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www.trauma-informed-california.orgSanta Cruz, CA
Is There Really an Opioid Epidemic?
March 2019
The California Center of Excellence for Trauma Informed Care
looked into the well-publicized US opioid crisis (The White House,
2017), often reported with images and statistics related to
overdoses, hospitalizations and child abuse. After looking at data
collected over time and from multiple sources, it became clear that
actual opioid misuse has been slowly decreasing in recent years and
likely since the early 1990s, even while overdoses steeply
increased. Although research on opioid use goes back to the 1970s,
this white paper focuses only on the past decade.
Across the country, there is widespread alarm regarding an
unfolding “opioid epidemic” (Bruder, 2018). Mainstream and
alternative media alike are brimming with reports about how the
opioid crisis is tearing American families apart (Macy, 2018b),
disrupting the foster care system (Birnbaum & Lora, 2018), and
destabilizing our economy (Florence et al., 2016).
The dramatic rise in the rates of opioid-related overdose deaths
in the US between 2013 and 2016 has led people to believe that
rates of misuse and abuse of opioids have similarly increased.
While there is clear data showing an opioid overdose increase in
recent years (see Figure 1), over the same time frame
(from around 2014 to the present) there has actually been a
small but noticeable decline in opioid misuse by almost every age,
gender, and race in America (see Figures 2 and 4).
There is an opioid overdose epidemic.
The increase in overdose deaths related to opioids in recent
years is striking. Big Pharma created addictive, lethal yet still
legal opioids for medical treatment of pain and claimed that these
innovative synthetic opioid pharmaceuticals were non-addictive and
safe (Macy, 2018a). Convinced by misleading marketing campaigns
about the safety and effectiveness of these drugs, doctors ramped
up their prescribing of opioids (Lopez, 2017a). According to the
Centers for Disease Control and Prevention (CDC), sales of opioid
pain relievers in the US increased by 300 percent between 1999 and
2010 (CDC, 2013). Meanwhile, according to data analysis available
from the National Institutes of Health (NIH) US National Library of
Medicine, no significant change occurred in the amount of pain
reported by Americans over the parallel time period of 2000 to 2010
(Daubresse et al., 2013). At the same time, emergency departments
increased opioid utilization and decreased non-opioid analgesic use
(Chang et al., 2014).
Furthermore, the pharmaceutical industry has produced
rapid-onset delivery systems for numerous synthetic opioids and
specifically fentanyl, which is 50 times more potent than street
heroin and approximately 100 times more potent than morphine (Drug
Enforcement Administration, 2017).
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California Center of Excellence for Trauma Informed Care
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Figure 1It is clear from CDC data that the overall US opioid
overdose death rate has dramatically risen. In particular, the rate
of overdose deaths involving fentanyl actually doubled each year
from 2013 to 2016 (from 0.6 in 2013, to 1.3 in 2014, 2.6 in 2015,
and 5.9 in 2016).Age-Adjusted US Opioid Overdose DeathRates,
1999–2016, Deaths per 100,000
0
3
6
9
12
15
Any Opioid
HeroinNatural & Semi-SyntheticOpioids (e.g.,
oxycodone,hydrocodone)
Methadone
Other Synthetic Opioids(e.g., fentanyl, tramadol)
201620142012201020082006200420022000
Age-Adjusted US Overdose Death Ratesfor Selected Opioids,
2011–2016, Deaths per 100,000
0
3
6
9
12
15
OxycodoneMorphineMethadoneHydrocodone
HeroinFentanyl
201620152014201320122011
Source: Hedegaard, Warner, & Miniño, 2017, data table for
Figure 4; and Hedegaard et al., 2018 Analysis: California Center of
Excellence for Trauma Informed Care
Once the “opioid epidemic” started gaining widespread attention,
the response from government agencies, regulators, doctors, and
medical groups was to aggressively limit opioid prescriptions. By
2017, when the CDC reported the lowest opioid prescription rates in
10 years (CDC, 2018), many people who were dependent on opioids no
longer had ready, inexpensive access to legal sources and turned to
the street, often with heroin as their only or best choice. Putting
people who are inexperienced into an illicit market that sells
products which are untested and unknown in terms of potency and
additives (such as fentanyl) increases overdose risk. In drug harm
assessments, heroin already scores at the top of the scale for harm
to users. The effect of a drug on breathing and heart function is a
major determinant of
harm, and drugs such as heroin that can be taken intravenously
have a high risk of causing sudden death from respiratory
depression (Nutt, 2007).
