Article Text

Download PDFPDF
The link between unemployment and opioid prescribing. An instrumental variable approach using evidence from England
  1. Sotiris Vandoros1,2,
  2. Xiangpu Gong1,
  3. Ichiro Kawachi2
  1. 1 King’s College London, London, UK
  2. 2 Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
  1. Correspondence to Sotiris Vandoros, Bush House, 30 Aldwych, London WC2B 4BG, UK;vandoros{at}


Background Unemployment has been associated with chronic pain, which is often treated with prescription opioids. Opioid mortality has been included in the so-called category of ‘deaths of despair’ due to the role of lack of opportunity. While previous studies have found an association between unemployment and opioids, the relationship is endogenous and examining any effect is challenging.

Objective The objective of this paper is to study the association between unemployment and opioid prescribing in England.

Data and Methods We used data from the GP prescribing database in England for the period 2011–2017 and followed ordinary least squares (OLS) and Instrumental Variable econometric approaches, controlling for other confounders. We used the number of foreign direct investment projects and the number of registered companies as instruments for unemployment, taking population size into account.

Results The OLS model suggests that an increase in the unemployment rate by 1 percentage point is associated with 0.017 additional opioid defined daily doses per capita—a 0.9% increase compared with the mean of 1.745. According to the instrumental variable model, an increase in unemployment by 1 percentage point leads to an increase in the number of opioid doses prescribed per capita by between 0.315 and 0.437, which constitutes a 18–25% increase compared with the mean of 1.745.

Conclusions Unemployment appears to have an impact on opioid prescribing volume in England. This reveals yet another negative effect of unemployment on health. Relevant labour market policies may play a protective role with regards to opioid use.


Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Contributors SV, IK: study conception, design and interpretation of results; XG: data collection; SV and XG, statistical analysis; SV, XG and IK: critical revision and drafting of manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests The authors declare that they have no conflict of interest. All authors have completed the ICMJE uniform disclosure form and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work.

  • Patient consent for publication Not required.

  • Ethics approval This study does not involve human subjects, so ethics approval was not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.