Access to Substance Abuse Treatment, Drug Overdose Deaths, and Crime

(Click here for a larger interactive version. Hover over each county to see county-specific estimates.)

The Issue:

Fueled in part by a raging opioid epidemic, drug overdose deaths have surged in the United States since 1999. More people currently die from drug overdoses than from motor vehicle accidents, as drug-related deaths have become the leading category of fatalities due to external causes. Yet access to treatment remains extremely limited. Currently, only about 1 in 10 people who need treatment for a substance use disorder receive that treatment. But there is evidence that increasing access to treatment reduces drug-related deaths. Moreover, providing greater access to treatment can have a broader community impact by reducing crime.

Increasing the number and availability of substance abuse treatment centers could reduce drug related deaths and crime.

The Facts:

• There were more than 63,600 drug overdose deaths in the United States in 2016. This is more than triple the overdose death rate in 1999, representing about 19.8 overdose deaths per 100,000 residents (age-adjusted), according to a report by the National Center for Health Statistics. Men are more likely to die of drug overdoses than women and overdose death rates are higher for adults between 25 and 54. While overdose death rates give one measure of the increasing severity of the problem, they do not include all the costs to individuals, family and society from substance abuse.
• Despite increasing severity of addiction problems, particularly with respect to opioids, access to substance abuse treatment is very limited. In 2016, an estimated 21.0 million (1 in 13) people aged 12 or older needed substance use treatment, according to the Substance Abuse and Mental Health Services Administration. However, only 2.2 million people, about 10.6 percent, of those who needed it received substance use treatment at a specialty facility (see page 32 of this report.) Lack of health coverage or cost constraints are among the primary barriers that people say stand in the way of getting treatment (see here.) Many also cite lack of transportation or inconvenient locations for treatment as an impediment to getting help. Across all U.S. counties, 38 percent of counties did not have a treatment facility for substance use disorders in 2016 and access was particularly difficult for people in rural areas. Even when there are treatment centers present, they are often at capacity and those seeking help can face long waiting lists — this is especially the case for people seeking to fight opioid addiction with medication-assisted therapies.
• There is variation across the country in the rates of overdose deaths and the availability of treatment facilities (see map). Many counties in different parts of the United States have high drug-induced death rates relative to the rest of the country but do not have a single stand-alone substance use treatment facility, especially in rural areas. The map shows the availability of substance abuse treatment (SAT) centers in 2012 as well as the average drug-induced deaths per 100,000 residents between 2008 and 2012 on a county-by-county basis. The counties in the darkest hues of red are among those with the highest rates of drug-induced deaths and also fewest numbers of treatment facilities—zero in many cases. Counties such as Nye, NV (37.9 deaths per 100,000), Tazewell, VA (37.5 deaths per 100,000) and Citrus County, FL for instance (24.5 deaths per 100,000), did not have a single stand-alone treatment center in 2012. Counties in darker blue in West Virginia, or Rio Arriba County, NM (67.6 deaths per 100,000), for instance, also had high rates of drug-induced mortality, but had more treatment centers than the median county. These data do not capture treatment that takes place in settings such as hospitals, so they do not offer a complete view of the total availability of treatment in each county. However, stand-alone treatment facilities are the primary setting for delivery of substance-abuse treatment in the United States, most commonly through outpatient care (though some independent facilities offer residential treatment in which clients temporarily live at the treatment site). The types of treatment offered vary from one facility to another, including 12-step programs, medication-assisted therapies that use medications to mitigate the severe withdrawal symptoms, psychotherapy and mental health programs, among others.
• We find evidence that increasing access to treatment facilities reduces drug-induced deaths. Studies that look at the effectiveness of drug treatment seldom focus on the impact of treatment on reducing drug-induced deaths. They tend to focus on particular treatment strategies or research trials, and the impact on overdose deaths is difficult to observe at this scale since it is a severe, but relatively infrequent, consequence of drug use. In our research, we looked at how drug-induced death rates change across U.S. counties as the number of treatment centers changes over time, after taking into account other factors that could impact drug-induced mortality (see here and here). We find that adding one additional treatment facility leads to a 0.5 percent decline in the drug-induced mortality rate in that county. This measure provides an average effect of adding an additional treatment center but does not give more indication as to which types of treatment offered might be more effective. It is possible that greater access to treatment could also reduce other causes of death beyond drug overdoses. For instance, drug use disorders are also associated with higher risk of contracting some infectious diseases, such as Hepatitis C, and with higher rates of suicide and homicide (see here).
• Increased access to substance abuse treatment has benefits that go beyond the individuals who receive the treatment, reducing crime in the surrounding community. There is a strong connection between substance abuse and crime. Approximately 60 percent of people arrested for most types of crimes test positive for illegal drugs at arrest. Drug use can cause violent and property crimes through three main channels. Being under the influence of drugs can make people both more likely to commit violent crimes, by triggering aggression, and make them more vulnerable to becoming victims by lowering their vigilance. At the same time, addiction can lead people to commit crimes in order to finance their drug purchases. Lastly, the illicit nature of the drug trade is often associated with violence as rival gangs compete for turf and dominance. For this reason, it is possible that reducing drug use disorders through expanded treatment could lower crime. In our research we find that adding treatment facilities in a county has the effect of reducing local crime — both violent and financially motivated crimes. The strongest effect is in the reduction of homicides: we find that an additional treatment facility reduces homicides by between 0.18 and 0.24 percent, depending on the homicide data used. We also find that adding an additional treatment facility has a significant effect on reducing robbery, motor vehicle theft, burglary and larceny. Other researchers who have looked at the expansion of insurance coverage for substance use treatment also find that increasing access to treatment significantly decreases robbery, aggravated assault and larceny theft. Researchers looking at increases in health insurance coverage more broadly, such as the Affordable Care Act’s expansions of Medicaid, have also documented significant associated reductions in violent crime and property crime (see here and here). And there is some evidence that efforts to restrict the supply of drugs can be an effective way to reduce suicides, but only in places where substance-abuse treatment facilities are broadly available.