The Opioid Crisis in America - Part I (Issues in Pain Management)

Turning the Improbable
Into the Exceptional!
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The Advocacy Foundation, Inc.
Helping Individuals, Organizations & Communities
Achieve Their Full Potential
Since its founding in 2003, The Advocacy Foundation has become recognized as an effective
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Dedication
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Every publication in our many series’ is dedicated to everyone, absolutely everyone, who by
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We pray that you will bear in mind:
Matthew 19:26 (NIV)
Jesus looked at them and said, "With man this is impossible,
but with God all things are possible." (Emphasis added)
To all of us who daily look past our circumstances, and naysayers, to what the Lord says we will
accomplish:
Blessings!!
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The Transformative Justice Project
Eradicating Juvenile Delinquency Requires a Multi-Disciplinary Approach
The way we accomplish all this is a follows:
The Juvenile Justice system is incredibly overloaded, and
Solutions-Based programs are woefully underfunded. Our
precious children, therefore, particularly young people of
color, often get the “swift” version of justice whenever they
come into contact with the law.
Decisions to build prison facilities are often based on
elementary school test results, and our country incarcerates
more of its young than any other nation on earth. So we at
The Foundation labor to pull our young people out of the
“school to prison” pipeline, and we then coordinate the efforts
of the legal, psychological, governmental and educational
professionals needed to bring an end to delinquency.
We also educate families, police, local businesses, elected
officials, clergy, and schools and other stakeholders about
transforming whole communities, and we labor to change
their thinking about the causes of delinquency with the goal
of helping them embrace the idea of restoration for the young
people in our care who demonstrate repentance for their
mistakes.
1. We vigorously advocate for charges reductions, wherever possible, in the adjudicatory (court)
process, with the ultimate goal of expungement or pardon, in order to maximize the chances for
our clients to graduate high school and progress into college, military service or the workforce
without the stigma of a criminal record;
2. We then enroll each young person into an Evidence-Based, Data-Driven Restorative Justice
program designed to facilitate their rehabilitation and subsequent reintegration back into the
community;
3. While those projects are operating, we conduct a wide variety of ComeUnity-ReEngineering
seminars and workshops on topics ranging from Juvenile Justice to Parental Rights, to Domestic
issues to Police friendly contacts, to CBO and FBO accountability and compliance;
4. Throughout the process, we encourage and maintain frequent personal contact between all
parties;
5 Throughout the process we conduct a continuum of events and fundraisers designed to facilitate
collaboration among professionals and community stakeholders; and finally
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6. 1 We disseminate Quarterly publications, like our e-Advocate series Newsletter and our e-Advocate
Quarterly electronic Magazine to all regular donors in order to facilitate a lifelong learning process
on the ever-evolving developments in the Justice system.
And in addition to the help we provide for our young clients and their families, we also facilitate
Community Engagement through the Restorative Justice process, thereby balancing the interesrs
of local businesses, schools, clergy, elected officials, police, and all interested stakeholders. Through
these efforts, relationships are rebuilt & strengthened, local businesses and communities are enhanced &
protected from victimization, young careers are developed, and our precious young people are kept out
of the prison pipeline.
This is a massive undertaking, and we need all the help and financial support you can give! We plan to
help 75 young persons per quarter-year (aggregating to a total of 250 per year) in each jurisdiction we
serve) at an average cost of under $2,500 per client, per year.*
Thank you in advance for your support!
* FYI:
1. The national average cost to taxpayers for minimum-security youth incarceration, is around
$43,000.00 per child, per year.
2. The average annual cost to taxpayers for maximun-security youth incarceration is well over
$148,000.00 per child, per year.
- (US News and World Report, December 9, 2014);
3. In every jurisdiction in the nation, the Plea Bargain rate is above 99%.
The Judicial system engages in a tri-partite balancing task in every single one of these matters, seeking
to balance Rehabilitative Justice with Community Protection and Judicial Economy, and, although
the practitioners work very hard to achieve positive outcomes, the scales are nowhere near balanced
where people of color are involved.
We must reverse this trend, which is right now working very much against the best interests of our young.
Our young people do not belong behind bars.
- Jack Johnson
1
In addition to supporting our world-class programming and support services, all regular donors receive our Quarterly e-Newsletter
(The e-Advocate), as well as The e-Advocate Quarterly Magazine.
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The Advocacy Foundation, Inc.
Helping Individuals, Organizations & Communities
Achieve Their Full Potential
…a collection of works on
The Opioid Crisis in America
Evidence-Based Solutions at the Grassroots Level
Part I – Issues in Pain Management
“Turning the Improbable Into the Exceptional”
Atlanta
Philadelphia
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John C Johnson III
Founder & CEO
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Biblical Authority
______
1 Corinthians 10:13-14
13
No temptation has overtaken you except what is common to mankind. And God is
faithful; he will not let you be tempted beyond what you can bear. But when you are
tempted, he will also provide a way out so that you can endure it.
James 4:7-10
7
Submit yourselves, then, to God. Resist the devil, and he will flee from you. 8 Come
near to God and he will come near to you. Wash your hands, you sinners, and purify
your hearts, you double-minded. 9 Grieve, mourn and wail. Change your laughter to
mourning and your joy to gloom. 10 Humble yourselves before the Lord, and he will lift
you up.
15
and call on me in the day of trouble;
I will deliver you, and you will honor me.”
Psalm 50:15
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Table of Contents
…a collection of works on
The Opioid Crisis in America
Evidence-Based Solutions at the Grassroots Level
Part I – Issues in Pain Management
______
Biblical Authority
I. Introduction………………………………………………………..…........17
II. The National Trauma (The Guardian)…………………………………….. 35
III. Opioid Crisis Fast Facts (CNN)………………………………………….. 41
IV. The Main Offenders……………………………………………………… 47
a. Oxycodone
b. Heroin
c. Fentanyl
V. Treatments……………………………………………………………….. 101
a. Naloxone
b. Methadone
c. Buprenarphine
d. Behavior Modification
VI. References……………………………………………………………….. 137
Attachments
A. State Targeted Grants Response to the Opioid Crisis
B. Fighting the Opioid Crisis - Deloitte Insights
C. the Opioid Crisis in North America – Position Paper
Copyright © 2018 The Advocacy Foundation, Inc. All Rights Reserved.
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I. Introduction
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 beginning in the late
1990s and continuing throughout the first two decades of the 2000s. 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.
According to the U.S. Drug Enforcement Administration, "overdose deaths, particularly
from prescription drugs and heroin, have reached epidemic levels." :iii Nearly half of all
opioid overdose deaths in 2016 involved prescription opioids. From 1999 to 2008,
overdose death rates, sales, and substance abuse treatment admissions related to
opioid pain relievers all increased substantially. 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.
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Drug overdoses have since become the leading cause of death of Americans under 50,
with two-thirds of those deaths from opioids. In 2016, over 64,000 Americans died from
overdoses, 21 percent more than the almost 53,000 in 2015. By comparison, the figure
was 16,000 in 2010, and 4,000 in 1999. Figures from June 2017 indicate the problem
has worsened. While death rates varied by state, public health experts estimate that
nationwide over 500,000 people could die from the epidemic over the next 10 years. In
Canada, half of the overdoses were accidental, while a third was intentional. The
remainder were unknown. Many of the deaths are from an extremely potent
opioid, fentanyl, which is trafficked from Mexico. The epidemic cost the United States an
estimated $504 billion dollars in 2015.
CDC director Thomas Frieden said that "America is awash in opioids; urgent action is
critical." The crisis has changed moral, social, and cultural resistance to street drug
alternatives such as heroin. In March 2017, Larry Hogan, the governor of Maryland,
declared a state of emergency to combat the opioid epidemic, and in July 2017 opioid
addiction was cited as the "FDA's biggest crisis." On October 26, 2017,
President Donald Trump agreed with his Commission's report and declared the
country's opioid crisis a "public health emergency."
History in North America
Opiates such as morphine have been used for pain relief in the United States since in
1800s, and were popular for the civil war injuries. 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. Bayer began marketing heroin commercially in 1898.
Beginning around 1920, however, the addictiveness was recognized, and doctors
became reluctant to prescribe opiates. Heroin was made an illegal drug with the Anti-
Heroin Act of 1924, the U.S. Congress banned the sale, importation, or manufacture of
heroin.
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. 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. 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. 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". By 1973, there were 1.5
overdose deaths per 100,000 people.
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Modern prescription opiates such as vicodin and percocet entered the market in the
1970s, but acceptance took several years and doctors were apprehensive about
prescribing them. Until the 1980s, physicians had been taught to avoid prescribing
opioids because of their addictive nature. A brief letter published in the New England
Journal of Medicine (NEJM) in January 1980, titled "Addiction Rare in Patients Treated
with Narcotics", generated much attention and changed this thinking. A group of
researchers in Canada claim that the letter may have originated and contributed to the
opioid crisis. 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. The original author,
Dr. Hershel Jick, has said that he never intended for the article to justify widespread
opioid use.
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. 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.
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According to the Substance Abuse and Mental Health Services Administration’s
National Survey on Drug Use and Health, in 2016, more than 11 million Americans
misused prescription opioids, nearly 1 million used heroin, and 2.1 million had an
addiction to prescription opioids or heroin.
While rates of overdose of legal prescription opiates has leveled off in the past decade,
overdoses of illicit opiates have surged since 2010, nearly tripling.
Oxycodone
Oxycodone is the most widely recreationally used opioid in America. The U.S.
Department of Health and Human Services estimates that about 11 million people in the
U.S. consume oxycodone in a non-medical way annually.
Oxycodone was first made available in the United States in 1939. In the 1970s, the FDA
classified oxycodone as a schedule II drug, indicating a high potential for abuse and
addiction. In 1996, Purdue Pharma introduced OxyContin, a controlled
release formulation of oxycodone. In 2010, Purdue Pharma reformulated OxyContin,
using a polymer to make the pills extremely difficult to crush or dissolve in water to
reduce OxyContin abuse. The FDA approved relabeling the reformulated version as
abuse-resistant.
OxyContin was removed from the Canadian drug formulary in 2012. 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.
Heroin
4-6% of people who misuse prescription opioids turn to heroin, and 80% of heroin
addicts began by abusing prescription opioids.
In 2014, it was estimated that more than half a million Americans had an addiction to
heroin.
Fentanyl
Fentanyl, a newer synthetic opioid painkiller, is 50 to 100 times more potent than
morphine and 30 to 50 times more potent than heroin, 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. 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.
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Fentanyl-laced heroin has become a big problem for major cities, including Philadelphia,
Detroit and Chicago. 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.
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.
According to the Centers for Disease Control and Prevention (CDC), death rates from
synthetic opioids, including fentanyl, increased over 72% from 2014 to 2015. 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 that a large proportion of the increase in
deaths is due to illegally-made fentanyl; as the statistics on overdose deaths (as of
2015) do not distinguish pharmaceutical fentanyl from illegally-made fentanyl, the actual
death rate could, therefore, be much higher than reported.
Those taking fentanyl-laced heroin are more likely to overdose because they do not
know they also are ingesting the more powerful drug. The most high-profile death
involving an accidental overdose of fentanyl was singer Prince.
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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). Another 31 lbs. was seized
on November 6, 2017, near the U.S.-Mexico border.
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. In Cleveland, a person was caught selling
blue fentanyl pills disguised to look like doses of the milder opioid painkiller oxycodone.
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.
In 2016 the medical publication STAT reported that while Mexican cartels are the main
source of heroin smuggled into the U.S., Chinese suppliers provide both raw fentanyl
and the machinery necessary for its production. 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. 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.
Pill Mills
A pill mill is an operation that dispenses narcotics to patients without a legitimate
medical purpose. This is done at clinics and doctors offices, and the doctors will go
through checkups extremely quickly to prescribe painkillers at the end. These clinics will
often charge an office fee of 200 to 400 dollars and will go through about 60 patients a
day which makes these doctors large amounts of money in a short amount of
time. These check-ups are fast and patients will often show old MRI's or give old
information, so that the doctor will prescribe the painkillers more easily. Common
characteristics of pill mills are long lines outside of the clinic and cash only transactions.
One doctor prescribed 3.3 million pills over the course of 3 years. These pill mills are
also large suppliers of the illegal painkiller black markets on the streets. Dealers will
often hire people to go into pill mills to get painkiller prescriptions so that the dealers can
increase their supply. There have been attempts recently to shut down pill mills. 250 pill
mills in Florida were shut down in 2015. Florida clinics also are no longer allowed to
dispense painkillers directly from their clinics which has helped reduce the distribution of
prescription opiates.
Trafficking
As the number of opioid prescriptions rose, drug cartels began flooding the U.S.
with heroin from Mexico. For many opioid users, heroin was cheaper, more potent, and
often easier to acquire than prescription medications. According to the CDC, tighter
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prescription policies by doctors did not necessarily lead to this increased heroin
use. The main suppliers of heroin to the U.S. have been Mexican transnational criminal
organizations. From 2005–2009, Mexican heroin production increased by over 600%,
from an estimated 8 metric tons in 2005 to 50 metric tons in 2009. Between 2010 and
2014, the amount seized at the border more than doubled. According to the DEA,
smugglers and distributors "profit primarily by putting drugs on the street and have
become crucial to the Mexican cartels."
Illicit fentanyl is commonly made in Mexico and trafficked by cartels. North America’s
dominant trafficking group is Mexico’s Sinaloa cartel, which has been linked to 80
percent of the fentanyl seized in New York.
Causes
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.
What the U.S. Surgeon General dubbed "The Opioid Crisis" likely began with overprescription
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. In the late 1990s,
around 100 million people or a third of the U.S. population was estimated to be affected
by chronic pain. This led to a push by drug companies and the federal government to
expand the use of painkilling opioids. Between 1991 and 2011, painkiller prescriptions in
the U.S. tripled from 76 million to 219 million per year.
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The most commonly prescribed opioids have
been oxycodone (OxyContin and Percocet) and hydrocodone (Vicodin). With the
increase in volume, the 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.
Despite the increased use of painkillers, there has been no change in the amount of
pain reported in the U.S. 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.
The Ensuring Patient Access and Effective Drug Enforcement Act, which was signed
into law by President Obama on April 19, 2016, decreased the DEA's ability to intervene
in the opioid crisis by modifying the Controlled Substances Act to require the DEA to
prove "imminent danger to the public health and safety" before seizing shipments of
controlled substances.
Effects
Effects of the opioid epidemic are multifactorial. The high death rate by overdose, the
spread of communicable diseases, and the economic burden are major issues caused
by the epidemic.
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. It has also left thousands of children suddenly in need of foster care after
their parents have died from an overdose.
In Alberta, a 2017 report stated that emergency department visits as a result of opiate
overdose rose 1000% in the past five years.
In 2016, a study estimated that prescription opioid overdoes, abuse and dependence in
the United States in 2013 cost was approximately $78.5 billion. Most of which was
attributed to health care and criminal justice spending, along with lost productivity.
However, in two years, statistics show significantly larger estimate because the
epidemic has worsened with overdose and with deaths doubling in the past decade.
White House stated on November 20th, 2017, in 2015 alone, the opioid epidemic cost
the United States an estimated $504 billion.
Spread of disease by drug users has also been an issue. Rates of hepatitis
B and C diagnosis tripled over five years. The most effective medications to cure
hepatitis C cost around $100,000 for a six-month course. Outbreaks of HIV among drug
users have been reported in cities like Austin, Indiana, where 200 new cases were
diagnosed.
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Demographics
In the U.S., addiction and overdose victims are mostly white or Native American and
working-class. One physician conjectured that this may be due to doctors being less
likely to prescribe opiates to black patients because of past drug abuse stereotypes.
In America, those living in rural areas of the country have been the hardest hit as a
percentage of the national population, Canada is similarly affected, with 90% of cities
with the highest hospitalization rates having a population below 225,000. Western
Canada has an overdose rate nearly 10 times that of the eastern provinces.
Prescription drug abuse has been increasing in teenagers, especially as 12- to 17-yearolds
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. Deaths from overdose of heroin affect a
younger demographic than deaths from other opiates. The Canadian Institute for Health
Information found that while overall, a third of overdoses were intentional, among those
ages 15-24, nearly half were intentional.
State-to-State Variability: Prescribing rates for opioids varies differently across the
states. In 2012, healthcare providers in the highest-prescribing state wrote almost three
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times as many opioid prescriptions per person as those in the lowest prescribing state.
However, Health issues that cause people pain do not vary much from place to place
and do not explain this variability in prescribing.
In Palm Beach County, Florida, overdose deaths went from 149 in 2012 to 588 in 2016.
In Middletown, Ohio, overdose deaths quadrupled in the 15 years since 2000.
In British Columbia, 967 people died of an opiate overdose in 2016, and the Canadian
Medical Association expected over 1,500 deaths in 2017.
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.
Outside North America
Approximately 80 percent of the global pharmaceutical opioid supply is consumed in the
United States.
It has also become a serious problem outside the U.S., mostly among young
adults. 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. 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?"
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.
Some worry that the epidemic could become a worldwide pandemic if not
curtailed. Prescription drug abuse among teenagers in Canada, Australia,
and Europe were at rates comparable to U.S. teenagers. 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.
From January to August 2017, there were 60 fatal overdoses of fentanyl in the UK.
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Countermeasures
The U.S. Government
In 2010, the US government began cracking down on pharmacists and doctors who
were over-prescribing opioid painkillers. An unintended consequence of this was that
those addicted to prescription opiates turned to heroin, a significantly more potent but
cheaper opioid, as a substitute. A 2017 survey in Utah of heroin users found about 80
percent started with prescription drugs.
In 2010, the Controlled Substances Act 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.
In 2011, the federal government 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. 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 funding for
opioid research and treatment.
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In 2016, the U.S. Surgeon General listed statistics which describe the extent of the
problem. The House and Senate passed the Ensuring Patient Access and Effective
Drug Enforcement Act which was signed into law by President Obama on April 19,
2016, and may have decreased the DEA's ability to intervene in the opioid crisis. 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), and was signed into law by
President Obama.
As of March 2017, President Donald Trump appointed a commission on the epidemic,
chaired by Governor Chris Christie of New Jersey. [92][93][94] 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." Trump nominated
Representative Tom Marino to be director of the Office of National Drug Control Policy,
or "drug czar", however, on Oct. 17, 2017, Marino withdrew his nomination after it was
reported that his relationship with the drug industry might be a conflict of interest. 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".
In April 2017, the Department of Health and Human Services announced their "Opioid
Strategy" consisting of five aims:
1. Improve access to prevention, treatment, and recovery support services to
prevent the health, social, and economic consequences associated with opioid
addiction and to enable individuals to achieve long-term recovery;
2. Target the availability and distribution of overdose-reversing drugs to ensure the
broad provision of these drugs to people likely to experience or respond to an
overdose, with a particular focus on targeting high-risk populations;
3. Strengthen public health data reporting and collection to improve the timeliness
and specificity of data and to inform a real-time public health response as the
epidemic evolves;
4. Support cutting-edge research that advances our understanding of pain and
addiction leads to the development of new treatments, and identifies effective
public health interventions to reduce opioid-related health harms; and
5. Advance the practice of pain management to enable access to high-quality,
evidence-based pain care that reduces the burden of pain for individuals,
families, and society while also reducing the inappropriate use of opioids and
opioid-related harms.
SAMHSA administers the Opioid State Targeted Response grants, a two-year program
authorized by the 21st Century Cures Act which provided $485 million to states and
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U.S. territories in the fiscal year 2017 for the purpose of preventing and combatting
opioid misuse and addiction.
State and Local Governments
In July 2016, governors from 45 U.S. states and three 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.
In March 2017, several states issues responses to the opioid crisis. The Governor
of Maryland declared a State of Emergency to combat the rapid increase in overdoses
by increasing and speeding up coordination between the state and local jurisdictions. In
2016, about 2,000 people in the state had died from opioid overdoses. Delaware, which
has the 12th-highest overdose death rate in the U.S., 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. A similar
plan was created 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. In Maine, new laws were imposed which capped the maximum daily
strength of prescribed opioids and which limited prescriptions to seven days.
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
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trying to pass H.B. 299 into law which would allow relatives to petition a court to
mandate substance-abuse treatment for adults.
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. In
February 2017, officials in Everett, Washington filed a lawsuit against the Purdue
Pharma, 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.
Prescription Drug Monitoring
The Canadian Government
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. 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.
As of April 2017, prescription drug monitoring programs (PDMPs) exist in every state. A
person on opioids for more than three months has a 15-fold (1,500%) greater chance of
becoming addicted. 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. The Centers for Disease Control and
Prevention (CDC) was tasked with establishing and publishing a new guideline, and
was heavily lobbied.
In The Media
Media coverage has largely focused on law-enforcement solutions to the epidemic,
which portray the issue as criminal rather than medical. In early 2016 the national desk
of the Washington Post began an investigation with assistance from the fired DEA
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egulator, Joseph Razzazzisi, on the rapidly increasing numbers of opioid related
deaths.
While media coverage has focused more heavily on overdoses among whites, use
among most races has increased at similar rates. Deaths by overdose among white,
black, and native Americans increased by 200-300% from 2010-2014. During this time
period, overdoses among hispanics increased 140%, and the data available on
overdoses by asians was not comprehensive enough to draw a conclusion.
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.
Treatment
The opioid epidemic is often discussed in terms of prevention, but helping those who
are already addicts is talked about less frequently. 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. Neither is guaranteed to successfully treat opioid
addiction. Which, or which combination, is most effective varies from person to person.
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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.
Naloxone
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.
Methadone
Methadone has been used for opioid dependence since 1964, and studied the most of
the pharmacological treatment options. It is a synthetic long acting opioid, so it can
replace multiple heroin uses by being taken once daily. 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.
Buprenorphine
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.
Unlike methadone treatment, which must be performed in a highly structured clinic,
buprenorphine, according to SAMHSA, can be prescribed or dispensed in physician
offices. Patients can thereby receive a full year of treatment for a fraction of the cost of
detox programs.
Behavioral Treatment
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
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etter results when accompanied by behavioral treatment. Popular behavioral treatment
options include group or individual therapy, residential treatment centers, and Twelvestep
programs such as Narcotics Anonymous.
Safe Injection Sites
North America's first "safe injection site" opened in Vancouver. Rather than try to treat
to prevent people from using drugs, these sites are intended to allow addicts to use
drugs in an environment where help is immediately available in the event of an
overdose. Health Canada has licensed 16 safe injection sites in the country. In Canada,
about half of overdoses resulting in hospitalization were accidental, while a third were
deliberate overdoses.
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II. The National Trauma
How Prescription Drugs Sparked a National Trauma
The Guardian
Wednesday, October 25, 2017
Aggressive marketing of painkillers made from opium poppy led to a generation of addicts
and the deaths of almost 100 people a day from overdoses
The trips to resorts in the sun traps of Florida, Arizona and California were a great
chance for medics to network, take a break from patients and learn about new
treatments. There were even freebies – fishing hats, cuddly toys to take back for the
kids, music CDs. And the visits were all expenses paid.
But such events laid the groundwork for a national crisis.
From 1996 to 2001, American drug giant Purdue Pharma held more than 40 national
“pain management symposia” at picturesque locations, hosting thousands of American
doctors, nurses and pharmacists.
Q&A
Why is there an opioid crisis in America?
Almost 100 people are dying every day across America from opioid overdoses – more
than car crashes and shootings combined. The majority of these fatalities reveal
widespread addiction to powerful prescription painkillers. The crisis unfolded in the mid-
90s when the US pharmaceutical industry began marketing legal narcotics, particularly
OxyContin, to treat everyday pain. This slow-release opioid was vigorously promoted to
doctors and, amid lax regulation and slick sales tactics, people were assured it was safe.
But the drug was akin to luxury morphine, doled out like super aspirin, and highly
addictive. What resulted was a commercial triumph and a public health tragedy. Belated
efforts to rein in distribution fueled a resurgence of heroin and the emergence of a
deadly, black market version of the synthetic opioid fentanyl. The crisis is so deep
because it affects all races, regions and incomes
The healthcare professionals had been specially invited, whisked to the conferences to
be drilled on promotional material about the firm’s new star drug, OxyContin, and
recruited as advocates, the US government later documented.
But OxyContin was to become ground zero in an opioid crisis that has now engulfed the
United States.
The pill comprises oxycodone, a semi-synthetic opioid loosely related to morphine and
originally based on elements of the opium poppy. Such strong painkillers were
traditionally used to ease cancer pain, but beginning in the mid-1990s, pills based on
oxycodone and the similar compound hydrocodone began being branded and
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aggressively marketed for chronic pain instead – a nagging back injury from manual
labor or a car accident, for example.
From 1996 to 2002, Purdue more than doubled its sales force and distributed coupons
so doctors could let patients try a 30-day free supply of these highly addictive drugs.
Prescriptions issued for OxyContin in the US increased tenfold over those six years,
from 670,000 a year to more than six million. A bulletin from the American Public Health
Association in 2009, reviewing the rise of prescription opioids, is titled “The promotion
and marketing of OxyContin: commercial triumph, public health tragedy”. The document
also asserted that Purdue had played down the risks of addiction. In a landmark case,
the company was fined more than $600m in 2007 for misleading the public, but it
was making billions – at the time the only company making this kind of money from
high-strength opioids.
By 2002 prescription opioids were killing 5,000 people a year in America and that
number tripled over the following decade.
Coast-to-Coast
One of the key regions of the US affected early in the crisis was central Appalachia, an
area covering much of West Virginia and eastern Kentucky known for small towns,
rolling hills and physically taxing industries, including coalmining, agriculture and lumber
production. Here, the proliferation of opioids encouraged abuse and the pills came to be
known as “hillbilly heroin”.
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Even taken exactly as prescribed, they were addictive, blocking pain (without treating its
cause) and reducing stress. But people also began grinding them up to snort or inject
for a potent high.
“At the time, it wasn’t understood how addicting these prescription pain medications
were,” Michelle Lofwall, associate professor at the Center on Drug and Alcohol
Research at the University of Kentucky School of Medicine told the Guardian in a
2014 report. “But they really hurt people here and across the nation.”
In the new millennium, addiction spread coast to coast.
And as use of the drugs spread, the distribution of pills spilled out from primary-care
doctors’ offices and hospitals to illegal deals on street corners. They were also sold in
vast quantities through barely regulated “pain treatment centers” in places such as
Florida, which became known as “pill mills”. People with spurious pain complaints
flocked to feed their own dependency or sell the pills on.
In 2003, rightwing media blowhard Rush Limbaugh admitted he was hooked on opioids.
Actor Heath Ledger had prescription opioids in his system, along with a cocktail of
sedatives, when he was found dead in New York in 2008 at 28.
In 2011 the US government reported that deaths from prescription opioid overdoses
had overtaken combined fatalities from heroin and cocaine.
By 2012, sales of prescription opioids were grossing $11bn in the US annually and,
with insufficient regulatory oversight, causing 15,000 fatal overdoses.
The street-drug epidemic of crack in the 80s and early 90s wrought particular havoc
among low-income, urban African Americans, while the sordid blight of backyardcooked
methamphetamine was at its height among more rural, white populations in the
90s and early 21st century.
In contrast, the opioid crisis rippled out from neat pharmacy counters
across broader income and geographical bands. The typical addict was most likely to be
white, male and middle-aged, but the drug has a wide grip.
Gradually, the authorities began shutting down pill mills and warning health
professionals and the public that opioids were far from a magic bullet.
But for many, the squeezing of supply, combined with a chronic lack of resources to
treat addiction, didn’t help them quit, it made them desperate. A new, even darker
chapter unfolded: the resurgence of street heroin and the emergence of a treacherous
street-drug version of its synthetic cousin, fentanyl.
Fast forward to today and America is losing almost 1,000 people a week to drug
overdoses. Two-thirds of those are opioid fatalities – with the pill problem still pervasive,
but with a rising number of heroin and fentanyl deaths.
In 2015, a quarter of drug overdose deaths involved heroin, compared with 8% in 2010.
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The death rates are highest in West Virginia, New Hampshire, Kentucky and Ohio, but
the opioid epidemic has spread nationwide, as this map shows.
In 2014, renowned actor Philip Seymour Hoffman died of a heroin overdose in New
York, after 23 years of sobriety. Last year Prince died when he overdosed on pills
containing fentanyl – and the world suddenly became familiar with this synthetic narcotic
being milled in Mexico from Chinese ingredients and rushedinto the US illegal drug
market.
On Thursday Donald Trump is expected to declare the opioid crisis to be a “national
emergency”.
Other developed countries, including the UK, have been grappling with a rise in opioid
addiction, too, although Britain’s public health system means the issue of massive overprescription
is less acute.
But the US is the epicentre and the origin of the crisis, consuming more than 80% of
global opioid pills even though it has less than 5% of the world’s population and no
monopoly on pain.
National data has stated that the volume of opioid pills prescribed in the US since 1999
has quadrupled, and so has the number of opioid overdoses.
But “there has not been an overall change in the amount of pain Americans have
reported in that period”, the government reported.
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142 Fatal Overdoses a Day
Overdoses killed more people in the US in 2015 than car crashes and gun deaths
combined. The daily death toll is 142 fatal overdoses, 91 of them from opioids, adding
up to almost 52,000 drug overdose deaths in 2015.
Declaring a national state of emergency over opioids will focus fresh attention and
increase government powers to cut red tape and release funding to expand treatment.
Action such as providing all police departments and other first responders with the
overdose antidote naloxone, which helps save lives, is being urged.
But if Trump succeeds in his determination to repeal the Obama administration’s
Affordable Care Act, which brought health insurance to millions more Americans, it will
hinder those seeking affordable treatment programs.
And in recent public pronouncements, the president appears to be stuck in the failed
80s mentality of “Just say No” to drugs, and in blaming individuals for becoming
dependent on dangerous pills their doctors told them were safe.
He called for drug prosecutions to increase, and said: “The best way to prevent drug
addiction and overdose is to prevent people from abusing drugs in the first place.” He
emphasized the administration’s efforts to stop the flow of drugs over the Mexico-US
border, but did not mention the pharmaceutical companies producing opioids within the
US.
Although Trump said Congress was too beholden to the pharmaceutical companies,
which shower Washington with donations and persuasive lobbyists, his declaration
embarrassingly coincided with news that the man who was poised to be his new
national drug policy “czar” had to withdraw from consideration because he had
sponsored legislation that hindered attempts to crack down on opioids.
“In 2015, the amount of opioids prescribed in the US was enough for every American to
be medicated around the clock for three weeks,” warned a recent draft report by a
commission on the crisis led by the combative New Jersey governor, Chris Christie.
It concluded: “Our citizens are dying. We must act.”
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III. Opioid Crisis Fast Facts
(CNN) Here's a look at the opioid crisis.
Sun October 29, 2017
Experts say the United States is in the throes of an opioid epidemic, as more than two
million of Americans have become dependent on or abused prescription pain pills and
street drugs.
Opioids are drugs formulated to replicate the pain reducing properties of opium. They
include both legal painkillers like morphine, oxycodone, or hydrocodone prescribed by
doctors for acute or chronic pain, as well as illegal drugs like heroin or illicitly made
fentanyl. The word "opioid" is derived from the word "opium."
During 2015, there were 52,404 overdose deaths in the United States, including 33,091
(63.1%) that involved an opioid. That's an average of 91 opioid overdose deaths each
day.
The number of opioid prescriptions dispensed by doctors steadily increased from 112
million prescriptions in 1992 to a peak of 282 million in 2012, according to the market
research firm IMS Health. The number of prescriptions dispensed has since declined,
falling to 236 million in 2016.
Common Opioids
Opioids bind to receptors in the brain and spinal cord, disrupting pain signals. They also
activate the reward areas of the brain by releasing the hormone dopamine, creating a
feeling of euphoria or a "high."
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Opioids such as morphine and codeine are naturally derived from opium poppy plants
more commonly grown in Asia, Central America and South America. Heroin is an illegal
drug synthesized from morphine.
Hydrocodone and oxycodone are semi-synthetic opioids, manufactured in labs with
natural and synthetic ingredients. Between 2006 and 2014, the most widely prescribed
opioid was hydrocodone (Vicodin). In 2014, 7.8 billion hydrocodone pills were
distributed nationwide. The second most prevalent opioid was oxycodone (Percocet). In
2014, 4.9 billion oxycodone tablets were distributed in the United States.
The International Narcotics Control Board reported that in 2015, Americans represented
about 99.7% of the world's hydrocodone consumption.
Fentanyl is a fully synthetic opioid, originally developed as a powerful anesthetic for
surgery. It is also administered to alleviate severe pain associated with terminal
illnesses like cancer. The drug is up to 100 times more powerful than morphine. Just a
small dose can be deadly. Illicitly produced fentanyl has been a driving factor in the
number of overdose deaths in recent years.
Methadone is another fully synthetic opioid. It is commonly dispensed to recovering
heroin addicts to relieve the symptoms of withdrawal.
Addiction
Opioid use disorder is the clinical term for opioid addiction or abuse.
People who become dependent on opioids may experience withdrawal symptoms when
they stop taking the pills. Dependence is often coupled with tolerance, meaning that
opioid users need to take increasingly larger doses of the medication for the same
effect.
About 11.5 million Americans age 12 and older misused prescription pain medicine in
2016, according to the Substance Abuse and Mental Health Services
Administration. About 948,000 or 0.3% of the US population age 12 and up used heroin
in 2016.
People who become dependent on pain pills may switch to heroin because it is less
expensive than prescription drugs. The National Institute on Drug Abuse estimates that
half of young people who inject heroin turned to the street drug after abusing
prescription painkillers, also that three in four new heroin users start out using
prescription drugs.
The number of overdose deaths related to heroin increased 533% between 2002 and
2016, from an estimated 2,089 in 2002 to 13,219 in 2016.
A drug called naloxone, available as an injection or a nasal spray, is used as a
treatment for overdoses. It blocks or reverses the effects of opioids and is often carried
by first responders.
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Regulation and Funding
In 2013, the cost of medical care and substance abuse treatment for opioid addiction
and overdose was an estimated $78.5 billion, according to a report in the journal
Medical Care. Forty-nine states have prescription drug monitoring programs, databases
which enable health care providers to curb "doctor shopping" by patients who obtain
opioid prescriptions from multiple physicians. Missouri's program is not yet statewide but
has enacted legislation to authorize it.
The 21st Century Cures Act, passed in 2016, allocated $1 billion over two years in
opioid crisis grants to states, providing funding for expanded treatment and prevention
programs. In April 2017, Health and Human Services Secretary Tom Price announced
the distribution of the first round of $485 million in grants to all 50 states and US
territories.
In August 2017, Attorney General Jeff Sessions announced the launch of an Opioid
Fraud and Abuse Detection Unit within the Department of Justice. The unit's mission is
to prosecute individuals who commit opioid-related health care fraud. The DOJ is also
appointing US attorneys who will specialize in opioid health care fraud cases as part of
a three-year pilot program in 12 jurisdictions nationwide.
State legislatures are also taking action, introducing measures to regulate pain clinics
and limit the quantity of opioids that doctors can dispense.
Emergence of a Crisis
1861-1865 - During the Civil War, medics use morphine as a battlefield anesthetic.
Many soldiers become dependent on morphine after the war.
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1898 - Heroin is first produced commercially by the Bayer Company. At the time, heroin
is believed to be less habit-forming than morphine, so it is dispensed to individuals who
are addicted to morphine.
1914 - Congress passes the Harrison Narcotics Act, which requires that doctors write
prescriptions for narcotic drugs like opioids and cocaine. Importers, manufacturers and
distributors of narcotics must register with the Treasury Department and pay taxes on
product.
1924 - The Anti-Heroin Act bans the production and sale of heroin in the United States.
1970 - The Controlled Substances Act becomes law. It creates groupings (or schedules)
of drugs based on the potential for abuse. Heroin is a Schedule I drug while morphine,
fentanyl, oxycodone (Percocet, OxyContin) and methadone are Schedule II. Vicodin - a
hydrocodone-acetaminophen combination - was originally a Schedule III medication but
wasn't recategorized as a Schedule II drug until October 2014.
January 10, 1980 - A letter titled "Addiction Rare in Patients Treated with Narcotics" is
published in the New England Journal of Medicine. It was not a study and looked at
incidences of addiction in a very specific population of hospitalized patients who were
closely monitored. However, it would become widely cited as proof that narcotics were a
safe treatment for chronic pain.
1995 - OxyContin, a long acting version of oxycodone, which slowly releases the drug
over 12 hours, is introduced and aggressively marketed as a safer pain pill by
manufacturer, Purdue Pharma.
May 10, 2007 - The federal government brings criminal charges against Purdue Pharma
for misleadingly advertising OxyContin as safer and less addictive than other opioids.
The company and three executives are charged with "misleading and defrauding
physicians and consumers."Purdue Pharma and the executives plead guilty, agreeing to
pay a $634.5 million in criminal and civil fines. The three executives plead guilty on
criminal misdemeanor charges and are later sentenced to probation.
2010 - FDA approves an "abuse-deterrant" formulation of OxyContin, to help curb
abuse. However, people still find ways to abuse it.
May 20, 2015 - The DEA announces that it has arrested 280 people, including 22
doctors and pharmacists, after a 15-month sting operation centered on health care
providers who dispense large amounts of opioids. The sting, dubbed Operation Pilluted,
is the largest prescription drug bust in the history of the DEA.
March 18, 2016 - The CDC publishes guidelines for prescribing opioids for patients with
chronic pain. Recommendations include prescribing over-the-counter pain relievers like
acetaminophen and ibuprofen in lieu of opioids. Doctors are encouraged to promote
exercise and behavioral treatments to help patients cope with pain.
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March 29, 2017 - President Donald Trump signs an executive order calling for the
establishment of the President's Commission on Combating Drug Addiction and the
Opioid Crisis. New Jersey Governor Chris Christie is selected as the chairman of the
group, with Trump's son-in-law, Jared Kushner, as an adviser.
July 31, 2017 - After a delay, the White House panel examining the nation's opioid
epidemic releases its interim report, asking President Trump to declare a national public
health emergency to combat the ongoing crisis.
August 8, 2017 - Trump holds a press briefing on opioids at his New Jersey golf club
and says that a stronger law enforcement response is needed to combat the crisis. He
stops short of declaring a national public health emergency.
August 10, 2017 - The White House issues a press release stating that Trump is
directing his "administration to use all appropriate authority to respond to the opioid
emergency." The administration does not, however, make a formal declaration of a
national public health emergency, which would free up resources and funding to help
opioid addicts and jumpstart prevention programs.
September 22, 2017 - The pharmacy chain CVS announces that it will implement new
restrictions on filling prescriptions for opioids, dispensing a limited seven-day supply to
patients who are new to pain therapy.
October 26, 2017 - President Trump declares a national public health emergency to
combat the opioid crisis, telling an audience in the East Room of the White House that
"we can be the generation that ends the opioid epidemic."
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IV. The Main Offenders
Oxycodone
Oxycodone is a semisynthetic opioid synthesized from the baine, an
opioid alkaloid found in the Persian poppy, and one of the many alkaloids found in
the opium poppy. It is a moderately potent
opioid analgesic (orally roughly 1.5 times more
potent than morphine), generally indicated for
relief of moderate to severe pain. Oxycodone
was developed in
1917 in Germany as one of several semisynthetic
opioids
in an attempt to improve on the existing opioids.
Oxycodone is
available as single-ingredient medication
in immediate release and controlled
release.
Parenteral formulations of 10 mg/mL
and
50 mg/mL are available in the UK for
IV/IM administration. Combination products
are also available as immediate-release
formulations, with non-narcotic
analgesic ingredients such
as paracetamol (acetaminophen)
and nonsteroidal anti-inflammatory
drugs (NSAIDs), including aspirin and ibuprofen.
As it has euphoric effects similar to other opioids, oxycodone is
one of the drugs abused in the current opioid epidemic in the United States. An abusedeterrent
combination with naloxone is available in managed-release tablets. If injected,
the naloxone precipitates opioid withdrawal symptoms and blocks the effect of the
medication. However, there have been concerns raised about the effectiveness of the
abuse prevention measures.
Medical Uses
Oxycodone has been in clinical use since 1916, and it is used for managing moderate to
moderately severe acute or chronic pain. It has been found to improve quality of life for
those with many types of pain. Experts are divided regarding use for non-cancer-related
chronic pain, as most opioids have great potential for dependence and have also been
alleged to create paradoxical pain sensitivity.
Oxycodone is available as controlled-release tablet, intended to be taken every 12
hours. A 2006 review found that controlled-release oxycodone is comparable to instantrelease
oxycodone, morphine, and hydromorphone in management of moderate to
severe cancer pain, with fewer side effects than morphine. The author concluded that
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the controlled release form is a valid alternative to morphine and a first-line treatment for
cancer pain. In 2014, the European Association for Palliative Care recommended oral
oxycodone as a second-line alternative to oral morphine for cancer pain.
In the U.S., extended-release oxycodone is approved for use in children as young as 11
years old. The approved indication is for relief of cancer pain, trauma pain, or pain due
to major surgery, in children already treated with opioids, who can tolerate at least
20 mg per day of oxycodone; this provides an alternative to Duragesic (fentanyl) the
only other extended-release opioid analgesic approved for children.
Administration
In the United States, oxycodone is only approved for oral use, available as tablets and
oral solutions. In Spain, the Netherlands and the United Kingdom, oxycodone is also
approved for intravenous (IV) and intramuscular (IM) use. When first introduced in
Germany during World War I, both IV and IM administrations of oxycodone were
commonly used for postoperative pain management of Central Powers soldiers.
Available Forms
Oxycodone is available in a variety of formulations for oral or sublingual administration:
Immediate-release oxycodone (OxyFast, OxyIR, OxyNorm, Roxicodone)
Controlled-release oxycodone (OxyContin) – 12-hour duration
Oxycodone tamper-resistant (OxyContin OTR)
Immediate-release oxycodone with paracetamol (acetaminophen)
(Percocet, Endocet, Roxicet, Tylox)
Immediate-release oxycodone with aspirin (Endodan, Oxycodan, Percodan,
Rosiprin)
Immediate-release oxycodone with ibuprofen (Combunox)
Controlled-release oxycodone with naloxone (Targin, Targiniq, Targinact) – 12-
hour duration
Controlled-release oxycodone with naltrexone (Troxyca) – 12-hour duration –
pending regulatory approval
Parenteral formulations of oxycodone (brand name OxyNorm) are also available, and
are widely used in Europe.
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Side Effects
Serious side effects of
oxycodone include reduced
sensitivity to pain (beyond the
pain the drug is taken to
reduce), euphoria, anxiolysis,
feelings of relaxation,
and respiratory
depression. Common side
effects of oxycodone
include constipation (23%), na
usea (23%), vomiting (12%), s
omnolence (23%), dizziness (
13%), itching (13%), dry
mouth (6%),
and sweating (5%). [33][34] Less
common side effects
(experienced by less than 5%
of patients) include loss of
appetite, nervousness, abdom
inal pain, diarrhea, urine
retention, dyspnea,
and hiccups.
In high doses, overdoses, or in some persons not tolerant to opioids, oxycodone can
cause shallow breathing, slowed heart rate, cold/clammy skin, pauses in breathing, low
blood pressure, constricted pupils, circulatory collapse, respiratory arrest, and death.
Oxycodone overdose has also been described to cause spinal cord infarction in high
doses and ischemic damage to the brain, due to prolonged hypoxia from suppressed
breathing.
Oxycodone in combination with naloxone in managed-release tablets, has been
formulated to both deter abuse and reduce "opioid-induced constipation".
Dependence, Addiction, and Withdrawal
The risk of experiencing severe withdrawal symptoms is high if a patient has become
physically dependent and discontinues oxycodone abruptly. Medically, when the drug
has been taken regularly over an extended period, it is withdrawn gradually rather than
abruptly. People who regularly use oxycodone recreationally or at higher than
prescribed doses are at even higher risk of severe withdrawal symptoms. The
symptoms of oxycodone withdrawal, as with other opioids, may include "anxiety, panic
attack, nausea, insomnia, muscle pain, muscle weakness, fevers, and other flu-like
symptoms".
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Withdrawal symptoms have also been reported in newborns whose mothers had been
either injecting or orally taking oxycodone during pregnancy.
Hormone Imbalance
As with other opioids, chronic use of oxycodone (particularly with higher doses) often
causes concurrent hypogonadism or hormone imbalance.
Interactions
Oxycodone is metabolized by the enzymes CYP3A4 and CYP2D6, and its clearance
therefore can be altered by inhibitors and inducers of these enzymes. (For lists of
CYP3A4 and CYP2D6 inhibitors and inducers, see here and here, respectively.)
Natural genetic variation in these enzymes can also influence the clearance of
oxycodone, which may be related to the wide inter-individual variability in its halflifeand
potency.
Ritonavir or lopinavir/ritonavir greatly increase plasma concentrations of oxycodone in
healthy human volunteers due to inhibition of CYP3A4 and CYP2D6. Rifampicin greatly
reduces plasma concentrations of oxycodone due to strong induction of CYP3A4. There
is also a case report of fosphenytoin, a CYP3A4 inducer, dramatically reducing the
analgesic effects of oxycodone in a chronic pain patient. Dosage or medication
adjustments may be necessary in each case.
Pharmacodynamics
Oxycodone is a highly selective full agonist of the μ-opioid receptor (MOR), with
low affinity for the δ-opioid receptor (DOR) and κ-opioid receptor (KOR). [29][30] After
oxycodone binds to the MOR, a G protein-complex is released, which inhibits the
release of neurotransmitters by the cell by reducing the amount of cAMP produced,
closing calcium channels, and opening potassium channels.
Compound MOR (Ki) DOR (Ki) KOR (Ki) δ/μ (ratio) κ/μ (ratio)
Oxycodone 18 nM 958 nM 677 nM 53 38
Similarly to most other opioids, oxycodone increases prolactin secretion, but its
influence on testosterone levels is unknown. Unlike morphine, oxycodone
lacks immunosuppressive activity (measured by natural killer cell activity and interleukin
2 production in vitro); the clinical relevance of this has not been clarified.
Controversy
In 1997, a group of Australian researchers proposed (based on a study in rats) that
oxycodone acts on KORs, unlike morphine, which acts upon MORs. Further research
by this group indicated the drug appears to be a κ2b-opioid agonist. However, this
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conclusion has been disputed, primarily on the basis that oxycodone produces effects
that are typical of μ-opioid agonists.
In 2006, research by a Japanese group suggested the effect of oxycodone is mediated
by different receptors in different situations. Specifically in diabetic mice, the κ-opioid
receptor appears to be involved in the antinociceptive effects of oxycodone, while in
nondiabetic mice, the μ1-opioid receptor seems to be primarily responsible for these
effects.
Pharmacokinetics
Absorption
After a dose of conventional (instant-release) oral oxycodone, the onset of action is 10–
30 minutes, and peak plasma levels of the drug are attained within roughly 30–60
minutes; in contrast, after a dose of OxyContin (an oral controlled-release formulation),
peak plasma levels of oxycodone occur in about three hours. The duration of instantrelease
oxycodone is 3 to 6 hours, although this can be variable depending on the
individual.
Distribution
Oxycodone in the blood is distributed to skeletal muscle, liver, intestinal tract, lungs,
spleen, and brain. Conventional oral preparations start to reduce pain within 10–15
minutes on an empty stomach; in contrast, OxyContin starts to reduce pain within one
hour.
Metabolism
The metabolism of oxycodone in humans is extensive (about 95%) and complex, with
many minor pathways and resulting metabolites. Around 10% (range 8–14%) of a dose
of oxycodone is excreted essentially unchanged (unconjugated or conjugated) in
the urine. The major metabolites of oxycodone
are noroxycodone (70%), noroxymorphone ("relatively
high
concentrations"), and oxymorphone(5%). The immediate metabolism of oxycodone in
humans is as follows:
N-demethylation to noroxycodone predominantly via CYP3A4
O-demethylation to oxymorphone predominantly via CYP2D6
6-ketoreduction to 6α- and 6β-oxycodol
N-oxidation to oxycodone-N-oxide
In humans, N-demethylation of oxycodone to noroxycodone by CYP3A4 is the major
metabolic pathway, accounting for 45% ± 21% of a dose of oxycodone, while O-
demethylation of oxycodone into oxymorphone by CYP2D6 and 6-ketoreduction of
oxycodone into 6-oxycodols represent relatively minor metabolic pathways, accounting
for 11% ± 6% and 8% ± 6% of a dose of oxycodone, respectively.
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Several of the immediate metabolites of oxycodone are subsequently conjugated
with glucuronic acid and excreted in the urine. 6α-Oxycodol and 6β-oxycodol are further
metabolized by N-demethylation to nor-6α-oxycodol and nor-6β-oxycodol, respectively,
and by N-oxidation to 6α-oxycodol-N-oxide and 6β-oxycodol-N-oxide (which can
subsequently be glucuronidated as well), respectivelyrespectively. Oxymorphone is also
further metabolized, as follows:
3-glucuronidation to oxymorphone-3-glucuronide predominantly via UGT2B7
6-ketoreduction to 6α-oxymorphol and 6β-oxymorphol
N-demethylation to noroxymorphone
The first pathway of the above three accounts for 40% of the metabolism of
oxymorphone, making oxymorphone-3-glucuronide the main metabolite of
oxymorphone, while the latter two pathways account for less than 10% of the
metabolism of oxymorphone. After N-demethylation of
oxymorphone, noroxymorphone is further glucuronidated to noroxymorphone-3-
glucuronide.
Activity Contribution of Metabolites
A few of the metabolites of oxycodone have also been found to be active as MOR
agonists, some of which notably have much higher affinity for (as well as
higher efficacy at) the MOR in comparison. Oxymorphone possesses 3- to 5-fold higher
affinity for the MOR than does oxycodone, while noroxycodone and noroxymorphone
possess one-third of and 3-fold higher affinity for the MOR, respectively, and MOR
activation is 5- to 10-fold less with noroxycodone but 2-fold higher with noroxymorphone
relative to oxycodone. Noroxycodone, noroxymorphone, and oxymorphone also have
longer half-lives than oxycodone.
Compound
K i ([ 3 H]diprenorphine displace
ment)
EC 50 (hMOR1 GTPyS bin
ding)
Oxycodone 16.0 nM 343 nM
Oxymorphone 0.36 nM 42.8 nM
Noroxycodone 57.1 nM 1930 nM
Noroxymorpho
ne
C max (20
mg CR)
23.2 ±
8.6 ng/mL
0.82 ±
0.85 ng/m
L
15.2 ±
4.5 ng/mL
AUC (20
mg CR)
236 ±
102 ng/h/
mL
12.3 ±
12 ng/h/m
L
233 ±
102 ng/h/
mL
5.69 nM 167 nM ? ?
However, despite the greater in vitro activity of some of its metabolites, it has been
determined that oxycodone itself is responsible for 83.0% and 94.8% of its analgesic
effect following oral and intravenous administration, respectively. Oxymorphone plays
only a minor role, being responsible for 15.8% and 4.5% of the analgesic effect of
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oxycodone after oral and intravenous administration, respectively. Although the
CYP2D6 genotype and the route of administration result in differential rates of
oxymorphone formation, the unchanged parent compound remains the major
contributor to the overall analgesic effect of oxycodone. In contrast to oxycodone and
oxymorphone, noroxycodone and noroxymorphone, while also potent MOR agonists,
poorly cross the blood-brain-barrier into the central nervous system, and for this reason,
are only minimally analgesic in comparison. In accordance, while higher CYP2D6
activity increases the effects of oxycodone (owing to increased conversion into
oxymorphone), higher CYP3A4 activity has the opposite effect, and decreases the
effects of oxycodone (owing to increased metabolism into noroxycodone and
noroxymorphone).
Variation
Oxycodone is metabolized by the cytochrome P450 enzyme system in the liver, making
it vulnerable to drug interactions. Some people are fast metabolizers, resulting in
reduced analgesic effect, but increased adverse effects, while others are slow
metabolisers, resulting in increased toxicity without improved analgesia. The dose of
oxycodone must be reduced in patients with reduced hepatic function.
Elimination
Oxycodone and its metabolites are mainly excreted in the urine and sweat; therefore, it
accumulates in patients with kidney impairment.
Bioavailability
Oxycodone can be administered orally, intranasally, via intravenous, intramuscular,
or subcutaneous injection, or rectally. The bioavailability of oral administration of
oxycodone averages 60–87%, with rectal administration yielding the same results;
intranasal varies between individuals with a mean of 46%.
Morphine Equivalency
Taken orally, 20 mg of immediate release oxycodone is equivalent to 30 mg of
morphine. Extended release oxycodone is considered to be twice as potent as oral
morphine.
Chemistry
Oxycodone's chemical name is derived from codeine. The chemical structures are very
similar, differing only in that
Oxycodone has a hydroxy group at carbon-14 (codeine has just a hydrogen in its
place)
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Oxycodone has a 7,8-dihydro feature. Codeine has a double bond between
those two carbons; and
Oxycodone has a carbonyl group (as in ketones) in place of the hydroxyl group of
codeine.
It is also similar to hydrocodone, differing only in that it has a hydroxyl group at carbon-
14.
Oxycodone is marketed as various salts, most commonly as the hydrochloride salt.
The free base conversion ratios of different salts are: hydrochloride (0.896), bitartrate
(0.667), tartrate (0.750), camphosulphonate (0.576), pectinate (0.588),
phenylpriopionate (0.678), sulphate (0.887), phosphate (0.763), and terephthalate
(0.792). The hydrochloride salt is the basis of most American oxycodone products whilst
bitartrate, tartrate, pectinate, terephthalate and phosphate salts are also available in
European products. Methyiodide and hydroiodide are mentioned in older European
publications.
Biosynthesis
In terms of biosynthesis, oxycodone has been found naturally in nectar extracts from the
orchid family Epipactis helleborine; together along with another opioid: 3-{2-{3-{3-
benzyloxypropyl}-3-indol, 7,8-didehydro- 4,5-epoxy-3,6-d-morphinan.
Detection in Biological Fluids
Oxycodone and/or its major metabolites may be measured in blood or urine to monitor
for clearance, abuse, confirm a diagnosis of poisoning, or assist in a medicolegal death
investigation. Many commercial opiate screening tests cross-react appreciably with
oxycodone and its metabolites, but chromatographic techniques can easily distinguish
oxycodone from other opiates.
History
Freund and Speyer of the University of Frankfurt in Germany first synthesized
oxycodone from Thebaine in 1916, a few years after the German pharmaceutical
company Bayer had stopped the mass production of heroin due to hazardous use,
harmful use, and dependence. It was hoped that a thebaine-derived drug would retain
the analgesic effects of morphine and heroin with less dependence. Unfortunately, this
was ultimately not found to be the case.
The first clinical use of the drug was documented in 1917, the year after it was first
developed. It was first introduced to the US market in May 1939. In early 1928, Merck
introduced a combination product containing scopolamine, oxycodone,
and ephedrine under the German initials for the ingredients SEE, which was later
renamed Scophedal (SCOpolamine ePHEDrine and eukodAL). This combination is
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essentially an oxycodone analogue of the morphine-based ´twilight sleep´, with
ephedrine added to reduce circulatory and respiratory effects.
The personal notes of Adolf Hitler's physician, Dr. Theodor Morell, indicate Hitler
received repeated injections of "eukodal" (oxycodone).
In the early 1970s, the United States government classified oxycodone as a schedule II
drug.
Purdue Pharma—a privately held company based in Stamford, Connecticut, developed
the prescription painkiller OxyContin. Upon its release in 1995, OxyContin was hailed as
a medical breakthrough, a long-lasting narcotic that could help patients suffering from
moderate to severe pain. The drug became a blockbuster, and has reportedly
generated some thirty-five billion dollars in revenue for Purdue.
General
Society and Culture
Legal Status
Oxycodone is subject to international conventions on narcotic drugs. In addition,
oxycodone is subject to national laws that differ by country. The 1931 Convention for
Limiting the Manufacture and Regulating the Distribution of Narcotic Drugs of
the League of Nations included oxycodone. [70] The 1961 Single Convention on Narcotic
Drugs of the United Nations, which replaced the 1931 convention, categorized
oxycodone in Schedule I. Global restrictions on Schedule I drugs include "limit[ing]
exclusively to medical and scientific purposes the production, manufacture, export,
import, distribution of, trade in, use and possession of" these drugs; "requir[ing] medical
prescriptions for the supply or dispensation of [these] drugs to individuals"; and
"prevent[ing] the accumulation" of quantities of these drugs "in excess of those required
for the normal conduct of business".
Australia
Oxycodone is in Schedule I (derived from the Single Convention on Narcotic Drugs) of
the Commonwealth's Narcotic Drugs Act 1967. In addition, it is in Schedule 8 of the
Australian Standard for the Uniform Scheduling of Drugs and Poisons ("Poisons
Standard"), meaning it is a "controlled drug... which should be available for use but
require[s] restriction of manufacture, supply, distribution, possession and use to reduce
abuse, misuse and physical or psychological dependence".
Canada
Oxycodone is a controlled substance under Schedule I of the Controlled Drugs and
Substances Act (CDSA).
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Canadian Legislative Changes
In February 2012, Ontario passed legislation to allow the expansion of an already
existing drug-tracking system for publicly funded drugs to include those that are
privately insured. This database will function to identify and monitor patient’s attempts to
seek prescriptions from multiple doctors or retrieve from multiple pharmacies. Other
provinces have proposed similar legislation, while some, such as Nova Scotia, have
legislation already in effect for monitoring prescription drug use. These changes have
coincided with other changes in Ontario’s legislation to target the misuse of painkillers
and high addiction rates to drugs such as oxycodone. As of February 29, 2012, Ontario
passed legislation delisting oxycodone from the province’s public drug benefit program.
This was a first for any province to delist a drug based on addictive properties. The new
law prohibits prescriptions for OxyNeo except to certain patients under the Exceptional
Access Program including palliative care and in other extenuating circumstances.
Patients already prescribed oxycodone will receive coverage for an additional year for
OxyNeo, and after that, it will be disallowed unless designated under the exceptional
access program.
Much of the legislative activity has stemmed from Purdue Pharma’s decision in 2011 to
begin a modification of Oxycontin’s composition to make it more difficult to crush for
snorting or injecting. The new formulation, OxyNeo, is intended to be preventative in this
regard and retain its effectiveness as a painkiller. Since introducing its Narcotics Safety
and Awareness Act, Ontario has committed to focusing on drug addiction, particularly in
the monitoring and identification of problem opioid prescriptions, as well as the
education of patients, doctors, and pharmacists. [76] This Act, introduced in 2010,
commits to the establishment of a unified database to fulfil this intention. [77] Both the
public and medical community have received the legislation positively, though concerns
about the ramifications of legal changes have been expressed. Because laws are
largely provincially regulated, many speculate a national strategy is needed to prevent
smuggling across provincial borders from jurisdictions with looser restrictions.
In 2015, Purdue Pharma's abuse-resistant OxyNEO and six generic versions of
OxyContin had been on the Canada-wide approved list for prescriptions since 2012. In
June 2015, then federal Minister of Health Rona Ambrose announced that within three
years all oxycodone products sold in Canada would need to be tamper-resistant. Some
experts warned that the generic product manufacturers may not have the technology to
achieve that goal, possibly giving Purdue Pharma a monopoly on this opiate.
Canadian Lawsuits
Several class action suits across Canada have been launched against the Purdue
group of companies and affiliates. Claimants argue the pharmaceutical manufacturers
did not meet a standard of care and were negligent in doing so. These lawsuits
reference earlier judgments in the United States, which held that Purdue was liable for
wrongful marketing practices and misbranding. Since 2007, the Purdue companies have
paid over CAN$650 million in settling litigation or facing criminal fines.
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Germany
The drug is in Appendix III of the Narcotics Act (Betäubungsmittelgesetz or BtMG). The
law allows only physicians, dentists, and veterinarians to prescribe oxycodone and the
federal government to regulate the prescriptions (e.g., by requiring reporting).
Hong Kong
Oxycodone is regulated under Part I of Schedule 1 of Hong Kong's Chapter 134
Dangerous Drugs Ordinance.
Japan
Oxycodone is a restricted drug in Japan. Its import and export is strictly restricted to
specially designated organizations having prior permit to import it. In a high-profile case
an American who was a top Toyota executive living in Tokyo, who claimed to be
unaware of the law, was arrested for importing oxycodone into Japan.
Singapore
Oxycodone is listed as a Class A drug in the Misuse of Drugs Act of Singapore, which
means offences in relation to the drug attract the most severe level of punishment. A
conviction for unauthorized manufacture of the drug attracts a minimum sentence of 10
years of imprisonment and corporal punishment of 5 strokes of the cane, and a
maximum sentence of life imprisonment or 30 years of imprisonment and 15 strokes of
the cane. The minimum and maximum penalties for unauthorized trafficking in the drug
are respectively 5 years of imprisonment and 5 strokes of the cane, and 20 years of
imprisonment and 15 strokes of the cane.
United Kingdom
Oxycodone is a Class A drug under the Misuse of Drugs Act. For Class A drugs, which
are "considered to be the most likely to cause harm", possession without a prescription
is punishable by up to seven years in prison, an unlimited fine, or both. Dealing of the
drug illegally is punishable by up to life imprisonment, an unlimited fine, or both. In
addition, oxycodone is a Schedule 2 drug per the Misuse of Drugs Regulations 2001
which "provide certain exemptions from the provisions of the Misuse of Drugs Act
1971".
United States
Under the Controlled Substances Act, enacted in 1971 by President Richard
Nixon, oxycodone is a Schedule II Controlled Substance whether by itself or part of a
multi-ingredient medication. The DEA lists oxycodone both for sale and for use in
manufacturing other opioids as ACSCN 9143 and in 2013 approved the following
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annual aggregate manufacturing quotas: 131.5 metric tons for sale, down from 153.75
in 2012, and 10.25 metric tons for conversion, unchanged from the previous year.
Effects
Recreational Use
Oxycodone, like other opioid analgesics, tends to induce feelings of euphoria, relaxation
and reduced anxiety in those who are occasional users. These effects make it one of
the most commonly abused pharmaceutical drugs in the United States.
Preventive Measures
In August 2010, Purdue Pharma reformulated their long-acting oxycodone line,
marketed as OxyContin, using a polymer, Intac, to make the pills extremely difficult to
crush or dissolve in water to reduce OxyContin abuse. The FDA approved relabeling the
reformulated version as abuse-resistant in April 2013.
Pfizer manufactures a preparation of short-acting oxycodone, marketed as OXECTA,
which contains inactive ingredients, referred to as tamper-resistant AVERSION®
Technology. It does not deter oral abuse. Approved by the FDA in the US in June 2011,
the new formulation makes crushing, chewing, snorting, or injecting the opioid
impractical because of a change in its chemical properties.
Australia
The non-medical use of oxycodone existed from the early 1970s, but by 2015, 91% of a
national sample of injecting drug users in Australia had reported using oxycodone, and
27% had injected it in the last six months.
Canada
Opioid-related deaths in Ontario had increased by 242% from 1969 to 2014. By 2009 in
Ontario there were more deaths from oxycodone overdose than from cocaine
overdose. Deaths from opioid pain relievers had increased from 13.7 deaths per million
residents in 1991 to 27.2 deaths per million residents in 2004. The abuse of oxycodone
in Canada became a problem. Areas where oxycodone is most problematic are Atlantic
Canada and Ontario, where its abuse is prevalent in rural towns, and in many smaller to
medium-sized cities. Oxycodone is also widely available across Western Canada,
but methamphetamine and heroin are more serious problems in the larger cities, while
oxycodone is more common in rural towns. Oxycodone is diverted through doctor
shopping, prescription forgery, pharmacy theft, and overprescribing.
The recent formulations of oxycodone, particularly Purdue Pharma's crush-, chew-,
injection- and dissolve-resistant OxyNEO which replaced the banned OxyContin product
in Canada in early 2012, have led to a decline in the abuse of this opiate but have
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increased the abuse of the more potent drug fentanyl. According to a Canadian Centre
on Substance Abuse study quoted in Maclean's magazine, there were at least 655
fentanyl-related deaths in Canada in a five-year period.
In Alberta, the Blood Tribe police claimed that from the fall of 2014 through January
2015, oxycodone pills or a lethal fake variation referred to as Oxy
80s containing fentanyl made in illegal labs by members of organized crime were
responsible for ten deaths on the Blood Reserve, which is located southwest
of Lethbridge, Alberta. Province-wide, approximately 120 Albertans died from fentanylrelated
overdoses in 2014.
United Kingdom
Abuse and diversion of oxycodone in the UK commenced in the early- to mid-
2000s. The first known death due to overdose in the UK occurred in 2002. However,
recreational use remains relatively rare.
United States
In the United States, more than 12 million people use opioid drugs recreationally. In
2010, 16,652 deaths were related to opioid overdose in combination with other drugs
such as benzodiazepines and alcohol. In September 2013, the FDA released new
labeling guidelines for long acting and extended release opioids requiring manufacturers
to remove moderate pain as indication for use, instead stating the drug is for "pain
severe enough to require daily, around-the-clock, long term opioid treatment." The
updated labeling will not restrict physicians from prescribing opioids for moderate, as
needed use.
Oxycodone is the most widely recreationally used opioid in America. The U.S.
Department of Health and Human Services estimates that about 11 million people in the
US consume oxycodone in a non-medical way annually. In 2007, about 42,800
emergency room visits occurred due to "episodes" involving oxycodone. Diverted
oxycodone may be taken orally or ingested through insufflation; used intravenously, or
the heated vapors inhaled. In 2008, recreational use of oxycodone and hydrocodone
were involved in 14,800 deaths. Some of the cases were due to overdoses of the
acetaminophen component, resulting in fatal liver damage.
Reformulated OxyContin is causing some recreational users to change to heroin, which
is cheaper and easier to obtain.
Economics
The International Narcotics Control Board estimated 11.5 short tons (10.4 t) of
oxycodone were manufactured worldwide in 1998; by 2007 this figure had grown to 75.2
short tons (68.2 t). United States accounted for 82% of consumption in 2007 at 51.6
short tons (46.8 t). Canada, Germany, Australia, and France combined accounted for
13% of consumption in 2007. In 2010, 1.3 short tons (1.2 t) of oxycodone were illegally
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manufactured using a fake pill imprint. This accounted for 0.8% of consumption. These
illicit tablets were later seized by the U.S. Drug Enforcement Administration, according
to the International Narcotics Control Board. The board also reported 122.5 short tons
(111.1 t) manufactured in 2010. This number had decreased from a record high of 135.9
short tons (123.3 t) in 2009.
Names
Expanded expression for the compound oxycodone in the academic literature include
"dihydrohydroxycodeinone", "Eucodal", "Eukodal", "14-hydroxydihydrocodeinone", and
"Nucodan". In a UNESCO convention, the translations of "oxycodone"
are oxycodon (Dutch), oxycodone (French), oxicodona (Spanish), األوكسيكودون (Arabic),
羟 考 酮 (Chinese), and оксикодон (Russian). The word "oxycodone" should not be
confused with "oxandrolone", "oxazepam", "oxybutynin", "oxytocin", or "Roxanol".
Research
There are a few case reports that oxycodone may have antidepressant effects in some
individuals with severe, treatment-resistant major depressive disorder.
Oxycodone has been shown to successfully treat agitation in >85 years old dementia
patients. Agitation level during the oxycodone treatment phase was significantly lower
than during the placebo phase.
Heroin
Heroin, also known as diamorphine among other names, is an opioid most commonly
used as a recreational drug for its euphoric effects. Medically it is used in several
countries to relieve pain or in opioid replacement therapy. Heroin is typically injected,
usually into a vein; however, it can also be smoked, snorted or inhaled. Onset of effects
is usually rapid and lasts for a few hours.
Common side effects include respiratory depression (decreased breathing), dry
mouth, euphoria, and addiction. Other side effects can include abscesses, infected
heart valves, blood borne infections, constipation, and pneumonia. After a history of
long-term use, withdrawal symptoms can begin within hours of last use. When given by
injection into a vein, heroin has two to three times the effect as a similar dose
of morphine. It typically comes as a white or brown powder.
Treatment of heroin addiction often includes behavioral therapy and
medications. Medications can include buprenorphine, methadone, or naltrexone. A
heroin overdose may be treated with naloxone. An estimated 17 million people as of
2015 use opiates such as heroin, which together with opioids resulted in 122,000
deaths. The total number of opiate users has increased from 1998 to 2007 after which it
has remained more or less stable. In the United States about 1.6 percent of people
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have used heroin at some point in time. When people die from overdosing on a drug,
the drug is usually an opioid.
Heroin was first made by C. R. Alder Wright in
1874 from morphine, a natural product of
the opium poppy. Internationally, heroin is
controlled under Schedules I and IV of
the Single Convention on Narcotic Drugs. It is
generally illegal to make, possess, or sell
heroin without a license. In
2015 Afghanistan produced about 66% of the
world's opium. Often heroin, which is illegally
sold, is mixed with other substances such as
sugar or strychnine.
Uses
Recreational
The original trade name of heroin is typically
used in non-medical settings. It is used as a
recreational drug for the euphoria it
induces. Anthropologist Michael Agar once
described heroin as "the perfect whatever
drug." Tolerance develops quickly, and
increased doses are needed in order to
achieve the same effects. Its popularity with recreational drug users, compared
to morphine, reportedly stems from its perceived different effects. In particular, users
report an intense rush, an acute transcendent state of euphoria, which occurs while
diamorphine is being metabolized into 6-monoacetylmorphine (6-MAM) and morphine in
the brain. Some believe that heroin produces more euphoria than other opioids; one
possible explanation is the presence of 6-monoacetylmorphine, a metabolite unique to
heroin – although a more likely explanation is the rapidity of onset. While other opioids
of recreational use produce only morphine, heroin also leaves 6-MAM, also a psychoactive
metabolite. However, this perception is not supported by the results of clinical
studies comparing the physiological and subjective effects of injected heroin and
morphine in individuals formerly addicted to opioids; these subjects showed no
preference for one drug over the other. Equipotent injected doses had comparable
action courses, with no difference in subjects' self-rated feelings of euphoria, ambition,
nervousness, relaxation, drowsiness, or sleepiness.
Short-term addiction studies by the same researchers demonstrated that tolerance
developed at a similar rate to both heroin and morphine. When compared to the
opioids hydromorphone, fentanyl, oxycodone, and pethidine(meperidine), former addicts
showed a strong preference for heroin and morphine, suggesting that heroin and
morphine are particularly susceptible to abuse and addiction. Morphine and heroin were
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also much more likely to produce euphoria and other positive subjective effects when
compared to these other opioids.
Some researchers have attempted to explain
heroin use and the culture that surrounds it
through the use of sociological theories.
In Righteous Dopefiend, Philippe Bourgois
and Jeff Schonberg use anomie theory to
explain why people begin using heroin. By
analyzing a community in San Francisco, they
demonstrated that heroin use was caused in
part by internal and external factors such as
violent homes and parental neglect. This lack
of emotional, social, and financial support
causes strain and influences individuals to
engage in deviant acts, including heroin
usage. They further found that heroin users
practiced "retreatism", a behavior first
described by Howard Abadinsky, in which
those suffering from such strain reject
society's goals and institutionalized means of
achieving them.
Medical Uses
medically useful.
In the United States heroin is not accepted as
Under the generic name diamorphine, heroin is prescribed as a strong pain
medication in the United Kingdom, where it is given
via subcutaneous, intramuscular, intrathecal or intravenously. Its use includes treatment
for acute pain, such as in severe physical trauma, myocardial infarction, postsurgical
pain, and chronic pain, including end-stage cancer and other terminal illnesses.
In other countries it is more common to use morphine or other strong opioids in these
situations. In 2004 the National Institute for Health and Clinical Excellence produced
guidance on the management of caesarian section, which recommended the use
of intrathecal or epidural diamorphine for post-operative pain relief.
Diamorphine continues to be widely used in palliative care in the UK, where it is
commonly given by the subcutaneous route, often via a syringe driver, if patients cannot
easily swallow morphine solution. The advantage of diamorphine over morphine is that
diamorphine is more fat soluble and therefore more potent by injection, so smaller
doses of it are needed for the same effect on pain. Both of these factors are
advantageous if giving high doses of opioids via the subcutaneous route, which is often
necessary in palliative care.
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Maintenance Therapy
A number of European countries including the United Kingdom allow the prescribing of
heroin for heroin addiction.
Diamorphine is also used as a maintenance drug to assist the treatment of opiate
addiction, normally in long-term chronic intravenous (IV) heroin users. It is only
prescribed following exhaustive efforts at treatment via other means. It is sometimes
thought that heroin users can walk into a clinic and walk out with a prescription, but the
process takes many weeks before a prescription for diamorphine is issued. Though this
is somewhat controversial among proponents of a zero-tolerance drug policy, it has
proven superior to methadone in improving the social and health situations of addicts.
The UK Department of Health's Rolleston Committee Report in 1926 established the
British approach to diamorphine prescription to users, which was maintained for the
next 40 years: dealers were prosecuted, but doctors could prescribe diamorphine to
users when withdrawing from it would cause harm or severe distress to the patient. This
"policing and prescribing" policy effectively controlled the perceived diamorphine
problem in the UK until 1959 when the number of diamorphine addicts doubled every 16
months during the ten years from 1959 to 1968. In 1964 the Brain
Committee recommended that only selected approved doctors working at approved
specialised centres be allowed to prescribe diamorphine and benzoylmethylecgonine
(cocaine) to users. The law was made more restrictive in 1968. Beginning in the 1970s,
the emphasis shifted to abstinence and the use of methadone; currently only a small
number of users in the UK are prescribed diamorphine.
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In 1994, Switzerland began a trial diamorphine maintenance program for users that had
failed multiple withdrawal programs. The aim of this program was to maintain the health
of the user by avoiding medical problems stemming from the illicit use of diamorphine.
The first trial in 1994 involved 340 users, although enrollment was later expanded to
1000, based on the apparent success of the program.
The trials proved diamorphine maintenance to be superior to other forms of treatment in
improving the social and health situation for this group of patients. It has also been
shown to save money, despite high treatment expenses, as it significantly reduces costs
incurred by trials, incarceration, health interventions and delinquency. Patients appear
twice daily at a treatment center, where they inject their dose of diamorphine under the
supervision of medical staff. They are required to contribute about 450 Swiss francs per
month to the treatment costs. A national referendum in November 2008 showed 68% of
voters supported the plan, introducing diamorphine prescription into federal law. The
previous trials were based on time-limited executive ordinances. The success of the
Swiss trials led German, Dutch, and Canadian cities to try out their own diamorphine
prescription programs. Some Australian cities (such as Sydney) have instituted legal
diamorphine supervised injecting centers, in line with other wider harm
minimization programs.
Since January 2009, Denmark has prescribed diamorphine to a few addicts that have
tried methadone and subutex without success. Beginning in February 2010, addicts
in Copenhagen and Odense became eligible to receive free diamorphine. Later in 2010
other cities including Århus and Esbjerg joined the scheme. It was supposed that
around 230 addicts would be able to receive free diamorphine. However, Danish addicts
would only be able to inject heroin according to the policy set by Danish National Board
of Health. Of the estimated 1500 drug users who did not benefit from the then-current
oral substitution treatment, approximately 900 would not be in the target group for
treatment with injectable diamorphine, either because of "massive multiple drug abuse
of non-opioids" or "not wanting treatment with injectable diamorphine".
In July 2009, the German Bundestag passed a law allowing diamorphine prescription as
a standard treatment for addicts; a large-scale trial of diamorphine prescription had
been authorized in that country in 2002.
On August 26, 2016 Health Canada issued regulations amending prior regulations it
had issued under the Controlled Drugs and Substances Act; the "New Classes of
Practitioners Regulations", the "Narcotic Control Regulations", and the "Food and Drug
Regulations", to allow doctors to prescribe diamorphine to people who have a severe
opioid addiction who have not responded to other treatments. The prescription heroin
can be accessed by doctors through Health Canada's Special Access Programme
(SAP) for "emergency access to drugs for patients with serious or life-threatening
conditions when conventional treatments have failed, are unsuitable, or are
unavailable."
Routes of Administration
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The onset of heroin's effects depends upon the route of administration. Studies have
shown that the subjective pleasure of drug use (the reinforcing component of addiction)
is proportional to the rate at which the blood level of the drug increases. Intravenous
injection is the fastest route of drug administration, causing blood concentrations to rise
the most quickly, followed by smoking, suppository (anal or vaginal
insertion), insufflation (snorting), and ingestion (swallowing).
Ingestion does not produce a rush as forerunner to the high experienced with the use of
heroin, which is most pronounced with intravenous use. While the onset of the rush
induced by injection can occur in as little as a few seconds, the oral route of
administration requires approximately half an hour before the high sets in. Thus, with
both higher the dosage of heroin used and faster the route of administration used, the
higher potential risk for psychological addiction.
Large doses of heroin can cause fatal respiratory depression, and the drug has been
used for suicide or as a murder weapon. The serial killer Harold Shipman used
diamorphine on his victims, and the subsequent Shipman Inquiry led to a tightening of
the regulations surrounding the storage, prescribing and destruction of controlled drugs
in the UK. John Bodkin Adams is also known to have used heroin as a murder weapon.
Because significant tolerance to respiratory depression develops quickly with continued
use and is lost just as quickly during withdrawal, it is often difficult to determine whether
a heroin lethal overdose was accidental, suicide or homicide. Examples include the
overdose deaths of Sid Vicious, Janis Joplin, Tim Buckley, Hillel Slovak, Layne
Staley, Bradley Nowell, Ted Binion, and River Phoenix.
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Chronic use of heroin and other opioids has been shown to be a potential cause
of hyponatremia, resultant because of excess vasopressin secretion.
Oral
Oral use of heroin is less common than other methods of administration, mainly
because there is little to no "rush", and the effects are less potent. Heroin is entirely
converted to morphine by means of first-pass metabolism, resulting
in deacetylation when ingested. Heroin's oral bioavailability is both dose-dependent (as
is morphine's) and significantly higher than oral use of morphine itself, reaching up to
64.2% for high doses and 45.6% for low doses; opiate-naive users showed far less
absorption of the drug at low doses, having bioavailabilities of only up to 22.9%. The
maximum plasma concentration of morphine following oral administration of heroin was
around twice as much as that of oral morphine.
Injection
Injection, also known as "slamming", "banging", "shooting up", "digging" or "mainlining",
is a popular method which carries relatively greater risks than other methods of
administration. Heroin base (commonly found in Europe), when prepared for injection,
will only dissolve in water when mixed with an acid (most commonly citric acid powder
or lemon juice) and heated. Heroin in the east-coast United States is most commonly
found in the hydrochloride salt form, requiring just water (and no heat) to dissolve.
Users tend to initially inject in the easily accessible arm veins, but as these veins
collapse over time, users resort to more dangerous areas of the body, such as
the femoral vein in the groin. Users who have used this route of administration often
develop a deep vein thrombosis. Intravenous users can use a various single dose range
using a hypodermic needle. The dose of heroin used for recreational purposes is
dependent on the frequency and level of use: thus a first-time user may use between 5
and 20 mg, while an established addict may require several hundred mg per day. As
with the injection of any drug, if a group of users share a common needle without
sterilization procedures, blood-borne diseases, such as HIV/AIDS or hepatitis, can be
transmitted. The use of a common dispenser for water for the use in the preparation of
the injection, as well as the sharing of spoons and/or filters can also cause the spread of
blood-borne diseases. Many countries now supply small sterile spoons and filters for
single use in order to prevent the spread of disease.
Smoking
Smoking heroin refers to vaporizing it to inhale the resulting fumes, not burning it to
inhale the resulting smoke. It is commonly smoked in glass pipes made
from glassblown Pyrex tubes and light bulbs. It can also be smoked off aluminium foil,
which is heated underneath by a flame and the resulting smoke is inhaled through a
tube of rolled up foil. This method is also known as "chasing the dragon".
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Insufflation
Another popular route to intake heroin is insufflation (snorting), where a user crushes
the heroin into a fine powder and then gently inhales it (sometimes with a straw or a
rolled-up banknote, as with cocaine) into the nose, where heroin is absorbed through
the soft tissue in the mucous membrane of the sinus cavity and straight into the
bloodstream. This method of administration redirects first-pass metabolism, with a
quicker onset and higher bioavailability than oral administration, though the duration of
action is shortened. This method is sometimes preferred by users who do not want to
prepare and administer heroin for injection or smoking, but still experience a fast onset.
Snorting heroin becomes an often unwanted route, once a user begins to inject the
drug. The user may still get high on the drug from snorting, and experience a nod, but
will not get a rush. A "rush" is caused by a large amount of heroin entering the body at
once. When the drug is taken in through the nose, the user does not get the rush
because the drug is absorbed slowly rather than instantly.
Suppository
Little research has been focused on the suppository (anal insertion) or pessary (vaginal
insertion) methods of administration, also known as "plugging". These methods of
administration are commonly carried out using an oral syringe. Heroin can be dissolved
and withdrawn into an oral syringe which may then be lubricated and inserted into the
anus or vagina before the plunger is pushed. The rectum or the vaginal canal is where
the majority of the drug would likely be taken up, through the membranes lining their
walls.
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Adverse Effects
Two Types of Heroin
Like most opioids, unadulterated heroin does not cause many long-term complications
other than dependence and constipation. The purity of street heroin varies greatly. This
variation has led to individuals inadvertently experiencing overdoses when the purity of
the drug was higher than they expected. Intravenous use of heroin (and any other
substance) with needles and syringes or other related equipment may lead to:
Contracting blood-borne pathogens such as HIV and hepatitis via the sharing of
needles
Contracting bacterial or fungal endocarditis and possibly venous sclerosis
Abscesses
Poisoning from contaminants added to "cut" or dilute heroin
Decreased kidney function (nephropathy), although it is not currently known if
this is because of adulterants or infectious diseases
Many countries and local governments have begun funding programs that
supply sterile needles to people who inject illegal drugs in an attempt to reduce these
contingent risks, and especially the spread of blood-borne diseases. The Drug Policy
Alliance reports that up to 75% of new AIDS cases among women and children are
directly or indirectly a consequence of drug use by injection. The United States federal
government does not operate needle exchanges, although some state and local
governments do support such programs.
Anthropologists Philippe Bourgois and Jeff Schonberg performed a decade of fieldwork
among homeless heroin and cocaine addicts in San Francisco, published in 2009. They
reported that the African-American addicts they observed were more inclined to "direct
deposit" heroin into a vein, while "skin-popping" was a far more widespread practice:
"By the midpoint of our fieldwork, most of the whites had given up searching for
operable veins and skin-popped. They sank their needles perfunctorily, often through
their clothing, into their fatty tissue." Bourgois and Schonberg describes how the cultural
difference between the African-Americans and the whites leads to this contrasting
behavior, and also points out that the two different ways to inject heroin comes with
different health risks. Skin-popping more often results in abscesses, and direct injection
more often leads to fatal overdose and also to hepatitis C and HIV infection.
A small percentage of heroin smokers, and occasionally IV users, may develop
symptoms of toxic leukoencephalopathy. The cause has yet to be identified, but one
speculation is that the disorder is caused by an uncommon adulterant that is only active
when heated. Symptoms include slurred speech and difficulty walking.
Cocaine is sometimes used in combination with heroin, and is referred to as
a speedball when injected or moonrocks when smoked together. Cocaine acts as
a stimulant, whereas heroin acts as a depressant. Coadministration provides an intense
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ush of euphoria with a high that combines both effects of the drugs, while excluding the
negative effects, such as anxiety and sedation. The effects of cocaine wear off far more
quickly than heroin, so if an overdose of heroin was used to compensate for cocaine,
the end result is fatal respiratory depression.
Withdrawal
The withdrawal syndrome from heroin (the so-called "cold turkey") may begin within 6–
24 hours of discontinuation of the drug; however, this time frame can fluctuate with the
degree of tolerance as well as the amount of the last consumed dose. Symptoms may
include: sweating, malaise, anxiety, depression, akathisia, priapism, extra sensitivity of
the genitals in females, general feeling of heaviness,
excessive yawning or sneezing, tears, rhinorrhea, sleep difficulties (insomnia), cold
sweats, chills, severe muscle and bone aches, nausea, vomiting, diarrhea, cramps,
watery eyes, fever and cramp-like pains and involuntary spasms in the limbs (thought to
be an origin of the term "kicking the habit").
Overdose
Heroin overdose is usually treated with an opioid antagonist, such
as naloxone (Narcan). This reverses the effects of heroin and other opioids and causes
an immediate return of consciousness but may result in withdrawal symptoms. The half-
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life of naloxone is shorter than most opioids, so that it has to be administered multiple
times until the opioid has been metabolized by the body.
Depending on drug interactions and numerous other factors, death from overdose can
take anywhere from several minutes to several hours. Death usually occurs due to lack
of oxygen resulting from the lack of breathing caused by the opioid. Heroin overdoses
can occur because of an unexpected increase in the dose or purity or because of
diminished opioid tolerance. However, many fatalities reported as overdoses are
probably caused by interactions with other depressant drugs such as alcohol
or benzodiazepines. It should also be noted that since heroin can cause nausea and
vomiting, a significant number of deaths attributed to heroin overdose are caused by
aspiration of vomit by an unconscious person. Some sources quote the median lethal
dose (for an average 75 kg opiate-naive individual) as being between 75 and 600
mg. Illicit heroin is of widely varying and unpredictable purity. This means that the user
may prepare what they consider to be a moderate dose while actually taking far more
than intended. Also, tolerance typically decreases after a period of abstinence. If this
occurs and the user takes a dose comparable to their previous use, the user may
experience drug effects that are much greater than expected, potentially resulting in an
overdose. It has been speculated that an unknown portion of heroin-related deaths are
the result of an overdose or allergic reaction to quinine, which may sometimes be used
as a cutting agent.
Pharmacology
When taken orally, heroin undergoes extensive first-pass metabolism via deacetylation,
making it a prodrug for the systemic delivery of morphine. When the drug is injected,
however, it avoids this first-pass effect, very rapidly crossing the blood–brain
barrier because of the presence of the acetyl groups, which render it much more fat
soluble than morphine itself. Once in the brain, it then is deacetylated variously into the
inactive 3-monoacetylmorphine and the active 6-monoacetylmorphine (6-MAM), and
then to morphine, which bind to μ-opioid receptors, resulting in the drug's
euphoric, analgesic (pain relief), and anxiolytic (anti-anxiety) effects; heroin itself
exhibits relatively low affinity for the μ
receptor. Unlike hydromorphone and oxymorphone, however, administered
intravenously, heroin creates a larger histamine release, similar to morphine, resulting in
the feeling of a greater subjective "body high" to some, but also instances
of pruritus (itching) when they first start using.
Both morphine and 6-MAM are μ-opioid agonists that bind to receptors present
throughout the brain, spinal cord, and gut of all mammals. The μ-opioid receptor also
binds endogenous opioid peptides such as β-endorphin, Leu-enkephalin, and Metenkephalin.
Repeated use of heroin results in a number of physiological changes,
including an increase in the production of μ-opioid receptors (upregulation). These
physiological alterations lead to tolerance and dependence, so that stopping heroin use
results in uncomfortable symptoms including pain, anxiety, muscle spasms, and
insomnia called the opioid withdrawal syndrome. Depending on usage it has an onset
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4–24 hours after the last dose of heroin. Morphine also binds to δ- and κ-opioid
receptors.
There is also evidence that 6-MAM binds to a subtype of μ-opioid receptors that are
also activated by the morphine metabolite morphine-6β-glucuronide but not morphine
itself. The third subtype of third opioid type is the mu-3 receptor, which may be a
commonality to other six-position monoesters of morphine. The contribution of these
receptors to the overall pharmacology of heroin remains unknown.
A subclass of morphine derivatives, namely the 3,6 esters of morphine, with similar
effects and uses, includes the clinically used strong analgesics nicomorphine (Vilan),
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and dipropanoylmorphine; there is also the
latter's dihydromorphine analogue, diacetyldihydromorphine (Paralaudin). Two other 3,6
diesters of morphine invented in 1874–75 along with
diamorphine, dibenzoylmorphine and acetylpropionylmorphine, were made as
substitutes after it was outlawed in 1925 and, therefore, sold as the first "designer
drugs" until they were outlawed by the League of Nations in 1930.
Chemistry
Heroin is derived from opium through a process involving various chemicals such
as acetone and acetic anhydride.
Detection in Body Fluids
The major metabolites of diamorphine, 6-MAM, morphine, morphine-3-glucuronide and
morphine-6-glucuronide, may be quantitated in blood, plasma or urine to monitor for
abuse, confirm a diagnosis of poisoning or assist in a medicolegal death investigation.
Most commercial opiate screening tests cross-react appreciably with these metabolites,
as well as with other biotransformation products likely to be present following usage of
street-grade diamorphine such as 6-acetylcodeine and codeine. However,
chromatographic techniques can easily distinguish and measure each of these
substances. When interpreting the results of a test, it is important to consider the
diamorphine usage history of the individual, since a chronic user can develop tolerance
to doses that would incapacitate an opiate-naive individual, and the chronic user often
has high baseline values of these metabolites in his system. Furthermore, some testing
procedures employ a hydrolysis step before quantitation that converts many of the
metabolic products to morphine, yielding a result that may be 2 times larger than with a
method that examines each product individually.
History
The opium poppy was cultivated in lower Mesopotamia as long ago as 3400 BCE. The
chemical analysis of opium in the 19th century revealed that most of its activity could be
ascribed to two alkaloids, codeine and morphine.
Diamorphine was first synthesized in 1874 by C. R. Alder Wright, an English chemist
working at St. Mary's Hospital Medical School in London. He had been experimenting
with combining morphine with various acids. He boiled anhydrous morphine alkaloid
with acetic anhydride for several hours and produced a more potent, acetylated form of
morphine, now called diacetylmorphine or morphine diacetate. The compound was sent
to F. M. Pierce of Owens College in Manchester for analysis.
Pierce told Wright:
Doses ... were subcutaneously injected into young dogs and rabbits ... with the following
general results ... great prostration, fear, and sleepiness speedily following the
administration, the eyes being sensitive, and pupils constrict,
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considerable salivation being produced in dogs, and slight tendency to vomiting in some
cases, but no actual emesis. Respiration was at first quickened, but subsequently
reduced, and the heart's action was diminished, and rendered irregular. Marked want of
coordinating power over the muscular movements, and loss of power in the pelvis and
hind limbs, together with a diminution of temperature in the rectum of about 4°.
Wright's invention did not lead to any further developments, and diamorphine became
popular only after it was independently re-synthesized 23 years later by another
chemist, Felix Hoffmann. Hoffmann, working at Bayer pharmaceutical company
in Elberfeld, Germany, was instructed by his supervisor Heinrich Dreser to acetylate
morphine with the objective of producing codeine, a constituent of the opium poppy,
pharmacologically similar to morphine but less potent and less addictive. Instead, the
experiment produced an acetylated form of morphine one and a half to two times more
potent than morphine itself. The head of Bayer's research department reputedly coined
the drug's new name, "heroin," based on the German heroisch, which means "heroic,
strong" (from the ancient Greek word "heros, ήρως"). Bayer scientists were not the first
to make heroin, but their scientists discovered ways to make it, and Bayer led
commercialization of heroin.
In 1895, the German drug company Bayer marketed
diacetylmorphine as an over-the-counter drug under the
trademark name Heroin. It was developed chiefly as
a morphine substitute for cough suppressants that did not have
morphine's addictive side-effects. Morphine at the time was a
popular recreational drug, and Bayer wished to find a similar
but non-addictive substitute to market. However, contrary to
Bayer's advertising as a "non-addictive morphine substitute,"
heroin would soon have one of the highest rates
of addiction among its users.
From 1898 through to 1910, diamorphine was marketed under
the trademark name Heroin as a non-addictive morphine
substitute and cough suppressant. In the 11th edition of
Encyclopædia Britannica (1910), the article on morphine
states: "In the cough of phthisis minute doses [of morphine]
are of service, but in this particular disease morphine is
frequently better replaced by codeine or by heroin, which
checks irritable coughs without the narcotism following upon
the administration of morphine."
In the U.S., the Harrison Narcotics Tax Act was passed in 1914
to control the sale and distribution of diacetylmorphine and other opioids, which allowed
the drug to be prescribed and sold for medical purposes. In 1924, the United States
Congress banned its sale, importation, or manufacture. It is now a Schedule I
substance, which makes it illegal for non-medical use in signatory nations of the Single
Convention on Narcotic Drugs treaty, including the United States.
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The Health Committee of the League of Nations banned diacetylmorphine in 1925,
although it took more than three years for this to be implemented. In the meantime, the
first designer drugs, viz. 3,6 diesters and 6 monoesters of morphine and acetylated
analogues of closely related drugs like hydromorphone and dihydromorphine, were
produced in massive quantities to fill the worldwide demand for diacetylmorphine—this
continued until 1930 when the Committee banned diacetylmorphine analogues with no
therapeutic advantage over drugs already in use, the first major legislation of this type.
Bayer lost some of its trademark rights to heroin under the 1919 Treaty of
Versailles following the German defeat in World War I.
Use of heroin by jazz musicians in particular was prevalent in the mid-twentieth century,
including Billie Holiday, sax legends Charlie Parker and Art Pepper, guitarist Joe
Pass and piano player/singer Ray Charles; a "staggering number of jazz musicians
were addicts".It was also a problem with many rock musicians, particularly from the late
1960s through the 1990s. Pete Doherty is also a self-confessed user of
heroin. Nirvana lead singer Kurt Cobain's heroin addiction was well
documented. Pantera frontman, Phil Anselmo, turned to heroin while touring during the
1990s to cope with his back pain. Many musicians have made songs referencing their
heroin usage.
Names
Society and Culture
"Diamorphine" is the Recommended International Nonproprietary Name and British
Approved Name. [1][87] Other synonyms for heroin include: diacetylmorphine, and
morphine diacetate. Heroin is also known by many street names including dope, H,
smack, junk, horse, and brown, among others.
Asia
Legal Status
In Hong Kong, diamorphine is regulated under Schedule 1 of Hong Kong's Chapter
134 Dangerous Drugs Ordinance. It is available by prescription. Anyone supplying
diamorphine without a valid prescription can be fined $10,000 (HKD). The penalty for
trafficking or manufacturing diamorphine is a $50,000 (HKD) fine and life imprisonment.
Possession of diamorphine without a license from the Department of Health is illegal
with a $10,000 (HKD) fine and/or 7 years of jail time.
Europe
In the Netherlands, diamorphine is a List I drug of the Opium Law. It is available for
prescription under tight regulation exclusively to long-term addicts for whom methadone
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maintenance treatment has failed. It cannot be used to treat severe pain or other
illnesses.
In the United Kingdom, diamorphine is available by prescription, though it is a
restricted Class A drug. According to the 50th edition of the British National
Formulary (BNF), diamorphine hydrochloride may be used in the treatment of acute
pain, myocardial infarction, acute pulmonary oedema, and chronic pain. The treatment
of chronic non-malignant pain must be supervised by a specialist. The BNF notes that
all opioid analgesics cause dependence and tolerance but that this is "no deterrent in
the control of pain in terminal illness". When used in the palliative care of cancer
patients, diamorphine is often injected using a syringe driver.
It is controlled in the UK by the Misuse of Drugs Act 1971. In the UK it is a class
A controlled drug and as such is subject to guidelines surrounding its storage,
administration and destruction. Possession of diamorphine without a prescription is an
arrestable offence. When diamorphine is prescribed in a hospital or similar environment,
its administration must be supervised by two people who must then complete and sign a
controlled drugs register (CD register) detailing the patient's name, amount, time, date
and route of administration. In the case of a physician administering diamorphine, then
he/she may administer the drug alone, however the rule requiring two registered
practitioners, such as a nurse, midwife or another physician to sign the CD register still
applies. The use of a witness when administering diamorphine is to avoid the possibility
of the drug being diverted onto the black market.
For safety reasons, many UK National Health Service hospitals only permit the
administration of intravenous diamorphine in designated areas. In practice this usually
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means a critical care unit, an accident and emergency department, operating
theatres by an anaesthetistor nurse anaesthetist or other such areas where close
monitoring and support from senior staff is immediately available. However,
administration by other routes is permitted in other areas of the hospital. This includes
subcutaneous, intramuscular, intravenously as part of a patient controlled
analgesia setup, and as an already established epidural infusion pump. Subcutaneous
infusion, along with subcutaneous and intramuscular injection (bolus administration), is
often used in the patient's own home, in order to treat severe pain in terminal illness.
Australia
In Australia diamorphine is listed as a schedule 9 prohibited substance under
the Poisons Standard (October 2015). A schedule 9 drug is outlined in the Poisons Act
1964 as "Substances which may be abused or misused, the manufacture, possession,
sale or use of which should be prohibited by law except when required for medical or
scientific research, or for analytical, teaching or training purposes with approval of the
CEO."
North America
In Canada, diamorphine is a controlled substance under Schedule I of the Controlled
Drugs and Substances Act (CDSA). Any person seeking or obtaining diamorphine
without disclosing authorization 30 days before obtaining another prescription from a
practitioner is guilty of an indictable offense and subject to imprisonment for a term not
exceeding seven years. Possession of diamorphine for the purpose of trafficking is an
indictable offense and subject to imprisonment for life.
In the United States, diamorphine is a Schedule I drug according to the Controlled
Substances Act of 1970, making it illegal to possess without a DEA license. Possession
of more than 100 grams of diamorphine or a mixture containing diamorphine is
punishable with a minimum mandatory sentence of 5 years of imprisonment in a federal
prison.
Abuse of Prescription Medication
Abused prescription medicine such as opioid can lead to heroin addiction. The number
of death from illegal opioid overdose follows the increasing number of death caused by
prescription opioid overdoses. Prescription opioids are relatively easy to obtain. This
may ultimately leads to heroin injection because heroin is cheaper than prescribed pills.
Production
Economics
Diamorphine is produced from acetylation of morphine derived from natural opium
sources. Numerous mechanical and chemical means are used to purify the final
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product. The final products have a different appearance depending on purity and have
different names.
Heroin Grades
Heroin purity has been classified into four grades. No.4 is the purest form – white
powder (salt) to be easily dissolved and injected. No.3 is "brown sugar" for smoking
(base). No.1 and No.2 are unprocessed raw heroin (salt or base).
Trafficking and Production
Traffic is heavy worldwide, with the biggest producer being Afghanistan. According to a
U.N. sponsored survey, in 2004, Afghanistan accounted for production of 87 percent of
the world's diamorphine. Afghan opium kills around 100,000 people annually.
In 2003 The Independent reported:
... The cultivation of opium [in Afghanistan] reached its peak in 1999, when 350 square
miles (910 km 2 ) of poppies were sown ... The following year the Taliban banned poppy
cultivation, ... a move which cut production by 94 percent ... By 2001 only 30 square
miles (78 km 2 ) of land were in use for growing opium poppies. A year later, after
American and British troops had removed the Taliban and installed the interim
government, the land under cultivation leapt back to 285 square miles (740 km 2 ), with
Afghanistan supplanting Burma to become the world's largest opium producer once
more.
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Opium production in that country has increased rapidly since, reaching an all-time high
in 2006. War in Afghanistan once again appeared as a facilitator of the trade. Some 3.3
million Afghans are involved in producing opium.
At present, opium poppies are mostly grown in Afghanistan (224,000 hectares (550,000
