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

Summary and Future Directions

In the Table we have summarized our hypotheses regarding the responsible drivers of the increased prescription opioid misuse in rural areas. We posited that increases could, in part, be attributed to (1) increased sales of opioid analgesics in rural areas that lead to greater availability for nonmedical use through drug diversion networks, (2) out-migration of upwardly mobile young adults from rural areas that increases economic deprivation and creates an aggregation of young adults at high risk for drug use, (3) tight kinship and social networks that allow faster diffusion of nonmedical prescription opioids among those at risk, and (4) increasing economic deprivation and unemployment that create a stressful environment that places individuals at risk for drug use. These factors interact in dynamic ways with identified risk factors that are not unique to nonmedical prescription opioid use to lead to epidemics of prescription opioid use and associated injury in rural areas.

The hypotheses we have proposed do not explain all the observed patterns of nonmedical prescription opioid use and overdose. For example, states such as Florida and Washington have relatively high rates of nonmedical prescription opioid overdose but are largely urban, whereas Iowa and North Dakota have relatively low rates despite substantial rural areas;[11,18,128] thus, the mapping of rural geographical area to increases in nonmedical prescription opioid overdose is not linear.

Furthermore, demographic factors in both urban and rural areas likely interact with the factors we have mentioned in ways that remain to be elaborated. For example, Black and Hispanic individuals face the same if not greater stress because of economic hardship than do Whites and yet have lower overall rates of nonmedical prescription opioid use.[52,53] The intersection of demographic factors such as race and ethnicity with drug and alcohol use remains among the unexplained anomalies in the epidemiological literature on substance use.[129]

Finally, although we focused on prescription opioids, there is growing evidence that the abuse of other prescription drugs such as stimulants and benzodiazepines is also increasing,[57,125] especially among adolescents and young adults.[82] Understanding the distinctions among underlying risk factors for misuse of distinct types of prescription drugs is an important public health priority, as prevention and intervention strategies may differ depending on the type of drug.

The differences in drug use between urban and rural areas are just 1 example of how macrolevel forces shape population-level patterns of drug use. A comprehensive understanding of why, for example, rates of alcohol and drug use differ across time, across countries, in countries across states, and across certain population subgroups is critical and understudied. Social norms, cultural traditions, attitudes, availability, and policies are all likely critical to understanding broad differences in prevalence of substance use across areas,[21,36,51,130] yet few efforts have been made to comprehensively collect this information across time and across geographical spaces to examine the influence and the interaction of these factors with more microlevel determinants such as families, peers, and genetics.

We suggest that a strategic comparison between groups with different outcomes is an important way forward for the study of macrolevel influences on substance use. We have demonstrated that comparing urban and rural drug use is one way to find variation in structural factors that affect individual-level risk, yet empirical data to test our model remain critical.

National studies with sufficient sample sizes of urban and rural adolescents, young adults, and older adults with information on the economic and social characteristics of geographical spaces such as counties and neighborhoods are needed to advance this literature. Furthermore, the incorporation of novel methods such as agent-based or other generative modeling[12,124] would be useful to correctly develop empirical tests in the context of a dynamic social and political space where individuals interact in networks and with their surroundings.

The crisis of nonmedical use of prescription opioids is an important public health priority, and the greatest public health threat remains concentrated in rural, low-income areas of the United States. Responding to this threat requires new theories from which new hypotheses can be developed and new data and methods that can be used to test novel hypotheses. Increased understanding of spatial factors is critical for developing a better model for the etiology of substance use considering the importance of physical setting, as well as for identifying points of intervention and prevention at a population level.