• poisoning;
  • opioid;
  • heroin;
  • cocaine;
  • psychotropic;
  • urbanization



This study was conducted to determine how the recently reported increase in drug poisoning mortality rates in the United States varied by degree of urbanization. Although drug poisoning is traditionally seen as an urban problem, evidence suggested that at least one component of the recent increase, deaths involving opioid analgesics, was increasing more rapidly in rural areas.


The study compared age-adjusted unintentional and undetermined drug poisoning mortality rates between 1999 and 2004 from the National Vital Statistics System (NVSS) in each of six urban–rural categories.


Unintentional and undetermined drug poisoning mortality rates rose 62% from 1999 to 2004. Metropolitan county rates rose 51%, an increase of 2.66/100 000, while nonmetropolitan county rates rose 159%, an increase of 4.81/100 000. By 2004, metropolitan and nonmetropolitan drug poisoning rates had roughly equalized. In the narcotic drug category, which included heroin, cocaine, and opioid analgesics, the most urban (“large central metro”) counties increased only 16% while the most rural (“noncore, nonmetropolitan”) counties increased 248%. Heroin rates did not increase significantly for any urban–rural category. Cocaine rate increases were largest in nonmetropolitan counties. Opioid analgesic rate increases ranged from a low of 52% in large central metro counties to an increase of 371% in nonmetropolitan, noncore counties.


Prescription drugs have replaced heroin and cocaine as the leading drugs involved in fatal drug overdoses in all urban–rural categories. Fatal drug overdoses are no longer a predominantly urban phenomenon. National prevention efforts will have to shift to address nontraditional populations using nontraditional drugs. Copyright © 2008 John Wiley & Sons, Ltd.