Tropical Cyclone Exposure and Psychoactive Drug–Related Death Rates

Importance: Tropical cyclone exposure exacerbates substance use and mental and behavioral health vulnerabilities in affected communities, potentially contributing to increases in psychoactive drug-related deaths (including drug overdoses, alcohol-related deaths, and other substance-related disorders). Prior research has not evaluated this association in a national multidecadal study by cyclone strength and demographic subgroup. Objective: To estimate the association between county-level tropical cyclone exposure and psychoactive drug-related death rates in the US. Design, Setting, and Participants: This case-control study used a bayesian conditional quasi-Poisson model to evaluate the association between county-level tropical cyclone exposure and monthly psychoactive drug-related death rates between January 1, 1988, and December 31, 2019. Participants included residents of counties in the contiguous US that were exposed to at least 1 tropical cyclone during the study period. Death data were obtained from the National Center for Health Statistics. Analyses were conducted between March 27, 2024, and June 25, 2025. Exposure: Monthly tropical cyclone-exposed days per county, defined by sustained wind speeds of at least 34 knots, categorized as gale to violent storms (34-63 knots) and hurricanes (≥64 knots). Main Outcomes and Measures: The main outcome was monthly county-level psychoactive drug-related death rates. Associations were estimated between each additional cyclone-exposed day and death rates in the subsequent 0 to 3 months. Analyses were stratified by cyclone strength, age, sex, and county-level social disadvantage (poverty level and percentage of racial and ethnic minority residents). Results: Among 1258 exposed counties between 1988 and 2019, 798 691 psychoactive drug-related deaths were recorded (29.5% females and 70.5% males; 99.8% aged ≥15 years). Median exposure was 2 tropical cyclone days (range, 1-27 days) during the study. Each additional cyclone-exposed day was associated with a 3.84% increase (95% bayesian credible interval [CrI], 1.83%-5.89%) in psychoactive drug-related death rates in the month of exposure, persisting up to 3 months after exposure (2.39% [CrI, 0.41%-4.40%]). Older children and younger adults (15-44 years old) demonstrated statistically higher increases than older adults after exposure. However, increases were limited to low-poverty counties regardless of racial composition (13.05% [CrI, 6.79%-19.68%] for low presence of racial and ethnic minority residents; 6.01% [CrI, 3.02%-9.08%] for high presence) in the month of tropical cyclone exposure. Conclusions and Relevance: In this case-control study of US counties, tropical cyclone exposure was associated with increased psychoactive drug-related death rates up to 3 months after exposure. These findings support the integration of substance use and mental health services into climate disaster preparedness and response planning.