999 and 2010. States with medical marijuana laws had higher overdose rates than did those without such laws when population-adjusted mortality was analyzed across years, although the rise in deaths over the study period was similar for both groups." Through some statistical magic [which your editor finds highly suspect], a large and significant "protective effect of medical marijuana laws was found in a covariate-adjusted, time-series model in which opioid analgesic mortality declined steadily based on years since medical marijuana laws were enacted." [Editor's note: the 25 percent decline by year found in the regression analysis of 1993–2010 data is not in evidence in a plot of the data, with the higher rate in states with medical marijuana laws widening in 2007–09, although it narrowed markedly in 2010 when the state of Washington took dramatic actions to reduce prescription opioid overdose. The authors did not conduct a sensitivity analysis excluding 2010 to better understand the extent that 2010 data were driving the regression results.]

Three states (California, Oregon, and Washington) had medical cannabis laws effective before 1999. Ten states (Alaska, Colorado, Hawaii, Maine, Michigan, Montana, Nevada, New Mexico, Rhode Island, and Vermont) implemented medical cannabis laws between 1999 and 2010. The study predicted the age-adjusted opioid overdose mortality rate by state and year using time-series regression models including state- and year-fixed effects. It included dummy variables for presence of a prescription monitoring program (associated with a higher overdose death rate postimplementation, but not significant), law requiring or permitting pharmacists to request patient identification (associated with a higher overdose death rate postimplementation, but not significant), increased state oversight of pain management clinics (associated with a lower overdose death rate postimplementation, but not significant [the only coefficient with the hypothesized sign]), and the unemployment rate (associated with a higher overdose death rate, but not significant). The regression suggests states with medical cannabis laws had a 24.8 percent lower mean annual opioid overdose mortality rate (95 percent CI, −37.5 percent to −9.5 percent; P = .003), even though the graphed data show their annual rates were higher. This pattern remained when the analysis was restricted to unintentional overdose or excluded overdoses that involved heroin as well as prescription opiates. [Editor's note: The analysis does not appear to test for spatial or temporal auto-correlation and does not consider the difference-in-differences approach commonly used in time series modeling.]

Read more (for main piece and commentary):

K. Hasegawa, J.A. Espinola, D.F.M. Brown, and C.A. Camargo, Jr. 2014. "Trends in U.S. Emergency Department Visits for Opioid Overdose, 1993–2010." Pain Medicine. Doi: 10.1111/pme.12461.

The National Hospital Ambulatory Medical Care Survey for 1993–2010 provides aggregate estimates of 731,000 emergency department (ED) visits for illicit and prescription opioid overdose (an average of 40,000 per year), with rates of 14 ED visits per 100,000 population and 37 ED visits per 100,000 emergency department visits. Of these, 41 percent were for prescription opioid overdose. Between 1993 and 2010, the national visit rate increased from 7 to 27 per 100,000 population, and from 19 to 63 per 100,000 emergency department visits. In stratified analyses of the visit rate per 100,000 emergency department visits, the rate increased significantly in several groups: age <20 years, age 20–29 years, age ≥50 years, whites, and patients in the South. [Editor's Note: This study uses a very narrow term, opioid overdose, that omits most patients seen because of opiate problems. For example, the Drug Abuse Warning Network estimate is 474,683 opiate-involved ED visits in 2007 (156 visits per 100,000 population). This study's estimate is roughly 65,000, or 21 per 100,000 population.]

Read more:

A. Kraut, L.A. Shafer, and C.B. Raymond. 2014. "Proportion of Opioid Use Due to Compensated Workers' Compensation Claims in Manitoba, Canada." American Journal of Industrial Medicine. Doi: 10.1002/ajim.22374.

From 1998 to 2010, 2.1 percent of those prescribed opioids in Manitoba Canada were Workers Compensation Board claimants. The claimants received 3.8 percent of the total opioid dosages of medication prescribed. In regression-adjusted analyses, they were more likely to be prescribed over 120 morphine equivalents per day (OR 2.06). To make these estimates, researchers linked Workers Compensation Board and Manitoba Center for Health Policy data.

