A sign outside a Morrow, Ohio, pharmacy is bad news for those seeking Oxy. Photo by Jennifer Durban/Flickr.

A greater likelihood of receiving medical care in an emergency room could be one of the reasons rural adolescents are more likely than urban youth to misuse painkillers, a new study says.

The study shows rural residents aged 12 to 17 were 35 percent more likely to have abused prescription painkillers in the past year than adolescents living in large cities.

The report, published in the National Rural Health Association’s Journal of Rural Health, indicates that the types of health services rural teens receive might explain the higher prescription painkiller misuse rates. Rural adolescents are more likely to use emergency room services than urban adolescents, and ER doctors are more likely to prescribe opioid painkillers than physicians in other clinical settings, the study found.

The Daily Yonder spoke to one of the study’s authors, Shannon Monnat, an assistant professor of sociology and demography at Penn State. Monnat is a researcher in the university’s Department of Agricultural Economics, Sociology, and Education, and an associate at the Population Research Institute.

She said the research is important, not just because prescription painkiller misuse is unsafe. She said painkiller abuse can lead directly to heroin use – with its greater danger of overdose – when the supply of prescription drugs is cut off.


How did you become interested in this research topic?

I’ve been interested in spatial inequalities and rural/urban differences for quite some time. I met my coauthor, Khary Rigg [University of South Florida’s Mental Health Institute], at a Robert Wood Johnson Foundation event, and he mentioned he was doing prescription drug abuse research. I said, “Have you looked at the rural issue, because from what little I’ve read, it’s sort of a problem in rural areas.” And he said, “No, I’m mostly interested in urban stuff.” But we started looking at the data, and ended up collaborating on this work. I had this awareness of rural issues and he had the substance abuse background. It opened up a whole line of research I had never thought of and now it’s some of the most interesting work I do.

Shannon Monnat is an assistant professor of sociology and demography at Penn State.
Shannon Monnat is an assistant professor of sociology and demography at Penn State.

Your study found that rural youth between 12 and 17 are more likely to have abused prescription painkillers in the last year. Was there a big difference in abuse? And is that what you expected to find? 

About 6.7% of rural adolescents reported using prescription painkillers in the last year [based on data from the 2011-12 National Survey of Drug Use and Health]. And that’s compared to 5.3% in large urban areas. In terms of the age group, older kids are more likely than younger kids. Each additional year in age increases the likelihood of abuse by 38%.

I expected to find a difference like this. Prescription painkillers have been an issue in rural areas for quite some time. In fact, the OxyContin epidemic first started in Appalachia, where pill mills first popped up. Beyond that we know that rural kids are more likely to binge drink and smoke cigarettes. There are these individual level and community level factors that seem to be influencing the higher usage of those substances. …

There were some surprising things that I didn’t anticipate and probably should have about some of the reasons why rural kids are more likely to abuse prescription painkillers. Chief among those is the greater reliance on emergency medical department services. Rural teens are more likely than urban teens to use emergency room services, where prescription painkillers are more often prescribed.

We know that rural areas face a shortage of primary care facilities, and often times the urgent-care clinic can be the only place a person in a rural area can go to get treatment. And that certainly increases their risk of being prescribed a painkiller, in comparison to if they have access to a primary care physician.

I also recently read the book Dreamland: The True Tale of America’s Opiate Epidemic, by Sam Quinones. He chronicles the prescription painkiller epidemic across small towns across the country. He talks about how pill mills popped up. He talks about how these rogue physicians in rural areas would charge hundreds of dollars for painkillers, even if they didn’t have a clinical reason to be prescribing them. And then he goes on to talk about how, when prescription painkillers became more difficult to get and more expensive because of prescription drug monitoring programs and the introduction of tamper proof pills that can’t be crushed or liquefied, many people transitioned to heroin.

Why are ER doctors more likely to write a pain prescription?

This data doesn’t tell us that.

You say the number of painkiller prescriptions is going up. Does this study say that’s more of an issue for rural areas, or are the prescriptions on the increase everywhere?

All we know is that there has been almost a doubling of opioid prescriptions written for adolescents and young adults since 1994.

We’ve seen increases in all sorts of prescriptions in the last 20 years. Pharmaceutical companies really advocate and advertise prescription use. At the same time, physicians have less time per patient. There have been a lot of changes in the medical field that require doctors to do a lot more paperwork. There are more people who are using more health services. There are a lot of health problems in the country: an aging population, more people with obesity, diabetes. And doctors have less time to spend per person. The easiest solution is for doctors to prescribe a drug because they simply don’t have time.

Are there any implications for rural policy makers in this study? Apart from doctors, parents, and others being more aware of the problem, what could policy makers do that would make a difference?

One of the things that we found was that the most common sources of prescription painkillers were friends and family members for rural and urban teens alike. While rural kids were less likely than urban kids to say they got them from friends and family, they were more likely to say they got them directly from a physician.

Source: Center for Disease Control.
Source: Center for Disease Control.

To me that suggests an intervention at the physician level to ensure that the prescribing of painkillers is clinically warranted. And to explore other methods of pain reduction, and to monitor adolescents who are prescribed prescription painkillers, because they are highly addictive. We know that adolescents’ brains are still developing, so if they begin prescription drug abuse as a teen, they are more likely to have major abuse problems as an adult.

Another thing is that we found that rural kids are more likely to be involved in the criminal justice system than urban kids. And often times being involved in the criminal justice system can be sort of an introduction to other people who abuse drugs.

So the use of family drug courts might be a good intervention strategy at the community level. One of the benefits of family drug court is that it could link early teen criminal offenders to prevention and treatment services. And it could link them to better education on the highly addictive nature of and consequences of prescription opioid abuse. If you can get to these teens early when they’re doing something minor, like breaking into a car, and these drug courts find that there might be a substance abuse issue going on too, they might be able to set these families up with treatment and counseling services too. Which would also be able to provide some information about how risky these painkillers are.

One of the things is that we found was that rural teens … don’t seem to understand how high the risk of overdose really is.

And then we found that the use of other substances is among the strongest predictors of opioid misuse as well. About half of the prescription painkiller deaths involved the use of other substances.

A really important effort is to target early substance abuse among rural and urban teens alike, because they often occur simultaneously. It’s not like one kind of drug abuse is a springboard into another, but the characteristics that predict opioid misuse predict binge drinking, for instance, and/or other illicit drug use. Preventing substance abuse at all levels is important.

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