Impact of prescription drug monitoring programs and pill mill laws on high-risk opioid prescribers: A comparative interrupted time series analysis

State-level variation in distribution of oxycodone and opioid-related deaths from 2000 to 2021: an ecological study of ARCOS and CDC WONDER data in the USA

OBJECTIVES

This study aims to characterise oxycodone's distribution and opioid-related overdoses in the USA by state from 2000 to 2021.

DESIGN

This is an observational study.

SETTING

More than 80 000 Americans died of an opioid overdose in 2021 as the USA continues to struggle with an opioid crisis. Prescription opioids play a substantial role, introducing patients to opioids and providing a supply of drugs that can be redirected to those seeking to misuse them.

METHODS

The Drug Enforcement Administration annual summary reports from the Automation of Reports and Consolidated Orders System provided weights of oxycodone distributed per state by business type (pharmacies, hospitals and practitioners). Weights were converted to morphine milligram equivalents (MME) per capita and normalised for population. The Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research provided mortality data for heroin, other opioids, methadone, other synthetic narcotics and other/unspecified narcotics.

RESULTS

There was a sharp 280.13% increase in total MME/person of oxycodone from 2000 to 2010, followed by a slower 54.34% decrease from 2010 to 2021. Florida (2007-2011), Delaware (2003-2020) and Tennessee (2012-2021) displayed consistent and substantial elevations in combined MME/person compared with other states. In the peak year (2010), there was a 15-fold difference between the highest and lowest states. MME/person from only pharmacies, which constituted >94% of the total, showed similar results. Hospitals in Alaska (2000-2001, 2008, 2010-2021), Colorado (2008-2021) and DC (2000-2011) distributed substantially more MME/person over many years compared with other states. Florida stood out in practitioner-distributed oxycodone, with an elevation of almost 15-fold the average state from 2006 to 2010. Opioid-related deaths increased +806% from 2000 to 2021, largely driven by heroin, other opioids and other synthetic narcotics.

CONCLUSIONS

Oxycodone distribution across the USA showed marked differences between states and business types over time. Investigation of opioid policies in states of interest may provide insight for future actions to mitigate opioid misuse.

Cross-sectional study of rapid tapering of opioid prescriptions following medical regulatory intervention in Alberta from 2013 to 2020

OBJECTIVE

To determine if inappropriate tapering/discontinuation of opioids to Alberta patients occurred from mid-2013-2020, as unintended consequences of prescribing guidelines, regulations and policies in response to the North American opioid crisis.

DESIGN

A population-based, repeated cross-sectional time-series study.

SETTING

Alberta, Canada.

PARTICIPANTS

Residents of Alberta, Canada aged 18 and older who received an opioid dispense from a community pharmacy from 2013 to 2020.

MAIN OUTCOME MEASURES

The prevalence of potential rapid tapering was measured at a given date (reference day), enveloped by a data window. Dose changes were measured as oral morphine equivalents (OME) per patient, at multiple time points ('data window' around a reference day). Chronic recipients were identified, and their prescriptions were contrasted 90 days before and after the reference day to measure OME/day changes.

RESULTS

Approximately 9000 dispenses (totalling ~6 million OME) per day were analysed from 2013 to 2020. The total number of opioid recipients was highly cyclic in nature (peaking in winter). The number of chronic opioid recipients remained somewhat stable from ~70K in 2013 to ~86K at the end of 2020. The number of chronic high and very high dose recipients presented a significant decrease after 2017. Approximately 11%-12% of chronic high-dose recipients experienced potential rapid dose tapering at a rate of 50% or more prereference to postreference day at any given point of time. For chronic very high dose recipients, approximately 11.5% experience potential rapid dose tapering at a rate of 50% or more prereference to postreference day at any given point of time. Potential discontinuation remained constant and the interventions did not have a significant impact on the trend.

CONCLUSION

The evidence suggests that changes in prescribing guidelines were not associated with an increase of rapid opioid tapering/discontinuation in Alberta.

Understanding the differential effect of local socio-economic conditions on the relation between prescription opioid supply and drug overdose deaths in US counties

BACKGROUND AND AIMS

Both local socio-economic conditions and prescription opioid supply are associated with drug overdose deaths, which exhibit substantial geographical heterogeneity across the United States. We measured whether the associations of prescription opioid supply with drug overdose deaths vary by local socio-economic conditions.

DESIGN

Ecological county-level study, including 3109 US counties between 2006 and 2019 (n = 43 526 county-years) using annual mortality data.

SETTING

United States.

CASES

A total of 711 447 drug overdose deaths.

MEASUREMENTS

We modeled overdose counts using Bayesian hierarchical Poisson models, estimating associations between four types of drug overdose deaths (deaths involving any drugs, any opioid, prescription opioids only and heroin), prescription opioid supply and five socio-economic indicators: unemployment, poverty rate, income inequality, Rey index (components include mean household income, % high school graduates, % blue-collar workers and unemployment rate), and American human development index (HDI; an indicator of community wellbeing).

FINDINGS

Drug overdose deaths and all substance-specific overdose deaths were higher in counties with higher income inequality [adjusted odds ratios (aORs) = 1.09-1.13], Rey index (aORs = 1.15-1.21) and prescription opioid supply (aORs = 1.14-1.21), and lower in counties with higher HDI scores (aORs = 0.75-0.92). Poverty rate, income inequality and HDI scores were found to modify the effect of prescription opioid supply on heroin overdose deaths. The plot of the interactions showed that when disadvantage is high, increasing prescription opioid supply does not increase heroin overdose deaths. The less disadvantage there is, indicated by lower poverty rates, higher HDI scores and lower income inequality, the greater the effect of increasing prescription opioid supply relative to population size on heroin overdose deaths in US counties.

CONCLUSIONS

In the United States, prescription opioid supply is associated with higher drug overdose deaths; associations are stronger in counties with less disadvantage and less income inequality, but only for heroin overdose deaths.

Association of Prescription Drug Monitoring Programs With Opioid Prescribing and Overdose in Adolescents and Young Adults

STUDY OBJECTIVE

Prescription opioid use is associated with substance-related adverse outcomes among adolescents and young adults through a pathway of prescribing, diversion and misuse, and addiction and overdose. Assessing the effect of current prescription drug monitoring programs (PDMPs) on opioid prescribing and overdoses will further inform strategies to reduce opioid-related harms.

METHODS

We performed interrupted time series analyses to measure the association between state-level implementation of PDMPs with annual opioid prescribing and opioid-related overdoses in adolescents (13 to 18 years) and young adults (19 to 25 years) between 2008 and 2019. We focused on PDMPs that included mandatory reviews by providers. Data were obtained from a commercial insurance company.

RESULTS

Among 9,344,504 adolescents and young adults, 1,405,382 (15.0%) had a dispensed opioid prescription, and 6,262 (0.1%) received treatment for an opioid-related overdose. Mandated PDMP review was associated with a 4.2% (95% CI, 1.9% to 6.4%) reduction in annual opioid dispensations among adolescents and a 7.8% (95% CI, 4.7% to 10.9%) annual reduction among young adults. For opioid-related overdoses, mandated PDMP review was associated with a 16.1% (95% CI, 3.8 to 26.7) and 15.9% (95% CI, 7.6 to 23.4) reduction in annual opioid overdoses for adolescents and young adults, respectively.

CONCLUSION

PDMPs were associated with sustained reductions in opioid prescribing and overdoses in adolescents and young adults. Although these findings support the value of mandated PDMPs as part of ongoing strategies to reduce opioid overdoses, further studies with prospective study designs are needed to characterize the effect of these programs fully.

Achieving Reductions in Opioid Dispensing: A Qualitative Comparative Analysis of State-Level Efforts to Improve Prescribing

OBJECTIVE

To determine whether any combinations of state-level public health activities were necessary or sufficient to reduce prescription opioid dispensing.

DESIGN

We examined 2016-2019 annual progress reports, 2014-2019 national opioid dispensing data (IQVIA), and interview data from states to categorize activities. We used crisp-set Qualitative Comparative Analysis to determine which program activities, individually or in combination, were necessary or sufficient for a better than average decrease in morphine milligram equivalent (MME) per capita.

SETTING

Twenty-nine US state health departments.

PARTICIPANTS

State health departments implementing the Centers for Disease Control and Prevention's Prevention for States (PfS) program.

MAIN OUTCOME

Combinations of prevention activities related to changes in the rate of prescription opioid MME per capita dispensing from 2014 to 2019.

RESULTS

Three combinations were sufficient for greater than average state-level reductions in MME per capita: (1) expanding and improving proactive reporting in combination with enhancing the uptake of evidence-based opioid prescribing guidelines and not moving toward a real-time Prescription Drug Monitoring Program; (2) implementing or improving prescribing interventions for insurers, health systems, or pharmacy benefit managers in combination with enhancing the uptake of evidence-based opioid prescribing guidelines; and (3) not implementing or improving prescribing interventions for insurers, health systems, or pharmacy benefit managers in combination with not enhancing the uptake of evidence-based opioid prescribing guidelines. Interview data suggested that the 3 combinations indicate how state contexts and history with addressing opioid overdose shaped programming and the ability to reduce MME per capita.

CONCLUSIONS

States successful in reducing opioid dispensing selected activities that built upon existing policies and interventions, which may indicate thoughtful use of resources. To maximize impact in addressing the opioid overdose epidemic, states and agencies may benefit from building on existing policies and interventions.

Systematic Identification and Categorization of Opioid Prescribing and Dispensing Policies in 16 States and Washington, DC

OBJECTIVES

State policies can impact opioid prescribing or dispensing. Some state opioid policies have been widely examined in empirical studies, including prescription drug monitoring programs and pain clinic licensure requirements. Other relevant policies might exist that have received limited attention. Our objective was to identify and categorize a wide range of state policies that could affect opioid prescribing/dispensing.

