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The opioid epidemic or opioid crisis is the rapid increase in the use of prescription and non-prescription opioid drugs in the United States and Canada in the 2010s. Opioids are a diverse class of moderately strong painkillers, including oxycodone (commonly sold under the trade names OxyContin and Percocet), hydrocodone (Vicodin), and a very strong painkiller, fentanyl, which is synthesized to resemble other opiates such as opium-derived morphine and heroin. The potency and availability of these substances, despite their high risk of addiction and overdose, have made them popular both as formal medical treatments and as recreational drugs. Due to their sedative effects on the part of the brain which regulates breathing, opioids in high doses present the potential for respiratory depression, and may cause respiratory failure and death.[2]
According to the U.S. Drug Enforcement Administration, "overdose deaths, particularly from prescription drugs and heroin, have reached epidemic levels."[3]:iii Nearly half of all opioid overdose deaths in 2016 involved prescription opioids.[1] From 1999 to 2008, overdose death rates, sales, and substance abuse treatment admissions related to opioid pain relievers all increased substantially.[4] By 2015, annual overdose deaths from heroin alone surpassed deaths from both car accidents and guns, with other opioid overdose deaths also on the rise.[5]
Drug overdoses have since become the leading cause of death of Americans under 50, with two-thirds of those deaths from opioids.[6] In 2016, 62,000 Americans died from overdoses, 19 percent more than in 2015, and had killed more Americans in one year than both the wars in Vietnam and Iraq combined.[7][6] By comparison, the figure was 16,000 in 2010, and 4,000 in 1999. Figures from June 2017 indicate the problem has worsened.[8][9] While death rates varied by state,[10] public health experts estimate that nationwide over 500,000 people could die from the epidemic over the next 10 years.[11]
In March 2017, Larry Hogan, the governor of Maryland, declared a state of emergency to combat the opioid epidemic,[12] and in July 2017 opioid addiction was cited as the "FDA's biggest crisis."[13] CDC director Thomas Frieden said that "America is awash in opioids; urgent action is critical."[14] The crisis has changed moral, social, and cultural resistance to street drug alternatives such as heroin.[15] On August 10, 2017, President Donald Trump agreed with his Commission's report released few weeks earlier and declared the country's opioid crisis a "national emergency."[16][17] On September 1, Trump nominated as "drug czar" Tom Marino, whose election campaign had been financed by pharmaceutical distribution companies that had lobbied for, and profited from, legislation co-sponsored by Marino which protected pharmacies suspected of diverting pills.[18]
Contents [hide]
1 Background in the United States
1.1 Main causes
1.2 Effects
1.3 Fentanyl
1.4 History of opiate use in the United States
1.5 Demographics
1.6 Outside the U.S.
2 Countermeasures
2.1 Federal government
2.2 State and local governments
2.3 Prescription drug monitoring
2.4 In the media
2.5 Solutions for addicts
2.5.1 Naloxone
2.5.2 Methadone
2.5.3 Buprenorphine
2.5.4 Behavioral treatment options
3 See also
4 References
5 External links
Background in the United States[edit]
Main causes[edit]
What the U.S. Surgeon General calls "The Opioid Crisis" likely began with over-prescription of powerful opioid pain relievers in the 1990s, which led to them becoming the most prescribed class of medications in the United States. As of 2016 more than 289 million prescriptions were written for opioid drugs per year.[19]:43In the late 1990s, many Americans were diagnosed with chronic pain, estimated to affect around 100 million people or a third of the U.S. population. This led to a push by drug companies and the federal government to expand the use of painkilling opioids.[10] Between 1991 and 2011, painkiller prescriptions in the U.S. tripled from 76 million to 219 million per year. Among the most common opioids prescribed have been oxycodone (OxyContin and Percocet) and hydrocodone (Vicodin). With the increase in volume, potency of opioids also increased. By 2002, one in six drug users were being prescribed drugs more powerful than morphine; by 2012, the ratio had doubled to one-in-three.[10]
Despite the increased use of painkillers, there has been no change in the amount of pain reported in the U.S.[20][19] This has led to differing medical opinions, with some noting that there is little evidence that opioids are effective for chronic pain not caused by cancer.[21]
Effects[edit]
When people continue to use opioids beyond what a doctor prescribes, whether to minimize pain or to enjoy the euphoric feelings, it can mark the beginning stages of an opiate addiction, with a tolerance developing and eventually leading to dependence, when a person relies on the drug to prevent withdrawal symptoms.[22]
