Table 4.
Summary of Measures and Findings for Included Studies.
| Author (Year) | Measure of SEM | Opioids involved | Overdose characteristic (intent; type) |
Measure of overdose | Main findings | Risk of bias |
|---|---|---|---|---|---|---|
| Amundsen (2015) | SES composite | Prescription & non-prescription | Intentional & unintentional; fatal | ICD-10 codes for opioid poisoning deaths | Socioeconomic Status: Three clusters were created from a two-step cluster analysis: Very low SES: persons of a younger age (15–44), lowest level of education, not participating in the workforce, some participation in shorter work-related training/support and a high level of means-tested social benefits; Disabled: persons of an older age (35–64), on a disability pension, low level of education, income higher than the minimum pension (due to the disability pension), not participating in the workforce, some in need of means-tested social welfare benefits, largest proportion of women; Edge of the workforce (higher SES): mainly aged 24–54 years, highest level of education, more years with income above the minimum pension, highest proportion with workforce participation and work-related training/support, less use of means-tested social welfare benefits. Heroin overdose death (very low SES vs. disabled vs. edge of workforce): 55.5% vs. 33.6% vs. 47.1%, p < 0.05 in cause of death cluster Heroin overdoses were most common in the very low SES cluster; other opioid overdoses were more common among those on disability and on the edge of the workforce. |
Poor |
| Binswanger et al. (2007) | Criminal justice involvement | Prescription & non-prescription | NR; fatal | ICD-10 codes for opioid poisoning deaths | Recent release from prison: Heroin-related deaths n; n/100,000 person-years (95 %CI) Overall: 18; 32 (20–50) Within 2 weeks after release: 6; 409 (184–91) More than 2 weeks after release: 12; 23 (14–40) Methadone-related deaths n; n/100,000 person-years (95 %CI) Overall: 18; 32 (20–50) Within 2 weeks after release: 5; 341 (142–818) More than 2 weeks after release: 13; 23 (14–40) Other opioid-related deaths n; n/100,000 person-years (95 %CI) Overall: 13; 23 (13−40) Within 2 weeks after release: 5; 341 (142–818) More than 2 weeks after release: 8; 14 (7−29) |
Fair |
| Bohnert et al. (2011) | Employment, SES composite, Criminal justice involvement | NR | Unintentional; fatal | Opioid overdose deaths identified through Office of the Medical Examiner (OME) | Unemployment rate: No significant associations were found between unemployment rate and overdose |
Fair |
| SES composite: Including percent of persons per precinct who had less than a high school education, earned less money annually than 200 % of the federal poverty level, and received public assistance, as well as the percent of households per precinct with a self-reported female head of household. The composite was scored in the direction of disadvantage, with more socioeconomically disadvantaged precincts scoring higher (range 23.4–189.0). Posterior median for opiate overdose: 0.35; 95 % credible interval: 0.05−0.64 | ||||||
| Misdemeanor arrest rate (per 1000): Posterior median for opiate overdose: 0.003; 95 % credible interval: 0.001−0.01 | ||||||
| Brinkley-Rubinstein et al. (2018) | Criminal justice involvement | Non-prescription | NR; fatal | Opioid overdose deaths identified through OME | Incarceration in year preceding death: Fentanyl-related overdose in those incarcerated the year preceding death (2015 vs. 2014): RR: 1.99, 95% CI: 1.11−3.57, p = 0.014 No significant differences in overdose rates were found by race/ethnicity, age, or gender over time. |
Poor |
| Burns et al. (2004) | Employment, Social support, | Non-prescription | NR; non-fatal | Self-reported lifetime history of overdose | Relationship dissatisfaction: MV logistic regression model found that dissatisfaction with relationships predicted overdose history (Wald-statistic 4.05, p < 0.05) No significant associations were found between employment status, social support, living alone/in temporary accommodation and overdose. |
