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Opioid 'Syndemic' Tests Rural America

November 17, 2016

image of a syringe and a bottle of pills with text- battling the intertwined epidemics of opioid misuse, hiv, and viral hepatitis
Ahead of National Rural Health Day observances on Thursday, Nov. 17 -- led by HRSA's Federal Office of Rural Health Policy -- the U.S. Centers for Disease Control and Prevention has found new reason for concern about the opioid epidemic in rural America.

​​​​​​​​​​​Spurred by the opioid epidemic and the mounting use of replacement drugs like heroin, hundreds of U.S. counties – many of them rural -- are increasingly vulnerable to simultaneous outbreaks of HIV and Hepatitis-C, federal health officials declared in a recent national conference call.

Particularly notable to epidemiologists has been a sharp increase across at least seven states in acute hepatitis infections among young people -- a pattern now broadly recognized as a "marker" of local and regional opioid epidemics in at least 200 U.S. counties.

"We are seeing a new trend of rising cases of Hepatitis C in some areas of the country among people who inject drugs," said RADM Jonathan Mermin of the Centers for Disease Control and Prevention in an Oct. 25 presentation hosted by the HHS Office of HIV/AIDS and Infectious Disease Policy.

"These persons," Dr. Mermin said, "are mainly young, often white, and have roughly equal gender distribution. They live in non-urban areas – suburban and rural, most commonly -- and many are previous prescription opioid users."

RADM Jonathan Mermin, M.D., M.P.H. Director, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Centers for Disease Control and Prevention
RADM Jonathan Mermin, M.D., M.P.H.
Director, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Centers for Disease Control and Prevention

The CDC reports that drug-related death rates are now 45 percent higher in rural communities than urban areas. Fewer than one in 10 opioid treatment centers nationwide are located in rural America, SAMHSA has noted.

​"There is a huge treatment gap," observed Dr. Cecelia McNamara Spitznas, of the White House Office of National Drug Control Policy. "Unfortunately, in many areas of the country, the treatment infrastructure is lacking."​

Known as "syndemic" conditions, affected communities could see three inter-related epidemics at one time, experts warned -- adding new emphasis for health ce​nters, free clinics and local practitioners on the importance of maintaining rigorous routine screening in primary care.​

One such instance happened in rural Scott County, Ind., last year and is now expected to cost $80 million to contain over the life of the infected population, said Mermin of the CDC.

Every day, 78 people die from an opioid overdose, according to department estimates. And new cases of Hepatitis-C increased more than 250 percent from 2010 to 2014.

a US map showing reported HCV cases by county. For detailed data this map displays, visit
Scope of an epidemic: U.S. map shows at-risk counties in red.

The Scott County experience – in which an average of one new HIV case per year suddenly rose to 11 in early 2015, before leaping to more than 200 today – represented "an explosive spread of HIV in a very short period of time," Mermin said. Most of those infected were injecting prescription opioids – crushed and dissolved -- when they contracted the virus, he said. And most are "co-infected" with Hepatitis.

The outbreak was stemmed through a combination of testing, needle exchange and linking people to clinical care and "medication assisted treatment"; but follow up for the county's population will be needed "for years to come," Mermin said.

Analysis of HCV and injection drug use prevalence suggest that an estimated 7 percent of the nation's 3,300 counties may be at risk for similar outbreaks. Nationwide, an estimated 22 million people are in need of opioid treatment.

"We have to learn how to treat safely and effectively," said U.S. Surgeon General Dr. Vivek Murthy. "But this is also about providing safe alternatives to opioids."

an image of U.S. Surgeon General Dr. Vivek Murthy speaking at an event
America's Doctor: Dr. Murthy has supported an array of initiatives to contain the opioid crisis, including launching, which calls on health professionals to pledge to combat opioid misuse through education on safe pain treatment, screening for opioid use disorder and leading a shift in public perceptions of addiction. “We have to stop treating addiction as a moral failing," Murthy says.

The effort builds upon the U.S. Department of Health and Human Services (HHS) Opioid Initiative (PDF - 364 KB), as well as the National Pain Strategy (PDF - 1 MB), the federal government's first coordinated plan to reduce the burden of chronic pain in the U.S.

Date Last Reviewed:  July 2017