Public Health Approach to Substance Use

Texas communities have been significantly affected by substance use whether by a criminal justice response, involvement with the child welfare system, utilizing the healthcare system, or experiencing the tragic loss of life due to an overdose. Harm reduction, prevention, treatment, and recovery supports for individuals and families can minimize community trauma caused by the historically punitive approaches to substance use.

Compounding the difficulty of ensuring adequate and appropriate responses, youth and adults who use substances often have a mental health concern, or vice versa. Research indicates that over 60 percent of adolescents who were receiving treatment for substance use also met criteria for a mental health diagnosis and one in four individuals with a serious mental illness also have a substance use disorder.1,2

The Toll of Overdoses and Substance Use

The toll of overdoses and substance use across the country has been reflected over recent years. Overdose deaths spiked 30 percent between 2019 and 2020 and rose another 15 percent between 2020 and 2021.3,4 The number of lives lost to overdose peaked in early 2023 with over 111,000 deaths reported in the 12-month ending in April.5 It’s estimated Texas has seen over 26,000 overdose deaths over the last five years, translating to over 26,000 families, children, parents, friends, and communities who lost a loved one.6 While deaths remain devastatingly high, there is hope. The United States saw the first decrease in annual drug overdose deaths in late 2023 and provisional data reflects a continued trend into 2024.7

Economic Costs

In addition to the harms caused to families and communities, the epidemic of addiction and overdoses is extremely financially costly. Alcohol and drug use is estimated to impact the U.S. economy by over $440 billion related to lost work productivity, criminal justice involvement, and healthcare.8 Other research suggests the economic cost is much higher when overdoses are factored in, estimates suggest this impact is more than $1 trillion.9 According to the Texas Hospital Association, the opioid crisis alone costs Texas $20 billion annually in non-fatal overdose care in emergency departments and intensive care units.10

According to the CDC, excessive alcohol use costs the American economy a loss of over $249 billion: $28 billion attributed to healthcare costs, $179 billion lost to workplace productivity, $13 billion for automobile collisions, and $25 billion to criminal justice involvement.11 More than 140,000 people die from excessive alcohol use in the United States each year and is the leading cause of preventable death.12 Further, excessive use of alcohol is associated with both short- and long-term risks that have large impacts on the health care system. Short-term risks include unintentional injuries, such as drownings and motor vehicle accidents, violence, and alcohol poisoning. Long-term effects include hypertension, heart and liver disease, strokes, various cancers, dependence, and memory issues.13

Impact to Children and Families

Increased attention on parental substance use issues have increased as the prevalence of substance use within the child welfare system has seen a more than 20 percent increase over the last two decades.14 The prevalence rate of substance use disorder among families is estimated to be between 60 and 70 percent of all substantiated child welfare cases, and 80 percent or more of parents whose children are placed in foster care.15 Texas has one the highest rates of parental substance use as a contributing factor in child removals, present in 59 percent cases, second to only neglect in 2022.16

While substance use in and of itself is not child abuse or neglect, it is a risk factor for child maltreatment and child welfare involvement. Risk factors are characteristics of a child or caregiver that may increase the likelihood of child maltreatment, according to the Children’s Bureau within the U.S. Department of Health and Human Services.17 In 39 reporting states, 95,794, or 23.8 percent of children victim of maltreatment have caregivers identified as having the drug abuse caregiver risk factor.18

Prioritizing substance use services and support is a critical component in addressing ways to improve the child welfare system. While child welfare involvement has significant impact on youth and families, those with parental substance use often experience even longer stays in care, higher rates of parental rights termination, greater likelihood of out-of-home placement, and higher rates of child re-victimization.19,20

Criminal Justice Responses

Nationally, substance use disorders (SUD) are common among people who are arrested (41%) and people incarcerated in federal (32%) or state prisons (49%).21,22 This means at least two million people with substance use disorders are arrested annually and about half a million people in state and federal prisons met the criteria for a SUD at the time of their incarceration.23 While there has been incremental progress, substance use is overwhelmingly responded to with punishment as opposed to treatment.