Poor |
| Brown and Wehby, 2019 | Homelessness & Housing, Income and poverty, Employment, Health insurance |
Prescription & non-prescription | Unintentional & undetermined; fatal | ICD-10 codes for opioid poisoning deaths | Median house price: Effect of median house price on opioid death rate: −0.0121, p < 0.05 The effect median house price on opioid and prescription opioid death rate estimates were only statistically significant among males (-0.0168, p < 0.05 and -0.0199, p < 0.01, respectively) but not among females. The effect median house price on opioid and prescription opioid death rate estimates were only statistically significant among non-Hispanic Whites (-0.0172, p < 0.05 and -0.0187, p < 0.01, respectively) but not among Black or Hispanic racial/ethnic groups. |
Fair |
| Median household income: Effect of median house price on prescription opioid rate: -0.0136, p < 0.01 | ||||||
| No significant associations were found between median household income, unemployment rate, proportion of the population with health insurance and opioid and prescription opioid overdose death. | ||||||
| Campbell et al. (2018) | SES composite | Prescription | NR; fatal & non-fatal | ICD-9 codes for non-fatal opioid poisonings & State death certificates | Neighborhood Deprivation Index: Neighborhood deprivation index was created based on home address and census tract variables (e.g. households in poverty) from the U.S. Census Bureau's 2006–2010 American Community Survey. No further information on how the index was created is provided. No significant associations were found between neighborhood deprivation indices and overdose. |
Fair |
| Carrà et al. (2017) | Criminal justice involvement, SES composite, Education, Employment, Social support | NR | NR; non-fatal | Self-reported lifetime history of non-fatal opioid overdose | Jail sentences over 6 months: AOR: 0.70, 95 % CI: 0.53−0.92 |
Poor |
| Area-level deprivation: Using residential postal codes, area-level deprivation score was calculated based on the Italian deprivation index at census block level. Five indicators (low level of education, unemployment, nonhome ownership, one parent family and overcrowding) were standardized and summed to create categorical tertiles: affluent, intermediate and deprived. Deprived vs. affluent: AOR: 2.61, 95% CI: 2.25−3.02 Intermediate vs. affluent: AOR: 1.09, 95% CI: 1.02−1.16 | ||||||
| No significant associations were found between compulsory education, unemployment, family situation and overdose death. | ||||||
| Cerdá et al. (2013) | Income and poverty, Homelessness & housing, Social support |
Prescription & non-prescription | Unintentional; fatal | Post-mortem toxicology and autopsy reports for analgesic opioids and heroin deaths | Higher median income (analgesic vs. heroin overdose death): OR: 1.40; 95% CI: 1.20−1.65 No significant associations were found between median house income and odds of analgesic vs. non-overdose death. Higher income inequality (analgesic vs. heroin overdose death): OR: 0.74; 95% CI: 0.61−0.91 No significant associations were found between income inequality and odds of analgesic vs. non-overdose death. |
Fair |
| Dilapidated Housing Structures: No significant associations were found between dilapidated housing structures, and the odds of analgesic overdose vs. non-overdose deaths, and analgesic overdose vs, heroin overdose deaths. | ||||||
| Family fragmentation (analgesic vs. non-overdose death): OR: 1.35, 95% CI: 1.05−1.72 No significant associations were found between family fragmentation and odds of analgesic vs. heroin overdose deaths. | ||||||
| Cheng et al. (2013) | Social support, Education, Employment |
