Browsing by Subject "Analgesics, Opioid"
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Item Assess Effectiveness of Opioid Prescription Policies for Acute Pain Management(2022-05-01T05:00:00.000Z) Machchhar, Arti; Reed, W. Gary; Phelps, Eleanor; Kandil, EnasBACKGROUND: In 2017, the Department of Health and Human Services (HHS) declared the Opioid Crisis a public health emergency. Regulatory agencies and institutions have adopted several guidelines to ensure opioids are prescribed appropriately. In October 2014, the DEA changed the schedule of hydrocodone combination products (HCPs) from schedule III to schedule II narcotics. This led to a substantial rise in Tylenol 3 prescriptions at the University of Texas at Southwestern Medical Center (UTSW) due to the institutional guideline that prevents residents from prescribing schedule II narcotics without documented approval from an attending physician. OBJECTIVE: We sought to evaluate whether the UTSW guideline preventing residents from prescribing schedule II narcotics serves to improve patient safety and pain management. METHODS: Prescription data and associated patient demographic data was pulled directly from the UTSW electronic medical record (EMR) for one year prior to and following the rescheduling of HCPs. Additional data was pulled for the 2019 and 2020 calendar years. The proportion of T3 and schedule II narcotic prescriptions was calculated for all time periods and stratified for age, race, provider type, and department. RESULTS: One year before the rescheduling of hydrocodone, the vast majority of prescriptions were schedule II narcotics at 98.92% and T3 was very rarely prescribed at 1.08%. In 2014 - 2015 following the rescheduling of HCPs, there was an overall decrease in opioid prescriptions and the proportion of T3 prescriptions rose to 49.94%. In 2019 and 2020, the overall number of opioid prescriptions increased to 17,297 in 2019 and 15,395 in 2020 and the proportion of T3 prescriptions decreased to 37.12% and 33.89% respectively. CONCLUSION: The rescheduling of HCPs led to the dramatic shift in Tylenol 3 prescriptions, indicating that regulatory agencies and institutional guidelines are driving prescribing habits. Tylenol 3 is being prescribed at a significant rate however, information regarding its addictive potential, metabolic effects, and potential adverse effects remains relatively unknown. The drug policies and institutional guidelines discussed disproportionately affect people of color and lower socioeconomic class.Item Decision Fatigue in Primary Care Opioid Prescribing(2020-05-01T05:00:00.000Z) Hughes, Jordan Gregory; Kandil, Enas; Reed, W. Gary; Greilich, PhilipBACKGROUND: Decision fatigue -- a psychological phenomenon describing the depletion of mental resources as one makes a series of decisions -- affects primary care physicians as they treat patients and prescribe medications throughout the course of the clinical day. This results in more inappropriate treatments being ordered as the day goes on. Because the United States faces an unprecedented epidemic of opioid abuse, we must understand the extent to which decision fatigue affects opioid prescribing, as the prescription of these drugs has been associated with both long-term use and overdose deaths. Additionally, we are unaware of the effect various national interventions to stem the tide of the opioid epidemic have had on decision fatigue in opioid prescribing. LOCAL PROBLEM: We are unaware of whether decision fatigue is playing a role in opioid prescribing, and if it is, how great the variation in prescription likelihood is throughout the clinical day in UT Southwestern's primary care clinics. The aim of this study is to measure PCPs' varying likelihoods of prescribing opioids throughout the clinical day, before and after major interventions were implemented to combat the epidemic, as this can serve as an indication of both the presence of decision fatigue and the impact of concerted interventions. METHODS: We used the years 2014 and 2017 to represent the pre- and post-intervention periods for study, as many major interventions to combat the opioid epidemic took place in 2016. Next, we analyzed the percentage of appointments in which opioids were prescribed in each hour of physicians' clinical days, at three exclusively primary care clinics at UT Southwestern. Scheduled appointment times were used as substitutes for visit times. We then excluded patients with cancer and those who had surgery within six weeks of an appointment, in order to minimize the number of appointments in which opioids may be prescribed by clear clinical indication. Finally, we employed logistic regression analysis to determine the predictive relationship between appointment time and opioid prescriptions, using physicians' prescription rates in their first clinic hour as the reference for calculating hourly odds ratios in each year. INTERVENTIONS: New legislation, updated healthcare guidelines, and national media coverage