Author ORCID Identifier

https://orcid.org/0000-0003-4886-6279

Date Available

1-9-2027

Year of Publication

2025

Document Type

Doctoral Dissertation

Degree Name

Doctor of Philosophy (PhD)

College

Pharmacy

Department/School/Program

Pharmaceutical Sciences

Advisor

Dr. Chris Delcher

Abstract

The opioid crisis in the United States has presented significant challenges for public health, healthcare systems, and society over the past decades. In 2022, approximately 6.1 million people were estimated to have opioid use disorder (OUD), yet only 17.5% people had accessed medications for OUD, suggesting a lack of access to appropriate treatments1. Given the prolonged period of the opioid crisis, the landscape of illicit opioid supply has rapidly evolved2–4. Between 2019 and 2022, the number of opioid-involved deaths surged by 64%, totaling 81,8065, largely attributed to synthetic opioids such as illicitly manufactured fentanyl and its analogues5. In response, US federal and state regulatory agencies have implemented multi-level pharmaceutical preventive interventions for OUD6. This dissertation aims to examine outcomes, both intended and possibly unintended, associated with tertiary (reduce disease severity7) and quaternary (mitigate unintended consequences of preventive interventions7,8) preventive pharmaceutical interventions aimed at addressing the opioid crisis from 2011 to 2019.

Chapter 1 introduces opioid crisis, OUD, pharmaceutical preventive interventions for OUD under the framework of four-level prevention strategies, and specific aims of this dissertation.

Part A delves into the tertiary prevention approach, focusing on the utilization of buprenorphine for OUD. In Chapter 2, a comprehensive review of the history of federal statutory changes on prescribing buprenorphine is conducted. Specifically, the dissertation examines buprenorphine dispensing following the 2016 buprenorphine access expansion policies (hereafter, 2016 expansions) in Chapter 3 and 4. Another comprehensive review of the outcomes following the 2016 expansions is conducted in Chapter 3. Additionally, the association between the 2016 expansions and buprenorphine dispensing in Texas is evaluated in Chapter 4. A multivariate generalized linear model is employed to compare buprenorphine dispensing in pre- and post-policy periods between January 2015 and September 2018, with subgroup analyses based on urban-rural status.

In Chapter 5, the dissertation investigates the association between initial buprenorphine dose and incidence rate of treatment discontinuation within 180 days of follow-up in Texas during the fentanyl crisis. A retrospective new-user cohort study from February 2017 to December 2019 is conducted, estimating incidence rate ratios using the negative binomial regression model with inverse probability of treatment weighting.

Part B investigates the quaternary prevention approach, examining potential unintended consequences of existing prevention approaches restricting access to prescription opioid analgesics for patients who relying on them for pain management, while also exploring protective interventions. In Chapter 6, a national policy evaluation study assesses the impact of the mandatory prescription drug monitoring program (PDMP) use laws on opioid analgesic dispensing among commercially insured adults with lung cancer diagnosis from 2011 to 2019. The state-level quarterly opioid analgesic utilization is estimated using an interaction-weighted difference-in-differences approach. Subgroup analyses are conducted based on the mandatory PDMPs with or without cancer exemptions.

Chapter 7 summarizes the findings, outlines policy implications, identifies future research needed, and concludes this dissertation work.

Digital Object Identifier (DOI)

https://doi.org/10.13023/etd.2024.532

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Available for download on Saturday, January 09, 2027

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