County-level aggregate costs arising from Indiana's opioid crisis.

• Author: Brewer, Ryan M.

DOWNLOADABLE FILES FOR THIS ARTICLE

* Appendix spreadsheet containing results for all 92 counties

* Ongoing opioid misuse damages estimation tool

This article examines the impact of Indiana's ongoing opioid misuse crisis at the county level. The purpose of this analysis is twofold: First, we provide local leaders detailed information on the full extent of damages local communities have experienced from the opioid crisis thus far to offer perspective of the scope of the problem at the local level. Second, we present an algorithm leaders can use to estimate the rate at which economic damages continue to accumulate per community.

We defined "community" as the county for three primary reasons:

1. Information was available allowing us to assess damages at the county level.

2. County-level data can be used as a point of reference to reflect local labor markets within Indiana.

3. Decision-making at the county level will be crucial in generating steps to end the opioid epidemic.

   We began by considering the statewide analysis by Brewer and Freeman, also published in this issue. (1) In that study, the total cumulative economic damages in Indiana arising from the epidemic from 2003 through 2017 were estimated to total $43.3 billion. Three distinct categories of damages were included in that sum:

1. Total aggregate direct costs associated with non-lethal opioid misuse.

2. Losses to gross state product stemming from labor market tightness and associated losses to workforce productivity (GSP losses).

3. The accumulating costs associated with deaths from opioid overdoses.

   Neither cost estimates for pain-and-suffering nor the investment costs necessary to repair accumulating damages were considered. These and perhaps other categories of damages from the opioid crisis-such as losses to productivity in family members of those deceased or injured from the crisis, medical costs associated with hepatitis and other non-HIV blood-borne illnesses, as well as costs associated with increased use of mental health counseling and antidepressants--have yet to be directly connected to the crisis in ways such that corresponding costs can be measured with a reasonable degree of accuracy.

   Figure 1 shows the estimated aggregate damages at the county level between 2003 and 2017. (More results, including per capita calculations, are found following the methodology).

   Methodology for allocating damages to counties

   In order to allocate statewide economic damages to the 92 Indiana counties each year, we considered three categories of damages separately, and the allocation method for each is outlined in the following sections.

1. Direct costs: Funerals, first response, acute hospitalization, long-term treatment, neonatal abstinence syndrome, foster care, arrests and court costs, property loss, incarceration, HIV and overdose death wage losses.

2. Indirect costs: Lost GSP in tight labor markets.

3. Present value of all lost future productivity of past opioid-related casualties.

   Direct costs (Category 1)

   Because detailed county-level information was absent for the various subcategories of direct costs, we apportioned the state-level direct costs across counties based on a combination of the data items that were available on a county-level basis. For several years of data, we obtained information on county-level, non-fatal, opioid-related emergency room (ER) visits (available for years 2009-2016) and county-level reported opioid deaths (available for years 2011-2016).

   We calculated county-level opioid fatalities each year by multiplying the estimated statewide opioid fatalities by the proportion within the state of reported opioid fatalities per county, as reported by the Indiana State Department of Health (ISDH). As discussed in the statewide analysis, ISDH numbers from the early years of the crisis underreported overdose deaths attributable to opioids.

   We calculated cumulative deaths in each county by summing the annual deaths over the crisis period (2003-2017). For years 2003-2010, when county-level opioid deaths were not reported, we estimated the opioid-related deaths in each county by multiplying state-level opioid deaths by the average proportion...