Senate Judiciary Committee Hearing on Senate Bill No. 181

Testimony of Lindsay LaSalle, Senior Staff Attorney, Alliance

Board Members March 22, 2017 Larry Campbell Christine Downton Jodie Evans I am Lindsay LaSalle, Senior Staff Attorney at the , the James E. Ferguson, II Jason Flom nation’s leading organization advocating alternatives to the failed war on Ira Glasser drugs. I want to thank the Senate Judiciary Committee for the opportunity to Carl Hart, PhD Mathilde Krim, PhD address you today and submit written testimony in favor of the -assisted David C. Lewis, MD treatment pilot project that SB181 would create. Pamela Lichty Ethan Nadelmann, JD, PhD Josiah Rich, MD Rev. Edwin Sanders The evidence is in. Heroin-assisted treatment, also known as heroin Michael Skolnik maintenance, is a feasible, effective, and cost-saving strategy for reducing George Soros Ilona Szabó de Carvalho drug use and drug-related harm among long-term heroin users for whom other Richard B. Wolf 1 treatment programs have failed. Permanent heroin maintenance programs Honorary Board Former Mayor have been established in the United Kingdom, Switzerland, the Netherlands, Rocky Anderson Germany, and Denmark, with additional trial programs having been Harry Belafonte 2 Richard Branson completed or currently taking place in Spain, Belgium, and Canada. Former Defense Secretary Frank C. Carlucci, III Findings from randomized controlled studies in these countries have yielded Deepak Chopra 3 unanimously positive results. Heroin-assisted treatment is associated with Rep. John Conyers, Jr. Walter Cronkite decreased illicit drug use, crime, overdose fatalities, and risky injecting, as [1916-2009] well as significant improvements in physical and mental health, employment, Ram Dass 4 Vincent Dole, MD and social relations. Given the consistently positive results, heroin-assisted [1913-2006] Former President of the Swiss treatment is not as controversial or radical as it may seem at first blush. Confederation Ruth Dreifuss Rather, it is a treatment modality that has gained traction within the scientific Former Surgeon General Joycelyn Elders community as a tried-and-true method for dealing with particularly refractory Judge Nancy Gertner (Ret.) Former Police Chief cases of heroin and the associated harms. Penny Harrington Former President of the Czech Republic Václav Havel I would like to first highlight the development and history of heroin-assisted [1936-2011] treatment in other countries and review the compelling evidence base that has Calvin Hill Arianna Huffington been amassed from the international experience before contextualizing the Former Governor Gary Johnson importance of SB181 within our own country and this state. Judge John Kane Former Attorney General Nicholas deB. Katzenbach TIMELINE AND DEVELOPMENT OF HEROIN-ASSISTED [1922-2012] Former Police Chief TREATMENT IN OTHER COUNTRIES Joseph McNamara [1934-2014] Former Police Commissioner Though heroin has been available by individual prescription in the United Patrick V. Murphy Kingdom since 1926,5 Switzerland opened the first supervised heroin-assisted [1920-2011] 6 Benny J. Primm, MD treatment centers as part of a clinical study in 1994. In 1999, after reviewing Dennis Rivera Former Mayor Kurt Schmoke the initial positive results of the Swiss study, the World Health Organization Charles R. Schuster, PhD recommended more randomized clinical trials on heroin maintenance.7 [1930-2011] 8 9 10 11 Alexander Shulgin, PhD Between 2002 and 2010, the Netherlands, Spain, Germany, Canada and [1925-2014] 12 Former Secretary of State the United Kingdom published the results of additional studies showing that George P. Shultz heroin is more effective than oral methadone for people who have not Russell Simmons Sting Judge Robert Sweet Former Chairman of the Federal Reserve Paul Volcker

benefitted from standard treatments. By 2010, heroin was registered for maintenance treatment in the United Kingdom, Switzerland, The Netherlands, Denmark, and Germany.13

