Why Do Deaths from Drugs Like Oxycodone Occur in Different Neighborhoods than Deaths from Heroin?
Magdalena Cerdá, PhD, MPH, is an assistant professor of epidemiology at the Columbia University Mailman School of Public Health and an alumna of the Robert Wood Johnson Foundation Health & Society Scholars program.
Rates of fatal overdoses caused by analgesic opioids (i.e. opiate-based painkillers) have increased dramatically in the United States over the past five years. The prevalence of nonmedical analgesic drug abuse (i.e. use for recreational or self-treatment purposes without a prescription, or using more medication than prescribed by a physician) is second only to that of marijuana abuse, and currently the number of fatal analgesic overdoses is greater than the number of heroin and cocaine overdoses combined. While research until now has focused on the role of individual characteristics, there is an increasing realization that neighborhoods also play an important role in shaping substance abuse.
In New York City, we found a geographic pattern to deaths from analgesic overdose. Fatal analgesic overdose, including the painkillers oxycodone and codeine, was more concentrated in economically disadvantaged neighborhoods with a prevalence of high divorce, single-parent homes than deaths from unintentional causes. Yet, compared to heroin overdose deaths, analgesic overdoses occurred in higher-income neighborhoods. This study is among the first to provide a framework that helps explain the geographical distribution of analgesic overdose in urban areas. The results were published in the December issue of the American Journal of Public Health.
We used a case-control study to obtain these findings. Using data from the Office of the Chief Medical Examiner of New York City, we compared 447 unintentional analgesic opioid overdose fatalities with 3,436 unintentional non-overdose fatalities and with 2,530 heroin overdose fatalities occurring in 59 New York City neighborhoods between 2000 and 2006. The non-overdose accidental deaths included instances like drownings, poisonings, falls, and other accidents.
We found that analgesic overdose deaths were almost one-and-a-quarter times less likely to occur in higher-income neighborhoods compared to non-overdose accidental deaths. They were also more than one-and–a-quarter times more likely to occur in neighborhoods with a higher prevalence of divorced and single-parent homes than non-overdose fatalities. These findings are consistent with studies on the neighborhood drivers of illegal drug overdose. In neighborhoods with a higher concentration of fragmented families, there may be greater opportunity for diversion and trafficking of analgesics obtained from legitimate prescription users.
Notably however, analgesic overdose fatalities occurred in different neighborhoods from heroin overdose fatalities. Analgesic overdose deaths were nearly one-and-a-half times more likely to occur in higher-income neighborhoods than deaths from heroin overdose, and more than one–and-a-quarter times more likely to occur in neighborhoods with less divorce and single-parent homes than heroin fatalities.
Why would analgesic overdose occur in different neighborhoods from heroin overdose? We have several hypotheses. First, pharmacies and physicians, which are the supply base to access analgesics, are more concentrated in higher-income neighborhoods. Second, a certain level of family cohesion may facilitate the diversion of analgesics from prescribed users to recreational users. Price also probably plays a role: the lower price of heroin relative to analgesics may create a disincentive to consume analgesics in lower-income neighborhoods.
These are all hypotheses, however. Given the increasing rates of analgesic overdose fatalities and the systematic distribution of overdose risk across urban neighborhoods, we need research to identify the particular neighborhood mechanisms that may distinguish the risk of analgesic overdose from that of illicit drug overdose. This will be the first step to designing effective, local programs to prevent deaths from analgesic overdose in urban neighborhoods.
At the same time, the health care system plays an important role in preventing analgesic overdose fatalities. In New York City, a series of localized interventions are being implemented to reduce deaths from prescription drug abuse. Interventions include collaboration between public health and public safety to conduct enhanced surveillance of mortality, morbidity, prescribing, crime and diversion data; legislation to require providers to check for use of controlled substances in the past six months when prescribing more controlled substances; establishing prescription standards and training providers to balance pain treatment with reducing opioid analgesic misuse; and investment in overdose prevention programs that increase naloxone dispensation to reduce fatalities from analgesic overdose.
Intersectoral collaboration is key to preventing more deaths from analgesic overdose: a combination of public health and public safety interventions will provide the way forward to reduce this important public health problem.
Funding for the study was provided by the National Institutes of Health (grants 1K01DA030449- 01, DA06534, and 1 R49 CE002096-01)