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Background on Opioid Epidemic

Dealing with the Opioid Epidemic -

A Training Resource

By Jim Messina, Ph.D., CCMHC, NCC, DCMHS-T
History of the Opioid Crisis: A NPR Podcast
America's Opiod Crisis
A 44 minute Podcast
This podcast describes how the US got into this Opioid Crisis over the past 150 years. 
Update on Epidemic
On July 31, 2017, The President's Commission on Combating Drug Addiction and Opioid Crisis put out its first interim report asking the President and the Cabinet to declare a state of emergency to quickly and aggressively address this crisis  (see article on Medscape at: 142 Americans die every day from a drug overdose and this declaration of a national emergency is the single most important recommendation said Chirs Christie who is chairman of the Presidential Commission in a press briefing. 

On June 16, 2017, The President's Commission on Combating Drug Addiction and Opioid Crisis conducted its first public meeting under the Direction of its chairperson Governor Chris Christie from New Jersey. The video of the entire event is available on the White House website at: this hearing there were 9 organizations presenting their recommendations to address this epidemic. It provides a first hand account of the national perspective on this epidemic and recommended steps to be taken to prevent, treat and support recovery from addiction from opioid, heroin or other drugs.  The website for The President's Commission on Combating Drug Addiction and Opioid Crisis is available on the White House website under the Office of National Drug Control Policy at:
Background on Oxycontin's Creators

You can read an amazing account of a family's empire behind the Oxycontin Epidemic in America in an article appearing in the October 30, 2017 New Yorker entitled: The Family that Built an Empire of Pain, by Patrick Radden Keefe. You can reach the article by clicking hereThis article gives us an insight into the contribution of just one pharmaceutical company to our current opioid crisis. It is very shocking to say the least. 


Prescription drugs are essential to improving the quality of life for millions of Americans living with acute or chronic pain. However, misuse, abuse, addiction, and overdose of these products, especially opioids, have become serious public health problems in the United States. A comprehensive response to this crisis must focus on preventing new cases of opioid addiction, identifying early opioid-addicted individuals, and ensuring access to effective opioid addiction treatment while safely meeting the needs of patients experiencing pain.


Prescription drug abuse and overdose is a serious public health problem in the United States. Drug overdose death rates in the U.S. increased five-fold between 1980 and 2008, making drug overdose the leading cause of injury death.3 In 2013, opioid analgesics were involved in 16,235 deaths — far exceeding deaths from any other drug or drug class, licit or illicit. According to the National Survey on Drug Use and Health (NSDUH), in 2012 an estimated 2.1 million Americans were addicted to opioid pain relievers and 467,000 were addicted to heroin. These estimates do not include an additional 2.5 million or more pain patients who may be suffering from an opioid use disorder because the NSDUH excludes individuals receiving legitimate opioid



A public health response to this crisis must focus on preventing new cases of opioid addiction, early identification of opioid addicted individuals, and ensuring access to effective opioid addiction treatment, while at the same time continuing to safely meet the needs of patients experiencing pain. It is widely recognized that a multi-pronged approach is needed to address the prescription opioid epidemic. A successful response to this problem will target the points along the spectrum of prescription drug production, distribution, prescribing, dispensing, use and treatment that can contribute to abuse; and offer opportunities to intervene for the purpose of preventing and treating misuse, abuse and overdose.


(Johns Hopkins School of Public Health (2015) The Prescription Opioid Epidemic: An Evidence-Based Approach)

What is Addiction?
Before we get into the Neuroscience of the use of Opioids let's try a short answer to: What is Addiction?  The Addiction Policy Forum has created a short, four-minute video that explains addiction, its history, its prevalence in the US and more. It helps dispel the myth that addiction is the result of a deficient character, and promotes the scientific view of addiction as a chronic disease that is treatable. Videos like this one are even more valuable in the face of the opioid epidemic. As more and more people encounter addiction in their friends and family, the need for community support instead of ostracism will grow. Help increase knowledge of and support for addiction treatment in your community by viewing and sharing the video which is available at:

The Neurobiology of Substance Use, Misuse, and Addiction

Substance use disorders result from changes in the brain that can occur with repeated use of alcohol or drugs. The most severe expression of the disorder, addiction, is associated with changes in the function of brain circuits involved in pleasure (the reward system), learning, stress, decision making, and self-control.


