S A M H S A

Opioid Overdose

TOOLKIT: Information for Prescribers

TABLE OF CONTENTS

INFORMATION FOR PRESCRIBERS

OPIOID OVERDOSE 3

TREATING OPIOID OVERDOSE 7

LEGAL AND LIABILITY CONSIDERATIONS 9

CLAIMS CODING AND BILLING 9

RESOURCES FOR PRESCRIBERS 9

ACKNOWLEDGMENTS, ETC. 11

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Acknowledgments

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Also see the other components of this Toolkit:

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Facts for CommunityMembers

Five Essential Steps for First Responders

Safety Advice for Patients&FamilyMembers

RecoveringfromOpioidOverdose: Resources for OverdoseSurvivors&FamilyMembers

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INFORMATION FOR PRESCRIBERS

Opioid overdose isamajorpublichealthproblem,accounting for almost17,000deathsa year intheUnited States [1].Overdose involvesbothmalesandfemales of all ages, ethnicities,and

demographicandeconomiccharacteristics,andinvolvesbothillicit opioidssuchasheroinand,increasingly,prescriptionopioidanalgesics suchasoxycodone,hydrocodone,fentanylandmethadone[2]. Physiciansandotherhealth care providers can makeamajor

contribution toward reducingthetoll of opioid overdose throughthe care they take inprescribingopioidanalgesicsandmonitoringpatients’ response,aswellastheiracuityinidentifyingandeffectivelyaddressing opioid overdose. FederallyfundedCME courses are available at no charge at www.OpioidPrescribing.com (five courses funded by the SubstanceAbuseandMentalHealthServicesAdministration)andon MedScape (two courses funded by theNationalInstituteonDrugAbuse).

OPIOID OVERDOSE The risk of opioid overdose can beminimizedthroughadherence to the followingclinicalpractices,which are supported by aconsiderablebody of evidence[3-6].

ASSESS THE PATIENT. Obtainingahistory of thepatient’s past use of drugs(eitherillicitdrugsorprescribedmedicationswithabusepotential) isanessential first step inappropriateprescribing.Suchahistoryshould includeveryspecificquestions. For example:

n Inthe past 6months, have you taken any medications to help you calmdown,keepfromgettingnervousor upset, raiseyourspirits, make you feelbetter,andthelike?

n Have you beentaking any medications to help you sleep? Have you beenusingalcohol for thispurpose?

n Have you ever takenamedication to help you withadrugor alcoholproblem?

n Have you ever takenamedication for anervousstomach?

n Have you takenamedication to give you moreenergyor to cut down onyourappetite?

The patienthistoryalsoshouldincludequestionsabout use of alcohol andover-the-counter (OTC) preparations. For example,theingredients inmanycommoncoldpreparationsincludealcoholandothercentral nervous system (CNS)depressants, so these productsshould not be usedincombinationwithopioidanalgesics. Positive answers to any of these questions warrant furtherinvestigation.

TAKE SPECIAL PRECAUTIONS WITH NEW PATIENTS. Manyexperts recommendthatadditionalprecautions betakeninprescribing for new patients [5,6]. These mightinvolvethefollowing:

1. Assessment: Inaddition to thepatient historyandexamination,the physi-cianshoulddeterminewhohasbeen caring for thepatientinthe past, what medications have beenprescribed and for whatindications,andwhat substances(includingalcohol,illicit drugsand OTC products)thepatient hasreportedusing.Medicalrecords shouldbeobtained(withthepatient’s consent).

2. Emergencies: In emergency situations, the physician should prescribe the smallest possible quantity, typically not exceedinga3 days’ supply of an opioid analgesic and arrange for a return visit the next day. At aminimum, the patient’s identity should be verified by asking for proper identification.

3. Limit quantities: Innon-emergency situations,onlyenough of anopioid analgesicshouldbeprescribed to meetthepatient’sneedsuntilthe nextappointment. The patientshould bedirected to return to the office for additionalprescriptions,astelephone ordersdo not allowthephysician to reassess thepatient’scontinuedneed for themedication.

