Rethinking urban-rural designations in public health surveillance of the overdose crisis and crafting an agenda for future monitoring

Abstract

Rurality has served as a key concept in popular and scientific understandings of the US overdose crisis, with White, rural, and low-income areas thought to be most heavily affected. However, we observe that overdose trends have risen nearly uniformly across the urban-rural designations employed in most research, implying that their importance has likely been overstated or incorrectly conceptualized. Nevertheless, urbanicity/rurality does serve as a key axis to understand inequalities in overdose mortality when assessed with more nuanced modalities-employing a more granular analysis of geography at the sub-county level, and intersecting rurality sociodemographic indices such as race/ethnicity. Using national overdose data from 1999-2021, we illustrate the intersectional importance of rurality for overdose surveillance. Finally, we offer recommendations for integrating these insights into drug overdose surveillance moving forward.

Keywords: Ethnography; Inequality; Opioids; Overdose; Rural urban categories; Surveillance.

Figure 1:. Drug overdose mortality per 100,000 population from 1999–2021, subdivided by six categories of urbanicity.

Records describing drug-related overdose were accessed through CDC WONDER[defined as underlying cause of death ICD-10 codes for drug-related accidental (X40-X44), intentional (X60–64), assault-related (X85), and undetermined intent (Y10-Y14)]. Urban-rural classification shown by 2013 NCHS Urban-Rural Classification Scheme for Counties. This figure highlights that trends in overdose show little variation by category of urbanicity; increases are observed across all six categories of urbanicity.

Figure 2 :. Drug overdose mortality per 100,000 people by race/ethnicity and type of drug involved, 1999–2021.

Drug overdose mortality definitions are described in figure 1 caption. Race and ethnicity were used as defined in the WONDER and NCHS databases. Racial and ethnic groups were defined first by ethnicity (Hispanic or Latino) and subsequently by race (non-Hispanic American Indian or Alaska Native, non-Hispanic Black, and non-Hispanic White). This figure highlights that during the study period, overdose increased significantly and at rates that were more impacted by race/ethnicity than by level of urbanicity. All urban and rural-designated counties showed worsening rates of overdose in each racial/ethnic category between the years 1999–2021.

Figure 3:. Population Density of Census Tracts in Los Angeles County in 2020.

This figure illustrates the wide range of census tract level population densities that can be observed within LA County. The histograms on the right display the population density by tract (population per sq. km), the overall populations by tract (population), and the areas of the tract (log-sq. km). The map shows population density for all tracts in Los Angeles County, excluding islands. Population data were drawn from the 2020 US census.