








































Treatment, Overdose, and Finding the Road to Recovery


COMMONWEALTH, Volume 20, Issue 1 (2018). © 2018 The Pennsylvania Political Science Association.  
ISSN 2469-7672 (online). http://dx.doi.org/10.15367/com.v20i2-3.188. All rights reserved.

Treatment, Overdose, and Finding  
the Road to Recovery

MICHAEL T. FLAHERTY
Private Clinical Practice

Previously with St. Francis Institute for Psychiatry and Addiction Services  
and the Institute for Research, Education and Treatment of Addiction

Knowing is not enough; we must apply. Willing is not enough;  
we must do.
—Goethe

To address the role of treatment in Pennsylvania’s overdose challenge, certain 
ideological impediments must be identified and addressed. A separateness of 
harm reduction from treatment as different approaches, a separateness of public 
health and public safety as partners in the solution, of public health from private 
insurance for treating the illness must all be overcome by a prioritized, uni-
fied vision. Without this, today’s policies cannot build on the available twenty- 
first-c entury science in both specialty care and general practice—let alone in 
our communities. Coupled with societal factors including universal stigma for 
the illness and those suffering it, these divides have created fertile ground for 
today’s predictable epidemic. Through collective determination with increased 
access to described interventions and treatment, including expanded access to 
medication- assisted treatments and an enhanced, broadened, skilled interdisci-
plinary and peer workforce built on a “recovery” philosophy, locally implemented 
efforts with county, state, and federal leadership can reverse the epidemic.

The Birth and Growth of a Predictable Epidemic

What happens when the largest preventable illness in America is 
historically minimized, undertreated, or simply denied (Rob-
ert Wood Johnson Foundation 2001; U.S. Department of Justice 



62 Michael T. FlaherTy

2001)? Prevention is minimized, and even though effective drug treatment 
exists, most people who need treatment don’t receive it.

There are many reasons for this, including: costs of treatment; demands 
of other more “acceptable” illnesses; inadequate accessibility or availability 
of treatment; or the belief of patients that they can handle the problem with-
out treatment, i.e., not being ready to stop using—a symptom of the illness. 
There is also a lack of health insurance coverage; privacy concerns; and, most 
recently, the sheer power of the illness that took over 63,000 American lives 
in 2016—4,642 in Pennsylvania alone (Lord 2018; U.S. Drug Enforcement 
Agency and University of Pittsburgh School of Pharmacy 2017)—all compli-
cated by an even greater barrier: stigma.

Adding to these historical challenges is the shortage of a sufficiently 
skilled, prepared, and receptive health care workforce. Many who are posi-
tioned to address addiction lack adequate training or the knowledge to effec-
tively assess, refer, intervene, or treat patients once they are identified as in 
need of treatment. Even if identified, a treatment capacity exists for only 10.8% 
who might need it (Hoge et al. 2013; Hyde 2013).

Opioid dependence and treatment especially remain fraught with chal-
lenges: stigma; skepticism regarding the effectiveness of treatment alterna-
tives; well- intended but often conflicting or underresourced plans of leaders 
and provider agencies dependent on site-ba sed service; restrictive funding and 
payment methodologies focused on enrolled clients within their agency; and 
treatment that is not necessarily grounded in the science of recovery (ONDCP 
2013). As this already- devastating epidemic continues to build destructive 
momentum, there is a fundamental question facing our country, our Com-
monwealth, and our communities: Is this an epidemic that we will mobilize to 
halt or to at least significantly slow, or is it one that we will minimally address 
and build industries around?

To mobilize effectively, existing ideological dichotomies must be acknowl-
edged and addressed. Treatment itself is often held distinct from other solu-
tions such as harm reduction or medication management that should, instead, 
be viewed as early- stage platforms for treatment and recovery (White and 
Mojer- Torres 2010). Public and private practice and funding remain largely 
distinct, generating separate systems of public and private care. Most nota-
bly, when adding the importance of overdose prevention to treatment, “public 
safety” must be joined and coordinated with public health efforts, just as “pre-
vention” and “harm reduction” must join with treatment in a broader effort 
to attain and sustain community, family and individual support, health, well-
ness, and recovery (Hickton and Leary 2015). Given these historical obstacles 
and others, e.g., treating pain as the fifth vital sign (Campbell 1996; Kolodny 



Treatment, Overdose, and Finding the Road to Recovery  63

et al. 2015), as well as the extraordinary profits that continue to be reaped by 
some from this illness, this “epidemic” has long been coming and should be 
no surprise.

Why Treatment Has Fallen Short

Stigma and Denial

No barrier to treatment is a more formidable obstacle than stigma, in the 
many forms that it takes. Most fundamentally, even the acceptance of the 
illness as an illness or disease remains denied by many in society and leader-
ship, creating a deep public bias that is hard to see, let alone overcome. Despite 
an extensive science that documents the illness medically, intergeneration-
ally, and chronically, with lethal outcomes if not addressed, many, including 
many public leaders, continue to hold the illness as self- caused, a bad choice 
gone worse, or a moral weakness for which society should give only limited 
resources, help, tolerance, and compassion.

Overlooked is the fact that at some point for each person suffering addic-
tion, without clinical intervention, choice is compromised, if not lost, and 
society’s denial of this now costs the United States over $700 billion dollars 
annually (NIDA 2018c). Consider the cost figures (see Tables 1 and 2) for 2014 
and 2016, the last year for which comparative cost data are available, remem-
bering that the drug abuse epidemic has grown exponentially since then.

Table 2. Pennsylvania Overdose Data 2014 and 2016

2016 Overdose deaths per 100,000 people: 37.9 (5th highest in nation)  
National average 14.7

2014 Overdose deaths per 100,000 people: 12.7 (10th highest in nation)

Pennsylvania Opioid Painkiller Prescriptions active per 100 citizens, 82 to 95  
(21st largest in country)

Sources: PPG 2017; Sauter 2016; CDC 2014.

Table 1. 2014 and 2016 costs of Drug abuse compared to Other chronic 
conditions

Substance Use in 2016 cost society $700 billion annually 

Substance Use in 2014 cost society $484 billion annually

Diabetes in 2014 cost society $131.7 billion annually

Cancer in 2014 cost society $171.6 billion annually

Sources: CDC 2014.



64 Michael T. FlaherTy

Stigma and the Lack of Unified Vision

Today’s health policy lacks both a unifying vision and, therefore, a unified will 
to prioritize and mobilize to prevent and treat addiction and build a capac-
ity for community and individual recovery. In fact, the barrier of stigma is 
reinforced by basic features of the existing system, within both the health care 
community and the general population. Consider, for example, that addic-
tion often is treated as criminal, while pain management is treated as medi-
cal. Pain management treatment tends to be delivered in medical settings, 
while addiction, if addressed at all, is more often addressed in public clinics 
or in jails, or in the case of overdose, by hospital emergency rooms or publicly 
employed first responders, often in public places such as bathrooms, cars, or 
churches.

Stigma is the overarching barrier if we are to solve substance use, addic-
tion, overdose, and the challenge of pain management. Today’s health policies 
and services are built upon accepted societal and medical stigma, against both 
the illness and the person suffering from it. This is so pervasive that many 
who struggle with addiction deny it, hide it, and do not seek help for it. Hospi-
tal ERs daily turn away those who have a higher probability for mortality than 
others admitted for suicidal ideation or other life- threatening medical condi-
tions (medical stigma), even as those same facilities shun adding treatment 
capacity, and more costly jail populations and the number of overdoses grow.

Fewer than 11% of U.S. medical schools teach courses in addiction 
(Morely- Forster et al. 2013), and half of today’s graduating physicians report 
“feeling unprepared” to treat it (Mezei and Murison 2011). As a result, alterna-
tive systems of care and community supports such as nonhospital withdrawal 
management and rehabilitation, recovery centers, halfway houses, and fam-
ily and peer supports have emerged to address this major illness outside of 
mainstream medicine. Without the needed medical leadership to restructure 
a stigma- based system of care, the unifying vision of what is needed to prevent 
and address overdose or addiction and facilitate both community and indi-
vidual recovery cannot take shape. Today, substance use pleads for attention 
from medicine.

For example, the medical and general population’s understanding of 
addiction and pain treatment remain separate and divided, e.g., addiction 
is often seen judgmentally as a weakness, while pain is viewed as a medical 
condition—at least until it leads to addiction. Stigma becomes further trans-
lated to clinical treatment when driven more by assured payment and level of 
service entered than by assessing the nature of the illness presented, match-
ing that assessment to a level of care (Mee- Lee et al. 2013), and meeting the 



Treatment, Overdose, and Finding the Road to Recovery  65

needs of the person continually along its progressive and at times regressive 
trajectory by offering each person an opportunity for recovery at each level 
and encounter.

There are other compelling examples of science unaddressed. For exam-
ple, according to the National Institute on Drug Abuse Principles of Quality 
Care, any treatment episode for a substance use disorder that is less than 90 
days in duration is clinically of little value (NIDA 2018b). How does Pennsyl-
vania stack up against this recommendation? How many in treatment today 
receive at least a 90- day episode of care? Shouldn’t this be a policy? It isn’t.

Or, at the service level, how many providers still claim that the very 
medications proven effective to treat addiction are a cop-o ut, and are sim-
ply replacements for illicit drugs? How many treatment systems involuntarily 
discharge a person from treatment for exhibiting the symptoms of the very 
illness for which they sought help, e.g., positive urine screens in treatment? 
And what makes us believe that those who suffer addiction can just stop? If a 
person cannot access care and continually fails despite losing his or her job, 
family, health, or freedom by ending up in jail, does it not speak of the absence 
of self- control? When a person is revived from his or her fourth overdose and 
expresses anger at the first responder/Samaritan for taking life- saving action, 
does it not speak of an absence of mental competence? This is the power of 
addiction that must be understood and addressed for solutions to be effective.

Systemic stigma can also be clearly seen in the very language used to 
describe those suffering from this illness or disease: e.g., “addict,” “junkie,” 
“dope head,” “substance abuser.” These are all terms that cement a context of 
fault and add to the resistance, rejection, or failure of treatment. These are 
“persons suffering with addiction” or “persons in recovery.” Language mat-
ters, and an “Addictionary” designed for the illness exists (Kelly, Dow, and 
Westerhoff 2010).

