Opioid Crisis Report: COVID-19 Increased Overdose Risk in Rural Communities

By Holly Broce, MHA, LCADC, President, Opioid Treatment Program (OTP) Division, Pinnacle Treatment Centers

When the COVID-19 pandemic swept across the nation and changed daily life for virtually everyone, mental health and addiction experts raised the alarm. They warned everyone the associated public health measures meant kids in schools would experience negative educational, emotional, and psychological consequences and adults across the country would likely experience increased stress, mental health problems, and alcohol and drug use.

They were right about our children and adolescents: mental health issues increased dramatically, which resulted in the publication of a Surgeon General’s Advisory on the precarious state of youth and teen mental health in 2022.

They were also right about our adults: across the board, adults in the U.S. and around the world report increased rates of anxiety, depression, stress, and alcohol and drug use.

A study published in February 2022 called “The Impact of the COVID-19 Pandemic on Drug Use Behaviors, Fentanyl Exposure, and Harm Reduction Service Support among People Who Use Drugs in Rural Settings” examines the effect of the pandemic on a specific demographic: adults in rural areas who regularly use illicit drugs, including heroin, black market opioid medications, and drugs associated with fentanyl, such as methamphetamine and cocaine.

The study authors preface the study by reminding readers that in rural areas, people who use drugs regularly – whether or not they receive a clinical diagnosis for substance use disorder or opioid use disorder (SUD/OUD) – were among the most vulnerable to the changes related to COVID-19 safety measures. The following factors increase their vulnerability:

• High rates of poverty
• Social isolation
• Limited resources, including:
  • Transportation
  • Insurance coverage
  • Family support
  • Social support
• Chronic homelessness
• Limited access to addiction treatment
• Job loss/unemployment
• Limited access to mental health treatment
• Chronic food insecurity

This article summarizes the findings of that study and discusses the ways in which we can offer lifesaving support in areas where demand for support is high, but access is low.

The Opioid Crisis: Where We Are Now

First, though, here’s a quick recap on the opioid crisis. This bullet list describes where we were before the pandemic, what happened during the pandemic, and where we are now:

• Overdose deaths stabilized between 2017 and 2019
• Overdose deaths began to increase before the pandemic
  • Fentanyl caused this increase
• Between April 2019 and April 2020, the Centers for Disease Control (CDC) reported 78,056 overdose deaths
• Overdose deaths increased dramatically in April 2020
• Between April 2020 and April 2021, the CDC reported 100,306 drug overdose deaths

That last bullet point describes the circumstances people who work in addiction treatment face today. We’re in the process of managing the effects of a worldwide pandemic on a group of people who, over the past two years, faced a series of unavoidable, unwanted, and uncontrollable events which, when taken as a whole, increased the overall likelihood of increased drug use and overdose death.

Now let’s take a look at that study.

The Rural Opioid Crisis: The Latest Trends

We know from direct experience about the disproportionate impact opioid addiction has had in rural areas in the U.S. over the past decade. The study we use in this article draws on data from residents of rural Illinois, but we support people in similar communities at many of our locations in nearby Kentucky, Ohio, and California. The rural experience in the U.S. is by no means monolithic. However, the barriers to treatment people in the rural U.S. face – and the impact of COVID-19 on those barriers – are nearly identical no matter which state consider. From California to Ohio to Pennsylvania to Illinois, people in the rural U.S. have a unique set of challenges to overcome.

To analyze the effect of COVID-19 on the opioid crisis in rural Illinois, researchers interviewed 50 residents and collected the following quantitative information:

• Demographics
• Drug availability
• Drug use
• Sharing practices, including drug preparation supplies and drug delivery supplies, including needles
• Mental health symptoms

The research team then interviewed 19 opioid users to gather qualitative information regarding the impact of COVID-19 on:

• Personal life
• Community life
• Drug acquisition
• Drug use
• Protective measures related to substance use

Just as a quick refresher, quantitative information refers to things you can count with numbers, while qualitative information refers to things that are open to interpretation, descriptive, and based in language as opposed to numbers.

Rural Drug Use During COVID-19: Quantitative Data

Now let’s take a look at how the study participants answered the survey questions. This first set of data includes the quantitative measures. We’ll look at specific details regarding study participants: demographics and drug use.

