Where Orange County Packs the Most Rehabs, Out-of-State Visitors Overdose Most

Boyd was 24 and drinking dangerously by the time he decided to get help. He was living in Chicago then, and he found his treatment program the way most people now do — through a search result. The facility was in Orange County, an affluent coastal stretch of Southern California, roughly 2,000 miles from his apartment, his family and everything he knew.

Boyd, a pseudonym used at his mother's request, completed detox there and stayed for therapy. He was readmitted twice more. At some point the program moved him to another of its locations nearby. Then, despite the sobriety pledge printed on the program's own website, he began to use fentanyl. In June 2024, two weeks after his final readmission, he was found unresponsive in a bathroom at that facility. He reached the emergency room in cardiac arrest. His heartbeat came back; his brain function largely did not. He died six days later, and the Orange County coroner ruled it an accidental fentanyl overdose.

Boyd's death is the opening of an essay published October 13 in The Conversation by Ilan Shrira and Joshua D. Foster, two psychologists who have spent years on a narrow question most treatment research skips: what does the business geography of the rehab industry do to the people inside it? Their underlying study, published in Substance Use & Misuse, arrives at a finding that inverts a comfortable assumption.

A finding that runs the wrong way

For more than a decade, the economics literature has pointed in one direction. Areas with more treatment facilities tend to record fewer overdoses — a relationship documented across several peer-reviewed studies that used facility counts as a proxy for access. More supply of care, the logic runs, means more people get care.

Shrira and Foster looked at Orange County and found the opposite, at least for one population. Their study area was not the county as a whole but a contiguous 10-city zone with the heaviest concentration of rehab facilities — 35 treatment centers per 100,000 residents. For comparison, the county overall had 14 per 100,000 in 2019 federal data, and the national figure sat near five.

The methodological move that makes the paper unusual is the comparison group. Because they could not measure the denominator of who was actually present in that zone, the researchers benchmarked overdoses against bodily injuries — one of the most common reasons anyone presents at an emergency department. If the share of overdose cases relative to injury cases in the study area was larger than in the rest of California, overdoses were disproportionately high there.

They then split patients by how far from home they were being treated, which is where the numbers separate dramatically.

Three groups, three different numbers

The analysis drew on more than 33 million emergency department visits across 323 California hospitals between 2019 and 2021, the most recent data available when the work began.

People who lived in the study area were treated for 4,108 overdoses. Relative to injuries, that was about 10 percent higher than expected compared with residents of other parts of California — a modest elevation.

Californians who travelled into the study area from elsewhere in the state were treated for 370 overdoses. Relative to injuries, that was 68 percent higher than expected compared with in-state visitors to other regions.

Then the out-of-state group: 316 overdoses, a rate 159 percent higher than expected relative to out-of-state visitors anywhere else in California.

The gradient matters more than any single figure. If the cluster of facilities simply attracted people who were already more likely to overdose, the elevation should be roughly similar across all three groups — the study area would be pulling in high-risk people regardless of origin. Instead the excess climbs steeply with distance from home, and more than doubles between in-state and out-of-state visitors.

The authors concede part of the first explanation. Some of the concentration is selection: a treatment hub does attract people with severe substance use. But they argue selection alone does not account for a difference that large between two groups of people who were, by definition, both away from home.

The economics that make density dangerous

To understand why distance would amplify risk, it helps to understand how a particular class of facility makes money.

Federal parity law and the Affordable Care Act required most private insurers to cover addiction treatment, and the effect was overwhelmingly positive — millions of people obtained care they could not previously afford. But Shrira and Foster point to the predictable side effect: large volumes of insurance money flowing into an industry with uneven regulatory oversight attracted operators whose business model is billing rather than recovery.

The schemes are well documented in federal prosecutions and journalism. A recruiter identifies a patient with a generous out-of-network plan; the facility covers travel, housing and living costs to get them enrolled; the program then bills the insurer for services at rates that can reach into the thousands of dollars per day. Out-of-network private insurance is the richest target because it carries higher spending limits.

