title: Opioid epidemic in the United States

text: Overdoses involving fentanyl have greatly contributed to the havoc caused by the opioid epidemic. In New Hampshire, two thirds of the fatal drug overdoses involved fentanyl, and most do not know that they are taking fentanyl. In 2017, a cluster of fentanyl overdoses in Florida was found to be caused by street sales of fentanyl pills sold as Xanax. According to the DEA, of fentanyl can be bought in China for $3,000 to $5,000, and then smuggled into the United States by mail or Mexican drug cartels to generate over $1.5million in revenue. The profitability of this drug has led dealers to adulterate other drugs with fentanyl without the knowledge of the drug user.


title: Opioid epidemic in the United States

text: One study found that, although relatively uncommon, "the presence of fentanyl in the stimulant supply increased significantly between 2011 and 2016, with the greatest increases occurring between 2015-2016; the presence of these products was concentrated in the U.S. Northeast."


title: Opioid epidemic in the United States

text: Fentanyl can also be found in opioids prescribed for breakthrough cancer pain in opioid-tolerant patients called Transmucosal immediate-release fentanyls (TIRFs.) TIRFS are subject to a US Food and Drug Administration (FDA) Risk Evaluation and Mitigation Strategy (REMS) to prevent inappropriate prescriptions of these extremely potent drugs.


title: Opioid epidemic in the United States

text: A 2020 study by Aventis Pharmaceuticals found that higher doses of naloxone, the opioid overdose-reversing medication, can help resuscitate a victim of an overdose involving synthetic opioids such as carfentanil, a substance that is 100 times as strong as fentanyl. According to "Health Crisis Alert", "Researchers gave monkeys the synthetic opioid carfentanil followed by different doses of naloxone. . . . After receiving naloxone, the monkeys’ brains were observed using Positron Emission Tomography imaging. The higher the level of naloxone, the higher the receptor occupancy."


title: Opioid epidemic in the United States

text: In the US, addiction and overdoses affect mostly non-Hispanic Whites from the working class. Native Americans and Alaska Natives experienced a five-fold increase in opioid-overdose deaths between 1999 and 2015, with Native Americans having the highest increase of any demographic group. There is significant speculation as to the root causes of the demographic differences, but thus far a credible explanation has yet to be found given the complexity of the issue and the difficulty in controlling for variables when investigating.


title: Opioid epidemic in the United States

text: In 2014, roughly 12 percent of young adults between the ages of 18 and 25 reported abusing prescribed opioids.


title: Opioid epidemic in the United States

text: In 2016, approximately 91 people died everyday from overdosing on opioids. Roughly half of these deaths were caused by prescribed opioids.


title: Opioid epidemic in the United States

text: In 2018, the opioid crisis continued to disproportionately affect non-Hispanic Whites and Native Americans with the National Institutes of Health (NIH) reporting a rise in opioid morbidity and opioid related fatalities. This is especially concerning considering the epidemiology of opioid affliction among white women, who are at a greater risk because they receive more prescription medications than men. According to the NIH (2018), "The opioid epidemic is increasingly young, white, and female" with 1.2million women being diagnosed with an opioid use disorder compared to 0.9million men in 2015.


title: Opioid epidemic in the United States

text: In the United States, those living in rural areas of the country have been the hardest hit. According to Rita Noonan from the CDC, in rural areas, the overall death rate for accidental injuries is 50% higher than in urban areas. Differences in a multitude of factors, such as income, social supports, and accessibility to health care resources, have led to rural communities majorly exceeding urban areas when it comes to the rate of opioid-involved overdose deaths.


title: Opioid epidemic in the United States

text: Non-medical prescription drug use rates have been increasing in teenagers with access to parents' medicine cabinets, especially as 12- to 17-year-old girls were one-third of all new users of prescription drugs in 2006. Teens used prescription drugs more than any illicit drug except cannabis, more than cocaine, heroin, and methamphetamine combined. In 2014, roughly 6 percent of teenagers between the ages of 12 and 17 reported abusing prescribed opioids. Deaths from overdose of heroin affect younger people more than deaths from other opiates.


title: Opioid epidemic in the United States

text: Prescription rates for opioids vary widely across states. In 2012, healthcare providers in the highest-prescribing state wrote almost three times as many opioid prescriptions per person as those in the lowest-prescribing state. Health issues that cause people pain do not vary much from place to place and do not explain this variability in prescribing. Researchers suspect that the variation results from a lack of consensus among elected officials in different states about how much pain medication to prescribe. A higher rate of prescription drug use does not lead to better health outcomes or patient satisfaction, according to studies.


title: Opioid epidemic in the United States

text: In Palm Beach County, Florida, overdose deaths went from 149 in 2012 to 588 in 2016. In Middletown, Ohio, overdose deaths quadrupled in the 15 years since 2000. In British Columbia, 967 people died of an opiate overdose in 2016, and the Canadian Medical Association expected over 1,500 deaths in 2017. In Pennsylvania, the number of opioid deaths increased 44 percent from 2016 to 2017, with 5,200 deaths in 2017. Governor Tom Wolf declared a state of emergency in response to the crisis.


title: Opioid epidemic in the United States

text: The high death rate by overdose, the spread of communicable diseases, and the economic burden are major issues caused by the epidemic, which has emerged as one of the worst drug crises in American history. More than 33,000 people died from overdoses in 2015, nearly equal to the number of deaths from car crashes, with the deaths from heroin alone outnumbering gun homicides. It has also left thousands of children suddenly in need of foster care after their parents have died from an overdose.


title: Opioid epidemic in the United States

text: Addiction does not only affect the people taking the drug but the people around them, like families and relationships. Conflict is usually the number one problem between family members and the people abusing heroin, the fighting becomes an everyday routine. In Jeff Schonberg and Philippe Bourgois's ethnography, Righteous Dopefiend, they did a participant observation from 1994 to 2006, and they focused on the lives of the homeless heroin addicts in San Francisco, California. They found that for example, Sonny is still in contact with his family, but he doesn't live with them, and he vowed to himself that he will never let his family see him at his worst, but he goes to his family usually for holidays and important dates, and when he is with them he is sober. This kind of relationship isn't always the case though. They observed another example with Tina whose parents have completely cut off contact with her, and she is left on the streets with nobody except the family she has created in the homeless society.


title: Opioid epidemic in the United States

text: A 2016 study showed the cost of prescription opioid overdoses, non-medical use, and dependence in the United States in 2013 was approximately $78.5billion, most of which was attributed to health care and criminal justice spending, along with lost productivity. By 2015 the epidemic had worsened with overdose and with deaths doubling in the past decade. The White House stated on November 20, 2017, that in 2015 alone the opioid epidemic cost the United States an estimated $504billion.


title: Opioid epidemic in the United States

text: Two employees of the University of Notre Dame were killed in a murder-suicide over the refusal of Dr. Todd Graham, 56, to renew the opioid prescription for the wife of Mike Jarvis, 48. United States Representative Jackie Walorski sponsored a bill in the memory of the doctor who would not over-prescribe; the Dr. Todd Graham Pain Management Improvement Act is intended to address the opioid epidemic.


title: Opioid epidemic in the United States

text: The National Safety Council calculated that the lifetime odds of dying from an opioid overdose (1 in 96) in 2017 were greater than the lifetime odds of dying in an automobile accident (1 in 103) in the United States.


title: Opioid epidemic in the United States

text: The opioid epidemic, combined with the Patient Protection and Affordable Care Act, has led to a situation called the Florida shuffle, where a drug user moves between drug rehabilitation centers so those centers may bill the user's insurance company.


title: Opioid epidemic in the United States

text: In one study, a decision analytical model of the US population aged 12 years or older found that "under the status quo, an estimated 484,429 individuals were projected to die of fatal opioid overdose" between 2020 and 2029. However, a combination of "reducing opioid prescribing, increasing naloxone distribution, and expanding treatment for opioid use disorder was associated with an estimated 179,151 lives saved when compared to the status quo."


title: Opioid epidemic in the United States

text: Healthcare professionals are also among those heavily affected by this epidemic. Studies have been done to determine how well nursing students, nurses, and even doctors are prepared to treat patients affected by opioid addictions. The studies have pointed to the fact that nurses and other healthcare professionals are highly undertrained in this area. As a result, many specific education programs have been proposed and implemented into nursing education institutions.


title: Opioid epidemic in the United States

text: After slight decreases in opioid fatalities 2017–2018, overdose deaths in the US increased in 2019, due largely to an increase in non-medical use of fentanyl. The COVID-19 pandemic's interference into both social safety and health care delivery systems has probably intensified the opioid epidemic. US media, on national, state, and local levels, infer that overdose deaths are increasing. But there is no national reporting system on overdose mortality to confirm these reports. Conclusions on the relationship between increasing overdose fatalities and the COVID-19 pandemic will require more research. Studies, such as those by Wainwright et al. and Ochalek et al. intimate that opioid use and overdose deaths may be increasing, just as reported by the media. But more study is needed.


title: Opioid epidemic in the United States

text: In addition, the COVID-19 pandemic has marked the start of health care policies that, should they be adopted permanently, could not only lessen the effects of the pandemic on overdoses, but also make overall treatment of opioid use disorder more effective by eliminating obstacles to previously proven therapies for these disorders.


title: Opioid epidemic in the United States

text: According to the US National Institute on Drug Abuse, the coronavirus disease 2019 (COVID-19) pandemic could hit certain populations, such as those suffering from substance use disorders and especially those with opioid use disorder, particularly hard. For opioid use disorder patients, COVID-19's effects on respiratory and pulmonary health is a significant threat.


title: Opioid epidemic in the United States

text: According to an April 2020 Health Affairs journal article "Once The Coronavirus Pandemic Subsides, The Opioid Epidemic Will Rage," recommended potential solutions include requiring doctors in large physician groups to get the federal waiver that would allow them to prescribe FDA-approved mediations to treat addiction. Under the Drug Addiction Treatment Act of 2000, physicians can obtain an "X-waiver" to prescribe buprenorphine.