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STATE PRESCRIPTION DRUG MONITORING PROGRAMS (PDMPs) have emerged as a key strategy for addressing the misuse andabuse of prescription opioids and thuspreventing opioid overdoses and deaths.Specifically, prescribers can checktheir state’s PDMP database to determine whether a patient is filling the prescriptions provided and/ or obtainingprescriptions for the sameor similar drug from multiple physicians. While man y states now have operational PDMPs, the programs

differ from state to state in terms of the exact information collected, how soon that information is available to physicians, and who may access the data. Therefore, information about the program in aparticular state is best obtained directly from the PDMP or from the state board of medicine or pharmacy.

SELECT AN APPROPRIATE MEDICATION. Rationaldrugtherapy demandsthattheefficacyand safety of allpotentiallyuseful medicationsbereviewed for theirrelevance to thepatient’sdiseaseor disorder[3,6]. Whenanappropriatemedicationhasbeenselected,the dose,

schedule,and formulation shouldbedetermined. These choices often are just as important in optimizing pharmacotherapy as the choice of medication itself. Decisions involve (1) dose (based not only on age and weight of the patient, but also on severity of the disorder, possible loading-dose requirement, and the presence of potentially interacting drugs); (2) timing of administration (such asabedtime dose to minimize problems associated with sedative or respiratory depressant effects); (3) route of administration (chosen to improve compliance/adherence as well as to attain peak drug concentrations rapidly); and (4) formulation (e.g., selectinga patch in preference to atablet, or an extended-release product rather than an immediate-release formulation). Additionalsafeguards are recommendedbeforeprescribinganopioid

analgesic. For example, even whensoundmedicalindications have been established,physicianstypicallyconsiderthreeadditional factors before deciding to prescribe[3,6]:

1. The severity of symptoms,interms of thepatient’sability to accommodatethem.Relief of symptomsisalegitimate goal of medi-cal practice,butusingopioidanalgesicsrequirescaution.

2. Thepatient’s reliability in taking medications,notedthrough observationandcarefulhistory-taking. The physicianshould assess a patient’shistory of andrisk factors for drugabusebeforeprescribing any psychoactivedrugandweighthebenefitsagainsttherisks. The likelydevelopment of physicaldependenceinpatientsonlong-term opioidtherapyshouldbemonitoredthroughperiodiccheck-ups.

3. The dependence-producing poten-tial of the medication. The physician shouldconsiderwhetheraproductwith less potential for abuse,or even anon-drugtherapy,wouldprovideequivalent benefits.Patientsshouldbewarned aboutpossibleadverseeffectscaused by interactionsbetweenopioidsand othermedicationsorillicitsubstances, includingalcohol.

At thetimeadrugisprescribed, patientsshouldbeinformedthatitis illegal to sell, give away, or otherwise share theirmedicationwithothers,including familymembers. The patient’sobligation extends to keepingthemedicationina lockedcabinetorotherwiserestricting access to itand to safelydisposing of any unusedsupply(visit http://www.fda. gov/ForConsumers/ConsumerUpdates/ ucm101653.htm for advicefromthe FDA on how to safelydispose of unused medications).

EDUCATE THE PATIENT AND OBTAIN INFORMED CONSENT. Obtaining informedconsentinvolvesinformingthe patientabouttherisksandbenefits of the proposedtherapyand of theethicaland legalobligationssuchtherapy imposes onboththephysicianandpatient[6]. Suchinformedconsent can servemultiple purposes:(1)itprovidesthepatientwith informationabouttherisksandbenefits of opioidtherapy;(2)it fosters adherence to thetreatmentplan;(3)itlimitsthe potential for inadvertentdrugmisuse; and(4)itimprovestheefficacy of the treatmentprogram. Patient education and informed consent

shouldspecificallyaddressthepotential for physicaldependenceandcognitive impairmentassideeffectsassociatedwith

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opioidanalgesics.Otherissuesthatshouldbeaddressedintheinformed consentortreatmentagreementincludethefollowing[6]:

n The agreementinstructsthepatient to stop takingallotherpainmedi-cations, unless explicitly told to continue by the physician. Such a state-mentreinforcestheneed to adhere to asingletreatmentregimen.

