{"id":10327,"date":"2025-03-01T14:07:38","date_gmt":"2025-03-01T19:07:38","guid":{"rendered":"https:\/\/www-test.dhss.delaware.gov\/dph\/dhan353\/"},"modified":"2025-03-02T00:52:54","modified_gmt":"2025-03-02T05:52:54","slug":"dhan353","status":"publish","type":"page","link":"https:\/\/www-test.dhss.delaware.gov\/dph\/php\/alerts\/dhan353\/","title":{"rendered":"php\/alerts\/dhan353 ~  Division of Public Health &#8212; Health Alert  &#8211; Delaware Health and Social Services &#8211; State of Delaware"},"content":{"rendered":"<div data-swiftype-index=\"true\">\n\n\n\n  <br>\n\n\n\n  <div class=\"container\" id=\"main_header\"> \n\n    <!-- BEGIN readspeaker div -->\n\n    <div class=\"rs_skip rsbtn rs_preserve\" id=\"readspeaker_button1\">\n\n      <a accesskey=\"L\" class=\"rsbtn_play\" href=\"https:\/\/app-na.readspeaker.com\/cgi-bin\/rsent?customerid=7262&#038;lang=en_us&#038;readid=main_content&#038;url=https:\/\/dhss.delaware.gov\/dph\/php\/alerts\/dhan353.html\" title=\"Listen to this page using ReadSpeaker\">\n\n        <span class=\"rsbtn_left rsimg rspart\"><span class=\"rsbtn_text\"><span>Listen<\/span><\/span><\/span>\n\n        <span class=\"rsbtn_right rsimg rsplay rspart\"><\/span>\n\n      <\/a>\n\n    <\/div>\n\n    <!-- END readspeaker div -->\n\n\n\n    \n\n    <header class=\"pull-left\">\n\n      <h1>Delaware Health Alert Network #<!--[type=EDIT name=\"DHAN Number\"]-->353 <!--[END]--> <\/h1>\n\n      <h2> <!--[type=EDIT name=\"DHAN Date\"]-->October 25, 2015 4:00 pm <!--[END]--> <\/h2>\n\n    <\/header>\n\n  <\/div><br>\n\n \n\n  <div class=\"container\">\n\n    <div class=\"row\">\n\n      <div class=\"col-md-3\" id=\"leftCol\">\n\n        <div class=\"panel-group\" id=\"accordion\">\n\n          <div class=\"panel sectionmenu_panel\">\n\n            <div class=\"panel-heading\">\n\n              <p class=\"panel-title\"><a class=\"agency_nav\" data-parent=\"#accordion\" data-toggle=\"collapse\" href=\"#collapseOne\"><strong><i class=\"fa fa-align-justify fa-fw\"><\/i> Public Health Menu<\/strong><\/a><\/p>\n\n            <\/div>\n\n\n\n            <div class=\"panel-collapse collapse in\" id=\"collapseOne\">\n\n              <div class=\"panel-body\" id=\"clf_nav\">\n\n                  <ul class=\"nav nav-stacked nav-pills-clf\" id=\"agency_sidebar\">\n    <li><a href=\"\/dph\/\"><h2>Home <i class=\"fa fa-home fa-fw\"><\/i><\/h2><\/a><\/li>\n    <li class=\"toplevel\"><a data-parent=\"#agency_sidebar\" data-toggle=\"collapse\" href=\"#HomeMenu\"><h2>About <i class=\"fa fa-caret-right fa-fw\"><\/i><\/h2><\/a>\n      <ul class=\"panel-collapse collapse\" id=\"HomeMenu\">\n        <li><a href=\"\/dph\/about.html\">About DPH<\/a><\/li>\n        <li><a href=\"\/dph\/sections.html\">Sections &#038; 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While\n\n\n  NPF-related overdoses can be reversed with naloxone, a higher dose or multiple number of doses per overdose event may be required to\n\n\n  revive a patient due to the high potency of NPF.[iii],[iv]\n\n\n<\/p>\n\n\n<p>\n\n\n  In March 2015, DEA issued a nationwide alert identifying fentanyl as a threat to public health and safety.[v] This was followed by a DEA\n\n\n  National Heroin Threat Assessment Summary, which noted that \u201cbeginning in late 2013 and throughout 2014, several states have\n\n\n  reported spikes in overdose deaths due to fentanyl and its analog acetyl-fentanyl.