Opioid-related deaths spiked more than 60% in two years during the pandemic, and that intensified the focus on treating opioid use disorder. But do some treatments impact employment prospects more than others?

In this episode of Six Hundred Atlantic, Boston Fed senior economist Mary Burke discusses certain opioid use disorder medications and how they affect job prospects for patients and reduce the economic burden on society.

ALLISON ROSS:

Hello, and thank you for joining us for this episode of Six Hundred Atlantic. I'm your host Allison Ross. And today, we're talking about opioid use disorder, but more specifically how OUD medications can impact employment. Mary Burke is a senior economist and policy advisor at the Boston Fed, and she's the co-author of a report titled "Can Treatment with Medications for Opioid Use Disorder Improve Employment Prospects? Evidence From Rhode Island Medicaid Enrollees." And this report is based on additional research from Mary and others at the Boston Fed. So, Mary, thanks so much for joining us on the podcast.

MARY BURKE:

Thank you, I'm delighted to be here.

ALLISON ROSS:

So, some might be surprised to hear that the Boston Fed is looking into the opioid crisis. How did you and the Boston Fed get involved in this work, and why is this important to the Fed?

MARY BURKE:

We got involved because the New England Public Policy Center concerns itself with anything that is a major public policy concern in the New England region and especially one that has economic implications. And the opioid crisis has very strong and negative economic implications, it carries a large burden for society. And Riley Sullivan the senior policy analyst in the New England Public Policy Center at the Fed started studying this issue in 2018 and wrote a policy brief describing the fiscal burden on the New England states and their costs, such as healthcare costs that fall on (the) public, law enforcement costs, reduced tax rates because of lowered unemployment if people are out of the labor force, and productivity costs on employers. In addition to obviously mortality costs, which are not always quantifiable, but they are very important things that we factor in.

ALLISON ROSS:

And let's look at the opioid crisis in general. So how does New England compare to other parts of the country? And has the situation improved or deteriorated since you actually started researching this subject?

MARY BURKE:

So, one of the reasons why we did focus on this is because New England has actually had above average rates of opioid use disorder and opioid-related deaths since as early as the early 2000s. Unfortunately, it was one of the regions that had relatively high opioid prescribing rates, which fueled the addiction in the early part of the crisis between 2000 and 2010. A lot of this was driven by Oxycontin prescribing. Since then, the crisis has sort of shifted to synthetic and illegal opioids, as there's been increased restrictions on prescription opioids. But even now, the New England region continues to suffer from above average death rates. And in terms of how the crisis has progressed since the Boston Fed started looking at this issue in 2018, for a while, it looked as if the death rates were stabilizing between, say, 2017 and 2019. But then the pandemic hit, the death rates spiked, and they've been elevated since then. And it's a combination of the obvious challenges for people with substance use disorders during lockdown, isolation, in some cases, being cut off from treatment at the same time as even more influx of illicit very, very deadly synthetic opioids, such as fentanyl and related opioids, which are just so much more deadly. So even if the same number of people are using these drugs, more people are going to die if they're subject to much more deadly types and they're not aware of what they're getting.

So, this is the unfortunate condition that we're in today, sort of like pushing against this wave of illicit opioids.

ALLISON ROSS:

And let's talk a little bit about some of the treatments. So, what are the different types of treatment for OUD?

MARY BURKE:

I like to divide them into sort of evidence-based treatments and non-evidence-based treatments. And so, by evidence-based treatments, I mean a combination of treatments that have been shown to be effective in helping people abstain from illicit opioid use for an extended period of time and to help people gain social functioning. So, in combination with behavioral therapy, which tends to be a component of many different treatments and that behavioral therapy can take many forms, but it's shown to be essential to also use medications. And so, there are three FDA-approved medications to treat opioid use disorder, and these include methadone, buprenorphine, and naltrexone. These have shown to be very effective, highly effective in reducing opioid related mortality. So that's obviously really important, but also helping people to increase their social functioning, there's been shown associated reductions in criminal activity. And so, there's been very strong endorsements from the World Health Organization, the Substance Abuse and Mental Health Services Administration in the United States, and sort of the public health entities around the world endorsing these medications. And as I said, they're evidence-based. They're backed by very, very strong medical science. Unfortunately, many people suffering from OUD are not taking these medications, and that's a very complex problem of the many factors that prevent more people from getting treated with these medications.

ALLISON ROSS:

And how do the different treatments impact, say, a person's ability to find a job?

