The Rural-Urban Opioid Divide and the Space In-Between

By: Mario Ramirez, MD

Reading Time: 4 minutes

Date: 03/28/2019

Filed Under: Opioid Epidemic, fentanyl, controlled substances

In my day to day emergency medicine practice, I routinely treat and manage opioid related overdoses, sometimes as frequently as three or four patients a day. And while the emergency clinical care of an opioid overdose is the same in rural, suburban, and urban emergency departments, I’ve often felt myself wondering what it is that drives the differences in these groups.

Why does it seem that some groups are more likely to overdose on intravenous synthetic opioids? Why do other groups seem to trend towards prescription opiate use? Are there differences in the long-term outcomes for these groups? Is there a best way to treat them, and should I be varying my approach across different demographic groups?

As it turns out, this is still an area of ongoing public health research but there are some important trends worth discussing here. While our foremost goal at AffirmHealth is to provide the best prescribing intelligence for administrators and clinicians, there is clearly a complex interface between the synthetic, intravenous, and prescription opioid worlds that requires a deeper level of understanding to help add meaning to the data we provide.

This post is meant to help our readers understand how the opioid epidemic varies between rural and urban populations and how to best contextualize information from those groups appropriately.

What Do Overdose Rates Look Like Between These Two Groups

In 2018, Monnat and Rigg[1] published their findings, “The Opioid Crisis in Rural and Small Town America,” in the University of New Hampshire Carsey School of Public Policy National Issue Brief #135. Referencing their data, they showed that opioid related mortality rates were higher in urban vs. 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 nonmetro counties.

But, they also found that between 1999 and 2016, that the rate of increase in overdose deaths increased more quickly in rural compared to urban counties: +158% in large central metro counties, +507% in large fringe metro counties, +429% in medium/small counties, and +740% in nonmetro counties.

The question, of course, is why do we observe these differences? What is it about large, urban areas compared to smaller rural areas that is driving these changes? And are there particular factors within each of these groups that we should be targeting to help stem the worsening epidemic?

What Is Causing These Opioid Geographical fine Differences?

Although a variety of theories have been put forth, there was a time when many settled on worsening financial stress and poverty as the key driver of illegal opioid use.

Noting the particularly high opiate overdose rates in the Northeast and Appalachia, many linked the worsening epidemic to the worsening economic and employment conditions of groups living in those regions and there was some hope that if economic conditions improved, that the epidemic would taper off. As it turns out, however, that hypothesis has proven less certain—it may be more closely linked to differences in prescription opiate supplies and other social factors than just economic conditions alone. 

In January 2019, CDC investigator Macarena Garcia and her team published their findings in the CDC Morbidity and Mortality Report[2] and showed that based on their analysis of prescribing rates from the AthenaHealth electronic record system, patients living in rural areas had nearly twice the odds of being prescribed an opioid containing pain medication compared to those in urban areas. In some comparisons, the difference was as large as 87%.  

Covering a similar period of time, Monnatt and Rigg, as well as other experts at the CDC, found that overdoses in urban vs. rural areas have diverged somewhat with urban overdoses more likely to include fentanyl and synthetic opioids, while rural areas continue to have higher rates of prescription overdoses.

This make sense given the differences in prescription rates between these groups, and also takes on added meaning in the context of an older 2014 study by Keyes et al., “Understanding the Rural-Urban Differences in Nonmedical Prescription Opioid Use and Abuse in the United States.[3]

In their paper, they noted that four factors: 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, could all be considered root causes for the worsening epidemic.

What Does It All Mean?

Taken together, the research from the papers above explains 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 would have seen improvement in overdose rates as economic conditions in the country improved from 2010 onwards (the Great Recession).

Instead, overdose rates have continued to worsen. Overall, as supplies of prescription opiates have tightened, we have seen a demographic shift with more users diverting to heroin, fentanyl, and other synthetics and a proportionate drop in the number of prescription related overdoses.

At the same time, opioid overdose rates are continuing to rise among fentanyl and other synthetic users and these particular types of drugs are spreading from urban America into more rural areas. As a result, overall opioid related overdose statistics continue to show that we are falling behind.

Prescribing Practices Going Forward

As we’ve written about in prior blog posts, there is no “one-size-fits-all” approach that works for every opioid user. There remain some patients for whom opiates are a vital mainstay for effective pain management when other approaches have failed.

But, the data above clearly suggest that we, as a clinical community, have much work to do in understanding how our prescribing practices across different groups have fueled the epidemic in the past, and how we need to adjust our opioid prescribing practices in the future to ensure that we are responsibly managing pain but minimizing diversion. 


[1] “The Opioid Crisis in Rural and Small Town America,”

[2] “Opioid Prescribing Rates in Nonmetropolitan and Metropolitan Counties Among Primary Care Providers Using an Electronic Health Record System—United States, 2014-2017,”

[3] Understanding the Rural-Urban Differences in Nonmedical Prescription Opioid Use and Abuse in the United States,”

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