Background

Many states have used opioid-related legislation to address the burden of substance use disorder, overdose, and death. As of mid-2018, some 1,300 bills were under consideration across the U.S.¹ Kentucky and West Virginia, which share the economically depressed central Appalachian region, have had some of the highest rates of overdose death in the nation.² While provisional CDC data point to a possible modest decline in Kentucky's overdose death rate, it remains among the highest in the nation, and West Virginia, with increasing overdose deaths, is often the state with the highest overdose death rate in annual analyses.³ The gravity of substance use disorder problems in these states is reflected in state declines in life expectancy.^{Reference Dwyer-Lindgren4}

Both Kentucky and West Virginia have enacted and implemented extensive opioid-related legislation in the six core areas identified by Parker and colleagues:

• Encouraging appropriate prescribing

• Educating the public and raising awareness

• Expanding access to addiction treatment and harm-reduction services

• Responding to overdoses

• Providing penalties for traffickers and treatment for those who need it

• Civil litigation and disciplinary action.^{Reference Parker, Strunk and Fiellin5}

Harm reduction has been the most recent trend and has gained some ground in these socially conservative states, despite local opposition based on the perception that offering services to people who use opioids puts neighboring populations at risk of harm.^{Reference Katz6} Prior work by investigators in West Virginia and other states has suggested that legislative initiatives to address opioid-related problems were associated with both reductions in overdose deaths due to prescription opioids and increases in deaths from illicit opioid overdose.^{Reference Gurka, Hu, Linn, Thompson and Christy7}

Types of Legislative Initiatives

We will set out examples of recent Kentucky and West Virginia enactments, then discuss early evidence regarding the impact of a recent Kentucky statutory innovation.

Following a taxonomy proposed by Beletsky, the “direct impact” group of these statutes authorizes actions specific to opioid burden mitigation, while the “indirect impact” group addresses initiatives that are intended to improve states' ability to respond to opioid issues. The “normative impact” approach includes legislation that (whether expressly or in effect) helps shift existing social or cultural norms that impede states' capacity to implement more effective approaches to opioid response.^{Reference Beletsky8} Some legislation has more than one type of impact.

Early Evidence of Legislative Impact

One of Kentucky's more unusual 2018 enactments requires the state's Administrative Office of the Courts to transmit five years' worth of “data regarding any felony or Class A misdemeanor conviction that involves the trafficking or possession of a controlled substance” or other acts prohibited by applicable law to the state's prescription drug monitoring program (PDMP) (2018 HB 333, codified as KRS 218A.205). The statute further mandates that the PDMP establish a system that supports querying patient data for information regarding the targeted convictions (KRS 218A.202(19)^{Reference Bohnert, Guy and Losby9}). With support from the U.S. Department of Justice, the Kentucky Injury Prevention & Research Center has partnered with the University of Kentucky's Institute for Pharmacy Outcomes and Policy to conduct interviews and surveys before and after implementation of the latter provision.

Survey questions were derived from interviews conducted between January and March 2018 that included representatives of licensing boards, professional associations, and state agencies. They were intended to assess prescriber and dispenser awareness and perception of the law as well as the law's likely impact on prescribing and dispensing behaviors. While there was some variation in responses, most (75-80%) respondents were unaware that drug conviction data would be available in the state's prescription drug monitoring program, and most (70-80%) agreed that having access to such data would be helpful in making controlled substance prescribing or dispensing decisions. A slightly smaller proportion, between 60-75% indicated their intent to request drug conviction data for use in treatment decisions.¹⁰ Assessment of the extent to which practitioners access drug conviction data and their use of the data in practice is in progress as of this writing.