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Prescription drug abuse (PDA) is an epidemic nationwide and has disproportionally impacted the Southern Appalachian region. Situated within a geographic area known for pervasive PDA and its consequences, The Gatton College of Pharmacy and Academic Health Sciences Center (AHSC) at East Tennessee State University are proactively engaging the Region and its health professions students to address the problem. Over the College’s six-year history of community engagement in PDA, efforts have focused on primary prevention activities, PDA treatment, awareness, education, and interprofessional collaboration as the key impact sectors. Notable programs include Generation Rx, Operation Rx Disposal, continuing education (CE) programming, and establishment of the ETSU Diversity-promoting Institutions Drug Abuse Research Program. In 2013-2014, 3 faculty and 38 Generation Rx pharmacy students engaged 4000 children and adolescents in PDA prevention education. Operation Rx Disposal employed 5 faculty members and 35 student pharmacists to assist more than 1000 households in removing unwanted medication from their homes through conduction of drug take-back events. Over 2000 health care providers from regional communities participated in PDA CE events conducted by 3 pharmacy faculty members. Additionally, 3 externally funded, PDA-specific grants totaling $2.26 million were awarded to pharmacy faculty members to engage communities, health care professionals, and students in innovative PDA prevention research. The College’s efforts have been nationally recognized by peers, professional organizations, state boards of pharmacy and within the evidentiary literature.

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: Prescription drug abuse is a major public health concern in the United States, associated with dramatic increases in morbidity and mortality over the past two decades. In recent years, disposal of unwanted, unused, and expired medications has been a pillar of national prevention efforts. Acknowledging increased policy and advocacy emphasis on improving prescription drug disposal behaviors of consumers, the purpose of this study was to evaluate the impacts of a targeted promotional campaign on participation in community-based drug take back events (TBE) in NE Tennessee. Methods: Between October 2013 and October 2017, 45 drug take-back events were held in 5 municipalities across NE Tennessee. A region-wide, promotional campaign including direct to consumer advertising (television, print, radio, etc) initiated spring 2014. Two methods of data collection were implemented: 1) donor surveys; and 2) drug donation weights (pounds) and dosage units collected. Controlled substance (CS) donations with identifiable dispensing dates were used to calculate donors’ possession time in months. One-way ANOVA, paired t-tests, and chi-square procedures were utilized to assess trends in donation weights, time to donation, and donor characteristics across the study period. Results: Total Disposal donations increased by 2.35 times (CS 2.61 times) from baseline after the initial promotional campaign. A total of 2300 CS donations were collected, with a spike in total pounds collected observed in spring of 2014 following initial marketing interventions. Donor possession time hdecreased by approximately one year during the length of the study (62.01 to 50.5 months). More than 1500 donor surveys were administered during the study. Half of all participants reported hearing about TBE through television promotions. Participants at urban events were 52.6% more likely than rural participants to hear about the event through newspaper promotion. Conclusion: Collaborative marketing across a TBE concentrated region increases CS disposal weight and decreases donor possession time.

Background: Interpersonal communication is inherent in a majority of strategies seeking to engage prescriber and pharmacist health care professionals (HCPs) in the reduction and prevention of prescription drug abuse (PDA). However, research on HCP PDA communication behavioral engagement and factors that influence it is limited. Objectives This study quantitatively examined communication behaviors and trait-level communication metrics, and qualitatively described prescription drug abuse-related communication perceptions and behaviors among primary care prescribers and community pharmacists. Methods: Five focus groups (N = 35) were conducted within the Appalachian Research Network (AppNET), a rural primary care practice-based research network (PBRN) in South Central Appalachia between February and October, 2014. Focus groups were structured around the administration of three previously validated trait-level communication survey instruments, and one instrument developed by the investigators to gauge HCP prescription drug abuse communication engagement and perceived communication importance. Using a grounded theory approach, focus group themes were inductively derived and coded independently by study investigators. Member-checking interviews were conducted to validate derived themes. Results: Respondents' trait-level communication self-perceptions indicated low communication apprehension, high self-perceived communication competence, and average willingness to communicate as compared to instrument specific criteria and norms. Significant variation in HCP communication behavior engagement was noted specific to PDA. Two overarching themes were noted for HCP-patient communication: 1) influencers of HCP communication and prescribing/dispensing behaviors, and 2) communication behaviors. Multiple sub-themes were identified within each theme. Similarities were noted in perceptions and behaviors across both prescribers and pharmacists. Conclusions: Despite the perceived importance of engaging in PDA communication, HCPs reported that prescription drug abuse communication is uncomfortable, variable, multifactorial, and often avoided. The themes that emerged from this analysis support the utility of communication science and health behavior theories to better understand and improve PDA communication behaviors of both prescribers and pharmacists, and thereby improve engagement in PDA prevention and treatment.

