Prescription drug abuse in Oklahoma : state of Oklahoma House of Representatives interim study 11-056.

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              Prescription Drug Abuse
in Oklahoma
State of Oklahoma House of Representatives
Interim Study 11‐056
September 14, 2011
Liz Langthorn, MPH
I j P ti S i
Jessica Hawkins
Pre ention Ser ices Injury Prevention Service
OK State Dept. of Health
Prevention Services
OK Dept. of Mental Health and
Substance Abuse Services
State’s Prevention Prioritization
• The ODMHSAS State Epidemiology Workgroup
gathered all available, valid data
• Analysis revealed highest consumption and
consequence patterns with:
1. Alcohol use among youth under age 21
2. Nonmedical use of prescription drugs
State’s Prevention Prioritization
• Oklahoma ranks #1 nationally for the nonmedical use of pain
relievers in the past p year for all age categories (NSDUH)
• Nearly 22% of Oklahoma 12th graders had used prescription
drugs without a doctor telling them to do so once or more in
their lifetime ‐ 9.6% had done so in the past 30 days (2010
OPNA)
• Oklahoma is over one and a half times the national average in
the nonmedical use of prescription pain relievers in the past
month among persons aged 12 and older (NSDUH)
National Prevention Strategy
• Practitioner training on opiod prescribing
• Clinical guidelines; Patient-provider agreements
• Public media/education campaigns Education
• Abuse deterrent formulation
• Consistent, utilized PMP databases
Monitoring
• Increase Screening and Brief Intervention • Collect and share data • Drug take back programs
bli d i f di l Disposal
• Public education on safe disposal •Aggressive enforcement activities; Increased regulation
Enforcement
•Law enforcement training
•Utilize PMPs for patient and provider problems U.S. Unintentional Poisoning Deaths by Year and Poison
Type, 1999–2006
Prescription Drug Source
72% from friend or relative
60% free
8% purchased
4% taken without permission
17% prescription from doctor
4% bought from drug dealer
Other sources:
Theft, internet, forgery
Unintentional Medication Overdose Death Rates — U.S.
and Oklahoma, 1999–2005
12
8
10
eath rate
4
6
djusted de
United States
Oklahoma
0
2
1999 2000 2001 2002 2003 2004 2005
Age-ad
Year
Unintentional Medication Overdose Deaths by Year-
Oklahoma, 1994-2006
450
300
350
400
deaths
200
250
mber of d
50
100
150
Num
0
1994 1996 1998 2000 2002 2004 2006
Unintentional Drug Overdose Death Rates and
Total Sales of Prescription Opioid Painkillers by Year in
12
.
ns
Oklahoma, 1994–2006
700
900
8
10
erson 00 person
500
6
old per pe
per 100,00
.
Deaths/100,000
Opioid sales
300
2
4
ligrams so
eath rate p
(mg/person)
0 100
'94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06
Mill
De
Medication Overdose Deaths by Age Group
250
150
200
ths
100
er of deat
0-19
20-39
40 59
50
Numbe
40-60+
0
1994 1996 1998 2000 2002 2004 2006
Medication Overdose Death Rates by County
Cimarron
Texas
Beaver
Harper
W d d
Woods Alfalfa Grant Kay
Osage
Ottawa
Washington
Rogers
Nowata
Craig
Ellis
Roger Mills
Woodward
Major
Dewey
Blaine
Garfield
Kingfisher
Noble
Payne
Logan
Pawnee
Creek
Lincoln
Muskogee
Tulsa
Wagoner Cherokee
Adair
Mayes Delaware
Beckham
Custer
Washita
Greer Kiowa
Caddo
Canadian Oklahoma
Cleveland
Grady
Hughes
Okfuskee
Pittsburg
McIntosh
Latimer
Haskell
Sequoyah
g
Okmulgee
Potta- Seminole
watomie
McClain
Jackson
Tillman
Comanche
Cotton
Stephens
Jefferson
Garvin
Carter
Murray
Pontotoc
Johnston
Coal
Atoka
g
Pushmataha
Le Flore
50+% Above State Rate Harmon
10-49% Above State Rate
At to 50% Below State Rate
> 50% Below State Rate
Love Bryan
Choctaw McCurtain
Marshall
n=2161
No Deaths
Overdose Deaths from Illicit Drugs vs. Prescription Drugs
Substance Involved in Unintentional Medication
Overdose Deaths
Substance Pos. Tests (%) Substance Pos. Tests (%)
Methadone 653 (Diazepam 94 (17) 2)
Hydrocodone 407 (11) Amitriptyline 87 (2)
Alprazolam 320 (8) Cocaine 85 (2)
Oxycodone 311 (8) Acetaminophen 76 (2)
Morphine 263 (7) Cyclobenzaprine 74 (2)
Alcohol 260 (7) Methamphetamine 72 (2)
Propoxyphene 140 (4) Olanzapine 37 (1)
Fentanyl 124 (3) Codeine 34 (1)
Carisoprodol 97 (2) Other medication 609 (16)
Case Study
Patient: 30 year old female
Chief Complaint: acute pain in the right elbow after a
slip and fall
Past Medical History: no major illnesses or medical
conditions. *Patient does have a history of 3‐4 visits to
urgent care clinic system for alleged injuries or pain
symptoms, whereupon she received opiate pain killers.
