Rural Appalachia’s Opioid Epidemic: A Scoping Review of Causal and Perpetuating Factors

The opioid crisis has raged rampant across North America, indiscriminately devastating both urban and rural communities. However, the crisis has disproportionately affected rural, de-industrialized Appalachia, where rates of opioid misuse and overdose are significantly higher than other regions.[1] This paper will explore the socioeconomic, geographical, and policy frameworks that have caused and perpetuated the opioid crisis in rural Appalachia. It will explore the endemic poverty, outmigration, cultural norms, social networks, and medical deficiencies that both made Appalachians more prone to the opioid crisis and continue to perpetuate it today. Though these factors laid the foundation for, and intensified, the ensuing epidemic, the opioid crisis was catalyzed by a lax regulatory framework that allowed for pharmaceutical companies to unscrupulously market their products and people to receive it in prolific quantities.

The opioid epidemic in rural Appalachia is undergirded by mounting economic stresses produced by deindustrialization and the departure of the coal industry. Coal-dependent counties account for half of Appalachia’s distressed counties since 1960, as there are few employment opportunities and insufficient public infrastructures that mitigate poverty.[2] American public policy has aided and amplified the exodus of these coal and manufacturing industries, which were often the only sources of employment in the economic region. Constrictive environmental policy, including the tightening of regulation on sulfur dioxide emissions at power plants in the 1970s, resulted in moving coal extraction to the low-sulfur coalfields of Wyoming, Montana, and North Dakota.[3] Climate consciousness exacerbated job loss in Appalachia, as the continued tightening of coal plant regulations has discouraged investment in new plants and retired a significant number of old plants.[4] Moreover, between 2008–2012, the Obama administration subsidized the production of natural gas and various forms of renewable energy. The consequent job growth in these sectors was at the expense of the coal industry, which lost 49,534 direct and indirect jobs in the same time span.[5] Coal companies also dramatically improved their efficiency through increased mechanization during the 1980s, effectively obsoleting many low-skill, high-paying mining jobs.

Deindustrialization has been another significant facilitator of job loss in rural Appalachia. This region relied heavily on the low-skill, livable wage, blue collar jobs that manufacturing provided to maintain local economies. Globalization and competition with countries allowing cheaper costs of labour disrupted the region’s traditional economic order. Manufacturing and coal jobs that provided livelihoods for many residents suddenly disappeared and were replaced by low-wage service sector jobs.[6] The relative lack of economic diversification in these rural areas left many with no chance of gainful employment. Many Appalachian state governments, like West Virginia’s, were beholden to the financial interests of coal and industry magnates, and thus never developed non-manufacturing or non-resource extraction economic infrastructure.[7] When economic instability set into the region, these magnates’ financial interests often hindered robust responses to industry change and mass unemployment. Appalachia’s longstanding traditions of economic and political patronage have further limited employment opportunities, as the jobs that remain are frequently used as a currency, as these jobs are traded between, and given to, family, friends and political supporters.[8] Thus, the impoverished, who are more likely to lack social capital, are often left with no opportunities to escape their poverty.

The disappearance of coal and manufacturing jobs has correspondingly led to the loss of jobs that were sustained by those industries. Many high skill jobs in finance, technology and services have relocated to urban centres, further worsening economic despair.[9] Consequently, devastated local economies are experiencing outmigration of skilled workers, intensifying concentrated multigenerational poverty for those who remain. Between 1995–2000, the Appalachian region’s net migration for workers with an undergraduate or graduate degree was -25,000.[10]

The seemingly hopeless and endemic poverty of America’s rural and deindustrialized regions has magnified the dangers of opioids like OxyContin and black tar heroin. These regions’ labour markets have remained unstable at best, and, at worst, nonexistent. Environmental policy and the forces of globalization have made alternatives to coal mining and manufacturing more attractive, consequently resulting in a decline in Appalachians’ pensions, union power, and average wages. Even low-income service jobs are subject to wage uncertainty due to business demand and managerial patronage.[11] As a result, many Appalachians have lost control over their poverty, instead being forced to rely temporary work, family help, and public assistance.[12] This has provided the foundation for opioid abuse, as opioids are often used as an economic coping mechanism. Thus, Appalachia’s opioid crisis can be explained, in part, by this, as higher rates of substance abuse are symptomatic of economic hopelessness.[13]

The aforementioned exodus of Appalachia’s educated class also has significant implications on the region’s opioid epidemic. Outmigration has not only perpetuated the crisis by concentrating poverty, but also by concentrating inadequate systems of education. Duncan notes that outmigration has socialized a culture of low standards, low expectations and poor educational attainment for the remaining impoverished cohort, [14] restricting their ability to obtain well-paying livelihoods. The lack of educational support infrastructure for the poor has significant implications, as studies consistently show that those without post-secondary degrees are more likely to develop drug use disorders. [15] Furthermore, past decades provided these low-skill, poorly educated workers with unionized, blue collar work. However, as previously detailed, labour market changes have dramatically decreased the quantity of these jobs. Case and Deaton found that the deterioration of the labour market and wage deflation have corresponded with an increase in substance-related deaths of despair, especially for Appalachia’s majority demographic: poor, white non-Hispanics.[16] Thus, though economic stress may not be the sole contributory factor, it is clear that widespread economic hopelessness is the foundation upon which Appalachia’s opioid crisis is built upon.

