Does the 'Moral Hazard' of Lifesaving Naloxone Justify Making It Hard to Get?

A study suggests that easier access to the overdose-reversing medication encourages opioid use.


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A couple of years ago, Maine's Republican governor, Paul LePage, vetoed a bill allowing pharmacists to dispense naloxone, an opiod antagonist that can save people's lives by reversing overdoses, without a prescription. "Naloxone does not truly save lives; it merely extends them until the next overdose," LePage wrote in his veto letter. "Creating a situation where an addict has a heroin needle in one hand and a shot of naloxone in the other produces a sense of normalcy and security around heroin use that serves only to perpetuate the cycle of addiction."

Maine legislators, who overrode LePage's veto, apparently disagreed with his objections. But a paper recently published by the National Bureau of Economic Research lends empirical support to LePage's argument about naloxone's impact on risky behavior, if not moral support to the implication that drug use should be as dangerous as possible for the sake of deterrence.

University of Virginia economist Jennifer Doleac and University of Wisconsin at Madison economist Anita Mukherjee wondered whether wider availability of naloxone, in addition to reversing overdoses that would otherwise be fatal, might encourage opioid use by making it less dangerous. Depending on how big that effect is, Doleac and Mukherjee write, "expanding Naloxone access might not in fact reduce mortality." Although "the risk of death per opioid use falls," they say, "an increase in the number or potency of uses means the expected effect on mortality is ambiguous."

Economists call this kind of effect "moral hazard": When people are protected from the consequences of their risky behavior, they may be more inclined to take risks. A classic example is seat belts, which protect motorists from potentially fatal injuries but may thereby encourage riskier driving. While "the moral hazard from seatbelts" seems to be "small relative to the safety-improving effect of seatbelts," Doleac and Mukherjee observe, research suggests that "automobile insurance, which also incentivizes riskier driving through moral hazard, causes a large increase in traffic fatalities." They also note evidence that new HIV treatments encourage riskier sexual practices.

To investigate the net impact of naloxone, Doleac and Mukherjee looked at what happened after states adopted laws aimed at encouraging its use by making it available without a doctor's prescription or by providing legal immunity to people who prescribe or administer it. Every state had enacted some such law by 2017. Over all, Doleac and Mukherjee found, the adoption of naloxone laws was associated with an increase in opioid-related theft, an increase in opioid-related emergency room visits, and no reduction in opioid-related deaths. "While Naloxone has great potential as a harm-reduction strategy," they conclude, "our analysis is consistent with the hypothesis that broadening access to Naloxone encourages riskier behaviors with respect to opioid abuse."

The increase in opioid-related theft, which amounts to something like five more thefts per 1 million residents, was neither large nor statistically significant by the conventional standard. Doleac and Mukherjee say the results "suggest that any social costs of Naloxone laws—in terms of additional property crime—are small." By contrast, the increase in opioid-related E.R. visits, 266 per 100,000 residents in each quarter, "is large and consistent with the hypothesis that Naloxone access increases the abuse of opioid drugs."

More E.R. visits do not necessarily translate into more deaths, since increased use of naloxone means any given overdose, whether or not it results in a trip to the hospital, is less likely to be fatal. "On average across all urban areas, we find that these laws have no signicant impact on the opioid-related death rate," Doleac and Mukherjee report. "Thus, while the risk per use has gone down due to Naloxone access, the number of uses increases enough that we find no net effect on opioid-related mortality."

That overall finding masks regional differences. In the Midwest, Doleac and Mukherjee say, naloxone laws were associated with a 14 percent increase in opioid-related deaths. Mortality also rose in the South, while it fell in the West and Northeast, but none of those changes was statistically significant. In rural areas outside of the Midwest, naloxone laws were associated with declines in opioid-related deaths, although the results were "generally statistically insignificant." The analysis also finds reduced mortality in the 25 largest cities, an encouraging but still statistically insignificant finding.