METHODS

We used stratified random sampling to select 16 states and Washington, DC, for our sample. We collected state regulations and statutes effective during 2020 from each jurisdiction, using search terms related to opioids, pain management, and prescribing/dispensing. We then conducted qualitative template analysis of the data to identify and categorize policy categories.

RESULTS

We identified three dimensions of opioid prescribing/dispensing laws: the prescribing/dispensing rule, its applicability, and its disciplinary consequences. Policy categories of prescribing/dispensing rules included clinic licensure, staff credentials, evaluating the appropriateness of opioids, limiting the initiation of opioids, preventing the diversion or misuse of opioids, and enhancing patient safety. Policy categories related to applicability of the law included the pain type, substance type, practitioner, setting, payer, and prescribing situation. The disciplinary consequences dimension included specific consequences and inspection processes.

DISCUSSION

Policy categories within each dimension of opioid prescribing/dispensing laws could become a foundation for creating variables to support empirical analyses of policy effects, improving operationalization of policies in empirical studies, and helping to disentangle the effects of multiple state laws enacted at similar times to address the opioid crisis. Several of the policy categories we identified have been underexplored in previous empirical studies.

The effect of pill mill legislation on suicides

OBJECTIVE

To examine the effect of pill mill legislation on suicides and drug-related suicides in the United States.

DATA SOURCES

We use state-level restricted use mortality data from the National Vital Statistics System for the period 2000-2016, along with state level sociodemographic data from the US Census Bureau and Bureau of Labor Statistics and opioid-related state health policy data from publicly available sources for the analysis.

STUDY DESIGN

The analyses use a difference-in-differences regression approach.

DATA COLLECTION/EXTRACTION METHODS

Publicly available secondary data were collected and merged with restricted use mortality data files from the National Vital Statistics System for the analysis.

PRINCIPAL FINDINGS

Our results show that pill mill legislation is associated with an 8.5% (p < 0.01) reduction in the drug related suicide rate, a 4.9% (p < 0.05) reduction in suicides among females, and a 4.7% (p < 0.05) reduction in suicides among individuals between age 45 and 64 years.

CONCLUSIONS

The findings indicate that pill mill legislation has been effective in reducing total suicides among females in the age group 45-64, and drug-related suicides in the population resulting in 658 fewer drug-related suicides for a given year if pill mill laws are adopted by every state.

Coverage of the opioid crisis in national network television news from 2000-2020: A content analysis

Background: News coverage has both negatively and positively influenced public awareness and perceptions surrounding the opioid crisis. This study aimed to describe and analyze national network television news framing of the scope and impact of the opioid crisis in the United States. Methods: We performed a retrospective content analysis on national network television evening news segments covering the opioid crisis from 1/2000 to 8/2020, which were obtained from the Vanderbilt Television News Archive. The database was queried for: opioid epidemic, oxycontin, heroin, fentanyl, and naloxone. Two independent reviewers quantitatively coded segment characteristics, including theme, geographic location, opioids mentioned, strategies for combatting the epidemic discussed, interviews conducted, and patient demographics. Changes in segment characteristics over time were analyzed using chi-square analyses and Fisher's exact tests. Results: News segments (N = 191) most commonly provided an overview of the epidemic (55.5%) and/or conveyed personal stories (40.3%). Prescription opioids (59.7%) and heroin (62.8%) were more often referenced than fentanyl (17.8%); the focus on heroin peaked in 2011-2015 (84.8%), while references to fentanyl significantly increased over time (p = 0.021). The most frequently interviewed people included patients with opioid use disorder (OUD) (47.1%), healthcare providers (36.7%), family members/friends (31.9%), and law enforcement (30.9%). Most of the featured patients with OUD were male (63.0%), white (88.4%), and young (< 40 years) adults (77.9%). Coverage of the crisis peaked in 2016. Conclusions: Evening news segments' emphasis on personal stories, while emotionally compelling, came at the cost of thematically-framed coverage that may improve public understanding of the complexities of the epidemic. The depiction of primarily white, young adult patients with OUD revealed a need for a greater emphasis in the news on underrepresented minorities and older adults, as these populations face additional stigma and disparities in OUD treatment initiation and retention.

Effects of State Opioid Prescribing Laws on Use of Opioid and Other Pain Treatments Among Commercially Insured U.S. Adults

BACKGROUND

There is concern that state laws to curb opioid prescribing may adversely affect patients with chronic noncancer pain, but the laws' effects are unclear because of challenges in disentangling multiple laws implemented around the same time.

OBJECTIVE

To study the association between state opioid prescribing cap laws, pill mill laws, and mandatory prescription drug monitoring program query or enrollment laws and trends in opioid and guideline-concordant nonopioid pain treatment among commercially insured adults, including a subgroup with chronic noncancer pain conditions.

DESIGN

Thirteen treatment states that implemented a single law of interest in a 4-year period and unique groups of control states for each treatment state were identified. Augmented synthetic control analyses were used to estimate the association between each state law and outcomes.

SETTING

United States, 2008 to 2019.

PATIENTS

7 694 514 commercially insured adults aged 18 years or older, including 1 976 355 diagnosed with arthritis, low back pain, headache, fibromyalgia, and/or neuropathic pain.

MEASUREMENTS

Proportion of patients receiving any opioid prescription or guideline-concordant nonopioid pain treatment per month, and mean days' supply and morphine milligram equivalents (MME) of prescribed opioids per day, per patient, per month.

RESULTS

Laws were associated with small-in-magnitude and non-statistically significant changes in outcomes, although CIs around some estimates were wide. For adults overall and those with chronic noncancer pain, the 13 state laws were each associated with a change of less than 1 percentage point in the proportion of patients receiving any opioid prescription and a change of less than 2 percentage points in the proportion receiving any guideline-concordant nonopioid treatment, per month. The laws were associated with a change of less than 1 in days' supply of opioid prescriptions and a change of less than 4 in average monthly MME per day per patient prescribed opioids.

LIMITATIONS

Results may not be generalizable to non-commercially insured populations and were imprecise for some estimates. Use of claims data precluded assessment of the clinical appropriateness of pain treatments.

CONCLUSION

This study did not identify changes in opioid prescribing or nonopioid pain treatment attributable to state laws.

PRIMARY FUNDING SOURCE

National Institute on Drug Abuse.

Impact of Three Safety Interventions Targeting Off-Label Use of Immediate-Release Fentanyl on Prescription Trends: Interrupted Time Series Analysis

Background: The Spanish health authorities are concerned by the off-label use of immediate-release formulations of fentanyl (IRF) in noncancer pain and cancer pain in patients with no chronic pain therapy. Aim: To evaluate the impact of different interventions to improve appropriateness of IRF prescription on off-label prescription. Patients and methods: We used interrupted time series (ITS) to estimate immediate and trend changes of IRF prescription for noncancer pain (NCP) and breakthrough cancer pain (BCP) in patients with and without chronic cancer pain therapy associated with two medication reviews (I1 and I2) and the issue of a safety warning letter (I3) with data from a Spanish region with 5 million inhabitants, from 2015 to 2018. Results: The use of IRF for NCP in the region Valencia was reduced from about 1,800 prescriptions per week to around 1,400. The first medication review was followed by an immediate level change of -192.66 prescriptions per week (p < 0.001) and a downward trend change of -6.75 prescriptions/week (p < 0.001), resulting in a post-intervention trend of -1.99 (p < 0.001). I2 was associated with a trend change of -23.07 (p < 0.001) prescriptions/week. After I3, the trend changed markedly to 27.23 additional prescriptions/week, for a final post-intervention trend of 2.17 (p < 0.001). Controlled-ITS provided comparable results. For potentially inappropriate BCP use, the second medication review was followed by a downward, immediate level change of -10.10 prescriptions/week (p = 0.011) and a trend change of 2.31 additional prescriptions/week (p < 0.001) and the issue of the safety warning (I3) was followed by a downward trend change of -2.09 prescriptions/week (p = 0.007). Conclusion: Despite IRF prescription for NCP decreased, the interventions showed modest and temporary effect on off-label prescription. Our results call for a review of the design and implementation of safety interventions addressing inappropriate opioid use.

Exploring perspectives on changing opioid prescribing practices: A qualitative study of community stakeholders in the HEALing Communities Study

BACKGROUND

Community-based perspectives are needed to more broadly inform policy-makers, public health practitioners, prescribers, and pharmacists about community-led and broader efforts to reduce opioid overprescribing, and ultimately reduce prescription opioid use disorder, overdoses and fatalities. The aim of this study is to explore community-based perspectives on efforts to change opioid prescribing practices in their communities.

METHODS

Semi-structured interviews were conducted with 388 community stakeholders across four states (Kentucky, Massachusetts, New York, Ohio) from November 2019 to January 2020 about community approaches and goals of community-led responses to the opioid crisis. Data analysis combined deductive and inductive approaches to identify themes and sub-themes related to improving opioid prescribing practices.

RESULTS

Three major themes and different subthemes were characterized: (1) acknowledging progress (i.e., healthcare providers being part of the solution, provider education, and prescription drug monitoring programs); (2) emergent challenges (i.e., physician nonadherence with safer opioid prescribing guidelines, difficulty identifying appropriate use of opioids, and concerns about accelerating the progression from opioid misuse to drug abuse); and (3) opportunities for change (i.e., educating patients about safer use and proper disposal of opioids, expanding prescriber and pharmacist education, changing unrealistic expectations around eliminating pain, expanding and increasing insurance coverage for alternative treatment options).

CONCLUSIONS

Community stakeholders appeared to support specific opportunities to reduce prescription opioid misuse and improve safer prescribing. The opportunities included culture change around pain expectations, awareness of safe disposal, additional provider education, and increased coverage and acceptability of non-opioid treatments.

