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    CHRONIC PAIN PATIENTS DID NOT CAUSE THE OPIOID CRISIS.

    It seems Australia has not learnt from the dire situation in America, whereby prescriptions to patients for legitimate opioids have DROPPED 60% in the last 10yrs, yet overdoses have DOUBLED in that same timeframe! In fact, reputable studies indicate where there is “No previous or current history of abuse/addiction, the percentage of abuse/addiction [in chronic pain patients] was calculated at 0.19%."

    Cracking down on legally issued prescriptions [as part of the failed War Against Drugs], in no way is a good outcome for those who have responsibly used their opioids for years, i.e. a cohort of people who are NOT addicted to their life-saving medications, & who ONLY use their legally prescribed pain relief as required!

    www.linkedin.com/posts/kevin-james-971278190_opioidcrisis-op...

    #opioidcrisis #OpioidEpidemic #opioidrestrictions #OpioidAddiction #OpioidUseDisorder #prescriptionopioids #opioidmedications #illicitdrugs #fentanyl #Addiction #Dependence #policymakers #StopTheStigma #ChronicPain #Chronicpainwarrior #chronicpainmanagement #overdoses

    4 people are talking about this
    Community Voices

    CHRONIC PAIN PATIENTS DID NOT CAUSE THE OIPIOID EPIDEMIC.

    It seems Australia has not learnt from the dire situation in America, whereby prescriptions to patients for legitimate opioids have DROPPED 60% in the last 10yrs, yet overdoses have DOUBLED in that same timeframe! In fact, reputable studies indicate where there is “No previous or current history of abuse/addiction, the percentage of abuse/addiction [in chronic pain patients] was calculated at 0.19%."

    Cracking down on legally issued prescriptions [as part of the failed War Against Drugs], in no way is a good outcome for those who have responsibly used their opioids for years, i.e. a cohort of people who are NOT addicted to their life-saving medications, & who ONLY use their legally prescribed pain relief as required!

    www.linkedin.com/posts/kevin-james-971278190_opioidcrisis-op...

    #opioidcrisis #OpioidEpidemic #opioidrestrictions #OpioidAddiction #OpioidUseDisorder #prescriptionopioids #opioidmedications #illicitdrugs #fentanyl #Addiction #Dependence #policymakers #StopTheStigma #ChronicPain #Chronicpainwarrior #chronicpainmanagement #overdoses

