Geography of Opioids

The great good folks at the inimitable CityLab have put together a rather enlightening piece on the ways the opioid epidemic differently impacts urban and rural America. Call it The Geography of Opioids.

Despair and Demand

U.S. opioid overdose deaths reached a record high in 2017. That's common knowledge. And local leaders across the country have been scrambling to figure out what’s driving this precipitous rise of opioid mortality. That's also common knowledge. What's not commonly known are the real reasons more and more Americans are dying because of opioids. Oh, people have put forth several theories: Aggressive Big Pharma marketing... Anxiety among Baby Boomers... Catastrophic corrosion of the Rust Belt... But we're still without one overriding reason for this monumental health problem. We still don't have a single overriding solution either. We do have urban and rural disparities though. In how we die. And why. And those disparities are greater than anyone believed.

That's what Syracuse University sociologist Shannon Monnat and the Institute for New Economic Thinking (INET) says anyway. And INET should know. Especially considering the nonpartisan, nonprofit has been deep-diving into America's most pressing issues for a decade now. Monnat should know too. After all, the Associate Professor of Sociology has been expertly examining the correlates and consequences of social disadvantage along the rural/urban continuum for her entire career. Dr. Monnat's "Deaths of Despair" study was especially effective at examining the intersections of place, public policy, and health. And her theories became one of the driving forces of the opioid conversation throughout the 2016 presidential campaign.

INET's new working paper shows there also seems to be some serious misconceptions about the opioid epidemic. For instance, the modern opioid crisis isn't a disproportionately rural phenomenon. In fact, INET's study finds the notion doesn't hold up at all. Despite what the so-called experts have been claiming since the 2016 election cycle. The rash of rural opioid overdose deaths are not a byproduct of the cities' War on Drugs either. Instead, two key factors predict the rate of opioid deaths, in both rural and urban communities — economic distress and the supply of opioids.

“I really do want to push back against this cliche that addiction does not discriminate,” Monnat told CityLab. “The physiological processes that underlie addiction themselves may not discriminate, but the factors that put people in communities at higher risk are are not spatially random.”

Monnat examines county-level drug mortality rates. Two-thirds of these deaths involve heroin, fentanyl, and various prescription opiates. She focuses on non-Hispanic whites — a racial group that, as of 2016, has the highest drug mortality rate. After controlling for demographics, she finds that the highest average drug mortality rates are in large metro counties. That's also where they've been most increasing. And have been most increasing since 2000. The rates decline the further one moves away from urban areas. (In an additional analysis, she crunches the numbers on all racial groups and finds similar results.)

“You get regional levels of despair and distress that seemed to reinforce and exacerbate the problem,” she says.

Urban vs Rural

Compared to urban counties, the average rate for most rural ones was 6.2 fewer deaths per 100,000 people in the 2014 to 2016 time period. But rural counties had a larger degree of variability amongst themselves. Southwest Pennsylvania, Central Appalachia, Central Florida, and the Mountain Northwest suffered higher-than-average rates of drug mortality; New York, Virginia, Texas, and the Mississippi Delta saw below-average rates.

So what predicted this variation? Monnat’s analysis found that both economic conditions and drug supply were related to higher mortality rates. With respect to economics, characteristics like family distress, population loss, and heavy reliance on mining and service industries seemed to drive up mortality rates. And on the supply side, Monnat looked at the government data on legal opioid prescriptions in each county. She also measured exposure to fentanyl—a powerful painkiller that has been manufactured illegally and is often mixed with heroin or other types of opiates; it’s been linked to many overdose deaths in recent years. For this metric, she used state level data on law enforcement encounters in which the person tested positive for this drug.

While both economic conditions and drug supply are factors determining drug mortality, Monnat points out that economic conditions continued to be important, even after controlling for the supply side factors. This is where Monnat’s findings contradict some previous studies and support others.

“What that means is that drug mortality rates aren’t higher in economically distressed places simply because they’ve had a greater supply of opioid prescribing there,” she said. “There’s something about economic distress in and of itself that helps to explain the variation that we’re seeing across the country and the magnitude of the drug crisis.”

The Importance of Geography

How important these factors were also varied: Generally, economic distress seemed to be a stronger determinant in rural areas, whereas in urban areas, it was the supply of drugs. But the effect of these factors was not observed just within county lines. Local economies are interconnected, which means that economic downturn has ripple effects beyond county lines, and drugs travel; that mean drug mortality may also spill over.

“A lot of what’s going on here are regional effects,” she said. “You get regional levels of despair and distress that seemed to reinforce and exacerbate the problem.”

The study has limitations, of course: It gives a snapshot of the crisis over a relatively short period of time, and it can’t say much about how important these predictors are for predicting geographical disparities in opioid overdose among different racial groups. But its findings nevertheless have widespread implications for policymakers grappling with this stubborn problem. Limiting opioid prescriptions and cracking down on illicit fentanyl might be of limited effectiveness when local economic conditions are struggling. Any successful approach would have to to be multifaceted and tailored to the specific region. It would also have to focus on the correct underlying factors that make certain communities more susceptible to this epidemic.

“It's no coincidence that widespread opioid prescribing first started in the most economically vulnerable places of the country—there was vulnerability there,” Monnat said. “These places had been primed to be vulnerable to opioids, which are drugs that numb both physical and mental pain, through decades of economic and social decline.”

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