MARY BURKE:

This was a subject of the recent working paper and research report, and it's a pretty complex question. But what we set out to find was, for individuals suffering from opioid use disorder, so they have a diagnosis, we can see this in the data, and you look at two people who are at a given time out of work. And then you follow these people over time, and you can see that one person, say, starts taking buprenorphine. So, you can see that they're being prescribed buprenorphine, and you compare them to somebody who otherwise similar characteristics and has not yet started taking buprenorphine. And the person who starts taking buprenorphine has a greater chance of finding a job subsequent to starting buprenorphine compared with someone who hasn't yet started taking the medication. So, the timing lines up really nicely, and it makes sense that when you get on these medications, it stabilizes your situation, it vastly improves your social functioning. And so, it makes sense that it would make it easier for someone to get hired or maybe even their motivation to go out and actually search for a job. It can be hard to even get the functioning level to search for a job, let alone to be hired into a job. However, we didn't find a similar association for methadone.

So, we did a similar analysis, but people who started methadone didn't have any big increase in their chance of finding a job, compared to people who didn't get it. And we think there are several reasons why. People who are taking methadone often have a more severe form of the disorder it is seen as sometimes; buprenorphine is not as effective for some people. I won't go into the detailed science of why that is. So, the types of people who are selecting into getting methadone might have other barriers to being employed, including having a more severe disorder. The population tends to have some different characteristics. They might be more likely to suffer from housing insecurity, lack access to transportation, just maybe worse off socioeconomically. Maybe they have less of a stable employment history that might make it harder for them to find a job. So, all of those factors. In addition, some other research has found that methadone itself might make it harder to maintain a job, because in order to get treated with methadone, typically you have to go to a specialized treatment facility every day and take your medication under supervision. So, that's going to take a lot of time out of your day. You might have to drive 10 miles to find the nearest methadone facility, because they're not located everywhere. It's hard to locate them. Just being treated on methadone could itself be a barrier to employment.

ALLISON ROSS:

If somebody was on one of these medications, could this actually help keep a person employed when they do have a job?

MARY BURKE:

What we did find is that right after somebody is first diagnosed with opioid use disorder, their chance of separating from a job – now, that could be a quit or it could be getting let go from the job – but their chance of separating from a job does go up. It could be a direct cause. Or it could be that they had something else wrong with their life that caused them to have this diagnosis, and at the same time, they said, "I can no longer maintain my job." But there is evidence from some other studies that people who are being treated with medications for opioid use disorder have higher productivity on the job than people who have an untreated opioid use disorder and who are employed. So, if you're not suffering the same productivity problems, you're more likely to be able to keep your job, because your performance is not going down. And as I said, we see this negative association between having an active opioid use disorder and the chance of separating from a job. It does look as if treatment moderates that separation risk. It does seem that it improves your social functioning and maintains your productivity if you are staying on the medication, which is not always a guarantee.

ALLISON ROSS:

And has OUD impacted the labor market?

MARY BURKE:

I think it has. I think that the evidence is still building for that case, because there have been a lot of studies such as ours that find these associations. If the chance of separating from a job once you've been diagnosed with an opioid use disorder goes up, that means that people with OUD are less likely to be employed. And we do find that they're less likely to be employed, and that is greater after diagnosis. There's been some studies that estimated that as much as like 20% of the decades-long decline in male labor force participation, this is nationwide, could be explained potentially by the increase in opioid use disorder over the same time period. So, there's strong associational evidence that some of these drags on labor force participation that we've been seeing decline, especially among prime-age men. who are disproportionately affected by the opioid crisis, that it has contributed to that decreased labor force participation. So, not only is it potentially holding back participation, which I think there's growing evidence, but it also, as I said, it's affecting productivity on the job. And those productivity costs are also potentially very high. So, it's both keeping people out of work and making people less effective if they are working.

ALLISON ROSS:

And going back to the Boston Fed, how does this research tie into our dual mandate?

MARY BURKE:

It ties directly into the dual mandate, because one of those pieces is maximizing employment, aiming for full employment. And so, helping as many people who want to work to find a job and be able to maintain jobs, that's the dual mandate. So, any policies … obviously the Fed doesn't get involved in these kinds of policies, but the New England Public Policy Center, we do research that helps support public policy more broadly, and that could be complementary to the Fed's efforts through monetary policy to maximize employment. Because if we help more people get access to medications for opioid use disorder, and if it's understood that this not only saves lives but could potentially boost employment prospects, then that could help more people move into the labor force and find jobs.

ALLISON ROSS:

All right. Mary, thank you so much for joining us.

MARY BURKE:

Thank you. It's been a pleasure.

ALLISON ROSS:

And as always, you can find more information on everything discussed today on our website. Don't forget to check out BostonFed.org/SixHundredAtlantic, where you can listen to interviews as well as our podcast seasons. You can also subscribe to our email list to stay up to date on new episodes. And don't forget to rate, review, share, and subscribe to Six Hundred Atlantic on your favorite podcast app. I'm Allison Ross, signing off for another episode of Six Hundred Atlantic. Thanks for listening.