Income protection policies can have a supportive role in preventing fatal drug overdoses, new study reports

Drug-involved overdose deaths increased by over 500% in 2022, according to a study at Columbia University Mailman School of Public Health, with trends attributed to synthetic opioids. National data shows that fentanyl and heroin in particular contributed substantially to the rise, particularly since 2014. However, the study also reports that income protection policies can have a supportive role in preventing fatal drug overdoses.

The findings are reported in the International Journal of Drug Policy.

Over 73,000 people died from an overdose in 2020, which subsequently increased to 106,699 people in 2021, a record for the highest number of overdose deaths in one year.

"And in fact, more recently, we entered a fourth wave of the overdose crisis, characterized by fatal overdoses in the context of polysubstance use," says Silvia Martins, MD, Ph.D., professor of Epidemiology at Columbia Public Health.

The COVID-19 pandemic exacerbated economic hardship, and as a result, the U.S government enacted income protection programs in conjunction with existing unemployment insurance (UI) to dampen COVID-19-related economic consequences.

"In the context of financial and economic stressors which are known to increase overdose risk, we hypothesized that we would observe lower levels of overall overdose and opioid deaths given that robust unemployment insurance benefits could be a buffer," said Martins, who is also director of the Substance Use Epidemiology Unit of the Department of Epidemiology at Columbia.

The researchers used data based on responses of 89,914 individuals 18 years of age or older from the pooled 2014—2020 Detailed Restricted Mortality files for all counties from the Centers for Disease Control and Prevention, aggregating at the county-quarter level. Included were deaths from any drug overdose, any opioid overdose, and any stimulant overdose. Data on unemployment insurance was obtained from the U.S. Department of Labor as well as statutes by the individual states.

Data from 30 states collected by the CDC indicates that rates were persistently stable or even increasing, suggesting that increases in overdose deaths observed after the start of the pandemic show minimal signs of abating.

"In fact, treatment disruptions and closures of harm reduction organizations in compliance with social distancing ordinances may have also contributed to worsening substance use morbidity and mortality during this period," noted Martins.

"We also theorized that states and counties with limited safety net policies may increase an individual's social, psychological, and biological vulnerability to developing a drug-use disorder, including opioid and stimulant use disorders. Such policies likely play a significant role in substance use initiation and subsequent development of substance use disorders as well as treatment access for such disorders," Martins noted.

For the entire study period of 2014 to 2020, a more robust weekly benefit replacement rate was inversely associated with fewer fatal overdoses from any drug, including fatal opioid and stimulant overdoses. A replacement of income with a more robust weekly benefit allowance rate was associated with fewer fatal drug, opioid and stimulant overdoses in the pre-COVID-19 period and with fewer fatal overdoses from any drug or stimulant in the COVID-19 period.

An earlier study that examined the relationship between state-level UI robustness and fatal opioid overdoses from 1999 to 2012 supports the current findings, although the research used data from earlier in the overdose epidemic and also different methods were used.

"While their earlier analysis shows that between 1999 to 2012, UI was associated with lower rates of opioid overdoses, our study builds and expands on findings from that research, as we examined the relationship between UI and any drug-involved mortality—including all other drug overdoses and stimulant overdoses—during the fourth wave of the epidemic intertwined with the COVID-19 period," observed Martins. I

In addition, the earlier study only examined fatal overdoses among "prime-age" people aged 25-54, whereas Martins and her team expanded our inclusion criteria to include everyone ages 18 and older.

"Our results therefore reinforce the notion of a call for a broader discussion on the protective role of the safety net programs to buffer drug-related harms," stated Martins.

Co-authors are Luis E. Segura, Megan E. Marziali, Emilie Bruzelius, Natalie S. Levy, Sarah Gutkind, and Kristen Santarin, Columbia Mailman School of Public Health; Katherine Sacks, Milken Institute; and Ashley Fox, University at Albany, SUNY.