The criminal justice system in Texas reflects similar law enforcement responses to drug and alcohol use. In 2022, there were over 8,000 drug possession arrests made in Texas, most of which were non-violent and for small amounts.24 Over 20,000 individuals, or one in five, in the Texas Department of Criminal Justice (TDCJ) population is there due to a drug-related or DWI offense.25

Service Access

Data indicates many individuals who need services or treatment for substance use don’t receive it: in 2023, only about one in four people aged 12 and older who needed substance use treatment in the past year report receiving it.26,27 A small proportion of individuals needing substance use treatment in Texas receive services through the state. According to HHSC, eligibility for state financial support is based on income, expenses, and other resources, and a person may be required to pay in some cases.”28

In FY 2022, only 34,562 adults and 2,763 youth with a substance use disorder were served by HHSC.29 Despite the limited number of individuals who were able to obtain these services, 602 individuals were still on a waitlist to receive substance use services in November 2022.30 The figures do not include the number of individuals who are not living in poverty (i.e., below 200 percent of FPL) but may still have trouble accessing HHSC-funded substance use services, creating an inaccurate reflection of the treatment needs in our state. Often this group of people is considered to fall within the Medicaid “coverage gap,” unable to access services due to Medicaid income qualifications, yet are unable to afford private insurance or pay for their services on a sliding scale.

Regardless of income, a sole diagnosis of SUD is insufficient to qualify for Medicaid coverage.31 This eligibility rule requires a person to have an additional physical or mental health condition, along with meeting Texas’s income eligibility. Limited is reflective of: in FY 2019, only 17,216 Medicaid claims were filed for substance use treatment services.32

Solutions and Efforts

Public health is the science of preventing disease and injury and promoting and protecting the health of populations and communities. Experts call for a public health system approach to address substance use, emphasizing prevention, access to care, and community wellness to improve the health, safety and well-being of the entire population, which includes those who use substances.

Substance use issues are multifaceted, requiring a multi-systemic approach to support individuals and communities. In 2010, Texas began shifting away from an acute care model to a focus on recovery. According to SAMHSA, recovery is built on hope, access to evidence-based treatment and recovery support services, and the pillars are health, home, purpose, and community.33

Recovery Housing

Recovery housing is an evidence-based, shared living environment that empowers individuals to achieve and maintain a life in recovery. This setting connects residents to supports and services, is centered on peer support, and is free from substance use. Recovery housing is associated with increased long-term recovery, decreased substance use, relapse/reoccurrence reduction, higher incomes, increased employment, improved family functioning, and lower rates of incarceration.34,35 Further, it has shown an estimated $29,000 cost savings per person when compared to someone who has no recovery support.36

During the 88th legislative session, Texas passed HB 299 (Murr/Johnson), establishing a clear definition of recovery homes and a voluntary accreditation process.37 HB 299 requires HHSC to adopt minimum standards for accreditation as a recovery house consistent with quality standards. The National Alliance for Recovery Residences (NARR) and the Oxford House, Inc. (OHI) are two models recognized by SAMHSA as national best practices and the only approved accrediting organizations in Texas.38,39 Texas Recovery Oriented Housing Network (TROHN) is the NARR-state affiliate responsible for overseeing the accreditation process. As of August 2024, Texas has 93 NARR-accredited recovery homes and over 300 OHI accredited homes operating in partnership with HHSC.40,41

Family-Centered Approaches

Parents with substance use disorder face many challenges associated with seeking, accessing, and remaining in treatment. These challenges are often compounded with other factors for specific populations, such as rural communities, BIPOC families, or those experiencing homelessness or housing insecurity.42,43,44 Family-centered interventions are supported by empirical evidence, have positive outcomes, and promote long-term change and recovery:

  • Mothers able to participate in residential treatment programs with their children is associated with enhanced parent-child bonding, improved interactive and reciprocal communication, and maternal sensitivity to the child’s needs.45
  • Parenting women with SUDs who participated in residential treatment with their infants stayed in treatment longer and had higher completion rates than women who did not have their children with them.46
  • Family counseling in SUD treatment is positively associated with increased treatment engagement and retention rates, treatment cost effectiveness, and improved outcomes for individual clients and their families, including reduced substance use, days of heavy alcohol consumption, drug related arrests, legal and family problems, and hospitalizations.47
  • Children’s time spent in foster care and likelihood of reunification with their parents is significantly associated with how quickly their parent can enter treatment, treatment length, and completion of treatment.48

Texas only has 10 Women with Children Residential Treatment Centers (WC RTC) across the state that offer substance use treatment services for women and children living together in a licensed treatment facility. Women are eligible for these programs if they are diagnosed with a substance use disorder and are either in their third trimester of pregnancy, have a child who can attend treatment, or have a child in the state’s custody who will be released to them while attending treatment.49 The services include counseling, parenting education, health education, skills training, and case management services. WC RTCs provide these services through either intensive residential treatment or supportive residential treatment, with time in clinical programming determining the level of care.