acres)), and in Southeast Asia, especially in the region known as the Golden
Triangle straddling Burma (57,600 hectares (142,000
acres)), Thailand, Vietnam, Laos (6,200 hectares (15,000 acres)) and Yunnan province
in China.
There is also cultivation of opium poppies in Pakistan (493 hectares (1,220 acres)),
Mexico (12,000 hectares (30,000 acres)) and in Colombia (378 hectares (930
acres)). According to the DEA, the majority of the heroin consumed in the United States
comes from Mexico (50%) and Colombia (43-45%) via Mexican criminal cartels such
as Sinaloa Cartel. However, these statistics may be significantly unreliable, the DEA's
50/50 split between Colombia and Mexico is contradicted by the amount of hectares
cultivated in each country and in 2014, the DEA claimed most of the heroin in the US
came from Colombia. As of 2015, the Sinaloa Cartel is the most active drug
cartel involved in smuggling illicit drugs such as heroin into the United States and
trafficking them throughout the United States. According to the Royal Canadian
Mounted Police, 90% of the heroin seized in Canada (where the origin was known)
came from Afghanistan. Pakistan is the destination and transit point for 40 percent of
the opiates produced in Afghanistan, other destinations of Afghan opiates are Russia,
Europe and Iran
Conviction for trafficking heroin carries the death penalty in most Southeast Asian,
some East Asian and Middle Eastern countries (see Use of death penalty worldwide for
details), among which Malaysia, Singapore and Thailand are the most strict. The
penalty applies even to citizens of countries where the penalty is not in place,
sometimes causing controversy when foreign visitors are arrested for trafficking, for
example the arrest of nine Australians in Bali, the death sentence given to Nola Blake in
Thailand in 1987, or the hanging of an Australian citizen Van Tuong Nguyen in
Singapore.
Trafficking history
The origins of the present international illegal heroin trade can be traced back to laws
passed in many countries in the early 1900s that closely regulated the production and
sale of opium and its derivatives including heroin. At first, heroin flowed from countries
where it was still legal into countries where it was no longer legal. By the mid-1920s,
heroin production had been made illegal in many parts of the world. An illegal trade
developed at that time between heroin labs in China (mostly in Shanghai and Tianjin)
and other nations. The weakness of government in China and conditions of civil war
enabled heroin production to take root there. Chinese triad gangs eventually came to
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play a major role in the illicit heroin trade. The French Connection route started in the
1930s.
Heroin trafficking was virtually eliminated in the U.S. during World War II because of
temporary trade disruptions caused by the war. Japan's war with China had cut the
normal distribution routes for heroin and the war had generally disrupted the movement
of opium. After World War II, the Mafia took advantage of the weakness of the postwar
Italian government and set up heroin labs in Sicily. The Mafia took advantage of Sicily's
location along the historic route opium took westward into Europe and the United
States. Large-scale international heroin production effectively ended in China with the
victory of the communists in the civil war in the late 1940s. The elimination of Chinese
production happened at the same time that Sicily's role in the trade developed.
Although it remained legal in some countries until after World War II, health risks,
addiction, and widespread recreational use led most western countries to declare heroin
a controlled substance by the latter half of the 20th century. In the late 1960s and early
1970s, the CIA supported anti-Communist Chinese Nationalists settled near the Sino-
Burmese border and Hmong tribesmen in Laos. This helped the development of
the Golden Triangle opium production region, which supplied about one-third of heroin
consumed in US after the 1973 American withdrawal from Vietnam. In 1999, Burma, the
heartland of the Golden Triangle, was the second largest producer of heroin,
after Afghanistan.
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The Soviet-Afghan war led to increased production in the Pakistani-Afghan border
regions, as U.S.-backed mujaheddin militants raised money for arms from selling opium,
contributing heavily to the modern Golden Crescent creation. By 1980, 60 percent of
heroin sold in the U.S. originated in Afghanistan. It increased international production of
heroin at lower prices in the 1980s. The trade shifted away from Sicily in the late 1970s
as various criminal organizations violently fought with each other over the trade. The
fighting also led to a stepped-up government law enforcement presence in Sicily.
Following the discovery at a Jordanian airport of a toner cartridge that had been
modified into an improvised explosive device, the resultant increased level of airfreight
scrutiny led to a major shortage (drought) of heroin from October 2010 until April 2011.
This was reported in most of mainland Europe and the UK which led to a price increase
of approximately 30 percent in the cost of street heroin and an increased demand for
diverted methadone. The number of addicts seeking treatment also increased
significantly during this period. Other heroin droughts (shortages) have been attributed
to cartels restricting supply in order to force a price increase and also to a fungus that
attacked the opium crop of 2009. Many people thought that the American government
had introduced pathogens into the Afghanistan atmosphere in order to destroy the
opium crop and thus starve insurgents of income.
On 13 March 2012, Haji Bagcho, with ties to the Taliban, was convicted by a U.S.
District Court of conspiracy, distribution of heroin for importation into the United States
and narco-terrorism. Based on heroin production statistics compiled by the United
Nations Office on Drugs and Crime, in 2006, Bagcho's activities accounted for
approximately 20 percent of the world's total production for that year.
Street Price
The European Monitoring Centre for Drugs and Drug Addiction reports that the retail
price of brown heroin varies from €14.5 per gram in Turkey to €110 per gram in
Sweden, with most European countries reporting typical prices of €35–40 per gram. The
price of white heroin is reported only by a few European countries and ranged between
€27 and €110 per gram.
The United Nations Office on Drugs and Crime claims in its 2008 World Drug Report
that typical US retail prices are US$172 per gram.
Harm Reduction
Harm reduction is a public health philosophy that seeks to reduce the harms associated
with the use of diamorphine. One aspect of harm reduction initiatives focuses on the
behaviour of individual users. This includes promoting safer means of taking the drug,
such as smoking, nasal use, oral or rectal insertion. This attempts to avoid the higher
risks of overdose, infections and blood-borne viruses associated with injecting the drug.
Other measures include using a small amount of the drug first to gauge the strength,
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and minimize the risks of overdose. For the same reason, poly drug use (the use of two
or more drugs at the same time) is discouraged. Injecting diamorphine users are
encouraged to use new needles, syringes, spoons/steri-cups and filters every time they
inject and not share these with other users. Users are also encouraged to not use it on
their own, as others can assist in the event of an overdose.
Governments that support a harm reduction approach usually fund needle and syringe
exchange programs, which supply new needles and syringes on a confidential basis, as
well as education on proper filtering before injection, safer injection techniques, safe
disposal of used injecting gear and other equipment used when preparing diamorphine
for injection may also be supplied including citric acid sachets/vitamin C sachets, stericups,
filters, alcohol pre-injection swabs, sterile water ampules and tourniquets (to stop
use of shoe laces or belts).
Another harm reduction measure employed for example in Europe, Canada and
Australia are safe injection sites where users can inject diamorphine and cocaine under
the supervision of medically trained staff. Safe injection sites are low threshold and
allow social services to approach problem users that would otherwise be hard to
reach. In the UK the Criminal Justice System has a protocol in place that requires that
any individual that is arrested and is suspected of having a substance misuse problem
be offered the chance to enter a treatment program.
This has had the effect of drastically reducing an area's crime rate as individuals
arrested for theft in order to supply the funds for their drugs are no longer in the position
of having to steal to purchase heroin because they have been placed onto
a methadone program, quite often more quickly than would have been possible had
they not been arrested. This aspect of harm reduction is seen as being beneficial to
both the individual and the community at large, who are then protected from the
possible theft of their goods.
During the late 1980s and early 1990s, Swiss authorities ran the ZIPP-AIDS (Zurich
Intervention Pilot Project), handing out free syringes in the officially tolerated drug scene
in Platzspitz park. In 1994, Zurich started a pilot project using prescription heroin in
heroin-assisted treatment (HAT) which allowed users to obtain heroin and inject it under
medical supervision. The HAT program proved to be cost-beneficial to society and
improve patients overall health and social stability and has since been introduced in
multiple European countries.
Research
Researchers are attempting to reproduce the biosynthetic pathway that
produces morphine in genetically engineered yeast. In June 2015 the S-reticuline could
be produced from sugar and R-reticuline could be converted to morphine, but the
intermediate reaction could not be performed.
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Allegations of CIA Drug Trafficking
A number of writers have claimed that the United States Central Intelligence
Agency (CIA) is or has been involved in drug trafficking. Books on the subject that have
received general notice include works by historian Alfred McCoy; English professor and
poet Peter Dale Scott; and journalists Gary Webb, Michael C. Ruppert and Alexander
Cockburn. These claims have led to investigations by the United States government,
including hearings and reports by the United States House of Representatives, Senate,
Department of Justice, and the CIA's Office of the Inspector General. The subject
remains controversial.
Following is a summary of some of the main claims made by geographical area.
Golden Triangle
While the CIA was sponsoring a Secret War in Laos from 1961 to 1975, it was accused
of trafficking in opium (an area known as the Golden Triangle).
In response to accusations by Rolling Stone magazine in 1968, and Alfred W. McCoy in
1972, the CIA made its own internal inquiries of its staff and clients in Laos concerning
the drug trade. It noted that trading in opium was legal in Laos until 1971. Cultural
background was also explored. Opium served the isolated Lao hill tribes as their sole
cash crop. Additionally, it was one of the few medicines available in their primitive living
circumstances. Nevertheless, the CIA had its own internal security agents investigating
any possible commercial exports from mid-1968 onwards. An American single plane
airline was barred from CIA airfields on suspicion of drug smuggling. A guerrilla
commanding officer was pressured into giving up dealing in opium. The CIA's own
conclusion was that small amounts of opium might have been smuggled via their
contract aircraft, given wartime conditions. The Agency's case officers even staged a
couple of impromptu raids on drug refineries, only to be reined in by their Office of
General Counsel
During its involvement, the CIA used the Meo (Hmong) population to fight Pathet
Lao rebels. Because of the war against Pathet Lao rebels, the Hmong depended upon
poppy cultivation for hard currency. The Hmong were very important to CIA operations
and the CIA was very concerned with their well-being. The Plain of Jars had been
captured by Pathet Lao rebels in 1964, which resulted in the Laotian Air Force not being
able to land their C-47 transport aircraft on the Plain of Jars for opium transport. The
Laotian Air Force had almost no light planes that could land on the dirt runways near the
mountaintop poppy fields.
Having no way to transport their opium, the Hmong were faced with economic ruin. Air
America was the only airline available in northern Laos. "According to several unproven
sources, Air America began flying opium from mountain villages north and east of
the Plain of Jars to Gen Vang Pao's headquarters at Long Tieng."
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The CIA's front company, Air America was alleged to have profited from
transporting opium and heroin on behalf of Hmong leader Vang Pao, or of "turning a
blind eye" to the Laotian military doing it. This allegation has been supported by former
Laos CIA paramilitary Anthony Poshepny (aka Tony Poe), former Air America pilots,
and other people involved in the war.
It is portrayed in the movie Air America. However, University of
Georgia historian William M. Leary, writing on behalf of Air America, claims that this was
done without the airline employees' direct knowledge and that the airline did not trade in
drugs. Curtis Peebles denies the allegation, citing
Leary's Study as Evidence
Historian Alfred W. McCoy stated that:
In most cases, the CIA's role involved various forms of complicity, tolerance or studied
ignorance about the trade, not any direct culpability in the actual trafficking ... [t]he CIA
did not handle heroin, but it did provide its drug lord allies with transport, arms, and
political protection. In sum, the CIA's role in the Southeast Asian heroin trade involved
indirect complicity rather than direct culpability.
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United States
Mena, Arkansas
A number of allegations have been written about and several local, state, and federal
investigations have taken place related to the alleged use of the Mena Intermountain
Municipal Airport as a CIA drop point in large scale cocaine trafficking beginning in the
early 1980s. Some conspiracy theories regarding the airport extend to alleging the
involvement of figures such as Oliver North and former presidents George H. W.
Bush and Bill Clinton.
An investigation by the CIA's inspector general concluded that the CIA had no
involvement in or knowledge of any illegal activities that may have occurred in Mena.
The report said that the agency had conducted a training exercise at the airport in
partnership with another Federal agency and that companies located at the airport had
performed "routine aviation-related services on equipment owned by the CIA".
A movie about these events called American Made focusing on the notorious pilot and
Medellin cartel drug smuggler Adler Berriman Seal, a.k.a. Barry Seal, in which Seal is
played by actor Tom Cruise was released on September 29, 2017.
Mexico
In October 2013, two former federal agents and an ex-CIA contractor told an American
television network that CIA operatives were involved in the kidnapping and murder
of DEA covert agent Enrique Camarena, because he was a threat to the agency's drug
operations in Mexico. According to the three men, the CIA was collaborating with drug
traffickers moving cocaine and marijuana to the United States, and using its share of the
profits to finance Nicaraguan Contra rebels attempting to overthrow
Nicaragua's Sandinista government. A CIA spokesman responded, calling it "ridiculous"
to suggest that the Agency had anything to do with the murder of a US federal agent or
the escape of his alleged killer.
Honduras
The Honduran drug lord Juan Matta-Ballesteros was the owner of SETCO, an airline
which the Nicaraguan Contras used to covertly transport military supplies and personnel
in the early 1980s. Writers such as Peter Dale Scott and Jonathan Marshall have
suggested that the U.S. government's desire to conceal or protect these clandestine
shipments led it to close the DEA office in Honduras when an investigation began into
SETCO, allowing Matta-Ballesteros to continue and expand his trafficking.
Nicaragua
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In 1986, the United States Senate Committee on Foreign Relations began investigating
drug trafficking from Central and South America and the Caribbean to the United States.
The investigation was conducted by the Sub-Committee on Terrorism, Narcotics, and
International Operations, chaired by Senator John Kerry, so its final 1989 report was
known as the Kerry Committee report. The Report concluded that "it is clear that
individuals who provided support for the Contras were involved in drug trafficking, the
supply network of the Contras was used by drug trafficking organizations, and elements
of the Contras themselves knowingly received financial and material assistance from
drug traffickers."
In 1996 Gary Webb wrote a series of articles published in the San Jose Mercury News,
which investigated Nicaraguans linked to the CIA-backed Contras who had smuggled
cocaine into the U.S. which was then distributed as crack cocaine into Los Angeles and
funneled profits to the Contras. His articles asserted that the CIA was aware of the
cocaine transactions and the large shipments of drugs into the U.S. by the Contra
personnel and directly aided drug dealers to raise money for the Contras. The Los
Angeles Times, The New York Times, and The Washington Post launched their own
investigations and rejected Webb's allegations. In May 1997, The Mercury
News executive editor Jerry Ceppos, who had approved the series, published a column
that acknowledged shortcomings in the series reporting, editing, and production, while
maintaining the story was correct "on many important points." Webb later published a
book based on the series, Dark Alliance: The CIA, the Contras, and the Crack Cocaine
Explosion.
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A 2014 movie depicted actor Jeremy Renner as Gary Webb. The movie about these
events was called Kill the Messenger.
Panama
In 1989, the United States invaded Panama as part of Operation Just Cause, which
involved 25,000 American troops. Gen. Manuel Noriega, head of government of
Panama, had been giving military assistance to Contra groups in Nicaragua at the
request of the U.S.—which, in exchange, allowed him to continue his drug-trafficking
activities—which they had known about since the 1960s. When the DEA tried to indict
Noriega in 1971, the CIA prevented them from doing so. The CIA, which was then
directed by future president George H. W. Bush, provided Noriega with hundreds of
thousands of dollars per year as payment for his work in Latin America. However, when
CIA pilot Eugene Hasenfus was shot down over Nicaragua by the Sandinistas,
documents aboard the plane revealed many of the CIA's activities in Latin America, and
the CIA's connections with Noriega became a public relations "liability" for the U.S.
government, which finally allowed the DEA to indict him for drug trafficking, after
decades of allowing his drug operations to proceed unchecked. Operation Just Cause,
whose ostensible purpose was to capture Noriega, pushed the former Panamanian
leader into the Papal Nuncio where he surrendered to U.S. authorities. His trial took
place in Miami, where he was sentenced to 45 years in prison.
Noriega's prison sentence was reduced from 30 years to 17 years for good
behavior. After serving 17 years in detention and imprisonment, his prison sentence
ended on September 9, 2007. He was held in U.S. custody before being extradited to
France where he was sentenced to 7 years for laundering money from Colombian drug
cartels.
Venezuela
A failed CIA anti-drug operation in Venezuela resulted in at least a ton of cocaine being
smuggled into the United States and sold on the streets. The incident, which was first
made public in 1993, was part of a plan to assist an undercover agent to gain the
confidence of a Colombian drug cartel. The plan involved the unsupervised shipment of
hundreds of pounds of cocaine from Venezuela. The drug in the shipments was
provided by the Venezuelan anti-drug unit which was working with the CIA, using
cocaine seized in Venezuela. The shipments took place despite the objections of the
U.S. DEA. When the failed plan came to light, the CIA officer in charge of the operation
resigned, and his supervisor was transferred.
In addition, the former Venezuelan anti-narcotics chief General Ramon Guillen Davila
and his chief civilian aide were both indicted in connection with the shipments. Because
Venezuela does not extradite its citizens, Guillen was not tried in the U.S., but his
civilian aide was arrested while in the United States and sentenced to 20 years.
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Fentanyl
Fentanyl, also known as Fentanil, is an opioid pain medication with a rapid onset and
short duration of action. It is a potent agonist of μ-opioid receptors. Fentanyl is 50 to 100
times more potent than morphine, but some fentanyl analogues, which are designed to
mimic the pharmacological effects of the original drug, may be as much as 10,000 times
more potent than morphine.
In the mid-1990s, fentanyl was introduced for palliative use with the fentanyl patch,
followed in the next decade by the introduction of the fentanyl lollipop, dissolving
tablets, and sublingual spray which are absorbed through
the tissues
inside the mouth. As of 2012, fentanyl was the most
widely
used
synthetic opioid in
medicine. In 2013,
1,700 kilograms
(3,750 lbs) were used globally. Fentanyl has a relatively wide therapeutic
index(270) which makes it a very safe surgical anaesthetic when
monitored carefully; however, its potency requires careful
measurements of
highly diluted fentanyl in solution.
Fentanyl patches are on the World Health Organization's List of Essential
Medicines, the most effective and safe medicines needed in a health system. Fentanyl
was first made by Paul Janssen in 1960. Janssen developed fentanyl by testing
chemicals similar in structure to pethidine (meperidine) for opioid activity. The
widespread use of fentanyl triggered the production of fentanyl citrate (the salt formed
by combining fentanyl and citric acid in a 1:1 stoichiometric ratio), which entered
medical use as a general anaesthetic under the trade name Sublimaze in the 1960s.
Fentanyl is illegally made and used as a recreational drug often disguised as other
medications or mixed with heroin, leading to thousands of overdose deaths from 2000
to 2017. Deaths have also resulted from improper medical use.
Intravenous and Intrathecal
Medical Uses
Intravenous fentanyl is often used for anaesthesia and analgesia. During anaesthesia it
is often used along with a hypnotic agent like propofol. It is also administered in
combination with a benzodiazepine, such as midazolam, to produce sedation for
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procedures such as endoscopy, cardiac catheterization, and oral surgery, or in
emergency rooms. It is often used in the management of chronic pain including cancer
pain.
Fentanyl is sometimes given intrathecally as part of spinal anaesthesia or epidurally
for epidural anaesthesia and analgesia. Because of fentanyl's high lipid solubility, its
effects are more localized than morphine, and some clinicians prefer to use morphine to
get a wider spread of analgesia.
Patches
Fentanyl transdermal patches (Durogesic/Duragesic) are used in chronic pain
management. The patches work by slowly releasing fentanyl through the skin into the
bloodstream over 48 to 72 hours, allowing for long-lasting pain management. Dosage is
based on the size of the patch, since, in general, the transdermal absorption rate is
constant at a constant skin temperature. Rate of absorption is dependent on a number
of factors. Body temperature, skin type, amount of body fat, and placement of the patch
can have major effects. The different delivery systems used by different makers will also
affect individual rates of absorption. Under normal circumstances, the patch will reach
its full effect within 12 to 24 hours; thus, fentanyl patches are often prescribed with a
fast-acting opiate (such as morphine or oxycodone) to handle breakthrough pain.
It is unclear if fentanyl gives long term pain relief to people with neuropathic pain.
In palliative care, transdermal fentanyl has a definite, but limited, role for:
people already stabilized on other opioids who have persistent swallowing
problems and cannot tolerate other parenteral routes such as subcutaneous
administration.
people with moderate to severe kidney failure.
troublesome side effects of oral morphine, hydromorphone, or oxycodone.
Care must be taken to guard against the application of external heat sources (such as
direct sunlight, heating pads, etc.) which in certain circumstances can trigger the
release of too much medication and cause life-threatening complications.
Duragesic was first approved by the College ter Beoordeling van Geneesmiddelen, the
Medicines Evaluation Board in the Netherlands, on July 17, 1995, as 25, 50, 75 and
100 µg/h formulations after a set of successful clinical trials, and on October 27, 2004,
the 12 µg/h (actually 12.5 µg/h) formulation was approved as well. On January 28,
2005, the U.S. Food and Drug Administration approved first-time generic formulations of
25, 50, 75, and 100 µg/h fentanyl transdermal systems (made by Mylan Technologies,
Inc.; brand name Duragesic, made by Alza Corp.) through an FTC consent agreement
derailing the possibility of a monopoly in the treatment of breakthrough chronic pain by
Alza Corp. In some cases, physicians instruct patients to apply more than one patch at
a time, giving a much wider range of possible dosages. For example, a patient may be
prescribed a 37.5 µg dosage by applying one 12.5 µg patch and one 25 µg patch
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simultaneously, or contingent on the large size of the (largest) 100 μg/h patch, multiple
patches are commonly prescribed for doses exceeding 100μg/h, such as two 75 μg/h
patches worn to afford a 150 μg/h dosage regimen. Although the commonly referred to
dosage rates are 12/25/50/75/100 µg/h, the "12 µg" patch actually releases 12.5 µg/h. It
is designed to release half the dose of the 25 µg/h dose patch.
Duragesic is manufactured by ALZA Corporation and marketed by Janssen
Pharmaceutica (both subsidiaries of Johnson & Johnson). During the period of June
2002 through June 2003, Duragesic sales totaled more than $1 billion.
As of July 2009, construction of the Duragesic patch had been changed from the gel
pouch and membrane design to "a drug-in-adhesive matrix designed formulation", as
described in the prescribing information. This construction makes illicit use of the
fentanyl more difficult.
Storage and Disposal
The fentanyl patch is one of a small number of drugs that may be especially harmful,
and in some cases fatal, with just one dose, if used by someone other than the person
for whom the drug was prescribed. Unused fentanyl patches should be kept in a secure
location that is out of children’s sight and reach, such as a locked cabinet.
When patches cannot be disposed of through a drug take-back program, flushing is
recommended for fentanyl patches because it is the fastest and surest way to remove
them from the home so they cannot harm children, pets and others who were not
intended to use them.
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Recalls
In February 2004, a leading fentanyl supplier, Janssen Pharmaceutica Products, L.P.,
recalled one lot, and then later, additional lots of fentanyl (brand name: Duragesic)
patches because of seal breaches which might have allowed the drug to leak from the
patch. A series of Class II recalls was initiated in March 2004, and in February 2008
ALZA Corporation recalled their 25 µg/h Duragesic patches due to a concern that small
cuts in the gel reservoir could result in accidental exposure of patients or health care
providers to the fentanyl gel.
In February 2011, the manufacturer suspended production of all Duragesic patches due
to quality control issues involving unspecified "microscopic crystallization" detected
during the manufacturing process of the 100 µg/h strength.
Intranasal
The bioavailability of intranasal fentanyl is about 70–90%, but with some imprecision
due to clotted nostrils, pharyngeal swallow and incorrect administration. For both
emergency and palliative use, intranasal fentanyl is available in doses of 50, 100, and
200 µg. In emergency medicine, safe administration of intranasal fentanyl with a low
rate of side effects and a promising pain reducing effect was demonstrated in a
prospective observational study in about 900 out-of-hospital patients.
In children, intranasal fentanyl is useful for the treatment of moderate and severe pain
and is well tolerated.
Sublingual
Abstral dissolves quickly and is absorbed through the sublingual mucosa to provide
rapid analgesia. Fentanyl is a highly lipophilic compound, which is well absorbed
sublingually and generally well tolerated. Such forms are particularly useful for
breakthrough cancer pain episodes, which are often rapid in onset, short in duration and
severe in intensity.
Lozenges
Fentanyl lozenges (Actiq) are a solid formulation of fentanyl citrate on a stick in the form
of a lollipop that dissolves slowly in the mouth for transmucosal absorption. These
lozenges are intended for opioid-tolerant individuals and are effective in treating
breakthrough cancer pain. It has also been used for breakthrough pain for patients with
nonmalignant (not cancer related) pain, but this application is controversial. The unit is a
berry-flavoured lozenge on a stick swabbed on the mucosal surfaces inside the
mouth—inside of the cheeks, under and on the tongue and gums—to release the
fentanyl quickly into the system. It is most effective when the lozenge is consumed
within 15 minutes. About 25 % of the drug is absorbed through the oral mucosa,
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esulting in a fast onset of action, and the rest is swallowed and absorbed in the small
intestine, acting more slowly. The lozenge is less effective and acts more slowly if
swallowed as a whole, as despite good absorbance from the small intestine there is
extensive first-pass metabolism, leading to an oral bioavailability of about 33 % as
opposed to 50 % when used correctly, (25 % via the mouth mucosa and 25 % via the
gut).
Actiq is produced by the pharmaceutical company Cephalon on a plastic stick; this
provides the means by which the drug can maintain its placement while it dissolves
slowly in the mouth for absorption across the buccal mucosa, in a manner similar to
sublingual buprenorphine/naloxone film strips. An Actiq lozenge contains two grams of
sugar (eight calories). Actiq has been linked to dental decay, with some users who had
no prior dental issues suffering tooth loss, and in the U.S many users have started their
own Facebook pages to educate users about the severe dental issues caused by the
so-called fentanyl lollipops. CBS News reported the issue 28 September 2009. The
status of a sugar-free version, called Actiq-SF, is unclear. Since the release
of Fentora—an effervescent buccal fentanyl tablet for breakthrough cancer pain—
Cephalon has indefinitely postponed plans to release a sugar-free version of Actiq.
Beginning late September 2006, a generic "oral transmucosal fentanyl citrate" has been
available, made by Barr Pharmaceuticals.
The United States Air Force Pararescue and Swedish armed forces combat medics
utilize lollipops with fentanyl. Navy corpsmen working with the United States Marine
Corps in Afghanistan use Fentanyl lollipops on combat casualties from IED blasts and
other mechanisms of injury. The lollipop is taped to the casualty's finger and inserted in
between the teeth and cheek (buccal area) of the patient. When enough of the
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medication has been absorbed the finger will generally fall from the patient's mouth,
thereby indicating that the medication has become effectively administered.
Other
Some preparations such as nasal sprays and inhalers may result in a rapid response,
but the fast onset of high blood levels may compromise safety. In addition, the expense
of some of these appliances may greatly reduce their cost-effectiveness. In children it is
unclear if intranasal fentanyl is as good as or the same as morphine.
A fentanyl patient-controlled transdermal system (PCTS) is under development, which
aims to allow patients to control administration of fentanyl through the skin during the
treatment of perioperative pain.
Adverse Effects
Fentanyl's most common side effects (more than 10% of patients) include diarrhoea,
nausea, constipation, dry mouth, somnolence, confusion, asthenia (weakness),
sweating, and less frequently (3 to 10 % of patients) abdominal pain, headache, fatigue,
anorexia and weight loss, dizziness, nervousness, hallucinations, anxiety, depression,
flu-like symptoms, dyspepsia (indigestion), dyspnoea (shortness of
breath), hypoventilation, apnoea, and urinary retention. Fentanyl use has also been
associated with aphasia.
Despite being a more potent analgesic, fentanyl tends to induce less nausea, as well as
less histamine-mediated itching, than morphine.
Fentanyl may produce more prolonged respiratory depression than other opioid
analgesics. In 2006 the U.S. Food and Drug Administration (FDA) began investigating
several respiratory deaths, but doctors in the United Kingdom were not warned of the
risks with fentanyl until September 2008. The FDA reported in April 2012 that twelve
young children had died and twelve more made seriously ill from separate accidental
exposures to fentanyl skin patches.
The precise reason for sudden respiratory depression is unclear, but there are several
hypotheses:
Saturation of the body fat compartment in patients with rapid and profound body
fat loss (patients with cancer, cardiac or infection-induced cachexia can lose
80 % of their body fat).
Early carbon dioxide retention causing cutaneous vasodilatation (releasing more
fentanyl), together with acidosis, which reduces protein binding of fentanyl,
releasing yet more fentanyl.
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Reduced sedation, losing a useful early warning sign of opioid toxicity and
resulting in levels closer to respiratory-depressant levels.
Fentanyl has a therapeutic index of 270.
Overdose
In July 2014, the Medicines and Healthcare Products Regulatory Agency (MHRA) of the
UK issued a warning about the potential for life-threatening harm from accidental
exposure to transdermal fentanyl patches, particularly in children, and advised that they
should be folded, with the adhesive side in, before being discarded. The patches should
be kept away from children, who are most at risk from fentanyl overdose.
Death from fentanyl overdose was declared a public health crisis in Canada in
September 2015, and it continues to be a significant public health issue. In 2016, deaths
from fatal fentanyl overdoses in British Columbia, Canada, averaged two persons per
day. In 2017 the death rate rose over 100% with 368 overdose related deaths in British
Columbia between January and April 2017.
Medical examiners concluded that musician Prince died on April 21, 2016, from an
accidental fentanyl overdose. The drug was among many identified in counterfeit pills
recovered from his home, especially some that were mislabeled as Watson 385, a
combination of hydrocodone and paracetamol.
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In the US Fentanyl caused 20,100 deaths in 2016, a rise of 540% over the past 3 years.
Pharmacology
Fentanyl provides some of the effects typical of other opioids through its agonism of
the opioid receptors. Its strong potency in relation to that of morphine is largely due to
its high lipophilicity, per the Meyer-Overton correlation. Because of this, it can more
easily penetrate the central nervous system.
Detection in Biological Fluids
Fentanyl may be measured in blood or urine to monitor for abuse, confirm a diagnosis
of poisoning, or assist in a medicolegal death investigation. Commercially-available
immunoassays are often used as initial screening tests, but chromatographic
techniques are generally used for confirmation and quantitation. Blood or plasma
fentanyl concentrations are expected to be in a range of 0.3–3.0 μg/l in persons using
the drug therapeutically, 1–10 μg/l in intoxicated patients and 3-300 μg/l in victims of
acute overdosage.
History
Fentanyl was first synthesized by Paul Janssen under the label of his relatively newly
formed Janssen Pharmaceutica in 1959. In the 1960s, fentanyl was introduced as an
intravenous anaesthetic under the trade name of Sublimaze. In the mid-1990s, Janssen
Pharmaceutica developed and introduced into clinical trials the Duragesic patch, which
is a formation of an inert alcohol gel infused with select fentanyl doses, which are worn
to provide constant administration of the opioid over a period of 48 to 72 hours. After a
set of successful clinical trials, Duragesic fentanyl patches were introduced into medical
practice.
Following the patch, a flavoured lollipop of fentanyl citrate mixed with inert fillers was
introduced under the brand name of Actiq, becoming the first quick-acting formation of
fentanyl for use with chronic breakthrough pain. Fentanyl has been developed into an
effervescent tab for buccal absorption much like the Actiq lollipop, followed by a buccal
spray device for fast-acting relief and other delivery methods currently in development.
A fentanyl product has been approved by the US Food and Drug Administration (FDA)
for breakthrough cancer pain called Onsolis. It uses a drug delivery technology called
BEMA (fentanyl buccal soluble film) on a small disc placed in the mouth. Unlike many
other fentanyl products, the drug cannot be abused by crushing and inhaling.
Fentanyl has a US DEA ACSCN of 9801 and a 2013 annual aggregate manufacturing
quota of 2,108.75 kg, unchanged from the prior year.
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Society and Culture
Brand Names
Brand names include Sublimaze, Actiq, Durogesic, Duragesic, Fentora, Matrifen,
Haldid, Onsolis, Instanyl, Abstral, Lazanda and others. Subsys is a sublingual spray of
fentanyl manufactured by Insys Therapeutics.
Legal Status
In the UK, fentanyl is classified as a controlled Class A drug under the Misuse of Drugs
Act 1971. In the Netherlands, fentanyl is a List I substance of the Opium Law. In the
U.S., fentanyl is a Schedule II controlled substance per the Controlled Substance Act.
Distributors of Abstral are required to implement an FDA-approved risk evaluation and
mitigation strategy (REMS) program. In order to curb misuse, many health insurers
have begun to require precertification and/or quantity limits for Actiq
prescriptions. [76][77][78]
Legal Action
On June 19, 2007, a $5.5 million jury verdict was awarded in a US case against
Johnson & Johnson subsidiaries, Alza Corporation and Janssen Pharmaceutica
Products, the manufacturers of the Duragesic fentanyl transdermal pain patch. This
case, the first Federal trial involving the Duragesic fentanyl patch, was tried in the
Federal District Court for the Southern District of Florida, West Palm Beach Division.
Public Health Advisories
The US Food and Drug Administration (FDA) has issued public health advisories related
to fentanyl patch dangers. Among these, in July 2005, the FDA issued a Public Health
Advisory, which advised that "deaths and overdoses have occurred in patients using
both the brand name product Duragesic and the generic product." In December 2007,
as part of this continuing investigation, the FDA issued a second Public Health
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Advisory stating, "The FDA has continued to receive reports of deaths and lifethreatening
side effects in patients who use the fentanyl patch. The reports indicate that
doctors have inappropriately prescribed the fentanyl patch... In addition, the reports
indicate that patients are continuing to incorrectly use the fentanyl patch..."
Recreational Use
Illicit use of pharmaceutical fentanyl and its analogues first appeared in the mid-1970s
in the medical community and continues in the present. United States authorities
classify fentanyl as a narcotic and an opioid. To date, more than 12 different analogues
of fentanyl have been produced clandestinely and identified in the U.S. drug traffic. The
biological effects of the fentanyl analogues are similar to those of heroin, with the
exception that many users report a noticeably less euphoric high associated with the
drug and stronger sedative and analgesic effects.
Fentanyl analogues may be hundreds of times more potent than street heroin, and tend
to produce significantly more respiratory depression, making it much more dangerous
than heroin to users. Fentanyl is used orally, smoked, snorted, or injected. Fentanyl is
sometimes sold as heroin or oxycodone, often leading to overdoses. Many fentanyl
overdoses are initially classified as heroin overdoses. Estonia has the highest rate of 3-
methylfentanyl overdose deaths in the EU, due to its high rate of recreational use.
Fentanyl is sometimes sold on the black market in the form of transdermal fentanyl
patches such as Duragesic, diverted from legitimate medical supplies. The gel from
inside the patches may be ingested or injected.
Another form of fentanyl that has appeared on the streets is the Actiq lollipop
formulation. The pharmacy retail price ranges from $15 to $50 per unit based on the
strength of the lozenge, with the black market cost ranging from $5 to $25, depending
on the dose. The attorneys general of Connecticut and Pennsylvania have launched
investigations into its diversion from the legitimate pharmaceutical market, including
Cephalon's "sales and promotional practices for Provigil, Actiq and Gabitril".
Non-medical use of fentanyl by individuals without opiate tolerance can be very
dangerous and has resulted in numerous deaths. Even those with opiate tolerances are
at high risk for overdoses. Once the fentanyl is in the user's system, it is extremely
difficult to stop its course because of the nature of absorption. Illicitly synthesized
fentanyl powder has also appeared on the United States market. Because of the
extremely high strength of pure fentanyl powder, it is very difficult to dilute appropriately,
and often the resulting mixture may be far too strong and, therefore, very dangerous.
Some heroin dealers mix fentanyl powder with heroin to increase potency or
compensate for low-quality heroin. In 2006, illegally manufactured, non-pharmaceutical
fentanyl often mixed with cocaine or heroin caused an outbreak of overdose deaths in
the United States and Canada, heavily concentrated in the cities of Dayton, Ohio;
Chicago; Detroit; and Philadelphia.
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Several large quantities of illicitly produced fentanyl have been seized by U.S. law
enforcement agencies. In June 2006, 945 grams (2.08 lbs) of 83 %-pure fentanyl
powder was seized by Border Patrol agents in California from a vehicle that had entered
from Mexico. Mexico is the source of much of the illicit fentanyl for sale in the U.S.
However, in April 2006, there was one domestic fentanyl lab discovered by law
enforcement in Azusa, California. The lab was a source of counterfeit
80 mg OxyContin tablets containing fentanyl instead of oxycodone, as well as bulk
fentanyl and other drugs. In November 2016, the DEA uncovered an operation making
counterfeit oxycodone and Xanax from a home in Cottonwood Heights, Utah. They
found about 70,000 pills in the appearance of oxycodone and more than 25,000 in the
appearance of Xanax. The DEA reported that millions of pills could have been
distributed from this location over the course of time. The accused owned a pill press
and ordered fentanyl in powder form from China.
The "China White" form of fentanyl refers to any of a number of clandestinely produced
analogues, especially α-methylfentanyl (AMF). This Department of Justice document
lists "China White" as a synonym for a number of fentanyl analogues, including 3-
methylfentanyl and α-methylfentanyl, which today are classified as Schedule I drugs in
the United States. Part of the motivation for AMF is that, despite the extra difficulty from
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a synthetic standpoint, the resultant drug is relatively more resistant to metabolic
degradation. This results in a drug with an increased duration.
In June 2013, the United States Centers for Disease Control and Prevention (CDC)
issued a health advisory to emergency departments alerting to 14 overdose deaths
among intravenous drug users in Rhode Island associated with acetylfentanyl, a
synthetic opioid analog of fentanyl that has never been licensed for medical use. In a
separate study conducted by the CDC, 82% of fentanyl overdose deaths involved
illegally manufactured fentanyl, while only 4% were suspected to originate from a
prescription.
Beginning in 2015, Canada has seen a widespread number of fentanyl overdoses.
Authorities suspect that the drug is being imported from Asia to the western coast by
organized crime groups in powder form and being pressed into pseudo-OxyContin
tablets. Traces of the drug have also been found in other recreational drugs including
cocaine, MDMA, and heroin. The drug has been implicated in multiple deaths from the
homeless to young professionals, including multiple teens and young parents. Because
of the rising deaths across the country, Health Canada is putting a rush on a review of
the prescription-only status of naloxone in an effort to combat overdoses of the drug.
Incapacitating Agent
Russian spetsnaz security forces used a "fentanyl gas" to incapacitate people rapidly in
the Moscow theater hostage crisis in 2002. The siege was ended, but about 130 of the
850 hostages died from the gas. The Russian Health Minister later stated that the gas
was based on fentanyl, but the exact chemical agent has not been identified.
Veterinary Use
Fentanyl in injectable formulation is commonly used for analgesia and as a component
of balanced sedation and general anaesthesia in small animal patients. Its potency and
short duration of action make it particularly useful in critically ill patients. In addition, it
tends to cause less vomiting and regurgitation than other pure-opioid agonists
(morphine, hydromorphone) when given as a continuous post-operative infusion. As
with other pure opioids, fentanyl can be associated with dysphoria in both dogs and
cats.
Transdermal fentanyl has also been used for many years in dogs and cats for postoperative
analgesia. This is usually done with off-label fentanyl patches manufactured
for humans with chronic pain. In 2012 a highly concentrated (50 mg/ml) transdermal
solution, trade name Recuvyra, has become commercially available for dogs only. It is
FDA approved to provide four days of analgesia after a single application prior to
surgery. It is not approved for multiple doses or other species. The drug is also
approved in Europe.
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V. Treatments
Naloxone
Naloxone, sold under the brandname Narcan among others, is a medication used to
block the effects of opioids, especially in overdose. Naloxone may be combined within
the same pill as an opioid to decrease the risk of misuse. When given intravenously,
naloxone works within two minutes, and when injected into a muscle, it works within five
minutes; it may also be sprayed into the nose. The effects of naloxone last about half an
hour to an hour. Multiple doses may be required, as the duration of action of most
opioids is greater than that of naloxone.
Administration to opioid-dependent individuals may cause symptoms of opioid
withdrawal,
including restlessness, agitation, nausea,
vomiting, a fast heart rate, and sweating. To prevent this,
small doses every
few minutes can be given until the desired
effect is reached. In those with previous heart
disease or taking medications that
negatively
affect
the
heart,
further heart problems
have
occurred. It
appears to be safe in
pregnancy,
after having been given to
a limited number of women. Naloxone is
a non-
selective and competitive opioid
receptor antagonist. It works by reversing the depression
of the central nervous system and respiratory system caused by opioids.
Naloxone was patented in 1961 and approved for opioid overdose by the Food and
Drug Administration in 1971. It is on the World Health Organization's List of Essential
Medicines, the most effective and safe medicines needed in a health system. Naloxone
is available as a generic medication. Its wholesale price in the developing world is
between $0.50 and $5.30 per dose. Vials of naloxone are not very expensive (less than
$25) in the United States. The price for a package of two auto-injectors in the US,
however, has increased from $690 in 2014 to $4,500 in 2016.
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Medical Uses
Opioid Overdose
Naloxone is useful both in acute opioid overdose and in reducing respiratory or mental
depression due to opioids. Whether it is useful in those in cardiac arrest due to an
opioid overdose is unclear.
It is included as a part of emergency
overdose response kits distributed
to heroin and other opioid drug users
and emergency responders. This has
been shown to reduce rates of deaths
due to overdose. A prescription for
naloxone is recommended if a person is
on a high dose of opioid (>100 mg of
morphine equivalence/day), is
prescribed any dose of opioid
accompanied by a benzodiazepine, or
is suspected or known to use opioids
nonmedically. Prescribing naloxone
should be accompanied by standard
education that includes preventing,
identifying, and responding to an overdose; rescue breathing; and calling emergency
services.
Preventing Opioid Abuse
Naloxone is poorly absorbed when taken by mouth, so it is commonly combined with a
number of oral opioid preparations, including buprenorphine and pentazocine, so that
when taken orally, just the opioid has an effect, but if misused by injecting, the naloxone
blocks the effect of the opioid. This combination is used in an effort to prevent abuse. In
Germany, tilidine is sold in a fixed combination with naloxone.
Other Uses
Naloxone can be used on infants that were exposed to intrauterine opiates administered
to mothers during delivery. However, there is insufficient evidence for the use of
naloxone to lower cardiorespiratory and neurological depression in these infants. Infants
exposed to high concentrations of opiates during pregnancy may have CNS damage in
the setting of perinatal asphyxia. Naloxone has been studied to improve outcomes in
this population, however the evidence is currently weak.
In people with shock, including septic, cardiogenic, hemorrhagic, or spinal shock, those
who received naloxone had improved blood flow. The importance of this is unclear.
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Naloxone is also experimentally used in the treatment for congenital insensitivity to pain
with anhidrosis, an extremely rare disorder (one in 125 million) that renders one unable
to feel pain or differentiate temperatures.
Naloxone can also be used as an antidote in overdose of clonidine, a medication that
lowers blood pressure.
Naloxone can also be used to treat itchiness brought on by opioid use.
Routes of Administration
Naloxone is most commonly injected intravenously for fastest action, which usually
causes the drug to act within a minute, and lasts up to 45 minutes. It can also be
administered via intramuscular, subcutaneous injection, or nasal spray. There is a pre
packaged nasal spray that does not require assembly and delivers a consistent dose. It
can be repeated if necessary. A non-FDA approved wedge device (nasal atomizer)
attached to a syringe may be used to create a mist that delivers the drug to the
nasal mucosa. This is useful near facilities where many overdoses occur that already
stock injectors.
If minimal or no response is observed within 2–3 minutes, dosing may be repeated
every 2 minutes until the maximum dose of 10 mg has been reached. If no response
occurs at this time, alternative diagnosis and treatment should be pursued. The effects
of naloxone may wear off before those of the opioids, and they may require repeat
dosing at a later time. Patients experiencing effects should be monitored for respiratory
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ate, heart rate, blood pressure, temperature, ABGs and level of consciousness. Those
with a greater risk for respiratory depression should identified prior to administration and
watched closely.
In April 2014, the US Food and Drug Administration (FDA) approved a hand-held
automatic injector naloxone product that is pocket-sized and can be used in nonmedical
settings such as in the home. It is designed for use by laypersons, including family
members and caregivers of opioid users at-risk for an opioid emergency, such as an
overdose. A nasal spray was developed in a partnership between LightLake
Therapeutics and the National Institute on Drug Abuse. The approval process was fasttracked
as one initiative to reduce the death toll caused by opiate overdoses. At the time
of approval, an estimated 16,000 annual deaths were attributed to prescription opioid
overdoses in the US.
Naloxone can be used along with oxycodone controlled release and may help reduce
constipation associated with opioids. Naloxone has low systemic bioavailability
when taken by mouth due to hepatic first pass metabolism, but it does block opioid
receptors that are located in the intestine.
Pregnancy and Breast Feeding
Special Populations
Naloxone is pregnancy category B or C in the United States. Studies in rodents given a
daily maximum dose of 10 mg naloxone showed no harmful effects to the fetus,
although human studies are lacking and the drug does cross the placenta, which may
lead to the precipitation of withdrawal in the fetus. In this setting, further research is
needed before safety can be assured, so naloxone should only be used during
pregnancy if it is a medical necessity.
Whether naloxone is excreted in breast milk is unknown.
Kidney and Liver Dysfunction
Currently, no established clinical trials have been conducted in person with insufficient
kidney function or liver disease, and as such, these people should be monitored closely
if naloxone is clinically indicated.
Cardiovascular Disease
Naloxone should be used with caution in people with cardiovascular disease as well as
those that are currently taking medications that could have adverse effects on the
cardiovascular system such as causing hypotension, pulmonary edema and arrhythmia.
There have been reports of abrupt reversals with opioid antagonists leading to
pulmonary edema and ventricular fibrillation.
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Side Effects
Naloxone has little to no effect if opioids are not present. In people with opioids in their
system, it may cause increased sweating, nausea, restlessness, trembling, vomiting,
flushing, and headache, and has in rare cases been associated with heart rhythm
changes, seizures, and pulmonary edema.
Besides the side effects listed above, naloxone also has other adverse events, such as
other cardiovascular effects (hypertension, hypotension, tachycardia, ventricular
fibrillation, ventricular tachycardia) and central nervous system effects, such as
agitation, body pain, brain disease, and coma. In addition to these adverse effects,
naloxone is also contraindicated in people with hypersensitivity to naloxone or any of its
formulation components.
Naloxone has been shown to block the action of pain-lowering endorphins which the
body produces naturally. These endorphins likely operate on the same opioid receptors
that naloxone blocks. It is capable of blocking a placebo pain-lowering response, if the
placebo is administered together with a hidden or blind injection of naloxone. Other
studies have found that placebo alone can activate the body's μ-opioid endorphin
system, delivering pain relief by the same receptor mechanism as morphine.
Pharmacology
Pharmacodynamics
Naloxone is a lipophilic compound that acts
as a non-selective and competitive opioid
receptor antagonist The pharmacologically
active isomer of naloxone is (−)-
naloxone. (+)-Naloxone is relatively inactive
at the opioid receptors. Naloxone's binding
affinity is highest for the μ-opioid receptor,
then the δ-opioid receptor, and lowest for
the κ-opioid receptor; naloxone has negligible affinity for the nociceptin
receptor. The Ki affinity values of (−)-naloxone for the μ-, δ-, and κ-opioid receptors
have been reported as 0.559 nanomolar (nM), 4.91 nM, and 36.5 nM, respectively,
whereas for (+)-naloxone, 3,550 nM, 8,950 nM, and 122,000 nM, respectively, have
been reported. As such, (−)-naloxone appears to be the active isomer. Moreover, these
data suggest that (−)-naloxone binds to the μ-opioid receptor with approximately 9-fold
greater affinity relative to the δ-opioid receptor and around 60-fold greater affinity
relative to the κ-opioid receptor.
If naloxone is administered in the absence of concomitant opioid use, no functional
pharmacological activity occurs, except the inability for the body to combat pain
naturally. In contrast to direct opiate agonists, which elicit opiate withdrawal symptoms
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when discontinued in opiate-tolerant people, no evidence indicates the development of
tolerance or dependence on naloxone. The mechanism of action is not completely
understood, but studies suggest it functions to produce withdrawal symptoms by
competing for opiate receptor sites within the CNS (a competitive antagonist, not a
direct agonist), thereby preventing the action of
both endogenous and xenobiotic opiates on these receptors without directly producing
any effects itself.
Pharmacokinetics
When administered parenterally (nonorally or nonrectally, e.g. intravenously or by
injection), as is most common, naloxone has a rapid distribution throughout the body.
The mean serum half life has been shown to range from 30 to 81 minutes, shorter than
the average half life of some opiates, necessitating repeat dosing if opioid receptors
must be stopped from triggering for an extended period. Naloxone is primarily
metabolized by the liver. Its major metabolite is naloxone-3-glucuronide, which is
excreted in the urine.
Chemistry
Naloxone, also known as N- allylnoroxymorphone or as 17-allyl-4,5α-epoxy-
3,14-dihydroxymorphinan-6- one, is
a synthetic morphinan derivative and
was derived from oxymorphone (14- hydroxydihydromorphinone), an
opioid analgesic. Oxymorphone, in
turn, was derived from morphine,
an opioid analgesic and naturally occurring constituent of
the opium poppy. Naloxone is a racemic mixture of
two enantiomers, (–)-naloxone (levonaloxone) and (+)-
naloxone (dextronaloxone), only the former of which is active
at opioid receptors. The drug is a
highly lipophilic, allowing it
to rapidly penetrate the brain and to
achieve a far greater
brain to serum ratio than that of
morphine. Opioid
antagonists related to naloxone
include cyprodime, nalmefene, nalodeine, naloxol, and naltrexone.
History
Naloxone was patented in 1961 by Jack Fishman, Mozes J. Lewenstein, and the
company Sankyo. It was approved for opioid abuse treatment in 1971 by the FDA with
opioid abuse kits being distributed by many states to medically untrained people
beginning in 1996. From the period of 1996 to 2014, the CDC estimates over 26,000
cases of opioid overdose have been reversed using the kits.
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Society and Culture
Names
Naloxone is the generic name of the drug and its INN, BAN, DCF, DCIT, and JAN,
while naloxone hydrochloride is its USAN and BANM.
The patent for naloxone has expired; consequently, it is available in generic medication.
Brand names of naloxone include Narcan, Nalone, Evzio, Prenoxad Injection, Narcanti,
Narcotan, and others.
Legal Status
In the United States, naloxone is classified as a prescription medication, though it is not
a controlled substance. While it is legal to prescribe naloxone in every state, dispensing
the drug by medical professionals (including physicians or other licensed prescribers) at
the point of service is subject to rules that vary by jurisdiction. In the following states,
you can purchase naloxone from a pharmacist directly without getting a prescription
from a doctor:
Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Florida, Georgi
a, Idaho, Illinois, Indiana, Iowa, Kentucky, Maine, Maryland, Massachusetts, Minnesota,
Nevada, New Hampshire, New Jersey, New Mexico, New York, North
Carolina, Ohio, Oregon, Pennsylvania, Rhode
Island, South
Carolina, Tennessee, Texas, Utah, Vermont, Washington, West Virginia and Wisconsin.
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While paramedics have carried naloxone for decades, law enforcement officers in many
states throughout the country carry naloxone to reverse the effects of heroin overdoses
when reaching the location prior to paramedics. As of July 12, 2015, law enforcement
departments in 28 states carry naloxone to quickly respond to opioid overdoses.
In Australia, as of February 1, 2016, naloxone is now available "over the counter" in
pharmacies without a prescription. It comes in single use filled syringe similar to law
enforcement kits.
In Canada, naloxone single-use syringe kits are distributed and available at various
clinics and emergency rooms. Alberta Health Services is increasing the distribution
points for naloxone kits at all emergency rooms, and various pharmacies and clinics
province-wide. Also in Alberta, take-home naloxone kits are available and commonly
distributed in most drug treatment or rehabilitation centres, as well as in pharmacies
where pharmacists can distribute single-use take-home naloxone kits or prescribe the
drug to addicts. All Edmonton Police Service and Calgary Police Service patrol cars
carry an emergency single-use naloxone syringe kit. Some Royal Canadian Mounted
Police patrol vehicles also carry the drug, occasionally in excess to help distribute
naloxone among users and concerned family/friends. Nurses, paramedics, medical
technicians, and emergency medical responders can also prescribe and distribute the
drug.
Following Alberta Health Services, Health Canada reviewed the prescription-only status
of naloxone, resulting in plans to remove it in 2016, allowing naloxone to be more
accessible. Due to the rising number of drug deaths across the country, Health Canada
proposed a change to make naloxone more widely available to Canadians in support of
efforts to address the growing number of opioid overdoses. In March 2016, Health
Canada did change the prescription status of naloxone, as "pharmacies are now able to
proactively give out naloxone to those who might experience or witness an opioid
overdose."
Pre-Hospital Access
Laws in many jurisdictions have been changed in recent years to allow wider distribution
of naloxone. Several states have also moved to permit pharmacies to dispense the
medication without the person first seeing a physician or other non-pharmacist
professional. Over 200 naloxone distribution programs utilize licensed prescribers to
distribute the drug, often through the use of standing medication orders whereby the
medication is distributed under the medical authority of a physician or other prescriber
(such as a pharmacist under California's AB1535).
Following the use of the nasal spray device by police officers on Staten Island in New
York, an additional 20,000 police officers will begin carrying naloxone in mid-2014. The
state's Office of the Attorney General will provide US$1.2 million to supply nearly 20,000
kits. Police Commissioner William Bratton said: "Naloxone gives individuals a second
chance to get help". Emergency Medical Service Providers (EMS) routinely administer
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naloxone, except where basic Emergency Medical Technicians are prohibited by policy
or by state law.
A survey of US naloxone prescription programs in 2010 revealed that 21 out of 48
programs reported challenges in obtaining naloxone in the months leading up to the
survey, due mainly to either cost increases that outstripped allocated funding or the
suppliers' inability to fill orders. The approximate cost of a 1 ml ampoule of naloxone in
the US is estimated to be significantly higher than in most Western countries.
Projects of this type are under way in many North American cities. CDC estimates that
the US programs for drug users and their caregivers prescribing take-home doses of
naloxone and training on its use have prevented 10,000 opioid overdose deaths.
Healthcare institution-based naloxone prescription programs have also helped reduce
rates of opioid overdose in North Carolina, and have been replicated in the US
military. Programs training police and fire personnel in opioid overdose response using
naloxone have also shown promise in the US, and effort is increasing to integrate opioid
fatality prevention in the overall response to the overdose crisis.
Pilot projects were also started in Scotland in 2006. Also in the UK, in December 2008,
the Welsh Assembly government announced its intention to establish demonstration
sites for take-home naloxone.
As of February 2016, Pharmacies across Alberta and some other Canadian jurisdictions
are allowed to distribute take-home naloxone kits. Additionally, the Minister of Health
issued an order to change basic life support provider's medical scope, within EMS, to
administer naloxone in the event of a suspected narcotic overdose. These are part of
the government's plan to tackle a growing fentanyl drug crisis.
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Identification
The CAS number of naloxone is 465-65-6; the anhydrous hydrochloride salt has CAS
357-08-4 and the hydrochloride salt with 2 molecules of water, hydrochloride dihydrate,
has CAS 51481-60-8.
Media
The 2013 documentary film Reach for Me: Fighting to End the American Drug Overdose
Epidemic interviews people involved in naloxone programs aiming to make naloxone
available to opioid users and people with chronic pain.
Methadone Maintenance
Methadone
Medical Uses
Methadone is indicated for the maintenance treatment of opioid dependency (i.e. opioid
use disorder per the fifth edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM). A 2009 Cochrane review found that methadone
was effective in retaining people in
treatment and in the
reduction or cessation of heroin use
as measured by selfreport
and urine/hair analysis
but did not affect
criminal activity or risk
of death.
The treatment of opioid-
dependent persons with
methadone will follow
one of two routes. MMT
(methadone
maintenance therapy) is
prescribed to individuals who wish to
abstain from illicit drug use but have failed to maintain
abstinence from opioids for significant periods. The
duration of methadone maintenance ranges
from a few months to
lifelong.
Methadone
reduction
programs are suitable for
addicted persons who wish to
completely stop using drugs.
The length of
the
reduction
program will
depend on
the starting
dose and speed of
reduction, this varies
between clinics and from person to person. In addition, enrollment in
methadone maintenance has the potential to reduce the transmission of infectious
diseases associated with opiate injection, such as hepatitis and HIV. The principal goals
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of methadone maintenance are to relieve opioid cravings, suppress the abstinence
syndrome, and block the euphoric effects associated with opioids. However, methadone
abuse does carry the potential for dependence. When used correctly, methadone
maintenance has been found to be medically safe and non-sedating, and provides a
slow recovery from opioid addiction. It is also indicated for pregnant women addicted to
opioids.
Pain
Methadone is used as an analgesic in chronic pain. Due to its activity at the NMDA
receptor, it may be more effective against neuropathic pain; for the same reason,
tolerance to the analgesic effects may be less than that of other opioids.
People with long-term pain will sometimes have to perform so-called opioid
rotation. Opioid rotation involves switching from one opioid to another, usually at
intervals of between a few weeks, or more commonly, several months. Opioid rotation
may allow for a lower equivalent dose, and hence fewer side effects may be
encountered to achieve the desired effect. Then, over time, tolerance increases with the
new opioid, requiring higher doses. This, in turn, increases the possibility of adverse
reactions and toxicity. Then it is time to rotate again to another opioid. Such opioid
rotation is standard practice for managing people with tolerance development. Usually
when doing opioid rotation, one cannot go down to a completely naive dose, because
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there is cross-tolerance carried over to the new opioid. However, methadone has a
lower cross-tolerance when switching to it from other opioids, than other opioids. This
means that methadone can start at a comparatively lower dose than other opiates, and
the time for the next switch will be longer.
Opioid Detoxification
Methadone is approved in the US, and many other parts of the world, for the treatment
of opioid addiction. Its use for the treatment of addiction is usually strictly regulated. In
the US, outpatient treatment programs must be certified by the Federal Substance
Abuse and Mental Health Services Administration (SAMHSA) and registered by the
Drug Enforcement Administration (DEA) in order to prescribe methadone for opioid
addiction.
Adverse Effects
On 29 November 2006, the U.S. Food and Drug Administration issued a Public Health
Advisory about methadone titled "Methadone Use for Pain Control May Result in Death
and Life-Threatening Changes in Breathing and Heart Beat". The advisory said that "the
FDA has received reports of death and life-threatening side effects in patients taking
methadone. These deaths and life-threatening side effects have occurred in patients
newly starting methadone for pain control and in patients who have switched to
methadone after being treated for pain with other strong opioid pain relievers.
Methadone can cause slow or shallow breathing and dangerous changes in heartbeat
that may not be felt by the patient." The advisory urged that physicians use caution
when prescribing methadone to people who are not used to the drug and that people
take the drug exactly as directed.
Adverse effects of methadone include:
Sedation
Diarrhea or constipation
Flushing
Perspiration and sweating
Heat intolerance
Dizziness or fainting
Weakness
Chronic fatigue, sleepiness and exhaustion
Sleep problems such as drowsiness, trouble falling asleep (Insomnia), and
trouble staying asleep
Constricted pupils
Dry mouth
Nausea and vomiting
Low blood pressure
Hallucinations or confusion
Headache
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Heart problems such as chest pain or fast/pounding heartbeat
Abnormal heart rhythms
Respiratory problems such as trouble breathing, slow or shallow breathing
(hypoventilation), light-headedness, or fainting
Loss of appetite, and in extreme cases anorexia
Weight gain
Memory loss
Stomach pains
Itching
Difficulty urinating
Swelling of the hands, arms, feet, and legs
Feeling restless or agitated
Mood changes, euphoria, disorientation
Nervousness or anxiety
Blurred vision
Decreased libido, missed menstrual periods, difficulty in
reaching orgasm, or impotence
Skin rash
Seizures
Central sleep apnea
Withdrawal Symptoms
Physical Symptoms
Lightheadedness
Tearing of the eyes
Mydriasis (dilated pupils)
Photophobia (sensitivity to light)
Hyperventilation syndrome (breathing that is too fast/deep)
Runny nose
Yawning
Sneezing
Nausea, vomiting, and diarrhea
Fever
Sweating
Chills
Tremors
Akathisia (restlessness)
Tachycardia (fast heartbeat)
Aches and pains, often in the joints or legs
Elevated pain sensitivity
Blood pressure that is too high (hypertension, may cause stroke)
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Cognitive Symptoms
Suicidal ideation
Susceptibility to cravings
Depression
Spontaneous orgasm
Prolonged insomnia
Delirium
Auditory hallucinations
Visual hallucinations
Increased perception of odors (olfaction), real or imagined
Marked decrease or increase in sex drive
Agitation
Anxiety
Panic disorder
Nervousness
Paranoia
Delusions
Apathy
Anorexia (symptom)
Methadone withdrawal symptoms are reported as being significantly more protracted
than withdrawal from opioids with shorter half-lives.
Methadone is sometimes administered as an oral liquid. Methadone has been
implicated in contributing to significant tooth decay. Methadone causes dry mouth,
reducing the protective role of saliva in preventing decay. Other putative mechanisms of
methadone-related tooth decay include craving for carbohydrates related to opioids,
poor dental care, and general decrease in personal hygiene. These factors, combined
with sedation, have been linked to the causation of extensive dental damage.
Overdose
Most people who have overdosed on methadone may show some of the following
symptoms:
Miosis (constricted pupils)
Vomiting
Hypoventilation (breathing that is too slow/shallow)
Drowsiness, sleepiness, disorientation, sedation, unresponsiveness
Skin that is cool, clammy (damp), and pale
Limp muscles, trouble staying awake, nausea
Unconsciousness and coma
Death
The respiratory depression of an overdose can be treated with naloxone. Naloxone is
preferred to the newer, longer acting antagonist naltrexone. Despite methadone's much
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longer duration of action compared to either heroin and other shorter-acting agonists,
and the need for repeat doses of the antagonist naloxone, it is still used for overdose
therapy. As naltrexone has a longer half-life, it is more difficult to titrate. If too large a
dose of the opioid antagonist is given to a dependent person, it will result in withdrawal
symptoms (possibly severe). When using naloxone, the naloxone will be quickly
eliminated and the withdrawal will be short lived. Doses of naltrexone take longer to be
eliminated from the person's system. A common problem in treating methadone
overdoses is that, given the short action of naloxone (versus the extremely longer-acting
methadone), a dosage of naloxone given to a methadone-overdosed person will initially
work to bring the person out of overdose, but once the naloxone wears off, if no further
naloxone is administered, the person can go right back into overdose (based upon time
and dosage of the methadone ingested).
Tolerance and Dependence
As with other opioid medications, tolerance and dependence usually develop with
repeated doses. There is some clinical evidence that tolerance to analgesia is less with
methadone compared to other opioids; this may be due to its activity at the NMDA
receptor. Tolerance to the different physiological effects of methadone varies; tolerance
to analgesic properties may or may not develop quickly, but tolerance to euphoria
usually develops rapidly, whereas tolerance to constipation, sedation, and respiratory
depression develops slowly (if ever).
Driving
Methadone treatment may impair driving ability. Drug abusers had significantly more
involvement in serious crashes than non-abusers in a study by the University of
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Queensland. In the study of a group of 220 drug abusers, most of them poly-drug
abusers, 17 were involved in crashes killing people, compared with a control group of
other people randomly selected having no involvement in fatal crashes. However, there
have been multiple studies verifying the ability of methadone maintenance patients to
drive. In the UK, persons who are prescribed oral Methadone can continue to drive after
they have satisfactorily completed an independent medical examination which will
include a urine screen for drugs. The licence will be issued for 12 months at a time and
even then, only following a favourable assessment from their own doctor. Individuals
who are prescribed methadone for either IV or IM administration cannot drive in the UK,
mainly due to the increased sedation effects that this route of use can cause.
Mortality
In the United States, deaths linked to methadone more than quadrupled in the five-year
period between 1999 and 2004. According to the U.S. National Center for Health
Statistics, as well as a 2006 series in the Charleston Gazette (West Virginia), medical
examiners listed methadone as contributing to 3,849 deaths in 2004. That number was
up from 790 in 1999. Approximately 82 percent of those deaths were listed as
accidental, and most deaths involved combinations of methadone with other drugs
(especially benzodiazepines).
Although deaths from methadone are on the rise, methadone-associated deaths are not
being caused primarily by methadone intended for methadone treatment programs,
according to a panel of experts convened by the Substance Abuse and Mental Health
Services Administration, which released a report titled "Methadone-Associated Mortality,
Report of a National Assessment". The consensus report concludes that "although the
data remains incomplete, National Assessment meeting participants concurred that
methadone tablets or diskettes distributed through channels other than opioid treatment
programs most likely are the central factors in methadone-associated mortality."
In 2006, the U.S. Food and Drug Administration issued a caution about methadone,
titled “Methadone Use for Pain Control May Result in Death.” The FDA also revised the
drug's package insert. The change deleted previous information about the usual adult
dosage. The Charleston Gazette reported, "The old language about the 'usual adult
dose' was potentially deadly, according to pain specialists."
Detection in Biological Fluids
Methadone and its major metabolite, 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine
(EDDP), are often measured in urine as part of a drug abuse testing program, in plasma
or serum to confirm a diagnosis of poisoning in hospitalized victims, or in whole blood to
assist in a forensic investigation of a traffic or other criminal violation or a case of
sudden death. Methadone usage history is considered in interpreting the results as a
chronic user can develop tolerance to doses that would incapacitate an opioid-naive
individual. Chronic users often have high methadone and EDDP baseline values.
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Pharmacology
Methadone acts by binding to the µ-opioid receptor, but also has some affinity for
the NMDA ionotropic glutamate receptor. Methadone is metabolized
by CYP3A4, CYP2B6, CYP2D6 and is a substrate for the P-Glycoprotein efflux protein
in the intestine and brain. The bioavailability and elimination half-life of methadone is
subject to substantial inter-individual variability. Its main route of administration is oral.
Adverse effects include sedation, hypoventilation, constipation and miosis, in addition to
tolerance, dependence and withdrawal difficulties. The withdrawal period can be much
more prolonged than with other opioids, spanning anywhere from two weeks to several
months. Many factors contribute to its metabolism and excretion rate including the
individual's body weight, history of use/abuse, metabolic dysfunctions, renal system
dysfunction, among others.
Mechanism of Action
Levomethadone (the R enantiomer) is a μ-opioid receptor agonist with higher intrinsic
activity than morphine, but lower affinity. Dextromethadone (the S enantiomer) does not
affect opioid receptors but binds to the glutamatergic NMDA (N-methyl-D-aspartate)
receptor, and thus acts as a receptor antagonist against glutamate. Methadone has
been shown to reduce neuropathic pain in rat models, primarily through NMDA
antagonism. Glutamate is the primary excitatory neurotransmitter in the CNS. NMDA
receptors have a very important role in modulating long-term excitation and memory
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formation. NMDA antagonists such as dextromethorphan (DXM), ketamine (a
dissociative anaesthetic, also M.O.A+.), tiletamine (a veterinary anaesthetic)
and ibogaine (from the African tree Tabernanthe iboga, also M.O.A+.) are being studied
for their role in decreasing the development of tolerance to opioids and as possible for
eliminating addiction/tolerance/withdrawal, possibly by disrupting memory circuitry.
Acting as an NMDA antagonist may be one mechanism by which methadone decreases
craving for opioids and tolerance, and has been proposed as a possible mechanism for
its distinguished efficacy regarding the treatment of neuropathic pain.
The dextrorotary form (d-methadone) acts as an NMDA antagonist and is devoid of
opioid activity: it has been shown to produce analgesia in experimental models of
chronic pain. Methadone also acted as a potent, noncompetitive α3β4 neuronal nicotinic
acetylcholine receptor antagonist in rat receptors, expressed in human embryonic
kidney cell lines.
Metabolism
Methadone has a slow metabolism and very high fat solubility, making it longer lasting
than morphine-based drugs. Methadone has a typical elimination half-life of 15 to 60
hours with a mean of around 22. However, metabolism rates vary greatly between
individuals, up to a factor of 100, ranging from as few as 4 hours to as many as 130
hours, or even 190 hours. This variability is apparently due to genetic variability in the
production of the associated cytochrome enzymes CYP3A4, CYP2B6 and CYP2D6.
Many substances can also induce, inhibit or compete with these enzymes further
affecting (sometimes dangerously) methadone half-life. A longer half-life frequently
allows for administration only once a day in Opioid detoxification and maintenance
programs. People who metabolize methadone rapidly, on the other hand, may require
twice daily dosing to obtain sufficient symptom alleviation while avoiding excessive
peaks and troughs in their blood concentrations and associated effects. This can also
allow lower total doses in some such people. The analgesic activity is shorter than the
pharmacological half-life; dosing for pain control usually requires multiple doses per
day.
The main metabolic pathway involves N-demethylation by CYP3A4 in the liver and
intestine to give 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP). This inactive
product, as well as the inactive 2-ethyl-5-methyl-3,3- diphenyl-1-pyrroline (EMDP),
produced by a second N-demethylation, are detectable in the urine of those taking
methadone.
Route of Administration
The most common route of administration at a methadone clinic is in a racemic oral
solution, though in Germany, only the R enantiomer (the L optical isomer) has
traditionally been used, as it is responsible for most of the desired opioid effects. The
single-isomer form is becoming less common due to the higher production costs.
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Methadone is available in traditional
pill, sublingual tablet, and two different formulations
designed for the person to drink. Drinkable forms
include ready-to-dispense liquid (sold in the United
States as Methadose), and "Diskets" which are
tablets designed to disperse themselves rapidly in
water for oral administration, used in a similar
fashion to Alka-Seltzer. The liquid form is the most
common as it allows for smaller dose changes.
Methadone is almost as effective when
administered orally as by injection. In fact, injection
of methadone does not result in a "rush" as with
some other strong opioids such
as morphine or hydromorphone, because its
extraordinarily high volume of distribution causes it
to diffuse into other tissues in the body, particularly
fatty tissue; the peak concentration in the blood is
achieved at roughly the same time, whether the
drug is injected or ingested.
Oral medication is usually preferable because it
offers safety, simplicity and represents a step away
from injection-based drug abuse in those recovering
from addiction. U.S. federal regulations require the
oral form in addiction treatment programs. Injecting Methadone pills can cause
collapsed veins, bruising, swelling, and possibly other harmful effects. Methadone pills
often contain talc that, when injected, produces a swarm of tiny solid particles in the
blood, causing numerous minor blood clots.
These particles cannot be filtered out before injection, and will accumulate in the body
over time, especially in the lungs and eyes, producing various complications such
as pulmonary hypertension, an irreversible and progressive disease. The formulation
sold under the brand name Methadose (flavored liquid suspension for oral dosing,
commonly used for maintenance purposes) should not be injected either. While it has
been done in extremely diluted concentrations, instances of cardiac arrest have been
reported, as well as damaged veins from sugars (even sugar-free syrups may cause
this damage due to the presence of similarly-damaging artificial sweeteners). Oral
medication also offers safety, simplicity and represents a step away from injectionbased
drug abuse in those recovering from addiction. U.S. federal regulations require
the oral form in addiction treatment programs.
Information leaflets included in packs of UK methadone tablets state that the tablets are
for oral use only and that use by any other route can cause serious harm. In addition to
this warning, additives have now been included into the tablets formulation to make the
use of them by the IV route more difficult.
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History
Methadone was developed in 1937 in Germany by scientists working for I.G.
Farbenindustrie AG at the Farbwerke Hoechst who were looking for a synthetic opioid
that could be created with readily available precursors, to solve Germany's opium
shortage problem. On September 11, 1941 Bockmühl and Ehrhart filed an application
for a patent for a synthetic substance they called Hoechst 10820 or Polamidon (a name
still in regular use in Germany) and whose structure had only slight relation to morphine
or the opiate alkaloids. (Bockmühl and Ehrhart, 1949) It was brought to market in 1943
and was widely used by the German army during WWII.
In the 1930s, meperidine went into production in Germany; however, production of
methadone, then being developed under the designation Hoechst 10820, was not
carried forward because of side effects discovered in the early research. After the war,
all German patents, trade names and research records were requisitioned and
expropriated by the Allies. The records on the research work of the I.G. Farbenkonzern
at the Farbwerke Hoechst were confiscated by the U.S. Department of Commerce
Intelligence, investigated by a Technical Industrial Committee of the U.S. Department of
State and then brought to the US. The report published by the committee noted that
while methadone was potentially addictive, it produced less sedation and respiratory
depression than morphine and was thus interesting as a commercial drug.
In the early 1950s, methadone (most times the racemic HCl salts mixture) was also
investigated for use as an antitussive.
From this research came a generally non-controlled—or controlled for having the same
precursors and effects of strong pure agonist agents of the open chain type, this one a
phenaloxam derivative, levopropoxyphene with optical isomerism and one of which
appeared to have no narcotic properties but was an antitussive which did have
dissociative effects if misused; the isomer form which is removed from the racemic salts
to yield dextromethorphan, or remove the other isomer to purify a dextropropoxyphene,
or left in to finish with a racemic salts mixture dimethorphan. The open chain opioids
tend to have at least one isomer that is at some level a strong pure mu opioid receptor
agent.
Isomethadone, noracymethadol, LAAM, and normethadone were first developed in
Germany, United Kingdom, Belgium, Austria, Canada, and the United States in the
thirty or so years after the 1937 discovery of pethidine, the first synthetic opioid used in
medicine, prolonging and increasing length and depth of satiating any opiate cravings
and generating very strong analgesia (the long metabolic half-life and the strong
receptor affinity at the mu opioid receptor sites, therefore imparting much of the satiating
and anti-addictive effects of methadone) by means of suppressing drug cravings and
the discovery in the early 1950s. of methadone's antitussive properties first tested in
dogs in Europe in 1952-1955 with different inert placebos, active placebos like codeine.
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It was only in 1947 that the drug was given the generic name “methadone” by the
Council on Pharmacy and Chemistry of the American Medical Association. Since the
patent rights of the I.G. Farbenkonzern and Farbwerke Hoechst were no longer
protected each pharmaceutical company interested in the formula could buy the rights
for the commercial production of methadone for just one dollar (MOLL 1990).
Methadone was introduced into the United States in 1947 by Eli Lilly and Company as
an analgesic under the trade name Dolophine, which is now registered to Roxane
Laboratories. Since then, it has been best known for its use in treating opioid
dependence. A great deal of anecdotal evidence was available "on the street" that
methadone might prove effective in treating heroin withdrawal and is not uncommonly
used in hospitals and other de-addiction centers to enhance rates of completed opioid
withdrawal. It was not until studies performed at the Rockefeller University in New York
City by Professor Vincent Dole, along with Marie Nyswander and Mary Jeanne Kreek,
that methadone was systematically studied as a potential substitution therapy. Their
studies introduced a sweeping change in the notion that drug addiction was not
necessarily a simple character flaw, but rather a disorder to be treated in the same way
as other diseases. To date, methadone maintenance therapy has been the most
systematically studied and most successful, and most politically polarizing, of any
pharmacotherapy for the treatment of people with drug addiction.
Methadone was first manufactured in the US by Eli Lilly, who obtained FDA approval on
August 14, 1947, for their Dolophine 5 mg and 10 mg Tablets. Mallinckrodt
Pharmaceuticals did not receive approval until December 15, 1947 to manufacture their
bulk compounding powder. Mallinckrodt received approval for their branded generic,
Methadose, on April 15, 1993 for their 5 mg and 10 mg Methadose Tablets. Mallinckrodt
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who also makes 5 mg, 10 mg and 40 mg generic tablets in addition to their branded
generic Methadose received approval for their plain generic tablets on April 27, 2004.
The trade name Dolophine was created by Eli Lilly after World War II and used in the
United States; the claim that Nazi leader Adolf Hitler ordered the manufacture of
methadone or that the brand name 'Dolophine' was named after him is an urban
legend. The pejorative term "adolphine" (never a widely used name for the drug)
appeared in the United States in the early 1970s as a reference to the aforementioned
urban myth that the trade name Dolophine was a reference to Adolf Hitler.
Brand Names
Society and Culture
Brand names include Dolophine, Symoron, Amidone, Methadose, Physeptone, and
Heptadon among others.
Methadone Maintenance Treatment
Cost
Methadone maintenance clinics in the US charge anywhere from $5 to $400 per week,
which may be covered by private insurance or Medicaid.
In Germany, methadone maintenance treatment (MMT) is fully covered by all public and
private insurance plans. The annual cost per person is less than 3000 euros,
while heroin-assisted treatment costs up to 10,000 euros per year.
MMT cost analyses often compare the cost of clinic visits versus the overall societal
costs of illicit opioid use.
As of 2015 China had the largest methadone maintenance treatment program with over
250,000 people in over 650 clinics in 27 provinces.
Medication
In the US, generic methadone tablets are not very expensive. The retail price ranges
between $0.25 and $2.50 per defined daily dose. Brand-name methadone tablets may
cost much more.
Controversy
Methadone substitution as a treatment of opioid addiction has been widely criticized in
the social sciences for its role in social control of addicts. It is suggested that
methadone does not function as much to curb addiction as to redirect it and maintain
dependency on authorised channels. Several authors apply a Foucauldian analysis to
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the widespread prescription of the drug and use in institutions such as prisons, hospitals
and rehabilitation centres. [76] Such critique centers on the notion that substance
addiction is reframed with a disease model. Thus methadone, which mimics the effects
of opioids and renders the addict compliant, is labeled as a “treatment” and so obscures
the disciplinary objectives of “managing undesirables”. [75]
Regulation
Methadone is a Schedule II controlled substance in the United States, with an ACSCN
of 9250 and a 2014 annual aggregate manufacturing quota of 31 875 kilos for
sale. Methadone intermediate is also controlled, under ACSCN 9226 also under
Schedule II, with a quota of 38 875 kilos. In most countries of the world, methadone is
similarly restricted. The salts of methadone in use are the hydrobromide (free base
conversion ratio 0.793), hydrochloride (0.894), and HCl monohydrate
(0.850). Methadone is also regulated internationally as a Schedule I controlled
substance under the United Nations Single Convention on Narcotic Drugs of 1961.
In Russia, methadone treatment is illegal. Gennadiy Onishchenko, Chief Sanitary
Inspector, claimed in 2008 that health officials are not convinced of the treatment's
efficacy. Instead, doctors encourage immediate cessation of drug use, rather than the
gradual process that methadone substitution therapy entails. People are often
given sedatives and non-opioid analgesics to cope with withdrawal symptoms.
Buprenarphine
Buprenorphine, sold under the brand name Subutex, among others, is an opioid used
to treat opioid addiction, acute pain, and chronic pain. It can be used under the tongue,
by injection, or as a skin patch. When used for opioid addiction it is recommended that a
health care provider observe the person while they take the medication. For longer term
treatment of addiction a combination formulation of buprenorphine/naloxone is usually
recommended. Maximum pain relief is generally within an hour with effects up to 24
hours.
Side effects may include respiratory depression (decreased breathing),
sleepiness, adrenal insufficiency, QT prolongation, low blood pressure, allergic
reactions, and opioid addiction. Among those with a history of seizures, there is a risk of
further seizures. Opioid withdrawal following stopping is generally mild. It is unclear if
use during pregnancy is safe and use while breastfeeding is not
recommended. Buprenorphine affects different types of opioid receptors in different
ways. Depending on the type of receptor it may be an agonist, partial agonist,
or antagonist.
Buprenorphine was approved for medical use in the United States in 1981. In 2012 9.3
million prescription for the medication were made in the United States. Buprenorphine
may also be used recreationally by injection or in the nose for the high it
produces. Some use it as a substitute for heroin. In the United States it is a Schedule
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III controlled substance. For the tablets the wholesale cost in the United States is
between 0.86 and 1.32 USD per daily dose as of 2017.
Opioid Addiction
Medical Uses
Its primary use is for the initial treatment of those with opioid addiction. It should only be
started once symptoms of withdrawal have begun. For longer term treatment of
addiction a combination formulation of buprenorphine/naloxone is usually
recommended. A once a month injection has been approved in the United States and
should be on available in 2018.
Buprenorphine vs. Methadone
Both buprenorphine and methadone are medications used for
detoxification, short-
and long-term opioid replacement therapy.
Effectiveness of buprenorphine and methadone
appear similar, with similar side effects.
Buprenorphine may have less respiratory
depression in cases of
abuse.
Inpatient Rehabilitation and
Detoxification
Rehabilitation
programs consist of "detox" and
"treatment" phases. The detoxification ("detox") phase
consists of medically supervised withdrawal from the
drug of dependency onto buprenorphine, sometimes aided
by the use of medications such
as benzodiazepines like oxazepam or diazepam (modern milder tranquilizers that assist
with anxiety, sleep, and muscle relaxation), clonidine (a blood-pressure medication that
may reduce some opioid withdrawal symptoms), and anti-inflammatory/pain relief drugs
such as ibuprofen and aspirin.
The treatment phase begins once the person is stabilized and receives medical
clearance. This portion of treatment consists of multiple therapy sessions, which include
both group and individual counseling with various chemical dependency counselors,
psychologists, psychiatrists, social workers, and other professionals. In addition, many
treatment centers utilize 12-step programs such as Narcotics Anonymous.
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Chronic Pain
A transdermal patch is available for the treatment of chronic pain. These patches are
not indicated for use in acute pain, pain that is expected to last only for a short period of
time, or pain after surgery, nor are they recommended for opioid addiction.
Adverse Effects
Common adverse drug reactions associated with the use of buprenorphine are similar
to those of other opioids and include: nausea and vomiting, drowsiness, dizziness,
headache, memory loss, cognitive and neural inhibition, perspiration, itchiness, dry
mouth, shrinking of the pupils of the eyes (miosis), orthostatic hypotension, male
ejaculatory difficulty, decreased libido, and urinary retention. Constipation and CNS
effects are seen less frequently than with morphine.
Respiratory Effects
The most severe side effect associated with buprenorphine is respiratory depression
(insufficient breathing). It occurs more often in those who are also
taking benzodiazepines, alcohol, or have underlying lung disease. The usual reversal
agents for opioids, such as naloxone, may be only partially effective and additional
efforts to support breathing may be required. Respiratory depression may be less than
with other opioids.
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Buprenorphine Dependence
Buprenorphine treatment carries the risk of causing psychological or physical
dependence. Buprenorphine has a slow onset and a long half-life of 24 to 60 hours.
Once a person has stabilized on the medication, there are three options: continual use,
switching to buprenorphine/naloxone, or medically supervised withdrawal.
Pain management
People on high-dose buprenorphine therapy may be unaffected by even large doses of
opioids such as oxycodone, morphine, or hydromorphone.
It is also difficult to achieve acute opioid analgesia in persons using buprenorphine for
opioid replacement therapy.
Pharmacodynamics
Opioid Receptor Modulator
Pharmacology
Buprenorphine has been reported to possess the following pharmacological activity:
μ-Opioid receptor (MOR): Weak partial agonist. Binds with high affinity, but only
partially activates the receptor. This behavior is responsible for buprenorphine's
ability to block most μ agonists and the phenomenon of withdrawal effects when
used in actively opioid dependent persons.
κ-Opioid receptor (KOR): Very weak partial agonist or functional antagonist.
Possible therapeutic applications as animal models show antidepressive,
anxiolytic, stress relieving, and anti-addictive properties with κ antagonists.
δ-Opioid receptor (DOR): Antagonist. Possible attenuation of drug reward.
Nociceptin receptor (NOP, ORL-1): Weak affinity. Very weak partial agonist. May
be involved in lack of respiratory depression with buprenorphine in overdose.
In simplified terms, buprenorphine can essentially be thought of as a non-selective,
mixed agonist–antagonist opioid receptor modulator, acting as a weak partial agonist of
the MOR, an antagonist of the KOR, an antagonist of the DOR, and a relatively lowaffinity,
very weak partial agonist of the ORL-1.
Although buprenorphine is a partial agonist of the MOR, human studies have found that
it acts like a full agonist with respect to analgesia. Conversely, buprenorphine behaves
like a partial agonist of the MOR with respect to respiratory depression.
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Buprenorphine is also known to bind to with high affinity and antagonize the putative ε-
opioid receptor.
Full analgesic efficacy of buprenorphine requires both exon 11- and exon 1-
associated μ-opioid receptor splice variants.
The active metabolites of buprenorphine are not thought to be clinically important in
its central nervous system effects.
Other Actions
Unlike some other opioids and opioid antagonists, buprenorphine binds only weakly to
and possesses little if any activity at the sigma receptor.
Buprenorphine also blocks voltage-gated sodium channels via the local
anesthetic binding site, and this underlies its potent local anesthetic properties.
Similarly to various other opioids, buprenorphine has also been found to act as an
agonist of the toll-like receptor 4, albeit with very low affinity.
Pharmacokinetics
Buprenorphine is metabolised by
the liver,
via CYP3A4 (also CYP2C8 seems to
be involved) isozymes of
the cytochrome P450 enzyme system,
into norbuprenorphine (by N-
dealkylation). The glucuronidation of
buprenorphine is primarily carried out
by UGT1A1 and UGT2B7, and that of
norbuprenorphine
by UGT1A1 and UGT1A3. These
glucuronides are then eliminated
mainly through excretion into the bile.
The elimination
half-life of
buprenorphine is 20–73 hours (mean 37). Due to the mainly hepatic elimination, there is
no risk of accumulation in people with renal impairment.
One of the major active metabolites of buprenorphine is norbuprenorphine, which,
contrary to buprenorphine itself, is a full agonist of the MOR, DOR, and ORL-1, and a
partial agonist at the KOR. However, relative to buprenorphine, norbuprenorphine has
extremely little antinociceptive potency (1/50th that of buprenorphine), but markedly
depresses respiration (10-fold more than buprenorphine). This can be explained by very
poor brain penetration of norbuprenorphine due to a high affinity of the compound for P-
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glycoprotein. In contrast to norbuprenorphine, buprenorphine and
its glucuronide metabolites are negligibly transported by P-glycoprotein.
The glucuronides of buprenorphine and norbuprenorphine are also biologically active,
and represent major active metabolites of buprenorphine. Buprenorphine-3-
glucuronide has affinity for the MOR (Ki = 4.9 pM), DOR (Ki = 270 nM) and ORL-1 (Ki =
36 µM), and no affinity for the KOR. It has a small antinociceptive effect and no effect on
respiration. Norbuprenorphine-3-glucuronide has no affinity for the MOR or DOR, but
does bind to the KOR (Ki = 300 nM) and ORL-1 (Ki = 18 µM). It has a sedative effect but
no effect on respiration.
Chemistry
Buprenorphine is a semi-synthetic analogue of thebaine [44] and is fairly soluble in water,
as its hydrochloride salt. It degrades in the presence of light.
Detection in Body Fluids
Buprenorphine and norbuprenorphine may be quantitated in blood or urine to monitor
use or abuse, confirm a diagnosis of poisoning, or assist in a medicolegal investigation.
There is a significant overlap of drug concentrations in body fluids within the possible
spectrum of physiological reactions ranging from asymptomatic to comatose. Therefore,
it is critical to have knowledge of both the route of administration of the drug and the
level of tolerance to opioids of the individual when results are interpreted.
History
In 1969, researchers at Reckitt & Colman (now Reckitt Benckiser) had spent 10 years
attempting to synthesize an opioid compound "with structures substantially more
complex than morphine [that] could retain the desirable actions whilst shedding the
undesirable side effects". Physical dependence and withdrawal from buprenorphine
itself, remains an issue because it is a long-acting opiate. Reckitt found success when
researchers synthesized RX6029 which had showed success in reducing dependence
in test animals. RX6029 was named buprenorphine and began trials on humans in
1971. By 1978, buprenorphine was first launched in the UK as an injection to treat
severe pain, with a sublingual formulation released in 1982.
Regulation
Society and Culture
In the United States, buprenorphine (Subutex) and buprenorphine
with naloxone (Suboxone) were approved for opioid addiction by the United States Food
and Drug Administration in October 2002. The FDA rescheduled buprenorphine from
a Schedule V drug to a Schedule III drug just before approval of Subutex and
Suboxone. The ACSCN for buprenorphine is 9064, and being a Schedule III substance
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it does not have an annual manufacturing quota imposed by the DEA. The salt in use is
the hydrochloride, which has a free base conversion ratio of 0.928.
In the years prior to Suboxone's approval, Reckitt Benckiser had lobbied Congress to
help craft the Drug Addiction Treatment Act of 2000 (DATA 2000), which gave authority
to the Secretary of Health and Human Services to grant a waiver to physicians with
certain training to prescribe and administer Schedule III, IV, or V narcotic drugs for the
treatment of addiction or detoxification. Prior to the passage of this law, such treatment
was not permitted in outpatient settings except for clinics designed specifically for drug
addiction.
The waiver, which can be granted after the completion of an eight-hour course, is
required for outpatient treatment of opioid addiction with Subutex and Suboxone.
Initially, the number of patients each approved physician could treat was limited to ten.
This was eventually modified to allow approved physicians to treat up to a hundred
patients with buprenorphine for opioid addiction in an outpatient setting. This limit was
recently increased by the Obama administration, raising the number of patients to which
doctors can prescribe to 275. Still, due to this patient limit and the requisite eight-hour
training course, many continuing patients can find it very difficult to get a prescription,
despite the drug's effectiveness.
In the European Union, Subutex and Suboxone, buprenorphine's high-dose sublingual
tablet preparations, were approved for opioid addiction treatment in September 2006. In
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the Netherlands, buprenorphine is a List II drug of the Opium Law, though special rules
and guidelines apply to its prescription and dispensation.
Brand Names
Buprenorphine is available under the trade names Cizdol, Suboxone, Subutex (typically
used for opioid addiction), Temgesic (sublingual tablets for moderate to severe pain),
Buprenex (solutions for injection often used for acute pain in primary-care settings),
Norspan and Butrans (transdermal preparations used for chronic pain).
Buprenorphine has been introduced in most European countries as a transdermal
formulation (marketed as Transtec) for the treatment of chronic pain not responding to
non-opioids.
Veterinary Medicine
It has veterinary medical use for treatment of pain in dogs and cats.
Depression
Research
A clinical trial conducted at Harvard Medical School in the mid-1990s demonstrated that
a majority of persons with non-psychotic unipolar depression who were refractory to
conventional antidepressants and electroconvulsive therapy could be successfully
treated with buprenorphine. Clinical depression is currently not an approved indication
for the use of any opioid.
Buprenorphine/samidorphan (ALKS-5461), a combination product of buprenorphine
and samidorphan (a preferential μ-opioid receptor antagonist), is currently
undergoing phase III clinical trials in the United States for augmentation of
antidepressant therapy for treatment-resistant depression.
Cocaine Dependence
In combination with samidorphan or naltrexone (μ-opioid receptor antagonists),
buprenorphine is under investigation for the treatment of cocaine dependence, and
recently demonstrated effectiveness for this indication in a large-scale (n = 302) clinical
trial (at a high buprenorphine dose of 16 mg but not a low dose of 4 mg).
Neonatal Abstinence
Buprenorphine has been used in the treatment of the neonatal abstinence syndrome, a
condition in which newborns exposed to opioids during pregnancy demonstrate signs of
withdrawal. Use currently is limited to infants enrolled in a clinical trial conducted under
an FDA approved investigational new drug (IND) application. An ethanolic formulation
used in neonates is stable at room temperature for at least 30 days.
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Obsessive–Compulsive Disorder
In one study, buprenorphine was found to be effective in a subset of individuals with
treatment-refractory obsessive–compulsive disorder.
Behavior Modification
Behavior Modification is based on methodological behaviorism, which refers to
limiting behavior-change procedures to behaviors that are observable and was
employed briefly during the late 1950s but predominately from the late 1970s to early
1980s. Specifically, behavior was modified through the use of presumed consequences,
including positive and negative reinforcement contingencies to increase desirable
behavior or by administering positive and negative punishment and/or extinction to
reduce behavior.
In contrast to behavior analysis, analyzing the
behavior-environment interactions (including
antecedent stimuli) was not considered relevant in
behavior modification; it also lacked the conceptual
piece (radical behaviorism) initially purposed by B. F.
Skinner. Subsequently, applied behavior
analysis (ABA) has superseded the early term
behavior modification since the 1990s.
Description
The first use of the term behavior modification
appears to have been by Edward Thorndike in 1911.
His article Provisional Laws of Acquired Behavior or Learning makes frequent use of the
term "modifying behavior". Through early research in the 1940s and the 1950s the term
was used by Joseph Wolpe's research group. The experimental tradition in clinical
psychology used it to refer to psycho-therapeutic techniques derived from empirical
research. It has since come to refer mainly to techniques for increasing adaptive
behavior through reinforcement and decreasing maladaptive behavior through extinction
or punishment (with emphasis on the former). Emphasizing the empirical roots of
behavior modification, some authors consider it to be broader in scope and to subsume
the other two categories of behavior change methods.
In recent years, the concept of punishment has had many critics, though these
criticisms tend not to apply to negative punishment (time-outs) and usually apply to the
addition of some aversive event. The use of positive punishment by board certified
behavior analysts is restricted to extreme circumstances when all other forms of
treatment have failed and when the behavior to be modified is a danger to the person or
to others (see professional practice of behavior analysis). In clinical settings positive
punishment is usually restricted to using a spray bottle filled with water as an aversive
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event. When misused, more aversive punishment can lead to affective (emotional)
disorders, as well as to the receiver of the punishment increasingly trying to avoid the
punishment (i.e., "not get caught").
Behavior modification relies on the following:
Reinforcement (Positive and Negative)
Punishment (Positive and Negative)
Extinction
Shaping
Fading
Chaining
Some Areas of Effectiveness
Functional behavior assessment forms the core of applied behavior analysis. Many
techniques in this therapy are specific techniques aimed at specific issues. Interventions
based on behavior analytic/modification principles have been extremely effective in
developing evidence-based treatments.
In addition to the above, a growing list of research-based interventions from the
behavioral paradigm exist. With children with attention deficit hyperactivity
disorder (ADHD), one study showed that over a several year period, children in the
behavior modification group had half the number of felony arrests as children in the
medication group. These findings have yet to be replicated, but are considered
encouraging for the use of behavior modification for children with ADHD. There is strong
and consistent evidence that behavioral treatments are effective for treating ADHD. A
recent meta-analysis found that the use of behavior modification for ADHD resulted in
effect sizes in between group studies (.83), pre-post studies (.70), within group studies
(2.64), and single subject studies (3.78) indicating behavioral treatments are highly
effective.
Behavior modification programs form the core of many residential treatment
facility programs. They have shown success in reducing recidivism for adolescents with
conduct problems and adult offenders. One particular program that is of interest
is teaching-family homes(see Teaching Family Model), which is based on a social
learning model that emerged from radical behaviorism. These particular homes use a
family style approach to residential treatment, which has been carefully replicated over
700 times. Recent efforts have seen a push for the inclusion of more behavior
modification programs in residential re-entry programs in the U.S. to aid prisoners in readjusting
after release.
One area that has repeatedly shown effectiveness has been the work
of behaviorists working in the area of community reinforcement for addictions. Another
area of research that has been strongly supported has been behavioral activation for
depression.
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One way of giving positive reinforcement in behavior modification is in providing
compliments, approval, encouragement, and affirmation; a ratio of five compliments for
every one complaint is generally seen as being effective in altering behavior in a desired
manner and even in producing stable marriages.
Of notable interest is that the right behavioral intervention can have profound system
effects. For example, Forgatch and DeGarmo (2007) found that with mothers who were
recently divorced, a standard round of parent management training (programs based on
social learning principles that teaches rewarding good behavior and ignoring bad
behavior combined with communication skills) could
help elevate the divorced
mother out of poverty. In
addition, parent management training
programs,
sometimes referred to
as behavioral parent training
programs, have shown relative
cost
effectiveness for
their efforts for
the treatment of
conduct
disorder. Thus,
such
intervention can
have profound effects on
socializing the child in a
relatively cost effective fashion
and help get the parent out of
poverty. This level of effect is
often looked for and valued by
those who practice behavioral
engineering and
results of this type
have caused the Association for Behavior
Analysis International to
take a position that those
receiving treatment have a right
to effective treatment and a right
to effective education.
In Job Performance
Based on the conceptual premises of classical behaviorism and reinforcement theory,
the Organizational Behavior Modification Model (aka O.B. Mod) represents a behavioral
approach to the management of human resources in organizational settings. The
application of reinforcement theory to modification of behavior as it relates to job
performance first requires analysis of necessary antecedents (e.g., job design, training)
of the desired behavior. After it has been determined that the necessary antecedents
are present, managers must first identify the behaviors to change. These behaviors
must be observable, measurable, task-related, and critical to the task at hand. Next, a
baseline measure of the behavior must be assessed and functional consequences
analyzed. Now that the link between the antecedent, behavior, and contingent
consequences has been established, an intervention to change the behavior can be
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introduced. If the intervention is successful in modifying the behavior, it must be
maintained using schedules of reinforcement and must be evaluated for performance
improvement. The O.B. Mod has been found to have a significant positive effect on task
performance globally, with performance on average increasing 17%.
A study that examined the differential effects of incentive motivators administered with
the O.B. Mod on job performance found that using money as a reinforcer with O.B. Mod
was more successful at increasing performance compared to routine pay for
performance (i.e., money administered on performance not using O.B. Mod). The
authors also found that using money administered through the O.B. Mod produced
stronger effects (37% performance increase), compared to social recognition (24%
performance increase) and performance feedback (20% performance increase).
Criticism
Behavior modification is critiqued in person-centered psychotherapeutic approaches
such as Rogerian Counseling and Re-evaluation Counseling, which involve "connecting
with the human qualities of the person to promote healing", while behaviorism is
"denigrating to the human spirit". B.F. Skinner argues in Beyond Freedom and
Dignity that unrestricted reinforcement is what led to the "feeling of freedom", thus
removal of aversive events allows people to "feel freer". Further criticism extends to the
presumption that behavior increases only when it is reinforced. This premise is at odds
with research conducted by Albert Bandura at Stanford University. His findings indicate
that violent behavior is imitated, without being reinforced, in studies conducted with
children watching films showing various individuals "beating the daylights out of Bobo".
Bandura believes that human personality and learning is the result of the interaction
between environment, behavior and psychological process. There is evidence,
however, that imitation is a class of behavior that can be learned just like anything else.
Children have been shown to imitate behavior that they have never displayed before
and are never reinforced for, after being taught to imitate in general.
Several people have criticized the level of training required to perform behavior
modification procedures, especially those that are restrictive or use aversives, aversion
therapy, or punishment protocols. Some desire to limit such restrictive procedures only
to licensed psychologists or licensed counselors. Once licensed for this group, postlicensed
certification in behavior modification is sought to show scope of competence in
the area through groups like the World Association for Behavior Analysis. Still others
desire to create an independent practice of behavior analysis through licensure to offer
consumers choices between proven techniques and unproven ones (see Professional
practice of behavior analysis). Level of training and consumer protection remain of
critical importance in applied behavior analysis and behavior modification.
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VI. References
1. https://en.wikipedia.org/wiki/Opioid_epidemic
2. https://www.theguardian.com/us-news/2017/oct/25/americas-opioid-crisis-how-prescription-drugs-sparked-anational-trauma
3. http://www.cnn.com/2017/09/18/health/opioid-crisis-fast-facts/index.html
4. https://en.wikipedia.org/wiki/Oxycodone
5. https://en.wikipedia.org/wiki/Heroin
6. https://en.wikipedia.org/wiki/Allegations_of_CIA_drug_trafficking
7. https://en.wikipedia.org/wiki/Fentanyl
8. https://en.wikipedia.org/wiki/Naloxone
9. https://en.wikipedia.org/wiki/Methadone
10. https://en.wikipedia.org/wiki/Buprenorphine
11. https://en.wikipedia.org/wiki/Detoxification
12. https://en.wikipedia.org/wiki/Group_psychotherapy
13. https://en.wikipedia.org/wiki/Psychotherapy
14. https://en.wikipedia.org/wiki/Residential_treatment_center
15. https://en.wikipedia.org/wiki/Twelve-step_program
16. https://en.wikipedia.org/wiki/Narcotics_Anonymous
17. https://www.samhsa.gov/sites/default/files/grants/pdf/other/ti-17-014-opioid-str-abstracts.pdf
18. https://dupress.deloitte.com/content/dam/dup-us-en/articles/fighting-opioid-crisis-heroin-abuse-ecosystemapproach/DUP_3406_Opioid-ecosystem_MASTER_FINAL.pdf
19. http://www.globalcommissionondrugs.org/wp-content/uploads/2017/09/2017-GCDP-Position-Paper-Opioid-
Crisis-ENG.pdf
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Page 140 of 166