title: Opioid epidemic in the United States

text: Other studies have looked at treatments for OUD during the COVID-19 pandemic. For example, one JAMA Internal Medicine research letter from December 2020 found that since the COVID-19 national emergency declaration, "the number of individuals filling buprenorphine prescriptions has plateaued but has not decreased; however, filled prescriptions for all medications collectively have decreased considerably."


title: Opioid epidemic in the United States

text: In 2010, the US government began cracking down on pharmacists and doctors who were overprescribing opioid painkillers. An unintended consequence of this was that those addicted to prescription opiates turned to heroin, a significantly more potent but cheaper opioid, as a substitute. A 2017 survey in Utah of heroin users found about 80 percent started with prescription drugs.


title: Opioid epidemic in the United States

text: In 2010, the Controlled Substances Act was amended with the Secure and Responsible Drug Disposal Act, which allows pharmacies to accept controlled substances from households or long-term care facilities in their drug disposal programs or "take-back" programs.


title: Opioid epidemic in the United States

text: In 2011, the federal government released a white paper describing the administration's plan to deal with the crisis. Its concerns have been echoed by numerous medical and government advisory groups around the world. In July 2016, President Barack Obama signed into law the Comprehensive Addiction and Recovery Act, which expands opioid addiction treatment with buprenorphine and authorizes millions of dollars in funding for opioid research and treatment.


title: Opioid epidemic in the United States

text: In 2011, the Obama administration began to deal with the crisis, and in 2016, President Barack Obama authorized millions of dollars in funding for opioid research and treatment, followed by CDC director Thomas Frieden stating that "America is awash in opioids; urgent action is critical." Soon after, many state governors declared a "state of emergency" to combat the opioid epidemic in their own states, and undertook major efforts to stop it. In July 2017, opioid addiction was cited as the "Food and Drug Administration's biggest crisis", followed by President Donald Trump declaring the opioid crisis a "national emergency." In September 2019, he ordered U.S. mail carriers to block shipments of fentanyl coming from other countries.


title: Opioid epidemic in the United States

text: In 2016, the US Surgeon General listed statistics which describe the extent of the problem. The House and Senate passed the Ensuring Patient Access and Effective Drug Enforcement Act which was signed into law by President Obama on April 19, 2016, and may have decreased the DEA's ability to intervene in the opioid crisis. In December 2016, the 21st Century Cures Act, which includes $1billion in state grants to fight the opioid epidemic, was passed by Congress by a wide bipartisan majority (94-5 in the Senate, 392–26 in the House of Representatives), and was signed into law by President Obama.


title: Opioid epidemic in the United States

text: , President Donald Trump appointed a commission on the epidemic, chaired by Governor Chris Christie of New Jersey. On August 10, 2017, President Trump agreed with his commission's report released a few weeks earlier and declared the country's opioid crisis a "national emergency". Trump nominated Representative Tom Marino to be director of the Office of National Drug Control Policy, or "drug czar". One interview in 2015 with the then Director of the White House Office of National Drug Control Policy under the Obama administration, Michael Botticelli, where he states that because opioid users are predominantly 'white and middle class', they "know how to call a legislator, [and] fight with their insurance company."


title: Opioid epidemic in the United States

text: However, on October 17, 2017, Marino withdrew his nomination after it was reported that his relationship with the drug industry might be a conflict of interest. In July 2017, FDA commissioner Scott Gottlieb stated that for the first time, pharmacists, nurses, and physicians would have training made available on appropriate prescribing of opioid medicines, because opioid addiction had become the "FDA's biggest crisis". Trump nominated his then deputy chief-of-staff, James Carroll as the acting director of the Office of National Drug Control Policy in 2018. Carroll was subsequently approved by the Senate in January 2019.


title: Opioid epidemic in the United States

text: In April 2017, the Department of Health and Human Services announced their "Opioid Strategy" consisting of five aims:


title: Opioid epidemic in the United States

text: The US Food and Drug Administration (FDA) has taken another approach to this epidemic: requiring manufacturers of long-acting opioids to sponsor educational programs for prescribers. The FDA hoped that these educational programs would help deter off-label and overprescribing; however, it is still unclear if these programs truly have a positive effect on reducing opioid prescriptions. In March 2019, two FDA specialists publicly demanded that the FDA suspend new opioid approvals, alleging that the FDA's oversight of opioid approvals had been dangerously deficient.


title: Opioid epidemic in the United States

text: In July 2017, a 400-page report by the National Academy of Sciences presented plans to reduce the addiction crisis, which it said was killing 91 people each day.


title: Opioid epidemic in the United States

text: The Substance Abuse and Mental Health Services Administration administers the Opioid State Targeted Response grants, a two-year program authorized by the 21st Century Cures Act which provided $485million to states and US territories in the fiscal year 2017 for the purpose of preventing and combatting opioid misuse and addiction.


title: Opioid epidemic in the United States

text: Dr. Thomas Frieden, former director of the Centers for Disease Control and Prevention, said that "America is awash in opioids; urgent action is critical." The crisis has changed moral, social, and cultural resistance to street drug alternatives such as heroin. Many state governors have declared a "state of emergency" to combat the opioid epidemic or undertook other major efforts against it. In July 2017, opioid addiction was cited as the "FDA's biggest crisis". In October 2017, President Donald Trump concurred with his Commission's report and declared the country's opioid crisis a "public health emergency". Federal and state interventions are working on employing health information technology in order to expand the impact of existing drug monitoring programs. Recent research shows promising results in mortality and morbidity reductions when a state integrates drug monitoring programs with health information technologies and shares data through centralized platform.


title: Opioid epidemic in the United States

text: The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act or the SUPPORT for Patients and Communities Act was introduced by the US House of Representatives on June 22, 2018, and was advanced on June 22, 2018. The bill includes Medicare and Medicaid reform in order to improve treatment, recovery, and prevention efforts while also strengthening the fight against synthetic drugs like fentanyl.


title: Opioid epidemic in the United States

text: On September 17, 2018, the US Senate approved the SUPPORT for Patients and Communities Act (H.R. 6). The committee reached a final agreement on terms of the bill on September 25, 2018. The final agreement included provisions from multiple other acts, such as The Opioid Crisis Response Act of 2018, The Helping to End Addiction and Lessen (HEAL) Substance Use Disorders Act of 2018, and the Synthetics Trafficking and Overdose Prevention (STOP) Act of 2018. The House and The Senate passed the final draft on September 28 and October 3, respectively. President Donald Trump signed the package into law on October 28, 2018.


title: Opioid epidemic in the United States

text: In July 2019, English multinational consumer goods corporation Reckitt Benckiser, parent of US pharmaceutical company Indivior, agreed to pay $1.4 billion to the U.S. Department of Justice and the Federal Trade Commission to resolve false marketing claims about the effectiveness of its opioid addiction drug, Suboxone, and to resolve charges over their scheme to direct patients towards doctors who were likely to prescribe Suboxone.


title: Opioid epidemic in the United States

text: In September 2019, President Trump issued an executive order to block shipments of fentanyl and counterfeit goods from other countries, where illegal distributors were using regular mail for deliveries. While China was a focus for the action, the order included any nation where it was either manufactured or shipped from. Trump claimed that the Chinese government had not done enough to stop the smuggling of fentanyl manufactured there:


title: Opioid epidemic in the United States

text: A March 25, 2020, report by ProPublica revealed that Walmart used its political influence with the Trump administration to avoid criminal prosecution for over-dispensing opioids in Texas.


title: Opioid epidemic in the United States

text: In July 2020, Indivior Solutions, Indivior Inc., and Indivior plc agreed to pay $600 million to resolve liability related to false marketing of Suboxone to MassHealth for use by patients with children under the age of six years old. Additionally, Indivior Solutions pled guilty to one-count of felony information.


title: Opioid epidemic in the United States

text: In response to the surging opioid prescription rates by health care providers that contributed to the opioid epidemic, US states began passing legislation to stifle high-risk prescribing practices (such as prescribing high doses of opioids or prescribing opioids long-term). These new laws fell primarily into one of the following four categories:


title: Opioid epidemic in the United States

text: In July 2016, governors from 45 US states and 3 territories entered into an interstate compact titled a "Compact to Fight Opioid Addiction" organized by Massachusetts Governor Charlie Baker where they agreed to adopt the strategies for addressing the opioid epidemic modeled after the policies implemented in Massachusetts. They agreed that collective action would be needed to end the opioid crisis, and they would coordinate their responses across all levels of government and the private sector, including opioid manufacturers and doctors.


title: Opioid epidemic in the United States

text: In 2017 Alabama had the highest overall opioid prescribing rate in the US. The University of Alabama – Birmingham has made a commitment to battle the opioid epidemic. UAB's “Addiction Scholars Program” trains health care professionals - doctors, nurses, therapists, and social workers with insights into addiction in a 15-month course. The UAB School of Nursing offers “Nursing Competency Suites” with training on treating infants born to opioid-addicted mothers. The university also began an “Opioid Stewardship Committee” to “…consistently and frequently address opioid stewardship.”


title: Opioid epidemic in the United States

text: Opioid data for Alabama indicated that, from 2006 to 2014 2.3 billion pain pills were prescribed in the state. McKesson Corporation distributed 728 million of these pain pills; Par Pharmaceutical manufactured 713 million. The highest number of the pills went to Senior Care Pharmacy in Northport AL.


title: Opioid epidemic in the United States

text: Arizona's Governor Doug Ducey signed the Arizona Opioid Epidemic Act on January 26, 2018, to confront the state's opioid crisis. In Maricopa County which includes Phoenix, 3,114 overdoses were reported from June 15, 2017, through January 11, 2018. The law provides $10million for treatment and limits an initial opioid prescription to five days with some exemptions. Arizona also implemented a new strategy of prescription drug monitoring programs in 2017. Since then, the number of opioid prescriptions filled has dropped nearly forty percent, while the number of opioid prescriptions written has dropped forty-three percent (King, 2018). The reductions in these numbers both show Arizona going in the right direction, although, even with the decrease, the number of deaths and overdoses continue to rise.


