S3E8 Drug Related Morbidity and Mortality in Maine: An Economic Perspective

This episode covers an article by Angela Daley, Prianka Sarker, Liam Siguad, Marcella Sorg, and Jamie Wren titled, “Drug-related Morbidity and Mortality in Maine: Lost Productivity from 2015-2020.” After briefly summarizing the article, we speak with Dr. Sorg and Prianka Sarker about the opioid epidemic and how we go about quantifying some of the costs of the opioid epidemic.

[00:00:00] Eric Miller: Of the significant challenges today, few are as insidious as the opioid crisis, which has divided public discourse and devastated communities across the country. In this episode, we’ll recap an article published in 2022, assessing the economic harm of lost labor productivity in Maine.

This is the Maine Policy Matters Podcast from the Margaret Chase Smith Policy Center at the University of Maine. I’m Eric Miller, research associate at the center. On each episode of Maine Policy Matters, we discuss public policy issues relevant to the state of Maine. Today we’ll be covering an article by Angela Daley, Priyanka Sarker, Liam Siguad, Marcella Sorg and Jamie Wren titled, “Drug Related Morbidity and Mortality in Maine: Lost Productivity from 2015 to 2020”. Daley is an assistant professor of economics at the University of Maine. Sarker and Wren are both research associates at the Margaret Chase Smith Policy Center, Sorg is a forensic anthropologist, and Siguad is a research assistant at the Mercatus Center in Arlington, Virginia, who was a graduate student at the time the study was conducted. After briefly summarizing the article, we will speak with Dr. Sorg and Priyanka Sarker about the opioid epidemic and how we go about quantifying some of the costs of the opioid epidemic.

This article is published in Volume 31, issue 1 of Maine Policy Review, a peer reviewed academic journal published by the Margaret Chase Smith Policy Center. For all citations for data provided in this episode, please refer to Daley et al.’s article, which can be found in the episode description.

The increase of prevalence of overdose deaths has been a devastating phenomenon since the pharmaceutical opioids, namely Oxycontin, kicked off an epidemic that has evolved and worsened since the late 1990’s. In addition to the heartbreaking losses, there have been significant economic impacts as well, with Maine ranking among the highest in the nation for per capita overdose death rate as of recent years.

The emotional toll on individuals, families, and communities is far reaching, leading to poor physical and mental health, reduced quality of life, lost productivity, increased accidents and crime, and higher social welfare and healthcare costs. The economic impact is staggering, estimated at just over 1 trillion in 2017 for the United States and 6.8 billion in 2017 for Maine alone. In this paper, Daley et al. use a human capital approach to estimate loss productivity from drug related morbidity and mortality in Maine. This approach measures the lost value to society that occurs when individuals cannot fully contribute to market and non-market activities. For example, individuals may be less likely to participate in the labor market, or they may be less productive due to absenteeism, problems with concentration and memory, impaired judgment or interpersonal challenges. This loss of productivity negatively affects their earnings as well as their productivity of their employers and the economy as a whole. Of course, drug related morbidity and mortality also affect non-market activities, such as household work, caregiving, and volunteering.

There are a lot of statistics and figures published in this piece, so we recommend giving the original article a read if you’re interested in learning more, but we’ll cover some of the major takeaways.

Also, it is important to note that the authors used all illicit drugs, not just opioids, for this analysis. This analysis found that drug related morbidity is lower among females. However, the prevalence of illicit drug use disorder has been increasing for both males and females from 2015 to 2019, and 18-25 year olds are the age group where the percentage of illicit drug use disorder is highest.

The annual loss productivity due to drug-related morbidity on market activities was greater than non-market activities for males, and the inverse is true for females. However, due to the higher prevalence of drug use among males led to higher non-market costs than female non-market costs. In 2019, $40 million in market activity and $62 million in non-market activity was lost among females and among males. $104 million in market activity and $64 million in non-market activity was lost. In total for 2019, approximately $144 million in market activity, and $126 million in non-market activity was lost in Maine due to drug-related morbidity.

Drug related deaths concentrated among individuals aged from 25-64, so there were many years of potential life lost. In fact, the authors found that among individuals aged from 25-54, account for more than 80% of years of loss productivity in 2020. Life loss productivity in 2020 for females was estimated to be valued at $170 million and $564 million for males yielding a total of about $734 million lost for Maine.

Those numbers may be large, but they’re also emitting the reduction in quality of life as well as the value of life. Some estimates that include methods of valuing life lost yield much higher economic costs. All of these approaches to understanding the entire societal effect of the overdose epidemic are helping to inform program and policy decisions that aim to address this crisis.

And now onto our conversation with Dr. Marcy Sorg and Priyanka Sarker.