Case Study
Past Surgical History: appendectomy (1 year ago), right
knee arthroscopy (15 years ago)
Allergies: PCN
Current Medications: none
Social History: married; 2 children; employed; non‐smoker
Physical Exam:
T: 98.7°C RR: 24
HR: 114 BP: 130/85
Case Study
General: no acute distress; no evidence of intoxication;
no objective evidence of being in acute pain
Right elbow: no visible signs of trauma or disease in the
elbow; the elbow is stable without evidence of
ligamentous disruption; no evidence for blood in the
joint or boney injury; patient claims diffuse tenderness
to palpation in all areas of her elbow.
X‐Rays: normal
Case Study Data from the Oklahoma Prescription
Monitoring Program
Date Medication/Strength Quantity
3/3/2008Soma 350mg #40
3/7 Lortab 10mg #42
Date Medication/Strength Quantity
5/9 Soma 350mg #60
5/11 Midrin #40
3/12 Soma 350mg #60
3/14 Lortab 7.5mg #20
3/21 Lortab 10mg #20
3/ 22 Tylenol w/ Codeine #40
5/21 Lortab 10mg #60
5/23 Soma 350mg #60
5/28 Lortab 7.5mg #30
y / 4 6/1 Lortab 5mg
3/24 Tylenol w/ codeine #40
3/25 Lortab 10mg #42
3/27 Soma 350mg #60
4/8 Lortab 10mg #42
/ 5 g
#20
6/5 Lortab 10mg* #60
6/ 6 Soma 350mg* #60
6/ 6 Lortab 5mg* #20
4/14 Soma 350mg #60 6/ L b
4/18 Lortab 10mg #42
4/28 Lortab 10mg #42
4/28 Soma 350mg #60
/ Mid i #
12 Lortab 7.5 #30
6/14 Lortab 5mg #40
6/16 Lortab 5mg #15
6/17 Lortab 10mg #60
5/2 Midrin 40 6/20 Soma 350mg #60
5/2 Lortab 5mg #30
5/6 Lortab 10mg #60
6/25 Lortab 7.5mg #30
6/30 Xanax #5
Case Study Data from the Oklahoma Prescription
Monitoring Program
Date Medication/Strength Quantity
7/1 Midrin #30
Date Medication/Strength Quantity
8/3 Tylox 5mg #30
7/3 Lortab 10mg* #60
7/3 Lortab 10mg* #60
7/8 Lortab 7.5mg #30
7/10 Soma 350mg #60
8/6 Tylox 5mg #20
8/9 Darvocet N-100 #20
8/14 Lortab 10mg #30
8/15 Lortab 10mg #60
7/10 Lortab 10mg #60
7/15 Lortab 10mg #60
7/17 Lortab 10mg #30
7/18 Lortab 10mg #30
8/15 Soma 350mg #60
8/18 Lortab 5mg #20
8/19 Lortab 7.5mg #30
8/21 Soma #60
7/19 Lortab 5mg #20
7/21 Lortab 10mg #60
7/23 Lortab 7.5mg #40
7/24 Soma 350mg #60
/
8/21 Lortab 10mg #30
8/25 Lortab 7.5mg #30
8/27 Lortab 5mg #30
9/1 Lortab 7.5mg #18
7/25 Lortab 7.5mg #40
7/28 Lortab 10mg #60
7/31 Tylox #20
9/8 Lortab 7.5mg #60
9/ 12 Tylox 5mg #20
9/17 Lortab 7.5mg #120
Case Study Data from the Oklahoma Prescription
Monitoring Program
Date Medication/Strength Quantity
9/26 Soma 350mg* #30
Date Medication/Strength Quantity
1/12/2009 Morphine Sulfate 15mg #90
1/12 Ambien #30
9/26 Lortab 10mg* #15
9/26 Lortab 10mg* #60
10/3 Lortab 10mg #30
10/10 Lortab 10mg #60
10/23 Lortab 10mg #30
11/4 Lortab 10mg #30
11/12 Lortab 10mg #30
11/21 Lortab 10mg #30
11/ 22 Lortab 7.5mg #20
11/24 Talwin #15
11/25 Lortab 10mg #60
12/5 Ambien #30
12/8 Lortab 10mg #60
12/22 Lortab 10mg #60
12/ 31 Lortab 10mg #60
Case Study Total in 10 months:
