OTHER FEDERAL MEASURES

[Note:  This posting is a continuation of a report on the development of a civics unit of study.  This unit is directing students to formulate informed positions on the opioid epidemic.  It is being developed in real time.  Writer wants to express gratitude to Wikipedia for identifying the bulk of the research this blog has used in the development of this unit.[1]]

This blog is currently reviewing the various reactions by the federal government in relation to the opioid crisis.  This posting will continue this review by listing further factoids.  Here are those factoids:

·        In the last posting, Tom Marino was identified as being nominated by the Trump Administration to be the new “drug czar.”  This was disrupted, on October 17, 2017, when Marino withdrew his name for further consideration.  He cited the fact he had had a long-lasting relationship with the drug industry and this could be used to accuse him as having a conflict of interest.[2]

·        Scott Gottlieb, FDA commissioner, finally declared, in July 2017, that dispensing and prescribing agents – pharmacists, nurses, and doctors – were to have appropriate training in prescribing opioids.  The commissioner cited the epidemic problem and summarized his concern by classifying opioid addiction as the “FDA’s biggest crisis.”[3]

·        Also, as one could judge over-due, the Department of Health and Human Services (HHS), issued a strategy to meet the crisis.  Its “Opioid Strategy” identified five aims.  Here are those aims as stated by HHS:

-         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;

-         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;

-         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;

-         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

-         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.[4]

·        Using another approach, the FDA began to regulate the producers of long-acting opioids.  These businesses were required to provide educational programs so that prescribers would have the information to prevent off-label[5] and to prevent over-prescribing.  Despite this move, there does not seem to be sufficient evidence that this stated policy has been effective.[6]

·        The reported grant program (reported in the last posting), SAMHSA begins administrating it in July 2017.  It did this by issuing plans developed by the National Academy of Sciences.  In that report, the academy points out that 91 people die every day of the opioid addiction epidemic.[7]  Eventually in 2017, SAMHSA started issuing grants.  The whole program is set up for a two-year run and provides grants totaling $485 million to states and territories of the US.  As the authorizing legislation – the 21^st Century Cures Act – sets out, the aim of the grants is to prevent and combat opioid over-use and the resulting addiction.[8]

          That ends what this blog is prepared to report regarding the federal government’s reaction to the opioid crisis.  Next, the blog will address various countermeasures in the form of medical practices.

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[1] The writer also wants to state that where possible, he has checked the sources and has at times added to the listed research.

[2] Peter Baker, “Tom Marino, Drug Czar Nominee, Withdraws in Latest Setback for Trump’s Opioid Fight,” The New York Times, October 17, 2017, accessed August 16, 2018, https://www.nytimes.com/2017/10/17/us/politics/trump-says-drug-czar-nominee-tom-marino-withdraws-from-consideration.html?_r=0 AND Bill Whitaker (correspondent), “Ex-DEA Agent:  Opioid Crisis Fueled by Drug Industry and Congress,” CBS’ 60 Minutes, October 17, 2017, accessed August 16, 2018, https://www.cbsnews.com/news/ex-dea-agent-opioid-crisis-fueled-by-drug-industry-and-congress/ .

[3] “FDA’s Scott Gottlieb:  Opioid Addiction Is FDA’s Biggest Crisis Now,” CNBC, July 21, 2017, accessed August 16, 2018, https://www.cnbc.com/video/2017/07/21/fdas-scott-gottlieb-opioid-addiction-is-fdas-biggest-crisis-now.html .

[4] Nora Volkow (presenter), “Federal Efforts to Combat the Opioid Crisis:  A Status Update on CARA and Other Initiatives,” National Institute on Drug Abuse, October 25,2017, accessed August 16, 2018, https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2017/federal-efforts-to-combat-opioid-crisis-status-update-cara-other-initiatives .

[5] Google defines “off-label” as follows:  relating to the prescription of a drug for a condition other than that for which it has been officially approved.  See https://www.google.com/search?q=what+does+the+term+off-label+mean&oq=what+does+the+term+off-label+mean&aqs=chrome..69i57j0l5.13540j1j4&sourceid=chrome&ie=UTF-8 , accessed August 16, 2018.

