Get reimbursed for COVID-19 testing and treatment of uninsured individuals.     Learn more »

Diversion Key to Rural Opioid Crisis

Health care providers in different states prescribe at different levels. NJ, NY, HI, MN, and CA prescribe the lowest per 100 users. AL, WV, OK, TN, and KY prescribe the highest per 100 people.
Rural health researchers note that clinicians in different states prescribe opioid painkillers at markedly different rates. As the number of prescriptions rise, so does the peril of drug diversion for illicit use. Above: State abbreviations with number of prescriptions per 100 residents.

Clinicians in small towns and rural hospitals may be contributing to the opioid crisis "through less-than-careful prescribing practices," according to new research into how the epidemic has become so prevalent in rural communities.

"People who are being prescribed opioids for legitimate purposes can overdose, they can become dependent, and they can run into a variety of problems," University of Southern Maine researcher John H. Gale told a Jan. 18 webinar audience.

John Gale spent 16 years in clinical management and is a trustee of the HRSA-supported National Rural Health Association and a widely published expert on substance misuse in rural America.

The misuse of prescription painkillers and illicit opiates in isolated communities "is a huge problem … and it's not getting better fast enough," Gale warned, adding that the pills too often are prescribed as stopgap relief for dental infections and injuries in patients who live at a distance from providers.

Emergency rooms, he said, are a "major source of (drug) diversion" into local communities, calling it "a long-standing issue."

"Really helping (prescribers) to understand the role they play in contributing to the problem -- and through that, reducing the supply and diversion -- and providing alternatives to opioids for pain management" is crucial to stemming the crisis, he said.

The problem is most pronounced in 10 predominately-rural states with high concentrations of health care shortage areas, poverty and long travel distances to specialists. Alabama, Tennessee, West Virginia, Kentucky and Oklahoma lead the nation.

Once addicted, patients commonly turn to heroin as a cheaper substitute. Long depicted as primarily an urban scourge, heroin use is increasingly prevalent in rural America. 

"It's incredibly inexpensive (and) easily accessible, and in many cases people without health insurance have actually used heroin as pain management," reported  Gale.

Exacerbating the crisis, treatment is scarce and opioid users often "burn through" relationships and become dangerously estranged from supportive social circles –- drawing the attention of local law enforcement officials in the process.

The very nature of rural life –- typically, geographically insular communities where neighbors know one another by face, name and reputation -- hampers the ability to treat people so stigmatized.

According to the CDC, as many as 1 in 4 people receiving prescription opioids long term in a primary care setting struggles with addiction.Further, addiction services –- methadone clinics, for example -- "tend to be clustered around urban areas," and counselors are "loathe to provide people with more than one day's dose at a time" … so "it's not uncommon to hear of people travelling two, three, or four hours each way" to get treatment, Gale said.

HRSA's Federal Office of Rural Health Policy reported Thursday that only about one in 10 methadone clinics nationally are located in rural areas, and 60 percent of rural counties have no clinician legally authorized to prescribe buprenorphine, an office-based opioid treatment, leaving patients marooned.

"Those who have to travel farther for care are less likely to complete treatment," Gale said, adding: "They often return to the relationships that got them in trouble in the first place."

Further, misuse of prescription pain relievers is highest among specific groups of rural residents who tend to be less mobile, including young people, pregnant women and victims of domestic violence, explained Gale.

Research strongly suggests, he said, that community-based efforts –- beginning with tighter prescription controls in rural emergency rooms and wider availability of drugs like buprenorphine that can be administered locally to wean patients off opioids –- are crucial first steps in breaking the cycle of rural addiction.

Visit the HRSA-funded Rural Health Research Gateway HRSA Exit Disclaimer for a full transcript of the webcast, slide deck and discussion of on-going projects in Maine, Vermont, Michigan and elsewhere -- including one hospital in rural Illinois that managed to get nearly all of its 56 patients off opioids in four months with the help of a visiting pain management specialist.                   

Read about HRSA efforts to expand treatment through health centers.

The CDC released its Guideline for Prescribing Opioids for Chronic Pain in the spring of 2016, urging clinicians to be much more conservative in who receives them and calling the decision to prescribe "momentous HRSA Exit Disclaimer."

Date Last Reviewed:  February 2018