\u201d[vi] Similar to previous fentanyl overdose\n\n\n  outbreaks, most of the more than 700 fentanyl-related overdose deaths reported to DEA during this timeframe were attributable to\n\n\n  illicitly-manufactured fentanyl\u2014not diverted pharmaceutical fentanyl\u2014and either mixed with heroin or other diluents and sold\n\n\n  as a highly potent form (sometimes under the street name \u201cChina White\u201d). The DEA report noted that the \u201ctrue number is\n\n\n  most likely higher because \u201cmany coroners\u2019 offices and state crime laboratories do not test for fentanyl or its analogs\n\n\n  unless given a specific reason to do so.\u201d<sup>6<\/sup>\n\n\n<\/p>\n\n\n<p>\n\n\n  Reports on state drug seizures (or confiscations) from the National Forensic Laboratory Information System (NFLIS), a program of the\n\n\n  DEA\u2019s Office of Diversion Control, indicate a significant increase in the total number of fentanyl drug seizures reported by\n\n\n  forensic laboratories around the country from 2012 to 2014 (618 in 2012; 945 in 2013; 4,585 in 2014).[vii] More than 80% of drug seizures\n\n\n  in 2014 were concentrated in 10 states (see link to official CDC alert for listing of states). The number of states reporting 20 or more\n\n\n  fentanyl seizures every six months is increasing. From July to December 2014, 18 states reported 20 or more fentanyl drug seizures (see\n\n\n  link to official CDC alert for map showing states impacted). Previously, six states reported 20 or more fentanyl drug seizures from July\n\n\n  to December 2013.\n\n\n<\/p>\n\n\n<p>\n\n\n  These increases raise serious concerns for public health if fentanyl seizures serve as a proxy for increased overdose risk.\u00a0 Recent\n\n\n  fentanyl-related fatal overdose data from several of the top 10 states with highest seizure counts suggest fatalities have increased in\n\n\n  states reporting large increases in fentanyl seizures.\u00a0 Two of the top-five states, Ohio and Maryland, both reported sharp increases\n\n\n  in fentanyl-related deaths in 2014\u2014Ohio reported 514 fentanyl-related fatal overdoses in 2014 compared to 92 in 2013,[viii] and\n\n\n  Maryland reported 185 fentanyl-related fatal overdoses in 2014 compared to 58 in 2013[ix] Massachusetts, another top-five state, is\n\n\n  currently investigating whether an abnormally sharp increase in opioid-related deaths in 2014 is attributable to fentanyl.[x] Florida,\n\n\n  another state reporting increases in fentanyl-related drug seizures, recently reported 397 fatal overdoses attributable to fentanyl in\n\n\n  2014, up from 185 in 2013[xi].\n\n\n<\/p>\n\n\n<p>\n\n\n  Fentanyl poses a significant danger to public health workers, first responders, and law enforcement personnel that may unwittingly come\n\n\n  into contact with it either by absorbing through the skin or accidental inhalation of airborne powder.\u00a0 In August 2015, New Jersey\n\n\n  law enforcement officers conducting a narcotics field test on an illicit substance experienced shortness of breath, dizziness, and\n\n\n  respiratory distress after coming into contact with an unknown substance, which forensic laboratory testing determined to be a mix of\n\n\n  cocaine, heroin, and fentanyl.\n\n\n<\/p>\n\n\n<h3>\n\n\n  Recommendations\n\n\n<\/h3>\n\n\n<p>\n\n\n  CDC suggests the following actions in response to increases in fentanyl-related overdose deaths:\n\n\n<\/p>\n\n\n<ul>\n\n\n  <li>\n\n\n    <strong>Improve detection of fentanyl outbreaks<\/strong> to facilitate effective response.