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Invited Commentary
Public Health
June 22, 2018

The Opiates and the (Voting) Masses

Author Affiliations
  • 1Center for Quantitative Health, Massachusetts General Hospital, Harvard Medical School, Boston
JAMA Netw Open. 2018;1(2):e180451. doi:10.1001/jamanetworkopen.2018.0451

The rise of Donald Trump as a viable (and successful) political candidate and the worrying trends in opiate addiction rates have both been covered extensively before and after the 2016 election. For example, innumerable reporters during the campaign traveled to districts that swung heavily to Trump seeking to better understand these voters and the issues that drove them.1 Furthermore, the staggering rise in the use of prescribed and illicit opiates has garnered a significant amount of coverage in the media and academia over the past few years.2 Linking these topics, many of the pieces profiling Trump-supporting communities made clear mention of the rise in opiate addiction as a major concern for these communities.

The article by Goodwin et al3 explores this convergence of the (worsening) opiate epidemic in many communities and the political shifts within them that enabled Trump to be elected president. Using a unique data set that included county-level Medicare Part D data, the authors found that, after controlling for a number of socioeconomic covariates, rates of prescriptions for opiates were correlated with voting margins for Trump in the 2016 presidential election.

This article builds on previous literature showing that public health, in particular public mental health, does not exist in a vacuum. Rather, it is in a constant state of flux with economic and other societal forces, both influencing and being influenced by these other key factors. In this dynamic, steep declines in housing prices can be seen to be linked with increases in antidepressant prescriptions,4 and passage of legislation protecting undocumented immigrants can have profound impacts on rates of depression for individuals affected by the legislation.5

Taken broadly, these findings are not surprising in and of themselves. Clinicians in the mental health field know that patients’ mental health can change based on environmental factors outside of their control. The value of these sorts of studies, if they can be validated through replication and other means, lies in their ability to serve as a quantitative correlation and/or outcome that can be used to highlight the burden of mental illness caused by a variety of public policies. Relative to the rest of medicine, psychiatry has been burdened by the perception (fair or not) that it lacks quantifiable metrics that can be used for advocacy and policy. Articles like that by Goodwin et al are good examples of how available data sources can be used creatively to test whether mental health trends might be correlated with key outcomes such as elections. As elections are how political leaders are chosen in a democracy, arguments for focusing on mental health in this context may be particularly convincing to elected policy makers.

The article raises a number of important questions. What is at the root of the observed dynamic between opiate use and voting behavior? Are these trends specific to voting for Trump or are there other candidates who perform similarly at the state level? Unfortunately the authors were limited in what they could answer. Data constraints limited them to only some covariates of the many that might capture some of the observed correlation. Also, as the data were not in a time series, the researchers were not able to apply more rigorous statistical methods that might better support the county-level correlations that have been observed to link factors like unemployment with opiate use.6 Even if there were time-series data available, US presidential elections are infrequent (and unique) enough that it is often difficult to discern trends in voting behavior. Furthermore, the uniqueness of Trump as a candidate and his coalition when compared with past presidential elections make it difficult to extrapolate clear lessons that can be applied to the public health and political realms more broadly. Finally, 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.

These limitations aside, this article’s 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. Further work will undoubtedly continue to explore these connections and, by extension, bring attention to the importance of addressing mental health and addiction in the policy realm.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2018 Rosenquist JN. JAMA Network Open.

Corresponding Author: James Niels Rosenquist, MD, PhD, Massachusetts General Hospital, 185 Cambridge St, Room 2266, Boston, MA 02114 (jrosenquist@partners.org).

Conflict of Interest Disclosures: None reported.

Kaplan  T. This is Trump country. New York Times. March 4, 2016. https://www.nytimes.com/interactive/2016/03/04/us/politics/donald-trump-voters.html. Accessed May 5, 2018.
Eyre  E. Drug firms poured 780M painkillers into WV amid rise of overdoses. Charleston Gazette-Mail. December 17, 2016. https://www.wvgazettemail.com/news/cops_and_courts/drug-firms-poured-m-painkillers-into-wv-amid-rise-of/article_99026dad-8ed5-5075-90fa-adb906a36214.html. Accessed May 5, 2018.
Goodwin  JS, Kuo  Y-F, Brown  D, Juurlink  D, Raji  M.  Association of chronic opioid use with presidential voting patterns in US counties in 2016.  JAMA Netw Open. 2016;1(2):e180450. doi:10.1001/jamanetworkopen.2018.0450Google ScholarCrossref
Lin  H, Ketcham  JD, Rosenquist  JN, Simon  KI.  Financial distress and use of mental health care: evidence from antidepressant prescription claims.  Econ Lett. 2013;121(3):449-453. doi:10.1016/j.econlet.2013.09.004Google ScholarCrossref
Venkataramani  AS, Shah  SJ, O’Brien  R, Kawachi  I, Tsai  AC.  Health consequences of the US Deferred Action for Childhood Arrivals (DACA) immigration programme: a quasi-experimental study.  Lancet Public Health. 2017;2(4):e175-e181. doi:10.1016/S2468-2667(17)30047-6PubMedGoogle ScholarCrossref
Hollingsworth  A, Ruhm  C, Simon  K. Macroeconomic conditions and opioid abuse. http://www.nber.org/papers/w23192.pdf. National Bureau of Economic Research working paper 23192. Published February 2017. Revised March 2017. Accessed May 5, 2018. doi:10.3386/w23192
3 Comments for this article
Opiate crisis visibility and voting patterns
Ben Park, MD | Private practice
The number of people using opiates is a small number unable to significantly impact election outcomes. In an informal survey chronic opiate users were actually less likely to vote. However, in areas with high rates of opioid use people are more likely to know someone whom the opioid crisis has impacted.

For the most part people view the flood of opiates destroying the social fabric as an issue where government has been either ineffective or causal. They are not surprised that the push for pain as a "5th vital sign" resulted in increased opioid use that should have been
anticipated or that the FDA approved opiates that do more harm than good. Trump voters are known to be dissatisfied with the status quo, which includes the opioid crisis.
Much Ado About Nothing?
John Kelly, MD, MPH | Adjunct Faculty, Preventive Medicine, Loma Linda University School of Medicine
Dear Sir(s):

The fact that opioid use is higher in rural counties, especially those in the rust belt and in Appalachia, and the fact that support for President Trump was also higher in rural counties, likely explains much more than 18% of the variance, and certainly more than 6% (the adjusted number).

With all due respect for the fact that genuine science does exist and can be done in analyzing politics and drug use, this is nowhere near an example of that. There are numerous holes in this 'work,' and I am surprised it took reader comments to
point them out.

John Kelly, MD, MPH
Opioids and Voters Preferences
Jacob Korula, M.D. |
The authors use retrospective Medicare claims data to demonstrate a significant difference in voter preference for the Republican party in those who use and abuse opioids. In these users, over 80% were white, 50 % were disabled and 24% had end stage renal disease. The sample comprised 73% who were age eligible for Medicare, of whom 9% were opioid users compared to 44% in the disabled group. This selects a group of younger, chronically ill (higher co-morbidity, 24%), and disabled persons on public healthcare who were unemployed, an inherently biased and possibly disaffected subgroup. It is not surprising to note their voter preference. More importantly, what was the real purpose of this study and how does it help in solving the problem of opioid use in this epidemic? This flawed study despite the enormous effort does not provide valid and meaningful data to answer both questions in a credible manner.