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    1 Comment for this article
    Scott Wierson, BSEE | Research and Expert Witness
    What were the estimated average dosage levels used by the victims for each type of drug?
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    Original Investigation
    December 30, 2019

    Association Between Automotive Assembly Plant Closures and Opioid Overdose Mortality in the United States: A Difference-in-Differences Analysis

    Author Affiliations
    • 1Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
    • 2Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
    • 3Department of Sociology, Yale University, New Haven, Connecticut
    • 4Center for Global Health, Massachusetts General Hospital, Boston
    • 5Harvard Medical School, Boston, Massachusetts
    JAMA Intern Med. Published online December 30, 2019. doi:10.1001/jamainternmed.2019.5686
    Key Points

    Question  Are closures of US automobile assembly plants associated with increases in opioid overdose mortality rates among working-age adults?

    Findings  In this difference-in-differences study, US manufacturing counties that experienced an automotive assembly plant closure were compared with counties in which automotive plants remained open from 1999 to 2016. Automotive assembly plant closures were associated with a statistically significant increase in county-level opioid overdose mortality rates among adults aged 18 to 65 years.

    Meaning  Automotive assembly plant closures were associated with increases in opioid overdose mortality, highlighting the potential importance of the role of declining economic opportunity in the US opioid overdose crisis.


    Importance  Fading economic opportunity has been hypothesized to be an important factor associated with the US opioid overdose crisis. Automotive assembly plant closures are culturally significant events that substantially erode local economic opportunities.

    Objective  To estimate the extent to which automotive assembly plant closures were associated with increasing opioid overdose mortality rates among working-age adults.

    Design, Setting, and Participants  A county-level difference-in-differences study was conducted among adults aged 18 to 65 years in 112 manufacturing counties located in 30 commuting zones (primarily in the US South and Midwest) with at least 1 operational automotive assembly plant as of 1999. The study analyzed county-level changes from January 1, 1999, to December 31, 2016, in age-adjusted, county-level opioid overdose mortality rates before vs after automotive assembly plant closures in manufacturing counties affected by plant closures compared with changes in manufacturing counties unaffected by plant closures. Data analyses were performed between April 1, 2018, and July 20, 2019.

    Exposure  Closure of automotive assembly plants in the commuting zone of residence.

    Main Outcomes and Measures  The primary outcome was the county-level age-adjusted opioid overdose mortality rate. Secondary outcomes included the overall drug overdose mortality rate and prescription vs illicit drug overdose mortality rates.

    Results  During the study period, 29 manufacturing counties in 10 commuting zones were exposed to an automotive assembly plant closure, while 83 manufacturing counties in 20 commuting zones remained unexposed. Mean (SD) baseline opioid overdose rates per 100 000 were similar in exposed (0.9 [1.4]) and unexposed (1.0 [2.1]) counties. Automotive assembly plant closures were associated with statistically significant increases in opioid overdose mortality. Five years after a plant closure, mortality rates had increased by 8.6 opioid overdose deaths per 100 000 individuals (95% CI, 2.6-14.6; P = .006) in exposed counties compared with unexposed counties, an 85% increase relative to the mortality rate of 12 deaths per 100 000 observed in unexposed counties at the same time point. In analyses stratified by age, sex, and race/ethnicity, the largest increases in opioid overdose mortality were observed among non-Hispanic white men aged 18 to 34 years (20.1 deaths per 100 000; 95% CI, 8.8-31.3; P = .001) and aged 35 to 65 years (12.8 deaths per 100 000; 95% CI, 5.7-20.0; P = .001). We observed similar patterns of prescription vs illicit drug overdose mortality. Estimates for opioid overdose mortality in nonmanufacturing counties were not statistically significant.

    Conclusions and Relevance  From 1999 to 2016, automotive assembly plant closures were associated with increases in opioid overdose mortality. These findings highlight the potential importance of eroding economic opportunity as a factor in the US opioid overdose crisis.