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Are We Reviving Too Many Opioid Overdoses? Is This Really a Question?

A new paper suggests the overdose-reversing drug naloxone presents a “moral hazard.” The economists’ case is built on an immoral premise.

A new paper by economists at the University of Virginia and the University of Wisconsin suggests that naloxone, the life-saving antidote for opioid overdoses, might actually be bad for society. The researchers decided to look at what happened before and after naloxone became more widely available in various parts of the United States and ended up drawing appalling connections between access to naloxone and an increase in opioid-related crimes, theft, and ER visits.

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Suppose, for a moment, that these findings are true (though a thoughtful debate on the methodology broke out on Twitter almost immediately). The implication is that naloxone merely keeps criminals alive longer providing them the opportunity to do more crime, and that because of this, it would seem to follow, perhaps we ought to reconsider expending resources toward keeping these societal miscreants from dying at the hands of their own woes.

Until now, I had not realized that economists and public policy experts were in the habit of advocating, if obliquely, for de facto death sentences for opioid-related crimes. While the term “moral genocide” seems extreme, it certainly comes to mind. As an ER physician, let me verify for the record that even if naloxone availability increases opioid-related ER visits, I’m just fine with that.

Knowing an oncoming train when they see it, the authors explicitly pre-empt expected accusations that they are arguing against naloxone availability. After 26 pages of hand-wringing, in which human lives are weighed against societal woes of theft and ER visits, with language peppered with demeaning terms such as “opioid abuser” and cherry-picked anecdotes about kids having Narcan parties, the authors want us to believe that they are just simple economists innocently reporting the facts and that all they mean to say, dear reader, is that we need to do more than simply expand naloxone access. (They note in their conclusion that their findings “do not necessarily imply” that naloxone access should be reduced but that local treatment options should be increased.) But if that were the case, they would not have titled their paper “The Moral Hazard of Lifesaving Innovations: Naloxone Access, Opioid Abuse, and Crime,” and instead opted for something along the lines of “Naloxone Is Not Enough: Factors Associated With Long-Term Health and Social Outcomes.”

Instead, their paper offers takeaways such as “the moral hazard generated by Naloxone is indeed a problem.” While the term moral hazard is an economic term meaning that people engage in riskier behaviors when the consequences are lessened, the authors seem to have embraced a broader definition as well. They quote a Dayton, Ohio, police officer who complained of having to give naloxone to the same person 20 times, submitting that saving one man’s life repeatedly is, and this is an actual quotation, “a waste of police resources.” Citing this quotation in an academic paper leaves very little room to think this data set was designed to be anything other than ammunition for righteous crusaders who think, from the perch of public policy, that a very good way to solve the problems of opioid users might be to just “Let Them Die.”

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Let us not pretend that research like this focusing on opioids is random. As my Brigham and Women’s Hospital and Harvard Medical School colleague Scott Weiner (an expert on opioid treatment) points out, medical treatments for opioid addiction receive particularly negative attention because of the moral undertones associated with drug addiction. “Imagine that there is a drug, which treats diabetes, yet people’s diet and exercise habits keep worsening, causing more cases of diabetes. You wouldn’t blame the drug that is trying to treat the condition,” he said. “You’d instead figure out the underlying cause—in this case more potent synthetic opioids, which have permeated the illicit drug marketplace.”

More troubling is the authors failure to reckon with the concept of linear time. Naloxone saves lives in the short term, they allow, but may not in the long run because users become emboldened and engage in even riskier behaviors (again, the moral hazard argument, similar to one that seat belt advocates eventually licked in the 1970s). While this observation correctly conveys the importance of expanding opioid treatment programs, it appears callously indifferent to the forward arrow of that ever pesky fourth dimension, which insists that tomorrow occur after today. “We can’t give patients opportunities to access other evidence-based opioid therapies if they’re already dead,” said Alister Martin, a resident emergency physician at Brigham and Women’s Hospital and Massachusetts General Hospital, in Boston, who has worked on bringing long-term treatment planning into emergency rooms.

This shines light on a common misunderstanding about naloxone. Naloxone saves lives, yes, but it was never intended to be a long-term monotherapy that would solve the opioid crisis. When I treat opioid patients, my goal is to provide them with both short- and long-term treatment options. And in order for long-term remission rates to improve, more work and innovation do remain necessary. We must open more treatment centers, make opioid alternatives easier to access, and even consider supervised drug use. We must do whatever saves lives now and then try to convert those immediate saves into sustained successes. “Naloxone is not the cure for the opioid epidemic. It should be thought of as a life-saving Band-Aid that allows a person to live another day and then attempt to recover,” Weiner said.

So, until we are able to improve aspects of the entire system, and indeed, until we overcome this national crisis, let’s just try to keep everyone alive for as long as possible. I am willing to treat a patient who shows up in my ER overdosing once, twice, or 20 times. While I realize I can’t always make them stop using, I know one thing for certain: I can’t make anyone undead.

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Disclaimer: The opinions expressed in this article are solely those of the author and do not reflect the views and opinions of Brigham and Women’s Hospital.

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