ESSAYS ON REGULATING PAIN AND PLEASURE Bryce Alexander Pardo, Doctor of Philosophy

241 Pages·2017·2.26 MB·English

by  Bryce Pardo

ABSTRACT

Title of Dissertation: ESSAYS ON REGULATING PAIN AND
PLEASURE

Bryce Alexander Pardo, Doctor of Philosophy,
2018

Dissertation directed by: Professor Peter Reuter, Department of Public
Policy

Psychoactive substances play an important role in modern society. They can be of
therapeutic value, but their abuse by individuals remains an important policy challenge.
Changes in technology and medicine, coupled with evolving norms surrounding the use of
psychoactives, have altered much of the drug policy landscape in the last two decades.
Currently, the opioid overdose crisis is one of the most challenging public health problems
facing state and local jurisdictions. Excessive supply of prescription medications and the
arrival of new synthetic opioids, often designed to circumvent regulatory control, have
been linked to a tens of thousands of fatal overdoses in the United States in recent years.
Advances in chemistry and trade contribute to the recent increase in number of new
psychoactive substances (NPS) that mimic controlled drugs, overwhelming many
regulatory systems. At the same time, an increasing number states in the US have started
to relax access to cannabis for medical and recreational purposes.
The following three essays explore questions related to contemporary drug policy. Chapter
2 quantitatively assesses the relationship between the design of prescription drug
monitoring programs (PMPs) and opioid overdose-related outcomes. The analysis departs
from a dichotomous specification found in much of the literature and shows that robustness
of policy design is negatively associated with prescription opioid overdose-related
outcomes.
Chapter 3 provides a comprehensive and theoretical analysis of how jurisdictions across
the globe have approached new psychoactive substances (NPS). It includes a conceptual
framework for regulating new substances, assesses the market drivers behind NPS, and
offers some considerations regarding policy evaluations going forward.
Chapter 4 applies some of the analytical considerations in Chapter 3 to empirically assess
the relationship between cannabis and its synthetic analogs. Using two years of data for all
fifty states, I quantitatively explore the relationship between legal access to medical
cannabis and exposure to cannabimimetics, showing that there may be a substitution effect.
I end with a summary chapter of policy implications and avenues for future research.
ESSAYS ON REGULATING PAIN AND PLEASURE

by

Bryce A. Pardo

Dissertation submitted to the Faculty of the Graduate School of the
University of Maryland, College Park, in partial fulfillment
of the requirements for the degree of
Doctor of Philosophy
2018

Advisory Committee:
Professor Peter Reuter, Chair
Professor Beau Kilmer
Professor Thomas Loughran
Professor Linda Simoni-Wastila
Professor Robert Sprinkle
Professor Eric Wish
© Copyright by
Bryce A. Pardo
2018
Dedication

To my sister, Larissa Pardo.
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Acknowledgements
This dissertation is the result of the institutional and individual support from the faculty
and staff at the University of Maryland and the wider drug policy community. First and
foremost, I would like to express my deep gratitude to my advisor and dissertation chair,
Professor Peter Reuter, for his mentorship and support. He has improved the clarity and
arguments of my ideas; his work continues to shape my thinking about drug and crime
policy. I would also like to thank Dr. Beau Kilmer from RAND’s Drug Policy Research
Center for his guidance and instruction. There are countless individuals of the scholarly
drug policy community who I have come to know and engage over the last five years. My
interactions with them have always been rewarding and have often led me to explore new
ideas or refine old ones. Any errors in this manuscript are mine alone.
I am fortunate to have received financial support from the University’s Ann G. Wylie
Fellowship and the School of Public Policy. Without such support this work may have
never been completed.
Lastly, I want to thank my family, especially my sister for her patience and encouragement.
I owe a tremendous debt to my parents for cultivating my intellectual curiosity as a child.
My partner has been by my side throughout this endeavor, helping me with much of the
financial and emotional burdens of a doctoral program. Without her love and support I do
not think I would have been able to undertake this work.

