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Natural Experiments to Address Prescription Drug Misuse

posted on Mon, Nov 7 2016 2:10 pm by Lainie Rutkow

In September, I had the opportunity to attend the National Public Health Law Conference in Washington, DC. The conference is a wonderful venue for networking with public health law colleagues and learning about contemporary public health law problems. 

One of the conference sessions, led by Corey Davis, Deputy Director of the Southeastern Region of the Network for Public Health Law, examined how law can be used to address drug overdose. With almost 19,000 U.S. deaths associated with opioid pain relievers in 2014, morbidity and mortality related to prescription drug misuse and diversion are one of today’s most pressing public health challenges. Laws and policies intended to address this epidemic are rapidly proliferating.

Corey and I recently published an editorial in the Journal of General Internal Medicine where we highlight some of the ways in which laws may help to improve decision-making about the issuance of opioid prescriptions by health care providers. In the editorial, we mention pill mill laws, which now regulate pain management clinics in 11 U.S. states. We also discuss prescription drug monitoring programs (PDMPs), which collect data about dispensed controlled substances and can be queried by health care providers.

And, we explore other, more upstream, steps that state governments can take to reduce the health risks associated with prescription opioids, such as requiring medical schools to teach their students about evidence-based use of opioid pain relievers and pain management strategies, with reference to resources including CDC’s recently released guideline for prescribing opioids for chronic pain.

These diverse legal approaches to reducing prescription opioid misuse, addiction, and overdose have given rise to a series of natural experiments throughout the United States. For example, there is great variation in the structure and implementation of PDMPs among the 49 states with active programs. States house their PDMPs in different agencies within the public health system, including Boards of Pharmacy, Departments of Health, and Law Enforcement Agencies. States also vary in whom they allow to access PDMP data (e.g., health care providers; law enforcement officials), and in whether they require health care providers to register with and subsequently query the PDMP, at least in some circumstances.

While it’s notable that so many states have enacted laws to establish and implement PDMPs, the evidence base about the effectiveness of these programs is relatively small. In particular, there is little available evidence regarding whether different PDMP characteristics – such as where they’re housed and which entities have access to PDMP data – impact their effectiveness. Additionally, PDMPs often do not capture key information such as the demographics and diagnosis of the patient.

Unfortunately, morbidity and mortality associated with prescription opioids continue to increase. While it’s promising that so many states have already used different types of laws to respond to this public health problem, it is extremely important that those laws be rigorously evaluated to determine whether they are having their intended effects. Only then can we truly recognize best practices and recommend specific legal options to state governments as a means to address prescription opioid misuse and related harms.


This blog post was developed by Lainie Rutkow, J.D., Ph.D., M.P.H., Associate Professor of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health and Co-Director of the Johns Hopkins Center for Law and the Public's Health.

The Network for Public Health Law provides information and technical assistance on issues related to public health. The legal information and assistance provided in this post does not constitute legal advice or legal representation. For legal advice, readers should consult an attorney in their state.

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