Overdose deaths involving both heroin and fentanyl have risen
significantly in recent years. It has been difficult to capture
long-term misuse and overdose death data on specific drugs in the
opioid class (i.e., fentanyl, heroin, hydrocone, methadone,
morphine, and oxycodone) because they have often not been listed
separately in drug use surveys and mortality codes. However, the
specificity of death certificate reporting on drug overdose deaths
has improved since 2011. An analysis of 2011 to 2016 data from the
CDC’s National Center for Health Statistics (NCHS) found that the
rate of drug overdose deaths involving fentanyl did not
statistically change from 2011 to
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Is There Really an Opioid Epidemic?
3
2013 and then increased on average by about 113 percent each
year from 2013 through 2016 (see Figure 1). The rate of drug
overdose deaths involving heroin increased on average by about 34
percent per year from 2011 to 2014 and then by about 20 percent per
year from 2014 through 2016 (Hedegaard et al., 2018).
Overall, opioid-related overdose was the contributing cause for
more than 42,000 deaths in 2016. The categories of overdoses
responsible for those deaths include poisoning by opium, heroin,
other opioids, methadone, other synthetic narcotics, and other
unspecified narcotics (SAMHSA, 2018c). Deaths involving more than
one opioid category are counted in both categories. Based on
preliminary CDC data (as of August 2018), the overall 2017 US
opioid overdose toll in terms of number of deaths is estimated at
49,068, with nearly 30,000 of those deaths related to fentanyl and
fentanyl analogs. The parallel CDC preliminary estimate for 2017
overdose deaths involving heroin is 15,958 and the National
Institute on Drug Abuse (NIDA) calculated that there has been a
7.6-fold increase from 2002 through 2017 in the total number of
heroin overdose deaths in the US (NIDA, 2018). However, the steep
rise in heroin overdose deaths does not automatically mean that
heroin misuse is also increasing rapidly or even at all.
A subtle but misleading conceptual switchWhile the overdose
crisis is real, as Figure 1 makes abundantly clear, the alarm about
an increase in the number of people misusing or being addicted to
opioids does not appear grounded in facts. If, instead, it is not
the rates of opioid misuse and abuse that have rapidly increased,
but solely the rates of opioid overdose deaths, it becomes evident
that the opioid crisis cannot be viewed as an addictive behavioral
problem for individuals alone (Drum, 2017). Rather, it should be
seen as a public health issue that has its roots in pharmaceutical
companies’ marketing of unsafe drugs as safe medical treatments for
pain,
combined with the failure of the health care system to
adequately address pain care and treatment for drug addiction,
which is often linked to underlying socioeconomic and mental health
problems.
It is essential to note that the subtle but misleading
conceptual switch from “opioid overdose epidemic” to “opioid
epidemic” shifts the responsibility from the public and its
institutions to individual doctors (or dealers) and patients (or
addicts). As a result, those seeking measures to combat the “opioid
epidemic” will look to punitive approaches that have the strong
likelihood of additionally harming individuals while not actually
addressing the factors that pose a real danger to public
health.
Strong cultural and historical messages have often portrayed
drug misuse, addiction, and overdoses as the fault of the
individual for substance abuse and often also for breaking the law.
The idea that opioid misuse and addiction are destroying the
country posits people as enemies who must be combatted. A focus on
rational public health approaches that look at reducing lethal
means, providing the public with access to high-quality
information, and providing researched, effective interventions and
treatments for people who are suffering physically and mentally can
save lives. Is the goal of the policy to save lives or to punish
people for struggling with opioid addiction?
There is no “opioid epidemic.”From a public health perspective,
when the number of people exposed to an addictive substance
increases, a resulting increase in overall use is expected (more
exposed, more addicted). The data does not support this
expectation. To show the lack of increase requires a deep dive into
data sets, in which meaning may be masked by changes in definitions
and reporting questions, missing data, and inconsistency over time.
But when looking at the clear evidence that results from such an
effort, it becomes difficult to understand why unquestioned
reiteration of and speculation on the “opioid epidemic” continues
unabated.
