The opioid crisis has continued disrupting communities and claiming lives since its origins in the 1990s. Federal and state government, along with nonprofits, businesses, and residents, have worked together to try to mitigate the consequences of the opioid crisis, such as limiting the prescribing of opioids. However, U.S. opioid mortality is continuing to increase and is exacerbated by the COVID-19 pandemic, up 44 percent from 2019 to 2020. Because opioid mortality is increasing at a rapid rate, current policy actions must be evaluated to assess their effectiveness at decreasing opioid mortality. One current state policy that has not been thoroughly researched is naloxone access laws (NALs).
Naloxone is an opioid antagonist: it binds to opioid receptors and can reverse and block the effects of opioids. Naloxone temporarily stops opioid overdoses, so further medical help can be received. Its effects can last anywhere from 30 to 90 minutes. A prescription is required to obtain naloxone which is a barrier to accessing naloxone, especially for those most at risk for an opioid overdose.
NALs are state laws that increase access to naloxone. NALs vary greatly in how they increase access to naloxone, such as allowing for third party prescriptions or providing civil, criminal, and professional immunity to prescribers and dispensers. NALs were first enacted in April 2001 by New Mexico.
What do U.S. Drug and Opioid Mortality Look Like?
U.S. drug and opioid mortality has continued to increase over the entire 1999–2020 time period (Fig. 1). In 2020, drug mortality was 91,799 deaths, more than four times the number of drug deaths in 1999. In this century, 915,520 people died from a drug death. Within drug mortality, most of the deaths currently involve opioids, with 70 percent of the drug deaths in 2020 involving opioids. Opioid mortality steadily increased from 4,030 deaths in 1999 to 64,306 deaths in 2020, almost 1,500 times more deaths than in 1999. Opioid mortality has steadily increased since 1999 with a substantial increase in 2016. From 2015 to 2016 and 2016 to 2017, opioid mortality increased by almost 1,000 deaths, a 44 and 23 percent increase, respectively. Another substantial increase in opioid mortality occurred in 2020, when opioid mortality increased from 44,624 deaths to 64,306 deaths from 2019 to 2020, a 44 percent increase. These patterns show that drug and opioid mortality are still increasing and are exacerbated by the pandemic.
Fig. 1: U.S. Drug and Opioid Mortality, 1999–2020
In the U.S., not every community, township, city, nor state is affected equally by the opioid crisis or drugs generally. Counties in the Appalachian Mountains and Northeast, as well as select counties in and surrounding New Mexico, have the most drug deaths per capita in 2020 (Fig. 5). The Appalachian Mountains is the worst hit area in 2020. The three counties with the highest drug deaths per capita in 2020 all reside in West Virginia—McDowell, Logan, and Summers county, respectively. Of the top ten worst counties, six counties are in West Virginia.
Fig. 2: Logged Number of Drug Deaths per 10,000 People by U.S. County, 2020
Do NALs Work?
In short, the regressions show that NALs are associated with an increase in opioid mortality, meaning that they might make the opioid crisis worse instead of better. The regression analysis reveals that NALs are associated with a 0.698 increase in opioid deaths per 10,000 people or 128 percent increase in the mean opioid death rate. The event study shows the same positive association (Fig. 6). Before NALs are implemented, the association of NALs on opioid mortality is small and not statistically discernable from zero. However, after NALs are implemented, the association of NALs on opioid mortality increases considerably and is statistically discernable from zero. In one year of implementation, NALs are associated with a 0.636 increase in opioid deaths per 10,000 people or a 116 percent increase in the mean opioid death rate.
Fig. 3: Event-Study Regression of Effect of NALs on Opioid Death Rate
In comparison to the mean, the association of NALs on opioid mortality is staggering as NALs are associated with over a doubling of the number of opioid deaths in a county. These results question the effectiveness of NALs at reducing opioid mortality by showing that NALs might substantially increase opioid mortality. However, these results should not be used as evidence for causality because the state adoption of NALs is not random. Thus, states that have not yet implemented NALs are not good counterfactuals, thus violating the parallel trends assumption of DiD analysis. If NALs increase opioid mortality, NALs must be repealed and replaced with new policy solutions to help combat the rising increase in opioid mortality and save lives.
Elizabeth McAvoy is a senior at Indiana University Bloomington, pursuing a Law & Public Policy BSPA and Philosophy/Political Science BA. Elizabeth is also a research assistant for various projects at Indiana University, including the Indiana Nonprofits Project, for which she won the Indiana University Bloomington 2022 Provost’s Award for Undergraduate Research and Creative Activity.
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