While the epidemic has been framed as one that mostly affects rural America, new research shows that overdose rates are actually higher in urban areas.
The common narrative of the national opioid crisis has been that this “disease of despair” has affected rural areas the most.
However, a new working paper argues that economic depression and access to opioids are the biggest determinants of overdose rates in both rural and urban areas.
“I really do want to push back against this cliche that addiction does not discriminate,” Shannon Monnat, the paper’s author and a sociologist at Syracuse University, told Pacific Standard. “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.”
Looking at non-Hispanic whites and controlling for demographics, Monnat found that overdose rates were highest in urban areas. The rate decreased the further one moved from cities, a trend that held true for all racial groups. Overall, urban counties had an average of 6.2 more deaths per 100,000 people than rural counties.
Interestingly, supply and demand interacted differently in rural and urban settings. In the city, supply of drugs seemed to have the biggest effect on overdose rates. In rural areas, economic distress was the stronger predictor of overdose rates.
“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.”
Monnat did find that some of the things associated with rural living were connected with an increased risk for overdose. For example, areas with an economy heavily dependent on mining or the service industries had higher rates of overdose. Controlling for how many drugs were supplied to an area, places with higher economic distress had higher overdose rates.
“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.”
Places hardest hit by the crisis, like West Virginia, had both economic vulnerabilities and an excessive supply of opioids, Monnat said.
“It’s no coincidence that widespread opioid prescribing first started in the most economically vulnerable places of the country—there was vulnerability there. 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.”