(Illustration by Eric Nyquist)
Among opportunities for philanthropic grantmaking, the US overdose crisis is an unusual case: an enormous problem that retains abundant opportunity for funders to inexpensively harvest lifesaving impact at scale. For most other large problems addressed by philanthropy (e.g., climate change, cancer), the marginal cost of meaningful impact is expensive, and/or our best option is investment in new ideas that are still trying to achieve proof of concept. What accounts for philanthropy’s lack of interest in the overdose crisis?
Overdose is the single largest cause of death for Americans under 50, exceeding heart disease, cancer, COVID-19, car accidents, suicide, and homicide. During the 12-month period ending June 2024, US overdose deaths totaled 96,800. To place that figure in context, annual US deaths from AIDS peaked at 51,670, total US combat deaths in Vietnam were 40,934, and US gun-related homicides in 2022 were 19,651. Across race and gender, Native American and African American males have had the highest rates of overdose fatality since 2019.
There is a portfolio of evidence-based best practices recommended by the US Centers for Disease Control and Prevention and the World Health Organization for reducing population-level overdose fatalities. Some of these practices established proof of concept for safety and efficacy decades ago. Most are substantially cheaper than less effective treatments readily reimbursed by Medicare. Take, for example, the distribution of naloxone—a medication that, when administered, swiftly reverses an opioid overdose.
The Stanford-Lancet Commission on the North American Opioid Crisis identifies expanded naloxone distribution as the single largest opportunity to reduce overdose fatalities, predicting that a 30 percent increase in access would lead to a 25 percent reduction in deaths. Even better, naloxone distribution is cheap. According to the San Francisco Department of Public Health, naloxone distribution to heroin users for overdose reversal has an incremental cost-effectiveness ratio of $438 per overdose death prevented. My organization, the Overdose Crisis Response Fund, has collected reports of thousands of overdose reversals from grantee organizations across 17 states and found a marginal cost per overdose rescue as low as $41.
Increased naloxone distribution is not simply a Band-Aid. The fear that naloxone distribution increases net overdose fatality, due to moral hazard effects, was proven a myth over 10 years ago by evidence of overdose rates preceding and following statewide implementation in Massachusetts. Additionally, a national study of 76,325 overdose survivors discovered that upwards of 93 percent were still alive one year later. This latter finding indicates that overdose rescues with naloxone don’t simply (and futilely) delay death by days or weeks; they potentially buy people years of time to engage with treatment and recovery.
Yet philanthropy has shown little interest in the overdose crisis. Despite the clear case for large-scale, inexpensive, and directly lifesaving impact versus the largest cause of death for Americans under 50, a nationwide survey of naloxone distribution programs found that 59 percent had annual budgets of less than $100,000, and 34 percent had budgets of less than $25,000. At these minuscule funding levels, the founders of these programs are doing work that directly saves the lives of other human beings and are not able to earn a living from it.
Philanthropic funders might respond that the overdose crisis is a problem for which public sector funding must take the lead. Unfortunately, public sector funding for overdose response, including grantmaking out of opioid litigation settlements, is a political process, not a public health process. Distribution of public sector funds is guided most strongly by what is politically and culturally acceptable among voters, not by scientifically established evidence of safety and efficacy. The public sector actually needs private philanthropy to de-risk evidence-based efforts that are not yet politically feasible.
Funder Preferences, Popular Need
I’ve been trying for years to attract private philanthropic support to the overdose crisis. In my experience, funders ignore overdose response efforts for primarily two reasons.
1. Philanthropy is more committed to conceptual frameworks than to tangible impact. Over the course of the overdose crisis, several trends in philanthropic funding have waxed and waned. All of these trends have been resistant to engagement with overdose. It has been maddening to face funders more committed to their chosen theory of change than to directly, cheaply, and quickly preventing the loss of human life.
My conversations with funders have tended to go something like the following:
Funder: “We only fund systems change.”
Me: “Does that mean we can’t spend $438 to save someone’s life until we’ve fixed Medicare?”
Funder: “We only fund social determinants of health.”
