Geographical Aspects of Recent Trends in Drug-Related Deaths, with a Focus on Intra-National Contextual Variation

Social and economic determinants of drug overdose deaths: a systematic review of spatial relationships

PURPOSE

To synthesize the available evidence on the extent to which area-level socioeconomic conditions are associated with drug overdose deaths in the United States.

METHODS

We performed a systematic review (in MEDLINE, EMBASE, PsychINFO, Web of Science, EconLit) for papers published prior to July 2022. Eligible studies quantitatively estimated the association between an area-level measure of socioeconomic conditions and drug overdose deaths in the US, and were published in English. We assessed study quality using the Effective Public Health Practice Project Quality Assessment Tool. The protocol was preregistered at Prospero (CRD42019121317).

RESULTS

We identified 28 studies that estimated area-level effects of socioeconomic conditions on drug overdose deaths in the US. Studies were scored as having moderate to serious risk of bias attributed to both confounding and in analysis. Socioeconomic conditions and drug overdose death rates were moderately associated, and this was a consistent finding across a large number of measures and differences in study designs (e.g., cross-sectional versus longitudinal), years of data analyzed, and primary unit of analysis (e.g., ZIP code, county, state).

CONCLUSIONS

This review highlights the evidence for area-level socioeconomic conditions are an important factor underlying the geospatial distribution of drug overdose deaths in the US and the need to understand the mechanisms underlying these associations to inform future policy recommendations. The current evidence base suggests that, at least in the United States, employment, income, and poverty interventions may be effective targets for preventing drug overdose mortality rates.

Use of tobacco and other illicit drugs among adolescent boys and young men in Kampala, Uganda: A result of low parental attention?

INTRODUCTION

Although the use of illicit drugs is common among young people, limited data exists on the use of illicit drugs among adolescent boys and young men (ABYM). We assessed the use of tobacco, marijuana and khat among ABYM to inform the design of harm-reduction interventions.

METHODS

This secondary analysis uses data from a formative study conducted among 2,500 ABYM across the five divisions of Kampala between July and August 2020. Survey questions were adopted from the Global Youth Tobacco Survey and Global School-based Student Health Survey. We computed proportions of ABYM that had ever used any form of tobacco or marijuana or khat in the past year and the proportion that had used any of these products in the past 30 days (i.e. 'current users'). In a sub-group analysis, we assessed if any patterns existed between ABYM's use of illicit drugs and selected parental attention attributes.

RESULTS

Of 2,500 ABYM, 47.3% (n = 1,182) were aged 15-19 years. Overall, 16.4% (n = 410) reported past-year use of tobacco products while 11.6% (n = 289) and 10.5% (n = 263) reported past-year use of marijuana and khat, respectively. Current use of any illicit drugs was higher among past-year khat (46%, n = 133) and marijuana users (36.9%, n = 97) than past-year tobacco users (4%, n = 17). Current use of any illicit drugs was higher among out-of-school than in-school ABYM and increased with increasing age and education levels. However, parental attention was lower among out-of-school than in-school ABYM and decreased with increasing age and education levels.

CONCLUSION

Use of illicit drugs is common among ABYM and increased with age and education levels but parental attention among current illicit drug users decreased with increasing age and education levels. These findings suggest that interventions intended to improve parental attention among illicit drug users may help to reduce the prevalence of illicit drug use among ABYM.

Social vulnerability predictors of drug poisoning mortality: A machine learning analysis in the United States

BACKGROUND AND OBJECTIVES

Drug poisoning is a leading cause of unintentional deaths in the United States. Despite the growing literature, there are a few recent analyses of a wide range of community-level social vulnerability features contributing to drug poisoning mortality. Current studies on this topic face three limitations: often studying a limited subset of vulnerability features, focusing on small sample sizes, or solely including local data. To address this gap, we conducted a national-level analysis to study the impacts of several social vulnerability features in predicting drug mortality rates in the United States.

METHODS

We used machine learning to investigate the role of 16 social vulnerability features in predicting drug mortality rates for US counties in 2014, 2016, and 2018-the most recent available data. We estimated each vulnerability feature's gain relative contribution in predicting drug poisoning mortality.

RESULTS

Among all social vulnerability features, the percentage of noninstitutionalized persons with a disability is the most influential predictor, with a gain relative contribution of 18.6%, followed by population density and the percentage of minority residents (13.3% and 13%, respectively). Percentages of households with no available vehicles, mobile homes, and persons without a high school diploma are the following features with gain relative contributions of 6.3%, 5.8%, and 5.1%, respectively.

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

We identified social vulnerability features that are most predictive of drug poisoning mortality. Public health interventions and policies targeting vulnerable communities may increase the resilience of these communities and mitigate the overdose death and drug misuse crisis.

