Do Redlined, Segregated Neighborhoods Bear a Disproportionate Burden of Fatal Opioid Overdoses?

Uzzi et al. (2025) examine whether neighborhood conditions shaped by past redlining and present-day racialized economic segregation are associated with fatal opioid overdose deaths. They analyze census-tract–level data from Chicago, combining Cook County Medical Examiner overdose records with historical redlining maps and contemporary census data from 2017–2019 and 2020–2022. They find that neighborhoods experiencing high levels of disadvantage in the past and/or present had significantly more fatal overdoses than advantaged neighborhoods. Before COVID-19, persistently disadvantaged tracts averaged about 2.6 more overdose deaths per tract. During the pandemic, previously advantaged but newly disadvantaged tracts experienced nearly 4 additional deaths per tract on average.

Why This Article Was Selected for The Policy Scientist

This article addresses a policy issue of first-order importance: the persistent geographic concentration of opioid overdose deaths and the extent to which long-run neighborhood conditions help explain that pattern. The topic is timely given continued post-COVID increases in overdose mortality and growing interest in place-based policy responses. Uzzi and colleagues (2025), who have published extensively in this area, extend a well-established literature on redlining, segregation, and health outcomes by linking historical housing policy to contemporary overdose mortality at fine spatial scale. The data are high quality, combining medical examiner records with validated historical and census measures. Similar dynamics plausibly apply to other segregated cities.

Full Citation and Link to Article

Uzzi M, Ricard JR, Belton I, Linton SL, Marineau L, Johnson RM, Latkin C, & Nesoff E (2025). Fatal opioid overdoses by historical and contemporary neighborhood-level structural racism. JAMA Health Forum, 6(11), e253986. https://doi.org/10.1001/jamahealthforum.2025.3986 

Central Research Question

This study asks whether neighborhood conditions shaped by historical housing policies and contemporary patterns of racialized economic segregation are associated with differences in fatal opioid overdose deaths across urban neighborhoods. Specifically, the authors examine whether census tracts exposed to disadvantage in the past, the present, or both experience higher numbers of opioid-involved overdose deaths than consistently advantaged neighborhoods. The analysis focuses on Chicago and compares two periods—before the COVID-19 pandemic (2017–2019) and during the pandemic (2020–2022)—to assess whether these associations changed during a major social and public health shock.

Previous Literature

The article builds on a large interdisciplinary literature documenting racial and spatial disparities in overdose mortality and access to treatment. Prior research has shown that Black and Latino communities have experienced disproportionate increases in opioid-related deaths in recent years, particularly during later waves of the overdose epidemic dominated by fentanyl. Related work links residential segregation, neighborhood disadvantage, and disinvestment to poorer health outcomes, including violence, chronic disease, and limited access to medications for opioid use disorder. Studies of redlining have demonstrated long-run effects of 1930s housing policies on wealth, neighborhood conditions, and health. However, relatively few studies directly connect these historical processes to overdose mortality, and even fewer examine how past and present neighborhood conditions interact. This study extends prior work by integrating historical redlining and contemporary segregation into a single framework and applying it to opioid overdose deaths at a fine geographic scale.

Data

The authors use multiple high-quality data sources. Opioid-involved overdose deaths come from the Cook County Medical Examiner’s Office and include detailed toxicology information and geocoded locations of death. These deaths are aggregated to the census tract level for analysis. Historical redlining is measured using Home Owners’ Loan Corporation maps from 1939, which classified neighborhoods based on perceived mortgage risk. Contemporary racialized economic segregation is measured using census-based income and race data from the American Community Survey, operationalized through the Index of Concentration at the Extremes. The final sample includes 796 Chicago census tracts in the pre-pandemic period and 792 tracts during the pandemic period. Together, these data allow the authors to link historical policy exposure, current neighborhood conditions, and overdose mortality over time.

Methods

The study uses a serial cross-sectional, ecological design with spatial statistical methods. Census tracts are categorized into four neighborhood types based on combinations of historical redlining and contemporary segregation: sustained advantaged, sustained disadvantaged, contemporary advantaged, and previously advantaged. The authors estimate quasi-Poisson spatial regression models to examine associations between neighborhood category and the number of overdose deaths per tract. Spatial autocorrelation is addressed using eigenvector spatial filtering, and population density is included as a control. To improve interpretability, the authors calculate average marginal effects, which express differences in the expected number of overdose deaths between neighborhood groups. Analyses are conducted separately for the pre-COVID and COVID periods to account for structural breaks associated with the pandemic. While the methods are appropriate for spatial count data, the design remains observational and associational rather than causal.

Findings/Size Effects

The results show large and consistent differences in overdose mortality across neighborhood types. Before the pandemic, census tracts experiencing sustained disadvantage had, on average, about 2.6 more fatal opioid overdoses per tract than sustained advantaged neighborhoods. Previously advantaged tracts—those not historically redlined but currently disadvantaged—had roughly 2.1 additional deaths per tract, while contemporary advantaged tracts had nearly 1 additional death per tract. During the COVID-19 period, overdose mortality increased across all neighborhoods, but disparities widened in specific groups. Previously advantaged tracts experienced the largest increase, with nearly 3.8 more deaths per tract than sustained advantaged neighborhoods. Sustained disadvantaged tracts averaged about 3.1 additional deaths per tract. In contrast, contemporary advantaged tracts were no longer statistically different from sustained advantaged neighborhoods during the pandemic. These results indicate that both long-term disadvantage and recent shifts toward disadvantage are associated with substantially higher overdose mortality.

Conclusion

This study provides strong descriptive evidence that opioid overdose deaths are geographically concentrated in neighborhoods shaped by long-standing and contemporary disadvantage. By linking historical housing policy to present-day mortality outcomes, the authors demonstrate how past decisions continue to structure current public health risks. The findings are particularly relevant in the context of rising overdose deaths following the COVID-19 pandemic and increasing interest in place-based interventions. Although the analysis is limited to Chicago, similar patterns of segregation and disinvestment exist in many U.S. cities, suggesting broader relevance. The study’s spatial methods and use of validated data sources strengthen confidence in the results, but future research using causal inference designs would be needed to more clearly identify mechanisms and policy leverage points.