title: Opioid epidemic in the United States

text: In October 2016, the state began the Arkansas Naloxone Project, a partnership of the State Drug Director's Office, DHS, and the Criminal Justice Institute (CJI) to allocate kits containing the nasal spray naloxone to first responders, schools, libraries, as well as drug treatment and recovery agencies to reverse the effects of opioid overdose. The project, funded by federal grants and the Arkansas Blue & You Foundation, distributed 7,000 kits and provided training to 8,000 individuals. Additionally, the Drug Director's Office and the CJI developed an app, nARcansas, a free opioid overdose training vehicle that shows how to administer the life-saving antidote and provide other information about opioids and overdoses, in both English or Spanish versions. The project has saved lives in almost half of Arkansas’ 75 counties, with the most success in Pulaski County, the state's most populated.


title: Opioid epidemic in the United States

text: In California, SB 482 took effect on October 2, 2018, requiring doctors and other healthcare professionals to check the Controlled Substance Utilization Review and Evaluation System, also known as CURES, before issuing any opioid prescriptions. SB 1109 was signed by Governor Jerry Brown in September 2018 (to take effect on January 1, 2019), requiring certain healthcare professionals undergo mandatory continuing education courses on the risk of addiction with opioids. In addition, this law would require outpatient pharmacies to apply warning labeling on all opioid prescription bottles cautioning patients of the risk of overdose and addiction associated with the drug. SB 1109 also targets vulnerable populations like students, requiring schools to provide students participating in youth sports or athletic programs with the CDC's Opioid Factsheet for Patients, that again address the risks of opioid use. In 2019, the city of San Francisco began a program called the Drug Overdose Prevention & Education (DOPE) Project, which trains individuals with substance use disorder, their families or anyone who may live in their communities who wants to help people suffering from overdoses. The DOPE Project, the largest single city naloxone-distribution effort in the US, instructs its advocates in the use of the nasal spray naloxone, an opioid reversal antidote. The group, able to save nearly 1,800 overdosing people in 2019, is currently challenged by the rise in fentanyl and methamphetamine use.


title: Opioid epidemic in the United States

text: Overdose death from the drug fentanyl increased by 300% from 2018 to 2019, according to the Denver Department of Public Health and Environment. Overall death from all drug overdoses increased slightly over the same time period. Denver has created an “early warning system” to let drug rehab organizations know if fentanyl has been found in the area's recreational drug supply. The Harm Reduction Action Center, one of those organizations, provides substance users with a needle exchange and fentanyl-testing strips.


title: Opioid epidemic in the United States

text: In 2016, then Colorado Attorney General Cynthia Coffman launched the Naloxone for Life Initiative which initially distributed 7,000 naloxone kits around the state. The state medical director then issued an order to make the drug available without prescription. Applying the drug has been successful. Denver's paramedics administered the opioid-overdose reversal drug to over 700 individuals in 2018. Colorado experienced a small decrease in opioid overdose deaths between 2017 and 2018.


title: Opioid epidemic in the United States

text: In 2019 there were 1,200 opioid deaths in the state, a figure that will be reached shortly as 2020 has seen a 22% increase in opioid overdose mortality. The isolation of the COVID-19 pandemic, compounded by personal financial and other anxieties, has caused intense difficulty for people coping with addiction disorders as well as depression. Most traditional businesses have been affected by the pandemic, and the narcotic channel has remained active.


title: Opioid epidemic in the United States

text: Delaware, which has the 12th-highest overdose death rate in the US, introduced bills to limit doctors' ability to over-prescribe painkillers and improve access to treatment. In 2015, 228 people had died from overdose, which increased 35%to 308in 2016.


title: Opioid epidemic in the United States

text: The District began a program of free distribution of the nasal spray naloxone in 2018 with 17 locations dispensing the non-injection overdose-reversing drug. In 2020, due to a 50% increase in opioid overdose deaths, the District doubled the distribution to 35 locations in every ward throughout the city. The death statistics from D.C.’s Office of the Chief Medical Examiner are grim: 75% of overdose mortality are individuals 40-69, 70% are male, 84% are Black.


title: Opioid epidemic in the United States

text: In 2011, Florida passed a law creating a program that would provide monitoring and enforcement against illegal diversion of prescription pills in Florida (sometimes called the "Flamingo Express"). The law had not yet been enacted when Governor Rick Scott took office, and Scott proposed to repeal it before it came into practice. Scott told reporters the program "had no state funding, is complicated by contract challenges, is unproven and could infringe on innocent people’s privacy."


title: Opioid epidemic in the United States

text: The isolation accompanying the COVID-19 pandemic is hurting Georgians with opioid use disorder. Nationwide, overdoses of opioids jumped 42% in May 2020, according to the Overdose Detection Mapping Application Program, a United States government operation that tracks data from hospitals, ambulance, and police reports. The Georgia Council on Substance Abuse advised all first responders in the state to carry and be conversant with the administration of naloxone “…at all times.” The nasal version of naloxone is critical for first responders during the pandemic as it can be dispensed at arm's length very quickly. The council further brought forth a substantial increase in Emergency Department visits due to opioid overdose. Because of the COVID-19 pandemic, individuals, they said, are missing personal counseling and 12-step meetings. The group also stated that calls to its CARES Warm line grew by 65 percent in three months with a higher intensity than ever experienced.


title: Opioid epidemic in the United States

text: In 2020, the Overdose Detection Mapping Program noted an 18% increase in opioid overdoses, prompting the US Department of Health and Human Services (HHS) to provide Hawaii with a $2 million (US) grant to increase opioid use disorder treatments. The grant will be divided between the Hawaii State Rural Health Association and the West Hawaii Community Health Center to develop new addiction therapy programs or grow access to existing initiatives.


title: Opioid epidemic in the United States

text: The 2020 coronavirus pandemic resulted in a crisis within a crisis in Chicago as opioid overdose mortality doubled in the first five months of the year, compared to 2019 from 416 deaths to 924. Overdose deaths increased throughout the state, with the largest upturn in Cook County. Fentanyl, usually combined with heroin, was the drug at the center of 81% of the deaths, up from 74% in 2019.


title: Opioid epidemic in the United States

text: Indiana has been one of the states seriously affected by the epidemic. In 2015, 1,600 people died from drug overdose; 1,000 of those deaths were opioid-related. By 2017, opioid-related deaths had increased to over 1,200, followed by a small, measured decline since then. In 2018, drug overdose deaths fell 12.9%, almost three times the US average decline, as the state government focused on evidence-based, transformative programs to continue the decline. In 2020, SAMSHA provided a $1 million grant to the state of Indiana and its Social Services Administration to distribute the nasal spray naloxone to individuals in the state whom the ISSA determined were at risk from opioid overdose.


title: Opioid epidemic in the United States

text: The Chief of Police of Lawrence, IN, (pop.40,000) ordered his officers to cease the administration of the opioid antagonist nasal spray naloxone during the Coronavirus pandemic, fearing that his first responders risk COVID-19 infection exposure by dispensing the intra-nasal drug. The Indiana Department of Homeland Security rejected the chief's order as not being evidence-based and encouraged the administration of the drug by the city's police. A near-by city, Ft. Wayne's (pop.267,000), police continue to disburse the drug which resulted in 233 individuals restored by Narcan in the first quarter 2020.


title: Opioid epidemic in the United States

text: In September 2017, Kansas received over $500,000 to implement programs and changes to help stop the opioid epidemic. A majority of the money went to drug courts to help prevent crimes and intervene with addicts early on.


title: Opioid epidemic in the United States

text: The 2020 COVID-19 pandemic has contributed to a significant increase in drug overdose in Kentucky as the state's second largest county, Fayette, witnessed overdose increases of over 40% in the first few months of the year. The county does have an anti-overdose program which, over five years, has distributed over 8,000 naloxone doses. Additionally, the state monitors drug overdose through its Kentucky Overdose Data to Action (KyOD2A) program run by the Department for Public Health, collecting raw data and linking those in need of treatment with available centers as well as supporting community interventions as needed. KyOD2A also partners with the state's prescription electronic reporting system to monitor opioid prescriptions.


title: Opioid epidemic in the United States

text: In 2017, the Louisiana Department of Health documented an increase in opioid overdoses. Respondents to the state's HIDTA Drug Treatment and Prevention Survey reported high levels of fentanyl use and an 83% increase of inpatient admissions for fentanyl and other opioids. In response to the growing epidemic in Louisiana, the Advisory Council on Heroin and Opioid Prevention and Education, also known as the HOPE Council, was created as an effort to combat opioid use and established a health surveillance and data collection strategy through interagency coordination. In 2019, the Louisiana Comprehensive Opioid Abuse Program Action Plan and the Louisiana's Opioid Response Plan 2019 were released. These types of efforts, however, have been hindered by continued opioid overprescription. In 2018, Louisiana providers wrote 79.4 opioid prescriptions for every 100 persons, compared to the average U.S. rate of 51.4 prescriptions, making Louisiana among the top five of opioid prescribers in the U.S. that year. In New Orleans, NOLA Ready, the City of New Orleans emergency preparedness campaign, sponsors a 1-hour training with the New Orleans Health Department where the general public can learn how to identify an overdose and administer Naloxone. The New Orleans Public Library (NOPL) has also responded by training librarians and the public on opioid prevention and overdose treatment.


title: Opioid epidemic in the United States

text: Opioid overdose mortality grew by over 90% in some parishes in Louisiana due to the coronavirus pandemic which has affected the capacity of many state residents to remain drug-free. State officials feared this would lead to still more overdose-related deaths and a long-term effect of more addiction-related disease, ushering in more homelessness and family-alienation. On the reverse of that phenomena, state experts fear that those with substance use disorder are more vulnerable to COVID-19 due to damaged lungs and respiratory systems causing a higher rate of infection. Added to that is the fact that those individuals are affected by stay-at-home orders, where they are more likely to succumb the temptation of use and overdose. There are many social services groups, like Capital Area Human Services, providing therapy as well as opioid-reversal drugs; and No Overdose Baton Rouge, which offers clean syringes, the opioid antagonist nasal spray naloxone, and sterile smoking devices, attempting to help.