77 Prescriptions
3,488 pills
▫ Physician #1 (32 prescriptions; 1,575 pills)
▫ Physician #2 (10 prescriptions; 440 pills)
▫ Physician #3 (9 prescriptions; 390 pills)
▫ 17 other physicians/PAs (26 prescriptions; 1,083 pills)
Summary
National epidemic of prescription drug abuse
Most obtained from friends/relatives
Oklahoma “leading” the nation
Prescription opioids
Particularly methadone; Oxycodone and hydrocodone growing fastest
Middle‐aged adults; White males
Females catching up
Poly‐substance ingestion
Lack of public awareness of dangers of mixing multiple drugs/alcohol/illicits
Opportunities for prevention; Requires strategies driven by data
Prevention plan will require interagency collaboration
References
WISQARS. Fatal injury report. 2007, United States Unintentional Poisoning Deaths and Rates per
100,000 All Races, Both Sexes, All Ages ICD-10 Codes: X40-X49. Queried 1 Sept, 2010.
CDC. Emergency Department visits involving nonmedical use of selected prescription drugs – United
States, 2004-2008. MMWR 59(23);705-709. Available at
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5923a1.htm
Paulozzi LJ, et al. Increasing deaths from opioid analgesics in the United States.
Pharmacoepidemiology and Drug Safety, 2006; 15: 618-627.
Warner M, et al. Increase in fatal poisonings involving opioid analgesics in the United States, 1999-
2006. NCHS data brief, no 22. Hyattsville, MD: National Center for Health Statistics. 2009.
Available at http://www.cdc.gov/nchs/data/databriefs/db22.htm
Piercefield E, et al. Increase in Unintentional Medication Overdose Deaths — Oklahoma, 1994–2006.
Am J PrevMed. 2010 Oct;39(4):357-63.
Boscarino JA, et al. Risk factors for drug dependence among out-patients on opioid therapy in a large
US health-care system. Addiction 2010;
Washington State Interagency Guideline for Opioid Dosing for Chronic Non-cancer Pain – an
education aid to improve care and safety with opioid therapy. 2010 Update. Available at
www.bt.cdc.gov/coca/pdf/OpioidGdline.pdf
C.A.R.E.S. Alliance. Accessed 10 September, 2010. www.caresalliance.org.

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Okla State Agency	Mental Health and Substance Abuse Services, Oklahoma Department of
Okla Agency Code	'452'
Title	Prescription drug abuse in Oklahoma : state of Oklahoma House of Representatives interim study 11-056.
Alternative title	Rx drug abuse in Oklahoma
Authors	Hawkins, Jessica. Langthorn, Liz. Oklahoma. Department of Mental Health and Substance Abuse Services. Oklahoma. State Department of Health. Oklahoma. Legislature. House of Representatives.
Publisher	Oklahoma Department of Mental Health and Substance Abuse Services
Publication Date	2011-09-14
Publication type	Research Report/Study Report to Governor or Legislature
Subject	Medication abuse--Oklahoma.