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California Center of Excellence for Trauma Informed Care
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Figure 2A close examination of the data reveals clear evidence
that, at the very least, there is no opioid misuse epidemic.Trend
in Nonmedical Use of Prescription Opioids Among US Adolescents
Estimated percent with lifetime use, 2002–2015
A. Trend in Nonmedical Use of Prescription OpioidsAmong US
AdolescentsEstimated percent with lifetime use, 2002–2015
Source: McCabe, West, Verliz, McCabe, Stoddard, & Boyd,
2017, excerpt from Figure 1 Excerpt: California Center of
Excellence for Trauma Informed Care
B. Past Year Heroin Use Among People Aged 12 or OlderPercent
using in past year by age group, 2002–2017
00.1%0.2%0.3%0.4%0.5%0.6%0.7%0.8%
Age 18 to 25
Age 12 or OlderAge 26 or OlderAge 12 to 17
201720142011200820052002
Data Source: SAMHSA, 2018a, Figure 22 Table Analysis: California
Center of Excellence for Trauma Informed Care
It is important to keep the overall picture in focus: even when
there were increases in opioid use, the increase increments are
such small percentages that while the trend line rise may look
dramatic, the increases are still small in actual proportion.
One of the few longer-term (2002–2015) studies of prescription
opioid use in the United States, published by the American Academy
of Pediatrics in 2017 (McCabe, West, Verliz, McCabe, Stoddard,
& Boyd, 2017), shows a relatively steady trend in lifetime
nonmedical use of prescription opioids among US adolescents until a
noticeable decline between 2013 and 2015 (see Figure 2A). By adding
the data trends from the annual National Survey on Drug Use and
Health (NSDUH) published by the Substance Abuse and Mental Health
Administration (SAMHSA) that extend to 2017 and show no increase in
past year heroin use among the 12–17 age group, it can be shown
that the data does not support any increased lifetime or past year
opioid prescription or heroin use among US adolescents
(see Figure 2B).
Between 2002 and 2012, there was an increase in past year heroin
use in the 18 to 25 age group: the rate goes from .04 percent of
the age 18–25 population to .08 percent—less than 1 percent of that
total age group. The data for this age group also shows a
noticeable decline since 2014 (see Figure 2B).
For yet another look, the trend line for first use of heroin
shows an overall reduction between 2002 and 2016 among adolescent
persons aged 12 to 17 (see Figure 3). Notably, between 2013 and
2016, the count of 12–17 youths who used heroin for the first time
in each of those years went down from 21,000 to 8,000, a decrease
of more than 60 percent. This time period is when the “opioid
epidemic” was supposedly growing exponentially—which, again, is the
case for opioid overdoses, but not for opioid misuse.
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Is There Really an Opioid Epidemic?
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Figure 3Although it is clear that people aged 26 and older drove
the overall increase in initial heroin use between 2013 and 2016,
the overall upward trend line for first-time use is not nearly as
steep as the overdose deaths trends in Figure 1.
Source: SAMHSA, 2018b Analysis: California Center of Excellence
for Trauma Informed Care
Not one of the multiple studies consulted for this white paper
shows a clear dramatic increase in the overall percentages of the
population misusing either opioids in general or heroin in
particular. For example, although it is clear that initial heroin
use by people aged 26 and older drove the overall increase in
first-time users (see Figure 3), particularly between 2013 and
2016, the overall upward trend in the number of people who used
heroin for the first time in any given year is not nearly as steep
as the opioid overdose deaths trend lines (compare Figure 3 to
Figure 1). In the overall group of people aged 12 and older, the
number of first-time heroin users was 169,000 in 2013, and after a
dramatic spike and dip, the count ended up at 170,000 in 2016, an
increase of only a little over half of one percent. In the category
of first-time heroin users aged 26 and older, the count of 82,000
in 2013 ended up lower after its spike and dip, at 80,000 in 2016
(see Figure 3).
The downward trend for past year misuse of opioids among people
older than 12 holds true for all ages and ethnicities. The
2015–2017 results of the SAMHSA
National Survey on Drug Use and Health show that across all
demographics—male or female; White, Black, or Latino; West,
Midwest, South, or Northeast—misuse of opioids has not
significantly increased and has in fact gone down in most cases
(see Figure 4).
The widespread fear of a growing opioid epidemic that is
damaging our youth and families and wreaking havoc on entire cities
and states may be true in terms of overdoses, but it is certainly
not true in terms of overall opioid misuse or heroin abuse.
