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Medication Abuse / Inhalant Abuse

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1 Medication Abuse / Inhalant Abuse
Medicine Misuse /Abuse Montgomery County, Maryland Safe & Drug Free Schools 2006 Symposium University of MD Shady Grove Campus Wm. Ray Bullman National Council on Patient Information and Education June 20, 2006 NCPIE / Bullman / June 20, 2006

2 Objectives: Medicine Misuse / Abuse
Medication Abuse / Inhalant Abuse Objectives: Medicine Misuse / Abuse Define the problem Review National Data Licit and illicit drug use Review the 2004 MD State Dept of Ed. Maryland Adolescent Survey Discuss next steps: In search of solutions! NCPIE / Bullman / June 20, 2006

3 Medication Abuse / Inhalant Abuse
Pharming Kids “getting high” using Rx or OTC drugs Creatine Vicodin Trend called “pharming” with a “p-h” unlike farming with “f” that requires acres to grow opium, cocaine and marijuana. Started to see this with illegal manufacture of Ecstasy tablets. To kids “pharming” not about specific drug, but whatever can get their hands on and what information can learn and share fast on the internet or through instant messaging. For instance, a few kids in Florida discovered they could buy Dextromethorphan powder on internet along with dissolvable capsules. Resulted in deaths. Whole world of behavior going on below sight line of adult Americans Andro GHB NCPIE / Bullman / June 20, 2006 47

4 Desired: Appropriate Drug Use
Medication Abuse / Inhalant Abuse Desired: Appropriate Drug Use Over the Counter (OTC) Medicines High margin of safety (but surprises happen) Through prescription by licensed provider For Indicated Use Listed on the FDA regulated package insert For “Off-Label” Use By regulated prescription (with DEA number) for known drugs of potential abuse OTC: Vitamins and “Natural” remedies Cold remedies (decongestants, antihistamines) Non-steroidal anti-inflammatory drugs (NSAID) SURPRISES: Opiates, tobacco, tylenol, dextromorphan cough syrup, pseudoephedrine, ephedra, Pain relievers (acetaminophen) Prescription: Antibiotics, anti-viral, steroids, psychotropics, antihypertensives, OTCs at higher strength, the whole PDR NCPIE / Bullman / June 20, 2006

5 Desired: Shared Decision Making
Medication Abuse / Inhalant Abuse Desired: Shared Decision Making Provider-patient shared decision for drug use Provider believes drug useful for treatment Communicates rationale to patient Benefits outweigh the risks Patient agrees that drug will be useful Understands rationale Accepts risks for desired benefit Patient takes medicine as directed Provider gets patient feedback NCPIE / Bullman / June 20, 2006

6 Problem: Medicine Misuse
Medication Abuse / Inhalant Abuse Problem: Medicine Misuse Drugs not taken as intended Provider prescribes for “wrong reason” Patient does not take drug as directed Unintentional: forgetfulness, too many drugs, mind-altering drug interactions Intentional: patient doesn’t feel need or believes drug not working and doesn’t discuss with the provider Drugs diverted to another person Potential problem & illegal (with prescribed drugs) Wrong reason: e.g. antibiotics for virus infections, antibiotics and anti-virals for agriculture, stimulants to study Not as directed: intentional: anti-malarials or antibiotics for full course, stopping antidepressants (esp SSRIs) Diversion monitoring: drug testing program such as in military NCPIE / Bullman / June 20, 2006

7 Problem: Medicine Abuse
Medication Abuse / Inhalant Abuse Problem: Medicine Abuse Interactions affecting decision-making Individual - a voluntary decision to use Psychologically pleasurable Physically enhancing for specific outcomes Environmental – friends & groups affect decision Drug is available at a “reasonable” price Drug enhances group bonding Drug connected to desired group activities NCPIE / Bullman / June 20, 2006

8 Medication Abuse / Inhalant Abuse
"Generation Rx“ Today's teenagers are more likely to have abused medications than a variety of illegal drugs like Ecstasy, cocaine, crack, and methamphetamine. Nearly one in five teens (19 percent or 4.5 million) report abusing prescription medications to get high One in 10 (10 percent or 2.4 million) report abusing cough medicine to get high. (Partnership for a Drug-Free America, 2005 Partnership Attitude Tracking Study) NCPIE / Bullman / June 20, 2006

