Exploring the Role of Despair in Opioid Misuse in the United States: A Mental Health Issue on the Rise Among the Economically Marginalized

Background: Opioid misuse is a devastating problem in the United States. Attempts to understand the opioid misuse and opioid related deaths have largely been focused on the supply side factors. But a demand side theorization suggests increasing deaths from suicide, alcohol, and drugs occurring among less educated and unskilled workers, may offer more insight by suggesting possible pathways to opioid misuse and deaths. This theorization, termed as “deaths of despair” indicate a sense of hopelessness arising due to declining incomes, disengagement from the labor force, weakened family structures, community decline, and isolation. Theory suggests these changes are occurring due to economic stagnation where despair has been suggested as the possible mediator. While despair has been much discussed in the context of opioid epidemic, but there has been little empirically grounded work in this area. This study fills this gap by examining (i) psychometric properties of despair and (ii) if despair mediates the relationship between economic marginalization and opioid misuse.

Methods: Data was obtained from the 2019 National Survey on Drug Use and Health. The sample consists of 41,540 respondents aged 12+. First, a confirmatory factor analysis (CFA) was conducted to compare the factor structure (single vs. multi-factors, formative vs. reflective) of despair. Second, a theoretical mediation model was estimated to test the direct and indirect effects between the independent variable, poverty (proxy for economic marginalization; dichotomous—above vs. below federal poverty line) and outcome, opioid misuse (dichotomous—no opioid misuse vs. opioid misuse) with despair as the mediating variable. Mplus was used to estimate all models and 95% confidence interval was used for all results.

Results: CFA results supported the one factor model with 6 items (nervousness, hopelessness, restlessness, anhedonia, effort, worthless) with all factor loadings >= 0.7 and acceptable fit indices (χ2 = 4900.13, p=0.00, RMSEA=0.1, SRMR=0.03, CFI=0.97, TLI=0.95). Results support the theoretical mediation model with good fit indices (χ2 = 2285.05, p=0.00, RMSEA=0.05, SRMR=0.03, CFI=0.96, TLI=0.94). The direct (0.12), indirect (0.08), and total effect (0.19) coefficients are significant. Poverty increases the probability of despair and opioid misuse by 25% each (OR=1.25) and despair increases the probability of opioid misuse by 99% (OR=1.99). Lastly, the probability of opioid misuse is 16% higher when despair mediates the relationship between poverty and opioid misuse (OR=1.16).

Conclusion: The study has theoretical and practical implications. First, this is the first study to our knowledge to examine despair’s factor structure and test it as a mediating variable, thus confirming significant part of “deaths of despair” theory. Second, it underscores the role of economic factors while identifying despair as the mechanism through which it impacts opioid misuse. Thus, despair could be targeted in interventions, but it is equally important to address a lack of economic resources or opportunities in treatment programs. Lastly, results also highlight the need to address poor economic conditions at a macro level (community, state, or federal) as these macro conditions leads to individual experiences of despair driving up the opioid misuse and deaths.