Effects of County-Level Opioid Dispensing Rates on Individual-Level Patterns of Prescription Opioid and Heroin Consumption: Evidence From National U.S. Data

OBJECTIVE

The authors examined directly whether county-level changes in opioid dispensing rates affect individual-level prescription opioid misuse, frequency of use, and dependence, as well as the same outcomes for heroin.

METHODS

Using data from the restricted-access National Survey on Drug Use and Health, the Centers for Disease Control and Prevention's retail opioid prescription database, the Prescription Drug Abuse Policy System, and the U.S. Census, the authors applied fixed-effects models to determine whether county-level dispensing rates affected prescription opioid outcomes as intended and whether changes in rates adversely affected heroin use outcomes. Bayes factors were used to confirm evidence for null findings.

RESULTS

The sample included 748,800 respondents age 12 and older from 2006 to 2016. The odds of prescription opioid misuse, increased frequency of misuse, and dependence were 7.2%, 3.5%, and 10.4% higher, respectively, per standard deviation increase in the county-level opioid dispensing rate per 100 persons. There was no evidence for any association between opioid dispensing rates and the three heroin outcomes. The odds ratio was nonsignificant according to frequentist techniques in fixed-effects models, and Bayesian techniques confirmed very strong support for the null hypothesis.

CONCLUSIONS

County-level opioid dispensing rates are directly associated with individual-level prescription opioid misuse, frequency of misuse, and dependence. Changes in dispensing were not associated with population shifts in heroin use. Reductions in opioid dispensing rates have contributed to stemming prior increases in prescription opioid misuse while not adversely affecting heroin use. Physicians and other health care providers can take action to minimize opioid dispensing for tangible benefits regarding prescription opioid misuse without adverse effects on heroin use.

Primary care provider perspectives on and utilization of a mandatory prescription drug monitoring program in New York City

BACKGROUND

The ways in which prescription drug monitoring programs (PDMPs) have been integrated into primary care practice remain understudied, and research into physician utilization of PDMPs in states where PDMP use is mandated remains scant.

OBJECTIVES

To characterize primary care physician perspectives on and utilization of a mandatory PDMP in New York City.

METHODS

We conducted face-to-face, in-depth interviews with primary care physicians who reported that they currently prescribed opioid analgesic medication. We used a thematic analytic approach to characterize physician perspectives on the PDMP mandate and physician integration of mandatory PDMP use into primary care practice.

RESULTS

Primary care providers demonstrated a continuum of PDMP utilization, ranging from consistent use to the specifications of the mandate to inconsistent use to no use. Providers reported a range of perspectives on the purpose and function of the PDMP mandate, as well as a lack of clarity about the mandate and its enforcement.

CONCLUSION

Findings suggest a need for increased clinical and public health education about the use of PDMPs as clinical tools to identify and treat patients with potential substance use disorders in primary care.

Medicaid expansion and opioid supply policies to address the opioid overdose crisis

Background: The opioid overdose crisis remains of critical concern after historic increases in overdose mortality in the United States between 2020 and 2021. Improving access to buprenorphine -a partial opioid agonist and one of three FDA-approved medications for opioid use disorder (OUD) treatment- and reducing inappropriate opioid prescriptions may help curb mortality. Here, we examined the impact of Medicaid expansion and pain management clinic laws on opioid prescription rates and buprenorphine availability. Methods: We examined both retail opioid prescriptions per 100 persons in the state population using data from the Centers for Disease Control and Prevention and data on buprenorphine distributions in kilograms per 100,000 persons in the state population from the Automated Reports and Consolidated Ordering System database. We employed difference-in-difference frameworks to estimate the impact of Medicaid expansion on buprenorphine access and retail opioid prescription rates. Models considered three separate treatment variables: Medicaid expansion, pain management clinic ("pill mill") laws, and the interaction of Medicaid expansion and pain management clinic laws. Results: Findings showed that Medicaid expansion was associated with increased access to buprenorphine in expansion states that also employed more stringent supply-side policies, including pain management clinic laws, relative to states that did not implement policies targeting the over-supply of prescription opioids over the same time period. Conclusions. Together, Medicaid expansion and policies limiting inappropriate opioid prescriptions show promise for improving the accessibility of buprenorphine treatment for OUD.

Flipping the script: The effects of opioid prescription monitoring on specialty-specific provider behavior

Mandatory access Prescription Drug Monitoring Programs (MA-PDMPs) aim to curb the epidemic at a common point of initiation of use, the prescription. However, there is recent concern about whether opioid policies have been too restrictive and reduced appropriate access to patients with the most need for opioid pharmaceuticals. We assess MA-PDMP's effect on specialty-specific opioid prescribing behavior of Medicare providers. Our findings suggest that requiring providers to query a PDMP differentially affects opioid prescribing across provider specialties. We find a three to four percent decrease in prescribing for Primary Care and Internal Medicine providers. This result is driven by healthcare providers at the lower end of the prescribing distribution. There is also suggestive evidence of an increase in opioid use disorder treatment drugs prescribed by these same providers. We also find no evidence for the hypothesis that MA-PDMPs restrict prescribing by providers who treat patients with potentially high levels of pain, few drug substitutes, or urgency for pain treatment (e.g., Oncology/Palliative care). This result is not dependent on whether a state provides exemptions for these providers. Our results indicate that MA-PDMPs may help close provider-patient informational gaps while retaining a provider's ability to supply these drugs to patients with a need for opioids.

The effect of state policies on rates of high-risk prescribing of an initial opioid analgesic

BACKGROUND

Multiple state policies, such as prescription drug monitoring programs (PDMPs) and duration limits, have been implemented to decrease high-risk opioid prescribing. Studies demonstrate that many policies decrease certain opioid prescribing behaviors, but few examine their intended effects on the targeted high-risk prescribing practices, nor disentangle the effects of concurrent state or federal policies likely to influence those practices.

METHODS

Forty-one million initial prescriptions for new opioid episodes from 2007 to 2018 were identified using national pharmacy claims. We identified high-risk initial prescriptions, defined as >7 days' supply, average daily MME >90, or concurrent with benzodiazepines and estimated three multivariable logistic regression models to assess the association between policies and outcomes controlling for patient, prescriber, and county characteristics.

RESULTS

Initial prescriptions for >7 days declined from 23.8% in 2007 to 14.9% in 2018, associated with mandatory and interoperable PDMPs and prescription duration limits but not other policies examined. Initial prescriptions with daily MME > 90 declined from 13.2% to 1.9%, associated with pain management clinic laws but not consistently with other policies. Initial prescriptions concurrent with benzodiazepines declined only modestly from 6.9% to 6.5%, associated with pain management clinic laws but not other policies examined.

CONCLUSIONS

The opioid policy environment has changed rapidly with a range of different policies being implemented addressing high-risk prescribing. PDMP laws mandating prescriber use and pain clinic laws both appear efficacious but decrease different types of high-risk opioid prescribing. New policies should be considered in light of the prevalence of the problem being addressed.

Mapping the research addressing prescription drug monitoring programs: A scoping review

ISSUES

Prescription drug monitoring programs are a harm minimisation intervention and clinical decision support tool that address the public health concern surrounding prescription drug misuse. Given the large number of studies published to date and the ongoing implementation of these programs, it is important to map the literature and identify areas for further research to improve practice.

APPROACH

A scoping review was undertaken to identify the research on prescription drug monitoring programs published between January 2015 and April 2021.

KEY FINDINGS

A total of 153 citations were included in this scoping review. The majority of the studies originated from the USA and were quantitative. Results on program effectiveness are mixed and mainly examine their association with opioid-related outcomes. Unintended consequences are revealed in the literature and this review also highlights barriers to program use.

IMPLICATIONS

Overall, findings are mixed despite the large number of studies published to date. Mapping the literature identifies priority areas for further research that can advise policymakers and clinicians on practice improvement.

CONCLUSION

Results on prescription drug monitoring program effectiveness are mixed and mainly examine their association with opioid-related outcomes. This review highlights barriers to prescription drug monitoring program effectiveness related to program use and system integration. Further research is needed in these areas to improve prescription drug monitoring program use and patient outcomes.

Davis C, Rudolph KE, Keyes KM, Hasin DS, Cerdá M. Prescription Opioid Laws and Opioid Dispensing in US Counties: Identifying Salient Law Provisions With Machine Learning

BACKGROUND

Hundreds of laws aimed at reducing inappropriate prescription opioid dispensing have been implemented in the United States, yet heterogeneity in provisions and their simultaneous implementation have complicated evaluation of impacts. We apply a hypothesis-generating, multistage, machine-learning approach to identify salient law provisions and combinations associated with dispensing rates to test in future research.

METHODS

Using 162 prescription opioid law provisions capturing prescription drug monitoring program (PDMP) access, reporting and administration features, pain management clinic provisions, and prescription opioid limits, we used regularization approaches and random forest models to identify laws most predictive of county-level and high-dose dispensing. We stratified analyses by overdose epidemic phases-the prescription opioid phase (2006-2009), heroin phase (2010-2012), and fentanyl phase (2013-2016)-to further explore pattern shifts over time.

RESULTS

PDMP patient data access provisions most consistently predicted high-dispensing and high-dose dispensing counties. Pain management clinic-related provisions did not generally predict dispensing measures in the prescription opioid phase but became more discriminant of high dispensing and high-dose dispensing counties over time, especially in the fentanyl period. Predictive performance across models was poor, suggesting prescription opioid laws alone do not strongly predict dispensing.

CONCLUSIONS

Our systematic analysis of 162 law provisions identified patient data access and several pain management clinic provisions as predictive of county prescription opioid dispensing patterns. Future research employing other types of study designs is needed to test these provisions' causal relationships with inappropriate dispensing and to examine potential interactions between PDMP access and pain management clinic provisions. See video abstract at, http://links.lww.com/EDE/B861.