9 Medication Abuse / Inhalant Abuse
"Generation Rx“ 1 in 4 teens report having a fried who abuses medicines to get high 1 in 3 report being offered an Rx or OTC medicine for the purpose of abuse Teen abuse of Rx & OTC medicines is greater than the combined abuse of ecstasy, meth, and heroin. Every day, 2,700 teens try an Rx medicine to get high for the first time* This suggests: Rx & OTC abuse has penetrated teen culture and become “normalized.” (Partnership for a Drug-Free America, 2005 Partnership Attitude Tracking Study; * National Survey on Drug Use and Health) NCPIE / Bullman / June 20, 2006

10 Medication Abuse / Inhalant Abuse
Any Illicit Drug Use in Past Month among Youths Aged 12 to 17, by State (Percentages, Annual Averages Based on 2003 and 2004 NSDUHs. SAMHSA) Teen Drug Abuse – We’re all in it together…. NCPIE / Bullman / June 20, 2006

11 Medication Abuse / Inhalant Abuse
Any Illicit Drug Use Other Than Marijuana in Past Month among Youths Aged 12 to 17 (Percentages, Annual Averages Based on 2003 and 2004 NSDUHs, SAMHSA) Some Even Worse than Others… NCPIE / Bullman / June 20, 2006

12 Medication Abuse / Inhalant Abuse
Non-medical Use of Pain Relievers in Past Year among Youths Aged 12 to 17 (Percentages, Annual Averages Based on 2003 and 2004 NSDUHs, SAMHSA) For Both Illicit & Licit Drugs… NCPIE / Bullman / June 20, 2006

13 New Landscape of Substance Abuse
Medication Abuse / Inhalant Abuse New Landscape of Substance Abuse # of Teens Who Have Ever Tried: (in millions) Marijuana 8.6 million Inhalants million Rx Medicine 4.5 million Cough Medicine 2.4 million Crack/Cocaine 2.4 million Ecstasy million Meth million LSD million Heroin million Ketamine 1 million GHB 1 million (Partnership Attitude Tracking Study, 2005) NCPIE / Bullman / June 20, 2006

14 Rx Abuse: ? on the Continuum
Medication Abuse / Inhalant Abuse Rx Abuse: ? on the Continuum Abuse of Rx medicines falls in the middle of the teen drug use continuum – less common than marijuana and more common than other drugs: Lifetime Use % Marijuana 37 Inhalants 30 Prescription Medicine 19 (not prescribed for them) Cough Medicine 10 Cocaine / Crack 10 Methamphetamine 8 Ecstasy 8 LSD 6 Heroin 5 Ketamine (Special K) 4 GHB 4 (Partnership for a Drug-Free America, 2005 Partnership Attitude Tracking Study) NCPIE / Bullman / June 20, 2006

15 Medication Abuse / Inhalant Abuse
Thank Goodness it’s only Pot …. Drugged Driving As Common As Alcohol-Impaired Driving Among Teens Each day 9,000+ new driver's licenses are issued to 16- and 17-year-olds, greatest risk for marijuana use. These same teens say that cars are the second most popular place for smoking marijuana. Monitoring the Future survey reports that approximately one in six (15%) teens reported driving under the influence of marijuana, a number nearly equivalent to those who reported driving under the influence of alcohol (16%). More than 2.9 million driving-age teens reported lifetime use of marijuana, and last year more than 750, and 17-year-olds reported driving under the influence of illicit drugs. According to the PRIDE Surveys, when asked where they use, approximately one in seven (14%) high school seniors cited "in a car," making cars the second most popular location after at "a friend's house" (20.4%). Marijuana impairs many of the skills required for safe driving, such as concentration, coordination, perception and reaction time, and these effects can last up to 24 hours after smoking the drug-It is critical that parents know the dangers associated with drugged driving and are vigilant in monitoring their teen drivers. (Alliance for Consumer Education) Gentlemen, don’t start Your engines…… NCPIE / Bullman / June 20, 2006

