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1.
MMWR Morb Mortal Wkly Rep ; 69(33): 1117-1121, 2020 Aug 21.
Artigo em Inglês | MEDLINE | ID: mdl-32817603

RESUMO

Syringe service programs (SSPs), which provide access to sterile syringes and other injection equipment and their safe disposal after use,* represent a highly successful human immunodeficiency virus (HIV) prevention intervention. SSPs are associated with a 58% reduction in the incidence of HIV infection among persons who inject drugs (1). In addition, SSPs have led efforts to prevent opioid overdose deaths by integrating evidence-based opioid overdose education and naloxone distribution (OEND) programs (2-4). OEND programs train laypersons to respond during overdose events and provide access to naloxone and directions for drug delivery (2-4). SSPs are ideal places for OEND because they provide culturally relevant services designed to reach persons at high risk for experiencing or observing an opioid overdose. A 2013 survey found that only 55% of SSPs in the United States had implemented OEND (5). To characterize current implementation of OEND among SSPs, and to describe the current reach (i.e., the ratio of persons who received naloxone per opioid overdose death and the ratio of naloxone doses distributed per opioid overdose death) of SSP-based OEND programs by U.S. Census division,† a survey of known U.S. SSPs was conducted in 2019, which found that 94% of SSPs had implemented OEND. In addition, the reach of SSP-based OEND programs varied by U.S. Census division. Scaling up of SSP-based OEND delivery programs could be a critical component for areas of the country with high opioid overdose death rates and low reach.


Assuntos
Overdose de Drogas/prevenção & controle , Educação em Saúde/organização & administração , Naloxona/provisão & distribução , Programas de Troca de Agulhas/organização & administração , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Overdose de Drogas/mortalidade , Humanos , Naloxona/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/mortalidade , Estados Unidos/epidemiologia
2.
Value Health ; 23(8): 1096-1108, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32828223

RESUMO

OBJECTIVES: Several evidence-based interventions exist for people who misuse opioids, but there is limited guidance on optimal intervention selection. Economic evaluations using simulation modeling can guide the allocation of resources and help tackle the opioid crisis. This study reviews methods employed by economic evaluations using computer simulations to investigate the health and economic effects of interventions meant to address opioid misuse. METHODS: We conducted a systematic mapping review of studies that used simulation modeling to support the economic evaluation of interventions targeting prevention, treatment, or management of opioid misuse or its direct consequences (ie, overdose). We searched 6 databases and extracted information on study population, interventions, costs, outcomes, and economic analysis and modeling approaches. RESULTS: Eighteen studies met the inclusion criteria. All of the studies considered only one segment of the continuum of care. Of the studies, 13 evaluated medications for opioid use disorder, and 5 evaluated naloxone distribution programs to reduce overdose deaths. Most studies estimated incremental cost per quality-adjusted life-years and used health system and/or societal perspectives. Models were decision trees (n = 4), Markov (n = 10) or semi-Markov models (n = 3), and microsimulations (n = 1). All of the studies assessed parameter uncertainty though deterministic and/or probabilistic sensitivity analysis, 4 conducted formal calibration, only 2 assessed structural uncertainty, and only 1 conducted expected value of information analyses. Only 10 studies conducted validation. CONCLUSIONS: Future economic evaluations should consider synergies between interventions and examine combinations of interventions to inform optimal policy response. They should also more consistently conduct model validation and assess the value of further research.


Assuntos
Analgésicos Opioides/administração & dosagem , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Transtornos Relacionados ao Uso de Opioides/terapia , Análise Custo-Benefício , Redução do Dano , Humanos , Cadeias de Markov , Modelos Econométricos , Naloxona/economia , Naloxona/provisão & distribução , Antagonistas de Entorpecentes/economia , Antagonistas de Entorpecentes/provisão & distribução , Uso Indevido de Medicamentos sob Prescrição/economia , Uso Indevido de Medicamentos sob Prescrição/prevenção & controle , Anos de Vida Ajustados por Qualidade de Vida
3.
Medicine (Baltimore) ; 99(22): e20033, 2020 May 29.
Artigo em Inglês | MEDLINE | ID: mdl-32481373