in 2016, including: the CDC's "Guideline for Prescribing Opioids for Chronic Pain—United States", the FDA's "General Principles for Evaluating the Abuse Deterrence of Generic Solid Oral Opioid Drug Products: Guidance for Industry, 2016", the Comprehensive Addiction and Recovery Act of 2016, the Surgeon General's call to providers to end the opioid crisis, and the opioid crisis becoming top health news story of 2016. RESULTS: 34,972 clinic visits in 2014 and 42,313 clinic visits in 2017 met our inclusion criteria. In 2014, patients were prescribed an opioid at 5.34% of all primary care appointments, while in 2017, they were prescribed at a rate of 4.34% (2014 vs 2017 OR=1.290; 95% CI, 1.217-1.367). While the overall rates of opioids decreased from 2014 to 2017, the hourly likelihoods of patients being prescribed opioids steadily increased throughout the clinical day in both years (p<0.01 in 2014 and 2017). In fact, each year had hours in which physicians' opioid prescription odds ratio was over 1.6, when compared to their first clinical hour. DISCUSSION: While there was a significant decrease in the overall likelihood of being prescribed opioids in 2017 compared to 2014, the variation in hourly prescription likelihoods is similar in both years. The results show that while interventions to combat the opioid epidemic were successful in reducing the overall amount of opioids prescribed, they had minimal impact on the effect of decision fatigue. Clinical decision support tools, integrated into the electronic medical record, have been proven to reduce the clinical variation that indicates the presence of decision fatigue. In light of this, this project should be continued, and decision fatigue measured, after implementation of such tools.Item Delivery Continuity and Neonatal Disposition to Birthing Parent in Individuals with Substance Use Disorder at Parkland Health(2024-01-30) Afsari, Macy; White, Alesha; Morillos, Stephanie; Fisher, Amber; McNeil, Jessica; Faucher, Mary Ann; Cordova, Polly; Onisko, Nancy S.; Andino, Aldo; Kern, Joshua; Kleinschmidt, Kurt; McIntire, Donald D.; Adhikari, Emily H.OBJECTIVE: Infants born to individuals with substance use disorder (SUD) are at increased risk of removal from their parent. Individuals with SUD in pregnancy receive obstetric care by a multidisciplinary care team (MCT) at our safety-net hospital. We evaluated factors associated with delivery continuity and neonatal discharge to birthing parent among patients with SUD. STUDY DESIGN: This is a retrospective cohort study of pregnant patients with SUD who accessed Parkland Health (PHHS) between July 28, 2021 and June 25, 2022. We compared MCT interactions among patients who did and did not deliver at PHHS as well as neonatal disposition and outcomes for infants born to individuals with SUD and with specifically opioid use disorder (OUD). RESULTS: Among 256 pregnant individuals with SUD who accessed care in our system, 144 (56%) received care by our MCT during pregnancy or at the delivery hospitalization. 98 of these patients delivered at PHHS and 46 delivered elsewhere (68% vs 32%, p<0.001). Significantly more eligible individuals who delivered at PHHS accepted medication-assisted treatment (MAT) compared to those who did not (88% vs 70%, p=0.025). Of 139 patients with SUD who delivered at PHHS, 91 (65%) infants were discharged home with the birthing parent. Parents who went home with their infants were more likely to use cannabis (33% vs 4%, p<0.001) and less likely to use opioids (34% vs 63%, p=0.003). They attended more prenatal visits (median [IQR] 9 [5,11] vs 1 [0,4], p<0.001) and met less frequently with our multidisciplinary team providing integrated SUD treatment (1 [0,10] vs 4 [1, 14.5], p=0.026). Neonates discharged with the birthing parent were less likely to have a positive meconium (7% vs 75%, p<0.001) or urine toxicology (2% vs 67%, p<0.001) and were less likely to have a 5-minute Apgar <4 (0% vs 4%, p=0.04). Of 62 patients with OUD, 31 (50%) were discharged with their neonate. Those who used opioids alone were more likely than individuals with opioid-polysubstance misuse to retain charge of their infant (78% vs 43%, p=0.018). CONCLUSION: Increased interactions and MAT with a team specializing in care of pregnant patients with SUD is associated with delivery continuity. Neonatal disposition and outcomes are influenced more by maternal drug of choice and prenatal care attendance than by MCT interactions because of variance in SUD complexity. Opioid-polysubstance misuse is associated with separation of maternal infant dyad.Item Ice-POP: Ice Application for Post-Operative Pain: A Randomized Controlled Trial(2021-05-01T05:00:00.000Z) Kenyon, Laura Elizabeth; Kho, Kimberly A.; Shields, Jessica; Weix, PatrickBACKGROUND: The Opioid Crisis is directly linked to over-prescription of opioids by physicians. Non-opioid and non-pharmacologic forms of post-operative pain management need to be explored. Cryotherapy, accomplished with the use of ice, is