My friendly local pharmacy has started selling naloxone kits to the general public. They think everyone should have one. The idea is that you never know when you’re going to have someone overdose in your home.
As the opioid crisis spreads like a curse across North America, naloxone – a lifesaving drug that neutralizes the effects of an opioid overdose – is not confined to first responders anymore. Schools in Toronto are stocking up in it. Librarians across the U.S. have been trained to administer it to overdosing visitors. Everywhere, the message is: make sure you have some on hand, just in case.
So what is the effect of naloxone on reducing drug-related deaths? Jennifer Doleac decided to find out. As an economist at the University of Virginia, she studies the consequences (and the unintended consequences) of public policy. She and her fellow researcher, Anita Mukherjee at the University of Wisconsin, thought that the widespread rollout of naloxone across the U.S. provided a natural experiment in drug policy and moral hazard.
The concept of moral hazard is simple. If you reduce the risk of any given behaviour, then people might do more of it. The classic example was the introduction of seat belts in cars. It turned out that seatbelts saved lives – but not as many as you might think, because they also encouraged some people to drive faster and more carelessly.
Most of us are rational actors – even drug addicts. As drug users realize they’re far less likely to die from an overdose, some start using more powerful drugs, in higher doses. Some switch to fentanyl (which is far deadlier than heroin). Some “use” more often. “You wouldn’t think that people caught in the depths of addiction would respond to incentives,” Prof. Doleac says. “But they do.”
There’s plenty of anecdotal evidence for what’s happened since naloxone became common. In their paper, the professors cite media reports that describe naloxone parties, where people use heroin and prescription painkillers knowing that they have easy access to naloxone in case they overdose. First responders say they’re fed up with saving the same people over and over again. Recently The New York Times chronicled the depressing story of Patrick Griffin, a long-time addict with a heroin and fentanyl habit, who once managed to overdose no fewer than four times in six hours. Each time, emergency medical workers revived him. Despite his family’s pleading and his frequent near-death experiences, Mr. Griffin stubbornly refuses to go into treatment. One town councillor in Ohio got so annoyed with repeat offenders that he proposed cutting them off after the first two overdoses.
Naloxone has caused a variety of other unintended consequences, the researchers say. Drug-related theft is up. So are emergency-room visits. There’s even evidence that in one region of the U.S. – the Midwest – naloxone use actually increased overall drug mortality.
Prof. Doleac expected that their results would be controversial. What she did not expect was the enraged reaction from people in the public-health world. The moment their paper was published this week, the twittersphere exploded. She was deluged with abuse, even death threats.
“The public health community should acknowledge the behavioural effects we find here,” she says. “But they really don’t like the idea that there might be trade-offs.” Why the resistance? As fierce advocates for more harm-reduction strategies, such as access to naloxone, they’re afraid that admitting to any potential downside would weaken their arguments for more resources and strengthen the resistance against them.
Economists have seen this all before. After the development of treatments that turned HIV from a death sentence into a manageable condition, risky sexual behaviour among gay men exploded. One study, cited by the researchers, found that treating HIV-positive men more than doubled their number of sexual partners, and led to a sharp increase in HIV incidence. Then as now, public-health activists didn’t want to deal with the evidence.
To be clear, nobody – certainly not Prof. Doleac – thinks we should withhold lifesaving treatment from drug users. But we shouldn’t ignore the evidence either. Naloxone is no magic bullet. The overwhelming lesson of the opioid crisis is how intractable it is. There are no quick wins and no easy fixes. Another example: when the formulation of OxyContin was changed to make it more tamper-resistant, opioid-related deaths did not decline, as expected. People just switched to heroin.
“We need to experiment with a variety of approaches,” Prof. Doleac concludes. “And we should be humble.”