In the extensive literature on price dispersions that exists to date, there is a gap in the analysis of how market structure affects prices as well as the degree of dispersion in prices. Specifically, the literature is deficient in analyzing how price levels and price dispersion are affected by the number of firms operating in a market. I use secondary data to look at the prices of prescription drugs at the retail level in nine hundred and seventy pharmacies across one hundred and sixty five markets in Maryland and compare price dispersion across these brick and mortar pharmacies as well as across a separate set of pharmacies that only operate online. I compare online versus offline price dispersion, as well as price dispersion in purely offline markets from the structure of the market’s context. Stahl’s (1989) theoretical model is used to formulate and test the hypotheses that an increase in the proportion of positive search cost consumers in a market will cause price levels to rise and price dispersion to initially increase and then decrease. Furthermore, in markets with the proportion of positive search cost consumers above a threshold level, an increase in the number of firms will also lead price levels to rise and price dispersion to initially increase and then decrease. Conversely, in markets with positive search cost consumers below the threshold level, an increase in the number of firms will lead to lower price levels, i.e. the competitive outcome. For the analysis, I look at prices at the pharmacy level and price dispersion at the market level and determine the proportion of high search cost consumers for a specific pharmacy or a specific market relative to the other pharmacies and markets in the dataset. I find that a significant part of the differences in prices for a homogeneous prescription drug can be attributed to asymmetric information and that price dispersion is higher in markets with a greater number of firms, and price levels are higher in low income neighborhoods.

Background: In recent years, there has been an increase in prescription drug abuse, particularly among adolescents and young adults. While substance abuse on college campuses has remained a pervasive public health concern, rates of nonmedical prescription drug use surpass commonly abused drugs. The three most commonly abused prescription drugs (central nervous system (CNS) depressants, opioids, and stimulants) were assessed to identify differences among student characteristics, as well as their relationship with abuse. Purpose: The purpose of this study is to conduct a secondary analysis to explore demographic variables (race, gender, academic performance, living arrangement, alcohol and other drug usage, and affiliation with a fraternity/sorority) and their relationship with nonmedical prescription drug use. Also, this study aims to identify potential strategies and provide suggestions to address nonmedical prescription drug abuse for future interventions. Methods: Data was obtained from the 2009 National College Health Assessment. The study consisted of n = 1,417 undergraduate students attending Virginia Commonwealth University. Initially, overall prevalence rates for past-year illicit use of prescription CNS depressant, opioids, and stimulant use were examined. Bivariate analyses were conducted to identify differences among users and nonusers for each class of prescription drug using Pearson’s Chi-Square test of significance. Multiple logistic regressions were used to examine associations between these demographics and illicit use of each prescription drug. Interactions between individual demographics and drug use were also examined. Results: The past year prevalence use of nonmedical prescription central nervous system depressants, opioids, and stimulants use were 4, 11.2, and 8.7% respectively. According to bivariate analyses, nonmedical use was higher among certain college students, however characteristics varied by type of prescription drug. Multiple logistic regression analyses indicated that students living off campus (OR = 2.12, 95% CI = 1.03, 4.35) and reported use of alcohol (OR = 3.91, 95% CI = 1.21, 12.64) and marijuana (OR = 4.41, 95% CI = 2.28, 8.54) were more likely to use prescription depressants. Students with a GPA of a C or lower (OR = 1.50, 95% CI = 1.03, 2.17), and reported use of marijuana (OR = 3.25, 95% CI = 2.22, 4.78) were more likely to use prescription opioids. Nonmedical prescription stimulant use was highest among White students (OR = 2.02, 95% CI = 1.28, 3.30) with a GPA of a B or lower (OR = 2.06, 95% CI = 1.28, 3.30) and reported lifetime use of alcohol (OR = 7.96, 95% CI = (2.50, 25.41). Conclusions: The results of this study provide insight into the demographic variables and their relationship with nonmedical prescription drug abuse. The findings have important implications for identifying potential strategies to address nonmedical prescription drug abuse and will assist in the development of targeted and tailored interventions.

