Opioids are symptom, symbol of ‘larger social and economic problems’. Counties with the highest rates of chronic prescription opioid use were far more likely to back Donald Trump in the 2016 presidential election, a new study of Medicare claims data found.
Trump took 59.96% of the vote in the 693 counties with opioid prescription rates significantly higher than the national average among counties, compared with 38.67% of the vote in the 638 counties with rates significantly lower than the mean, reported James Goodwin, MD, of the University of Texas Medical Branch Sealy Center on Aging, and colleagues in JAMA Network Open.
The cross-sectional study found that a county’s vote for Trump correlated with the adjusted rate of Medicare Part D enrollees receiving long-term opioid prescriptions (intraclass correlation coefficient of 0.42, P<0.001). As a control for specificity, they also looked at insulin prescriptions but found no correlation with voting patterns.
“Opioids are a symptom and a symbol of much larger social and economic problems, and those social and economic problems came to bear during the 2016 election,” Shannon Monnat, PhD, Lerner Chair for Public Health Promotion at Syracuse University in New York, told MedPage Today.
Monnat, who was not involved in the current study, reported shortly after the 2016 election that Trump also over-performed in counties with the highest rates of drug-, alcohol- and suicide-related mortality, all of which are tied together by pessimism, frustration and despair, she said.
“What seems to be coming through pretty consistently in this research now is at the core of substance misuse and the overdose crisis is really disconnection and isolation,” she said. “Work, family, community — those are the three most important arenas through which we assign meaning in our lives.”
The current study from Goodwin’s group examined the association between voting patterns in 3,100 of 3,142 U.S. counties and the rate of chronic opioid use among 20% (3,764,361) of all Medicare Part D enrollees. In high-use counties — which were concentrated mostly in the South and Appalachian areas — greater than 20.10% of Medicare Part D enrollees studied had opioid prescriptions for 90 days or more compared with 10.85% of those in low-use counties.
The authors noted that approximately two-thirds of the association found in the study can be attributed to socioeconomic characteristics — particularly income disparities, disability and unemployment — but that presumably all of the association between opioid use and voting patterns could be explainable by “socioeconomic, legal, environmental, and cultural factors” if more data were available.
The high opioid-use counties were more likely to be rural, have more unemployment (9.48% versus 8.13%), and had a larger proportion of the population comprised of non-Hispanic whites (85% versus 79%). The median household income was lower in these counties ($45,268 versus $60,577 in low opioid-use counties; P<0.001 for all).
In a general sense, opioid users and Trump voters shared economic stressors and the sense of being isolated, forgotten or overlooked, Goodwin told MedPage Today. Individuals in these communities were dissatisfied with the status quo and wanted radical change, he said.
Monnat added that these counties contain fewer social and recreational facilities and are also characterized by higher levels of family distress — more single-parent families, higher divorce rates — which can contribute to the use of opioids.
“Given that both candidates focused on opiate addiction as a major campaign issue, it is difficult to infer that opiate prescription rates are somehow linked with voting behavior based on the candidates’ respective campaign promises and/or platforms,” wrote James Niels Rosenquist, MD, PhD, of Massachusetts General Hospital in Boston, in a commentary that accompanied the study, who added that the study “findings add to a growing body of literature showing the interrelationship between public (mental) health and society, including the all-important economic and political realms.”
“When you discuss the opioid epidemic, it is discussed in public health terms and the solutions tend to be public health solutions such as education, prevention, and treatment centers, which are critically important,” Goodwin said. “If there’s an implication of our study it’s that we have to broaden our discussion and understanding about some of the issues behind the opioid crisis.”
Eighteen percent of the Medicare recipients in the study were younger than 65 years, and 60.6% were female; 81.1% were non-Hispanic white, 9.3% were non-Hispanic black, and 5.3% were Hispanic.
Among those ages 65 and older, chronic opioid users were more likely to be disabled (OR 2.72), have end-stage renal disease (OR 1.37), or have one or more comorbidities (OR 3.64 for three or more), and more frequently were women (15.2% versus 11.9%).
Study limitations included the fact that associations were made at a county level between the presidential vote and opioid use, instead of at an individual level. However, Gallup interviews with county residents found that community feelings of poverty and poor health were equally if not more influential in voting patterns than individual economic factors, proving the importance of such contextual effects on opioid use. Additionally, prescriber behavior and the use of non-prescription opioids (which are the cause of half of opioid-related deaths), were not examined.
Goodwin reported no disclosures. Co-authors reported relationships with the National Institute on Drug Abuse, the Agency for Healthcare Research and Quality, Physicians for Responsible Opioid Prescribing, and the American College of Medical Toxicology.