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

Rural Area Use vs Urban Area Use

We next considered specific factors that might explain the urban versus rural differences in nonmedical prescription opioid use. We hypothesized that 4 factors might be particularly relevant in explaining these patterns. These hypotheses have an empirical basis but require testing.

More Increased Availability in Rural Than Urban Areas

Although availability of prescription opioids has increased in all areas, there is evidence that it has increased more in rural areas. Specifically, per capita sales data indicate that states with large rural populations such as West Virginia are among the highest prescribers of opioid analgesics. The data are not entirely consistent with increased availability in rural areas, however, with Florida being a central outlier.

Several nonrural counties in Florida have the highest mean milligrams of opioids dispensed as of 2008,[90] and many of the top-prescribing doctors and clinics are in the state of Florida, although recent data indicate that control measures are reducing diversion of and doctor shopping for opioids in Florida.[91] Considering the evidence in total, however, a general picture emerges whereby high prescription rates in many rural counties indicate increased availability in these areas. The marketing of prescription opioids such as OxyContin has been more aggressive in rural communities such as those surrounding Appalachia.[92]

Rural populations are on average older than are urban populations;[93,94] thus, there may be more chronic pain for which management with opioid analgesics is indicated. Furthermore, evidence indicates that chronic pain and injury are more common in rural than in urban areas.[95–97] Finally, qualitative research indicates that prescription drug use in rural areas such as Appalachian Kentucky is an embedded part of the culture of the area, with prescription narcotics often prescribed to maintain a steady workflow in mines and other heavy labor occupations.[98] A higher density of available opioids may create opportunities for illegal markets in rural areas because family and friends are a primary distribution source of nonmedical prescription opioids.[68–73,99]

Out-Migration of Young People

In the past 2 decades, rural areas have evidenced an out-migration of many young adults during peak producing ages. For example, data from the 2010 census indicated that the percentage of individuals older than 65 years in West Virginia (which has a high proportion of rural counties) is twice the percentage of those aged 18 to 24 years (in 1970 the percentages of these 2 age groups were approximately equal).[100]

There are 2 consequences of this out-migration that may be related to increases in nonmedical prescription opioid use in rural areas. First is the effect on the economic conditions of the area. Areas with an aging workforce have less new economic infrastructure.[93,101,102] Adverse economic conditions and high rates of unemployment may create greater vulnerability to drug use in these populations. Second is a selection effect. Young adults who stay in economically deprived areas may have a greater accumulation of risk factors for problematic drug use and may be more likely to have established drug dependencies at a young age that cause downward social drift.

Although data on young adult migration patterns in the United States are scant, substantial research has documented that adolescents in rural areas overall have lower academic aspirations and academic achievement[103,104] as well as fewer returns on academic investment.[103–105] Individuals who have the material resources and aspirations to migrate to urban areas are likely different from individuals who stay on an array of risk factors for drug use, including educational attainment. Data on differences in young adult migration as it relates to risk factors for prescription opioid use are critical for testing and advancing these hypotheses.

Social and Kinship Networks

The influence of family structures and family life is a central cultural difference between rural life and urban life. Although rural areas are increasingly connected to urban spaces as urbanization continues in the United States, there are substantial differences in social norms, expectations, and cultural values between families of rural versus urban areas.[106–108] For example, in many rural areas a higher value is placed on work and on investment in the community than on education.[109] Individuals in rural areas report knowing the members of their social network longer and being more closely related to members of their social network than are individuals in urban areas.[106] Furthermore, substantial sociological research has documented that individuals in rural areas trust their neighbors more and are more likely to engage socially with neighbors and others who are geographically close.[108,110] Ties to the community are often stronger in rural areas, and greater value is placed on maintaining strong social capital.[107]

In the context of such strong social and kinship networks, economic hardship associated with industrial restructuring and rural to urban migration of youths may generate strain not only in affected individuals but also in the broader social network, increasing the risk for illicit drug use across the social structure.[107] However, strong social ties with family and community may serve as a buffer against the stress of economic hardship,[111] in which case strong social ties would be associated with reduced drug use in rural areas. Testing and differentiating these pathways are critical for advancing our understanding of rural communities and drug use.

Family structures in rural areas are also larger and fertility rates are higher,[112] suggesting that rural kinship networks are often wider than are urban kinship networks. Substantial empirical evidence indicates that, in contrast to the sources of other illicit drugs, one of the main sources of illicit prescription opioids is the diversion of prescriptions legitimately filled by parents, relatives, friends, or acquaintances.[68–72,99] Thus, family networks matter more for prescription drugs than for other drugs because they are more often obtained from family members, whereas other drugs are more often obtained through friends or the drug trade.

Interestingly, OxyContin use has been significantly associated with increased social capital in rural areas,[113] suggesting that nonmedical prescription opioid distribution networks integrate into social networks in important ways in isolated rural communities. The breadth and proximity of the social network in rural areas may allow faster diffusion of prescription drugs to potential nonmedical users, and sources of prescription opioids through families may be more accessible in rural areas. These wide social networks with close ties across individuals may facilitate the distribution of prescription opioid medication. Little research has mapped social networks of prescription opioid diversion in rural areas; the hypotheses we have outlined provide a road map for addressing the potential differences in diversion and dissemination of prescription opioids in rural versus urban settings.

Structural Stressors of Modern Rural Living

Although there are stressors associated with living in both urban and rural areas, economic downturns have more adversely affected rural areas in the United States;[114] thus, stress owing to unemployment and lack of available industry may be more strongly felt in rural areas. It has been well documented that geographical context shapes risk of drug use,[21,22,25,115–117] including poverty and unemployment.[27,28,118–124] Rural counties in particular have faced job sector and industry shifts as populations shift to meet the labor demands of changing markets,[125,126] resulting in long-term economic deprivation, high rates of unemployment, and fewer opportunities for establishing a long-term career with potential for upward mobility.[125]

Numerous economic analyses have revealed mismatches between the skills of residents and the jobs available to them, and industrial restructuring predicts a shift into poverty of many in the United States.[24,80] Furthermore, in the United States, there have been decreases in the wage rate for low-skilled jobs[126] and the demand for manufacturing jobs[127] coupled with an increase in the demand for high-skilled workers.[80,86] These factors affect rural more than urban counties,[127] which generally have a greater diversity of labor markets and workers.