Revisiting the Role of the Urban Environment in Substance Use: The Case of Analgesic Overdose Fatalities

Objectives. We examined whether neighborhood social characteristics (income distribution and family fragmentation) and physical characteristics (clean sidewalks and dilapidated housing) were associated with the risk of fatalities caused by analgesic overdose.Methods. In a case-control study, we compared 447 unintentional analgesic opioid overdose fatalities (cases) with 3436 unintentional nonoverdose fatalities and 2530 heroin overdose fatalities (controls) occurring in 59 New York City neighborhoods between 2000 and 2006.Results. Analgesic overdose fatalities were less likely than nonoverdose unintentional fatalities to have occurred in higher-income neighborhoods (odds ratio [OR] = 0.82; 95% confidence interval [CI] = 0.70, 0.96) and more likely to have occurred in fragmented neighborhoods (OR = 1.35; 95% CI = 1.05, 1.72). They were more likely than heroin overdose fatalities to have occurred in higher-income (OR = 1.31; 95% CI = 1.12, 1.54) and less fragmented (OR = 0.71; 95% CI = 0.55, 0.92) neighborhoods.Conclusions. Analgesic overdose fatalities exhibit spatial patterns that are distinct from those of heroin and nonoverdose unintentional fatalities. Whereas analgesic fatalities typically occur in lower-income, more fragmented neighborhoods than nonoverdose fatalities, they tend to occur in higher-income, less unequal, and less fragmented neighborhoods than heroin fatalities.Rates of fatal overdoses caused by analgesic opioids have increased dramatically in the United States, particularly over the past 5 years.1–3 The prevalence of nonmedical analgesic drug abuse is second only to that of marijuana abuse, and currently the number of fatal overdoses attributed to opioid analgesics, such as oxycodone, hydrocodone, and codeine, is greater than the number attributed to heroin and cocaine combined.4Urban areas have long been associated with elevated risks of substance abuse and subsequent mortality from unintentional drug poisoning. From 1997 to 2002, the number of overdose deaths involving opioid analgesics increased 97% in urban areas during a time when the rate of overdose from all drugs increased 27%.5 From a public health burden standpoint, understanding the determinants of analgesic overdose mortality in large urban areas is critical to help stem the tide of mortality from analgesics, as all available data suggest that analgesic overdose mortality in these areas will continue to increase in the coming years.6Extant epidemiological research in the area has predominantly been concerned with the role of individual characteristics in explaining the prevalence of analgesic overdose throughout the United States.5,7–12 Analgesic opiate overdose decedents have been reported to be primarily White, male, and adult (ranging in age from 25 to 54 years) and to exhibit a high prevalence of concurrent psychotherapeutic drug use.5,7–10 However, several organizing frameworks in the field (principally rooted in ecosocial theory) suggest that environments operate jointly with individual factors to influence the risk of substance use.13–15In addition to individual characteristics such as psychiatric morbidity, genetic vulnerability, gender, and age,16–20 these frameworks suggest that interconnected components of influence shape drug use. These components include social policies and regulations that affect the allocation of social and health resources21–26; social and physical features of the neighborhood environment that structure the availability of drugs, influence norms around use, and generate sources of stress that contribute to drug use13,14,27–37; and interpersonal characteristics, such as social support and social networks, that mediate the relationship between the neighborhood environment and drug use.28,31,38–42 Despite this conceptual orientation, few studies have attempted to provide an understanding of the contextual factors that may explain the geographic distribution of analgesic overdose in an urban environment.Of particular interest in the urban context are the features of neighborhoods that can shape drug overdose. Established conceptual frameworks suggest 2 such features: primary determinants of infrastructure, employment, education, and health care resources, including residential segregation, income distribution, and neighborhood deprivation, and secondary determinants that are consequences of these fundamental conditions and may mediate their impact on drug use, including the quality of the built environment, social norms around drug use, and family fragmentation.15 Drawing on this framework, we examined 3 features of the neighborhood environment that have been previously linked with drug overdose: income distribution, quality of the built environment, and family fragmentation.35,37,43,44First, neighborhood income distribution has been consistently linked to drug abuse or overdose fatalities.27,35,44,45 For example, research has shown that in New York City neighborhoods with more unequal income distributions, drug overdoses are more likely than other causes to lead to unintentional deaths.35,44 The erosion of social capital and greater mistrust of authority found in more unequal neighborhoods may lead to a greater reluctance to seek medical help in cases of overdose.46 Furthermore, underinvestment in health and social resources could contribute to longer response times on the part of paramedics and limited access to substance abuse treatment. It is plausible that these same processes may drive a higher risk for analgesic opiate overdose in more unequal neighborhoods.Second, studies have shown a positive association between poor quality of the built environment (dilapidated buildings, vandalism of public property, and littering) and risk of drug overdose.43,44,46 Deterioration of the built environment has been linked with higher levels of distress.47 In turn, people with higher levels of distress may be more vulnerable to drug abuse and overdose than people low in distress.48,49 Moreover, reduced social capital reflected in a vandalized and littered built environment may discourage neighborhood residents from interacting with each other and from developing relationships that would enable to them to intervene to prevent the development of drug distribution networks in the neighborhood.50Third, family fragmentation (e.g., a high prevalence of divorced, separated, or single-parent families) represents a social mechanism through which neighborhoods may influence analgesic overdose. Disruption of the neighborhood social fabric may manifest in personal forms of disorganization within adult relationships.51,52 Studies of crime have shown that family disruption influences the collective ability of local residents to promote adult and youth conformity to local norms and laws.53–55 A high prevalence of fragmented families in a neighborhood reduces the neighborhood’s ability to monitor young people and respond to delinquency and crime.56 Such disorganization may have direct consequences in terms of access to and consumption of analgesics, given that the formation of drug-selling and drug-consuming networks may be more likely in neighborhoods where residents do not monitor delinquent activity consistently.57Furthermore, disrupted families may be less likely to exert informal control over the abuse of analgesics by other family members.57 Given that consumption of analgesics occurs most frequently at home,58 the absence of a family support and control net is particularly problematic.This study had 2 aims. First, we examined the roles that the 3 features of the neighborhood social and physical environment just described—income distribution, the quality of the built environment, and family fragmentation—play in the risk of unintentional death from analgesic overdose in New York City. Second, we examined whether analgesic opiate overdoses in New York City are driven by distinct neighborhood factors than heroin overdose, the historically most prevalent form of illicit opiate overdose in urban areas.59,60     