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Table of Contents
List of Tables ..................................................................................................................... vi
List of Figures ................................................................................................................... vii
List of Abbreviations ....................................................................................................... viii
1 Introduction ................................................................................................................. 1
1.1 Scope .................................................................................................................... 1
1.2 Definition of pain and pain relief ......................................................................... 1
1.3 Definition of pleasure ........................................................................................... 4
1.4 Contemporary drug policy ................................................................................... 8
1.5 Research Motivation .......................................................................................... 15
1.6 Organization of the dissertation ......................................................................... 18
2 Do More Robust Prescription Drug Monitoring Programs Reduce Opioid Overdose
Deaths? .............................................................................................................................. 23
2.1 Background ........................................................................................................ 23
2.2 Data and methods ............................................................................................... 26
2.2.1 Design ......................................................................................................... 26
2.2.2 Data ............................................................................................................. 27
2.2.2.1 Dependent variables ................................................................................ 27
2.2.2.1.1 Overdose deaths ................................................................................. 27
2.2.2.1.2 Emergency department discharges .................................................... 30
2.2.2.2 Independent variables .............................................................................. 31
2.2.3 Statistical Analysis ...................................................................................... 36
2.2.3.1 Overdose deaths ...................................................................................... 36
2.2.3.2 Emergency department discharges .......................................................... 38
2.3 Results ................................................................................................................ 38
2.3.1 Descriptive Statistics ................................................................................... 38
2.3.2 Regression Results ...................................................................................... 52
2.3.2.1 Overdose deaths ...................................................................................... 52
2.3.2.1.1 Prescription opioids ........................................................................... 52
2.3.2.1.2 Heroin ................................................................................................ 56
2.3.2.1.3 Heroin and fentanyl-laced heroin ...................................................... 59
2.3.2.2 Emergency department discharges .......................................................... 62
2.3.2.2.1 Prescription opioids ........................................................................... 62
2.3.2.2.2 Heroin ................................................................................................ 64
2.4 Discussion .......................................................................................................... 66
2.4.1 Limitations .................................................................................................. 72
2.4.2 Strengths ..................................................................................................... 73
3 New psychoactive substances: options toward regulating new forms of drug-induced
pleasure ............................................................................................................................. 75
3.1 Introduction and scope ....................................................................................... 75
3.2 Background ........................................................................................................ 76
3.3 Defining the phenomenon .................................................................................. 80
3.4 Policy literature review ...................................................................................... 90
3.5 Precautionary principle and its application to psychoactives............................. 92
3.6 Regulatory frameworks ...................................................................................... 97
3.6.1 International and regional efforts ................................................................ 98
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3.6.2 Foodstuff, dietary supplement, and consumer protection laws................. 105
3.6.3 Specific commodity regulation ................................................................. 110
3.6.4 Regulating under medicines legislation .................................................... 118
3.6.5 Narcotics laws ........................................................................................... 123
3.6.6 Total Ban ................................................................................................... 130
3.7 Application and tradeoffs ................................................................................. 150
3.8 Conclusion: Applying frameworks to NPS ...................................................... 155
4 Access to cannabis and its relationship with synthetic cannabis receptor agonists . 163
4.1 Introduction ...................................................................................................... 163
4.1.1 State cannabis policy reforms ................................................................... 163
4.1.2 Synthetic cannabinoid receptor agonists ................................................... 167
4.1.3 Literature review ....................................................................................... 169
4.2 Data and Methodology ..................................................................................... 173
4.2.1 Dependent Variable .................................................................................. 175
4.2.2 Independent Variables .............................................................................. 175
4.2.3 Analytical approach .................................................................................. 178
4.3 Results .............................................................................................................. 181
4.3.1 Descriptive results ..................................................................................... 181
4.3.2 Regression results ..................................................................................... 186
4.4 Discussion ........................................................................................................ 190
4.4.1 Limitations ................................................................................................ 193
4.4.2 Strengths ................................................................................................... 194
5 Conclusion and Policy Implications ........................................................................ 195
6 References ............................................................................................................... 204

