Opioids

Opioids are a class of drugs that include the illegal drug heroin, synthetic opioids such as Fentanyl, and pain relievers available by prescription such as codeine, oxycodone, Vicodin, morphine, and others.

opiate painkillers

All opioids are chemically related and interact with opioid receptors on nerve cells in the brain and on the spinal column. Opioid pain relievers are generally safe when taken for a short time and as prescribed by a doctor, but because they produce euphoria in addition to pain relief, they can be misused (taken in a different way or in a larger quantity than prescribed, or taken without a doctor’s prescription). Regular use—even as prescribed by a doctor—can lead to dependence and, when misused, opioid pain relievers can lead to addiction, overdose, and death. 

An opioid overdose can be reversed with the drug naloxone (Narcan) when given right away. Improvements have been seen in some regions of the country in the form of decreasing availability of prescription opioid pain relievers and decreasing misuse among the Nation’s teens. However, since 2007, overdose deaths related to heroin have been increasing. Fortunately, effective medications exist to treat opioid use disorders including methadone, Buprenex and Vivitrol. 

A National Institute of Drug Abuse (NIDA) study found that once treatment is initiated, both a Buprenex/Vivitrol combination and an extended-release Vivitrol formulation are similarly effective in treating opioid addiction. However, Vivitrol requires full detoxification, so initiating treatment among active users is difficult. These medications help many people recover from opioid addiction.

What are Prescription Opioids?

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Opioids are a class of drugs naturally found in the opium poppy plant. Some prescription opioids are made from the plant directly, and others are made by scientists in labs using the same chemical structure. Opioids are often used as medicines because they contain chemicals that relax the body and can relieve pain. Prescription opioids are used mostly to treat moderate to severe pain, though some opioids can be used to treat coughing and diarrhea. Opioids can also make people feel very relaxed and high, which is why they are sometimes used for non-medical reasons. This can be dangerous because opioids can be highly addictive. Overdoses and death are common. Heroin is one of the world’s most dangerous opioids, and is never used as a medicine in the United States.

How Do People Misuse Opioids?

Prescription opioids used for pain relief are generally safe when taken for a short time and as directed by a doctor, but they can be misused. People misuse prescription opioids by:

  • taking the medicine in a way or dose other than prescribed
  • taking someone else’s prescription medicine
  • taking the medicine for the effect it causes—getting high

How Do Prescription Opioids Affect the Brain?

Opioids bind to and activate opioid receptors on cells located in many areas of the brain, spinal cord, and other organs in the body, especially those involved in feelings of pain and pleasure. When opioids attach to these receptors, they block pain signals sent from the brain to the body and release large amounts of dopamine throughout the body. This release can strongly reinforce the act of taking the drug, making the user want to repeat the experience.

Opioid misuse can cause slowed breathing, which can cause hypoxia, a condition that results when too little oxygen reaches the brain. Hypoxia can have short- and long-term psychological and neurological effects, including coma, permanent brain damage, or death. Researchers are also investigating the long-term effects of opioid addiction on the brain, including whether damage can be reversed.

What are Other Health Effects of Opioid Medications?

Older adults are at higher risk of accidental misuse or abuse because they typically have multiple prescriptions and chronic diseases, increasing the risk of drug-drug and drug-disease interactions, as well as a slowed metabolism that affects the breakdown of drugs. Sharing drug injection equipment and having impaired judgment from drug use can increase the risk of contracting infectious diseases such as HIV.

Prescription Opioids and Heroin

Prescription opioids and heroin are chemically similar and can produce a similar high. Heroin is typically cheaper and easier to get than prescription opioids, so some people switch to using heroin instead. Nearly 80 percent of Americans using heroin (including those in treatment) reported misusing prescription opioids prior to using heroin. However, while prescription opioid misuse is a risk factor for starting heroin use, only a small fraction of people who misuse pain relievers switch to heroin. This suggests that prescription opioid misuse is just one factor leading to heroin use.

The Numbers

More than 64,000 Americans died from drug overdoses in 2016, including illicit drugs and prescription opioids. This number has nearly doubled over the past ten years. 2015 was the worst year for drug overdoses in U.S. history. Then 2016 came along. In that year alone, drug overdoses killed more people than the entire Vietnam War did.

A chart of US drug overdoses going back to 1999.

