A Pathway to Hope, Part 2: Framing the Problem

How do we begin to understand the impact of the opioid epidemic? An understanding about the problems the epidemic created, the challenges state and local governments might face as they attempt to address these problems, and the importance of generating evidence are all essential to any chance of successful healing for families and communities. Bill Evans, Keough-Hesburgh Professor of Economics and co-founder of the Wilson-Sheehan Lab for Economic Opportunities at Notre Dame, dives into the history and context of the opioid epidemic.

This discussion took place at the University of Notre Dame’s Summit on the Opioids Settlement: A Pathway to Hope which focused on how to most effectively distribute the nearly $50 billion in settlement dollars to maximize the impact on our communities and citizens.

Held in August 2024, this summit brought together attorneys general from across the country to discuss best practices to proactively evaluate the efficacy of opioid abatement programs and develop strategies to best distribute the funds. Led by the University of Notre Dame’s Poverty Initiative, the summit explores how evidence-based practices can inform decision making and ensure that the Opioids Settlement best helps those victims it is meant to serve.

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Transcript

1: 0:06

It's my great pleasure to introduce my colleague and, fellow Leo co founder, Bill Evans. Bill Evans joined the economics department in 2007 here at Notre Dame and is the university's first Keough Hesburgh professor, which is arguably the most prestigious faculty appointment at the university. This professorship was designed to attract premier scholars to Notre Dame to contribute to both the academic life as well as the Catholic mission of the university. He is among the most highly cited economists in the world. His research covers a broad range of areas, including health economics and the economics of education. But what Bill really loves to do is just tackle hard questions. And I'll never forget, when he walked into my office seven years ago and he slapped down a, an Excel printout of a graph, which is something that happened quite often when your office is near Bill Evans, and he said, take a look at this. And the graph showed a sudden spike in, deaths related to heroin overdoses. And he said, something's going on here. And whenever Bill comes into your office with a graph and says something's going on here, you know what he's going to do for the next two to three to five years. And, so it's not surprising, fast forward today, that Bill, along with, our colleague, Ethan Lieber, are among the nation's leaders in advancing understanding of the supply side forces that have led to a sharp increase in drug overdoses and deaths in this country. So If you have not familiarized yourself with that work, fear not, because Bill is going to share that and other, research going on, about the opioid crisis. So it's my pleasure to, invite Bill Evans up here, and I'll turn it over to you, Bill.

