Over the past 2 decades, drug-related deaths have grown to be a major U.S. public health problem. County-level differences in drug-related mortality rates are large. The relative contributions of social determinants of health to this variation, including the economic, social, and healthcare environments, are unknown.

Using data from the U.S. Centers for Disease Control and Prevention Multiple-Cause of Death Files (2006–2015, analyzed in 2017); U.S. Census Bureau; U.S. Department of Agriculture Economic Research Service; Agency for Healthcare Research and Quality; and Northeast Regional Center for Rural Development, this paper modeled associations between county-level drug-related mortality rates and economic, social, and healthcare environments. Spatial autoregressive models controlled for state fixed effects and county demographic characteristics.

The average county-level age-adjusted drug-related mortality rate was 16.6 deaths per 100,000 population (2006–2015), but there were substantial geographic disparities in rates. Controlling for county demographic characteristics, average mortality rates were significantly higher in counties with greater economic and family distress and in counties economically dependent on mining. Average mortality rates were significantly lower in counties with a larger presence of religious establishments, a greater percentage of recent immigrants, and counties with economies reliant on public (government) sector employment. Healthcare supply factors did not contribute to between-county disparities in mortality rates.

Drug-related mortality rates are not randomly distributed across the U.S. Future research should consider the specific pathways through which economic, social, and healthcare environments are associated with drug-related mortality.