The Dutch government supported the rollout of heroin maintenance as regular addiction treatment alongside other existing interventions in 2004 and, in December 2006, the Dutch Medicines Evaluation Board approved both inhalable and injectable heroin as a medicinal product for maintenance treatment.14 As of July 2011, 650 patients receive heroin-assisted treatment in 17 clinics throughout the country.15 In Switzerland, a national referendum to permit heroin maintenance passed with 68% of the public vote in 2008.16 There are now 23 facilities in Switzerland providing heroin-assisted treatment, including two located in prisons, serving nearly 1,500 people.17 Though Denmark never hosted a clinical trial, the government approved a proposal to allow heroin-assisted treatment in 2008 based on the overwhelming evidence from other countries.18 Five heroin maintenance clinics now serve an estimated 300 people.19 Germany’s parliament voted to allow heroin-assisted treatment in 2009 and it is now available in nine clinics serving approximately 500 patients throughout the country.20 In the United Kingdom, three clinics remained open after the conclusion of their trial program and currently serve approximately 100 people.21 In January 2012, the government gave approval for the roll-out of additional heroin maintenance clinics after the Department of Health concluded that heroin-assisted treatment “is now evidenced as a clinically-effective second-line treatment . . . .”22 Moreover, approximately 500 people in the United Kingdom receive prescription heroin directly from their physician for maintenance treatment.23

In addition to permanent treatment programs, trial programs are currently operating in Canada (a second study began in 2011)24 and Belgium (also began in 2011).25 Luxembourg is considering the implementation of similar trials.26

KEY RESEARCH FINDINGS

Results from the European and Canadian trials and permanent programs demonstrate that “prescribed pharmaceutical heroin does exactly what it is intended to do: it reaches a treatment refractory group of addicts by engaging them in a positive healthcare relationship with a physician, it reduces their criminal activity, improves their health status, and increases their social tenure through more stable housing, employment, and contact with family.”27 Moreover, these substantial benefits come with improved cost-savings compared to standard treatments28 and with no negative impacts on the larger community.29

E2 Heroin Maintenance is Cost-Effective

Though heroin-assisted treatment is initially more expensive than standard treatment modalities such as methadone, the up-front expense is more than re- paid with significant societal savings due to, among other factors, reduced medical and law enforcement costs.30 A cost-benefit analysis of the Swiss program showed the benefits of heroin maintenance per day amounted to twice the daily treatment costs.31 It is estimated that heroin-assisted treatment saves approximately 12,000 euros per patient per year in the Netherlands,32 9,000 dollars per patient per year in Switzerland,33 and 6,300 euros per patient per year in Germany,34 compared to methadone maintenance.

Heroin-Assisted Treatment Reduces Crime

Researchers in Spain,35 England,36 Switzerland,37 and Germany38 have reported significant reductions in crime among heroin maintenance participants. The Swiss heroin treatment group, for example, showed significant reductions in criminal charges compared to the methadone maintenance group, including charges for drug use and/or possession (11% vs. 38%), property theft (4% vs. 24%), and other offense/charge in the prior six months (19% vs. 57%).39 The German trial also reported that participants in the heroin maintenance group engaged in criminal activities less often than those in the methadone group, with fewer reported days of crime against property (10.3 vs. 37.5), less frequent arrests (2.1 vs. 2.8 times a year), and less frequent convictions (0.25 vs. 0.54 times).40 Another German study found that the percentage of individuals who had committed at least one offense in the respective year dropped from 79% to 45% in the heroin group compared to 79% to 63 % in the methadone group.41 Similarly, the average number of offenses also declined in the heroin group from 76.7% to 26.8%—a significantly greater drop than the methadone group, where it only declined to 49%.42

Heroin-Assisted Treatment Reduces Drug Use

Every heroin-assisted treatment trial has shown a marked decrease in street heroin use.43 A Cochrane systematic review concluded that “[e]ach study found a superior reduction in illicit drug use in the heroin arm rather than in the methadone arm . . . the measures of effect obtained are consistently statistically significant.”44 The United Kingdom trial, for instance, reported over a two-thirds (72 percent) reduction in illicit drug use among heroin- assisted treatment participants.45 Similar reductions in street heroin use were reported from heroin maintenance trials in Switzerland (74 percent),46 Germany (69 percent),47 and Canada (67 percent).48 Heroin-maintenance patients also experience less (and less severe) cravings, helping to explain their decreased use.49 Heroin-assisted treatment has also demonstrated an added benefit of reducing participants’ use of alcohol and other drugs.50

E3 Retention Rates in Heroin-Assisted Treatment Surpass Those of Conventional Treatment

Studies consistently demonstrate that retention rates in heroin-assisted treatment are high. The Swiss trial found that 93% of patients remained in treatment at 12 months, 50% at 3.3 years, and 30% at the six-year mark.51 Moreover, some studies have found that patients who have failed other treatments stay in heroin maintenance programs significantly longer than their counterparts who only receive methadone. Retention rates in the Canadian trial at 12 months were 87.8% for those receiving heroin-assisted treatment versus 54.1% for the control group receiving methadone.52 In the German study, retention at 12 months was also higher in the heroin maintenance group than in the methadone group (67 % vs. 40 %).53