The Opioid Epidemic Explained

This latest drug epidemic is not solely about illegal drugs. It began, in fact, with a legal drug. Back in the 1990s, doctors were persuaded to treat pain as a serious medical issue. There’s a good reason for that: About 100 million U. S. adults suffer from chronic pain, according to a report from the Institute of Medicine.

Chronic Pain The Silent Condition

Pharmaceutical companies took advantage of this concern. Through a big marketing campaign they got doctors to prescribe products like OxyContin and Percocet in droves — even though the evidence for opioids treating long-term non-cancer related chronic pain is very weak despite their effectiveness for severe short-term, acute pain—while the evidence that opioids cause harm in the long term is very strong. So painkillers inundated society, landing in the hands of not just patients but also teens rummaging through their parents’ medicine cabinets, other family members and friends of patients, and the black market.

As a result, opioid overdose deaths trended up — sometimes involving opioids alone, other times involving drugs like alcohol and benzodiazepines (Xanax, Ativan, Valium) typically prescribed to relieve anxiety. By 2015, opioid overdose deaths totaled more than 33,000 — close to two-thirds of all drug overdose deaths. The numbers have grown exponentially over the past three years.

What Can We Do?

Seeing the rise in opioid misuse and deaths, officials have cracked down on prescription painkillers. Law enforcement, for instance, now threaten doctors with incarceration and loss of their medical licenses if they prescribed the drugs unscrupulously. Ideally, doctors should still be able to get painkillers to patients who truly need them — after, for example, evaluating whether the patient has a history of drug addiction. But doctors, who weren’t conducting even such basic checks, are now being instructed to give more thought to their prescriptions.

Yet many people who lost access to painkillers are still addicted. So some who could no longer obtain prescribed painkillers turned to cheaper, more potent opioids bought off the street, such as heroin and Fentanyl. Not all painkiller users went this direction, and not all opioid users started with painkillers. But statistics suggest many did. A 2014 study in JAMA Psychiatry found many painkiller users were moving on to heroin, and a 2015 analysis by the Centers for Disease Control and Prevention (CDC) found that people who are addicted to prescription painkillers are 40 times more likely to be addicted to heroin.

So other types of opioid overdoses, excluding painkillers, also rose. That doesn’t mean cracking down on painkillers was a mistake. It appears to have slowed the rise in painkiller deaths, and it may have prevented doctors from prescribing the drugs to new generations of people with drug use disorders. But the likely solution is to get opioid users into treatment. According to a 2016 report by the Surgeon General of the United States, just 10 percent of Americans with a drug use disorder obtain specialty treatment. The report found that the low rate was largely explained by a shortage of treatment options. Given the exorbitant cost of health care in America today, that is simply unacceptable. Federal and state officials have pushed for more treatment funding, including medication-assisted treatment like methadone and Buprenex.

Source: National Institute on Drug Abuse; National Institutes of Health; U. S. Department of Health and Human Services.

COUNTERFEIT OXYCODONE WARNING!

COUNTERFEIT PAIN PILLS CONTAINING DANGEROUS SYNTHETIC OPIOIDS!

Originally posted July 18, 2017
National Institute of Drug Abuse
https://www.drugabuse.gov/

Health and safety agencies in Iowa have issued an advisory to warn Iowans of counterfeit pain pills containing dangerous synthetic opioids. The Iowa Division of Criminal Investigation’s (DCI) laboratory analyzed pills made to resemble the prescription pain reliever oxycodone, finding them to contain more powerful and illicit synthetic fentanyl and U-47700, putting users at higher risk of opioid overdose. U-47700, also known as “Pink” or “U4” on the streets, is a synthetic opioid pain medication currently being distributed as a dangerous designer drug. Since 2015, reports have surfaced of numerous deaths due to street use of U-47700. Law enforcement agencies have traced illegal importation into the United States primarily from clandestine chemical labs in China. It is available through the Dark Web.

Heroin and a Handgun

U-47700 has been seized by law enforcement on the street in powder form and as tablets. Typically, it appears as a white or light pinkish, chalky powder. It may be sold in glassine bags stamped with logos imitating heroin, in envelopes and inside knotted corners of plastic bags. In Ohio, authorities seized 500 pills resembling a manufacturer’s oxycodone immediate-release tablets, but they were confirmed by chemical analysis to contain “Pink.” U-47770 has also been identified and sold on the Internet misleadingly as a “research chemical” at roughly $30 per gram.

