American Public Health Association Statement

 

American American P ub ublic lic Health Association 800 I Street, NW • Was hingt on, DC 20001-37 20001-3710 10 (202) 777-APHA • Fax: (202) 777-2534 [email protected] • http://www.apha.org

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Preventing Overdose Through Education and Naloxone Distribution Policy Date: 10/30/2012 Policy Number: LB-12-02

Related APHA Policies APHA APH A P olicy olicy Statement LB-11-03 – Reducing Uni Unintenti ntentional onal Pres Prescripti cription on Drug Overdoses Abstract Opioid Opio id overdose deaths dea ths represent re present a publ public ic hea health lth crisis crisis requiring requiring inn innovati ovative, ve, evi e vidence-bas dence-bas ed rresponses. esponses. Communi Community-based ty-based overdose e ducation and naloxone naloxone distributio distribu tion n programs demonstrate promisi promising ng approaches with the potential to be sc scaled aled up and a nd adapted to a range of settin se ttings gs aand nd populati populations ons at risk for overdose from prescript presc riptio ion n opio opioid id analgesics analgesics and heroin. This pol policy icy statement calls on federal feder al agencies, agenc ies, elected officials, officials, local local and a nd state health departments, and health he alth care professionals to support public education and training, development and dissemination of best practices, and broader implementation of these promising interventions as a core element of a comprehensive approach to opioid overdose. Problem Statement The Centers for Disease Control and Prevention (CDC) characterizes prescription drug overdoses as an epidemic.[1] Drug poisoning deaths have become a leading cause of injury death in the United States. Between 1980 and 2008, the annual number of drug poisoning deaths increased from about 6,100 to 36,500. A substantial proportion of this increase is attributable to the dramatic rise in unintentional overdoses involving prescription opioid analgesics (including hydrocodone, oxycodone, and methadone). In 2008, 40% of all drug poisoning deaths involved opioid analgesics, and the number of overdose deaths involving opioid analgesics has more than tripled since 1999 (accounting for 14,800 deaths in 2008). Opioid overdose mortality is not limited to prescription analgesics; heroin was involved in 3,000 overdose deaths in 2008.[2] A growing body of research demonstrates a strong association between the increase in opioid overdose mortality and the rise over the past two decades in the use and misuse of prescription opioid analgesics.[3] Since 1999, the rate of unintentional drug poisoning deaths has increased among all racial/ethnic groups, with the highest rates ra tes observed in non-Hispanic non-Hispanic Whites and American Indians/Alaska Nativ Na tives. es. Rate Ratess of uni unintenti ntentional onal drug poisoni poisoning ng deaths, par particul ticularly arly deaths in invol volvi ving ng prescr prescrip iptio tion n opi opioi oid d analg ana lgesics, esics, have risen faster fas ter in rural areas are as than in urban settin se ttings.[4] gs.[4] Avail A vailable able data suggest that overdose mortality mortality risk is associated as sociated with lower socioeconomic status; a study from the state of Washington showed that Medicaid enrollees had a 5.7 greater risk of overdose death than nonenrollees.[5] Higher rates of overdose deaths have also been associated with mental illness as well as polydrug use and other indicators of substance use disorders, including among patients seen in Veterans Health Administration facilities.[6–8] Prevention of increased poisoning death rates is a Healthy People 2020 objective.[9] In its 2011 Prescription Drug Abuse Prevention Plan, the Office of National Drug Control Policy notes that “[p]rescription drug misuse and abuse is a major public health and public safety crisis.”[10] The growing severity of the opioid overdose epi e pidemi demicc warrants warr ants urgent attention as a public public health crisis re requi quiring ring a ccomp omprehensive, rehensive, multip multipronged ronged strategy. strate gy. Proposed Recommendations Statement A growing body of evidence and experience supports innovative community-level approaches to preventing opioid overdose deaths in the broader context of  efforts to reduce the risk of overdose throug through h prim primary ary pre preventio vention n of opio opioid id m misuse isuse (see (se e aalternativ lternativee s trategies belo be low). w). These communi community-l ty-level evel strategies stra tegies draw upon the lessons learned and insights gained from harm reduction programs, including needle exchange programs, with respect to engaging individuals at risk of  opioid overdose and their peers as active agents in overdose prevention by providing education and training in responding effectively to opioid overdose.  