Understanding Rural- Urban Differences Involving Opioid Analgesics in the United States, 2002 to 2014: Implications for Policies to Increase Health Equity in Rural Communities

Background and Purpose: Opioid use, particularly the non-medical use of opioid analgesics (NMOA), continues to be a major public health issue in the United States and a major challenge for social workers in specialty and non-specialty settings. Data from the most recent national surveys suggest that the rate of NMOA use is only slightly lower in rural communities as compared to more urbanized communities. This may obscure more obvious disparities when examined by level of urbanization. This study analyzed data from national systems by level of urbanization to provide greater contextual understanding of NMOA use and its relative impact on morbidity and mortality in rural and urbanized communities.

Methods: The data for this paper were derived from many sources and including (1) the National Survey on Drug Use and Health (NSDUH) (2) the Behavioral Health Treatment Locator files,(3) the Health Care Utilization Project (HCUP), and (4) the Center for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research (WONDER) system. De-identified data on physician's holding waivers to prescribe buprenorphine from their offices (DATA 2000) were obtained from administrative files provided by the Drug Enforcement Administration. All data were analyzed by level of urbanization consistent with each data system's definition and categorization of county level of urbanization.

Results: Nationally, past year use of NMOAs declined between 2002 and 2014, but the relative percent change was much greater in completely rural communities (-42.07%). Data also show that rural and small communities consistently had fewer resources in terms of substance use treatment (45%), opioid treatment programs (1%), and were more likely to be without any DATA 2000 waived physicians (72%). In addition, this study found the largest increases in emergency department visits among medium and small metro communities and rural communities (119% 121%, and 104% respectively). Interestingly, the largest increases in in-patient stays were found in medium metropolitan communities (83%). The rate of drug poisoning deaths involving NMOAs appears to have flipped from a higher rate in more urbanized communities in 1999 to higher rates in less urbanized communities with the largest changes found in rural (1.2 to 7.7 drug poising deaths per 100,000) and micropolitan (1.4 to 7.8 drug poisoning deaths per 100,000) communities.

Conclusions and Implications: There are a number of limitations that impact this study as a result of drawing from multiple data systems and results should be interpreted with care. Nevertheless, these findings suggest real disparities in the capacity of rural communities to respond to the opioid epidemic. To reduce these disparities and increase health equity among rural populations, social work can promote a number of policies including financial strategies (loan repayments and locality pay) to attract skilled social workers to rural communities, reconfiguring personnel structures in Federally Certified Health Clinics to include social work practitioners and recovery specialists, and taking advantage of advances in technologies to increase capacity without necessarily building a brick and mortar clinic. Additional policies as well as future research directions will be discussed.