Facilitator Molly Lowe Associate Director of Training and Technical - - PDF document

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CAPT Webinar

Strategies to Reduce the Harm of Prescription Drug Misuse

May 30, 2017

Findings from the Research Literature

Josh Esrick, Policy Analyst, SAMHSA’s CAPT Shai Fuxman, Senior Training and Technical Assistance Associate, SAMHSA’s CAPT

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Facilitator

Molly Lowe

Associate Director of Training and Technical Assistance SAMHSA’s CAPT

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This training was developed under the Substance Abuse and Mental Health Services Administration’s Center for the Application of Prevention Technologies task order. Reference #HHSS283201200024I/HHSS28342002T. The views expressed in this webinar do not necessarily represent the views, policies, and positions of the Substance Abuse and Mental Health Services Administration or the U.S. Department of Health and Human Services. This webinar is being recorded and archived, and will be available to all webinar participants. Please contact the webinar facilitator if you have any concerns or questions.

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Objectives

• Define the core components of strategies to

prevent both fatal and nonfatal overdose from prescription drugs

• Identify potential advantages and disadvantages
• f strategies to reduce the harm of prescription

drugs

• Describe the need for developing a

comprehensive approach to reducing the non- medical use of prescription drugs and preventing

• verdoses

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Preventing Prescription Drug Misuse: Strategies from the Research Literature

Strategies to Reduce Demand (4/13) Strategies to Reduce Demand (4/13) Strategies to Reduce Supply (4/27) Strategies to Reduce Supply (4/27) Strategies to Reduce Harm (Today) Strategies to Reduce Harm (Today)

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Presenters

Josh Esrick

Policy Analyst SAMHSA’s CAPT

Shai Fuxman

Senior T/TA Associate SAMHSA’s CAPT

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Strategies to Prevent the Non- medical Use of Prescription Drugs

Strategies to Prevent Supply Strategies to Prevent Harm Strategies to Prevent Demand

• Patient Education
• Prescriber Education
• Social Marketing

Campaigns

• Information

Dissemination Campaigns

• Prescriber Education
• Tracking and Monitoring
• Retail Access

Restrictions

• Enforcement Strategies
• Storage and Disposal
• Naloxone

Education and Distribution

• Overdose

Education

• Prescriber

Education

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Desired Outcomes Associated with Preventing NMUPD and Opioid Overdose

Harm Harm Demand Demand Supply Supply

Decreasing availability Decreasing availability Preventing dependence and misuse Preventing dependence and misuse Reducing nonfatal and fatal overdose Reducing nonfatal and fatal overdose

• Prescription
• pioid diversion
• Multiple

prescriber episodes (“doctor shopping”)

• Inappropriate

prescribing (“pill mills”)

• Prescription
• pioid diversion
• Multiple

prescriber episodes (“doctor shopping”)

• Inappropriate

prescribing (“pill mills”)

• Lack of

knowledge about potential dangers

• f prescription
• pioid misuse
• Mental health

disorders

• Chronic pain
• Lack of

knowledge about potential dangers

• f prescription
• pioid misuse
• Mental health

disorders

• Chronic pain
• Loss of tolerance
• Polysubstance

use and misuse

• Loss of tolerance
• Polysubstance

use and misuse

Outcomes Outcomes Example Risk Factors Example Risk Factors Strategy Strategy Strategy Strategy Strategy Strategy

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Evidence-Based Continuum1

Promising/ Emerging/ Undetermined Promising/ Emerging/ Undetermined Supported/ Well-Supported Supported/ Well-Supported

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A Note About Evidence

• There is less evidence for NMUPD

prevention strategies (compared to strategies for preventing other substances).

• A lack of evidence does not mean that a

strategy is ineffective.

• Practitioners should rely on experience

working with other substances.

• It is important for practitioners to collect

evaluation data to build the evidence around strategies.

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Opioid Use and Misuse

Strategies to Reduce the Harm of Prescription Drug Misuse

Findings From the Research Literature

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Defining Harm Reduction Strategies

Efforts aimed at decreasing fatal and nonfatal

• verdoses from

both prescription and illicit opioids (such as heroin).