    Community Voices
    Dez Nelson
    Dez Nelson @naac_hq
    contributor

    CDC Guidelines Are Harming Pain Patients Amid National Opioid Crisis

    The National Academies released a new consensus report on December 19, 2019, and the Federal Drug Administration (FDA) released an announcement the same day communicating their intention to “develop the evidence” for a new practice guideline for the treatment of acute pain. This announcement comes on the heels of an ongoing public health disaster that the Centers for Disease Control & Prevention (CDC) caused by implementing recommendations from the National Academy of Medicine and ignoring dissenting specialists in the field, and that the Drug Enforcement Agency (DEA) has perpetuated via SWAT-style raids on doctor’s offices across the country. The National Academies There are three bodies under the National Academies: The National Academy of Engineering (NAE) The National Academy of Sciences (NAS) The National Academy of Medicine (NAM) All of these bodies are non-governmental organizations (NGOs) and they’re responsible for providing advice to the federal government in regard to science and technology, among other important topics. It may be of import to note that the National Academies were exempted from the bulk of the Federal Advisory Committee Act of 1972 (FACA). They say, to ensure their autonomy. The Federal Advisory Committee Act FACA is an important piece of legislation that governs how advisory committees operate. The purpose of the legislation was to provide transparency in federal rule-making based on advisory committees’ recommendations. In 1997, amendments were passed to the law, which exempted the National Academies from many of FACA’s requirements. The Recommendations and the Public Relations Campaign That Shaped a National Crisis The Institute of Medicine (IOM) (which was recently renamed to the National Academy of Medicine or NAM) released a torrent of studies in the early 2010s with recommendations to public health agencies to undertake a couple of massive public health projects, including the development of the National Pain Strategy (NPS) and the CDC Guideline. The National Pain Strategy & The CDC Guideline To ensure that a federal pain strategy was implemented nationwide, the NAM released the report Relieving Pain in America (2011) and its recommendations are the foundation of the NPS. The report Living Well with Chronic Illness (2012), on the other hand, was largely the catalyst to the controversial CDC Guideline, which was based on recommendations the IOM made in this subsequent report. The CDC Guideline is the tool necessary to make the provisions of the NPS a national reality. It’s important to note here that there was no “opioid crisis” at the time the National Pain Strategy was commissioned (the CDC Guideline included). In fact, a curious statement can be found in some of the first pages of the NPS: “The actions in this strategy would be undertaken in the context of the dual crises of pain and opioid dependence, overdose, and death in the United States.” The so-called “opioid crisis” was not even a blip on the radar when the NPS or CDC Guideline were commissioned: As you can see, it wasn’t until 2011 that rumblings about drug overdoses and an “addiction epidemic” can be seen spiking ever so slightly in a quiet echo through the news cycle. You can see in the trend graphic that there was no known crisis (of pain and opioid dependence, overdose and death in the United States) until federal agencies in partnership with certain NGOs — such as the IOM and Physicians for Responsible Opioid Prescribing (PROP) — began getting heavily involved in attempting to create these massive public health initiatives. Fast forward barely a couple of years, and the CDC begins spending an undisclosed amount of taxpayer money on a public relations campaign for their guideline that was published on March 15, 2016, despite a cacophony of dissent. Interestingly, the NPS was also released in March 2016, only days after the CDC guideline. Similarly, in the same period, we can see a significant increase in how often the terms “drug overdose,” “opioid crisis,” “addiction epidemic” and “opioid epidemic” are referred to in the press. Taxpayer money shouldn’t be used for coordinated PR campaigns to convince us that an unpopular guideline is beneficial, despite never officially tracking outcomes, even after harms have become clear. The above trend graphic also demonstrates how often the crisis is framed as one catalyzed by patients and their physicians, something the NPS alluded was an objective for how they wanted to frame these crises before the crises were known to exist. Remember, the IOM made their recommendations for all of this back in 2011 and 2012, recommendations these initiatives are based on. The CDC inflated overdose statistics, exploited known systems failures in the death investigation process and they exploited popular misconceptions of the process in an attempt to justify their unpopular, unscientific guideline. All of this created the appearance of the guideline as a national necessity, because the crisis has been repeatedly framed as a prescription drug crisis that doctors are responsible for, this isn’t the case. Instead, we’re in the midst of an illicit drug and polypharmacy crisis. Please