n The patientagrees to obtaintheprescribedmedicationfromonlyone physicianand,ifpossible,fromonedesignatedpharmacy.

n The patientagrees to take themedicationonlyasprescribed (for some patients,it may bepossible to offer latitude to adjustthe dose as symptomsdictate).

n The agreementmakesitclearthatthepatientisresponsible for safe-guardingthewrittenprescriptionandthesupply of medications,and arrangingrefillsduringregular office hours.Thisresponsibilityincludes planningahead so as not to runout of medicationduringweekendsor vacationperiods.

n The agreementspecifiestheconsequences for failing to adhere to the treatmentplan,which may includeweaninganddiscontinuation of opioidtherapyifthepatient'sactionscompromisehisorher safety.

Bothpatientandphysicianshouldsigntheinformedconsent agreement,anda copy shouldbeplacedinthepatient'smedicalrecord. Italso ishelpful to givethepatienta copy of theagreement to carrywith himorher, to documentthesourceandreason for any controlleddrugs inhisorherpossession.Somephysiciansprovidealaminated card that identifiestheindividualasapatient of theirpractice.Thisishelpful to otherphysicianswho may see thepatientandinthe event thepatientis seeninanemergencydepartment.

EXECUTE THE PRESCRIPTION ORDER. Carefulexecution of the prescriptionorder can preventmanipulation by thepatientorothers intent onobtainingopioids for non-medicalpurposes. For example,federal law requiresthatprescriptionorders for controlledsubstancesbesigned anddatedonthe day they are issued.Alsounderfederal law, every prescriptionordermustinclude at leastthefollowinginformation: Nameandaddress of thepatient Name,addressandDEAregistrationnumber of thephysician Signature of thephysician Nameandquantity of thedrugprescribed Directions for use Refillinformation Effective date ifotherthanthe date onwhichtheprescription was written

Many states imposeadditional requirements,whichthephysician can determine by consultingthe state medicallicensingboard.Inaddition, there are specialfederalrequirements for drugsindifferentschedules of the federalControlledSubstances Act (CSA), particularly those inSchedule II,wheremanyopioidanalgesics are classified. Blankprescriptionpads,aswell

asinformationsuchasthenames of physicianswhorecentlyretired, left the state, ordiedall can beused to forge prescriptions. Therefore, itisasound practice to store blankprescriptionsin asecureplaceratherthanleavingthem inexaminingrooms.

NOTE: The physicianshouldimmediately reportthetheftor loss of prescriptionblanks to the nearest field office of thefederalDrug EnforcementAdministrationand to the state board of medicineorpharmacy.

MONITOR THE PATIENT’S RESPONSE TO TREATMENT. Properprescription practicesdo not endwhenthepatient receivesaprescription.Plans to monitor for drugefficacyand safety, compliance, andpotentialdevelopment of tolerance mustbedocumentedandclearly communicated to thepatient[3]. Subjectivesymptoms are important

inmonitoring,as are objectiveclinical signs(suchasbodyweight,pulse rate, temperature,blood pressure, andlevels of drugmetabolitesinthebloodstream). These can serveasearlysigns of therapeuticfailureorunacceptable adversedrugreactionsthatrequire modification of thetreatmentplan. Askingthepatient to keepalog of

signsandsymptomsgiveshimorhera sense of participationinthetreatment

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programandfacilitatesthephysician’sreview of therapeuticprogressandadverse events. Simply recognizing the potential for non-

adherence, especially during prolonged treatment, isasignificant step toward improving medication use [7]. Steps such as simplifying the drug regimen and offering patient education also improve adherence, as do phone calls to patients, home visits by nursing personnel, convenient packaging of medication, and periodic urine testing for the prescribed opioid as well as any other respiratory depressant. Finally,thephysicianshould convey to the

patientthroughattitudeandmannerthat any medication,nomatter how helpful,isonly part of anoveralltreatmentplan. Whenthephysicianisconcernedabout

thebehaviororclinicalprogress (or thelack thereof) of apatientbeingtreatedwithan opioidanalgesic,itusuallyisadvisable to seek aconsultationwithanexpertinthedisorder for which the patient is being treated and an expert inaddiction.Physiciansplacethemselves at riskiftheycontinue to prescribingopioidsin theabsence of suchconsultations[6].