Heroin Maintenance Can Be a Stepping Stone to Other Treatments and Even Abstinence

While retention rates are high, the majority of patients who do discontinue treatment do not relapse. Rather, results from studies of heroin-assisted treatment have undermined several myths about heroin and its habitual users: given relatively unlimited availability, heroin users will voluntarily stabilize or reduce their dosage or switch to other treatments, and some will even choose abstinence. Indeed, the Swiss study found that more than 60 percent of those who exited heroin maintenance did so in order to take up another treatment option.54 The majority of those seeking other treatment went into a methadone maintenance program, but almost 40 percent went into an abstinence program.55

Heroin-Assisted Treatment Improves Health, Social Functioning, and Quality of Life

All published studies that have examined the question have reported that patients in heroin-assisted treatment see improvements on measures of physical and mental health, including better nutritional status, cardiac function, and body-mass index as well as lower overdose and infectious disease rates.56 Researchers in Germany found that health improvements were seen as early as the first few months of treatment but became more pronounced as time in treatment increased.57 Moreover, studies have found that quality of life improves significantly for those in heroin-assisted treatment. The Swiss trial demonstrated long-term improvement in reduced proportions of patients with an unstable housing situation (baseline: 43% vs. 18 months: 21%), homelessness (baseline: 18% vs. 18 months: 1%), unemployment (baseline: 73% vs. 18 months: 45%) and those receiving welfare payments (baseline: 63% vs. 18 months: 54%).58 Marked improvements in the social domain were also evident in the German trial with

E4 a significantly higher proportion of patients in stable housing (baseline: 76% vs. 24 months: 91%) and stable jobs (baseline: 15% vs. 24 months: 26 %).59

Heroin Maintenance Does Not Pose Nuisance or Other Neighborhood Concerns

Two community impact studies evaluating the establishment and operation of heroin-assisted treatment clinics have found that they do not result in any negative impacts, such as changes in street public nuisance or amount of criminal offenses, for those residing and working in surrounding areas.60 In Canada, no impact was detected of either the introduction of the heroin maintenance clinics or the increase in the number of attending patients on the number of violent or property crimes or acts of public disorder committed in the clinic vicinity.61 In the United Kingdom, Metropolitan Police figures revealed no significant changes in monthly or average annual crime levels in the areas where treatment centers were located over the two-year trial period.62

Heroin-Assisted Treatment Can Reduce the Black Market for Heroin

Though heroin-assisted treatment programs only serve a small minority of the population that uses heroin, it is this subgroup that consumes the majority of the heroin supply. For this reason, heroin maintenance can actually help destabilize local heroin markets. One published article concluded that heroin maintenance participants “accounted for a substantial proportion of consumption of illicit heroin, and that removing them from the illicit market has damaged the market’s viability.”63 The authors further state that “by removing retail workers [who] no longer sold drugs to existing users, and . . . no longer recruited new users in to the market . . . the heroin prescription market may thus have had a significant impact on heroin markets in Switzerland.”64

HEROIN-ASSISTED TREATMENT IN NEVADA

A scientifically proven treatment, the efficacy of which is virtually unquestioned, remains unexamined and unutilized in the United States because domestic policy fails to recognize and treat drug use as a health issue. But we cannot arrest or incarcerate our way out of a chronic disease like heroin addiction. The failed war on drugs has proved as much. Illicit drug use in America has been steadily increasing despite our punitive policies.65 Approximately 156,000 new people started using heroin in 2012, nearly double the number of people in 2006.66 Moreover, the number of people meeting the Diagnostic and Statistical Manual of Mental Disorders criteria for dependence or abuse of heroin doubled from 214,000 in 2002 to 467,000 in 2012.67 Nevada echoes these national trends and ranks tenth in the nation in illicit drug use rates.68 Experts have called heroin addiction an “epidemic” in

E5 southern Nevada in particular.69 A number of local news reports have also indicated that treatment providers and law enforcement are seeing a significant rise in heroin use and heroin seizures in Nevada generally.70 A shocking 619 people died of drug overdose deaths in Nevada in 2015.71 Statistics from the Division of Public and Behavioral Health show heroin deaths in Nevada have doubled in recent years.72 In short, we are confronted in this state, and the nation at large, with a growing and serious heroin epidemic. We cannot continue to rely on the same strategies and expect a different result. Politics can no longer trump science - and compassion, common sense, and fiscal prudence - in dealing with and addressing drug use and abuse.