Numerous  Num erous pil pilot ot prog programs rams and ev evalu aluatio ations ns hav havee demon demonstrated strated the feasi feasibi bili lity ty and viabi viabili lity ty of of prov proviidi ding ng educati education on and and traini training ng on on overdose overdose risk risk factors, sig signs, ns, and and symptoms; appropriate responses to an overdose; and emergency administration of an opioid antidote to revive individuals experiencing an overdose. Lessons and  best practices practices from th these ese pil pilot ot com commu muni nity ty program programss have bro broad ad relev relevance ance and li likel kely y benefici beneficial al appl applications ications to to the current—and current—and growi growing— ng—op opio ioid id overdose overdose epidemic. A 2012 survey published in Morbidity and Mortality Weekly Report (MMWR) demonstrated the potential impact of these community-level approaches by assessing 188 opioid overdose prevention programs operating in 15 states and the District of Columbia. The survey documented that an estimated 53,032 people had received training in overdose prevention, including administration of an opioid overdose antidote, through these programs. The programs received more than 10,000 reports of successful overdose reversals through administration of the antidote by individuals who had received training. The opioid overdose antidote distributed through these programs and administered by laypeople was naloxone; this opioid antagonist, approved by the Food and Drug Administration (FDA), reverses the effects of an opioid overdose and rapidly restores breathing to a normal rate. Naloxone has no potential for abuse and causes no adverse effects in a  person who who has not not taken opi opioi oids.[11 ds.[11]] Multiple studies have shown that programs that educate laypeople/bystanders on how to recognize the signs and symptoms of overdose and train individuals on how to intervene by using rescue breathing, administering naloxone, and calling emergency personnel result in opioid overdose reversals and save lives.[12–15] A 2008 study concluded that, after basic training, laypeople did just as well as medical professionals in recognizing the symptoms of an overdose and determining when to use tthe he medicatio medication. n. 16 In 200 2009, 9, the American American Jo Journal urnal of Publ Public ic Health AJPH ubl ubliished a stud stud showin showin that “o “overdo verdose se revention revention ro rams that

 

  include the distribution of intranasal naloxone by non-medical personnel are feasible for city public health departments.”[17] Similarly promising results have been reported from evaluations of projects that adapt community-based opioid overdose prevention strategies to clinical settings, including substance abuse treatment and pain management programs. A Massachusetts study demonstrated the effectiveness of an overdose education and naloxone distribution intervention among individuals primarily recruited from inpatient detoxification units and methadone maintenance treatment programs.[18] Operation OpioidSAFE (Womack Army Medical Center, Fort Bragg, NC) and Project Lazarus (Wilkes County, NC) both work to educate patients and  prescribers  prescrib ers about recog recogni nizi zing ng an and dm min inim imiz iziing th thee risk riskss associated wi with th prescript prescriptio ion n opio opioid id analg analgesics. esics. These efforts incl include ude the the di distri stribu buti tion on of of naloxo naloxone ne kits kits and education of caregivers/family members of individuals who take opioids so that they can recognize the signs and symptoms of overdose and intervene should they witness a loved loved one e xperiencing xperiencing an overdose. Between Betwe en 2009 and 2011, overdose dea deaths ths in Wilkes Wilkes County decreased decrea sed 69%, while while overall prescriptions prescriptions for opi opioi oids ds generally held steady. Project Lazarus reports that in 2011 “not a single Wilkes County resident died from a prescription opioid from a prescriber within the county, down from 82% in 2008.”