Currently Viewing:
Supplements Deaths, Dollars, and Diverted Resources: Examining the Heavy Price of the Opioid Epidemic
The Economic Burden of the Opioid Epidemic on States: The Case of Medicaid
Douglas L. Leslie, PhD; Djibril M. Ba, MPH; Edeanya Agbese, MPH; Xueyi Xing, PhD; and Guodong Liu, PhD
Estimated Costs to the Pennsylvania Criminal Justice System Resulting From the Opioid Crisis
Gary Zajac, PhD; Samaan Aveh Nur, BA; Derek A. Kreager, PhD; and Glenn Sterner, PhD
Considering the Child Welfare System Burden From Opioid Misuse: Research Priorities for Estimating Public Costs
Daniel Max Crowley, PhD; Christian M. Connell, PhD; Damon Jones, PhD; and Michael W. Donovan, MA
The Opioid Epidemic, Neonatal Abstinence Syndrome, and Estimated Costs for Special Education Services
Paul L. Morgan, PhD; and Yangyang Wang, MA
Opioid Misuse, Labor Market Outcomes, and Means-Tested Public Expenditures: A Conceptual Framework
Joel E. Segel, PhD; Yunfeng Shi, PhD; John R. Moran, PhD; and Dennis P. Scanlon, PhD
Participating Faculty
Currently Reading
Preventing the Next Crisis: Six Critical Questions About the Opioid Epidemic That Need Answers
Dennis P. Scanlon, PhD; and Christopher S. Hollenbeak, PhD
The Cost of the Opioid Epidemic, In Context
Sarah Kawasaki, MD; and Joshua M. Sharfstein, MD
The Opioid Epidemic: The Cost of Services Versus the Cost of Despair
Alonzo L. Plough, PhD, MPH

Preventing the Next Crisis: Six Critical Questions About the Opioid Epidemic That Need Answers

Dennis P. Scanlon, PhD; and Christopher S. Hollenbeak, PhD
The articles and commentaries in this special issue of The American Journal of Managed Care® add to a growing body of literature on the opioid epidemic that has plagued the United States since extended-release oxycodone hydrochloride (OxyContin) was approved by the FDA in 1995.1 Although other published studies have focused on various aspects of the epidemic, including the clinical efficacy and addictive properties of opioids or strategies to prevent addiction and treat opioid use disorder,2-14 the articles in this issue focus on the costs to state governments. Although the policy that ushered in the opioid epidemic was established at the national level, state governments and associated municipal governments, along with families and individuals, have borne the brunt of the costs. States, counties, cities, towns, and villages are ground zero for the epidemic, representing the political boundaries within which overdose occurs and where services are delivered to those who are harmed by opioids. As illustrated in the articles presented in this supplemental publication, the services provided by state and local governments are significant and costly, spanning well beyond healthcare for treatment15 and prevention.16 Other costs are associated with policing, judicial services, and corrections17; administering programs for children and families impacted by the epidemic18; the education system, including the provision of special education services for children born with neonatal abstinence syndrome19; reductions in revenues that are received from states in the form of income and sales taxes due to work force exits; and additional expenses for administering other means-tested programs, such as food or income support programs.20

Aggregate data speak volumes, with alarming trends in mortality, morbidity, healthcare, and social program costs well documented in the collection of articles published in this supplemental issue and elsewhere.21-26 In this commentary, we raise several important, broader questions that we believe have not received sufficient attention but are critically important for learning from the current opioid epidemic and preventing the potential burdens that could be associated with the next epidemic.

What Are the Real Opportunity Costs of the Opioid Epidemic?

Economists use the term “opportunity cost” to acknowledge that using resources for one purpose reduces or eliminates the ability to use those resources for a different purpose. This concept, which has enormous societal implications, is perhaps best understood in the context of an individual family’s budget. If the refrigerator breaks and needs to be replaced, then the funds used for the replacement are no longer available for other purposes, such as paying for meals or gas for the car. The same is true in society, where governments operate within fixed budgets but face unexpected circumstances that require the immediate expenditure of resources, such as responding to a natural disaster. 

The opioid epidemic is one of those circumstances in which the crisis has required an immediate response by state and local governments to “pick up the pieces” through the provision of social services at a magnitude and cost that were unthinkable prior to 1995. The amount of money spent on first responders and medical treatments and the number of children left parentless because of the epidemic is enormous.27-30 Few individuals question whether state governments should be responding to the social needs of their constituents; however, less has been written about what has been relinquished—that is, the true opportunity costs—because of this response, along with the broader impact that this has on states and their citizenry. This is an important omission and one that needs to be discussed, not only to compensate states, but also to engage more constituents in understanding how those who are not directly affected by the epidemic lose out as a result.

