Trends and Geographic Patterns in Drug-Poisoning Death Rates in the U.S., 1999–2009

Abstract

Background Drug poisoning mortality has increased substantially in the U.S. over the past 3 decades. Previous studies have described state-level variation and urban–rural differences in drug-poisoning deaths, but variation at the county level has largely not been explored in part because crude county-level death rates are often highly unstable. Purpose The goal of the study was to use small-area estimation techniques to produce stable county-level estimates of age-adjusted death rates (AADR) associated with drug poisoning for the U.S., 1999–2009, in order to examine geographic and temporal variation. Methods Population-based observational study using data on 304,087 drug-poisoning deaths in the U.S. from the 1999–2009 National Vital Statistics Multiple Cause of Death Files (analyzed in 2012). Because of the zero-inflated and right-skewed distribution of drug-poisoning death rates, a two-stage modeling procedure was used in which the first stage modeled the probability of observing a death for a given county and year, and the second stage modeled the log-transformed drug-poisoning death rate given that a death occurred. Empirical Bayes estimates of county-level drug-poisoning death rates were mapped to explore temporal and geographic variation. Results Only 3% of counties had drug-poisoning AADRs greater than ten per 100,000 per year in 1999–2000, compared to 54% in 2008–2009. Drug-poisoning AADRs grew by 394% in rural areas compared to 279% for large central metropolitan counties, but the highest drug-poisoning AADRs were observed in central metropolitan areas from 1999 to 2009. Conclusions There was substantial geographic variation in drug-poisoning mortality across the U.S.

Factors Associated With County-Level Differences in U.S. Drug-Related Mortality Rates

“…Consistent with recent research on drug overdose trends, 2,3,5 this study found significant geographic disparities, including large within-state disparities, in drug-related mortality rates. Average drug-related mortality rates were higher among counties characterized by greater economic and family distress, including rates of poverty, unemployment, disability, no college degree, public assistance, rental stress, divorce/separation, and single-parent families.…”

“…1 The economic, social, and emotional tolls of these deaths are substantial, but some parts of the U.S. are bearing heavier burdens than others. 2–5 Empirical explanations for this geographic heterogeneity are lacking. Most existing studies of drug mortality examine temporal trends rather than geographic differences, 3–7 and those that examine geographic disparities are largely descriptive, emphasizing differences in population composition (e.g., age, race) rather than the “fundamental” social determinants of health 8 known to contribute to geographic differences in other types of mortality and morbidity.…”

Increasing Disparities in Mortality by Socioeconomic Status

“…Their emphasis on a widening of the mortality difference by educational attainment and its link to drug overdoses is echoed in a recent study by Ho (21). Analyses of the geographical distribution of drug-poisoning deaths found a broad-based phenomenon with large increases in both rural and urban areas (40,41).…”

Drug use Pattern among Health Care workers

“…This result suggests the pattern of drug use in the work place may not be uniform across all work places in the US. The reason for the differences, though not examined in this study, may be based on geography or specific work place characteristics [15][16][17][18][19][20]. Since all the positive amphetamine results were found in health care workers diagnosed with ADD, it is possible, the finding may be a reflection of more people with ADD working in the health care industry compared to the general US work force.…”

“…The limitation of this study is the limited number of drugs of abuse screened by the medical center which may possibly underestimate the use of drugs of abuse such as synthetic opiates and other drugs by the medical center staffs and this study may not be generalizable to other health care facilities in the nation as several studies have reported on the geographic variation in drugs of abuse use in the US and Canada [15][16][17][18].…”