As we have just demonstrated, not only does faith offer personal and social resources helping people avoid and/or recover from substance abuse, its impact is often made manifest at the local congregational level, as places of worship host spiritual or religious 12-step type fellowship meetings. We will now build on and extend the work of Grim and Grim (
2016), who produced the first economic valuation of the contribution of religion to American society at the national level. The study put the annual contribution in dollar terms, with a mid-range estimate of nearly $1.2 trillion. This includes the fair market value of community services provided by religious organizations such as an estimated 129,680 congregational substance abuse recovery programs (
2016, p. 17). The study did not, however, conduct a valuation of each type of community service, but rather used an algorithm based on in-depth studies of individual congregations by Cnaan et al. (
1999,
2006,
2013) and Cnaan (
2015). Johnson (
2016) argued, however, that while the study was valuable and groundbreaking, it
undervalued the economic impact of religion.
White House Valuation of Opioid Crisis Based on Value of a Statistical Life (VSL)
Within the Executive Office of the President, the Council of Economic Advisers (CEA) is charged with offering the President objective economic advice on the formulation of both domestic and international economic policy using the best data available. The CEA chairpersons require Senate confirmation. In November 2017, the CEA issued a report (Council of Economic Advisers
2017) offering a new valuation of the adverse impact of the opioid crisis on the American economy, titled “The Underestimated Cost of the Opioid Crisis.” The brief 14-page report changed the national discussion on the crisis by putting a $504 billion value on the human cost of substance abuse. While there is no perfect methodology for estimating the cost of a lost or ruined human life, over the years researchers have reached a consensus that economic valuations of a fatality, i.e., the value of a statistical life (i.e., VSL) is in millions of dollars (Viscusi
2013).
4 VSL is used by various government agencies to estimate the economic cost–benefit value of certain risk-reduction policies, such as the economic value of lowering speed limits to reduce traffic fatalities or building a levee to prevent catastrophic flooding or, in this case, spending money on substance abuse prevention to save lives.
5 The 2017 CEA report reviewed research on the range of empirical estimates of the VSL used by the federal government regulatory and health agencies in order to estimate the economic cost of the opioid crisis (Robinson and Hammitt
2016; Viscusi
2015; Viscusi and Aldy
2003; Viscusi and Masterman
2017). The CEA report (
2017, p. 4) identified three federal agencies that have issued formal guidance on VSL to inform their rulemaking and regulatory decision making: the US Department of Transportation (DOT), the US Environmental Protection Agency (EPA), and the US Department of Health and Human Services (HHS).
6
In the end, the White House presented cost estimates under three alternative VSL assumptions: low ($5.4 million), middle ($9.6 million), and high ($13.4 million), based on the US DOT and similar to those used by HHS. Thus, their low fatality cost estimate of $221.6 billion is the product of the adjusted number of fatalities (i.e., 41,033) and the VSL assumption of $5.4 million. Their fatality cost estimates thus range from a low of $221.6 billion to a high of $549.8 billion, which is the product of fatalities and the high estimate. Their estimates also take into account that opioid fatalities are more common among younger age-groups, as also shown in the same table under the age-dependent VSL assumption. Finally, the CEA estimate includes non-fatality costs in addition to the cost of fatalities each year. They estimated those costs by using the estimates of Florence et al. (
2016) to calculate a measure of per-person costs of opioid misuse among those who did not die within the year and then multiplying that per-person cost by the number of individuals with an opioid use disorder in 2015. Florence et al. (
2016) estimates of increased costs due to prescription opioid misuse were $58.0 billion (according to the 2015 value of dollar), broken down as follows: $29.4 billion: increased health care and substance abuse treatment costs; $7.8 billion: increased criminal justice costs; and $20.8 billion: reduced productivity among those who do not die of an overdose.
