Assessing County-Level Vulnerability for Opioid Overdose and Rapid Spread of Human Immunodeficiency Virus and Hepatitis C Infection in South Dakota

Disentangling opioids-related overdose syndemics: a scoping review

This article reviews research investigating the synergistic interaction of opioid-related morbidity and mortality with other social, psychiatric, and biological conditions, to describe how and why it is syndemic. Opioid-related overdose syndemics are driven by commercial interests, emerging in communities facing social and economic disadvantage, and interacting with a range of other health conditions. We included articles that empirically investigated an opioid-related syndemic, discussed syndemic co-factors associated with opioid use, or framed opioid consumption conceptually in relation to syndemics. Most articles were conducted in and first authored by investigators from North America. These articles were published in journals focused on general public health (n = 20), drug use and addiction (n = 18), and infectious disease or HIV (n = 15). Most original research articles (n = 60) employed quantitative methods. Unlike scholarship from other disciplines, specifically the controversial "Deaths of Despair" (DoD) framework, most research on opioid-related overdose syndemics fails to fully articulate the macro-structural drivers of localized disease clustering. Instead, the syndemics scholarship emphasizes the clinical manifestations of opioid and substance use, illustrating a problem in translation at the heart of syndemic theory. Moreover, syndemics scholarship on opioid impacts remains largely disconnected from the wider DoD discourse, which represents a missed opportunity for equity-oriented research. Re-directing attention to the sociopolitical forces that shape opioid-related overdose syndemics is necessary to prevent future commercially-driven health crises and repair lives harmed by these deadly syndemics.

Methods for jurisdictional vulnerability assessment of opioid-related outcomes

In 2020, an estimated 2.7 million people in the US had opioid use disorder, increasing their risk of opioid-related morbidity and mortality. While jurisdictional vulnerability assessments (JVA) of opioid-related outcomes have been conducted previously in the US, there has been no unifying methodological framework. Between 2019 and 2021, we prepared ten JVAs, in collaboration with the Council of State and Territorial Epidemiologists, the Centers for Disease Control and Prevention, and state public health agencies, to evaluate the risk for opioid-involved overdose (OOD) fatalities and related consequences. Our aim is to share the framework we developed for these ten JVAs, based on our study of the work of Van Handel et al. from 2016, as well as a summary of 18 publicly available assessments of OOD or associated hepatitis C virus infection vulnerability. We developed a three-tiered framework that can be applied by jurisdictions based on the number of units of analysis (e.g., counties, ZIP Codes, census tracts): under 10 (Tier 1), 10 to <50 (Tier 2), and 50 or more (Tier 3). We calculated OOD vulnerability indices based on variable ranks, weighted variable ranks, or multivariable regressions, respectively, for the three tiers. We developed thematic maps, conducted spatial analyses, and visualized service provider locations, drive-time service areas, and service accessibility relative to OOD risk. The methodological framework and examples of our findings from several jurisdictions can be used as a foundation for future assessments and help inform policies to mitigate the impact of the opioid overdose crisis.

A Vulnerability Assessment for a Future HIV Outbreak Associated With Injection Drug Use in Illinois, 2017-2018

The current opioid crisis and the increase in injection drug use (IDU) have led to outbreaks of HIV in communities across the country. These outbreaks have prompted country and statewide examination into identifying factors to determine areas at risk of a future HIV outbreak. Based on methodology used in a prior nationwide county-level analysis by the US Centers for Disease Control and Prevention (CDC), we examined Illinois at the ZIP code level (n = 1,383). Combined acute and chronic hepatitis C virus (HCV) infection among persons <40 years of age was used as an outcome proxy measure for IDU. Local and statewide data sources were used to identify variables that are potentially predictive of high risk for HIV/HCV transmission that fell within three main groups: health outcomes, access/resources, and the social/economic/physical environment. A multivariable negative binomial regression was performed with population as an offset. The vulnerability score for each ZIP code was created using the final regression model that consisted of 11 factors, six risk factors, and five protective factors. ZIP codes identified with the highest vulnerability ranking (top 10%) were distributed across the state yet focused in the rural southern region. The most populous county, Cook County, had only one vulnerable ZIP code. This analysis reveals more areas vulnerable to future outbreaks compared to past national analyses and provides more precise indications of vulnerability at the ZIP code level. The ability to assess the risk at sub-county level allows local jurisdictions to more finely tune surveillance and preventive measures and target activities in these high-risk areas. The final model contained a mix of protective and risk factors revealing a heightened level of complexity underlying the relationship between characteristics that impact HCV risk. Following this analysis, Illinois prioritized recommendations to include increasing access to harm reduction services, specifically sterile syringe services, naloxone access, infectious disease screening and increased linkage to care for HCV and opioid use disorder.