As the number of opioid prescriptions rose, drug cartels began flooding the U.S. with heroin. For many opioid users, heroin was cheaper, more potent, and often easier to acquire than prescription medications.[8] According to the CDC, tighter prescription policies by doctors did not necessarily lead to this increased heroin use.[21] The main suppliers of heroin to the U.S. have been Mexican transnational criminal organizations.[8] From 2005–2009, Mexican heroin production increased by over 600%, from an estimated 8 metric tons in 2005 to 50 metric tons in 2009.[8] Between 2010 and 2014, the amount seized at the border more than doubled.[23] According to the DEA, smugglers and distributors "profit primarily by putting drugs on the street and have become crucial to the Mexican cartels."[3]:3
Opiate self-injection paraphernalia
The opioid epidemic has since emerged as one of the worst drug crises in American history: more than 33,000 people died from overdoses in 2015, nearly equal to the number of deaths from car crashes, with deaths from heroin alone more than from gun homicides.[24] It has also left thousands of children suddenly in need of foster care after their parents have died from an overdose.[25]
Fentanyl[edit]
There have always been drug addicts in need of help, but the scale of the present wave of heroin and opioid abuse is unprecedented. In Maryland, the first six months of 2015 saw 121 fentanyl deaths. In the first six months of 2016, the figure rose to 446.
Christopher Caldwell,
senior editor The Weekly Standard[15]
Fentanyl, a newer synthetic opioid painkiller, is 50 to 100 times more potent than morphine and 30 to 50 times more potent than heroin,[15] with only 2 mg becoming a lethal dose. It is pure white, odorless and flavorless, with a potency strong enough that police and first responders helping overdose victims have themselves overdosed by simply touching or inhaling a small amount.[26][27][28] As a result, the DEA has recommended that officers not field test drugs if fentanyl is suspected, but instead collect and send samples to a laboratory for analysis. "Exposure via inhalation or skin absorption can be deadly," they state.[29]
Fentanyl-laced heroin has become a big problem for major cities, including Philadelphia, Detroit and Chicago.[30] Its use has caused a spike in deaths among users of heroin and prescription painkillers, while becoming easier to obtain and conceal. Some arrested or hospitalized users are surprised to find that what they thought was heroin was actually fentanyl.[15] According to CDC director Thomas Frieden:
As overdose deaths involving heroin more than quadrupled since 2010, what was a slow stream of illicit fentanyl, a synthetic opioid 50 to 100 times stronger than morphine, is now a flood, with the amount of the powerful drug seized by law enforcement increasing dramatically. America is awash in opioids; urgent action is critical.[14]
According to the Centers for Disease Control and Prevention (CDC), death rates from synthetic opioids, including fentanyl, increased over 72% from 2014 to 2015.[22] In addition, the CDC reports that the total deaths from opioid overdoses may be under-counted, since they do not include deaths that are associated with synthetic opioids which are used as pain relievers. The CDC presumes[when?] that a large proportion of the increase in deaths is due to illegally-made fentanyl; as the statistics on overdose deaths do not distinguish pharmaceutical fentanyl from illegally-made fentanyl, the actual death rate could therefore be much higher than reported.[31]
Those taking fentanyl-laced heroin are more likely to overdose because they do not know they also are ingesting the more powerful drug.[32] In March 2017, New Jersey police arrested a person possessing nearly 31 pounds (14 kg) of fentanyl (14 kg would yield 7 million lethal doses).[33][34] Among those who died from overdosing on fentanyl was singer Prince.[34][35]
Fentanyl has surpassed heroin as a killer in several locales: in all of 2014 the CDC identified 998 fatal fentanyl overdoses in Ohio, which is the same number of deaths recorded in just the first five months of 2015.[36] In Cleveland, a person was caught selling blue fentanyl pills disguised to look like doses of the milder opioid painkiller oxycodone.[36] The U.S. attorney for Ohio stated:
One of the truly terrifying things is the pills are pressed and dyed to look like oxycodone. If you are using oxycodone and take fentanyl not knowing it is fentanyl, that is an overdose waiting to happen. Each of those pills is a potential overdose death.[36]
In 2016 the medical publication STAT reported that while Mexican cartels are a main source of heroin smuggled into the U.S., Chinese suppliers provide both raw fentanyl and the machinery necessary for its production.[36] In British Columbia, police discovered a lab making 100,000 fentanyl pills each month, which they were shipping to Calgary, Alberta. 90 people in Calgary overdosed on the drug in 2015.[36] In Southern California, a home-operated drug lab with six pill presses was uncovered by federal agents; each machine was capable of producing thousands of pills an hour.[36]
History of opiate use in the United States[edit]
In the early 1900s, as veterans of the First World War were returning home from overseas, there were few options to help relieve pain, and doctors mainly turned to morphine.[37] Opiates soon became known as a wonder drug and were prescribed for a wide array of ailments, even for relatively minor treatments such as cough relief. Beginning around 1920, however, their addictiveness was recognized and not too long afterwards heroin was made an illegal drug.[37] In the Anti-Heroin Act of 1924, the U.S. Congress banned the sale, importation, or manufacture of heroin.
