Matthew & Arianne Slocum

TABLE OF CONTENTS

1) Introduction .................................................................................................................. 3

2) Opioid Origins .............................................................................................................. 6

A) A Brief History of Opioids in the U.S. ................................................. 9

B) Opioid Uses .................................................................................................... 13

C) Pennsylvania Opioid Usage .................................................................. 17

3) The Addictive Nature of Opioids ................................................................... 20

A) Neurological and Biochemical Causes For Addiction ......... 22

B) Pennsylvania Addiction Rates ............................................................ 26

4) Current Treatment Methodologies for Opioid Addiction .............. 29

A) Psychological Therapy ............................................................................. 31

B) Medical Therapy .......................................................................................... 33

C) Treatment Analysis .................................................................................... 35

5) The Benefits of Marijuana for Pain Relief and Addiction ................ 38

A) The Promise of Marijuana for Pennsylvania ............................... 43

6) Sources .......................................................................................................................... 45

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INTRODUCTION

For over a century, opioids were widely regarded as wonder drugs. Applications of the drug have ranged from pain relief for war injuries to recreational use. Even in this day and age, their use in managing acute and chronic pain is largely considered standard care. However, in the face of an ever-growing epidemic, it may be time to rethink standard care.

Since 1999, the number of overdose deaths involving opioids has quadrupled.i According to the Centers for Disease Control, more than 33,000 people were killed as a result of opioid overdose in 2015 (the highest death rate on record).ii It’s the addictive nature of the narcotic drugs that draw users in and deteriorate their health over time.

As personal injury attorneys, The Slocum Firm has witnessed firsthand doctors overzealously prescribing opioids and the devastating effects they have on injured accident victims. With overdose rates at an all time high, securing a replacement for opioid painkillers is more of a priority than ever before.

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A slew of new studies have revealed that a better alternative is available. Cannabis not only eliminates pain, but also helps to curb opioid addiction. However, before discussing cannabis as an alternative to opioids, it’s first important to understand opioids and how we arrived at the epidemic we currently face. Afterall, opioid misuse and abuse dates back well before the United States was even a country.

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OPIOID ORIGINS

Opium is a substance derived from the milky juice of unripened seed pods harvested from the opium poppy plant.iii The earliest reference of opium dates back to 3400 B.C. when the opium poppy was cultivated in lower Mesopotamia.iv Although, archeological evidence now suggests that the Neanderthals may have utilized opium over thirty thousand years ago.v

Fast forward to the 17th century and ships chartered by Queen Elizabeth I were instructed to purchase the finest Indian opium and transport it back to England.vi In 1750, the British East India Company assumed control of the two largest opium growing districts in India, Bengal and Bihar.vi With control over opium production, Britain was able to successfully carve out a large portion of the market.

High demand for Chinese goods created a trade deficit, since the Chinese had no use for European goods. In an effort to repay China for their trade, Britain offered the country opium.

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By 1767, the British East India was exporting a staggering 2,000 chests of opium per year to China.vi Opium addiction quickly spread throughout China causing serious social and economic distress. On March of 1839, the Chinese government confiscated and destroyed over 20,000 chests of opium subsequently leading to two opium wars.vii

While China was battling to keep British opium out of the country, the United States was freely importing opium into the country. The effects of opium trade may not have been as detrimental to the U.S., but problems were still evident.

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A BRIEF HISTORY OF OPIOID USE IN THE U.S.

The United States has struggled with painkiller abuse dating all the way back to the late 1800’s. With the dawn of industrialization and the advent of advanced transportation networks, many Asians flocked to find work in the land of opportunity, bringing opium with them. Opium quickly became a common recreational drug.viii Troubled by the overwhelming use of opium, medical professionals were eager to find an alternative pain reliever.

In 1810, a German pharmacist's assistant by the name of Friedrich Serturner managed to isolate a crystal compound from crude opium.ix The compound came to be known as morphine and was thought to be a safer alternative to opium. From 1861 to 1865 the civil war swept the country leaving an estimated 476,000 injured soldiers in its wake.x Soldiers were treated with morphine to douse the pain of their wounds. Many of the injured U.S. soldiers who were treated with morphine soon fell victim to its addictive nature.