[6] Andrew A. Kolodny, David T. Courtwright, Catherine S. Hwnag, Peter Kreener, John L. Eadie, Thomas W. Clark, and George Caleb Alexander, “The Prescription Opioid and Heroin Crisis:  A Public Health Approach to an Epidemic of Addiction,” Annual Review of Public Health, vol. 36, 559-574, 2015, accessed August 16, 2018, https://www.annualreviews.org/doi/10.1146/annurev-publhealth-031914-122957 .

[7] Dina Fine Maron, “Major Science Report Lays Out a Plan to Tamp Down Opioid Crisis,” Scientific American, July 13, 2017, accessed August 16, 2018, https://www.scientificamerican.com/article/major-science-report-lays-out-a-plan-to-tamp-down-opioid-crisis/ .

[8] Nora Volkow (presenter), “Federal Efforts to Combat the Opioid Crisis:  A Status Update on CARA and Other Initiatives.”

INITIAL FEDERAL REACTIONS

[Note:  This posting is a continuation of a report on the development of a civics unit of study.  This unit is directing students to formulate informed positions on the opioid epidemic.  It is being developed in real time.  Writer wants to express gratitude to Wikipedia for identifying the bulk of the research this blog has used in the development of this unit.[1]]

Another aspect of the opioid crisis is how the federal government has reacted to it.  This posting highlights that reaction by reporting lists of factoids and insights that convey that governmental activity.  That governmental reaction seems to have begun in 2010.

Factoids:

·        In 2010 the federal government began implementing a policing policy by subjecting pharmacists and doctors, found to be over-prescribing opioids supposedly to patients suffering from pain, appropriate oversight.[2]

·        Legislation was enacted in 2010 that permitted pharmacies to accept controlled drugs from households and long-term care facilities as a “take-back” effort.  The legislation was an amendment to the existing law, Controlled Substance Law, and named the Secure and Responsible Drug Disposal Act.[3]

·        Under the Obama Administration, a white paper was issued in 2011.  It reviewed the administration’s strategy to confront the epidemic.  Picking up this information, a number of medical and government advisory groups from other countries began to echo this plan.[4]

·        In 2016, President Barack Obama signed legislation which greatly increased addiction treatment for those who have over-used opioids.  Included were authorization to spend millions of federal dollars on research and treatment especially using buprenorphine which has been found to reduce cravings for the opioid drugs.  That legislation is entitled the Comprehensive Addiction and Recovery Act.[5]

·        Unfortunately, another law enacted in 2016, Ensuring Patient Access and Effective Drug Enforcement Act, is thought to have decreased the ability of the DEA to use its resources in meeting the crisis.[6] 

·        Yet another piece of legislation, that same year of 2016, the 21^st Century Cures Act, was enacted.  It called for spending a billion dollars in state grants.  State governments were to spend that money to fight the epidemic.  This law was passed with overwhelming, bipartisan support both in the Senate and in the House of Representatives.[7]

·        The new administration under President Trump instituted a number of steps to address the crisis.  The President first named the New Jersey Governor, Chris Christie, to head a commission to study the epidemic;[8] he then, as a result of the commission’s report, nominated Tom Marino to be director of the Office of National Drug Control Policy (popularly known as the “drug czar”).[9]  In all, the Trump administration has labelled the epidemic a “national emergency.”[10]

Insights:

·        Federal government crackdown on over-prescribers led to an unintended consequence; addicted users, having more difficulty obtaining prescriptions, turned to using heroin instead.  For example, one finding from Utah was that 80% of heroin users began their drug-taking with prescription drugs.[11]

·        Tom Marino, the nominated drug czar, attributes government’s reaction to the opioid crisis to the fact that typical users are mostly white and middle class – they are more apt to call a legislator and effectively complain to their insurance companies for more liberal coverage of drug treatment.  Apparently that segment of the population is more likely to know how to communicate their demands.[12]

The next posting will continue to report on the federal government’s reaction to the opioid epidemic.

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[1] The writer also wants to state that where possible, he has checked the sources and has at times added to the listed research.

[2] “America’s Opioid Epidemic Is Worsening,” Economist, March 6, 2017, accessed August 13, 2018, https://www.economist.com/graphic-detail/2017/03/06/americas-opioid-epidemic-is-worsening AND Christopher Caldwell, “American Carnage:  The New Landscape of Opioid Addiction,” First Things, April 2017, accessed August 13, 2018,  https://www.firstthings.com/article/2017/04/american-carnage , an excellent review article.

