Opioid use disorder and rural America

Opioid use disorder burden in rural communities

Although the overall prevalence of drug use in rural areas is lower than that in urban areas, the looming opioid epidemic has caused the rate of overdose deaths in rural areas to increase and surpass the rate seen in urban areas [ ]. As shown in Fig. 3.1 , the Centers for Disease Control and Prevention (CDC) reported a 325% increase in drug overdose deaths from 1999 to 2015 in nonmetropolitan counties of residence compared with 198% among metropolitan counties of residence [ ]. In 2017, age-adjusted drug overdose rates were highest among states with large rural populations, such as West Virginia, Kentucky, Maine, and Ohio ( Fig. 3.2 ) [ ]. Additionally, several studies have reported that nonmedical prescription drug use has been mostly concentrated in nonmetropolitan areas, which is a change from the previous experience of urbanized areas [ ].

In a meta-analysis by Brady et al. [ ], the investigators reviewed qualitative and quantitative studies in order to identify risk factors associated with prescription drug overdose death. Twenty-nine studies were assessed for six risk factors: sex, age, race, psychiatric disorders, substance use disorder, and urban/rural residence. All were associated with drug overdose deaths except for urban/rural residence. These findings are of particular interest because rural overdose death rates are exceeding those in urban areas, yet the most current meta-analysis did not find a statistical association. This could be due to the wide array of ways rurality can be assessed in studies. Studies often describe urban and rural by population density, or by grouping micropolitan and metropolitan as urban. Varying definitions of rurality may result in attenuation of the overall effect it has on overdose deaths [ , ].

Human immunodeficiency virus

Between 2008 and 2014, the overall number of new HIV diagnoses among persons who inject drugs (PWID) fell in the United States. This was driven largely by the approximate 50% decline among urban PWID of color [ ]. However, transmission by injection drug use (IDU) in nonurban areas contributed to new HIV cases in greater proportion than in urban areas [ ]. The HIV outbreak in Scott County, Indiana, was the first in the United States that resulted from the rural opioid epidemic. Additional outbreaks have emerged since then. Between January and July 2017, 57 HIV cases emerged across 15 counties in the southern coalfield counties of West Virginia [ ]. Although 60% of the cases reported male-to-male sexual (MSM) contact as the mode of transmission and 10% endorsed both MSM contact and IDU, 23% either could not be found or refused to speak to the CDC investigators, raising the possibility that some or all had IDU risk. From January 2018 through February 2019, 30 PWID were diagnosed with HIV in Cabell County, West Virginia, a county that had previously averaged eight new HIV cases annually based on data from 2013 to 2017 [ ].

Between 2015 and 2018, 129 new HIV cases emerged in the cities of Lowell and Lawrence, Massachusetts [ ]. Although Lowell and Lawrence are not rural communities, early arrival of fentanyl, homelessness, incarceration, and a decline in HIV testing were factors that played a crucial role in the spread of HIV there—the same factors that are increasingly evident in rural communities [ ].

Hepatitis C, B, and A virus infections

The CDC reported a 2.9-fold increase in reported cases of acute hepatitis C virus (HCV) infections from 2010 through 2015, reflecting the increased rates of IDU, occurring mostly among young white persons living in rural communities [ , ]. Interestingly, the states with the highest rates of new HCV infections during this period—Kentucky, West Virginia, and Tennessee—were not receiving CDC funding for case finding. This reflected not only underascertainment and underreporting in these communities but also the deeper issue of limited healthcare and public health resources in rural communities with a high burden of opioid use disorder (OUD) and IDU.

Using data from the National Notifiable Diseases Surveillance System, the CDC assessed acute hepatitis B virus (HBV) infections in the same three states where HCV infections were high. Acute HBV infections also increased in Kentucky, West Virginia, and Tennessee ( Fig. 3.3 ) among non-Hispanic whites aged 30–39 years in nonurban communities [ ]. While the rate remained stable for the United States overall, the rate of HBV infections increased by 114% in 5 years in these three states [ ].

In the past few years, hepatitis A virus (HAV) outbreaks have occurred among people who use drugs (PWUD), the homeless community, and men who have sex with men [ ]. In 2017, the CDC received over 1000 reports of acute HAV infection from California, Kentucky, Michigan, and Utah. The majority of these cases were among IDU and non-IDU persons who use drugs and/or homeless individuals [ ]. In March 2018, a cluster of HAV infections was reported by the Kanawha-Charleston Health Department in West Virginia. Testing confirmed that the outbreak, primarily among persons who use drugs and homeless persons, was caused by genotype 1B, the strain identified in ongoing HAV outbreaks in multiple states [ ]. A retrospective review identified a total of 664 outbreak-associated cases from January 1, 2018 to August 28, 2018 that were epidemiologically linked to “… an identified outbreak case, a laboratory specimen matching the outbreak strain, or occurred in a person at high risk for infection (e.g., reported injection or noninjection drug use, experienced homelessness or unstable housing, or was recently incarcerated) ….” Morbidity included hospitalization among 57% ( n = 380) of the cases. Although mortality from HAV infection is unusual, one death has been reported in this outbreak, and deaths have been reported in San Diego and other localities with recent HAV outbreaks. This may have been exacerbated by concurrent past or current HCV infection in 314 cases (47%), past or current HBV infection in 65 cases (10%), and homelessness in 100 cases (15%). As routine surveillance data on incident cases continues to become available, the CDC expects increases in HAV infection among PWUD and/or homeless people—two characteristics that are evident in rural communities [ ].