- All right, so for those of
you I haven't formally met,
I'm Matt Harris, it's nice to meet you.
And thank you for sticking with me,
because this is a tough hour.
You guys have been given a nap
primer in the form of lunch,
and now you gotta listen to a guy
talk about economics for 30 minutes,
and that's just not fair to you,
so thanks in advance for your patience.
A couple of things that have
been really positive today
is there's way more going on in this state
to address the opioid crisis
than I knew about before today.
It's been beyond impressive,
and a privilege to hear about the work
that multiple parties
around the state are doing.
The second thing is that
I heard several people,
including Dr. Loyd, Judge
Slone, and Director Rausch
talking about supply and demand,
and that just makes my
internal econ nerve very happy.
As the slide behind here includes
my co-author Larry Kessler,
Larry if you could raise
a hand, in the back.
Everything I know about the
economic impact of opioids
I've done in partnership with Dr. Kessler
over the last four years.
And so it's, even though
he's not up here with me,
I wanted him to be on
the title slide as well.
And when thinking about what to say today
to try to make good use of your time,
it was a bit of a tough tact
to figure out how to take.
I don't think I need to convince this room
that opioids have an economic impact.
That's kind of preaching to the choir.
That's why you guys are here.
Everybody's here because they believe
this is a problem that
warrants our attention.
In trying to come up
with a specific magnitude
for what is the economic
impact of opioids on the state
also seem like kind of
a poor hill to die on
for a few reasons.
One is that we don't have adequate data.
We still don't have full and complete data
to be able to assess
the full impact of this.
Second is it's really
difficult to disentangle
correlation and causality.
And the reason that I'm up here,
is 'cause with Larry and
I have had some success
working on those kinds of projects,
and some cases being able
to isolate causal effects.
The third part is that of everything
I'm going to talk about today almost,
there is somebody in this room
with better institutional knowledge
in that area than I have.
And so I acknowledge that the
data that I'm working with
is subject to limitations,
then you guys probably know
more about each one of
the specific buckets
that we're going to talk about.
There we are, so what I...
Um, help.
(audience laughing)
Oh yeah.
Like I said, about anything in here today,
somebody's gonna have
better institutional knowledge than me.
So what I thought it
made sense, is I suspect
that many of you in the
room may be specialists,
a bit like I am.
And what I thought would make sense
is just to talk through some
of the different buckets
through which opioids
have economic impact,
through these distinct channels.
So we know that opioids
have economic impact
through mortality, through life and death.
Dr. Kessler and I have done
some of the first research
on how opioids causally effect
labor force participation.
We know opioids have economic impact
through law enforcement, the judiciary,
and the corrections system.
Also through healthcare utilization.
Through education and
human capital formation,
but we also, Dr. Kessler and I
were doing some early research
on how prescription opioids,
and more specifically,
efforts to reduce prescribing,
are affect in children and families.
And the two things that I wanted to spend,
to really make the goals
of the talk are one,
is everybody's talking through
best practices tomorrow.
I hope that some of the
linkages that we can talk about
between these areas can form the basis,
or help along some of those discussions
about how can everybody work together,
how can we all work in
concert to best address this.
And the second thing is we leave here,
and go back to our communities,
I wanted to provide
everybody here some material,
some ammunition, to be able
to make the cold blooded case,
for why these programs and
why this is worth funding.
As the panel on solving the stigma,
just had some incredible stories.
It's hard to hear some of
the things that get said
about people with dependency,
and people with addiction.
There's an acronym
that's kinda been reverberating
in my head of HSFC,
which means have some compassion.
But in the absence of that,
we need to be able to say
that this is worth fighting,
this is worth doing.
And the different success
on addressing these problems to the state,
here's the prize at the end of the row.
So I love that 70 by seven, you know,
but in the absence of
that, let's make the case
that this is certainly worth doing.
Now part of the reason the
economic impact of opioids
is difficult to assess is usually
when you think of an impact,
you think of something
like a cannonball splash.
You think of a single impact,
and that impact displaces things.
And in some sense, you can
measure that displacement,
and there you go.
Has anybody here ever had
the singular experience
of throwing a sodium brick
into a body of water?