Me: “Does that mean we can’t spend $438 to save someone’s life until we’ve solved poverty?”
Funder: “We only fund health equity.”
Me: “Overdose-response organizations don’t solely target Native and African American men, but given that those two groups have the highest per capita rates of overdose fatality, overdose response funding might be the cheapest and easiest way to actually save their lives.”
Funder: “We only fund effective altruism.”
Me: “Are you seeing a lot of opportunities to save human lives, this year, for less than $438 per capita? Because when I see effective altruism putting tens of millions of dollars into the threats of AI and farm-animal welfare, I have to assume you aren’t.”
2. Philanthropy follows public opinion, rather than leading it. From the perspective of many people working within the overdose crisis, philanthropy is not outpacing the general public in its ability to identify injustices and support stigmatized populations. Instead, philanthropy always seems to be a lagging indicator of public opinion, as evidenced by the sudden and enormous floods of new funding following tipping point events in public awareness (e.g., Sandy Hook, #MeToo, Black Lives Matter).
To people working on problems that are less popular, it can appear as though funders adopt new program areas because of their wish to participate in issues where public awareness has achieved a certain amplitude, rather than the discovery of new lines of sight to incremental and tangible impact. Many of us working on the overdose crisis suspect that our issue simply doesn’t poll high enough to attract philanthropic support.
Prioritizing Outputs Over Theories
Philanthropy’s failure to address the overdose crisis offers generalizable insights that can help funders avoid overlooking clear and present opportunities for impact in any field of grantmaking.
To start, net present value (NPV) analysis is a quantitative decision-making method that forces us to understand that impact isn’t a function only of the size of the benefits achieved, but also of both the time it takes to achieve these benefits and the likelihood that they will ever come to pass. Greater reliance on NPV could help funders return theories of change to their proper places as means of pursuing impact, rather than as ends in themselves.
The overdose crisis offers philanthropy a generalizable hypothesis: There is an inverse relationship between how much sympathy a population attracts and how much impact remains to be gained on its behalf.
For example, unyielding dedication to “systems change” or “social determinants of health” fails the NPV test, because these approaches commit to hopes of large returns irrespective of either potential timelines or the probability of success. These approaches have built-in inclinations to fund noble failures in preference to easy wins.
Effective altruism (EA) professes to pursue quantitatively validated opportunities for impact, and so it would seem inclined to support inexpensive, certain, and short-term investments to save lives from overdose. Yet, EA supporters have ignored this issue. At least two reasons seem to be at work.
First, even though EA claims to treat all life on an even basis for philanthropic returns, EA funders appear to limit their parameters to populations they already favor. Secondly, EA displays bias toward areas that allow funders to feel they are participating in scientific innovation, often under cover of the concept of “longtermism.” One hundred thousand Americans a year are dying of overdose now. When are “the threats of artificial intelligence”—a popular topic in the EA community—expected to cause deaths at the same level?
Funders can also avoid overlooking easy wins by adopting a degree of contrarianism. For instance, they can recognize when peer institutions are behaving (in private sector terms) as growth investors, chasing areas that are trending even when “valuations” on the basis of impact per dollar are too expensive. The overdose crisis demonstrates that there is abundant unharvested impact available for funders open to operating as value investors—i.e., bargain hunters that avoid following the crowd.
But probably the easiest way for funders to outpace public opinion, and thereby identify low-hanging fruit for social impact, is to serve the people who attract the least sympathy. St. Jude Children’s Research Hospital treats about 8,000 child cancer patients a year and, on top of revenue from research grants and reimbursed services, raises about $2.5 billion of philanthropic funding. Overdose kills about 100,000 people per year, and organizations nationwide can’t raise $438 to save the next life.
The overdose crisis offers philanthropy a generalizable hypothesis: There is an inverse relationship between how much sympathy a population attracts and how much impact remains to be gained on its behalf. Those funders who have a broad and unsentimental concept of the value of human life, who prize impact above all else, and who are willing to be contrarian have abundant opportunity to harvest the impact left behind by philanthropy’s bias to support people who are easy to like.
Read more stories by Colin Dwyer.