Pink is very toxic or deadly in even small doses. Labels on the packaging may state NOT FOR HUMAN CONSUMPTION or FOR RESEARCH PURPOSES ONLY, most likely to avoid legal detection. Fatalities due to U-47770 in the United States join the growing incidents of drug overdose deaths from opioid pain medication. Those who abuse U-47770 may be at high risk of addiction and substance abuse disorder, overdose and death. Fatalities have been reported in New York, New Hampshire, Ohio, Texas, Wisconsin and North Carolina.

In July 2016, a toxicology case report was published in the Annals of Emergency Medicine that detailed events in which fentanyl and U-47700 were being sold misleadingly as the prescription opioid pain medication Norco or Vicodin (acetaminophen and hydrocodone) on the streets of Northern and Central California. In one patient who presented to the emergency room, nalaxone (Narcan) was administered which reversed respiratory depression and pinpoint pupils. After additional chemical analysis, it was found the Norco contained hydrocodone, fentanyl, and U-47700.

Reports indicated that Pink and prescription fentanyl may have been contained in the drug cocktail that led to the death of pop star legend Prince in April 2016. In Utah, two 13-year old boys died in September 2016 reportedly due to use of U-47770 purchased from an Internet website. U-47700 (“Pink”) is a novel synthetic opioid agonist with selective action at the mu-opioid receptors in the brain and on the spinal column. It was originally developed by chemists at Upjohn Pharmaceuticals in the 1970’s as a potent pain reliever for use with cancer patients, post-operative patients with intractable pain, or extremely painful trauma injuries. Although it was never commercially made available, the patent and chemical details remained available, and have been produced on the black market.

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U-47700 has a similar chemical profile as morphine and other mu-opioid receptor agonists; however, it has been reported by the National Institute of Drug Abuse (NIDA) that Pink is “far more potent than morphine” –  possibly by seven to eight times. Unfortunately, the strength of the product can never be assured, and may be much stronger, especially when manufactured overseas in illicit labs as a designer drug. On November 14, 2016, the DEA placed U-47700, as well as its related isomers, esters, ethers, and salts into Schedule I of the Controlled Substances Act due to an imminent hazard to public safety and health. Substances in Schedule I have a high potential for abuse, no currently accepted medical use, and a lack of accepted safety for use under medical supervision.

Temporary emergency scheduling of dangerous illicit drugs is one tool the DEA uses to help restrict potentially fatal and new street drugs. Scheduling will last at least 24 months, with a possible 12-month extension if the DEA needs more time to determine whether the chemical should remain permanently as a Schedule I drug. According to the Federal Register, there are no current experimental or approved new drug applications for U-47700, which can typically hinder its permanent placement in Schedule I if approved. DEA’s Final Order is available in the Federal Register with details on threats to public safety. Prior to DEA’s scheduling, several states had already outlawed the drug under emergency orders, including Florida, Ohio, Wyoming and Georgia.

BOTTOM LINE

U-47700, known on the streets as “Pink” or “U4”, is a dangerous designer drug exported from illegal labs in China to the U.S. It is a strong opioid analgesic, reportedly 7 to 8 times more potent than morphine. Authorities in many U.S. cities have reported that Pink is sold on the streets or over the Internet, often falsely promoted as a prescription opioid like Norco or Percocet, or as heroin. In fact, many of these products have contained the potent designer drug Pink, as well as fentanyl. U-47700 is now illegal in all forms, and the DEA has temporarily placed the substance into Schedule I of the Controlled Substances Act, pending further review, due to an imminent hazard to public safety and health. It is considered not safe for human consumption, and has no acceptable medical use.

Clusters of overdoses and deaths of Pink were reported in U.S. cities in 2015 and 2016. Some of these deaths involved children. According to one case report, the use of naloxone (Narcan) in an emergency setting reversed the effects of U-47700, but this may not always be the case. Emergency physicians should contact their local poison control center, medical toxicologist or public health department in cases where there is a reasonable suspicion of ingestion of designer drugs to help protect the surrounding community. Special lab analysis is typically needed to identify drugs like “Pink,” leaving communities at risk.