Patterns, trends and determinants of medical opioid utilization in Canada 2005-2020: characterizing an era of intensive rise and fall

BACKGROUND

Into the 21st century, the conflation of high rates of chronic pain, systemic gaps in treatment availability and access, and the arrival of potent new opioid medications (e.g., slow-release oxycodone) facilitated strong increases in medical opioid dispensing in Canada. These persisted until post-2010 alongside rising opioid-related adverse (e.g., morbidity/mortality) outcomes. We examine patterns, trends and determinants of opioid dispensing in Canada, and specifically its 10 provinces, for the years 2005-2020.

METHODS

Raw data on prescription opioid dispensing were obtained from a large national community-based pharmacy database (IQVIA/Compuscript), converted into Defined-Daily-Doses/1,000 population/day for 'strong' and 'weak' opioid categories per standard methods. Dispensing by opioid category and formulations by province/year was assessed descriptively; regression analysis was applied to examine possible segmentation of over-time strong opioid dispensing.

RESULTS

All provinces reported starkly increasing strong opioid dispensing peaking 2011-2016, and subsequent marked declines. About half reported lower strong opioid dispensing in 2020 compared to 2005, with continuous inter-provincial differences of > 100 %; weak opioids also declined post-2011/12. Segmented regression suggests breakpoints for strong opioids in 2011/12 and 2015/16, coinciding with main interventions (e.g., selective opioid delisting, new prescribing guidelines) towards more restrictive opioid utilization control.

CONCLUSIONS

We characterized an era of marked rise and fall, while featuring stark inter-provincial heterogeneity in opioid dispensing in Canada. While little evidence for improvements in pain care outcomes exists, the starkly inverting opioid utilization have been associated with extensive population-level harms (e.g., misuse, morbidity, mortality) over-time. This national case study raises fundamental questions for opioid-related health policy and practice.

Primary Care Implementation of a Mandatory Prescription Drug Monitoring Program in New York City

The ways in which prescription drug monitoring programs (PDMPs) have been integrated into clinical practice remain understudied, and research into PDMP implementation in states where PDMP use by providers is mandated remains scant. This qualitative study describes how use of a state-mandated PDMP influenced clinical practice and opioid analgesic prescribing. We conducted face-to-face, in-depth interviews with 53 New York State-licensed primary care physicians who reported that they currently prescribed opioid analgesic medication, including those providers who reported consistent use of the PDMP (n = 38) in this sample. We used a thematic analytic approach to identify patterns of PDMP implementation into practice following enactment of the New York State legislative usage mandate. Among physicians who consistently used the PDMP, we found two distinct groups: (1) physicians who reported no change in their clinical practice and (2) physicians who acknowledged changes to both clinical practice and administrative management. In the latter group, most physicians felt the PDMP had benefited their patient relationships by fostering dialogue around patient substance use; however, some used the PDMP to dismiss patients from care. Findings suggest that increased education for providers relating to judicious prescribing, opioid use disorder, and best practice for PDMP utilization are needed.

What to Do When Everything Happens at Once: Analytic Approaches to Estimate the Health Effects of Co-Occurring Social Policies

Social policies have great potential to improve population health and reduce health disparities. Increasingly, those doing empirical research have sought to quantify the health effects of social policies by exploiting variation in the timing of policy changes across places. Multiple social policies are often adopted simultaneously or in close succession in the same locations, creating co-occurrence that must be handled analytically for valid inferences. Although this is a substantial methodological challenge for researchers aiming to isolate social policy effects, only in a limited number of studies have researchers systematically considered analytic solutions within a causal framework or assessed whether these solutions are being adopted. We designated 7 analytic solutions to policy co-occurrence, including efforts to disentangle individual policy effects and efforts to estimate the combined effects of co-occurring policies. We used an existing systematic review of social policies and health to evaluate how often policy co-occurrence is identified as a threat to validity and how often each analytic solution is applied in practice. Of the 55 studies, only in 17 (31%) did authors report checking for any co-occurring policies, although in 36 studies (67%), at least 1 approach was used that helps address policy co-occurrence. The most common approaches were adjusting for measures of co-occurring policies; defining the outcome on subpopulations likely to be affected by the policy of interest (but not other co-occurring policies); and selecting a less-correlated measure of policy exposure. As health research increasingly focuses on policy changes, we must systematically assess policy co-occurrence and apply analytic solutions to strengthen studies on the health effects of social policies.

Inappropriate Opioid Prescribing in Oregon's Coordinated Care Organizations

OBJECTIVES

The objective of this study is to identify demographic and clinical characteristics of patients with a pain diagnosis who fill potentially inappropriate opioid prescriptions within the Oregon Medicaid population.

METHODS

Using de-identified Oregon Medicaid claims data (2010-2014), a series of logistic regression models was estimated to identify factors associated with receipt of potential inappropriate opioid prescriptions among patients with acute or chronic pain. Analyses included a total of 204,364 records, representing 118,671 unique patients.

RESULTS

The percentage of patients with a pain diagnosis filling at least 1 inappropriate opioid prescription decreased over the study period, falling from 32.5% in 2010 to 22.3% in 2014. Multivariate logistic regression results indicated that white and older enrollees were more likely to fill an inappropriate prescription over the study period. The odds of filling an inappropriate opioid prescription were also greater for patients with chronic health conditions, psychiatric disorders, and substance use disorder. Results were similar for patients diagnosed with either acute or chronic pain, chronic pain only, or acute pain only.

CONCLUSIONS

Inappropriate opioid prescribing for patients with pain diagnoses decreased over the study period, which stands in stark contrast to other state Medicaid programs. However, in 2014, almost 23% of patients in the Oregon Medicaid program filled at least 1 inappropriate opioid prescription, suggesting additional strategies are needed to further reduce potential inappropriate prescribing. Medicaid programs may consider adopting enhanced prescription drug monitoring program features, enacting pain clinic legislation, and implementing additional prior authorization policies to reduce inappropriate prescribing of opioids.

Differential impact of mitigation policies and socioeconomic status on COVID-19 prevalence and social distancing in the United States

BACKGROUND

The spread of COVID-19 has highlighted the long-standing health inequalities across the U.S. as neighborhoods with fewer resources were associated with higher rates of COVID-19 transmission. Although the stay-at-home order was one of the most effective methods to contain its spread, residents in lower-income neighborhoods faced barriers to practicing social distancing. We aimed to quantify the differential impact of stay-at-home policy on COVID-19 transmission and residents' mobility across neighborhoods of different levels of socioeconomic disadvantage.

METHODS

This was a comparative interrupted time-series analysis at the county level. We included 2087 counties from 38 states which both implemented and lifted the state-wide stay-at-home order. Every county was assigned to one of four equally-sized groups based on its levels of disadvantage, represented by the Area Deprivation Index. Prevalence of COVID-19 was calculated by dividing the daily number of cumulative confirmed COVID-19 cases by the number of residents from the 2010 Census. We used the Social Distancing Index (SDI), derived from the COVID-19 Impact Analysis Platform, to measure the mobility. For the evaluation of implementation, the observation started from Mar 1st 2020 to 1 day before lifting; and, for lifting, it ranged from 1 day after implementation to Jul 5th 2020. We calculated a comparative change of daily trends in COVID-19 prevalence and Social Distancing Index between counties with three highest disadvantage levels and those with the least level before and after the implementation and lifting of the stay-at-home order, separately.

RESULTS

On both stay-at-home implementation and lifting dates, COVID-19 prevalence was much higher among counties with the highest or lowest disadvantage level, while mobility decreased as the disadvantage level increased. Mobility of the most disadvantaged counties was least impacted by stay-at-home implementation and relaxation compared to counties with the most resources; however, disadvantaged counties experienced the largest relative increase in COVID-19 infection after both stay-at-home implementation and relaxation.

CONCLUSIONS

Neighborhoods with varying levels of socioeconomic disadvantage reacted differently to the implementation and relaxation of COVID-19 mitigation policies. Policymakers should consider investing more resources in disadvantaged counties as the pandemic may not stop until most neighborhoods have it under control.

Opioid Prescribing to Medicare Part D Enrollees, 2013-2017: Shifting Responsibility to Pain Management Providers

OBJECTIVE

To examine opioid prescribing frequency and trends to Medicare Part D enrollees from 2013 to 2017 by medical specialty and provider type.

METHODS

We conducted a retrospective, cross-sectional, specialty- and provider-level analysis of Medicare Part D prescriber data for opioid claims from 2013 to 2017. We analyzed opioid claims and prescribing trends for specialties accounting for ≥1% of all opioid claims.

RESULTS

From 2013 to 2017, pain management providers increased Medicare Part D opioid claims by 27.3% to 1,140 mean claims per provider in 2017; physical medicine and rehabilitation providers increased opioid claims 16.9% to 511 mean claims per provider in 2017. Every other medical specialty decreased opioid claims over this period, with emergency medicine (-19.9%) and orthopedic surgery (-16.0%) dropping opioid claims more than any specialty. Physicians overall decreased opioid claims per provider by -5.2%. Meanwhile, opioid claims among both dentists (+5.6%) and nonphysician providers (+10.2%) increased during this period.

CONCLUSIONS

From 2013 to 2017, pain management and PMR increased opioid claims to Medicare Part D enrollees, whereas physicians in every other specialty decreased opioid prescribing. Dentists and nonphysician providers also increased opioid prescribing. Overall, opioid claims to Medicare Part D enrollees decreased and continue to drop at faster rates.

The impact of state-mandated opioid prescribing restrictions on prescribing patterns surrounding reverse total shoulder arthroplasty

Background

Orthopedic surgeons are the third-highest prescribers of opioid medications, and the recent opioid crisis has placed more scrutiny on physicians and their prescribing habits. House Bill 21, a new law limiting the prescription of opioid medications, was signed in Florida on July 1, 2018 and similar laws have been passed in a number of other states as well. The purpose of this study was to understand the effect of new legal mandates on opioid prescribing patterns and dependence rates for patients undergoing reverse shoulder arthroplasty.

