YAFI Online Programming //Law Related to Pharmacy Practice


Connecting the Opioid Dots: Prescriptions Down, Fatalities Up

Educational Objectives

After participating in this activity, pharmacists will be able to:

  • Describe the historical and recent trends in the abuse of controlled substances
  • Identify the types of drugs and patterns of use which increase the risk of overdose fatalities.
  • Compare regulatory and public policy efforts to reduce misuse and dangers from prescription and illicit controlled substances.
  • Describe the role of the pharmacist and other health professions in reducing overdose risks.

Session Offered

Release Date: February 18, 2019

Expiration Date: February 15, 2022

Course Fee


Session Codes

19YC03-ACB38 Pharmacist

19YC03-TVK87 Pharmacy Technician

Accreditation Hours

2.0 hours of CE


Drug overdose death rates increased almost five-fold between 1999 and 2016 and have impacted all demographic groups. Drug overdose has become the leading cause of accidental death in the U.S. and is largely fueled by opioid drugs, with other drugs also becoming significant factors. In the last decade, heroin and illicitly manufactured synthetic drugs such as fentanyl have replaced prescription opioids as the primary contributors to the overdose crisis. In response to the crisis, government and professional organizations and other policy makers have proposed a variety of solutions to the problem. This lesson will review the development of the problem and some proposed solutions that impact health care providers including addiction prevention and treatment, pain treatment guidelines, and prescribing limits on controlled substances.

Accreditation Statements

The University of Connecticut School of Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

Pharmacists and pharmacy technicians are eligible to participate in this application-based activity and will receive up to 0.2 CEU (2 contact hours) for completing the activity, passing the quiz with a grade of 70% or better, and completing an online evaluation. Statements of credit are available via the CPE Monitor on- line system and your participation will be recorded with CPE Monitor within 72 hours of submission


Grant funding: Daiichi Sankyo, Inc.

Cost: Free

Initial Release Date: February 18, 2019
Expiration Date: February 15, 2022

To obtain CPE credit, visit the UConn Online CE Center

Use your NABP E-profile ID and the session code 19YC03-ACB38 for pharmacists or 19YC03-TVK87 for pharmacy technicians to access the online quiz and evaluation.

First- time users must pre-register in the Online CE Center. Test results will be displayed immediately and your participation will be recorded with CPE Mon- itor within 72 hours of completing the requirements.

For questions concerning the online CPE activities, email joanne.nault@uconn.edu


Gerald Gianutsos, Ph.D., J.D., R.Ph., is an Emeritus Associate Professor of Pharmacology at the University of Connecticut, School of Pharmacy.

Faculty Disclosure

Dr. Gianutsos has no actual or potential conflicts of interest associated with this article.

Disclosure of Discussions of Off-label and Investigational Drug Use

This activity may contain discussion of off label/unapproved use of drugs. The content and views presented in this educational program are those of the faculty and do not necessarily represent those of the University of Connecticut School of Pharmacy. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.



"To every discovery mankind has ever made, from the lighting of the first fire to the splitting of the atom, there has been a good side and a bad side. Opium is no different. It can stop pain and, as Thomas Sydenham observed over 300 years ago, few doctors would be hard-hearted enough to practise medicine without it. Millions have been saved by it: yet it has also destroyed millions of lives, enslaved whole cultures and invidiously corrupted human society to its very core."1


Readers are no doubt already aware that the “corrupted human society” forecast by British novelist and poet Martin Booth in 1999 is the occurrence of an opioid overdose crisis, which claimed 48,068 lives in 2017. The opioid crisis is the most visible segment of an overall tragedy of fatal drug overdose; total overdose deaths reached 70,237 in 2017 (up from 68,400 in the previous 12-month period [a 9.6% increase], 43,982 in 2013 and 17,000 in 1999).2,3 These alarming statistics place drug overdose as the leading cause of accidental deaths in the U.S., more than traffic accidents, AIDS at its peak, or the numbers dying during the Vietnam War.4


The impact of the rise in overdose deaths is so pronounced that in 2017, the life expectancy in the U.S. dropped, attributed at least in part to an increase in drug overdose and suicide. Life expectancy also declined in 2015 and stayed flat in 2016, marking the first three-year period of general decline since the late 1910s.5 However, the current trend is the result of more people dying in their 20s and 30s.


