Geospatial analysis: Using Spatial-Temporal Cluster Detection Methods to Monitor

Opioid Related Mortality Rates in The United States

Amalia Mendes & Kelly Janus

amendes@clarku.edu
kjanus@clarku.edu

Clark University
Advanced Vector GIS, 2018
 Abstract
This project accomplishes two tasks. First, it utilizes yearly reports of age adjusted
mortality rate due to opioid-related deaths in all US counties from 1999 to 2015 to search for
spatial and spatial-temporal hotspots of high and low opioid-related mortality rates. Second, it
uses the explanatory variables of poverty, education attainment, and prescription drug rate from
medicare part d to find correlation between these factors and hotspots for high mortality rate.
Through conducting 1) clustering analysis using inverse distance squared and queen’s
case neighborhood weighting and 2) Getis Ord Gi* hotspot analysis, it was discovered that
counties in eastern Kentucky and New Mexico have the highest neighborhood clustering of
opioid related mortality. Using queen’s case neighborhood weighting, notable coldspots were
found in the Great Plains region, namely South Dakota and Nebraska. An emerging hot spot
analysis from 1999 to 2009 and from 1999 to 2014 discovered that no emerging coldspots exist
and confirmed that hotspots exist in eastern Kentucky and New Mexico. There are no
neighborhood regions of growing coldspots to indicate that the rate of opioid related deaths are
falling.
Regression statistics using explanatory variables for education attainment, poverty
percentage, and medicare part d prescription rates show that the explanatory variables account
for only 7% of the overall trends; however, the model accounted for 54% when using
Geographically Weighted Regression (GWR) thus increasing the model’s performance. This
merits further study for potential conditions which lead to or accompany high opioid related
mortality rates.

