Trends in rx_drug_abuse_final

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Education Track, National Rx Drug Abuse Summit, April 2-4, 2013. Trends in Rx Drug Abuse presentation by Dr. Andrew Kolodny, Tess Benham and Sherry Green

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Trends in rx_drug_abuse_final

  1. 1. Trends  in  Rx  Drug  Abuse     Dr.  Andrew  Kolodny   Chairman,  Department  of  Psychiatry,   Maimonides  Medical  Center   Tess  Benham     Program  Manager,  Na?onal  Safety  Council   Hon.  Sherry  L.  Green,  JD  Chief  Execu?ve  Officer,  Na?onal  Alliance  for   Model  State  Drug  Laws  
  2. 2. Learning  Objec?ves  1.  Iden?fy  recent  increasing  trends  in  the   misuse  and  abuse  of  prescrip?on  drugs.  2.  Evaluate  the  state  laws  and  regula?ons  that   exist  on  a  state  level  across  the  country.  3.  Outline  ini?a?ves  that  can  be  taken  back  and   implemented  in  your  state.  
  3. 3. Disclosure  Statement  •  Andrew  Kolodny  has  no  financial  rela?onships   with  proprietary  en??es  that  produce  health   care  goods  and  services.    •  Tess  Benham  has  no  financial  rela?onships   with  proprietary  en??es  that  produce  health   care  goods  and  services.    •  Sherry  Green  has  no  financial  rela?onships   with  proprietary  en??es  that  produce  health   care  goods  and  services.    
  4. 4. Overview  of  the  Opioid   AddicAon  Epidemic   April  2  –  4,  2013   Omni  Orlando  Resort     at  ChampionsGate  
  5. 5. Presenta?on  Outline  I.  Past  opioid  epidemics  II.  Current  epidemic  III.  Reasons  for  the  current  epidemic  IV.  The  chronic  pain  controversy  V.  Strategies  to  control  the  epidemic  
  6. 6. The Opium Poppy Papaver Somniferum 6
  7. 7. Crude Opium Latex on Poppy Head 7
  8. 8. Opioids•  Morphine•  Codeine•  Heroin•  Hydrocodone (Vicodin, Lortab)•  Methadone•  Oxycodone (Percocet, Oxycontin)•  Hydromorphone (Dilaudid)•  Meperidine (Demerol)
  9. 9. Winslows Soothing Syrup for infants Active Ingredient: Morphine
  10. 10. Source: The New York Times Magazine, June 5, 1977
  11. 11. 12  
  12. 12. Rates of ED visits for nonmedical use of selected opioid analgesics increased significantly in the US 40 35 2004 2005 2006 2007 2008ED visits per 100,000 population 30 25 20 * 15 * * * * 10 * 5 * * 0 * * Fentanyl Hydrocodone Hydromorphone Methadone Morphine Oxycodone * Indicates a rate that was significantly less than the rate in 2008. Note: Drug types include combination products , e.g, combinations of oxycodone and aspirin. 13
  13. 13. Opioid-­‐Dependent  Infants  in  Tennessee    
  14. 14. Unintentional Drug Overdose Deaths United States, 1970–2007 38,329 drug overdose deaths in 2010 Cocaine Heroin YearNational Vital Statistics System, http://wonder.cdc.gov
  15. 15. Drug Overdose Deaths by Major Drug Type, United States, 1999–2010 Opioids Heroin Cocaine Benzodiazepines 18,000 16,000 14,000 12,000 Number of Deaths 10,000 8,000 6,000 4,000 2,000 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 YearCDC, National Center for Health Statistics, National Vital Statistics System, CDC Wonder. Updated with 2010 mortality data.