Attachment A
State Targeted Grants Response
to the Opioid Crisis
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Substance Abuse and Mental Health Services Administration
TI-17-014: State Targeted Response to the Opioid Crisis Grants
(Opioid STR) Individual Grant Awards
ALABAMA
Year 1 Year 2
$ 7,967,873 $ 7,967,873
PROJECT SUMMARY
The Alabama Department of Mental Health (ADMH) proposes to enhance and expand opioid
use disorder prevention, treatment, recovery support and related services for unserved and
underserved populations and locations in Alabama. This statewide initiative, the Alabama
Opioid Strategic Targeted Response (STR), will seek to implement life-saving strategies to aid
in combating the state’s current opioid epidemic. Alabama has one of the highest rates of
painkiller use in the world. The relationship between painkiller use and illicit opioid use is
taking a devastating toll on the state with opioid-related overdoses and deaths steadily climbing
each year. ADMH will collaborate with its state partners to conduct a needs assessment to
identify gaps in the state’s system of care which block access to OUD treatment and related
services. The needs assessment will support development of a strategic plan to specifically target
state spending to areas and populations of greatest need. Based upon needs known to date,
ADMH will utilize the Alabama Opioid STR to (1) expand access to medications approved by
the FDA for treatment of opioid use disorders,; (2) improve retention in care for individuals who
have been diagnosed with an OUD; (3) improve the skills of Alabama’s workforce for delivery
of evidence-based services for OUDs; (4) reduce stigma and improve public awareness of
Alabama’s opioid misuse and addiction crisis and of treatment options available; (5) increase the
availability of Naloxone in unserved areas of the state with high overdose death rates; and (6)
enhance statewide coordinated efforts of the strategic prevention framework (SPF) in areas
identified as high need and target prescription drug misuse with youth and adults. The targets for
Alabama’s Opioid STR will be (1) individuals who are not able to access OUD treatment or
related services because they don’t have the money or insurance to cover the cost of such; (2)
individuals in areas of the state in which OUD services are not available; (3) individuals in areas
of the state with high overdose and death rates; (4) minorities, veterans, and referrals from the
criminal justice system who are significantly underrepresented in the state’s OUD treatment
programs. A 24/7 hotline will be established and a treatment related media campaign will be
implemented to promote improved access to care. ADMH will leverage the resources of its
partners, including BRSS TACS and the ATTC in securing training for the OUD workforce in
evidence-based practices that include Motivational Interviewing and Shared Decision Making.
The use of Peer Support Specialists will be utilized in every aspect of this initiative.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