Establishing a vision to address overdose and substance use in Pennsyl-
vania and each region, county, or community can be a first step to crafting 
an effective solution. Policies and systems of care should be steered to fulfill 
this vision. The author has suggested as one vision, “providing each person 
and community the most efficient and effective care along a continuum of 
assessed severity and need capable of addressing the illness and initiating 
recovery.”

From within the framework of this vision, life- saving treatments, includ-
ing medical stabilization and medication support, could be initiated before 
more expensive approaches involving hospitalization and rehabilitation are 
employed, without compromising the goal of attaining individual recovery 
(White and Mojer- Torres 2010). Incarceration, when necessary, should offer 



66 Michael T. FlaherTy

medical stabilization, the initiation of treatment and recovery, and, upon com-
pletion, preparation for safe community reentry from incarceration, includ-
ing medication and linkage to peer supports. Medication-a ssisted treatment 
in correctional settings has been shown to reduce the risk of overdose upon 
release (Wakeman and Rich 2015). Because the deployment of these practices 
is too infrequent, overdoses remain highest in those who have dropped out 
or been discharged from treatment or who are returning from rehab or jail, 
because their lower physical tolerances are too easily overcome by the power-
ful drugs that await them in the community.

Treatment must be continuous and aligned to the principles of chronic 
disease management, with coverage and access assured even between systems 
(e.g., jail and community) or treatment agencies (e.g., outpatient treatment 
and inpatient care). Insufficient treatment capacity, coupled with stronger 
illegal drugs and the widespread trafficking in those drugs driven by greed, 
has fueled this predictable epidemic. As to payment, a private fee- for- service 
model, without any record of success in public health, has been foisted upon a 
national public health problem with constraints that make it difficult to reach 
those most at risk for overdose or their families. These payment mechanisms 
shape what is offered as treatment. Other reimbursement schemes need to 
be developed such as funded prevention, brief screening and limited agency 
funding, case rate funding, and funding for outreach (e.g., peer supports), 
emergency care coverage, and targeted value- based funding for high- risk per-
sons so that we can reach those most in need to prevent overdose death.

To overcome inherent medical stigma, we must first see it. We must 
acknowledge that substance use treatment, except for pain management, has 
become segregated from general medical care and generalist and specialist 
training and practice (vs. Common Elements of Success: “Integrated Care” 
below). As a result, rather than coalescing a prioritized will to address an epi-
demic, profitable industries have arisen to address parts of it. Jails, courts, and 
child protective services are functioning at, or in some cases beyond, maxi-
mum capacity. Police have become first responders, new profitable and more 
addictive medications have been developed, acute treatment systems build on 
treating other advanced but related medical disorders, emergency rooms see 
overdoses daily, etc. The needed specialty demands for community preven-
tion, intervention, treatment, and recovery remains resourced to below 3% of 
the now nearly $700+ billion annual cost of the illness (NIDA 2016e, 2018c).

Substance use effects all populations. The opioid epidemic has brought 
an added 1.35 million Americans into poverty and lowered the national life 
expectancy (now 78.6) in the United States each year for the past six years 
(NIDA 2016c; Pittsburgh Post- Gazette Editorial Board 2017; U.S. Department 



Treatment, Overdose, and Finding the Road to Recovery  67

of Health and Human Services, Office of the Surgeon General 2016). Unique 
stigma exists also toward the poor, female, adolescent, older, or racial minori-
ties, etc. Each has its own face that must be transcended with specificity and 
a sensitive transformation of science to reach its mark.

Even treatment itself stigmatizes the person by focusing almost exclu-
sively on the pathology, measuring success as the attainment of abstinence, 
compliance, and adherence to treatment, too often leaving out the emerging 
science and positive added outcomes of recovery and the many measures of 
it (Flaherty, Kurtz, and White 2014; White and Kurtz 2008). With a vision 
and an awareness of the pervasiveness of stigma we can begin to construct a 
healthier, more relevant approach to a prevention and treatment system that 
can bring solutions, hope, and science to this epidemic.

Treatment Capacity and Workforce Development

Another barrier to reducing overdoses is the existing capacity for substance 
use treatment. Today, the United States has a national capacity for only 10.8% 
of those who would meet clinical criteria for such treatment (ONDCP 2013). 
In Pennsylvania most programs for those severely addicted operate at capacity 
and with waiting lists.

Moreover, the science itself has changed from seeing the illness as an acute 
or temporary problem (e.g., like a broken bone or a cold) to being potentially 
lifelong and best addressed within a “continuum of care” as a chronic illness 
(Appendix A). This approach would be like that taken with other chronic con-
ditions such as diabetes, HIV, high blood pressure, depression, etc., and has 
been described in paradigm- changing research since the turn of the century 
(McLellan et al. 2000; Scott and Dennis 2007; Flaherty 2006). Health care for 
chronic conditions is very different from the care for acute, episodic illnesses, 
and our state agencies and treatment providers, already too few, struggle in 
an earn- to- survive, fee-f or- service model often offering only what the specific 
location and level of care provides.

Substance use calls for experiential (i.e., in real world) support while hav-
ing vigorous referral to the levels of medical care necessary to best address 
everyone (Commonwealth of Pennsylvania Department of Drug and Alcohol 
Programs 2014; Mee- Lee et al. 2013). But the severity of the illness and its 
science have moved faster than the services and skills of the workforce to 
address it in a community. New technologies, medications, professional col-
laborations, complex multiple diagnoses, increased collaboration with peer 
and family supports, care management, electronic health records, parity, and 
health insurance or managed care have all led to increased expectations for 



68 Michael T. FlaherTy

modernization without increased dollars to meet the added burden to front- 
line providers.

In short, today’s system, while deserving our full respect for what it does 
accomplish, is drastically overburdened by existing calls for service, mod-
ernization, technology, change, and accountability. As a result, today’s sub-
stance use specialty workforce suffers a 30%–40% annual attrition of workers 
(SAMHSA 2013). Additionally, the illness appears in all general medical condi-
tions and settings, creating a need for exponential cross- disciplinary integrated 
care and clinical expansion, training, and development (SAMHSA 2013).

We need to strengthen our application of prevention science (Kolodny 
et al. 2015; Tarter, Cochran, and Reynolds 2018), expand opportunities for 
earlier intervention in general medical care, and increase treatment capacity, 
especially with medication support—linking each person and his or her fam-
ily to recovery science and peer and family supports. Substance use treatment 
needs to be a focus across all medical disciplines to become a more mod-
ernized interdisciplinary workforce with screens and assessments, integrated 
treatment, and ongoing recovery checkups in all general and specialty medi-
cal settings, e.g., primary care, health centers, general health care, and across 
all hospital disciplines. This broader, more educated, and more competent 
collaborative health care workforce with peer and community involvement 
is the only workforce capable of reaching addiction and ultimately reducing 
overdose (Hoge et al. 2013, 2017).

Addiction, Overdose, and the Brain—The Power of Addiction

Addiction has a complex biological nature. This illness has the power to impact 
a person’s brain and create an insatiable immediacy for the need for drugs that 
removes judgment from the person, at least temporarily, obviating the choice 
to not seek more drugs or to never use again. Neurologists now believe this 
may possibly be tied to repetitive but rebuffed electrical impulses (cravings) 
in the brain. Short of overdose and death, this loss of choice is the first, worst, 
and most underestimated manifestation of the illness. It can be said that the 
person at this point does not really have an addiction; instead, the addiction 
has him or her. Moreover, studies have shown there is a genetic transfer of vul-
nerability for the illness to offspring, creating a predisposition for increased 
risk in the future (NIDA 2016a; Sliboda, Glantz, and Tarter 2012).

Addiction, at whatever level of severity (Mee-L ee et al. 2013), too often leads 
to a life of misery and death, with generational and broader societal impacts 
and decades of cost. For these reasons, the American Society on Addiction 
Medicine and the National Institute of Drug Abuse classify addiction as a 



Treatment, Overdose, and Finding the Road to Recovery  69

“disease” (ASAM 2017; NIDA 2018a). This is a classification that society, 
policymakers, public health professionals, law enforcement, and others must 
understand and embrace if we are to properly assess the disease and appreci-
ate its power, lethality, and costs. Only by doing so can we adequately design 
the steps to effectively address addiction while building individual, family, 
and community recovery based on medical safety and continued wellness.

The power of addiction can remove choice cognitively and experientially. 
Once a person is stabilized medically, treatment must not just address pathol-
ogy but also access and build recovery strengths in individuals, families, 
and the community, i.e., build measurable recovery capital, resiliency, and 
strength (Granfield and Cloud 1999). Treatment must be medically precise, 
person- centered, and ongoing, while continually offering hope and recov-
ery. A consensus definition of recovery, as a unifying construct for all, was 
achieved in 2012 by SAMHSA:

Recovery is a process of change through which individuals improve 
their health and wellness, live a self-d irected life, and strive to reach 
their full potential. SAMHSA has delineated four major dimensions 
that support a life in recovery: health, home, purpose and community.

The vision of recovery is grounded in medical stability and returned cognitive 
capacity. Both take time.

When Treatment Becomes the Problem—Pain, Prescriptions,  
and Diversion

Reportedly, as many as 80% of those who are currently addicted to opioids 
began their addiction with prescription pain medications (NIDA 2018a; 
Muhuri, Groener, and Davies 2013; Jones 2013). In 1995, the president of the 
American Pain Society introduced a campaign entitled, “Pain is the Fifth 
Vital Sign,” which encouraged health care professionals to assess pain with the 
same “zeal” as they did other vital signs. This campaign suggested increased 
access to opioids for chronic, noncancer pain (Campbell 1996), and was fol-
lowed by thousands of pain- related educational presentations, sponsorships, 
and grants funded by big pharma across the country (U.S. GAO 2003).

During this campaign, some researchers inaccurately proclaimed the risk 
of addiction and tolerance with real pain to be low, adding that concerns about 
addiction should not constrain prescribing (Porter and Jick 1980; Fishbain et 
al. 2008). Prescriptions of opioids soared, as has addiction (U.S. GAO 2003). 
Today, Pennsylvania has active opioid prescriptions sufficient for up to 90% 



70 Michael T. FlaherTy

of its citizens to have their own full prescription. Pharma is big business in 
Pennsylvania and across the nation (CDC 2017a), and pain relief is a big part 
of big pharma. Seeking quick solutions for pain and addiction, and capturing 
the enormous profits that can be generated, is big business.

