Substance Related Deaths Among American Indians and Alaska Natives in Oregon and Washington, 2010-2012

BACKGROUND:  American Indian and Alaska Native (AI/AN) populations continue to suffer poor health outcomes related to drugs and alcohol, despite some improvements in recent years (Walters et. al. 2002). Many AI/AN live on reservations and tribal lands in rural areas. While rural areas were once considered a “safe haven” from substance abuse, offering a close-knit protective environment, research since the 1990’s show that rural areas experience significant impacts from substance use (Lambert et. al. 2008). Given lingering substance abuse and access to care issues in tribal communities, we investigated the relationship of race and rurality on substance related mortality in Oregon and Washington.

METHODS:  Using race-corrected death certificate data from Oregon and Washington (2010-2012), we used logistic regression to examine the primary outcome of substance-related deaths by race and residence in a rural county, controlling for age and sex.  Substance-related deaths include deaths with drugs (prescription medications and illicit drugs) or alcohol listed as an underlying or contributing cause of death on the death certificate (Northwest Portland Area Indian Health Board, 2012). Our independent variables were race (AI/AN vs. non-Hispanic White (NHW)) and rurality (rural vs urban, defined by NCHS’s 2013 Urban-Rural classification scheme), with sex and age as control variables. All analyses were conducted using SAS version 9.4.

RESULTS:  Bi-variate analysis showed that AI/AN race (OR=1.70, 95% CI: 1.59, 1.81) and residence in a rural county (OR=1.08, 95% CI: 1.04, 1.11) were associated with increased odds of substance-related deaths. After controlling for age, sex, and rural residence, AI/AN had significantly higher odds of substance-related deaths compared to NHW (adjusted OR=1.22, 95% CI: 1.14, 1.30). When controlling for race, age, and sex, substance related mortality was higher in rural areas compared to urban areas (adjusted OR=1.06, 95% CI: 1.03, 1.10). 

CONCLUSIONS:  Our results support other studies that have found relatively higher mortality from substance abuse in rural areas. Our results also suggest that AI/AN communities experience a higher burden of substance related mortality than their NHW counterparts, regardless of residence in an urban or rural community. The reasons for these disparities are complex, and include higher rates of illness and injury among AI/AN, persistent socio-economic disparities, historical trauma, and chronic underfunding for behavioral health services in tribal communities.  Future studies should further investigate the relationship between substance related mortality, rurality, and access to services in AI/AN communities, to inform public health priorities in both rural and urban communities.