Tag Archives: opioid overdose

“Cruel and Unusual” Neglect in Prisons

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

HEAL Blog has long been banging the drum of patient healthcare access in incarcerated populations. Under Estelle v. Gamble (1976), the U.S. Supreme Court found that denying medical treatment is unconstitutional under the 8th Amendment’s “cruel and unusual punishment” clause, and established the criteria under which prisoners must file suit – “deliberate indifferent.” This essentially means that, if a patient needs medical attention, this cannot be denied, and that, if medical staff deems treatment necessary and orders it, that order must be honored, and that treatment order cannot be countermanded. Additionally, neither security staff, nor internal bureaucracies can hinder said treatment order in any way, and treatment decisions must be made based on medical need, rather than on convenience or the needs for security (Schoenly, n.d.). Estelle v. Gamble basically made inmates the only Americans for whom healthcare is a Constitutional right.

Gavel next to stethoscope

Photo Source: CorrectionalNurse.net

This argument has been successfully made as it relates to HIV, and more recently Hepatitis C (HCV), as numerous courts have ruled in favor of plaintiffs for whom HCV treatment has been denied. Courts have repeatedly rule that, regardless of the costs associated with treatment, prisons are required by the Constitution to provide Direct-Acting Antiviral (DAA) HCV drugs to inmates. Unfortunately for the states, this has the potential to explode correctional pharmacy budgets – a valid concern that, nonetheless, runs counter to case law. In order to avoid having to pay for treatment, many prisons actively avoid the Federally mandated HIV/HCV screenings required in Federal prisons by making state-level inmate screening “on request.”

When conducting research on state screening requirements, an official from the Kentucky Department of Corrections (KDOC) informed me that the state does NOT require inmates to be screened for either HIV or HCV during the intake process or on a regular basis. This is troubling, as Kentucky has the 3rd highest rate of HCV in the U.S. – 2.7 per 100,000 (Centers for Disease Control and Prevention, 2017). Kentucky also has the 10th highest rate of Opioid Overdose Deaths, having seen a 12% increase to a rate of 23.6 per 100,000 in 2016 (Kaiser Family Foundation, 2017).

Many, if not most, of those opioid drug-related death are a result of Injection Drug Use (IDU), the leading cause of new HCV infections in the U.S. With the high rate of arrest for illicit prescription opioid and heroin IDU comes a marked increase in the number of inmates living with HIV and HCV acquired via IDU. Incarceration settings are, perhaps, the best location for the U.S. to begin actively eradicating the HCV epidemic, but cost concerns make that an unlikely occurrence. Further complicating the issue is that prisons, jails, and youth correctional facilities do not have the same price bargaining powers enjoyed by Medicaid, Ryan White (AIDS Drug Assistance Programs – ADAP), and private insurers, meaning that prisons often pay the highest prices for HCV DAAs and other prescription drugs. This must change, if the U.S. hopes to adequately approach eradicating HCV.

Next week, HEAL Blog will take a look at some recent HCV-related issues in the U.S. correctional system.

References:

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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Voluntary Involuntary Opioid Abuse Treatment

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

Kicking an opioid drug abuse habit is one of the most difficult habits to break. So difficult is the prospect of quitting that reports are coming out of Massachusetts indicating that some people facing opioid-related drug charges are asking judges to lock them up – inside a treatment program center for 90 days from which they cannot leave.

These requests are in response to several issues, not the least of which include overcrowded treatment programs with long waitlists that reject patients whose insurance will not adequately compensate the cost of inpatient treatment, often the only way to ensure that those undergoing treatment cannot gain access to heroin or other opioid drugs while attempting to detox. In 2016, roughly 8,000 people will be committed to substance abuse treatment in MA, up 40% from five years ago (Brown, 2016).

Technically, a patient cannot request their own involuntary committal; it requires a close relative, probation officer, or emergency room doctor (or other official) to petition the court on your behalf. If you agree not to oppose the petition, a judge is likely to approve the petition. If a judge agrees to the involuntary commitment, that’s a bed in an inpatient facility paid for by the state, rather than the patient or private insurance, and for a length of treatment longer than for which most insurance programs are willing to pay.

Vivitrol for Opiod Dependence

Photo Source: Vivitrol.com

Treatment prospects are much less diverse for those already incarcerated. The Federal government recently approved spending more than $23 million to fund treatment projects that include giving monthly injections of Vivitrol (Alkermes, Inc.) – a blocker that attaches to certain opioid receptors in the brain and blocks the pleasurable feelings associated with taking opioids (Alkermes, nd.b) – to inmates in an attempt to break the cycle of opioid addiction. Eight states (Arizona, Colorado, Illinois, North Carolina, Rhode Island, Vermont, Wisconsin, and Wyoming) are the recipients of these grants – $2.8 – $3 million over three years (Associated Press, 2016). Each of these states intends to utilize these services to patients in different ways, and at different points in their respective sentences.