title: Opioid epidemic in the United States

text: In Maine, new laws were imposed which capped the maximum daily strength of prescribed opioids and limited prescriptions to seven days.


title: Opioid epidemic in the United States

text: In March 2017, the governor of Maryland declared a state of emergency to combat the rapid increase in overdoses by increasing and speeding up coordination between the state and local jurisdictions. The previous year about 2,000 people in the state had died from opioid overdoses.


title: Opioid epidemic in the United States

text: Boston Medical Center has changed its approach to addiction and overdose treatment, due to the pandemic. It now offers telehealth appointments which officials believe are more effective than tradition in-person treatment, as more people are participating. Additionally patients are able to get doses of methadone and addiction medications like buprenorphine without an in-person visit. The state's Department of Public Health indicated that there was a downturn in total overdose deaths in the first quarter of 2020 but that rates of overdose mortality among Black men and women, as well as Hispanic men's overdose incidents, showed a notable increase. A COVID-19 Rapid Response Fund disbursed grants to nonprofits serving opioid addiction sufferers and the Boston Resiliency Fund awarded $500K to similar groups.


title: Opioid epidemic in the United States

text: In 2016, the number of deaths within Massachusetts was the highest it had ever been and twice the national average with 29.7 deaths per 100,000. In order to regulate the use of opioids, Governor Charlie Baker signed Bill H.4056 or the STEP Act into law on March 14, 2016. Due to the STEP Act, opioid prescribing rates fell by 29 percent. According to the Boston Indicators, in 2020 the rate of overdoses related to opioid use disorder was 30.2 per 100,000 people. This was about 1.6% lower than the rate in 2016.


title: Opioid epidemic in the United States

text: The STEP Act's primary focus is on limiting the supply of opioids and providing patients with the opportunity to request less than their total prescribed amount of opioids at the pharmacy. These components of the STEP Act are broken down as follows:


title: Opioid epidemic in the United States

text: A similar plan to Massachusetts was created in Michigan, when the state introduced the Michigan Automated Prescription System (MAPS), allowing doctors to check when and what painkillers had already been prescribed to a patient, and thereby help keep addicts from switching doctors to receive drugs.


title: Opioid epidemic in the United States

text: On May 22, 2019, Minnesota Governor, Tim Walz, signed the Opiate Epidemic Response Bill, otherwise known as 'Chapter 63', into law. This law aims to raise funding to combat the opioid epidemic, specifically in Minnesota, via the taxation of pharmaceutical companies, prescribers, and medication distributors. The gathered funds will be deposited into the 'opiate epidemic response account' and allocated by the Opioid Epidemic Response Advisory Council, created through the bill's legislation. The council will be in charge of distributing the funds throughout the state to ensure the most significant impact on those communities hit hardest by the opiate epidemic. The state hopes to collect upwards of $20 million in fees annually to contribute to funding programs created by the council.


title: Opioid epidemic in the United States

text: In December 2019, the National Council on Alcoholism and Drug Abuse (NCADA-STL) reported that St. Louis had a new high of opioid overdose deaths at 1018. When the COVID-19 pandemic occurred three months later, it impacted opioid overdoses incidents significantly, particularly among the Black community in North St. Louis County, North St. Louis City and parts of South City. Combatting the intersecting outbreaks, local Federally Qualified Health Centers (FQHC) have combined to provide simultaneous Narcan, nasal spray naloxone, an opioid antagonist, and increased access to COVID-19 resting.


title: Opioid epidemic in the United States

text: By May 2020, Nevada experienced a 23% increase in opioid overdose deaths, when compared to 2019. Overdose deaths in the state peaked in 2011 but were on the decline ever since, until 2020. Over half those deaths involved fentanyl. The Nevada Overdose to Action program reported it was difficult to ascribe the increase to the COVID-19 pandemic, but, like health care providers across the country, the group felt that the isolation and stress caused by the pandemic contributed to the increase in mortality.


title: Opioid epidemic in the United States

text: The Overdose Mapping Application Program, developed by University of Baltimore, has reported an increase in overdose-related mortality, particularly in southern Nevada. The deaths, thought to be connected to individuals ingesting opioids when isolated, can be prevented with the use of the opioid antagonist naloxone as recommended by the Southern Nevada Health District.


title: Opioid epidemic in the United States

text: The state suffered 3021 drug-related deaths in 2019 when 3.99 million opioid prescriptions were dispensed, down slightly from 3102 in 2018 when 4.3 million opioid prescriptions were filled. In the first quarter 2020, drug-related deaths were 789. The coronavirus pandemic has overshadowed another, longer term crisis in the state – the opioid epidemic. Detox centers have cut down on accepting patients, people in 12-step programs must meet online, and individuals who successfully complete rehab face more hurdles – unemployment and homelessness. “It’s almost like everything has been stopped in time,” said John Pellicane, Director of the Office of Mental Health and Addiction Awareness Task Force in Camden County, New Jersey. Phone calls to the state's addiction hotline, ReachNJ, increased from an average 3,500/month to 4,000/month. Morris County overdoses increased by 41% in first quarter 2020. There were 100 more overdose deaths in the same period – statewide. Bergen County suspended all face-to-face substance use disorder counseling and meetings. The state does not approve of virtual meetings or counseling due to confidentiality concerns and trust issues.


title: Opioid epidemic in the United States

text: In 2020, New Jersey Attorney General Gurbir Grewal announced that, during the COVID-19 pandemic, all medical personnel were required to prescribe the opioid antagonist naloxone to individuals ingesting higher doses of opioids or those combining opioids with benzodiazepines, such as Xanax, an anti-anxiety medication. This regulation, already in the process of being recommended by various state entities, was adopted quickly in response to the coronavirus pandemic and a concomitant increase in overdose mortality. First responders also reported an increase in dispensing naloxone to those suffering from overdoses. It was thought that providing naloxone to individuals whose prescriptions were the equivalent or 90 morphine milligrams would free medical emergency workers and police from responding to overdose exigencies. By May 2020, Gov. Phil Murphy's administration reported that mortality from opioid overdoses had increased 20%. To counter the trend, the state sent 11,000 doses of the nasal spray naloxone. The first shipment went to 178 emergency medical service teams across the state.


title: Opioid epidemic in the United States

text: The New York State Department of Health reported that the Office of National Drug Control Policy wanted to use New York's police training policy on opioids as a model for other states. Additionally, in 2019 NYSDOH began the NY State Opioid Data Dashboard, which provides datapoints to educate local opioid-prevention officials and policy makers on the epidemic. The dashboard includes quarterly updates on opioid overdose information like mortality, ED visits and hospitalization by county throughout the state. NYSDOH also developed I-Stop, a requirement for all prescription-providing health care professionals to report and track their prescriptions for controlled substance drugs, thereby stemming patients from seeing many doctors for prescriptions. The combination of the COVID-19 pandemic and the opioid crisis causes unique problems for recovering addicts who rely on community support in a time of social distancing. A Binghamton NY addiction resource center, Truth Pharm, has revamped its naloxone training to a virtual model. Additionally, even virtual naloxone training can be more than simply administering a life-saving drug as it provides those struggling with addiction a human contact and the ability to discuss specific needs and issues.


title: Opioid epidemic in the United States

text: In 2020, there was a 25.8% increase in opioid overdose cases and a 38% increase in overdose deaths in the Rochester area (Monroe County). Concern over the overdose growth has led to legislators introducing legislation in the state Assembly that would require pharmacies to offer a dose of naloxone to individuals receiving an opioid prescription. Naloxone is presently available in New York state without a prescription. The new legislation provides funding for the payment of co-pays or free naloxone if the individual has no insurance.


title: Opioid epidemic in the United States

text: At 24.6 deaths per 1,000 people, Ohio has the 5th highest rate of drug overdose deaths in the United States. The Governor's Cabinet Opiate Action Team (GCOAT) was created in 2011 by Governor John Kasich and is "one of the nation's most aggressive and comprehensive approaches to address opioid use disorder and overdose deaths, including a strong focus on preventing the nonmedical use of prescription drugs". GCOAT utilizes partnerships with various state agencies including the Ohio Board of Pharmacy. The strategy suggests regulations that are encompassed under three main categories: (1) to promote the responsible use of opioids, (2) to reduce the supply of opioids, and (3) to support overdose prevention and expand access to naloxone. The legislation reduced the number of opioid doses by over 80million between 2011 and 2015. Also, unintentional drug related overdose deaths involving prescription opioids have decreased from 45% in 2011 to 22% in 2015. However, Ohio has not seen a decrease in fentanyl distribution. The coronavirus pandemic of 2020 reduced treatments for those suffering from substance use disorders in many Ohio counties, leading to increases in drug overdoses. For example, Highland County experienced double the amount of drug overdose calls to the sheriff's department from May 2019 to May 2020. The number of overdoses in Franklin County increased by 50% in the first four months of 2020.


title: Opioid epidemic in the United States

text: The city of Philadelphia suffers from the highest rate (among all US big cities) of drug overdose in the country, averaging three mortalities per day in 2019, a situation intensified by the 2020 coronavirus pandemic. Prevention Point Philadelphia, the US's largest syringe-exchange organization, doubled the amount of the nasal spray naloxone it distributed in the first month of the city's stay-at-home order. The city's overdose mortality rated remained the same as it was pre-pandemic, providing an indication that more naloxone was being administered to overdose victims. Several Philadelphia-based public health and criminal justice support groups were providing cell phones to homeless people and inmates recently released from prison so they can experience telehealth healthcare provider visits and renew prescriptions for opioid antagonist medication. The Pennsylvania Harm Reduction Coalition (PAHRC) initiated a new postal service-based naloxone distribution program that delivers the drug directly to the home. The group also included PPE gloves and face shields with the naloxone kits in an attempt to limit coronavirus dispersal.