\n\n\n    <ul>\n\n\n      <li>\n\n\n        <em>Public health departments<\/em>: Explore methods for more rapidly detecting drug overdose outbreaks, including fentanyl.[xii]\n\n\n        <ul>\n\n\n          <li>Use existing surveillance systems such as medical examiner data, emergency medical services data or near real-time emergency\n\n\n          department data\n\n\n          <\/li>\n\n\n          <li>In outbreak situations of dramatically increased opioid overdose, at sentinel sites, or in jurisdictions with high drug\n\n\n          overdose burden, consider asking emergency departments to report fatal and nonfatal opioid overdose cases to them within 48\n\n\n          hours.[xiii] This may be a resource-intensive approach.\n\n\n          <\/li>\n\n\n          <li>Consider engaging local poison centers to assist with tracking and treatment of patients.\n\n\n          <\/li>\n\n\n          <li>Review data on drug seizures involving fentanyl or acetyl-fentanyl within the jurisdiction such as those published by\n\n\n          National Forensic Laboratory Information System (NFLIS) to stay abreast of geographic changes in supply (see <a href=\"http:\/\/www.deadiversion.usdoj.gov\/nflis\/spec_rpt_opioids_2014.pdf\">NFLIS Report<\/a> or (<a href=\"http:\/\/www.deadiversion.usdoj.gov\/nflis\/spec_rpt_opioids_2014.pdf\">http:\/\/www.deadiversion.usdoj.gov\/nflis\/spec_rpt_opioids_2014.pdf<\/a>).\n\n\n          <\/li>\n\n\n          <li>Identify and track decedent demographics and risk factors (e.g., drug type and route of administration) along with geographic\n\n\n          concentrations of cases to better inform public health surveillance and overdose prevention efforts.[xiv]\n\n\n          <\/li>\n\n\n        <\/ul>\n\n\n      <\/li>\n\n\n      <li>\n\n\n        <em>Medical examiners and coroners:<\/em> Screen for fentanyl in suspected opioid overdose cases in regions reporting increases in\n\n\n        fentanyl seizures, fentanyl-related overdose fatalities or unusually high spikes in heroin or unspecified drug overdose fatalities.\n\n\n        Not all jurisdictions routinely test for fentanyl.\n\n\n        <ul>\n\n\n          <li>Screen specimens from fatal drug overdose deaths using an enzyme-linked immunosorbent assay (ELISA test) with the capacity to\n\n\n          detect fentanyl. If an ELISA test is positive for fentanyl, conduct confirmatory testing by gas chromatography\/mass spectrometry\n\n\n          (GC\/MS). If no fentanyl is detected by GC\/MS, then fentanyl analogs should be suspected and subsequent testing considered.[xv]\n\n\n          <\/li>\n\n\n          <li>Implement standardized mechanisms for determining cause of death and methods of reporting to ensure death reports are\n\n\n          complete and accurate.[xvi] SAMHSA has published consensus recommendations for uniform standards and case definitions for\n\n\n          classifying opioid-related deaths (See <a href=\"http:\/\/www.tandfonline.com\/doi\/pdf\/10.1080\/10550887.2013.824334\">Consensus\n\n\n          Recommendations<\/a> or <a href=\"http:\/\/www.tandfonline.com\/doi\/pdf\/10.1080\/10550887.2013.824334\">http:\/\/www.tandfonline.com\/doi\/pdf\/10.1080\/10550887.2013.824334<\/a>).\n\n\n          It is especially important to include the word \u201cfentanyl\u201d on the death certificate when the drug is a contributing\n\n\n          cause of death.