Every substance has slightly different effects on the brain, but all addictive drugs, including alcohol, opioids, and cocaine, produce a pleasurable surge of the neurotransmitter dopamine in a region of the brain called the basal ganglia; neurotransmitters are chemicals that transmit messages between nerve cells. This area is responsible for controlling reward and our ability to learn based on rewards. As substance use increases, these circuits adapt. They scale back their sensitivity to dopamine, leading to a reduction in a substance’s ability to produce euphoria or the “high” that comes from using it. This is known as tolerance, and it reflects the way that the brain maintains balance and adjusts to a “new normal”—the frequent presence of the substance. However, as a result, users often increase the amount of the substance they take so that they can reach the level of high they are used to. These same circuits control our ability to take pleasure from ordinary rewards like food, sex, and social interaction, and when they are disrupted by substance use, the rest of life can feel less and less enjoyable to the user when they are not using the substance.


Repeated use of a substance “trains” the brain to associate the rewarding high with other cues in the person’s life, such as friends they drink or do drugs with, places where they use substances, and paraphernalia that accompany substance-taking. As these cues become increasingly associated with the substance, the person may find it more and more difficult not to think about using, because so many things in life are reminders of the substance.


Changes to two other brain areas, the extended amygdala and the prefrontal cortex, help explain why stopping use can be so difficult for someone with a severe substance use disorder. The extended amygdala controls our responses to stress. If dopamine bursts in the reward circuitry in the basal ganglia are like a carrot that lures the brain toward rewards, bursts of stress neurotransmitters in the extended amygdala are like a painful stick that pushes the brain to escape unpleasant situations. Together, they control the spontaneous drives to seek pleasure and avoid pain and compel a person to action. In substance use disorders, however, the balance between these drives shifts over time. Increasingly, people feel emotional or physical distress whenever they are not taking the substance. This distress, known as withdrawal, can become hard to bear, motivating users to escape it at all costs. As a substance use disorder deepens in intensity, substance use is the only thing that produces relief from the bad feelings associated with withdrawal. And like a vicious cycle, relief is purchased at the cost of a deepening disorder and increased distress when not using. The person no longer takes the substance to “get high” but instead to avoid feeling low. Other priorities, including job, family, and hobbies that once produced pleasure have trouble competing with this cycle.


Healthy adults are usually able to control their impulses when necessary, because these impulses are balanced by the judgment and decision-making circuits of the prefrontal cortex. Unfortunately, these prefrontal circuits are also disrupted in substance use disorders. The result is a reduced ability to control the powerful impulses toward alcohol or drug use despite awareness that stopping is in the person’s best long-term interest.


This explains why substance use disorders are said to involve compromised self-control. It is not a complete loss of autonomy—addicted individuals are still accountable for their actions—but they are much less able to override the powerful drive to seek relief from withdrawal provided by alcohol or drugs. At every turn, people with addictions who try to quit find their resolve challenged. Even if they can resist drug or alcohol use for a while, at some point the constant craving triggered by the many cues in their life may erode their resolve, resulting in a return to substance use, or relapse.


(HHS Office of the Surgeon General (2016). Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health)

Epidemic Defined

The CDC's official definition of an epidemic is: "The occurrence of more cases of disease than expected in a given area or among a specific group of people over a particular period of time.”


