HOUSE OF REPRESENTATIVES STAFF ANALYSIS
BILL #: CS/HB 1091 Substance Abuse Prevention
SPONSOR(S): Professions & Public Health Subcommittee, Caruso
TIED BILLS: IDEN./SIM. BILLS: SB 1442
REFERENCE ACTION ANALYST STAFF DIRECTOR or
BUDGET/POLICY CHIEF
1) Professions & Public Health Subcommittee 13 Y, 0 N, As CS Woodruff McElroy
SUMMARY ANALYSIS
An estimated 53 million people worldwide use opioids. An overabundance of opioids in the body can lead to a
fatal overdose. An opioid antagonist, such as Narcan, is a drug that blocks the effects of exogenously
administered opioids. Opioid antagonists are used in opioid overdoses to counteract life-threatening
depression of the central nervous system and respiratory system, allowing an overdose victim to breathe
normally. In 2019, Florida reported 5,268 opioid overdose deaths. This was the second highest overdose death
rate reported by any state.
Under current law, an authorized health care practitioner may prescribe and dispense an emergency opioid
antagonist to a patient or caregiver, and pharmacists may dispense an emergency opioid antagonist pursuant
to a prescription or pursuant to a non-patient-specific standing order. A patient or caregiver can store and
possess approved emergency opioid antagonists and, in an emergency, when a physician is not immediately
available, administer the emergency opioid antagonists to a person believed in good faith to be experiencing
an opioid overdose, regardless of whether that person has a prescription for an emergency opioid antagonist.
Emergency responders and crime laboratory personnel are authorized to possess, store, and administer
emergency opioid antagonists. Current law affords civil liability immunity to anyone who possess, administers,
prescribes, dispenses, or stores an approved emergency opioid antagonist.
Current law allows, rather than mandates, emergency medical technicians and paramedics who provide basic
and advanced life support services to report controlled substances overdoses to the Department of Health
(DOH).
HB 1091 amends s. 381.887, F.S., to reflect that the purpose of the section is for the prescribing, ordering, and
dispensing of emergency opioid antagonists. The bill requires DOH to develop and implement a statewide
awareness campaign to educate the public on opioid overdoses and the safe disposal of opioids. It allows a
pharmacist to order and dispense an emergency opioid antagonist to a patient or caregiver.
The bill expressly authorizes personnel of a law enforcement agency or other agency, including, correctional
probation officers and child protective investigators to possess, store, and administer emergency opioid
antagonists.
Finally, the bill amends s. 401.253, F.S., to require a basic life support service or advanced life support service
that treats and releases, or transports to a medical facility, a person in response to an emergency call for
suspected or actual overdose of a controlled substance to report such incidents to DOH.
The bill has a significant, negative, recurring fiscal impact on DOH, and no fiscal impact on local governments.
The bill has an effective date of July 1, 2021.
This document does not reflect the intent or official position of the bill sponsor or House of Representatives .
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FULL ANALYSIS
I. SUBSTANTIVE ANALYSIS
A. EFFECT OF PROPOSED CHANGES:
Background
Opioids
Opioids are psychoactive substances derived from the opium poppy, or their synthetic analogues.1
They are commonly used as pain relievers to treat acute and chronic pain. An individual experiences
pain because of a series of electrical and chemical exchanges among the individual’s peripheral
nerves, spinal cord, and brain.2 Opioid receptors occur naturally and are distributed widely throughout
the central nervous system and in peripheral sensory and autonomic nerves. 3 When an individual
experiences pain, the body releases hormones, such as endorphins, which bind with targeted opioid
receptors.4 This disrupts the transmission of pain signals through the central nervous system and
reduces the perception of pain.5 Opioids function in the same way by binding to specific opioid
receptors in the brain, spinal cord and gastrointestinal tract, thereby reducing the perception of pain.6
Opioids include prescription medications used to treat pain, as well as illegal drugs. Opioids include7:
Buprenorphine (Subutex, Suboxone)
Codeine
Fentanyl (Duragesic, Fentora)
Heroin
Hydrocodone (Vicodin, Lortab, Norco)
Hydromorphone (Dilaudid, Exalgo)
Meperidine
Methadone
Morphine
Oxycodone (OxyContin, Percodan, Percocet)
Oxymorphone
Tramadol
U-47700
It is estimated that 53 million people worldwide use opioids.8 Opioids are commonly abused, with an
estimated 35.6 million people worldwide suffering from drug use dependence.9 Opioids can create a
euphoric feeling because they affect the regions of the brain involved with pleasure and reward, which
can lead to abuse.10 Continued use of these drugs can lead to the development of tolerance and
1 World Health Organization, Opioid Overdose, https://www.who.int/news-room/fact-sheets/detail/opioid-overdose (last visited Mar. 30,
2021).
2 Medical News Today, What is pain, and how do you treat it? (Sept. 7, 2020),
https://www.medicalnewstoday.com/articles/145750#:~:text=People%20feel%20pain%20when%20specific,immediate%20contraction%
20of%20the%20muscles (last visited Mar. 18, 2021).
