title: What we know, and don't know, about the impact of state policy and systems-level interventions on prescription drug overdose.
abstract: BACKGROUND
  Drug overdose deaths have been rising since the early 1990s and is the leading cause of injury death in the United States. Overdose from prescription opioids constitutes a large proportion of this burden. State policy and systems-level interventions have the potential to impact prescription drug misuse and overdose.
  
  
  METHODS
  We searched the literature to identify evaluations of state policy or systems-level interventions using non-comparative, cross-sectional, before-after, time series, cohort, or comparison group designs or randomized/non-randomized trials. Eligible studies examined intervention effects on provider behavior, patient behavior, and health outcomes.
  
  
  RESULTS
  Overall study quality is low, with a limited number of time-series or experimental designs. Knowledge and prescribing practices were measured more often than health outcomes (e.g., overdoses). Limitations include lack of baseline data and comparison groups, inadequate statistical testing, small sample sizes, self-reported outcomes, and short-term follow-up. Strategies that reduce inappropriate prescribing and use of multiple providers and focus on overdose response, such as prescription drug monitoring programs, insurer strategies, pain clinic legislation, clinical guidelines, and naloxone distribution programs, are promising. Evidence of improved health outcomes, particularly from safe storage and disposal strategies and patient education, is weak.
  
  
  CONCLUSIONS
  While important efforts are underway to affect prescriber and patient behavior, data on state policy and systems-level interventions are limited and inconsistent. Improving the evidence base is a critical need so states, regulatory agencies, and organizations can make informed choices about policies and practices that will improve prescribing and use, while protecting patient health.
authors.affiliation: Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Hwy MS F62, Atlanta, GA 30341, USA. Electronic address: EQD4@cdc.gov.
authors.forename: Tamara M
authors.initials: TM
authors.lastname: Haegerich
authors.affiliation: Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 601 Sunland Park Dr Suite 200, El Paso, TX 79912, USA. Electronic address: LBP4@cdc.gov.
authors.forename: Leonard J
authors.initials: LJ
authors.lastname: Paulozzi
authors.affiliation: Policy Research Analysis and Development Office, Office of the Associate Director for Policy, Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA 30029, USA. Electronic address: WMU6@cdc.gov.
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Manns
authors.affiliation: CDR, US Public Health Service, Senior Advisor, Office of Public Health Strategy and Analysis, Office of the Commissioner U.S. Food and Drug Administration, 10903 New Hampshire, Silver Spring, MD 20993, USA. Electronic address: Christopher.M.Jones@fda.hhs.gov.
authors.forename: Christopher M
authors.initials: CM
authors.lastname: Jones
mesh_terms: D000701:Analgesics, Opioid / Q000009:adverse effects; D002986:Clinical Trials as Topic / Q000379:methods; D015331:Cohort Studies; D003430:Cross-Sectional Studies; D062787:Drug Overdose / Q000175:diagnosis / Q000453:epidemiology* / Q000517:prevention & control*; D006291:Health Policy / Q000331:legislation & jurisprudence* / Q000639:trends; D006801:Humans; D057970:Inappropriate Prescribing / Q000009:adverse effects* / Q000331:legislation & jurisprudence* / Q000639:trends; D055553:Prescription Drugs / Q000009:adverse effects*; D014481:United States / Q000453:epidemiology
chemical_list: D000701:Analgesics, Opioid; D055553:Prescription Drugs
keywords: Evaluation; Opioids; Overdose; Pain; Policy; Prescribing