This dissertation comprises three discrete empirical papers, with an introductory essay that evaluates the impact of different federal policies on prescription drug prices, utilization, and spending. Two main databases are used: (a) Medicaid State Drug Utilization Data and (b) the Medical Expenditure Panel Survey (MEPS) data. These two databases are designed to track Medicaid drug utilization and overall medical use and expenditures, respectively. The variables of interest in this dissertation are prescription drug price, prescription drug use and spending, and overall drug expenditures. The objective of the first paper (Chapter 2) is to examine whether oncology drug prices have significantly changed because the Medicaid rebate increased under the Patient Protection and Affordable Care Act (ACA). The analytic sample includes top-selling oncology drugs, both branded and generic, over an 8-year time period. The prices of top-selling oncology drugs in 2006 were followed through 2013 to find the extent to which drug prices have changed while controlling for state fixed-effect, package size, type of manufacturer, brand or generic, and drug strength. Thus, this study examines whether and to what extent oncology drug prices have changed after the increase in the Medicaid rebate under the ACA. The second paper’s objective (Chapter 3) is to study whether Medicare Part D has reduced racial disparities in diabetes drug use, coverage, and spending since its implementation in 2006. The analytic sample includes individuals aged 55 years and older who had diabetes from 2001 to 2010. Although the impact of Medicare Part D has been studied from different perspectives, its impact on racial disparities in drug use, coverage, and expenditures among diabetics has not been studied yet. The third paper (Chapter 4) focuses on the association between closing the Medicare doughnut hole and prescription drug utilization and spending for Medicare Part D beneficiaries with chronic diseases through 2013. The objective of the third paper is to determine whether the provisions of the ACA that close the coverage gap have affected prescription drug utilization and out-of-pocket (OOP) spending among Medicare seniors with Part D coverage.

The rates of non-medical prescription drug use in the United States (U.S.) have increased dramatically in the last two decades, leading to a more than 300% increase in deaths from overdose, surpassing motor vehicle accidents as the leading cause of injury deaths. In rural areas, deaths from unintentional overdose have increased by more than 250% since 1999 while urban deaths have increased at a fraction of this rate. The objective of this research was to test the hypothesis that cultural, economic, and environmental factors prevalent in rural America affect the rate of substance use disorder (SUD) in that population, and that diagnosis of these disorders across rural and urban populations may not be generalizable due to these same effects. This study applies measurement invariance analysis and factor analysis techniques: item response theory (IRT), multiple indicators, multiple causes (MIMIC), and latent class analysis (LCA), to the DSM-IV abuse and dependency diagnosis instrument. The sample used for the study was a population of adult past-year illicit drug users living in a rural or urban area drawn from the 2011-2012 National Survey on Drug Use and Health data files (N = 3,369| analyses 1 and 2; N = 12,140| analysis 3). Results of the IRT and MIMIC analyses indicated no significant variance in DSM item function across rural and urban sub-groups; however, several socio-demographic variables including age, race, income, and gender were associated with bias in the instrument. Latent class structures differed across the sub-groups in quality and number, with the rural sample fitting a 3-class structure and the urban fitting 6-class model. Overall the rural class structure exhibited less diversity and lower prevalence of SUD in multiple drug categories (e.g. cocaine, hallucinogens, and stimulants). This result suggests underlying elements affecting SUD patterns in the two populations. These findings inform the development of surveillance instruments, clinical services, and public health programming tailored to specific communities.

In my senior year at ETSU I produced a documentary about opioid abuse in East Tennessee. In 2016, two local health care providers and a university collaborated on a project that would bring an opioid treatment center to Gray, Tennessee. The center includes a methadone clinic, an addition that piqued the concern of many citizens living in Gray. The film evaluates the concerns citizens had about the clinic and explores the issue of opioid abuse in East Tennessee.