The opioid epidemic: a geography in two phases

ABSTRACT

The United States has been experiencing a drug overdose mortality epidemic marked by the introduction and spread of opioids across rural and urban communities over the past 20 years. The current Coronavirus (COVID-19) pandemic has overshadowed the opioid epidemic but aggravated the opioid problem by hindering access to health services and increasing the number of people out of work. Research on the geography of the opioid epidemic has focused on the association between declining local economic opportunities and increases in drug overdose mortality since 2000, but the link has not always been strong. This study identifies two phases comprising the epidemic and examines their differing demographic and geographic natures. Results show that in the first phase, beginning around 2000 and ending in the early 2010s, drug overdose mortality rates soared among the middle aged as prescription opioid painkillers drove the epidemic. Physical disability is associated with chronic pain, and during this period, drug overdose deaths rose most in areas with high physical disability rates. The researchers found little evidence that the aggravation of local economic problems was associated with increases in drug overdose mortality in the 2000s. Since the early 2010s, opioid drug reformulation and declining prescription rates have resulted in ebbing mortality from prescription opioids. At the same time, illicit opioids such as heroin and, increasingly, fentanyl and related synthetic opioids rapidly entered the scene-causing a growing share of drug overdose deaths, marking the beginning of what the researchers call the illicit opioid phase of the epidemic. In this phase, drug overdose mortality has risen, particularly among young adult males, and its geography has shifted markedly. Physical disability seems less a factor in rising drug overdose mortality than local (county) economic hardship and outmigration in the northeastern quadrant of the United States, where the marketing of these drugs currently appears most developed.