see Fudin et al. on illicit fentanyl and its analogs which continue to proliferate on the street and drive overdose rates. This is why interventions continue to fail; we’re focusing on the wrong premise. It’s Possible History Will Repeat Itself Despite Harms We may be headed down a path of further assaultive crises in the future due to continued mismanagement by some involved in developing and justifying these interventions. It’s not just patients with complicated chronic medical problems and their doctors who will be forced to suffer under a regime of poorly designed policies, now acute care patients are being thrown into the mix. “In August 2018, the U.S. Food and Drug Administration contracted the National Academies of Sciences, Engineering, and Medicine (NASEM) to help advance the development of evidence-based guidelines for opioid analgesic prescribing for acute pain resulting from specific conditions or procedures” (NASEM 2019). While it’s great that NASEM may be employed in this endeavor, we’ve heard this all before. The Consensus Report NASEM released states: “Trustworthy guidelines help clinicians translate current research in basic science and diagnostic and therapeutic interventions into clinical practice, with the goal of improving patient health and societal outcomes.” Only, the CDC’s 2016 practice guideline is anything but “trustworthy,” and the “evidence” they continue to push is either extremely low or non-existent, as the Agency for Healthcare Research & Quality (AHRQ) recently admitted and as I’ve detailed in-depth in Part I and Part II of this series and in Systems Thinking: How It Can Solve The Overdose Crisis. Patients have not experienced “improvements” in their health, and society has not seen improved outcomes despite premature announcements of “success” by self-proclaimed experts. What’s more, none of these federal agencies, NGOs or anyone else involved have bothered to call for or develop any control systems that would track patient-reported outcomes due to their interventions and recommendations, despite emerging evidence of their harms. If recent history is any kind of guide for future trajectories, we could be well on our way to forcing similarly unscientific practice standards onto every single doctor that treats American citizens, something millions of Americans were already contending with via the release of the first guideline aimed at chronic care that the CDC even admitted was misapplied. It was “misapplied” because the environment remains punitive. The DEA continues to meddle in the practice of medicine with SWAT-style force. The FDA, CDC and HHS have all released announcements acknowledging the public health disaster the guideline’s application has caused, but those announcements will remain moot, and the DEA is sure to continue increasing its interference if guidelines on acute care are published. Summary It appears federal agencies have not only been ignoring important stakeholders’ dissent to these low evidence interventions, but they also continue to barrel forward with their strategy in partnership with many others no matter the cost — even if the cost is American lives. The CDC Guideline was the result of recommendations provided by the National Academy of Medicine, and the history of this crisis and how it’s been managed doesn’t provide any reassurance that anyone at NASEM can do any better in these endeavors. It also appears as if we may actually be in the grips of a largely inflated crisis that continues on with no remediation, while trillions in taxpayer money continue to be spent on a failed drug war that now includes patients and their doctors. Federal agencies and their collaborating NGOs have failed to mitigate continued harm to Americans with complex chronic conditions. A new practice standard for acute care is not likely to add any benefit to sick or injured Americans and all of this continues despite addiction being rather uncommon and overdoses rare under the care of a licensed physician. Conclusion This simply cannot be allowed to continue without some serious remedial steps. Thousands (at least) have died due to these policies. Millions more have been left to suffer pointlessly. All due to how this crisis has been framed using taxpayer dollars to convince the American people that we need to spend billions on interventions that have shown no return on investment for the American people. Overdoses continue to climb unabated despite the interventions already employed and yet, Americans are expected to accept further restrictions on legal access to these life-saving medications. As long as we don’t have the full data on the harms these agencies and others are causing to the public via their public health interventions, and the longer they can continue developing practice standards that continue to trump individualized care without the participation of more moderate voices, the more people could potentially be harmed. It’s time the American people demanded that these projects be brought to a halt until appropriate controls can be put in place for the public’s safety, and an emergency review of the Drug Enforcement Agency’s conduct over the last several decades can be scrutinized by the appropriate stakeholders, including Congress. For a more in-depth view of this piece, please see the extended version.