That's just a Louisiana thing, okay.
(audience laughing)
So my high school chemistry teacher
may or may not have suffered
some mental health issues,
but every year she would
take a class out to a lake,
and have a sodium brick, coated in oil,
because sodium, as it turns out,
is really explosive when it oxidizes,
and would hurl it into this
bayou, and it would explode.
And so then you'd be waiting
for things to calm down,
and then you'd hear a second explosion,
because a big chunk of the brick
would've gone up and come back down,
and had a secondary explosion.
And then a tertiary explosion.
And then a quaternary explosion.
You hear four or five of these bangs.
And the economic impact
of prescription opioids
is a lot more like that sodium
brick than a cannonball.
It doesn't hit one area, it
hits several of those areas.
And the waves of those
areas bounce off each other,
but the interaction, the intersection,
the linkages between those impacts
are what I do wanna
spend most of our time on
talking about today.
So we will talk a bit about magnitudes,
but the estimates of
these magnitudes vary,
and in some cases are just not known,
because we don't have
experimental variation
most of the time.
We don't have a double blind
randomized control trial.
We don't have C130s flying over
and dropping crates of opioids
in some jurisdictions, but not others.
That's not what we have,
it's a social problem.
And the incidents of
opioids is tightly wound up
with everything else that we care about,
in terms of social
factors and demographics.
And so trying to get that
experimental variations
is quite difficult, but we do
wanna get to those linkages,
and kinda put one caveat
that why you guys are here
is really important, because
it has to be a whole puzzle
that's gonna solve the opioid crisis.
There already is evidence
that when efforts to reduce prescribing
happen in a vacuum, there
are adverse consequences
that we can well document.
So, two things that I
think are worth repeating,
one comes from a friend of
mine, Jason Hockenberry,
down at Emory, he and I
were talking some years ago,
and he had a quote that stuck with me.
He said, "There's some optimal
number of opioids prescribed,
"and that number is not zero."
So commissioner Piercey
had a comment on that,
that I wanted that to echo, and that is
there are people, lots of people
with legitimate chronic pain needs,
and we wanna make sure those people
do get what they need in
order to ease their suffering.
But at the same point, I think would agree
that we're probably well
past the optimal number
in terms of what's out there now.
The second thing is that
almost everything we can do
is gonna be really trading
what we call type one for type two errors.
Now for those of you
who are not stats nerds,
a type one error is
when I go to the doctor,
and the doctor tells me I'm pregnant.
A type two error is when a
pregnant woman goes to the doctor
and the doctor says you're not pregnant.
So what we mean is that
anything that we do,
is in all likelihood gonna
result in two things.
It's gonna result in say some
people who don't need opioids
not getting them.
It will also result in some
people who do need opioids
not getting them.
And we need to be aware
that no matter what we do,
there's an exchange rate
that comes with that.
And it's about trying to define
a set of policies and a set of actions
that are going to give us
the best exchange rate.
So, with all that
disclaimer, here's a few,
here's what I can tell you
about the economic impact
of opioids in the state of Tennessee.
As special agent in charge, Farmer,
was talking about earlier today,
overdose deaths continue
to be on the rise,
and we hope this is a
plateau, but as of 2017,
there were 1,269 overdose deaths
in the state of Tennessee.
So, in almost every aspect,
Tennessee is weirdly representative
of the United States.
We're almost exactly 2% of the population.
And we're almost exactly
2% of the population
in most aspects in most
parts of our state.
Except overdose deaths, and
a few other indicators too,
but we're well north of 2%
of the total overdose deaths
in the United States.
The Centers for Disease Control estimates
the average net present value,
so take all the future
costs, all the future losses
from someone passing
away from an overdose,
and use some discount rate
and back it after the present,
CDC estimates that each one of those cases
is 1.3 million dollars per year.
Now a lot of that impact
comes from foregone earnings,
from the labor force participation
that that individual does not do,
because, as Dr. Loyd
said, he can't find a way
to treat dead people.
Similarly employers have not found a way
to employ the deceased either.
So what we know less about
though is a couple of things
that are equally important.
