Understanding the Rural–Urban Differences in Nonmedical Prescription Opioid Use and Abuse in the United States

Katherine M. Keyes, PhD; Magdalena Cerdá, DrPH; Joanne E. Brady, SM; Jennifer R. Havens, PhD; Sandro Galea, MD, DrPH


Am J Public Health. 2014;104(2):e52-e59. 

In This Article

Nonmedical Prescription Drugs vs Other Illicit Drugs

Many of the well-documented risk factors for illicit drug use predict both nonmedical prescription opioid use and other illicit drug use. Therefore, these cannot readily explain why nonmedical prescription opioid use is increasing, especially in rural areas. For example, nonmedical prescription drug users are more likely to be male,[52,53] be young,[54] be polydrug users,[55] have comorbid psychopathology,[54,56–59] and have positive expectations about the effects of use.[60–62] These are all risk factors for illicit drug use more generally. We identified 3 factors for which empirical evidence indicates specificity in association with nonmedical prescription opioid use versus other illicit drugs.

Increased Availability and Access

Prescription opioids became widely available in the mid-1990s. Between 1997 and 2007, per capita retail purchases of methadone, hydrocodone, and oxycodone increased 13-fold, 4-fold, and 9-fold, respectively.[63] By 2010, enough prescription opioids were sold to medicate every adult in the United States with a dose of 5 milligrams of hydrocodone every 4 hours for 1 month.[64]

A study of national trends found that during 1999 through 2008, overdose death rates, sales, and substance abuse treatment admissions related to prescription opioids increased in parallel.[64] This coincided with a larger movement in the medical community in the late 1990s to identify and treat pain as a fifth vital sign; bodies such as the American Pain Society established guidelines that included aggressive treatment of reported pain, and a campaign initiated by the Department of Veterans Affairs in part fueled the movement with the intention of improving pain management and treating chronic pain.[65–67]

Increased medical use of prescription opioids has resulted in increased access to opioids for nonmedical use, either through the nonmedical use of legitimately acquired prescriptions or through formal or informal distribution networks.[68–73] Studies indicate that the large majority of adults who use opioids nonmedically obtain them from friends and relatives or from street-level dealers.[68–73] A substantial proportion of overdose deaths and emergency department visits occurs among individuals who have never received a prescription.[10,74–76] The proliferation of illicit high-volume prescribers and clinics (so-called pill mills) has also contributed to increases in overdoses in states such as Florida and Texas.[18,77]

Although availability of and access to prescription opioids have clearly increased across all areas of the United States, evidence regarding changes in the availability and access of illicit drugs, such as heroin and cocaine, is more mixed. Data on emergency department visits suggest that emergency department visits for prescription opioids more than doubled from 2004 to 2010, whereas cocaine-related visits increased 10% and heroin-related visits decreased.[78] National survey research indicates no evidence of an increase in the proportion of adolescents and adults who report that drugs such as marijuana are fairly easy or very easy to obtain over the past 10 years[79] (we did not assess comparable data on opioids), suggesting that the availability of nonopioid illicit drugs may not be keeping pace with the availability of prescription opioids, at least among adolescents.

However, data from the National Drug Threat Assessment indicates that heroin and cocaine availability is increasing nationally,[80] although information on comparisons with availability of prescription opioids is not available. Although the available evidence thus suggests that increases in prescription opioid availability have outpaced that of illicit drugs, the nonmedical prescription opioid use epidemic may portend future increases in illicit drug use as well, considering that nonmedical prescription opioid users are more likely than are nonusers to transition to heroin and other illicit drugs.[81]

Lower Perceptions of Harm

Adolescents perceive prescription opioids such as OxyContin and Vicodin as more harmful than other prescription drugs such as Adderall and amphetamines, but they perceive prescription opioid use as less harmful than the use of almost all other drugs except experimental alcohol and occasional marijuana use.[82] Lower perceptions of harm for prescription opioids compared with other illicit drugs could be owing to 2 factors.

First, opioid use for pain management is increasingly common; thus, nonmedical users observe and are acquainted with the effective pharmacological action of the drugs among individuals in social and kin networks. Second, prescription opioid use does not necessarily involve routes of transmission with higher social stigma and greater adverse health consequences such as smoking, snorting, and injecting,[83,84] although some evidence indicates that rural nonmedical prescription opioid users are more likely to use nonoral modes of administration than are urban users.[85,86]

Self-medicating for Pain

When used as prescribed under medical supervision, opioid analgesics are effective and used as standard practice in managing acute and chronic pain.[87,88]

Because of the fast action in reducing pain and anxiety symptoms, many individuals who overuse legitimate prescriptions or obtain prescription opioids illegally do so to manage existing chronic or acute pain or emotional problems.[89]