The U.S. opioid crisis is the deadliest drug crisis in the nation’s history and is not abating. This brief summarizes what is known about the relationships between opioid misuse, health, healthcare use, and crime. The authors show that the opioid crisis has led to worsening health, increased mortality, increased healthcare use, and modest increases in crime. In addition, the policies designed to curb opioid misuse and its associated harms have had only limited success

Maclean, Johanna Catherine

Mallatt, Justine

Ruhm, Christopher J

Simon, Kosali

Syracuse University Research Facility and Collaborative Environment

1    How Has the Opioid Crisis Affected Health, Health Care Use, and Crime in the United States?  Johanna Catherine Maclean, Justine Mallatt, Christopher J. Ruhm, and Kosali Simon The U.S. opioid crisis is the deadliest drug crisis in the nation’s history and is not abating. The crisis costs the country at least $600 billion a year.1 The roots of today’s crisis trace back to the over-prescribing of pharmaceutical painkillers between the mid-1990s and 2010. Heroin misuse then became more dominant between 2010 and 2013, partially due to state and federal policies that limited access to prescription opioids without providing support for underlying opioid use disorder or adequately accounting for substitution to chemically similar illicit opioids. In 2013, the crisis entered its third wave as fully synthetic, hyper-potent opioids, including fentanyl and its analogs, entered the illicit drug supply, spurring an acceleration in the rate of overdoses.   To better understand the relationships between opioid misuse, health, health care use, and crime, we reviewed the research on these relationships in the health and applied economics literatures. We found that the opioid crisis has led to worsening health, increased mortality, increased health care use, and modest increases in crime. Further, we found that policies designed to curb opioid use and associated harm have had limited success in reversing the crisis.  U.S. Policies Designed to Curb Opioid Use Have Not Been Fully Successful in Mitigating the Opioid Crisis Excessive opioid use is costly to the health care system, increasing overall medical costs (above and beyond direct expenditures on opioids), emergency department visits, opioid RESEARCH BRIEF #90 March 21, 2023   KEY FINDINGS • Prescription opioid suppliers played a central role in sparking the crisis by over-prescribing opioids.  • The opioid crisis has led to worsening health and has increased health care use and cost. • There is a causal relationship between opioids and crime, but the link is not as strong as in previous drug crises.  • State and federal policy responses have demonstrated mixed effectiveness in reducing rates of opioid misuse, overdoses, and health care service use.  2  use disorder treatment, and costs associated with neonatal abstinence syndrome. Opioids were developed to treat pain and so have the potential to improve health. However, research suggests that any benefits are small (as these medications are not more effective in treating chronic pain than alternative pain management therapies) and are offset by dramatic costs associated with misuse.2,3   Suppliers of prescription opioids played a role in originating and fueling the opioid crisis: pharmaceutical companies lobbied for more aggressive treatment of pain through medication and marketed opioids extensively to prescribers. Differences in physician prescribing rates explain a substantial amount of variation in opioid use across the U.S., and areas with looser prescribing culture experienced harsher consequences of the opioid crisis.4 Although the healthcare system was lax in monitoring the overprescribing of opioids during the mid-1990s to 2010, ironically, the availability of medications used to treat opioid use disorder like methadone and buprenorphine continues to be highly restricted. Due to numerous factors, such as prescriber ceilings and waiver requirements, stigma over the use of medications to treat OUD (e.g., abstinence only programs), and lack of insurance coverage, only 17% of Americans with opioid use disorder receive these effective medications.5 Finding ways to expand access to and use of these medications is important for mitigating the harms of the crisis.  The Opioid Crisis is Linked to Crime, but Not to the Same Extent as in Previous Drug Crises  If you Nationally, crime rates have fallen from their peak in the early 1990s for nearly three decades. The rapidly accelerating rates of opioid misuse during the same time period did not hinder the overall pattern of falling crime rates. Previous drug crises, such as the urban heroin wave of the 1970s, the crack epidemic of the 1980s, and the methamphetamine crisis of the early 2000s, all helped drive increasing gun and property crime. The opioid crisis has not done so. One reason may be that opioid misuse has been viewed through a softer lens as more of a medical problem than a criminal issue. Because SUDs are viewed differently, the criminal justice system has developed diversion and other remedial programs designed to facilitate treatment and remove criminal charges from records. This change has led to differential consequences than in earlier epidemics. Another distinction between opioids and past illicit drugs is that the influx of addictive prescription opioids in the early part of the crisis were obtained through legal prescriptions. Further, opioid use is generally not linked with aggressive behavior, which might promote crime, to the same extent as some drugs characterizing earlier epidemics (e.g., cocaine).  While opioid misuse does not seem to have reversed broader declines in crime, studies have established a modest causal link between opioid misuse and crime, especially illicit drug crime like the possession and sale of heroin, fentanyl, and diverted opioid medications.6 Medications that treat and decrease opioid use disorder (MOUD) have been associated with decreases in crime.7 MOUD reduces crime through reduced use of opioids and associated behaviors linked with crime (e.g., intoxication, theft, victimization).  