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Overdose Deaths Involving Opioids, by Type of Opioid, 1999-20152

National Center for Health Statistics (NCHS), Multiple Cause of Death 1999-2015

2,000 4,000 6,000 8,000 10,000 12,000 14,000 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Heroin Natural and Semi-synthetic Opioids Synthetic

• pioids (e.g.,

fentanyl) Methadone

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Harm Reduction Strategies: Three Categories

Overdose Education Overdose Education Naloxone Education & Distribution Naloxone Education & Distribution Prescriber Education Prescriber Education

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Is your state, tribe, jurisdiction,

• r community

currently implementing any harm reduction strategies?

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Prescriber Education3,4,5,6

Involves teaching prescribers:

• How to recognize an individual at risk
• When/how to refer a patient to

treatment

• How to talk to patients about the

danger of overdose

• About using tools to identify cases of

poly-substance use

• About strategies to prevent overdose

deaths

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Overdose Prevention Strategies that Involve Prescribers7,8

• Prescribing naloxone

to patients at increased risk of

• verdose
• Writing third-party

naloxone prescriptions to family members and peers Prescriber Education Prescriber Education

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For More Information

Prescriber Education For more information on venues and delivery methods for prescriber education, visit https://captconnect.edc.org/ to access the materials from the first webinar in this series.

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Potential Advantages and Challenges

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• Potentially cost-effective
• Opportunity to inform

prescribers about new best practices (e.g., guidelines and alternatives to habit- forming medications)

• Target population can be

busy and difficult to reach

• More effective when used

by all prescribers and pharmacists

• Implementation may

require a prescriber or recognized medical expert to implement

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Overdose Education9,10,11

Involves teaching groups close to the problem:

• How to prevent overdoses from occurring
• How to recognize when an individual is at risk for
• verdose
• How to recognize when an overdose is occurring
• How to appropriately respond to an overdose
• Laws relevant to overdoses (such as Good

Samaritan laws)

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Potential Audiences for Overdose Education Strategies

Health Care Professionals Health Care Professionals Professional First Responders Professional First Responders People Who Use Opioids Illicitly People Who Use Opioids Illicitly People Who use Prescription Opioids Medically People Who use Prescription Opioids Medically

Overdose Education Overdose Education

Family Members of People Who Use Opioids Illicitly Family Members of People Who Use Opioids Illicitly

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Law Enforcement Training on Harm Reduction12,13,14,16,16,17

Involves preparing law enforcement to better respond to and prevent drug overdoses. Topics include:

• Purpose of harm-reduction training
• Foundational information on prescription drugs

and other opioids

• Signs and symptoms of an overdose
• Purpose of naloxone, how it works, and how to

administer it Overdose Education Overdose Education

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Overdose Education for People Who Use Drugs18,19,20,21,22,23

Overdose Education Overdose Education Informs people who use drugs about:

• Behaviors that increase
• verdose risk (such as

change in tolerance, mixing substances)

• How to recognize when an
• verdose is occurring
• Steps to take when

witnessing an overdose

Photo source: http://findings.org.uk/PHP/dl.php?file=Horyniak_D_ 1.cab&s=d 24

Good Samaritan Education24

• Intended to raise awareness of Good

Samaritan laws and policies, and the specific protections they provide, and build confidence in them.

• Audiences include:
• Law enforcement and criminal

justice professionals

• Members of the drug-using

community

• Lay first responders

Overdose Education Overdose Education

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Potential Advantages and Challenges

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• Can raise

awareness of dangers of

• pioid misuse
• Can be

combined with naloxone distribution

• Warning about dangerous substances on

the market can lead individuals with dependence to seek out other harmful substances

• Good Samaritan laws are only effective if

both law enforcement and potential 9-1-1 callers are educated

• Good Samaritan laws and policies are not

present in all states

• Accessing people who use drugs (and

their friends/families) can be challenging

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Participant Questions

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What is Naloxone?