"All carrots and no stick": Perceived impacts, changes in practices, and attitudes among law enforcement following drug decriminalization in Oregon State, USA

BACKGROUND

By passing Ballot Measure 110 (BM 110), Oregon became the first U.S. state to decriminalize noncommercial possession of drugs that are illegal under the Controlled Substances Act. This study examined the perceived impacts of BM 110 on law enforcement and Oregon communities.

METHODS

Our team visited four geographically distinct Oregon counties in August 2022 (two urban, two rural). The qualitative study involved conducting 34 hour-long interviews with law enforcement, other criminal legal system personnel, and representatives from emergency medical services/fire and substance use treatment and harm reduction agencies. Interviewees were asked about their perceptions of BM 110's effects on law enforcement, their communities, and agencies.

RESULTS

Law enforcement interviewees viewed BM 110 as a failure; they perceived it resulted in an erosion of their authority. They expressed frustration that they could not use drug possession as a "tool" for investigations to pursue and build cases, establish probable cause, and impose what they believed necessary for social order. Law enforcement personnel in all four counties indicated they routinely seized drugs and drug paraphernalia during encounters with people using drugs, even when that was the only offense being committed. Police lacked knowledge that BM 110 included support for harm reduction services, housing assistance, and employment support. Law enforcement personnel had different opinions and practices regarding issuing Class E violations; those who did not issue them viewed them as a waste of time because they are not entry points into the criminal legal system.

CONCLUSION

This study provides insights into drug decriminalization in Oregon. This examination is critical for informing BM 110's continued implementation as Oregon proceeds with increased treatment and support service provision. Our findings have important implications regarding other states' design and implementation of drug policy alternatives, including ones that remove law enforcement's role in addressing drug use.

Understanding the differential effect of local socio-economic conditions on the relation between prescription opioid supply and drug overdose deaths in US counties

BACKGROUND AND AIMS

Both local socio-economic conditions and prescription opioid supply are associated with drug overdose deaths, which exhibit substantial geographical heterogeneity across the United States. We measured whether the associations of prescription opioid supply with drug overdose deaths vary by local socio-economic conditions.

DESIGN

Ecological county-level study, including 3109 US counties between 2006 and 2019 (n = 43 526 county-years) using annual mortality data.

SETTING

United States.

CASES

A total of 711 447 drug overdose deaths.

MEASUREMENTS

We modeled overdose counts using Bayesian hierarchical Poisson models, estimating associations between four types of drug overdose deaths (deaths involving any drugs, any opioid, prescription opioids only and heroin), prescription opioid supply and five socio-economic indicators: unemployment, poverty rate, income inequality, Rey index (components include mean household income, % high school graduates, % blue-collar workers and unemployment rate), and American human development index (HDI; an indicator of community wellbeing).

FINDINGS

Drug overdose deaths and all substance-specific overdose deaths were higher in counties with higher income inequality [adjusted odds ratios (aORs) = 1.09-1.13], Rey index (aORs = 1.15-1.21) and prescription opioid supply (aORs = 1.14-1.21), and lower in counties with higher HDI scores (aORs = 0.75-0.92). Poverty rate, income inequality and HDI scores were found to modify the effect of prescription opioid supply on heroin overdose deaths. The plot of the interactions showed that when disadvantage is high, increasing prescription opioid supply does not increase heroin overdose deaths. The less disadvantage there is, indicated by lower poverty rates, higher HDI scores and lower income inequality, the greater the effect of increasing prescription opioid supply relative to population size on heroin overdose deaths in US counties.

CONCLUSIONS

In the United States, prescription opioid supply is associated with higher drug overdose deaths; associations are stronger in counties with less disadvantage and less income inequality, but only for heroin overdose deaths.

Associations between Circumstances Surrounding Overdose and Underlying Classes of Polysubstance Overdose Deaths

BACKGROUND

The overdose crisis is worsening, with polysubstance overdose deaths involving psychostimulants increasing in the U.S. Substance-specific prevention and intervention activities may not be as effective for polysubstance use, so we sought to classify substances used among overdose decedents to identify unique factors related to these classes.

METHODS

We used data from the Nevada State Unintentional Drug Overdose Reporting System, Jan 2019-Jun 2021, which comes from death certificates, coroner/medical examiner reports, and postmortem toxicology. Latent class analysis, multinomial logistic regression, and Chi-squared tests determined underlying drug use classes, differences in characteristics and circumstances surrounding overdose, and assessed relationships between circumstances and drug use classes.

RESULTS

We identified four latent classes: (1) prescription drugs (19.1%), (2) predominately methamphetamine (31.4%), (3) multi-drug (28.9%), and (4) opioid and stimulant (20.6%). Compared to other classes, the prescription drug class had a higher percentage of female decedents, from rural counties, with mental health diagnoses, who died at home. The predominately methamphetamine class had a higher percentage of decedents experiencing homelessness. The multi-drug use class had higher percentage of younger and Hispanic decedents. Those in the opioid and stimulant class had higher odds of being recently released from an institutional setting, compared to the multi drug class.

