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.
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 (firstname.lastname@example.org).
Conflict of Interest Disclosures: None reported.
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Rosenquist JN. The Opiates and the (Voting) Masses. JAMA Netw Open. 2018;1(2):e180451. doi:10.1001/jamanetworkopen.2018.0451
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