\n\n\n          <\/li>\n\n\n        <\/ul>\n\n\n      <\/li>\n\n\n      <li>\n\n\n        <em>Law enforcement:<\/em> Law enforcement can play an important role identifying and responding to increases in the distribution\n\n\n        and use of illicitly manufactured fentanyl.\n\n\n        <ul>\n\n\n          <li>Investigating officers are advised to consider the potential exposure to fentanyl through skin exposure and\/or inhalation of\n\n\n          aerosolized drug, and utilize appropriate safety precautions and personal protective equipment[xvii].\n\n\n          <\/li>\n\n\n          <li>Test drug samples seized or collected by law enforcement or found at the scene of death to detect fentanyl or fentanyl\n\n\n          analogs.[xviii]\n\n\n          <\/li>\n\n\n          <li>Prioritize and expedite testing of drug samples taken from drug overdose scenes, if possible.\n\n\n          <\/li>\n\n\n          <li>Share data on fentanyl and acetyl-fentanyl drug seizures with local health departments, coroners, and medical examiners.\n\n\n          <\/li>\n\n\n        <\/ul>\n\n\n      <\/li>\n\n\n    <\/ul>\n\n\n  <\/li>\n\n\n  <li>\n\n\n    <strong>Expand Use of Naloxone:<\/strong> Naloxone is a safe and effective antidote to all opioid-related overdoses, including heroin\n\n\n    and fentanyl, and is a critical tool in preventing fatal opioid overdoses.[xix]<sup>,[xx]<\/sup> Depending on state and local laws, this\n\n\n    medication can potentially be administered effectively by EMS, law enforcement[xxi], people at high risk for overdose[xxii], or family\n\n\n    and friend bystanders who have obtained the medication[xxiii],\n\n\n    <ul>\n\n\n      <li>\n\n\n        <em>Health Care Providers<\/em>: Multiple doses of naloxone may need to be administered per overdose event because of\n\n\n        fentanyl\u2019s increased potency relative to other opioids.<sup>3<\/sup>\n\n\n        <ul>\n\n\n          <li>Increase the amount of naloxone on hand for first responders such as law enforcement and other EMS personnel given the\n\n\n          increased amount needed and rate of use during a fentanyl outbreak<sup>4<\/sup>\n\n\n          <\/li>\n\n\n          <li>Recognize and treat opioid overdose patients, with particular focus on how to respond to fentanyl and acetyl fentanyl\n\n\n          overdose.<sup>4<\/sup>\n\n\n          <\/li>\n\n\n        <\/ul>\n\n\n      <\/li>\n\n\n      <li>\n\n\n        <em>Harm reduction organizations:<\/em> Expand naloxone access to persons at risk for opioid-related overdose and their family\n\n\n        members.[xxiv]\n\n\n        <ul>\n\n\n          <li>Provide take-home naloxone kits and encourage people who use heroin and\/or misuse opioid analgesics\u2014or know people that\n\n\n          do\u2014to carry them.\n\n\n          <\/li>\n\n\n          <li>Train those using drugs how to effectively administer naloxone and emphasize the importance of overdose prevention tactics,\n\n\n          such as rescue breathing and calling 911.