Introduction opioids is linked to other health issues such

The United States of America is still
grappling with an opioid epidemic which
was only just declared a public health
emergency in late 2017 (Allen, 2017). The
crisis began due a variety of factors, one of
which being over-prescription of pain
medications by doctors who were assured of
the minimal effects of addictions by
pharmaceutical companies. These
prescriptions resulted in widespread misuse
by approximately 11.5 million persons and
was indicative of the medications’ addictive
properties (Felter, 2017). More than 115
people died from opioid-related overdoses
per week in 2017 alone (National Institute
on Drug Abuse, 2018). The opioid epidemic
is an umbrella-term for deaths related to
opioids ranging from prescribed pain
relievers to heroin. These opioids and
opiates and can be classified into two broad
categories- legally manufactured
medications and illicit narcotics. Misuse of
as an increase in neonatal abstinence
syndrome and infectious diseases such as
HIV and Hepatitis C (Felter, 2017).
Beyond being a public health issue,
the crisis has begun to threaten national
security and has led to an economic burden
of 78.5 billion dollars annually for
healthcare, addiction treatment, and criminal
activity (About the U.S. Opioid Epidemic,
2018). For these reasons, thorough study of
spatial and spatial temporal clustering
coupled with studies of explanatory
variables is necessary to help understand and
combat this public health emergency.
Objective
This study aims to examine the
spatial distribution and cluster patterns of
opioid related overdoses throughout the
United States at a county level. The study
will try to identify areas most vulnerable to
overdose using neighborhood clustering and
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hotspot analysis. In addition to the hotspot
analysis, the study will also analyze whether
if there has been an increase or decrease in
opioid related overdoses over the years by
looking at emerging hot spot analysis. GIS
techniques will be used to achieve the
objectives of this study and gain an
understanding of if there are any spatial
patterns that exist within the country. In
addition to this, regression analysis using
Data
Our data consists of four primary data
sources which are listed in Table 1.
The first data source is county-level data of
age adjusted opioid-related mortality
collected yearly from 1999 to 2015 and
standardized by the Center for Disease
Control. The age adjusted mortality rate
compares an expected death rate
-standardized for 8 age groups of both men
Table 1: Data sets used in study
GeoDA will allow an exploration of whether
there is a statistical significance between the
prescriptions, education, poverty, and opioid
overdoses.
The study will try to identify the
relationships between prescriptions,
education, poverty and opioid overdoses in
the United States of America at a county
level with the hope of contributing to policy
development and curbing the crisis.
and women- to mortality due to or
corresponding with opioid use (Curtin,
2018). Opioid related deaths are considered
any death in which the deceased has
detectable amounts of opioids and/or opiates
in his or her system including drugs which
are prescription and/or synthetic (Common
Sense for Drug Policy).
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 For Specific Time Interval in Specific County:
Total Age Total Total
Population Group Number of Pop. in
in County in (Range) Deaths in Age
Time Age Group Group
Interval
T R m p
Table 2: Variables used in calculating age adjusted mortality rate
Age adjusted death rate is used
because crude death rate fails to take into
account the fact that older populations are
more likely to have a higher crude death rate
than younger populations. This way, a
country with more elderly people would be
over-represented compared to a county with
more young people.
All Deaths
Crude Death Rate = T otal P opulation
x 100,000
According to Buescher, “The main purpose
of age-adjusted death rates is to control for
differences in the age distribution of various
populations before making mortality
comparisons” (2010). There are multiple
ways to do this. One is to take tha age
specific death rates per 100,000 people, A,
and multiply this by the standard population
proportion (see Table 2). Then sum across
the age groups to create an overall age
adjusted death rate.
In this data set, opioid related
mortality qualifies as any overdose death
which involves at least one form of opioid
(Common Sense for Drug Policy). Four
major categories of opioids included are
natural and synthetic opioids, including but
not limited to morphine, codeine,
Percent of total Proportion Age ​Specific ​Death
population in of deaths Rate per 100,000
Age Group within pop. people
(standard group
population
proportion)
p m
T p
A= mp x 10^5
oxycodone, methadone, tramadol, fentanyl,
heroine, and heroine derivatives (CDC).
According to the CDC, “In approximately 1
in 5 drug overdose deaths, no specific drug
is listed on the death certificate. In many
deaths, multiple drugs are present, and it is
difficult to identify which drug or drugs
caused the death (for example, heroin or a
prescription opioid, when both are present)”
(National Center for Drug Statistics).
The Prescription Claims data is
compiled by Medicare Part D and spans
from 2013 to 2015. The data is taken on a
county level. This study focuses on the
number of opioid prescription claims and the
number of refill claims.
The Education dataset is compiled
by the Census Bureau and spans from 2011
to 2015. The data is taken on a county level.
This study focuses on the number of
individuals in each county who are over 25
and have less than a 9th grade education.
The Poverty dataset is compiled by the
Census Bureau and spans from 2011 to
2015. The data is taken on a county level.
This study focuses on the number of
individuals in each county who are over 18
years old and legally living in poverty.
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Methodology: ​The methodology used for this study encompassed 4 broad steps.

Figure 1: Generalized Methodology flow chart

1.Pre-Processing Data: The sheet only required us to calculate the

After the data was downloaded, it
was preprocessed in order to export it into
ArcMAp. The first excel sheet-Opioid
Mortality, was cleaned for special
characters, separated by year (17 individual
sheets). The concatenate function was used
to concatenate ‘0’ to the states
(Alabama-Connecticut) FIPS column. A
mean column was added to calculate mean
mortality rates for the year 2011-2015 to
match the ACS explanatory variables that
were 5 year estimates.
The second excel sheet comprised of
prescription claims obtained from Medicare.
mean prescription claims from 2013-2015
and rename the columns properly. Finally
the ACS data that included poverty and
education was cleaned for special characters
and percentage values were calculated on
the basis of each county. Once all the data
was formated, they were joined to the
counties shapefile.
Variables used include 1)
Variable-Percentage of population 18 and
above below the poverty line, 2) Population
25 and above with an education less than 9th
grade, and 3) Average prescription claims
from Medicare Part D.