Around World War II, doctors used opiates in lieu of surgery. This made prescriptions for opiates skyrocket.[37] In the 1950s, heroin addiction was known among jazz musicians, but still fairly unknown by average Americans, many of whom saw it as a frightening condition.[15] The fear extended into the 1960s and 1970s, although it became common to hear or read about drugs such as marijuana and psychedelics, which were widely used at rock concerts like Woodstock.[15] Heroin addiction began to make the news when famous people such as Janis Joplin, John Belushi, Jim Morrison and Lenny Bruce, whom most people did not know were addicted, died from overdoses. During and after the Vietnam War, addicted soldiers returned from Vietnam, where heroin was easily bought. Heroin addiction grew within low-income housing projects during the same time period.[15] In 1971, congressmen released an explosive report on the growing heroin epidemic among U.S. servicemen in Vietnam, finding that ten to fifteen percent were addicted to heroin. "The Nixon White House panicked," wrote political editor Christopher Caldwell and declared drug abuse "public enemy number one".[38] By 1973, there were 1.5 overdose deaths per 100,000 people.[15]
In the 1980s, many medical experts did not believe that opioids were addictive. A brief letter published in the New England Journal of Medicine (NEJM) in January 1980, titled "Addiction Rare in Patients Treated with Narcotics", was subsequently cited over 600 times to support this position.[39][40] A group of researchers in Canada claim that the letter may have originated and contributed to the opioid crisis.[39] The NEJM published its rebuttal to the 1980 letter in June 2017, pointing out among other things that the conclusions were based on hospitalized patients only, and not on patients taking the drugs after they were sent home.[41] The original author, Dr. Hershel Jick, has said that he never intended for the article to justify widespread opioid use.[39]
In the mid-to-late 1980s the crack epidemic followed widespread cocaine use in American cities. The death rate was worse, reaching almost 2 per 100,000. In 1982, Vice President George H. W. Bush and his aides began pushing for the involvement of the CIA and the U.S. military in drug interdiction efforts, the so-called War on Drugs.[42] By comparison, as of 2016, the present opioid epidemic is killing on average 10.3 people per 100,000. In some states it is far worse: over 30 per 100,000 in New Hampshire and over 40 per 100,000 in West Virginia.[15]
Demographics[edit]
In the U.S., addiction and overdose victims are mostly white and working-class. Geographically, those living in rural areas of the country have been the hardest hit as a percentage of the national population,[43] Prescription drug abuse has been increasing in teenagers, especially as 12- to 17-year-olds were one-third of all new abusers of prescription drugs in 2006. Teens abuse prescription drugs more than any illicit drug except marijuana, more than cocaine, heroin and methamphetamine combined, per the Office of National Drug Control Policy’s 2008 Report Prescription for Danger.
