Republican Support and Economic Hardship: The Enduring Effects of the Opioid Epidemic

This paper establishes a causal connection between the opioid epidemic and the political realignment toward the Republican Party in the United States from the mid-2000s through 2022. The authors—Carolina Arteaga and Victoria Barone—exploit rich geographic variation in Purdue Pharma’s initial marketing strategy for OxyContin, drawn from unsealed litigation records, to construct a quasi-exogenous measure of community-level exposure to the epidemic.

The identification strategy rests on a documented feature of OxyContin’s 1996 launch: Purdue initially targeted the established cancer pain market—physicians and patients already using MS Contin—as an entry point into the much larger noncancer pain market. Areas with higher cancer mortality in 1996 received disproportionate pharmaceutical marketing, leading to outsized opioid prescription growth that spilled over from cancer patients to the broader population through shared physicians. The authors use 1996 commuting-zone (CZ) cancer mortality rates as a proxy for this initial targeting, interacted with year fixed effects in an event-study specification with CZ and state-year fixed effects. The sample covers 625 CZs across the continental United States from 1982 to 2022.

The empirical chain runs through three stages. First, the instrument strongly predicts opioid supply: by 2012, a one-standard-deviation higher 1996 cancer mortality rate led to an additional 0.97 opioid doses prescribed per capita, 65% above the baseline mean. Second, the resulting epidemic caused measurable mortality and economic hardship. A one-standard-deviation increase in 1996 cancer mortality caused drug-induced deaths in 2017 to be 46% above the pre-epidemic average; by 2012 the same increase caused prescription opioid deaths to be 61% higher. Excess mortality was concentrated among individuals under age 55, with no significant effects for those aged 55 and older. The epidemic also raised disability applications: SSDI applications rose by 12% and SSI applications by 7.6% by 2012, effects that persisted through 2020. SNAP enrollment in exposed CZs was 8% higher by 2022, equivalent to a 0.14 standard deviation increase.

Third, and centrally, the communities that endured these health and economic shocks shifted persistently toward the Republican Party. By the 2022 House elections, a one-standard-deviation increase in 1996 cancer mortality increased the Republican two-party vote share by 4.5 percentage points. Effects of similar magnitude appear in presidential elections (4.6 percentage points) and gubernatorial elections (4.3 percentage points). The vote-share shift is consistent across gender, age, race, and education, with no detectable change in voter turnout. The shift translates into actual seat gains: beginning in 2012, exposed areas consistently elected more Republican House members, moving the chamber’s roll-call voting in a more conservative direction. The effect is not driven by anti-incumbent sentiment—results hold regardless of which party held the seat at the time.

The paper identifies three reinforcing mechanisms. First, the Republican Party repositioned itself during this period as the advocate of “forgotten America” and working-class economic hardship, a message that resonated acutely in opioid-devastated communities. Second, conservative-leaning newspapers covered the epidemic at higher rates, and their coverage tracked local mortality; liberal-leaning outlets showed no such correlation. Fox News covered opioid stories at 1.5 times the rate of CNN and 1.7 times the rate of MSNBC, emphasizing crime, trafficking, and cartels at twice the frequency of liberal outlets. Third, exposed communities expressed stronger preferences for Republican-favored policy responses: higher police presence, greater sense of safety around law enforcement, and lower support for marijuana legalization on state ballot initiatives.

Pre-trend tests show no relationship between 1996 cancer mortality and outcomes before OxyContin’s launch. Out-of-sample exercises using 1976 cancer mortality find no analogous pattern in the pre-epidemic period (1982–1994). Placebo instruments based on unrelated causes of death yield null results. The baseline findings are robust to controlling for the China import shock, NAFTA, the 1994 Republican Revolution, the 2001 and 2008–2009 recessions, declining unionization, robot adoption, Fox News introduction, deaths of despair, and Southern and rural political realignment.

Q: What is the paper’s central research question? A: The paper asks whether the opioid epidemic causally increased Republican vote share in communities most severely affected by the crisis. It documents a causal chain from pharmaceutical marketing through drug mortality and economic hardship to political realignment, contributing the first causal estimate of a major public health crisis’s effect on partisan voting.

Q: What is the identification strategy, and why is 1996 cancer mortality a valid instrument? A: Purdue Pharma explicitly targeted physicians in the cancer pain market at OxyContin’s 1996 launch, then used those established relationships to expand into the noncancer pain market. CZs with higher cancer mortality in 1996 received disproportionate marketing, generating differential opioid prescription growth unrelated to pre-existing political or economic trends. Pre-trend tests confirm no differential patterns before 1996, out-of-sample tests using 1976 cancer mortality find no relationship with pre-epidemic outcomes, and placebos using unrelated causes of death yield null results.