\n\n\n          <\/li>\n\n\n        <\/ul>\n\n\n      <\/li>\n\n\n    <\/ul>\n\n\n  <\/li>\n\n\n<\/ul>\n\n\n<h4>\n\n\n  For more information\n\n\n<\/h4>\n\n\n<ul>\n\n\n  <li>CDC Health alert 10\/26\/2015 (full document) <a href=\"http:\/\/emergency.cdc.gov\/han\/han00384.asp\">http:\/\/emergency.cdc.gov\/han\/han00384.asp<\/a>\n\n\n  <\/li>\n\n\n  <li>\n\n\n    <em>CDC Health Advisory: Recommendations for Laboratory Testing for Acetyl Fentanyl and Patient Evaluation and Treatment for Overdose\n\n\n    with Synthetic Opioid<\/em> at <a href=\"http:\/\/emergency.cdc.gov\/han\/han00350.asp\">http:\/\/emergency.cdc.gov\/han\/han00350.asp<\/a>\n\n\n  <\/li>\n\n\n  <li>DEA Issues Nationwide Alter on Fentanyl as Threat to Health and Public Safety at <a href=\"http:\/\/www.dea.gov\/divisions\/hq\/2015\/hq031815.shtml\">http:\/\/www.dea.gov\/divisions\/hq\/2015\/hq031815.shtml<\/a>\n\n\n  <\/li>\n\n\n  <li>\n\n\n    <em>Fentanyl SAMHSA letter to physicians<\/em> and fact sheet at: <a href=\"http:\/\/buprenorphine.samhsa.gov\/20130715114030811.pdf\">http:\/\/buprenorphine.samhsa.gov\/20130715114030811.pdf<\/a>\u00a0\n\n\n  <\/li>\n\n\n  <li>\n\n\n    <em>Special Report: Opiates and Related Drugs Reported in NFLIS, 2009-2014<\/em> at <a href=\"http:\/\/www.deadiversion.usdoj.gov\/nflis\/spec_rpt_opioids_2014.pdf\">http:\/\/www.deadiversion.usdoj.gov\/nflis\/spec_rpt_opioids_2014.pdf<\/a>\n\n\n  <\/li>\n\n\n  <li>\n\n\n    <em>SAMHSA Opioid Overdose Toolkit<\/em> at: <a href=\"http:\/\/store.samhsa.gov\/shin\/content\/SMA13-4742\/Overdose_Toolkit_2014_Jan.pdf\">http:\/\/store.samhsa.gov\/shin\/content\/SMA13-4742\/Overdose_Toolkit_2014_Jan.pdf<\/a>\n\n\n  <\/li>\n\n\n  <li>Call Poison Control at 1-800-222-1222 or use the\u00a0<a href=\"http:\/\/triage.webpoisoncontrol.org\/\" target=\"_blank\">web<strong>POISON<\/strong>CONTROL\u00ae<\/a>\u00a0online tool for guidance\n\n\n  <\/li>\n\n\n<\/ul>\n\n\n<p>\n\n\n  [i] Algren D, Monteilh C, Rubin C, et al. Fentanyl-associated fatalities among illicit drug users in Wayne County, Michigan (July\n\n\n  2005-May 2006). Journal Of Medical Toxicology: Official Journal of the American College Of Medical Toxicology [serial online]. March\n\n\n  2013; 9(1):106-115.\n\n\n<\/p>\n\n\n<p>\n\n\n  [ii] U. S. Department of Justice, Drug Enforcement Administration, DEA Investigative Reporting, January 2015\n\n\n<\/p>\n\n\n<p>\n\n\n  [iii] Centers for Disease Control and Prevention. Notes from the field: Acetyl fentanyl overdose fatalities &#8211; Rhode Island, March-May\n\n\n  2013. MMWR: Morbidity &#038; Mortality Weekly Report [serial online]. August 30, 2013; 62(34):703-704. <a href=\"http:\/\/www.cdc.gov\/mmwr\/preview\/mmwrhtml\/mm6234a5.htm\">http:\/\/www.cdc.gov\/mmwr\/preview\/mmwrhtml\/mm6234a5.htm<\/a>\n\n\n<\/p>\n\n\n<p>\n\n\n  [iv] Centers for Disease Control and Prevention. Recommendations for Laboratory testing for Acetyl Fentanyl and Patient Evaluation and\n\n\n  Treatment for Overdose for Synthetic Opioids. HAN Health Advisory. June 20, 2013. <a href=\"http:\/\/stacks.cdc.gov\/view\/cdc\/25259\">http:\/\/stacks.cdc.gov\/view\/cdc\/25259<\/a>\n\n\n<\/p>\n\n\n<p>\n\n\n  <a class=\"anchors_link\" href=\"http:\/\/cms-internet.dhss.state.de.us\/dph\/php\/alerts\/#_ednref5\">[v]<\/a> DEA Issues Nationwide Alert on\n\n\n  Fentanyl as Threat to Health and Public Safety. March 8, 2015. <a href=\"http:\/\/www.dea.gov\/divisions\/hq\/2015\/hq031815.shtml\">http:\/\/www.dea.gov\/divisions\/hq\/2015\/hq031815.shtml<\/a>\n\n\n<\/p>\n\n\n<p>\n\n\n  <a class=\"anchors_link\" href=\"http:\/\/cms-internet.dhss.state.de.us\/dph\/php\/alerts\/#_ednref6\">[vi]<\/a> National Heroin Threat\n\n\n  Assessment Summary. DEA Intelligence Report. April 2015. <a