The CEA took this non-fatal total cost of $58.0 billion and divided it by the 1.9 million individuals who had a prescription opioid disorder in 2013 (the reference year of Florence et al. (
2016) study), resulting in an average cost of approximately $30,000 per person. The CEA applied that average cost to the 2.4 million people with opioid disorders in 2015, resulting in a total cost of $72.3 billion for non-fatal costs (the CEA also included heroin disorders as well as prescription opioid misuse).
Valuation of Congregation-Based Substance Abuse Recovery Support Programs
Using the White House CEA’s methodology as a blueprint, we can estimate an economic valuation of congregation-based abuse recovery support programs’ contribution to American society and its economy. Detailed data are not available for the nearly 130,000 congregational substance abuse recovery groups. However, data are available for A.A., which has been conducting surveys of their members every 3 to 4 years since 1968 (Alcoholics Anonymous
1970). A.A. conducts these surveys to keep members informed of the current membership trends. As a proxy, the A.A.’s surveys, in combination with other data summarized in Table
2, are particularly useful for making valuation of religious and spiritual substance abuse recovery programs, mainly because many A.A. groups meet in churches and other faith congregations (see the “
Spiritual but Not Religious Substance Abuse Recovery (Ex. 12-Step Programs)” section).
7Table 2
Data used in proxy valuation of religious and spiritual substance abuse recovery programs held in congregations
Length of sobriety | Alcoholics Anonymous ( 2014) |
Risk of relapse over time | |
Age structure of A.A. members | Alcoholics Anonymous ( 2014) |
Mortality rates | National Vital Statistics Reports (Xu et al. 2018) |
Relative mortality risk of people with alcohol use disorder | |
Total membership | Alcoholics Anonymous ( 2018a) |
Numbers of groups | Alcoholics Anonymous ( 2018a) |
VSL | |
Non-fatality costs of addiction | |
Number of religious and spiritual substance abuse recovery programs held in congregations | |
We will now go through a series of steps leading to a valuation of the nearly 130,000 congregation-based recovery support groups for people struggling with drug or alcohol abuse using data from A.A. as a proxy. The basic building block is the number of people who have been saved from death by these groups. We know that A.A. reports 1,297,396 members in the USA (Alcoholics Anonymous
2018b, May). If we were to count each one of these members as a life saved and then apply the same VSL used by the CEA (
2017) (i.e., low, $5.4 million; middle, $9.6 million; and high, $13.4 million) to estimate the cost associated with overdose mortality, this would equal a low estimate of $7.0 trillion, a middle of $12.5 trillion, and a high of $17.4 trillion. These figures are of course unreasonable valuations for several reasons. First, the high estimate is nearly equal to the entire US economy. Second, not all of these people would have died due to substance abuse. Finally, they do not represent the actual number of people in congregational programs, which likely equals or exceeds the A.A. membership figure.
We now offer a more reasonable way of estimating the lives saved and the statistical value of those lives through a series of steps using the data summarized in Table
2 (see Appendix Table
6, for calculations). First, we begin by breaking down the A.A.
total membership by
age structure, knowing that people die at different rates according to age. We also know that people addicted to alcohol are much more likely to die than those who are not. We then apply the
relative mortality rate to people with alcohol use disorder, which is estimated to be 3.45 higher than that of sober people (Laramée et al.
2015), and arrive at the excess deaths for each age-group, which would have occurred had it not been for A.A. However, to assume that all people in A.A. will stay sober and reduce their risk of death is unreasonable, given that some A.A. members relapse and thus put themselves at a higher risk. Adopting a conservative approach, we take into our calculation only A.A. members who have been sober for 5 years or more and are likely to stay sober. According to Dennis et al. (
2007), 86% of people reaching this threshold tend to remain sober.
To explain our calculations, we will first discuss the process without taking age differences into account. In the overall US population, 849.3 people per 100,000 die yearly according to the latest mortality data (Xu et al.
