The purpose of this study was to determine the predictive utility of the theory of planned behavior (TPB) in predicting and explaining pharmacists’ intention to utilize a prescription drug monitoring program (PDMP) database, when the validity of the prescription/patient need is in question. The study tested the significance of each TPB model construct variable (attitude [A], subjective norm [SN], and perceived behavioral control [PBC]) in predicting pharmacists’ high intention, compared to non-high intention (dichotomous variable). In addition, the study examined the additional contribution of pharmacists’ perception of prescription (PPDA) drug abuse and perceived obligation (PO) to the TPB model. Demographic and practice characteristics were also explored in relation to the TPB model predictors, A, SN and PBC. A mail questionnaire was sent to a random sample of 998 Texas community pharmacists with active licenses. Three focus groups were conducted to collect information regarding pharmacists’ beliefs toward PDMP database utilization. The usable survey response rate was 26.2%. Due to data that were not normally distributed, intention was dichotomized into high intention and non-high intention. The TPB constructs were significant predictors of pharmacists’ high intention. Pharmacists with positive attitudes were almost twice as likely to have high intention (odds ratio [OR] = 1.8, 95% confidence interval [CI] = 1.2 – 2.8). However, SN was the strongest predictor of pharmacists’ high intention (OR = 2.2, 95% CI = 1.4 – 3.3). Pharmacists who reported substantial PBC were also twice as likely to have high intention (OR = 1.9, 95% CI = 1.2 – 3.0). PPDA was not significantly related to pharmacists’ high intention. However, pharmacists’ PO was shown to predict high intention above that explained by the TPB model (OR = 1.8, 95% CI = 1.0 – 3.1). The results of this study support the utility of the TPB model with PO in predicting pharmacists’ high intention to utilize a PDMP database. Interventions that address pharmacists’ A, SN, PBC, and PO may be necessary to increase pharmacists’ high intention to utilize a PDMP database when it becomes available. Future studies using intention as a predictor of pharmacists’ behavior are needed to assess the influence of intention on PDMP utilization. / text

Thesis advisor: Julie H. Mortimer / The unifying theme of this dissertation is the growing importance of pharmaceutical products in health care and in society more broadly. The first two chapters use structural and reduced-form models to study the effects of various policies on the choice and utilization of prescription drugs. The third chapter surveys the empirical literature on the competitive effects of a class of pricing arrangements used in the pharmaceutical and many other industries. Chapter 1. One of the criticisms leveled against direct-to-consumer advertising of prescription drugs is that it overemphasizes the use of pharmaceuticals at the expense of other forms of treatment. In “Choice of Depression Treatment: Advertising Spillovers in a Model with Complementarity,” I study how antidepressant TV ads affect demand for psychotherapy. Antidepressant advertising can increase demand for therapy if the products are complements or if advertising has spillover effects. To disentangle the different channels, I develop a discrete-choice demand model that allows for complementarity between products, advertising spillovers, and flexible unobserved preference heterogeneity. Individual-level panel data on treatment choices and price variation allow me to separately identify complementarity and correlated preferences, whereas the average price of TV advertising, used as an instrument, identifies the causal effect of antidepressant ads on demand for each product. The results indicate that even though antidepressants and psychotherapy are substitutes, drug advertising increases demand for therapy through a spillover effect. Allowing for time-invariant and time-varying unobservables that can be correlated across products critically affects the estimated degree of complementarity and advertising elasticities. Chapter 2. While prescription drugs have enabled the cost-effective treatment of a myriad of diseases, many pharmaceuticals come with potential for abuse. The growing use of opioid medications for chronic pain led to widespread misuse, addiction, and skyrocketing overdose death rates. In “Did Plain-Vanilla Prescription Drug Monitoring Programs Reduce Opioid Use? Evidence from Privately Insured Patients,” I explore whether prescription drug monitoring programs (PDMPs) with no registration or use mandates were effective in reducing the utilization of opioid prescription drugs. Exploiting the staggered introduction of such programs between 2008 and 2010, I use difference-in-differences to estimate their causal effect on the number of prescriptions, days supply, and dosage per capita. Based on data from privately insured adults, the estimation results reveal that PDMPs successfully reduced opioid utilization, especially of high-dosage prescriptions. A battery of robustness checks suggests that the estimated effects are caused by the PDMPs and not by confounding factors such as broader trends in health care, attrition, out-of-state purchases, or other anti-opioid policies. Chapter 3. The assumption that buyers pay the same price for each unit of the good they purchase underlies many economic analyses. However, linear pricing is one of many pricing arrangements used in practice. In “Empirical Evidence on Conditional Pricing Practices: A Review,” Julie Holland Mortimer and I review the existing empirical studies on the competitive impact of conditional pricing practices (CPPs), under which the price of a product may depend on a quantity, share, bundling, or other requirement. Examples of CPPs include all-units and loyalty discounts, full-line forcing contracts, and exclusivity arrangements. A common thread unifying the empirical literature is that CPPs often have both procompetitive and anticompetitive effects and that their net effect may depend on the details of the arrangements and the characteristics of the markets in which they are used. / Thesis (PhD) — Boston College, 2020. / Submitted to: Boston College. Graduate School of Arts and Sciences. / Discipline: Economics.

