The rate of fatal drug overdoses has been rising more rapidly in rural areas for the past decade. And although the overall overdose death rate continues higher in urban and suburban America, the escalation in rural America has been more pronounced in recent years.

In 2020 the rate of deaths involving synthetic opioids which include fentanyl, fentanyl-like drugs and tramadol was higher in urban counties (18.3 deaths per 100,000 population) than in rural counties (14.3 per 100,000). But that isn’t true across the board. Eight states — California, Connecticut, Maryland, New York, North Carolina, North Dakota, Vermont and Virginia — had higher drug overdose death rates in rural areas.

The comparison comes as the incidence of deaths from drug overdoses has been rising everywhere. In 2000 there were fewer than 10,000 U.S. drug overdose deaths, according to Centers for Disease Control and Prevention (CDC) data. By 2019 the number had reached nearly 50,000. That number climbed to more than 107,000 in 2022 and 112,000 in 2023.

Although Biden administration officials believe they may have “flattened the curve” on the rate of fatal drug overdoses, the problem remains immense. CDC estimates that the opioid crisis cost the country more than $1.5 trillion in 2021.

In response, the federal government has allocated more than $10 billion in discretionary spending for the 10-year period ending 2028. Additionally, $50 billion is being allocated among all 50 states as part of a settlement with drug manufacturers and providers.

Bayla Ostrach.jpgBayla Ostrach, applied medical anthropologist

In some cases, though, rural areas get shortchanged in the allocation, according to Bayla Ostrach, a North Carolina-based applied medical anthropologist who studies drug abuse harm reduction and consults with governments and other entities on the issue.

“In one recent round of 10 federal funding grants, half went to California and New York,” says Ostrach, who owns Fruit of Labor Action Research & Technical Assistance. “Programs there already get state funding. For instance, East Tennessee and West Virginia didn’t get anything. In many cases harm reduction money goes to places that already get a lot of funding.”

Ostrach calls “harm reduction” a set of strategies geared toward acknowledging that some level of risky drug use will occur — and the resulting efforts to make it safer. These strategies involve efforts that can include distributing clean syringes, training more people to recognize drug overdoses, and making anti-overdose medications such as Narcan more readily available.

“Harm reduction is a proven strategy for saving lives,” says Ostrach. “There is more than 40 years’ worth of evidence internationally and in the U.S. that this works.”

Additionally, the opioid crisis has made it more difficult for pharmacists to get enough substitute addiction treatment drugs such as buprenorphine in stock, according to Ostrach. Pharmacists have been told that physicians were over-prescribing opioids for years, which now makes pharmacists suspect when opioid or similar prescriptions come through their door legitimately.

Pharmacists are hesitant to carry and prescribe such drugs — even the addiction treatment drugs — because of increased scrutiny by the federal Drug Enforcement Administration. “They worry that the DEA may say I’m doing something suspicious,” says Ostrach.

“In some regards the DEA makes it difficult to get what are known and proven safest and most effective responses to opioid use,” says Ostrach. “But there has been progress. Good things have been said coming out of this White House and multiple administrations about investing in overdose prevention and reducing deaths. But they haven’t necessarily followed through with investing in the most evidence-based approaches.”

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For his part, Ostrach is upfront about advocating for the decriminalization of a number of drugs so they can actually be better used, regulated and controlled. “Often it is not the substance itself that is the problem but the criminalization of its use and lack of resources to prevent overdose deaths,” he says. “We’ve seen this in every age. A hundred years ago it was panic about alcohol, then crack cocaine in the '80s. It’s not about the substance but the policy responses to it.”

Beginning about 25 years ago, prescriptions for opioids to relieve pain proliferated in U.S. medicine. The ensuing crackdown caused users, who had become addicted, to turn to other illicit drugs such as heroin and eventually fentanyl. Now fentanyl has made its way into numerous illicit drugs, either by design, or, as Ostrach contends, by accident because makers of illicit drugs often unknowingly have combined particles.

To some extent, the federal government recognizes these issues. The 2022 National Survey on Drug Use and Health found that 8 million adults misused prescription pain relievers at least once in the previous year, with approximately 1 million of them in non-metropolitan areas.

"Rural people are likely to live far from treatment centers and harm reduction services and often struggle to meet court requirements in places where public transit is sparse," says a recent story on the Daily Yonder, a news site devoted to rural issues. "Available treatments for stimulant addiction lag far behind those for opioid addiction, and there’s less funding to provide them."

A 2019 study found that in addition to barriers to healthcare access in rural areas, such as travel time and cost of care, there was a lack of treatment programs available in rural areas. There was also a negative perception of treatment for substance use disorder among rural providers.

"Our findings consistently identified a lack of medication providers and rural-specific implementation challenges," the authors conclude. Their review found a lack of rural-focused studies involving consumers, treatment outcomes or barriers for underserved populations. They call for innovative interventions and treatments for opioid use in rural areas.

The paper in the American Journal of Alcohol and Drug Abuse focuses on health and illness but does not also consider social and cultural dimensions of health and illness. The medical anthropology discipline, which Ostrach practices, also takes into account factors other than biological factors like germs. 

A hypothetical example, based on real-life situations, describes a woman in East Africa who dies after becoming HIV positive. A physician likely would conclude that the AIDS virus killed her. But a medical anthropologist might explain her death by finding that the woman was infected by a husband who contracted the disease and transmitted it to her in a culture that discourages protection. When she became sick, she did not have access to medical care and went untreated.

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