Substance abuse common in both urban and rural areas, but rural users less likely to seek treatment

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By Melissa Patrick
Kentucky Health News

In some ways, substance abuse is worse in urban areas, but rural drug users are less likely to get treatment, according to two studies recently released by the Rural and Underserved Health Research Center at the University of Kentucky.

The studies looked at the last 10 years, which included several significant developments in the field. In 2008-2010 came the first parity laws, which ensure equal coverage of treatment for mental illness and addiction in most group health plans, including Medicaid; 2011-13 saw the early expansion of insurance under the Patient Protection and Affordable Care Act; and 2014-15 saw clarification of the parity laws and further insurance expansions, including Medicaid.

The first study, “Illicit Drug and Opioid Use Disorders among Non-Metropolitan Residents,” found that the percentage of adults with substance-use disorders was about the same in rural areas as in metropolitan areas. However, research authors Tyrone Borders and Hefei Wen note that there are some “statistically significant” differences that indicate more serious problems in urban areas.

For example, the share of urban adults with an illicit drug-use disorder in the previous year, 3.33 percent, was significantly higher than the rural rate of 2.86 percent. Also, the share of urban adults with any type of drug-use disorder in 2014-15 was significantly higher than in 2011-13, when it was 3.07 percent.

Heroin more common in cities, prescription painkillers in rural areas

The number of adults with heroin-use disorders in the past year was “significantly higher” in metropolitan areas than rural areas, the researchers report. The most recent data show that 0.31 percent of urban residents had a heroin-use disorder in the previous year, half again as high as the 0.20 percent in rural areas.

Disorders involving the use of prescription pain relievers were more common in rural areas, involving 1 percent of the population in rural areas and 0.87 percent in metropolitan areas. Overall opioid-use disorders were virtually the same in urban and rural areas, 1.07 percent and 1.09 percent respectively, and those rates have been stable over time, the researchers report.

The researchers say they are particularly concerned about recent increases in heroin use disorders

“Heroin is more frequently injected than prescription pain relievers and is associated with hepatitis C and HIV transmission,” they note. “Moreover, because the compounds contained in heroin are often unknown, it is associated with a higher risk of overdose mortality than prescription pain reliever use.” Heroin is increasingly laced with painkillers that are much more powerful.

The report concludes: “Additional policies and interventions are arguably warranted to further promote access to treatment and reduce the prevalence of drug use disorders in the U.S.”

Rates in 2014-15 of perceived need for treatment, and use of treatment, among rural Americans with drug use disorders in the previous year (Click for larger image)

The second study, “Perceived Treatment Need and Utilization for Illicit Drug and Opioid Use Disorders in Non-Metropolitan Areas,” looked at the perceived need for treatment of substance-use disorders, compared to the actual use of treatment.

This research by the same authors found that overall, the rates of perceived need for treatment and actual use of treatment were low among rural residents with drug-use disorders, and have changed little since 2008, despite the implementation of policies to increase access to treatment.

“Perceived need for treatment” was defined as persons recognizing they have a drug problem and thinking that formal treatment could be beneficial. “Perceiving a need for treatment is considered an essential first step in the treatment-seeking process and has been shown to be strongly associated with treatment utilization,” the authors write.

They found that the rates of perceived need for treatment for use of illicit drugs was about the same in urban and rural areas, and those perceptions haven’t changed much in the last decade. For rural residents, this rate ranged from a high of 11.3 percent in 2011-13 to a low of 6.7 percent in 2014-15.

Among people with opioid-use disorders, the rural and urban rates were also about the same, but the perceived need for treatment in rural areas more than doubled between 2008-10 and 2011-13, from 7.8 percent to 18.5 percent. The rate declined to 13.4 percent in 2014-15.

The study found that 26.7 percent of urban adults with an opioid-use disorder got treatment during the study period, significantly higher than the 17.9 percent among rural adults. However, the gap almost disappeared in 2014-15, when the urban and rural rates were 24.3 and 24.1 percent, respectively.

The difference was even greater in treatment for heroin use, 48.6 percent for urban adults and 25.7 percent for rural ones. There was little difference in treatment rates for abuse of prescription painkillers: 19.5 percent for urban adults and 20.6 percent for rural.

However, the perceived need for treatment of disorders related to prescription painkillers was significantly higher in rural areas, 13.2 percent, than the urban rate of 8.1 percent. Among those with a heroin-use disorder, the rural rate was higher, but the difference wasn’t statistically significant.

The researchers suggest several overlapping policy issues to consider: a need for improved insurance reimbursements for screening and treatment in rural primary care; a need to address the limited access to behavioral-health and substance-abuse treatment in rural areas; the need for targeted substance-abuse treatment, needle exchanges, and safe-sex education programs in areas with rising heroin use; and issues around the limits on the number of patients that can receive medication assisted treatment for opioid use.

They also say that stimulating positive perceptions about treatment among illicit drug users and their families and friends could encourage them to get treatment.

The studies used data from the National Survey on Drug Use and Health for the years 2008-2015. The data were combined to create adequate sample sizes and to reflect different substance-use treatment policies during the study period. The results were adjusted for demographic, social and economic factors as well as whether the person had health insurance.

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