ALASKA
Year 1 Year 2
$ 2,000,000 $ 2,000,000
PROJECT SUMMARY
In the last several years, Alaska has seen a dramatic rise in opioid use and opioid overdose
related deaths. There is a gap in available behavioral health and substance abuse services
throughout the State. This project will help Alaska’s unmet need to combat the opioid crisis by
increasing the capacity and number of prescribers of Medication Assisted Treatment (MAT),
increasing the number of Alaskan served, and augmenting present prevention efforts. From
2009–2015, the Alaska Bureau of Vital Statistics mortality database has shown a steady increase
of drug overdose deaths totaling 774 people. The number of treatment admissions for opiates
and heroin has more than tripled since 2007. Populations who most frequently access OUD
treatment tend to be female, white or Alaska Native, between 25-44 years old, and have a high
school diploma or GED. There are inadequate resources for MAT for OUD in Alaska. There are
four opioid treatment programs (OTPs) and relatively few physicians are waivered to prescribe
buprenorphine and many of those do not actively accept patients. The purpose of the Alaska
STR to the Opioid Crisis grant is to increase access to treatment, reduce unmet treatment needs,
and reduce opioid overdose related deaths through prevention, treatment, and recovery activities
for OUDs in the State of Alaska. Specifically, Alaska will focus on the following three goals: 1)
increase provider capacity in the state for medication assisted treatment, 2) increase the number
of clients receiving appropriate OUD/MAT treatment, and 3) decrease the negative impacts of
opioid use. To meet these goals Alaska will track the following objectives: 1) number of OUD
prescribers trained, 2) number of OUD prescribers receiving buprenorphine waivers, 3) number
of OUD prescribers implementing MAT, 4) number of behavioral health providers with training
on OUDs, 5) number of people who receive OUD treatment, 6) number of people who receive
OUD recovery services, 7) numbers and rates of opioid use, and 8) numbers and rates of opioid
overdose-related deaths. To achieve these goals and objectives, this project will utilize a fourprong
approach to address gaps in prevention, treatment, and recovery. To strengthen prevention
efforts, the project will decrease access to opioid medications through the purchasing and
distribution of drug disposal bags, and provide naloxone kits in remote areas of Alaska. To build
capacity to provide office-based opioid treatment (OBOT), Alaska will utilize Vermont’s proven
OBOT Hub and Spoke treatment approach to target three to five behavioral health agencies in
high needs communities. The MAT learning collaborative, the Opioid Addiction Treatment
ECHO, will help to expand services by increasing the number of physicians, physician
assistants, and advanced nurse practitioners willing to prescribe buprenorphine and/or
naltrexone. This project will also engage Alaska’s expanding system of re-entry coalitions to
facilitate access to MAT for individuals who are returning to the community from the
Department of Corrections. This project will serve 160 unduplicated clients in Year 1 and 180
unduplicated clients in Year 2 (project total = 340)
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

GOVERNMENT of AMERICAN SAMOA
Year 1 Year 2
$ 250,000 $ 250,000
PROJECT SUMMARY
The “Taula’i” project aims to build capacity amongst service providers in order to effectively
address Opioid Use Disorders (OUD). Data has not captured OUDs in the past, therefore, the
prevalence of OUDs in American Samoa is uncertain at this time. Given the trends of other licit
and illicit substances, it is imperative that American Samoa have an established infrastructure
that is equipped to intervene as early as possible for OUD suspected cases. Five primary goals
will be accomplished with this project: (1) to increase awareness and knowledge of the general
public, health professionals, and behavioral health service providers about OUD; (2) to conduct
a needs assessment that will identify the level of need and readiness of the behavioral health
system to address OUDs; (3) to develop a territorial strategic plan for the treatment and
prevention of OUD in American Samoa; (4) to effectively identify adult opioid use or OUD in
the community through extensive data collection (Behavioral Health Survey) and screening; and
(5) implement evidence based practices for the treatment of OUD. The average number of
individuals enrolled per annum in the SSA’s Substance Abuse, Prevention, and Treatment
(SAPT) program is 300. The average number of individuals identified as having an OUD in the
U.S. was approximately 9% of all Substance Use Disorders while less than 1% of admissions are
comprised of Asian/Pacific Islanders (SAMHSA, 2004). This project will aim to screen at least
1000 adults aged 18-90 throughout the course of the grant and will serve at least 40 adults
identified as having an OUD.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

ARIZONA
Year 1 Year 2
$ 12,171,518 $ 12,171,518
PROJECT SUMMARY
The overarching goal of the Arizona Opioid State Targeted Response project is to increase
access to Opioid Use Disorder (OUD) treatment, coordinated and integrated care, recovery
support services and prevention activities to reduce the prevalence of OUDs and opioid-related
overdose deaths. The project approach includes developing and supporting state, regional, and
local level collaborations and service enhancements to develop and implement best practices to
comprehensively address the full continuum of care related to opioid misuse, abuse and
dependency. The proposed activities within the Arizona Opioid State Targeted Response project
will work synergistically with the existing efforts to reduce OUDs and OUD deaths currently
underway in Arizona by: (1) creating a new streamlined data-driven decision-making process to
target and tailor treatment and prevention resources where they are most needed in the state; (2)
expanding modes and type of training statewide for OUD prevention and treatment providers,
law enforcement and community members around OUD and overdose prevention, MAT and
integrated care models; (3) expanding law enforcement access to Naloxone kits to prevent opioid
overdose; (4) expanding navigation and access to MAT and integrated treatment and recovery
systems through new venues, new providers, new model processes and by increasing the number
of high risk individuals served; and (5) increasing the ability to ensure the likelihood of recovery
success by expanding peer support services, recovery homes and recovery supports to pregnant
and parenting women. Measureable prevention objectives to reduce OUDs and opioid-related
deaths will include: equipping law enforcement with Naloxone; expanding access to prescription
drug drop boxes for proper disposal; increasing community knowledge and awareness through
trainings and evidence-based programs and practice; and increasing access to Screening, Brief
Intervention and Referral to Treatment (SBIRT). Measurable treatment objectives to reduce
OUDs and opioid-related deaths will include: stigma reduction and knowledge of Medication
Assisted Treatment options (MAT); enlisting new MAT providers in the community; increasing
access to peer support services; increasing access to 24/7 services for MAT; increasing MAT
treatment navigation for criminal justice involved individuals; increasing recovery supports for
pregnant and parenting women; and increasing access to MAT in residential and recovery home
settings. Target populations will include, at minimum: individuals with OUDs living in rural and
underserved urban areas; individuals with OUDs being released from correctional settings;
pregnant and parenting women with OUDs; young adults ages 18-25 years; and older adults ages
55 years and older. The project will serve 5,069 individuals in year one and 7,604 individuals in
year two for a total project reach of 12,673 individuals.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

ARKANSAS
Year 1 Year 2
$ 3,901,295 $ 3,901,295
PROJECT SUMMARY
Arkansas has the lowest percentage of people with an opioid addiction for which buprenorphine
is available. For this reason, STR treatment and recovery funding will be used to expand the
statewide availability of Medication-Assisted Treatment (MAT) in three populations of focus:
pregnant and parenting women; individuals re-entering the community from incarceration; and
individuals who received naloxone for an overdose as part of the state’s PDO prevention efforts.
Arkansas is a Prescription Drug/Opioid Overdose (PDO) Prevention Grant recipient, and a
statewide comprehensive needs assessment to identify the communities at highest risk of Opioid
Use Disorder (OUD) is ongoing. The results of this assessment will also be used to help assess
current availability of treatment/prevention resources across the state. STR funding will allow
the DHS Division of Behavioral Health Services to expand the statewide availability of MAT,
working together with eight regional treatment center contractors that are funded through the
SAMHSA Substance Abuse Prevention and Treatment Block Grant. The goals of the grant are
to: expand PDO prevention efforts by supplying naloxone to first-responder agencies in
additional communities and expanding the ongoing media campaign and health literacy efforts;
train families and healthcare providers on recognition of signs of opioid addiction, referrals to
treatment, and interventions; increase access to OUD treatment using Evidence-Based Practices
(EBPs); and provide OUD recovery support through peer specialists and recovery coaches
associated with OUD treatment centers. Both target communities for PDO prevention activities
and communities of focus for STR initiatives will be selected by an advisory council convened
by the State Drug Director that was created by the PDO Prevention Grant, the PDO Advisory
Council. Utilizing a single advisory council for both grants will ensure the creation of a
comprehensive and consistent strategic plan for prevention and treatment/recovery activities
across the state and equitable utilization of resources among all state entities. The PDO Advisory
Council is a subcommittee of the existing Arkansas Alcohol and Drug Policy Coordinating
Council, which is tasked with oversight of substance abuse expenditures and policies. Two
additional task forces will be created specific to the goals of this grant – the EBP committee,
which will be concerned with implementation of collaborative efforts to provide MAT together
with counseling services to the three priority populations of focus, and the Peer Specialist
committee, which will map out steps to provide comprehensive peer support to clients during
recovery. An additional 375 people per year, or 750 across the life of the grant, will be served at
one of the eight funded treatment providers with treatment and recovery services. A recent
change in Medicaid for Arkansas will allow sustainability of the programs started with this
funding. Estimated number of people to be served as a result of the award of this grant – 750
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