Thank you both for joining us today as this article covered drug related morbidity and mortality through 2020. While most everyone is aware that the fatal overdose epidemic has gotten worse, what is the current state of the opioid epidemic in Maine and what are some of the primary drivers lately?

[00:06:03] Marci Sorg: The opioid epidemic has really continued to challenge Maine in a lot of ways. I can mention several primary drivers, at least from my perspective, and they’re all really interrelated. First there’s already a large population in Maine that is experiencing addiction to opioids and that population. And it’s probably more than 8% of the population of Maine. It potentially grows whenever new users are persuaded to try opioids. And it potentially decreases when people transition from using drugs to long-term recovery or if they pass away.

And secondly, drug trafficking is an international problem with influences beyond Maine, beyond our borders, and it’s generally out of reach of Maine’s policies. Yet it’s affecting Maine’s epidemic every day.

The third thing I could mention is the particular drugs that are trafficked during the last seven or eight years. Non-pharmaceutical fentanyl has been the most influential of the drugs. Fentanyl is a really rapid acting opioid, and it’s a lot stronger and more potentially lethal than other opioids that were common in the past. And it causes approximately 80% of Maine’s drug deaths, although, most of those drug deaths have more than one drug. So fentanyl’s just one of usually three or four.

The fourth thing that I mentioned, and there are five things altogether is the access to appropriate treatment modalities. And that includes not only the medications like Suboxone and methadone, but also and very important inpatient and outpatient treatment programs and peer support programs.

Maine’s been working pretty hard to increase treatment resources. The fifth thing is stigma. Addiction is still mostly hidden from public view not only from the public at large, but healthcare providers and even users themselves engage in stigmatizing behaviors. It creates barriers to treatment, barriers to problem solving, and it’s a strong barrier to asking for help. Many of the persons who die from overdose are using alone. We believe partly due to stigma. And there may be no one who notices they have overdosed until it’s too late to reverse the overdose. So these are five things that I think are main drivers of the problem in Maine today.

[00:09:10] Eric Miller: Thank you Marci. And as a data researcher on this team myself, it’s really hard to parse exactly how much influence each of those drivers have. And as it is a data scarce problem we can just try to get whatever insights we can. And so, especially since the, in the Covid 19 pandemic coming in 2020, that was hypothesized to be linked toward deaths.

But it’s even really hard to parse out on the data end how much influence Covid-19 has had on fatal overdoses. We just know that it came along with more illicit supply and other such factors and increased housing costs and what have you. The Covid-19 rise in fatal overdoses. How does Maine seem to compare to other states?

[00:10:01] Marci Sorg: After Covid-19 was over there’s still a residual effect that’s pretty important. I think it’s important to also, to mention that the deaths from drug overdoses, they’re a national problem, not just a Maine problem. And it takes up to two years for the state data to filter up to the federal data and be shown in drug rates and overdose rates and so forth.

And, so it takes two years before we can get numbers that’ll allow us to compare one state to another, and that’s a pretty important thing. Right now, we’re in 2023. We are dealing with 2021 data. We have some preliminary data from 22, but mostly it’s 2021. So that is still sort of within the pandemic.

What happens at the federal level when the state data come up is that they get normalized so that the state age structures, for example, are weighted so that they can be compared. So the federal CDC has reported that the US age adjusted drug overdose death rate was 32.4 deaths per a hundred thousand population.

That’s for the country as a whole. The highest rates were in West Virginia and they had 90, Columbia had 63.6 now. So that’s the range for the highest. Maine’s rate in 2021 was 46. For all drugs, that is, not just opioids. It we were number seven in the country for all drugs. If you look just at opioids, we rank at 41.4 deaths per hundred thousand, and that’s number five in the country.

So it’s pretty high. For comparison, Vermont, both Vermont and New Hampshire are less than Maine. Maine’s, vermont was 39.4 and New Hampshire was 30.7. So they’re a little bit lower than Maine, the lowest in the country. By the way, we’re in Nebraska, South Dakota, and Iowa, which were 11 and 13 and 15 respectively.

So that’s a lot lower than these other states, including us. Provisional data for 2022 at least, from our perspective as in collecting those data, it suggests that 2022 increase was about 10%.

[00:12:42] Eric Miller: Very interesting. It’s so hard to, or so fascinating rather, to assess these regional trends and how various populations are affected by different substances more so than others. Because the plain states that have a lower rate of opioid age adjusted rate fatal overdoses, have other substance uses that are more dominant in, in those areas. Not the, to the extent is not necessarily the same across all states and substance epidemic type of course, but it’s, it is something that is, is kind of curious in the public health researcher perspective. And so this. Huge impact, of course, has the human cost. And one difficult thing is assessing and quite often controversial and highly debated thing, is assessing the economic impact of the opioid crisis.