In Palm Beach County, Florida, overdose deaths went from 149 in 2012 to 588 in 2016.[44]
In Middletown, Ohio, overdose deaths quadrupled in the 15 years since 2000.[45]
There has been a difference in the number of opioid prescriptions written by doctors in different states. In Hawaii, doctors wrote about 52 prescriptions for every 100 people, whereas in Alabama, they wrote almost 143 prescriptions per 100 people. Researchers suspect that the variation results from a lack of consensus among doctors in different states about how much pain medication to prescribe. A higher rate of prescription drug use does not lead to better health outcomes or patient satisfaction, according to studies.[8]
Outside the U.S.[edit]
Approximately 80 percent of the global pharmaceutical opioid supply is consumed in the United States.[47]
It has also become a serious problem outside the U.S., mostly among young adults.[48] The concern not only relates to the drugs themselves, but to the fact that in many countries doctors are less trained about drug addiction, both about its causes or treatment.[20] According to an epidemiologist at Columbia University: "Once pharmaceuticals start targeting other countries and make people feel like opioids are safe, we might see a spike [in opioid abuse]. It worked here. Why wouldn’t it work elsewhere?" [20] The majority of deaths worldwide from overdoses were from either medically prescribed opioids or illegal heroin. In Europe, prescription opioids accounted for three-quarters of overdose deaths among those between ages 15 and 39.[48] Some worry that the epidemic could become a worldwide pandemic if not curtailed.[20] Prescription drug abuse among teenagers in Canada, Australia, and Europe were at rates comparable to U.S. teenagers.[20] In Lebanon and Saudi Arabia, and in parts of China, surveys found that one in ten students had used prescription painkillers for non-medical purposes. Similar high rates of non-medical use were found among the young throughout Europe, including Spain and the United Kingdom.[20]
Countermeasures[edit]
This section is in a list format that may be better presented using prose. You can help by converting this section to prose, if appropriate. Editing help is available. (August 2017)
Federal government[edit]
In 2010, the US government began cracking down on pharmacists and doctors who were over-prescribing opioid pain killers. The unintended consequence of this was that users turned to cheaper but illegal heroin, a significantly more potent opioid, as a substitute,[10] including addicted patients who were denied opioid prescriptions as doctors tried to cut back painkiller drug abuse.[15] A 2017 survey in Utah of heroin users found about 80 percent started with prescription drugs.[49] As a result, by 2015 nationwide deaths from prescription opioids had increased by 15% and for heroin users by 23%.[10][50]
In 2010, the CSA was amended with the Secure and Responsible Drug Disposal Act which allows pharmacies to accept controlled substances from households or long term care facilities in their drug disposal programs or "take-back" programs.[51]
In 2011, the Obama administration released a white paper describing the administration's plan to deal with the crisis. Its concerns have been echoed by numerous medical and government advisory groups around the world.[52][53][54]
In 2016, the U.S. Surgeon General listed statistics which describe the extent of the problem.[19]
In July 2016, President Barack Obama signed into law the Comprehensive Addiction and Recovery Act, which expands opioid addiction treatment with buprenorphine and authorizes millions of dollars in new funding for opioid research and treatment.[55]
In December 2016, the 21st Century Cures Act, which includes $1 billion in state grants to fight the opioid epidemic, was passed by Congress by a wide bipartisan majority (94-5 in the Senate, 392-26 in the House of Representatives),[56] and was signed into law by President Obama.[57]
As of March 2017, President Donald Trump appointed a commission to deal on the epidemic, chaired by Governor Chris Christie of New Jersey.[58][59][60]
In June 2017, the FDA asked the manufacturer to remove its injectable form of oxymorphone (Opana ER) from the US market, because the drug's benefits may no longer outweigh its risks, this being the first time the agency has asked to remove a currently marketed opioid pain medication from sale due to public health consequences of abuse.[61]
In July 2017, FDA commissioner Dr Scott Gottlieb stated that for the first time, pharmacists, nurses, and physicians, would have training made available on appropriate prescribing of opioid medicines, because opioid addiction had become the "FDA's biggest crisis".[13]
On August 10, 2017, President Trump agreed with his Commission's report released few weeks earlier and declared the country's opioid crisis a "national emergency."[16][17]
