To Combat the Opioid Epidemic, We Must Be Honest About All Its Causes
Published October 26, 2017, in the Harvard Business Review. Reposted with permission.
The opioid epidemic is a source of deep national anguish in the United States: It now kills almost 100 Americans each day, more than motor vehicle accidents. President Donald Trump today officially declared the epidemic a national public health emergency. Although he hasn’t allocated any additional federal funding to address the crisis, the announcement could accelerate efforts at the federal, state, and local levels to identify and implement ways to combat it. As his administration strives to galvanize efforts, it would benefit from drawing on the growing body of research that examines the medical and economic origins and effects of the crisis.
Every part of the country is battling opioid addiction, but the worst-hit states include Ohio, West Virginia, and New Hampshire. The most recent definitive data on the prevalence of the problem comes from the National Survey on Drug Abuse and Health, which surveyed 51,200 Americans in 2015. Based on weighted estimates, 92 million, or 37.8%, of American adults used prescription opioids the prior year (2014); 11.5 million, or 4.7%, misused them; and 1.9 million, or 0.8%, had a use disorder. The epidemic is spreading so rapidly that it’s likely the numbers are higher now.
By comparison, there are 17.1 million heavy alcohol users among adults over 18, according to the 2015 survey. But the opioid epidemic’s rapid rise, lethality, and protean effects on American society have galvanized the nation.
It’s likely that there are multiple causes of the problem. Doctors have played their part. “We started it,” author and surgeon Atul Gawande told Vox’s Sarah Kliff in an interview in September. Gawande acknowledged that in an effort to better treat pain in the mid-1990s, doctors overprescribed opioids without adequate attention to the consequences. Many experts at the time contended that pain had previously been undertreated in routine medical practice.
Pharmaceutical companies have also been implicated. Several investigations have established that drug makers fueled the epidemic to increase their own sales. In September, Senator Claire MacAskill of Missouri released the first findings of her inquiry into opioid manufacturers and distributors, reporting that one company, Insys, “repeatedly employed aggressive and likely illegal techniques to boost prescriptions.”
The role of health insurers has received less attention, but recent scrutiny has highlighted insurers’ practice of providing easy access to opioids while limiting access to less-addictive, more-expensive pain medication and addiction treatment, according to analysis from the New York Times and ProPublica.
In addition, socioeconomic forces play a powerful part in the epidemic. Unemployment, lack of health insurance, and poverty are all associated with a higher prevalence of prescription opioid misuse and use disorders among adults.
Of course, these financial disadvantages could be consequences, not causes, of the epidemic, but it seems plausible that hopelessness and social trauma are to blame in part. The geographic distribution of opioid misuse is revealing: Areas of social dislocation, such as poor and densely populated parts of cities, and Appalachia, have some of the highest rates of addiction. Racial and ethnic minorities in urban areas have historically struggled with economic hardship and high rates of drug use. But since the 1970s rural communities have been affected by a sharp decline in manufacturing jobs. This led to high rates of unemployment, financial insecurity, and few options for upward mobility, setting the stage for increased substance use, including opioids.
The soaring death rates from opiate abuse have led to an increase in the mortality rate among working-age white Americans. History offers only one other recent example of a large industrialized country where mortality rates rose over an extended period among working-age white adults: Russia in the decades before and after the Soviet Union’s collapse. The economic and social contexts have been eerily similar, and substance abuse has been a dominant factor in both countries: alcohol in Russia, opiates in the United States. The Russian experience, like the American one, was fueled in part by social dislocation as the Soviet Union’s economy collapsed and Russian workers experienced a dramatic loss in financial security.
Researchers estimate the economic cost of the U.S. opioid epidemic may be as high as $80 billion a year, even excluding the economic value of a lost life. For those living with addiction, it’s very difficult to maintain regular employment: Nearly one-third of prime-working-age men who are not in the labor force take prescription pain medication on a daily basis, Princeton economist Alan B. Krueger found in 2016.
Building on this research, Krueger recently estimated that opioids could account for about 20% of the decline in labor-force participation from 1999 to 2015. This reduction in the proportion of working-age Americans who are employed is alarming. Krueger’s evidence: Participation in the labor force fell more in counties where relatively more opioid medication is prescribed. While this research isn’t definitive, the connection between opioids and economic productivity is certainly suggestive.
Whether opioid addiction is the cause or the result of widespread economic dislocation in America may be academic at this point. As Krueger points out, “Regardless of the direction of causality, the opioid crisis and depressed labor force participation are now intertwined in many parts of the U.S.”
Countering the epidemic requires a multipronged approach. Making addiction treatment more widely available is one first step. Many insurers don’t cover treatment, and many individuals struggling with addiction lack insurance. In most states, Medicaid covers less than half the cost of treatment medication, but Harvard researchers found that states that expanded Medicaid and actively promoted naloxone experienced greater reductions in opioid-related deaths than states that didn’t.
In addition to treatment for addiction, doctors need to rethink how they treat pain — and should more actively use prescription drug monitoring programs to identify suspicious patterns of opioid use — and insurers need to cover effective non-opioid pain remedies. For the uninsured, further expanding coverage through the Affordable Care Act could help increase access to preventive care for illness, partially eliminating the need for painkillers. In the end, however, addiction — to opioids and their more common cousin alcohol — may reflect deep-seated social and economic ailments that will never fully yield to medical remedies. Naloxone and drug rehab will never treat joblessness, poverty, lack of economic opportunity, and the hopelessness that results. That will require economic, not addiction, rehabilitation.