CALIFORNIA
Year 1 Year 2
$ 44,749,771 $ 44,749,771
PROJECT SUMMARY
California’s project is “Medication Assisted Treatment (MAT) Expansion”. California will strategically
focus on populations with limited or no MAT access including rural areas, American Indian and Native
Alaskan (AI/NA) tribal communities and statewide access to buprenorphine. The grant focuses on two
projects: the California Hub and Spoke System (CA H&SS) and the Tribal MAT Project. The MAT
Expansion Project complements other collaborative efforts California has implemented to expand MAT
access and reduce opioid related deaths in California. The MAT Expansion Project is projected to serve
20,892 over the two-year grant period. The goals of the project are to implement the Hub and Spoke
model in various areas throughout California which will improve access to Narcotic Treatment Programs
(NTPs), Medication Units in counties with the highest overdose rates. The MAT Expansion Project will
also increase the availability of buprenorphine statewide and increase MAT utilization for tribal
communities. California’s H&SS will be based on Vermont’s current Hub and Spoke model. California’s
system will be built off of the strengths of the NTPs which will act as the Hubs and the physicians who
prescribe buprenorphine in office-based settings which will function as the Spokes. Hubs will serve as the
regional consultants and subject matter experts on opioid dependence and treatment. Hubs will also
dispense methadone and buprenorphine, provide care to the clinically complex buprenorphine patients,
will be able to manage buprenorphine inductions when needed, and will also provide support to the
Spokes when they need clinical or programmatic advice. Spokes will provide ongoing care for patients
with milder addiction (managing both induction and maintenance). A Spoke will be comprised of at least
one prescriber and a MAT team to monitor adherence to treatment, coordinate access to recovery
supports, and provide counseling. Patients will be able to move between the Hub and Spoke based on
clinical severity. The Tribal MAT Project will create a project designed to meet the specific MAT needs
of California’s American Indian and Native Alaskan tribal communities. The California Department of
Health Care Services (DHCS) will meet with the tribal stakeholders to design the project. DHCS will
include culturally appropriate treatment services in the Tribal MAT Project. The MAT Expansion Project
will also fund prevention activities such as prevention specialists, provision of naloxone, coordination
with local opioid coalitions, and training conducted by the University of California, Los Angeles (UCLA)
and the California Society of Addiction Medicine (CSAM). In addition, the project will conduct a
statewide needs assessment and create a strategic plan. The CA H&SS will also participate in a Learning
Collaborative which is a vehicle to create the connection that is needed to have an effective network with
bidirectional patient movement and team care. UCLA will conduct an evaluation of project efforts which
will include the required federal performance measures in addition to other data elements. Estimated
number of people to be served as a result of the award of this grant – 20,892
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

COLORADO
Year 1 Year 2
$ 7,869,651 $ 7,869,651
PROJECT SUMMARY
The Office of Behavioral Health (OBH) within the Colorado Department of Human Services
(CDHS) proposes to address gaps in prevention, treatment, and recovery services through
expansion of medication assisted treatment (MAT) and crisis and emergency services;
professional trainings; naloxone distribution; transitional housing support for high utilizers;
media campaigns; and coordination of services with the criminal justice system. OBH estimates
that nearly 40,000 individuals in Colorado are in need of treatment for opioid use disorder
(OUD), and exiting services are unable to meet this need. CO-OSTR will focus on these highneed
populations, who face significant barriers: 1) uninsured/underinsured persons seeking
MAT; 2) family members and children of individuals with OUD; 3) persons reentering the
community from incarceration; 4) persons who interact with the emergency departments and the
state crisis services; 5) individuals seeking treatment in a primary care setting; 6) high-utilizers
of the criminal justice or emergency department services with unstable housing. Treatment data
show these demographics for the populations of focus: primary age group is 25-44, with males
having a higher prevalence of heroin and no gender gap for prescription misuse. Less than 4%
identify as LGBT, approximately 80% are White, and Hispanic populations representing 38% of
the underinsured. Rural areas have the greatest gaps in care, especially west of the Rocky
Mountains, while urban areas have the highest population in need of services. Identified gaps
include access to affordable MAT and residential treatment, lack of capacity for providers to
prescribe MAT, knowledge of naloxone and other resources to prevent overdose, connection to
treatment following crisis, lack of family resources, gaps between the justice system and
substance use disorder treatment, and access in tribal communities. Evidenced-based strategies
for addressing gaps include identifying and bridging gaps in funding; trainings for primary care
providers, law enforcement, and tribal providers; prevention counseling for families; and a
communications plan to reduce stigma. Project goals include identifying unmet needs through
stakeholder engagement and strategic planning; expanding access to and capacity for prevention,
treatment, and recovery services; and data collection and analysis to continue to improve the
state systems serving the population. Outcome data includes number of people receiving
treatment and recovery services, rates of opioid use and related deaths, and providers trained and
implementing MAT. Over 2 years, grant activities will provide treatment and recovery services
for 12,793 individuals with OUD in Year 1 and 9,765 in Year 2, serving 22,558 individuals
across the life of the grant. OBH will also provide prevention services to 800 families, and train
300 new providers to prescribe medication assisted treatment.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

CONNECTICUT
Year 1 Year 2
$ 5,500,157 $ 5,500,157
PROJECT SUMMARY
The Connecticut Department of Mental Health and Addiction Services, in partnership with nine
organizations and at least 11 high need communities in which opioid use and overdose deaths are most
prevalent, proposes to launch a series of targeted responses intended to reduce the negative impact of
opioid use on Connecticut citizens and communities. These targeted responses build on, and will be
implemented within the context of, the state’s evolving recovery-oriented system of care, helping to
continue to shift the focus of care from responding to acute episodes to a prevention and recovery
management framework that spans prevention, to pre-recovery outreach and engagement, to recovery
initiation through active treatment and recovery supports services, to long-term recovery maintenance. A
sample of these responses includes:
• Conducting expansive prevention and early intervention activities resulting in every Connecticut
community being able to benefit from the proposed activities;
• Increasing availability of clinic-based medication-assisted treatment (MAT);
• Partnering recovery coaches with hospital emergency departments to initiate MAT and provide
on-going recovery support;
• Enhancing substance abuse residential programs to be MAT-compatible;
• Supporting existing behavioral health treatment programs by expanding their ability to utilize
evidence-based practices and enhance their recovery supports;
• Providing vouchers for treatment for individuals with limited income or insurance gaps;
• Expanding recovery support services for young adult opioid users and their families;
• Providing MAT to pre-release Department of Correction inmates;
• Supporting courts with diversion and treatment for arrestees with substance use disorders;
• Supporting municipal police departments with two urban-based Law Enforcement Assisted
Diversion (LEAD) teams;
• Expanding faith-based recovery support; and
• Improving timely access to detox and other services by expanding transportation availability.
Connecticut has considerable momentum to implement this project. Recent community awareness of
opioid problems has galvanized community groups into action. Community coalitions including local
government leaders, health professionals, educators, police, and behavioral health experts have formed to
address this epidemic. The Connecticut Alcohol and Drug Policy Council (ADPC) was charged by
Governor Malloy in 2015 to make necessary recommendations including legislative and policy changes
to address the opioid crisis. Governor Malloy also commissioned a comprehensive statewide strategic
plan by Yale University resulting in the CT Opioid Response (CORE) report in 2016. These new federals
resources will be used to more fully implement the thirteen ADPC goals and the CORE plan.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

DELAWARE
Year 1 Year 2
$ 2,000,000 $ 2,000,000
PROJECT SUMMARY
The intent of the State Targeted Response (STR) to the Opioid Crisis grant is to focus
Delaware’s efforts on making substance abuse treatment readily accessible to those struggling
with opiate addiction. To provide this much-needed support, services will be created through the
development of three new recovery support centers and the strategic deployment of newlytrained
recovery coaches who will work to ensure that treatment services are accessible at the
time of the addicted person’s moments of vulnerability. The opiate epidemic has challenged the
state of Delaware, as it has other states; this epidemic has reached all three of Delaware’s
counties (New Castle, Kent and Sussex). While the majority of those struggling with opiate
addiction were White males, women are increasingly using heroin and are not being treated at
the same rate as men. To further complicate the opiate epidemic in Delaware is the fact that
there is a growing problem among young White pregnant women. In addition to the increase in
the numbers of adults battling opiate addictions, 2014 was the first year where the admission age
into treatment was considerably younger than in the preceding years. Despite the efforts made in
Delaware to expand the system’s treatment capacity, data depicting the growing opioid epidemic
in Delaware reveal that there are doctors and nurse practitioners who are certified to prescribe
Buprenorphine as a treatment alternative, yet who are not. The goals of this grant are to expand
the system’s treatment capacity and to improve the access and effectiveness of opiate-related
treatment for individuals battling with opioid usage. Without strengthening the treatment and
support networks that provide those battling opioid addictions with improved access to opiate
related treatment and strengthening community support, the existing resources neither will be
able to support the growing needs nor produce long-term solutions to the opioid problem.
Delaware’s intends to address the following key touch points to reach those with opiate
additions: at the time of an arrest, at the time of release from prison, after admission to
emergency room for an overdose, after being revived with naloxone, and when opioid addicted
women realize they are pregnant. It is at the aforementioned touch points occur when a person is
vulnerable and may be more willing to change their lifestyle. Through the recovery support
centers, opiate addicted individuals early in the recovery process will be able to receive recovery
services. In order to provide this additional treatment support, Delaware will develop recovery
coaches who will assist the individual with gaining access to services that help support ongoing
recovery. Recovery coaches also will be used to identify and provide support to those opiatedependent
individuals who are pregnant and provide support following delivery. It is believed
that the creation and deployment of the additional resources will enable Delaware to address
more efficiently the increased demand for access and to provide more timely delivery of
treatment for those battling opiate addiction.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

DISTRICT of COLUMBIA
Year 1 Year 2
$2,000,000 $2,000,000
PROJECT SUMMARY
The District of Columbia Department of Behavioral Health (DBH) will implement the District Opioid
Targeted Strategy (DOTS) Project. Some DOTS activities will address all individuals in the District with
or at risk for Opioid Use Disorders (OUDs), but DOTS will specifically target middle-aged heroin-using
African-American males because local data indicate they are most affected. DOTS has 5 goals:
1. Engage in strategic planning focused on District-wide OUD needs;
2. Decrease in the incidence of OUD through prevention;
3. Increase access to OUD treatment and improve care coordination for Medication Assisted
Treatment (MAT) clients;
4. Expand recovery support services (RSS) for individuals with OUD; and
5. Enhance recruitment and engagement for individuals with OUDs.
Ten (10) measurable objectives present DOTS’ specific strategies and interventions: (1.1) Conduct a
District-wide opioid needs assessment; (1.2) Develop a District-wide strategic plan informed by the needs
assessment; (2.1) Design, implement, and evaluate an OUD prevention social marketing campaign
focusing on prescription opioids for youth and young adults; (3.1) Expand MAT by providing treatment
cost assistance to facilitate methadone-based MAT for 100 high-need Qualified Medicare Beneficiary
(QMB) Program enrollees annually; (3.2) Place five Clinical Care Coordinators (CCCs) at three DBHcontracted
methadone clinics, one private MAT clinic, and one private Medicaid-participating private
physician providing office-based MAT to coordinate behavioral health/primary care and ensure treatment
linkages for 30 clients; (4.1) Train and certify 25 Recovery Coaches through District certification; (4.2)
Obtain nationally recognized certification for DBH Recovery Coaches through the International Coach
Federation and/or the International Certification & Reciprocity Consortium; (4.3) Provide additional RSS
to 560 individuals with OUDs annually who exceed their $700 RSS cap by raising that cap to $1,200;
(5.1) Engage and recruit 560 individuals with Opioid Use Disorders, primarily from the target population,
by implementing SBIRT-trained Peer Outreach Teams; (5.2) Use existing resources to improve treatment
referrals from the Department of Corrections (DOC) through DBH’s electronic health records system and
improve MAT referrals from Family Treatment Court (FTC). DOTS will focus on the high-need target
population because they play a major role in the DBH-funded OUD treatment system and because the
District is expanding buprenorphine-based MAT through other channels. Peer-based outreach (5.1),
methadone support for QMBs (3.1), and additional RSS funding (4.3) are focused on the target
population. The prevention campaign (2.1) will focus on youth because existing efforts already cater to
the target population. The CCCs (3.2) are a holistic, patient-centered approach to improving all MAT in
the District, including for the target population. The RSS infrastructure improvement (4.1, 4.2) and
DOC/FTC referrals (5.2) similarly serve a broad OUD audience. Finally, needs assessment and strategic
planning efforts (1.1 & 1.2) will help DBH assert its oversight role as the Single State Agency by
coordinating fragmented opioid efforts. Estimated number of people to be served as a result of the award
of this grant – 2125
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

FEDERATED STATES of MICRONESIA
Year 1 Year 2
$ 250,000 $ 250,000
PROJECT SUMMARY
The Federated States of Micronesia (FSM) is in a Compact of Free Association with the United States. FSM is
comprised of 600 islands situated across the archipelago of the Caroline Islands, located between the Philippines
and Hawaii across one million square miles of the North Pacific Ocean. Sixty of the FSM islands are inhabited with
a total FSM population is 116,900 (2008 estimate FSM Statistics Office) living in four states: Chuuk, Yap, Pohnpei,
and Kosrae). The total distance across FSM, from east to west, is 1,800 miles, the distance from Northern Maine to
Miami and encompasses two time zones. The four states that comprise the FSM are geographically, politically,
culturally, and linguistically distinct and indicates that the distance and population dispersion across so many
islands present a formidable challenge to data collection and to the provision of preventive and treatment services.
The Federated States of Micronesia (FSM) is submitting this application in response to Funding Opportunity
Announcement (FOA) TI-17-014. This application is entitled “FSM Response to the Opioid Crisis Grant
Application: A System of Health Care Approach to a Medical and Public Health Problem in a Low Resourced
Island Setting” (FSM Opioid STR Project) and it focuses on addressing an emerging public health crisis in the
FSM, Opioid and other drugs, including prescribed medications, that are now appearing in the FSM. Though not as
rampant as in other US States, FSM is now in the same situation other US States were 10 years ago with the Opioid
crisis. FSM wishes to prevent the onslaught of Opioid before it is too late. This project is based on both a medical
and a public health approach incorporating a system of care approach to Opioid and its pathway drugs, the general
population will receive preventive health messaging and awareness while those suffering from Opioid use disorder
(OUD) will directly receive psychosocial counseling and drug therapy. This is the target or population of focus. The
aim is to prevent further spread of the Opioid situation before it wipes out the most productive members of FSM
society while providing a recovery program or treatment to those who are addicted to Opioid using both a medical
and public health model based on science and best practices. This project will adopt the SAMHSA’s Opioid
Overdoses Prevention Toolkit as it guide in setting up its activities and Pathway to Change curriculum. The SPF 5
STEP will also be used throughout the planning process. The intent of this application is to establish a treatment
program for individuals with OUDs as a means to respond and to address all the risk factors for OUDs and its
pathway drugs. This program will be based on science and culturally appropriate practices. This project will use the
Strategic Prevention Framework to identify and implement evidence - base strategies and program models that
target individual, group and environmental change that are specifically adapted to each state.
The goals and associated objectives are as follows:
Goal 1: Build capacity and infrastructure for data driven Opioid abuse prevention, treatment, and recovery at each
of the FSM states: Chuuk, Pohnpei, Yap and Kosrae.
Goal 2: Reduce the onset and /or progression of Opioid use and abuse of other illicit drugs and pathway drugs.
Goal 3: Reduce perceived acceptability of Opioid use and other drugs use among the youth and adult population.
Activities:
• Strengthen enforcement of laws regarding Opioid and other illicit drugs.
• Enhance the state Prescription and Drug Monitoring Program
• Establish and /or enhance statewide and community-based recovery support systems, networks and
organizations to develop capacity at the state and national levels to design and implement peer and other
recovery support services.
• Train OUD prevention and treatment providers, such as physicians, nurses, counselors, community
workers, case managers and health aid.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

FLORIDA
Year 1 Year 2
$ 27,150,403 $ 27,150,403
PROJECT SUMMARY
Florida’s Opioid State Targeted Response Project is designed to address the opioid crisis by providing
evidence based prevention, medication-assisted treatment, and recovery support services. The four goals
of this proposal include reducing opioid-related deaths, preventing prescription opioid misuse among
young people, increasing the number of individuals trained to provide medication-assisted treatment and
recovery support services, and increasing access to medication-assisted treatment among individuals with
opioid use disorders. Middle and high school students in high-need rural counties will receive schoolbased
life skills training proven to prevent prescription opioid misuse. Funds will also be used to
purchase and distribute naloxone, an opioid overdose antidote proven to reduce opioid overdose deaths.
Uninsured and underinsured individuals with opioid use disorders will be targeted to receive medicationassisted
treatment, recovery support, and overdose prevention services. The majority of the funding will
be used for methadone maintenance and buprenorphine maintenance because controlled trials
demonstrate that these services are most effective at retaining individuals in care, reducing illicit opioid
use, and reducing opioid-related mortality. Funds will also be used for an extended release formulation of
naltrexone that blocks the effects of opioids and is approved for the prevention of relapse to opioid
dependence. Hospital-based pilot programs will seek to initiate buprenorphine assisted treatment with
individuals who have overdosed on opioids and coordinate ongoing care with community-based
providers. Preliminary and conservative estimates indicate that funds can be used to serve at least 2,789
individuals during the first year and a total of 5,578 individuals over the two-year project period. Funds
will also be used provide training and technical assistance on medication-assisted treatment and recovery
support services to a variety of stakeholders, including potential prescribers, peers in recovery, child
welfare staff, and court staff, among others. The American Society of Addiction Medicine’s
computerized structured interview and clinical decision support tool will also be piloted by providers. A
competitive hiring process will be used to select a full-time Project Director who will be responsible for
overall project oversight and management to ensure that goals and objectives are met, strategic planning,
tracking measurable objectives, implementing quality improvement initiatives, and ensuring compliance
with all aspects of the terms and conditions of the award. An epidemiologist will assist with data analysis,
develop reports to inform strategic planning and evaluation activities, critically review grant funded
reports and analyses, and advise key project staff and sub-recipients regarding surveillance data.
Qualified peer specialists will be employed in six regions to assist with regional needs assessments,
conduct quality assurance visits with providers, and manage activities related to the development of
recovery-oriented systems of care. Behavioral Health Consultants will train and assist child protective
investigators. Estimated number of people to be served as a result of the award of this grant 5578
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

GEORGIA
Year 1 Year 2
$ 11,782,710 $ 11,782,710
PROJECT SUMMARY
Georgia Opioid State Targeted Response to Opioid Crisis (Opioid STR)
Population to be served: Treatment funds will serve 2,350 persons in year 1 and 4,008 in year 2 for a total
of 5,658. It is estimated that 750 first responders and other stakeholders will be trained in year 1 and
1,500 in year 2. Project summary: The Georgia Opioid STR project will develop a targeted response to
the opioid crisis in the state through prevention, treatment and recovery initiatives, Project activities will
strengthen infrastructure with a focus on addressing gaps in evidence based practices and services and
creating a continuum of prevention and recovery oriented treatment. Strategies/interventions: Prevention
activities will include: 1) a statewide media campaign on opioid misuse and abuse, 2) an increase in the
number of SPF opioid pilot programs, 3) a school transition mentor pilot for opioid/prescription drug
misuse and abuse prevention, and 4) Naloxone education and training for first responders, law
enforcement, and public safety. Treatment and recovery activities will include expansion of detox
capacity by 8 beds across 2 providers in 2 locations; increased bed capacity at 1ne provider site by 4
intensive residential beds, 8 semi-dependent beds, and 8 independent beds; implementation of peer
specialist programs in 2 hospital ERs; employment of four part-time staff to ensure fidelity to Georgia
Association of Recovery Residences recovery housing standards; requiring each treatment provider
expanding MAT services to have a peer specialist staff to engage individuals and link them to treatment
resources; providing training about recovery from opioid use disorder for behavioral health, DFCS,
corrections, and other stakeholders; implementing a warm Line run by peers; implementing MAT via a
pharmacy benefit in eight treatment provider locations and implementation of a Department of
Community Supervision MAT Vivitrol pilot. Project goals: Eight project goals with measurable
objectives have been established.
1. Increase awareness about opioid misuse and abuse and provide training for the public,
communities, schools, and first responders to prevent opioid misuse and abuse in Georgia.
2. Expand detox services for individuals with an opioid use disorder in targeted areas.
3. Expand access/bed capacity of residential services for individuals with an opioid use disorder in
targeted areas.
4. Incorporate certified peer specialists in identified emergency rooms to ensure immediate
connection for individuals who have experienced an opioid overdose or individuals with an
opioid use disorder who are presenting for services.
5. Establish funding to support the infrastructure of recovery transitional housing.
6. Expand/develop recovery support services for individuals with an opioid use disorder.
7. Implement a warm line, run by peers, for individuals struggling with opioid use disorder.
8. Develop MAT clinical based capacity for DEA approved medications.
Estimated number of people to be served as a result of the award of this grant – 6358
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

HAWAII
Year 1 Year 2
$2,000,000 $2,000,000
PROJECT SUMMARY
Hawaii State Targeted Response to Opioids (HI-STR) Abstract: The Hawaii State Response to
Opioids (HI-SBIRT) project leverages prevention and treatment intervention strategies to
address rates of opioid use, misuse and fatalities across the state. The HI-STR project is
collaborative effort between the Substance and Mental Health Administration (SAMHSA),
Hawai'i's state agencies, community organizations and healthcare providers that will expand and
enhance Hawai'i's continuum of health promotion, prevention and care for persons at risk of, or
suffering from Opioid Use Disorders (OUD). The project moves Hawaii toward realizing its
goal of a seamlessly integrated healthcare system that takes a public health approach to
addiction. Opioid use and related fatalities, particularly due to opioid prescription misuse, are a
growing concern for the state. The HI- STR project will address these concerns through three
key activity tracks (1) education and awareness, which will promote public awareness of the
dangers of opioid use and provide training to health professionals to better identify and assist
persons at risk or suffering from opioid use disorders; (2) care coordination and integration
which will target more efficient and effective ways to integrate primary and behavioral health
care to reduce risk and better treat persons affected by opioid misuse and abuse; and (3) policy
shaping which targets policies and protocols aimed at improving access and expanding proven
interventions and prevention strategies such Medication Assisted Treatment (MAT). By the end
of the project, Hawaii will have increased access to opioid treatment for over 400 individuals.
Further, it will result in expanded services to areas in the state with the most un-met need such
as Kauai Island. It will also result in the implementation and expansion of proven and effective
policies and strategies related to opioids, such as use of a Prescription Drug Monitoring Program
(PDMP). Through linking and leveraging a wide range of resources and efforts already
underway, the project will serve to expand and enhance the State’s efforts to ensure a statewide
system of care that is substantially more integrated, effective and accessible. The project aligns
with the primary goals of the state and the Hawaii Department of Health to engage in a more
proactive approach to addressing emerging healthcare issues (preventative healthcare) which, in
turn, will decrease the resources needed to treat chronic conditions (reactive healthcare) over
time.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

IDAHO
Year 1 Year 2
$ 2,000,000 $ 2,000,000
PROJECT SUMMARY
Idaho's Response to the Opioid Crisis (IROC) will address the opioid epidemic which Idaho is
currently facing using a multifaceted approach that seeks to expand access to Medication
Assisted Treatment (MAT), reduce access to opioids through prevention efforts, enhance the
recovery oriented system of care, and reduce opioid-related deaths.
Through IROC, Idaho will focus on serving 840 people in year one and 1,025 people in year two
who have an Opioid Use Disorder (OUD) diagnosis, are uninsured, are within the 18-36 year old
age group and who are re-entering communities from the Criminal Justice System. IROC will:
Approach 1) Introduce publicly-funded MAT to Idaho by adding Methadone and Suboxone to
the array of treatment and recovery support services (RSS) that are currently available.
Individuals with OUD who are eligible for substance use disorder (SUD)-related services will be
able to access these medications at various locations throughout the state. This will be
accomplished by increasing the number of Suboxone and Methadone providers in Idaho,
training traditional treatment providers in evidence-based treatment models focused on OUD,
and by creating a system in which traditional treatment providers can refer individuals to MAT
services. Through the MAT program, IROC will seek to provide services to no less than 250
Idahoans per year who are in need of medication.
Approach 2) Reduce access to opioids and prevent overdose deaths by: Using prescriber report
cards to create social norms of decreased opioid prescribing; reducing diversion of opioids by
establishing drop-box programs in pharmacies statewide; and educating prescribers on use of the
Prescription Drug Monitoring Program (PDMP) and the Center for Disease Control and
Prevention’s (CDC’s) prescribing guidelines, which will result in fewer prescriptions for opioids
being written and filled. Among other objectives, these steps seek to reduce the number of
prescriptions per capita by 5%, decrease the percentage of clients on high dose opioid therapy by
5%, and increase the rate of PDMP use by 10% within a one-year period.
Approach 3) Broaden the boundaries of Idaho’s recovery-oriented system of care to engage
persons in a recovery process from the point of initial contact. Among other objectives, this
system of care seeks to reduce overdose events and fatalities, reduce “no shows” through
immediate contact with a peer, and to help support services and sober recreational activities to
the OUD population.
Approach 4) Increase the use of Naloxone to reverse opiate overdoses through training and
provision of Naloxone to first responders and others (including Federally Qualified Health
Centers) and other community members who may come in contact with individuals, at risk of
opiate overdose. This will be accomplished by identifying a minimum number of first responder
agencies that will begin carrying Naloxone, performing community and provider trainings, and
by providing Naloxone kits to identified and trained entities.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

ILLINOIS
Year 1 Year 2
$ 16,328,583 $ 16,328,583
PROJECT SUMMARY
The Illinois Department of Human Services, Division of Alcoholism and Substance Abuse
(IDHS/DASA), submits this application in response to SAMHSA/CSAT announcement # TI-17-014,
State Targeted Response to the Opioid Crisis Grants (Opioid-STR). IDHS/DASA is the Illinois Single
State Authority (SSA) for substance use disorder (SUD) issues. Evidence of the multiple impacts of the
opioid crisis among Illinois residents is provided in regards to: increased primary opiate clients among
IDHS/DASA-funded treatment admissions, increased need for medication assisted treatment (MAT) for
persons with opioid use disorders (OUD), increasing numbers of opiate overdose deaths, and increasing
numbers of opiate-related emergency department visits and general hospital admissions. Evidence is also
provided of the relative lack of MAT and Naloxone overdose reversal services in large areas of the state,
especially in central and southern Illinois. A summary is provided of current statewide initiatives and
programs that have been implemented in response to the opioid crisis in our state, to include recent
establishment of the Illinois Statewide Opioid Advisory Council that is chaired by IDHS/DASA. In
response to this crisis, IDHS/DASA proposes a comprehensive array of OUD treatment and recovery
support services that includes: expanded outpatient methadone treatment (OMT) and recovery home
services; several primary healthcare-based outreach, linkage, MAT, and case management services;
Vivitrol injection and linkage services for county jail prisoners and drug court offenders with OUD;
community-based outreach, linkage, and recovery management services; hospital ED-based screening,
recovery coaching, and linkage services; Suboxone education, consultation and support for general
hospital medical staff; and establishment of an Illinois Opioid Crisis Line. The opiate related prevention
services that are proposed include: expanded Naloxone purchase, training, and distribution services in
counties of high need and for emergency medical services (EMS) personnel; opiate-related enhancements
to the Illinois Prescription Monitoring Program (PMP); opioid awareness activities for Illinois high
school coaches and athletic directors; establishment of a statewide opiate awareness campaign; and
development of an automated reporting system for the Illinois Drug Overdose Prevention Program
(DOPP). A data collection plan is provided that describes data collection, management, analysis, and
reporting in response to federal requirements and a local decision to administer the SAMHSA/GPRA tool
to persons admitted to the expanded OMT and recovery home services. The organizational experience,
resources, and qualifications of IDHS/DASA, the participating treatment, recovery support, and
prevention provider organizations, and the strategic planning contractor are described. Biographical
sketches for the Illinois SSA, the Project Director, and other administrative grant staff are provided. A
line-item budget and narrative justification is proposed for each of the two years of SAMHSA funding. A
total of $16,328,583 is requested in each of the two potential years of this SAMHSA-funded award.
Estimated number of people to be served as a result of the award of this grant – 9800
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

INDIANA
Year 1 Year 2
$ 10,925,992 $ 10,925,992
PROJECT SUMMARY
The purpose of Indiana’s Integrated Response to the Opioid Epidemic is to use funds authorized
by the 21 st Century Cures Act to expand existing prevention, treatment, and recovery services
for OUDs, identify and implement new evidence-based programs across the continuum of care
to address OUDs and opioid use in general, and focus on providing intensive support to areas
with limited access to treatment and related services. The proposed work will address OUDrelated
needs across Indiana, but will focus particularly on the needs of underserved populations
throughout the state; underserved areas range from small, rural counties to large metropolitan
areas, and share a disproportionate burden of the OUD epidemic. Within this group,
programming also will focus on individuals or populations that are especially at risk from OUDs
or for whom the impact of an OUD is disproportionately severe, including pregnant women,
adolescents, and individuals leaving the criminal justice system in order to re-integrate into the
community. The proposed work focuses on six strategic goals that are predicated on the needs
identified prior to and during the preparation of this application. These are: 1) Expansion of
Residential/Inpatient Detoxification and Treatment, including increased capacity, training in
MAT and EBPs, and provision of service linkages; 2) Deployment of Mobile Crisis Teams
focused on overdose reversal, referral to treatment, crisis management, and short-term
therapeutic solutions; 3) Development and Implementation of I-ECHO, a statewide training
protocol for all healthcare professionals that will focus on OUD case management and
specialized learning; 4) Development of a Recovery Coach Initiative that will engage peers and
professionals with individuals who are in emergency rooms for OUD overdose to ensure
systematic engagement with all aspects of the spectrum of care; 5) Expansion of Provider
Access to Integrated Prescription Drug Monitoring and Electronic Health Records, with a
particular focus on mitigating costs for lower-income healthcare organizations; and 6) Undertake
Statewide Social Marketing and Health Communications Campaigns that intelligently are
targeted to vulnerable population segments using culturally-competent language and strategies.
In implementing these strategies, we expect to a) increase the number of people in who receive
OUD treatment; b) increase the number of people who receive OUD recovery services; c)
increase the number of providers implementing MAT; d) increase the number of OUD
prevention and treatment providers trained; e) reduce numbers and rates of opioid use, and; f)
reduce numbers and rates of opioid overdose-related deaths. Estimated number of people to be
served as a result of the award of this grant – 21000
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

IOWA
Year 1 Year 2
$ 2,728,077 $ 2,728,077
PROJECT SUMMARY
The Iowa Opioid State Targeted Response project will expand capacity of the existing regional
prevention and treatment provider network with a focus on accessible opioid treatment. A
thorough assessment and strategic action plan involving local stakeholders will provide the
foundation for implementation of evidence-based practices, including medication assisted
treatment (MAT). The focus of this project is to build community capacity for a successful
community response to the opioid crisis through the following goals:
• Build an enhanced, statewide infrastructure to address opioid misuse in Iowa
• Increase awareness of opioid risks through statewide prevention efforts
• Increasing the use of medication assisted treatment and other evidence-based practices in
Iowa.
The Iowa Opioid STR project will leverage the service improvements gained through other
opioid grants, making these evidence-based practices more accessible to the community of focus
(18-44yr olds) and other Iowans affected by opioid use disorder across the state. Prevention
efforts will include localized information dissemination and statewide environmental efforts
through a media campaign to raise awareness of the risks of prescription drugs and heroin use.
Goals include increasing the awareness of naloxone availability and promoting utilization of the
Prescription Monitoring Program. Expanded opioid treatment capacity will benefit Iowans
across the state through regional, community-based, or telehealth partnerships with medical
service providers.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

KANSAS
Year 1 Year 2
$ 3,114,402 $ 3,114,402
PROJECT SUMMARY
The increase in both use and overdose rates is a trend being seen across many areas of Kansas.
While the increasing trend is a shared commonality, the needs and gaps, access and treatment
needs as well as risk and protective factors differ considerably between urban, rural, frontier, and
suburban populations in the state. In order to ensure a targeted approach that will be most
effective and outcomes driven, Kansas will utilize epidemiological data to inform a regional
approach to our proposed implementation plan. A Request for Proposal process will be initiated
upon grant award for four regional projects and one special project with specific emphasis on the
medication-assisted therapy being provided at the nine methadone clinics in Kansas. This
approach will allow for each region to conduct a comprehensive needs assessment and create
implementation plans to meet the specific needs, gaps, access concerns, as well as risk and
protective factors specific to their geographic, demographic and cultural differences. Based upon
review of multiple data sources it was determined that the state would be divided into four
primary regions and one specific targeted project. Kansas has been affected by the prescription
and heroin poisoning epidemic that has plagued the United States in recent years. From 1999 to
2014, drug poisoning death rates have tripled-placing deaths from poisoning the leading cause of
injury related deaths in Kansas. Drugs, including prescription, over the counter and illicit drugs,
account for more than 80% of all poisoning deaths. Along with an increase in heroin and
synthetic opioid deaths, Kansas has seen an increase in the number of individuals age 26 and
older who report having misused a prescription opioid pain reliever within the past year. The
Behavioral Risk Factor Surveillance System (BRFSS) data indicate that 59.7% of individuals
age 18 and older report misusing pain medication for pain relief. In the most recent data from the
Kansas Communities That Care Student Survey, 9.24% of all 6th, 8th, 10th, and 12 th graders
report that there is ‘no risk’ when taking prescriptions not prescribed to them. These increases in
opioid related drug misuse and deaths parallel the increase in prescription opioid availability.
According to data from the Kansas prescription drug monitoring program, the Kansas Tracking
and Reporting of Controlled Substances (KTRACS), there were over 4.2 million Schedule II-IV
prescriptions and over 256 million pills dispensed in Kansas in 2014. Furthermore, more than
100,000 Kansas patients had overlapping prescriptions for opioids and benzodiazepines and
more than 75,000 patients had more than 90 morphine milligram equivalent per day of opioid
prescriptions in 2014. According to experts Kansas is the 16th highest opioid prescribing state in
the country.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

KENTUCKY
Year 1 Year 2
$ 10,528,093 $ 10,528,093
PROJECT SUMMARY
With over 1200 overdose deaths in 2015, opioid use disorder has reached epidemic levels in
Kentucky. Addressing this epidemic is a top priority across all levels of government and public
and private partners. While Kentucky has made great strides, much work remains. Guided by the
Recovery-Oriented System of Care Framework, the purpose of the Kentucky Opioid Response
Effort (KORE) is to implement a comprehensive targeted response to Kentucky’s opioid crisis
by expanding access to a full continuum of high quality, evidence-based opioid prevention,
treatment, recovery, and harm reduction services and supports in high-risk geographic regions of
the state. Informed by data on populations most in need, the KORE will focus on three primary
populations: pregnant and parenting women, individuals re-entering society upon release from
criminal justice settings, and adolescents and young adults. A composite risk index identified
nine geographic regions at highest-risk for OUD including the greater Lexington area, the
greater Louisville area, Northern Kentucky and Eastern Kentucky. Efforts in these nine high-risk
regions and with the populations of focus will inform statewide scaling-up efforts. The KORE
offers the state an opportunity to dedicate much needed resources to address five overarching
goals: (1) preventing opioid misuse and abuse; (2) increasing access to OUD treatment services,
including Medication- Assisted Treatment; (3) increasing the availability of recovery support
services designed to improve treatment access and retention and support long-term recovery; (4)
increasing availability of naloxone; and (5) enhancing statewide coordination and evaluation of
healthcare and public safety strategies targeting opioid misuse and overdose. A comprehensive
performance assessment system will support ongoing evaluation of progress against proposed
goals, objectives, and activities and guide continuous quality improvement efforts. Though a
multifaceted and complex response is necessary, Kentucky’s singular focus is to end the opioid
epidemic and to save lives!
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

LOUISIANA
Year 1 Year 2
$ 8,167,971 $ 8,167,971
PROJECT SUMMARY
The Louisiana Department of Health, Office of Behavioral Health (OBH) proposes to implement the
Louisiana Opioid State Targeted Response (STR) Initiative to enhance existing statewide prevention,
treatment, and recovery support services offered for individuals experiencing or at risk for opioid use
disorder (OUD). The priority populations to be served by this grant are: (1) the under- and uninsured, (2)
individuals living in areas with high prevalence rates of overdose or opioid overdose deaths and (3) the
criminal justice population. In addition, African American males represent a sub-population of those
disproportionately affected by this epidemic due to increased opioid use and will be a population of
focus. The goals of the Louisiana Opioid STR Initiative include: 1) Increase public and professional
awareness and education for prevention and treatment of opioid use, misuse, and abuse; 2) Increase by
1,670 the number of individuals with a OUD diagnosis who are being treated with EPBs (835 per year for
two years); and 3) Increase recovery support services for 600 OUD clients (300 per year for two years).
Prevention, intervention, treatment and recovery support activities will be supported by the grant. The
prevention priority for the Louisiana Opioid STR Initiative will be to utilize the existing SPF-based
infrastructure as a basis to prevent prescription drug misuse and abuse through a statewide awareness and
education campaign, with special activities planned within each of Louisiana’s ten Local Governing
Entities (LGE) and coordination with the ten Opioid Treatment Programs (OTP), designated as
Methadone clinics. Activities will be based on the strategies outlined in SAMHSA’s Opioid Overdose
Prevention Toolkit, including public education through a media campaign and provider training, with an
intervention strategy of Naloxone education and distribution to target populations. OBH will enhance and
expand the existing OUD treatment availability statewide by building the capacity of the local OTPs and
other behavioral health provider networks to provide access to evidence-based treatments, particularly
Medication Assisted Treatment (MAT), and education and training on non-opioid alternatives. A
specialized approach working with the Department of Corrections will allow treatment services for
offenders participating in re-entry-programs at two designated facilities. This will be an integral part of
the treatment services provided to the OUD population. Recovery support services provided to
individuals with OUD will include building capacity for the 10 LGE regions to have staff to serve as
Behavioral Health Recovery Support Specialists to provide local visibility and coordination with local
resources for referral and access to services for the OUD population. This comprehensive approach to
prevention, treatment and recovery supports will help to address the myriad of problems in Louisiana
associated with illicit opioid use. The identified goals and outcomes will move the state toward
improvements in treatment for OUD and a reduction in the number of lives lost to the opioid epidemic
which has plagued our nation and our state. Estimated number of people to be served as a result of the
award of this grant – 2270
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

MAINE
Year 1 Year 2
$ 2,039,029 $ 2,039,029
PROJECT SUMMARY
The Maine Opioid State Targeted Response project (Maine Opioid STR) estimates that we will
serve up to 270 uninsured adults and youth with opioid use disorder over the two-year grant
period by providing evidence based Medication Assisted Treatment (MAT) through existing or
new MAT models including but not limited to the provision of MAT within Opiate Health
Homes within the 1st and 2nd Congressional Districts of Maine. Within this population, the
program will prioritize pregnant and parenting women and IV drug users in keeping with the
Substance Abuse Prevention and Treatment Block Grant. The focus for treatment in urban areas
will be based on wait lists and demonstrated ability to increase capacity from existing providers
and provider networks. The focus for treatment and capacity building in rural areas will be
uninsured adults and youth with opioid use disorder living in the Western Public Health District
(Androscoggin, Franklin and Oxford Counties), Downeast Public Health District (Washington
and Hancock Counties), and Aroostook Public Health District (Aroostook County). The rural
community of focus also prioritizes pregnant and parenting women, IV drug users, and includes
individuals transitioning from correctional facilities to the community, and tribal members living
in these counties. The goal of the Maine Opioid STR project is to improve outcomes for
uninsured adults in Maine who receive MAT for opioid use disorder. This will be accomplished
by implementing Opiate Health Homes and a “hub and spoke” model of service delivery, where
services will be delivered through existing systems of care, including Federally Qualified Health
Centers, hospitals and hospital systems and existing community partnerships. In addition,
existing contracts will be leveraged for education and training of prescribers of medication
assisted treatment and psychosocial interventions. Prevention interventions will include opioid
misuse community education sessions and implementation of Prime for Life curriculum in
community settings. Vendors contracted as “hubs” will be required to work with local recovery
supports through explicit and verified links.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

MARYLAND
Year 1 Year 2
$ 10,036,843 $ 10,036,843
PROJECT SUMMARY
The proposed program, “M.O.R.R. - Maryland Opioid Rapid Response”, is designed to increase
access to and enhance services for individuals with an Opioid Use Disorder (OUD) through
reducing unmet treatment need and enhancing prevention efforts. This will be accomplished
through implementation of a strategic plan to fill the gaps in evidence-based services, design of
primary and secondary prevention methods and placement of more emphasis on peer and other
recovery support. Maryland believes strongly in the benefits of prevention. We will add to
doctor-patient conversations about the dangers of opioid use through social media campaigns,
create harm reduction street and community outreach programs to encourage individuals to enter
treatment, and make strides in reducing the stigma associated with substance related disorders
(SRD) through education provided by the media/website/apps. The common thread will be
connecting individuals with appropriate support resources. Maryland’s
OUD crisis is growing at such a tremendous rate that increasing the opportunities for treatment
is essential. We believe that creating crisis services with care coordination and expanding lower
level of care beds will both move individuals into treatment and reduce unintentional deaths.
Strategic expansion of naloxone distribution with training for providers, consumers and others
will reduce deaths also. Support for primary care providers through provision of consultation on
SRDs and technical assistance regarding prescribing will increase quality for and the number of
providers providing evidenced-based practice (EBP) treatment. A full array of workforce
development and training across the treatment system including Trauma Informed Care (TIC)
and technology transfer will provide the skills, knowledge base, and confidence desired by
treatment providers and peer support staff. Data analysis and monitoring through a quality
improvement system will provide valuable information to policy makers. We are committed to
providing quality and evidence-based services while transforming our statewide system. In
2015, the need for opioid maintenance treatment (OMT) exceeded 8 per 1,000 in all regions of
the state. The opioid unintentional death rate exceeded 14.0 in all regions except one. Our goals
for this program are to significantly reduce opiate use disorders and opiate related deaths by (1)
strengthening prevention efforts through reducing over prescription of opiates and improving
public understanding of OUD, (2) supporting providers through the availability of consultation,
technical assistance and workforce development and training, and (3) strategically expanding
services needed by individuals with OUDs through expansion of treatment and care services,
peer support, recovery, naloxone distribution, harm reduction outreach, crisis services and lower
intensity 3.1 facilities. Our plan is to serve an additional 21,000 individuals annually and 42,000
over the two years. We will also train over 1,400 individuals each year. We are very excited
about the opportunity to make a difference in individuals’ lives, save lives and end our public
health crisis.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

MASSACHUSETTS
Year 1 Year 2
$ 11,742,924 $ 11,742,924
PROJECT SUMMARY
Unintentional opioid overdose (OD) has been a leading cause of death in Massachusetts since
2005, with four-and a-half times more people dying from ODs than from motor vehicle
accidents during the first half of 2015. We propose to employ strategies that utilize a framework
of recovery-oriented systems of care (ROSC) to provide a comprehensive, coordinated method
to “wrap-around” individuals by building connections throughout our entire prevention,
treatment and recovery service system with the goal of addressing opioid misuse, abuse and
overdose. We seek to serve 10,312 individuals over the two-year project period through
implementing the following activities:
1. Prevention programming: a) Overdose Education and Naloxone Distribution expansion
in high-priority communities with a significant opioid overdose problem; b) A first
responder post-overdose follow-up initiative to provide in-person, home-based outreach
and support after 911 calls for an overdose, and offer assistance accessing other available
services; c) Overdose prevention training and technical assistance for health and human
services providers to meet the rising demand for overdose prevention education and
training; and d) convening a Pharmacy Workgroup to further define and address systemic
barriers to accessing naloxone, culminating in the development of a guidance document.
2. Treatment and Recovery Services programming: a) Office Based Opioid Treatment
(OBOT) expansion to at least seven new community-based sites; b) Re-entry treatment
and recovery support services pre-release including MAT induction, treatment and
recovery planning, and post-release linkages to services and recovery support, case
management and recovery coaching; c) A Recovery Support Center (RSC)-based peer
support model for pregnant, post-partum and parenting women (PPW).
3. We also plan to implement three treatment and recovery focused Training and Technical
Assistance (T&TA) initiatives: a) OBOT T&TA to support the new OBOT clinical sites;
b) Opioid ECHO telehealth to employ videoconferencing technology where healthcare
teams can connect to a community of subject matter experts and other learners; and c)
capacity building at RSC sites to support and enhance the provision of evidence-based
services for PPW and their families.
Overall we anticipate the MA Opioid-STR grant activities will improve, expand and enhance
access to treatment, support sustained recovery, and prevent opioid misuse, abuse and overdose
to achieve life-saving results.
Estimated number of people to be served as a result of the award of this grant – 10312
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

MICHIGAN
Year 1 Year 2
$ 16,372,680 $ 16,372,680
PROJECT SUMMARY
The purpose of the Michigan Opioid STR project is to increase access to treatment; reduce unmet
treatment need; and reduce opioid overdose related deaths through the provision of prevention, treatment
and recovery activities for OUDs. To achieve our purpose for the project, the Office of Recovery Systems
of Care will:
1. improve the state infrastructure for individuals with an OUD;
2. train Prepaid Inpatient Health Plan and provider administration on infrastructure improvements,
and training provider staff on evidence based interventions and fidelity measures;
3. implement evidence based prevention and treatment interventions with accompanying fidelity
instruments to ensure that the quality of the intervention is consistent across the provider
network;
4. improve access to psychiatric services and psychotropic medications to individuals with an OUD;
5. expand the availability and use of specially trained peers for MAT and drug free programming;
6. expand outreach and engagement activities to primary care and law enforcement sites;
7. increase supports to the prisoner re-entry population with an OUD;
8. expand the use of peers in emergency departments and primary care settings;
9. expand overdose education and naloxone distribution; and
10. disseminate a statewide media campaign for the purpose of public education.
The Michigan Opioid STR initiative will: improve awareness of the risks associated with using opioid
based medications as well as illegal opioids; increase the availability of prevention focused evidence
based practices for individuals considered to be part of the selected or indicated portion of the population;
educate physicians on the CDC Prescriber Guidelines for responsible opioid prescribing; increase access
to Medication Assisted Treatment, withdrawal management, and residential treatment services for
individuals with Opioid Use Disorders
(OUDs); increase availability of treatment and recovery support services to individuals with OUDs;
improve the quality of services for individuals with OUDs; increase treatment and support services
available to individuals re-entering the community from prison; and revise policy and contractual
language to reflect standards of care as identified in Michigan’s Medication Assisted Treatment
Guidelines for Opioid Use Disorders. In 2015, 1,980 individuals died from a drug overdose in Michigan.
Opioids, illicit and prescription were involved in 64.1% of these deaths. Between 1999 and 2015, opioid
involved overdose deaths increased more than 10 times, and have increased sharply since 2012. In 2015,
the American Indian/Alaskan Native population had the highest rate of death due to opioid involved
overdose. During the same year, adults aged 25 to 34 showed the highest overdose death rates, and
males’ overdose death rates were higher than female Wayne State University, School of Social Work,
will serve as the evaluator for the project. Estimated number of people to be served as a result of the
award of this grant – 15090
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

MINNESOTA
Year 1 Year 2
$ 5,379,349 $ 5,379,349
PROJECT SUMMARY
The Minnesota Department of Human Services, Alcohol and Drug Abuse Division (Single State
Authority) proposes a comprehensive Minnesota State Targeted Response to the Opioid Crisis
(“MN Opioid STR”). This proposal reflects collaborative planning efforts between The
Minnesota Department of Human Services Alcohol and Drug Abuse Division, Health Care
Administration and Office of Indian Policy along with the Minnesota Department of Health
(MDH). The proposed MN Opioid STR expedites opioid treatment and recovery resources
(Minnesota’s Model of Care approach) and supports integration of services at each point in the
continuum (e.g. behavioral treatment and Office Based Opioid Treatment (OBOT)/( MAT)
Medication Assisted Treatment). In 2015, Minnesota ranked first among all states when
measuring the age-adjusted disparity rate ratio (DRR) of deaths due to drug poisoning among
American Indians/Alaska Natives relative to Whites (out of 16 states for which data are
available) and Blacks relative to Whites (out of 38 states for which data are available). The MN
Opioid STR is a comprehensive effort that recognizes urgent need to provide immediate
response for the following target populations: American Indian; African American;
Women/Pregnant Mothers and infants with Neonatal Abstinence Syndrome. Minnesota also
recognizes that greater Minnesota and the Twin Cities metro area have different demographics
related to opioid use and require different strategies to address service gaps. For prevention
efforts, Minnesota draws upon the Strategic Prevention Framework (SPF) to guide planning and
implementation of activities. Proposed activities include: Increasing access to “Rule 25”
assessments and expediting access to treatment for Minnesotans experiencing opioid use
disorder; increasing opioid-specific peer recovery and care coordination specialists; piloting of
Parent Child Assistance Program (PCAP) peer mentoring for pre- and post-natal support of
mothers experiencing opioid use disorder and infants with Neonatal Abstinence Syndrome
(NAS); expanding Office Based Opioid Treatment/Medication Assisted Treatment
(OBOT/MAT) in both the number of providers and their geographic reach, supported by launch
of an Opioid-focused Minnesota Project ECHO (Extension for Community Healthcare
Outcomes); Expanded access to naloxone for Opioid Treatment Programs and Emergency
Medical Service (EMS) teams; Implementation of a statewide media campaign that expedites
access to treatment resources through web-based tools such as an opioid-treatment “Fast-
Tracker” and an Opioid Prescribing Improvement Program: Prescriber Education Campaign.
Minnesota expects to serve 109,852 individuals in the State of Minnesota through the proposed
MN Opioid STR. Measurable outcomes include reducing the number of opioid related deaths
overall and reducing disparities for identified target populations, increasing retention in care,
reducing opioid misuse for all age groups, increasing opioid-specific treatment and recovery
services options and geographic locations throughout the State of Minnesota.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

MISSISSIPPI
Year 1 Year 2
$3,584,702 $3,584,702
PROJECT SUMMARY
Mississippi is poised to respond to the opioid crisis through the Mississippi State Targeted Opioid Project
(mSTOP). Over the two year project, mSTOP will serve an estimated 1500 persons who use opiate
medications or heroin and are at risk for misuse/abuse and overdose, primarily Caucasians between the
ages of 18 and 45 in the top seven counties where opioid use disorder (OUDs) is prevalent. In addition,
the media campaign will impact approximately 300,000 additional citizens. Additional populations of
focus are pregnant women, returning veterans and their families, and individuals re-entering the
community from correctional facilities. MSTOP aims to enhance prevention, treatment and recovery
services. Goal 1: Prevent and manage opioid overdose; (Strategy 1.1) Educate individuals who use
opioids, and those that may witness an overdose, on how to recognize and appropriately respond to an
overdose; (Strategy 1.2) Make system-level improvements to increase availability and use of naloxone;
Goal 2: Implement and expand clinically appropriate evidence-based treatment service options and
availability; (Strategy 2.1) Increase access and utilization of medication-assisted treatment
(MAT);(Strategy 2.2) Increase access to an array of psychosocial treatment services; (Strategy 2.3)
Identify and treat opioid abuse during pregnancy; Goal 3: Prevent opioid misuse and abuse; (Strategy 3.1)
Promote the use of best practices among health care providers for prescribing opioids for pain
management;(Strategy 3.2): Increase the capacity of opioid users to avoid misuse/abuse; (Strategy 3.3)
Promote clear and concise guidance on the safe home storage and appropriate disposal of prescription
opioid medications; and (4) Use evaluation science and surveillance to improve success; (Strategy 4.1):
Use epidemiological data to guide implementation.( Strategy 4.2) Use epidemiological data to guide
evaluation. (Strategy 4.3) Optimize and expand data sources. Evidence-based psychosocial interventions
will be used to address the specific needs of the population of focus: Screening, Brief Intervention,
Referral to Treatment (SBIRT) and the Community Reinforcement Approach (CRA). At least four
Community Mental Health Centers will receive funding to provide these evidenced-based treatment
programs for persons with OUDs. A statewide communications campaign will be developed that includes
targeted opiate-related health education. Under the leadership of the Mississippi Department of Mental
Health (DMH) Bureau of Alcohol and Drug Services (BADS), mSTOP will leverage existing resources
and programs to maximize project effectiveness. The project will make use of partnerships and
collaborations to bridge resources of health care, public health and law enforcement to enhance
professionals awareness about prevention and treatment methods, create an environment that facilitates
sharing of data and increases the likelihood of sustainability. Estimated number of people to be served as
a result of the award of this grant – 1500
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

