After adjusting for key confounders, each 1 SD decrease in median household income was associated with an increase of 12·8% (95% CI 11·0–14·6; p<0·0001) in drug-related deaths within counties. Each 1 SD increase in jail and prison incarceration rates was associated with an increase of 1·5% (95% CI 1·0–2·0; p<0·0001) and 2·6% (2·1–3·1; p<0·0001) in drug-related mortality, respectively. The association between drug-related mortality and income and incarceration persisted after controlling for local opioid prescription rates. Our model accounts for a large proportion of within-county variation in mortality from drug use disorders (R²=0·975). Between counties, high rates of incarceration were associated with a more than 50% increase in drug-related
Reduced household income and high incarceration rates are associated with poor health. The rapid expansion of the prison and jail population in the USA over the past four decades might have contributed to the increasing number of deaths from drug use disorders.