1. Welfare reform that reduced benefits may have encouraged enrollment in disability-related assistance programs that may increase opioid access, which could impact opioid-related mortality.
2. In addition to supply-side determinants, demand-side factors such as changes in welfare reform and its indirect effects should be considered when evaluating opioid-related mortality.
Evidence Rating Level: 5 (Poor)
Study Rundown: Since the mid-1990s, deaths from opioid overdose has increased dramatically. Focus has been placed on supply-side factors concerning access to opioids. However, demand-side factors such as government policies and social support should be considered. In 1996, changes to welfare programs reduced benefits that could have led to states promoting enrollment in disability-related assistance programs, which require a medical diagnosis for qualification. Welfare reform in combination with relatively stationary low-skilled worker wages may also have drawn people who already had musculoskeletal conditions to seek disability benefits. Opioid-related mortality increased during the same time period that the proportion of disability recipients with a musculoskeletal diagnosis also increased. Considering that musculoskeletal disorders are likely to be treated with opioids, this suggests that these two factors are correlated.
A weakness of the study is that a correlation does not necessarily mean that there is a causal relationship. In addition, increased opioid access might not be the reason behind increased deaths in disability insurance recipients. Opioid diversion is pervasive in the United States, and opioid-related mortality amongst those without a valid prescription is common. Nevertheless, when addressing the issue of reducing the number of deaths attributed to opioids, it is important to consider factors such as policy changes and social support that may have an indirect impact on opioid-related mortality.
In-Depth [expert opinion]: This study analyzed trends in the percentage of awards to disabled workers with a musculoskeletal diagnosis, the percentage of adults reporting persistent lower back pain over the past 3 months, and the drug poisoning overdose mortality rate per 100 000 persons from 1980 to 2013, all relative to 1997. The authors noted that as rates of disability increased, the proportion of disability assigned to musculoskeletal problems also increased. Although rates were flat for the 20 years prior, the proportion of disability recipients with musculoskeletal issues such as back pain increased from 13.4% to 36.1% in 1994 and 2014, respectively. However, there was not a corresponding increase in self-reported back pain during the same time period.
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