The public should be aware that drugs obtained on the street, even though they look like an authentic prescription medication, may be fake and deadly. Don’t take any prescription drug, legal or otherwise, unless it is prescribed specifically for you by a doctor and is dispensed by a reliable pharmacy.

The Worst Man-Made Epidemic in History

The following is comprised of excerpts from Sam Quinones’ Dreamland: The True Tale of America’s Opiate Epidemic. I want to praise Quinones for this seminal work. Personally, it has defined for me the very nightmare I, and countless others, have lived, each to his or her own level, after discovering the morphine molecule through seemingly acceptable pain medications like Vicodin, Percocet and OxyContin. You can purchase a copy of Dreamland here: Dreamland

AS HEROIN AND OXYCONTIN addiction consumed the children of America’s white middle class, parents hid the truth and fought alone. Quietly. Friends and neighbors who knew shunned them. “When your kid’s dying from a brain tumor or leukemia, the whole community shows up,” said a mother of two addicts. “They bring casseroles. They pray for you. They send you cards. When your kid’s on heroin, you don’t hear from anybody, until  they die. Then everybody comes and they don’t know what to say.”

These parents made avoidable mistakes, and when a son died or entered rehab for the fourth time, they again hid the truth, believing themselves alone, which they were as long as they kept silent. This pervasive lie was easily swallowed. It often lay buried beneath lush lawns, shiny SUVs, and the bedrooms of kids who lacked for nothing. It was easier to swallow, too, because some of these new addicts were high school athletes – the charismatic golden youth of these towns. Athletes opened the door for other students who figured that if cool jocks were using pills, how bad could it be?

One addict was Carter, from one of of California’s wealthiest communities, the son of a banker. Carter had been a high school star in football and baseball. With no break from sports during the year, he battled injuries that never healed. A doctor prescribed Vicodin for him, with no warning on what Vicodin contained, or suggestions for how it should be used. Sports were king in Carter’s town. It was a place of gleaming mansions, but he felt no sense that education was of value in providing choices in life, much less for the love of learning. These kids’ futures were assured. Sports were what mattered. Dads would brag to friends about their sons’ athletic exploits, then berate their boys for poor play, urging greater sacrifice. From the athletic director down to parents and teachers they heard, “You need grades so you can play. That was the vibe we got,” said Carter.

Many new athlete-addicts were not from poor towns where sports might be a ticket out for a lucky few. The places where opiate addiction settled hard were often middle- and upper-class. Parents were surgeons and developers and lawyers who provided their kids with everything. Yet sports were as much a narcotic for these communities as they were to any ghetto. Love of learning seemed absent, while their school weight rooms were palatial things, and in many of them pain pills were quietly commonplace. Just as opiates provided doctors with a solution to chronic-pain patients, Vicodin and Percocet provided coaches with the ultimate tool to get kids playing again.

Carter’s coach told him stories of players years before who were gulping down Vicodin before practices and games. “In my town, the stands were always filled. You wanted to be the hero. So you think, ‘I can’t look weak. I gotta push myself.’ I would get these small injuries. The coaches wouldn’t pay any attention. I taught myself to not pay attention to any injuries.” Most athletes on every team on which Carter played used pills, for injury or recreation. Soon Carter grew addicted to Vicodin, and then to OxyContin. From there, as a student athlete at a Division I university, he began using heroin.

Football players were seen as symbols of this American epidemic. Their elevated status on campus left some of them unaffected by consequences. Carter was caught selling pills and was told not to do it again. Above all, though, players were in constant pain and were expected to play with it. If opiates were now for chronic pain, well, football players endured more chronic pain than most. Necks, thighs, and ankles ached all season. Medicating injuries to get athletes playing through the pain was nothing new. But as oxycodone and hydrocodone became the go-to treatment for chronic pain, organized sports – and football in particular – opened as a virtual gateway to opiate addiction in many schools. Thus, with the epidemic emerged the figure of the heroin-addicted football player. Though, of course, few wanted to talk too much about that.

By 2008, when Jo Anna Krohn’s son died, these kinds of delusions had been accepted for almost a decade in places like Salt Lake, Albuquerque, Charlotte, Minneapolis, and other cities that had for that same decade been the drivers and beneficiaries of the greatest boom in the history of U.S. consumer spending. But it was in beat-down Portsmouth, Ohio, where one mother had the gumption to own the truth and say something about it.

