<p> The forces driving the prescription opioid epidemic currently raging across the United States include aggressive marketing, weak regulation, addiction, freely prescribing doctors, a glut of pills available for sharing, and easy access to illicit drugs like heroin. This thesis aims to quantitatively analyze the interactions between these drivers through construction of a System Dynamics model, in order to determine the efficacy of policy intervention through Prescription Drug Monitoring Programs. The System Dynamics model simulates the flow of doctors&rsquo; prescriptions to the two very different classes of prescription opioid patients. One class is the long-term pain patients whose tolerance and appetite for opioids grows over time, leading them to higher doses, often dangerously high, and yet also frequently to feeling under-medicated; the other is those patients prescribed opioids for short-term pain, who typically find that they have been given more pills than they need.</p><p> These &ldquo;extra&rdquo; pills find their way into the hands of friends and family who, in common with the patients who received prescriptions, are in jeopardy of addiction to the opioids. Those addicted repeatedly visit doctors, shopping for more. Sensitivity analysis results reveal that drug diversion is a major contributor to the opioid death rate; that mandatory PDMP use will slow but not stop opioid proliferation, and will cause long term pain patients to be under-treated in larger numbers; that a significant number of people addicted to prescription opioids will transition to heroin use for reasons of price and availability; and that the rate of opioid overdose deaths will remain high until and unless society is better educated about the risks of addiction. Overall, the study helps conclude that the efforts of state governments and the FDA will be insufficient to stem the flow of opioids, and that there is no simple intervention to thwart drug diversion and sharing of pills.</p>

<p> The United States is experiencing an unprecedented crisis of prescription and illicit opioid misuse, addiction and overdose. Coincident with the increase in opioid misuse and addiction in the U.S. over the past decade are rising rates of prescription opioid injection and transmission of infectious diseases such as hepatitis C virus (HCV) and endocarditis. </p><p> Following the 2015 HIV outbreak in Scott County, Indiana associated with injection of the prescription opioid oxymorphone, and a decade-long increase in viral hepatitis infection rates, especially in areas of the U.S. with long-standing prescription opioid misuse and addiction, policymakers, public health practitioners, and other stakeholders have become increasingly concerned about prescription opioid injection misuse and related harms. </p><p> Syringe Services Programs (SSPs)&mdash;evidence-based programs that provide sterile injection equipment and comprehensive infectious disease, substance use, and overdose prevention and treatment services&mdash;have been identified as a potential key intervention in response to the opioid crisis and increasing opioid injection. However, there is limited recent research characterizing the population of people injecting prescription opioids and other drugs that can help guide how to best position SSPs to reach and impact this population. Further, the policy environment for SSPs is rapidly evolving, with multiple states enacting laws, regulations, and policies in recent years to enable the establishment of SSPs. Collectively, the research gaps around prescription opioid injection and the changing policy environment for SSPs has created a critical need to better define the characteristics of people who inject prescription opioids, to identify the services and resources needed by this population, and to understand how SSPs are navigating the evolving policy environment in order to maximize their role in response to the opioid crisis. </p><p> This dissertation research aims, through the use of mixed methods, to address these knowledge and policy gaps through: 1) systematically reviewing the literature to synthesize what is known about the population of individuals who inject prescription opioids in the U.S.; 2) estimating the magnitude of prescription opioid injection in the United States; 3) examining overall, sociodemographic, and substance use trends and correlates of prescription opioid injection among a nationally representative sample to identify populations at-risk for prescription opioid injection and related harms; and 4) using these quantitative findings to inform a qualitative exploration of SSPs&rsquo; responses to the rapidly changing policy environment in the midst of the evolving opioid epidemic and how they can be further leveraged to reduce the harms associated with opioid injection. This dissertation accomplishes these aims through three separate, but related studies. Taken together, the new knowledge produced from this dissertation can be used to inform the development, prioritization, and implementation of policies, programs, and practices that aim to reduce prescription opioid injection and its related harms and expand the role of SSPs in response to the U.S. opioid crisis.</p><p>