Methods

A retrospective review of 143 patients who underwent primary reverse shoulder arthroplasty from 2017 to 2019 was performed. There were 87 patients in the pre-legislation group (group 1), compared to 56 in the post-legislation group (group 2). Demographics data and opioid prescriptions provided 90 days before and after surgery were obtained using the physician drug monitoring database. Descriptive statistics and Student's t-tests were used to examine differences.

Results

Preoperatively, both groups received similar numbers of pills and total morphine equivalents (TMEs; group 1: 47.3 pills and 59.9 TMEs, group 2: 30.9 pills and 24.8 TMEs) (P = .292, P = .081). Group 1 had 88.5% of patients fill an opioid prescription postoperatively, compared to 50.9% of group 2 (P < .001). Postoperatively, initial opioid prescriptions were higher in average pills for group 1 (26 pills with an average of 375.6 TMEs) compared to group 2 (18 pills with an average of 199.6 TMEs) (P < .001, P = .122). For the entire postoperative course, patients in group 1 filled prescriptions for an average of 1740.7 TMEs and 84 pills, compared to 461.9 TMEs and 32 pills in group 2 (P = .035, P < .001). In the cohort, 17.8% of group 2 had multiple recorded opioid prescriptions, compared to 70.1% of group 1. There were also significant differences observed in postoperative dependence rates, with 23.0% in group 1 compared to 12.5% in group 2 (P = .043).

Conclusions

State-mandated opioid prescribing restrictions have been successful in decreasing opioid prescribing and dependence rates for orthopedic shoulder patients. Further efforts are required to reduce preoperative prescriptions involving chronic shoulder pathology as current legislature has not had an impact on this. Legislative changes may be an effective way to help reduce abuse and opioid dependence in shoulder arthroplasty patients; however, further research is needed.

Effects of Implementation and Enforcement Differences in Prescription Drug Monitoring Programs in 3 States: Connecticut, Kentucky, and Wisconsin

Background and aims:

Prescription Drug Monitoring Programs (PDMPs) were designed to curb opioid misuse and diversion by tracking scheduled medications prescribed by medical providers and dispensed by pharmacies. The effects of PDMPs on opioid prescription, misuse and overdose rates have been mixed due in part to variability in states’ PDMPs and difficulties measuring this complexity, and a lack of attention to implementation and enforcement of PDMP components. The current study uses qualitative interviews with key informants from 3 states with different PDMPs, Connecticut, Kentucky and Wisconsin to explore differences in the characteristics of the PDMPs in each state; how they are implemented, monitored and enforced; and unintended negative consequences of these programs.

Methods:

We conducted in-depth interviews with key informants from each state representing the following sectors: PDMP and pain clinic regulation agencies, Medicaid programs, state licensing boards, pharmacies, emergency medicine departments, pain management clinics, first responders, drug courts, drug treatment programs, medication assisted treatment (MAT) providers, and harm reduction organizations. Interview guides explored participants’ experiences with and opinions of PDMPs according to their roles. Data analysis was conducted using a collaborative, constant comparison method.

Results:

While all 3 states had mandated registration and reporting requirements, the states differed in the implementation and enforcement of these and the extent to which provider prescribing was monitored. These, in turn, influenced how medical providers perceived the PDMP and changed how providers prescribed opioids. Unintended consequences of state PDMPs included under-prescribing for pain and “dumping” patients who were long term users of opioids or who had developed opioid use disorders and may explain the increase in illicit heroin or opioid use.

Conclusion:

State PDMPs with similar mandates may differ greatly in implementation and enforcement. These differences are important to consider when determining the effects of PDMPs on opioid misuse and overdose.

Protocol: mixed-methods study of how implementation of US state medical cannabis laws affects treatment of chronic non-cancer pain and adverse opioid outcomes

BACKGROUND

Thirty-three US states and Washington, D.C., have enacted medical cannabis laws allowing patients with chronic non-cancer pain to use cannabis, when recommended by a physician, to manage their condition. However, clinical guidelines do not recommend cannabis for treatment of chronic non-cancer pain due to limited and mixed evidence of effectiveness. How state medical cannabis laws affect delivery of evidence-based treatment for chronic non-cancer pain is unclear. These laws could lead to substitution of cannabis in place of clinical guideline-discordant opioid prescribing, reducing risk of opioid use disorder and overdose. Conversely, state medical cannabis laws could lead to substitution of cannabis in place of guideline-concordant treatments such as topical analgesics or physical therapy. This protocol describes a mixed-methods study examining the implementation and effects of state medical cannabis laws on treatment of chronic non-cancer pain. A key contribution of the study is the examination of how variation in state medical cannabis laws' policy implementation rules affects receipt of chronic non-cancer pain treatments.

METHODS

The study uses a concurrent-embedded design. The primary quantitative component of the study employs a difference-in-differences design using a policy trial emulation approach. Quantitative analyses will evaluate state medical cannabis laws' effects on treatment for chronic non-cancer pain as well as on receipt of treatment for opioid use disorder, opioid overdose, cannabis use disorder, and cannabis poisoning among people with chronic non-cancer pain. Secondary qualitative and survey methods will be used to characterize implementation of state medical cannabis laws through interviews with state leaders and representative surveys of physicians who treat, and patients who experience, chronic non-cancer pain in states with medical cannabis laws.

DISCUSSION

This study will examine the effects of medical cannabis laws on patients' receipt of guideline-concordant non-opioid, non-cannabis treatments for chronic non-cancer pain and generate new evidence on the effects of state medical cannabis laws on adverse opioid outcomes. Results will inform the dynamic policy environment in which numerous states consider, enact, and/or amend medical cannabis laws each year.

Modeling Mitigation Strategies to Reduce Opioid-Related Morbidity and Mortality in the US

IMPORTANCE

The US opioid epidemic is complex and dynamic, yet relatively little is known regarding its likely future impact and the potential mitigating impact of interventions to address it.

OBJECTIVE

To estimate the future burden of the opioid epidemic and the potential of interventions to address the burden.

DESIGN, SETTING, AND PARTICIPANTS

A decision analytic dynamic Markov model was calibrated using 2010-2018 data from the National Survey on Drug Use and Health, Centers for Disease Control and Prevention, National Health and Nutrition Examination Survey, the US Census, and National Epidemiologic Survey on Alcohol and Related Conditions-III. Data on individuals 12 years or older from the US general population or with prescription opioid medical use; prescription opioid nonmedical use; heroin use; prescription, heroin, or combined prescription and heroin opioid use disorder (OUD); 1 of 7 treatment categories; or nonfatal or fatal overdose were examined. The model was designed to project fatal opioid overdoses between 2020 and 2029.

EXPOSURES

The model projected prescribing reductions (5% annually), naloxone distribution (assumed 5% reduction in case-fatality), and treatment expansion (assumed 35% increase in uptake annually for 4 years and 50% relapse reduction), with each compared vs status quo.

MAIN OUTCOMES AND MEASURES

Projected 10-year overdose deaths and prevalence of OUD.

RESULTS

Under status quo, 484 429 (95% confidence band, 390 543-576 631) individuals were projected to experience fatal opioid overdose between 2020 and 2029. Projected decreases in deaths were 0.3% with prescribing reductions, 15.4% with naloxone distribution, and 25.3% with treatment expansion; when combined, these interventions were associated with 179 151 fewer overdose deaths (37.0%) over 10 years. Interventions had a smaller association with the prevalence of OUD; for example, the combined intervention was estimated to reduce OUD prevalence by 27.5%, from 2.47 million in 2019 to 1.79 million in 2029. Model projections were most sensitive to assumptions regarding future rates of fatal and nonfatal overdose.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that the opioid epidemic is likely to continue to cause tens of thousands of deaths annually over the next decade. Aggressive deployment of evidence-based interventions may reduce deaths by at least a third but will likely have less impact for the number of people with OUD.

State pain management clinic policies and county opioid prescribing: A fixed effects analysis

BACKGROUND

The U.S. has seen an unprecedented rise in opioid-related morbidity and mortality, and states have passed numerous laws in response. Researchers have not comprehensively established the effectiveness of pain management clinic regulations to reduce opioid prescribing using national data.

METHODS

We combine a policy dataset from the Prescription Drug Abuse Policy System with the Centers for Disease Control and Prevention county-level opioid prescribing data, as well as with numerous government datasets for county- and state- level covariates. We predict retail opioid prescriptions dispensed per 100 people using county fixed-effects models with a state-level cluster correction. Our key predictors of interest are the presence of any state-level pain management clinic law and eight specific subcomponents of the law.

RESULTS

Pain management clinic laws demonstrate consistent, negative effects on prescribing rates. Controlling for county characteristics, state spending, and the broader policy context, states with pain management clinic laws had, on average, 5.78 fewer opioid prescriptions per 100 people than states without such laws (p < .05). Five specific subcomponents demonstrate efficacy in reducing prescribing rates: certification requirements (B = -6.02, p < .05), medical directors (B = -6.14, p < .05), dispenser and dispensing amount restrictions (B = -8.60, p < .01; B = -15.51, p < .001), and explicit penalties for noncompliance (B = -6.02, p < .05). Three subcomponents had no effect: prescription quantity restrictions and requirements to register with or review prescription drug monitoring programs.

CONCLUSIONS

Implementation of pain management clinic laws reduced county-level opioid prescribing. States should review specific components to determine which forms of law are most efficacious.

