5. Drug Policy and The Rise and Decline of Racial Stratification of Prescribing and Overdose Mortality

Background: Escalating drug overdoses have undermined population health. Prior research demonstrates how structural conditions, social contexts, and systemic racism produce racial differences in health. But what happens when morbidity and mortality is driven by advantage in access that ultimately becomes the pathway to poor outcomes? Within the context of prescription drug overdose mortality, higher White overdose rates may stem from an advantaged position within healthcare institutions leading to easier access to psychoactive medications. Laws applying universally across the population may address processes by which social privileges generate health problems. Yet, despite some laws being comprehensive in application across the population, they may not be equitable in impact. Such inequity has the potential to interrupt social advantage as much as disrupt disadvantage.

Methods: To consider these ideas, we examine laws establishing Prescription Drug Monitoring Programs (PDMPs) – state-level controlled substance prescription databases – as governmental responses to control overdose mortality. We merge multiple data sets including a policy database with several policy covariates, morality data, prescribing data, and census data, among other sources. We employed lead-lag two-way fixed effects models to examine the impact of such policies.

Results: We find reduced opioid overdose rates by two years post-implementation – with similar effects specifically for prescription opioids, benzodiazepines, and psychostimulants – but find PDMPs effective for reducing overdose mortality for Whites only beginning in year 2 (b=-0.904, p<.05).

Conclusions: Although often sources of inequality themselves, drug policies may directly address overprescribing among an advantaged population, and ultimately disrupt a key mechanism by which overdose mortality among Whites became elevated. However, given that overdose mortality among Black and Latinx people has quickly escalated in more recent years, these patterns may ultimately benefit an advantaged group, while leaving unaddressed mortality among disadvantaged groups. We consider the wider implications of these findings for public policy and social inequality.