Perplexed by the morphine crisis, doctors once again turned to Germany, who exported crates of their new wonder drug, heroin to

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the U.S. heroin was marketed as a safe, non-addictive substitute for morphine.xi The drug was sold in over-the-counter kits and was administered as freely as aspirin is today. It was not until 32 years later in 1920 that the federal government recognized the danger of heroin and banned opioids from over-the-counter sales.xi

In response to the rising concerns and increased regulation, the medical community synthetically created pharmaceutical products to mimic the pain-relieving aspects of opium. These synthetic products became known as opioids, and like heroin, were touted to be a much safer alternative to opium-related drugs.

By the mid to late 1970s, doctors were well aware that prescription opioids were highly addictive. However, an article in the New England Journal of Medicine left the medical profession questioning what they knew.

The article detailed an analysis of 11,882 patients who were treated with narcotics. The findings stated that “the development of

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addiction is rare in medical patients with no history of addiction.”viii Once again, doctors were duped into relying on opioids to relieve pain.

The cycle of seemingly safe drugs leading to addiction catastrophes is one that has continued on to the modern day. The opioids of today may be different, but the game remains the same.

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OPIOID USES

Today, painkillers are currently the second largest class of pharmaceutical drugs behind cancer medicines.xii Doctors use opioids as remedies for post-surgery pain, cancer pain, pain arising from disabling diseases, and pain related to serious injuries or trauma. Common prescription opioids include codeine, fentanyl, hydrocodone, hydromorphone, meperidine, methadone, and oxycodone.xiii

Unfortunately, opioid use is more frequent and widespread than ever before. America counts for less than 5% of the world’s population.xiv Yet, Americans consume 80% of the world’s opioid supply.xiv In 2015, a whopping 300 million pain prescriptions were written in the U.S.xii Worse, 99% of physicians wrote prescriptions extending the three day dosage limit.xii An estimated 25% of all opioid prescriptions were overextended 27 days to span an entire month.xii

In addition to the risk of addiction and death, negative side effects related to prolonged opioid use include drowsiness, nausea,

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constipation, dizziness, paranoia, and respiratory depression.xv Long-term use of opioids can lead to vomiting, liver damage, brain damage, constipation, and abdominal distention.

Luckily, elected officials and medical professionals are taking some action. Hydrocodone was reclassified from a schedule III drug to a schedule II drug due to its high risk of abuse. In the past five years, doctors have reduced the number of opioid prescriptions by 9.2%.xiv Nevertheless, the number of filled prescriptions and days of medication per prescription increased 8% between 2009 and 2013.xiv

While opioid usage and addiction is widespread, data from the Philadelphia health department reveals that addiction and overdose varys greatly by demographic. Overdose rates were over three times higher among males than females.xvi Additionally, rates were two times higher among white individuals than individuals of other ethnicities.xvi Individuals ranging from 45 to 54 years of age proved to be the most susceptible to opioid overdose.xvi

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Nonetheless, opioid addiction affects all Americans regardless of age, ethnicity, or gender. Sadly, the beautiful state of Pennsylvania is no exception to the countrywide opioid trends.

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PENNSYLVANIA OPIOID USAGE

Like the rest of the country, the medical industry in Pennsylvania continues to struggle with large statewide opioid addiction rates. The number of opioid prescriptions decreased close to 0.1 prescriptions per capita from 2013 to 2015,xvii but the number of drug overdose related deaths actually increased 20.1% from 2014 to 2015 according to the CDC.xviii Of those 3,500 fatalities, nearly 60% were a result of opioids.xix

Looking to turn the tide in the opioid battle, Governor Tom Wolf signed a bill in November of 2016 to strengthen the Prescription Drug Monitoring Program, restrict the number of pills that can be prescribed to minors, create more locations for the drop off of prescription drugs, and establish an education curriculum for the medical profession on safe prescribing. Currently, it’s believed that more than 170,000 Medicare enrollees actively shop for doctors who are willing to write opioid prescriptions.xx The use of multiple pharmacies and doctors has historically made tracking opioid usage difficult.

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Under the new Prescription Drug Monitoring Program, all physicians and dispensers lawfully authorized to prescribe or handle controlled substances must register with the program.xxi Each time a patient is prescribed a controlled substance a record is created so that abuse is easier to detect.

While increased monitoring and regulation is a step in the right direction, the problem will continue to persist due to the addictive nature of opioids. What makes the synthetic concoctions so addictive? Allow us to explain.