[19,20] Despite this established and rapidly growing body of evidence in support of the value of expanding access to and use of naloxone among pain patients and individuals who misuse or abuse opioids, naloxone is currently available to laypeople in only 15 states and the District of Columbia through facilities such as drug treatment programs, community-based organizations, parents’ groups, and medical clinics. Notably, community-based overdose education and naloxone distribu di stributio tion n programs do not yet eexi xist st in many of the sstates tates that have the high highest est rates of opioid opioid use and overdose deaths.[11] The rising overdose overdose mortality rates  provid  prov idee stark testim testimon ony y to tthe he urgent urgent need to scale up p prom romiisin sing g app approaches roaches to reach iindi ndivi vidual dualss at risk of of overdose overdose throug through h iill llici icitt heroin heroin use and/or and/or nonm nonmedi edical cal use of prescription opioids, as well as patients prescribed high doses of opioids (e.g., ≥100 mg morphine equivalent dose per day) or receiving opioids from multiple prescribers. According to the FDA, the total number of prescriptions dispensed for all major opioid formulations from US outpatient retail pharmacies in 2009 was 257,706,62 257,706,624.[21] 4.[21] When aappl pplied ied to 2009 US Census Bureau B ureau da data, ta, this represents repres ents an a n average avera ge of 0.84 opioi opioid d prescripti presc riptions ons per person per son in the United States, or 2.27 opioid prescriptions per US household. A CDC C DC editorial editorial note accompanyi a ccompanying ng the above-menti a bove-mentioned oned MMWR survey of 188 commun community ity-base -based d overdose prevention prevention programs noted that: “The findings in this report suggest that distribution of naloxone and training in its administration might have prevented numerous deaths from opioid overdoses. Syringe exchange and harm reduction programs for injection drug users were early adopters of opioid overdose prevention interventions, including providing naloxone. More noninjection opioid users might be reached by opioid overdose prevention training and (where feasible) provision of naloxone in jails and prisons, substance abuse treatment programs, pare nt support group groups, s, and physici physician an offices offices…. …. Re Reaching aching users of prescript presc riptio ion n opioi opioid d analgesics is important important beca use a large proportion of drug overdose deaths have been associated with these drugs…. To address the substantial increases in opioid-related drug overdose deaths,  publicc health agenci  publi agencies es could could consid consider er comp comprehensi rehensive ve measures th that at inclu include de teachi teaching ng llayperson aypersonss how to respond respond to overdo overdoses ses and admi admini nister ster naloxon naloxonee to those those in need.”[11] Opposing Arguments/Evidence A 2009 review published in AJPH considered a series of potential objections to the scale-up of overdose education and naloxone distribution programs and evaluated the evidence supporting supporting these concerns. [22] The potential objectio objections ns fell fe ll withi within n 2 categories: ca tegories: (1) doubts doubts regardin re garding g the effec e ffectiv tiveness eness,, both  pharmacol  pharm acologi ogicall cally y and p practical ractically ly,, of llayperson ayperson-admi -admini nistered stered nal naloxo oxone ne and (2) (2) fears that overdo overdose se education education and nal naloxo oxone ne distri distribut butiion program programss would would result result iin n in incre crease ased d opioid opioid use. The revi re view ew authors evaluated the first potential potential obj objection, ection, findi finding ng that a preponderance of evidence w weigh eighed ed against a gainst it. it. The concern about pharmacologi pharmacological cal efficac y relates to the relati efficacy re latively vely short half-l half-life ife of naloxon naloxone, e, leading to fear that once admi admini nistere stered d its opioi opioid d antagonist antagonist eeffec ffects ts may wear w ear off while while rrecipi ecipients ents stil s tilll have opioids opioids in their system, thus potenti potentiall ally y resultin resulting g in a re recurrenc currencee of overdose. The authors cited data on the experience e xperience of both communi community-based ty-based overdose  