Indiana University-Purdue University Indianapolis (IUPUI) / Opioid misuse and addiction has been widely identified as a public health problem, contributing substantially to the nation’s morbidity and mortality. Over the past two decades, misuse of prescription opioids pain relievers has substantially increased; heroin use has resurged; and, more recently, abuse of high-potency synthetic opioids such as fentanyl have fueled the epidemic. Nearly 12 million Americans (or 4.4%) aged 12 and older misused some type of opioid (prescribed or illegal) in the past year. Furthermore, the percentage of substance use treatment admissions attributable to opioids nearly doubled in the U.S., from 20.8% in 2000 to 40.5% in 2015. The purpose of this dissertation research was to investigate associations between prescription pain reliever use and subsequent negative health outcomes, including opioid misuse or addiction, and neonatal abstinence syndrome. This research focused on three specific aims: Specific Aim #1: Examine heroin use among Indiana’s substance use treatment population to measure the extent, trends, and patterns of use, as well as to assess the relationship between prescription opioids and subsequent heroin use; Specific Aim #2: Analyze 2014 INSPECT (Indiana’s prescription drug monitoring program) data to identify factors that increase patients’ likelihood to engage in opioidrelated risk behaviors; and Specific Aim #3: Review U.S. trends in neonatal abstinence syndrome (NAS) incidence from 2008-2014, measure regional variability, and identify personal and environmental risk factors associated with NAS. / 2020-08-09

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For patients afflicted with symptoms of anxiety and insomnia, benzodiazepines are generally a safe and effective short-term pharmacological treatment option. Although considered safer than other sedative-hypnotic medications, substantial concern exists regarding the addictive nature and abuse potential of benzodiazepines along with potentially inappropriate prescribing and utilization in clinically vulnerable populations. These medication misadventures can have a significant impact on public health. Examples of medication misadventures as they pertain to benzodiazepines include the prescribing and use in clinically vulnerable populations for whom they are contraindicated or their efficacy has not been evaluated, the development of tolerance or addiction, abuse of the medication, and the manifestation of negative health outcomes including cognitive impairment, withdrawal symptoms upon discontinuation, or the reoccurrence of a preexisting substance use disorder. In order to better understand medication misadventures associated with benzodiazepines retrospective analyses using populations extracted from large health claims databases are employed. To understand how benzodiazepine use may lead to adverse events causing patient harm, the risk of exacerbations in benzodiazepine users diagnosed with chronic obstructive pulmonary disease was estimated. The inherent risk of benzodiazepine addiction and abuse was estimated in an HIV-infected population, a population with a high prevalence of substance use disorders. This risk was estimated by first determining whether HIV-infected individuals are more likely to have any benzodiazepine use compared to their uninfected counterparts, and secondly, by examining the association between HIV-infection and potentially problematic benzodiazepine use. Finally, in an effort to mitigate unexpected and undesirable consequences to public health associated with the prescription drug abuse epidemic in the US, states have implemented prescription drug monitoring programs (PDMPs) to track the prescribing and dispensing of controlled substance medications. The effect of these programs on benzodiazepine dispensing is evaluated on a state and national level. Findings will provide healthcare professionals a better understanding regarding the risk of medication misadventures involving benzodiazepines when evaluating their appropriateness in patients with anxiety, depression, and insomnia. Additionally, policymakers will understand the implications of PDMPs on the dispensing of benzodiazepines as they become a more widely used tool to combat prescription drug abuse and diversion.

Background Gabapentinoids (gabapentin and pregabalin), a class of FDA-approved antiepileptic medications with expanded indications for certain neuropathic pain conditions, have been prescribed off-label for almost all types of pain in the US opioid epidemic. Methods We used IBM® MarketScan® Research Databases (2015-2018) and collected primary data. In Aim 1, we described the geographic variation in gabapentinoids and opioids for pain by US state and metropolitan statistical area (MSA). In Aim 2, we implemented a controlled multiple baseline interrupted time series analysis and assessed the impact of including gabapentin in states’ prescription drug monitoring programs (PDMP) and listing gabapentin as a Schedule V controlled substance. In Aim 3, we developed an algorithm to identify potential gabapentin misuse and/or abuse in administrative claims data. Results The pattern of the geographic variation in gabapentinoids was similar to that of opioids across states and MSAs. Including gabapentin in PDMPs and Schedule V controlled ABSTRACT viii substance classification were effective in curbing the growth of gabapentin use and reducing opioid-related adverse events. Our algorithm identified approximately one in six patients with gabapentin use as having potentially misused and/or abused gabapentin. Multiple comorbidities and drug use were associated with gabapentin misuse and/or abuse. Conclusions Gabapentinoids may have been widely used as alternative or adjuvant analgesics to opioids for pain across the US. Policy makers should consider including gabapentin in proactive PDMPs and scheduling of gabapentin. Monitoring requirements and individualized safety measures should be put in place for patients who potentially misuse and/or abuse gabapentin.