The demand-side perspective argues that the drug overdose epidemic is a consequence of changes in the economy that leave behind working-class people who lack a college education. In contrast, the supply-side perspective maintains that the epidemic is primarily due to changes in the licit and illicit drug environment, whereas a third, distinct perspective argues that income inequality is likely a key driver of the epidemic. To evaluate these competing perspectives, we use a two-level random intercept model and U.S. state-level data from 2006 to 2017. Contrary to the demand-side approach, we find that educational attainment is not associated with drug-related mortality. In support of the supply-side approach, we provide evidence indicating that opioid prescription rates are positively associated with drug-related mortality. We also find that income inequality is a key driver of the epidemic, particularly the lack of resources going to the bottom 20% of earners. We conclude by arguing that considerations of income inequality are an important way to link the arguments made by the demand-side and the supply-side perspectives.
Keywords: deaths of despair; drug overdose epidemic; income inequality; mortality; population health.