Social Determinants of Mortality of COVID-19 and Opioid Overdose in American Rural and Urban Counties.

Objectives: Both COVID-19 deaths and opioid overdose deaths continue to increase in the United States. Little is known about the characteristics of counties with high rates of mortality for both.

Methods: We analyzed county-level data on COVID-19 mortality from January 1 to May 31, 2020, and on opioid overdose mortality during 2014-2018. The outcome variable, "high-risk county" was a binary indicator of high mortality rates (above 75% quartile) for both COVID-19 and opioid overdose. We conducted geospatial logistic regression models separately for urban and rural counties to identify social determinants of health associated with being a high-risk county.

Results: After adjusting for other covariates, the overall mortality rate of COVID-19 is higher in counties with larger population size and a higher proportion of racial/ethnic minorities, although counties with high rates of opioid overdose mortality have lower proportions of racial/ethnic minorities, a higher proportion of females, and are more economically disadvantaged. Significant predictors of rural counties with high mortality rates for both COVID-19 and opioid overdose include higher proportions of Blacks (Adjusted odds ratio [aOR], 1.04; 95%CI, 1.01-1.07), American Indians and Alaska Natives (aOR, 1.07; 95%CI, 1.02-1.13), and two or more races (aOR, 1.34; 95%CI, 1.13-1.60). Additional predictors for high-risk urban counties include population density (aOR, 1.12; 95%CI, 1.04-1.22) and higher unemployment rates during the COVID-19 pandemic (aOR, 1.23; 95%CI, 1.07-1.41).

Conclusions: Rural counties with high proportions of racial/ethnic minorities and urban counties with high unemployment rates are at high mortality risk for COVID-19 and opioid overdose.