Source: http://www.copeaustralia.com.au/home-mobile/naloxone/

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Naloxone Education and Distribution25,26,27

• Naloxone distribution programs provide access to

naloxone to individuals at risk for overdose and first responders who may witness an overdose

• Naloxone education informs the following

populations of the role of naloxone in preventing

• verdoses:
• Prescribers and dispensers
• Potential first responders (both lay and

professional)

• Broader community

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State Naloxone Access Laws28,29

• Allow naloxone to be

prescribed/dispensed to:

• substance users with

documented risk factors for overdose

• lay administrators

(nonmedical first responders, potential

• verdose bystanders,

family and friends of

• pioid users)

Naloxone Education and Distribution Naloxone Education and Distribution

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• Traditional prescriptions
• Third-party prescriptions
• Collaborative practice

agreements

• Standing orders
• Protocol orders

Types of Naloxone Access

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Overdose Education and Naloxone Distribution Programs27,29,30,31,32,33

• Overdose education and

naloxone distribution (OEND) programs provide training on:

• recognizing and

preventing opioid

• verdoses
• how to administer

naloxone.

Naloxone Education and Distribution Naloxone Education and Distribution

• Program participants are also provided prescriptions

for naloxone

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Potential Audiences for OEND Programs

Naloxone Education and Distribution Naloxone Education and Distribution

• Mental health centers
• Treatment facilities

(including methadone clinics)

• Homeless shelters
• Veterans’ Affairs

facilities

• People who use opioids

(and their family and friends)

• Professional and lay first

responders

• Broader community

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Project Lazarus8,34,35,36

Project Lazarus addresses drug overdose deaths, with a focus on prescription drug overdoses. Its

• verdose prevention program includes:
• Community activation and coalition building
• Monitoring and epidemiological surveillance
• Prescriber, patient, and law enforcement training

and education

• Overdose reversal medication

https://www.projectlazarus.org/

Naloxone Education and Distribution Naloxone Education and Distribution

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Potential Advantages and Challenges

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• Reduces rates of overdose

deaths

• When naloxone is

administered by a professional first responder, individuals who use drugs can be referred to services

• The education component of

these strategies promotes proper use of naloxone

• Can reduce fatalities but not

the underlying substance use disorders

• Prevention practitioners may

face critiques that giving naloxone to people who use drugs could encourage further use

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Additional Strategies to Note

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Efforts to Connect Individuals to Treatment38

• Increase access and connect individuals to

treatment for substance use disorders, especially medication-assisted treatment (MAT).

• MAT involves integrating medications (e.g.,

methadone, buprenorphine, naltrexone) in conjunction with behavioral therapies and counseling to treat opioid addiction.

https://www.samhsa.gov/medication-assisted-treatment

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Strategies to Reduce Non-opioid Prescription Overdoses

• Antidotes (e.g., Flumazenil

for benzodiazepine

• verdoses)
• Guidance for prescribers

(e.g., risks associated with mixing prescriptions)

• Safe storage

recommendations to prevent accidental poisonings

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Participant Questions

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A Comprehensive Approach to Reduce NMUPD and Opioid Overdose

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Selection as Part of a Strategic Process

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Developing a Comprehensive Approach to Reducing NMUPD and Opioid Overdose

Anytown, U.S.

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Comprehensive Approach: Example

Risk Factors for Anytown Strategies for Anytown Lack of knowledge about potential dangers of prescription opioid misuse Social marketing campaign Inappropriate prescribing Prescriber education Polysubstance use Overdose education

Problem: Anytown experienced high rates of

• pioid overdose over the past five years

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What NMUPD prevention strategies are you currently implementing or interested in implementing?

