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Portraying a More Complete Picture of Illicit Drug Use Epidemiology and Policy for Rural America: A Competing Viewpoint to the CDC's MMWR Report

2018; Wiley; Volume: 34; Issue: 1 Linguagem: Inglês

10.1111/jrh.12289

1748-0361

Tyrone F. Borders,

Prenatal Substance Exposure Effects

Illicit drug use, including the misuse of prescription painkillers, is a substantial public health concern in many urban as well as rural areas nationally. An article recently published in the CDC's Morbidity and Mortality Weekly Report (MMWR) by Mack and colleagues1 provides further evidence that drug use disorder prevalence rates are similar across metropolitan and nonmetropolitan areas, although I have questions about the authors’ interpretation of their findings on trends in drug use prevalence rates. In this commentary, I provide a competing interpretation of the findings presented in the Mack and colleagues article and introduce readers to a collection of articles appearing in the Winter 2018 issue of The Journal of Rural Health that further advance our limited knowledge of drug use epidemiology and policy approaches for addressing the causes and consequences of substance abuse. Let me first address some of the findings contained in the recent article published in MMWR in which Mack et al report on illicit drug use, drug use disorders, and overdose mortality rates across large metropolitan, small metropolitan, and nonmetropolitan areas.1 Based on analyses of the National Survey on Drug Use and Health (NSDUH), they reported that past-month drug use (illicit drug use and the misuse of prescription pain relievers) prevalence rates were similar across large metropolitan, small metropolitan, and nonmetropolitan residents ages 12 years and older in 2012–2014 and that past-month drug use prevalence rates increased significantly for all groups since 2003–2005. The authors go on to report that past-year drug use disorder prevalence rates declined over time, stating, “Among nonmetropolitan residents, the prevalence of past-year illicit drug use disorders decreased 12.8%, from 18.8% during 2003–2005 to 16.4% during 2012–2014” (p.5). Based on the latter statistics, they conclude that the “lower prevalence of illicit drug use disorders in rural areas during 2012–2014” is an “encouraging” sign (p. 11). However, the latter conclusion is arguably a misleading characterization of illicit drug use prevalence rates in rural America. The drug use disorder prevalence rates reported in the Mack et al paper are among past 12-month drug users. In other words, the denominator is past 12-month users, which is an important point to recognize. As shown in the Mack et al article, past-month drug use rates have been increasing in recent years. It is possible that the decline in past-year drug use disorder rates among nonmetropolitan drug users as reported by Mack et al is largely or partially attributable to an increasing number of drug users, including recreational marijuana users. I and a colleague at the University of Kentucky recently conducted analyses of changes in illicit drug use prevalence rates among adults ages 18–64 that portray a very different picture. Like Mack et al, we analyzed several years of NSDUH data, finding that rates of past-year drug use disorders of any type, opioid use disorders, heroin use disorders, and prescription pain reliever use disorders (primarily opioid pain relievers) are similar among metropolitan and nonmetropolitan residents. We estimated the past-year drug use disorder prevalence at 3.33% and 2.86% among metropolitan and nonmetropolitan adults ages 18–64 in the 2014–2015 period. Prevalence rates for any type of drug use disorder did not change from 2008–2010 to 2014–2015 among adults ages 18–64, and we found no changes in the prevalence rates for opioid and prescription painkiller use disorders over time among metropolitan or nonmetropolitan residents. Of some concern, we did find a significant increase in the prevalence of a heroin use disorder among metropolitan and nonmetropolitan adults ages 18–64 from 2008–2010 to 2014–2015. The differences in drug use disorder prevalence rates that I described above are not trivial because their interpretations have very different implications for rural and urban health policy. A so-called “encouraging” decline in prevalence rates among drug users could imply that fewer drug users are transitioning to drug use disorders and that substance use treatment supply needs may be waning. In contrast, the finding that the prevalence of drug use disorders among the overall population of nonmetropolitan adults ages 18–64 has remained stable over recent years points to a continued need for ensuring access to substance use treatment. In summary, the MMWR report statistics are not inaccurate, but the conclusion that declines in drug use disorder prevalence rates are “encouraging” is an incomplete message to relay to policy makers and should be considered within the context of a wider body of research indicating that drug use disorders are a persistent problem in rural areas. Regardless of the illicit drug use disorder prevalence rates reported, effective strategies for addressing drug use may differ between metropolitan and nonmetropolitan areas. This issue of The Journal of Rural Health contains several articles that further contribute to the body of knowledge about rural substance use, its consequences, and treatment access. Also using NSDUH data, Chavez and colleagues’ article found that insurance rates have improved nationally among adults ages 18–25 with psychological distress and alcohol or drug use disorders since the implementation of the Affordable Care Act (ACA), but that a disparity in insurance rates persists among nonmetropolitan as compared to metropolitan persons.2 They found that increases in insurance coverage have not translated into sustained improvements in access to mental health or alcohol and drug use treatment. Federally qualified health centers in rural areas have potential to expand treatment access for drug abuse, but the paper by Jones shows that the majority of federally qualified health centers nationally do not offer any substance use treatment services.3 The paper also shows that federally qualified health centers have much lower odds of offering or considering offering medication-assisted treatment for opioid use disorder. Bernat and Choi found that nonmetropolitan adolescents ages 14–17 in Florida had higher odds of lifetime and past 30-day smoking, in addition to other smoking-related risk factors.4 Their paper also provides insight into how programs and policies could be targeted toward rural families and schools to reduce adolescent smoking. Illicit drug use poses other serious public health concerns in rural America, as pointed out in the article by Staton and associates.5 They found an alarmingly high rate of injection drug use, which has been found to be associated with Hepatitis C and HIV transmission, among women in rural jails in the Appalachian region of Kentucky. The paper by Brown and colleagues shows that neonatal abstinence syndrome (NAS) rates are substantially higher in rural than large metropolitan areas nationally.6 Within Kentucky, a state with a high rate of opioid prescription painkiller misuse, access to opioid addiction treatment for pregnant women was found to be significantly worse in rural than metropolitan areas. Because mental health problems are frequently among the stronger if not strongest predictor of illicit drug use, improving access to mental health care in rural communities could be a key strategy for reducing concomitant drug use disorders. The article by Hoeft and colleagues provides a very informative and useful summary of how task-sharing, which “allows a limited number of specialists to practice in teams with other providers and community resources to reach populations in need,” could be further implemented in rural areas to improve mental health services access.7 In closing, the uses of illicit and licit substances remain substantial population health concerns in rural America. As this commentary has pointed out, the CDC's recent report suggesting that drug use disorder prevalence rates are declining among past-year drug users portrays only a small piece of the overall picture of rural drug use and related issues. Although rates of drug use and disorders are comparable among rural and urban adults, approaches for reducing the correlates and consequences of drug use may differ for rural and urban areas of the United States. The Winter issue of The Journal of Rural Health contains several articles that add to the limited body of knowledge in this area, but much more work is needed to further understand how we might reduce substance use and facilitate treatment access among persons who have already developed a substance use disorder.