Association Between Automotive Assembly Plant Closures and Opioid Overdose Mortality in the United States

Abstract

IMPORTANCE Fading economic opportunity has been hypothesized to be an important factor associated with the US opioid overdose crisis. Automotive assembly plant closures are culturally significant events that substantially erode local economic opportunities.OBJECTIVE To estimate the extent to which automotive assembly plant closures were associated with increasing opioid overdose mortality rates among working-age adults. DESIGN, SETTING, AND PARTICIPANTSA county-level difference-in-differences study was conducted among adults aged 18 to 65 years in 112 manufacturing counties located in 30 commuting zones (primarily in the US South and Midwest) with at least 1 operational automotive assembly plant as of 1999. The study analyzed county-level changes from January 1, 1999, to December 31, 2016, in age-adjusted, county-level opioid overdose mortality rates before vs after automotive assembly plant closures in manufacturing counties affected by plant closures compared with changes in manufacturing counties unaffected by plant closures. Data analyses were performed between EXPOSURE Closure of automotive assembly plants in the commuting zone of residence. MAIN OUTCOMES AND MEASURESThe primary outcome was the county-level age-adjusted opioid overdose mortality rate. Secondary outcomes included the overall drug overdose mortality rate and prescription vs illicit drug overdose mortality rates. RESULTSDuring the study period, 29 manufacturing counties in 10 commuting zones were exposed to an automotive assembly plant closure, while 83 manufacturing counties in 20 commuting zones remained unexposed. Mean (SD) baseline opioid overdose rates per 100 000 were similar in exposed (0.9 [1.4]) and unexposed (1.0 [2.1]) counties. Automotive assembly plant closures were associated with statistically significant increases in opioid overdose mortality. Five years after a plant closure, mortality rates had increased by 8.6 opioid overdose deaths per 100 000 individuals (95% CI, 2.6-14.6; P = .006) in exposed counties compared with unexposed counties, an 85% higher increase relative to the mortality rate that would have been expected had exposed counties followed the same outcome trends as unexposed counties. In analyses stratified by age, sex, and race/ethnicity, the largest increases in opioid overdose mortality were observed among non-Hispanic white men aged 18 to 34 years (20.1 deaths per 100 000; 95% CI, 8.8-31.3; P = .001) and aged 35 to 65 years (12.8 deaths per 100 000; 95% CI, 5.7-20.0; P = .001). We observed similar patterns of prescription vs illicit drug overdose mortality. Estimates for opioid overdose mortality in nonmanufacturing counties were not statistically significant.CONCLUSIONS AND RELEVANCE From 1999 to 2016, automotive assembly plant closures were associated with increases in opioid overdose mortality. These findings highlight the potential importance of eroding economic opportunity as a factor in the US opioid overdose crisis.

Stigma as a fundamental hindrance to the United States opioid overdose crisis response

“…Given the complexity of the US opioid overdose crisis, an effective response will require a multicomponent portfolio of public health, social, and economic policy interventions to address its social and structural determinants [11][12][13][14][15][16][17]. Health system interventions will also be necessary to implement primary, secondary, and tertiary prevention of opioid overdoses [37].…”

“…Concomitant with the rapid expansion in the magnitude of the opioid overdose crisis is an expansion in its scope, with increasingly syndemic [6] involvement of cocaine and psychostimulants [7][8][9][10]. There are multiple, interrelated, and deeply rooted social and economic determinants of the US opioid overdose crisis, none of which are likely to provide a sufficient explanation for the crisis when considered in isolation [11][12][13][14][15][16][17]. Although the epidemiology of opioid use and opioid use disorders (OUDs) has changed over time, the stigma attached to opioid use has endured [18].…”

Association of Obesity With Prescription Opioids for Painful Conditions in Patients Seeking Primary Care in the US

“…[3][4][5][6] Other researchers have posited that trends in chronic pain, depression, and socioeconomic despair related to stagnant wages, job loss, and declining social status have increased the demand for prescription opioids among patients. [7][8][9][10][11][12][13] Another potential demand-side factor that has received less attention is obesity. Obesity has a strong positive association with chronic pain through a physiologic mechanism of increasing the risk and severity of painful conditions, such as arthritis and low back pain.…”

The Economic Underpinnings of the Drug Epidemic

“…One of the clearest manifestations of this hypothesized process is the recent intensification of diagnoses of substances use disorders (SUDs) and drug overdose deaths (Gaydosh et al 2019;Murphy et al 2018). Both quantitative and qualitative research accounts suggest that local risk environments characterized by dampened economic opportunity can influence substance use Monnat 2019;Venkataramani et al 2020). In this sense, drug deaths may represent a particularly extreme version of individual-level responses to societal pressures.…”