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 Figure 2: Variable-Opioid Mortality Ranges

Figure 3: Variable- Percentage of Population (18 and above) below Poverty Line

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Figure 4: Population (25 and above) with education less than 9th Grade

Figure 5: Average Prescription Claims (2013-2015)

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2. Hot Spot Analysis:
A hotspot analysis was conducted using
contiguity edges corners, Queen’s case, for
each individual year from 1999-2015 to
understand where the hotspots and cold
spots for drug mortality rates were clustered
through the years. This method was used to
identify which states had significant
hotspots and a further analysis was
conducted on those states. A similar study
that utilizes a Getis ord Gi* was conducted
to identify hotspots of opioid mortality in a
paper titled: Hot spots in mortality from
drug poisoning in the United States,
2007–2009. The study found various
hotspots in California, Nevada, Arizona,
New Mexico, Oklahoma, the Gulf coast and
the Appalachian region while cold spots
were seen Central plains, Texas and Alaska
(Rossen, 2013). Primary hotspots were
found in the Appalachian region of
Kentucky and New Mexico.
3. Ordinary Least Squares:
An ordinary least squares (OLS) was used in
our study to determine variables
contributing to the opioid death mortality
rates as utilized in the study titled: Spatial
Trends in Opiate Overdose Death in North
Carolina: 1999-2015. The study used
variables such as race, disability, poverty,
unemployment, uninsured and less than high
school (Cordes, 2017). The explanatory
variables used in our model were-
prescription claims from Medicare Part D,
population over 25 years of age with a
less-than 9th grade education, and
individuals over 18 who live in poverty.
In order to model spatially varying
relationships between the dependent and
explanatory variables, local form of linear
regression was used using Geographically
Weighted Regression (GWR) as used in the
study titled: Spatial Analysis of Drug
Poisoning Deaths in the American West,
particularly Utah, that mapped the
population density and unemployment rates
in relation to drug poisoning rates. (Kerry,
2016). The GWR used an adaptive kernel
with an AICc bandwidth. Both residuals
from the OLS and GWR were checked for
spatial autocorrelation using the Moran’s I
tool in ArcMap using an inverse distance
conceptualization .
4. Emerging Hot Spot Analysis and Time
Cube:
The feature to point tool was used to create
centroids in each county that represented age
adjusted death rate for each year. After
consolidating all of the attribute data per
county into feature points, the data editor
was used to reposition the feature points.
When using emerging hot spot analysis, the
tool looks at the geographic coordinates for
all feature points, and the feature points
needed to be in different geographic
locations so that the hexagonal fishnet tool
can distinguish between each point. The
editor tool was used to shift, all of the points
for each year by a negligible distance so that
the attribute features in each county
remained clustered around the geographic
center of the county while having different
geographic attributes. The attribute for the
age adjusted death rate was listed for all
points under “MEDIAN”, short for median
age adjusted death rate per county (same as
mean). The tool Create Space Time Cube
was used on the data. Missing values were
extrapolated using spatial temporal
neighbors. Emerging Hot Spot Analysis
used this space time cube and focused on the
“MEDIAN” data. The Visualize Time Cube
in 3d tool was run and a 3d version of the
time cube was viewed in ESRI’s ArcGlobe.
5. Bivariate Local Indicators of Spatial
Association (BiLISA):
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Our study used a BiLISA to identify local
clusters and spatial outliers for the states of
New Mexico and Kentucky. A similar study
titled: ‘Approaches to Patient Record
Linking: How Much Difference Can It
Make?’ used a similar technique to draw a
relationship between patient risk measures
and prescription rates (Kreiner, 2017). The
BiLISA method was used in GEODA to
indicate how spatial autocorrelation varied
over the study region using the three
explanatory variables- poverty, education
Results
Our raw opioid mortality by county data
indicated that there has been a drastic
increase in opioid related mortality rates
Figure 6: Opioid mortality rate 1999
and prescription claims with our dependent
variable, opioid mortality. Additionally, the
method enabled us to map out what kind of
relationship and which polygon had a
statistically significant relationship with its
neighbors. The weights chosen for the
BiLISA were queen contiguity with first
order of contiguity. This was done rather
than inverse distance squared because we
found that inverse distance squared was too
strict and while using it we did not have
enough significant results
throughout the United States as seen in the
comparison of 1999 and 2015 as shown in
figures 6 and 7.
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 Figure 7: Opioid mortality rate 2015
The results from the optimized hotspot
analysis using the Getis-Ord Gi* displays a
cluster of opioid mortality hotspots in the
states of Oregon, Nevada, Utah,
New-Mexico, Arizona, Kentucky, Florida
and Virginia. The state of California shows a
reduction in hotspots of opioid mortality
rates while Kentucky and New Mexico
appear to increase along the years from
1999-2015. This could be due to the fact that
opioid related deaths are decreasing in
California or because opioid related deaths
are becoming spread out by county thus
becoming less spatially significant. As
opposed to the hotspots, a consistent belt of
cold spots appear to be running north to
south in the central plains in 1999 and 2015
and spreading to the East coast of New York
and Pennsylvania in 2015, see figures 8 and
9. This tells us that the north south central
plaines areas are consistently privy to less
opioid related mortality than their neighbors
to the east and west. This also tells us that
northern new york either has a reduction in
opioid related deaths from 1999 to 2015 or
by comparison to the surrounding areas, has
less opioid related mortality, thus indicating
a faster increase in opioid related mortality
in surrounding regions. By looking at
figures 6 and 7, it can be concluded that
opioid related deaths in northern New York
have worsened; however, they have
comparatively worsened more in
surrounding counties such as New York
City, northern Pennsylvania, and Boston.
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 Figure 8: Hotspot analysis, year 1999