• Patient education
• Prescriber education
• Social marketing campaigns
• Information dissemination

campaigns

• Tracking and monitoring
• Retail access restrictions
• Enforcement strategies
• Proper storage and disposal
• Overdose education
• Naloxone education and

distribution

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Where to Find Out More

Resources on Strategies to Reduce the Harm of Prescription Drug Misuse

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SAMHSA Opioid Overdose Prevention Toolkit

• Facts for Community Members
• Five Essential Steps for First

Responders

• Information for Prescribers
• Safety Advice for Patients &

Family Members

• Recovery from Opioid Overdose

Available at store.samhsa.gov

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Revised NMUPD Decision Support Tools

• Overview of Factors and

Strategies

• Understanding Who is at Risk
• Programs and Strategies

Available at samhsa.gov/capt/

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Revised NMUPD Decision Support Tools (cont.)

Example: Overdose Education and Naloxone Distribution Programs

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Online Portal of Environmental Strategies Available to CSAP prevention grantees at captconnect.edc.org/

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Example: State Naloxone Access Laws

Online Portal of Environmental Strategies (cont.)

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Addressing Opioid Overdose: Understanding Risk Factors and Prevention Strategies

Available to webinar participants at the conclusion of today’s event (and at captconnect.edc.org/)

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Addressing Opioid Overdose: Understanding Risk Factors and Prevention Strategies (cont.) Example: Harm Reduction Strategies

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Implementing Strategies to Prevent NMUPD and Opioid Overdose

Upcoming opportunities and resources:

• National webinars
• Peer sharing/learning

communities on implementation challenges and best practices

• Stories and videos from

practitioners

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The CAPT is Here to Help

CAPT Resource Team Coordinator Northeast Resource Team Gisela Rots grots@edc.org Central Resource Team Chuck Klevgaard cklevgaard@edc.org Southeast Resource Team Lourdes Vazquez lvazquez@edc.org Southwest Resource Team Marie Cox mariecox@ou.edu West Resource Team Alyssa O’Hair aohair@casat.org

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Contact Information

If you have questions or comments about this webinar, please don’t hesitate to contact:

Amanda Dougherty

Training and Technical Assistance Associate adougherty@edc.org 312-962-4558

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Evaluation

Please take the time to complete a brief feedback form: https://www.surveymonkey.com /r/feedback-CAPT-1814 Thank you for sharing your thoughts!

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References

1. Puddy, R. W. & Wilkins, N. (2011). Understanding Evidence Part 1: Best Available Research Evidence. A Guide to the Continuum of Evidence of Effectiveness. Atlanta, GA: Centers for Disease Control and Prevention. 2. United States Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), Multiple Cause of Death 1999-2015 on CDC WONDER Online Database, released 2016. Data for year 2015 are compiled from the Multiple Cause of Death File 2015, Series 20, No. 2U, 2016. 3. Franklin, G. M., Mai, J., Turner, J., Sullivan, M., Wickizer, T., & Fulton-Kehoe, D. (2012). Bending the prescription opioid dosing and mortality curves: Impact of the Washington State opioid dosing guideline. American Journal of Industrial Medicine, 55(4), 325-331. 4. American Medical Association. (2013). State Medical Licensure Requirements and Statistics (pp. 65-69): American Medical

• Association. Retrieved from https://www.acep.org/uploadedFiles/ACEP/CME/CME-State-CMERequirements_2013.pdf.

5. Lofwal, M. R., Wunsch, M. J., Nuzzo, P. A., & Walsh, S. L. (2011). Efficacy of continuing medical education to reduce the risk

• f buprenorphine diversion. Journal of Substance Abuse Treatment, 41(3), 321–329.

6. Cochella, S., & Bateman, K. (2012). Provider detailing: an intervention to decrease prescription opioid deaths in Utah. Pain Medicine, 12(Suppl 2) S73–S76. 7. Albert, S., Brason II, F. W., Sanford, C. K., Dasgupta, N., Graham, J., & Lovette, B. (2011). Project Lazarus: Community- based overdose prevention in rural North Carolina. Pain Medicine, 12, S77-S85. 8. Project Lazarus. (n.d.b). Project Lazarus results for Wilkes County. Retrieved from http://projectlazarus.org/project-lazarus- results-wilkes-county