Dolerac and Mukherjee suggest one reason for the variability might be the availability of drug treatment. "It appears that Naloxone access increases opioid-related mortality in places with limited treatment and decreases it in places with more treatment," they write. "We do not have enough statistical power to be sure that these effects are statistically different from one another, but this pattern is consistent with the hypothesis that broadening Naloxone access has less detrimental effects in places with more resources available to help those suffering from addiction."

Dolerac and Mukherjee's main finding, that greater access to naloxone was not associated with a decrease in opioid-related deaths, contrasts with the conclusions of an NBER paper published last year. In that study, University of Colorado at Denver economist Daniel Rees and his co-authors found that the adoption of naloxone laws was associated with a decrease in opioid-related deaths of 9 to 11 percent. Rees et al. used annual state-level data through 2014, while Doleac and Mukherjee used monthly city- and county-level data through 2015.

Assuming that Doleac and Mukherjee's results hold up, do they prove Paul LePage right? "Our findings do not necessarily imply that we should stop making Naloxone available to individuals suffering from opioid addiction, or those who are at risk of overdose," they write. "They do imply that the public health community should acknowledge and prepare for the behavioral effects we find here."

More to the point, the collectivist calculus of public health tends to obscure the moral issue raised by legal obstacles that make naloxone harder to obtain. The morally relevant level of analysis is not "society as a whole" but the individual who wants naloxone and the state that stands in his way. Naloxone indisputably saves people's lives, and it would be unconscionable to block access to it based on speculation about how the availability of that lifesaving option might affect other people's behavior. That is like banning seat belts or HIV treatment because the extra assurance they provide might encourage some people to behave more recklessly.

This is the logic of prohibition, which endangers the lives of drug users to deter people who otherwise might join them. One way it does that is by making drug potency unpredictable, which makes overdoses more likely, thereby increasing the need for naloxone. LePage is not wrong to think that making naloxone hard to get is consistent with this plan. He is wrong to think the plan is morally defensible.

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  1. It's not a fucking moral hazard if it has nothing do with you. Seriously, the whole idea of moral hazards require a completely statist mindset to exist.

    1. When you start from the position that getting pleasure from drugs is immoral, regardless of safety.

      Don't eat food that tastes good either. That's immoral, even when it happens to be good for you.

      Asceticism is all the rage among busybodies. You must subscribe to their conception of virtue, or else face real punishment.

      1. Immoral is still second to the required belief that immorality is anyone else's business but yours and God's.

      2. Asceticism is all the rage among busybodies. You must subscribe to their conception of virtue, or else face real punishment.

        These are the same people that travel the world in jets, hold annual passes for Disneyland and shop at Whole Paycheck. Diogenes they are not.

    2. It's disappointing that there wasn't a greater reduction in mortality, but I think this is because fatal overdoses are generally intentional suicides, and so they take greater precautions to not be found in time. Whereas if they were accidental (according to prevailing addiction mythology), they would be more likely to be discovered and saved.

    3. "It's not a fucking moral hazard if it has nothing do with you."

      "Seriously, the whole idea of moral hazards require a completely statist mindset to exist."
      Using taxpayer money to reward people who chose not to work represents a moral hazard, and I resent it.

      1. That's what I mean. You can't have moral hazard without the state involved to create them.

        1. Which seems to be OK for at least two of the reason writers.

    4. Moral Hazard was my favorite Duke.

      1. No, no; Moral, Hazzard was the county seat. Didn't come up on the show much.

    5. EVERYTHING in medical care has something to do with you because there is no such thing as a heavy consumer who actually carries their own bills. And because of the distribution, the concentration, and the persistence of medical spending over time (even absent the impact of moral hazard), there is no possibility that it can ever be otherwise.

      Moral hazard is a concept of INSURANCE - transferring financial risks around to others - not statism.

      The second you agree that even a smidgen of 'catastrophic' 'insurance' is going to have to exist in that space; then you damn well have to deal with moral hazard.
      The second you argue that it doesn't need to exist; then you are going to have to argue the ethics/limits of 'being complicit' in someone else's death.