Q: How strong is the first stage linking 1996 cancer mortality to opioid prescriptions? A: The relationship between 1996 cancer mortality and opioid prescriptions is positive and statistically significant from 1998 through 2020. By 2012—the year prescription rates peaked nationally at 81.3 per 100 persons—a one-standard-deviation higher cancer mortality rate led to an additional 0.97 morphine-equivalent doses prescribed per capita, 65% above the baseline mean. CZs in the highest cancer mortality quartile experienced a 1,800% increase in grams of oxycodone per capita between 1997 and 2010, compared to less than half that in the lowest quartile.

Q: What are the effects on drug-induced mortality? A: Drug-induced mortality (a broad measure covering deaths from prescription opioids, heroin, and fentanyl) rose continuously in exposed CZs after 1996. By 2017, a one-standard-deviation increase in 1996 cancer mortality caused drug-induced deaths to be 46% above the pre-epidemic average. By 2012, the same increase caused prescription opioid deaths specifically to be 61% higher relative to the pre-epidemic average. Excess mortality was concentrated among individuals under age 55, with no statistically significant effects for those aged 55 and older.

Q: What are the effects on disability program take-up? A: Applications for Social Security Disability Insurance (SSDI) rose by 12% and Supplemental Security Income (SSI) applications rose by 7.6% by 2012 for a one-standard-deviation increase in 1996 cancer mortality. These effects persisted: SSDI recipients grew by 15% and SSI recipients by 3.2% by 2020 in similarly exposed CZs. The increases in disability were concentrated among individuals under age 55, paralleling the mortality effects.

Q: What are the effects on SNAP enrollment? A: Exposed CZs showed a continuous increase in SNAP enrollment over two decades following the epidemic’s onset. By 2020, a one-standard-deviation increase in 1996 cancer mortality corresponded to an 8% increase in the share of the population receiving SNAP benefits, equivalent to 0.14 standard deviations. By 2022, the corresponding figure remains 8%, indicating persistent economic strain in exposed communities.

Q: What is the magnitude of the political effects in House elections? A: A one-unit increase in the 1996 cancer mortality rate yielded a 7.9-percentage-point increase in the 2022 Republican House vote share relative to 1996. Scaled to one standard deviation (0.58 units), this corresponds to a 4.5-percentage-point increase in the Republican two-party vote share by the 2022 midterms. The vote-share shift became statistically significant beginning in 2006, but only translated into consistent seat-level Republican gains starting in 2012.

Q: When did opioid exposure start winning Republicans additional House seats? A: Although the Republican vote share in exposed areas began increasing around 2006, actual seat flips did not become consistent until 2012. The paper explains this lag by noting that initial vote-share gains were concentrated in communities with low baseline Republican support, where additional votes did not immediately cross the winning threshold. Starting in 2010, median-baseline-Republican CZs also began shifting, enabling additional seat changes.

Q: How large are the presidential and gubernatorial election effects? A: In presidential elections, a one-standard-deviation increase in 1996 cancer mortality raised the Republican vote share by 4.6 percentage points. In gubernatorial elections, the same increase raised the Republican vote share by 4.3 percentage points after approximately six election cycles (corresponding to 2017–2020). These effects are described as comparable in magnitude to the difference in Republican vote share between the top and bottom quartiles of NAFTA vulnerability.

Q: Does the political shift reflect increased polarization toward extremist candidates? A: No. The paper finds no increase in the probability of electing candidates at the extremes of the Nokken-Poole ideological scale in any given election year. The ideological shift in the House composition arises from changes in which party wins seats rather than from the election of more extreme Republicans. Campaign donations to Republican candidates did not increase; rather, donations to Democratic candidates declined (in 2016, a one-standard-deviation increase in cancer mortality widened the Republican-Democrat donation gap by 0.44 standard deviations). The shift is interpreted as a change in voting preferences in previously Democratic-leaning areas, not heightened polarization.

Q: Is the shift driven by anti-incumbent sentiment? A: The authors test this by splitting the sample by the incumbent’s party at the time of each election and by redefining the outcome as the incumbent’s vote share. Neither exercise produces evidence of a systematic anti-incumbent response. The changes in Republican vote share are not statistically distinguishable based on whether the incumbent was a Republican or Democrat. If anything, after 2016 there is a slight increase in the likelihood of incumbents retaining their seats.

Q: Where geographically are the Republican gains largest? A: Using state-level treatment effects estimated from an in-differences model interacting cancer mortality with state-year indicators, the paper finds a strong positive correlation between the magnitude of the epidemic’s effect on economic hardship (measured by SNAP participation) and the magnitude of the Republican vote-share increase. This correlation is strongest with a lag: SNAP effects measured in 2006 are most predictive of vote-share shifts in 2022, indicating that deterioration in community economic fabric preceded and predicted the political realignment.