href=\"http:\/\/www.dea.gov\/divisions\/hq\/2015\/hq052215_National_Heroin_Threat_Assessment_Summary.pdf\">http:\/\/www.dea.gov\/divisions\/hq\/2015\/hq052215_National_Heroin_Threat_Assessment_Summary.pdf<\/a>\n\n\n<\/p>\n\n\n<p>\n\n\n  [vii] Drug Enforcement Administration (DEA). Unpublished Data provided to CDC\n\n\n<\/p>\n\n\n<p>\n\n\n  [viii]<a href=\"http:\/\/www.healthy.ohio.gov\/~\/media\/HealthyOhio\/ASSETS\/Files\/injury%20prevention\/2014%20Ohio%20Preliminary%20Overdose%20Report.pdf\">http:\/\/www.healthy.ohio.gov\/~\/media\/HealthyOhio\/ASSETS\/Files\/injury%20prevention\/2014%20Ohio%20Preliminary%20Overdose%20Report.pdf<\/a>\n\n\n<\/p>\n\n\n<p>\n\n\n  [ix] Maryland Department of Health. (2014). Drug and Alcohol Related Intoxication Deaths in Maryland, 2014 <a href=\"http:\/\/bha.dhmh.maryland.gov\/OVERDOSE_PREVENTION\/Documents\/2015.05.19%20-%20Annual%20OD%20Report%202014_merged%20file%20final.pdf\">http:\/\/bha.dhmh.maryland.gov\/OVERDOSE_PREVENTION\/Documents\/2015.05.19%20-%20Annual%20OD%20Report%202014_merged%20file%20final.pdf<\/a>\n\n\n<\/p>\n\n\n<p>\n\n\n  [x] Personal communication between CDC and Massachusetts Department of Public Health\n\n\n<\/p>\n\n\n<p>\n\n\n  [xi]<a href=\"https:\/\/www.fdle.state.fl.us\/Content\/Medical-Examiners-Commission\/MEC-Publications-and-Forms\/Documents\/2014-Annual-Drug-Report-FINAL.aspx\">https:\/\/www.fdle.state.fl.us\/Content\/Medical-Examiners-Commission\/MEC-Publications-and-Forms\/Documents\/2014-Annual-Drug-Report-FINAL.aspx<\/a>\n\n\n<\/p>\n\n\n<p>\n\n\n  [xii] Centers for Disease Control and Prevention. Nonpharmaceutical fentanyl-related deaths&#8211;multiple states, April 2005-March 2007.\n\n\n  MMWR: Morbidity &#038; Mortality Weekly Report [serial online]. July 25, 2008; 57(29):793-796. <a href=\"http:\/\/www.cdc.gov\/mmwr\/preview\/mmwrhtml\/mm5729a1.htm\">http:\/\/www.cdc.gov\/mmwr\/preview\/mmwrhtml\/mm5729a1.htm<\/a>\n\n\n<\/p>\n\n\n<p>\n\n\n  [xiii] Mercado-Crespo M, Sumner S, Spelke M, Sugerman D, Stanley C. Notes from the field: Increase in fentanyl-related overdose deaths &#8211;\n\n\n  Rhode Island, November 2013-March 2014. MMWR: Morbidity &#038; Mortality Weekly Report [serial online]. June 20, 2014; 63(24):531.\n\n\n  <a href=\"http:\/\/www.cdc.gov\/mmwr\/preview\/mmwrhtml\/mm6324a3.htm\">http:\/\/www.cdc.gov\/mmwr\/preview\/mmwrhtml\/mm6324a3.htm<\/a>\n\n\n<\/p>\n\n\n<p>\n\n\n  [xiv] Levy B. Undetermined risk factors associated with drug overdose deaths, New Mexico \u2013 New Mexico, Feb.2014 (Epi-Aid 2012-022).\n\n\n<\/p>\n\n\n<p>\n\n\n  [xv] Centers for Disease Control and Prevention. Notes from the field: Acetyl fentanyl overdose fatalities &#8211; Rhode Island, March-May\n\n\n  2013. MMWR: Morbidity &#038; Mortality Weekly Report [serial online]. August 30, 2013; 62(34):703-704. <a href=\"http:\/\/www.cdc.gov\/mmwr\/preview\/mmwrhtml\/mm6234a5.htm\">http:\/\/www.cdc.gov\/mmwr\/preview\/mmwrhtml\/mm6234a5.htm<\/a>\n\n\n<\/p>\n\n\n<p>\n\n\n  [xvi] Centers for Disease Control and Prevention. Nonpharmaceutical fentanyl-related deaths&#8211;multiple states, April 2005-March 2007.\n\n\n  MMWR: Morbidity &#038; Mortality Weekly Report [serial online]. July 25, 2008; 57(29):793-796. <a href=\"http:\/\/www.cdc.gov\/mmwr\/preview\/mmwrhtml\/mm5729a1.htm\">http:\/\/www.cdc.gov\/mmwr\/preview\/mmwrhtml\/mm5729a1.htm<\/a>\n\n\n<\/p>\n\n\n<p>\n\n\n  [xvii]<a href=\"http:\/\/www.cdc.gov\/niosh\/ershdb\/emergencyresponsecard_29750022.html\">http:\/\/www.cdc.gov\/niosh\/ershdb\/emergencyresponsecard_29750022.html<\/a>\n\n\n<\/p>\n\n\n<p>\n\n\n  [xviii] US Department of Justice, Drug Enforcement Administration. 