• Demographics:
  • Average age: 40
  • Gender:
    • 52% male
    • 48% female
  • Race:
    • 88% white
    • 12% non-white, Hispanic, African American
  • Education:
    • 42% had some high school
    • 32% graduated high school the equivalent
  • Housing:
    • 62% were homeless
    • 38% had access to safe, consistent housing
  • Food insecurity:
    • 92% reported using public food support systems in the six months before the survey
    • 8% reported no food insecurity
  • Drug Use (most common drugs used in the month before the survey):
    • Methamphetamine: 96%
    • Heroin: 60.5%
    • Fentanyl: 45.2%
    • Prescription anxiolytics (benzodiazepines, i.e., Xanax)
    • Prescription opiates: 37.5%
    • Cocaine: 30.6%
  • Intravenous Drug Use:
    • Heroin or methamphetamine: 100%
    • Two or more drugs in same injection: 58.7%

We include all these details to drive the point home about the people in this study. The quantitative data shows clearly they’re low income, high school educated or lower, and face very real housing and food insecurity. In addition, all participants in this study report regular intravenous drug use, which is among the most dangerous and risky type of drug use we encounter.

Rural Drug Use During COVID-19: Qualitative Data

Researchers divide the answers to the qualitative questions into four categories. We’ll list those categories now, along with select quotes from the study participants themselves about their experiences during the study period, August 2020-May 2021.

Changing Drug Costs and Formulations

• Half the study participants agreed or strongly agreed with the sentence, “The types of drugs I use has changed during this time due to availability.”
• 2/3^rds of study participants agreed or strongly agreed with the sentence, “The process of getting drugs has been more difficult during this time.”
• One study participant said, “Heroin is harder to find anymore. Over the summer…everybody went to get these beans, little capsules full of fentanyl. And they’re cheap, they’re $10. And usually, that one little bean will get you high all day…compared to like $20 to $30 for heroin.”
• Another said, “This ice [methamphetamine], like I stopped buying it actually, because it skyrocketed in price…overnight it went from $60 to $80 to $200, but I know how to make my own.”

Increasing Drug Use, Mental Health, and Injection Behavior

• Many participants said they increased their drug use during this time, due to more time at home because of unemployment, or boredom because stay-at-home orders gave them more free time.
• One participant said about her drug use among her peer group, “It seems like it’s increased, I think because everyone is inside more, and they get bored.”
• Another said, “Yeah, it’s increased a little bit, I have more time on my hands.”
• With regards to the mental health effects of the pandemic stress on their drug use, one participant answered, “Maybe it might have got worse…I probably do more drugs now.”
• A vast majority of participants reported they felt more “depressed, less motivated, and more anxious” during the study period than before.

Perceived Risk of Overdose

• Half the study participants said that during the study period, they were more likely to use drugs alone. Over half said they worried about getting “a bad batch of drugs that is dangerous.”
• One participant said, ““…before the COVID, I never had fentanyl. The last two times I’ve had it, it’s almost killed me. So now I use test strips on everything I get.”
• With regards to the fentanyl beans mentioned above, on study participant said, “I started doing that, but they were just shooting too strong, people were falling out on them, so I just started snorting them.”

Those last two bullet points bring us directly to the most important part of this study: the analysis of the use and effectiveness of harm reduction measures.

Use of Harm Reduction Measures

In the area of rural Illinois where researchers conducted this study, an organization called The Community Action Place (tCAP) remained open, operational, and provided harm-reduction services to local residents. Across the board, participants identified tCAP as an important part of, to put it bluntly, staying alive during the pandemic. tCAP supports people across 19 counties in Southern Illinois, and provides access to clean syringes, cotton, fentanyl test strips, naloxone (a lifesaving anti-overdose medication), infectious disease testing, and safe sex supplies.

To emphasize the importance of harm reduction measures, we’ll include two salient comments from participants in the study. We understand that harm reduction can be a controversial topic, and many people – including addiction treatment professionals – do not endorse all measures related to the harm reduction approach to the opioid crisis.

With that in mind, consider this answer from a person who utilized tCAP harm reduction services during the pandemic:

“There’s been a lot less concern about where all these people are going to get their needles because there are a lot more of them out there. New ones, which is amazing. Um, this Narcan is so much easier to get ahold of, which has been amazing. I’ve used it many a time. The [tCAP staff] are lifesavers.”