2: 1:57

I'm a pacer, so I'm gonna be going all around the stands, Thank you very much, Jim, for the nice introduction. Thank you all for wanting to be here, to help try to tackle this problem. I'm going to get right into it. I only have 20 minutes to describe 40 years of misery. as Jim said, my colleague Ethan Lieber and I have been working on the opioid crisis for the past seven or eight years. we've taken a particular tact to take a look at this, primarily on the supply side. What I'm going to do is summarize some statistics that have been uncovered by us and other people about the nature of the epidemic, and we're going to talk about then seven observations I'm going to make. About what these numbers imply, about the, settlement funds, some factors to consider when dispersing funds, the challenges that states face, when they're, distributing them, and then we're going to end up talking about the importance of evidence as we move forward. the, before we get started, just some background to help frame the subject matter. The primary way we're measuring the strength of the epidemic is the drug poisoning death rate, which is deaths per 100, 000 individuals. This is a long term time series of the death rate from 1980 through, 2022. And, a lot of the focus has been on the post 2000 time period, but notice that between 1980 and 2000, things were increasing steadily over that time period. so this is actually a 40 year epidemic in the making. most of these deaths have actually been generated by, an increase in deaths from opioids. And if we take a look at non opioid deaths, they've increased some, but it's still what's driving the train is the opioid, crisis. 81 percent of the increase has been, deaths due to opioids. just to put some numbers on these, There's been a 940 percent increase in deaths between 1980 and 2022, but the number of opioid deaths has gone up by 2500%, which is just staggeringly large. the fact that strikes me the most is that between 1999 and 2021, there's been about a million deaths from drug poisonings. If you were to total the total number of US soldiers that have died in all military conflicts since the Revolutionary War, it's about the same number. and so it's on the scale of armed conflict that our country has faced, in its 200 some odd year history. the first point that I want to make about the way we have to expend these funds Is that any expenditures we make have to recognize the extreme plasticity of this epidemic? It is ever changing. And to some degree, we're always fighting the last battle. just to give you some notion of this, opioid deaths are primarily coming from three different categories in the vital statistics. opioids, heroin, and synthetic opioids. Opioids is primarily going to be your prescription medicine. If we were to take a look at the death rates from opioids by itself from 1999 and 2022, notice that it's increasing dramatically through 2010. Then it starts to decline considerably. the decline is, primarily due to the reformulation of OxyContin that discouraged people from abusing the drug. what happened was As they reformulated it, people moved to heroin. And heroin then took over. It lasted for maybe three, four years. and then notice that heroin drops off because, synthetic opioids, primarily fentanyl, took over. The thing about this graph here is that the left axis is fentanyl, the right axis is heroin and opioids by itself. Notice the extreme difference in the level. It's hard to put them on the same graph because it looks like nothing's going on for prescription drugs. but it was fairly large. Until, until fentanyl took over. So this is an ever changing epidemic, and we can't just think of this as fighting a fixed position. and so the fact that we're going to be having these expenditures over a reasonable period of time, I think we got to save some money in the chamber there, to deal with the ever changing nature of it. Since we moved from sort of agricultural products to chemistry products. It's been a much more difficult, epidemic to contain. One of the more interesting ways in which this plasticity has realized itself has been in recent years. A lot of the funds are earmarked for opioid substance abuse. I think one of the more disturbing aspects of it is although opioid poisonings dominate mortality, it's not all about opioid abuse and it's become, to some degree, a poisoning epidemic. And that's indicated by what's going on with the deaths associated with cocaine and methamphetamines. Let me go over the cocaine. This is the cocaine death rate from 1999. through 2022, the bulk of cocaine deaths was primarily coming from crack, not powder cocaine. however, notice that around 2013, cocaine deaths start to go through the roof. now what's driving this, is cocaine with synthetic opioids. And at the retail level, there's a lot of mixture of cocaine with fentanyl right now. If you were to take a look at cocaine deaths without any synthetic opioids, they're actually pretty flat over this time period. And 100 percent of the increase in the cocaine mortality since 2013 has been a mixture of cocaine and fentanyl and so therefore if we're going to earmark all this money for opioid abuse We're not going to get this at all because this is cocaine abuse. It just happens to be an adulterated product. Now Methamphetamines is having a similar Movement here, but it ends up to be about 50 percent of the increase in meth since 2013 is due to meth with fentanyl The other increase is the movement from an ephedrine base, pseudoephedrine base to a p2p method for meth production, which ends up to be much more volatile substance. And so as a result, I think we have to worry about, these poisonings as well. third point I want to make is that the crisis is heavily concentrated among the economically most vulnerable. it's very difficult to measure socioeconomic status in the mortality statistics. There are limited measures of them on their death certificates. Education, however, is one that's been, reported on the death certificates since 1989. it ends up to be strongly correlated with income and poverty. People with high school degree or less have five times the poverty rate of people with a college degree. it is a decent measure of socioeconomic status. if we take a look at opioid death rates from 89 through 2021, for people that are 25 and older, where most education is completed, people with a four year degree have seen an increase of about 250 