  16. 16. Primary  non-­‐heroin  opiates/syntheAcs  admission  rates,  by  State    (per  100,000  populaAon  aged  12  and  over)   17  
  17. 17. Primary  non-­‐heroin  opiates/syntheAcs  admission  rates,  by  State    (per  100,000  populaAon  aged  12  and  over)   18  
  18. 18. Primary  non-­‐heroin  opiates/syntheAcs  admission  rates,  by  State    (per  100,000  populaAon  aged  12  and  over)   19  
  19. 19. Primary  non-­‐heroin  opiates/syntheAcs  admission  rates,  by  State    (per  100,000  populaAon  aged  12  and  over)   20  
  20. 20. Primary  non-­‐heroin  opiates/syntheAcs  admission  rates,  by  State    (per  100,000  populaAon  aged  12  and  over)   21  
  21. 21. Primary  non-­‐heroin  opiates/syntheAcs  admission  rates,  by  State    (per  100,000  populaAon  aged  12  and  over)   22  
  22. 22. UnintenAonal  overdose  deaths  involving  opioid  analgesics   parallel  per  capita  sales  of  opioid  analgesics  in  morphine   equivalents  by  year,  U.S.,  1997-­‐2007   *   Number  of     Opioid  sales  (mg/ Deaths   person)  Source:  Na?onal  Vital  Sta?s?cs  System,  mul?ple  cause  of  death  dataset,  and  DEA  ARCOS  *  2007  opioid  sales  figure  is  preliminary.  
  23. 23. Rates of Opioid Sales, OD Deaths, and Treatment, 1999–2010 8 Opioid Sales KG/10,000 Opioid Deaths/100,000 Opioid Treatment Admissions/10,000 7 6 5 Rate 4 3 2 1 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 YearCDC. MMWR 2011
  24. 24. 25  
  25. 25. 26  
  26. 26. Dollars Spent Marketing OxyContin (1996-2001)Source: United States General Accounting Office: Dec. 2003, “OxyContin Abuse and Diversion andEfforts to Address the Problem.” 27
  27. 27. Industry-funded organizationscampaigned for greater use of opioids•  Pain Patient Groups•  Professional Societies•  The Joint Commission•  The Federation of State Medical Boards 28
  28. 28. Industry-funded “education” emphasizes:•  Opioid addiction is rare in pain patients.•  Physicians are needlessly allowing patients to suffer because of “opiophobia.”•  Opioids are safe and effective for chronic pain.•  Opioid therapy can be easily discontinued. 29
  29. 29. “Only four cases of addiction among11,882 patients treated with opioids”Porter J, Jick H. Addiction rare in patients treatedwith narcotics. N Engl J Med. 1980 Jan 10;302(2):123Cited 677 times (Google Scholar) 30
  30. 30. N Engl J Med. 1980 Jan 10;302(2):123. 31
  31. 31. I think that after 20 years of a failedexperiment that there are not many peoplesupporting this except for the die-hards andthe pharmaceutical industry.Jane C. Ballantyne, MD FRCAProfessor, Univ. of Washington Source: New York Times, April 9, 2012. Tightening the Lid on Pain Prescriptions .
  32. 32. The Emperor’s New Paradigm:Patient Selection, Risk Stratification & Monitoring 34
  33. 33. Urine  Tox  Results  in  Chronic  Pain  PaAents  on  Opioid  Therapy  Source:  Couto  JE,  Goldfarb  NI,  Leider  HL,  Romney  MC,  Sharma  S.  High  rates  of  inappropriate  drug  use  in  the  chronic  pain  popula?on.  Popul  Health  Manag.  2009;12(4):185–190.   35  
  34. 34. Controlling  the  epidemic:   A  Three-­‐pronged  Approach  •  Primary  Preven?on-­‐  prevent  new  cases  of  opioid   addic?on.  •  Secondary  Preven?on-­‐  provide  people  who  are   addicted  with  effec?ve  treatment.  •  Supply  control-­‐  collaborate  with  law   enforcement,  DEA  and  OPMC  to  over-­‐prescribing   and  black-­‐market  availability.   36  
  35. 35. Opioid manufacturers continue to advertise opioids assafe and effective for chronic pain.
  36. 36. Controlling the Epidemic: Potential Interventions•  Opioid Label Changes•  Hydrocodone Up-scheduling•  Prescription Drug Monitoring Programs•  Tamper-Resistant Formulations
  37. 37. This is a false dichotomy Aberrant drug use behaviors are common in pain patients 63% admitted to using opioids for purposes other than pain192% of opioid OD decedentswere Pain Patients prescribed opioids for Drug Abuserschronic pain. 35% met DSM V criteria for addiction21. Fleming MF, Balousek SL, Klessig CL, Mundt MP, Brown DD. Substance Use Disorders in a Primary Care Sample ReceivingDaily Opioid Therapy. J Pain 2007;8:573-582.2. Boscarino JA, Rukstalis MR, Hoffman SN, et al. Prevalence of prescription opioid-use disorder among chronic pain patients:comparison of the DSM-5 vs. DSM-4 diagnostic criteria. J Addict Dis. 2011;30:185-194.3. Johnson EM, Lanier WA, Merrill RM, et al. Unintentional Prescription Opioid-Related Overdose Deaths: Description ofDecedents by Next of Kin or Best Contact, Utah, 2008-2009. J Gen Intern Med. 2012 Oct 16.