The results from well-designed randomized controlled trials, which have been peer reviewed and published in high-impact scientific journals, as well as steadily accumulating clinical experience can inform the successful development and implementation of a heroin-assisted treatment program in Nevada that will reach the most marginalized and hard-to-treat heroin users. Such a program will undoubtedly result in significant health, safety, and cost benefits for your state. But passing SB181 would also do significantly more than that. It would represent a significant paradigm shift in how we address and treat drug addiction in the United States. Nevada has the opportunity to serve as a model for treating drug use as what it is—a health issue that should be combated with evidence-based, rigorously studied treatments with proven benefits for the users, their families, and the community as a whole. I sincerely hope you will make the most of the opportunity before you.

Thank you, again, for the opportunity to submit testimony on this groundbreaking legislation.

Sincerely,

Lindsay LaSalle Senior Staff Attorney

E6 1 See, e.g., Fischer, B., Oviedo-Joekes, E., Blanken, P., et al. (2007). Heroin-assisted treatment (HAT) a decade later: A brief update on science and politics. J Urban Health, 84, 552-62. 2 Strang, J., Groshkova, T. & Metrebian, N. (2012). New heroin-assisted treatment: Recent evidence and current practices of supervised injectable heroin treatment in Europe and beyond. European Monitoring Centre for Drugs and Drug Addiction Insights. Luxembourg: Publications. 3 See, e.g., van den Brink, W., Hendricks, V. M., Blanken, P., et al. (2003). Medical prescription of heroin to treatment resistant heroin addicts: two randomised controlled trials. British Medical Journal, 327, 310–316; Haasen, C., Verthein, U., Degkwitz, P., et al. (2007). Heroin-assisted treatment for opioid dependence. British Journal of Psychiatry, 191, 55–62; March, J. C., Oviedo-Joekes, E., Perea-Milla, E., Carrasco, F. et al. (2006). Controlled trial of prescribed heroin in the treatment of opioid addiction. Journal of Treatment, 31, 203–211; Oviedo-Joekes, E., Brissette, S., Marsh, D., et al. (2009). Diacetylmorphine versus methadone for the treatment of opiate addiction. The New England Journal of Medicine, 361, 777–786; Perneger, T. V., Giner, F., del Rio, M. & Mino, A. (1998). Randomised trial of heroin maintenance programme for addicts who fail in conventional drug treatments. British Medical Journal 317, 13–18; Strang, J., Metrebian, N., Lintzeris, N., et al. (2010). Supervised injectable heroin or injectable methadone versus optimised oral methadone as treatment for chronic heroin addicts in England after persistent failure in orthodox treatment (RIOTT): a randomised trial. Lancet, 375, 1885–1895. 4 See, e.g., Ferri, M., Davoli, M., & Perucci, C.A. (2005). Heroin maintenance for chronic heroin dependents. Cochrane Database Syst Rev., 2. 5 Metrebian, N., Carnwath, Z., Mott, J., Carnwath, T., Stimson, G.V., Sell, L. (2006). Patients receiving a prescription for diamorphine (heroin) in the United Kingdom. Drug Alcohol Rev, 25, 115-21. 6 Rehm, J., Gschwend, P., Steffen, T., Gutzwiller, F., Dobler-Mikola, A. & Uchtenhagen, A. (2001). Feasibility, safety, and efficacy of injectable heroin prescription for refractory opioid addicts: a follow-up study. Lancet, 358, 1417-23. 7 Ali, R., Auriacombe, M., Casas, M., Cottler, L., Farell, M., Kleiber, D., Kreuzer, A., Ogborne, A., Rehm, J. & Ward, P. (1999). Report of the external panel on the evaluation of the Swiss scientific studies of medically prescribed narcotics to drug addicts. Geneva: WHO. 8 van den Brink et al. (2003), supra note 3. 9 March, J.C. et al. (2006), supra note 3. 10 Haasen et al. (2007), supra note 3. 11 Oviedo-Joekes et al. (2009), supra note 3. 12 Strang et al. (2010), supra note 3. 13 Strang et al. (2012) supra note 2 at 19, 25. 14 Blanken, P., van den Brink, W., Hendriks, V. M., et al. (2010). Heroin-assisted treatment in the Netherlands: History, findings, and international context. European Neuropsychopharmacology, Supplement 2, 105–158. 15 Strang et al. (2012), supra note 2 at 149. 16 Id. at 103. 17 Strang et al. (2012), supra note 2 at 104. 18 Id. at 145. 19 Id. at 147. 20 Strang et al. (2012), supra note 2 at 126. 21 Id. at 138. 22 Id. at 143-44. 23 Lintzeris, N., Strang, J., Metrebian, N., et al. (2006). Methodology for the Randomised Injecting Opioid Treatment Trial (RIOTT): Evaluating injectable methadone and injectable heroin treatment versus optimised oral methadone treatment in the UK. Harm Reduction Journal, 3, 28-33. 24 Providence Health Care, Salome, http://www.providencehealthcare.org/salome/outcomes.html.