Read more:

S.E. McCabe, B.T. West, P. Veliz, K.A. Frank, and C.J. Boyd. 2014. "Social Contexts of Substance Use Among U.S. High School Seniors: A Multicohort National Study." Journal of Adolescent Health, doi: 10.1016/j.jadohealth.2014.06.017

An analysis of pooled 2002–11 data from the Monitoring the Future study found that U.S. high school seniors most often used prescription opioids, stimulants, and sedatives nonmedically at home. In contrast, they most often used alcohol, marijuana, and polydrugs at a party. Most substance use occurred in the presence of other people with the exception of nonmedical use of prescription stimulants, which was a solitary behavior.

Read more:

Roe, S. 2014. "An Initial Evaluation of Web-Based Overdose Education (Master's Thesis)." University of Washington, Seattle. Dissertations and Theses, Aug. 27.

Among 422 people who 1) visited www.stopoverdose.org after Internet and Facebook advertising for targeted residents of King and Spokane Counties in Washington state and 2) responded to a posttest quiz about overdose recognition and response, most respondents were 35 or older and female. The mean quiz score 16.2 out of 18.0 possible points, including 1.48 out of 2.00 possible points for items concerning the state's Good Samaritan Law. Respondents indicating professional interest in the topic were more likely than ones indicating personal interest to be 35 or older and to have received prior overdose education and less likely to know someone at risk for opioid overdose and to report planning to obtain take-home naloxone. Knowledge scores did not differ significantly between these groups.

Read more:

M.K. Schaefer and J.F. Perz. 2014. "Outbreaks of Infections Associated With Drug Diversion by U.S. Health Care Personnel." Mayo Clinic Proceedings 89(7):878–87, doi: http://dx.doi.org/10.1016/j.mayocp.2014.04.007.

During 2004–13, six outbreaks of infections stemmed from drug diversion in U.S. healthcare settings. All occurred in hospital settings. Implicated healthcare professionals included three technicians and three nurses, including one nurse anesthetist. Two outbreaks involved tampering with opioids administered through patient-controlled analgesia pumps and resulted in gram-negative bacteremia in 34 patients. The remaining outbreaks involved tampering with syringes or vials containing fentanyl and resulted in hepatitis C transmission to 84 patients. Almost 30,000 patients were targeted for notification advising testing.

Read more:

M. Vuolo, B.C. Kelly, B.E. Wells, and J.T. Parsons. 2014. "Correlates of Prescription Drug Market Involvement Among Young Adults." Drug and Alcohol Dependence. Doi: 10.1016/j.drugalcdep.2014.08.002.

This study continues the analysis of data from 404 young adult prescription drug misusers sampled from New York City nightlife scenes. Those from the wealthiest parental class and heterosexuals had higher odds (OR=6.8) of selling prescription drugs, Having a stimulant prescription (OR=4.14), having sold other illegal drugs (OR=6.73), and college bar scene involvement (OR=2.73) also increased the odds of selling. Odds of being approached to sell were higher for males (OR=1.93), sedative prescription holders (OR=2.11), and those involved in the college bar scene (OR=2.09).

Read more:

Professional Education

J. Hoppe, M.A. Howland, and L. Nelson. 2014. "The Role of Pharmacies and Pharmacists in Managing Controlled Substance Dispensing." Pain Medicine. Doi: 10.1111/pme.12531.

The epidemic of prescription opioid-related morbidity and mortality demonstrates the need for a fresh, open, and balanced approach to managing pain while minimizing adverse personal and public health outcomes. Interventions by pharmacists when prescriptions appear to be inappropriate have raised the ire of prescribers who feel their professional judgment is being questioned and their time is being usurped from patient care. Pharmacists, however, represent an important check and balance in the opioid analgesic prescribing chain, and prescribers should embrace their involvement and recognize that the time and effort of the pharmacist are directed at improving care of individual patients and keeping a watchful eye on the public health. Pharmacies need to keep a mindful eye toward professional practices of physicians and use noninvasive means, such as database inquiries, before directly contacting a prescriber. Collaboration is the most professional approach that can be taken to assure the joint priority of caring for patients in distress will be accomplished effectively and safely.