  38. 38. Please  visit  www.supportPROP.org   Follow  us  on  Twi[er   @supportPROP   40  
  39. 39. Trends  in  Prescrip?on  Drug  Abuse   April  2  –  4,  2013   Omni  Orlando  Resort     at  ChampionsGate  
  40. 40. Who  is  NSC?  Our  Mission:    The  Na?onal  Safety  Council  saves  lives    by  preven?ng  injuries  and  deaths  at  work,  in  homes  and  communi?es,    and  on  the  roads  through  leadership,  research,  educa?on  and  advocacy.  
  41. 41. •  Na?onal  Governors   Associa?on  Policy   Academy  •  Report  Release   (April  2012)  
  42. 42. Opportuni?es  for  Ac?on  •  Build  State  Capacity  to  Address  Rx  Drug   Overdoses  •  Increase  Access  and  U?liza?on  of  Prescrip?on   Monitoring  Programs  (PMPs)  •  Support  Responsible  Opioid  Prescribing  •  Advocate  for  Overdose  Educa?on  Programs  
  43. 43. Increase  Access  and  U?liza?on  of  (PMPs)  •  Allow  authorized  delegates  •  Move  to  real-­‐?me  data  collec?on  intervals  •  Share  PMP  data  with  other  states  •  Proac?ve  alerts  
  44. 44. Support  Responsible  Prescribing  •  Deter  forma?on  of  pill  mills  •  Provide  guidance  and  educa?on  on   responsible  prescribing  of  controlled   substances  •  Increase  u?liza?on  of  PMPs  by  prescribers  and   dispensers  
  45. 45. Overdose  Educa?on  Programs  •  Provide  overdose  educa?on  •  Naloxone  distribu?on  •  Good  Samaritan  laws  
  46. 46. Ques?ons  Tess  Benham  Na?onal  Safety  Council  tess.benham@nsc.org  
  47. 47. Snapshot  of  Laws,  RegulaAons  and   Policies  on:  State  PrescripAon  Drug  Monitoring  Programs  (PMPS)  State  RegulaAon  of  Pain  Clinics  State  Prescribing  PracAces  for  the  Treatment  of          Non-­‐Cancer  Pain   April  2  –  4,  2013   Omni  Orlando  Resort     at  ChampionsGate  
  48. 48. Who  is  NAMSDL?  •  501  (c)(3)  nonprofit  corpora?on  •  Successor  to  the  President’s  Commission  on  Model  State  Drug   Laws  •  19  ½  years  •  Funded  by  Congress  •  Provides  legisla?ve  and  policy  services  on  drug  and  alcohol   laws  to  a  variety  of  stakeholders  at  the  state  and  local  level  
  49. 49. State  PrescripAon  Drug  Monitoring  Programs  (PMPS)  –   InformaAon  Tools  •  PMP-­‐  statewide  electronic  database  that  collects  designated   data  on  prescrip?on  controlled  substances  and  some?mes   drugs  of  concern    49  states  with  PMP  laws    44  states  with  opera?onal  programs    
  50. 50. InformaAon  Tools  Cont…  •  12  common  categories  of  recommenda?ons  by  6  en??es      PMP  Center  of  Excellence  at  Brandeis  University      School  of  Medicine  and  Public  Health  at  University  of   Wisconsin-­‐Madison    Mitre  Corpora?on,  Office  of  Na?onal  Coordinator  for   Health  Informa?on  Technology  and  the  Substance  Abuse   and  Mental  Health  Services  Administra?on    NAMSDL    Alliance  of  States  with  PMPS    American  Cancer  Society  