A problem of this magnitude is bound to attract attention from many arenas, including legislators and policy makers. In March of 2017, the President’s Commission on Combating Drug Addiction and the Opioid Crisis was established to recommend policies and practices for combating drug addiction with a focus on opiates. The Commission issued a 138-page report in November of 2017, and underscored the seriousness of the issue by asking: “If a terrorist organization was killing 175 Americans a day [the average number of overdose deaths at the time the report was published] on American soil, what would we do to stop them?”6 The Commission made 56 recommendations in many different areas to address the growing problem.6 These include addiction prevention, addiction and overdose treatment and recovery, research and development (especially in pain management and addiction) and increased Federal funding. Pharmacists and technicians have seen first-hand the exacerbation and tragic consequences of the crisis. They should also ask themselves what they can do to help reduce the death toll. This lesson will focus on the scope of the drug overdose problem and review some attempts to alleviate the problem.


Full List of References

1. Booth M. Opium: A History. St. Martin's Griffin. 1999.

2. National Institute on Drug Abuse. Overdose Death Rates. Retrieved from: https://www.drugabuse.gov/related-topics/trendsstatistics/overdose-death-rates

3. Hedegaard H, Miniño AM, Warner M. Drug overdose deaths in the United States, 1999–2017. NCHS Data Brief, no 329. Hyattsville, MD: National Center for Health Statistics. 2018. Retrieved from: https://www.cdc.gov/nchs/products/databriefs/db329.htm

4. Sullivan A. The poison we pick. NY Mag. February 19, 2018. Retrieved from: http://nymag.com/intelligencer/2018/02/americas-opioidepidemic.html

5. Fox M. U.S. life expectancy falls for second straight year-as drug overdoses soar. NBC News December 21, 2017. Retrieved from: https://www.nbcnews.com/storyline/americas-heroin-epidemic/u-slife-expectancy-falls-second-straight-year-drug-overdoses-n831676

6. Report of The President’s Commission On Combating Drug Addiction And The Opioid Crisis. November 1, 2017. Retrieved from: https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Final _Report_Draft_11-1-2017.pdf

7. Centers for Disease Control and Prevention. U.S. drug overdose deaths continue to rise; increase fueled by synthetic opioids. Retrieved from: https://www.cdc.gov/media/releases/2018/p0329-drugoverdose-deaths.html

8. Centers for Disease Control and Prevention. Understanding the epidemic. Retrieved from: https://www.cdc.gov/drugoverdose/epidemic/index.html

9. White House. The opioid crisis. Retrieved from: https://www.whitehouse.gov/opioids/

10. Murphy SL, Xu JQ, Kochanek KD, Arias E. Mortality in the United States, 2017. NCHS Data Brief, no 328. Hyattsville, MD: National Center for Health Statistics. 2018. Retrieved from: https://www.cdc.gov/nchs/products/databriefs/db328.htm

11. Jones CM, Einstein EB, Compton WM. Changes in synthetic opioid involvement in drug overdose deaths in the United States, 2010-2016. JAMA 2018;319(17):1819-1821.

12. Reisine T. Opiate receptors. Neuropharmacology 1995; 34(5): 463- 472.

13. Schiller EY, Mechanic OJ. Opioid, Overdose. StatPearls. April 14, 2018. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK470415/

14. Boyer EW. Management of Opioid Analgesic Overdose. N Engl J Med 2012; 367:146-155.

15. Substance Abuse and Mental Health Services Administration. Preventing the Consequences of Opioid Overdose: Understanding Naloxone Access Laws. Retrieved from: https://www.samhsa.gov/capt/sites/default/files/resources/naloxoneaccess-laws-tool.pdf

16. Compton WM, Jones CM, Stein JR, Wargo EM. Promising roles for pharmacists in addressing the U.S. opioid crisis. Res Soc Admin Pharm. 2017; E-pub ahead of print. Retrieved from: https://www.sciencedirect.com/science/article/pii/S15517411173097 74?via%3Dihub

17. Kolodny A, Courtwright DT, Hwang CS, et al. The prescription opioid and heroin crisis: A public health approach to an epidemic of addiction. Ann Rev Pub Hlth. 2015;36:559-574.