3 Gjermund Henriksen, Frode Willoch, Imaging of Opioid Receptors in the Central Nervous System, Brain (2008) 131 (5): 1171-1196.
4 Id.
5 Id.
6 U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, SAMHSA Opioid
Overdose Toolkit: Facts for Community Members (2018).
7 Florida Department of Law Enforcement, Drugs Identified in Deceased Persons by Florida Medical Examiners 2019 Report, (Nov.
2020).
8 United Nations Office on Drugs and Crime, World Drug Report 2019, Global Overview of Drug Demand and Supply (Jun. 2019),
https://wdr.unodc.org/wdr2019/prelaunch/WDR19_Booklet_2_DRUG_DEMAND.pdf (last visited Mar. 30, 2021).
9 Supra note 1.
10 National Institute on Drug Abuse, How Do Opioids Affect the Brain and Body?, (June 2020)
http://www.drugabuse.gov/publications/research-reports/prescription-drugs/opioids/how-do-opioids-affect-brain-body (last visited Mar.
18. 2021).
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psychological and physical dependence.11 This dependence is characterized by a strong desire to take
opioids, impaired control over opioid use, persistent opioid use despite harmful consequences, a higher
priority given to opioid use than to other activities and obligations, and a physical withdrawal reaction
when opioids are discontinued.12
An overabundance of opioids in the body can lead to a fatal overdose. In addition to their presence in
major pain pathways, opioid receptors are also located in the respiratory control centers of the brain.13
Opioids disrupt the transmission of signals for respiration in the identical manner that they disrupt the
transmission of pain signals (figure 1). This leads to a reduction, and potentially cessation, of an
individual’s respiration. Oxygen starvation will eventually stop vital organs like the heart, then the brain,
and can lead to unconsciousness, coma, and possible death.14 Within 3-5 minutes without oxygen,
brain damage starts to occur, soon followed by death.15 However, this does not occur instantaneously
as people will commonly stop breathing slowly, minutes to hours after the drug or drugs were used.16
An opioid overdose can be identified by a combination of three signs and symptoms referred to as the
“opioid overdose triad”:17
Pinpoint pupils.
Unconsciousness.
Respiratory depression.
Figure 1
Source: Maya Doe-Simkins, MPH, Boston Medical Center.
The rise in opioid overdose deaths can be outlines in three distinct waves:
1. The first wave began with increase prescribing of opioids in the 1990s, with overdose deaths
involving prescription opioids increasing since at least 1999.
2. The second wave began in 2010, with rapid increase in overdose deaths involving heroin.
3. The third wave began in 2013 with significant increases in overdose deaths involving synthetic
opioids, particularly those involving illicitly manufactured fentanyl. The market for illicitly
manufactured fentanyl continues to change, and it can be found in combination with heroin,
counterfeit pills, and cocaine.18
11 Supra note 6.
12 Supra note 1.
13 Pattinson, K.T.S., Opioids and the Control of Respiration, BJA, Vol. 100, Issue 6, Pages 747-758.
http://bja.oxfordjournals.org/content/100/6/747.full (last visited Mar. 18, 2021).
14 Harm Reduction Coalition, Guide to Developing and Managing Overdose Prevention and Take-Home Naloxone Projects, (Aug. 31,
2020) http://harmreduction.org/our-work/overdose-prevention/ (last visited Mar. 18, 2021).
15 Id.
16 Id.
17 Supra note 1.
18 Centers for Disease Control and Prevention, Understanding the Epidemic, https://www.cdc.gov/drugoverdose/epidemic/index.html
(last visited Mar. 30, 2021).
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More than 70,000 Americans died from drug-involved overdose in 2019, including illicit drugs and
prescription opioids.19 Overall, drug overdose deaths increased from 2018 to 2019 with 70,630 drug
overdoses reported in 2019.20 The following graph provides information on the total number of U.S.
overdose deaths involving any opioid21 from 1999 to 2019.22 Opioid-involved overdose deaths
increased from 21,088 in 2010 to 47,600 in 2017 and remained steady in 2018 with 46,802.23 This was
following by a significant increase in 2019 to 49,860 overdose deaths.24
In 2019, Florida reported 5,268 opioid overdose deaths.25 This was an 11.9 percent increase from
2018.26 Florida also experienced 4,152 opioid and 10,464 all drug non-fatal overdoses between July
and September 2019.27
Opioid Antagonist
An opioid antagonist, such as Narcan or Naloxone, is a drug that blocks the effects of exogenously
administered opioids. Opioid antagonists are used in opioid overdoses to counteract life-threatening
depression of the central nervous system and respiratory system, allowing an overdose victim to
breathe normally.28 This occurs because opioid antagonists create a stronger bond with opioid
receptors than opioids. This forces the opioids from the opioid receptors and allows the transmission of
signals for respiration to resume.29 This effect lasts only for a short period of time30 with the narcotic
19 National institute on Drug Abuse, Overdose Death Rates, https://www.drugabuse.gov/drug-topics/trends-statistics/overdose-death-
rates (last visited Mar. 30, 2021).