While these medications can be a godsend for some, for others they can 
advance and compound the illness, causing iatrogenic dependence or avoid-
ance of treatment itself by increasing self- dosing. Studies show that conserva-
tively 26% of those being treated for pain develop dependence (Banta- Green 
et al. 2009). If not closely medically managed with sustained person- centered 
care, principles of recovery, and concern for community and population 
health, diversion becomes a real possibility and problem. With over 255 mil-
lion opioid pain prescriptions active in 2016, it is estimated that some 11 mil-
lion Americans used these prescriptions illicitly (Volkow 2017).

Personal medical care is required in all addictions, whether they origi-
nated via illicit drugs, addiction treatment, or iatrogenic pain management. 
The medications used as a part of the treatment for opioid dependence must 
be promptly available but carefully managed to allow for patient relief while 
minimizing the possibility of diversion of these medications for illicit use, 
profit, and harm to the community. Achieving better medical management 
of such medications is necessary, as is maintaining a continuity for treatment 
should iatrogenic dependence occur (U.S. Department of Health and Human 
Services (HHS) 2013). Pennsylvania’s model for methadone treatment, which 
includes close medical management, might provide a successful, proven 
model for all agonist1 treatment for addiction.

New pain management protocols and guidelines (AAPM 2015) have now 
been developed, suggesting “sliding scale” protocols for pain treatment, often 
beginning with nonopioid medications. This said, prescribing practices, 
diversion, and narrow pain management treatment are large sources of today’s 
epidemic and barriers to reducing overdose. On January 1, 2017, Pennsylvania 
launched its own prescription drug monitoring program (PDMP), which will 
allow physicians to more accurately know if patients are “doctor shopping,” 
or using opioids or other medications that could be problematic to treatment. 
A strong clinical use of computerized monitoring has been shown to reduce 
overdose nationally (CDC 2017b). Pennsylvania is attributing a 12%–18% 
reduction in opioid prescriptions in its first year to this program (Lord 2018). 
(For more information on PDMPs in PA, see Mirigian et al. in this issue.)

The Economy and the Cartels

In the “perfect storm” from which this epidemic has emerged, several lethal 
and converging forces have been identified to have fueled the epidemic and 



Treatment, Overdose, and Finding the Road to Recovery  71

undermined efforts to end it: absence of a unifying vision, denial and unad-
dressed stigma, inadequate medical preparation, anemic prevention, over-
burdened treatment, a weary and nonintegrative workforce, excessive and 
uninformed prescribing in the quest to eliminate pain, and opportunities to 
profit from the illness itself. A final force is the economy and the drug cartels.

Nationally prominent author and journalist Sam Quinones has laid out 
what our federal Drug Enforcement Agency also has reported: Pennsylva-
nia, and Appalachia more generally, are major targets for the distribution 
of cheaper and enhanced heroin from outside our borders that can become 
lower- cost replacements for prescribed opioids (Quinones 2015). Shunning 
mafia- a nd gang- controlled cities, Mexican cartels from small towns (e.g., 
Xalisco, Mexico) have targeted more rural American communities (e.g., cen-
tral Ohio, southwestern Pennsylvania, and West Virginia) where their heroin 
can capture already- existing markets spawned by the heavily prescribed use 
and misuse of prescribed opioid medications. In a sense, the cartels let strong 
medical centers and physicians set the stage for their market.

It is no accident that, as prescription practices become monitored and 
are more constrained, illicit heroin has become more accessible and has been 
made more powerful with fentanyl (often from China) and the even more 
deadly carfentanyl. In this progression, without extraordinary intervention, 
overdoses will increase. Those distributing these less costly, highly lethal sub-
stances prey on poverty and victimize captive users as part of their “busi-
ness as usual” underworld economy. This explains why there is a need for 
the joint participation of public safety or law enforcement in any overdose 
reduction plan. Further, with many communities having lost industries and 
jobs, cultures have arisen in which drug use is common, and in which drug 
distribution and income, given a seeming lack of alternatives, has become a 
tolerated part of a struggling existence (Vance 2016). In such communities, 
drug use goes up, as do specialty medical care needs, where prescriptions can 
be obtained. Too often these communities and the prescribed medications 
become the foundation for an economy based largely on selling medications 
while reverting simultaneously to alternative cheaper, illicit drugs from the 
cartels. Now we have the perfect storm for the epidemic.

Plans and Resources: Treatment and a Coordinated, 
Continuing Need for Action

In addressing opioid use, overdose, and barriers to treatment, science does 
offer twenty- first- century practices that, when combined with local imple-
mentation and enhanced services, are proving effective in reducing overdose 
while enhancing treatment access and building community resilience and 



72 Michael T. FlaherTy

recovery. A partial summary of recent national efforts, and Pennsylvania’s 
plan and efforts, can be found in Appendix B.

In scanning these many documents, the reader will quickly see the array 
and magnitude of both prevention strategies and treatment activities that can 
be brought to bear to address overdose and reduce death, while simultane-
ously initiating treatment and recovery. A summary of common strategies 
proving effective, based on a review of these documents, is below.

Best Practice in Overdose Treatment—Actions

Prevention as the Best First Practice

Prevention as a science is covered in another article in this volume (Tarter, 
Cochran, and Reynolds). Suffice it to say that more than any other proposed 
or actual solution, preventing the problem in the first place is the optimal 
solution. Also, by addressing overdose with prevention you can initiate and 
strengthen treatment. Kolodny and colleagues (2015) have framed just such 
a model for public health to address the opioid epidemic based on proven 
prevention science. In their model to address overdose, they align existing 
SAMHSA prevention science paradigmatic classifications to build the follow-
ing preventative model.

Primary (Universal) Prevention
The aim of primary prevention is to reduce the incidence of a disease or con-
dition. Opioid addiction is typically chronic, life- long, difficult to treat, and 
associated with high rates of morbidity and mortality. Thus, bringing the 
opioid addiction epidemic under control requires effort to prevent new cases 
from developing, including greatly reducing access to such medications for 
pain management, which can lead to iatrogenic dependence.

Secondary (Selective) Prevention
The aim of secondary prevention is to screen for a health condition after its 
onset, but before it causes serious complications. Efforts to identify and treat 
opioid-ad dicted individuals early during the disease are likely to reduce the risk 
of overdose, psychosocial deterioration, transition to injection opioid use, and 
medical complications. One science- based guide of such prevention is NIDA’s 
“Principles of Substance Abuse Prevention for Early Childhood” (2016b).

Tertiary (Indicated) Prevention
Tertiary prevention strategies involve both therapeutic and rehabilitative 
measures once a disease is firmly established. The goal of tertiary prevention 



Treatment, Overdose, and Finding the Road to Recovery  73

of opioid addiction is to prevent overdose deaths, medical complications, 
psychosocial deterioration, transition to injection drug use, and injection- 
related infectious diseases. Doing so is accomplished mainly by ensuring 
that opioid-ad dicted individuals can access effective and affordable opioid 
addiction treatment. Here, timely access to treatment, especially those includ-
ing medication- assisted treatments such as buprenorphine, methadone, and 
naltrexone (pill or injectable), would fit into a prevention strategy for both 
the individual and the community. Additionally, certain “harm reduction” 
strategies would be made more available, e.g., syringe exchange programs and 
readily available NARCAN accessibility. Such prevention strategy needs to be 
incorporated into Pennsylvania’s Strategic Prevention Framework and Plan 
and implemented in each county.

By adding what is presented in detail by Tarter, Cochran, and Reynolds 
in this issue to Kolodny’s generally accepted schematic rubric, Pennsylvania 
could indeed have one of the finest prevention programs in the nation.

Treatment

Outreach
An overdose is best addressed by quickly reviving the person from the over-
dose and connecting him or her immediately to further treatment. This is 
best achieved by applying naloxone (aka NARCAN) to revive the person if 
unconscious, and then connecting the survivor, via a “warm handoff,” to an 
agency or professional who can assist the person to obtain treatment with-
out delay. Today in Pennsylvania, the person must agree to such treatment 
until an involuntary admission or “hard handoff” law is justified and is 
enacted in Pennsylvania (e.g., upon second overdose or through earlier fam-
ily intervention).

Overdose drug deaths far exceed death by suicide, e.g., in 2015 the National 
Institute on Mental Health reported just over 40,000 deaths attributed to sui-
cide (many by drugs) vs. 54,404 overdose drug deaths (Rudd, Seth, and Scholl 
2016). Both Pa. 2010 Act 50 Article XXIII-A , section (1) xvii and the Mental 
Health Procedures Act of 1976 should be reviewed to answer key questions 
such as: Is the overdosed person evidencing a “clear and present danger to 
self or others” with a likelihood of possible death within 30 days? Involuntary 
admission can be to outpatient or inpatient settings. On December 8, 2017, 
Pennsylvania Senator Jay Costa (D- 43) introduced Senate Bill 391 to allow 
families to obtain court- mandated treatment. While likely to have opposi-
tion from civil rights advocates, payers, and even many in recovery, given 
the power of today’s drugs and the severity of the illness with related loss of 



74 Michael T. FlaherTy

mental competence (hijacked brain) and hope, such examination and revised 
laws are necessary. Thirty- eight states, including Pennsylvania, currently have 
some form of involuntary admission law for substance use, but these laws are 
too cumbersome, unknown, and weak compared to similar laws for mental 
health. Any new law should include overdose survivors, families of those lost, 
providers, civil rights and peer advocates, and all counties that will need to 
educate the public and implement the revised law.

In addressing opioid overdose, individual recovery cannot begin unless 
the person is alive and physically able to initiate it. Today’s typical treatments 
are too institutionally centric to reach those most at risk. Outreach and novel 
points of access (e.g., mobile treatment, needle exchanges, food banks, fire-
houses, hotels, community safe centers, trained pastors, and peer linkage) are 
potentially productive initiatives, as is involuntary treatment. Pennsylvania 
has been historically more conservative in its approaches to overdose. It is 
worth noting, though, that some states and major cities have found successful 
avenues to treatment through involuntary treatment and by expanding harm 
reduction approaches such as access to safe- drug consumption/t reatment 
sites, and by changing police responses to low- level crimes such as taking 
the person to treatment or safe consumption/treatment sites. Seattle’s Law 
Enforcement Assisted Diversion (LEAD) Program is one model highly sup-
ported by both the police and the community (Collins, Lonczak, and Clifase 
2015). Throughout Ohio and in Pittsburgh, Pennsylvania, police have recently 
initiated Quick Response Teams as a follow- up to any overdose.2

What makes these newer harm- reduction approaches appealing is that they 
reduce human suffering while lowering overdose and societal costs (e.g., incar-
ceration, health, etc.) and improving access to treatment. Addressing over-
dose prevention mandates a harm-re duction component within the treatment 
continuum. Keeping a person alive, while offering an alternative to untreated 
addiction, is society’s mission and task. Beyond that the disease will win.