[3] “Secure and Responsible Drug Disposal Act of 2010,” Legislation Text:  Public Law 111-273-Oct. 12, 2010, Government Publishing Office, accessed August 13, 2018, https://www.gpo.gov/fdsys/pkg/PLAW-111publ273/pdf/PLAW-111publ273.pdf .

[4] “Tackling the Opioid Public Health Crisis,” Wayback Machine, June 7, 2016, cite no longer on-line AND “First Do No Harm:  Responding to Canada’s Prescription Drug Crisis,” National Advisory Council [of Canada] on Prescription Drug Misuse, March 2013, accessed by http://www.ccsa.ca/resource%20library/canada-strategy-prescription-drug-misuse-report-en.pdf AND “UK:  Task Force Offers Ideas for Opioid Addiction Solutions, Delhidailynews.com (DDN), June 11, 2014, accessed August 13, 2018, http://www.delhidailynews.com/news/UK--Task-Force-offers-ideas-for-opioid-addiction-solutions-1402491160/ .

[5] “Summary of the Comprehensive Addiction and Recovery Act,” American Society of Addiction Medicine, n. d., accessed August 13, 2018, https://www.asam.org/advocacy/issues/opioids/summary-of-the-comprehensive-addiction-and-recovery-act .

[6] Scott Higham and Lenny Bernstein, “How Congress Allied with Drug Company Lobbyists to Derail the DEA’s War on Opioids,” The Washington Post, October 15, 2017, https://www.washingtonpost.com/ .

[7] Mike DeBonis, “Congress Passes 21^st Century Cures Act:  Boosting Research and Easing Drug Approvals,” The Washington Post, December 7, 2016.

[8] Kelly O’Donnell, “Opioid Epidemic:  Trump to Set Up Commission on Addiction Crisis,” NBC News, March 29, 2017, accessed August 13, 2018, https://www.nbcnews.com/storyline/americas-heroin-epidemic/opioid-epidemic-trump-set-commission-addiction-crisis-sources-say-n739861 AND Newt Gingrich, Van Jones, and Patrick Kennedy, “It’s Time to ‘Trump’ Opioid Addiction in the United States,” The Hill, February 27, 2017, accessed August 13, 2018, http://thehill.com/blogs/pundits-blog/healthcare/321256-its-time-to-trump-opioid-addiction-in-the-united-states AND Tim Hains, “President Trump Hosts an Opioid and Drug Abuse Listening Session,” Real Clear Politics, March 29, 2017, accessed August 13, 2018, https://www.realclearpolitics.com/video/2017/03/29/president_trump_hosts_an_opioid_and_drug_abuse_listening_session.html .

[9] Cristiano Lima, “Trump to Tap Rep. Tom Marino as ‘Drug Czar,’” Politico, September 1, 2017, accessed August 13, 2018, https://www.politico.com/story/2017/09/01/trump-tom-marino-drug-czar-242277 .

[10] Christopher Ingraham, “White House Opioid Commission to Trump:  ‘Declare a National Emergency’ on Drug Overdoses,” The Washington Post, July 31, 2017 AND Joel Achenbach, John Wagner, and Lenny Bernstein, The Washington Post, August 10, 2017, https://www.washingtonpost.com/politics/trump-declares-opioid-crisis-is-a-national-emergency-pledges-more-money-and-attention/2017/08/10/5aaaae32-7dfe-11e7-83c7-5bd5460f0d7e_story.html?utm_term=.8026b824f0b6 .

[11] Alex Stuckey, “Poll:  Many Utahns Know People Who Seek Treatment for Opioid Addictin, but Barriers Remain,” The Salt Lake Tribune, April 3, 2017, accessed August 13, 2018, http://archive.sltrib.com/article.php?id=5110951&itype=CMSID .

[12] Katharine Q. Seelye, In Heroin Crisis, White Families Seek Gentler War on Drugs,” The New York Times, October 30, 2015, https://www.nytimes.com/2015/10/31/us/heroin-war-on-drugs-parents.html .