However, when opioid overdose rates are published, the reader is
left to assume that abuse rates must be increasing at the same pace
or even faster. Making the distinction between overdose deaths and
opioid misuse is only the first step. It is also important to
understand that the drug category labeled “opioids” is a group of
chemically similar drugs that includes—along with
heroin—prescription pain relievers, such as hydrocodone (e.g.,
Vicodin®), oxycodone (e.g., OxyContin®), fentanyl, tramadol, and
morphine. The 2017 National Survey on Drug Use and Health
calculation of the number of
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California Center of Excellence for Trauma Informed Care
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Figure 4Overall, the percentages of people over the age of 12
who misuse opioids are declining. The trend has been unsteady only
in the Midwest, with the misuse rate going from 4.5 percent in 2015
to 4.2 percent in 2016, and then moving up to 4.4 percent in
2017.Past Year Misuse of Opioids Among PeopleAged 12 or Older, by
Demographic CharacteristicsPercentages, 2015–2017
3%
4%
5%
6% MalesWhiteTotalHispanic or LatinoFemalesBlack orAfrican
American
201720162015Data Source: SAMHSA, 2017 and 2018b, Table 1.65B
Analysis: California Center of Excellence for Trauma Informed
Care
Past Year Misuse of Opioids Among PeopleAged 12 or Older, by
Geographic RegionPercentages, 2015–2017
3%
4%
5%
6% WestMidwestSouthNortheast
201720162015Data Source: SAMHSA, 2017 and 2018b, Table 1.94B
Analysis: California Center of Excellence for Trauma Informed
Care
Note: Another critical point is that the NSDUH questionnaire
undergoes changes over the years in order to address the changing
needs of policymakers and researchers and to allow for such things
as the addition and removal of specific prescription drugs from
year to year as they come onto or are removed from the market.
These changes can sometimes cause breaks in trend
lines. One such change was a 2015 partial redesign of NSDUH
questions about drug misuse to shift the focus from lifetime misuse
to past year misuse. That is why the reported data in the two
graphs on past year opioid misuse (as distinct from just heroin
misuse) shows only the trend from 2015 to 2017 and does not make a
comparison to previous years.
past year US illicit drug users found that prescription pain
reliever misuse is more widespread than misuse of other
prescription drugs and more widespread than misuse of cocaine,
hallucinogens, methamphetamine, inhalants, and heroin (see Figure
5).
Opioids are a serious issue and require a serious response.At
this point, it is clear that misuse of opioids, especially those in
the category of legally prescribed pain relievers, is problematic,
even though the number opioid misusers is not skyrocketing the way
that the number of opioid overdose deaths is. Yet, in the midst of
a so-called “opioid epidemic,” why is there so little attention
being paid to the increase in prescriptions for opioid pain
relievers, prescribed pain reliever misuse, and extremely increased
lethal risks in the vehicles of delivery for opioids?
It can be argued that the public discourse has become fixated on
the reckless, criminal individual and the profiteering, unethical
doctor, rather than looking at the public policies and the
corporate drug companies’ culpability in providing more access to,
stronger potencies of, and more effective and lethal delivery
mechanisms for prescription opioids, which lead to increased
overdoses.
There is pressure to faithfully believe and not to question that
the youth of today are being drastically affected by the opioid
crisis. There are national ads of personal stories sponsored by the
White House about how easy it is to get addicted (McCammon, 2018).
Adolescents are not using more opioids, prescription or otherwise.
Nonetheless, certain young people may be at higher risk for both
opioid addiction and overdose. Economic and social problems
increase those risks (Dube et al., 2003).
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Is There Really an Opioid Epidemic?
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Figure 5Misuse of prescription pain relievers—a category that
includes opioids such as hydrocodone, oxycodone, fentanyl,
tramadol, and morphine—outpaced other types of illicit drug use in
2017.Numbers of Past Year Illicit Drug Users Among People�Aged 12
or Older, 2017, Millions of People
0 1 2 3 4Prescription Sedative Misuse
HeroinInhalants
MethamphetamineHallucinogens
Prescription Tranquilizer MisusePrescription Stimulant
Misuse
CocainePrescription Pain Reliever Misuse 3.2
0.8
0.40.50.6
1.41.71.8
2.2
Source: SAMHSA, 2018a, Figure 11 Analysis: California Center of
Excellence for Trauma Informed Care
In light of the frequent connection between trauma exposure and
substance abuse, this white paper was produced by the California
Center of Excellence for Trauma Informed Care as part of its
mission to advance research-based policies and practices that
respond to the needs of trauma-exposed clients by focusing on
safety, skills, and designing practices that encourage trauma
recovery. Summer intern Sara Kaufman, a student at Amherst College,
conducted research for this paper. Gabriella Grant, director,
edited and additionally researched the paper. Pam Winter, of
WinterPM, developed the visual layout of the data and the visual
communication.
