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prescribed.9 Finally, a recent study from the Federal Reserve found that “adults who have been personally exposed to the opioid epidemic have somewhat less favorable assessments of economic conditions than those who have not been exposed.”10 To explore how a county’s economic conditions relate to the opioid crisis, we examine geographic and statistical relationships between indicators of economic opportunity, substance use, and prescription opioid prevalence. We analyze data from 2006 through 2016 for most counties in the U.S. We use four separate measures that serve as proxies for different aspects of the opioid crisis, including retail opioid sales, Medicare Part D opioid prescriptions, opioid-related hospitalizations, and drug overdose deaths. These indicators do not directly measure opioid misuse or opioid use disorder, however currently no local measures exist that are nationally representative. Measures of prescription opioid prevalence include retail opioid sales, measured in volume of medical morphine equivalents, and Medicare Part D opioid prescriptions. Opioid-related hospitalizations are measured as the number of unique hospital stays or emergency department visits for which the use of any opioid (prescription, synthetic, or heroin) was listed as a cause of the stay. Our measure of drug overdose deaths includes deaths due to any substance (excluding alcohol and tobacco). Unfortunately, we did not have access to data on county-level opioidrelated overdose deaths. All data are measured as rates per 100,000 people. Our measures of economic opportunity include poverty rates, unemployment rates, and the employment-to-population ratio. The latter measures the number of individuals employed relative to a county’s entire population. For simplicity, we present descriptive trends for poverty and unemployment rates, and include the employment-to-population ratio only in statistical models. More details on the data and methods can be found in the Appendix. TRENDS IN ECONOMIC OPPORTUNITY, OPIOID PRESCRIPTIONS, AND SUBSTANCE USE MEASURES 6.0% 2.1% 1.5% 4.8% 1.8% 1.0% 3.9% 1.1% 0.6% 0.0% 2.0% 4.0% 6.0% 8.0% Past year misuse Past month misuse Opioid use disorder Under 100% Poverty 100-200% Poverty Over 200% Poverty 3 National measures of opioid prescribing and substance use have been consistently rising since the early 2000s. Part of this rise corresponded with economic declines; however, rates continued to rise even after economic indicators showed improvement. The increase at the national level masks variation in rates across the country. National Trends Indicators of substance use and opioid prevalence have risen substantially over the past 15 years. Figure 2 shows the relationship between two measures of economic opportunity and aggregate levels of retail opioid sales, Medicare Part D opioid prescriptions, opioid-related hospitalizations, and drug overdose deaths. Unemployment and poverty rates increased during the Great Recession. More specifically, unemployment rates peaked in 2010 at a rate of nearly 10 percent, while poverty rates increased slowly throughout the early 2000s, increased markedly between 2008 and 2011, and then declined through 2016. Figure 2. National Trends in Unemployment, Poverty, and Measures of Substance Use and Opioid Prevalence Sources: Poverty: U.S. Census Bureau Small Area Income and Poverty Estimates. Unemployment: Bureau of Labor Statistics. Prescription opioid sales: Drug Enforcement Administration (DEA) Automation of Reports and Consolidated Orders System (ARCOS), measured in kilograms of medical morphine equivalence per 100,000. Medicare Part D Prescriptions: Centers for Medicare & Medicaid Services (CMS) Prescription Drug Event File. Drug overdose deaths: CDC Small Area Estimates. Hospitalizations: Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases and State Emergency Department Databases. 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 0 10 20 30 40 50 60 70 80 90 2000 2002 2004 2006 2008 2010 2012 2014 2016 Prescriptions (millions) Medicare Part D Opioid Prescriptions Claims Poverty Rate Unemployment Rate