David Beheshti

This paper studies how the prevalence of opioids affects joint physician-patient decisions over medical procedures. Following Alpert et al. (2022), we utilize variation in opioid exposure due to state policies that affected OxyContin's marketing and market entry. Our results suggest that higher availability of opioids led to a substantial (21%) increase in the number of elective surgical discharges, such as knee replacements, hip replacements, and back surgeries. We also consider effects for non-elective surgical discharges—procedures where we expect a much smaller response to the availability of opioids—and find a statistically insignificant increase of 1%. Finally, we investigate medical discharges—procedures where no response is expected—and find no detectable effect. This increase in elective procedures is consistent with a model of physician behavior that incorporates patient pain and post-surgical well-being into surgical decisions and where decreases in the "hassle" of prescribing pain-reducing medication pushes marginal patients to undergo surgeries that they might not otherwise elect. Our results highlight an important tradeoff: while liberal opioid prescribing has led to widespread misuse and abuse, the availability of opioids may allow some patients to undergo quality-of-life improving surgeries that would otherwise be too painful.

Extreme weather has become more frequent and intense over the past few decades. Given that the United States population has been historically highly mobile, direct and indirect effects of extreme weather could catalyze people to migrate. We test this empirically by exploiting spatial and temporal variation in temperature and precipitation at the county level over 6 decades (1950-2010). A non-parametric estimation yields an inverted U-shape relationship between temperature and net-migration, where decades in which the average temperature was more extreme are associated with lower net-migration. The effects are strongest for the most extreme average temperatures. We also find that extreme precipitation is associated with lower net-migration. These results are important as migration could mitigate the detrimental effects of climate change in the developed world. 

In this paper, we examine the importance of individual physicians in explaining the significant variation in prescription drug spending in Medicare Part D. By tracking prescribing behavior before and after physician relocations, we find that movers' prescribing converges toward the average of their new location. However, this convergence is far from complete, highlighting the importance of idiosyncratic physician-specific factors. Overall, these physician-specific factors explain about 60 to 70 percent of the cross-sectional variation in prescription drug spending, suggesting that physicians are one of the most important supply-side determinants of this variation. We investigate several potential mechanisms behind this partial convergence.

A growing literature has examined how mandatory access prescription drug monitoring programs (MA PDMPs), laws that require providers to consider a patient's prescription history before prescribing controlled substances, affect opioid-related outcomes. However, evidence of their impact on non-opioid-related prescribing is mixed. This paper investigates the effect of MA PDMPs on prescribing patterns of stimulants and benzodiazepines. Using updated difference-in-differences methodology, we show that MA PDMPs led to decreases in stimulant prescribing but had no significant effects on benzodiazepine prescribing. Our findings highlight that MA PDMPs do have effects on non-opioid drug prescribing, but these effects differ substantially across drug types.

The onset of the opioid crisis coincided with the beginning of nearly 15 years of declining labor force participation in the US. Furthermore, the areas most affected by the crisis have generally experienced the worst deteriorations in labor market conditions. Despite these time series and cross-sectional correlations, there is little agreement on the causal effect of opioids on labor market outcomes. I provide new evidence on this question by leveraging a natural experiment which sharply decreased the supply of hydrocodone, one of the most commonly prescribed opioids in the US. I identify the causal impact of this decrease by exploiting pre-existing variation in the extent to which different types of opioids were prescribed across geographies to compare areas more and less exposed to the treatment over time. I find that areas with larger reductions in opioid prescribing experienced relative improvements in employment-to-population ratios, driven primarily by an increase in labor force participation. The regression estimates indicate that a 10 percent decrease in hydrocodone prescriptions increased the employment-to-population ratio by about 0.7 percent. These findings suggest that policies which reduce opioid misuse may also have positive spillovers on the labor market.

