Pain and Epilepsy in the Context of Changing Controlled Substance Policy: Essays on Opioid Restrictions, Gabapentin Scheduling, and Socioeconomic Disparities Restricted; Files Only

Abstract

Chronic pain and substance use increased in tandem throughout the first two decades of the 21^st century, with patients living with pain being at particularly high risk for developing substance use disorders. Although the National Academies of Science recommends that policies and programs address both pain and opioids, policy responses and their associated evaluations tend to focus solely on reducing drug supply. The first two chapters of this dissertation quantify the effect of such policies on patients with chronic conditions. Chapter 1 evaluates policies that require clinicians to consult prescription drug monitoring programs when prescribing opioids. Using heterogeneity-robust difference-in-differences methods with the Health and Retirement Study data, this chapter examines the effect of these policies on pain and physical impairment. The percentage of older adults reporting being frequently troubled by pain increases, but no changes were detected in physical impairment. Chapter 2 focuses on a Virginia policy that classifies gabapentin, an anti-epileptic medication commonly prescribed off label for chronic pain, as a controlled substance. This chapter uses a triple-difference design, leveraging variation in timing, place, and medication in conjunction with all-payer claims data for patients with epilepsy diagnoses, and finds that the policy reduces adherence. Chapter 3 extends our understanding of the epidemiology of pain onset and recovery by 1) describing disparities in pain by education arise and evolve across the adult life course, including age-specific incidence, persistence, and recovery patterns, and 2) investigating the extent to which biopsychological factors and access-to-care characteristics explain the educational disparities in the development of pain. The data come from the Medical Expenditure Panel Survey, which documents pain at multiple time points. Pain prevalence, cumulative incidence, and persistence all showed a dose-response relationship with education, with the lowest education group being significantly disadvantaged in every pain-related outcome. Self-rated physical health and insurance status both explained a significant portion of the relationship between education and pain development. 

Table of Contents

Introduction   1

Chapter 1 : Do Must-Access Prescription Drug Monitoring Programs (PDMPs) Affect Pain and Physical Impairment Outcomes in Older Adults?      4

1.1       Abstract            4

1.2       Introduction   5

1.2.1   Conceptual Model     7

1.2.2   New Contribution      8

1.3       Methodology 9

1.3.1   Data Sources 9

1.3.2   Must-Access PDMPs 9

1.3.3   Outcomes       11

1.3.4   Sample             12

1.3.5   Empirical Approach 12

1.4       Results              13

1.5       Discussion     19

1.6       Conclusion    23

1.7       Works Cited   24

Chapter 2 : Short-Term Impact of Scheduling Gabapentin on Medication Adherence Among Epilepsy Patients in Virginia     28

2.1       Abstract            28

2.2       Introduction   29

2.3       Methods           31

2.3.1   Policy 31

2.3.2   Data    32

2.3.3   Population      32

2.3.4   Outcomes       33

2.3.5   Timeframe      34

2.3.6   Statistical Analysis   34

2.4       Results              36

2.5       Discussion     41

2.5.1   Limitations     43

2.6       Conclusions  45

2.7       References     47

Chapter 3 : Educational Attainment and Pain Incidence: When and How Does the Disparity Arise? 54

3.1       Abstract            54

3.2       Introduction   56

3.2.1   Theoretical Background        58

3.3       Methods           60

3.3.1   Data    60

3.3.2   Population      61

3.3.3   Outcomes       61

3.3.4   Independent Variable              62

3.3.5   Mediators        62

3.4       Statistical Approach 64

3.4.1   Aim 1  64

3.4.2   Aim 2  65

3.5       Results              66

3.5.1   Aim 1  66

3.5.2   Aim 2  71

3.6       Discussion     73

3.7       Conclusion    75

3.8       References     77

About this Dissertation

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School	Laney Graduate School
Department	Health Services and Research Health Policy
Degree	Ph.D.
Submission	Dissertation
Language	English
Research Field	Health Sciences, Public Health
Keyword	PDMPs controlled substances pain
Committee Chair / Thesis Advisor	Courtney R Yarbrough, Emory University
Committee Members	David H Howard, Emory University Stephen W Patrick, Emory University Nicholas Giordano, Emory University

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