  51. 51. InformaAon  Tools  Cont…  •  Increase  use  of  PMP  as  health  care  tool  •  Frequency  of  dispenser  repor?ng    Real  ?me  –  OK    Daily/24  hours  –  5  states:  DE,  KS,  MN,  ND,  WV      Weekly/7  Days  –  31  states:  AL,  AZ,  AR,  CA,  FL,  GA,  HI,  ID,  IL,   IN,  IA,  KY,  LA,  ME,  MA,  MS,  MT,  NV,  NH,  NM,  NC,  OH,  OR,   SD,  TN,  TX,  UT,  VT,  VA,  WA,  WY        Twice  monthly  –  4  states:  CO,  CT,  MI,  NJ      Monthly  –  5  states:  AK,  NY,  PA,  RI,  SC  
  52. 52. InformaAon  Tools  Cont…  •  Expand  categories  of  authorized  users    Delegates  or  authorized  agents  of  prescribers/dispensers  –   21  states:  DE,  ID,  IN,  IA,  KS,  KY,    ME,  MD,  MA,  MN,  MT,  NM,   NY,  ND,  OH,  SD,  TN,  UT,  VA,  WA,  WV    Mental  health/substance  abuse  professionals,  peer   review/  quality  improvement  commirees  –  7  states:  IN,   KS,  MD,  ND,  SD,  TN,  UT  
  53. 53. InformaAon  Tools  Cont…  •  Mandatory  use  of  PMP  by  prescribers    13  states      4  -­‐  Limited  circumstances:    CO,  LA,  OK,  NC      2  -­‐  If  prescriber  believes  pa?ent  wants  prescrip?on  for    non-­‐medical  purpose:    NV,  DE          6  -­‐  Upon  the  ini?a?on  of  designated  circumstances,  such    as  ini?al  prescribing  or  dispensing  of  specified    substances,  and  periodically  thereaser:  KY,  NM,  NY,  OH,    TN,  WV        1  -­‐  Department  of  Health  to  promulgate  regula?ons    outlining  when  prescribers  have  to  use  the  PMP  prior  to    seeing  a  new  pa?ent:    MA    
  54. 54. InformaAon  Tools  Cont…  •  Proac?ve  or  unsolicited  alerts/reports    42  states:  AL,  AK,  AZ,  AR,  CA,  CT,  DE,  FL,  HI,  ID,  IL,  IN,  KS,   KY,  LA,  ME,  MA,  MI,  MS,  MT,  NV,  NH,  NJ,  NM,  NY,  NC,  ND,   OH,  OK,  PA,  RI,  SC,  SD,  TN,  TX,  UT,  VT,  VA,  WA,  WV,  WI,  WY  •  Interstate  sharing    Other  state  PMPs  –  20  states:  AL,  AR,  DE,  HI,  IL,  KS,  ME,   MD,    MA,  MS,  MT,  NV,  NH,  NC,  OR,  RI,  SD,  UT,  VA,  WI      Authorized  users  in  other  states  –  8  states:  AK,  CA,  CO,  ID,   IA,  MN,  TX,  WY    Both  –  15  states:    AZ,  CT,  IN,  KY,  LA,  MI,  NJ,  NM,  NY,  ND,   OH,  SC,  TN,  WA,  WV  
  55. 55. State  RegulaAon  of  Pain  Clinics  •  8  states  as  of  12/31/2012  have  adopted  pain  clinic  regula?on   acts:  FL,  KY,  LA,  MS,  OH,  TN,  TX,  WV  •  14  common  components  •  Defini?on  of  “pain  clinic”    Publically  or  privately  owned  facility    Majority  of  pa?ents  on  a  monthly  basis  prescribed  or   dispensed  specified  substances  as  part  of  treatment  for   pain  
  56. 56. State  RegulaAon  Cont…  •  Registra?on,  cer?fica?on  or  licensure      Exemp?ons:    long-­‐term  care,  nursing  homes,  hospice   facili?es,  state  operated  facili?es  •  Clinic  owners  must  hold  certain  licenses/board  cer?fica?ons    Physician  with  unrestricted  license  to  prac?ce    Board  cer?fica?on  by  American  Board  of  Pain  Medicine  or   American  Board  of  Interven?onal  Pain  Physicians    Subspecialty  in  pain  management,  hospice  or    pallia?ve   care    Comple?on  of  residency  or  fellowship  in  pain  medicine    