One is we're not sure
about the ripple effects
of overdose deaths, and family spillovers.
We know they can't be good,
but there hasn't been a way,
no rigorous study that I've seen
has really quantified those.
And so that number leaves that out.
The second thing is that we don't,
we sometimes struggle to think about
what's the correct counterfactual
for an overdose death?
From an economic perspective,
that's a bit tricky,
because what do we mean by that?
So suppose not, suppose
somebody does not overdose.
It's a very different state of the world
if they're getting an
ideal course of treatment,
and they are being managed and
sort of trying to, I guess,
I think rehabilitative is
probably a poor choice of words,
but it's the one that stuck
in my head at the moment.
That's very different verses
somebody who's being cut loose
back onto the street.
And so that economic
impact, that 1.3 million
should probably be thought
of as a lower bound
of the best case scenario.
Or some, were there other factors
that were not taken into consideration,
but somebody is getting
the right treatment,
they are getting the right follow up,
they are getting the best
that evidence based practices
have to offer, so that they can live
the most fulfilling life that they can.
The second thing I wanna talk about
is the economic impact on the labor force.
So the comprehensive impact is
really difficult to measure.
And we got involved with
this, Dr. Kessler and I did,
because a lot of early impact studies
focused on the loss of life,
and the lost productivity through there,
but a lot less had been
done on the living.
And we actually got into this
because one of our senior
colleagues, Dr. Matt Murray,
was going out and doing outreach work
in counties to the east of here.
And business leaders,
employers were saying to him
we have jobs, we know
there's people not working.
We're not seeing the applications come in.
We're not seeing people
show up to do the work.
We're hearing about this opioid thing,
is there some truth to that?
Is this what's causing that?
And so we took that seriously.
We were curious about it because
particularly in parts of the world
where you have a lot of
people with chronic ailments,
and with comorbidities,
and with chronic pain,
there is, from a labor force perspective,
the potential for ambiguous effects.
It's certainly true that
to the extent that opioids
have therapeutic value,
that they can help people
who suffer from chronic pain function,
in order to be able to go back to work,
and there's been some
really helpful work done
that's looked at Vioxx,
that when Cox-2 inhibitors
were taken off the market,
we saw evidence of decreased
presenteeism at work,
and in some cases, decreased
labor force participation.
On the other hand, there's
the negative effect
certainly to be concerned about,
which is mostly why we're here today,
the concerns about dependence and misuse
reduce labor force
participation et cetera.
And so that relationship
might look a lot more like
heavy alcohol or illicit drug use.
As it turns out, light alcohol use
looks like it's pretty
good for your career.
So (laughing) what we did,
that's assuming of course,
that people are telling
the truth, right, so,
in Dr. Loyd's version of the world,
where no one ever has more than two beers,
maybe we don't take that as seriously.
So what we did is we empirically examined
the relationship between per
capita schedule II opioids,
and labor force participation.
We got, we wrote to 50 states,
and compiled what was at the time,
it's amazing how fast
data moves sometimes,
at the time a novel dataset of 10 states
were grateful to the
Tennessee Department of Health
for being the providers for
the data here in Tennessee.
And we chose county-level
analysis for two reasons,
one was data availability.
There is still, it's still not possible
to match individual prescribing history
to individual labor force data.
We're working to try to get
to more of a micro level,
but at the moment,
the county's still about
as good as we can go.
The second thing is for a lot of us,
been a lot of conversation in the room
this morning about diversion,
and that's exactly right.
So if we wanna capture
what the effects of,
the aggregate effects of opioids
and labor market outcomes are,
a county is a pretty good
measure for two reasons.
One, is it's a relatively effective proxy
for somebody's immediate physical network.
That, you know, due to
the magic of the internet,
we have friends across the world,
but most of the people we hang out with
tend to be in our county.
The second is it's a
kind of an unnatural area
for asocial networks, but
also for opportunities
for economic and community development,
and to think about
endeavors in that regard.
But because not everybody who uses opioids
is being prescribed, not
everybody who's being prescribed
is using all of them,
diversion is a big deal.
But aggregating out to the county level
helps us do a better job of
capturing that aggregate effect.
