Medics take a woman out of a grocery store where she was found unresponsive after overdosing on opioids.
Medics take a woman out of a grocery store where she was found unresponsive after overdosing on opioids. Brian Snyder/Reuters

According to a new study, economic despair is not the primary factor driving abuse of opioids.

America’s devastating opioid epidemic is one of the biggest problems the country faces. More than 2.5 million Americans are currently addicted to powerful opioids. Drug deaths have shot up since 2010, rising some 28 percent in just the past year, with nearly 175 Americans losing their lives to opioids everyday.

One persistent narrative, backed by a good deal of expert opinion, is that the epidemic is an outgrowth of deepening economic and geographic inequality, with “deaths of despair” brought on by the lack of high-paying, family-supporting jobs for working- and middle-class Americans, who then turn to drugs to cope with the pain and distress of economic dislocation.

A recent NBER study provides new evidence that lagging economic conditions are not the primary explanation. The working paper, authored by Christopher Ruhm of the University of Virginia, argues that supply of these drugs is a more significant cause than despair itself.

To get at this, the study compares data on deaths from opioids to key indicators of local economic conditions and the availability of opioids in different places, as well as individual factors that have been shown to bear on drug deaths. It covers the decade-and-a-half from 1999 to 2015, during which America saw the tremendous run-up in opioid deaths.

The study makes use of a large-scale dataset on drug deaths based on death-certificate records from the Multiple Cause of Death (MCOD) files of the U.S. Centers for Disease Control. The data include information on overdose deaths involving both prescription and illicit opioids, as well as those due to drug poisonings, non-drug suicides, and alcoholic liver disease. To capture local economic conditions, the study looks at county-level data on income, housing prices, unemployment, poverty, and international trade. It also includes a series of control variables for a wide range of individual characteristics that bear on opioid deaths, such as race, ethnicity, gender, and education.

The rise in opioid deaths in hard-hit places in Appalachia and the Rust Belt suggests a close connection with the despair wrought by economic decline. And it is true that the counties that experienced the most dramatic economic decline between 1999 and 2015 also saw the largest increases in opioid deaths.

However, the correlation turns out to be weak once other factors are controlled for. Economic conditions explain less than 10 percent of the rise in opioid fatalities, according to the study.

Perhaps the biggest hole in the case that economic distress causes opioid abuse is the fact that the drug epidemic has starkly worsened since 2010, even as the economy recovered from the Great Recession. If economic despair really was at work, we should have seen opioid use level off as jobs were generated and the unemployment rate started to fall. But we haven’t: Opioid deaths have skyrocketed in recent years, as the chart below shows.

There was a spike in both prescription and illegal opioid deaths in 2007–2008, coincident with the economic crash and the onset of the recession. But while deaths from prescription opioids started to level off and then decline around 2010, deaths from illegal opioids shot up and far surpassed 2007–2008 levels.

(Data from NBER working paper by Christopher Ruhm. Graphic by Madison McVeigh/CityLab)

The study argues that it is the increasing availability of illegal opioids that is the main factor in the surge in drug deaths since about 2010. This, it contends, can be seen in the higher rate in fatalities among certain groups of people.

It is important to note that there are other explanations for why illicit drug use expanded around 2010. In the years prior, doctors prescribed drugs like OxyContin liberally and widely for chronic pain, particularly in Rust Belt and Southern states. Some individuals who were prescribed opioids—often simply because of severe pain—became addicted. However, as the crisis grew, regulators and medical professionals started to tighten access to these drugs. This caused a significant change in the drug environment, and played a role in changing the landscape of America’s drug deaths.

This, the change in the drug environment, is the crux of Rhum’s study. “If economic conditions are the primary driver of the fatal drug epidemic, there would be no reason to expect these shifts in the drug composition to affect the distribution of the demographic groups killed by overdoses,” the study reads. “Instead, individuals self-medicating for their ‘despair’ would simply switch to the newly more available types of drugs.”

But the report finds that there have been significant changes in who is dying from drug abuse over the studied period. As the opioid epidemic took hold, the number of drug deaths amongst younger white men skyrocketed. At the same time, groups that had previously experienced a higher rate of drug deaths started to fall. This shift to different groups would not have happened if despair were the main factor, Ruhm argues. “Put succinctly, the fatal overdose epidemic is likely to primarily reflect drug problems rather than deaths of despair.”

The charts below illustrate this, showing the huge spikes in deaths from illegal opioids among men, younger adults, and white people, starting around 2010 or 2011. The first graph shows a wide divergence between men and women in deaths from illegal opioids. While men have always died at higher rates than women, take a look at the huge gap in male versus female deaths starting around 2010.

(Data from NBER working paper by Christopher Ruhm. Graphic by Madison McVeigh/CityLab)

The second graph shows a similar pattern for adults between the ages of 20 and 39. Again, we not only see a sharp uptick of illicit opioid use around 2010, but also a growing gap between young adults and other age groups.

(Data from NBER working paper by Christopher Ruhm. Graphic by Madison McVeigh/CityLab)

The third graph shows the pattern for white people versus African Americans, Hispanics, and people of other races.

(Data from NBER working paper by Christopher Ruhm. Graphic by Madison McVeigh/CityLab)

Ultimately, the study argues, the higher death rates among these demographic groups points to the growing availability of these drugs as the main culprit of the opioid epidemic. This does not mean that economic distress does not lead individuals to use drugs. The pain that comes from job loss and economic insecurity surely takes its toll on many Americans. But the reality is that drug use has surged as the economy has recovered, while cheap illegal opioids have become more widely available. This is no longer just an inner-city problem, as it was during the heroin epidemic of the 1960s and 1970s. Today, opioid use has spread to small towns, suburbs, and rural areas.

Curtailing this deadly epidemic means acting on both the supply of these drugs and the demand for them. On the supply side, it means addressing the flow of heroin in the United States and stopping the over-prescription of opioids, which is how many people who go on to use cheaper illegal drugs get hooked to begin with. On the demand side, it means raising awareness about their use among high-risk groups and developing better treatments for opioid users.

It’s time to stop blaming the opioid epidemic on economic distress, and start focusing on curbing the availability and use of these dangerous drugs.

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