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THE ADDICTIVE NATURE OF OPIOIDS

A study conducted in 2012 found that an estimated 2.1 million americans suffer from substance abuse disorders related to prescription opioid pain relievers.xxii With the exception of methadone, drug overdose deaths related to opioid addiction have continued to rise year after year at a steady rate.xvi

In order to combat addiction and fatality rates, it’s important to understand the underlying factors driving opioid addiction. The disheartening transition from a patient in pain to an addict in a downward spiral can be explained both neurologically and biochemically.

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NEUROLOGICAL AND BIOCHEMICAL CAUSES FOR ADDICTION

Opioid tolerance, dependence, and addiction manifest as a result of changes in the brain. Addiction occurs in a pattern consisting of three repeating behaviors.xxiii

1) Individual experiences compulsion to seek and take an opioid.

2) Individual loses control in limiting the intake of the opioid.

3) A negative emotional state is induced when an individual’s access to the opioid is prevented.

Ultimately, opioid usage activates the mesolimbic reward system, which generates signals in the ventral tegmental area to release dopamine.xxiv The release of dopamine creates an overwhelming sense of pleasure, which the brain then associates with opioid use. For many, the euphoric feeling is so strong, that it’s continually sought after. However, repeated use of opioids at escalating doses alters the brain so that it begins to function normally when opioids are present.

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Once the brain chemistry is altered, lack of opioids causes the brain to function abnormally, creating the symptoms of withdrawal. Alas, as the brain normalizes the presence of opioids, opioid receptors become less responsive to the presence of the opioid. A continuing increase in dosage is required to experience the same level of pleasure originally experienced. In effect, the user is trapped in continual pursuit of opioids. Worse, the opioid receptors are not the only part of the brain altered by the use of opioids. Prolonged use of opioids has been proven to result in the brain’s impaired ability to regulate the hypothalamus gland, the pituitary gland, the basal forebrain, the brainstem, the amygdala, and the adrenal glands. On top of brain impairment, opioid usage affects virtually every system in the body, making the process of opioid withdrawal grueling. Withdrawal symptoms can include low energy, hot and cold sweats, irritability, anxiety, goose bumps, agitation, muscle aches, insomnia, abdominal cramping, vomiting, and diarrhea.xxv

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Nonetheless, it’s important to note that reactions to opioid use will vary based on several components. Scientific studies have revealed that over 50% of opioid addiction cases are a result of genetic factors.xxvi Research shows that children of addicts are eight times more likely to develop an addiction.xxvii Additionally, the type of opioid and the recommended dosage makes a difference. The stronger an opioid is, the higher the risk of abuse and addiction.xxviii Fentanyl, Hydromorphone, and Oxycodone are all relatively strong analgesics compared to Morphine, Hydrocodone, and Codeine.

Given a proper understanding of how an addiction to opioids is developed, it’s worth examining the level of addiction in the state of Pennsylvania.

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PENNSYLVANIA ADDICTION RATES

Given the countywide rate of opioid addiction and abuse, it should come as no surprise that the addiction rate in Pennsylvania has reached crisis levels. In 2014, Pennsylvania ranked as the 8th worst state in the country in terms of drug overdose deaths.xxix

Heroin was the most frequently identified drug in the toxicology reports, but fentanyl was not far behind.xvi Year after year, overdose rates related to opioid usage continue to climb. As previously stated, overdose rates increased a staggering 20.1% from 2014 to 2015.xviii

Much like the data produced by Philadelphia, overdose rates appear to follow the same demographic pattern. Approximately 67% of overdose victims were male and 84% of victims were white.xix

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Overall, 21 out of 67 Pennsylvania counties have an overdose rate greater than that of the state average.xix It’s imperative statewide that addiction is curbed, because continuing increases in overdose fatalities would be devastating. Of course, curing addiction starts with better withdrawal treatment. Current withdrawal treatments have continuously proven to be ineffective.

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Provided by: The Pennsylvania State Coroners Association

Provided by: The Pennsylvania State Coroners Association

CURRENT TREATMENT METHODOLOGIES FOR

OPIOID ADDICTION

For an individual working to overcome opioid addiction, successfully withdrawing alone is a near impossible task. Professional help is typically required and there are two common methods for treating opioid addiction. Those two methods are psychological therapy, and medical therapy.

