Opioid Overdoses Deaths Higher in Rural Than Urban Areas

A new report published by the Centers for Disease Control and Prevention (CDC) reports preventable deaths due to opioids are far higher in rural counties compared to urban counties, and now significantly outweigh the overall national death rate.

Interview with Mark Faul, PhD, MA

Excess death rates from unintentional opioid overdose remain considerably higher in rural areas of the US, and according to the Centers for Disease Control and Prevention (CDC), there could be a number of challenges to addressing this problem.

Accidental overdose deaths are higher in rural than urban areas in America.In a recent report, the CDC laid out new data on the 5 leading causes of excess deaths in rural regions of the country.¹ Opioid-related deaths, in particular, remain a prevalent issue for rural communities, with approximately 50% higher age-adjusted death rates compared to urban areas of the country.

The research highlights a major cause of mortality in rural counties of the country, and according to Mark Faul, PhD, MA, a senior health scientist at the CDC, many of the challenges rural communities face with opioid deaths relate to emergency care resources, which are scarce and geographically challenged.

“The first thing to note is that about 15% or 20% of all EMS, who are the first folks to arrive on the scene and potentially administer naloxone, are in rural areas that account for about 80% of the land mass in America,” Dr. Faul told Practical Pain Management.

The geographic disadvantages for emergency personnel can be tremendous, considering the time it takes to cover such distances and the time it takes for an opioid overdose to become fatal, Dr. Faul explained.

“It doesn’t mean there was no response at all, it just means that when there’s an opioid overdose and there’s crisis, it’s harder to make the optimal response in a rural community, given those constraints,” said Dr. Faul.

Rural areas also typically have far less paramedic personnel on call who are trained to administer the opioid antagonist naloxone. Basic EMT personnel are not permitted to administer naloxone, and while this statute has been overridden by about more than half of states, which by law can determine their EMS policies, it is still the general national policy, Dr. Faul noted.

Preventable Deaths: A Disparity Between Urban and Rural America

Of the 1,622,304 deaths that occurred in the US in 2014, 62% have been associated with the 5 leading causes of death in the country,² which include:

• Heart disease
• Cancer
• Unintentional injury
• Chronic lower respiratory disease (CLRD)
• Stroke

The analysis by the National Center for Health Statistics (NCHS), aggregated data based on counties in the US, approximately 1,200 of which are considered metropolitan (Urban) and 2,000 are considered non-metropolitan (rural), according to Macarena C. Garcia, DrPH, MIS, senior health scientist at the CDC.

This new data compares death rates in urban counties versus rural counties to better understand why some areas of the country are more plagued by preventable deaths than others.

However, the all-cause age-adjusted death rate for the US actually appears to be dropping, having reached a historic low of 724.6 per 100,000 population.³ The problem appears to be that death rates in rural areas of the country are not dropping as slowly as the rest of the country (830.5), especially compared to mortality rates in urban parts of the country (704.3).³

The term “excess deaths” refers to deaths among people aged <80 years in excess of the amount that would be expected if the death rates for each cause were the same across every state, with the number being based off of the 3 states with the lowest death rates.^1,4-5

According to the CDC, from 2009 to 2014, age-adjusted death rates for unintentional injuries were approximately 50% higher in rural areas, compared to urban areas.

There could be several factors to help explain this difference, especially considering “unintentional injury” is an umbrella term for deaths related to trauma from motor vehicle accidents, accidental poisoning, and other forms of injury not associated with the use of opioid drugs. Demographic data also shows residents of rural areas typically are older, poorer, and sicker than those living in urban areas.⁶

Preventing Preventable Deaths in Rural America

But according to Dr. Faul, emergency care resources for rural communities are often stretched thin, something that has led the CDC to take a public stance advocating for increased naloxone training and access to basic EMS staff. Some states are expanding access even more aggressively, particularly Ohio, which now allows highway patrol officers to possess and administer the drug.

There is also the possibility that prescriber behavior may differ between those practicing in urban areas versus those practicing in rural ones. According to Dr. Faul, the CDC’s new guidelines on the use of opioid drugs for the treatment chronic noncancer pain conditions could be a useful tool for helping improve prescriber behavior with opioids and raise awareness about their dangers.

The CDC guidelines⁷ have come under notable scrutiny by physicians and organizations that represent them, however. There even have been suggestions the CDC guidelines could have an undesired effect in pain management, incentivizing primary physicians to refer patients with chronic noncancer pain to pain specialist practices, introducing problems with patient access to pain management. Some doctors may steer clear of opioids, altogether.

“We’re in the process of doing evaluation of the guidelines and putting some funding out toward analyzing what’s working or not working.” Since the CDC currently lacks any data on the possible impact the CDC guidelines could be having on prescribing behaviors of health care providers, the organization has no public response to any such claims.

View Sources

1. Garcia MC, Faul M, Massetti G, et al. Reducing potentially excess deaths from the five leading causes of death in the rural United States.Surveillance Summaries. 2017;66(2);1-7.
2. Yoon PW, Bastian B, Anderson RN, et al. Potentially preventable deaths from the five leading causes of death—United States, 2008–2010.MMWR Morb Mortal Wkly Rep. 2014;63:369-74.
3. Kochanek KD, Murphy SL, Xu JQ, et al. Deaths: Final data for 2014.Natl Vital Stat Rep. 2016;65(4).
4. Yoon PW, Bastian B, Anderson RN, et al. Potentially preventable deaths from the five leading causes of death—United States, 2008–2010.MMWR Morb Mortal Wkly Rep. 2014;63:369-74.
5. García MC, Bastian B, Rossen LM, et al. Potentially preventable deaths among the five leading causes of death—United States, 2010 and 2014.MMWR Morb Mortal Wkly Rep. 2016;65:1245-55.
6. Health Resources and Services Administration. Mortality and life expectancy in rural America: Connecting the health and human service safety nets to improve health outcomes over the life course. Rockville, MD: S. Department of Health and Human Services, Health Resources and Services Administration. 2015.
7. Dowell D, Haegerich TM, Chou R, et al. CDC guideline for prescribing opioids for chronic pain — United States, 2016.Recommendations and Reports. 2016;65(1);1-49.