In addition to these states, the West Virginia Division of Corrections (DOC) has started a pilot program where it offers an injection of Vivitrol to its soon-to-be-released inmates struggling with opioid addiction. WV, along with neighboring OH and KY, have been incredibly hard hit by opioid abuse. One drawback of this pilot program is that the DOC does not follow up on offenders after they have served their entire sentence, so no information is available on the recovery efforts of six of the participants. This creates a problem with the program, as there is no evidence of its efficacy outside of the incarceration or parole period (Holdren, 2016). Additionally, there are simply not enough treatment centers who provide Vivitrol injections in WV, and those that exist are inconveniently located to those located in some of the hardest hit counties and locations, requiring patients to make 1.5- to 3-hour roundtrips to treatment receive injections.

The primary issue with Vivitrol is the cost – between $1,000 and $1,300 per injection on a monthly basis (Johnson, 2016). For inmates enrolled in Medicaid, Vivitrol injections cost just $3 (in WV); those not on Medicaid must pay their insurance’s prescription fee or foot the entire $1,300 on their own. Alkermes does offer a Patient Assistance Program, which offers co-pay assistance up to $500 each month (Alkermes, n.d.a). Additionally, because the drug is relatively new, there is little evidence, yet, that use of Vivitrol proves effective in the long-term. What data there is, however, points to excellent results.

References

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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The Negative Impact of Opioid Drugs Upon Children and Young Adults

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

In early November 2016, a conference held at Xavier University in Ohio drawing hundreds of doctors, nurses, social workers, and addiction specialists began releasing shocking (though unsurprising) data related to the prescription opioid and heroin epidemic’s negative impact on children and teenagers. The findings indicate what many in healthcare already knew: we are at risk of creating a generation of children whose lives are fundamentally altered for the worse by addiction.

In the past few months, HEAL Blog has doggedly followed the unrelenting opioid-fueled devastation in the state of Ohio, and we have frequently brought to the fore the plight of children whose lives are have been put at risk due to their caretakers’ substance addiction and abuse. What we haven’t yet really covered has been the growing risk posed to children and teens whose access to opioids is made possible by their caretakers.

A study released in the Journal of the American Medical Association (JAMA) Pediatrics showed a 165% increase in opioid poisonings in children from 1997 to 2012 (Luthra, 2016). The rate of toddlers hospitalized more than doubled, and teens were found to be increasingly at risk of overdose (both intentional and unintentional) because they gained access to their parents’ prescription opioids without their knowledge. Both of these issues point to the need to better address overprescribing of opioid drugs, as well as to better stress the need for safer storage of prescription drugs.

Roughly 1 in 10 high school students admit to taking prescription opioid drugs for nonmedical reasons (McCabe, West, Boyd, 2013; Luthra, 2016), and roughly 40% say they got those drugs from their own prior prescriptions (Fortuna, Robbins, Caiola, Joynt, Halterman, 2016). This suggests that (1.) parents are not properly securing their own prescriptions and (2.) parents are not properly monitoring their children’s use and disposal of prescriptions. These suppositions raise questions about whether or not parents whose children or teens overdose should (or do) face negligence charges.

Prescribing guidelines continue to be tightened, as the U.S. Centers for Disease Control & Prevention (CDC) and the U.S. Food & Drug Administration (FDA) have both attempted to get physicians to limit prescriptions to shorter periods, and there is little evidence that imposing penalties upon people who fail to properly store or dispose of medications will have any appreciable impact on the adult behaviors. The concern, however, is whether or not those penalties will result in lower levels of abuse and poisoning on the part of children and teens.

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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Ohio’s Opioid Nightmare Continues

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

Yet again, Ohio’s drug users and first responders are being overwhelmed by heroin laced with a stronger opioid drugs. Seven fatal overdoses occurred in one day in Cleveland on Saturday, September 24 (Kaufman, 2016). The following Tuesday saw 27 heroin overdoses in a 24-hour period in Columbus, including two fatalities. One patient had been released from the hospital after being treated for an earlier overdose just thirty minutes prior to being picked up for a second overdose; there were two such overdose victims that first responders treated twice in the same day for being overdosed (Sullivan, 2016).