Read more:


Employer Gets New Trial to Prove Drug Tests Were Not Medical Examinations or Disability-Related Inquiries
Jackson Lewis, Kathryn J. Russo, Lexology
August 26, 2014

The Sixth Circuit Court of Appeals vacated a U.S. District Court's judgment and granted Dura, a Tennessee auto glass manufacturer, a new trial to prove that drug tests it administered to its employees—including tests for prescription medications—were not "medical examinations" or "disability-related inquiries" under the Americans with Disabilities Act (ADA) [Bates v. Dura Automotive Systems, Inc., No. 11–6088 (Sixth Cir., Aug. 26, 2014)]. At the new trial, the district court will be required to instruct the jury to decide whether the drug tests were medical examinations or disability-related inquiries in accordance with the ADA's statutory definitions and the definitions set forth in the EEOC's Enforcement Guidance: Disability-Related Inquiries and Medical Examinations of Employees Under the ADA Part B.2 (July 27, 2000) and the EEOC's Enforcement Guidance: Preemployment Disability-Related Questions & Medical Examinations (Oct. 10, 1995). In particular, the appellate court emphasized the "test design factor," i.e., whether the test is designed to reveal an impairment or the employee's health.

Read more:

Why the White House Has Shifted Its Policy on Tackling Drug Use—And Why It's Not Alone
Katie Zezima, Washington Post
August 26, 2014

This article discusses the White House shifting its drug policy away from incarcerating low-level offenders towards helping them access addiction treatment. Both political parties agree that a public health-based approach to drug addiction is the best way to address prescription drug and heroin abuse. One reason for the shift is the increase in drug overdoses and public opinion toward providing treatment to people with addictions.

Read more:

Pharmacist Develops Naloxone Nasal Spray to Reverse Drug Overdoses
Krystle Vermes, Pharmacy Times
August 27, 2014

Dr. Daniel Wermeling, a pharmacy professor at the University of Kentucky has developed a nasal spray of naloxone, which he believes is quicker and more effective than injected delivery. The spray is in a final round of clinical trials and could be available to the public as early as next year. Dr. Wermeling's company, AntiOp, collaborated with Reckitt Benckiser Pharmaceuticals, Inc, which has the option to acquire all rights to the product upon its FDA approval.

Read more:

Chicago and Two California Counties Sue Over Marketing of Painkillers
John Schwartz, New York Times
August 24, 2014

The city of Chicago, Ill., and two California counties filed lawsuits claiming drug companies "aggressive marketing" fueled widespread abuse, addiction, overdose, and death, and cost taxpayers millions of dollars in insurance claims. The Chicago lawsuit against five drug companies asserts that about 1,100 emergency room visits in the city in 2009 could be attributed to opioid abuse and overdose. The California lawsuit asserts that drug makers urged doctors to extend beyond traditional uses of the drugs and prescribe them to treat extreme conditions, such as acute pain after surgery or injury or cancer pain, while underplaying the high risk of addiction.

Read more:

By End of August, CVS Will Offer Narcan Without Prescription to Counter Opiate Overdoses
Linda Borg, Providence Journal
August 23, 2014

CVS Pharmacy will offer Narcan without a prescription at all of its 60 pharmacies in Rhode Island by the end of August. CVS will offer a nasal spray and an injection. Pharmacists are currently undergoing training on how to help customers properly administer the drug.

Read more:

Rx Safes, Inc. Announces New War on Drugs
PR Newswire
August 28, 2014

Rx Safes, Incorporated has begun manufacturing a fingerprint-keyed medication lockbox.

Read more:

Pill-Addicted Veterans Get Second Chance With Treatment Court
Jen Christensen, CNN
August 27, 2014

Veteran treatment courts are successfully rehabilitating people. Half of veterans prescribed medical opioids continue to use them chronically. CNN interviews Nicholas Stefanovic about his experience with veterans treatment court when he was battling an addiction to opioids.