    Jamie Marich

    Why You Shouldn't Judge Someone for Opioid Addiction

    If there was a category in my high school yearbook for “Most Likely to Become a Junkie,” I would not have been a contender. Indeed, I was voted “Class Brain,” and none of my smarts could prevent me from developing an addiction problem on top of an already budding mental illness. I spent the fall of 2000 in a state of suicidal use, not caring whether I’d ever wake up. Even as I tried to get sober and well shortly after turning 21, I didn’t think I’d make it past 24. The period of days from July 4 to July 8 are quite celebratory. People across the U.S. are in a festive place on the Fourth of July, my belly button birthday is July 6 and my sobriety anniversary is July 8. This year I turn 40, a momentous occasion for me who once believed I couldn’t ever survive this long. I also celebrate 17 years of sobriety. At the start of these special days, my spirit was somewhat dampened when I saw a friend post a “joke” from a parody account set up to represent an Ohio municipality. The post apologized to members of the city for having a scaled-back fireworks display this year, due to the fact they’ve spent so much money on Narcan — a medication to help reverse an opioid overdose. And they “thanked the junkies” for ruining everyone’s freedom celebration. I have a very crude sense of humor and I am not a person who is easily offended, but this “joke” infuriates me in a way I struggle to put into words. Whenever you talk shit about alcoholics or addicts due to your own ignorance, misinformation, resentments or unhealed wounds, you are also talking shit about me and scores of people whom I love. There are many others who would look at me and the life I’ve built today and say, “But Jamie, you’re different.” I’m really not. Yes, I am successful by every conventional American definition of the word. That’s because recovery defines my lifestyle today, and it began in a place where I was just as desperate as any other “junkie” who may need revived in the back of an ambulance. People who meet me now or only knew a very public version of me as a child can have difficulty attuning to this reality. A few years ago, after marriage equality became the law of the land, I attended my first same-sex wedding in my hometown. The ceremony was beautiful. I cried through most of it, not ever believing I would see this in my lifetime. My illusions of liberal paradise were short-lived. I was seated randomly with one of the groom’s family members. He came around at the beginning of the reception and introduced me, “Dr. Jamie Marich,” to everyone at the table. He gushed about how accomplished I was, that I was an author, and everyone at the table seemed impressed. Toward the end of the meal, the opiate crisis came up as a topic of conversation. One of the family members stated quite bluntly what a travesty it was that we wasted so much money on Narcan, especially for frequent fliers. “They should just let the junkies die already.” Of course, this was not the first time I’d heard talk like this. A few years prior, at an extended family event, I heard someone opining that the government should euthanize people who fail treatment after three tries. And yet this was at a gay wedding, where most in attendance seemed to be tolerant. My stomach churned, unable to finish my meal, realizing just how much of a stigma problem we still have on our hands. I found myself in that familiar position of freeze, wanting to say so much yet fearing danger if I did. I wanted to ask that guy, “What if it was your child in the back of that ambulance,” or challenge him with, “And what issue is happening in your life that you’re failing to address? I’m sure your stuff is causing harm to those you love, just maybe in a different way? Have you ever considered that scapegoating addicts may help you feel better about yourself and the role that people like you play in perpetuating a trauma epidemic that people take opiates for?” At one point, the mother of the person making the comment said to me, “I’m sorry if this is upsetting you; this isn’t the best dinner conversation.” In fairness, the mother — a nurse — challenged her son and also seemed put-off by his comments. “What’s upsetting to me,” I finally managed through that pain of freeze, “is that I am a person with 15 years in recovery. Alcohol and opiates. And I could very well have been one of the junkies you’re talking about.” Everyone seemed embarrassed and tried shifting the conversation to congratulating me on my recovery and how “well I had done.” I’m just glad I had the chance to start somewhere. I never needed Narcan or professional assistance to come out of an overdose or withdrawal, but I was getting close to the point where I could have. And many people in my network of recovery today, including sponsees who are working to make a difference in the world, required professional assistance for their lives to be saved. Yes, some of them had to go through the system of care multiple times before they got it. And I’m so glad they did; because so many parts of the medical and care system (however flawed they may be) did not give up on them, they eventually learned not to give up on themselves. A person I interviewed for my dissertation research was pronounced dead on arrival twice during overdoses, and would go through 26 rounds of professional treatment. She eventually got access to the proper trauma-focused treatment she required, later going on to make a big difference in her community. Every day, I get to see what happens when we don’t give up on people. Many people who work for me or with me are in long-term recovery. As a professional serving people at all levels of recovery from addiction and mental illness, I am privileged to behold miracles and know that recovery is possible. I know it can be frustrating — for as many recovery stories as I witness, I see just as many people struggling to get it. And I’ve known way too many people who have died far too young. If you are a first responder, work in the hospitals or in criminal justice, seeing the consequences of addiction play out in full living color, I realize you may be jaded. It’s not easy trying to deal with people who are in the grips of it. I invite any of you to come and hang out with people like me some time. See what happens farther down the road when people get well. I also recognize an addict or alcoholic may have caused great pain in your life and this can be a hardening experience. I am the first to admit the damage we can cause in the lives of others around us, and I realize no apology can ever begin to heal those wounds. For those of us who make it through, we do our best to make amends through changed behavior. And please realize that even those of us in recovery have been impacted by the consequences of others’ addictions. I’ve been married to two people in active addiction. The son of my recovery sponsor was killed by a driver under the influence of alcohol. And although there has been pain to wade through, we’ve both chosen to be part of the solution, which first and foremost means being present for people who need recovery. There’s always a fear when we advocate for these compassionate approaches to recovery that such softness will only give people more excuses. So let me share the piece of direction that changed my life which, I believe, embraces the delicate balance between validating and challenging people. When my first recovery sponsor heard the story of my life and the progression of my disease she said, “Jamie, after everything you’ve been through, it’s no wonder you became addicted. What are you going to do about it now?” People only respond to challenge and direction when they have first been validated and humanized. It’s not the other way around. Shame fuels the progression of addiction , and the comments and jokes on social media — no matter how innocuous they seem to you — are part of the problem. Intoning the wisdom of Anais Nin, “shame is the lie that someone told you about yourself.” For many of us, that starts with unhealed trauma and escalates by contact with others who would have us believe the lie. We say in the treatment field that guilt is when you feel bad about the things you do, and shame is when you believe you are those bad things. Shame teaches that those messages of defectiveness define you. I’m grateful I hung around long enough to learn the difference, and I’m even more grateful I met people along the way who helped me to uncover a deeper truth about who I really am. For as much professional therapy as I’ve received and as much time as I spend growing in my spiritual practice, I am further grateful I can still acknowledge my vulnerability. I am only human. If I stop taking care of myself, the chance is very real that I could be in the back of an ambulance, even after 17 years in recovery, for reasons connected to m y addiction and mental health. To the people who will inevitably need revived from an overdose somewhere in the world today, I send you my love, my empathy, and if you want them, my prayers. We are not separate.