With the introduction of the powerful opioids, fentanyl and carfentanil, not only those who are addicted to prescription opioid drugs and heroin face increased risks; first responders, emergency personnel, and law enforcement officers also face increased risks of being sickened by exposure to these drugs during raids and rescue situations. So great are the risks to first responders and SWAT teams that the Drug Enforcement Agency (DEA) released a warning about the dangers of handling these powerful opioids without extreme caution (Jones, 2016).

All over the state of Ohio, first responders and crime labs are taxed to the breaking point responding to opioid and heroin overdoses. Jamie Landrum, a Cincinnati police officer, is quoted: “We were literally going from one heroin overdose, and then being on that one, and hearing someone come over [the radio] and say, ‘I have no more officers left,’” Landrum said. Three more people overdosed soon after that (Harper, 2016). At one overdose scene, a patient required at least four doses of Naloxone to be revived; after the fourth dose, he was still not responding.

Beyond the primary concerns of overdose is the reality that these drugs were never meant for use in humans, and therefore, has no human testing data from which to extrapolate even the most basic information: the lethal dose per kilogram of body weight, or how long carfentanil stays in someone’s system. This makes responding to overdoses more difficult.

Naloxone rescue kit

Photo Source: Yourblogondrugs.com

What this means for local, state, and Federal governments is more: more overdoses, more Naloxone, more time spent on each call, and ultimately more money in areas already strapped for resources. And while there’s great outcry for more resources, there seems to be little appetite for holding the pharmaceutical companies that produce these opioids financially liable for the havoc their products have wreaked upon the populace.

At this point, penalties and criminal charges have been largely reserved for prescribing physicians and individual pharmacists; holding anyone higher up the food chain responsible for the opioid epidemic has proven difficult, as the industry is very active in combating any efforts to either curb prescribing habits or to hold anyone in the industry accountable. What we really need are a few brave politicians who are willing to forego the promises of the industry that supports their reelection campaigns, and who will do what’s best for their constituents.
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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

 

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Ohio Opioid Epidemic Grows As Death Toll Mounts

By: Marcus J. Hopkins, Blogger

Two weeks ago, police in East Liverpool, Ohio, made global news after posting an arrest scene photo of a four-year-old child in his car seat, while with his grandmother and her boyfriend sat in the front seats, overdosed on heroin. The image has served as both a poignant reminder of the often overlooked consequences of opioid and heroin addiction and as a point of controversy for addiction and child advocates.

Map of Ohio, showing East Liverpool

Photo Source: Google Maps

The East Liverpool police posted the photo in an effort to bring attention to the havoc that opioid and heroin abuse wreaks on not only the user, but on the lives of the people around them. Both overdose victims received doses of naloxone – a fast acting drug that reverses the effects of opioid drugs – at the scene, an act which very like saved their lives. The driver, James Acord (47), was sentenced to 360 days in jail after pleading ‘No Contest’ to charges of child endangerment and operating a vehicle under the influence. the boy’s grandmother, Rhonda Pesak (50), who was awarded custody of the child on July 25, 2016, was sentenced to 180 days in jail after withdrawing her initial ‘Not Guilty’ plea to a charge of child endangerment, and reentering a plea of ‘No Contest.’

The child has since been relocated to live with his great aunt and uncle in South Carolina. His mother initially lost custody of him in December 2012 – four-and-a-half months before he was birth – as a result of her addiction to crack. Custody had initially been awarded to his great grandparents, and custody battles for the boy have involved his birth parents, a grandmother, two great aunts, and a friend, spanning four different states. Essentially, this boy’s life has been negatively impacted by drug addictions of some sort since before he was born.

Addiction advocates have criticized the East Liverpool police for “shaming” people who use drugs; child advocates have criticized the city for failing to obscure the identity of the child, which was done after the images were posted by news agencies. East Liverpool Service-Safety Director, Brian Allen, responded with the following statement:

If we hadn’t, Rhonda Pasek would have received a slap on the wrist and that little boy would have gone back to her – that’s not going to happen now. I doubt she will see that child again (Gould & Graham, 2016).

In the five days that followed the posting of the photograph, East Liverpool, a city of only 11,000 people, saw seven more overdoses and one death from heroin. But, this is just a small vignette of a much larger portrait. On Friday, September 09, Ohio authorities reported at least 21 overdoses in a single day in Akron, OH, bringing the total number of overdose deaths, this year, to 112 in the city. At least 24 people were hospitalized for overdoses, last month, while attending a music festival in the state (Karimi, 2016). In July, along, Akron police reported more than 90 overdoses and eight deaths (Las Vegas Review-Journal, 2016).

