In opioid crisis, rural areas taking a hard hit
Naomi Penney
Research Analyst
The Polis Center at IUPUI
According to the Indiana State Department of Health, the opioid crisis has affected every county in the state.1 While the problem may be statewide, the specifics of the crisis differ in important ways when comparing urban and rural areas, with rural areas being particularly hard hit, even after adjusting for population density.2,3 The Polis Center, MPH and IBRC, with funding from the Lilly Endowment have been engaged in a social network analysis project for the past year, to collect data to create visual representations of the organizational networks in Marion County that are addressing the opioid crisis. The project, the Indiana data Partnership (IDP) has collected data from over 2,000 organizations. Data collection is now beginning in non-metropolitan areas around the state.
There are several important factors that differentiate rural communities from urban ones, that have had considerable impact on the opioid crisis; demographics, economy, the role of social and community networks, and access to health care.4,5,6
Demographics
Over the past two decades rural populations have become older due to the out-migration of youth. Older populations may have a greater prevalence of chronic pain in rural areas than urban areas due to an increased likelihood of having worked in jobs requiring physical labor, such as agriculture.
Economics
As populations age and younger workers leave, a complex inter-related set of problems is created. The presence of fewer workers impacts the economic infrastructure in terms of job creation, job availability, and matching of the skills needed for the available jobs 5. A smaller job applicant pool does not attract large employers. Thus there are fewer opportunities for communities to create new services and staff them.
Social and Community Networks
In the past, it was generally believed that the social and kinship networks seen in rural areas was a protective factor to the blights visited upon urban areas. However, more current research is challenging this notion in two ways, in relation to the substance use crisis. The first is the issue of access to prescription and non-prescription drugs. The use of prescription opioids by family members and friends has been reported to be a significant factor in the growing epidemic in rural areas5. Adding to this this is the fact that many smaller communities are less anonymous. There is often a fear of stigma when seeking treatment for substance use disorders and other mental health diagnoses.
Access to Care
Populations living in rural areas are spread out over large geographic areas. In any community there may only be one provider of mental health services, there may be no detox services or other related services such as MAT in the community. This forces people living in these areas to travel large distances to receive help or even know there is help available7. Addressing the crisis across sectors of community services has proven to be even more necessary than in urban areas6.
Implications
The IDP project is uniquely positioned to help organizations in rural communities build their collective capacity to prevent and treat substance use disorders. IDP has previously identified and analyzed the networks and clusters of organizations addressing the opioid crisis in Marion County. The Polis Center is now beginning similar work in non-metropolitan areas around the state. Via this work, IDP will provide rural communities a better understanding of existing and potential collaborative networks. We will compare the urban networks in Marion County with rural networks to identify whether different network characteristics have evolved in these different environments. We imagine that because there are fewer organizations in rural areas, that the organizational networks will be denser than those in urban areas. This conjecture is based on the fact that rural organizations often have fewer choices in terms of other organizations with whom they can collaborate to try to provide the full range of needed prevention and treatment services to their communities. As with social and kinship networks, that are reported to be longer lasting and more connected in rural than in urban areas, rural services networks may be similarly stronger, although they may face unique barriers to collaboration due to concerns about protecting patient confidentiality in a close knit community.
1. CDC/NCHS. (2018). National Vital Statistics System, Mortality. Retrieved from https://wonder.cdc.gov. Atlanta, GA: U.S. Department of Health and Human Services, CDC. Hagstrom, J. (2017). Opioid Effects on Farm Country, DTN HEADNEWS (Jan. 1, 2017), https://perma.cc/CA5E-QVM5
2. Cicero, T.J., Surratt, H, Inciardi, J.A., Munoz, A. (2007). Relationship between therapeutic use and abuse of opioid analgesics in rural, suburban, and urban locations in the United States. Phamracoepidemiology Drug Safety, 16(8): 827-840.
3. Dew, B., Elifson, K. & Dozier, M. (2007). Social and Environmental Factors and Their Influence on Drug Vulnerability and Resiliency in Rural Populations. National Rural Health Association, Fall, 16-21.
4. Hazlett, A.C. (2018). Rural America and the opioid crisis: Dimension, impact, and Response. Drake Journal of Agricultural Law, 23(1),45-55.
5. Keyes, K.M., et al., (2014). Understanding the rural-urban differences in nonmedical prescription opioid use and abuse in the United States. American Journal of Public Health, 104(2), e52-e59.
6. Martin, L., & Alderman, M. (2016). A systems approach is the only way to address the opioid crisis. Health Affairs, doi: 0.1377/blog20160613.055320/full/