Purpose	Better Prescribing and Reporting Methods for Pain Management Physicians/Pharmacists - strengthening physician-pharmacist communication with families, respecting HIPAA. Oklahoma now ranks near the top in the dispensing of highly addictive prescription drugs by its licensed physicians.; The study will also look at what other methods might be developed for strengthening one-way ‘HIPAA sensitive’ communications between the family members of those involved in prescription drug abuse and dispensing physicians and pharmacists for the discovery of additional possible means of reporting.--H of R website
Contents	State's Prevention Prioritization; National Prevention Strategy; U.S. Unintentional Poisoning Deaths by Year and Poison Type, 1999-2006; Prescription Drug Source; Unintentional Medication Overdose Death Rates - U.S. and Oklahoma, 1999-2005; Unintentional Medication Overdose Deaths by Year - Oklahoma, 1994-2006; Unintentional Drug Overdose Death Rates and Total Sales of Prescription Opioid Painkillers by Year in Oklahoma, 1994-2006; Medication Overdose Deaths by Age Group; Medication Overdose Death Rates by County [map]; Overdose Deaths from Illicit Drugs vs. Prescription Drugs; Substance Involved in Unintentional Medication Overdose Deaths; Case Study; Case Study Data from the Oklahoma Prescription Monitoring Program; Case Study Total in 10 months; Summary; References
Notes	originally a Powerpoint presentation
OkDocs Class#	M1400.8 P933d 2011
Digital Format	PDF, Adobe Reader required
ODL electronic copy	Downloaded from agency website: www.ok.gov/.../Rx_Drug_Abuse_in_OK_-_Interim_Study_11-056_09.14.11[1].pdf
Rights and Permissions	This Oklahoma state government publication is provided for educational purposes under U.S. copyright law. Other usage requires permission of copyright holders.
Language	English
Full text	Prescription Drug Abuse in Oklahoma State of Oklahoma House of Representatives Interim Study 11‐056 September 14, 2011 Liz Langthorn, MPH I j P ti S i Jessica Hawkins Pre ention Ser ices Injury Prevention Service OK State Dept. of Health Prevention Services OK Dept. of Mental Health and Substance Abuse Services State’s Prevention Prioritization • The ODMHSAS State Epidemiology Workgroup gathered all available, valid data • Analysis revealed highest consumption and consequence patterns with: 1. Alcohol use among youth under age 21 2. Nonmedical use of prescription drugs State’s Prevention Prioritization • Oklahoma ranks #1 nationally for the nonmedical use of pain relievers in the past p year for all age categories (NSDUH) • Nearly 22% of Oklahoma 12th graders had used prescription drugs without a doctor telling them to do so once or more in their lifetime ‐ 9.6% had done so in the past 30 days (2010 OPNA) • Oklahoma is over one and a half times the national average in the nonmedical use of prescription pain relievers in the past month among persons aged 12 and older (NSDUH) National Prevention Strategy • Practitioner training on opiod prescribing • Clinical guidelines; Patient-provider agreements • Public media/education campaigns Education • Abuse deterrent formulation • Consistent, utilized PMP databases Monitoring • Increase Screening and Brief Intervention • Collect and share data • Drug take back programs bli d i f di l Disposal • Public education on safe disposal •Aggressive enforcement activities; Increased regulation Enforcement •Law enforcement training •Utilize PMPs for patient and provider problems U.S. Unintentional Poisoning Deaths by Year and Poison Type, 1999–2006 Prescription Drug Source 72% from friend or relative 60% free 8% purchased 4% taken without permission 17% prescription from doctor 4% bought from