Association Between State-Level Prescription Opioid Limitation Laws & Suicide Outcomes
Suicide is a significant and growing public health concern, and a leading cause of death in the United States (U.S.). Suicide ranks in the top ten leading causes of death for those ages 10-64, and accounted for almost 45,000 deaths in 2016 in the U.S. In addition to the human toll, suicide annually accounts for more than $50 billion in medical- and work-related losses in the U.S. Further, the U.S. suicide rate has increased approximately 25% since 1999. Concurrently, opioid misuse and overdose—driven in large part by overprescribing—have grown to epidemic proportions. From 1999 to 2010, sales of opioid analgesics quadrupled in the U.S., mirrored closely by rates of opioid-related overdose deaths, emergency department (ED) visits, and substance abuse treatment admissions. Since 2010, opioid-overdose deaths have further grown by 80%, to total 42,249 in 2016.
Evolving state-level opioid policies aim to prevent opioid-related harms along a continuum. Because most who use opioids non-medically were initially exposed to them via a prescription, many state laws seek to prevent or limit access to prescription opioids (“opioid prescription limitation laws”). Those policies associated with reductions in opioid prescribing and unintentional overdoses include pain clinic regulations, robust prescription drug monitoring programs (PDMP), and prescribing guidelines. No previous study has examined the relationship between state-level opioid prescription limitation laws and suicide or nonfatal suicide outcomes.
To address this important gap in the evidence, we propose to link key national datasets and use innovative epidemiological and policy methods to understand the impact of statelevel opioid prescription limitation policies on fatal and nonfatal suicide outcomes. Specifically, we will use data from the Prescription Drug Abuse Policy System (PDAPS), OptumInsight commercial claims, and Centers for Disease Control and Prevention (CDC) Wide-ranging Online Data for Epidemiologic Research (WONDER).
The specific aims of the project are to:
Aim 1: Create a coding system for state opioid prescription limitation laws. We will analyze these laws using the PDAPS and a novel policy dataset to identify law features (e.g., whether a PDMP includes a use mandate) and develop a fine-grained coding system that differentiates state opioid prescription limitation laws by their specific components that may be relevant for suicidal ideation, attempts, and deaths.
Aim 2: Use law coding (Aim 1) and CDC WONDER data to estimate the state-level association between opioid prescription limitation laws and suicide mortality. We will model the state-level time series of suicide rates, treating opioid prescription limitation laws as a time-varying covariate, using state fixed effects to isolate within-state associations between prescription limitation laws and suicide mortality. We will conduct sub-analyses among each sex, in rural versus urban inhabitants, and restricted to opioid-specific suicides.
Aim 3a: Evaluate the state-level association between opioid prescription limitation laws and nonfatal suicide outcomes (separately for attempt and ideation). We will identify non-fatal suicide attempt rates using OptumInsight administrative claims data that include ED treatment and hospitalization diagnostic codes. We will identify non-fatal suicide ideation rates using the same data that also include outpatient treatment diagnostic codes. Using a similar approach as in Aim 2, we will estimate the within-state association between opioid prescription limitation laws and changes in suicide-related outcomes, including among different sexes and rural versus urban patients.
Aim 3b: Evaluate the state-level association between opioid prescription limitation laws and nonfatal suicide outcomes (separately for attempt and ideation) among cohorts of patients receiving opioids in high dosages and with mental health and substance use disorders. After constructing patient cohorts using OptumInsight data, we will estimate the effect of opioid prescription limitation laws on suicide outcomes.
This study is significant because its focus is at the nexus of two National Center for Injury Prevention and Control Director’s priority areas—opioid-related harms and suicide. Specifically, this proposal seeks to understand the consequences of opioid prescription limitation laws as they relate to a prevalent national public health harm: suicide. Given that no study has investigated this relationship and that few have classified these laws other than as binary measures, it is also highly innovative. Results will help inform public health planning and population-level suicide prevention strategies.