The social and demographic fabrics of rural Appalachia have further created an environment conducive to the spread of opioid abuse by normalizing opioid use and stigmatizing treatment for addiction. The region’s historical reliance on strenuous, labour-intensive work is one normalizing factor of prescription drug use. Coincident with good-paying Appalachian jobs becoming scarcer, new painkillers with supposedly no withdrawal or addictive effects like Percocet and OxyContin emerged, allowing workers to continue working without seeking treatment for their chronic pain or injuries. Thus, it was ordinary for significant numbers of former workers who were “chronically invalid” from occupational-induced pain to become addicted to prescription painkillers.[17] Furthermore, the ease with which OxyContin could be procured, coupled with incessant economic depression, resulted in the development of an OxyContin economy.[18] This economic system rewards daily OxyContin users in Rural Appalachia with higher positions of social capital and popularity among drug-using peers, consequently creating both social and economic pressure to use the drug. [19] The resultant widespread cultural acceptance of drug misuse has amplified the risk of abuse.

Moreover, the existence of large and strong kinship networks in rural Appalachia help to disseminate prescription opioids. Legitimate prescriptions are filled, then diverted through the network to addicts or pill merchants.[20] These networks also function as a barrier to addiction treatment, as they make remove the ability for addicts to retain anonymity while receiving treatment. [21] Thus, pursuing treatment in areas with small populations is attached with more social stigma, deterring addicts from seeking help.

Geographical factors, including the limited availability of primary care physicians and multidisciplinary alternatives to painkillers, have also facilitated the opioid epidemic’s pervasiveness in rural Appalachia. The disproportionate clustering of primary care physicians (PCPs) into urban areas has consequently resulted in PCP shortages across rural America. Despite accounting for 20 percent of the general US populace, rural Americans only have access to 9 percent of PCPs.[22] The poor tend to organize their lives around their immediate surroundings, often due to the financial barriers of transportation and the opportunity cost of travelling longer distances.[23] The poor’s proximate lifestyle, combined with increased travel time due to the shortage of PCPs, has discouraged the rural poor from visiting their doctors. This unwillingness to visit PCPs has exacerbated many rural patients’ chronic pain to the point where they must overuse emergency departments, [24] which prescribe opioids more frequently than PCPs.[25]

However, the role of rural PCPs as liberal prescribers of opioid medication should not be understated. The shortage of medical specialists and multidisciplinary therapists in rural areas is a significant contributing factor to increased incidences of drug prescriptions, as rural doctors lack the ability to refer patients in chronic pain to specialists who can treat pain without opioids.[26] Even if they were able to refer the patient to these specialists, cost and the travel distance are often prohibitive to the patient.[27] Thus, the inaccessibility and unaffordability of physiotherapy, occupational therapy, massage therapy, and acupuncture, combined with patients’ high demand for pain treatment, caused many PCPs to prescribe opioids. Further, overburdened rural PCPs, who, on average, oversaw 2300 patients, were often unable to spend the time necessary to properly diagnose or offer treatment for chronic pain. [28] Instead, in some counties, they prescribed opioids at rates five to six times higher than urban PCPs, further intensifying the epidemic.[29]

The economic, social, and geographical contexts of Rural Appalachia created the conditions necessary for its opioid crisis, however, the crisis was catalyzed by public policy’s failure to regulate the pharmaceutical industry. When pain crusaders removed the stigmatization of opioids in the 1990s, state and federal public policy lagged behind. Pharmaceutical companies engaged in mass advertising and sales campaigns for their new synthetic prescription opioids, using exaggerated and dangerous claims to encourage the prescription of their drug. More egregious, however, were the gifts of free travel, meals, and excessive consulting fees paid to the doctors by pharmaceutical companies in return for prescribing drugs like OxyContin.[30] For the first six years after its market debut, OxyContin drug reps were not limited by any federal or state guidelines prohibiting the exchange of premiums, trips, and giveaways for doctors’ prescriptions.[31] In those six years, OxyContin prescriptions for chronic pain rose from 670,000 to 6.2 million.[32] Not only did the number of prescriptions increase, but also the strength of dosages. Purdue’s tying of drug rep bonuses to selling higher-priced, higher-dosage variants of OxyContin directly caused more cases of opioid-dependence and overdose.[33] Moreover, the absence of federal regulations prohibiting drug companies from influencing content and speaker selection at continuing medical education seminars allowed companies like Purdue to further incentivize prescribing more OxyContin.[34] The lack of regulations in this case was especially problematic for rural Appalachia because the region’s PCPs were specifically targeted by drug companies.[35] Intractable pain laws in some Appalachian states, such as Ohio, further exacerbated the issue by exempting doctors from prosecution for prescribing opiates.[36]