RESUMO

Though overall death from opioid overdose are increasing in the United States, the death rate in some states and population groups is stabilizing or even decreasing. Several states have enacted a Naloxone Accessibility Laws to increase naloxone availability as an opioid antidote. The extent to which these laws permit layperson distribution and possession varies. The aim of this study is to investigate differences in provisions of Naloxone Accessibility Laws by states mainly in the Northeast and West regions, and the impact of naloxone availability on the rates of drug overdose deaths.This cross-sectional study was based on the National Vital Statistics System multiple cause-of-death mortality files. The average changes in drug overdose death rates between 2013 and 2017 in relevant states of the Northeast and West regions were compared according to availability of naloxone to laypersons.Seven states in the Northeast region and 10 states in the Western region allowed layperson distribution of naloxone. Layperson possession of naloxone was allowed in 3 states each in the Northeast and the Western regions. The average drug overdose death rates increased in many states in the both regions regardless of legalization of layperson naloxone distribution. The average death rates of 3 states that legalized layperson possession in the West region decreased (-0.33 per 100,000 person); however, in states in the West region that did not allow layperson possession and states in the Northeast region regardless of layperson possession increased between 2013 and 2017.The provision to legalize layperson possession of naloxone was associated with decreased average opioid overdose death rates in 3 states of the West region.


Assuntos
Analgésicos Opioides/envenenamento , Overdose de Drogas/mortalidade , Acesso aos Serviços de Saúde/legislação & jurisprudência , Naloxona/provisão & distribução , Antagonistas de Entorpecentes/provisão & distribução , Estudos Transversais , Overdose de Drogas/tratamento farmacológico , Acesso aos Serviços de Saúde/tendências , Humanos , Naloxona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Estudos Retrospectivos , Governo Estadual , Estados Unidos
4.
Am J Public Health ; 110(6): 881-887, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32298179

RESUMO

Objectives. To examine early impacts of laws that require naloxone to be prescribed to patients at increased overdose risk.Methods. Using data from 2014 to 2018 from a large pharmacy chain, CVS Pharmacy, we examined the effects of naloxone-prescribing mandates 90 days before and after they took effect in Arizona, Florida, Rhode Island, Vermont, and Virginia. We compared the number of naloxone doses initiated directly by prescribers and by pharmacy standing order, prescriber specialty, pharmacies dispensing, and payor type by applying linear models and the χ2 test.Results. Naloxone-prescribing mandates increased pharmacy naloxone provision 255% from 90 days before to after implementation. This approach appeared to engage more prescribers (1028 before to 4285 after), complement ongoing naloxone provision under pharmacy standing orders, expand geographic reach (from 40% to 80% of pharmacies dispensing), and broaden the naloxone payor mix in 4 (P < .05) of 5 states.Conclusions. Mandating the prescribing of naloxone quickly expands access to this life-saving medication for more people in more places. Other states should consider mandating the coprescription of naloxone to individuals at increased risk of overdose.


Assuntos
Overdose de Drogas , Prescrições de Medicamentos/estatística & dados numéricos , Controle de Medicamentos e Entorpecentes/legislação & jurisprudência , Naloxona , Overdose de Drogas/tratamento farmacológico , Overdose de Drogas/prevenção & controle , Acesso aos Serviços de Saúde/legislação & jurisprudência , Humanos , Naloxona/provisão & distribução , Naloxona/uso terapêutico , Estados Unidos
6.
Med J Aust ; 212(7): 314-320, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32124984

