Dataset Information

Association Between Automotive Assembly Plant Closures and Opioid Overdose Mortality in the United States: A Difference-in-Differences Analysis.

ABSTRACT: Importance:Fading economic opportunity has been hypothesized to be an important factor associated with the US opioid overdose crisis. Automotive assembly plant closures are culturally significant events that substantially erode local economic opportunities. Objective:To estimate the extent to which automotive assembly plant closures were associated with increasing opioid overdose mortality rates among working-age adults. Design, Setting, and Participants:A county-level difference-in-differences study was conducted among adults aged 18 to 65 years in 112 manufacturing counties located in 30 commuting zones (primarily in the US South and Midwest) with at least 1 operational automotive assembly plant as of 1999. The study analyzed county-level changes from January 1, 1999, to December 31, 2016, in age-adjusted, county-level opioid overdose mortality rates before vs after automotive assembly plant closures in manufacturing counties affected by plant closures compared with changes in manufacturing counties unaffected by plant closures. Data analyses were performed between April 1, 2018, and July 20, 2019. Exposure:Closure of automotive assembly plants in the commuting zone of residence. Main Outcomes and Measures:The primary outcome was the county-level age-adjusted opioid overdose mortality rate. Secondary outcomes included the overall drug overdose mortality rate and prescription vs illicit drug overdose mortality rates. Results:During the study period, 29 manufacturing counties in 10 commuting zones were exposed to an automotive assembly plant closure, while 83 manufacturing counties in 20 commuting zones remained unexposed. Mean (SD) baseline opioid overdose rates per 100?000 were similar in exposed (0.9 [1.4]) and unexposed (1.0 [2.1]) counties. Automotive assembly plant closures were associated with statistically significant increases in opioid overdose mortality. Five years after a plant closure, mortality rates had increased by 8.6 opioid overdose deaths per 100?000 individuals (95% CI, 2.6-14.6; P?=?.006) in exposed counties compared with unexposed counties, an 85% higher increase relative to the mortality rate that would have been expected had exposed counties followed the same outcome trends as unexposed counties. In analyses stratified by age, sex, and race/ethnicity, the largest increases in opioid overdose mortality were observed among non-Hispanic white men aged 18 to 34 years (20.1 deaths per 100?000; 95% CI, 8.8-31.3; P?=?.001) and aged 35 to 65 years (12.8 deaths per 100?000; 95% CI, 5.7-20.0; P?=?.001). We observed similar patterns of prescription vs illicit drug overdose mortality. Estimates for opioid overdose mortality in nonmanufacturing counties were not statistically significant. Conclusions and Relevance:From 1999 to 2016, automotive assembly plant closures were associated with increases in opioid overdose mortality. These findings highlight the potential importance of eroding economic opportunity as a factor in the US opioid overdose crisis.

SUBMITTER: Venkataramani AS

PROVIDER: S-EPMC6990761 | biostudies-literature | 2020 Feb

REPOSITORIES: biostudies-literature

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Association Between Automotive Assembly Plant Closures and Opioid Overdose Mortality in the United States: A Difference-in-Differences Analysis.

Venkataramani Atheendar S AS Bair Elizabeth F EF O'Brien Rourke L RL Tsai Alexander C AC

JAMA internal medicine 20200201 2

<h4>Importance</h4>Fading economic opportunity has been hypothesized to be an important factor associated with the US opioid overdose crisis. Automotive assembly plant closures are culturally significant events that substantially erode local economic opportunities.<h4>Objective</h4>To estimate the extent to which automotive assembly plant closures were associated with increasing opioid overdose mortality rates among working-age adults.<h4>Design, setting, and participants</h4>A county-level diff ...[more]

PMID: 31886844

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Project description:Importance:The Patient Protection and Affordable Care Act (ACA) permits states to expand Medicaid coverage for most low-income adults to 138% of the federal poverty level and requires the provision of mental health and substance use disorder services on parity with other medical and surgical services. Uptake of substance use disorder services with medications for opioid use disorder has increased more in Medicaid expansion states than in nonexpansion states, but whether ACA-related Medicaid expansion is associated with county-level opioid overdose mortality has not been examined. Objective:To examine whether Medicaid expansion is associated with county?×?year counts of opioid overdose deaths overall and by class of opioid. Design, Setting, and Participants:This serial cross-sectional study used data from 3109 counties within 49 states and the District of Columbia from January 1, 2001, to December 31, 2017 (N?=?3109 counties ×?17 years?=?52?853 county-years). Overdose deaths were modeled using hierarchical Bayesian Poisson models. Analyses were performed from April 1, 2018, to July 31, 2019. Exposures:The primary exposure was state adoption of Medicaid expansion under the ACA, measured as the proportion of each calendar year during which a given state had Medicaid expansion in effect. By the end of study observation in 2017, a total of 32 states and the District of Columbia had expanded Medicaid eligibility. Main Outcomes and Measures:The outcomes of interest were annual county-level mortality from overdoses involving any opioid, natural and semisynthetic opioids, methadone, heroin, and synthetic opioids other than methadone, derived from the National Vital Statistics System multiple-cause-of-death files. A secondary analysis examined fatal overdoses involving all drugs. Results:There were 383?091 opioid overdose fatalities across observed US counties during the study period, with a mean (SD) of 7.25 (27.45) deaths per county (range, 0-1145 deaths per county). Adoption of Medicaid expansion was associated with a 6% lower rate of total opioid overdose deaths compared with the rate in nonexpansion states (relative rate [RR], 0.94; 95% credible interval [CrI], 0.91-0.98). Counties in expansion states had an 11% lower rate of death involving heroin (RR, 0.89; 95% CrI, 0.84-0.94) and a 10% lower rate of death involving synthetic opioids other than methadone (RR, 0.90; 95% CrI, 0.84-0.96) compared with counties in nonexpansion states. An 11% increase was observed in methadone-related overdose mortality in expansion states (RR, 1.11; 95% CrI, 1.04-1.19). An association between Medicaid expansion and deaths involving natural and semisynthetic opioids was not well supported (RR, 1.03; 95% CrI, 0.98-1.08). Conclusions and Relevance:Medicaid expansion was associated with reductions in total opioid overdose deaths, particularly deaths involving heroin and synthetic opioids other than methadone, but increases in methadone-related mortality. As states invest more resources in addressing the opioid overdose epidemic, attention should be paid to the role that Medicaid expansion may play in reducing opioid overdose mortality, in part through greater access to medications for opioid use disorder.