Community Socioeconomic Disadvantage and the Survival of Infants With Congenital Heart Defects

Objectives. We examined the association between survival of infants with severe congenital heart defects (CHDs) and community-level indicators of socioeconomic status.Methods. We identified infants born to residents of Arizona, New Jersey, New York, and Texas between 1999 and 2007 with selected CHDs from 4 population-based, statewide birth defect surveillance programs. We linked data to the 2000 US Census to obtain 11 census tract–level socioeconomic indicators. We estimated survival probabilities and hazard ratios adjusted for individual characteristics.Results. We observed differences in infant survival for 8 community socioeconomic indicators (P < .05). The greatest mortality risk was associated with residing in communities in the most disadvantaged deciles for poverty (adjusted hazard ratio [AHR] = 1.49; 95% confidence interval [CI]  = 1.11, 1.99), education (AHR = 1.51; 95% CI = 1.16, 1.96), and operator or laborer occupations (AHR = 1.54; 95% CI = 1.16, 1.96). Survival decreased with increasing numbers of indicators that were in the most disadvantaged decile. Community-level mortality risk persisted when we adjusted for individual-level characteristics.Conclusions. The increased mortality risk among infants with CHDs living in socioeconomically deprived communities might indicate barriers to quality and timely care at which public health interventions might be targeted.Advances in medical and surgical care for individuals born with congenital heart defects (CHDs) has improved survival in recent years, yet despite this progress, mortality due to CHDs remains a significant public health issue.1,2 CHDs are the most common type of birth defect and are the leading cause of death among those born with birth defects.3,4 CHDs necessitate medical and often surgical intervention early in life, and timely detection and quality care can improve health outcomes.5,6 Medical factors such as low birth weight, preterm birth, severity of the condition, and the presence of comorbidities are well-established risk factors for mortality, particularly during the neonatal period.7 Nonmedical factors (particularly race/ethnicity) also play an important role in the survival of infants with birth defects and potentially contribute significantly to unexplained survival differences.8 Several factors that influence access to and use of care have been examined among cohorts of infants born with CHDs, but these have been limited to race/ethnicity,2,9–16 medical insurance,9,16–20 and distance to specialty care.10,17,21,22 Assessment of the potential impact of socioeconomic status (SES) on survival has been challenging, largely because SES has been defined and measured in many ways and is often unavailable in large, population-based data sets. SES has been investigated as a risk factor for the occurrence of different types of birth defects,23–28 but few published population-based studies have included SES as a risk factor for CHD-related mortality.Community-level factors related to socioeconomic conditions have been associated with decreased access to pediatric subspecialty care and early mortality of infants with low birth weight,29,30 and they might provide evidence of contextual factors that could potentially influence the survival of infants with CHDs, who require timely medical intervention.31–33 In this population-based study, we estimated the association of census tract–level indicators of SES with the survival of infants born with CHDs and examined the potential impact of communities on observed racial/ethnic disparities in infant survival.