percent in drug poisoning mortality. That's a pretty large increase over time period. People with some college, but not necessarily a four year degree, has gone up by 850 percent. But if we were to take a look at people with high school degree or less, that has gone up by 1500 percent. It is so heavily concentrated in the group of people who the economy has left behind over the past 40 years. now, there is a large literature across many different disciplines that talks about socioeconomic status and health. And there's a fairly pronounced gradient where people with lower levels of socioeconomic status, whether it's measured by income or wealth or education, tend to have much worse health habits and much higher disease incidence rates, both physical and mental disease. So the likely participants in any intervention that's going to be funded by opioid settlements is going to be someone who is, on average, struggling, more, more likely to be struggling than, the general person in the population. And so as a result, I think there has to be an effort to potentially focus on more global programs that deal with many issues, opioid abuse. Let me give you some evidence here. I took the National Survey of Drug Use and Health for 2022. I identified the people in it, who the survey indicates have an opioid substance use disorder, and then I took a look at a bunch of co occurring conditions. And people with an opioid substance abuse disorder compared to those that do not have it, they have four times the rate of co occurring serious mental illness. three times the rate of any mental illness, four times the rate of serious psychological distress, twice the rate of co occurring alcohol use disorder, twice the rate of adverse childhood experience, five times the rate of not being employed, and four times the rate of homelessness. And the substance use disorder is a manifestation of a larger set of problems that a lot of individuals are having. And to take the substance abuse out from the rest of it. Might not be as effective a program as trying to deal with a lot of these things together in a more comprehensive way. All right, The fourth point I want to make is that it's relatively easy to generate statistics on the people who have died or have been, experiencing overdoses as a result of a crisis, but this is a multi generational crisis. And any solution has to reflect this point. just to give you some numbers here. The impact of the crisis on children, forget about the fact that they could die from poisonings or whatever, just people who are living with individuals, there are 10 million children who are living in a household Where in the previous year, someone had use of a serious drug other than, marijuana. So there's 10 million kids exposed in the household to an adult that's using crack or cocaine or meth or opioids or fentanyl or whatever the case might be. It's been estimated that there are 325, 000 children, between 2011 and 21, that have lost a parent to drug overdoses. So there's a third of a million in that group. an estimate that I've actually done with Ethan and our colleague Casey Buckles is that there are 1. 5 million children, who are living away from a parent in 2015, and 1. 5 million more because of the rise in drug use since 1996. Family life has been incredibly disrupted as a result of this. and a lot of that family life has been taken up by grandparents. Sam Quinones, who I think is one of the leading writers on this, epidemic, argues that if it weren't for grandparents stepping up, we'd be in an even much worse situation than we are right now. Grandparents are taking in the children. They're providing primary parenting in a lot of situations. It's possibly impacting their wealth, their plans for retirement, their physical and mental health as well. And so therefore any investment that we make has to recognize the fact that one adult could be affecting three generations with their drug use and the way we think about this. Not only, are people being affected when they're 6, 7, 8, 9, but they're also being affected at birth, through neonatal abstinence syndrome. It's a group of conditions that are caused when a newborn withdraws. From inter uterine exposure to opioids, babies born with NAS have higher delivery costs, higher readmission rates at the time of birth. But there's growing evidence that there's a long term consequence of this, in that, they tend to have lower test scores, a greater chance of repeating classes, and much higher rates of neurodevelopment and cognitive and behavioral problems later on in life. We are just starting to see this growing. it has been estimated that through birth certificates, there were 375 children born, with NAS between 1999 and 2022. Using birth certificate data, they estimate that this is probably understating the problem by a half. And think of there's probably 700, 000 children in the United States right now, that are suffering from this. in the state of West Virginia, 6 percent of babies are born with NAS. Nationwide, it's about 0. 8%. the problem is just staggering in that state. All right, the other thing I think we have to worry about tremendously in terms of the, this, any expenditures we make is that we have to be vigilant about unintended consequences. so how do we get into this situation? We got into this situation because back in the 1990s, Doctors said, hey, we have this epidemic of untreated pain, people with chronic conditions are walking around unable to perform their daily tasks because they're in pain. So we need to treat those with prescription opioids, which is a fine goal, but this is really the initial stage of the opioid crisis. We throw on that the advertising that was done by Purdue Pharma, and we end up having a full blown crisis on us. No one intended for this to happen. It did. Um, OxyContin is a drug of choice. it's abused quite heavily. Pharma responds and they reformulate OxyContin to make it, less likely for people to snort or to inject. And what happened, it encouraged a large group of people to shift to heroin, and as a result, we ended up with a heroin problem. Again, it was not intended, it just happened that way. during the early 2000s, there was a lot of methamphetamine that was coming from Mexican drug gangs. The Mexican government cracked down on the imports of raw, levels of pseudo phedrine to decrease the chance that it's made. So what happened then is that this encouraged the, the drug