20 Id.
21 Any opioid includes prescription opioids (natural and semi-synthetic opioids and methadone), heroin and synthetic opioids other than
methadone (primarily fentanyl).
22 Id.
23 Id.
24 Id.
25 Center for Disease Control and Prevention, Drug Overdose Deaths, https://www.cdc.gov/drugoverdose/data/statedeaths/drug-
overdose-death-2019.html (last visited Mar. 30, 2021).
26 Center for Disease Control and Prevention, 2018-2019 Drug Overdose Death Rate Increase,
https://www.cdc.gov/drugoverdose/data/statedeaths/drug-overdose-death-2019.html (last visited Mar. 30, 2021).
27 Florida Department of Health, Non-Fatal Opioid and All Drug Overdose Surveillance Report, Florida Q4-2019,
http://www.floridahealth.gov/statistics-and-data/fl-dose/_documents/non-fatal-od-2019-q4.pdf
28 Harm Reduction Coalition, Understanding Naloxone, (Sept. 8, 2020) http://harmreduction.org/issues/overdose-
prevention/overview/overdose-basics/understanding-naloxone/ (last visited Mar. 18, 2021).
29 Supra note 13.
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effect of the opioids returning if still present in large quantities in the body. In this scenario, additional
doses of an opioid antagonist would be required and it is why it is generally recommended that anyone
who has experienced an overdose seek medical attention.
In February 2019, Florida issued a statewide Standing Order for Naloxone. The Standing Order
authorizes pharmacists to dispense certain naloxone formulations to emergency responders for
administration to persons exhibiting signs of opioid overdose.31 Under the Standing Order, emergency
responders, including law enforcement, firefighters, paramedics, and emergency medical technicians,
can go to a pharmacy or community-based program for training on opioid antagonist administration and
receive an opioid antagonist without a patient-specific prescription. Access to naloxone is available at
most pharmacies in Florida. The following map provides information on pharmacy locations where
naloxone is available a prescription.32
Florida law allows an authorized health care practitioner to prescribe and dispense an emergency
opioid antagonist to a patient or caregiver, and pharmacists may dispense an emergency opioid
antagonist pursuant to a prescription or to a non-patient-specific standing order.33 Current law defines a
“caregiver” as a family member, friend, or person in a position to have recurring contact with a person
at risk of experiencing an opioid overdose.34 Current law broadly defines a “person” to include
30 The half-life for a common opioid antagonist in adults ranged from 30 to 81 minutes. Acute opiate withdrawal is a potential side-effect
of naloxone; however, this would be time limited to the half-life of naloxone.
31 Florida Department of Health, State of Florida, Statewide Standing Order for Naloxone (Feb. 25, 2019),
http://www.floridahealth.gov/licensing-and-regulation/ems-system/_documents/standing-order-naloxone.pdf (last visited Mar. 30, 2021).
32 New America, National Naloxone Access Map,
https://opioidepidemic.maps.arcgis.com/home/item.html?id=153b0c32fefc432eae6a0e8439b9f56b (last visited Mar. 30, 2021). The
National Naloxone Map accumulates data from many difference sources, with participation from thousands of CVS, Walmart, and
Walgreens pharmacies, along with other independent distributors. The map is meant to be a community effort, and contributing
locations is encouraged to participate, to make it the best possible representation of resources. The map is not complete, and naloxone
prescription needs and costs vary by state, but this effort represents over 25,000 locations to obtain naloxone.
33 S. 381.887, F.S.
34 S. 381.887(1)(c), F.S.
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individuals and children.35 Therefore, an authorized health care practitioner may prescribed any person
falling under the definition an emergency opioid antagonist.
Any person prescribed an opioid antagonist, or distributed an emergency opioid antagonist pursuant to
a non-patient-specific standing order, may store and possess approved emergency opioid antagonists.
In an emergency, when a physician is not immediately available, that person may administer the
emergency opioid antagonists to an individual believed in good faith to be experiencing an opioid
overdose, regardless of whether that person has a prescription for an emergency opioid antagonist.36
Current law also allows emergency responders and crime laboratory personnel to possess, store, and
administer emergency opioid antagonists.
A person who possess, administers, prescribes, dispenses, or stores an approved emergency opioid
antagonist is afforded the civil liability immunity protections under s. 768.13, F.S. (Good Samaritan Act).
Prescription Drug Disposal
Currently, the recommended method of disposing unused prescription medications is to take them to a
drug take-back location.37 However, if there is not a drug take-back location in the area or if the person
cannot go to one promptly, the U.S. Food and Drug Administration (FDA) provides two
recommendations:
That drugs on the drug flus list be disposed of immediately by being flushed down a toilet. The
FDA has identified and created a list of drugs that are either dangerous to be kept unused for an
extended period of time or are sought-after for their misuse and abuse potential. Many of the
drugs on the flush list are prescription opioids.38
If the drug is not on the flush list, the FDA recommends that the drug be mixed with an
unappealing substance in a sealed container and thrown away in the trash.39
In either case, the FDA also recommends that all personal information on the prescription label
be deleted before throwing away or recycling the drug conta