Medical Stabilization and Treatment
Medical stabilization from opioid use disorder itself is necessary for a depen-
dent person to return to normal functioning and quality of life and to avoid the 
many potential consequences of opioid dependence such as trauma, suicide, 
HIV and hepatitis C infection, family suffering, and early death. Treatment 
has been proven to address these consequences while improving the overall 
social functioning of the person and family wellness. The Surgeon General 
Report (U.S. HHS 2016) and National Institute on Drug Abuse (2018b) outline 
well the effectiveness of opioid treatment.



Treatment, Overdose, and Finding the Road to Recovery  75

There are a variety of approaches in treating opioid use. The three most 
common outpatient approaches are treatment in opioid treatment programs 
(OTPs), generally in methadone clinics, which are monitored and regulated by 
both the state and federal government (SAMHSA, DEA); office- based opiate 
treatment programs (OBOTs), generally in buprenorphine dispensing centers, 
which are unmonitored individual specialty–trained medical practices; and 
abstinence- based specialty substance use treatment, which can include some 
medication, e.g., naltrexone (pill or injectable) or psychiatric medication, but 
usually do not use agonist medication. These comprise most of Pennsylvania’s 
providers and are licensed and monitored by the state. Given the severity of 
addiction, residential and inpatient care may also be warranted, if available. 
These, too, may include medication- supported recovery.

OBOTs, the fastest- growing approaches, have strengths and weaknesses, 
including easier access to medication but lighter medical monitoring, less 
counseling, and greater opportunity for medication diversion (Alderks 2017). 
Some more sophisticated OTPs, which have by regulation increased medi-
cal oversight and counseling, have begun to incorporate buprenorphine and 
naltrexone (i.e., Vivitrol) into their treatment protocols, which previously had 
used only methadone. This progression seems to be moving toward a “com-
prehensive opioid treatment center” model, which would seem both clinically 
and scientifically evolutionary and a positive step for all.

Mention must be made of treating opioid- o r heroin- dependent pregnant 
women and their babies. It is estimated that today some 2.1 million Ameri-
cans use illicit opioids and another 467,000 are addicted to heroin. Studies 
also indicate that for every five individuals with this illness, there will be 
one child born with dependence and withdrawal or neonatal abstinence syn-
drome (Volkow 2014). Across America, births of such babies and the increased 
burden on the child welfare system are growing at unprecedented rates. The 
cost and implications of this growth are astronomical if the child is untreated 
and can be lifelong. However, with early recognition, good prenatal care, and 
substance use treatment, the outcomes can be brought to near- normal in com-
parison to nonaddicted populations.

There is a well- developed and exacting science, for both mother and 
child.3 This population should be a priority, and to its credit, Pennsylvania 
has recently funded a Center of Excellence, the Maternal Addiction Treat-
ment, Education, and Research (MATER), at Thomas Jefferson University in 
Philadelphia. Thomas Jefferson University has been a national and interna-
tional leader in working with the population for decades, and the work of its 
new Center of Excellence needs to be vigorously disseminated.



76 Michael T. FlaherTy

Augmenting these “outreach” and “treatment” services are local peer 
groups and 12- step fellowships, such as Narcotics Anonymous, Alcoholics 
Anonymous or Al- Anon, and many nonfellowship free supports such as Sage’s 
Army (western Pennsylvania) Family Resource Center (www.familyresourcectr 
.org), Bridge to Hope (western Pennsylvania), and other organizations gener-
ally accessible through local county drug and alcohol programs. All can assist 
in identifying sources of help and potential avenues to recovery. Some, like 
Bridge to Hope, offer parent and family support groups to help cope with loss 
and ongoing grief as well as to enable family members to identify problems 
and empower them to action. Community reinforcement and family training 
(CRAFT) is but one proven educational and training program that prepares 
family members for earlier, scientifically grounded intervention (Foote et al. 
2014). These peers, fellowships and supports, and family groups complement 
formal treatment and are a modern “must,” as part of any ultimate safety net 
for communities. They have an impact that cannot be overestimated as being 
vital to any ultimate solution.

All treatment approaches are not equal, nor are they interchangeable. The 
severity of the illness must be accurately assessed and properly matched to 
the appropriate level of care so that medical safety and stabilization can be 
achieved first, creating an opportunity for longer-te rm treatment and recov-
ery. Too often individuals are turned away from treatment, especially in hos-
pital emergency room settings or by waiting lists in outpatient programs. Such 
actions very often negate the desire for treatment and increase the probability 
of overdose. A personal review of overdose death records (unpublished) by 
this author has shown that over 63% of the nearly 100 who died from opi-
oid/heroin overdose had sought prior treatment or had prior criminal justice 
involvement before their demise. Why did that treatment or encounter not 
stick? Was the treatment appropriate to the presenting need of the person? 
Would a peer support or medication have made a difference?

When treatment is accessed, the person should be carefully screened for 
the severity of the presenting illness. The American Society on Addictive 
Medicine Patient Placement Criteria (Mee- Lee et al. 2013) and the Pennsylva-
nia Placement Criteria (Commonwealth of Pennsylvania 2014) are two excel-
lent examples of the guidance now required in Pennsylvania and some other 
states to properly place a person in a matched level of care. Further assessment 
of the severity of the illness can be enhanced through the use of any of several 
more focused addiction severity measurement scales, e.g., Addiction Severity 
Index (ASI) (McLellan et al. 1980);4 or with withdrawal management instru-
ments such as The Clinical Opiate Withdrawal Scale (COWS) (Wesson and 
Ling, 2003), or the Severity of Opiate Dependence Scale (Sutherland et al. 



Treatment, Overdose, and Finding the Road to Recovery  77

1986). Residential or hospital care may first be warranted by the results of this 
critical initial assessment.

If outpatient treatment is recommended, methadone (OTP) or buprenor-
phine (OBOT) or naltrexone injection (nonagonist Vivitrol) treatment should 
be considered as being more successful in preventing overdose and provid-
ing more time to stabilize the patient for early recovery. Standard outpatient 
treatment may not use agonist medication. However, in today’s populations 
of stronger opioids and heroin, both the World Health Organization5 and 
SAMHSA (2016) recommend that all individuals with an opioid dependence 
diagnosis be considered for medication- supported treatment. Standard out-
patient treatment may use naltrexone or the monthly injectable Vivitrol or 
other nonagonist medications to fortify abstinence. Vivitrol, an opioid block-
ing agent, is also used in OTPs and OBOTs when it has been determined 
medically safe to do so. It is also successfully used with those newly returning 
to the community from jail or rehab.

Sadly, only 20% of the people addicted to opioids today receive treatment 
(U.S. HHS, Office of the Surgeon General 2016). This problem is made even 
more acute by the insufficient preparation of large numbers of practicing 
U.S. physicians in the treatment of addictions. Only 2.2% of all physicians 
are approved to use the most common treatment medication, buprenorphine, 
and 90% of those 2.2% are practicing in urban areas, leaving most rural coun-
ties without proper care (NIDA 2016d). Many barriers and challenges exist for 
communities to recruit and retain physicians (or nurse practitioners) trained 
in addictions or to attract enough opioid- treatment practitioners (DeFlavio et 
al. 2015; Huhn and Dunn 2017; Stein et al. 2015). Increasing properly managed 
access to medication support may be the greatest single treatment step that 
can be taken today to slow overdose deaths and give treatment and recovery 
a chance.

Once matched to one of seven possible levels of care (Mee- Lee et al. 
2013) for initial treatment, the person should proceed along a continuum or 
levels of care over time based on assessed progress and medical judgment. 
Once in treatment, the person usually remains in treatment for a sufficient 
period to be medically stable and initiate early recovery. As noted above, 
the National Institute on Drug Abuse suggests a 90- day continuum of care 
as minimal (NIDA 2018b). Medication-a ssisted treatment often takes years 
and may continue for a lifetime. Still, in general, for every dollar spent in 
substance use treatment minimally a $7 savings to society is returned; $8 for 
medication- supported treatment due partly to decreases in criminal behav-
ior and re- incarceration (NIDA 2018c). Put simply, treatment more than pays 
for itself!



78 Michael T. FlaherTy

Common Elements in Successful Treatment and Overdose Prevention

Having underscored earlier prevention and access to specialized, patient 
matched, skilled treatment with general medical care as a basic need, the 
author’s personal experience and a review of the clinical guidance listed in 
Appendix A has allowed him to identify common elements as cross-c utting, 
impactful, and promising. These common elements for such success are dis-
cussed in the next sections.

Ready Access to Treatment and a Continuum of Care
For a treatment system to be effective, it must provide ready access to treat-
ment and a continuum of care over a sufficient length of time so that the patient 
achieves personal safety and medical stability and is positioned to have a real-
istic opportunity for recovery. Twenty- four/seven crisis centers, urgent care 
centers, mobile units, and emergency rooms, when properly organized and 
staffed, have proven to be effective as points of first access for medical care 
and the initiation of medication and treatment (D’Onofrio, O’Connor, and 
Pantalon 2015).

Medication- Assisted Treatment (MAT)
Timely access to medication-assisted treatment is also critical to the creation 
of an effective treatment system. These medications are used to help a patient 
function without illicit opioids or alcohol while balance is gradually restored 
to the brain circuits that have been altered by prolonged substance use. It 
should be noted that patients who receive MAT for fewer than 90 days have 
not shown improved outcomes; similarly, detox alone is almost universally 
not successful (U.S. HHS, Office of the Surgeon General 2016, 4–21). Some 
studies suggest that individuals who receive MAT for fewer than three years 
are more likely to relapse than those who are in treatment for three or more 
years (American Medical Association 1998; Joseph, Stancliff, and Langrod 
2000; Kakko et al. 2003). Three medications are most commonly used to treat 
opioid use disorders: methadone, buprenorphine, and naltrexone.