    6. That's completely untrue. Whenever risk is shared, there is the possibility of moral hazard.

      The idea of moral hazard first arose in the context of insurance. Obviously, insuring something made you more willing to do things that expose you to (now insurance) loss.

      A seatbelt makes you safer if you collide with another car, but doesn't help the guy in the other car. You now have a reduced incentive to avoid the collision that will harm or kill that other guy.

    7. The reality of moral hazard exists and is state of its own. It's cause and effect. There's a difference between helping someone get off drugs, and abetting their addiction. The wages of sin is death.

  2. Try as I might, I can muster little sympathy for junkies. I say this as a drug user.

    1. I can easily do it when the decision is as simple as not barring them from doing it. They could do something to help themselves with almost no consequence to anyone not involved. We say no because we're afraid it says something about our collective morality.

      That's bullshit.

      1. And as long as they pay for it. But somehow we repeatedly see pleas gor needle exchanges and narcan rescues paid for by the public and presented as "solutions." If that's not externalizing your costs and a moral hazard, I don't know what is.

        You're free to kill or save yourself on your own dime.

        1. It's because we're so deep in the statist perversion that it's tough even to see what the "most libertarian" thing would be at this point; this is why the practical matter of the "most libertarian" first step in the real world always creates more disagreement among folks who agree on more fundamental matters.

          We persecute the junkies, banning their right to do what they want with their own bodies, and we hand productive citizens the enormous bill. Then we pay for them when they do disobey the law, handing the productive citizens the bill for their ODs too (and their AIDS treatment). (It's like how the taxpayer subsidizes both to promote the tobacco industry and to destroy it.) So how are we to evaluate something like needle exchanges? Are they good only if they can be proven to save the public money (they do, as far as I know)? But junkies are people too; the fact that the state offers parasitism for people who make choices they have every right to make does not change that. I view needle exchanges as a partial amelioration of the injustice done to junkies by the state's monstrous, useless, and sadistic infringement of their rights by banning them from purchasing clean needles on the open market. We should bill them for the needle cost and nothing more.

          I'm not about to put every potential loosening of nanny laws into a cost analysis until we get rid of every last shred of public support for private "bad" choices. We'd never get anywhere with that attitude.

          1. I'm not aware of a federal needle ban today.

            Remember, we must have open borders immediately and can't tolerate pragmatic compromises, or, ideally abolishing the welfare state (gee, that kinda sounds like ending the drug war, doesn't it?). Sorry, that dog don't hunt. If libertarians want to play their principles card, then they can damn well live by it. I'm not about to continue promoting more Socially Liberal, Fiscally when-I-get-around-to-it, either. We're certainly not getting anywhere that way.

            1. There is no federal needle ban. There are needle bans in every state. You said "funding," not "federal funding," so I assumed you opposed funding for them at any level of government, including the level that instituted the ban.

              Frankly, as indicated I would vote against public funding for these programs too; I think legalizing them is sufficient. (Plenty of people would donate anyway.) But what to say if forced to choose between, say, banning junk food and subsidizing junk food (a choice not unlike the real one we face today)? Or banning gas and subsidizing gas? My vote is against the ban, generally. It's a judgment call, I acknowledge, but I am inclined that way. I take both "social" and "economic" incremental progress on freedom where I can get it, thank you very much.

              As for this latest post: I don't speak for "libertarians" in general, and like most people here I oppose open borders. Also I am the kind of "social liberal" who supports an unconditional abortion ban, the death penalty (and not just for murder), an overturning of Obergefell, an unapologetic abolition of all antidiscrimination laws, a trans ban and female ground combat ban in the military, Confederate statues kept up, and so forth. I didn't really see any engagement with my view, just an attack on a strawman I do not represent.