Since 1999 the rate of overdose deaths involving opioids including both prescription pain medication and heroin nearly quadrupled

Heroin use has increased across the US among men and women, most age groups, and all income levels


Factors Driving the Epidemic

Interrelated factors

  • Wider availability of prescription opioids
  • 1999-2013 the amount of prescription opioids dispensed in the US nearly quadrupled
  • Increasing non-medical use and overdose
  • Changing economics and supply of heroin
  • Cheaper, available, higher purity, synthetics
  • Increasing heroin use and overdose
  • Lack of access to treatment
  • 80% with SUD are not in treatment


Epidemic by the numbers

On an average day:

  • 650,000 opioid prescriptions dispensed
  • 3,900 people initiate nonmedical use of prescription opioids
  • 580 people initiate heroin use
  • 91 people die from an opioid related overdose

Opioid Deaths in the USA in 2015

Heroin Deaths in the USA in 2015

Re-emergence of Fentanyl

  • Schedule II synthetic opioid analgesic
  • Up to 50-100x more potent than morphine and 30-50x than heroin
  • Mixed with adulterants and sold as “synthetic heroin”
  • 2015 death rate from synthetic opioids increased 72.2%
  • Comes from several sources
    • Diverted from legal medical use
    • Clandestine – manufactured in Mexico or China
Fentanyl: A Briefing Guide for First Responders from US Department of Justice: DEA
Given the increasing potency and prevalence of illicit fentanyl and fentanyl-like products entering the US drug trade, the Drug Enforcement Agency published recommendations for law enforcement and first responders to minimize dangerous exposures. You can read this report at:

Synthetic Opioid Deaths in 2015

Natural Opioid Deaths in the USA

Risk Groups for Prescription Opioid Misuse

  • Men ages 25-54
  • White and American Indian/Alaska Natives
  • People in rural areas, especially in the Appalachian region
  • People who obtain multiple controlled substance prescriptions from multiple providers
  • Teens and young adults (One in four teens has misused or abused a prescription drug at least once in their lifetime)
  • People who take high daily dosages of opioid pain relievers (veterans with injuries, those with occupational injuries)
  • Increasingly women and older adults over 65


Risk groups for Heroin Addiction

  • People who are addicted to prescription opioid painkillers are at most risk for addiction to heroin
  • People who are addicted to cocaine
  • People without insurance or enrolled in Medicaid
  • Non-Hispanic whites
  • Males
  • People living in large metropolitan areas, particularly in the Northeast and Midwest

The relationship between Heroin and Prescription Opioids

  • Both prescription opioids and heroin are chemically related and just as addictive
  • Act on nerve cells in the brain and nervous system the same way – pleasurable effects and relieve pain
  • People who are addicted to prescription opioid painkillers are at high risk for addiction to heroin 19x more likely to use
  • Injecting drug use (IDU) increases the risk of serious, long-term viral infections such as HIV, Hepatitis B and C
  • 11% of new HIV infections are from Injecting Drug Use (IDU)
  • 50% of new Hepatitis C infections are from Injecting Drug Use (IDU)
  • 114% increase in Emergency Room and Doctor visits
  • Neo-natal abstinence syndrome
  • Increase in fractures in older adults due to falls
  • Significant co-occurring Myocardial Infarction (health attacks) with SUD
  • Anxiety, mood disorders, depression


The Hepatitis Infection Epidemic

  • 150% increase in new infections 2010-2013
  • Almost 50% of new cases associated with injection drug use
  • Occurring in young people (<30), in rural and suburban areas
  • Use of oral prescription opioids before transitioning to injecting

Addiction Technology Transfer Center's  ATTC Resources: at:
  • HCV Current
  • Online and in-person curriculum and training
  • Downloadable provider tools

Making this Epidemic More Personal – What’s Happening in Our Own Back Yard?

On the morning of February 25, 2017 as this website was being uploaded the following article appeared in the Tampa Bay Times: From the shadow of pill mills, a new drug crisis emerges in Tampa Bay.  It was written by John Romano a Times Columnist. Here is a summary of what he had to say:

We are six years past the peak of the pill mill epidemic, and Pinellas County is going through another killer drug crisis. Eliminating pill mills and doctor shopping was a necessary first step. But Florida, and many other states, never fully invested in the second step, which should have been providing better rehab and follow-up for opioid addicts caught in the court system. The statistics are still preliminary but the number of fatal overdoses in Pinellas jumped at least 53 percent from 2015 to 2016. There were 274 confirmed overdoses and, with seven cases still pending, the final tally could eclipse the 280 deaths in 2010 when oxycodone abuse was rampant. Pasco County had a 34 percent increase in drug deaths in 2016. Hillsborough County has not yet tallied its numbers, but expects an increase. This time around, it is being driven by a combination of heroin and fentanyl. The potency is higher and the cost cheaper, and so the results are tragically familiar.


