The Opioid Epidemic in Rural America

You might be surprised by some of the statistics related to opioid abuse in rural America. The opioid epidemic has hit some rural areas harder than others.

Metropolitan areas may have a reputation for more drugs, violence, and crime, but problems lurk in rural America, too.

In 2017, more than 72,000 Americans died due to drug overdoses, and the majority of those fatalities (67.8%) were linked to opioid drugs. Opioids include both illegal heroin and legal prescription pain relievers such as oxycodone, hydrocodone, codeine, morphine, and fentanyl.

As a result, it’s no exaggeration to say there is an opioid epidemic in America. Especially in less populated areas.

Demographics of opioid epidemic in rural America

Of the 15 counties with the highest opioid prescription rates for 2017, 14 of those were rural.

More opioid deaths have been recorded in smaller country communities, too, according to data from the Centers for Disease Control and Prevention.

It used to be metropolitan areas had more overdose deaths, but that trend has steadily reversed, starting in the early 2000s.

People in less-populated counties also had an 87% greater likelihood of being prescribed opioids. Addiction-managing medicines such as buprenorphine only made up a small fraction — 0.2% — of prescriptions, however.

Obviously there are a substantial number of opioids being prescribed in rural America. The good news is that the likelihood of receiving opioids through your doctor or a clinic dropped after March 2016, due to more vigilance in doling out potentially addictive medications.

Reasons for the opioid abundance itself vary.

Causes of opioid epidemic

In terms of the big picture, many fingers point to pharmaceutical companies. In the late 1990s, drug manufacturers claimed opioids were not addictive, and health care professionals began to prescribe them with more frequency. More pills created more problems.

Keeping the focus on what drives more rural prescriptions, these areas typically report more incidences of chronic pain. They also tend to have older populations. Conditions linked to aging — arthritis, cancers, joint-replacement or back surgeries — and injuries from more physically demanding jobs (mining, logging) typically mean more ongoing aches.

In addition to health conditions and injuries, more isolated areas typically have fewer treatment options for pain management and addiction. Those factors can make opioids a more viable option, regardless of the risks.

Despite opioid prescription becoming a downward trend, opioid-linked deaths are increasing — most likely due to heroin and illegally produced fentanyl.

Analyzing CDC maps of counties and U.S. states where opioids are prescribed the most and least, prescription rates have dropped in much of the United States. In 2012, there were 255 million opioid prescriptions written, but by 2017 that number had dropped to 191 million. Despite that, rural areas still have the most prescriptions being filled.

Opioids and seniors

Stereotypically, one might think senior citizens’ drugs of choice would be blood thinners and cholesterol medications. Opioids are rattling around in those pill bottles too.

An Agency for Healthcare Research and Quality report found that in 2015 and 2016, approximately 4 million seniors filled four or more opioid prescriptions. Nearly 10 million had at least one prescription filled during those years. In 2015 there were approximately 47.8 million people ages 65 and older in the United States, accounting for 14.9% of the entire U.S. population.

Other studies, such as a 2018 University of Michigan National Poll on Healthy Aging, found that 29% of older adults had been prescribed opioids for pain within the past two years.

Opioids cost users and the health care system alike. In 2015, for emergency room visits and hospital stays related to opioid use, bills averaged $14,900, compared to $13,200 for non opioid-linked treatments.

Socioeconomic conditions also contribute to opioid use. Seniors who earned low incomes, had more basic Medicare coverage and public health plans, or lived in rural areas were more likely to resort to frequent opioid use. That’s compared to older people who earned middle and higher incomes, had more comprehensive health insurance plans, or lived in urban and suburban settings.

Seniors Face Specific Risks

Older adults face unique problems if they use opioids improperly. Aging patients do not metabolize medications as quickly as younger patients do. Improper dosing can result in respiratory depression, memory loss, confusion, falls, and fractures as well as overdoses.

In addition, older people tend to be prescribed more medications. Sometimes it’s due to more health complications. It can also be because they tend to see multiple specialists, increasing the likelihood of risky drug interactions.

Also, cognitive decline and dementia in older adults may not be recognized due to opioid use, which presents a new set of problems.

When people use opioids, their pain sensitivity to some milder unpleasant stimuli may be reduced. At the same time, more severe or persistent pain may become more intense.

Managing that pain properly — and safely — is key.

If dependency sets in and the patient seeks other drugs — such as heroin or other illicit substances — they put themselves at risk for hepatitis C or HIV because they may be sharing needles to inject drugs.

Data collected by the CDC has found a 33.3% increase in heroin deaths in 2014 and 2015 for people who were 65 and older, compared to heroin deaths increasing by 21% overall. In a 2014 survey, 94% of respondents being treated for opioid addiction said they resorted to heroin because it was cheaper and easier to obtain.

Fewer People, More Problems

Opioids are problematic for many reasons for people in nonmetropolitan areas. Unintentional injury is one of the top five causes of death nationwide. (Heart disease, cancer, chronic lower respiratory diseases, and stroke are the other four leaders.) People in less urban areas are more likely to die from the leading five causes than metropolitan residents.

In more isolated communities, it can take longer for emergency personnel to arrive on the scene of an incident. It can also take longer to transport a patient to a hospital or trauma center.

First responders aren’t always trained in administering medications that may reverse an overdose, so the delay in help arriving and the lack of expertise can complicate matters.

Rural communities — and aging baby boomers who used drugs in the past — may be more casual about using drugs and sharing them. Most people probably know someone who has shared their medications with a family member or friend when they’re coping with pain and anxiety. Like other matters related to opioid use, those are good intentions that can easily go wrong.



  • – CDC Reports Rising Rates of Drug Overdose Deaths in Rural Areas
  • – Drug Overdose Deaths
  • – Facts for Features: Older Americans Month: May 2017
  • – Family Doctors in Rural America Tackle Crisis of Addiction and Pain
  • – Heroin Use Is Driven by Its Low Cost and High Availability
  • – Leading Causes of Death in Rural America
  • – More Opioids Being Prescribed in Rural America
  • – New AHRQ Reports Highlight Seniors’ Struggles with Opioids
  • – Older Adults’ Experiences with Opioid Prescriptions
  • – Opioid Addiction 2016 Facts & Figures
  • – Prevention, Diagnosis, and Management of Opioids, Opioid Misuse and Opioid Use Disorder in Older Adults
  • – Reducing Potentially Excess Deaths from the Five Leading Causes of Death in the Rural United States
  • – Rural Older Adults Hit Hard by Opioid Epidemic
  • – U.S. Opioid Prescribing Rate Maps
  • – What Is the U.S. Opioid Epidemic?
  • – The Changing Face of Heroin Use in the United States: A Retrospective Analysis of the Past 50 Years

Medical disclaimer:

Sunshine Behavioral Health strives to help people who are facing substance abuse, addiction, mental health disorders, or a combination of these conditions. It does this by providing compassionate care and evidence-based content that addresses health, treatment, and recovery.

Licensed medical professionals review material we publish on our site. The material is not a substitute for qualified medical diagnoses, treatment, or advice. It should not be used to replace the suggestions of your personal physician or other health care professionals.

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