Solving the opioid crisis demands improving the upstream socio-economic problems that creates the fertile environment for despair and subsequent addiction. Initiating a policy that increases jobs and education; reduces poverty, opioid overdoses, and hopelessness; and simultaneously improves the nation’s infrastructure can be realized using previously or proposed appropriated legislation. Before the 2018 election, the Senate approved $8.3B opioid legislation by a vote of 99 to one. Even in hyper-partisan Washington, there was recognition that America is facing an issue. Now let’s get serious.
In 2018, 67,000 Americans lost their lives to overdose. 47,000 due were opioid-related. According to the CDC, for the first time since World War I and the Spanish flu ravaged the country a century ago, life expectancy has dropped three consecutive years in the US, and this is directly attributable to opiates. The same number of Americans who died from combat in all wars since 1775, have died of overdose in the past 20 years.
How can we successfully attack the opioid epidemic? The President’s Commission made 56 recommendations and the sweeping Senate and House legislation contained 70 proposals. No doubt implementing all of these would make a difference, but these are downstream, after the demand and the consumption. While promising better treatment of addicts, the opioid legislation does not include a targeted effort to stop and reverse the huge increases in the demand for opiates by attacking the underlying causes: un- and underemployment, poverty, the perceived need for disability compensation, and poor education.
To be successful, improved medical and law enforcement approaches must be complemented by comprehensive upstream remedies to reduce the demand for drugs because drug abuse is fundamentally a social and economic problem as well as a medical problem.
Joe Biden understands the critical need for and economic dignity of good paying jobs brought by improving the infrastructure. He is proposing a $1T effort. And he understands the necessity to end the opioid crisis, proposing $125B pumped into communities, research, and targeted treatments. President Trump promised $1T infrastructure investment in his campaign in 2016. Nothing happened. He is promising it again in his 2020 campaign. A track record of promises kept is critical in a crisis. With the proposed funds and those already authorized, creating a focused program that could simultaneously produce social and infrastructure improvements could: (1) ameliorate the opioid crisis; (2) Improve infrastructure; and (3) increase jobs.
With the election occurring in November, no substantial legislation will occur before January. However, once the new year comes, Congress should pass, and the president sign an infrastructure bill resulting in good paying jobs, and target spending in the areas of highest opioid use. This two-pronged effort could make a real difference.
Creating infrastructure projects as a partial antidote to opioid use makes economic sense. The annual cost of the opioid crisis is estimated to be $504B, including medical and disability costs, and unemployment compensation. It is estimated that physical infrastructure repairs of $700 Billion per year for the next 7 years. Jobs will reduce the environment for addiction.
Relationships between employment and opioid consumption are clear. According to one economic analysis, as the unemployment rate for a given county increases by one percentage point, the opioid death rate per 100,000 rises by 0.19 (3.6%) and the opioid overdose ED visit rate per 100,000 increases by 0.95 (7.0%).
There are countless examples of successful infrastructure investment that can be models in addressing a social problem like opioid addiction. For example, the creation of federal enterprise, economic, or empowerment zones have seen positive results in nearly every state. Creating a focused program, especially rural and poorer America where the opioid problem is particularly acute, caused by hopelessness and despair, could simultaneously produce social and infrastructure improvements in an economically efficient manner. The employee would be paid for work on the infrastructure project, and together with previously appropriated unemployment benefits, would be above the federal poverty level. Medicaid eligibility would be maintained. The focused program would also pay for vocational education to prepare for the future.
This program would bring worker re-training, a living wage, health benefits, and drug rehabilitation. Enhanced worker skills would be transferable after the infrastructure project is completed. This proposal would not only help stabilize communities with improved infrastructure, but could link hope and opportunity and be the first step in a solution our nation desperately needs.
Richard Boxer, MD is a clinical professor at the David Geffen School of Medicine at UCLA.
Jonathan Fielding, M.D., M.P.H., M.A., M.B.A., is distinguished professor of Health Policy and Management at the UCLA Jonathan and Karin Fielding School of Public Health.
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