Exponential Increase in Drug Poisoning Deaths

A recent paper published in Science examines trends in drug poisoning deaths over the past 40 years. It finds that drug poisoning mortality (and this is per-population, not simply the raw totals) has been increasing at an exponential rate since 1979. That was the year we switched over from ICD-8 to ICD-9, so presumably the prior data was not directly comparable. Otherwise I’m guessing they would have gone back further to see how far back the trend holds.

An unbroken exponential trend with an r-squared of 0.99 begs for some sort of explanation. Most opioid epidemic narratives describe discrete events or policy changes or changes in prevailing attitudes, like the release and aggressive marketing of OxyContin in 1996, the change in attitudes regarding pain management and opioids over the 1990s, the rise of the “Xalisco Boys” heroin cartel in the 90s and 00s, the reformulation of OxyContin to be abuse-deterrent in 2010, and the emergence of illicit fentanyl as a substitute for heroin in the 2014 to present period.  All of these things happened. All of these things were the mechanism by which drug poisonings increased at the time they were increasing. Each discrete item might explain, in a narrative sense, a few years of the time series. But it seems like there must be some kind of physical law compelling the trendline, and all the narrative is just detail. It’s as if someone wrote an economic history book describing a few specific inventions and innovations and said, “This explains the modern world,” but then failed to note that there was a nearly unbroken trend of exponentially increasing productivity and consumption. Yes, the assembly line, the shipping container,  electricity, and the transistor were the means by which we experienced exponential growth in productivity.  But there’s some kind of underlying law driving the emergence of these inventions. It's quite possible that even but for these particular developments, the exponential growth would have happened anyway. 

If something is growing exponentially, it’s worth looking for some driver that would explain an exponential pattern. Population growth comes to mind, but that’s obviously not right. It is the rate per population that is growing exponentially, not the raw number of poisoning deaths. My best guess is that the driver is economic growth. We are getting richer at an exponential rate. That allows us to buy more of all goods and services. When we get richer, we don’t just keep doing the same things and simply buy more stuff with our higher earnings. We don’t simply buy more houses and more automobiles and greater tonnage of food. To some degree we buy nicer versions of the things we already had. So bigger homes, safer (and more reliable and more fuel efficient and more comfortable) automobiles, tastier food of a much wider variety than was available decades ago. Even granting this, there’s only so much consumption we can do. When we get more productive, we “consume” some of that capacity by working less. There is, as economists say, a substitution effect and an income effect. Our incomes rise as we get more productive, but we trade work hours for labor hours as is becomes easier to satisfy our material needs. If your pay doubled, you could enjoy twice as much stuff with no extra leisure (by not working any fewer hours) or the same amount of stuff with a lot more leisure (by cutting your working hours in half). Most people tend to prefer something in between either of these extremes.

[A temporary bump in your hourly wage is likely to cause you to work more hours, assuming you know the change is temporary and your wage will predictably revert back to baseline. You will make hay while the sun shines. But if the sun promises to shine more brightly permanently, you'll eventually notice that you can meet your hay quota in fewer working hours and can thus afford more leisure.]

There is a lot of commentary about how “wages have stagnated” in the United States since the 1970s. Supposedly only the rich have enjoyed the rising incomes, and the middle-class and below have stagnated or even seen declining incomes. I think that narrative is basically wrong. I actually think that basically everybody has seen an enormous expansion of their overall option set, it's just that some have chosen to consume more leisure and others more work. (Survey data on how people spend their time backs up my story fairly well.) “Productivity” in general, the option of working for more pay and more command over material goods, has increased basically for everybody. But people are heterogeneous in their preferences for work vs. leisure. More and more prime-age males are leaving the workforce voluntarily. Many of them are taking prescription opioids, recreationally or medically. I think it’s wrong-headed to try to explain this as an “income inequality” story or to claim that these people “lack opportunity.” These people actually have a lot of command over material resources. It is not the case (as many commentators imply) that their zero market income implies zero access to resources. They generally have access to non-market income or other resources. Family members. Government safety net programs. The black market. Their labor market income vastly understates their actual command over material goods and services. In my view, these people are enjoying the same exponential growth in productivity as the rest of us. They are simply choosing to consume more leisure. The fact that everyone else is working productively increases their non-market remunerations. A higher-paid parent can afford to give a higher allowance to his/her man-child, and a higher-paid tax base can fund a more “generous” social safety net. Some people are pushing a universal basic income in anticipation that robots will make a lot of us obsolete. I think these people are implicitly acknowledging my point: the enormous productivity of the robot economy will presumably create the cornucopia from which we can afford the UBI. I do not support a UBI, I am just pointing out that I'm not the first to notice that non-workers enjoy the benefits of rising productivity. Some of these people are choosing to consume all of their share of enhanced productivity in the form of leisure. 

