By Iris Smith, Ph.D.

According to the U.S. Census, 3% of the U.S. land mass is considered urban, while 97% is considered rural. Over 80% of the population resides in urban areas compared to 19.3% in rural areas.¹  Definitions of “rural” vary considerably across studies, often dichotomizing communities as one or the other, leading to generalizations and discounting the differences between and within rural communities. 

The reality is that while some rural counties are impoverished and disadvantaged, others are among the wealthiest counties in the U.S.²  Regional differences are often not considered. The southern region of the U.S. has higher rates of morbidity and mortality compared to other rural areas, with people of color having the poorest outcomes.³ Research has documented numerous rural health disparities with regard to the 5 leading causes of death in the U.S. (heart disease, cancer, stroke, unintentional injuries, and chronic respiratory disease). Rural communities have also been significantly impacted by substance misuse, including opioids.  Some studies have found that rural youth have a higher prevalence of stimulant, methamphetamine, and tobacco use and may have an earlier age of onset of use compared to youth that live in metropolitan areas.³

Much of the research on rural health disparities has focused on the individual risk factors without attention to the social, structural, and policy level factors that increase disease risk. Structural factors such as limited access to treatment including lack of transportation, high levels of unemployment, and intergenerational poverty, and low levels of education have been recognized as contributors to the risk of addiction in many rural areas.  However, few studies have examined the impact these factors have on drug use behaviors within the communities. A systematic recent review of 32 peer-reviewed qualitative studies found that economic strain sometimes led to riskier behaviors among opioid users. For example, several studies reported that respondents switched from snorting to injecting to reduce the cost of using or engaged in riskier injection practices such as multiple injections per episode and sharing injections with other users. Self-medicating with opioids for the relief of physical pain or mental distress was also noted by several studies. Carpooling to urban areas when drug supply chains became unstable was also common. Studies also found that while social networks could be a positive influence on users by supporting recovery and mediating stigma, in families with intergenerational drug use they could also influence the development of risky behaviors.⁴

Rural health disparities, including substance use, result from an overlapping array of individual, social, and structural factors. Reducing these disparities requires an understanding of the unique circumstances and confluence of factors in the focus community. The National Institute on Minority Health and Health Disparities has proposed a useful research framework that reflects the multiple interacting levels of influence that need to be addressed.⁵

Resources

Afifi RA, Parker EA, Dino G, Hall DM, Ulin B. (2022). Reimagining Rural: Shifting Paradigms About Health and Well-Being in the Rural United States.  Annual Review of Public Health, 43 pg.135-154. Online access:  https://doi.org/10.1146/annurev-publhealth-052020-123413

Jaffiajee R, Allison L, Bohnert SB, Goldstick JE (2019) Characteristics of US Counties with High Opioid Overdose Mortality and Low Capacity to Deliver Medications for Opioid Use Disorder.  JAMA Network Open https://jama.jamanetwork.com/article.aspx?doi=10.1001/jamanetworkopen.2019.6373&utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamanetworkopen.2019.6373

Miller CE & Vasan RS (2021) The Southern Rural Health and Mortality Penalty:  A Review of Regional Health Inequities in the United States.  Social Science Medicine, 268:113443. Online free access:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7755690/pdf/nihms-1640235.pdf

National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Roundtable on the Promotion of Health Equity; Roundtable on Population Health Improvement. Achieving Rural Health Equity and Well-Being: Proceedings of a Workshop. Washington (DC): National Academies Press (US); 2018 Mar 14. Available from: https://www.ncbi.nlm.nih.gov/books/NBK531876/ doi: 10.17226/24967

Thomas N, VandeVen K, Mulrooney KJD (2020) The Impact of rurality on Opioid-Related Harms:  A Systematic Review of Qualitative Research.  International Journal of Drug Policy 85; pg. 102607. https://doi.org/10.1016/j.drugpo.2019.11.015