16 Attitudes – Rx Medicine Abuse
Medication Abuse / Inhalant Abuse Attitudes – Rx Medicine Abuse % Agree strongly / somewhat Rx drugs easier to get than illegal drugs 56 Rx drugs, even if not prescribed by doctor, 40 are much safer to use than illegal drugs There is nothing wrong with using Rx drugs 31 w/out a doctor’s prescription once in a while Rx pain relievers, even if they are not prescribed 29 by a doctor, are not addictive. (Partnership for a Drug-Free America, 2005 Partnership Attitude Tracking Study) NCPIE / Bullman / June 20, 2006

17 Medication Abuse / Inhalant Abuse
% Great Risk ’04 ‘05 Trying Rx pain relievers (Vicodin, Oxycontin, Tylox) that a doctor did not prescribe for you Trying the Rx drugs Ritalin or Adderall that a doctor did not prescribe for you (Partnership for a Drug-Free America, 2005 Partnership Attitude Tracking Study) NCPIE / Bullman / June 20, 2006

18 Good News / Not So Good News
Medication Abuse / Inhalant Abuse Good News / Not So Good News 2005 Partnership Attitude Tracking Study shows that substance abuse among 7th -12th graders continues to decline. After years of  adolescent drug use seen in the mid 90’s, the trend continues to reverse. The two exceptions are: inhalant and Prescription (Rx) medicine abuse. The use of alcoholic beverages has generally been in decline among American teens for the last several years, and that decline continued (in all three grades) in 2005. (Sources: Partnership for a Drug-Free America, 2005 Partnership Attitude Tracking Study; 7,300 teens in grades 7–12; Univ. of MI, Monitoring the Future, Dec. 2005) NCPIE / Bullman / June 20, 2006

19 Rx Abuse = Entrenched Behavior (1)
Medication Abuse / Inhalant Abuse Rx Abuse = Entrenched Behavior (1) Teen smoking & drinking continue to , but teenage abuse of Rx drugs has become "an entrenched behavior" that many parents fail to recognize (May 2006) For a third straight year, PD-FA study showed that about 1 in 5 teens have tried Rx painkillers such as Vicodin or OxyContin to get high -- about 4.5 million teens. (Univ. of MI study showed 1 in 10 H.S. seniors had experimented with Rx painkillers) Many teens feel experimenting with Rx drugs is safer than illegal highs. (Partnership for a Drug-Free America, 2005 Partnership Attitude Tracking Study; 7,300 teens in grades 7 – 12) NCPIE / Bullman / June 20, 2006

20 Rx Abuse = Entrenched Behavior (2)
Medication Abuse / Inhalant Abuse Rx Abuse = Entrenched Behavior (2) 40% said Rx medicines were "much safer" than illegal drugs, while 31% said there was "nothing wrong" with using prescription drugs "once in a while." The study further found that 29% of teens believe Rx pain relievers are non-addictive. (Partnership for a Drug-Free America, 2005 Partnership Attitude Tracking Study) NCPIE / Bullman / June 20, 2006

21 Reasons for Rx Pain Reliever Abuse?
Medication Abuse / Inhalant Abuse Reasons for Rx Pain Reliever Abuse? Widespread availability and generally easy access. Generally cheap Less of a stigma attached to their use (than others) Relatively easy to get on the Internet Generally regarded as safer than “street drugs” (Partnership for a Drug-Free America, 2005 Partnership Attitude Tracking Study) NCPIE / Bullman / June 20, 2006

22 Medication Abuse / Inhalant Abuse
Past Month Illicit Drug Use among Persons Aged 12 or Older, by Age (2004 National Survey on Drug Use and Health, SAMHSA) Medication Abuse / Inhalant Abuse NCPIE / Bullman / June 20, 2006

23 Medication Abuse / Inhalant Abuse
Past Month Use of Selected Illicit Drugs among Youths Aged 12 to 17 ( National Survey on Drug Use and Health, SAMHSA) NCPIE / Bullman / June 20, 2006