The US is currently in the midst of the worst drug overdose epidemic in its history, with nearly 64,000 drug overdose deaths in 2016. In response, pharmaceutical companies have begun introducing abuse-deterrent painkillers, pills with properties that make the drug more difficult to misuse. The first such painkiller, a reformulated version of OxyContin, was released in 2010. Previous research has found no net effect on opioid mortality, with users substituting away from OxyContin toward heroin. This paper explores health effects of the reformulation beyond mortality.  Exploiting variation across states in OxyContin misuse prior to the reformulation, I find large relative increases in the spread of hepatitis B and C in states most likely to be affected by the reformulation. In aggregate, the estimates suggest that absent the reformulation we would have observed between 66-75% fewer cases of hepatitis C and 46-60% fewer cases of hepatitis B. I document further evidence that points to the likely cause of these effects: the reformulation led individuals to substitute from OxyContin to heroin, which is substantially more likely to be injected, increasing exposure to blood-borne diseases.

Syphilis, a sexually transmitted infection that can lead to serious health complications, was almost eliminated in the United States by 2000. But since then, its incidence began to increase, recently reaching a 60-year peak. We suggest that the introduction of the highly active antiretroviral therapy (HAART) drug regimen, which transformed HIV into a manageable chronic disease, is partly responsible, as HIV+ and HIV- individuals altered their sexual behavior after the introduction of HAART. To test this empirically, we exploit variation in HAART takeup based on spatial variation in pre-HAART AIDS prevalence, sex, and time in a triple differences framework. We find that a one standard deviation increase in the pre-HAART AIDS prevalence rate led to a 21 percent increase in the syphilis incidence rate, and that in the absence of HAART, there would have been 78 percent fewer syphilis cases between 1996 and 2006. These results highlight the need to consider unintended consequences that could stem from behavioral changes following the introduction of life-saving medical innovations.

Why did the introduction of pre-exposure prophylaxis (PrEP), whose clinical trials demonstrate over 95% efficacy in preventing HIV, coincide with a plateau in diagnoses that ended decades of steady decline? This study draws on epidemiological, pharmaceutical, and Census data to estimate PrEP’s real-world effectiveness and investigate why the drug failed to substantially reduce population-level HIV transmission. To overcome selection bias in uptake, we exploit two facts: PrEP is used almost exclusively by men who have sex with men, and regional concentrations of male same-sex partnerships vary widely. Using a synthetic-control approach, we show that counties with higher male same-sex partnership rates experienced greater PrEP uptake, which in turn, lowered transmission rates. Our findings indicate that 76 additional users avert one new diagnosis. Finally, while PrEP uptake is similar between Black and White men, eight-times greater incidence among Black men implies significant underutilization relative to need, diminishing the drug’s real-world effectiveness.

Over the last two decades the federal and state governments have implemented a wide variety of policies intended to reduce unnecessary opioid prescribing, diversion, and abuse. An important policy action has been statewide mandatory access prescription drug monitoring programs (PDMPs) that help prescribers identify patients at ‘high risk’ for suspected misuse, diversion, and doctor shopping, and have been found to significantly reduce opioid prescribing, but have been also linked to increased use of illicit substances like heroin and related overdose mortality. Patient advocacy groups have expressed concerns that restrictions, like mandatory PDMPs, which reduce access to necessary pain medications may explain some of the unintended substitution towards illicit substances by individuals suffering from severe pain, and who are no longer able to receive adequate opioid analgesics. This study examines whether supply side restrictions on opioid prescribing, as a result of mandatory access state PDMPs, have led to increased pain in settings of outpatient, hospital inpatient and long-term nursing home residents. Using multiple self-reported and proxy measures of pain (use of over-the-counter (OTC) pain medication), across several proprietary data sets capturing nationally representative samples of commercially insured, Medicare and difference-in-differences framework, we find no evidence that these programs have led to increased pain in these populations. These results suggest that targeted policies like state PDMPs may be successful in reducing inappropriate prescribing, without restricting access to necessary pain medication.