CONSIDER PRESCRIBING NALOXONE ALONG WITH THE PATIENT’S INITIAL OPIOID PRESCRIPTION. Withproper education,patientsonlong-termopioidtherapy andothers at risk for overdose may benefit fromhavinganaloxonekit to use inthe event of overdose [8]. Patients who are candidates for such kits

include those who are:

n Takinghigh doses of opioids for long-term management of chronicmalignantornon-malignantpain.

n Receivingrotatingopioidmedication regimens(andthus at risk for incomplete cross-tolerance).

n Dischargedfromemergencymedical care followingopioid intoxicationorpoisoning.

n At highrisk for overdose because of alegitimatemedicalneed for analgesia,coupledwithasuspectedorconfirmedhistory of substanceabuse,dependence,ornon-medical use of prescrip-tionorillicitopioids.

n Completingmandatoryopioiddetoxificationorabstinence programs.

n Recentlyreleasedfromincarcerationanda past userorabuser of opioids(andpresumablywithreducedopioidtoleranceand highrisk of relapse to opioiduse).

Italso may beadvisable to suggestthattheat-riskpatient create an “overdose plan” to sharewithfriends,partnersand/or caregivers.Suchaplanwouldcontaininformationonthesigns of overdose and how to administernaloxoneorotherwiseprovide emergency care (as by calling911).

DECIDE WHETHER AND WHEN TO END OPIOID THERAPY. Certainsituations may warrantimmediatecessation of prescribing. These generallyoccurwhenout-of-controlbehaviorsindicatethat continuedprescribingisunsafeorcausingharm to thepatient[3]. Examplesincludealteringorsellingprescriptions,accidentalor intentional overdose, multipleepisodes of runningoutearly(due to excessiveuse),doctorshopping,orthreateningbehavior. Whensuch events arise,itisimportant to separatethepatient

asapersonfromthebehaviorscaused by thedisease of addiction, as by demonstratingapositiveregard for thepersonbutno tolerance for theaberrantbehaviors. The essential steps are to (1) stop prescribing,(2)tellthe

patientthatcontinuedprescribingis not clinicallysupportable (andthus not possible),(3) urge thepatient to accept areferral for assessment by anaddictionspecialist,(4)educatethepatient aboutsignsandsymptoms of spontaneouswithdrawaland urge thepatient to go to theemergencydepartmentifsymptomsoccur, and(5)assurethepatientthatheorshewillcontinue to receive care for thepresentingsymptomsorcondition[6].

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Identification of apatientwhoisabusingaprescribedcontrolled drug presents amajortherapeuticopportunity. The physicianshould have aplan for managingsuchapatient,typicallyinvolvingworkwith thepatientandthepatient’sfamily,referral to anaddictionexpert for assessmentandplacementinaformaladdictiontreatmentprogram, long-termparticipationina12-Stepmutualhelpprogramsuchas NarcoticsAnonymous,andfollow-up of any associatedmedicalor psychiatriccomorbidities[3]. In all cases, patients should be given the benefit of the physician’s

concern and attention. It is important to remember that even drug-seeking patients often have very real medical problems that demand and deserve the same high-quality medical care offered to any patient [3,6].

TREATING OPIOID OVERDOSE Inthetimeit takes for an overdose to becomefatal,itispossible to reverse the respiratorydepression and other effects of opioids through respiratorysupportandadministration of theopioidantagonist naloxone(Narcan)[9].Naloxoneisapproved by the FDA andhasbeen used for decades to reverse overdose andresuscitateindividualswho have overdosedonopioids. The safety profile of naloxoneisremarkablyhigh,especiallywhen

usedin low doses andtitrated to effect[8,9].Ifgiven to individuals who are not opioid-intoxicatedoropioid-dependent,naloxone producesnoclinicaleffects, even at high doses. Moreover,whilerapid opioidwithdrawalintolerantpatients may beunpleasant,itis not typicallylife-threatening. Naloxoneshouldbe part of anoverallapproach to opioid overdose

thatincorporatesthefollowing steps.