Alternative Criminal Justice Responses

Research has long reinforced that punitive responses to addiction and substance use are not effective problem-solving approaches, therefore expanding imprisonments is not an effective drug control and prevention strategy.50 Mental health and substance use treatment are better provided in voluntary, non-carceral, clinical treatment settings rather than jails or prisons.

Enforcing drug-related laws costs state and federal governments an estimated $10 billion annually; however, increased incarceration has not resulted in reduced rates of drug use, drug arrests or overdose deaths.51,52 When comparing state imprisonment rates to indicators of drug use problems: self-reported use, overdose deaths, and drug arrests, no statistically significant relationship is found.53 Rather, prevention, treatment, diversion and alternative sentencing, and law enforcement focus on trafficking are found to be more effective strategies for not only reducing drug use and crime, but supporting individuals with substance use disorders.54

Texas Behavioral Health and Justice Technical Assistance Center

Established in 2022 by the Texas HHSC Office of Forensic Coordination, the TA Center provides free, specialized technical assistance for behavioral health and justice professionals to reduce and prevent justice involvement for people with mental illness, substance use disorders, and intellectual and developmental disabilities.

Pre-Arrest Diversion

Communities across the country have implemented deflection and pre-arrest diversion (DPAD) initiatives to link people who use drugs to evidence-based care and services instead of incarceration.55 Pre-arrest diversion programs provide an alternative outcome to reduce the number of persons who are arrested and placed in jail because of a behavioral health problem, shifting responses to mental health and substance use from the criminal justice system to the behavioral health system. Instead of punishment, pre-arrest diversion steers people toward treatment and support.56

In 2023, HHSC’s Office of Forensic Coordination partnered with the Texas Institute for Excellence in Mental Health at UT Austin to launch the Texas Pre-Arrest Diversion Learning Collaborative.57 The Collaborative is a peer-to-peer learning opportunity for county behavioral health and law enforcement stakeholder to learn, plan, and implement strategies to support pre-arrest diversion, including police-mental health partnerships, crisis call diversion, diversion centers, remote co-response.58

Harm Reduction

Harm reduction can be defined as “an approach that emphasizes engaging directly with people who use drugs to prevent overdose and infectious disease transmission, improve the physical, mental, and social well-being of those served, and offer low-threshold options for accessing substance use disorder treatment and other health care services.”59 Harm reduction not only treats people with dignity, but is proven effective and is part of a comprehensive prevention strategy and the continuum of care.60 Harm reduction has been identified as a federal drug policy priority and is a strategic priority of the U.S. Department of Health and Human Services (HHS). HHS released Harm Reduction Framework, the first document comprehensively outlining harm reduction and its role throughout HHS. While national conversations have seemed promising, many barriers remain in Texas.

Texas Laws

State laws, such as limited protections during overdose 911 calls and the illegality of fentanyl strips and syringes, prevent more lives from being saved. Under current Texas law, fentanyl strips and clean syringes are considered drug paraphernalia. During 87th legislative interim session, the House Public Health Committee held a hearing focused on overdoses and individuals with lived experience, family and friends, law enforcement, and subject matter experts discussed barriers and challenges. To reduce these barriers, stakeholders have advocated for legislative action. A slew of bills were filled to decriminalize fentanyl strips and syringes during the 88th legislative session but were unsuccessful.

Good Samaritan

Drug overdose laws, commonly known as “Good Samaritan laws” (GSLs) have been filed in Texas every subsequent legislative session since the Governor’s veto in 2015. During the 87th legislation session, an agreeable version was passed through HB 1694 (Raney/Schwertner). The law provides a defense against prosecution for some, however it is more accurately described as an overdose bystander law because of its various exceptions and burdens outlined here.61 Texas is now among 48 states passing a version of a GSL, however broad variations make measuring certain outcomes difficult.62