More recently the SAMHSA (2016) and American Medical Association 
(2018) published guidance that, recognizing the increased addictive power of 
today’s medications and illicit drugs, suggests:

 

Opioid withdrawal alone is not recommended for treatment of opioid 
use disorders in most patients because of increased risks of overdose 
death and infectious disease, particularly HIV through intravenous 
drug use, following detoxification (moderate quality evidence, strong 



Treatment, Overdose, and Finding the Road to Recovery  79

recommendation). In the absence of contraindications, medically 
supervised opioid agonist treatment should be offered to patients. 
Buprenorphine/naloxone is the preferred first-l ine treatment. Metha-
done is an alternative in certain patient populations (high- quality evi-
dence, strong recommendation). (SAMHSA 2016, 338)

Naloxone/NARCAN
Community awareness, training, and ready access to naloxone (NARCAN) 
throughout communities are critical to saving lives, thereby preserving 
opportunities for treatment. Among those needing access are active users, 
counselors, families, first responders, schools, ERs, hotels, jails, fire stations, 
and other locations that may be potential points of connection between survi-
vors and providers of treatment via “warm handoff” or person- to- person con-
nectivity. Anyone with a diagnosis of opioid dependence and his or her family 
members should have NARCAN. Of course, access to NARCAN will not be 
enough if those who have it do not know how to use if effectively. What also 
is needed, therefore, is strong community prevention awareness and training, 
including special training (e.g., CRAFT, how to use NARCAN) for parents 
and other family members. Such interventions generally are protected by sup-
portive Good Samaritan laws, which provide an important measure of legal 
protection for those providing help as volunteers.

Prescription Drug Monitoring Program
Active participation and coordination of prescribing via a prescription drug 
monitoring program (PDMP) by all prescribers is another key step. Pennsyl-
vania became the 49th state to adopt such a program through Act 191 of 2014. 
That program went into effect on January 1, 2017, and already seems to have 
made a difference in prescribing rates. (For more information on PDMPs in 
Pennsylvania, see Mirigian et al. in this issue.) Opioid prescribing also can 
be reduced by following CDC guidelines and alternative pain management 
techniques.6

Other Effective and Suggested Strategies

Expand Capacity
Open bed capacity must be increased to meet acute needs. A key policy step 
would be to seek adjustments to federal restrictions (e.g., federal IMD exclu-
sion) to allow expanded Medicaid and Tricare coverage of residential care. 
Pennsylvania should advocate for this, either as a change in law or a waiver 
to existing law, and should seek reductions in federal restrictions to speed 



80 Michael T. FlaherTy

accessing methadone treatment. Another important step would be to establish 
24/7 available crisis walk- in centers for behavioral health that can determine a 
diagnosis and provide up to 23 hours of on- site (non- 24- hour inpatient) care 
before “warm handoff” discharge to inpatient admission, rehab, or outpatient 
continuing care. Medication initiation should also be available at these sites.

Focus on High- Risk Populations
Outreach should be expanded to high-risk populations, such as pregnant and 
addicted women and newborns, Drug Court participants and postincarcera-
tion populations, post-detox/rehab populations, youth (18–25), and returning 
veterans. Drug take- back boxes should be more extensively deployed. A sys-
tem that provides 24/7 access to care points across the state should be devel-
oped, and a priority should be assigned for targeted prevention and enhanced 
training for parents, clergy, and others in the community.

 

Make More Expansive Use of Specialty Courts
There should be expanded use of Drug Courts and, where appropriate, Family 
Court, guided by twenty- first- century best practices, including peer support.7 
Best practices from other parts of the country, such as the LEAD (Seattle) 
model, should be considered for adoption here, and there should be additional 
skill resource and skill development for law enforcement.

Provide Adequate Time for Treatment
There needs to be support for retention in treatment sufficient to achieve 
medical stabilization and early recovery. Withdrawal management or “detox” 
alone should only be offering medical stabilization as the precursor to treat-
ment. Beyond treatment, programs should offer recovery as a return to a posi-
tive life for oneself and in the community. Individual, family, and community 
recovery measures should be established to build and measure clinical out-
comes and resiliency, i.e., strengthened individual and community recovery 
capital. For sustained overdose and substance use reduction, implement a 
statewide Recovery-O riented System of Care (SAMHSA 2012; White 2008). 
Ninety- day minimal care should be encouraged and should be a monitored 
and managed goal.

Collaborate and Implement Community Plans
Leaders in each community should initiate community meetings that bring 
together citizens, public health and public safety leaders, and payers to design 
and implement a local plan that includes initiatives such as addressing stigma 



Treatment, Overdose, and Finding the Road to Recovery  81

and overdose while building individual and community resilience and health, 
i.e., increasing recovery capital. Recovery capital is measurable as the quantity 
and quality of internal and external resources that the community can bring 
to bear on the initiation and maintenance of recovery. Having a local plan 
empowers each community but does not replace broader efforts to address 
root causes of the problem, e.g., increased and improved medical training 
and preparedness, increased law enforcement efforts, and aligned new policy 
development for communities to know, and upon which to act. All final solu-
tions are local. Families and communities are the beginning and end of those 
solutions.

Collect and Learn from Data
Each overdose should be anonymously reviewed to strengthen local systems, 
including the study of failed early- intercept points for system improvement. 
This data can be used to understand trends and to improve local efforts, while 
larger efforts support broader and longer- term solutions, i.e., building recov-
ery capital. The thoughtful use of this data will also convey to each family 
that no death is without meaning and that from each loss, system and com-
munity strength will grow: hope arises from loss. The identities of victims are 
not needed, so HIPPA or other confidentiality concerns need not be barriers.

Augment Professional Efforts
The building of peer and family supports in each community can augment 
the existing professional workforce. Local universities or colleges, along with 
professional counselor organizations, should build career pathways for those 
in sustained recovery or those with firsthand experience of the illness (e.g., 
family members) to become “Peer Supports” that can help individuals, treat-
ment agencies, or families and communities in ways that other professionals 
cannot. For example, peers can be a warm handoff person, support a person 
to enter treatment, reach out to families who need help, increase retention 
in treatment, assist with transportation, etc. Pennsylvania now has a certi-
fication path for Peer Supports,8 and increasingly public health payers are 
beginning to recognize and pay for these services. The development of these 
workers, whether paid or volunteer, is proving essential to the long- term real-
ization of success in addressing overdose and ultimately preventing addiction. 
Peers are not a replacement for professional treatment but are an enhancement 
of it. In America today, there are over 40 million adults living in recovery 
(White 2012), and one in four families is personally affected by substance use 
(NIDA 2016c). 



82 Michael T. FlaherTy

Strengthen Integrated Care
The twenty- first-c entury model for care is integrated care with parity. In 
recent years, large health systems and medical practices have found that 
community- based generalist outpatient care (e.g., primary care, community 
health centers, group practices, etc.) can be more efficient in reaching all pop-
ulations with quality care (Christensen et al. 2009). What if each such outpa-
tient center had a certified addiction specialist physician or nurse practitioner 
and behavioral counselor with peer accessibility that then naturally brought 
this specialized service to the community? These centers would indeed be 
meeting community needs without having to face so many other issues and 
barriers, e.g., lack of knowledge, access, losing patients in referrals. In San 
Francisco, at the Zuckerberg San Francisco General Hospital, all physicians 
in all specialties are trained to assess and treat addiction in the location where 
the patient is seen—with addiction- certified specialists on 24/7 call.9

In Boston, based on a community needs assessment, Massachusetts Gen-
eral Hospital opened specialized addiction services with 24/7 access to all 
levels of care, including same- day buprenorphine treatment and referral. 
To assure no one gets lost in the cracks, each patient is assigned a recovery 
coach.10 Outpatient integration of care is also growing via 23/7 Crisis Stabili-
zation Centers linked to hospitals, and behavioral experts being added to gen-
eralist sites such as primary care, health centers, family practice groups, etc.

Recovery—The Path to Hope and Solution

Informed national and local leaders have all concluded that we can neither 
legislate nor arrest our way out of this epidemic. We cannot even treat our 
way out of it without long-te rm specifically designed universal, selected, and 
indicated prevention strategies built upon a unified vision and driven by a 
coordinated and determined implementation effort that recognizes existing 
barriers and overcomes them. This means doing nearly everything noted in 
this document at the local level—with leadership from science and policy-
makers alongside strong citizen involvement. The solution, like the problem, 
is complex and requires complex adaptive reasoning with culturally sensi-
tive community approaches and systems, such as those used in addressing 
diabetes, HIV, Zika, and other complex, societal illnesses (Institute of Medi-
cine 2001). Today’s established institution- based medical model can’t go far 
enough to meet the present challenges. We must first establish the will and 
a vision that can lead to recovery and hope—recovery for each person, each 
family, each community, each county, each state, leading to recovery for our 
nation. A vision that can do this is required. We cannot afford to cast off a 
single person without simultaneously losing our way.



Treatment, Overdose, and Finding the Road to Recovery  83

Who we are as a society is the true challenge of addiction and this epi-
demic. It has been a long time coming (see Burke and Buchanich in this 
issue). The challenge of addiction and all its societal manifestations needs to 
be continually addressed for its many root causes. Adapting a solution using 
complex, adaptive approaches developed by local groups across America and 
around the world means inserting their voices with best practice and the 
emerging science and solutions for recovery. This twenty- first- century “medi-
cal model” (Barber 2012; Flaherty 2012) promises to each person and family 
who seeks help an opportunity for recovery, i.e., an improved quality of life, 
and not just partial care or the maintenance of misery. Communities across 
America are insisting on the values of wellness and recovery as their standard 
of care with their limited public dollars and stronger collective approaches to 
the problem. Recovery, as defined above, is offered to everyone, family and the 
community at large, by bringing shared goals and measures into a partnership 
with applied best science and practice.

