Inflaming addiction experts, an unpublished economics paper is suggesting that the nationwide push to use more of an overdose-reversing drug is actually increasing opioid deaths in some parts of the Midwest and increasing crime nationwide.
The claim, made by economists Jennifer Doleac of the University of Virginia and Anita Mukherjee of the University of Wisconsin, Madison, angered some overdose experts after its release Tuesday, sparking a Twitter debate pitting economists against public health experts.
More than 42,000 people a year in the US die of opioid overdoses, largely from painkiller pills, heroin, or the synthetic opioid fentanyl. On Tuesday, the CDC reported that emergency room visits for opioid overdoses increased 30% from July of 2016 to September of 2017 in 45 states.
Public health officials nationwide have responded to the crisis in part by promoting so-called harm reduction measures that include broadening access to naloxone — a prescription drug that reverses opioid overdoses — to emergency responders, family members, and drug users themselves. A recent presidential commission on the overdose crisis, which is now killing more people than the AIDS crisis at its height, recommended that all police officers carry naloxone in all 50 states, for example.
The new study raises the question of the “moral hazard” in widening access to naloxone. Moral hazard is when a new innovation, whether seat belts or HIV treatment, leads to more dangerous behavior, such as driving faster or engaging in more unsafe sex.
“Reducing the risks associated with risky behaviors will tend to increase those behaviors,” Doleac told BuzzFeed News by email.
Naloxone, the paper suggests, could lead to worse behavior — such as committing crimes to get money to buy drugs or taking higher doses of drugs — among drug users who know they might be saved from an overdose that would otherwise kill them.
To test the idea, the economists compared crime and death rates across states before and after the passage of laws meant to increase access to naloxone, such as “good Samaritan” laws for people who report overdoses that protect them from arrest, or blanket prescriptions for naloxone to communities.
“It will be easier for people to obtain Naloxone in places that pass laws broadening access to the drug than in places that don’t — so that creates an experiment,” Doleac said.
Generating a good deal of disagreement among public health experts, the study concludes that, instead of saving lives, allowing wider access to naloxone statistically increases thefts and emergency room visits “with no reduction in opioid-related mortality.” The paper also suggests that the advent of naloxone laws is driving some drug users to seek out fentanyl, an opioid more than 30 times more potent than heroin and now the leading cause of fatal overdoses nationwide, triggering “a 14% increase in opioid-related mortality” in Midwestern states.
“The main takeaway is that public health officials need to prepare for the behavioral effects that we find in our paper,” Doleac said. “Distributing Naloxone can be a useful harm-reduction strategy, but on its own this is not a solution to the opioid epidemic. We find some evidence that greater availability of local drug treatment can help — when Naloxone saves someone’s life, we need somewhere they can go for rehabilitation.“
Released Wednesday, the working study led to immediate criticism from harm-reduction experts who see expanding the availability of naloxone as a key step in limiting fatal overdoses.
A 2017 economics study, for example, had found that naloxone access laws decreased opioid overdose deaths by 11% to 9%, for example. (But that study only looked at the state level, unlike the new one.)
More fundamentally, the critics see the paper as uninformed about how opioid addiction works: Opioids create a physical dependence that triggers a need for daily doses of the drug to forestall the agony of withdrawal, which combines the sudden worst symptoms of a flu with soul crushing feelings of depression. Giving naloxone to someone who is overdosing — dying from lack of oxygen as their breathing slows and then ceases — can throw users into abrupt withdrawal pain (by blocking receptors in the brain that respond to opioids). Withdrawal is the very situation that they are seeking to avoid in the first place, making naloxone the opposite of a seat belt.
Moreover, recent studies suggest that illicit drug users don’t know how much, or whether, they are getting fentanyl in the cheap bags of illicit heroin they buy on the street. That variability in potency, rather than the strength of fentanyl itself, may be driving the surge of opioid overdose deaths. People think they are taking identical doses of heroin or illicit pills as those they took yesterday, and instead they may contain a fatal dose. Fentanyl deaths are now more numerous than either heroin or painkiller pill overdoses.
“This paper doesn’t adequately control for the distribution of the ‘poison’ i.e. fentanyl in this crisis,” medical epidemiologist Dan Ciccarone of the University of California, San Francisco, said in an email to a harm-reduction expert list maintained by the National Institute on Drug Abuse. “It is like blaming rising use of cigarette filters on rising lung cancer rates — without controlling for the amount of tar in the cigarettes.”
Fentanyl is tainting the heroin supply in the Midwest (where this week’s CDC emergency room report found a 70% increase in overdose visits) in uneven fashion, and Ciccarone suspects the study is simply picking up the deaths from that variability. “Fentanyl is not only the likeliest cause of rising rates of death, but may also be increasing folks’ dependency. It alone may be causing a worsening spiral effect,” he said. “This needs further examination before we start blaming naloxone.”
But emergency medicine expert Lewis Nelson of the Rutgers New Jersey Medical School, a supporter of naloxone programs, told BuzzFeed News that the study “raises some good questions,” about moral hazard in use of the overdose-reversal drug. Undoubtedly some drug users are chasing ever higher highs, he said, and could potentially take more risks if they thought they could rely on the people around them to revive them with naloxone.
“This is not an angelic population — just like people everywhere they will make bad decisions,” Nelson said.
Still, on balance, naloxone likely saves lives, Nelson said.
There is also the risk that someone treated with naloxone will try to counteract the feelings of withdrawal by injecting more heroin, potentially giving themselves a fatal dose when the reversal drug wears off after about a half hour. It’s worth bearing in mind that not everyone treated with naloxone would have died from their overdose, he added, making statistics on reversals sloppy measures. “When we talk about ‘lives saved’ by naloxone, we are often seeing an exaggerated number.”
Still, on balance, naloxone likely saves lives, Nelson said.
“It’s worth asking the question how much making naloxone available is shifting the risks of overdoses onto someone else, though,” he said. Many public health experts agree with the study’s suggestion that naloxone alone without ready drug addiction treatment — only about 1 in 10 people seeking the best treatment can get it today — is only a Band-Aid on the crisis.
A big problem in arguing over studies about economic data or crime reports to tease out overdose effects is that the data on heroin, fentanyl, and overdoses is poor. A study out in February suggests the CDC’s estimate of 33,000 opioid-related deaths in 2015 was actually a huge undercount, for example, with the true number likely around 40,000. And economics studies, in general, have “modest or even low credibility,” a Journal of Economic Surveys analysis found.
“How well do we understand the distribution, variability and mixtures of opioids that are available on US streets? Not well at all,” Ciccarone told BuzzFeed News. “A more robust surveillance strategy would examine the poison as well as the unfortunate outcome.”