So I'm gonna apologize for one slide,
and one slide only, and this is it.
This is as hard as I'm gonna nerd today.
(audience laughing)
But this is a equation
for the relationship
between opioids and labor market outcomes
controlling for other stuff.
And what we really want
is that number beta two,
that number beta two
is gonna be the effect
that we wanna try to find
of how opioids effect
labor market outcomes.
Now what we need
in order to have a
snowball's chance in hell
of having a good estimate is
we need prescription opioids
and the unobservable stuff
that affects the labor market
to be independent.
We need them to be unrelated.
That's probably not the case,
there's sort of a laundry list of things
that we can think of
that might generate
correlations between opioid use
and the unobservable mojo
that drives the labor
market at a county level.
So what we did for our paper
was we used what was called
an instrumental variables approach.
And the basic idea behind the IV
is that we wanna find something
that is correlated with
opioids per capita,
that's not correlated with
the unobservable things
that drives the labor market, and use that
to be able to get the
estimate of opioids per capita
on labor force participation.
So what we did is we
used Medicare Part D data
to get the national
distribution of prescribers,
and we used a couple of
measure of how many prescribers
do you have, and the right
tail of the distribution,
how many really serious,
heavy, heavy, heavy
prescribers do you have.
And the thought experiment behind this
is if you were to extract
one of these heavy
prescribers from accounting,
is opioids per capita gonna change, yes.
Is the unobservable mojo
that drives the labor market
gonna change, no, probably not.
And what we found from
this was shocking to us,
that at the mean, a 10% increase
in opioids prescribed per capita
led to a .56 percentage point decrease
in labor force participation.
And so putting that into real terms,
in terms of what it means,
that means that raw up
in opioid prescribing
from 2000 to present would've
been enough to explain
about half of the decline
in labor force participation
that we've seen over that span.
And so what we think about,
what that means in Tennessee,
'cause this was a multi-state analysis,
a 10% decrease in prescription opioid use
we estimate would lead to an increase
of $825 million in personal income.
And that's lot.
That's not distributed
evenly over the state either.
So when we consider that
we have up here a chart
of county by country, sort of a heat map,
of if you were to successfully decrease
opioid prescribing by 10% in
each one of these counties,
what would happen to personal income.
This projector actually
does this color scheme good,
which is great.
You see that the median answer up here
is most of the modal answer,
generally speaking, opioid prescribing
would lead to an increase
in personal income,
on the order of $120 to $150
per head in most counties,
and that's real money.
That's a big economic impact.
But there's even more
that we still don't know,
that we struggle to understand.
For example, so Dr. Kessler
and I wrote that paper,
which yay, good for us.
We also know that there is
these dynamics that happen
between labor force participation
and economic development.
That when you have a thriving workforce,
you're a better place
for business to locate.
When businesses locate to your county,
people tend to reenter the workforce
because there's better jobs
and better opportunity.
So what we know less about
is the extent to which
either A, economic development
averts opioid usage.
There's anecdotes and success
stories that we can point to,
but the plural of anecdote is not data,
that we can't yet causally
identify that relationship.
By the same token, there's stories,
but we also, it's less
clear to the extent,
to which opioid use has affects
beyond what we're picking up,
because we're not capturing,
that having a reputation
as an opioid hotbed may not make you
a favorable location for business.
Trying to estimate that is worth doing,
but it's something that
we're still struggling
to be able to do.
So when we think about
the economic impact of
of law enforcement,
judiciary, and corrections,
the two numbers that I pulled up here
were number of felons
incarcerated per year
from Tennessee Department
of Corrections website,
and as our friends from TBI
pointed out this morning,
a lot of the blue, a lot
of the other isn't opioids.
That's also amphetamines
and other substances
going on there too.
What do we know about the
economic cost of that?
Well, for starters we know
that crime is very costly.
And we know the story that Miss
Clift told this morning is,
it stops you right in
your tracks, doesn't it?
Drug crimes directly
affect people's lives.
They also affect property costs.
They also require people to take measures
they otherwise wouldn't, in
order to protect themselves
and their property, and their family.
We also know that the
enforcement are costly,
that in a world without a
prescription opioid epidemic,
our friends in law enforcement community
would be able to use those resources
to address other problems.
