UNIVERSITY PARK, Pa. — American visitors to Florida who died in the state were 63% more likely to have died from a drug overdose compared to visitors to all other states during the first two decades of the 2000s, according to researchers. They published their findings earlier this month in the journal Injury Prevention.

“Our research findings point to a health hazard not just for Florida but for Americans in general and a need for more legislation at the state and federal levels to address the issue,” said Ilan Shrira, lead author of the study and a social psychologist in the psychology department at Penn State.

Shrira and study co-author Joshua Foster, professor of psychology at the University of South Alabama, examined the more than 47 million death certificates of American permanent residents who died between 2003 and 2020. The certificates were de-identified and listed the county of residence, county of death and cause of death, allowing the researchers to determine the number of deaths due to drug poisoning at the county level throughout the U.S.

They used the data to calculate proportionate mortality ratios, a metric traditionally used to determine if a certain occupation has a higher proportion of death from a specific cause compared to the rest of the population. For example, federal data show that firefighters are at greater risk of death from cancer than the general population. In this case, the researchers looked at the proportion of drug overdose deaths among visitors to Florida compared to drug overdose deaths among visitors to all other states. They also studied Florida residents who died in the state within and outside their home county.

The researchers found that compared to the rest of the nation, visitors to Florida were on average 63% more likely to have died from a drug overdose over the 18-year period. From 2014 to 2020, in Palm Beach County alone, that number jumped to 214% compared to all other counties throughout the U.S.

Florida residents had a slightly elevated overdose mortality ratio compared to the rest of the nation during the 18-year period. Residents who died within their home county were 6.7% more likely to have died of a drug overdose, while those who died in state but in a different county were 13% more likely to have died of a drug overdose, according to the researchers.

“Roughly 15% to 20% of Americans die outside of their home county,” Shrira said. “Fewer Americans die outside their home state. Our methodology allowed us to look at people who resided outside of Florida but who died in the state and narrow the cause of death to drug poisoning. And when you compare the visitors to Florida and visitors to any other state, the proportion of deaths due to overdoses is much higher – 63% higher – among visitors to Florida compared to all the other people in the United States who died outside their home state.”

The researchers identified two issues that may account for the high proportion of drug overdose deaths among visitors to the state. During the first decade of the 2000s, the state saw an increase in “pill mills,” or pain management clinics that overprescribed opioid painkillers and avoided regulations by operating as a cash business instead of accepting health insurance. Mortality ratios peaked at this time before state legislation in 2010 and 2011 largely ended the pill mills, Shrira said.

The second issue arose in the latter half of the 2010s after the passage of the Affordable Care Act, which required insurance companies to cover substance use treatment to address the opioid epidemic, according to Shrira. Florida has had a thriving drug recovery community dating back to the 1960s. However, the recent insurance law expansion has attracted some unscrupulous treatment providers to the industry, who have taken advantage of the lucrative insurance reimbursements, but with little motivation to offer high-quality care to patients, he said. The number of treatment facilities in Florida increased from 617 in 2011 to 725 in 2019. Many of these centers, Shrira said, targeted out-of-state patients because their insurance plans had fewer restrictions than insurance plans available to Florida residents. Exploitative practices kept patients in a treatment loop known as the “Florida Shuffle,” in which patients would receive treatment, enter a sober home and then relapse, sending them back to the treatment center. The greater concentration of treatment centers in Palm Beach County may account for the high overdose mortality ratios there during these years, Shrira said.

“People looking to get help for a substance use disorder were being lured to Florida by deceptive marketing by people who may have no interest in helping them, putting many at an increased risk of a fatal overdose,” he said. “The authorities have cracked down on some of these practices and have made some high-profile arrests and prosecutions, but there are many reports that it’s still happening. Anyone in the U.S. who considers traveling to enter a treatment clinic far from their home should be extra careful about what type of place they are actually going to, and have a ready way to get back home if needed.”