The Forum tackled the challenges of the opioid crisis, hearing reports from public health experts, healthcare providers, law enforcement officials, and patient advocates who have been deeply involved in this complex crisis. The panel highlighted the extent of the opioid crisis and offered compelling illustrations of successful interventions.
Today, almost 12.5 million Americans are trapped in substance abuse. The cost of substance abuse is $559 billion annually for all substances, and $72.5 billion for prescription opioids, similar to the costs of chronic diseases such as diabetes, HIV, and asthma. In 2014, 1.9 million Americans abused prescription pain medications, and drug overdose deaths reached a new peak at 47,055 people, or the equivalent of about 125 Americans every day. At the same time, sufficient opioid prescriptions are written each year for every adult in the US to have a 30-day supply. How did we get here?
According to Lisa David, Executive Director of Public Health Solutions in New York, 20 years ago, improving pain management was an important clinical goal. Adequate pain management became a requirement for medical practice because it was associated with improved patient outcomes. What started out as good medical practice became a nightmare for millions.
Prescription Pain Medication Sales and Deaths
Pain Medication Prescriptions By State
Healthcare professionals, focused on pain management, sometimes prescribed opioids inappropriately or without taking into account the risk for abuse and addiction. For example, in the US, an estimated 14% to 22% of pregnant women receive an opioid prescription during their pregnancy. For most of whom, opioids are contraindicated. Consequently, neonatal abstinence syndrome (NAS) or opioid withdrawal increased by almost 300% between 2000 and 2009. National healthcare expenditures for treating babies with NAS grew from $731 million in 2009 to nearly $1.5 billion in 2012.
Greater availability of opioids created a street market for them among drug seekers. Once opioids are used, tolerance to them drives users to seek stronger drugs. Thus, prescription opioids became a gateway to heroin, fentanyl, and stronger opioids such as carfentanil (an elephant tranquilizer) and other synthetic opioids. The epidemic of opioid abuse brings with it a wave of new HIV and Hepatitis C cases, Ms. David pointed out, with its attendant public health implications and costs.
According to Ms. David, once legitimately prescribed opioids entered the market, easier access to them expanded the demographics of abuse to include white men and women, 18-25-year-olds, and people with annual incomes greater than $50,000.
Today, 42 states have enacted programs to address the issues of opioid abuse. In addition, medication-assisted treatment is available to help people get through opioid withdrawal, including methadone, buprenorphine/naloxone (Suboxone), and injectable naltrexone (Vivitrol).
Ms. David reported on New York State’s programs, including the 2012 “I-STOP” law, which requires prescribers to participate in the New York prescription monitoring program (PMP). That initiative reduced by 60% the number of people who obtained multiple prescriptions from opioids from different providers.
In 2014, the law was further strengthened to enact measures to support addiction treatment, create new penalties regarding illegal drug distribution, improve accessibility to naloxone anti-overdose kits, and expand public education campaigns to prevent opioid and heroin use.
In 2016, electronic prescribing of opioids was required so that prescriptions were checked against the database to eliminate multiple sources. Insurance coverage for addiction treatment and reporting of opioid overdoses were mandated. Furthermore, medical education for providers on opioid prescribing has been expanded, and providers are restricted to writing only a 7-day prescription of opioids for acute pain.
Ms. David acknowledged significant cultural challenges to overcoming opioid abuse. She noted that popular opinion often claims that providing treatment for overdoses coddles addicts and doesn’t address the problem. This attitude leaves users facing the stigma of admitting addiction and need for treatment. Physicians don’t want these patients in their practice and anticipate a lengthy recovery period. Furthermore, as prescription opioids become harder to obtain, users may move to heroin. In fact, heroin overdose is now the leading cause of accidental death in New York State. “The scale of the problem, its cost, and its harm to people’s lives make this crisis a major public policy issue,” Ms. David concluded.
“The problem of opioid abuse is dominating State medical societies,” according to Tim Maglione, JD, Senior Director, Government Relations, Ohio State Medical Association. In Ohio, 6 people die each day of opioid overdoses, many of whom started with prescription opioids. Recently, in the course of only 6 days, 174 people in Cincinnati overdosed on heroin mixed with fentanyl, a new street drug.
