MedicalResearch.com: What is the background for this study? What are the main findings?
Response: Drug overdoses are the leading cause of injury death in the United States, resulting in approximately 52,000 deaths in 2015. Although prescription drugs, in particular opioid pain relievers, were primarily responsible for the rapid expansion of this large and growing public health crisis, illicit drugs (heroin, illicit fentanyl, cocaine, and methamphetamines) now are contributing substantially to the problem. Understanding differences in illicit drug use, illicit drug use disorders, and overall drug overdose deaths in metropolitan and nonmetropolitan areas is important for informing public health programs, interventions, and policies.
We found that the prevalence of self-reported past-month use of illicit drugs increased significantly across urban status (large metropolitan, small metropolitan, and nonmetropolitan) between 2003-2005 and 2012-2014. Prevalence was higher for males than females, however, in the large metropolitan group, the percentage increase in prevalence from 2003–2005 to 2012–2014 was greater for females (23.4%) than for males (21.6%). There were notable differences by age. During 2012–2014, respondents aged 18–25 years had the highest prevalence of past-month use of illicit drugs for all urban levels. For respondents in this age group, the prevalence increased slightly from 2003–2005 to 2012–2014 in large metropolitan areas while the prevalence remained stable among small metropolitan area respondents and nonmetropolitan area respondents. Past-month use of illicit drugs declined over the study period for the youngest respondents (aged 12–17 years), with the largest decline among small metropolitan area youth.
We also found that all three geographic groups experienced statistically significant declines during 2012–2014 in overall prevalence of drug use disorders among those who used illicit drugs in the past year. For residents in large metropolitan areas, prevalence declined 12.6%. For residents in small metropolitan areas, prevalence declined 20.7%. Among nonmetropolitan residents, the prevalence of past-year illicit drug use disorders declined 12.8%.
In 2015, there were nearly six times as many drug overdose deaths in metropolitan areas than in nonmetropolitan areas. The overall percentage change in the number of deaths for nonmetropolitan areas between 1999 and 2015 was 325%, and 198% for metropolitan areas. All age group categories showed increases in drug overdose deaths from 1999 to 2015. In 2015, the drug overdose death rate for rural females was higher than for urban females; the opposite was found for males (the urban rate was higher than the rural rate).
MedicalResearch.com: What should clinicians and patients take away from your report?
Response: The results depict a mixture of hope and concern. Regardless of urban/rural status, illicit drug use among youth generally declined over a ten year time period, but increased substantially in other age groups (age 26-34 and 35 years and older). The increase between 1999 and 2015 in overdose deaths is concerning and carries across urban status, sex, race, and intent. Drug use and subsequent overdoses continue to be a critical and complicated public health challenge across rural and urban areas.
Consideration of where people live and where they die from overdose could enhance specific overdose prevention interventions, such as distribution of and training on naloxone administration or rescue breathing. Educating prescribers on CDC’s guideline for prescribing opioids for chronic pain and facilitating better access to medication-assisted treatment with methadone, buprenorphine, or naltrexone could benefit communities with high rates of opioid use disorders.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Response: Monitoring trends in illicit use and drugs involved in overdoses is critical as they have changed rapidly in recent years. The type of drug involved in overdose deaths varies by urban status with rates of heroin and cocaine related overdose deaths being higher in more urban areas.
Although past-month use of illicit drugs was lower in rural areas compared to urban areas, the prevalence of drug use disorders among people reporting past-year illicit drug use in rural areas was similar to that in urban areas. Studies have found that persons with substance use disorders are at higher risk for drug use-related morbidity and mortality and are a target population for interventions. Further, given research indicating that rural areas have less access to substance abuse treatment services and other risk reduction strategies compared to urban areas, the similar prevalence of drug use disorders in this study underscores the importance of scaling up these critical interventions in nonmetropolitan areas. Monitoring and understanding differences in access to and use of substance abuse treatment services will continue to be important.
In both urban and rural areas, the majority of overdose deaths occurred in a home, and rescue care could fall to friends or relatives who might lack knowledge about naloxone administration and follow-up care. Interventions for opioid overdoses, such as naloxone administration, rescue breathing, or calling 911, are most useful when someone is present to administer them. In private locations, such as homes, bystanders might not know to call for emergency services after giving naloxone.
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Mack KA, Jones CM, Ballesteros MF. Illicit Drug Use, Illicit Drug Use Disorders, and Drug Overdose Deaths in Metropolitan and Nonmetropolitan Areas — United States. MMWR Surveill Summ 2017;66(No. SS-19):1–12. DOI: http://dx.doi.org/10.15585/mmwr.ss6619a1
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