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57

References

9. Oliver, R. L., & Taylor, A. (2003). Chronic Opioid Rules: Prescribing opioids for chronic pain requires set rules, a written plan, periodic re-evaluation, and vigilance to prevent illegal diversion of controlled substances. Practical Pain Management, 3(2), 1-8. 10. Albert, S., Brason Ii, F. W., Sanford, C. K., Dasgupta, N., Graham, J., & Lovette, B. (2011). Project Lazarus: Community-Based Overdose Prevention in Rural North Carolina. Pain Medicine, 12, S77-S85. 11. Davis, C. (2016). Legal interventions to reduce overdose mortality: Naloxone access and overdose Good Samaritan laws. Robert Wood Johnson Foundation. Retrieved from https://www.networkforphl.org/_asset/qz5pvn/naloxone-_FINAL.pdf 12. Bureau of Justice Assistance. (2014). Law enforcement naloxone toolkit. Washington, DC: U.S. Department of Justice. Retrieved from https://www.bjatraining.org/tools/naloxone/all 13. The Network for Public Health Law. (2014). Legal interventions to reduce overdose mortality: Naloxone access and overdose Good Samaritan laws. Retrieved from https://www.networkforphl.org/_asset/qz5pvn/network-naloxone-10-4.pdf 14. New York State Division of Criminal Justice Services. (2014). Opioid overdose and intranasal naloxone training for law enforcement: Trainer’s guide. Retrieved from https://www.bjatraining.org/sites/default/files/naloxone/Opioid%20Overdose%20Intranasal%20Naloxone%20Training%20- %20Trainer%20Guide.pdf 15. North Carolina Harm Reduction Coalition. (2015). Law enforcement departments carrying naloxone. Retrieved from http://www.nchrc.org/law-enforcement/us-law-enforcement-who-carry-naloxone/ 16. U.S. Department of Justice. (2014). Attorney General Holder announces plans for federal law enforcement personnel to begin carrying naloxone. Retrieved from http://www.justice.gov/opa/pr/attorney-general-holder-announces-plans-federal-law- enforcement-personnel-begin-carrying

58

References

17. Saucier, C. D., Zaller, N., Macmadu, A., & Green, T. C. (2016). An initial evaluation of law enforcement overdose training in Rhode Island. Drug And Alcohol Dependence, 162, 211-218. 18. Bowser, B. P., Jenkins-Barnes, T., Dillard-Smith, C., & Lockett, G. (2010). Harm reduction for drug abusing ex-offenders:

• utcome of the California prevention and education project MORE project. Journal Of Evidence-Based Social Work, 7(1), 15-29.

19. Horyniak, D., Higgs, P., Lewis, J., Winter, R., Dietze, P., & Aitken, C. (2010). An evaluation of a heroin overdose prevention and education campaign. Drug And Alcohol Review, 29(1), 5-11. 20. Wagner, K. D., Valente, T. W., Casanova, M., Partovi, S. M., Mendenhall, B. M., Hundley, J. H., & ... Unger, J. B. (2010). Evaluation of an overdose prevention and response training programme for injection drug users in the Skid Row area of Los Angeles, CA. The International Journal On Drug Policy, 21(3), 186-193. 21. Maldjian, L., Siegler, A., & Kunins, H. V. (2016). Evaluation of overdose prevention trainings in New York City: Knowledge and self-efficacy among participants 12 months after training. Substance Abuse, 37(3), 459-465. 22. Winhusen, T., Theobald, J., Lewis, D., Wilder, C. M., & Lyons, M. S. (2016). Development and initial testing of a tailored telephone intervention delivered by peers to prevent recurring opioid-overdoses (TTIP-PRO). Health Education Research, 31(2), 146-160. 23. Doyon, S., Klein-Schwartz, W., Anderson, B. A., & Welsh, C. (2013). A novel approach to informing the public about the risks of

• verdose and nonmedical use of prescription medications. The American Journal On Addictions, 22(2), 108-112.

