This month, we offer the second installment of our new feature in ACEP Now that highlights key research studies published in this month’s issue of Annals of Emergency Medicine. The following is a summary of “Naloxone ‘Moral Hazard’ Debate Pits Economists Against Physicians” from the August issue of Annals of Emergency Medicine.

An economics research paper arguing that naloxone distribution has had unintended consequences, such as increased crime because opioid users didn’t die from their overdoses, prompted an emotional response from advocates for people with opioid use disorder and criticism about research methods from physicians. Critics cited both the apparent underlying message of the paper and its analytical methods.

The debate, which took place largely via Twitter, illuminated a cultural gulf between the disciplines of economics, working at a more theoretical level, and emergency and addiction medicine, whose practitioners are working with real people struggling with addiction.

What set off many critics was the use of the term “moral hazard” and the paper’s emphasis on criminality. Some readers thought the analysis was making a moral judgment about people with opioid-use disorder. However, one author explained that moral hazard is an economics term that refers to a particular kind of unintended consequence. To their many supporters, the economists were simply following a common practice in their field of looking for moral hazard from public health policies to evaluate their overall impact on society. The researchers wanted to measure what happened after multiple states approved legislation to expand the use of naloxone to reverse opioid overdoses.

They studied opioid-related crime and opioid-related emergency department visits, comparing states that implemented naloxone laws with those that didn’t. They found a 14% increase in opioid-related mortality in the Midwest and “suggestive evidence” that broadening naloxone access increased the use of fentanyl. They concluded there was also an increase in opioid-related arrests correlated to naloxone laws.

Critics said the state laws studied were highly variable and the time period too short to understand the laws’ effects and whether they resulted in actual distribution and use of the reversal drug. They also said that increased ED visits were to be expected, as naloxone use is meant to result in an ED visit, and that ED use rose during the same time period with Medicaid expansion. The economist authors reanalyzed parts of their work in response to criticism and said their conclusions remained valid.

Jan Greene is a health care writer based in northern California.

Reference

1. Doleac JL, Mukherjee A. The moral hazard of lifesaving innovations: naloxone access, opioid abuse, and crime. SSRN website. Accessed July 22, 2018.