RESUMO

OBJECTIVES: To characterise the community pharmacy supply of naloxone by supply type - individual prescription, prescriber bag, and non-dispensed (supplied over the counter or expired) - during 2014-2018; to examine whether the 2016 rescheduling of naloxone as an over-the-counter drug influenced non-dispensed naloxone supply volume. DESIGN, SETTING: Analysis of monthly naloxone prescriptions (Pharmaceutical Benefits Scheme) and sales data (IQVIA), 2014-2018, for Australia and by state and territory; time series analysis of non-dispensed naloxone supply to assess effect of rescheduling on naloxone supply. MAJOR OUTCOMES: Total naloxone supply to community pharmacies; prescribed and non-dispensed naloxone supply. RESULTS: During 2014-2018, 372 351 400 µg units of naloxone were sold to community pharmacies: non-dispensed naloxone accounted for 205 866.5 units (55.3%), prescriber bags for 155 841 units (41.8%), and individual prescriptions for 10 643.5 units (2.9%). Population-adjusted national naloxone sales to community pharmacies increased between 2014 and 2018 (per year: incidence rate ratio [IRR], 1.15; 95% CI, 1.09-2.22). This increase was primarily attributable to increased volumes of prescriber bag naloxone (IRR, 1.63; 95% CI, 1.50-1.78) and, to a lesser extent, increased individual prescription supply (IRR, 2.04; 95% CI, 1.85-2.26). Non-dispensed naloxone supply volume was unchanged at the national level (IRR, 0.93; 95% CI, 0.85-1.01); changes in non-dispensed supply immediately following rescheduling and subsequently were not statistically significant in time series analyses for most jurisdictions. CONCLUSIONS: Total naloxone supply to community pharmacies in Australia increased between 2014 and 2018, but rescheduling that enabled over-the-counter access did not significantly influence the volume of non-dispensed naloxone.


Assuntos
Comércio/estatística & dados numéricos , Serviços Comunitários de Farmácia/organização & administração , Prescrições de Medicamentos/estatística & dados numéricos , Naloxona/provisão & distribução , Austrália , Comércio/tendências , Controle de Medicamentos e Entorpecentes/legislação & jurisprudência , Modelos Lineares , Antagonistas de Entorpecentes/provisão & distribução , Medicamentos sem Prescrição/provisão & distribução , Estudos Retrospectivos
9.
Int J Drug Policy ; 71: 113-117, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31301549

RESUMO

BACKGROUND: In 2014, California signed into law AB1535 permitting pharmacists to dispense naloxone upon request and without physician or midlevel provider prescription. OBJECTIVE: We sought to determine pharmacist knowledge of AB1535, participation, availability of naloxone, future plans for participation, and out-of-pocket charges to consumers amongst outpatient pharmacies in selected California counties. METHODS: All pharmacies in Plumas, Lake, Lassen, Humboldt, Shasta, Fresno, and San Diego Counties were identified. Between January 30 and March 30, 2017, pharmacies meeting inclusion criteria were contacted and the pharmacist-on-duty were queried regarding knowledge, participation, availability, and cost of naloxone. RESULTS: A total of 2296 pharmacies were identified in the 7 counties. Twenty-six were unwilling or unable to participate and an additional 1648 were excluded because of licensing or special pharmacy status. Six-hundred-twenty-two pharmacies completed the survey. There was variation in knowledge of AB1535, participation in, immediate availability of naloxone, charge, and expressed future interest in participation identified. Charge to consumers was similarly variable amongst surveyed pharmacies within counties. CONCLUSIONS: Despite considerable public health and political support, the passage of CA AB1535 has not resulted in broad current, future planned participation, or availability of naloxone in selected counties. Out-of-pocket costs to the consumer remain highly variable.


Assuntos
Naloxona/provisão & distribução , Antagonistas de Entorpecentes/provisão & distribução , Assistência Farmacêutica/legislação & jurisprudência , Farmacêuticos/estatística & dados numéricos , California , Custos de Medicamentos , Pesquisas sobre Serviços de Saúde , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Naloxona/economia , Antagonistas de Entorpecentes/economia , Farmacêuticos/legislação & jurisprudência
11.
JAMA Netw Open ; 2(6): e195388, 2019 06 05.
Artigo em Inglês | MEDLINE | ID: mdl-31173125