Ohio’s recently enacted Good Samaritan law offers immunity from prosecution to people trying to get help for someone overdosing on drugs or overdose victims, themselves, who seek assistance. The law, which went into effect, this month, covers people calling 911, contacting a police officer, or taking an overdose victim to a medical facility for up to two times; upon the third time, they would become subject to prosecution. This law, sign by current Ohio Governor, John Kasich, was passed in an effort to provide those offering assistance to overdose victims some measure of protection in the face of Ohio’s clear opioid and heroin abuse epidemic.

HEAL Blog will continue covering the epidemic in the coming weeks with more information and updates as they become available.
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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

 

References:

 

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Milk, Bread, Ground Beef, and Overdose Medication

By: Marcus J. Hopkins, Blogger

The HEAL Blog has been following the issue of opioid addiction very closely, largely because Injection Drug Users (IDUs) represent a large proportion of new Hepatitis C (HCV) infections in the U.S., particularly in rural parts of the country. The Appalachian Mountain region serves as a prime example of how heroin and opioid addiction can lead to a rash of both HIV and HCV outbreaks; it also serves as excellent proving grounds for how Harm Reduction methods can help to prevent mass outbreaks, as well as save lives.

Harm Reductions measures are those that focus on preventive measures that have been shown to lessen the risk to individuals through various legal means. As they relate to opioid addiction, one of the most important measures is increased access to Naloxone, a medication that is used to block the effects of opioid drugs, such as slowed breathing and loss of consciousness. Naloxone – sold under the brand name, Narcan – is a nasal spray that is used to counteract the effects of an opioid overdose. It is currently listed on the World Health Organization’s “List of Essential Medicines,” the most important medications needed in a basic health system, and increasing ease of access without a prescription is something for which advocates have long fought.

Last week, in the city of Huntington, WV, 26 people overdosed on opioid drugs in a period of only four hours from a particularly potent batch of heroin. Of those 26 overdose cases, none of the patients died, as first responders and hospitals were quick to react, delivering a total of 12 doses of Naloxone, including the two used by Huntington police. One patient had to be revived using three doses (Struck, 2016). The remaining patients were revived using bag valve masks, a handheld device used to provide ventilation to patients who aren’t breathing. The users who overdosed ranged in age from 20 to 59, demonstrating that the opioid epidemic affects people of virtually every age range. In Cabell County, where Huntington is located, there were 440 overdoses by June of this year, 26 of which resulted in death; the state of West Virginia, itself, ranks highest in the number of overdose deaths in the U.S.

In Kentucky, the next state over and less than fifteen miles from Huntington, Kroger grocery store locations with pharmacies on site began offering Naloxone over the counter without a prescription at 96 locations, including 80 pharmacies in the Louisville Division (Warren, 2016). Kentucky currently ranks in the top five states for overdose deaths, which makes it an excellent test market for the efficacy of offering Naloxone without a prescription. That said, the Kroger locations in Ashland, KY – the city nearest Huntington, WV – does not yet offer the drug over the counter.

Naloxone rescue kit

Photo Source: Yourblogondrugs.com

When we discuss expanding Naloxone access, there are a number of ways that access can be broadened – (1.) Naloxone can be carried by first responders; (2.) Naloxone can be carried also by state employees (such as school officials); (3.) Naloxone can be sold without a prescription to anyone. WV does not currently allow the sale of Naloxone without a prescription, although WV HB 4035 seeks to do just that. Access to first responders, including police and other emergency personnel, was expanded beyond just Emergency Medical Technicians (EMTs) in May of this year, but it is unclear, yet, whether or not HB 4035 will be ratified and made into law by the end of this year. In an election year, particularly in the latter half, little of substance seems to get done.

What is important, however, is that we continue to fight to expand access to this lifesaving drug. Politics and personal peccadillos aside, saving someone’s life should never fall prey to moralizing of whether or not opioid abuse is wrong, nor should saving a life be predicated upon whether or not one agrees with the lifestyle choices of the victim. When lives are at risk, every reasonable action should be taken to ensure that those lives are saved.

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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In Case of Overdose, Please Spray Naloxone

By: Marcus J. Hopkins, Blogger

For the past two weeks, HEAL Blog has covered various issues related to Harm Reduction and opioid abuse, but not much attention has been given, on our part, to what happens when using injection drugs goes awry and results in an overdose. This is where two specific Harm Reduction methods – Good Samaritan laws and expanded access to the opioid antagonist, Naloxone – come into play.