a non-pharmacologic form of pain relief. There is limited data regarding cryotherapy and its application in abdominal surgery. OBJECTIVE: To investigate the effectiveness of cryotherapy as an additional form of pain control in women undergoing total laparoscopic hysterectomy (TLH) for benign gynecologic conditions through a randomized trial. METHODS: 52 patients were randomized evenly to receive standardized post-operative pain management with or without cryotherapy (abdominal ice packs applied directly following surgery). VAS pain scores and narcotic usage were collected at the patient's pre-op appointment, before surgery, at discharge, during a 1-day post-op phone interview, and at a 2-week post-op appointment. Questions about the patient's perception of pain were asked during the postoperative day 1 phone call. Quality of recovery scales were collected at enrollment and the 2-week post-op appointment. Demographic data, VAS pain scores, and narcotic usage were analyzed for significance via the student's t-test. RESULTS: There was no statistically significant difference (p < 0.05) between the patient group receiving ice and no ice based on demographics, VAS pain score, narcotic usage, quality of recovery, and perception of pain control. However, for patients using ice, VAS pain scores were lower on postoperative day 1 and narcotic usage was lower in the post-anesthesia care unit (PACU). Patient perception of ice was largely positive with 87% of patients reporting they would use ice again while 83% would recommend ice to family/friends. Of note, less than half (38%) of opioids prescribed were used within 2 weeks post-op. CONCLUSION: Based on the minimal risks of ice, low cost, and perceived benefit by patients including the opportunity for patient autonomy, we would recommend using ice immediately following surgery. Ice is a reasonable alternative to decrease the number of opiates prescribed.Item Improving Adherence to Opioid Prescribing CDC Guidelines for Chronic Pain(2021-05-01T05:00:00.000Z) Zamir, Aemen; Reed, W. Gary; Kandil, Enas; Phelps, EleanorBACKGROUND: The Centers for Disease Control and Prevention have released treatment guidelines for chronic pain care as concerns about opioid overuse and abuse increase. Additionally, The Texas Medical Board has outlined their policy for the use of medication for non-malignant chronic pain purposes in Rule 170.3 of the Texas Administrative Code. Some of the requirements include a signed pain management agreement, regular review of the Prescription Monitoring Program, a urine drug screen, and documentation of completion of requirements in patient's medical records. OBJECTIVE: Establish baseline adherence to TMB policy for opioid prescribing and implement electronic medical record tools to facilitate completion of requirements METHODS: A preliminary chart review of patients on the opioid registry, an intervention in early phase of implementation meant to easily identify patients receiving opioids for chronic pain, was conducted to determine baseline adherence to Rule 170.3 amongst physicians. Several CDC guidelines which corresponded with TMB requirements were chosen. Post-intervention data was collected from the chronic opioid registry regarding the percentage of patients who had annual review of Prescription Monitoring Database, a urine drug screen, a pain management agreement, and documentation of completion of requirements in patient's medical records. RESULTS: Of the 206 patients studied through chart review pre-intervention, only 6% had all three TMB mandated elements in their charts. After implementing the EMR tools meant to facilitate completion of TMB laws and CDC guidelines, the percentage of patients with a urine drug screen and review of PDMP increased while the percentage of patients with a pain management agreement in their chart decreased. CONCLUSION: Poor compliance in the UTSW system necessitates tools that will streamline the process for completing and documenting the requirements. The implementation of the EHR tools and the opioid registry best practice alerts, as they were rolled out by the Opioid Task Force, helped facilitate completion of requirements.Item [News](1987-11-20) Adell, DianeItem Opioid Treatment for Chronic Pain and Interdisciplinary Care(2015-08-31) Warrington, Lacy Kay; Robinson, Richard C.; Noe, Carl; Gatchel, Robert J.BACKGROUND: The amount of individuals suffering from chronic pain (3 months or more) is growing. Along with this growth, the amount of money spent on medical treatment of chronic pain with or without relief is growing. A major issue that stems from this is the misuse and abuse of prescription opioid medication. This brings a massive loss of productivity and quality of life. SUBJECTS: Patients included in the current study suffer from chronic pain, are at least 18 years of age, and are capable of providing informed consent, and reading and speaking English. EMCPM provides an interdisciplinary program including; cognitive-behavioral