title: Opioid epidemic in the United States

text: Beaver County PA, after experiencing a decline in opioid overdose deaths from 2017, saw a 30% increase in those deaths since the pandemic began, according to UPMC Western Psychiatric Hospital addiction medicine services. The county also suffered from an increase in domestic violence, child abuse, and worsening drug and alcohol use disorder, all attributed to the isolation caused by the pandemic.


title: Opioid epidemic in the United States

text: The state suffered 1,103 overdose fatalities in 2018. In 2020, state substance use disorder remedial facilities were concerned about the impact of COVID-19. They emphasized the importance of group meetings; several have moved the meetings outside. The Phoenix Center, in Greenville, limited large meetings and restricted visitor access to its in-patients. Other providers have turned to on-line meetings, but participation is down.


title: Opioid epidemic in the United States

text: The South Carolina Department of Alcohol and Other Drug Abuse Services (SC DAODAS), concerned about the effects of the coronavirus pandemic on state residents suffering from substance use disorder, fears a setback in its battle with the opioid epidemic. The apprehension that self-quarantining and the isolation it brings can cause loneliness, anxiety, boredom, clinical depression or PTSD can lead to enhanced overdose risk. In April 2020, the department provided over 7,000 boxes of Naloxone, the nasal spray overdose reversal drug while encouraging afflicted South Carolinians to take advantage of the DAODAS’ system of state-licensed and nationally accredited service providers. The department also encouraged individuals to reach out to friends and family during this crisis.


title: Opioid epidemic in the United States

text: Carter County, Tennessee, population 56K, has experienced nearly 60 opioid overdose deaths since 2014, a year in which 8.1 million opioid prescriptions were written in the entire state, population 6.5 million. To stem that consequence of addiction, the county's drug prevention alliance embarked on a controversial policy – providing naloxone distribution training to around 600 children and teenagers. Some of the children have taught what they learned to their peers and distributed naloxone at community events where one child handed out 70 doses of the drug. The region is a conservative one where residents, law enforcement and school boards have objected, considering naloxone a “waste of resources” and the training not child-appropriate.


title: Opioid epidemic in the United States

text: A spike in overdoses and overdose deaths due to the COVID-19 pandemic led Memphis-area Baptist Hospitals and Integrated Addiction Care (IAC), an outpatient rehab group, to set up a 24/7 hotline for individuals struggling with addiction. The Shelby County Health Department stated that people with substance use disorder issues should have access to both the care they need and to naloxone, the nasal spray opioid antagonist. The free hotline is staffed by physician professionals who can provide medical advice or direct callers to an emergency department.


title: Opioid epidemic in the United States

text: Studies have found that after the implementation of "pill mill laws" in Texas, opioid dose, volume, prescriptions and pills dispensed within the state were all significantly reduced.


title: Opioid epidemic in the United States

text: The number of opioid overdoses in Burlington, Vermont increased by 76% in 2020; the number of nonfatal overdose emergency room visits went up 100% in the same period, according to Burlington's police department. But the number of overdose fatalities went down for the first time since 2014. The overdose increases are due to an influx of fentanyl, a synthetic opioid, as well as the pressures of the COVID-19 pandemic; the mortality decreases are the result of safety measures, such as the community distribution of naloxone.


title: Opioid epidemic in the United States

text: The state of Wisconsin established the HOPE (Heroin, Opiate Prevention and Education) agenda to face the Opioid Epidemic. The Enactment of Act 262 took place on April 9, 2018. The act focuses on bettering substance use disorder counseling, which is critical in the opioid withdrawal process.


title: Opioid epidemic in the United States

text: In 2017, Rep. Edward Redd and Sen. Todd Weiler proposed amendments to Utah's involuntary commitment statutes which would allow relatives to petition a court to mandate substance-abuse treatment for adults.


title: Opioid epidemic in the United States

text: In February 2017, officials in Everett, Washington, filed a lawsuit against Purdue Pharma, the manufacturer of OxyContin, for negligence by first, allowing and also failing to prevent drugs being illegally trafficked to city residents. The city wants the company to pay the costs of handling the crisis.


title: Opioid epidemic in the United States

text: In West Virginia, leading the nation in overdose deaths per capita, lawsuits sought to declare drug distribution companies a "public nuisance" in an effort to place accountability upon the drug industry for the costs associated with the epidemic. On May 3, 2021, the city of Huntington filed a lawsuit against three major drug manufacturers accusing them of their role in stoking the opioid crisis through their excessive shipment of painkillers.


title: Opioid epidemic in the United States

text: The Massachusetts Taxpayers' Foundation published a report which contains an analysis of the economic impact of the opioid epidemic in Massachusetts. In 2017, the state lost a total of $15.2 billion. Out of that total, at least $5.5 billion was dedicated to funding opioid-related services; and $9.7 billion was lost as a result of losses in productivity as 32,687 people were kept out of the workforce due to opioids. The report also analyzes forgone wages due to deaths related to opioid overdoses accounted for over $1.1 billion in losses from 2015 to 2017. Therefore, the total amount lost taking into account forgone wages and lost productivity is about $7 billion per year.


title: Opioid epidemic in the United States

text: The social effects of the opioid epidemic include the costs associated with healthcare and the criminal justice system. In regards to healthcare, costs can be attributed to Neonatal Abstinence Syndrome treatment and emergency services. Neonatal Abstinence Syndrome or NAS occurs when a woman abuses opioids during pregnancy, thus causing the baby to experience withdrawal symptoms when born. According to the National Institute on Drug Abuse, in 2017 out of every 1000 hospital births, 13.7 of those births involved an infant born with NAS. Additionally, the responses to opioid related incidents involve costs related to Narcan, transport to the hospital, and first responders. In 2016 and 2017, the total cost of all these factors was $43 million. Meanwhile, in patient and ICU costs were $538 million and $271 million, respectively.


title: Opioid epidemic in the United States

text: In regards to the criminal justice system, a report from the Massachusetts Health Policy Forum states that the effect of the opioid issue on the criminal justice system is estimated to be $500 million. The Middlesex sheriff's office notes that of the 73% of the prisoners with alcohol or drug addiction are involved in opioids. The analysis by the Massachusetts Taxpayers' Foundation notes that handling prisoners battling opioid use disorders costs $470 million each year.


title: Opioid epidemic in the United States

text: In May 2019, in the first successful prosecution of top pharmaceutical executives for crimes related to the prescribing of opioids, the founder and four former executives of Insys Therapeutics Inc. were convicted by a federal jury in Boston in connection with bribing medical practitioners to prescribe Subsys, a highly-addictive sublingual fentanyl spray intended for cancer patients experiencing breakthrough pain, and for defrauding Medicare and private insurance carriers. The company declared bankruptcy about two weeks after they lost the case.


title: Opioid epidemic in the United States

text: Dozens of states are suing pharmaceutical companies, accusing them of causing the epidemic. Suits filed by almost 2,000 cities, counties, and tribal lands have been rolled into a single federal case scheduled to be heard in Fall 2019. In the first state case to reach a decision, on August 26, 2019, Oklahoma district court judge Thad Balkman found the pharmaceutical company Johnson & Johnson responsible for creating a "public nuisance" under state law, and ordered the company to pay a fine of $572 million. The company said they will appeal. Two other drug makers had previously settled with the state of Oklahoma. Purdue Pharma, the maker of OxyContin, agreed to a fine of $270 million in March 2019, and Teva Pharmaceuticals, which makes generic drugs, agreed to pay $85 million in May.


title: Opioid epidemic in the United States

text: On October 4, 2021, a landmark trial began in a Cleveland court. The defendants are pharmacy chains and operators, including Walmart, Walgreens and CVS. These chains are accused of not having enough trained staff and sophisticated systems to responsibly dispense opioids. Lawyers allege that pharmacies have not fulfilled their legal responsibility to act as a "last line of defense,” and that the chains enable illegal street dealing of prescription opioids.


title: Opioid epidemic in the United States

text: Lake and Trumbull Counties in northeast Ohio were the plaintiffs and alleged the chains had “substantially contributed to the crisis of opioid overdose and deaths….” in the counties. In November 2021, a 12-person jury, after five and a half days of deliberation, held the retailers accountable for contributing to a “public nuisance.” This was the first jury verdict in the decades-long crisis. The retailers said they would appeal the jury's verdict.


title: Opioid epidemic in the United States

text: On August 17, 2022, CVS, Walgreens and Walmart were forced to pay out $650.5 million to Lake and Trumbull County.


title: Opioid epidemic in the United States

text: In February 2020, 21 US states turned down an $18 billion (US), 18-year offer from McKesson, Cardinal Health Inc. and AmerisourceBergen Corp. that would have resolved litigation against the pharmaceutical companies over their distribution of the addictive painkillers. A letter from the attorneys general of Ohio, Florida and Connecticut (among others) said the settlement, as “currently structured,” was not acceptable to the states. This particular offer was part of the proposed $50 billion (US) agreement to find a resolution to over 2,000 lawsuits from both local and state governments attempting to recoup billions of dollars they have spent combatting the crisis.


title: Opioid epidemic in the United States

text: Four major drug manufacturers and distributors, J&J, McKesson, Cardinal Health, and AmerisourceBergen, have agreed to a settlement announced by a group of state attorneys general in July 2021. The settlement, $26 billion (US), will be used on the prevention of opioid addiction and treatment programs. J&J will pay $5 billion (US) over the next five years; the remaining $21 billion (US) will be paid by the other firms. The settlement, when approved by a "significant" group of states and local governments, will settle more than 4,000 individual legal actions. All four of the manufacturing firms disputed all allegations in the lawsuits.