Alternatives to Opioid Education and a Prescription Drug Monitoring Program Cumulatively Decreased Outpatient Opioid Prescriptions

Introduction

Deaths have increased, and prescription medications are involved in a significant percentage of deaths. Emergency department (ED) changes to managing acute pain and prescription drug monitoring programs (PDMPs) can impact the potential for abuse.

Methods

We analyzed the impact of a series of quality improvement initiatives on the opioid prescribing habits of emergency department physicians and advanced practice providers. We compared historical prescribing patterns with those after three interventions: 1) the implementation of a PDMP, 2) clinician education on alternatives to opioids (ALTOs), and 3) electronic health record (EHR) process changes.

Results

There was a 61.8% decrease in the percentage of opioid-eligible ED discharges that received a prescription for an opioid from 19.4% during the baseline period to 7.4% during the final intervention period. Among these discharges, the cumulative effect of the interventions resulted in a 17.3% decrease in the amount of morphine milligram equivalents (MME) prescribed per discharge from a mean of 104.9 MME/discharge during the baseline period to 86.8 MME/discharge. In addition, the average amount of MME prescribed per discharge became aligned with recommended guidelines over the intervention periods.

Conclusions

Initiating a PDMP and instituting an aggressive ALTO program along with EHR-modified process flows have cumulative benefits in decreasing MME prescribed in an acute ED setting.

Association of State-Level Opioid-Reduction Policies With Pediatric Opioid Poisoning

IMPORTANCE

Opioid-reduction policies have been enacted by US states to address the opioid epidemic. Evidence of an association between policy implementation and decreased rates of pediatric opioid poisoning provides further justification for expanded implementation of these policies.

OBJECTIVE

To examine the association of 3 state-level opioid-reduction policies with the rate of opioid poisoning in children and adolescents.

DESIGN, SETTING, AND PARTICIPANTS

This interrupted time series analysis used data from the National Poison Data System (NPDS), a database of poisoning information reported to poison control centers across the US. Individuals younger than 20 years who experienced poisoning associated with 1 or more prescription opioids from January 1, 2005, to November 30, 2017, were included. The analysis focused on 3 widespread policy interventions: the prescription drug monitoring program (PDMP), pain clinic legislation, and opioid prescribing guidelines. Data analysis was performed from January 30, 2020, to March 30, 2020.

EXPOSURES

Any opioid poisoning in individuals younger than 20 years that was reported to the NPDS.

MAIN OUTCOMES AND MEASURES

Opioid poisoning rates per million person-months before and after implementation of each of the 3 policies, overall and stratified by age (≤4 years, 5-9 years, 10-14 years, and 15-19 years).

RESULTS

A total of 338 476 opioid poisoning incidences in children and young adults were reported to the NPDS within the study period. Of this study population, the mean (SD) age was 9.74 (7.15) years, and 179 011 (52.9%) were female. The implementation of a PDMP was associated with a reduction in the monthly rate of opioid poisoning in children and adolescents (-0.07 per million person-months; 95% CI, -0.09 to -0.04) in the postimplementation period. This reduction was observed for all age groups except for the 10- to 14-year age group (-0.03 per million person-months; 95% CI, -0.05 to 0.00). Pain clinic legislation was associated with an immediate reduction in opioid poisoning (-6.22 per million person-months; 95% CI, -8.98 to -3.47). This association was statistically significant across all ages except for the 4 years or younger group. Analysis of the association of implementation of opioid prescribing guidelines was limited because of insufficient follow-up data and did not show an immediate or monthly change in the rate of opioid poisoning.

CONCLUSIONS AND RELEVANCE

Results of this study suggest that certain state-level opioid-reduction policies were associated with decreases in pediatric opioid exposures across age groups. Further examination of the underlying mechanisms of these associations, including age group-specific outcomes, may expand and strengthen policies that reduce opioid poisoning, misuse, and overdoses in children and adolescents.

A Rapid Review of the Impact of Systems-Level Policies and Interventions on Population-Level Outcomes Related to the Opioid Epidemic, United States and Canada, 2014-2018

OBJECTIVES

In the United States, rising rates of overdose deaths and recent outbreaks of hepatitis C virus and HIV infection are associated with injection drug use. We updated a 2014 review of systems-level opioid policy interventions by focusing on evidence published during 2014-2018 and new and expanded opioid policies.

METHODS

We searched the MEDLINE database, consistent with the 2014 review. We included articles that provided original empirical evidence on the effects of systems-level interventions on opioid use, overdose, or death; were from the United States or Canada; had a clear comparison group; and were published from January 1, 2014, through July 19, 2018. Two raters screened articles and extracted full-text data for qualitative synthesis of consistent or contradictory findings across studies. Given the rapidly evolving field, the review was supplemented with a search of additional articles through November 17, 2019, to assess consistency of more recent findings.

RESULTS

The keyword search yielded 535 studies, 66 of which met inclusion criteria. The most studied interventions were prescription drug monitoring programs (PDMPs) (59.1%), and the least studied interventions were clinical guideline changes (7.6%). The most common outcome was opioid use (77.3%). Few articles evaluated combination interventions (18.2%). Study findings included the following: PDMP effectiveness depends on policy design, with robust PDMPs needed for impact; health insurer and pharmacy benefit management strategies, pill-mill laws, pain clinic regulations, and patient/health care provider educational interventions reduced inappropriate prescribing; and marijuana laws led to a decrease in adverse opioid-related outcomes. Naloxone distribution programs were understudied, and evidence of their effectiveness was mixed. In the evidence published after our search's 4-year window, findings on opioid guidelines and education were consistent and findings for other policies differed.

CONCLUSIONS

Although robust PDMPs and marijuana laws are promising, they do not target all outcomes, and multipronged interventions are needed. Future research should address marijuana laws, harm-reduction interventions, health insurer policies, patient/health care provider education, and the effects of simultaneous interventions on opioid-related outcomes.

The state of the science in opioid policy research

OBJECTIVE

Characterize the state of the science in opioid policy research based on a literature review of opioid policy studies.

METHODS

We conducted a scoping review of studies evaluating the impact of U.S. state-level and federal-level policies on opioid-related outcomes published in 2005-2018. We characterized: 1) state and federal policies evaluated, 2) opioid-related outcomes examined, and 3) study design and analytic methods (summarized overall and by policy category).

RESULTS

In total, 145 studies were reviewed (79 % state-level policies, 21 % federal-level policies) and classified with respect to 8 distinct policy categories and 7 outcome categories. The majority of studies evaluated policies related to prescription opioids (prescription drug monitoring programs (PDMPs), opioid prescribing policies, federal regulation of prescription opioids, pain clinic laws) and considered policy impacts with respect to proximal outcomes (e.g., opioid prescribing behaviors). In total, only 29 (20 % of studies) met each of three key criteria for rigorous design: analysis of longitudinal data with a comparison group design, adjustment for difference between policy-enacting and comparison states, and adjustment for potentially confounding co-occurring policies. These more rigorous studies were predominately published in 2017-2018 and primarily evaluated PDMPs, marijuana laws, treatment-related policies, and overdose prevention policies.

CONCLUSIONS

Our results indicated that study design rigor varied notably across policy categories, highlighting the need for broader adoption of rigorous methods in the opioid policy field. More evaluation studies are needed regarding overdose prevention policies and policies related to treatment access. Greater examination of distal outcomes and potential unintended consequences are also warranted.

Effects of the Ohio Opioid Prescribing Guidelines on Total Joint Arthroplasty Postsurgical Prescribing and Refilling Behavior of Surgeons and Patients

BACKGROUND

The opioid epidemic has been declared a public health crisis, with thousands of Americans dying from overdoses each year. In 2017, Ohio passed the Opioid Prescribing Guidelines (OPG) limiting narcotic prescriptions for acute pain. The present study sought to evaluate the effects of OPG on the prescribing behavior of orthopedists following total knee arthroplasty (TKA) and total hip arthroplasty (THA).

METHODS

An institutional database was queried to compare morphine equivalent dose (MED) prescribed at discharge, acute follow-up (<90 days), and chronic follow-up (>90 days) pre-OPG and post-OPG. Cases were identified over a 2-year period starting 1 year before OPG implementation.

RESULTS

Nine orthopedic surgeons performed 1160 TKAs (692 pre-OPG, 468 post-OPG) and 834 THAs (530 pre-OPG, 304 post-OPG). Total MED for TKA and THA dropped post-OPG (1602.6 ± 54.3 vs 1145.8 ± 66.1, P < .01; 1302.3 ± 47.0 vs 878.3 ± 62.2, P < .01). Much of the total MED decrease was accounted for by the decrease in discharge MED, which was the largest in magnitude (904.8 ± 16.4 vs 606.2 ± 20.0, P < .01; 948.4 ± 19.6 vs 630.6 ± 25.9, P < .01). Seven of the 9 surgeons statistically reduced mean MED prescribed at discharge following OPG. The percentage of patients receiving new narcotic scripts at acute follow-up increased post-OPG for both TKA (41.5% vs 47.2%, P = .05) and THA (18.3% vs 25.7%, P = .01).

CONCLUSION

Orthopedists reduced total MED prescribed after TKA and THA following the onset of OPG. The majority of this decrease is explained by decreased MED at discharge. Conversely, the post-OPG period saw slightly more new narcotic scripts written during acute follow-up.

Implementation and enforcement of state opioid prescribing laws

BACKGROUND

In response to the role overprescribing has played in the U.S. opioid crisis, in the past decade states have enacted four main types of laws to curb opioid prescribing: mandatory prescription drug monitoring program (PDMP) enrollment laws requiring clinicians to register with a PDMP; mandatory PDMP query laws requiring clinicians to check a PDMP prior to prescribing opioids; pill mill laws regulating pain management clinics; and opioid prescribing cap laws limiting the dose/duration of opioid prescriptions. While 47 states now have one or more of these laws in place, little is known about implementation and enforcement strategies, facilitators, and barriers.

