Using Census Data to Understand County-Level Differences in Overall Drug Mortality and Opioid-Related Mortality by Opioid Type

Shannon M. Monnat, PhD; David J. Peters, PhD; Mark T. Berg, PhD; Andrew Hochstetler, PhD

Disclosures

Am J Public Health. 2019;109(8):1084-1091. 

In This Article

Discussion

Counties are important analytical units for understanding how ecological conditions relate to population health. Consistent with recent research on the geography of drug overdose, we found substantial county-level variation in overall drug mortality rates.[2–4,29] After controlling for demographic controls, overall drug mortality rates are higher in counties characterized by more economic disadvantage, larger concentrations of blue-collar and service industries and occupations, and higher rates of opioid prescribing.

Our study also shows important geographic variation in mortality from specific types of opioids. Using latent profile analysis methods, we found that counties cluster into 6 distinct "classes" of opioid mortality, characterized by differential mortality rates and changes in rates from different types of opioids. The geographic patterns for these classes closely match those found in recent analyses that examined levels and changes in mortality rates for prescription opioids, heroin, and synthetic opioids across US states, leading us to have strong confidence in our classes.[6]

We found substantial variation in the importance of different place-level factors for different opioid mortality classes—an empirical observation not considered in previous research on geographic differences in opioid mortality.[19,30] For example, we found that high rates of prescription opioid deaths and deaths from combinations of synthetic and prescription opioids (synthetic+ class) cluster in more economically disadvantaged counties, but economic disadvantage is associated with lower odds of membership in the heroin classes. High blue-collar and service worker presence—what we might collectively think of as the "working class"—were associated with increased odds of being in all 5 high opioid mortality classes versus the low mortality class. The nature of blue-collar and service work might increase risk for work-related injury or physical wear and tear, thereby increasing demand for pain treatments in these contexts.[31]

Moreover, qualitative accounts show that declines in good-paying and secure employment for the working class have manifested in collective psychosocial despair, family and community breakdown, and increased substance misuse.[32,33] Graham and Pinto[34] show that working-class Whites are less hopeful and optimistic about their futures than are any other group in the United States. Optimism in this group started to decline in the 1970s[34] and continued to do so throughout the 1990s and 2010s.[35] Interventions aimed at addressing the overdose crisis in these places must consider the likely absence of alternative pain treatment services, underfunded public services resulting from community economic disinvestment, and the need for services that address not just drug addiction but chronic pain and despair.

By contrast, the heroin and syndemic classes (counties with high mortality across all types of opioids) are more urban, have larger shares of professional workers, and are less economically disadvantaged. Interventions in these places should be structured differently on the basis of their relatively advantaged social and economic contexts. However, it is also possible that there are groups of disadvantaged residents in these counties that are driving these higher overdose rates.

Collectively, our findings highlight the importance and value of census data for understanding geographic variation in a timely and important population health crisis. Census data allow a more complete understanding of the ecological correlates of drug mortality, helping to inform the development of place-specific policies to address health crises. Our findings support the contention that population health crises and their causes and consequences follow different trajectories across places. The opioid crisis is not monolithic across the United States. Each class we identified is distinct in its socioeconomic and labor market conditions, suggesting different causes and the need for different policy responses to address the crisis. We call on researchers to explore place-based trajectories and to use historical and forthcoming census and ACS data to better understand heterogeneity in this and other population health crises.

Limitations

Findings should be considered in light of some limitations. First, because this is ecological research, we do not distinguish between place-based and individual effects, and we cannot account for individual decedents' duration of residence. Second, aggregate measures of county-level conditions mask important in-county differences. Third, death certificates may misclassify cause of death, leading to an undercount of opioid deaths.[7] We attempted to minimize this concern by including mortality from deaths where an opioid was not specified on the death certificate. Fourth, relationships between county environments and drug mortality likely play out over an extended period, but we considered only relatively recent county conditions (2000 onward) and did not consider changes in county environments over time. Future research should examine the role of changing labor markets since the 1980s and concomitant socioeconomic changes on drug mortality rates.

Finally, it was beyond the scope of our study to examine variation in mortality rates across demographic subgroups (e.g., gender, race/ethnicity, age). Future research should examine whether relationships between the ecological measures we assessed and opioid mortality rates apply equally to opioid and other drug mortality across these subgroups.

Public Health Implications

National policy strategies to combat the opioid crisis cannot be assumed to be universally applicable. For example, policies targeting the prescription opioid supply are unlikely to be effective in places characterized by high rates of heroin and synthetic opioid overdose. Addressing our opioid overdose crisis requires more than supply side interventions. A multifaceted supply and demand–based response is required.[20] In addition to important national policies to combat the opioid and larger drug crisis, emphasis should be placed on developing locally and regionally tailored interventions. Ultimately, interventions are unlikely to be effective if they do not consider the diverse social and economic profiles of places and if they do not address structural upstream contributors to the opioid crisis.

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