Urban-Rural Differences in Drug Overdose Deaths

HOST: The immense human toll of the drug epidemic in the United States has impacted both urban and rural communities across the country, and a new report from NCHS this month focused on the differences in overdose mortality between these regions.  The lead author of the new report, Merianne Spencer, joined us to discuss the new study:

HOST:  Why is it important to compare overdose death rates between urban and rural areas of the country?

MS:  There continues to be a rise in drug overdose deaths year after year.  Looking broadly in 1999 the drug overdose death rates was 6.1; whereas in 2020 the jerk overdose death rates was 20.3 per 100,000 this is almost a five-fold increase in rates across 21 years.  So understanding national statistics on drug overdose deaths is important for looking at the trends for demographic and regional characteristics for public health research and practice.  Also previously in other studies we’ve seen that rural communities typically have worse health outcomes.  For instance, rural communities may have varying experiences that urban communities in terms of access to quality health care or medical resources.  And so we were interested at looking at the urban rural difference in drug overdose death rates as this can give insights to specific risk factors that can vary from urban and rural areas across our country.

HOST: Drug abuse of course has been a national issue for a long time.  It seems years ago, drug abuse overdose deaths was believed to be more of a problem in urban settings versus in rural settings or in the suburbs. What does your study show?

MS:  Nationally, drug overdose death rates in urban areas continue to be higher.  So in 2020 the rate was 28.6 in urban areas whereas in rural areas it’s 26.2 per 100,000.  That said, this study does highlight cases where the rate in urban areas was not necessarily higher than in rural areas.  For instance, if you focused on females – the rate among females was 17.0 per 100,000 in urban areas versus 17.9 per 100,000 in rural areas.  Also if you looked at it by select drugs – overdose deaths involving psychostimulants with abuse potential or those involving natural and semisynthetic opioids had higher rates in rural areas.  There were also eight states where drug overdose death rates were higher in rural counties compared to urban counties.  So yeah, it’s interesting looking at this study where you can see that, yes overall at the national level urban rates were higher, but there are cases where it’s higher by specific subgroups.

HOST:  The study focuses only on 2020, the year 2020, but how the trends in overdose deaths changed overtime between urban and rural settings?

MS:  The trends in overdose deaths have changed over time between urban and rural settings.  Rates are higher in urban areas from 1999 to 2003 compared to rural areas and they were also higher in 2016 through 2020.  But there was a time from 1999 to 2020 where rates were higher in rural areas, being 2007 through 2015.  There were increases in overdose rates involving synthetic opioids other than methadone from that overlapping period. Which includes fentanyl, fentanyl analogs and tramadol and although we’ve been seeing over the recent time period that rates in urban rural areas have increased, the increases were larger in urban areas, which likely helped push this overall higher rate in urban areas in the subsequent years or more recent years of the study

HOST:  So basically there was a period not too long ago where overdose death rates were higher in rural areas?

MS:  Yes between 2007 and 2015 but most recently the difference has been that urban areas have a higher rate than rural areas from 2016 all the way till 2020 the most recent year of this study.

HOST: You mentioned that fentanyl has been driving much of the increase – fentanyl and other synthetic opioids, but the majority of those are fentanyl deaths or is that correct?

MS: Yeah I think it’s fair to say that drug overdose deaths involving fentanyl could be what’s driving the increase in both urban and rural areas.  That said I should mention that the report doesn’t look specifically at fentanyl but rather a broader category that includes fentanyl.  So this increase in the report that we’re seeing, while it could include Fentanyl we have to keep in mind that other drugs are part of that category as well.

HOST:  This raises another question – if fentanyl is accounting for so much of this increase, is it problematic from a surveillance standpoint or from a statistical standpoint to have fentanyl wedged into a broader category?  Would it would it not be a more useful practice to have fentanyl in its own category, such as heroin and cocaine, for example?

MS:  You’re raising an interesting question since I know there’s been increased interest with specifically fentanyl, and in the past we’ve at NCHS published some reports on using a method that went back to the literal text or the written information on death certificate records to tease out specifically drug overdose deaths involving fentanyl, fentanyl analogs, metabolites and precursors of fentanyl, and then reporting that.  So we do have national statistics on fentanyl, specific reports,but because that involves an analysis of the literal text and a special method that’s separate from looking at the standardized ICD 10 codes that are included in national reports or for surveillance purposes that most people usually use and track.  And that’s available on CDC WONDER and other sources. I could see strengths to reporting in the broader category as well as taking that more refined method to report specifically on fentanyl deaths, so I should say that there are other ways to look or access those specific rates.  It’s just that it happens at this report does not do that.