State and Federal Policies Designed to Reduce Misuse and Overdoses Have had Mixed Effectiveness  States and federal agencies have implemented various policies aiming to reduce opioid misuse and its associated harmful outcomes. These include encouraging the reformulation of OxyContin® to make it harder to misuse, legislating prescription drug 3  monitoring programs, pain clinic management laws, implementing harm reduction policies like naloxone access laws and syringe exchange programs, tightening drug scheduling for hydrocodone, and expanding access to MOUD.   Although there is evidence that the menu of supply-targeted policies decreased access to opioid prescriptions, research shows that some of the policies may have unintentionally accelerated the crisis’ transition to heroin and fentanyl. For example, prescription drug monitoring programs reduced access to prescription opioids without providing access to the treatment necessary to address underlying addiction, leading some consumers to substitute with heroin. There is evidence that expanding access to MOUD is effective at reducing overdoses. There is mixed evidence on the effectiveness of harm reduction policies.8 Despite all the policies implemented to combat the crisis, the mortality toll has kept rising, increasingly due to fentanyl.9 _________________________________________________________________________ Data and Methods We focus our review on U.S. health and applied economic studies using scientific models designed to estimate the causal effect of policies on opioid-related outcomes. We located studies by searching online sources and through conversations with economists and researchers active in this area of research.  References 1. White House Council of Economic Advisers. (2017). The Underestimated Cost of the Opioid Crisis. https://www.hsdl.org/?view&did=806029.  2. Stambaugh, J.E., Reder, R.F., Stambaugh, M.D., Stambaugh, H., & Davis, M. (2001). Double-blind, randomized comparison of the analgesic and pharmacokinetic profiles of controlled-and immediate-release oral oxycodone in cancer pain patients. The Journal of Clinical Pharmacology, 41(5), 500-506. 3. Mucci-LoRusso, P., Berman, B.S., Silberstein, P.T., Citron, M.L., Bressler, L., Weinstein, S.M., Kaiko, R.F., Buckley, B.J., & Reder, R.F. (1998). Controlled-release oxycodone compared with controlled-release morphine in the treatment of cancer pain: a randomized, double-blind, parallel-group study. European Journal of Pain, 2(3), 239-249. 4. Finkelstein, A., Gentzkow, M., & Williams, H.L. (2019). Place-based drivers of mortality: {Evidence from Migration. National Bureau of Economic Research Working Paper Series. 25975. 5. Mauro, P. M., Gutkind, S., Annunziato, E. M., & Samples, H. (2022). Use of Medication for Opioid Use Disorder Among US Adolescents and Adults with Need for Opioid Treatment, 2019. JAMA Network Open, 5(3), e223821. 6. Mallatt, J. (2018). The effect of prescription drug monitoring programs on opioid prescriptions and heroin crime rates. Social Science Research Network Working Paper Series. 3050692. 7. Bondurant, S.R., Lindo, J.M., & Swensen, I.D. (2018). Crime, homicides, and substance abuse treatment. Journal of Urban Economics. 124-133. 8. Packham, A. (2019). Are syringe exchange programs helpful or harmful? New evidence in the wake of the opioid epidemic (2019). National Bureau of Economic Research Working Paper Series. 26111. 9. Centers for Disease Control and Prevention. (2021). Understanding the epidemic. https://www.cdc.gov/drugoverdose/epidemic/index.html.  Acknowledgements The authors thank Alexandra Punch and Shannon Monnat for edits on previous versions of this brief. This brief is part of a series of briefs summarizing findings from a special issue of the ANNALS of the American Academy of Political and Social Science on the social and community consequences of the U.S. opioid crisis.   4  Recommended Citation Maclean, J., Mallat, J., Ruhm, C., & Simon, K. (2023). How Has the Opioid Crisis Affected Health, Health Care Use, and Crime in the United States? Lerner Center Population Health Research Brief Series. 212. https://surface.syr.edu/lerner/212   About the Authors Johanna Catherine Maclean (jmaclea@gmu.edu) is Associate Professor of Policy and Government in the Schar School of Policy and Government at George Mason University. Justine Mallatt (Justine.Mallatt@bea.gov) is a Research Economist, U.S. Bureau of Economic Analysis. Christopher J. Ruhm (cjr6e@virginia.edu) is Professor of Public Policy and Economics at University of Virginia’s Batten School of Leadership and Public Policy. Kosali Simon (simonkos@iu.edu) is a Distinguished Professor at Indiana University’s O’Neill School of Public and Environmental Affairs. Maclean, Ruhm, and Simon are Research Associates of the National Bureau of Economic Research (NBER).  SYRACUSE UNIVERSITY LERNER CENTER FOR PUBLIC HEALTH PROMOTION & POPULATION HEALTH RESEARCH BRIEF SERIES  Series Editor - Shannon M. Monnat 426 Eggers Hall | Syracuse | New York | 13244 syracuse.edu | lernercenter.syr.edu  To access all our briefs, visit: https://surface.syr.edu/lerner/  The mission of the Syracuse University Lerner Center for Public Health Promotion & Population Health is to improve population and community health through research, education, and outreach focused on the social, spatial, and structural determinants of physical, mental, and behavioral health and health disparities.  

How Has the Opioid Crisis Affected Health, Health Care Use, and Crime in the United States?

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How Has the Opioid Crisis Affected Health, Health Care Use, and Crime in the United States?

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