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PSYCHOLOGICAL THERAPY

Psychological therapy involves the use of psychological counseling without any prescription medications. Patients work directly with a psychologist who applies scientifically validated procedures to curb opioid dependence. Approaches to psychotherapy include interpersonal, cognitive behavioral, and additional methods of talk therapy.xxx

In addition to individual psychotherapy, group therapy may also be utilized. Groups free addicts from shame and isolation, allowing them to help themselves by helping others.xxxi Psychotherapy has proven to be most effective for patients with no prior addiction history, patients returning from a hospital or jail, patients who have only temporarily relapsed, or patient who have successfully completed a more intensive addiction program.xxxii

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MEDICAL THERAPY

Unlike psychological therapy, medical therapy involves the application of medications to suppress or mitigate withdrawal symptoms. Drugs used to treat opioid addiction fall into three major categories. The categories are as follows:

Agonist: An agonist acts like an opioid and activates opioid receptors to create the same stimulating feeling.xxxiii

Partial Agonist: A partial agonist activates the opioid receptors and creates stimulation. However, the level of stimulation is to a lesser degree in comparison with agonists.xxxiii

Antagonist: Unlike agonists and partial agonists which fire opioid receptors, antagonists attach to the receptors to block opioids from creating stimulation.xxxiii

The most commonly utilized drugs for medical therapy include methadone, buprenorphine, and naltrexone.xxxiv Methadone is a leading agonist. The drug reduces the euphoric effect of opioids while simultaneously reducing withdrawal symptoms. Buprenorphine is a partial agonist that works much like methadone on a smaller scale. Naltrexone is an antagonist with no known addictive qualities. The drug blocks opioid receptors to stop opioids from creating stimulation.

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TREATMENT ANALYSIS

Given the various methods for addiction treatment one might wonder how effective they truly are. In short, the answer is not effective enough. Studies have shown that psychological therapy is not particularly effective unless it is paired with medical therapy.xxxv Furthermore, psychological therapy only works when a patient is willing to make changes.xxxi Being that many addicts are reluctant participants at best, psychological therapy is usually rendered ineffective.

On the flip side, medical therapy is more effective at treating addiction, but their application comes with a price. Like any pharmaceutical drug, methadone and buprenorphine both contain undesirable side-effects with long-term use. A study conducted by the Albert Einstein College of Medicine found that addicts undergoing methadone treatment often experience severe chronic pain as a result of the treatment.xxxvi Patients with chronic pain detailed the isolation it brought about. A mother undergoing treatment suffered to the extent that she was unable to take her children to the park. A married husband was left unable to visit his wife in prison.

In many cases, medical therapy drugs must be taken indefinitely and for some, that could mean a lifetime.xxxvii In a sense, these treatments are no better than being on the opioids themselves.

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In fact, methadone overdose is an issue the U.S. is currently battling with. Despite the fact that methadone related fatalities decreased 9.1% in 2015, methadone related drug overdose is still a concern.xxxviii Ultimately, current psychological and medical therapies are not ideal for curbing addiction or preventing relapse.

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THE BENEFITS OF MARIJUANA FOR PAIN RELIEF AND ADDICTION

As states across the U.S. continue to ratify the use of marijuana for medicinal purposes, new medical benefits of the natural herb continue to be discovered. Several medical studies have confirmed marijuana’s ability to deal with chronic pain. In a comprehensive study led by Harvard University, researchers systematically scrutinized 28 different studies analyzing the effects of cannabinoids on pain.xxxix Researchers concluded that the use of medical marijuana for chronic pain treatment is supported by high quality evidence. One particular study found cannabis to be 20 times more potent than Aspirin as an anti-inflammatory.xxxx Furthermore, an investigation of states with legalized medical marijuana programs has provided even more promising insights.

Researchers have discovered that states with legalized medical marijuana programs have been associated with 24.8% lower analgesic overdose rate than states without.xxxxi Moreover, states with medical marijuana laws that have existed for six years or more witnessed an overdose reduction rate of approximately 33.7%.xxxxi

Surprisingly, states that implemented opioid abuse policies without legalizing marijuana made negligible progress in reducing opioid overdose death rates.xxxxii While this research is speculative and utilizes only indirect evidence, it does prove encouraging for additional research.