On September 1, 2017, Trump nominated Representative Tom Marino as director of the Office of National Drug Control Policy, or "drug czar".[62] Pharmaceutical distribution companies had contributed $134,000 to Marino's election campaigns in 2014 and 2016, more than contributions from any other industry. Pharmaceutical distibutors had lobbied for legislation which Marino co-sponsored in 2016, the Ensuring Patient Access and Effective Drug Enforcement Act, which made it harder for the DEA to shut down pharmacies suspected of diverting pills.[18]
State and local governments[edit]
In July 2016, governors of most U.S. states and territories entered into a formal "Compact to Fight Opioid Addiction." They agreed that collective action would be needed to end the opioid crisis, and they would coordinate their responses across all levels of government and the private sector, including opioid manufacturers and doctors.[63]
In March 2017, the Governor of Maryland, as an urgent response to the crisis, declared a State of Emergency to combat the rapid increase in overdoses by increasing and speeding up coordination between the state and local jurisdictions.[64][12] In 2016, about 2,000 people in the state had died from opioid overdoses.[65]
In March 2017, Delaware, which has the 12th-highest overdose death rate in the country, introduced bills to both limit doctors' ability to over-prescribe painkillers and improve access to treatment. In 2015, 228 people had died from overdose, which increased 35%—to 308—in 2016.[66]
In March 2017, a similar plan was begun in Michigan, which introduced the Michigan Automated Prescription System (MAPS), allowing doctors to check when and what painkillers have already been prescribed to a patient, and thereby help keep addicts from switching doctors to receive drugs.[67][68]
During the 2017 General Session of the Utah Legislature, Rep. Edward H. Redd and Sen. Todd Weiler proposed amendments to Utah's involuntary commitment statutes by trying to pass H.B. 299 into law which would allow relatives to petition a court to mandate substance- abuse treatment for adults.[69][49]
In Maine, new laws were imposed which capped the maximum daily strength of prescribed opioids and which limited prescriptions to seven days. But some doctors were then concerned that patients would turn to using street drugs like heroin to extend their use of painkillers.[15]
In West Virginia, which leads the nation in overdose deaths per capita, lawsuits seek to declare drug distribution companies a "public nuisance" in an effort to place accountability upon the drug industry for the costs associated with the epidemic.[70][71]
In February 2017, officials in Everett, Washington filed a lawsuit against the manufacturer of OxyContin for negligence by allowing drugs to be illegally trafficked to residents and failing to prevent it. The city wants the company to pay the costs of handling the crisis.[72]
Prescription drug monitoring[edit]
In 2016, the CDC published its "Guideline for Prescribing Opioids for Chronic Pain", recommending opioids only be used when benefits for pain and function are expected to outweigh risks, and then used at the lowest effective dosage, with avoidance of concurrent opioid and benzodiazepine use whenever possible.[73] Silvia Martins, an epidemiologist at Columbia University, has suggested getting out more information about the risks:
The greater “social acceptance” for using these medications (versus illegal substances) and the misconception that they are “safe” may be contributing factors to their misuse. Hence, a major target for intervention is the general public, including parents and youth, who must be better informed about the negative consequences of sharing with others medications prescribed for their own ailments. Equally important is the improved training of medical practitioners and their staff to better recognize patients at potential risk of developing nonmedical use, and to consider potential alternative treatments as well as closely monitor the medications they dispense to these patients.[48]
As of April 2017, prescription drug monitoring programs (PDMPs) exist in every state.[74] A person on opioids for more than three months has a 15-fold (1,500%) greater chance of becoming addicted.[21] PDMPs allow pharmacists and prescribers to access patients’ prescription histories to identify suspicious use. However, a survey of US physicians published in 2015 found only 53% of doctors used these programs, while 22% were not aware these programs were available.[75] The Centers for Disease Control and Prevention (CDC) was tasked with establishing and publishing a new guideline, and was heavily lobbied.[76][77]
In the media[edit]
Media coverage has largely focused on law-enforcement solutions to the epidemic, which portray the issue as criminal rather than medical.[78] There has been differential reporting on how white suburban or rural addicts of opioids are portrayed compared to black and Hispanic urban addicts, often of heroin, reinforcing stereotypes of drug users and drug-using offenders.[79] In newspapers, white addicts' stories are often given more space, allowing for a longer backstory explaining how they became addicted, and what potential they had before using drugs. Black and Hispanic addicts are more likely to be dehumanized, portrayed criminally, and mentioned more briefly.[79]
