A new study has ignited controversy in the world of drug abuse prevention, applying the economic theory of "moral hazard" to the opioid crisis.
The working paper, posted March 6, examines the effects of laws that have increased access to anti-overdose medication naloxone. It found an increase in opioid-related ER visits and criminal activity, while mortality from opioid overdoses was unaffected, or even rose in certain areas.
Naloxone, an opioid antagonist medication that can save the life of an overdose victim, has been heralded as a key to curbing the opioid crisis. All 50 states and the District of Columbia have passed laws making naloxone more accessible.
But Jennifer Doleac of the University of Virginia and her co-author Anita Mukherjee of the University of Wisconsin argue in their study that naloxone is another example of a lifesaving innovation that results in a moral hazard.
Moral hazard is the theory that when you give people a safeguard to protect them against risky behavior, they will do the risky behavior more. For example, a 1975 study argued that safety features in cars made people drive more recklessly and get in more accidents.
"Broad naloxone access doesn't seem to be helping and might be making things worse," Doleac said in an interview. "We don't have clear answers yet. That's one of the depressing parts of working on this topic."
Doleac and Mukherjee examined data from 2006-2015 and found that after laws made naloxone easier to access, opioid-related ER visits and crimes increased. Opioid-related deaths did not decrease, but increased 14 percent in the Midwest.
The authors admit that the working paper has yet to be peer reviewed. The study has elicited strong criticism, ranging from professional disagreement to vicious personal attacks on Twitter.
The strongest criticism is that the study shows correlation but not causation. The increase in ER visits could be a result of any number of factors, and the expanded access to naloxone might be a coincidence. If murder rates and ice-cream sales both increase, it doesn't mean ice-cream causes murder; it's more likely that higher temperatures cause a spike in murders.
A key component of academic economics is ruling out the possibility of mistaking correlation for causation. The study might not be peer-reviewed yet, but the authors reviewed the findings very thoroughly before putting it online because they knew it would cause a stir.
"We expected some pushback," Doleac said. "But we didn't expect all the pushback."
Someone who uses naloxone to revive an overdose victim is supposed to call 911 before doing anything, which could account for the spike in ER visits. Good Samaritan laws, which grant immunity for possession and paraphernalia offenses when calling 911, could also explain the correlation.
Naloxone laws don't necessarily mean people actually have the medicine immediately.
"[Doleac and Mukherjee's] study assumes the passage of these laws lead immediately to everyone having easy access to naloxone when they need it, when this is not the case," Leana Wen, Baltimore's health commissioner, told Olga Khazan of The Atlantic.
A 2012 study examined communities where people actually had naloxone kits, and opioid-related death rates decreased. There's also the argument that the opioid crisis is getting worse in general, and the rate of opioid-related deaths would be much higher if naloxone wasn't accessible.
The study reinforces one important point related to increased naloxone access: it isn't a magic bullet that will single-handedly reverse the opioid crisis. Overdose victims still need medical treatment because the effects of naloxone wear off after 30 minutes. Even if it saves someone's life, that person is still addicted and needs a long-term solution.
The study found that naloxone access had the best outcomes in large cities with treatment programs and fast 911 response times. Doleac thinks this finding is encouraging, and she doesn't want her study to discourage wider access to naloxone. She just thinks fighting the opioid crisis requires a more thorough solution.
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Headline updated to note that the generic name of the anti-overdose drug is naloxone. Narcan is a form of naloxone trademarked by Adapt Pharma and was not on the market during the period of time studied by the authors.