The Opioid Crisis, Health, Healthcare, and Crime: A Review of Quasi-Experimental Economic Studies

AuthorJohanna Catherine Maclean,Justine Mallatt,Christopher J. Ruhm,Kosali Simon
Published date01 September 2022
Date01 September 2022
ANNALS, AAPSS, 703, September 2022 15
DOI: 10.1177/00027162221149285
The Opioid
Crisis, Health,
Healthcare, and
Crime: A
Review of
We review quasi-experimental studies that examine the
relationship of opioids to health, healthcare, and crime
in the U.S. Our findings align with the general percep-
tion that the opioid crisis has negatively impacted
health and increased healthcare costs; we find limited
evidence that appropriate opioid use enhances work
capacity or carries other benefits. Extant studies sug-
gest that opioids also increase crime, although the link
is not as strong as has been observed in previous drug
epidemics. This finding is consistent with the fact that
opioids are pharmacologically different than stimulant
substances like cocaine that have dominated earlier
drug epidemic periods. We argue that the healthcare
system has a potentially important role to play in com-
batting the opioid crisis, largely through the provision
of treatments that address underlying addiction, and
through the development of strategies to effectively
curtail access to the drugs.
Keywords: opioids; opioid use disorder; health;
healthcare; crime
Each day, the United States records about 136
fatal opioid overdoses, or over 49,000 deaths per
year (Centers for Disease Control and
Johanna Catherine Maclean is an associate professor in
the Schar School of Policy and Government at George
Mason University. She completed her PhD in econom-
ics at Cornell University in 2012 and is a health and
labor economist working mainly in the areas of sub-
stance use (tobacco product, alcohol, and illicit drugs),
mental health, and public policies. She is a coeditor at
the Journal of Policy Analysis and Management, an
associate editor at the Journal of Health Economics, a
research associate in the Health Economics Program at
the National Bureau of Economic Research (NBER),
and a research affiliate at the Institute for Labor
Economics (IZA). Her work has been funded by the
National Institutes of Health, Food and Drug
Administration, American Cancer Society, Robert
Wood Johnson Foundation, Washington Center for
Equitable Growth, Wellbeing Trust, and the American
Heart Association.
Prevention [CDC] 2021c). Between 1999 and 2019, the opioid crisis has claimed
over 500,000 American lives (CDC 2021c). And these are actually undercounts
since opioid involvement is not completely reported on death certificates. The
scale of this crisis is immense, and it is challenging to meaningfully quantify its
impact on American society. For example, 58,220 Americans died in the Vietnam
war (National Archives 2018); and in 2019, there were 37,595 motor vehicle fatali-
ties (CDC 2021a). The opioid crisis, which began in the mid-1990s, has now
entered its third decade and shows no sign of abating. Figure 1, which reports fatal
opioid overdoses from 1999 through 2020, demonstrates that death rates have
increased in virtually every year. The economic costs of the crisis are large: the
Council of Economic Advisers estimates that the crisis costs the U.S. $596 billion
each year (White House Council of Economic Advisers 2017), and some calcula-
tions indicate that the costs are considerably higher (Florence etal. 2016).1
From an economic perspective, the opioid crisis is seen as an interaction
between supply-side and demand-side factors and feedback between the two. In
particular, supply-side factors created a setting ripe for the overuse of this
extremely addictive medication. In the 1980s and 1990s, prescribing regulations
were limited in the U.S. Pharmaceutical suppliers (both manufacturers and dis-
tributors) responded to this permissive regulatory environment by engaging in an
extraordinarily well-financed, aggressive, and sophisticated marketing strategy
aimed at changing social norms around opioids and targeting states with rela-
tively lax prescribing laws. These forces interacted with demand-side factors that
determined which groups would be most susceptible to the crisis in its initial
stages: fundamental changes in the U.S. labor market (e.g., foreign competition,
automation of routine tasks, declining strength of labor unions) weakened eco-
nomic prospects for specific groups of Americans, in particular White men with
lower levels of education, and these individuals were disproportionately and
negatively impacted during the initial stages of the crisis (see Monnat, this vol-
ume, for a discussion of disparities). Over time, interactions between supply- and
Justine Mallatt is a research economist at the U.S. Bureau of Economic Analysis. She received
her doctorate from Purdue University in 2018. Her research focuses on the opioid crisis, sub-
stance misuse, and health economics. At the BEA, she researches issues related to the measure-
ment of economic activity in the national accounts.
Christopher J. Ruhm is a professor of public policy and economics at the University of Virginia.
He received his doctorate from the University of California at Berkeley in 1984. He is also a
research associate at the National Bureau of Economic Research and research fellow at the
Institute of Labor Economics. Prior to joining UVA, he held positions at the University of North
Carolina at Greensboro and Boston University. From 1996 to 1997, he served as senior econo-
mist on President Clinton’s Council of Economic Advisers. His recent research focuses on work-
family policies and on examining how aspects of health are produced.
Kosali Simon, an economist, is a distinguished professor, Herman B. Wells Professor and
O’Neill Chair at Indiana University, Bloomington, O’Neill School of Public and Environmental
Affairs. She is also the associate vice provost of health sciences for the campus. She is editor of
Journal of Health Economics (JHE), coeditor of Journal of Human Resources, president-elect
of the American Society of Health Economists (ASHEcon), and a member of the U.S.
Congressional Budget Office’s (CBO) panel of health advisors. In 2021, she was elected to the
National Academy of Medicine.
demand-side factors, public policies designed to curb opioid use, and changes in
the types of opioids available in drug markets allowed the crisis to continue;
expand in scope; and impact a larger, and more diverse, share of the U.S.
In this article, we use our previously developed conceptual model (Maclean
etal. 2020) and review relationships between opioids, health outcomes, health-
care, and crime.2 Our review focuses on U.S. economic studies using quasi-
experimental methods. Quasi-experiments are empirical investigations that are
designed to draw causal inferences without assigning people to experimental and
control groups: in this case, these are studies that gather observational data from
populations that have experienced public policy in different ways. We located
studies by searching online sources3 and through conversations with economists
and researchers conducting research using quasi-experimental methods to esti-
mate the effect of public policies on opioid outcomes. We focus on the U.S. as
this country has arguably been hardest hit, to date, by the opioid crisis, which is
generally viewed as originating in this country. Further, the U.S. has adopted a
wide range of policies—targeting both supply- and demand-side factors—at the
local, state, and federal levels designed to curtail the crisis. Collectively, these
features suggest that the U.S. is an interesting and important “laboratory” to
understand the global opioid crisis.4 Our focus on quasi-experimental methods
that leverage variation from policy changes is motivated by an interest in under-
standing the role of public policies in curbing the crisis. We consider both health
Trends in Fatal Opioid Overdoses: 1999 to 2020
NOTE: Data are drawn from the CDC. See text for details.

To continue reading

Request your trial

VLEX uses login cookies to provide you with a better browsing experience. If you click on 'Accept' or continue browsing this site we consider that you accept our cookie policy. ACCEPT