In July 2017, a 400-page report by the National Academy of Science presented plans to reduce the addiction crisis, which it said was killing 91 people each day.[80]
Solutions for addicts[edit]
Main article: Drug abuse treatment
The opioid epidemic is often discussed in terms of prevention, but helping those who are already addicts is talked about less frequently.[78] Opioid dependence can lead to a number of consequences like contraction of HIV and overdose. For addicts who wish to treat their addiction, there are two classes of treatment options available: medical and behavioral.[81] Neither is guaranteed to successfully treat opioid addiction. Which, or which combination, is most effective varies from person to person.[82] These treatments are doctor-prescribed and -regulated, but differ in their treatment mechanism. Popular treatments include naloxone, methadone, and buprenorphine, which are more effective when combined with a form of behavioral treatment.[82]
Naloxone[edit]
Naloxone is used mostly as a rescue medication for opioid overdose. It is an opioid antagonist, meaning it binds to opioid receptors but does not turn them on. It also happens that naloxone binds to opioid receptors more strongly than heroin or any prescription opioids. This means that when someone is overdosing on opioids, naloxone can be administered, allowing it to take the place of the opioid drug in the person's receptors, turning them off. This blocks the effect of the receptors. Naloxone is sometimes administered with other drugs such as buprenorphine, as a way to taper off buprenorphine over time. Naloxone binds to some of the receptors, blocking the effectiveness of some receptors in case of relapse.[82]
Methadone[edit]
Methadone has been used for opioid dependence since 1964, and studied the most of the pharmacological treatment options.[83] It is a synthetic long acting opioid, so it can replace multiple heroin uses by being taken once daily.[82] It works by binding to the opioid receptors in the brain and spinal cord, activating them, reducing withdrawal symptoms and cravings while suppressing the "high" that other opioids can elicit. The decrease in withdrawal symptoms and cravings allow the user to slowly taper off the drug in a controlled manner, decreasing the likelihood of relapse. It is not accessible to all addicts. It is a regulated substance, and requires that each dose be picked up from a methadone clinic daily. This can be inconvenient as some patients are unable to travel to a clinic, or avoid the stigma associated with drug addiction.[82]
Buprenorphine[edit]
Buprenorphine is used similarly to methadone, with some doctors recommending it as the best solution for medication-assisted treatment to help people reduce or quit their use of heroin or other opiates. It is claimed to be safer and less regulated than methadone, with month-long prescriptions allowed. It is also said to eliminate opiate withdrawal symptoms and cravings in many patients without inducing euphoria.[84]
Unlike methadone treatment, which must be performed in a highly structured clinic, buprenorphine, according to SAMHSA, can be prescribed or dispensed in physician offices.[85] Patients can thereby receive a full year of treatment for a fraction of the cost of detox programs.[84]
Behavioral treatment options[edit]
It is less effective to use behavioral treatment without medical treatment during initial detoxification. It has similarly been shown that medical treatments tend to get better results when accompanied by behavioral treatment.[81] Popular behavioral treatment options include group or individual therapy, residential treatment centers, and Twelve-step programs such as Narcotics Anonymous.[83] Residential treatment centers allow for a 24-hour drug-free environment to decrease the chances of relapse. These centers allow addicts to be in supportive environments during the difficult time of detox.[86]
Twelve-step programs are one of the most well-known options. The philosophy is that a group of people sharing the same addiction can remain abstinent with the support of and connection to others who empathize and understand. There is also a spiritual, though not religious, component to it, with freedom to believe as one chooses.[87]
See also[edit]
Crack epidemic
List of deaths from drug overdose and intoxication
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Jump up ^ Juliet Eilperin & Carolyn Y. Johnson, paying tribute to Biden and bipartisanship, signs 21st Century Cures Act Tuesday, Washington Post (December 13, 2016).
Jump up ^ "Opioid Epidemic: Trump to Set Up Commission on Addiction Crisis", NBC News, March 29, 2017
Jump up ^ "It's time to 'Trump' opioid addiction in the United States", The Hill, Feb. 27, 2017
Jump up ^ "President Trump Hosts an Opioid and Drug Abuse Listening Session", Real Clear Politics, March 29, 2017
Jump up ^ Commissioner, Office of the. "Press Announcements – FDA requests removal of Opana ER for risks related to abuse". www.fda.gov. Retrieved 2017-06-15.
