Bowling alone, dying together: The role of social capital in mitigating the drug overdose epidemic in the United States

Highlights

• Variation in overdose deaths suggest as-yet unidentified moderating factors exist.

• Press reports emphasize the role of community fragility in the overdose epidemic.

• County-level social capital has a protective effect on age-adjusted overdose mortality.

• Promoting social capital could play a role in a policy response to drug overdose.

Abstract

Background

Drug overdose deaths have risen precipitously over the last fifteen years. Substantial geographic variation, beyond a simple rural-urban dichotomy, exists in the concentration of overdose deaths, suggesting the existence of as-yet unidentified environmental variables that predict resilience (or vulnerability) to drug overdoses. Motivated by reports highlighting the role of community fragility in the opioid epidemic, we explore whether social capital attenuates overdose death rates.

Methods

We conducted an ecologic temporal trends study from 1999 to 2014 to investigate the association between mortality due to drug overdose and social capital. Data from multiple sources were compiled at the county-level to produce an analytic dataset comprising overdose mortality, social capital, and a host of potentially confounding variables indicated by the literature (N = 49,664 county-years). Multinomial logistic regression was used to estimate the likelihood that a county falls in low (<4 deaths per 100,000), moderate, or high (>16 deaths per 100,000) categories of annual overdose morality.

Results

We observed a strong and statistically significant inverse association between county-level social capital and age-adjusted mortality due to drug overdose (p < 0.01). Compared to the lowest quintile of social capital, counties at the highest quintile were 83% less likely to fall in the “high-overdose” category and 75% less likely to fall in the “moderate-overdose” category.

Conclusion

This study finds large-sample evidence that social capital protects communities against drug overdose. This finding could help guide policymakers in identifying where overdose epidemics are likely to occur and how to ameliorate them.

Introduction

A recent editorial noted that the year 2014 marked the “highest number of individuals considered to have opioid addiction since statistics began to be collected in the late 19th century” (Olsen, 2016). More than ten million Americans report non-medical use of prescription opiates and two million non-medical users of opiates meet criteria for substance use disorders (Olsen, 2016). Climbing rates of opiate use and abuse have precipitated increases in morbidity and mortality. Over the last 20 years, drug overdose fatalities have increased throughout the United States (US) for all gender, age, and racial/ethnic subgroups (Rossen et al., 2016). In 2014, almost 50,000 Americans fatally overdosed on drugs; opiates accounted for about 60% of total drug poisonings, the nation’s leading cause of accidental death (Rudd et al., 2016). Age-adjusted death rates for all-drug poisonings have doubled in the last fifteen years, from 6.1 per 100,000 in 1999 to 14.7 per 100,000 in 2014 (Rudd et al., 2016).

Epidemiologic evidence suggests that temporal increases in overdose deaths are due to both prescription opioids and, more recently, illicit opioid use, particularly heroin. These trends are interrelated since most people who have initiated heroin use recently report doing so after being prescribed analgesic opiates (Rudd et al., 2016). Furthermore, opioid use and abuse is most pronounced among non-Hispanic (NH) whites, the group with the largest increases in overdose death rates since 1999 (Rossen et al., 2016). The deleterious effects of increased opiate prescriptions have prompted the Centers for Disease Control and Prevention (CDC) to issue new, more stringent guidelines about their use (Dowell et al., 2016). Moreover, policymakers at all levels of government have attempted to deal with the opiate epidemic. Congress has extended funding for states’ Prescription Drug Monitoring Programs through 2020 and required Veterans Affair’s opiate prescriptions to use state monitoring programs (United States Congress, 2016a) and significantly expanded funding for opiate prevention efforts and law enforcement targeting the trafficking of opiates (United States Congress, 2016b). At the state level, almost all states have passed legislation expanding access to Naloxone (Davis and Carr, 2015). Despite these efforts, the crisis shows few signs of abating (Olsen, 2016).

Both scholarly articles (McLean, 2016, Sundquist et al., 2016) and popular press reports (Achenbach and Keating, 2016) often cite the role of community fragility in contributing to the opiate epidemic. A recent New York Times article (Kolata and Cohen, 2016) notes that “the nation is seeing a cohort of whites who are isolated and left out of the economy and society and who have gotten ready access to cheap heroin and to prescription narcotic drugs.” Indeed, the spike in opiate overdoses drives the finding that absolute mortality among middle-aged (45–54 years) whites has increased since 1999 (Case and Deaton, 2015). Substantial geographic variation, beyond a simple rural-urban dichotomy, exists in the concentration of overdose deaths (Rossen et al., 2013), suggesting the existence of as-yet unidentified environmental variables that predict resilience (or vulnerability) to overdoses.

One potentially protective factor is social capital—the extent and depth of social trust, norms, and networks (Sirianni and Friedland, 2001). The central premise of social capital is that social networks matter (Field, 2008). More concretely, social capital consists of five characteristics: (1) the density of community and personal networks; (2) civic engagement and participation; (3) a sense of belonging in the community; (4) reciprocity and cooperation with fellow citizens; (5) trust in the community (De Silva et al., 2005). Neighborhood associations, religious congregations, and civic organizations are sources of social capital. Research from political scientist Robert Putnam posited that high levels of social capital can predict a variety of social outcomes, such as lower crime levels, higher rates of volunteerism, and longer life expectancy. Drawing on several national surveys of membership and participation in civic organizations over three decades, Putnam argued that levels of social capital have been declining in the US since 1950, a phenomenon he described as “bowling alone” (Putnam 2000).

Scholars have long used social capital to explain variation in health outcomes between communities. State-level measures of social capital have been associated with better self-reported health (Kawachi et al., 1999) and reduced mortality (Kawachi et al., 1997, Weaver and Rivello, 2006). At the county level, social capital has been shown to explain the “rural paradox”—the observation that rural communities experience lower all-cause death rates (Yang et al., 2011) and infant mortality (Yang et al., 2009) than their poorer socioeconomic indicators and health behaviors would predict. Social capital is thought to explain the link between inequality and worsened health (Yamaguchi, 2014), and neighborhood income inequality is associated with fatal drug overdoses in New York City (Galea et al., 2003). In contrast, scholars found no relationship between regional measures of “civicness”, a concept similar to social capital, and drug overdoses in Italy after controlling for income; instead, provincial wealth was the primary driver of overdose fatalities, with wealthier provinces experiencing more overdose deaths (Gatti et al., 2007). In this paper, we address a gap in knowledge by leveraging multiple data sources to explore whether social capital moderates drug overdose deaths.