Prescription & non-prescription | Unintentional; fatal | Post-mortem toxicology and autopsy reports for deaths with at least one opioid | Marital Status: Married (opioid overdose decedents vs. state-level population): 33.9% vs. 68.2%, p < 0.001 |
Fair |
| Educational Attainment: Less than high school education (opioid overdose decedents vs. state-level population): 18.5% vs. 6.9%, p < 0.001. Graduate education (opioid overdose decedents vs. state-level population): 8.7% vs. 29.9%, p < 0.001 | ||||||
| Unemployment (opioid overdose decedents vs. state-level population): 64% vs. 5%, p < 0.001 | ||||||
| Cochran et al. (2017) | Health insurance | Prescription | NR; fatal & non-fatal | ICD-9 codes for opioid poisoning deaths and hospitalization and ED visits | Medicaid eligibility type: General Assistance vs. Temporary Assistance for Needy Families: ARR: 1.58, 95% CI: 1.28−1.94, p < 0.001 Supplemental Security Income vs. Temporary Assistance for Needy Families: ARR: 1.26, 95% CI: 1.08−1.48, p = 0.004 |
Good |
| Coolen et al. (2009) | Health insurance | Prescription | Unintentional; fatal | ICD-10 codes for opioid poisoning deaths | Medicaid enrollment: Rate of deaths attributed to Prescription Opioid OD by Medicaid Status comparing the Medicaid population to anyone not enrolled in Medicaid in Washington; Age adjusted rate and relative risk (95 % CI): Medicaid vs. Non-Medicaid- 30.8; 5.7 (5.3−6.1) Medicaid PRC vs. Non-Medicaid - 381.4; 92.6 (64.1−129.5) |
Fair |
| Cropsey et al. (2013) | Education, Demographics, Employment, Homelessness & housing, Social support, Criminal justice involvement |
NR | NR; non-fatal | Self-reported lifetime history of non-fatal opioid overdose | Educational Attainment: High school completion in individuals recently released from prison (opioid overdose vs. no opioid overdose vs. no opioid use): 85% vs. 77% vs. 66%, p < 0.001 |
Poor |
| Ethnicity: Caucasian ethnicity in individuals recently released from prison (opioid overdose vs. no opioid overdose vs. no opioid use): 82% vs. 58% vs. 25%, p < 0.001 Sex: Female sex in individuals recently released from prison (opioid overdose vs. no opioid overdose vs. no opioid use): 47%, vs. 32% vs. 27% p < 0.001 | ||||||
| No significant associations found between employment status, housing situation, marital status or living situation and overdose in in individuals recently released from prison. | ||||||
| Dunn et al. (2016) | Employment, Criminal justice involvement, Health insurance, Social support |
Prescription & non-prescription | NR; non-fatal | Self-reported lifetime history of non-fatal opioid overdose | No significant associations were found between employment status, incarceration in the past 30 days, health insurance status, marital status and opioid overdose. | Poor |
| Feng et al. (2016) | Income & poverty | Prescription & non-prescription | Intentional & unintentional; fatal & non-fatal | ICD-9 codes for opioid poisoning deaths and hospitalization and ED visits | Median household income: Quartile 1 (lowest) vs. 4 (highest): AOR: 1.80, 95% CI: 1.27−2.57 Quartile 2 vs. 4: AOR: 1.89, 95% CI: 1.34−2.66 Quartile 3 vs. 4: AOR: 1.24, 95% CI: 1.00−1.54 |
Fair |
| Fernandes et al. (2015) | Health insurance | Prescription | Unintentional; fatal | ICD-10 codes for opioid poisoning deaths | Medicaid enrollment: Opioid overdose fatality rates, comparing the Medicaid population to anyone not enrolled in Medicaid in Montana; Overdose rates (Medicaid vs. non-Medicaid): 38.2/100,000 (30.7−45.7) vs. 4.7/100,000 (4.1−5.3) |
Fair |
| Hasegawa et al. (2014) | Health insurance, Income & poverty | Prescription & non-prescription | Intentional & unintentional; non-fatal | Opioid -related near-fatal events involving mechanical ventilation Opioid-related hospitalization |
Insurance status: Medicare vs. Private: AOR:1.08, 95 % CI: 0.95−1.24 Medicaid vs. Private: AOR:1.17, 95 % CI: 1.04−1.32 Self-pay vs. Private: AOR: 0.83, 95% CI: 0.75−0.93 Other vs. Private: AOR:1.68, 95% CI: 1.44−1.95 |