RECOGNIZE THE SIGNS OF OVERDOSE. Anopioid overdose requiresrapiddiagnosis. The most commonsigns of overdose include[3]:

n Paleandclammy face

n Limpbody

n Fingernailsorlipsturningblue/purple

n Vomitingorgurglingnoises

n Cannotbeawakenedfromsleeporisunable to speak

n Verylittleornobreathing

n Veryslowornoheartbeat

Signs of OVERMEDICATION,which may progress to overdose, include[3]:

n Unusualsleepinessordrowsiness

n Mentalconfusion,slurredspeech, intoxicatedbehavior

n Sloworshallowbreathing

n Pinpointpupils

n Slowheartbeat, low bloodpressure

n Difficultywakingtheindividual fromsleep

Because opioids depress respiratory function and breathing, one telltale sign of an individual inacritical medical state is the “death rattle.” Often mistaken for snoring, the “death rattle” is an exhaled breath with avery distinct, labored sound coming from the throat. It indicates that emergency resuscitation is needed immediately [8].

SUPPORT RESPIRATION. Supporting respirationisthesingle most important intervention for opioid overdose and may belife-savingon its own.Ideally, individualswho are experiencingopioid overdose shouldbeventilatedwith100% oxygen beforenaloxoneisadministered to reducetherisk of acutelunginjury [3, 8]. Insituationswhere100% oxygen is not available, rescue breathing can bevery effective in supporting respiration [8]. Rescue breathinginvolvesthefollowingsteps:

n Verifythattheairwayisclear.

n Withonehandonthepatient'schin,tilt theheadbackandpinchthe nose closed.

n Placeyourmouth over thepatient's mouth to makea seal andgive2slow breaths(thepatient's chest shouldrise, but not thestomach).

n Followupwithonebreathevery 5seconds.

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ADMINISTER NALOXONE. Naloxone(Narcan)shouldbe given to any patient who presents with signs of opioid overdose, or when overdose is suspected [8]. Naloxone can be given by intramuscular or intravenous injection every2 to 3minutes [8-10]. The most rapid onset of actionisachieved by intravenous

administration,whichisrecommendedinemergencysituations [9].Intravenousadministrationgenerallyisusedwithpatients who have nohistory of opioiddependence.Opioid-naivepatients may begivenstarting doses of up to 2mgwithoutconcern for triggeringwithdrawalsymptoms[8]. The intramuscularroute of administration may bemore

suitable for patientswithahistory of opioiddependencebecause itprovidesasloweronset of actionandaprolongedduration of effect,which may minimizerapidonset of withdrawal symptoms[8].

Pregnant patients. Naloxone can safely be used to manage opioid overdose inpregnantwomen. The lowest dose to maintain spontaneous respiratory drive should be used to avoid triggering acuteopioidwithdrawal,which may cause fetal distress[8].

MONITOR THE PATIENT’S RESPONSE. Patientsshouldbe monitored for re-emergence of signsandsymptoms of opioid toxicity for at least4hoursfollowingthelast dose of naloxone (however, patientswho have overdosedonlong-actingopioids requiremoreprolongedmonitoring)[8]. Most patientsrespond to naloxone by returning to

spontaneousbreathing,withmildwithdrawalsymptoms[8]. The responsegenerallyoccurswithin3 to 5minutes of naloxone administration. (Rescue breathingshouldcontinuewhilewaiting for thenaloxone to take effect.) The duration of effect of naloxoneis30 to 90minutes.

