Lack of Education Is Fueling Overdose Crisis

By Pat Anson, PNN Editor

Anti-opioid activists have long claimed that excessive prescribing of opioids over a decade ago created an “epidemic of addiction” that lingers to this day. Once hooked on prescription opioids, patients turned to stronger and more lethal drugs — like heroin and illicit fentanyl — sending the overdose rate to record levels.

A large new study debunks that theory, showing that socioeconomic factors – particularly lack of education -- play a hidden but central role in the overdose crisis.

"The analysis shows that the opioid crisis increasingly has become a crisis involving Americans without any college education," said lead author David Powell, PhD, a senior economist at RAND, a nonprofit research organization. "The study suggests large and growing education disparities within all racial and ethnic groups --- disparities that have accelerated since the beginning of the COVID-19 pandemic."

Powell looked at data from the National Vital Statistics System from 2000 to 2021, and identified over 912,000 fatal overdoses for which there was education information on the people who died.

His findings, published in JAMA Health Forum, show that overdose deaths increased sharply among Americans without a college education and nearly doubled in recent years for those who don’t have a high school diploma. The findings are notable because they came during a period when per capita consumption of prescription opioids plummeted, sinking to levels last seen in 2000.

For people with no college education, the overdose death rate increased from 12 deaths per 100,000 individuals in 2000 to 82 deaths per 100,000 in 2021. That rate is sharply higher than Americans who have some college education. In 2000, their overdose rate was 4.6 deaths per 100,000 people, which rose to 18.6 deaths per 100,000 in 2021.

Trends in Overdose Deaths by Educational Attainment

JAMA HEALTH FORUM

Powell is not the first researcher to link socioeconomic factors to overdose deaths. The so-called “deaths of despair” were first reported in 2015 by Princeton researchers Angus Deaton and Anne Case, who found that economic, social and emotional stress were major factors in the reduced life expectancy of middle-aged white Americans, who increasingly turned to substance abuse to dull their physical and emotional pain.

Education plays a significant role in socioeconomic status. People without college degrees are more likely to have blue-collar jobs requiring manual labor, which raise the risk of work-related injuries and conditions such as arthritis. One recent study found that people who did not finish high school in West Virginia, Arkansas and Alabama were three times more likely to have joint pain compared to those with bachelor degrees in California, Nevada and Utah.

“Overall, the analysis suggests that the opioid crisis has increasingly become a crisis disproportionately impacting those without any college education. Research is needed to understand the driving forces behind this gradient, such as isolating the independent roles of differences in income, employment, family composition, health care access, and other factors,” said Powell.

“Overdose death rates grew during the COVID-19 pandemic, and the education gradient increased further, although it is unclear what role the pandemic had relative to changes in fentanyl penetration in illicit drug markets and other factors.”

Powell says education merits further attention in understanding how and why the opioid crisis continues to intensify and lower U.S. life-expectancy.

Teens Who Abuse Rx Opioids More Likely to Try Heroin

By Roger Chriss, PNN Columnist

A new study from the University of Southern California finds that teens who abuse prescription opioids are more likely to start using heroin by high school graduation.  

Published in JAMA Pediatrics, the study tracked nearly 3,300 students in ten public high schools in the Los Angeles area from 2013-2017. Nearly 600 of those students reported using prescription opioids to get high.

By the end of high school, a total of 70 students had started using heroin, including about 12% of those who abused opioid medication. Only 1.7% of students who did not misuse prescription opioids tried heroin.

The researchers looked closely at not only the nonmedical use of prescription opioids, but also the use of other substances. A family history of smoking, alcohol and drug problems, and interpersonal factors such as impulsiveness, anxiety, depression and delinquent behavior were also assessed.

Among all the different factors, the best predictor of heroin use was the abuse of prescription opioids. This tendency was significantly stronger than the use of alcohol, cannabis, cigarettes or other non-opioid drugs.

"Prescription opioids and heroin activate the brain's pleasure circuit in similar ways," said senior author Adam Leventhal, PhD, director of the USC Institute for Addiction Science. "Teens who enjoy the 'high' from prescription opioids could be more inclined to seek out other drugs that produce euphoria, including heroin.”

Researchers also found that students who initiated heroin use were more likely to be male, have less parental monitoring, more delinquent behavior, and impulsive personalities.

The USC study adds to previous research on the complex drug use trajectories that culminate with heroin. It has long been known that nonmedical prescription opioid use is associated with later heroin use, with some anti-opioid activists claiming that 80% of heroin addicts begin by abusing prescription opioids. That is a misleading statistic, as I discussed in a previous column.

There clearly is an association between the misuse of prescription opioids and heroin use, but as the USC researchers found, many other factors are also involved and more research is needed. Their study, for example, did not look at how teens who misused prescription opioids obtained them.  Most likely, they were obtained from friends or family members.

The USC study findings not only advance our understanding of heroin initiation, but also signal the importance of developing better policies to prevent nonmedical opioid use.

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.