OTHER STATE REACTIONS

[Note:  This posting is a continuation of a report on the development of a civics unit of study.  This unit is directing students to formulate informed positions on the opioid epidemic.  It is being developed in real time.  Writer wants to express gratitude to Wikipedia for identifying the bulk of the research this blog has used in the development of this unit.[1]]

As already reported there have been trans-state efforts to meet the opioid crisis.  Another such effort was initiated in early 2018.  A number of senators wrote a letter to President Trump expressing their concern that the president was not giving the epidemic enough attention.  The letter charged that the White House Office of Nation Drug Control Policy (ONDCP) has shown a lack of oversight in the nation’s coordination of policy to meet the fentanyl, heroin, opioid epidemic.

          Among the evidence the letter cites is the fact that there has not been in both the ONDCP and the DEA a permanent, confirmed leadership since the Trump administration has taken office.  This is due to the fact the Administration has not submitted qualified candidates for those positions.  The letter obviously asked for such candidates to be submitted not only for those two agencies but for the Department of Justice, the Substance Abuse and Mental Health Services Administration (SAMHSA), and other positions.[2]

          There is some good news associated with state efforts.  According to targeted research,[3] life-saving use of a new treatment, Buprenorphine, are being used in state efforts.  The comparison research has shown that increased use of this treatment has lowered death rates among opioid addicts.  This was determined by comparing the efforts of various states.

          In terms of this treatment, there is also the case study of France.  There, Buprenorphine, which has been part of the established treatment for opioid addiction for decades, has lowered the death rate due to opioid by 79% over a four-year period.  Today, 64% of opioid user in France use this drug to curb cravings and, consequently, reduce overdosing.[4]

          This ends this review of state/local efforts.  This unit of study should emphasize local efforts and the information in this and the previous posting is meant to get student efforts started.  Generally, the judgement here is that states and local authorities have not been energetic enough.  As a reminder, over 42,000 people die every year due to this epidemic; that’s 116 a day.  Next topic in this blog will be federal government efforts in addressing this tragic epidemic.

[P.S.:  Update on some previously reported factoids and insights: 

·        Purdue Pharma was aware of the addictive qualities of opioid drugs well before this quality was generally known.[5]

·        The pharmaceutical industry spent around $46 million in marketing opioids in mainly payments to doctors.  This payed off in ensuing years as the industry enjoyed profits of $14.7 billion due to the selling of these drugs.[6]

·        Early use of the opioids, beyond their then primary use in treating terminal patients, began in injury prone areas of the nation where agriculture and coal mining are chief employment avenues.][7]

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[1] The writer also wants to state that where possible, he has checked the sources and has at times added to the listed research.

[2] The letter was signed by Senators Maggie W. Hassen, Edward Markey, Dianne Feinstein, Sheldon Whitehouse, Richard Blumenthal, Catherine Cortez Masto, Sherod Brown, Jeanne Shaheen, Tammy Balwin, and Elizabeth Warren and dated January 17,2018.

[3] German Lopez, “The States Taking the Opioid Epidemic Seriously (and Not), in One Map,” Vox, February 22, 2018, accessed August 9, 2018, https://www.vox.com/policy-and-politics/2018/2/22/17037346/opioid-epidemic-state-policy-map .  The research was conducted by Avalere Health.

[4] “This Opioid Addiction Treatment Helped France Combat Its Own Epidemic,” NBC Nightly News with Lester Holt, posted on Facebook July 25, 2018, accessed August 10, 2018, https://www.facebook.com/nbcnightlynews/videos/this-opioid-addiction-treatment-helped-france-combat-its-own-epidemic/10156761894368689/ .

[5] MSNBC Live with Velshi and Ruhle, August 9, 2018.  The portion of the broadcast dedicated to this topic consisted mostly of an interview with author, Beth Macy, as she spoke of her recently published book, Dopesick:  Dealers, Doctors, and the Drug Company that Addicted America (August 2018).

[6] Ibid.

[7] Ibid.

STATES REACT TO OPIOID CRISIS

[Note:  This posting is a continuation of a report on the development of a civics unit of study.  This unit is directing students to formulate informed positions on the opioid epidemic.  Writer wants to express gratitude to Wikipedia for identifying the bulk of the research this blog has used in the development of this unit.[1]]

After sharing a short history and a list of factoids and insights regarding the opioid crisis/epidemic, this blog will now report on how government has reacted to the challenge opioids represent.  In true federalist fashion, this review will begin with a look at what the state governments have done.

