Challenges of opioid use disorder in rural settings

It is generally accepted that the prescription opioid (PO) epidemic had its beginnings in rural communities of the United States. This chapter reviews the origins, scope, and impacts of the opioid epidemic in rural geographic areas, with a particular focus on the ways in which these may be unique from urban or nonrural areas. We first review the scope of the problem, including the complex factors contributing to opioid use in rural settings, as well as opioid overdose trends and infectious disease transmission. We also discuss the clinical impact on treatment for opioid use disorder (OUD) and harm reduction strategies, as well as testing and treatment for infectious disease. Next, we discuss clinical considerations when treating persons with OUD in rural environments, including logistical barriers and concurrent stimulant use, as well as innovations in treatment delivery for rural settings (e.g., including novel treatment models, telehealth, sustained release formulations of medications). Overall, the data are clear that rural regions have been disproportionately affected by the opioid crisis, yet geographic isolation, economic strain, and other factors have presented challenges for efforts to expand evidence-based OUD treatment and harm reduction services. Efforts to identify new and creative methods for eliminating barriers to treatment access, including novel pharmacological-, technological-and systems-based approaches, are essential to reducing opioid-related deaths, infectious disease, economic costs, and other consequences in our rural communities.