2018). This means that out of the total A.A. membership of 1,297,396 people (Alcoholics Anonymous
2018b, May), 11,019 can be expected to die due to all causes (e.g., age, accident, disease, etc.). However, if all these A.A. members were still addicted to alcohol (i.e., had alcohol use disorder), the mortality rate would be three to four times higher or, as estimated by Laramée et al. (
2015), 3.45 times higher, which would be 38,015 people. This is 26,996 more deaths than would be generally expected; in other words, these are 26,996 people who would have possibly died but did not because they were the sober members of A.A. We could stop here; however, to be more conservative in our estimate, realizing that there are high rates of relapse in the first years of sobriety, we will focus on counting as successful only 49% of that total (13,228), which is the share of A.A. members who have achieved five or more years of sobriety. Moreover, even among those achieving 5 years or more of sobriety, 86% are likely to relapse (Dennis et al.
2007). Applying this additional condition means that 11,376 people are alive this year who otherwise would not have been without achieving sobriety.
Using a similar process, we now incorporate into the calculations A.A. membership age differences from the 2016 A.A. membership survey. Combining these data with age- and gender-specific mortality data (Xu et al.
2018) will yield an age-adjusted total estimate of 9878 people alive this year who otherwise would not have been without achieving sobriety through A.A. (see Appendix Table
6, for calculations). This estimation may seem by some as overly conservative, especially because a common story of A.A. members is that were it not for A.A., they would be in jail, institutionalized, or dead. Nevertheless, it is appropriate to incorporate into our estimates these theoretically and empirically relevant factors.
The age-adjusted estimate of 9878 lives saved through A.A. annually provides a proxy that can be used to estimate the economic impact of congregation-based recovery groups. Dividing this number by the 61,904 A.A. groups in the USA (Alcoholics Anonymous
2018b, May) indicates that 0.16 lives are saved per group each year. Multiplying this figure of 0.16 lives per group by the 129,680 faith congregations with recovery groups provides an estimate of 20,693 lives saved each year. Taking this figure and applying the VSL from the CEA provide three age-adjusted estimates of the value of these congregational efforts: low, $111.7 billion; middle, $198.6 billion; and high, $277.3 billion (see Table
3).
Table 3
Estimated annual valuation of congregational substance abuse recovery programs.
Sources: A.A. (
2014,
2018, May), CEA (
2017), Dennis et al. (
2007), Grim and Grim (
2016), Laramée et al. (
2015) and National Vital Statistics Reports (Xu et al.
2018).
CEA Sources: Aldy and Viscusi (
2008), US DOT (
2016a,
b), CDC WONDER database, multiple cause of death files, Substance Abuse and Mental Health Services Administration (
2016) and Ruhm (
2017)
Low | 111.7 | 39.3 | 151.0 |
Middle | 198.6 | 39.3 | 237.9 |
High | 277.3 | 39.3 | 316.6 |
Further, following the CEA’s estimate of non-fatality costs, we can also consider the shorter-term fatality prevention benefit of those who have been sober. Dennis et al. (
2007) found that 66% of the alcoholics who remain sober for 1 year or more did not relapse. We can use this as a reasonable estimate of the number of people who remain sober in any given year. The 2016 A.A. survey reports that 73% of A.A. members are sober for 1 year or more, which equals 947,099 people. If 66% of these do not relapse during the year, we can estimate that 625,085 people are kept from entering the rehab or criminal justice systems. Turning that into a per-group number would be 10.1 persons per group; across the 129,680 congregational support groups, that would be 1,309,463 people. Using the CEA’s estimate for
non-
fatality costs of addiction ($30,000 each), this would be $39.3 billion worth of value (see Table
3). Adding this to the VSL estimates yields the total annual valuations of congregational recovery support groups at a low $151.0 billion, a middle $237.9 billion, and a high $316.6 billion.
Volunteer addiction recovery support groups meeting in congregations around the USA contribute up to $316.6 billion in benefit to the US economy every year at no cost to tax payers. And this represents only a portion of the faith-based work addressing the addiction crisis.