Mr. Maglione reported on Ohio’s extensive efforts to address the opioid abuse crisis. He acknowledged the critical role played by the Ohio legislature and the important contributions by Ohio Governor John Kasich. Since 2011, Ohio has developed a multi-pronged approach to fight drug abuse, he reported, with a program to:
1. Prevent drug abuse before it starts
2. Reduce the pill supply
3. Prevent diversion
4. Increase enforcement and interdiction efforts
5. Save lives
6. Expand treatment options and recovery support
Ohio supports a broad array of programs to stimulate conversations throughout the community in order to stop abuse before it starts. Programs for healthcare providers, parents and caregivers, teachers and students, and for the whole community include specific topics for each audience. Information meetings are held at PTA meetings, in community settings such as churches, and in homes. In addition, email campaigns and online programming are targeted to specific groups to raise awareness of the risk of opioid abuse and strategies to deter it.
Details of Ohio’s many opioid abuse prevention programs can be accessed online:
• Safe Medication and Responsible Treatment (SMART)
• Start Talking Program
• Parents 360 Rx
• 5 Minutes for Life
A broad coalition of community entities brings the message of opioid drug abuse prevention to a wide variety of constituencies from students to parents who have lost a child to drug overdose. Some of the groups include:
• Drug Free Action Alliance (DFAA)
• Ohio Youth-led Prevention Network
• Ohio College Initiative to Enhance Student Wellness
• Grief to Advocacy to Prevention (GAP)
Ohio also requires every school district to include instruction in prescription opioid abuse prevention, and provides programming to support this. Ohio State Troopers and Ohio National Guard members, and local law enforcement officials speak to school sports teams about responsible decision-making, leadership and encouraging those in their peer group to live a drug-free lifestyle.
Five years ago, one county in Ohio had 15 pain clinics, many of them not run by physicians and also illegal, but attracting “patients” from 8 states. In one Ohio town with a population of 75,000, a single pain clinic dispensed more opioid prescriptions than the Cleveland Clinic. Ohio has shut down these “Pill Mills”—illegal pain clinics that dispensed opioid prescriptions for profit, rather than for medical necessaity.
For the medically valid Pain Management Clinics, significant restrictions were enacted to reduce abuse, including mandatory registration and use of State prescription drug monitoring program (PDMP)—the Ohio Automated Rx Reporting System (OARRS). The legislature allocated $1.5M to help integrate the OARRS system with practice management systems and electronic medical records. The number of Ohio prescribers with an OARRS account increased from 5,000 to 36,000 since 2010, and queries to the database rose from 510,000 in 2010 to 16.5 million in 2015. The system also is linked to other States via PMP InterConnect®.
New regulations require parental consent when opioids are prescribed to minors, and new prescribing guidelines limit opioid prescribing in emergency rooms to a 3-day supply, require re-evaluation at a specific threshold for chronic pain prescriptions, and for acute pain, the guidelines recommend non-pharmacologic therapy first, non-opioid therapy next, and a minimum quantity if opioids are prescribed.
Opioid Doses Dispensed to Ohio Patients
There were 92 million fewer opioid doses prescribed in 2015 compared to 2012.
The new initiatives have been effective. The number of patients seeking multiple opioid prescriptions dropped from 3,000 to 720 from 2009 to 2015, and there was a 22% decrease in the number of patients with excessive opioids prescribed.
The strategies for presenting diversion focus on new rules for hospice storage and disposal of opioids and highly visible drug take-back programs.
In 2013, Ohio Attorney General Mike DeWine developed the Heroin Unit to go after opiate traffickers and to work with communities affected by the opiate epidemic. The unit combines the skills of the Ohio Organized Crime Investigations Commission (OOCIC), the Ohio Bureau of Criminal Investigation (BCI), the Special Prosecutions Section, and drug-abuse outreach specialists.
For five consecutive years, the Ohio Highway Patrol has set new records for drug seizures, and disciplinary actions have been taken against rogue prescribers. The Joint Study Committee on Drug Use Prevention Education, which is a coalition of lawmakers, educators, law enforcement officials, and medical professionals, is currently evaluating drug use prevention education in schools.
Mr. Maglione focused on legislative efforts that are saving the lives of people who overdose. HB 110 amends the Good Samaritan Law to train emergency responders on optimal responses to drug overdoses, including providing the opioid antidote, naloxone, while HB 4 makes naloxone available through pharmacies via physician standing order. Today, 1,000 pharmacies in 79 of Ohio’s 88 counties offer naloxone without a prescription. The legislature allocated $1 million for law enforcement and first responders to purchase naloxone, and 19,782 naloxone doses were administered by EMS in 2015, Mr. Maglione reported.