Lax regulations on pain clinics that wrote prescriptions for opioids (i.e. pill mills) were also responsible for creating the opioid crisis. Ohio only required a building lease and a doctor with a schedule II narcotic DEA permit to open a pill mill.[37] These pill mills were effectively legal drug dealing enterprises, as pill mill doctors charged visit fees in return for liberal, both in pill count and dosage, prescriptions.[38] This resulted in prolific quantities of OxyContin and other prescription drugs becoming available in a region already economically and socially prone to opioid abuse, thus inciting the epidemic. It is important to note that the enormous numbers of drugs flooding into rural Appalachia would not have been possible without Supplemental Security Income (SSI) and its accompanying Medicaid Card, which paid for addicts’ prescriptions at the cost of a three-dollar co-pay.[39] The ability for rural Appalachia’s vast impoverished populace, the cohort at greatest risk of opioid abuse, to procure incredulous amounts of opioids at almost no cost directly resulted in the explosion of opioids across the region.

In recent years, American federal and Appalachian state governments have worked to combat the opioid crisis by curtailing the policy loopholes that were traditionally abused to obtain prescription drugs. One such bill, Ohio’s 2011 House Bill 93, limited the ability to start pain clinics and eliminated Ohio’s intractable pain law.[40] Other DEA regulations have limited the ability for pharmaceutical companies to unscrupulously market their drugs, and many of these companies have been fined for their misleading advertising.[41] However, the damage was already inflicted on the people of rural Appalachia, and the region’s opioid crisis continues to persist today.

The continuance of the opioid crisis is in large part owing to America’s federalist framework that delegates authority to states on the regulation of pain clinics. When Appalachian states instituted prescription monitoring, many addicts travelled weekly to Florida on the “OxyContin Express” to buy pills. Without a unitary approach to the regulation of pill mills and prescriptions, people will continue to travel to states with weaker drug control legislation to fill their prescriptions. Deindustrialized Europe has not faced as severe of an opioid crisis, largely due to the centralization of pharmaceutical legislation, which unitarily restricts the amounts that can be prescribed and how pharmaceutical companies are able to advertise.[42]

Furthermore, though Appalachia has now significantly limited legal opioid prescriptions, there has not been comprehensive legislation aiding the recovery of prescription opioid addicts. As rural areas are underserved by drug treatment, detoxification and rehabilitation centres,[43] addicts are less likely to seek treatment. The recent reluctance of PCPs to prescribe legal opiate painkillers has turned many addicts to black tar heroin, which has penetrated into rural Appalachia. In this way, rural Appalachia’s opioid epidemic, has transformed from crisis centered around OxyContin, to a crisis centered around heroin.

The cumulative economic, social, and geographic qualities of rural Appalachia made the region susceptible to, and perpetuated, the opioid crisis. However, the epidemic’s catalyst lay in the policy frameworks surrounding pharmaceutical regulation and drug procurement. While more stringent regulations have mitigated some of the damage caused by the crisis, the opioid epidemic will continue until the underlying factors, including endemic poverty and the inaccessibility of medical and addiction treatment, are addressed.

Endnotes

[1] Laura Moody, Emily Satterwhite, and Warren K. Bickel, “Substance Use in Rural Central Appalachia: Current Status and Treatment Considerations,” Journal of Rural Mental Health 41, no. 2 (2017).

[2] Elgin Mannion and Dwight B. Billings, “Chapter 17: Poverty and Income Inequality in Appalachia,” in Population Change and Rural Society, eds. William A. Kandel and David L. Brown, Dordrecht, The Netherlands: Springer (2005), 368.

[3] “Coal Production in the United States — An Historical Overview,” Energy Information Administration, October 2006, accessed at https://www.steelonthenet.com/pdf/EIA_06-Oct-06.pdf.

[4] Drew Haerer and Lincoln Pratson, “Employment trends in the US Electricity Sector, 2008–2012,” Energy Policy 82 (2015): 86, accessed at doi: 10.1016/j.enpol.2015.03.006.

[5] Ibid., 94.

[6] Sam Quinones, Dreamland, New York, NY: Bloomsbury Press (2015), 24.

[7] Ibid., 18

[8] Rural Poverty in America, ed. Cynthia M. Duncan, Westport, CT: Auburn House (1993), 111.