drug dealer Other sources: Theft, internet, forgery Unintentional Medication Overdose Death Rates — U.S. and Oklahoma, 1999–2005 12 8 10 eath rate 4 6 djusted de United States Oklahoma 0 2 1999 2000 2001 2002 2003 2004 2005 Age-ad Year Unintentional Medication Overdose Deaths by Year- Oklahoma, 1994-2006 450 300 350 400 deaths 200 250 mber of d 50 100 150 Num 0 1994 1996 1998 2000 2002 2004 2006 Unintentional Drug Overdose Death Rates and Total Sales of Prescription Opioid Painkillers by Year in 12. ns Oklahoma, 1994–2006 700 900 8 10 erson 00 person 500 6 old per pe per 100,00. Deaths/100,000 Opioid sales 300 2 4 ligrams so eath rate p (mg/person) 0 100 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 Mill De Medication Overdose Deaths by Age Group 250 150 200 ths 100 er of deat 0-19 20-39 40 59 50 Numbe 40-60+ 0 1994 1996 1998 2000 2002 2004 2006 Medication Overdose Death Rates by County Cimarron Texas Beaver Harper W d d Woods Alfalfa Grant Kay Osage Ottawa Washington Rogers Nowata Craig Ellis Roger Mills Woodward Major Dewey Blaine Garfield Kingfisher Noble Payne Logan Pawnee Creek Lincoln Muskogee Tulsa Wagoner Cherokee Adair Mayes Delaware Beckham Custer Washita Greer Kiowa Caddo Canadian Oklahoma Cleveland Grady Hughes Okfuskee Pittsburg McIntosh Latimer Haskell Sequoyah g Okmulgee Potta- Seminole watomie McClain Jackson Tillman Comanche Cotton Stephens Jefferson Garvin Carter Murray Pontotoc Johnston Coal Atoka g Pushmataha Le Flore 50+% Above State Rate Harmon 10-49% Above State Rate At to 50% Below State Rate > 50% Below State Rate Love Bryan Choctaw McCurtain Marshall n=2161 No Deaths Overdose Deaths from Illicit Drugs vs. Prescription Drugs Substance Involved in Unintentional Medication Overdose Deaths Substance Pos. Tests (%) Substance Pos. Tests (%) Methadone 653 (Diazepam 94 (17) 2) Hydrocodone 407 (11) Amitriptyline 87 (2) Alprazolam 320 (8) Cocaine 85 (2) Oxycodone 311 (8) Acetaminophen 76 (2) Morphine 263 (7) Cyclobenzaprine 74 (2) Alcohol 260 (7) Methamphetamine 72 (2) Propoxyphene 140 (4) Olanzapine 37 (1) Fentanyl 124 (3) Codeine 34 (1) Carisoprodol 97 (2) Other medication 609 (16) Case Study Patient: 30 year old female Chief Complaint: acute pain in the right elbow after a slip and fall Past Medical History: no major illnesses or medical conditions. Patient does have a history of 3‐4 visits to urgent care clinic system for alleged injuries or pain symptoms, whereupon she received opiate pain killers. Case Study Past Surgical History: appendectomy (1 year ago), right knee arthroscopy (15 years ago) Allergies: PCN Current Medications: none Social History: married; 2 children; employed; non‐smoker Physical Exam: T: 98.7°C RR: 24 HR: 114 BP: 130/85 Case Study General: no acute distress; no evidence of intoxication; no objective evidence of being in acute pain Right elbow: no visible signs of trauma or disease in the elbow; the elbow is stable without evidence of ligamentous disruption; no evidence for blood in the joint or boney injury; patient claims diffuse tenderness to palpation in all areas of her elbow. X‐Rays: normal Case Study Data from the Oklahoma Prescription Monitoring Program Date Medication/Strength Quantity 3/3/2008Soma 350mg #40 3/7 Lortab 10mg #42 Date Medication/Strength Quantity 5/9 Soma 350mg #60 5/11 Midrin #40 3/12 Soma 350mg #60 3/14 Lortab 7.5mg #20 3/21 Lortab 10mg #20 3/ 22 Tylenol w/ Codeine #40 5/21 Lortab 10mg #60 5/23 Soma 350mg #60 5/28 Lortab 7.5mg #30 y / 4 6/1 Lortab 5mg 3/24 Tylenol w/ codeine #40 3/25 Lortab 10mg #42 3/27 Soma 350mg #60 4/8 Lortab 10mg #42 / 5 g #20 6/5 Lortab 10mg #60 6/ 6 Soma 350mg* #60 6/ 6 Lortab 5mg* #20 4/14 Soma 350mg #60 6/ L b 4/18 Lortab 10mg #42 4/28 Lortab 