Poor |
| No significant associations between income quartiles of residence and frequency of ED visits or hospitalizations for non-fatal overdose | ||||||
| Hollingsworth et al. (2017) | Employment | Prescription & non-prescription | Intentional & unintentional; fatal & non-fatal | ICD-10 codes for opioid poisoning deaths Opioid-related ED visits |
County-level Employment: Effect of unemployment rate on opioid death rate: 0.19, p < 0.01 Effect of unemployment rate on opioid overdose ED visit rate: 0.95, p < 0.01 State-level Employment: Effect of unemployment on opioid death rate: 0.33, p < 0.01 Effect of unemployment on opioid overdose ED visit rate: 0.35, p < 0.01 |
Good |
| Jenkins et al. (2011) | Criminal justice involvement, Homelessness & housing |
Prescription & non-prescription | NR; non-fatal | Self-reported heroin overdose in the past year | Incarceration: Incarceration of 5+ days: AOR: 1.88, 95% CI: (1.04–3.40) |
Poor |
| No permanent housing was not associated with non-fatal overdose. | ||||||
| Marshall et al. (2017) | Income & poverty, Education |
Prescription & non-prescription | Intentional & unintentional; fatal | Opioid overdose deaths identified through coroners | Median household income: Adjusted Mortality Ratio (AMR; 95 % CI) for PO deaths $59,410–83,900 vs. < $59,410: 0.65 (0.52–0.81) $83,910–97,460 vs. < $59,410: 0.58 (0.42–0.80) $97,470 vs. < $59,410: 0.50 (0.33–0.74) AMR (95 % CI) for heroin deaths: $97,470 vs. < $59,410: 0.33 (0.15–0.70) % Below Poverty level: AMR (95 % CI) for PO deaths 6.35–9.99 % vs. < 6.35 %: 1.45 (1.10–1.89)16.86 % vs. < 6.35 %: 2.90 (1.02–4.68) AMR (95 % CI) for heroin deaths 16.86 % vs. < 6.35 %: 2.18 (1.02–4.68) |
Fair |
| % Higher education: AMR (95 % CI) for PO deaths (95 % CI) 41.6–56.7 % vs. < 28.0 %: 0.59 (0.39–0.89)56.8 % vs. < 28.0 %: 0.45 (0.28–0.72) No significant association was found between higher education and mortality ratio for heroin deaths | ||||||
| McAuley and Best (2012) | Criminal justice involvement | Prescription & non-prescription | Unintentional; fatal | Post-mortem reports for deaths with at controlled drugs | Incarceration with heroin-related death: Prison release within 14 days of death [AOR (95% CI): 2.499 (1.046−5.969)] Prison release within 15−28 days of death [AOR (95% CI): 2.499 (1.046−5.969)] Incarceration with Methadone-related death: No significant association with prison release within 14 or 15−28 days of death |
Fair |
| Meiman et al. (2015) | Health insurance, Income & poverty |
Prescription & non-prescription | Intentional & unintentional; fatal & non-fatal | ICD-9 codes for opioid poisoning deaths and hospitalization and ED visits | Insurance Status and Poverty: In the relationship between those who use heroin versus those who use prescription opioids, there is a significant relationship in participants aged 18−34 when participants are separated into groups based on insurance status and poverty (p < 0.01) and in participants aged 35 and older when participants are separated into groups based on insurance status and poverty (p < 0.01) |
Fair |
| Nadpara et al. (2018) | Social support | Prescription | NR; non-fatal | Post-overdose reports for overdose with prescription opioids | Marital Status: Never Married vs. Married: AOR: 1.35 (1.01–1.82) Widowed vs. Married: AOR: 2.04 (1.40–2.97) |
Fair |
| Ochoa et al. (2005) | Criminal justice involvement, Income& poverty, Homelessness & housing |
Non-prescription | NR; non-fatal | Self-reported on a scale of 1−10 | Incarceration and Recent overdose: Incarcerated ≥20 months vs. Never incarcerated: AOR (95% CI): 2.99 (1.52–5.88) |
Poor |
| Sex Work: Ever been paid money for sex vs. No: OR (95% CI); 1.53 (1.05−2.23) | ||||||
| Homelessness: No association between homelessness and recent overdose | ||||||