Figure 9: Hotspot analysis, year 2015

The emerging hotspot analysis for 1999 to
2009 and for 1999 to 2014 are included in
figures 10 and 11. These maps tell two
stories. They were broken up in two time
periods to examine decadal differences in
the progression of the opioid epidemic. In
figure 10 from 1999 to 2009 we see regions
of intensifying hot spots in Appalachia,
specifically eastern Kentucky, throughout
New Mexico, and scattered in northern
California/southern Oregon. There is a
diminishing cold spot region over the north
and south regions of the central plains.
Much of the country is oscillating hot spot,
which is indicative of a series of years where
the opioid related mortality was both
increasing and slightly decreasing in
respective counties. The major conclusion
from figure 10 is that there are no persistent
cold spots or emerging cold spots. This tells
that throughout the country the opioid
related mortality rate is increasing or
remaining constant.

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Figure 11 spans from 1999 to 2014. It
shows no intensifying hot spots on the
continental United States; however, many of
the regions which were indicated as
intensifying hot spots in figure 10 remain as
consecutive hotspots in figure 11. This
indicates that over the longer time interval
these are counties with consistently high
opioid related mortality. At a smaller time
scale as seen in figure 10, the nuance of
these regions worsening is seen, but it is lost
at a larger time scale in figure 11. In figure
11 the area of cold spots seen in north south
Figure 10: Emerging Hot Spot Analysis for 1999 to 2009
regions of the great plains is more
constricted and definitively surrounded by
polygons indicating new hot spot regions.
The cold spots in southern Texas which are
seen in figure 10 are gone in figure 11 and
replaced with new hotspot, no pattern
detected, or oscillating hot spot.
Both maps indicate the overall trend of
greater rates of opioid related mortality in
the United States, with the most significant
regions being in Appalachia and New
Mexico. [note, empty areas of the map are a
phenomena of larger counties]
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 Figure 11: Emerging Hot Spot Analysis for 1999 to 2014

The ordinary least square results (refer to
table 4) suggested that our model of
explanatory variables accounted for an
extremely low percentage (7%) of the opioid
mortality rates in the U.S. The coefficients
from the OLS summary table indicated that
the mortality rate would increase with an
increase of poverty and prescription claims
while it was seen that education levels had
an inverse relationships. The higher the
number of individuals who have attained
education lower than 9th grade, the lower
the mortality rates.