24. Banta-Green, C. J., Kuszler, P. C., Coffin, P. O., & Schoeppe, J. A. (2011). Washington’s 911 Good Samaritan Drug Overdose Law - Initial Evaluation Results. Retrieved from Alcohol & Drug Abuse Institute, University of Washington: http://adai.uw.edu/pubs/infobriefs/ADAI-IB-2011-05.pdf

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59

References

25. Wheeler, E., Jones, T. S., Gilbert, M. K., & Davidson, P. J. (2015). Opioid Overdose Prevention Programs Providing Naloxone to Laypersons — United States, 2014. Morbidity and Mortality Weekly Report (MMWR), 64(23), 631- 635. 26. Haegerich, T. M., Paulozzi, L. J., Manns, B. J., & Jones, C. M. (2014). What we know, and don’t know, about the impact of state policy and systems-level interventions on prescription drug overdose. Drug and Alcohol Dependence, 145, 34-47. 27. Green, T. C., Heimer, R., & Grau, L. E. (2008). Distinguishing signs of opioid overdose and indication for naloxone: an evaluation of six overdose training and naloxone distribution programs in the United States. Addiction, 103(6), 979-989. 28. Banta-Green, C. J., Kuszler, P. C., Coffin, P. O., & Schoeppe, J. A. (2011). Washington’s 911 Good Samaritan drug

• verdose law—Initial evaluation results. Seattle, WA: Alcohol and Drug Abuse Institute, University of Washington.

Retrieved from http://adai.uw.edu/pubs/infobriefs/ADAI-IB-2011-05.pdf 29. Walley, A. Y., Doe-Simkins, M., Quinn, E., Pierce, C., Xuan, Z., & Ozonoff, A. (2013). Opioid overdose prevention with intranasal naloxone among people who take methadone. Journal of Substance Abuse Treatment, 44(2), 241–247. doi: 10.1016/j.jsat.2012.07.004 30. Bagley, S. M., Peterson, J., Cheng, D. M., Jose, C., Quinn, E., O’Connor, P. G., & Walley, A. Y. (2015). Overdose Education and Naloxone Rescue Kits for Family Members of Individuals Who Use Opioids: Characteristics, Motivations, and Naloxone Use. Substance Abuse, 36(2), 149-154. 31. Ashrafioun, L., Gamble, S., Herrmann, M., & Baciewicz, G. (2016). Evaluation of knowledge and confidence following

• pioid overdose prevention training: A comparison of types of training participants and naloxone administration
• methods. Substance Abuse, 37(1), 76-81.

60

References

32. Bagley, S. M., Forman, L. S., Ruiz, S., Cranston, K., & Walley, A. Y. (2017). Expanding access to naloxone for family members: The Massachusetts experience. Drug And Alcohol Review, 33. Williams, A. V., Marsden, J., & Strang, J. (2014). Training family members to manage heroin overdose and administer naloxone: randomized trial of effects on knowledge and attitudes. Addiction (Abingdon, England), 109(2), 250-259. doi:10.1111/add.12360 34. Albert, S., Brason II, F. W., Sanford, C. K., Dasgupta, N., Graham, J., & Lovette, B. (2011). Project Lazarus: Community- based overdose prevention in rural North Carolina. Pain Medicine, 12, S77–S85. Retrieved from http://prescribetoprevent.org/wp-content/uploads/2012/11/pm2011albert.pdf 35. Community Care of North Carolina. (n.d.). Project Lazarus: A community-wide response to managing pain. Retrieved from https://www.communitycarenc.org/population-management/chronic-pain-project/ 36. Project Lazarus. (n.d.a). The Project Lazarus model. Retrieved from http://projectlazarus.org/about-lazarus/project- lazarus-model 37. Centers for Disease Control and Prevention (2016). Syringe services programs. Available at https://www.cdc.gov/hiv/risk/ssps.html 38. Schwartz, R. P., Gryczynski, J., O’Grady, K. E., Sharfstein, J. M., Warren, G., Olsen, Y., . . . Jaffe, J. H. (2013). Opioid Agonist Treatments and Heroin Overdose Deaths in Baltimore, Maryland, 1995–2009. American Journal of Public Health, 103(5), 917-922.