preventiion p  prevent program rogramss and m medi edical cal setting settingss supp supporti orting ng tthe he effectiven effectiveness ess of a sing singlle dose of naloxo naloxone, ne, noti noting ng tthat hat many many commu communi nity-b ty-based ased prog programs rams provi provide de trained trained laypeople laypeop le with 2 doses in the eevent vent that a sing single le dose is ineffec ineffectiv tive. e. They also considered the possibi possibili lity ty that these thes e programs may inadvertently inadvertently discourage discourage other  appropriate appropri ate responses, includin including g ca call llin ing g 911 for the assistance of trained paramedi para medics. cs. However, the authors found that structural structura l barriers, includi including ng fears fear s of law enforcement involvement in responding to 911 calls for assistance at the scene of an overdose, result in delays and low rates of use of emergency services,  particul  parti cularly arly amon among g peers of opio opioiid misusers misusers most most llik ikely ely to wi witness tness an ov overdose. erdose. The auth authors ors con conclu cluded ded that that “[i]n “[i]n all all cases of opi opioi oid d overdose, overdose, itit makes makes intui intuiti tive ve sense to reduce the time it takes to administer naloxone by getting it into the hands of those best positioned to respond rapidly…. The logic and support for placing time-critical medications in the hands of nonmedical persons is not new. Epinephrine injections are made available as a life-saving measure for people at risk for  suffering anaphylaxis, anaphylaxis, and gl glucagon ucagon inj injections ections are provided provided to diabetes patients in case of severe se vere in insuli sulin n re reactions.”[22] actions.”[22] The revi re view ew also addresse d the potential objectio objection n that “naloxo “naloxone ne aavail vailabil ability ity may may eencourage ncourage more frequent or hi higher-vol gher-volume ume drug use by acting a cting as a safety safe ty net.” The authors judged this outcome to be highly unlikely and unsupported by available evidence, noting that “studies suggest that increasing health awareness through traini training ng programs that aaccompany ccompany naloxone naloxone distri distributi bution on actually reduces the use of opi opioi oids ds and increases increa ses users’ desire to seek s eek addiction addiction treatment.”[22] treatment.”[ 22] Extensive discussion at an FDA workshop on expanding access to naloxone overwhelmingly supported this conclusion.[23] As noted in the FDA’s postmeeting summary: “Speakers commented on the concer concern n that increasing increa sing the the overa ll availabi availabili lity ty of naloxon naloxonee might llead ead to incre increase ased d drug use by giving giving a false f alse sense se nse of sec security urity,, and suggested this was not a likely concern. An overview of research related to attitudes and behaviors related to [sexually transmitted diseases,] and in particular to [human papill papillomavi omavirus] rus] vaccination (Gardasil), (Gardasil), presented prese nted at the meetin mee ting g re reported ported no as associatio sociation n with an increase increa se in unprotecte unprotected d se sex x among sexually sexually activ ac tivee women. Similarly Similarly,, no evidence for greate greaterr risk-taking has been seen s een in the area are a of protective equip equipment ment to prevent chi c hild ldhood hood inj injuries uries (such a s bike helmets). One speaker said that such interventions do not necessarily lead to more risky behaviors. Instead, the results are dependent on the prevention strategy, the target of  the strategy, str ategy, ind indiv ivid idual ual characteristics chara cteristics and a nd the larger social context.”[24] In summary, the AJPH review evaluated and ultimately provided compelling and persuasive counterarguments to potential objections to expanding overdose  prevention and nal  preventi naloxo oxone ne distri distribut butiion program programs, s, findi finding ng st strong rong supp support ort fo forr in increasing creasing these in init itiiativ atives es through through both both comm commun unit ity y programs programs and phy physici sician an prescripti prescription on in the context of broader “appropriate illicit opioid supply and demand reduction measures.” The authors concluded: “Naloxone “Nalox one is an e minently minently safe and nonabusable nonabusable ssubstance ubstance that has 1 pharmacolog pharmacological ical functi function: on: to reverse the effec e ffects ts of opi opioi oids ds on the brain bra in and respiratory system in order to prevent the ultimate adverse event, death. Indeed, one can purchase dozens of more dangerous and abusable substances over the counter at a  

 