  3. Do seat belts and air bags create moral hazard by making motorists think they can drive less safely too?

    1. "A classic example is seat belts, which protect motorists from potentially fatal injuries but may thereby encourage riskier driving."

      Does reading the article before posting create a moral hazard?

      1. Dude, nobody reads the articles.

          1. They're the noise you scroll past to open the comments.

      2. No.
        Nor does it generate more coherent posts.

  4. https://reason.com/blog/2018/02.....nt_7123510
    "Making the overdose-reversing drug naloxone more readily available will reduce overdoses."
    It is utterly idiotic that the FDA makes this a prescription drug in the first place. But in Texas, State Legislatures have enabled a single doctor to write a prescription for ALL Texas residents to "access" Narcan, as a bypass to the idiots at the FDA... for exampe, see http://www.dallasnews.com/busi.....pharmacies ... As I recall, one doctor wrote it for all CVS pharms, another for Walgreen's... Or was it the same doctor? Not sure...
    WHY can they do that for Narcan, but they don't do it for utterly stupid "medical devices" like the "lung flute"? I think there is SOME moral culpability going on when you get hooked to heroin... Yet "junkies" are more "politically correct", and deserving an FDA bypass, than I am, for accessing a simple, cheap plastic flute! I wrote to my state rep and asked her to "enable" a state-wide prescription for the "lung flute" and the "ear popper" as samples of this utterly stupid trashy micro-management from the nannies and ninnies at the FDA... No dice, not even a response! Junkies deserve more freedom than I do, it seems...

  5. The concept of "moral hazard" requires some level of rational thought on the users behalf. There aren't too many people that arrive at the decision to use heroin from a rational standpoint. The amount of people that would rationally arrive at the decision that I'm not going to use heroin if and only if naloxone is available has to be even smaller.

    1. It doesn't reduce overdoses because you still have to go to the ER. It's like an EpiPen; it keeps you alive long enough to get actual medical help. The "needle in the one hand and Narcan in the other," visualization is asinine. Addicts are famous for pitching a huge fit when you hit them with Narcan in the ER. They go into full withdrawals in like 5 seconds. The OTC Narcan is probably pretty expensive. I don't think junkies are using it just to sober up. Also, since most overdoses cause the user to pass out, it's concerned friends/family/whoever that is keeping the injector, possibly without the addict even knowing. Even if it's the addict keeping it, at least they're taking an interest in their own well-being, which is pretty rare.


    2. That whole agency thing is a bitch, isn't it?

  6. Yes, killing people for doing something tends to cause people to do it less. That fact, however, doesn't make killing people okay. To say that it does is just to embrace utilitarianism. If these drugs save people's lives, society has no moral right to prevent them from getting access to them because doing so will allegedly save other lives.

    It is really that simple.

    1. And society has no moral right to force me to pay for them.

      1. I 100% agree, but I believe these to be two different issues.

        1. Not according to Briggs or Mangu-Ward.

          There are real solutions to the opioid crisis, many of them driven by new and better technologies for dealing with drug dependence and its side effects. Suboxone, a medication that reduces cravings and makes highs less appealing, has gained some ground, though it faces opposition in a rehab culture that seeks to penalize and moralize. Needle exchanges reduce overall risk and help users stay healthy. And Narcan, which can revive opioid poisoning victims, has seen more widespread adoption both by first responders and by the families of people at risk.

          And just who do you think is going to pay for those?

          1. Just because they are conflating the issues does not mean they are actually intertwined. You can easily and logically do one without the other.

            1. You mean like how positive rights in the tax code and contracts for marriage weren't actually intertwined with gay marriage? You can easily and logically handle all of those with contract rights and legislation. Two separate issues, right?

      2. I agree. But saying people should be able to get them is not the same as saying you should pay for them.

    2. I agree, the political solution is the wrong way to handle it.

  7. Health care does not truly save lives; it merely extends them until the next illness.

    1. Life is an STD which is invariably fatal.

    2. Yep.

      Life is a terminal disease, everything that lives will eventually die.