MISSOURI
Year 1 Year 2
$ 10,015,898 $ 10,015,898
PROJECT SUMMARY
The proposed Missouri Opioid State Targeted Response (Opioid STR) project will expand
access to integrated prevention, treatment, and recovery support services for individuals with
opioid use disorder (OUD) throughout the state. Primary focus will be on rigorous,
multidisciplinary provider training and education on Medication Assisted Treatment (MAT) and
the provision of evidence-based treatment services to uninsured individuals with OUD
presenting for care within state-funded programs. Primary prevention activities will center
around increased awareness and decreased availability of opioids, led by local agencies in high
risk areas. Prevention of overdose deaths will be accomplished through training clinical
providers and at-risk individuals on Overdose Education and Naloxone Distribution practices,
and providing telemedicine didactic and consultation services to primary care providers treating
chronic pain. Recovery support services will be provided in the form of Recovery Community
Centers, recovery housing, and recovery management checkups, all delivered with a focus on
peer engagement. The State of Missouri Department of Mental Health (DMH) will lead the
project, with administration, implementation, and evaluation activities provided by the Missouri
Institute of Mental Health (MIMH) – University of Missouri, St. Louis, as well as healthcare
agencies, additional academic institutions, and content experts throughout the state. The primary
goals of the Opioid STR project include: 1) Increase provider and student-focused opioid use
and overdose prevention initiatives and programs; 2) Increase access to evidence-based MAT for
uninsured individuals with OUD through provider training, direct service delivery, healthcare
integration, and improved transitions of care; 3) Increase the number of individuals with an
OUD who receive recovery support services; and 4) Enhance sustainability through policy and
practice changes as well as demonstrated clinical and cost effectiveness of grant-supported
protocols. Combined with coordinated interagency collaboration and sophisticated evaluation,
the Opioid STR project will aim to transform the system of care for OUD in Missouri. This will
be accomplished by developing evidence-based protocols, implementing multimodal
professional training and consultation programs, and delivering effective and compassionate
services to individuals in high need throughout the state. Estimated number of people to be
served as a result of the award of this grant – 1750
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

MONTANA
Year 1 Year 2
$ 2,000,000 $ 2,000,000
PROJECT SUMMARY
The Montana Opioid (STR) will fund training and infrastructure development for the hub and
spoke model of opioid use disorder (OUD) treatment, medication assisted treatment, peer
support & recovery services, naloxone/narcan training & distribution, and opioid disposal bag
education & distribution to achieve “A comprehensive continuum of services for OUD
prevention and treatment, grounded in evidence-based practice and adapted to the needs of our
frontier state.” The project will focus on the following populations: American Indians, pregnant
women, veterans and individuals involved in the criminal justice system. American Indians
comprise the largest racial minority in Montana with 6.3% of residents identifying as Native
American. There are more than 12,000 live births in Montana annually, and the total population
of women of childbearing age (15-44) in Montana is 186,922. Veterans comprise almost 10% of
Montana’s (99,034 total), the percentage highest in the nation. All of these groups suffer from
disproportionately high rates of substance use disorder, including Opioid Use Disorders (OUD).
Often OUD is criminalized instead of treated medically. Every year, thousands of Montanans
move through the Justice System for substance abuse related offenses, including opioid use.
From 2010-2014, “drug possession” was the number one female and number two male adult
conviction offense in the state. It is estimated 90% of the individuals currently held in Montana
jails are there for substance abuse related offenses. To improve Montana’s response to the opioid
epidemic, particularly among our populations of focus for this grant, we will focus on two
primary goals: 1) Support OUD prevention programs and services in Montana and 2) Develop
comprehensive, evidence-based services for OUD treatment in Montana. To support prevention
programs and services, Montana will publish a comprehensive OUD needs assessment and
strategic plan, increase access to and training on naloxone/narcan use for emergency medical
systems and law enforcement providers in the state, and increase access to disposal bags among
individuals receiving an opioid prescription in our state. To develop a comprehensive continuum
of OUD treatment, Montana will implement six Hub and Spoke models for OUD treatment, with
Hubs agreeing to implement Medication Assisted Treatment (MAT) and Peer Support and
Recovery Services and contract with at least two smaller Spoke sites to implement these services
with the assistance of the MAT providers at the Hub sites. Montana will work to increase the
number of Montana providers trained on Opioid prescribing guidelines, peer support and
recovery services and the use of MAT. In all, Montana intends to serve 2,215 clients with MAT
treatment at 18 Hub and Spoke Sites by the end of the project period, with 90% of these
individuals (1993 total) receiving peer support and recovery services.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

NEBRASKA
Year 1 Year 2
$ 2,000,000 $ 2,000,000
PROJECT SUMMARY
The purpose of Nebraska’s Opioid STR program is to substantially reduce the incidence of
abuse of prescription and illicit opioid drugs in Nebraska through ongoing collaboration between
practitioners, experts and leaders across the continuum of care. The program will also work to
mitigate the effects of opioid use disorders (OUD), including both prescription opioids and illicit
drugs, such as heroin, by identifying statewide needs, increasing access to treatment, including
Medication Assisted Treatment (MAT), and reducing prescription drug overdose (PDO) deaths
through the provision of prevention, treatment and recovery activities. The Division of
Behavioral Health will partner with other agencies to provide services to underserved
populations statewide without duplicating efforts. Nebraska’s goals include: completing a needs
assessment; developing a comprehensive strategic plan; implementing prevention initiatives
including, opioid prescribing guidelines, The Dose of Reality media campaign, safe drug
disposal initiatives, funding community coalitions to provide OUD prevention EBPs in
communities of need, and provide Naloxone to at risk populations and providers; implementing
clinically appropriate evidence-based practices (EBPs) for OUD treatment including training
providers in the ECHO model, funding access to Naloxone, enhancing the utilization of MAT
through the funding of Suboxone, creating an Addiction Medicine Fellowship, and developing a
curriculum supplement to the peer support curriculum specific to opioids; assistance to patients
with treatment costs by providing funding for Suboxone; and training treatment providers who
serve consumers transitioning from criminal justice settings or other rehabilitative settings. DBH
intends to serve the entire population of the state through training and prevention initiatives,
while targeting high burden areas of the state for outreach, training and technical assistance.
Nebraska proposes to increase the number of clients served by DBH in the opioid replacement
therapy service by 5% each year, resulting in approximately 36 more individuals receiving this
service over course of the project period. Nebraska further intends to supply 1000 Naloxone kits
to high risk clients each year, resulting in 2000 Nebraskan’s having access to this life-saving
drugs. Finally, Nebraska intends to serve approximately 340 individual’s receiving assistance
with treatment and in support of their path to recovery by providing funding for Medication
Assisted Treatment through the use of Suboxone.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

NEVADA
Year 1 Year 2
$ 5,663,328 $ 5,663,328
PROJECT SUMMARY
The opioid crisis in Nevada can be classified as a public health epidemic. Nevada’s Governor
has been instrumental in bringing awareness to the crisis, convening state and national experts to
develop policy and practice to address the issues, and supporting the implementation of
prevention, intervention, and treatment solutions. In 2015, the Governor signed model
legislation into law, expanding access to naloxone, requiring use of the Prescription Drug
Monitoring Program, and the implementation of a Good Samaritan Law. In 2017, the
Governor’s Controlled Substances Act will establish prescribing standards of care, increase
education for prescribers related to addiction and standards of care, and develop syndromic
surveillance for monitoring overdose related emergency room and inpatient admissions. Nevada
has also benefited from several awards to address prescription drug abuse and prevention,
including the Strategic Prevention Framework – Partnership for Success Cooperative Agreement
(PFS) and the Harold Rodgers grant. The expansion of Medicaid has made healthcare, including
substance use disorder treatment and medication assisted treatment widely available to
individuals who previously did not have access. Opioid treatment programs statewide remain
well-under capacity for the numbers of individuals they are capable of providing treatment to.
Yet despite these efforts and resources, the epidemic continues to grow in Nevada. Nevada
consistently demonstrates some of the highest rates of drug overdose mortality in the country.
The Centers for Disease Control and Prevention’s (CDC) has reported Nevada has one of the
highest rates of prescription painkillers sold and drug overdose deaths per capita. Inpatient
hospitalizations and emergency room visits have increased from a combined 10,264 episodes in
2014, to 15,266 episodes in 2015. Heroin deaths increased 22% in the same time period. The
epidemic is complex and multifaceted meaning the approaches needed to adequately address the
crisis must also be multifaceted and complex. Nevada’s vast geography and healthcare provider
shortage contribute to a challenging environment to implement community based strategies to
combat the crisis. Stigma and lack of knowledge about available services continue to prevent
individuals to seek treatment and physicians from linking and referring individuals to much
needed opioid use disorder treatment and recovery supports despite availability within treatment
centers. This funding opportunity will allow Nevada to address the unique needs of its
communities and establish a sustainable, coordinated, recovery-oriented system of care using the
Collaborative Opioid Prescribing Model, overdose response and treatment engagement
programs, overdose education and naloxone distribution, prescriber education and expansion of
office based opioid treatment, recovery communities and peer supports, enhanced data
collection, and information sharing between public health and law enforcement while
maximizing existing resources including Medicaid reimbursement.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

NEW HAMPSHIRE
Year 1 Year 2
$ 3,128,366 $ 3,128,366
PROJECT SUMMARY
NH Department of Health and Human Services (DHHS) seeks this grant to implement a comprehensive
approach to address New Hampshire’s opioid use disorder crisis through various prevention, treatment,
and recovery services targeted at high-risk populations. Populations have been selected due to their high
risk of initiation of substance use, opioid use disorder (OUD), and overdose events and fatalities. The
identified target populations of focus include pregnant women with OUD and parents in recovery, youth
in recovery, children and families involved with the Division of Children, Youth and Families (DCYF)
due to substance use, and incarcerated men and women scheduled to re-enter the community. NH
anticipates serving approximately 988 individuals. NH plans to implement specialized selective
prevention services, treatment services, and peer recovery support services to meet the goals of the State
Targeted Response to the Opioid Crisis Grant. NH has chosen Evidence-Based Practices (EBP) that are
designed for the populations of focus and will implement those practices with selected community-based
providers and organizations that can demonstrate willingness and readiness to engage in this specialized
work. Unique to this proposal is the emphasis on a strong collaboration between a multitude of DHHS
and other state agencies, all of which are experiencing the challenges of the state’s opiate crisis for the
populations they serve. The single state authority for substance abuse, the Bureau of Drug and Alcohol
Services (BDAS) will work in close collaboration with DHHS agencies, including but not limited to the
DCYF, Division of Public Health Services (DPHS), and the Bureau of Children’s Behavioral Health
(BCBH) as well as New Hampshire Governor Christopher P. Sununu’s Office, the NH Department of
Corrections (DOC), and stakeholders to ensure proper EBP selection and project implementation across
the prevention, treatment, and recovery programs proposed. NH requests the full funding over the two
year period, equaling $6,256,732 and intends to use this grant to open access to critical services that may
not be accessible for the target populations due to insurance coverage barriers, as well as for services that
are not yet part of any benefit plan. Examples of these services include; family peer support, youth peer
support, enhanced care coordination, support services that increase treatment engagement (childcare,
transportation), and parenting education. Evaluation of program design, grant progress and individual
participant outcomes is essential in meeting grant obligations and ensuring fidelity to practices and
program design. NH is eager to partner with other STR funded states to participate in SAMHSA’s
national evaluation and is committed to working alongside SAMHSA’s priorities for this funding as a
means to increase access to treatment, reduce unmet treatment need, and reduce opioid overdose related
deaths through the provision of prevention, treatment and recovery activities for opioid use disorder
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

NEW JERSEY
Year 1 Year 2
$ 12,995,621 $ 12,995,621
PROJECT SUMMARY
The goal of the New Jersey State Targeted Opioid Response Initiative (STORI) is to address the
opioid crisis confronting the state using a variety of strategies. The key objectives are to increase
access to treatment, reduce unmet treatment need and reduce opioid related deaths. To address
these objectives, a new fee-for-service treatment initiative will be developed that will include a
wide range of levels of care and the use of evidenced based practices, particularly medication
assisted treatment (MAT). New Jersey’s proposal provides family and peer recovery supports,
community education programs, and training. STORI targeted groups include individuals with
Opioid Use Disorder (OUD) such as Opioid Overdose Recovery Program (OORP) clients and
other overdose survivors, veterans, individuals released from incarceration in last 60 days, and
young and older adults. Prevention efforts will focus on community education programs for
older adults with the goal to reduce demand for and misuse of opiate prescriptions. Additional
training on naloxone will be provided to schools, jails and prisons, and naloxone kits will be
distributed. STORI services will encompass training of primary health and behavioral health
care practitioners on best practices for the prescribing of opiates and expanded use of MAT.
STORI will provide peer training for volunteers in the Law Enforcement Addiction Assisted
Recovery and Referral Program. Under the leadership of Governor Chris Christie, New Jersey
has responded to the state’s increasing numbers of opiate overdose deaths and adverse events
with numerous initiatives. New Jersey intends to leverage all these initiatives with this current
grant opportunity to maximize its efforts. One initiative is the OORP which is currently
operating in 11 counties and will be expanded to the remaining 10 counties through STORI.
OORP utilizes Recovery Specialists and Patient Navigators to engage individuals who were
reversed from an opioid overdose and provide non-clinical assistance, recovery supports and
referrals for assessment and OUD treatment. Another key initiative in this grant is the
development of Support Team for Addiction Recovery (STAR) in high risk counties consisting
of a community-based group of case managers and recovery specialists who will provide case
management services and recovery support through a team approach. Family support will be
provided through the development of three regional Family Support Centers. Anticipated
outcomes of the STORI include: reduction/abstinence from drugs and alcohol, increase in
employment, reduced criminal justice involvement, increase in stable housing, increased social
connectedness, and increased percentage of individuals completing treatment at the
recommended level of care. Additional outcomes include: reducing opioid overdoses, increasing
retention in treatment, reducing the length of time to relapse and prolonging recovery, and
increasing number of individuals receiving MAT. It is estimated that STORI will serve 8,671
individuals annually and 17,342 individuals over the two-year project.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

NEW MEXICO
Year 1 Year 2
$ 4,792,551 $ 4,792,551
PROJECT SUMMARY
In 2014, New Mexico had the second highest drug overdose death rates in the country, with
almost half of these deaths caused by prescription opioids. The purpose of the NM Opioid STR
Initiatives is to address this tremendous opioid crisis by expanding access to treatment, reducing
unmet treatment need, and reducing opioid overdose-related deaths through the provision of
prevention, treatment and recovery services for Opioid Use Disorders (OUDs) in New Mexico.
This includes prescription opioids, as well as illicit opioids such as heroin. The NM opioid STR
Initiative will be overseen by the NM Behavioral Health Services Division (BHDS), which is the
Single State Drug and Alcohol Authority (SSA) in the state, and will expand access to quality
services by: supplementing and expanding existing OUD prevention, treatment, and recovery
activities currently managed by BHSD, and developing and incorporating new successful
implementation models and approaches to support expanded services and ensure long term
sustainability. Enhancing and expanding access to prevention, treatment and recovery services
for OUD is critical for all NM communities because it will improve outcomes for persons with
OUD and support a strong and sustainable OUD prevention and treatment system. Expanding
access to comprehensive OUD services will be achieved through the following goals: (I) develop
a comprehensive response to the opioid epidemic; (2) implement a coordinated and sustainable
approach to OUD service expansion; (3) expand the OUD prevention services array; (4) expand
the OUD treatment services array; (5) expand the OUD recovery services and supports array;
and (6) utilize an ongoing Continuous Quality Improvement (CQI) framework to ensure data
informed decisions. We anticipate reaching a total of 9,850 individuals annually, for a total of
19,700 individuals over the two-year grant period.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

NEW YORK
Year 1 Year 2
$ 25,260,676 $ 25,260,676
PROJECT SUMMARY
The New York State Office of Alcoholism and Substance Abuse Services (OASAS) in
partnership with the Research Foundation for Mental Hygiene, Inc.(RFMH) will undertake a
multi-pronged approach to address the issues of Opioid Use Disorders in the unserved and
underserved areas of the State. OASAS has identified high need areas in the state and through its
existing infrastructure will enhance treatment and recovery services. OASAS’s proposal is to
develop Centers of Treatment Innovation in high need areas which will include developing
Telehealth capacity; increasing the number of prescribing practitioners for medication assisted
treatment via training and mentoring; having care managers to bridge the gap between
behavioral health and primary care; use of locally placed Peer Recovery Support Staff to
improve treatment engagement and retention; enhanced clinical staff; and providing reentry
support for individuals being released from jails/ correctional facilities. OASAS will also utilize
a multi-level prevention approaches including delivery of evidence-based prevention services to
underserved, hard-to-reach youth and other at risks populations, foster care settings and
permanent supportive housing; provide training and distribution of Naloxone kits; and a targeted
media campaign. To support a growing recovery community OASAS will develop a youth and
young adult statewide recovery network and local community networks. OASAS looks to
establish a social media campaign that promotes health, recovery and wellness, establish peer
supports and to provide technical assistance and support to local communities and networks of
young people across New York State. Estimated number of people to be served as a result of the
award of this grant – 22830
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

NORTH CAROLINA
Year 1 Year 2
$ 15,586,724 $ 15,586,724
PROJECT SUMMARY
The Division of Mental Health, Developmental Disabilities, and Substance Abuse Services
(DMHDDSAS) of the North Carolina Department of Health and Human Services (NC DHHS),
the State Mental Health Authority (SMHA) and the Single State Authority (SSA) for substance
use will serve North Carolinians at highest risk for Opioid Use Disorder (OUD) through the
proposed project, the NC State Targeted Response to the Opioid Crisis (NC Opioid STR).
Opioid use disorders are pervasive throughout North Carolina, due to the use of illegal opiates
such as heroin, as well as misuse of prescription opioids; as such, this proposal will identify the
areas of highest need with the intent of serving as many individuals and areas as funds will
allow. Over the past several years, North Carolina has experienced an increase in opioid and
heroin use, misuse and overdose. In response, the state has developed strategies and
implemented several initiatives to address the problem. The Cures Act provides the opportunity
to consolidate those efforts, as well as enhance and expand services and supports to meet the
needs of the citizens of North Carolina. Given the impact on our state, the governor has made
this a top priority of his administration. Under the leadership and direction of the Office of the
Governor, the Office of the Attorney General and the Secretary of DHHS, this project will
strengthen the foundation for prevention, treatment and recovery services, an essential
component of North Carolina’s broader efforts to address this challenge and ensure the health
and safety of individuals, families and communities in our state.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

NORTH DAKOTA
Year 1 Year 2
$ 2,000,000 $ 2,000,000
PROJECT SUMMARY
The purpose of North Dakota’s State Targeted Response to the Opioid Crisis Grant project is to
address gaps and build upon existing statewide efforts and infrastructure by increasing access to
evidence-based treatment and recovery services for opioid use disorder and reducing opioid
overdose related deaths through the provision of primary and secondary prevention.
Approximately 14.5 percent of North Dakota high school students reported using prescription
drugs without a prescription one or more times during their lifetime (YRBS, 2015). Overdose
deaths in North Dakota increased from 20 deaths in 2013 to 61 deaths in 2015 (CDC/NCHS,
National Vital Statistics System, Mortality). As of February 2017, almost nine percent (8.8%) of
licensed pharmacists in the state (80 of 905) are signed up to prescribe naloxone. The first goal
is to increase evidence-based treatment and recovery services for individuals with Opioid Use
Disorder (OUD), with a focus on individuals reentering communities from criminal justice
settings. The following, summarized, objectives were identified to achieve this goal: (1) increase
utilization of Medication-Assisted Treatment (MAT); (2) Increase access to peer and other
evidence-based recovery support services. The second goal is to increase implementation of
evidence-based primary and secondary prevention strategies. The following, summarized,
objectives were identified to achieve this goal: (1) decrease access to unneeded prescription
opioid medication; (2) increase availability and utilization of naloxone. The third goal is to
increase utilization of effective treatment services for Opioid Use Disorder (OUD) by increasing
communication efforts to reduce stigma surrounding Opioid Use Disorder (OUD), Medication
Assisted Treatment (MAT) and needle exchange/syringe service program. To address the state’s
capacity needs, and to effectively implement evidence-based strategies across the full continuum
of care, the Division has developed a hybrid system design to implement evidence-based
strategies that will most rapidly address needs and gaps from both the state and community
levels. This project has the potential to impact the entire state, which has an estimated
population of 756,927. Evaluation data will be collected to answer the evaluation questions
posed in the FOA including data required by SAMHSA and additional measures as needed to
successfully evaluate the project.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

NORTHERN MARIANA ISLANDS
Year 1 Year 2
$ 250,000 $ 250,000
PROJECT SUMMARY
The Community Guidance Center, under the Commonwealth Healthcare Corporation, also the
designated Commonwealth of the Northern Mariana Islands Jurisdiction and State Primary and
Behavioral Health System are with interest and efforts in pursuing the State Targeted Response
to the Opioid Crisis Grants (Short Title: Opioid STR) Funding Opportunity Announcement
(FOA) No. TI-17-014. This pursued FOA provides opportunity for the Community Guidance
Center with obtaining much needed resources to strengthen current substance use disorder
prevention and treatment level of care and efforts to provide an inter-clinic and prevention unit
platform towards the related priorities established within the Wellness Clinic, Recovery Clinic,
and the Prevention Unit which focuses on providing a continuum of wellness and recovery
intervention services, substance use/abuse prevention services to include mental health
promotion contingent to available resources obtain through State and Federal support. Identified
within the project proposal are efforts to increase clinical and program capacity in hopes of
having these designated personnel and clinicians provide macro, mezzo, and micro efforts to
engage prevention and treatment intervention strategies specific to the Opioid Crisis that has
been experienced throughout the nation, territories, and affiliates. The established project name
is the Family and Community Driven Care, Addressing the Opioid Crisis in the CNMI. CGC
current has strength and ability to have mental health, substance use treatment, and substance
abuse prevention within one agency, individuals, families, and community organizations within
the CNMI will be included to address current gaps of services identified within primary care and
the community. Due to the uncertainty and proposed project that will be established within the
CGC Wellness Clinic, Recovery Clinic and the Prevention Unit, the estimated number of people
to be served as a result of the award of this grant
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

OHIO
Year 1 Year 2
$ 26,060,502 $ 26,060,502
PROJECT SUMMARY
Unintentional drug overdose continued to be the leading cause of injury-related death in Ohio. In
2015, drug overdoses caused the deaths of 3,050 Ohio residents, which is the highest number on
record. Opioids (heroin, fentanyl and prescription) remained the driving factor behind
unintentional drug overdoses in Ohio. The sharp increase in overdose deaths coupled with
National Survey on Drug Use and Health (NSDUH) prevalence data on individuals needing but
not receiving treatment led to the identification of priority target areas to focus project efforts.
The targeted strategies outlined in Ohio’s Opioid STR proposal will impact over 8 million
Ohioans, which represents 75 percent of the state population, and encompasses 53 percent of
counties and board areas. Ohio’s Opioid STR Project goals focus on building a community
system of care (prevention, early intervention, treatment and recovery support) that emphasizes
service integration between physical health care, emergency health care, behavioral health care,
criminal justice, and child welfare. Strategies and activities undertaken for this effort build upon
Ohio’s on-going efforts to address the opioid epidemic and are designed to reduce overdose
deaths and enhance the ability of individuals with opioid use disorder to receive treatment using
evidence-based approaches. A three-pronged approach is adopted to operationalize the identified
strategies and activities. This includes 1) department-directed strategies and activities focusing
on counties of the state with highest opioid overdose deaths and treatment need, 2) departmentdirected
strategies and activities to be deployed statewide, and 3) Alcohol, Drug Addiction and
Mental Health Services (ADAMHS) Boards identified projects consistent with the goals and
objectives of the Ohio Opioid STR Project. Ohio’s Opioid STR Project emphasizes evidencebased
practices throughout the needed continuum of services and interventions: PAX Good
Behavior Game and Botvin Lifeskills for primary prevention, Screening, Brief Intervention and
Referral to Treatment (SBIRT) for early intervention, and Medication-Assisted Treatment
(MAT) for opioid use disorder, using the ECHO model and other training methodologies to
expand treatment capacity. Additional evidence-based practices include Sobriety, Treatment and
Recovery Teams (START) for child welfare and Trauma Informed Care to address the vicarious
trauma experienced by professionals in multiple systems and families who are facing the
consequences of Ohio’s opioid epidemic on a daily basis.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

OKLAHOMA
Year 1 Year 2
$ 7,283,229 $ 7,283,229
PROJECT SUMMARY
The Oklahoma Opioid STR integrated System of Care (ISOC) will serve persons with, or at risk
for Opioid Use Disorder (OUD) statewide. The ISOC will include promotion, prevention, early
intervention, treatment, and recovery supports. The goal is to provide treatment to 2,200 people
over two years, and to distribute 7,000 naloxone kits available to help those in need. This ISOC
will be built within the robust comprehensive ODMHSAS system that includes Certified
Community Addiction and Recovery Centers (CCARCs), Community Mental Health Centers
(CMHCs), and Certified Community Behavioral Health Clinics (CCBHCs). Oklahoma
welcomes this opportunity to more fully address the opioid crisis. Through this much-needed
SAMHSA funding, the ODMHSAS will create an integrated system of care (ISOC). The ISOC
goals encompass prevention services that will save lives in the future through decreasing opioid
and heroin overdose and non-medical use of prescription drugs. In addition, the ISOC will
provide early and easy access to services through: outreach; early identification and linkage to
appropriate levels of treatment; crisis intervention and linkage to appropriate level of treatment;
and recovery support services, all of which will save lives today. Oklahoma’s ISOC will ensure
that those with or at risk of opioid addiction are afforded every opportunity to achieve recovery
and become productive citizens with bright futures. Lives will be saved today, families will be
preserved, and futures will be reclaimed. Measurable goals and objectives include: 1) Develop
and disseminate messages aimed to prevent abuse of opioids and increase service utilization; 2)
Mobilize community outreach workers to deliver training, disseminate material, drive service
referrals, and increase local action on opioid prevention; 3) Train the primary care workforce in
non-opioid alternative to pain management and safe opioid prescribing; 4) Train workforce in
best practices; 5) Implement a model of practice facilitation in selected areas focusing on uptake
of opioid prescribing guidelines; 6) Enhance the Prescription Drug Monitoring Program; 7)
Expand overdose education and naloxone distribution statewide; 8) Engage comprehensive
treatment agencies and crisis units to fill gaps and provide a fuller array of services; 9) Employ
strategies to increase access to treatment for persons with or at risk for OUDs, including those
who are uninsured and underinsured; 10) Identify, refer and provide treatment for those coming
out of jails and prisons; 11) Identify those most in need of treatment through data analysis, and
require comprehensive treatment agencies to outreach and engage into treatment; 12) Require
comprehensive treatment agencies to maintain waivered prescriber on staff; 13) Provide
additional 60 slots of high intensity residential services; 14) Develop increased capacity in
Oxford Houses for those with OUD; 15) Expand capacity for peer recovery support providers to
deliver services; 16) Train all levels of staff in evidence-based practices; 17) Provide
consultation for prescribers of Medication Assisted Treatment; and 18) Conduct comprehensive
evaluation of all activities.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

OREGON
Year 1 Year 2
$ 6,564,425 $ 6,564,425
PROJECT SUMMARY
The OR-Opioid STR aims to 1) enhance state and community-level efforts to advance public
health interventions that reduce PDO and problematic prescribing of controlled substances, 2)
increase the number of DATA-waived providers in Oregon who are actively prescribing FDA
approved medication for OUD, 3) enhance and expand the provision of peer support services
design to improve treatment access and retention and support long-term recovery, 4) provide
treatment transition and coverage for patients reentering the community from the criminal justice
system,5) implement access to FDA approved medication for MAT in combination with social
interventions, 6) establish statewide public education campaign on opioid and 7) establish a
more robust network of recovery resources in places most affected by opioid epidemic in
Oregon. This grant will supplement the existing CDC and SAMHSA grant that Oregon has and
expand those efforts across the state. A continuous need assessment will be part of the grant
activities. The Oregon Dept. of Corrections and Oregon Health and Human
Sciences University will be two of the sub-grantees. More partnering organization will be
identified with grant progress. The project will overall aim to increase access MAT across the
state, in addition a special focus would be on Oregon's Tribal communities. This is because
currently the Oregon Tribes do not have a robust system of needs assessment even though opioid
use disorder is a major burden in the Native American population (according to Medicaid data).
The project will also keep a focus on rural and frontier counties, since in Oregon, opioid use
disorder is mostly a rural issue. Despite of this high need in rural areas there is significant low
access to MAT provider sin these regions. A significant proportion of this population also turns
to heroin once opioid becomes too expensive to afford, among individuals living with chronic
pain. This is true in certain urban areas as well, such as the Portland Metro area since heroin is
easily available. In Oregon, Opioid Use disorder is primarily an access, training, and education
issue. For example, only 30% of the DATA waived providers actually prescribe MAT
medication. The STR grant project will drive the efforts of training providers on CDC's
prescribing guideline, and community engagement and outreach. In addition, the Oregon
Prescription Drug Monitoring Program will also be enhanced to get at least 95% of the high
prescribing providers. This will allow for more accurate and targeted needs assessments in
moving forward. The project will be done in collaboration with Department of Public Health,
county health departments, criminal justice system, and regional Medicaid providers. Several of
the infrastructure, such as ongoing evaluation, technical support, policy model, and
sustainability plans, are already in place.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

PALAU
Year 1 Year 2
$ 250,000 $ 250,000
PROJECT SUMMARY
The Project Rx Monitoring shall be the incubator for the development of a Prescription Drug
Monitoring Program in the entire catchment area of the Republic of Palau to enable prevention,
treatment and recovery from the emerging opioid addiction disorders.
Goal 1: Increase knowledge and awareness among prescribers, providers, and
partners in prescription drug monitoring program. Knowledge base will be assessed at
the beginning of the project. There are 96 prescribers in Palau as of 2016, over 100 nurses,
and over 80 allied health providers. All of the providers will be surveyed to get a baseline
score of their knowledge. In the two year period, a training plan will be developed and
implemented to increase knowledge.
Goal 2. Implement the SPF Model to assess, develop a strategic plan, build capacity,
implementation plan and evaluation plan. The SPF model will be utilized to address the
other key areas of the issue.
Goal 3. Increase access to Opioid Treatment Services through Community Engaging
There are four pharmacies, three private clinics, 8 outlaying area dispensaries, and the main
hospital. As the plan is developed, a baseline of treatment services will be established and
the project aims to increase capacity by 100%.
Goal 4. Strengthen local capacity in technology for training, services, monitoring, and
electronic health service/resource access. Ministry of Health is currently using the Health
Information System (HIS) as Electronic Health Record for Palau. This records patient
encounters, diagnosis, services received and billing. For the next 1-2 years, ICT will
develop the inventory and supply, ancillary services and the pharmacy module. Linking this
other module to the current HIS will ensure proper inventory of the supplies used for
services received and will also keep track of the medications for all patients. Aside from
adding modules to the system, ICT also proposes to upgrade the Graphical User Interface
(GUI) of the system. The aim is to make the EHR accessible online and can be viewed
across platforms. Aside from the EHR component, ICT will also move forward with
electronic human resource system called Human Resource Information System (HRIS). The
system backbone is already in place and is ready for enhancements. This system will include
modules that will keep track of employee training earned both off-island and in house.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

PENNSYLVANIA
Year 1 Year 2
$ 26,507,559 $ 26,507,559
PROJECT SUMMARY
Pennsylvania proposes to address the opioid crisis by increasing access to treatment, reducing
unmet treatment need, and reducing opioid overdose related deaths through the provision of
prevention, treatment, and recovery activities for opioid use disorder (OUD). The project will
support a comprehensive response to the opioid epidemic using a strategic planning process to
conduct needs and capacity assessments. The results of the assessments will identify gaps and
resources from which to build upon existing substance use prevention and treatment activities.
Initial strategies have been developed and will include:
• Provide clinically-appropriate treatment services to 6,000 individuals who are uninsured
or underinsured.
• Expand treatment capacity for Medication Assisted Treatment for OUD.
• Expand treatment capacity for underserved populations by targeted workforce
development and cultural competency training.
• Improve quality of prescribing practices through prescriber education.
• Increase community awareness of OUD issues and resources through public awareness
activities.
• Expand implementation of warm hand-off referral practices to increase the number of
patients transferred directly from the emergency department (ED) to substance use
treatment.
• Increase the number of youth receiving evidence-based prevention and life skills
education programs.
• Improve identification and referral of students for assessment and treatment by providing
training to school personnel.
• Expand Pennsylvania’s integration of its Prescription Drug Monitoring Program (PDMP)
data at the point-of-care, promoting ease-of-use of this data in clinical decision making.
Estimated number of people to be served as a result of the award of this grant – 13400
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

PUERTO RICO
Year 1 Year 2
$4,811,962 $4,811,962
PROJECT SUMMARY
The MHAASA proposes a 2-year PR Opioid STR for populations in use of opioids and at risk of
overdose. Infrastructure PDMP and opioid overdose surveillance systems; transition to treatment of
opioid using inmates; four new methadone dispensing sites integrating the RTSH EBP; TND EBP
secondary prevention for adolescents; media education and provider/responder training, are strategies to
be coordinated with public (DCR) and private (CBO and FQHC) stakeholders. The summarized goals
are: 1. Develop a needs assessment to identify high prevalence areas, existing providers, funding sources,
and gaps in opioid prevention and treatment; 2. Develop a PR strategic plan to address data infrastructure
and opioid use prevention, treatment and recovery gaps; 3. Implement proven EBP’s in secondary
prevention of opioid misuse in adolescent populations; 4. With collaborative partners, expand access to
EBP opioid treatment in public and private provider systems; 5. With Corrections system, link inmates
with opioid use history to treatment upon release; and 6. Train providers and responders on overdose
prevention and opioid treatment topics. Objectives include: 1a. Establish collaborative agreements for
participation of public/private stakeholder entities for project participation and in needs assessment,
description of available services and funding sources and identification of services gaps in YR 01; 1b.
Complete Needs Assessment by 12/31/17; 2a. Complete Strategic Plan by 3/31/18 to address major needs
identified; 2b. In YR 01, implement data collection and monitoring systems, including SMART MIS
enhancements, PDMP, and overdose surveillance system; 3a. By 6/30/18, implement CSAP proven
prevention EBP in 3 CBO’s for adolescent opioid users; 3b. By end of project, evidence prevention
outcomes; 3c. By 6/30/18, train all Methadone Program, FQHC and private buprenorphine providers on
RTSH EBP; 3d. By project end, evidence improved treatment and recovery outcomes of EBP enhanced
services; 4a. By beginning of YR 02, expand Methadone Treatment to Eastern Region; 4b. By beginning
YR 02, expand access to MAT in San Juan and Vega Baja; 4c. By beginning of YR 02, provide RTSH
EBP to at least 60 opioid users in 6 Methadone Treatment Centers; 4d. By beginning YR 02, expand
buprenorphine treatment to 2 new primary healthcare settings; 5a. Link about 150 offenders with history
of opioid use to treatment within 90 days of discharge; 5b. Retain for at least 6 months, at least 75% of
offenders in treatment/recovery services; 5c. Prevent opioid overdose events and progression to
dependence in opioid using adolescents through Project TND EBP services; 6a. Attain adequate
insurance coverage and cost reductions for opioid prevention, treatment and recovery services; 7a.
Increase knowledge and response skills of at least 85% of clinical staff trained; 7b. Train about 500
providers and responders on opioid prevention and treatment topics to promote coalitions to improve
quality. Annually, the project will serve 350 unduplicated opioid users in treatment/recovery services;
200 in primary and secondary prevention; and 500 through provider and responder training. Estimated
number of people to be served as a result of the award of this grant – 900
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

RHODE ISLAND
Year 1 Year 2
$ 2,167,007 $ 2,167,007
PROJECT SUMMARY
The RI State Targeted Response (STR) will address the strategies identified in our State’s
Overdose Prevention and Intervention Action Plan including increasing access to treatment,
reducing unmet treatment needs and reducing overdose deaths through prevention, treatment and
recovery support initiatives. The RI-STR will ensure that all federal, state and private funding is
synchronized to move forward the state’s action plan and is alleviating identified gaps. The goals
of the RI-STR initiative are 1) to reduce the number of prescription drug/opioid overdose-related
deaths and adverse events among individuals 18 years of age and older, 2) increase access to
treatment, reduce unmet need and opioid overdose related deaths through the provision of
prevention, treatment and recovery activities for prescription and illicit drugs 3) support a
comprehensive response using a strategic planning process and needs and capacity assessments
(most prevalent, number and location of providers, existing activities and funding sources –
gaps) epidemiological data. The state will achieve these goals by increasing the number of
DATA waivered health providers including physicians, physician assistants, nurse practitioners;
increasing access to behavioral healthcare and psychiatry in high risk communities primary care
settings; enhancing access to psychiatrists in the current OPT Health Homes and providing
fentanyl testing assistance; increasing access to recovery housing and specialized medicated
assisted treatment peer support specialists; incorporating opioid and prescription drug misuse
outreach, education into current regional prevention task forces through the implementation of a
high school based education specifically targeting high risk communities and through the
promotion of a grassroots communication strategy for the education and prevention of
prescription drug and opioid overdose; finally, through the distribution of naloxone to
community based outreach teams and individuals leaving the Department of Corrections. The
communities of focus include: West Warwick, Cranston, Hopkinton, Providence, Charlestown,
Johnston, Pawtucket, Westerly, Warwick, Woonsocket, Central Falls and North Providence. The
initiatives that will be supported will increase integration of behavioral healthcare into health
settings with the goal of increasing DATA waivered clinicians. Reduce recidivism of overdose
incidents by enhancing access to psychiatrists in the OPT-Health Homes, testing for Fentanyl,
and the provision Recovery Housing with staff that is trained in recovery supports and MAT.
Prevention strategies will leverage existing systems to increase access to Naloxone, develop a
statewide communication plan that will be implemented at a grass roots level through the
regional prevention task forces. The Task Forces will also implement an Opioid Prevention
education strategy in the high schools. Estimated number of people to be served as a result of
the award of this grant – 8783
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

SOUTH CAROLINA
Year 1 Year 2
$ 6,575,623 $ 6,575,623
PROJECT SUMMARY
The South Carolina Department of Alcohol and Other Drug Abuse Services (DAODAS) as the
Single State Authority for substance use disorder (SUD) services, is requesting $6,575,623 a
year for two years from SAMHSA’s Center for Substance Abuse Treatment and Center for
Substance Abuse Prevention under RFA# TI-17-014 to address the opioid crisis by increasing
access to treatment, reducing unmet treatment needs, and reducing opioid overdose-related
deaths through the provision of prevention, treatment, and recovery activities for opioid use
disorder (OUD). DAODAS has partnered with Behavioral Health Services Association of South
Carolina Inc. (BHSA) and all 32 county alcohol and drug abuse authorities that provide SUD
prevention, intervention, treatment, and recovery-support services statewide; S.C. Association
for the Treatment of Opioid Dependence and its members that operate Opioid Treatment
Programs in all regions of the state; Medical University of South Carolina; S.C. Department of
Health and Environmental Control; S.C. Department of Corrections; S.C. Pharmacy Association;
and Faces and Voices of Recovery South Carolina. The application proposes a comprehensive
response to the opioid epidemic by:
• conducting a thorough needs assessment that will be the basis for strategic and
sustainability plans;
• addressing stigma and need for action through a statewide multimedia campaign;
• expanding and enhancing the state’s Prescription Drug Monitoring Program;
• expanding and enhancing the state’s Opioid Overdose Prevention Program;
• providing financial assistance to indigent South Carolinians for medications and talk
therapy;
• expanding access to clinically appropriate, evidence-based practices for OUD treatment;
• enhancing and expanding provision of peer support and other recovery-support services;
• providing assistance to individuals returning to their communities from criminal justice
settings; and
• partnering with MUSC to expand medication-assisted treatment/OUD services across the
state.
The initiative will include developing a resource website, expanding the use of the MUSC
Center for Telehealth, academic detailing, expansion of the SBIRT program, and the
implementation of the Project ECHO model. Estimated number of people to be served as a
result of the award of this grant – 3870
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

SOUTH DAKOTA
Year 1 Year 2
$ 1,999,997 $ 1,999,997
PROJECT SUMMARY
South Dakota’s State Targeted Response to the Opioid Crisis will assess need to formulate
action and create a responsive strategic plan to drive the tactical implementation of prevention,
treatment, and enhanced recovery support services statewide, impacting thousands of South
Dakotans through medication-assisted treatment, lifesaving naloxone distribution, telehealth
access to care, and workforce development. As the Single State Authority, the South Dakota
Department of Social Services, Division of Behavioral Health, will lead the project in
collaboration with ongoing efforts with the South Dakota Department of Health (through
Centers for Disease Control Data-Driven Prevention Initiative funding focused on prescription
drug overdose), the Division’s State SBIRT (Screening, Brief Intervention, and Referral to
Treatment) Implementation grant, and community providers to identify, leverage, and enhance
community-based resources in the areas of prevention, treatment, recovery, and peer support
services. The project will be led by Division Director Tiffany Wolfgang, and supported by
integration with a multidisciplinary team – the Opioid Abuse Advisory Committee – and key
personnel to assess, identify, and support the implementation of strategies that directly address
these broad goals. Key outcomes of this two-year project will include an outcome assessment
dashboard for ongoing performance metric evaluation, a collaboratively developed statewide
strategic plan to address opioid use/misuse in South Dakota, empowered and engaged
communities with increased awareness of the opioid issues within our state, culturally
responsive materials and strategies that can impact our most vulnerable populations (most
notably Native Americans, who have higher-than-average incidences of opioid use in the state),
better equipped first responders to incidences of opioid overdose, extensive provider, prescriber
and physician training in the areas of prevention and evidence-based treatment models, capacity
building and planning for statewide Medication-Assisted Treatment access through telehealth
delivery, and a statewide virtual support ‘hub’ and ‘spoke’ model (teleECHO® clinic) for
enhanced workforce training and staffing of complex OUD cases. An estimated 22,000
individuals are projected to be served by the project through the provision of treatment services
and connection/referral to community-based resources and providers.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

TENNESSEE
Year 1 Year 2
$ 13,815,132 $ 13,815,132
PROJECT SUMMARY
The Tennessee Opioid STR Grant will work to reduce the number of overdose related deaths
through naloxone distribution, train professionals and key stakeholders on opioid overdose
disorders, implement an Opioid Overdose Rapid Response System, improve access and
availability of clinical treatment and recovery services, expand access to medication assisted
treatment, and implement new strategies for pregnant women and supplement existing resources.
The three populations of focus for the Tennessee Opioid STR grant are: 1) Individuals at high
risk for overdose. Research indicates that the high availability of prescription drugs in Tennessee
is contributing to the addiction problem across the state. The pockets of the state where
individuals at high risk of overdose are located were determined using factors that significantly
predicted drug poisoning, overdose death rates, and opioid use disorders. 2) Individuals with a
diagnosis of opioid or heroin use disorder. Research shows that Tennesseans are three times
more likely to identify prescription opioids as their primary substance of abuse than the national
average while heroin treatment rates have grown more than four times in the past five years in
metropolitan counties of the state from a low of 6.9 per 10,000 of poverty population to 28.8. 3)
Pregnant women abusing opioids or heroin. Over the past decade, we have seen a nearly ten-fold
rise in the incidence of babies born with NAS in Tennessee. Infants with NAS stay in the
hospital longer than other babies and often have serious medical and social problems. Universal
prevention strategies will be used to reach the targeted population. It is estimated that the
unduplicated number of individuals to receive treatment and recovery services will be 3,408 the
first year and 3,408 the second year. Prevention Objectives - Culturally tailoring existing Harm
Reduction training material to targeted areas. Provide opioid overdose trainings and medical
forums. Conduct a statewide Media Campaign. Distribute Overdose Safety Kits and naloxone to
targeted areas. Utilize the Opioid Overdose Rapid Response System to target high need areas for
training and naloxone distribution. Conduct Train the Trainer on the Stanford Chronic Pain Self-
Management Program (CPSMP). Treatment Objectives – Enhance clinical treatment services by
providing buprenorphine and VIVITROL injections. Expand capacity and number of individuals
served though outpatient tele-treatment. Improve access and availability to clinical treatment and
recovery services. Provide engagement, retention and detox, when appropriate, from all opioids
for pregnant women.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

TEXAS
Year 1 Year 2
$ 27,362,357 $ 27,362,357
PROJECT SUMMARY
The Texas Targeted Opioid Response (TTOR) program will allow the Texas Health and Human
Services Commission (HHSC) to expand prevention and treatment efforts that promote recovery
and early intervention for populations identified as high risk for opioid use disorders (OUD).
This program will enhance outreach and education for the public, provide training to enhance
workforce, and target individuals at risk of developing OUDs, or a potential overdose, while
increasing access to enhanced recovery oriented treatment. Based on available data, TTOR will
focus on three populations at highest risk for OUD and its related consequences: people who live
in major metropolitan areas; women who are pregnant and postpartum; and people who have a
history of prescription opioid misuse or are at risk of developing an opioid issue (including
persons being treated for chronic pain, veterans, and rural areas with high rates of abuse). The
Texas Statewide Behavioral Health Strategic Plan (2017-2021) identified access to treatment,
unmet treatment needs, fortifying re-entry services, and increasing recovery support services
(RSS) as essential for behavioral health planning in Texas. TTOR will address the alarming
opioid crisis trends by working in concert with this plan and augmenting it with a variety of
additional activities for those at highest risk of OUD. Through a variety of community contracts,
TTOR will serve approximately 14,710 persons over a two-year period. TTOR will partner with
the state agency representatives on the Texas Statewide Behavioral Health Coordinating Council
in addition to consumers, advocates, and provider members that serve on the Behavioral Health
Advisory Council to ensure stakeholder input is incorporated and to coordinate and ensure
efficient use of resources. TTOR will ensure a comprehensive approach to treatment, access to
housing, employment, immunization and testing will also be increased for the populations of
focus. In addition to traditional prevention activities, TTOR will provide training and technical
assistance to peers, providers, and prescribers working in settings ranging from primary care to
jails. Topics will include opioid use and misuse, the importance of evidence-based practices with
a focus on Medication Assisted Treatment, overdose prevention, and RSS. Licensed Chemical
Dependency Counselors will be added to the Outreach, Screening Assessment, and Referral
programs that are available through Local Mental Health and Behavioral Health Authorities.
TTOR funding will also allow for enhanced Mobile Crisis Outreach Teams and the addition of
peer supports outreach teams focused on intervention, prevention and supports. These additions
will enhance early identification and service connections for opioid users in crisis and/or seeking
treatment options. Finally, TTOR will expand opiate treatment capacity to address waitlist and
access constraints. Estimated number of people to be served as a result of the award of this grant
– 14710
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

UTAH
Year 1 Year 2
$ 5,537,458 $ 5,537,458
PROJECT SUMMARY
The UT Opioid STR will address the opioid (prescription opioids and illicit opioids) crisis
through the provision of evidence-based prevention, treatment, and recovery services for
unfunded, underserved youth (age 12-17) and adults (18+) at risk, or with an opioid use disorder.
The UT Opioid STR will enhance existing, science-based prevention activities, improve access
to effective care, strengthen recovery support services and expand Naloxone distribution and
needle exchange initiatives. Project goals are to: prevent/ reduce opioid misuse, reduce overdose
deaths, expand access to evidence-based treatment, increase partnerships with physical health
and promote recovery. Since 2002, the rate of Utah drug poisoning deaths has increased at an
alarming rate. This preventable public health problem has outpaced deaths due to firearms, falls,
and motor vehicle crashes. Currently, Utah is fourth in nation for opioid overdose with 630
opioid deaths in 2015. The number of individuals reporting opioids as their primary substance of
abuse upon treatment entry has increased from 19% in 2010 to 29% in 2016. DSAMH data also
shows a corresponding increase in the rate of injection drug use; 18,2% in 2010 to 28.6% in
2016. The Utah Statewide Epidemiological Outcomes Workgroup (SEOW) will develop a needs
assessment to identify high need geographic areas and subpopulations. This needs assessment
will then drive the development of Utah’s strategic plan. Prevention activities will be planned
and implemented using the Strategic Prevention Framework and designed to reduce risk factors
and enhance protective factors for opioid use disorder. Funds will be used to expand and
enhance the Use only as Directed and the Stop the Opidemic prevention campaigns and
associated activities. In addition, funds will be used to expand the number of community
coalitions using the evidence-based Communities that Care (CTC) operating system and provide
resources to coalitions to help them address the opioid crisis locally. UT Opioid STR will create
the LSAA Opioid Treatment and Recovery Support Project, and the Opioid Community
Partnership Initiative. Both projects will require partnerships with physical healthcare providers.
An Area Plan Process will allow local communities to develop plans to address treatment gaps
and enhance existing services. Treatment opportunity will be expanded and the quality of service
will be enhanced through the use of evidence based practices such as Medication Assisted
Therapy (MAT). The UT Opioid STR will also strengthen the statewide recovery community
network, expand capacity and enhance the quality of recovery support services for individuals
and families. UT Opioid STR will also work with the Utah Department of Health to increase
training and distribution of Naloxone. In addition funds will be allocated to targeted
communities to expand Needle Exchange programs. Estimated number of people to be served as
a result of the award of this grant – 14376
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

VERMONT
Year 1 Year 2
$2,000,000 $2,000,000
PROJECT SUMMARY
Vermont Department of Health (VDH), Division of Alcohol and Drug Abuse Programs
(ADAP). The Vermont Opioid STR project will support a pilot drug disposal project with
Vermont Sheriffs, rapid response funding for prevention projects identified by Vermont’s RPP
Grantees, enhance Vermont’s Prescription Monitoring System’s usability, provide workforce
development opportunities including Office Base Opioid Treatment training, increase recovery
supports in select emergency departments and telephone recovery supports, and community
education opportunities through local adult education centers. The project goals are as follows:
increase medication assisted treatment capacity for opioid use disorder; increase workforce
capacity to treat substance use disorders; improve coordination of care and retention in
treatment; address prescription drug diversion through implementation of a drug disposal
program; increase regional capacity to implement community-specific opioid strategies; and
decrease opioid-related overdose deaths. The overall population of focus is individuals 18 years
or older who are currently experiencing opioid use disorder, with components of this project
having special populations of focus such as prevention of opioid use for individuals’ 18-25 and
individuals 18 years or older who enter an emergency department because of an opioid overdose.
The measurable objectives in this project are the following: increase treatment initiation and
engagement in opioid use disorder treatment; increase access to medication assisted treatment
per 10,000 Vermonters age 18-64; increase the number of Licensed Alcohol and Drug Abuse
Counselors; increase percentage of Vermont Counties with at least one permanent drug disposal
site; and increase the percentage of Vermont counties with at least one formal team
implementing community-specific opioid strategies. Over the project period this project will
serve approximately 13,730 Vermonters through the expanded treatment and recovery services.
Of those, 1,090 individuals will be served in the first year, with 12,640 being served in the
second year of the project period. The vision of this project is to allow for an increase in the
workforce, both in the treatment and recovery fields, enhancements to clinical tools to decrease
opioid use and increase access to treatment, and to allow our prevention programs more ability
in responding to prevention needs that are identified in Vermont. This project has been
constructed in a way that will allow existing programs to adopt the project outcomes and
activities to allow for an effective sustainability plan. Estimated number of people to be served
as a result of the award of this grant – 13730
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