Recovery can occur with medication or without medication. Recovery has 
many pathways with specific phases and can be measured in each person 
and family as increased resilience, strength, and wellness (individual recovery 
capital); or in each community (community recovery capital) as assets to pre-
vent, treat, and end addiction growth (Flaherty, Kurtz, and White 2014; White 
and Kurtz 2008, 26). Known as “recovery-o riented systems of care” (ROSC) 
for mental health and substance use, ROSC is nothing short of transformative 
as it moves health systems away from institution-ba sed, crisis- oriented, acute, 
deficit-f ocused, and professionally directed and controlled models of care to a 
vision of care that is directed by each community and those people in recov-
ery in the community (Christensen, Grossman, and Hwang 2009; Institute 
of Medicine 2001; SAMHSA 2012). A recovery- oriented system of care, when 
applied, is a grassroots- originated, complex, adaptive systems approach. It is a 
network of indigenous and professional services and relationships that builds 
the health of each community from within with prevention, early interven-
tion, and treatment linked to short-t erm, long- term, and sustained recovery of 
individuals, families, and the community. Further, ROSC builds the local val-
ues and policies into a culture and environment that will remain continuously 
supportive of these recovery practices in general medical (e.g., integrated and 
primary care) and specialty care (e.g., acute substance use treatment).

A ROSC system joins the community with providers and leaders to adopt 
and implement principles and objectives used in implementation, e.g., in a 
county (Hancock, Ohio), a city (Philadelphia), or in states such as Connecti-
cut, Texas, North Carolina, Ohio, etc. (Kelly and White 2011). ROSC measures 
are now embedded in the federal funding to each state for implementation 
within that state’s block grant. A ROSC system is not a federal, state, or local 



84 Michael T. FlaherTy

agency, but a community network of indigenous and professional services 
and relationships that can achieve and support the long- term recovery of 
individuals and families within the larger cultural and policy environment 
of each community in which overdose is to be ended through specifically 
designed prevention, early-i ntervention, treatment, and long- term recovery 
(SAMHSA 2010). By combining the strategies of overdose prevention (includ-
ing harm reduction) with best science and practice within a ROSC, short- a nd 
long-t erm solutions to this epidemic become accessible and hope returns as 
a reality.

Resources and a full bibliography of this modern science, includ-
ing evaluations of it, are available at www.samhsa.gov (search: recovery);  
williamwhitepapers.com; the Recovery Institute at Harvard University 
(info@recoveryanswers.org); the SAMHSA- funded Addiction Technology 
Transfer Centers (www.attcnetwork.org); or the Institute for Research, Edu-
cation and Training in the Addictions (IRETA) in Pittsburgh, PA (www.ireta 
.org). ROSC, in part or in whole, is now emerging across the globe and in 
over 30 states. ROSC, with the system changes noted in this document, brings 
state, county, and community leadership, guidance, and implementation for 
long- term resolution of the epidemic, stigma, and illness. It is hope made 
real through an empowered community. Our policymakers need to under-
stand that, while there are no quick solutions to the problem of addiction 
and overdose, a community- based solution joined with science, best prac-
tice, and local systems of care offers to Pennsylvania—and the country—the 
best option for a long- term solution to today’s opioid challenge. It addresses 
the barriers and challenges while offering a sustainable twenty- first- century 
model of care for each person that can end an epidemic through the recovery 
from its causes.



Treatment, Overdose, and Finding the Road to Recovery  85

APPENDIX A

The continuum of care to address addiction (Surgeon General 2016)

enhancing 
health 

Primary 
Prevention 

early 
intervention Treatment recovery Support 

Promoting Addressing Screening Intervening through Removing barriers 
optimum physical individual and and detecting medication, and providing 
and mental environmental substance use counseling, and other supports to aid the 
health and well- risk factors problems at an supportive services to long-term recovery 
being, free from for substance early stage and eliminate symptoms process. Includes 
substance misuse, use through providing brief and achieve and a range of social, 
through health evidence-based intervention, as maintain sobriety, educational, legal, 
communication programs, needed. physical, spiritual, and other services 
and access to policies, and and mental health, that facilitate 
health care strategies. and maximum recovery, wellness, 
services, income functional ability. and improved 
and economic Levels of care quality of life.
security, and include: Outpatient 
workplace Services; Intensive 
certainty. Outpatient/Partial 

Hospitalization 
Services; Residential/ 
Inpatient Services; 
and Medically-
Managed Intensive 
Inpatient Services.

APPENDIX B: SUMMARY OF NATIONAL, PENNSYLVANIA,  
AND OTHER OVERDOSE PREVENTION PLANS AND ACTIONS

This summary is not meant to be exhaustive of all efforts but does reflect links 
to recent key federal, Pennsylvania, and others states’ resources and efforts to 
address overdose.

National Resources to Address Overdose

Key national guiding documents and resources can be found in the U.S. 
Department of Health and Human Services (www.hhs.gov), the National 
Center For Disease Control (www.cdc.gov), the Substance Abuse and Mental 
Health Services Administration (www.samhsa.gov), the National Institute for 
Drug Abuse (www.drugabuse.gov), the Health Resources and Services Admin-
istration (www.hrsa.gov), the White House Office of National Drug Control 
and Policy (www.ondcp.gov), the American Society for Addiction Medicine 
(www.asam.org), the American Psychiatric Association (www.psychiatry 
.org), and within health care-focused foundations such as the Pew Charitable 
Trusts (www.pewtrusts.org), or insurance plans and managed care companies 



86 Michael T. FlaherTy

such as Community Care Behavioral Health in Pennsylvania (www.ccbh.org) 
or nationally, Optum Health (www.optum.com). Once at the site, search “opi-
oids” or “overdose.”

Many of these entities have their recommendations combined in the 
November 2016 Surgeon General’s Report: Facing Addiction in America (see: 
addiction.surgeongeneral.gov/). In July 2017, the newly commissioned White 
House Task Force submitted its “interim plan” calling for a declaration of a 
National State of Emergency, to increase beds and promote barrier regula-
tion removal, among other things. This full “interim” report is available at: 
www.whitehouse.gov/sites/whitehouse.gov/files/ondcp/commissioninterim 
-report.pdf.

Pennsylvania Resources to Address Overdose

Pennsylvania itself has produced several notable plans replete with recom-
mendations. Pennsylvania and the University of Pittsburgh School of Phar-
macy have long collaborated to offer a Technical Assistance Center that 
provides a wealth of information on the status of overdose death rates and 
causes across Pennsylvania through an interactive website at www.peru.pitt 
.edu/pennsylvania-heroin-overdose-prevention-technical-assistance-center/. 
This database is updated daily, providing up-to-date information about 
overdose prevention, data on overdose deaths from Pennsylvania coun-
ties, and data on a variety of factors that can support county prevention 
efforts. In 2016 the University of Pittsburgh’s Institute of Politics published 
a comprehensive plan entitled A Continuum of Care Approach: Western 
Pennsylvania’s Response to the Opioid Epidemic, available at iop.pitt.edu/
publications/policy-and-research-reports (see under “Health & Human 
Services”). This report expanded on the 32 recommendations presented 
in the (Western Pennsylvania) U.S. Attorney’s Working Group on Drug 
Overdose and Addiction: Prevention, Intervention, Treatment and Recovery 
Final Report and Recommendations, published in September 2014, avail-
able at: www.justice.gov/sites/default/files/usao-wdpa/legacy/2014/09/29/
US%20Attorney%27s%20Working%20Group%20on%20Addiction%20
Final%20Report.pdf. The Pennsylvania Department of Drug and Alcohol 
Programs has a published response at www.ddap.pa.gov/overdose/Pages/ 
Department%20Focus%20on%20Addressing%20Overdose.aspx, and a 
2016–2017 State Plan that includes many OD prevention and treatment initia-
tives. This plan is available at www.ddap.pa.gov/Reports/State%20Plan%20
and%20Annual%20Reports/2016-2017%20DDAP%20State%20Plan.pdf. 



Treatment, Overdose, and Finding the Road to Recovery  87

The PA Association of County Drug and Alcohol Administrators has a 
Plan (opioidaction.org/report/), as does the Center for Rural Pennsylvania 
(www.rural.palegislature.us/publications_heroin_and_opioid_addiction 
_public_hearings.html).

Other Plans to Address Overdose

Other states have also published plans, as have successful programs such 
as Vermont’s “Hub/Spoke” model (dvha.vermont.gov/administration/1hub 
-spoke-health-home-framework-payment-12-10-12.pdf), which is being 
replicated in part via Centers of Excellence in Pennsylvania with state 
and federal funds (21st Century Cures Act). See: dhs.pa.gov/citizens/ 
substanceabuseservices/centersofexcellence/index.html.

NOTES

1. A chemical substance that binds to and activates certain receptors on cells, causing 
a biological response. Fentanyl and methadone are examples of opioid receptor agonists. 
Suboxone is a partial agonist. Agonists are addictive.

2. See the video here: https://youtu.be/x2SP0GusLp0.
3. An overview can be found at: https://ncsacw.samhsa.gov/resources/opioid- use 

-disorders-and-medication-assisted-treatment/treatment-of-opioid-use-disorders-in 
-pregnancy.aspx.

4. See www.myaddiction.com/articles/drugs/what-is-the-addiction-severity-index.
5. http://www.who.int/substance_abuse/activities/treatment_opioid_dependence/

en/.
6. See: https://www.cdc.gov/drugoverdose/pdf/Guidelines_Factsheet- a.pdf .
7. See: www.NDCI.org.
8. See: info@pacertboard.org.
9. For more information, contact D. Coffa, M.D, at DianaCoffa@ucsf.edu.
10. The point of contact for more information is Sarah Wakeman, M.D., FASAM, at 

swakeman@partners.org.

          
 

       

REFERENCES

Alderks, C. E. 2017. Trends in the Use of Methadone, Buprenorphine, and Extended-r elease 
Naltrexone at Substance Abuse Treatment Facilities: 2003–2015 (Update). Rockville, 
MD: Substance Abuse and Mental Health Services Administration.

American Academy of Pain Management (AAPM). 2015. Pain Management Guidelines. 
Available at http://www.painmed.org/library/clinical- guidelines/. Accessed August 
15, 2017.

American Medical Association (AMA). 1998. “Effective Medical Treatment of Opiate 
Addiction. National Consensus Development Panel on Effective Medical Treatment 
of Opiate Addiction.” The Journal of the American Medical Association 280 (Decem-
ber): 1936–1943.



88 Michael T. FlaherTy

———. 2018. Reversing the Opioid Epidemic. Available at https://www.end- opioid 
- epidemic.org/. Accessed April 20, 2018.