          The main reaction has been legislation to block those prescribing protocols that have led to “high-risk” prescribing practices.  For example, there are now laws against doctors and clinics from prescribing the drug on long-term bases.  Summarily, there have been four categories of laws:

·        Laws mandating that those receiving prescriptions sign-up to a database record known as the Prescription Drug Monitoring Program (PDMP).  This is a statewide record and it includes the names of all patients who are being prescribed “controlled substance” drugs.

·        Laws mandating that anytime a prescriber – doctor or clinic worker – is about to prescribe an opioid, he/she is to check the PDMP.

·        Laws limiting the amount and duration over which these drugs can be prescribed.

·        Regulation laws that establish the necessity to monitor clinics – some known as “pill mills” – to drastically decrease the number of opioid prescriptions they issue.  This is particularly aiming at non-medical prescriptions.[2]

These developments should be added to the short history of the crisis already reported in this blog.

          As for factoids, the following is offered:

·        Governors of 45 states and 3 territorial governors organized themselves, in July 2016, to draw up an agreement, “Compact to Fight Opioid Addiction.”  The compact calls on the governors to coordinate their actions to help end the crisis.  This includes policies to address both governmental and private activities and protocols.  Special attention should be given to how the compact focuses on opioid producers and doctors.[3]

·        After the state of Maryland experienced about 2,000 deaths from opioid overdoses in 2016, the governor declared, in March 2017, a state of emergency.  Practically, that declaration meant coordination between state authorities and those of local jurisdictions.[4]

·        Other states that have introduced and/or enacted legislation to fight the opioid crisis have been Deleware,[5] Michigan, including instituting the Michigan Automated Prescription System (MAPS) which mirrored the efforts of PDMP,[6] Maine,[7] Utah,[8] West Virginia,[9] and Washington.[10]  Of special note, Texas officials are focusing their efforts on pill mills,[11] and Washington filed suit, in 2017, against Purdue Pharma for related negligence in their marketing activities associated with opioids.[12]

·        Another special case is that of Arizona.  There, early in 2018, Governor Doug Ducey signed into law the Arizona Opioid Epidemic Act.  This act makes available $10 million to treat those who have been victimized by the ill effects of the drug.  It also limits patients, with exemptions, to five-dose-prescriptions.[13]

As for generalizations, there seems to be two:

·        State governments have been moved to act, including the legislating of laws, by the numbers of overdoses, deaths, and costs their citizens have suffered because of the increased prescribing and consumption of opioid drugs.  Illustrative example is that of Arizona that suffered in the Phoenix area 3,114 overdoses from mid-June 2017 to the end of January 2018.  That situation led to the enactment of the Arizona Opioid Epidemic Act (see above).[14]

·        State action has seemed to have positive effects on controlling the prescribing of opioids as exemplified by both Florida (previously noted in this blog) and Texas.[15]

Next posting will pickup this review of state actions.

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[1] The writer also wants to state that where possible, he has checked the sources and has at times added to the listed research.

[2]  Emma E. McGinty, Elizabeth A. Stuart, Alexander G. Caleb, Colleen L. Barry, Mark C. Bicket, and Lainie Rutkow, “Protocol:  Mixed-Methods Study to Evaluate Implementation, Enforcement, and Outcomes of U. S. State Laws Intended to Curb High-Risk Opioid Prescribing,” Implementation Science, vol. 13, no. 1, accessed August 6, 2018, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5828404/ .

[3] “A Compact to Fight Opioid Addiction,” National Governors Association, July 13, 2016, cite no longer on-line AND Gale Pryor, “6 Ways States Are Fighting the Opioid Epidemic,” Athenainsight, May 19, 2017, accessed August 6, 2018, https://www.athenahealth.com/insight/6-ways-states-are-fighting-opioid-epidemic .

[4]  “Hogan-Rutherford Administration Declares State of Emergency, Announces Major Funding to Combat Heroin and Opioid Crisis in Maryland,” Office of Governor Larry Hogan, March 1, 2017, accessed August 6, 2018, http://governor.maryland.gov/2017/03/01/hogan-rutherford-administration-declares-state-of-emergency-announces-major-funding-to-combat-heroin-and-opioid-crisis-in-maryland/ AND Bill Turque, “Maryland Governor Declares State of Emergency for Opioid Crisis, The Washington Post, March 1, 2017, accessed August 6, 2018, https://www.washingtonpost.com/local/md-politics/hogan-declares-opioid-state-of-emergency/2017/03/01/5c22fcfa-fe2f-11e6-99b4-9e613afeb09f_story.html?utm_term=.b47c113320ff AND Pat Warren, “Gov. Hogan Announces Opioid Epidemic State of Emergency,” March 1, 2017, accessed August 6, 2018, https://baltimore.cbslocal.com/2017/03/01/gov-hogan-announces-opioid-epidemic-state-of-emergency/ .