***

ACROSS PORTSMOUTH, AT THE Counseling Center, Ed Hughes thought silence was a huge part of the story. Opiates had exploded all those plans Hughes had in the mid-1990s to consolidate the Counseling Center’s operations and focus on improving its internal workings. The center opened years before in a small house. By 1992 it began residential treatment with 16 beds. This quickly increased to 150 beds, with a huge waiting list, and a staff of close to 200. It moved its outpatient center into an abandoned three-story school due entirely to the swarms of new opiate addicts.

“We’ve never seen anything move this fast,” said Hughes. A decade and a half in, Ed Hughes was still waiting for the arc of addicted clients to plateau and curve downward. Kids were coming to the center from across Ohio. Many, said Hughes, grew up coddled, bored, and unprepared for life’s hazards and difficulties. They’d grown up amid the consumerist boom that began in the mid 1990s. Hughes believed parenting was changing as well. “Spoiled rich kid” syndrome seeped into America’s middle class. Parents shielded their kids from complications and hardships, and praised them for minor accomplishments – all as they had less time for their kids.

“You only develop self-esteem one way, and that’s through accomplishment,” Hughes said. “You have a lot of kids who have everything and look good, but they don’t have any self-esteem. You see twenty-somethings: They have a nice car, money in their pocket, and they got a cell phone… a big-screen TV. I ask them, ‘Where the hell did all that stuff come from? You’re a student.’ ‘My mom and dad gave it to me.’ And you put opiate addiction in the middle of that?” Hughes added, “Then the third leg of the stool is the fifteen-year-old brain.”

Hughes saw this all the time: Adult drug users incapable of making mature choices. This happened because opiates stunted the part of their brain controlling rational action. ¹ “We’ve got twenty-five- to thirty-year-old, opiate-addicted people who are going on fifteen. Their behavior, the way their brain works, is like an adolescent,” said Hughes. “It’s like the drug came in there and overwhelmed that brain chemistry, and the front of the brain did not develop.” He added, “The front of the brain has to develop through mistakes. But the first reaction to the addicted person is to head back to the family: ‘Will you rescue me?’ Whatever the person’s rescued from, there’s no learning. There’s no experiences, no frontal brain development. They’re doing well and then some idea comes into their head and they’re off a cliff. It may not be a decision to use [drugs]. Most relapse comes not from the craving for the drug. It comes from this whole other level of unmanageability, putting myself in compromising situations, or being dishonest, being lazy – being a fifteen-year-old.”

***

FIVE YEARS AFTER PORTSMOUTH found itself swept up in a national epidemic, the victims of America’s opiate scourge had emerged from the shadows and the silence. They were everywhere now. Heroin had traveled a long way from the back alleys of New York City and William Burrough’s Junky. The town of Simi Valley agonized over a spate of opiate overdose deaths – eleven in a single year. Simi Valley, conservative and religious, has long been an enclave for cops. Many LAPD officers live in the town. Simi’s vice mayor at the time was a Los Angeles police officer. So for years Simi was one of America’s safest towns. According to the crime statistics, it still is. But with pills everywhere and heroin sold in high schools, its kids were now also dying of dope. Simi youths clogged the methadone clinic. Nearby, Thousand Oaks, Moorpark, and Santa Clarita told similar stories. Low crime and high fatal overdoses was the new American paradigm.

Susan Klimuski, whose son Austin died from a heroin overdose, formed a coalition to fight back. It was called Not One More. It received support from city council and the town’s retail core. Yet these were times when heroin was still invisible, conveniently hidden away, at least to anyone who wasn’t a junkie, or a parent of one. Then, on Super Bowl Sunday 2014, America awoke to the news that one of its finest actors was dead. Philip Seymour Hoffman, forty-six, was found that morning in his Greenwich Village apartment, a syringe in his arm and powder heroin in packets branded with the Ace of Spades near his corpse. Blood tests showed he had heroin in his system, combined with cocaine, amphetamine, and benzodiazepine. The Oscar-winning actor – a father of three- had checked into rehab the previous May for ten days, and then, pronouncing himself sober again, left to resume a hectic film schedule. This death hit me right between the eyes. I was a die-hard fan of Hoffman’s acting. He had a heroin habit in college (twenty years ago), but managed to get clean. At least for two decades. Hoffman’s death awoke America to the opiate epidemic.