18. Drug Policy Alliance. A Brief History of the Drug War. Retrieved from: http://www.drugpolicy.org/issues/brief-history-drug-war

19. Nixon RM. Remarks about an intensified program for drug abuse prevention and control. June 17, 1971. Retrieved from: http://www.presidency.ucsb.edu/ws/?pid=3047

20. Drug Enforcement Administration. DEA History. Retrieved from: https://www.dea.gov/history

21. Pergliozzi JV, LeQuang JA, Taylor A, Raffa RB. Going beyond prescription pain relievers to understand the opioid epidemic: the role of illicit fentanyl, new psychoactive substances, and street heroin. Postgrad Med. 2018; 130(1): 1-8.

22. Compton WM and Volkow ND. Abuse of prescription drugs and the risk of addiction. Drug and Alcohol Depend. 2006; 81:103-107.

23. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016. JAMA. 2016;315(15):1624-1645.

24. Keuhn BM. Opioid prescriptions soar. JAMA 2007; 297(3):249-251. doi:10.1001/jama.297.3.249.

25. Brennan F. The US Congressional “Decade on Pain Control and Research” 2001–2011: A Review. J Pain Palliative Care Pharmacother. 2015; 29(3): 212-227. 26. Porter J, Jick H. Addiction Rare in Patients Treated with Narcotics. N Engl J Med 1980; 302:123.

27. Leung PTM, Macdonald EM, Dhalla IA, Juurlink DN. A 1980 Letter on the risk of opioid addiction. N Engl J Med 2017; 376:2194-2195.

28. Drug Enforcement Administration. Schedules of Controlled Substances: Rescheduling of Hydrocodone Combination Products From Schedule III to Schedule II. Fed Reg. 2014; 79(163): 49661- 49682. Retrieved from: https://www.deadiversion.usdoj.gov/fed_regs/rules/2014/fr0822.htm

29. Rose ME. Are Prescription Opioids Driving the Opioid Crisis? Assumptions vs Facts. Pain Med. 2018; 19(4): 793-807.

30. Agarin T, Trescot A, Agarin A, et al. Reducing Opioid Analgesic Deaths in America: What Health Providers Can Do. Pain Phys. 2015; 18(3):E307- 22. http://www.painphysicianjournal.com/current/pdf?article=MjMxNA%3 D%3D&journal=88

31. Centers for Disease Control and Prevention. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR 2016; 65(1): 1-49. Retrieved from: https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm?CDC_AA_ref Val=https%3A%2F%2Fwww.cdc.gov%2Fmmwr%2Fvolumes%2F65%2Frr %2Frr6501e1er.htm

32. Centers for Disease Control and Prevention. Calculating Total Daily Dose of Opioids for Safer Dosage. Retrieved from: https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dosea.pdf 33. Centers for Disease Control and Prevention. Opioid Overdose. Retrieved from: https://www.cdc.gov/drugoverdose/index.html

34. Federation of State Medical Boards. Guidelines for the Chronic Use of Opioid Analgesics. Aril 2017. Retrieved from: https://www.fsmb.org/siteassets/advocacy/policies/opioid_guidelines _as_adopted_april-2017_final.pdf

35. Anson P. Medicare finalizes plan to reduce high dose opioids. Pain News Network. April 02, 2018. Retrieved from: https://www.painnewsnetwork.org/stories/2018/4/2/medicarefinalizes-plan-to-reduce-high-dose-opioids

36. Davis CS, Lieberman AJ, Hernandez-Delgado H., Suba C. Laws limiting the prescribing or dispensing of opioids for acute pain in the United States: A national systematic legal review. Drug Alc Depend. 2019: 194(1): 166-172.

37. National Conference of State Legislatures. Prescribing Policies: States Confront Opioid Overdose Epidemic. Retrieved from: http://www.ncsl.org/research/health/prescribing-policies-statesconfront-opioid-overdose-epidemic.aspx

38. Lutz J. Opioid Prescribing Guidelines: A State-By-State Overview. Updated February 20, 2018. Retrieved from: https://www.affirmhealth.com/blog/opioidprescribing-guidelines-a-state-by-state-overview

39. Shah A, Hayes CJ, Martin BC. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use — United States, 2006–2015. MMWR 2017;66:265–269. Retrieved from: https://www.cdc.gov/mmwr/volumes/66/wr/mm6610a1.htm

40. Davis CS. The SUPPORT for Patients and Communities Act — What Will It Mean for the Opioid-Overdose Crisis? N Engl J Med 2019; 380:3- 5.