E7 25 Demaret, I., Herné, P., Lemaître, A. & Ansseau, M. (2011). Feasibility assessment of heroin-assisted treatment in Liège, Belgium. Acta Psychiatricia, N 111\1, 3-8. 26 Ferri et al. (2005), supra note 4. 27 Small, D. & Drucker, E. (2006). Policy makers ignoring science and scientists ignoring policy: The medical ethical challenges of heroin treatment. Harm Reduction Journal, 3, 16. 28 Bammer, G., van den Brink, W., Gschwend, P., et al. (2003). What can the Swiss and Dutch trials tell us about the potential risks associated with heroin prescribing? Drug and Alcohol Review, 22(3), 363-71; Dijkgraaf, M. G., van der Zanden, B. P., de Borgie, C.A., et al. (2005). Cost utility analysis of co-prescribed heroin compared with methadone maintenance treatment in heroin addicts in two randomised trials. BMJ, 330, 1297-1302. 29 Lansier, B., Brochu, S., Bovd, N. & Fischer, B. (2010). A heroin prescription trial: Case studies from Montreal and Vancouver on crime and disorder in the surrounding neighbourhoods. International Journal of Drug Policy, 21, 28-35; Miller, P., McKenzie, S., Lintzeris, N., Martin, A. & Strang, J. (2010). The community impact of RIOTT, a medically supervised injectable maintenance clinic in south London. Mental Health and Substance Use: Dual Diagnosis 3, 248–259; Miller, P., McKenzie, S., Walker, J., Lintzeris, N. & Strang, J. (2011). Investigating the effect on public behaviour of patients of a medical supervised injectable maintenance clinic. Drugs and Alcohol Today, 11, 204–209. 30 Bammer et al., supra note 28; Dijkgraaf et al. (2005), supra note 28. 31 Bammer, supra note 28. 32 Dijkgraaf et al. (2005), supra note 28. 33 Brehmer, C. & Hen, P.X. (2001). Medical prescription of heroin to chronic heroin addicts in Switzerland - a review. Forensic Science International, 121, 23-26. 34 Haasen, C. (2009). Gesundheitsökonomische Begleitforschung (unpublished economic evaluation report, German heroin-assisted treatment trial). 35 March et al. (2006), supra note 3. 36 Metrebian, N., Shanahan, W., Wells, B. & Stimson, G. (1998). Feasibility of prescribing injectable heroin and methadone to opiate-dependent drug users: associated health gains and harm reductions. MJA, 168(12), 596-600. 37 Killias, M. and Rabassa, J. (1997). Less Crime in the Cities Through Heroin Prescription? Preliminary Results from the Evaluation of the Swiss Heroin Prescription Projects. The Howard Journal, 36(4). 38 Löbmann, R. & Verthein, U. (2009). Explaining the Effectiveness of Heroin-assisted Treatment on Crime Reductions. Law and Human Behavior, 33:1. 39 Perneger et al. (1998), supra note 3. 40 Dijkgraaf et al. (2005), supra note 28. 41 Lobmann & Verthein. (2009). Explaining the effectiveness of heroin-assisted treatment on crime reductions. Law and Human Behavior, 33(1), 83–95. 42 Id. 43 Haasen et al. (2007), supra note 3 at 55-62; P., Vincent, M. H., Maarten, W. J., Koeter, Van Ree, J.M. & van den Brink, W. (2005). Matching of treatment-resistant heroin-dependent patients to medical prescription of heroin or oral methadone treatment: Results from two randomized controlled trials. Addiction, 100, 89-95; Franziska, G., Gschwend, P., Schulte, B., Rehm, J., & Uchtenhagen, A. (2003). Evaluating long-term effects of heroin-assisted treatment: The results of a 6-year follow-up. European Addiction Research, 9, 73-79; March et al. (2006), supra note 3 at 203-211; Oviedo-Joekes et al. 2009, supra note 3. 44 Ferri et al. (2005), supra note 4 at 10. 45 Strang et al. (2010), supra note 3. 46 Rehm et al. (2001), supra note 6. 47 Haasen et al. (2007), supra note 3. 48 Oviedo-Joekes et al. 2009, supra note 3. 49 Blanken, P., Hendriks, V.M., Koeter, M. et al. (2012). Craving and illicit heroin use among patients in heroin-assisted treatment. Drug Alcohol Depend, 120, 1-3. 50 M., Hendriks, V.M., Van Ree, J.M., van den Brink, J. (2010). Outcome of long-term heroin-assisted treatment offered to chronic, treatment-resistant heroin addicts in the