We also know that incarceration is costly,
and so in terms of what
it costs operationally
to incarcerate somebody, Tennessee
Department of Corrections
will give you a much better number
than whatever guesstimate
I could put up here.
Judge Slone was kind enough
to forward me an article
done by a group at RTI,
and the principle there, Gary Zarkin,
on that project has shown
that diverting people
from prison into treatment,
as Judge Slone is known for doing as well,
has been shown to be
highly cost effective.
In terms of the magnitude for Tennessee,
I struggle to cook you up a
specific estimate for that,
just because I don't have enough
data to be able to do that.
But we know that keeping
people out of prison
is highly cost effective and helpful.
But a lot of the opportunity cost,
and so a man,
a pure recovery specialist
who spoke earlier right?
You're absolutely right,
that one of the things
that often gets omitted from
the cost of incarceration
is that if somebody's incarcerated,
they're not working, or they are working,
they're not being paid for it.
And they're not contributing
to the tax base.
And so that's a big economic cost
that doesn't get talked about.
The other thing too we noticed
that the dynamic costs matter a lot.
If somebody has a felony
conviction that's on them,
they're 10% less likely to be employed
through the balance of their life,
and also they're likely to
be working for lower wages.
And so in audit studies,
people with felony convictions,
so an audit study by the
way is kinda interesting.
That's where a group will
send a bunch of resumes out
to a bunch of companies and
see who gets a call back.
And people who have signaled
they have a felony conviction
are 50% likely to get a call back.
So not only does
incarceration from drug crimes
have operational costs,
and accounting costs,
it has an economic cost well beyond that.
And if you extrapolate that
forward over the lifecycle,
what it truly costs the GDP of Tennessee
to incarcerate somebody is massive.
And so if we can avoid
that, so much the better.
One of the things that we
don't know as much about
is we don't fully understand yet
how incarceration affects the families,
and how it affects the children,
and how those costs
compound over the lifecycle.
But understanding that is key component
to getting to something
closer to the full picture
of what this opioid epidemic
is doing to our state
on economic terms.
When we talk about NAS births,
that's hard to look at.
There's the, the number's still climbing.
In 2017, there were 1070 NAS births.
Among hospital costs
for an infant with NAS,
they average $19,340, so
about an additional $16,000
just in hospital costs,
compared to a child without NAS births.
And as Director Rausch, and
Judge Slone earlier shared
that that doesn't stop there,
there are significant costs that happen
over the course of that
child's first year,
and beyond that.
Children born with NAS are 33% more likely
to have educational disabilities
requiring classroom
therapy, and other concerns.
And the thing to remember
is most of these studies
are happening on a
relatively young cohort.
The children who are able to finally see
the educational outcomes
of what it means for NAS
are the most about 10 or 11 years old.
The true long term
lifecycle cost for that,
we're not gonna unfortunately know that
for probably another 10 to 20 years.
That's gonna take longer
to still extrapolate
to what the full cost of that means.
And the other thing I think
about that's worth addressing
in the opioid epidemic is
Tennessee's on the verge of,
or at least there's efforts underway,
to convert Medicaid into a block grant.
And over time, that will
lead to slower increases
in the amount of federal money
that comes into the state for Medicaid.
And if you have more babies being born
with neonatal abstinence syndrome,
and those babies are
very expensive to treat,
80% of those babies are
happening on Medicaid,
and that spends the budget a lot thinner
for other babies, for
other people who need care,
and puts a much greater
economic burden on the state.
In terms of the economic
impact of healthcare,
Curtis Florence and colleagues at the CDC
estimate that based on matched samples,
so they're controlling for
what comorbidities you have,
they're controlling for demographics,
they're controlling for
health state, et cetera.
They find that individuals
who are opioid dependent
cost about an additional
$15,500 on average
to treat per year.
If we extrapolate that,
the estimated number of opioid
dependents in Tennessee,
assuming we're nationally representative,
which we're probably worse
than nationally representative,
that's another $617
million in healthcare costs
that we're ringing up over
the course of the year.