41. Hedegaard H, Bastian BA, Trinidad JP, Spencer M, Warner M. Drugs most frequently involved in drug overdose deaths: United States, 2011–2016. National Vital Statistics Reports; vol 67 no 9. Hyattsville, MD: National Center for Health Statistics. 2018. Retrieved from: https://www.cdc.gov/nchs/data/nvsr/nvsr67/nvsr67_09-508.pdf

42. Compton WM, Jones CM, Baldwin GT. Relationship between nonmedical prescription-opioid use and heroin use. N Engl J Med. 2016;374(2):154-63.

43. National Institute on Drug Abuse. Prescription opioids and heroin. Updated January 2018. Retieved from: https://www.drugabuse.gov/publications/researchreports/relationship-between-prescription-drug-abuse-heroinuse/introduction

44. Minozzi S, Amato l, Davoli M. Development of dependence following treatment with opioid analgesics for pain relief: a systematic review. Addiction. 2013; 108(4): 688-696.

45. Vowles KE, McEntee ML, Julnes PS, et al. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain 2015; 156(4): 569-576.

46. Higgins C, Smith BH, Matthews K. Incidence of iatrogenic opioid dependence or abuse in patients with pain who were exposed to opioid analgesic therapy: a systematic review and meta-analysis. Br J Anaes. 2018; 120(6): 1335-1344.

47. Carise D, Dugosh KL, McLellan AT, et al. Prescription OxyContin Abuse Among Patients Entering Addiction Treatment. Am J Psychiat. 2007; 164(11): 1750-1756.

48. Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA Psychiatry. 2014;71(7):821-826.

49. Lankenau SE, Teti M, Silva K, et al. Initiation into Prescription Opioid Misuse among Young Injection Drug Users. Int J Drug Policy. 2012 Jan; 23(1): 37–44.

50. O’Donnell J, Gladden RM, Mattson CL, Kariisa M. Notes from the Field: Overdose Deaths with Carfentanil and Other Fentanyl Analogs Detected — 10 States, July 2016–June 2017. MMWR 2018; 67:767– 768. Retrieved from: https://www.cdc.gov/mmwr/volumes/67/wr/mm6727a4.htm

51. Chester KL. Fentanyl: The Next Wave of the Opiate Crisis. Statement to the United States House of Representatives Subcommittee on Oversight and Investigations Committee on Energy and Commerce. March 21, 2017. Retrieved from: https://docs.house.gov/meetings/IF/IF02/20170321/105739/HHRG115-IF02-Wstate-ChesterK-20170321.pdf

52. Campo-Flores A. Fentanyl’s New Foe: A Quick Test Strip That Can Prevent Overdoses. WSJ Updated January 2, 2019. Retrieved from: https://www.wsj.com/articles/fentanyls-new-foe-a-quick-test-stripthat-can-prevent-overdoses11546252200?mod=hp_lista_pos3&mod=djemHL_t

53. Centers for Disease Control and Prevention. Fentanyls and the Safety of First Responders: Science and Recommendations. Posted June 26, 2018. Retrieved from: https://blogs.cdc.gov/niosh-science-blog/2018/06/26/fentanyls-andfirst-responders/

54. Wilber DQ. Fentanyl smuggled from China is killing thousands of Americans. LA Times October 19, 2018. Retrieved from: http://www.latimes.com/politics/la-na-pol-china-fentanyl-20181019- story.html?outputType=amp

55. Harper J. Despite Warnings, FDA Approves Potent New Opioid Painkiller. NPR Health News. November 2, 2018. Retrieved from: https://www.npr.org/sections/healthshots/2018/11/02/663395669/despite-warnings-fda-approves-potentnew-opioid-painkiller

56. Sun EC, Dixit A, Humphreys K, et al. Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis. BMJ 2017; 356:j760.

57. Drug Enforcement Administration. A Pharmacist’s Guide to Prescription Fraud. Retrieved from: https://www.deadiversion.usdoj.gov/pubs/brochures/pharmguide.h tm

58. Pitcher MH, Von Korff M, Bushnell MC, Porter L. Prevalence and profile of high impact chronic pain in the United States. J. Pain. August 8, 2018. Epub ahead of print. https://www.jpain.org/article/S1526-5900(18)30358-4/fulltext

59. Ray S, Hoffman K. Opioid stigma is keeping many cancer patients from getting the pain control they need. Stat News. July 6, 2018. Retrieved from: https://www.statnews.com/2018/07/06/cancer-patients-pain-opioidstigma/