Dissertations and Theses (Open Access)

Date of Award

Summer 8-2025

Degree Name

Doctor of Philosophy (PhD)

Advisor(s)

ELLEN BRECKENRIDGE, PHD, JD, MPH

Second Advisor

GRETCHEN GEMEINHARDT, PHD,

Third Advisor

CICI BAUER, PHD

Abstract

Opioid prescribing for children and adolescents continues to be a significant health crisis in the United States. Early naïve exposure to opioid prescriptions has been linked to later misuse, opioid use disorder, and death. In response to the crisis, many states have implemented opioid prescribing limit laws (OPLLs) aimed at reducing exposure to opioids. These laws vary widely in their approach, including differences in dosage restrictions, prescription duration limits, informed consent requirements, educational provisions, and whether they offer explicit protections specifically for minors. Despite their widespread adoption, there is limited understanding of how heterogeneity in legal regulations affects outcomes for pediatric patients. This dissertation systematically coded 71 statutory features across all 50 states and the District of Columbia as of December 2024, including both adult-focused and pediatric-specific prescription controls. Multidimensional scaling and k-means clustering reduced legal variation into five policy typologies, reflecting combinations of overall statutory comprehensiveness and minor specific limits: Low No Minor, Moderate No Minor, Moderate Minor, High No Minor, and High Minor. No state fit in the Low Minor category. Negative binomial regression models evaluated associations with opioid-related mortality across five pediatric age groups (< 1, 1 to 4, 5 to 9, 10 to 14, and 15 to 17 years) from 2018-2024 one year after the initiation of most of the OLLs across states. Models adjusted for state-level socioeconomic and contextual variables, including median household income, uninsured rate, Medicaid and CHIP enrollment, and political alignment with statistical significance set at p-value = 0.05. States classified in the Moderate Minor typology included moderately comprehensive factors with a specific minor provision, demonstrated significantly lower adolescent (15 to 17 years) (IRR=2.49, p-value = 0.034) opioid mortality rates relative to equally comprehensive laws lacking pediatric provisions (Moderate No Minor ( IRR = 5.78, p-value = < 0.001). Moderate Minor states presented as lower mortality rates across all age groups, whereas the Low No Minor policy states showed higher rates of mortality across age groups. These findings indicate that the structure of the law along with specific pediatric focus matters. Laws that clearly identify enforceable prescribing limits, require consent, and provide education for both providers and patients while not being overly complex achieve reductions in youth mortality. This work contributes a rigorous legal epidemiologic framework to guide refinement of OPLLs toward approaches that better safeguard opioid naive children and adolescents.

Download

Share

COinS