title: Opioid epidemic in the United States

text: The United States’ three largest pharmaceutical distributors, AmerisourceBergen, Cardinal Health and McKesson reached an agreement in October 2019 where they will pay two Ohio counties a combined US$215 million. As part of the deal, Israel drug manufacturer Teva will also provide US$20 million in cash and US$25 million worth of Suboxone, an opioid addiction treatment. Cuyahoga County (Cleveland) and Summit County (Akron) brought the suit in US Federal District Court (Northern District of Ohio). The settlement averted what would have been the first federal trial over the US opioid crisis. The defendants offered no admission of wrongdoing.


title: Opioid epidemic in the United States

text: More than 2,600 lawsuits against the US pharmaceutical industry are still in the offing. The plaintiffs in those cases said the Ohio settlement allows them time to attempt to negotiate a national settlement. It also pressures the participants to work out a deal, as every partial settlement diminishes the aggregate total the companies will be able to pay.


title: Opioid epidemic in the United States

text: The two counties had reached a similar settlement of US$20.4 million with Johnson & Johnson and its subsidiary Ethicon, Inc. earlier in October 2019.


title: Opioid epidemic in the United States

text: Homicide by overdose is the act of giving someone a specified controlled substance which causes that person to die. They are considered an easy way to murder an addict as no one will suspect it's anything but a routine overdose. However states are charging people even when the overdose was unintentional.


title: Opioid epidemic in the United States

text: As of 2019, half of all US states have "homicide-by-overdose" or "drug-induced homicide" (DIH) laws. While these laws date back to the 1980s, they were originally used infrequently. Prosecutions dramatically increased in the 21st century. (In 2000, there were 2 prosecutions; in 2017, there were 717 prosecutions.) In 2017, legislators in at least 13 states introduced bills to enhance these laws or create new ones.


title: Opioid epidemic in the United States

text: In 2016, the CDC published its "Guideline for Prescribing Opioids for Chronic Pain", recommending opioids only be used when benefits for pain and function are expected to outweigh risks, and then used at the lowest effective dosage, with avoidance of concurrent opioid and benzodiazepine use whenever possible. Silvia Martins, an epidemiologist at Columbia University, has suggested getting out more information about the risks:


title: Opioid epidemic in the United States

text: Hence, a major target for intervention is the general public, including parents and youth, who must be better informed about the negative consequences of sharing with others medications prescribed for their own ailments. Equally important is the improved training of medical practitioners and their staff to better recognize patients at potential risk of developing nonmedical use, and to consider potential alternative treatments as well as closely monitor the medications they dispense to these patients. As of April 2017, prescription drug monitoring programs (PDMPs) exist in every state. A person on opioids for more than three months has a 15-fold (1,500%) greater chance of becoming addicted.


title: Opioid epidemic in the United States

text: The CDC's "Guideline for Prescribing Opioids for Chronic Pain" offers many non-pharmacological options as alternatives to prescribing opioids. Physical therapist interventions is an example that is offered in regards to an alternative to prescribing opioids.


title: Opioid epidemic in the United States

text: PDMPs allow pharmacists and prescribers to access patients' prescription histories to identify suspicious use. However, a survey of US physicians published in 2015 found only 53% of doctors used these programs, while 22% were not aware these programs were available. Following the implementation of pill mill laws and prescription drug monitoring programs in Florida, there was a large decline in opioid prescriptions written by high-risk prescribers (those prescribing the top 5th of opioids by volume). The Centers for Disease Control and Prevention (CDC) was tasked with establishing and publishing a new guideline, and was heavily lobbied.


title: Opioid epidemic in the United States

text: A 2018 study by the University of Florida concluded that there is little evidence that drug-monitoring databases are having a positive effect on the number of drug overdoses in the US. Researcher Chris Delcher also concluded that "there was a concurrent rise in fatal overdoses from fentanyl, heroin and morphine" due to ease of availability and lower cost following prescription drug crackdowns.


title: Opioid epidemic in the United States

text: The American Medical Association (AMA) has created an Opioid Task Force for helping physicians to combat the epidemic. The AMA has suggested 6 actions for physicians to take:


title: Opioid epidemic in the United States

text: The Opioid Task Force 2018 Progress Report states that between 2013 and 2017 opioid prescriptions have decreased by 22.2%, which includes a 9% decrease from 2016 to 2017 alone. The AMA Opioid Task Force also reports a 389% increase in physician participation in PDMPs. Further, physicians are encouraged to co-prescribe naloxone to those at risk of overdose. In 2017 alone, weekly filled naloxone prescriptions have doubled from 3,500 to 8,000 and more than 50,000 physicians were certified in 2017 to provide in-office buprenorphine. Patrice A. Harris, chair of the AMA Opioid Task Force, urges increased participation by physicians, saying "what is needed now is a concerted effort to greatly expand access to high quality care for pain and for substance use disorders. Unless and until we do that, this epidemic will not end."


title: Opioid epidemic in the United States

text: Media coverage has largely focused on law-enforcement solutions to the epidemic, which portray the issue as criminal, whereas some see it as a medical issue. There has been differential reporting on how white suburban or rural addicts of opioids are portrayed compared to black and Hispanic urban addicts, often of heroin, reinforcing stereotypes of drug users and drug-using offenders. In newspapers, white addicts' stories are often given more space, allowing for a longer backstory explaining how they became addicted, and what potential they had before using drugs. In early 2016 the national desk of "The Washington Post" began an investigation with assistance from fired Drug Enforcement Administration regulator Joseph Razzazzisi on the rapidly increasing numbers of opioid related deaths.


title: Opioid epidemic in the United States

text: While media coverage has focused more heavily on overdoses among whites, use among African, Hispanic and Native Americans has increased at similar rates. Deaths by overdose among white, black, and Native Americans increased by 200–300% from 2010 to 2014. During this time period, overdoses among Hispanics increased 140%, and the data available on overdoses by Asians was not comprehensive enough to draw a conclusion.


title: Opioid epidemic in the United States

text: In August 2014, the website "Annals of Emergency Medicine" collaborated with the "Academic Life in Emergency Medicine" (ALiEM) and posted a discussion board about the opioid epidemic. The discussion acquired a little over 1000 readers and lasted roughly 14 days. There were four questions posted on the discussion that encouraged readers to share their opinions on how opioids should be prescribed and used.


title: Opioid epidemic in the United States

text: In July 2019 the Washington Post and the Charleston (WV) Gazette-Mail gained a court order after a year-long battle with the Drug Enforcement Administration (DEA). The order allowed the Post access to the DEA Automation of Reports and Consolidated Orders System (ARCOS), a system that traces the manufacture, distribution and retail sale of every pain pill in the US. The Post's analysis of the data indicated 76 billion oxycodone and hydrocodone pain pills were distributed throughout the US 2006–2012. 57 billion (75%) of these pain pills were distributed by these companies: McKesson Corp., Walgreens, Cardinal Health, AmerisourceBergen, CVS and Walmart. Nearly 67 billion (88%) of the drugs were manufactured by SpecGx, a subsidiary of Mallinckrodt; Actavis Pharma; and Par Pharmaceutical, a subsidiary of Endo Pharmaceuticals. The greatest number of pills/person were found in West Virginia – 66.5; Kentucky – 63.3; Tennessee – 57.7; and Nevada – 54.7. The highest opioid overdose rate 2006-2012 was in West Virginia. Rural communities were hit particularly hard. 306 pills/person/year were shipped to Norton VA; 242 to Martinsville VA; 203 the Mingo County WV; and 175 to Perry County KY.


title: Opioid epidemic in the United States

text: The opioid epidemic is often discussed in terms of prevention, but helping those who are already addicted is addressed less frequently. Opioid dependence can lead to a number of consequences like contraction of HIV and overdose. For addicted persons who wish to treat their addiction, there are two classes of treatment options available: medical and behavioral. Neither is guaranteed to successfully treat opioid addiction. Which treatment, or combination of treatments, is most effective varies from person to person.


title: Opioid epidemic in the United States

text: These treatments are doctor-prescribed and -regulated, but differ in their treatment mechanism. Popular treatments include kratom, naloxone, methadone, and buprenorphine, which are more effective when combined with a form of behavioral treatment.


title: Opioid epidemic in the United States

text: Accessing treatment, however, can be difficult. The strict regulation of opioid treatment programs dates back to the early 20th century. Before 1919, physicians prescribed milder forms of opiates to help wean patients off opium. In "Webb v. United States", the Supreme Court ruled that doctors could no longer prescribe narcotics to aid in treating a narcotic use disorder. Thus, morphine dispensaries emerged in communities to fill the treatment gap and were the early precedents to modern methadone clinics.


title: Opioid epidemic in the United States

text: It is still difficult for providers to prescribe opioids for medication-assisted treatment despite the data that show individuals addicted to opioids have better outcomes with that than abstinence-based treatment programs. Programs are required to be accredited by SAMHSA or the Drug Enforcement Administration which is a lengthy, time- and resource-consuming process including intensive training and site visit reviews. To stay in operation, they must submit to re-accreditation every 1–3 years.


title: Opioid epidemic in the United States

text: Accredited programs are also able to administer buprenorphine, provided that those prescribing and administering the drug have completed the 8–24 hours of SAMHSA training. Office-based physicians who wish to prescribe buprenorphine for the treatment of opioid use disorder must also complete the required training, as well as apply for and receive a waiver from SAMHSA. Under regulation, physicians may not have more than 30 buprenorphine patients in their first year of prescribing the drug. They may apply to have this limit increased to 100 patients by year two and 275 patients by year three.


title: Opioid epidemic in the United States

text: In December 2015, the US Government Accountability Office began a survey of the laws and regulations around opioid treatment programs and medication-assisted treatment and found that they were barriers to getting people with opioid use disorders the treatment they need. Despite the fact that there is a shortage of opioid treatment programs across the United States, many clinicians do not want to start their own because the time and effort required to comply with the regulations is prohibitive.