HOST:  You alluded to the other drugs that are having an impact here is it accurate to say that meth or other psychostimulants are having a bigger impact in rural areas than in urban areas?

MS:  So in our report we were seeing higher rates of drug overdose deaths that had a greater impact in certain urban areas versus rural areas and vice versa.  So deaths involving cocaine, heroin and synthetic opioids other than methadone were higher in urban areas whereas psychostimulants with abuse potential and natural and semi synthetic opioids were higher in rural areas compared to urban areas.

HOST: Your study points out that there are almost three times as many states in which overdose death rates are higher in urban areas than in rural areas – I think it’s 23 to 8, 23 states versus 8 states.  What about in the other 19 states that the study doesn’t mention?

MS:  There are three jurisdictions where there were no rural counties in that jurisdiction; that’s Delaware, District of Columbia and Rhode Island.  And because of this we can’t compare the rural rates in that given jurisdiction compared to an urban rate because there was just just urban rates in that area.  So we don’t report on those three jurisdictions, but for the remaining states that you mentioned that we we didn’t talk about higher versus lower it was because we found that the drug overdose death rates in the urban areas compared to the rural areas were similar or not statistically significantly different from each other.  And so there are some states where there isn’t an urban-rural difference and those are the the 19 states that you that you mentioned.

HOST:  Is there any more research planned that will get deeper into some of these issues between urban and rural areas?

MS:  That’s a good question.  We don’t have any specific reports planned within NCHS that look at urban-rural differences, but you know there’s been a lot of interest in the health disparities of drug overdose death.  There will be other reports, maybe not specifically focusing or drilling down on urban and rural differences, but definitely just looking at national level statistics on other health disparities involving the drug overdose epidemic.

HOST: Anything else you’d like to add?

MS:  I should mention that this data brief highlights some differences between demographic subgroups as well as the urban-rural differences. So you’ll see in the report that males had double the rate of overdose stats compared to females, and this is shown in both urban and rural areas and you’ll also see in the report that non-Hispanic American Indian or Alaskan Native people had higher rates in both urban-rural areas and whereas non-Hispanic Asian people have had the lowest rates. I think it’s also worth mentioning that the difference in urban and rural rates for non-Hispanic blacks were 37.4 per 100,000 in urban areas and 18.9 per 100,000 in rural areas.  And so this is an interesting finding because the rate of urban areas was nearly double compared to the rate of rural areas for non-Hispanic black people.  While we do observe higher rates in urban areas and rural areas for other subgroups such as non-Hispanic whites and Hispanics, the urban-rural difference was not as large compared to non-Hispanic blacks and it might highlight some things that others might want to look at or delve into in future studies.

HOST: Thank you Merianne.


HOST:  Nationally, overdose deaths in America topped 108,000 in the one-year period ending in February of this year – a 12% increase over the same period last year.  These numbers were featured in the latest monthly release of overdose deaths in the country from the National Vital Statistics System.  Deaths from drug overdoses were higher in all states except four:  Nebraska, Ohio, Pennsylvania, and Maryland.


The arrival of the pandemic in 2020 caused a significant jump in the nation’s death rate that year.  That increase in mortality continued in 2021, with increases in death rates for 8 of the 10 leading causes of death.  These data were featured in the latest quarterly release of mortality data for the country, covering mainly the period through Quarter 4 of 2021.


NCHS also released three studies on births in July.  Early in the month, a study was released on changes in primary and repeat cesarean deliveries, showing a 4% increase in primary cesareans from 2019 to 2021 – but a 1% drop in repeat cesareans each year from 2016 to 2021.

There has been a great deal of variation in the pattern of births in the country since the pandemic began. In the first half of 2021, there was a 2% decline in births compared with the first half of 2020.  However, in the second half of 2021, there was a 4% INCREASE from the same point a year earlier.

And a third report in July looked at gestational diabetes among U.S. mothers.  The rate of diabetes during pregnancy was nearly 8 in 100 births in 2020 – up 30% from 2016.

And last, the Center released the latest quarter of data on health insurance coverage in the U.S., showing 8% of all Americans had no insurance in Quarter 1 of 2022, continuing a steady decline from a year earlier when 9.5% of Americans had no insurance.