  57. 57. State  RegulaAon  Cont…  •  Restric?ons  on  prescribing  or  dispensing  controlled   substances    Louisiana  –  limits  prescrip?ons  to  non-­‐refillable  30  day   supply    Florida  –  document  reason  for  prescribing  more  than  72   hour  dose  of  controlled  substances  for  treatment  of  pain    West  Virginia  –  limits  dispensing  of  controlled  substances   to  72  hour  supply  
  58. 58. State  RegulaAon  Cont…  •  Requirement  to  access  a  state’s  PMP  •  Enforcement  experience    Reduc?on  of  “pill  mills”    Unintended  consequences  –  some  claims  that  legi?mate   pa?ents  having  difficulty  accessing  pain  medica?ons    Some  “pill  mill”  operators  re-­‐labeled  themselves  as   wellness  clinics  or  weight  loss  centers  
  59. 59. Prescribing  of  Controlled  Substances  for  the   Treatment  of  Non-­‐Cancer  Pain  •  Policies,  guidelines,  rules,  strategies,  and  guides    Federa?on  of  State  Medical  Boards    Utah  Department  of  Health    Journal  of  Pain    Washington  State    American  Society  of  Interven?onal  Pain  Physicians    U.S.  Food  and  Drug  Administra?on  (FDA)    Dr.  Scor  Fishman  –  “Responsible  Opioid  Prescribing:    A   Physician’s  Guide”  
  60. 60. Prescribing  Cont…  •  7  commonly  recommended  prescribing  prac?ces  •  Educa?on  on  designated  topics:    pain  management,   prescribing  of  controlled  substances,  addic?on  and  addic?on   treatment,  use  of  the  state’s  PMP    Statute  or  regula?on  -­‐  14  states:  AR,  CA,  FL,  GA,  KY,  MA,   MI,  NM,  OH,  OR,  TN,  TX,  UT,  WA    Medical  board  policy  -­‐  4  states:    MI,  MN,  MT,  VA  
  61. 61. Prescribing  Cont…  •  Physical  exam  and/or  screening  for  substance  abuse  and   addic?on    Statute  or  regula?on  -­‐  25  states  +  D.C.:    AL,  AR,  DE,  DC,  FL,   GA,  IA,  KY,  LA,  ME,  MN,  MS,  NV,  NH,  NJ,  NM,  OH,  OK,  OR,   RI,  TN,  TX,  UT,  VA,  WA,  WV    Medical  board  policy  -­‐  39  states:    AL,  AZ,  CA,  CO,  CT,  DE,  FL,   GA,  HI,  ID,  IA,  KS,  KY,  ME,  MD,  MA,  MI,  MN,  MS,  MO,    MT,   NE,  NV,  NH,  NM,  NC,  OH,  OK,  OR,  PA,  RI,  SC,  SD,  UT,  VA,   WA,  WV,  WI,  WY  
  62. 62. Prescribing  Cont…  •  Treatment  plan,  including  informed  consent,  with   periodic  review;  treatment  agreement  with  provider/ pa?ent  responsibili?es    Statute  or  regula?on  -­‐  25  states  +  D.C.:  AL,  AR,  DE,  DC,  FL,   GA,  IA,  KY,  LA,  ME,  MN,  MS,  NV,  NH,  NJ,  NM,  OH,  OK,  OR,   RI,  TN,  TX,  UT,  VA,  WA,  WV    Medical  board  policy  -­‐  41  states:  AL,  AZ,  AR,  CA,  CO,  CT,  DE,   FL,  GA,  HI,  ID,  IA,  KS,  KY,  ME,  MD,  MA,  MI,  MN,  MS,  MO,   MT,  NE,  NV,  NH,  NM,  NY,  NC,  OH,  OK,  OR,  PA,  RI,  SC,  SD,  UT,   VA,  WA,  WV,  WI,  WY  
