Essays on the Economics of Increasing Public Naloxone Availability to Reduce Overdose Deaths

Dowd, William and Zucchelli, Eugenio and Walker, Ian (2024) Essays on the Economics of Increasing Public Naloxone Availability to Reduce Overdose Deaths. PhD thesis, Lancaster University.

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Abstract

Between 2013 and 2022, the opioid overdose mortality rate in the United States more than tripled from 7.9 to 25.0 deaths per 100,000, claiming 500,000 lives. This thesis is concerned with one intervention used to address this crisis: naloxone distribution to the public (i.e., non-medical professionals). Naloxone is a medication that reverses the dangerous effects of an opioid overdose. However, some theoretical and empirical evidence suggests that the protective effect of naloxone might increase risk-taking related to opioid use. The thesis begins with a meta-analysis of studies that estimated the effect of naloxone distribution on fatal overdoses by exploiting variation in state laws designed to strengthen naloxone distribution (Chapter 2). Findings indicate that laws providing immunity to prescribers and dispensers had a statistically significant, reductive effect on fatal overdoses, while laws that protected recipients of naloxone or facilitated its distribution through pharmacies had no significant effect. The thesis then estimates the effectiveness of naloxone distribution based on two large-scale naloxone giveaway events held in Pennsylvania (Chapter 3). Difference-in-differences analyses revealed a large and statistically significant decrease in fatal overdoses immediately following the first giveaway but an increase following the second. The seemingly contradictory findings are explained by the changing composition of the opioid supply between the giveaways, specifically the presence of xylazine—a non-opioid tranquilizer for which naloxone is ineffective. Finally, an economic evaluation of Pennsylvania’s naloxone giveaways revealed that giveaways were cost-effective from a limited healthcare perspective and cost-saving from a broader societal perspective, but that cost-effectiveness was sensitive to increases in overdose risk (Chapter 4). Taken together, these findings suggest that naloxone distribution is a valuable tool to reduce opioid overdose deaths, but that policymakers must be aware of contextual factors (e.g., opioid supply composition) and should combine naloxone distribution with educational initiatives to prevent riskier opioid use.