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. 2025 Apr;46(2):238-246.
doi: 10.1177/29767342241262125. Epub 2024 Jul 23.

Associations Between Drug Overdose Mortality and Recovery Ecosystems in the United States: A County-Level Analysis Using a Novel Index

Amy E Wahlquist  1 , Stephanie M Mathis  1 , Laura Hunt Trull  1 , Kusse Koirita Toitole  1 , Andrew Howard  2 , Ernest Fletcher  2 , Michael Meit  1
Affiliations

Associations Between Drug Overdose Mortality and Recovery Ecosystems in the United States: A County-Level Analysis Using a Novel Index

Amy E Wahlquist et al. Subst Use Addctn J. 2025 Apr.

Abstract

Background: Communities with robust recovery ecosystems could reduce negative outcomes associated with substance use disorders (SUDs) and facilitate the recovery process. This cross-sectional study examined the relationship between drug overdose mortality rates in the United States and the strength of county-level recovery ecosystems, as measured by the Recovery Ecosystem Index (REI).

Methods: The REI assesses the strength of county-level recovery ecosystems in the United States. Comprised of 14 indicators across 3 component classes, overall and component scores ranging from "one" (strongest) to "five" (weakest) were calculated for each county using standardized values of the indicators. County-level analyses included: (1) correlational analyses between drug overdose mortality rates (n = 2076) and REI scores (overall score and by component); and (2) quadrant analysis (n = 2076), dividing counties based on their drug overdose mortality rates and overall REI scores.

Results: Drug overdose mortality rates were inversely related to REI overall, SUD treatment component, and continuum of SUD support component scores, indicating that lower (stronger) scores corresponded to higher rates. Conversely, REI infrastructure and social component scores were positively related to rates. Counties were relatively evenly distributed across quadrants, with 26% (n = 537) with a strong REI score and high overdose mortality rate, 24% (n = 489) with a strong REI score and low overdose mortality rate, 20% (n = 409) with a weak REI and high overdose mortality rate, and 31% (n = 641) with a weak REI and low overdose mortality rate.

Conclusions: REI scores were generally inversely associated with drug overdose mortality rates in US counties, suggesting that communities have stronger recovery systems and services as the burden of SUD increases. Given relative variation in the scale of drug overdose mortality and strength of recovery ecosystems among counties, results could guide the identification of communities where the need for expanded recovery systems and services may be particularly critical.

Keywords: United States; county-level; drug overdose mortality; mapping tool; recovery ecosystem; substance use disorder.

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Conflict of interest statement

Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.