Patientsshouldbeobservedafterthattime for re-emergence of overdose symptoms. The goal of naloxonetherapyshould berestoration of adequatespontaneousbreathing,but not necessarilycompletearousal[8-10]. More than one dose of naloxone may be required to revive

the patient. Those who have taken longer-acting opioids may require further intravenous bolus doses or an infusion of naloxone [8]. Therefore, itisessential to get theperson to an emergencydepartmentorothersource of acute care asquickly aspossible, even ifheorsherevivesaftertheinitial dose of naloxoneandseems to feelbetter.

SIGNS OF OPIOID WITHDRAWAL: Withdrawal triggered by naloxone can feelunpleasant.As aresult,somepersonsbecomeagitatedor combative when this happens and need help to remain calm. The signsandsymptoms of opioidwithdrawal

inanindividualwhoisphysicallydependenton opioids may include,but are not limited to, the following: body aches, diarrhea,tachycardia, fever, runny nose,sneezing, piloerection,sweating, yawning,nauseaorvomiting,nervousness, restlessness orirritability,shiveringortrembling, abdominalcramps,weakness,andincreased bloodpressure[9].Withdrawalsyndromes may beprecipitated by aslittleas 0.05 to 0.2 mg intravenousnaloxoneinapatienttaking 24 mg per day of methadone. In neonates, opioidwithdrawalalso may

produceconvulsions,excessivecrying,and hyperactive reflexes [9].

NALOXONE-RESISTANT PATIENTS: Ifapatient does not respond to naloxone,analternative explanation for theclinicalsymptomsshouldbe considered. The most likelyexplanationisthat thepersonis not overdosingonanopioidbut rathersomeothersubstanceor may even be experiencinganon-overdosemedicalemergency. Apossibleexplanation to consideriswhether theindividualhasoverdosedonbuprenorphine, along-actingopioidpartialagonist.Because buprenorphinehasahigheraffinity for the opioidreceptorsthandootheropioids,naloxone may not beeffective at reversingtheeffects of buprenorphine-inducedopioid overdose [8]. In all cases, support of ventilation, oxygenation,

and blood pressure should be sufficient to prevent thecomplications of opioid overdose andshould begiventhehighestpriorityifthepatient’s response to naloxoneis not prompt.

NOTE: Allnaloxoneproducts have anexpiration date. Itisimportant to checktheexpiration date andobtain replacementnaloxoneasneeded.

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LEGAL AND LIABILITY CONSIDERATIONS Health care professionals who are concerned about legal risks associatedwithprescribingnaloxone may bereassured by thefact thatprescribingnaloxone to manageopioid overdose isconsistent withthedrug’sFDA-approvedindication,resultinginnoincreased liability so longastheprescriberadheres to generalrules of professionalconduct. State laws andregulationsgenerallyprohibit physiciansfromprescribingadrugsuchasnaloxone to athird party, suchasacaregiver.(Illinois,Massachusetts, New York,and Washington State are theexceptions to thisgeneralprinciple.)More informationon state policiesisavailable at www.prescribetoprevent. org/ or from individual state medical boards.

CLAIMS CODING AND BILLING Most privatehealthinsuranceplans,Medicare,andMedicaid cover naloxone for thetreatment of opioid overdose, butpoliciesvary by state. The cost of take-homenaloxoneshould not beaprohibitive factor. Not allcommunitypharmaciesstocknaloxoneroutinelybut can alwaysorder it. If you are caring for alargepatientpopulation likely to benefitfromnaloxone you may wish to notifythepharmacy when you implementnaloxoneprescribingasaroutinepractice. The codes for Screening,BriefIntervention,andReferral to

Treatment(SBIRT) can beused to billtime for counselingapatient about how to recognize overdose and how to administernaloxone. Billingcodes for SBIRT are asfollows:

CommercialInsurance: CPT 99408(15 to 30minutes)

Medicare:G0396(15 to 30minutes)

Medicaid:H0050(per15minutes)

RESOURCES FOR PRESCRIBERS Additional information on prescribing opioids for chronicpainisavailable at the followingwebsites:

www.opioidprescribing.com. Sponsored by the Boston UniversitySchool of Medicine, withsupportfromSAMHSA,thissite presents coursemodulesonvariousaspects of prescribingopioids for chronicpain. To viewthelist of courses and to register, go to http://www.opioidprescribing.com/overview. CMEcredits are available at nocharge.