The Florida Department of Law Enforcement reported heroin deaths in Florida were up about 75 percent, and fentanyl deaths were up 70 percent from 2014 to 2015. Higher totals are expected when the state's 2016 reports are released later this year.


A county commissioner from Palm Beach and a state senator from Miami-Dade have recently called on Gov. Rick Scott to declare a public health emergency, as he did in 2011 for the oxycodone crisis. "In Florida, it's an epidemic. Nationally, this is a pandemic,'' said Jim Hall, the co-director for the Center for Applied Research on Substance Abuse at Nova Southeastern University. "We've gone beyond a crisis level to an emergency level.''


Fentanyl is a painkiller, along the lines of morphine, often used to treat cancer patients. Produced mostly in Asia and apparently funneled through Mexico, it is far more powerful than heroin. Variations of fentanyl, including carfentanil, which is an animal tranquilizer that can be 100 times more potent than heroin, can be deadly with just a few drops.


"It's a lot cheaper than heroin, especially the analogs,'' said Bill Pellan, director of investigations for the Pinellas-Pasco Medical Examiner's Office. "They can take a tiny bit, and cut it with whatever, and now they have a lot more bags to sell. The same quantity of heroin might get you 10 baggies, versus 100 baggies with fentanyl. It's cheap and it's available, so there's a demand for it.''


At one point, it was difficult to know if users realized they were getting heroin laced with fentanyl. There was an outbreak early last year in Tampa Bay with fentanyl being pressed into Xanax pills that led to a handful of deaths for the unsuspecting. Now, however, investigators say some users have told them they look for fentanyl. Bill Pellan said labs are seeing examples of confiscated supplies in syringes or baggies that contain fentanyl but no heroin.


What should we do? We need to work in a united collaborating way to intervene early in the lives of youth to address those issues which drive them to experiment. We need to engage with users in better wrap around services which support them in their efforts to free themselves from this addiction. We need to get the whole community to be supportive of the efforts to work on ridding our local communities from this sourge.

Click on this link to see his entire article

How a Florida Community is Facing this Crisis 

Read about how Sarasota created a Coalition in it's community to address this epidemic and how their efforts are working. Read article on the SAMSHA website at:

Strategies for Addressing this Epidemic

A. Evidence Based

Some evidence-based interventions exist to inform action to address this public health emergency; these should be scaled up and widely disseminated. Furthermore, many promising ideas are evidence-informed, but have not yet been rigorously evaluated. The urgent need for action requires that we rapidly implement and carefully evaluate these promising policies and programs. The search for new, innovative solutions also needs to be supported.

  • Supported by research and/or promising practices
  • Understanding that SUD’s are a brain disease that can be treated

B. Cross System

The desired goal is developing approaches that intervene all along the supply chain, and in the clinic, community and addiction treatment settings. Interventions aimed at stopping individuals from progressing down a pathway that will lead to misuse, abuse, addiction and overdose are needed. Effective primary, secondary and tertiary prevention strategies are vital. The importance of creating synergies across different interventions to maximize available resources is also critical.

  • Legal, health, government, private/public, education, research/science, law enforcement, first responders, all personal need to be engaged.

C. Comprehensive

Used appropriately, prescription opioids can provide relief to patients. However, these therapies are often being prescribed in quantities and for conditions that are excessive, and in many cases, beyond the evidence base. Such practices, and the lack of attention to safe use, storage and disposal of these drugs, contribute to the misuse, abuse, addiction and overdose increases that have occurred over the past decade. What is needed are efforts to maximize the favorable risk/benefit balance of prescription

opioids by optimizing their use in circumstances supported by best clinical practice guidelines.

