IHP 515 Module 3 Milestone One Example

Milestone One: Opioid Overdose Deaths in Harlan County, 2019-2023

[Student Name]

Southern New Hampshire University

IHP 515: Population-Based Epidemiology

Module Three Milestone One

[Instructor Name]

[Date]

Milestone One: Opioid Overdose Deaths in Harlan County, 2019-2023

Descriptive epidemiology asks three questions about a health problem: when is it happening, who is affected and where? Answering them carefully comes before any attempt to explain causes, because good description reveals patterns that suggest hypotheses and guides where to act. This milestone describes opioid overdose deaths across Harlan, a composite county of some 212,000 residents, from 2019 through 2023, using death certificates, medical examiner reports and census estimates.

National Context

Rudd et al. (2016) documented rapid increases in overdose deaths in the United States, with opioid-involved deaths rising steeply and the largest recent growth involving heroin and synthetic opioids such as fentanyl. Their report showed that the epidemic had moved from prescription opioids toward illicit drugs, a transition that shaped how many communities experienced the crisis in the years that followed.

Time

Harlan County's overdose death rate was fairly stable at 17 to 19 per 100,000 from 2016 through 2019, then rose each year: 22.4 in 2020, 26.9 in 2021, 30.1 in 2022 and 33.5 in 2023. The share of deaths with fentanyl detected in toxicology rose from 31% in 2019 to 78% in 2023. Deaths clustered modestly in late spring and summer and in the weeks after holiday periods. A sharp jump in the second quarter of 2020 coincided with pandemic restrictions and the temporary closure of the county's only opioid treatment program.

Table 1. Overdose Death Rates in Harlan County

Note. Figures are illustrative for the composite county.

Person

Over the five years, 72% of those who died were men. The highest rates were among adults aged 25 to 44, at 75 per 100,000 in 2023, followed by those aged 45 to 64. Rates among Black residents rose fastest, from 14.2 per 100,000 in 2019 to 41.8 in 2023, overtaking rates among white residents, which rose from 19.5 to 32.6. Nearly a quarter of decedents had left jail or prison within the prior twelve months, and 31% had a documented nonfatal overdose in the preceding twelve months. Fewer than one in five had any record of treatment with methadone or buprenorphine in the year before death.

Place

Deaths were mapped by residence across the county's six planning areas. The highest rate, 58 per 100,000, occurred in the Eastside area, which has the county's highest poverty rate and the plant closure that cost about 900 jobs in 2020. Two rural areas in the north had rates above the county average despite small numbers, and a third of deaths in those areas occurred with no one present to call for help. The lowest rate was in the affluent Westfield area, at 12 per 100,000.

Interpreting Differences Across Groups and Places

Krieger (2001) offers terms for interpreting such patterns without reducing them to individual behavior. Socioeconomic position, discrimination and the social production of disease direct attention to the conditions that shape exposure and access, such as job loss, incarceration, neighborhood poverty and unequal access to treatment. The faster rise among Black residents and the concentration in Eastside suggest that differences in drug supply exposure, treatment access and the aftermath of incarceration may be at work, rather than differences in individual choices.

A Population Perspective

Rose (1985) distinguished the causes of individual cases from the causes of a population's overall rate. Harlan's rise across nearly every group and area suggests a shift in a population-level exposure, fentanyl's spread through the county's street drugs, layered on top of existing vulnerabilities. That perspective implies that prevention must include population-wide measures, such as broad naloxone distribution, as well as efforts focused on the highest-risk groups identified here.

Circumstances of Death

Medical examiner reports add detail that rates alone cannot. In 2023, 61% of deaths occurred in a private residence, and in 44% of cases the person was alone, meaning no one was present to call for help or give naloxone. Naloxone was administered by a bystander or emergency responder in only 18% of deaths. Most people who died had used alone at home, and many of those in the northern rural areas lived more than twenty minutes from the nearest emergency medical services station. Among those with prior nonfatal overdoses, the median time from the last emergency visit to death was about four months, a window in which treatment or naloxone might have been offered. These circumstances point to specific opportunities: getting naloxone into homes, reducing solitary use and connecting people to treatment after an emergency visit.

Hypotheses

The description suggests four hypotheses for further study. First, fentanyl contamination of the local drug supply is the main driver of the county-wide increase. Second, the closure of the treatment program in 2020 contributed to the rise in 2020 and 2021. Third, release from incarceration without treatment is a major risk factor for death. Fourth, the faster rise among Black residents reflects later arrival of fentanyl in some drug markets combined with lower access to medication treatment.

Data Limitations

Death certificates vary in how thoroughly drugs are listed, especially in earlier years when toxicology testing was less complete. Race is recorded by funeral directors and may be misclassified. Place is based on residence rather than where the overdose occurred. Rates for small areas and groups are unstable from year to year.

Comparing with the State

Harlan's 2023 rate of 33.5 per 100,000 compares with a statewide age-adjusted rate of about 29 per 100,000 in the same year, suggesting the county's burden is somewhat higher than average, though age adjustment for the county would refine the comparison.

Next Steps

The next milestone will review evidence on interventions that address these patterns, including naloxone distribution and medication treatment after overdose. Later work will plan surveillance improvements and analyses to test the hypotheses.

Conclusion

Harlan County's overdose deaths nearly doubled over five years, rising fastest among Black residents and concentrating among adults aged 25 to 44, men, people recently released from incarceration and residents of the poorest area, as fentanyl came to dominate toxicology results. Careful description by time, person and place points to where action is most urgent and what questions to ask next.

References

Krieger, N. (2001). A glossary for social epidemiology. Journal of Epidemiology and Community Health, 55(10), 693-700. https://doi.org/10.1136/jech.55.10.693

Rose, G. (1985). Sick individuals and sick populations. International Journal of Epidemiology, 14(1), 32-38. https://doi.org/10.1093/ije/14.1.32

Rudd, R. A., Aleshire, N., Zibbell, J. E., & Gladden, R. M. (2016). Increases in drug and opioid overdose deaths: United States, 2000-2014. MMWR. Morbidity and Mortality Weekly Report, 64(50-51), 1378-1382. https://doi.org/10.15585/mmwr.mm6450a3