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THE OPIOID CRISIS AND ECONOMIC OPPORTUNITY: GEOGRAPHIC AND ECONOMIC TRENDS By Robin Ghertner and Lincoln Groves, Ph.D. INTRODUCTION Opioid use disorder has reached epidemic levels in the United States, with a 200 percent increase in overdose deaths from opioid and heroin use between 2000 and 2014.1 The Centers for Disease Control and Prevention (CDC) estimated that over 60,000 drug overdose deaths occurred in 2016, with overdose death rates three times the rate of 1999.2 Overdose death rates involving opioids have risen dramatically, with deaths due to synthetic opioids other than methadone doubling from 2015 to 2016.2 Lower-income individuals, including those on Medicaid and the uninsured, are more likely to misuse opioidsi and have opioid use disorder than the general U.S. population. 3–5 As shown in Figure 1, in 2016, individuals under the poverty line were 2.1 percentage points more likely to have misused opioids in the past twelve months than individuals above 200 i Throughout this brief the terms opioids, opioid misuse, and opioid use disorder include the use of prescription opioids as well as heroin and synthetic opioids. percent of the poverty level. They were over twice as likely to have has an opioid use disorder. In fact, even as rates of nonmedical use of opioids among the lowincome population decreased from the 2003-2005 period to the 2012-2014 period, rates of dependency rose by over 50 percent.3 In 2012, the CDC issued a report stating that “Medicaid recipients and other lowincome populations are at high risk for prescription drug overdose.”6 While the individual-level relationship is clear, the relationship between community prevalence of opioid use disorder and economic conditions has not been fully studied. This relationship is important for decision-makers at the federal, state, and local levels to understand as they consider policy and budgetary proposals to address the crisis. The opioid crisis has not affected the nation uniformly. The extent to which it may be concentrated in areas with higher poverty and fewer employment opportunities may exacerbate This study examines relationships between indicators of economic opportunity and the prevalence of prescription opioids and substance use in the United States. Overall, areas with lower economic opportunity are disproportionately affected by the opioid crisis. However, the extent of that relationship varies regionally. (1) The prevalence of drug overdose deaths and opioid prescriptions has risen unevenly across the county, with rural areas more heavily affected. Specific geographic areas, such as Appalachia, parts of the West and the Midwest, and New England, have seen higher prevalence than other areas. (2) Poverty, unemployment rates, and the employment-to-population ratio are highly correlated with the prevalence of prescription opioids and with substance use measures. On average, counties with worse economic prospects are more likely to have higher rates of opioid prescriptions, opioid-related hospitalizations, and drug overdose deaths. (3) Some high-poverty regions of the country were relatively isolated from the opioid epidemic, as shown by our substance use measures, as of 2016. 2 disparities in access to health care and treatment options in such communities. Figure 1. Past Year Opioid Misuse and Use Disorder by Poverty Status, 2016 Source: 2016 National Survey on Drug Use and Health. Note: Includes nonmedical use of prescription painkillers or use of heroin. N = 56,897. All differences across poverty status within each category are statistically significant at p < 0.001. One recent study found that increases in county unemployment rates predict increases in opioid death rates and that macroeconomic shocks drive the overall drug death rate.7 Another study found that per capita opioid-related hospital stays and emergency department visits are higher, and have increased at higher rates, in low-income communities than in higher income communities. 8 In addition, labor force participation has fallen by a greater percentage in areas where relatively more opioid pain medication is