And while there’s several different ways to do it we’ll focus on the one that was discussed in the article that was published in Maine Policy Review, and that is years of Potential Life Lost. So, Priyanka, would you mind explaining the concept of years of potential life lost and how it factors into the calculation of economic cost in this paper?

[00:13:58] Prianka Sarker: Yes, of course. So the concept of years of potential life lost means the years lost due to premature mortality. In other words, when a person dies before an expected normal age, then the gap we have between their age at death and the age that they would have otherwise lived. It’s called the potential years lost.

We have different life expectancy for both males and females based on the age groups and we usually expect people to leave approximately up to that age. For example, if say there is a 40 year old person, we would normally expect them to live, say another 40 years. Now if they die from an avoidable cause like drug overdose today, then we would be losing those 40 years.

So for example, if we have 10 people from that age group dying from overdoses today, then we would have a total of 400 years of potential life lost. Now in our paper, we attempt to calculate the productivity loss that is associated with these years of potential life lost. We tried to measure the value of productivity that would have been possible to achieve, if we could have avoided this drug related deaths that occurred during the study period in the state of Maine. So as long as a person is alive and they’re active, they’re contributing to the economy in various ways, like by working in the labor market, doing household shores, taking care of children, or by volunteering.

So when people die prematurely from drug overdoses, we lose several productive years from their lives. In our paper, we calculate the annual as well as the total lifetime value of these productive years for each person. And once we have an estimate for each person, multiplying that by number of debts, then give us a sense of how much productivity losses are occurring in the state due to this premature deaths.

[00:16:15] Eric Miller: For those of you who would like some more nitty gritty details, you’re more welcome to reference the paper. But that was a great overview of how you all came to those numbers in the paper. So this essay specifically will be included in a larger cost report that I’m actually leading the charge on.

There are several previous iterations of this cost report dating back to 2000. So there’s one published in 2000, 2005 and 2010. And then we’ll be publishing an update that includes 2020 in the near future. Due to the changes in the, and waves in the opioid epidemic is it safe to expect that the economic cost to be increasing.

[00:16:59] Prianka Sarker: I think it’s fairly safe to expect higher economic costs in the upcoming report. As you have said that the current analysis that we have in our paper will form a portion of the last larger cost report, which is under preparation. One reason I reiterate that is in our paper, we only consider the cost from lost productivity.

There are many other costs associated with substance use disorder, such as treatment costs, reduced quality of life, incarceration, social welfare, and such other costs, and as you say, those will be covered in the larger report. So in our paper, even though we focused only on the productivity aspect, still, the numbers are high compared to productivity losses that were calculated in the earlier version of the reports.

The last iteration of the cost report from Maine, which you mentioned in 2010. So that estimated the cost around 1.4 billion. And in 2017, a report which was based on the entire USA. And that focused only on the cost of opioids alone, estimated the cost for Maine to be around 6.8 billion. So just looking at the trends, I think, yes, it’s pretty safe to expect the numbers to be quite high in the upcoming report compared to the earlier ones.

[00:18:26] Eric Miller: Yeah, it’s incredible what’s been happening. And tragic, of course. The larger cost report will also include alcohol, which I think will, which people will find surprising, the degree of alcohol, use related disorders and mortality. And how the magnitude of effect economic costs that has as well.

Because more people die due to alcohol related disorders than opioid. But it’s really difficult to capture all of the alcohol related deaths because if someone dies of old age but was an alcoholic, then it’s considered a natural death. So, we are undercounting in our analysis, but we kind of have to recognize that and state that in our assessment.

So we have addressed the, increased economic cost of lives lost. What are some measures being implemented to address the crisis, and what are some significant barriers we face as public health researchers?

[00:19:26] Marci Sorg: I guess I can answer that. Maine has really been working very hard to address the crisis for a while, and to make those actions visible to the public.

And that’s done on mainedrugdata.org, a website where all the data are kept and updated all the time. I’ll mention just a few things. One of the most important areas has been the increase in distribution of overdose reversal drug, naloxone, or it’s sometimes called Narcan, that’s the trade name.

Naloxone is used by both law enforcement and the emergency system. Both EMS and the emergency room use it as well as community members. They use it to reverse overdoses. If the person’s still found, they are still alive, and the state has distributed hundreds of thousands of doses over the last seven years.

So we, we do publish the absolute numbers of the distribution on the Maine drug data.org website. The second thing I’ll mention is improving access to care in rural areas. The development of the options program, and that acronym stands for Overdose Prevention through intensive Outreach, Naloxone and Safety.

And that program has increased the pathways to recovery and treatment. It uses what’s called a non-responder model. Options liaisons are people that are hired in each county to respond to overdoses talk to the person who survives an overdose, and provide referrals to resources and referrals to treatment, depending on the needs of that person

That program has recently been expanded quite a bit. The third thing I’ll mention is treatment. And people need treatment not only to have it, but to have it close to where they live and work. Unfortunately though and part of this is due to Covid pandemic, there’s been a real labor shortage in healthcare and it’s slowed the expansion of treatment programs.