The legislature recognized that, once addicts have survived overdose or have accepted the need for recovery treatment, they need services for treatment and recovery. In 2016, Ohio allocated $2.5 million to fund 900 new beds for recovery programs and $5.5 million for Medication Assisted Treatment. Medicaid coverage was expanded to 400,000 Ohioans so recovery services were accessible. Addiction Specialists have been added to prison staffs, and a referral hotline was put in place.
Mr. Maglione concluded by pointing out that it takes a comprehensive program involving all aspects of the community to address the crisis of opioid abuse, as depicted here:
Addressing Opioid Abuse
The opioid abuse problem begins with the drug supply chain, John Coleman, PhD, President of the Prescription Drug Research Center, told the Forum. As a Retired Special Agent for the US Drug Enforcement Agency (DEA), Dr. Coleman had well-informed insights into the commerce of illegal drug distribution. “Pill mills, rogue or corrupt healthcare providers, and Internet pharmacies are the local sources of controlled substances that drive the opioid crisis, but how do they get controlled substances?” Dr. Coleman asked.
To answer that question, Dr. Coleman reminded the Forum of the Controlled Substances Act (CSA) of 1970, which limited the distribution of Controlled Substances only to certified customers such as pharmacy buying groups, Group Purchasing Organizations (GPOs), hospital groups, and Integrated Delivery Networks (IDNs). Today, three companies control 85% of all drug distribution in the US: AmerisourceBergen Corporation, Cardinal Health, Inc., and McKesson Corporation, and they have many branches in all the States. Overall, there are 937 registered US distributors of controlled substances in the nation.
Federal law requires distributors of controlled substances to “design and operate a system to disclose… suspicious orders of controlled substances,” that is, “orders of unusual size, orders deviating substantially from a normal pattern, and orders of unusual frequency,” and to report them to the nearest DEA field office.
In 2005, investigations of DEA-registered wholesale distributors found that some were unlawfully supplying criminal enterprises with controlled substances. As a result, the DEA launched a special enforcement probe directed against drug supply chain entities. Between 2006 and 2015, more than a dozen wholesale distributors, including the big three: McKesson, Cardinal Health, and AmerisourceBergen, were fined and/or had their DEA registration(s) suspended for failing to report suspicious orders as required by law for orders ranging from 3 million to 48 million dosage units of controlled drugs, per instance.
The outcomes of these regulatory actions have been fines up to $150 million, suspension or revocation of DEA registration, and agreement to a Memoranda of Understanding (MOA). The MOA stipulates the specific evidence for the violations. In agreeing to an MOA, the distributor admits a guilty plea to those specified charges, may be liable for a fine, and agrees to make the necessary changes to abide by the law. While the MOA indemnifies the drug distribution company against further Federal prosecution, it does not protect against prosecution by the states.
“Can States regulate wholesale distributors of controlled substances?” Dr. Coleman rhetorically asked the Forum. His answer focused on Florida’s House Bill 7095: “An act relating to prescription drugs.” The law, enacted in 2011, requires that wholesale distributors must:
• Assess orders for greater than 5,000 unit doses of any one controlled substance in any one month to determine whether the purchase is reasonable.
• Take reasonable measures to identify its customers, understand the normal and expected transactions conducted by those customers, and identify those transactions that are suspicious in nature.
• Establish internal policies and procedures for identifying suspicious orders and preventing suspicious transactions.
• Report to the department any regulated transaction involving an extraordinary quantity of a listed chemical, an uncommon method of payment or delivery, or any other circumstance that the regulated person believes may indicate that the listed chemical will be used in violation of the law.
• Maintain records that document the report submitted to the department in compliance with this paragraph.
The results of Florida’s legislation were compelling. In 2010, the State’s average medical distribution of the prescription opioid oxycodone was 82,500 grams, whereas, the national average was about 23,000 grams per 100,000 people. By 2015, Florida’s average had fallen to 20,800 grams, close to the national average of 18,000 grams per 100,000 people.
Medical Distribution of Oxycodone
The States can easily access the evidence accumulated by the Federal government and could seek reimbursements from the companies for the costs incurred by illegal distribution of controlled substances.