Project description:ImportanceDeaths due to opioid overdose have tripled in the last decade. Efforts to curb this trend have focused on restricting the prescription opioid supply; however, the near-term effects of such efforts are unknown.ObjectiveTo project effects of interventions to lower prescription opioid misuse on opioid overdose deaths from 2016 to 2025.Design, setting, and participantsThis system dynamics (mathematical) model of the US opioid epidemic projected outcomes of simulated individuals who engage in nonmedical prescription or illicit opioid use from 2016 to 2025. The analysis was performed in 2018 by retrospectively calibrating the model from 2002 to 2015 data from the National Survey on Drug Use and Health and the Centers for Disease Control and Prevention.InterventionsComparison of interventions that would lower the incidence of prescription opioid misuse from 2016 to 2025 based on historical trends (a 7.5% reduction per year) and 50% faster than historical trends (an 11.3% reduction per year), vs a circumstance in which the incidence of misuse remained constant after 2015.Main outcomes and measuresOpioid overdose deaths from prescription and illicit opioids from 2016 to 2025 under each intervention.ResultsUnder the status quo, the annual number of opioid overdose deaths is projected to increase from 33 100 in 2015 to 81 700 (95% uncertainty interval [UI], 63 600-101 700) in 2025 (a 147% increase from 2015). From 2016 to 2025, 700 400 (95% UI, 590 200-817 100) individuals in the United States are projected to die from opioid overdose, with 80% of the deaths attributable to illicit opioids. The number of individuals using illicit opioids is projected to increase by 61%-from 0.93 million (95% UI, 0.83-1.03 million) in 2015 to 1.50 million (95% UI, 0.98-2.22 million) by 2025. Across all interventions tested, further lowering the incidence of prescription opioid misuse from 2015 levels is projected to decrease overdose deaths by only 3.0% to 5.3%.Conclusions and relevanceThis study's findings suggest that interventions targeting prescription opioid misuse such as prescription monitoring programs may have a modest effect, at best, on the number of opioid overdose deaths in the near future. Additional policy interventions are urgently needed to change the course of the epidemic.

Project description:Importance:The use of benzodiazepines or alcohol together with opioids increases overdose risk, but characterization of co-involvement by predominant opioid subtype is incomplete to date. Understanding the use of respiratory depressants in opioid overdose deaths (OODs) is important for prevention efforts and policy making. Objective:To assess the prevalence and number of alcohol- or benzodiazepine-involved OODs by opioid subtypes in the United States from 1999 to 2017. Design and Setting:This repeated cross-sectional analysis used data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (WONDER) database of all opioid-involved poisoning deaths from January 1, 1999, to December 31, 2017, for the United States. State-level binge drinking prevalence rates for 2015 to 2017 were obtained from the Behavior Risk Factor Surveillance System of the Centers for Disease Control and Prevention, and benzodiazepine prescribing rates for 2012 (most recent available data) were obtained from IMS Health, a commercial database. Data were analyzed from July 10, 2018, to May 16, 2019. Main Outcomes and Measures:Prevalence of alcohol or benzodiazepine co-involvement for all OODs and by opioid subtype, nationally and by state. Results:From 1999 to 2017, 399?230 poisoning deaths involved opioids, of which 263 601 (66.0%) were male, and 204?560 (51.2%) were aged 35 to 54 years. Alcohol co-involvement for all opioid overdose deaths increased nonlinearly from 12.4% in 1999 to 14.7% in 2017. By opioid subtype, deaths involving heroin and synthetic opioids (eg, fentanyl; excluding methadone) had the highest alcohol co-involvement at 15.5% and 14.9%, respectively, in 2017. Benzodiazepine co-involvement in all OODs increased nonlinearly from 8.7% in 1999 to 21.0% in 2017. Benzodiazepines were present in 33.1% of prescription OODs and 17.1% of synthetic OODs in 2017. State-level rates of binge drinking were significantly correlated with alcohol co-involvement in all OODs (r?=?0.34; P?=?.02). State benzodiazepine prescribing rates were significantly correlated with benzodiazepine co-involvement in all OODs (r?=?0.57; P?<?.001). Conclusions and Relevance:This study found that alcohol and benzodiazepine co-involvement in opioid-involved overdose deaths was common, varied by opioid subtype, and was associated with state-level binge drinking and benzodiazepine prescribing rates. These results may inform state policy initiatives in harm reduction and overdose prevention efforts.

Dataset Information

Association Between Automotive Assembly Plant Closures and Opioid Overdose Mortality in the United States: A Difference-in-Differences Analysis.

Publications

Association Between Automotive Assembly Plant Closures and Opioid Overdose Mortality in the United States: A Difference-in-Differences Analysis.

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