therapy, group cognitive-behavioral therapy focusing on psychoeducation, and physical therapy. Patients receive 8 sessions of individual CBT, group CBT, and physical therapy throughout the program. Patients receive these sessions twice a week throughout the 4 week program. METHOD: This study used outcomes that measure ratings of pain; pain, pain interference, depression, anxiety, sleep disturbance, sleep related impairment, satisfaction with participation in discretionary social activities, satisfaction with social roles and activities, and global health. Opioid status was determined as “no,” “decreased,” or “same” for each patient after oral morphine equivalents were calculated at baseline and monitored throughout the 4-week program. One-way within-subjects ANOVAs were conducted for each opioid status as the factor and the outcome measure T scores as the dependent variable. If significant, polynomial contrasts were used to determine linear effects. One-way within-subjects ANCOVAs were then conducted for each opioid status as the factor, outcome measure T scores as the dependent variable and pre-program outcome measure T scores as the covariate to control for pre-morbid dysfunction. If significant, polynomial contrasts were used to determine linear effects. Finally, three Pearson correlations were run between percent change of outcome measure T scores and pre-, post-, and percent change in morphine equivalents. RESULTS: Overall, individuals with chronic pain who participated in a four-week interdisciplinary pain program maximized their results by maintaining no or low opioid dosage, or by decreasing moderate-high opioid doses throughout the program, as expected. Individuals who entered the interdisciplinary pain program with no opioid use showed significantly more improvement (p<.01) than those with initial opioid use over the course of the program on several outcome measures; pain (composite pain rating and pain interference), depression, anxiety, social satisfaction (satisfaction with participation in discretionary social activities and satisfaction with social roles and activities), and global health. Significant (p<.01) linear effects were also found on all previously mentioned outcome measures. Anxiety levels showed significantly more improvement (p<.01) over the course of the pain program only when a control for pre-morbid anxiety was added. A significant (p<.01) linear effect was also found. Individuals who entered the interdisciplinary pain program using opioid medication and decreased the dosage of opioid medication over the course of the program reported significantly more improvement (p<.01) in pain (both composite pain rating and pain interference) and social satisfaction (satisfaction with participation in discretionary social activities only when controlled for pre-morbid social satisfaction with participation in discretionary social activities) when compared with participants who maintained initial opioid dosage. Significant (p<.01) linear effects were found on all three outcome measures. Individuals who maintained a low opioid dosage over the course of the interdisciplinary pain program reported significantly more improvement (p<.01) on; pain (composite pain rating and pain interference), anxiety, sleep (sleep-related impairment only), social satisfaction (satisfaction with participation in discretionary social activities and satisfaction with social roles and activities), and global health. Significant (p<.01) linear effects were found on all of the above measures except pain related impairment. Weak Pearson correlations (r=22) between pre-morphine equivalent and percent change in sleep-related impairment was found. This was again found between post-morphine equivalent and percent change in sleep-related impairment (r=29), as well as a weak negative correlation with pain interference (r=-.28). More research is indicated to determine the relationship between these correlations. Pearson correlations between percent change in morphine equivalent and percent change in outcome measure T scores did not yield any significant (r>.29) correlations.Item Outcomes of an Interdisciplinary Pain Management Program: Does Participants' Opioid Status Predict Improvement?(2014-09-01) Harding, Megan Rose; Gatchel, Robert J.; Robinson, Richard C.; Noe, CarlBACKGROUND: Chronic pain is a prevalent and costly illness that affects 1 in 5 Americans. Interdisciplinary pain management programs have demonstrated cost-effectiveness and significant benefits for a variety of chronic pain conditions. Interdisciplinary programs combined with opioid cessation have also demonstrated effectiveness for patients with chronic pain despite tapering opioid dosage. SUBJECTS: 41 participants who completed a 4-week interdisciplinary pain management program were included in this study. METHOD: Participants completed measures of pain rating, pain interference, and anxiety at admission and discharge. Oral morphine equivalents were calculated based on a chart review