Q: How did conservative and liberal media differ in covering the opioid epidemic? A: Republican-leaning local newspapers covered the opioid epidemic more extensively than Democratic-leaning papers throughout the epidemic period, and their coverage tracked local opioid mortality rates; Democratic-leaning coverage showed no such correlation with local incidence. Fox News covered opioid stories at 1.5 times the rate of CNN and 1.7 times the rate of MSNBC. In terms of content, Republican-leaning newspapers showed 23% higher frequency of economic hardship keywords, 19% higher frequency of illegal activity and crime keywords, and 22% higher frequency of rehabilitation and treatment keywords relative to Democratic-leaning papers. Fox News emphasized crime, drug trafficking, and cartels at double the frequency of more liberal outlets.

Q: How did voter policy preferences align with Republican versus Democratic platforms? A: Using 2020 CCES data, the authors find that higher 1996 cancer mortality predicts a greater expressed preference for increasing the number of police officers on the street and a greater reported sense of safety around law enforcement—both consistent with the Republican Party’s law enforcement approach. Conversely, exposure to the epidemic predicts lower support for marijuana legalization on state ballot initiatives across 18 states from 2012 to 2023, indicating opposition to a key Democratic harm-reduction policy.

Q: What role did political actors themselves play in driving the realignment? A: Relatively little. The opioid epidemic was largely absent from House floor speeches until 2015 and from campaign advertising until 2020. Neither party took a clear legislative lead on the issue during the first two decades of the crisis. The authors interpret the political realignment as driven primarily by the Republican Party’s broader repositioning as the champion of working-class economic hardship and by differential media framing, rather than by active legislative competition over opioid policy.

Q: What major confounds are ruled out? A: The authors control for exposure to the China import shock, NAFTA, the 1994 Republican Revolution, the 2001 and 2008–2009 recessions, declining unionization, robot adoption, Fox News entry, deaths of despair (which include but are not limited to opioid deaths), and the political realignment of the South, rural areas, evangelicals, and the population over 65. Results remain robust across all these specifications. Placebo instruments using unrelated causes of death yield null results.

Q: Could the vote-share effects be mechanically driven by opioid-related deaths removing Democratic voters from the electorate? A: The authors perform a back-of-the-envelope calculation and estimate that even if all opioid-related deaths would have been Democratic votes, the mechanical effect on the Republican vote share is at most 0.22 percentage points relative to the observed 2020 vote share—far smaller than the estimated 4.5-percentage-point shift by 2022. The result is also inconsistent with a turnout mechanism, as voter turnout shows no meaningful change with epidemic exposure.

Opioid epidemic exposure instrument: The paper measures community-level exposure to the opioid epidemic using cancer mortality rates in 1996, the year OxyContin launched. This instrument is grounded in Purdue Pharma’s documented marketing strategy of targeting the cancer pain market first; areas with more cancer patients received disproportionate pharmaceutical marketing, generating differential opioid prescription growth that extended well beyond cancer patients to the broader noncancer population through shared physicians.

Commuting zone (CZ): The paper’s unit of geographic analysis, defined to capture local economic markets. There are 720 CZs in the US, encompassing all metropolitan and nonmetropolitan areas. The authors use 625 CZs with more than 20,000 residents, which account for more than 99% of all opioid deaths and total population.

Two-party Republican vote share: The ratio of votes for Republican candidates to the total votes for both Republican and Democratic candidates in a given election. The paper tracks this measure for House, presidential, and gubernatorial elections from 1976 or 1982 through 2020 or 2022, depending on data availability.

Drug-induced mortality: The paper’s broadest mortality measure, covering deaths from poisoning and medical conditions caused by legal or illegal drugs, including prescription opioids, heroin, and synthetic opioids such as fentanyl. It is distinguished from the narrower measures of prescription opioid deaths and all opioid deaths.

Issue ownership: The political science concept, used in the paper to describe how the Republican Party repositioned itself during the epidemic period as the voice of working-class economic hardship, “forgotten America,” and “America left behind.” The paper contrasts this with Democratic ownership of income inequality and argues that Republican ownership of the hardship narrative made the party’s message especially salient in heavily opioid-affected communities.

Path dependency in pharmaceutical marketing: Purdue’s strategy of concentrating initial OxyContin promotion in cancer-market areas, then later focusing on top-prescribing physicians (the highest three deciles of the distribution), meant that areas receiving high initial cancer-market promotion continued to receive disproportionate promotion as the company expanded to the noncancer market. This created a persistent targeting advantage for high-cancer CZs throughout the epidemic’s first wave.

Nokken-Poole ideological measure: A roll-call-based measure of elected House members’ ideology along the liberal-conservative dimension. The paper uses this measure to show that the epidemic shifted the composition of the House toward more conservative members, not by electing more extreme candidates in any given election, but by changing which party won seats over time.