gangs to move from an ephedrine base to a P2P based method of methamphetamine, which just ends up to be so much worse, in terms of many different dimensions of the problem. back in 2018, Trump meets with Xi over dinner at the G20 summit in Buenos Aires. He asked, Xi to categorize fentanyl as a scheduled drug in China to decrease dark web production of the drug that was being sold in the United States that ended up to be relatively successful and that In a very short order a lot of these dark web pages closed down. However, they didn't get rid of the precursors That are used to make fentanyl So they just shipped them in large quantities to Mexican drug gangs who are now producing them in incredibly large quantities bringing across the border so in all of this A lot of good intentions end up having a very large negative result. And in any expenditure that we make, it has to be the case that we have to watch out to make sure that we're not doing harm. How are we going to do that? We're going to, the only way we're going to do that is we have to worry about the evidence base that we're using to try to establish whether these programs are working on right now. there was a question last night. by Pat Brown, who asked, When you're trying to fund these programs, what's the evidence base that you're using? and I think that's a really difficult question. the National Opioid Settlements, And their list of remediation uses the phrase evidence based 22 times. So it's clearly in the forefront, for the people that constructed this, that we need to invest in things that we have some information about. The problem is that there's really no definition of the quality of evidence. and so it could be the case that the focus on evidence based really doesn't restrict things whatsoever. Because anyone can say, oh, I have evidence based programs. We're not asking what the quality of the evidence actually is. And so it could be that there's going to be very little impact of this characteristic. however, I think that there's also another problem here, and that if we take this to its logical extreme, and we have a relatively precise definition of what evidence based policies are, This could be incredibly restrictive in that it fixes the evidence at any point in time and says hey, we can only use the information we have right now. and I would say the stock of evidence may not be so great, otherwise we wouldn't have 100, 000 people dying a year. there's a delicate balance that needs to be considered here about taking some risks on some programs because the stock of evidence that we have right now might not be the best in order to tackle this problem. Okay? It might be safe for governments to spend the money on what we know works right now. but it may not be enough. It might just be incremental changes. and there could be some very large gains from experimentation. Like having, maybe two step processes. You pilot and then you expand when programs that actually work. Last point that I want to make. I think there's a fundamental need for evaluation in everything that we're doing. The plasticity of the epidemic, the unintended consequences, the lack of information we have about what works right now, I think it has to be the case that as we go along, as we fund new interventions, as we talk about new programs, we have to take the role of evaluation important in this context. There is some support for this in the documents, it says monitoring, surveillance, data collection, and evaluation of programs and strategies described in this opioid abatement strategy list are permissible expenditures. Given the number of governments that are going to be receiving funds across large geographies and the specific needs associated with each of these different communities, there's going to be an incredible variety of programs and interventions. What I think we need to do is create a culture of evaluation among the grant recipients that takes this seriously. This has to be the case because someone's problem today is going to be someone else's problem in two years. And therefore, that community needs to know exactly what someone else did to abate this. And the only way that we're going to do this is to take evaluation seriously. Now, the cost of evaluation are real. It does take money, it does take resources. However, you don't need to hire McKinsey. Okay? There is an army of academics out there that are willing to eat a large portion of these costs for you because they want to have the answers. That is their job. That is what we are interested in is expanding knowledge. And so therefore, generate partnerships with academics. Find the local academics that are interested in this issue. They're going to be your friends in this context. I think the benefits of evaluation are incredibly large. There's opportunity for communities to learn from others. The plasticity of this means that we can, it's going to be ever changing in one state versus another, and we can learn from each other, in this particular context. Let me end this by saying, we have to take evaluation seriously. Because some time ago we did not. 1996, Purdue Pharmaceuticals starts advertising OxyContin after its release, and they have this incredibly powerful piece of information that they give to doctors. A study in the New England Journal of Medicine that says only one percent of, people that take opioids are going to become addicted to it. Study by, Porter and Jick. Now, what's that study? that study is actually A hundred word letter to the editor that talks about what is the chance of opioid addiction when you receive in hospital, opioids from physicians after your surgery. What is OxyContin, what was Purdue Pharmaceuticals trying to do? Encourage people to take opioids for the rest of their life. This is what we in statistics call an out of sample prediction. back then, physicians did not take the evaluation seriously. They did not take the evidence seriously. They did not look up this 100 word study. Had they, maybe we wouldn't be in the situation we're in. And so therefore, let's take evaluation seriously now as we're moving forward so we have the data that's necessary from us in order to answer those questions. Those are some of the observations I have on this. Thank you for your attention. I really appreciate it, and we'll go on from there. So we're gonna do Q& A now. We have some, one, where's the second one? Over there? Okay, so if anyone has a question,