[Do not read any of this as scolding the life-choices of non-workers. This post is a judgment-free attempt to explain the trends in drug overdose deaths.]

I don't completely believe all of this. I don't think the 2010 to present trends were inevitable. I think this era is dominated by a surge of black market drug poisonings that never would have happened if people (including recreational users) had ready access to prescription opioids. I also think the rise in deaths from the late 1990s to 2010 are probably overstated. I think nobody has gotten a proper handle on how inaccurate cause of death assignments really are and how much this affects the national statistics. Also, an exponential rise in the death rate obviously can't go on forever. It has to hit some natural limit. At some point, all the hard core drug addicts die off, or the very high death rates scare off the next generation of would-be users, or the number of possible addicts hits a maximum beyond which no more normal people are tempted to join their ranks. Any exponential process that "explains" rising death rates is going to bump into a ceiling and stop working as an explanation. Something's gotta give. Mercifully, 2018 finally saw fewer drug poisonings than the prior year. Still, I do take seriously the idea that a richer society makes it easier to indulge vices. With exponential growth in productivity, with heterogeneous preferences for leisure and vice, and with transfers of income (government and private) between the working and the non-working, we should expect something like what we're currently seeing.

What's a better explanation? Or does this phenomenon even need one? Where else should we expect to see exponential trends if this basic story is right? Divorce rates? Alcohol-related deaths? What about the decline in smoking? Is that a fatal counter-example? What observable vices to we expect to indulge more as society gets richer?
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This didn't fit into the flow of the post, but I wanted to draw a caricature of someone with an extreme preference for leisure trying to maximize his utility in today and compare that to thirty or forty years ago. Maybe thirty years ago, a marginally employed convenience store clerk (or perhaps a clerk at a movie rental store) would have earned enough for a small apartment. He'd have just enough income for the essentials and some disposable income for cable TV, maybe a nice stereo, and a couple of weekly video rental. If he is the intellectually curious type, he can get free books and magazines (and movie rentals, come to think of it) from the library. Today, an unemployed man-child would have much greater riches available to him. Maybe his parents get him a smart phone and put him on the family plan. Maybe he has his own laptop (a Christmas or birthday gift), or uses the family desktop computer (because Mom and Dad don't need it when they're at work anyway). He gets internet basically for free, and it's of no marginal cost to his parents for him to access it. He can watch tons of free videos all day long without subscribing to any service, and if he wants to watch movies he can use his parents' paid streaming service for no additional cost. Assuming he's acquired the smartphone or laptop described above, he can probably find a few public places with free WiFi. He might envy the freedom and independence of his 30-years-ago self, but he can get the basket of goods that his doppelganger has for free, and he has access to things that didn't exist 30 years ago (again, for free). Many forms of entertainment have gotten dramatically cheaper, and the people bankrolling his leisure are much richer. That lifestyle doesn't sound appealing to me, but I can understand why some people take it over the "bullshit job" that's their next best option. People get locked into bad patterns and it's hard to break out of them. I could also comprehend someone living this life for a few years and feeling guilty or regretful about their life choices and dulling their regret with drug use. Certainly there are people like this. I think we need to reframe our description of them from "They're completely missing out on economic growth" to "They're consuming their share of economic growth as excessive leisure and vice consumption."

Interesting paper here about how people who are outside the labor force are spending their time.