State-specific provisions widely vary from providing arrest protections to sentence mitigation. Research suggests a law like the one passed by Texas will do little to reduce overdose deaths: legal protections from charge, prosecution, or mitigation at sentencing are not shown to have a significant impact on reducing overdose deaths.63,64 Alternatively, reductions in overdose deaths are seen in more comprehensive laws including legal protections from arrest.65 Further, states that combine comprehensive GSLs with naloxone access laws have the greatest positive impact on saving lives and preventing overdoses.66 States with the greatest comprehensive effort to encourage overdose reports before they become fatal have included protections for other legal penalties, expanded the nature of reportable emergencies, and broadened the range of offenses protected.67

References

  1. National Institute on Drug Abuse. (April 2020). Common comorbidities with substance use disorders research report. https://nida.nih.gov/publications/research-reports/common-comorbidities-substance-use-disorders/part-1-connection-between-substance-use-disorders-mental-illness ↩︎
  2. Ibid. ↩︎
  3. National Center for Health Statistics. (2022, May 11). U.S overdose deaths in 2021 increase half as much as in 2020 – but are still up 15% [press release]. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2022/202205.htm ↩︎
  4. McPhillips, D. (2023, September 13). Overdose deaths continue to rise in the US, reaching another record level, provisional data shows. CNN. https://www.cnn.com/2023/09/13/health/overdose-deaths-record-april-2023/index.html ↩︎
  5. Ibid. ↩︎
  6. Ahmad ,F.B., Rossen, L.M., & Sutton, P. (2022). Provisional drug overdose death counts, November 2022. National Center for Health Statistics. 2022. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm ↩︎
  7. Ahmad ,F.B., Cisewski, J.A., Rossen, L.M., & Sutton, P. (2024). Provisional drug overdose death counts, July 2024. National Center for Health Statistics. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm ↩︎
  8. U.S. Surgeon General. Addiction and substance misuse reports and publications. (n.d.). U.S. Health and Human Services. Retrieved August 9, 2024 from https://www.hhs.gov/surgeongeneral/reports-and-publications/addiction-and-substance-misuse/index.html= ↩︎
  9. Florence, C., Luo, F., & Rice, K. (2021). The economic burden of opioid use disorder and fatal opioid overdose in the United States, 2017. Drug and Alcohol Dependence, 218 (2021). https://www.sciencedirect.com/science/article/pii/S0376871620305159 ↩︎
  10. Texas Hospital Association. (2018). Texas hospitals’ commitment to addressing the opioid crisis. https://www.tha.org/tha_opioid_response_whitepaper/ ↩︎
  11. Centers for Disease Control and Prevention. (2019). The cost of excessive alcohol use. U.S. Department of Health and Human Services.  https://www.cdc.gov/alcohol/onlinemedia/infographics/cost-excessive-alcohol-use.html ↩︎
  12. Centers for Disease Control and Prevention. (2022). Excessive alcohol deaths. U.S. Department of Health and Human Services.   https://www.cdc.gov/alcohol/features/excessive-alcohol-deaths.html ↩︎
  13. America’s Health Rankings. (2022). Excessive Drinking, 2020. United Health Foundation. https://www.americashealthrankings.org/explore/annual/measure/ExcessDrink/state/TX ↩︎
  14. https://ncsacw.acf.hhs.gov/files/statistics-2020.pdf ↩︎
  15. Oliveros, A., & Kaufman, J. (2011). Addressing substance abuse treatment needs of parents involved with the child welfare system. Child welfare, 90(1), 25–41. ↩︎
  16. https://www.acf.hhs.gov/sites/default/files/documents/cb/afcars-tar-tx-2022.pdf ↩︎
  17. https://www.acf.hhs.gov/sites/default/files/documents/cb/cm2022.pdf ↩︎
  18. Ibid. ↩︎
  19. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4158612/#:~:text=It%20is%20estimated%20that%2060,%2C%20&%20Otero%2C%202007) ↩︎
