摘要：Objectives. We examined whether neighborhood social characteristics (income distribution and family fragmentation) and physical characteristics (clean sidewalks and dilapidated housing) were associated with the risk of fatalities caused by analgesic overdose. Methods. In a case-control study, we compared 447 unintentional analgesic opioid overdose fatalities (cases) with 3436 unintentional nonoverdose fatalities and 2530 heroin overdose fatalities (controls) occurring in 59 New York City neighborhoods between 2000 and 2006. Results. Analgesic overdose fatalities were less likely than nonoverdose unintentional fatalities to have occurred in higher-income neighborhoods (odds ratio [OR] = 0.82; 95% confidence interval [CI] = 0.70, 0.96) and more likely to have occurred in fragmented neighborhoods (OR = 1.35; 95% CI = 1.05, 1.72). They were more likely than heroin overdose fatalities to have occurred in higher-income (OR = 1.31; 95% CI = 1.12, 1.54) and less fragmented (OR = 0.71; 95% CI = 0.55, 0.92) neighborhoods. Conclusions. Analgesic overdose fatalities exhibit spatial patterns that are distinct from those of heroin and nonoverdose unintentional fatalities. Whereas analgesic fatalities typically occur in lower-income, more fragmented neighborhoods than nonoverdose fatalities, they tend to occur in higher-income, less unequal, and less fragmented neighborhoods than heroin fatalities. Rates of fatal overdoses caused by analgesic opioids have increased dramatically in the United States, particularly over the past 5 years. 1–3 The prevalence of nonmedical analgesic drug abuse is second only to that of marijuana abuse, and currently the number of fatal overdoses attributed to opioid analgesics, such as oxycodone, hydrocodone, and codeine, is greater than the number attributed to heroin and cocaine combined. 4 Urban areas have long been associated with elevated risks of substance abuse and subsequent mortality from unintentional drug poisoning. From 1997 to 2002, the number of overdose deaths involving opioid analgesics increased 97% in urban areas during a time when the rate of overdose from all drugs increased 27%. 5 From a public health burden standpoint, understanding the determinants of analgesic overdose mortality in large urban areas is critical to help stem the tide of mortality from analgesics, as all available data suggest that analgesic overdose mortality in these areas will continue to increase in the coming years. 6 Extant epidemiological research in the area has predominantly been concerned with the role of individual characteristics in explaining the prevalence of analgesic overdose throughout the United States. 5,7–12 Analgesic opiate overdose decedents have been reported to be primarily White, male, and adult (ranging in age from 25 to 54 years) and to exhibit a high prevalence of concurrent psychotherapeutic drug use. 5,7–10 However, several organizing frameworks in the field (principally rooted in ecosocial theory) suggest that environments operate jointly with individual factors to influence the risk of substance use. 13–15 In addition to individual characteristics such as psychiatric morbidity, genetic vulnerability, gender, and age, 16–20 these frameworks suggest that interconnected components of influence shape drug use. These components include social policies and regulations that affect the allocation of social and health resources 21–26 ; social and physical features of the neighborhood environment that structure the availability of drugs, influence norms around use, and generate sources of stress that contribute to drug use 13,14,27–37 ; and interpersonal characteristics, such as social support and social networks, that mediate the relationship between the neighborhood environment and drug use. 28,31,38–42 Despite this conceptual orientation, few studies have attempted to provide an understanding of the contextual factors that may explain the geographic distribution of analgesic overdose in an urban environment. Of particular interest in the urban context are the features of neighborhoods that can shape drug overdose. Established conceptual frameworks suggest 2 such features: primary determinants of infrastructure, employment, education, and health care resources, including residential segregation, income distribution, and neighborhood deprivation, and secondary determinants that are consequences of these fundamental conditions and may mediate their impact on drug use, including the quality of the built environment, social norms around drug use, and family fragmentation. 15 Drawing on this framework, we examined 3 features of the neighborhood environment that have been previously linked with drug overdose: income distribution, quality of the built environment, and family fragmentation. 35,37,43,44 First, neighborhood income distribution has been consistently linked to drug abuse or overdose fatalities. 27,35,44,45 For example, research has shown that in New York City neighborhoods with more unequal income distributions, drug overdoses are more likely than other causes to lead to unintentional deaths. 35,44 The erosion of social capital and greater mistrust of authority found in more unequal neighborhoods may lead to a greater reluctance to seek medical help in cases of overdose. 46 Furthermore, underinvestment in health and social resources could contribute to longer response times on the part of paramedics and limited access to substance abuse treatment. It is plausible that these same processes may drive a higher risk for analgesic opiate overdose in more unequal neighborhoods. Second, studies have shown a positive association between poor quality of the built environment (dilapidated buildings, vandalism of public property, and littering) and risk of drug overdose. 43,44,46 Deterioration of the built environment has been linked with higher levels of distress. 47 In turn, people with higher levels of distress may be more vulnerable to drug abuse and overdose than people low in distress. 48,49 Moreover, reduced social capital reflected in a vandalized and littered built environment may discourage neighborhood residents from interacting with each other and from developing relationships that would enable to them to intervene to prevent the development of drug distribution networks in the neighborhood. 50 Third, family fragmentation (e.g., a high prevalence of divorced, separated, or single-parent families) represents a social mechanism through which neighborhoods may influence analgesic overdose. Disruption of the neighborhood social fabric may manifest in personal forms of disorganization within adult relationships. 51,52 Studies of crime have shown that family disruption influences the collective ability of local residents to promote adult and youth conformity to local norms and laws. 53–55 A high prevalence of fragmented families in a neighborhood reduces the neighborhood’s ability to monitor young people and respond to delinquency and crime. 56 Such disorganization may have direct consequences in terms of access to and consumption of analgesics, given that the formation of drug-selling and drug-consuming networks may be more likely in neighborhoods where residents do not monitor delinquent activity consistently. 57 Furthermore, disrupted families may be less likely to exert informal control over the abuse of analgesics by other family members. 57 Given that consumption of analgesics occurs most frequently at home, 58 the absence of a family support and control net is particularly problematic. This study had 2 aims. First, we examined the roles that the 3 features of the neighborhood social and physical environment just described—income distribution, the quality of the built environment, and family fragmentation—play in the risk of unintentional death from analgesic overdose in New York City. Second, we examined whether analgesic opiate overdoses in New York City are driven by distinct neighborhood factors than heroin overdose, the historically most prevalent form of illicit opiate overdose in urban areas. 59,60