3: 22:23

go ahead. Yeah, so you can just

4: 22:26

I'm Joanne Cogdell from Naxos Neighbors. In terms of research, one of the things that is very concerning to me is that we do have lots of research on what works and we're not doing it. And so I would propose that it is not good intentions gone wrong, but it is stigma and intentional, not putting resources into the people that need it the most that is causing the problem. So we've known for a long time that syringe service programs. For the first time, a person who goes has a five times more likely to enter into treatment, and three times more likely To remain substance free, but yet we don't fund them. We create legal barriers to them. We know they work, but we're not doing it. So I'm very concerned about additional research about what works if we are not going to take the time and energy and be serious. About giving the money and the resources and legal, pathway to those things that really work that are uncomfortable for us. And secondly, I just wanted to throw out there a question about the educational attainment and its relationship to overdose, because you did say we are looking at deaths. And so I just want to caution that tale, because we're not looking at overdoses. And what we find is that the more educated a person is, the less likely they are to die from an overdose. And about two years ago at the opioid prevention sites in New York City, they saw an enormous influx from 7 a. m. to 9 a. in the morning of professionals coming to be supervised while they used cocaine. Because they knew what was happening, and they knew how to keep themselves safe. I just want to caution about looking at deaths and deciding about the correlation with education, because what it does perhaps tell us is that we're doing a horrible job at educating those who are not professionals about how to stay safe.

2: 24:23

So the interesting thing about, the disparity in education is that if you take a look at usage rates of opioids or other very significant drugs, between low and high education. Low educated maybe have twice the use, two and a half times the use of higher educated people, but they have nine times the deaths. And there is this disconnect. Now, it's also the case that if you take a look at sort of success in things like rehab, higher educated tend to have more, success. so there is this disparity that's happening, and I think things like, support groups are gonna be much smaller for, on average, low educated groups than high educated groups, which the support network means a lot in terms of recovery. So I think there's a lot of disparities between those two groups, that are not just reflected in drug usage rates, because that can't explain all the difference. on your first point, there's this nice webpage, that is put up, on the education side that has fairly extensive summaries of programs that have quality evidence that work in terms of what programs work in education. I don't think we have something, remotely like that on the substance abuse side. And so if you're a local official in a small rural county, you're stuck in terms of figuring out what you're going to make an investment in because it's not easy necessarily for you to figure out where to make that investment. And so one thing that could be done is, take some of these resources to put together a What Works webpage. so people have the information that's available, have some people make some decisions about what is quality evidence. I think that would be incredibly useful expenditure that could be made to make this thing a little bit easier for local officials to make decisions about where to make expenditures.

5: 26:19

Thank you. I was curious to know if there are studies or correlation between children who are prescribed Ritalin, or other drugs to assist them in focusing from kindergarten or preschool on. to what do we see when they are young adults or adults in terms of use of other types of drugs or stimulants? Because I think there's some interesting questions to be asked between what goes on in that space as well as to people who maybe come to it from a pain side of things.

2: 26:51

Yeah, I'm not, I don't know of whether there's, some, long term evidence on child ritalin use in an adult. I'm not sure about that. I know the data constraints to actually answer that question are relatively high, because you need data that spans a long period of time. There is some, research that's going on now that's trying to take a look at what are some of the long term economic consequences of childhood ritalin use, and we're a little bit better, at, taking a look at that because I can get data on your earnings from administrative records. I have a more difficult time necessarily identifying your drug use through administrative records. So I think we're good. starting to worry about that question right now, but I don't know what research there is, but that's a really important question.

1: 27:38

Thank you, Bill.