Essays on Vulnerable Populations Restricted; Files Only

Abstract

Drug use is one of the largest public health concerns in the United States. It is one of the main risk factors for both all-cause mortality and disability. Not only can it impact an individual's health and well-being, but individuals who use drugs are more likely to face housing insecurity, poverty, incarceration, and unemployment. In short, it can affect every aspect of someone's life. 

In addition to the internalities of drug use, there are also several externalities. Children of individuals who use drugs are particularly vulnerable. While in-utero, fetuses are susceptible to drug dependence from substances that pass from the mother. This exposure can lead to several long-term health concerns such as behavioral, motor, or learning problems. Moreover, parental drug use is one of the main risk factors for child maltreatment, an issue that disproportionately affects infants. Policies aimed at reducing drug use have the potential to improve quality of life along a number of axes, including a greater impact beyond just the individual consuming drugs. The papers in this dissertation employ causal inference techniques to provide new evidence about the effects of drug policy on the internalities and externalities of drug use. 

The first analysis shows that broad-targeted opioid legislation, initial prescription limits, can be effective to reduce an externality of the opioid epidemic, neonatal abstinence syndrome. The second paper focuses on expansions to access of Narcan, showing that changes to underlying consumption patterns of opioids kept the policy from reducing opioid deaths as expected. When considering prenatal substance exposure more generally, the third study shows that mandatory reporting policies for healthcare workers result in both a higher number of reports to Child Protective Services and a higher number of substantiated reports of child maltreatment. These results hold in states where prenatal substance use is not criminalized. Thus, it is unclear whether this increase is from true cases of maltreatment or is due to the stigmatization of parental drug use. These further our understanding of how drug policy affects vulnerable populations, providing a foundation for further research.

Table of Contents

Contents

1 Neonatal abstinence syndrome and state-level opioid policies 1

1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

1.2 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

1.2.1 Opioid use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

1.2.2 Opioid policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

1.2.3 Elasticity of opioid demand . . . . . . . . . . . . . . . . . . . . . . . . 14

1.2.4 Prior research on NAS . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

1.3 Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

1.3.1 NAS data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

1.3.2 Birth and fetal death data . . . . . . . . . . . . . . . . . . . . . . . . . 20

1.3.3 Policy data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

1.3.4 Measurement concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

1.4 Empirical analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

1.5 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

1.5.1 Comparison to past literature . . . . . . . . . . . . . . . . . . . . . . . 33

1.6 Mechanism analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

1.7 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

2 How to save a life? Exploring the role of expanded naloxone access amid rising

opioid deaths 38

2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

2.2 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

2.2.1 Opioid antagonist access laws and regulations . . . . . . . . . . . . . 46

2.2.2 Opioid deaths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

2.2.3 The moral hazard problem . . . . . . . . . . . . . . . . . . . . . . . . 55

2.2.4 Opioid use disorder treatment . . . . . . . . . . . . . . . . . . . . . . 57

2.3 Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

2.3.1 Opioid use data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

2.3.2 Opioid deaths data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

2.3.3 Opioid use disorder treatment . . . . . . . . . . . . . . . . . . . . . . 61

2.3.4 Policy data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

2.4 Empirical analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

2.4.1 Heterogeneity analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

2.5 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

2.5.1 Opioid use and the moral hazard theory . . . . . . . . . . . . . . . . 72

2.5.2 Opioid deaths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

2.5.3 Fentanyl exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

2.5.4 Polydrug deaths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

2.5.5 Opioid treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

2.6 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80

3 Prenatal substance exposure and expansions in mandatory reporting of child

maltreatment 83

3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

3.2 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

3.3 Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

3.3.1 Mandatory Reporting and Child Abuse and Child Neglect Laws . . 91

3.3.2 National Child Abuse and Neglect Data System . . . . . . . . . . . . 94

3.4 Estimation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

3.5 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

3.6 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

Appendix A Chapter 1 — Opioid legislation 108

Appendix B Chapter 1 — Comparison to past literature 112

Appendix C Chapter 2 — How Opioid Antagonists Work 117

Appendix D Chapter 2 — Four Axes of Access 121

Appendix E Chapter 2 — Border Analysis 124

Bibliography 131

About this Dissertation

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School	Laney Graduate School
Department	Economics
Degree	Ph.D.
Submission	Dissertation
Language	English
Research Field	Economics, General
Keyword	Health Substance use
Committee Chair / Thesis Advisor	Sara Markowitz, Emory University
Committee Members	Matthew Grennan, Emory University Melvin Livingston, Emory University

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