21 CFR part 1310. Control of a chemical precursor used in the illicit\n\n\n  manufacture of fentanyl as a list 1 chemical. Federal Register 2007; 72:20039&#8211;47. Available at <a href=\"http:\/\/frwebgate.access.gpo.gov\/cgi-bin\/getpage.cgi?dbname=2007_register&#038;position=all&#038;page=20039\">http:\/\/frwebgate.access.gpo.gov\/cgi-bin\/getpage.cgi?dbname=2007_register&#038;position=all&#038;page=20039<\/a>.\n\n\n<\/p>\n\n\n<p>\n\n\n  [xix] U.S. Department of Health and Human S. Opioid Abuse in the United States and Department of Health and Human Services Actions to\n\n\n  Address Opioid-Drug-Related Overdoses and Deaths. Journal of Pain &#038; Palliative Care Pharmacotherapy [serial online]. June 2015;\n\n\n  29(2):133-139. <a href=\"http:\/\/aspe.hhs.gov\/sp\/reports\/2015\/OpioidInitiative\/ib_OpioidInitiative.pdf\">http:\/\/aspe.hhs.gov\/sp\/reports\/2015\/OpioidInitiative\/ib_OpioidInitiative.pdf<\/a>\n\n\n<\/p>\n\n\n<p>\n\n\n  [xx] SAMHSA opioid overdose toolkit. <a href=\"https:\/\/store.samhsa.gov\/shin\/content\/SMA13-4742\/Overdose_Toolkit_2014_Jan.pdf\">https:\/\/store.samhsa.gov\/shin\/content\/SMA13-4742\/Overdose_Toolkit_2014_Jan.pdf<\/a>\n\n\n<\/p>\n\n\n<p>\n\n\n  [xxi] Davis C, Carr D, Southwell J, Beletsky L. Engaging law enforcement in overdose reversal initiatives: Authorization and liability\n\n\n  for naloxone administration. American Journal of Public Health [serial online]. June 11, 2015. <a href=\"http:\/\/ajph.aphapublications.org\/doi\/abs\/10.2105\/AJPH.2015.302638?url_ver=Z39.88-2003&#038;rfr_id=ori%3Arid%3Acrossref.org&#038;rfr_dat=cr_pub%3Dpubmed\">\n\n\n  http:\/\/ajph.aphapublications.org\/doi\/abs\/10.2105\/AJPH.2015.302638?url_ver=Z39.88-2003&#038;rfr_id=ori%3Arid%3Acrossref.org&#038;rfr_dat=cr_pub%3Dpubmed<\/a>\n\n\n<\/p>\n\n\n<p>\n\n\n  [xxii] Coffin P, Sullivan S. Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal. Ann Intern Med.\n\n\n  2013:158:1-9 &#038; Walley A, Xuan Z, Hackman H, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone\n\n\n  distribution in Massachusetts: interrupted time series analysis. BMJ 2013:346: 1-12. <a href=\"http:\/\/www.bmj.com\/content\/346\/bmj.f174.long\">http:\/\/www.bmj.com\/content\/346\/bmj.f174.long<\/a>.\n\n\n<\/p>\n\n\n<p>\n\n\n  [xxiii]Wheeler E, Jones T, Gilbert M, et al. Opioid overdose prevention programs providing naloxone to laypersons \u2013 United States,\n\n\n  2014.MMWR: Morbidity &#038; Mortality Weekly Report [serial online]. June 19, 2015; 64(23):631-635. <a href=\"http:\/\/www.cdc.gov\/mmwr\/preview\/mmwrhtml\/mm6324a3.htm\">http:\/\/www.cdc.gov\/mmwr\/preview\/mmwrhtml\/mm6324a3.htm<\/a>\n\n\n<\/p>\n\n\n<p>\n\n\n  [xxiv] Centers for Disease Control and Prevention. <a href=\"http:\/\/www.cdc.gov\/mmwr\/preview\/mmwrhtml\/mm6426a3.htm?s_cid=mm6426a3_w\">Vital\n\n\n  Signs: Demographic and Substance Use Trends Among Heroin Users \u2014 United States, 2002\u20132013<\/a>. MMWR 2015; 64(26);719-725.\n\n\n<\/p>\n\n\n<p>\n\n\n  ************************************\n\n\n<\/p>\n\n\n<p>\n\n\n  You are receiving this email because you are a registered member of the Delaware Health Alert Network. If you are not a member and would\n\n\n  like to subscribe, please register at <a href=\"https:\/\/healthalertde.org\">https:\/\/healthalertde.org<\/a>\n\n\n<\/p><br>\n\n\n<br>\n\n\n<p class=\"smalltext\"><a href=\"http:\/\/www.adobe.com\/products\/acrobat\/readstep2.html\"><img loading=\"lazy\" decoding=\"async\" alt=\"Download Adobe Acrobat Reader\" height=\"21\" src=\"\/wp-content\/uploads\/dhss\/img\/getacro60.gif\" width=\"60\"><\/a> Please note: Some of the files available on this page are in Adobe PDF format which requires Adobe Acrobat Reader.  