  8. A study suggests that easier access to the overdose-reversing medication encourages opioid use.

    So? What's wrong with opioid use that 'encouraging' it is not to be done? Rush Limbaugh had a pretty good career while using so it doesn't seem particularly life-destroying.

    1. I suspect the difference is employability, market-place worth and the support systems that come with it. Why can't the guy living here just be Rush Limbaugh?

      I think the issue here is there are plenty of people who'd have been annoyed by Rush Limbaugh if he were living in a tent demanding the county to mach schnell when it comes to cleaning up his own trash.

  9. You keep a junkie alive who in an absence of widespread availability of Narcan would be dead, you're going to get more crime as well, even if you legalized heroin--it's hard to keep a job and have money to buy the stuff if your habit requires a near-lethal dose.

    My ambulance company's chief says that it's not unusual to revive the same people over an over. And we're in a nice suburban area.

    1. So lets deny junkies medical treatment and let them die because we have decided their lives are no longer valuable enough to be worth saving. Who else' life do you think isn't worth saving?

      1. At some point, yes. Libertarians seem to have no qualms about defining away humanity as anything before coming down the birth canal. Why should we be compelled to save someone from their own repeated poor decisions?

        1. No one is suggesting compulsion of anyone. They're suggesting simply that we allow the use of the drug.

  10. National Bureau of Economic Research lends empirical support to LePage's argument about naloxone's impact on risky behavior, if not moral support to the implication that drug use should be as dangerous as possible for the sake of deterrence.

    There's certainly anecdotal evidence that it does. But this also shouldn't be a political decision. I suppose it becomes a political decision when the "people" are paying the bills.

    This whole thing becomes a tricky conundrum. It's a problem that has more hands than Vishnu.

    On the one hand, we don't want to see people dying in the street for something that has a medically straightforward fix. On the other hand, no one wants their neighborhood turned into Insite. On another hand, as long as drugs are illegal, the market is perverted with dangerous and synthetic drugs leading to more overdoses. On another hand, there's evidence that providing services to drug addicts makes it easy for them and creates magnet effect that prolongs and intensifies the problem. On another hand, it seems unfair to watch people die for something that we could fix if there was a political will to get at the root of the problem: the drug war.

  11. Every state had enacted some such law by 2017. Over all, Doleac and Mukherjee found, the adoption of naloxone laws was associated with an increase in opioid-related theft, an increase in opioid-related emergency room visits, and no reduction in opioid-related deaths.

    Insite has seen a dramatic-- almost shocking-- increase in overdose deaths. Insite blames shadowy external forces and Russian trolls.

  12. Wait. What?
    We repeal the mandates for seat belts and airbags, and drug use goes down? Or just drug deaths?

    1. Unrelated... except, seat belts and airbags, encourage more risky driving. There are more accidents, but the driver survives, but is proscribed opiates to deal with the long-term whiplash pain.


    And that is all you need to know.

  14. Sounds more like risk homeostasis or compensation than "moral hazard" to me.

    This is a well known phenomenon where, when you institute visible safety measures, people act in a more risky manner, resulting in roughly the same level of actual accidents. People avoid the edges of cliffs, put a handrail there, and they'll go right up to the edge, and maybe lean on it.

    If you want safety measures to actually reduce risk, rather than increase risky behavior, they need to be inconspicuous.

    1. Yes, it's risk homeostasis.

      Basically, every addict now has a choice of either the same amount of horse at a lower risk of death, or MORE smack at the same risk of death. A terrific change for the addict, but some people, who hate when other people enjoy themselves without dying, are not so happy.

  15. Next up, limiting production of sutures because ready availability of them could increase stabbings.

  16. If it's life-saving libs are after why not save some of the millions of dead babies c/o Planned Parenthood?
    Or even some of the almost half-million folks who died from tobacco last year...

    1. Zygote =/= baby, and don't give them any encouragement about the second one.

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