of program completers. Participants were divided into three groups based on opioid status throughout the program (no opioid, decreased opioid, and same opioid). RESULTS: Participants with a no opioid status significantly improved on pain rating and pain interference scores from admission to discharge (p < .01). Participants with a decreased opioid status significantly improved on pain rating scores (p < .05) but not on pain interference scores from admission to discharge. Participants with a same opioid status did not significantly improve on either pain rating or pain interference scores from admission to discharge. Additionally, a participant status of “same opioid” was a significant predictor of post-pain interference scores where participants in this group could expect to have 5.46 T-score points higher at discharge. Additionally, younger participants were predicted to have higher post-pain interference scores. DISCUSSION: Participants who had a no opioid or decreased opioid status throughout the program fared better than those who chose to remain on the same opioid dose. These findings indicate that prescription pain relievers may not have the desired effect for patients with chronic pain seeking interdisciplinary treatment. Future research on the impact of prescription pain relievers on potential benefits of an interdisciplinary pain management program is needed.Item Simple Measures to Reduce Opioid Prescriptions Following Pediatric Spinal Fusion Surgery: A Multidisciplinary Quality Improvement Project(2022-02-01) Winsauer, Andrew; Charu, Sharma; Bukowsky, Stacie; Greenberg, Sandi; Birch, Craig; Ramo, BrandonBACKGROUND: The opioid epidemic is one of the biggest challenges facing modern healthcare. Among the adolescent and young adult populations opioid overdose is one of the leading causes of death. LOCAL PROBLEM: Within pediatric orthopaedics, spinal fusion is a common procedure making up 7% of the surgical volume at our institution. Spinal fusion also has high postoperative opioid prescribing rates. Review of baseline data showed that there was wide variability in prescribing habits. The goal of this quality initiative was to reduce and standardize post-operative opioid prescribing following spinal fusion procedures. METHODS: Data, including opiate-prescribing habits and a patient survey to assess patient and parent satisfaction with pain control, was collected retrospectively in the pre-intervention phase for 99 consecutive Adolescent and Juvenile Idiopathic Scoliosis patients undergoing spinal fusion surgery. This was followed with 2 PDSA cycles following implementation of a new protocol during which prospective surveys were administered to a total of 273 patients. Physician prescribing data was collected for 150 patients during the sustain phase. INTERVENTIONS: A multi-pronged approached was utilized consisting of the following aspects: 1) Instruction to orthopaedic trainees to limit opioid prescriptions to 45 and 40 for PDSA cycles 1 and 2, respectively. 2) A pharmacy-led education program with an opioid tapering handout given to families and encouragement of usage of non-opioid pain control. 3) A call to the prescribing physician from pharmacy if the prescribed dosage was greater than the maximum allowed. RESULTS: There was a significant reduction in opioid prescriptions from a preintervention mean of 48.5 doses to a PDSA 1 mean of 39.0, PDSA 2 mean of 37.5, and a sustain phase mean of 36.4 (p=0.000). This represented an estimated reduction of 22.8% over the course of the study. During this time, there was no significant change in patient and parent reported postoperative pain. CONCLUSIONS: Through simple measures, our institution was able to significantly reduce total opioid prescriptions following spinal fusion surgeries while maintaining good pain control.Item Substance use in pregnancy: impacts of state policies on maternal and child outcomes(2023-05-09) Faherty, Laura J.The opioid crisis has had a substantial effect on pregnant women, with the number of pregnant women with an opioid use disorder diagnosis at delivery quadrupling from 1999 to 2014, and the incidence of neonatal opioid withdrawal syndrome increasing nearly seven fold from 2000 to 2014. The speaker, a clinician-researcher with extensive experience for this population, will discuss (1) the evolution of state policies related to substance use in pregnancy over the past two decades, (2) her research on the effects of these policies on the mother-infant dyad, (3) the rapidly-growing evidence base on the harmful impacts of punitive policies towards substance use in pregnancy, and (4) future research directions and opportunities to improve care for maternal-infant dyads affected by opioid use in the perinatal period.Item Understanding Institutional Physician Chronic Opioid Prescription Practices for the Improved Implementation of Newly Developed EMR Tools(2021-03-12) Gagrani, Sonal; Reed, W. Gary; Phelps, Eleanor; Kandil, EnasBACKGROUND: Chronic non-cancer