By Pat Anson, PNN Editor

The U.S. opioid crisis is a lot more complex than many people think. Instead of a single “epidemic” fueled by prescription opioids, researchers say there are three types of opioid epidemics occurring in different parts of the country simultaneously.

A team of researchers at Iowa State University studied death certificate data from all 3,079 counties in the lower 48 states and found distinct regional differences in the opioids that caused the most overdoses.

Cities in New England have been hit hard by illicit fentanyl and other synthetic opioids; the Rockies and Midwest are plagued by heroin; and a prescription opioid epidemic still lingers in many rural counties in the South and West.

A fourth epidemic – dubbed a “syndemic” by researchers – involves multiple drugs and exists in counties where the opioid crisis first erupted, particularly in mid-sized cities in Kentucky, Ohio and West Virginia. 

About 25 percent of all U.S. counties fall into one of these epidemic categories.   

“Our results show that it’s more helpful to think of the problem as several epidemics occurring at the same time rather than just one,” said co-author David Peters, PhD, an associate professor of sociology at Iowa State University. “And they occur in different regions of the country, so there’s no single policy response that’s going to address all of these epidemics. There needs to be multiple sets of policies to address these distinct challenges.”

LEADING CAUSE OF OPIOID OVERDOSES

Overdose deaths linked to prescription opioids peaked nationwide in 2013 and have fallen in recent years. But researchers say some counties with poor economies continue to struggle with prescription drugs. Over one-third of the counties in Tennessee, Oklahoma, Nevada and Utah fall into this category.

“We find that prescription-related epidemic counties, whether rural or urban, have been ‘left behind’ the rest of the nation. These communities are less populated and more remote, older and mostly white, have a history of drug abuse, and are former farm and factory communities that have been in decline since the 1990s. Overdoses in these places exemplify the ‘deaths of despair’ narrative,” researchers reported in the journal Rural Sociology.

“By contrast, heroin and opioid syndemic counties tend to be more urban, connected to interstates, ethnically diverse, and in general more economically secure. The urban opioid crisis follows the path of previous drug epidemics, affecting a disadvantaged subpopulation that has been left behind rather than the entire community.” 

The study found heroin overdose deaths clustered along two major corridors, one linking El Paso to Denver and another linking Texas and Chicago. Those findings correspond with known drug routes used by cartels smuggling heroin into the U.S. from Mexico.

The study only looked at death certificate data up to 2016, missing the full impact of the CDC opioid guideline, as well as the widening scope of the fentanyl and counterfeit drug crisis. As PNN has reported, hundreds of people have died on the west coast this year after ingesting counterfeit oxycodone laced with fentanyl.

“We are waiting to obtain the 2017 and 2018 data from CDC, but I expect the number of Rx opioid epidemic counties have transitioned to the synthetic+Rx epidemic and the opioid syndemic,” Peters told PNN in an email. “Fentanyl mixtures are replacing Rx pills and heroin in many places, mainly because fentanyl analogs are cheap to produce and generate more profits for drug traffickers.”

Given the expanding nature of the opioid crisis, Peters and his colleagues say tighter regulation of opioid prescribing and dispensing will have little effect on overdoses. The same is true for law enforcement efforts to stop drug traffickers and smuggling.

Instead they recommend expanding access to addiction treatment, as well as long-term investment in struggling communities to reduce both economic despair and the demand for drugs.