The General Motors Assembly Plant stands beyond a fence in Doraville, Georgia, U.S., on Dec. 12, ... [+]
There are a multitude of factors that have played a role in the opioid crisis that our country currently faces.
While we may consider supply factors—whether from ilicit sources or from health care providers—as a key driver in this epidemic, it’s also important to consider economic forces as a potential contributor.
In a new study, researchers found that closing of local automotive assembly plants may be one of the factors that has led to increases in deaths from opioid overdose.
The study was published online today in JAMA Internal Medicine.
The findings from the study underscore the role of diminished economic opportunities as a key driver in the ongoing national opioid epidemic, and add to prior research that demonstrates the role of job loss as a factor tied to increased opioid use in the U.S.
"Major economic events, such as plant closures, can affect a person's view of how their life might be in the future. These changes can have a profound effect on a person's mental well-being, and could consequently influence the risk of substance use," said lead author Atheendar Venkataramani, MD, PhD, an Assistant Professor of Medical Ethics and Health Policy, in a press release. "Our findings confirm the general intuition that declining economic opportunity may have played a significant role in driving the opioid crisis."
Harshal Kirane, MD, Medical Director, Wellbridge, Addiction Treatment and Research, Calverton, New York agrees, explaining “while there are many complex factors to consider in a study of this sort, it is likely that opioid use intensifies in communities following a plant closure.” “With fewer and fewer available financial resources, the likelihood of shifting to less expensive opioids goes up. Overall, this greatly increases the risk of exposure to synthetic opioids which are now clearly responsible for a large portion of overdose deaths.”
Kirane emphasizes that “unemployment, especially unexpected job loss as often occurs with manufacturing closures, takes a devastating toll on psychological wellbeing. In the face of despair, opioids can offer a mirage of relief. In addition, job loss may also mean a loss of access to healthcare services, loss of social connection, and loss of self-worth - all of which are identified risk factors for substance use.”
The study evaluated the number of opioid-related deaths over from 1999-2016 in 112 manufacturing counties near major automotive manufacturing plants. Researchers used multiple sources of data, and put together a database of all automotive assembly plants in operation as of 1999, noting each plant's location and date of closing, where it was relevant. They also identified counties located within commuting locales that contained one or more of the plants that closed.
Of the manufacturing counties studied, 29 of them dealt with an automotive assembly plant closure during the study period. Results demonstrated that 5 years after the plants closed, opioid overdose death rates among adults ages 16 to 65 in those counties were 85% higher than expected, compared to counties where plants did not close.
The group of people noted to have the largest increase in opioid overdose mortality after an automotive plant closure were non-Hispanic white men between 18-34 years old, followed by non-Hispanic white men ages 35-65 years old. There were also increases seen in opioid overdose mortality for younger non-Hispanic white women.
While the study does demonstrate a link or association between plant closures and fatal opioid overdoses, what’s important to understand is that such closures were clearly not the only cause of the opioid crisis in this context.
Other drivers, such as number of prescriptions dispended, were important aspects of the epidemic in the early 2000’s. The opioid crisis developed and expanded due to access to the drugs along with the factors that are integral in leading to opioid addiction itself. While initial access to opioids was linked to overprescribing, there has now been a decline in prescribing rates since 2010. But understanding how demand has changed over the past decade is a more complex issue, to say the very least.
“Over the past two decades, the astronomical U.S. opioid supply is an identified driver of the crisis,” said Kirane.” Efforts to constrain the supply by way of education, public policy and prescribing guidelines are demonstrating positive changes.”
As evidence of such progress, “in 2017, national opioid prescribing rates decreased roughly 30% compared to the prior 10-year peak,” offered Kirane. “Importantly, however, outlier communities persist with rates greater than 7 times the national average. In the wake of an economic downturn, such communities are especially vulnerable to opioid-related deaths.”
"Our results are most relevant for the worsening population health trends in the industrial Midwest and South, regions that have experienced some of the largest increases in opioid overdose deaths and in which the automotive production and other manufacturing industries have long been economically and culturally significant," said Venkataramani. "While we as clinicians recognize and take very seriously the issue of overprescribing, our study reinforces that addressing the opioid overdose crisis in a meaningful way requires concurrent and complimentary approaches to diagnosing and treating substance use disorders in regions of the countries hardest hit by structural economic change."
"Until we can achieve structural change to address the fundamental drivers of the crisis, there are some health care system and health policy changes that can be implemented immediately," said senior author and co-study lead Alexander Tsai, MD, an associate professor of psychiatry at the Massachusetts General Hospital and Harvard Medical School. "There is an urgent need to rapidly lower the threshold for accessing evidence-based treatment for substance use disorders, for example, at the level of state Medicaid policy and private payor utilization management."
Kirane agrees, stating that “an overwhelming body of evidence highlights that medications for opioid use disorder are a vital component of effective care. There are many options available today that are widely misunderstood, so the most effective first step is seeking support and getting informed.”
Kirane qualifies his approach by explaining that “addiction is a chronic brain disorder that is most effectively managed by an individualized approach—one size does not fit all.”
As far as where the opioid crisis is headed in 2020, Kirane is pragmatic, admitting that despite “many notable gains, the road ahead for the US opioid crisis remains grim.”
“In 2018, nearly 70,000 overdose deaths occurred in the US,” said Kirane. This is a sobering statistic, reminding us that much work needs to be done. Kirane further explains that “effective approaches for managing opioid addiction are known but remain underutilized, with access to overdose education and naloxone rescue limited for many Americans.”
He continues, offering that “these [overdose education and naloxone] are only the low hanging fruit we have yet to seize, the much deeper issue rests in the overwhelming portion of Americans that struggle with addiction but never connect with any form of clinical care.”
A key point that Kirane makes is the necessity of “bringing addiction care into mainstream medicine. Stigma, ignorance and fear remain the major hurdles ahead.”