American Society on Addiction Medicine (ASAM). 2017. “Definition of Addiction.” Avail-
able at https://www.asam.org/quality-practice/definition-of-addiction. Accessed
August 15, 2017.

Banta- Green, C. J., J. O. Merrill, S. R. Doyle, D. M. Boudreau, and D. A. Calsyn. 2009. 
“Opioid Use Behaviors, Mental Health and Pain–Development of a Typology of 
Chronic Pain Patients.” Drug & Alcohol Dependency 104 (September): 34–42. 

Barber, M. 2012. “Recovery as the New Medical Model for Psychiatry.” Psychiatric Services 
63 (March): 277–279.

Campbell, J. N. 1996. “APS 1995 Presidential Address.” Pain Forum 5 (Spring): 85–88. 
Centers for Disease Control and Prevention (CDC). 2017a. “Opioid Overdose Prescribing 

Data.” August 30. Available at https://www.cdc.gov/drugoverdose/data/prescribing.
html. Accessed April 20, 2018.

———. 2017b. “What States Need to Know about PDMPs.” October 3. Available at https://
www.cdc.gov/drugoverdose/pdmp/states.html. Accessed December 29, 2017.

Christensen, C. M., J. H. Grossman, and J. Hwang. 2009. The Innovator’s Prescription: A 
Disruptive Solution for Health Care. New York: McGraw Hill. 

Collins, S. E., H. S. Lonczak, and S. L. Clifase. 2015. LEAD Program Evaluation: Criminal 
Justice and Legal System Utilization and Associated Costs. Seattle: University of Wash-
ington, Harborview Medical Center, Harm Reduction Research and Treatment Lab. 

Commonwealth of Pennsylvania Department of Drug and Alcohol Programs. 2014. Penn-
sylvania’s Placement Criteria for Adults, 3rd ed. Harrisburg: Pennsylvania Depart-
ment of Drug and Alcohol Programs. Available at http://www.ddap.pa.gov/Manuals/
PA%20Client%20Placement%20Criteria%20(PCPC)%20Edition%203%20Manual 
.pdf. Accessed August 17, 2017.

DeFlavio, J. R., S. A. Rolin, B. R. Nordstrom, and L. A. Kazal, Jr. 2015. “Analysis of Barriers 
to Adoption of Buprenorphine Maintenance Therapy by Family Physicians.” Rural 
Remote Health 15 (February): 1–11.

D’Onofrio, G., P. G. O’Connor, and M. V. Pantalon. 2015. “Emergency Department- 
Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence: A Random-
ized Clinical Trial.” The Journal of the American Medical Association 31 (April): 
1636–1644. 

Fishbain, D.A., B. Cole, J. Lewis, H. L. Rosomoff, and R. S. Rosomoff. 2008. “What Per-
centage of Chronic Nonmalignant Pain Patients Exposed to Chronic Opioid Analge-
sic Therapy Develop Abuse/Addiction and/or Aberrant Drug-R elated Behaviors? A 
Structured Evidence- Based Review.” Pain Med 9 (May–June): 444–459. 

Flaherty, M., ed. 2006. Special Report: A Unified Vision for the Prevention and Manage-
ment of Substance Abuse Disorders; Building Resiliency, Wellness and Recovery—A 
Shift from an Acute Care to a Sustained Care Recovery Management Model. Pitts-
burgh: Institute for Research, Education and Training in the Addictions. 

———. 2012. “A Medical Model for Today.” Psychiatric Services 63 (May): 510.
Flaherty, M., E. Kurtz, and W. White. 2014. “An Interpretive Phenomenological Analy-

sis of Secular, Spiritual and Religious Pathways of Long- Term Recovery.” Alcoholism 
Treatment Quarterly 32 (October): 337–356. 

Foote, J., C. Wilkens, N. Kosanke, and S. Higgs. 2014. Beyond Addiction. How Science and 
Kindness Help People Change (CRAFT). New York: Simon and Schuster. 

Granfield, R., and W. Cloud. 1999. Coming Clean: Overcoming Addiction without Treat-
ment. New York: New York University Press.

       



Treatment, Overdose, and Finding the Road to Recovery  89

Hickton, D. J., and M. L. Leary. 2015. National Heroin Task Force Final Report and Recom-
mendations. Washington, DC: U.S. Department of Justice and White House Office of 
National Drug Control Policy. 

Hoge, M. A., G. E. Stuart, J. A. Morris, Y. H. Huey, M. T. Flaherty, and M. Paris. 2017. 
“Behavioral Health Workforce Development in the United States.” In Workforce 
Development Theory and Practice in the Mental Health Sector, eds. M. Smith and 
A. Jury. Hershey, PA: IGI Global, 37–59. 

Hoge, M., G. Stuart, J. Morris, M. T. Flaherty, M. Paris, and E. Goplerud. 2013. “Men-
tal Health and Addiction Workforce Development: Federal Leadership Is Needed to 
Address the Growing Crisis.” Health Affairs 32 (November): 2005–12. 

Huhn, A. S., and K. E. Dunn. 2017. “Why Aren’t Physicians Prescribing More Buprenor-
phine?” Journal of Substance Abuse Treatment 78 (July): 1–7. 

Hyde, P. S. 2013. Report to Congress on the Nation’s Substance Abuse and Mental Health 
Workforce Issues. Washington, DC: U.S. Department of Health and Human Sciences, 
Substance Abuse and Mental Health Services Administration (SAMHSA). Avail-
able at https://store.samhsa.gov/shin/content//PEP13-RTC-BHWORK/PEP13-RTC 
- BHWORK.pdf. Accessed on August 17, 2017.

Institute of Medicine. 2001. Crossing the Quality Chasm. The New Health System for the 
21st Century. Washington, DC: National Academy Press, Appendix B, 309–322.

Jones, C. M. 2013. “Heroin Use and Heroin Use Risk Behaviors among Nonmedical Users 
of Prescription Opioid Pain Relievers—United States, 2002–2004 and 2008–2010.” 
Drug and Alcohol Dependence 132 (September): 95–100. 

Joseph, H., S. Stancliff, and L. Langrod. 2000. “Methadone Maintenance Treatment 
(MMT): A Review of Historical and Clinical Issues.” Mount Sinai Journal of Medicine 
67 (October–November): 347–364. 

Kakko, J., K. D. Svanborg, M. J. Kreek, and M. Heilig. 2003. “1- Year Retention and Social 
Function after Buprenorphine- Assisted Relapse Prevention Treatment for Heroin 
Dependence in Sweden: A Randomized, Placebo- Controlled Trial.” Lancet 361 (Feb-
ruary): 662–668. 

Kelly, J., and W. White. 2011. Addiction Recovery Management: Theory, Research and Prac-
tice. New York: Humana Press. 

Kelly, J. F., S. J. Dow, and C. Westerhoff. 2010. “Does Our Choice of Substance- Related 
Terms Influence Perceptions of Treatment Need? An Empirical Investigation with 
Two Commonly Used Terms.” Journal of Drug Issues 40 (October): 805–818. 

Kolodny, A., D. T. Courtwright, C. S. Hwang, P. Kreiner, J. L. Eadie, T. W. Clark, and 
G. C. Alexander. 2015. “The Prescription Opioid and Heroin Crisis: A Public Health 
Approach to an Epidemic of Addiction.” Annual Review of Public Health 36 (March): 
559–574.

Lord, R. 2018. “Doctors Are Prescribing Fewer Opioids Following Measures by State 
Insurers.” Pittsburgh Post-Gazette, January 8.

McLellan, A. T., D. C. Lewis, C. P. O’Brien, and H. D. Kleber. 2000. “Drug Dependence, 
a Chronic Medical Illness: Implications for Treatment, Insurance, and Outcome 
Evaluation.” The Journal of the American Medical Association 284 (October): 1689–
1695. 

McLellan, A. T., L. Luborsky, C. P. O’Brien, and G. E. Woody. 1980. “An Improved Diag-
nostic Instrument for Substance Abuse Patients: The Addiction Severity Index.” Jour-
nal of Nervous and Mental Diseases 168: 26–33.

Mee- Lee, D., G. D. Shulman, M. J. Fishman, D. R. Gastfriend, and M. M. Miller, eds. 
2013. The ASAM Criteria: Treatment Criteria for Addictive, Substance- Related, and 

     

  



90 Michael T. FlaherTy

Co-Occurring Conditions, 3rd ed. Chevy Chase, MD: American Society of Addiction 
Medicine. 

Mezei, L., and B. Murison. 2011. “Pain Education in North American Medical Schools.” 
Journal of Pain 12 (December): 1199–1208.

Morley- Forster, P. K., J. V. Pergolizzi, R. Taylor, R. A. Axford- Gatley, and E. M. Sellers. 
2013. “Mitigating the Risk of Opioid Abuse through a Balanced Undergraduate Pain 
Medicine Curriculum.” Journal of Pain Research 6 (December): 791–801. 

Muhuri, P. K., J. C. Groener, and M. C. Davies. 2013. Associations of Nonmedical Pain 
Reliever Use and Initiation of Heroin Use in the United States. Rockville, MD: Sub-
stance Abuse and Mental Health Services Administration. Available at http://archive 
.samhsa.gov/data/2k13/DataReview/DR006/nonmedical-pain-reliever-use-2013.pdf.
Accessed August 15, 2017. 

National Institute on Drug Abuse (NIDA). 2016a. “Drug Facts: Genetics and Epigenetics 
of Drug Addiction.” February. Available at https://www.drugabuse.gov/sites/default/
files/genetics_and_epigenetics_drugfacts_2.pdf. Accessed February 1, 2018.

———. 2016b. “Principles of Substance Abuse Prevention for Early Childhood.” March. 
Available at https://www.drugabuse.gov/publications/principles-substance-abuse 
- prevention- early- childhood. Accessed February 1, 2018.

———. 2016c. “Rates of Nonmedical Prescription Opioid Use and Opioid Use Disorder 
Double in 10 Years.” June 22. Available at https://www.niaaa.nih.gov/news- events/
news- releases/rates- nonmedical- prescription-op ioid- use-a nd- opioid-u se- disorder 
- double- 10. Accessed February 1, 2018.

———. 2016d. “Buprenorphine Prescribers Treat below Current Patient Limits.” Septem-
ber 20. Available at https://www.drugabuse.gov/news-e vents/news- releases/2016/09/
buprenorphine-prescribers-treat-below-current-patient-limits. Accessed February 1,
2018.