    Community Voices

    I suffer from #Arachnoiditis #ChronicPain and so many other issues, but I have so many symptoms and I feel like I never know what is causing what. Having to explain it to the doctors seems impossible. I am in pain even though I am on medication and with the fake #OpioidEpidemic creating havoc there is nothing but epidural steroid injections in my neck and SI joints that they do over and over and no end in sight....so tired of it all....

    Community Voices

    Only recently did my primary care physician (whom I’ve know for many many years) take pity on me, the chronic pain patient who had already tried EVERYTHING else after 18 years of doing my time (chronic pain time, not prison, come on guys, like we have the energy for crime).
    At this point, I was losing my mind from pain due to #Fibromyalgia and #Lupus as well as the eighteen year stint with #Endometriosis . Not a day without pain, no more work, existing, not living.
    So here I am, thanking God for the relief to come. My dr says to me...don’t expect a pain day to ever be better than a 6 (on that STUPID pain scale... where really, my pain goes from tolerable to intolerable. Every month is like jumping through a million hoops to get my script. My doctor messes up the script, the pharmacy needs to triple check their asses, I’m being accused of asking early when February had 28 DAYS, and for once - my math is right.
    There is no situation here where I don’t look like a drug seeker when all I need is the dr to okay the pharmacy, but it’s like pulling teeth.
    And my pain is never better than a six. #worthit ?
    #PainManagement

    4 people are talking about this

    Roseanne Barr Says 'Roseanne' Character Killed By Opioid Overdose

    Update: As Barr said last month, her character was indeed killed by an opioid overdose. In the episode that aired Tuesday, the story of the Conner family picked up three weeks after Roseanne’s funeral. They all believe she died of a heart attack in her sleep. But then Jackie (Laurie Metcalf) finds out that the autopsy revealed she actually “OD’d on opioids.” Dan (John Goodman) remembers how Roseanne had knee surgery and was taking opioids, though at first he thought she only took them for two days. But then the family realizes she had been stashing pills all over the house, including a bottle prescribed to someone else. Jackie suggests that maybe Roseanne took pills right before going to bed, and “with her health issues, it was enough to stop her breathing.” Roseanne Barr said Monday her titular character, Roseanne, will be killed off by an opioid overdose on the show’s spinoff, “The Conners.” “It wasn’t enough to just do what [ABC] did to me. They had to cruelly insult the people who love that family in that show,” Barr told conservative personality Brandon Straka on his YouTube show “Walk Away.” “Roseanne” was abruptly canceled by ABC in May after Barr posted racist tweets about former President Barack Obama’s adviser Valerie Jarrett. In May, “Roseanne” remake included a storyline about Roseanne (the character) abusing prescription opioids for knee pain. During the episode, Roseanne says she’s taking the medications for pain but begins getting the drugs from friends when her prescription runs out. Her husband also offers to get a prescription for his back, so she can have more. Many people who abuse opioids do not get addicted because of their prescriptions — it’s typically from prescriptions of those close to them. Studies have shown between less than 1 percent to 12 percent of chronic pain patients become addicted to opioids. While the percentage of people with chronic pain who become addicted is low, the latter study found that 21 to 29 percent of chronic pain patients misuse opioids. According to the Centers for Disease Control and Prevention, more than 200,000 people died in the U.S. from prescription opioid overdoses between 1999 and 2016. ABC told The Mighty it would not confirm the character’s fate. Although the network has not confirmed anything, John Goodman, who played Roseanne’s husband Dan, said in late August her character was going to be killed off. ABC announced the spinoff series in June, and said Barr would have no financial or creative involvement in the new series. “The Conners” premieres Oct. 16.