  . . understandable that regulators r egulators did no nott foresee fore see the utility utility of nalox naloxone one aass a public public health interventi intervention on carried car ried out by people who are ar e not medi medical cal profession profes sionals. als. In I n the midst midst of our ccurrent urrent eepi pidemi demicc of ac accidental cidental deaths related re lated to illi illicit cit and presc riptio ription n opi opioi oids, ds, however, these restrictions are untenable. untenable. The status sta tus quo must be challenged challeng ed by a public public health ethic that seeks s eeks to ‘advocate and work for the empowerment of di disenfra senfranchised nchised communi community ty members, aiming aiming to ensure that the  basicc resources and cond  basi condit itio ions ns necessary for heal health th are acce accessib ssiblle to all.’”[22] all.’”[22] Alternative Strategies A ra nge of alternativ a lternativee strate s trategi gies es to address the pres prescripti cription on opi opioi oid d overdose eepi pidemi demicc have ha ve been bee n proposed by various various fe federal deral agencies, age ncies, public public health officials, officials, and  pol  poliicymakers. cymakers. These strategies iincl nclude ude iimp mplem lementati entation on o off prescripti prescription on d drug rug m moni onitori toring ng p program rograms, s, volu voluntary ntary or or mandated mandated prescriber prescriber education, education, proper proper medicatio medication n disposal, di sposal, develo development pment of abuse-deterrent abuse-dete rrent formul formulation ationss of prescr prescrip iptio tion n opi opioi oid d analgesics, substance abuse s cree ni ning ng and acces ac cesss to tre atment, and law enforcement e nforcement efforts targeting prescription opioid misuse and diversion.[10,25,26] These alternative strate strategi gies es offer a potential range of compl complementary ementary aapproaches pproaches to overdose eeducation ducation and naloxone naloxone distribu distributio tion n programs, but they are not sufficient in and of themselves to address fully the urgencies of opioid overdose as a public health crisis. These strategies aim only secondarily to reduce opioid overdose as a byproduct of their primary goals of reducing the supply and preventing the misuse of prescription opioids. Although these goals reflect important components compon ents of a comp c omprehensive, rehensive, public public health–based approach, they ca nnot ful fully ly substitute substitute for the need nee d for strategies str ategies that in intervene tervene at the poi point nt of overdose itself. Moreover, the evi e vidence dence base for the effe effectiveness ctiveness and a nd impact impact of many of these strate strategi gies es is incompl incomplete ete and still still evolvi evolving.[27] ng.[27] An addi a dditio tional nal li limi mitation tation of these alternative strategies—with stra tegies—with the exce pti ption on of substance substanc e abuse treatment—is their focus on prescr prescrip iptio tion n opioid opioid analgesics. analgesics. As the  prescription  prescripti on o opi pioi oid d epi epidemi demicc evolves, evolves, increasin increasing g evidence evidence indi indicates cates a concurrent concurrent ri rise se in h heroi eroin n use, pot potenti entiall ally y associated associated with with th thee impl implementati ementation on of of strategies strategies to reduce availability, diversion, and misuse of prescription opioid analgesics.[28] Community-level overdose education and naloxone distribution programs have been  pi  pilo loted ted and fi field eld tested among among h heroi eroin n users, wit with h ampl ample evidence evidence suppo supporti rting ng th their eir feasi feasibi bili lity ty and acceptabilit acceptability y iin n this this popul populatio ation. n. Finally, community-level overdose education and naloxone distribution programs represent both a significant harm reduction innovation and a uniquely public health–grounded contribution to the overdose epidemic, bringing an important and otherwise absent perspective to bear on proposed solutions to the overdose epidemic. Action Steps