RESUMO

Importance: Despite the increasingly important role of pharmacies in the implementation of naloxone access laws, there is limited information on the impact of such laws at the local level. Objective: To evaluate the availability (with or without a prescription) and cost of naloxone nasal spray at pharmacies in Philadelphia, Pennsylvania, following a statewide standing order enacted in Pennsylvania in August 2015 to allow pharmacies to dispense naloxone without a prescription. Design, Setting, and Participants: A survey study was conducted by telephone of all pharmacies in Philadelphia between February and August 2017. Pharmacies were geocoded and linked with the American Community Survey (2011-2015) to obtain information on the demographic characteristics of census tracts and the Medical Examiner's Office of the Philadelphia Department of Public Health to derive information on the number of opioid overdose deaths per 100 000 people for each planning district. Data were analyzed from March 2018 to February 2019. Main Outcomes and Measures: Availability and out-of-pocket cost of naloxone nasal spray (with or without a prescription) at Philadelphia pharmacies overall and by pharmacy and neighborhood characteristics. Results: Of 454 eligible pharmacies, 418 were surveyed (92.1% response rate). One in 3 pharmacies (34.2%) had naloxone nasal spray in stock; of these, 61.5% indicated it was available without a prescription. There were significant differences in the availability of naloxone by pharmacy type and neighborhood characteristics. Naloxone was both more likely to be in stock (45.9% vs 27.8%; difference, 18.0%; 95% CI, 8.3%-27.8%; P < .001) and available without a prescription (80.6% vs 42.2%; difference, 38.4%; 95% CI, 23.0%-53.8%; P < .001) in chain stores than in independent stores. Naloxone was also less likely to be available in planning districts with very elevated rates of opioid overdose death (≥50 per 100 000 people) compared with those with lower rates (31.1% vs 38.5%). The median (interquartile range) out-of-pocket cost among pharmacies offering naloxone without a prescription was $145 ($119-$150); costs were greatest in independent pharmacies and planning districts with elevated rates of opioid overdose death. Conclusions and Relevance: Despite the implementation of a statewide standing order in Pennsylvania more than 3 years prior to this study, only one-third of Philadelphia pharmacies carried naloxone nasal spray and many also required a physician's prescription. Efforts to strengthen the implementation of naloxone access laws and better ensure naloxone supply at local pharmacies are warranted, especially in localities with the highest rates of overdose death.


Assuntos
Naloxona/administração & dosagem , Antagonistas de Entorpecentes/administração & dosagem , Farmácias/estatística & dados numéricos , Administração por Inalação , Honorários Farmacêuticos , Gastos em Saúde/estatística & dados numéricos , Humanos , Naloxona/economia , Naloxona/provisão & distribução , Antagonistas de Entorpecentes/economia , Antagonistas de Entorpecentes/provisão & distribução , Sprays Nasais , Medicamentos sem Prescrição/administração & dosagem , Medicamentos sem Prescrição/economia , Medicamentos sem Prescrição/provisão & distribução , Transtornos Relacionados ao Uso de Opioides/economia , Transtornos Relacionados ao Uso de Opioides/reabilitação , Farmácias/economia , Philadelphia , Medicamentos sob Prescrição/administração & dosagem , Medicamentos sob Prescrição/economia , Medicamentos sob Prescrição/provisão & distribução
12.
J Pharm Pract ; 32(4): 412-421, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29478362

RESUMO

BACKGROUND: The Centers for Disease Control and Prevention (CDC) reports a 200% escalation in the rate of opioid overdose deaths in the United States. Unfortunately, Ohio has been deemed the epicenter of the nation's opioid epidemic. In 2015, Ohio passed a bill that permits a pharmacist to distribute naloxone without a prescription. OBJECTIVES: This survey was aimed to discover pharmacists' knowledge of naloxone and Ohio law, perceived barriers that may prohibit naloxone dispensing, and Ohio pharmacists' general confidence, comfort, perception, and experience dispensing naloxone per physician protocol. METHODS: Pharmacists' knowledge of naloxone and Ohio law pertaining to dispensing naloxone; perceived barriers to naloxone distribution; and overall experience, willingness, comfort, and perceptions of personally supplying naloxone were assessed using multiple-choice and Likert-type scale questions through an e-mail survey. RESULTS: Overall, Ohio pharmacists were knowledgeable about naloxone and displayed confidence in their training and ability to provide patient education on naloxone. Pharmacists were less certain about Ohio law pertaining to naloxone distribution, especially those who have been in practice longer. Pharmacists indicated several barriers to dispensing naloxone and the need for more training. Younger pharmacists were more likely to report a concern with clientele who would frequent their pharmacy and moral and ethical concerns as barriers to dispensing naloxone. CONCLUSION: Additional educational programs should be delivered to Ohio pharmacists to inform them of the state law and policies. Continuing education programs that review substance abuse and attempt to reduce social stigma may assist with increasing naloxone distribution to those in need, especially, if directed toward younger pharmacists in Ohio.