  • Address the combined and interrelated epidemics
  • Prevention, intervention, and treatment

Evidence informed Public Policy


Everyone has a role

  • Addiction/Behavioral Health treatment providers
  • Healthcare providers/professionals
  • Hospitals
  • Law enforcement/lawmakers
  • Peers/peer support organizations
  • Educators/colleges/universities/schools
  • Faith leaders
  • Families
  • Drug prevention coalitions


Public Health Approach

“By adopting an evidence-based public health approach, America has the opportunity to take genuinely effective steps to prevent and treat substance-related issues”.

  • Prevent initiation
  • Prevent escalation from use to disorder
  • Shorten the duration of illness
  • Reduce the number of substance related deaths

(HHS Office of the Surgeon General (2016).Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health) 


The Public Health Approach

We are all part of the solution!!

1.    Prevention
2.    Early Intervention
3.    Treatment
4.    Recovery


1. Prevention


2. Early Intervention


3. Treatment

Long term

  • Detox is a first step


  • Methadone
  • Buprenorphine
  • Naltrexone

Psychosocial Interventions

  • CBT (relapse prevention, 12 step facilitation, social skills)
  • Individual, group, family counseling

Recovery Supports

  • Peers

4. Recovery 

An Integrated Approach

  • Focusing on the Whole Person
  • Integrating behavioral health into the HIV care continuum
  • Integrating behavioral health into the primary care system
  • Integrating behavioral health into the education/school systems


Community Partnerships

Goal: Every door is the right door

  • SUD Treatment Programs and Emergency Rooms
  • Public health and behavioral health programs
  • Primary care and SUD treatment programs
  • Schools and prevention coalitions
  • Entitlement programs (Medicaid) and SUD treatment programs
  • HHS training and Technical Assistance center collaborative

What the People Involved with this Epidemic can do


1. The people who are over-using prescription pain killers (opioids) can do

Talk with their doctors about:

  • The risks of prescription painkillers and other ways to manage their pain
  • Making a plan on when and how to stop, if a choice is made to use prescription painkillers

Use prescription opioids only as instructed by their doctors

Store prescription painkillers in a safe place and out of reach of others

Never use another person's prescription opioids


2. The Prescribers

  • Talk with your patients about the risks of taking prescription opioids, including addiction/tolerance, overdose and death
  • Prescribe the lowest effective dose, only the quantity needed for the expected duration of pain and/or discuss other options to manage pain
  • Follow best practices for responsible opioid prescribing
    • CDC guidelines for chronic pain
    • American Society for Addictive Medications (ASAM) guidelines
    • Use your state’s Prescription Drug Monitoring Program (PDMP) to identify patients who might be misusing prescription drugs and are at risk of overdose
    • Become trained to provide medications for addiction


3. Healthcare/Treatment Provider

  • Treat the whole person – integrated approach
  • Address health beliefs, wellness, health literacy
  • Regularly screen for depression and use of substances
  • Talk with your patients about the risks of using opioids
  • Identify and reach out to potential partners in your communities, provide information on your services


4. All of Us

  • Learn more about the risks of using heroin and other drugs
  • Learn how to recognize and respond to an opioid overdose (SAMHSA Overdose Tool Kit)
  • Know how to access treatment resources in your community (State
    • Behavioral Health Agency, Mental Health/Substance Abuse Treatment Agencies,
    • Be aware of what policies and practices that the State is implementing
    • Stay updated!