One of the things that I've been,
I've been grateful for the
discussion that's happened
around ACEs this morning, I
think that's absolutely vital,
and it's something that
we need to talk about.
Aside from the harrowing emotional impact,
ACEs is also really
economically expensive.
Estimates of the lifetime costs
of adverse childhood experiences,
like sexual assault and violence
range from 200 grand to 800 grand.
So Dr. Kessler and I's
followup sort of said okay,
well we have this clever way to identify
the causal effect of
opioids, but lets take a look
at what's happening with
opioids and child maltreatment.
And what we found was we
used much stronger words
than perplexing, it was really confusing.
We found that opioids look
like they were doing good
for child maltreatment.
And in a world as saturated
in opioids as we are,
it (sighing) that didn't seem right.
So we decided to dig a bit deeper.
And I'm sure most of them
in the room probably knew,
we were probably the last ones to know,
again, back to the
institutional knowledge thing,
that although overdose deaths
and our awareness of opioids
continues to increase, opioid prescribing,
prescription opioid prescribing
peaked about seven years ago.
And we see the same pattern
if we take a look at the data
that we have to be able
to do the analysis,
that opioid prescribing
peaked around 2010 or 2012,
and what you see is, I wish this graph
were scaled a bit better,
but you see there is a
bit of a trough here.
And there's a bit of a kink there.
That along the time that
opioid prescribing peaks,
you see this uptick and allegations
in substantiated cases
of child maltreatment.
So what we thought we had
was something closer to this conversation.
So my parents, this is me dating myself,
I'm 40, and my parents took
me to see "Ghostbusters"
in the theater when I was like five.
I didn't realize it was a
comedy for another 13 years,
like when you're five,
(audience laughing)
when you're a five year old,
this is actually pretty scary.
So there was this great conversation
between Egon and Walter Peck from the EPA,
Walter Peck's coming in and saying
you have this dangerous
containment unit, shut it off.
Egon's saying there might
be some danger here,
but if you shut it off, it's
gonna get a whole lot worse.
And they didn't listen,
and they did shut it off.
And things got a whole lot worse.
And what we're seeing is some evidence
that attempts to shut it off, and a vacuum
are generating adverse
consequences as well.
So in terms of prescription
drug monitoring programs,
the good news is they have been effective
in reducing schedule II opioids,
and there's evidence shows,
some shows that they reduce
foster care admissions.
But implementations of PDMPs is also led
to increased heroin related crimes
in counties with high opioid use.
So at the time the PDMP goes into effect,
it's not a level playing field.
You have some cases in places
with relatively low levels of dependence,
and some places with much
worse areas of dependence.
And as you would expect,
the adverse consequences
of restricting opioids are worse in places
with entrenched dependence.
The reformulation of OxyContin,
partially because it happened earlier,
before there was as great
of a level of awareness
of a need for support structures,
the consequences of that
were quite a big use.
There's increased heroin use,
increased heroin overdose deaths,
and increased hepatitis C incidence
in the aftermath of the
reformulation of OxyContin.
And so as we controlled for
kind of an unobserved
initial conditions problem,
we looked at the
reformulation of OxyContin,
and we said okay, let's take a look
during that part where
prescriptions are falling,
and child maltreatment is on the uptick,
what we found that in places
with low opioid dependence,
there was no relationship
between time and child maltreatment.
But in places with high
levels of opioid dependence,
the results we have so far suggest
that as opioid prescribing falls,
due to the policies
that have gone in place
to reduce prescribing,
that one side effect
that we're seeing is
increased child maltreatment.
We're not clear on the mechanism.
I do think substitution
to worst substances
is one candidate mechanism.
It's also true that I
think just withdrawal
and distress of people are cut off
from the thing they're dependent on,
I have three kids, I have a
seven year old, a six year old,
and a three year old.
And I love them with all my heart,
and they try my patience
to the limit daily.
I can't imagine trying to do
that going through withdrawal.
But in terms of this paper,
Commissioner Piercey, I'd
love to talk about this
with you offline, and get your
take on what we're finding,
and what else we should be looking at,
we're working on this
paper in very real time.
We also are trying to evaluate
how the implementation
of a must-access PDMP
affects child maltreatment.
