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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.

Prescription drug misuse is growing among college students. According to the U.S. Department of Justice, 559 full-time college students begin non-medically using prescription pain relievers every day. Within the last 12 months, nearly 12% of college students reported using prescription medications prescribed to a different person. Count It! Lock It! Drop It! is an initiative of the Coffee County Anti-Drug Coalition in Coffee County, Tennessee that educates the public on how prescription drug misuse can be prevented by counting, locking, and disposing of unused or expired medication. In collaboration with Count It! Lock It! Drop It! developers, a multi-pronged campaign using printed flyers and posters, residence hall door hangers, residence hall advisor t-shirts, campus yard signs, as well as digital and social media was developed and implemented in fall 2017 at East Tennessee State University. The objectives of this study were to: 1) assess exposure to the Count It! Lock It! Drop It! campaign among college students; and 2) examine perceptions and behaviors concerning medication storage and disposal among college students. A cross-sectional, online survey was conducted in November-December of 2017. Study participants were recruited from a series of listservs and included students 18 years of age and older currently enrolled at the University (n=274). Study variables included if and how students were exposed to the campaign, if they possessed expired or unused medications, if they counted, locked, or disposed of medication, and the likelihood of completing these tasks. Descriptive analyses were conducted using SPSS, version 24. Students reported print materials such as flyers as the most common channel of exposure. Among students reporting unused or expired medications in their household, a small percentage locked medication in a secure location in the past 30 days (13.7%), with a smaller percentage counting medication in the past 30 days (4.8%). The most common method of disposal was to discard of medication in the household trash, while the least common was to give to a friend or family member. Only 7.7% donated medications at a live take-back event, while 23.1% donated at a permanent disposal location. Students’ intentions for counting, locking, and disposing of medications varied. More students strongly disagreed than agreed that counting medications would become part of a two-week routine. More students disagreed than agreed with placing medications in a secure location, but results were more evenly dispersed relative to those for counting medications. Students generally agreed with disposing of expired or unused medications. Overall, this study suggests printed materials are a good way to reach college students for the Count It! Lock It! Drop It! initiative, that students do not commonly count or secure medications, and that students do not agree that counting or securing medications will be part of their standard routine.

To evaluate the effectiveness of the West Virginia Prescription Drug Abuse Quitline (WVPDAQ). Descriptive data and inferential analyses are provided for the period of operations from 9/11/2008 to 3/1/2010. Chi-square tests for Independence compared differences between callers completing at least one follow-up survey against callers completing only the baseline intake survey were observed. A Wilcoxon signed rank sum test tested differences between the scores of intake callers and follow-up callers at the one-week (n = 177) and one-month (n = 89) intervals. A total of 1,056 calls were received, including 670 intakes, 177 1st follow-ups, 89 2nd follow-ups, and 36 3rd follow ups, and 84 caller satisfaction surveys. Chi-square analyses determined that callers who only completed the intake survey tended to have initiated drug use at a younger age (< or = 39 years of age, chi2 = 7.63, p = .02). Longitudinal findings indicated significant self-reported declines in daily drug use (p < .0001), increased intentions to quit in the next 30 days (p < .0001), and declines in requesting a referral for treatment (p < .0001) at the one-month follow-up. Finally, approximately 19% (n = 17) of callers reported obtaining a counseling/ treatment appointment as a result of calling the WVPDAQ at the one-month follow up. Preliminary results suggest the WVPDAQ has established itself as a meaningful resource to combat prescription drug abuse in West Virginia. Sustainable funding and greater integration of the WVPDAQ into existing and developing treatment infrastructure could provide more affordable options for the state of West Virginia and its citizens.

