Opioid Overdose Risk Mitigation

August 31, 2015

Dear Colleague:

In 2014, an average of 1.5 people died each day from a fatal prescription opioid overdose in Virginia. Fatal prescription opioid overdoses increased by 8.3% in 2014 (n=547) compared to 2013 (n=505). In addition, fatal heroin overdoses increased by 12.2% in 2014 (n=239) compared to 2013 (n=213). Although there is a lag time for confirmative toxicology results, preliminary data for the first six months of 2015 already show a 24.8% increase in the number of fatal heroin overdoses (n=126) compared to the first six months of 2014 (n=101).

My communication today will highlight three topics related to our collective efforts to address the epidemic of opioid abuse and overdose in Virginia.

  • Adoption of the SAMHSA Opioid Overdose Prevention Toolkit: Information for Prescribers as risk mitigation guidelines for the prescription of opioid analgesics in Virginia
  • Expanded access to naloxone in Virginia
  • Statewide, regional and local initiatives to address prescription drug and heroin abuse

SAMHSA Opioid Overdose Prevention Toolkit: Information for Prescribers

The Virginia General Assembly during its 2015 Session directed the Virginia Department of Health (VDH) in collaboration with the Department of Health Professions (DHP) to issue “risk mitigation guidelines on the prescription of the class of potent pain medicines known as extended-release and long-acting (ER/LA) opioid analgesics to include co-prescription of an opioid antagonist.” Just as the clinical community’s response to opioid abuse and overdose is not only in the hands of specialists in addiction medicine, the Department of Behavioral Health and Developmental Services (DBHDS), DHP and VDH share in the public health response.

DBHDS, DHP and VDH are adopting as risk mitigation guidelines for the prescription of opioid analgesics the SAMHSA Opioid Overdose Prevention Toolkit: Information for Prescribers (HHS Publication No. (SMA) 14-4742. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014), which is available at http://store.samhsa.gov/shin/content//SMA14-4742/Toolkit_Prescribers.pdf

The Information for Prescribers stresses that physicians and other healthcare providers can reduce the toll of opioid overdose through the care they take in prescribing opioid analgesics and monitoring the patient’s response, as well as by identifying and addressing overdose.  When considering use of an opioid analgesic:

  • Assess the patient, and take special precautions with new patients
  • Use the Virginia Prescription Monitoring Program (http://www.dhp.virginia.gov/pmp/)
  • Select an appropriate medication
  • Educate the patient and obtained informed consent
  • Execute the prescription order carefully
  • Consider prescribing naloxone along with the patient’s initial opioid prescription


  • Monitor the patient’s response to treatment
  • Decide whether and when to end opioid therapy
  • Consider prescribing naloxone to a patient at high risk of overdose

Information for Prescribers, under the heading Resources for Prescribers, provides links to additional information and courses on prescribing opioids for chronic pain. CME credits are available.

 We still have the option to develop Virginia-specific opioid abuse and overdose risk mitigation guidelines. Developing these guidelines would require the collective effort of the state agencies, professional boards, professional associations and interested healthcare professionals. To help us determine the need for Virginia-specific guidelines, we ask that you complete this short online survey (https://www.surveymonkey.com/r/VDHOpioid), which will remain open for 60 days.

Expanded access to naloxone

The General Assembly also passed legislation this year to expand access to naloxone so that family members and other individuals can possess and use naloxone to reverse an opioid overdose at home or in the community.

Per the Code of Virginia §54.1-3408 X, “Notwithstanding the provisions of § 54.1-3303, pursuant to an oral, written, or standing order issued by a prescriber, and in accordance with protocols developed by the Board of Pharmacy in consultation with the Board of Medicine and the Department of Health, a pharmacist may dispense naloxone or other opioid antagonist used for overdose reversal and a person may possess and administer naloxone or other opioid antagonist used for overdose reversal to a person who is believed to be experiencing or about to experience a life-threatening opiate overdose.”

The Board of Pharmacy has approved a “Protocol for the Prescribing and Dispensing of Naloxone” (https://www.dhp.virginia.gov/pharmacy/). The DBHDS Office of Substance Abuse Services has established REVIVE! as the Opioid Overdose and Naloxone Education (ONE) program for the Commonwealth of Virginia. REVIVE! provides training to professionals, stakeholders, and others on how to recognize and respond to an opioid overdose emergency with the administration of naloxone (http://www.dbhds.virginia.gov/individuals-and-families/substance-abuse/revive). Both sources include guidance on prescribing and dispensing naloxone for intranasal administration, as well as by auto-injector.

Statewide, regional and local initiatives on prescription drug and heroin abuse

Virginia’s response to the epidemic of opiate abuse and overdose is not limited to a healthcare response. In September 2014, Governor McAuliffe signed Executive Order 29 establishing the Governor’s Task Force on Prescription Drug and Heroin Abuse. The Task Force is co-chaired by the Secretary of Health and Human Resources and Secretary of Public Safety and Homeland Security and includes representatives from the Office of the Attorney General, legislature, and judiciary, as well as relevant state and local agencies, law enforcement, health and behavioral health care professionals, providers, community advocates, and individuals with personal experience with addiction. The Task Force was created to recommend immediate steps to address a growing and dangerous epidemic of prescription opioid and heroin abuse in Virginia, with the ultimate goal of improving public safety and public health. See the Task Force website (http://www.dhp.virginia.gov/taskforce/) for information on its activities and recommendations.

At the local and regional level, clinicians and other healthcare professionals are encouraged to engage with local agencies, law enforcement, community advocates, community service boards, and other community partners to create local solutions to address substance abuse prevention and treatment, as well as respond to the epidemic of opioid overdose. Regarding opioid overdose, the SAMHSA Opioid Overdose Prevention Toolkit also provides: Facts for Community Members; Five Essential Steps for First Responders; Safety Advice for Patients & Family Members; and Recovering from Opioid Overdose. All documents are available at: http://store.samhsa.gov/product/Opioid-Overdose-Prevention-Toolkit-Updated-2014/SMA14-4742.

Thank you for your efforts as clinicians to prevent or reduce the risk of opiate abuse by the patients under your care and as members of your community to support efforts to stem the epidemic of opioid prescription drug and heroin abuse, overdose and overdose deaths in Virginia.


Marissa J. Levine, MD, MPH, FAAFP             David Brown, DC                                Debra Ferguson, PhD

State Health Commissioner                              Director                                                  Commissioner

Department of Health                                        Department of Health Professions   Department of Behavioral Health &

Developmental Services