The vulnerable point in the model is coverage expiry. Once a plan's treatment days run out, a patient who relapses can be readmitted and the billing cycle restarts. That structure creates a financial incentive that points away from durable recovery — and, in the worst cases, toward keeping a patient inside the system.

The revolving door, priced

This is the mechanism the paper names directly. Patients can cycle through treatment, relapse and re-enrolment, with each relapse carrying its own overdose risk, because a relapse is what reopens the payer's wallet. The far end of the pattern is the one Boyd's family described: a readmission followed, two weeks later, by a fatal overdose inside a facility that advertised sobriety.

Travelling far from home sharpens every part of that trap. A patient arriving from another state has little chance to inspect the facility's real conditions before committing. They are separated from the family and friends who might notice something wrong. Brokers sometimes arrange a California insurance policy on arrival and pay the premiums on the patient's behalf. And when coverage ends and the facility discharges them, the return trip may be unaffordable — leaving a choice between homelessness somewhere new and staying inside the treatment economy that at least provides a bed.

That last dynamic is the one that pushes the study's framework past fraud into harm. A substandard program in a dense market is not merely a bad purchase. It can be the thing that puts a person in a county where they have no support network, no housing and, per the emergency data, a substantially elevated chance of an overdose they did not have before they arrived.

Orange County is not an accident

Orange County was not chosen at random, and the paper does not pretend otherwise. It has one of the highest concentrations of addiction treatment programs in the country and has been identified by the Department of Justice as a national centre of treatment-related kickback fraud. California's oversight of the industry has been criticised repeatedly — by state senators, by the Orange County Register's own investigations, and by the state auditor.

The structural explanation is regulatory arithmetic. A high density of facilities in a compact geography makes misconduct harder to detect per facility, because complaint volume overwhelms inspection capacity. The same density makes the market more attractive to operators who want to blend into a legitimate-looking local industry.

The study is careful about scope. Its data stop in 2021. It measures emergency department presentations, not deaths, so it captures overdoses that reached a hospital rather than the larger number that never did. And it cannot assign individual patients to individual facilities, meaning the paper can establish that the geography is associated with excess overdose without proving that any named operator caused any particular case.

Why oversight has not caught up

The paper's sharpest institutional claim concerns the California Department of Health Care Services, the agency that licenses and oversees treatment centres. A state audit found the agency slow to investigate complaints — averaging nearly a year to close most investigations, and about three months in cases where a patient died at a facility. The audit covered fiscal years 2020-21 through 2022-23.

A DHCS spokesperson told The Conversation that the audited period was significantly affected by pandemic-era delays, that improvements were already under way, and that the department had proactively assigned staff to Orange County to handle the region's complaint volume.

Shrira and Foster flag a structural gap the audit could not close: even when a facility's licence is revoked or suspended for serious violations, nothing prevents the owner from opening another rehab under a different corporate name and running the same playbook. Oversight attaches to licences, and licences do not attach to people.

For anyone weighing treatment options, the study's practical warning is narrow and specific. Travelling a long distance to enter a facility you have never seen in person removes your ability to verify anything about it, and it removes the support network that would otherwise catch a decline early. For people seeking opioid addiction treatment, where the fentanyl exposure risk is highest, that trade-off is the one to think hardest about.

What this means for families

The finding does not argue that treatment centers cause overdoses, and reading it that way would be a mistake. It argues that a treatment market without effective oversight can produce a geographic overhang of risk — an area where the density of beds outruns the density of accountability, and where the people most exposed are the ones who travelled furthest to be there.

That reframes what a family should look for. Not just whether a program is licensed, but how its levels of care are structured, who owns it, how many entities operate under the same ownership, what happens at the end of an insurance authorisation, and whether the facility is close enough to home that a relative can walk through the door unannounced. Boyd's mother spoke to the coroner's office after her son died. The study's central insight is that the information she needed was available before he checked in — it simply was not where a person searching online would encounter it.