The Opioid Epidemic: The Nexus of Geography, Education, Commerce and Healthcare (Part 1)
By Mario
At Opportunity Labs, we’re focused on complex issues that exist at the intersection of health, education, commerce, and housing. The opioid epidemic in America is exactly this type of problem. It is also one that I have personally witnessed unfolding in emergency departments across the country.
Despite efforts across the public health, law enforcement, education and workforce systems over the past 20 years to combat this crisis, America’s opioid epidemic has only gotten worse. From 1999-2017, nearly 400,000 Americans died from prescription and illicit opioid overdoses, roughly 130 people every day. Some of these have been patients I’ve cared for personally.
Understanding the history of the epidemic is critical to finding sustainable solutions. It intensified in three waves beginning with prescription and semi-synthetic opioid—hydrocodone, oxycodone, etc.—abuse in the 1990s, and accelerating into a massive onslaught of synthetic opioid—fentanyl, Carfentanil, etc.—overdoses today.
The opioid epidemic knows no geographic or socioeconomic boundaries. Mortality data confirms this truth. But, what has often been overlooked, misunderstood, or simply ignored by federal and state level policy makers is why the epidemic’s demographic profile has shifted as it has evolved.
The data provides important takeaways for both policymakers and practitioners looking for innovative solutions in their local communities.
Why Are There Differences in the Rural, Suburban, and Urban Opioid Epidemics?
A seminal 2018 study confirmed that opioid related mortality rates were higher in urban counties than in rural counties:
13.4/100,000 deaths in large central metro counties,
16.4/100,000 in large fringe metro counties,
14.8/100,000 in medium/small metro counties, and
12.6/100,000 in non-metro counties.
For context on death rates per 100,000 vis-a-vis guns and car accidents from Real Clear Policy:
Higher opioid death rates in urban areas in not surprising. But the researchers also found that between 1999 and 2016, the change in overdose deaths increased more rapidly in rural counties than in urban counties:
+158% in large central metro counties,
+507% in large fringe metro counties,
+429% in medium/small counties, and
+740% in non-metro counties.
Why did this happen?
For years, a prominent theory was that economic distress was the primary driver in the increase of opioid deaths outside of cities. Casual observers and experts alike pointed to the particularly high overdose rates in the Northeastern United States and Appalachian regions as key proof point in their argument. The data tells a more complicated story. Increased mortality rates are actually more closely linked to differences in opiate supplies, prescription trends, and other associated social factors.
It’s About Prescribing, Geography, Social Capital and Commerce
In early 2019, CDC investigator Macarena Garcia and her team analyzed electronic health records to prove that patients living in rural areas had nearly twice the odds of being prescribed an opioid containing pain medicine compared to their peers residing in urban areas. In some instances, the difference was as high as 87%.
Covering a similar period of time, another team of CDC researchers found that overdoses in urban vs. rural areas have diverged with urban overdoses more likely to include fentanyl and synthetic opioids, while rural areas continue to have higher rates of prescription overdoses.
This makes sense given the differences in prescription rates between these two demographic groups, and also takes on added meaning in the context of a large body of research related to the epidemic’s geographic and social capital inputs.
For instance, in one study, researchers noted four factors that should be considered root causes of the worsening epidemic:
greater opioid prescribing rates in rural areas creating a supply to generate illegal markets,
out-migration of young adults,
greater rural social and kinship network connections that facilitated drug diversion and distribution, and
economic stressors that created vulnerability to more general drug use.
What Does It All Mean?
Taken together, the research helps to explain the demographic changes we’ve seen in the epidemic over the last few years. If the epidemic had been solely linked to worsening economic conditions, we likely would have seen improvements in overdose rates as we emerged from the Great Recession beginning in 2010.
Instead, as supplies of prescription opiates have tightened, there has been a demographic shift with users diverting to heroin, fentanyl, and other synthetics with a proportionate drop in the number of prescription related overdoses but a continuing rise in fatalities. Tracking with that observation, law enforcement has seen a proportionate rise in the spread of synthetic opioids out of urban America and into more rural areas.
Additionally, the social fabric of rural communities has influenced how the epidemic has grown.
Managing the Opioid Epidemic—What Can We Learn?
Federal efforts to combat the epidemic have utilized a dual-sided approach with attention focused on the problem as both a public health and a law enforcement issue. Federal government spending on opioid related research, clinical care, and Department of Justice initiatives across 57 programs totaled nearly $11 billion in FY2017 and FY2018. Despite this increase in spending, the problem is intensifying.
There are some pockets of success, however, that are representative of efforts that other communities should work to better understand.
A 2018 op-ed in the New York Times highlighted Hawaii, Massachusetts, North Dakota, Oklahoma, Rhode Island, Utah, Vermont, and Wyoming as states where overdose rates are decreasing. The article rightly observes that this progress could be attributed to increased access to Naloxone—an overdose treatment medication—and anti-addiction medications such as Buprenorphine and methadone. A key lever of improving access to these medications was the increase medical insurance coverage for individuals in some of these states where Medicaid was expanded under the Affordable Care Act.
At the city level, Dayton, Ohio, a community that once led the nation in per capita overdose fatalities, has seen significant improvement over the past year—in Montgomery County, which includes Dayton, fatalities were down 54% as of November 2018. Local leaders there attribute the success in reducing overdose deaths to a variety of measures including state Medicaid expansion, decreasing Carfentanil availability, improved access to Naloxone, and community support for people completing rehabilitation. Through a variety of initiatives, there has been a strengthening of social capital, including increasing the number of recovery support groups, new teams of social workers to facilitate placement in treatment programs, and associated efforts to break the social stigma that often accompanies drug and substance abuse problems.
At the local level, a project in North Carolina stands out as a model. Project Lazarus in Wilkes County, an area that stood out for its disproportionate share of overdose deaths, started in 2008-2009 and is currently expanding to other areas in the state. The work includes an interdisciplinary, “community coalition of medical professionals, hospital officials, law enforcement agents, members of the faith community, and social services and education representatives” working to address the crisis. Their approach has included:
Community activation and coalition-building,
Epidemiological surveillance and monitoring,
Prevention of overdoses through medical education, and
Use of rescue medications to reverse overdoses.
Observations and Lessons Learned
These success stories demonstrate why solutions to complex problems, including the opioid epidemic, demand deep experience and expertise across interconnected opportunity domains. The healthcare, education, and commerce sectors have played a critical role in the worsening epidemic and now have to be inclusively unwound and reconfigured if we’re going to find sustainable solutions that can be implemented at scale.
More importantly, the interventions above illustrate the importance of meeting the problem where it is, not where we prefer it to be. This epidemic manifests differently from community to community, thus solutions that are created locally can be much more impactful than top down approaches cooked up in windowless offices far away from the problem.
At Opportunity Labs, our team is working with local partners every day to address problems just like these. We partner with organizations that have big ideas to solve the hardest problems and are looking for collaborators who will roll up their sleeves and do the hard work of helping them bring their solutions to life.