Additional Background Information on this Epidemic

Prevalence of Pain and Substance Use Disorders (SUD)

100 million Americans have persistent pain-IOM study, 2011

Pain costs society at least $560‐$635 billion annually -IOM study,


  • $261‐$300 billion in health care costs
  • $297‐$336 billion in lost productivity

In 2013, 1.9 million people had a substance use disorder

SAMHSA, 2014


Prescribed Opioid Abuse

Over 16,000 died of an opioid‐related overdose-SAMHSA, 2014

4.3 million nonmedical users of Prescribed opioids age 12 or older-SAMHSA, 2014

467,000 adolescents were current nonmedical users of prescribed opioids, with 168,000 having an addiction to them-SAMHSA, 2014

Abuse of Other Controlled Prescribed Medications

A. Stimulants

  • 17% of college students abuse prescribe ADHD medications
  • 20% of middle and high school students with prescribed medications are asked by friends for medications; 50% give medications to friends

B. Benzodiazepines

  • Overdose deaths quadrupled between 2001 and 2013
  • PA: Present in 50% of drug‐related overdose deaths - 40% involved alprazolam
  • GA: Misuse of alprazolam leading cause of drug‐related death -35%, 231 out of 644

C. Sedatives

  • Violence
  • “Ambien defense” to murder
  • Zolpidem sleep medication is most common date rape drug - DEA
  • Impaired driving “sleep‐driving”

Partial Progress

Decrease in prescription drug abuse‐related deaths

  • CDC: 3% nationwide in 2012
  • SAMHSA: 14% among adults ages 18 to 25 nationwide in 2011

Decrease in prescription opioid‐related deaths

  • CDC: 5% nationwide in 2012 - 1st time in over a decade
  • 27% in FL between 2010 and 2012
  • 29% in Staten Island between 2011 to 2013

Heroin Use

517,000 had a heroin use disorder, compared with 189,000 in 2002-SAMHSA, 2014

Between 2002 and 2013, the rate of heroin‐related overdose deaths nearly quadrupled. Over 8,200 died in 2013-CDC

People who abuse prescribed opioids rarely use heroin, and the transition to heroin use appears to occur at a low rate-NIDA 2016

Researchers suggest that the major drivers of the recent heroin use increases and related deaths are:

  • Increased accessibility
  • Lower market price
  • High purity


Heroin Supply

A. Heroin Pills

  • Counterfeit oxycodone containing heroin in KY & OH
  • Indistinguishable from legitimate pills; identified through lab tests

B. Heroin laced with fentanyl

  • 40 times as strong as pure heroin
  • 700 heroin-fentanyl‐related deaths from late 2013 through 2014
  • 74 people overdosed in 3 days in Chicago

C. “China White” – heroin laced with acetyl fentanyl-analog

  • Deaths jumped 500% -43 in ME between 2013 and 2014
  • 600% increase in deaths -49 in Cabarrus County, NC

D. Hollywood – “exceptionally” lethal form of heroin

  • 8 people overdosed in 1 week in Western Massachusetts

AbuseRelated Trends

A. Hepatitis C and HIV transmissions

  • Outbreak in southeastern Indiana community of 4,200: 170 with HIV and 122 with hepatitis C-06/2015
  • Miami‐Dade and Broward County are the top two counties in the U.S. for new HIV cases; transmissions presumed to be associated w/ opioid abuse/heroin use-09/2015

B. Profiteering

  • Opioid analgesic pill mills
  • Fraud and abuse in urine drug testing
  • Buprenorphine pill mills

C.  Demands for action and kneejerk responses

OpioidFocused Policy Responses

Supply reduction efforts limited to prescribed opioid analgesics vs. all controlled prescribed medications

Tremendous advances in opioid overdose rescue

Inadequate demand reduction - interventions and treatment


Federal Activity

CDC guidelines

  • Could be adopted by legislatures and licensing boards
  • Likely to be adopted by insurers
  • Congressional investigation into process and potential conflicts of interest

H.R. 2805, S. 1134: Would create the Pain Management Best Practices Inter‐Agency Task Force

HHS regulations

  • Increase use of buprenorphine for opioid dependence
  • Increase number of prescribers
  • Increase patient limit