We also wanna know if we can triangulate
these adverse family
outcomes, using data from
FBI and UCR, to look at
arrests for runaways,
and domestic violence.
And we're also interested
in how does accessibility
of MAT and other alternative therapies,
how does it mitigate
the adverse consequences
of those reduced supply,
as part of our efforts
to help guide the conversation
on what the ideal bucket of services is
to have to be able to address this thing.
So, you know, in terms of
the key takeaways from this,
the main one is that there
are substantial economic gains
to be had from a number of fronts
of addressing this epidemic.
If you want a number, I'll be
happy to give you a number.
I'd rather not do it here,
come find me outside,
I'll tell you what my best guess is,
but I'll tell ya there's also
a hell of a confidence
interval around that,
just because there's a whole
lot that we still don't know.
But it's big.
The second thing is that all
these facets of our population
are inexorably linked.
And evidence is shown that for
any solution to be effective,
each of these components
has to go into place
mindful of how these things are linked,
and mindful of how these
factors are interrelated.
So, the work that Matt Yancey
and his team are doing is fantastic.
The work that Dr. Loyd
is doing is fantastic.
The work that our friends
from the judiciary system,
like Judge Slone and her friends from TBI
are doing are fantastic.
Commissioner Piercey, Dr. Pack,
it all has to be able to work together.
It all has to be able to come together
or adverse consequences are
gonna slip through the cracks
and be a big problem with that.
The one caveat, and I
have to just offer this,
is that no matter what plans
of action come from this,
the one thing we know
from empirical research
on behavioral interventions,
and for experiments,
is that people sometimes respond to things
in unanticipated ways.
About two years ago, I taught my kids
about the virtue of saving,
and gave them piggy banks,
so they could start, you know,
putting away a few nickels,
dimes and quarters, and things like that.
And they were messing around
in the front seat of my car
while I was cleaning out the garage,
and they decided to start saving,
I realized they were saying,
"Banking, banking, banking."
What they were doing was
taking all of my loose change
and shoving it in my tape deck.
(audience laughing)
So sometimes lessons that we impart
to try to have positive nudges
respond in unanticipated way.
On a much more harrowing
note, there are stories
of places where fecal
illness is a problem,
and property rights are a problem.
And well meaning health and
developing country types
have gone in and built privies
to contain fecal illness,
and have come back and they've seen
an increased mortality because
of property right concerns,
people have used the
privies as chicken coops,
and that sort of passes things around.
So sometimes you don't
always get the behaviors
that you're gonna expect.
And even solid evidence-based practices
may have unanticipated spillovers.
There's been some evidence,
some early evidence,
that syringe exchange
programs in some cases
have led to increases in HIV.
There's been a paper by Anita Mukherjee,
And Jennifer Doleac
that was controversial,
that showed that increased
access to Naloxone
led to increased overdose deaths,
and partly because I think that Naloxone
was happening in a vacuum,
without people having the
support structure around,
that we need, and that comes back to why
this has to happen together,
that you are in the right room,
and this has to be a cohesive solution.
Judge Slone earlier said
that he'll be shocked
if the number came back at
less than five to one ROI,
in terms of what investing in recovery
would do for economic gain.
And I think that's probably right,
but I don't think that's
gonna happen immediately.
There's gonna be some challenges,
they'll be fits and starts,
they'll be issues with scalability,
they'll be issues with fidelity.
And anytime a given economic impact talk
about investing in health,
the phrase that I always say
is health is a long gain.
The gains down the road are massive
but it takes time for the dynamics
to be able to work for you.
And so, if I can help you make that case,
let me know.
The two things that I'll tell
you that we, as economists,
can be useful for,
is that we're really good
at getting causal inference
out of non-experimental data.
So if you need to be
able to know the effect
of A on B, but you don't
have a double blind trial,
call Dr. Kessler or I, we'll
be happy to see if we can help.
The second thing is that as
you go into implement programs,
economists are often helpful
as program evaluators,
so there's other people
can that do that too,
but if we can help, please let us know,
and thank you guys very much
for sitting through an
econ talk after lunch.
(audience applauding)
