UNIVERSITY PARK, Pa. — Visitors to a 10-city region in Orange County, California, with a large concentration of substance use disorder treatment centers experience disproportionately high levels of overdose, according to a new study led by a researcher at Penn State.
Out-of-state visitors to this region had the most pronounced levels. They were 159% more likely to experience a drug overdose when visiting this region compared to other parts of the state. The study was published in the journal Substance Use & Misuse .
“You’d expect that in a place where there’s a lot of treatment centers, there would be a buffer against relapses and overdoses. But our study shows that this area of Orange County, where there is an abundance of treatment centers, is a hotspot for overdoses, especially for out-of-state visitors,” said Ilan Shrira , lead author of the study and a social psychologist at Penn State. “One possible explanation may be the lack of oversight in the industry, allowing for fraudulent and predatory practices by some bad actors that can harm those seeking treatment and contribute to overdose risk.”
Substance use disorder treatment programs are an effective means to reduce the risk of continued drug use and of overdose, the researchers explained. Previous studies in the field have shown that the presence of treatment centers in a community predicted lower rates of overdose and death in the surrounding area.
However, while working on a different study, Shrira said he detected an overdose hotspot in Orange County even though it’s home to a high concentration of substance use disorder treatment facilities. This coastal region just south of Los Angeles, known for its beaches and luxe towns like Newport Beach and Laguna Beach, has become a popular recovery destination for visitors from other parts of the country.
Shrira and study co-author Joshua Foster, professor of psychology at the University of South Alabama, wanted to assess how overdoses in Orange County — specifically the 10-city hub where treatment facilities are disproportionately located — compared to the rest of the state.
They analyzed over 33 million records from 323 emergency room locations in California between 2019 and 2021, the most recent data available when they began the project. The data were derived from the State Emergency Department Databases for the state of California and contained information on the patient’s visit, demographic characteristics, diagnosis codes, residence zip code and hospital identifier to pinpoint each emergency room’s location. The researchers used this information to calculate the odds of drug overdose for residents of Orange County, residents of other counties in California and residents of other states.
The researchers found that the likelihood of overdose was higher within the region where treatment centers were concentrated. Local residents within the treatment hub experienced a slight elevation in overdoses, but visitors to the region experienced higher levels. The odds of California residents from other counties experiencing an overdose were 68% greater within the treatment hub. Most notably, out-of-state visitors were 159% more likely to overdose within the treatment hub compared to other parts of the state.
There are two factors that may account for the greater overdoses in this area, the researchers explained. First, the greater availability of treatment services attracts visitors with substance use disorders to the area, which increases the overall number of people who use drugs in the local population and thus who are at risk of substance misuse and overdose.
Second, the treatment industry has grown significantly over the last two decades due to the increase in substance use disorder rates and legal changes requiring insurance companies to cover substance use treatment. That, in turn, has attracted some unethical providers to the field who use predatory practices to keep patients, particularly out-of-state residents, in a treatment loop. According to the researchers, addiction treatment fraud is prevalent in Southern California, particularly in Orange County. In 2021, the last year of data collection in this study, the U.S. Department of Justice filed criminal charges against at least 10 substance abuse facility owners and patient recruiters allegedly involved in kickback schemes in the county.
In these instances, unscrupulous treatment center operators can profit by exploiting insurance reimbursements, the researchers said. If a patient relapses, their insurance coverage typically resets, enabling the center to begin a new billing cycle. Out-of-state patients are often targeted, particularly those with private insurance because they tend to have less restrictive spending limits. Shrira said this dynamic can create an incentive for centers to prioritize profit over medical care, further contributing to overdose risk.
“There are also patient brokers, who receive huge commissions for bringing patients to rehab centers. They recruit people outside of California, promising quality care in ‘paradise’ and even paying for one-way airfare,” Shrira said. Once away from home, patients are isolated from family and friends, often without a way to get home.
The researchers said that the findings point to the need for stronger regulatory oversight of the industry. For example, in a previous study , Shrira and Foster found American visitors to Florida who died in the state were more likely to have died from a drug overdose compared to visitors to all other states, pointing to the need for stronger regulatory oversight of the industry. After Florida enacted new laws on the treatment industry in recent years, overdoses and fraud have both decreased.
“But this isn’t just a local Orange County issue. Most of the victims come from the rest of the United States,” Shrira said. “You have a lot of vulnerable people who are trying to get help, trying to get well, and some of them are being hurt instead.”
Substance Use & Misuse
Data/statistical analysis
People
Excessive Overdoses Where Treatment Centers Are Concentrated: A Case Study of Orange County, California
1-Apr-2026