The True Cause of the Opioid Epidemic

New research supports the idea that economic distress led to an increase in opioid abuse. But some say the origins of the epidemic are far more complicated.

Signs are displayed downtown in the struggling city of Williamsport, which has recently seen an epidemic of opioid use among its population on July 13, 2017 in Williamsport, Pennsylvania. With a population just over 29,000, Williamsport has a poverty rate of over 27%. As cities across the nation continue to cope with an epidemic of opioid use, often in areas with few employment prospects, Williamsport recently experienced 36 heroin overdoses in a 24 hour period.
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In 2015, Jennifer Silva, a professor of sociology and anthropology at Bucknell University, began interviewing people in the coal region of northeastern Pennsylvania. She was working on a project, which would become the book We’re Still Here, about how poor and working-class Americans were affected by the collapse of the coal industry—the major job provider in the region.

She was curious how the regional decline might have shaped her subjects’ politics. But she quickly noticed a startling trend alongside the growing unemployment: Her subjects and their families were struggling with opioid abuse. At community meetings, doctors and coroners would debate solutions to the problem. Should they be arresting people? Should they be creating support groups? She describes one desperate parent who asked whether Donald Trump’s proposed border wall would keep black tar heroin from getting to Pennsylvania.

Silva’s interviewees might have been representative of an awful connection between job loss and opioid abuse, a connection that continues to be bolstered by research. A study published on Monday in the journal JAMA found that counties with automotive assembly plants that closed had, five years after the closure, 85 percent higher rates of opioid-overdose mortality, relative to counties where automotive assembly plants remained open.

While the study authors can’t say that it was the laid-off autoworkers, specifically, who died of overdoses, the findings gave the researchers the sense that declining economic opportunities are a big part of what drove the opioid epidemic. After all, there are a number of potential connections between joblessness and addiction, says Atheendar S. Venkataramani, an assistant professor of health policy at the University of Pennsylvania and the lead author of the study. Losing a job might mean losing access to health insurance. It could lead to isolation and loneliness, or a sense that there’s little left to live for. “If you feel like the American dream is no longer accessible,” Venkataramani says, “then one may also feel that, Well, it’s not really worth investing in myself ... because investing in yourself is one way to access the fruits of the American dream.

Venkataramani’s study can be read as yet another sign that Americans are dying “deaths of despair”—that the reason the life expectancies of poor Americans are stagnating or declining is that their dwindling economic opportunities spur them toward drugs, alcohol, and suicide. Many other studies have also found connections between different types of job loss and different types of drug abuse. One 2017 paper, which I wrote about at the time, found that with each percentage-point increase in the unemployment rate, the death rate from opioids rises by 3.6 percent. Another found that economic downturns that lower housing prices, such as the Great Recession, are associated with more opioid-related deaths. A meta-analysis published in the International Journal of Drug Policy examined 28 studies published from 1990 to 2015 in 12 different countries and found that both economic recessions and individual unemployment increases illegal drug use of various kinds. And late last year, another paper found that a rise in manufacturing-related job loss corresponded with an increase in opioid-related deaths.

The authors of these studies tend to speculate that as people lose their jobs, they grow depressed, and they turn to opioids to cope. Opioids can, for some people, provide a soothing, antidepressive effect in addition to pain relief.

A social problem that has, since 1999, killed more than 700,000 Americans—about the population of Boston—has more than one cause. Rich people die from opioids, and so do college kids. In fact, these unemployment studies are tempting precisely because they provide an easy explanation for why so many people became opioid addicts all at once. Job loss is terrible—of course it could make you do something terrible. It’s harder to explain addiction that strikes you down in your prime.

In fact, some researchers say widespread job loss is far from the only—or even the main—force that inflamed the opioid epidemic. That argument, they say, might let Big Pharma off the hook too easily.

Keith Humphreys, a professor of mental health policy at Stanford, told me the car-plant-closure study had “a plausible hypothesis,” but was “flawed.” Humphreys told me the paper should have measured the supply of opioids in the counties where the automotive plants were. It should have had a “negative control,” he said—a measure of the change in something generally thought unrelated to job loss, such as the rate of Alzheimer’s diagnoses, to be sure it was picking up distress-related opioid use. Humphreys also said Venkataramani and his co-authors should have examined alcohol and suicides—two other factors that often go with opioids when it comes to the health consequences of economic despair. I don’t think this [study] would convince anybody who wasn’t convinced before they got to the first word of the article,” Humphreys said.