Good Samaritan laws are ones that provide legal protection to people who provide reasonable assistance to people who are, or whom they believe to be, injured, ill, in peril, or otherwise incapacitated. As it relates to drug overdoses, Good Samaritan laws allow bystanders, medical professionals, or anyone, really, to treat an overdose victim using reasonable methods – such as the application of Naloxone for opioid overdoses – without fear of being later prosecuted, should the person survive and decide, for whatever reason, to sue the person who performed the life saving measure.

Naloxone, itself, is referred to as an “opioid antagonist” – a drug medication that counteracts life-threatening depression of the central nervous system and respiratory system, allowing the overdose patient to breathe normally. It’s also a nonscheduled (i.e. – non-addictive) prescription medication (Harm Reduction Coalition, n.d.), meaning that there is no chance of becoming addicted to the drug. It can be delivered via injection into the muscle, vein, or under the skin, or, more commonly, by nasal spray. The latter application, under the product name “Narcan,” is the generally preferred method of treating overdose victims.

RESPOND to an OPIOID OVERDOSE! You can save a life! [Naloxone Kit]

Photo Source: Washington.edu

When discussing “expanding access to Naloxone,” we’re speaking of more than simply making it more readily available; we’re also discussing how it can be procured, not only by medical emergency personnel and authority figures, but by minimally trained people, which can include essentially anyone, from family members to neighbors to your local postal worker. In fact, CVS pharmacy locations have made Narcan available without a prescription (over the counter, essentially) in 22 states (Thurston, 2016), allowing virtually anyone to procure the overdose cure with minimal hassle, and minimal cost.

Cost is, of course, an issue that must be dealt with, whenever we speak of medical treatments. While Naloxone is relatively inexpensive – depending on the location, between $20-$40 a shot (and in some cases, $6/dose with rebates) – the increased and increasing demand for the drug has cause some drug manufacturers – Amphastar Pharmaceuticals, in particular – to increase their prices to meet the cost of production, raw materials, and labor. Amphastar makes the naloxone most widely used by health departments and police, and is currently the only manufacturer that makes naloxone in a dosage that can be administered nasally (All Things Considered, 2015).

Naloxone, however, is not a panacea, for all its potential live-saving benefits. While the increased availability of Naloxone does translate into more overdose victims being saved, it may not be able to keep up with the increase in opioid and heroin abuse. In Louisville, KY, for example, 40 people in the metro area have died from a drug overdose as of March 21st, 2016, whereas that number was 31 in 2016 (Mora, 2016). While these numbers will, of course, fluctuate from year to year, Jefferson County (where Louisville is located) has the highest overdose rate in the state; Kentucky, as a whole, has the third highest rate in the nation.

In addition to the concerns about increasing opioid abuse levels, areas that are hardest hit by opioid addiction (and thus require larger amounts of Naloxone) may find themselves unable to keep up with the cost of treating patients. Opioid addiction and overdose rates continue to soar in suburban and rural areas, where financial resources may already be taxed by the basic functions of governance. Rural areas, in particular, face significant issues outside of just the cost of procuring doses – reaching and delivering naloxone to far flung overdose patients requires additional resources, both in terms of human and transportation resources.

While the increased access to Naloxone and Good Samaritan laws protecting those who use it are undoubtedly a good thing, they are only two parts of the Harm Reduction stratagem. Without additional efforts, such as Doctor Shopping Laws, Mandatory Prescription Drug Monitoring Programs, and Federally- and state-funded recovery services, we will continue to struggle with the growing opioid and heroin abuse epidemic. As Louisville city councilman stated, “I don’t think we’ve seen the worst of our heroin or opioid problem; I think we’re still in an upward trajectory” (Mora).

References:

All Things Considered. (2015, September 10). Price Soars For Key Weapon Against Heroin Overdoses. National Public Radio: All Things Considered. Retrieved from: http://www.npr.org/sections/health-shots/2015/09/10/439219409/naloxone-price-soars-key-weapon-against-heroin-overdoses

Harm Reduction Coaliation. (n.d.). Understanding Naloxone. New York, NY: Harm Reduction Coalition. Retrieved from: http://harmreduction.org/issues/overdose-prevention/overview/overdose-basics/understanding-naloxone/

Mora, C. (2016, April 04). Opioid overdose deaths increase, despite naloxone prevalence. Louisville, KY: WLKY News. Retrieved from: http://www.wlky.com/news/opioid-overdose-deaths-increase-despite-naloxone-prevalence/38859616

Thurston, J. (2016, March 31). CVS locations in Vermont to sell naloxone without prescription. Colchester, VT: WPTZ New Channel 5. Retrieved from: http://www.wptz.com/news/cvs-locations-in-vermont-to-sell-naloxone-without-prescription/38762902

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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