[This article was updated December 12 to reflect a response from the author of the paper.]
An article published December 7 by the Brookings Institution, a prominent Washington, DC think tank, is under fire for promoting the idea that harm reduction approaches—like syringe exchange and naloxone—may encourage “riskier opioid use” and increase rates of opioid-related deaths.
The focus of the criticism is the choice of which articles to cite—and which not to cite—by the authors of the Institution’s “research roundup.” The paper was written by Jennifer L. Doleac, an associate professor of Economics at Texas A&M University, Anita Mukherjee, an assistant professor of Risk and insurance at the University of Wisconsin-Madison, and Molly Schnell, a postdoctoral Fellow at the Stanford Institute for Economic Policy Research.
“New work by Packham and Wells (2018) suggests that syringe exchange programs—a staple of harm-reduction efforts—reduce HIV rates as intended but unintentionally increase opioid-related mortality by making it easier, cheaper, and safer to use heroin” the authors state.
But as many readers pointed out, the Packham and Wells article is a working paper—meaning it has not yet been subjected to peer review, nor published in any journal. The authors simultaneously don’t cite decades of existing peer-reviewed studies that show syringe exchange programs do not increase mortality rates.
@BrookingsEcon to RESCIND this piece and have it undergo peer review by subject matter experts,” tweeted Leo Beletsky, associate professor of Law and Health Sciences at Northeastern University. “It ignores much of the empirical evidence base on the topics it purports to analyze. This is not a balanced, informed analysis and will do public health harm if left uncorrected.”
This publication doesnt comport w basic standards of scientific balance. It completely ignores, nevermind engage, body of evidence disproving its about harm reduction programs. Policymakers trust @BrookingsInst to provide information they can use to make decisions. Please RETRACT https://t.co/eqPdYdPfEx
— Leo Beletsky (@LeoBeletsky) December 10, 2018
Others in the medical and public health communities agreed:
I wrote to @BrookingsInst outlining my concerns with their opioid research roundup (https://t.co/FPqAzuL4oQ). At the core of my argument against the article is a fundamentally flawed study regarding the impact of naloxone access legislation (https://t.co/GEKRzSHtSb). pic.twitter.com/O2wVx8Di2m
— Lucas Hill, PharmD (@HillPharmD) December 11, 2018
— Alex Wodak (@AlexWodak) December 11, 2018
I am hurt. And angry. How is this laziness acceptable and able to get a platform when people are actually out there dying?!?! And while people are out there saving lives and doing the real work?!?! I…just…can’t. https://t.co/RxQRWdj50x
— Sheila Vakharia PhD MSW (@MyHarmReduction) December 11, 2018
“The most shocking claim in the article is that harm reduction increases risky drug use behavior, even though there is no evidence of this,” tweeted Alex Gertner, an MD-PhD candidate at University of Chapel Hill. “The whole point of harm reduction is to help people to reduce risky behavior.”
In addition to the Packham and Wells article, the authors also cite their own paper, “The Moral Hazard of Lifesaving Innovations: Naloxone Access, Opioid Abuse, and Crime,” published earlier this year by IZA Institute of Labor Economics, a German think tank, to support the idea that increased access to naloxone increases opioid use, opioid-related crime, and, in some places, deaths from overdoses.
That article was also confronted by a barrage of methodological criticism when it was published. For example, as Gertner pointed out at the time, “the authors find that naloxone access laws lead to more opioid-related emergency department visits, the premise being that naloxone access laws increase opioid overdoses. But there’s a far more likely explanation: People are generally instructed to seek medical care for overdose after receiving naloxone.”
Filter reached out to Jennifer L. Doleac, the lead author of the paper, through Brookings, and was instructed to email questions. Shannon Meraw, Brookings’ media relations manager, responded to questions with the following: “Worth noting—we’ve received several questions related to your numbers 1 and 2. The authors will be updating the piece to clarify why some of the findings cited are different from those supported by many public health advocates (economists tend to think about these issues differently than folks in other disciplines). I’m not sure when that will be finalized, but we will include an editor’s note when it is.”
Doleac has also tweeted: “Sincere request: If you think our post on opioid has missed relevant studies from public health or any other discipline, please email them to me. Vague allusions to decades of evidence aren’t persuasive but I do like reading good research, & am willing/able to change my priors!”
Putting this here for max visibility. I’m genuinely curious what amazing studies people think we’ve missed. Email is the best way to contact me — don’t assume I will see your tweets. https://t.co/SKs8IQ2PrZ
— Jennifer Doleac (@jenniferdoleac) December 10, 2018
Doleac seemed to be referring to a tweet thread of Gertner’s that referenced “decades of evidence.” But in the same thread, Gertner provided a link to a literature review of studies on this exact topic.
Plus, as many pointed out, looking into previous research on a topic is generally done before a lit review is written, not after.
Meraw added in her email: “Brookings of course doesn’t take a position on any issue, but as we provide a platform for individuals to do so, we do want to make sure the debate is properly contextualized.”
Brookings may not officially “take a position,” but many policymakers look to the the think tank to form their views. The New York Times called Brookings “the most prestigious think tank in the world.” So by choosing who to give a platform to (and who not), Brookings effectively does take positions.
7/ It’s hard to overstate how shocking it is for mainstream organization like @BrookingsInst to host a view that harm reduction increases risk. This is in line with arguments during HIV crisis that we shouldn’t provide condoms and anti-virals since it’d increase risky behaviors.
— Alex Gertner (@setmoreoff) December 8, 2018
Meraw said that she would pass Filter‘s questions along to lead author Jennifer L. Doleac, and this article will be updated if we receive a response.
In the midst of the overdose crisis, harm reduction ideas have been making their way into mainstream discussions. That’s a good thing—but it also means more people than ever are talking about harm reduction with very little familiarity with what it means. It’s likely that vigilance from researchers and experts with deep knowledge of harm reduction methodologies will increasingly be required to prevent damaging inaccuracies being received as fact.
UPDATE – December 12:
Filter received the following response from Doleac by email:
“I find it utterly disheartening that a discipline as important as public health is filled with so many people who collectively have so little understanding of rigorous research methods. Advocates should acknowledge that many of their strongly-held priors are not evidence-based. Anecdotes and personal experience are valuable but are not a substitute for the rigorous causal inference methods used in the studies that our post highlighted.”
On December 11, the Brookings Institution’s article was also updated “to contextualize and clarify its discussion of harm reduction policies.” A few paragraphs have been added that read:
“The results of the Doleac and Mukherjee study suggest that broadening access to naloxone can unintentionally increase opioid abuse by reducing the cost of overdose. That is, while naloxone saves lives in the moment—which is clearly a priority for policymakers and public health officials—it may increase rates of drug abuse and possibly even mortality.
These findings suggest that harm-reduction policies—like policies in many contexts—involve tradeoffs. Economists have found evidence of similar unintended consequences in other public health settings, so the idea that such tradeoffs are possible is not new or unique to opioid-related legislation.
We recognize that these findings strongly contrast with previous work by public health researchers that suggested few, if any, trade-offs that result from harm reduction policies. We believe that the research described above credibly establishes a causal effect, but given the stakes at-hand—and the impact drug abuse can have on individuals, their families, and society at-large—this is clearly an area that needs further study. In the meantime, policymakers should acknowledge and work to mitigate any potential unintended consequences when implementing harm-reduction policies.”
The new paragraphs do not link to any of the referenced “previous work by public health researchers.”