However, these, the numbers of treatment programs have been increasing in the state.

[00:21:51] Eric Miller: Thank you for plugging Maine Drug Data Hub. We’ll have a link to that in the description of this episode as well. You can find all sorts of data and reports if you would like to learn more. This upcoming question wouldn’t have been mentioned if it wasn’t making headlines in the past couple months.

But the FDA recently made Naloxone or Narcan a product that could be acquired over the counter. There’s been a lot of speculation of how this could help deter overdose deaths. But we, it’s really difficult to completely understand. And so some, we’re going to ask our guests to do some friendly speculating as to what exactly that change in the rule from the FDA will, how that will affect the overdose crisis.

[00:22:36] Marci Sorg: Yeah, I’ve got a couple comments here. Apparently this over-the- counter Naloxone will not be rolled out until the summertime. So it’s not happening right now yet. In order to get over-the-counter Naloxone, the customer is still going to have to pay for it at the pharmacy. And so that price range that will be charged is not yet known.

It’s also not known if they’re going, the, if Naloxone’s going to be offered in all of the pharmacies or how much of it’s going to be available? Unfortunately we think that the presence of stigma, which is still very much present in our communities, may still keep people from asking for it at their pharmacies.

And also we think that the price may be a deterrent, particularly for low income folks. Maine’s program of state funded Naloxone is likely to continue in the next little while, even after the over-the-counter Naloxone is available and it’s going to be a pretty important source for people who can’t afford to buy it.

This program, it’s called the Maine Naloxone Distribution Initiative, MNDI, it provides Naloxone at no cost to a group of four tier one distributor organizations who then distribute it to a wide range of tier two organizations and individuals. Anyone who is in need of reversing overdoses regularly or maybe just needs to have it on hand.

[00:24:18] Eric Miller: Thank you so much for indulging in some speculation there. It’s of course, it’s very difficult for us in this field to assess what is happening in data that’s in, or the present day, what’s in front of us, let alone projecting into the future, and especially with a massive real change like this.

So we’ve covered quite a bit of ground here in the, just touching the opioid crisis as a whole, as well as some of the economic factors. But are there some other things regarding this subject that you all would like to share that we haven’t already covered?

[00:24:51] Marci Sorg: I guess it’s important to just say that Maine’s working really hard to understand the issues that are faced by people living with substance use disorder.

And we’re focused on opportunities for, intervention and effective resources. We’re looking much more at people who survive overdoses and at non-fatal overdose events. We’ve increased the availability of public data as we’ve mentioned already today. Maine also provides a monthly overdose report, and I wanted to mention that.

And that report has statistics just from the previous month that, it uses suspected overdoses. Some of those cases haven’t been confirmed, but we have a pretty good idea how many of them are going to turn into confirmed overdoses. Those data are provisional and they change slightly. But we now have a pretty timely idea of the overdose trends on a monthly basis.

And it includes not only the fatal overdoses, but the non-fatal overdoses that are reported to us by the Naloxone distributors by the EMS, by the emergency room, and all of these events. Fatal and non-fatal add up to big numbers which shows us the real size of the problem. Finally, I will mention that I think the discussions about overdose and substance use disorder are much more likely these days to be taking place in public spaces. And that suggests to us that stigma has been declining. In the broader community, and I think that’s a very meaningful change.

[00:26:45] Eric Miller: I strongly agree. Thank you both so much for joining us today and shed some light on and update the paper that was published recently in Maine Policy Review.

What you just heard was Dr. Marcella Sorg and Priyanka Sarker’s discussion of their article, “Drug-related Morbidity and Mortality in Maine: Lost Productivity from 2015 to 2020,” and the current state of the opioid epidemic. Maine Policy Review is a peer reviewed academic journal published by the Margaret Chase Smith Policy Center.

The editorial team for Maine Policy Review is made up of Joyce Rumery, Linda Silka, and Barbara Harrity. Jonathan Rubin directs the Policy Center. A thank you to Jayson Heim and Katherine Swacha, script writers for Maine Policy Matters, and to Daniel Soucier, our production consultant.

In two weeks, we’ll be discussing changing demographics in Maine and how attractive Maine is to young people.

We’d like to thank you for listening to Maine Policy Matters from the Margeret Chase Smith Policy Center at the University of Maine. You can find us online by searching Maine Policy Matters on your web browser. If you enjoyed this episode, please follow us on your preferred social media platform to stay updated on new episode releases.

I’m Eric Miller. Thanks for listening and please join us next time on Maine Policy Matters.