METHODS

From November 2017 to February 2019, we interviewed 114 professionals involved in state opioid prescribing law implementation and enforcement in 20 states and identified common themes.

RESULTS

Implementation efforts focused on awareness campaigns and targeted training of key front-line implementers. Enforcement strategies included active, complaint-based, and automated strategies. Collaboration across agencies and stakeholders, particularly health agencies and law enforcement, was identified as an important facilitator of implementation and enforcement. Two key interrelated barriers were identified: the complexity of state opioid prescribing laws in terms of which providers, patients, and prescriptions they applied to, and IT infrastructure.

CONCLUSION

Despite differing approaches, our findings suggest similar barriers to implementation and enforcement across state opioid prescribing laws. Strategies are needed to ease implementation and enforcement of laws that apply only to specific sub-sets of providers, patients, or prescriptions and address issues of access and data utilization of the PDMP.

Prescription Drug Monitoring Programs and Prescription Opioid-Related Outcomes in the United States

Prescription drug monitoring programs (PDMPs) are a crucial component of federal and state governments' response to the opioid epidemic. Evidence about the effectiveness of PDMPs in reducing prescription opioid-related adverse outcomes is mixed. We conducted a systematic review to examine whether PDMP implementation within the United States is associated with changes in 4 prescription opioid-related outcome domains: opioid prescribing behaviors, opioid diversion and supply, opioid-related morbidity and substance-use disorders, and opioid-related deaths. We searched for eligible publications in Embase, Google Scholar, MEDLINE, and Web of Science. A total of 29 studies, published between 2009 and 2019, met the inclusion criteria. Of the 16 studies examining PDMPs and prescribing behaviors, 11 found that implementing PDMPs reduced prescribing behaviors. All 3 studies on opioid diversion and supply reported reductions in the examined outcomes. In the opioid-related morbidity and substance-use disorders domain, 7 of 8 studies found associations with prescription opioid-related outcomes. Four of 8 studies in the opioid-related deaths domain reported reduced mortality rates. Despite the mixed findings, emerging evidence supports that the implementation of state PDMPs reduces opioid prescriptions, opioid diversion and supply, and opioid-related morbidity and substance-use disorder outcomes. When PDMP characteristics were examined, mandatory access provisions were associated with reductions in prescribing behaviors, diversion outcomes, hospital admissions, substance-use disorders, and mortality rates. Inconsistencies in the evidence base across outcome domains are due to analytical approaches across studies and, to some extent, heterogeneities in PDMP policies implemented across states and over time.

Impact of a State Opioid Prescribing Limit and Electronic Medical Record Alert on Opioid Prescriptions: a Difference-in-Differences Analysis

BACKGROUND

Prescribing limits are one policy strategy to reduce short-term opioid prescribing, but there is limited evidence of their impact.

OBJECTIVE

Evaluate implementation of a state prescribing limit law and health system electronic medical record (EMR) alert on characteristics of new opioid prescriptions, refill rates, and clinical encounters.

DESIGN

Difference-in-differences study comparing new opioid prescriptions from ambulatory practices in New Jersey (NJ) to controls in Pennsylvania (PA) from 1 year prior to the implementation of a NJ state prescribing limit (May 2016-May 2017) to 10 months after (May 2017-March 2018).

PARTICIPANTS

Adults with new opioid prescriptions in an academic health system with practices in PA and NJ.

INTERVENTIONS

State 5-day opioid prescribing limit plus health system and health system EMR alert.

MAIN MEASURES

Changes in morphine milligram equivalents (MME) and tablet quantity per prescription, refills, and encounters, adjusted for patient and prescriber characteristics.

KEY RESULTS

There were a total of 678 new prescriptions in NJ and 4638 in PA. Prior to the intervention, median MME/prescription was 225 mg in NJ and 150 mg in PA, and median quantity was 30 tablets in both. After implementation, median MME/prescription was 150 mg in both states, and median quantity was 20 in NJ and 30 in PA. In the adjusted model, there was a greater decrease in mean MME and tablet quantity in NJ relative to PA after implementation of the policy plus alert (- 82.99 MME/prescription, 95% CI - 148.15 to - 17.84 and - 10.41 tabs/prescription, 95% CI - 19.70 to - 1.13). There were no significant differences in rates of refills or encounters at 30 days based on exposure to the interventions.

CONCLUSIONS

Implementation of a prescribing limit and EMR alert was associated with an approximately 22% greater decrease in opioid dose per new prescription in NJ compared with controls in PA. The combination of prescribing limits and alerts may be an effective strategy to influence prescriber behavior.

The Association of State Opioid Misuse Prevention Policies With Patient- and Provider-Related Outcomes: A Scoping Review

Policy Points This scoping review reveals a growing literature on the effects of certain state opioid misuse prevention policies, but persistent gaps in evidence on other prevalent state policies remain. Policymakers interested in reducing the volume and dosage of opioids prescribed and dispensed can consider adopting robust prescription drug monitoring programs with mandatory access provisions and drug supply management policies, such as prior authorization policies for high-risk prescription opioids. Further research should concentrate on potential unintended consequences of opioid misuse prevention policies, differential policy effects across populations, interventions that have not received sufficient evaluation (eg, Good Samaritan laws, naloxone access laws), and patient-related outcomes.

CONTEXT

In the midst of an opioid crisis in the United States, an influx of state opioid misuse prevention policies has provided new opportunities to generate evidence of policy effectiveness that can inform policy decisions. We conducted a scoping review to synthesize the available evidence on the effectiveness of US state interventions to improve patient and provider outcomes related to opioid misuse and addiction.

METHODS

We searched six online databases to identify evaluations of state opioid policies. Eligible studies examined legislative and administrative policy interventions that evaluated (a) prescribing and dispensing, (b) patient behavior, or (c) patient health.

FINDINGS

Seventy-one articles met our inclusion criteria, including 41 studies published between 2016 and 2018. These articles evaluated nine types of state policies targeting opioid misuse. While prescription drug monitoring programs (PDMPs) have received considerable attention in the literature, far fewer studies addressed other types of state policy. Overall, evidence quality is very low for the majority of policies due to a small number of evaluations. Of interventions that have been the subject of considerable research, promising means of reducing the volume and dosages of opioids prescribed and dispensed include drug supply management policies and robust PDMPs. Due to low study number and quality, evidence is insufficient to draw conclusions regarding interventions targeting patient behavior and health outcomes, including naloxone access laws and Good Samaritan laws.

CONCLUSIONS

Recent research has improved the evidence base on several state interventions targeting opioid misuse. Specifically, moderate evidence suggests that drug supply management policies and robust PDMPs reduce opioid prescribing. Despite the increase in rigorous evaluations, evidence remains limited for the majority of policies, particularly those targeting patient health-related outcomes.

Strengths and weaknesses of existing data sources to support research to address the opioids crisis

Better opioid prescribing practices, promoting effective opioid use disorder treatment, improving naloxone access, and enhancing public health surveillance are strategies central to reducing opioid-related morbidity and mortality. Successfully advancing and evaluating these strategies requires leveraging and linking existing secondary data sources. We conducted a scoping study in Fall 2017 at RAND, including a literature search (updated in December 2018) complemented by semi-structured interviews with policymakers and researchers, to identify data sources and linking strategies commonly used in opioid studies, describe data source strengths and limitations, and highlight opportunities to use data to address high-priority public health research questions. We identified 306 articles, published between 2005 and 2018, that conducted secondary analyses of existing data to examine one or more public health strategies. Multiple secondary data sources, available at national, state, and local levels, support such research, with substantial breadth in data availability, data contents, and the data's ability to support multi-level analyses over time. Interviewees identified opportunities to expand existing capabilities through systematic enhancements, including greater support to states for creating and facilitating data use, as well as key data challenges, such as data availability lags and difficulties matching individual-level data over time or across datasets. Multiple secondary data sources exist that can be used to examine the impact of public health approaches to addressing the opioid crisis. Greater data access, improved usability for research purposes, and data element standardization can enhance their value, as can improved data availability timeliness and better data comparability across jurisdictions.

Impact of Iowa's Prescription Monitoring Program on Opioid Pain Reliever Prescribing Patterns: An Interrupted Time Series Study 2003-2014

OBJECTIVE

To evaluate the impact of Iowa's prescription monitoring program (PMP), implemented in 2009, on opioid pain reliever (OPR) prescribing patterns.

METHODS

We conducted interrupted time series analyses using 2003-2014 health insurance claims from a private health insurer in Iowa. OPR prescriptions for all beneficiaries were included. Another data set included only OPR prescription for new opioid users required to have six months of insurance coverage. We evaluate four OPR prescribing patterns: 1) average daily dosage in morphine milligrams equivalents (MME), 2) MME per prescription, 3) average days' supply per prescription, and 4) prescription rate per 1,000 insured person-years. We examined confounding and effect measure modification of the relationship between PMP and prescribing patterns by age and sex.

RESULTS

During the 12 years of follow-up, 1,512,388 insured Iowans contributed 6,169,634.92 person-years of follow-up. Of these, 505,274 patients filled 2,401,818 OPR prescriptions and 360,688 new OPR users filled as many first OPR prescriptions. The increasing trend of OPR prescription rates from 2003 to 2009 declined post-PMP. Similarly, there was a large decline in MME per day and MME per prescription. The OPR days' supply kept increasing post-PMP implementation, albeit at a slightly slower rate than pre-PMP implementation. There was no confounding by age and sex; however, we observed heterogeneity by age and sex; patients aged ≥50 years and females received higher doses and more prescriptions pre-PMP and experienced the greatest declines post-PMP.

CONCLUSIONS

Our study suggests that Iowa PMP implementation may have resulted in declines in OPR prescribing, and this impact varies by patient age and sex.

