Tuesday, December 1, 2020

Remember the Opioid Crisis?

The COVID-19 pandemic is deservedly the main public health story of our time. But spare a thought for the opioid crisis, which hasn't gone away, and has led to the deaths of about 500,000 Americans in the last two decades. Johanna Catherine Maclean, Justine Mallatt, Christopher J. Ruhm, and Kosali Simon provide an update and overview in "Economic Studies of the Opioid Crisis" (November 2020, National Bureau of Economic Research Working Paper 28067). 

As they point out, the number of deaths from the opioid epidemic is just the starting point for looking at social costs: "Data from the National Survey of Drug Use and Health (NSDUH)--the official government source for substance use statistics in the U.S.--indicate that in 2018, 1.7 million Americans met diagnostic criteria for prescription opioid use disorder (OUD) and over 500,000 for heroin-related OUD (McCance-Katz, 2018). These numbers represent a lower bound on the true prevalence of OUD as individuals are likely to under-report this condition in survey settings and since the NSDUH excludes groups likely to have disproportionately high rates of OUD (e.g., institutionalized and homeless individuals)." Indeed, the combination of deaths and diseases is the main factor causing average life expectancy among non-Hispanic whites to reverse its pattern of increases over time, and instead to start declining around the year 2000.

The authors re-tell the basic story of the opioid crisis, as I have told it here before. It's a commonly viewed as a three-stage event. The first stage from the late 1990s up to about 2010 was an explosive rise in prescription opioids: for example, sales of prescription opioids quadrupled from 1999-2014, but the share of Americans reporting that they were in pain was not rising during this time. It's common to say that this rise was driven by aggressive marketing from the pharmaceutical industry, and marketing did indeed rise. But it seems to me that health care providers also bear a substantial share of the blame for their susceptibility to that marketing. In the second stage, restrictions were imposed on prescription opioids, which then led to a rise in heroin usage. In the third stage, there has been a shift from heroin to fentanyl, which provide a much cheaper high in much less volume--and thus are easily smuggled across national borders in ordinary-looking mailed packages.  

Now that the opioid crisis has been unleashed, and has morphed from a prescription drug crisis into the heroin/fentanyl crises, what's to be done? 

There's still room for identifying physicians who are dramatically more likely to prescribe opioids, and pushing back against that behavior. One study looked at county-level data on what counties have a higher or lower share of doctors who are high-prescribers of opioids. The study also looked at people moving between counties--and whose average health status should be about the same before and after the move. It found that about 30% of the variation in opioid deaths across countries is explained by physician prescribing behavior. There's some evidence that if a state has a "prescription drug monitoring program," which is a centralized database recording all individual prescriptions, and if physicians enter the information into the database and check it before prescribing, it can make a difference in opioid-related mortality, crime, the health of newborns, and the number of children who end up in foster care. Other states have had success with pain management clinics laws," which seek to regulate "pill mills" that are prescribing especially high volumes of these drugs. 

But as noted above, the opioid crisis stopped being primarily a prescription drug issue a few years ago. In addition, steps to reduce prescriptions of opioids always run some risk of nudging users into the illegal opioid markets. Given that the past wars on other illegal drugs have not been notably successful in raising the price or reducing the quantity of illegal drugs, the main policy proposals  here involve trying other methods to protect public health from opioid abuse. 

For example, trying to assure easy access to naloxone, especially among first-line responders including police, seems to have some benefits. Another option is to make treatment cheaper and more available. The authors write (citations omitted):  

Recent estimates suggest that only one in ten individuals with OUD [opioid use disorder] receive medication for treating it in a given year, although there have been recent expansions in availability of DEA-waivered providers of buprenorphine. While there are many reasons why individuals do not receive treatment--including strong psychological barriers to treatment and stigma--commonly stated causes include inability to pay and lack of insurance coverage ...

Overuse of opioids is of course not physically contagious. But there is a sense in which it is socially contagious and also socially destructive in ways that go beyond the harms to individuals.