In 2010, Florida had 24.7% of physician-buyers of oxycodone in America and accounted for 88% of all oxycodone dispensed by physician-buyers. By 2015, Florida had only 4.3% of physician-buyers of oxycodone in the US and accounted for only 6.4% of all oxycodone dispensed by physician-buyers, a decline of 93% in just 4 years. In 2010, Florida Medical Examiners reported 1,516 deaths “caused” by oxycodone. By 2014, only 470 deaths were reported to be “caused” by oxycodone, a decline of 69% in just four years.
In concluding, Dr. Coleman noted that it costs the States significant resources to address the problems caused by illegal behavior among drug distributors. Those distributors acknowledge their guilt when they sign MOAs. While the MOA gives companies immunity from additional Federal prosecution on these charges, theSstates can still prosecute. The States can easily access the evidence accumulated by the Federal government and could seek reimbursements from the companies for the costs incurred by illegal distribution of controlled substances, Dr. Coleman concluded.
Fred Wells Brason II was a Hospice chaplain in 2004 in North Carolina, when he observed that opioid medications prescribed to his Hospice patients for terminal pain often went missing. Eventually, he discovered that some family members and caregivers were stealing, sharing, or selling the Hospice medications.
Compelled to understand why this was happening and how to intervene in the opioid abuse process, Mr. Brason spent four years researching solutions and building alliances. In order to develop an effective plan for intervening at a point in the pathway to opioid abuse where change was possible, he needed to understand the who, what, when, where, why, and how of opioid overdose. The paths to opioid overdose were varied and were reported among people from age 14 to 72:
• Patient misuse
• Family/friends sharing to self-medicate
• Accidental ingestion
• Recreational user
• Substance Use Disorder
“Opioid abuse affects every population,” Mr. Brason learned in his research. “We realized we needed to reach everyone.” In 2004-2005, he focused on raising awareness of the opioid abuse problem and worked to persuade State agencies that it was essential to share their data on opioid issues. “Data are essential,” Mr. Brason said, “We need to know today who overdosed on what drug and who prescribed it” if we want to intervene effectively.
By 2006, legislation was enacted by North Carolina to limit opioid prescribing to a 3-day supply accompanied by a referral to a source for ongoing care. The State adopted provider education and prescriber toolkits to guide pain management and deter opioid abuse.
In 2008, Mr. Brason founded and became President and CEO of Project Lazarus. Project Lazarus is a nonprofit organization founded on the belief that communities are ultimately responsible for their own health and that every drug overdose is preventable. The organization’s mission is to prevent opioid/opiate poisonings, present responsible pain management, and promote substance use treatment and support services. “All laws get implemented at the community level,” Mr. Brason reminded the Forum. Therefore, Project Lazarus works intensively with communities to implement local programs to prevent, intervene, and treat opioid addiction through expert support and small (~$10,000) grants.
The Project Lazarus model can be conceptualized as a wheel, with three core components (The Hub) that must always be present, and seven components (The Wheel), which can be initiated based on specific needs of a community.
The model puts the community at the hub of the process, starting with raising community awareness of the problem of prescription opioid overdose. A coalition is formed to coordinate all sectors of the local community to create a response. Then, data and evaluations are collected to ensure that the community’s approach, using locally available resources, meets their locally identified needs.
From the hub, communication and coordination go outward, including community education to improve the public’s ability to recognize and avoid the dangers of opioid abuse, and provider education to improve treatment of chronic pain and support addiction and mental health treatment. Pain patient support is provided to safely and effectively manage pain.
Hospital emergency department policies are developed to identify and avoid drug-seeking behavior and to provide opioid overdose rescue medications. “Naloxone is readily available in four FDA-approved devices,” Mr. Brason reminded the Forum. “Make sure they are on your State formularies.”
A focus on harm reduction helps people who do abuse opioids to prevent overdose death. Finally, treatment programs are put in place to help those with addiction recover. “Treatment must be available to all who need it, without stigma. No one chooses addiction,” Mr. Brason told the Forum.
Project Lazarus Model
The Project Lazarus model can be conceptualized as a wheel, with three core components (The Hub) that must always be present, and seven components (The Wheel) which can be initiated based on specific needs of a community.
Project Lazarus was first implemented in Wilkes County, North Carolina in 2008. In that year, 82% of drug overdoses were related to prescription opioids; by 2011, this plummeted to 0%. Substance abuse incidences in schools fell from 7.3 per 1,000 in 2011-2012 to 2.5 per 1,000 2014-2015. Substance-abuse-related Emergency visits decreased 15.3%. Diversion tips increased and crime was down by 10%.
