Jennifer Doleac and Anita Mukherjee (D & M) have a controversial paper about policies to increase the use of Naloxone and the effects of those policies on the opioid epidemic. Opioids suppress respiration and overdoses can suppress it entirely. Naloxone is an opioid antagonist which can be administered to overdosed users to block this effect and keep the patient breathing. All 50 US states enacted laws to make the drug more available with the expectation that this would decrease the opioid death rate. D & M argued, however, that these laws had the unintended and paradoxical consequence of increasing opioid use to such a degree that there was no change in the opioid death rate.
Some people believe that this paper implies that doctors and first responders (I’ll just say doctors from here on) should not use Naloxone on overdosed opioid users. Or they believe that it implies that states should not work to increase access to Naloxone. Those people are outraged.* However, those policies don’t follow from D & M’s paper, and I’ll say why here.
From D & M’s abstract:
…many states have increased access to Naloxone, a drug that can save lives when administered during an overdose. However, Naloxone access may unintentionally increase opioid abuse… We exploit the staggered timing of Naloxone access laws to estimate the total effects of these laws. We find that broadening Naloxone access led to more opioid-related emergency room visits… with no reduction in opioid-related mortality. These effects are driven by urban areas and vary by region. We find the most detrimental effects in the Midwest, including a 14% increase in opioid-related mortality in that region.
Here’s the mechanism that, in D & M’s view, explains the paradox. Greater Naloxone availability made opioid use less dangerous. When users learned this, they responded by consuming more opioids. Increased opioid use led to more overdoses. So although a smaller proportion of overdoses were fatal, the death rate stayed the same, and in some regions may have increased. An increase in a risky behaviour in response to measures that reduce its harm is an example of a ‘moral hazard’ problem.‡
For the sake of argument, let’s assume that the moral hazard is real† and see what would follow. Imagine that a doctor is working in a Midwestern ED and that she knows about D & M’s findings. A man stumbles into the ED lobby with shallow breathing and contracted pupils. He falls unconscious to the floor. The doctor recognises an opioid overdose and concludes that the patient will likely die if she doesn’t administer Naloxone. She reflects, however, that the widespread availability of Naloxone in her region has increased the opioid death rate. Should she administer Naloxone?
The doctor can approach this question from at least two moral frameworks. The consequentialist framework looks at all the outcomes of giving or not giving the drug and chooses the action that does the most good (in this example, we’ll reduce ‘doing the most good’ to ‘saving the most lives’). The other framework says that a doctor who can save a patient’s life has the duty to do so, and except in extraordinary circumstances this duty overrides any calculations the doctor might make about outcomes for the population.
So, what does the doctor’s choice look like to a consequentialist? If the doctor gives Naloxone, she will save one life. However, because we have assumed that the moral hazard is real, saving that life will also promote opioid use. In calculating the lives saved, she must subtract an increase in deaths from the life of the patient that she saved in the ED. Conversely, not giving the patient Naloxone costs the ED patient his life but may reduce mortality for other users.
The doctor’s choice is simple. To justify not saving the patient, she would have to believe that her killing the ED patient would save more than one life among the users outside the ED. However, it’s implausible that one additional death on top of more than 50,000 annual opioid deaths would have such an effect. The consequentialist doctor will administer Naloxone.
But, she asks, what if all doctors stopped using Naloxone? Perhaps that would increase the danger of opioid use in a discernible way, possibly leading to fewer total deaths.
This calculation might favour withholding treatment, but only if other doctors also withhold Naloxone. However, other doctors won’t do this because most believe that if they can rescue a dying patient they must do so (this is the second framework). There are many explanations for why doctors have this duty, but almost everyone agrees that there is such a duty.
Moreover, a sophisticated consequentialist doctor would likewise affirm that she has this duty. Medicine wouldn’t work if doctors didn’t behave this way. Health care requires patients to trust doctors to an extraordinary degree: patients allow themselves to be rendered unconscious on tables so that surgeons can cut into them! We wouldn’t do this if we didn’t trust in doctors’ commitments to our well-being. Except in battlefield triage, doctors should not and do not calculate whether to allow one patient to die to save others. Doing so would damage medicine as an institution, with consequences outweighing any possible benefit from undoing the moral hazard of Naloxone.
Bottom line: a possible Naloxone moral hazard raises no questions about the ethical practice of medicine. It may, however, be relevant to public policy choices, including laws affecting the practice of medicine. But do D & M’s findings imply that restricting access to Naloxone is the right policy choice? D & M do not think so.
Our findings do not necessarily imply that we should stop making Naloxone available to individuals suffering from opioid addiction, or those who are at risk of overdose. They do imply that the public health community should acknowledge and prepare for the behavioral effects we find here. Our results show that broad Naloxone access may be limited in its ability to reduce the epidemic’s death toll because not only does it not address the root causes of addiction, but it may exacerbate them. Looking forward, our results suggest that Naloxone’s effects may depend on the availability of local drug treatment: when treatment is available to people who need help overcoming their addiction, broad Naloxone access results in more beneficial effects. Increasing access to drug treatment, then, might be a necessary complement to Naloxone access in curbing the opioid overdose epidemic.
Our policy choices are not limited to ‘increase Naloxone availability’ vs ‘keep Naloxone restricted’. The space of policy choices is much bigger. A third choice would be to:
- Do better at preventing opioid addiction (e.g., by changing opioid prescription strategies and reducing the diversion of prescription drugs),
- Provide better access to addiction treatment for current users, and
- Increase the availability of Naloxone to reduce the harm of overdoses.
Suppose that we could hold the population rate of opioid use constant through (1) and (2) or, better, reduce it. Then increasing Naloxone availability (3) in that context would lower the opioid death toll, despite the moral hazard. Moral hazard models do us a service by showing that harm reduction strategies, although potentially beneficial, may not be sufficient.
*I believe that the outrage is motivated by a concern that viewing Naloxone as a moral hazard will contribute to the devaluing of the lives of opioid users. That those lives are devalued is beyond question. How else to explain the lack of effort to address the epidemic of opioid deaths? What I argue here is that even if Naloxone availability creates a moral hazard, that does not imply that we should not make Naloxone available.
‡’Moral Hazard’ is a deeply unfortunate misnomer. The construct says nothing about the moral character of opioid users.
†The empirical validity of D & M’s paper is, of course, important. It’s just a different question than the one I am addressing here.
