A new research paper on the life-saving medication naloxone, which reverses opioid overdoses, is spreading dangerous misinformation that could cost lives.
The paper is entitled The Moral Hazard of Lifesaving Innovations: Naloxone Access, Opioid Abuse, and Crime, and is authored by two US researchers: Jennifer L. Doleac and Anita Mukherjee. The paper claims that access to naloxone – one of the WHO’s essential medicines – encourages “riskier behaviours with respect to opioid abuse”, increases “opioid-related theft”, and does not reduce opioid-related deaths.
The paper has not been peer-reviewed, yet its findings have been widely cited in the press – including by the Washington Post and CNN. Though less than two weeks have passed since its publication, this paper has the potential to have profound effects on public policy; it is ammunition for the countless policymakers and press pundits who would rather perpetuate the failure of prohibition than introduce policies that reduce harm.
The most devastating aspect of this story is that the paper itself is wholly misleading; the premise and assumptions made undermine the paper’s methodology, rendering its conclusions meaningless.
The paper claims to be studying “naloxone access”, yet makes little effort to measure how accessible naloxone is.
How can a variable like naloxone access be measured? There’s no single answer. When Release investigated the accessibility of take-home naloxone in England, we considered the proportion of people who use opiates that received naloxone to take home, the types of barriers in place for people who want take-home naloxone, and whether target groups – such as people who access needle-syringe programmes – were being provided with the medication.
Unfortunately, the authors of the paper didn’t chose to consider of any these aspects of naloxone access; instead, they considered naloxone access to have been expanded “if a Naloxone law [was] passed at any date within the month”. This is, of course, not an accurate way to understand if naloxone is accessible.
At Release’s research found, despite regulations coming into effect in England in October 2015 to widen naloxone access, many local authorities in the country did not provide take-home naloxone until well over a year later. The medication also continues to be inaccessible to many people across the country.
The authors’ bizarre decision to measure naloxone access by legislative reform invalidates the entire paper, seeing as a legislative change is in no way reflective of the extent of the medication’s provision and its accessibility. The authors recognise that their approach is problematic because it assumes “an ideal scenario [in which] naloxone access laws lead immediately to everyone having easy access to Naloxone when they need it”. Nonetheless, the premise of the research paper relies upon this assumption.
The paper uses a host of other imperfect and strange proxies to measure drug use trends.
The authors state that “while each of the datasets we use is an imperfect proxy for our outcomes of interest, in combination they paint a compelling picture of opioid-related behaviours”. One of the more outlandish examples of this was the decision to use Google search trends to ascertain people’s interests in drug treatment.
The paper claims that a 1.4 per cent decline in Google searches for the term “drug rehab” after naloxone access laws were passed is “consistent with the hypothesis that Naloxone access reduces opioid abusers’ interest in treatment for their addiction”.
Read that one more time.
The authors claim that a 1.4 per cent decline in certain Google searches is evidence that the introduction of naloxone laws dissuades people from seeking help. And that is just one of many such proxies in this paper which are clearly inaccurate for measuring just about anything meaningful.
The study claims that “abuse and overdose involving opioids” rose following changes in naloxone laws by citing increases in opioid-related emergency room visits and increases in arrests for opioid offences.
These factors are not appropriate measurements for the prevalence of problematic use or, as the authors like to say, opioid “abuse”. While opioid-related emergency room visits could be affected by rises in use, numbers could also be affected by a range of other factors – including purity fluctuations, increases in fentanyl contamination, and people feeling more comfortable to contact emergency services after using opioids. There are also any number of reasons for an increase in recorded opioid-related arrests – including intensified policing.
The authors’ bias is demonstrated throughout the piece by their use of dehumanising language about people who use opioids.
The paper consistently makes use of negative clichés and stigmatising language to describe people who use drugs. In one instance, the authors describe their hypothesis of how “saving more addicts' lives increases the stock of drug users and the pool of people who need to fund their addictions”. Note to researchers: if you find yourself referring to any group of people as stock, as if they were goods on a warehouse shelf, you’re doing something seriously wrong.
The authors employ further patronising and infantilising language throughout the paper, in one instance claiming that “it may seem surprising that drug users respond to incentives in a sophisticated way”. Such discourse suggests that the authors had bias and expectations when writing the paper, and that a low standard of evidence was sufficient to confirm these biases.
Instead of engaging with people who work in harm reduction and public health to ascertain the appropriate type of language to use, the authors further demonised and dehumanized an already stigmatised group.
The findings of this majorly flawed study may have serious consequences if used by policymakers and the press to reinforce misconceptions about people who use opioids and naloxone. The paper disregards the intricacies of opioid use and naloxone, and perpetuates stigmatising stereotypes about people who are already marginalised.
In a lengthy tweet-thread responding to this paper, public health expert Leo Beletsky warned that this paper is particularly dangerous because of emerging policies rolling back naloxone access around the US.
“In its current form, this analysis will likely further fuel those restrictions”, he said. “Whether intended or not, its impact will be measured in lost lives that could have been saved by naloxone”.
In its current form, this analysis will likely further fuel those restrictions. Whether intended or not, its impact will be measured in lost lives that could have been saved by naloxone
— Leo Beletsky (@LeoBeletsky) March 12, 2018
Read Leo Beletsky’s full thread on the paper here.
You can also read the paper itself here – The Moral Hazard of Lifesaving Innovations: Naloxone Access, Opioid Abuse, and Crime.