There is no denying that opioid addiction is a serious problem,
especially for those addicted; however, the media and policy
responses to the problem fail to put the emphasis in the places
where it is most crucially needed.
Rhetorical and emotional responses ignore the failure of public
policies, government agencies, and legislatures to take effective
action, especially in connection with the real needs of pain
patients and the shortage of accessible and affordable addiction
treatment. While Congress has funded a number of opioid response
programs, many public health experts point out that these are
scattershot efforts without a coherent plan (Lopez, 2018).
Insufficient, inconsistent funding and the stigmatization of
addiction as a moral failure impede the implementation of proven
effective approaches, such as greater access to both non-opioid
options for dealing with chronic pain and medication-assisted
addiction treatment. The public and policymakers benefit from
understanding addiction as a chronic, relapsing condition, and the
opioid overdose death crisis requires a safety-focused response.
For a better example, the State of Vermont health care system has
integrated addiction treatment into the rest of health care, so
that patients have affordable access to both intensive treatment
and effective follow-up care (Lopez, 2017b).
It is time to stop being alarmist about the pseudo “opioid
epidemic.” The fear induced by reporting by reputable media and
highly quoted think tanks about the overwhelming amounts of opioid
misuse and abuse across our country is simply not supported by the
research data. It is time to start focusing on the root causes of
the opioid overdose epidemic and on providing safe pain care and
effective interventions for those who are suffering. u
www.trauma-informed-california.org | [email protected](831)
515-7570 | Santa Cruz, CA
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California Center of Excellence for Trauma Informed Care
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reFerencesBirnbaum, E., & Lora, M. (2018, June 20). Opioid
crisis sending thousands of children into foster care. The Hill.
https://thehill.com/policy/healthcare/393129-opioid-crisis-sending-thousands-of-children-into-foster-care.
Bruder, J. (2018, July 31). The Worst Drug Crisis in American
History. The New York Times.
https://www.nytimes.com/2018/07/31/books/review/beth-macy-dopesick.html.
Centers for Disease Control and Prevention (2013, July 5). Vital
Signs: Overdoses of Prescription Opioid Pain Relievers and Other
Drugs Among Women—United States, 1999–2010. MMWR 2013;
62(26);537–542.
https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6226a3.htm.
Centers for Disease Control and Prevention (2018, October 3).
Opioid Overdose: U.S. Prescribing Rate Maps.
https://www.cdc.gov/drugoverdose/maps/rxrate-maps.html.
Chang H., Daubresse M., Kruszewski S., & Alexander, G.
(2014, May). Prevalence and treatment of pain in EDs in the United
States, 2000 to 2010. American Journal of Emergency Medicine 2014;
32(5): 421-31. https://www.ncbi.nlm.nih.gov/pubmed/24560834.
Daubresse M., Chang H., Yu Y., Viswanathan S., Shah, N.,
Stafford, R., Kruszewski S., & Alexander, G. (2013, October).
Ambulatory diagnosis and treatment of nonmalignant pain in the
United States, 2000–2010. Medical Care 2013; 51(10): 870-878.
https://www.ncbi.nlm.nih.gov/pubmed/24025657.
Drug Enforcement Administration (2017). Drugs of Abuse: A DEA
Resource Guide, 2017 Edition.
https://www.dea.gov/sites/default/files/sites/getsmartaboutdrugs.com/files/publications/DoA_2017Ed_Updated_6.16.17.pdf#page=40.
Drum, K. (2017, November 7). Here’s How President Trump Should
Be Fighting the Opioid Epidemic. Mother Jones.
https://www.motherjones.com/kevin-drum/2017/11/heres-how-president-trump-should-be-fighting-the-opioid-epidemic/.
Dube, S.R. et al. (2003, March). Childhood abuse, neglect, and
household dysfunction and the risk of illicit drug use: the adverse
childhood experiences study. Pediatrics, 111(3): 564-72. Retrieved
January 21, 2019 from
http://pediatrics.aappublications.org/content/111/3/564.long.
Florence, C.S., Zhou, C., Luo, F., Xu, L. (2016, October). The
Economic Burden of Prescription Opioid Overdose, Abuse, and
Dependence in the United States, 2013. Medical Care, 54(10):901–6.
Retrieved January 21, 2019 from
https://www.ncbi.nlm.nih.gov/pubmed/27623005.
Hedegaard, H. Warner, M., & Miniño, A.M. (2017, December).