Table 4: OLS result table

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All variables chosen for the model were
statistically significant in our model (as
shown in column-Probability) and were not
redundant as the values of the VIF ranged
from 1-1.17 proposing each variable played
an important contribution to opioid mortality
rates. Our Jarque-Bera statistic was not
statistically significant revealing that our
model was not biased.
When the OLS residuals were checked for
spatial autocorrelation, the results indicated
Table 5: Comparison of OLS and GWR results
Similar to the OLS residuals, the GWR
residuals were checked for spatial
autocorrelation and the output reflected a
random spatial pattern with a low Z-score of
-0.65 and a high p-value of 0.5.
In order to check the relationship between
the dependent variable and explanatory
variables throughout the study area, all the
coefficients obtained from the GWR were
Figure 12: Coefficients of Poverty
them to be clustered at a Z-score of 76.48
and p-value of 0.00 inferring there was
clustering of over and under predictions.
Our results from the geographically
weighted regression (GWR) (to identify if
our dependent and explanatory variables
were non-stationary) improved our overall
model drastically. An increase was seen in
the adjusted R2 (7% to 54%) and a
significant decrease in the AICc value
(20183.59 to 17833) (table 5).
mapped. As seen in figures 12, 13, and 14-
poverty, education and prescription claims
are strong predictors in the areas categorized
as hotspots for opioid mortality in the U.S
suggesting that all three variables are indeed
are a cause of the high opioid mortality
rates; however, additional explanatory
variables are missing from our model which
will be addressed in further study.
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 Figure 13: Coefficients of Education

Figure 14: Coefficients of prescription Claims

To understand where the GWR coefficients Kentucky and New-Mexico have a

were statistically significant, a t-value was statistically significant relationship (95%
calculated for each coefficient and mapped confidence interval, values greater than
(figure 15 to 17). As displayed in the three 1.96) between the explanatory variables and
figures, it can be seen that the states of the opioid mortality rates.

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 Figure 15: GWR-Significant Coefficients of Poverty

Figure 16: GWR-Significant Coefficients of Prescription Claims

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 Figure 17: GWR-Significant Coefficients of Education

The BiLISA results for the two states chosen different parts of Kentucky and
for further analysis enabled us to evaluate New-Mexico using the three explanatory
different pattern processes occuring in variables.

Table 6: Result summary of BiLISA in GEODA

We can infer that both poverty and the contrary, New-Mexico presented random
education have a positive spatial spatial autocorrelation for poverty and
autocorrelation with opioid mortality rates in opioid mortality rates and negative spatial
Kentucky while a negative spatial autocorrelation for education and
autocorrelation for prescription claims. On prescription Claims.

Conclusion
Studies such as these are significant in helping researchers and health experts understand
where the opioid crisis is worst, how these places evolve over time, and if there are any
predictive factors from the explanatory variables for education, poverty, and prescription rate

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that can explain or are correlated with the existence of hotspots. This study shows a great deal
about the spatial and spatial temporal arrangement of regions of the country with
higher-than-average opioid abuse and the explanatory variables which may explain these regions.
It also tells of what is not known: which explanatory variables correlate with regions of high
opioid abuse? Based on background research and further readings, it was not entirely surprising
that hotspots appeared in eastern Kentucky and New Mexico, nor was it surprising from
emerging hot spot analysis that the country as a whole is seeing an increase in opioid related
mortality rates. One of the most surprising results was that poverty, education, and prescription
rates only account for 7% of the hotspot activity and only 54% of the hotspot activity when
GWR is applied. This indicates that the assumed factors which contribute to drug related
problems -namely high poverty rates, poorly educated population, and high prescription rates by
doctors and pharmaceutical companies- do not tell the whole story when it comes to predicting
“outbreaks” of drug dependency. Further research is needed to find causes for hotspots of
opioid-related mortality, although perhaps further research would show that this is a problem
which is affecting the entire population regardless of income, education levels, and prescriptions.
A possible avenue of study would be to juxtapose state laws regarding opioids, including
resources for opioid addiction, restrictions on prescriptions, and punishments for possession to
see if these factors influence or cause the growth of hotspots in the United States. The opioid
epidemic is a national emergency and, with work and study, perhaps in the future we can find
informed solutions to this epidemic and help for those affected.

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