The Effects of County-Level Naloxone Distribution on Drug Usage and Health: Evidence from Indiana

• In Event: Measuring Illicit Fentanyl Markets and Evaluating Overdose Intervention

Abstract

The opioid crisis remains a central public health challenge in the United States, with policymakers increasingly relying on harm-reduction strategies such as expanding access to naloxone, a drug designed to reverse the potentially life-threatening effects of an opioid overdose. While naloxone is highly effective at reversing overdoses at the individual level, there is limited evidence on how increasing its supply within public health systems affects population-level outcomes. This paper examines a statewide naloxone distribution program in Indiana that provided naloxone kits directly to county health departments, substantially increasing institutional access for first responders.

I ask whether increasing the supply of naloxone within local public health systems improves health outcomes or generates unintended behavioral responses. To answer this question, I construct a novel county-year panel dataset covering all 92 Indiana counties from 2014 to 2023. The data combine administrative records on naloxone kit distributions, emergency medical services (EMS) runs, opioid-related health outcomes, and drug-related crime. Leveraging staggered county participation in the program, I employ a difference-in-differences research design to estimate the causal effects of increased naloxone supply.

I first document a strong first-stage effect: program participation increases naloxone administrations by approximately 22.9 percent relative to the pre-treatment mean, with larger effects in counties receiving more kits per capita. Despite this increase in emergency response, I find little evidence of improvements in health outcomes, including drug-related emergency department visits and hospitalizations. Estimates of opioid-related mortality are generally imprecise, though dose-response analyses suggest mortality may increase in higher-intensity treatment areas.

To better understand behavioral responses, I examine drug-related crime as a proxy for changes in drug use. I find that opioid-related arrests increase by approximately 13 percent following program adoption, with similar increases in possession offenses. These patterns are consistent with increased drug-related activity and suggest that expanded naloxone access may alter risk perceptions or usage behavior.

These findings highlight an important policy tradeoff. While naloxone distribution programs successfully increase life-saving interventions by first responders, they may also generate unintended consequences that offset health benefits. The results underscore the importance of considering behavioral responses and local context when designing harm-reduction policies. More broadly, this paper contributes to a growing literature showing that the effectiveness of opioid-related interventions depends critically on institutional settings and implementation strategies, offering guidance for policymakers seeking to combat the opioid crisis.

Author

• Robert Stroud Payne, Jr., Vanderbilt University
  Presenting Author