The ‘Vicious Cycle’ Of Rural Drug Addiction


When Laura Jones wrote the grant for West Virginia’s first syringe exchange program, she estimated it would help about 75 people access clean needles each year. Six months into the program, her staff have seen more than 200 people come through their small clinic’s door.

“We haven’t advertised it at all since we opened, and now I don’t think we ever can,” said Jones, director at Milan Puskar Health Right, the free primary care clinic home to the program. “The demand is that huge. We just can’t help that many people.”

Since the program’s initiation, three other syringe exchange programs have popped up across the state, all in densely populated areas. Most who come to the clinic are addicted to some type of opioid-based drug, and fear sharing used needles will leave them with the Hepatitis C virus currently ravaging Appalachia.

It’s gotten to the point where now drug addiction is ubiquitous with rural communities

But while addiction doesn’t discriminate in West Virginia, the state currently leading the country in drug overdose deaths, the opioid crisis is taking a particular toll on those most isolated. In the state’s rural Boone County, the overdose death rate is 81 per every 100,000 person. By comparison, in the state’s most urban area, Kanawha County, the overdose rate isn’t even half as high, at 35 per every 100,000 person.


Jones has seen entire families addicted to heroin show up at her clinic after driving hours from their small town — making the long trip there just to get clean needles.

“Access is the biggest problem for rural communities. It’s what that keeps them stuck in the cycle of abuse,” Jones said. “We have not even scratched the surface of reaching those people — we just don’t have the means.”

This imbalance between rural and urban abuse is replicated in every state reeling from the growing opioid crisis.

“States have been cracking down on physicians’ ability to prescribe opioids,” said Brock Slabach, vice president of the National Rural Health Association. “But once an addict runs out, there are few rural programs available to help them with the next step. What is available is heroin. It’s a completely vicious cycle.”

There are multiple explanations for why people living in rural areas may be more likely to get addicted to drugs. Rural populations are usually older, and older populations are more susceptible to chronic pain treated by opioid-based pain medication — a common introduction to the slippery slope of opioid abuse. And in these rural areas, where existing jobs are often more physically demanding, work injuries are common. Instead of risking job loss, injured employees often rely on these pain medications to numb the problem.


But the sheer distance from addiction treatment is the main reason that rural areas see so much long-term drug abuse — abuse that can lead to an overdose.

Not having nearby access to methadone or suboxone — medications nearly mandatory for a successful recovery — isn’t the only problem, said Slabach. It’s also the fact that, without easily accessible health workers, there may not be any signs of support that can motivate addicts to quit in the first place.

“It’s kind of like when you’re drowning and you don’t think anything can save you,” he said. “It’s hard to know that you can be helped, it’s an all-consuming process. Someone has to reach out their hand and guide you in the right direction.”

We have not even scratched the surface of reaching those people

But with many states cutting back on public health funds, getting this kind of holistic care to small communities is nearly impossible. Instead, some rural health workers give addicts the number for a drug abuse hotline — which can only do so much.

“It’s gotten to the point where now drug addiction is ubiquitous with rural communities,” Slabach said. “We need the government to put the money where their mouth is.”


With such a limited supply of addiction treatment centers, Slabach said that rural hospital emergency rooms see the brunt of this epidemic. In rural Pennsylvania, data shows that hospitalizations for opioid overdoses has jumped 315 percent since 2000 — much higher than the rate in urban counties. In rural Tennessee, some hospitals that serve rural areas estimate they see an average of two to three people a week overdosing from opioid use.

Jones said it’s common to see people go to the ER, detox, and then return to their community only to succumb to their addiction in a matter of days.

“Almost everyone relapses,” she said.

She’s seen some addicts try to quit cold turkey, only to show up at her office, pale and shaking, believing they were about to die. She didn’t feel confident telling them they weren’t.

There are few options she’s able to give them in an area where the waiting list to get into a residential treatment program for opioid addiction is consistently maxed out.

“The hardest thing is when someone asks ‘I’ve been thinking about treatment, where can I go?’ — but we don’t have an answer for them,” Jones said. “All I can tell them is to call back every day at 4 pm and we’ll see if anyone has dropped off the list.”

And from her experience working with opioid addicts from outlying communities, Jones said that stigma may also be to blame for this cycle of untreated rural addiction.

“In small towns where everyone knows you, there’s a fear of going to a local doctor to seek care. There’s the fear people will talk, will judge you,” she said. “But what people don’t know is that half of the town is addicted.”