  20. https://www.casey.org/media/24.07-QFF-SF-Keep-families-together-substance-use_fnl.pdf ↩︎
  21. Substance Abuse and Mental Health Services Administration. (n.d.). SAMHSA Data Analysis System (DAS), NSDUH: Public data (2019) [Data set]. Retrieved August 11, 2024 from https://datatools.samhsa.gov/nsduh/2019/nsduh-2019-ds0001/crosstab?row=UDPYILAL&column=NOBOOKY2&weight=ANALWT_C ↩︎
  22. Bureau of Justice Statistics. (n.d.). Survey of Prison Inmates Data Analysis Tool (SPI DAT) [Data set]. U.S. Department of Justice. Retrieved August 11, 2024 from https://spi-data.bjs.ojp.gov/dashboard ↩︎
  23. Widra, W. (2024). Addicted to punishment: Jails and prisons punish drug use far more than they treat it. Prison Policy Initiative. https://www.prisonpolicy.org/blog/2024/01/30/punishing-drug-use/#:~:text=Public%20health%20research%20has%20long,%2Dcarceral%2C%20clinical%20treatment%20settings ↩︎
  24. https://cde.ucr.cjis.gov/LATEST/webapp/#/pages/explorer/crime/crime-trend ↩︎
  25. https://www.tdcj.texas.gov/documents/Statistical_Report_FY2023.pdf ↩︎
  26. Substance Abuse and Mental Health Services Administration. (2024). Key substance use and mental health indicators in the United States: Results from the 2023 National Survey on Drug Use and Health (HHS Publication No. PEP24-07-021, NSDUH Series H-59). Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/report/2023-nsduh-annual-national-report ↩︎
  27. https://www.filesbff.org/Survey_Conducted_by_NORC.pdf ↩︎
  28. https://www.hhs.texas.gov/services/mental-health-substance-use/adult-substance-use/adult-substance-use-residential-treatment ↩︎
  29. HHSC data request, received December 7, 2022. ↩︎
  30. Ibid. ↩︎
  31. Boozang, P., Bachrach, D. & Detty, A. (2014). Coverage and delivery of adult substance abuse services in Medicaid managed care [PDF].Mannatt Health Solutions, Centers for Medicare & Medicaid Services. https://www.medicaid.gov/sites/default/files/2019-12/cms-adult-substance-abuse-services-coverage.pdf ↩︎
  32. HHSC data request, received December 7, 2022. ↩︎
  33. Substance Abuse and Mental Health Services Administration. (2022). Recovery and recovery support. https://www.samhsa.gov/find-help/recovery ↩︎
  34. Blue, S.C. & Rosenburg, L. (2017). Recovery housing issue brief: Information for state policymakers. National Council for Behavioral Health. https://narronline.org/wp-content/uploads/2017/09/Recovery-Housing-Issue-Brief_May-2017.pdf ↩︎
  35. Ibid. ↩︎
  36. RecoveryPeople. (2021). Stakeholder comments concerning Texas Health & Human Services legislative appropriations request submission. https://recoverypeople.org/recovery-housing-exceptional-item-request/ ↩︎
  37. RecoveryPeople. (2023). HB 299: Voluntary recovery housing accreditation. https://recoverypeople.org/wp-content/uploads/2023/06/HB-299-Breakdown.pdf ↩︎
  38. Ibid. ↩︎
  39. RecoveryPeople. (n.d.). What does HB 299 mean for referral agents. Retrieved August 9, 2024 from https://recoverypeople.org/what-does-hb-299-mean-for-referral-agents/ ↩︎
  40. Texas Health and Human Services Commission. (n.d.). Adult substance use recovery residences. Retrieved November 11, 2022, from https://www.hhs.texas.gov/services/mental-health-substance-use/adult-substance-use/adult-substance-use-recovery-residences ↩︎
  41. Oxford Houses. (n.d.). Oxford Houses of Texas – directory, as of 08/09/24. Retrieved August 9, 2024 from https://www.oxfordhouse.org/pdf/tx_directory_listing.pdf ↩︎
  42. https://aspe.hhs.gov/sites/default/files/private/pdf/263216/ChallengesIssueBrief.pdf ↩︎
  43. https://www.cffutures.org/files/CFFComprehensiveFramework.pdf ↩︎
  44. https://cwrp.ca/sites/default/files/publications/Strategies%20To%20Enhance%20Substance%20Abuse%20Treatment%20For%20Parents%20Involved%20With%20Child%20Welfare.pdf ↩︎