Based on these promising results, a statewide roll-out of Project Lazarus was funded by the Kate B. Reynolds Foundation and the State’s Office of Rural Health fund in 2012. In 2013, the Project’s statewide outcomes were evaluated and the positive findings led to Project Lazarus implementation in 82 of North Carolina’s 100 counties by 2016.
In conclusion, Mr. Brason said, “To identify the drivers for substance abuse, you have to look at the beginning and the end of the process and everything in between. In order to save lives, we have to change lives. Communities can do that. We have to change the village to change the individual.”
Sen. Sandy Pappas (MN): If providers must check the prescription drug monitoring database every time they write an opioid prescription, how is patient privacy protected?
Mr. Maglione: There is strict regulation of who can view the database, including physicians and their nurse-delegates, pharmacists, patients, and law enforcement people under specific circumstances. There are substantial fines for misuse of the database.
Sen. Brent Hill (ID): We uncovered one doctor who was charging patients $100 for an oxycodone prescription. He wrote prescriptions for 20,000 doses. How can we prevent this?
Mr. Brason: Prescription drug monitoring programs (PDMP) capture the volume of prescribing. You can identify outliers from the average and contact them to determine why they are prescribing differently from their peers. The goal is not to intimidate physicians but to have greater awareness of prescribing patterns and see if education is needed or if this is a Pill Mill.
Sen. Tonya Schuitmaker (MI): I supported a bill to require that all opioid prescribers check the database before prescribing. The Michigan State Medical Society pushed back, saying that it was too cumbersome to check the database. How difficult is it?
Mr. Maglione: You have to make it administratively easy to query the database. In Ohio, the state allocated funds to ensure providers would have easy access. It is optimal if the database interfaces with the electronic medical record.
Mr. Brason: Legislation should not only make it mandatory to check the database but also to provide a referral for the patient to a program or a provider who will manage their ongoing care.
Sen. David Long (IN): Affordable access to opioid addiction treatment is critical. A recovery program can cost $32,000, and sometimes once through is not enough. How can we decrease the cost of opioid abuse? Are there sustainable models for funding treatment and recovery?
Ms. Lisa David: States can mandate that health insurance companies cover addiction treatment and use those funds to expand what services are available. There should be no pre-authorization and no review of the case for at least two weeks.
Mr. Brason: Treatment needs to come with wraparound services and peer-recovery support. No State has enough money to provide residential care for all. Support has to be provided at the home and community levels. With Project Lazarus, we were able to build wraparound programs with only a $10,000 start-up grant and coordination of a coalition of community resources.
An executive with over 25 years of experience in bringing much-needed health care services to the public sector, Lisa David joined Public Health Solutions (PHS) in 2015 as President and CEO. Public Health Solutions has spent the past 50 years improving the health outcomes of underserved people in New York, and serves over 200,000 clients annually. PHS works to help people gain access to health insurance, proper foods and nutrition, and reproductive and family services.
The organization conducts high-profile research into underserved communities, including those who have contracted HIV, suffer from childhood obesity, or are at risk to become pregnant as teenagers, in order to help create programs and policies that provide effective remedies. PHS is also engaged in advocacy and policy work aimed at eliminating smoking in New York City.
Public Health Solutions serves as a fiscal conduit for several programs working within New York City and State to provide assistance to patients and clients with Opioid addictions and related issues. Ms. David leads the Public Health Solutions team in creating strategies, building relationships and providing expertise in each of our service areas.
Before joining Public Health Solutions, Ms. David was the interim CEO of Medicines360, a not-for-profit pharmaceutical company that brought an affordable, long-acting birth control method to low income women. She is still a member of the Board.
Ms. David was also EVP and COO of Planned Parenthood Federation of America for six years, where she was responsible for supporting the strategy and work of all 67 US affiliates, along with Planned Parenthood global services in Africa and South America. During her tenure, she was able to work with affiliates to overcome the 2008-2009 economic downturn, prepare for the Affordable Care Act, and build out digital health services.
Prior to her appointment at Planned Parenthood, Ms. David was the Vice Chair for Administration of the Department of Obstetrics and Gynecology at the Columbia School of Physicians and Surgeons, where she partnered with the Chair to implement a financial turnaround of the Department and to build out three subspecialty programs: Prenatal Pediatrics, focused on fetal anomalies and high-risk multiple births, Gynecologic Oncology, and Reproductive Endocrinology. During her tenure, Department revenue grew from $18 million to $62 million annually.