Opioid Prescribing Behaviors - Prescription Behavior Surveillance System, 11 States, 2010-2016

Problem/Condition

In 2017, a total of 70,237 persons in the United States died from a drug overdose, and 67.8% of these deaths involved an opioid. Historically, the opioid overdose epidemic in the United States has been closely associated with a parallel increase in opioid prescribing and with widespread misuse of these medications. National and state policy makers have introduced multiple measures to attempt to assess and control the opioid overdose epidemic since 2010, including improvements in surveillance systems.

Period Covered

2010–2016

Description of System

The Prescription Behavior Surveillance System (PBSS) was created in 2011. Its goal was to track rates of prescribing of controlled substances and possible misuse of such drugs using data from selected state prescription drug monitoring programs (PDMP). PBSS data measure prescribing behaviors for prescription opioids using multiple measures calculated from PDMP data including 1) opioid prescribing, 2) average daily opioid dosage, 3) proportion of patients with daily opioid dosages ≥90 morphine milligram equivalents, 4) overlapping opioid prescriptions, 5) overlapping opioid and benzodiazepine prescriptions, and 6) multiple-provider episodes. For this analysis, PBSS data were available for 2010–2016 from 11 states representing approximately 38.0% of the U.S. population. Average quarterly percent changes (AQPC) in the rates of opioid prescribing and possible opioid misuse measures were calculated for each state.

Results and Interpretation

Opioid prescribing rates declined in all 11 states during 2010–2016 (range: 14.9% to 33.0%). Daily dosage declined least (AQPC: -0.4%) in Idaho and Maine, and most (AQPC: -1.6%) in Florida. The percentage of patients with high daily dosage had AQPCs ranging from -0.4% in Idaho to -2.3% in Louisiana. Multiple-provider episode rates declined by at least 62% in the seven states with available data. Variations in trends across the 11 states might reflect differences in state policies and possible differential effects of similar policies.

Public Health Actions

Use of PDMP data from individual states enables a more detailed examination of trends in opioid prescribing behaviors and indicators of possible misuse than is feasible with national commercially available prescription data. Comparison of opioid prescribing trends among states can be used to monitor the temporal association of national or state policy interventions and might help public health policymakers recognize changes in the use or possible misuse of controlled prescription drugs over time and allow for prompt intervention through amended or new opioid-related policies.

Opioid prescribing patterns among medical providers in the United States, 2003-17: retrospective, observational study

OBJECTIVE

To examine the distribution and patterns of opioid prescribing in the United States.

DESIGN

Retrospective, observational study.

SETTING

National private insurer covering all 50 US states and Washington DC.

PARTICIPANTS

An annual average of 669 495 providers prescribing 8.9 million opioid prescriptions to 3.9 million patients from 2003 through 2017.

MAIN OUTCOME MEASURES

Standardized doses of opioids in morphine milligram equivalents (MMEs) and number of opioid prescriptions.

RESULTS

In 2017, the top 1% of providers accounted for 49% of all opioid doses and 27% of all opioid prescriptions. In absolute terms, the top 1% of providers prescribed an average of 748 000 MMEs-nearly 1000 times more than the middle 1%. At least half of all providers in the top 1% in one year were also in the top 1% in adjacent years. More than two fifths of all prescriptions written by the top 1% of providers were for more than 50 MMEs a day and over four fifths were for longer than seven days. In contrast, prescriptions written by the bottom 99% of providers were below these thresholds, with 86% of prescriptions for less than 50 MMEs a day and 71% for fewer than seven days. Providers prescribing high amounts of opioids and patients receiving high amounts of opioids persisted over time, with over half of both appearing in adjacent years.

CONCLUSIONS

Most prescriptions written by the majority of providers are under the recommended thresholds, suggesting that most US providers are careful in their prescribing. Interventions focusing on this group of providers are unlikely to effect beneficial change and could induce unnecessary burden. A large proportion of providers have established relationships with their patients over multiple years. Interventions to reduce inappropriate opioid prescribing should be focused on improving patient care, management of patients with complex pain, and reducing comorbidities rather than seeking to enforce a threshold for prescribing.

The effect of an opioid prescription days' supply limit on patients receiving long-term opioid treatment

BACKGROUND

Since 2016, an increasing number of states have passed laws restricting the days' supply for opioid prescriptions, yet little is known about how these laws affect patients. This study evaluates the effect of the Tennessee Prescription Regulatory Act, which was implemented on Oct. 1st, 2013 and restricted the maximum days' supply that could be dispensed for any opioid prescription by any prescriber to 30 days, on patients receiving long-term opioid treatment.

METHODS

A quasi experimental model, an interrupted time series (ITS), was used with observational data to estimate the effect of the policy on monthly patient opioid prescription outcomes. Data for this study came from the Tennessee Controlled Substance Monitoring Database between October 1st, 2012 and October 31st, 2014. The study population included patients receiving long-term opioid treatment who filled an opioid prescription in at least 4 months in the 12-month pre-policy period and received at least one prescription in the pre-policy period with a days' supply exceeding 30 days. Three outcomes were measured each month for every patient based on their opioid prescriptions: per-prescription days' supply per-prescription, daily morphine milligram equivalent (DMME), and total opioid prescriptions. All models controlled for individual fixed effects, age, and benzodiazepine prescriptions and utilized cluster robust standard errors to address serial correlation.

RESULTS

The change in law was associated with a decline in the average days' supply by -5.30 days (95% CI: -5.64, -4.96), and number of prescriptions by -1.3% (95% CI: -3%, -0.07%), but an increase in the average DMME by 1.41 (95% CI: 0.37, 2.45).

CONCLUSIONS

Prescribers responded to the Addison Sharp Prescription Regulatory Act by significantly decreasing the days' supply in opioid prescriptions among current patients receiving long-term opioid treatment who had at least one prescription exceeding the maximum days' supply set by the law in the pre-policy period.

Prescriber responses to a pain clinic law: Cease or modify?

BACKGROUND

Pain clinic laws are designed to cease or modify high-risk prescribing behavior. However, prior evaluations have not differentiated between these types of prescriber responses in their analysis, even though they may have different implications for patients. The purpose of this analysis is to investigate the effect of a 2016 Tennessee pain clinic law on the two types of prescriber responses.

METHODS

We used data on opioid prescriptions from the Tennessee Controlled Substances Monitoring Database (CSMD) between July 1^st, 2015 and July 1^st, 2017. Prescribers were assigned to the cessation or modification group based on the date of their last opioid prescription during the time period July 1^st, 2015 to July 1^st, 2018 and its relationship to the change in law. A risk score was developed based on five indicators to capture two categories of risky prescriber behavior: increased risk for diversion or increased patient's risk of overdose. Within-prescriber differences were used to assess the effect of the law on several outcomes that capture the quantity and content of opioid prescriptions.

RESULTS

There was a significant decline in the number of prescriptions (cessation mean = -45.18 pval<0.001; continuation mean = -24.41 pval<0.001) and patients (cessation mean = -16.68pval<0.001; continuation mean = -10.92 pval<0.001) in both prescriber response groups, but the magnitude of decline was much larger in the cessation group. High-risk prescribers were more likely to cease prescribing than modify.

CONCLUSIONS

Prescribers who ceased prescribing in response to the pain clinic law disproportionately contributed to overall declines in opioid prescriptions.

Substance Use Stigma, Primary Care, and the New York State Prescription Drug Monitoring Program

Prescription drug monitoring programs (PDMPs) are databases that track controlled substances at the provider, patient, and pharmacy levels. While these databases are widely available at the state level throughout the United States, several jurisdictions in recent years have mandated the use of these systems by health care providers. This study explores the implementation of mandatory PDMP technology in primary care practice and the effects on treatment of people with possible substance use disorders. Findings are based on 53 in-depth interviews with primary care providers in New York City, collected shortly following the passage of legislation mandating use of a PDMP by health care providers in New York State. Findings suggest that use of the PDMP highlighted tensions between provider stigma toward substance use disorders and the clinical care of people who use drugs, challenging their stereotypes and biases. The parallel clinical and law enforcement purposes of PDMP technology placed providers in dual roles as clinicians and enforcers and encouraged the punitive treatment of patients. Finally, PDMP technology standardized the clinical assessment process toward a "diagnosis first" approach, consistent with prior scholarship on the implementation of emerging medical technologies.

The association between pain clinic laws and prescription opioid exposures: New evidence from multi-state comparisons

OBJECTIVES

States in the US are controlling opioid prescribing to combat the opioid epidemic. Prescription Drug Monitoring Programs (PDMPs) were widely adopted, whereas less attention was given to pain clinic laws. This study examined the associations of mandatory use of PDMPs and pain clinic laws with prescription opioid exposures.

METHODS

State-level quarterly prescription opioid exposures reported to the National Poison Data System during 2010-2017 were analyzed. The primary outcome was age-adjusted rates of prescription opioid exposures per 1,000,000 population. The primary policy variables included the implementation of mandatory use of PDMPs alone, the implementation of pain clinic laws alone, and the implementation of both mandatory use of PDMPs and pain clinic laws. Linear regressions were used to examine the associations, controlling for other opioid policies, marijuana policies, socioeconomic factors, state fixed effects, time fixed effects, and state-specific time trends.

RESULTS

Requiring mandatory use of PDMPs alone was not associated with significant changes in prescription opioid exposures. The implementation of pain clinic laws with or without concurrent mandatory use of PDMPs was associated with 5 fewer prescription opioid exposures per 1,000,000 population or a 9 % reduction compared to the pre-policy period (p < 0.01). Further analysis revealed that the reduction associated with pain clinic laws was pronounced in exposures reported by healthcare facilities.

CONCLUSIONS

This multi-state study provided new evidence that the implementation of pain clinic laws was associated with a significant reduction in prescription opioid exposures. Pain clinic laws may deserve further evaluation and consideration.