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. 2018 Mar 13;319(10):1013-1023.
doi: 10.1001/jama.2018.0900.

Trends and Patterns of Geographic Variation in Mortality From Substance Use Disorders and Intentional Injuries Among US Counties, 1980-2014

Laura Dwyer-Lindgren  1 , Amelia Bertozzi-Villa  1 , Rebecca W Stubbs  1 , Chloe Morozoff  1 , Shreya Shirude  1 , Jürgen Unützer  2 , Mohsen Naghavi  1 , Ali H Mokdad  1 , Christopher J L Murray  1
Affiliations

Trends and Patterns of Geographic Variation in Mortality From Substance Use Disorders and Intentional Injuries Among US Counties, 1980-2014

Laura Dwyer-Lindgren et al. JAMA. .

Abstract

Importance: Substance use disorders, including alcohol use disorders and drug use disorders, and intentional injuries, including self-harm and interpersonal violence, are important causes of early death and disability in the United States.

Objective: To estimate age-standardized mortality rates by county from alcohol use disorders, drug use disorders, self-harm, and interpersonal violence in the United States.

Design and setting: Validated small-area estimation models were applied to deidentified death records from the National Center for Health Statistics (NCHS) and population counts from the US Census Bureau, NCHS, and the Human Mortality Database to estimate county-level mortality rates from 1980 to 2014 for alcohol use disorders, drug use disorders, self-harm, and interpersonal violence.

Exposures: County of residence.

Main outcomes and measures: Age-standardized mortality rates by US county (N = 3110), year, sex, and cause.

Results: Between 1980 and 2014, there were 2 848 768 deaths due to substance use disorders and intentional injuries recorded in the United States. Mortality rates from alcohol use disorders (n = 256 432), drug use disorders (n = 542 501), self-harm (n = 1 289 086), and interpersonal violence (n = 760 749) varied widely among counties. Mortality rates decreased for alcohol use disorders, self-harm, and interpersonal violence at the national level between 1980 and 2014; however, over the same period, the percentage of counties in which mortality rates increased for these causes was 65.4% for alcohol use disorders, 74.6% for self-harm, and 6.6% for interpersonal violence. Mortality rates from drug use disorders increased nationally and in every county between 1980 and 2014, but the relative increase varied from 8.2% to 8369.7%. Relative and absolute geographic inequalities in mortality, as measured by comparing the 90th and 10th percentile among counties, decreased for alcohol use disorders and interpersonal violence but increased substantially for drug use disorders and self-harm between 1980 and 2014.

Conclusions and relevance: Mortality due to alcohol use disorders, drug use disorders, self-harm, and interpersonal violence varied widely among US counties, both in terms of levels of mortality and trends. These estimates may be useful to inform efforts to target prevention, diagnosis, and treatment to improve health and reduce inequalities.

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Conflict of interest statement

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Figures

Figure 1.
Figure 1.. County-Level Mortality From Alcohol Use Disorders
A, Age-standardized mortality rate for both sexes combined in 2014. B, Relative change in the age-standardized mortality rate for both sexes combined between 1980 and 2014. A and B, the color scale is truncated at approximately the first and 99th percentile as indicated by the range given in the color scale. C, Age-standardized mortality rate for both sexes combined in 1980, 1990, 2000, and 2014. The bottom border of the boxes indicates the 25th percentile; middle line, the 50th percentile; and top border indicates the 75th percentile across all counties; whiskers indicate the full range across counties; and the circles indicate the national-level rate.
Figure 2.
Figure 2.. County-Level Mortality From Drug Use Disorders
A, Age-standardized mortality rate for both sexes combined in 2014. B, Relative change in the age-standardized mortality rate for both sexes combined between 1980 and 2014. A and B, the color scale is truncated at approximately the first and 99th percentile as indicated by the range given in the color scale. C, Age-standardized mortality rate for both sexes combined in 1980, 1990, 2000, and 2014. The bottom border of the boxes indicates the 25th percentile; middle line, the 50th percentile; and top border indicates the 75th percentile across all counties; whiskers indicate the full range across counties; and the circles indicate the national-level rate.
Figure 3.
Figure 3.. County-Level Mortality From Self-harm
A, Age-standardized mortality rate for both sexes combined in 2014. B, Relative change in the age-standardized mortality rate for both sexes combined between 1980 and 2014. A and B, the color scale is truncated at approximately the first and 99th percentile as indicated by the range given in the color scale. C, Age-standardized mortality rate for both sexes combined in 1980, 1990, 2000, and 2014. The bottom border of the boxes indicates the 25th percentile; middle line, the 50th percentile; and top border indicates the 75th percentile across all counties; whiskers indicate the full range across counties; and the circles indicate the national-level rate.
Figure 4.
Figure 4.. County-Level Mortality From Interpersonal Violence
A, Age-standardized mortality rate for both sexes combined in 2014. B, Relative change in the age-standardized mortality rate for both sexes combined between 1980 and 2014. A and B, the color scale is truncated at approximately the first and 99th percentile as indicated by the range given in the color scale. C, Age-standardized mortality rate for both sexes combined in 1980, 1990, 2000, and 2014. The bottom border of the boxes indicates the 25th percentile; middle line, the 50th percentile; and top border indicates the 75th percentile across all counties; whiskers indicate the full range across counties; and the circles indicate the national-level rate.
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Comment in

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