Given growing incidence Public of opioid fatalities, coupledshould with the serious, amyriad adverse with use, misuse, and abuse of opioids of  in the Unitedthe States, the American Health Association undertake renewed effortconsequences to reduce andassociated prevent the adverse public health consequences opioi opioid d use, aabuse, buse, and misuse; increa increase se awa awarenes renesss aamon mong g the public public and hea lth professionals professionals of the risks associated ass ociated with opioi opioid d use and misuse; improve improve recogni rec ognitio tion n of the signs signs and a nd symp symptoms toms of overdose and a nd educate the public public and hea health lth profess professio ionals nals regarding what to do if someone eexperiences xperiences an a n overdose; im improve prove acces ac cesss to tre atment and re covery services; se rvices; support public, public, pri private, vate, aand nd comm communi unity-based ty-based eefforts, fforts, includi including ng data c ol ollectio lection n and re resea search, rch, to understand and tackle the myriad factors contributing to the rise in opioid use, misuse, and abuse; and advance policies and programs that increase access to evidence-based interventions that reduce fatalities from opioid overdose. Therefore, • The federa l government government should should undertake a coordinated coordinated national effort focused foc used on the prevention prevention of overdose fatalities, fatalities, with a particular particular emphasis on education and awareness efforts targeting patients, health professionals, and the public that are centered on the effectiveness of naloxone as a potentially life-saving opioid antagonist. • Federal, state, and local elected officials and agency staff should ensure that efforts designed to reduce and prevent opioid misuse do not have a chilling effect on effective pain management for people in need and do not unintentionally create a situation in which individuals are driven to misuse other drugs instead of  securing treatment and support for recovery from drug use. • All federal agencies involved in research, policies, regulation, and programs related to opioid misuse should coordinate efforts and develop and disseminate information to health professionals, individuals, families, and communities to increase awareness of the signs and symptoms of overdose, improve awareness of  and facil fa cilitate itate aacce ccess ss to naloxo naloxone ne aass a life-sa life-sa ving ving interventi intervention on for opioi opioid d overdose, aand nd support entry into treatment a nd recovery rec overy for those indivi individual dualss s eeking such services. • The US Department of Health and Human Services and its agencies (including the National Institutes of Health, Centers for Disease Control and Prevention, Food and Drug Administration, Agency for Healthcare Research and Quality, and Health Resources and Services Administration) and the Department of  Veterans Affairs should provide funding for research, identification, and dissemination of best practices for reducing and preventing opioid misuse, abuse, and overdose. • Congress and the admini administration stration should should increase and imp improve rove fe deral surveill surveillance ance efforts and data coll collection ection regardi regar ding ng opioi opioid d use, misuse, misuse, and a nd deaths to ensure that policies and programs are designed to target the actual causes of opioid misuse and death and to monitor the impact of any new efforts on access to pain management, the incidence and prevalence of opioid misuse, and overdose deaths from opioids. • Congress should should support best practices pra ctices by providi providing ng resource resourcess to ffedera ederall agencies for technical assistance and toolki toolkits ts to comm c ommuni unity ty programs and health hea lth  professionalss who wi  professional wish sh to d diistri stribut butee naloxon naloxone. e. • Federal, state, and local elected officials and agency staff should support increased access to—and funding of—drug treatment and recovery. • Local Loca l and state health departments should iincrea ncrease se awareness awa reness among the publ public ic and hea health lth profess professio ionals nals of the signs signs and a nd symptoms symptoms of overdose, improve improve awareness of and facilitate access to naloxone, and support entry into treatment and recovery for those individuals seeking such services.  

