Question 1. I am interested in understanding what puts individuals at risk for experiencing an opioid overdose. Opioid overdose is currently the leading cause of accidental death in adults in the United States. Opioid overdose accounted for over 33,000 deaths in the US in 2015, outpacing deaths from both fire arms and motor vehicle accidents. While we understand some potential risk factors for overdose, (genetic predisposition, concomitant drug use, and change in tolerance) we need to expand our understanding of these risk factors, particularly as new opioids are introduced into circulation e.g. synthetic opioids such as Fentanyl.
There are a number of structural stratifiers that we know are associated with increased risk of overdose. For instance, gender is a structural determinant of health that is associated with overdose – men are at higher risk of experiencing an overdose from both heroin and opioid analgesics than women. Age and race are also important structural stratifiers that should be considered when evaluating overdose. Structural stratifiers like occupation and income are more challenging with this at-risk population since it is common for individuals to be self-employed or non-traditionally employed (e.g. pan handlers, sex workers, or drug dealers). Income may still be a useful measure, but we have to account for its distinctness from traditional means of “employment”, as traditional employment may provide social/symbolic capital and peer networks that are not necessarily present in non-traditional employment environments.
As for intermediary determinants: housing (dwelling and conditions of) is a material determinant that should be considered when evaluating overdose risk. For one, we know that physical isolation increases ones risk of fatal overdose because it decreases that likelihood that someone will be able to reverse the overdose with naloxone or call for medical support. A lack of housing pushes people to use in the fringes (in isolated locations like alleys, underpasses, locked public bathrooms etc) which increase their risk of a fatal overdose. Psychosocial stressors may also have a significant effect on the risk of overdose – as negative life events, acute stress and lack of social support may all be associated with overdose.
Question 2. Neighborhood characteristics could contribute to the incidence of overdose in a number of ways. First, exposure and accessibility to heroin/opioids may differ significantly based on neighborhood characteristics. A neighborhood that has active and “outdoor” drug dealing may increase the ease in which someone has access to opioids, which may lead to developing an opioid use disorder, and subsequent risk of overdose. Second, “neighborhood” (geographic) characteristics may also contribute to the incidence of overdose because states and counties have different laws pertaining to harm reduction efforts. These policy-driven characteristics may change risk factors based on where you live. Living in a state or county that does not have access to opioid substitution therapy or syringe exchanges may also increase your risk of overdose because you do not have access to educational services about safe injection practicing (e.g. tester shot to see how potent the drug is in order to decrease risk of overdose – this is particularly crucial now that heroin and opioid analgesics are so frequently laced with more potent synthetic opioids like fentanyl). Even in a state like CA that has access to harm reduction services, not all neighborhoods have equal access to services. Living in a neighborhood that does not have adequate access to these resources may also increase risk of overdose. Finally, socioeconomic factors earlier in life course could contribute to overdose as well. One example: research has shown an association between mental health and substance use. Low SES early in life may result in less access to medical care, and less opportunity to receive mental health support.