VIRGIN ISLANDS
Year 1 Year 2
$250,000 $250,000
PROJECT SUMMARY
Under the auspices of the State Targeted Response to the Opioid Crisis Grant, the United States Virgin
Islands (USVI) has established five goals to serve a projected population pool of 2,918 individuals that
may be in need of opioid use disorder treatment annually: offer equal access to treatment; expand
availability of recovery and transition support, educate providers, patients, and families; broaden
community-based engagement activities; and increase the number of providers. The USVI is an
unincorporated territory of the United States of America and is comprised of the St. Thomas/St.
John/Water and Hassle Island District and the St. Croix District. Per the 2010 Census, the total
population of the USVI is 106,405; however, a more recent local census placed the population at 105,080
in 2012. Approximately, 76 percent of the population is African-American/Black, 13.5% is
Caucasians/White, and 17.5% is Hispanic/Latino. In December 2016, the Centers for Disease Control
announced that 91 Americans die every day from an opioid overdose.2 As of 2017, the United States
Virgin Islands (USVI) appears to have escaped the effects of the sprawling effects of this epidemic;
however, lack of data, access to treatment, and continuity of care may be clouding a true depiction of
what impact opioids may be having here in the territory. Data being reported in emerging studies suggest
Caucasians and Hispanic/Latino are at high-risk of opioid use disorder. Similarly, since 2014, the USVI
has experienced an increase in the number of Caucasians and Hispanic/Latino males being admitted in
emergency rooms and treatment centers. In response to the Department of Health and Human Services,
Substance Abuse and Mental Health Services Administration (SAMHSA’s) funding opportunity
announcement, the (USVI) has identified three communities of focus as having the highest risk for opioid
use disorder: 1) returning military veterans and their families – of all races, ethnicities, and ages; 2) youth
aged 12 to 25 – of all races and ethnicities; and 3) minority groups (White and Hispanic communities);
and thus, requesting funding to address gaps in our systems of care; delivery of psychosocial and
evidence-based treatments interventions; and the expansion of the availability of Opioid Use Disorder
(OUD) treatments. Addressing the needs of these specific groups will not only allow the USVI to address
emerging opioid use disorders here in the territory; but also contribute to the aims of the SAMHSA to: a)
address the opioid crisis by increasing access to treatment; b) reducing unmet treatment needs; and c)
reducing opioid overdose related deaths through the provision of prevention, treatment, and recovery
activities for opioid use disorder including prescription opioids, as well as illicit drugs such as heroin.
The USVI has established a triangulated strategy of prevention, treatment, and education which is
supported via four measurable objectives to facilitate the achievement of its stated goals: 1) expansion of
accessibility of OUD treatments and recovery services, 2) reduction in overall opioid use, 3) prevention
of opioid overdose related deaths, and 4) increased numbers of trained prevention and treatment
providers. Estimated number of people to be served as a result of the award of this grant – 2918
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

VIRGINIA
Year 1 Year 2
$ 9,762,332 $ 9,762,332
PROJECT SUMMARY
Virginia Opioid Prevention Treatment and Recovery (OPT-R). The Virginia Department of Behavioral
Health and Developmental Services will lead the state’s project to serve populations in rural and urban
areas with high and emerging needs based on rates of prescription opioid drug and heroin overdoses. The
state will use a variety of treatment strategies including medication assisted treatment and recovery
support services, as well as public education strategies to prevent opioid use. Virginia’s local Community
Services Boards (CSB), other state agencies and community organizations will be partners in the effort.
The demographics in the targeted regions are characterized as predominantly white and male.
Asian/Pacific Islanders and Native American individuals are the least represented across all communities.
White individuals are the most represented in all areas, except Richmond, where Black individuals
account for more than half of the population. More than 1,250 people in Virginia will likely die of a drug
overdose in 2017, in large part due to a surge in opioid abuse. People ages 25 to 44 accounted for more
than half of all drug-related deaths from 2007 to 2014. Approximately 1,340 people will be served
throughout the project: during Year 1, a total of 1,100 individuals will be admitted for MAT services, and
an additional 240 will be served in Year 2. It is estimated that 70% of those who engage in MAT will also
engage in Recovery Services: 770 participating in Year 1 and an additional 168 in Year 2. Based on
population counts in the targeted areas, over five million people will be served through community wide
prevention strategies. The following goals have been established: Goal 1- Prevention: To decrease
prescription drug abuse and heroin overdoses through the implementation of a comprehensive array of
strategies including: Community Capacity Building, Education, Tracking and Monitoring, Supply and
Harm Reduction prevention strategies. Goal 2-Treatment: Increase the number of people who receive
OUD treatment after the implementation of strategies to improve access to these services. Goal 3-
Recovery Services: Increase the number of people receiving OUD recovery services after the
implementation of a comprehensive recovery strategy across high need areas in the Commonwealth.
Objectives include: increasing individuals engaged in treatment; educating prescribers about opioid
medications; increasing the number of qualified buprenorphine prescribers who use these products in
conjunction with the CSB system; developing core knowledge and competencies for health professional
education for addiction and pain management that places specific emphasis on appropriate use of opioids,
SBIRT, and addiction as treatable disease; distributing Naloxone along with education on how to reverse
an overdose; increasing Peer Recovery Specialists in hospitals and communities; engaging community
members to address prescription drug and heroin overdoses; conducting public awareness and education
campaigns to prevent opioid drug use; and increasing safe storage and disposal locations to reduce access
to opioid drugs. Estimated number of people to be served as a result of the award of this grant – 5001340
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

WASHINGTON
Year 1 Year 2
$ 11,790,256 $ 11,790,256
PROJECT SUMMARY
The WA-Opioid STR Project is designed to address our state’s opioid epidemic by
implementing the Washington State Interagency Opioid Working Plan, comprised of four goals:
(1) Prevent opioid misuse and abuse, (2) Link individuals with opioid use disorders to
treatment/support services, (3) Intervene in opioid overdoses to prevent death, and (4) Use data
and information to detect opioid misuse/abuse, monitor mortality, and evaluate interventions.
The Division of Behavioral Health and Recovery (DBHR) will implement the WA-Opioid STR
Project with these strategies/objectives related to the four goals. Goal 1 (Prevention): add five
Community Prevention Wellness Initiative sites, increase prescriber/consumer education
opportunities, complete an evidence-based practice analysis, provide a minimum of ten Safe
Storage/Drug Take-back grants, design and implement a statewide public education campaign
(including a tribal component). Goal 2 (Treatment/Recovery Support): Implement six hub and
Spoke Projects, provide a minimum of five Medication Assisted Treatment (MAT) trainings,
design/implement a Substance Use Disorder Peers Initiative, increase treatment access with a
Financial Hardship Initiative, reduce correctional recidivism and overdoses through adult and
juvenile reentry projects, develop a Low-barrier Buprenorphine Pilot to increase treatment
access, engage a minimum of five tribes to design a tribal treatment information campaign, and
operationalize Mobile MAT clinics. Goal 3 (Opioid Overdose): Enhance Naloxone distribution.
Goal 4 (Data): Enhance the Washington State Prescription Drug Monitoring System. Key
populations of focus will include Prevention: Communities/schools with elevated Risk Scores
including opioid prevalence; adolescent opioid prescribers including dentists, primary care, and
sports injury professionals; tribal communities; youth; parents; and older adults. Treatment:
Individuals with Opioid Use Disorders (OUD), prescribers, substance use disorder treatment
providers, individuals with OUD reentering into the community from juvenile and adult
correctional facilities, homeless with OUD, individuals with OUD living in rural/frontier
communities, and tribal communities. Overdose: Individuals with OUD and their
friends/families. Data: Prescribers and community OUD service planning partners. The WA-
Opioid STR Project is expecting to directly serve more than 24,000 Washington state residents
within the initial year of the grant award and over 50,000 across two years. In addition, the
project will reach hundreds of thousands of Washingtonians each year through local and
statewide public information campaigns.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

WEST VIRGINIA
Year 1 Year 2
$ 5,881,983 $ 5,881,983
PROJECT SUMMARY
The West Virginia Bureau for Behavioral Health and Health Facilities (BBHHF) will implement
the State Targeted Response to the Opioid Crisis Grant (Opioid STR) program. The purpose of
the Opioid STR program is to increase access to OUD treatment; supplement evidence-based
prevention, treatment, and recovery activities pertaining to opioids currently undertaken; and
support a comprehensive response to the opioid epidemic statewide. The Opioid STR program
will serve individuals in West Virginia that are at high risk for opioid use disorder (OUD),
including the following target populations: rural populations, uninsured and underinsured
individuals, individuals reentering the community from the criminal justice system, pregnant
women, homeless individuals, and veterans and military families. West Virginia has the highest
rate of opioid drug overdoses in the nation. The Opioid STR program will advance primary
prevention activities across the state by developing a needs assessment based on statewide
epidemiological data; developing a comprehensive state strategic plan to address the gaps in
prevention, treatment, and recovery identified in the needs assessment; and increasing training
opportunities to ensure prevention staff, contractors, and coalition leaders and members are welleducated
in the fields of OUD prevention, behavioral and public health, and evidence-based
program models and paradigms. Secondary prevention will be provided through Syringe
Services Programs and enhanced capacity to provide Hepatitis B and C testing. To deliver
evidence-based implementation strategies to the target populations, including medication and
psychosocial interventions, the Opioid STR program will supplement current treatment and
recovery activities, including MAT programs through the Comprehensive Opioid Addiction
Treatment (COAT) model; Drug Free Moms and Babies Project; the West Virginia Division of
Corrections’ (WVDOC) MAT (Vivitrol) Program; specialized peer recovery supports for high
risk populations; telehealth expansions, and education and training activities. The opioid use
prevention and treatment evidence-based practices that will be used in the Opioid STR program
include Medication Assisted Treatment (MAT); Screening, Brief Intervention, Referral,
Treatment (SBIRT) Model; Trauma-Informed Care; Peer-Based Recovery Support Services; and
Motivational Interviewing. The Opioid STR prevention program follows SAMHSA’s Strategic
Prevention Framework (SPF). Over the two year project period, the Opioid STR program
anticipates serving 3,150 individuals with recovery coaching and peer supports; 520
pregnant/postpartum women with with prevention, early intervention, treatment, and recovery
support services for SUD; and 780 individuals with MAT through the WVU COAT program.
Goals of the program are to: 1) Increase use of epidemiological data to demonstrate the critical
gaps in availability of treatment of OUDs in geographic, demographic, and service-level terms;
2) Reduce opioid overdose related deaths through prevention activities; and 3) Increase access to
evidence-based OUD treatment to reduce unmet treatment needs.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

WISCONSIN
Year 1 Year 2
$ 7,636,938 $ 7,636,938
PROJECT SUMMARY
The Wisconsin State Targeted Response to the Opioid Crisis (WI Opioid STR) will focus on utilizing a
Chronic Care Model to expand access to treatment and recovery of opioid use disorders, advance opioid
prevention, and reduce opioid-related overdose deaths. Since the early 2000s, Wisconsin has experienced
a surge in opioid misuse and its related harmful consequences. Since the start of this increase, the ageadjusted
death rate from opioid overdose has increased over fivefold. Over the last decade alone, the
number of opioid-related deaths in Wisconsin has nearly doubled. Among Wisconsin’s 72 counties, the
number of counties with any opioid-related deaths increased from 36 counties to 58 counties between
2004 and 2015. According to a 2016 report by the Centers for Disease Control and Prevention (CDC),
Wisconsin’s rate of drug and opioid overdose deaths per 100,000 population exceeds the national average
(Rudd, et al., 2016). Wisconsin ranks 16th in the United States in the percent change (worsening) in
prescription opioid-related deaths from 2012 to 2014 (Wisconsin Office of Health Informatics, 2016). A
four-factor process was used to identify an initial group of high risk communities to engage in project
activities: urban/rural classification; cultural populations; risk indicators based on opioid poisoning
deaths, hospital admissions, emergency room visits, and naloxone Emergency Medical Services (EMS)
runs; and protective factors including coalitions, engaged public health departments, drug court
alternatives, and buprenorphine prescribers. In addition, the most recent available Prescription Drug
Monitoring Program (PDMP) data was reviewed for each county. WI will use this data and identify
additional data to include in a needs assessment for pinpointing communities of high need of prevention,
treatment and recovery services related to opioid use disorders. Wisconsin is home to approximately 5.7
million people. Wisconsin’s overall population is 88 percent white, 7 percent African American, 3
percent Asian, and 1 percent American Indian/Alaska Native. 23 percent of the population is Hispanic. 23
percent of the population is under the age of 18 and 15 percent is over the age of 65. 65 percent of
Wisconsin’s 72 counties are considered rural (non-metro), and 13 percent of the population lives below
the poverty level. Population characteristics within each county will be reviewed as part of the needs
assessment and used in determining targeted areas for prevention services and training. The State of
Wisconsin, Department of Health Services has a unique opportunity to support initiatives outlined in a
January 2017 Report to the Governor from the Governor’s Task Force on Opioid Abuse. The Wisconsin
Opioid STR project will focus on the reduction of opioid-related deaths and other adverse events and
treatment and recovery interventions within high need Wisconsin communities by implementing the
following principal programs:
• Hospital, community-based and other recovery coaches with lived addiction experience to
provide outreach to persons experiencing opioid overdose or addiction,
• Add, increase or expand opioid treatment capacity and provide treatment funds for uninsured or
under-insured persons and rural, underserved areas of the state,
• Addiction/Recovery Resource Hot Line,
• Expand opioid prevention efforts at regional prevention centers, and
• Training in evidence-based approaches for community direct service workers.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

WYOMING
Year 1 Year 2
$2,000,000 $2,000,000
PROJECT SUMMARY
The Wyoming State Targeted Response grant aims to address the opioid crisis by increasing
access to treatment, reducing unmet treatment needs, and reducing opioid overdose related
deaths through the provision of treatment and recovery activities for opioid use disorder (OUD).
The response includes addressing the misuse of prescription opioids and illicit drugs such as
heroin. Efforts for this rural and frontier state will be supported through data-driven prevention,
treatment, and recovery processes that build capacity and infrastructure including culturally
appropriate training, technical assistance, data gathering, and implementation of evidence-based
programs, practices, and policies through a needs-based funding model. This effort complements
existing services within the community mental health and substance use disorder centers
(CMHC/SUDC) that are available to every county in Wyoming. The SAMHSA Opioid
Overdose Prevention Toolkit will be fully utilized to implement data-driven and comprehensive
OUD prevention, treatment, and recovery system planning. The Wyoming STR Program will
work with the State Epidemiological Outcomes Workgroup (SEOW) and the Wyoming Client
Information System (WCIS) to identify and prioritize counties and populations with the highest
need. According to the 2015 U.S. Census Bureau, the average population density of Wyoming is
six persons per square mile compared to the national average of 91 persons per square mile. The
resulting rural and frontier nature is not only a risk factor for higher SUD rates, it also creates
pockets of limited healthcare access within certain counties. The SEOW and WCIS will help
pinpoint the counties that experience opioid overdose death-related disparities by analyzing
opioid rates of use, health consequences, treatment access, poverty, and health insurance
coverage. The successful implementation/execution of the project will be ensured by the
Advisory Council along with measurable targets and goals.
SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grant Awards – Abstracts (2017)

Page 142 of 166

Attachment B
Fighting the Opioid Crisis
Deloitte Insights
Page 143 of 166

Fighting the opioid crisis
An ecosystem approach to a wicked problem
A report from the Deloitte Center for Government Insights

Fighting the opioid crisis
ABOUT THE AUTHORS
KEVIN M. BINGHAM
Kevin M. Bingham, ACAS, MAAA, is a principal at Deloitte Consulting LLP, leader of Deloitte’s Claim Predictive
Modeling and Medical Professional Liability practices, and co-chair of the Casualty Actuarial Society
Innovation Council. He has co-authored six articles on the opioid epidemic and is deeply passionate about
preventing opioid dependency and addiction before the habits ever form.
TERRI COOPER
Terri Cooper, PhD, is a principal at Deloitte Consulting LLP and the leader of the Federal Health sector for
Deloitte. Prior to taking over leadership for the Federal Health sector, she was the lead client service partner
for the National Institutes of Health and national leader of the Life Sciences Research and Development
practice. Cooper’s PhD focused on opioid pain management, reflecting her commitment to solving the opioid
epidemic.
LINDSAY MUSSER HOUGH
Lindsay Musser Hough, CGFM, PMP, MPA, is a principal at Deloitte Consulting LLP. She supports state government
leaders through efforts focused on policy development and operations improvement, with a focus
on health care, human services, and workforce development. Formerly, she worked for the US Government
Accountability Office. Like so many of us, Hough has been personally impacted by the opioid epidemic, and
is committed to curbing this epidemic in her own community and across the country.
ABOUT THE DELOITTE CENTER FOR
GOVERNMENT INSIGHTS
The Deloitte Center for Government Insights shares inspiring stories of government innovation, looking at
what’s behind the adoption of new technologies and management practices. We produce cutting-edge research
that guides public officials without burying them in jargon and minutiae, crystalizing essential insights
in an easy-to-absorb format. Through research, forums, and immersive workshops, our goal is to provide
public officials, policy professionals, and members of the media with fresh insights that advance an understanding
of what is possible in government transformation.
Deloitte Consulting LLP provides a wide range of services to government agencies and health
care organizations. Our work in health care transformation includes ranges from strategy design
to advanced analytics. Reach out to any of the contacts listed in this article for more information.

An ecosystem approach to a wicked problem
CONTENTS
Introduction | 2
The scale of the opioid crisis | 3
The impact of the epidemic | 4
A wicked problem? | 7
What can we learn if we view the opioid crisis as an
ecosystem? | 9
Conclusion | 13
1

Fighting the opioid crisis
Introduction
Most people know of the game called Six Degrees of Kevin Bacon. Based on
the concept of “six degrees of separation,” it was invented by three college
students who believed that every person in the entertainment industry stands
no more than six acquaintance links away from the actor Kevin Bacon. 1 Now,
consider a similar exercise focused on the much-publicized opioid and heroin
epidemic. Many people today, the authors included, find themselves just “one
degree” away from this calamity, having seen friends, family members, and
communities devastated by opioid abuse and heroin use.
A
CRISIS that has spread so broadly, and penetrated
so deeply, demands wide-scale, integrated
solutions, with contributions from
all impacted sectors. The concept of an “ecosystem”
provides a metaphor for the kind of collaboration
needed to take on the opioid epidemic. Having
studied several other solution ecosystems that
have made the most progress in addressing societal
problems, Deloitte finds that they often have five elements
in common. 2 They:
1. Engage a broad community of “wavemakers” to
innovate, convene, and fund its own solutions.
3. Attack the problem with a portfolio of
interventions.
4. Create an innovation engine to drive ideas for
solutions that upend the problem.
5. Develop solutions embedded in well-functioning
markets.
Government agencies, communities, and health
care organizations engaged in the fight to end the
opioid crisis may wish to consider incorporating
these elements into their strategies.
2. Establish an ecosystem integrator to “hold the
whole” and create the space for aligned action
by others.
2

An ecosystem approach to a wicked problem
The scale of the opioid crisis
A few gut-wrenching facts illustrate how this
crisis touches the average American:
• In 2012, health care providers wrote 259 million painkiller prescriptions, enough to give
every adult in the United States his or her own bottle of pills. 3
• The United States has less than 5 percent of the world’s population, yet consumes roughly
80 percent of the global opioid supply. 4
• The number of prescriptions for opioids has increased from 76 million in 1991 to nearly 207
million in 2013. 5
• Drug overdose deaths reached record highs in 2014, fueled in large part by the abuse of
narcotic painkillers and heroin. 6
• In 2014, 47,055 Americans died from drug overdoses, an increase of more than 14 percent
from 2013. Of those deaths, 28,647—or 61 percent—involved the use of opioids. From 2000
to 2014 nearly half a million people died from overdoses in the United States. 7
• In 2014, there were approximately one-and-a-half times more drug overdose deaths than
deaths from motor vehicle crashes. 8
ANECDOTAL examples also abound. One cannot
miss the many news stories, articles,
documentaries, political speeches, and state
legislative efforts devoted to opioid and heroin addiction,
or the untimely deaths of individuals linked
to opioids. The opioid and heroin epidemic touches
nearly every American. Some are prescribed opioids
for pain relief, some are battling opioid and heroin
dependency and addiction, while others have lost a
loved one or friend to an overdose. It’s hard to believe
that just two decades ago, when opioids were
mainly prescribed as end-of-life cancer drugs, most
Americans felt little connection to the problem of
opioid use and heroin abuse.
The opioid epidemic cuts across every sector of
society. Much like an environmental disaster—the
ongoing release of toxic chemicals into air and water,
for example—it endangers not just one population,
but an entire social ecosystem, a community
of interconnected individuals and interests. Such
a broad crisis requires an equally broad response,
with collaboration from stakeholders in all of the
ecosystem’s many sectors.
3

Fighting the opioid crisis
The impact of the epidemic
“For too long we’ve viewed drug addiction through the lens of
criminal justice. The most important thing to do is reduce demand.
And the only way to do that is to provide treatment—to see it
as a public health problem and not a criminal problem.”
——
President Barack Obama, speaking at the National
Prescription Drug Abuse and Heroin Summit, March 2016
PRESIDENT Obama’s statement highlights the
critical shift underway across the country, as
communities start to treat addiction as a public
health crisis. The impacts of the epidemic extend
far beyond the domains of substance abuse treatment
and criminal justice. Opioid addiction eats at
the core of our communities—it strains our health
care resources, stresses our child welfare systems,
reduces the economic vitality of American families,
and drains our first responders. It requires governments
to continually shift resources to respond to
emergent issues.
The opioid and heroin epidemic touches a plethora
of government programs, impacting children and
families, law enforcement professionals, educators,
health care providers—not to mention taxpayers.
(For details, see the sidebar “The widespread impact
of opioid abuse and heroin use.”)
To address these far-reaching impacts, state and
federal agencies have devoted a staggering volume
of resources to fighting the opioid and heroin epidemic.
Figure 1 depicts some of the organizations
and programs involved in targeting the opioid crisis.
The widespread impact of opioid abuse and heroin use
Medicaid
• Opioid addiction increases the patient load at medical offices, puts greater strain on emergency rooms
treating individuals who overdose, and adds costs for detoxification programs.
• An estimated 9–14 percent of Medicaid beneficiaries have substance abuse disorders; Medicaid is one
of the largest single payers of medications for treating such disorders. 9
Child welfare
• Roughly 65 percent of children served by Indiana’s Department of Child Services come from homes
affected by addiction. 10
• Between 2014 and 2015, the total number of children removed from their homes by New Hampshire’s
Department of Children, Youth, and Families increased by 36 percent. Almost half of all child removals in
2015 involved allegations of parental substance abuse, drug abuse, or poisoning/noxious substances. 11
• According to the Substance Abuse and Mental Health Services Administration (SAMHSA), the average
number of addicted babies born each year ranges from 100,000 to 375,000.
• In Florida, during 2003–2006 the number of babies born with neonatal abstinence syndrome (NAS),
which occurs in newborns exposed to opiates while in the mother’s womb, increased by 173 percent. 12
• Parents battling addiction are more likely to face financial problems and have trouble paying for their
children’s needs or making required child support payments.
4

An ecosystem approach to a wicked problem
The widespread impact of opioid abuse and heroin use
Workforce
and economic
development
• One in six unemployed workers is addicted to alcohol or drugs, almost double the rate for full-time
workers. 13
• 12.5 percent of part-time employed adults use illicit drugs. That number jumps to 18.1 percent for the
unemployed. 14
• Of the estimated 10 percent of Americans who suffer from addiction to some sort of substance, most
are unemployed. 15
Criminal
justice
• As of late 2011, about 2,400 inmates in male, medium security federal institutions participated in
residential drug treatment. Another 3,000 were on waiting lists, and the average wait for enrollment
exceeded three months. 16
• Between 1998 and 2012, the number of drug offenders in federal prisons grew 63 percent. Drug
offenders made up 52 percent of the federal prison population at year-end 2012. 17
• In Pennsylvania, approximately 90 percent of inmates have a history of substance abuse and/or mental
health issues. 18
Treatment
centers
• Drug treatment centers are often overcrowded, lack proper funding, and may be out of reach for those
who don’t have the financial means or appropriate eligibility.
• At the same time, policy makers continue to debate the most appropriate treatment approaches. 19
• In 2016, the president of the United States proposed $1 billion in new funding over two years to expand
access to treatment for heroin and prescription drug abuse. Some states are also increasing funding
for treatment. Nevertheless, the dramatic increase in opioid and heroin users makes it difficult for
treatment centers to keep up with demand.
Workers’
compensation
• The prescription costs per workers’ compensation claim continue to grow, along with the number of
prescriptions per claim.
• 75 percent of injured workers get opioids but don’t receive opioid management services, such as urine
drug testing, psychological and psychiatric evaluation, physical therapy, or exercise. 20
• With approximately 20 percent of all medical spending going toward prescription drugs, workers’
compensation insurance programs are trying hard to reduce the use of addictive prescription drugs for
injured workers and help workers return more quickly to their jobs.
Adolescents
and education
• A 2012 study showed that 16 percent of teens had misused a prescription painkiller at least once.
• As addiction in teens has increased, the National Association of School Nurses has endorsed the
incorporation of naloxone—used to treat a narcotic overdose—into school emergency response
protocols. 21
Public health
• For every overdose in 2014, there were 733 nonmedical users, 108 people with abuse/dependence, 26
emergency room visits for misuse or abuse, and 10 abuse treatment admissions. 22
• Drug overdose deaths now surpass motor vehicle crashes as the leading cause of injury death in the
United States. 23
States across the country have undertaken a number
of measures to combat the epidemic. They include:
• Prevention efforts: Ranging from mandatory
prescription drug monitoring programs (PDMP)
to prescriber guidelines
• Treatment efforts: Including expanded access
to treatment and easier access to the overdose
antidote naloxone
• Legal and criminal justice efforts: By, among
other initiatives, offering early release to individuals
in prison who are addicted to opioids, so
they can obtain managed treatment, and prosecuting
individuals who prescribe opioids illegally
Despite the vast breadth and depth of these efforts,
the United States has not turned the tide on the epidemic.
5

Fighting the opioid crisis
Figure 1. The opioid crisis ecosystem
Curbing the opioid crisis lies in wide-scale, integrated solutions, with contributions
from all impacted sectors. The concept of an “ecosystem” offers insight into how to
drive the kinds of collaborative, creative solutions needed to tackle this epidemic.
The opioid ecosystem involves organizations and programs across
government, health care, and the nonprofit sector.
The opioid ecosystem involves organizations
and programs across government, health
care, and the nonprofit sector.
Workforce development
Workers' compensation
Human services
Social services
State legislatures
Governors
Federal
government
Public health
Drug and alcohol services
Health care/medicaid agencies
Mental health/behavioral health
Health services
Corrections
Public safety
Health care providers
Pharmacists
Hospitals
Health plans
Insurers
Life sciences
organizations
Pharmaceutical innovators
Community partners
Individuals in
recovery
6

An ecosystem approach to a wicked problem
A wicked problem?
GIVEN the widespread impact of the problem,
curbing the opioid crisis lies in wide-scale,
integrated solutions, with contributions
from all impacted sectors. The concept of an “ecosystem”
offers insight into how to drive the kinds
of collaborative, creative solutions needed to tackle
this epidemic.
The term “ecosystem,” as first used in the field of
botany, refers to a localized community of living
organisms that interact with one another and with
their particular environment
of air, water, mineral
soil, and other elements.
These organisms
influence one another
and their terrain; they
compete and collaborate,
share, and create
resources and co-evolve.
When faced with external
disruptions, they
adapt together. 24
Business
strategist
James Moore noticed
the parallels to the
world of commerce in
the 1990s. In a 1993 article in the Harvard Business
Review, he wrote, “I suggest a company be viewed
not as a member of single industry but as a part of a
business ecosystem that crosses a variety of industries.
In a business ecosystem, companies co-evolve
capabilities around a new innovation: They work cooperatively
and competitively to support new products,
satisfy customer needs, and eventually incorporate
the next round of innovations.” 25
Nonprofits and governments have embraced the
ecosystem concept as a way to address what are
often called “wicked problems.” Wicked problems
are generally identified through a combination of
unique characteristics; 26 we have highlighted some
The concept of an
“ecosystem” offers
insight into how to
drive the kinds of
collaborative, creative
solutions needed to
tackle this epidemic.
of those characteristics that are most relevant to the
opioid crisis: 27
• Different parties have different definitions
of the problem: Demand or supply issue?
Prevention or treatment focus? Criminal
justice or health orientation? While most all involved
can agree on some basic outcome measures
in the fight against the opioid crisis—such
as a reduction in overdoses—there is no agreement
across the ecosystem
on the root of the problem.
When you couple that with
a diverse set of actors you
get differing definitions of
the problem and hence differing
definitions for what
“success” really means.
• The sources are diverse.
The source of the
opioid epidemic is not just
due to the inflow of illegal
drugs and the creation of
new prescription drugs.
The complex reality is
that the crisis is driven by
many problems, such as
lack of alternative pain management treatments
for sufferers of chronic pain, loose prescribing
practices, inadequate training for physicians
and consumers, and treatment programs and
reimbursement strategies that haven’t evolved
to support the longer-term treatment needed for
addiction to opioids.
• The problem is emergent and shifting.
With growth in the use of opioids over the last
20 years, the nature of the crisis has changed.
Opioid addiction no longer springs mainly from
recreational use of illicit drugs; many people
now become addicted while using legally prescribed
painkillers. As opioid use increased,
7

Fighting the opioid crisis
and users became desperate for supply sources,
some physicians began to set up “pill mills”—
storefront offices established with the sole purpose
of churning out prescriptions for opioids.
Then law enforcement cracked down on the
abuse, and many doctors came under more scrutiny
for prescribing practices, making the drugs
more difficult to obtain. Individuals struggling
with addiction turned from prescription pills to
the street drug, creating a fresh opportunity for
heroin distributors. Once focused primarily on
urban areas, their networks quickly adapted to
the new demand, targeting communities suffering
from economic loss and hardship, including
rural and rust belt communities. 28 And today,
governments face a new challenge—how to follow
up with patients after the use of the overdose
antidote naloxone, in order to help curb their addiction
long term. The opioid crisis is a criminal
justice crisis, a physical health crisis, a behavioral
health crisis, a public health crisis, and a
human services crisis. Each piece of it requires a
separate set of strategies.
• There will never be one answer. An emergent
and shifting problem by definition means
that solutions have to be flexible, creative, and
continually refreshed, with engagement from all
parties in the ecosystem. Part of the reason there
will never be “one answer” to address the opioid
crisis is because of the varied demographic factors
that contribute to the challenge. Research
shows that many different social determinants,
including interpersonal, household, and community
dynamics, strongly influence substance
abuse. 29 For example, heroin kills more people in
New England and the Midwest than in the rest of
the country, and heroin victims are more likely
to be men in their 20s and early 30s. Prescription
opioids, on the other hand, impact people
across the country, especially people aged 45–54
and including a substantial number of women. 30
Effective prevention strategies differ between
rural and urban communities, and whether
the addiction begins with abuse of prescription
drugs or heroin. 31
Recent efforts, driven by key governors across
the country, have recognized the need for multifaceted
strategies that consider geographic differences.
For example, Pennsylvania’s strategies
extend from health to corrections to education to
emergency management. In Massachusetts, the
2014 task force identified more 35 recommendations
involving data, policy action, prevention,
intervention, treatment, and recovery. Many
other states have developed similar plans involving
the entire state government.
8

An ecosystem approach to a wicked problem
What can we learn if we
view the opioid crisis
as an ecosystem?
RESEARCHERS have found five common elements
in effective ecosystem interventions.
The five elements, and their implications
for addressing the opioid epidemic, are
described below. 32
1. ENGAGE A BROAD COMMUNITY
OF “WAVEMAKERS” TO
INNOVATE, CONVENE, AND
FUND ITS OWN SOLUTIONS
Across the country, stakeholders in the opioid crisis
are coming together through commissions, roundtables,
and conferences. They analyze the root
causes of the problem, highlight successful solutions,
and make recommendations for state, local,
and federal government agencies. As these convening
groups develop and shift into implementation,
it is critical that they engage new partners and collaborate
on novel solutions that stakeholders can
implement themselves. Partners at the table for
discussions of opioid abuse should not be limited to
health and criminal justice stakeholders; new and
unusual partners should be brought into the fold,
including people who are in recovery. Which groups
are uniquely impacted by the crisis? Who are some
of the common stakeholders across all sectors? How
might one engage innovators, technologists, and
experts drawn from beyond the traditional stakeholder
groups?
One effective model comes from the world of children’s
behavioral health, which has adopted a “systems
of care” philosophy. This approach recognizes
that it takes collaboration by a wide range of partners
to appropriately serve the shifting and complex
needs of children. Recent reports show that the
“systems of care” approach has realized a positive
One way to achieve a
healthy ecosystem is
to make sure that the
success of each party
depends on the success
of all other parties.
return on investment, in terms of both cost avoidance
and improved outcomes. 33
Stakeholders should try to implement solutions
that benefit everyone at the table. Solutions that
are “single-threaded” through government agencies
will likely have limited impact. One way to achieve a
healthy ecosystem is to make sure that the success of
each party depends on the success of all other parties.
For example, workers’ compensation programs
are often viewed as benefits programs, providing
income replacement for injured workers until they
can return to work. However, given the volume of
opioids they saw being prescribed for work-related
injuries, workers’ compensation insurers were some
of the first organizations to recognize the critical
role that physicians played in preventing opioid addiction.
Today, workers’ compensation insurers are beginning
to utilize advanced detection tools. Thanks to
their unique position in the ecosystem—where they
touch health care, consumers, and governments—
they are effectively leveraging state and federal
guidelines, physician education, and advanced analytics
to help prevent dependency and addiction.
9

Fighting the opioid crisis
2. ESTABLISH AN ECOSYSTEM
INTEGRATOR TO “HOLD THE
WHOLE” AND CREATE THE SPACE
FOR ALIGNED ACTION BY OTHERS
State governors and their administrations are increasingly
serving as “integrators” in the anti-opioid
ecosystem. State commissions, such as the Commonwealth
of Virginia Governor’s Task Force on
Prescription Drug and Heroin Abuse, the Commonwealth
of Massachusetts Governor’s Opioid Working
Group, and New York’s Heroin and Opioid Task
Force, are helping to drive real action. They achieve
this through improved coordination and alignment
of strategies focused on opioid abuse and heroin use
prevention, intervention, treatment, recovery, and
enforcement. Given the attention these commissions
have received, and the resources their work
has attracted, state leaders might wish to consider
how such bodies can drive ongoing implementation
and innovation after they deliver their final reports.
Through working sessions, implementation groups,
and coordinated action plans at the governor’s level,
government can integrate the activities of executive
agencies, community organizations, and health care
providers, making the overall effort more effective.
The integrator role, however, need not be limited to
governments. Give the wide-scale impact of the opioid
crisis, other organizations may be able to step
into the role of integrator. Foundations or companies
that focus on public health, economic development,
or the welfare of children and families may
be well-positioned to drive collaboration across the
ecosystem. They may also be particularly adept at
tailoring efforts to the unique needs of a community
or region.
3. ATTACK THE PROBLEM WITH A
PORTFOLIO OF INTERVENTIONS
Successful ecosystems recognize that working together
doesn’t necessarily mean agreeing on one
best solution. Instead, it means coordinating a full
portfolio of strategic interventions which, when taken
together, have the best chance of hitting the goal.
For example, in recent years, anti-opioid initiatives
have enhanced their focus on education. They have
done so with the understanding that it isn’t enough
just to educate primary care physicians: Effective
physician and patient education on the adverse impacts
of opioids involves multiple players and strategies.
In 2012, Physicians for the Responsible Prescribing
of Opioids (PROP) submitted a petition to the Food
and Drug Administration (FDA) requesting labeling
changes for all opioids prescribed for non-cancer
pain. In 2013, the Drug Enforcement Agency (DEA)
and the National Association of Attorneys Generals
endorsed this proposal, asking the FDA to place a
“black box warning” label on opioids prescribed to
pregnant women. In March 2016, the Centers for
Disease Control and Prevention (CDC) issued new
guidelines for prescribing opioids for chronic pain.
In addition, state agencies, federal agencies, physicians,
and medical colleges have been updating their
educational materials to better warn physicians
about the risks of opioid abuse and addiction. This
portfolio of interventions has prompted pain clinics
and emergency rooms to stop, or drastically reduce,
the use of opioids for chronic conditions. Following
a multipronged educational effort, one health plan
reported a 29 percent decline in high-risk members
prescribed opioids. 34
Governments and health providers are developing
protocols that acknowledge the need to take a “portfolio
of interventions” approach when trying to cure
addiction. Detoxification rarely solves the problem
on its own, as individuals who go through detox programs
often relapse later. A more effective strategy
combines a number of interventions—which may
include detoxification, abstinence-oriented treatment,
and/or supervised opioid replacement treatment,
such as methadone. Although this proposal
has sparked controversy, in October 2015 Massachusetts
Governor Charlie Baker introduced legislation
giving hospitals more flexible power to hold an
individual against his or her will for three days after
the administration of an overdose antidote. One of
the most interesting aspects of this policy is that it
emphasizes the shift in focus from a criminal justice
perspective to a health care one, as it brings clinicians
directly into the decision-making process for
this type of treatment. 35
Whether the solutions involve education, treatment,
or enforcement, efforts to address any aspect
10

An ecosystem approach to a wicked problem
of the opioid epidemic are likely to be most successful
when they employ a portfolio of interventions,
rather than a single, “silver bullet” solution. For example,
research shows that for some people, combining
medication-oriented treatment with behavioral
treatments is the most effective way to address
addiction. 36 That makes it critical to engage multiple
partners across the ecosystem.
4. CREATE AN INNOVATION ENGINE
TO DRIVE IDEAS FOR SOLUTIONS
THAT UPEND THE PROBLEM
Groups fighting the opioid epidemic try to approach
the problem from every possible angle. But members
are the first to admit that without new solutions,
the epidemic probably won’t let up anytime
soon.
New solutions emerge when partners in an ecosystem
interact cooperatively and competitively to
drive innovation. Governments should consider
going beyond roundtables and commissions: They
need to create opportunities for new partnerships
to form. Examples of successful innovation engines
that have been used to address other social problems
include:
Prize-based challenges: Incentives for innovations
that produce public value have seen significant
success. Organizers define the challenge, offer
a prize, and then open the competition for individuals
or teams to offer solutions. This model has
worked so well in addressing problems that range
from nursing home care to space travel that the US
government has established its own platform for
hosting challenges—Challenge.gov. Turning an aspect
of the opioid epidemic into a challenge could
help drive the sorts of cooperation and competition
this complex issue requires. In fact, the Substance
Abuse and Mental Health Services Administration
(SAMHSA) has already seen strong participation
in two recent challenges launched around recovery
support and prevention. 37 A local organization
might challenge the community to find a way to provide
more widespread access to naloxone, or a biotech
organization might offer a prize for solutions
that encourage Americans to dispose appropriately
of their leftover opioid prescriptions (which sit, at
risk for misuse, in 60 percent of medicine cabinets
across the country). 38
Pay for Success (PFS): This is an approach for
social services that ties payment for services to outcomes.
Governments are increasingly partnering
with funders to explore this model of delivery. In its
simplest form, it means that instead of paying an organization
for each service rendered or via a grant,
the government pays a service organization—wholly
or in part—based on performance against particular
metrics. Since many social service organizations
lack the base funding to support their efforts,
this model calls upon foundations or corporations
to provide startup loans or outright grants, bridging
the gap until the service organization earns its
performance-based payments. Pay for Success projects
are being implemented to address issues such
as homelessness, recidivism, and early childhood
education. 39 The model is helping to forge new partnerships:
A review of current projects shows active
engagement from corporations, foundations, and
social services agencies.
Given its progress so far in tackling intractable issues
such as homelessness, this model may have
something to offer the fight against the opioid epidemic.
Imagine a Pay for Success model to reduce
relapses for those in recovery. Such an effort could
bring together employers, government, health care
providers, and social services agencies—all of whom
have an interest in helping individuals recover fully.
Advanced analytics: Governments today are collecting
more and more information related to opioid
addiction. From databases that monitor prescription
drugs and Medicaid enterprise solutions, to
systems that track licensing violations and digital
archives of vital records—all these data sets contain
critical information about opioid use and abuse.
Data scientists are connecting data from these different
sources and then using it in new and innovative
ways to help identify patients’ pill-seeking
behaviors, and prevent opioid addiction and dependency
before the habits form. These approaches
may offer ways to engage stakeholders across traditional
boundaries, leading to new solutions.
For example, prescription drug monitoring programs
contain databases of prescription informa-
11

Fighting the opioid crisis
tion, which can be updated and accessed by providers
and pharmacists. They offer an avenue for
data-driven decision making and accountability in
an ecosystem context. Effective prescription drug
monitoring programs can keep a broad spectrum of
stakeholders informed and create a common body
of truth. In one recent study of prescription drug
monitoring programs, implementation of this technology
correlated with a 30 percent drop in opioid
prescriptions. 40
At the same time, government leaders should keep
in mind that new solutions may bring unintended
consequences. For example, as mentioned previously,
a number of states have worked aggressively
to close illegal “pill mills.” Although this drastically
reduced the illicit supply of opioids, it also left large
numbers of individuals suffering from addiction
without detoxification options. Unfortunately, some
of those sufferers turned to heroin to feed their addictions.
Thus, a win on the opioid abuse front became
a loss on the heroin trafficking front. When
a community considers any intervention, it must
evaluate the plan and then monitor its implementation
from the perspective of the entire ecosystem.
5. DEVELOP SOLUTIONS EMBEDDED
IN WELL-FUNCTIONING MARKETS
In efforts to address other “wicked problems,” success
has relied not just on effective interventions,
but on interventions that were sustainable in the
context of real-world markets. For example, the
battle against malaria depends on having viable
markets for the purchase and sale of mosquito
nets, medical treatments, and diagnostic devices.
Similarly, solutions to the problems of adequate
housing in slums, sanitation in poor communities,
and traffic congestion have emerged when the
solution could be brought to bear “organically,
sustainably, and profitably.” 41 Clearly, there is
signi-ficant room for innovation in the fight against
opioid abuse and heroin use. Whether one is trying
to reduce cost of long-term treatment, or figure out
how to improve access to the overdose antidote
naloxone, the challenges offer opportunities for
market-oriented solutions.
One such opportunity may already be taking shape.
The US health care market is transitioning—albeit
slowly—to “value-based care,” a model that links
provider payments to patient outcomes rather than
volume of services. This model might also drive better
outcomes for people suffering from addiction.
Today, many programs set rigid rules about how
long treatment lasts and where patients receive
it. For instance, a program might limit in-patient
care to 21 days and then provide minimal out-patient
support. But opioid addiction requires more
intensive care than this, over a longer period. Recent
research indicates that individuals in recovery
may suffer relapses two, three, or even four years
after treatment. What if payment to a doctor or a
treatment program were linked directly to patient
outcomes? If the movement to a value-based health
care model is successful, health care providers
might find more effective and sustainable ways to
treat patients recovering from opioid addiction.
Other new solutions that rely on products available
in the marketplace are currently being tested
in pockets across the United States. For example,
Illinois recently passed legislation to launch a pilot
program that will have participating pharmacies
dispense medications that contain hydrocodone in
bottles that are secured with combination locks. 42
The cost of the locking devices and the additional
effort that pharmacies must expend to use them
will likely be key factors in the sustainability of the
program. Other promising products already on the
market include pouches that can be used to safely
dispose of medication 43 and long-acting treatments
for opioid addiction. Solutions that rely on custombuilt
tools might work well in pilot implementations.
But to make these solutions sustainable, the
tools must be available for purchase, at prices that
are viable in a functioning market. Ecosystems need
to create a climate in which developers of innovative
tools against opioid addiction can thrive in the open
market.
12

An ecosystem approach to a wicked problem
Conclusion
THE opioid epidemic is a “wicked problem” of
the worst kind. It hurts all of us, every day,
as it cuts lives short, rips families apart, and
leaves loved ones in mourning. Even as the number
of deaths continues to rise, physicians keep
prescribing opioids to their patients, knowing that
there are few alternative pain management treatments
that are as quick to use.
An ecosystem approach could become the best hope
in the battle against opioid addiction. From engaging
new partners in the fight and aligning action
across the ecosystem, to using a portfolio of interventions,
driving innovation, and using markets
to support sustainable solutions, the ecosystem is
likely to generate the most powerful response. This
collaborative approach inspires all stakeholders—
across the boundaries of public health, criminal
justice, economic development, and human services—to
act as a single, integrated community and
point the way toward powerful new solutions. We
need those innovations to ensure that people in future
generations all stand far more than six degrees
apart from the opioid and heroin epidemic.
13

Fighting the opioid crisis
ENDNOTES
1. Hilary Bentman, “6 degrees? Try 1,” Albright College, http://albright.edu/spotlight/SixDegrees.html.
2. William D. Eggers and Anna Muoio, Wicked opportunities, Deloitte University Press, April 15, 2015, http://dupress.
com/articles/wicked-problems-wicked-opportunities-business-trends/.
3. Centers for Disease Control and Prevention, “Opioid painkiller prescribing: Where you live makes a difference,”
CDC Vital Signs, July 2014, http://www.cdc.gov/vitalsigns/opioid-prescribing/index.html.
4. Steve Straehley, “U.S.: 5% of world population; 80% of opioid consumption,” AllGov, December 15, 2014, http://
www.allgov.com/news/controversies/us-5-percent-of-world-population-80-percent-of-opioid-consumption-
141215?news=855100.
5. Nora D. Volkow, “America’s addiction to opioids: Heroin and prescription drug abuse,” presentation to the
National Institute on Drug Abuse, May 14, 2014, https://www.drugabuse.gov/about-nida/legislative-activities/
testimony-to-congress/2016/americas-addiction-to-opioids-heroin-prescription-drug-abuse.
6. Centers for Disease Control and Prevention, “Drug overdose deaths hit record numbers in 2014,” press release,
December 18, 2015, http://www.cdc.gov/media/releases/2015/p1218-drug-overdose.html.
7. Ibid; Rose A. Rudd, Noah Aleshire, Jon E. Zibbell, and R. Matthew Gladden, “Increases in drug and opioid overdose
deaths—United States, 2000–2014,” Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention,
January 1, 2016, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm?s_cid=mm6450a3_w.
8. Centers for Disease Control and Prevention, “Drug overdose deaths hit record numbers in 2014”; Rudd, Aleshire,
Zibbell, and Gladden, “Increases in drug and opioid overdose deaths—United States, 2000–2014.”
9. “Medicaid coverage and financing of medications to treat alcohol and opioid use disorders,“ Substance Abuse
and Mental Health Services Administration, 2014, http://store.samhsa.gov/shin/content/SMA14-4854/SMA14-
4854.pdf.
10. Bennett Haeberle, “Child welfare cases soar within Indiana’s heroin epidemic,” Wishtv.com, February 4, 2016,
http://wishtv.com/2016/02/04/child-welfare-cases-soar-within-indianas-heroin-epidemic/.
11. Kristen Senz, “Child welfare & the opioid crisis, part 2: The rising (human) cost of drug addiction,” Manchesterinklink.com,
June 27, 2016, http://manchesterinklink.com/child-welfare-the-opioid-crisis-part-2-the-rising-humancost-of-drug-addiction/.
12. “Born addicted: Neonatal abstinence syndrome,” Recovery Connection, May 4, 2012, https://www.recoveryconnection.com/born-addicted-neonatal-abstinence-syndrome/.
13. Annalyn Kurtz, “1 in 6 unemployed are substance abusers,” CNN Money, November 26, 2013, http://money.cnn.
com/2013/11/26/news/economy/drugs-unemployed/.
14. “Results from the 2012 National Survey on Drug Use and Health: Summary of national findings,” NSDUH Series
H-46, HHS publication no. (SMA) 13-4795, Rockville, MD: Substance Abuse and Mental Health Services
Administration, 2013, http://archive.samhsa.gov/data/NSDUH/2012SummNatFindDetTables/NationalFindings/
NSDUHresults2012.htm#ch8.
15. James White, “The vicious cycle of drug abuse and unemployment,” Shatterproof, June 27, 2014, http://www.
shatterproof.org/blog/entry/the-vicious-cycle-of-drug-abuse-and-unemployment.
16. “Bureau of Prisons: Growing inmate crowding negatively affects inmates, staff, and infrastructure,” United States
Government Accountability Office, September 2012, http://www.gao.gov/assets/650/648123.pdf.
14

An ecosystem approach to a wicked problem
17. “Drug offenders in federal prisons: Estimates of characteristics based on linked data,” Bureau of Justice Statistics,
October 2015, http://www.bjs.gov/content/pub/pdf/dofp12_sum.pdf.
18. J.J. Abbott, “Where the opioid crisis and criminal justice reform meet,” PA.Gov., May 31, 2016, https://www.governor.pa.gov/blog-where-the-opioid-crisis-and-criminal-justice-reform-meet/.
19. American Association for the Treatment of Opioid Dependence, Inc., Increasing access to medication to treat
opioid addiction—increasing access for the treatment of opioid addiction with medications, http://www.aatod.org/
policies/policy-statements/increasing-access-to-medication-to-treat-opioid-addiction-increasing-access-for-thetreatment-of-opioid-addiction-with-medications/.
20. Thomas A. Robinson, “WCRI studies show 75 percent of injured workers get opioids, but don’t get opioid management
services,” Workers Compensation Research Institute, October 1, 2014, https://www.lexisnexis.com/
legalnewsroom/workers-compensation/b/recent-cases-news-trends-developments/archive/2014/10/01/wcristudies-show-75-percent-of-injured-workers-get-opioids-but-don-t-get-opioid-management-services.aspx.
21. Michelle Faust, “School nurses stock drug to reverse opioid overdoses,” National Public Radio, September 16,
2015, http://www.npr.org/sections/health-shots/2015/09/16/440770695/school-nurses-stock-drug-to-reverseopioid-overdoses.
22. “Prescription drug abuse and overdose: Public health perspective,” CDC’s Primary Care and Public Health Initiative,
October 24, 2012, http://www.cdc.gov/primarycare/materials/opoidabuse/docs/pda-phperspective-508.
pdf.
23. US Food and Drug Administration, “FDA commissioner Margaret A. Hamburg statement on prescription opioid
abuse,” April 3, 2014, http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm391590.htm.
24. Eamonn Kelly, Introduction: Business ecosystems come of age, Deloitte University Press, April 2015, http://dupress.
com/articles/business-ecosystems-come-of-age-business-trends/.
25. James F. Moore, “Predators and prey: A new ecology of competition,” Harvard Business Review, May 1993, https://
hbr.org/1993/05/predators-and-prey-a-new-ecology-of-competition/ar/1, accessed March 17, 2015.
26. John C. Camillus, “Strategy as a wicked problem,” Harvard Business Review, May 2008.
27. Eggers and Muoio, Wicked opportunities.
28. Sam Quinones, Dreamland: The True Tale of America’s Opiate Epidemic (Bloomsbury Press, 2015).
29. “Substance abuse across the life stages,” Office of Disease Prevention and Health Promotion, https://www.
healthypeople.gov/2020/leading-health-indicators/2020-lhi-topics/Substance-Abuse/determinants.
30. Evan Horowitz, “US facing not one, but two opioid epidemics,” Boston Globe, May 2, 2016, https://www.bostonglobe.com/metro/2016/05/01/facing-not-one-but-two-opioid-epidemics/66CMuMtPuKHtZPx7tOxsPM/story.
html.
31. Ibid.
32. Eggers and Muoio, Wicked opportunities.
33. Beth A. Stroul, Sheila A. Pires, Simone Boyce, Anya Krivelyova, and Christine Walrath, Return on investment in
systems of care, National Technical Assistance Center for Children’s Mental Health, April 2014, http://gucchdtacenter.georgetown.edu/publications/Return_onInvestment_inSOCsReport6-15-14.pdf.
34. Samantha DuPont, Athan Bezaitis, and Murry Ross, “Stemming the tide of opioid overuse, misuse and abuse,”
Health Affairs, http://healthaffairs.org/blog/2015/09/22/stemming-the-tide-of-prescription-opioid-overusemisuse-and-abuse/.
15