Read more:

Denver Mom Survives Darkness of Prescription Drug Abuse Epidemic
Michael Martinez, Ana Cabrera, and Sara Weisfeldt, CNN
August 27, 2014

A CNN reporter interviews Cynthia Scudo, a mother of 8 and a grandmother of 18, about her struggles with addiction. She abused prescription pain relievers and then used heroin because it was cheaper. Scudo has been sober for three years. Doctors say prescription opiate abuse can be a gateway drug to heroin and prescription drug abuse is a massive problem in the United States.

Read more:

Adam's Story: When Prescription Drugs Are Deadly
Stephanie Elam, Chuck Conder, CNN
August 27, 2014

A CNN reporter interviews the parents of Adam Montgomery, a 27 year old who died from a cocktail of oxycodone, hydromorphone, alprazolam, and methadone. The Drug Enforcement Agency alleges Dr. Julio Diaz prescribed Montgomery more than 2,000 pills in the 6 weeks before his death. Dr. Diaz is awaiting sentencing on charges including illegal drug distribution. (Includes 4-minute15-second video)

Read more:

Drug Overdoses Kill More Albertans Than Vehicle Crashes
Catherine Griwkowsky, Edmonton Sun
August 27, 2014

In 2012, more people in Alberta, Canada, died from drug overdoses than vehicle crashes (387 versus 345). Edmonton's Streetworks Manager Marliss Taylor called for more education for drug users and for professionals, a broader community education program, and a community-based naloxone program.

Read more:

Other State and Local News

Staten Island University Hospital Offers Free Training, Narcan Kit to Combat Drug Overdose Kathryn Carse, Staten Island Advance
August 26, 2014

Staten Island University Hospital is hosting a training and distributing free Narcan Kits on Sept. 9, 2014. The training will focus on recognizing the signs of overdose and how to administer the nasal spray. The Narcan kits are being provided through the New York State Department of Health.

Read more:

Once-A-Month Shot That Blocks High From Opiates Making Inroads in Maine
Jackie Farwell, Bangor Daily News
August 27, 2014

Maine drug addicts are using naltrexone once a month to prevent them from getting high. Naltrexone, also known as Vivitrol, blocks the brain's opioid receptors, thwarting the euphoric effects of heroin and prescription pain relievers. Experts question how well Vivitrol will work in the long term. Drug abusers must completely detox from opiates for at least a week before their first injection. Vivitrol injections can cost $800 to $1,000, more than double the expense of a month's worth of Suboxone. Vivitrol users also are at risk of an overdose if they skip an injection or take opiates. [Editor's Disclosure: one of my staff ran a treatment site in the randomized trial of Vivitrol.]

Read more:

Deadly Drug Mix: Fentanyl Makes a Comeback
Don Sapatkin, Philadelphia (Pa.) Inquirer
August 24, 2014

Philadelphia's Office of Addiction Services reported that at least 50 people died of drugs laced with illicit fentanyl in the first half of 2014, more than double the number for all of last year. Most were among the 173 overdoses involving heroin or morphine. Two-thirds of the 280 drug overdoses (22 of them fatal) reported this year in Camden involved suburban residents. Fentanyl began reappearing last year, when the Drug Enforcement Agency cataloged more fentanyl-laced drug samples from Pennsylvania than any other state.

Read more:

GBI: Overdose Deaths Decrease in 2013 While Deaths Related to Illicit Drugs Increase
Joe Johnson, Athens (Ga.) Banner–Herald
August 23, 2014

The Medical Examiner's Office in Georgia reported that drug overdose deaths declined from a peak of 729 in 2010 to 686 in 2012 and 630 in 2013. Deaths attributed to only illicit drugs, however, rose from 82 in 2011 to 94 in 2012 and 106 in 2013. Alprazolam was the most common prescription drug in people who died from overdoses in 2013, followed by hydrocodone and methadone. Whites accounted for 90.6 percent of all overdose deaths.