  63. 63. Prescribing  Cont…  •  Use  of  the  state  PMP    Statute  or  regula?on  -­‐  5  states:  KY,  LA,  NM,  TN,  WV    Medical  board  policy  -­‐  2  states:    NC,  WA  •  Referral  to  specialists  for  addi?onal  evalua?on  and  treatment,   or  steps  to  take  for  suspected  abuse  or  diversion    Statute  or  regula?on  -­‐  22  states  +  D.C.:    AL,  CA,  DE,  DC,  FL,   GA,  IA,  KY,  LA,  ME,  MS,  NE,  NH,  NJ,  NM,  OH,  OK,  OR,  TN,   TX,  UT,  VA,  WA    Medical  board  policy  -­‐  38  states:    AL,  AZ,  CA,  CO,  CT,  DE,  FL,   HI,  ID,  IA,  KS,  KY,  ME,  MD,  MA,  MI,  MN,  MS,  MO,  MT,  NE,   NV,  NH,  NM,  NC,  OH,  OK,  OR,  PA,  RI,  SC,  SD,  UT,  VA,  WA,   WV,  WI,  WY  
  64. 64. Prescribing  Cont…  •  Restric?ons  on  Schedule  II  controlled  substances,  including   opioids    Statute  or  regula?on  -­‐  45  states  +  D.C.:    AL,  AZ,  AR,  CA,  DE,   DC,  FL,  GA,  ID,  IL,  IN,  IA,  KS,  KY,  LA,  MD,  MA,  MI,  MN,  MS,   MO,  MT,  NE,  NV,  NH,  NJ,  NM,  NY,  NC,  ND,    OH,  OK,  OR,  PA,   RI,  SC,  SD,  TN,  TX,  UT,  VT,  VA,  WA,  WV,  WI,  WY    Medical  board  policy:  2  states  –  UT,  WA  
  65. 65. Prescribing  Cont…  •  Complete  and  accurate  medical  records    Statute  or  regula?on  -­‐  27  states  +  D.C.:  AL,  AR,  CA,  DE,  DC,   FL,  GA,  IA,  KY,  LA,  ME,  MS,  MO,  NV,  NH,  NJ,  NM,  ND,  OH,   OK,  OR,  RI,  TN,  TX,  UT,  VA,  WA,  WV    Medical  board  policy  -­‐  41  states:  AL,  AZ,  AR,  CA,  CO,  CT,  DE,   FL,  GA,  HI,  ID,  IA,  KS,  KY,  ME,  MD,  MA,  MI,  MN,  MS,  MO,   MT,  NE,  NV,  NH,  NM,  NY,  NC,  OH,  OK,  OR,  PA,  RI,  SC,  SD,  UT,   VA,  WA,  WV,  WI,  WY  
  66. 66. Prescribing  Cont…   •  Implementa?on  of  recommended  prac?ces  –  facilita?on  of  the   use  of  legi?mate  pain  management  prac?ces    Integrated,  interdisciplinary  approach  that  promotes   referrals  to  specialists  and  the  use  of  alterna?ves  and   adjuncts  to  controlled  substances        Use  of  opioids  for  chronic  pain  must  be  associated  with   documented  func?onal  outcomes  
  67. 67. Prescribing  Cont…    Restric?ons  on  dispensing  by  prescribers    Support  in  payment  systems  for  referrals  to  specialists,   including  qualified  pain  management  and  addic?on   treatment  professionals.  e.g.,  reimbursement  for   psychological/psychiatric  evalua?ons  for  high  risk  pa?ents    Mandated  referral  to  a  pain  management  specialist  if  the   pa?ent  is  receiving  a  certain  dosage  of  opioids  
  68. 68. NAMSDL  CONTACT  INFORMATION  Sherry  L.  Green   WEBSITE:  www.namsdl.org  Chief  Execu?ve  Officer   Sarah  Kelsey  NAMSDL  Headquarters  Office   Legisla?ve  Arorney  215  Lincoln  Ave.,  Suite  201   NAMSDL  Santa  Fe,  NM  87501   1598  Gray  Fox  Trail  Phone:  703-­‐836-­‐7496   Charloresville,  VA  22901  Cell:  703-­‐801-­‐8350   Phone:  703-­‐836-­‐6100,  Fax:  505-­‐820-­‐1750   Ext.  119  Email:  sgreen@namsdl.org   Email:  skelsey@namsdl.org  Heather  Gray  Research  Arorney   Kevin  Smith  NAMSDL   Government  Affairs  Coordinator  9841  Cedar  Glade   NAMSDL  Memphis,  TN  38016   113  Manchester  Ave.  Phone:  703-­‐836-­‐6100,     Earlville,  IA  52041  ext.  114   Phone:  703-­‐836-­‐6100,  Email:  hgray@namsdl.org   Ext.  118   Cell:  563-­‐929-­‐0519   Email:  ksmith@namsdl.org  

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