pain (CNCP) affects a significant portion of the United States population each year and is often treated with chronic opioids. There has been a rise in prescription opioids over the past 20 years, accompanied by a rise in overdose deaths as well. In order to improve patient safety related to opioid prescribing, several state and national policies including the 2016 "CDC Guidelines for Prescribing Opioids for Chronic Pain" have been developed recently to guide CNCP management. These recommendations include the use of pain management agreements, urine drug screening, prescription monitoring programs (PMP) and risk and pain assessments among others. LOCAL PROBLEM: In Texas, several recent policies have made CNCP practices mandatory, requiring support in order to enforce them. At the University of Texas Southwestern Medical Center (UTSW), there is no current reliable measure of CNCP policy adherence. Preliminary chart review by students at our institution showed low adherence overall, which may be secondary to poor documentation. METHODS: A set of surveys were developed to subjectively measure physician barriers to policy adherence, attitudes toward the policy components and current opioid prescribing practices. This survey was administered via electronic communication before and after the intervention to any physician at our academic medical center prescribing chronic opioids to at least one patient. Implementation science outcomes of appropriateness, adoption and acceptability were targeted by these surveys in order to inform implementation strategies for the intervention. INTERVENTIONS: A multi-faceted intervention including an electronic medical record (EMR) navigator tool, chronic opioids registry and physician education was developed by the institutional opioid task force to improve accessibility, documentation and understanding of opioid prescribing guideline recommendations. RESULTS: Physicians who had used the EMR navigator tool reported overall greater use of several guideline-concordant treatment components compared to those who had not used it (p < .05). Physicians who received opioid prescribing training were more aware and familiar with the policy (p < .0001). Those who were more familiar with the policy were more likely to use pain management agreements, urine drug screens and pain assessments. No specific barriers to policy adherence stood out as a remediable concern. Only a small percentage of respondents reported co-prescribing naloxone for high-risk CNCP individuals. CONCLUSION: An EMR navigator tool to improve accessibility of treatment components is effective in improving policy adherence at an academic medical center. Physician education is also effective in improving awareness and familiarity with the policy. Future steps include the study of patient-centered outcomes surrounding the intervention. There is also room for the support of other CNCP guidelines including co-prescription of naloxone for high-risk individuals and decreasing chronic opioid prescription strengths at our institution.Item Using the Electronic Medical Record to Ensure Compliance with Opioid Prescription Laws in Texas(2019-03-28) Bender, Christopher McLean; Reed, W. Gary; Kandil, Enas; Fish, JasonBACKGROUND: The American population currently finds itself in the midst of a prescription drug overdose epidemic. This crisis has been fueled by an overreliance on opioid medications for the treatment of chronic pain. The state of Texas medical board (TMB) enacted a law change that restricts and regulates the prescribing and dispensing of controlled substances with respect to patients experiencing chronic pain. LOCAL PROBLEM: At the onset of this project, the University of Texas Southwestern (UTSW) system had no comprehensive measures in place to ensure compliance with these rules, and the current state of compliance was unknown. METHODS: Three clinics were chosen for observation to help understand the process of opioid prescribing for chronic pain treatment and the steps necessary to comply with the new law. Multiple Plan, Do, Study, Act (PDSA) cycles were applied to the process of baseline data measurement culminating in a final estimate of 3.1% ± 0.4% of applicable patient records written by UTSW providers in compliance with the law. INTERVENTIONS: Tools in the electronic medical record system (EMR) for tracking the use of scheduled medications in the treatment of chronic pain as well as for ensuring compliance with the new law have been developed and are in the process of implementation at the clinics with the largest populations of opioid-prescribed chronic pain patients. RESULTS: A chronic opioid registry was created, containing about 200 patients. Data retrieval is in process to determine the current rate of compliance. CONCLUSION: This project has successfully created a registry of the patients at UTSW on chronic opioid therapy and built an EMR structure that will ensure that these patients are cared for in a fashion compliant with TMB laws.