Within days of covering the story of Hoffman’s death, media outlets from coast to coast discovered that thousands of people were dying. Heroin abuse, the news reports insisted, was surging. Almost all the new heroin addicts were hooked first on prescription painkillers. It was not just the pain, however. This scourge was connected to the conflation of bigger forces: of economics, of aggressive prescription drug marketing, of poverty and prosperity. But this was tough to articulate in four-minute interviews, and a lot of it got lost in the media’s rush to discover and report the new plague. Attorney General Eric Holder described an “urgent and growing public health crisis,” and called on police and paramedics to carry naloxone, an effective antidote to opiate overdose. The problem also prompted Surgeon General Vivek H. Murthy, M.D., M.B.A. to issue a report in November 2016 on alcohol, drugs and health. This is the most comprehensive health crisis report issued by a surgeon general since cigarette smoking. You can read a PDF of the entire report here.

Two decades since the evolving pain revolution,² a consensus emerged that opiates are not helpful for some varieties of chronic pain, including back pain, migraines, and fibromyalgia. In fact, it was finally decided that opiate use is risky. Many clinics and physicians developed policies against using opiates for chronic non-cancer pain. One 2007 survey of studies of back pain and opiates found that “use disorders” were common among patients, and “aberrant” use behavior occurred in up to 24 percent of the cases. It was unclear whether opiates had a positive effect on back pain in the long term. Personally, I have found that opiates do nothing more than create a euphoria that tends to distract me from the pain for a few hours, only to ebb, thus requiring more opiates. By the end of the 2000s, it was already common for people to go from abusing opiate painkillers to a heroin habit. Purdue Pharma, the inventor of OxyContin (who paid a $635.5 million fine for falsely claiming their formulation of the drug oxycodone in time-released pills was far less addictive) recognized this, and in 2010 they reformulated OxyContin with an abuse deterrent, supposedly making the drug even harder to deconstruct and inject.

Unfortunately, by this time, heroin had spread to most corners of the country because the rising sea level of opiates flowed there first. “What started as an OxyContin and prescription drug addiction problem in Vermont as now grown into a full-blown heroin crisis,” said Governor Shumlin. What made New York City the dominant heroin market for much of the twentieth century – its vast number of addicts, and its immigrants from poppy-rich regions of the globe – was now true of most of America. Most of the country’s heroin was coming from Mexico, through the Southwest, trucked into New York. The entrepreneurial Xalisco brothers from Nayarit, Mexico, devised a system for selling heroin across the United States that resembles pizza delivery. An addict calls and places an order, and an operator directs him to an intersection or parking lot. The dealer carries balloons of heroin in his mouth. He simply spits out what the addict ordered. If the cops move on the dealer, he washes the balloons down his throat with a swig from a nearby bottle of water. No evidence, no arrest. The dealers have also been known to deliver to the door for “clients” that are home-bound due to illness or disability.

What started as a concern among physicians for a solution to chronic pain was hijacked by greedy Big Pharma, eventually morphing into nationwide heroin use and addiction resulting from the medical community and the government tightened the reins on prescriptions. Of course, whenever drugs are involved, there is always someone at the ready to provide a system of delivery to dope-sick addicts and chronic pain sufferers hankering for release.

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¹ Adolescence and young adulthood is a period of continued brain growth and change. The frontal lobes, key to executive functioning, such as planning, working memory, and impulse control, are among the last areas of the brain to mature. Age is a risk factor that is associated with the onset of drug use in adolescence and young adulthood. Adolescence is a developmental period associated with the highest risk for developing a substance use disorder.

² During the 1990s changes in attitudes and techniques in pain treatment were coming quickly. In 1996, the president of the American Pain Society, Dr. James Campbell, proposed that pain should be assessed in the same manner as other vital signs. They trademarked the slogan, “Pain: The Fifth Vital Sign.” This led to the 0-10 pain intensity scale now prevalent in every ER and doctor’s office in America. Essentially, doctors were finally given more power in prescribing opiates to patients suffering from chronic pain who were not cancer patients.

References

Quinones, Sam. (2015). Dreamland: The True Tale of America’s Opiate Epidemic. New York, NY: Bloomsbury Press

Winters, K. and Arria, K. (2011). “Adolescent Brain Development and Drugs.” The Prevention Researcher, 18(2), 21–24.