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

• DOI: http://doi.org/10.1177/00027162221149285
• Published date: 01 September 2022
• Date: 01 September 2022

ANNALS, AAPSS, 703, September 2022 15

DOI: 10.1177/00027162221149285

The Opioid

Crisis, Health,

Healthcare, and

Crime: A

Review of

Quasi-

Experimental

Economic

Studies

By

JOHANNA CATHERINE

MACLEAN,

JUSTINE MALLATT,

CHRISTOPHER J. RUHM,

and

KOSALI SIMON

1149285ANN THE ANNALS OF THE AMERICAN ACADEMYTHE OPIOID CRISIS, HEALTH, HEALTHCARE, AND CRIME

research-article2022

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

Introduction

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.

Correspondence: jmaclea@gmu.edu

16 THE ANNALS OF THE AMERICAN ACADEMY

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.

THE OPIOID CRISIS, HEALTH, HEALTHCARE, AND CRIME 17

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.

population.

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

FIGURE 1

Trends in Fatal Opioid Overdoses: 1999 to 2020

NOTE: Data are drawn from the CDC. See text for details.