title: Opioid epidemic in the United States

text: Individual-level barriers to accessing medication-assisted treatment also exist. The federal regulations regarding program admission into treatment programs are considered "high-threshold." Individuals seeking treatment must meet several criteria to be eligible for treatment. These criteria require potential patients to:


title: Opioid epidemic in the United States

text: In addition to these federal criteria, each state may have its own criteria individuals must meet. The US GAO also cited the cost of treatment and lack of health insurance coverage for MAT as barriers for many addicted to opioids. While methadone treatments are covered by Medicaid for low-income individuals, the extent of coverage depends on which state they are in and if the state has opted into Medicaid expansion under the Affordable Care Act.


title: Opioid epidemic in the United States

text: Buprenorphine, on the other hand, is not covered by Medicaid or, often, even by private health insurers. Because buprenorphine must typically be paid for out-of-pocket, lower-income individuals are often priced out of the lower-risk MAT. In some areas this creates major disparities along racial lines with the higher-risk treatment utilized by lower-income individuals - disproportionately represented by people of color - and the lower-risk treatment only accessible to higher-income individuals - disproportionately represented by whites.


title: Opioid epidemic in the United States

text: Other individual-level barriers may include transportation, especially for those who live in rural areas. The nearest Opioid Treatment Program (OTP) could be up to an hour away, and when daily methadone doses are required for treatment, this may interfere with the success of the MAT or the client's compliance in the program. In rural Vermont, 48% of respondents in treatment reported they had missed an appointment due to travel challenges. Because of issues like these, it is estimated that, nationwide, only 10% of individuals who would be eligible to receive MAT actually receive the treatment.


title: Opioid epidemic in the United States

text: The price of opioid treatment may vary due to different factors, but the cost of treatment can range from $6,000 to $15,000 a year. Based on the research, most addicts come from lagging economic environment which multiple addicts do not have the support or funding to complete alternative medication for the addictions.


title: Opioid epidemic in the United States

text: Methadone has been used for opioid dependence since 1964, and is the most-studied of the pharmacological treatment options. It is a synthetic long-acting opioid, so it can replace multiple heroin uses by being taken once daily. It works by binding to the opioid receptors in the brain and spinal cord, activating them, reducing withdrawal symptoms and cravings while suppressing the "high" that other opioids can elicit. The decrease in withdrawal symptoms and cravings allow the user to slowly taper off the drug in a controlled manner, decreasing the likelihood of relapse. It is not accessible to all addicts. It is a regulated substance, and requires that each dose be picked up from a methadone clinic daily. This can be inconvenient as some patients are unable to travel to a clinic, or wish to avoid the stigma associated with drug addiction.


title: Opioid epidemic in the United States

text: Buprenorphine is used similarly to methadone, with some doctors recommending it as the best solution for medication-assisted treatment to help people reduce or quit their use of heroin or other opiates. It is claimed to be safer and less regulated than methadone, with month-long prescriptions allowed. It is also said to eliminate opiate withdrawal symptoms and cravings in many patients without inducing euphoria. Probuphine is an implantable form of buprenorphine lasting six months. Rates of buprenorphine use increased between 2003 and 2011, with sales increasing, on average, by 40%.


title: Opioid epidemic in the United States

text: Unlike methadone treatment, which must be performed in a highly structured clinic, buprenorphine, according to SAMHSA, can be prescribed or dispensed in physician offices. Patients can thereby receive a full year of treatment for a fraction of the cost of detox programs.


title: Opioid epidemic in the United States

text: Buprenorphine/naloxone is a combination medication that has been approved by the FDA in 2002 for treatment of opioid dependence. It is a combination medication that contains two separate drugs: buprenorphine and naloxone.


title: Opioid epidemic in the United States

text: Buprenorphine works as a partial opioid agonist. It is given in combination with Naloxone because Naloxone works as an opioid antagonist, meaning it will block the effects of the opioid medication. This combination medication can reduce a person's opioid withdrawal symptoms while they are discontinuing opioids after a period of long-term use.


title: Opioid epidemic in the United States

text: While buprenorphine/naloxone is indicated for the treatment of opioid use disorder, it does contain an opioid which means a person may be at risk of developing dependence to it as well.


title: Opioid epidemic in the United States

text: Behavioral treatment is less effective without medical treatment during the initial detoxification. It has similarly been shown that medical treatments tend to get better results when accompanied by behavioral treatment. For opioid dependence, popular non-pharmacological treatment options include cognitive behavioral therapy (CBT), group or individual therapy, residential treatment centers, and twelve-step programs such as Narcotics Anonymous. Since addictive behavior is a learned behavior in opioid dependence, cognitive behavioral therapy aims to promote positive motivation to change that behavior. Studies such as the Rat Park series indicate that a greater focus on improving the environments of those with opioid use disorders could also be beneficial.


title: Opioid epidemic in the United States

text: Harm reduction programs operate under the understanding that certain levels of drug use are inevitable and focus on minimizing adverse effects associated with drug use. In the context of the opioid epidemic, harm reduction strategies are designed to improve health outcomes and reduce overdose deaths. Because many pain sufferers are also depressed, a challenge of harm reduction is that some applications, such as the use of drugs to reverse or avoid opioid overdose can nullify the effects of antidepressant medications which depend on the natural human opioid system.


title: Opioid epidemic in the United States

text: One of the first serious efforts to spread the harm reduction practices to combat heroin overdoses in American and beyond occurred in a conference in Seattle in January 2001 called "Preventing Heroin Overdose: Pragmatic Approaches." The conference was co-sponsored by the Alcohol and Drug Abuse Institute at the University of Washington and the Lindesmith Center (later known as the Drug Policy Alliance), which was led by Ethan Nadelmann, financed by George Soros, and aimed to end the War on Drugs and promote harm reduction. The conference brought "scholars, researchers, doctors and other health care providers, drug-treatment providers and a handful of police officials" from across North America and Europe together to discuss approaches in combatting heroin overdoses. While some strategies endorsed in the program, including needle-exchange programs and good samaritan laws, became mainstream in American drug policy, other approaches that were advocated at the conference, including safe injection sites, have yet to be widely endorsed in the United States. Nadelmann said at the time of the conference, "We could cut heroin overdoses in half if the information from this conference was widely disseminated."


title: Opioid epidemic in the United States

text: Naloxone (Narcan) can be used as a rescue medication for opioid overdose or as a preventive measure for those wanting to stop using opiates. It is an opioid antagonist, meaning it binds to opioid receptors, which prevents them from being activated by opiates. It binds more strongly than other drugs, so that when someone is overdosing on opioids, naloxone can be administered, allowing it to take the place of the opioid drug in the person's receptors, turning them off. This blocks the effect of the receptors.


title: Opioid epidemic in the United States

text: Take-home naloxone overdose prevention kits have shown promise in areas exhibiting rapid increases in opioid overdoses and deaths due to the increased availability of fentanyl and other synthetic opioids. Many counties offer naloxone training programs with the aim of educating the surrounding community on how to use naloxone. Early implementation of programs that widely distribute THN kits across these areas can substantially reduce the number of opioid overdose deaths. Additionally, persons at risk for opioid overdose did not engage in riskier, compensatory drug use as a result of having access to naloxone kits.


title: Opioid epidemic in the United States

text: Despite the illegality of injecting illicit drugs in most places around the world, many injectable drug users report willingness to utilize overdose prevention centers. Those at especially high risk for overdose were significantly more willing. This observed willingness suggests that safe injection sites would be best utilized by people who could benefit most from them.


title: Opioid epidemic in the United States

text: As of 2018, legislation in the US did not allow for the opening of overdose prevention centers; there were no government-sponsored sites but several efforts were underway to try to create them.


title: Opioid epidemic in the United States

text: Critics of overdose prevention centers say they enable and exacerbate drug use. Data from 2014 suggested that safe injection sites could reduce overdoses while not increasing the number of drug users.


title: Opioid epidemic in the United States

text: The CDC defines needle exchange programs (NEP), also known as syringe services programs, as "community-based programs that provide access to sterile needles and syringes free of cost and facilitate safe disposal of used needles and syringes". NEP were first established in the US in the late 1980s as a response to the HIV pandemic. Because federal funding has long been banned from being used for NEP, their prominence in the US has been minimal. However, in early 2016, in the face of the ever-increasing heroin crisis, Congress effectively rolled back those regulations and is now allowing federal funding to support certain aspects of NEP. NEP are cited by the CDC as a vital aspect of the multi-faceted approach to the opioid crisis.


title: Opioid epidemic in the United States

text: While opposition to NEP includes fears of increased drug use, studies have shown that they do not increase drug use among users or within a community. NEP have also been known to increase admittance into addiction treatment centers, offer counseling, housing support and help users begin the path to recovery through outreach from trusted staff. In addition, NEP that operate on a one-for-one basis help to drastically reduce the amount of discarded needles in public. Both the Center for Disease Control and National Institute of Health support the idea that NEP are a crucial aspect to a comprehensive approach to the opioid crisis.


title: Opioid epidemic in the United States

text: As of 2018, some retailers had begun experimenting with the use of blue light bulbs in bathrooms in order to deter addicts from using such spaces to inject opiates. Blue lights are said to make finding veins to inject more difficult. However, a 2013 study has found that the use of blue lights are unlikely to deter drugs users from injecting in public washrooms and may increase drug use-related harm.


title: Opioid epidemic in the United States

text: A "pill mill" is a clinic that dispenses narcotics to patients without a legitimate medical purpose. This is done at clinics and doctors offices, where doctors examine patients extremely quickly with a purpose of prescribing painkillers. These clinics often charge an office fee of $200 to $400 and can see up to 60 patients a day, which is very profitable for the clinic. Pill mills are also large suppliers of the illegal painkiller black markets on the streets. Dealers may hire people to go to pill mills to get painkiller prescriptions.


title: Opioid epidemic in the United States

text: There have been attempts to shut down pill mills. 250 pill mills in Florida were shut down in 2015. Florida clinics also are no longer allowed to dispense painkillers directly from their clinics, which has helped reduce the distribution of prescription opiates. Since the implementation of pill mill laws and drug monitoring programs in Florida, high-risk patients (defined as those who use both benzodiazepines and opioids, those who have been using high opioid doses for extended periods of time, or "opioid shoppers" that obtain their opioid painkillers from multiple sources) have shown significant reductions in opioid use.


