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Drug Alcohol Depend. 2017 Apr 1;173:1-9. doi: 10.1016/j.drugalcdep.2016.12.011. Epub 2017 Jan 25.

Bowling alone, dying together: The role of social capital in mitigating the drug overdose epidemic in the United States.

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Department of Government, Harvard University, 1737 Cambridge St, Cambridge, MA 02138, USA. Electronic address:
Department of Family and Community Medicine, Baylor College of Medicine, 3701 Kirby Dr., Suite 600 (MS: BCM700), Houston, TX 77098, USA. Electronic address:



Drug overdose deaths have risen precipitously over the last fifteen years. Substantial geographic variation, beyond a simple rural-urban dichotomy, exists in the concentration of overdose deaths, suggesting the existence of as-yet unidentified environmental variables that predict resilience (or vulnerability) to drug overdoses. Motivated by reports highlighting the role of community fragility in the opioid epidemic, we explore whether social capital attenuates overdose death rates.


We conducted an ecologic temporal trends study from 1999 to 2014 to investigate the association between mortality due to drug overdose and social capital. Data from multiple sources were compiled at the county-level to produce an analytic dataset comprising overdose mortality, social capital, and a host of potentially confounding variables indicated by the literature (N=49,664 county-years). Multinomial logistic regression was used to estimate the likelihood that a county falls in low (<4 deaths per 100,000), moderate, or high (>16 deaths per 100,000) categories of annual overdose morality.


We observed a strong and statistically significant inverse association between county-level social capital and age-adjusted mortality due to drug overdose (p<0.01). Compared to the lowest quintile of social capital, counties at the highest quintile were 83% less likely to fall in the "high-overdose" category and 75% less likely to fall in the "moderate-overdose" category.


This study finds large-sample evidence that social capital protects communities against drug overdose. This finding could help guide policymakers in identifying where overdose epidemics are likely to occur and how to ameliorate them.


Drug overdose; Drug poisonings; Ecologic; Opioids; Overdose mortality; Social capital

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