24 Medication Abuse / Inhalant Abuse
Youths Aged 12 to 17 Among 12 or 13 year olds: 1.7% used Rx-type drugs non-medically, 1.2% used inhalants, and 1.1% used marijuana. Among 14 or 15 year olds: Marijuana was the dominant drug used (7.3%), followed by Rx-type drugs used non-medically (4.1%) and inhalants (1.6%). Among 16 or 17 year olds: Marijuana also was the most commonly used drug (14.5%), followed by Rx-type drugs used non-medically (5.1%), hallucinogens (1.7%), and cocaine (1.1%). Only 0.9% of youths aged 16 or 17 used inhalants. Among all youths aged 12 to 17 in 2004, 10.6% were current illicit drug users: 7.6% used marijuana, 3.6% used Rx-type drugs non-medically, 1.2% used inhalants, 0.8% used hallucinogens, and 0.5 % used cocaine. The rate of current illicit drug use among youths aged 12 to 17 gradually declined between 2002 and The rate was 11.6% in 2002, 11.2% in 2003, and 10.6% in This represents a statistically significant change between 2002 and 2004, but not between 2002 and 2003 or between 2003 and   (2004 National Survey on Drug Use and Health, SAMHSA) NCPIE / Bullman / June 20, 2006

25 Q: What types of Rx medications are teens abusing?
Medication Abuse / Inhalant Abuse A: The National Survey on Drug Use and Health identifies 4 types of Rx medications that are commonly abused: Pain relievers Stimulants Sedatives Tranquilizers 11% of teens aged reported lifetime non-medical use of pain relievers and 4% reported lifetime non-medical use of stimulants. NCPIE / Bullman / June 20, 2006

26 They’re Getting them from Somewhere!
Medication Abuse / Inhalant Abuse They’re Getting them from Somewhere! % ‘04 ‘05 Use Rx pain relievers such as Vicodin, Oxycontin, Tylox, that a doctor did not prescribe for them Use the Rx drugs Ritalin or Adderall that a doctor did not prescribe for them (Partnership for a Drug-Free America, 2005 Partnership Attitude Tracking Study) NCPIE / Bullman / June 20, 2006

27 Medication Abuse / Inhalant Abuse
…Meet Willie Sutton… Willie Sutton (aka "The Actor" & "Slick Willie“) for his ingenuity in executing robberies in various disguises. Fond of expensive clothes, Sutton was described as being an immaculate dresser. Although he was a bank robber, Sutton had the reputation of a gentleman; people present at his robberies stated he was quite polite. One victim said witnessing one of Sutton's robberies was like being at the movies, except the usher had a gun. When asked why he robbed banks, Sutton simply replied, "Because that's where the money is.“ NCPIE / Bullman / June 20, 2006

28 …May I Use Your Bathroom?…
Medication Abuse / Inhalant Abuse …May I Use Your Bathroom?… The source of drugs is now the family medicine cabinet more than any dealer. PD-FA found 62% of teens said Rx pain relievers are easy to find at home. And 52% say Rx pain relievers are "available everywhere." (Partnership for a Drug-Free America, 2005 Partnership Attitude Tracking Study) NCPIE / Bullman / June 20, 2006

29 “Because That’s Where the Drugs Are ”
Medication Abuse / Inhalant Abuse “Because That’s Where the Drugs Are ” % Easy to get from parents’ medicine cabinet 62 Are available everywhere 52 They are not illegal drugs Easy to get through other people’s Rxs 50 Teens can claim they have a prescription if caught 49 They are cheap Safer to use than illegal drugs 35 Less shame attached to using 33 Easy to buy over Internet 32 Parents don’t care as much if you get caught 21 (Partnership for a Drug-Free America, 2005 Partnership Attitude Tracking Study) NCPIE / Bullman / June 20, 2006