[9] Connor Bailey, Leif Jensen, & Elizabeth Ransom, Rural America in a Globalizing World, Morgantown, WV: West Virginia University Press (2014).

[10] Daniel T. Lichter et al., “Emerging Patterns of Population Redistribution and Migration in Appalachia,” Demographic and Socioeconomic Change in Appalachia, April 2005, accessed at https://www.prb.org/wp-content/uploads/2004/04/EmergPatternsPopAppalachia.pdf.

[11] Rural Poverty in America, ed. Cynthia M. Duncan, 119.

[12] Rural Poverty in America, ed. Cynthia M. Duncan, 113.

[13] Khary K. Rhigg, Shannon M. Monnat, and Melody N. Chavez, “Opioid-related mortality in rural America: Geographic heterogeneity and intervention strategies,” International Journal of Drug Policy 57 (2018): 125, https://doi.org/10.1016/j.drugpo.2018.04.011.

[14] Rural Poverty in America, ed. Cynthia M. Duncan, 119.

[15] Sylvia S. Martins et. al., “Nonmedical prescription drug use among US young adults by educational attainment,” Social Psychiatry and Psychiatric Epidemiology 50, no. 5 (2015): 720, https://doi.org/10.1007/s00127-014-0980-3.

[16] Anne Case and Angus Deaton, “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century,” Proceedings of the National Academy of Sciences 112, no. 49 (2015), https://doi.org/10.1073/pnas.1518393112.

[17] Robert Coles, “Life in Appalachia — the Case of Hugh McCaslin,” in Poor Americans: How the White Poor Live, Piscataway, NJ: Transaction Publishers (1971), 36.

[18] Quinones, Dreamland, 212.

[19] Adam B. Jonas et. al., “OxyContin® as currency: OxyContin® use and increased social capital among rural Appalachian drug users,” Social Science and Medicine 74, no. 10 (2012), https://doi.org/10.1016/j.socscimed.2011.12.053.

[20] Rhigg, “Opioid-related mortality,” International Journal of Drug Policy, 125.

[21] Ibid.

[22] Roger A. Rosenblatt and L. Gary Hart, “Physicians and Rural America,” Western Journal of Medicine 173, no. 5 (2000), accessed at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071163/.

[23] Anselm L. Strauss, “Medical Ghettos,” in Poor Americans: How the White Poor Live, Piscataway, NJ: Transaction Publishers (1971), 159–165.

[24] Jeannie L. Haggerty et al., “Features of Primary Healthcare Clinics Associated with Patients’ Utilization of Emergency Rooms: Urban-Rural Differences,” Healthcare Policy 3, no. 2 (2007), https://doi.org/10.12927/hcpol.2007.19394.

[25] Jason A. Hoppe et al., “Opioid Prescribing in a Cross Section of US Emergency Departments,” Annals of Emergency Medicine 66, no. 3 (2015), https://dx.doi.org/10.1016/j.annemergmed.2015.03.026.

[26] Jacob P. Prunuske et al., “Opioid prescribing patterns for non-malignant chronic pain for rural versus non-rural US adults: a population-based study using 2010 NAMCS data,” Biomed Health Services Research 14 (2014), https://dx.doi.org/10.1186%2Fs12913-014-0563-8.

[27] Christiane Brems et al., “Barriers to healthcare as reported by rural and urban interprofessional providers,” Journal of Interprofessional Care 20, no. 2 (2006): 113–114, https://doi.org/10.1080/13561820600622208.

[28] Quinones, Dreamland, 98.

[29] Moody, Satterwhite, and Bickel, “Substance abuse in rural Appalachia,” Journal of Rural Mental Health.

[30] Quinones, Dreamland, 134.

[31] Ibid.

[32] Ibid., 138

[33] Harriet Ryan, Lisa Girion, and Scott Glover, “You want a description of hell? OxyContin’s 12-hour problem,” Los Angeles Times, May 5, 2016, accessed at http://www.latimes.com/projects/oxycontin-part1/.

[34] Quinones, Dreamland, 135.

[35] Moody, Satterwhite, and Bickel, “Substance abuse in rural Appalachia,” Journal of Rural Mental Health.

[36] Quinones, Dreamland, 337.

[37] Ibid., 197

[38] Khary K. Rhigg, Samantha J. March, and James A. Inciardi, “Prescription Drug Abuse & Diversion: Role of the Pain Clinic,” Journal of Drug Issues 40, no. 3 (2010), https://doi.org/10.1177%2F002204261004000307.

[39] Quinones, Dreamland, 210.

[40] Ibid., 338

[41] Ibid., 267

[42] “Pharmaceutical legislation for medicinal products for human use,” EudraLex, accessed November 11 2018, accessed at https://ec.europa.eu/health/documents/eudralex/vol-1_en.

[43] Rhigg, “Opioid-related mortality,” International Journal of Drug Policy.