E8 Netherlands. Addiction, 105(2), 300-308; Eiroa-Orosa, F.J., Haasen, C., Verthein, U. et al. (2010). Benzodiazepine use among patients in heroin-assisted vs. methadone maintenance treatment: Findings of the German randomized controlled trial. Drug Alcohol Depend, 112(3), 226-33; Haasen, C., Eiroa-Orosa, F.J., Verthein, U. et al. (2009). Effects of heroin-assisted treatment on alcohol consumption: findings of the german randomized controlled trial. Alcohol, 43(4), 259-64. 51 Perneger et al. (1998), supra note 3; Rehm et al. (2001), supra note 6. 52 Oviedo-Joekes et al. (2007), supra note 1 at 777. 53 Haasen et al. (2007), supra note 3. 54 Rehm et al. (2001), supra note 6. 55 Id. 56 Strang et al. (2012), supra note 2 at 48-50. 57 Haasen et al. (2007), supra note 3 at 55-62. 58 Rehm et al. (2001), supra note 6. 59 Vertein, U., Bonorden, K., Degkwitz, P., et al. (2008). Long-term effects of heroin-assisted treatment in Germany. Addiction, 103, 960-966. 60 Lansier et al., supra note 29; Miller et al. (2010, 2011), supra note 29. 61 Lansier et al. (2010), supra note 29. 62 Miller et al. (2010, 2011), supra note 29. 63 Killias, M., Aebi, M.F., Jurist, K. (2000). The Impact of Heroin Prescription on Heroin Markets in Switzerland. Crime Prevention Studies, 11. 64 Id. 65 National Institute on Drug Abuse. (2014). Drug Facts, available at http://www.drugabuse.gov/publications/drugfacts/nationwide-trends. 66 National Institute of Drug Abuse. (2014). What is the scope of heroin use in the United States?, available at http://www.drugabuse.gov/publications/research-reports/heroin/scope- heroin-use-in-united-states. 67 Id. 68 Office of National Drug Control Policy, Nevada Drug Control Update, available at https://www.whitehouse.gov/sites/default/files/docs/state_profile_-_nevada.pdf. 69 Heroin use on the rise in Nevada. Kolo8 News Now, available at http://www.kolotv.com/home/headlines/Heroin-Use-on-the-Rise-in-Nevada-243990401.html. 70 Chereb, S. (2014, April 5). Heroin use, deaths, on the rise in Nevada. Reno Gazette- Journal, available at http://www.rgj.com/story/news/crime/2014/04/05/heroin-use-deaths- rise-nevada/7350407/; Kitchen, R. (2014, February 6). Heroin use on the rise in Nevada. Kolo8 News Now, available at http://www.kolotv.com/home/headlines/Heroin-Use-on-the- Rise-in-Nevada-243990401.html; Potter, J. (2012, October 2). Drug abuse turning deadlier in Nevada. 2News, available at http://www.ktvn.com/story/19708773/drug-abuse-turning- deadlier-across-nevada. 71 Centers for Disease Control and Prevention, Number and age-adjusted rates of drug overdose deaths by state, US 2015, available at https://www.cdc.gov/drugoverdose/data/statedeaths.html. 72 Office of Public Health Informatics and Epidemiology and Office of Vital Records of the Division of Public and Behavioral Health, Heroin and Opioid Related Mortality 2008-2012, available at http://health.nv.gov/PUBLICATIONS/2008- 2012_Heroin_and_Opioid_Related_Mortality_Fast_Facts_e_1.0_2014-03-06.pdf.

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