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

Recent worldwide estimates are of 53 million users of opioids annually, and of 585,000 drug-related deaths, of which two thirds are due to opioids. There are considerable international differences in levels of drug death rates and substance abuse. However, there are also considerable variations within countries in drug misuse, overdose rates, and in drug death rates particularly. Wide intra-national variations characterize countries where drug deaths have risen fastest in recent years, such as the US and UK. Drug deaths are an outcome of drug misuse, which can ideally be studied at a relatively low spatial scale (e.g., US counties). The research literature suggests that small area variations in drug deaths to a considerable degree reflect contextual (place-related) factors as well as individual risk factors. We consider the role of area social status, social cohesion, segregation, urbanicity, and drug supply in an ecological regression analysis of county differences in drug deaths in the US during 2015-2017. The analysis of US small area data highlights a range of factors which are statistically significant in explaining differences in drug deaths, but with no risk factor having a predominant role. Comparisons with other countries where small area drug mortality data have been analyzed show differences between countries in the impact of different contextual factors, but some common themes. Intra-national differences in drug-related deaths are considerable, but there are significant research gaps in the evidence base for small area analysis of such deaths.