Drug Overdose Deaths in the United States, 1999–2016. NCHS Data
Brief No. 294, data table for Figure 4. Centers for Disease Control
and Prevention.
https://www.cdc.gov/nchs/products/databriefs/db294.htm.
Hedegaard, H., Bastian, B.A., Trinidat, J.P., Spencer, M., &
Warner, M. (2018, December). Drugs Most Frequently Involved in Drug
Overdose Deaths: United States, 2011–2016. Centers for Disease
Control and Prevention.
https://www.cdc.gov/nchs/data/nvsr/nvsr67/nvsr67_09-508.pdf.
Lopez, G. (2018, March 22). Congress’s omnibus bill adds $3.3
billion to fight the opioid crisis. It’s not enough. Vox.
https://www.vox.com/policy-and-politics/2018/3/22/17150294/congress-omnibus-bill-opioid-epidemic.
Lopez, G. (2017a, December 21). The opioid epidemic, explained.
Vox.
https://www.vox.com/science-and-health/2017/8/3/16079772/opioid-epidemic-drug-overdoses.
Lopez, G. (2017b, December 18). The single biggest reason
America is failing in its response to the opioid epidemic. Vox.
https://www.vox.com/science-and-health/2017/12/18/16635910/opioid-epidemic-lessons.
Macy, B. (2018a). Dopesick: Dealers, Doctors, and the Drug
Company that Addicted America. New York: Little, Brown and Company,
Hachette Book Group.
https://www.amazon.com/Dopesick-Dealers-Doctors-Company-Addicted/dp/0316551244.
Macy, B. (2018b, July 20). “I Am Going to Die if I Keep Living
the Way I Am.” She Was Right. The New York Times. Retrieved from
https://www.nytimes.com/2018/07/20/opinion/sunday/opioid-addiction-treatment.html.
McCabe, S. E., West, B. T., Veliz, P., McCabe, V. V., Stoddard,
S. A., & Boyd, C. J. (2017, March). Trends in Medical and
Nonmedical Use of Prescription Opioids Among US Adolescents:
1976–2015. Pediatrics. Retrieved August 18, 2018 from
http://pediatrics.aappublications.org/content/early/2017/03/16/peds.2016-2387.
McCammon, S. (2018). White House Ad Campaign Aims To Prevent
Youth Opioid Abuse. Retrieved August 1, 2018, from
https://www.npr.org/2018/06/07/617906373/with-real-life-stories-white-house-ad-campaign-
aims-to-prevent-youth-opioid-abus.
Meier, B. (2018, May 29). Origins of an Epidemic: Purdue Pharma
Knew Its Opioids Were Widely Abused. The New York Times.
https://www.nytimes.com/2018/05/29/health/purdue-opioids-oxycontin.html.
National Institute on Drug Abuse (2018, August). Overdose Death
Rates. Retrieved August 17, 2018 from
https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates.
Nutt, D., King, L. A., Saulsbury, W., & Blakemore, C.
(2007). Development of a rational scale to assess the harm of drugs
of potential misuse. The Lancet, 369(9566), 1047–1053.
https://doi.org/10.1016/S0140-6736(07)60464-4.
SAMHSA Center for Behavioral Health Statistics and Quality
(2017, September). Results from the 2016 National Survey on Drug
Use and Health: Detailed Tables.
https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2016/NSDUH-DetTabs-2016.pdf.
SAMHSA Center for Behavioral Health Statistics and Quality
(2018a, September). Key Substance Use and Mental Health Indicators
in the United States: Results from the 2017 National Survey on Drug
Use and Health.
https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHFFR2017/NSDUHFFR2017.pdf.
SAMHSA Center for Behavioral Health Statistics and Quality
(2018b, September). Results from the 2017 National Survey on Drug
Use and Health: Detailed Tables.
https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHDetailedTabs2017/NSDUHDetailedTabs2017.pdf.
SAMHSA Center for the Application of Prevention Technologies
(2018c, June). Using International Classification of Diseases (ICD)
Codes to Assess Opioid-Related Overdose Deaths.
https://www.samhsa.gov/capt/sites/default/files/capt_resource/using-icd-10-codes-to-assess-opioid-related-overdose-deaths.pdf.
The White House (2017, October 26). Remarks by President Trump
on Combatting Drug Demand and the Opoid Crisis.
https://www.whitehouse.gov/briefings-statements/remarks-president-trump-combatting-drug-demand-opioid-crisis/.