Every taxpayer should realize that the opportunity cost of having to expend resources on providing services related to the opioid epidemic has resulted in fewer or inferior services that add value and enhance the well-being of society. For example, with state budget money being diverted to the epidemic, less has been spent on repairing aging transportation infrastructure. Additionally, less money has been spent on public education, including the amount spent on teachers and students, likely exacerbating the large gap in education and performance that exists compared with other industrialized countries in areas like science, technology, engineering, and mathematics. Moreover, fewer resources have undoubtedly been available for economic development and investments in job creation for the future.

In short, much of the press coverage and public discourse about the opioid epidemic has been focused disproportionately on assigning blame and highlighting the direct costs, such as the most recent death count or the latest attempt to make naloxone treatment available to the public without a prescription. Much less attention has been placed on the fact that because of the opportunity costs, every American has borne the brunt and will continue to withstand the harmful effects of resources being diverted to the epidemic—funds that could have been made available for a more productive societal use if the opioid epidemic had been avoided. These damages are currently being considered in the pending multidistrict legislation in the Cleveland District,31 as well as in the myriad other lawsuits and settlements, such as in Oklahoma, where the state government is trying to recover expenditures from those alleged to have created the epidemic—primarily drug manufacturers and distributors—in efforts that are reminiscent of the tobacco settlement of 1998.32-37 Regardless of the outcome of these lawsuits, it seems certain that any damages that are awarded will not come close to covering the opportunity costs of the epidemic. In this sense, it is critical that constituents, community leaders, and politicians learn from this disaster and do everything in their power to ensure that the next similar preventable epidemic does not occur and further divert public resources that should otherwise be used to advance society.

Has the Federal Government Failed States by Inadequately Performing Its Fiduciary Responsibility?

Federalism in the United States means that the power and authority to govern are intentionally divided between the federal and state governments, with specific responsibilities delegated to each governmental unit. This concept is critical when we think about responsibilities in the opioid epidemic and whether various governmental entities charged with oversight have adequately performed their fiduciary responsibilities. Although state governments are responsible for certain areas, such as medical professional licensure and the regulation of health insurance within the state’s borders, other responsibilities related to the opioid epidemic fall to the federal government to organize and regulate on behalf of all states.

For example, rather than having 50 states independently regulate the safety and efficacy of pharmaceuticals, which would be quite costly, individual commonwealths, instead, defer to the FDA. In the case of the opioid epidemic, criticism has been directed at the FDA for the initial decision to approve prescription opioids; there was additional criticism for delaying to act after the addictive properties of these compounds became clear. The FDA has also been disparaged for failing to take action against drug manufacturers for the allegedly unethical and deceptive advertising that was used to market drugs.38 In response to this, a 2017 Consensus Report released by the National Academies to address prescription opioid misuse recommended that the FDA adopt stricter policies regarding how opioids are advertised to the public and to prescribers.39

Has the FDA failed in its fiduciary responsibility to the states by not providing the appropriate oversight required? Equally important is the question of whether the FDA is capable of making the right decisions to prevent the next looming epidemic, which has the potential to wreak similar havoc on the states. These are complex questions that cannot be answered in this commentary; however, they are critical questions, and answering them will require the balanced consideration of several important points, 3 of which will be highlighted below.

First, as part of the scientific process for drug approval, historically, the FDA has focused on efficacy and safety.39 Addictive properties should certainly be considered part of a drug’s safety profile before it reaches market, but it is unclear whether the FDA’s approval process includes appropriate and durable mechanisms to account for the likelihood of patient addiction, particularly with such controlled substances as narcotics.40 The FDA did not identify these significant addictive risks and associated sequelae prior to the release of each opioid drug to market.41

Second, as the alarming mortality rate rose, the devastation brought about by these drugs became clear, and the deceptive nature of opioid drug advertising by industry became more obvious.42 If the FDA becomes aware of drug advertising that is inconsistent with FDA-approved product labeling, it issues the drug manufacturer a written notice requesting that the material be withdrawn.39 However, beyond that, drug advertisements are not required to receive preapproval from the FDA prior to the release of the promotional material to the public. To prevent the next epidemic, a serious conversation about the FDA approval process, as well as about postapproval drug monitoring and management, is critically needed. In fact, it has been suggested and outlined in the 2017 consensus statement of the National Academies.39

Third, the FDA has been criticized for being “captured” by the very industry it is supposed to regulate—the pharmaceutical industry—based on how the FDA receives its financial resources from industry and the perceived favors associated with relationships between FDA regulators and industry.43 For example, news stories have documented how FDA employees who worked on opioid regulation accepted high-paying jobs with Purdue—the company at the epicenter of current lawsuits.44 This raises the question of whether appropriate procedures and firewalls are in place to prevent the ethical compromises that can occur when the regulator is “captured” by industry. Since states rely on the federal government to perform these critical roles, it is important to assess whether that will prevent the next epidemic.

Copyright AJMC 2006-2020 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
Welcome the the new and improved, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up