  45. Conners, N. A., Bradley, R. H., Whiteside-Mansell, L., & Crone, C. C. (2001). A comprehensive substance abuse treatment program for women and their children: An initial evaluation. Journal of Substance Abuse Treatment, 21(2), 67-75 ↩︎
  46. https://www.cffutures.org/files/CFFComprehensiveFramework.pdf ↩︎
  47. Substance Abuse and Mental Health Services Administration. Substance Use Disorder Treatment and Family Therapy. Treatment Improvement Protocol (TIP) Series, No. 39. SAMHSA Publication No. PEP20-02-02-012. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2020. ↩︎
  48. Green, B. L., Rockhill, A., & Furrer, C. (2007). Does substance abuse treatment make a difference for child welfare case outcomes? A statewide longitudinal analysis. Children and Youth Services Review, 29(4), 460–473. https://doi.org/10.1016/j.childyouth.2006.08.006 ↩︎
  49. https://www.hhs.texas.gov/services/mental-health-substance-use/adult-substance-use/adult-substance-use-women-children-residential-treatment ↩︎
  50. Volkow, N.D. Addiction should be treated, not penalized. Neuropsychopharmacol, 46, 2048–2050 (2021). https://doi.org/10.1038/s41386-021-01087-2 ↩︎
  51. Pearl, B. (2018). Ending the war on drugs: By the numbers. Center for American Progress. https://www.americanprogress.org/issues/criminaljustice/reports/2018/06/27/452819/ending-war-drugs-numbers/ ↩︎
  52. Gelb, A., Stevenson, P., Fifield, A., Fuhrmann, M., Bennett, L., Horowitz, J., & Broadus, E. (2021). More imprisonments does not reduce state drug problems. The Pew Charitable Trusts. https://www.pewtrusts.org/-/media/assets/2018/03/pspp_more_imprisonment_does_not_reduce_state_drug_problems.pdf ↩︎
  53. Gelb, A., Stevenson, P., Fifield, A., Fuhrmann, M., Bennett, L., Horowitz, J., & Broadus, E. (2021). More imprisonments does not reduc3 state drug problems. The Pew Charitable Trusts. https://www.pewtrusts.org/-/media/assets/2018/03/pspp_more_imprisonment_does_not_reduce_state_drug_problems.pdf  ↩︎
  54. Ibid. ↩︎
  55. https://www.thenationalcouncil.org/program/deflection-and-pre-arrest-diversion-to-prevent-opioid-overdose/ ↩︎
  56. https://www.rti.org/impact/pre-arrest-diversion-program-people-experiencing-mental-health-crisis ↩︎
  57. https://texas-behavioral-health.nyc3.digitaloceanspaces.com/uploads/texas-pre-arrest-diversion-learning-collaborative-application.pdf ↩︎
  58. https://www.hhs.texas.gov/sites/default/files/documents/aug-2023-sbhcc-agenda-item-4.pdf ↩︎
  59. Substance Abuse and Mental Health Services Administration. (2022). Harm reduction. https://www.samhsa.gov/find-help/harm-reduction ↩︎
  60. Ibid. ↩︎
  61. Covington, C. (2021, November 21). Why critics say Texas’ new ‘good Samaritan’ law for overdoses doesn’t go far enough. KUT 90.5 Texas Standard. https://www.kut.org/texasstandard/2021-11-12/why-critics-say-texas-new-good-samaritan-law-for-overdoses-doesnt-go-far-enough ↩︎
  62. Reader, S.W., Walton, G.H., & Linder, S.H. (2022). Review and inventory of 911 Good Samaritan Law provisions in the United States. International Journal of Drug Policy, 110, 103896. https://doi.org/10.1016/j.drugpo.2022.103896 ↩︎
  63. Hamilton, L., Davis, C.S., Kravitz-Wirtz, N., Ponicki, W., & Cerdá, M. (2021). Good Samaritan laws and overdose mortality in the United States in the fentanyl era. International Journal of Drug Policy, 91, 103294. https://doi.org/10.1016/j.drugpo.2021.103294 ↩︎
  64. Reader, S.W., Walton, G.H., & Linder, S.H. (2022). Review and inventory of 911 Good Samaritan Law provisions in the United States. International Journal of Drug Policy, 110, 103896. https://doi.org/10.1016/j.drugpo.2022.103896 ↩︎
  65. Hamilton, L., Davis, C.S., Kravitz-Wirtz, N., Ponicki, W., & Cerdá, M. (2021). Good Samaritan laws and overdose mortality in the United States in the fentanyl era. International Journal of Drug Policy, 91, 103294. https://doi.org/10.1016/j.drugpo.2021.103294 ↩︎
  66. Ibid. ↩︎
  67. Ibid. ↩︎

Updated on December 13th, 2024



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