[5]  “Delaware Lawmakers Tackle Opioid Addiction Epidemic,” March 23, 2017, accessed August 6, 2018, https://web.archive.org/web/20170324175427/http://www.newsworks.org/index.php/local/item/102456-delaware-lawmakers-tackle-opioid-addiction-epidemic?_topstory .

[6]  “Governor Snyder Rolls Out Plan to Fight Opioid Addiction,” WILX News, March 23, 2017, accessed August 6, 2018, http://www.wilx.com/content/news/Governor-Snyder-rolls-out-plan-to-fight-opioid-addiction-416981693.html AND Rick Pluta, “Snyder:  Efforts to Stop Opioid Abuse Aren’t Working,” BBC World Service, March 23, 2017, accessed August 6, 2018, http://www.michiganradio.org/post/snyder-efforts-stop-opioid-abuse-aren-t-working .

[7] Christopher Caldwell, “American Carnage:  The Landscape of Opioid Addiction,” First Things, April 2017, accessed June 18, 2018, https://www.firstthings.com/article/2017/04/american-carnage .

[8] “H. B. 299 Substance Abuse and Mental Health Act Amendments – Bill Text,” n. d., accessed August 7, 2018, https://le.utah.gov/~2017/bills/static/HB0299.html AND Alex Stuckey, “Poll:  Many Utahns Know People Who Seek Treatment for Opioid Addiction, but Barriers Remain,” The Salt Lake Tribune, April, 2017, accessed August 7, 2018. http://archive.sltrib.com/article.php?id=5110951&itype=CMSID .

[9] Scott Higham and Lenny Bernstein, “Opioid Distributors Sued by West Virginia Counties Hit by Drug Crisis,” March 9, 2017, accessed August 7, 2018, https://www.washingtonpost.com/national/health-science/lawsuits-filed-against-drug-distributors-in-west-virginia/2017/03/09/f9e3165e-0501-11e7-b1e9-a05d3c21f7cf_story.html?utm_term=.d34bb4da534a AND Ailsa Chang, “Lawyer behind West Virginia County Lawsuit against Opioid Distributors,” NPR, April 20,2017, accessed August 7, 2018, https://www.npr.org/2017/04/20/524936058/lawyer-behind-west-virginia-county-lawsuit-against-opioid-distributors .

[10]  Note:  this refers to a lawsuit filed by a city, Everett, Washington.  See “U. S. City Sues OxyContin Maker for Contribution to Opioid Crisis,” NPR, February 3, 2017, accessed August 7, 2018,   https://www.npr.org/2017/02/03/513196772/u-s-city-sues-oxycontin-maker-for-contributing-to-opiod-crisis .

[11] Tatyana Lyapustina, Lainie Rutkow, Hsien-Yen Chang, Matthew Daubresse, Alim F. Ramji, Mark Faul, Elizabeth A Stuart, and G. Caleb Alexander, “Effect of a “Pill Mill” Law on Opioid Prescribing and Utilization:  The Case of Texas,” PMC/US National Library of Medicine/National Institutes of Health, 2016, accessed August 7, 2018, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4976392/ .

[12] “U. S. City Sues OxyContin Maker for Contribution to Opioid Crisis,” NPR.

[13] Joan Magtibay, “Ducey Signs Sweeping Law to Confront Arizona Opioid Crisis,” Cronkite News, January 26,2018, accessed August 7, 2018, https://cronkitenews.azpbs.org/2018/01/26/ducey-signs-sweeping-plan-confront-arizona-opioid-crisis-law/ .

[14] Ibid.

[15] Tatyana Lyapustina, Lainie Rutkow, Hsien-Yen Chang, Matthew Daubresse, Alim F. Ramji, Mark Faul, Elizabeth A Stuart, and G. Caleb Alexander, “Effect of a “Pill Mill” Law on Opioid Prescribing and Utilization:  The Case of Texas.”