Read more:

Rate of Drug OD Deaths in City Has Jumped By 41 Percent in 4 Years, Health Department Reveals
Erin Durkin, New York Daily News
August 28, 2014

The New York City Health Department reported that the drug overdose death rate in the city rose by 41 percent since 2010 (from 8.2 to 11.6 per 100,000 residents. Most deaths, 77 percent, involved an opioid. The death rate from heroin doubled from 3.1 to 6.2, while the prescription opiate death rate leveled off. The Bronx had the highest heroin death rate at 8.8, followed closely by Staten Island at 8.6. Queens saw the sharpest increase, from 1.9 to 4.3.

Read more:

Tennessee Cracks Down on Prescription Drugs
Eric Alvarez, WZTV
August 25, 2014

The Tennessee Board of Pharmacy suspended the license of two Rutherford County pharmacies. Corder's Community Pharmacy for missing more than 5,800 hydrocodone pills. The Murfreesboro Pain Management Clinic surrendered its certification after investigators found the business distributed controlled substances without keeping proper records.

Read more:

Other Resources

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention. Opioid Painkiller Prescribing: Where You Live Makes a Difference. CDC Vital Signs, July 2014.

This issue brief discusses prescribing across the United States. Health care providers in the highest-prescribing state wrote almost three times as many opioid pain relievers prescriptions per person as those in the lowest prescribing state. There are twice as many pain reliever prescriptions per person in the United States as in Canada. Data suggest that where health care providers practice influences how they prescribe. Higher prescribing of pain relievers is associated with more overdose deaths. The issue brief also discusses what can be done to prevent overprescribing while ensuring patients' access to safe, effective pain treatment. Changes at the state level show particular promise.

Read more:

Request for Proposal

Chronic Pain Management Research Grant
Milbank Foundation
Postmarked by November 1, 2014

Interventions for Youth who Misuse/Abuse Prescription Stimulant Medications in High School and/or College-Attending Youth (U01)
National Institutes of Health
Deadline: November 13, 2014, by 5 p.m.

National Take-Back Event

National Take-Back Initiative
Drug Enforcement Administration
September 27, 2014

Take-Back Events and Drop Boxes

City Sets Hazardous Waste, Drug Drop-Off Event
Dayton (Ohio) Daily News

August 22, 2014

Encouraging Proper Disposal: OU Health Science Center Receives Rx Disposal Box
Jessica Bruha, Norman (Okla.) Transcript
August 27, 2014

Escambia Sheriff's Office Schedules Drug Take-Back
NorthScambia.com (Florida)
August 27, 2014

Dispose of Unwanted Prescriptions in the Marshalltown PD Drop Box
Tama News–Herald, The Toledo Chronicle (Iowa)
August 27, 2014

Fillmore Police Collect Expired Prescription Drugs
Ventura County (Calif.) Star
August 22, 2014

Medreturn Box Available at Wrentham Public Safety Building
Heather Gillis Harris, Wicked Local Foxborough (Massachusetts)
August 27, 2014

Drop Boxes Help Combat Prescription Drug Abuse
WNYT (New York)
August 25, 2014

Save the Date

Sixth Annual American Medicine Chest Challenge: National Day of Awareness and Safe Disposal of Prescription and Over-the-Counter Medicine
American Medicine Chest Challenge
November 8, 2014

Upcoming Conferences and Workshops

2014 Arkansas Prescription Drug Abuse Summit
University of Arkansas, Criminal Justice Institute
September 10, 2014
Little Rock, Arkansas

Twenty-Seventh Annual NPN Prevention Research Conference
National Prevention Network
September 15–18, 2014
Hartford, Connecticut

2014 Harold Rogers PDMP National Meeting
Brandeis University, Prescription Drug Monitoring Program Training and Technical Assistance Center
September 22–24, 2014
Washington, District of Columbia

Fifth Annual Prescription Drug Abuse Symposium: Reversing the Tide of Opioid Abuse
Office of the Indiana Attorney General
October 16–17, 2014
Indianapolis, Indiana

Empowered Health Consciousness and Prescription Drugs: Facilitator Certification Training With Special Focus on Workplace and Parents
Organizational Wellness
November 4, 2014

142nd Annual Meeting and Exposition
American Public Health Association
November 15–19, 2014
New Orleans, Louisiana

National Prescription Drug Abuse Summit
April 6–9, 2015
Atlanta, Georgia
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.