| Ødegård et al. (2010) | Criminal Justice Involvement | NR | NR; fatal | ICD-8,910 codes for opioid poisoning deaths | Incarceration: Death from overdose during the 2 weeks after release from prison was 10 times higher (ARR: 10.2; 95% CI: 4.4–23.9), and in the 3-week period more than six times higher (ARR: 6.5, 95% CI; 2.7–15.7), than the risk during other time spent outside prison. In prison, however, the risk of overdose was less than 1/10th of the risk outside (ARR: 0.08, 95% CI 0.01–0.57) |
Fair |
| Patrick et al. (2016) | Employment, Education |
Prescription | Intentional & unintentional; fatal | ICD-10 codes for opioid poisoning deaths | Unemployment Rate: Unemployment rate was not associated with a decrease of opioid-related overdose deaths rates |
Fair |
| Educational Attainment: Educational attainment was associated with a decrease of 0.08 opioid-related overdose deaths per 100,000 population annually (-0.08: 95% CI: -0.40, -0.24) | ||||||
| Paulozzi et al. (2009) | Social support, Education, Income & Poverty |
Prescription | Unintentional; fatal | ICD-10 codes for opioid poisoning deaths | Marital Status and College Education: The methadone group had fewer people who were married (p = 0.024), and fewer people who had attended college (p = 0.048) No association between type of overdose decedents and poverty rate by county. |
Fair |
| Ponicki et al. (2018) | Income & Poverty, Demographics |
Prescription | NR; non-fatal | ICD-9 codes for opioid-related poisoning | Median Household Income: No association between median HH income/% of families in poverty with zip code rates of prescription opioid poising hospitalizations |
Good |
| Indigenous ancestry: Association of % American Indians with zip code rates of prescription opioid poising hospitalizations Relative Rate (95% CI): 1.015 (1.008, 1.023) Association of zip code within an American Indian reservation with zip code rates of prescription opioid poising hospitalizations; Relative Rate (95% CI): 0.473 (0.294, 0.753) | ||||||
| Rintoul et al. (2010) | SES composite, Employment |
Prescription | Intentional & unintentional; fatal | Post-mortem toxicology and autopsy reports for opioid-related deaths | Socioeconomic Status: Socioeconomic status using residential address and the Victorian Index of Relative Socioeconomic Disadvantage. Lower scores/quintiles indicate an area has many people with low levels of education, employed in low-skill jobs, and many households with low income. Unintentional drug toxicity deaths: Quartile 1 vs. Quartile 4: Rate ratio (95% CI): 3.0 (1.4–6.1) |
Fair |
| Employment status: No association between unemployed and on other government benefits versus all other employment status types with fatal drug toxicity cases involving oxycodone (2003−2009) | ||||||
| Seal et al. (2001) | Homelessness & housing, Criminal Justice Involvement, Income & poverty, SES Composite |
NP | NR; non-fatal | Self-reported history of overdose | Currently Homeless: Homeless at the time of the interview vs. not homeless: OR (95% CI): 2.59 (1.87, 3.59) Criminal Justice Measures: Arrested 3 or more times in the past year: AOR (95% CI); 2.50 (1.61, 3.87) No association between total length of time incarcerated and prevalence of recent OD Prohibited Income Received money or drugs in exchange for sex within the last 6 months: OR (95% CI); 2.08 (1.38, 3.14) Social Marginalization Score Respondents were assigned 1 point for each of the following variables they reported: being currently homeless; spending 5 or more years in jail, identifying as lesbian, gay, bisexual, or transgender, and engaging in sex work for money or drugs in the past 6 months. For each additional characteristic that a participant reported, the likelihood of associated overdose increased in a stepwise fashion. One point: OR (95% CI); 2.33 (1.46, 3.72) Two points: OR (95% Cl); 3.73 (2.27, 6.14) Three points or more: OR (95% Cl); 6.76 (3.45, 13.2) |
Poor |