When I ran these criticisms by Venkataramani, he defended his findings. He said it wasn’t possible to measure the supply of opioids in the counties he studied with the available data, and that it would be difficult to find a suitable negative control for a study such as this. And there weren’t enough alcohol-related deaths and suicides to include them in the study.

Humphreys pointed out that even if the decline of manufacturing jobs did cause the opioid epidemic, it would be cold comfort to policy makers. They can’t snap their fingers and reopen scores of factories across the country. “Who doesn’t want to revive those areas?” he said. “If we knew how to bring manufacturing back, we would do it.” To stop the opioid epidemic, he argued, we should focus on changes we can actually make.

More compelling, to Humphreys, is a recent National Bureau of Economic Research paper that did examine a potential policy solution. For the paper, researchers studied the handful of states that used so-called triplicate programs for their prescriptions of opioids. Triplicates were a rudimentary type of prescription-drug-monitoring program, in which doctors were required to use a special type of pad to prescribe controlled substances, and provide a copy of the prescription to a state monitoring agency. Physicians found these forms a hassle to use, and they were therefore reluctant to prescribe the drugs that required the use of triplicates.

Purdue, the maker of OxyContin, in turn marketed its opioid painkiller less aggressively in states that used triplicates, the paper found. And as a result, fewer people died of opioid overdoses in those states. The paper found that non-triplicate states would have had an average of 44 percent fewer opioid-overdose deaths from 1996 to 2017 if they had been triplicate states. Perhaps most damning, the relationship between being a triplicate state and experiencing fewer opioid-overdose deaths held even when the authors controlled for the state’s economic conditions. In other words, despairing or not, patients who were prescribed opioids took them.

The triplicate paper, in essence, makes it look like the opioid epidemic was mostly the fault of Big Pharma’s marketing, not the result of an economic shock. But David Powell, a senior economist at Rand and an author of the triplicate paper, thinks both could be true. To get the worst drug overdose epidemic in U.S. history, he says, “you need a huge rise in opioid access, in a way that misuse is easy, but you also need demand to misuse the product.”

The next step will be for researchers to see how the marketing of opioids interacted with economic conditions to increase the likelihood that a given place would succumb to addiction. In the meantime, researchers working on the ground say opioid addiction looks like the result of a perfect storm of poverty, trauma, availability, and pain.

When Silva, the Bucknell sociologist, asked her subjects about their painkiller addictions, they would often link their problems back to the decline of coal. When the coal jobs went away, they said, families fell apart. Some people started drinking heavily and abusing their children—who then went on to be traumatized themselves and sought the relief of OxyContin. Some grew bored and aimless without a job, and they started abusing drugs to fill the time or to ease their sense of purposelessness. Some had to switch to other manual jobs, and days of heavy lifting eventually took their painful toll. OxyContin was just a short doctor’s visit away—in one case, a doctor would simply refill opioid prescriptions by phone. “The men and women in this book suffer from physical pain—muscles torn and backs worn out by heavy lifting and repetitive tasks,” Silva writes. But they also “turn to food and Percocet, heroin and cigarettes, to manage the feelings of anxiety, disappointment, and trauma from their pasts.”

Her interviewees had easy access to opioids, yes, but they also felt betrayed by the world. When Silva presented her work recently, an economist told her, “This is, like, an everything problem.”

“I thought that was a really smart way of putting it,” she told me. Indeed, in one of their studies, the Princeton economists Anne Case and Angus Deaton, who coined the “deaths of despair” hypothesis, noted that opioid overdoses, suicides, and alcohol abuse are the results of “cumulative distress,” or the overall “failure of life to turn out as expected.”

The solutions to this “everything problem” are not clear. Silva told me that the opioid epidemic had made some of her interviewees even more resentful, because they saw their neighbors as too weak to pull themselves out of addiction. At times, they seemed to almost celebrate the pain of withdrawal from opioids, as a necessary way of toughening up. “They actually end up supporting programs that would give people less help or less aid, because they feel like it’s enabling to keep giving help to people who refuse to get better,” she told me.

One of Silva’s interviewees tried to convince her that stress is how people grow. But stress can also make people hurt.