The West Virginia Prescription Drug Abuse Quitline (WVPDAQ) is a resource that offers education and support to individuals and families affected by prescription drug abuse. The WVPDAQ began functioning September 11, 2008, through the use of mobile phone and laptop technology. Although some helplines and quitlines use some aspects of remote technology, most function through traditional call center and landline technology, making the WVPDAQ unique. This article describes the process evaluation of the WVPDAQ and outlines both the positive findings and challenges faced by the WVPDAQ. Lessons learned and future recommendations for remote quitline endeavors are also presented. It is hoped that the experiences and information regarding the WVPDAQ presented can provide best-practice insight for public health practitioners and evaluation personnel who are considering using alternative technologies to deliver quitline services.

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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Health financing policies implemented by nations around the world vary based on who receives coverage and what health system resources are covered. Although, many health systems are attempting to move towards Universal Health Coverage, part of their populations continue to incur out-of-pocket payments for using all or some health services. Some health systems restrict health insurance for certain migrant populations, providing coverage for emergency care only, or none at all. Other health systems fail to provide coverage for prescription drugs, leaving those without the ability to pay out-of-pocket for medications behind. The lack of financial protections against catastrophic or impoverishing healthcare expenditures for these patients may deter them from seeking the care they need or increase the risk of severe financial hardships. This dissertation addresses these migrant and drug coverage gaps by examining the impacts of health financing policies and how these can be changed to move health systems towards Universal Health Coverage. First, this dissertation examines restrictions to refugee health policy in Canada by conducting an interpretive policy analysis to reveal how political actors strategically use causal stories to enact policy change. Second, quantitative studies assessing the effects of health insurance on migrants’ health-related outcomes are systematically reviewed. Third, this dissertation explores a provincial health system without universal prescription drug coverage to establish associations between health services use, prescription drug coverage and immigrant category. Finally, given migrants experience health outcome and health services utilization disparities, an exploratory analysis of factors that impede or assist migrants’ access to prescription drugs is conducted to uncover how these factors influence their health. While each study is distinct, together, these chapters build on each other using mixed methodological approaches to identify ways that address health financing policy gaps to reduce health inequities, build inclusive and cost-effective health systems and strengthen global health security. / Dissertation / Doctor of Philosophy (PhD)

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Prescription drug abuse is a public health problem of epidemic proportions in the United States. Provider-patient communication underpins many initiatives aimed at preventing and reducing the public health burden of prescription drug abuse. The characteristics of and factors contributing to this interpersonal process, however, have not been fully explored. The purpose of this research was to examine: 1) the overall problem of prescription drug abuse and provider-patient communication about prescription drug abuse from the patient perspective; and 2) provider-patient communication about prescription drug abuse from the prescriber perspective. In 2014-2015, semi-structured interviews were conducted with 20 patients from primary care and addiction medicine and 10 prescribers from multiple health professions and medical fields in Central and South Central Appalachia. The interviews were audio-recorded and transcribed verbatim. Thematic analysis, facilitated by qualitative data analysis software, was used to generate themes. Patients perceived prescription drug abuse as a problem, both in terms of its prevalence and contribution to negative consequences. Patients connected abuse to accessibility, identifying routes of access, routine practices, and rationales involved in the acquisition and distribution of prescription drugs for abuse. With regard to provider-patient communication, patients reported different levels of engagement in prescription drug abuse-related communication with healthcare providers—active, passive, and no/limited. Prescribers likewise reported different patterns of prescription drug abuse-related communication with patients—informative, counteractive, and supportive. Collectively, patients and prescribers described a range of factors—personal and environmental—that positively and negatively influence provider-patient communication and, by association, prescriber delivery and patient receipt of healthcare related to prescription drug abuse. When comparing the perspectives of patients and prescribers, multiple similarities in their prescription drug abuse-related communication perceptions and behaviors were identified. The findings of this research have implications for: 1) clinical practice to mitigate prescription drug abuse and improve patient prescription drug abuse-related communication behaviors; 2) patient- and prescriber-targeted interventions to improve provider-patient communication about prescription drug abuse; and 3) future research to continue to advance understanding of provider-patient communication about prescription drug abuse.