Fighting the opioid crisis
35. David Scharfenberg, “Baker would give hospitals the power to hold addicts,” Boston Globe, October 11, 2015, https://
www.bostonglobe.com/metro/2015/10/10/baker-would-give-hospitals-new-power-force-treatment-addicts/
MRFtW46UED68LVpGFbyZgK/story.html.
36. “What are the treatments for heroin addiction?,” National Institute on Drug Abuse, https://www.drugabuse.gov/
publications/research-reports/heroin/what-are-treatments-heroin-addiction.
37. “Department of Health and Human Services,” Challenge.gov, https://www.challenge.gov/agency/departmentof-health-and-human-services/.
38. Alene Kennedy-Hendricks, Andrea Gielen, Eileen McDonald, Emma E. McGinty, Wendy Shield, and Colleen L.
Barry, Medication sharing, storage, and disposal practices for opioid medications among US adults, JAMA Internal
Medicine, June 2016, http://archinte.jamanetwork.com/article.aspx?articleid=2527388.
39. “Pay for Success 101,” Nonprofit Finance Fund, http://www.payforsuccess.org/learn-out-loud/pfs-101.
40. P Yuhua Bao, Yijun Pan, Aryn Taylor, Sharmini Radakrishnan, Feijun Luo, Harold Alan Pincus, and Bruce R. Schackman,
“Prescription drug monitoring programs are associated with sustained reductions in opioid prescribing by
physicians,” Health Affairs 35, no. 6 (2016): pp. 1,045–1,051, http://content.healthaffairs.org/content/35/6/1045.
41. William D. Eggers and Paul Macmillan, The Solution Revolution: How Business, Government, and Social Enterprises
Are Teaming Up to Solve Society’s Toughest Problems (Harvard Business Review Press, 2013), p. 169.
42. John Russell and Ameet Sachdev, “Illinois law will bring lockable pill bottles, but will they work?” Chicago Tribune,
September 2, 2015, http://www.chicagotribune.com/business/ct-locked-pill-bottles-0903-biz--20150902-story.
html.
43. Caitlin Hill, “Medsaway pouches attract partners for social enterprise Verde Environmental,” Minnesota
Business Magazine, November 20, 2014, http://minnesotabusiness.com/medsaway-pouches-attractpartners-social-enterprise-verde-environmental.
16

An ecosystem approach to a wicked problem
ACKNOWLEDGEMENTS
The authors would like to thank the following individuals for their thoughtful contributions to this article:
Pedro Arboleda, Penny Brierley-Bowers, Bruce Chew, Claire Boozer Cruse, Keianna Dixon, Merrill
Douglas, William Eggers, Tiffany Fishman, Wade Horn, John Keith, Rod Kleinhammer, Russ Pederson,
and China Widener.
CONTACTS
Kevin M. Bingham
Principal
Deloitte Consulting LLP
+1 860 725 3056
kbingham@deloitte.com
Terri Cooper
Principal
Deloitte Consulting LLP
+1 212 313 1735
tecooper@deloitte.com
Lindsay Musser Hough
Principal
Deloitte Consulting LLP
+1 717 695 5367
lhough@deloitte.com
William D. Eggers
Executive director, Deloitte Center
for Government Insights
Deloitte Services LP
+1 571 882 6585
weggers@deloitte.com
Cathryn Marcuse
Strategic marketing manager, Deloitte
Center for Government Insights
Deloitte Services LP
+1 571 882 8075
camarcuse@deloitte.com
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Page 144 of 166

Attachment C
The Opioid Crisis in North America
Position Paper
Page 145 of 166

POSITION PAPER
THE OPIOID CRISIS
IN NORTH AMERICA
October 2017

THE COMMISSIONERS
KOFI ANNAN
Chairman of the Kofi Annan Foundation and
Former Secretary General of the United
Nations, Ghana
JOYCE BANDA
Former President of Malawi
ALEKSANDER KWASNIEWSKI
Former President of Poland
RICARDO LAGOS
Former President of Chile
PAVEL BÉM
Former Mayor of Prague, Czech Republic
OLUSEGUN OBASANJO
Former President of Nigeria
RICHARD BRANSON
Entrepreneur, founder of the Virgin Group,
co-founder of The Elders, United Kingdom
GEORGE PAPANDREOU
Former Prime Minister of Greece
FERNANDO HENRIQUE CARDOSO
Former President of Brazil
JORGE SAMPAIO
Former President of Portugal
MARIA CATTAUI
Former Secretary-General of the International
Chamber of Commerce, Switzerland
GEORGE SHULTZ (HONORARY CHAIR)
Former Secretary of State,
United States of America
NICK CLEGG
Former Deputy Prime Minister, United Kingdom
JAVIER SOLANA
Former European Union High Representative for
the Common Foreign and Security Policy, Spain
RUTH DREIFUSS (CHAIR)
Former President of Switzerland and
Minister of Home Affairs
THORVALD STOLTENBERG
Former Minister of Foreign Affairs and
UN High Commissioner for Refugees, Norway
CESAR GAVIRIA
Former President of Colombia
MARIO VARGAS LLOSA
Writer and public intellectual, Peru
ANAND GROVER
Former UN Special Rapporteur on the right of everyone
to the enjoyment of the highest attainable
standard of physical and mental health, India
ASMA JAHANGIR
Former UN Special Rapporteur on Arbitrary,
Extrajudicial and Summary Executions, Pakistan
PAUL VOLCKER
Former Chairman of the US Federal Reserve
and of the Economic Recovery Board,
United States of America
ERNESTO ZEDILLO
Former President of Mexico
MICHEL KAZATCHKINE
Former Executive Director of the Global Fund to
Fight AIDS, Tuberculosis and Malaria, France
2

TABLE OF CONTENTS
EXECUTIVE SUMMARY 3
CURRENT SITUATION 5
ROOTS OF THE CRISIS 6
Increase in prescription opioids 6
Increase in non-medical use 6
Inadequate Treatment and other services 7
Move from prescription opioids to
heroin and synthetic opioids 8
THE EPIDEMIC IN CANADA 8
REACTIONS BY AUTHORITIES AND OTHERS 9
LESSONS LEARNED 10
Lack of harm reduction measures
and treatment 10
Treatment of chronic pain 11
Is this a uniquely American crisis? 11
RECOMMENDATIONS 12
1

© Mukhina1/ Dreamstime

EXECUTIVE SUMMARY
North America is facing an epidemic of opioid addiction
and opioid overdose with an unprecedented level of
mortality. The crisis was spurred by a broad expansion
of medical use of opioids, which began in the 1990s as a
legitimate response to the under-treatment of pain, but
which was soon exploited by the unethical behavior of
pharmaceutical companies eager to increase their revenue.
The rise in supply fed high levels of diversion among an
economically stressed and vulnerable population. The
present wave of opioid dependence differs from the heroin
crises of the 1980s and 1990s, both in the sheer extent and
in the social backgrounds of a large part of the affected
populations. In Canada, which is second only in per capita
opioid consumption to the United States, the rise in fatal
overdoses is more linked to higher potency or ad-mixing
of other drugs in areas where there was already a relatively
high incidence of heroin use.
Initial reactions were to limit prescriptions and to introduce
pills that were harder to manipulate. The reduced supply
of prescription opioids, however, drove an important
minority of people with addiction to less expensive and
more accessible street heroin. Under what has become
known as the “iron law of prohibition”, cheaper and more
potent opioids—including fentanyl and its derivatives—
increasingly appeared on the market. This has even further
accelerated the rate of fatal overdoses.
Media and government attention has primarily focused on
the supply through doctors. The fact that most addictions
start with diverted supplies rather than among pain patients
has been largely ignored. Policymakers have also failed to
address the role of economic upheaval, unemployment,
inequality, and other systemic sources of despair in
increasing the risk for addiction and decreasing the odds
of recovery. Health systems were completely unprepared
and treatment is still dominated by abstinence-focused
programs, where no regulatory standards have to be met.
Furthermore, among other factors, prejudice against the
most effective treatments for opioid addiction—opioid
substitution therapy (OST)—has translated into lack of
treatment for those in need. Opioid substitution therapy
has proven effective in treating addictions to heroin and
should be offered to those dependent on or addicted to
prescription opioids.
While in recent years media and politicians have been
more open to viewing addiction as a public health
problem, leadership is needed to turn this into an urgent
and commensurate response to the crisis.
To mitigate the current crisis, the Global Commission on
Drug Policy recommends:
• n Do not cut the supply of prescription opioids without
first putting supporting measures in place. This
includes sufficient treatment options for people with
addiction and viable alternatives for pain patients.
• n Make proven harm reduction measures and
treatment widely available, especially naloxone
distribution and training, low-threshold opioid
substitution therapy, heroin-assisted treatment,
needle and syringe programs, supervised
injection facilities, and drug checking. In
states that have not yet done so, legally
regulate the medical use of marijuana.
• n This crisis shows the need for well-designed
regulation with proper implementation, including
guidelines and training on prescription, and
regular monitoring. The aim is to achieve the
right balance in regulation to provide effective
and adequate pain care, while minimizing
opportunities for misuse of these medications.
This includes improving the regulation of
relationships between the pharmaceutical
industries on the one hand and doctors and
lawmakers on the other; prescription guidelines
that ensure adequate relief for pain patients; and
training for physicians on evidence-based opioid
prescribing, which is funded by neutral bodies.
• n Decide to de facto decriminalize drug use
and possession for personal use at municipal,
city or State/Province levels. Do not pursue
such offenses so that people in need of health
and social services can access them freely,
easily, and without fear of legal coercion.
• n More research is needed in critical areas:
•§
The most effective treatments for
addiction to prescription opioids
•§
The link between economic, physical
and psychological problems and the
opioid crisis (“crisis of despair”).
§ • The exact role of fentanyl and its derivatives
in overdoses, especially how and when
fentanyl is added and whether the distribution
of test kits could play a positive role.
3

While these recommendations, if followed, would help curb
opioid-related mortality in the United States and Canada,
underlying problems remain. The Global Commission on
Drug Policy has consistently called for the decriminalization
of personal use and possession, and for alternatives to
punishment for non-violent, low-level actors in illicit drug
markets. The criminalization of drug use and possession
has little to no impact on the levels of drug use but instead
encourages high-risk behaviors, such as unsafe injecting,
and deters people in need of drug treatment from seeking
it and from using other health services and harm reduction
programs that would help them. The health, economic and
social benefits of decriminalization have been shown in
countries that took this step decades ago.
The Global Commission on Drug Policy also calls for the
elimination of illicit drug markets by carefully regulating
different drugs according to their potential harms. The most
effective way to reduce the extensive harms of the global
drug prohibition regime and advance the goals of public
health and safety is to get drugs under control through
responsible legal regulation. Therefore, the commission
adds two more far-reaching recommendations:
• n End the criminalization and incarceration
of people who use drugs nation-wide
in Canada and the United States.
• n Allow and promote pilot projects for the responsible
legal regulation of currently illicit drugs including
opioids, to replace and bypass criminal organizations
that drive and benefit from the current black market.
© PureRadiancePhoto/Shutterstock
4

CURRENT SITUATION
About 64,000 people died from drug overdoses in the
United States in 2016. 1 The vast majority of these deaths
involved an opioid drug, 2 which is the classification
that includes the opium derivatives heroin, morphine,
oxycodone and synthetic drugs, including the various
forms of fentanyl. Most opioid overdose deaths involved
a combination of drugs (polydrug use), i.e. an opioid and,
typically, a substance in the depressant class, such as alcohol
or anti-anxiety medications like benzodiazepines, although
stimulants like cocaine also sometimes contribute. 3
Overdose is now the leading cause of unintentional injury
death in the United States. Annually, it kills more than car
accidents and takes more lives than US soldiers were lost in
the deadliest year of the Vietnam War (16,899 in 1968) or at
the height of the HIV/AIDS epidemic in the United States
(43,115 in 1995).
American drug policy has a history of racial bias, and law
enforcement has disproportionately affected communities
of color. Current drug policy is characterized by repressive
law enforcement, lengthy mandatory minimum sentences
and the mass incarceration of people of color. 10 In contrast,
the current problem is seen as primarily affecting white
people and a new portrayal has been emerging: that of
an innocent victim worthy of empathy and deserving
less punitive responses. 11 In recent years, the media and
politicians have been more open to viewing addiction as a
public health problem and expanding treatment and harm
reduction measures like naloxone distribution. 12
While Canada does not keep national statistics, in
2016 there were 2,458 known opioid overdose deaths,
excluding Quebec where data is not available. 4 Regional
variance, differences in demographic variables, and lack
of national surveillance data from Canada, means that
there is currently no good way to accurately compare its
epidemic to that of the United States but a comparison of
two localities might give an idea of the extent of the crisis.
The hardest hit county in the United States—McDowell
County, West Virginia—had an overdose death rate of
93 per 100,000 in 2013-2015. 5 The hardest hit township in
Canada—Vancouver Coastal—has a rate of 42 per 100,000
in 2017 so far. 6 There are indications that First Nations are
disproportionately affected 7 and that the rise in overdose
deaths caused by higher potency or ad-mixing of other
drugs in areas where there was already a relatively high
incidence in heroin use plays a bigger role in Canada than
in the United States.
30,000
64,000
estimated deaths
from drug overdoses
in 2016
50,000
40,000
Although media and politicians in the United States have
traditionally portrayed opioid addiction as a problem
concentrated in the African-American community and
associated with poverty—and responded with harsh
criminal justice penalties—research shows that since the
1960s, at least half of all people with opioid use disorders
have been white. By 2010, 90% of all new users were white. 8
And while heroin addiction has typically been framed
as an urban problem, the current epidemic has hit rural
communities hard. Although opioid addiction is still most
concentrated among the poorest people, this epidemic is
especially dire among the people who have fared the worst
since the financial crash of 2008: the working class and
those who have fallen out of the middle class, or expected,
but did not attain, middle class lifestyles. 9
10,000 deaths
per year
20,000
Drug Overdose Deaths
1980 to 2016
1980
1990 2000
2010 2015
Sources: Centers for Disease Control and Prevention; state health departments, county coroners and medical examiners
THE NEW YORK TIMES
The New York Times (adapted)
5

ROOTS OF THE CRISIS
INCREASE IN PRESCRIPTION OPIOIDS
The current problem began with efforts to address the
genuine issue of under-treatment of pain, which were
soon exploited by pharmaceutical companies eager to
expand their market. Lenient regulation of pharmaceutical
marketing and direct selling to doctors by pharmaceutical
representatives increased drug-related harm. In both
Canada’s universal health care system and the marketbased
system in the United States, many practices that
incentivize increased prescribing are legal. Some examples
are: use of data by pharma representatives to target specific
doctors to try to get them to prescribe more; bonuses for
salespeople who are able to spike prescribing; targeted
payments to doctors for speaking engagements and other
services; inaccurately representing risks 13 and (in the United
States) emphasizing patient satisfaction measures. 14
Attempts to expand opioid prescribing from use for acute
pain and terminal cancer patients to chronic pain began in
the early 1990s. However, a major catalyst for the epidemic
was the introduction of extended-release oxycodone
(Oxycontin) in 1996—along with claims by its manufacturer
that it was less addictive and effective for a full 12 hours. 15
These claims have harmed both patients and illicit users.
When pain patients were left in agony in under those 12
hours, they were told to take higher doses, rather than use
it more frequently.
Some users rapidly discovered that the pills could be
crushed to defeat the time-release mechanism and snorted
or injected to produce a highly addictive short-acting drug.
Moreover, news of how to misuse the drug, accompanied
by enticing discussions of its effects, spread rapidly
through the growing use of the internet and via stories in
other media. One study found that six months after the
increase in sensational media coverage of opioids, related
mortality rose in concert, explaining 88% of the variance in
death rates. 16
INCREASE IN NON-MEDICAL USE
Opioid prescriptions for chronic pain rose dramatically
from the mid-1990s onwards. 17 But 65% of all opioid
prescriptions are still given for acute pain, such as from
surgery or dental work—and these, too, rose sharply. 18
Typically only one third (1/3) of a prescription for acute
pain is used by the patient 19 and the unused pills have high
monetary value: each pill can sell for US$30 or more. In the
context of rising inequality, along with the disappearance
of manufacturing jobs, long-term unemployment and the
economic catastrophe of 2008, the temptation to use the
drugs for emotional relief or sell them for cash grew.
DEPENDENCE VS ADDICTION
In order to understand the opioid epidemic, it is
critical to distinguish between two concepts that
unfortunately are often conflated: addiction and
dependence.
Dependence means relying on a substance to
function and to avoid suffering withdrawal symptoms
on abrupt cessation. It is a natural result of regularly
taking certain medications (including opioids, some
blood pressure medications and antidepressants). It
will affect nearly all patients who take opioids daily for
months.
Addiction, in contrast, is defined by the US National
Institute on Drug Abuse (NIDA) as a condition
“characterized by compulsive drug seeking and
use, despite harmful consequences.” 20 It only affects
a minority of people who take opioids. The best
estimate suggests that fewer than 8% of chronic pain
patients who have not previously suffered from an
addiction and who take opioids long-term develop
new addictions. 21
Stable methadone and buprenorphine patients
in opioid substitution therapy, for example, have
dependence, not addiction, and it is important to
make the distinction. 22 Unfortunately, the American
Psychiatric Association’s Diagnostic and Statistical
Manual (DSM) used the term “substance dependence”
to refer to addiction 23 until the publication of the
current manual DSM-5 in 2013, where its equivalent is
called “Substance Use Disorder, Severe”.
The World Health Organization’s International
Classification of Diseases (ICD), now ICD-10, still
uses “dependence” to mean compulsive use of a
substance despite negative consequences, 24 rather
than simply needing a drug to function.
The European Monitoring Centre for Drugs and Drug
Addiction (EMCDDA) in turn defines problematic
drug use (or high-risk drug use) as “recurrent drug use
that is causing actual harms (negative consequences)
to the person (including dependence, but also other
health, psychological or social problems), or is placing
the person at a high probability/risk of suffering such
harms.” 25
6

Throughout the crisis, media accounts have tended
to highlight “innocent victims”—people who became
addicted following medical exposure to opioids. However,
data from the United States from recent years shows that
70-80% 26 of people who misuse medical opioids get them
from sources other than their doctor: usually from family
and friends or simply by taking them from other people’s
medicine cabinets. And while chronic pain is highest among
older people, addiction risk is highest among the young.
New addictions are uncommon among pain patients
who do not have current or past addictions (including
alcoholism) or mental illness. 27 It has further been reported
that the availability of prescription opioids has increased
among those already using drugs. 28
INADEQUATE TREATMENT AND OTHER SERVICES
North Americans who have become addicted to prescription
opioids find health systems completely unprepared to deal
with their needs. In both the United States and Canada,
treatment is still dominated by abstinence-focused
programs. 29 Relapse following detoxification is extremely
common and, in this period, the risk of overdoses is
heightened due to loss of tolerance. 30 In contrast, opioid
substitution therapy has been proven to reduce mortality,
typically using methadone or buprenorphine. 31
Prejudice against opioid substitution therapy with
methadone and buprenorphine—and the over-regulation
of these drugs—has negatively affected the response to
the crisis. In the United States, as of 2015, only 8-10% of
treatment programs offered opioid substitution therapy, 32
often provided for periods too limited to be effective. 33
Insurance coverage of addiction treatment has improved
to some extent and “parity” with treatment for physical
conditions is required under the Affordable Care Act.
Treatment providers are not required, however, to meet
any federal standards, and the care on offer is rarely based
on evidence. 34 Outright fraudulent, abusive and neglectful
treatment is common. 35
Over-regulation of opioid substitution therapy also means
that methadone treatment is provided only in specialized,
OPIOID SUBSTITUTION THERAPY, MAINTENANCE AND MEDICATION ASSISTED TREATMENT
Opioid substitution therapy (OST),
also called opioid replacement
therapy (ORT), opioid agonist
therapy (OAT) or maintenance,
involves replacing street opioid use
with medical use under some degree
of supervision, typically with a longeracting
opioid. Commonly used
drugs for opioid substitution therapy
are methadone or buprenorphine
(Suboxone, Subutex).
Opioid substitution therapy,
continued as long as needed,
including indefinitely, is the only
treatment repeatedly shown to cut
the death rate from opioid addiction
by 50% or more 36 and it is the most
effective known treatment for opioid
addiction according to the World
Health Organization (WHO). 37 It is
endorsed by several UN agencies, 38
the US National Institute on Drug
Abuse, 35 Health Canada, 40 the U.K.’s
National Institute of Health and
Care Excellence, 41 the US Institute of
Medicine, 42 and many others. It has
been repeatedly shown to reduce
the spread of HIV and other bloodborne
diseases, reduce drug use and
injecting, as well as cutting crime. 43
When on opioid substitution therapy,
a person does not get “high” and
does not suffer from withdrawal
symptoms. Craving is reduced.
Addiction is replaced by physical
dependence. Once stabilized, most
patients can drive, work and care
for their families, 44 benefiting from
no longer being criminalized. Other
patients, however, can still benefit
from opioid substitution therapy
because it reduces overdose risk
by maintaining tolerance to opioids
(i.e. a patient who relapses and uses
heroin can withstand the dose they
were used to) and reducing the rate
of use.
There is significant literature from
Europe demonstrating that providing
supervised access to pharmaceutical
heroin itself (heroin-assisted
treatment or HAT) is effective for the
small number of people for whom
methadone treatment does not
work. 45 Drugs like hydromorphone
(Dilaudid) are also showing promise. 46
In the United States, a monthly
injectable form of long-acting
naltrexone (Vivitrol) was approved in
2010 as a third medication option for
opioid addiction treatment. 47 In the
United States, opioid substitution
therapy and extended release
naltrexone are grouped together in
the category “medication assisted
treatment” (MAT), to distinguish
these treatments from abstinenceonly
methods. Less than half a dozen
trials of long-acting naltrexone have
been published and they show
promising results in terms of reducing
relapse. 48 There is little long-term
data, however, and extended-release
naltrexone has not been shown
to reduce mortality or disease. It
may even increase overdose death
risk upon cessation. 49 Vivitrol is not
approved in Canada, although it is
available under the country’s special
access program in reaction to the
opioid crisis. 50
7

highly regulated clinics. Buprenorphine can be prescribed
by doctors outside clinics but numerous administrative
hurdles are involved, resulting in the number of qualified
prescribers being extremely limited. In addition, despite
often overwhelming demand, each doctor is limited to a
maximum of 275 patients. 51
MOVE FROM PRESCRIPTION OPIOIDS TO
HEROIN AND SYNTHETIC OPIOIDS
In 2010 the government began cracking down on “pill
mills”, which issued opioid prescriptions regardless of
a patient’s actual medical need. 52 In the same year an
“abuse deterrent” formula of Oxycontin was introduced. 53
As a result, some of the people who were addicted to
prescription opioids shifted to heroin, which was cheaper
and easier to use. 54 Around 80% of people with opioid
use disorder start by taking prescription pills. Of those
who start with prescription opioids, only fewer than 4%
ever try heroin. 55 Nonetheless, given the large number
of people who had started taking opioid pills, 4% of that
large number switching to heroin has been sufficient to
exacerbate the overdose crisis—especially when heroin
mixed with fentanyl and its derivatives started to appear.
The number of fentanyl-related deaths in the United States
rose by 72% between 2014 and 2015 alone. 56
The rise of fentanyl is an expression of Richard Cowan’s “Iron
Law” of prohibition, 57 which suggests that strict bans on
one substance will promote the use and sale of similar but
more potent drugs that are easier to smuggle. This is true
for fentanyl: it is completely synthetic (no need to grow and
harvest poppy) and cheaper to make and transport. Fentanyl
is about 50 times more potent than morphine per milligram
– and some derivatives are even stronger. Carfentanil, for
example, is 10,000 times more potent than morphine. 58
THE INDIANA HIV EPIDEMIC
In rural Scott County, Indiana (est. pop. in 2016:
23,730), a number of people were addicted to
a prescription opioid, Opana. In 2012, the drug
was “reformulated” to deter misuse by snorting;
unfortunately, this drove users to start injecting. 59 The
county’s only HIV testing site, a branch of Planned
Parenthood, was defunded and shuttered in 2013. 60
The spread of HIV was dramatic: while in 2014, five
people tested positive for HIV, by the end of 2015
nearly 200 were infected.
Indiana’s government had long opposed the provision
of clean needles to people who use drugs on moral
grounds, despite overwhelming data showing that
such programs do not increase drug use but do
fight disease. It took four months during which up
to 20 new infections were reported per week, until
eventually Governor (now Vice President) Mike Pence
agreed to the implementation of a needle exchange
program. This harm reduction measure was effective
in ending the rise in new infections.
The transition from licit prescription opioids to illicit
heroin also demonstrates once again how narrow and
often arbitrary the boundaries between licit and illicit
psychoactive substances are. There can be little justification
for prohibiting and repressing the use of the latter, while
allowing almost uncontrolled consumption of the former.
THE EPIDEMIC IN CANADA
Whereas Canada is second only to the United States in per
capita opioid consumption, and rates of overdose have
risen along with prescribing in recent years, 61 no nationwide
figures on annual overdose rates are available. It is therefore
not entirely clear how Canadian overdose rates compare
to those in the United States and how much of Canada’s
opioid epidemic is associated with medical use.
The prescribing of high doses of opioids in Canada has
been linked with greater numbers of opioid-related
emergency department visits and hospital admissions. 62
However, nearly half of Canada’s known opioid overdose
deaths occur in British Columbia, which has had high
rates of injecting drug use for decades. More than 80%
of overdose victims in this region are male 63 —while, in
contrast, chronic pain populations tend to be more than
half female. 64 This suggests that the Canadian epidemic is
also driven by illegal, rather than medical, use.
There are indications that the recent rise in deaths is linked
with toxicity from the current flood of illegally manufactured
fentanyl and derivatives, rather than an increase in the
number of people with addiction linked to pain prescribing.
Data from British Columbia shows that the rise in deaths is
exclusively seen in those linked to fentanyl and derivatives;
other types of opioid overdose deaths have not risen. 65
Without better national data, however, it is impossible to
know whether this is true for all of Canada.
In contrast to the United States, Canada has a universal
8

health care system which should, if international experience
is a guide, offer some protection from a further rise of opioid
overdoses. For example, one study from the U.K. found
that a doubling of prescribing was not associated with an
increase in overdose deaths—and the authors suggested
that one reason for this protection is the U.K.’s National
Health Service. 66 Other factors, such as having lower levels
of inequality and having suffered less from the 2008 financial
crash compared to the United States, should also indicate
that the opioid crisis will affect Canada to a lesser extent.
Even though the Conservative government, in power
until two years ago, fought against the expansion of harm
reduction services, such as safe injection sites, Canada
does provide relatively more maintenance treatment and
harm reduction services compared with the United States.
Heroin-assisted treatment exists but is only available to
several hundred people. 67 The new Canadian government
supports the expansion of harm reduction, but as of
now, the number of people who need it far exceeds its
availability and reach. 68
REACTIONS BY AUTHORITIES AND OTHERS
Both the United States and Canada have reacted to the
epidemic by creating guidelines for doctors aimed at
reducing opioid prescribing 69 and by cracking down on
those seen as overprescribing. These policies have indeed
reduced the medical supply—but the overdose death rate
has continued to rise. 70
The Canadian government views addiction as a health
problem rather than one for the criminal justice system 71
and this approach also has bipartisan support in the
United States—stopping short of actual decriminalization,
however. The current administration has, nevertheless,
been sending some mixed signals with parts seemingly
supporting a health-centered approach and others
reverting to “law and order” rhetoric.
There are some examples of positive developments. In
regions of North Carolina, intensive education for physicians
combined with emergency measures have resulted in
decreased mortality. 72 In Seattle, a program called Law
Enforcement Assisted Diversion (LEAD) was developed to
avoid arresting people who use drugs and instead provide
them with needed social services, including treatment, if
desired. It is now being tested in at least seven other states
and tests are scheduled to start in many more.
Another successful intervention to prevent overdose is
also possibly going to be expanded. “Supervised injection
facilities” (SIFs), which have a very positive trajectory in
Europe, were pioneered in North America by a program
in Vancouver called Insite. Supervised injection facilities
allow people who take drugs to do so in safe, hygienic,
calm conditions, with medical help available in the event
of an overdose. No one has ever died of an overdose
in a SIF, which now operate in around 66 cities in ten
countries. 73 Research on Insite suggests that it has cut the
local overdose death by 35% 74 and other studies show that
SIFs increase treatment admissions, cut drug-related crime
and disease and do not encourage riskier drug use. 75 In the
United States, the legal framework for SIFs is not clear, 74
Known as “Needle Park”, Platzspitz in Zurich became the biggest open drug scene in Europe in the late 1980s and early 1990s. Harm reduction and treatment services, such as Safe
Injection Facilities and Heroin-Assisted Treatment, proved to be a highly effective response: the open drug scenes rapidly disappeared and drug-related deaths dropped 50% within
ten years.
© 1989 Olivia Heussler /clic.li GmbH
9

ut nonetheless Seattle, New York and San Francisco are
considering opening SIFs. A secret site in the United States
has already monitored some 2,500 injections over three
years with zero deaths. 77
Over half a dozen studies now suggest that medical
marijuana can reduce opioid use, both as a treatment for
pain and as a safer alternative for people with addiction.
According to one of them, states with medical marijuana
access have 25% lower opioid addiction and overdose
rates; 78 another study found that in medical marijuana
states, each doctor writes 1,800 fewer annual opioid
prescriptions. 79 A Massachusetts study found that increased
distribution of the overdose reversal medication naloxone
cut overdose death rates nearly in half. 80 Both the United
States and Canada have moved to expand access to
naloxone in a number of different ways. Many states now
provide it to first responders, such as police and firefighters.
Over 600 American programs that distribute naloxone
directly to people who use drugs and their loved ones were
operating as of 2014. 81 And at least 30 states now have
“standing orders” or other measures that make naloxone
available without a prescription at pharmacies, at sites like
syringe exchange programs, and at rehabilitation centers. 82
LESSONS LEARNED
Exponentially increasing a poorly controlled supply of
opioids to a population under severe economic stress—
and thereby providing both a source of short-term solace
and a source of income to distressed communities—has
had very adverse consequences. While some pain patients
have benefited from increased access, flooding the streets
with these drugs has done tremendous harm at a time
when a large portion of the population in the United States
was suffering from wage stagnation, uncertain economic
prospects, and unemployment.
The crackdown on the medical supply, carried out without
providing adequate treatment and harm reduction
measures, pushed illicit users who had previously taken
drugs of known dose and purity to impure street drugs,
where the dosage of the active ingredient is unknown. This
has increased overdose and mortality.
LACK OF HARM REDUCTION MEASURES
AND TREATMENT
Unfortunately, recognizing that a problem originated
with an increased medical supply does not mean that
simply cutting that supply will solve it. Closing “pill mills”
and expelling patients suspected of drug misuse from
medical care does not treat addiction: it merely offers drug
traffickers a large group of new customers.
To avoid expanding illegal markets, people who lose
access to prescription opioids need to be offered
immediate access to appropriate harm reduction services
and treatment. No patient should be summarily cut off
from opioids: if misuse is discovered, patients should be
able to seamlessly transition to maintenance treatment or
other alternatives as needed. Otherwise, the result will be
increased amounts of harm and death.
Insite in Vancouver, BC, was the first Safe Injection Facility to open in North America ten years ago.
©2011 AFP/Laurent Vu The
10

Furthermore, while some patients can benefit from
counseling and intensive psychiatric or job-training
services in addition to opioid substitution therapy, there
is no evidence that requiring such participation improves
outcomes. 83 Mandating attendance, however, does increase
cost (limiting the number of patients who can get care), while
also deterring those who would accept medication with
fewer strings attached. This is not acceptable when people
are dying because they cannot get treatment. Patients
seeking abstinence should have access to relevant services,
but “low threshold” care should also be available.
Both methadone and buprenorphine are too heavily
regulated in the United States: limiting methadone to
specialty clinics and limiting the number of patients to whom
doctors can prescribe buprenorphine has made opioid
substitution therapy far too difficult to get, particularly in
rural areas. Canada does allow office-based methadone
prescribing, but it has not expanded buprenorphine access
sufficiently.
The North American opioid epidemic also highlights how
unprepared many communities are to provide appropriate
harm reduction and treatment services for people with
addiction. Rural communities are hard to serve effectively;
these same communities have both the highest levels of
overdose deaths and the greatest resistance to expanding
harm reduction and maintenance treatment.
Failing to provide treatment for those who have relied
on medical opioids after the supply is cut will inevitably
increase the overdose risk due to switching from drugs of
known purity and potency to those where these factors are
variable. The only way to reduce harm for those addicted to
opioids is to provide safer alternatives that are acceptable
to them, including opioid substitution therapy with
methadone, buprenorphine, and medical-grade heroin or
hydromorphone.
cuts or inability to get opioids at all: one survey by pain
patient advocates found that two thirds (2/3) of all patients
had their doses either reduced or eliminated 86 —even
though no study has been conducted as to whether pain
patients who are stable on opioids receive any benefit or
are harmed by involuntarily tapering off opioids. 87 Though
there is little data, dozens of associated suicides have been
reported both by physicians and by patient advocates. 88
Chronic pain patients and people at the end of life should
not be made to suffer because others misuse these
medications.
The regulation of pain prescribing must balance the need
for legitimate access—including recognition of barriers
to care, such as requiring frequent doctor visits for stable
patients—with appropriate controls to minimize diversion. 89
Regulation of opioids needs to balance benefits and harms.
IS THIS A UNIQUELY AMERICAN CRISIS?
At the moment, Europe, Australia and New Zealand are
not seeing an opioid epidemic comparable to that in
North America: 90 prescribing rates are lower, universal
health care is available in most countries and, while there
has been recent economic distress in many places, it has
largely occurred in the presence of a stronger social safety
net. However, fentanyl and derivatives have recently been
showing up in the U.K.—and drug epidemics often strike
based to some degree on “fashion” among people who
use drugs, which is unpredictable. European countries and
others around the world should take heed of the lessons
learned in the United States and Canada.
TREATMENT OF CHRONIC PAIN
The epidemic has also revealed deep problems with the
way pain is treated. While opioids clearly do benefit some
patients, 84 they do not work for many and yet there are
few alternatives. Health insurance often does not cover
enough physical therapy or behavioral support for painful
conditions for which these are helpful; access to alternative
treatments that show promise (as well as those that are
unproven) is also limited.
Given the prevalence of chronic pain from which about
25-50 million people suffer in the United States, 85 there
needs to be a much greater investment in developing new
treatments. Understanding of how to best use opioids
for those who will benefit also needs to be improved.
Meanwhile, numerous pain patients report arbitrary dose
11

RECOMMENDATIONS
• n Do not cut the supply of prescription opioids without
first putting supporting measures in place. This
includes sufficient treatment options for people with
addiction and viable alternatives for pain patients.
• n Make proven harm reduction measures and
treatment widely available, especially naloxone
distribution and training, low-threshold opioid
substitution therapy, heroin-assisted treatment,
needle and syringe programs, supervised
injection facilities, and drug checking. In
states that have not yet done so, legally
regulate the medical use of marijuana.
• n This crisis shows the need for well-designed
regulation with proper implementation, including
guidelines and training on prescription, and
regular monitoring. The aim is to achieve the
right balance in regulation to provide effective
and adequate pain care, while minimizing
opportunities for misuse of these medications.
This includes improving the regulation of
relationships between the pharmaceutical
industries on the one hand and doctors and
lawmakers on the other; prescription guidelines
that ensure adequate relief for pain patients; and
training for physicians on evidence-based opioid
prescribing, which is funded by neutral bodies.
• n Decide to de facto decriminalize drug use
and possession for personal use at municipal,
city or State/Province levels. Do not pursue
such offenses so that people in need of health
and social services can access them freely,
easily and without fear of legal coercion.
While these recommendations, if followed, would help curb
opioid-related mortality in the United States and Canada,
underlying problems remain. The Global Commission on
Drug Policy has consistently called for the decriminalization
of personal use and possession, and for alternatives to
punishment for non-violent, low-level actors in illicit drug
markets. The criminalization of drug use and possession
has little to no impact on the levels of drug use but instead
encourages high-risk behaviors, such as unsafe injecting,
and deters people in need of drug treatment from seeking
it and from using other health services and harm reduction
programs that would help them. The health, economic and
social benefits of decriminalization have been shown in
countries that took this step decades ago. 91
The Global Commission on Drug Policy also calls for the
elimination of illicit drug markets by carefully regulating
different drugs according to their potential harms. The
most effective way to reduce the extensive harms of the
global drug prohibition regime and advance the goals
of public health and safety is to get drugs under control
through responsible legal regulation. Therefore, the
commission adds two more far-reaching recommendation:
• n End the criminalization and incarceration
of people who use drugs nation-wide
in Canada and the United States.
n • Allow and promote pilot projects for the responsible
legal regulation of currently illicit drugs including
opioids, to replace and bypass criminal organizations
that drive and benefit from the current black market.
• n More research is needed in critical areas:
•§
The most effective treatments for
addiction to prescription opioids.
•§
The link between economic, physical
and psychological problems and the
opioid crisis (“crisis of despair”).
•§
The exact role of fentanyl and its derivatives
in overdoses, especially how and when
fentanyl is added and whether the distribution
of test kits could play a positive role.
12

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ADDITIONAL RESOURCES
www.beckleyfoundation.org
www.countthecosts.org
www.cupihd.org
www.druglawreform.info
www.drugpolicy.org
www.hivlawcommission.org
www.hri.global
www.hrw.org
www.igarape.org.br
www.intercambios.org.ar
www.icsdp.org
www.idhdp.com
www.idpc.net
www.inpud.net
www.incb.org
www.ohchr.org/EN/HRBodies/HRC/Pages/
WorldDrugProblem.aspx
www.talkingdrugs.org
www.tdpf.org.uk
www.unaids.org/en/targetsandcommitments/
preventinghivamongdrugusers
www.unodc.org
www.who.int/topics/substance_abuse/en/
www.wola.org/program/drug_policy
16

ACKNOWLEDGEMENTS:
EXPERT REVIEW PANEL
Holly Bradford
Richard Elliott
Thomas Kerr
Susan Sherman
Steffanie Strathdee
Maia Szalavitz
Jasmine Tyler
Ambros Uchtenhagen
GLOBAL COMMISSION ON DRUG POLICY
SECRETARIAT
Khalid Tinasti
Barbara Goedde
Eric Grant
Anna Iatsenko
SUPPORT
Open Society Foundations
Virgin Unite
Oak Foundation
The Swiss Federal Department
of Foreign Affairs
REPORTS BY
THE GLOBAL COMMISSION ON DRUG POLICY
• n War on Drugs (2011)
• n The War on Drugs and HIV/AIDS:
How the Criminalization of Drug Use
Fuels the Global Pandemic (2012)
• n The Negative Impact of the War on Drugs on Public Health:
The Hidden Hepatitis C Epidemic (2013)
• n Taking Control:
Pathways to Drug Policies That Work (2014)
• n The Negative Impact of Drug Control on Public Health:
The Global Crisis of Avoidable Pain (2015)
• n Advancing Drug Policy Reform:
a New Approach to Decriminalization (2016)
http://www.globalcommissionondrugs.org/reports/
CONTACT
secretariat@globalcommissionondrugs.org
www.globalcommissionondrugs.org

GLOBAL COMMISSION ON DRUG POLICY
The purpose of the Global Commission on Drug Policy is
to bring to the international level an informed, science based
discussion about humane and effective ways to reduce
the harms caused by drugs and drug control policies to
people and societies.
GOALS
• n Review the base assumptions, effectiveness and
consequences of the ‘war on drugs’ approach
• n Evaluate the risks and benefits of different
national responses to the drug problem
• n Develop actionable, evidence-based recommendations
for constructive legal and policy reform
www.globalcommissionondrugs.org

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Advocacy Foundation Publishers
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Advocacy Foundation Publishers
The e-Advocate Quarterly
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Issue Title Quarterly
Vol. I 2015 The Fundamentals
I
The ComeUnity ReEngineering
Project Initiative
Q-1 2015
II The Adolescent Law Group Q-2 2015
III
Landmark Cases in US
Juvenile Justice (PA)
Q-3 2015
IV The First Amendment Project Q-4 2015
Vol. II 2016 Strategic Development
V The Fourth Amendment Project Q-1 2016
VI
Landmark Cases in US
Juvenile Justice (NJ)
Q-2 2016
VII Youth Court Q-3 2016
VIII
The Economic Consequences of Legal
Decision-Making
Q-4 2016
Vol. III 2017 Sustainability
IX The Sixth Amendment Project Q-1 2017
X
The Theological Foundations of
US Law & Government
Q-2 2017
XI The Eighth Amendment Project Q-3 2017
XII
The EB-5 Investor
Immigration Project*
Q-4 2017
Vol. IV 2018 Collaboration
XIII Strategic Planning Q-1 2018
XIV
The Juvenile Justice
Legislative Reform Initiative
Q-2 2018
XV The Advocacy Foundation Coalition Q-3 2018
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XVI
for Drug-Free Communities
Landmark Cases in US
Juvenile Justice (GA)
Q-4 2018
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Issue Title Quarterly
Vol. V 2019 Organizational Development
XVII The Board of Directors Q-1 2019
XVIII The Inner Circle Q-2 2019
XIX Staff & Management Q-3 2019
XX Succession Planning Q-4 2019
XXI The Budget* Bonus #1
XXII Data-Driven Resource Allocation* Bonus #2
Vol. VI 2020 Missions
XXIII Critical Thinking Q-1 2020
XXIV
The Advocacy Foundation
Endowments Initiative Project
Q-2 2020
XXV International Labor Relations Q-3 2020
XXVI Immigration Q-4 2020
Vol. VII 2021 Community Engagement
XXVII
The 21 st Century Charter Schools
Initiative
Q-1 2021
XXVIII The All-Sports Ministry @ ... Q-2 2021
XXIX Lobbying for Nonprofits Q-3 2021
XXX
XXXI
Advocacy Foundation Missions -
Domestic
Advocacy Foundation Missions -
International
Q-4 2021
Bonus
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Vol. VIII
2022 ComeUnity ReEngineering
XXXII
The Creative & Fine Arts Ministry
@ The Foundation
Q-1 2022
XXXIII The Advisory Council & Committees Q-2 2022
XXXIV
The Theological Origins
of Contemporary Judicial Process
Q-3 2022
XXXV The Second Chance Ministry @ ... Q-4 2022
Vol. IX 2023 Legal Reformation
XXXVI The Fifth Amendment Project Q-1 2023
XXXVII The Judicial Re-Engineering Initiative Q-2 2023
XXXVIII
The Inner-Cities Strategic
Revitalization Initiative
Q-3 2023
XXXVIX Habeas Corpus Q-4 2023
Vol. X 2024 ComeUnity Development
XXXVX
The Inner-City Strategic
Revitalization Plan
Q-1 2024
XXXVXI The Mentoring Initiative Q-2 2024
XXXVXII The Violence Prevention Framework Q-3 2024
XXXVXIII The Fatherhood Initiative Q-4 2024
Vol. XI 2025 Public Interest
XXXVXIV Public Interest Law Q-1 2025
L (50) Spiritual Resource Development Q-2 2025
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LI
Nonprofit Confidentiality
In The Age of Big Data
Q-3 2025
LII Interpreting The Facts Q-4 2025
Vol. XII 2026 Poverty In America
LIII
American Poverty
In The New Millennium
Q-1 2026
LIV Outcome-Based Thinking Q-2 2026
LV Transformational Social Leadership Q-3 2026
LVI The Cycle of Poverty Q-4 2026
Vol. XIII 2027 Raising Awareness
LVII ReEngineering Juvenile Justice Q-1 2027
LVIII Corporations Q-2 2027
LVIX The Prison Industrial Complex Q-3 2027
LX Restoration of Rights Q-4 2027
Vol. XIV 2028 Culturally Relevant Programming
LXI Community Culture Q-1 2028
LXII Corporate Culture Q-2 2028
LXIII Strategic Cultural Planning Q-3 2028
LXIV
The Cross-Sector/ Coordinated
Service Approach to Delinquency
Prevention
Q-4 2028
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Vol. XV 2029 Inner-Cities Revitalization
LXIV
LXV
LXVI
Part I – Strategic Housing
Revitalization
(The Twenty Percent Profit Margin)
Part II – Jobs Training, Educational
Redevelopment
and Economic Empowerment
Part III - Financial Literacy
and Sustainability
Q-1 2029
Q-2 2029
Q-3 2029
LXVII Part IV – Solutions for Homelessness Q-4 2029
LXVIII
The Strategic Home Mortgage
Initiative
Bonus
Vol. XVI 2030 Sustainability
LXVIII Social Program Sustainability Q-1 2030
LXIX
The Advocacy Foundation
Endowments Initiative
Q-2 2030
LXX Capital Gains Q-3 2030
LXXI Sustainability Investments Q-4 2030
Vol. XVII 2031 The Justice Series
LXXII Distributive Justice Q-1 2031
LXXIII Retributive Justice Q-2 2031
LXXIV Procedural Justice Q-3 2031
LXXV (75) Restorative Justice Q-4 2031
LXXVI Unjust Legal Reasoning Bonus
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Vol. XVIII 2032 Public Policy
LXXVII Public Interest Law Q-1 2032
LXXVIII Reforming Public Policy Q-2 2032
LXXVIX ... Q-3 2032
LXXVX ... Q-4 2032
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The e-Advocate Journal
of Theological Jurisprudence
Vol. I - 2017
The Theological Origins of Contemporary Judicial Process
Scriptural Application to The Model Criminal Code
Scriptural Application for Tort Reform
Scriptural Application to Juvenile Justice Reformation
Vol. II - 2018
Scriptural Application for The Canons of Ethics
Scriptural Application to Contracts Reform
& The Uniform Commercial Code
Scriptural Application to The Law of Property
Scriptural Application to The Law of Evidence
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Legal Missions International
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Issue Title Quarterly
Vol. I 2015
I
II
God’s Will and The 21 st Century
Democratic Process
The Community
Engagement Strategy
Q-1 2015
Q-2 2015
III Foreign Policy Q-3 2015
IV
Public Interest Law
in The New Millennium
Q-4 2015
Vol. II 2016
V Ethiopia Q-1 2016
VI Zimbabwe Q-2 2016
VII Jamaica Q-3 2016
VIII Brazil Q-4 2016
Vol. III 2017
IX India Q-1 2017
X Suriname Q-2 2017
XI The Caribbean Q-3 2017
XII United States/ Estados Unidos Q-4 2017
Vol. IV 2018
XIII Cuba Q-1 2018
XIV Guinea Q-2 2018
XV Indonesia Q-3 2018
XVI Sri Lanka Q-4 2018
Vol. V 2019
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XVII Russia Q-1 2019
XVIII Australia Q-2 2019
XIV South Korea Q-3 2019
XV Puerto Rico Q-4 2019
Issue Title Quarterly
Vol. VI 2020
XVI Trinidad & Tobago Q-1 2020
XVII Egypt Q-2 2020
XVIII Sierra Leone Q-3 2020
XIX South Africa Q-4 2020
XX Israel Bonus
Vol. VII 2021
XXI Haiti Q-1 2021
XXII Peru Q-2 2021
XXIII Costa Rica Q-3 2021
XXIV China Q-4 2021
XXV Japan Bonus
Vol VIII 2022
XXVI Chile Q-1 2022
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The e-Advocate Juvenile Justice Report
______
Vol. I – Juvenile Delinquency in The US
Vol. II. – The Prison Industrial Complex
Vol. III – Restorative/ Transformative Justice
Vol. IV – The Sixth Amendment Right to The Effective Assistance of Counsel
Vol. V – The Theological Foundations of Juvenile Justice
Vol. VI – Collaborating to Eradicate Juvenile Delinquency
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The e-Advocate Newsletter
Genesis of The Problem
Family Structure
Societal Influences
Evidence-Based Programming
Strengthening Assets v. Eliminating Deficits
2012 - Juvenile Delinquency in The US
Introduction/Ideology/Key Values
Philosophy/Application & Practice
Expungement & Pardons
Pardons & Clemency
Examples/Best Practices
2013 - Restorative Justice in The US
2014 - The Prison Industrial Complex
25% of the World's Inmates Are In the US
The Economics of Prison Enterprise
The Federal Bureau of Prisons
The After-Effects of Incarceration/Individual/Societal
The Fourth Amendment Project
The Sixth Amendment Project
The Eighth Amendment Project
The Adolescent Law Group
2015 - US Constitutional Issues In The New Millennium
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2018 - The Theological Law Firm Academy
The Theological Foundations of US Law & Government
The Economic Consequences of Legal Decision-Making
The Juvenile Justice Legislative Reform Initiative
The EB-5 International Investors Initiative
2017 - Organizational Development
The Board of Directors
The Inner Circle
Staff & Management
Succession Planning
Bonus #1 The Budget
Bonus #2 Data-Driven Resource Allocation
2018 - Sustainability
The Data-Driven Resource Allocation Process
The Quality Assurance Initiative
The Advocacy Foundation Endowments Initiative
The Community Engagement Strategy
2019 - Collaboration
Critical Thinking for Transformative Justice
International Labor Relations
Immigration
God's Will & The 21st Century Democratic Process
The Community Engagement Strategy
The 21st Century Charter Schools Initiative
2020 - Community Engagement
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Extras
The Nonprofit Advisors Group Newsletters
The 501(c)(3) Acquisition Process
The Board of Directors
The Gladiator Mentality
Strategic Planning
Fundraising
501(c)(3) Reinstatements
The Collaborative US/ International Newsletters
How You Think Is Everything
The Reciprocal Nature of Business Relationships
Accelerate Your Professional Development
The Competitive Nature of Grant Writing
Assessing The Risks
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About The Author
John C (Jack) Johnson III
Founder & CEO
Jack was educated at Temple University, in Philadelphia, Pennsylvania and Rutgers
Law School, in Camden, New Jersey. In 1999, he moved to Atlanta, Georgia to pursue
greater opportunities to provide Advocacy and Preventive Programmatic services for atrisk/
at-promise young persons, their families, and Justice Professionals embedded in the
Juvenile Justice process in order to help facilitate its transcendence into the 21 st Century.
There, along with a small group of community and faith-based professionals, “The Advocacy Foundation, Inc." was conceived
and developed over roughly a thirteen year period, originally chartered as a Juvenile Delinquency Prevention and Educational
Support Services organization consisting of Mentoring, Tutoring, Counseling, Character Development, Community Change
Management, Practitioner Re-Education & Training, and a host of related components.
The Foundation’s Overarching Mission is “To help Individuals, Organizations, & Communities Achieve Their Full Potential”, by
implementing a wide array of evidence-based proactive multi-disciplinary "Restorative & Transformative Justice" programs &
projects currently throughout the northeast, southeast, and western international-waters regions, providing prevention and support
services to at-risk/ at-promise youth, to young adults, to their families, and to Social Service, Justice and Mental
Health professionals” everywhere. The Foundation has since relocated its headquarters to Philadelphia, Pennsylvania, and been
expanded to include a three-tier mission.
In addition to his work with the Foundation, Jack also served as an Adjunct Professor of Law & Business at National-Louis
University of Atlanta (where he taught Political Science, Business & Legal Ethics, Labor & Employment Relations, and Critical
Thinking courses to undergraduate and graduate level students). Jack has also served as Board President for a host of wellestablished
and up & coming nonprofit organizations throughout the region, including “Visions Unlimited Community
Development Systems, Inc.”, a multi-million dollar, award-winning, Violence Prevention and Gang Intervention Social Service
organization in Atlanta, as well as Vice-Chair of the Georgia/ Metropolitan Atlanta Violence Prevention Partnership, a state-wide
300 organizational member, violence prevention group led by the Morehouse School of Medicine, Emory University and The
Original, Atlanta-Based, Martin Luther King Center.
Attorney Johnson’s prior accomplishments include a wide-array of Professional Legal practice areas, including Private Firm,
Corporate and Government postings, just about all of which yielded significant professional awards & accolades, the history and
chronology of which are available for review online. Throughout his career, Jack has served a wide variety of for-profit
corporations, law firms, and nonprofit organizations as Board Chairman, Secretary, Associate, and General Counsel since 1990.
www.TheAdvocacyFoundation.org
Clayton County Youth Services Partnership, Inc. – Chair; Georgia Violence Prevention Partnership, Inc – Vice Chair; Fayette
County NAACP - Legal Redress Committee Chairman; Clayton County Fatherhood Initiative Partnership – Principal
Investigator; Morehouse School of Medicine School of Community Health Feasibility Study - Steering Committee; Atlanta
Violence Prevention Capacity Building Project – Project Partner; Clayton County Minister’s Conference, President 2006-2007;
Liberty In Life Ministries, Inc. – Board Secretary; Young Adults Talk, Inc. – Board of Directors; ROYAL, Inc - Board of
Directors; Temple University Alumni Association; Rutgers Law School Alumni Association; Sertoma International; Our
Common Welfare Board of Directors – President)2003-2005; River’s Edge Elementary School PTA (Co-President); Summerhill
Community Ministries; Outstanding Young Men of America; Employee of the Year; Academic All-American - Basketball;
Church Trustee.
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www.TheAdvocacyFoundation.org
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