30 Medication Abuse / Inhalant Abuse
OTC Medicine Abuse “Chugging cough medicine for an instant high certainly isn't a new practice for teens… recent coverage of the dangerous, potentially deadly practice of intentionally overdosing on cough and cold medicine has put parents, educators, and emergency departments on the alert.” Why Are Kids Abusing Cough and Cold Remedies? Before the FDA replaced the narcotic codeine with dextromethorphan as an OTC cough suppressant in the 1970s, teens were simply guzzling down cough syrup for a quick buzz. Over the years, teens have discovered they could get high by taking mass quantities of any of the multitude of OTCs containing DXM. Found in tablets, capsules, gel caps, and lozenges, as well as syrups, dextromethorphan-containing products are labeled DM, cough, cough suppressant, or Tuss (or contain "tuss" in the title). Medicines containing dextromethorphan are easy to find, affordable for cash-strapped teens, and perfectly legal. And because it's found in over-the-counter medicines, many teens are naively assuming that DXM can't be that dangerous. (http://kidshealth.org/parent/positive/talk/cough_cold_medicine_abuse.html NCPIE / Bullman / June 20, 2006

31 What Happens When Teens Abuse DXM?
Medication Abuse / Inhalant Abuse What Happens When Teens Abuse DXM? Taking mass quantities of products containing DXM can cause hallucinations, loss of motor control, and "out-of-body" (disassociative) sensations. Other possible side effects of DXM abuse include: confusion, impaired judgment, blurred vision, dizziness, paranoia, excessive sweating, slurred speech, nausea, vomiting, abdominal pain, irregular heartbeat, high blood pressure, headache, lethargy, numbness of fingers and toes, redness of face, dry and itchy skin, loss of consciousness, seizures, brain damage, and even death. Large quantities can also cause a high fever. This is a real concern for teens who take DXM while in a hot environment or while exerting themselves at a rave or dance club, where DXM is often sold and passed off as similar-looking drugs like PCP. (http://kidshealth.org/parent/positive/talk/cough_cold_medicine_abuse.html) NCPIE / Bullman / June 20, 2006

32 Medication Abuse / Inhalant Abuse
Q: What cough medicines are target for abuse (contain dextromethorphan, or DXM?) Medication Abuse / Inhalant Abuse There are over 100 OTC medicines that contain DXM, either as the only active ingredient or in combination with other active ingredients, including: -Alka-Seltzer Plus Cold & Cough Medicine -Vicks NyQuil LiquiCaps -Dayquil LiquiCaps -Coricidin HBP Cough/Cold -Dimetapp DM -Robitussin cough Products -Sudafed cough products -Triaminic cough syrups -Tylenol Cold products -Vicks 44 Cough Relief products There also are a number of store brands that contain DXM. NCPIE / Bullman / June 20, 2006

33 OTC Abuse – Be on the Lookout
Medication Abuse / Inhalant Abuse OTC Abuse – Be on the Lookout If you suspect that a child may be abusing OTC medicines or if your teen often attends raves or dance clubs where DXM can likely be found in abundance, it might be a good idea to: Lock your medicine cabinet, or keep those OTC medicines that could potentially be abused in a less accessible place. Avoid stockpiling OTC medicines. Having too many OTC medications at your teen's disposal could make abusing them more tempting. Keep track of how much is in each bottle or container in your medicine cabinet. NCPIE / Bullman / June 20, 2006

34 OTC Abuse – Be on the Lookout
Medication Abuse / Inhalant Abuse OTC Abuse – Be on the Lookout Keep an eye out for not only traditional-looking cough and cold remedies in your teen's room, but also strange-looking tablets (DXM is often sold on the Internet and at raves in its pure form in various shapes and colors). Look for possible warning signs of DXM abuse. Monitor your child's Internet usage. Be on the lookout for suspicious websites and s that seem to be promoting the abuse of DXM or other drugs, both legal and illegal. NCPIE / Bullman / June 20, 2006

35 Combating Abuse: 3-Step Approach for Parents
Medication Abuse / Inhalant Abuse 1. Educate themselves about the medicines that kids are abusing. 2. Communicate with their kids about the medically appropriate use of medications, & the harmful consequences of intentionally abusing them. 3. Safeguard their own medications & ask their friends to do the same. 4. Flush / Don’t Flush? Pharmacy return? (Depends) NCPIE / Bullman / June 20, 2006

