Addiction to opioids, cocaine, and other hard drugs is turning increasingly deadly in the United States, with more than 64,000 drug-related deaths in 2016 alone, according to the National Institute on Drug Abuse. But not every community has felt the impact of those deaths equally. A study published today in the American Journal of Preventive Medicine suggests that geography is far less important in explaining those deaths than your job and your family life.
The study, conducted at Syracuse University, mapped 515,000 drug-related deaths from 2006 to 2015, and compared those statistics county-by-county to social and economic factors like the divorce rate and the availability of medical care from various government sources.
The analysis found no real difference between rural and urban overdose rates. Instead, high rates of divorce and a greater proportion of single-parent homes were most closely linked to counties with higher rates of drug deaths. The next largest contributing factors were certain economic indicators, including more people dependent on the the mining industry or on some kind of public assistance. It’s the first national study of county-level differences in drug overdose deaths.
Study author Shannon Monnat explains that, at the root of the problem, drug abuse is really about disconnection and isolation. “Work and family are two of the most important arenas to which we assign meaning,” says Monnat, an associate professor of sociology at Syracuse University. “Lacking or losing attachment to those institutions and the people in them can diminish meaning in our lives.”
The drug overdose hotspots clustered in diverse regions of the United States: In the Appalachian Mountains of West Virginia and Kentucky, branching out through southern Ohio and Indiana; the Gulf Coast of Louisiana and Mississippi; large swaths of the Southwest (which might be deceptive, since counties in that region are few and geographically large); parts of Oklahoma; and Northern California and parts of the Pacific Northwest. But there are relatively fewer deaths in Texas, most of the Midwest, many parts of the South through Alabama stretching up through the Carolinas and Virginia, and upstate New York.
Even within some US states, there is a massive disparity between counties with a very high rate of drug-related deaths and counties with fewer overdoses. West Virginia revealed the biggest range, with the worst county experiencing an overdose death rate of more than 100 per 100,000 people over the decade-long study period, while other counties were down closer to 10 deaths per 100,000. Across the nation, the average age-adjusted drug-related death rate was 16.6 deaths per 100,000 people.
Social factors aren’t the only things that lead people to a lethal drug overdose. The hotspot map matches closely to a separate map of opioid prescriptions put together by the Centers for Disease Control and Prevention, looking at the year 2015. The CDC notes that, like deaths from all kinds of drug use analyzed in the Syracuse study, opioid prescription rates are “inconsistent across the U.S.” Out of all drug deaths the new study looked at, opioids accounted for 43 percent of the overdoses, while cocaine and benzodiazepines (a class that includes prescription medications like Valium and Klonopin) were each involved in another 12 percent of deaths.
“Now we are in the second wave of the epidemic, in which prescription opioids are still overprescribed, and still contribute to morbidity and mortality, but now illicit opioids are playing a bigger role in deaths,” says Anna Lembke, medical director of addiction medicine at Stanford University, and the author of Drug Dealer, M.D. (Lembke was not involved in the study, but has testified as an expert witness in litigation against drug manufacturers.) “In this second wave of the epidemic, I think social determinants of health like poverty, unemployment, social distress and alienation, are bigger contributors, probably because they’re independent risk factors for addiction and drug overdose.”
Those social factors don’t seem to be mitigated by available medical care, at least according to the available government data. Drug deaths were a tiny bit higher in areas that were designated a “mental healthcare professional shortage area,” by the Department of Health and Human Services’ definition, but not enough to be statistically significant.
Just because there are enough psychiatrists and addiction counselors to go around, however, it doesn’t mean that the people who need it most can actually receive or pay for the therapy they need. “This variable says nothing about people’s access to care or the quality of that care,” Monnat says. “Medication assisted treatment has been shown to be a very effective treatment for opioid addiction, yet access to MAT remains shamefully low.”
What did seem to make an impact were more people working in the public sector (aka government), which generally provides better job stability and higher incomes in impoverished regions, and a greater number of religious establishments that provide community structure. While having a better job helps avoid the stress of economic insecurity, your co-workers can also provide the kind of social structure that helps people feel connected to the world.
“We live in an era of individualism and personal responsibility, characterized by disinvestment in social safety nets, declines in social cohesion, loss of connections, and increased loneliness,” Monnat says. “Combatting today’s opioid problem, and tomorrow’s new drug problem, involves all of us reflecting on what kind of society we want.”
Update 12/5/19: This story has been updated to reflect the fact that Anna Lembke has served as an expert witness.
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