Assuntos
Naloxona/provisão & distribução , Antagonistas de Entorpecentes/provisão & distribução , Assistência Farmacêutica/organização & administração , Farmacêuticos/organização & administração , Adulto , Fatores Etários , Idoso , Overdose de Drogas/tratamento farmacológico , Prescrições de Medicamentos , Controle de Medicamentos e Entorpecentes , Feminino , Pesquisas sobre Serviços de Saúde , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Ohio , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Educação de Pacientes como Assunto , Farmacêuticos/estatística & dados numéricos
16.
JAAPA ; 31(10): 47-52, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30252764

RESUMO

The treatment of patients with acute and chronic pain not attributed to cancer or end-of-life conditions is a challenge for many clinicians. Although CDC guidelines that focus on the primary care setting have provided critical recommendations, evidence-based guidance is lacking on optimal duration of opioid treatment for postoperative and acute care in specialty settings. Over the last 2 decades, the liberal use of opioids has resulted in many unintended consequences, including dependence and abuse, illicit distribution of legally and illegally prescribed opioid medication, progression to IV heroin and an epidemic of overdoses, and most recently an increase in the incidence of HIV among patients sharing syringes, frequently in communities with historically low HIV rates. This article analyzes these complex issues and proposes strategies to help clinicians improve patient care through education and responsible prescribing.


Assuntos
Epidemias/legislação & jurisprudência , Epidemias/prevenção & controle , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Prática de Saúde Pública , Política de Saúde , Humanos , Naloxona/provisão & distribução , Naloxona/uso terapêutico , Antagonistas de Entorpecentes/provisão & distribução , Antagonistas de Entorpecentes/uso terapêutico , Assistentes Médicos , Estados Unidos
17.
J Addict Nurs ; 29(3): 157-162, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30180000

RESUMO

PROBLEM: In 2014, there were approximately 200,000 incidents of an unintentional opioid overdose nationwide. The 2016 Centers for Disease Control and Prevention opioid prescription guidelines identified a knowledge deficit regarding opioid prescribing among primary care providers as a contributing factor to this epidemic. PURPOSE: The purpose of this quality assurance project was to provide education on opioid overdose and distribution of naloxone kits through a presentation to primary care providers at Veterans Administration facilities in the southeast region of the United States. METHODS: A convenience sampling strategy was utilized for this project. Primary care providers who prescribe opioids or care for patients at risk of an opioid-related event or death were invited to participate. A Likert scale survey was used to determine the effectiveness of the presentation. RESULTS: The results of the survey showed a potential for improving medical providers' perceptions and comfort with prescribing naloxone kits. The mean score at pretest was 32 of 50 (64%) in contrast to 42 of 50 (84%) after attending the presentation. Attending this quality assurance presentation was related to an increased awareness of naloxone kit availability and Centers for Disease Control and Prevention recommendations regarding the safe administration of opioids. CONCLUSION: This educational presentation can assist providers in identifying patients who are prescribed opioids and at risk for accidental overdose and death.


Assuntos
Analgésicos Opioides/envenenamento , Overdose de Drogas/prevenção & controle , Educação Continuada/organização & administração , Hospitais de Veteranos/organização & administração , Naloxona/administração & dosagem , Naloxona/provisão & distribução , Antagonistas de Entorpecentes/administração & dosagem , Antagonistas de Entorpecentes/provisão & distribução , Atenção Primária à Saúde/organização & administração , Garantia da Qualidade dos Cuidados de Saúde , Conscientização , Centers for Disease Control and Prevention, U.S. , Overdose de Drogas/epidemiologia , Overdose de Drogas/enfermagem , Prescrições de Medicamentos , Educação Continuada/normas , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Guias de Prática Clínica como Assunto , Atenção Primária à Saúde/normas , Fatores de Risco , Sudeste dos Estados Unidos/epidemiologia , Estados Unidos
18.
J Law Med Ethics ; 46(2): 367-381, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30146989

RESUMO

This paper focuses on the most common state policy responses to the opioid crisis, dividing them into six broad categories. Within each category we highlight the rationale behind the group of policies within it, discuss the details and support for individual policies, and explore the research base behind them. The objective is to better understand the most prevalent state responses to the opioid crisis.