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List of Tables
Table 1.1: Validation of Pleasure........................................................................................ 7
Table 2.1: Point Allocation to Rules to Create Score Variable ........................................ 34
Table 2.2: Descriptive statistics for dependent variables .................................................. 39
Table 2.3: Descriptive Statistics for OPR overdose deaths for states with and without
PMPs ................................................................................................................................. 44
Table 2.4: Descriptive Statistics for heroin overdose deaths for states with and without
PMPs ................................................................................................................................. 45
Table 2.5: Descriptive Statistics for OPR ED discharges for states with and without PMPs
........................................................................................................................................... 46
Table 2.6: Descriptive Statistics for heroin ED discharges for states with and without
PMPs ................................................................................................................................. 47
Table 2.7: Comparison of states with and without operational PMPs, overdose death rates
selected years .................................................................................................................... 49
Table 2.8: Comparison of states with and without operational PMPs, emergency
department discharge rates selected years ........................................................................ 51
Table 2.9: Analysis of log of age-adjusted OPR overdose death rate, SEs calculated with
state-level clustered robust standard errors. ...................................................................... 55
Table 2.10: Analysis of log of age-adjusted heroin overdose death rate, SEs calculated
with state-level clustered robust standard errors. .............................................................. 58
Table 2.11: Analysis of log of age-adjusted estimated heroin/fentanyl overdose death
rate, SEs calculated with state-level clustered robust standard errors. ............................. 61
Table 2.12: Analysis of log of OPR ED discharge rates, SEs calculated with state-level
clustered robust standard errors. ....................................................................................... 63
Table 2.13: Analysis of log of heroin ED discharge rates, SEs calculated with state-level
clustered robust standard errors. ....................................................................................... 65
Table 2.14: Analysis of log of age-adjusted OPR overdose death rate, Unweighted Score
SEs calculated with state-level clustered robust standard errors. ..................................... 68
Table 3.1: Comparative analysis of blanket bans and defining psychoactivity .............. 133
Table 3.2: Summary of main regulatory options available ............................................ 148
Table 3.3: Logic model for regulating different classes of NPS ..................................... 159
Table 4.1: SCRA Reports, percentage of total reports by year reported to NFLIS ........ 183
Table 4.2: Descriptive statistics for states with and without operational dispensaries ... 185
Table 4.3: Regression results, SCRA exposure calls to poison control centers ............. 189

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List of Figures
Figure 2.1: US Overdose death rate 1999-2015................................................................ 24
Figure 2.2: Score of Prescription Monitoring Programs, National Average .................... 40
Figure 2.3: Score of Prescription Monitoring Programs, Maine ...................................... 41
Figure 2.4: Score of Prescription Monitoring Programs, Florida ..................................... 41
Figure 2.5: Score of Prescription Monitoring Programs, Louisiana ................................. 42
Figure 2.6: Score of Prescription Monitoring Programs, Delaware ................................. 42
Figure 3.1: Number of Drugs Controlled by Schedule, 1971 - July 2017 ........................ 78
Figure 3.2: Decision-making under the old and proposed systems Source: European
Commission (2013) ......................................................................................................... 102
Figure 3.3: Regulatory tradeoffs for controlling NPS .................................................... 154
Figure 4.1: Qualifying ailments for medical marijuana in Colorado and Oregon, July
2016................................................................................................................................. 166
Figure 4.2: THC to SCRA Affinities .............................................................................. 169
Figure 4.3: Age distribution of synthetic cannabinoid and cannabis-related emergency
department (%) visits: 2011; DAWN ............................................................................. 171
Figure 4.4: Rates of Synthetic Cannabinoid Exposure Calls by State ............................ 184
Figure 4.5: Registered medical marijuana patients per 1000 .......................................... 185

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