36 Medication Abuse / Inhalant Abuse
Drug Abuse in the Montgomery County Public Schools (MCPS) Source: Maryland Department of Education Maryland Adolescent Survey Data specific to Montgomery County NCPIE / Bullman / June 20, 2006

37 MCPS Beer, Wine, Coolers Use
Medication Abuse / Inhalant Abuse MCPS Beer, Wine, Coolers Use Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey NCPIE / Bullman / June 20, 2006

38 Medication Abuse / Inhalant Abuse
MCPS “Hard” Liquor Use Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey NCPIE / Bullman / June 20, 2006

39 MCPS 5+ Drinks/Same Occasion
Medication Abuse / Inhalant Abuse MCPS 5+ Drinks/Same Occasion Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey NCPIE / Bullman / June 20, 2006

40 Medication Abuse / Inhalant Abuse
MCPS Cigarette Use Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey NCPIE / Bullman / June 20, 2006

41 MCPS Smokeless Tobacco Use
Medication Abuse / Inhalant Abuse MCPS Smokeless Tobacco Use Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey NCPIE / Bullman / June 20, 2006

42 MCPS Steroids for Body Building
Medication Abuse / Inhalant Abuse MCPS Steroids for Body Building Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey NCPIE / Bullman / June 20, 2006

43 MCPS Marijuana or Hashish Use
Medication Abuse / Inhalant Abuse MCPS Marijuana or Hashish Use Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey NCPIE / Bullman / June 20, 2006

44 Medication Abuse / Inhalant Abuse
MCPS LSD Use Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey NCPIE / Bullman / June 20, 2006

45 MCPS Mescaline, ‘shroom Use
Medication Abuse / Inhalant Abuse MCPS Mescaline, ‘shroom Use Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey NCPIE / Bullman / June 20, 2006

46 Medication Abuse / Inhalant Abuse
MCPS PCP Use Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey NCPIE / Bullman / June 20, 2006

47 Medication Abuse / Inhalant Abuse
MCPS Amphetamine Use Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey NCPIE / Bullman / June 20, 2006

48 MCPS Methamphetamine Use
Medication Abuse / Inhalant Abuse MCPS Methamphetamine Use Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey NCPIE / Bullman / June 20, 2006

49 MCPS Cocaine (not crack) Use
Medication Abuse / Inhalant Abuse MCPS Cocaine (not crack) Use Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey NCPIE / Bullman / June 20, 2006

50 MCPS Designer Drugs -- MDMA, Ecstasy Use
Medication Abuse / Inhalant Abuse Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey NCPIE / Bullman / June 20, 2006

51 MCPS Narcotic (not Heroin) Use
Medication Abuse / Inhalant Abuse MCPS Narcotic (not Heroin) Use Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey NCPIE / Bullman / June 20, 2006

52 MCPS Barbit. or Tranquilizer Use
Medication Abuse / Inhalant Abuse MCPS Barbit. or Tranquilizer Use Source: 1994, 1996, 1998, 2001, 2002, 2004 Maryland Adolescent Survey NCPIE / Bullman / June 20, 2006

53 Medication Abuse / Inhalant Abuse
Discussion Montgomery County (like all other counties), has a drug use problem Misuse, abuse, and dependence Who chooses to become an addict? (rhetorical question) What can we do? (prevention strategies) Primary – healthy community, social norms Secondary – identify high risk, early intervention, prescription drug monitoring Tertiary – effective treatment easily accessed Next steps? NCPIE / Bullman / June 20, 2006

54 Medication Abuse / Inhalant Abuse
Web-Based Resources (NCPIE) (PD-FA) (CHPA) (NIDA) (NIDA) (SAMHSA) (Univ. of MI) (ACE) NCPIE / Bullman / June 20, 2006

55 Medication Abuse / Inhalant Abuse
Contact Information Wm. Ray Bullman, M.A.M. Executive Vice President National Council on Patient Information and Education 4915 Saint Elmo Ave., Suite 505 Bethesda, MD (301) Phone - NCPIE / Bullman / June 20, 2006


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