www.pcss-o.org or www.pcssb.org. Sponsored by theAmericanAcademy of AddictionPsychiatryincollaborationwith otherspecialtysocietiesandwithsupport fromSAMHSA,thePrescriber’sClinical Support System offers multiple resources related to opioidprescribingandthe diagnosisandmanagement of opioid use disorders.

www.medscape.com. Two course modules sponsored by theNationalInstituteon DrugAbuseand posted onMedScape can be accessed at http://www.medscape. org/viewarticle/770687 and http://www. medscape.org/viewarticle/770440.CME credits are available.

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REFERENCES 1. Centers for DiseaseControlandPrevention(CDC).CDCgrand rounds:Prescriptiondrug overdoses —A U.S. epidemic. MMWR Morb Mortal Wkly Rep.2012;61(1):10–13.

2. HarvardMedicalSchool.Painkillersfuelgrowthindrugaddiction; Opioid overdoses now killmorepeoplethancocaineorheroin. Harvard Ment Hlth Let.2011;27(7):4–5.

3. BeletskyL,Rich JD, Walley AY. Prevention of fatal opioid overdose. JAMA.2012 Nov 14;308(18):1863–1864.

4. IsaacsonJH,Hopper JA, Alford DP, Parran T. Prescriptiondrug use andabuse.Risk factors, red flags,andpreventionstrategies. Postgrad Med. 2005;118:19.

5. Coffin PO, Sullivan SD. Cost-effectiveness of distributingnaloxone to heroinusers for lay overdose reversal. Ann Internal Med. 2013;58:1–9.

6. Finch JW, Parran TV, Wilford BB, Wyatt SA. Clinical,legalandethical considerationsinprescribingdrugswithabusepotential.InRiesRK, Alford DP, Saitz R, Miller S, eds. Principles of Addiction Medicine, Fifth Edition.Philadelphia, PA: Lippincott,Williams&Wilkins,Ch.109, in press 2013.

7. MichnaE, Ross EL,HynesWL, et al.Predictingaberrantdrug behaviorinpatientstreated for chronicpain:Importance of abuse history. J Pain Symptom Manage. 2004;28:250.

8. BMJEvidenceCentre.Treatment of opioid overdose withnaloxone. British Medical Journal.UpdatedOctober 23, 2012. [Accessed March 24, 2013, at www.bmj.com]

9. RxList [Accessed March 24, 2013, at www.rxlist.com]

10. Drugs.com [Accessed March 24, 2013, at www.drugs.com]

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Acknowledgments This publication was prepared for the Substance Abuse and Mental Health Services Administration (SAMHSA) by the Association of State and Territorial Health Officials, in cooperation with Public Health Research Solutions, under contract number 10-233-00100 with SAMHSA, U.S. Department of Health and Human Services (HHS). LCDR Brandon Johnson, M.B.A., served as the Government Project Officer.

Disclaimer The views, opinions, and content of this publication are those of the authors and do not necessarilyreflecttheviews,opinions,orpolicies of SAMHSAorHHS.

Public Domain Notice Allmaterialsappearinginthisvolume except those takendirectlyfromcopyrighted sources are inthepublicdomainand may bereproducedorcopiedwithout permissionfromSAMHSAortheauthors.Citation of thesourceisappreciated. However, thispublication may not bereproducedordistributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA, HHS.

Electronic Access and Copies of Publication This publication may be ordered from SAMHSA’s Publications Ordering Web page at www.store.samhsa.gov. Or, please call SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727) (EnglishandEspañol).

Recommended Citation SubstanceAbuseandMentalHealthServicesAdministration.SAMHSAOpioid OverdosePreventionToolkit:Information for Prescribers. HHS Publication No. (SMA) 13-4742. Rockville, MD: SubstanceAbuseandMentalHealthServices Administration, 2013.

Originating Office Division of Pharmacologic Therapies, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857.

HHS Publication No. (SMA) 13-4742 Printed 2013