Rural Communities and the Opioid Epidemic
Over the last two decades, prescription opioid misuse (POM) has become a critical public health and policy issue. The morbidity, mortality, and economic burden caused by POM are substantial. A recent report estimated that POM cost the US more than $55 billion in healthcare and criminal justice expenses. Additionally, the rate of treatment admissions and emergency room visits related to POM have quadrupled since 1999, and prescription opioids are now implicated in more deaths annually than cocaine and heroin combined.
POM in rural areas is of particular concern to policymakers. In my own work, I have found that rural adolescents are 35% more likely than urban adolescents to misuse prescription opioids. And opioid-related deaths and treatment admissions are especially high in states with large rural populations like Maine, Kentucky, Ohio, and West Virginia. In fact, the origins of the POM epidemic can be traced back to rural America, where media reports of OxyContin misuse first began to surface.
Although POM is a nationwide problem, it is believed that the drivers of the epidemic in rural towns are different from those found in large metropolitan cities. Compared to urban residents, rural residents have been found to have lower income and educational attainment, a higher proportion of manual labor occupations, less access to illicit street drugs, worse self-rated health, and greater frequency of emergency department use. Each of these factors have been found to be associated with POM in various adult populations. Rural towns also tend to suffer from service deficits, such as a lack of trained addiction professionals and a shortage of drug prevention programs.
Rural POM has, unfortunately, received very little attention, partly because widespread knowledge of the problem is lacking. Rural communities are, by definition, usually far from large population centers which results in small towns being overlooked by policymakers and the national media. The research community has also ignored rural POM, as most studies are designed to get nationally representative results. Such broadly designed studies tend to obscure the specific circumstances rural Americans face. The result has been national initiatives that have been largely ineffective at addressing POM in rural towns.
Because interventions are often informed by national data, it is easy for policymakers to overlook the unique characteristics of rural communities. A recent example should help illustrate this point. Currently, a national strategy for reducing opioid deaths has been to improve access to the overdose reversal drug Naloxone. A big part of this plan is to get Naloxone into the hands of more emergency medical personnel (e.g., paramedics) so they can intervene more efficaciously and prevent deaths. This strategy has generally been lauded as a success, with several communities noting drops in opioid overdoses. Unfortunately, this strategy has been less successful in rural areas, because it doesn’t take into account the longer response and transport times. Additionally, research shows that rural areas rely more heavily on volunteer and/or low skilled staff as first responders. These factors are likely contributors to the higher overdose death rates in rural communities.
A serious shortage of treatment facilities also make rural communities particularly vulnerable to the opioid epidemic. This means that many people are placed on long waiting lists, which forces them to remain in active addiction and vulnerable to overdose. Another issue is the low number of drug treatment courts (DTCs) in rural towns. DTCs are specialized courts where offenders are processed with their addiction in mind, unlike traditional courts that favor long prison sentences. DTCs involve a multidisciplinary team of criminal justice and treatment professionals who work together in order to provide a comprehensive treatment plan for offenders struggling with addiction. Recently, the National Association of Drug Court Professionals announced that DTCs now number more than 3,000 nationwide. This expansion, however, has been much slower in non-metropolitan areas, and these programs are still relatively rare in rural towns. Not surprisingly, drug courts in rural counties are often beset with challenges, including a lack of social service programs, wrap around services, and drug free housing for participants.
Stigma is another huge problem. And although stigma is not unique to rural towns, the difficulty with maintaining anonymity in small communities sometimes causes people to discontinue treatment prematurely or avoid it altogether. The potential embarrassment of being outed as an “addict” or “junkie” in rural areas where “everyone knows everyone” is a powerful deterrent to seeking help.
I have been investigating POM for almost a decade now, but it wasn’t until a conversation I had a few years ago at the Annual Symposium with another New Connections Network member (Shannon Monnat) about what it was like growing up in a rural town that I became interested in rural and urban differences in the epidemic. Having lived exclusively in urban cities (Miami, Toronto, Tampa, Philadelphia), rurality has never been on my radar. In fact, in my early research, I am embarrassed to say that I never even included rural status as a control variable. My thinking was that addiction was addiction, and it didn’t much matter where a person lived. I was wrong.
As social and behavioral scientists, I know that, ultimately, we are studying people. But I would remind my fellow scientists that individuals don’t live in a vacuum, and community characteristics need to be thoughtfully factored into our investigations. So, for all the researchers working with large or national data sets, if you’re not controlling for rural status, you should. And if for some reason you can’t, it should probably be acknowledged as a limitation. We would all do well to consider rural status in our research and wherever possible shine a light on the often forgotten challenges facing rural communities.
Khary Rigg, PhD, is an assistant professor in the Department of Mental Health Law & Policy and the Florida Mental Health Institute at the University of South Florida. He is also a current fellow with the Center for Public Health Initiatives at the University of Pennsylvania. Follow Khary on Twitter at @krigg01.