IHP 515 Module 9 Final Project Example

Opioid Overdose Deaths in Harlan County: An Epidemiologic Profile and Recommendations for Prevention

[Student Name]

Southern New Hampshire University

IHP 515: Population-Based Epidemiology

Module Nine Final Project

[Instructor Name]

[Date]

Opioid Overdose Deaths in Harlan County: An Epidemiologic Profile and Recommendations for Prevention

Executive Summary

Across Harlan, the composite county profiled here, yearly opioid overdose deaths climbed from the high thirties to the low seventies between 2019 and 2023, nearly doubling the death rate, as fentanyl came to be detected in close to four of every five deaths. Risk peaked in young and middle-aged adults and in men, and was especially high for people just out of jail, people with a prior nonfatal overdose and residents of the county's poorest area, and rates rose fastest among Black residents. Most people died at home and alone. The evidence supports broad naloxone distribution, medication treatment begun during emergency visits and before people leave custody and better surveillance, with specific targets and monitoring.

Context

Rudd et al. (2016) documented a steep national rise in overdose deaths, with opioid-involved deaths growing fastest and the recent surge driven by heroin and synthetic opioids such as illicit fentanyl. Harlan's experience follows that national arc a few years later: stable rates through 2019, then annual increases coinciding with fentanyl's arrival in local drug markets and with disruptions during the pandemic.

Descriptive Findings

The crude death rate climbed each year from 2019 through 2023, reaching about 34 per 100,000, and a simplified age adjustment showed Harlan's burden exceeding that of a younger neighboring county whose crude rate appeared higher. Adults aged 25 to 44 had a 2023 rate of about 75 per 100,000. Men accounted for nearly three quarters of deaths. Rates among Black residents roughly tripled over the period and overtook those among white residents. By place, the Eastside area, marked by high poverty and a major plant closure, reached 58 per 100,000. Nearly a quarter of decedents had left incarceration within the prior year, about three in ten had survived an earlier overdose within twelve months and fewer than one in five had recent medication treatment. Most died in a residence, and in over two in five deaths no one else was present.

Causal Reasoning

Several causes appear to act together. Fentanyl's spread through the local drug supply is the most likely driver of the county-wide rise, given the parallel increase in fentanyl detection across groups and areas. The 2020 closure of the county's treatment program probably contributed to some deaths among its former patients but explains only a small share of the rise, since deaths increased among non-patients and in neighboring counties too. Jail release without treatment and prior nonfatal overdose mark periods of very high risk. The faster rise among Black residents likely reflects differences in the timing of fentanyl's arrival in certain markets and in treatment access, rather than individual behavior. These conclusions rest on observational data and are subject to confounding, which the planned analyses will examine.

A Population and High-Risk Strategy

Rose (1985) argued that when a risk factor is widespread, a population strategy that shifts risk for everyone can prevent more deaths than focusing only on the highest-risk individuals. Fentanyl contamination affects nearly everyone who uses illicit drugs in Harlan, so population-wide measures such as broad naloxone availability are essential. At the same time, the descriptive data identify moments of extreme risk, after jail release and after a nonfatal overdose, where targeted action can have outsized benefit. The recommendations combine both strategies.

Evidence for Recommended Actions

Walley et al. (2013) found in an interrupted time series across Massachusetts communities that overdose education and naloxone distribution were associated with lower overdose death rates, with larger reductions where more people were reached. Larochelle et al. (2018) followed overdose survivors and found that methadone and buprenorphine in the following year were associated with substantially lower mortality. Both findings come from observational designs, but their consistency, dose-response patterns and clear mechanisms support action.

Recommendations

First, distribute naloxone widely, including mailed kits, pharmacy standing orders, distribution at jail release and emergency departments and outreach to households and rural areas where people use alone. Second, start buprenorphine in emergency departments for patients after overdose and before release from jail, with a warm handoff to community treatment. Third, restore and protect treatment capacity, including a plan to keep medication available during emergencies. Fourth, expand outreach in the Eastside area and among Black residents through trusted community partners. Fifth, strengthen surveillance as described below.

Table 1. Recommendations, Targets and Measures

Note. Targets are illustrative and should be set with community partners.

Surveillance and Evaluation

Thacker and Berkelman (1988) describe surveillance as continuing, organized data work that supports planning and evaluation and must reach those who can act. Harlan will add near-real-time emergency department alerts, standardize toxicology testing, link death, jail, treatment and pharmacy records and publish a monthly dashboard. The primary outcome for evaluating the recommendations is the age-adjusted overdose death rate, tracked quarterly and compared with state trends, with secondary measures for each recommendation and results reported by race and area to confirm that gaps are narrowing.

Limitations

County rates rest on small numbers and are unstable, especially for subgroups. Death certificates varied in completeness before toxicology was standardized. Causal conclusions are qualified by possible confounding, and the evidence for interventions comes from other settings. The profile should be updated annually as new data arrive.

Estimates of subgroup trends will be revisited with pooled multiyear data before any subgroup-specific targets are finalized.

Conclusion

Harlan County's overdose crisis follows the national shift to fentanyl but falls unequally, concentrating in moments and places of high risk. Epidemiologic description, careful causal reasoning and evidence from other communities point to a clear response: make naloxone ubiquitous, start treatment at the moments of greatest risk, protect treatment capacity, reach the most affected communities and measure whether deaths fall.

References

Larochelle, M. R., Bernson, D., Land, T., Stopka, T. J., Wang, N., Xuan, Z., Bagley, S. M., Liebschutz, J. M., & Walley, A. Y. (2018). Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: A cohort study. Annals of Internal Medicine, 169(3), 137-145. https://doi.org/10.7326/M17-3107

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

Thacker, S. B., & Berkelman, R. L. (1988). Public health surveillance in the United States. Epidemiologic Reviews, 10(1), 164-190. https://doi.org/10.1093/oxfordjournals.epirev.a036021

Walley, A. Y., Xuan, Z., Hackman, H. H., Quinn, E., Doe-Simkins, M., Sorensen-Alawad, A., Ruiz, S., & Ozonoff, A. (2013). Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: Interrupted time series analysis. BMJ, 346, Article f174. https://doi.org/10.1136/bmj.f174