| Shah et al. (2005) | Social Support | Prescription & non-prescription | Unintentional; fatal | Post-mortem toxicology and autopsy reports for opioid-related deaths | Marital Status: Decedents who died from methadone co-intoxication with prescription drugs were significantly more likely to be living with a partner or married (44.1% versus 29.0% for methadone alone and 25.0% for methadone and illicit drugs) p < 0.05 |
Fair |
| Sharp and Melnik (2015) | Health insurance | Prescription & non-prescription | NR; fatal | ICD-10 codes for opioid poisoning deaths | Medicaid Status: Rate ratios comparing death rates between 2003 and 2012: Medicaid: 5.3; Non-Medicaid: 3.9 Deaths per 100,000 among all New York state residents not enrolled in Medicaid increased from 0.73 in 2003 to 2.82 in 2012, while among Medicaid enrollees, the rates increased from 1.57 to 8.31 over the same period. New York state Medicaid enrollees had higher death rates for opioid analgesic poisonings than did those not enrolled in Medicaid, and the differences increased over time. |
Fair |
| Sherman et al. (2007) | Homelessness & housing, Education, Criminal justice involvement, Employment |
NR | NR; non-fatal | Self-reported history of overdose | Homelessness: Homeless in the past 6 months vs. not homeless in overdose: AOR (95% CI): 2.9 (1.5, 5.7) |
Poor |
| No significant association between education/recent incarceration/employment and overdose | ||||||
| Siegler et al. (2014) | Education, Income & poverty |
Prescription & non-prescription | Unintentional; fatal | ICD-10 codes for opioid poisoning deaths | Education: Unintentional opioid overdose deaths with Education: College or more vs. less than high school: AOR (95% CI): 2.13 (1.44, 3.16) |
Good |
| No significant association between neighborhood poverty and unintentional opioid overdose | ||||||
| Visconti et al. (2015) | Income & poverty | Prescription & non-prescription | Unintentional; fatal | Post-mortem toxicology and autopsy reports for opioid-related deaths | Poverty: Decedents above poverty line (%)/decedents below poverty line (%) by race: Decedents below the poverty line were more likely to be African-American (23.2 % compared to 11.9%, p = 0.03) Decedent age and sex distributions were similar across areas above and below the poverty line |
Fair |
| Wagner et al. (2015) | Homelessness & housing Criminal justice involvement |
Prescription & non-prescription | NR; non-fatal | Self-reported history of overdose | Homelessness: Homeless in the past 6 months: ≥1 overdose in the past six months: 35 (77.8 %) No overdoses in the past six months: 315 (59.7 %) p = 0.02 |
Poor |
| Criminal justice measures: Arrested for drug possession in the past 6 months: AOR (95% CI); 5.17 (2.37, 11.24) ≥1 OD in the past six months vs. No OD in past 5 months Arrested: 19 (43.2 %) vs. 135 (25.7 %); p = 0.02 Arrested for drug possession 12 (27.3 %) vs. 38 (7.3 %) p < 0.001 Police presence caused hurried or rushed injection 18 (40.9 %) vs. 133 (25.3 %); p = 0.03 No association between being somewhat/very fearful that police are going to arrest or interfere with drug use, having their syringes confiscated by police. | ||||||
| Zlotorzynska et al. (2014) | Income & poverty | Prescription & non-prescription | NR; non-fatal | Post-overdose reports for opioid-related ODs | Income Assistance: The risk of overdose for those injecting on the three days beginning with cheque day was significantly higher than for those injecting on other days; OR (95% CI): 2.06 (1.80–2.36) The risk of overdose on the three days beginning with cheque day was significantly higher for those injecting opioids alone; OR (95% CI): 2.16 (1.83–2.55) Exclusive opioid use was reported in 66 % of overdoses that occurred on the three days beginning with cheque day, while 75 % of overdoses on other days involved opioid use; OR (95% CI): 0.63 (0.47–0.84) |
Fair |
Statistically significant results denoted in bold.