    FDA Is Seeking Input From Chronic Pain Patients About Opioids

    In a blog post published on Monday, Scott Gottlieb, the Food and Drug Administration commissioner, said the FDA is listening to opioid-related concerns from patients with chronic pain. “We’ve heard the concerns expressed by these individuals about having continued access to necessary pain medication, the fear of being stigmatized as an addict, challenges in finding health care professionals willing to work with or even prescribe opioids, and sadly, for some patients, increased thoughts of or actual suicide because crushing pain was resulting in a loss of quality of life,” Gottlieb wrote. Over a year ago, the FDA created the Opioid Policy Steering Committee with the goal of reducing exposure to opioids, preventing more addictions and developing and cultivating the use of medications to treat opioid addiction. This committee received public input from patients who use opioids to manage their chronic pain. Now, the FDA is asking for input from chronic pain patients again to learn more about the “impacts of chronic pain, [patient] views on treatment approaches for chronic pain, and the challenges or barriers they face accessing treatments.” Gottlieb said the FDA wants to “strike the right balance” between making policies that give patients who need opioids the proper accessibility and preventing opioid exposures that lead to new addictions. Most patients with chronic pain do not develop an addiction. While studies vary on percentages, one study stated that less than 1 percent of those who take opioids long-term develop an addiction. Another study said 8 to 12 percent of people with chronic pain develop an addiction. This study also said that misuse (but not addiction) of opioids among chronic pain patients can be between 21 to 29 percent. The FDA is considering coming up with a strategy in the next few months to encourage medical professional societies to create evidence-based guidelines on how to prescribe medications for acute medical needs and assess prescribing behavior as well as adding new prescribing information to opioid labels. Gottlieb wrote: We believe such guidelines could encourage the use of an appropriate dose and duration of an opioid for some common procedures and promote more rational prescribing, including that patients are not being under prescribed and patients in pain who need opioid analgesics are not caught in the cross hairs. In short, having sound, evidence-based information to inform prescribing can help ensure that patients aren’t over prescribed these drugs; while at the same time also making sure that patients with appropriate needs for short and, in some cases, longer-term use of these medicines are not denied access to necessary treatments. The Centers for Disease Control and Prevention published guidelines for prescribing opioids for chronic pain in 2016. The guidelines were not well received by patients, who said the guidelines led to less doctors prescribing opioids for their pain. Gottlieb also said the FDA will be developing guidance documents for the most efficient path for developing drugs that can be used to treat various types of pain. This is an effort to promote more drug innovation for pain. Patients with chronic pain can attend the FDA’s “Patient-Focused Drug Development for Chronic Pain” meeting on July 9 from 10 a.m. to 4 p.m. Patients can attend in person in Maryland or through a webinar by registering online.

    Walmart Offers DisposeRx, Opioid Prescription Disposal Solution

    On Wednesday, Walmart announced it plans to tackle the opioid epidemic by helping people safely dispose of unused opioids. It’s the first pharmacy chain to offer a drug disposal solution at all of its pharmacies, the big-box retailer said in a statement. DisposeRx is a small packet that contains ingredients that turn essentially any medication (pill, powder, liquids, etc) into a biodegradable gel that renders them useless. More than 65 percent of people who abuse opioids have access to them from family or friends, according to the Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Institute of Abuse. A study in August 2017 found that most opioid prescriptions given after surgery go unused or are leftover, but 90 percent of people did not dispose of the drugs properly and instead held onto them, raising the risk of misuse. Beginning immediately, anyone who picks up a Class II opioid will receive a free DisposeRx packet and an opioid safety brochure. People who routinely fill opioid prescriptions like those with a chronic illness will receive a new DisposeRx packet every six months. Pharmacy customers can also request a free packet at any time. The packets will also be available at Sam’s Club pharmacies. Walmart isn’t the first large pharmacy chain to tackle the opioid epidemic. CVS announced last September their pharmacies would begin limiting opioid prescriptions to a 7-day supply for certain acute conditions and prioritize immediate-release formulations before extended-release medications, policies that concerned some in the chronic pain community. Like Walmart, CVS will also counsel patients about proper opioid use. With its new program, Walmart pharmacists can talk to customers about safe opioid disposal as well as distribute opioid awareness brochures outlining risks and helpful resources. CVS will have onsite opioid disposal services in 750 locations. Walmart will have the DisposeRx available at all 4,700 locations.