And now this one, from another person who used tCAP services:

“This is kinda wearing me down, and, um, you know, just with everything adding up. So, starting tCAP just, um, is kind of like a beacon of light for me. Like I mean, it makes you feel like there is hope, you know?”

And finally, this one:

“This is one of the poorest counties in the state, and possibly in the nation, in my opinion, and we need all the help we can get. So, I think it’s a wonderful thing…you know, like the majority of people don’t give a f&@k about drug users…and I think it’s awesome that somebody’s looking out for the little guy…I’m actually proud of myself being a part of the program.”

We understand people make the argument that harm reduction services enable, rather than reduce, illicit drug use.

In some very limited cases, that may be true.

However, as addiction treatment professionals, we know people who work in harm reduction always work toward sobriety and abstinence, with the understanding that for some people, simply surviving the day comes first. And as addiction treatment professionals, when we see people in active addiction say things like “they’re lifesavers” and “tCAP is a beacon of light” and “I’m proud of myself” we know they’re on the right track.

Why?

Because we work to save lives. We work to give people hope. And we know that with self-confidence and a sense of personal pride, a person has a much greater chance of surviving addiction and embracing a life in recovery.

That’s our takeaway: now let’s look at how the researchers interpreted the data they collected.

The Results: What the Researchers Conclude

When we read the data in this report, we’re grateful that a team of qualified researchers confirmed, with a valid and responsible scientific approach, what we lived through and witnessed ourselves. The pandemic was a rough period for people with addiction – especially low-income people in rural areas with significant opioid and methamphetamine use problems. The mitigation measures made a challenging situation more challenging on structural, personal, and interpersonal levels.

We did what we knew how to do. We stayed open and responded by offering addiction treatment services to as many people in need as we could. That included our medication units in Kentucky, Ohio, and California. We’ll talk more about our med units in a moment.

First, let’s get back to the people of rural Illinois, and look at how the researchers interpreted the data about them we shared above.

After analyzing the information in the quantitative survey, researchers found that:

• Drug use increased during the pandemic
• Increased drug use raised overall risk of overdose death due to presence of fentanyl products known as beans or buttons
• Decreased availability of heroin led to:
  • Increase in methamphetamine use
  • Presence of fentanyl in methamphetamine

After analyzing the information in the quantitative survey, researchers reported increased:

• Use of opioids or other drugs in isolation
• Experience of overdose
• Witness of overdose
• Depression
• Anxiety
• Loneliness

We’ll add that these findings correspond to the time period during which fentanyl-related opioid and methamphetamine overdose deaths increased nationwide. That data is available on the CDC website here. After analyzing their data and results in context, the study authors concluded that the best way to support people in rural Illinois was with an increase in targeted support in several key areas.

Here’s what they recommend.

Reducing Opioid and Methamphetamine Overdose Risk in Rural Areas

• Ensure access to harm reduction services, including:
  • Needle programs
  • Naloxone
  • Fentanyl test strips
• Increase Mobile harm reduction units:
  • Participants in the study emphasized the importance of these units for:
    • Naloxone
    • Fentanyl test strips
  • Participants said mobile harm reduction units increased feelings of personal and community resiliency
• Increase overall dose prevention efforts, including distribution of:
  • Naloxone
  • Fentanyl test strips
• Expand treatment access, including:
  • Counseling
  • Therapy
  • Education
  • Community support

We have to be honest.

We’re right there with them on their approach.

The idea is to bring the treatment to where the people are, rather than make them come to us. This removes location as a barrier to treatment. Removing location as a barrier reduces other barriers, like time, money, and transportation. That’s why an expanded presence in rural areas is crucial. For people on medication-assisted treatment for opioid use disorder (MAT for OUD), our med units simplify daily access to medication.

When we coordinate the best known treatment for OUD – licensed MAT programs – with expanded access to rural areas, and connect that to harm reduction, counseling, therapy, and social support, then we know we can help low-income people in rural areas in the ways they need it most. They become part of a larger community, and we become part of theirs. We know this collaborative approach can work. We can find the people who need help – and help them in any way we can. The opioid epidemic reaches deep into some of the most isolated areas in the country, but we’re catching up, one community at a time.