10mg #42 4/28 Soma 350mg #60 / Mid i # 12 Lortab 7.5 #30 6/14 Lortab 5mg #40 6/16 Lortab 5mg #15 6/17 Lortab 10mg #60 5/2 Midrin 40 6/20 Soma 350mg #60 5/2 Lortab 5mg #30 5/6 Lortab 10mg #60 6/25 Lortab 7.5mg #30 6/30 Xanax #5 Case Study Data from the Oklahoma Prescription Monitoring Program Date Medication/Strength Quantity 7/1 Midrin #30 Date Medication/Strength Quantity 8/3 Tylox 5mg #30 7/3 Lortab 10mg* #60 7/3 Lortab 10mg* #60 7/8 Lortab 7.5mg #30 7/10 Soma 350mg #60 8/6 Tylox 5mg #20 8/9 Darvocet N-100 #20 8/14 Lortab 10mg #30 8/15 Lortab 10mg #60 7/10 Lortab 10mg #60 7/15 Lortab 10mg #60 7/17 Lortab 10mg #30 7/18 Lortab 10mg #30 8/15 Soma 350mg #60 8/18 Lortab 5mg #20 8/19 Lortab 7.5mg #30 8/21 Soma #60 7/19 Lortab 5mg #20 7/21 Lortab 10mg #60 7/23 Lortab 7.5mg #40 7/24 Soma 350mg #60 / 8/21 Lortab 10mg #30 8/25 Lortab 7.5mg #30 8/27 Lortab 5mg #30 9/1 Lortab 7.5mg #18 7/25 Lortab 7.5mg #40 7/28 Lortab 10mg #60 7/31 Tylox #20 9/8 Lortab 7.5mg #60 9/ 12 Tylox 5mg #20 9/17 Lortab 7.5mg #120 Case Study Data from the Oklahoma Prescription Monitoring Program Date Medication/Strength Quantity 9/26 Soma 350mg* #30 Date Medication/Strength Quantity 1/12/2009 Morphine Sulfate 15mg #90 1/12 Ambien #30 9/26 Lortab 10mg* #15 9/26 Lortab 10mg* #60 10/3 Lortab 10mg #30 10/10 Lortab 10mg #60 10/23 Lortab 10mg #30 11/4 Lortab 10mg #30 11/12 Lortab 10mg #30 11/21 Lortab 10mg #30 11/ 22 Lortab 7.5mg #20 11/24 Talwin #15 11/25 Lortab 10mg #60 12/5 Ambien #30 12/8 Lortab 10mg #60 12/22 Lortab 10mg #60 12/ 31 Lortab 10mg #60 Case Study Total in 10 months: 77 Prescriptions 3,488 pills ▫ Physician #1 (32 prescriptions; 1,575 pills) ▫ Physician #2 (10 prescriptions; 440 pills) ▫ Physician #3 (9 prescriptions; 390 pills) ▫ 17 other physicians/PAs (26 prescriptions; 1,083 pills) Summary National epidemic of prescription drug abuse Most obtained from friends/relatives Oklahoma “leading” the nation Prescription opioids Particularly methadone; Oxycodone and hydrocodone growing fastest Middle‐aged adults; White males Females catching up Poly‐substance ingestion Lack of public awareness of dangers of mixing multiple drugs/alcohol/illicits Opportunities for prevention; Requires strategies driven by data Prevention plan will require interagency collaboration References WISQARS. Fatal injury report. 2007, United States Unintentional Poisoning Deaths and Rates per 100,000 All Races, Both Sexes, All Ages ICD-10 Codes: X40-X49. Queried 1 Sept, 2010. CDC. Emergency Department visits involving nonmedical use of selected prescription drugs – United States, 2004-2008. MMWR 59(23);705-709. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5923a1.htm Paulozzi LJ, et al. Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiology and Drug Safety, 2006; 15: 618-627. Warner M, et al. Increase in fatal poisonings involving opioid analgesics in the United States, 1999- 2006. NCHS data brief, no 22. Hyattsville, MD: National Center for Health Statistics. 2009. Available at http://www.cdc.gov/nchs/data/databriefs/db22.htm Piercefield E, et al. Increase in Unintentional Medication Overdose Deaths — Oklahoma, 1994–2006. Am J PrevMed. 2010 Oct;39(4):357-63. Boscarino JA, et al. Risk factors for drug dependence among out-patients on opioid therapy in a large US health-care system. Addiction 2010; Washington State Interagency Guideline for Opioid Dosing for Chronic Non-cancer Pain – an education aid to improve care and safety with opioid therapy. 2010 Update. Available at www.bt.cdc.gov/coca/pdf/OpioidGdline.pdf C.A.R.E.S. Alliance. Accessed 10 September, 2010. www.caresalliance.org.
Date created	2011-09-26
Date modified	2013-03-12

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