Author ORCID Identifier

https://orcid.org/0000-0002-6560-5655

Date of Award

Spring 5-2-2022

Degree Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Department

Economics

First Advisor

Dr. Michael Pesko

Second Advisor

Dr. James Marton

Third Advisor

Dr. Elizabeth Armstrong-Mensah

Fourth Advisor

Dr. Keith Teltser

Abstract

This dissertation consists of three essays on substance abuse. The first essay examines whether restricting access to legal prescription opioids has an impact on substance abuse behavior. Following the increase in people taking hydrocodone combination products (HCPs) in dangerous amounts, the Drug Enforcement Administration (DEA) requested the Department of Health and Human Services (DHHS) to conduct thorough research on HCPs. After evaluating the medical evidence, the DHHS recommended that all HCPs be transferred from a Schedule III to a Schedule II controlled substance. In 2014, the Drug Enforcement Administration (DEA) implemented the rescheduling of HCPs. The total number of HCPs prescriptions in the U.S fell from 136.7 million in 2013 to 83.6 million in 2017. Subsequently, the number of persons misusing HCPs also declined from 7.2 million in 2015 to about 5.5 million in 2018 (National Survey on Drug Use and Health, 2020). Using data from the 2005 to 2019 Treatment Episode Data Set (TEDS) survey, I analyze the effect of the policy on substance abuse behavior. I employ a difference-in-differences strategy that explores the cross-state variation in the pre-implementation hydrocodone prescription rate. I find evidence that suggests that the rescheduling led to a reduction in the utilization of hydrocodone combination medications. Given this evidence of a "first-stage" effect, I also assess whether the decline in legally-obtained opioid prescriptions affects the misuse of other substances. I find that a one percentage point increase in the mean hydrocodone prescription (i.e., 13kg per 100,000 residents) increases alcohol abuse treatments by 63 treatments per 100,000 adults, marijuana abuse treatments by 40 treatments per 100,000 adults, and cocaine abuse treatments by 13.2 treatments per 100,000 adults.

The second essay investigates whether the rescheduling of HCPs could potentially have a spillover effect on crime. By reducing the supply of HCPs through the rescheduling, the policy may have had an unintended consequence on the cost of obtaining illegal prescription opioids. To explore this question, I use arrest data from 2006 to 2019 from the Uniform Crime Reporting (UCR) program provided by the Federal Bureau of Investigation (FBI) combined with a difference-in-differences strategy. I find evidence that the rescheduling of HCPs led to an increase in violent crimes. I estimate that violent crimes increased by 23.9 offenses per 100,000. The increase in violent crimes is driven by an increase in aggravated assault crimes.

The final essay in my dissertation investigates the impact of the Affordable Care Act's (ACAs) Medicaid expansion on the access and the utilization of substance use disorder (SUD) treatment. After the implementation of the Affordable Care Act, individuals with SUD have greater access to treatment through various programs and policy changes. To estimate the effect of the policy, I exploit the variation in the timing of the Medicaid expansion across states. I find that the ACA's Medicaid expansion led to a 36% decrease in the number of uninsured substance abuse patients and a 90% increase in Medicaid insurance coverage among the same group. Following the gains in insurance coverage among substance abuse patients, one would expect an increase in the utilization of substance abuse treatment. I measure the utilization of substance abuse treatment using the number of admissions per 100,000 non-elderly adults and treatment completion status. The results show that the ACA's Medicaid expansion had no statistically significant effect on substance abuse treatment admissions. A potential explanation for this is that access to health insurance coverage alone may not impose a substantial barrier to seeking substance abuse treatment.

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