title: Opioid epidemic in the United States

text: As the number of opioid prescriptions rose, drug cartels began flooding the US with heroin from Mexico. For many opioid users, heroin was cheaper, more potent, and often easier to acquire than prescription medications. According to the CDC, tighter prescription policies by doctors did not necessarily lead to this increased heroin use. The main suppliers of heroin to the US have been Mexican transnational criminal organizations.


title: Opioid epidemic in the United States

text: From 2005 to 2009, Mexican heroin production increased by over 600%, from an estimated 8 metric tons in 2005 to 50 metric tons in 2009. Between 2010 and 2014, the amount seized at the border more than doubled. According to the Drug Enforcement Administration, smugglers and distributors "profit primarily by putting drugs on the street and have become crucial to the Mexican cartels."


title: Opioid epidemic in the United States

text: Illicit fentanyl is commonly made in Mexico and trafficked by cartels. North America's dominant trafficking group is Mexico's Sinaloa Cartel, which has been linked to 80 percent of the fentanyl seized in New York.


title: Immortan Joe

text: Immortan Joe is a fictional character and the main antagonist of the 2015 film "". He is portrayed by Hugh Keays-Byrne. Immortan Joe also appears in the , and will return in the 2024 prequel film "Furiosa" as a supporting protagonist, portrayed by Chris Hemsworth.


title: Immortan Joe

text: In the film, Immortan Joe is the "ruler of the wasteland... He wears a clear, plastic carapace — chest armor — over oozing sores, his long, white hair flaring around a skeleton-smile mask he uses to hide a breathing apparatus." Several versions of his carapace, which display medals made from car and mobile phone parts and some actual military insignia (such as the U.S. Navy officer cap insignia), were created at Artisan Armours in the United Kingdom.


title: Immortan Joe

text: Writing about the film for ABC News, Michael Rothman described Immortan Joe as "a real bad guy who looks nothing like any villain that's ever graced the silver screen". "Vanity Fair" Joanna Robinson described him as "nightmarish" and "a fairly classic Miller creation with a skull fetish even a teenage goth would envy". Spencer Kornhaber of "The Atlantic" wrote, "Perhaps the closest 2015 has gotten to providing fodder for 'Greatest Villains of All Time' lists was in "Mad Max: Fury Road", where slaver-warlord Immortan Joe sported a nauseating headpiece and an equally nauseating dadbod."


title: Glossary of cricket terms

text: This is a general glossary of the terminology used in the sport of cricket. Where words in a sentence are also defined elsewhere in this article, they appear in italics. Certain aspects of cricket terminology are explained in more detail in cricket statistics and the naming of fielding positions is explained at fielding (cricket).


title: Glossary of cricket terms

text: Cricket is known for its rich terminology. Some terms are often thought to be arcane and humorous by those not familiar with the game.


title: Glossary of cricket terms

text: Such unintentional shots can frequently fool the wicket keeper and may often fortunately result in runs.


title: Hypochlorous acid

text: Hypochlorous acid (HClO, HOCl, or ClHO) is a weak acid that forms when chlorine dissolves in water, and itself partially dissociates, forming hypochlorite, ClO. HClO and ClO are oxidizers, and the primary disinfection agents of chlorine solutions. HClO cannot be isolated from these solutions due to rapid equilibration with its precursor, chlorine.


title: Hypochlorous acid

text: Because of its strong antimicrobial properties, the related compounds sodium hypochlorite (NaClO) and calcium hypochlorite (Ca(ClO)) are ingredients in many commercial bleaches, deodorants, and disinfectants. The white blood cells of mammals, such as humans, also contain hypochlorous acid as a tool against foreign bodies. In living organisms, HOCl is generated by the reaction of hydrogen peroxide with chloride ions under the catalysis of the heme enzyme myeloperoxidase (MPO).


title: Hypochlorous acid

text: Like many other disinfectants, hypochlorous acid solutions will destroy pathogens, such as COVID-19, adsorbed on surfaces. In low concentrations, such solutions can serve to disinfect open wounds.


title: Hypochlorous acid

text: Hypochlorous acid was discovered in 1834 by the French chemist Antoine Jérôme Balard (1802–1876) by adding, to a flask of chlorine gas, a dilute suspension of mercury(II) oxide in water. He also named the acid and its compounds.


title: Hypochlorous acid

text: Despite being relatively easy to make, it is difficult to maintain a stable hypochlorous acid solution. It is not until recent years that scientists have been able to cost-effectively produce and maintain hypochlorous acid water for stable commercial use.


title: Hypochlorous acid

text: When acids are added to aqueous salts of hypochlorous acid (such as sodium hypochlorite in commercial bleach solution), the resultant reaction is driven to the left, and chlorine gas is formed. Thus, the formation of stable hypochlorite bleaches is facilitated by dissolving chlorine gas into basic water solutions, such as sodium hydroxide.


title: Hypochlorous acid

text: The acid can also be prepared by dissolving dichlorine monoxide in water; under standard aqueous conditions, anhydrous hypochlorous acid is currently impossible to prepare due to the readily reversible equilibrium between it and its anhydride:


title: Hypochlorous acid

text: The presence of light or transition metal oxides of copper, nickel, or cobalt accelerates the exothermic decomposition into hydrochloric acid and oxygen:


title: Hypochlorous acid

text: Salts of hypochlorous acid are called hypochlorites. One of the best-known hypochlorites is NaClO, the active ingredient in bleach.


title: Hypochlorous acid

text: Hypochlorous acid reacts with a wide variety of biomolecules, including DNA, RNA, fatty acid groups, cholesterol and proteins.


title: Hypochlorous acid

text: Knox "et al." first noted that HClO is a sulfhydryl inhibitor that, in sufficient quantity, could completely inactivate proteins containing sulfhydryl groups. This is because HClO oxidises sulfhydryl groups, leading to the formation of disulfide bonds that can result in crosslinking of proteins. The HClO mechanism of sulfhydryl oxidation is similar to that of monochloramine, and may only be bacteriostatic, because once the residual chlorine is dissipated, some sulfhydryl function can be restored. One sulfhydryl-containing amino acid can scavenge up to four molecules of HClO. Consistent with this, it has been proposed that sulfhydryl groups of sulfur-containing amino acids can be oxidized a total of three times by three HClO molecules, with the fourth reacting with the α-amino group. The first reaction yields sulfenic acid (R–SOH) then sulfinic acid (R–SOH) and finally R–SOH. Sulfenic acids form disulfides with another protein sulfhydryl group, causing cross-linking and aggregation of proteins. Sulfinic acid and R–SOH derivatives are produced only at high molar excesses of HClO, and disulfides are formed primarily at bacteriocidal levels. Disulfide bonds can also be oxidized by HClO to sulfinic acid. Because the oxidation of sulfhydryls and disulfides evolves hydrochloric acid, this process results in the depletion HClO.


title: Hypochlorous acid

text: Hypochlorous acid reacts readily with amino acids that have amino group side-chains, with the chlorine from HClO displacing a hydrogen, resulting in an organic chloramine. Chlorinated amino acids rapidly decompose, but protein chloramines are longer-lived and retain some oxidative capacity. Thomas "et al." concluded from their results that most organic chloramines decayed by internal rearrangement and that fewer available NH groups promoted attack on the peptide bond, resulting in cleavage of the protein. McKenna and Davies found that 10 mM or greater HClO is necessary to fragment proteins in vivo. Consistent with these results, it was later proposed that the chloramine undergoes a molecular rearrangement, releasing HCl and ammonia to form an aldehyde. The aldehyde group can further react with another amino group to form a Schiff base, causing cross-linking and aggregation of proteins.


title: Hypochlorous acid

text: Hypochlorous acid reacts slowly with DNA and RNA as well as all nucleotides in vitro. GMP is the most reactive because HClO reacts with both the heterocyclic NH group and the amino group. In similar manner, TMP with only a heterocyclic NH group that is reactive with HClO is the second-most reactive. AMP and CMP, which have only a slowly reactive amino group, are less reactive with HClO. UMP has been reported to be reactive only at a very slow rate. The heterocyclic NH groups are more reactive than amino groups, and their secondary chloramines are able to donate the chlorine. These reactions likely interfere with DNA base pairing, and, consistent with this, Prütz has reported a decrease in viscosity of DNA exposed to HClO similar to that seen with heat denaturation. The sugar moieties are nonreactive and the DNA backbone is not broken. NADH can react with chlorinated TMP and UMP as well as HClO. This reaction can regenerate UMP and TMP and results in the 5-hydroxy derivative of NADH. The reaction with TMP or UMP is slowly reversible to regenerate HClO. A second slower reaction that results in cleavage of the pyridine ring occurs when excess HClO is present. NAD is inert to HClO.


title: Hypochlorous acid

text: Hypochlorous acid reacts with unsaturated bonds in lipids, but not saturated bonds, and the ClO ion does not participate in this reaction. This reaction occurs by hydrolysis with addition of chlorine to one of the carbons and a hydroxyl to the other. The resulting compound is a chlorohydrin. The polar chlorine disrupts lipid bilayers and could increase permeability. When chlorohydrin formation occurs in lipid bilayers of red blood cells, increased permeability occurs. Disruption could occur if enough chlorohydrin is formed. The addition of preformed chlorohydrin to red blood cells can affect permeability as well. Cholesterol chlorohydrin have also been observed, but do not greatly affect permeability, and it is believed that Cl is responsible for this reaction.


title: Hypochlorous acid

text: "E. coli" exposed to hypochlorous acid lose viability in less than 0.1 seconds due to inactivation of many vital systems. Hypochlorous acid has a reported of 0.0104–0.156 ppm and 2.6 ppm caused 100% growth inhibition in 5 minutes. However, the concentration required for bactericidal activity is also highly dependent on bacterial concentration.