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Individual and county-level variation in outcomes following non-fatal opioid-involved overdose
  1. Evan Marie Lowder1,
  2. Joseph Amlung2,
  3. Bradley R Ray3
  1. 1 Criminology, Law and Society, George Mason University, Fairfax, Virginia, USA
  2. 2 Regenstrief Institute, Indianapolis, Indiana, USA
  3. 3 School of Social Work, Wayne State University, Detroit, Michigan, USA
  1. Correspondence to Dr Evan Marie Lowder, Criminology, Law and Society, George Mason University, Fairfax, VA 22030, USA; elowder{at}


Background A lack of large-scale, individually linked data often has impeded efforts to disentangle individual-level variability in outcomes from area-level variability in studies of many diseases and conditions. This study investigated individual and county-level variability in outcomes following non-fatal overdose in a state-wide cohort of opioid overdose patients.

Methods Participants were 24 031 patients treated by emergency medical services or an emergency department for opioid-involved overdose in Indiana between 2014 and 2017. Outcomes included repeat non-fatal overdose, fatal overdose and death. County-level predictors included sociodemographic, socioeconomic and treatment availability indicators. Individual-level predictors included age, race, sex and repeat non-fatal opioid-involved overdose. Multilevel models examined outcomes following non-fatal overdose as a function of patient and county characteristics.

Results 10.9% (n=2612) of patients had a repeat non-fatal overdose, 2.4% (n=580) died of drug overdose and 9.2% (n=2217) died overall. Patients with a repeat overdose were over three times more likely to die of drug-related causes (OR=3.68, 99.9% CI 2.62 to 5.17, p<0.001). County-level effects were limited primarily to treatment availability indicators. Higher rates of buprenorphine treatment providers were associated with lower rates of mortality (OR=0.82, 95% CI 0.68 to 0.97, p=0.024), but the opposite trend was found for naltrexone treatment providers (OR=1.20, 95% CI 1.03 to 1.39, p=0.021). Cross-level interactions showed higher rates of Black deaths relative to White deaths in counties with high rates of naltrexone providers (OR=1.73, 95% CI 1.09 to 2.73, p=0.019).

Conclusion Although patient-level differences account for most variability in opioid-related outcomes, treatment availability may contribute to county-level differences, necessitating multifaceted approaches for the treatment and prevention of opioid abuse.

  • epidemiology
  • geography
  • mortality
  • multilevel modelling
  • substance abuse

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  • Contributors EML and BRR conceived the study. EML and JA cleaned and coded the study data. EML conducted the data analysis, with intellectual contribution from BRR. EML and BRR codrafted the manuscript. All authors approved the final manuscript. EML takes responsibility for its final content.

  • Funding This work was funded through Indiana’s State Opioid Response Grant from the Substance Abuse and Mental Health Services Administration (TI081689-01).

  • Disclaimer The contents are solely the responsibility of the authors and do not necessarily represent the official views of the State of Indiana or the Substance Abuse and Mental Health Services Administration. The funding source played no role in the design, conduct or reporting of this investigation.

  • Competing interests EML and BRR contracted with Indiana’s Management Performance Hub to complete this work as part of the Indiana’s State Opioid Response Grant from the Substance Abuse and Mental Health Services Administration.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data may be obtained from a third party and are not publicly available. Deidentified, patient-level data were provided to the researchers by the Indiana Management Performance Hub (MPH). MPH has an established process for external data requests. More information can be found at the following link:

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