Tackling the Substance Abuse Crisis: The Role of Access to Treatment Facilities

This paper is now published in the Journal of Health Economics.

Using detailed data from New Jersey on substance abuse facility openings and closings from 2005-2020, the universe of ER admissions from 2008-2015 (and hospitalizations that come through the ER), and the locations of patients and clinics, the authors show that closing substance abuse facilities has large effects on drug-related ER visits. 

Even when located in areas with other facilities, substance abuse facility closures increased drug-related ER visits by 16.7% overall. By comparison, the opening of facilities in previously unserved areas reduced drug-related ER visits by 6.7% overall and by 9.4% among Black patients. 

“It is interesting that closures have effects that are larger in absolute value than openings even though most of these closures are occurring in areas that had other facilities,” the authors write. “This finding indicates that scarce treatment spaces are a real constraint in areas that suffer closures. Closures may also have larger effects than openings because they reflect the fully ‘ramped up’ impact of a center, whereas new centers may take some time to reach their full capacity.”

Other key findings

To enable their geographic analysis, the authors assign each facility geographic coordinates and a census block group. In addition to the effect of closures on overall ER visits, the authors find:

• As distance to a substance abuse facility increases, so do drug-related ER visits. Drug-related substance abuse ER visits increase by 46.9 per 100,000 people for each additional mile from the closest substance abuse facility. Relative to the average number of substance abuse visits of 2,624 during the sample period, this represents an increase of approximately 1.8% per mile.
• Four miles is the magic number. Drug-related substance abuse ER visits significantly increase when census block groups are more than 4 miles away from a facility. The effect of facility openings and closures are similar in census block groups within 1, 2, or 3 miles of a facility. While distance does affect ER visits related to alcohol, the effects are much smaller, perhaps because patients often receive treatment for alcohol abuse in settings outside substance abuse centers such as local Alcoholics Anonymous groups.
• Some groups that are more responsive than others to changes in access to treatment facilities. Black people and youths 15-24 are most affected, perhaps because they face larger transportation barriers. Men are more affected than women, perhaps because they have higher rates of ER use for drug abuse.

Background on ER visits and substance abuse facilities in New Jersey

During the authors’ sample period, approximately 1 in 12 ER visits were for substance abuse disorders. Substance abuse and mental health-related ER visits increased 47% over the authors’ sample period. All other ER visits increased by 11%. 

The authors’ final facility list includes 845 substance abuse treatment facilities that ever operated in New Jersey between 2005 and 2020. Openings exceeded closings in every year except 2013. Between 2008 and 2015 most new facilities opened in areas that were already served by at least one facility—only 24 opening facilities were located more than 3 miles from another facility.

Over the sample period, the majority of the substance abuse treatment facilities in New Jersey were outpatient clinics (rather than residential facilities) and relatively few facilities offered medication-assisted treatment (for example methadone or buprenorphine), even though medication-assisted treatment has been shown to save lives by preventing overdoses.

“Hence, our power to measure the effectiveness of different types of treatment is limited,” the authors write. “However, we show that our main results are robust to excluding these types of facilities, suggesting that improving access to even ordinary outpatient treatment facilities without medication-assisted treatment effectively reduces drug-related ER visits.”