———. 2016e. “Media Guide.” October. Available at https://www.drugabuse.gov/publications/ 
media-guide/science-drug-abuse-addiction-basics. Accessed February 1, 2018.

———. 2018a. “Drug Facts.” January. Available at https://www.drugabuse.gov/publications/ 
drugfacts/heroin. Accessed February 1, 2018.

———. 2018b. Principles of Drug Abuse Treatment: A Research Based Guide, 3rd ed. 
Available at https://www.drugabuse.gov/publications/principles-drug-addiction 
-treatment-research-based-guide-third-edition/acknowledgments. Accessed Febru-
ary 1, 2018.

———. 2018c. “Magnitude—Drug Abuse Is Costly.” Available at https://archives.drugabuse 
.gov/publications/drug- abuse-a ddiction- one- americas- most- challenging- public 
-h ealth- problems/magnitude. Accessed February 1, 2018.

Office of National Drug Control Policy (ONDCP). 2013. National Drug Control Strategy. 
Washington, DC: White House. Available at http://www.whitehouse.gov/ondcp/2013- 
national- drug- strategy. Accessed June 19, 2017.

Pittsburgh Post-Gazette Editorial Board. 2017. “Dying Young: The Opioid Crisis is Affect-
ing U.S. Life Expectancy.” Pittsburgh Post-Gazette, December 27.

Porter, J., and H. Jick. 1980. “Addiction Rare in Patients Treated with Narcotics.” New 
England Journal of Medicine 302 (January): 123. 

Quinones, S. 2015. Dreamland: The True Tale of America’s Opiate Epidemic. New York: 
Bloomsbury Press. 

Robert Wood Johnson Foundation. 2001. Substance Abuse: The Nation’s Number One 
Health Problem. Princeton, NJ: Brandeis University Schneider Institute for Health 
Policy.

   

     

    

          

         

    
        

  
  



Treatment, Overdose, and Finding the Road to Recovery  91

Rudd, R. A., P. Seth, F. David, and L. Scholl. 2016. “Increases in Drug and Opioid-I nvolved 
Overdose Deaths—United States, 2010–2015.” Morbidity and Mortality Weekly Report 
65 (December): 1445–1452.

Sauter, M. B. 2016. “10 States with the Most Drug Overdoses.” 24/7 Wall Street Journal, 
June 24. Available at http://247wallst.com/special-r eport/2016/06/24/10-s tates- with 
-the-most-drug-overdoses/2/. Accessed August 14, 2017. 

Scott, C. K., and M. L. Dennis. 2007. “Managing Addiction as a Chronic Condition.” 
Addiction Science and Clinical Practice 4 (December): 45–55.

Sliboda, Z., M. Glantz, and R. Tarter R. 2012. “Revisiting the Concepts of Risk and Protec-
tive Factors for Understanding the Etiology and Development of Substance Use and 
Substance Use Disorders: Implications for Prevention.” Substance Use & Misuse 47 
(June–July): 944–962.

Stein, B. D., A. J. Gordon, A. W. Dick, R. M. Burns, A. Liccardo, R. Pacula, C. M. Farmer, 
D. L. Leslie, and M. Sorbero. 2015. “Supply of Buprenorphine Waivered Physicians: 
The Influence of State Policies.” Journal of Substance Abuse Treatment 48 (January): 
104–111.

Substance Abuse and Mental Health Services Administration (SAMHSA). 2010. Recovery- 
Oriented Systems of Care (ROSC) Resource Guide. September. Available at https://
www.samhsa.gov/sites/default/files/partnersforrecovery/docs/ROSC_Resource_
Guide_Book.pdf. Accessed February 1, 2018.

———. 2012. Addictions and Mental Health Recovery Dialogue: Similarities and Differ-
ences in Our Communities. September 13. Available at https://www.samhsa.gov/sites/
default/files/similarities- differences- dialogue.pdf. Accessed February 1, 2018.

———. 2013. “Report to Congress on the Nation’s Substance Abuse and Mental Health 
Workforce Issues.” January 24. Available at https://store.samhsa.gov/shin/content/
PEP13-R TC- BHWORK/PEP13- RTC- BHWORK.pdf. Accessed February 1, 2018.

———. 2016. “Medication- Assisted Treatment of Opioid Use Disorders.” Available 
at https://store.samhsa.gov/product/Medication-Assisted-Treatment-for-Opioid 
- Addiction- in- Opioid- Treatment- Programs/SMA12- 4108. Accessed February 1, 
2018.

Sutherland, G., G. Andrews, C. Taylor, G. Phillips, M. Gossop, and R. Brady. 1986. “The 
Measurement of Opiate Dependence.” Addiction 81 (April): 485–494.

Tarter, R. E., G. Cochran, and M. Reynolds. 2018. “Prevention of Opioid Addiction.” Com-
monwealth: A Journal of Pennsylvania Politics and Policy 20 (2–3): 37–58.

U.S. Department of Health and Human Services (HHS), Office of the Surgeon General. 
2016. Facing Addiction in America: The Surgeon General Report on Alcohol, Drugs, 
and Health. Washington, DC: Substance Abuse and Mental Health Services Admin-
istration.

U.S. Department of Health and Human Services (HHS), Behavioral Health Coordinating 
Committee, Prescription Drug Abuse Subcommittee. 2013. “Addressing Prescrip-
tion Drug Abuse in the United States, Current Activities and Future Opportunities.” 
Washington, DC: U.S. Department of Health and Human Services. Available at http//
www.cdc.gov/drugoverdose/pdf/hhs_prescription_drug_abuse_report_09.2013.pdf. 
Accessed February 1, 2018

U.S. Department of Justice (DOJ). 2001. Substance Abuse—The Nation’s Number One 
Health Problem. May. Washington, DC: U.S. Department of Justice. Available at 
https://www.ncjrs.gov/pdffiles1/ojjdp/fs200117.pdf. Accessed February 1, 2018.

U.S. Drug Enforcement Agency and University of Pittsburgh School of Pharmacy. 2017. 
Analysis of Overdose Deaths in Pennsylvania, 2016. Philadelphia: DEA Philadelphia 

    

     



92 Michael T. FlaherTy

Division and the University of Pittsburgh. Available at https://info.publicintelligence 
.net/DEA- OverdoseDeathsPA- 2016.pdf. Accessed February 1, 2018.

U.S. Government Accountability Office (GAO). 2003. OxyContin Abuse and Diversion and 
Efforts to Address the Problem. Washington, DC: United States Government Account-
ing Office.

Vance, J. D. 2016. Hillbilly Elegy: A Memoir of a Family and Culture in Crisis. New York: 
Harper Collins.

Volkow, N. 2014. Testimony to the Senate Caucus on International Narcotics Control. 
“America’s Addiction to Opioids: Heroin and Prescription Drug Abuse.” May 14. 
Available at https://www.drugabuse.gov/about- nida/legislative- activities/testimony 
- to- congress/2016/americas- addiction- to-o pioids-h eroin- prescription- drug- abuse. 
Accessed February 1, 2018.

———. 2017. Testimony to Congress. “Federal Efforts to Combat the Opioid Crisis: A Sta-
tus Update on CARA and Other Initiatives.” October 25. Available at https://www 
.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2017/federal 
-efforts-to-combat-opioid-crisis-status-update-cara-other-initiatives. Accessed Feb-
ruary 1, 2018.

Wakeman, S. E., and J. D. Rich. 2015. “Addiction Treatment within the U.S. Correctional 
Facilities: Bridging the Gap between Current Practice and Evidenced- Based Care.” 
Journal of Addictive Diseases 34 (June): 220–225.

Wesson, D. R., and W. Ling. 2003. “The Clinical Opiate Withdrawal Scale (COWS).” Jour-
nal of Psychoactive Drugs 35 (2): 253–259.

White, W. L. 2008. Recovery Management and Recovery- Oriented Systems of Care: Scien-
tific Rationale and Promising Practices. Pittsburgh, PA: Northeast ATTC, Great Lakes 
ATTC and Philadelphia Department of Behavioral Health and Disability.

———. 2012. Recovery/Remission from Substance Use Disorders: An Analysis of Reported 
Outcomes in 415 Scientific Reports, 1868–2011. Pittsburgh: Philadelphia Depart-
ment of Behavioral Health and Intellectual disAbility Services, Great Lakes Addic-
tion Technology Transfer Center. Available at https://www.naadac.org/assets/1959/
whitewl2012_recoveryremission_from_substance_abuse_disorders.pdf. Accessed 
February 1, 2018.

White, W., and E. Kurtz. 2008. Recovery- Linking Addiction Treatment & Communi-
ties of Recovery: A Primer for Addiction Counselors and Recovery Coaches. Pitts-
burgh: Northeast ATTC. Available at http://www.williamwhitepapers.com/
pr/2006RecoveryLinkageMonograph.pdf. Accessed February 1, 2018.

White, W., and L. Mojer- Torres. 2010. Recovery- Oriented Methadone Maintenance. 
Pittsburgh: Northeast ATTC, Great Lakes ATTC and Philadelphia Department of 
Behavioral Health and Mental Retardation Services. Available at http://www.william 
whitepapers.com. Accessed February 1, 2018. 

    
            

Michael T. Flaherty is a clinical psychologist specializing in addiction treatment and 
recovery. He has over 37 years of practice and leadership of major institutions includ-
ing the St. Francis Institute for Psychiatry and Addiction Services and the Institute for 
Research, Education and Treatment of Addiction in Pittsburgh, Pennsylvania. He has 
authored many articles and studies on addictions, workforce development, and recovery. 
Recently he served as a senior adviser for the U.S. Department of Justice/White House 
Office of National Drug Control Policy Heroin Task Force, and as coleader of the U.S. 
Attorney Western Pennsylvania Task Force on Overdose Prevention.


	Structure Bookmarks
	The Birth and Growth of a Predictable Epidemic
	Why Treatment Has Fallen Short
	Plans and Resources: Treatment and a Coordinated, Continuing Need for Action
	Best Practice in Overdose Treatment—Actions
	Recovery—The Path to Hope and Solution
	APPENDIX A
	APPENDIX B: SUMMARY OF NATIONAL, PENNSYLVANIA,  AND OTHER OVERDOSE PREVENTION PLANS AND ACTIONS
	NOTES
	REFERENCES




