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Dying for Care: How Policy Shapes Opioid Mortality and Treatment Access

Friday, November 6, 1:45 to 3:15pm, Property: Boston Marriott Copley Place, Floor: 3rd Floor, Room: Simmons

Session Submission Type: Panel

Abstract

The opioid crisis remains one of the most consequential public health emergencies in American history, killing tens of thousands annually and disproportionately devastating communities already burdened by poverty, housing instability, and inadequate healthcare access. Despite decades of policy responses, the treatment gap persists, and well-intentioned interventions have at times produced harmful unintended consequences. This panel brings together four papers that use rigorous causal identification strategies to examine how criminal justice reform, treatment delivery infrastructure, coercive legal mechanisms, and provider behavior each shape opioid-related mortality and access to medication for opioid use disorder (MOUD). The first paper examines California's landmark criminal justice reforms—AB 109 (2011) and Proposition 47 (2014)—leveraging exogenous variation in incarceration driven by federal court orders. Using synthetic control and difference-in-differences approaches, the authors find that these reforms increased unsheltered homelessness by 10–20 percent and were associated with rising overdose hospitalizations and a decline in criminal justice referrals to treatment, raising important questions about the unintended consequences of decarceration for vulnerable populations. The second paper evaluates a pandemic-era policy that expanded access to medication-assisted treatment by permitting mobile methadone units (MMUs) to operate in communities. Using Uniform Crime Report data from 2017–2024 and two-way fixed effects and event study designs, the authors find a temporary increase in arrests for property and violent crime following MMU introduction—a provocative finding that complicates the narrative around expanding low-barrier treatment options. The third paper provides the first county-level causal evidence on the mortality effects of involuntary commitment (IC) laws for substance use disorder. Exploiting staggered state adoption in a difference-in-differences framework, the author finds that IC adoption increased opioid-involved mortality by approximately 5 deaths per 100,000 residents within five years—concentrated in urban counties with existing treatment infrastructure, suggesting that iatrogenic effects may be most severe precisely where treatment capacity exists to receive court-ordered patients. The fourth paper turns to the supply side of treatment, asking whether provider prescribing behavior responds to community-level overdose crises. Exploiting the staggered geographic diffusion of illicitly manufactured fentanyl across U.S. counties from 2013 to 2022 and using propensity-score matched difference-in-differences, the author finds that fentanyl-driven overdose mortality shocks increase buprenorphine prescribing by 7–17 percent, with effects growing monotonically over time—suggesting that overdose deaths serve as salient signals that partially close the treatment gap. Together, these papers illuminate a critical and underexplored set of policy levers—incarceration, mobile treatment delivery, coerced care, and provider response—that collectively shape who lives and who dies in the opioid crisis. The panel will advance policy-relevant conversations about how to design interventions that expand access to life-saving treatment without generating the unintended harms that have too often accompanied well-meaning reforms.

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