A free copy of Adobe Acrobat Reader can be downloaded directly from <a href=\"http:\/\/www.adobe.com\/products\/acrobat\/readstep2.html\">Adobe <\/a>. If you are using an assistive technology unable to read Adobe PDF, please either view the corresponding text only version (if available) or visit Adobe&#8217;s <a href=\"http:\/\/access.adobe.com\">Accessibility Tools page<\/a>.<\/p>\n\n\n\n<!--[END]-->\n\n  \n\n        <div class=\"panel panel-danger\">\n\n          <div class=\"panel-heading\">    \n\n      <h2>Categories of Health Alert messages:<\/h2>\n\n       <\/div>\n\n       <div class=\"panel-body\">\n\n      <ul>\n\n        <li><strong>Health Alert:<\/strong> Conveys the highest level of importance; warrants immediate action or attention.<\/li>\n\n        <li><strong>Health Advisory:<\/strong> Provides important information for a specific incident or situation; may not require immediate action.<\/li>\n\n        <li><strong>Health Update:<\/strong> Provides updated information regarding an incident or situation; unlikely to require immediate action.<\/li>\n\n            <\/ul>\n\n         <div><strong>NOTE: This page is for informational purposes only and dated material (e.g. temporary websites) may not be available.<\/strong><\/div>\n\n          <\/div> \n\n        <\/div><br>  \n\n\n\n      <\/div>\n\n    <\/div>\n\n  <\/div><!-- \/container -->\n\n  <\/div>","protected":false},"excerpt":{"rendered":"<p>Listen Delaware Health Alert Network #353 October 25, 2015 4:00 pm Public Health Menu Home About About DPH Sections &#038; Programs Office Locations Contact Info Calendar Services A-Z Services Air &#038; Water Quality Birth, Death, &#038; Marriage Records Clinics Health Data &#038; Statistics Emergency Preparedness Health &#038; Wellness Healthy Homes Healthy Workplaces Laboratory Restaurant Inspections [&hellip;]<\/p>\n","protected":false},"author":8,"featured_media":0,"parent":9294,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"inline_featured_image":false,"footnotes":""},"class_list":["post-10327","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/www-test.dhss.delaware.gov\/dph\/wp-json\/wp\/v2\/pages\/10327","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www-test.dhss.delaware.gov\/dph\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www-test.dhss.delaware.gov\/dph\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www-test.dhss.delaware.gov\/dph\/wp-json\/wp\/v2\/users\/8"}],"replies":[{"embeddable":true,"href":"https:\/\/www-test.dhss.delaware.gov\/dph\/wp-json\/wp\/v2\/comments?post=10327"}],"version-history":[{"count":1,"href":"https:\/\/www-test.dhss.delaware.gov\/dph\/wp-json\/wp\/v2\/pages\/10327\/revisions"}],"predecessor-version":[{"id":11503,"href":"https:\/\/www-test.dhss.delaware.gov\/dph\/wp-json\/wp\/v2\/pages\/10327\/revisions\/11503"}],"up":[{"embeddable":true,"href":"https:\/\/www-test.dhss.delaware.gov\/dph\/wp-json\/wp\/v2\/pages\/9294"}],"wp:attachment":[{"href":"https:\/\/www-test.dhss.delaware.gov\/dph\/wp-json\/wp\/v2\/media?parent=10327"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}