Jump up ^ "Trump to tap Rep. Tom Marino as 'drug czar'". Politico. September 1, 2017. Retrieved 13 October 2017.
Jump up ^ "A Compact to Fight Opioid Addiction", National Governors Assoc., July 13, 2016
Jump up ^ "Hogan-Rutherford Administration Declares State of Emergency, Announces Major Funding to Combat Heroin and Opioid Crisis in Maryland", Maryland.gov, March 1, 2017
Jump up ^ "Gov. Hogan Announces Opioid Epidemic State Of Emergency", CBS Baltimore, March 1, 2017
Jump up ^ "Delaware lawmakers tackle opioid addiction epidemic", Newsworks, March 23, 2017
Jump up ^ "Governor Snyder rolls out plan to fight opioid addiction", WILX, March 23, 2017
Jump up ^ "Snyder: Efforts to stop opioid abuse aren’t working", Michigan Radio, March 23, 2017
Jump up ^ "HB0299". le.utah.gov. Retrieved 2017-07-27.
Jump up ^ "Opioid distributors sued by West Virginia counties hit by drug crisis". Washington Post. Retrieved 2017-06-27.
Jump up ^ "Lawyer Behind West Virginia County Lawsuit Against Opioid Distributors". NPR.org. Retrieved 2017-06-27.
Jump up ^ "U.S. City Sues OxyContin Maker For Contributing To Opioid Crisis", NPR, Feb. 3, 2017
Jump up ^ Dowell, Deborah; Haegerich, Tamara; Chou, Roger (March 15, 2016). "CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016". JAMA. 315: 1624–45. PMID 26977696. doi:10.1001/jama.2016.1464. Retrieved March 18, 2016.
Jump up ^ Missouri is final state to pass PDMP program; US News & World Report; April 13, 2017
Jump up ^ Rutkow Lainie; et al. (2015). "Most primary care physicians are aware of prescription drug monitoring programs, but many find the data difficult to access". Health Affairs. 34 (3): 484–492. doi:10.1377/hlthaff.2014.1085.
Jump up ^ Matthew Perrone, Associated Press. "Painkiller politics: Effort to curb prescribing under fire". The Washington Times. Retrieved 2017-06-13.
Jump up ^ Ghorayshi, Azeen. "Missouri Is The Only State In The US Where Doctors Have No Idea What Prescriptions People Are Getting". BuzzFeed. Retrieved 11 April 2017.
^ Jump up to: a b McGinty, E. "Criminal Activity or Treatable Health Condition? News Media Framing of Opioid Analgesic Abuse in the United States". Psychiatric Services. 67: 405–411.
^ Jump up to: a b Netherland, J. (December 2016). "The War on Drugs That Wasn't: Wasted Whiteness, "Dirty Doctors," and Race in Media Coverage of Prescription Opioid Misuse". Cult Med Psychiatry. 40 (4): 664–686.
Jump up ^ "Major Science Report Lays Out a Plan to Tamp Down Opioid Crisis", Scientific American, July 13, 2017
^ Jump up to: a b Veilleux, Jennifer. "A Review of Opioid Dependence Treatment: Pharmacological and Psychosocial Interventions to Treat Opioid Addiction". Clinical Psychology Review. 30.2: 155–166.
^ Jump up to: a b c d e Dixon, David (May 13, 2017). "Opioid Abuse Treatment and Management: Medical Care". Medscape.
^ Jump up to: a b "WHAT ARE MY TREATMENT OPTIONS?". TURN TO HELP. June 11, 2017.
^ Jump up to: a b "My View: New approach needed for opioid epidemic", Portland Tribune, July 25, 2017
Jump up ^ Buprenorphine, SAMHSA
Jump up ^ "Heroin Abuse Solutions". Narconon New Life Retreat. June 12, 2017.
Jump up ^ "12 Step Programs for Drug Rehab & Alcohol Treatment". American Addiction Centers. June 6, 2017.
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