Ms. David also spent 17 years as a consultant, partnering with Chartis, Women’s Health Management Solutions and APM.
Tim Maglione leads the OSMA’s government relations team which relentlessly advocates for physicians, saving them time while promoting their profession. The OSMA’s government relations team is dedicated to ensuring quality healthcare for all Ohioans and works to inform patients and the public of critical issues impacting health care. Tim is a graduate of The Ohio State University and earned his law degree from Capital University Law School.
Mr. Coleman served thirty-two years as a Special Agent of the U.S. Drug Enforcement Administration (DEA) before retiring in January 1998 as one of its top management officials. His career included progressively important permanent assignments in the United States and Europe. His domestic field service included assignments as Special Agent in Charge of three separate DEA Field Divisions and Associate Special Agent in Charge and Assistant Special Agent in Charge of two others. As Assistant Administrator for Operations, the third highest position in the DEA, Mr. Coleman supervised an annual operating budget of $816 million, and managed the activities of over 7,000 employees in 19 domestic divisions and 75 overseas offices. Mr. Coleman's career included extensive executive and policymaking experience at the uppermost levels of government service. Mr. Coleman began his career in 1965 as an entry-level undercover drug agent on the streets of New York City and went on to eventually hold several of the most important positions in the agency. From 1991 until retirement in 1998, Mr. Coleman served at the highest rank (SES-06) of the federal Senior Executive Service. From 1991 to 1994, Mr. Coleman served as the Assistant Administrator for Operations, the highest non-Presidentially appointed position in the DEA. John Coleman is President of the Board of Directors of Drug Watch International.
Fred Wells Brason II is the President/CEO of Project Lazarus, a community based opioid overdose prevention model reaching North Carolina and various parts of the United States including the U.S. Military and Tribal Groups.
Mr. Brason is also Project Director for Community Care of North Carolina’s Medicaid Management System Statewide Chronic Pain Initiative. He serves on the SAMHSA/CSAT Emerging Opioid Overdose Surveillance Group and is a member of the National Association of Drug Diversion Investigators (NADDI). Mr. Brason also serves on the Advisory Board for the NC Controlled Substance Reporting System, consults for the North Carolina Medical Society Opioid Death Reduction Task Force, and Co-Chairs the SAMSHA/ASTHO expert panel for Opioid Prescriber toolkit publication. He has also served on the FDA scientific workshop committees for the role of Naloxone in Opioid Overdose Fatality Prevention and Assessment of Analgesic Treatment of Chronic Pain. Mr. Brason received the 2012 Robert Wood Johnson Foundation Community Health Leader Award.
Other Fall 2016 Forum Highlights articles:
In 2014, 1.9 million Americans abused prescription pain medications, and drug overdose deaths reached a new peak at 47,055 people, or the equivalent of about 125 Americans every day.
Executive Director of Public Health Solutions
New York, NY
The New York prescription monitoring program (PMP) reduced by 60% the number of people who obtained multiple prescriptions from opioids from different providers.
Heroin overdose is now the leading cause of accidental death in New York State. “The scale of the problem, its cost, and its harm to people’s lives make this crisis a major public policy issue.”
Ohio State Medical Association
In one Ohio town with a population of 75,000, a single pain clinic dispensed more opioid prescriptions than the Cleveland Clinic.
In 2016, Ohio allocated $2.5 million to fund 900 new beds for recovery programs and $5.5 million for Medication Assisted Treatment.
President of the Prescription Drug
Pill mills, rogue or corrupt healthcare providers, and Internet pharmacies are the local sources of controlled substances that drive the opioid crisis, but how do they get controlled substances?
Between 2006 and 2015,
more than a dozen wholesale distributors, including the
big three: McKesson,
Cardinal Health, and AmerisourceBergen, were fined and/or had their DEA registration(s) suspended for failing to report suspicious orders.
Fred Wells Brason II
Project Lazarus is a nonprofit organization founded on the belief that communities are ultimately responsible for their own health and that every drug overdose is preventable.
Treatment must be available to all who need it, without stigma. No one chooses addiction.
Sen. Sandy Pappas
Sen. Brent Hill
Sen. Tonya Schuitmaker
Sen. David Long
Executive Director of Public Health Solutions
New York, NY
Ohio State Medical Association
President of the Prescription Drug
Fred Wells Brason II
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