As states pass regulations to curb opioid abuse, what are the consequences for legitimate pain management? Between 1999 and 2010, sales of opioid analgesics (e.g., OxyContin, morphine) increased by more than 300%, and opioid overdose deaths rose 265% for men and 415% for women. Federal and state authorities have responded with a variety of policy changes to address the abuse and diversion of prescription painkillers. Most notably at the state level, there has been widespread adoption of prescription drug monitoring programs (PDMP). These electronic registries keep records of prescriptions filled for controlled substances, allowing states to track quantities of prescriptions filled by individuals or issued by prescribers and detect behavior that might be inappropriate. Several studies have estimated the impact of state PDMPs in opioid sales, abuse, and overdoses. However, no study addresses an equally important question—how do policies designed to curb opioid use affect medically appropriate pain management for people suffering from severe or chronic pain? Opioid painkillers are considered essential for pain management in many individuals, some of whom are vulnerable and facing severe disability or terminal disease. The possibility that policies are restricting legitimate analgesia is an important consideration that needs addressing.

We use 2003-2010 home health agency-level panel data from the Centers for Medicare and Medicaid Services’ Home Health Compare to assess the effect of state opioid policies on pain improvements in Medicare home health patients. We approach the question with two fixed effects models. The first estimates pain improvements as a result of whether a state has implemented a PDMP. The second model uses state grades produced by the University of Wisconsin’s Pain & Policy Studies Group that measure the extent to which state policies achieve balance between ensuring legitimate access to analgesics and restricting inappropriate abuse. We control for endogeneity between state policies and pain management practices with two-stage least squares models using instruments related to exogenous state characteristics that predict the adoption of state policies. While intuition might suggest that tighter restrictions on opioids would lead to more incidents of pain in patients and that states with more balanced policies would produce better pain management results, our results indicate the opposite conclusion. We find a significant positive relationship between pain improvements and a state having an operational PDMP and a significant negative relationship between a higher grade for balance and pain improvements. Our findings suggest that home health agencies are adapting their models of care to state opioid policies. The results are consistent with the hypothesis that when opioid policies are more restrictive, agencies are substituting away from easier and cheaper pain management strategies (i.e., administering opioids) to more comprehensive and effective but more expensive strategies that incorporate therapies and other non-pharmaceutical approaches to pain management. This study provides an important initial look at the effect of state opioid policies on health. Not only are more restrictions not impeding effective pain management, at least in the area of home health care, they appear to improve pain outcomes.