 

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• The medical community, pharmaceutical companies, the FDA, and other entities involved in the dissemination of information regarding opioids should develop educational materials aimed at health professionals and patients (including family members) that specifically address the risks associated with prescription opioids and include information regarding signs and symptoms of overdose and the role that naloxone can play in reversing an overdose from opioids. • Professional preparation schools and programs for health care providers and public health, allied health, health education, and health communication  professionalss shou  professional should ld strengt strengthen hen th their eir professi professional onal preparation preparation and and trai traini ning ng wi with th respect to tthe he risks risks associated associated with with prescri prescripti ption on opi opioi oids, ds, sign signss and sympto symptoms ms of  overdose, and how to work with patients and their families in an effort to prevent and reduce misuse and overdose. Training should address safe storage of   prescripti  prescrip tion on d drug rugs, s, access to naloxon naloxone, e, what to do iin n respon response se to an ov overdose, erdose, an and d how how to suppo support rt entry into into treatment treatment and recovery services. services. References 1. US Centers for Disease Control and Prevention. CDC grand rounds: prescription drug overdoses—a U.S. epidemic. MMWR Morb Mortal Wkly Rep. 2012;61(1):10–13. 2. Warner M, Chen LH, Makuc DM, Anderson RN, Miniño AM. Drug Poisoning Deaths in the United States, 1980–2008. Hyattsville, MD: National Center for  Health Statistics; 2011. NCHS data brief 81. 3. Paulozzi LJ, Budnitz DS, Xi Y. Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiol Drug Saf. 2006;15(9):618–627. 4. Paulozzi LJ, Xi Y. Recent changes in drug poisoning mortality in the United States by urban-rural status and by drug type. Pharmacoepidemiol Drug Saf. 2008;17(10):997–1005. 5. US Centers for Disease Control and Prevention. Overdose deaths involving prescription opioids among Medicaid enrollees—Washington, 2004–2007. MMWR  Morb Mortal Wkly Rep. 2009;58(42):1171–1175. 6. Bohnert AS, Ilgen MA, Ignacio RV, McCarthy JF, Valenstein M, Blow FC. Risk of death from accidental overdose associated with psychiatric and substance use di disorders. sorders. Am J Psychi Psyc hiatry. atry. 2012;169(1 2012;169(1):64 ):64–70. –70. 7. Toblin RL, Paulozzi LJ, Logan JE, Hall AJ, Kaplan JA. Mental illness and psychotropic drug use among prescription drug overdose deaths: a medical examiner  chart review. J Clin Clin P Psychiatry. sychiatry. 2010;71 2010;71(4):4 (4):491–496. 91–496. 8. Hall Ha ll AJ, Logan JE, Toblin Toblin RL, Kapl Ka plan an JA, JA , Kraner JC, Bixl Bixler er D, Crosby AE, P aulozzi aulozzi LJ. Pa Patterns tterns of abuse a mong mong unintenti unintentional onal pharmac pharmaceutical eutical overdose fatalities. JAMA 2008;300(22):2613–2620. 9. US Department of Health Hea lth and Human Services. Hea Health lthy y Pe ople ople 2020 topi topics cs and objectives: objectives: in inju jury ry and violence violence prevention. prevention. Avail A vailable able at: http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=24. Accessed October 10, 2012. 10. Office of National Drug Control Policy. Epidemic: responding to America’s prescription drug abuse crisis. Available at: http://www.w http: //www.whi hitehouse.gov/si tehouse.gov/sites/defa tes/defaul ult/fil t/files/ondcp/i es/ondcp/issuesssues-content/prescripti content/prescription-drug on-drugs/rx_abuse s/rx_abuse_plan.pdf. _plan.pdf. Acce A ccessed ssed October 10, 2012. 2012. 11. US Centers for Disease Control and Prevention. Community-based opioid overdose prevention programs providing naloxone—United States, 2010. MMWR  Morb Mortal Wkly Rep. 2012;61(6):101–105. 12. Enteen L, Bauer J, McLean R, Wheeler E, Huriaux E, Kral AH, Bamberger JD. 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