Drug Overdose Mortality of Residents and Visitors to Cities

Abstract

Background: The ongoing drug epidemic in the United States has shown that there are geographic differences in overdose fatalities. This article introduces a new way to study spatial differences in drug-related mortality, by distinguishing the fatalities of residents and visitors to a region. Methods: Using records of United States deaths from 2001 to 2020, this study examined fatal overdoses among residents and visitors to U.S. metropolitan areas. Results: The findings revealed that the drug fatality levels of residents and visitors differed from one another in many cities. These differences were most pronounced in larger metro areas, where the drug mortality of visitors was disproportionately high. Conclusions: Discussion focuses on implications and possible explanations for these findings, as well as their potential connection to classical conditioning of drug tolerance. More generally, comparing the fatalities of residents and visitors may provide a way to tease apart the roles of person-specific and location-specific contributors to overdose risk.

Keywords:

• Drug overdose
• mortality
• metropolitan areas
• drugs

Declaration of interest

The authors report there are no competing interests to declare.

Notes

1 Importantly, the PMR value for residents of a metro area was independent of the overall size of its Census population, because the PMRs were based on the proportion of all deaths that were due to drug poisoning.

2 Relative to the PMRs for all poisonings (in Table 1), the PMRs for the different drug types (in Table 4) were slightly inflated, and this inflation was very likely the result of a coding bias between urban and rural regions. Specifically, previous research has found that medical examiners (or coroners) in more rural areas are less likely to detect the specific drugs that led to an overdose, relative to medical examiners in larger cities (Dasgupta et al., 2008; Peters et al., 2020). As a result, deaths occurring in cities tend to list a greater number of T-codes on the death certificate, thereby producing inflated values for drug-specific PMRs in urban (vs. rural) areas. Thus, the absolute PMR value (how far each PMR value deviated from the null 100 value) for each drug type should be interpreted with caution, and are not directly comparable to the PMRs we reported in other sections of this paper.

Importantly, however, these resident and visitor groups were all processed by medical examiners inside the same 10 cities. Therefore, it is reasonable to make inferences in this section based on the disparity between resident PMR and visitor PMR for each drug type—the comparison between each pair was informative about which of the two groups had a higher fatality burden when a particular kind of drug was involved.

3 One salient event that overlapped with the study period was the coronavirus pandemic, which begin early in 2020. The pandemic may have influenced travel to larger cities relative to smaller cities, in ways that could have affected the proportion of visitors who died of drug overdose in specific areas. To examine whether our results were different when excluding the year 2020 from our analysis, we calculated the PMRs for all drug overdoses in the ten largest cities (like those reported in Table 1) but for the period of 2001-2019. The results for this 19-year period found the PMR for residents at home to be 101.9, while for visitors to these cities the PMR was 142.3. The PMRs for the 20-year period (reported in Table 1) were 101.8 and 142.9, respectively. Thus, excluding the year 2020 did not change these findings much.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.