National Pain Strategy and National Legislation

  • Population Research
  • Prevention and Care
  • Disparities
  • Service Delivery and Reimbursement
  • Professional Education and Training
  • Public Education and Communication
  • ER/LA opioid REMS-under review
  • Abuse‐deterrent guidance, approvals, and labeling
  • Opioid labels – “severe enough”
  • DEA enforcement-distributors, pharmacies
  • Hydrocodone rescheduling
  • Secure and Responsible Drug Disposal Act - rule effective 10/9/14
  • Stop Overdose Stat Act of 2015 – H.R. 2850: Naloxone
  • Jason Simcakoski Memorial Opioid Safety Act – S.1641: VA/DOD guidelines for opioid therapy for chronic pain
  • Opioid Overdose Reduction Act of 2015 – S.707: Good Samaritan
  • Protecting Our Infants Act of 2015 – H.R. 1462, S.799: Requires Agency for Healthcare Research and Quality to report on NAS-enacted Nov. 25, 2015

Results of National Initiative

On March 26, 2015, HHS Secretary Sylvia M. Burwell announced a department-wide initiative focused on combatting the opioid epidemic. The HHS Opioid Initiative focuses on three priority areas:

  • “Opioid prescribing practices to reduce opioid use disorders and overdose,
  • The expanded use of naloxone, used to treat opioid overdoses,
  • Expanded use of Medication-assisted Treatment (MAT) to reduce opioid use disorders and overdose.”

Over the last fifteen years, prescription opioids have been increasingly prescribed to treat acute and chronic pain; they have also been increasingly misused and implicated in drug overdose deaths. After a sharp increase in the number of opioid prescription filled in the U.S. during the first decade of the twenty-first century, opioid prescribing and deaths began to level out around 2012, though each remain high.  In fact, at least half of all U.S. opioid overdose deaths involve a prescription opioid.

State Activity

Safer prescribing standards-push to adopt CDC guidelines

  • Opioids for pain
  • Buprenorphine for opioid dependence
  • Limits to FDA‐approved indication

Prescriber education requirements

Mandatory Pain Management Prescription data checks

Pain clinic registration and regulation

Good Samaritan, naloxone laws

Step therapy


Unintended Consequences

A. Access to care

  • Ability to find qualified and willing providers
  • Harassment and denials at pharmacies

B. Core systems and values

  • Consistency in federal policy -CMS, CDC
  • Federal supremacy - states’ attempted medication bans
  • State plenary police powers - states regulate the professions – not the federal government
  • Compassion
  • People with pain, addiction, hepatitis C
  • Women and newborns
  • Privacy of patients and providers
  • Law enforcement access
  • Prescription monitoring programs

Resources for this Additional Background Section:

Barnes, M.C. & Arndt, G. (2013). The best of both worlds: Applying federal commerce and state police powers to reduce prescription drug abuse. Journal of Health Care & Policy 271.


Barnes, M.J. & Sklaver, S.L. (2013). Active verification and vigilance: A method to avoid pcivil and criminal liability when prescribing controlled substances, Depaul Journal of Health Care Law,15(2), 93-145. 

Chou, R., Turner, J.A., Devine, E.B., Hansen, R.N., Sullivan, S.D., Blazina, I., Dana, T., Bougatsos, C. & Deyo, R.A. (2015). The effectiveness and risks of long-term opioid therapy for chronic pain: A systematic review for a national institutes of health pathways to prevention workshop. Annals of Internal Medicine, 16,:276-286. doi:10.7326/M14-2559

Deyo. R.A. (2015). Opioids for low back pain. BMJ,350. doi:

Sehgal, N., Manchikanti, L. & Smith, H.S. (2012). Prescription opioid abuse in chronic pain: A review of opioid abuse predictors and strategies to curb opioid abuse. Pain Physician, 15, ES67-ES92.

Simon, K., Worthy, S.L., Barnes, M.C. & Tarbell, B. (2015). Abuse‐deterrent formulations: Transitioning the pharmaceutical market to improve public health and safety, Therapeutic Advance in Drug Safety, 6(2) 67–79. DOI: 10.1177/2042098615569726

Online Resources

Florida Behavioral Health Association:

NOPE Task Force (Narcoptics Overdose Prevention & Education Task Force) at: