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Giving Compass' Take:
• Elias Nosrati, Jacob Kang-Brown, Michael Ash, Martin McKee, Michael Marmot, and Lawrence P King investigated the relationship between drug use disorders and economic decline, incarceration rates, and mortality.
• How can funders work to address the underlying causes of drug use disorders?
• Learn about harm reduction as a cure for the opioid crisis.
The USA has an ongoing epidemic of opioid addiction, with age-standardized mortality rates from drug use disorders increasing by more than 600% since 1980.1More than 72000 overdose deaths occurred in 2017, making drug use disorders the second leading cause of death nationwide for people aged 15–49 years in the USA. The number of overdose deaths has increased in every county since 1980, but at considerably different rates, ranging from 8% to more than 8000%. Popular understanding of the unprecedented increase in overdose deaths focuses on the role of pharmaceutical companies in increasing the availability of opioid pain medication and, once addiction has been established, affected individuals substituting prescription opioids with heroin and fentanyl.
Another body of research emphasizes the increasing demand for drugs, driven by economic decline and downward social mobility. However, this research remains inconclusive and does not explain the geographical variation in such deaths. We argue that these two explanations, although valid, are incomplete and that incarceration represents another major driver of the epidemic in drug-related deaths. Extensive evidence has linked incarceration to various factors that are associated with drug overdoses, including stigma, unemployment, family disruption, and neighborhood decline. In the USA, individuals are incarcerated in either state prison or local jail. In 2014, 1562300 people were incarcerated in state and federal prisons, usually serving a sentence of 1 year or longer, whereas 744600 people were incarcerated in local jails, most of whom were in pretrial detention. Although at any time point jails hold about half as many people as state prisons, in 2014, 11.4 million people were admitted to jail, which is almost 20 times higher than the 626096 people admitted to prisons each year.
More than half a million drug-related deaths have occurred in the USA in the past three and half decades, however, no studies have investigated the association between these deaths and the expansion of the incarcerated population, which began in the mid-1970s. In this analysis, we aimed to use previously unavailable panel data to examine the association between incarceration rates and drug-related deaths.
We empirically tested the associations between reduced household income (as a measure of economic decline), incarceration, and age-standardized mortality rates from drug use disorders between 1983 and 2014. We used previously unavailable jail and prison incarceration county-level panel data from the Vera Institute of Justice and mortality data from the US National Vital Statistics System. We confirmed the association between household income and drug-related deaths that has been hypothesized in the existing literature, and highlight a second and largely neglected determinant of the overdose epidemic—jail and prison incarceration rates—which together might be better predictors of overdose deaths than local opioid prescription rates alone. Our study adds to the scientific understanding of the public health crisis in the USA and could have major implications for public policy.