Assuntos
Transtornos Relacionados ao Uso de Opioides/terapia , Política Pública , Governo Estadual , Analgésicos Opioides/administração & dosagem , Prescrições de Medicamentos , Tráfico de Drogas/legislação & jurisprudência , Educação Médica Continuada , Educação em Saúde , Humanos , Legislação de Medicamentos , Naloxona/provisão & distribução , Antagonistas de Entorpecentes/provisão & distribução , Programas de Troca de Agulhas , Tratamento de Substituição de Opiáceos , Manejo da Dor , Médicos/legislação & jurisprudência , Uso Indevido de Medicamentos sob Prescrição/prevenção & controle , Programas de Monitoramento de Prescrição de Medicamentos , Estados Unidos
19.
J Law Med Ethics ; 46(2): 472-484, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-30146993

RESUMO

The rising cost of the opioid antagonist and overdose reversal agent naloxone is an urgent public health problem. The recent and dramatic price increase of Evzio, a naloxone auto-injector produced by Kaléo, shows how pharmaceutical manufacturers entering the naloxone marketplace rely on market exclusivity guaranteed by the patent system to charge prices at what the market can bear, which can restrict access to life-saving medication. We argue that 28 U.S.C. § 1498, a section of the federal code that allows the government to use patent-protected products for its own purposes in exchange for reasonable compensation, could be used to procure generic naloxone auto-injectors, or at least bring Kaléo to the negotiating table. Precedent exists for the use of § 1498 to procure pharmaceuticals, and it could give meaning to the federal government's recent declaration of a public health emergency around the opioid epidemic, discourage new market entrants from charging exorbitant prices, and yield important public health benefits.


Assuntos
Acesso aos Serviços de Saúde/legislação & jurisprudência , Naloxona/economia , Antagonistas de Entorpecentes/economia , Patentes como Assunto/legislação & jurisprudência , Analgésicos Opioides/efeitos adversos , Overdose de Drogas/tratamento farmacológico , Humanos , Naloxona/provisão & distribução , Naloxona/uso terapêutico , Antagonistas de Entorpecentes/provisão & distribução , Antagonistas de Entorpecentes/uso terapêutico , Transtornos Relacionados ao Uso de Opioides , Saúde Pública , Estados Unidos
20.
J Law Med Ethics ; 46(2): 422-436, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30146999

RESUMO

The national opioid epidemic is severely impacting Indian Country. In this article, we draw upon data from the Centers for Disease Control and Prevention to describe the contours of this crisis among Native Americans. While these data are subject to significant limitations, we show that Native American opioid overdose mortality rates have grown substantially over the last seventeen years. We further find that this increase appears to at least parallel increases seen among non-Hispanic whites, who are often thought to be uniquely affected by this crisis. We then profile tribal medical and legal responses to the opioid epidemic, ranging from tribally-operated medication-assisted therapy to drug diversion courts rooted in traditional tribal cultures.


Assuntos
Índios Norte-Americanos/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides/etnologia , Transtornos Relacionados ao Uso de Opioides/terapia , Analgésicos Opioides/efeitos adversos , Indústria Farmacêutica/legislação & jurisprudência , Overdose de Drogas/mortalidade , Redução do Dano , Acesso aos Serviços de Saúde , Humanos , Naloxona/provisão & distribução , Antagonistas de Entorpecentes/provisão & distribução , Tratamento de Substituição de Opiáceos , Punição , Apoio Social , Centros de Tratamento de Abuso de Substâncias , Estados Unidos/epidemiologia , United States Indian Health Service
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