The US opioid epidemic isn’t about despair—it’s about supply

Are opioids killing Americans because the economy is bad?
Are opioids killing Americans because the economy is bad?
Image: Reuters/Brian Snyder
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In 2017, Princeton economists Anne Case and Angus Deaton released an explosive research paper: “Mortality and morbidity in the 21st century.” Following up on research they published in 2015, the duo found that death rates for middle-aged white Americans without a college degree rose significantly between 1999 and 2015.

Case and Deaton credited the increase to rising deaths from drug overdoses and suicide—what they called “deaths of despair.” The researchers connected the uptick in such deaths to worsening economic conditions for this group, from a decline in income to a lower likelihood of having a job or getting married over this period.

Case and Deaton are highly influential researchers (Deaton won the 2015 Nobel Prize in economics), and their compelling conclusions fit a common story about the economic suffering of America’s white working class. “The news media—left, right, and center—had a pre-existing narrative of middle-aged white malaise, and they slotted the Case and Deaton reports into that narrative,” wrote Columbia University statistician Andrew Gelman on his blog.

Yet there is good reason to believe that Case and Deaton are wrong.

A newly released working paper from the National Bureau of Economic Research, by economist Christopher Ruhm, challenges the claim that these are “deaths of despair.” Rather, Ruhm’s analysis suggests that mortality is rising due to the increased availability of highly addictive opioids, and that economic conditions do little to predict where the epidemic has hit hardest. In other words, the US is facing a drug crisis, not an economic one.

Ruhm, a professor at the University of Virginia, begins his argument by posing several questions that point to flaws in Case and Deaton’s conclusions. For example: Why have there been sharp increases in fatalities in locales with comparatively strong economies, such as Massachusetts? Why haven’t people in other developed economies where some people have experienced stagnation seen the same relative rise in mortality? Why hasn’t the opioid-fueled drug epidemic subsided in the past several years as economic conditions for low-income Americans have improved?

The reason, says Ruhm, is the “drug environment.” The overprescribing of opioids and the increased availability of cheap heroin from Mexico is a much better explanation for the US’s jump in mortality than socioeconomic decline.

Ruhm’s paper goes on to make a statistical case for his position. The analysis shows that while, yes, there is a correlation between worsening economic circumstances and higher mortality, that relationship almost entirely disappears when you account for demographics. Overall, Ruhm says that knowing the age, racial, geographic, and educational makeup of a county in 1999 would tell you a lot more about its future mortality rate than knowing that county’s future economic trajectory. Changes in economic conditions, like unemployment and income, explain less than 10% of the rise in mortality, according to his research.

Assuming they are accurate, Ruhm’s findings have important implications for tackling mortality problem among non-college-educated American whites who are afflicted by drug addiction. Addressing the crisis through an economic lens could be disastrous. Resources dedicated to creating jobs and boosting education levels, while likely useful in the long run, are unlikely to stem the tide of the epidemic. Instead, money must be poured into providing the care that those addicted to drugs badly need.