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In 2003, researchers conducted a study attempting to show a direct correlation between marijuana use and opioid relapse. The experiment instead proved the opposite. Opioid abusers were 16% less likely to relapse with the aid of marijuana.xxxxiii As a matter of fact, patients diagnosed with chronic pain who had legal access to marijuana were found to voluntarily decrease opioid use by 64%.xxxxiv Another 44% of patients were able to eliminate opioid use altogether within 7 months of their prescription date.xxxxv

For those reluctant to completely eliminate opioid usage, it’s been shown that adding cannabis to opioids actually makes them safer. The issue with using opioids alone is that they stimulate the opioid receptors in the cardio-respiratory centers of the brain. Manipulating this portion of the brain is a fatal game being that it controls the heart and lung functions within the body. Interestingly enough, there are no cannabinoid receptors in this part of the brain. Therefore, when cannabis is combined with opioids, the cannabinoids are attracted to the cannabinoid receptors, which in turn spreads the opioid dosage throughout the brain.xxxxvi In effect, the concentration is more evenly dispersed so that the effective dosage amount essentially decreases.

In addition to helping prevent opioid addiction, cannabis has also been shown to curb addiction. In a select number of states,

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medical marijuana has been approved for use as a treatment for opioid addicts. Massachusetts is one such state, and Dr. Gary Witman of Canna Care Docs has already begun treating opioid addicts with marijuana. Out of 80 patients Dr. Witman has worked with so far, more than 75% of programs participants have completely eliminated the use of harder drugs.xxxxvii

The utilization of cannabis for pain relief and opioid addiction would not only be beneficial for patients’ health, but would also be beneficial from an economic standpoint. The costs of opioid abuse in the United States are staggering. The breakdown of expenses related to opioid abuse are as follows:xxxxviii

Costs from employee’s premature death $11.2 BillionCosts from lost employment $ 7.9 BillionCosts from excess medical prescriptions $23.7 BillionCosts due to incarceration from opioid abuse $2.3 BillionPolice Costs $ 1.5 BillionTotal Costs $46.6 Billion

If marijuana was able to successfully reduce opioid addiction by just 10%, the U.S. would be looking at an annual cost saving of $5 billion. The savings would likely be much larger considering the 10% scenario is modest when compared to aforementioned

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research findings. The United States would likely be looking at a cost savings closer to $32.62 billion.

While the research surrounding cannabis and its role in pain management is enough to warrant excitement, marijuana’s potential applications for the state of Pennsylvania are even more exciting.

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THE PROMISE OF MARIJUANA TOHELP WITH PENNSYLVANIA’S

ADDICTION PROBLEM

Marijuana holds a very bright future for Pennsylvania. In April of 2016, the state legalized the use of medical marijuana.xxxxix In January of this year applications to obtain permits for growing, processing, and dispensing marijuana were released.xxxxx The medical marijuana program may not be fully operational just yet, but it is well underway. Medical marijuana is currently approved to treat 17 medical conditions including cancer, autism, epilepsy, HIV/AIDS, PTSD, ALS, and chronic pain.xxxxxi Allowing the drug to be prescribed for pain relief will undoubtedly turn the tide in the battle on opioid addiction. Nonetheless, approving the use of medical marijuana for addiction treatment would be an even greater win.

Safer pain relief is just around the corner for Pennsylvanians. For the sake of accident victims and all of those suffering through excruciating pain, The Slocum Firm hopes that marijuana is properly utilized to its full extent. It is imperative that the Food and Drug Administration, with the help of the U.S. Congress, conduct clinical studies on marijuana use for opioid addiction treatment. Preliminary studies have proven marijuana’s effectiveness as a treatment option for opioid addicts, but a government run study would solidify the evidence once and for all.

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SOURCES

i "Understanding the Epidemic." Centers for Disease Control and Prevention. Centers for Disease Control and Preven-tion, 16 Dec. 2016. Web. 19 Mar. 2017.

ii "Opioid Overdose | Drug Overdose | CDC Injury Center." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 09 Feb. 2017. Web. 20 Mar. 2017.

iii "Opium." Encyclopædia Britannica. Encyclopædia Britan-nica, Inc., n.d. Web. 20 Mar. 2017.

iv "Cannabis, Coca, & Poppy: Nature's Addictive Plants." DEA Museum. DEA Museum, n.d. Web. 19 Mar. 2017.

v "The Plant Of Joy." A Brief History of Opium. BLTC, n.d. Web. 20 Mar. 2017.

vi "Opium Throughout History." PBS. Public Broadcasting Service, n.d. Web. 19 Mar. 2017.

vii "Opium Wars." Encyclopædia Britannica. Encyclopædia Britannica, Inc., n.d. Web. 20 Mar. 2017.

