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On Balance: Evaluating Policy Responses to the Opioid Epidemic

June 10, 2020
By: Clayton Masterman

More than 450,000 Americans died of an opioid overdose between 1999 and 2018. There were fifteen fatal opioid overdoses for every 100,000 individuals in 2018, a ratio five times greater than in 1999. While public health researchers and policymakers have rightly turned their attention toward remedying the global coronavirus pandemic, the U.S. opioid epidemic continues to take lives. In my dissertation, An Empirical Analysis of Policy Responses to the Opioid Epidemic, I analyzed the effect of various state and federal interventions to reduce opioid abuse and overdoses. This analysis can contribute to the benefit-cost analysis of policies that aim to decrease opioid consumption and overdose deaths.

State responses to the opioid epidemic have taken a variety of forms. Among the most controversial have been naloxone access laws, which make it easier for individuals to acquire the drug that reverses an ongoing opioid overdose. From 2006 to 2016, most states enacted one or more different laws to make naloxone accessible to opioid users and others so that they can administer it to individuals experiencing an overdose. Laws that let individuals purchase naloxone directly from a pharmacist without a patient-specific prescription from another healthcare provider decrease overdose deaths by about ten percent. Three thousand fewer fatal overdoses would occur annually if every state enacted such laws (relative to a world in which no states have such laws). Using a VSL of $10 million, those lives saved amount to approximately $300 billion in monetized benefits between 2006 and 2016. In contrast, laws that immunize prescribers, pharmacists, or naloxone administrators from civil or criminal liability arising out of naloxone provision or administration had no statistically significant effect on overdose deaths. The benefits of naloxone access laws were concentrated in white users, heroin overdoses, and urban areas. Accordingly, the results indicate that making naloxone even more widely available, particularly as an over-the-counter medication, would save a significant number of lives.

At the federal level, the FDA has taken the lead in regulatory responses to the epidemic. In April 2014, the FDA required opioid manufacturers to place a boxed warning on the labels of all extended release opioids. The new label warned prescribers that extended release opioids expose users to a risk of abuse and death. It highlighted particular risks for pregnant women and children and instructed prescribers to evaluate repeat users for signs of abuse. Comparing opioid prescription rates to repeat and first-time users before and after the introduction of the warning reveals that the warning decreased opioid prescriptions to repeat opioid users by 30%. The warning did not affect prescriptions to pregnant women, children, or individuals with a higher predicted risk of fatal opioid overdose. It also decreased the number of days of opioids in the average prescription and increased the probability that repeat users received a nonopioid pain medication. Informing prescribers about the risks of opioids was modestly successful. But the disparity in effects between repeat users and individuals with relatively higher predicted fatal overdose risk suggest that prescribers use repeat opioid use as a heuristic for actual risk. Accordingly, disseminating information as a fatality reduction strategy will be of limited use when actual overdose risk is not easily observable, such as for individuals who use both prescription and illicit opioids.

Though the FDA has taken the lead in regulatory responses to the opioid epidemic, other regulatory agencies may be able to take complementary steps. For example, labor market interventions could be appropriate given the frequency with which individuals receive opioid prescriptions for workplace injuries. Restricted access Vital Statistics data demonstrate that counties with higher workplace fatalities also have higher opioid overdoses. The association is largest in rural and suburban counties with higher-than-average prescription opioid overdose rates. Using state-level opioid policies as an instrument for opioid overdose rates, reveals that opioid abuse (as measured by fatal overdose rates) increases on-the-job fatal injuries. Conversely, using neighboring county’s worker fatality rates as an instrument for a county’s own worker fatality rate provides no evidence that acute injuries lead to more opioid overdose fatalities. Jointly, the instrumental variable results indicate that opioid abuse caused approximately 3,000 workplace fatalities between 2006 and 2016. Using a VSL of $10 million, these fatalities increased the social costs of the opioid epidemic by roughly $30 billion. This research not only demonstrates that fatal worker injuries have gone uncounted as a part of the opioid epidemic, but also that interventions that reduce opioid abuse at work could reduce those fatalities.

In short, I found strong evidence that interventions at state and federal levels have been effective at combatting opioid overdose, but more can still be done. The significant benefits of naloxone access laws—and the low costs of enacting them—indicate that federal action maximizing the drug’s availability would be beneficial. Warnings that highlight risks can decrease opioid abuse but may not affect fatality rates when overdose risk is hard for prescribers to observe. Moreover, such warnings impose costs on repeat users who may not abuse opioids. Finally, the positive association between fatal overdose rates and on-the-job injuries further suggest that labor market interventions to decrease opioid abuse will decrease on-the-job fatalities.

Clayton Masterman holds a JD and a PhD in law and economics from Vanderbilt University and is the 2020 SBCA Dissertation Award Winner.
06/11/2020 7:08pm
The association between opioid abuse and work fatalities is great new knowledge. There are so many additional secondary impacts that could be enumerated. One in particular would be domestic violence.
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