The opioid epidemic in America is a widely acknowledged problem, and it disproportionately affects rural communities. Is it a public health problem, a legal issue, or both? And to what extent is the problem driven by circumstances particular to rural life?
Rural doctors acknowledge the difficulty of getting patients to physical therapy and rehabilitative care for their injuries, and often resort to prescribing opioid pain medicine instead. Their ability and their incentives changed drastically in the late 1990s as Purdue Pharmaceutical introduced OxyContin to the market, aggressively marketing it as a safe method of approaching an under-treated problem-- chronic pain. In 2001, the Joint Commission on Accreditation of Healthcare Organizations released a new set of guidelines mandating a much greater focus on treating pain than before in order for hospitals to receive accreditation. Sixteen years after the Joint Commission's revised pain guidelines, the unintended consequences for rural America are clear. Opioid overdoses, including those from users of heroin who switched from prescription pain pills, have increased the fastest in the rural states of Kentucky, West Virginia, Oklahoma, and Alaska. As the standards for prescribing opiates relaxed, rural areas suffered from an accelerating spiral of addiction, ending in many instances with the user switching from prescription pills to heroin, and ultimately incarceration or death.
The political will to enact legislative solutions has been haphazard. Politicians on the right and left cannot seem to agree whether to treat the problem as a legal issue or as one of public health. As many of the rural states hit hardest are run by Republicans, many of them have turned to well-worn tough on crime rhetoric that polices the boundary between rural and urban areas in the harshest way possible.
In rural counties, some prosecutors are turning to drug-induced homicide charges against heroin users who have provided heroin on which another person has fatally overdosed. In the far exurban orbit of St. Louis, rural prosecutors like Thomas Gibbons of Madison County, IL couch their use of the tactic in language of protection of family and place: "I fear for the existence of the county my sons grow up in.We intend to absolutely make an example of these people in public." The policy rationale of DIH charges is that prosecutors can leverage the threat of serious jail time to induce addicts to inform on their dealers. However, it is often addicts who procure drugs for a group and themselves overdose who are charged with this crime. By 'othering' addicts (see Gibbons use of the phrase "these people") and claiming that those charged are conspiring with non-locals, these charges alienate and exclude the addicts of these rural communities.
Right wing pundits and politicians are also visibly casting about for ways to characterize opioids and heroin as a problem 'imported from urbanity'. See Maine Governor Paul LePage's racist and demonstrably incorrect statement that the heroin problem in his rural state was mostly the fault of black city-dwellers.
Commentators who don't resort to the claim that opioid problems originate in the Hogarthian metropolis resort to familiar claims about personal responsibility and moral failings. See, for example, J.D. Vance's claim that heroin addiction in rural America is about misplaced priorities and a decline in community values. Or David French and Kevin Williamson's vitriolic one-two punch declaring that "The truth about these dysfunctional, downscale communities is that they deserve to die."
In contrast to these claims about the moral failings of the rural addict, public health literature provides a clearer-headed view. Recent writings on rural opioid addiction in the public health literature identifies a confluence of geographical factors that spur the phenomenon. Rural areas have high rates of opioid prescription for chronic conditions. Kinship networks can encourage diffusion of bad behavioral health practices. And opportunities are limited in rural areas, tending to produce mental health issues that coincide with addiction.
As Lisa Pruitt points out, people turning to drugs are a symptom of despair and malaise about declining prospects and downward mobility in rural areas. This theory does not locate the driver for addiction in either unsavory connections to urban spaces, like the Paul LePage characterization, or in poor personal character of some 'bad apples' who reject the traditional values of rural communities like the conservative commentators above. Viewing opiate overdoses as deaths of despair is all about structural pressures that reduce opportunity in rural places, combined with veritable spigot of easily available drugs.
Unfortunately, it's hard to tell what's likely to change in the next few years for the better. The Secretary of Agriculture for the Obama administration, Tom Vilsack, made big efforts to bring the rural opioid epidemic to the attention of Washington in the last years of his tenure. The new administration has been quiet on the issue, but if Mike Pence's foot-dragging attitude toward needle exchanges in Indiana is any indication, it might be a long time before these rural places get a public health approach that works.