viii Moghe, Sonia. "Opioids: From 'wonder Drug' to Abuse Epi-demic." CNN. Cable News Network, 14 Oct. 2016. Web. 20 Mar. 2017.

ix Mandal, MD Dr Ananya. "Morphine History." News-Medi-cal.net. News Medical Life Sciences, 27 Oct. 2013. Web. 20 Mar. 2017.

x "Civil War Casualties." Civil War Trust. Civil War Trust, n.d. Web. 19 Mar. 2017.

xi "History of Heroin." Narconon International. Narconon International, n.d. Web. 20 Mar. 2017.

xii Gusovsky, Dina. "Americans Still Lead the World in Some-thing: Use of Highly Addictive Opioids." CNBC. CNBC, 27 Apr. 2016. Web. 20 Mar. 2017.

xiii "Opioid (Narcotic) Pain Medications." WebMD. WebMD, n.d. Web. 20 Mar. 2017.

xiv "America's Pain Points." Express Scripts. Express Scripts, 9 Dec. 2014. Web. 20 Mar. 2017.

xv "The Effects of Opiate Use." DrugAbuse.com. Drug-Abuse.com, 29 Jan. 2016. Web. 20 Mar. 2017.

46

xvi "The Epidemic of Overdoses From Opioids in Philadel-phia." Philadelphia Department of Public Health (2016): 1-6. 1 Nov. 2016. Web. 21 Mar. 2017.

xvii Tavernise, Abby Goodnough and Sabrina. "Opioid Pre-scriptions Drop for First Time in Two Decades." The New York Times. The New York Times, 20 May 2016. Web. 20 Mar. 2017.

xviii "Drug Overdose Death Data." Centers for Disease Control and Prevention. Centers for Disease Control and Preven-tion, 16 Dec. 2016. Web. 20 Mar. 2017.

xix Wenner, David. "PA Overdose Deaths Surge Again." Penn Live. Penn Live, 8 Aug. 2016. Web. 20 Mar. 2017.

xx Toomey, Pat, and Sherrod Brown. "Toomey's Take: Seniors Forgotten Victims in Opioid Epidemic." Pat Toomey | U.S. Senator for Pennsylvania. Pat Toomey, 14 Mar. 2016. Web. 20 Mar. 2017.

xxi "What Pennsylvania Physicians Need to Know about the Prescription Drug Monitoring Program." PA Med Society. Pennsylvania Medical Society, n.d. Web. 20 Mar. 2017.

xxii Volkow, Nora. "America's Addiction to Opioids: Heroin and Prescription Drug Abuse." NIDA. NIDA, 14 May 2014. Web. 20 Mar. 2017.

xxiii Koob, G., “The Neurobiology of Addiction: Where We Have Been and Where We Are Going,” Journal of Drug Issues, 2009 Jan; 39(1): 115–132.

xxiv Kosten, Thomas R., and Tony P. George. "The Neurobiology of Opioid Dependence: Implications for Treatment." Sci-ence & Practice Perspectives. National Institute on Drug Abuse, July 2002. Web. 24 Mar. 2017.

xxv "Opioids (Narcotics): Addiction, Withdrawal and Recovery." Addictions And Recovery. Addictions And Recovery, n.d. Web. 24 Mar. 2017.

xxvi Prescott, C. A., & Kendler, K. S., “Genetic and environmental contributions to alcohol abuse and dependence in a pop-ulation-based sample of male twins,” American Journal of Psychiatry, 1999. 156(1): p. 34-40.

47

xxvii Merikangas, K. R., Stolar, M., Stevens, D. E., Goulet, J., et al., “Familial transmission of substance use disorders,” Archives of General Psychiatry, 1998. 55(11): p. 973-9.

xxviii Fields, H., “The Doctor's Dilemma: opiate analgesics and chronic pain,” Neuron,2011 Feb 24; 69(4): 591–594.

xxix “Analysis of Drug-Related Overdose Deaths in Pennsylva-nia, 2015.” DEA. DEA, July 2016. Web. 20 Mar. 2017.

xxx “Understanding Psychotherapy and How It Works." Ameri-can Psychological Association. American Psychological Association, n.d. Web. 21 Mar. 2017.

xxxi "Treating Opiate Addiction, Part II: Alternatives to Mainte-nance."Harvard Health. Harvard Health, May 2005. Web. 22 Mar. 2017.