CONCLUSIONS

These underlying classes were associated with several characteristics and circumstances that can prove useful for prevention, treatment, and harm reduction agencies when designing programs and interventions to target specific groups of people at-risk for drug overdose.

County-level predictors of US drug overdose mortality: A systematic review

BACKGROUND

This systematic review summarized published literature on county-level predictors of drug overdose mortality in the United States (US).

METHODS

Peer-reviewed studies and doctoral dissertations published in English between 1990 and July 19, 2022 were identified from PubMed, Web of Science, ProQuest Dissertations & Theses, PsycINFO, CINAHL, and EconLit. Eligible studies examined at least one county-level predictor of drug overdose mortality in US counties. Two reviewers independently completed screening, quality assessment (with an adapted National Institutes of Health Quality Assessment Tool), and data extraction. Results were qualitatively summarized and grouped by predictor categories.

RESULTS

Of 56 studies included, 42.9% were subnational, and 53.6% were limited to opioid overdose. In multiple studies, measures related to opioid prescribing, illness/disability, economic distress, mining employment, incarceration, family distress, and single-parent families were positively associated with drug overdose mortality outcomes, while measures related to cannabis dispensaries, substance use treatment, social capital, and family households were negatively associated with drug overdose mortality outcomes. Both positive and negative associations were documented for smoking, uninsurance, healthcare professional shortage status, physicians per capita, unemployment, income, poverty, educational attainment, racial composition, and rurality. Findings within studies also differed by subpopulation (by race/ethnicity, gender, age, or rurality) and the type of drugs involved in overdose.

CONCLUSIONS

The findings of this review provide relatively mixed evidence regarding many county-level predictors of overdose mortality, several of which also vary between subpopulations, supporting the importance of additional research to elucidate pathways through which the county context may shape risk of fatal overdose.

Association between law enforcement seizures of illicit drugs and drug overdose deaths involving cocaine and methamphetamine, Ohio, 2014-2019

BACKGROUND

The United States continues to experience a crisis of mounting opioid overdose deaths involving cocaine and methamphetamine (hereafter illicit stimulants). Law enforcement drug seizure data present a unique opportunity to examine the association between illicit-stimulant-involved overdose deaths (ISODs) and the illicit drug supply. Our objective is to better understand correlations between illicit drug market trends and increases in ISODs in Ohio in 2014-2019.

METHODS

This observational study analyzes the universe of ISODs and drug seizures in Ohio from 2014 to 2019. We use graphs and descriptive statistics to characterize trends over time and estimate a time series model of their association. ISODs were summed to yield monthly statewide counts of seizures containing methamphetamine, cocaine, illicitly manufactured fentanyl (IMF), and other non-IMF opioids (e.g., heroin). All rates were calculated per 100,000 persons.

RESULTS

Roughly 80% of ISODs in Ohio from 2014 to 2019 involved an opioid, with IMF co-occurring in 90% of ISODs by 2019. Methamphetamine and cocaine seizures containing IMF were associated with 0.439 (p < .01) and 0.457 (p < .01) additional deaths per 100,000 persons per month, respectively. IMF seizures not containing cocaine nor methamphetamine were also associated with additional ISODs (0.119, p < .01) and seizures of illicit stimulants not containing IMF were not associated with ISODs.

CONCLUSIONS

The number of ISODs was extremely high when IMF was co-involved and relatively low without IMF involvement. By demonstrating how supply-side trends correspond with ISOD rates, the current study bolsters the analytical utility of law enforcement seizures and complements growing literature in the field.

Preventing Pediatric Chronic Postsurgical Pain: Time for Increased Rigor

Chronic postsurgical pain (CPSP) results from a cascade of events in the peripheral and central nervous systems following surgery. Several clinical predictors, including the prior pain state, premorbid psychological state (e.g., anxiety, catastrophizing), intraoperative surgical load (establishment of peripheral and central sensitization), and acute postoperative pain management, may contribute to the patient’s risk of developing CPSP. However, research on the neurobiological and biobehavioral mechanisms contributing to pediatric CPSP and effective preemptive/treatment strategies are still lacking. Here we evaluate the perisurgical process by identifying key problems and propose potential solutions for the pre-, intra-, and postoperative pain states to both prevent and manage the transition of acute to chronic pain. We propose an eight-step process involving preemptive and preventative analgesia, behavioral interventions, and the use of biomarkers (brain-based, inflammatory, or genetic) to facilitate timely evaluation and treatment of premorbid psychological factors, ongoing surgical pain, and postoperative pain to provide an overall improved outcome. By achieving this, we can begin to establish personalized precision medicine for children and adolescents presenting to surgery and subsequent treatment selection.