xxxi Rounsaville, B., “Psychotherapy/Counseling for Opiate Ad-dicts: Strategies for Use in Different Treatment Settings,” International Journal of Addictions, July 3, 2009.

xxxiii "What's This Agonist / Antagonist Stuff?" NAABT.org. The National Alliance of Advocates for Buprenorphine Treat-ment, n.d. Web. 21 Mar. 2017.

xxxiv "What Are the Treatments for Heroin Addiction?" NIDA. National Institute on Drug Abuse, n.d. Web. 20 Mar. 2017.

xxxv Woody, George, Thomas McLellen, Lester Luborsky, and Charles O'Brien. "Psychotherapy with Opioid-Dependent Patients." Psychiatric Times. Psychiatric Times, 01 Nov. 1998. Web. 22 Mar. 2017.

xxxvi Karasz, Alison, Leah Zallman, Karina Berg, Marc Goure-vitch, Peter Selwyn, and Julia Arnstein. "The Experience of Chronic Severe Pain in Patients Undergoing Methadone Maintenance Treatment." Journal of Pain & Symptom Management. Journal of Pain & Symptom Management, Nov. 2004. Web. 20 Mar. 2017.

xxxvii "'Unbroken Brain' Explains Why 'Tough' Treatment Doesn't Help Drug Addicts." NPR. NPR, 07 July 2016. Web. 20 Mar. 2017.

xxxviii "Morbidity and Mortality Weekly Report (MMWR)." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 29 Dec. 2016. Web. 22 Mar. 2017.

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xxxixi Hill, K. P. "Medical Marijuana for Treatment of Chronic Pain and Other Medical and Psychiatric Problems: A Clinical Review."JAMA. U.S. National Library of Medicine, 23 June 2015. Web. 22 Mar. 2017.

xxxx Russo, Ethan B. "Cannabinoids in the Management of Dif-ficult to Treat Pain." NCBI. NCBI, Feb. 2008. Web. 22 Mar. 2017.

xxxxi "Study on the Relationship Between Medical Cannabis Laws and Opioid Analgesic Overdose Deaths." Wolters Kluwer. Wolters Kluwer, 01 Oct. 2014. Web. 20 Mar. 2017.

xxxxii Bachhuber, M., et al, “Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999–2010,” JAMA Internal Medicine, 2014 Oct; 174(10): 1668–1673

xxxxiii Epstein, D.H., and K.L. Preston. "Does Cannabis Use Predict Poor Outcome for Heroin-Dependent Patients on Mainte-nance Treatment? A Review of Past Findings, and More Evidence Against." Addiction (Abingdon, England). U.S. National Library of Medicine, Mar. 2003. Web. 20 Mar. 2017.

xxxxivi Boehkne, K., “Medical Cannabis Use Is Associated With Decreased Opiate Medication Use in a Retrospective Cross-Sectional Survey of Patients With Chronic Pain,” Journal of Pain, June 2016, Volume 17, Issue 6, Pages 739–744

xxxxv Haroutounian, S., et al, “The Effect of Medicinal Cannabis on Pain and Quality-of-Life Outcomes in Chronic Pain: A Prospective Open-label Study,” Clinical Journal of Pain, December 2016, Volume 32, Issue 12.

xxxxvi Sulak, Dustin. "Dr. Dustin Sulak on America's Opiate Ad-diction Crisis and How Medical Cannabis Can Help." Proj-ect CBD. Project CBD, 25 July 2016. Web. 22 Mar. 2017.

xxxxvii Villani, Chris. "Doctors Pioneer Pot as an Opioid Substi-tute."Boston Herald. Boston Herald, 04 Oct. 2015. Web. 20 Mar. 2017.

xxxxviii Birnbaum, H., et al, “Societal Costs of Prescription Opioid Abuse, Dependence, and Misuse in the United States,” Pain Medicine, 2011; 12: 657–667

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xxxxixi "What You Need to Know About Medical Marijuana in PA."Governor Tom Wolf. Governor Tom Wolf, 15 Apr. 2016. Web. 23 Mar. 2017.

xxxxx "Pennsylvania Medical Marijuana Program." PA.gov. PA.gov, n.d. Web. 23 Mar. 2017.

xxxxxi Nicholson, Bruce. "During an Opioid Epidemic, Medical Marijuana Is a Safe, Non-Addictive Option." PennLive.com. PennLive, 12 Mar. 2017. Web. 23 Mar. 2017.

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